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Cohort 5 Team Sharing CallCUSP FOR SAFE SURGERY:
SURGICAL UNIT-BASED SAFETY PROGRAM (SUSP)
Kristina Weeks, MHS, DrPh(c) (Facilitator)
Community Medical Center-New Jersey
Boston Medical Center-Massachusetts
Ty Cobb Regional Medical Center-Georgia
November 19, 2014
Polling Question
2
What is your role in your clinical area?SurgeonQuality Improvement practitionerInfection preventionistOR nurseOR technicianAnesthesiologistOR managerEducatorCoordinating EntityOther
DRAFT-Pending AHRQ Final Approval
Deep-Rooting Your Data 2
COMMUNITY MEDICAL CENTER PERI-OPERATIVE SERVICES
A SAFE SURGICAL JOURNEY
Patricia Lees, BSN, RN
Administrative Director of Perioperative Services
Community Medical Center
• Community Medical Center (CMC) is a fully
accredited acute care hospital and offers a comprehensive array of services.
• 500 bed hospital• Toms River, New Jersey• CMC has earned the Joint Commission Gold
Seal of Approval for its Stroke, Heart Failure, Acute Coronary Syndrome, Cardiac Rehabilitation and Total Joint Replacement-Hip and Knee programs.
Team members
Administrative Director of Perioperative Services Vice President/CNO Director of Patient Care PACU/SDS/PAT Assistant Director of Patient Care O.R. Perioperative Educator Director Epidemiology/Infection Control Director of Quality Director of Patient Care Surgical/Orthopedic Unit Chair Department of Surgery Chair Department of Orthopedics Chair Department of Anesthesia
Beginning
CEO hospital commitment letter to participate signed 4-9-2014 Concentration on Total Joints, Hysterectomy, & Colon Surgery Educate staff on the science of safety
Sue Sheridan Patient Advocate video
Conduct HSOPS (Hospital Survey on Patient Safety)
Completed by staff throughout perioperative division
Achieved 97% compliance
Review results of HSOPS with staff/surgeons/anesthesia
Administration present during staff presentations
Conduct multidisciplinary team meeting to develop plan/set goals Continue to foster the culture of safety
Utilizing the results of the HSOPS to establish strengths/weaknesses
First meeting look at what protocols already in place
What is working/not working
SCIP compliance
ACTIONS IN PLACE PRIOR TO STARTING
Since February 2013 Department of Orthopedics review all orthopedic SSI’s.
Since February 2014 all Surgical Site Infections are reviewed by Chief of Surgery/Infection Control/Perioperative Management.
Specialty chair’s invited when necessary for review. Review of OR SSI’s include patient profile, antibiotics, post op
care, etc. Review AORN standards and reinforce traffic patterns, etc. and
implement environmental cleaning changes. Pre-Admission Testing started giving every orthopedic total joint
patient CHG wipes x2 days prior to surgery. SCIP protocol in place – 99% compliance.
REVIEW OF DATA-ALL SSI’s Patient Name – Account number
Admit date/discharge date
ED/Direct Admit/Inpatient/Outpatient
Residence/PTA
Age/Allergy/Height/Weight
Glucose – date/time/result
Pre-existing Conditions/Comorbidities
Prep CHG prior to surgery # of days
Bowel prep
MRSA/MSSA screen
Decolonized
Case type
Preoperative Diagnosis
Date of procedure
Name of procedure
Open/Laparoscopic
Skin prep
Wound classification
ASA
Surgery time
Anesthesia type
Irrigation type/volume
Subcutaneous closure –staples/sutures
Blood transfusions
Tourniquet times
Preoperative antibiotics dose/time
Intraoperative antibiotics dose/time
Implants/devise/drains
FO2 delivered (anesthesia)
O2 saturation
OR room
Temp/Humidity OR room
Surgeon/Assistant/Anesthesia/RN/Circulator/Others
PACU temp
Culture date
Where culture obtained
Culture results
CT obtained/results
Reported to NHSN
Reviewed with chairman
Notes – OP report & Pathology report
PRE-ADMISSION TESTING CHANGES
Implemented new Anesthesia Pre-admission Testing Guideline CHG Preps usage expansion:
◦ Sage prep given to all Total Joint and Colon surgery patients
◦ X 3 days plus the day of surgery Urine C & S for all Total Joint patients MRSA/MSSA nasal swab of all Total Joint patients Report all glucose results above 250 to surgeon and perioperative
management The day before surgery PAT works with the OR pharmacy to ensure
SCIP compliance with regards to ordered antibiotics
SYSTEM DISORDER
HGB/HCT
GLUCOSE
CBC & DIFF
BUN/CREAT
LYTES
PT/PTT/INR
LIVER FUNC
POC Preg on admission
EKG
CXR OTHER
MALE: 0 yrs to 39 yrs NO TESTING REQUIRED
40 yrs and over X
FEMALE: 0 yrs to 49 yrs NO TESTING REQUIRED
50 yrs and over X Menstruating female X
PATIENTS WITH UNDERLYING MEDICAL CONDITIONS RECEIVING ANESTHESIA TESTING IS REQUIRED
Hemorrhage/Bleeding Disorder/Hematologic x X Repeat day of surgery if abnormal
Cardiovascular Disease/Hypertension X
Severe Pulmonary Disease X X
Diabetes Mellitus on meds X *EKG over 40 yrs
Symptomatic Liver Disease X X X X
Renal Failure X X X
Sever Pancreatic Disease X X X X X
Leukemia X
DRUG THERAPY Digoxin in conjunction with diuretics X
Chronic Steroid Treatment X x X
Immunosuppressive Therapy X All Total Joints: □- Urine C &C □ MRSA/MSSA Nasal Swab□Type & Screen/ Blood Consent □ Type & Cross match / Blood Consent _____units Additional Testing: ____________________________________________________________________________________________Day of Surgery / Procedure Orders as follows: □ NPO □ SCD/ Flowtrons □ Prep and clip Area _________________________________________________________________
Anesthesia Pre-Admission Testing Requirements
Operating Room Protocol Changes
Removal of skull caps Pre-operative antibiotic selection (weight based) and re-dosing protocols
◦ Anesthesia re-dosing when appropriate
◦ Resistance pattern reviewed for E.Coli and added to re-dosing form
◦ Recommended Adult Re-dosing Forms laminated and on all anesthesia Pyxis machines
Use of alcohol based prep only
◦ CHG or Prevail (betadine with alcohol)
◦ Betadine to be used only for surgeries involving exposure to mucous membranes
Implement DEBRIEFING after every surgery to include
Wound Classification and Foley Catheter Increased monitoring of personal belongings into the OR Increased monitoring of everyone with regards to changing of scrubs from
outside
RECOMMENDED ADULT REDOSING INTERVALS FOR ANTIBIOTICS COMMONLY USED FOR
SURGICAL PROPHYLAXIS
RECOMMENDED REDOSING INTERVAL (FROM INITIATION OF PREOPERATIVE DOSE)
ANTIBIOTIC & USUAL DOSING
2 Hours Ampicillin/Sulbactam (Unasyn) 3grams Ampicillin 1-2grams
Piperacillin/Tazobactam (Zosyn) 3.375grams
4 Hours Aztreonam 1-2grams Cefazolin 1-2grams
6 Hours Clindamycin 600-900mg Cefotetan 1-2grams
8 Hours Gentamicin Metronidazole 500mg
NO REDOSING Ceftriaxone 1-2grams Ertapenem 1gram
Levofloxacin 500mg Vancomycin 1gram
Antimicrobial Dosing Pearls
As a general rule, redosing is recommended when surgery duration extends beyond 2 half-lives of any antibiotic given If more than one antibiotic is required for the procedure, determine redosing schedule for each individual antibiotic
o For example if a surgery lasts 5 hours and the patient received Cefazolin and Gentamicin, another dose of Cefazolin should be administered at the 4-hour mark. A second dose of Gentamicin would only be required if the surgery extended beyond 8 hours.
2014 Sensitivity 2013 Sensitivity 2012 Sensitivity E.coli Klebsiella E.coli Klebsiella E.coli Klebsiella Ampicillin 48% 0% 50% 0% 47% 0% Piperacillin/Tazobactam 95% 85% Not Done Not Done 96% 82% Levofloxacin 61% 85% 71% 97% 75% 82%
New Committee – September 2014 Surgical Services Executive Committee
◦ Chair Department of Surgery
◦ Vice Chair Department of Surgery
◦ Chair Department of Urology
◦ Chair Department of OB/GYN
◦ Chair Department of Orthopedics
◦ Chair Department of Anesthesia
◦ Member Department of Surgery
◦ Member Department of Surgery
◦ Administrative Director of Perioperative Services
◦ Director Epidemiology/Infection Control
Team meets monthly to review protocol changes and provide support for implementation processes.
Others invited as needed. Example: Chair of Infection Control invited several times to assist in antibiotic protocols.
NEXT STEPS
Continue to develop a “Just Culture” Continue to monitor:
◦ Changing of gloves and gown at closure with regards to colon surgery
◦ Antibiotics choice, re-dosing & sensitivities
◦ Debriefings being conducted
◦ Correct wound classification
◦ Foley catheter usage Post-operative management
◦ Where is patient discharge to
◦ Dressing changes Surgical Services Executive Committee looking at need for A1c on select patients Mandate all elective surgery patients are interviewed and screened by PAT 48 hours
before surgery. To include chart completion with regards to H&P’s. Surgical Services Executive Committee to develop colon bundle Clipping of patient outside the OR suite – implementation by end 2014.
◦ Clipper Vac trial to begin 10/20/2014 Early Recover Protocol
Part of the program is to adopt a logo foryour safety program – this is our logo – A SAFESURGICALJOURNEY
BOSTON MEDICAL CENTER TEAM EXPERIENCESPamela Rosenkranz, RN, BSN, M.Ed, Sherry Prasad, and Donna Amado, MSN, RN, CNOR Mohammad Eslami, MD
Boston Medical Center500 beds in an urban, safety net, and academic medical centerOur SUSP team consists of surgeons, anesthesiologists, nurse
managers, nurse educators, infection control leaders, senior VP, and the dedicated vascular team (circulating nurses, scrub techs).
Boston Medical Center• The Vascular SUSP team was assembled in February 2013
to implement “crew resource management.”• SUSP was implemented in April 2014• We have completed HSOPS and used feedback to build our bundle.• Technical work is reflected in our action plan.• Adaptive work consists of more open communication and
encouraging team members to not only present problems at team meeting but also in real-time.
• Challenges consist of interdisciplinary hurdles and problems in the vascular flow process outside the intra-op realm.
Boston Medical Center
We are working on:
1. Improve communication between team members.
2. Investigate peri-operative processing and hand-offs in between hospital unit.
3. Evaluate OR traffic by reducing activity in the OR.
4. Create dedicated ORs for Vascular Surgery to standardize the environment.
5. Create a Vascular Surgery Debriefing Form (our bundle).
Boston Medical Center
What we hope to focus on in the future:
1. Determine the state of safety culture.
2. Implement an ideal vascular process flow.
3. Evaluate effectiveness of patient safety with feedback.
4. Improve patient education practices to better prepare them before and after surgery.
5. Focus on the PACU to in-patient to discharge processes.
Boston Medical Center
Questions for other teams:
• How have you addressed excessive traffic in the OR?
• While most of the other teams are colorectal, we focus on vascular. How do other teams approach complex cases with co-morbidities and how do they standardize the care post-op to discharge and beyond?
Sheri Fields RN OR Nurse Manager
Ty Cobb Regional Medical Center
Hospital Team Experience
Ty Cobb Regional Medical Center56 bed rural hospital in Northeast
GeorgiaServing a community of more than
50,000 residents in Franklin and surrounding counties
New facility opened in July 2012 as a result of combining 2 small outdated facilities
Around 200 cases per month, a little over 5% are colorectal surgeries
SUSP Team FormationDiverse mixture of frontline staff,
physicians and managersCommitted employees
Our Team
Sheri Fields RN - OR NM and Team Project Manager
Rosemary Gray - Infection Control Preventionist
Myra Howell RN - OR ANM Dr. Richard White - Surgeon Jeremy Corbett RN - OP SurgerySharon Voyles CST- Scrub TechDonna Toney - PharmacistDon Ruch CRNATina Thomas RN - Quality DirectorEvelyn Murphy CCO – Hospital Executive
SUSP PlanRealistic planEvaluated what we were doing
nowImplement ways to improveScience of Patient Safety Video
and completed the Perioperative Staff Safety Assessment
Initial HSOPS – Problems Identified
Valuable insight even with decreased response rate
Staff feel that the OR team works well together
They feel that the manager takes safety seriously
Cooperation between hospital units could be improved
Before SUSP:CHG ShowerSCIP recommendationsOral antibiotics with bowel prepHand hygienePatient educationSafe Surgery ChecklistIntra operative warming of
patients
What we’ve added so far…Pre-warmingCHG clothsRe-dosing antibioticsSeparate closing instruments Change of gloves/gownsInfection Prevention Pamphlet
ChallengesSmall number of colorectal casesTimeStaff changes/challenges
SuccessesOR staff buy-inOther departments supportiveChanges well accepted
Next steps
Develop audit toolContinued educationContinued improvement on SCIP
complianceIncentives for staff compliance
Questions??
Contact
Sheri Fields, OR Manager
Rosemary Gray, Infection Preventionist
