4 Attachment C: Surgical Services Gap Analysis

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Attachment C: Surgical Services Gap Analysis

AHRQ MRSA Prevention

Gap Analysis – Surgical Services

Instructions

Organization Name:
Date Completed:
Surgical Service Name:
Type of Surgical Service: Purpose:	Cardiac Surgery Orthopedic Surgery Neurosurgery To evaluate existing resources and processes and identify areas of improvement to facilitate interventions to reduce the incidence and prevalence of surgical site infections caused by methicillin-resistant Staphylococcus aureus (MRSA), the primary goal of participation in the AHRQ Safety Program for MRSA Prevention.
Outcome:	This gap analysis will be completed twice, once at the beginning and once at the end of participation in the AHRQ Safety Program. When completed at the start of the Safety Program, it will be used by the project team to understand needs of participating hospitals and by participating hospitals to prioritize areas for improvement and advocate for institution-level and service-level resources. When completed at the end of the Safety Program, both the project team and the participating hospitals will use the gap analysis to assess progress in building infrastructure and capacity to sustainably reduce MRSA infections.
Instructions:	Public reporting burden for the collection of information is estimated to average 1 hour per response. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer, Attention: PRA, Paperwork Reduction Project (0935-0143), AHRQ, 5600 Fishers Lane, MS 0741A, Rockville, MD 20857. The confidentiality of your responses is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information that could identify you will not be disclosed unless you have consented to that disclosure. This gap analysis has two parts. The first part addresses infection prevention program structure, activities, and resources and is to be completed by the Infection Prevention Team. The second part addresses infection control activities, including those related to MRSA prevention, on the participating surgical service and should be completed by the Project Lead for the participating service in collaboration with the infection preventionist working with the service. For each item, enter answers directly into the data portal in the indicated space. For some items, there will be a dropdown menu to allow you to select your answers.

PART 1: Infection Prevention Program Structure & Resources

Item Description	Response
INFECTION PREVENTION PROGRAM STRUCTURE AND RESOURCES
Staffing
Number of infection preventionists (ICP) fulltime equivalents (FTEs) for the hospital
Is there a hospital epidemiologist?	No Yes, full-time Yes, part-time
If yes, how much time does the hospital epidemiologist dedicate to the infection prevention program (% effort of hours/week or FTEs)
Is the hospital epidemiologist available to the infection prevention program on a daily basis?	No Rarely Usually Always
Senior Leadership
To whom does the infection prevention program report (provide position title and department, not a specific name)?
How often does infection prevention leadership meet with senior leadership?	Weekly Monthly Quarterly Annually Never Other:
Does senior leadership actively promote/support infection prevention activities (check all that apply)?	No Yes: Infection Control Committee member Yes: Provides adequate funding for infection prevention Yes: Provides funding for infection prevention member training Yes: Promotes infection prevention messages via newsletters, screen savers, etc. Yes: Provides backup to the infection prevention program if employees do not follow policies and procedures Yes: Other:
Data Analysis and Management
Is a data analyst available to assist with obtaining, managing, analyzing, and reporting infection prevention data?	No Yes, full-time Yes, part-time
Is access to the data analyst support adequate to meet program goals?	Yes / No
Select existing method of storing infection data. (check all that apply)	Paper Microsoft Excel or other spreadsheet Microsoft Access or other relational database Software that is part of the electronic health record system Standalone infection prevention software Other: (describe)
For which of the following surgical procedures is data submitted to CDC/NHSN (check all that apply)?	Hip replacement Knee replacement Laminectomy Spinal fusion Craniotomy Coronary artery bypass graft Cardiac valve replacement
Microbiology
Is there a microbiology laboratory on site?	Yes / No
Does the infection prevention team have access to microbiology results as soon as those results are finalized?	Yes / No
Does your lab have the capacity to process surveillance cultures either on-site or by sending samples to a reference laboratory?	Yes / No
Does your lab have access to a rapid test to detect S. aureus nasal colonization, either on-site or by sending samples to a reference laboratory?	Yes / No
Interactions with Services
Is an infection preventionist assigned to each surgical service?	Yes, all services Yes, only services for which surgical site infection surveillance is performed Yes, other: No
If an infection preventionist is assigned to all or some surgical services, does the infection preventionist participate in their surgical service’s patient safety/quality improvement meetings?	Yes, all services Yes, some services, specify: No

Surgical Site Infection Surveillance
Surgical Site Infections (SSI)
Please indicate which procedure(s) will be the focus of your facility’s participation in the AHRQ MRSA Prevention Program? (check all that apply) *The electronic version will supply branching logic for items below so that only relevant questions will be asked based on the response to this question.	Hip replacement Knee replacement Laminectomy spinal fusion Craniotomy Coronary artery bypass graft Cardiac valve replacement
Is surveillance performed for SSIs associated with hip replacement?	Yes / No
If yes, with what frequency?	Quarterly, ongoing throughout the year Intermittently, One quarter per year Intermittently, Two quarters per year Other:
If yes, how are SSI cases detected (select all that apply)?	Chart review of all hip replacement procedures Chart review of a sample of hip replacement procedures Electronic algorithms to detect patients who may have an SSI (e.g., readmission, receipt of antibiotics) only, without additional chart review Electronic algorithms to detect patients who may have an SSI (e.g., readmission, receipt of antibiotics) followed by chart review Communication with surgeons to identify cases Communication with patients via letters after discharge to identify cases Other:
If yes, are the SSI data fed back to the surgical service?	Yes / No
If yes to providing SSI data feedback to the surgical service, indicate the frequency of data feedback to the surgical service.	Notification of each SSI as soon as it is identified Monthly Quarterly Other: Feedback not provided
If yes to performing SSI surveillance associated with hip replacement, do you have a process to validate the SSI data?	Yes / No
If yes to validating SSI data, how is the surveillance data validated (choose all that apply)?	Review of a proportion of cases by a second infection preventionist Discussion of challenging cases at a regular meeting Comparison to postoperative wound infection diagnosis codes Other:
Is surveillance performed for SSIs associated with knee replacement?	Yes / No
If yes, with what frequency?	Quarterly, ongoing throughout the year Intermittently, One quarter per year Intermittently Two quarters per year Other:
If yes, how are SSI cases detected (select all that apply)?	Chart review of all knee replacement procedures Chart review of a sample of knee replacement procedures Electronic algorithms to detect patients who may have an SSI (e.g., readmission, receipt of antibiotics) only, without additional chart review Electronic algorithms to detect patients who may have an SSI (e.g., readmission, receipt of antibiotics) followed by chart review Communication with surgeons to identify cases Communication with patients via letters after discharge to identify cases Other:
If yes, are the SSI data fed back to the surgical service?	Yes / No
If yes to providing SSI data feedback to the surgical service, indicate the frequency of data feedback to the surgical service.	Notification of each SSI as soon as it is identified Monthly Quarterly Other: Feedback not provided
If yes to performing SSI surveillance associated with knee replacement, do you have a process to validate the SSI data?	Yes / No
If yes to validating SSI data, how is the surveillance data validated (choose all that apply)?	Review of a proportion of cases by a second infection preventionist Discussion of challenging cases at a regular meeting Comparison to postoperative wound infection diagnosis codes Other:
Is surveillance performed for SSIs associated with spinal fusion?	Yes / No
If yes, with what frequency?	Quarterly, ongoing throughout the year Intermittently, One quarter per year Intermittently Two quarters per year Other:
If yes, how are SSI cases detected (select all that apply)?	Chart review of all adult spinal fusion procedures Chart review of a sample of adult spinal fusion procedures Electronic algorithms to detect patients who may have an SSI (e.g., readmission, receipt of antibiotics) only Electronic algorithms to detect patients who may have an SSI (e.g., readmission, receipt of antibiotics) followed by chart review Communication with surgeons to identify cases Communication with patients via letters after discharge to identify cases Other:
If yes, are the SSI data fed back to the surgical service?	Yes / No
If yes to providing SSI data feedback to the surgical service, indicate the frequency of data feedback to the surgical service.	Notification of each SSI as soon as it is identified Monthly Quarterly Other: Feedback not provided
If yes to performing SSI surveillance associated with spinal fusion, do you have a process to validate the SSI data?	Yes / No
If yes to validating SSI data, how is the surveillance data validated (choose all that apply)?	Review of a proportion of cases by a second infection preventionist Discussion of challenging cases at a regular meeting Comparison to postoperative wound infection diagnosis codes Other:
Is surveillance performed for SSIs associated with laminectomy?	Yes / No
If yes, with what frequency?	Quarterly, ongoing throughout the year Intermittently, One quarter per year Intermittently Two quarters per year Other:
If yes, how are SSI cases detected (select all that apply)?	Chart review of all laminectomy procedures Chart review of a sample of laminectomy procedures Electronic algorithms to detect patients who may have an SSI (e.g., readmission, receipt of antibiotics) only Electronic algorithms to detect patients who may have an SSI (e.g., readmission, receipt of antibiotics) followed by chart review Communication with surgeons to identify cases Communication with patients via letters after discharge to identify cases Other:
If yes, are the SSI data fed back to the surgical service?	Yes / No
If yes to providing SSI data feedback to the surgical service, indicate the frequency of data feedback to the surgical service.	Notification of each SSI as soon as it is identified Monthly Quarterly Other: Feedback not provided
If yes to performing SSI surveillance associated with laminectomy, do you have a process to validate the SSI data?	Yes / No
If yes to validating SSI data, how is the surveillance data validated (choose all that apply)?	Review of a proportion of cases by a second infection preventionist Discussion of challenging cases at a regular meeting Comparison to postoperative wound infection diagnosis code Other:
Is surveillance performed for SSIs associated with craniotomy?	Yes / No
If yes, with what frequency?	Quarterly, ongoing throughout the year Intermittently, One quarter per year Intermittently Two quarters per year Other:
If yes, how are SSI cases detected (select all that apply)?	Chart review of all craniotomy procedures Chart review of a sample of craniotomy procedures Electronic algorithms to detect patients who may have an SSI (e.g., readmission, receipt of antibiotics) only Electronic algorithms to detect patients who may have an SSI (e.g., readmission, receipt of antibiotics) followed by chart review Communication with surgeons to identify cases Communication with patients via letters after discharge to identify cases Other:
If yes, are the SSI data fed back to the surgical service?	Yes / No
If yes to providing SSI data feedback to the surgical service, indicate the frequency of data feedback to the surgical service.	Notification of each SSI as soon as it is identified Monthly Quarterly Other: Feedback not provided
If yes to performing SSI surveillance associated with craniotomy, do you have a process to validate the SSI data?	Yes / No
If yes to validating SSI data, how is the surveillance data validated (choose all that apply)?	Review of a proportion of cases by a second infection preventionist Discussion of challenging cases at a regular meeting Comparison to postoperative wound infection diagnosis codes Other:
Is surveillance performed for SSIs associated with coronary artery bypass grafting (CABG)?	Yes / No
If yes, with what frequency?	Quarterly, ongoing throughout the year Intermittently, One quarter per year Intermittently Two quarters per year Other:
If yes, how are SSI cases detected (select all that apply)?	Chart review of all CABG procedures Chart review of a sample of CABG procedures Electronic algorithms to detect patients who may have an SSI (e.g., readmission, receipt of antibiotics) only Electronic algorithms to detect patients who may have an SSI (e.g., readmission, receipt of antibiotics) followed by chart review Communication with surgeons to find cases Communication with patients via letters after discharge to find cases Other:
If yes, are the SSI data fed back to the surgical service?	Yes / No
If yes to providing SSI data feedback to the surgical service, indicate the frequency of data feedback to the surgical service.	Notification of each SSI as soon as it is identified Monthly Quarterly Other: Feedback not provided
If yes to performing SSI surveillance associated with coronary artery bypass grafting (CABG), do you have a process to validate the SSI data?	Yes / No
If yes to validating SSI data, how is the surveillance data validated (choose all that apply)?	Review of a proportion of cases by a second infection preventionist Discussion of challenging cases at a regular meeting Comparison to postoperative wound infection diagnosis codes Other:
Is surveillance performed for SSIs associated with cardiac valve replacement?	Yes / No
If yes, with what frequency?	Quarterly, ongoing throughout the year Intermittently, One quarter per year Intermittently Two quarters per year Other:
If yes, how are SSI cases detected (select all that apply)?	Chart review of all cardiac valve replacement procedures Chart review of a sample of cardiac valve replacement procedures Electronic algorithms to detect patients who may have an SSI (e.g., readmission, receipt of antibiotics) only Electronic algorithms to detect patients who may have an SSI (e.g., readmission, receipt of antibiotics) followed by chart review Communication with surgeons to find cases Communication with patients via letters after discharge to find cases Other:
If yes, are the SSI data fed back to the surgical service?	Yes / No
If yes to providing SSI data feedback to the surgical service, indicate the frequency of data feedback to the surgical service.	Notification of each SSI as soon as it is identified Monthly Quarterly Other: Feedback not provided
If yes to performing SSI surveillance associated with cardiac valve replacement, do you have a process to validate the SSI data?	Yes / No
If yes to validating SSI data, how is the surveillance data validated (choose all that apply)?	Review of a proportion of cases by a second infection preventionist Discussion of challenging cases at a regular meeting Comparison to postoperative wound infection diagnosis codes Other:

PART 2: Service Level Infection Prevention Activities

Please indicate which of the following strategies are implemented for patients undergoing the procedure that is being evaluated in the Safety Program. If your site has more than one service participating, Part 2 should be completed for each service separately.

Item	Response
Please indicate the procedure for which you are completing this section. If your facility has more than one surgical service participating in the AHRQ MRSA Safety Program or if a participating service performs more than one listed procedure, please complete this section for each procedure that will be a focus of your facility’s participating.	Hip replacement Knee replacement Laminectomy Spinal fusion Craniotomy Coronary artery bypass graft Cardiac valve replacement
Is preoperative S. aureus surveillance performed by cultures, polymerase chain reaction (PCR) or other testing methodology?	Yes, for both methicillin-sensitive S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA) Yes, for MRSA only No
If yes, are results available in time to guide decision-making about antibiotic prophylaxis?	Yes, always Yes, most of the time Yes, sometimes Yes, rarely No
If yes, is there a system in place to monitor compliance with the preoperative testing?	Yes, the surgical service measures compliance Yes, infection prevention measures compliance Yes, both the surgical service and the infection prevention team measure compliance No, compliance is not measured
If yes, how often is feedback about preoperative testing compliance provided to the service?	Weekly Monthly Quarterly Other: Feedback not provided
Is chlorhexidine (CHG) treatment (bathing) recommended to patients prior to the surgical procedure?	Yes, for all patients undergoing the procedure Yes, for patients with MSSA or MRSA colonization or infection prior to the procedure Yes, for patients with MRSA colonization or infection only prior to the procedure No
If yes, how is the CHG treatment provided to patients?	CHG given to patients at pre-op visit Patients provided instructions/prescription to purchase at drugstore Patient does not apply CHG themselves; CHG treatment is performed in pre-op area only Other:
If yes, is the patient provided instructions for how to apply CHG?	Yes, the patient receives instructions for how to apply the CHG No N/A
If yes, what is the CHG treatment regimen that is recommended? (select all that apply)	5 days of CHG bathing prior to surgical procedure for all patients with MRSA or MSSA colonization or infection 5 days of CHG bathing prior to surgical procedure for all patients with MRSA (NOT MSSA) colonization or infection CHG bathing the night before the surgical procedure for all patients CHG bathing the morning of the surgical procedure for all patients CHG bathing in the preoperative area for all patients CHG bathing in the preoperative area for patients who missed their recommended regimen Other:________
If yes, is there a system in place to monitor compliance?	Yes, the surgical service measures compliance Yes, infection prevention measures compliance Yes, both the surgical service and the infection prevention team measure compliance No
If yes, how often is feedback about compliance provided to the service?	Weekly Monthly Quarterly Other: Feedback not provided
Is intranasal Mupirocin or iodophor decolonization performed prior to the surgical procedure?	Yes, Mupirocin for all patients Yes, iodophor for all patients Yes, Mupirocin for patients with MSSA and MRSA colonization only Yes, iodophor for patients with MSSA and MRSA colonization only Yes, Mupirocin for patients with MRSA colonization only Yes, iodophor for patients with MRSA colonization only No
If yes, how is the Mupirocin or iodophor treatment provided to patients?	Given to patients at pre-op visit Patients provided instruction/prescription to purchase at drugstore Patient does not perform nasal decolonization themselves; nasal decolonization treatment performed in pre-op area only Other:
If yes, is the patient provided instructions for how to apply Mupirocin or iodophor?	Yes, the patient receives instructions for how to apply the Mupirocin or iodophor No N/A
If yes, what is the intranasal Mupirocin or iodophor regimen that is recommended? (select all that apply)	5 days of intranasal Mupirocin or iodophor prior to surgical procedure for all patients with MRSA or MSSA colonization or infection 5 days of intranasal Mupirocin or iodophor prior to surgical procedure for all patients with MRSA (NOT MSSA) colonization or infection Intranasal Mupirocin or iodophor the night before the surgical procedure for all patients Intranasal Mupirocin or iodophor the morning of the surgical procedure for all patients Intranasal Mupirocin or iodophor in the preoperative area for all patients Intranasal Mupirocin or iodophor in the preoperative area for patients who missed their recommended regimen Other:________
If yes, is there a system in place to monitor compliance?	Yes, the surgical service measures compliance Yes, infection prevention measures compliance Yes, both the surgical service and the infection prevention team measure compliance No
If yes, how often is feedback about compliance provided to the service?	Weekly Monthly Quarterly Other: Feedback not provided
Is there a formal protocol for skin antiseptic preparation prior to incision?	Yes / No
If yes, is there a system in place to monitor compliance?	Yes, the surgical service measures compliance Yes, infection prevention measures compliance Yes, both the surgical service and the infection prevention team measure compliance No
If yes, how often is feedback about compliance provided to the service?	Weekly Monthly Quarterly Other: Feedback not provided
Is there a protocol for the location where hair is removed from the patient before the surgical procedure?	Yes, it allows for hair removal in the operating room (OR) Yes, it requires that hair removal occurs outside of the OR, ideally in the pre-operative area No, there is not a protocol N/A, hair is not removed prior to the procedure Other:
Is there a protocol to ensure proper surgical hand scrub for staff before the surgical procedure?	Yes / No
If yes, is there a system in place to monitor compliance?	Yes, the surgical service measures compliance Yes, infection prevention measures compliance Yes, both the surgical service and the infection prevention team measure compliance No
If yes, how often is feedback about compliance provided to the service?	Weekly Monthly Quarterly Other: Feedback not provided
Is there a protocol for proper surgical attire for staf?f	Yes / No
If yes, is there a system in place to monitor compliance?	Yes, the surgical service measures compliance Yes, infection prevention measures compliance Yes, both the surgical service and the infection prevention team measure compliance No
If yes, how often is feedback about compliance provided to the service?	Weekly Monthly Quarterly Other: Feedback not provided
Does the facility have training programs for staff in the following areas (check all that apply):	Application of skin prep, required training Application of skin prep, optional training Surgical hand scrub, required training Surgical hand scrub, optional training Surgical attire, required training Surgical attire, optional training None of the above
Does the facility have guidelines for selection of peri-procedure antibiotics?	Yes / No
Does the facility have recommendations for dosing peri-procedure antibiotics according to weight?	Yes / No
Does the facility have a protocol for the addition of vancomycin to pre-procedure antibiotic prophylaxis for patients with MRSA?	Yes / No
Does the facility have a protocol in place to ensure pre-procedure antibiotics are administered at the appropriate time prior to incision?	Yes / No
If yes, is there a system in place to monitor compliance? (select all that apply)	Yes, the surgical service measures compliance Yes, infection prevention measures compliance Yes, antibiotic stewardship measures compliance No
If yes, how often is feedback about compliance provided to the service?	Weekly Monthly Quarterly Other: Feedback not provided
Does the facility have a protocol in place to ensure re-dosing of antibiotics during the procedure when indicated?	Yes / No
If yes, is there a system in place to monitor compliance? (select all that apply)	Yes, the surgical service measures compliance Yes, infection prevention measures compliance Yes, antibiotic stewardship measures compliance No
If yes, how often is feedback about compliance provided to the service?	Weekly Monthly Quarterly Other: Feedback not provided
Does the facility have a protocol in place to ensure peri-operative antibiotic prophylaxis is stopped within 24 hours (or 48 hours for cardiac surgery)?	Yes / No
If yes, is there a system in place to monitor compliance?	Yes, the surgical service measures compliance Yes, infection prevention measures compliance Yes, antibiotic stewardship measures compliance No
If yes, how often is feedback about compliance provided to the service?	Weekly Monthly Quarterly Other: Feedback not provided
Does the facility have a protocol in place to ensure optimal glycemic control in the peri-operative period?	Yes / No
If yes, is there a system in place to monitor compliance?	Yes, the surgical service measures compliance Yes, infection prevention measures compliance Yes, both the surgical service and the infection prevention team measure compliance No
If yes, how often is feedback about compliance provided to the service?	Weekly Monthly Quarterly Other: Feedback not provided
Does the facility have a protocol in place to ensure proper patient warming in the operating room?	Yes / No
If yes, is there a system in place to monitor compliance?	Yes, the surgical service measures compliance Yes, infection prevention measures compliance Yes, both the surgical service and the infection prevention team measure compliance No
If yes, how often is feedback about compliance provided to the service?	Weekly Monthly Quarterly Other: Feedback not provided
Does the facility have a protocol for implementation of the central line associated bloodstream infection (CLABSI) prevention insertion bundle in the OR?	Yes / No
If yes, indicate which of the following elements are included: (select all that apply)	Aseptic technique Maximal sterile barrier precautions CHG for skin preparation Avoidance of the femoral site Application of a sterile dressing
If yes, is there a system in place to monitor compliance?	Yes, the unit measures compliance Yes, infection prevention measures compliance Yes, both the surgical service and the infection prevention team measure compliance No
If yes, how often is feedback about compliance provided to the service?	Weekly Monthly Quarterly Other: Feedback not provided

1 | Instructions