Challenges in Implementing Pre-surgical Chlorhexidine Shower or Bath for Prevention of Surgical Site Infection

BACKGROUND: Guidelines for prevention of surgical site infection (SSI) recommend using pre-surgical chlorhexidine bathing or shower to reduce bioburden on the skin. However, there is considerable variation in how and to what extent this intervention is implemented. Understanding barriers to implementation are essential for effective implementation. We undertook a systems approach to examining challenges to implementation of pre-surgical chlorhexidine bathing or shower at an academic medical center. METHODS: Barriers and facilitators to implementation were assessed using direct observations and interviews of front line providers. Results were categorized with deductive coding using the Systems Engineering Initiative for Patient Safety Model (SEIPS), which has five major components - tools/technology, tasks, person, environment and organization. RESULTS: Major barriers to implementation of pre-surgical showering or bathing in the five SEIPS categories were: Person—lack of ownership and role ambiguity regarding who should be responsible for dispensing the product, limited ability to measure compliance with the intervention and workflow changes to pre-operative visits to accommodate education about pre-surgical chlorhexidine bathing; Task—uncertainty about duration of chlorhexidine on the skin and number of showers required pre-operatively; Tools/Technology—pros and cons of product selection (liquid vs. wipes), and lack of documentation in the electronic medical record; Environment—the pre-operative surgical visit not being conducive to education regarding the use of chlorhexidine because of time constraints; Organization—cost of the product and lack of policy governing the use of chlorhexidine were noted. CONCLUSION: Although seemingly simple, pre-surgical showering or bathing is a complex behavioral intervention. A systems engineering approach may be useful in assessing barriers and facilitators to devise effective interventions for high fidelity compliance with the goal of preventing SSI. DISCLOSURES: All authors: No reported disclosures.