PREOPERATIVE PREPARATION OF SURGICAL PATIENT AND PATIENT SAFETY

1. SEMINAR ON PATIENT SAFETY
&PREOPERATIVE PREPARATION OF
SURGICAL PATIENT
Presented by
Dr Tsedale (MI)
Modulator Dr Assefa (MD,General Surgeon)

2. OUTLINE
 INTRODUCTION
 PREVALANCE
 PATIENT SAFETY INCIDENT&CONTRIBUTING FACTOR
 STARATEGYS FOR PATIENT SAFETY
 PREOPERATIVE PREPARATION OF SURGICAL PATIENT
 SPECIFIC PREOPERATIVE PREPARATION
 FACTORS AFECTING PATIENT OUT COME
 PATIENT OUT COME SCORING SYSTEM
 REFERENCE

3. OBJECTIVE
 Be able to understand
 The importance of patient safety and the scale of the
problem
 Medical errors, their range and definition
 Patient safety principles that are specific to the surgeon
 Dealing with the ‘second victim’ of a medical error
 Surgical, medical and anesthetic aspects of assessment
 How to optimize the patient’s condition
 How to take consent
 How to organize an operating list

4. INTRODUCTION
 Medicine will never be a risk-free
enterprise.
 worldwide, despite all the
improvements in treatment and
investment in technologies, training
and services,
 there remains the challenge of
dealing with unsafe practices,

5. PREVALENCE OF ADVERSE
HEALTHCARE EVENTS
 there were between 44 000 and 98 000
preventable deaths annually due to medical
error in US hospitals
 WHO estimated that even in advanced
hospital settings, one in ten
COMMON CAUSES
 inadequate communication between
healthcare staff, or between medical staff
 Poor communication b/n their patients or
family members, ranks highest in frequency.

6. PATIENT SAFETY
INCIDENTS
 A near miss =An incident that could
not harm by chance or through a
timely intervention
 A no-harm event= An incident that
occurs and reaches the patient but
results in no injury to the patient.

7. FACTORS CONTRIBUTE TO
PATIENT SAFETY.
 Human factors
 inadequate patient assessment
 Failure to use or interpret appropriate
tests
 Error in performance of an operation
 Inadequate monitoring or follow up of
treatment
 Fatigue, overwork, time pressures
 Personal or psychological factors,

8. System failures
 Poor communication between
healthcare providers
 Inadequate staffing levels
 Lack of coordination at handovers
 Environment design, infrastructure
 Equipment failure, due to lack of
parts or skilled operators
 Inadequate systems to report and
review patient safety incidents

9. STRATEGIES FOR PATIENT
SAFETY
 WHO has adopted a strongleadership
role with many initiatives aimed at
addressing safety challenges, ‘Safe
surgery saves lives
countries have developed important
strategies
 regulating and licensing of physicians
and institutions;
 developing and adopting policies for
patient safety and quality

10. Cont..
 clinical audits and reporting
 Using information technology
 Communicating openly with
patients
 Reporting adverse events and near
misses
 Staff communication, understanding
the work environment

11. PATIENT SAFETY AND THE
SURGEON
 Surgery is one of the most complex
health interventions .
 More than 100 million people
worldwide require surgical treatment
every year for different reasons.
 Problems associated with surgical
safety in developed countries
 half of he avoidable adverse events
that result in death or disability.

12. COMMON SURGICAL ERROR
 the wrong patient in the operating
room
 surgery performed on the wrong side
or site;
 the wrong procedure performed;
 failure to communicate changes in the
patient’s condition;
 disagreements about proceeding
 retained instruments or swabs

13. CHEKLIST
 Checklists in the operating theatre
as standard safety protocols since
the ‘Safe Surgery Saves Lives’
 The use of a perioperative surgical
safety checklist in eight hospitals
 a reduction from 11.0 per cent
before, to 7.0 per cent of major
complication

14. SURGICALSAFETY CHECKLIST
 SIGN IN
 Explain Patients identity,
procedure, consent
 Anesthesia safety check completed
 Does patient have a:Known allergy?
 Difficult airway/aspiration risk
 Risk of >500ml blood loss(7ml/kg in
children)?NoYes

15. TIME OUT
 Confirm all team members have
introduced themselves by name and role
 Anticipated critical events Surgeon
reviews: what are the critical or
unexpected steps,
 operative duration, anticipated blood
loss?
 Anesthesia team reviews any concern
 Nursing team reviews: has sterility

16. Cont...
 confirmed? are there equipment issues
or any concerns?
 Surgeon, anaesthesia professional
 nurse verbally confirm patient site
procedure
 Has antibiotic prophylaxis been given
within the last 60 minutes?YesNot
applicable
 Is essential imaging displayed?YesNot
applicable

17. SIGN OUT
 Nurse verbally confirms with the team:
 The name of the procedure recorded
 checkThe instrumentcounts are
correct
 Surgeon, anesthesia professional and
nurse review the key concerns for
recovery and management of this
patient

18. CARING FOR THE SECOND
VICTIM
 The first victim of an adverse event is
the patient and their family.
 Doctors do not purposely set out to
injure patients
 when it does happen due to an error
 they may experience a range of
emotions including distress, shame,
guilt, fear and depression

19. A real story of harm from a
medical error
 A couple took their 14 year old girl to hospital with a
complain of persistent vomiting and diarrhea and yellowish
discoloration of eye and Coca-Cola colored urine . The
Pediatrician kept the child & ordered fluid resuscitation
and vt k for sever dehydration and suspect obstructive
jaundice since INR was elevated
the nurse secure iv line and start fluid resuscitation and gave
10 ml adrenaline by considering vt k while the pediatrician
prepare for shock child who is not responding for fluid 4year
old male child admitted with the diagnosis of septic shock .
 Then the baby starts cried continuously. When she suddenly
stopped crying, her parents realized she was no longer
breathing. They try to shout and call the nurse , where the
staff immediately began to resuscitate.

20. Cont..
The girl died later that afternoon.
As the grieving parents tried to understand what had
happened, they looked at the vial of medicine they had
remaining. It said EPINEPHRINE.
They realized their baby had not been given as they had
thought. Clinical staff told them that the vitamin K and
epinephrine bottles were similar in size and color and were
easy to confuse. “Look-alike "packaging is an ever-present
challenge in dispensing of medications.

21. PREOPERATIVE PREPARATION
 PATIENT ASSESSMENT
 The aim of a structured assessment
is to enable surgery to go ahead
safely.
 done by the surgical, nursing team
and/Oran aesthetic team at
outpatient or inpatient setting.

22. cont..
 Appropriate hx and examination should
performed
 Hx post medical and surgical hx should
asses
 Examination
 General Anaemia, jaundice, cyanosis,
nutritional status,
 Cardiovascular Pulse, blood pressure, heart
sounds, bruits,peripheral oedema

23. Cont..
 Respiratory Respirator rate and effort,
chest expansionand percussion note,
 Gastrointestinal Abdominal masses,
ascites, bowel sounds,
 Neurological Consciousness level, GCS
 sensation, muscle power, tone and
reflexes
 Airway assessment

24. EXAMINATION SPECIFIC TO
SURGERY
 At preoperative assessment,
 the clinical findings, site, side, specific
imaging or investigation findings related
to the pathology
 for which the surgery is proposed should
be noted.
 Investigations
 Full blood count,Urea and electrolytes
 Electrocardiography, Chest
radiographyUrinalysis, liver ,function test

25. SPECIFIC PREOPERATIVE
PROBLEMAND MANAGEMENT
Cardiovascular disease
 poor left ventricular function
 cardiomegaly.
 Ischemic changes can be seen on
ECG
 Hypertension, referred to a
cardiologist

26. Cont..
 blood pressure should be controlled to
 near 160/90 mmHg.
 If a new antihypertensive is
introduced, a stabilization period of at
least 2 weeks should be allowed.
 Patients with angina which is not well
controlled should be investigated
further by a cardiologist
 Elective surgery should be postponed
for three to six months

27. CONT..
If patient on antiplatelet
 If surgery cannot be postponed and the
risk of significant perioperative bleeding
is low,
 the dual antiplatelet therapy can be
continued during surgery.
 over the perioperative period. Ongoing
treatment with betablockers and statins
is known to reduce perioperative
morbidity and mortality.

28. CONT..
Dysrhythmias
 In patients with atrial fibrillation, beta-
blockers, digoxin or calcium channel blockers
 should be started preoperatively (or
continued if the patient is already on the
treatment
 Warfarin in patients with atrial fibrillation
should be stopped 5 days preoperatively to
achieve an INR (international normalized ratio)
of 1.5 or less,

29. Cont..
 Valvular heart disease
 While anesthetic management is
altered to achieve hemodynamic
stability in moderate valvular diseases,
 the patients with severe aortic and
mitral stenosis may benefit from
valvuloplasty
 before undergoing elective non-
cardiac surgery

30. Cont..
 Anemia and blood transfusion
 patients found to be anemic at preoperative treated
with iron and vitamin supplements.
 major procedure, preoperative transfusion may be
considered below a hemoglobin level of 8 g/dL.
Respiratory system
 The patient’s current respiratory status should be
compared with
 their ‘normal state’. check for evidence of right heart
failure.
 Stop Smoking

31.  GASTRO INTESTINAL SYSTEM
 Patients are advised not to take solids
within 6 hours and clear fluids within 2
hours befor .
 Infants are allowed a clear drink up to
2 hours, mother’s milk up to 3 hours
 and cow or formula milk up to 6 hours
before.
 .

32. Cont..
Renal disease
 Underlying conditions leading to chronic renal
failure, such as diabetes mellitus,
 hypertension and ischaemic heart disease,
 should be stabilized before elective surgery.
 Malnutrition
 2 weeks before surgery is required to have any
impact on subsequent assessment both under
and over nutrition

33. Cont..
Diabetes mellitus
 before embarking on elective surgery.
Any history of hyper- and
hypoglycemic episodes,
 hospital admissions, should be noted.
 HbA1c levels should be checked.
 if they are operated on in the morning
advised to omit the morning dose of
medication and breakfast

34. Cont..
 the patient’s blood sugar levels should be checked
every 2 hours.
 For those on the afternoon list, breakfast can be
given with half their regular dose of insulin
 (or full-dose oral anti-diabetic agents) and then
managed with regular blood sugar checks as above.
 An intravenous insulin sliding scale should be started
for insulin-dependent diabetes mellitus
 undergoing major surgery or if blood sugar is difficult
to control for other reasons.

35. Coagulation disorders
 Patients with a low risk of
thromboembolism can be given
 thromboembolism-deterrent stockings to
wear during the perioperative period.
 High-risk patients with a history of
recurrent
DVT, pulmonary embolism (PE) and arterial
thrombosis will be on warfarinand replaced
by low molecular weight heparin or factor Xa
inhibitors

36. Airway assessment
 Airway assessment (Samsoon and
Young modified Mallampati test).
 Grade 1Fauces, pillars, soft palate
and uvula seen
 Grade 2 Fauces, soft palate with
some part of uvula seen
 Grade 3 Soft palate seen
 Grade 4Hard palate only seen

37. PREOPERATIVE ASSESSMENT IN
EMERGENCY SURGERY
 the same as in elective surgery,
except that the opportunity to
optimise the condition is limited by
time constraints.
 Medical assessment and treatments
should be started
 (e.g. according to the Advanced
Trauma Life Support (ATLS)
 guidelines)

38. RISK ASSESSMENT AND CONSENT
The risk of death doubles with the presence of
 peripheral vascular disease, stroke, heart
failure, myocardial infarction or renal failure
 each independently increases the risk of death
by about 1.5 times the baseline
 Valid consent implies that it is given voluntarily
by a competent and informed person
 In emergency situations or in an unconscious
patient, consent may not be obtained and the
procedure carried out ‘in the best interests of
the patient

39. ARRANGING THE THEATRE LIST
 The date, place and time of operation
should be matched with
 availability of personnel.
 The operating list should be distributed as
early as possible to all staff who are
involved in
 Priorities patients, e.g. children and
diabetic patients should
 be placed at the beginning of the list; life-
and limb-threatening
 .

40. Taking a comprehensive
consent
 Lead in Introduce yourself and identify the
patient
 Explore How much does the patient know
 Diagnosis Why the operation is being proposed
 Treatment Explain whether the treatment
proposed is in
accordance with protocols and if not why not
 Options Discuss all the options including that
of doing

41. Cont..
 Results Explain likely outcome in terms of
pain, mobility, work, diet and return to
normal activities
 Eventualities For example, the possibility
of needing to remove the testicle in a
hernia operation
 Sound mind Ask if they have understood
 Open question Check if further
clarification is needed
 Notes Document everything discussed and
agreed

42. Factors that predispose patients to a high
risk of morbidity and mortality
 Patient factors
 History severe cardiac disease
 Severe respiratory disease
 Aged >70 years
 Metabolic disease (renal failure, poorly controlled
 diabetes)

43. Surgical factors
 Prolonged duration of surgery (>1.5 hours)
 Extensive surgery (e.g. oesophagectomy, gastrectomy)
 Type of surgery (thoracic, abdominal, vascular)
 Emergency surgery
 Acute massive blood loss (>2.5 litres)
 Severe multiple trauma e.g. >3 organs or >2 systems or
 ≥2 body cavities open

44. American Society of Anesthesiologists risk scoring system
grade.
 I. Patient is a completely healthy fit
patient.
 II. Patient has mild systemic disease.
 III. Patient has severe systemic disease that
is not incapacitating.
 IV. Patient has incapacitating disease that is
a constant threat to life.
 V.A moribund patient who is not expected
to live 24 hour with or without surgery.
 E. Emergency surgery, E is placed after the
Roman numeral.

45. Cont..
 The rate of postoperative
complications was found to be
closely related to the ASA class (ASA
score I = 0.41/1,000; scores IV and
V = 9.6/1,000)
 with emergency surgeries (ASA I =
1/1,000 increases to 26.5/1,000 in
classes IV and V

46. Summary
 Understanding patient safety incident
 The majority of near misses or adverse events are due
to system factors
 lessons learnt will prevent future injuries
 The WHO& has established a number of international
initiatives for patient safety
 Pre operation assessment
 Hx taking PE and investigation and obtimizing the the
risk taking informed conscent is very important

47. Reference
 1.Baily &love 26 edition
 2.schwartz 11th edition
 3.WHO safe surgery guide line
 4.united states surgeon association guide line
 5.uptodate 2021

48. END
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