TN SCIP Participant Group Best Practices Sharing

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TN SCIP Participant GroupBest Practices
Sharing

• Infection-1 Prophylactic Antibiotic Received
  Within One Hour Prior to Surgical Incision
• Johnson City Medical Center

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Hospital Characteristics

• Located in Upper East Tennessee in Johnson City,
  a 443 bed not-for-profit, acute-care teaching
  facility with a Level I Trauma Center
• Average daily census is 437
• Annual Volume of surgery is 4916

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Hospital Characteristics

• Perform orthopedic, vascular, cardiothoracic,
  neurological, general, gynecological,
  laparoscopic, laser, urological, pediatric,
  plastic, ear, nose and throat and transplant
  surgeries
• SCIP Team composition consists of Pharmacist,
  Clinical Integration RN, Med/Surgical nurses and
  leaders, CVICU nurse leader, SDS, PACU and OR
  nurses

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Infection-1 QI JourneyHeres How We

• The Opportunity for Improvement was identified
  during the Surgical Infection Prevention project
• Members from all departments involved formed a
  committee where they mapped out various places in
  hospital the patient came from to OR.
• Initial committee involved Medical Director,
  Holding nurses and manager, surgeons,
  anesthesiologists, OR nurses and infection
  control department. Each area went to own
  department and educated their team on the changes

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Infection-1 QI JourneyHeres How We

• Small tests were done and determined many delays
  occurred before patient entered the OR so the
  Holding nurse started Antibiotic as patient left
  holding area to OR.
• Challenges included waiting to receive ABX from
  the Satellite Pharmacy. A medication
  refrigerator was purchased for holding area to
  keep ABX. Needed buy-in from OR circulators to
  recognize need to re-dose where appropriate.

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Infection-1 QI JourneyHeres How We

• We have concurrent abstractors who look at
  records and reports are abstracted post-discharge
  then posted on organizations webpage for anyone
  with access to our email system to view

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Lessons Learned / Successes

• Perseverance
• Lots of education
• Buy-in from all departments involved
• Tied performance into annual incentive

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TN SCIP Participant GroupBest Practices
Sharing

• Infection-3 Prophylactic Antibiotics
  Discontinued within 24 hours after Surgery End
  Time
• Williamson Medical Center

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Hospital Characteristics

• Location Williamson Medical Center
• Franklin, Tennessee
• Average daily census 86
• Volume of surgery 500/month
• Types of surgery All services with the
  exception of Cardiac and Neuro
• SCIP Team composition CNOs, Quality and
  Perioperative Depts

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Infection-3 QI JourneyHeres How We

• Identified our opportunity for improvement
  Chart Reviews
• We brought in the Chief of Staff to help with
  Physician buy in. With his help it was
  relatively easy to get surgeons to realize that
  they needed to begin D/C of ATB at 24hours.
• Implemented our interventions Surgeons began
  changing orders and we began the process. We
  still were having some charts come back beyond 24
  hours.
• Identified / overcame our challenges Upon
  review we realized that there was confusion on
  number of doses. The surgeons were including
  the dose given at time of surgery as 1 of the 4
  doses. Pharmacy read the orders as the patient
  needed 4 additional doses. Overcame this by
  changing the orders to only 3 doses and have had
  great success.
• Monitored our ongoing performance Continually
  monitor with chart reviews and still find issues,
  but not with the surgeons. It is usually as
  simple as a dose being given a few minutes late,
  which puts us over the 24 hour cut off.

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Lessons Learned / Successes

• Lessons Learned When preparing for this we
  realized we did not do anything elaborate to make
  this happen but our CNO was instrumental to have
  the buy in of our Chief of Staff. He is well
  respected with the physicians and they listen to
  him. The best advice is to have a physician
  champion.

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TN SCIP Participant GroupBest Practices
Sharing

• Infection-7 Colon Surgery Patients with
  Immediate Postoperative Normothermia
• Gateway Medical Center

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Hospital Characteristics

• Clarksville, TN
• Average daily census is 110
• Volume of surgery
• Types of surgery
• Joy Wilson, Dana Sandefur, Vickie Duncan

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Infection-7 QI JourneyHeres How We

• Identified we had room for improvement early
• Inconsistency of device used to obtain
  temperature, Low room temps in OR, and pt. temps
  on arrival to facility were low.
• Addressed issue with Head of the Department of
  Surgery who is the lead anesthesiologist and PACU
  staff
• Ordered new temporal thermometers for both areas,
  and educated all involved in process, adjusted OR
  room temps, placed bair huggers on patients
  immediately on arrival to the preop area.
• There were no additional challenges
• Monitored our ongoing performance

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Lessons Learned / Successes

• People want to do the right thing, however we
  must provide them with the tools and information
  to help them succeed.

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TN SCIP Participant GroupBest Practices
Sharing

• Infection-7 Colon Surgery Patients with
  Immediate Postoperative Normothermia
• Middle Tennessee Medical Center

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Hospital Characteristics

• Middle Tennessee Medical Center is a 286-bed
  private, not-for-profit hospital located in
  Murfreesboro, Tennessee. MTMC is a member of
  Saint Thomas Health Services and Ascension
  Health. Established in 1927, MTMC has been
  serving the health care needs of Middle
  Tennesseans from Rutherford, Cannon, Coffee,
  Warren, and DeKalb counties for 75 years.
• Average daily census of 190
• During April 2007 a total of 609 inpatient
  surgeries were performed
• With the exception of cardiovascular we perform
  all surgeries
• Our team is known by the name Higher Ground, it
  includes surgeon representation from each of the
  sub-specialties, patient care services,
  anesthesia as well as quality and administration

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Infection-7 QI JourneyHeres How We

• The Higher Ground Team was established initially
  to work on 0730 start starts and OR room
  turnover. Rather than establish a second team
  SCIP results are brought to this group prior to
  going out to Medical Staff meetings. The team
  prioritizes the actionable items.
• The current process for maintaining normothermia
  in patients undergoing colon surgery was
  flowcharted. This was compared to what was
  recommended by professional organizations. A gap
  analysis identified where to focus our efforts.
• It was decided to use a warming blanket with the
  Bair Hugger utilize esophageal temperature
  monitors as well as a forehead temperature strip
  and to maintain a room temperature of 68 degrees.
  
• The General Surgery Team Leader and the General
  Surgeons agreed and the changes were put into
  place.
• For this particular standard we have met any
  resistance. This monitored on a case by case
  basis.

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Lessons Learned / Successes

• Utilizing a current team that understood the
  process was helpful and time-saving.
• Understanding the current process and knowing the
  gaps helped to keep everyone focused.
• Keeping the data in front of everyone was a key
  to success.

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TN SCIP Participant GroupBest Practices
Sharing

• Card-2 Patients on Beta Blocker Therapy Prior to
  Admission Who Received a Beta Blocker
  Perioperatively
• St. Francis Hospital

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Hospital Characteristics

• Memphis, Tennessee
• 400 Average daily census
• 10,500 Surgery cases/year
• General, Ortho, Neuro, Cardiac, Ophth, ENT,
  Plastics, Bariatrics, Urology, Podiatry
• SCIP Team composition
• CNO CMO
• Director, Surgery Advanced Practice Nurse
• Pharm- D Anesthesiologist
• Nurse Managers Infection Control
• Quality Management Cardiac Surgeon

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Card-2 QI JourneyOur Process at SFH

• A BB monitor/reminder sheet is placed on all
  inpatient units and the Same Day Surgery unit. It
  lists all BB utilized at SFH for the purpose of
  prompting physicians nurses.
• Same Day Surgery Nurses review patients charts
  for medications to determine if they are on BB
• If they are and the patient has not taken the BB,
  the patient will receive the BB in Preop Holding
• Inpatient unit nurses review charts for surgery
  patients on BB. If on BB the patient will take BB
  with a sip of water..
• Ongoing performance is monitored via SCIP data.

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Results

• 100 for CABG Patients for April May
• 1st Quarter, 2007, SCIP result was 88.1

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TN SCIP Participant GroupBest Practices
Sharing

• Card-2 Patients on Beta Blocker Therapy Prior to
  Admission Who Received a Beta Blocker
  Perioperatively
• Williamson Medical Center

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Hospital Characteristics

• Location Williamson Medical Center
• Franklin, Tennessee
• Average daily census 86
• Volume of surgery 500/month
• Types of surgery All services with the
  exception of Cardiac and Neuro
• SCIP Team composition CNOs, Quality, PAT,
  Perioperative, and Anesthesia Depts

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Card-2 QI JourneyHeres How We

• Identified our opportunity for improvement
  Based upon the measure and discussing with
  Anesthesia Chief our need to investigate.
• Investigated the root causes Determined through
  meeting with Surgery Committee that this is not
  something the surgeons were willing or
  comfortable to manage.
• Engaged leadership / physicians / front line
  staff Our CNO engaged the Chief of Anesthesia
  for help. It was determined the best way to
  capture these patients would be at their PAT
  appointment. Anesthesia would document the
  patients on Beta- Blockers on their record. On
  the 2nd interview at the time of surgery we would
  verify that those patients had taken their
  Beta-Blocker or if they had not give it to them
  in the Periop- Holding Area prior to surgery.
• Implemented our interventions Changed
  Anesthesia History Sheet so that we could
  document beta-blocker therapy
• Identified / overcame our challenges Smooth
  transition and Anesthesia interviews every
  patient immediately prior to surgery, so we have
  had good success.

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TN SCIP Participant GroupBest Practices
Sharing

• VTE-12 Prophylaxis Ordered Prophylaxis Given
  Within 24 hours Prior to Surgery to 24 hours
  After Surgery
• UT Medical Center

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Hospital Characteristics

• 1924 Alcoa Highway, Knoxville, Tn. 37920
• Average daily census - 349
• Volume of surgery 1379/Month
• Level 1 Trauma Hospital with a wide variety of
  surgeries including the specialties of the Heart
  Lung Vascular Institute and Stroke Center.
• Our SCIP team is composed of Physicians, a
  Service Line VP, Pharmacist, RNs and P.I. Staff.

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VTE-12 QI Journey

• Historically UT had a DVT PI team that focused on
  prevention of DVT/PE for all admissions.
• This team accomplished implementing a new order
  set for DVT prophylaxis and recognition
  throughout the organization of the need for DVT
  prophylaxis.
• Literature review, comparison of our rates to
  AHRQ PSI 12 rate and extensive data mining
  demonstrated that there still existed an
  opportunity for improvement in our post operative
  DVT rates.

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VTE-12 QI Journey

• The SCIP team began in July 2006. This team was
  based upon the guidelines of CMS.
• The new team membership includes staff level RNs.
• A major education campaign for physicians began
  with presentations being emailed to the program
  directors of the departments.
• Reminders were placed on physicians computer
  screens when they signed into the patients
  system.
• Emails were sent out to all physicians, nurse
  managers and unit secretaries about DVT
  importance and the order sheets that were
  available to aid them in their decision-making.
• Concurrently team meetings were taking place to
  identify obstacles and/or areas that could be
  improved.
• A presentation was made to the Nursing
  Leadership committee.

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VTE-12 QI Journey

• A pilot was initiated in the recovery room to
  encourage better utilization of our DVT orders
  post operatively.
• Buy in has been slow with staff and physicians
  due to new change in practice.
• The PI team has had to launch a large amount of
  education in order to demonstrate the validity of
  this new measure.

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Lessons Learned / Successes

• Data demonstrates that we also need to focus on
  AHRQ data along with the core measures.
• Data is best analyzed monthly to monitor and
  identify new areas of interest and/or education.
• Due to barriers of increased hospital volumes and
  limited staff nurse availability the team is
  structured utilizing rapid cycle PDSA to support
  quicker outcome results.
• This is an ongoing process that never ends.

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Lessons Learned / Successes

• Change is somewhat painful and slow.
• When making change throughout a large institution
  it is like trying to turn a very large vessel at
  sea. It takes time and patience.
• The best success that we can experience is
  knowing that we are providing better care for our
  patients.

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