ORTHOPEDIC CARE MANAGEMENT MEETING MINUTES DECEMBER 7, 2011 LGH D.R.#3 0730

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1 ORTHOPEDIC CARE MANAGEMENT MEETING MINUTES DECEMBER 7, 2011 LGH D.R.# ATTENDANCE Dr. Cooke, Orthopedic Division Chief Dr. Zartman Dr. Sieger, Chair of Ortho Care Management Molly Lalla Wendy Fitts Dr. Reese, Osteoporosis Cindy Poucel Ashley Graeff, PA Brian Stambaugh Jennifer Costello Stacey Youcis Melody Dillman Guests Dr. Essis, Surgical Director of Ortho Center Dr. Westphal, Assistant Director of Ortho Center Susan Snyder Margi Bowers Donna Straley Ann Horning Dr. Kontra, Infection Specialists Dr. Greene, Infection Specialists MINUTES The minutes from the November 2, 2011 meeting were approved as written. Melody Dillman welcomed our visitors for today s meeting to discuss infection control. INFECTION PRESENTATION & MRSA SCREENING (Dr. Greene & Dr. Kontra) DOH data on Orthopedics showed that we stood out for our total knee infections. Dr. Greene stressed that a plan needs to be developed to reduce these infections Dr. Kontra went over the current infection rate for the total knees Most infections were Staph aureus It was suggested that Mupirocin nasal ointment bid for 5 days pre-operatively Chlorhexadine shower night before and morning of surgery also daily for 5 days if infected

2 Proposal 1. Pilot of all elective total joint procedures at LGH over 12 months 2. Screen patients one week prior to scheduled procedure 3. Screen by PCR for both MRSA and MSSA 4. Treat positive patients with mupirocin x5 days and chlorhexadine showers daily for same 5 days pre-operatively 5. Re-screening post eradication TBD (controversial as eradication Rx highly effective and PCR can detect dead organism DNA) 6. Vancomycin prophylaxis for MRSA positive patients 7. Measure prospective infection rates and track epidemiology vs. historical LGH data 8. Calculate intervention effectiveness and cost savings to LGHealth Initial steps needed Lab instrumentation acquisition (done) Education, infrastructure and protocol development Screen week before PCR method (available in 1 hour) Machine will be up and running by February or March 2012 (for MSSA & MRSA) 7-14 days out (may be done ahead of time) Different things looked at for this data same room, staff, antibiotics, surgeon, etc. per Wendy Fitts. With this there was no common area for the infections. A protocol needs to be developed. Melody Dillman and Susan Snyder will be developing a sheet to follow Visits to homes prior to surgery out of town patients receive phone call prior to admittance Suggestion of developing a task force to set some of the process up 6 months after the new machine is here and in use Dr. Kontra and Dr. Greene will attend this meeting again and share the data they have gathered. Unanimous decision all agreed on this program all joints will be followed for this program NEW MEETING DATE/TIME FOR ORTHOPEDIC CARE MANAGEMENT The new meeting time for this committee will be the second Wednesday of each month from in Stager 2. This will begin in January 11, COMPUTERIZED PHYSICIAN ORDER ENTRY: PRE OP KNEE REPLACEMENT ORDERS Type & Screen and Type & Crosshatch these are good for 3 days Type & Stamp only when needed Call physicians Melody Dillman will get approval from Dr. Zartman and Dr. Sieger for the orders. A meeting will be set up with Dr. Bator from Pathology, Brian Stambaugh and Barb A. Miller from the Lab, Dr. Sieger, Melody Dillman, Dr. Yelcick, Donna Straley and other OR personnel to discuss allowing more time for getting tests completed.

3 The last item on the agenda, Aromatherapy will be tabled until the next meeting, which is scheduled for January 11, 2012 in Stager 2 from The meeting dates for 2012 will be the second Wednesday of each month from in Stager 2. Meeting adjourned at Recorded by Pamela A. Rineer, Executive Secretary

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6 [Type text] ORTHOPEDIC CARE MANAGEMENT TEAM DATE: April 11, 2012 TIME: AM PLACE: D.R. 2 Attendance: Refer to roster TOPIC DISCUSSION ACTION/FOLLOW-UP APPROVAL OF MINUTES Dr. Sieger called the meeting to order. Minutes were reviewed and approved as written. The minutes were approved as written. TOPIC : Welcome of Guests Update: Staphylococcus Aureus Screening & Treatment, Antibiotic selection for MRSA positive result Antibiotic selection for Joint Replacement Surgery Beta Lactam Allergy Guests with us today are: -Deb Hess, Infection Control -Dr. Lauter, Hospitalist -Dr. Kontra, Infection Control - Dr. Rockwell, Anesthesia Stacey Youcis reported that both she and Melody Dillman have gone out to the office practices to discuss the screening & treatment. - It will be extra work for the office staff - It will be an extra cost - Offices will work with the Pre Anesthesia Clinic - Order sets will be changed as to the type of medication needed - If result is positive isolation will be needed PAL, Quest and Ephrata are alternate facilities for this screening but Quest and Ephrata do NOT collect specimens. - SIP/SCIP lists Cleocin as antibiotic option if patient has a beta lactam allergy - Cleocin is a static drug not cidal - Cleocin does not have any aerobic gram negative coverage at all; does - PCR will be ready April 19, Start date for pilot is July 1, no retesting on admission - if result is positive, patient will receive weight based ancef & vancomycin - MRSA positive placed in isolation - exploring idea of nurse navigator to centralize efforts for this pilot - identified most commonly used laboratory facilities other than LGH -Spoke with Dr. Greene on this - stay with Vancomycin, which takes 1 hour to run into the system

7 Orthopedic Care Management -2- Meeting Minutes April 11, 2012 TOPIC DISCUSSION ACTION/FOLLOW-UP have good anaerobic coverage but they are not the bacteria we worry about for Ortho Surgery - problem arises when given too soon prior to the procedure - Vancomycin is also static but has numbers that are far better pretty much 100% across the board. - Dr. Zartman suggested calling back to the OR room to check if case is on time - MRSA needs Vancomycin and Anciph so the room would only need to be called for these cases - MSSA do not need to get Vancomycin use Anceph, which needs to be done 1 hour prior to cut - SCIP measures when antibiotic is started Cindy Poucel will check with Wellspan, who is at 100%, to see what they are doing to Multimodal Pain Regimen Xarel discussion Dr. Gutierrez spoke with Dr. Casale and he stated that Dr. Casale said if Celebrex is used short time there should be no problem Dr. Lauter expressed the need to inform all physicians why Celebrex is being used and monitor data from this time forward. Stacey Youcis asked Dr. Lauter to get with HRS physicians on this matter. Need a standardized order set HPS need to get in touch with Dr. Groff concerning patients given Celebrex Fluids need to be drunk up to 2 hours prior to the procedure Dr. Parris has used this drug but has stopped due to bleeds occurring with it. achieve this percentage. The pain management sheet was reviewed. Changes: - Change under post operative medications was Acetaminophen (Tylenol) should be 975 rather than 1 gram - Dilaudid 2mg PO every 4 hours PRN should add Q1 or Q2 Dr. Zartman gives Xarelto 12 to 24 hours after surgery VTE rate before and after need data for this use Blood transfusion new sheet

8 Orthopedic Care Management -3- Meeting Minutes April 11, 2012 TOPIC DISCUSSION ACTION/FOLLOW-UP will be laminated and hung on the Bridge cart for nursing. This will provide information to all *need to check whether need 1 or more laminated sheets to hand This will be re-communicated at the May 2, 2012 Orthopedic Division (the new sheet) Molly will review this sheet at the staff meetings being held. Dr. Zartmen asked that all LABS be kept on the chart until everything is electronic. The rest of today s agenda items will be tabled and moved to May 9, 2012 when this committee meets again. Should be Live in October. DO NOT THROW AWAY ANY LAB ADJOURNMENT The meeting adjourned at 0800 Recorded by: Pamela A. Rineer, Executive Secretary

9 [Type text] ORTHOPEDIC CARE MANAGEMENT TEAM DATE: January 11, 2012 TIME: AM PLACE: Stager #2 Attendance: Refer to roster TOPIC DISCUSSION ACTION/FOLLOW-UP APPROVAL OF MINUTES TOPIC : Welcome of Guests MULTIMODAL PAIN MANAGEMENT: MAXIMUM DOSE OF BUPIVACAINE The meeting was called to order by Dr. David Sieger. Minutes of the December 7, 2011 meeting were then read and approved as written. Dr. David Sieger introduced the Anesthesia Physicians, who were here to discuss Multimodal Pain Management - Dr. Paul Hester, Chief of Anesthesia - Dr. Fernando Gutierrez, Section Chief for Musculoskeletal & Neuroscience services - Dr. Nicholas Rockwell, leads Periop Best practice and care Melody Dillman introduced our other guest, Janice Marlett, RN, who is shadowing Debbie Reich, Education. Melody Dillman went over the data from her presentation on pain management and Dr. Zartman s regiment. Nurses on 4L saw good results from the use of this regiment Medications and dosages were reviewed Our Pharmacy suggests that there is a switch from using Lyrica to Neurontin Anesthesia discussed the shortage of Bupivacaine that is occurring right now along with the maximum dose allowed Dr. Rockwell discussed the regiment of Dr. Zartman, which he suggests should be used for all patients. Every patient should receive TLC = Tylenol, Lyrica & Celebrex along with Spinal Blocks and local injection The minutes were approved as written. Melody Dillman informed the group that she spoke with physicians after the last meeting and the acceptance of using Lavender Oil for Aromatherapy was approved. It was felt that Dr. Zartman has the right idea and some type of regiment should be used for all patients to control pain. Dr. Rockwell attended a seminar on Pain Management and he was kind enough to share the information with this committee.

10 Orthopedic Care Management -2- Meeting Minutes January 11, 2012 UPDATE ON PMR TOPIC DISCUSSION ACTION/FOLLOW-UP Dr. Rockwell will be working with others in developing a policy to follow on this Lanyce Horn added that a new pain management protocol is very close to being completed for use throughout the facility This is a very good starting point but there is a need to build on this PATIENT FEEDBACK CONCERNING ROLE OF COACH, EVENING WALKING PROGRAM, PT/OT INVOLVEMENT WITH COACH too Dr. David Sieger invited Dr. Rockwell, Dr. Hester and Dr. Gutierrez to attend the January 31, 2012 Orthopedic Division Dinner meeting to discuss this issue further. Sheri Edgar, PMR Manager, reported on the progress PMR is having with getting to the patients earlier and using the 4L gym rather than the patient s rooms. Physician must write in progress note, NOT ON A SCRIPT, justification of the following items for home use - Commode - Hospital bed - Wheelchair It was requested that a sticker or some type of notation be put on the chart so there is no need for either the nurse or physician to write every time. Melody Dillman reported that we recently received feedback from patients that their coach was not able to actively participate with hospital routine = evening walking program The Anesthesia physicians will attend the January 31, 2012 Orthopedic Division Dinner meeting By using the 4L gym rather than the patient s bedside, there is a better focused approach to their therapy. The progress note on the 3 mentioned items must come from the physician NOT the physical therapist. Sheri Edgar will go back and check what may be used on the chart and report back to this committee. The group expressed that there was a need to be specific on assessment team decision concerning dialogue between therapy and nursing FALL RATE Melody Dillman shared data concerning falls 1 st quarter there were 2 falls that returned to the operating room 2 nd quarter was much better and so was the 3 rd quarter Dr. Rockwell suggested when looking at data need to look at out of bed time when tracking the falls data

11 Orthopedic Care Management -3- Meeting Minutes January 11, 2012 TOPIC DISCUSSION ACTION/FOLLOW-UP Debbie Reich, from Education, shared the topics that were used from the last 5 years at the Orthopedic conferences. Any suggestions should be ed to Debbie at her LGH ORTHOPEDIC CONFERENCE Debbie would like to have suggestions of topics this group would like address of TOPICS to see used for this year s conference Speakers names 6 presenters for the day conference needed 1 hour sessions Cost for outside people is $150 and our staff members are FREE Need to be open to orthopedic items rather than LG items dareich@lghealth.org MRSA/MSSA SCREENING XARELTO COMPUTERIZED PHYSICIAN ORDERS: HIP REPLACEMENT POST OP Melody Dillman reported that we have our 1 st patient coming in next week that has been screened positive. They are receiving treatment Issue with loading Xarelto has been resolved and it is now OK Should be drawn in PACU INR monitoring with the use of Xarelto A surgeon preference right now Less costly Need pre authorization Serum Creatinine put on orders Post Op Melody Dillman and Susan Snyder, infection control, will take care of the education of MRSA/MSSA screening and notify the offices. It was recommended by Lanyce Horn to take this to the AC Taskforce. Jennifer Costello, Pharmacy, will discuss this at that meeting for use in orthopedics Dr. David Sieger and Melody Dillman will review these order sets and proceed ADJOURNMENT The meeting adjourned at 0755 Recorded by: Pamela A. Rineer, Executive Secretary

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