presented by: ramona mcconnell, rn kim faulkner-russell, rn cnor amy rahe, rn capa
TRANSCRIPT
Heart of the Rockies Regional Medical CenterSalida, Colorado
Presented by:Ramona McConnell, RN
Kim Faulkner-Russell, RN CNOR Amy Rahe, RN CAPA
CUSP for Safe Surgery Perioperative Staff Safety Assessment
Purpose of this form: The purpose of this form is to tap into your experiences at the frontlines of patient care to find out what risks jeopardize patient safety in your clinical area.
Who should complete this form: All staff members.
How to complete this form: Provide as much detail as possible when answering the 4 questions. Drop off your completed safety assessment form in the location designated by the SUSP team. When to complete this form: Any staff member can complete this form at any time. Name (Optional):
Job Title:
Date:
Clinical Area:
Assess Risk for Harm
1. Please describe how you think the next patient in your clinical area will be harmed.
2. Please describe what you think can be done to prevent or minimize this harm.
Assess Risk for Surgical Site Infection
1. Please describe how you think the next patient in the OR will get a surgical site infection.
2. Please describe what you think can be done to prevent this infection.
Thank you for helping to improve safety in your workplace!
This form can be found on our website:https://armstrongresearch.hopkinsmedicine.org/susp/cusp/resources.aspx
SUSP Pre-Mortem Tool
*The CUSP Premortem Tool is adapted from the work of Gary Klein at http://hbr.org/2007/09/performing-a-project-premortem/ar/1
© 2013 The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins University
SUSP Hospital Team Experience
Presented byKathleen Sandelli, RN, CIC
Virginia Chipps, RN, BSN, CPAN
ST. FRANCIS HOSPITAL & MEDICAL CENTERHartford, CT
Located in central Connecticut
• Population 125,000
Urban, major teaching hospital affiliated with the University of Connecticut Medical School
• Licensed for 617 beds, 65 bassinets
Based on the membership template provided by Armstrong Institute / SUSP project
Contacted mangers of all areas involved in the care of colorectal patients
Explained the project and time commitment Asked them to solicit volunteers
First committee meeting in January 2013
SUSP Team Formation
Modeled our plan after a PI project where we successfully implemented changes to reduce deep sternal wound infections in cardiac surgery patients.
Determined which practices to focus on for the pre-op, intra-op and post-op phases of care
Incorporated many suggestions from the coaching calls
SUSP Plan Development
Main committee Meets monthly All members assigned to a subcommittee
2 subcommittees Meet monthly Assigned specific areas of focus Report progress/recommendations back to main
committee
SUSP Team Structure
Area of Focus Research and develop a bundle of best practices for
preparing the colorectal patient for surgery
Subcommittee led by Dr. Amanda Ayers, private practice colorectal surgeon Laura Sanzari, BSN RN, NSQIP Surgical Clinical Reviewer
Subcommittee #1 (The Preppies)
Oral antibiotics No change in current practice Neomycin & Flagyl day before surgery
Mechanical bowel prep No strong recommendation in literature Done by most of our colorectal surgeons
Hibiclens shower (7/1/13*) Night before & morning of surgery
* Implemented by colorectal surgery group
Preop BundleRecommendations / Implementation
Hair clipping – if needed (7/1/13) Moved to the pre-op area (not OR) AORN recommendation
Chlorahexidine cloth wipes to abdomen (7/1/13) Done in pre-op area
Skin prep with Chloraprep (9/1/13) Identified in Staff Safety Survey as needing improvement Now done by surgeon, resident or PA Re-educated OR staff, physicians and PAs on proper technique,
coverage area and dry time Timers purchased to assure 3 minute dry time
Preop Bundle Recommendations
IV antibiotics Rocephin 2g IV and Flagyl 500mg IV
Redosing not required unless surgery is > 6 hours We have been using Invanz and Flagyl Change will save $30,000 / year
Penicillin allergic patients Cipro 400mg IV and Flagyl 500mg IV
Based on new recommendations released 1/2013**Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery . American Journal Health System
Pharmacy vol. 70, Feb 2013
Preop Bundle Recommendations
Presented by Dr. Ayers at the January 2014 Department of Surgery business meeting
Best opportunity to reach both hospital employed and private practice surgeons performing colorectal surgery
Packets given to each surgeon containing: A letter from Chief of Surgery and SUSP physician
champions explaining bundle components and requesting adoption
Questionnaire about their current practices Patient handouts
Preop Bundle Implementation
Called or emailed surgeons who did not attend the meeting.
Emailed letter and patient handouts
Met with office managers Explained SUSP project & pre-op bundle Given packet
Handouts also sent electronically Can customize with their contact information
Preop Bundle Implementation
Hibiclens showers Pre-op antibiotics and mechanical prep
(Miralax) Mechanical bowel prep only
Patient Handouts
Subcommittee led by Dr. Scott Ellner and Dr. William Marshall Maureen Gethings MSN, RN, OR Nurse Manager
Areas of Focus Normothermia Glucose control Appropriate use of blood products
Subcommittee #2 (SUSPects)
Normothermia Cases audited – all compliant
Glucose Control Tracked glucose levels on all diabetic colorectal surgical
patients in pre-op, PACU and post-op units Results indicated there was room for improvement in this
area
Normothermia and Glucose Control
Developing comprehensive plan for optimizing management of the diabetic patient HgA1c drawn on all diabetic patients as soon as possible
once need for surgery identified
If preop HgA1c is elevated (non-emergent cases) PCP / Endocrinologist to address diabetes management Ideally want to see 2 weeks of adequate glucose control pre-op Consideration of postponing case if HgA1c > 8.5
Appropriate glucose management during hospital stay
Glucose Management Goals
Administration of blood products is associated with increased risk of SSI
Our NSQIP data shows our blood product usage is above average
Blood Product Use
Beginning audit of colon surgery charts since January 2013
Identify patterns of usage and opportunities for improvement
If audit results indicate room for improvement Treat pre-op anemia - time permitting Evaluate blood product conservation strategies Establish appropriate threshold for transfusion in
hemodynamically stable patient
Blood Products
Administered patient safety surveys in February 2013
HSOPS Staff Safety Assessment (4 questions)
Evaluated responses and assigned them to categories
Helped guide subcommittee work
Safety Surveys
Analyzed responses from staff safety assessment
Identified common and recurring themes
Defect chosen – preop area Production pressure and lack of a consistent closed loop Communication between disciplines Assigned to subcommittee with members of affected
areas
CUSP
Implementation of the colorectal preoperative bundle Added bonus - savings of $30,000 with antibiotic change
Raised awareness of the impact of SSI’s and the role of each discipline in prevention
Committee is engaged and enthusiastic
Improved lines of communication between disciplines
SUCCESSES
Multiple groups working with some overlap in agendas (PAT, SUSP, Exit Only)
Employed surgeons vs. private practice general surgeons
A few resistant to implementing all the bundle elements
Coordination of diabetes management Must begin at time of decision for surgery
CHALLENGES
SCIP misses – shave vs. clip Different staff responsible for clipping Learning curve for terminology Will resolve April 1st with documentation in EPIC
Timing with EPIC implementation on April 1 Competing priorities
CHALLENGES
Continued use of the pre-op bundle components
Improved glucose management
Maintaining improved communication
Once established, will need to be audited to ensure continued compliance
Sustainability of SUSP
SUSP TeamExecutive Champion Patricia Jagoe MSN Executive Director, Surgery Physician Champion Scott Ellner, DO Vice Chair, Surgery
Director of Surgical Quality Team Leaders (2) Ginny Chipps, RN, BSN, CPAN
Kathy Sandelli, RN, CIC Nurse Manager, PACU Infection Prevention
Physicians Amanda Ayers, MD William Marshall, DO
Colorectal Surgeon Director of Trauma
Physician Assistants (2) Mary Ann Mecca, PA-C Kim Bellevance, PA-C Kathryn Sonneborn, PA-C
Surgery Lead PA Surgery Surgery
Anesthesia (2) Frank Rosenberg, MD Sivasenthil Arumugam, MD
Director of Anesthesia Anesthesiologist
Surgical Quality (1) Laura Sanzari, RN, BSN NSQIP Coordinator Pre-op Unit (4) Lori Zagaja, RN BSN
Diane Stadmeyer, RN, MSN Carol Branche, RN Ann McAdoo, RN
Nurse Manager Supervisor Staff Nurse Staff Nurse
PACU (2) Michelle Drabkin, RN BSN Ginny Chipps RN BSN
Staff Nurse Nurse Manager
SUSP TeamOperating Room (8) Maureen Gethings, RN, MSN
Vilma Marquez, RN Christine Thoering, RN BSN Ester Coutan-Julien RN Pam Rowley, CST Marcia Schwer, CST Dawn Hydes, RN MSN Diana Martin, RN MSN
Nurse Manager Staff Nurse Staff Nurse Staff Nurse Surgical Tech Surgical Tech Nurse Educator Nurse Educator
Post Op Unit (2) Linda Morris, RN, MSN Joanne Krol, RN BSN Zina Ruban, RN, BSN
Staff Nurse Staff Nurse Clinical Nurse Leader
Infection Prevention (2) Kathy Sandelli RN Infection Preventionist Director, Infection Prevention
Research (1) Alph Emmanuel, MD Department of Surgery Pharmacy (1) Greg Kratz, PharmD OR Pharmacist Ad Hoc Members (3) John Jorge
Patricia Yario, RN Stacey Glowaky, RN
Central Sterile Processing Case Management SCIP Data Abstractor
Please feel free to contact us with any further questions:
◦Kathy Sandelli (860)714-5472
◦Virginia Chipps (860) 714-5586
QUESTIONS/COMMENTS
Content Call Evaluation
We want to ensure that the content calls provide useful and pertinent information for the SUSP teams. For this reason we request that you complete
a brief evaluation following each call. The evaluation may be found at the following link:
https://www.research.net/s/SUSP_C1_2_Content_Eval
If you are not able to reach the link from the slide, please cut & paste the URL into your browser.
Next Call“Deep Rooting your Data”
Date: Tuesday, April 1, 2014 Time: 4pm EST