PREVENTION OF POSTOPERATIVE PULMONARY COMPLICATIONS: Reducing Postoperative Mechanical Ventilation Rowena Chona O. Sano, MSN, RN, CNL, CPHQ Memorial Hermann Greater Heights Hospital Houston, TX
Nothing to disclose Speaker Disclosure
Objectives Upon completion, participants will be able to: Describe a multi-disciplinary process Discuss an approach to improve preoperative screening and optimization Illustrate several interventions across the continuum of care to decrease incidence of patients on ventilation greater than 48 hours post-surgery.
A 260-bed facility with 50 years of history in the community Service Lines and Programs: Heart & Vascular Neurosciences Oncology Services and Cancer Center Orthopedics and Sports Medicine Bariatric Surgery and Weight Management Women s Services Wound Care Certification and Accreditations: Primary Stroke Center Accredited Chest Pain Center Accredited Joint Center Accredited Cancer Center Accredited Bariatric Program Accredited TIRR rehabilitation program
Project Charter: Reduction of Post-op Vent >48 hours Exec Sponsor: W. Tidwell, COO *Team Leader: Dr. R. Adams *Facilitator: R. Sano Problem Statement Prolonged intubation increases the risk of hospital acquired injuries such as laryngeal injury and development of central line infections and ventilator associated pneumonia. Prolonged intubation is defined by American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) as having total cumulative duration of ventilator-assisted respirations greater than 48 hours during the postoperative hospitalization and any subsequent hospitalizations within 30 days after a principal operative procedure. MHGH rate for the rolling 6 month (Nov 2015-April 2016) was 1.6% compared to the national mean of 0.5% (not risk adjusted). Customers Primary: Patients Secondary: Care providers, including surgeons, intensivists, nurses, respiratory therapists High Level Needs: Reduce the risk of hospital acquired injury and infection, and the associated costs of care for post-operative patients. Project Alignment with Strategic Plan System Strategies FY17 Quality and Safety in Care Delivery (NSQIP Post-Op Occurrence, AHRQ Patient Safety Indicator, Hospital Acquired Infections) Project Scope Include MHGH Surgical patients General, Vascular, Thoracic, Orthopedics, Urology, Plastics, Gynecology cases only - ICU/CVICU Exclude All patients on vent >48 hours for reasons not related to surgery Non-surgical patients Project Goals Reduce the number of post-operative patients needing ventilator-assisted respirations over 48 hours within 30 days after principal operative procedure by 25-50% by Sep 2017. Types of Waste Observed Defects prolonged intubation Waiting increased length of stay, poor communication, inefficient decisionmaking Business Case Post-surgical patients with accumulated intubation hours >48 hours require additional period of high level of care resulting in additional: costs from higher level of nursing care; care and treatment by a licensed respiratory therapist; anesthesia for patient safety and comfort; doses of antibiotics to prevent/ treat possible infections, and laboratory tests for diagnosis/ confirmations. Increased post-op occurrence also impacts reimbursements.
Leadership: Executive Sponsor Surgeon Champion/Leader Team Members: Pre-Admit/IntraOp Respiratory Therapy Anesthesia Intensivist ICU Organization Development Quality/Patient Safety Facilitator: Project Team Wes Tidwell Dr. Ronnie Adams Lakeisha Catley, Debra House-Shannon Kimberli Morris Dr. Ashvin Reddy, Dr. Medea Mshvildadze Dr. Jose Melendez Scott Ellis Zaida Majumder Robert Graham, Jamie Nelson Rowena Sano
Baseline Data Ventilator > 48 Hours Raw Baseline data Post-Project Goals Period Jan 1, 2016 to Dec 31, 2016 Jan 1, 2017 to Sep 30, 2017 Patients Sampled 1,802 Rate of occurrence < 1.05% (25% reduction) Occurrences 26 Occurrence Rate 1.4% -- two times greater than national comparison Hypothesized decreased rate of Pneumonia and Unplanned Intubation occurrences
Process Flow
Process Measures Process Change Process Measures Measure Compliance STOP BANG Questionnaire (SBQ) Incentive Spirometer (IS) Patient Teaching * Late add-on Anesthesia Face to Face (f2f) Assessment Fast Track Extubation within 6 hours postop % of pts who received SBQ 55% to 99% % of pts who received IS patient education Day Surgery 66% % of pts with f2f assessment 44% to 55% % of pts that used fast track protocol 0% to 30%
Results Raw Baseline data Raw Post Intervention Data Period Jan 1, 2016 to Dec 31, 2016 Jan 1, 2017 to Sep 30, 2017 Patients Sampled 1,802 1,306 Occurrences 26 12 Occurrence Rate 1.4% 0.9% % Change n/a 35% decrease
References Brueckmann, B., Villa-Uribe, J. L., Bateman, B. T., Grosse-Sundrup, M., Hess, D.R., Schlett, C. L., Eikermann, M. (2013). Development and validation of a score for prediction of postoperative respiratory complications. Anesthesiology, 118 (6), 1276-1285. Cassidy, M. R., Rosenkranz, P., McCabe, K., Rosen, J. E., & McAneny, D. (June 2013). ICOUGH Reducing postoperative pulmonary complications with a multidisciplinary patient care program. JAMA Surg, 148 (8), 740-745. doi:10.100/jamasurg.2013.375 Fuchshuber, P. R., Greif, W., Tidwell, C. R., Klemm, M. S., Frydel, C., Wali, A., Rosas, E., Clopp, M.P. (Winter 2012). The power of the National Surgical Quality Improvement Program - Achieving a zero pneumonia rate in general surgery patients. The Permanente Journal, 16(1), 39-45. Lakdawala, L. (2011). Creating a safer perioperative environment with an obstructive sleep apnea screening tool. Journal of PeriAnesthesia Nursing, 26 (1), 15-24.