implementation of the surgical care outcomes assessment program (scoap… · 2015. 7. 16. · scoap...
TRANSCRIPT
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Implementation of the Surgical
Care Outcomes Assessment
Program (SCOAP) and the
Introduction of the
WHO/SCOAP Surgical Safety
Checklist
E. Patchen Dellinger, MD, FACS
Professor of Surgery, Chief of General Surgery
University of Washington Medical Center (UWMC),
Seattle, Washington
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Surgical Safety: Unrecognized as
public health issue
Known surgical
complications
of 3-16%
Known death
rates of 0.4-
0.8%
At least 7 million disabling complications –including 1 million deaths – worldwide each year
=
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Problem 2: Failure to use
existing safety know-how
• High rates of preventable surgical site
infection result from inconsistent timing of
antibiotic prophylaxis
• Anesthetic complications are 100-1000x
higher in countries that do not adhere to
monitoring standards
• Wrong-patient, wrong-site operations persist
despite high publicity of such events
-
WHO’s 10 Objectives for Safe
Surgery
The team will:
1. Operate on the correct patient at the correct site.
2. Use methods known to prevent harm from anesthetics, while protecting the patient from pain.
3. Recognize and effectively prepare for life-threatening loss of airway or respiratory function.
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WHO’s 10 Objectives for Safe
Surgery
4. Recognize and effectively prepare for risk of high blood loss.
5. Avoid inducing an allergic or adverse drug reaction for which the patient is known to be at significant risk.
6. Consistently use methods known to minimize the risk for surgical site infection.
-
WHO’s 10 Objectives for Safe
Surgery (cont.)7. Prevent inadvertent retention of
instruments or sponges in surgical wounds.
8. Secure and accurately identify all surgical specimens.
9. Effectively communicate and exchange critical information for the safe conduct of the operation.
10. Hospitals and public health systems will establish routine surveillance of surgical capacity, volume and results.
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Advantages of Using a Checklist
• Can be customized to local setting and needs
• Can be deployed in an incremental fashion
• Is supported by scientific evidence and expert
consensus
• Has been evaluated in diverse settings
around the world
• Ensures adherence to established safety
practices
• Minimal resources required to implement a
far-reaching safety intervention
-
What is this tool that addresses
the 10 objectives?
-
What is this tool that addresses
the 10 objectives?
-
WHO and the ChecklistSafe Surgery Saves Lives
WHO encourages local institutions
to modify the list to address local
needs.
Anesthesia machine safety checks
are reliably done in the U.S. but
not in all other places in the world
-
London, UK
EURO EMRO
WPRO I
SEARO
AFRO
PAHO I
Amman, JordanToronto, Canada
New Delhi, India
Manila, Philippines
Ifakara, Tanzania
WPRO II
Auckland, NZ
PAHO II
Seattle, USA
The Checklist was piloted in 8 cities
-
Doing the Checklist at University of
Washington Medical Center (UWMC)
• We had been discussing briefing and
debriefing in the Division of General
Surgery
• I saw the checklist as an opportunity to
institutionalize briefing and debriefing
• We had added antibiotic administration
to the JCAHO-mandated “time out”
many years ago
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S C O A P Surgical Care and Outcomes Assessment Program
•Voluntary collaborative of surgeons in Washington state
•Grassroots organization
• Includes 51 of 65 rural small hospitals and large urban referral centers.
•SCOAP surgeons define the metrics for quality
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S C O A P Surgical Care and Outcomes Assessment Program
• Currently following colon/rectal, bariatricoperations, appendectomy, & vascularoperations with a pediatric module in development
• Quarterly feedback on process compliance and outcome
• Hospitals can compare their performance with other SCOAP hospitals
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Operative Re-interventionAll Colon/Rectal Surgery
Q1 2006 through Q2 2007
2007
0%
4%
8%
12%
16%
20%
A B C D E F G H I J K L M N O P
Hospital
% o
f P
roced
ure
s
Aggregate Data Hospital Average
(358)
(7)
(49)
(35)
(165)
(260)(44)
(24)
(3) (19)
(254)
(8)
(542)
(168)
(102)
(26)
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Transfusion-free ProceduresElective Colon/Rectal Surgery
Q1 2006 through Q2 2007
2007
0%
20%
40%
60%
80%
100%
A B C D E F G H I J K M N O P
Hospital
% o
f P
roced
ure
s
Aggregate Data Hospital Average
(292)
(6)
(30)
(30)(57)
(204)
(21)
(18)
(218)
(3) (7)
(465)(103)
(72)
(14)
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NormothermiaElective Colon/Rectal Surgery
Q1 2006 through Q2 2007
2007
0%
20%
40%
60%
80%
100%
A B C D E F G H I J K M N O P
Hospital
% o
f P
roced
ure
s
Aggregate Data Hospital Average
(6)
(3)
(7)
(14)
(280) (30) (17)
(195)
(102)
(28) (48) (20) (460)(223)
(72)
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Glucose Testing among DiabeticsElective Colon/Rectal Surgery
Q1 2006 through Q2 2007
2007
0%
20%
40%
60%
80%
100%
A C D E F H J M N O
Hospitals with 5+ diabetics
% o
f P
roced
ure
s
Aggregate Data Hospital Average
(34)
(9) (6)
(11)
(27)
(5)
(31)
(38)
(15)
(15)
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VTE ChemoprophylaxisElective Colon/Rectal Surgery
Q1 2006 through Q2 2007
2007
0%
20%
40%
60%
80%
100%
A B C D E F G H I J K M N O P
Hospital
% o
f P
roced
ure
s
Aggregate Data Hospital Average
(6)
(30)
(2) (14)
(7)
(215)
(294)
(30)
(57)
(204)
(20)
(17)
(466)
(99)
(72)
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Post-op B-Blockers for Current UsersAll Colon/Rectal Surgery
Q1 2006 through Q2 2007
2007
0%
20%
40%
60%
80%
100%
A C D E F G H J M N O P
Hospitals w/ 5+ Current Users
% o
f P
roced
ure
s
Aggregate Data Hospital Average
(74)
(12)
(11)
(46)
(54)
(13)
(5)
(50)(172)
(45)
(33)
(5)
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12+ Lymph Nodes RemovedColon Cancer Surgery Q1 2006 through Q2 2007
2007
0%
20%
40%
60%
80%
100%
A B C D E F G H I J K L M N O P
Hospital
% o
f P
roced
ure
s
Aggregate Data Hospital Average
(67)
(1)
(21)
(17)
(55)
(72)
(18)
(10)
(1)
(2)
(43)
(1)
(106)
(23)
(28)
(6)
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VTE ChemoprophylaxisElective Colon/Rectal Surgery
All SCOAP Patients
50%
60%
70%
80%
90%
100%
Q1 2006 2 3 4 Q1 2007 2
% o
f P
roced
ure
s
2007
-
Imaging AccuracyAppendectomy Procedures
All SCOAP Patients
2007
(399)(1152) (394) (244)
80%
85%
90%
95%
100%
Year 2006 Q1 2007 Q2 2007 Q3 2007
% o
f P
roc
ed
ure
s w
ith
Im
ag
ing
(Denominator)
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Re-operation for Complications All Colon/Rectal Surgery
All SCOAP Patients
0%
5%
10%
15%
20%
Q1 2006 2 3 4 Q1 2007 2
% o
f P
roced
ure
s
2007
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Negative Appendectomy
0%
5%
10%
15%
20%
Year 2006 Q1 2007 Q2 2007 Q3 2007
% o
f P
rocedure
s
2007
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“Safe Surgery Saves Lives-
SCOAP Checklist”
Implementation at UWMC
First phase
• Safety attitudes questionnaire collected
before introduction of the checklist and
again after
• Baseline data on use of checklists among
all general surgery cases
• 500+ cases followed with basic data collected
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UWMC Safety Attitudes
Questionnaire - Results
Agree or strongly agree Before After
Feel safe as patient here 83% 85%
Briefing important before op. 91% 94%
Encouraged to report concerns 79% 90%
Difficult to speak, perceived prob. 19% 21%
Good team - docs & nurses 53% 65%
Freq disregard rules (others?) 19% 15%
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UWMC Safety Attitudes
Questionnaire - Results
Agree or strongly agree After
Checklist easy to use 56%
Checklist improved O.R. safety 60%
Took a long time to complete 23%
I would want checklist for me 88%
Communication was improved 81%
Checklist helped to prevent errors 67%
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Communication Quality and
Surgical Morbidity
Davenport. JACS 2007;205: 778-784
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Behavioral Marker Risk Index (BMRI)
• Briefing
• Information sharing
• Inquiry
• Vigilance and awareness
Adjusted Odds Ratio
Risk Factor Complication or Death
BMRI 4.82
ASA 1.51
Mazzocco. Amer J Surg 2009; 197: 678-85
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Behavioral Marker Risk Index and
Postoperative Complications
Mazzocco. Amer J Surg 2009; 197: 678-85
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“Safe Surgery Saves Lives-
SCOAP Checklist”
Implementation at UWMC
Second Phase
• Checklist introduced in March 2008-all
general surgeons to champion
• Posted (2’ x 3’) in all O.R.s
• 500 Additional cases followed with basic
data collected
• Safety attitudes re-surveyed
• 10’ training video made (see SCOAP website)
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Timing of “Time Out”
Checklist procedures were
timed by data collector
Results
RANGE MEAN
0:58 seconds to 3:58 minutes 2:16 minutes
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Feedback: General Surgeons, Nurses,
and Anesthesiologists
“Surgeon leadership is key to taking this
seriously and making it a meaningful
pause that offers safety.” – General
surgeon
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Feedback: General Surgeons, Nurses,
and Anesthesiologists
• “At first it seemed somewhat
burdensome due to length. It now takes
me about one minute to run through the
list, which I don't think is anything
excessive.” – General surgeon
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Challenges Ahead• Institutionalizing the checklist – Every O.R.,
Every Case
• Supporting the culture change that the
checklist suggests
• Getting the “buy-in” of all Surgeons
• Streamlining the checklist to meet the needs
of individual hospitals and specialties while
preserving the essentials
• Remembering the Debriefing !
• Integrating the checklist into the EMR?
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“Safe Surgery Saves Lives” and
SCOAP and UWMCWorking Together
• Expanded the WHO checklist to include
important SCOAP metrics that we were
inconsistently applying
• Started the Washington State SCOAP
Checklist Coalition
• Enlisted the assistance of the
Washington State Hospital Association
and third party payers and major
employers to promote the checklist
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Washington State Checklist
Implementation
65 hospitals have notified SCOAP
and the Washington State Hospital
Association (WSHA) that they have
implemented a Surgical Safety
Checklist
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“The estimate that up to 23,000 people died in
2004 in Canadian hospitals because of
preventable adverse events is staggering.
Checklists in aviation have been in use pretty
well since the Wright brothers.
One wonders whether such checklists would
have been introduced much earlier in medicine if
surgeons shared the fate of their patients, as
pilots share that of their passengers.”
Adrian Boelen, retired pilot, Dorval, Que
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More Informationwww.who.int/patientsafety/safesurgery/en.index.html
www.safesurg.org
www.scoap.org
www.nbc.com/ER/video/episodes/#vid=1059351