No Show – Oh No!

No Show – Oh No!


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OBSTRUCTIVE SLEEP APNEA IN PEDIATRIC PATIENTS: DEVELOPING AN EFFECTIVE PREOPERATIVE SCREENING PATHWAY Team Leader: Nancy Rudyk, RN, MN, CNS Hospital for Sick Children, Toronto, Ontario, Canada James Robertson, MD, FRCPC, Penny Demarchi, RN, Cyndie Davey, RN, Lily Cugliari-Kobayashi, RN, Jacqui McCallum, RN

Introduction: The preoperative assessment of children prior to surgical and diagnostic procedures requires the evaluation for obstructive sleep apnea (OSA) symptoms. Research has shown that less than 3 % of children diagnosed with OSA are formally evaluated by an otolaryngologist or have had an overnight polysomnograph testing, usually in preparation for adenotonsillectomy. Frequently children that are assessed in the Preanesthesia Assessment Clinic (PAC), at the Hospital for Sick Children, present with an undiagnosed history of OSA symptoms. A comprehensive preoperative screening for OSA symptoms is essential to ensure that the appropriate post operative monitoring is booked for the child prior to the day of surgery to prevent unnecessary cancellation or delay in surgery. Objectives: The objectives of this presentation will: 1. Describe the prescreening and triage process utilized by the PAC team to assess the child for OSA symptoms 2. Outline the OSA clinical algorithm used in the PAC to determine post operative care Method: The preoperative assessment includes the child’s: 1) night time sleep history, 2) day time activity level and 3) behavior patterns. The development of an OSA algorithm provides a guideline for the PAC staff to determine the appropriate post operative care that the child will likely require. Conclusion: The OSA algorithm has recently been implemented in the PAC to prescreen children that may be a risk prior to general anesthesia. This has been an effective tool to prescreen children for OSA symptoms and decreasing unnecessary surgical cancellations.

PREOPERATIVE PAPERWORK INITIATIVE Team Leader: Nichole Bach, RN IV, BSN, CAPA University of Colorado Hospital, Aurora, Colorado Michelle Ballou, RN, BSN, CPAN, AIP Perianesthesia Nurse Manager, Christine Woodman, RN, BSN, MSA, CPAN, AOP Perianesthesia Nurse Manager, Chris Raeburn, MD, Catherine Kleiner, PhD, RN, Research Nurse Scientist

Although Joint Commission and hospitals strive to improve safety by instituting requirements for perioperative paperwork, the timeframe for when this should be available on the chart is undefined in most institutions. At the University of Colorado Hospital, data shows history and physicals (H&P’s) and preoperative orders are completed at the bedside 10 minutes or less before surgical start 21% of the time. Preoperative nurses scramble to ensure necessary documents are completed and orders are carried out appropriately for the safety of the patient ultimately causing delayed OR starts and orders. Perioperative Services’ plan for improving this process was a comprehensive initiative which included EMR training for physicians and RN

super-users, instituting a standard that included preoperative orders available for nurses to act upon two hours before surgical start time and H&P’s available 20 minutes before surgical start time. In September, an all-encompassing kick-off began with EPIC trainers, Physicians and RN super-users. Each surgeon was retrained on EPIC input of orders and notes to meet the standard. An EPIC report was utilized to collect data and surgeons not meeting the standard were given more one on one training by EPIC educators. The month prior to the kick off, data showed that H&P’s successfully met the standard 65% of the time, and preoperative orders successfully met it only 5.3% of the time. Monthly data collection is occurring on each surgical service to monitor compliance and looks promising for increased compliance and increased RN efficiency while ensuring patient safety in the preoperative setting.

FIRST CASE ON-TIME START INITIATIVE Ellana Stolyar, RN, BSN, CPAN, CAPA, Patricia SheehyMcCann, RN, BSN, CPAN, CAPA NYU Langone Medical Center, New York, NY Team Member: Courtney Trebling, RN, BSN, CNOR

A significant amount of delays in first case start times became apparent to staff and leadership. Delays at the beginning of the day often result in need for overtime, dissatisfaction of patients, staff and physicians. A case beginning after 7:35am is considered a late start. Due to this problem a collaborative initiative was launched in pre-operative area to identify the main causes attributing to delays. We implemented a strategy to decrease the delays and achieve an on time start rate of 55% or higher. Staff RN’s identified a delay reason for every case entering the operating room. Data was analyzed and the top ten delay reasons were identified: (1) The surgeon late arrival (2) The surgeon is speaking with the patient (3) The anesthesiologist is speaking with the patient (4) Miscellaneous ( uncooperative patient, jewelry issue, etc.) (5) Consent is wrong, incomplete, missing (6) Paperwork is missing (7) Patient is not marked (8) Bathroom needs (9) Procedure booked is incomplete (10) Pre-op medication administration is delayed. There was a significant improvement in on time start after this initiative began. We concluded, in order to achieve our goal, surgeons need to arrive no later then 7:00am, anesthesiologists need to arrive no later then 7:10am, patients need to be admitted no later then 7:00am, and patients must leave pre-op area no later than 7:25am. Implications for our practice include continue to collect data and analyze data monthly, create a visual on-time start board to show our progress.

NO SHOW e OH NO! Team Leader: Amy Durig, BSN, RN Summa Akron City Hospital, Akron, Ohio Team Member: Victoria Wells, MSN, RN, CAPA

Background Information Related to the Problem Identification: When patients do not keep their scheduled appointments in Pre-Admission Testing it results in financial loss and

ASPAN NATIONAL CONFERENCE ABSTRACTS poor efficiency. This affects staffing and/or an inability to accommodate physician requests for patient appointments. Objectives of Project:  Identify who, when, and why patients do not show up for appointments  Analyze results to find themes to determine an action plan  Discuss improved communication strategies with secretaries and office schedulers  Compare pre and post strategy results for further action Process of Implementation: No Shows were tracked for a period of six weeks prior to and six weeks after strategies were implemented. A secretary was coached to use scripting for appointment reminder phone calls. A letter was drafted for office schedulers describing improvement goals including an appointment notice for patients with contact information for appointment cancellation. Communication was recognized as a catalyst for improvement. Statement of the Successful Practice: The team leader learned that both pre and post action plan female patients between the age of 26 and 49 were most likely to not show up for a morning appointment. The most common reason to not show up for an appointment was interference with work schedule. Implications: Pretesting departments should consider women between the ages of 26 and 49 when scheduling pre-testing appointments. Flexibility with this patient population may provide better attendance and improved schedule effectiveness. Audits will be ongoing after implementation of a plan to meet the needs of this patient population.

IMPROVING PERIOPERATIVE OUTCOMES FOR THE ADULT PATIENT WITH OBSTRUCTIVE SLEEP APNEA AFTER GENERAL ANESTHESIA Team Leader: Jill Setaro, RN, MSN, CPAN Stony Brook Medicine, Stony Brook, NY Carole Capps, RN, BSN, CPAN, Edna Giffen, RN, MSN, CPAN, Amy Ferrara, RN, BSN, CPAN, Michelle Knipe, RN, Henriette Lucas, RN, BSN, Karen Wiederkehr, RN, BSN, CPAN

Abstract: Care of the patient with Obstructive Sleep Apnea (OSA) has proved challenging in the postoperative setting. It has been observed that this patient population requires a high level of observation to maintain airway patency and oxygenation. Patients with OSA frequently present with an increased risk of difficult intubation and an increased sensitivity to sedative and analgesia medications. Postoperatively, patients with OSA are at risk for apnea, desaturation, and cardiac dysrhythmias. The question of how to effectively manage the patient with obstructive sleep apnea after surgery emerged while caring for this population in the recovery period. Literature review supported the need for improved, consistent care of the patient with sleep apnea. A failure mode effect analysis performed in the PACU demonstrated several high-risk modes that jeopardize the safety of patients with OSA. Utilizing the Chronic Care Model for improving patient outcomes, we examined the patient experience through the perioperative phase of the health care system. This resulted in the delivery system design of a nursing standard of care. Integrating clinical information sys-


tems to improve preoperative screening with the use of the STOP questionnaire will assist in identifying high-risk patients early in the surgical process. Intensive postoperative monitoring and discharge planning will provide the resources required for the patient to return safely to the community after surgery. Implementing this standard has assisted in producing a proactive multidisciplinary team approach to the management of surgical patients with obstructive sleep apnea. This comprehensive plan results in safe, consistent care, educated patients and staff and improves patient outcomes after general anesthesia.

PRE-OPERATIVE ISOLATION STATUS ASSESSMENT: WHAT AN IMPACT WE CAN MAKE Team Leader: Mandi L. Glova, BSN, RN Johns Hopkins Hospital, Bloomberg Children’s Center, Baltimore, MD

Background/Problem: Within the pediatric pre-op area at Johns Hopkins Hospital, pediatric surgical patients are placed on isolation precautions based upon a positive culture from a previous date. Although this positive result is not always recent, in many cases, it is more than a year old and lacks accuracy. Surgical patients regularly receive antibiotics in the OR making a post-operative culture swab ineffective. Therefore initiating the isolation precaution in the pre-op area warranted or not, ensures compliance for the entire hospital stay. In most cases, once discharged, communication about isolation follow up and follow through is neglected. Regardless to the time between visits or admissions; once the child re-enters the hospital isolation precautions are implemented and must be maintained. Objective/Purpose: A literature review was conducted to examine the most current evidence using the Johns Hopkins Hospital Evidence Based Practice Model. The purpose of this study was to: investigate the preoperative assessment of the isolation status of children and identify those children on isolation; swab the patient in the PreOp Unit to rule out multidrug resistant organism (MDRO). Method/Process: Preoperatively, all pediatric patients’ isolation status would be identified. The PreOp nurse would obtain a doctor’s order to swab those children who have been designated MDRO status in the PreOp Unit before going to surgery. Significance of the Problems/Findings: This initiative revealed that by assessing isolation status and obtaining a swab pre-operatively, patients no longer affected by the multidrug resistant organism (MDRO) can be removed from isolation while allowing those with continued infection or colonization to be appropriately isolated. The psychosocial impact of isolation precautions on pediatric patients and their families is a growing concern. The negative body image that results not only impacts patient satisfaction but staff as well. Likewise, there is also a significant impact on resources related to the cost and waste occurring when unwarranted isolation precautions are taken. Implications for Perianesthesia Nurses: By creating this preoperative isolation status assessment initiative that identifies those patients who warrant continued isolation protocols, nurses have the power to improve patient & staff satisfaction as well as lower the cost while reducing waste created by unwarranted isolation precaution measures.