On the CUSP at RCH

M. Arget Fraser Health Authority

February 2013

Objectives

•To highlight the importance between teamwork and patient outcomes

•To introduce the Comprehensive Unit-based Safety Program (CUSP) including its components

•To highlight the work being done at RCH as part of CUSP

•To showcase where CUSP has been successful elsewhere in North America

Intervention 1. Antimicrobial coverage perioperatively

a) Appropriate use of prophylactic antibiotics

b) Antiseptic prophylaxis

2. Appropriate hair removal 3. Maintenance of perioperative glucose

control 4. Perioperative normothermia

How about Teamwork?

• Healthcare is all about relationships • Effective teams result in better patient

outcomes

Results from BC culture survey

Some Context: RCH

• Royal Columbian Hospital is the 430 bed

tertiary trauma centre for Fraser Health Authority, which serves 36% of the BC population

• 8,300 operations annually – 850 open-heart surgeries – 800 neurosurgeries

How about Culture/Teamwork at RCH? Safety Attitudes Questionnaire (SAQ) • Administered within FHA at SMH, BH, RCH in Spring 2012 • Scientifically-validated instrument for measuring patient

safety culture • Domains for SAQ

– Teamwork Climate – Safety Climate – Job Satisfaction – Stress Recognition – Working Conditions – Perceptions of Senior Management – Perceptions of Local Management

0 20 40 60 80

Job Satisfaction

Stress Recognition

Teamwork Climate

Safety Climate

Perceptions of Local Management

Working Conditions

Perceptions of Senior Management

Average Percent Positive

Overall Domain Scores for RCH Surgical Services

SAQ Results

0 20 40 60 80 100

RCH OR

RCH Surgical Day Care

RCH 4S

RCH PACU

RCH 3S

RCH 3N

RCH 4N

Culture Risk Score

Culture Risk Score by Location

SAQ Results

Variable Events/ Total Cases

% Observed

% Expected

Odds Ratio

Decile/ Comments

Pancreatectomy Morbidity

7/13 53.85 26.81 1.24 10/NI

Pancreatectomy SSI

6/13 46.15 14.19 1.59 10/NI

Colectomy Morbidity

76/170 44.71 32.01 1.59 10/NI

Colectomy SSI 36/160 22.5 12.94 1.74 10/NI

NSQIP Targeted Procedures – RCH – January – December 2011

* Indicates High Outlier / NI = Needs Improvement / AE = As Expected

•CUSP or Comprehensive Unit-based Safety Program is a program designed to change a unit’s workplace culture and also improve patient safety.

•CUSP empowers staff and physicians to take responsibility for safety and work as a team to improve their environment.

Introducing CUSP

Five Components of CUSP Component Method

1. Science of safety education Introductory talk to explain the approach to addressing safety at a local level

2. Staff Safety Assessment Two question survey to team members asking: 1) How will the next patient be harmed? 2) What can we do to prevent this?

3. Senior executive partnership Senior executive attends CUSP meetings, making resources available to address safety concerns and assist with system-wide barriers

4. Learning from defects Teams are trained to use a structured tool to learn from defects

5. Implement teamwork and communication tools

Review unit-level safety data (e.g. SSI) monthly and develop local quality improvement initiatives to improve teamwork, communication and address identified hazards

Science of Safety Education Four Key Principles

• Understand that safety is a property of the system • Understand the basic principles of safe design that include:

standardize work, create independent checks (checklists) for key processes, and learn from mistakes

• Recognize that the principles of safe design apply to teamwork as well as technical work • Understand that teams make wise decisions when there is diverse and independent input

Staff Safety Assessment

Four Questions: (Focusing on General Surgery) 1. Please describe how you think the next patient in the OR will

be harmed? 2. Please describe what you think can be done to prevent or

minimize this harm 3. Please describe how you think the next patient in the OR will

get a surgical site infection 4. Please describe what you think can be done to prevent this

infection

Results of Safety Assessment Issue from Assessment Frequency of Response

Traffic 6

Large number of people in OR 5

Antibiotic timing 4

Sterile Technique 4

Pre-op planning; equipment; noise/disruption

3

surgical check list; sterility of surgical equipment; safety culture; correct scrubbing;

2

Handwashing; lack of assistance in OR; Temperature; IV ports; ventilation; poorly cleaned rooms; food in OR; protocol; no mask

1

N=16 (Surgeons, Anesthesia, Nursing, Medical Staff)

OR Traffic

• Airborne contaminants and colony forming units (CFUs) correlate positively with traffic flow and the number of persons in ORs.

• OR foot traffic disrupts air flow and increases risks of SSI.

• Door openings also can result in potential distractions.

(Andersson et al., 2012; Parikh et al., 2010)

Data Collection Tool

Data Collection • A total of 8 cases observed.

– 614 minutes of case time were recorded – Average case time was 76.75 minutes (35-134)

• 354 DSs were recorded

– Average 44.25 door swings/case (18-101)

• Average # of personnel present :6.1 (4-14)

OR Traffic Results (8 in Total)

0

20

40

60

80

100

120

140

160

1 2 3 4 5 6 7 8

Door SwingsCase Tme (min)

Case 1 – Hernia Repair Case 2 – Hernia Repair Case 3 – P. Dialysis insertion Case 4 – Close Nose Reduction Case 5 – C section Case 6 – C section Case 7 – VP shunt insertion Case 8 - Appendectomy

Surgical Cases

Doo

r Sw

ings

/ Cas

e Ti

me

5-6 6 6-7 3-4 4-14 5-12 6-7 5-7 Range of Personnel Present

Analysis

-The average DSs per hour: 34.59. This is consistent with other studies.

-A DS takes approximately 20 seconds. -This result tells us: for each surgical hour, the

doors had opened for 11.53 minutes. -This can be translated into: 19% of the time,

the air flow in the theatre was interrupted.

Reasons for Door Opening

• Supply/equipment • Information • Break/shift change • Scrub in • Observation • Complicated & unplanned surgeries account

for more DSs.

Comparison with Other Studies Study Our

Study Bansal & Hackenberger, 2012

Condron et al., 2012

Lynch et al., 2009

Panahi et al., 2011

Parikh et al., 2010

Young & O’Regan, 2009

Study Length

2wks 5wks ? 3mos 7mos 1mos 3mos

Total DSs

354 25,048 638 3,071 9,657 2,887 4,273

Studied Cases

8 108 ? 28 116 26 46

Case Time (Min)

614 626hrs ? 1,367 13,863 4,350 Mean: 5h18m/case

DSs Per Hour

34.59 Peak hrs:40 Average: 33

? 37 41.4 39.82 Mean: 19.2

Next Steps

• Work on addressing traffic

• Learning from defects

• Implement teamwork and communication tools

• Expanding beyond general surgery

Success with CUSP at other Medical Centres

103 ICUs…mean rate of CR-BSI per 1000 catheter-days decreased from 7.7 at baseline to 1.4 at 16 to 18 months of follow-up (P<0.002).

Success with CUSP at other Medical Centres

Baseline mean SSI rate was 27.3%; . After commencement of interventions, the rate dropped to 18.2% for the subsequent 12 months —a 33.3% decrease

CUSP Collaborative

• The American College of Surgeons asked RCH if they want to be part of a collaborative including only five sites along with Johns Hopkins as support

• Ronald Reagan UCLA Medical Centre • New York Hospital of Queens (Flushing, NY) • Mills-Peninsula Health Services (Burlingame, CA) • Saint Elizabeth Medical Centre (Utica, NY) • Royal Columbian Hospital

Why it works?

• Clear process

• Clear tools to measure improvement

• Literature that demonstrates success

• Requires support and buy-in from all stakeholders

RCH CUSP Steering Group Surgeons: •Dr. Blair •Dr. Vikis

Administration: •C. Sawyer (Manager) •S. Hardiman (Director)

Anesthesia: •Dr. Merchant

Nursing: •L. Manten •K. Peterson •S. Martel

Quality Improvement: •M. Arget Michael.arget@fraserhealth.ca

Students: W. Choi D. Fedorov M. Ho Y. Wong

References

Andersson, A. E., Bergh, I., Karlsson, J., Eriksson, B. I., & Nilsson, K. (2012). Traffic flow in the operating room: An explorative and descriptive study on air quality during orthopedic trauma implant surgery. American Journal of Infection Control, 40(8), 750-5.

Bansal, M., & Hackenberger, L. (2012). Increasing awareness of the impact of high volumes of foot traffic in operating rooms on patient outcomes among clinicians and support staff. Drexel University School of Public Health.

Condron, M., Landmesser, S., & Young, M. (2012). Traffic patterns in operating rooms: Issues and solutions. Thomas Jefferson University Hospital.

Lynch RJ ; Englesbe MJ ; Sturm L ; Bitar A ; Budhiraj K ; Kolla S ; Polyachenko Y ; Duck MG ; Campbell DA Jr. (2009). Measurement of foot traffic in the operating room: Implications for infection control. American Journal of Medical Quality, 24(1): 45-52.

Panahi, P., Stroh, M., Casper, D. S., Parvizi, J., & Austin, M. S. (2011). Operating room traffic is a major concern during total joint arthroplasty. The Association of Bone & Joint Surgeons.

Parikh, S. N., Grice, S. S., Schnell, B. M., & Salisbury, S. R. (2010). Operating room traffic: Is there any role of monitoring it? Journal of Pediatric Orthopedic, 30(6): 617-23.

Young, R. S., & O’Regan, D. J. (2009). Cardiac surgical theatre traffic: Time for traffic calming measures? Interactive Cardiovascular and Thoracic Surgery, 10: 526-9.