In summary, in this session, we have learned that pre-boosts and breaks are essential not only to ensure a good day, but also to reduce adverse events, improve efficiency and make sure that our patients are kept safe. The second, top tip for safe surgery I'd like to take you through is surgical checklists. Their history, implementation, and their use.
The surgical checklist is a simple low-cost intervention proven in both human and veterinary medicine to reduce postoperative complications by at least 10%. In this session, we will discover how to to introduce and use a checklist to maximise its its effectiveness, to understand the importance of bespoke design of checklists, to consider how to implement them successfully, and to discuss the rationale for assigning the role of checklist coordinator and empowering somebody in this role. How many things can you keep on your mental scratch pad at one time?
The answer is 7, plus or minus 2, and that's only if you don't get distracted by another task in the meantime. Only 7. Well, that does explain why when I go to the local shop, I never remember all of the items that I need.
It also suggests why things are forgotten in the hospital environment. We simply can't be expected to remember everything. Therefore, to ensure that we keep our patients safe, we must use checklists.
Like many advances in medicine, the safety checklist has its roots in the military. In 1935, the US Army Air Corps started a final set of aircraft evaluations for contract to supply the US Army with potentially up to 200 long-range bomber aircraft. There were 3 aircraft competing for this large and lucrative deal.
And legend has it that all of the initial evaluations consisting of about 40 hours of flight time, had been done and went in favour of the Boeing model 299. The final flight was merely a formality. Boeing's entry had already earned itself the nickname the Flying Fortress, as it could carry considerably more bombs and fly faster and further than any of the other entries.
Flying the Model 299 that day with two highly experienced army pilots, Boeing's chief test pilot, along with a Boeing mechanic and representative of the engine manufacturer. After takeoff, the model 299 began to climb, but within a few seconds, the aircraft stalls and falls to the ground, bursting into flames upon impact. Although all on board escaped or were rescued, both pilots later died because of their injuries.
Compared to the typical plane at the time, the Model 299 was a complex aircraft with additional controls and instruments that required attention. Finding no evidence of mechanical malfunction, the accident investigation team assigned to this crash concluded that pilot error was the cause. Evidently, the pilots had made a simple but fatal mistake, and a newspaper at the time went on to state that the Model 299 was just too much plane for one man to fly.
This could have been the end of the story, but for the huge potential advantage the bomber would give the US Army if it could be flown safely. After some deliberation, the solution to the problem was simple, ingenious, but most of all effective. It was the pilot's checklist.
It turned out the pain was not too much for one man's memory, a simple too much for one man, but merely too much for one man's memory. And a simple checklist could ensure that none of the crucial steps during the key periods of flight were forgotten. Four checklists were initially developed takeoff flight before landing and after landing.
All pilots were taught how to use this checklist as part of their normal flying training, and the initial 12 model 299s tested by the army went on to fly almost 2 million miles without serious incident. And the army went on to order over 10,000 of this aircraft. The checklist was idea was so successful that it enabled aviation and aeronautical engineering to become more and more complex.
And checklists were developed for more and more parts of the flight for emergency situations, as well as more routine scenarios. At a one day was approached by the World Health organisation in 2006, who noted a steep increase in the amount of surgery being performed, which had affected the safety and quality, which had now become a big issue. A team was gathered with the remit of improving safety within hospitals and reducing harm.
Something that was cheap, simple, effective and transmissible was required. They created the checklist by looking at the key areas where common problems developed. They tested it in 8 hospitals around the world.
4 were in high income countries, America, the UK, Canada, and New Zealand, and 4 in lower or middle-income countries, Manila, Jordan, New Delhi, and Tanzania. They collected date 3 months before implementation and 3 months afterwards. At grey really worried how meagre the intervention was.
They hadn't provided any new equipment, no new staff or clinical resources to the hospital. What they found was amazing. 47% reduction in death rates, a 36% reduction in major surgical complications.
In fact, major surgical complications fell in all 8 hospitals. Infection and death rates dropped by 50%. Equally important, the health providers began to believe in the power of checklists.
Many had started out suspecting that it was just another bureaucratic distraction from the real business of dealing with patients. Three months later, 78% of participants said they'd personally seen the checklist to prevent an error in the operating room. 80% said it had improved care, and 93% of staff asked if they were having an operation.
Would they want the checklist used? Said yes. They also saw improvements in administering antibiotics duringlos, using oxygen monitoring during operations in making sure the right patient had the right surgery at the right time.
And lots of this was attributed to communication. We know within veterinary surgery, we have had a recent research has told us that there's a decrease in anaesthetic duration associated with checklist use, and increased administration of planned periopererative antibiotics before incision, increased completion of safety measures, and a decrease of unexpected return to the operating room. We also know that another paper by Cray at Al in 2018 shows that decreased odds of perioperative and post-operative surgical complications occur.
There's a reduction in post-operative surgical site infections associated with the use of the checklist. And the odds of occurrence of more than one complication. Which is reduced by over 40% after implementation of the surgical safety checklist.
It's important when we design checklists within our settings that we imple we we design it for one area first. It's a good idea to start with a relatively small area where you can get good buy in and good feedback and then work from there. What are the questions that we should ask and why?
What if evolution has occurred? We need to consider the questions asked and their relevance to the setting. Has there been a specific incident which requires inclusion?
We could use critical incident reporting systems to help us identify areas where improvement interventions are required. As in this slide, you see that the, the report from the critical, incident report shows that regurgitation right at the bottom here, has been a problem. And therefore, it's really essential that we make sure that we have a difficult area of aspiration risk mentioned as a in the signing.
We know that when we implement checklists, there's certain key features that we need to follow. We need to make sure the equipment and the processes that are required to support the use of checklists are in place before implementation begins. This could be ensuring that the checklist has been designed and printed ready for use, or is available on the computer system.
We need to make sure that we spread the work. Word, start with colleagues who are likely to be supportive and build a team of strong leaders who are prepared to champion the checklist. We need to present and explain the checklist to the whole team, taking time so that they understand the benefits, including lower complication rates, increased patient safety, and decreased costs.
And then we want to implement the checklist in just one area. We want to work through any concerns that individuals have, customise the checklist to suit the setting in which it's to be used. And then we can expand it to other areas.
When we're using The, surgical safety checklist. We want to make sure we designate and empower a checklist coordinator. And that a single person should be made responsible for performing performing the surgical safety checklist.
In practise, this will often be the circulating nurse, although any member of the team may prompt the checklist. A responsible person should feel empowered to ensure that all members of the team listen and participate attentively to the checklist so that communication is effective. Non-urgent interruptions should be discouraged, and the person leading the surgical safety checklist should feel comfortable stopping the flow of the checklist to politely remove mind.
All personnel present that their full attention is required. The checking should be halted if there's any difficulty confirming a point, for example, identifying a patient or confirming owner consent, and only resume when confirmation is made. Certain points have been found to indicate good use of the checklist.
We're just going to run through those now. We need to remember that a checklist is about a person or a patient and not just about the paper it's written on. So we need to make sure that the checklist is triggered at the appropriate times.
That the correct and complete team are present throughout. That it's used at the right times at the sign in, the time out, and the sign out. The start at the end of the checklist are verbally declared.
That there's a single person leading the checklist. Other than critical duties, everyone should be engaged and involved. And we should only continue the checklist after verbal confirmation of the previous section has been made.
We need to adopt a challenging response style to make the checklist effective. And we want to make sure that all items are consciously checked rather than just tick boxing things. We need to make sure the checklist is physically referenced throughout and it's in and and it's completed in its entirety without interruptions.
We need to make sure that we recognise that often our first attempt is not always our best. And checklists should be, tools that grow through an iterative cycle with adaptions being made to suit the team and the environment. So we enter a plan, do study act cycle where we regularly review the checklist and make sure it still serves us and works for us.
So in this section, we've looked at surgical safety checklists, their history, implementation and use.
