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  • Problem: Surgical site infections (SSIs) are a serious patient risk but can be reduced with a proven pre-operative treatment. The compliance rate for providing this treatment is only 58% for pediatric patients in Intensive and Cardiac Intensive Care.
  • Root Causes Discovered:
    • Provision of a Chlorhexidine Gluconate (CHG) bath not documented—CHG kills bacteria and protects from infection
    • Confusion about the required timeframe to provide the CHG bath
    • Misunderstanding of the purpose of the CHG bath
    • High census and acuity can cause the CHG bath to be overlooked
  • Solution:
    • Changed terminology from “CHG Bath” to “CHG Treatment”
    • Initiated universal CHG treatments for all PICU and CICU patients
    • Empowered trained technicians to provide the treatment if the RN is busy
    • Eliminated 4-hour timeframe before surgery requirement since CHG is effective for 24 hours
    • Mapped CHG treatment order to the Medication Administration Record (MAR) and required CHG wipe be scanned (like a medication) before administration
    • Provided tip sheets on rationale and procedure for CHG treatment
  • Results: Compliance with pre-operative CHG treatment in PICU and CICU increased from 58% to 93% within the first month of implementation










The Problem

According to the Centers for Disease Control and Prevention (CDC), Surgical Site Infections (SSIs) account for 20% of all hospital-acquired infections and are associated with an increase in mortality. SSIs also contribute to increased length of hospital stays and an estimated annual cost of $3.3 billion1-3. Among pediatric hospitals, SSIs are the 3rd largest contributor to patient harm across the Solutions for Patient Safety Network4. (SPS), a network of 140+ children’s hospitals working together to make progress on the journey to do no harm. SPS is the only such effort in the nation focusing on pediatric and employee safety.

The SPS Network used factor analysis and evidence in the medical literature to create an SSI Prevention Bundle—a small set of practices proven to improve patient outcomes. This bundle has produced a sustained reduction in the network SSI rate.4

Driscoll Children’s Hospital implemented the SSI Prevention Bundle in 2018 with high compliance initially, but adherence to the bundle has waned over time and falls below the network average. Further analysis revealed that the biggest opportunity for improving compliance was in the Pediatric Intensive Care Unit (PICU) and Cardiac Intensive Care Units (CICU).

Carolyn Walker RN, MPH, and Director of Performance Improvement at Driscoll Children’s Hospital decided to lead a project aimed at improving the compliance rate. Carolyn chose this project to be part of her GLSS Lean Six Sigma Black Belt Training & Certification.

“Baseline compliance with pre-operative CHG Bath is 58% in the combined Pediatric Intensive Care Unit (PICU) and Cardiac Intensive Care Units (CICU),” says Carolyn. “This increases the risk of surgical site infections (SSIs).”

“As part of the SPS network, we sponsor an internal course for our staff on performance improvement, using the Model for Improvement, PDSA. For this project, I felt that a more detailed approach, with DMAIC and the Black Belt techniques, was needed. I am not new to performance improvement, but I wanted to hone my skills, especially since we’re managing the improvement course.”

The Root Causes

The improvement team conducted a Process Walk and interviewed nurses responsible for completing the pre-operative CHG bath. This provided several revelations:

  • All nurses were found to be similar in procedures and compliance.
  • Most nurses endeavored to comply with the requirements but expressed frustration that it was difficult to remember to complete the bath, or more commonly, to document the bath after it was completed.
  • There was no prompt within Epic (the Electronic Medical Record System) and accessing the care flowsheet for documentation was not part of their usual workflow.

The team explored these areas further with the root cause analysis techniques of the Fishbone Diagram and 5 Whys.

While there was a lack of data to confirm root causes, developing Hypothesis Statements, as learned in the GLSS Training and Certification, helped the team understand how to use logic and observation to unearth root causes. This enabled them to move quickly and pinpoint two key root causes:

  • RN staff often forgets when a particular patient needs a pre-operative bath
  • RNs often provide the bath but do not document

The Solutions

Customizing the Impact and Effort Matrix from the GLSS training, the team evaluated numerous potential solutions looking for those that provided the most benefit for the least investment.

During the discussion of potential solutions, the pre-operative bath was reframed by the team as an antimicrobial treatment, much like the administration of antibiotics. This led to treating the application of CHG as a medication rather than hygiene.

Carolyn says, “There was a special moment—an ‘aha!’ moment—which is always fun because we don’t always have those. During a meeting, the clinical educator, a frontline nurse, said, ‘You know, why are we looking at this as a bath? It’s really not a bath. It’s a medication and we should be treating it like we treat an antibiotic or any other medication that we would give to prevent infection.’ That turned our thinking on its head.

This demonstrated the power of having frontline experts who complete the process involved in the project. Not only did they come up with effective interventions, but the improvements made their jobs easier and were readily accepted by the rest of the staff.”

Ultimately, three simple but powerful solutions negated the need for additional, more difficult interventions. These were:

  • Add the CHG treatment as a daily order for all patients in the PI/CICU through the use of an admission order set rather than only before surgery
  • Add the treatment to the Medication Administration Record (MAR)
  • Enable the ability to scan the CHG wipe which automatically updates the MAR as administered

The GLSS Training and Certification guided me to use specific tools and methodology every step of the way. It was so interesting for me to go through the training exercises and see what they bring. So I think for me, it added to my toolkit from what I am accustomed to. GLSS opened my eyes to some other tools and options that I didn’t know about or didn’t know how to use. Also, for my situation, I like the online option very much. Going at my pace and the consistent example that GLSS used was super helpful.

The Results

“The solutions resulted in a 35% improvement in the completion of preoperative CHG treatment from 58% to 93%,” says Carolyn.

“We will explore expanding this improvement house-wide. It is expected to not only decrease SSIs but other hospital-acquired infections as well, particularly Central Line-Associated Bloodstream Infections furthering our journey to improve pediatric and employee safety.”


  • 1 Ban, K.A., “American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update”. Journal of the American College of Surgeons, 224(1): (2017), 59-74.
  • 2 Awad, S.S., “Adherence to surgical care improvement project measures and post-operative surgical site infections”. Surgical Infection (Larchmt), 13(4): (2012): 234-7.
  • 3 Zimlichman, E., et al., “Health Care-Associated Infections. A Meta-analysis of Costs and Financial Impact on the US Health Care System”. JAMA Intern Med, 173(22): (2013): 2039-46.
  • 4 Solutions for Patient Safety. 2017, May 2. SPS Change Package Surgical Site Infections (SSI): Hospital Acquired Condition. Package_SPS.pdf