Sioux Falls VA Medical Center
Sioux Falls, South Dakota, USA
The team from Sioux Falls VA Medical Center is a member of IHI’s IMPACT network and a participant in the Learning and Innovation Community on Reducing Surgical Complications.
Steven Julius, MD, Chief of Staff (Sponsor)
John Ryan, MD, Surgical/Specialty Care Service Line Site Director (System Leadership)
Michelle Laska, RN, National Surgical Quality Improvement Program (NSQIP) Manager (Day-to-Day Leader)
Diane Bottolfson, MD, Anesthesiologist
Karen Ishmael, RN, Perioperative Nurse
Darla Bruggeman, RN, Quality Management Professional
Connie Sivertson, RN, Patient Safety Officer
We will decrease perioperative harm by 50 percent in our pilot population within one year with the implementation of systems that reliably deliver recommended perioperative surgical care.
- Our main focus in this project will be prevention of cardiovascular events and improvement of the culture of safety in the perioperative system.
- We will continue to focus on surgical site infection (SSI) prevention and implement those changes we have already established in a pilot population from a previous collaborative.
Our pilot population is defined as all inpatient, elective surgery patients in all surgical specialties performed in this hospital, including general, vascular, thoracic, orthopedic, urologic, Ear, Nose and Throat (ENT), plastic, and gynecologic.
Twenty surgical cases were reviewed every month and data was collected on each case regarding the following measures:
Number of perioperative adverse events per 100 surgical admissions
Percent of opportunities for anti-SSI measures that were completed successfully
Percent of surgical patients who receive all appropriate anti-SSI measures
SCIP VTE-2: Percent of surgical patients who received appropriate VTE prophylaxis within 24 hours before or after the start of surgery
SCIP Card-2: Percent of surgical patients admitted on beta blockers for whom beta blockade was continued during the hospital stay
SCIP INF-1: Percent of patients with on-time prophylactic antibiotics administration
SCIP INF-2: Percent of patients with appropriate prophylactic drug administered
SCIP INF-3: Percent of patients with timely prophylactic antibiotic discontinuation
SCIP INF-6: Percent of cases with appropriate hair removal
SCIP INF-7: Percent of colorectal (or all) patients with normal body temperature on arrival at the Post-Anesthesia Care Unit (PACU) [*Note: The team measured all patients]
[SCIP = Surgical Care Improvement Project measure; VTE = venous thromboembolism; INF = Infection]
Surgical Site Infection
Sioux Falls VA was a member of a previous collaborative that focused on preventing surgical site infections in the clean surgical case population. As a result, we began this project with increasing compliance on the five SCIP measures [INFECTION (INF) 1, 2, 3, 6, and 7].
- On-Time Antibiotic Prophylaxis: A prophylactic antibiotic dose was ordered preoperatively and entered in the computer. The pharmacy would then fill the order the night before surgery and deliver the drug to either the Same Day Surgery (SDS) area or the ward where the patient was admitted. The dose of antibiotics was taped to the patient’s hard chart and verified. When the patient entered the OR, the anesthetist would then take the antibiotic and, after induction or the administration of a subarachnoid block, the antibiotic would be started.
- Appropriate Prophylactic Antibiotic: A computerized order set and template was created using the SCIP Guidelines for approved antibiotic usage, appropriate for the specific type of surgery and accounting for those patients with allergies.
- Timely Prophylactic Antibiotic Discontinuation: Education and efforts to ensure “buy-in” of the surgeons were the initial changes, but they proved to be insufficient. Subsequently, changes were made in the computerized orders, changing the wording to ensure the correct timing of the discontinuation. After several attempts, we now have the wording correct and by our results graph, it has proven to be a reliable process.
- Appropriate Hair Removal: Approved hair clippers were trialed, employees were polled on likes and dislikes, and four of the favorite clippers were purchased. All razors were removed from the OR, wards, and SDS area.
- Normothermia in Post-Anesthesia Care Unit: We purchased temporal thermometers for the PACU as these were felt to be the most accurate. Bair Hugger warming devices were already utilized in the OR for long cases (< 1 hour). Bair Paws warming device units were purchased for every room in the SDS area, the ORs, and the PACU. The gowns are placed on the patients upon admission and are plugged in the warming units when they visit each area during their perioperative experience.
Although performing reasonably well in this measure, we sought to improve the process by providing a centralized location for ordering, using the SCIP guidelines.
- VTE Prophylaxis: There were primarily three steps in our plan to ensure compliance: education of the surgeons on this measure; development of an inpatient VTE prophylaxis computerized ordering template, created according to the recommended SCIP guidelines (used postoperatively); and creation of a preoperative planning template so the scheduling surgeon can request a VTE prophylaxis dose be given by anesthesia pre-incision.
From the results graph, we noted an unreliable process in this measure. After drilling down, we found this to be a documentation problem.
- Cardiac–Beta Blockade: Beta blockers were not being properly documented when patients were admitted through SDS. As a result, we added a line to the preoperative evaluation form that specifically asked when the patient took their beta blockers.
Communication and Teamwork
- Preoperative Planning Template: This is a template found in the computerized patient record system (CPRS) that the surgeons fill out at the time they decide to schedule surgery. It is a series of checks with a few free text boxes. The surgeons are able to indicate specific information on this template regarding the surgery such as preoperative antibiotics, required anesthesia, bowel prep, special equipment needs, positioning in the OR, and about 13 other items. This template and all its information can then be accessed in CPRS by the scheduling clerk, the SDS nurses, anesthesia, and the OR nurses. This has, in turn, reduced the amount of phone calls and questions each of these areas might have as the needs are clear and precise, as well as the preoperative diagnosis and the name of the proposed surgery. (We were unable to obtain buy-in to institute a “Pre-Procedural Briefing”, so this template is our solution.)
- “Time In” and “Time Out”: We have done the traditional surgical “time out” for a few years now ― where we verify the right patient, right surgery, right site, right x-rays, and the right implants ― but early in the collaborative we renamed the time out to the “time in” to coincide with coming into the operating room. However, immediately after surgical closure, we now perform what we call a time out before the surgeon or any other team members leave the OR. Verification is done regarding the surgical procedure, postoperative diagnosis, specimens, wound class, blood loss, and if the surgical instrument counts are correct. Accuracy in recording operative information has greatly improved.
- Used FMEA for “Uncontrolled Bleeding in the OR”: Using a multidisciplinary approach, creative thinking, and great leadership, this failure mode and effects analysis (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 making 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. Each action plan was assigned to an employee and a completion deadline to implement the changes proposed.
Summary of Results / Lessons Learned / Next Steps
Summary of Results:
- In less than 12 months we reduced our complication rate by over 50 percent.
- We have reached our target goal in all measures we monitored over the last year. In some cases, a reliable process was instituted and since then a consistently high compliance rate was noted.
Key Lessons Learned:
- Team participation and support from those in leadership roles are a must.
- Use evidence-based research, like the SCIP Guidelines, before requesting major process or practice changes.
- Meet with multidisciplinary staff to review any process or practice change; many regulations need to be considered with proposing change.
- Processes that are only somewhat unreliable can still be made better; sometimes they just need very creative solutions.
- It is difficult to create one set of standards a large group will agree upon, but once done, it provides one solid standard of care for every patient.
- Educate, educate, educate; this can not be done enough. Increased measure percentages were usually noted after staff meetings where compliance issues were addressed.
- When changes are made, the need for continual reinforcement is necessary.
- It is necessary to meet regularly to keep people interested and informed.
- Post results for staff and leadership to read. Send emails for reminders, results, and encouragement. Keep results current.
- We discovered that we needed to ensure the changes we had made from the previous collaborative were sustained and/or reinforced.
- It is very important to follow up on those with assigned tasks.
- Finally, we gained invaluable insight regarding serious sequelae from previously regarded minor to moderate degrees of harm.
We know that constant vigilance and monitoring is necessary to keep the measurement results in line; it also helps to reinforce any changes that have been made. We have decided that the results of this collaborative will be presented to our Surgery Interdisciplinary Meeting. Collaboratively, we will then consider our own self-improvement agenda, surely to include compliance to measures used to monitor any recent changes.
Michelle Laska, RN
Sioux Falls VA Medical Center