Date of Graduation
Summer 8-9-2024
Document Access
Project/Capstone - Global access
Degree Name
Master of Science in Nursing (MSN)
College/School
School of Nursing and Health Professions
Program
Kaiser cohort MSN capstone
Abstract
Abstract
Problem: Over the past year, the department failed to meet SSI Bundle Metrics scores consistently due to process identification failures and documentation lapses.
Context: The post-op warming temperature documentation and practices project focused on addressing critical quality issues related to documentation and education gaps in the post-anesthesia care unit (PACU) microsystem. This project took place in a 249-bed hospital in Northern California, which includes 15 post-surgical bays. The PACU primarily serves patients needing acute care post-surgery, with surgical cases handled, including general surgery, plastic surgery, neurosurgery, orthopedic and spine surgery, vascular surgery, and urology.
Interventions: The design phase saw the implementation of three collaborative interventions using the Plan, Do, Study, Act (PDSA) tool. Recognizing gaps in knowledge about SSI Bundle metrics, the team utilized huddles and staff meetings to reinforce and refresh the necessary understanding. Solutions were implemented through team meetings, leader rounding, Kamishibai cards, and direct report rounding, fostering a sense of teamwork and shared responsibility.
Measures: The project's outcome measure was the percentage of compliance in the SSI Monthly Compliance Report, with a target of 90% or higher. To evaluate the intervention, process measures included the percentage of staff adhering to correct temperature documentation, the percentage documenting the use of warming devices, and the percentage of RNs able to explain the post-op warming process. These process measures were collected from KPHC, the SSI Audit Tool, and process observations using Kamishibai cards. The balancing measure considered was the percentage of staff who incur incremental overtime due to strict documentation adherence.
Results: The project, which sought to raise the documentation of post-operative warming from 77% to above 90% by July 31, 2024, has consistently achieved 100% result year-to-date.
Conclusion: The project demonstrated that staff were more likely to follow standards and protocols with thorough education, adequate support, and sufficient equipment. It proved valuable and sustainable, provided ongoing education, and promoted ongoing process observations, particularly for new staff members. The project proved successful with documentation adherence that was consistently achieved at 100% from its initiation this year.
Keywords: post-op warming, kamishibai, education, documentation, adherence, SSI, PDSA
Recommended Citation
Vergel, Dorothy, "An Initiative to Improve SSI Bundle Metrics Adherence Specific to Post-Op Warming and Temperature Documentation Practices in the Post-Anesthesia Care Unit" (2024). Master's Projects and Capstones. 1742.
https://repository.usfca.edu/capstone/1742
