based training for
the entire staff and
did in-services on all
the nursing units.
MRSA screening
has to be completed
before the patient
goes to the OR, so
timing and planning
is key. We had to
make sure every-
body was aware of
the expectation before the process was implemented, this ensured
success of the screening program.
Once the bundle was fully implemented, we knew auditing was inte-
gral to its success. We monitored bundle adherence manually through
chart audits and eventually with help from our EMR, through a report.
The report, which I receive every day, lists each of our SSI bundle
items, along with the documentation of the bundle elements. If any-
thing is listed as incomplete or incorrectly documented, I do a manual
chart audit. Depending on the non-compliant item, I either go back to
the nursing team to determine the contributing factors or to the physi-
cian leadership who will then address the non-compliance with their
teams.
Ultimately, each division weighed in on exactly what constituted an
implant. That helped us standardize the protocol and eliminate confu-
sion.
Our EMR played another key role. When a case is scheduled, the
surgeon is able to identify if the patient is going to be receiving an
implant. A "yes" creates a visual cue — a picture of a little screw
6 4 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • M a r c h 2 0 1 7
When patients come in to meet
the surgeon, usually a couple of
weeks before the surgery, we
try to get them down to the lab
for their MRSA screening.
