Improving Patient Outcomes in Surgery: Implementation of the WHO Safety Checklist Using a Knowledge Translation Approach

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1 Improving Patient Outcomes in Surgery: Implementation of the WHO Safety Checklist Using a Knowledge Translation Approach Associate Professor Brigid Gillespie PhD RN FACORN NHMRC TRIP Fellow, NHMRC Centre for Research Excellence in Nursing Centre for Health Practice Innovation GRIFFITH UNIVERSITY b.gillespie@griffith.edu.au

2 Acknowledgements National Health & Medical Research Council: NHMRC Translating Research Into Practice (TRIP) Fellowship Griffith University & Gold Coast University Hospital Collaborative Grant Scheme Professor Andrea Marshall, TRIP Mentor Gold Coast University Hospital Stakeholder participants

3 Background Approx. 40% adverse events (AE) occur in the operating room (OR), with > 50% AE avoidable (De Vries et al, 2008) Mortality rates associated with surgery estimated at 0.4% to 0.8% (Yi et al, 2002) In response to AE rates, the World Health Organisation (WHO) 2008 Safe Surgery Saves Lives campaign (WHO, 2008) Introduction of WHO Surgical Safety Checklist (SSC) in 122 countries and over 4,100 hospitals worldwide (WHO, 2013)

5 Why is SSC important? Improves teamwork and patient safety in the OR (Spiess, 2013) An aid memoir for including key information or actions that may otherwise be overlooked or forgotten (Low et al, 2012) Results of several meta analyses suggest associations with SSC use and reductions in mortality, wound infection, pneumonia, blood loss, and any complication (Bergs et al, 2014; Bouchard et al, 2012; Gillespie et al, 2014)

6 Evidence practice gap How consistently is the WHO SSC used? Barriers and facilitators to implementation and sustained use of SSC are contextual (Foucade et al, 2012) Australian observational study found that only 20/160 (12.5%) of surgical teams actually performed timeout (2 nd phase of SSC) (Gillespie et al, 2012) Haphazard introduction of SSC, organisational and team culture (Gillespie et al, 2010a; Gillespie et al, 2010b) SSC a tick and flick exercise (Foucade et al, 2012) Perceived duplication of information, redundancy Lack of leadership and ownership of the process

7 Realist evaluation Purpose: To explain when, why and how implementation strategies worked, or did not work well What aspects of checklist implementation determined success or failure in various situations and contexts? Results: 35 studies using a surgical safety checklist included Despite implementation strategies, checklist compliance (i.e., completions and item usage) rates still variable ranging from 19% to 100% Longitudinal decline in checklist adherence rates

8 Implementation Number of studies (n=35) Reported in: Types of interventions n* % Opinion leaders Bittle; Bohmer et al; Conley et al; Stryer et al; Yuan et al. Modelling Bohmer et al; Conley et al; Haugen et al; Norton & Rangel. Widespread communication Bashford et al; Bell & Pontin; Berrisford et al.; Haugen et al; Haynes et al; Kearns et al; Levy et al; Norton & Rangel; Stryer et al; van Klei et al; van Klei et al. Educational sessions Askarian et al; Bashford et al; Bliss et al; Bohmer et al; de Vries et al; Gillespie et al; Haugen et al; Haynes et al; Helmio et al; Kwok et al; Levy et al; Royal Bolton; Sparkes & Rylah; Stryer et al; Kasatpibal et al; Yuan et al. Self assessment Bashford et al. Clinical training Bashford et al; Berrisford et al.; Bittle; Calland et al.; Haugen et al; Haynes et al; Kwok et al; Norton & Rangel; Sewell et al; Vats et al; Yuan et al. Audit and feedback Bashford et al; Berrisford et al.; Bittle; Bliss et al; Haugen et al; Truran et al; van Klei et al. Environmental redesign Mainthia et al. Rewards / incentives 0 0 Coercion 0 0 Restrictions / sanctions 0 0 Performance data Askarian et al; Berrisford et al.; Bliss et al; de Vries et al; Haynes et al; Kwok et al; Sewell et al; Yuan et al. Approach Planned Askarian et al; Bashford et al; Bell & Pontin; Berrisford et al.; Bittle; Bliss et al; Conley et al; Haugen et al; Haynes et al; Helmio et al; Kwok et al; Norton & Rangel; Royal Bolton; Stryer et al; van Klei et al; Yuan et al. Limited / none Bohmer et al; Calland et al.; Gillespie et al; Levy et al; Mainthia et al; Pe rez Guisado; Sewell et al; Sparks et al; Takal et al; Vats et al; Kearns et al; Levy et al; Sewell et al; Sparkes & Rylah; Takala et al; Rydenfalt et al.; Truran et al; Vats et al; Vogts et al; Kasatpibal et al. Evidence of tailoring Foucade et al.

9 Key findings Sustained use of surgical checklists is discipline specific and likely successful when medical staff are actively participating and leading the implementation process. Involving clinicians in adapting the checklist to their context and encouraging them to reflect on and evaluate the implementation process enables greater participation and ownership Research Centre for Clinical and Community Practice Innovation

10 Research Centre for Clinical and Community Practice Innovation

11 Study methods Methodology: Knowledge translation (KT) perspective, i.e., methods that support research use and uptake Aim: Assess the feasibility and acceptability of a multifaceted intervention tailored to promote the use of WHO SSC Design: 3 phased study Data collection: Structured observations of 20 surgical teams (phases 1 and 3) Stakeholder interviews anaesthetists, surgeons, nurses, educators, managers, healthcare consumers (phases 1 and 3)

12 Phase 2: KT intervention Stakeholder engagement at all levels, including healthcare professionals working in various roles in surgery, and healthcare consumers Feasibility will be assessed relative to: a. the time required during implementation, and b. the human and material resources needed to sustain it in practice. If additional time and personnel are required Acceptability will be assessed using compliance and usage rates (obtained through observational audit). Following piloting, the implementation intervention will be tailored to the contextual nuances of the environment

13 Phase 1 Results (10 cases observed) Sign In Time Out Sign Out Present % % % Anaesthetic Consultant Surgical Consultant Scout or Scrub Nurse Anaesthetic Nurse Initiated % % % Anaesthetic Consultant Surgical Consultant Scout or Scrub Nurse Anaesthetic Nurse Participated % % % Anaesthetic Consultant Surgical Consultant Scout or Scrub Nurse Anaesthetic Nurse

14 Phase 1 Results (10 cases observed) SSC Domain Total Item Completion/(Total Number of Items in Domain x Total Number of Cases Observed) % Sign In 99/ Time Out 57/ Sign Out 0/70 0.0

15 Initial impressions Team members performed sign in phase independently of each other (not in the room at same time) Items on the SSC are confirmed only when they directly relate to patient/case etc Surgical consultants not always present at timeout Sign out not observed Checks conducted independently in relation to pathology and specimens between scrub and scout rather than confirming with other team members

16 KT Model COM B system framework (Michie et al. 2011, Implementation Science 6: 42: pp. 4)

17 Interview questions Skills and knowledge: What is you understanding of the purpose of the SSC? Can you describe how you do the SSC? Beliefs about consequences: What do you think might happen of the SSC is not done? How do you feel if the SSC or particular items are not used? Beliefs about capacity: How easy or difficult is the SSC to do? What would help you to perform certain aspects better? Environmental context: In what ways do you think the organisation regulates behaviour in relation to the use of the SSC? Do you think that the SSC should be standardised? (Adapted from Michie et al, 2005)

18 Preliminary findings (n=37) Emphasis of importance of activities based on task or role orientation Disparate expectations held by team members Time a major barrier to performing checks Nursing and anaesthetic assessments occur independently of each other, nurses anticipate problems by identifying information deficits Strong leadership from someone who does not sacrifice accuracy for speed Doing the SSC perceived as a forced conversation Lack of definitions for items in sign out phase Not doing sign out does not impact on quality of the handover from OR to recovery room

19 Implications for implementation Education is not the panacea for successful implementation! Interventions to change professional behaviour have modest effects depending on how they are selected, e.g., selection based on disciplinary discretion rather than on explicit rationale that takes targeted behaviour and context into account It important to examine checklist adherence when evaluating any primary or secondary outcomes credited to be the result of using checklists as a safety tool Not about what is done but more about how all of the strategies interact multifaceted intervention

20 Thank you!

Associate Professor Brigid Gillespie discloses that she is a member of the AORN Journal

Associate Professor Brigid Gillespie discloses that she is a member of the AORN Journal Brigid M. Gillespie PhD RN Associate Professor NHMRC Research Centre for Excellence in Nursing Research Centre for Health Practice Innovation Griffith Health Institute Griffith University Gold Coast Campus