WHO Surgical safety checklist Successes and obstacles In Implementation

by: Dr.Dina Baroudi. on 26-12-2009

Introduction
Patient safety is defined as the actions undertaken by individuals and organizations to protect health care recipients from being harmed by the effects of health care services. This definition verifies that health care in general is a risky field. Facts , figures, and media assure the harmfulness connected to healthcare . Globally, adverse events that occur in hospital settings vary between 4%-16% , half of those adverse events are related to surgical procedures, 50% of which are preventable. The World Health Organization, as the highest authority regulating the heath sector world wide , acknowledged this problem and developed through the patient safety division within the organization scientifically approved methods aiming to reduce the risk linked to surgical procedures and launched the first and advanced surgical safety checklist. The development of this checklist passed through several processes such as consultation of international experts , limited and multi-center trials , pilot location implementation and finally the advanced version of the checklist. In order to have the checklist widely implementable , the WHO gave the freedom to health institutions to modify the list according to their needs provided that the basic elements of the original list are present , however, modification of the list must consider the same guidelines of the list itself in being focused , brief, actionable, verbal, collaborative, tested, and integrated
Initiative Summary
The Checklist(CL) was launched in 2008 as a second global safety challenge, " Safe surgery save life" as an initiative of WHO World Alliance for patient safety with the aim to diminish the number of surgical deaths across the world , it contains 19 items as a core of surgical safety principles to keep common problems in the front of everyone's mind .The CL can be applied in all healthcare settings , requires only few minutes to be completed at three critical points during operative care , before anesthesia administration , before skin incision and before the patient leaves the operating room , with the aim to assure safe anesthesia delivery , appropriate administration of antibiotics and above all effective team work inside the operating theater.
The famous study that was published in the New England journal after implementing the list on a good sample of patients showed that there is a reduction in deaths from 1.5 % to 0.8% and inpatient complication from 11% to 7%.
Important Remarks about the checklist ( CL)
1- The CL is an additional tool to assure patient safety in the operating room
2- The CL is not indented to replace other institutional policy already present on site such as the patient acceptance into the operating room , the universal protocol for patient identification , Site marking., and time out process .
3- The CL is designed to eliminate the need to memorize.
4- The CL carefully guides the staff inside the operating room to the most commonly performed tasks during surgery.
5- The WHO accepted the need of some health care institutes to add additional safety issues based on the institute scope of services, therefore the modification of the list was permitted , as an example is the importance of neonate temperature in neonatal surgery.
6- The CL improves communication among staff involved in patient care into the operating room.
7- The CL debriefing is a very powerful tool to establish the post operative patient management plan.
M. S .Basharahil Hospital Journey with the checklist.
Complying with hospital mission in providing quality and safe medical practice , patient safety in the hospital is a main concern issue with a serious support from leadership. The Anesthesia department in the hospital published in January 2009 a review article about Patient Safety in Anesthesia, the article was very well accepted and the topic was presented on national and international patient safety events. At that time the checklist was still a drafted first edition , it is with no doubt that we can never speak about patient safety in general and anesthesia in particular and ignore the newly developed WHO checklist , therefore the checklist was introduced briefly as a new initiative with shared goals to assure patient safety in surgical setting. The initial implementation of the checklist started on an unofficial base in February 2009 on a very small scale of surgeries as a test of staff acceptance , in which we carefully choose the cases and intentionally prioritize cooperative surgeons. During this phase we were always guided by the WHO CL implementation manual and other WHO published materials , we were shocked by the primary results that we obtained specially when it goes on antibiotic administration time , equipment malfunction issues , and debriefing at the end of surgery , although we had no what so ever problem in complying with items related to patient acceptance into surgery as regards patient identification , site , procedure , consent . Here we realized that the checklist addresses issues not covered by our implemented policies and raised the question of the appropriateness of our antibiotic administration policy.
On August 2009, and on the occasion of celebrating the first anniversary of the check list , we were approached through e-mails from the Safe surgery save life group in Harvard Public health , in which they are encouraging the hospital institution to implement the checklist and register the hospital with the initiative , so we did our part and we presented to the hospital administration as an improvement project in operating room as a joint project between quality department and Anesthesia department. We obtained the full support from the hospital manager in this regards and we started the full implementation , here we have to confess that we were surprised and overwhelmed by the full support that we obtained from Harvard public health , we were free to ask any question as regards implementation and we were always promptly supplied with supporting materials and evidences.
Checklist modification:
Although the checklist covered the most important aspects in assuring patient safety in the surgical setting , our implementing team had meetings on what we can add to the list to make the checklist even better tailored to our hospital. We reached a consensus that some modification are needed :
1- End Tidal CO2 - : We understand the WHO standpoint that in order to have the CL able to be implemented world wide , specially when it goes to the underdeveloped countries with limited resources that they limit the mandatory essential monitoring to pulse oxymeter. In our hospital and complying with Anesthesia department mandatory monitoring policy where essential monitoring to all anesthetized patient are SPO2-ETCO2-BP-ECG-TEMP , so we added to the sign in section of the checklist the ETCO2 , as calibrated and ready to work .
2- Malamapati Score : The checklist address the issue of patient airways evaluation and the need to have special equipment and assistance to deal with difficult airways , however we found it appropriate to standardize this item in adding the difficult airway grading known as Malamapati score , all patient with score III-IV , need to have the presence of assistance and special equipment .
3- Bleeding Time / Clotting Time by regional anesthesia : Complying with the checklist aim to assure the safety of the patient as a last minute check , we found that addressing the issue of coagulation status of the patient prior to undergo regional or central block is a useful tool to avoid serious adverse events if neglected ,so we added this item as a safe heaven .
4- Alderlt Scoring in the debriefing .Patient admission and discharge from our recovery room is based on Alderlt score , prior to implementing the CL , the patient recovery score based on Aldert was primarily evaluated in recovery room and thereafter , and we never had a debriefing at the end of surgery , therefore in an effort to inform the all team of patient status upon the ending of surgery we summarize it as evaluating the recovery score , and we found it a very useful tool as well for quality measurement purpose .
After this modification , our checklist get approved and implementation was enforced to all patient , here we discovered the first pitfall we encountered during the initial implementation trial, we were excluding emergency surgery , in fact the CL is the tool needed in case of emergency patient ,just to assure patient safety within a chaotic situation.
Checklist Acceptance:
The acceptance of checklist implementation vary from person to person , therefore in evaluating the acceptance of the CL we found it appropriate to have it categorized ,
First as Staff acceptance and Patient Acceptance , and within the staff , as Nursing staff ,Anesthesiologist , Junior Physician , senior physician .
1- Staff Acceptance:
a- Nursing Staff : The CL / Actually solved some nursing problem in operating room , specially when it goes on team work . therefore our nursing staff were too eager to implement and improve the implementation , although some misunderstanding at the start if the CL is going to replace other measures taken before , in this regard we made a meeting and confirm that the CL is not a substitute of any other processes and it is an adding tool .
b- Anesthesiologist : The acceptance from our anesthesia department was as well very good , the list give the legal permission to the anesthesiologist not to touch the patient if not the all team is there , it improves the communication with surgeon .
c- Junior Surgeon: Junior surgeon accepted the CL very good and found it as a tool to have a voice within the team and to express some concern freely and may be because the new generation of physician are more and more oriented to quality care than older generation.
d- Senior Physician: in the first phase we encountered resistance in form of taking the list lightly, not implement the debriefing, it is some body concern but not there concern, make the patient asleep I will come latter , all this statement now by the presence of checklist is passer .
2- Patient Acceptance
We were expecting that the patient will feel annoyed by the redundancy of our procedure , parallel to implementing the checklist we were undergoing a patient satisfaction survey in Anesthesia based on Iowa patient satisfaction scale , so we found it appropriate to modify a question asking the patient if he/ she feel annoyed by the redundancy of some procedure inside the operating room , surprising to all of us that the patient feel well about this redundancy , and feel better when he/ she see that the all team are gathered together inside the operating room and seriously discuss his and her safety . our result in satisfaction must be the best backup for some resisting people claiming that the patient will become afraid and feared from the checklist process .
Mortality and Morbidity study :
By now the checklist is implemented to 460 patient , and if we consider mortality during surgery as the 30 days we have a 0% mortality , therefore studying the effectiveness of checklist as regards mortality will give a vague numbers .
Morbidity .
The checklist detect the defect in antibiotic administration implementation , although our policy is clear that timing is essential and must be within 0-60 minutes prior to skin incision ,but in 67% of cases this was not implemented mainly due to the discrepancy between operating room scheduled time and actual time , so we change the policy in a way that the antibiotic will be given to the patient in the operating room . this raised the adherence of timing to 75% , comparing the Surgical skin infection trending we found that in July 2009 a rate of 4.2% prior to CL and Antibiotic administration changes and by November 2009 we have a rate of 2.3% .
Avoiding adverse events:
3 patient from 460 patient CL avoided a major complication as regards being allergic and there medical file was not flagged.
2 Patients from 460 confirm to have difficult airways through the CL and was not detected pre operatively .
10 times equipment failure was addressed and equipment was removed and not re circulated.
1 of 460 patients avoided re admission in operating room where the issue of not feeling satisfied with homeostasis was addressed.
1 of 460 case the blood needed for surgery was not ready in laboratory prior to surgery.
Compliance Measurements
Guided by the Harvard group , to measure our compliance for implementation based on the SCOAP guidelines , our next step is going to have a retrospective study of our compliance for the previous 460 patient however starting 2010 – we will be measuring this case by case ,a s we are waiting for our IT department to establish a computerized method for this.
Conclusion:
1- Patient Safety in surgery is a priority.
2- All effort must be forwarded to assure the safety of the patient.
3- Avoiding post operative complication in form of preventing skin infection by proper antibiotic administration is a safety issue .
4- Improve communication among staff in operating room lead to improve safety .
5- Hospital policy in patient acceptance into surgery and universal protocol must be implemented and it is a safety issue.
6- WHO checklist is a powerful tool to assure patient safety in operating room as an adding value to assure patient safety.
7- Proper implementation must be measured and trending of compliance must be evaluated.
8- The 19 items addressed by the WHO must be a never happened event goal in the operating room.
9- Safety is not residing in a piece of equipment , it is a collaboration between members , and can be achieved by better communication and full adherence to system.
Acknowledgment :
It is due to thank the hospital leadership , represented by the hospital general manager Eng.Turki M. Basharahil for the full support of the program , Harvard Public health represented by Mrs Lizabeth Edmendson for her permanent encouragement during implementation, WHO patient safety division , Alliance for patient safety Dr. Agnes Leotsakos for providing us with all needed educational materials.Prof Dr.Jamal El-Kheshen Infection Control leader in M.S.Basharahil hospital for supplying us with all needed SSI information.
We encourge all hospital to adopt the Surgical safety checklist and Register there hospital with www.who.int/safesurgery and
www.safesurg.org
correspond to baroudid@hotmail.com