Introduction
Confronted with data showing that, in industrialised countries, in-patient surgery had an adverse event rate of 3–17 per cent, and that approximately half of these surgical adverse events were deemed preventable,Reference Gawande, Thomas, Zinner and Brennan1,Reference Kable, Gibberd and Spigelman2 the World Health Organization (WHO) commissioned the Safe Surgery Saves Lives programme, with an aim to reduce surgical ‘never events’, near misses and avoidable complications. The result was the WHO guidelines for safe surgery, which included a surgical safety checklist.3 A pilot introduction of the checklist in 3955 patients in hospitals worldwide showed reductions in in-patient post-operative complications of 36 per cent, with similar reductions in mortality.Reference Haynes, Weiser, Berry, Lipsitz, Breizat and Dellinger4 Since 2010, the ‘WHO checklist’ has now become a mandatory part of UK surgical practice in the operating theatre setting.
Following on from this, the National Health Service (NHS) developed National Safety Standards for Invasive Procedures. These were designed to help facilitate the synthesis of local safety standards for invasive procedures, which, like the WHO checklist, are designed to promote procedural safety. These local safety standards for invasive procedures are aimed at invasive procedures conducted in the clinical environment, for which the WHO checklist is not suitable, to allow for customisation to the individual requirements of the procedure or department.
In November 2017, we commenced a working feasibility analysis of a local anaesthetic endonasal procedures out-patient clinic service at Freeman Hospital, Newcastle upon Tyne. Fundamental to introducing an innovative ambulatory out-patient practice is the development of a novel local safety standard for invasive procedures to support this procedure. Here, we present the new safety standard developed for this purpose.
Safety standard development and process
The WHO surgical safety checklist3 was used as the base template for this ambulatory endonasal surgery local safety standard for invasive procedures, as it is well established and familiar to surgical staff. Example local safety standards for invasive procedures from the NHS Improvement website were also reviewed.5 Relevant processes and checks from the WHO surgical checklist were retained. After review of the clinic process, and consultation with all members of the surgical team, further points were added. These points related to procedure- and situation-specific perceived risks, such as reactions to topical anaesthetic and vasoconstrictive agents, and highlighted deviations from usual post-procedure requirements, such as the need for an in-patient bed or for nasal packing to be removed.
The local safety standard for invasive procedures is completed for each patient by relevant medical or nursing staff at key points before, during and after the procedure. It also contains prompts for a pre-list team brief, and a debrief checklist for completion at the end of the list. The debrief checklist has been created to highlight areas of perceived good practice, as well as recurring issues or areas of perceived improvement. The local safety standard for invasive procedures and debrief checklist can be seen in Figure 1.
(a) Local safety standard for invasive procedures checklist and (b) debrief document for an endonasal procedures clinic.
The local safety standard for invasive procedures was subject to review by the local departmental clinical governance lead, and key medical and nursing team members, prior to implementation. A two-session pilot of the local safety standard for invasive procedures was undertaken, where compliance and opinions on the process were reviewed. Feedback from staff members was overwhelmingly positive, and no further alterations to the document were required. A copy of each patient's local safety standard for invasive procedures and the list debrief document are retained for audit purposes.
Conclusion
Local safety standards for invasive procedures are now an essential safety aspect of procedures performed in the clinical setting. Our local safety standard for invasive procedures for ambulatory endonasal procedures has been introduced in Newcastle upon Tyne hospitals, to good reception from medical and nursing staff.
Increasingly, there is a shift toward ambulatory services, directed by patient choice, technological advances and the opportunity for cost savings. In addition to endonasal procedures, there are other procedures within ENT that can be performed under local anaesthesia in the ambulatory setting, such as adult grommet insertions, minor facial plastic surgery procedures, or fractured nasal bone manipulations. For those looking to implement such ambulatory services, this local safety standard for invasive procedures can easily be modified and adapted for such procedures, to enhance patient safety and conform to current standards of practice. We therefore hope that this local safety standard for invasive procedures will provide a useful template for those considering implementing ambulatory procedural services within the specialty of ENT.
Competing interests
None declared
