QIP SCIP11.15Chester.ppt

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  • 1. Working Together -Appropriate Antibiotic Administration The Health Network of THE CHESTER COUNTY HOSPITAL
  • 2.  
  • 3. About Us……..
    • Acute Care Hospital-221 Beds
    • Open Heart Surgery and Interventional Cardiology with Electrophysiology Services
    • Heart Surgery program affiliated with Cleveland Clinic
    • Level III NICU and Pediatric Unit with Children’s Hospital of Philadelphia Neonatologists and Pediatricians on site 24/7
    • Oncology Program affiliated with University of Pennsylvania Cancer Center
    • Beta Site for Siemens EMR and CPOE
  • 4. Surgical Antibiotic Beginning
    • In September 2002, QIP performed baseline data abstraction at PA hospitals:
    • Our Hospital sample:
      • N=18 cases
    • Small sample size, but a beginning………
  • 5. QIP Baseline Report
  • 6. Continuing the Journey
    • Joined QIP Surgical Infection Prevention Collaborative in June 2003
    • Advised to trial process with small patient population to begin improvement processes
    • Focused on antibiotic usage :
      • Timing
      • Appropriateness
      • Discontinuation
    • Goal was to achieve 100% compliance with antibiotic usage
  • 7. Surgical Infection Prevention Team
    • Orthopedic Surgeon
    • General Surgeon
    • Cardiac Surgeon
    • Microbiologist
    • Infection Control Practitioner
    • Nursing Director of OR
    • Quality Staff (2)
    • OR Staff Nurse
    • Pharmacist
  • 8. First Step
    • Presented information and recommendations to department of surgery
      • Majority feared delay in flow of patients from pre-op area to OR
      • Concerned antibiotic levels would be inadequate at time of incision
      • Wanted antibiotic administered in ambulatory care to observe for adverse reactions
      • For inpatients, wanted antibiotic given 45 minutes pre-op and prior to transport
  • 9. Second Step
    • Met with department of anesthesia to gain their support for administering the antibiotic
    • Major reluctance at first, but bought in soon after
    • Holding nurse assigned to coordinate flow of patients
    • Dept of Surgery assigned urologist to be the liaison to our team
  • 10. Small Steps
    • We selected antibiotic usage for Hip, Knee and Bowel Resection patients
    • Specific Indicators:
      • Prophylactic Antibiotic Within 1 Hour Prior To Incision
      • Appropriate Antibiotic Selection for Surgical Patients
      • Discontinuation of Antibiotics Within 24 Hours After Surgery End Time
  • 11. Surgeon Buy-In
    • General surgeons and orthopedic surgeons agreed to the trial
    • Two homogeneous groups
    • Generally focused on good patient outcomes
    • Known to adopt changes more easily than some
  • 12. Being Well-Prepared
    • Prior to beginning of trial:
      • Developed form to place in front of each chart prior to sending patient to OR
        • Pre-op antibiotic reminder form
        • In large letters, reminded anesthesia to document time antibiotic given on their anesthesia record
    • Placed laminated signs about timing, appropriateness, and discontinuation of antibiotics every place we could find a bare spot!
      • Educate, educate, educate - all stakeholders
  • 13. Walking in Their Shoes
    • Spent a day in the OR observing and documenting antibiotic administration processes
    • Found wide variation
    • Validated that standardization was important to good care and outcomes
  • 14. Trial Begun-Glitches Happen
    • August 2003
    • Hips, Knees and Bowel Resection patients
    • Glitches Happen
      • Documentation issues with anesthesia-old form-old habits
      • Some inpatients administered antibiotic prior to transport (as before)
      • Re-educated
  • 15.  
  • 16.  
  • 17. Spread Just Happened
    • Slowly but surely, anesthesia adopted process of antibiotic administration for all surgeries
    • Did not discuss with all surgeons prior to this change-it just happened!
    • No disgruntled surgeons showed up at my door
    • In fact, were okay with change-they saw no adverse effect from changes
  • 18. Current Status
    • Process for timing, appropriateness and discontinuation being maintained
    • Certain surgical specialties are late adopters
    • SIP data being submitted for Public Reporting and JCAHO
  • 19.  
  • 20.  
  • 21. Maintaining the Gain
    • In top 10% Nationally for administering antibiotic within one hour prior to incision
    • Better than PA rate for discontinuation of antibiotic
    • There is not comparative data for recommended antibiotic measure
  • 22. What didn’t work?
    • Trying to take on too much for beginning a large process change
      • Physician approach
      • Patient populations
    • Assuming that one strong education effort is all that is needed
    • When antibiotic is given in holding area before patient is wheeled into OR, abx timing is can be delayed
      • Solution: Roll the clamp when you roll the wheels!
  • 23. What has worked
    • Using small population of patients to begin
    • Written form for antibiotic reminder
    • Collaborating with other hospitals
    • Engaging anesthesia and OR staff
    • During OR pause, asking about antibiotic
    • Adding documentation about antibiotic on OR nursing form
    • Putting the antibiotic on pre-op and post-op surgical order sets (so it is discontinued within 24 hrs.)
  • 24. What else has worked?
    • Drilling down any charts that fall out for physician and specialty
    • Giving feedback to the physicians individually and at medical section and committee meetings, including governing board meetings
    • Forming a Surgical Infection Prevention taskforce that meets monthly to review data and work on insulin protocol and hypothermia
    • This taskforce presents progress at Patient Safey and quality meetings and board committee on a quarterly basis
  • 25. Problems we still face…
    • Physicians are not documenting reason for continuing antibiotic-prophylaxis vs treatment
    • Unasyn was given for bowel resections, but not approved until July 1, 06 discharges
    • Certain surgical specialties are locked into old theories
    • Final data broken down into specialties…........
  • 26.