 safe surgery 2015: sc Rick Foster, MD February 17,2011

I do not have any relevant financial relationships with any commercial interests related to the content of this activity to disclose.

“we're good at making sure we do most of these things most of the time, but we're not good at doing all of them all of the time.” -Atul Gawande, MD “…because each slip represents an opportunity for harm to your love ones,” -Alex Haynes, MD Harvard School of Public Health

three central problems in surgical safety  unrecognized as a public health issue  lack of data on surgery and outcomes  failure to use existing safety know-how

Four Categories for Surgical Standards: CONTROL OF INFECTION AND CONTAMINATION ANESTHESIA AND PATIENT MONITORING SURGICAL OPERATOR QUALITY ASSURANCE

WHO’s 10 Objectives for Safe Surgery 1.The team will operate on the correct patient at the correct site. 2.The team will use methods known to prevent harm from administration of anesthetics, while protecting the patient from pain. 3.The team will recognize and effectively prepare for life-threatening loss of airway or respiratory function. 4.The team will recognize and effectively prepare for risk of high blood loss. 5.The team will avoid inducing an allergic or adverse drug reaction for which the patient is known to be at significant risk.

WHO’s 10 Objectives for Safe Surgery 6. The team will consistently use methods known to minimize the risk for surgical site infection. 7. The team will prevent inadvertent retention of instruments or sponges in surgical wounds. 8. The team will secure and accurately identify all surgical specimens. 9. The team will 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.

Why a Checklist?

London, UK EUROEMRO WPRO I SEARO AFRO PAHO I Amman, Jordan Toronto, Canada New Delhi, India Manila, Philippines Ifakara, Tanzania WPRO II Auckland, NZ PAHO II Seattle, USA International Pilot Study 8 Evaluation Sites - Nearly 8,000 Patients

SiteCases Inpatient Complication Inpatient Death %1.0% %1.1% %0.8% %1.0% %1.4% %3.6% %2.1% %1.4% Total %1.5% Outcomes at Baseline

Results - Process Measures BaselineChecklistP-value Objective Airway Evaluation 64.0%77.2%<0.001 Abx at 0-60 Mins Except Dirty Cases 56.1%82.6%<0.001 Verbal Pt/Site Confirmation 54.4%92.3%<0.001 Two IVs /Central Line if EBL≥ %63.2%0.32 Pulse Oximeter 93.6%96.8%<0.001 Sponge Count 84.6%94.6%<0.001 All Six Safety Indicators Done 34.2%56.7%<0.001

Results – All Sites BaselineChecklistP value Cases Death 1.5%0.8%0.003 Any Complication 11.0%7.0%<0.001 SSI 6.2%3.4%<0.001 Unplanned Reoperation 2.4%1.8%0.047

Change in Death and Complications Income Classification Change in Death and Complications by Income Classification Change in Complications Change in Death High Income10.3% -> 7.1%*0.9% -> 0.6% Low and Middle Income 11.7% -> 6.8%*2.1% -> 1.0%* * p<0.05

Survey of Attitudes to Checklist Use Among Clinicians at Study Site Survey of Attitudes to Checklist Use Among Clinicians at Study Site (n=229) The checklist was easy to use78.6% The checklist improved operating room safety 79.0% The checklist took a long time to complete18.3% Communication was improved through use of the checklist 84.3% The checklist helped prevent errors in the operating room 78.2% If I were having an operation, I would want the checklist to be used 92.6%

Stanford University, United States E/O Mortality declined from.88 to.80 Reported Patient Safety Never Events (PSN) rose from 559 to 637 Reported events due to errors/complications decreased from 35.2% to 24.3% Mean OR start to incision time was shorter There was improvement in the belief (SAQ) that all personnel take responsibility for patient safety Tsai Thomas, Boussard Tinna, Welton, Mark, Morton, John. Does a surgical safety checklist improve patient safety culture and outcomes? [Abstract]. In: American College of Surgeons Annual Clinical Congress October 3-7; Washington D.C. Journal of American College of Surgeons. (N=12,247)

SURPASS Checklist, The Netherlands 100 item checklist implemented in 6 high performing hospitals Compared to controls the test hospitals had a greater than one-third reduction in complications and achieved an almost 50% reduction in deaths (from 1.5% to 0.8%) (N=7,580) de Vries EN, et al. Effect of a Comprehensive Surgical Safety System on Patient Outcomes. N Engl J Med 2010; 363:

Veterans Health Affairs, United States Implemented a surgical team training program incorporating a modified version of a surgical checklist in the operating theatres of 74 facilities Experienced a mortality reduction of 18% Neily J, Mills PD, et al. Association Between Implementation of a Medical Team Training Program. JAMA Oct 20;304(15):

The Use of the WHO Surgical Safety Checklist and Cost Savings The use of the Checklist can generate cost savings for hospitals. The use of the Checklist decreased complications by more than 1/3 rd in the original study published in the NEJM. 1 Cost savings from the use of the Checklist has the potential to save hospitals >$8,000 per surgical complication Haynes AB et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med Jan 29;360(5): Epub 2009 Jan Semel ME, Resch S, Haynes AB, Funk LM, Bader A, Berry WR, Weiser TG, Gawande AA. Adopting a surgical safety checklist could save money and improve the quality of care in U.S. hospitals. Health Aff (Millwood) 2010 Sep;29(9):

Virginia Mason Hospital- Seattle In order for the Checklist to work well it has to be used “right”- requires behavioral change Improving communication between all OR team members is critical to successful implementation Annual Meeting of the American Society Anesthesiologists

Vision: Vision: That all SC hospitals and providers deliver safe, high quality healthcare in a caring and compassionate manner to each patient, every time Mission: Mission: To establish a culture of continuous improvement in the quality, efficacy and safety of patient care across all healthcare organizations and providers statewide

Create an organizational culture of safety with engaged leadership Actively improve the quality & outcomes of evidence-based care for key patient populations Eliminate preventable serious adverse events and unintended patient harm Establish a patient-centered environment of care with open and transparent communication

Built on a strong mission and strategic foundation Collaboration and shared accountability among key stakeholders- “seat at the table for everyone” Active communication and knowledge sharing Effective use of QI tools and methodologies Education built around active learning model Focus on measurable process and outcomes performance indicators Environment that encourages innovation

partners  dr. atul gawande and the safe surgery 2015 team from harvard school of public health  pht services, ltd.  health sciences south carolina  blue cross blue shield of SC

almost 900,000 surgery cases in one year  364,000 inpatient surgery cases  523,764 outpatient surgery cases Estimated 8,500 surgical related deaths per year!

 2,893 patients’ lives could be saved! FACT: Doctors can avoid complications if they use the surgical checklist. if the checklist could reduce mortality by one-third in south carolina …

 vision Every surgical patient in South Carolina will receive the highest quality and safest care in all surgical settings.  purpose Develop an integrated system for hospital surgical teams that focuses on process improvement, establishing a just culture of open communication, learning and team work and reducing near misses and adverse events by providing the highest quality of care and the safest environment using evidence based medicine in the surgical setting. safe surgery 2015: sc

 Establish a statewide multidisciplinary leadership team to guide and direct Safe Surgery 2015  Establish surgical safety teams in every hospital in SC  Provide a Team Training Program that can be accessed by any SC hospital or other surgical care provider  Implement a common set of standards/guidelines for team based surgical care built around the WHO checklist  Create a common statewide data base of key surgical safety process and outcomes measures/indicators improvement aims

goal By 2014 a modified version of the WHO Surgical Safety Checklist with team based communication will be used in every operating room for every surgical patient every time a surgical procedure is performed in the state of South Carolina. 100% of hospitals committed To date, all SC acute care hospitals with surgical suites have fully committed to implementing the surgical checklist.

Checklist Modification Basics One size doesn’t fit all Need to have full team buy-in 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

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? When You Use the Checklist When You Use the Checklist :

Surgical point of contact completed the survey Over 90% of hospitals responded that they implemented the WHO (modified) Surgical Safety Checklist in % of their hospital based OR rooms Need to drill down further to determine if implementation of checklist processes are consistent in and among all SC hospitals Need more surgeons to be on board with the checklist 75% of the hospitals feel that SURGEONS are the best group to help implement the checklist Over 60% said team training would help 100% think the checklist has improved safety and 100% would want the checklist used on them baseline assessment of hospitals

 cardiac surgery  ambulatory surgery centers safe surgery subgroups

 inpatient mortality rates  unplanned return to operating room within 48 hours  surgical site infections Harvard team to determine clinical data definitions of these three data components Ask South Carolina Hospitals to track identified data components Use SSI data reported through CDC NHSN system (HIDA program) Explore data using administrative claims from Office of Research and Statistics (ORS) key surgical outcome indicators

data subgroup  recommend hospitals track data measures for “unintended” consequences using existing state and national level data measures data measures include: Surgical Care Improvement Project (SCIP): CMS Surgical AHRQ indicators: ORS HIDA infection measures: DHEC/NHSN

implementation effectiveness Safety culture assessment by all surgical team members checklist implementation/utilization assessment by OR managers and directors assessment of checklist application and team-based communication in each OR by circulating nurses

 Will be distributed within 2011 with re-measurement  Use survey questions from the Safety Attitudes Questionnaire (OR Version)  Conduct survey to better understand attitudes and opinions regarding surgical safety  Distribute to participants of the Operating Room Team  Anonymous and confidential culture of safety survey

South Carolina teams will conduct on site visits to evaluate implementation effectiveness of the surgical checklist Effectiveness tools developed by research team from Harvard School of Public Health Outcomes will be assessed using multiple data metrics Identify Team Training as a critical component of the implementation process and imbed in the overall educational component Exploring a TeamSTEPPS Training Course that is customized for the OR Encourage customization while maintaining the basic components in the surgical checklist that need to be included in the checklist shaping the path in safe surgery 2015:sc

Currently surgical teams do most of the right things, on most patients, most of the time. The checklist helps us do all the right things, on all the patients, all of the time. safe surgery reality check

contact information  lorri gibbons, rn, bsn, cphq Vice President, Quality Improvement and Patient Safety  learn more about scha’s partnership with dr. atul gawande and his safe surgery 2015 team by visiting our website hospitals-partner-with-dr-atul-gawande