DEPARTMENT OF SURGERY

BMSH

CLINICAL MEETING

TOPIC: SURGICAL SAFETY

PRESENTER: DR BATUBO ( TEAM e)

OUTLINE

INTRODUCTION SAVE SURGERY SAVES LIVE OBJECTIVES CASE SCENERIO THE CHECKLIST ADVANTAGES HOW TO RUN THE CHECKLIST: In detail

Sign inTime outSign out

MODIFICATION IMPLEMENTATION THE WAY FORWARD IN BMSH CONCLUSION

Introduction Surgery is regarded as a high risk and complex industry

Complications of surgical care have become a major cause of death and disability worldwide.

Studies done by Kable et al., 2002

Rate of mortality during general anaesthesia is reported to be as high as 1 in 150 in parts of sub-Saharan Africa

Avoidable surgical complications account for a large proportion of preventable medical injuries and death

Countries Death rate Rate of major complication

Developed 0.4- 08% 3- 22

Developing 5- 10%

Safety in surgery require the reliable execution of multiple necessary steps in care by health team working together for the benefit of the patient

To minimize unnecessary loss of life, the CHECKLIST was develop by the SAFE SURGERY SAVES LIVES initiative of WHO in 2008

Objective OF 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 anaesthetics, 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.

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 and 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.

The Case Scenario

45 year old with breast cancer.

Elective mastectomy.

Patient wants immediate reconstruction by plastic surgeon.

General surgeon does mastectomy.

Preference card is lost so instrument set not standard.

Scrub tech leaves because of family emergency.

Circulator becomes scrub nurse.

Circulating nurse is now covering two OR’s Plastic surgeon comes into room “early”. Wants to begin reconstruction before general surgeons is

finished Plastic surgeon “disruptive” saying procedure going “too slow”. General surgeon insists on completing the mastectomy first. The breast specimen was lost. Surgeons had never worked together before and did not talk

before procedure. No “plan” for how surgery was to take place. Nursing staff very stressed by level of workload.

Complete system breakdown

The checklist was developed

The Surgical Checklist The Checklist divides the operation into three phases

OPERATION

(Sign In)before induction of anaesthesia

(Time Out)after induction and before surgical incision

(Sign Out)Immediately after wound closure but before removing the patient from the operating

room

Impact of checklist in the operating room New England journal of medicine (2009) by Save

Surgery Saves LivesHypothesis: 19 item surgical safety checklist improve

1. Team communication and consistency of care2. Reduce complications and deaths associated with surgery

12 months ( 2007-2008)Canada, India, Jordan, New Zealand, Philippines, Tanzania,

England, USA16yr and olderNon- cardiac surgery

FINDINGS

Pre-checklist checklist P-value

# of patients 3733 3955

Mortality 1.5% 0.8% 1/2 0.003

Complication rate 11.0% 7.0% 3rd ˂0.001

2nd study in 2011 by John et al.They put the operating team through several critical

operating room scenerio ½ a time they went in with a checklist½ a time without a checklist

FINDINGS

critical management steps were adhere to96% with checklist76 without checklist

CHECKLISTS REMIND US TO DOCRITICAL THINGS

Advantages of the ChecklistCheck list can help PREOP

Improve1. Appropriate antibiotic administration2. Prevention of hypothermia REDOSING

3. Availability of equipment in operating room

4. COMMUNICATION, SAFETY CULTURE

Reduce1. Specimen problems - - - loss, wrong test

2. Inaccuracies in documentation

3. Surgical related complications

4. Mortality and morbidity

It is intended as a tool for use by clinicians interested

Safety of their operations

Reducing unnecessary surgical death &

complication

How To Run The Checklist: In detail

IN 3 PARTS Sign in

Before induction of anaesthesia Ready to go back to the theatre

Time out Before skin incision Safe to start operation or procedure

Sign out Before patient leave operating room Safe to end operation and safe to

send patient to next point of care

Operating Room

Sign in

Take place in the theatre reception Safe to go back to the theatre Perform by

Preop nurse and circulatorDoes not involve surgeon or

anaesthestist Pre- procedure preparation

Relevant lab. Results, implant, devices, special equipments

DVT prophylaxis- assessment done

Warming – warming device set up in operating room if needed

Time out- safe to start the operation Perform by the entire surgical team Team introductions Pharmaceuticals e.g antibiotics and other Risk of blood loss Positioning/padding/straps- changes in

position, equipment Radiology – relevant images reviewed/

available Equipment e.g implant, anything special

anyone needs Fire risk assessment need to be done

heat and fuel( e.g alcohol-based prep, O2)

˃60min procedure

Expectected duration Antibiotic re-dosing plan Active warming DVT prophylaxis

Sign out

Safe to end operation, safe to send patient to next point of care

Perform by the surgeon

Opportunities for improvement

Patient recovery and managementPostop expectation are discussedMeds e.g antibiotics, painTubes/ linesPost-op studies ( labs, radiology)Destination: ICU, HOME OR WARDKey concern

Operation note and orders

Modification The Checklist can be modified to account for differences among

facilities with respect to their processes, the culture of their operating rooms and the degree of familiarity each team member has with each other.

However, removing safety steps because they cannot be accomplished in the existing environment or circumstances is strongly discouraged.

Many of the steps on the Checklist are already followed in operating rooms around the world; few, however, follow all of them reliably.

Implementation Requires adapting the Checklist to local routines and

expectations.

With sincere commitment by hospital leaders.

The heads of surgery, anaesthesia and nursing departments must publicly embrace the belief that safety is a priority and that use of the WHO Surgical Safety Checklist can help make it a reality.

They should use the Checklist in their own cases and regularly ask others how implementation is proceeding.

Barrier to implementationtime constraints duplication of existing processes

lack of communication between team members checklist too long to completesome items did not fit in their operating room Could yes/no answer prevent moving on

to the next question

THE WAY FORWARD IN BMSH?

Conclusion Checklists have been useful in many different environments,

including patient care settings.

This WHO Surgical Safety Checklist has been used successfully in a diverse range of healthcare facilities with a range of resource constraints.

Studies shows that with education, practice and leadership, barriers to implementation can be overcome.

With proper planning and commitment the Checklist steps are easily accomplished and can make a profound difference in the safety of surgical care and reducing mortality and morbidity.

THANK YOU