The Surgical Checklist and Beyond

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Learn about the principles behind the surgical checklist and the evidence for adopting the checklist and how one NHS Board has applied the checklist to their surgical theatres and how another has expanded the checklist principle to other areas.

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The Surgical Checklist and Beyond

  1. 1. Surgical Checklists and Beyond Jill Ferbrache, Practice Educator, SPSP Fellow Claire Gordon, Consultant Acute Medicine, SPSP Fellow
  2. 2. A checklist
  3. 3. Surgical Checklists
  4. 4. SUB HEADING TO BE
  5. 5. SUB HEADING TO BE
  6. 10. Around 500 beds 50 – 70 patients/day through trolleys Co-located Medical Admissions Unit Medical specialities, neuro, oncology, infectious diseases, rheumatology and dermatology. Increasing complexity, changing work patterns
  7. 11. Government concern regarding Lothian’s performance against the 4h Emergency Care Standard Reducing bed base, better ‘capacity’ than other sites Boarding
  8. 12. <ul><li>Delayed discharges/ Length of stay </li></ul><ul><li>Flow – discharges occur late in the day </li></ul><ul><li>Boarding! </li></ul>
  9. 13. <ul><li>When an ED is busy, mortality increases </li></ul><ul><li>Fail-proof mechanisms necessary to avoid omissions </li></ul><ul><li>Human fallibility, we cannot be in ‘control’ all the time, everywhere </li></ul>
  10. 14. 50% pts had allergies documented 50% medical patients had VTE prophylaxis prescribed 20-30% of patients had oxygen prescribed 60% had Consultant impression and plan clearly documented
  11. 15. Sepsis audit: Average time to antibiotics close to 4h, fluids 4h Investigations not chased before moved to a downstream ward Juniors stressed about not handing over jobs before patients moved downstream Investigations ordered, not chased
  12. 16. Decision to have a Consultant sticky and a Junior checklist Consultants to document impression and plan Juniors to complete checklist: investigations, kardex, fluids, warfarin, insulin, oxygen, VTE prophylaxis
  13. 17. <ul><li>POST TAKE WARD ROUND </li></ul><ul><li>Date………………. Time………... Cons……………. </li></ul><ul><li>Bloods seen Y/N/na X-rays seen Y/N/na ECG seen Y/N/na </li></ul><ul><li>Kardex: Written Y/N Allergies recorded Y/N </li></ul><ul><li>Thromboprophylaxis prescribed Y/N </li></ul><ul><li>Oxygen prescribed Y/N/na </li></ul><ul><li>Insulin charted Y/N/na Warfarin Y/N/na </li></ul><ul><li>IV fluids prescribed Y/N/na </li></ul><ul><li>Outstanding Jobs………………………………………………. </li></ul><ul><li>…………………………………………………………………… </li></ul><ul><li>…………………………………………………………………… </li></ul><ul><li>Signed………………………………… Bleep………………… </li></ul>
  14. 18. <ul><li>CONSULTANT SUMMARY Date............................Time............................ </li></ul><ul><li>Impression .......................................................................................................................................................................................................................................................................................................................................................................................................................... </li></ul><ul><li>Plan..................................................................................................................................................................................................................................................................................................................................................................................................................................... </li></ul><ul><li>Signed........................................................... </li></ul><ul><li>Name...........................................Contact No ............................... </li></ul>
  15. 19. <ul><li>Consultants initially very positive Impression/ plan documentation up to 95% </li></ul><ul><li>Naming and shaming helping to keep them on their toes </li></ul><ul><li>Most frequent complaint is of added time to ward round </li></ul>
  16. 20. <ul><li>Junior Checklist </li></ul><ul><li>Paper version failed </li></ul><ul><li>Ambiguity around tick boxes or Y/N/na </li></ul><ul><li>Data from cycle 2 showing when stickies used, VTE prophylaxis and allergy documentation rose to 98% </li></ul>
  17. 21. <ul><li>Data about sticky completion fed back weekly </li></ul><ul><li>Now Junior sticky completion approaching 100% </li></ul>
  18. 22. Sticky Completion Dr Morse on call New Docs Stickies ran out
  19. 23. <ul><li>3 rd cycle of comprehensive audit </li></ul><ul><li>Sticky completion 95% </li></ul><ul><li>VTE prophylaxis 95% </li></ul><ul><li>Allergy documentation 95% </li></ul><ul><li>Oxygen prescribing improving 67% </li></ul><ul><li>Cons imp/plan 80% </li></ul>
  20. 24. <ul><li>Presented nationally </li></ul><ul><li>Classic example of PDSA in action </li></ul><ul><li>Rolling cohorts of juniors involved </li></ul><ul><li>Now part of culture??? </li></ul><ul><li>New docs – some teething problems ‘blanks’ - improving </li></ul>
  21. 25. <ul><li>General ward </li></ul><ul><li>Recognition of the deteriorating patient </li></ul><ul><li>Communication between ‘silos’ </li></ul><ul><li>Repeated ‘handovers’ </li></ul><ul><li>Trying to introduce safety briefs, failed ‘huddles’ </li></ul><ul><li>Anticipatory care, LCP </li></ul><ul><li>Trying to improve quality </li></ul>
  22. 26. <ul><li>Date……………….. Time…………WR…………………. </li></ul><ul><li>Review </li></ul><ul><li>Daily goals : 1)………………………………………………… </li></ul><ul><li>2)………………………………………………… </li></ul><ul><li>3)………………………………………………… </li></ul><ul><li>4)………………………………………………… </li></ul><ul><li>5)………………………………………………… </li></ul><ul><li>Nursing : PVC Y/N Needed Y/N Review site </li></ul><ul><li>Incontinent? Diarrhoea? </li></ul><ul><li>For LCP? </li></ul><ul><li>Pharmacy : Antibiotics………………..……………… </li></ul><ul><li>Thromboprophylaxis Y/N </li></ul><ul><li>Dosette box Y/N </li></ul><ul><li>Patient at risk of deterioration Y/N </li></ul><ul><li>FOR ESCALATION/ NOT FOR ESCALATION/ UNDECIDED </li></ul><ul><li>FOR CPR/ DNACPR/ UNDECIDED </li></ul><ul><li>Signed………………………….. Bleep…………………. </li></ul>
  23. 27. <ul><li>Making it easy to ‘do the right thing’ </li></ul><ul><li>Every patient, every time </li></ul><ul><li>Measureable improvement </li></ul><ul><li>Create confidence and trust in our system </li></ul><ul><li>Humility to accept our fallibility </li></ul><ul><li>Embedding this in all staff </li></ul>

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