Preventing Surgical Complications

1. Preventing Surgical Complications Insert Date here Presenter: Preventing Surgical Complications

2. 1000 Lives Campaign To save 1,000 lives and to avoid 50,000 episodes of harm in Welsh healthcare between 21 April 2008 and 21 April 2010. Preventing Surgical Complications

3. Content Areas • Improving leadership for quality • Reducing healthcare associated infections • Improving critical care* • Improving medicines management • Reducing surgical complications* • Improving general medical and surgical care • Development Sites *Trusts Only Preventing Surgical Complications

4. Hospital blunders 'kill 90,000 patients'Rebecca Smith, Medical Editor, Daily Telegraph 29.11.07 More than 90,000 patients die and almost one million are harmed each year because of hospital blunders, research suggests. Researchers found that up to half of the mistakes made were preventable Preventing Surgical Complications

5. Preventing Surgical Complications • Preventing post operative wound (surgical site) infections • Antibiotics • Hair removal • Glycaemic control • Normothermia • Creating a team culture • Team briefing • Preventing cardio vascular complications • DVT prophylaxis • Beta blockers Preventing Surgical Complications

6. Evidence Patients who develop post operative wound infections • are twice as likely to die as other postoperative patients. • Up to 60% more likely to spend time in an intensive care unit. • If it develops after discharge, they’re five times more likely to be readmitted to the hospital. Preventing Surgical Complications

7. Whole surgical pathway Pre Operative Assessment Surgical ward / Day care ward Anaesthetic room Theatres Recovery Surgical Wards Primary Care Preventing Surgical Complications

8. Appropriate use of antibiotics • Antibiotics within 1 hour before surgical incision* • Prophylactic antibiotic agent consistent with locally determined guidelines • Discontinuation of prophylactic antibiotics within 24 hours of surgery *Due to the longer infusion time required for vancomycin, it is acceptable to start this antibiotic (e.g., when indicated because of beta-lactam allergy or high prevalence of MRSA) within 2 hours prior to incision. Preventing Surgical Complications

9. Antibiotics cont. Exceptions: • within two hours if patient receiving vancomycin, • If surgery is being carried out with tourniquet control, all antibiotic administration must be completed before the tourniquet is inflated and within one hour prior to surgical incision. • Women undergoing caesarean section should receive the antibiotic as soon as the umbilical cord is clamped. Preventing Surgical Complications

10. Evidence • Appropriate antibiotic selection occurred in 92.6% of cases; • Antibiotics were given within one hour of incision time to 55.7% of patients; and • Prophylactic antibiotics were discontinued within 24 hours of surgery end time for only 40.7% of patients. (Bratzler 2005) • Patients who received the first dose either more than 60 minutes before incision or after incision had higher rates of POWI, and the further the dose time was from incision, the greater the rate of POWI (Classen 1992). Preventing Surgical Complications

11. Use Recommended Hair Removal Methods Only electric shavers to be used to remove hair at the site of incision. Preventing Surgical Complications

12. Evidence • Three trials involving 3193 people compared shaving with clipping and found that there were statistically significantly more SSIs when people were shaved rather than clipped • Seven trials involving 1213 people compared shaving with removing hair using a depilatory cream and • found that there were statistically significantly more SSIs when people were shaved than when a cream was used (Tanner 2006) Preventing Surgical Complications

13. Maintenance of Postoperative Glycaemic Control • All diabetic patients (whether insulin or tablet controlled) should have capillary glucose monitoring instituted at a minimum frequency of 4 times daily prior to transfer to the operating theatre. • All diabetic patients should have their management reviewed to ensure tight glycaemic control is attained. • All surgical units should have procedures in place to identify and manage all patients with diabetes. This will include access to appropriately trained diabetes specialist teams. *NOTE that, for the purposes of this campaign, “tight glucose control” is defined as serum glucose levels between 5.0-10.0 mmol/l , throughout postoperative period. Preventing Surgical Complications

14. Hypothermia Preventing Surgical Complications

15. Maintenance of Postoperative Normothermia • Patients are risk assessed for the potential to develop inadvertent hypothermia during surgery (documented). • Patients with a core temperature of less than 36oC pre operatively do not commence their anaesthesia and surgery until they have been warmed using forced warm air. Active warming should continue throughout the procedure. • All patients at risk and / or with surgery anticipated to last >30 minutes, are warmed intra operatively using forced warm air.* *If this is not a practical intervention e.g. exposed surface area too extensive to allow forced warm air, then evidence from a small study suggests that electric blankets underneath the patient will maintain core temperature (Just 2003). Preventing Surgical Complications

16. Maintenance of Postoperative Normothermia - cont • All patients routinely have their temperature monitored; 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. • Healthcare professionals should ensure that intravenous fluids (500 ml or more) and blood products are warmed to 37°C using an appropriate fluid warming device. • Patients who arrive in recovery with a temperature less than 36oC should be warmed using forced warm air. Preventing Surgical Complications

17. Maintenance of Postoperative Normothermia – pre assessment In the perioperative period, ideally during the patient’s pre operative assessment appointments, patients who have the following risks should be identified as being at higher risk of developing hypothermia perioperatively: - ASA grade greater than I (the higher the grade, the greater the risk) − undergoing combined general and regional anaesthesia − undergoing major or intermediate surgery − at risk of cardiovascular complications (for example, age over 50 years). Preventing Surgical Complications

18. Evidence – favour treatment • Two studies recorded the occurrence of cardiac events after surgery. • Four studies examined the need for blood transfusion between groups. • Two studies recorded the incidence of postoperative wound infection. • One study recorded the occurrence of pressure damage. The results of this study did not reach statistical significance, but the author points out that warming of patients did reduce the risk of pressure ulcer occurrence by half, which is clinically significant. Preventing Surgical Complications

19. Team briefing at start of list Some of the ways in which team briefings can be developed are: • Allocating five minutes before the start of the operating list where the core members of the team e.g. surgeon, scrub nurse, circulating nurse, ODP and anaesthetist can meet to discuss the requirements of that operating list and any safety concerns. • Identify in advance a list of safety issues for discussion e.g. patient allergies, anticipated complications etc., potentially using a structured checklist • Using a de-briefing session at the end of the operating list to review any issues raised, answer concerns or discuss incidents. Preventing Surgical Complications

20. Aims of interventions Preventing Surgical Complications

21. Evidence • increased employee satisfaction, improved perceptions of safety climate, • Reduction in potential for wrong site surgery and • better interprofessional empathy and understanding (Defontes & Surbida, 2003). • increased confidence • across the OT team to speak up when spotting potential problems (Burke 2005) Preventing Surgical Complications

22. Identifying patients at risk and provide appropriate DVT prophylaxis • Documented DVT risk assessment of every surgical patient • All high-risk surgical/orthopaedic patientsshould receive graduated compression stockings combined with heparins. • Intermediate-risk surgical patientsconsidered for graduated compression stockings combined with heparins. • Low-risk surgical patientsdo not require specific prophylaxis other than early mobilisation, unless other factors are present which increase overall risk and thus place them in intermediate or high-risk categories Preventing Surgical Complications

23. Where can we make the most difference to mortality? • 20% of patients undergoing major surgery experience a DVT. From data available on PEDW there were 14,206 major operations . 14202/100 * 20 = 2841 for one year. • In 2006/7 there were 9579 hip and knee replacements. Between 45-51% of orthopaedic patients suffer a DVT (NICE 2007). 9579/100 * 45 = 4310 9579/100* 51 = 4885 • Estimated that the risk of pulmonary embolism following high-risk surgery to be up to 5% in the highest risk groups (orthopaedics) 9579/100 * 5 = 478 Preventing Surgical Complications

24. Continue beta blockers for patients admitted on beta blockers Beta blockers should be continued in patients undergoing surgery who are receiving them to treat angina, symptomatic arrhythmias, hypertension, or other ACC/AHA class I guideline indicators. Preventing Surgical Complications

25. Evidence • continuous beta-blocker use remained significantly associated with a lower 1-year mortality than among nonusers (Hoeks et al 2007) • Mortality in the patients who had beta blockers discontinued postoperatively (50%) was significantly greater than in the patients in whom beta blockers were continued (Shammash et al 2001) Preventing Surgical Complications

26. The PDSA Cycle Plan Act Study Do Preventing Surgical Complications

27. PDSA • Small changes, one patient, one list, one team • Measure – did it work, if not try something different • Spread if did work • Identify a pilot population • Measure • Are you already doing it? – measure compliance Preventing Surgical Complications

28. Finally Contact details Peggy.edwards@npsa.nhs.uk Content Specialist Preventing Surgical Complications