A checklist for the operating theatre!

[BOAC]

I can hardly believe it - apparently until now, hospitals have not had a formalised system to ensure:
1) It is the right patient they are going to cut open
2) It is the right bit of the right patient they are going to cut off
3) They have got all the tools back out of the patient that they put in.

You could call those the 'killer items'?

Let me see - when did people start doing operations? How long before they adopt some system similar to our CRM - to the nearest 1000 years? Heaven help us.

[point8six]

There is a company consisting of retired pilots (CRM instructors etc.) who are conducting "CRM" type courses for the medics (UK).
So don't dismay, apparently the BMA shown interest for some time in reducing the authority gradient, especially in the operating theatre. This checklist will help with post-operative treatment, whereas the course may help with decision-questioning in pre-operation matters.

[BOAC]

Originally Posted by .86

This checklist will help with post-operative treatment,

I was rather hoping it mght help with operative treatment?It looks as if one has to hope that the poor patient is still alive for the post-operative treatment.

[jolly girl]

BOAC my friend,
Are you familiar with the article "the Checklist" from the New Yorker?
Annals of Medicine: The Checklist: Reporting & Essays: The New Yorker
All the best,
Jolly

[BOAC]

Thanks, JG - I see the Dec 2007 article says "He has also been asked to develop a program for surgery patients" so there is a glimmer of light, but I also see he does not hold out much hope of progress.

[Rick Studder]

BOAC, I know very well the problem you are addressing. The statistics on maltreatment are frightening -- and a lot goes unreported. There is no doubt that health care, not to say patients, would benefit tremendously by implementing CRM principles. But health care is lagging behind, a physician today has the authority of a captain 40 years ago, or worse. The cultural and organizational challenges are huge.

That said, most people in health care are very capable, professional, and caring; it's the routines and the culutural attidtude that are lacking. And you cannot transfere the standradization from aviation directly, most health care problems are more fuzzy than the problems a pilot would encounter during a normal day. However, there is no doubt that the introduction of mandatory checklists would be a tremendous improvement in many situations. I have mentioned the CRM method in aviation to many physicians; most have never heard of it. There is a long way to go.

[OneOffDave]

Form my reading of the report, it was about the adoption of a standardized universal (International) checklist rather than implying that UK hospitals did things in a hap-hazard manner. I've had over 40 surgeries and for each oone, there were the patient id checks at the point of being taken from the ward to theatre, the handover to theatre staff and once in the anaesthetic room. There were checks also that my consent form was signed, the operation site was appropriately marked and I'd fasted appropriately. Allergies were also checked verbally with me gasints the information on the front of my notes. Both my name and DOB were checked against my notes and my wristband.

There were also post-op checklists too, to make sure I was fit enough to return to the ward or, for day surgery, go home.

[alf5071h]

The article ‘Have you ever made a mistake?’ (page 2442) should be required reading for all professionals – medical and aviation alike.
Although at first it might be seen as an aviation input to medicine, read it again. It is, in the same way, an input to aviation – the common feature being the fundamentals of human behavior, which we strive to shape and control.
A checklist can be a crutch to lean on but not for everything; a checklist can be a tool to shape thinking, or be the bounding guidance for safe behavior.
However, having provisioned a checklist, we must then remember to use it.

[gingernut]

from this weeks Health Service Journal

Treatment checklists cut deaths by 15pc

6 April, 2010
Treatment “checklists” have led to a 15 per cent reduction in patient deaths in three hospitals, research has shown.


The aim of the lists is to cut down the number of avoidable deaths and to improve patient care.

Implementing care bundles can lead to reductions in death rates in the clinical diagnostic areas targeted and in the overall hospital mortality rate

Each printed list - also known as a care bundle - includes details of best practice treatment, such as when to administer antibiotics, the types of blood samples needed or the optimum level of oxygen saturation in the blood.
Some 7 per cent of hospital admissions result in something going wrong (an adverse event), of which about 8 per cent cause death.
Around half of adverse events are avoidable, research has shown.
In the latest study, the North West London Hospitals Trust implemented eight care bundles known to help reduce risks for patients.
The bundles covered 13 diagnostic areas with the highest number of deaths at the trust in 2006-07, including stroke, heart failure and chronic obstructive pulmonary disease.
The trust serves about 500,000 people at three hospital sites: Northwick Park Hospital, Central Middlesex Hospital and St Mark’s Hospital.
Researchers looked at the effect of the bundles on the hospital’s standardised mortality ratio.
An HSMR of 100 equates to the same risk of death as the English national average, while 120 equates to 20 per cent above the national average and 80 to 20 per cent below.
After the care bundles were introduced, the trust’s HSMR fell from 89.6 in 2006-07 to 71.1 in 2007-08 - the lowest among acute trusts in England.
Overall, 255 fewer deaths occurred (174 of these in the targeted diagnoses) than if the 2006-07 death rates applied.
The researchers said their methods could be used to reduce death rates in other hospitals.
Writing in the British Medical Journal, they said: “Implementing care bundles can lead to reductions in death rates in the clinical diagnostic areas targeted and in the overall hospital mortality rate.”

[Pilot Positive]

This is a growing discipline within the medical industry supported by the likes of Attrainability and Air2Med - ex TCs applying their CRM experiences.

Surgeons are actively looking to improve operatability as a cohesive team in a controlled environment and the many lessons of multi-crew interaction (e.g checklist use, briefings, communication loops, allocation of roles, leadership/followership, DODAR & NITS, confirmation bias & error chain avoidance etc...) can be applied to the surgical environment. After all there are CRM similairites to amputating the wrong leg and shutting down the wrong engine... which has happened in both professions.

See the thread below for more:

http://www.pprune.org/safety-crm-qa-...-aviation.html

[Genghis the Engineer]

A very interesting paper on the subject:

http://www.endo.gr/cgi/reprint/NEJMsa0810119v1.pdf ,

and there's some background material about it at

Annals of Medicine: The Checklist : The New Yorker

The critical quote so far as I can see is from the results of the first paper:

The rate of death was 1.5% before the checklist was introduced and declined to 0.8% afterward (P = 0.003). Inpatient complications occurred in 11.0% of patients at baseline and in 7.0% after introduction of the checklist (P<0.001).

In other words, they roughly halved the death rate in operations by use of a checklist. Given that we've been using checklists of this nature in aviation since I believe the late 1940s, it's just astounding that it took so long for medicine to catch up.

G

[Pilot Positive]

What's more astounding is that we go through OPC/LPC checks every 6 months whilst surgeons/Drs, from what I understand, do not go through any further recurrency checking after they have completed their training. Its all hands on experience.

Perhaps that's something that could be introduced as well? Simulated patient surgery for recurrency purposes? That'll be another first...

[Genghis the Engineer]

Medical simulators would be difficult and expensive, but regular debriefed peer review wouldn't be. When I was a university lecturer I got this from one of my senior colleagues every 6 months, which is a slightly less serious job if you screw up than surgery!

G

[BOAC]

Simulated patient surgery for recurrency purposes? That'll be another first...

- ok doc, you can expect renal or heart failure at ANY point in this test opertaion on an in-growing toenail. We need to see the correct responses and drills - any questions?

[Pilot Positive]

. yes. I was thinking more along the lines of using animals which might have similar organs (pigs?) to practice manual use of endoscopes/borescopes and/or stitching techniques and the such like.

But yeah why not, throw in a few curve balls to test capacity and see how they handle things (loss of blood pressure, nurses fainting, patients waking up, kids stuffed toy left inside the patient, godzilla attack etc...)

[Cheeks]

As a doctor with an interest in CRM and non-technical skills teaching (or Crisis Resource Management as it's known here, just to be different), I've used simulators, SOPs and rehearsed drills at a couple of stages during my training.

The most obvious example is life support (BLS and ALS) which is taught and, for the most part, practised as per national SOPs laid down by the resus council.

Medicine has lagged behind in the use of simulation, debriefing and non-technical skills. There are probably a number of reasons for this - the idea of change, a lack of time (both instructor and trainee) and a lack of facilities (even finding a seminar room is a hard task). The introduction of SOPs and checklists is seen negatively by many it's seen to disempower the doctor and create inflexible, unnecessary duplication of effort - there might even be some truth in that.

However, this is changing. Many hospitals, mostly the larger teaching hospitals at the moment, are investing in simulation suites and schedule time for their trainees to participate and feedback. Anaesthetics, as a speciality is leading the way in this.

The introduction of a pass/fail assessment is still a long way off and it probably won't save that many lives but it will eventually come in some form or another.

[Cheeks]

Originally Posted by BOAC

- ok doc, you can expect renal or heart failure at ANY point in this test opertaion on an in-growing toenail. We need to see the correct responses and drills - any questions?

That's not too far from what a number of places are doing. The major difference is that problems manifest themselves in a variety of ways and consequently, there's no 'drill' for most things.

[Pilot Positive]

2 way street?

Cheeks,

In terms of CRM, how does the situation compare to either other European NHS's (e.g France) or the US? How is CRM actively applied in these countries?

I ask because I think it could be a 2 way thing. Not just medicine learning from aviation but also aviation learning from medicine - just not sure where the mutual exchange benefit lies.


PP

[Cheeks]

Originally Posted by Pilot Positive

In terms of CRM, how does the situation compare to either other European NHS's (e.g France) or the US? How is CRM actively applied in these countries?

To be honest, I don't know. Judging by material published by SESAM, it varies by hospital or medical school more than it does by country at the moment. It seems that Europe is slightly ahead of the US.

I ask because I think it could be a 2 way thing. Not just medicine learning from aviation but also aviation learning from medicine - just not sure where the mutual exchange benefit lies.

Maybe.

Having done very little flying it's hard for me to say. I would suggest that medicine is much more non-standard than aviation. Who you work with, who your backup is changes hour to hour, how the problem presents varies and there are many 'problems' that are really just normal variants or reporting errors.

Perhaps the thing medicine has to offer is flexibility and critical thinking?

[BOAC]

Originally Posted by cheeks

there's no 'drill' for most things.

- the comment was, of course, in a non-cosmetically surgical way, 'tongue-in-cheek(s)'