Teamwork, Communication, O.R. Safety & SSI Reduction

2011 Infection Prevention Leadership Teamwork, Communication, O.R. Safety & SSI Reduction Teamwork, Communication, O.R. Safety & SSI Reduction 2 Presented by: E. Patchen Dellinger, MD, FACS Professor of Surgery, Chief of General Surgery University of Washington Medical Center (UWMC) Seattle, Washington Disclosures This presentation was sponsored by 3M. 3 1

Preventing SSI in the O.R. Prophylactic Antibiotics Procedure selection Antibiotic choice Timing Dose Duration Patient warming FiO 2 Glucose control Hair removal Skin preparation Hand scrub Surgical technique Wound protectors Antibacterial sutures Teamwork 4 Prophylactic Antibiotics Procedure selection Antibiotic choice Timing Dose Duration Patient warming FiO 2 Glucose control Hair removal Skin preparation Hand scrub Surgical technique Wound protectors Antibacterial sutures Teamwork 5 6 2

Other Centers Experience with Briefings and Checklists Communication Failures Before and After Team Briefing ures Number of procedures with n recorded communication failu Before Briefing After Briefing Number of communication failures recorded during the procedure 7 Lingard. Arch Surg 2008;143:12-17 Surgical Safety Checklist (WHO and SCOAP) In early 2008 I was privileged to participate in the development of the WHO Surgical Safety Checklist and later to lead one of the pilot hospitals in its implementation. 8 Doing the Checklist at UWMC We had been discussing briefing and debriefing in the Division of General Surgery I saw the checklist as an opportunity to institutionalize briefing and debriefing We had added antibiotic administration to the JCAHO-mandated time out many years ago 9 3

UWMC Safety Attitudes Questionnaire - Results Agree or strongly agree After Checklist easy to use 56% Checklist improved O.R. safety 60% Took a long time to complete 23% I would want checklist for me 88% Communication was improved 81% Checklist helped to prevent errors 67% 10 Checklist and Complications Before After n=3773 n=3955 SSI 6.2% 3.4% Unplan Return-O.R. 2.4% 1.8% Any Complic 11.0% 7.0% Death 1.5% 0.8% Haynes. NEJM 2009; 360: 491-9 11 Changes in Safety Attitudes and Change in Complication Rates Haynes. BMJ Qual Saf 2011;20:102e107 12 4

Checklist and Complications Before After n=3760 n=3820 SSI 3.8% 2.7% Complic/100 pts 27.3 16.7 Pts with Complic 15.4% 10.6% Death 1.5% 0.8% de Vries. NEJM 2010; 363: 1928-37 13 Checklist Completion and Complications Checklist Completion Complic Above median 7.1% Below median 11.7% de Vries. NEJM 2010; 363: 1928-37 14 5

Communication Quality and Surgical Morbidity Davenport. JACS 2007;205: 778-784 16 Impact of Briefings on Delays All reported delays Surgeon-reported delays Communication breakdowns 31% reduction 82% reduction 19% reduction Nundy. Arch Surg 2008; 143:1068-72 18 6

Behavioral Marker Risk Index (BMRI) Briefing Information sharing Inquiry Vigilance and awareness Adjusted Odds Ratio Risk Factor Complication or Death BMRI 4.82 ASA 1.51 Mazzocco. Amer J Surg 2009; 197: 678-85 20 Challenges Ahead Institutionalizing the checklist Every O.R., every case Supporting the culture change that the checklist suggests Getting the buy-in of all surgeons Streamlining the checklist to meet the needs of individual hospitals and specialties while preserving the essentials Remembering the debriefing! 21 7

Prior to Skin Incision: All Team Members Briefing (Attending Surgeon Leads): Each person introduces self by name and role Surgeon, Anesthesia team and Nurse confirm patient (at least 2 identifiers), site, procedure Personnel exchanges: timing, plan for announcing changes Description of procedure and anticipated difficulties Expected duration of procedure Expected blood loss & blood availability Need for instruments/supplies/iv access beyond those normally used for the procedure Questions/issues from any team member and invitation to speak up at Nursing/Tech reviews: Equipment issues (instruments ready, trained on, requested implants available, gas tanks full) Sharps management plan Other patient concerns Anesthesia reviews: Airway or other concerns Special meds (beta blockers, etc.) Allergies Conditions affecting recovery any time in the procedure 22 Prior to Skin Incision: All Team Members Briefing (Attending Surgeon Leads): Each person introduces self by name and role Surgeon, Anesthesia team and Nurse confirm patient (at least 2 identifiers), site, procedure Personnel exchanges: timing, plan for announcing changes Description o of procedure pocedueand anticipated difficulties Expected duration of procedure Expected blood loss & blood availability Need for instruments/supplies/iv access beyond those normally used for the procedure Questions/issues from any team member and invitation to speak up at Nursing/Tech reviews: Equipment issues (instruments ready, trained on, requested implants available, gas tanks full) Sharps management plan Other patient concerns Anesthesia reviews: Airway or other concerns Special meds (beta blockers, etc.) Allergies Conditions affecting recovery any time in the procedure 23 Prior to Skin Incision: All Team Members Briefing (Attending Surgeon Leads): Each person introduces self by name and role Surgeon, Anesthesia team and Nurse confirm patient (at least 2 identifiers), site, procedure Personnel exchanges: timing, plan for announcing changes Description o of procedure pocedueand anticipated difficulties Expected duration of procedure Expected blood loss & blood availability Need for instruments/supplies/iv access beyond those normally used for the procedure Questions/issues from any team member and invitation to speak up at Nursing/Tech reviews: Equipment issues (instruments ready, trained on, requested implants available, gas tanks full) Sharps management plan Other patient concerns Anesthesia reviews: Airway or other concerns Special meds (beta blockers, etc.) Allergies Conditions affecting recovery any time in the procedure 24 8

After Skin Closure Complete: No Retained Objects, Debriefing, Care Transition All Team Members (Attending Surgeon Leads): Surgeon and Anesthesia: Confirm final needles/sponges/ Key concerns for patient instruments count correct recovery Nursing/Tech show Surgeon and What is the plan for pain mgmt? Anesthesia all sponges and laps in What is the plan for prevention holders ( Show Me Ten ) of PONV? Confirm name of procedure If specimen, confirm label and instructions (e.g., orientation of specimen, 12 lymph nodes for colon CA) Equipment issues to be addressed? Response planned (who/when) What could have been better? Improvement planned (who/when) Does patient need special monitoring (time in RR, ICU, tele?) If patient has elevated blood glucose, plan for insulin drip formulated If patient on beta blocker, postop continuation plan formulated 25 After Skin Closure Complete: No Retained Objects, Debriefing, Care Transition All Team Members (Attending Surgeon Leads): Surgeon and Anesthesia: Confirm final needles/sponges/ Key concerns for patient instruments count correct recovery Nursing/Tech show Surgeon and What is the plan for pain mgmt? Anesthesia all sponges and laps in What is the plan for prevention holders ( Show Me Ten ) of PONV? Confirm name of procedure If specimen, confirm label and instructions (e.g., orientation of specimen, 12 lymph nodes for colon CA) Equipment issues to be addressed? Response planned (who/when) What could have been better? Improvement planned (who/when) Does patient need special monitoring (time in RR, ICU, tele?) If patient has elevated blood glucose, plan for insulin drip formulated If patient on beta blocker, postop continuation plan formulated 26 After Skin Closure Complete: No Retained Objects, Debriefing, Care Transition All Team Members (Attending Surgeon Leads): Surgeon and Anesthesia: Confirm final needles/sponges/ Key concerns for patient instruments count correct recovery Nursing/Tech show Surgeon and What is the plan for pain mgmt? Anesthesia all sponges and laps in What is the plan for prevention holders ( Show Me Ten ) of PONV? Confirm name of procedure If specimen, confirm label and instructions (e.g., orientation of specimen, 12 lymph nodes for colon CA) Equipment issues to be addressed? Response planned (who/when) What could have been better? Improvement planned (who/when) Does patient need special monitoring (time in RR, ICU, tele?) If patient has elevated blood glucose, plan for insulin drip formulated If patient on beta blocker, postop continuation plan formulated 27 9

Intraoperative Behavior and Surgical Site Infections Significant behavior elements: Exchange of surgical team members Movement in the O.R. Noise Visitors Not significant elements: Preparation of patient - extended v. standard Hand scrub - extended v. standard Type of cap/mask Distance to surgical tables maintained Change of patient s position Beldi. Am J Surg 2009; 198: 157-62 31 Effect of Noise in the O.R. on SSI Risk Kurmann. Br J Surg 2011; 98: 1021-25 32 JAMA 2010; 304:1693-1700 11

Team Training in the O.R. Day-long onsite learning session involving Surgeons Anesthesiologists Nurse anesthetists Nurses Technicians Neily. JAMA 2010; 304:1693-1700 34 Team Training in the O.R. (Content) Work as a team Challenge each other about safety risks Conduct checklist guided briefings and postoperative debriefings Communication strategies recognize red flags rules of conduct for communication stepping back to reassess a situation effective communication during care transitions Neily. JAMA 2010; 304:1693-1700 35 Team Training and Mortality Neily. JAMA 2010; 304:1693-1700 36 12

Team Training and Mortality In each facility, for every reported increase in degree of briefings and debriefings, mortality was reduced by 0.6 per 1000 procedures (95% CI, 0.3-0.8, 0.8, p-0.001) Neily. JAMA 2010; 304:1693-1700 37 Improvements Reported by Medical Team Training Facilities From Structured Interviews Neily. JAMA 2010; 304:1693-1700 Clearly, culture, communication and teamwork in the O.R. have an enormous amount to do with patient outcome, including SSI risk and many other potential complications. 39 13

Thank You 40 14