A partnership of the Healthcare Association of New York State and the Greater New York Hospital Association

Interventions to Enhance OR Safety Across the Continuum of Surgical Care

March 20, 2014

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Agenda

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Maimonides Medical Center Improving Surgical Safety and

Outcomes

Patrick Borgen, MD Chairman Department of Surgery Samuel Kopel MD, Chief Medical Officer

Sheila Namm Esq. RN, MA, Sr. VP Professional Affairs Susan Goldberg RN, BSN, MPA, VP Organizational Performance

Sameh Samy MBBCH, MSA, CPHQ, Director of Quality Outcomes

March 20, 2014

Strategies for Improving Surgical Safety and Reducing Surgical Site Infections:

Creating the Infrastructure

• Established formal Surgical Safety Committee • Recruited senior physician champions • Included a core team of experts: Surgery,

Anesthesiology, Pharmacy, Infectious Disease, Nursing, Performance Improvement

• Department Chairs commitment to clinician accountability

• Data driven and action oriented

Process Changes Across the Surgical Continuum: Pre-Operative

• Pre-Operative Risk Assessment Portsmouth

(POSSUM Score) • Comprehensive evidence based pre-

operative risk assessment tool • 12 physiologic factors/6 operative

parameters • Second opinion by attending surgeon in complex cases

Process Changes Across the Surgical Continuum: Pre-Operative cont.

• Mandatory hospitalist pre-operative medical evaluation for in-patient procedures

• Long term plan is to apply to all same day surgical admissions

• Utilization of EMR to facilitate best practice – Mandatory pathways for VTE risk and

prophylaxis – Appropriate antibiotic selection algorithms

Process Changes Across the Surgical Continuum: Peri-Operative

• Pre-Operative Checklist/Time-Out • Post-Operative De-Briefing • Team STEPPS Training and

Implementation: Off-Site Two Day Kick-Off; Master Trainers

Identified On Site Training; OR’s closed for 3 hours- 300 + staff members participated Anchoring: Focus on briefs, debriefs, huddles Rapid Cycle PDCA; small tests of change

Process Changes Across the Surgical Continuum: Post-Operative

• Medical Co-Management of General Surgery and Vascular Patients – Kick-off in 2013 Dedicated hospitalists Well received by Nursing, Residents , and

Attending Physicians Early results are promising Expansion to Orthopedic and Neurosurgery

patients

Process Changes Across the Surgical Continuum: Post-Operative cont.

• Modified Early Warning System (MEWS) – Six vital signs entered into monitoring device equipped

with software that auto- calculates the score • Respiratory Rate • Heart Rate • Systolic BP • Level of Consciousness • Temperature • Hourly Urine Output (previous 2 hours)

• RN algorithmic response to the score triggering notification to RRT, SICU RN Manager, LIP, Attending MD, Medical Hospitalist, Chief Resident

• RRT rounding on high risk patients at night

Improving Outcomes for Surgical Patients With BMI>40

• The Challenges – Medical:

• Diabetes • Obstructive sleep apnea • Coronary artery disease • Risk for thromboembolic disease • Skin and soft tissue infection

– Physical: • Mobility challenges • Pressure Ulcers

– Social service and post-discharge needs: • Home bound • Nutritional requirements and counseling

– Care giver support

Continuum of Consistent Care and Expectations

• Develop reasonable “Best Practices” • Educate providers with supporting evidence

• Discuss plan of care with patient and family • Rationale for intensified evaluation and

therapy • Create reasonable expectations based on

“Best Practices” • Implement “Sensitivity Training” for staff

specific to high BMI patients

Complexity of Care for High BMI Patients:

Consistent Education/Information From All Providers

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Process Changes Across the Surgical Continuum: Post-Operative Discharge Planning

• Post Operative Teaching; – Wound care management educational material

with physician contact information – Confirmation of follow-up appointment

• Ambulatory Surgery: Registered Nurse follow-up phone calls 24 hours post-discharge

Surgical Outcomes

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Post-op VTE Post-op Sepsis

• 58.3% decrease in the post-op VTE risk-adjusted rate

• 53.1% decrease in the post-op sepsis risk-adjusted rate

Surgical Outcomes NHSN – Colon Infections Surgical Mortality Rate

• 23.3% decrease in the colon infection rate

• 22.5% decrease in the surgical mortality rate

2014: NEXT STEPS

• Videotaping of Time-Outs: 5% of all cases Standardized criteria for critique by objective

reviewers Real time feedback to the surgical team

• Mandatory hospitalist pre-operative evaluation expansion to Ambulatory procedures

• Physician report cards • Two attending physicians present during high-risk

cases (Whipple)

Hospital Discussion and Question and Answer

Performance To Date and Next Steps

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Reduce Harm across the Board

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NYSPFP Educational Resources

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NYSPFP Educational Resources

Videos are available on the NYSPFP website: https://www.nyspfp.org/Members/Initiatives/InfectionPrevention/SSI/Tools.aspx

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Overall SSI SIR

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New York State PFP SSI Status

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↓40%

↓52% ↓26%

↑27%

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Colon SSI SIR

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Source: NHSN (Q1 2012-Q2 2013). Notes: Progress is seen as movement toward the bottom right corner of the figure, indicating both reduction in harm and low current event rate. Eight HENs showed improvement below -30 percent and are not shown on the graph: DFW, Dignity, EHEN, Intermountain, LifePoint, NJ, VHA, and WA. Current rates are above benchmark. Three HENs are not shown because reporting was under 60 percent: Iowa, Minnesota, and Ohio Children's.

SSI-Colon Surgery Standardized Infection Ratio (SIR), Current Rate, and Percent Improvement by HEN (HENs with at least 60 Percent Reporting) (NHSN), Q1 2012 – Q2 2013

Source: NHSN (n = 2,614 to 2,673 HEN-aligned hospitals, depending on the quarter).

National SSI-Colon Surgery Standardized Infection Ratio (SIR) (NHSN), PfP-Aligned Hospitals (n = 2,614)

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High Performing Hospitals in NYSPFP

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High Performance in NYS

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Colon SSI Prevention Upcoming Events

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Registration and further information available on the NYSPFP website: https://www.nyspfp.org/Members/myCalendar.aspx