Radio NZ National
Saturday Morning with Kim Hill – 12 March 2011 – 08.46am
Professor Alan Merry talks about the World Health Organisation’s Safe Surgeries
Saves Lives Programme, founded by Dr Atul Gawande.
KIM HILL:
Last week I spoke to surgeon and writer, Dr Atul Gawande, whose latest book about
the complex business of surgery is called: The Checklist Manifesto, How to Get
Things Right. A basic checklist, it's a simple thing, plenty of other complex
endeavours use it, construction, aviation. Dr Gawande found that it helps save lives
in the OR, the Operating Room. He heads the World Health Organisation's Safe
Surgeries Saves Lives program and we're talking about that and as he said,
Auckland Hospital is one of eight around the world to trial the checklist. Professor
Alan Merry, Head of the Department of Anaesthesia - I've been practicing –
Anaesthesiology, say it for me.
ALAN MERRY:
Anaesthesiology. [Laughs]
KIM HILL:
I knew you'd say it right. I suppose you had to go to university to say that, heads the
Save Anaesthesia Group of the WHO's program and he's with me now in our
Auckland studio, good morning and welcome.
ALAN MERRY:
Good morning Kim.
KIM HILL:
Just going back to Dr Gawande's book, The Checklist Manifesto, he says that when
the results first came in from your hospital and the seven others on the trial, the
results were so astonishing that he had to go back and start looking for mistakes.
Because the rate of major complications for surgical patients in all eight hospital fell
by 36 per cent after introduction of the checklist and deaths fell by 47 per cent. Now,
was that your specific experience or we're talking about an average that's
raised up by others, if you see what I mean?
ALAN MERRY:
No, that is an average. The effect size was greater in the low income countries as
you might expect and in a country like New Zealand and other places like Seattle,
where the standards were already high, the effect was smaller. But it was still more
than I would have expected and still quite convincing.
KIM HILL:
Just run it past me again, how did you employ the checklist - what was it? How did it
work?
ALAN MERRY:
Well we're still doing it, of course. But it's basically three phases, so the first phase
is when the patient is brought into the operating room there are checks done in the
operating room involving not just, as is often in the past been the case, one person,
say the nurse, but actually involving more than one of the teams. Ideally all three,
but as a minimum the anaesthetist and the nurse checking together, because…
KIM HILL:
What's the thinking behind that?
ALAN MERRY:
Well it's to get people talking to each other and engaging. The checklist isn't just
about the checks, it's actually designed to promote communication and teamwork.
And so the other thing, of course, is that many of these checks – people often ask,
weren't these done before? Well they were, but typically these checks were done in
the holding area. Now in the last…
KIM HILL:
You mean before they got to the operating room, yes?
ALAN MERRY:
Before they got to the operating room and in the last 20 years or so I have had three
occasions when patients were checked in the holding area and then taken to the
wrong operating room and so I've ended up with a patient on the table in front of me
that was, in fact, meant to be in the operating room next door.
KIM HILL:
And so you've raised the completely wrong operation, that's everybody's nightmare.
ALAN MERRY:
Well it's interesting because one of the things that - so I work in the cardiac unit at
Auckland Hospital now, it used to be Greenlane and I do a regular tutorial on how to
check the anaesthesia machine and one of things that I actually do with the trainees
is I get one of them to role model being the patient. And the aim is for them to
actually show that they will check the patient, which they frequently don't, despite
that strong hint. And my point is you can be really clever, you can do very good
anaesthesia and surgery and be utterly brilliant, but if you've got the wrong patient,
it's not very good.
KIM HILL:
So really, just...
ALAN MERRY:
So it's a very fundamental…
KIM HILL:
Yeah…
ALAN MERRY:
Very fundamental.
KIM HILL:
Shaking assumptions that are made so easily that nobody bothers to think about
them.
ALAN MERRY:
Well that's right and one of the great risks - and it's a risk even with our checklist - is
that the people get into the mindset of going through the motions. And one of the
things that we really are trying to do is get people to engage in it. There's some
small print at the bottom that says that you can modify for local conditions and that's
important, because what we want is for people to think about how to make it work in
their own operating room. There are actually three phases. There's another
phase just before the incision, which is called the time-out, where you just stop
everything and check that you really are on track and that everybody's got the right
mindset. And at that point, there's actually a very novel thing which is introducing
each other, particularly new people or people that aren't known.
KIM HILL:
Back to the team thing.
ALAN MERRY:
That's right. Now interestingly I thought that would be a real - go down like a lead
balloon idea.
KIM HILL:
Like let's all hold hands and make friends.
ALAN MERRY:
And obviously if you're in a particular, very close knit team where everybody's
worked together for 20 years and it's all - everybody knows each other then all you
need to do is just say, we all know each that's fine. But what's been intriguing to me
is that it's turned out, I'm not the only person with a bad memory for names and I
think some of the surgeons have been quite pleased to have an excuse to say, you
know, let's just introduce ourselves…
KIM HILL:
Why don't you wear nametags?
ALAN MERRY:
Well we do to some extent, but you know you're in greens, they're often quite hard to
read. I don't know if you've noticed that, but even in social functions when people
have nametags, you can sort of end up peering rather hard at them to try to see what
they're saying.
KIM HILL:
Yes, I have.
ALAN MERRY:
And so it is a very good thing just to do the introduction.
KIM HILL:
Dr Gawande said that he, in the process of trying to set this up - this trial of the eight
hospitals, he was thrown out of more operating rooms than he could count. There
was resistance to the idea and you've hinted at this. Why?
ALAN MERRY:
Well it's a glass three-quarters full. I think that the good news is that the major
people and most of the people at Auckland Hospital really got behind it, and the
university as well. So we did it as a combined thing and there was a lot of support.
But people are resistant to change and I think part of it is that everybody is trying to
do the right thing. They put a lot of time and effort into getting their own systems
working well and then somebody comes along with a new idea and says why aren't
you doing this, or please would you do this? I think it's a bit natural to be resistant.
And the thing that flipped it of course was getting the data that showed actually this
makes a difference. And then it becomes much harder to say well, I don't want to do
it.
KIM HILL:
I mean presumably there are what Atul Gawande would call heroic surgeons, I
suspect who say, this is bureaucracy gone mad and I don't need this stupid
business and leave me alone, I've got a patient to operate on here.
ALAN MERRY:
Well more reasonably I think there's a view that there is too much paperwork and too
many things that we have to go through. And there is this risk that it becomes just a
go through the motion…
KIM HILL:
Another form…yeah.
ALAN MERRY:
And that is something that has to be managed and Dr Gawande last week talked a
bit about the design of checklists and the importance of getting them short and
meaningful.
KIM HILL:
And the difficulty of what you leave out.
ALAN MERRY:
Precisely, it's more about what you leave out then what you put in.
KIM HILL:
You've been involved in the Health, Quality and Safety Commission. This
presumably incorporates this concept.
ALAN MERRY:
It's one of the initiatives. We actually - the initiative was ahead of that, but it is one of
the ones that we are going to be putting weight behind, if you like. Keeping that
momentum going, because all of these things have a tendency to get off to a good
start and then to drift a bit. So I think we do need to do some reinforcement of it.
But it's only one of many initiatives that we will be looking at over the next year and
beyond.
KIM HILL:
What are some of the other ones?
ALAN MERRY:
Well one of the big problems that occurs in healthcare is medication errors and there
is a long-term plan to move New Zealand towards a much more systematic
electronic prescribing and checking of medications. But that will take some years
and a lot of money. And the first step is that we are trying, this year, to roll-out a
standardised adult in-patient prescribing form for all hospitals in New Zealand, which
means that staff that move around - junior staff and some nurses - wherever they
are, they'll be using the same prescription form. And not only that, but it will be one
that's been well designed. So for example, some of the errors that occur involve the
decimal point and that's actually quite serious errors if you get in the wrong place.
KIM HILL:
You get 10 times too much.
ALAN MERRY:
Precisely, or too little - equally bad actually depending on the circumstances – but
the form has a pre-printed decimal point and it's standardised. It's got a
standardised way of writing prescriptions. . And that may seem, again, like an
obvious thing, but the fact is I don't think any country in the world has got a
standardised form across its entire system. We will probably be the first.
KIM HILL:
So what everybody goes and gets their own sorts for forms?
ALAN MERRY:
Each hospital introduces its own. One of the intriguing things is that some of them
are good. There's always this argument well, our form is actually already excellent.
Why should we take the standardised one?
KIM HILL:
Yes.
ALAN MERRY:
Well the answer, of course - and the aviation people discovered this, because the
way aviation safety improved was to move away from what you mentioned, the
heroic concept of everybody trying to be the best, to say, actually what we need is
something that's good that we know that works well and get everybody to do the
same. Now as Dr Gawande said last week, that's not dumbing down and what's
more it's not saying you shouldn't vary treatment around patients. Clearly
every patient's different and clearly treatments need to be tailored in a very specific
way to each individual. But once you've decided to actually administer a particular
treatment, to give drugs for example, that's a process and it's the processes that we
need to standardise. Now the adoption of process engineering - and the checklist is
really just a process engineering tool - is something that healthcare's been a bit slow
over.
KIM HILL:
One of the other things you're involved in - and we haven't got very long to talk about
it actually – but it's Lifebox. And at this particular point, where the world does seem
to be falling apart in a third world direction generally speaking, I thought it might be
useful to talk about it. What's the Lifebox?
ALAN MERRY:
Well it's actually one of the elements on the checklist which is a pulse oximeter,
which is a monitoring device that measures the oxygen in your bloodstream. When I
started anaesthesia some 30 years ago, we didn't have that monitoring and we had
to rely on looking at the colour of the patient and other signs to tell if their oxygen
levels were falling. And that's actually quite difficult. This monitoring…
KIM HILL:
Because you mean they have to be quite far gone before they…
ALAN MERRY:
Because really it's quite a late sign so you can be quite bad before it becomes
apparent that there's a problem. Whereas the pulse oximetry is a fantastic monitor
which has changed the face of modern anaesthesia. And in a country like New
Zealand, it's used universally. But there's a big gap. We've done some work that
suggests that 77,000 operating rooms around the world - and some millions of
operations are done without this monitoring. It's actually a symbolism on this
because it goes without a lot of other things. Those other places that have poor
standard of care, low qualifications of staff and many other things. So this is a
project in which the primary thing is the - we've sourced and specified a very low cost
pulse oximeter that is also very high quality. It's one that any of us would be happy
to use in New Zealand in our patients. And we have built around that an educational
package and advocacy package with the whole message of which is that the safe
management of surgery does include safe anaesthesia, that does include the
technology and it does include the skills and the resources to respond to the
information on that technology.
KIM HILL:
Again, a very simple idea.
ALAN MERRY:
It is and it's been going now for some six or seven years.
KIM HILL:
Where's the money coming from?
ALAN MERRY:
Well we are looking to various sources. We've had a substantial donation from
Smile Train. We've had various individual including I might say, Dr Gawande has
contributed generously. It is possible to go online on the website and actually donate
and that has gone live recently and we're hoping that many – particularly
anaesthesia providers will be enthusiastic. Because for US$250 which is what
one of these costs, you can conceive of actually putting one of these devices into an
operating room and saving lives, which is quite an exciting idea really.
KIM HILL:
I just need to check, I talked to Atul Gawande about music and what music he likes
to listen to. Do you ever - do people delivering the anaesthetic get to choose the
music?
ALAN MERRY:
Yes, it varies - a lot depends on people's view. I am probably - I quite like quietish
classical music but I do - one thing is though that there are - and it's the same
cockpit in the aeroplane, there are times of the proceedings when actually what I
need is quiet. The critical moments, at the beginning and end in particular or if
something is going wrong, I just ask if we could please keep things quiet.
KIM HILL:
I'm sure that were I conscious, I'd agree with you. It's nice to talk to you, thank you.
I've been talking to Dr Alan Merry, nine o'clock now.