Heart of the Rockies Regional Medical Center Salida, Colorado Presented by: Ramona McConnell, RN Kim Faulkner-Russell, RN CNOR Amy Rahe, RN CAPA

This form can be found on our website: https://armstrongresearch.hopkinsmedicine.org/susp/cusp/resources.aspx

*The CUSP Premortem Tool is adapted from the work of Gary Klein at http://hbr.org/2007/09/performing-a-project-premortem/ar/1 © 2013 The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins University SUSP Pre-Mortem Tool

SUSP Hospital Team Experience Presented by Kathleen Sandelli, RN, CIC Virginia Chipps, RN, BSN, CPAN

ST. FRANCIS HOSPITAL & MEDICAL CENTER Hartford, CT Located in central Connecticut Population 125,000 Urban, major teaching hospital affiliated with the University of Connecticut Medical School Licensed for 617 beds, 65 bassinets

SUSP Team Formation Based on the membership template provided by Armstrong Institute / SUSP project Contacted mangers of all areas involved in the care of colorectal patients Explained the project and time commitment Asked them to solicit volunteers First committee meeting in January 2013

SUSP Plan Development Modeled our plan after a PI project where we successfully implemented changes to reduce deep sternal wound infections in cardiac surgery patients. Determined which practices to focus on for the pre-op, intra-op and post-op phases of care Incorporated many suggestions from the coaching calls

SUSP Team Structure Main committee 2 subcommittees Meets monthly All members assigned to a subcommittee 2 subcommittees Meet monthly Assigned specific areas of focus Report progress/recommendations back to main committee

Subcommittee #1 (The Preppies) Area of Focus Research and develop a bundle of best practices for preparing the colorectal patient for surgery Subcommittee led by Dr. Amanda Ayers, private practice colorectal surgeon Laura Sanzari, BSN RN, NSQIP Surgical Clinical Reviewer

Preop Bundle Recommendations / Implementation Oral antibiotics No change in current practice Neomycin & Flagyl day before surgery Mechanical bowel prep No strong recommendation in literature Done by most of our colorectal surgeons Hibiclens shower (7/1/13*) Night before & morning of surgery * Implemented by colorectal surgery group

Preop Bundle Recommendations Hair clipping – if needed (7/1/13) Moved to the pre-op area (not OR) AORN recommendation Chlorahexidine cloth wipes to abdomen (7/1/13) Done in pre-op area Skin prep with Chloraprep (9/1/13) Identified in Staff Safety Survey as needing improvement Now done by surgeon, resident or PA Re-educated OR staff, physicians and PAs on proper technique, coverage area and dry time Timers purchased to assure 3 minute dry time

Preop Bundle Recommendations IV antibiotics Rocephin 2g IV and Flagyl 500mg IV Redosing not required unless surgery is > 6 hours We have been using Invanz and Flagyl Change will save $30,000 / year Penicillin allergic patients Cipro 400mg IV and Flagyl 500mg IV Based on new recommendations released 1/2013* *Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery . American Journal Health System Pharmacy vol. 70, Feb 2013

Preop Bundle Implementation Presented by Dr. Ayers at the January 2014 Department of Surgery business meeting Best opportunity to reach both hospital employed and private practice surgeons performing colorectal surgery Packets given to each surgeon containing: A letter from Chief of Surgery and SUSP physician champions explaining bundle components and requesting adoption Questionnaire about their current practices Patient handouts

Preop Bundle Implementation Called or emailed surgeons who did not attend the meeting. Emailed letter and patient handouts Met with office managers Explained SUSP project & pre-op bundle Given packet Handouts also sent electronically Can customize with their contact information

Patient Handouts Hibiclens showers Pre-op antibiotics and mechanical prep (Miralax) Mechanical bowel prep only

Subcommittee #2 (SUSPects) Subcommittee led by Dr. Scott Ellner and Dr. William Marshall Maureen Gethings MSN, RN, OR Nurse Manager Areas of Focus Normothermia Glucose control Appropriate use of blood products

Normothermia and Glucose Control Cases audited – all compliant Glucose Control Tracked glucose levels on all diabetic colorectal surgical patients in pre-op, PACU and post-op units Results indicated there was room for improvement in this area

Glucose Management Goals Developing comprehensive plan for optimizing management of the diabetic patient HgA1c drawn on all diabetic patients as soon as possible once need for surgery identified If preop HgA1c is elevated (non-emergent cases) PCP / Endocrinologist to address diabetes management Ideally want to see 2 weeks of adequate glucose control pre-op Consideration of postponing case if HgA1c > 8.5 Appropriate glucose management during hospital stay

Blood Product Use Administration of blood products is associated with increased risk of SSI Our NSQIP data shows our blood product usage is above average

Blood Products Beginning audit of colon surgery charts since January 2013 Identify patterns of usage and opportunities for improvement If audit results indicate room for improvement Treat pre-op anemia - time permitting Evaluate blood product conservation strategies Establish appropriate threshold for transfusion in hemodynamically stable patient

Safety Surveys Administered patient safety surveys in February 2013 HSOPS Staff Safety Assessment (4 questions) Evaluated responses and assigned them to categories Helped guide subcommittee work

CUSP Analyzed responses from staff safety assessment Identified common and recurring themes Defect chosen – preop area Production pressure and lack of a consistent closed loop Communication between disciplines Assigned to subcommittee with members of affected areas

SUCCESSES Implementation of the colorectal preoperative bundle Added bonus - savings of $30,000 with antibiotic change Raised awareness of the impact of SSI’s and the role of each discipline in prevention Committee is engaged and enthusiastic Improved lines of communication between disciplines

CHALLENGES Multiple groups working with some overlap in agendas (PAT, SUSP, Exit Only) Employed surgeons vs. private practice general surgeons A few resistant to implementing all the bundle elements Coordination of diabetes management Must begin at time of decision for surgery

CHALLENGES SCIP misses – shave vs. clip Different staff responsible for clipping Learning curve for terminology Will resolve April 1st with documentation in EPIC Timing with EPIC implementation on April 1 Competing priorities

Sustainability of SUSP Continued use of the pre-op bundle components Improved glucose management Maintaining improved communication Once established, will need to be audited to ensure continued compliance

SUSP Team

SUSP Team

QUESTIONS/COMMENTS Kathy Sandelli (860)714-5472 Please feel free to contact us with any further questions: Kathy Sandelli (860)714-5472 ksandell@stfranciscare.org Virginia Chipps (860) 714-5586 vchipps@stfranciscare.org

Content Call Evaluation We want to ensure that the content calls provide useful and pertinent information for the SUSP teams. For this reason we request that you complete a brief evaluation following each call. The evaluation may be found at the following link: https://www.research.net/s/SUSP_C1_2_Content_Eval If you are not able to reach the link from the slide, please cut & paste the URL into your browser. Next Call “Deep Rooting your Data” Date: Tuesday, April 1, 2014 Time: 4pm EST