July 2012 SAR Risk Adjusted Pneumonia Outcomes Odds RatioDecileStatus ALLCASES1.67 9 High Outlier/Needs Improvement GEN1.55 9As expected VASC1.28 9As expected ENT n/a
Pneumonia Working Group Engage manager of General Surgery, Vascular, ENT - units T8/9 Audit of current practice Improvement Charter/SBAR Gather the team What to do?
*Rosenkranz et al. (July 24 2011). “ICOUGH”: The Development of a Multidisciplinary Program to Address Postoperative Pulmonary Complications. Powerpoint lecture presented at ACS NSQIP National Conference in Westin Copley Place, Boston MA.
I ncentive Spirometer DB+ CO ral Care U nderstand/ Education G et out of bed/Mobility H OB 30˚ Pain Control % Patients17%52%60%21% 17% chair 76% walking48%86% Audit Results
PDSA, Improvement Charter… Goal: I ncentive Spirometer DB+ CO ral Care U nderstand/ Education G et out of bed/Mobility H OB 30˚ Pain Control % Patients 17%52% 60% 21% 17% chair 76% walking 48%86%
Goal 50% reduction in post-op pneumonia rates in General Surgery, Vascular and Otolaryngology by June 2013