Care of the Surgical Patient

Care of the Surgical Patient Why review care? Patients: Patient quality of care and safety are foremost. We want to insure that every patient receives the best care every time. Employees: Review and reinforce great care practices. We have several new employees that are learning our processes. Provide an opportunity for employees to ask questions and share knowledge. Workflow: Assist staff in understanding each step of patient care to improve workflow. Interdepartmental: Assist staff in understanding work processes of other departments involved in the care of the patient.

Care of the Surgical Patient Pre-op Orders: The physician enters pre-op orders and a surgical case request. Surgery is scheduled. It is important to watch for ‘sign and held’ orders and release them. Pre-op checklist: New checklist created to guide nurses/aides through the process of preparing a patient for the OR and endoscopy. The checklist is not a permanent part of the chart. Label and sign it and place in the record prior to surgery. Documentation: Add Pre-Op-Proc flowsheet to document preparation of the patient in the medical record. Communication: A hand off of care should occur between the OR and unit staff when the patient leaves the unit and upon return.

Care of the Surgical Patient Preparing for patient arrival The bed: Liko sheet added for joint patients and patients with open abdominal surgery, SCD pumps should be added to the bed of these same patients, zero scale after adding these items. Record a note on the white board defining if equipment was added to the bed prior to zero. Remove stickers from chargeable items such as Polar cooler supplies. Add date next to the sticker when placing it on the charge card. Necessary papers: Place the surgical admission packet papers in the room. Add the charge card after patient label is applied. Equipment/supplies: ortho chair, Polar coolers, IV pump and tubing when applicable. Key point: observation surgical patients do not need IV placed on a pump unless Peds or at risk patient Nurse Call assignment: assign yourself to the room as soon as you know that you are getting a patient.

Care of the Surgical Patient Post-op Care Weights: daily including upon arrival to the unit I&O: accurate, apply urimeter if low outputs that need close monitoring Activity: dangle day of surgery and ambulate if able, walk at least 4 times a day, patient should be out of bed in chair. Document distance, assist level, assistive devices and tolerance in the record. Turn, cough, deep breath, IS. Again document. Oxygen: Try maneuvers to get saturation up. Do not start oxygen without an order. Think of oxygen as a medication. Dressings: surgical Ag used for most open procedures. Can leave on for 3 days and reinforce as needed. Change if ‘falling’ off or supersaturated. Discontinuation of lines: Night nurse to remove early in the morning when completing I&Os. Exceptions: medical reason to leave drain, tube or IV in place must be documented and communicated.

Care of the Surgical Patient Orders: Add Signed/Held column to your patient list. Use your worklist. Communicate orders during report. Pain assessments/reassessments: Add Due Tasks column to your patient list. This will assist in alerting you to complete pain reassessments. Reassess every 4 hours and within appropriate time frame after intervention. Documentation: Add LDAs for surgical wounds. Insure that you are documenting on the correct LDA. Remove LDAs when complete. Education: remember to document all education completed. Add special instructions to the AVS Care Plans: Complete care plans. Contact SC/PACU for incomplete pre-op and immediate post-op care plan problems. Diet: Doctor usually orders advance diet as tolerated. Nurse must enter the diet order for the type of diet and change as indicated by patient tolerance in order to get a tray. ADAT diet order does not print in Nutrition Services.

Surgical Care Improvement Project IMPROVING PATIENT SAFETY BY REDUCING POSTOPERATIVE COMPLICATIONS The four most common complications after surgery are: Infection Blood clots Cardiac events Respiratory events

Surgical Care Improvement Project FOUR TARGET AREAS Infection Prevention Appropriate timing and use of antibiotics Appropriate hair removal Postoperative normothermia Postoperative glucose control – specific to cardiac surgery

Surgical Care Improvement Project FOUR TARGET AREAS Venous Thromboembolism Prevention VTE prophylaxis ordered and received Cardiac events Beta blockers for patients on beta blockers prior to admission Respiratory events (for ventilated patients) HOB elevated Stress ulcer prophylaxis Vent weaning protocol

Surgical Care Improvement Project SCIP-1 ANTIBIOTIC RECEIVED WITHIN 1 HOUR PRIOR TO SURGERY The risk of infection increases progressively with greater time intervals between administration and skin incision.

Surgical Care Improvement Project SCIP-1 ANTIBIOTIC RECEIVED WITHIN 1 HOUR PRIOR TO SURGERY

Surgical Care Improvement Project SCIP-2 APPROPRIATE ANTIBIOTIC SELECTION Goal of prophylaxis with antibiotics is to use an agent that is: safe cost-effective has a spectrum of action that covers most of the probable intraoperative contaminants for the operation Surgical Stratum Routine ABX PCN or Cephalosporin Allergy Ortho Cefazolin Vancomycin Vancomycin OR Clindamycin Colon Cefazolin PLUS Metronidazole Clindamycin PLUS Gentamycin Hysterectomy Clindamycin PLUS Gentamycin

Surgical Care Improvement Project SCIP-2 PROPHYLACTIC ANTIBIOTIC SELECTION

Surgical Care Improvement Project SCIP-3 PROPHYLACTIC ANTIBIOTIC DISCONTINUED WITHIN 24 HOURS AFTER SURGERY Short duration of antibiotics is effective in preventing post op infections Longer duration of antibiotics is more likely to cause development of drug resistant bacteria

Surgical Care Improvement Project SCIP-3 PROPHYLACTIC ANTIBIOTIC DISCONTINUED WITHIN 24 HOURS AFTER SURGERY

Surgical Care Improvement Project SCIP-6 APPROPRIATE HAIR REMOVAL Studies show that shaving causes multiple skin abrasions that later may become infected.

Surgical Care Improvement Project SCIP-6 APPROPRIATE HAIR REMOVAL

Surgical Care Improvement Project SCIP-9 URINARY CATHETER REMOVED ON POD 1 OR POD 2 The risk of catheter-associated urinary tract infection (UTI) increases with increasing duration of indwelling urinary catheterization.

Surgical Care Improvement Project SCIP-9 URINARY CATHETER REMOVED ON POD 1 OR POD 2

Surgical Care Improvement Project SCIP-CARD 2 BETA BLOCKER PREADMIT WHO RECEIVED BETA BLOCKER PERIOPERATIVELY Research has shown a significant increase in mortality when beta-blocker therapy is withdrawn in the perioperative period.

Surgical Care Improvement Project SCIP-CARD 2 BETA BLOCKER PREADMIT WHO RECEIVED BETA BLOCKER PERIOPERATIVELY

Surgical Care Improvement Project SCIP-VTE 2 VTE PROPHYLAXIS RECEIVED WITHIN 24 HOURS BEFORE OR AFTER SURGERY VTE is one of the most common complications. Appropriate prophylaxis is the most effective strategy to reduce morbidity and mortality. Ortho Colon Hysterectomy Any of the following: LMWH LDUH Factor Xa inhibitor Warfarin SCD ASA Xarelto Elequis

Surgical Care Improvement Project SCIP-VTE 2 VTE PROPHYLAXIS RECEIVED WITHIN 24 HOURS BEFORE OR AFTER SURGERY

Infection Prevention - Orthopedics EVIDENCE BASED PRACTICES ADOPTED BY JRMC In addition to SCIP, JRMC has adopted the following best practices recommended by IHI for prevention of infections in total knee and hip replacements: Use an alcohol-containing antiseptic agent for preoperative skin preparation Instruct patients to bathe or shower with chlorhexidine gluconate (CHG) soap for at least three days before surgery Screen patients for MRSA and decolonize carriers

QUALITY Reduce Surgical Infections from 4.3 to below 3.1/1000 surgeries. MAY 0.0 YTD 4.2

Care of the Surgical Patient What’s next? Revising the Standards of Care for the Surgical Patient Questions?