March
Highlights of Performance Improvement at SHC
Quality Improvement and Patient Safety Committee
chaired by Joseph Hopkins, associate chief of staff
Massive
Transfusion Guidelines
A pilot program began in April in the emergency department for five
SHC trauma patients requiring massive transfusion. Results of the pilot
will be reported to the QIPSC in May.
The purpose of the guidelines is to facilitate efficient and effective
procurement and delivery of blood products for trauma and other patients
who meet criteria for massive transfusion.
The guidelines alert the OR and labs to provide extraordinary
support for an emergency and to standardize laboratory monitoring to
aid clinicians in crisis situations.
Overall the guidelines are intended to ensure optimum
collaboration among clinical services to maintain correct transfusion
products to meet individual needs, facilitate communication, and ensure
the receipt of the right product in the right - usually urgent - timeframe.
Sponge
Counts in Operating Rooms
Richard
Whyte, medical director of operating room services, reported that the
Operating Room Medical Committee has reviewed a policy for OR sponge
counts following recommendations by members of the OR nursing staff.
While not requiring a time-out for a sponge count, the OR will champion
a rigorous safety procedure and work with surgeons to ensure support
and oversight.
100,000 Lives Campaign
The
Medical Board has approved SHC participation in the Institute for Healthcare
Improvement [IHI] Patient Safety Campaign designed to save 100,000 lives
in 2005 and 2006.
Work
on five of the program's six initiatives is under way and a rapid response
team is being considered. Internal SHC data as well as outside benchmarking
and strategies are being analyzed regarding Rapid Response Teams.
The
campaign's six improvement initiatives include:
- Acute MI care
- Prevent ventilator associated pneumonia
- Deploy rapid response teams
- Prevent central line associated infections
- Prevent Adverse Drug Events
- Prevent Surgical Site Infections.
Stroke Measures
(JCAHO Disease Specific Certification for Primary Stroke Center)
Three of four measures reflect a consistent trend of 95 percent
or better
Stroke-6: Lipid Profile During Hospitalization dropped
during second quarter. An investigation with key stakeholders (neuroscience
physicians and staff) is under way to examine ordering and accessing
data on patients who receive lipid profiles during hospitalization or
30 days prior.
