Call 3: Background of Each Checklist

Item

Topics Covered on the Last Webinar

• Review of articles that have been written about the impact of the checklist.

• The importance of data to physicians and how to talk to physician’s about data.

• Building a Checklist Implementation Team:– The role that this team plays– Who should be on the team– How often the team should meet– How to find the “right” people to lead this work

Meet the Team

Lizzie EdmondsonSurgical Area Senior Program

Manager Harvard School of Public Health

Today’s Topics• Poll• An in depth discussion of why each item is

on the South Carolina Checklist Template. • Overview of what is to come in 2013

– Part II of the webinar series– January 23, 2013 In-Person Meeting

Poll 1• When the checklist is performed in your ORs, does the

surgeon share the following information when all team members are present: (Click on the information that is routinely shared by surgeons in your hospital)– Operative plan– Possible difficulties– Expected duration– Anticipated blood loss– Implants or special equipment needed

• How often do the surgeons in your hospital share this information with the entire team?– <50%– >50%– Every case performed

Background of Checklist Items

JC/Standard of Practice

WHO/SC Checklist

SCIP

South Carolina Checklist

Integrates routine safety practices from the Joint Commission, Surgical Care

Improvement Project and the WHO Surgical Safety Checklist Into One Streamlined

Process

A Key Step In Successful

Implementation: Educating Surgical

Team Members About Checklist Items

JC/Standard of Practice

WHO/SC Checklist

SCIP

Before Induction of Anesthesia

Where should it take place?

A best practice is to have this part of the checklist performed in the OR.

Why should this be performed in the OR?

While many of these items are performed in the pre-op area most hospitals do not perform

these safety checks together as a team.

It is important to have the surgical tech involved in this conversation – Hospitals that perform this section in the OR

have had techs contribute important information.

At a minimum who should participate?

Anesthesiologist/CRNACirculating Nurse

Surgical tech

Verify Patient Identification A Joint Commission

• The intent is:– To reliably identify the individual as the person

for whom the service or treatment is intended;– Match the service or treatment to that

identifier. Use at least two ways to identify patients.

• Acceptable identifiers include the patient’s name, date of birth, medical record number or other person specific identifiers.

Verify Surgical SiteA Joint Commission

• Assures the procedure is performed on the correct place on the patient’s body.

• The surgical site must be confirmed multiple times before skin incision.

Verify Surgical Procedure to be Performed Matches the Consent

A Joint CommissionTeam members will verify that the consent is

consistent with the patient’s expectations and the teams understanding of the intended

procedure/site.

Verify Site MarkedA Joint Commission

Verifying correct site marking in the operating room prior to induction is a redundancy step for the patient and team to assure the correct site was marked, and

that there are not any discprencies.

Verify Known AllergiesThe WHO/SC Checklist

• This item confirms that the team is aware of any allergies that pose a risk to the patient.

• There have been cases where the patient has told different care providers different information.

• It is important for the surgical team to confirm this multiple times with the patient and amongst the surgical team.

Verify Patient PositioningPast Joint Commission

Requirement/Standard of Practice

This step verifies that the team is prepared and aware of the intended patient position

for the procedure and that positioning devices are available.

Verify the Anesthesia Safety Check Has Been Completed

The WHO/SC ChecklistThis is a verbal verification that a complete

formal inspection of the anesthetic equipment, medications, and patient’s

anesthetic risk was performed before the case.

Anesthesia Provider Shares Anticipated Airway or

Aspiration RiskThe WHO/SC Checklist

This is a prompt for the anesthesia provider to share information from the airway

assessment that was performed on the patient in the pre-op holding area.

Anesthesia Provider Shares Risk of Significant Blood loss

The WHO/SC Checklist• This is a prompt for the anesthesia provider to

share information with the rest of the team.• If the patient is at risk for significant blood loss

the team should discuss if two IVs/central access are planned, type and crossmatch/screen, and confirm blood availability.

• The checklist asks for the team to discuss blood loss one more time when the surgeon is present. There are times when the surgeon is the only person that holds this information.

Anesthesia Provider Shares Risk of Hypothermia

Surgical Care Improvement Project (SCIP)

• SCIP recommends that patients should be warmed if the duration of the procedure is > 1 hour.

• This item is to confirm if warming is needed and in place.

Anesthesia Provider Shares Risk of Venous

Thromboembolism Surgical Care Improvement Project (SCIP)/CMS Quality

MeasureIf a patient is at risk for a DVT the surgical team should confirm that boots and/or anticoagulants

are in place.

JC/Standard of Practice

WHO/SC Checklist

SCIP

Before Skin Incision:The Briefing

Where should it take place:?

In the OR, immediately before skin incision

Why should this be performed?

The Joint Commission gave us a place to stop with the Time Out. The SC Checklist asks the team to discuss additional information

at this time.

At a minimum who should participate?

Anesthesiologist/CRNACirculating Nurse

SurgeonSurgical tech

Other people that are in the room

Entire Surgical Team: Is everyone ready to perform

the time out?SC Checklist

This is a prompt to get everybody that is in the OR to stop and participate in the Joint Commission Time Out and the Briefing.

Entire Surgical Team: Please State Your Name and

RoleWHO/SC Checklist

• Teams are more efficient when they refer to each other by name.

• Research has shown that if somebody says something at the beginning of a case and is activated they will be more likely to voice their concerns if they see something.

• Everyone that is in the room should introduce themselves at this time including, reps, observers, and students.

Patient’s Name, Surgical Procedure to Be Performed,

and Surgical SiteA Joint Commission

• It is required for the entire surgical team to verify the patient’s name, the surgical procedure to be performed, and the surgical site before skin incision.

• The Joint Commission now requires that all surgical team members actively participate in the Time Out.

Has antibiotic prophylaxis been given within the last 60 minutes?

Surgical Care Improvement Project (SCIP)/CMS Quality

Measure• This is a prompt for the anesthesia provider

to verbally confirm with the team that the antibiotics have been completely infused prior to skin incision.

• It is also recommend that a plan for antibiotic re-dosing is also discussed at this time.

Surgeon Shares: Operative Plan

WHO/SC ChecklistThis is an opportunity for the surgeon to

share critical information with the surgical team.

Surgeon Shares: Possible DifficultiesWHO/SC Checklist

• This is a prompt for the surgeon to discuss anything unique about the procedure and non-routine steps.

• If no difficulties are expected the surgeon may state that they do not expect anything unusual and that it is a routine case.

Surgeon Shares: Expected DurationWHO/SC Checklist

• It is recommended that the surgeon inform the team of the expected duration.

• Informing the team of the expected duration helps the anesthesiologist plan appropriately and for the nursing team to plan for subsequent procedures.

Surgeon Shares:Anticipated Blood Loss

WHO/SC Checklist• This is another check to confirm the

estimated blood loss. • It is recommended that blood loss be

discussed multiple times, especially when the surgeon is not in the room before the induction of anesthesia.

Surgeon Shares:Implants

or Special Equipment Needed WHO/SC Checklist

(Previously Recommended by TJC)• It is recommended that the surgeon briefly

discuss the equipment and implants that are needed for the case.

• Discussing equipment and implant issues before skin incision have been shown to decrease the number of times the circulator leaves the room, ultimately decreasing OR time.

Anesthesia Provider Shares:Anesthetic Plan

WHO/SC ChecklistIt is recommended that the

anesthesiologist/CRNA shares the anesthetic plan with the surgical team, particularly any concerns with major

morbidities.

Anesthesia Provider Shares:Airway Concerns

WHO/SC Checklist• This is a prompt for the

anesthesiologist/CRNA to share airway concerns with the surgical team.

• If there are no airway concerns the anesthesiologist/CRNA may state that there they do not have any concerns.

Anesthesia Provider Shares:Other Concerns

WHO/SC Checklist• This is a prompt for the

anesthesiologist/CRNA to share any other concerns that they might have about the patient.

• Sometimes people won’t share concerns unless they are given the specific opportunity to do so.

Circulating Nurse and Scrub Tech Share Sterility, Indicator

ResultsStandard of Practice

• It is recommended that the scrub nurse/ technologist verbally confirm that the sterilization was performed and that for heat sterilized instruments, a sterility indicator has verified successful sterilization.

• It is important to have the scrub nurse/technologist contribute to the briefing.

Circulating Nurse and Scrub Tech Share Equipment Issues

WHO/SC Checklist (Previously Recommended by

TJC)It is recommended that the circulating nurse and Scrub Tech raise any concerns about instrumentation immediately before skin

incision.

Circulating Nurse and Scrub Tech Share Other Concerns

WHO/SC Checklist• This is an opportunity for the circulating

nurse and scrub tech to share any other concerns that they have.

• Sometimes people won’t share concerns unless they are given the specific opportunity to do so.

Surgeon Says:“Does anybody have any

concerns? If you see something that concerns you during this case

please speak up.”WHO/SC Checklist

This statement helps set a tone of openness during the case and encourages team

members to verbalize any concerns regarding patient care.

JC/Standard of Practice

WHO/SC Checklist

SCIP

Before The Patient Leaves The Room: The Debriefing

Where should it take place?

In the OR, after the sponge counts have been confirmed

Why should this be performed?

This is an opportunity for the entire surgical team to come

together one last time and talk about the patient.

At a minimum who should participate?

Anesthesiologist/CRNACirculating Nurse

SurgeonSurgical tech

Other people that are in the room

Circulating Nurse Reviews With the Team: Instrument,

Sponge, and Need Counts Are Correct

Standard of PracticeThis items prompts the circulating nurse to

announce the final count status to the team. This allows teams to appropriately reconcile

counts as needed.

Circulating Nurse Reviews With the Team:

Name of Procedure Performed

WHO/SC ChecklistThis item prompts the team to verbally confirm

the name of the procedure that was performed. The nurse should confirm with the surgeon how to record what procedure was done and how it should be recorded in the

patient records.

Circulating Nurse Reviews With the Team:

Specimen Labeling WHO/SC Checklist

• This item prompts the nurse to read back the specimen labeling including the patient’s name, specimen description, and any orienting marks to the surgical team.

• This will help prevent mislabeling or mishandling of specimens.

The Entire Team Discusses:Equipment Problems That

Need to Be AddressedWHO/SC Checklist

• This is an opportunity to discuss any equipment problems. This is an opportunity to fix many of the equipment issues that frustrate surgical team members.

• We highly recommend that your hospital develops a system to capture this feedback and fixes equipment problems when they are identified.

The Entire Team Discusses:Key Concerns for Patient

Recovery and ManagementWHO/SC Checklist

• This is an opportunity for the entire surgical team to have a conversation about the patient before the end of the case.

• It is recommended that team members review post-op recovery and management plan focusing on intraoperative or anesthetic issues that might affect the patient.

The Entire Team Discusses:What Could Have Been Done to Make This Case Safe and

More Efficient? WHO/SC Checklist

• The final item on the checklist prompts the team to discuss anything that they could have done to improve patient safety or efficiency.

• The goal of this item is to improve team communication and promote transparency.

Overview Of What Is To Come In 2013

Part II of the Educational Series

February 7, 2013Topics that will be covered:

Checklist CustomizationSmall-Scale Testing

Physician EngagementWide-Scale ImplementationMonitoring Your ProgressSustaining Checklist Use

Second Surgical Teamwork Collaborative MeetingWednesday, January 23rd, 2013

South Carolina Hospital Association

Columbia, SC

Before We See You In January• Form a checklist implementation team and schedule

regular meetings. • Block time to participate in the Part II of the Educational

Series. This will start February 7th, 2013.• If you haven’t already, administer the Safe Surgery 2015

Culture Survey. Please contact Katie Jahreis to get started (kjahreis@hsph.harvard.edu).

• If you feel like your hospital has a good checklist and it is used routinely ask Ashley Kay Childers to come to your hospital for a site visit (childer@clemson.edu).

We Will Still Be Holding Office

Hours:Wednesdays 2:00-

3:00

?Questions

We Will Be Sending You An Email With:

• A document that describes where each checklist item is derived from and references to the literature supporting each item.

• A link to watch the recording of today’s webinar and to download today’s slides.

Resources

Website:www.safesurgery2015.org

Email: safesurgery2015@hsph.harvard.edu