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University of Colorado Hospital

Focus-PDCA
Performance Improvement Team Worksheet

Department__AIP PACU_____________ Date12/2013_____________
Primary Contact Person_Miranda Bishop Extension__86203___

(F) Find a Process to Improve (name the process, describe the beginning and ending steps in
the process, name the customers served; state why it is important to work on this now).

Opportunity Statement

Patients arrive in the PACU from the OR after thoracic surgery in a great deal of pain. Most
patients are not expecting that amount of pain and others are not expecting the location
(i.e. shoulder). There needs to be a protocol for pain management for cardiothoracic
patients that helps to ease their pain without over sedating them. It is important to
approach this because it impacts not only patient satisfaction, but the healing process for
these patients.


Circle all that apply:
Dimension of Performance: Dimensions of health care performance are those definable,
preferably measurable, attributes of the system that are related to its functioning to maintain,
restore, or improve health care.
- Efficiency - Safety
- Staff Satisfaction - Effectiveness
- Patient Centeredness - Continuity

Prioritization:
- High Risk - High Impact on Performance
- High Volume - High Potential for Improvement
- Problem Prone - Supports Critical Success Factors
- Low Volume - Patient Safety

Other________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

(O) Organize a team that knows the process:
List Team Members:

Acute Pain Service: Dr. Fiegel, Robert Montgomery, CNS,
Cardiothoracic Surgery: Dr. Mitchell, Dr. Weyant, Dr. Meguid, Dr. Mauchley
PACU RN: Miranda Bishop, RN

(C) Clarify the current knowledge
What do we know about the process?

Currently, when patients arrive in the PACU from OR after thoracic surgery with pain, they are
medicated in similar pattern as any other surgical patient. They are given titrated amounts of
Fentanyl and Dilaudid at nurse discretion.

(U) Understand sources of variation:
Why are we looking at this process? Why is the process not going the way planned?

The amount of narcotic given to patients can cause them to become drowsy and more sedated.
This would cause impaired respiratory function leading to atelectasis or pneumonia, thus,
decreasing healing after surgery. Patients are also given narcotics for referred ipsilateral should
pain when research shows that non-opioid analgesic as an adjunct can better treat this specific
type of pain.

(S) Select the improvement:

Collaborated with Acute Pain Service and Cardiothoracic Surgery to establish a protocol for pain
management in thoracotomy patients including non-opioids and opioids.

(P) Plan the improvement:

Staff completed a questionnaire for thoracic surgery patients that they took care of identifying
their pain management in the PACU. The results were compiled and concluded that majority of
patients were receiving only narcotics. Upon meeting with Acute Pain Service and Cardiothoracic
Surgery, a pain management protocol was created with a multimodal opioid and non-opioid
approach for thoracic surgery patients in all phases of care within the hospital.


(D) Implement the improvement:

PACU staff was educated on the new protocol via PowerPoint presented by PACU RN Miranda
Bishop. Acute Pain Service met with Epic and submitted the suggested changes for a new
protocol. The protocol went live in Epic in August. There is a set of pre-checked and optional
check boxes for anesthesia and cardiothoracic residents to complete prior to the patients surgery
and this protocol will apply throughout the entire hospitalization.

(C) Check the results:

Staff was asked to complete the same questionnaire concerning the pain management of the
thoracic surgery patients. Results show that a more multimodal approach was utilized making
pain and sedation scores lower than prior to the protocol.

(A) Act to hold the gain:

Ongoing education with be provided to staff on the use of the Thoracic Analgesia protocol. I will
coordinate with the nurse educator to ensure the protocol will be included in new staff orientation.

Repeat PDCA as needed and maintain documentation in your department.

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