Surgical Checklists and Beyond

Jill Ferbrache, Practice Educator, SPSP FellowClaire Gordon, Consultant Acute Medicine, SPSP Fellow

A checklist

Surgical Checklists

SUB HEADING TO BE

SUB HEADING TO BE

Around 500 beds50 – 70 patients/day through trolleysCo-located Medical Admissions UnitMedical specialities, neuro, oncology, infectious diseases, rheumatology and dermatology.

Increasing complexity, changing work patterns

Government concern regarding Lothian’s performance against the 4h Emergency Care Standard

Reducing bed base, better ‘capacity’ than other sites

Boarding

Delayed discharges/ Length of stay

Flow – discharges occur late in the day

Boarding!

When an ED is busy, mortality increases

Fail-proof mechanisms necessary to avoid omissions

Human fallibility, we cannot be in ‘control’ all the time, everywhere

50% pts had allergies documented

50% medical patients had VTE prophylaxis prescribed

20-30% of patients had oxygen prescribed

60% had Consultant impression and plan clearly documented

Sepsis audit: Average time to antibiotics close to 4h, fluids 4h

Investigations not chased before moved to a downstream ward

Juniors stressed about not handing over jobs before patients moved downstream

Investigations ordered, not chased

Decision to have a Consultant sticky and a Junior checklist

Consultants to document impression and plan

Juniors to complete checklist: investigations, kardex, fluids, warfarin, insulin, oxygen, VTE prophylaxis

POST TAKE WARD ROUND

Date………………. Time………... Cons…………….

Bloods seen Y/N/na X-rays seen Y/N/na ECG seen Y/N/na

Kardex: Written Y/N Allergies recorded Y/N

Thromboprophylaxis prescribed Y/N

Oxygen prescribed Y/N/na

Insulin charted Y/N/na Warfarin Y/N/na

IV fluids prescribed Y/N/na

Outstanding Jobs……………………………………………….

……………………………………………………………………

……………………………………………………………………

Signed………………………………… Bleep…………………

CONSULTANT SUMMARY Date............................Time............................

Impression ....................................................................................................

......................................................................................................................

......................................................................................................................

..........................................................................

Plan...............................................................................................................

......................................................................................................................

......................................................................................................................

..........................................................................

Signed...........................................................

Name...........................................Contact No ...............................

• Consultants initially very positive Impression/ plan documentation up to 95%

• Naming and shaming helping to keep them on their toes

• Most frequent complaint is of added time to ward round

Junior Checklist

Paper version failed

Ambiguity around tick boxes or Y/N/na

Data from cycle 2 showing when stickies used, VTE prophylaxis and allergy documentation rose to 98%

Data about sticky completion fed back weekly

Now Junior sticky completion approaching 100%

Sticky Completion

0

20

40

60

80

100

week beginning

%ageJunior

Senior

Dr Morse on call

New Docs

Stickies ran out

3rd cycle of comprehensive audit

Sticky completion 95%

VTE prophylaxis 95%

Allergy documentation 95%

Oxygen prescribing improving 67%

Cons imp/plan 80%

• Presented nationally

• Classic example of PDSA in action

• Rolling cohorts of juniors involved

• Now part of culture???

• New docs – some teething problems ‘blanks’ - improving

• General ward

• Recognition of the deteriorating patient

• Communication between ‘silos’

• Repeated ‘handovers’

• Trying to introduce safety briefs, failed ‘huddles’

• Anticipatory care, LCP

• Trying to improve quality

Date……………….. Time…………WR………………….Review

Daily goals: 1)…………………………………………………2)…………………………………………………3)…………………………………………………4)…………………………………………………5)…………………………………………………

Nursing: PVC Y/N Needed Y/N Review siteIncontinent? Diarrhoea?For LCP?

Pharmacy: Antibiotics………………..………………Thromboprophylaxis Y/NDosette box Y/NPatient at risk of deterioration Y/N FOR ESCALATION/ NOT FOR ESCALATION/ UNDECIDEDFOR CPR/ DNACPR/ UNDECIDEDSigned………………………….. Bleep………………….

Making it easy to ‘do the right thing’

Every patient, every time

Measureable improvement

Create confidence and trust in our system

Humility to accept our fallibility

Embedding this in all staff