Effect of Colon Bundle Implementation in a Community Hospital. Michael Barringer, MD, FACS CHS Cleveland

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1 Effect of Colon Bundle Implementation in a Community Hospital Michael Barringer, MD, FACS CHS Cleveland

2 Doug Hobson, MD, Surgeon Champion Mike Barringer, MD, Surgeon Champion No Disclosures Except for a Great Team Charles Tomlinson, MD, CMO, Administrative Sponsor Cindy Proctor, BSN MBA CPHQ, Director Performance Improvement, Facilitator Brian Hudson, MT(ASCP) CIC, Infection Preventionist, Team Lead Carolyn Talley, RN, NSQIP Data Coordinator Tammy Tysinger, RN, OR Assistant Manager Michelle Suits, RN, Outpatient Surgery/Recovery Michelle Newsome, RN, Surgical Unit Ashley McCurry, RN, Surgical Unit/ICU Lori Shires, RN, Surgical Unit Assistant Manager, Clinical Educator Angie McCraw, RN, Assistant Manager Wound Center Lynne Bivens, RN, Surgical Unit Case Manager

3 CHS Cleveland Rural community hospital serving approximately 100,000 people 5 General Surgeons 100 colon procedures per year 50% of cases elective

4 The Beginning Identification of higher than expected Colon SSI s on initial Small and Rural NSQIP report Focus on Colon Surgeries as an initial overall strategy to reduce all surgical site infections Desire to decrease length of stay and hopefully costs

5 Process PDSA Patient Mapping and Identification of Key Drivers Accumulate catalog of Best Practices from NSQIP and other publications Meeting of all Surgeon Stakeholders and choose catalog elements by consensus Develop electronic Colon Bundle order set and Colon Surgery Bundle check list for patients and all healthcare providers involved Implement and monitor process

6 Key Driver Diagrams Aim: Reduce Surgical Site Infections (Colon; Total Hip Replacement; Total Knee Replacement; Hysterectomy) by 40% during 2014 (as compared to 2013 baseline data) per NHSN definitions (deep and organ space infections). Outcomes Reduce SSI Surgical Site Infection Reduction Primary Key Drivers Standardized Pre-Op Care Secondary Key Drivers Appropriate Preop Bathing Preop Screening/ Clearance (concurrent infections/ comorbities) Surgical Prep Changes to Test/ Interventions Two CHG baths/one CHG Wipe prior to surgery; Clean Sheets Monitor SSI concurrent infection/comorbidity data Research MRSA Screening Best Practice (Nares Only) Research Bowel Prep Best Practice Skin Prep Standardization per manufacturer recommendation Effective Infection Prevention Aseptic Technique Appropriate OR Attire Instrument Sterilization OR Room Cleaning OR Traffic Scrub Best Practice Hand Hygiene Observation Massimo Manufacturer Guidelines Glove Assessment Research OR Attire Best Practice (Masks, Caps, Scrubs) Sterilization Process Best Practice Assessment Implement AORN recommendations in comparison with Aramark definitions Baseline OR Traffic

7 Key Driver Diagrams Surgical Site Infection Reduction Aim: Reduce Surgical Site Infections (Colon; Total Hip Replacement; Total Knee Replacement; Hysterectomy) by 40% during 2014 (as compared to 2013 baseline data) per NHSN definitions (deep and organ space infections). Outcomes Primary Key Drivers Secondary Key Drivers Appropriate Drain Care Changes to Test/ Interventions Complete Gap Analysis of current practice vs. Best Practice Reduce SSI Evidence Based Care Wound Care Evaluate use of wound protectors and wound closure technique Standardization of postoperative wound care (review best practice; poll surgeons on current practice through Survey Monkey) Core Body Temp Develop Forced Air Warmer policy (Pre & Intra procedure) Preop Abx Develop Antibiotic Redose Guidelines Surgeon Best Practice 2 tray set up Implement 2-table set up for all colon surgeries Glucose Management Pre, intra and postoperative Glucose Management

8 Key Driver Diagrams Surgical Site Infection Reduction Aim: Reduce Surgical Site Infections (Colon; Total Hip Replacement; Total Knee Replacement; Hysterectomy) by 40% during 2014 (as compared to 2013 baseline data) per NHSN definitions (deep and organ space infections). Outcomes Primary Key Drivers Secondary Key Drivers Changes to Test/ Interventions Patient/Family Education Disposition Plan Develop standardized education; (begin preoperatively; incorporate technology such as video; include smoking cessation) Interactive staff education Reduce SSI Appropriate Discharge Planning Standardize Hospital, Home Health, Rehab & Long Term Care education Appropriate Dressing Availability Determine availability of supplies at home Follow-Up Appt Review SSI to determine correlation between f/u appt and timing of SSI Orders for & Collection of Wound Cultures Work with providers (HHC, LTC, Rehab, ED physicians) to call surgeon for culture process

9 Multiphase Powerplan

10 Colon Surgery Bundle You had been scheduled for a colon resection and it is very important for you to understand our responsibilities and your role in the process of getting you ready for surgery, what you should expect while in the hospital aa well as what to do when you return home. Please keep this paper with you before, during and after your surgery. Check the box when a step is completed,. If one of your healthcare providers completes the step they will check it for you. Before surgery at home We will teach you about your expected experience before surgery in the doctor's office and at your preoperative visit and during your time in the hospital. It is important for you to be an active part of your recovery. Bowel Cleansing- instructions will be given to you in the physician's office. Cleaning out your intestinal tract prior to your operation is necessary to reduce your chances of infection. Antibiotics - you will be given a prescription for 2 antibiotics to take by mouth to reduce your chances of infection. Will take them 2 times the day before your surgery. You will be given instructions on when to take them. Breathing Exercise Device-you will be given a device to help you practice breathing deeply (incentive spirometer) and instructed in how to use it at your preoperative visit. Practice prior to coming into the hospital and bring it back with you when you return. While in the hospital you will need to use it hourly and told to use it when you return home. Breathing deeply reduces your chances of developing lung problems such as pneumonia after surgery. Skin Cleansing- you will receive Chlorhexidine soap to use to take a shower or bath the night before and morning of surgery. Smoking - if you are a smoker, we strongly encourage you to stop prior to surgery to reduce your chances of having problems with your lungs during your recovery. Morning of Surgery at the Hospital Skin Cleansing- on the morning of surgery the nurses will use Chlorhexidine Wipes to further cleanse the skin and help reduce your chances of infection. Antibiotics - in addition to the antibiotics you took by mouth we will give you intravenous antibiotics just prior to your surgery to further reduce your chances of infection. Leg Pumps- while you are getting ready to go to sleep, pumps are placed on both legs to compress your calves to decrease your chances of getting clots in your legs. These will be worn after surgery as well. Heparin - prior to your surgery you will receive an injection underneath your skin. This medication will help prevent blood clots during and after surgery. After Surgery Oxygen - you will receive oxygen for at least the first 24 hours after your surgery to help with your breathing and healing. Leg Pumps-the pumps placed on your calves to decrease your chances of getting clots will be worn after surgery as well while you are in bed but can be removed at any time to allow you to get up and walk. Lovenox- is a longer acting blood thinner used after surgery to help prevent blood clots. You will receive an injection of it daily unless your doctor feels it is not necessary. Chewing Gum- you will be encouraged to chew gum at least 4 times a day to increase your intestines activity. Diet - you will be encouraged to start taking liquids the evening after your surgery. Do not feel like this is something you have to do if you have any nausea or are uncomfortable taking anything by mouth. Activity-it will be very important for you to begin moving around and increasing your activity level to for you to have a speedy recovery. We will get you out of bed the evening after surgery and up and walking at least 3 times a day. If you need pain medication to make this easier to do, we will give it to you. Wound Dressing- you will have your dressing removed on the second day after surgery The wound may be left open or a lighter dressing reapplied if needed for your comfort. Skin Cleansing- following the removal of your wound dressing we will assist you in cleansing the incision with chlorhexidine when you bathe daily. Pathology Report- your surgeon will give you the results of her pathology report as soon as it is available. At times the report may not be complete prior to your discharge from the hospital and will be given to you in the doctor s office. Day of Discharge and Follow-up Education - you will be given instructions on how to take care of your wound and how to recognize any signs of infection. You will also be given instructions on your activity level and diet. Skin Cleansing-you will be given additional chlorhexidine soap for daily wound and body washing if you do not have enough left from that you received prior to surgery. Surgeon Follow-up- you will be given an appointment to be seen in your surgeon s office within 4 days of your discharge from the hospital so that your wound may be checked. You are to call sooner if you have any questions or concerns. Primary Care Doctor Follow-up - if your surgeon feels it is appropriate, you may receive an appointment to see your primary care physician within 7 days of discharge. Follow-up Phone Call-you will receive a phone call within a few days after you leave. A nurse at the hospital will call to make sure you are doing well and see if you have any concerns. Smoking - if you are a smoker, we strongly encourage you to continue to not smoke to reduce your chances of having problems with your lungs during your recovery and to improve your overall health.

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14 1. Getting started Tips for Others Utilize NSQIP data to identify area and delve deeper into data Focus on quality and outcomes and their new emerging role in the payment process to incentivize participation Utilize best practices studies to develop doable plan 2. How to sustain Concurrent monitoring with group and individual feedback as directed by the Surgeon Champion and Infection Control officer. Meetings as necessary to address identified barriers created by system process changes. Be transparent with successes as well as failures and especially include physician-focused feedback

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