1. Preventing Surgical Complications 8 th October Presenter: Peggy Edwards & Rachel Kindred

2. Preventing Surgical Complications 1000 Lives Campaign To save 1,000 lives and to avoid 50,000 episodes of harm in Welsh healthcare between 21 April 2008 and 21 April 2010.

3. Preventing Surgical Complications Content Areas Improving leadership for quality Reducing healthcare associated infections Improving critical care* Improving medicines management Reducing surgical complications* Improving general medical and surgical care Development Sites *Trusts Only

4. Preventing Surgical Complications Hospital blunders 'kill 90,000 patients' Rebecca Smith, Medical Editor, Daily Telegraph 29.11.07 More than 90,000 patients die and almost one million are harmed each year because of hospital blunders, research suggests. Researchers found that up to half of the mistakes made were preventable

5. Preventing Surgical Complications Preventing post operative wound (surgical site) infections –Antibiotics –Hair removal –Glycaemic control –Normothermia Creating a team culture –Team briefing Preventing cardio vascular complications –DVT prophylaxis –Beta blockers

6. Preventing Surgical Complications Evidence Patients who develop post operative wound infections are twice as likely to die as other postoperative patients. Up to 60% more likely to spend time in an intensive care unit. If it develops after discharge, they’re five times more likely to be readmitted to the hospital.

7. Preventing Surgical Complications Whole surgical pathway Pre Operative Assessment Surgical ward / Day care ward Anaesthetic room Theatres Recovery Surgical Wards Primary Care

8. Preventing Surgical Complications Appropriate use of antibiotics Antibiotics within 1 hour before surgical incision* Prophylactic antibiotic agent consistent with locally determined guidelines Discontinuation of prophylactic antibiotics within 24 hours of surgery *Due to the longer infusion time required for vancomycin, it is acceptable to start this antibiotic (e.g., when indicated because of beta-lactam allergy or high prevalence of MRSA) within 2 hours prior to incision.

9. Preventing Surgical Complications Antibiotics cont. Exceptions: within two hours if patient receiving vancomycin, If surgery is being carried out with tourniquet control, all antibiotic administration must be completed before the tourniquet is inflated and within one hour prior to surgical incision. Women undergoing caesarean section should receive the antibiotic as soon as the umbilical cord is clamped.

10. Preventing Surgical Complications Evidence Appropriate antibiotic selection occurred in 92.6% of cases; Antibiotics were given within one hour of incision time to 55.7% of patients; and Prophylactic antibiotics were discontinued within 24 hours of surgery end time for only 40.7% of patients. (Bratzler 2005) Patients who received the first dose either more than 60 minutes before incision or after incision had higher rates of POWI, and the further the dose time was from incision, the greater the rate of POWI (Classen 1992).

11. Preventing Surgical Complications Antibiotics measures Measures Percent on-time appropriate prophylactic antibiotics administered on time. Prophylactic antibiotics discontinued within 24 hours after surgery end time.

12. Preventing Surgical Complications Use Recommended Hair Removal Methods Only electric shavers to be used to remove hair at the site of incision.

13. Preventing Surgical Complications Evidence Three trials involving 3193 people compared shaving with clipping and found that there were statistically significantly more SSIs when people were shaved rather than clipped Seven trials involving 1213 people compared shaving with removing hair using a depilatory cream and found that there were statistically significantly more SSIs when people were shaved than when a cream was used (Tanner 2006)

14. Preventing Surgical Complications Use Recommended Hair Removal Methods – measure Measure Name Percent of elective surgical patients with appropriate hair removal

15. Preventing Surgical Complications Hypothermia

16. Preventing Surgical Complications Maintenance of Postoperative Normothermia Patients are risk assessed for the potential to develop inadvertent hypothermia during surgery (documented). Patients with a core temperature of less than 36 o C pre operatively do not commence their anaesthesia and surgery until they have been warmed using forced warm air. Active warming should continue throughout the procedure. All patients at risk and / or with surgery anticipated to last >30 minutes, are warmed intra operatively using forced warm air.* *If this is not a practical intervention e.g. exposed surface area too extensive to allow forced warm air, then evidence from a small study suggests that electric blankets underneath the patient will maintain core temperature (Just 2003).

17. Preventing Surgical Complications Maintenance of Postoperative Normothermia - cont All patients routinely have their temperature monitored; in the hour before surgery, before induction, every 30 minutes during surgery, on arrival in the recovery room and every 15 minutes during the recovery period. Healthcare professionals should ensure that intravenous fluids (500 ml or more) and blood products are warmed to 37°C using an appropriate fluid warming device. Patients who arrive in recovery with a temperature less than 36oC should be warmed using forced warm air.

18. Preventing Surgical Complications Maintenance of Postoperative Normothermia – pre assessment In the perioperative period, ideally during the patient’s pre operative assessment appointments, patients who have the following risks should be identified as being at higher risk of developing hypothermia perioperatively: - ASA grade greater than I (the higher the grade, the greater the risk) − undergoing combined general and regional anaesthesia − undergoing major or intermediate surgery − at risk of cardiovascular complications (for example, age over 50 years).

19. Preventing Surgical Complications Evidence – favour treatment Two studies recorded the occurrence of cardiac events after surgery. Four studies examined the need for blood transfusion between groups. Two studies recorded the incidence of postoperative wound infection. One study recorded the occurrence of pressure damage. The results of this study did not reach statistical significance, but the author points out that warming of patients did reduce the risk of pressure ulcer occurrence by half, which is clinically significant.

20. Preventing Surgical Complications Maintenance of Postoperative Normothermia - measure Measure Name Percent of appropriate elective surgical patients with perioperative normothermia

21. Preventing Surgical Complications Team briefing at start of list Some of the ways in which team briefings can be developed are: Allocating five minutes before the start of the operating list where the core members of the team e.g. surgeon, scrub nurse, circulating nurse, ODP and anaesthetist can meet to discuss the requirements of that operating list and any safety concerns. Identify in advance a list of safety issues for discussion e.g. patient allergies, anticipated complications etc., potentially using a structured checklist Using a de-briefing session at the end of the operating list to review any issues raised, answer concerns or discuss incidents.

22. Preventing Surgical Complications Aims of interventions

23. Preventing Surgical Complications Evidence increased employee satisfaction, improved perceptions of safety climate, Reduction in potential for wrong site surgery and better interprofessional empathy and understanding (Defontes & Surbida, 2003). increased confidence across the OT team to speak up when spotting potential problems (Burke 2005)

24. Preventing Surgical Complications Creating a team culture - measure Measure Name Percent compliance with using daily team briefings including the core team

25. Preventing Surgical Complications Identifying patients at risk and provide appropriate DVT prophylaxis Documented DVT risk assessment of every surgical patient All high-risk surgical/orthopaedic patients should receive graduated compression stockings combined with heparins. Intermediate-risk surgical patients considered for graduated compression stockings combined with heparins. Low-risk surgical patients do not require specific prophylaxis other than early mobilisation, unless other factors are present which increase overall risk and thus place them in intermediate or high-risk categories

26. Preventing Surgical Complications Where can we make the most difference to mortality? 20% of patients undergoing major surgery experience a DVT. From data available on PEDW there were 14,206 major operations. 14202/100 * 20 = 2841 for one year. In 2006/7 there were 9579 hip and knee replacements. Between 45-51% of orthopaedic patients suffer a DVT (NICE 2007). 9579/100 * 45 = 4310 9579/100* 51 = 4885 Estimated that the risk of pulmonary embolism following high-risk surgery to be up to 5% in the highest risk groups (orthopaedics) 9579/100 * 5 = 478

27. Preventing Surgical Complications Identifying patients at risk and provide appropriate DVT prophylaxis – measures Measure Name Percentage of surgical patients who have been assessed for the risk of developing a DVT. Percent of eligible (risk assessed as a medium or high risk) surgical patients receiving DVT prophylaxis

28. Preventing Surgical Complications Continue beta blockers for patients admitted on beta blockers Beta blockers should be continued in patients undergoing surgery who are receiving them to treat angina, symptomatic arrhythmias, hypertension, or other ACC/AHA class I guideline indicators.

29. Preventing Surgical Complications Evidence continuous beta-blocker use remained significantly associated with a lower 1-year mortality than among nonusers (Hoeks et al 2007) Mortality in the patients who had beta blockers discontinued postoperatively (50%) was significantly greater than in the patients in whom beta blockers were continued (Shammash et al 2001)

30. Preventing Surgical Complications Continue beta blockers for patients admitted on beta blockers - measures Measure Name Percent of surgical patients on maintenance beta blockade who were continued on beta blockade

31. Preventing Surgical Complications What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in the improvements that we seek ? Model for improvement ActPlan StudyDo aims measurements interventions

32. Preventing Surgical Complications PDSA Small changes, one patient, one list, one team Measure – did it work, if not try something different Spread if did work Identify a pilot population Measure Are you already doing it? – measure compliance

33. Preventing Surgical Complications Interested Need leaders in each areas Need people to record measures Look at PDSAs

34. Preventing Surgical Complications Finally Contact details Peggy.edwards@npsa.nhs.uk Content Specialist