Keryn Bonner, Ryde Hospital: To PAC or not to PAC - Is the PACage safe to deliver?
Upcoming SlideShare
Loading in...5
×

Like this? Share it with your network

Share

Keryn Bonner, Ryde Hospital: To PAC or not to PAC - Is the PACage safe to deliver?

  • 499 views
Uploaded on

Keryn Bonner, Nurse Unit Manager – Perioperative Unit, Ryde Hospital delivered this presentation at the 2013 Elective Surgery Redesign Conference. The National Conference focussed solely on......

Keryn Bonner, Nurse Unit Manager – Perioperative Unit, Ryde Hospital delivered this presentation at the 2013 Elective Surgery Redesign Conference. The National Conference focussed solely on assisting Australian Hospitals to meet the National Elective Surgery Target, including:
Streamlining Surgical Pathways
Improving Access & Patient Experience
Reducing Waiting Times
Incorporating Latest Technological Innovations
For more information on the annual event, please visit the conference website: http://www.healthcareconferences.com.au/electivesurgery

  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
    Be the first to like this
No Downloads

Views

Total Views
499
On Slideshare
494
From Embeds
5
Number of Embeds
1

Actions

Shares
Downloads
5
Comments
0
Likes
0

Embeds 5

https://twitter.com 5

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide

Transcript

  • 1. TO  PAC  or  not  TO  PAC   IS  THE  “PACage”     SAFE  TO  DELIVER?  
  • 2. Presented  by   Kerry  Bonner   NUM  Perioperative  Unit  &  Pre  Admission   Clinic   Ryde  Hospital,  NSW   25th  November,  2013.  
  • 3. HISTORICAL  BACKGROUND    Ryde  Hospital  was  established  in  1934,   and  provides  inpatient,  outpatient  and   community  services.      Total  Bed  base  of  approximately  182  .    This  includes  64  sub-­‐acute  beds  in  the   Graythwaite  Rehabilitation  Centre,   opened  in  September  2013.  
  • 4.      The  Hospital  is  part  of  the  Northern   Sydney  Local  Health  District.      Allied  with  Royal  North  Shore  Hospital   as  Royal  North  Shore  Ryde  Health   Service    Affiliated  with  the  University  of   Sydney.  
  • 5.  Peri  Operative  Services  include,  Screening,   PAC,  Day  Surgery,  Day  of  Surgery   Admissions,  Operating  Theatres  and  PACU    In  2009  Ryde  Peri  Operative  Unit  was   recognized  for  achieving  the  best  results  in   NSW  Health  Patient  Satisfaction  Survey,   for  Public  and  Private  Hospitals.  
  • 6. BACKGROUND   CHALLENGING  AND  CHANGING  THE   PROCESS  OF  ATTENDANCE  AT  A  PRE   ADMISSION  CLINIC  PRIOR  TO  ELECTIVE   SURGERY  
  • 7. NATURE  OF  THE  PROBLEM    Booking  forms  entered  into  the  system   by  admission  clerical  staff.    Appointment  for  PAC  based  on  discharge   intention  not  on  individual  needs      Patient’s  not  appropriately  assessed  prior   to  admission  
  • 8.   Regardless  of  medical  or  surgical  history   and  co-­‐morbidities  day  surgery  patients   routinely  were  not  required  to  attend  PAC   unless  requested  by  VMO.     This  system  did  not  take  into  account  the   demographics  of  this  area  with  a  significant   number  of  pa8ents  aged  60+  nor  did  it   address  discharge  planning  needs  relevant   to  an  aging  popula8on  
  • 9.   Consents  not  being  rec8fied  prior  to  day   of  admission     The  number  of  pa8ents  being  cancelled   on  arrival     The  number  of  unplanned  overnight   stays     Delays  in  transfer  to  Opera8ng  Suite     Delays  in  discharging  pa8ents  home  
  • 10. Audi8ng  Process  for  Data   Collec8on     Complex     Difficult  to  Extract     Time  Consuming  
  • 11. Planning  and  Implementing   Solutions   were    Once  the  benefits  of  screening   recognised  a  multi  disciplinary   approach  was  taken  involving  the   stake  holders.     Staff  involved:-­‐    Admission  Clerks    Bed  Manager    Registered  Nurse  
  • 12.  Allied  Health    Anaesthetic  Department    Nurse  Manager  Operating  Theatre/Peri   Operative  Unit    Director  of  Nursing    Visiting  Medical  Officers  
  • 13. Objectives   Effective  Pre-­‐op  screening  :-­‐    Appropriate  patients  attend  PAC    PAC  resources  utilised  efficiently    Significant   issues   identified   and   acted   upon  prior  to  admission    Referrals  to  other  health  professionals   if  required  
  • 14.  Decreased  day  of  surgery  cancellations    Consent  issues  rectified  –       o  signatures   N   ncorrect  procedures   I   ncorrect  sites   I   bbreviations   A  Decreased  unplanned  overnight   admissions  
  • 15.   Decreased  unplanned  admissions   to  CCU/HDU     BeKer  pa8ent  outcomes.  
  • 16. CLINICAL  SCREENING  PROCESS   INFORMATION  REQUIRED  :   NAME,  AGE,  LOCALITY,  LANGUAGE,   LENGTH  OF  STAY    URGENCY   ADMISSION  DATE,  PRE-­‐OP   REQUIREMENTS,  PROCEDURE,   CONSENT,  MEDICAL/SURGICAL/ SOCIAL  HISTORY   RFA  IN  CLINICAL  SCREENER  TRAY  IN  ADMISSIONS  OFFICE   SCREENING  OF  HEALTH  QUESTIONAIRE  &  VMO  HISTORY   NO  PAC   REVIEW   RECENT  PRE-­‐ADMISSSION   CLINIC  (WITHIN  3   MONTHS)   NO  CHANGE  IN  HEALTH   STATUS  OR  POST  –OP   NEEDS   NO  PROBLEMS  WITH   PREVIOUS  ANAESTHETICS   PHONE  SCREEN  TO  DECIDE   IF  PAC  OR  NO  PAC   PHONE   INTERVIEW   IF  REQUIRED   PAC   •  •  APPOINTMENT   MADE   •  •  WHEN  INFORMATION  IS  CORRECT   PATIENT  IS  CATEGORISED  PAC  OR  NO   PAC   •  •  •  HEALTHY,  UNDER  60  YEARS   NO  CO-­‐MORBIDITIES  OR   SIGNIFICANT  MEDICAL  HISTORY   OTHER  THAN  THE  REASON  FOR   ADMISSION   NO  MEDICATION  EXCEPT  OCT,  HRT   NO  PREVIOUS  PROBLEMS  WITH   ANAESTHETICS   ADMISSION  IF  FOR  MINOR/SHORT   STAY  PROCEDURE   NO  SOCIAL  ISSUES  RE  TRANSPORT   AND  HAS  A  RESPONSIBLE  ADULT   OVERNIGHT  IF  DAY  PATIENT   POST-­‐OP  HOME  SUPPORT  
  • 17. GUIDELINES  FOR  ATTENDANCE  AT   PRE-­‐ADMISSION  CLINIC    Patient  Indicators    Surgical  Indicators    Anaesthetic  Indicators  
  • 18. PRE-­‐ANAESTHESIA  INVESTIGATIONS   DETERMINED  BY  COMPLEXITY  OF   SURGERY   MINOR  GENERAL  SURGERY  AND  DAY  SURGERY  -­‐  anal  surgery,  appendectomy,  diagnos8c  laparoscopy,  excision  skin  lesions,   No  Tests  Required   breast  lumpectomy,  elec8ve  hernia  repair,  endoscopic  sinus  surgery,  tympanoplasty,  adenoidectomy,  gastroscopy.   UROLOGY   MSU     UPPER  GI  SURGERY,  Cholecystectomy   FBC,  UEC,  LFT   LOWER  GI  &  MAJOR  GENERAL  SURGERY  e.g.  Small  bowel  resec8on,  colectomy,  colostomy,  diagnos8c  laparotomy,   gastrectomy   FBC,  UEC,  G&H,  LFT,  VIT  B12,  FOLATE,   IRON  STUDIES   VASCULAR  SURGERY  e.g.  Varicose  Veins   PERIPERAL  VASCULAR  SURGERY   No  tests  Required   FBC,  UEC,  ECG   LOWER  LIMB  SURGERY  E.G.  Hip  Arthroplasty,  Total  Hip  Replacement,  Femoral  fractures,  Total  Knee  Replacement,  Tibial   Osteotomy   FBC,  UEC,  G&H,  LFT,  VIT  B12,  FOLATE,   IRON  STUDIES   HIP  REVISION  OR  KNEE  SURGERY   FBC,  UEC,  X-­‐MATCH  2  UNITS   ARTHROSCOPIC  PROCEDURES,  LIGAMENT  RECONSTRUCTIONS  TENDON  REPAIRS   No  tests  Required   OPERATIONS  ON  THE  FOOT   No  tests  Required   UPPER  LIMB  SURGERY  &  HAND  SURGERY   No  tests  Required   SHOULDER  ARTHROSCOPY   No  tests  Required   OPEN  SHOULDER  PROCEDURES   FBC,  UEC,  LFT,  VIT  B12,  FOLATE,  IRON   STUDIES   SHOULDER  ARTHROSCOPY/REPLACEMENTS   FBC,  UEC,  G&H,  LFT,  VIT  B12,  FOLATE,   IRON  STUDIES   REMOVAL  OF  METAL  WARE  FROM  ANY  SITE   No  tests  Required  
  • 19. ADDITIONAL  INVESTIGATIONS  IF   PATIENT  HAS  RELEVANT  INDICATIONS  &  HAS   NOT  BEEN  RECENTLY  TESTED   Full Blood Count 1.  > 60yrs[except minor surgery] 2.  History/examination suggestive of anemia. 3.  Known cardiac, pulmonary or renal disease. 4.  Malignancy. 5.  Coagulation disorders. 6.  Sepsis Urea, Electrolytes 1.  > 60yrs[except minor surgery] 2.  Known cardiac, renal disease. 3.  Diabetes Mellitus. 4.  Drugs that interfere with electrolyte homeostasis or renal function. 5.  Intercurrent vomiting/diarrhea. Liver Function Tests 1.  Known liver disease. 2.  High alcohol intake. 3.  Hepatitis carrier. 4.  Poor nutritional status. 5.  Intra-abdominal malignancy. Coagulation Profile 1.  Warfarin/heparin therapy. 2.  Hepatic disease/jaundice. 3.  Coagulation disorders. Blood Sugar Level 1.  Diabetes Mellitus. 2.  BMI >35. 3.  Positive urine sugar. 4.  Chronic Steroid therapy. HbA1C 1.  IDDM if not done in past 3 months. 2.  IDDM with brittle/ unstable disease.
  • 20. ECG 1.  Age > 50yrs [male]; >60 yrs. [female] 2.  History/examination suggestive of undiagnosed or worsening cardiac disease. [E.g. chest pain, SOBOE] 3.  Pacemakers. 4.  Previous MI/CCF/Arrhythmia/ Valve lesion. 5.  Patients with risk factors such as diabetes, hypertension, and vascular disease. 6.  BMI > 35. Not required if performed in last 6 months and condition stable. CXR 1.  History/examination suggestive of undiagnosed or worsening respiratory disease. 2.  Close exposure to active TB within past year. 3.  Known irreversible cardiac or pulmonary disease and not had CXR within last 6 months. Infection Control 1.  MRSA swabs if previous history, all DOSA, all residents in Health Care Facilities 2.  HIV/Hepatitis if deemed high risk. 3.  Midstream urine for all joint replacements, recurrent UTI’s, positive nitrates on urine dipstick. Group and Hold 1.  Anemia. 2.  Severe Sepsis Mid Stream Urine 1.  Hysterectomy 2.  Joint Replacement Spirometry 1.  Unstable and/or significant CAL or respiratory illness. 2.  BMI > 40. 3.  Spinal deformity. 4.  Neuromuscular disease. 5.  Previous pneumonectomy. Additional blood tests: 1.  ABG 2.  ? Obstructive Sleep Apnoea: Sleep studies. 3.  Cervical Spine X-ray in at-risk patients with Down’s Syndrome, Rheumatoid arthritis 4.  Thyroid Function tests. 5.  Drug. 6.  Troponin levels 7.  B HCG
  • 21. RYDE  PRE-­‐ADMISSION  CLINIC   PATIENT   DAY   DOSA   ADMIT  DAY  PRIOR   ED  CLERK    NAP  PATIENT   RECEPTION  PAC  WAITING  ROOM   BILLING  FOR  ECG   INTERPRETER   (IF  REQUIRED)   PHARMACIST   (IF  REQUIRED)   MEDICAL  OFFICER   CHART   MEDICATIONS   CHART  FLUIDS   CHART  PREP   AS  REQUIRED   ECG   SCREEN  FOR  MRSA   (IF  REQUIRED)   NURSE   U/A   MSU   FAX   ANAESTHETIST   INSTRUCTIONS   PHOTOCOPIED  &   GIVEN  TO  PATIENT   PATHOLOGY   X-­‐RAY   (IF  REQUIRED)   NURSE   CHECKS   PATIENT    OUT   EMR   NURSE   REFERALS  TO     DIETICIAN   DIABETES     DIETICIAN   ORTHOPAEDIC   OCCUPATIONAL   THERPAIST  
  • 22. PATIENT  REFERRALS  FROM  PAC  
  • 23. DESIRED  OUTCOMES    Key  Performance  Indicators  met    All  appropriate  investigations  completed  and   reviewed    Assessment  by  appropriate  health  care   professionals    Bariatric  patients  identified  as  per  policy    Discharge  planning  commenced  &  risks   identified  and  managed  
  • 24.   Decreased  Day  of  Surgery  Cancellations     Decreased  Unplanned  Overnight  Admissions     Decreased  Unplanned  Admissions  to  CCU/ HDU     Maximise  Operating  Theatre  Utilisation     Ensure  First  Case  on  Time  KPI’s  are  met     Partnering  with  Consumers  e.g.  GP’s.  
  • 25. WHY  HAVE  PAC  NUMBERS   INCREASED?    Aging  population    New  Policies/Guidelines    CALD  patients    Increase  volume  of  patients    -­‐  “one   hospital/two  sites”    Contributing  life  style  factors    Bariatric  (correlates  with  Global  trends)    Diabetic  
  • 26. WHERE  ARE  WE  NOW?    HOSPITALIST    ANAESTHETIST  -­‐    VMO  &  REGISTRAR      3  NURSES    ECG  NURSE    PHARMACIST    CLERK    CLINICAL  SCREENER  
  • 27. PRE-­‐ADMISSION  DATA  2013       Jan-­‐13   Feb-­‐13   Mar-­‐13   Apr-­‐13   May-­‐13   Jun-­‐13   Total  number  of   surgical  patients   screened     114   245   217   176   244   226   157   228   237   248           Total  number  surgical   admissions   110   245   217   176   244   226   157   228   237   248           104%   100%   100%   100%   100%   100%   100%   100%   100%   82   176   147   113   174   175   111   166   174   74.55%   71.84%   67.74%   64.20%   71.31%   77.43%   Total  No  of  medical   patients  screened   7   7   8   7   8   8   2   6   4   9           Total  number  of   medical  admissions   7   7   8   6   8   8   2   6   4   9           100.00%   100.00%   100.00%   116.67%   100.00%   100.00%   114   118   113   114   147   92   %  patient  screened   through  PPP  process   (benchmark  100%)   Total  No  Day  only   surgical  admissions   No  of  D/O  as  a  %  of   total  admissions   (Benchmark  80%)   %  of  Total  Medical   admissions  screened   Total  PAC  attendance   Jul-­‐13   Aug-­‐13   70.70%   72.81%   Sep-­‐13   Oct-­‐13   Nov-­‐13   Dec-­‐13   100%  #DIV/0!   #DIV/0!   188           73.42%   75.81%  #DIV/0!   #DIV/0!   100.00%   100.00%   100.00%   100.00%  #DIV/0!   #DIV/0!   140   114   121   170          
  • 28. Total  PAC   attendance  as  %  of   104%   Total  Admissions   No  of  Day  Only   64   patients  at  PAC   Day  Only  patients   attending  PAC  as  %   56.14%   of  Total  PAC   Day  Only  patients   attending  PAC  as  %   58.18%   of  Total  Admissions   No  of  ECG's  in  clinic       No  of  ECGs  other       ECG's  as  %  of   patients  attending   PAC   ECG's  as  %  of  total   admissions   Total  No  of  admit   day  prior  seen  in  the   clinic   Admit  day  prior  as  a   %  of  total  admissions   (Benchmark  <  10%)   48%   52%   65%   60%   41%   89%   50%   51%   74   68   66   92   65   85   67   80   62.71%   60.18%   57.89%   62.59%   30.20%   31.34%   37.50%   95   98   8   0.00%   69%  #DIV/0!   #DIV/0!       118               70.65%   60.71%   58.77%   66.12%   69.41%  #DIV/0!   #DIV/0!           37.70%   28.76%   54.14%   29.39%   33.76%   47.58%  #DIV/0!   #DIV/0!           98   134   73   78   101   108   152                   16   12   14   5   9   11   5   13                   80.51%   86.73%   85.96%   91.16%   79.35%   55.71%   88.60%   89.26%   89.41%  #DIV/0!   #DIV/0!           0.00%   38.78%   52.53%   62.50%   60.66%   34.51%   55.41%   49.12%   47.68%   66.53%  #DIV/0!   #DIV/0!           0   9   5   8   6   6   0.00%   3.67%   2.30%   4.55%   2.46%   2.65%   3   5   5   Number  of   cancellations  on  Day   5   3   2   of  Surgery                                                                                                                                                                               13   6   5   8.28%   2.63%   2.11%   2   2   5   4                       1.61%  #DIV/0!   #DIV/0!           4                      
  • 29.     Jan-­‐13   Feb-­‐13   Mar-­‐13   Apr-­‐13   May-­‐13   Jun-­‐13   No  of  Cancellations  as   a  %  Of  Total   Admissions   (Benchmark  <2%)   4.55%   1.22%   0.92%   1.70%   2.05%   2.21%   1.27%   0.88%   2.11%   3   6   6   10   4   5   4   5   7   2.73%   2.45%   2.76%   5.68%   1.64%   2.21%   2.55%   2.19%   2.95%   8   8   7   No  of  Cancellations   day  prior   No  of  cancellations   day  prior  as  a  %  of  the   total  admissions   Number  of  actual   admit  day  priors  for   the  month                           Jul-­‐13   Aug-­‐13   Sep-­‐13   Oct-­‐13   Nov-­‐13   Admit  day  prior  as  a  %   of  total  admissions   (Benchmark  <  10%)   0.00%   0.00%   0.00%   0.00%   0.00%   0.00%   5.10%   3.51%   2.95%   Number  of  Unplanned   overnight  stays   2   3   5   1   6   2   1   5   3   2%   2%   3%   1%   3%   1%   1%   3%   2%   No  of  of  unplanned   overnight  stays  as  a  %   of  the  total  day  only   surgery   Dec-­‐13   1.61%  #DIV/0!   #DIV/0!   4           1.61%  #DIV/0!   #DIV/0!   3           1.21%  #DIV/0!   #DIV/0!   4           2%  #DIV/0!   #DIV/0!  
  • 30. SUSTAINING  CHANGE    Best  practice    Policy  Directives    Review  of  Data    Peer  Review    Consultation  with  Stake  Holders  
  • 31. FUTURE  SCOPE    Increased  PAC  sessions    Nurse  based  PAC  
  • 32. ULTIMATE  AIM     O  DELIVER  A  SAFE  AND   T COMPLETE  PATIENT   EXPERIENCE     he  “PACage”  is  safe  to  deliver. T   Yes!!    
  • 33. QUESTIONS??   THE  END   THANK  YOU   Presenta8on  Compiled  and  Edited  By  Kerry  Bonner  NUM  &  Margaret  LyKle  CNS  Ryde  Peri-­‐op