WHO Safe Surgery Checklist

Transcription

1 WHO Safe Surgery Checklist Basia Kutryba,WHO CC Krakow; Gerald Dziekan, Program Coordinator for WHO Safe Surgery; Website:

2 3,865 hospitals representing 122 countries have registered as Safe Surgery Saves Lives Participating Hospitals countries have dedicated resources to implement the WHO Surgical Safety Checklist at a national level. Safe Surgery Saves Lives Newsletter published by the Safe Surgery Saves Lives Team WHO Patient Safety Programme Harvard School of Public Health

3 How Hazardous is Health Care? Five System Barriers to Achieve Ultrasafe Healthcare, R.Amalberti, Y.Auroy, D.Berwick, P.Barach; Annals of Internal Medicine, May 3, 2005 vol.142 no

4 Patient Safety % acute admissions USA 3.7% Australia 16.6% England 10.8% Denmark 9% New Zealand 12.9% Canada 7.5% Japan 11%

5 Where will we be in five years? Patients can expect cleaner care through improved hand hygiene Surgery is safer with the use of the surgery checklist Learning is broader with improved global knowledge management and partnership Patients are partners in preventing avoidable harm in the health care setting

6 The Surgical burden Estimated 234 million major operations performed worldwide each year vs.136 million births 1 in 25 people Estimated 25% of inpatient surgery followed by complications app. 7 million disabling complications/year 0.5 5% death after surgery app. 1 million death/year Weiser et al. An estimation of the global volume of surgery: a modeling strategy based on available data. Lancet 2008; 372: Complications rate 3%-17% Death rate 0.4%-0.8% Kable AK, Gibberd RW, Spigelman AD. Int J Qual Health Care 2002;14:

7 Science Daily (Dec. 9, 2007) Surgical Objects Accidentally Left Inside About 1,500 Patients In US Each Year Every year, in the United States about 1,500 people have surgical objects accidentally left inside them after surgery, according to medical studies. About two-thirds of the surgical objects left behind are sponges, which can lead to pain, infection, bowel obstructions, problems in healing, longer hospital stays, additional surgeries and in rare cases, death ( )

8 Surgical Safety Checklist

9 No. Indicator list Name 1 C-section rate 2 Case fatality for stroke 3 Case fatality for AMI 4 Exclusive breastfeeding 5 Operating theatre performance 6 Prophylactic antibiotic use 7 Use of blood components 8 Post-operative thromboembolism 9 AMI patients prescribed aspirin at discharge 10 Day surgery rate 11 Length of stay 12 Smoke free hospital audit 13 Needle-stick injuries

10 The Checklist was piloted in 8 hospitals PAHO I Toronto, Canada EURO London, UK EMRO Amman, Jordan PAHO II Seattle, USA WPRO I Manila, Philippines AFRO Ifakara, Tanzania SEARO New Delhi, India WPRO II Auckland, NZ

11 ...and was found to reduce the rate of postoperative complications and death by more than one-third! Haynes et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. New England Journal of Medicine 360: (2009)

12 Results: All sites Baseline Checklist P value Cases Death 1.5% 0.8% Any Complication 11.0% 7.0% <0.001 SSI 6.2% 3.4% <0.001 Unplanned Reoperation 2.4% 1.8% Haynes et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. New England Journal of Medicine 360: (2009)

13 Survey of staff at pilot sites 79% thought it easy to use 79% thought it improved care 84% thought it improved communication 78% thought it reduced errors 93% would want the checklist used if they were having surgery

14 What the checklist is NOT A piece of paper A panacea to all problems of surgical safety A regulatory tool Set in stone

15 "Checklists play a role, but they're not a magic bullet," said James P. Bagian, MD, chief patient safety officer at the Veterans Health Administration, where he helped pioneer the use of checklists in medicine to avoid wrong-site surgeries. "We use them to drive a conversation, but that conversation needs the participation of the people involved in a meaningful way. If it's just going to be done pro forma, you might as well talk about who did what in snowboarding in the Olympics

16 Implementation Build a team (anesthesia, nursing, and surgery) Find a champion in each discipline Buy-in from clinical and administrative leadership Complex interventions involving structural, process, and behavioral changes Checklists cannot compensate for systems that will not change to improve safety Modify the Checklist and trial it Local relevance Brevity Start small start where it is easy Lead by example

17 Implementation Checklist requires strong leadership from all clinical disciplines (Surgeons, Nurses, Anesthesiologists, others) Identify champions from these groups and mobilize Local experience is key Interdisciplinarity Need to break borders between different clinicians Avoidance of the silo principle Leveling of hierarchy Contributions are necessary from all members of team

18 When We Use the Checklist: Does the entire team stop all activity at the three critical points in care? Does the team verbally confirm each item on the Checklist? Are the items verified without reliance on memory? Does the Checklist promote communication?

19 Implementation Policies must change Checklists are complex interventions involving structural, process, and behavioral changes Checks by operative teams cannot compensate for systems that will not change to improve safety Support from hospital and OR administration will help Lead by example Use the checklist in your operations Demonstrate utility among your peers Combine formal educational sessions and materials with mentoring Be willing to be self-reflective

20 Modification One size doesn t fit all Local adaptation Keep it short (each section < 1min) Don t remove teamwork items Introduction of team members by name and role Review of specific patient concerns Discussion of key concerns before patient leaves the OR

21 Measurement Know where you are Collect data processes and outcomes Before - after Continuous vs. episodic, e.g. fixed collection period (1 month) Example of measures to observe Process indicators # of times antibiotic prophylaxis wasn t giving within 60 minutes # of times blood wasn t available # of times circulating nurse goes for supplies Case length Length of operating day Outcomes indicators from charts Wound infections Surgical deaths Unplanned Return to the operating theatre Anecdotal Evidence Collect stories of when the Checklist makes a difference in your operating theatres

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25 Adult Cardiac Surgery Check List (Template) Before Induction SIGN IN PATIENT HAS CONFIRMED IDENTITY SITE PROCEDURE CONSENT SITE MARKED/NOT APPLICABLE ANESTHESIA SAFETY CHECK COMPLETED PULSE OXIMETER ON PATIENT AND FUNCTIONING UNOS ID# (IF APPLICABLE) DOES PATIENT HAVE A KNOWN ALLERGY? NO YES DRUGS LATEX OTHER DIFFICULT AIRWAY/ASPIRATION RISK? NO YES, AND EQUIPMENT/ASSISTANCE AVAILABLE RISK OF >500ML BLOOD LOSS OR (7ML/KG IN CHILDREN)? NO YES, AND ADEQUATE INTRAVENOUS ACCESS AND FLUIDS PLANNED BLOOD AVAILABLE SIGN (NURSING): SIGN (ANESTH): Before Skin Incision TIME OUT CONFIRM ALL TEAM MEMBERS HAVE INTRODUCED THEMSELVES BY NAME AND ROLE: SURGEON, ANESTHESIA PROFESSIONAL AND NURSE VERBALLY CONFIRM PATIENT PROCEDURE PERFUSION TEMP PREP PROTOCOL ANTICIPATED CRITICAL EVENTS SURGEON REVIEWS: CRITICAL OR UNEXPECTED STEPS, AIRWAY OR VENTILATORY ISSUES OPERATIVE DURATION, ANTICIPATED BLOOD LOSS? FLUID MANAGEMENT ANESTHESIA TEAM REVIEWS: ANY PATIENT-SPECIFIC CONCERNS? NURSING TEAM REVIEWS: HAS STERILITY (INCLUDING INDICATOR RESULTS) BEEN CONFIRMED? ARE THERE EQUIPMENT ISSUES OR ANY CONCERNS? HAS ANTIBIOTIC PROPHYLAXIS BEEN GIVEN WITHIN THE LAST 60 MINUTES? YES NOT APPLICABLE DVT PROPHYLAXIS? COMPRESSION STOCKINGS SQ HEPARIN IS ESSENTIAL IMAGING DISPLAYED? YES NOT APPLICABLE SIGN (SURG): SITE/SIDE POSITION BLOOD BORN PATH IMPLANTS AND EQUIP. NURSE VERBALLY CONFIRMS WITH THE TEAM: NAME OF THE PROCEDURE THAT INSTRUMENT, SPONGE AND NEEDLE COUNTS ARE CORRECT OR NOT APPLICABLE POST PUMP ABX MEDICATION/DRIPS HOW THE SPECIMEN IS LABELLED including PATIENT NAME WHETHER THERE ARE ANY EQUIPMENT PROBLEMS TO BE ADDRESSED SURGEON, ANESTHESIA PROFESSIONAL AND NURSE Before Patient Leaves Room SIGN OUT REVIEW THE KEY CONCERNS FOR RECOVERY AND MANAGEMENTOF THIS PATIENT SIGN (NURSING): SIGN (SURG):

26 General Thoracic Surgery Check List (Template) Before Induction SIGN IN PATIENT HAS CONFIRMED IDENTITY SITE PROCEDURE CONSENT SITE MARKED/NOT APPLICABLE H & P CURRENT ANESTHESIA SAFETY CHECK COMPLETED PULSE OXIMETER ON PATIENT AND FUNCTIONING UNOS ID# (IF APPLICABLE) DOES PATIENT HAVE A KNOWN ALLERGY? NO YES DRUGS LATEX OTHER DIFFICULT AIRWAY/ASPIRATION RISK? NO YES, AND EQUIPMENT/ASSISTANCE AVAILABLE RISK OF >500ML BLOOD LOSS OR (7ML/KG IN CHILDREN)? NO YES, AND ADEQUATE INTRAVENOUS ACCESS AND FLUIDS PLANNED BLOOD AVAILABLE OR NA Before Skin Incision TIME OUT CONFIRM ALL TEAM MEMBERS HAVE INTRODUCED THEMSELVES BY NAME AND ROLE SURGEON, ANESTHESIA PROFESSIONAL AND NURSE VERBALLY CONFIRM PATIENT SITE PROCEDURE ANTICIPATED CRITICAL EVENTS SURGEON REVIEWS: CRITICAL OR UNEXPECTED STEPS, AIRWAY OR VENTILATORY ISSUES OPERATIVE DURATION, PROSTHETICS, ANTICIPATED BLOOD LOSS? FLUID MANAGEMENT ANESTHESIA TEAM REVIEWS: ANY PATIENT-SPECIFIC CONCERNS? NURSING TEAM REVIEWS: HAS STERILITY (INCLUDING INDICATOR RESULTS) BEEN CONFIRMED? ARE THERE EQUIPMENT ISSUES OR ANY CONCERNS? HAS ANTIBIOTIC PROPHYLAXIS BEEN GIVEN WITHIN THE LAST 60 MINUTES? YES OR NA DVT PROPHYLAXIS? COMPRESSION STOCKINGS SQ HEPARIN IS ESSENTIAL IMAGING DISPLAYED? YES NOT APPLICABLE Before Patient Leaves Room SIGN OUT NURSE VERBALLY CONFIRMS WITH THE TEAM: NAME OF THE PROCEDURE THAT INSTRUMENT, SPONGE AND NEEDLE COUNTS ARE CORRECT OR NOT APPLICABLE HOW THE SPECIMEN IS LABELLED CHECK PATIENT NAME NUMBER OF SPECIMENS TISSUE TYPE/ NODAL STATIONS WHETHER THERE ARE ANY EQUIPMENT PROBLEMS TO BE ADDRESSED SURGEON, ANESTHESIA PROFESSIONAL AND NURSE REVIEW THE KEY CONCERNS FOR RECOVERY AND MANAGEMENT OF THIS PATIENT SIGN (NURSING): SIGN (ANESTH): SIGN (SURG): SIGN (NURSING): SIGN (SURG):

27 Survey at registered hospitals (Summer 2010) To Learn: If hospitals have implemented the Checklist Extent and quality of Checklist use Barriers that hospitals have faced and strategies that they utilized to overcome them Local Checklist adaptation

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29 Data Collection at a National Level "Surgical Vital Statistics" Number of surgical procedures performed in the operating theatre per 100,000 population per year Number of Operating Theatres per 100,000 population Number of surgeons per 100,000 population Number of anesthesia professionals per 100,000 population Day-of-surgery mortality rate Postoperative in-hospital mortality rate Weiser et al. Standardised metrics for global surgical surveillance. Lancet 2009; 374: