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OUR NSQIP JOURNEY Drilling Down NSQIP Data

OUR NSQIP JOURNEY Drilling Down NSQIP Data. Nanaimo Regional General Hospital Kelli Jennison-Gustafson RN SCR CNE. NRGH. Acute Care Facility and Trauma Center 292 Beds 56 Surgical Beds Busiest ER on Vancouver Island We employ over 1,700 individuals locally. In the beginning….

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OUR NSQIP JOURNEY Drilling Down NSQIP Data

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  1. OUR NSQIP JOURNEY Drilling Down NSQIP Data Nanaimo Regional General Hospital Kelli Jennison-Gustafson RN SCR CNE

  2. NRGH Acute Care Facility and Trauma Center 292 Beds 56 Surgical Beds Busiest ER on Vancouver Island We employ over 1,700 individuals locally

  3. In the beginning… July 2011 1st day on the job – NSQIP conference in Boston August 2011 Office set-up: get the word out to staff and surgeons SCR training, “CPT and ICD-9 codes “ Sept 2011 Ramp-up: start of chart reviewing and data collection Goal: 40 charts per 8 day cycle

  4. Benefits of Participation

  5. Top 3 Occurrences Post-Operative Occurrence Summary On Non Risk Adjusted Cases with Confirmed 30-Day Follow-Up

  6. Pre-Initiative Audit

  7. Template for Drilling down UTI Cases

  8. Reducing UTIs Back to Basics

  9. Changes to be Implemented • Nurse education Foley Insertion Training + Regular skills assessment for Care providers • Patient education Improved education for care of Foley Catheter at home • Application of GRIP-LOK on all patients with a urinary catheter

  10. Where are we now? Continue to educate surgical staff in catheter care; best practice Follow up audit of practice changes to confirm compliance and assess for improvements Monitor our monthly post op occurrence rates from NSQIP and compare this with our pre-initiative results Review and compare results with our risk adjusted SAR from NSQIP

  11. Post Initiative Audit

  12. OUR NSQIP TEAM AT NRGH SURGEON CHAMPION: Dr. Blair Rudston-Brown and Dr. Scott Neilson SCR: Debera Coles and Judy Lekisch QI Consultant: John Kristiansen SURGICAL CNE: Kelli Jennison-Gustafson and Tammy Joseph Kelli.Jennison-Gustafson@viha.ca

  13. ACKNOWLEDGEMENTS Angela Tecson- BC SCR Support BC Patient Safety & Quality Council- NSQIP Clinical Improvement SharePoint Centers for Disease Control- UTI Guidelines Institute for Healthcare Improvement      Surrey Memorial Hospital- Fraser Health- UTI Reductions

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