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Join SUSP Affinity Groups! Learn from experts and other SUSP hospital teams who are working on what you’re working on . Click this link SUSP Affinity Group Registration Link to register for an affinity group by Tuesday, May 20 th ! . Hospital Team Experiences. Noble Hospital - PowerPoint PPT Presentation
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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!
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
Palmetto Health Baptist
Palmetto Health Baptist
• 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
Palmetto Health Baptist
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
Palmetto Health Baptist
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
Palmetto Health Baptist
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
Palmetto Health Baptist
THIS MONTH’S FOCUS:
Palmetto Health Baptist
• 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
Palmetto Health Baptist
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
Palmetto Health Baptist
• 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
Palmetto Health Baptist
• 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
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!