EP20EO Clinical nurses are involved in the review, action planning, and evaluation of patient safety data at the unit level.

Transcription

1 Exemplary Professional Practice CULTURE OF SAFETY EP20EO Clinical nurses are involved in the review, action planning, and evaluation of patient safety data at the unit level. Example B: Provide one example, with supporting evidence, of an improvement in patient safety that resulted from clinical nurses involvement in the evaluation of patient safety data at the unit level. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data. Background/ Problem Unintended hypothermia during surgical procedures is a common occurrence associated with adverse patient outcomes. A patient s core body temperature drops an average of 1.5 degrees Centigrade (C) during the first hour of anesthesia (Lippincott Procedures, 2015). According to Hart, Bordes, Hart, Corsino, & Harmon (2011), unintended perioperative hypothermia, defined as a temperature below 36 degrees C, occurs in up to 20 percent of surgical patients. Adverse effects of hypothermia include a threefold increase in the incidence of morbid cardiac outcomes, increases in surgical blood loss, a 20% increase in allogeneic transfusion, and a tripling of surgical site infections (SSIs) (Hart et al., 2011, p 259). Additional complications cited by Hooper et al. (2010) include altered medication metabolism, changes in pain perception, patient discomfort, extended post-anesthesia recovery time and prolonged hospital stays. Advocate BroMenn Medical Center (ABMC) began participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) in March, The ACS NSQIP is a data-driven, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care. During retrospective NSQIP general and vascular surgery chart reviews, Ara Peterson, MSN, RN, Surgical Clinical Registered Nurse (RN) Reviewer, noted on January 14, 2014 patients were hypothermic in the (OR). Subsequent chart reviews of general and vascular surgical patients revealed only 78 percent of patients in January 2014 and 70 percent of patients in February 2014 had a first OR temperature of greater than or equal to 36.0 C. Audit findings were presented to Perioperative Leadership. Sonia Vercler, RN, CGRN, Perianesthesia Nurse Manager, shared the audit findings with clinical nurses on the Perioperative Shared Governance Council. After review of the data, Perioperative Shared Governance Council members identified perioperative hypothermia as a clinical problem with the potential to impact patient safety, and initiated a quality improvement project. EP20EO ExB Advocate BroMenn Medical Center 1

2 Goal Statement The goal was to increase the percentage of general and vascular surgery patients with a first OR body temperature of 36 degrees C or above, as measured by retrospective/sampled NSQIP data. Description of the Intervention/Initiative/Activities From March to May 2014, the Perioperative Shared Governance Council conducted a literature review of evidence-based practice (EBP) guidelines for maintaining normothermia in the perioperative timeframe. According to the Association of Perioperative Registered Nurses (AORN) Perioperative Standards and Recommended Practices (2013), unplanned hypothermia during surgery happens in three phases. First, the redistribution phase occurs upon induction of anesthesia when there is a rapid shift in body heat from the body s core to its periphery resulting in a core temperature drop of approximately 1.5 degrees C during the first hour. The second phase, a slow linear decrease in temperature, occurs during the second and subsequent hours of anesthesia because the heat loss exceeds the patient s ability to produce heat. The final phase occurs after three to five hours of anesthesia when the patient s temperature will plateau and remain constant or rise. Patient temperatures are taken preoperatively in (SDS), intraoperatively prior to anesthesia induction and throughout the procedure, and postoperatively upon arrival to the Post Anesthesia Care Unit (PACU). Clinical nurses on the council determined one opportunity to decrease perioperative hypothermia was prewarming patients prior to transfer to the OR. According to Hart et al. (2011), prewarming in the preoperative area, when applied for at least 30 minutes, may prevent redistribution of body heat and resultant hypothermia (p. 263). Forced air warming is a technique the OR used intraoperatively to promote normothermia. However, Hart et al. (2011) note intraoperative warming techniques fail to eliminate the initial fall in temperature, and therefore active prewarming is recommended (p.263). Raising the temperature of the patient s skin and peripheral tissues triggers vasodilatation ahead of anesthesia induction which minimizes the effect of anesthesiainduced vasodilatation (Hooper et al., 2010, p. 352). In July 2014, SDS clinical nurses recommended prewarming general and vascular surgical patients with use of forced air warming and thermal caps to raise patient body temperatures to 36.5 degrees C prior to surgery as a method to prevent unintended hypothermia. By reducing the effects of the redistribution phase, the goal of prewarming was to increase the percentage of general and vascular surgery patients with a first OR temperature of 36 degrees C. Prewarming recommendations were implemented in August All general and vascular surgery patients admitted to SDS were to have a foil hat applied prior to OR, and any general or vascular surgery patients admitted to SDS with a body temperature less than 36.5 degrees C were to have an active warming device placed prior to surgery. NSQIP retrospective chart EP20EO ExB Advocate BroMenn Medical Center 2

3 reviews of general and vascular surgical patients were completed to maintain a consistent patient database from January 2014 (pre-intervention) through February 2015 (6 months post-intervention). Participants Name & Credentials Discipline Title Department Director, Trayce Bartley, MSN, Perioperative Surgical RN Charge Nurse Pre-admission Susan Berry, BSN, RN (clinical Testing Barbara Hancock, RN, CNOR Michael Hoeft, BSN, RN, CNOR (clinical Kevin Irwin, RN, CGRN (clinical Heather Meece, BSN, RN, CPAN Vanessa Middlebrooks, CRCST, CIS Megan Noreiko, BSN, RN, CNOR Ara Peterson, MSN, RN Yvonne Rees, RN, CGRN Anne Stein, BSN, RN Support Central - Shift Lead (clinical Surgical Clinical RN Reviewer II (clinical Post Anesthesia Care Unit Central Service Quality Resource Management EP20EO ExB Advocate BroMenn Medical Center 3

4 Sonia Vercler, RN, CGRN Shelly Walters, BSN, RN Nurse Manager until November 14, 2015 II (clinical, Post- Anesthesia Care Unit, Pre- Admission Testing Pre-admission Testing Outcomes Pre- Intervention Post-Intervention Through use of prewarming techniques, SDS clinical nurses took steps to protect patients from unintended perioperative hypothermia and the associated risks. The goal of increasing the percentage of patients with a first OR temperature greater than or equal to 36 C was met with post-intervention data ranging from 88 to 91 percent from November 2014 to February 2015 compared to 70 to 78 percent pre-intervention in January and February Additional incidental benefits of prewarming included patient comfort and relaxation and peripheral vasodilation for easier intravenous access. EP20EO ExB Advocate BroMenn Medical Center 4

5 References Conner, R., Spruce, L., & Burlingame, B. (Eds.). (2013). Perioperative standards and recommended practices (2013). Denver, CO: AORN. Hart, S., Bordes, B., Hart, J., Corsino, D., & Harmon, D. (2011). Unintended Perioperative Hypothermia. The Ochsner Journal, 11(3), Hooper, V., Chard, R., Clifford, T., Fetzer, S., Fossum, S., Godden, B., Martinez, E., Noble, K., O Brien, D., Odom-Forren, J., Peterson, C., Ross, J., & Wilson, L. (2010). ASPAN's Evidence-Based Clinical Practice Guideline for the Promotion of Perioperative Normothermia: Second Edition. Journal of Perianesthesia, 25(6), Lippincott Procedures. (2015). Hypothermia prevention, OR. Retrieved from: jlm EP20EO ExB Advocate BroMenn Medical Center 5