1. Care of the Surgical Patient

2. 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.

3. 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.

4. 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.

5. 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.

6. 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.

7. 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

8. 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

9. 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

10. 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.

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

12. 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

13. Surgical Care Improvement Project
SCIP-2
PROPHYLACTIC ANTIBIOTIC SELECTION

14. 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

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

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

17. Surgical Care Improvement Project
SCIP-6
APPROPRIATE HAIR REMOVAL

18. 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.

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

20. 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.

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

22. 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

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

24. 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

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

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