Question & Answer/Necrotizing Faciitis

Thank you Laurie for asking the following question:
Can you please clarify the IP&C precautions that need to be taken in PACU for a patient who has necrotizing fasciitis? We had an incident last week where the nurses were unsure whether or not this patient could be accepted post operatively into the PACU.

Answer:
Indeed they can come into PACU on droplet precautions. The pts that cannot would be any who requires airborne precautions: TB, measles, varicella virus such as chicken pox/disseminated shingles.

For more information on necrotiaing faciitis, please read the following article

http://www.medscape.com/viewarticle/443523

The 4 C's of Cardiac Arrest Care

From Medscape Emergency Medicine > Viewpoints
The 2010 AHA Guidelines: The 4 Cs of Cardiac Arrest Care
Amal Mattu, MD
Posted: 12/30/2010


The year 2010 marks the 50th anniversary of the introduction of cardiopulmonary resuscitation (CPR). During these past 50 years, tremendous research has been conducted to evaluate techniques, medications, and devices designed to advance the care of victims of cardiac arrest. The American Heart Association (AHA) developed the first CPR guidelines in 1966 and since that time has published frequent updates of the guidelines to help educate the public and medical establishment about optimal care for patients with cardiac arrest and other emergency cardiovascular conditions.

This past November, the newest set of guidelines pertaining to CPR and emergency cardiovascular care were published by the AHA in a supplement issue of Circulation. The guidelines consist of 16 parts. They address not only cardiac arrest, but also post-arrest care, dysrhythmias, acute coronary syndromes, stroke, cardiac arrest in special situations (eg, pregnancy, pulmonary embolism, etc), pediatric considerations, and ethics. Part I is a summary statement of the major changes in cardiac arrest and emergency cardiovascular care since the previous set of guidelines, which were published in 2005. The highlights of this "Executive Summary" are summarized below. For purposes of brevity, this discussion will focus on adult patients with acute cardiac conditions (cardiac arrest and dysrhythmias), excluding acute coronary syndromes, stroke, and pediatric considerations. The reader should note that the bulk of guideline recommendations, as in past years, are concentrated on victims of primary cardiac arrest and are not necessarily relevant to victims of pulmonary arrest (eg, drowning, drug overdose, etc).
Study Summary

Change from "A-B-C" to "C-A-B." A major change in basic life support is a step away from the traditional approach of airway-breathing-chest compressions (taught with the mnemonic "A-B-C") to first establishing good chest compressions ("C-A-B"). There are several reasons for this change.
Most survivors of adult cardiac arrest have an initial rhythm of ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), and these patients are best treated initially with chest compressions and early defibrillation rather than airway management.

Airway management, whether mouth-to-mouth breathing, bagging, or endotracheal intubation, often results in a delay of initiation of good chest compressions. Airway management is no longer recommended until after the first cycle of chest compressions -- 30 compressions in 18 seconds. The 30 compressions are now recommended to precede the 2 ventilations, which previous guidelines had recommended at the start of resuscitation.

Only a minority of cardiac arrest victims receive bystander CPR. It is believed that a significant obstacle to bystanders performing CPR is their fear of doing mouth-to-mouth breathing. By changing the initial focus of resuscitation to chest compressions rather than airway maneuvers, it is thought that more patients will receive important bystander intervention, even if it is limited to chest compressions.
Basic life support. The traditional recommendation of "look, listen, and feel" has been removed from the basic life support algorithm because the steps tended to be time-consuming and were not consistently useful.
Other recommendations:
1. Hands-only CPR (compressions only -- no ventilations) is recommended for the untrained lay rescuers to obviate their fears of mouth-to-mouth ventilations and to prevent delays/interruptions in compressions.
2. Pulse checks by lay rescuers should not be attempted because of the frequency of false-positive findings. Instead, it is recommended that lay rescuers should just assume that an adult who suddenly collapses, is unresponsive and not breathing normally (eg, gasping) has had a cardiac arrest, activate the emergency response system, and begin compressions.
3. Pulse checks by healthcare providers have been de-emphasized in importance. These pulse checks are often inaccurate and produce prolonged interruptions in compressions. If pulse checks are performed, healthcare providers should take no longer than 10 seconds to determine if pulses are present. If no pulse is found within 10 seconds, compressions should resume immediately.
4. The use of end-tidal CO2 (ETCO2) monitoring is a valuable adjunct for healthcare professionals. When patients have no spontaneous circulation, the ETCO2 is generally ≤ 10 mm Hg. However, when spontaneous circulation returns, ETCO2 levels are expected to abruptly increase to at least 35-40 mm Hg. By monitoring these levels, interruptions in compressions for pulse checks become unnecessary.
5. CPR devices. Several devices have been studied in recent years, including the impedance threshold device and load-distributing band CPR. No improvements in survival to hospital discharge or neurologic outcomes have been proven with any of these devices when compared with standard, conventional CPR.
6. Electrical therapies
*Patients with VF or pulseless VT should receive chest compressions until a defibrillator is ready. Defibrillation should then be performed immediately.
*Chest compressions for 1.5-3 minutes before defibrillation in patients with cardiac arrest longer than 4-5 minutes have been recommended in the past, but recent data have not demonstrated improvements in outcome.
*Transcutaneous pacing of patients who are in asystole has not been found to be effective and is no longer recommended.
7. Advanced cardiac life support. Good basic life support, including high-quality chest compressions and rapid defibrillation of shockable rhythms, is again emphasized as the foundation of successful advanced cardiac life support. The recommendations for airway management have undergone 2 major changes: (1) the use of quantitative waveform capnography for confirmation and monitoring of endotracheal tube placement is now a class I recommendation in adults; and (2) the routine use of cricoid pressure during airway management is no longer recommended.

As they did in 2005, the AHA acknowledges once again that as of 2010, data are "still insufficient ...to demonstrate that any drugs improve long-term outcome after cardiac arrest."
Several important changes in recommendations for dysrhythmia management have occurred:
For symptomatic or unstable bradydysrhythmias, intravenous infusion of chronotropic agents (eg, dopamine, epinephrine) is now recommended as an equally effective alternative therapy to transcutaneous pacing when atropine fails;
As noted above, transcutaneous pacing for asystole is no longer recommended; and
Atropine is no longer recommended for routine use in patients with pulseless electrical activity or asystole.

Post-cardiac arrest care. Post-cardiac arrest care has received a great deal of focus in the current guidelines and is probably the most important new area of emphasis. There are several key highlights of post-arrest care:
Induced hypothermia, although best studied in survivors of VF/pulseless VT arrest, is generally recommended for adult survivors of cardiac arrest who remain unconscious, regardless of presenting rhythm. Hypothermia should be initiated as soon as possible after return of spontaneous circulation with a target temperature of 32°C-34°C.
Urgent cardiac catheterization and percutaneous coronary intervention are recommended for cardiac arrest survivors who demonstrate ECG evidence of ST-segment elevation acute myocardial infarction regardless of neurologic status. There is also increasing support for patients without ST-segment elevation on ECG who are suspected of having acute coronary syndrome to receive urgent cardiac catheterization.
Hemodynamic optimization to maintain vital organ perfusion, avoidance of hyperventilation, and maintenance of euglycemia are also critical elements in post-arrest care.

Author's Viewpoint
The AHA 2010 guidelines represent significant progress in the care of victims of cardiac arrest. Most important is the stronger emphasis on post-cardiac arrest care. Induced hypothermia is underscored, and perhaps the most important advance is the recommendation for urgent percutaneous coronary intervention in survivors of cardiac arrest. The wealth of data thus far indicate that post-arrest percutaneous coronary intervention may be the most significant advance toward improving survival and neurologic function since defibrillation was first introduced decades ago.
In reviewing these guidelines, I must admit, however, that I was disappointed that AHA hesitated to adopt the concepts of "cardiocerebral resuscitation" (CCR). CCR also promotes the "C-A-B" approach to resuscitation, but it fosters even further delays in airway intervention -- withholding any form of positive pressure ventilations, in favor of persistent chest compressions, for as long as 5-10 minutes after the cardiac arrest. The current guidelines recommend withholding positive pressure ventilation for a mere 18 seconds. First described in 2002,CCR has been studied more recently as well and demonstrated marked improvements in rates of resuscitation and neurologic survival. I think that CCR should be incorporated into basic life support protocols for victims of primary cardiac arrest as quickly as possible to further improve outcomes.
Optimal management of cardiac arrest in the current decade can be summarized simply by "the 4 Cs": Cardiovert/defibrillate, CCR, Cooling, and Catheterization.

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