LANCASTER GENERAL HEALTH

Transcription

1 Lori Abel RN, M.Ed.

2 NO DISCLOSURES

3 Penn Medicine Lancaster General Health LANCASTER GENERAL HEALTH Integrated Health System serving Lancaster Pennsylvania with a regional population ~1 million 631 licensed beds 40 operating rooms 38,340 surgeries annually Joined ACS/NSQIP in October 2013-Multispeciality Option

4 Surgeon Champion Mark Burlingame, MD Administrator Bree Bond CRNA, MSN Surgical Case Reviewers Lori Abel RN, M.Ed. Deborah Mimnall RN, MSN

5 10 Our first SAR July showed pneumonia to be 8 in the 5 th 7 decile - All Case 6 5 Model. First ISAR October 2014 to H10 and the 8 th decile - next three 1 0 SAR/ISAR periods. 5 7/1/2014 SAR PNEUMONIA DECILE RANK ALL CASE MODEL 10 10/1/2014 ISAR 1/1/2015 SAR /1/2015 ISAR 7/1/2015 SAR

6 Identified 3 problem areas within our surgical population: 1. Interpretation of radiological reports 2. Post operative sedation causing increased aspiration risk 3. Inconsistencies in post operative pulmonary care

7 Starting in October 2014 we presented our pneumonia data at various meetings that included key physicians from administration, radiology, anesthesiology and medicine. Nursing, quality leadership, and infection control practitioners were also included Literature review of published guidelines that identified reduction strategies for post-operative pulmonary complications in surgical patients was completed

8 After ongoing education to our surgeons on the validity of the ACS NSQIP data, it was apparent that an aggressive action plan was necessary to address perioperative pneumonia. Our July 2015 SAR confirmed pneumonia to be a significant outlier and justified our actions. Action plans were developed to address the 3 problem areas that were found in the in-depth chart review.

9 Education provided by our Chairman of Radiology to our radiologists on the ACS NSQIP data and findings. This education included pneumonia definitions, consistency of radiology readings/terminology and the recommendations for follow up studies.

10 Anesthesia evaluated the need for consistency of care in PACU regarding: incentive spirometry use, head of bed> 30degrees, and early coughing and deep breathing exercises. Evaluation of new reversal agents of neuromuscular blockage to reduce the incidence of pharyngeal muscle dysfunction and hypoventilation in the immediate post-operative period is ongoing.

11 Our Surgical Clinical Effectiveness Teams (CET) reviewed order sets and recommended the removal of routine sedation orders. This change began in spring of 2015 with the orthopedic order sets and these results are being evaluated by the other clinical teams. Revision of post-operative order sets to reflect the new changes in pulmonary care.

12 Experts in the Quality and Nursing Departments led clinical inservices to staff on the importance of post-operative pulmonary care and the clinical effects of sedation causing increased risk of aspiration. We referenced the ICOUGH program from Boston Medical Center to highlight the importance of the need to redefine our post operative pulmonary care. Key areas included coughing and deep breathing, incentive spirometry(is) instruction preoperative in the holding area, HOB elevation starting in PACU and continuing throughout hospital stay, early mobility and education of patients and families. Revision of nursing documentation of pulmonary care in the electronic medical record (EMR).

13 Developed a standardized respiratory protocol in August 2015 that enhanced the RT role in identifying at risk patients for early intervention. Development and ongoing evaluation of standardized order sets in the EMR to enhance RT role in post-operative pulmonary care.

14 These quality improvement activities began with our Colorectal, Orthopedic and Neurosurgery patient populations and continued to be spread across all surgical services through Ongoing assessment of data led to further education and refining of our action plans.

15 We utilized the ACS NSQIP SAR/ISAR data to measure our progress. Decile rank from H10 in October 2014 to Decile L1 in April /July Odds ratio from 2.02 to 0.39 July 2014 SAR October 2014 ISAR January 2015 SAR April 2015 ISAR July 2015 SAR October 2015 ISAR January 2016 SAR April 2016 ISAR Decile rank 5 H L1 L1 Odds Ratio July 2016 SAR Events 4/484 22/ / / / / / /2800 6/2887

16 DECILE RANK ODDS RATIO

17 ACS NSQIP return on investment calculation estimates each pneumonia case costing $22,000. To date we have prevented 27 cases saving $594,000 following implementation of our action plans. ACS NSQIP data includes 20% of surgical cases. Expanding our sample data to our surgical population we estimate a cost savings to be in excess of $2.9 million.

18 SKEPTICISM Required support from our key leadership that included our Surgeon Champion (Chairman Department of Surgery), Chief of Physicians Executives (Pulmonologist), Chairmen of Radiology and Medicine departments Education of surgeons led to understanding the validity of NSQIP data

19 TIME Revision of order sets, nursing documentation in the EMR Education of staff Despite these barriers we continued to see improvement in our data with the ongoing education and heightened awareness of all staff to the pneumonia initiative.

20 Ask for feedback from key leadership and revise the team and action plans based on these recommendations. It is important for the SCR to present the ACS NSQIP data at established surgical quality meetings on a regular basis. The SCR needs to be critically involved in the identification of the opportunities for improvement in the care of the surgical patient. Once opportunities are identified begin working on the Who, What, Where, When, Why as part of the Plan Do Study Act of process improvement.

21 Your hospital received a Semi-Annual Report (SAR) that identified Pneumonia as Needs Improvement. This can occur EXCEPT: A. Your site is a (H) High statistical outlier for Pneumonia. B. Your sites odds ratio is in the 10 th Decile. C. Your sites confidence interval is entirely above 1. D. Your sites odds ratio is in the 5 th Decile.

22 According to the Institute of HealthCare Improvement, post-operative pneumonia A. is the 3 rd most common surgical complication behind urinary tract and wound infections. B. is the 5 th most common surgical complication behind urinary tract, wound infections, VTE and sepsis. C. is not common in elective surgical patients but primarily seen in trauma and ventilator supported patients. D. is commonly seen in patients who smoke and have a history of pulmonary disease.

23 Institute of HealthCare Improvement. Improvement Report: Reduction in incidence of Post-Operative Pneumonia emberreportreduction in IncidenceofPostoperative pneumonia.htm Cassidy, MR; Rosenkranz,P; McCabe, K; Rosen, JE; McAney, D: ICOUGH Reducing Postoperative Pulmonary Complication with a Multidisciplinary Patient Care Program. JAMA Surg 2013 Aug; 148(8) American College of Surgeons National Quality Improvement Program-Return on Investment Calculation Pneumonia April 8,