GENERAL ANZJSurg.com
Ward safety checklist in the acute surgical unit Kristopher M. Blucher,* Samuel E. Dal Pra,* James Hogan† and Arkadiusz Peter Wysocki* *Griffith University School of Medicine, Brisbane, Queensland, Australia †WiltshireHogan, Forecasting and Modelling, Wellington, New Zealand
Key words checklist, surgery, ward round. Correspondence Dr Arkadiusz Peter Wysocki, Griffith University School of Medicine, Logan Hospital, Corner Armstrong and Loganlea Roads, Meadowbrook, Qld. 4131, Australia. Email: [email protected] K. M. Blucher BSc; S. E. Dal Pra BSc; J. Hogan LL.B, B.Com (Hons); A. P. Wysocki, MBBS, FRACS. Accepted for publication 12 November 2013. doi: 10.1111/ans.12496
Abstract Background: Deficiencies in daily ward rounds are increasingly identified. A ward safety checklist has recently been devised to improve the fast-paced surgical ward round. Methods: Over 2 weeks the morning post-take surgical ward round was evaluated using the ward safety checklist. In order to avoid the Hawthorne effect, doctors involved were not aware their performance was being observed. Results: One hundred patient encounters were evaluated. The three phases of the card safety checklist showed statistically significant improvement but for many components compliance was below 100%. Conclusion: Implementing this simple checklist has provided our unit with a starting point in how to overcome some of the deficiencies of the post-take surgical ward round.
Introduction Medical practice checklists seek to create a total quality environment by improving consistency (e.g. World Health Organization surgical safety checklist http://www.who.int/patientsafety/safesurgery/en/ index.html). Amin et al. from the University College London Hospital recently designed the four-phase ward safety checklist (WSC).1 This checklist consists of three standardizing phases: introduction (phase 1), time-out (phase 3) and action (phase 4) phases while allowing for a non-standardized speciality-specific component (phase 2). Our acute surgical care unit (ASU) embraced the WSC process to improve the unit’s function, viewing the WSC as particularly relevant for the currently non-standardized post-take ward round.2 The current ward round was felt to lack structure and perhaps this is why it was incomplete: junior doctors were often returning to the bedside to explain the proposed treatment plan or to modify fluid and medication prescriptions. This study was designed to assess the completeness of the current ward round, to identify deficiencies and to determine whether the checklist is a useful tool in improving consistency.
Methods Two medical students evaluated the morning ASU round using the WSC over 10 consecutive work days. The phases and components of the checklist are listed in Table 1 whereas the actual checklist may © 2013 Royal Australasian College of Surgeons
be found in the original article.1 Baseline data were collected during the first 5 days. Junior surgical staff were then formally educated on WSC and encouraged to implement the checklist. Follow-up data were collected during week 2. The staff who were not advised their use of WSC were being monitored and did not know their performance was being observed in order to avoid the Hawthorne effect. This well-documented observation (people whose behaviour is being studied modify their actions simply because they are being studied) was suspected in another study of improving compliance with a medical ward round checklist.2,3 Categorical variables across WSC phases are presented as frequency (percentage). Whether WSC training significantly altered staff behaviour was tested using a chi-square test across the three measured WSC phases between the two observation periods, using Microsoft Excel.
Results Over the 2 consecutive weeks, 100 morning ASU ward round patient encounters were assessed: 49 before and 51 after implementation of WSC. Results are presented in Table 1. Prior to WSC training, 31% of the introduction phase components were completed. Post WSC training, this increased to 52% (P < 0.001). Most apparent improvements were ‘appropriate preparation’, ‘introduction of team’ and ‘hand hygiene’. ANZ J Surg 84 (2014) 745–747
746
Blucher et al.
Table 1 Results pre and post introduction of ward safety checklist (WSC)
Number of patients Number of unique patients INTRODUCTION PHASE Appropriate preparation Introduction of team Confirm patient identity Hand hygiene Phase total TIME-OUT PHASE Check patient understanding Fluid and/or food balance Multi-resistant Staphylococcus aureus status Infection control markers Antibiotics Results/scans checked Allergies Drug chart review Venous thromboembolism risk/treatment Drips and catheters, drip site review Confirms team understanding/checks for team issues Confirms patient understanding at end of round/prompts for questions Hand hygiene Phase total ACTIONS PHASE Documents signed/dated Confirm team ownership of tasks Confirms discharge objectives Communicates to missing team members Phase total Overall total
Within the time-out phase, WSC training resulted in a significant increase in the ‘fluid and/or food balance’ and ‘results/scans checked’ components, with other components not changing significantly. Several areas were difficult to assess (multi-resistant bacterial colonization status, antibiotics, allergies, venous thromboembolism prophylaxis). Some components like ‘drug chart review’, ‘infection control markers’ and ‘hand hygiene’ had already high baseline compliance and offered little scope for improvement. Overall, compliance with this phase increased from 37% to 45% (P < 0.001). Compliance with the actions phase improved from 48% to 56% (P = 0.04) but only the ‘confirm team ownership of tasks’ component increased significantly. The ‘documents signed/dated’ was consistently highly performed within both periods.
Discussion The WSC enhanced the three studied components of the ward round. The greatest benefit was seen in the introduction part of the round: staff were much more likely to wash their hands, tuck in ties and name badges, and introduce team members. Formal patient identification rarely occurred but there were no instances of misidentification. Some elements of the time-out phase were difficult to formally assess. The drug chart was reviewed in 100% of patients before and after introduction of the WSC. However, items that also appear on the medication chart (venous thromboembolism prophylaxis, antibiotics and allergies) did not appear to be formally assessed. It is likely these processes were not evident to the asses-
Before WSC
After WSC
Chi-squared test P-value
49 41 (84%)
51 40 (79%)
— —
20 (41%) 31 (63%) 7 (14%) 2 (4%) 60 (31%)
46 (90%) 49 (96%) 1 (2%) 10 (20%) 106 (52%)
— — — —
Ward safety checklist in the acute surgical unit Kristopher M. Blucher,* Samuel E. Dal Pra,* James Hogan† and Arkadiusz Peter Wysocki* *Griffith University School of Medicine, Brisbane, Queensland, Australia †WiltshireHogan, Forecasting and Modelling, Wellington, New Zealand
Key words checklist, surgery, ward round. Correspondence Dr Arkadiusz Peter Wysocki, Griffith University School of Medicine, Logan Hospital, Corner Armstrong and Loganlea Roads, Meadowbrook, Qld. 4131, Australia. Email: [email protected] K. M. Blucher BSc; S. E. Dal Pra BSc; J. Hogan LL.B, B.Com (Hons); A. P. Wysocki, MBBS, FRACS. Accepted for publication 12 November 2013. doi: 10.1111/ans.12496
Abstract Background: Deficiencies in daily ward rounds are increasingly identified. A ward safety checklist has recently been devised to improve the fast-paced surgical ward round. Methods: Over 2 weeks the morning post-take surgical ward round was evaluated using the ward safety checklist. In order to avoid the Hawthorne effect, doctors involved were not aware their performance was being observed. Results: One hundred patient encounters were evaluated. The three phases of the card safety checklist showed statistically significant improvement but for many components compliance was below 100%. Conclusion: Implementing this simple checklist has provided our unit with a starting point in how to overcome some of the deficiencies of the post-take surgical ward round.
Introduction Medical practice checklists seek to create a total quality environment by improving consistency (e.g. World Health Organization surgical safety checklist http://www.who.int/patientsafety/safesurgery/en/ index.html). Amin et al. from the University College London Hospital recently designed the four-phase ward safety checklist (WSC).1 This checklist consists of three standardizing phases: introduction (phase 1), time-out (phase 3) and action (phase 4) phases while allowing for a non-standardized speciality-specific component (phase 2). Our acute surgical care unit (ASU) embraced the WSC process to improve the unit’s function, viewing the WSC as particularly relevant for the currently non-standardized post-take ward round.2 The current ward round was felt to lack structure and perhaps this is why it was incomplete: junior doctors were often returning to the bedside to explain the proposed treatment plan or to modify fluid and medication prescriptions. This study was designed to assess the completeness of the current ward round, to identify deficiencies and to determine whether the checklist is a useful tool in improving consistency.
Methods Two medical students evaluated the morning ASU round using the WSC over 10 consecutive work days. The phases and components of the checklist are listed in Table 1 whereas the actual checklist may © 2013 Royal Australasian College of Surgeons
be found in the original article.1 Baseline data were collected during the first 5 days. Junior surgical staff were then formally educated on WSC and encouraged to implement the checklist. Follow-up data were collected during week 2. The staff who were not advised their use of WSC were being monitored and did not know their performance was being observed in order to avoid the Hawthorne effect. This well-documented observation (people whose behaviour is being studied modify their actions simply because they are being studied) was suspected in another study of improving compliance with a medical ward round checklist.2,3 Categorical variables across WSC phases are presented as frequency (percentage). Whether WSC training significantly altered staff behaviour was tested using a chi-square test across the three measured WSC phases between the two observation periods, using Microsoft Excel.
Results Over the 2 consecutive weeks, 100 morning ASU ward round patient encounters were assessed: 49 before and 51 after implementation of WSC. Results are presented in Table 1. Prior to WSC training, 31% of the introduction phase components were completed. Post WSC training, this increased to 52% (P < 0.001). Most apparent improvements were ‘appropriate preparation’, ‘introduction of team’ and ‘hand hygiene’. ANZ J Surg 84 (2014) 745–747
746
Blucher et al.
Table 1 Results pre and post introduction of ward safety checklist (WSC)
Number of patients Number of unique patients INTRODUCTION PHASE Appropriate preparation Introduction of team Confirm patient identity Hand hygiene Phase total TIME-OUT PHASE Check patient understanding Fluid and/or food balance Multi-resistant Staphylococcus aureus status Infection control markers Antibiotics Results/scans checked Allergies Drug chart review Venous thromboembolism risk/treatment Drips and catheters, drip site review Confirms team understanding/checks for team issues Confirms patient understanding at end of round/prompts for questions Hand hygiene Phase total ACTIONS PHASE Documents signed/dated Confirm team ownership of tasks Confirms discharge objectives Communicates to missing team members Phase total Overall total
Within the time-out phase, WSC training resulted in a significant increase in the ‘fluid and/or food balance’ and ‘results/scans checked’ components, with other components not changing significantly. Several areas were difficult to assess (multi-resistant bacterial colonization status, antibiotics, allergies, venous thromboembolism prophylaxis). Some components like ‘drug chart review’, ‘infection control markers’ and ‘hand hygiene’ had already high baseline compliance and offered little scope for improvement. Overall, compliance with this phase increased from 37% to 45% (P < 0.001). Compliance with the actions phase improved from 48% to 56% (P = 0.04) but only the ‘confirm team ownership of tasks’ component increased significantly. The ‘documents signed/dated’ was consistently highly performed within both periods.
Discussion The WSC enhanced the three studied components of the ward round. The greatest benefit was seen in the introduction part of the round: staff were much more likely to wash their hands, tuck in ties and name badges, and introduce team members. Formal patient identification rarely occurred but there were no instances of misidentification. Some elements of the time-out phase were difficult to formally assess. The drug chart was reviewed in 100% of patients before and after introduction of the WSC. However, items that also appear on the medication chart (venous thromboembolism prophylaxis, antibiotics and allergies) did not appear to be formally assessed. It is likely these processes were not evident to the asses-
Before WSC
After WSC
Chi-squared test P-value
49 41 (84%)
51 40 (79%)
— —
20 (41%) 31 (63%) 7 (14%) 2 (4%) 60 (31%)
46 (90%) 49 (96%) 1 (2%) 10 (20%) 106 (52%)
— — — —
