Surgical Safety - Canadian Patient Safety Institute

Implementation of the Surgical
Care Outcomes Assessment
Program (SCOAP) and the
Introduction of the
WHO/SCOAP Surgical Safety
Checklist
E. Patchen Dellinger, MD, FACS
Professor of Surgery, Chief of General Surgery
University of Washington Medical Center (UWMC),
Seattle, Washington
Surgical Safety: Unrecognized as
public health issue
Known surgical
complications
of 3-16%
Known death
rates of 0.40.8%
=
At least 7 million
disabling
complications –
including 1 million
deaths – worldwide
each year
Problem 2: Failure to use
existing safety know-how
• High rates of preventable surgical site
infection result from inconsistent timing of
antibiotic prophylaxis
• Anesthetic complications are 100-1000x
higher in countries that do not adhere to
monitoring standards
• Wrong-patient, wrong-site operations persist
despite high publicity of such events
WHO’s 10 Objectives for Safe
Surgery
The team will:
1. Operate on the correct patient at the
correct site.
2. Use methods known to prevent harm from
anesthetics, while protecting the patient
from pain.
3. Recognize and effectively prepare for lifethreatening loss of airway or respiratory
function.
WHO’s 10 Objectives for Safe
Surgery
4. Recognize and effectively prepare for risk
of high blood loss.
5. Avoid inducing an allergic or adverse drug
reaction for which the patient is known to
be at significant risk.
6. Consistently use methods known to
minimize the risk for surgical site infection.
WHO’s 10 Objectives for Safe
Surgery (cont.)
7. Prevent inadvertent retention of
instruments or sponges in surgical
wounds.
8. Secure and accurately identify all
surgical specimens.
9. Effectively communicate and exchange
critical information for the safe
conduct of the operation.
10. Hospitals and public health systems
will establish routine surveillance of
surgical capacity, volume and results.
Advantages of Using a Checklist
• Can be customized to local setting and needs
• Can be deployed in an incremental fashion
• Is supported by scientific evidence and expert
consensus
• Has been evaluated in diverse settings
around the world
• Ensures adherence to established safety
practices
• Minimal resources required to implement a
far-reaching safety intervention
What is this tool that addresses
the 10 objectives?
What is this tool that addresses
the 10 objectives?
WHO and the Checklist
Safe Surgery Saves Lives
WHO encourages local institutions
to modify the list to address local
needs.
Anesthesia machine safety checks
are reliably done in the U.S. but
not in all other places in the world
The Checklist was piloted in 8 cities
PAHO I
Toronto, Canada
EURO
EMRO
London, UK
Amman, Jordan
WPRO I
Manila, Philippines
PAHO II
Seattle, USA
WPRO II
Auckland, NZ
AFRO
Ifakara, Tanzania
SEARO
New Delhi, India
Doing the Checklist at University of
Washington Medical Center (UWMC)
• We had been discussing briefing and
debriefing in the Division of General
Surgery
• I saw the checklist as an opportunity to
institutionalize briefing and debriefing
• We had added antibiotic administration
to the JCAHO-mandated “time out”
many years ago
SCOAP
Surgical Care and Outcomes Assessment Program
• Voluntary collaborative of surgeons
in Washington state
• Grassroots organization
• Includes 51 of 65 rural small
hospitals and large urban referral
centers.
• SCOAP surgeons define the
metrics for quality
SCOAP
Surgical Care and Outcomes Assessment Program
• Currently following colon/rectal, bariatric
operations, appendectomy, & vascular
operations with a pediatric module in
development
• Quarterly feedback on process
compliance and outcome
• Hospitals can compare their performance
with other SCOAP hospitals
Operative Re-intervention
All Colon/Rectal Surgery
Q1 2006 through Q2 2007
% of Procedures
20%
16%
(7)
(8)
12%
(168)
(165)
8%
(24)
(35)
(358)
(49)
(260)
(26)
(254)
(102)
(44)
(542)
4%
(19)
(3)
0%
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Hospital
Aggregate Data
Hospital Average
2007
Transfusion-free Procedures
Elective Colon/Rectal Surgery
Q1 2006 through Q2 2007
% of Procedures
100%
80%
(3)
60%
(30)
(292)
(7)
(14)
(72)
(57)
(30)
(204)
(18)
(465)
(103)
(6)
40%
(218)
(21)
20%
0%
A
B
C
D
E
F
G
H
I
J
K
M
N
O
P
Hospital
Aggregate Data
Hospital Average
2007
Normothermia
Elective Colon/Rectal Surgery
Q1 2006 through Q2 2007
% of Procedures
100%
80%
(280)
(30)
(17)
(28)
(48)
(3)
(20)
(102)
(7)
(195)
60%
(460)
(223)
(6)
(72)
(14)
40%
20%
0%
A
B
C
D
E
F
G
H
I
J
K
M
N
O
P
Hospital
Aggregate Data
Hospital Average
2007
Glucose Testing among Diabetics
Elective Colon/Rectal Surgery
Q1 2006 through Q2 2007
% of Procedures
100%
80%
(11)
60%
(15)
(31)
(34)
(9)
(6)
(15)
40%
(27)
(5)
20%
(38)
0%
A
C
D
E
F
H
J
M
N
O
Hospitals with 5+ diabetics
Aggregate Data
Hospital Average
2007
VTE Chemoprophylaxis
Elective Colon/Rectal Surgery
Q1 2006 through Q2 2007
% of Procedures
100%
(30)
80%
(215)
(6)
(7)
(20)
60%
(466)
(204)
(17)
40%
(294)
(72)
(57)
20%
(99)
(30)
(2)
(14)
0%
A
B
C
D
E
F
G
H
I
J
K
M
N
O
P
Hospital
Aggregate Data
Hospital Average
2007
Post-op B-Blockers for Current Users
All Colon/Rectal Surgery
Q1 2006 through Q2 2007
% of Procedures
100%
80%
(12)
(45)
(54)
(11)
(74)
(172)
(13)
60%
(5)
(50)
(33)
(46)
40%
(5)
20%
0%
A
C
D
E
F
G
H
J
M
N
O
P
Hospitals w/ 5+ Current Users
Aggregate Data
Hospital Average
2007
12+ Lymph Nodes Removed
Colon Cancer Surgery
Q1 2006 through Q2 2007
% of Procedures
100%
80%
(1)
(1)
(1)
(17)
60%
(10)
40%
(67)
(72)
(21)
(28)
(106)
(23)
(55)
(43)
(6)
(18)
20%
(2)
0%
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Hospital
Aggregate Data
Hospital Average
2007
VTE Chemoprophylaxis
Elective Colon/Rectal Surgery
All SCOAP Patients
% of Procedures
100%
90%
80%
70%
60%
50%
Q1 2006
2
3
4
Q1 2007
2
2007
Imaging Accuracy
Appendectomy Procedures
All SCOAP Patients
% of Procedures with Imaging
100%
95%
90%
85%
(1152)
(399)
(394)
(244)
Q2 2007
Q3 2007
80%
Year 2006
Q1 2007
(Denominator)
2007
Re-operation for Complications
All Colon/Rectal Surgery
All SCOAP Patients
% of Procedures
20%
15%
10%
5%
0%
Q1 2006
2
3
4
Q1 2007
2
2007
Negative Appendectomy
% of Procedures
20%
15%
10%
5%
0%
Year 2006
Q1 2007
Q2 2007
Q3 2007
2007
“Safe Surgery Saves LivesSCOAP Checklist”
Implementation at UWMC
First phase
• Safety attitudes questionnaire collected
before introduction of the checklist and
again after
• Baseline data on use of checklists among
all general surgery cases
• 500+ cases followed with basic data collected
UWMC Safety Attitudes
Questionnaire - Results
Agree or strongly agree
Before After
Feel safe as patient here
83%
85%
Briefing important before op.
91%
94%
Encouraged to report concerns
79%
90%
Difficult to speak, perceived prob. 19%
21%
Good team - docs & nurses
53%
65%
Freq disregard rules (others?)
19%
15%
UWMC Safety Attitudes
Questionnaire - Results
Agree or strongly agree
Checklist easy to use
Checklist improved O.R. safety
Took a long time to complete
I would want checklist for me
Communication was improved
Checklist helped to prevent errors
After
56%
60%
23%
88%
81%
67%
Communication Quality and
Surgical Morbidity
Davenport. JACS 2007;205: 778-784
Behavioral Marker Risk Index (BMRI)
•
•
•
•
Briefing
Information sharing
Inquiry
Vigilance and awareness
Risk Factor
BMRI
ASA
Adjusted Odds Ratio
Complication or Death
4.82
1.51
Mazzocco. Amer J Surg 2009; 197: 678-85
Behavioral Marker Risk Index and
Postoperative Complications
Mazzocco. Amer J Surg 2009; 197: 678-85
“Safe Surgery Saves LivesSCOAP Checklist”
Implementation at UWMC
Second Phase
• Checklist introduced in March 2008-all
general surgeons to champion
• Posted (2’ x 3’) in all O.R.s
• 500 Additional cases followed with basic
data collected
• Safety attitudes re-surveyed
• 10’ training video made (see SCOAP website)
Timing of “Time Out”
Checklist procedures were
timed by data collector
Results
RANGE
MEAN
0:58 seconds to 3:58 minutes
2:16 minutes
Feedback: General Surgeons, Nurses,
and Anesthesiologists
“Surgeon leadership is key to taking this
seriously and making it a meaningful
pause that offers safety.” – General
surgeon
Feedback: General Surgeons, Nurses,
and Anesthesiologists
• “At first it seemed somewhat
burdensome due to length. It now takes
me about one minute to run through the
list, which I don't think is anything
excessive.” – General surgeon
Challenges Ahead
• Institutionalizing the checklist – Every O.R.,
Every Case
• Supporting the culture change that the
checklist suggests
• Getting the “buy-in” of all Surgeons
• Streamlining the checklist to meet the needs
of individual hospitals and specialties while
preserving the essentials
• Remembering the Debriefing !
• Integrating the checklist into the EMR?
“Safe Surgery Saves Lives” and
SCOAP and UWMC
Working Together
• Expanded the WHO checklist to include
important SCOAP metrics that we were
inconsistently applying
• Started the Washington State SCOAP
Checklist Coalition
• Enlisted the assistance of the
Washington State Hospital Association
and third party payers and major
employers to promote the checklist
Washington State Checklist
Implementation
65 hospitals have notified SCOAP
and the Washington State Hospital
Association (WSHA) that they have
implemented a Surgical Safety
Checklist
“The estimate that up to 23,000 people died in
2004 in Canadian hospitals because of
preventable adverse events is staggering.
Checklists in aviation have been in use pretty
well since the Wright brothers.
One wonders whether such checklists would
have been introduced much earlier in medicine if
surgeons shared the fate of their patients, as
pilots share that of their passengers.”
Adrian Boelen, retired pilot, Dorval, Que
More Information
www.who.int/patientsafety/safesurgery/en.index.html
www.safesurg.org
www.scoap.org
www.nbc.com/ER/video/episodes/#vid=1059351