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, November 17 th Leader: Dr. Jeff Dattilo Facilitator: 2009 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: Candis Kinkus, Administrative Director for Laboratories 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: How to Notify Patient and Family 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 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. Jeff Dattilo called the Perioperative Quality Improvement Committee meeting to order. The minutes from October 2009 were approved. The committee has no new members to introduce today. 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 Intracranial Aneurysm Nerve Palsy Case: Stephanie Randa a) Report on Progress of Task Force Deployed to Address Communication Issues:
Rhonda Tully No standardization of Radiology Request Forms Dr. Dattilo updated the committee on this project, which stemmed from the inability to identify an aneurism by the Radiologist, who stated that the problem was an inability to identify clinical information on the request form. In hindsight from the M&M, the charge was to see if there could be a standardization of the Radiology request form. Rhonda Tully presented a small sample of variations of Radiology request forms for the committee to see (approx 15-16 forms). Dr. Dattilo then showed the group the OPOC request form. Ms. Tully explained that this program presents difficulty for Radiology because it doesn t interface with other programs. Dr. Dattilo stated he had discovered the same issues. Ms. Tully also showed the Radiology request form that is in Star Panel, which interfaces well but requires a short tutorial before you can use it. Dr. Peter Bream stated that Interventional Radiology (IR) is in the process of adding a dedicated consultation form for IR instead of a Radiology request, although this would not work for others. Ms. Tully stated that it is her understanding that there is a movement by the VMG clinics to put together an Outpatient Order Entry system. The Outpatient Order Entry system is headed up by Margaret Head although the first meeting has not yet occurred. Dr. Bream stated that the barrier relates to the Wiz order not recognizing outpatients in electronic order entry. The committee noted that no other Star forms require a tutorial. Ms. Susie Leming-Lee stated that this is a large issue and perhaps it should go to the Patient Safety Committee. Ms. Tully stated that it has to be a directive from VMG for clinicians to use it. Ms. Leming-Lee stated that VMG representatives sit on the Safety Council because it is an enterprise-wide committee. She feels the Safety Council may not be aware of this issue. Susan Moseley is the contact person to get something on the Safety Council. Dr. Dattilo and Rhonda Tully will ask to be on the next Hospital Safety Committee agenda to present this issue and request help for change. Dr. Peter Bream Need for more specific orders for Radiological Studies Dr. Dattilo stated that this falls back to a previous M&M discussion. One item was to make sure there was digital imaging equipment in all critical care units, which has been accomplished. Another issue was a way to quickly retrieve the clinical information. Dr. Bream stated that the ER Radiology Reading room has a hot phone which is manned 24 hours a day. There are also Attendings present 24 2
hours a day now. Emergent questions should call that number. If unexpected finding occur, the Radiologist also contacts the doctor who ordered the image, and that information is put right into the dictation. A recommendation was made by this committee that all stat printed Radiology orders have a line stating If you need urgent input on this order call l It should also be listed in the Wiz order system on emergent orders. Rhonda Tully will try to get a slot placed on order sheet with hot line number to call. 1. Exposure Case: Stephanie Randa a) Meet with Administrative Leadership of Anesthesiology, Surgery, and the SSIPC to Discuss Resolutions to the Following Issues: 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 3
Communication Triggers for Contact Investigation Make scrubs readily available, not in the machine so that scrubs can be easily changed Case cancellation if Surgeon is ill 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 Nancye Feistritzer Add tab to Star Panel to document the correct notification contact family member Barbara Martin Develop a Tool that will provide a method for Determining if a Patient is Still Appropriate for Transfer: Ms. Martin will ask for the Creation of Identification of Primary Caretaker Form and take this Form to the ICC Medical Directors Forum and then to the ICCC for Discussion Ms. Martin stated that this agenda item is one that needs to go to ICC Medical Directors Forum which was canceled last due to Day in the Life. The committee will meet again this month. A short discussion was held by the group led by Dr. May discussing how each intensive care unit has a different process for this, which creates an inconsistent overall process. Dr.May stated that a transfer data form should be easy, and queried in a Star form, with no more than 5 questions total, including family member contact. Ms. Martin stated that Star information is now mapped to the EDW. Ms. Martin will bring it to the next ICC Medical Directors meeting and revisit what the next step needs to be. 4
Barbara Martin Identify high risk population at patient s initial visit. Consider an in-dwelling catheter for drainage to allow monitoring of bleeding (if it happens). 7:15 to 7:30 B. Safety and Care Issues Related to Previous M&M Conferences Dr. Jeff Dattilo and Committee Members 1. Risk of Exposure: Disinfection and Sterilization of Instrument Case: Patient Exposed to Unsterile Instruments: a) Disclosure of Error to Patient and Family: What is most efficient and effective method? 3. Central Line Placement: Safety Committee Meeting Update: Dr. Peter Bream a) Presentation of the Central Line Placement Credentialing to Institutional Critical Care Committee Credentialing and Create a Website and Video Dr. Bream stated that after speaking with the Safety Council, he is not sure who is supposed to give him the green light as a next step to build a website and create a video. Ms. Barbara Martin, speaking for the Vascular Access Committee and the Institutional Critical Care Committee gave Dr. Bream the green light. Dr. Bream felt this was his sense of it as well and he will move forward. Dr. Rajnish Gupta 4. Update: Patient with Hematoma related to Epidural Placement: Coagulation Protocol Progress Report Dr. Gupta stated that his group has been trying to figure out an effective tool for rare events to get people s attention. There is an MRI epidural hematoma protocol in Wiz order that directs the MRI suite, radiology, and the ordering physician what to do with regards to the MRI. He is trying a different model which would put everything you need to know, who to call, etc. on one piece of paper. The new form has not gone live yet. The problem is for people to know where to find the form. He has also created a website for residents and staff explaining how to use the protocol. Dr. Gupta plans to continue to improve on this. No further action is needed by this committee. 5
Susie Leming-Lee for Devin Carr 5. Update: Packing of Surgical Wound Not Being Removed: Prevention a) Create Method to Address Nursing Handoff Process Regarding Packing of Patient s Wound b) Create a Learning Module after Surgical Wound Packing Issue is Resolved IV. NEXT STEPS Dr. Jeff Dattilo A. Summary of Today s Meeting Activities, Next Steps & Evaluation. Dr. Dattilo summarized the meeting discussion and plan of action for all agenda items discussed. Members not present will have items deferred until next meeting on December 15 th. The meeting was adjourned. Next Meeting Date: Tuesday December 15 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