New checklist makes the cardiac catheterisation lab a safer place for patients

Safety in a high-risk environment

Home to a host of extremely complex procedures to do with the heart, the cardiac catheterisation laboratory or CCL is a high-risk environment. More than 100,000 procedures are performed in CCLs each year in the UK, and with increasing volume and complexity of procedures comes greater potential for error. Since 2010 it has been mandatory for all UK theatre teams to use safety checklists before operating, yet despite this there are no standardised systems currently in place in CCLs.

In 2013, a Shine-funded project at Royal Brompton and Harefield NHS Foundation Trust set out to develop a safety checklist for the CCL. This was derived from the World Health Organisation (WHO) safe surgery checklist but specifically modified for use in the CCL.

Dr Elizabeth Haxby, Lead Clinician in Clinical Risk at Royal Brompton Hospital, explains:

‘The WHO safe surgery checklist has been shown to reduce morbidity and mortality during surgical procedures. We wanted to develop a similar style checklist specifically for the CCL and see what impact it could have on safety, efficiency, staff experience and department costs, whilst also for the first time examining its effect on patient experience.’

Developing and testing a checklist

Following a three month development process using PDSA cycles to gather staff feedback, the team arrived at a simple, standardised checklist that could be applied to the range of different procedures taking place in the CCL. This was introduced at Royal Brompton Hospital, a specialist referral centre for treatment of complex adult and paediatric heart and lung disease.

The checklist procedure has four parts:

• Team brief: given by the operator to the team before the start of the list, followed by the three part checklist.
• Sign in: pre-procedure checks carried out by a nurse prior to the patient being put on the table.
• Time out: a briefing delivered by the operator immediately prior to the start of the case.
• Sign out: a debrief from the operator, post-procedure checks and confirmation of case details for ward handover.

Benefits to safety and efficiency

The team achieved 95% implementation of all stages of the checklist, with safety climate surveys showing that staff regarded it positively and would like one to be used if they ever needed an intervention themselves. As well as acting as a safety net to ensure that no part of the process was forgotten, the checklist also created a collaborative atmosphere where team members better understood their roles and had more opportunities to raise concerns.

The team recorded efficiency benefits when using the checklist, with some procedures showing shorter than average duration. Anecdotal evidence also illustrated safety benefits. In one case, the operator mentioned at the ‘time out’ that he planned to use an electrical cauterising knife, but opted for a more suitable knife when the physiologist alerted him to the patient’s hip replacement.

‘Procedures were more efficient and there were fewer interruptions, because details had all been covered in the team brief and checklist. We saw a reduction in screening times where the checklist was used, meaning less radiation exposure for patients,’ says Dr Haxby.

Patients felt safer when the checklist was used

The team also collected rare evidence about the impact of the checklist on patients themselves. Previously only used in operating theatres when patients are asleep, the team used the checklists while patients were awake, questioning them afterwards about the experience.

Almost 60% of patients noticed staff implementing the checklist and felt safer that it was being used. For those who didn’t notice that the checklist had been used, knowing afterwards that one was used was highly reassuring. For those in the control group in which a checklist was not used, almost 90% said they would have liked one to have been used.

Encouraging safer practice in all acute cardiac care

The team is now exploring the possibility of implementing a checklist in emergency scenarios. It also recently held the first ever national symposium specifically debating safety and quality in acute cardiac care, attended by more than 80 health care professionals involved with CCL procedures. The British Cardiovascular Society has since further encouraged national dialogue by publishing new guidance about the use of safety procedure checklists in the CCL.