Transcript Antibiotic Ordering and Administration Improvement Project Perioperative Services

Antibiotic Ordering and
Administration Improvement
Project
Perioperative Services
Vanderbilt University Medical Center
Nashville, TN
Team Members:
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Nimesh Patel
Betty Sue Minton
Tom Connor
Dr. Dan Beauchamp
Dr. Paul St. Jacques
Nancye Feistritzer
Audrey Kuntz
Barbara Martin
Judy Hassell
Tom Mack
Frances Sanders
Dr. Rashid Ahmad
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Dr. Mike Higgins
Susie Leming-Lee
Dr. Drew Gaffney
Stephanie Randa
Dr. Willie Melvin
Gwen Holder
Russ Waitman
Fred Haitch
Fred Hargrove
Carolyn Maness
Susan Moseley
Dr. Tom Talbot
Christie Todd
Improvement Model*
*Improvement Model from: Langley et al. The Improvement
Guide: A Practical Approach to Enhancing Organizational
Performance. Josey-Bass Publishers.1996.
What are
are we
we trying
trying to
to accomplish?
accomplish?
What
Aim:
Aim:
To administer
administer antibiotics
antibiotics within
within 60
60
To
minutes of
of the
the surgical
surgical incisions
incisions
minutes
100% of
of the
the time
time
100%
How will
will we
we know
know that
that aa
How
change is
is an
an improvement?
improvement?
change
The patients
patients sampled
sampled from
from UHC
UHC
The
(using the
the SCIP/CMS
SCIP/CMS criteria)
criteria) will
will
(using
demonstrate that
that antibiotics
antibiotics are
are
demonstrate
administered within
within 60
60 minutes
minutes prior
prior
administered
to incision
incision 100%
100% of
of the
the time.
time.
to
What changes
changes can
can we
we make
make that
that
What
will result
result in
in an
an improvement?
improvement?
will
Process Analysis
Analysis
Process
Flowchart, Cause
Cause &
& Effect
Effect Diagram
Diagram
Flowchart,
Method
No process
to ensure
staff documents
administration
of antibiotics
Machinery/Equipment
People
Surgeons not following
Antibiotic Protocol
Lack of knowledge or
training regarding
Antibiotic Protocol
Limited Computer
access in
Holding Room
VPIMS prompt
not implemented,
No forcing function
Antibiotic orders
Are not being scanned
to the standard site in
Star Panel
No standard
Star Panel tab
for Antibiotic orders
or Pre-op orders
Unable to read
pre-operative orders
Nurses not following
Antibiotic Protocol
Nurses lack training
Scanners produce
Poor scanned copies
of pre-operative
orders
No Pre-operative
orders for patients
Antibiotic orders
are not available
in the Holding Room
Antibiotic orders can
not be found in
Nurse unable
Star Panel
to verify
Clinic staff not
order is valid
scanning orders
into Star Panel
No activation date
on scanned orders
No pre-operative
orders written by the surgeon
Chaotic environment
in Holding Room
esp. for first case of day
Obtaining Antibiotic
orders are not
high priority
compared to other
activities that must be
completed in
order to send patient
to OR on time
No paper orders
for Antibiotics
available in
Patient’s chart
in Holding Room
No Antibiotic Protocol Wiz Orders
Antibiotic Wiz Orders
not developed
Lack of Clinic staff
training
regarding documents
needed for
surgery patient
All Staff, Surgeons, House Staff
have not received Antibiotic
Administration Protocol training
Antibiotic Protocol
E-Learning Module
Only 67% complete
Hand written orders are
difficult to
read due to
poor scanning quality
Antibiotic Protocol
E-Learning Module
is not mandatory
Environment
Policy and Procedure
Materials
Failure to provide timely
Administration of
antibiotics
To the Patient
Monday, May 07, 2007
ANTIBIOTIC ORDERING AND ADMINISTRATION PROCESS
Pre-Operative Phase of Antibiotic Ordering and Administration
Pre-Operative Phase: Clinic
Patient seen by
Surgeon in
Clinic for Preoperative
Evaluation
Yes
Does Patient
need
antibiotics?
No
Physician
determines
appropriate
antibiotic for the
Patient
Yes
Physician writes
or enters WIZ
antibiotic orders
Office staff
scan Antibiotic
order into Star
Panel
Are antibiotic
orders scanned
in Star Panel?
No
No orders for
antibiotics
written
Chart
Manager
picks up
physician
orders at the
Clinic
No
Does
physician’s
staff drop the
orders off in the TVC
Drop Box?
Yes
Is the
No
patient’s
surgery the
next day?
Yes
Chart Manager picks up
orders from TVC drop box
Note: When the resident
arrives in Holding Room
to mark the patient’s
surgical site the resident
will write the antibiotic
orders if the patient
needs antibiotics? Why ?
Holding Room
Nurse
researches Star
Panel for
patient’s
antibiotic orders
on day of
Surgery
Chart Manager takes orders
to the Holding Room evening
prior to patient’s surgery
Does Holding
Room Nurse find
patient’s antibiotic
order in Star
Panel?
Yes
Holding
Room Nurse
attempts IV
access
Does
Holding Room
Nurse obtain IV
access?
Yes
1
No
No
Holding Room
Nurses contacts
Anesthesia
provider
Holding Room
Nurse does not
give antibiotics
Chart Manager
holds physician
orders until day
before surgery
Anesthesia
provider obtains
IV access
Chart Manager takes
orders to the Holding
Room evening prior
to patient’s surgery
Holding Room Nurse
accesses Antibiotic
Orders via the Patient's
chart
Pre-Operative Phase: Holding Room
1
Does Holding No
Room Nurse need
to hold antibiotic
order per
Physician
Yes
order?
Holding Room Nurse
follow physician/surgeon
order regarding the
“holding of the antibiotic”
Are Yes
antibiotics in
the Pyxis
machine?
No
Holding Room
Nurse calls
Pharmacy to
obtain ordered
antibiotic
Pharmacy
sends
antibiotics to
Holding Room
for patient
Holding Room
Nurse obtains
ordered
antibiotics from
the Pyxis
No
Is Vancomycin
or quiolone
ordered ?
Yes
Holding Room Nurse will
administer the Vancomycin
or quiolone per physician
order and Surgical
Prophylactic Antibiotic
Protocol
Holding Room Nurse
documents antibiotic
administration in VPIMS
Is administrationNo
of antibiotic
greater than 3
hours
prior to incision?
Yes
Holding Room
Nurse obtains
second order for
Antibioitics
Holding Room
Nurse obtains
antibiotic from the
Pyxis
Holding Room
Nurse verifies
ordered
antibiotic with
Anesthesia per
the Holding
Room Report
Holding
Room Nurse
documents
A????
Patient to OR
2
Wednesday, May 09, 2007
ANTIBIOTIC ORDERING AND ADMINISTRATION PROCESS
Intraoperative Phase
Value Step
2
Anesthesia
Provider
administers
ordered antibiotic
within 60 minutes
of surgical
incision
Value Step
Post-Operative Phase: PACU (Recovery)
Yes
Does VPIMS
alert indicate
patient should
receive a redose of
prophylacitc
antibiotics?
Anesthesia
Provider verifies
the
administration of
the antibiotic
during the “Time
Out” phase of the
surgical process
Anesthesia
provider
administers
prophylactic
antibiotic per
protocol
Case ends
No
Post-Operative Phase: Patient Care Unit
Yes
3
Transport Patient
to Patient Care
Unit
Is patient to
receive
prophylactic
antibiotics?
No
End of Process
Nurse
administers
prophylactic
antibiotic per
Surgical
Prophylactic
Antibiotic
Protocol
Nurse documents
the
administration of
prophylactic
antibiotic in the
MAR per Nursing
Documentation
standards
End of Process
Staff transports
patient to PACU
Does patient
require ordered
prophylactic
antibiotic?
The Nurse
administers the
prophylactic
antibiotic per
Surgical Prophylatic
Antibiotic Protocol
End of PACU
Phase of Care
3
What changes
changes can
can we
we make
make that
that
What
will result
result in
in an
an improvement?
improvement?
will
Changes Identified
Identified
Changes
CHANGES
PDSA Cycle
PLAN - DO
PLAN - DO
STUDY
ACT
• This endeavor was successful as evident by the
baseline rate going from 51% to 98%
• We continue to collect data as part of the
SCIP/CMS Metrics.
• Reports are presented to, the Perioperative
Managers and Directors Committee weekly, of the
Perioperative Enterprise Committee monthly and
quarterly to Quality Council and LDI.