A Practical Checklist?

It seems like checklists are the "in" thing in patient safety right now.  It makes sense; follow this list of things and you won't hurt patients.  The problem is, they only work when you use them.  

While doing some background research on checklists in prehospital settings, I found this gem in the open access Scandinavian Journal of Trauma, Resuscitation, and Emergency Medicine.  The article is the print version of an oral presentation, so it isn't "science" but it is practical.  Prehospital airway management is a hotbed of controversy right now.  The data seem to point to worse outcomes, delays to definitive care, and decay of skills.  With all of these problems, anything to make the procedure safer is a welcome addition.  Enter the "checklist."

This group of prehospital providers created a novel approach to their airway management.  They took a disposable plastic sheet and printed it up with the following graphic:

Notice anything cool?  While it still has a text driven checklist (on left), the visual representations offer a rapid and convenient way to prepare for intubation.

Their checklist approach is broken into  the following areas:

Pre-anesthesia checklist

Monitoring:

Equipment:

Drugs

Staff

It would be easy to replace their text with the more familiar "P's" of intubation:

Preparation

Positioning

Preoxygenation

Pretreatment

Push the Drugs

Placement with Proof

Post-Intubation Management

On the far right you'll also notice a box for induction medications and maintenance medications. 

The thing I really like about this list is the visual representation of the equipment.  Just looking at it, I believe that it would really decrease the time in the "preparation" phase.  Look at what it includes:

Equipment for bag ventilation: oral and nasal airways

Drugs for the procedure (I would like to see these boxes include dosing guides for the common medications)

Equipment for intubation:

2 laryngoscope handles and blades

2 different sized endotracheal tubes

syringe

tube holder

qualitative end tidal CO2 detector with BVM connector

Backup Equipment: 

Bougie

LMA

This is HUGE.  How many of you out there really take the time and get your backup equipment out before you need it?  This demonstrates true foresight.

The only thing that I see missing is the suction.   

When working clinically by myself or with the residents, I'm constantly running through a little mental checklist that includes most items on the above list.  Being able to pull out a little plastic sheet that has the list already prepared would free my mind up to think ahead and address other important issues with the sick patient in front of me.  I can easily see how this has potential to really make both prehospital and emergency intubations safer.

Below is a video demonstration of the checklist in action:

Reference:

A pre-hospital emergency anaesthesia pre-procedure checklist R Mackenzie , J French, S Lewis and A Steel from Scandinavian Update on Trauma, Resuscitation and Emergency Medicine 2009 Stavanger, Norway. 23 – 25 April 2009 Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2009, 17(Suppl 3):O26

Safe Patients, Smart Hospitals

Peter Pronovost, MD, PhD is a name synonymous with patient safety.  He and his team have made patient safety a respectable area of expertise within the house of medicine.  He recently published a book, Safe Patients Smart Hospitals, which explains his quest to improve patient safety, first at Johns Hopkins, and now across the country.  While well written, I wouldn't recommend it to the random reader unless you have an interest in patient safety.

As someone who has a strong interest in making my patients safer, I found many helpful pearls within the pages.  As many of you know the recent media has a myopic focus on checklists as a major way to reduce error.  This is partially due to a misunderstanding of the work that Dr. Pronovost's team has performed.  While checklists do work, and that is clear from the NEJM article listed above, 2 very important facets of their technique have been somewhat ignored: changing culture and rigorous data gathering.

As Dr. Pronovost explains, patient safety depends on 3 things: Translating Research Into Practice (TRIP), a Comprehensive Unit-based Safety Program (CUSP), and rigorous data collection.

TRIP and CUSP have since morphed together into an inseparable approach to teaching about safety.  The two are difficult to discuss as separate entities and as I learn more, I hope to share more details with you.

TRIP is the approach to a problem from a research standpoint; it is the background research.  When they first began their central line project, the team went through all of the guidelines, recommendations, and original research and boiled it down into 5 practical points that needed to occur to reduce central line infections.  This became the checklist.

CUSP is all about culture, and changing culture.  Personally, this is where the rubber meets the road.  Without addressing culture, challenging the status quo, and making people accountable to their actions, a checklist is just a piece of paper sitting in a stack somewhere.  The CUSP program works with the individuals, identifies where failures occur, and changes the status quo. It encourages people to speak up, and gives them the authority to be able to.  It was fascinating to read about the challenges their team faced when moving from one unit to another and how CUSP made all of the difference.

The final important factor in patient safety is rigorous data collection.  Remember "Measure Something?"  This is often the limiting factor in safety research.  The data must be as good if not better than any other research trial or else the conclusion cannot be supported, and therefore, the intervention will be questioned.  The point is made over and over: Physicians are scientists at heart.  It is so true.

So what does this mean to an emergency physician?  If you take the 30,000 foot view, this is a very simple and easily reproducible approach to create change:

-Identify a problem
-Look for evidence of how to fix the problem
-Simplify the solutions as much as possible, you really want a short list
-Start to institute it in your department.

Just like in education, make sure to give feedback to your team on how they're doing, as well as soliciting their input.  If you do this and combine it with strict data collection, you will likely see marked improvements in the departments' morale all while making the care you provide much, much safer.

Making M&M Better: The Healthcare Matrix

First, I think Michelle Lin must be psychic.  If you didn't catch her post on morbidity and mortality conference yesterday, then read it!  In fact, read her blog daily.  It contains an amazing wealth of information of interest to anyone interested in faculty development and teaching.

At the conclusion of her post, she gave a glimpse into a tool called the Healthcare Matrix.  Always showing the she is leading the curve, her program already uses it in their M&M conferences.  I had this post planned out for several days since our program is just making the switch and I think it is going to be an awesome tool.  So what if you aren't in a residency and don't have M&M conferences?  Take a close look at it, because it very nicely illustrates a method to investigate errors and suggest potential solutions.  Here we go.

The Healthcare Matrix is a tool developed by some brilliant minds at Vanderbilt  University Medical Center.  They linked the Institute of Medicine's "dimensions of quality," which are safe, timely, effective, efficient, equitable, and patient centered, with the ACGME core competencies for residency programs.  Unfortunately for educators, the competencies of professionalism, communication and interpersonal skills, and practice based learning and improvement are very difficult to teach let alone assess.  Since you cannot have quality care without quality education and vice versa, this tool attempts to present a formative approach to this problem.

So how is this tool used?  First, notice the aims across the top and the competencies down the left side.  The first step is to ask a yes/no question about patient care related to the aims.  Was the care we gave safe?  Was the care timely? And so on and so forth.  For each column that receives a "no" answer the specific competency is examined to determine their contributions to the low quality care given to the patient.  The final step occurs beneath the green bar at the bottom.  In the "Practice-Based Learning and Improvement" row, the user attempts to suggest strategies that can be pursued to improve the system of care.

In an article in the Journal on Quality and Patient Safety, Bingham et al give 2 examples of the matrix in use.  In the first case, a resident was asked to provide an account of a case that went poorly.  The resident compiled a list of "important learning topics and issues. . ."  Here is what the resident turned in:

1. DIC—what is it?

2. DIC in pregnancy—what are the causes?

3. Fibrinolysis in DIC (significance of an in vitro clot test)

4. Local anesthetic toxicity

5. Postpartum hemorrhage with regional anesthesia versus general anesthesia

6. Pulmonary edema secondary to massive transfusion/ volume resuscitation

7. Hypocalcemia from massive transfusion

8. Blood-tinged epidural aspirate—significance?

9. Carboprost, misoprostol, and methylergonovine maleate-indications and uses

10. Third-spacing—can specific IV fluids prevent it?

11. Arterial-line indications—use with massive transfusions or not?

12. Who needs a type and cross? Why does it take 30 minutes?

If you apply these 12 learning points to the matrix, you realize that they only cover 4 of the cells within the matrix, most of which fall into medical knowledge.  This is in keeping with the typical discussion that occurs in a M&M conference, with the attending physicians demonstrating how smart they are to the residents who should have "known better."  


In this case the resident was then was asked to complete the matrix and this is what was returned:

As you can now see, the resident was able to identify issues within 17 of the 36 cells.  Even more importantly, 5 cells fall into the PBLI row and have a HUGE potential for translating into improved patient care.

It doesn't take much imagination to see that the use of this tool will uncover care issues and likely will promote learning as a team.  With luck, gone will be the days of severe hindsight bias and the "shame and blame" approach to dealing with medical errors.  While the matrix contains a great deal of information, the cellular approach allows for focused learning.

With a little practice, this tool will be easy to use and will provide a nice forum for improving not only M&M but patient care overall.

If you already use this tool, please comment on it and let me know your experiences.  I'm looking forward to working with our residents with this tool and any advice will be helpful.

Some Tips:
This is best used as a framework for improvement.  Residents seem to do best when they have to relate each cell to their M&M presentation.

All of the cells do not need to be filled.  Improvements in learning will occur simply because the tool provides a guide for reflecting on all of the factors related to the case.

Try having the attending and resident each fill out the matrix and see where the similarities and differences occur.

Keep a copy of the completed record the residents portfolio, this is a great tool to document learning of competencies that have been difficult to assess and document that learning has occurred.


Reference:
Bingham JW, Quinn DC, Richardson MG, Miles PV, Gabbe SG. Using a healthcare matrix to assess patient care in terms of aims for improvement and core competencies. Jt Comm J Qual Patient Saf. 2005 Feb;31(2):98-105. PMID: 15791769

Patient Safety: Whose Job Is It Anyhow?

Today I went somewhere that I've never been before.  Despite working my job in the emergency department for the last 2 and a half years, I had never been to the medical staff dining room.  As I perused the bulletin board filled with newspaper clippings of local physicians in the news, I came upon a letter to the editor written by a physician somewhere in the midwest.

 The headline  made reference to airlines and checklists and caught my eye right away.  Unfortunately, the writer used his podium to rail against the current patient safety movement.  He made fun of checklists, insisted that an "airline" style of patient safety is too expensive and manpower intensive, and, in general, failed to acknowledge medical errors are a huge issue!

Reading though to the end, I was disappointed that the authors' narrow view misses the fact that if we are to improve patient safety, we all must focus on change.  The airline industry is often held as an example because of the remarkable record of safety.  It wasn't always this way.  In the late 1970's, a spate of incidents caused the entire industry to take a critical look at their processes and design new ways to deal with the errors.  Checklists, team training, simulation, process redesign, and multiple other safety innovations were the result of their efforts.  They took the time to test their ideas and redesign them.  In short, they changed, and they're still doing it!

Medicine can learn a lot from their efforts.  The message isn't that 2 doctors (pilots) per patient (plane) with 3 nurses (hostesses and hosts) and a host of support staff armed with checklists will make care safer.  The message is that we need to study our processes, learn about the latent conditions that predispose us to err and make changes to eliminate them.  We can create tools to improve care.  These may be checklists but they're not the only tool to use.  We can study staffing and it's effects on waiting, technology, teamwork, and more.  This list goes on and on.  Perhaps the best thing we can learn from the airline industry isn't about the tools they use, but the methods they used to create the environment in which all players want to be a positive deviant.  After all, being ahead of the curve when it comes to refining the process of providing safe care is at the heart of our oath towards humanity: "Primum non nocere, or first, do no harm."

Formula One and Patient Handoffs

Gentlemen, start your engines! Who can resist the high octane, high speed formula one races? Okay, maybe a lot of people could care less about these high stakes races but if you look closely at a successful race team, some patterns of excellence begin to appear that have crossover lessons applicable to medicine. This was recognized by some British physicians who recently published a their experience in using the lessons learned to improve patient handoffs.

Handoffs have become a real hot topic in medicine. With the increase in resident work hours restrictions, handoffs have been identified as one of the more hazardous times in patient care.

This study was an interesting prospective intervention looking at performance change before and after the introduction of a standard handoff protocol. The specific protocol was designed to look at the transfer of a child after surgery for congenital heart disease to the ICU. Before the researchers began their protocol design, they spent a day with the Ferrari F1 racing team at the team headquarters in Maranello, Italy. (How can I sign up for this?)

Why Formula One? The pitstop in Formula One racing is a great example of how a multiprofessional team functions together under high stakes conditions to perform a complex task with minimal error. Think about it: stop car, jack it up, change 4 tires, fully fuel it, clean the drivers visor, drop the jacks, and back to the races, all in about. . .7 SECONDS! Needless to say, the lessons to be gleaned were many and became the basis for the new protocol.

To be truthful, the actual results of this study are not nearly as interesting as the lessons that they learned. Their protocol did result in a decrease in errors to be sure: technical errors went from 5.42 to 3.15, information omissions dropped from 2.09 to 1.07, multiple errors dropped from 39% to 11.5% and so on, but I digress.

So what did they learn that is useful to us?

Leadership: In F1 racing, there is a "lollipop" man who coordinates the entire procedure. How many of you walk into a trauma resuscitation and know who will lead the team, what resident is doing what, which nurse is on monitor duty, drug administration duty, or documentation duty? In this particular study, these roles became defined.

Task Sequence: In racing as well as aviation, the order of events is known. In handovers we are terribly inconsistent with our information. We often have no set sequence to follow leading to omission of critical information. This study broke a critically ill patients transfer into 3 phases: equipment and technology handover, information handover, discussion and plan. This allowed the team to focus on specific transfer issues and markedly decreased technical handoff errors.

Task Allocation: In racing, each team member does only 1 or 2 tasks. Need I make a reference to medicine? In the study protocol, when a transfer took place, people were assigned a specific task who were identified to receive the critical information about their task, ie ventilator, pumps, drains, monitor, etc.

Predicting and Planning: In racing, there is a method used called Failure Modes and Effects Analysis which allows breakdown of tasks and risks to predict problems. Use of a similar tool allowed these researchers to identify and refine safety checks and develop tools such as a ventilator transfer sheet to streamline the transfer of care.

Discipline and Composure: In racing, there is little to no verbal communication; the whole stop only takes 7 seconds. In medicine, handovers can be chaotic, with multiple people trying to give information to others at the same time. The nurses rarely know what the docs say to each other and vice versa. Having the discipline to allow one practitioner to talk uninterrupted can minimize the loss of information during a handoff.

Checklists: Well established in racing and aviation. I'll be posting more on this later, lots more. . .

Involvement: More of an aviation trait, but all team members are trained to speak up with concerns. In medicine, we have a long way to go to improve this area. Simply encouraging the behavior as part of the protocol was how this particular study addressed the issue.

Briefing: Again, well established in racing and aviation. In the emergency department, I rarely see this employed. Multidisciplinary handoffs are far from the norm and are potentially a rich area for improvement.

Situational Awareness: The previously mentioned lollipop man has this responsibilty in racing. Being at the front of the car, the driver doesn't go until he or she gives the okay. Identifying one person to stand back and make safety checks when handoffs occur or other chaotic processes such as codes can improve the overall situational awareness.

Training: Racing and aviation are fanatical about training and repetition. Despite being experts, the pit crew practices time and time and time again to improve their skills. Pilots routinely make trips to the simulator to practice the usual and unusual situations they may face. In the study, they found that staff turnover limited the ability to train. This situation is so common in emergency medicine as well. Instead of long and grueling training, this study focused on a simple process that could be learned in 30 minutes and made helpful training sheets available at EVERY bedside as a memory prompt.

Review Meetings: In racing and aviation, review of past actions is a way of life. Creating an open forum to frequently review problems and suggest solutions will promote lasting change in medicine. Everyone from residents, nurses, docs, and ancillary staff should be encouraged to attend and provide input.

Handoffs are a way of life in emergency medicine. It's pretty easy to look at this study and see parallels that would make our practice safer for patients. Simply focusing on improving the culture in one or two of the themes above will yield exciting dividends in the long run. Are you in?

Reference:

Catchpole KR et al. Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. Paediatr Anaesth. 2007 May; 17(5): 470-8. PMID: 17474955

Clinical Oversight: Conceptualizing the Relationship Between Supervision and Safety

Have you ever stopped and wondered what good clinical supervision means? Supervision is one of those concepts in academics that we are expected to do with little, if any, guidance. Many factors within medicine have led to an increase in the expected levels of supervision recently. Work hours restrictions, Medicare rules, and a call to arms about patient safety have prompted calls for more and better supervision. The problem is, "What is appropriate clinical supervision?" This article took a qualitative observational research approach to looking at this exact problem with a goal of defining a conceptual model of clinical supervision.

Methods:

This study uses a qualitative approach referred to as grounded theory methodology. Participants were faculty and teaching teams from the emergency department and general medical floor. To minimize the Hawthorne effect, incomplete disclosure was employed, i.e. the participants knew they were being observed, but they didn't know what was being observed. Observational data were collected and refined over a single calendar year.

Results:

Their analysis revealed that supervisory activities related to patient care are distinct from other types of supervision, such as formal teaching. These activities seem to fall along a continuum from less to more involved.

Routine Oversight: These are activities planned in advance and expected by all involved in the clinical setting. In a sense, routine oversight is simply monitoring the trainees activities. In emergency medicine, this type of oversight is used when hearing case presentations from students or residents followed by probing, refinement, and confirmation of the management plan.

From my perspective, this is the bread and butter supervision that we all do from shift to shift.

Responsive Oversight: In this type of oversight, the direct involvement of the supervisor increases either as a result of a direct request from the trainee or in response to a concerning clinical situation. This can involve repeating history and exam findings, observing trainees in action, or coaching learners at the bedside (i.e. supervising procedures).

Triggers that increase supervisor vigilance often result in responsive oversight. These include:

• Clinical Cues: unexpected changes in patient conditions, unstable patients
• Information from a secondary source: family or nursing concerns brought to the supervisor
• Language Discrepancies: Clinical presentation not matching clinical data (labs, radiology, etc)

I find that this level of supervision varies from learner to learner depending on my trust in the trainees abilities and confidence.

Direct Patient Care: This is the highest level of supervision and often is initiated when the supervisor realizes that the clinical situation has exceeded the learners ability to manage the care of the patient. This may happen quickly, as one would expect when working with medical students, or may happen only in extraordinary situations with senior trainees.

Personally, when working with senior trainees, I find that this becomes more of "Team Management" with the senior assuming control of some tasks while I handle other tasks to manage a critical ill patient.

Backstage Oversight: The final type of oversight occurs with little trainee knowledge. Backstage oversight includes seeing patients independently of the trainees (we do this a LOT in emergency medicine) or reviewing pertinent patient data such as labs or radiology in the absence of learners.

Final thoughts: As a junior faculty member, finding the right balance of supervision to learner autonomy has been a challenge. This article confirms what we probably all do in our day to day clinical practice. It demonstrates that supervision is a fluid process involving an ebb and flow of involvement that is linked to learner and patient factors. Increased awareness of factors that should prompt us to upgrade our level of supervision will benefit our learners and potentially make patient care a little bit safer.

Reference:

Kennedy TJT, Lingard L, Baker, GR, Kitchen L, Regehr G. Clinical Oversight: Conceptualizing the Relationship Between Supervision and Safety. J Gen Intern Med. 2007 Aug;22(8):1080-5. PMID: 17557190