Elizabeth Cox

Attention to Skin in the Perioperative Setting

Purpose: Our hospital is a level one trauma center performing over 100 surgeries daily. With the advent of Centers for Medicare and Medicaid state stage three and four skin breakdowns not present on admission will no longer be reimbursed, the Perianesthesia Care Unit took a proactive stance at skin integrity issues. Recognizing opportunity to improve our practice in reporting, documenting and informing to divisions skin related concerns, our division developed a proactive process of tracking and communicating with in-patient divisions.

Patient Registratation in the Preoperative Area: A New Process

Purpose: In the past, patients arrived to the main registration area to check in for surgery where they would be registered in the hospital computer. They would wait for their blood to be drawn and then wait to transfer to the preoperative holding area. This caused delays in surgery start times and caused patients to move about our department for services. Leadership wanted a faster, more concise process to decrease wait times and increase patient satisfaction.

Standardization of Hand-Off in PACU

Problem: There were a variety of tools and methods utilized in the PACU for hand-off report. Due to the introduction of the electronic medical record (EMR), some nurses used no written form, while others find the EMR cumbersome for report and preferred a written hand-off communication tool. The attending anesthesiologist wanted the form to be utilized by the providers to indicate if follow-up was required on x-rays or blood work. The hand-off procedure needed to be standardized to improve communication among nurses and physicians in the PACU.

Shadowing a Floor Nurse: Increasing Our Scope

Problem: Our Level one hospital performs over 100 surgery cases a day. Our Perianesthesia (PACU)department must concisely and timely transfer patients to the intensive care units, observation units and floors after anesthesia sign out. A potential barrier to patient flow is the quick pace limiting communication and relations within interdepartments. To proactively improve the RN to RN interaction between PACU staff and other divisional lead charge nurses with the institution, the PACU participated in a program similar to our hospitals’ “Walk a Mile in My shoes” program.

Hip and Knee Joint Replacement Certification Survey: Collaboration for Center of Excellence

Implementation: Monthly interdisciplinary meetings were initiated with staff, division leadership, surgeons and hospital safety members participating. The team followed an action plan to identify work flow, completion dates, and identification of responsible parties. PACU specifics were detailed to before and after surgical care. Opportunities to streamline nuances specific to this patient population such as DVT prophylaxis and timing of antibiotic administration were identified early. Although orientation and yearly competencies were already incorporated into the care of joint patients, additional modules for education such as hip precautions and Post-operative complications were added. PACU staff participated in “mock survey” reviews to increase awareness of potential questions asked.

Opioid Administration Post-operatively: Reviewing the Process and Identifying Standards and Expectations for Safe, Effective Care

As healthcare faces demands to decrease length of stay and increase patient satisfaction, hospital staff seeks to streamline the discharge process. Evidence suggests an interdisciplinary discharge process results in increased nurse satisfaction, reduced incidence of medical errors and hospital acquired infections. The purpose of the Vascular Surgery and Transplant Unit (VSTU) Discharge by Eleven Project is to identify barriers to discharge and increase efficiency throughout the discharge process. A patient database was developed to detect variables affecting early discharge. An improvement plan was implemented focusing on timeliness of writing discharge orders by surgical residents and early recognition of potential discharge by nursing, medical and casemanagement staff. Subsequently, the ‘VSTUResidentSurvival Guide’was createdhighlighting the expectationsof nurses rounding daily with attending physicians and residents to identify discharges for the next day. Methods of communication included the team leaders, who served as discharge champions, and utilization of the assignment board as a visual cue.Nurseswere instructed to communicate that discharge occurs before eleven to every admission. Discharge times and customer satisfaction scores were posted weekly. The five month study showed an increase in the satisfaction with speed of the discharge process (75 to 89.3) and overall satisfaction with the process (83.6 to 89.3) based on Press Ganey raw scores. The percent of discharges by eleven increased from 11% to 15% and late discharges decreased from 50% to 37%. These findings suggest that by targeting unit specific variables early discharges can be increased.