Day One
8:00-8:15 am
Opening & Welcome
Co-Moderators:
Paul M. Schyve, MD
Senior Vice President
The Joint Commission
Sharon McNamara, RN, MS, CNOR
Director of Surgical Services & Board Member, CSPS
WakeMed Health & Hospitals
Raleigh, North Carolina
8:15-10:30 am
Violence in the OR "Never Tolerated" Events
Violence in the workplace is displayed in a multitude of behaviors; threats, intimidation, physical/verbal attacks, property damage and sexual harassment. The Mission of the Council on Surgical and Perioperative Safety (CSPS) is to promote a culture of patient and worker safety within a caring perioperative environment. The CSPS Team (comprised of surgeons, anesthesiologists, CRNAs, perioperative nurses, peri-anesthesia nurses, surgical technologists, and PAs) has taken a position which states that; "responsibility for providing a perioperative practice environment free of violence is shared among the organization, members of the perioperative health care team, patients and families." Through a multimedia presentation, discussion, and an interactive exercise, this team will examine initiatives designed to facilitate and foster effective communication and team work dynamics essential for the realization of that Mission.
Daniel Vetrosky PhD, PA-C (Moderator)
Assistant Professor, Department of Physician Assistant Studies
University of South Alabama
Faculty Representing the Council on Surgical Perioperative Safety:
Sharon McNamara, RN, MS, CNOR
William P. Schecter, MD, FACS
Professor of Clinical Surgery
University of California, San Francisco
Tom McKibban CRNA, MS
Butler County Anesthesia Services, LLC
Mid-America Anesthesia Professionals, LLC
Mark J. Lema MD, PhD
Professor and Chair of Anesthesiology
University at Buffalo, SUNY
Rowell Park Cancer Institute
Buffalo, NY
Pamela Windle MS, RN,NE-BC, CPAN, CAPA, FAAN
Nurse Manager, St. Luke's Episcopal Hospital
Margaret Rodriguez, CST, CFA, FAST, BS, Board of Directors, CSPS
10:30-10:45
Break
10:45 am-12:45 pm
Wrong Site Surgery
A panel presentation and discussion featuring a team from Beth Israel Deaconess Medical Center with recent wrong site surgery experience speaking on the sentinel event and the steps taken to improve their culture of safety.
Elena Canacari, RN
Director of Perioperative Services, Beth Israel Deaconess Medical Center
Charlotte Guglielmi, RN, MSN
Perioperative Nurse Specialist
Beth Israel Deaconess Medical Center
AORN President Elect
Donald W. Moorman, MD, FACS
Vice Chair of Clinical Affairs, Department of Surgery
Beth Israel Deaconess Medical Center
Eswar Sundar, MD
Beth Israel Deaconess Medical Center
12:45-1:45 pm
Lunch
1:45-3:00 pm
The New Universal Protocol
Ms. Kuhny will introduce the most recent revisions to the Universal Protocol as well as address questions about the upcoming changes.
Louise Kuhny, RN, MPH, MBA, CIC
Senior Associate Director, Standards Interpretation Group
The Joint Commission
3:00-3:15 pm
Break
3:15-4:30 pm
Technology and State of the Arts
This presentation will focus on why an organization should consider building a state of the art operating room (efficiency, satisfaction, volume, quality, safety). In addition, the faculty will discuss why standardizing is important if you do proceed with building along with the selection of a vendor with proved success in installations and patient safety
Terri Freguletti, RN, MS
Administrator, Perioperative Services
Hackensack University Medical Center
Day Two
Track Sessions
A. Infection Control
Moderator: Sharon McNamara, RN, MS, CNOR, Director of Surgical Services and Board Member, CSPS
B. Utilization of Handoffs in Perioperative Care
Moderator: Paul M. Schyve, MD, Senior Vice President, The Joint Commission
7:30-8:45 am
1A. Blood Borne Pathogens: The CDC Perspective on Perioperative Safety
The reuse of syringes and the contamination of medications, equipment and devices have been identified as common factors in outbreaks of hepatitis B virus or hepatitis C virus infections. Notifications affecting tens of thousands of patients have resulted from outbreaks and other incidents involving infection control errors. This presentation will review findings from these investigations along with recommended practices and prevention strategies to reduce bloodborne pathogen risks in the perioperative environment.
Joseph Perz, PhD
Acting Prevention Team Leader
Division of Health Care Quality Promotion
Centers for Disease Control and Prevention, Atlanta, GA
1B. Adding Predictability into The Workplace: Clinical Pathways, Checklists and Standardization
This session will focus on the ways that predictability can influence safe patient care. Examples of checklists, clinical pathways and standard processes will be presented to demonstrate this concept and its application perioperative patient safety.
Charlotte Guglielmi, RN, MSN
Perioperative Nurse Specialist
Beth Israel Deaconess Medical Center
Boston, MA
9:00—10:15 am
2A. Retained Surgical Objects
In the last several years, multiple forces joined together to make hospital administrators and risk managers, surgeons and perioperative care nurses take action and address the persistent problem of retained surgical items (RSI). The surgical patient safety project “NoThing Left Behind” seeks to make RSI a true “never happen” event through implementation of an evidence-based, multi-stakeholder OR policy; refinement and dissemination of OR best practices and processes of care for surgeons, nurses and radiologists; and evaluation and application of new technological adjuncts to count and/or detect surgical items.
Verna Gibbs, MD
Professor Clinical Surgery, UCSF
2B. Strategies to Prevent Surgical Site Infections in Strategies to Prevent Surgical Site Infections
Kelly Fugate, ND, RN
Associate Project Director, Specialist, Division of Standards and Survey Methods
The Joint Commission
10:30-11:45 am
3A. Impact of Temperature, Oxygen, Glucose & Other Non-pharmacological Agents on SSI
Surgical wound infections remain a common cause of serious morbidity. Although traditionally considered to be “surgical” problems, there is increasing evidence that anesthetic management influences infection risk. For example, mild hypothermia (which occurs in nearly all unwarmed surgical patients) triples infection risk. Similarly, risk is doubled in patients given 30% rather than 80% perioperative oxygen. While it is likely that glucose control and optimal management of vascular volume further decreases risk, these interventions have yet to be fully evaluated.
Daniel I. Sessler, MD
Professor and Chair
Department of Outcomes Research
The Cleveland Clinic
3B. Postoperative Respiratory Depression : Time for a Wake-Up Call
Data will be presented demonstrating an increase I postoperative respiratory depression and respiratory arrests over the last decade. Potential contributing factors for this lethal complication will be discussed including increasing obesity rates with associated sleep apnea, multimodal therapy, production pressures, higher acuity ambulatory and floor patients, and other factors.
Lorri A. Lee, MD
Associate Professor
Departments of Anesthesiology and Neurological Surgery (adj)
University of Washington
12:00 am--12:45pm
Lunch
1:15 -- 2:30 pm
4A. VTE Prophylaxis in Perioperative Patients
Venous Thromboembolism (VTE) is a common but highly preventable perioperative complication. Critical care and spinal cord injury patients are at the highest risk of developing a deep vein thrombosis (DVT). Following general surgery procedures, the approximate risk for DVT is 15-40%. This risk nearly doubles after hip or knee replacement surgery or hip fracture surgery. The true prevalence of perioperative pulmonary embolism (PE) is unknown, and it varies according to the type of surgery, the use and type of prophylaxis, and the mode of diagnosis. Despite overwhelming evidence for the effectiveness of regimens for DVT prophylaxis, the concern over bleeding risks often dissuades physicians to comply with guidelines. Preoperative risk stratification determines the level of aggressiveness of DVT prophylaxis. Preoperative anticoagulation is safe and effective when used carefully. A case study will describe the DVT prophylaxis bridging protocol for the orthopedic population. The roles of the nurses, physicians and pharmacists will be explained. DVT rates and compliance to guidelines will be shared.
Rodney Thill, MD, Program Director in Surgery
Advocate Christ Medical Center
Zahra Khudeira, PharmD, MA, Medication Safety Officer
Advocate Christ Medical Center
Oak Lawn, IL
4B. Handoffs and Medication Safety in the Perioperative Environment
This presentation will provide an overview of two process improvement initiatives underway at Massachusetts General Hospital. The first is called "Smart Labels,"a method to improve medication labeling and communication in the perioperative environment including audio and visual readback of the drug name and real-time clinical alerts for drug recalls and outdated medications. The second is a focus on dashboards for hand-offs and communication and the impact on patient safety within Massachusetts General.
Wilton C. Levine, MD
Department of Anesthesia and Critical Care
Bethany J. Daily, MHA
Administrative Director, OR Business and Information Services, Massachusetts General Hospital
*Note: Agenda Subject to Change. Last updated on April 21, 2009.