1. On the CUSP at RCH M. Arget N.P. Blair Fraser Health Authority April 2013

2. 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

3. 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

4. How about Culture? Healthcare is all about relationships Effective teams result in better patient outcomes

5. Results from BC culture survey

6. 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

7. 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

8. SAQ Results

10. VariableEvents/ Total Cases % Observed % Expected Odds Ratio Decile/ Comments Pancreatectomy Morbidity 11/1861.1126.721.4010/NI Pancreatectomy SSI 9/1752.9418.981.9510/NI Colectomy Morbidity 84/19942.2131.321.5110/NI Colectomy SSI52/19426.8013.082.1510/NI NSQIP Targeted Procedures – RCH – July 2011 – June 2012 * Indicates High Outlier / NI = Needs Improvement / AE = As Expected

11. 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

12. Five Components of CUSP ComponentMethod 1. Science of safety educationIntroductory talk to explain the approach to addressing safety at a local level 2. Staff Safety AssessmentTwo 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 partnershipSenior executive attends CUSP meetings, making resources available to address safety concerns and assist with system-wide barriers 4. Learning from defectsTeams 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

13. 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

14. 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

15. Results of Safety Assessment #1 Issue from AssessmentFrequency of Response Traffic6 Large number of people in OR5 Antibiotic timing4 Sterile Technique4 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)

16. 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)

17. Data Collection Tool

18. 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)

19. OR Traffic Results (8 in Total) 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 Door Swings/ Case Time 5-6 6 6-7 3-4 4-14 5-12 6-7 5-7 Range of Personnel Present

20. 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.

21. Reasons for Door Opening Supply/equipment Information Break/shift change Scrub in Observation Complicated & unplanned surgeries account for more DSs.

22. Comparison with Other Studies Study Our Study Bansal & Hacken berger, 2012 Condro n et al., 2012 Lynch et al., 2009 Panahi et al., 2011 Parikh et al., 2010 Young & O’Rega n, 2009 Study Length 2wks5wks?3mos7mos1mos3mos Total DSs 35425,0486383,0719,6572,8874,273 Studied Cases 8108?281162646 Case Time (Min) 614626hrs?1,36713,8634,350Mean: 5h18m/c ase DSs Per Hour 34.59Peak hrs:40 Average : 33 ?3741.439.82Mean: 19.2

23. Safety Assessment Round #2

25. 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 2 nd (Tuesday) & 8 th (Monday), 2013 -5 hours per day -0900 – 1400

26. Results: Normothermia Type of Surgery (total – 22) Mean temperature PREINTRAPOST General (4)36.635.936.4 Gyne (4)36.7n/a36.4 Neuro (4)36.435.236.3 Ortho (5)36.736.136.3 Plastics (2)36.735.936.3 Vascular (3)36.735.736.1 Mean temperatures of all Surgeries monitored PREINTRAPOST 36.635.836.3

27. Results: Normothermia Temperature

28. 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).

29. 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

30. 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

31. Next Steps Work on addressing traffic and keeping patients warm Learning from defects Implement teamwork and communication tools Expanding beyond general surgery

32. 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