Join SUSP Affinity Groups!
Learn from experts and other SUSP hospital teams who
are working on what you’re working on
Early recovery
protocol (ERP)
Preop care
coordination
Pain management, fluid
management, postop
mobility
Glucose control, bowel
prep, oral antibiotics
Antibiotic prophylaxis,
normothermia, skin prep
OR traffic, sterile
technique, surface
contamination
Traci Hedrick, MD
University of Virginia
Melanie Morris, MD
University of Alabama
Skandan Shanmugan, MD
University of Pennsylvania
Mariana Pehar
Johns Hopkins Hospital
Coaching calls every
other month
SCIP measures
Environmental
management
Quarterly Coaching Calls
Click this link SUSP Affinity Group Registration Link to register
for an affinity group by Tuesday, May 20th!
DRAFT – final pending AHRQ approval
Hospital Team
Experiences
Noble Hospital
Molly Carlin MSN, RN
Noble Hospital
93 Bed Hospital
Noble Hospital is in a 40,000+
community in Westfield, MA
We provide service to seven
surrounding towns
SUSP Team
• Kristen Kroll
CST
• Michael
Cromwell CST
• Kathie Keleher
CST
• Nadya Guseva
CST
• Karen Raymaakers
OR RN
• Lida Powell OR RN
• Pamela Kislus OR
RN
• Rhonda Partyka OR
RN
• Deb Daniels OR RN
SUSP Leadership
Team
• Ann Reichert- Director of Risk
Management
• Mary Jane Lamb- Infection Control
• Dr. Schonholz- Surgeon Champion
• Dr. Desai- Chief of Anesthesiology
• Kim Samele- Director of
Perioperative Services
• Molly Carlin- Perioperative Clinical
Coordinator; SUSP Coordinator
Noble Hospital
• Describe how you developed and
implemented your SUSP project
SUSP team formation- Development of
your SUSP plan
HSOPS administration
Technical and adaptive work that you
addressed How and why did you make
these choices?
Challenges and successes that you
experienced during this process
Noble Hospital
SUSP Team Formation
The SUSP leadership team has
gone through some transitions. At
one month into the SUSP journey
we had a change in nursing
leadership. The SUSP leadership
team was chosen by the previous
nursing manager.
Noble Hospital
SUSP Team Formation
Being part of the SUSP team has
been an open opportunity to all of
the staff. The staff has been very
excited to come to meetings, bring
attention to safety concerns, have
a hand in the planning process,
gathering data and implementing
change.
Noble Hospital
HSOPS administration
• 98% completion rate
• Excitement
• The SUSP team’s excitement for change
has proliferated to the entire staff.
• Reasoning
• The SUSP team provided to the staff why
completing the HSOPS survey was
important
• Encouragement
• They encouraged each other to complete
the surveys!
• We have a great staff!!
Noble Hospital
Technical and adaptive work
• Infection Control
• Standardization of the cleaning
process
• Skin Asepsis
•
•
•
•
•
Audit
Review of policy; plans for revision of
Standardization of prep
Purchasing sterile prep tray
Creation of an education module
Noble Hospital
Technical and adaptive work
• Equipment
• Safety straps
• Sliding stretchers
• New Armboards
• Organization
• Ordering problems
• Unable to find proper equipment in
emergency situations
• Safety
• Electrosurgical education module
Noble Hospital
SUSP Challenges
• Time!!!!
• Surgeon involvement
• Anesthesiologist involvement
Noble Hospital
Successes
• 98% completion of HSOPS
• Growth as a team
• Increase in safety
Noble Hospital
• What’s next for your team?
• Begin Audit on Normothermia
• Antibiotic procedure and policy
Noble Hospital
• How have you obtained
physician buy-in?
Questions
Hospital Team Experiences
Palmetto Health Baptist
Anne Brittain PhD RT(R)(M)(QM), CPHQ
PI Project Manager
Palmetto Health Baptist
• Located in the heart of
downtown Columbia,
SC
• Part of a 5 hospital
system
• 489 bed acute care
hospital
• 4,000+ physicians,
staff and volunteers at
PHB alone
• Celebrating 100th
anniversary in 2014
Palmetto Health Baptist
Palmetto Health Baptist
• Team Formation- We wanted:
– Mixture of peri-op and inpt care staff
– Mixture of frontline staff, educators, physicians,
and management
– People who are interested and willing to work
• SUSP Plan
– Implement The Joint Commission Center for
Transforming Healthcare’s recommendations
for reducing colorectal SSI’s with a goal of
reducing our colon SSI rate to <5.81/100 cases
Palmetto Health Baptist
Joint Commission Center for Transforming HealthCare
recommendations to reduce Colorectal SSI:
1.
2.
3.
4.
5.
Pre-Op health optimization
Pre-Op CHG bathing
Alcohol based prep agents
Peri-op patient warming
Weight-based antibiotic dosing
with redosing after 4 hours
6. Entire team changes
gowns/gloves after anastomosis
7. Segregation of clean and dirty
instruments during and after
anastomosis
8. Ensuring wound classification is
correct at end of case
Palmetto Health Baptist
HSOPS Administration
– Educated staff prior to
beginning survey process
– Daily reports of participation
rates
– Resent survey link as many
times as needed
– Promised homemade Italian
cookies to all units that had >
60% participation
– Results shared at monthly
meeting with staff and
physicians
Palmetto Health Baptist
PSSA Administration
– Created a fact sheet
related to science of
safety and SUSP
– Did the survey at a
monthly staff meeting
– Core group convened to
categorize results
– Results shared and
discussed with staff at
next staff meeting
– Same process followed
with physicians
Palmetto Health Baptist
• Back to Basics Campaign
–
–
–
–
–
Hand hygiene
OR traffic
Surgical scrub
Sterile Technique
EVS in all areas
• Safe Surgery Checklist
• Surgeon engagement
– Monthly update and
participation at surgeon led
surgical services meeting
– Surgeon drilldown and
review of all colorectal SSI
THIS MONTH’S FOCUS:
Palmetto Health Baptist
Colon SSI Drilldown
•
•
•
•
•
•
•
•
•
•
Gender (male)
Procedure (open)
Operative Time (>4hr)
ASA (>2)
Emergency? (yes)
Transfusion (yes)
Ostomy (yes)
BMI (>25)
Age (>70)
Smoker (yes)
•
•
•
•
•
•
•
•
•
Wound class (>clean-contaminated)
Left colon/Rectum (yes)
Diabetic pt pre-op A1c (>8.0)
Peri-Op BG (>200)
Pre-Op Albumin (<3.3)
Pre-Op Steroids (yes)
Cancer pt (yes)
Multiple comorbidities (yes)
Redose abx for case > 4 hrs
(no)
Palmetto Health Baptist
FY13
• Colon SSI rate =
7.917/100 cases.
• Patients who ended
up with a colon SSI
had an average of 5.8
risk factors.
• 5% SSI pts > 9 risk
factors
FY14
• Colon SSI rate is
5.988/100 cases.
• Patients who ended
up with a colon SSI
had an average of 7
risk factors.
• 40% SSI pts > 9 risk
factors
Equates to a 25% decrease in infection rate with
those that get an SSI being at higher risk
Palmetto Health Baptist
• Successes
– Implementation of CHG baths pre-op
– Setting the same expectations for everyone
– Physician engagement in process
• Getting beyond “our patients are sicker” & questioning whether or
not it is “really an infection”
– Staff awareness of infections
• Challenges
–
–
–
–
New hospital opening
New management team in OR
Push back from a few very vocal surgeons
Staff fear
Palmetto Health Baptist
• What’s next for your team?
– Regroup once “aftershocks” of new hospital
grand opening die down
– Continue with a new focus in our “Back to
Basics” campaign each month
– Audits to gauge implementation of the various
TJC Center for Transforming Healthcare
recommendations
– Expansion of current SSI drilldown as newly
identified factors emerge
Thank you!
Questions?
anne.brittain@palmettohealth.org
Join SUSP Affinity Groups!
Learn from experts and other SUSP hospital teams who
are working on what you’re working on
Early recovery
protocol (ERP)
Preop care
coordination
Pain management, fluid
management, postop
mobility
Glucose control, bowel
prep, oral antibiotics
Antibiotic prophylaxis,
normothermia, skin prep
OR traffic, sterile
technique, surface
contamination
Traci Hedrick, MD
University of Virginia
Melanie Morris, MD
University of Alabama
Skandan Shanmugan, MD
University of Pennsylvania
Mariana Pehar
Johns Hopkins Hospital
Coaching calls every
other month
SCIP measures
Environmental
management
Quarterly Coaching Calls
Click this link SUSP Affinity Group Registration Link to register
for an affinity group by Tuesday, May 20th!
DRAFT – final pending AHRQ approval