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Experience with the implementation of the WHO checklist and briefing in the operating theatre

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Experience with the implementation of the WHO checklist and briefing in the operating theatre. Krishna Moorthy. IV Internacional Conference on Patient Safety. (Madrid, Ministry of Health and Consumer Affairs, 2008)

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Experience with the implementation of the WHO checklist and briefing in the operating theatre

  1. 1. Improving safety and teamwork in the operating theatre Krishna Moorthy Senior Lecturer and Consultant Upper GI Surgeon
  2. 2. Incidence of Surgical Adverse Events Country/ Study N Year AE Surgical AE Preventable Harvard (HMPS) 30,195 1991 3.7% 50% 50% USA (UT/CO) 15,000 2000 2.9% 50% 50% UK 1014 2001 10.8% 71.8% 55%
  3. 3. Wrong site/ operation/ patient Scale of the problem • 1 in 50,000 procedures in the USA • 1500 to 2500 cases/ year Kwaan et al. Arch Surg. 2006;141: 353-8
  4. 4. Rare!!!! Wrong site surgery- 2500 per year of 75 million procedures in the US-0.0003% 10 million flights per year in the US In aviation- this would translate to 1 crash per day
  5. 5. SSI Bratzler, D. W. et al. Arch Surg 2005;140:174-182.
  6. 6. Teamwork Pre-op Intra-op Post-op Surg Urol Surg Urol Surg Urol Equip 56% 61% 82% 91% 89% 95% Comm 61% 71% 55% 57% 90% 84% Patient 90% 94% 93% 93% 97% 92%
  7. 7. Team tas k P f d N 5 Surgeon briefs team abo ut proced ure 24 76 11 Team communicate about Antibiotic prop hylaxis 32 68 The team discussed equipment needs- 18-22% of cases Antibiotic prophylaxis was discussed- 32% cases DVT prophylaxis was checked- 10% of cases Scrub nurses informed surgeon of swab, instrument and needle count in 16% of cases although performed counts in 100% of cases Team confirmed patient identity, procedure and site- 8- 16% of cases
  8. 8. SURGICAL SAFETY CHECKLIST (DRAFT) SAFE SURGERY SAVES LIVES GLOBAL PATIENT SAFETY CHALLENGE WORLD HEALTH ORGANISATION SIGN IN – PRIOR TO INDUCTION OF ANAESTHESIA, VERIFY: □ PATIENT CONFIRMED IDENTITY, SITE, PROCEDURE AND CONSENT □ SITE MARKED/NOT APPLICABLE □ ANAESTHESIA SAFETY CHECK COMPLETED □ PULSE OXIMETER ON PATIENT AND FUNCTIONING DOES PATIENT HAVE A: KNOWN ALLERGY □ NO □ YES DIFFICULT AIRWAY/ASPIRATION RISK □ NO □ YES, AND NEEDED EQUIPMENT AND ASSISTANCE AVAILABLE RISK OF >500CC BLOOD LOSS (7CC/KG IN CHILDREN) □ NO □ YES, AND ADEQUATE IV ACCESS AND FLUIDS PLANNED TIME OUT – PRIOR TO SKIN INCISION: □ CONFIRM ALL TEAM MEMBERS HAVE INTRODUCED THEMSELVES BY NAME D ROLE □ SURGEON, ANAESTHETIST AND NURSE VERBALLY CONFIRM PATIENT NAM OCEDURE, AND SITE ANTICIPATED CRITICAL E □ SURGEON REVIEWS: W IVE DURATION? ANTICIPATED BLOOD LOSS? □ ANAESTHESIA TEAM R - □ NURSING TEAM REVIE ISSUES OR ANY CONCERNS? ANTIBIOTIC PROPHYLAXIS GI □ YES □ NOT A ESSENTIAL IMAGING DISPLAYED □ YES □ NOT APPLICABLE SIGN OUT – PRIOR TO THE PATIENT LEAVING THE OPERATING TH TRE: NURSE VERBALLY CONFIRMS WITH THE TEAM: □ THE NAME OF THE P □ THAT INSTRUMENT, CABLE) □ HOW THE SPECIMEN □ WHETHER THERE AN SURGEON, ANAESTHESIA PROFESSIONAL AND NURSE REVIEW: □ WHAT ARE THE KEY CONCERNS FOR RECOVERY AND MANAGEMENT O IS PATIENT? _______________________________ ______________ SIGNATURE (ON BEHALF OF ENTIRE TEAM DATE FOR PURPOSES OF QUALITY IMPROVEMENT ONLY) •Patient identification •Highlights anaesthetic risks •Allergic reactions •Patient identification •Highlights anaesthetic risks •Allergic reactions • Wrong site surgery • antibiotic prophylaxis • Equipment problems • shared mental model • specimen mislabelling • counts
  9. 9. 8 Pilot Sites PAHO II Seattle, USA London, UK EURO EMRO Amman, Jordan WPRO I SEARO AFRO PAHO I Toronto, Canada New Delhi, India Manila, Philippines Ifakara, Tanzania WPRO II Auckland, NZ
  10. 10. WHO Checklist project Data collection 360 patients Checklist Data collection 360 patients • Measures: Processes and clinical outcome (complications and LOS)
  11. 11. I/V antibiotics Pre-checklist Post-checklist Antibiotics 80% 20% Given Not given
  12. 12. Antibiotic timing Pre-checklist Post-checklist 52% 14% 3% 31% 71% 7% 2% 20% in time after incision over 60 min No antibiotics
  13. 13. Patient outcomes 15 45 4 7 15 1 0 5 10 15 20 25 30 35 40 45 50 Pre‐checklist Post‐checklist Surgical site Other Death infection complications
  14. 14. g spec ig 5 Surgeon briefs team abo ut proced ure 24 76 11 Team communicate about Antibiotic prop hylaxis 32 68 The team discussed equipment needs in 70% of cases (vs 20%) Antibiotic prophylaxis was discussed in all cases (vs 32%) DVT prophylaxis was discussed in only 50% of cases (vs 10%) Scrub nurses informed surgeon of swab, instrument and needle count in 85% (vs 16%) of cases although performed counts in 100% of cases Team confirmed patient identity, procedure and site in100% of cases (vs 15%)
  15. 15. Benefits of the WHO checklist • Reduces assumptions “When we have an adverse event and we talk to people, they will say....I assumed that somebody had checked” • Adds redundancy to safety processes “There is no excuse for getting halfway through the operation and somebody discovering that we don’t have the right instruments. It is unthinkable but it still happens ”
  16. 16. • Improves teamwork and communication “I always wondered who these people were in the theatre that I was working with sometimes but being busy you wouldn’t approach them but you know that they are part of team.........now ( with WHO checklist use) I understand their role better” “There is a terrible tendency for the team actually not being a team----realisation that we are a team”
  17. 17. Compliance 18
  18. 18. Reasons • Effectiveness? • Hierarchy • The timing of the checks • Viewed as increased work load- yet another checklist • Only if everybody is on board • No improvement perceived in surgical team efficiency (Interview study underway, Imperial College, 2008)
  19. 19. Perceived limitations “ Has it improved equipment availability, has it improved anticipation of problems and so on..... Rather than the actual...... Has right box been ticked” “It sounds a bit artificial sometimes. Its trying to be everything to every nation and to every standard of medicine” “It is a very different way of communication for many people”
  20. 20. Increase uptake and compliance • Demonstration of its effectiveness “ If you can demonstrate to a surgeon that 10 minutes spent in the beginning of the list-----will actually go smoothly without headaches......and they may get an extra case done” • Organisational modification • Organisational and clinical leadership • Training- changing the culture • Public awareness and media pressure
  21. 21. UK- next steps
  22. 22. Issues • Content of the checklist • Ownership and signatures • In patients notes • Mandated or not?
  23. 23. SURGICAL SAFETY CHECKLIST (DRAFT) SAFE SURGERY SAVES LIVES GLOBAL PATIENT SAFETY CHALLENGE WORLD HEALTH ORGANISATION SIGN IN – PRIOR TO INDUCTION OF ANAESTHESIA, VERIFY: □ PATIENT CONFIRMED IDENTITY, SITE, PROCEDURE AND CONSENT □ SITE MARKED/NOT APPLICABLE □ ANAESTHESIA SAFETY CHECK COMPLETED □ PULSE OXIMETER ON PATIENT AND FUNCTIONING DOES PATIENT HAVE A: KNOWN ALLERGY □ NO □ YES DIFFICULT AIRWAY/ASPIRATION RISK □ NO □ YES, AND NEEDED EQUIPMENT AND ASSISTANCE AVAILABLE RISK OF >500CC BLOOD LOSS (7CC/KG IN CHILDREN) □ NO □ YES, AND ADEQUATE IV ACCESS ND FLUIDS PLANNED TIME OUT – PRIOR TO SKIN INCISION: □ CONFIRM ALL TEAM MEMBE LE □ SURGEON, ANAESTHETIST URE, AND SITE ANTICIPATED CRITICAL EV □ SURGEON REVIEWS: W URATION? ANTICIPATED BLOOD LOSS? □ ANAESTHESIA TEAM R - □ NURSING TEAM REVIE T ISSUES OR ANY CONCERNS? ANTIBIOTIC PROPHYLAXIS GIV □ YES □ NOT AP ESSENTIAL IMAGING DISPLAYED □ YES □ NOT APPLICABLE SIGN OUT – PRIOR TO TH : NURSE VERBALLY CONFIRM □ THE NAME OF THE PR □ THAT INSTRUMENT, S LE) □ HOW THE SPECIMEN IS □ WHETHER THERE ANY E SURGEON, ANAESTHESIA PROFESSIONAL AND NURSE REVIEW: □ WHAT ARE THE KEY CONCERNS FOR RECOVERY AND MANAGEMENT HIS PATIENT? _______________________________ ______________ SIGNATURE (ON BEHALF OF ENTIRE TEAM DATE FOR PURPOSES OF QUALITY IMPROVEMENT ONLY) Drop pulse oximetryDrop pulse oximetry checks • Prior to draping •Two identifiers •Add DVT prophylaxis check • Temperature maintenance check •Flexibility to add specialty specific checks • Prior to closure of skin incision
  24. 24. Make it ‘stick’- national campaigns • Existing systems for prevention of wrong site surgery • Improve compliance with High Impact Intervention #4 (reducing SSI) of the Saving Lives Campaign • Prevention of DVT
  25. 25. Acknowledgments • Amit Vats, Kamal Nagpal- research fellows • Boston- Dr Atul Gawande, Tom Weiser, Alex Haynes, Dr Bill Berry • World Health Organisation (WHO) • Rachel Davies • Prof Charles Vincent • Prof Lord Ara Darzi

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