Use this table to quickly find a mentor for the reduction of Surgical Complications with demographics similar to your own, or use 'ctrl+f' in your web browser to search for specific key words on this page.
Baystate Medical Center – Springfield, MA
Availability Status: Available to answer requests
Licensed Beds: 636
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: April 2002
Mentor Contact Name: Jan Fitzgerald, RN
Mentor Contact Email: janice.fitzgerald@bhs.org
Mentor Contact Phone: 413-794-2531
Additional Information:
We have developed reliable processes/systems/interventions to administer antibiotics, screen and treat high risk patients with beta blockers and DVT prophylaxis and apply preventative strategies to preempt VAP and post-op respiratory failure as well as a process to validate surgical event, hospital-acquired events and Patient Safety Indicator (PSI) accuracy prior to external reporting. We have also developed/instituted an evidence-based systematic review of all events to learn from each event as we build to identify and mitigate findings/errors in our process redesign.
Our work has resulted in cost savings of between $13,000 and $47,000 per case depending on which event occurs as well as what the patients original reason for admission. Additionally, our internal review of externally reported events has helped us to ensure this data is accurate (margin of error 60% with coded events) prior to clinical review. This not only helps to mitigate CMS HAC rule but also helps to identify issues.
Antibiotic administration started at 11% (2002) within 60 minutes prior to incision and have been well over the national benchmark x 8 years. Now sustained rates of 99-100%
Antibiotic discharge at 24 hours initially at 0% in 2002. Now sustained rates of >98% in all populations x 8 years.
Beta Blockers initially <20% (2002) now at >95% in eligible patients.
DVT prophylaxis <35% in 2003 now at 100% patients screened and 100% of patients getting appropriate treatment based on risk x 5 years.
Prevention of post-operative VAP rate has dropped significantly to < NHSN top 25th benchmark in last 2 years.
SSI rates are lowest in 14 years 1.0-1.3 (surgical volume approximate 29,000/year). Any infection is treated as a potentially preventable event and undergoes a systematic review.
Potentially preventable post-op MI and DVT rates are <0.05%.
See graphs of their results.
Mentor designation - 3/13/07
Information updated - 2/24/10
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Brookwood Medical Center – Birmingham, AL
Availability Status: Available to answer requests
Licensed Beds: 550
Teaching / Non-Teaching Status: Non-teaching
Setting: Urban
Start Date of Intervention Work: January 2003
Mentor Contact Name: Alison R. Garretson, RN, MBA
Mentor Contact Email: alison.garretson@tenethealth.com
Mentor Contact Phone: 205-877-2662
Additional Information:
The SCIP team at Brookwood Medical Center (BWMC) has been refining their SCIP processes since the beginning of 2003. We meet monthly utilizing a PDCA framework to encourage a systematic approach. At these monthly meetings, all unit directors must present any patient cases that occurred in their unit where SCIP care was not appropriate (i.e., what was the factor for failure) and must provide an action plan for the upcoming month. At physician led PI committees, we are beginning to engage the physicians in presenting the data, rather than just listening to a SCIP team member present the data. We also discuss "near misses" or cases whose care was corrected or redirected concurrently to help facilitate discussion related to an offensive (vs. defensive) approach to appropriate patient care.
Departments own specific SCIP indicators and work diligently to see that their interventions provide for positive outcomes for our patients. The pre-op area and Anesthesia own pre-op antibiotic timing. Anesthesia also owns perioperative beta-blocker administration and have even developed their own order sets. Through our daily patient care conferences, in conjunction with case management and nursing, we are able to ensure core measure compliance on our patient populations for post op antibiotic timing and VTE. The OR owns clip vs. shave and assists with pre-op antibiotic timing. The entire perioperative unit owns normothermia on all patients. While one department may own a measure, it takes input from each department to ensure this ''machine" runs smoothly and each patient receives the quality care they deserve.
Mid 2006 - 2007 data:
We were able to maintain high 90th percentile ratings in pre-op antibiotics and appropriate antibiotic selection.
For post-op antibiotics, we recognized a 12% increase over one month in our post operative antibiotic rate to 84.4% by having a pharmacist staffed in the PACU to review post operative medication orders and make changes per approved protocol.
Between July - September 2007 data
• Prophylactic Antibiotic Received within One Hour Prior to Surgical Incision – Overall Rate 96%
• Surgical Patients with Appropriate Selection of Prophylactic Antibiotic – Overall Rate 100%
• Surgical Patients with Appropriate Prophylactic Antibiotic Discontinuation – Overall Rate 96.9%
• Major Cardiac Surgical Patients with Controlled Post-Operative Serum Glucose 93%
• Surgical Patients with Appropriate Hair Removal 100%
• Colorectal Surgical Patients with Normothermia in PACU 100%
• Surgery Patients on Beta Blocker Therapy Prior to Admission Who Received a Beta Blocker During the Perioperative Period 100%
• Surgery Patients with Recommended VTE Prophylaxis Ordered 92.6%
• Surgery Patients Who Received Appropriate VTE Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery 85%
2009 data:
Over the last year, we have been able to maintain high 90th percentile ratings in pre-op antibiotics and appropriate antibiotic selection.
For post-op antibiotics, by having a pharmacist staffed in the PACU to review post-operative medication orders and make changes per approved protocol, we have been able to maintain high 90% month-to-month ratings. We also implement daily patient care discussions to facilitate appropriate care.
Over the last quarter of 2009, our performance has been the following:
• Major Cardiac Surgical Patients with Controlled Post-Operative Serum Glucose - 94.9%
• Surgical Patients with Appropriate Hair Removal - 98.6%
• Surgical Patients with Normothermia in PACU - 99.4%
• Surgery Patients on Beta Blocker Therapy Prior to Admission Who Received a Beta Blocker During the Perioperative Period - 100%
• Surgery Patients with Recommended VTE Prophylaxis Ordered - 93%
• Surgery Patients Who Received Appropriate VTE Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery - 88.4%
Surgery patients with urinary catheter removed on POD 1 or POD 2 - 93.7%
We monitor our surgical site infection rates as well as incidence of adverse perioperative events. Since implementing SCIP at BWMC, we have seen a marked decrease in SSI. We identify infections and monitor each case type according to National Nosocomial Infection Surveillance System (NNIS) criteria and benchmarks for consistent and accurate identification and measurement. Since 2003, our average overall infection rate per 100 cases has decreased from 0.78 to 0.49. Additionally, any identified adverse perioperative event is evaluated in its appropriate physician-led process improvement committee.
Mentor designation - 12/6/07
Information updated - 3/10/10
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Centra Health – Lynchburg, VA
Availability Status: Available to answer requests
Licensed Beds: 403
Teaching / Non-Teaching Status: Non-teaching
Setting: Urban
Start Date of Intervention Work: October 2002
Mentor Contact Name: Claudia Butler, MBA, Managing Director, Performance Improvement
Mentor Contact Email: claudia.butler@centrahealth.com
Mentor Contact Phone: 434-200-4123
Additional Information:
We are fortunate to have a surgeon and an anesthesia champion involved in the development of antibiotic prophylaxis policy for antibiotic timing and choice. We have 2 hospitals and both hospitals are assisting in SCIP project. As part of peer review and education, we send letters to the surgeons for any chart that has a SCIP indicator that failed. We also send quarterly outcomes with a breakdown of procedure specific so as to create some competition among cardiac surgeons, general surgeons and gyn. For 2 years, Centra Health has been on the Healthgrades.com "Distinguished Hospital - Patient Safety" list (which includes a low rate of surgical complications as one of its measures).
Centra is currently at 95% for antibiotic timing, 95% antibiotic selection, 100% cardiac 6 am glucose, 100% hair removal 90% for post op temp for colorectal surgery.
Complication rate (2005 actual vs expected): 6.60% vs 10.2%
Complication rate (first six months of 2006 vs expected): 6.60 % vs 10.6%
[3/13/07]
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OSF St. Joseph Medical Center – Bloomington, IL
Availability Status: Available to answer requests
Licensed Beds: 145
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: June 2004
Mentor Contact Name: Kathy Haig
Mentor Contact Email: kathy.m.haig@osfhealthcare.org
Mentor Contact Phone: 309-662-3311 ext. 1347
Additional Information:
OSF St. Joseph Medical Center has consistently achieved compliance with Surgical Safety indicators included 95% or better with surgical prophylactic selection, administration within an hour, use of clippers, 90% or better normothermia, and 85% glycemic control with cabg procedures. This is a result of sustained success since our involvement with the IHI Surgical Safety project in 2004 in which the surgical change package was implemented. These processes include those above as well as DVT assessment and intervention, bleeding risk assessment, use of perioperative blockade, increasing the FiO2 post-op in the PACU and standardization of preparation and recovery care for the surgical patient.
Prophylactic antibiotic within one hour of incision = FY2006 93-100%
Appropriate Selection of prophylactic antibiotic = FY2006 = 92-100%
Appropriate prophylactic antibiotic discontinuation = FY2006 = 69-86%
Cardiac Post op Serum Glucose FY2006, Quarter 4 = 80-100%
Percent of appropriate hair removal = 97%
Colorectal surgical patient with normothermia = 90%
DVT assessment and interventions = 100% consistently
[3/13/07]
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St. Joseph Medical Center (Franciscan Health System) – Tacoma, WA
Availability Status: Available to answer requests
Licensed Beds: 320
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: March 2003
Mentor Contact Name: Estelle Villwock, MSM, BBA-MIS, BSN, RN
Mentor Contact Email: estellevillwock@fhshealth.org
Mentor Contact Phone: 253-426-6329
Additional Information:
Franciscan Health System is a three-hospital system in Washington State's South Sound: 3 hospitals with 3 cultures; regional committees and teams; one standard of care. The SCIP project is a multifaceted project with teams established for all of the measures and a central committee that meets quarterly with representation from all teams. Each team reviews data on compliance and outcomes and address system changes to enhance the success of improvements in surgical care. The SCIP initiative is a strong force in all of our hospitals, has reached the care provided at the bedside of patients and our successes and challenges are reviewed at all levels of our organization. SJMC piloted flagging the medication reconciliation record for Beta Blockers preoperatively and communicating whether or not Beta Blocker was taken to Anesthesia. We have incorporated a physician advisory panel of surgeons, anesthesiologists, and internists to facilitate process improvement.
We have achieved for this last quarter SCIP-Inf-1 Timing - FHS All-85%; St. Joseph Medical Center 86%.
For SCIP-Inf 2 Selection - FHS All 96%; St. Joseph Medical Center 96%
For SCIP-Inf 3 Duration - FHS All 74%; St. Joseph Medical Center 71%.
For our new measures for our cardiac surgery patients, our SCIP-Inf 4 PostOp Glucose Control Rate is at 97.4%. For glucose control, we have establised a protocol based on the Portland Protocol and are measuring our outcomes at 120mg/dl.
[3/13/07]
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St. Joseph's Mercy Health Center – Hot Springs, AR
Availability Status: Available to answer requests
Licensed Beds: 296
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: April 2005
Mentor Contact Name: Lynn Pellegrino, RN, MSN, APRN-BC
Mentor Contact Email: lpellegrino@htsp.mercy.net
Mentor Contact Phone: 501-622-1840
Additional Information:
Keys to our success include:
• The development of an interdisciplinary team chaired by the Director of the Operating Room and the Inpatient Diabetes Clinician
• Concurrent chart review
• Weekly outcome reports to administration
• Administrative support to implement hospital processes, hospital ministry goals and physician committee integration
Our proactive approach in tracking these measures and sharing our trends through a dashboard approach to our Executive PI Council and Hospital Board, celebrating our victories and discussing our challenges with physicians, nursing staff and ancillary departments has improved quality as it relates to decreased surgical site infections.
We implemented the four components of the Surgical Site Infections intervention and the additional fours measures with the Surgical Complications module through the following:
Appropriate use of antibiotics and timing of antibiotics prior to surgery and timely discontinuation post-surgery was accomplished through development of standing orders; hospital-based formulary antibiotic tables for physicians and nurse practitioners; physician/staff education; color-coded alert cards with measures placed outside the chart; and a physician sticker to indicate reason for continuation of antibiotics prior to or post surgery; daily concurrent reviews and weekly/monthly reporting to Administration, the PI Council and Executive PI Council and the hospital board. Additionally, a stop card is placed outside each surgical case to alert staff and physician when the 24 and/or 48 hour window for antibiotic discontinuation is due. The PACU staff communicates to the pharmacy when the last dosage of antibiotic is given in the OR to begin the 24-48 hour clock of antibiotic administration following surgery.
Appropriate hair removal was accomplished by removing razors throughout the hospital, training on clipper use, and updating all documentation forms to reflect current practice of no shaving.
Maintenance of postoperative glucose control has been through our Diabetes Advisory Committee, Inpatient Diabetes Clinicians and the inclusion of our perfusionist on the SCIP Team through the use of a tight sliding scale protocol, measuring and graphing blood glucose control prior to surgery, throughout surgery and post surgery; updating standing orders to reflect a Post Day 1 and Post Day 2 blood sugar on non-diabetics; use of the Glucomander (insulin calculator which bases insulin titration on blood glucose values) during and following surgery to obtain tight blood sugar control.
Maintenance of perioperative temperature management has been through the use of temperature management units, use of warmed fluids and warming blankets starting from pre-assessment, controlling temperatures in the OR, and most importantly changing to a temporal artery thermometer. Temperatures are being tracked on all surgeries and our forms have been updated with the 96.8-100.4 range.
Additional measures for Surgical Complication Reduction have been the following:
Beta blockers for patients on beta blockers prior to admission have been addressed through staff and physician education, daily concurrent review, inclusion of beta blocker administration on the OR checklist, anesthesia orders, PACU form and inclusion in the time-out prior to surgery. The importance of documentation of home use of beta blockers has been incorporated into medication reconciliation and is a component of our pre-assessment education process for patients.
VTE prophylaxis has been undertaken through establishing a sub-committee of the existing SCIP committee. One of our hospitalists has become the champion for this project. To date, a DVT assessment is completed as part of the nursing admission assessment and a sticker is placed on the physician orders if DVT prophylaxis is not addressed, standing orders have been updated, physician/staff education undertaken through physician CME programming. Future plans include incorporation into our Physician Order Entry System. "Urinary catheter removed postoperatively Day 1 or postoperative Day 2" is a new measure that has been "hardwired" into the nursing admission assessment to determine initial justification and into the daily Nursing Observation Flow Sheet. A foley sticker to assist the physician in clinical justification beyond the 48-hour period post surgery has been incorporated into existing surgical order sets.
For all the above measures, data is tabulated weekly per surgery type based on concurrent 100% chart reviews shared with administration. Physicians with measures that fall out are sent a personal letter indicating the medical record # in question and a copy of the current guidelines for that measure. Teachable moments have been a successful tool to work collaboratively and positively with the unit managers when process breakdowns occur. "Mercy Bucks" and "Great Catch" certificates are awarded to staff who identify problem areas and go the extra mile to improve clinical processes.
From 2005 to 2009, the cost savings to our organization regarding decreasing surgical infections has been roughly 36% since FY 05 with the incorporation of the SCIP measures.
2009 Data:
Our discontinuation of antibiotics within 24 hours compliance has improved from 68% to 95% and has achieved greater than 96% discontinuation within 48 hours for cardiac surgeries.
Antibiotic within 24 hours of incision time has increased from 75% to over 96%.
Hair removal without shaving is currently at 100% following removal of razors, training of staff on clippers and changing of internal processes.
Surgery patients with perioperative temperature management compliance has increased through staff education to intervene when temperature ranges are low from pre-assessment. Compliance is 100%.
Blood glucose control compliance has increased through use of the Glucomander to deliver calculated IV insulin through blood glucose reading during surgery and following. Compliance is currently at 83%.
Surgical Site Infection rate for all procedures has decreased from 1.11% to .35% from 2004 to 2009.
Mentor designation - 3/13/07
Information updated - 3/3/10
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St. Mary's Hospital and Medical Center – Grand Junction, CO
Availability Status: Available to answer requests
Licensed Beds: 356
Teaching / Non-Teaching Status: Teaching
Setting: Rural
Start Date of Intervention Work: March 2003
Mentor Contact Name: Cathy Roberts, RN, MS, Performance Improvement Manager
Mentor Contact Email: cathy.roberts@stmarygj.org
Mentor Contact Phone: 970-244-2566
Additional Information:
St. Mary's began work on the SIP project in 2003 with the Colorado Foundation for Medical Care sponsored SIP Collaborative. We initially focused on our CABG population, but within a year we had spread the focus to include orthopedics. In 2003, we joined the Premier/CMS Hospital Incentive Demonstration Project which included the CABG, hip and knee populations. By early 2004, we developed a SIP team to look at the following populations: CABG, hips/knees, and laminectomy and by 2005 we had expanded our focus to all SCIP populations. We have been very successful by involving key staff and physicians in this process. We have developed tools that have supported this success. Additionally, we track our outcomes and report process indicators to our team and physician champions monthly.
St. Mary's has been successful with administration of prophylactic antibiotics within one hour of incision time. We currently perform at or above 95% for all populations. Our OR staff and anesthesiologists play a big role in our success. We also implemented a tool to prompt for antiobiotics documentation during the time out process. Providing ongoing feedback to physician champions has also assisted in our success.
Discontinuation of the prophylactic antibiotics within the 24-hour time frame (48 hours for CABG) has also been a challenge, but we found that pre-printed order sets developed in collaboration with the physician groups has really led to our success in this area. We currently perform consistently above 90% and again provide monthly feedback.
We closely monitor our Surgical Site infection rates and in 2004 we saw an overall decrease of 30%.
[3/13/07]
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Sioux Falls VA Medical Center – Sioux Falls, SD
Availability Status: Available to answer requests
Licensed Beds: 45 acute care, 58 transitional care
Teaching / Non-Teaching Status: Teaching
Setting: Urban (serving a large, rural population)
Start Date of Intervention Work: May 2007
Mentor Contact Name: Michelle Laska, RN
Mentor Contact Email: michelle.laska@va.gov
Mentor Contact Phone: 605-336-3230 ext. 6528
Additional Information:
By focusing on improving the culture of teamwork and communication peri-operatively and increasing compliance with the infection, VTE, and Cardiac SCIP measures, the team at the Sioux Falls VA Medical Center sought to decrease the number of intra-operative and post-op surgical complications. Our pilot population for this collaborative was defined as all inpatient, elective surgery patients in all surgical specialties performed which included general, vascular, thoracic, orthopedic, urologic, ENT, plastic, and gynecologic.
Our overall aim was to decrease peri-operative harm by 50% in the pilot population within one year with the implementation of systems that reliably deliver recommended peri-operative surgical care. Our main focus was the prevention of cardiovascular events and improvement of the culture of safety in the peri-operative system. Sioux Falls VA was a member of a previous collaborative that focused on preventing surgical site infections in the clean surgical case population and we maintained those changes from this earlier work. As a result, we began this project with a high level of compliance on the following five measures: On-time antibiotic prophylaxis, appropriate prophylactic antibiotic, timely prophylactic antibiotic discontinuation, appropriate hair removal, and normothermia in post-anesthesia care unit.
Although performing reasonably well with the SCIP VTE-2 measure, we sought to improve the process by providing a centralized location for ordering, using the SCIP guidelines. There were primarily three steps in our plan to ensure compliance: 1) Education of the surgeons on this measure; 2) Development of an inpatient VTE prophylaxis computerized ordering template created according to the recommended SCIP guidelines (used post-operatively); and 3) Creation of a pre-operative planning template so the scheduling surgeon can request a VTE prophylaxis dose be given by anesthesia pre-incision.
During the collaborative, we discovered that we had an unreliable process in the beta blocker measure. After drilling down, we noted documentation inconsistentcies. Specifically, beta blockers were not being properly documented when patients were admitted through SDS. We simply added a question to their pre-operative evaluation form that asked when the patient took their beta blockers. As a result, compliance percentages reached 100% consistently after this was implemented.
Achieving higher levels of effective communication and teamwork were also crucial to our success:
• A pre-operative planning template is embedded in the computerized patient record system (CPRS). Surgeons utilize this template when scheduling surgery. The surgeons are able to indicate specific information on this template such as pre-op antibiotics, required anesthesia, bowel prep, special equipment needs, positioning in the OR, and about 13 other items. This information can then be accessed in CPRS by the scheduling clerk, the SDS nurses, anesthesia, and the OR nurses. This, in turn, has reduced phone calls and questions each of these areas might have had previously. (We were unable to obtain "buy-in" to institute a “pre-procedural briefing,” so this template is our solution.)
• We did the traditional "time out" for the last few years to verify the right patient, right surgery, right site, right x-rays, and the right implants. However, early in the collaborative, we renamed this process the "time in" to coincide with the patient entering the room. We now perform what we call a "time out" immediately after surgical closure and before the surgeon or any other team members leave the OR. Verification is done regarding the surgical procedure, post-op diagnosis, specimens, wound class, blood loss, and if the counts are correct. Accuracy in recording operative information has greatly improved.
• We used a failure mode and effects analysis (FMEA) for “uncontrolled bleeding in the OR.” Using a multidisciplinary approach, creative thinking, and great leadership, this FMEA on a hypothetical problem was a very positive and successful experience. Ten employees were part of this experience, and the team appreciated being included, and being given the opportunity to make a difference. Seven action plans were developed in response to the failure modes identified during this process. An executive summary was presented to leadership for their review.
Here are five main contributors to our success in this collaborative:
1. Appoint team members who are driven and support your aim. They must be those who are in authoritative roles and can initiate change.
2. Meet regularly and keep meetings informative and productive. Invite a multidisciplinary panel when discussing change in practice or process. Use evidence-based research when proposing major changes in practice.
3. Educate, educate, educate! Continual reinforcement is necessary when changes are made. Follow up with those assigned with tasks.
4. Monitor compliance to changes made. Post results for staff to monitor improvement and encourage commitment.
5. Evaluate results and note trends. Find out what is working and what isn't. Make changes for continual improvement and to achieve a high level of compliance.
In less than 12 months we reduced our complication rate by over 50%.
Number of perioperative adverse events per 100 surgical admissions: We sought to decrease peri-operative adverse events by 50%. We started at 60% and have been under 30% for the last 6 months.
Our target monthly goals for all the measures were 95% or better.
Percent of opportunities for anti-SSI measures that were completed successfully: We have been maintaining between 95-100%.
Percent of surgical patients who receive all appropriate anti-SSI measures: Out of 16 months, we reached our goal 13 times.
SCIP VTE-2: Percent of surgical patients who received appropriate VTE prophylaxis within 24 hours before or after the start of surgery: For the last 8 months we have met our goal.
SCIP Card-2: Percent of surgical patients admitted on beta blockers for whom beta blockade was continued during the hospital stay: This was an unreliable process at the beginning but after process changes were made, we have achieved 100% compliance for the last 5 months.
SCIP INF-1: Percent of patients with on-time prophylactic antibiotics administration: Over the last 16 months, we reached our goal 14 times.
SCIP INF-2: Percent of patients with appropriate prophylactic drug administered: We have maintained 100% compliance with this measure due to computerized templates designed according to the SCIP recommendations for antibiotic administration.
SCIP INF-3: Percent of patients with timely prophylactic antibiotic discontinuation: We have had 100% compliance with this measure for the last 10 months.
SCIP INF-6: % cases with appropriate hair removal: We have had 100% compliance with this measure over the last 16 months.
SCIP INF-7: % of colorectal (or all) patients with normal body temperature on arrival at the Post-Anesthesia Care Unit (PACU) - we measured all patients: Fifteen of the last sixteen months, we have met our goal.
For more information (including charts), see the Sioux Falls VA Medical Center Improvement Story
Mentor designation - 11/13/08
Information updated - 2/26/10
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– Brevard, NC
Availability Status: Available to answer requests
Licensed Beds: 25
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: May 2003
Mentor Contact Name: Scotta L. Orr, RN, BSN, MPH, Director of Quality/Accreditation Services
Mentor Contact Email: sorr@tchospital.org
Mentor Contact Phone: 828-862-6383
Additional Information:
The SIPP team includes an Infection Control Practitioner, Director of Surgical Care Services, Director of Quality, Case Management, and Anesthesiology.
Staff and public were educated: Patients were educated regarding use of Hibiclens shower prior to surgery. Staff were educated as to who (and where) would start the preoperative prophylactic antibiotic; appropriate antibiotic choices for surgery; and discontinuation of antibiotic within 24 hours after surgery end time.
• In 2005, a normothermia campaign was initiated. Preoperatively, patients receive warmed fluids, forced air warming blankets and socks.
• Pharmacy added alert to MAR stating to “discontinue prophylactic antibiotic within 24 hours of surgery end time.”
• The evolution of Bedside Medication Verification created the need for revisions to the process which were implemented.
• 99% of patients are normothermic throughout the operative experience.
• June 2007: prophylactic antibiotic within 1 hour prior to surgery was 100%; up from 48% compliance in May 2003.
• Appropriate prophylactic antibiotics are administered 100% of the time and has held at high compliance since May 2003.
• Discontinuation of prophylactic antibiotics within 24 hours of surgery end time was 100% in June 2007 compared to a compliance rate of 74% in May 2003.
• Razors have been removed from the surgery areas.
• Patients continue to receive Hibiclens and an education tool at their pre-op visit.
• Protocols for DVT prophylaxis and glucose control have been implemented and are being monitored and revised as needed.
• Transylvania Community Hospital’s inpatient surgical site infection rate has been consistently below 2.7% for the past three consecutive years.
[2/8/08]
