Headliners
Quality CornerThe Quality Management Department is pleased to announce a series of “Coffee Break” educational opportunities starting August 31st. Over the past year, we have written a series of articles published in the Capsule giving a broad overview of the Core Measures. In this issue, we will begin a more in-depth series focusing on one or two points at a time.
The Quality Management Department is pleased to announce a series of “Coffee Break” educational opportunities starting August 31st. We will be going to various units at 7:30 am and 7:30 pm to provide information on Core Measures. Additionally, we are starting Core Measure Teams to provide education and support on the nursing units.
Over the past year, we have written a series of articles published in the Capsule giving a broad overview of the Core Measures. In this issue, we will begin a more in-depth series focusing on one or two points at a time.
The Core measures compare the quality of care for hospitals across the nation base on patient results. Compliance with core measures reduces the incidence of complications, infections and reoccurrence of the condition or disease.
Core measures began in 1999 when the Joint Commission solicited data from Healthcare organizations, providers, consumers and experts across the nation. In 2001, the initial four measures were developed-Acute myocardial infarction (AMI), Heart failure (HF), Pneumonia (PN) and Pregnancy and related conditions (PR). The Joint commission worked in conjunction with the Centers for Medicare and Medicaid (CMS) to develop measure sets that were common to both organizations. In the fall of 2003 a fifth set of measures was added- Surgical Infection Prevention (SIP). SIP was further refined and developed into the Surgical Care Improvement Project (SCIP).
Our goal, in all measures, is to achieve 100% compliance. This means our patients have received evidence-based, timely and appropriate care, meeting national standards, to ensure optimal outcomes. A key component to achieving success is documentation-both by the physician and the nurse. If care is not documented, the results are reported as negative outcomes.
The first SCIP indicator we will focus on is post-operative prophylactic antibiotics. In general, Ancef is an acceptable choice. All departments will be given a binder containing a list of acceptable and alternative choices. If an alternative antibiotic is used, we need physician documentation supporting the choice.
Prophylactic antibiotics need to be discontinued within 24 hours of the end of surgery. It is important to know the end time, which can be found on the Post –operative order sheets (stamped by PACU), the Anesthesia Record, the OR report or the PACU record. Cross-reference this end time to the MAR to be sure the last scheduled dose of antibiotics falls within this time frame. If the end time is not within the 24 hours, contact the pharmacy to reschedule the dose. Remember that these guidelines are for prophylactic antibiotics only. If the patient has an infection, antibiotics may be given as long as necessary.
Debbie Isaacs, Quality Dept.