Meeting Minutes Perioperative Quality Improvement Committee Meeting Aim: To review systems issues uncovered by the morbidity and mortality process related to surgical patients with the goal to identify and Correct systems issues determined to be detrimental to patient care or staff safety. Meeting Date: Tuesday, October 20 th 2009 Leader: Dr. Jeff Dattilo Facilitator: Scribe: : 6:30 a.m. -7:30 a.m. Attendance: Please see Attendance List Susie Leming-Lee Mary Kay Matthys Project: Perioperative Quality Improvement Committee Location: Objective(s) of the meeting 5245 D Medical Center North, Blalock Conference Room Guest/New Member/s: Note: Record additional attendance on opposite side 1. To review issues related to the September 2009 M&M Conference 2. To continue review of issues related to the June 12 th M&M Conference 3. To review update Management of Trauma Patients with Orthopedic Injury 4. To review Risk of Exposure: Disinfection and Sterilization of Instrument Case: Patient Exposed to Unsterile Instruments; review VA Out Policy 5. To review update on Central Line Placement and Management: SonoSite Training for Residents and Faculty/Boot Camp 6. To review update Coagulation Protocol Progress Report Update 7. To review update Packing of Surgical Wounds Not Being Removed once patient leaves OR Update Pillar Quality & People I. INTRODUCTIONS 6:30 to 6:31 Dr. Jeff Dattilo A. Purpose of Today s Perioperative Quality Improvement Committee Meeting Dr. Jeff Dattilo called the Perioperative Quality Improvement Committee meeting to order. The Perioperative Quality Improvement Committee Minutes of September 2009 were approved. Action Steps/Conclusion: 6:31 to 6:33 Dr. Jeff Dattilo B. Introductions of New Committee Members or Guest: Dr. William Nealon, Surgeon in Chief 6:33 to 6:35 Dr. Jeff Dattilo C. Ground Rules and Housekeeping Dr. William Nealon was unable to be present to be introduced today due to a prior conflict. Action Steps/Conclusion: The ground rules are available and there were no housekeeping issues. II. III. NEW BUSINESS- No New Business BUSINESS FROM PREVIOUS MEETING 6:35 to 7:00 Dr. Jeff Dattilo A. Update on M&M Conference September 2009 Cases: Recommendations for Action 1. Intracranial Aneurysm Nerve Palsy Case: Dr. Dattilo stated that this case highlighted 2 problems: 1. a need for a clinical relevance box with some sort of proof that it had been looked at by Radiology;
2. Radiology needs to attend the Quarterly M&M on a consistent basis. Dr. Dattilo spoke with Drs. Bream, Stokes and Meranze regarding this issue. Dr. Dmochowski stated he communicated with Radiology re: the M&M case agenda, in particular Dr. Bream. Stephanie Randa a) Report on Progress of Task Force Deployed to Communication Issues: Dr. Dattilo stated that it is imperative that Radiology attends the M&M Quarterly meetings, especially if their department has involvement with a case. Dr. Dmochowski stated he notified Radiology re: the M&M case agenda by e- mail, and he will continue to do so. Ms. Rhonda Tully told Dr. Dmochowski to copy her also on the e-mail. She will ensure the appropriate staff attends the meetings. Need for more specific orders for Radiological Studies Ms. Randa stated that a clinical relevance box to be look at by Radiology under advisement. Ms. Randa will continue to keep the committee apprised of updates. Need for two pieces of information when orders are specific to Ms. Tully stated outpatient Wiz order system Radiology: is in need of improvement. Her ultimate ICD-9 Code solution would be Outpatient Order entry Brief, one line form. Star Panel does have a Radiology descriptor of what the Form included but it takes training to use and physician is looking fo is difficult to get to. During the discussion, It related to the patient s was discovered that there is no condition standardization of Radiology forms institution Improve wide. Dr. Dattilo stated his service uses communication OPOC for ordering Radiology tests because between specialties Vascular Surgery orders tests at virtually every visit. This form requires an ICD 9 code to exit. He is not sure who receives the form and does the scheduling. It is accessed through Star Panel. Dr. Dattilo will count # of clicks Vascular clinic needs to complete OPOC order form. Outpatient order forms need to be more standardized across the board. If there already is such a plan, where is the sequencing of the redesign at this time? If no plan is underway, a copy of all outpatient forms should be gathered and put in a slide show and taken to the Safety Committee. Dr. Dattilo will also speak with Margaret Head to see if there is already a systematic plan for standardizing outpatient Radiology order forms before further action is planned. 2
2. Exposure Case: Stephanie Randa and Nancye Feistritzer a) Ad hoc Group Progress Report on Following Issues: Ms. Stephanie Randa has followed up on the scrub issue. She was told it would be a budgetary issue for the linen dept but they are willing to help work through it. She was hoping to get this done before the opening of the new bed tower but it does not look like that will happen in time. She was also told that Anesthesia is not calling in for break relief after that being recommended. Dr. Furman asked for additional information on this. Dr. Nealon and Furman will meet with Dr. May and Stephanie to get up to speed on how these issues have arisen. Implement both isolation and contact isolation precautions at the beginning of the treatment when Strep is present When aerosolized particles are present consider higher quality level of mask Staff, Surgeons, Anesthesia providers in the OR having close direct with body fluids should wear impervious gowns, double glove, and use boot covers Limit excessive OR Traffic Remove shoe covers before leaving OR Consider Showering if exposed to harmful pathogens Communication Triggers for Contact Investigation Make scrubs readily available, not in the machine so that scrubs can be easily changed Ms. Stephanie Randa stated that she will follow-up on this after the opening of the new bed tower. 3
Case cancellation if Surgeon is ill Ms. Randa stated that the rest of the Exposure cases issues should be taken to the Surgical Site Infection Prevention Collaborative group. IV. OLD BUSINESS 7:00 to 7:25 Dr. Jeff Dattilo A. M&M Conference June 2009 Cases: Recommendations for Action 1. Need to employ Standard Institutional Communication at every level of contact with every patient. Reevaluation before transfer needs to happen with all patients and documented in all cases. Nancye Feistritzer Meet with Family Council to discuss need to collect more data regarding family needs Add tab to Star Panel to document the correct notification contact family member Ms. Feistritzer was unable to be present today, so this will be tabled until the next meeting. Ms. Feistritzer was unable to be present today, so this will be tabled until the next meeting. Barbara Martin Develop/design a tool that will allow determination if patient is still appropriate for transfer Ms. Barbara Martin was to meet with the Critical Care Committee. She stated that most units have an expectation in place that the Attending is called to notify regarding transfer. This process is not hardwired into the clinical practice. Dr. May is working hard to get this put in place. In regard to family communication and involvement in multidisciplinary rounds, Ms. Martin stated there was a presentation at the last ICCC (Institutional Critical Care Committee) discussing this and relaxing family visitation when the services move to the new tower. Should a mandate for family communication be consistent and apply to all units? ICUs have a single process whereby they identify the primary caregiver, and they have triggers for which they will notify that family. Ms. Martin will take a request for Identification of Primary Caretaker Form back to the Committee and provide a progress report to the PQIC at the November meeting. 4
Identify high risk population at patient s initial visit. Consider an in-dwelling catheter for drainage to allow monitoring of bleeding (if it happens). Get Radiology contact to call with reading when film does not post electronically. Floor team needs to actively look for signs of complications after surgical procedures. Look into purchasing x- ray machines that allow digital reading at bedside. Have bedside ultrasounds available 7:15 to 7:30 B. Safety and Care Issues Related to Previous M&M Conferences 1. Management of Trauma Patients with Orthopedic Injury: Dr. Roger Dmochowski a) Dr. Dmochowski will work to provide a solution for the Management of Patients se Physiological Parameters are out of bounds Dr. Dmochowski reported that he met with Drs. Furman, Morris, Phillip and Miller. They feel the system for monitoring of critical values currently in place is adequate. This item is to be put to bed (accomplishment bucket). 2. Risk of Exposure: Disinfection and Sterilization of Instrument Case: Patient Exposed to Unsterile Instruments: Dr. Jeff Dattilo a) Prevention of Event: Provide the Out policy and procedure from the VA Dr. Jeff Dattilo and Committee Members b) Disclosure of Error to Patient and Family: What is most efficient and effective method? This item was referred to the Universal Protocol Committee. Ms. Nancye Feistritzer is working on this. It should be resolved in the next 6 weeks. It will be reported on next month. Dr. Peter Bream 3. Central Line Placement: Safety Committee Meeting Update: a) Central Line Placement Boot Camp and Other Interventions 5
1) Sonosite Conference for Attendings 2) Create a Credentialing Certification Program Dr. Bream was unable to attend today. He did, however, send information to the committee via e-mail. His next step is to work with administrators to create formal curriculum. Ms. Barbara Martin stated Vascular Safety Committee is also working with Dr. Bream on video. Dr. Rajnish Gupta 2. Update: Patient with Hematoma related to Epidural Placement: Coagulation Protocol Progress Report Dr. Gupta has not attended these committee meetings for several months, so he will be contacted for a progress report so this Old Business agenda item can be put to bed. Ms. Susie Leming-Lee will send Dr. Gupta an e-mail requesting a progress report. Stephanie Randa 3. Update: Packing of Surgical Wound Not Being Removed: Prevention a) Create Method to Address Nursing Handoff Process Regarding Packing of Patient s Wound Dr. Jeff Dattilo IV. NEXT STEPS b) Create a Learning Module after Surgical Wound Packing Issue is Resolved A. Summary of Today s Meeting Activities, Next Steps & Evaluation. Ms. Randa had excused herself at this point in the meeting, so she will be contacted for an update, again to put this agenda item to bed. Ms. Susie Leming-Lee will also contact Ms. Randa to request a progress report on the wound packing prevention project. Dr. Dattilo summarized the meeting discussion and plan of action for all agenda items discussed. Dr. Dattilo adjourned the meeting. Next Meeting Date: Tuesday November 17 th 2009 Recorder: Mary Kay Matthys Start : 6:30 a.m. End : 7:30 a.m. Location: Blalock Conference Room, 5245 MCN Signature Line:, Chairperson/Leader of Meeting/Improvement Initiative 6