The influence of Occupation and Teamwork on the Successful Use of the WHO Surgical Checklist: Experiences of Swedish Healthcare Professionals

Background: Every year, some 300 million operations are performed around the world, with approximately 700,000 in Sweden. This represents about one surgical procedure per 25 people. All these operations are not free of risk. The safety of patients can be enhanced by teamwork, good communication and checklists ensuring adherence to safety routines. The aim of the present study was to describe the experience of Swedish healthcare professionals of using the WHO surgical checklist, with special emphasis on different occupations and teamwork. Methods:A descriptive cross-sectional statistical study, including healthcare professionals from two departments at a university hospital in the western part of Sweden, was conducted. Data were collected from one hundred and ninety-six healthcare professionals, using a self-administered questionnaire that contained 12 questions. The Mantel-Haenszel and Pearson χ2 tests were used for ordered and unordered categorical variables. Results: One hundred and ninety-six healthcare professionals, aged 21-73, and 6 different categories with 5-25 years experiences participated. Regarding the usage of the checklist at different departments, the biggest different was about responsibility to implementation of the checklist (p=0,001), using the checklist in the emergency situations (p=0.04), if the checklist improve patient’s safety (p=0.04), and if the list has been completed correctly (p=0,006). Regarding the training for using the checklist, anaesthetist nurses were most negative with 75,5%, and the operating nurses were most positive with 39.2 %. 66,0 % of nurse anaesthetists, the checklist was adapted to the department. Majority of all the occupations thought that the checklist improved patients safety, and that the checklist had been correctly completed. Conclusion: Different departments and different occupations experience difficulties using the checklist in the Swedish healthcare system. More research is needed to investigate the experiences of healthcare professionals, whether different occupations report differently about using the checklist and whether teamwork is influenced by using the checklist. A further understanding of the checklist and its importance, as well as its content, could increase the safety of patients due to improved compliance. Key words: WHO checklist, surgery, occupation, teamwork questionnaire, research .

An Evidence-based General Anesthesia and Prone Position Nursing Checklist: Development and Testing

Background and Aim: Prone positioning during general anesthesia is one of the most difficult practices for the perioperative nurse. Patients in this position are vulnerable to many preventable complications. However, no studies have developed an evidenced-based tool to improve nursing practice during general anesthesia and prone positioning. This study aimed to develop and test a general anesthesia and prone position nursing checklist for use by the circulating nurse. Methods: The WHO checklist development model and evidence-based methods guided the checklist development process. A prospective pre-post study was performed between November 2020 and March 2021. We prospectively observed circulating nurses that attended to prone general anesthesia during posterior lumbar spine surgery for three months before and after the introduction of the general anesthesia and prone position nursing risk checklist. The main outcomes were successful delivery of essential prone positional nursing practices during each surgery and the nurse's opinion of the checklist’s efficacy and utility. Results: A general anesthesia and prone position nursing checklist comprised of 4 pause points and 22 necessary nursing practices was developed. Seventy-two nurses participated in this study. Use of the checklist significantly increased the average performance of essential practices during each surgery from 72.72% to 95.45%. Three measures had a compliance rate of 100%. The delivery rate of 14 measures was significantly improved, 91.7% of nurses considered the checklist easy to use, and 94.4% nurses would want the checklist to be used if they underwent a prone position and general anesthesia operation. Conclusions: A general anesthesia and prone position nursing checklist was developed. The instrument was found to be an effective and positively received tool for facilitating key measures of prone positioning during nursing care, translating evidence into practice, and standardizing the nursing process.

Improving the Outcome of GMP Inspections by Improving Proficiency of Inspectors through Consistent GMP Trainings

Approximately 90% of the pharmaceutical inspectors in a pharmacy practice regulatory agency in West Africa have not updated their training on Good Manufacturing Practice (GMP) inspection in at least eight years. However, in the last two years the inspectors relied on learning-on-the job skills. During this time, the agency introduced about 17% of its inspectors to hands-on GMP trainings. GMP is the part of quality assurance that ensures the production or manufacture of medicinal products is consistent in order to control the quality standards appropriate for their intended use as required by the specification of the product. Inspection reports on the Agency’s GMP inspection format in-between 2013 to 2019 across the six geopolitical zones in the country were reviewed retrospectively for gap analysis. Sampling was done in two phases. During the first phase sampling of reports was done by random selection, using a stratified sampling method. In the second phase, inspectors from the Regulatory Agency from different regions were contacted on phone to send in four reports each by email. For those that forwarded four reports, two, were selected. However for those who forwarded one or two, all were considered. Also, the Agency’s inspection format/checklist was compared with the World Health Organization (WHO) GMP checklist and the GMP practice observed. The purpose of this study was to evaluate the reporting skills and the ability of inspectors to interpret findings vis-à-vis their proficiency in inspection activities hence the efficiency of the system. Secondly, the study seeks to establish shortfalls or adequacies of the Agency’s checklist with the aim of reviewing and improving in-line with best global practices. It was observed that different inspectors have different styles and methods of writing reports from the same check-list/inspection format, leading to non-conformances. Interpretations of findings were found to be subjective. However, it was also observed that inspection reports from the few inspectors with the hands-on training in the last two year were more coherent. This indicates that pharmaceutical inspectors need to be trained regularly to increase their knowledge and skills in order to be kept on the same pace. It was also observed that there is a slight deviation in placing sub indicators under the GMP components in the Agency’s GMP inspection format, as compared to the WHO checklist.

MONITORING OF MEASLES RUBELLA VACCINATION SESSIONS AT SCHOOLS IN PUNE CITY

Introduction: India with the support of WHO launched one of the world's largest vaccination campaigns against measles and rubella on 5 February 2017. The campaign was launched to vaccinate children in the age group of 9 months to 15 years with measles and rubella vaccine. In Maharashtra state the campaign started from 27th November 2018. All eligible children were vaccinated at the following session sites: Schools, Health sub-centers, Anganwadi centers, xed outreach sessions and mobile posts in villages and urban areas, Government health facilities will vaccinate on all days of campaign. Aim and objectives: To monitor vaccination injection practices, cold chain maintenance and safe needle disposal at measles rubella vaccination sessions at schools in Pune city. Material and methods: Study was a cross sectional study. 5 schools in each 5 Wards (Bibewadi, Kondwa, Hadapsar, Wanowri, and Dhankawadi) out of the 15 wards of Pune Municipal Corporation were MR vaccination campaign session will take place will be studied in 2nd week of the campaign. After obtaining permission from the WHO surveillance medical ofcer The above mentioned sites were visited on vaccination day. A structured Performa based on WHO checklist were lled on observation of all the sites selected. Results: 92% of the vaccinators have attended training sessions, 16% of the vaccinators were wearing gloves, Swabbing of the skin done by 52% , 80% of the vaccinators were administering vaccine through subcutaneous route, cold chain were maintained to 100% perfection and Safe needle disposal practices were maintained to 100%. Conclusion: Need for better training to healthcare workers about safe practices and proper implementation of vaccination campaign.

EP.WE.406Adherence to operative standards for ulnar polydactyly excision in times of COVID-19 pandemic

Aims Simple ulnar polydactyly excision is a very common surgical procedure ideally performed within the first 6 months of infants life and under local anaesthetic. In conditions preceding COVID-19 pandemic this procedure was performed in controlled environment of operating theatres on a weekly basis. Increase in pressure on the NHS and operating theatre reorganisation meant elective procedures had to be cancelled with no alternatives in sight. We have suggested therefore, it be performed in a clinic environment instead under strict supervision and guidelines. No recommendations however, have been implemented when considering completion of WHO checklist and standard operation documentation. We investigated therefore adherence to typical Evelina Hospital theatre guidelines when considering documentation. Methods Completed documentation for each patient undergoing ulnar polydactyly excision in clinic room was reviewed between May 2020 and December 2020. Categories of WHO checklist completion, operation note present and legible, appropriate local anaesthetic information and instrument count correct were reviewed. Results 92% of procedures did not have WHO checklist completed. Furthermore, as many as two thirds of the documents were completed illegibly and did not contain required information. Conclusions Following the transfer of ulnar polydactyly excision procedure to clinic rooms we found the quality of documentation to be substandard. This provides opportunity for error and cause for concern. We introduced therefore standardised operative documentation pack to be completed at each polydactyly excision procedure in clinic room. Re-audited results showed improved compliance with standard operative rules and regulations and therefore improved quality of care.

EP.FRI.792 Laparoscopic port positioning in paediatric appendicectomy - a closed loop audit

Aims Laparoscopic appendicectomy is the most common laparoscopic procedure performed in children, typically with a suprapubic (SP) left-hand port position. This has been associated with bladder injury. Pre-operative bladder emptying can reduce the risk of this complication. The aim of this study was to evaluate compliance with local policy mandating left iliac fossa port placement (LIFPP) rather than SP. We assessed the rate of LIFPP before and after an educational intervention, and also audited if voiding status was included as part of the paediatric WHO checklist. Methods Retrospective data was collected before and after implementation of education, for 50 consecutive patients aged <16 years undergoing laparoscopic appendicectomy. The education programme targeted operating department practitioners, paediatric nurses and surgeons, and included seminars and regular dissemination of the local protocol. Data analysis was performed using GraphPad Prism. Results Patients were evenly distributed by gender with 94% above the age of 10. Mean age was 13.8 years. There was a statistically significant improvement in compliance with LIFPP, from 72% to 100% (p < 0.0001) after introduction of improved education, as well as significantly improved documentation of pre-operative voiding status from 12% to 40% (p = 0.0026). The rate of catheterisation intra-operatively was reduced from 20% to 8% (p = 0.1478). Conclusions Improved education has led to a significantly increased compliance with local port placement policy. Documentation of pre-operative voiding status has been included in the paediatric WHO checklist ‘SIGN IN’ section locally.

738 Lessons from the National Patient Safety Agency Alerts

Aim The National Patient Safety Agency (NPSA) reviews incident reports from all NHS trusts, and reports deemed critical are issued as NPSA alerts. We aim to highlight important learning points from NPSA alerts to facilitate wider dissemination and prevent similar incidents, and overall improve patient safety. Method All patient safety alerts obtained from NPSA since inception (2008) till June 2020 were screened. We identified safety alerts that could be relevant to surgical practice, and further details of each alert were obtained from the Central Alerting System (CAS) website. Information obtained from CAS website was reviewed by consultant surgeons to identify specific learning points. Results 1857 alerts were reported by NPSA of which 94 were relevant to surgical practice. Alerts were grouped into four themes: pre-operative(N = 4), intra-operative(N = 34), post-operative(N = 29), others(N = 8), and no specific learning point identified(N = 19). Pre-operative alerts focused on safety checks to avoid errors and improve patient safety e.g., WHO checklist. Majority of the intra-operative alerts were due to difficulty with use of specific equipment(n = 22) e.g., advanced haemostatic devices. Post-operative alerts highlighted specific issues with implants especially in breast and orthopaedic surgery(N = 23), and patient review following procedures(N = 6). Conclusions In spite of alerts occurring in a specific speciality, there is wider applicability to all surgical specialities e.g., pre-operative risk assessment in elderly patients requiring urgent surgery or confirming pregnancy status in immediate pre-operative period. Emphasis should be laid on staff training on using specialist equipment including troubleshooting. Raising awareness of these NPSA alerts may help prevent similar incidents.

WHO Surgical Complication Prevention Checklist: a Comparative Analysis of Two Clinics

The aim of the study was to examine the effectiveness of the adherence to the WHO surgical safety checklist.Material and methods. A comparative analysis of the performance of the surgical departments in two clinics was carried out: in the first clinic the WHO checklist was applied to control the performance of the surgical department; in the second clinic these recommendations were not used. The results of 3012 (first clinic) and 3527 surgical interventions (second clinic) were analyzed. The authors studied the frequency of postoperative complications, the effectiveness when using all the points of the recommendations.Results. The frequency of antibiotic prophylaxis during general surgical operations in clinic I was 89.3%, in clinic II - 63.7%, the frequency of infection in the area of ​​surgical intervention was by 13.2% and up to two times higher in clinic II, mortality rates after surgery were also significantly higher in clinic II; consequently, the duration of inpatient treatment was 8.7 in clinic I versus 16.4 days in clinic II.Conclusion. The adherence to the surgical safety checklist can effectively reduce the number of postoperative complications, mortality, and reduce the time of inpatient treatment.

Writing’s on the wall: improving the WHO Surgical Safety Checklist

Background and problemThe WHO Surgical Safety Checklist has been shown to improve patient safety as well as improving teamwork and communication in theatres. In 2009, it was made a mandatory requirement for all NHS hospitals in England and Wales. The WHO checklist is intended to be adapted to suit local settings and was modified for use in Gloucestershire Hospitals NHS Foundation Trust. In 2018, it was decided to review the use of the adapted WHO checklist and determine whether improvements in compliance and engagement could be achieved.AimThe aim was to achieve 90% compliance and engagement with the WHO Surgical Safety Checklist by April 2019.MethodsIn April 2018, a prospective observational audit and online survey took place. The results showed compliance for the ‘Sign In’ section of the checklist was 55% and for the ‘Time Out’ section was 91%. Engagement by the entire theatre team was measured at 58%. It was proposed to move from a paper checklist to a wall-mounted checklist, to review and refine the items in the checklist and to change the timing of ‘Time Out’ to ensure it was done immediately prior to knife-to-skin.ResultsFollowing its introduction in September 2018, the new wall-mounted checklist was reaudited. Compliance improved to 91% for ‘Sign In’ and to 94% for ‘Time Out’. Engagement by the entire theatre team was achieved 100% of the time. Feedback was collected, adjustments made and the new checklist was rolled out in stages across all theatres. A reaudit in December 2018 showed compliance improved further, to 99% with ‘Sign In’ and to 100% with ‘Time Out’. Engagement was maintained at 100%.ConclusionsThe aim of the project was met and exceeded. Since April 2019, the new checklist is being used across all theatres in the Trust.