On the CUSP at RCH

M. ArgetN.P. Blair

Fraser Health AuthorityApril 2013

Objectives

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

•To highlight the importance between teamwork and patient outcomes

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

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

Intervention1.Antimicrobial coverage perioperatively

a) Appropriate use of prophylactic antibiotics

b) Antiseptic prophylaxis

2.Appropriate hair removal3.Maintenance of perioperative glucose control4.Perioperative normothermia

How about Culture?

• 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

SAQ Results

SAQ Results

Variable Events/ Total Cases

% Observed

% Expected

Odds Ratio

Decile/Comments

Pancreatectomy Morbidity

11/18 61.11 26.72 1.40 10/NI

Pancreatectomy SSI

9/17 52.94 18.98 1.95 10/NI

Colectomy Morbidity

84/199 42.21 31.32 1.51 10/NI

Colectomy SSI 52/194 26.80 13.08 2.15 10/NI

NSQIP Targeted Procedures – RCH – July 2011 – June 2012

* 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 EducationFour 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 #1Issue 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)

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

Surgical Cases

Doo

r S

win

gs/

Cas

e T

ime

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 StudiesStudy Our

StudyBansal & 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:40Average: 33

? 37 41.4 39.82 Mean: 19.2

Safety Assessment Round #2

Safety Assessment Round #2

Normothermia Where

Royal Columbian Hospital

Post-Anesthetic Care Unit (PACU)

Data collection process

- Reviewed the charts of surgical patients in the PACU-Recorded their temperature (pre-, intra-, and post- op)-Recorded the type of procedure performed

Duration

-Over 2 days

- April 2nd (Tuesday) & 8th (Monday), 2013

-5 hours per day - 0900 – 1400

Results: Normothermia Type of Surgery(total – 22)

Mean temperature

PRE INTRA POST

General (4) 36.6 35.9 36.4

Gyne (4) 36.7 n/a 36.4

Neuro (4) 36.4 35.2 36.3

Ortho (5) 36.7 36.1 36.3

Plastics (2) 36.7 35.9 36.3

Vascular (3) 36.7 35.7 36.1

Mean temperatures of all Surgeries monitoredPRE INTRA POST

36.6 35.8 36.3

Results: Normothermia T

empe

ratu

re

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)• The Ottawa Hospital• Royal Columbian Hospital

Next Steps

• Work on addressing traffic and keeping patients warm

• Learning from defects

• Implement teamwork and communication tools

• Expanding beyond general surgery

RCH CUSP Steering GroupSurgeons: •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