Exemplary Professional Practice: Culture of Safety

Magnet Recognition Program® Request for Additional Documentation
Homestead Hospital
Homestead, FL

MGN20140102

 

 

EP20EO Clinical nurses are involved in the review, action planning, and evaluation of patient safety data at the unit level.

 

EP20EOb: Provide two examples, with supporting evidence, of an improvement in patient safety that resulted from clinical nurses’ involvement in the evaluation of patient safety data at the unit level. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data.

 

The SSI data to demonstrate improvement in patient safety were incomplete and inconsistent time increments were used to document pre-, intervention, and post-intervention data. Pre and post-implementation data intervals were not consistent. The pre-implementation data are monthly; post-implementation data reflected missing months.

 

• Please provide uniformly reported pre-, intervention, and post-intervention SSI data to demonstrate the reduction in “the rate of colorectal SSIs at Homestead Hospital to be less than the expected benchmark rate”.

______________________________________________________________________

 

A new example is provided below.

 

Example 2

 

NAME OF INITIATIVE

 

Surgical Site Infection Reduction Program

BACKGROUND/PROBLEM

 

Surgical Site Infections (SSI) are a major cause of morbidity, mortality and increased health care costs in surgical patients (Coello R, Charlett A, Wilson J, et al., 2005; Kaye KS, Anderson DJ, Sloane R, et al., 2009; Kirkland KB, Briggs JP, Trivette SL, et al., 1999; de Lissovoy G, Fraeman K, Hutchins V, et al., 2009). Patients who have colorectal surgeries tend to experience higher rates of SSI (Cima et. al., 2012).  Bundled perioperative measures have been recommended by The Joint Commission Center for Transforming Health Care to reduce SSI rates in colorectal surgery (CRS) (The Joint Commission [TJC], 2013), Data derived from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) demonstrates that bundling care can be an effective means of preventing infections (American College of Surgeons [ACS], June 30, 2012).  The ACS encourages the utilization of the “comprehensive unit-based safety program” or CUSP, an evidence-based multidisciplinary approach to safety improvement that focuses on the involvement of frontline staff such as nurses and technicians (Center for Innovation in Quality Patient Care, No date.).

 

Homestead Hospital was an active participant of the ACS NSQIP program. Since NSQIP released their report semiannually with a 6-month lag time, Performance Improvement Nurse and NSQIP Coordinator Patricia Yulkowski, RN, calculated the SSI rate quarterly using the formula below. This enabled her to react to more real-time data and go through the “Plan, Do, Check, Check, Act” (PDCA) cycle more quickly. She noted that the SSI rates were 11.38 in March 2012 and 11.81 in June 2012.

 

SSI rate = Number of SSI occurrences within 4 rolling quarters           X 100
                Total number of colorectal cases within 4 rolling quarters

 

In July of 2012, when the official NSQIP report came out, Yulkowski  reviewed with the Surgical Services Department (SSD) leadership the December 2011 ACS NSQIP report.  They noted that the SSI observed rate at Homestead Hospital was 14.71, higher than the expected rate of 9.93. This corroborated Yulkowski’s quarterly SSI rate calculations and indicated an opportunity for improvement in regards to CRS SSI. Furthermore, Yulkowski conducted a chart review. It revealed that 5/6 cases of colorectal SSI at Homestead Hospital had required an additional surgery to correct the problem. She then assembled a interprofessional team in August of 2012 to begin addressing the problem of colorectal SSIs at Homestead Hospital based upon ACS recommendations.

 

GOAL STATEMENT

 

To reduce the colorectal SSI rate at Homestead Hospital.
          
DESCRIPTION OF THE INTERVENTION/INITIATIVE/ACTIVITY (IES)

 

The team utilized the PDCA model to guide the inquiry. They developed and implemented multiple interventions across the entire surgical episode of care.

 

Plan
In August of 2012, the first assembly of an interprofessional team consisting of members from the Surgical Services Committee (SSC), Medical Staff, and PI department was conducted. The team was charged with the task of determining the best way to implement the ACS NSQIP bundled approach in reducing colorectal SSI’s at Homestead Hospital. Throughout the project, the team exchanged information and met informally via email and telephone calls. Yulkowski became the communication hub and ensured that team members were apprised of project updates. The group determined that changes needed to be made to processes involving the pre-operative, intra-operative, and post-operative stages of colorectal procedures as follows:

 

Action Plan for Changes

1. Pre-operative changes

1. Pre-operative bathing using 4% Chlorhexidene Gluconate showers

1. Evening before and morning of scheduled surgery
1. Application of warming gown (Bair Paws)
1. Maintain normothermia throughout surgical experience
2. Pre-operative clipping in the pre-operative suite when applicable
3. Pre-operative antibiotics within one hour of incision
4. Appropriate surgical hand scrub by all members of surgical team

2. Intra-operative changes

1. Glove change prior to fascia closure
2. Sterile instrumentation tray for skin closure
3. Re-dosing of antibiotics for procedures >4 hours in length
4. Limit traffic in the surgical suite

3. Post-operative changes

1. Application of Mepilex dressing immediately post-operatively

 

 

Clinical Nurses Involvement in Unit-Level Data Review and Action Planning

 

Yulkowski engaged the clinical nurses in the data review and action planning processes through the Surgical Services Unit Practice Council (UPC) chaired by Clinical Nurse Archelle Quintana, RN. She attended the UPC meeting in September 2012 and presented the department’s SSI rates. The SSI rates were 11.38 and 11.81 respectively, in March 2012 and June 2012. The portion of the SSI action plan that the clinical nurses were able to influence was the intra-operative phase pertaining to fascia closure. OR Clinical Nurse Shannon Newton, RN together with a surgical technician volunteered to develop the log and collect the data in the OR. On the other hand, Clinical Nurses Janice Gates, RN, Jessy Varkey, RN and Barbara Gross, RN participated in developing the sterile closing tray and process during fascia closure. Clinical Nurse Educator Lamberto Hernandez, RN presented the 2011 ACS/NSQIP results  during the October 2012 staff meeting in a presentation titled “Surgical Site Infection: A Closer Look” to inform the staff and harvest additional feedback for the action plan.

 

Do
The initial testing and implementation began in August 2012 and continued through March 2013.  The team introduced warming gowns in August 2012; hair clipping outside of the surgical suite in September 2012; and the intraoperative portion of the SSI bundle in December 2012. The team integrated the CUSP framework within the PDCA to guide the implementation of the necessary practice changes. The CUSP was introduced during the “Do” stage of the PDCA because it speaks specifically to the gradual introduction of practice changes aimed at improving safety by allowing enough time for full integration into practice. The framework’s components were:

1. Train staff in the science of safety.
1. The implementation of each practice change was preceded by an educational presentation to SSD staff. Hernandez delivered all staff education in-person. He presented a total of 5 educational sessions (August 2012, September 2012, October 2012, December 2012, and March 2013) to the clinical staff during the implementation period.  Some of the sessions included simulation activities on the use of new supplies / equipment.
2. Engage staff to identify defects.
1. Hernandez conducted the educational sessions during staff meetings. He encouraged the staff to provide input regarding the proposed changes during that time or by directly contacting a project team member with any concerns.
3. Senior executive partnership.
1. Todd Mangione, D.O. became the physician champion for the project.  Dr. Mangione reviewed the changes proposed through the new SSI bundle and assisted in the education and roll-out to the medical staff via the Medical Executive Committee (MEC).

Check

4. Continue to learn from defects.

 

Clinical Nurses Involvement in Evaluation of Unit-Level Patient Safety Data

 

Throughout the project, Yulkowski used quarterly data to track progress and to determine the effectiveness of interventions. After its initial implementation in December 2012, the team made revisions to the pre-operative checklist based on staff feedback during the February 2013 Surgical Services staff meeting.  The proposed changes were presented; approved during the March 2013 staff meeting; and implemented thereafter. The team also introduced the post-operative portion of the SSI bundle at this time. Yulkowski received the benchmarked NSQIP data semiannually. Accordingly, she updated the clinical nurses, Medical Executive Committee and Board Members through meeting presentations and poster boards every 6 months.

 

Act

5. Implement tools for change.

 

The team added most process changes to the preoperative checklist and the Ambulatory Care Services assessment sheet. Yulkowski and Mangione have jointly presented the semiannual SSI report to the MEC in June 2012 and January 2013. Yulkowski routinely conducted chart reviews on SSI to determine root cause.

 

PARTICIPANTS

 

Members of the interprofessional SSI bundle project team included:

 

Name/Credentials	Title	Department	Role in the Team
Patricia Yulkowski, RN	Performance Improvement Nurse	Performance Improvement	Team Lead; Surgical Nurse Reviewer for ACS-NSQIP; Data collection, analysis & interpretation
Archelle Quintana, RN, CPAN	Clinical Nurse	Surgical Services	UPC Chair and coordinated UPC’s involvement in the initiative
Shannon Newton, RN	Clinical Nurse	Surgical Services	UPC Member; developed data collection log; participated in data collection
Janice Gates, RN, CNOR	Clinical Nurse	Surgical Services	Developed sterile tray and process for fascia closure
Jessy Varkey, MSN, RN, CNOR	Clinical Nurse then; PI Nurse now	Surgical Services	Developed sterile tray and process for fascia closure
Barbara Gross, RN	Clinical Nurse	Surgical Services	Developed sterile tray and process for fascia closure
Wanda Vargas-Rosado, BSN, RN, CNOR	Assistant Nurse Manager	Surgical Services	Administrative support with the planning and roll-out of SSI bundle
Lamberto Hernandez, BSN, RN, CNOR	Clinical Nurse Educator then; Patient Care Supervisor now	Surgical Services	Clinical education of staff on colorectal SSI bundle components
Pam Rozas, RN	Information Systems Coordinator	Surgical Services	Data collection, trial and Unit Practice Council Chair when project was rolled-out; responsible for implementation of Bair Paws warming gowns.
Edlina Hilson, MSN, MBA-HAS, RN, CCRN	Patient Care Supervisor then; Clinical Nurse now	PACU	Assisted with revision of pre-operative checklist.
Jessica Roldan, BSN, RN, CGRN	Patient Care Supervisor	Endoscopy	Assisted with revision of pre-operative checklist.
Mary Montejo, BSN, RN, CWS	Wound and Ostomy Coordinator	Wound Care	Assisted with acquisition and staff education on use of Mepilex dressing.
Wendy Rey, RN	Manager	Infection Control	Assisted with acquisition of Chlorhexedine Gluconate for showers.
Rosa Flores	Surgical Technologist	Surgical Services	Assisted with implementation of SSI bundle.
Tiffanie Watson	Surgical Technologist	Surgical Services	Assisted with implementation of SSI bundle.
Todd Mangione, D.O	General Surgeon	Medical Staff	Physician Surgeon Champion for ACS-NSQIP.  Responsible for physician education on CRS SSI bundle implementation

 

 

OUTCOME(S)

 

From  the July 2013 ACS NSQIP Semiannual Report data (based on 2012 reporting period), the hospital was identified as achieving a meritorious composite quality score based on a combination of 9 surgical outcomes.

 

Exhibit EP20EOda:  Homestead Hospital Colorectal SSI Rate

 

 

Legend:

1. Presentation of 2011 ACS/NSQIP results by Yulkowski to SSD leadership – July 2012
2. Initiation of project team activities to address SSI rates.  Warming gowns introduced – August 2012
3. Introduced hair clipping outside of surgical suite – September 2012
4. Remainder of changes to pre-operative checklist implemented. Introduction of intra-operative portion of SSI bundle – December 2012
5. Finalization of pre-operative checklist with changes.  Introduction of post-operative portion of SSI bundle – March 2013

 

Analysis: Above graph shows that the Surgical Services department achieved their goal of reducing colorectal SSI rate as evidenced by 5 data points below the baseline post-intervention.

 

References

 

American College of Surgeons [ACS]. (June 30, 2012). New surgical patient safety program reduces surgical site infections by one-third in patients who undergo colorectal operations. Retrieved from http://site.acsnsqip.org/news/new-surgical-patient-safety-program-reduces-surgical-site-infections-by-one-third-in-patients-who-undergo-colorectal-operations/.

 

ACS NSQIP. (December 2011). ACS NSQIP Semiannual report: Site summary, Homestead Hospital. [Online]. Retrieved from: http://site.acsnsqip.org/

 

ACS NSQIP. (March 2013). ACS NSQIP Interim semiannual report: Site summary, Homestead Hospital. [Online]. Retrieved from: http://site.acsnsqip.org/

 

ACS NSQIP. (September 2013). ACS NSQIP Interim semiannual report: Site summary, Homestead Hospital. [Online]. Retrieved from: http://site.acsnsqip.org/

 

Center for Innovation in Quality Patient Care. (No date). CUSP framework. Retrieved from http://www.hopkinsmedicine.org/innovation_quality_patient_care/ areas_expertise/improve_patient_safety/cusp/five_steps_cusp.html

 

Cima, R., Dankbar, E., Lovely, J., Pendlimari, R., Aronhalt, K., Nehring, S., and…Quast, L. (2012). Colorectal surgery surgical site infection reduction program: a national surgical quality improvement program-driven multidisciplinary single-institution experience. Journal of the American College of Surgeons, 216(1), 23-33. doi: 10.1016/j.jamcollsurg.2012.09.009.

 

Coello, R., Charlett, A., Wilson, J., et al. (2005). Adverse impact of surgical site infections in English hospitals. J Hosp Infect, 60, 93e-103e.

 

Kaye, K.S., Anderson, D.J., Sloane, R., et al. (2009). The effect of surgical site infection on older operative patients. Journal of the American Geriatrics Society, 57, 46e-54e. Kirkland, K.B., Briggs, J.P., Trivette, S.L., et al. (1999). The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infection Control & Hospital Epidemiology, 20, 725e-730e.

 

de Lissovoy, G., Fraeman, K., Hutchins, V., et al. (2009). Surgical site infection: incidence and impact on hospital utilization and treatment costs. American Journal of Infection Control, 37, 387e-397e.

 

The Joint Commission. (2013). The Joint Commission’s implementation guide for NPSG.07.05.01 on surgical site infections: The SSI change project. Retrieved from http://www.jointcommission.org/assets/1/18/ Implementation_Guide_for_NPSG_SSI_1.PDF

 

 

Summary Attachments/Hyperlinks/Evidences

 

Exhibit EP20EOda: Homestead Hospital Colorectal SSI Rate

 

 

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