Interventions to Enhance OR Safety Across the Continuum of Surgical Care March 20, 2014 1 A partnership of the Healthcare Association of New York State and the Greater New York Hospital Association
NYS PARTNERSHIP FOR PATIENTS Agenda 2
Maimonides Medical Center Improving Surgical Safety and Outcomes Patrick Borgen, MD Chairman Department of Surgery Samuel Kopel MD, Chief Medical Officer Sheila Namm Esq. RN, MA, Sr. VP Professional Affairs Susan Goldberg RN, BSN, MPA, VP Organizational Performance Sameh Samy MBBCH, MSA, CPHQ, Director of Quality Outcomes March 20, 2014
Strategies for Improving Surgical Safety and Reducing Surgical Site Infections: Creating the Infrastructure Established formal Surgical Safety Committee Recruited senior physician champions Included a core team of experts: Surgery, Anesthesiology, Pharmacy, Infectious Disease, Nursing, Performance Improvement Department Chairs commitment to clinician accountability Data driven and action oriented
Process Changes Across the Surgical Continuum: Pre-Operative Pre-Operative Risk Assessment Portsmouth (POSSUM Score) Comprehensive evidence based preoperative risk assessment tool 12 physiologic factors/6 operative parameters Second opinion by attending surgeon in complex cases
Process Changes Across the Surgical Continuum: Pre-Operative cont. Mandatory hospitalist pre-operative medical evaluation for in-patient procedures Long term plan is to apply to all same day surgical admissions Utilization of EMR to facilitate best practice Mandatory pathways for VTE risk and prophylaxis Appropriate antibiotic selection algorithms
Process Changes Across the Surgical Continuum: Peri-Operative Pre-Operative Checklist/Time-Out Post-Operative De-Briefing Team STEPPS Training and Implementation: Off-Site Two Day Kick-Off; Master Trainers Identified On Site Training; OR s closed for 3 hours- 300 + staff members participated Anchoring: Focus on briefs, debriefs, huddles Rapid Cycle PDCA; small tests of change
Process Changes Across the Surgical Continuum: Post-Operative Medical Co-Management of General Surgery and Vascular Patients Kick-off in 2013 Dedicated hospitalists Well received by Nursing, Residents, and Attending Physicians Early results are promising Expansion to Orthopedic and Neurosurgery patients
Process Changes Across the Surgical Continuum: Post-Operative cont. Modified Early Warning System (MEWS) Six vital signs entered into monitoring device equipped with software that auto- calculates the score Respiratory Rate Heart Rate Systolic BP Level of Consciousness Temperature Hourly Urine Output (previous 2 hours) RN algorithmic response to the score triggering notification to RRT, SICU RN Manager, LIP, Attending MD, Medical Hospitalist, Chief Resident RRT rounding on high risk patients at night
Improving Outcomes for Surgical Patients With BMI>40 The Challenges Medical: Diabetes Obstructive sleep apnea Coronary artery disease Risk for thromboembolic disease Skin and soft tissue infection Physical: Mobility challenges Pressure Ulcers Social service and post-discharge needs: Home bound Nutritional requirements and counseling Care giver support
Continuum of Consistent Care and Expectations Develop reasonable Best Practices Educate providers with supporting evidence Discuss plan of care with patient and family Rationale for intensified evaluation and therapy Create reasonable expectations based on Best Practices Implement Sensitivity Training for staff specific to high BMI patients
Complexity of Care for High BMI Patients: Consistent Education/Information From All Providers 15
Process Changes Across the Surgical Continuum: Post-Operative Discharge Planning Post Operative Teaching; Wound care management educational material with physician contact information Confirmation of follow-up appointment Ambulatory Surgery: Registered Nurse follow-up phone calls 24 hours postdischarge
Surgical Outcomes Post-op VTE Post-op Sepsis 58.3% decrease in the post-op VTE risk-adjusted rate 53.1% decrease in the post-op sepsis risk-adjusted rate March 18, 2014 17
Surgical Outcomes NHSN Colon Infections Surgical Mortality Rate 23.3% decrease in the colon infection rate 22.5% decrease in the surgical mortality rate
2014: NEXT STEPS Videotaping of Time-Outs: 5% of all cases Standardized criteria for critique by objective reviewers Real time feedback to the surgical team Mandatory hospitalist pre-operative evaluation expansion to Ambulatory procedures Physician report cards Two attending physicians present during high-risk cases (Whipple)
Hospital Discussion and Question and Answer
Performance To Date and Next Steps
NYS PARTNERSHIP FOR PATIENTS Reduce Harm across the Board 22
NYS PARTNERSHIP FOR PATIENTS 23
NYS PARTNERSHIP FOR PATIENTS NYSPFP Educational Resources 24
NYS PARTNERSHIP FOR PATIENTS NYSPFP Educational Resources 25 Videos are available on the NYSPFP website: https://www.nyspfp.org/members/initiatives/infectionprevention/ssi/tools.aspx
NYS PARTNERSHIP FOR PATIENTS 26
NYS PARTNERSHIP FOR PATIENTS Overall SSI SIR 27
NYS PARTNERSHIP FOR PATIENTS New York State PFP SSI Status 27% 40% 52% 26% 28
NYS PARTNERSHIP FOR PATIENTS Colon SSI SIR 29
SSI-Colon Surgery Standardized Infection Ratio (SIR), Current Rate, and Percent Improvement by HEN (HENs with at least 60 Percent Reporting) (NHSN), Q1 2012 Q2 2013 Source: NHSN (Q1 2012-Q2 2013). Notes: Progress is seen as movement toward the bottom right corner of the figure, indicating both reduction in harm and low current event rate. Eight HENs showed improvement below -30 percent and are not shown on the graph: DFW, Dignity, EHEN, Intermountain, LifePoint, NJ, VHA, and WA. Current rates are above benchmark. Three HENs are not shown because reporting was under 60 percent: Iowa, Minnesota, and Ohio Children's.
National SSI-Colon Surgery Standardized Infection Ratio (SIR) (NHSN), PfP-Aligned Hospitals (n = 2,614) Source: NHSN (n = 2,614 to 2,673 HEN-aligned hospitals, depending on the quarter).
NYS PARTNERSHIP FOR PATIENTS High Performing Hospitals in NYSPFP 32
NYS PARTNERSHIP FOR PATIENTS High Performance in NYS 33
NYS PARTNERSHIP FOR PATIENTS Colon SSI Prevention Upcoming Events 34 Registration and further information available on the NYSPFP website: https://www.nyspfp.org/members/mycalendar.aspx