TN SCIP Participant Group Best Practices Sharing

1. TN SCIP Participant Group�Best Practices� Sharing Infection-1: Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision Johnson City Medical Center

2. Hospital Characteristics Located in Upper East Tennessee in Johnson City, a 443 bed not-for-profit, acute-care teaching facility with a Level I Trauma Center Average daily census is 437 Annual Volume of surgery is 4916

3. Hospital Characteristics Perform orthopedic, vascular, cardiothoracic, neurological, general, gynecological, laparoscopic, laser, urological, pediatric, plastic, ear, nose and throat and transplant surgeries SCIP Team composition consists of Pharmacist, Clinical Integration RN, Med/Surgical nurses and leaders, CVICU nurse leader, SDS, PACU and OR nurses

4. Infection-1 QI JourneyHere�s How We: The Opportunity for Improvement was identified during the Surgical Infection Prevention project Members from all departments involved formed a committee where they mapped out various places in hospital the patient came from to OR. Initial committee involved Medical Director, Holding nurses and manager, surgeons, anesthesiologists, OR nurses and infection control department. Each area went to own department and educated their team on the changes

5. Infection-1 QI JourneyHere�s How We: Small tests were done and determined many delays occurred before patient entered the OR so the Holding nurse started Antibiotic as patient left holding area to OR. Challenges included waiting to receive ABX from the Satellite Pharmacy. A medication refrigerator was purchased for holding area to keep ABX. Needed buy-in from OR circulators to recognize need to re-dose where appropriate.

6. Infection-1 QI JourneyHere�s How We: We have concurrent abstractors who look at records and reports are abstracted post-discharge then posted on organization�s webpage for anyone with access to our email system to view

7. Lessons Learned / Successes Perseverance Lots of education Buy-in from all departments involved Tied performance into annual incentive

8. TN SCIP Participant Group�Best Practices� Sharing Infection-3: Prophylactic Antibiotics Discontinued within 24 hours after Surgery End Time Williamson Medical Center

9. Hospital Characteristics Location: Williamson Medical Center Franklin, Tennessee Average daily census: 86 Volume of surgery: 500/month Types of surgery: All services with the exception of Cardiac and Neuro SCIP Team composition: CNO�s, Quality and Perioperative Depts

10. Infection-3 QI JourneyHere�s How We: Identified our opportunity for improvement: Chart Reviews We brought in the Chief of Staff to help with Physician buy in. With his help it was relatively easy to get surgeons to realize that they needed to begin D/C of ATB at 24hours. Implemented our interventions: Surgeon�s began changing orders and we began the process. We still were having some charts come back beyond 24 hours. Identified / overcame our challenges: Upon review we realized that there was confusion on number of doses. The surgeon�s were including the dose given at time of surgery as 1 of the 4 doses. Pharmacy read the orders as the patient needed 4 additional doses. Overcame this by changing the orders to only 3 doses and have had great success. Monitored our ongoing performance: Continually monitor with chart reviews and still find issues, but not with the surgeon�s. It is usually as simple as a dose being given a few minutes late, which puts us over the 24 hour cut off.

11. Lessons Learned / Successes Lessons Learned: When preparing for this we realized we did not do anything elaborate to make this happen but our CNO was instrumental to have the buy in of our Chief of Staff. He is well respected with the physicians and they listen to him. The best advice is to have a physician champion.

12. TN SCIP Participant Group�Best Practices� Sharing Infection-7: Colon Surgery Patients with Immediate Postoperative Normothermia Gateway Medical Center

13. Hospital Characteristics Clarksville, TN Average daily census is 110 Volume of surgery Types of surgery Joy Wilson, Dana Sandefur, Vickie Duncan

14. Infection-7 QI JourneyHere�s How We: Identified we had room for improvement early Inconsistency of device used to obtain temperature, Low room temps in OR, and pt. temps on arrival to facility were low. Addressed issue with Head of the Department of Surgery who is the lead anesthesiologist and PACU staff Ordered new temporal thermometers for both areas, and educated all involved in process, adjusted OR room temps, placed bair huggers on patients immediately on arrival to the preop area. There were no additional challenges Monitored our ongoing performance

15. Lessons Learned / Successes People want to do the right thing, however we must provide them with the tools and information to help them succeed.

16. TN SCIP Participant Group�Best Practices� Sharing Infection-7: Colon Surgery Patients with Immediate Postoperative Normothermia Middle Tennessee Medical Center

17. Hospital Characteristics Middle Tennessee Medical Center is a 286-bed private, not-for-profit hospital located in Murfreesboro, Tennessee. MTMC is a member of Saint Thomas Health Services and Ascension Health. Established in 1927, MTMC has been serving the health care needs of Middle Tennesseans from Rutherford, Cannon, Coffee, Warren, and DeKalb counties for 75 years. Average daily census of 190 During April 2007 a total of 609 inpatient surgeries were performed With the exception of cardiovascular we perform all surgeries Our team is known by the name Higher Ground, it includes surgeon representation from each of the sub-specialties, patient care services, anesthesia as well as quality and administration

18. Infection-7 QI JourneyHere�s How We: The Higher Ground Team was established initially to work on 07:30 start starts and OR room turnover. Rather than establish a second team SCIP results are brought to this group prior to going out to Medical Staff meetings. The team prioritizes the actionable items. The current process for maintaining normothermia in patients undergoing colon surgery was flowcharted. This was compared to what was recommended by professional organizations. A gap analysis identified where to focus our efforts. It was decided to use a warming blanket with the Bair Hugger; utilize esophageal temperature monitors as well as a forehead temperature strip and to maintain a room temperature of 68 degrees. The General Surgery Team Leader and the General Surgeons agreed and the changes were put into place. For this particular standard we have met any resistance. This monitored on a case by case basis.

19. Lessons Learned / Successes Utilizing a current team that understood the process was helpful and time-saving. Understanding the current process and knowing the gaps helped to keep everyone focused. Keeping the data in front of everyone was a key to success.

20. TN SCIP Participant Group�Best Practices� Sharing Card-2: Patients on Beta Blocker Therapy Prior to Admission Who Received a Beta Blocker Perioperatively St. Francis Hospital

21. Hospital Characteristics Memphis, Tennessee 400 Average daily census 10,500 Surgery cases/year General, Ortho, Neuro, Cardiac, Ophth, ENT, Plastics, Bariatrics, Urology, Podiatry SCIP Team composition CNO CMO Director, Surgery Advanced Practice Nurse Pharm- D Anesthesiologist Nurse Managers Infection Control Quality Management Cardiac Surgeon

22. Card-2 QI JourneyOur Process at SFH A BB monitor/reminder sheet is placed on all inpatient units and the Same Day Surgery unit. It lists all BB utilized at SFH for the purpose of prompting physicians & nurses. Same Day Surgery Nurses review patients charts for medications to determine if they are on BB If they are and the patient has not taken the BB, the patient will receive the BB in Preop Holding Inpatient unit nurses review charts for surgery patients on BB. If on BB the patient will take BB with a sip of water.. Ongoing performance is monitored via SCIP data.

23. Results 100% for CABG Patients for April & May 1st Quarter, 2007, SCIP result was 88.1%

24. TN SCIP Participant Group�Best Practices� Sharing Card-2: Patients on Beta Blocker Therapy Prior to Admission Who Received a Beta Blocker Perioperatively Williamson Medical Center

25. Hospital Characteristics Location: Williamson Medical Center Franklin, Tennessee Average daily census: 86 Volume of surgery: 500/month Types of surgery: All services with the exception of Cardiac and Neuro SCIP Team composition: CNO�s, Quality, PAT, Perioperative, and Anesthesia Depts

26. Card-2 QI JourneyHere�s How We: Identified our opportunity for improvement: Based upon the measure and discussing with Anesthesia Chief our need to investigate. Investigated the root causes: Determined through meeting with Surgery Committee that this is not something the surgeons were willing or comfortable to manage. Engaged leadership / physicians / front line staff: Our CNO engaged the Chief of Anesthesia for help. It was determined the best way to capture these patients would be at their PAT appointment. Anesthesia would document the patients on Beta- Blockers on their record. On the 2nd interview at the time of surgery we would verify that those patients had taken their Beta-Blocker or if they had not give it to them in the Periop- Holding Area prior to surgery. Implemented our interventions: Changed Anesthesia History Sheet so that we could document beta-blocker therapy Identified / overcame our challenges: Smooth transition and Anesthesia interviews every patient immediately prior to surgery, so we have had good success.

27. TN SCIP Participant Group�Best Practices� Sharing VTE-1&2: Prophylaxis Ordered & Prophylaxis Given Within 24 hours Prior to Surgery to 24 hours After Surgery UT Medical Center

28. Hospital Characteristics 1924 Alcoa Highway, Knoxville, Tn. 37920 Average daily census - 349 Volume of surgery � 1379/Month Level 1 Trauma Hospital with a wide variety of surgeries including the specialties of the Heart Lung Vascular Institute and Stroke Center. Our SCIP team is composed of Physicians, a Service Line VP, Pharmacist, RNs and P.I. Staff.

29. VTE-1&2 QI Journey Historically UT had a DVT PI team that focused on prevention of DVT/PE for all admissions. This team accomplished implementing a new order set for DVT prophylaxis and recognition throughout the organization of the need for DVT prophylaxis. Literature review, comparison of our rates to AHRQ PSI 12 rate and extensive data mining demonstrated that there still existed an opportunity for improvement in our post operative DVT rates.

30. VTE-1&2 QI Journey The SCIP team began in July 2006. This team was based upon the guidelines of CMS. The new team membership includes staff level RNs. A major education campaign for physicians began with presentations being emailed to the program directors of the departments. Reminders were placed on physician�s computer screens when they signed into the patient�s system. Emails were sent out to all physicians, nurse managers and unit secretaries about DVT importance and the order sheets that were available to aid them in their decision-making. Concurrently team meetings were taking place to identify obstacles and/or areas that could be improved. A presentation was made to the Nursing Leadership committee.

31. VTE-1&2 QI Journey A pilot was initiated in the recovery room to encourage better utilization of our DVT orders post operatively. Buy in has been slow with staff and physicians due to new change in practice. The PI team has had to launch a large amount of education in order to demonstrate the validity of this new measure.

32. Lessons Learned / Successes Data demonstrates that we also need to focus on AHRQ data along with the core measures. Data is best analyzed monthly to monitor and identify new areas of interest and/or education. Due to barriers of increased hospital volumes and limited staff nurse availability the team is structured utilizing rapid cycle PDSA to support quicker outcome results. This is an ongoing process that never ends.

33. Lessons Learned / Successes Change is somewhat painful and slow. When making change throughout a large institution it is like trying to turn a very large vessel at sea. It takes time and patience. The best success that we can experience is knowing that we are providing better care for our patients.