Cranial Nerves

Cranial Nerve & Major Functions:

On I Olfactory -smell
Old II Optic -vision
Olympus III Oculomotor -eyelid and eyeball movement
Towering IV Trochlear -innervates superior obliqueturns eye downward and laterally
Tops V Trigeminal -chewing face & mouth touch & pain
A VI Abducens -turns eye laterally
Finn VII Facial -controls most facial expressions secretion of tears & salivataste
And VIII Vestibulocochlear(auditory) -hearing equillibrium sensation
German IX Glossopharyngeal -taste senses carotid blood pressure
Viewed X Vagus-senses aortic blood pressure, slows heart rate,stimulates digestive organs Some XI Spinal Accessory -controls trapezius & sternocleidomastoid,controls swallow
Hops XII Hypoglossal -controls tongue movements

Now go ahead and try this test!

http://www.wisc-online.com/Objects/ViewObject.aspx?ID=AP11504

Required Organizational Practices (ROP's)

The following information covers Sunnybrook's Required Organizational Practices (ROP's). These are common to all healthcare facilities in Canada.

ROP: Transfer of Accountability
What does the process look like when you accept a patient from another area (internal or external to the hospital) or from another service provider (shift-to-shift handover)?
Hint: mention and show the Transfer of Accountability Tool; read the TOA policy
· What kind of information is typically shared?
· Can you show me how and where you document this transfer process?
· What electronic systems are available to help transfer information?
Hint: if applicable to your area, mention and show the Patient Sign Out System or eDischarge System
· What happens when you can’t find the new caregiver assigned to your patient?


ROP: Reporting of Adverse Events and Near Misses
· Can you show me how you report a patient safety incident?
o Hint: Demonstrate the Safety Report system on Sunnynet
· Describe what happens with that report.
o Hint: Does your manager discuss them with you and your colleagues? How do you hear about them?
· What kinds of conversations do you have with your team about incidents that happen in your area?
· What learning has occurred as a result of staff/physicians reporting an incident(s)?
Hint: have you made any changes? Improvements? Implemented new policies or procedures?
· How would you define a near miss?
Hint: a near miss is an error or hazardous situation that was identified and resolved before any patient consequence or harm occurred.
· Does this hospital have a policy on reporting adverse events and near misses?
Hint: a formal policy is currently in the approval process and will be available with all other policies and standards on Sunnynet.
· How are you informed of common patient safety incidents that occur in your area?
Hint: managers or educators may discuss safety trends at staff meetings, or via email or communication boards.


ROP: Educating Patients and Families about their role in safety
· How and when do you involve patients and their families in discussions about safety?
Hint: the Patient Information Handbook has important information about patient safety and is available on all patient care units and from Communications & Stakeholder Relations. It is handed out in the PAC.
· How can patients or families report safety concerns?
Hint: patients and families can speak directly to their caregivers or managers on the unit, as well as representatives from Patient Relations if they have concerns
· What kind of information/resources do you have to share with patients and families about safety?
Hint: the Patient Information Handbook has important information about patient safety and is available on all patient care units and from Communications & Stakeholder Relations
Hint: Posters indicating the Top 5 Patient Safety Tips are available in many units and common patient/family areas

ROP: Adopt client safety as a written, strategic priority or goal
· Is patient safety made a priority in this hospital?
Hint: It is a Strategic Goal of this organization to lead in safety best practices.
Hint: Sunnybrook also has an ‘Accountability for Patient Safety’ Policy that lays the foundation for patient safety culture at Sunnybrook. An Incident Decision Tree has been developed to complement the policy and serves to emphasize the ‘just culture’.


· How does the hospital support patient safety?
Hint: The Department of Quality & Patient Safety provides leadership and expertise in patient safety to all levels of the organization. A Patient Safety Leadership Team is responsible for developing and facilitating the implementation of corporate patient safety initiatives. These include initiatives such as Patient Safety WalkArounds and Monthly Patient Safety Educational Rounds.
· Sunnybrook has a strategic goal to lead in safety best practices. Do you think there are any practices on your unit that directly contribute to that strategic goal?


ROP: Organizational client safety plan
· What kinds of initiatives or projects do you think are part of the organizations client safety plan?
Hints: Patient Safety WalkArounds
Disclosure Policy
Safety Reporting System
Surgical Site Infection Prevention
Venous Thromboembolism Prevention
Transfer of Accountability Tool


ROP: Disclosure of adverse events to patients and families
· What is your role in the disclosure of an adverse event, error or near miss to your patients and/or their family?
· How and when do you involve your patients in discussions about an adverse event?
Hint: Initial disclosure of the adverse event should take place as soon as practically possible after it has occurred or has been identified.
Hint: Disclosure to the patient should occur when the patient is able to comprehend the information. Disclosure to the patient’s substitute decision-maker may occur prior to this if appropriate.
Hint: Follow-up disclosure meetings may be required for thorough disclosure for any adverse event, especially for critical incidents.
· Does this organization have a policy on disclosing adverse events to patients and families?
Hint: Yes – the Sunnybrook Policy for the Disclosure of Adverse Medical Events and Unanticipated Outcomes of Care can be found on Sunnynet
· What kinds of supports are available to help you in a situation when you might have to disclose an error to a patient or their family?
Staff may access the Risk Manager/Shift Manager at pager 1400 for guidance and support.
Any time that a critical incident occurs, 24/7, physicians may contact their Department Chief for guidance and support. If the Department Chief is unavailable, a physician may contact the Medical Director on Call through Communications at ext. 4244.
The role of the Department Chief/Medical Director on Call/ Shift Manager/Risk Manager is to facilitate the staff’s/physician’s discussion about and investigations concerning the critical incident and to help plan the disclosure conversation with the patient and / authorized or substitute decision-maker.
· How would you document the process of disclosing an error to a patient or their family?
Hint: Notify the most responsible physician.
Complete an online e-safety report of the event.
Record in the patient’s chart the disclosure made to the patient and / or the patient’s SDM and who was involved in the disclosure.


ROP: Medication reconciliation at admission to the organization
· What is medication reconciliation?
Hints: A process to prevent medication errors and subsequent adverse events
Involves a systematic process to obtain a thorough medication history called a Best Possible Medication History (BPMH)
BPMH is then compared to medication orders at transitions in care (admission, transfer, discharge) in order to identify and resolve discrepancies
Partnership between health care professionals and patients/ families to ensure accurate and complete transfer of medication information at transitions in care
· Can you describe the process used in this area to reconcile the patients’ medications when they are admitted?
Hint: Will vary unit to unit, but consider who does it, when it is done and where it is documented in your area (some or all of the following may apply)
BPMH is documented on the Pre-Admission Medication List
The goal is to perform medication reconciliation for all patients however the pharmacist may give priority to select patients
When transcribing admission orders, the RN may compare the Pre-Admission Medication List to the admission orders to identify discrepancies
· What kinds of documentation or tools are available to help you conduct medication reconciliation?
Hints: Pre-Admission Medication List (PR 99630)
Medication Administration Record (MAR)
Patients and caregivers, personal medication lists, patients’ medication supply
Patients’ community pharmacy
Ontario Drug Benefit (ODB) Drug Profile Viewer (shows prescriptions filled for ODB patients [65 years of age and older, social assistance, Trillium]). This can be accessed in the Emergency Department and by pharmacists. When accessed, a copy is printed and placed in the chart.
e-Discharge (General Internal Medicine and Cardiology)
· How might you describe a Best Possible Medication History?
Hints: More comprehensive than a traditional primary medication history
Obtained through a systematic patient interview with verification of information from other sources (medication lists, community pharmacy, government medication databases, prescription vials)
Focuses on what the patient is actually taking as opposed to what was prescribed An accurate, up-to-date, complete medication list
· What kind of support/information is available to you to make sure medication reconciliation happens?
Hint: Unit pharmacist
Pharmacy Department
Clinical Nurse Educator or Advanced Practice Nurse
Patient Safety Pharmacists (patti.madorin@sunnybrook.ca, sandra.knowles@sunnybrook.ca)


ROP: Medication reconciliation at time of transfer or discharge
· Can you describe the process used in this area to reconcile the patients’ medications when they are transferred from another area?
Hint: Will vary unit to unit, but consider who does it, when it is done and where is it documented in your area (some or all of the following may apply)
Pharmacists review transfer orders and compare them to the Pre-Admission Medication List and existing medication profile (if applicable). Any discrepancies that are noted (other than discontinuation of certain ICU medications on transfer to the ward) are communicated to the team
When transcribing orders, RN may also use the Pre-Admission Medication List and previous MAR to verify changes and identify discrepancies in transfer orders
· Can you describe the process used in this area to reconcile the patients’ medications when they are discharged from your unit?
Hint: Will vary unit to unit, but consider who does it, when it is done, where it is documented and what is given to the patient, receiving service provider and receiving facility (if applicable) in your area (some or all of the following may apply)
Generally the physician is responsible for reviewing pre-admission medications and current medication orders to decide upon the discharge medication list and any required discharge prescriptions
The Discharge Prescription includes an area to document medications which have been stopped in hospital.
The physician completes a Discharge Notification Summary which is sent to the family doctor. This too has a section for recording medication changes.
For patients with significant medication changes, pharmacists are available to provide counselling before discharge. A detailed medication schedule is provided.
· What kinds of documentation or tools are available to help you conduct medication reconciliation?
See above section re: Med Rec at admission
· What kind of support/information is available to you to make sure medication reconciliation happens?
See above section re: Med Rec at admission
· What kind of information is given to the patient or their family to ensure they understand how to take their medications?


ROP: Use of at least 2 patient identifiers before providing service / care
· When do you typically verify your patient’s identity?
Hint: before providing any service or care, such as medication administration, obtaining lab specimens, administering treatment or beginning a procedure
· How do you double-check or verify the patient’s identification?
Hint: at least 2 identifiers must be used when checking the patient’s identification.
Hint: Room number or bed number are NOT appropriate identifiers
· Can you describe an event when a patient was not properly identified? How was that error prevented from recurring while that patient was under care here?
· What do you do when two patients in your area have similar names?
Hint: list any methods your unit uses to distinguish patients with similar names, including flagging charts, highlighting names on the board, assigning their care to different caregivers, etc.


ROP: Verification processes for high risk activities
· What would you consider a high risk activity conducted in your area?
Hint: examples include administering high risk medications, conducting procedures, receiving critical lab test results, etc.
· What does your team do to prevent adverse events associated with these high risk activities?
Examples: independent double checks for medications, checklists, surgical pause, verbal order read-back, standardized order sets, barcode scanning, MAR to MAR checking, blood transfusion policies, etc.
· What kinds of discussions occur with your team about patient safety in these situations?
Hint: do you discuss high risk activities or concerns at staff meetings? Do you have a safety committee who looks at preventing errors in high risk situations?
· Can you show me the process for administering high-risk medications?
· How do you receive and relay critical information to members of your team?

ROP: Abbreviations, symbols and dose designations NOT to be used
· Does the organization have a list of abbreviations that can’t be used?
Hint: Yes, the “Do Not Use Abbreviations” list is part of the Medication Order Writing Policy found on Sunnynet.
· Can you show me where I might find that “Do Not Use” list?
Hint: found with other policies and procedures on Sunnynet
· What information was provided to you at your orientation about the use of abbreviations in the organization?


ROP: Ongoing training on infusion pumps
· Can you show me how you use this piece of equipment?
· Describe the training you received on this piece of equipment.
· How often do you get to review your training on this piece of equipment?


ROP: Annual patient safety training for all staff
· What was the last patient safety topic you learned about?
Hint: this could include local patient safety topics (unique to your unit) or corporate topics such as: medication reconciliation, disclosure of adverse events, fall prevention, hand hygiene, transfer of accountability, patient safety culture survey, medication safety, pressure ulcer prevention, etc.
· How often you learn about new patient safety topics?
· Can you describe a patient safety initiative you know is important to this organization?
Hints: VTE Prophylaxis, Surgical Site Infection Prevention, Patient Safety Culture Survey, Safety Reporting, Disclosure, Systems Reviews, Patient Safety WalkArounds, Hand Hygiene, SMART pump training, Transfer of Accountability, Medication Reconciliation, Allergy policy, etc.
· What kinds of patient safety topics were discussed at your orientation?
Hint: Patient Safety presents at the bi-annual recertification.
· Are there any organization-wide educational forums where you can learn about patient safety topics?
Hint: Monthly Patient Safety Educational Rounds!


ROP: All staff have clearly defined roles and responsibilities for patient safety
· How would you describe your role in keeping patients safe at this hospital?
· What kinds of policies are in place to help you understand your role in patient safety?
Hint: Accountability for Patient Safety Policy
· Are there supports available to you in this organization to help you make better decisions about patient safety?
Hint: Managers can access patient safety reports and trend data. Representatives from Quality & Patient Safety, Risk Management, Patient Relations and Clinical Ethics are available for support with patient safety issues.
· Describe when/how patient safety is discussed in this area.
Hint: morning rounds, staff meetings, quality councils, departmental forums, etc.


ROP: Hand Hygiene
· Can you describe the hand hygiene protocol used in this area?
Hint: remember the 4 moments of hand hygiene!
· What kind of training have you received on this hand hygiene protocol?
Hint: hand hygiene education modules are available on the Infection Prevention & Control page of Sunnynet
· What kind of information have you received about how well you and your team follow this protocol?
Hint: have you ever seen the compliance for your unit? Did you ever speak about it at a staff meeting?
· What kinds of changes have you seen in this area related to hand hygiene?
· What do you think we could do better in meeting our hand hygiene targets?


ROP: Infection rates are tracked and shared
· If you wanted to know what the C. difficile rates were for your unit, who would you contact?
Hint: Infection Prevention & Control does the important work of tracking our hospital infection rates and can provide such data to units
· What kinds of discussions have occurred in this area about infection prevention?
· How do you communicate to others when an infection has occurred?
· Think about the last time your team/unit discussed infection rates – what were some of the concerns and improvements that were shared?


ROP: Falls Prevention
· Describe how your patients are assessed for their risk for falls.
Hint: mention and demonstrate any specific risk assessment tools used
· When a patient is identified as being at risk, what is the process for identifying and implementing the appropriate strategies?
Hint: Universal strategies such as appropriate lighting, keeping floors clean and dry, access to call bells, locking beds/stretchers when transferring patients.
Hint: Consider strategies for specific risk factors in individual patients, such as a regular toileting schedule, low bed and/or mat on the floor, hip guards to minimize injury from a fall, etc.

· What kind of information / data have you received to know how often falls occur in your area?
Hint: Managers can access patient safety reports and trend data related to falls.
· What patient safety strategies have been put in place here to prevent falls with your patients?
Hint: Mention any program-specific algorithms or guidelines and/or RNAO best practice guidelines on fall risk reduction
· How are staff educated and supported to implement best practices regarding fall risk reduction?
Hint: mention corporate and unit-specific orientation, in-services, decision tools (e.g. algorithms), inter-professional team consultations, etc.

Nalbuphine (Nubain)

The Acute Pain Service (APS) is revising its standard order sets to reflect the fact that low-dose
nalbuphine has been approved by the Pharmacy & Therapeutics Committee as the first-line treatment for opioid-induced pruritus and as a third-line option for postoperative nausea & vomiting (PONV).
Prescribing is restricted to the APS and Anesthesiology. Nalbuphine is a mixed opioid
agonist-antagonist that, when given in low doses (< 5 mg), can reverse the unwanted effects of other opioids. Because it is acting as an antagonist, lowdose nalbuphine does not require additional monitoring for opioid side effects. Nalbuphine will be used in a dose of 4 mg IV Q4H PRN. Ward nurses are authorized to infuse nalbuphine via minibag over 10-15 minutes; other nurses (ICU’s,ER) can also administer it by direct injection diluted in 2-5 mL of NS over 15 seconds. For IV Drug Monograph, click:
http://sunnynet.ca/data/pharmacy/htdocs/iv_drugs/nalbuphine.pdf

SAQ #49

DO THE TEAM’S RESEARCH ACTIVITIES MEET RESEARCH AND ETHICS REQUIREMENTS? GREEN, HIGH

SUMMARY OF RELATED STANDARD(S) 14.4 The team’s research activities for surgical care services meet applicable research and ethics protocols and standards.

Process Currently in Place - Evidence of Current Status
• All approved research projects must follow P&P including ethics committee approval

Improvement Strategy / Action Plan
Reassess in June

SAQ #48

DOES THE TEAM DISCUSS ORGAN DONATION WITH THE CLIENT? RED, HIGH

SUMMARY OF RELATED STANDARD(S) 8.5 Prior to a procedure, the team discusses organ donation with the client, and provides an opportunity for the client to consent to organ donation

Process Currently in Place - Evidence of Current Status
Unless Sunnybrook has a policy outside the ICU-ER that states otherwise, TGLN would only expect a call at end-of-life from the other units when it is family initiated, as we have not designated these units to report all deaths or to approach families.
You can order hard copies of these FAQs through Woodlands to place on the units. The PDF file can be used on the hospital intranet if available.
Below is the information that we have provided to other hospitals who have asked us about surgical accreditation standards of consenting patients.
What is the TGLN policy about discussion organ and tissue donation?
We only approach families in end of life situations and so our policies and procedures are related to this work in hospitals. None of our procedures or guidelines contemplate the situation the surgical standard is proposing. Where we do have a position in speaking with ‘healthy’ Ontarians’ is through our communication strategy that is targeted to Ontario Citizens and promotes registration of consent at OHIP offices.
What are other hospitals in the province doing?
In checking with our coordinators across the province we have identified that three hospitals are currently asking a question about donation at the point of admission. An additional three hospitals have discussed whether they would ask a question about donation preference but have not implemented one as yet. They are questioning the appropriateness of asking this question to patients coming for care. They are concerned about untrained staff asking this question and perceptions of the public that they will not be treated or questioning the hospitals standard of care. *See also PDF sent from GTL

Improvement Strategy / Action Plan
Reassess in June

SAQ #47

IS THERE A TEAM WITH DIFFERENT PROFESSIONALS WITH CLEAR ROLES AND RESPONSIBILITIES? GREEN, LOW

SUMMARY OF RELATED STANDARD(S) 3.1 The organization identifies an interdisciplinary team to deliver surgical care services.13.2 Team members receive education and training on information systems and other technology

Process Currently in Place - Evidence of Current Status
• Nurses, patient service partners, environmental service providers, patient administrative assistants work together in PAC, SDS, PACU and SSSU. Each have defined roles and responsibilities but work together collaboratively to meet patient and family requirements
• Anesthesia care team involves anesthesiologists, Anesthesia Assistants, Respiratory Therapists, Nurse Practioners and Acute Pain Service

Improvement Strategy / Action Plan
Reassess in June

SAQ #46

IS THERE A COMMITMENT TO ONGOING LEARNING IN THE SURGICAL CARE TEAM? GREEN, LOW

SUMMARY OF RELATED STANDARD(S) 1.4 The team collaborates with other services, programs, providers and organizations to identify, address, and coordinate services across the continuum of care.

Process Currently in Place - Evidence of Current Status
• PAC redesign includes increased involvement with CCAC
• service specific discharge planning groups ie: orthopedics,
• breast patients are linked with the Odette Centre
• updated PAC pamphlet and Day of Surgery Booklet

Improvement Strategy / Action Plan
1. goal is to have information on web by end of April
2. CCAC inservice for SSSU

SAQ #45

IS THERE A COMMITMENT TO ONGOING LEARNING IN THE SURGICAL CARE TEAM? GREEN, LOW

SUMMARY OF RELATED STANDARD(S) 4.5 The team receives specific education and training to deliver surgical care services.4.6 The team supports student and volunteer placement on the surgical care team.4.7 The team monitors and meets each team member’s ongoing education, training, and development needs.

Process Currently in Place - Evidence of Current Status
• Staff meetings and inservices-interdisciplinary speakers are invited
• Education days , Recert
• Conference support OPANA, NAPAN, Oncology day
• Staff encouraged to join professional association (OPANA)
• Summer students and co-op volunteers
• Nurse Champions Block areas
• Increased hospital awareness of PeriAnesthesia process ie: tours, shadow days
• SSSU development and expansions
• PAC redesign and pamphlet development
• Regular Email updates
• Regular Blog information updates

Improvement Strategy / Action Plan
• P&P development
PEP day in May

SAQ #44

DOES THE TEAM SHARE RESEARCH AND BENCHMARK INFORMATION AGAINST OTHER ORGANIZATIONS? GREEN, LOW

SUMMARY OF RELATED STANDARD(S) 14.5 The team shares benchmark and best practice information with its partners and other organizations.

Process Currently in Place - Evidence of Current Status
• Inservices and educational opportunities such as journal articles
• Strategic Balanced Scorecard
. OR data office statistics are gathered and benchmarked to ensure we meet obligations, wait times, cancellations and number of funded cases
• Reflective practice

Improvement Strategy / Action Plan
Reassess in June

SAQ #43

ARE TEAM MEMBERS’ COMPETENCY AND PERFORMANCE REGULARLY CHECKED? GREEN, LOW

SUMMARY OF RELATED STANDARD(S) 4.1 Each team member has the necessary credentials or license from the professional college.4.8 Team leaders regularly evaluate and document each team member’s performance in an objective, interactive, and positive way.

Process Currently in Place - Evidence of Current Status
• Yearly license registration through CNO
• CPR recertification q2yrs
• ACLS q2 yrs recommended
• Orientation performance evalutation tool is used to evaluate performance in the areas of safety in practice, skills and procedures, critical thinking, communication, documentation etc
• Recertification q2yrs for Advanced Nursing Competencies, held on recert day
• Hospital recertifications can be done through e-learning, specific WHIMIS days, and on PEP day.
• Inservices provided on new equipment such as ICP EVD’s, 12 lead monitor, Lifepac 20, neoteric OR blood fridge
• Reflective practice

Improvement Strategy / Action Plan
• Performance evaluations

SAQ #42

HOW DOES THE TEAM DECIDE WHICH GUIDELINES IT WILL USE? GREEN, LOW
SUMMARY OF RELATED STANDARD(S) 14.1 The organization has a process to select evidence-based guidelines for surgical care services.14.2 The team reviews guidelines to make sure they are up-to-date and reflect current research and best practice information.14.3 The team’s guideline review process includes seeking input from staff and service providers about the applicability/ease to use of the guidelines

Process Currently in Place - Evidence of Current Status
• College of Nurses
• Ontario PeriAnesthesia Nurses Association
• National Association of PeriAnesthesia Nurses
• Surgical Site Infection Best Practice guidleines for Gen surg and Cardiac groups directly affects SDS pre-op area: clipping, pre-warming, IP&C,
• Pre-and post-op Acute Pain Service guidelines
• Discharge criteria/guidelines P&P for PACU, SDS, SSSU

Improvement Strategy / Action Plan
Reassess in June

SAQ #41

ARE CLIENT RECORDS KEPT UP-TO-DATE AND SECURE? GREEN, LOW

SUMMARY OF RELATED STANDARD(S) 12.1 The team maintains an accurate and up-to-date record for each client. 12.2 The team meets applicable legislation for protecting the privacy and confidentiality of client information.12.3 Clients have opportunities to access their records.

Process Currently in Place - Evidence of Current Status
• The team follows SHSC on-line P&P on Privacy and Security of Personal Health Information
• ‘My Chart’ is available for pt access on the Sunnybrook internet site
• Charts are locked in secure areas overnight

Improvement Strategy / Action Plan
Reassess in June

SAQ #40

DOES THE TEAM HAVE ACCESS TO CLIENT INFORMATION NEEDED TO DO THE WORK? GREEN, LOW

SUMMARY OF RELATED STANDARD(S) 12.4 Staff and service providers have timely access to the client record.12.5 The team shares client information and coordinates its flow among service providers, other teams, and other organizations, as required.

Process Currently in Place - Evidence of Current Status
• Handover Tool within perianesthesia department
• Pt’s current and previous chart
• EPR
Improvement Strategy / Action Plan
Reassess in June

SAQ #39

DOES THE TEAM CONDUCT AN ADMISSION PROCESS? GREEN, LOW

SUMMARY OF RELATED STANDARD(S) 7.9 The team conducts a comprehensive admission process for clients undergoing surgical or other invasive procedures.

Process Currently in Place - Evidence of Current Status
• Registration confirms 2 pieces of ID, Bradma and ID armband are correct
• Or checklist confirms information between the RN and the Patient
• Charts are checked 1 day pre-op and on pt arrival to SDS to ensure pre-op orders have been followed, including diabetic protocols, SSI protocols
• Consent is verified for accuracy with patient
Improvement Strategy / Action Plan
Opthalmology working group

SAQ #38

HOW DOES THE TEAM DETERMINE WHETHER TO PROVIDE SERVICES TO THE CLIENT? GREEN, LOW
SUMMARY OF RELATED STANDARD(S) 6.5 With the client’s permission, the team gathers health history information to determine the need for service.

Process Currently in Place - Evidence of Current Status
• PAC screening requires a surgeon’s history and physical
• Pt must answer the anesthetic questionnaire which the PAC nurse then assesses. From there, the patient may require a telephone only appointment, an office appointment with the RN, RN-GP, RN-anesthesia, depending on patients comorbidities
• PAC appointment and assessment to determine fitness for surgery. If at high risk, bed allocation to the ICU’s may be arranged pre-op. Also patients identified as appropriate for SSSU admissions are assessed as per criteria in policy
• Ongoing assessments throughout all phases of PeriAnesthesia by RN’s
• Diabetic patient require the services of Diabetic APN prior to returning home on the day of surgery so that they are aware of their insulin needs
Improvement Strategy / Action Plan
Reassess in June

SAQ #37

DOES THE TEAM HAVE A STANDARDIZED PROCESS FOR PRIORITIZING AND SCHEDULING ELECTIVE PROCEDURES? GREEN, LOW
SUMMARY OF RELATED STANDARD(S) 6.7 The team uses a standardized process to prioritize and schedule elective procedures.

Process Currently in Place - Evidence of Current Status
• Done through the OR booking office and supported by OR booking policies.
• Diabetic patients are usually booked as first case of the day
Improvement Strategy / Action Plan
Reassess in June

SAQ #36

DOES THE TEAM PROVIDE CLIENTS WITH INSTRUCTIONS ON HOW TO PREPARE FOR THE PROCEDURE? GREEN, LOW
SUMMARY OF RELATED STANDARD(S) 7.6 The team provides the client with instructions on how to prepare for the procedure, and outlines possible consequences of failing to follow the instructions.
Process Currently in Place - Evidence of Current Status
• Pre-and post-op onsite teaching in PAC
• Odette Centre has primary RN’s and APN’s who do comprehensive teaching
• Updated PAC pamphlet given to patient at surgeon’s office visit to prepare them for their PAC appointment
• “Day of Surgery” booklet given to patients at their PAC appointment with written instructions along with verbal instructions
• A family member who speaks English is encouraged to come to PAC/SDS with patient for emotional support, as well as educational support
Improvement Strategy / Action Plan
1. update surgical information in PAC-ongoing

All Washed Up!

SAQ #35

HAVE CLIENTS BEEN TOLD WHO IS RESPONSIBLE FOR COORDINATING THEIR SERVICES? GREEN, LOW
SUMMARY OF RELATED STANDARD(S)
6.2 From their first contact with the organization or team, clients and families are informed of the team member who is responsible for coordinating their service, and told how to reach that person.
Process Currently in Place - Evidence of Current Status
* Surgeon’s office
*PAC pamphlet and Surgical Journey booklet redesigned to increase patient awareness and help walk them through the process
*the Handover tool was developed to increase communication of pts history and surgery throughout the PeriAnesthesia areas
*SMART page: surgeon paged to speak to pt and family when necessary
*increased awareness through Sunnybrook Web: My Chart
Improvement Strategy / Action Plan
Reassess in June

SAQ #34

DO TEAM MEMBERS RECEIVE A COMPREHENSIVE ORIENTATION THAT INCLUDES THE EQUIPMENT USED IN THE SURGICAL CARE AREA? GREEN, HIGH
SUMMARY OF RELATED STANDARD(S) 4.2 The team orients new team members about their roles and responsibilities, the team goals and objectives, and the organization as a whole.4.3 The team orients new team members about the safe use of equipment, devices, and supplies used in delivering surgical care services.4.4 REQUIRED ORGANIZATIONAL PRACTICE: Staff and service providers receive ongoing, effective training on infusion pumps.
Process Currently in Place - Evidence of Current Status
• corporate orientation for new Sunnybrook Staff: 8 days
• unit orientation: depends on the needs of the nurse can be 1-3 months. Combination of class and buddy time. Needs are discussed with the orientee, preceptors, educator and manager
• preceptor/mentorship program
• new grad initiative
• George Brown Critical Care course
• Inservices on new equipment and procedures
• Staff will now be recertified q2yrs on pumps Ongoing PeriAnesthesia tours during orientation week for nurses new to Sunnybrook
Improvement Strategy / Action Plan
Reassess in June

SAQ #33

DOES THE TEAM HAVE THE INFORMATION SYSTEMS NEEDED TO DELIVER SURGICAL CARE SERVICES? GREEN, LOW
SUMMARY OF RELATED STANDARD(S)
13.1 The team identifies its needs for new technology and information systems 13.2 Team members receive education and training on information systems and other technology.
Process Currently in Place - Evidence of Current Status
• Staff are educated and trained on the current information systems used at SHSC: EPR, Intranet, WOW (workstation on wheels)
Improvement Strategy / Action Plan
Bed Management System implemented in December-still needs fine tuning

SAQ #32

HOW DOES THE TEAM RESPOND TO PEOPLE WHO ARE WAITING FOR SERVICES? GREEN, LOW
SUMMARY OF RELATED STANDARD(S) 6.8 The team regularly reviews the needs of clients who are waiting for services and responds to those who are in an emergency or crisis situation.6.9 If the team is unable to meet the needs of potential clients or referring organizations, the team explains the reasons, facilitates access to services offered by other organizations, and records the information for use in service planning.
Process Currently in Place - Evidence of Current Status
• There is a cancelled OR task force committee. Patients will be identified on the OR schedule if previously cancelled
• Registration area is adjacent to the waiting room
• Wait and see list is monitored by the OR and specific surgical services ie: ortho
• Ministry standards are followed ie 1A, 1B, 1C
• PACU has 2 RN’s on each shift (24-7) to accommodate more OR’s
• SSSU open Monday 0730-Saturday 11:30
• Pt flow monitors to adjust OR schedule according to needs
Improvement Strategy / Action Plan
March2010-onward
Reassess in June

SAQ #31

DOES THE TEAM HAVE SPECIFIC, COMMON GOALS FOR ITS SURGICAL CARE SERVICES? GREEN, LOW
SUMMARY OF RELATED STANDARD(S) 2.1 The team works together to develop goals and objectives.2.2 The team’s goals and objectives for its surgical care services are measurable and specific.
Process Currently in Place - Evidence of Current Status
• SPANC-Sunnybrook PeriAnesthesia Nursing Council-involves all nurses within the PeriAnesthesia Departments. Goals included the development of the PeriAnesthesia Handover Tool to improve safety and communication of report at patient transfer through Perianesthesia
• OPANA –increased staff involvement with Professional Association has led to greater understanding of professional and practice Standards
Improvement Strategy / Action Plan
March2010-onward
Continued work around TOA to improve safety-VERBAL TOA IMPLEMENTED

SAQ #30

IS THERE A PROCEDURE TO RECOGNIZE TEAM MEMBERS? YELLOW, LOW PRIORITY
Summary of Related Standard(s) 5.5 The team has a fair and objective process to recognize team members for their contributions.
Process Currently in Place - Evidence of Current Status
• Organizational formal reward program
• Years of service awards
• Nurses week/perianesthesia nurses week
• SPANC blog recognizes accomplishments and introduces new staff
• SPANC offers the opportunity to be involved with change and recognition of group effort
• Letters from patients and families
Improvement Strategy / Action Plan
March2010-onward
Reassess in June

SAQ #29

IS THERE A STAFFING PROCEDURE THAT IS FAIR, TRANSPARENT, AND EVALUATED REGULARLY? YELLOW, LOW PRIORITY
Summary of Related Standard(s) 5.1 The organization has defined criteria that are used to assign team members to clients and other responsibilities in a fair and equitable manner.5.2 Team members have input on work and job design, including the definition of roles and responsibilities, and case assignments, where appropriate.5.3 Team leaders regularly evaluate the effectiveness of staffing and use the information to make improvements.
Process Currently in Place - Evidence of Current Status
• As per ONA contract
• It supports the standards of practice as per CNO and OPANA standards—schedule redesigned to balance shift workload and weekend safety
• TL’s are assigned in every area. This role was developed with staff input
• All members are encouraged to be involved in new initiative or processes as they develop
• Breaks are scheduled with ample RN coverage
Improvement Strategy / Action Plan
March2010-onward
new schedule being implemented

SAQ #28

ARE CLIENTS ABLE TO ACCESS THE TEAM’S SERVICES? YELLOW, LOW PRIORITY
Summary of Related Standard(s) 6.1 The team identifies, and removes , barriers that prevent clients, families, service providers, and referring organizations from accessing services.
Process Currently in Place - Evidence of Current Status
• Multicultural environment with translation services
• Patient flow steering committee with several sub-groups to assist with patient flow issues
• There is an orthopedic task force that deals with the wait and see list
• Beds have been opened to decrease cancellations by developing the SSSU
• There is an increased focus on discharge planning pre-operatively and streamlining ambulatory services
• Revised and redesigned process to increase efficiency in the Pre-Admission Clinic as per the Lean Methodology
• All clients have access to the phlebotomy/ECG/medical imaging areas pre-operatively if tests have been ordered
• Rapid Response Team is available for the Surgical Short Stay Unit, should their services be required
• OT and PT sees the breast patients in the SSSU for post-op teaching
• CCAC also involved with SSSU-dressing packages are available for patients to take home
Improvement Strategy / Action Plan
March2010-onward
Reassess in June

SAQ #27

DOES THE TEAM HAVE THE RESOURCES AND SUPPORTS NEEDED TO ACHIEVE ITS GOALS AND OBJECTIVES? YELLOW, LOW PRIORITY
Summary of Related Standard(s)
2.3 The team identifies the resources needed to achieve goals and objectives.2.4 The team has access to the supplies and equipment needed to deliver surgical care services.2.5 The organization provides support to the team to deliver quality surgical care services.
Process Currently in Place - Evidence of Current Status
• SPANC-Sunnybrook PeriAnesthesia Nursing Council-involves all nurses within the PeriAnesthesia Departments. Goals included the development of the PeriAnesthesia Handover Tool to improve safety and communication of report at patient transfer through Perianesthesia
• OPANA –increased staff involvement with Professional Association has led to greater understanding of professional Standards
• Learning and development opportunities are provided through Organizational Development workshops, monthly inservices and staff meetings, educational days ie PEP day, recertification day, conferences, SPANC meetings and Blog
• Patient information materials have been developed for PAC and Day of Surgery with written instructions given to patients to ensure they understand pre-op information
• Policies and procedures are available to staff on-line
• Manager/educator support available
• Equipment and supplies are available on all units and replenished daily
Improvement Strategy / Action Plan
March2010-onward
Reassess in June

SAQ #26

HOW DOES THE TEAM USE THE INFORMATION IT COLLECTS ABOUT THE QUALITY OF ITS SERVICES? YELLOW, HIGH PRIORITY
Summary of Related Standard(s)
16.3 The team compares its results with other similar interventions, programs, or organizations.16.4 The team uses the information it collects about the quality of its services to identify successes and opportunities for improvement, and makes improvements in a timely way.16.5 The team shares evaluation results with staff, clients, and families.
Process Currently in Place - Evidence of Current Status
. We have perianesthesia contacts at other facilities through OPANA networking. Ideas and questions are shared and if applicable are further shared with staff.
. Picker scores
Improvement Strategy / Action Plan
March2010-onward
Reassess in June

SAQ #25

ARE THERE PROCEDURES TO IMPROVE HOW THE TEAM WITH DIFFERENT PROFESSIONALS WORK TOGETHER? YELLOW, HIGH PRIORITY
Summary of Related Standard(s)
3.3 The organization encourages all team members to develop skills to improve the interdisciplinary approach and team functioning.3.4 The team develops standardized processes and procedures to improve teamwork and minimize duplication.3.5 The organization provides workspace to support interdisciplinary team functioning and interaction.3.6 The interdisciplinary team communicates regularly to coordinate services, roles, and responsibilities.3.7 The interdisciplinary team follows a formal process to regularly evaluate its functioning, identify priorities for action, and make improvements.
Process Currently in Place - Evidence of Current Status
• Unit council has been reestablished to include all of the PeriAnesthesia departments.
• PEP day includes the OR, PeriAnesthesia as well as members from the Holland Site
• With the Regional Block area program, AA’s and Anesthesia work with the RN in a pre-op environment
• Group education sessions: inservices with surgeon, anesthesia involvement
• OR and Support services quality and operations committee includes membership from PeriAnesthesia, B6 clinics, OR and Holland Centre. Includes Director, 4xPCMs, 3xCE’s ,AA’s, perfusionists
• Consistent Team Leaders provide continuity
Improvement Strategy / Action Plan
November 2009 - February 2010
1. PACU TL is Sheryl 1 yr
2.Unit based council needs assistance: difficulty finding staff who will volunteer their time. Need to recruit. Lan and Sandi are the co-chairs and attend corporate nursing council and then relay information to staff.
March2010-onward
Ongoing need to have consistent interest from staff in attending unit coucil

SAQ #24

HOW DOES THE TEAM RESPOND TO PEOPLE WHO ASK FOR SERVICES OR INFORMATION? YELLOW, HIGH PRIORITY
Summary of Related Standard(s)
6.3 The team responds in a timely way to requests for services and information. 6.4 The team gives potential clients, families, providers, and referring organizations information about the organization and its services.
Process Currently in Place - Evidence of Current Status
• OPANA Board of Director reps share information with other groups regarding current practices
• Pamphlet and booklets redesigned for PAC and also for SSSU
• PACU visitor policy
• Pre-op classes available in PAC
• Pre-op teaching in PAC and SDS
• Post-op/discharge teaching in SDS and SSSU
• f/u call made by SSSU nurses within 48 hours of discharge
• physicians are available via SMART page during business hours
Improvement Strategy / Action Plan
November 2009 - February 2010
1. Planning information kiosks for PAC
2. update pamphlets for specific surgeries in PAC and SDS/SSSU
March2010-onward
Late career initiate nurses working on pamphlets

SAQ #23

IS THERE A PROCESS FOR IDENTIFYING AND REDUCING RISKS TO TEAM MEMBERS DELIVERING SURGICAL CARE SERVICES? YELLOW, HIGH PRIORITY
Summary of Related Standard(s)
5.4 The team has a process for identifying and reducing risks to team members while delivering surgical care services..
Process Currently in Place - Evidence of Current Status
• Schedule was redesigned for 2 RN coverage at all times: minimal staffing guidelines as per standards
• Staff are encouraged and reinforced to use e-safety reports for near misses, bullying, actual events, sentinel events
• IPAC rep available and does regular rounds
• Hand hygiene training
• ARO/MRSA screening in PAC with f/u in SDS and PACU
• Violence prevention: unit has ID badge scan entry after hours
• Panic buttons available
• Emergency call system in place
• Safety walkabouts with senior leadership
• Safety committee: staff regularly inspect the workplace environment to identify existing/potential concerns and report to manager, or send broken equipment to biomedical engineering
• Hand hygiene products are located at POC
• Occupational Health and Safety available for staff when ill, or returning to work after extended leave
• WHIMIS, fire and safety, back safety, violence prevention programmes etc available through education days or through e-learning
Improvement Strategy / Action Plan
November 2009 - February 2010
PACU least restraint algorithm indicates issues surrounding Emergence Delerium
March2010-onward
Ongoing

SAQ #22

HOW DOES THE TEAM HANDLE CLIENT RIGHTS, COMPLAINTS, AND ETHICS ISSUES? YELLOW, HIGH PRIORITY
Summary of Related Standard(s):
8.8 The team provides clients and families with access to emotional support and counseling. 8.9 The team educates clients and families about their rights, and investigates and resolves any claims that these rights have been violated.8.10 The team follows the organization’s process to identify, address, and record all ethics-related issues.
Process Currently in Place - Evidence of Current Status
• Patient advocacy promoted
• RN’s and physicians listen to patients when they voice their concerns
• We have implemented a cancellation kit with a follow up letter from Dr. Keith Rose being edited
• Ongoing educational information regarding potential ethical issues such elder abuse, violence in the workplace, bullying
• Staff follows the process to escalate patients’ concerns. Manager is available Mon-Fri and a shift manager is available after hours to deal with client/family concerns.
. In-services are provided to staff when necessary
• If further assistance is required, patient advocacy office is available for client and family concerns.
Improvement Strategy / Action Plan
July 2009-Oct 2009
in-service PACU regarding Least Restraint/Consent to Treament/Deirium in Oct
November 2009 - February 2010
Hospital initiative re least restraint- policy being updated
Developing an algorithm for PACU re: least restraint
March2010-onward
Ongoing project

SAQ #21

HOW DOES THE TEAM MAKE SURE CLIENTS AND FAMILIES ARE PREPARED FOR THE END OF SERVICES? YELLOW, HIGH PRIORITY
Summary of Related Standard(s):
11.1 The team tells clients and families what to expect during transition or end of service.11.2 The team works with other teams, services, and organizations to determine the client’s placement and develop a follow-up plan. 11.3 The team provides the client, family, or caregiver with instructions for post-procedure care and the possible consequences of failing to follow the instructions. 11.5 REQUIRED ORGANIZATIONAL PRACTICE: The team transfers information effectively among service providers at transition points.11.6 Following transition or end of service, the team contacts clients, families, or referral organizations or teams to evaluate the transition, and uses this information to improve its transition and end of service planning.
Process Currently in Place - Evidence of Current Status
• Discharge planning is started in PAC and instructions for discharge are given as accurately as possible. (Sometimes patients discharge plans change intra or post op)
• PAC initiates CCAC, SW
• During PAC appointment, pt’s post-op needs are assessed by anesthesia to ensure that the surgeon has requested the most appropriate level of care for patient post-operatively.
• Ambulatory patients are requested to have a responsible adult drive them home and stay with them for the first night post-operatively. This information is given in PAC appointment, on day of surgery, and again post-operatively. It is included in the booklet "My surgical Journey” and on the back of the Consent form there is also a signature required from the patient or SDM that they understand this information.
• SSSU patients are aware that they are to be discharged before 9am on POD #1. Information is given to them by surgeon, in PAC appointment, and again in SSSU. Discharge orders must be on the patients chart by the time patient leaves PACU.
• Written materials are given upon discharge and verbal discharge teaching is done to patient and family members
• The SSSU provides courtesy telephone call-backs to ensure that patient pain control is adequate.
-Patient Flow is working on determining Standard Length of Stay.
The new BMS will also assist in identifying possible discharges/discharge times.
Improvement Strategy / Action Plan
July 2009-Oct 2009
PAC information pamphlet and 'My Surgical Journey' booklet printed and available.
PAC pamphlet is dispersed in the Surgeon’s office to prepare patients for their PAC appt.
My Surgical Journey booklet is given to the patient at their PC appointment.
November 2009 - February 2010
Patients having a telephone appt only, or who have their PAC appointment elsewhere are mailed their booklet with instructions. Surgical care pathways to be designed for SSSU patients
March2010-onward
Ongoing project

SAQ #20

WHAT KINDS OF EDUCATION, SUPPORT, AND COUNSELLING ARE AVAILABLE FOR CLIENTS AND FAMILIES? YELLOW, HIGH PRIORITY
Summary of Related Standard(s): 8.7 The team provides clients and families with education related to service needs. 8.8 The team provides clients and families with access to emotional support and counseling.
Process Currently in Place - Evidence of Current Status
• Patient Focused Care model
• Pre and post op teaching is done
• Accessibility to Social work, chaplain, physio and occupational health as required
Improvement Strategy / Action Plan
November 2009 - February 2010
1. Would like to have PAC information available on the internet for patients to access
2. Development of a video that could be played in the PAC waiting room with pre-and post op info
March2010-onward
Ongoing project with late career nurses

SAQ #19

WHAT IS INCLUDED IN THE CLIENT’S PRE-OPERATIVE ASSESSMENT? GREEN FLAG, LOW PRIORITY
Summary of Related Standard(s): 7.3 The team assesses the client’s physical and psychosocial health.7.7 The pre-procedure assessment includes processes to evaluate the client’s post-procedure pain.7.8 The pre-operative assessment includes processes to evaluate the client’s post-operative
Process Currently in Place - Evidence of Current Status
• Surgeon H & P and anesthesia questionnaire
• Medical hx, health status, nutrition status, mental health
• ARO/MRSA
• Medication reconciliation form
• Allergies
• Labwork
• ECG
• Other tests as applicable
• PONV assessed by anesthesia
• Handover tool started in PAC to increase communication amongst health care providers
Improvement Strategy / Action Plan
November 2009 - February 2010
moving towards increasing the number of nurse-only pre-admission assessments
March2010-onward
Ongoing project-anticipated pt increase of 800-1200 with Women’s program moving to SB campus

SAQ #18

DOES THE TEAM CONDUCT A PRE-OPERATIVE ASSESSMENT? GREEN FLAG, LOW PRIORITY
Summary of Related Standard(s): 7.2 The team completes a timely pre-operative assessment for each client. 7.4 The team considers the client’s needs and expectations, family and caregiver involvement, and staffing resources during the assessment process.7.5 The team has access to diagnostic services, results, and expert consultation to complete a proper pre-operative assessment.
7.13 The team has a process for forwarding the information obtained from the pre-operative assessment and admissions process to service providers in the operating room.
Process Currently in Place - Evidence of Current Status
• PAC redesign plans includes ALL patient screening including all previous known ‘healthy’ patients (optha, gyne, plastics)
• Assess family support systems is part of the assessment
• CCAC, SW,PT, OT consulted
• Scheduled pre-op classes for ACL and Breast, and cardiac patients
Improvement Strategy / Action Plan
November 2009 - February 2010
PACU nurse/telephone triage tool March2010-onward
Ongoing project

SAQ #17

DOES THE TEAM USE A PROCEDURE-SPECIFIC CARE MAP? GREEN FLAG, LOW PRIORITY
Summary of Related Standard(s): 7.1 the team uses a procedure-specific care map to guide the client through preparation for and recovery from the procedure.
Process Currently in Place - Evidence of Current Status
• SSI (Surgical Site Infection) procedures with the cardiac and general surgery groups to provide best practice and evidence based practice pre- and intra- op
• Surgery specific pre and post-op standard printed orders
• Pre-op screening tool in PAC
• Spinal care pathway for SSSU patients transferring to Holland Centre
• Discharge criteria in PACU and OPP
• SSSU admission and discharge criteria’s
Improvement Strategy / Action Plan
November 2009 - February 2010
1. Develop surgery specific care plans
2. Develop standardized doctor's orders for PACU
March2010-onward
Ongoing project

SAQ #16

DOES THE TEAM UNDERSTAND AND FOLLOW POLICIES TO PREVENT AND CONTROL INFECTIONS? GREEN FLAG, HIGH PRIORITY
Summary of Related Standard(s): 5.1 The organization develops an IPAC education program that is tailored to the organization, its services, and client populations. 5.2 The IPAC education program specifies each staff member’s/service provider’s/volunteer’s role in preventing/controlling infections. 5.3 The IPAC education program covers personal precautions and high-risk activities performed in the organization.5.4 Staff, service providers, and volunteers attend the IPAC education program at orientation and regularly.5.6 The organization provides its staff, service providers, and volunteers with access to IPAC education materials, resources, information, and tools.5.7 The organization monitors compliance with its infection prevention, control policies and procedures.
Process Currently in Place - Evidence of Current Status
• PACU 1:1 with ARO positive patients. Designated equipment and PPE worn. Curtains define patient area and ESP’s and PSP’s are specially trained for environmental cleaning
• Fit mask testing for N95 masks for all staff
• ARO testing is initiated in PAC and followed through the process
• IP&C P&P’s available on-line
• Q2yr certification for PPE application
• Hand hygiene retreat with IP&C involvement to occur in May
• PeriAnesthesia SSI committee members for both CV and Gen surg. Keep staff up-to-date on new initiatives
• Universal precautions are also adhered to
Improvement Strategy / Action Plan
November 2009 - February 2010
1. IPAC RN's invited to Staff meetings to talk about MRSA precautions in the perianesthesia environment with no definite isolation rooms
2. inservice also discussed how Eating and drinking in patient care areas is not permitted by staff or visitors
March 2010 – onward
Follow up with staff

SAQ #15

HOW DOES THE TEAM IDENTIFY, REPORT, AND MANAGE INFECTIONS? YELLOW, HIGH
Summary of Related Standard(s) 9.1 The organization has a process to detect suspected healthcare-associated infections 9.2 The process identifies who is responsible and what the reporting relationships are for infection prevention and control issues. 9.4 The organization has policies and procedures to contain and prevent the spread of infectious agents, including ventilation, isolation and other precautions, and cohorting as necessary.
Process Currently in Place - Evidence of Current Status
• ARO & respiratory screening is done in PAC. PAC follows isolation precautions if pt is known MRSA
• Results are followed up, the OR is informed, it is noted on OR schedule. EPR is checked the night before by the PAA in SDS and PACU to double check ARO status of all patients
• Isolation precautions are followed as soon as a patient is admitted to SDS pre-operatively and information is communicated on the handover tool
• Isolation precautions are followed post-operatively in PACU, SDS. At this time, MRSA and Isolated patients do not meet the admission criteria for the SSSU, as per IPAC the curtains no longer meet isolation criteria after 12 hours
• On-line P&P IP&C standards are followed
• If there is a break in communication, or a pt has not been identified in a timely manner, an e-safety report is filed and IP&C is informed immediately.
• Pt with identified isolation precautions will only be admitted to an isolation room once transferred out of PACU
· the bed management system will flag ARO's
· -manager and educator attend monthly Gen surg and Cardiac SSI meetings and relay information back to staff. Inservices have been held regarding pre-warming Gen surg patients in SDS, and correct clipping method for cardiac patients, as well as mouth care.
· All Patients are instructed by PAC to take chlorhexidine showers for 3 days prior to their surgical date
· Braden Skin Risk documentation is started in PAC
· Mandatory Hand Hygiene classes for all staff. ABHR strategically located and signs posted to encourage staff and visitors to comply with HH.
· all staff required to be N95 fit-tested q 2 yrs, as well, are req'd to pass IPAC PPE class q2
· Self surveillance for ARO: healthy workplace environment promoted.
· Flu clinics also available yearly by Occ Health
· Visitors are also requested to abstain from visiting if they are unwell. 1 visitor per patient is encouraged: visitor policy in effect.
· No food or drink at bedside, for staff and visitors.
· no hand or wrist jewelry when providing direct patient care


Improvement Strategy / Action Plan
July 2009-October 2009
1.PeriAnesthesia Handover Tool being utilized well.
2. IPAC RN's have attended staff meetings and education days to assist with education regarding PPE and HH
November 2009 - February 2010
1. Currently there are some MRSA in-patients who go to the OR, and then isolation requirements are not relayed to the PACU staff. The BMS is being introduced Nov 17 this will identify ARO flags. There are identified super users in each unit who will help the other staff learn the system
2. Hospital committee on Transfer of Accountability working on standardized SBAR tool between units. This will help also help identify ARO positive patients. TOA to be rolled out in January 2010.
3. Braden Skin Risk documentation needs to be completed in PACU will require inservicing on the importance of this tool
March 2010 - onward
1. Reassess to see if the BMS is identifying all ARO patients
2. Reassess to see how the TOA guide is working at identifying ARO pts at handover
3. Reassess to see if PACU is completing the BSR doc

SAQ #14

DOES THE TEAM EDUCATE CLIENTS AND FAMILIES ABOUT PREVENTING INFECTIONS? GREEN, HIGH
Summary of Related Standard(s) 7.1 The organization provides clients and families with information and education about preventing infections .7.2 The information and education provided to clients and families about IPAC covers hand hygiene and respiratory etiquette 7.3 Information provided to clients and families is documented in the client record.7.4 Families and visitors have access to hand hygiene resources and personal protective equipment if necessary.7.5 Staff, service providers, and volunteers encourage clients, families, and visitors to follow effective hand hygiene behaviour.
Process Currently in Place - Evidence of Current Status
• PAC provides chlorhexidine soap to pts with pre-op instructions.
• Staff educates families and patients on HH and PPE when needed
• Hand hygiene posters and sanitizer available at POC and upon entrance to hospital and units
Improvement Strategy / Action Plan
Reassess in June

SAQ #13

DOES THE TEAM EDUCATE CLIENTS AND FAMILIES ABOUT THEIR ROLE IN PROMOTING SAFETY? YELLOW, HIGH
Summary of Related Standard(s) 15.3 REQUIRED ORGANIZATIONAL PRACTICE: The team educates its clients and families in writing/verbally about the client and family’s role in promoting safety.
Process Currently in Place - Evidence of Current Status
• There is a patient handbook available in PAC
• Patients and families are given verbal information regarding Hand Hygiene and PPE
• Written materials complements verbal information regarding discharge instructions
• Availability of a responsible adult to drive a patient home and care for the pt for the first post-op night is a condition of discharge from OPP. Pt’s sign an agreement, this is for their safety.
• Patients and their family and friends are instructed that the patient should be the only person pushing the PCA button
Improvement Strategy / Action Plan
Nov-Feb
1. Signs on doors to SDS indicating no food or drinks
2. ABHR on walls at every entrance, as well as notices regarding signs and symptoms of flu

SAQ #12

HOW DOES THE TEAM HANDLE SENTINEL EVENTS, NEAR MISSES, AND ADVERSE EVENTS? YELLOW, HIGH
Summary of Related Standard(s) 15.5 The team identifies, reports, records, and monitors sentinel events, near misses, and adverse events.15.6 The team follows the organization’s policy and process to disclose adverse events to clients and families.
Process Currently in Place - Evidence of Current Status
• E-safety reports
• No blame culture encourages staff to file reports
• Quality and Risk Management will f/u with patient/family for an adverse/sentinel event
• Staff debriefing sessions after adverse events
• Development of the PeriAnesthesia Handover tool
Improvement Strategy / Action Plan
Reassess in June

SAQ #11

HOW ARE MEDICATION ERRORS AND INCIDENTS HANDLED BY THE TEAM? YELLOW, HIGH
Summary of Related Standard(s) 10.7 The team documents all incidents involving medications, and uses this information to make improvements.
Process Currently in Place - Evidence of Current Status
• E-safety reports are filed as soon as possible for near misses and adverse events. They are also trended.
• MD informed if necessary
• No blame policy
Improvement Strategy / Action Plan
E-safety reporting changes were relayed to staff.
The changes should make the reporting more user-friendly.

SAQ#10

HOW ARE MEDICATIONS MANAGED IN THE SURGICAL CARE AREA? GREEN, HIGH
Summary of Related Standard(s) 10.1 The team identifies who is responsible for prescribing/storing/handling/and disposing of medications, as well as recording medication information in the client record.10.6 The team follows the organization’s policies on storing/ disposing of medications safely and securely.10.2 Before dispensing medication, a qualified team member reviews each prescription for completeness/accuracy.10.3 A qualified team member fills the prescription and dispenses the medication in a timely/accurate way.10.4 The team responds to requests for medication and medication information after hours and in emergencies.10.5 The team has a process to evaluate client requests to bring in or self-administer their own medication.

Process Currently in Place - Evidence of Current Status
• N/A in PAC, other than Patient Medication Record and Allergy record initiated
• PACU, SDS and SSSU follow specific pre and post op orders
• College Of Nurses standards of practice guidelines are followed
• Night cupboard is available to access necessary medications
• Medication fridges
• Narcotic cupboard with regular scheduled counts
• McKessin narcotic cart will be implemented in near future
• Regular stocked drugs in all areas dependant on the need
• Emergency medication trays available on arrest cart
• Designated pharmacist
• Independent Double check for heparin and insulin, PCA's and Epidurals

Improvement Strategy / Action Plan
Jan 2010-March2010
1. McKessin cabinets now implemented and staff using them as narcotic cupboard
2. symbiq pumps implemented in all areas infusing medications

SAQ#9

IS HAND HYGIENE IMPORTANT TO THE TEAM? GREEN, HIGH

Summary of Related Standard(s) 6.1 REQUIRED ORGANIZATIONAL PRACTICE: The organization delivers education and training for staff/service providers/and volunteers on hand hygiene.6.4 The organization’s staff, service providers and volunteers have access to alcohol-based hand rubs at the point-of-care and service delivery.6.5 REQUIRED ORGANIZATIONAL PRACTICE: The organization evaluates compliance with hand hygiene practices.

Process Currently in Place - Evidence of Current Status
• HH session on PEP day May 8th with goal to achieve 100% compliance
• Hand hygiene audits have been done by IP&C
• HH e-learning module
• Waterless, alcohol based hand rub at every unit entrance, work station, bedside. POC
• HH posters at strategic locations
• P&P on intranet

Improvement Strategy / Action Plan
July 2009-ongoing
1. ongoing auditing by OHS
2. staff awareness of compliance percentages

SAQ#8

IS THERE A TEAM FOCUS ON IMPROVING SAFETY? YELLOW, HIGH
Summary of Related Standard(s) 15.1 The team is trained to identify, reduce, and manage safety risks 15.2 Staff and service providers participate in regular safety briefings to share information about potential safety problems, reduce the risk of error, and improve the quality of service

Process Currently in Place - Evidence of Current Status
• Safety Walkabouts done by senior leadership identify key issues to be addressed in PACU and SDS
• E-safety reporting: trends are shared with staff
• Inservices regarding issues and practices (also posted on Blog)
• WHIMS and Fire Safety
• Code Orange simulation exercise and pandemic planning
• E-learning modules

Improvement Strategy / Action Plan
Nov 2009-ongoing: review in February
1. Shelly and Dale represent PACU Safety Committee
2. Stania and Pam have volunteered to be Mground Reps for Safety committee

SAQ#7

HOW DOES THE TEAM CARE FOR THE CLIENT FOLLOWING THE PROCEDURE? GREEN, HIGH
Summary of Related Standard(s) 9.1 One or more designated team members observe the client during the transfer from the operating room to the Post-Anesthesia Care Unit (PACU).9.2 the team continues to monitor and provide bedside care to clients as they recover from anaesthetic.9.3 the team applies standardized criteria when determining whether a client is fit for discharge

Process Currently in Place - Evidence of Current Status
• Anesthesiologist and OR nurse transfer patient from the OR to PACU and report is received from Anesthesiologist
• PACU staff have critical care training and in-depth orientation to the PACU patient
• A new handover tool provides a concise and comprehensive report about the client’s surgical journey. This includes PAC/SDS med-surg history, operation and highlights and a PACU report to phase 2 recovery areas
• Verbal report PRN
• Opthalmology patients return direct to SDS post-op, if there are concerns, report is given by Anesthesia Assistant or the OR nurse.
• Emergency and crash cart available
• PACU staffed 1:2 nurse: patient ration unless patient requirement dictates otherwise ie: critical care vented pt, isolated patient
• SDS staffed 1:3-5 nurse: patient ratio as per OPANA guidelines
• Aldrete scoring system is utilized and part of the PACU discharge policy
• PADDS scoring system is part of the SDS policy
• Pain number scoring system is used throughout PeriAnesthesia departments
• PONV reported in documentation and on Handover. Pain flow sheet has an algorithm in dealing with this issue for patients on PCA/Epidural infusions

Improvement Strategy / Action Plan
Nov 2009-June 2010
1. Ophthalmology task force
2. Develop care pathways for SDS and SSSU for newer procedures

SAQ #6

DOES THE TEAM RECONCILE THE CLIENT’S MEDICATIONS AT TRANSITION OR END OF SERVICE? YELLOW, HIGH
Summary of Related Standard(s): 11.4 REQUIRED ORGANIZATIONAL PRACTICE: The team reconciles medications with the client at referral or transfer, and communicates information about the client’s medications to the next provider of service within or outside the organization.

Process Currently in Place - Evidence of Current Status
• Reconciliation in PAC on 'Medication Record'
• Pamphlet instructs patient to bring meds in pre-op
-in SDS pre-op the pt is asked if there has been any changes in their meds since their PAC appt, and also which meds they took on the morning of their surgery date
-medications are also listed by the pt on the anesthetic questionnaire
• OPP and SSSU patients are instructed on use of newly ordered meds and when to resume pre- op meds and pt's are sent home with a prescription
· PACU checks post-op surgeons orders

Improvement Strategy / Action Plan
Nov 2009-Feb 2010
1. PACU to complete MAR for patients staying overnight

SAQ #5

DOES THE ANAESTHETIST CONDUCT A PRE-ANAESTHETIC ASSESSMENT? YELLOW, HIGH
Summary of Related Standard(s) 7.12 the anaesthetist conducts a pre-anaesthetic assessment prior to the commencement of the procedure.
Process Currently in Place - Evidence of Current Status
· In PAC patients are triaged by the nurse into appointment type. Ie: telephone consult by nurse, PAC appt with nurse, PAC appt with nurse and GP, PAC appt with nurse and anesthetist
· Pre-op, anesthesia does an assessment in the OR holding area/induction room/Block area
· In -patients who are having surgery are s/b the anesthesia resident on-call the night before
· in the ED, pt's are assessed by anesthesia if surgery is required.
Improvement Strategy / Action Plan
July 2009-October 2009
Due to the Schulich construction, holding area no longer available pre-op, however anesthesia still conducting pre-anesthetic assessment outside OR room Reassess process in February
Jan 2010-March2010
Implementation of Surgical Safety Checklist includes anesthesiologists involvement

SAQ #4

WHAT INFORMATION IS USED TO DECIDE ON THE RANGE OF THE TEAM’S SERVICES? GREEN, LOW
Summary of Related Standard(s):
1.1 The team collects information about its clients and the community.
1.3 The team’s scope of services is aligned with the organization’s strategic direction.
1.5 The team regularly reviews its services and makes changes as needed.
Process Currently in Place - Evidence of Current Status
• Historical utilization reports from Canadian Institute for Health Information
• WTS (Wait Time Strategy)
• Service specific information-clients are from specific internal programmes ie: Schulich, oncology, opthalmology, gyne, plastics, trauma, medical imaging
• CCAC, PT/OT, nursing arrangements in PAC/SSSU-for clients who need additional support in the community
• PAC redesign project
• New SSSU, and ongoing expansion of its’ services from 6-8 beds
Improvement Strategy / Action Plan
1. Develop PAC policy (Carol, Ramona, Pam)
2. Develop nurse/telephone process (Pam, Ramona)
3. Update SSSU policy (Carol, Ramona)
4. Expansion of SSSU to 11 beds (Carol, SSSU staff)

SAQ #3

DOES THE TEAM ASSESS THE CLIENT’S MEDICATIONS AT ADMISSION? GREEN FLAG, HIGH PRIORITY
Summary of Related Standard(s): 7.10 7.11 REQUIRED ORGANIZATIONAL PRACTICE: The team reconciles the client’s medications upon admission to the organization, with the involvement of the client.
Process Currently in Place - Evidence of Current Status
• Patients are instructed to bring their medications to PAC and SDS with them in their original containers
• Patients have written instructions in ‘Day of Surgery’ booklet on which medications to take on the morning of surgery
• Medications are listed on the anesthetic questionnaire
• Transcribed by RN onto Patient Medication Form and checked for accuracy with patients.
Improvement Strategy / Action Plan
November 2009 - February 2010
1. Same Day Surgery PAC : are they able to reconcile pt's medication on inpatient medication record document? Does one need to be developed for outpatients?'

SAQ #2

BEFORE PROVIDING SERVICES, IS THE CLIENT’S INFORMED CONSENT OBTAINED? GREEN FLAG, HIGH PRIORITY
Summary of Related Standard(s) 8.1, 8.2, 8.3, 8.4, 8.6
Process Currently in Place - Evidence of Current Status
· Surgeon obtains informed consent in the office. The original consent is placed in the chart at end of PAC appointment
· Verified on Day of Surgery and also during the PAC appointment
· APPLE PIE and TIME OUT done by OR staff includes anesthesia
Improvement Strategy / Action Plan
November 2009 - February 2010
1. Surgical checklist
2. Block checklist being implemented in Regional block area
Communication / Staff Training / Education Plan
· Delia participated in Grand Rounds outlining Block area responsibility with regards to safety checklist
· PILOT done in Nov/Dec in Block area.

SAQ #1

PeriAnesthesia Accreditation 2010
Self-Assessment Questions (in order of priorities)
1. DOES THE TEAM HAVE SPECIFIC WAYS TO MONITOR ACTIVITIES THAT ARE HIGH-RISK, E.G. CRITICAL TESTS, OR MEDICATION ADMINISTRATION? RED FLAG, HIGH PRIORITY
SUMMARY OF RELATED STANDARD(S): 15.4 REQUIRED ORGANIZATIONAL PRACTICE: The team uses verification processes and other checking systems for high-risk activities.
PROCESS CURRENTLY IN PLACE:
• Independent Double Check (IDC) for high risk meds insulin and heparin, PCA's and Epidurals
• E-safety reports on near misses and adverse events
• Equipment alarms. Equipment is sent to biomed if it is not working. PCA and Epidural pumps are regularly checked by biomed.-new pain pumps to be implemented possibly in March 2009 -will require in servicing
· SMART pumps being rolled out December 2009
· Block Safety Checklist
· McKessin cabinets for narcotics on MGround and M2 PACU
IMPROVEMENT STRATEGY / ACTION PLAN
July 2009- October 2009
-IDC implemented over the summer
-E-safety reports are encouraged to be completed.
-ongoing equipment repairs are done through Biomed
November 2009 - February 2010
1. McKessin cabinet rollout Nov 17th. Super users: Ramona, Carly, Deborah K
2. Symbiq SMART pumps rolled out in December. Super users: Ramona, Carly, Carrie, Debbie Mulgrave, Sirkka
3. Block safety checklist to be implemented in Jan 2010. Ramona, Carol, Delia
4. Novo glucose meters will be rolled out in January
March 2010 - onward
1. New pain pump rollout? Will need volunteer super users.
Plan for spreading improvement to related services / areas?
With units moving on Mground, SSSU RN's will need to be in serviced on McKessin cabinets

Inhaled Anesthetics (Health & Wellbeing: Anesthesiology)

Happy New Year!
It's been a while and I thought I would upate our blog. I hope you find this interesting!

Inhaled Anesthetics (Health & Wellbeing: Anesthesiology)