Implementation of the Surgical

Care Outcomes Assessment

Program (SCOAP) and the

Introduction of the

WHO/SCOAP Surgical Safety

Checklist

E. Patchen Dellinger, MD, FACS

Professor of Surgery, Chief of General Surgery

University of Washington Medical Center (UWMC),

Seattle, Washington

Surgical Safety: Unrecognized as

public health issue

Known surgical

complications

of 3-16%

Known death

rates of 0.4-

0.8%

At least 7 million disabling complications –including 1 million deaths – worldwide each year

=

Problem 2: Failure to use

existing safety know-how

• High rates of preventable surgical site

infection result from inconsistent timing of

antibiotic prophylaxis

• Anesthetic complications are 100-1000x

higher in countries that do not adhere to

monitoring standards

• Wrong-patient, wrong-site operations persist

despite high publicity of such events

WHO’s 10 Objectives for Safe

Surgery

The team will:

1. Operate on the correct patient at the correct site.

2. Use methods known to prevent harm from anesthetics, while protecting the patient from pain.

3. Recognize and effectively prepare for life-threatening loss of airway or respiratory function.

WHO’s 10 Objectives for Safe

Surgery

4. Recognize and effectively prepare for risk of high blood loss.

5. Avoid inducing an allergic or adverse drug reaction for which the patient is known to be at significant risk.

6. Consistently use methods known to minimize the risk for surgical site infection.

WHO’s 10 Objectives for Safe

Surgery (cont.)7. Prevent inadvertent retention of

instruments or sponges in surgical wounds.

8. Secure and accurately identify all surgical specimens.

9. Effectively communicate and exchange critical information for the safe conduct of the operation.

10. Hospitals and public health systems will establish routine surveillance of surgical capacity, volume and results.

Advantages of Using a Checklist

• Can be customized to local setting and needs

• Can be deployed in an incremental fashion

• Is supported by scientific evidence and expert

consensus

• Has been evaluated in diverse settings

around the world

• Ensures adherence to established safety

practices

• Minimal resources required to implement a

far-reaching safety intervention

What is this tool that addresses

the 10 objectives?

What is this tool that addresses

the 10 objectives?

WHO and the ChecklistSafe Surgery Saves Lives

WHO encourages local institutions

to modify the list to address local

needs.

Anesthesia machine safety checks

are reliably done in the U.S. but

not in all other places in the world

London, UK

EURO EMRO

WPRO I

SEARO

AFRO

PAHO I

Amman, JordanToronto, Canada

New Delhi, India

Manila, Philippines

Ifakara, Tanzania

WPRO II

Auckland, NZ

PAHO II

Seattle, USA

The Checklist was piloted in 8 cities

Doing the Checklist at University of

Washington Medical Center (UWMC)

• We had been discussing briefing and

debriefing in the Division of General

Surgery

• I saw the checklist as an opportunity to

institutionalize briefing and debriefing

• We had added antibiotic administration

to the JCAHO-mandated “time out”

many years ago

S C O A P Surgical Care and Outcomes Assessment Program

•Voluntary collaborative of surgeons in Washington state

•Grassroots organization

• Includes 51 of 65 rural small hospitals and large urban referral centers.

•SCOAP surgeons define the metrics for quality

S C O A P Surgical Care and Outcomes Assessment Program

• Currently following colon/rectal, bariatricoperations, appendectomy, & vascularoperations with a pediatric module in development

• Quarterly feedback on process compliance and outcome

• Hospitals can compare their performance with other SCOAP hospitals

Operative Re-interventionAll Colon/Rectal Surgery

Q1 2006 through Q2 2007

2007

0%

4%

8%

12%

16%

20%

A B C D E F G H I J K L M N O P

Hospital

% o

f P

roced

ure

s

Aggregate Data Hospital Average

(358)

(7)

(49)

(35)

(165)

(260)(44)

(24)

(3) (19)

(254)

(8)

(542)

(168)

(102)

(26)

Transfusion-free ProceduresElective Colon/Rectal Surgery

Q1 2006 through Q2 2007

2007

0%

20%

40%

60%

80%

100%

A B C D E F G H I J K M N O P

Hospital

% o

f P

roced

ure

s

Aggregate Data Hospital Average

(292)

(6)

(30)

(30)(57)

(204)

(21)

(18)

(218)

(3) (7)

(465)(103)

(72)

(14)

NormothermiaElective Colon/Rectal Surgery

Q1 2006 through Q2 2007

2007

0%

20%

40%

60%

80%

100%

A B C D E F G H I J K M N O P

Hospital

% o

f P

roced

ure

s

Aggregate Data Hospital Average

(6)

(3)

(7)

(14)

(280) (30) (17)

(195)

(102)

(28) (48) (20) (460)(223)

(72)

Glucose Testing among DiabeticsElective Colon/Rectal Surgery

Q1 2006 through Q2 2007

2007

0%

20%

40%

60%

80%

100%

A C D E F H J M N O

Hospitals with 5+ diabetics

% o

f P

roced

ure

s

Aggregate Data Hospital Average

(34)

(9) (6)

(11)

(27)

(5)

(31)

(38)

(15)

(15)

VTE ChemoprophylaxisElective Colon/Rectal Surgery

Q1 2006 through Q2 2007

2007

0%

20%

40%

60%

80%

100%

A B C D E F G H I J K M N O P

Hospital

% o

f P

roced

ure

s

Aggregate Data Hospital Average

(6)

(30)

(2) (14)

(7)

(215)

(294)

(30)

(57)

(204)

(20)

(17)

(466)

(99)

(72)

Post-op B-Blockers for Current UsersAll Colon/Rectal Surgery

Q1 2006 through Q2 2007

2007

0%

20%

40%

60%

80%

100%

A C D E F G H J M N O P

Hospitals w/ 5+ Current Users

% o

f P

roced

ure

s

Aggregate Data Hospital Average

(74)

(12)

(11)

(46)

(54)

(13)

(5)

(50)(172)

(45)

(33)

(5)

12+ Lymph Nodes RemovedColon Cancer Surgery Q1 2006 through Q2 2007

2007

0%

20%

40%

60%

80%

100%

A B C D E F G H I J K L M N O P

Hospital

% o

f P

roced

ure

s

Aggregate Data Hospital Average

(67)

(1)

(21)

(17)

(55)

(72)

(18)

(10)

(1)

(2)

(43)

(1)

(106)

(23)

(28)

(6)

VTE ChemoprophylaxisElective Colon/Rectal Surgery

All SCOAP Patients

50%

60%

70%

80%

90%

100%

Q1 2006 2 3 4 Q1 2007 2

% o

f P

roced

ure

s

2007

Imaging AccuracyAppendectomy Procedures

All SCOAP Patients

2007

(399)(1152) (394) (244)

80%

85%

90%

95%

100%

Year 2006 Q1 2007 Q2 2007 Q3 2007

% o

f P

roc

ed

ure

s w

ith

Im

ag

ing

(Denominator)

Re-operation for Complications All Colon/Rectal Surgery

All SCOAP Patients

0%

5%

10%

15%

20%

Q1 2006 2 3 4 Q1 2007 2

% o

f P

roced

ure

s

2007

Negative Appendectomy

0%

5%

10%

15%

20%

Year 2006 Q1 2007 Q2 2007 Q3 2007

% o

f P

rocedure

s

2007

“Safe Surgery Saves Lives-

SCOAP Checklist”

Implementation at UWMC

First phase

• Safety attitudes questionnaire collected

before introduction of the checklist and

again after

• Baseline data on use of checklists among

all general surgery cases

• 500+ cases followed with basic data collected

UWMC Safety Attitudes

Questionnaire - Results

Agree or strongly agree Before After

Feel safe as patient here 83% 85%

Briefing important before op. 91% 94%

Encouraged to report concerns 79% 90%

Difficult to speak, perceived prob. 19% 21%

Good team - docs & nurses 53% 65%

Freq disregard rules (others?) 19% 15%

UWMC Safety Attitudes

Questionnaire - Results

Agree or strongly agree After

Checklist easy to use 56%

Checklist improved O.R. safety 60%

Took a long time to complete 23%

I would want checklist for me 88%

Communication was improved 81%

Checklist helped to prevent errors 67%

Communication Quality and

Surgical Morbidity

Davenport. JACS 2007;205: 778-784

Behavioral Marker Risk Index (BMRI)

• Briefing

• Information sharing

• Inquiry

• Vigilance and awareness

Adjusted Odds Ratio

Risk Factor Complication or Death

BMRI 4.82

ASA 1.51

Mazzocco. Amer J Surg 2009; 197: 678-85

Behavioral Marker Risk Index and

Postoperative Complications

Mazzocco. Amer J Surg 2009; 197: 678-85

“Safe Surgery Saves Lives-

SCOAP Checklist”

Implementation at UWMC

Second Phase

• Checklist introduced in March 2008-all

general surgeons to champion

• Posted (2’ x 3’) in all O.R.s

• 500 Additional cases followed with basic

data collected

• Safety attitudes re-surveyed

• 10’ training video made (see SCOAP website)

Timing of “Time Out”

Checklist procedures were

timed by data collector

Results

RANGE MEAN

0:58 seconds to 3:58 minutes 2:16 minutes

Feedback: General Surgeons, Nurses,

and Anesthesiologists

“Surgeon leadership is key to taking this

seriously and making it a meaningful

pause that offers safety.” – General

surgeon

Feedback: General Surgeons, Nurses,

and Anesthesiologists

• “At first it seemed somewhat

burdensome due to length. It now takes

me about one minute to run through the

list, which I don't think is anything

excessive.” – General surgeon

Challenges Ahead• Institutionalizing the checklist – Every O.R.,

Every Case

• Supporting the culture change that the

checklist suggests

• Getting the “buy-in” of all Surgeons

• Streamlining the checklist to meet the needs

of individual hospitals and specialties while

preserving the essentials

• Remembering the Debriefing !

• Integrating the checklist into the EMR?

“Safe Surgery Saves Lives” and

SCOAP and UWMCWorking Together

• Expanded the WHO checklist to include

important SCOAP metrics that we were

inconsistently applying

• Started the Washington State SCOAP

Checklist Coalition

• Enlisted the assistance of the

Washington State Hospital Association

and third party payers and major

employers to promote the checklist

Washington State Checklist

Implementation

65 hospitals have notified SCOAP

and the Washington State Hospital

Association (WSHA) that they have

implemented a Surgical Safety

Checklist

“The estimate that up to 23,000 people died in

2004 in Canadian hospitals because of

preventable adverse events is staggering.

Checklists in aviation have been in use pretty

well since the Wright brothers.

One wonders whether such checklists would

have been introduced much earlier in medicine if

surgeons shared the fate of their patients, as

pilots share that of their passengers.”

Adrian Boelen, retired pilot, Dorval, Que

More Informationwww.who.int/patientsafety/safesurgery/en.index.html

www.safesurg.org

www.scoap.org

www.nbc.com/ER/video/episodes/#vid=1059351