Safe Surgery Checklist to Brief and De brief

Transcription

1 afe urgery Checklist to Brief and De brief Limerick 29 th March 2014 James Clarke Consultant Anaesthetist London World Health Organisation 1

2 The question Why go to a 5 step process? when some of us we had enough trouble implementing the 3 step check list the 5 step process an overview 1. The additional 2 steps 2. Why do them advantages and disadvantages 3. Is there any evidence that it makes a difference 2

3 Hospital afety Compared with Other High Risk Activities Himalayan Mountaine ering urgical Mortality In hospital mortality due to poor care Coal Mining Microlight aircraft or Helicopters Road afety Chemical Industry Anaesthesia Mortality Chartered Flight Blood Transfusion Mortality (UK) Commercial Large Jet Aviation Railways Nuclear Industry No system beyond this point VERY UNAFE Risk rate ULTRA AFE Amalberti et al. An Int Med 2005 Briefing 3

4 Briefing definition A meeting in which people are given instructions or information Oxford Dictionary urgical Briefing (also called a huddle) Is carried out at the start of the operating list before the first patient is anaesthetised (also helps list start on time) In some hospitals it appears as the first procedure on the operating list 4

5 Briefing has 4 main roles 1. To walk through the list and anticipate any problems that might occur, such as equipment, test results, patients not ready, ICU bed availability etc and resolve them so that the list runs more efficiently to develop contingency plans Briefing has 4 main roles 1. To walk through the list and anticipate any problems that might occur, such as equipment, test results, patients not ready, ICU bed availability etc and resolve them so that the list runs more efficiently to develop contingency plans 2. To come together as a team for that list 5

6 Briefing has 4 main roles 1. To walk through the list and anticipate any problems that might occur, such as equipment, test results, patients not ready, ICU bed availability etc and resolve them so that the list runs more efficiently to develop contingency plans 2. To come together as a team for that list 3. To open communication between different team members to ensure everyone is on the same page Briefing has 4 main roles 1. To walk through the list and anticipate any problems that might occur, such as equipment, test results, patients not ready, ICU bed availability etc and resolve them so that the list runs more efficiently to develop contingency plans 2. To come together as a team for that list 3. To open communication between different team members to ensure everyone is on the same page 4. To flatten hierarchy to allow anyone with concerns to speak out 6

7 Teamwork Teamwork The ability to maintain and nurture a wide range of human relationships, which blend elements of cooperation with, competition There is extensive evidence from both evolutionary and developmental psychology that cooperation is socially rewarding for the individual as well as the group. Christopher Bergland, world class endurance athlete, coach, author, and political activist. 7

8 Teamwork why it s important 1. We are hardwired as a species to work in cooperation 2. Each team member brings different knowledge, skills and personality styles to problem solving 3. Bring help and support to each other when things are difficult 4. Teams allow cross checking on progress and direction 5. Teams allow errors to be detected earlier 6. Wisdom of Crowds 7. Teams can change the status quo and allow innovation Human Factors 8

9 What makes us fallible (unsafe)? What we think Overloading our cognitive state What we do Overloading our behavioral repertoire What we feel Overloading our emotional state Our environment Fast versus slow thinking. Intuition versus problem solving Briefing is about the eight key human factors in surgical safety (TOT) 9

10 Communication 10

11 Communication cycle 11

12 tandardised communication BAR B A R ituation Background Assessment Recommendation BAR Originally developed By Kaiser ermanente Based on military models of communicating critical information ersonality and Teams 12

13 ersonality styles Ask Merrill & Read s framework: self awareness and team working Analytic Do it right or not at all! Technical pecialist Wants to know HOW Likes to plan We re great! Relationship pecialist Wants to know WHY Cooperative and loyal Amiable Controls emotions Driver Just do it! Command pecialist Wants to know WHAT Likes to take charge Let s do it all! ocial pecialist Wants to know WHO Energetic and optimistic Expressive hows emotions Tell How to recognise personal style The Driver: Command pecialist erceived positively as: Decisive Independent ractical Determined Efficient Assertive A risk taker Direct A problem solver erceived negatively as: ushy One man/woman show Tough Demanding Dominating An agitator Cuts corners Insensitive 13

14 analytical will withdraw Under extreme stress driver will become autocratic amiable will submit expressive will become offensive or sarcastic Briefing 14

15 How to do it takes about 5 10 minutes and some evidence suggests it saves about 30 minutes Everyone present (including recovery staff?) Each person introduces themselves Christian name mandatory, surname optional (helps flatten hierarchy) Brief description of one s role in the team How to do it (takes about 5 10 minutes) Everyone present (including recovery staff?) Each person introduces themselves Christian name mandatory, surname optional (helps flatten hierachy) Brief description of one s role in the team Go through operating list. urgeon says what he / she will be doing and what equipment is needed. Everyone present should be asked if they have any concerns or wish to make a comment about any aspect of the list 15

16 Australian A T The 7 rule rior lanning & reparation revents iss oor erformance Briefing 16

17 Debriefing 17

18 Debriefing To learn, improve...(and) for reflection Briefing and Debriefing in the cardiac operating room. Analysis of impact on theatre team attitude and patient safety. Interactive CardioVasc Thoracic urgery Volume 10, Issue 1 p ortis et al Debriefing Carried out at the end of the list Main aim To learn what went well and what went wrong, so that problems can be fixed for future operating lists. econdary aim To thank people for what went well 18

19 Debriefing glitches Make a record of what did not go well (glitches) Collect your glitches If a major safety concern has occurred, then it needs to be addressed immediately Less important glitches should be collected and solutions worked out at a later date Glitches example of a glitch list Date List changed at last minute urgeon late Anaesthetist late atient not ready Delay in getting patient from ward No Recovery bed available No ICU bed available No junior doctor to assist Broken equipment Op list Notes missing X rays, CT scan results missing Not enough staff for list No available beds No radiology when needed Constant interruptions during list Operation not listed correctly Bloods not ready Equipment not available 19

20 Using Deming s Model for Improvement Deming's DA cycle on how to solve problems (glitches) DA cycles create continuous model of improvement Incremental Innovation A D A A D A D D A D A D A D 20

21 DA cycles create continuous model of improvement To make it work best it is a GROU activity of those directly involved in the process. It is not top down The best solutions often come from the most unexpected people so ensure Everyone s voice is heard A D A D A D A D A D A D A D Always start by mapping the process out as it actually is Then map out an improved process Then try it and see if its better Using Deming s Model for Improvement How to make your working life smarter, safer and more rewarding Act to solve glitches cheduling & Briefing Debriefing and collecting glitches Doing the list 21

22 Evidence 22

23 Advantages of a 5 step model 2010 survey of English Trusts by atient afety First 1. Decreased surgical harm to patients 2. Improved team working and communications 3. Improved efficiency Main advantages of a 5 step model 2010 survey of English Trusts by atient afety First 1. Decreased surgical harm to patients (currently about 10%) 10% of all hospital beds occupied by the result of error (estimated cost to average hospital 2,000,000 per year) Cost to NH England of DVTs and Es 325 million (NICE) I: Cost to NH England 457 million (NICE & lowman 2001) Litigation costs: surgical costs 3.7 billion 23

24 A urgical afety Checklist to Reduce Morbidity and Mortality in a Global opulation Alex B. Haynes, M.D., M..H., Thomas G. Weiser, M.D., M..H., William R. Berry, M.D., M..H., tuart R. Lipsitz, c.d., Abdel Hadi. Breizat, M.D., h.d., E. atchen Dellinger, M.D., Teodoro Herbosa, M.D., udhir Joseph, M.., ascience L. Kibatala, M.D., Marie Carmela M. Lapitan, M.D., Alan F. Merry, M.B., Ch.B., F.A.N.Z.C.A., F.R.C.A., Krishna Moorthy, M.D., F.R.C.., Richard K. Reznick, M.D., M.Ed., Bryce Taylor, M.D., Atul A. Gawande, M.D., M..H., for the afe urgery aves Lives tudy Group ublished at January 14, 2009 ( /NEJMsa ) Results All ites Baseline Checklist value Cases Death 1.5% 0.8% Any Complication 11.0% 7.0% <0.001 I 6.2% 3.4% <0.001 Unplanned Reoperation 2.4% 1.8% It was found to reduce the rate of postoperative complications and death by more than one-third Haynes et al. A urgical afety Checklist to Reduce Morbidity and Mortality in a Global opulation. New England Journal of Medicine 360: (2009) 24

25 Main advantages of a 5 step model 2010 survey of English Trusts by atient afety First 2. Improved team working and communications Christian et al showed improved team working and planning resulted in shorter operating times for complex surgery Leeds have reported that in orthopaedic trauma with the introduction of the 5 step model they have increased number of patients on their lists from 3.5 to 4.5 (>30 % improved efficiency 25

26 Impact on delays Briefings & debriefings Timeouts Early preparation of patient Team-working 26

27 Improved Glitch Report over 4 months 0.0% Broken equipment 0.0% 1.7% 5.0% 6.6% urgical equipment not available 12.5% 13.3% 22.5% Late tart 26.6% 35.0% 70.0% 82.5% Jan Dec Nov Oct 0.0% Beds 0.0% 8.3% 17.5% 13.3% urgeon Late 25.0% 30.0% 55.0% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% utting briefing and debriefing into action 27

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29 Adoption of Innovation Early Majority Late Majority 34% 34% Early adopters 13.5% Innovators 2.5% Laggards 16% High peed of adoption Low E Rogers Diffusion of Innovation 1995 Thank you for inviting me to Munster 29