antibiotic ordering and administration improvement project perioperative services vanderbilt...
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Antibiotic Ordering and Administration
Improvement Project
Perioperative Services Vanderbilt University Medical Center
Nashville, TN
Team Members:
• 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
• 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 we trying to accomplish?
Aim: To administer antibiotics within 60 minutes of the surgical incisions
100% of the time
What are we trying to accomplish?
Aim: To administer antibiotics within 60 minutes of the surgical incisions
100% of the time
How will we know that a change is an improvement?
The patients sampled from UHC (using the SCIP/ CMS criteria) will demonstrate that antibiotics are
administered within 60 minutes prior to incision 100% of the time.
How will we know that a change is an improvement?
The patients sampled from UHC (using the SCIP/ CMS criteria) will demonstrate that antibiotics are
administered within 60 minutes prior to incision 100% of the time.
What changes can we make that will result in an improvement?
Process Analysis
Flowchart, Cause & Effect Diagram
What changes can we make that will result in an improvement?
Process Analysis
Flowchart, Cause & Effect Diagram
Failure to provide timelyAdministration of
antibiotics To the Patient
Machinery/Equipment People
Policy and Procedure MaterialsEnvironment
Surgeons not following Antibiotic Protocol
Nurses not following Antibiotic Protocol
No paper orders for Antibiotics
available in Patient’s chart
in Holding Room
Antibiotic orders Are not being scanned to the standard site in
Star Panel
No Antibiotic Protocol Wiz Orders
Limited Computer access in
Holding Room
Antibiotic ProtocolE-Learning Module Only 67% complete
All Staff, Surgeons, House Staff have not received Antibiotic
Administration Protocol training
Lack of knowledge or training regarding
Antibiotic Protocol
Antibiotic orders are not available
in the Holding Room
Antibiotic Protocol E-Learning Module is not mandatory
Antibiotic orders can not be found in
Star Panel
MethodNo process to ensure
staff documents administration of antibiotics
No standard Star Panel tab
for Antibiotic orders or Pre-op orders
VPIMS prompt not implemented,
No forcing function
Antibiotic Wiz Orders not developed
Lack of Clinic staff training
regarding documents needed for
surgery patient
Chaotic environment in Holding Room
esp. for first case of day
Nurse unable to verify
order is valid
Hand written orders are difficult to read due to
poor scanning quality
Obtaining Antibiotic orders are not high priority
compared to other activities that must be
completed in order to send patient
to OR on time
Unable to read pre-operative orders
Clinic staff not scanning orders into Star Panel
No Pre-operative orders for patients
No pre-operative orders written by the surgeon
Scanners produce Poor scanned copies
of pre-operative orders
No activation date on scanned orders
Nurses lack training
Physician writes or enters WIZ
antibiotic orders
Are antibiotic orders scanned in Star Panel?
Office staff scan Antibiotic order into Star
Panel
ANTIBIOTIC ORDERING AND ADMINISTRATION PROCESS Monday, May 07, 2007
Holding Room Nurse accesses Antibiotic
Orders via the Patient's chart
Holding Room Nurse
researches Star Panel for patient’s
antibiotic orders on day of Surgery
Holding Room Nurse verifies
ordered antibiotic with
Anesthesia per the Holding
Room Report
Holding Room Nurse attempts IV
access
Holding Room Nurse documents antibiotic
administration in VPIMS
Yes
Holding Room Nurse obtains
ordered antibiotics from
the Pyxis
No
Is administration of antibiotic
greater than 3 hours
prior to incision?
No
Yes
Holding Room Nurse obtains
second order for Antibioitics
Holding Room Nurse obtains
antibiotic from the Pyxis
Does Patient need
antibiotics?
No orders for antibiotics
written
Yes
No
Patient seen by Surgeon in
Clinic for Pre-operative Evaluation
Physician determines appropriate
antibiotic for the Patient
Are antibiotics in
the Pyxis machine?
Yes
No
Holding Room Nurse calls
Pharmacy to obtain ordered
antibiotic
Does Holding Room
Nurse obtain IV access?
Holding Room Nurses contacts
Anesthesia provider
Yes
No
Anesthesia provider obtains
IV access
Does Holding Room Nurse find patient’s antibiotic
order in Star Panel?
Yes
No
Does Holding Room Nurse need to hold antibiotic
order per Physician
order?
No
Yes
1
1
Holding Room Nurse follow physician/surgeon
order regarding the “holding of the antibiotic”
Pharmacy sends
antibiotics to Holding Room
for patient
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 ?
Chart Manager picks up orders from TVC drop box
Does physician’s
staff drop the orders off in the TVC
Drop Box?
Chart Manager takes orders to the Holding Room evening
prior to patient’s surgery
No
Yes
Chart Manager takes orders to the Holding Room evening prior to patient’s surgery
Chart Manager picks up physician
orders at the Clinic
Is the patient’s
surgery the next day?
Chart Manager holds physician orders until day before surgery
No
Yes
Holding Room Nurse does not give antibiotics
Is Vancomycin or quiolone ordered ?
Holding Room Nurse will administer the Vancomycin or quiolone per physician
order and Surgical Prophylactic Antibiotic
Protocol
No
Yes
Patient to OR 2
Pre-Operative Phase of Antibiotic Ordering and Administration
Pre-Operative Phase: Holding Room
Pre-Operative Phase: Clinic
Holding Room Nurse documents
A????
Anesthesia Provider
administers ordered antibiotic within 60 minutes
of surgical incision
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
Value Step
The Nurse administers the
prophylactic antibiotic per
Surgical Prophylatic Antibiotic Protocol
2
ANTIBIOTIC ORDERING AND ADMINISTRATION PROCESSWednesday, May 09, 2007
Anesthesia provider
administers prophylactic antibiotic per
protocol
Case ends
Post-Operative Phase: PACU (Recovery)
Staff transports patient to PACU
End of PACU Phase of Care
Does patient require ordered
prophylactic antibiotic?
Transport Patient to Patient Care
Unit
3
3Is patient to
receive prophylactic antibiotics?
Nurse administers prophylactic antibiotic per
Surgical Prophylactic
Antibiotic Protocol
End of Process
Nurse documents the
administration of prophylactic
antibiotic in the MAR per Nursing Documentation
standards
Post-Operative Phase: Patient Care Unit
Intraoperative Phase
Yes
No
End of Process
Yes
No
Value Step
What changes can we make that will result in an improvement?
Changes Identified
What changes can we make that will result in an improvement?
Changes Identified
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.