Sustainable changes to improve theatre efficiency through implementation of a locally adapted checklist for use in Tanzania.

1. Sustainable change
Lifebox KCMC
Dr E Joynes
THET conference London
October 2017

2. Background
• Kilimanjaro Christian Medical Centre (KCMC)
• Referral hospital for Northern Tanzania
• Health partnership between Lifebox and
KCMC
• Projects to promote safe anaesthesia

3. Sustainable projects
– Equipment – a little yellow box
– Education – National nurse curriculum
– Efficiency and safety in theatre

4. How to maintain this partnership?
– Lifebox fellow
– Education and empowerment of local faculty
– Pulse oximeters and Lifebox training
– Funding

5. How to maintain this partnership?
– Regular follow up of quality improvement (QI)
projects
– Communication and good relationships

6. Successful projects
The Surgical Safety Checklist
• Multiple attempts to roll out checklist at KCMC
• A needs assessment was carried out
• Surgical heath care staff education
• Checklist was implemented

7. Theatre efficiency
• Theatre cancellations before and after
checklist
• Number of operations
• Cancellations
• Reasons for cancellations
• Start/finish times

8. Checklist
• Audited:
– Sign in
– Time out
– Handover to recovery
• We assumed improved compliance would
result in improved
– Safety
– Efficiency
– Reduced cancellations

9. Findings: Checklist
• Morning team brief 59%
• Sign-in 87%
• Sign-out 67%
• Recovery handover 35%

10. Table 1: Compliance with checklist
First audit cycle Second audit cycle
Sign-in 41% 87%
Sign-out 0% 67%

11. Table 3. Operations and cancellation rate
Theatre
After checklist
Ops
planned
Ops
done
Ops
cancel
Start
Time
earliest
Start
time latest
Finish
time
latest
1 207 189 18 (9%) 9.30 12.45 20.00
2 270 189 81 (30%) 9.00 16.20 20.00
4 366 280 86 (23%) 8.30 13.00 20.00
5 235 190 45 (19%) 9.15 16.00 21.00
average 269 212 20%
Before
checklist
1 509 401 108 (21%) 8.40 12.50
2 449 278 171 (38%) 9.15 16.15
4 826 514 312 (38%) 8.55 13.40
5 525 350 175 (33%) 9.00 13.30
average 577 386 33%

12. Table 4: Reason for cancellations
Surgical Anaesthetic Patient Theatre
(delay/chan
ge/
Out of
time)
Not
paid
Before
Checklist
10.5%
(76)
0.5%
(4)
24%
(126)
57%
(402)
8%
(59)
After
Checklist
8%
(21)
2%
(6)
41%
(111)
39%
(103)
10%
(25)

13. Discussion: Checklist
• Compliance improved after implementation.
– ENT (100%)
– Ophthalmology (0%)
• Sign-in 87%
• Sign out 67%
• Pre-operative assessment: recognise/prevent problems
• Sign-out improved following critical incident
• Development of safety culture

14. Discussion: Checklist
• Barriers:
– Lack of seniors
– Lack of ownership in theatre
– Communication
– Extra work
– Paper checklist (not in notes) versus wall laminate
– Lack of compliance - sign-out and recovery handover
– Improved compliance during audit week

15. Discussion: Efficiency
• Cancellations decreased
– 39%
• Improved efficiency

16. Discussion: Efficiency
• Cancellations due to theatre efficiency
– 57%
– 39%
• Patient factors increased after implementation
– 24%
– 41%
• Patient problems highlighted in pre-op
assessment

17. Recommendations
1. Education/awareness
2. Satellite theatres
3. Introduce to obstetrics and emergencies
4. Champion/fellow
5. Handover to recovery

18. Conclusion
• Successful healthcare change through a
sustainable partnership between KCMC and
Lifebox
• Barriers – lack of fellow, more work, lack of
communication and structure

19. 5.19

20. References
• The Lancet commission on Global Surgery, 2015.
Accessed 7/4/2017 at
www.lancetglobalsurgery.org
• Haynes AB, Weiser TG, Berry WR, Lipsitz SR,
Breizat AHS et al. A Surgical Safety Checklist to
Reduce Morbidity and Mortality in a Global
Population. New England Journal of Medicine
2009; 360: 491-499.