Hospital Team Sharing Call Medical Center of Central Georgia Carroll Hospital in Maryland

1. Hospital Team Sharing CallMedical Center of Central GeorgiaCarroll Hospital in Maryland SUSP Cohort 3 June 10, 2014

2. The Medical Center of Central Georgia Betty Casey, RN, MSN, CNOR, AVP Surgical Services, Felicia Simmons, RN, BSN, Nurse Director, Perianesthesia Services, Robin Mole, RN, BSN, Specialty Services Manager, Leslie Reynolds, RN, BSN, Infection Prevention

3. The Medical Center of Central Georgia • SUSP Team and hospital environment • MCCG - licensed capacity 637 beds - Level 1 Trauma/Teaching Hospital • Primary and secondary service area of twenty-eight counties of central and south Georgia with a population of approximately 796,000 residents.  • SUSP team: Betty Casey, RN, MSN, CNOR, AVP Surgical Services, Rhonda Beeland, RN, BSN, CNOR Nurse Director Surgery Center, Felicia Simmons, RN, BSN, Nurse Director, Perianesthesia Services, Robin Mole, RN, BSN, Specialty Services Manager, Perianesthesia Services, Beverly Brantley, RN, BSN, CNOR, Nurse Manager, Main OR Surgery Center, Leslie Reynolds, RN, BSN Infection Prevention, Anesthesia services representative, Neuro-surgical services representative, and front-line staff representation.

4. The Medical Center of Central Georgia • Development and Implementation of the SUSP project SUSP Team Formation: • The data showed we had opportunities for improvement in the Neurosurgical services line. Development of Plan: Root Cause Analysis was done on each SSI. Data was placed on an Excel spreadsheet. Items that placed patient at an increased risk for infection were shaded. Trends were noted in: • glucose management • intra-operative temps (starting temps below 36 degrees C) • Infecting pathogens column showed MRSA/MSSA as major players.

5. How and Why: • Chart review (random sampling of 10 charts) indicated starting temps below 36 degrees Celsius 40-50% of the time. • We also had no consistent testing/treatment to establish nasal colonization status for MRSA or MSSA. • Based on these facts, we decided we needed to actively pre-warm the patients and provide some type of treatment for nasal reservoir. Challenges: • Supply issues • Documentation (electronic vs. paper) • Staff education Hospital Survey on Patient Safety (HSOPS): • Fifty percent of our staff either disagreed or were neutral to the survey statement: “After we make changes to improve patient safety, we evaluate their effectiveness”. We knew it was important to keep them informed!

6. S. aureus MRSA/ Coag – Staph S. aureus S aureus x 3 MRSA x 1 S aureus

7. Initial Intra-Operative Temperature for Spinal Cases

8. The Medical Center of Central Georgia What we are working on now: • Digging into the data on glucose management in the Neurosurgical Services population. • Diabetes Healthways is attending service line meeting to “fine tune” our process/make recommendations. • Anesthesia attends our meetings and is providing input on glucose management intra-operatively.

9. The Medical Center of Central Georgia What’s next for your team? • Concurrent (real time) feedback to staff • Increased awareness of the impact of hypothermia and it’s impact has led to discussions in other surgical service lines. • Dr. Ken McDonald, MD/Anesthesia is presenting a comprehensive overview of the importance of normothermia peri-operatively to all divisions within Surgical Services.

10. The Medical Center of Central Georgia Questions we have for the SUSP teams: • Do you have a hard stop on Hgb A1C levels for elective surgical cases? • How are you addressing physicians who do not optimize their patients preoperatively?

11. Carroll Hospital Center Gap Analysis April 26, 2014 Effective Strategies for Implementing NPSG 07.05.01: Surgical Site Infections April 23, 2014

12. Private, nonprofit 193-bed. community hospital • Full array of surgical services including minimally invasive and robotic options • 8,034 Inpatient & Outpatient Surgeries • 176 colon surgeries

13. The Journey • Deep SSIs added to hospital quality dashboard in FY 2012 • Target met in FY 2012 and 2013 • 20% reduction in FY 2013

14. Something changed…

15. Deep SSI target for the entire fiscal year nearly exceeded in one single quarter!

16. Investigation of the usual suspects • Personnel • Implant #s • Preventative measures followed • Environmental factors • Sterilization process

17. Actions Taken • OR cleaning revamped using Virex spray and cloths rather than antimicrobial wipes • Air vent cleaning back on schedule • Higher grade air filters • Flash sterilization monitoring improved • Policy enforced to assure appropriate sterilization of instruments brought in by reps

18. Actions Taken • Random OR observations resumed • Use of antimicrobial sutures considered but later declined • Vascular SSIs presented at Vascular M&M • Referred some to physician peer review • SCIT (Surgical Care Improvement Team)/ Eliminate SSI re-formed

19. Gap Analysis The Joint Commission’s Implementation Guide for NPSG 07.05.01 on Surgical Site Infections • Provides accredited hospitals with 23 effective implementation practices • Leadership (3) • Practitioner-Focused (3) • Process-Focused (17)

20. Identified weaknesses: • Practitioners accept and/or take responsibility • Aligned and coordinated education for staff and LIPs • Acting on identified SSI issues • Support of migration of SSI evidence-based practices from one medical service to another

21. What’s next? • Consideration of expanding use of PICO dressings • Review Implementation of a Surgical Comprehensive Unit-Based Safety Program to Reduce Surgical Site Infections • Considering a sub-committee to evaluate preoperative patient education and review resources posted on the SUSP web site

22. QUESTIONS?