September 18, 2014 Lynne Hall

GAPP COACHING CALLPROCEDURAL HARM WORKING

SESSION

Successes Doctors Specialty Hospital consistently uses the surgical

checklist on all surgical cases to reduce procedural harm.

The AORN Comprehensive checklist is working properly for the Crisp Regional Medical staff. The same assessment will be moved to SDC.

Ty Cobb Regional Medical Center is successfully completing the Safe Surgery checklist for surgical patients.

Floyd Medical Center is working with the OR team including physicians, staff and educators to incorporate the WHO surgical checklist into their OR.

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HOSPITAL SHARING

Roadblocks –All hospitals are working on Procedural Harm and have hard-wired the OR checklist into their systems. Solution: They will need to drill down into their data in order to decrease their numbers with the appropriate PSI data

HOSPITAL SHARING

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FAILURE TO RESCUE(FTR)

Failure to rescue is shorthand for failure to rescue (a patient) from a complication of an underlying illness or a complication of medical care.Failure to Rescue - AHRQ Patient Safety Networkpsnet.ahrq.gov/popup_glossar...Agency for Healthcare Research and Quality

PARTNERSHIPS INCLUDE: • Agency for Healthcare Research and Quality (AHRQ)• National Quality Forum (NQF)• The Joint Commission• Josie King Foundation (Condition Help)• Robert Woods Johnson Foundation

FAILURE TO RESCUE – BOLD LEAPT AIM

FTR – NATIONAL IMPLICATIONS

As many as 159,000 patients died from in-hospital cardiac arrest in 2013

15,900 – 31,800Nationally, the

potential number of Lives SAVED!

(based on 10-20% reduction)

Rapid Response Teams respond to the spark before it becomes a fire!!

Provide Mentor Support and monthly coaching calls/webinars

Leadership Buy-in and Champion to assist with spread throughout the organization

Formation of Rapid Response Team (RRT)Most common “Failure to Rescue”

event…..Sepsis related

FTR – KEY LEARNINGS

Standardize RRT policy and protocolsEducation of entire staff AND Patients

and Families about when and who to call

Analyze data and give feedback to entire hospital on regular basis

Establish mock drills and practice!

FTR – KEY LEARNINGS

Participate in Drills and SimulationsRRT call simulationsCode Blue Grand Rounds

Identify at risk populations earlyObesePeople with significant comorbidities and the elderly with or without comorbidities: COPD CAD CHF HTN Diabetes

FTR – RAPID CYCLE INNOVATIONS

Use of Early Warning systems Rothman Index MEWS

Open Safety huddlesReview all codesGaHEN hospitals have adapted an RRT

Bundle to include: Sepsis Screens Blood glucose within 5 minutes on all RRT calls Adding lactic acid levels to ABG’s done during

RRT calls

FTR – RAPID CYCLE INNOVATIONS

FTR RESULTS

FTR RESULTS

FTR – A HOSPITAL STORY

Continue spread nationally byEncouraging the use of RRT’s by identifying at-risk patients

Getting patients and families involvedUsing PSI-4 as one measurement indicator

Couple that with mortality rate, RRT and Code review, and patients moved to a higher level of care

FTR – FUTURE OBJECTIVES

PROCEDURAL HARM

Procedural Harm-related harm includes all coded complications directly related to medical and surgical procedures.

We have focused on surgical procedures

WHAT IS PROCEDURAL HARM

Working on Procedural Harm leads toDecrease in mortality rateDecrease in injuries related to surgery

Accidental Puncture or laceration Foreign bodies left in surgery Iatrogenic Pneumothorax Perioperative Hemorrhage or Hematoma Postoperative Respiratory Failure Rate Postoperative Wound Dehiscence

Overall patient harm

ADVANTAGES

The PatientThe Healthcare WorkerThe Environment

Look at activity in the OR at a minimum

3 INFECTIOUS PATHOGEN TRANSMISSION

Aseptic practicesSurgical AttireSurgical hand antisepsisSkin antisepsisMaintaining a sterile fieldTraffi c Patterns

Watch who and how many times the circulator goes in and out of the OR suite

HOW?

5 steps1. Pre-op brief – what is the operation? Who

is the patient? Any issues?2. Sign-in – Introduction of staff; operation

being performed; site marked; Any issues?3. Time-out – Stop!4. Sign-out – Final counts correct? Blood

loss? Any issues?5. Post-op Debrief – Anything to improve on?

What could be improved

THE WHO CHECKLIST

http://www.youtube.com/watch?v=6-myLENTBO4 – Correct Surgical Checklist

http://www.youtube.com/watch?v=REyers2AAeI - How not to do a surgical Checklist

VIDEO

Correct use of the surgical checklistObservation

How often do people come in and out of OR during the procedure?

What surgeries are causing the most problems and how do you address?

Do not disturb signs for OR doors/phones??

Break out the Surgical checklist to make sure each piece is being done

“TESTS OF CHANGE”

GRAPHS

TRANSPARENCY CRITERIA FOR LEAPT

3 Ways to be Transparent1. Put LEAPT data on Website2. Put LEAPT data in a public area in the

hospital3. Possibly put on GHA website

Important: Please let us know how you make your data public

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GAPP UPDATES

Mandatory Meeting Attendance If you miss a call you can listen to the recording within 1

week. Complete eval, and notify topic lead that you listened to get credit.

Data Submission: Due 3rd or each month – send to Lynne Hall (lhall@gha.org)

TOC (1 for sepsis and 1 for additional topic area) Checklist (1 per hospital)

Worker Safety Data (if in WS group) Send to Jean Allred (jallred@gha.org) due 15 th of month (about 45 days after end of reporting

month).

Next Coaching Call Workers Safety Working Session October 23 rd, 2014 1 -2

pm

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