Obstetric anaesthetic safety checklist: Guideline development through team simulation

Bridie James, Helen Bryant, Sarah Nelson, Hilary Swales, Samar Al-Rawi, University Hospital Southampton

Introduction Pregnancy is a risk factor for difficult and failed intubation (rate 1:300).1 The number of caesarean sections (CS) performed under general anaesthesia (GA) has steadily declined and has become infrequent (8.2%2). This, combined with changes in the working hours of trainees, has lead to some trainees working unsupervised with little experience in administering GAs in the obstetric population.3!Obstetric theatres are often situated distant from the main theatre complex. NAP 4 recommends the use of checklists particularly when anaesthesia is performed in remote sites. Babolhavaeji et al demonstrated that the use of such checklists can reduce error. 4 Use of surgical checklists has furthermore improved teamwork and staff morale. 5 MBRRACE recommends the practice of drills for managing peri-operative airway crises. 6!Method A simple Obstetric GA checklist detailing actions before and during induction of an obstetric GA was introduced into the maternity theatres in our hospital. This was initially aimed for use during Category 1 caesarean sections, however due to positive support, its remit was expanded for use during all obstetric GAs. !!!!!!!!!!!!!!!!!!!!

!The usefulness and utilisation of the checklist was monitored using a feedback form over a 6-month period. Results showed excellent support for the concept, however a low uptake (6 cases, 9.2% of GA cases throughout this period). In order to elucidate barriers to use, a further questionnaire was sent to all obstetric theatre practitioners and anaesthetists. !Using the feedback gained, the original checklist was used as a framework for modification and testing in a multidisciplinary simulation environment using both novice and experienced obstetric anaesthetists and ODPs. We introduced a visually appealing simple flow chart with a traffic-light system. This depicted actions before and at induction with a pneumonic to aid recall of the key actions – SAFE PIT STOP. !A formalised and organised rollout programme included the emailing of key team members, display of colourful laminates throughout theatres and the department, and a presentation at a departmental meeting, in order to alert potential users and promote its use. Uptake of use was subsequently audited.

Results Preliminary feedback demonstrated that all respondents agreed that the checklist was a useful reminder and may help trainees manage a situation infrequently encountered. 10 respondents (91%) agreed that the checklist improved communication between anaesthetist and ODP.

!In the re-audit using the modified checklist 31 obstetric GAs were undertaken. The response rate was 97%. The GA checklist was used in 24/30 (80%) of these cases. Reasons for omission of use included: lack of time, the anaesthetist already had their own checklist, one respondent was unaware of the checklist.

!

!

!

!

!

!

!

!

!

!

!

!

!

Discussion Through repeated team simulation, the benefits and pitfalls of prototype checklists can be identified to facilitate development. In this situation, the format improvement and team approach increased uptake of use from 9% to 80% of obstetric GA cases. Testing and modifying the checklist in a multidisciplinary simulation environment proved very useful for a number of reasons. • It reinforced that the ODP is a vital and valued member of the team • It enabled engagement and allowed shared ownership of an important communication tool• Any suggestions or criticism could be made directly in person in a welcoming forum• Suggestions were immediately considered, before re-adjustment as necessary and re-trial • Direct involvement by the ODPs also added credentials to the implementation of the tool • It allowed us a unique insight into the management techniques of our colleagues of varying seniority in a

simulated challenging scenario!The final checklist was deemed to be a success. It has been well used, ratified by the consultant body and engagement of the whole team was instrumental in achieving this goal. We still face some challenges - these include lack of clinical engagement and lack of familiarity due to a high trainee turnover; however with time, regular re-enforcement and the inclusion in the formal trainee induction programme, we hope its use will become part of standard practice.

1. 4th National Audit Project of the Royal College of Anaesthetists; Major complications of airway management in the UK, March 20112. National Obstetric Anaesthetic Database NOAD3. Searle RD, Lyons G. Vanishing experience in training for obstetric general anaesthesia:an observational study. International Journal of Obstetric Anesthesia; Volume 17, Issue 3, Pages 233–237, July 20084. Babolhavaeji F et al. Checklist for emergency induction of anaesthesia in critical care. Anaesthesia 2013, 68, 5. Implementing the Surgical Safety Checklist: The Journey So Far. Patient Safety First. June 20106. MBRRACE-UK Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK 2014

Yes,%6%

No,%60%Yes,%24%

No,%6%

Original checklist use Modified checklist use

Service improvement PDSA cycle

Obstetric anaesthetic safety checklist: Guideline development through team simulation

Bridie James, Helen Bryant, Sarah NelsonHilary Swales, Samar Al-Rawi, University Hospital Southampton

• A general anaesthesia checklist was developed to improve safety in obstetric care 1,2

!

!

• The initial checklist was under utilised. Lengthy format, poor visual impact and lack of multidisciplinary engagement inhibited success

!

!

• Re-design involved team simulation and open feedback to create an improved checklist, with the benefit of enhancing ownership

!

!

• The improved checklist was well received and engagement of the theatre team in its evolution was deemed to be instrumental in its realisation

!

!

• The huge success of implementation is demonstrated by an increase in uptake from 9% to 80%

!