DRAFT – final pending AHRQ approval Join SUSP Affinity Groups! Learn from experts and other SUSP...

DRAFT – final pending AHRQ approval

Join SUSP Affinity Groups!Learn from experts and other SUSP hospital teams who are working on what you’re working on

Early recovery protocol (ERP)

Preop care coordination

SCIP measures Environmental management

Pain management, fluid management, postop mobility

Glucose control, bowel prep, oral antibiotics

Antibiotic prophylaxis, normothermia, skin prep

OR traffic, sterile technique, surface contamination

Traci Hedrick, MDUniversity of Virginia

Melanie Morris, MDUniversity of Alabama

Skandan Shanmugan, MDUniversity of Pennsylvania

Mariana PeharJohns Hopkins Hospital

Coaching calls every other month Quarterly Coaching Calls

Click this link SUSP Affinity Group Registration Link to register for an affinity group by Tuesday, May 20th!

https://www.surveymonkey.com/s/SUSP_Affinity_Groups

Hospital Team Experiences

Noble HospitalMolly Carlin MSN, RN

Noble Hospital

93 Bed HospitalNoble Hospital is in a 40,000+

community in Westfield, MAWe provide service to seven

surrounding towns

SUSP Team

• Kristen Kroll CST• Michael Cromwell

CST• Kathie Keleher

CST• Nadya Guseva

CST

• Karen Raymaakers OR RN

• Lida Powell OR RN• Pamela Kislus OR RN• Rhonda Partyka OR

RN• Deb Daniels OR RN

SUSP LeadershipTeam

• Ann Reichert- Director of Risk Management

• Mary Jane Lamb- Infection Control• Dr. Schonholz- Surgeon Champion• Dr. Desai- Chief of Anesthesiology • Kim Samele- Director of Perioperative

Services• Molly Carlin- Perioperative Clinical

Coordinator; SUSP Coordinator

Noble Hospital• Describe how you developed and

implemented your SUSP projectSUSP team formation- Development of

your SUSP plan HSOPS administrationTechnical and adaptive work that you

addressed How and why did you make these choices?

Challenges and successes that you experienced during this process

Noble Hospital SUSP Team Formation

The SUSP leadership team has gone through some transitions. At one month into the SUSP journey we had a change in nursing leadership. The SUSP leadership team was chosen by the previous nursing manager.

Noble Hospital SUSP Team Formation

Being part of the SUSP team has been an open opportunity to all of the staff. The staff has been very excited to come to meetings, bring attention to safety concerns, have a hand in the planning process, gathering data and implementing change.

Noble Hospital HSOPS administration

• 98% completion rate• Excitement

• The SUSP team’s excitement for change has proliferated to the entire staff.

• Reasoning• The SUSP team provided to the staff why

completing the HSOPS survey was important• Encouragement

• They encouraged each other to complete the surveys!

• We have a great staff!!

Noble HospitalTechnical and adaptive work

• Infection Control• Standardization of the cleaning process

• Skin Asepsis• Audit• Review of policy; plans for revision of • Standardization of prep• Purchasing sterile prep tray• Creation of an education module

Noble HospitalTechnical and adaptive work

• Equipment• Safety straps • Sliding stretchers• New Armboards

• Organization• Ordering problems• Unable to find proper equipment in emergency

situations• Safety

• Electrosurgical education module

Noble HospitalSUSP Challenges

• Time!!!!• Surgeon involvement• Anesthesiologist involvement

Noble Hospital Successes

• 98% completion of HSOPS• Growth as a team• Increase in safety

Noble Hospital

• What’s next for your team?• Begin Audit on Normothermia• Antibiotic procedure and policy

Noble Hospital

• How have you obtained physician buy-in?

Questions

Hospital Team Experiences Palmetto Health Baptist

Anne Brittain PhD RT(R)(M)(QM), CPHQPI Project Manager

Palmetto Health Baptist

• Located in the heart of downtown Columbia, SC

• Part of a 5 hospital system

• 489 bed acute care hospital

• 4,000+ physicians, staff and volunteers at PHB alone

• Celebrating 100th anniversary in 2014


• Team Formation- We wanted:– Mixture of peri-op and inpt care staff– Mixture of frontline staff, educators, physicians,

and management– People who are interested and willing to work

• SUSP Plan– Implement The Joint Commission Center for

Transforming Healthcare’s recommendations for reducing colorectal SSI’s with a goal of reducing our colon SSI rate to <5.81/100 cases


Joint Commission Center for Transforming HealthCare recommendations to reduce Colorectal SSI:

1. Pre-Op health optimization2. Pre-Op CHG bathing3. Alcohol based prep agents4. Peri-op patient warming5. Weight-based antibiotic dosing

with redosing after 4 hours6. Entire team changes

gowns/gloves after anastomosis7. Segregation of clean and dirty

instruments during and after anastomosis

8. Ensuring wound classification is correct at end of case


HSOPS Administration– Educated staff prior to

beginning survey process– Daily reports of participation

rates – Resent survey link as many

times as needed– Promised homemade Italian

cookies to all units that had > 60% participation

– Results shared at monthly meeting with staff and physicians

http://butterygoodness.files.wordpress.com/2009/12/dsc_0905.jpg


PSSA Administration– Created a fact sheet

related to science of safety and SUSP

– Did the survey at a monthly staff meeting

– Core group convened to categorize results

– Results shared and discussed with staff at next staff meeting

– Same process followed with physicians

• Back to Basics Campaign– Hand hygiene– OR traffic– Surgical scrub– Sterile Technique– EVS in all areas

• Safe Surgery Checklist• Surgeon engagement

– Monthly update and participation at surgeon led surgical services meeting

– Surgeon drilldown and review of all colorectal SSI


THIS MONTH’S FOCUS:


• Gender (male)• Procedure (open)• Operative Time (>4hr)• ASA (>2)• Emergency? (yes)• Transfusion (yes)• Ostomy (yes)• BMI (>25)• Age (>70)• Smoker (yes)

• Wound class (>clean-contaminated)• Left colon/Rectum (yes)• Diabetic pt pre-op A1c (>8.0)• Peri-Op BG (>200)• Pre-Op Albumin (<3.3)• Pre-Op Steroids (yes)• Cancer pt (yes)• Multiple comorbidities (yes)• Redose abx for case > 4 hrs

(no)

Colon SSI Drilldown


FY13• Colon SSI rate =

7.917/100 cases. • Patients who ended

up with a colon SSI had an average of 5.8 risk factors.

• 5% SSI pts > 9 risk factors

FY14• Colon SSI rate is

5.988/100 cases.• Patients who ended

up with a colon SSI had an average of 7 risk factors.

• 40% SSI pts > 9 risk factors

Equates to a 25% decrease in infection rate with those that get an SSI being at higher risk


• Successes– Implementation of CHG baths pre-op– Setting the same expectations for everyone– Physician engagement in process

• Getting beyond “our patients are sicker” & questioning whether or not it is “really an infection”

– Staff awareness of infections

• Challenges – New hospital opening – New management team in OR– Push back from a few very vocal surgeons – Staff fear


• What’s next for your team?– Regroup once “aftershocks” of new hospital

grand opening die down– Continue with a new focus in our “Back to

Basics” campaign each month– Audits to gauge implementation of the various

TJC Center for Transforming Healthcare recommendations

– Expansion of current SSI drilldown as newly identified factors emerge

Thank you!

Questions?

[email protected]

DRAFT – final pending AHRQ approval

Join SUSP Affinity Groups!Learn from experts and other SUSP hospital teams who are working on what you’re working on

Early recovery protocol (ERP)

Preop care coordination

SCIP measures Environmental management

Pain management, fluid management, postop mobility

Glucose control, bowel prep, oral antibiotics

Antibiotic prophylaxis, normothermia, skin prep

OR traffic, sterile technique, surface contamination

Traci Hedrick, MDUniversity of Virginia

Melanie Morris, MDUniversity of Alabama

Skandan Shanmugan, MDUniversity of Pennsylvania

Mariana PeharJohns Hopkins Hospital

Coaching calls every other month Quarterly Coaching Calls

Click this link SUSP Affinity Group Registration Link to register for an affinity group by Tuesday, May 20th!

https://www.surveymonkey.com/s/SUSP_Affinity_Groups

DRAFT – final pending AHRQ approval Join SUSP Affinity Groups! Learn from experts and other SUSP...

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