PACU GATEKEEPER PROCESSJennifer Allen, MSQSM, RN, CPAN, Kellie M. Kline, BSN, RN, LT,

NC, USN

National Naval Medical Center, Bethesda, Maryland

Background: The Operating Room has an 18 room capacity.

On the average day, 14 rooms are scheduled. The holding

room has a total of nine (9) spaces for preoperative preparation.

Because of this variance in capacity, the Post Anesthesia Care

Unit (PACU) is used for the first case overflow up to a maximum

of five (5) patients. This is complicated with Operation Iraqi

Freedom patients who require isolation precautions until

cleared by cultures and can’t be placed in holding. Objectives:

To develop a standardized process in the preoperative holding

room assignments of patients overflowing into the PACU. Im-

prove compliance with National Patient Safety Goals: Improve

the effectiveness of communication among caregivers; and Re-

duce the risk of health care-associated infections. Process of

Implementation: The Six Sigma DMAIC-R process improve-

ment format was followed during this project. It consists of: De-

fine; Measure; Analysis; Improvement; Control; and Results.

Successful Practice: Success is measured with the preopera-

tive patients being assigned to appropriate spaces for preopera-

tive preparation. Positive Outcomes: Improved

communication; transport staff stops, ask, and receive an as-

signed space; and clarification of Infection Control policies re-

lated to contact and droplet precautions in an open cohorted

space. Implications: An opportunity to improve communica-

tion and patient outcomes.

The views expressed in this abstract are those of the authors

and do not necessarily reflect the official policy or position

of the Department of the Navy, Department of Defense, nor

the U.S. Government.

TEAMWORK BETWEEN PREADMISSION AND DAYSURGERY TO IMPROVE SURGERY ON-TIME STARTMeggie Kwan, RN, BSN, CAPA, Project Leader;

Marianne Pham, RN, CAPA; Belma Miguel, RN, BSN, CAPA;

Lillian Bailey, RN, BSN, CAPA; Susan Lewis, RN, CNOR

St. Luke’s Episcopal Hospital - Houston, Texas

Prior to the implementation of Continuous Improvement pro-

cess in March 2007, the on-time readiness for surgery from

DSC to the OR was 35%. One of the main reasons for the patient

delay and cancellation was the incomplete and noncompliant

charts. There were missing orders, missing H&P and missing

test results, such as EKG or stress test, causing undue stress to

the patients, staff and physicians. In order to improve on-time

readiness for surgery we implemented the 5S/Workplace Organi-

zation (a LEAN Principle) throughout the department. The 5 S/

Workplace Organization refers to sift, sort, sweep, standardize

and sustain. Both departments mapped out the processes, stan-

dards were created, roles and responsibilities were defined, and

continuous improvement became a way of life for everyone. PAT

and DSC along with ancillary departments involved met weekly

to discuss problems and brainstorm on ways to improve the pro-

cess. The staff from both departments aimed at streamlining pro-

cesses improving the quality of care and product. Within 6

weeks of implementation we were able to decrease noncompli-

ant charts to less than 1%. As a result, we improved on-time read-

iness for surgery from DSC to the OR from 35% to 99%.

COMPLIANCE WITH ANTIBIOTIC TIMING PRIORTO SURGERYLillian Bailey, RN, ANM, BSN, CAPA, Project Leader

Meggie Kwan, RN, BSN, CAPA, Belma Miguel, RN, BSN, CAPA

St. Luke’s Episcopal Hospital - Houston, Texas

In partnership with The Surgical Care Improvement Project

(SCIP) we were interested in the reduction of surgical site infec-

tions (SSIs) which account for 40% of all hospital acquired infec-

tions. Research shows that by reducing SSIs, hospitals on the

average could recognize a savings of $3,152 and reduction in ex-

tended length of stay by seven days on each patient that de-

velops an infection. The team saw opportunities to begin

a new process within the neurosurgery and orthopedic ser-

vices. The goals were to improve antibiotic timing compliance

adhering to the SCIP guidelines. A committee was formed con-

sisting of nursing, pharmacy, physicians, and infection control.

Opportunities to improve antibiotic timing were discussed and

a need to reeducate MD and staff were identified. An antibiotic

protocol guideline was developed to guide physicians on what

antibiotic to order and to alert nurses to call MDs if antibiotic is

not ordered. Communication between the OR nurses and the

preoperative nurses played a big role in the right timing of anti-

biotic administration. As a result the antibiotic timing on the

neurosurgery and orthopedic cases is at 100% compliant and

we aim to sustain compliance.

TRAVELLING THE ROAD TO MEDICATIONRECONCILIATIONPresenter: Tanya L. Spiering, BSN, RN, CPAN

Clinical Practice Leader for PeriAnesthesia Services Bayhealth

Medical Center Dover, DE.

Medication reconciliation has continued to be a challenge

among health care organizations. It has been identified as an im-

portant aspect of patient safety by its inclusion among the Joint

Commission’s Patient Safety Goals. Our facility decided to pro-

ceed on the journey to successful medication reconciliation

two years ago by forming a multidisciplinary workgroup. This

group consisted of a Pharmacist and nurses from every specialty

with collaboration from physicians and other clinicians. The

tool that evolved has simplified the process of medication recon-

ciliation significantly and allowed for dissemination of gathered

information at discharge. This has allowed our facility to show

its commitment to the ever changing world of patient safety.

ANNUAL ASPAN CONFERENCE ABSTRACTS e11