‘WHO is kidding WHO’ Prospective Re-Audit of the implementation Pre-briefing and the WHO Surgical Safety Checklist at FPH August 2011 Department of Surgery Frimley Park Hospital NHS Foundation Trust G Lazz-Onyenobi, S Irwin, L. Godleman Supervised: Mr PFS Chong

The “5 Steps” Pre-list briefing WHO checklist Sign in pre-anaesthesia Time out pre-incision Sign out post-closure Post list de-briefing

Background of Surgical Safety Checklist at FPH  July 2009 Initial briefing to staff at FPH  Aug 2009 First WHO safety checklist (WHOSSC) adaptation for FPH launched in theatres  Dec 2009 FPH delegation to RCS England symposium on Patient safety  Jan 2010 Second staff briefing regarding “Pre-brief”  Feb 2011 Prospective audit of WHO SSC implementation at FPH  Jun 2011 FPH Surgical Safety training day with staff training and education on pre-brief and WHO SSC  Aug 2011 Re-auditing of WHO SSC implementation at FPH

What has happened in between the last audit and the present audit?  Staff training and education regarding pre-briefing and WHO SSC implementation at FPH Surgical Safety Day in June 2011  Simple Pre-brief template now available – “5 Ps” 1) PERSONNEL available and appropriate? 2) PROCEED with list as planned? 3) PROBLEMS with patient or procedure anticipated? 4) POSITION, PRODUCTS, PROTHESES requested? 5) POST-OP instructions for patient?  Re-auditing month 24 post launch (Aug 2011) after further staff training to complete the audit cycle

Audit Method  Audit designed to collate the following information 1. Data observed from all theatre – morning AM lists 2. WHO Surgical Safety check list implementation for 1 st patient on theatre list 3. Compliance of the “5 Steps” for 1 st patient 4. Leadership and execution of WHO SSC 5. Pre-brief implementation  Performed by ODPs or ATPs Blinded to other team members

Data collection  19 morning theatre lists at FPH  Random sample taken from 2 days of activity Speciality theatre listsNumber General Surgery9 Urology1 Trauma & Orthopaedics6 Obstetrics & Gynaecology2 Ophthalmology & ENT1

Pre-brief implementation data Present vs. Past  Performed in 87% (13/15) vs. 69% of theatre lists  77% vs. 88% of pre-briefs took < 5 minutes to complete  0% vs. 21% were performed with the patient awake  67% vs. 46% of lists started on time (1 st patient in theatre at start time)  65% vs. 49% of lists finished on time (Last patient out of theatre at finish time)

Team members present at Pre-brief  ODP were present at 100% cases - Performed prospective audit data collection Team membersPresent vs. Past (%) Consultant Surgeon92 % vs. 92% Anaesthetist100 % vs. 96% Theatre nurse100 % vs. 88% Other (student nurses)23 % vs. 33%

Discussions during Pre-brief  58% introduced team members and discussed adequacy of team skill mix  92% discussed the order of the list  1 in 4 lists were changed from original order (last audit)  76% anticipated specific clinical or logistical problems  84% requested specific products or equipment  46% discussed specific post operation plans for patients

WHO SSC implementation for 1 st patient on list  uhu WHO SSC steps and leadershipPresent vs. Past Adequate “sign in”100 % vs. 83% Main leader: ODP68 % vs. 47% Adequate “time out”89 % vs. 71% Main leader: Theatre nurse47 % vs. 88% Adequate “sign out”21 % vs. 48% Main leader: ODP100 % vs. 94% Theatre Nurse

Summary of latest audit versus last audit  Re-audited prospective data month 24 post WHO SCC launch and after WHO SCC staff training shows that 1. Pre-brief was performed in 9/10 theatres compared to 7/10 from previous audit 2. Pre-brief is not time consuming. The majority (77%) took < 5 minutes which is comparable to the previous audit results (83%) 3. Team members were more involved in the pre- brief compared to previous audit ( Anaesthetist 100% vs. 88%, theatre nurses 100% vs. 96%)

Summary of latest audit versus last audit % of patients had adequate “sign in” compared to 83% in previous audit 5. Less than 1 in 4 of patients received adequate “sign out”. Similar trend present in previous audit with more than 1 in 2 of patients 6. Main leaders of WHO SCC implementation were theatre nurses or ODPs comparable to previous audit

Conclusion  The results for this re-audit demonstrate some improvement in WHO SCC implementation and completion of the “5 Steps”.  Staff training of value as improvements seen in more prevalent pre-briefing in FPH theatres.  Signing out remains haphazard  Post-briefing assessment is almost absent at FPH – there is no improvement feedback loop.

Recommendation  Further staff training with particular focus on the “sign out” step and building an effective “post- briefing” culture at FPH Surgical Safety Day June  Designing a simple “post-briefing” template to emphasise usefulness and importance.  Practical measures to enhance safety  Repeat this audit again in 2012

STOP! Please do your team pre-brief & WHO safety checklist.