Date of Graduation

Fall 12-17-2021

Document Access

Restricted Project/Capstone - USF access only

Degree Name

Master of Science in Nursing (MSN)

College/School

School of Nursing and Health Professions

Program

Kaiser cohort MSN capstone

First Advisor

Carla S. Martin, MSN, RN, CIC, CNL, NEA-BC

Abstract

Problem: Surgical site infections can be prevented by improving adherence to evidence-based infection control practices of surgical instrumentation sterilization protocols. With education and departmental cultural changes, operating room scrub personnel learn the importance of point-of-use pre-cleaning of surgical instruments and increase adherence to protocol. Context: A ten operating room intra-operative department in a non-trauma hospital of a large health care system created a quality improvement project to decrease surgical site infection rates by increasing scrub personnel adherence to pre-cleaning protocol and safely transporting surgical instruments to the Central Sterile Processing (CSP) department. Interventions: A formal education session and huddle messages for five weekdays were provided to operating room nurses and surgical technicians. Measures: The adherence to protocol was measured through audits on the condition of the surgical instruments transported to CSP before and after the education and huddle sessions. Results: Surgical scrub personnel adherence to surgical instrument pre-cleaning protocol increased from 5% to 50% after formal education and staff huddles. Staff self-assessment of protocol adherence was 91% ten weeks after formal education. Conclusion: Formal education and enhanced staff awareness are effective strategies to increase staff adherence to evidence-based practice protocol. Future analysis of SSI rate after this project is necessary to measure SSI improvements and to plan further strategies for staff protocol adherence sustainment.

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