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

2. This form can be found on our website:

3. *The CUSP Premortem Tool is adapted from the work of Gary Klein at
© 2013 The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins University
SUSP Pre-Mortem Tool

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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. Preop Bundle Implementation
Presented by Dr. Ayers at the January 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

14. Preop Bundle Implementation
Called or ed surgeons who did not attend the meeting.
ed 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

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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

24. 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

25. 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

26. 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

27. 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

28. SUSP Team

29. SUSP Team

30. QUESTIONS/COMMENTS Kathy Sandelli (860)714-5472
Please feel free to contact us with any further questions:
Kathy Sandelli (860)
Virginia Chipps (860)

31. 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:
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