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Patient safety special focus

Reducing harm in perioperative care

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This intervention aims to improve care for adult patients undergoing elective surgical procedures in hospital

Keywords: Perioperative care, Surgical site infection, Teamwork

The goal

The aim is to prevent harm and deaths to patients undergoing surgical procedures by implementing actions to reduce surgical site infection (SSI) and to improve teamwork and communication.


From October 2006 to September 2007, the NPSA received over 128,000 reports of patient safety incidents from surgical specialties. While not all were serious, some regrettably led to patient harm or death.

Post-operative surgical site infections (SSIs) still occur and cause significant mortality and morbidity despite many advances in the surgical environment and techniques.

The intervention

This intervention has two distinct parts: four actions to reduce SSIs (outlined below); and improving teamwork and communication by implementing the World Health Organization’s surgical safety checklist.

For each of the five actions, trusts are asked to consider what they are trying to achieve and what changes they can make that will result in an improvement. The full guide recommends that practitioners should find out whether a protocol is already in place for each of the four actions to reduce SSIs and carry out an audit to measure current compliance, with an example of an aim statement for each one. It also suggests ways to establish whether a change has been an improvement, including creating definitions and exclusion criteria.

Actions to reduce SSIs

Appropriate use of prophylactic antibiotics

What is the trust trying to achieve? Find out if you already have a protocol in place. If so, perform an audit to find out the current level of compliance.

An example of an aim statement could be:

Within one year, 80% of clinically appropriate surgical patients will receive appropriate antibiotics on time. We will increase this to more than 90% within two years.

Changes to make for improvement

  • Involve your pharmacists and infection control team. They can help with a variety of actions such as helping develop criteria for appropriate prophylactic antibiotics, patient inclusion/exclusion criteria and developing prompt methods if these are not administered or discontinued.
  • The use of preprinted or computerised standing orders specifying antibiotic agent, timing, dose and discontinuation.
  • Changing operating room drug stocks to include only standard doses and standard drugs, reflecting national guidelines.
  • Using visible reminders/checklists/stickers.
  • Verifying antibiotic administration time during intra-operative ‘time out’ so action can be taken if not administered.

Maintenance of normothermia

Changes to make for improvement

  • Monitor the temperature of all patients routinely; in the hour before surgery, before induction, every 30 minutes during surgery, on arrival in the recovery room and every 15 minutes during the recovery period. Attention should be paid to the differentiation between core temperature obtained via the rectal or nasopharyngeal route and that recorded peripherally via tympanic recording.
  • Pre-operative, intra-operative and post-operative interventions of forced warm air fluid warming should be initiated in response to the patient’s recorded core temperature.
  • Assess patients for their potential to develop inadvertent hypothermia during surgery. Include identification of patients undergoing surgery anticipated to last >30 minutes, providing them with forced warm air intra-operatively. If this is not practical, for example, the exposed surface area is too extensive to allow forced warm air, then electric blankets underneath the patient will help maintain core temperature.
  • Ensuring that, where patients are pre-operatively assessed as having a core temperature under 36°C, their anaesthesia and surgery is delayed until they have been warmed using forced warm air. Active warming should continue throughout surgery.
  • Ensuring that IV fluids (500ml or more) and blood products are warmed to 37°C using an appropriate fluid-warming device.
  • Warm patients arriving in recovery with a temperature under 36°C using forced warm air.

Maintaining normal serum glucose level for known patients with diabetes

Changes to make for improvement

  • Regularly check perioperative blood glucose levels on all patients with diabetes to identify hyperglycaemia and hypoglycaemia.
  • Eliminate the use of sliding insulin dosage scales; if a sliding scale is used, standardise it by using a protocol and preprinted order form or computer order, which clearly designates the specific increments of insulin coverage.
  • Standardise to single concentration of IV infusion insulin.
  • Assign responsibility and accountability for blood glucose monitoring and control.

Use of recommended hair removal methods

Changes to make for improvement

  • Ensure there is an adequate supply of electric clippers and that staff are trained in their use.
  • Use reminders (signs, posters).
  • Educate patients not to self-shave pre-operatively.
  • Remove all razors from the entire hospital (except for men who wish to shave their faces).
  • Work with the purchasing department so that razors are supplied only to appropriate areas.

Improving teamwork and communication

This part of the intervention involves implementing the WHO surgical safety checklist. The NPSA issued an alert on the checklist in January and Patient Safety First will be supporting its implementation in trusts across England.

Click here for the ‘How to Guide’ for Reducing Harm in Perioperative Care

Case study: Leeds Teaching Hospitals NHS Trust

Patient Safety First’s perioperative care intervention promotes the use of a number of tools to improve safety, including briefing and debriefing and the WHO’s surgical safety checklist. The orthopaedic operating staff at Leeds Teaching Hospitals NHS Trust have supported this unanimously.

According to Jan Rayner, senior operating department practitioner, the contrast between surgical lists with and without these changes could not be more obvious. Surgical teams that have signed up to the recommended changes are less rushed, better prepared and simply more professional.

‘It’s all down to how much information is communicated to the whole of the team,’ Ms Rayner says. ‘Instead of a surgeon rattling out instructions as he walks through the door or the operating staff having to work from a printed list that frequently lacks essential details, we are given as much information as possible in a manner that allows for advance preparation of every bit of kit and provides a foolproof system of checks and double checks.’

‘Until we’ve had this final check, the surgeon insists that the blade doesn’t go onto the scalpel’

A leading improvement expert, orthopaedic surgeon Mark Emerton was already promoting the importance of making patient safety a priority before Patient Safety First was launched. In fact, the trust had been using the NPSA’s four-point checklist since it was introduced in 2005. 

However, important lessons were learnt from an incident that revealed more checks were needed, as Ms Rayner explains: ‘A patient was brought into the pre-operating room and started to receive an anaesthetic without having signed the consent form. It may not sound dangerous but it showed that a patient could be operated on without routine checks being done. We knew we needed a better system of ensuring safety in surgery.’

In April 2008, the team introduced a ‘time-out’ session before each operation, using the WHO safer surgery checklist. In order to make these changes effective, the team is now working with the trust to develop practice further using the perioperative care intervention, together with core elements of the NPSA and WHO checklists. 

The new ‘surgical communication checklist’ involves a 10-15 minute pre-op team briefing at the start of the day. At this time team members introduce each other. Interestingly, some surgeons have only got to know the names of some theatre staff since this briefing was introduced.

‘I naively assumed that everyone knew each others’ names and was surprised to find that some surgeons had been working for years without knowing the names of the theatre staff,’ Ms Rayner says.

Being on first-name terms brings subtle but significant changes to the atmosphere in theatre. Ms Rayner explains: ‘Previously, there would only be one reason why a surgeon would know your name, usually for notably good or bad performance. Now, it’s normal and there’s a much greater sense of team effort.

‘We feel confident to speak up if we spot anything unexpected and there’s a more dynamic approach from the whole team. We feel empowered and so performance improves. As one team member put it, positivity promotes productivity,’ she says.

Each operation is also analysed in advance during the briefing, with contributions from different team members. ‘The surgeon will highlight extra risk, for example a patient who is having a knee replacement who has several osteophytes or a valgus deformity. The anaesthetist tells us about patients with medical problems or a potential difficulty with intubation. There is time for the rest of the team to discuss problems and prepare essential equipment,’ Ms Rayner says.

Immediately before each operation, there is an extra check for good measure. ‘Until we’ve had this final check, the surgeon insists that the blade doesn’t go onto the scalpel,’ Ms Rayner adds.

A final team debriefing at the end of the day provides an opportunity to discuss the session, evaluate the team’s practice and consider possible improvements to safety and productivity.

Participants’ enthusiasm for this Patient Safety First intervention is infectious. As Ms Rayner explains: ‘This intervention means that instead of only the surgeons knowing the plan in advance, we all know what is going to happen; we’ve discussed the cases and feel that each member of the team is in control and aware of their responsibilities.’

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