AND SO THE JOURNEY BEGAN

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AND SO THE JOURNEY BEGAN

• THE GREATEST OBSTACLE TO
  EVERY
  JOURNEY HAS BEEN TAKING
• THE FIRST
  STEP..

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Mr Mark Taylor

• Consultant Surgeon
• Mater Hospital Site

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Presentation Overview

• Introduction To Peri-operative Safety
  
• The Model For Improvement
• The Change Cycle
• Peri-Operative Bundle
• Barriers / Successes
• Questions

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Aims

• A Brief Introduction to Patient Safety
• Identify the Knowledge, Skills Tools necessary
  to move forward
• To Highlight the Support Available

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Background

• Gap between best practice and actual clinical
  care is a consistent finding
• Clinicians are crucial to the quality of
  healthcare and engaging clinicians is a major
  leverage point in the drive to improve healthcare
• To date such engagement is insufficient across
  all countries and health systems

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Serious Events in Average Hospital350 beds with
13,600 admissions 5,400 surgeries
Source Advisory Board Company Analysis
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Surgical Site Infections Impact on Organisation /
Patient

• Mortality ?
• Re-admission ?
• Length of stay ?
  
  The CDC estimates an average of
  12 days
• Morbidity ?
• Cost for Trusts ?

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S. S. I. INTERVENTIONS

• Appropriate Use Of Antibiotics
• Appropriate Hair Removal
• Postoperative Glucose Control
  
  (Major Cardiac Surgery Patients Cared For
  In An ICU)
• Postoperative Normothermia
  (Colorectal
  Surgery Patients)
• These Components Of Care Are Supported By
  Clinical Trials And Experimental Evidence In The
  Specified Populations They May Prove Valuable
  For Other Surgical Patients As Well.

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• Common Sense Science
• Not all surgery is the same.
• Not all infections are the same.
• Certain surgeries need certain antibiotics to
  prevent infection.
• Antibiotics should be present in the tissue at
  the time of incision and throughout time the
  wound is open.
• A certain amount of antibiotic is required in
  order to be effective

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CHANGES IN PRACTICE

• Design protocols based on surgery type
• Initiate protocol as a standard
• Nursing and/or pharmacy drives protocol
• No reliance on individual physician memory
• Include guidance for exceptions
• Beta Lactam allergy
• Use your own formulary to narrow choices
• Makes protocol easier and saves costs

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SUMMARY

• Reduce Adverse Events Improve Patient Safety In
  Surgery
• Impact of S.S.I. on Patients Organisation
• What To Improve
• How To Improve

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Model for Improvement

• HOW TO IMPROVE
• Form The Team
• Set The Aims
• Establish The Measures
• Select The Changes
• Test The Changes
• Implement The Changes
• Spread The Changes

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The Change Cycle
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Repeated Use of the PDSA Cycle
Changes That Result in Improvement
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
A
P
What change can we make that
S
D
will result in improvement?
DATA
D
S
Implementation of Change
P
A
A
P
S
Wide-Scale Tests of Change
D
Hunches Theories Ideas
A
P
S
D
Follow-up Tests
Very Small Scale Test
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Model for Improvement

• Plan. List the tasks needed to address changes
  expected. Predict what will
  happen.
• Do. Describe what actually happens when you test
  the change. Test with one doctor on one
  patient
• Study. Describe the measured results and how they
  compare with predictions. Analyse
  results
• Act. Describe what modifications to the plan will
  be made for the next cycle of changes.
• 
  What have you learnt?

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Summary

• Know Your Staff
• Know Who To Pick On First Quick Wins
• Be In This For The Long Term
• Use the expertise of all of the team
• Team Decisions Are Sturdier Than Autocracy
• Celebrate Successes However Small
• Even The Big Rocks Eventually Move In A
  Fast-running Stream!

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BUNDLES

• Individual Elements
• Based On Solid Science
• Emphasis Initially On Process Rather Than Outcome
  
• Eventual End Point Is Outcome Improvement

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Why Use Care Bundles?

• A way of Bridging the gap between research and
  practice in clinical areas
• A method of translating research into practice
• Promotes evidenced-based change
• The bundle of care has a greater effect on the
  positive outcome of the patient (rather than 1
  measure in isolation)
• May reduces differences from unit to unit or even
  from clinician to clinician

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PERI-OPERATIVE BUNDLE

• Antibiotic prophylaxis
  
  
• Normothermia
  
• Glycaemic control
  
• Hair removal
  
• Deep venous thrombosis
  
• Pre-operative safety briefing
  

• 0-60 mins pre k.t.s.
• gt36 ?c peri-operatively
• blood sugars lt11mmols
• with clippers _at_ incision
• treat appropriate to the
  risk assessment
• before starting a cases

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S S I INTERVENTIONS

• Antibiotic Prophylaxis
  
  
  
  
  0-60 Mins Pre
  K.T.S.
  
  
  
• Glycaemic Control
  
  Blood
  Sugars lt11mmols
• Normothermia
  
  gt
  36 ?C Peri-operatively
• Hair Removal
  
  With Clippers _at_ Incision

• treat appropriate to the
  risk assessment

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SSI BUNDLE

• The Use Of Prophylaxis Antibiotic 0 60
  mins kts the appropriate choice of drug and the
  time of delivery
• Bratzler DW, Houck PM, Richard SC at al. Use of
  antimicrobial prophylaxis for major surgery
  baseline results from the National surgical
  Infection.
• The Maintenance Of Glycaemia Control
  Peri-operatively
• Latham R, Lancaster. AD, Courigton JF, Pirolo
  JS, Thomas CS. The association of diabetes and
  glucose control with surgical site infections
  among cardiothoracic surgery patients, Infection
  Control and Hospital epidemiology 22 (10)
  607-12, 2001
• The Maintenance Of Normothermia
  Peri-operatively
• National Association Theatre Nurse Standards and
  Recommendations
• for Safe Peri-Operative Practice 2005
• Hair Removal Time And Method Of Hair Removal
• A.J. Mangram et al, Guideline for Prevention of
  Surgical site infection, (1999)
• Hospital Infection Control Practices Advisory
  Committee

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ANTIBIOTIC PROPHYLAXIS

• Aim
  To Administer 0 - 60
  Mins Pre K.T.S.
• Introduction of Documentation to Record the
  Exact Time of Delivery and KTS
• Introduction of Protocol and Flow Chart
• Standardisation of Processes of Prophylaxis
  Delivery

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ANTIBIOTICPROPHYLAXIS FLOWCHART
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GLUCOSE CONTROL
Aim To Maintain Blood Glucose Levels 6-11 mmols

• 1. Introduction Of A Protocol Flowchart
• 2. Standardisation Of Glucose Monitoring For All
  Diabetic Patients Those Patients With A
  positive Urinalysis
  
  Pre Intra Hrly Post Op

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DIABETICFLOWCHART
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Normothermia

• Aim
• To Maintain Patients Temperature gt 36c
  lt37.5c
• 1.Introduction of Protocol Flowchart for
  monitoring
• 2.Standardisation of Equipment for Monitoring
  Patient temperature.
• 3. Standardisation of Process for Recording
  Patients temperature Pre intra hrly
  post

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NORMOTHERMIA FLOWCHART
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Hair Removal

• Aim
• To remove necessary hair as close to incision
  with clippers
• BURN THE BRIDGES Removed Razors
• 1. Educate Staff re Changes in Practice (Medical
  Nursing)
• 2. Source Clippers, Mitt and Obtain
• 3. Review Patient Information Leaflets and Amend
• 4.Co-ordinate Staff Training in the Use of
  Clippers
• 5. All Ward Staff Notified Not to Remove Hair
  Pre-operatively

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HAIRREMOVALFLOWCHART
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SSI BUNDLE

• Revised current protocols
• Added flowcharts
• Modified theatre documentation
• Written to lead clinician in surgery
• Implemented changes
• Design a staff/patient information sheet

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Process

• Protocols flowcharts in place
• Modified theatre documentation
• Ongoing awareness of documentation
• Monthly reporting of audit to SP5I
• Difficulties documentation compliance
• method of selecting charts

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CHALLENGES

• Staff Commitment
• Leadership
• Meeting the targets
• Additional documentation

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HOW MUCH BY WHEN Some is not a number Soon is
not a time Hope is not a plan
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Measurement

• Baseline audit
• Documentation review
• Development of an Audit tool
• Audit
• Dissemination of results
• Implement changes
• Re-audit

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Top Tips for Learning

• 1. IS OUR PRACTICE
• Research based?
• 2. DO WE HAVE
• Standardised processes
  and equipment ?
• 3. ARE WE
• Following procedural policy
  providing clearly documented
  evidence to support our practice?
  
  

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Top Tips To Keep Process Moving

• Dont Let Staff Forget About The Processes
• Simplify The Processes e.g. Flow Charts where
  possible
• Dont Be Afraid To Nag
• Use Willing Staff For PDSAs
• Dont Worry About The Laggards

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• WHAT WE HAVE LEARNED
• Steal Shamelessly
• Use Tried And Tested
  Methods
• Dont Re- Invent
• The Wheel

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THE BEGINNING

• Where Do We Begin?
• What Do We Know?
• Who Do We Need To Help Us?

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THE MIDDLE

• Staff Engagement
• Recording Mechanisms and Methods
• Protocols Flow Chart
• Trust Policy Changes

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THERES NO END
THERE IS NO END

• JUST CONTINUOUS
• IMPROVEMENTS

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Reporting Mechanisms

• Staff Engagement
• Monthly Meetings
• Monthly Audits
• Extranet
• Timelines
• Conference Calls
• Learning Sets

• Site Visits
• Progress Graphs
• Safety Forum Notice boards
• Updates In Trust News Publications

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QUESTIONS ?
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Peri-operative Support Team
Mrs Linda Cooper Theatre Services ManagerMater
Hospital Belfast 90 80 3303 Linda.Cooper1_at_belfastt
rust.hscni.net
Mr Mark TaylorConsultant Surgeon Mater Hospital
Belfast 90 80 3303 Mark.Taylor_at_belfasttrust.hscni
.net
Noeleen Magee I.P.C.N Lagan Valley Hospital
Lisburn92665141 Ext 2133noeleen.magee_at_setrust.h
scni.net
Sr Ruth Bailie Senior Nurse Manager
Theatres Mater Hospital Belfast 90 80
3300 Ruth.Bailie_at_belfasttrust.hscni.net