This session explores three local projects: one each from St. Louis Children's Hospital, Barnes-Jewish Hospital and Washington University School of Medicine.
Chapters (Click to go to chapter start)
Collaboration is Key: Interprofessional Leader Rounding and Preventable Harm Huddles to Reduce Primary Central - Line - Associated Bloodstream Infections
Impacts of a Pharmacy-Led Transitions-of-Care Service at an Academic Medical Center
Surgical Prehabilitation and Readiness: Healthy Ways for Shorter Stays
Hello, everyone. Welcome to our fourth and final session. I am Becky, director of patient safety, regulatory compliance and risk management at Barnes Jewish. I have the pleasure to introduce three different sessions. The first is from ST Louis Children's. I have Dr Dan Willis who is the assistant professor of pediatrics and director of Quality Improvement for the Division of pediatric hematology and oncology at ST Louis Children's in Washington University School of Medicine, specializing in solid tumors. He received his doctorate in medicine from the University of Kansas School of Medicine. He serves as the physician lead for the ST Louis Children's collapsing, preventable harm team and serves on the quality and safety coordinating subcommittee and the infection prevention subcommittee. He is prepared with Megan mckay who is a patient safety and quality improvement specialist that supports the division of pediatric hematology and oncology at Children's. She received her Master's of Science in Nursing with an emphasis in nursing education from the University of Missouri Columbia. Megan serves as a team member for children's peer support program we care and, and as the calling improvement specialist for the collapse e preventable harm team. Please welcome Dan and Mei and as they speak about inter professional leader rounding to reduce collapse these um in the Hammock unit. Great. Thank you so much for that introduction. Um You can see and hear me okay. Um We're really excited to present this, as mentioned, I'm Dan Willis. I'm a pediatric oncologist and joined by Megan mckay, my partner in crime. We're going to talk to you about a couple of different interventions that we implemented for cloud C reduction or central line associated bloodstream infections. Um In our presentation entitled, collaboration is Key. Um and we have no financial disclosures or conflicts of interest to report. And so as a as a health care quality community, we talk a lot about central line associated bloodstream infections or collapses. And so why are these so important and why do we spend so much time on them? Well, first of all collapses occur not infrequently and in oncology patients, they occur approximately 2.3 infections per 1000 central line days. Um And they're bad for the patient. They increase your risk for mortality, they prolong hospitalization and they increase antibiotic exposure um and can lead to escalation of care and admissions to the ICU. Um And in fact, each collapse it can cost up to $55,000. Um And so they're not rare, they're dangerous and they're expensive. And while we focus um always on cloud c reduction, the pandemic made this an even more pressing problem um Nationally during the pandemic, we saw an increase in hospital acquired infections in our pediatric oncology program was no different. And while we're proud to say that we're usually well below that metric of 2.3 infections per 1000 central line days. In 2020, we saw 11 total primary collapses which was um 350% increase over the year before. And while this was surely multifactorial, it required immediate action to make an improvement. Um So, to be successful and seeing that improvement, um we needed the structures and supports in place um within our institution. But also we need to bring our team back to the evidence. What do we know it's gonna reduce collapses? And so we have a hospital wide clouds, a team whose hospital goal is to provide oversight and standardization in central line care. But where do we get that standardization from? We are lucky to be part of the solutions for patient safety network. It's a network of like children's hospitals um that have really dug deep into the literature and found what is evidence based that will reduce when um when implemented are highly likely to reduce collapses and hospitalized Children. So that's how we inform how we standardize our central line care. Um but not only did we need the structures in place, we needed a culture where we could make meaningful change. And so we had to have a culture where safety was at the center. Um and so we used the pillars of higher of a high reliability organization to determine what our next steps. And so just to hit on a couple of these, um we have a preoccupation with failure. When we saw this dramatic increase, we couldn't write this off as a one off. We had to dig deeper and say um what's going on at the front line. And so that comes into sensitivity for to operations. Um Both interventions will talk through occur at the bedside with the bedside nurse and including patients and families. We need to know what's going really well at the bedside, preventing collapses and where are we falling short? What do we need to do next? I'm reluctant, reluctant to simplify interpretations is crucial. Um We can't just take one interpretation of what happened and run with it. We need to have all the right people at the table, having a dialogue and sharing information together. I'll jump down to deference for expertise. Um We have some really talented individuals here at ST Louis Children's Hospital. We have experts in what they do and we need to get those people in the room together, sharing information and calling us all a little bit higher. Um And so there was a call to action and we had a meeting at the hospital level that was attended by several units that had the highest risk for classy with a goal of refocusing um on achieving zero classy and believing that that was possible. Um And so what is the role of leadership and classy prevention? I think it's two to partner with the services that help in this effort, including infection prevention and vascular access and um environmental services as well as to model standard work and provide accountability. Um Additionally, I think it's to be present and engaged with the front line staff. And so we identified roles um to make sure that we would be successful in this venture and to make sure that we had um hospital level sponsorship as well as provider, leadership and nursing leadership, um nursing leadership at the unit level as well. And then experts both in the content and in the process is um and a mat and a metric to track our progress. So we had to call that action, we had the team in place and now we needed a guiding document to keep us focused at the task at hand. Um This is our key driver diagram. As you can see, there's a lot of working parts and I think the big takeaway from our key driver is it had a focused goal, but there was not one single intervention that was going to reduce clouds is it was all of these interventions working together. Um That was really going to drive our rate down and keep our patients safe. Um Today, we're going to speak to that last key driver, the culture to speak up, both interventions that we're going to share with you. Um We're engaging a lot of different team members at the bedside and it was information sharing um and thinking through together, what are we gonna do? How are we going to partner with patients and their families to, to protect them while they're in our care? So, the first one that we're gonna talk about is um inter professional leader rounding, which we actually got a little preview with some of the talks earlier today. Um And in this structure, we had a provider, either a physician or a nurse practitioner as well as a member of nursing leadership. And that could have been the nurse manager, the educator or safety specialist and they would enter the room with the bedside nurse um on a subset of admitted patients with central lines, um going into the room, we would perform an audit on the central line dressing and the solutions for patient safety bundle elements. We believe that there were many different benefits to this practice. Um One is it allowed us an opportunity for an audit with direct feedback in the moment to the nurse if there was areas for improvement or deficiencies. Um And having that, that immediate feedback was important to it, allowed us to interface with the patients and the families and engage in a conversation about what we do to keep them safe, how they can partner with us and to discuss any concerns or questions that they had. Um And then finally, it augmented our ability to have a preoccupation with failure by increasing the awareness of classy prevention practices and being a visual reminder of its importance. And so the triad team would enter the room and discuss a variety of different topics with the family and with the patient allowing time for the family to ask questions and expressed concerns. So topics may have included how we enter the central line, um and and cleaning procedures before doing that. Um As well as dressing integrity, um How we make sure that that dressing remains inclusive and clean, um ch g bathing and hand hygiene, how we clean surfaces that are touched frequently that are in the room and how we partner with environmental services for cleaning the rest of the room. Um And the goal was to talk to the family about how we prevent infections for, for the patient. And so these topics may have been emphasized or de emphasized depending on the needs of that patient in the family. In addition to education about the topics, it allowed us to present ourselves as a unified team to the family and to say these are the factors that your entire care team believes are important um to give parents permission to advocate for the child. Um We'd often state that we know that lapses can occur even with the best of intentions and that you as the parents or patients are part of the team preventing these infections. And so if you have concerns, please don't hesitate to speak up. And that's really important that they have that opportunity. The second intervention is called a preventable harm huddle. Um So this is an inter professional bedside huddle. We identify one patient a week that is at particularly high risk based on their course or their status for some of these hospital acquired conditions. We're gonna talk with the families about what puts them at risk. Um What we're doing to keep them safe and what specific mitigation strategies do we need to implement based on what we share with the family and what they share with us. Um It's a multidisciplinary group. We have to get all of the experts to the bedside. So you'll have the bedside nurse, um the patient, um and our family will be invited to participate. Um We'll bring in our charge nurse or resources who does a lot of education with families, nursing, leadership. Um We have our providers or nurse practitioners, they're um infection prevention, infectious disease and we really need vascular access. They are the experts on those lines and really help us troubleshoot in the moment with the family. Practically what this looks like is one child a week um is selected as being particularly high risk for multiple hospital acquired conditions. Um It's a scripted discussion and that everyone has a topic that they will speak to based on their area of expertise. Um It's important that there is a culture that is safe to speak. Anyone can ask questions. I feel like every I've gone, I've learned something from infection prevention or infectious disease, but it's an environment where we can go through and collaborate collaboratively think together. Um As we share information that might look like us sharing, you know, every day your child, you can expect your child will receive a CHD bath and we'll explain why how that's grounded in the literature and family might be able to share back with us. You know, I'm glad you bring that up. I'm having trouble having my child do this every day. And we can think through together um strategies to help keep that child safe by using what we know is going to prevent collapses. It's an opportunity also to make sure the family knows that every single person has a role in collapse prevention, including them. We need their partnership to be successful as well. Um and so what we saw was a dramatic and a sustained result. And so in this run chart, you can see that the classes, events which are the blue line, there were occurring fairly frequently in um in 2020 and 2021. Um with our center line being the red line. Um and as we initiated these projects, we didn't see an immediate fall. Um and knowing that it was multifactorial, we had to um persevere knowing that the interventions were sound and that the evidence um and that they were evidence based. Um and that we were seeing subjective improvements as we were doing these interventions as well. And after a few collapses in April of 2021, we went 542 days without a primary cloud sea, which was an unprecedented period of time for our, for our program and unit um an accomplishment that I think many and admittedly including myself didn't really think was possible. I mean, here's just one more way of looking at the data and this is a days between events chart or A T chart. And as you can see the average days between events with that center line again in red was around 30/20 20 and 2021. Um And there were times in there where the number of days in between clubs see events was closer to 10 or 20 days. Um the improvement we saw was was way up above the upper control limit, which was both cause for celebration. And I think continued motivation for our frontline staff to be able to see the hard work that they're doing um resulting in a, in a real change. Um and I'll show our process measure as well which was compliance with the solutions for patient safety bundle. And I think that this slide really highlights some of the challenges we faced. Um and as you can see the dashed line, there is that 93%, which was our goal compliance each month. Um and when we started this project, we really were seeing that number dip. Um and so in the blue line, that was our monthly monthly compliance effort. Um and it was rarely reaching 93%. Um The gray bar also represents the raw number of audits that we were doing each month. Um And as we saw staffing shortages or high census or high acuity, um it made it harder for us to complete these audits. And you could see that these numbers were, were falling and the percent compliance would fall. Um And by hard wiring these processes with consistent times in calendar reminders, we were able to push through these times. Um And although some weeks were more successful than others, I think that overall we were successful. Um And while the resources and investments were not small and had to be intentional, intentional, um they did have a tangible effect. Um I we're really proud of the data um that Dan was able to share, but I think something that doesn't speak to is some of those intangibles and the cultural shifts that we saw. Um I think to describe when we started inter professional rounds, you know, the leaders would step onto the unit and start to look for nurses to go around on their patients with them and do that triad leader, rounding and nurses were nowhere to be found would scatter into rooms, go into the med room. But I think it was because we didn't have an understanding of how important and crucial conversations are and really valuing the nurse, valuing how much insight they had into collapse prevention. And so I think as time went on and they continued being really faithful and doing this each week, um nurses were seeking out the leader to do rounds. I think there is a sense of empowerment and staff knowing. Yes, everything we're going to describe to you, this is what I'm doing every day to make sure your child is safe and we're able to integrate that learning instead of feeling the guilt and shame of when we do have a collapse. See um we retreat or hide from it. We're hitting it head on and we are doing things actively to keep Children safe when they are admitted on our unit. And so how do we keep the momentum? Um We have a couple different things that we're working on. So within our division who are trying to increase physician and nurse practitioner participation, we have representatives from both parties that work on our division level team. Um But when they're not on service, we have a large faculty. How do we bring in all of those people um to our clarity prevention efforts and help them understand there are crucial piece um to keeping Children safe from a cloud c when they're admitted um within our hospital, we are hoping to spread in professional leader around using that triad structure to other high risk areas of our organization. Um We are part of the SPS, has a human pioneer cohort. Um They are aware that our patient population is very at risk for cloud season. So how do we pull together other human divisions across the nation and share information with each other? We're really lucky to be part of that pioneer cohort. Um And on a larger level, we have been sharing our learning and some of our successes across the SPS Midwest regional network. We shared inter professional leader rounds with them through a PDS, a challenge and were recently selected um for that intervention that will be spread throughout our region. Um So with that, we'll conclude, I think that we um maybe still have a couple minutes left that were available to take some questions. We really enjoyed being able to share this work with you today. Um And thank you again, great presentation, Megan and Dan. Uh many accolades are being shared in the chat and the, and the question and answers. And um I believe we have one question that hasn't already been answered. And is there an algorithm to identify these specific patients? How do you choose which patient is at the highest risk to focus on? You want to take that one? Yeah, sure. I can take that one. I think there's not a perfect algorithm for that. And that is, that's a great opportunity and I appreciate the thought. Um what our process normally is is one of our assistant nurse managers who really helps um facilitate that. Each week we'll do some chart review. We'll look at with a new diagnosis or maybe a brand new central line where there's still lots of education gaps. Um, families are brand new to maybe the diagnosis, but also um going home with this central line for a long period of time. Um That's some of our criteria. Another one might be a patient who is significantly Neutra Penick. Um And is it a high risk at that moment in time? Do you have anything you want to add to that? I think that sounds great. We have time for one more question we have. How do you think the discussion and how that translates to patients who aren't discussed but also high risk? Yeah, and I can maybe take that one. I think that it's tricky and it takes about a half hour for each of these preventable harm huddles. Um But I think that when we do our leader rounding, we're able to hit a lot of patients um in that same week as well. Um And nurses that are, that are rounding on other patients also. And each one of those, um each one of those two times during the leader rounding, I think is kind of like a minimum, a miniature preventable harm huddle. Um And so we, we identify patients during that so that we can maximize the number of nurses that are able to participate and so often hitting just one patient for her nurse so that the nurse can take that information and, and make sure that she's spreading it to the other patients that she's covering as well. Well, I think that wraps up our time for questions. Appreciate your presentation, Megan and Dan, we're gonna move on to our second of three sessions from our local initiative um session. We have Mandy Tedder who um is a clinical pharmacy specialist. Mandy received a doctor in pharmacy degree from ST Louis College of Pharmacy. In addition to completing her P G Y one residency and PG Y two internal medicine residency at Barnes Jewish Hospital. She currently is a clinical pharmacy specialist focused on internal medicine and transitions of care. RBGH. And her presentation is impacts of a pharmacy led transitions of care service at an academic medical center. Welcome Mandy. Thank you for that introduction. Really excited to talk to you all today about our pharmacy transitions of care program. I have no financial conflicts to disclose and the objectives for my talk today are to recognize areas of focus for smoother care transitions as well as to describe outcomes from pharmacy based transitions of care service at Barnes Jewish hospital transitions of care is a particularly vulnerable time for our patients and when gaps occur in these transitions of care. It can lead to very poor outcomes, including medication errors, readmissions, and adverse events. And many groups have suggested core components to an ideal transitions of care. I particularly like this framework that was published in the journal of hospital medicine That describes these 10 domains as being structural supports of this bridge that patients act across um in order to have a successful transitions of care. And so if any of these pieces are missing, that makes that bridge less safe for them to cross. And one principle that really strengthens this bridge is to focus on these aspects throughout the entire patients stay rather than waiting until discharge to um focus in on a lot of these. And that is one aspect of our transitions of care program that we also try to embody um and focusing on discharge kind of all along rather than waiting until the end. But I think it's important to note that these domains really have to be tackled as a team based approach. This is so much for one person or one group to handle. And so really, we need to incorporate many of our team members to help with these successful transitions of care. So how can pharmacy help collaborate? And I really see as being involved in many of these aspects over half of these. Um And you know, we can really help with discharge planning, communication of information and organization of that mid safety is huge for us, educating patients helping with monitoring and managing those symptoms and then even outpatient follow up too. So we kind of considered those things in our pharmacy transitions of care program and pharmacy being involved in transitions of care isn't really a new concept. Um It was new for us here at Barnes Jewish, but there were already some programs out there that had been published um with varying populations, different interventions and outcomes seen. And when we reviewed the literature before we set up our program, we noted that the most successful hospital based transitions of care programs followed a standardized process, ensured effective communication amongst team members and had a dedicated service targeting patients undergoing transitions of care. And additionally, um programs that have pharmacists involved at multiple time points throughout the patient's care rather than just like one time point coming in at a mission being done. But being involved at multiple steps throughout the patient care process had the most successful outcomes. And so considering all of these things and the components in ideal transitions of care, we set up our 12-month pharmacy led inpatient transitions of care pilot in 2019. And when thinking about our targeted patient population, we really wanted to focus in on a patient population who we knew was high risk for readmission, but also disease states that we knew um also had a lot of medications and could really benefit from having a pharmacist more intimately involved in their care. So we decided to target congestive heart failure, chronic obstructive pulmonary disease or COPD and our acute myocardial infarction patients. And Um this, we just had one FTE dedicated to this pilot. So with us having a 1200 bed hospital, we really needed to scale this down. Um so we picked two of our cardiology floors of the hospital where many of these patients resided just to kind of scale down our patient population. And then we focused in on patients who were discharged to home For our exclusion criteria. We excluded patients who were admitted less than 24 hours left against medical advice, were discharged on hospice or had a history of solid organ transplant or active malignancy just because there is some separate work being done with those groups of patients to help with their transitions of care. And so we're really hoping for a very clean patient population to get in a good intervention and control arm to see exactly how our intervention would affect patients. So, like I said before, the most successful programs had a standardized process and have pharmacists involved in multiple time points throughout the patient's care process. And so we decided to really focus on the entire admission and be involved from start to finish in these patients days. So we come in and do a home medication list review when the patients admitted within 24 to 48 hours of hospital admission, we reconcile those against what is currently ordered in patient and work with the providers to clean up orders. At that time, we also review um the charts of these patients every single day and help optimize their medication list every day of their stay. This is really helpful for us too because we can identify barriers to discharge a lot earlier because we're looking at the charts so frequently. Um So if we start a medication that's maybe more expensive or would require some additional approval processes, we can identify that earlier in this day and kind of get those things worked out before the patients ready to go home. We'll review the discharge med rec before or after the provider submits that, um, for any issues with discrepancies at that point and make any optimal is ations at that point as well, will counsel the patient before they leave, go over all of their discharge medications really focus in on the changes that were made. And then our final touch point with these patients is a post hospital, um, phone call with them about three days after they're discharged. We find that sometimes patients are very overwhelmed in the hospital, especially when you're counseling them. They've got a ton of information right at the end. And so we kind of touched base with them once they're home and settled and have time to process everything to make sure they got all their medications. Nothing has fallen through the cracks at that point and to answer any additional questions at that time and I can't stress enough how collaboration is crucial to our process. Um We are also involved in our interdisciplinary rounds which happen every day um in our different areas of the hospital. So this focuses on an area of floor of the hospital. And all of these health care team members come together to talk about these patients and anticipated discharged dates as well as any barriers that we're noting. And so the collaboration that we see with this team is extremely helpful as some people are noticing different barriers than others and have more information about the patient's barriers. And so this has been really, really crucial for us to help get things going and get the ball rolling on some of these barriers and and working out solutions to these before the patients ready to go. And then we could not do this program without any of our physician or um other provider colleagues. And so we like to round with those groups when possible um to help kind of keep up to date on the clinical course and the medication practices at Barns, but also just to continue to build relationships and reports with the teams and attendings that we're working with. So what did we see from our pilot? We saw numerous discrepancies and interventions that we were able to make during this time. So our home med list reviews taking about 15 minutes per patient. We were doing these after the patient had already come up to the four. So I already had that initial agent P written. Um and that initial med review done by the provider and we were still noting over 2000 discrepancies at this time point. So about four discrepancies per patient, We were able to make an additional 140 for interventions based on things that we're finding on the home med list. And then currently inpatient ordered medications as well as any of the complaints by the patient. At that time, numerous interventions able to be made on the inpatient side while the patient was here And then discharged rhetoric was taking us a lot less time, I think because we were doing so much work on the front end to make sure everything was kind of cleaned up on the admission set. But we were still catching discrepancies here at this time point and able to still optimize a lot of medications at this time to over 200 interventions at discharge. We spent about 14 minutes with each patient counseling them and then that post discharge phone call is taking us about 12 minutes just to reinforce that met education check in and make sure the patient understood all their discharge instructions. What were our most common discrepancies? So, on admission, by far, the most common discrepancies, we were noting where patients were medications listed on the list that um, either the patient wasn't taking or we were missing medications that they were on at home but not ordered. On the inpatient side, we also saw a lot of incorrect dosages being listed here and this was really important because this was a very heavy heart failure patient population. So many of these patients were on diuretics and having that incorrect dose noted on the home list could really set us back if we were trying to diaries those patients while they were here, we either could get behind or over diaries them and cause adverse events. So catching these things early was really impactful. I think for length of stay in these patients and we'll talk about those outcomes in just a minute for discharge less discrepancies here. But we were still noting some duplicate therapies being added. And I think a lot of this was, you know, formulary switches that were made on the inpatient side and then continued both that medication and then their home medication on discharge. So we're cleaning up a lot of things like that. At the end, our most common interventions on admission where we are discontinuing a lot of medications and then we're also updating a lot of allergies at this time too. So allergies is something that we also ask about when we do the admission med rec. And so we are cleaning up a lot of um extraneous or clarifying a lot of allergies, especially in related in relation to our antibiotics for discharge. By far the most common intervention was sending scripts to the pharmacy. So we noted that many times, even though a patient was started on a new medication or um or had a dosage change, sometimes those scripts would not get sent to a pharmacy for some reason. And so we were catching those things before the patient left, got home and realized that issue. So for our outcomes, we were really interested in looking at 30 day readmissions for these patients. And though this wasn't statistically significant, we did see about a 1% decrease in the intervention arm versus our control arm. And so this was really a good sign to us that this work should be continued. And now if we are able to see more patients, maybe grow our team and increase our sample size, that maybe would we would see additional benefit and even statistically significant benefits in this area. But more interestingly, we saw a statistically significant reduction in length of stay in our patients. And I think that speaks to our work um all along and being involved in admission, but also throughout the patients stay because we're identifying those barriers to discharge a lot earlier and able to work those things out before the patient is ready to go and we figure those things out too late. We also looked specifically at our patients who are seen in our resident run clinic. We have many patients who follow with our residents for outpatient care. But then are admitted on the inpatient side. And so we were interested in a little bit more outcomes for those patients. And we actually noted that those patients followed up in clinic after their discharge At a higher rate. So about 7% higher post hospital visit show rate than our patients who were not followed by the pharmacist on the inpatient side. So that was kind of interesting to us too, as far as characteristics about these patients that maybe lended themselves to better outcomes. In our intervention group, we did see some subgroups that benefited more from pharmacist involvement. Um But looking at some of our groups that we wanted to focus on in the future. So the residents, the patients seen in that resident run clinic, um we saw a lot of benefit from those patients as well as patients who had a high readmission risk for. So um that's an institution specific scoring tool that we use to identify patients at high risk for readmission. And so those patients were also seeing a lot of benefit from pharmacist involvement too. And so those are two areas that we wanted to kind of focus on in the future. And then what about our multiple um step points? Did we need all of those things or did patients just benefit from one intervention over the other could be scaled this down in the future? And similarly to what the literature showed, we saw that patients who had multiple services or the pharmacists touch point at multiple times throughout their stay, um re admitted at a lesser rate than those who only got admission metric for instance. So this really helps kind of solidify this idea that we needed to keep our full comprehensive service going. So overall impacts over 2000 total discrepancies noted on our medication list, 529 additional interventions were able to be made. We had a large increase in our interdisciplinary team member collaboration as this was previously an area of the hospital that didn't have a clinical pharmacist. So we saw a lot more collaboration in those areas when we added the pharmacist there, Um 1% reduction and 30 day readmission rates, one day less length of stay and a 7% higher outpatient follow up rate for these patients. So where are we now? Um we are deciding to focus in on those patients who have high readmission risk scores or are followed in our resident run clinic moving forward because of the benefits that we saw from the pilot project in those patient populations and kind of our goals for our institution at this time, we're still completing that full comprehensive service. So from start to finish, we are involved in these patients care and we're starting to expand our service. We ultimately want to cover all of these eligible medicine patients who meet those two criteria. And so we are rolling out additional FTE S in a phased approach. Um if we're continuing to meet these key performance indicators, so we've already added three additional FTS to our team targeting medicine, teaching services, cardiology, teaching services and our hospitalist group. Um with hopes to add an additional six over the next few years um to complete all of these um services on those eligible medicine patients. So that's where we came from where we're at. Happy to take any questions that you guys may have at this time. I believe the question that was posted and was um I think you just answered it with the approval of new F T E s to implement this. I guess you can if you could expand maybe um and offer some insight to those that don't have a dedicated clinical pharmacists. How could they collaborate to institute this best practice? Yeah. So um yeah, the F T E s. So like I said, we're kind of growing our service in a phased approach just to um make sure that we're continuing to be impactful in those areas that were expanding too and make tweaks as needed. Um for institutions that are looking to expand pharmacy involvement in this work, I think um starting small and trialing this in certain areas of the hospital that worked really well for us to kind of see what worked and make quick changes. This also occurred over the COVID times. So we had to make some switches um and how we were talking with these patients from more in person to virtual and back and forth. And so, um by working at it from like a small standpoint in a pilot that kind of helps us work out some of those kinks before we were ready to really expand. So I think just being okay with trialing some things and redoing um as you kind of learn from the process, I think was helpful for this project and allowed us to have time to evaluate what we were um seeing from the outcomes and then kind of think about how we wanted to expand fully. Thank you. Anyone else have questions, please put it in the Q and A I think we have a, we have a couple more minutes to entertain another question, getting a lot of accolades. All right, I'm not seeing any come in. So thank you, Mandy for your time and your presentation. We'll, we'll move on to our third and final presenter, which is Melanie Cannon. Melanie coordinates a surgical preh ability ation and readiness program. Also known as far for the Department of Surgery at Washington University School of Medicine. She's responsible for managing staff and the recruitment and enrollment of patients, patient and provider education, clinical assessments and referrals. She also oversees the communication and documentation of patient progress and program compliance with pre surgical setting. Prior to working for the School of Medicine, Melanie was a staff nurse and nurse, clinical nurse educator for the abdominal transplant and have had a military biliary surgical unit at Barnes Jewish Hospital. She's here to speak to us about the surgical pre debilitation and rightness, healthy ways for shorter states. Welcome Melanie. Hello, everyone. Thank you. I'm excited to be here and present for you guys today. I'm gonna share my screen to get us started. Yeah, sorry about that. Okay, so welcome. We've made it to the afternoon. I'm so excited to be able to round out um this amazing symposium that you guys have put together today. I'm was so honored to be asked to present and I'm excited to talk about the program um that we have created here within the department of surgery. Um I'm going to talk today about the surgical pre debilitation and writing this um program or spar of which I am the nurse coordinator before we get started. I do wanna give a big shout out to Dr Dominic Sanford, who is the director of the spar program. Um and an amazing compatibility, very surgeon here. He um is out of town, couldn't be with us today, but he is really um the man behind the plan, took the initiative and dug in to make this program happen and I'm honored to work with him. He's been a great mentor and so let's dig into what we've been doing, first of all, um no financial relationships to disclose. So we've got that out of the way. So where are we right now. So looking at the situation, guys, we got a, we have a tsunami of sick patients coming our way. Currently, patients greater than 65 make up over a third of our surgical population. And that's expected to double over the next 40 years. That could include many of us. What's problematic though is that 80% of these patients have at least one chronic COVID CO morbid condition, excuse me, with 50% having multiple. That's a lot of frail folks coming into our health care system needing surgical interventions. What does that look like for us as health care providers? What's it look like for our patients? Furthermore, the situation shows that we're aware that with increased age, we see decreased functional status, which then in turn leads to an increased postoperative morbidity and mortality. That's nothing new. And since we haven't developed the technology to turn back time and reverse our patients age, we have to find other potentially modifiable factors. Our patients can work on with us before surgery. We identified that preoperative physical fitness and activity, nutritional status, pulmonary health and mental well being um such as depression and anxiety are all important predictive factors for surgical outcomes. So where does that take us? What's that lead to preh ability ation, ladies and gentlemen. So I would like to say we coined the term rehabilitation, but in fact, we did not, it's been around for a while. There are other places using it but Washington University Department of Surgery is the first um team that's been able to formalize a program, roll it out and begin the implementation. So we decided on pre debilitation, big word, big things coming, how do we make that happen? So Dr Sandford really put out the call, he rallied the team of motivated big thinkers across the spectrum of disciplines at Washoe all of course, during the pandemic. And when I say this is across the spectrum, I mean, across the spectrum, of course, we had physicians and surgeons and nurses who gave their input into what our patients were, what they needed, um who we needed to be working with. We brought in the patient safety and quality improvement leadership who helped us make sure what we were doing was safe and actually improving. We talked to physical therapists, registered dietitians who gave us the tips and tricks that our patients needed to be utilizing to prepare for surgery. We're using data coordinators who helped keep track of our databases and um compiling the information that's allowing us to see if what we're doing is working. We brought in the school of engineering staff which we don't often work with on the medical side. But these guys helped us figure out how to use Fitbit tracking to um work with our patients. The marketing and communication department were huge in helping us advertise educate, get our website set up so that the word was being spread and of course, Epic analyst, because we all know if it's not been charted, it hasn't been done. Epic has also been instrumental in setting up an actual star department for documentation as well as allowing us to set up an order set so that patients and providers um can be referred directly to the program via Epic. So after many meetings of these great minds, the pieces finally came together and our program was able to be rolled out starting in February of 2021. Now, first things first, though, we've got to have a catchy title for the program, which is where, where spar came from, which of course, we now know stands for surgical preh ability, ation and readiness. So we've got the name. Now, we need to determine who are we focused on who needs us the most After going through evidence, lots of research. Um and other data, we determined that the spar program was going to focus on patients over 70 years old, Who were going to be undergoing inpatient surgery with a greater than 48 hour stay and who had at least 14 days prior to surgery? Why 14 days? Well, if we're pre having patients, we need to be able to pre have them. We need time to work with our patients and we needed at least two weeks to do that for optimal results. So beginning in February of 2021 through January of 2022. Dr Stanford and I month by month, went to staff and leadership meetings for each of the department of Surgery sections and rolled out the program offering insight and answering questions and um asking for those patients that needed us to be referred to us. Now, what are we asking of patients? Well, currently, this is what our patients are doing in regards to each modifiable factor that we spoke about earlier. These are the specifics that the spark coordinators are working on with each patient. And this is really where the multidisciplinary collaboration really came in where the input from each of these other um disciplines gave us um a launching point for what we wanted to ask our patients to do as far as physical activity and mobility. Each of our patients is referred to outpatient physical therapy. Before surgery, we ask that they work on strengthening conditioning and a home exercise program and ask that the patients do this daily up through surgery. We know we need our patients up out of bed As quickly as post op Day one. And we have seen that with this strengthening, this has been much more doable for these patients. We also provide each of our patients a Fitbit smartwatch, you know, accountability is key, not only for our team members but our patients and spar is allowing our patients to be part of their surgical team. So with this Fitbit in education, they are able to track their own steps see what they're doing, see where we can improve. And the coordinators work to set goals with them so that they are getting ready physically for surgery. As far as respiratory status, each of our patients received an incentive parameter and education. We like our patients to do an incentives parameter up to 30 times a day in preparation for utilizing it after surgery. Our goal is to help prevent postoperative pneumonia. I always tell them it's an exercise like anything else just building your lungs up and getting ready um for that post surgical time and then of course, smoking cessation, not something we've always done a great job with here um within health care of the department of surgery. So, um the coordinators are able to order patients nicotine replacement therapy through epic. We can set them up with online or in person counseling and we offer them other options like applications that they can use on their phone and really work with them. We do lots of education on the importance of smoking cessation beyond just saying this isn't good for you guys. We tell them why and continue to encourage them weekly. With this nutritional optimization, your patients need to have their gas tank full and be nourished when coming in for surgery. So along with seeing registered dietitians before surgery, the coordinators work very hard on making sure patients know what foods are appropriate such as things high in protein and preparing for surgery and we're really making a big push for the use of immuno nutrition supplements to get patients nerds before and after surgery. Along with that comes the education of making sure the reasoning behind that is getting through the surgical time as well as that post operative healing time, setting them up for success, going into surgery and throughout and finally, mindfulness. My big push is your mental well being is just as important as your physical well being. They go hand in hand when one is struggling, the other is soon to follow. So we make sure that we talk to patients about anxiety, depression, all normal things they may be going through in this struggle in their time. But what can we do to offset that and get them ready for surgery? We help answer questions about anything and everything. We talk about relaxation techniques, gratitude, journaling, meditation and letting know, letting them know they're not alone. They can ask questions, they can reach out to us, we can help them in all of these aspects. All right. So let's talk a little more about these patients who are they, what are they looking like? So the most recent set of numbers that we've been able to grab our from um the 246 patients that were enrolled in spar between when it started in February 2021 last November 2022. At that point in time, 100 and 36 Had undergone surgery and we were able to get some post operative information from them. Those that had not undergone surgery at that point were, um, 58 of those were either continuing to go under neo adjuvant chemotherapy and radiation. Well, there are a few of those that do not make it to surgery due to disease progression or other things that make them not a candidate. And for those patients, I always say no harm done from what we have done with spark. Even if they don't, don't make it to surgery, the amount of um things that they've put in have only made themselves stronger. Couple of other numbers, most of our patients are in row For an excuse me, enrolled in spar for an average of 49.6 days that gives us some good time to make a difference in um their optimization. And the average age of those patients is 70 years old, which is right where we're wanting to hit them. Of note though, we've had patients as young as 36 and as old as 91, we will take pretty much anybody that needs to be referred to us. If you need spar, we will get you ready and, and let's look a little more into who these patients are that are being referred to us. Um, like we said, this is the department of surgery and these are some sick folks with the hepatic biliary, the colorectal, the transplant. We're seeing so many patients coming in for pancreatic cancers, colon receptions, liver transplants. So we really are seeing the sickest synthesis, sick, the frailest of the fray, we are trying to meet the people that need us where they are with this Spire program. That being said, how do we know and how do we determine that's far is working that our outcomes are what we want them to be. First, our team uses the A C S National Surgical Quality Improvement Program risk calculator to determine what these specific patients expected outcomes will be based on their specific procedure. You'll see on your screen, an example of that. So we can see here that compared to historical patients undergoing the same treatments at Barnes Jewish hospital, the spar patients are older, they are sicker and they have worse functional status. So are we setting ourselves up for failure or success with ours? Um Looking at our star patients because we are targeting the frailest of the frail. Let's see what the numbers tell us here. We can see that spar patients are beating the predicted outcomes of the A C S Equipped Surgical Risk calculator. These patients had lower observed to expected length of stay, discharge to facilities and death. Furthermore, in matched historical controls, spar patients had reduced rates of discharge to a facility and death. What I want you to take away from this specific slide is in medically high risk patients undergoing surgery 1 30 day mortality was prevented for every 24 patients enrolled in spar. One post acute care facility discharge was prevented for every 14 patients enrolled in spar as our numbers continue to grow. I anticipate this trend to continue, which is powerful for both our health care system and our patients. Spar is saving money. Spar is saving resources and spar is saving lives. Now, the numbers look good. But what are our patients feeling and saying about the program? Are we meeting them where they are improving their lives? Before and after surgery? I'm biased, but I seem to think we're doing a pretty good idea. These blurbs are a few of the feedback that we have received from a patient survey that we have sent out after the patient has can um finish the program. The program motivated me to get me a better physical emotional condition. This patient misses his Fitbit and wishes we could sell it to them. Um This patient loved being engaged with the staff and felt like they got out of the hospital sooner and most important to me, it helped this patient feel connected to the team success for me and my team is when my patients are happy and healthy. And that's the feedback that I've gotten from our patients, our providers. Um And the health and my team, as I conclude the program, I was looking through some, some different types of our, our mission statements and whatnot on um the Department of Surgery. And I came across um this position statement which I hadn't read before, but it really spoke to me in the moment says the Department of Surgery exists to respectfully serve patients. Their outcomes depend on the quality of care we deliver and the safety of our actions on our environment. The Department of Surgery therefore commits to discovery and implementation, measurement and improvement of quality and safety. Above all the collaborations of so many people within the Department of Surgery. And the B J H community has really allowed this far program to deliver on this commitment of serving and working with patients to provide them the exceptional care they deserve. I have been so um humbled to be a part of this program. I'm excited to be able to share it with you um guys today and I'm looking forward to seeing what the spar program has in store for our patients over the next few years. And I'll take any questions anyone has. Thank you. Great presentation, Melanie. Um While we wait for anyone to enter their question in the Q and A uh window, I did notice with a large interdisciplinary team, I'm wondering, can you share any insight on the strategies that was used as you were building this program to ensure team collaboration? That's a really good question. And it was getting a lot of people on the same um towards the same goals. And I think that was the thing we discovered, okay, what do we want our patients to do? We want to receive, we want to get to the sort of links of states that we have seen with other preh ability ation programs and really working towards that. I'll be honest, I initially was not in the first go round of one win. This program rolled out. I was working on the inpatient side with these patients that were coming in. But I think with the collaboration is all about the shared goals of what can we provide these patients, where can we meet them right now with the resources we have? And we were able to pull that together and say we can offer them fitbits, we can offer them incentives parameters and um you know, get that out to their, to the patients and um you know, work towards those shared goals of getting patients over the finish line out of the hospital, feeling good back to their best life. Well, there's a many comments. Um Thanking you, recognizing the great, great work and efforts. Um Wonderful. Thank you. It's been my honor and my pleasure to be a part of this program that's gotten off the ground. I've had tremendous mentors um from top to bottom and my patients are absolutely outstanding. Great. Thank you. Well, that concludes our last session. I want to thank all the presenters that spoke about our local initiatives um and really tighten a lot of the concepts we heard today um to close out this session. Uh We have Dr Emily Landon again to uh to wrap us up. We'll just go through this way for the sake of time. So, what a fantastic day and what wonderful presentations we have from everyone. I hope everyone is feeling inspired and motivated by all of our presentations just to recap. You know, first we learn about how our cognitive bias might impact how we collaborate with others and some techniques to mitigate our unconscious bias. And then we learned about positive leader walk grounds and the impact they can have on psychological safety and emotional exhaustion, which ultimately impacts our ability to effectively collaborate with others and care for our patients. And then we learned about what we each can do to be an active, effective team member, including creating a sense of belonging, being a first follower and managing our behaviors. And finally, we put it all together and we learned about how different teams across B J H ST Louis Children's Hospital in Washington University have employed these concepts to create programs to improve patient care here at our medical campus. Um It's just a few reminders. Um We still, we thank the foundation for their support of the program. Um And that this symposium was sponsored by Barnes Jewish Hospital, Washington University School of Medicine, ST Louis Children's Hospital BJC Healthcare in the Barnes Jewish Center for Practice Excellence. We do have continuing education credit available in order to obtain your credit, you have to do general the general session surveys, those are available in the conference exchange platform. Um where if you go to the navigation page and then select meeting calendar and then select the session and then take the survey and you need to do this for both the session that you have sessions you attended, as well as the overall meeting survey. We take a lot of time to read the feedback and look at comments for the meeting surveys and are always looking for ideas and speakers for future symposiums. The deadline to complete all of the surveys is Sunday, March 30th at 11:59 p.m. So make sure you get it done by then in order to receive your continuing education credit, um the certificates for CMI and A C P E will be um emailed once all the surveys have been completed. And then for C N E A S R T and C R C E, those will be available to print. Um And here's just a screenshot of how you print that out. The speaker information is also available and if you click on their name in the navigation page, you can download their presentation and also be able to see their contact information Um and then to access the recorded sessions, um they will be available for viewing on starting on Monday, March seven and then you would log into the meeting platform. Go to the meeting calendar and then click the session you'd like to view. So those will all be available starting next week. We also um I just want to give a reminder that we also have the abstracts that are available to view. Um We do have three abstracts that were recorded with additional information and we wanted to highlight those top abstracts uh that were selected by our abstract committee. Those included um the primary care physician transitions in the primary care medicine clinic by Dr Steve Wiest, improved safety through standard documentation by James Gross and Nick, you direct a new process, return for all NICU patients directly back to the NICU from the O R post operatively by Carly Wheeler. So make sure to check out those as well as all the other abstracts. And finally, um just as a reminder, get your calendar out, get it on there. Um our patient safety symposium um for 2024 will be on March one. so it's again that first Friday in March. So make sure to block that time out in your calendar. So you can enjoy this again next year again. Thank you so much to everybody. Um That was able to join us today for the symposium. Thank you and our presenters. Many thanks to my coach here, Jody Woodward and a huge thanks to Tammy Clark and Robin Gray who make all this possible and make sure that we've connected on all the details. Um So have a great day everybody and I hope to see you all again next year.
