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