QIP SCIP11.15Chester.ppt


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QIP SCIP11.15Chester.ppt

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