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September 1, 2015
We ended our August 25, 2015 Patient Safety Tip of the Week “Checklist for Intrahospital Transport” noting that our checklist was really chock full of items and were wary that we might contribute to a trend toward checklist fatigue that we discussed in our May 2015 What’s New in the Patient Safety World column “The Great Checklist Debate”.
Well, what if we could do something to make use of checklists easier and more manageable? A very insightful perspective by Eliot Grigg on improving use of checklists and avoiding checklist fatigue appears in the August 2015 issue of Anesthesia & Analgesia (Grigg 2015). While written from the view of an anesthesiologist, the concepts apply to almost any checklists in healthcare. We’ll discuss Grigg’s ideas in detail below. But first we need to look at some of the barriers and facilitators for checklist success.
A timely article in Nature (Anthes 2015) nicely summarizes some of the successful checklist implementations and also the failures. That article begins with some striking examples we noted in our May 2015 What’s New in the Patient Safety World column “The Great Checklist Debate”. The original introduction of the WHO Surgical Safety Checklist (Haynes 2009) was associated with striking reductions in both mortality and complication rates. But some studies, such as one done in Ontario, Canada (Urbach 2014) showed that implementation of surgical safety checklists was not associated with significant reductions in operative mortality or complications. And the stunning success of Peter Pronovost’s central line insertion checklist for preventing CLABSI’s at both Johns Hopkins and the Michigan Keystone Project (see our March 2011 What’s New in the Patient Safety World column “Michigan ICU Collaborative Wins Big”) had difficulty being replicated in the “Matching Michigan” program in the UK. So why such variable success in checklist project implementations?
One criticism of most studies on the impact of checklists is their before-after study designs. The argument is that there are often other patient safety initiatives and so many other confounding variables that might explain improvement in the “after” period. Also, the improvements in teamwork, communication, and culture that accompany such initiatives may play as important a role as the checklists themselves. Both are probably true. But in our May 2015 What’s New in the Patient Safety World column “The Great Checklist Debate” we did discuss a recent study using a different design (stepped wedge cluster randomized controlled trial) that demonstrated a significant positive impact of the WHO Surgical Safety Checklist on patient morbidity and mortality (Haugen 2015). The Haugen study even showed a “dose effect” in that larger reductions in complications were seen when all portions of the checklist were followed. And at least one other small randomized controlled trial showed a positive impact of a checklist on post-anesthesia patient handovers (Salzwedel 2013). So there is at least some evidence from better designed studies demonstrating a positive impact from checklists.
Mayer and colleagues found significant variability in use of the WHO Surgical Safety Checklist in the UK (Mayer 2015). Overall, checklist implementation was associated with reduced case-mix-adjusted complications after surgery and was most significant when all 3 components of the checklist were completed. Full, as opposed to partial, checklist completion provides a health policy opportunity to improve checklist impact on surgical safety and quality of care. You’ll also recall that in our May 2015 What’s New in the Patient Safety World column “The Great Checklist Debate” we noted a study that showed a similar “dose-response” effect as part of an overall significant positive impact of the WHO Surgical Safety Checklist on patient morbidity and mortality (Haugen 2015).
In a qualitative study of the implementation of the WHO Surgical Safety Checklist in the UK, Russ and colleagues (Russ 2015a) found 11 themes that represented barriers and 9 themes that represented facilitators. There was wide variation among English hospitals in the adoption and impact of checklist. You’ve often heard us use the saying “culture trumps ________” (fill in the blank with words like policy, procedure, strategy, tactics, vision, etc). In fact, “Culture trumps…Everything!”. Russ and colleagues found a major barrier to be general resistance to change, particularly among senior members of the staff, to be a major barrier. Hierarchical issues also were a barrier in that the person leading the checks (often a nurse) had difficulty when senior surgeons or anesthesiologists were not cooperative. Another organizational barrier was the manner in which the checklist implementation was rolled out. Where there was no planned approach or there was an “imposed” approach, there was little sense of ownership and buy-in was lacking.
But there were also barriers related to the time it took to complete the checklist and issues specific to the checklist. For example, there were design issues (eg. wording, layout, timing of items) and some of the items were not relevant to the particular type of surgery or procedure being done.
Interestingly, many providers questioned the validity of the evidence base for the success of the checklist. The pilot study showing such tremendous improvements included many developing world hospitals and many in the UK felt their systems were already better. A feeling that the checklist might also detract from other patient safety processes was also noted by some.
But Russ and colleagues also identified facilitators for use of the checklist. Having a “champion” is a success factor noted for many patient safety initiatives and the checklist is not different. Particularly having a senior clinician as a champion was seen as key. Also, having a person with strong leadership skills and an assertive presence in the OR leading the checklist process in the OR was particularly important. Organizational facilitators included provision of education and training, providing evidence of efficacy of the checklist and relevance to their local OR, training sessions on how to best use the tool, and feedback on impact of the checklist. Enforced accountability for compliance with the checklist was noted as a facilitator by some, a barrier by others. Inclusive input from the entire multidisciplinary team was a key facilitator. Integrating use of the checklist into existing workflows was an important facilitator, as was avoiding redundancy with other safety initiatives. Also important was the ability to modify the tool for the specific surgical context and to make it more user friendly. Making the checklist less of a “checking the boxes” process and more of a tool to enhance safety discussion was mentioned. Some accomplished this by displaying the checklist on the OR wall rather than using a paper checklist.
Russ and colleagues offer the following lessons for implementing change:
The issue of auditing is a sensitive one. If you implement any kind of improvement initiative in health care you need to collect data to determine whether it is producing the results you intended. But when auditing is perceived as a punitive measure you may inadvertently cause the project to fail. Clay-Williams and Colligan (Clay-Williams 2015) in their perspective on checklist in health care and aviation note that some of the intended benefits of checklists, such as enhanced teamwork and nurses speaking up, may be negated if compliance audits lead to sanctions.
Another study by Russ and colleagues (Russ 2015b) used a standardized observational tool to assess use of the WHO Surgical Safety Checklist on a sample of 5 English hospitals and found large variation across hospitals. They found that, on average, only two thirds of the items were checked, team members were absent in more than 40% of cases, and there was failure to pause or focus on the checks in more than 70% of cases.
“Matching Michigan” was a patient safety program aimed at decreasing central line infections in over 200 intensive care units (ICUs) in England, based upon the Michigan Keystone Project in the US. It largely failed to replicate the overwhelming success seen in The Michigan Keystone Project. CLABSI rates were already lower than those in the original Michigan cohort and improvements were already occurring due to other patient safety initiatives. Though the CLABSI rates did improve some, the “Matching Michigan” project was considered a failure by many. Dixon-Woods and colleagues conducted interview with staff of multiple English ICU’s participating in the program (Dixon-Woods 2013). One unit transformed its practices and culture in response to the program; five boosted existing efforts, and 11 made little change. They found that the perception of the program as a “top-down” initiative imposed on them and punitive in nature was detrimental to the potential success of the program. But individual ICUs’ histories and local context were also highly consequential: their past experience of quality improvement, the extent to which they were able to develop high quality data collection and feedback systems, and the success of local leaders in developing consensus and coalition all influenced the program’s impact on local practices.
Those researchers identified several things that needed to happen to ensure success at hospitals. One was that there had to be at least one senior physician who took a strong leadership role and worked with senior nurses. Also data collection needed to be rigorous and command credibility.
We’ll add one other critical factor that contributes to almost every patient safety or performance improvement program: size matters! By that we mean that initiatives involving smaller groups of staff are far more likely to be successful than big ones. The UK “Matching Michigan” program involved all the hospitals in the UK. The actual Michigan Keystone Project, on the other hand, involved only ICU’s at hospitals volunteering to participate. We think one of the secrets to success is the CUSP (Comprehensive Unit-Based Safety Program) approach (see our March 2011 What’s New in the Patient Safety World column “Michigan ICU Collaborative Wins Big”). In our own experience the patient safety and quality improvement projects that are most successful are those done in relatively small settings where the key participants all know each other and work closely together as affinity groups. Contrast the striking successes of the MHA Keystone ICU project to the relative lack of success of a large scale organizational intervention on patient safety at several UK hospitals. In the UK project there seemed to be a disconnect between the frontline staff and the group overseeing the project.
So what about that perspective by Eliot Grigg on improving use of checklists and avoiding checklist fatigue (Grigg 2015)? Grigg, of course, does offer many of the above-mentioned solutions like changing culture, flattening hierarchies, reducing the number of checklists, or changing the designs of checklists. But Grigg’s best argument is that we have technological capabilities to make the checklists more useable.
Grigg notes that “the goal of ‘smart checklists’ is not to threaten provider autonomy but to mentally offload the many repetitive tasks in health care that must be completed in a largely predictable sequence”. He stresses that the efficient checklist presents the right content at the right time and in the right context. He suggests “filtering” the checklists to only include those things that have yet to be done, often with the help of technology. In that regard, some of the following contextual factors need to be considered (for an OR case):
He gives as an example that a checklist item for antibiotic administration should not be needed if your Anesthesia Information System (AIS) or equivalent electronic OR management system has already documented that the antibiotic has been administered.
Grigg further discusses the aviation analogy of two types of checklist: normal and non-normal. “Normal” checklists are those that deal with the more mundane tasks that are an integral part of routine care. “Non-normal” checklists are those that deal with emergency situations (see our August 16, 2011 Patient Safety Tip of the Week “Crisis Checklists for the OR”). The latter need to be readily available when the emergency arises. An example might be a checklist for dealing with malignant hyperthermia. (Clay-Williams and Colligan (Clay-Williams 2015) refer to these “non-normal” checklists as “boldface” checklists” meaning they are items requiring immediate action.) Note also we have in several previous columns noted a guidance from the UK Civil Aviation Authority that has some excellent recommendations about the design of emergency checklists used in aviation (UK Civil Aviation Authority 2006). Many of those design recommendations could equally apply to the “crisis” checklists needed in places like the OR.
Grigg notes that a crucial component in implementing smart checklists is having devices and software systems in the OR communicate with each other. He notes that all devices should have USB ports and wireless capabilities and use a common language for communicating their current state with each other. He suggests that RFID technology could be used to identify and readily locate both equipment and providers in the OR. And the checklists then ought to be easily accessible electronically and interfaced with the AIS as well.
Let’s apply Grigg’s concepts to the “Ticket to Ride” type checklist we described in last week’s Patient Safety Tip of the Week “Checklist for Intrahospital Transport”. One of the success factors for that checklist was its availability online in their EMR. But let’s take it even further. Important flags, such as whether a patient is at risk for falls or for wandering, might be included on the checklist only if the information from the nursing assessments in the EMR indicates the patient is at risk. Items pertaining to MRI-compatibility of equipment could appear on the checklist only if the patient is being transported for an MRI. The EMR could also indicate whether an informed consent is necessary and has been completed for the particular procedure for which the transport is occurring. Presence of various pieces of equipment on the transport gurney could be indicated via RFID technology. Battery/power status indicators from the equipment could automatically appear on the checklist. Conceivably, the amount of oxygen remaining in the oxygen cylinder might be populated in the checklist automatically via Bluetooth or other wireless technology. Ideally even the availability of elevators needed for the transport might be conveyed in real time. And reminders about restarting feedings or insulin or other medications could populate the post-transport checklist only if they had been withheld prior to the transport. Having such “filtering” could obviously reduce the “Ticket to Ride” checklist to a more manageable size and free up staff to pay more attention to things like maintenance of lines and tubing and monitoring the patient during the transport.
So is there a downside to the type of system envisioned by Grigg? The obvious one is overreliance on electronic systems that might go down periodically. Should the system fail, we could be back at square one and fail to remember some key steps in various processes. However, having such electronic systems working 99+% of the time obviously would likely improve both efficiency and safety.
We remain active advocates of checklists in healthcare. But we’re also wary of checklist fatigue. The suggestions by Grigg to better use technology and filter checklist items out to make checklist more manageable are very valuable.
Some of our prior columns on checklists:
Grigg E. Smarter Clinical Checklists: How to Minimize Checklist Fatigue and Maximize Clinician Performance. Anesth Analg 215; 121(2): 57-573
Anthes E. Hospital checklists are meant to save lives - so why do they often fail? An easy method that promised to cut complications in surgery may not be so simple after all. Nature 2015; 28 July 2015
Haynes A, Weiser T, Berry W, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009; 360(5): 491-499
Urbach DR, Govindarajan A, Saskin R, et al. Introduction of surgical safety checklists in Ontario, Canada. N Engl J Med 2014; 370(11): 1029-1038
Haugen AS, Søfteland E, Almeland SK, et al. Effect of the World Health Organization Checklist on Patient Outcomes: A Stepped Wedge Cluster Randomized Controlled Trial. Annals of Surgery 2015; 261(5): 821-828
Salzwedel C, Bartz H-J, Kühnelt I, et al. The effect of a checklist on the quality of post-anaesthesia patient handover: a randomized controlled trial. Int J Qual Health Care 2013; 25(2): 176-181
Mayer EK, Sevdalis N, Rout S, et al. Surgical Checklist Implementation Project: The Impact of Variable WHO Checklist Compliance on Risk-adjusted Clinical Outcomes After National Implementation. A Longitudinal Study. Annals of Surgery 2015; Post Author Corrections: March 13, 2015 doi: 10.1097/SLA.0000000000001185
Russ SJ, Sevdalis N, Moorthy K, et al. A Qualitative Evaluation of the Barriers and Facilitators Toward Implementation of the WHO Surgical Safety Checklist Across Hospitals in England: Lessons From the “Surgical Checklist Implementation Project”. Annals of Surgery 2015; 261(1): 81-91
Clay-Williams R, Colligan L. Back to basics: checklists in aviation and healthcare. BMJ Qual Saf 2015; 24(7): 428-431 Published Online First: 12 May 2015
Russ S, Rout S, Caris J, et al. Measuring Variation in Use of the WHO Surgical Safety Checklist in the Operating Room: A Multicenter Prospective Cross-Sectional Study. J Am Coll Surg 2015; 220(1): 1-11.e4
Dixon-Woods M, Leslie M, Tarrant C, Bion J. Explaining Matching Michigan: an ethnographic study of a patient safety program. Implement Sci 2013; 8: 70
Civil Aviation Authority (UK). CAP 676: Guidance on the Design, Presentation and Use
of Emergency and Abnormal Checklists. 2006.
Print “Smarter Checklists”
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In our April 2015 What’s New in the Patient Safety World column “Pediatric Dosing Unit Recommendations” we discussed the American Academy of Pediatrics new Policy Statement on “Metric Units and the Preferred Dosing of Orally Administered Liquid Medications” (AAP 2015). That new policy statement recommends switching to sole use of metric dosing, i.e. strictly using milliliters for dosing of orally administered liquid medications in children and infants. Use of measures such as “teaspoon” and “tablespoon” should no longer be used. Moreover, it emphasizes that the correct abbreviation for milliliters is “mL” (rather than “ml”, “ML”, or “cc”). Dispensing devices are also critical. The statement recommends that pharmacies, hospitals, and healthcare centers distribute appropriate-volume milliliter-based dosing devices such as syringes. Another important point is that the syringe (or other dosing device) should not be significantly larger than the dose prescribed. It also recommends that manufacturers avoid labeling, instructions or dosing devices that contain units other than metric units.
Several other organizations have concurred with these recommendation and it should not just apply to pediatric patients.
Now a new national alert has been issued that recommends hospitals replace medication dosage cups that use units other than mL (NAN 2015). This follows reporting of a fatal event to the ISMP National Medication Errors Reporting Program in which a nurse confused two dosing scales that appear on a plastic oral liquid dosing cup. In that event drams were confused with mL, resulting in a fatal overdose of morphine.
Unfortunately, such cups are still available and it’s possible they will be found in your healthcare facility. The alert recommends that in their place you use available oral syringes that measure only in mL whenever possible. If a dosing cup must be used, ideally it should allow measurement in mL only.
AAP (American Academy of Pediatrics). Committee on Drugs. Policy Statement. Metric Units and the Preferred Dosing of Orally Administered Liquid Medications. Pediatrics 2015; 135(4): 784-787; originally published online March 30, 2015
NAN (National Alert Network). Move toward full use of metric dosing: Eliminate dosage cups that measure liquids in fluid drams. Use cups that measure mL. NAN 2015; June 30, 2015
It’s human nature to think we are doing better at something than we really are when we don’t know the data. A number of years ago we asked caregivers at a community hospital how well they provided care for patients with acute MI. They weren’t really sure because they sent most of their acute MI patients to a tertiary hospital. But they thought most of their patients would have received percutaneous coronary angioplasty within the prescribed timeframes. When they finally got around to requesting the data from the tertiary hospital it turned out that almost none of the patients got the angioplasty within the recommended timeframe, mainly because of transport delays and delays on arrival. Their patient population would have been much better off receiving thrombolytic therapy at the community hospital before being transported to a tertiary hospital. Once the hospital recognized this problem they began initiating thrombolytic therapy on-site and did a good job achieving this therapy within the prescribed timeframes for most acute MI patients. The problem was clearly one of lack of data availability and lack of timely feedback on performance.
The same applies to acute stroke care. A recent study from hospitals participating in the American Heart Association’s “Get With The Guidelines” (GWTG) program found that hospitals often overestimate their ability to deliver timely tPA to patients treated with tPA (Lin 2015). Less than one third of all hospitals responding to a survey accurately identified their door-to-needle (DTN) time performance. Respondents from hospitals in middle- and low-performing hospitals in particular overestimated their DTN performance.
The key message is that to improve care you need to provide comparative provider performance data routinely to caregivers.
There are many factors that go into running successful stroke programs. We’ve discussed those in the several prior columns listed at the end of today’s column. But there are a few new considerations.
One important factor is coming to a correct diagnosis of stroke. Prior to administering tPA we need to exclude certain stroke “look-alikes” or “mimics” (eg. migraine, post-ictal Todd’s paralysis, etc.). However, we may also fail to diagnosis acute strokes in some patients. A recent study (Richoz 2015) looked at acute stroke “chameleons” presenting to a university hospital emergency department. They found that 2.1% of strokes were missed initially. These were either misdiagnosed as other neurologic diseases (42%) or non-neurologic diseases (17%) or as unexplained decreased level of consciousness (21%) or as concomitantly present disease (19%). These strokes tended to be either very mild or very severe. At 12 months patients with these “chameleons” tended to have less favorable outcomes and higher mortality.
Another problem in thrombolytic therapy for acute stroke was recently noted by Bordoehl and colleagues (Brodoehl 2015). Because of the short half-life of tPA, it should be administered as a bolus followed by an immediate infusion. However, they note that in clinical practice there are sometimes delays between the application of the bolus and the start of the infusion. In addition, interruptions of the infusion may occur. They found that even 1-minute delays before the infusion is begun or interruptions of the infusion for more than 1-minute may affect serum tPA concentrations. Their results strongly suggest avoiding bolus-infusion delays by giving the bolus only when the infusion is ready. They went on to estimate the dosing of a potential second bolus depending on the duration of the delay/interruption to allow for the achievement of appropriate serum tPA concentrations. However, they stress that clinical safety data are needed to recommend the application of a second bolus.
Sustaining improvement is often difficult and another recent study illustrates the difficulties encountered in sustaining some components of good stroke care. Perhaps just as important as getting thrombolytic therapy to those eligible acute stroke patients is prevention of complications of stroke, such as UTI’s, pneumonia, and DVT. Williams and colleagues (Williams 2015) conducted a cluster-randomized quality improvement trial, randomizing hospitals to quality improvement training plus indicator feedback versus indicator feedback alone to improve deep vein thrombosis (DVT) prophylaxis and dysphagia screening. DVT prophylaxis improved more during the intervention period in the active intervention group but this improvement was not sustained afterward. For improving dysphagia screening quality improvement training was no better than feedback alone.
So, while we encourage you to make the major changes noted in our columns below, we also use the above examples to remind you that some of the other issues in stroke care also impact the outcomes for your patients.
Some of our previous columns on improving stroke care:
November 6, 2012 “Using LEAN to Improve Stroke Care”
March 18, 2014 “Systems Approach Improving Stroke Care”
September 23, 2014 “Stroke Thrombolysis: Need to Focus on Imaging-to-Needle Time”
January 27, 2015 “The Golden Hour for Stroke Thrombolysis”
May 12, 2015 “More on Delays for In-Hospital Stroke”
Lin CB, Cox M, Olson DM, et al. Perception versus actual performance in timely tissue plasminogen activation administration in the management of acute ischemic stroke. Journal of the American Heart Association 2015; DOI: 10.1161/JAHA.114.001298
Richoz B, Hugli O, Dami F, et al. Acute stroke chameleons in a university hospital: Risk factors, circumstances, and outcomes. Neurology 2015; 85: 505-511; published ahead of print July 15, 2015
Brodoehl S, Günther A, Witte OW, Klingner CM. How to Manage Thrombolysis Interruptions in Acute Stroke? Clinical Neuropharmacology 2015; 38(3): 85-88
Williams L, Daggett V, Slaven JE, et al. A cluster-randomised quality improvement study to improve two inpatient stroke quality indicators. BMJ Qual Saf 2015; published online 24 August 2015 doi:10.1136/bmjqs-2015-004188
We’ve done numerous columns discussing the role of fatigue in healthcare. We’ve also done numerous columns discussing the conflicting studies on the impact of resident work hour restrictions on patient outcomes, noting that overall there does not seem to be an impact of such restrictions in either direction. We’ve always suspected that any improvement due to reduction of resident fatigue is offset by the increased number of handoffs and reduction of continuity of care.
But most of the literature has focused on residents and training programs rather than attending physicians. Therefore, a new study from Ontario, Canada sheds important light on the impact on patient outcomes when their attending surgeon has performed late night surgery the previous night. The Canadian researchers (Govindarajan 2015) were able to use administrative (billing) data to identify cases in which a surgeon likely performed one or more procedures after midnight and then performed another surgery the next day. They then created a control group matched for the same surgeon and type of procedure and adjusted for other clinical variables. They essentially found no significant difference in outcomes between the two groups for the primary outcome (a composite of death, complications, and readmission within 30 days) or a number of secondary measures.
The study is limited in that the researchers did not know whether surgeons may have cancelled some cases voluntarily if they felt fatigued after a late night surgery or had lightened their elective schedule in anticipation of night call. They also had no measure of the actual hours of sleep a surgeon may have had the prior day/night. It also is limited by the use of administrative billing data to identify time of surgery. Nevertheless, the study included almost 39,000 patients operated on by 1448 attending surgeons and included data from 12 of the most commonly performed surgical procedures. We think their conclusion that the risks of adverse outcomes for elective daytime procedures were similar whether the surgeon had provided medical services the previous night is likely valid.
Note that this is a very different question from one we have addressed on numerous occasions. Several of our columns have questioned whether surgery should be done “after hours”, particularly for procedures that may not be true emergency ones (see our What’s New in the Patient Safety World columns for September 2009 “After-Hours Surgery – Is There a Downside?”, October 2014 “What Time of Day Do You Want Your Surgery?”, December 2014 “Another Procedure to Avoid Late in the Day or on Weekends” and January 2015 “Emergency Surgery Also Very Costly”).
In those columns we have pointed out that such surgeries and procedures involve considerations far beyond just the surgeon. Why should “after hours” surgery be more prone to adverse outcomes than regularly scheduled elective surgery? There are many reasons aside from the fact that patients needing emergency and after hours surgery are generally sicker. You are operating with a team that is likely different from your daytime team. All members of that team (physicians, nurses, anesthesiologists, techs, etc.) may not have the same level of expertise as your regular daytime team and the team dynamics between members is likely to be different. The post-surgery recovery unit is likely to be staffed much differently after-hours as well. The staff may be more likely to be unfamiliar with things like location of equipment. And some of the other hospital support services (eg. radiology, laboratory) may have lesser staffing after-hours. Just as importantly, many or all of the “on-call” staff that make up the after-hours surgical team have likely worked a full daytime shift that day so fatigue enters as a potential contributory factor. And there are always time pressures after hours as well. In addition, one of the most compelling reasons surgery is done at night rather than deferred to the next morning is the schedule of the surgeon or other physician for that next morning (either in surgery or the cath lab or his/her office). Because the surgeon does not want to disrupt that next day schedule, he/she often prefers to go ahead with the current case at night. Similarly, many hospitals run very tight OR schedules and adding a case from the previous night can disrupt the schedule of many other cases.
The current Canadian study is reassuring in that outcomes for the “next day” case do not seem to be adversely impacted by the surgeon’s previous night procedures. But it does not address outcomes of the cases done the previous night.
We highly recommend hospitals take a hard look at surgical cases done “after hours”. In particular, you need to determine which cases truly needed to be done after hours and, perhaps more importantly, which ones could have and should have been done during “regular hours”. If the latter are significant, you need to consider system changes such as reserving some “regular hours” for such cases to be done the following morning. You may have to alter the scheduling of cases for individual surgeons as well. For example, perhaps the surgeon on-call tonight should not have elective cases scheduled tomorrow morning. That way, if a case comes in tonight that should be done tomorrow morning you will have both a “free” OR room and a “free” surgeon. And you would need to develop a list of criteria to help you triage cases into “regular” or “after-hours” time slots.
Some of our previous columns on the “weekend effect” or “after-hours effect”:
Some of our other columns on the role of fatigue in Patient Safety:
November 9, 2010 “12-Hour Nursing Shifts and Patient Safety”
April 26, 2011 “Sleeping Air Traffic Controllers: What About Healthcare?”
February 2011 “Update on 12-hour Nursing Shifts”
September 2011 “Shiftwork and Patient Safety
November 2011 “Restricted Housestaff Work Hours and Patient Handoffs”
January 3, 2012 “Unintended Consequences of Restricted Housestaff Hours”
June 2012 “June 2012 Surgeon Fatigue”
November 2012 “The Mid-Day Nap”
November 13, 2012 “The 12-Hour Nursing Shift: More Downsides”
July 29, 2014 “The 12-Hour Nursing Shift: Debate Continues”
October 2014 “Another Rap on the 12-Hour Nursing Shift”
December 2, 2014 “ANA Position Statement on Nurse Fatigue”
August 2015 “Surgical Resident Duty Reform and Postoperative Outcomes”
Some of our other columns on housestaff workhour restrictions:
December 2008 “IOM Report on Resident Work Hours”
February 26, 2008 “Nightmares: The Hospital at Night”
January 2011 “No Improvement in Patient Safety: Why Not?”
November 2011 “Restricted Housestaff Work Hours and Patient Handoffs”
January 3, 2012 “Unintended Consequences of Restricted Housestaff Hours”
June 2012 “Surgeon Fatigue”
November 2012 “The Mid-Day Nap”
December 10, 2013 “Better Handoffs, Better Results”
April 22, 2014 “Impact of Resident Workhour Restrictions”
January 2015 “More Data on Effect of Resident Workhour Restrictions”
August 2015 “Surgical Resident Duty Reform and Postoperative Outcomes”
Govindarajan A, Urbach DR, Kumar M, et al. Outcomes of Daytime Procedures Performed by Attending Surgeons after Night Work. N Engl J Med 2015; 373: 845-853
APIC (Association for Professionals in Infection Control and Epidemiology) has published its updated guide to hand hygiene (APIC 2015). The guide begins with an overview summarizing the scientific evidence for hand hygiene in infection control. It also lists hand hygiene elements required by regulatory and accrediting bodies. It has a good section on hand hygiene products, including details about both ingredients and formulations and also delivery systems. The section on monitoring hand hygiene compliance covers direct observation, measuring product usage, and newer electronic or hi-tech methods but also notes the importance of timing of the monitoring to actually impact compliance. But the best sections are those on implementing multimodal hand hygiene programs and changing culture. These include elements regarding access to hand hygiene products, workflow considerations, supply chain issues, role of management, leadership, integration with organizational goals, educational and training issues, and more. A whole section is dedicated to strategies for behavior change. The APIC guide is well referenced and includes links to many valuable resources and tools.
Sharp Healthcare has a new video on hand hygiene that is quite good. Links to some hand hygiene videos we’ve used in the past can be found in our May 24, 2011 Patient Safety Tip of the Week “Hand Hygiene Resources”.
But our favorite video on HAI’s and hand washing is still the one done by the Penn State Hershey Medical Center Infection Control Team. This also sends a powerful message that is likely to be remembered. Its semi-animated format also introduces a bit of levity that makes this one an ideal video to be shown to patients and families as well.
Some of our other columns on handwashing:
January 5, 2010 “How’s Your Hand Hygiene?”
December 28, 2010 “HAI’s: Looking In All The Wrong Places”
May 24, 2011 “Hand Hygiene Resources”
October 2011 “Another Unintended Consequence of Hand Hygiene Device?”
March 2012 “Smile…You’re on Candid Camera”
August 2012 “Anesthesiology and Surgical Infections”
October 2013 “HAI’s: Costs, WHO Hand Hygiene, etc.”
November 18, 2014 “Handwashing Fades at End of Shift, ?Smartwatch to the Rescue”
January 20, 2015 “He Didn’t Wash His Hands After What!”
APIC (Association for Professionals in Infection Control and Epidemiology). Guide to Hand Hygiene Programs for Infection Prevention (2015).
Sharp HealthCare. "It's OK to Ask" (video)
Penn State Hershey Medical Center Infection Control Team/McGuckinMethodsIntl.
Healthcare Worker Hand Hygiene Educational Training Video.
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