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St. Luke's Infection-Free Future: Project Zero

By Dr. David C. Pate, News and Community
March 28, 2013

Project Zero is an example of St. Luke’s Triple Aim in action. Its success is contributing to better care and lower costs. We have many such examples of innovative efforts led by physicians – in this particular case, by Drs. Kevin Shea and Howard King – that we are profiling on the blog.  

Having physicians who are aligned with our mission, vision, and strategy of achieving the Triple Aim through accountable care is the critical difference that is making it possible for St. Luke's to lead the transformation of health care. Another ingredient of our secret sauce is leveraging our relationships with community organizations that have expertise St. Luke's can tap into, in this case, Boise State University and Micron. Read on.  

Engineers and researchers from Micron and Boise State University are helping St. Luke’s deliver better care at lower cost to our orthopedic surgery patients.

Efforts by Dr. Howard King, Dr. Kevin Shea, and dozens of participants of their Project Zero surgical site infection initiative have more than halved the already-low rate of infection in these surgery patients at our Boise hospital, and collaboration with Micron and Boise State is building on the team’s success.  

Project Zero started in April of 2011, after Dr. Bart Hill, St. Luke’s chief quality officer, asked Dr. King and Dr. Shea to develop a task force on surgical site infections. Work started with St. Luke’s ortho/neuro specialties, which have pioneered improvement projects in the past and were well prepared to try out a quality improvement effort.

From the start, the team has included representatives from different departments and work groups, including physicians from infectious disease, representatives from public health and equipment processing, the OR nursing staff, certified surgical technologists, and others.

“The success is due to the hard work of many committed staff members at St. Luke’s," Dr. Shea said. "We’ve had a lot of great support, without which we could not have gotten this done.”

Dr. Hill encouraged the group to establish its goals early on. The team worked its way through dozens of opportunities, ultimately choosing to focus on:

  • Reducing room traffic.
  • Limiting the time of door openings for each OR to maintain improved air quality.
  • Compliance with Surgical Care Improvement Project measures for antibiotic administration.
  • Improving communication with staff and surgeons about case scheduling and instrument requests.
  • Improving post-operative care protocols with reduced variation between surgeons and procedures.
  • Changing surgical attire and uniform policies.
  • Establishing a perioperative clinic to evaluate patients with medical co-morbidities and optimize their health before elective surgical procedures.
  • Improving communication with surgeons, anesthesiologists, and St. Luke’s hospitalists.
  • Improving communication between epidemiology and surgical and other staff members.
The group’s first goal was to cut the ortho/neuro service line infection rate by half by the end of 2012, but the name of the team summarizes the real objective: zero infections.

When the effort began, the surgical site infection rate was approximately  1.1 percent, which is considered reasonable by national standards; some hospitals have infection rates above 2 percent.

Project Zero is working.

In the 18-month period starting in January 2011, the group’s efforts have reduced surgical site infections for ortho/neuro by more than half. They have sustained rates at or below 0.5 percent in the last year, and they’re looking for further reduction of another 50 percent by June of next year.

Their work has prevented approximately 28 infections for total joint and spine fusion procedures. The potential morbidity and mortality of these infections is severe, and we are very proud of the processes they have developed that have improved ortho/neuro care and the lives of our patients.

In addition to the physical hurt of infection is the financial burden.  

The cost to treat these infections can range from $60,000 to more than $200,000, especially for more severe infection and/or MRSA. If we estimate that the average cost to treat is $100,000, Project Zero already has saved our patients, payers, St. Luke’s Health System, and the communities that own St. Luke’s approximately $2.8 million by lowering the infection rate.

“The cost to the patient and their family where there is an infection is enormous,” Dr. Shea observed. “As we move into an ACO model of health care, the cost savings for preventing infections will be critical as we improve care for our patients, and our own accountability for that care.”

So what did the trick? Why is the effort working?

“All these little things we did consistently,” Dr. Shea said. “It’s hard to know which thing has the most impact on it.”

Here’s how the Project Zero team went about tackling the problem:

Last May, as Project Zero was getting started, Dr. Shea visited an allograft harvest facility in Denver to learn more about their sterile techniques for harvest. He’d worked with them in his capacity as an orthopedic surgeon and pediatric trauma specialist and knew of their reputation for quality control.  

AlloSource, a community non-profit organization, has been meticulous about harvesting and processing skin, heart valves, cartilage, bone, tendons, and other tissues for human use. 

Dr. Shea came away impressed by their harvest techniques, focus upon infection prevention, and air management. Many of their processes were based upon the use of “clean room” practices in microbiology and computer chip production facilities. AlloSource treated air quality more like a computer company would, where even small particles can destroy computer chips during manufacturing.

Dr. Shea shared his findings with the Project Zero group, which then met with the chip processing and air cleaning HVAC staff at Micron. The group visited Micron twice last fall, and the Micron HVAC staff subsequently toured our Boise OR department and met with our HVAC staff. The Micron engineers recommended steps we might take to further reduce infection rates by lowering particulate counts.

At St. Luke’s February research symposium, Dr. Shea met BSU Engineering faculty members who are doing research on air quality and particulate counts. He talked about our interest in improving air quality in the OR, and our ongoing investigations with Micron.

Sin Ming Loo, on Boise State’s College of Engineering faculty, and his research team are using small particulate counters to look at air quality, and he is now working with the Project Zero team on a project to monitor the air quality in our ortho/neuro ORs to determine if we can further improve air quality, and perhaps further reduce infections.

Air quality monitoring, which will help us see how clean our rooms are, how circulation patterns vary throughout the day and across seasons, and how air flows through our structure, will begin this spring and continue for a year.

The Project Zero team continues to look for opportunities to improve care and reduce infections, and hopes to engage other surgical department leaders in their processes. Meetings with representatives from other specialties have started and there is interest in adopting the team’s approach.

Dr. Shea hopes that ultimately, Project Zero will achieve its name and put itself out of business.

“The work of this committee will continue until we hit our target: zero infections,” he said.

About The Author

David C. Pate, M.D., J.D., is president and CEO of St. Luke's Health System, based in Boise, Idaho. Dr. Pate joined the System in 2009. He received his medical degree from Baylor College of Medicine in Houston and his law degree from the University of Houston Law Center.