1. OUR NSQIP JOURNEY Drilling Down NSQIP Data Nanaimo Regional General Hospital Kelli Jennison-Gustafson RN SCR CNE

2. NRGH Acute Care Facility and Trauma Center 292 Beds 56 Surgical Beds Busiest ER on Vancouver Island We employ over 1,700 individuals locally

3. In the beginning… July 2011 1 st day on the job – NSQIP conference in Boston August 2011 Office set-up: get the word out to staff and surgeons SCR training, “CPT and ICD-9 codes “ Sept 2011 Ramp-up: start of chart reviewing and data collection Goal: 40 charts per 8 day cycle

5. Benefits of Participation

6. Occurrence Rank NSQIP Comparison 548,333 Cases Rank BC NSQIP Collaborative 35,881 Cases Rank NRGH Surgical Program 1,833 Cases Urinary Tract Infection (UTI) 2 7184 - 1.4% 1 848 - 2.6% 1 50 – 2.9% Surgical Site Infection (SSI) 1 9322 - 1.8% 2 794 - 2.4% 2 32 – 1.9% Sepsis 3 7413 - 1.4% 3 376 - 1.1% 3 12 – 0.7% Top 3 Occurrences Post-Operative Occurrence Summary On Non Risk Adjusted Cases with Confirmed 30-Day Follow-Up

8. Review audit results Review Pathway compliance Create outcome based UTI bundles Consult team members Teaching and enabling bundle Identify UTI cases and pt characteristics Enable UTI audit tool Chart reviews of known UTI cases Review current Ortho/epidural clinical order sets Identify occurrence Create team & set goals obtain audit tool & plan implementation PlanDoDo StudyAct

9. Pre-Initiative Audit

10. NSQIP IDN: Case #: MRN: Sex: Age: Diabetes: Patients functional status pre-operatively: Did the patient have a catheter: Date inserted: Where was the catheter inserted: (ER, OR, Floor) Who inserted?( RN, student, resident) Documentation of insertion, was it a simple or complicated procedure?(# of attempts) What prep was used? (Poviodine or normal saline) Principal operation: Elective or emergency procedure: Was the patient transferred from another hospital? Surgeon: Temperature on admission to PARR: Did the patient have an epidural? Date Removed? PO day#? Are there clinical orders sets for removal of Foley? (Ortho cases) What day was the Foley removed: If Foley remained in greater than 48 hours was there a reason: Type of catheter used: Is there documentation of patient symptoms of a UTI? What were the symptoms: Did the patient have a positive urinalysis or culture pre-operatively? If so, what organism was growing? Was there a positive urinalysis or culture post op: Type of bacteria growth in urine culture post op: Is there documentation of correct placement of drainage bag and tubing? Is there documentation of drainage bag changed every 24hours? Is the patient on antibiotics post op? Type of antibiotic and why? Was an antibiotic ordered prior to Foley removed? Template for Drilling down UTI Cases

11. Reducing UTIs Back to Basics

12. Changes to be Implemented Nurse education Foley Insertion Training + Regular skills assessment for Care providers Patient education Improved education for care of Foley Catheter at home Application of GRIP-LOK on all patients with a urinary catheter

15. Where are we now? Continue to educate surgical staff in catheter care; best practice Follow up audit of practice changes to confirm compliance and assess for improvements Monitor our monthly post op occurrence rates from NSQIP and compare this with our pre- initiative results Review and compare results with our risk adjusted SAR from NSQIP

16. Post Initiative Audit

17. OUR NSQIP TEAM AT NRGH SURGEON CHAMPION: Dr. Blair Rudston-Brown and Dr. Scott Neilson SCR: Debera Coles and Judy Lekisch QI Consultant: John Kristiansen SURGICAL CNE: Kelli Jennison-Gustafson and Tammy Joseph Kelli.Jennison-Gustafson@viha.ca

18. ACKNOWLEDGEMENTS Angela Tecson- BC SCR Support BC Patient Safety & Quality Council- NSQIP Clinical Improvement SharePoint Centers for Disease Control- UTI Guidelines Institute for Healthcare Improvement Surrey Memorial Hospital- Fraser Health- UTI Reductions