Cusp what is it how are we going to cause the next infection liza_deb

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  • First round notes:
    Add to the ‘reducing SSIs’ block “Emerging evidence, local opportunities to improve, collaborative learning
    NOTE: emphasize that we are coupling technical and adaptive work
    Think about color coding pieces (should Trip & CUSP be the same)
  • Educate and improve awareness about patient safety and quality of care to ALL PROVIDERS (techs, nurses, anesthetists, surgeons, residents)
    Empower staff to take charge, put their local wisdom to use, and improve safety in their work place
    Their voice NEEDS to be heard
    Partner unit with an actively participating hospital executive
    Send a message to frontline staff about the importance of the work
    Provide resources for unit improvement efforts
    Hold team accountable for improvement
    Provide tools to monitor outcomes, investigate and learn from defects and improve teamwork and safety culture
    First round notes:
    Emphasize role of hospital executive (how to make that more explicit)
    Emphasize that ‘this program taps into the wisdom of local staff’ (not just empowering)
    Must educate staff so they have the knowledge to improve their workplace.
    Must be staff driven or they won’t be empowered to take charge and improve care.
  • Now this is the slide that truly demonstrates the change in safety climate after CUSP was implemented and I am one of the nurses in the SICU group –so I can truly tell you that CUSP works!!! So we started CUSP-we had an executive meet with us monthly, we started safety projects…. And now after 1 year we were at 68% and now we are greater than 80%-- so CUSP truly has an impact. I see it as the umbrella with all the other safety initiatives dangling below it… I can not stress enough to start with CUSP than implement the different safety initiatives..
  • Low safety climate is more like moderate or neutral safety climate -
  • Speak up when you have concern
    Listen when others have concerns
    Support/Train Teamwork
    Reinforce Situational awareness
    Tell others about the defect so it does not occur else where
  • Our needle high in the stack….
  • Step 3 – Executive helped by allowing the finances to pilot the foley Temps
  • Explain Slide…
    “If everyone follows my orders, then the teamwork is great”
    Why the big disconnect???
    We went back and asked them what they meant by teamwork….
  • Yet when we look at the operating room, what we see is a workplace littered with anonymity.
    In the Safety Attitudes Questionairre, we asked surgical staff if they know the names of their collegues they work with in their OR or unit? Slide
    We learned some fascinating things
    WHO’S ON the SHIP?
    I’m guilty of this. When you operate in the room next John Cameron, somehow magically I end up with nursing student fresh out of school every day.
    KNOWING SOMEONES NAME GIVES THEM DIGNITY AND VALUE. IT ELIMINATES ERRORS OF ANONYNITY, and gives value to members of the team.
    IT’S THE BASIS FOR THE FOREMOST ITEM OF THE CHECKLIST:
  • Many surgeons and OR teams have for years developed standardized routines to make sure nothing gets missed. In working with Atul and the W.H.O. we all agreed that the most important routine was to make sure everyone knew who everyone else was at the beginning of the operation.
  • Explain slide
    Call me “marty”. Now they come in saying Hi Dr. Megid, Hi Dr. Brook, oh HI MARTY
  • This is a mess…Need to redo
  • First round notes:
    Add to the ‘reducing SSIs’ block “Emerging evidence, local opportunities to improve, collaborative learning
    NOTE: emphasize that we are coupling technical and adaptive work
    Think about color coding pieces (should Trip & CUSP be the same)
  • We need to be at the table
    Available
    Enthusiastic
    BUT, our voice should not always be the loudest
    Engage other frontline providers
    Guide discussion
    Serve as facilitator
  • Cusp what is it how are we going to cause the next infection liza_deb

    1. 1. © The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 CUSP Getting Started Elizabeth C. Wick, M.D. Deborah B. Hobson, B.S.N, R.N.
    2. 2. Objectives •To outline the steps of the comprehensive unit based safety program (CUSP) •To describe the use of adaptive and technical changes to prevent infections and improve surgical care
    3. 3. CUSP Comprehensive Unit Based Safety Program 3
    4. 4. History of CUSP • Started at Johns Hopkins Hospital in 2001 • A perfect storm created an atmosphere that supported CUSP – IOM report – A tragic patient event – Organizational management research – Work to decrease/eliminate blood stream infections • First units establishing CUSP at Johns Hopkins were ICUs
    5. 5. Where is CUSP? • 47 Units + at Johns Hopkins Hospital starting 2001 – ICUs, in-patient units, outpatient clinics, procedure areas, rehab areas, PACU’s, ORs, pharmacies • State collaboratives • National collaboratives (2009- present) • International – Canada, Spain, England, Peru, UAE, Portugal, Mexico, and others
    6. 6. Power of CUSP • Designed to improve safety culture and learn from mistakes • Structured framework that can be implemented throughout an organization • Values wisdom of frontline staff • Empowers staff to be actively involved in safety improvements • Helps eliminate barriers between staff and senior leadership
    7. 7. Johns Hopkins ICU program1 Michigan Keystone ICU program2,3 National On the CUSP: Stop BSI program Reductions in central line-associated blood stream infections (CLABSI) 1.Crit Care Med. 2004;32:2014-20. 2.N Engl J Med 2006;355:2725-32. 3.BMJ 2010;340:c309. Successful Efforts to Reduce Preventable Harm
    8. 8. Comprehensive Unit based Safety Program (CUSP) 1. Educate staff on science of safety 2. Identify defects 3. Assign executive to adopt unit 4. Learn from one defect per quarter 5. Implement teamwork tools Translating Evidence Into Practice (TRiP) 1. Summarize the evidence in a checklist 2. Identify local barriers to implementation 3. Measure performance 4. Ensure all patients get the evidence • Engage • Educate • Execute • Evaluate Reducing Surgical Site Infections • Emerging Evidence • Local Opportunities to Improve • Collaborative learning Technical Work Adaptive Work
    9. 9. The Vision of CUSP – Improve patient safety awareness and systems thinking at the unit level – Empower staff to identify and resolve patient safety issues – Integrate Safety Practices into daily work of all staff members – Create a patient safety partnership between executives and frontline caregivers – Provide tools to help CUSP teams investigate and learn from defects and improve teamwork and safety culture 9
    10. 10. CUSP Steps CUSP 1.Educate everyone in the Science of Safety 2. Identify defects (2 question survey) 3. Recruit executive as active CUSP team member 4. Learn from one defect per quarter 5.Implement teamwork tools Pre-CUSP 1.Conduct the culture assessment 2.Establish interdisciplinary CUSP team 3.Partner with senior executive 4.Gather unit outcome and safety information
    11. 11. What is Culture*? “The way we do things around here” Health and safety commission, 1993 Denham, 2007 1 attitude = opinion…everyone’s attitude = culture *aka Climate Slide courtesy of J. Bryan Sexton
    12. 12. Research has linked teamwork and safety climate to: • Decubitus Ulcers • Delays in OR and ICU • Bloodstream Infections in the ICU • Ventilator Associated Pneumonia •Wrong Site Surgeries • Post-Op Sepsis • Post-Op Infections • PE/DVT • RN Turnover • Absenteeism • Incident Reporting Rates/ Reporting Harm • Burnout • Spirituality • Unit Size Why Culture Matters… Colla, J.B. 2005 Slide courtesy of J. Bryan Sexton
    13. 13. © The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 WICUPOSTCUSP --SICUPOSTCUSP --SICUTime3 --WICUTime3 WICUPRECUSP SICUPRECUSP 0 10 20 30 40 50 60 70 80 90 100 S IC U P R E C U S P %ofrespondentswithinaclinicalareareportinggoodsafetyclimate Safety Climate Across 100 Clinical Areas WICU & SICU Climate Pre-Post CUSP
    14. 14. %ofrespondentswithinanICUreportinggood teamworkclimate Teamwork Climate Across Michigan ICUs: Keystone ICU Project                           No BSI (21%)No BSI (21%)                     No BSI 44%No BSI 44%                  No BSI 31%No BSI 31% No BSI = 5 months or more w/ zero 14
    15. 15. Surgical Infections (per 1000 discharges) 0 0.5 1 1.5 2 2.5 OR Safety Climate Level Group Average Low OR Safety Climate Mid OR Safety Climate High OR Safety Climate AHRQ National Average Source: Bryan Sexton
    16. 16. Culture in Safe Organizations • Commit to no harm • Focus on systems not people • Value Communication/teamwork • Accept responsibility for systems in which we work • Recognize culture is local • Seek to expose (not hide) defects • Celebrate safety
    17. 17. CUSP Steps CUSP 1.Educate everyone in the Science of Safety 2. Identify defects (2 question survey) 3. Learn from one defect per quarter 4. Implement teamwork tools Pre-CUSP 1.Conduct the culture assessment 2.Establish interdisciplinary CUSP team 3.Partner with senior executive 4.Gather unit outcome and safety information
    18. 18. CUSP OR Team Members Essential Team Members • Surgeons • Anesthesiologists • CRNAs • Circulating nurses • Scrub nurses / OR techs • Perioperative nurses • Executive partner • Nurse leaders Enhancing Team Members • Physician assistants • Nurse educators • Anesthesia assistants • Infection preventionists • OR directors • Patient safety officers • Chief quality officers • Ancillary staff 18
    19. 19. Andy Benson CRNA CRNA Lead Deb Hobson BSN “Coach” & Patient Safety Officer for Surgery Tracie Cometa RN Lead RN Sean Berenholtz MD Anesthesia Lead Lucy Mitchell RN, MS NSQIP SCR Elizabeth Wick MD Surgery Lead Renee Demski MBA Senior Director Quality Johns Hopkins Medicine Executive Steph Mullens CST Lead Tech Mary Grace Hensell RN Manager OR
    20. 20. CUSP Steps CUSP 1.Educate everyone in the Science of Safety 2. Identify defects (2 question survey) 3. Recruit executive as active CUSP team member 4. Learn from one defect per quarter 5.Implement teamwork tools Pre-CUSP 1.Conduct the culture assessment 2.Establish interdisciplinary CUSP team 3.Partner with senior executive 4.Gather unit outcome and safety information
    21. 21. Gather Unit Information Information for executive and team •Culture Survey Results •List of safety issues – Event reporting system summaries •Outcome data (NSQIP, other registries) •Patient satisfaction surveys •Unit statistics – Number of beds - – Staff/patient ratio – Staff turnovers - – Fall rates 21
    22. 22. Does SCIP gives us enough information? Johns Hopkins Comparison Hospitals Surgery patients who were given an antibiotic at the right time (within one hour before surgery) to help prevent infection 98% 97% Surgery patients who were given the right kind of antibiotic to help prevent infection 98% 98% Surgery patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery) 97% 96% Surgery patients needing hair removed from the surgical area before surgery, who had hair removed using a safer method (electric clippers or hair removal cream – not a razor) 100% 100% Patients having surgery who were actively warmed in the operating room or whose body temperature was near normal by the end of surgery. 98% 99% Johns Hopkins Hospital May 2010 SCIP Hospital Compare www.medicare.gov
    23. 23. NSQIP report 2009 23 Johns Hopkins ? ?
    24. 24. CUSP Steps CUSP 1.Educate everyone in the Science of Safety 2. Identify defects (2 question survey) 3. Recruit executive as active CUSP team member 4. Learn from one defect per quarter 5.Implement teamwork tools Pre-CUSP 1.Conduct the culture assessment 2.Establish interdisciplinary CUSP team 3.Partner with senior executive 4.Gather unit outcome and safety information
    25. 25. Science of Safety • Every system is perfectly designed to achieve the results it gets • Understand principles of safe design – standardize, create checklists, learn when things go wrong • Recognize these principles apply to technical and adaptive work • Teams make wise decisions when there is diverse and independent input Caregivers are not to blame 25
    26. 26. Educate the entire team on the Science of Safety •Science of Safety Video to be viewed later today •Share the Science of Safety Fast Facts with team members 26
    27. 27. Science&of&Improving&Patient&Safety&Fact&Sheet:&& CUSP&for&Safe&Surgery& Why&the&science&of&safety&matters1& • • • • Why&medical&errors&happen& • • • in the healthcare system that lead to complications vary widely among hospitals Surface&Defects&that&are&leading&to&complications& Tap into the wisdom of frontline staff. Ask frontline staff how the next patient will be harmed and what we can do to prevent it. Audit local performance to identify opportunities to improve. Create your own ‘bundle’ of care and focus on improving the system to prevent complications. Consider&your&work&area:&What&systemAlevel&factors&put&patients&at&ris Work&with&your&teams&to&apply&principles&of&safe&design&& 27
    28. 28. CUSP Steps CUSP 1.Educate everyone in the Science of Safety 2. Identify defects (2 question survey) 3. Recruit executive as active CUSP team member 4. Learn from one defect per quarter 5.Implement teamwork tools Pre-CUSP 1.Conduct the culture assessment 2.Establish interdisciplinary CUSP team 3.Partner with senior executive 4.Gather unit outcome and safety information
    29. 29. Two Question Survey 1. How will the next patient develop a wound infection? How can we prevent the next wound infection? 2. How will the next patient be harmed? How can we prevent that harm? 29
    30. 30. Surgery Staff Safety Assessment Staff Safety Assessment – ORCUSP 1. Please describe how you think the next patient in your unit/clinical area will be harmed. Name: Job Category: Date: Please describe what you think can be done to prevent or minimize this harm . 2. Please describe how you think the next patient in the OR will get a Surgical Site Infection. Please describe what you think can be done to prevent this infection. 30
    31. 31. How will the next patient be harmed? (SSI Specific) Percentage of Responses (%) 95 Responses from 36 Staff Members95 Responses from 36 Staff Members 31 Wick, et al. 2012.
    32. 32. 32 CUSP Step 2: Safety Issue Identified CUSP Steps 4 : Learn from Defects Opportunities to improve Infection Control • Skin preparation • Hypothermia • Contamination of bowel contents into the wound • Antibiotic timing • Selection and redosing • Length of case Coordination of Care • Increase utilization of preoperative evaluation center, • Improve surgical posting accuracy (case name and duration) • Computer assistance for antibiotic selection and redosing Communication and Teamwork • Improve communication throughout perioperative period • Empower team members to speak up • Improve compliance with briefings/debriefings • Implement teamwork tools Equipment/ Supplies • Accurate temperature probes • Point of care glucose monitoring • Under body warmers • Sanitizing wipes near anesthesia machine Policies/Protocols • Standardize care/protocols/policies • Monitor sterile technique policies Education/Training • Ongoing education (with supportive data) • Development of a SSI prevention checklist Wick, et al. 2012.
    33. 33. CUSP Steps CUSP 1.Educate everyone in the Science of Safety 2. Identify defects (2 question survey) 3. Recruit executive as active CUSP team member 4. Learn from one defect per quarter 5.Implement teamwork tools Pre-CUSP 1.Conduct the culture assessment 2.Establish interdisciplinary CUSP team 3.Partner with senior executive 4.Gather unit outcome and safety information
    34. 34. Gentamicin Interventions: • Increased amount of gentamicin available in the room • Added dose calculator in anesthesia record • Educated surgery, anesthesia and nursing in grand roundsDespite >95% compliance on SCIP
    35. 35. Normothermia Interventions: •Confirmed that temperature probes were accurate (trial comparing foley and esophageal sensors) •Initiated forced air warming in the pre-operative area
    36. 36. Skin Preparation Interventions: •Chlorehexidine wash cloths given to patients pre- operatively •Surgical skin preparation standardized to chloraprep (even in patients with ostomies) •Prep responsibility shifted to circulating nurse from resident •All nurses trained on chloraprep application
    37. 37. Separation of “Dirty” and “Clean” Instruments Intervention: • Built separate tray of instruments used for bowel anastomosis • Extra suction and bovie tip and gloves opened and changed after anastomosis • Educational sessions with scrub techs and nurses about instrument separation • Audits and education on the spot
    38. 38. CUSP Learning From a Defect Tool
    39. 39. SSI Prevention Interventions • Use of pre-operative chlorhexidine washcloths • Pre-warming in the pre-op area • Standardized skin preparation with chloraprep • Separation of dirty and clean instruments 39
    40. 40. CUSP Steps CUSP 1.Educate everyone in the Science of Safety 2. Identify defects (2 question survey) 3. Recruit executive as active CUSP team member 4. Learn from one defect per quarter 5.Implement teamwork tools Pre-CUSP 1.Conduct the culture assessment 2.Establish interdisciplinary CUSP team 3.Partner with senior executive 4.Gather unit outcome and safety information
    41. 41. Teamwork Tools: SSI Intervention Checklist Complete for Surgeons: Wick, S. Gearhart, J. Efron, Safar, Fang & Marohn Colorectal SSI Project Intervention Checklist Place completed form in “Colorectal Mail Slot” in PACU COMPLETED BY: DATE: Yes No YES NO NA YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO CHLORAPREP WASHCLOTHS AT HOME? PRE-OP WARMING: Bair hugger placed on patient in pre-op? Temp on admission to PREP Temp when leaving PREP Did patient do MECHANICAL BOWEL PREP? And take all ORAL ANTIBIOTICS? If NO, why? _________________________ ROOM TEMPERATURE: warmed to 72 degrees prior to patient arrival? PROPHYLAXIS ANTIBIOTIC SELECTION? Check box for antibiotic given: Standard: Cefotetan 2gm or Cefoxitin 2gm Penicillin Allergy: Clindamycin plus Gentamicin 5mg/kg SKIN PREPARATION: Chloraprep completed by RN or Surgical Attending? INSTRUMENTS: Clean and dirty instruments separated? HYPEROXIA administered In OR? In PACU or ICU? (Timing: ____ to ____) Patient Sticker Please Circle One For Each
    42. 42. Step 5: Implement Teamwork Tools Normothermia Maintenance Tool
    43. 43. 42% 17% 29% 26% 16% 20% 19% 18% Q32009 Q42009 Q12010 Q22010 Q32010 Q42010 Q12011 Q22011 Goal: 15% Quarter 3 Skin preparation protocol Pre-op wash clothes Quarter 4 CUSP kickoff Antibiotic deficiencies addressed Quarter1 Pre-op warming Enhanced sterile technique Intervention checklist 43 Colorectal SSI Rate by Quarter (NSQIP) Baseline SSI Rate: 27% Year 1 SSI Rate: 17%
    44. 44. COLORECTAL SURGERY CUSP Teamwork and Communication: Briefings and Debriefings Year 2
    45. 45. Root Causes of Hospital Sentinel Events 0 10 20 30 40 50 60 70 Organization culture Alarm systems Procedural compliance Competency/credentialing Continuum of care Physical environment Staffing levels Availability of info Patient assessment Orientation/training Communication Percent of events 45
    46. 46. Teamwork Surgeon: If the nurse follows my orders Nurse: If the surgeon listens to my concerns Armstrong Institute for Patient Safety and Quality
    47. 47. © The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011   %Agree “I know the names of the personnel I worked with during my last shift.”
    48. 48. Time-Out: The Universal Protocol • Right patient • Right procedure • Right site 49
    49. 49. © The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011
    50. 50.   %Agree Makary et al. Operating room briefings and wrong-site surgery. J Am Coll Surg 2007;204:236-43. It was difficult to speak up if I perceived a problem with patient care.”
    51. 51. Briefing/Debriefing Form Privileged and Confidential - For Peer Review Purposes Only The Johns Hopkins Hospital Operating Room Briefing/ Debriefing Tool© Attending Surgeon to utilize this tool is to prompt open interdisciplinary communication before and after surgery to promote a clear understanding of specifics for each case. ORMIS Case #___________________ Date ________________   Briefing – Before Every Procedure • Team introductions – first and last names including roles  (Circulator writes on board)  • Do the following match:  • Patient ID band, Informed Consent (read out loud), Site Marking, OR posting, patient’s verbalization of procedure  (if patient awake), other clinically relevant documentation (H&P, clinic note)  • Do we have any safety, equipment, instrument, implant or other questions or concerns?  • Have antibiotics been given, if indicated?  • What are the anticipated times of antibiotic redosing?  • Is glycemic control/ beta blockers indicated?  • Is the patient positioned to minimize injury?  • Has the Prep been applied properly, without pooling and allowed to dry?  • Have the goals and critical steps of the procedure been discussed?  • Is the appropriate amount of blood available?   • Is DVT prophylaxis indicated? If so, what?  • Has the patient received anticoagulants?  • Any Special Precautions? If yes, describe.                                                              • Are warmers on the patient?  • Is the time allotted for this procedure an accurate estimate?  • Has Attending reviewed latest/ final test results for Lab/ Radiology? Are Intraoperative X rays indicated?  ____________________ _____________________ ________________________ Circulating Nurse Anesthesia Provider Attending Surgeon Debriefing – After every procedure • Could anything have been done to make this case safer or more efficient?  • Has the SSI data collection form been completed?  • Are the patient name/ history number and the surgical specimen name and laterality    on the paperwork? (Paperwork/ labeling to be independently verified by Surgeon)  • Did we have problems with instruments?   • Plan for transition of care to post-op unit discussed? To include:  • Fluid Management/ blood (all slips in chart)  • Antibiotics – continue post-op (dose/interval)  • PACU tests/ Xrays  • Pain/ PCA plan  • New meds needed (immediate periop)  • Beta blockers (as required)  • Glycemic control (as required)  • DVT prophylaxis  _________________ ________________________ ________________________ Circulating Nurse Anesthesia Provider Attending Surgeon 06-07          Addressograph here  • No follow-up on comments • Too long • Same form used in all OR’s (neurosurgery, ortho, general surgery)
    52. 52. Briefing and Debriefing “real-time” identification of defects • Team developed new form based on specific needs • Candid discussion with surgeons about effective strategies for briefing/debriefing • RN given protected time to address defects and communicate fixes • Logbook of defects      Before induction of anesthesia   Before skin Incision   Before patient leaves OR    
    53. 53. Debriefing Defect Logbook 54
    54. 54. Example of Defects Addressed: Instruments Problem: Conflict with colorectal set •Increased fleet from 2 to 4 •Reorganized contents of set so it is only pulled for cases when it is really needed Impact: Instruments available when needed 55
    55. 55. Example of Defects Addressed: Instruments 137 instruments 54 instruments Impact: Fewer instruments to count and turnover Save money and time Revision of Laparoscopic GI Surgery Trays Problem: Many open instruments set up for lap cases which were never used
    56. 56. Examples of Defects Addressed: Postings Problem: Circulating RN and scrub could not tell from posting if an abdominal and perineal set-up was needed for a case •Worked with posting office to add “second setup needed” to posting sheet and surgeon notes section in ORIMIS Impact: RN and scrub can set up before discussing case with surgeon, fewer delays 57
    57. 57. Examples of Defects Addressed: Updating DPCs Problem: Equipment, supplies and/or instruments not available for cases •Decreased number of DPCs •Removed argon from colorectal DPCs •Decreased surgeon to surgeon variability (standardization) •Increased accuracy Impact: Fewer errors, less counting required, less instruments to return at end of case, increased efficiency 58
    58. 58. Hidden Cost-Savings Antibiotic Irrigation • Frontline providers questioned the inconsistency in use of antibiotic irrigation between surgeons • Solution: if effective, advocate for consistent use and if not proven stop using • NO EVIDENCE TO SUPPORT USE • $537,000/ year on antibiotic irrigation • Obtained surgeon and leadership buy-in for removing it from hospital formulary
    59. 59. Briefing Audit Tool Audits done by: Jennifer Bennett BA (medical student) Anna Chay BA (nursing student) Deborah Hobson RN (patient safety officer) Mike Rosen Ph.D. Sallie Weaver Ph.D. 60
    60. 60. Briefing Basics Compliance
    61. 61. 62 Colorectal SSI Rate by Quarter (NSQIP) Baseline SSI Rate: 27% Year 1 SSI Rate: 17%
    62. 62. COLORECTAL SURGERY CUSP Surfacing Defects in SSI Prevention Year 3
    63. 63. SSI Investigation Process • Every month • Patients with infections identified by NSQIP • Data abstracted by hand from ORIMIS, Metavision, POE, EPR 64
    64. 64. Surfacing Defects on Patients with Infections Q1 2012 Q2 2012 Patients with Infections 15 19 CUSP group surgeons 9 11 Antibiotic Selection 100% 100% Antibiotic Timing 100% 100% Warmer Use in OR 100% 100% SCIP Measures:
    65. 65. Surfacing Defects on Patients with Infections Q1 2012 Q2 2012 Patients with Infections 15 19 CUSP group surgeons 9 11 Antibiotic Dose (Gentamicin) 50% 100% Redosing 20% 0% Pre-op Warming* 55% 27% Incision Temp 44% 27% End Temp 44% 82% Recovery Room Temp 100% 91% Washcloths Use Pre-op* 55% 9% Standardized Skin Prep* 77% 64% Bowel Prep with Oral Antibiotics* 55% 36% Reduced Steroid Dosage 0% 100% Normothermia *CUSP
    66. 66. Addressing Defects: Tablet-based Pre-op Education Problem: Patients did not know why we do the preparations we do • Enhanced pre-op education to improvement patient compliance with preparation for surgery • Interactive • Teachback
    67. 67. Addressing Defects: Bowel Prep Kit and Reminder Call Problem: Patients frequently scheduled months before surgery and materials not available in all pharmacies • Patients will be given bowel prep materials when scheduled for surgery • Reminder phone calls 2 days before procedure Erythromycin Neomycin Biscodyl Dec 2012-Jan 2013 35 pts contacted 31/35 (89%) compliant with washcloths
    68. 68. 69 Addressing Defects: Patient Bowel Prep Compliance
    69. 69. 70 Addressing Defects: Chlorhexidine Washclothes Day of Surgery Problem: Patients not using pre-op chlorhexidine washclothes • Patients will be reminded with phone calls • Prep will provide washclothes on the day of surgery for patients who did not use
    70. 70. Colorectal SSI Rate by Quarter (NSQIP) 42% 17% 29% 26% 16% 20% 19% 18% 21% 24% 15% 21% 13% 18% Q32009 Q42009 Q12010 Q22010 Q32010 Q42010 Q12011 Q22011 Q32011 Q42011 Q12012 Q22012 Q32012 Q42012 Goal: 15% Quarter 3 Skin preparation protocol Pre-op wash clothes Quarter 4 CUSP kickoff Antibiotic deficiencies addressed Quarter1 Pre-op warming Enhanced sterile technique Intervention checklist Quarter4 Briefing/Debriefing Mechanical bowel prep with oral antibiotics 72 Baseline Year 1 Year 2 Year 3 SSI Rate: 27% SSI: 17% SSI Rate: 20% SSI Rate: 16%
    71. 71. COLORECTAL SURGERY CUSP Sustainability and Extending Scope of Work Year 4
    72. 72. Sustaining Quality Improvement • Creative tools to surface new defects •Event reporting •Briefing/debriefing •Readminister staff safety assessment • New technical projects •Pathways/ length of stay •Efficiency/ throughput •Patient satisfaction
    73. 73. Reassess Data NSQIP SAR 2013 Armstrong Institute for Patient Safety and Quality 76 • The good… no longer a high outlier for SSI • The bad… high outlier for length of stay
    74. 74. Goal of ERAS • Implement a standardized, patient centered protocol • Integrate the pre-operative, intra-operative, post-operative and post-discharges phases of care to reduce LOS • Improve patient experience and satisfaction and decrease variability
    75. 75. ERAS Main shifts in mentality • Pain management – Goal is to diminish narcotic intake • Fluid management – Goal is to avoid volume overload – bowel edema • Prevent starvation – Pre-op carbohydrate drink and early feeding after surgery • Activity – Goal is to induce early mobility and get the bowels moving!
    76. 76. Engaging Executive and Additional Providers Support Armstrong Institute for Patient Safety and Quality 80 Chris Wu, M.D. Liz Lins, MSN Anesthesiology/ Pain Management Nurse Manager, Marburg 2 Dreama Franklin, RN Care Coordinator Val Gaskins, RN ERAS Coordinator Ron Werthman Claro Pio Roda John Hundt, MHS Peter Pronovost, MD, PhD CFO Administrator, Anesthesia Administrator, Surgery SVP Quality and Safety
    77. 77. Financial Analysis to Support Incremental Cost of Program Expenses: •Surgeon and anesthesiologist 20% time •Nurse to support implementation •Nurse practitioner to expand capacity of pain service •Massimo fluid monitors (3) •Bis monitors
    78. 78. ERAS Process Map Armstrong Institute for Patient Safety and Quality
    79. 79. ERAS Kickoff Armstrong Institute for Patient Safety and Quality
    80. 80. ERAS Evaluation • Audit of processes (pain regimen, fluid in OR and post-op, education, mobility, diet etc.) • Length of Stay • Pain scores post-operative • HCAPS • 30 day Morbidity • Readmission  Monthly reports and feedback to optimize implementation
    81. 81. Armstrong Institute for Patient Safety and Quality
    82. 82. Our Model Comprehensive Unit based Safety Program (CUSP) 1. Educate staff on science of safety 2. Identify defects 3. Assign executive to adopt unit 4. Learn from one defect per quarter 5. Implement teamwork tools Translating Evidence Into Practice (TRiP) 1. Summarize the evidence in a checklist 2. Identify local barriers to implementation 3. Measure performance 4. Ensure all patients get the evidence • Engage • Educate • Execute • Evaluate Reducing Surgical Site Infections • Emerging Evidence • Local Opportunities to Improve • Collaborative learning Technical Work Adaptive Work
    83. 83. Colorectal SSI Rate by Quarter (NSQIP) 42% 17% 29% 26% 16% 20% 19% 18% 21% 24% 15% 21% 12% 17% 19% 12% 21% Q32009 Q42009 Q12010 Q22010 Q32010 Q42010 Q12011 Q22011 Q32011 Q42011 Q12012 Q22012 Q32012 Q42012 Q12013 Q22013 Q32013 Goal: 15% Quarter 3 Skin preparation protocol Pre-op wash clothes Quarter 4 CUSP kickoff Antibiotic deficiencies addressed Quarter1 Pre-op warming Enhanced sterile technique Intervention checklist Quarter4 Briefing/Debriefing Mechanical bowel prep with oral antibiotics 87 Baseline Year 1 Year 2 Year 3 Year 4 SSI Rate: 27% SSI Rate: 17% SSI Rate: 20% SSI Rate: 16% SSI Rate:? Quarter 3 SSI Investigation Electronic education Bowel prep kits
    84. 84. Lessons Learned • Colon SSIs can be prevented and outcomes improved • Change can not be “top down” • CUSP sends a clear message, all provider opinions and ideas are important and essential for improvement • Better teamwork  better outcomes  better culture and teamwork • It takes time, commitment and leadership support
    85. 85. Johns Hopkins Hospital Motto Our experience: Hospital level interventions(SCIP) pale in comparison to interventions at the work unit level (CUSP) We embrace local wisdom in for the care of colorectal surgery patients

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