August 5, 1997 · What we did at UHN • Pilot at TGH—non‐cardiac – revised checklist • 500...

August 5, 1997August 5, 1997

Pilotfatigue

Pilotfatigue

Glidescopenot working

Pilotfatigue


Decisionfor

Visual

Pilotfatigue


Decisionfor

Visual*Failure

ofCulture

The Pyramid The Pyramid ……andand……The PowerThe Power--DistanceDistanceIndexIndexPilots

E v e r y o n e E l s e

The Pyramid The Pyramid ……and..and..The PowerThe Power--DistanceDistanceIndexIndexPilots

SurgeonsAnesthesiologists

E v e r y o n e E l s e

The Surgical patient The Surgical patient ……2010 2010 vsvs 19901990

The Surgical patient The Surgical patient ……2010 2010 vsvs 19901990

•• Patient expectations especially in CanadaPatient expectations especially in Canada

The definition of a Canadian:The definition of a Canadian:

A disarmed American A disarmed American with healthcarewith healthcare

comprehensive, universal, portablecomprehensive, universal, portableaccessible, provincial administrationaccessible, provincial administration

The Surgical patient …2009 vs 1989

• Patient expectations especially in Canada

• Awareness of patient safety … PROFILE

The Surgical patient …2009 vs 1989


•• Awareness of patient safety Awareness of patient safety …… PROFILEPROFILE

•• More complex patients every yearMore complex patients every year

•• MedicoMedico‐‐legal implications significantlegal implications significant

•• Modelling of Modelling of patient care processespatient care processes after the after the

auto industry, and modelling of auto industry, and modelling of patient safetypatient safety

after the airline industryafter the airline industry

•• SAME DAY ADMIT**SAME DAY ADMIT**

Change is difficult!Change is difficult!

The Surgical patient The Surgical patient ……2009 vs 19892009 vs 1989


•• Awareness of patient safety Awareness of patient safety …… PROFILEPROFILE

•• More complex patients every yearMore complex patients every year

•• MedicoMedico‐‐legal implications significantlegal implications significant

•• Modelling of Modelling of patient care processespatient care processes after the after the

auto industry, and modelling of auto industry, and modelling of patient safetypatient safety

after the airline industryafter the airline industry

•• SAME DAY ADMIT**SAME DAY ADMIT**

Change is difficult!Change is difficult!

ItIt’’s about culture change and

s about culture change and

looking after the little things!


The beast needs a wakeup call!The beast needs a wakeup call!

Safe Surgery ChecklistSafe Surgery Checklist

Bryce Taylor MDBryce Taylor MDHospital Authority ConventionHospital Authority Convention

Hong KongHong KongMay 10, 2010May 10, 2010

The

My job todayMy job today

•• Report on WHO SSSL projectReport on WHO SSSL project

•• Results of the WHO checklist studyResults of the WHO checklist study

•• The CPSI effort The CPSI effort

•• Next steps Next steps …… up to you! up to you!

Bryce TaylorBryce TaylorHospital Authority ConventionHospital Authority Convention


Central Problems in Central Problems in Surgical SafetySurgical Safety

1.1. Unrecognized as a public health issueUnrecognized as a public health issue

2.2. Lack of data on surgery and outcomesLack of data on surgery and outcomes

3.3. Failure to use existing safety knowFailure to use existing safety know--howhow

Bottom line: Do we do the Bottom line: Do we do the ““little thingslittle things”” well?well?

The stakes are highThe stakes are high

WHOWHO’’ss 10 Objectives for Safe 10 Objectives for Safe SurgerySurgery

1.1. The team will operate on the The team will operate on the correct patient at correct patient at the correct sitethe correct site..

2.2. The team will use methods known to prevent The team will use methods known to prevent harm from administration of harm from administration of anaestheticsanaesthetics, , while protecting the patient from pain.while protecting the patient from pain.

3.3. The team will recognize and effectively The team will recognize and effectively prepare for lifeprepare for life--threatening loss of threatening loss of airwayairway or or respiratory function.respiratory function.

4.4. The team will recognize and effectively The team will recognize and effectively prepare for risk of prepare for risk of high blood losshigh blood loss..

5.5. The team will avoid inducing an The team will avoid inducing an allergic or allergic or adverse drug reactionadverse drug reaction for which the patient is for which the patient is known to be at significant risk.known to be at significant risk.

WHOWHO’’ss 10 Objectives for Safe 10 Objectives for Safe Surgery (cont.)Surgery (cont.)

6.6. The team will consistently use methods known The team will consistently use methods known to minimize the risk for to minimize the risk for surgical site infectionsurgical site infection..

7.7. The team will prevent The team will prevent inadvertent retention of inadvertent retention of instruments or spongesinstruments or sponges in surgical wounds.in surgical wounds.

8.8. The team will secure and accurately The team will secure and accurately identify all identify all surgical specimenssurgical specimens..

9.9. The team will effectively The team will effectively communicatecommunicate and and exchange critical information for the safe exchange critical information for the safe conduct of the operation.conduct of the operation.

10.10. Hospitals and public health systems will Hospitals and public health systems will establish routine surveillance of surgical establish routine surveillance of surgical capacity, volume and resultscapacity, volume and results..

What problems does this checklist What problems does this checklist address?address?

•• Correct patient, operation and Correct patient, operation and operative siteoperative site

•• Safe Safe AnaesthesiaAnaesthesia and and ResuscitationResuscitation

•• Minimizing risk of infectionMinimizing risk of infection•• Effective TeamworkEffective Teamwork

What is this tool that addresses the 10 What is this tool that addresses the 10 objectives?objectives?

London, UK EURO EMRO

WPRO I

SEARO

AFRO

PAHO I

Amman, JordanToronto, Canada

New Delhi, India

Manila, Philippines

Ifakara, Tanzania

WPRO II

Auckland, NZ

PAHO II

Seattle, USA

The Checklist was piloted in 8 citiesThe Checklist was piloted in 8 cities

What we did at UHNWhat we did at UHN•• Pilot at TGHPilot at TGH——nonnon‐‐cardiac cardiac –– revised checklistrevised checklist•• 500 cases pre500 cases pre‐‐checklist usage with post op datachecklist usage with post op data•• 500 cases using checklist 500 cases using checklist ……monitoring!!monitoring!!•• Identifiers, adverse events during surgery, blood loss, CP Identifiers, adverse events during surgery, blood loss, CP instability, RTS, pneumonia, shock, dialysis, ALOS, instability, RTS, pneumonia, shock, dialysis, ALOS, infection (types)infection (types)

•• Extend use to PMH (2 ORExtend use to PMH (2 OR’’s) one month laters) one month later•• Extend use to TWH one month subsequentlyExtend use to TWH one month subsequently•• Currently all 25,000 operations at UHN/yearCurrently all 25,000 operations at UHN/year•• Electronic confirmation on ORSOSElectronic confirmation on ORSOS•• Ongoing vigilance!!Ongoing vigilance!!•• It needed CEO/Board support, passionate leadership, It needed CEO/Board support, passionate leadership, champions, lots of champions, lots of gruntworkgruntwork

MethodsMethods

~ 500 operations intra~ 500 operations intra-- & & postoppostop complicationscomplications(ACS/NSQIP)(ACS/NSQIP)

1

MethodsMethods



checklistchecklist

1

2

ResultsResults

ResultsResults

~ 8000 operations~ 8000 operations

MorbidityMorbidity MortalityMortality

11% 7%* 11% 7%* (p<.001)(p<.001)

(actualactual 4% reduction)4% reduction)1.5% 0.8%* 1.5% 0.8%* (p<.003)(p<.003)

((actualactual 0.7% reduction)0.7% reduction)

3.2%*3.2%*HICHIC(P<.001)(P<.001)

4.9%*4.9%*LICLICP<.001P<.001

0.3%0.3%HICHIC

nsns

1.1%*1.1%*LICLICP<.006P<.006

TranslationTranslation

The World The World -- 234 million operations/yr234 million operations/yr-- ““millionsmillions”” spared spared compcomp’’nsns-- ““manymany”” lives savedlives saved

TranslationTranslation

The World The World -- 234 million operations/yr234 million operations/yr-- ““millionsmillions”” spared spared compcomp’’nsns-- ““manymany”” lives savedlives saved

Canada - ~ 2,000,000 operations/yr- > 60,000 spared comp’ns- $$$ saved- ~ ? change in mortality

"I cannot recall a clinical care innovation "I cannot recall a clinical care innovation in the past 30 years that has shown results in the past 30 years that has shown results

of the magnitude demonstrated by the of the magnitude demonstrated by the surgical checklist. surgical checklist.

This is a change ready right nowThis is a change ready right nowfor adoption by every hospital for adoption by every hospital

that performs surgery." that performs surgery."

Don BerwickDon Berwick , , IHIIHI

““The estimate that up to 23,000 people died in 2004 The estimate that up to 23,000 people died in 2004 in Canadian hospitals because of preventable adverse in Canadian hospitals because of preventable adverse events is staggering. Checklists in aviation have beenevents is staggering. Checklists in aviation have been

in use pretty well since the Wright brothers.in use pretty well since the Wright brothers.One wonders whether such checklists would haveOne wonders whether such checklists would have

been introduced much earlier in medicine if surgeons been introduced much earlier in medicine if surgeons shared the fate of their patients, as pilots share shared the fate of their patients, as pilots share

that of their passengers.that of their passengers.””

Adrian Adrian BoelenBoelen, retired pilot, Dorval, , retired pilot, Dorval, QueQue

The ChallengeThe Challenge


PerioperativePerioperative staffstaff••NursesNurses••AnesthesiologistsAnesthesiologists••SurgeonsSurgeons••OthersOthers


PerioperativePerioperative staffstaff••NursesNurses••AnesthesiologistsAnesthesiologists••SurgeonsSurgeons••OthersOthers

Standard Standard OperatingOperatingProcedureProcedure

The 7‐step Kotter model of change management

M&M roundsComplications

SepsisDelays

3-15% comp’n rateAvoidable deaths

SurgeonsAnesthetists

NursesCHAMPIONS*Avoid top/down

Engage in WHOExperimental design

FlexibilityModify to fit needs

Plan implementation

CEO support*Board supportWHO deadlinePrevious evidenceLow cost possible

high yieldMarc Auermann*

Educate nurses, surgeonsanesthetists

Division head meetingsEmail reminders, encouragement

Team charter*Report “nice catches”

Any concerns?

Test wkLarge, legible checklistTest week then go-live

Repeated visits, remindersAnswer questions

Responsibility of ALLElectronic record of compliance

Video demonstration“pilot” vs general implement’n

Report on successScientific evidenceCongratulatePartyFurther modifyDATA COLLECTIONEstablish:1. SOP2. CULTURE CHANGE

Implementation of the surgical checklistImplementation of the surgical checklist

M&M roundsComplications

SepsisDelays

3-15% comp’n rateAvoidable deaths

SurgeonsAnesthetists

NursesCHAMPIONS*Avoid top/down

Engage in WHOExperimental design

FlexibilityModify to fit needs

Plan implementation

CEO support*Board supportWHO deadlinePrevious evidenceLow cost possible

high yieldMarc Auermann*

Educate nurses, surgeonsanesthetists

Division head meetingsEmail reminders, encouragement

Team charter*Report “nice catches”

Any concerns?

Test wkLarge, legible checklistTest week then go-live

Repeated visits, remindersAnswer questions

Responsibility of ALLElectronic record of compliance

Video demonstration“pilot” vs general implement’n

Report on successScientific evidenceCongratulatePartyFurther modifyDATA COLLECTIONEstablish:1. SOP2. CULTURE CHANGE

Implementation of the surgical checklistImplementation of the surgical checklist

The key points of the The key points of the ““toolkittoolkit””(use project management if desired)(use project management if desired)

1.1. Prepare and educate Prepare and educate all all stakeholdersstakeholders2.2. Use previous evidence to engage OR staffUse previous evidence to engage OR staff3.3. Develop champions at every levelDevelop champions at every level4.4. Senior management endorsement (Senior management endorsement (not not decree!)decree!)5.5. Customize for your hospital (input from all)Customize for your hospital (input from all)6.6. Implement after a brief Implement after a brief ‘‘practice runpractice run’’-- persist!!persist!!7.7. Repeated visits and remindersRepeated visits and reminders8.8. Monitor, record and publicize compliance (eMonitor, record and publicize compliance (e--))9.9. Monitor and record Monitor and record ‘‘nice catchesnice catches’’, , ‘‘learningslearnings’’10.10.Celebrate and reward successesCelebrate and reward successes11.11. Public reporting (in Ontario)Public reporting (in Ontario)

Surgical Safety Checklist: Canada Final Draft

December 24, 2008

` Briefing - Before induction of anesthesia

Hand-off from ER, Nursing Unit or ICU

All team members introduce themselves by name and role

Anesthesia equipment safety check completed Patient information confirmed

- Identity (2 identifiers) - Consent(s) - Site and Procedure - Site, Side, and Level marked - Clinical documentation

- History and Physical, labs, biopsy, x-rays

Review final test results Confirm essential imaging displayed ASA Class Allergies (drugs, latex) Medications

- Antibiotic prophylaxis: Double dose? - Glycemic control - Beta blockers - Anticoagulant therapy (e.g., Warfarin)?

VTE Prophylaxis - Anticoagulant - Mechanical

Difficult Airway / Aspiration Risk - Confirm equipment / assistance available

Monitoring - Pulse oximetry, ECG, BP, arterial line, CVP, Temperature; urinary catheter draining?

Blood loss - Anticipated to be more than 500 ml (adult) or more than 7 ml/kg (child) - Blood products required and available - Patient grouped, screened, cross matched

Time Out - Before skin incision

Surgeon, Anesthesiologist, and Nurse verbally confirm

- Patient - Site, Side, and Level - Procedure - Antibiotic prophylaxis: Repeat dose? - Final optimal positioning of patient - adequate drying of the skin prep?

“Does anyone have any other questions or concerns before proceeding?”

Debriefing - Before patient leaves the OR

Surgeon reviews with entire team - Procedure - Important intra-operative events - Fluid balance / management

Anesthesiologist reviews with entire team - Important intra-operative events - Recovery plans (including postoperative ventilation, pain management, glucose and temperature)

Nurse(s) review(s) with entire team - Instrument / sponge / needle counts - Specimen labelling and management - Important intraoperative events (including

equipment malfunction) - any concerns re skin integrity?

Changes to postoperative destination?

What are the KEY concerns for this patient’s recovery and management?

Could anything have been done to make this case safer or more efficient?

Incident report to be completed?

Hand-off to PACU / RR, Nursing Unit or ICU

Briefing - Before induction (continued)

Surgeon(s) review(s) - Specific patient concerns, critical steps,

special instruments / implants,

Anesthesiologist(s) review(s) - Specific patient concerns, critical

resuscitation plans, possible MH?

Nurses(s) review(s) - Specific patient concerns, sterility indicator

results, equipment / implant issues - Family and visitors expectations

Patient positioning and support / Warming devices

Communicable disease?

PPE required? N95, isolation cart

Expected procedure time / Postoperative destination

Is this an oncology case?

Surgical Safety Checklist

In the last year at UHNIn the last year at UHN

•• Takes little time, patients satisfiedTakes little time, patients satisfied•• Reminders required less frequently with timeReminders required less frequently with time•• Details Details areare important, and potential problems and important, and potential problems and omissions omissions areare being picked up!being picked up!

•• Significant in startSignificant in start‐‐up time and effort, but up time and effort, but ……•• Costs virtually no money Costs virtually no money •• This is a This is a teamteam‐‐buildingbuilding opportunity!opportunity!•• It can always be changed...itIt can always be changed...it’’s flexible!s flexible!•• The two big issues are The two big issues are culture changeculture change and and

data collection!data collection!

We have foundWe have found……..

““you know only insofar as you can you know only insofar as you can measuremeasure”” Lord KelvinLord Kelvin

The pyramid The pyramid ……andand..The PowerThe Power--DistanceDistanceIndexIndex

The PowerThe Power--DistanceDistanceIndexIndex

The pyramid The pyramid ……and..and..

The Operating Room 2010The Operating Room 2010

What do the UHN OR What do the UHN OR staff think after one staff think after one

year of using theyear of using thesurgical checklist?surgical checklist?

q1q1

•• Do you think the use of Do you think the use of the checklist has the checklist has improved patient safety improved patient safety at UHN?at UHN?

0123456789

10

nurseanesthsurgeon

Not at all

To somedegree

Yes!

q2q2•• Do you find the conduct Do you find the conduct of the checklist of the checklist inconvenient?inconvenient?

0123456789

10

nurseanesthsurgeon

Not at all

To somedegree

Yes!

q3q3

•• How much time does How much time does the checklist take?the checklist take?

0123456789

10

nursesanesthsurgeon

minutes

q5

•• If you were to undergo If you were to undergo surgery, would you surgery, would you want the checklist to be want the checklist to be used?used?

0123456789

10

nursesanesthsurgeon

Don’tcare

Moderately positive

Yes!

q8q8

•• Are you comfortable in Are you comfortable in reminding other reminding other members of the team members of the team to carry out the to carry out the checklist?checklist?

0123456789

10

nursesanesthsurgeon

Very uncomfortable

Somewhatuncomfortable

Verycomfortable

q11q11

•• Do you think that use of Do you think that use of the checklist generally the checklist generally has improved has improved communication among communication among members of the OR members of the OR team?team?

0123456789

10

nursesanesthsurgeon

Not at all

somewhat

Yes!

……a few thoughts a few thoughts ……

Teamwork + Process/DetailsTeamwork + Process/Details

RISKRISK

A Culture ChangeA Culture Change……what it what it isis……....

The Era of AccountabilityThe Era of Accountability

““The Hawthorne effectThe Hawthorne effectin actionin action””

is itis itHeroism?Heroism?

ItIt’’s about culture change and

s about culture change and



Safe Surgery ChecklistSafe Surgery Checklist

Bryce Taylor Bryce Taylor Hospital Authority ConventionHospital Authority Convention


The

August 5, 1997 · What we did at UHN • Pilot at TGH—non‐cardiac – revised checklist • 500...

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