COMMITTEE CHAIR: Dr. Abida Solomon

TITLE: IMPROVING PROTOCOL ADHERENCE THROUGH STAFF EDUCATION: A QUALITY IMPROVEMENT INITIATIVE TO STANDARDIZE CHLORHEXIDINE GLUCONATE USE IN AN AMBULATORY OBSTETRIC CLINIC

ABSTRACT: Introduction: Surgical site infections (SSIs) following cesarean delivery remain a significant challenge in obstetric care, contributing to increased maternal morbidity, prolonged hospital stays, and higher healthcare costs. However, chlorhexidine gluconate (CHG) is recognized as an effective antiseptic agent for preoperative skin preparation; yet inconsistent nursing education and the lack of standardized protocols have contributed to suboptimal adherence and variable clinical outcomes. Purpose: This quality improvement project sought to implement and evaluate a structured preoperative skin care education protocol for obstetric (OB) nursing staff at a hospital-affiliated outpatient clinic in Texas. The overall aim was to determine whether implementing a structured education protocol could improve nursing knowledge and adherence to evidence-based SSI prevention practices compared with baseline practice. Method: The project was guided by the Plan-Do-Study-Act (PDSA) framework. A single-group pretest-posttest quality improvement design was conducted to evaluate the impact of an educational protocol on nursing staff adherence to preoperative skin care procedures. The intervention involved structured, in-person educational sessions that incorporated evidence-based best practices for preoperative skin cleansing and the consistent application of chlorhexidine gluconate (CHG) antiseptic for patients scheduled for cesarean delivery. Educational content was delivered to all obstetric nursing staff (RNs and LVNs) in the clinic setting using standardized materials and included the implementation of a new Epic SmartPhrase to guide documentation. Outcomes were measured as improvements in nurse knowledge scores and adherence to preoperative CHG skin preparation protocols, as documented through electronic health record (EHR) audits. The primary outcome, change in knowledge, was assessed using the Surgical Site Infection Prevention Knowledge Assessment (SSI-PKA) survey, a validated instrument aligned with CDC and AORN guidelines. The secondary outcome, change in adherence, was evaluated through pre- and post-intervention EHR audits. Descriptive statistics were used to analyze demographic variables, and adherence rates were analyzed using the Pearson chi-square test to compare pre- and post-intervention adherence rates. Changes in knowledge scores were assessed using paired t-tests. Results: Twenty-nine nursing staff completed the project and were included in the final analysis. Mean knowledge scores on the Surgical Site Infection Prevention Knowledge Assessment (SSI-PKA) increased from 6.1 (SD = 1.2) pre-intervention to 9.0 (SD = 0.8) post-intervention, representing a statistically significant improvement, t(28) = 12.45, p < .001. Retrospective baseline EHR audits demonstrated documentation adherence rates of 48.9% in August 2024 and 51.3% in January 2025. Following implementation of the educational intervention and Epic SmartPhrase documentation tool, adherence increased to 98.9%, with 287 of 290 audited charts demonstrating full compliance with required documentation elements. Conclusions: Findings suggest that a structured CHG educational intervention, combined with standardized EHR documentation tools, can significantly improve nursing knowledge and adherence to evidence-based SSI prevention practices. Integration of the Epic SmartPhrase supported workflow standardization and enhanced documentation consistency. Continued monitoring of SSI rates and long-term adherence is recommended to evaluate sustainability and the potential impact on patient outcomes.

Keywords: Antiseptics, cesarean section, chlorhexidine, infections, maternal morbidity, obstetric care, post-intervention, pre-intervention, preoperative skin care, povidone-iodine, surgical site infections

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https://pvpanther.zoom.us/j/92300477924?pwd=oRKjHJFPAAUqIf2RHG1kbsIVpkLv9H.1