On the CUSP at RCH

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 • Antimicrobial coverage perioperatively • Appropriate use of prophylactic antibiotics • Antiseptic prophylaxis • Appropriate hair removal • Maintenance of perioperative glucose control • Perioperativenormothermia

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

9. SAQ Results

10. NSQIP Targeted Procedures – RCH – July 2011 – June 2012 * Indicates High Outlier / NI = Needs Improvement / AE = As Expected

11. Introducing CUSP • 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.

12. Five Components of CUSP

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) • Please describe how you think the next patient in the OR will be harmed? • Please describe what you think can be done to prevent or minimize this harm • Please describe how you think the next patient in the OR will get a surgical site infection • Please describe what you think can be done to prevent this infection

15. Results of Safety Assessment #1

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) 5-6 6 6-7 3-4 4-14 5-12 6-7 5-7 Range of Personnel Present Door Swings/ Case Time 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

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

23. Safety Assessment Round #2

24. Safety Assessment Round #2

25. Normothermia

26. Results: Normothermia Mean temperatures of all Surgeries monitored

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