LEADING THE MAKING GREAT CARE CHALLENGE AFFORDABLE Checklists and Simulation Training Jason Cheng,...

LEADING THE

MAKING GREAT CARECHALLENGE

AFFORDABLE

Checklists and Simulation Training

Jason Cheng, DO; Paul Preston MD

NATIONAL QUALITY CONFERENCE: April 29 –– May 1, 2014

LEADING THE

MAKING GREAT CARECHALLENGE

AFFORDABLE

Speakers

Jason Cheng, D.O. Simulation Physician Champion Kaiser Permanente Southern California, Downey Medical Center L&D Perinatal CETT; Periop HRT, MedSurg Inpatient, Interventional

Radiology; Southern California Regional Simulation Human Factors Committee

2 2014 National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only.April 22, 2023

Learning Objectives

Understand the frequency of errors when managing emergencies Define the measured improvements when checklists are used Understand the 5 A’s to checklist success Look at a successful implementation in one KP facility Consider how these can best be used to break down interdisciplinary

barriers to communication and action


Critical Events in Your OR/PACU

More or Less Frequent? Organized or Chaotic? We are building more reliable systems and need to systematically

address our emergency skills


Where We Are Now

Reliance on memory for Critical Steps Show of hands – who is ACLS certified? What are all the Hs and Ts? “Gee, haven’t seen this in awhile…”


W. Wayne Babcock, M.D

“If a response is not instantly obtained by simple measures, a fixed emergency routine, posted on the walls of every operating room and drilled into every member of the staff,

should be enforced.”

P<0.001

With Checklists Without Checklists

75% Reduction in Failure to Adhere to Life Saving Processes of Care


Delivering optimal care to our patients from memory alone?

“The frequency of cognitive aid use correlated significantly with the MH treatment score….”


Latent knowledge activation?

Prospective

memory cue?

What we can learn from aviation…


PILOTS TRAIN TO FLY THE PLANE AND

DEAL WITH EMERGENCIES


Pilots Train In…

CRM

– Communication

– Teamwork

How to use checklists


5 A’s of Checklist Success

AWARENESS—did you know they exist? ACCESSIBILITY---can you get to them…easily??? ACTION—read it, write on it, hold it…if you don’t use it, you lose it! ASSESS—simulation, in service, test it to see how it works for you ACCOUNTABILITY—helps engage team members to stay on the

same page


Access in OR Consistent location Easy to see and reach when

needed Does not block daily workflow


L&D, Operating Rooms

Easily accessible by entrance

Located next to that other emergency equipment!

Easily visible


Lights, Camera…Simulation!


Periop Use of Checklists: BiMonthly Simulation

OR/Periop—OR, PACU

– 8 Main ORs, 2 PACUs, 1 MOB/Procedural Sedation Center

– HemorrhageCardiac Arrest

– Malignant HyperthermiaCardiac Arrest

– Fire/Airway Fire

– LASTDifficult AirwayCardiac Arrest

– Difficult AirwayHypoxiaCardiac Arrest

– AnaphylaxisCardiac Arrest


Simulation – L&D CETT

Monthly Involves OB, nursing team,

NICU team, anesthesiologists Checklist scenarios used:

– Massive HemorrhageCardiac Arrest

– Failed AirwayHypoxiaCardiac Arrest

– Fire


What have we learned?

Knowing what you didn’t’ know before! I thought, you thought, she thought…we all “assumed”… Roles may need to be more clearly defined! We’re not set up for this sort of thing! (system improvements needed) What goes where? Who does what?


Roles not clear, too many cooks in the kitchen!


Roles defined, everybody knows where to go!


Checklist helps redefine roles more clearly

Role of Circulating RN (or primary RN on floor) Role of Charge RN Who are the immediate first reponders to circulator and anesthesia? Who gets the checklist, and who reads it? What are the responsibilities dictated on the checklist—rehearsing the

roles! Is anesthesia or surgeon the best person to be the “leader”? What system improvements need to be made based on the

checklists? (emergency drugs, emergency equipment, communication protocols, etc)


Fire Simulation improvements

Gas valves labeled for specific OR


LOCAL ANESTHETIC TOXICITY SIMULATION

Emergency resuscitative medication from local anesthetic toxicity best kept inside regional anesthesia and nerve block carts


L&D CARDIAC ARREST/MASSIVE HEMORRHAGE

Original OR room small, poor access to emergency resuscitative equipment, especially with neonatal staff during muiltiple births

Emergency access limited during crash c-section sometimes 10 staff members in room


L&D Simulations

Entire wall knocked out and moved back further for greater access; OR monitors relocated to make more room for neonatal staff;


When and How NOT to Use

NOT when immediate action is required NOT preventing additional clinical actions NOT as a replacement for appropriate training NOT as a replacement for clinical judgment NOT instead of calling for appropriate help NOT selecting incorrect cognitive aid NOT distracting leader

April 22, 2023 2014 National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only.28

More Observations

Read these out loud! Some checklists (MH) work really well to guide the emergency

management – Read/Do Some checklists (Airway) will work best before you get into the

emergency – Preflight briefing Some checklists (Hypotension, hemorrhage) may often be used early

by an individual to double check themselves A lot of the time the first few steps will have been done before the

checklist is deployed- use as a quick review!


The Implementation Journey

Learn to manage OR emergencies using checklists– They work

– There is a lot of science in how to design them

– They will evolve over time

– They do disrupt our learned patterns

– Training is essential

Give us input on:– Usability of the checklists

– Implementation and training

– Ongoing checklist refinement and automation

April 22, 2023 2014 National Quality Conference © 2014 Kaiser Foundation Health Plan, Inc. For internal use only.30

The team that trains together makes music together!


LEADING THE MAKING GREAT CARE CHALLENGE AFFORDABLE Checklists and Simulation Training Jason Cheng,...

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