Disclosures To Report

1. Disclosures To Report • To remain compliant with the Accreditation Council for Continuing Medical Education (ACCME®) regulations, it is necessary to disclose to my audience that I am employed by The Regional Medical Center of Orangeburg & Calhoun Counties, Orangeburg Surgical Associates

2. Surgical Safety &Infection Prevention E. Arden Weathers, MD Thursday, September 16, 2010

3. Universal Protocol • The Universal Protocol applies to: • All surgical and non-surgical invasive procedures. • Hospitals can enhance safety by correctly identifying: • the patient, • the appropriate procedure • the correct site of the procedure.

4. Universal Protocol Revised 2010 • UP.01.01.01 – Conduct a pre-procedure verification process. • UP.01.02.01 - Mark the procedure site. • UP.01.03.01 - A time-out is performed immediately prior to starting procedures. TJC has kept the major principles of the original Universal Protocol in place but has provided local hospital systems with more flexibility in implementing them.

5. Pre-procedure VerificationUP.01.01.01 • Purpose: To make sure all relevant documents and related information or equipment are: • Available prior to the start of the procedure • Correctly identified, labeled, and matched to the patient identifiers • Reviewed and consistent with the patient’s expectations and with the teams understanding of the intended patient, procedure, and site Timing (when this verification occurs) and Location (where this verification occurs)is under local control.

6. Pre-procedure VerificationUP.01.01.01Elements of Performance 1) Implement a pre-procedure process to verify: • Correct Patient • Correct Site • Correct Procedure Note: The patient is involved in the verification process when possible.

7. Pre-procedure VerificationUP.01.01.01Elements of Performance 2) Identify items that must be available for procedure and use a standardized list to verify their availability. At a minimum, these items include the following: • Relevant documentation (H&P, signed consent, nursing assessment, and pre-anesthesia assessment) • Labeled diagnostic and radiology test results (images, scans, pathology, and biopsy reports) • Required blood products, implants, devices, and/or special equipment 3) Match items to be available in procedure area to the patient. Note: The expectation is that the standardized list is available and used consistently during procedure verification. It is not necessary to document that the standardized list was used for each patient.

8. Mark the procedure site UP.01.02.01Elements of Performance • Purpose: Marking the procedure site is one way to protect patients. Patient safety is enhanced when a consistent marking process is used throughout the hospital.

9. Mark the procedure site UP.01.02.01Elements of Performance 1) Identify procedures that require marking of the incision or insertion site. At a minimum, sites are marked when there is more than one possible location for the procedure and when performing the procedure in a different location would negatively affect quality or safety.

10. Mark the procedure site UP.01.02.01Elements of Performance 2) Mark the procedure site before the procedure is performed and, if possible, with the patient involved. 3) The procedure site is marked by a licensed independent practitioner who is ultimately accountable for the procedure and will be present when the procedure is performed. Marking the surgical site can be done by the following individuals:a) Operating surgeonb) Participating residentc) Participating licensed practitioner (including physician assistant or nurse practitioner) with a collaborative or supervisory agreement with the surgeon (Determination of this application is under local control.)

11. UP.01.03.01Time-out Time out is performed immediately prior to starting procedures • Purpose: To conduct a final assessment that the correct patient, site and procedure are identified. During a time-out, activities are suspended so that team members can focus on active confirmation of the patient, site and procedure.

12. Time-out UP.01.03.01Elements of Performance • The time-out has the following characteristics: • Standardized (as defined by the hospital). • Initiated by a designated member of the team. • Involves the immediate members of the procedure team, including: • Individual performing the procedure • Anesthesia • Circulating nurse • OR technician(s) • Other active participants who will be participating in the procedure from the beginning.

13. Time-out UP.01.03.01Elements of Performance 3)When two or more procedures are performed on the same patient, and the person performing the procedure changes, perform a time-out before each procedure is initiated. Note: Two different teams = two different timeouts. Or if hospital requires two consents = two timeouts.

14. Time-out UP.01.03.01Elements of Performance • During the time-out, the team members agree, at a minimum on the followng: • Correct patient identity • Correct site • Procedure to be done • Document the completion of the time-out.

15. National Time-Out Day June 16, 2010

16. Safe Surgery Saves Lives • The goal of the Safe Surgery Saves Lives Challenge is to improve the safety of surgical care around the world by ensuring adherence to proven standards of care in all states. • The WHO Surgical Safety Checklist has improved compliance with standards and decreased complications from surgery in eight pilot hospitals where it was evaluated.

18. WHO Surgical Safety Checklist • The checklist identifies three phases of an operation, each corresponding to a specific period in the normal flow of work. • In each phase, the checklist helps teams confirm that the critical safety steps are completed before it proceeds with the operation

19. tRMC Surgical Care Improvement Team

20. Surgical Safety Checklist Surgical Care Improvement Team adapted WHO form to align with The Joint Commission 2009 Standards and our facility policies 2 Piloted for one day in SDS and one OR suite. Involved staff by requesting feedback & providing several educational in-services. 1 Rapid Cycle 4 3 Made final changes based on feedback, inserviced all staff and released house-wide 6/15/09 for full implementation Edited form based on staff feedback and rolled out to SDS, all OR suites, Radiology, & Cath Lab for second pilot.

22. Surgical Safety Checklist • 18 revisions with 4 implementations before final roll out. • Significant staff involvement. • was the featured Hospital for SCHA Operation Safe Surgery Webinar in March 2009. • SCHA article regarding our process and progress.

24. Includes IHI Bundle Requirements

25. Opportunitiesfor Improvement • Physicians continue to complain about site marking • Still have to track down H&Ps • Still need communication tool on the back of form for in-patients • Compliance with cases performed outside of the operating room.

26. SCIP Core Measures • Beta Blocker Perioperatively • Perioperative Temperature Management • Prophylactic Antibiotic within an hour preoperatively • Prophylactic Antibiotic Selection • Prophylactic Antibiotic End within 24 Hours • Glucose Management Cardiac Patients (≤ 200 POD1 & POD2) • Appropriate Hair Removal • Urinary Catheter Removed • Recommended VTE (Ordered & Received)

27. SCIP Pocket Card Front Back

28. Core Measure Pocket Card Front Back

30. “How long should you try? Until….” Jim Rohn “Many of the great achievements of the world were accomplished by tired and discouraged men who kept on working” Author: Unknown