Sadea Cirugía Segura

CIRUGIA SEGURA

Jorge Rubio Elorza

Vocal académico SADEA

INTRODUCCIÓNINTRODUCCIÓN

• 234 millones cirugías/año

✔Muertes : 0,4-0,8% 1

millón

✔Complicaciones: 3 – 16%

7 millones dishabilidades

INTRODUCCIÓNINTRODUCCIÓN

• Estrategía OMS: CIRUGÍA SEGURA SALVA VIDAS

✔ Disminuir el número de MUERTES

QUIRÚRGICAS en el mundo

✔ Fortalecer las medidas de SEGURIDAD

✔ Implementar TÉCNICAS ANESTÉSICAS SEGURAS

✔ Evitar la INFECCIÓN QUIRÚRGICA

✔ Optimizar la COMUNICACIÓN en el equipo

quirúrgico

OBJETIVOS ESENCIALESOBJETIVOS ESENCIALES

• Realizar el Paciente y la cirugía CORRECTOS

• Prevenir los RIESGOS ANESTÉSICOS y evitar el

DOLOR

• Prevenir y manejar los RIESGOS DE VÍA AÉREA:

Difícil – Aspiración

• Reconocer y preparar el manejo de SANGRADO

MAYOR

• Evitar REACCIONES ALERGÍCAS y EFECTOS

FARMACOLÓGICOS ADVERSOS

OBJETIVOS ESENCIALESOBJETIVOS ESENCIALES• Minimizar riesgo de INFECCIÓN DE HERIDA

QUIRÚRGICA

• Prevenir la RETENCIÓN inadvertida de GASAS –

INSTRUMENTOS

• Identificar adecuadamente TODAS LAS MUESTRAS

DE PATOLOGÍA

• Comunicación adecuada para realizar una

CIRUGÍA SEGURA

• Establecer y difundir por las INSTITUCIONES y

EL SISTEMA DE SALUD INDICADORES DE

GESTIÓN

LISTA DE CHEQUEOLISTA DE CHEQUEO

LISTA DE CHEQUEOLISTA DE CHEQUEO

• CIRUGÍA SEGURA Prioritaria ESTRATEGIA – LIDERES y EQUIPO QUIRÚRGICO

✔ ADAPTABLE – NO REGULATORIO

✔ SIMPLE - BREVE

✔ FLUJO LABORAL NORMAL

✔ CREAR CULTURA PRACTICAS SEGURAS

RUTINARIAS

✔ SEGUIMIENTO – CUMPLIMIENTO – ADHERENCIA

minimizan RIESGOS COMUNES Y EVITABLES.

FASE DE ENTRADA

PRE-INDUCCIÓN ANESTÉSICA – SEGURIDAD DEL

PROCEDIMIENTO ANESTESIA - ENFERMERIA

✔ PACIENTE

Identificación – Sitio – Procedimiento -

Consentimiento

✔ SITIO

Marcación – No aplicable

✔ CHEQUEO DE ANESTESIA ABCDEes

Equipos – Medicaciones – Riesgos del paciente

FASE DE ENTRADA

✔ PULSO-OXÍMETRO

Disponibilidad – Visible – Alarmas audibles

✔ ALERGIAS

Alergeno reconocido – Confirmar o informar

✔ VÍA AÉREA

Difícil: Técnica – Equipo VAD disponible – 2º persona

Aspiración: RGE – estomago lleno

FASE DE ENTRADA

✔ SANGRADO

> 500 mls – Niños > 7 mls/kgr

Cirugía – Anestesiología

2 venas periféricas grandes

Líquidos – Sangre DISPONIBLES

• INDUCCIÓN ANESTÉSICA

FASE DE PAUSA

PRE-INCISIÓN QUIRÚRGICA – CONFIRMACIÓN

TODO EL EQUIPO QUIRÚRGICO

✔ INTEGRANTES

Identificación – Función – Capacidades

✔ PACIENTE Verbal

Nombre – Procedimiento – Sitio - Posición

✔ EVENTOS CRÍTICOS

Peligros críticos – Plan Quirúrgico

FASE DE PAUSAFASE DE PAUSA

✔ CIRUGIA

Pasos Modificados – Duración – SangradoSangrado severo – Lesiones – Morbilidad mayor

✔ ANESTESIA

Ptos sanguineos – Características - Comorbilidades

✔ ENFERMERIA

Esterilización OK – Problemas de equipo

FASE DE PAUSA

✔ PROFILAXIS ANTIBIÓTICA

< 60 minutos – Aplicación vs RedosificarProcedimientos NO aplicable

✔ IMAGENES

Perioperatorias

Necesarias pero NO disponible

No aplicable

• INCISIÓN QUIRÚRGICA

FASE DE SALIDA

PRE-SALIDA DEL QX – INFORMAR AL PERSONAL DE LA

UCPA

✔ PROCEDIMIENTO REALIZADO

✔ CONTEO DE INSTRUMENTAL, GASAS Y AGUJAS

Curaciones – Basura – Herida - imagenes

✔ MUESTRA DE PATOLOGÍA

Paciente – Nombre – Descripción - Marcas

FASE DE SALIDA

✔ INSTRUMENTOS - EQUIPOS

✔ UCPA TODO EL EQUIPO QUIRÚRGICO

Plan de manejo – Eventos de riesgo específicos

en recuperación

• INFORMACIÓN APROPIADA A TODO EL EQUIPO

• HISTORIA CLÍNICA

• EVALUACIÓN DE CALIDAD DEL SERVICIO

London, UK EURO EMRO

WPRO I

SEARO

AFRO

PAHO I

Amman, JordanToronto, Canada

New Delhi, India

Manila, Philippines

Ifakara, Tanzania

WPRO II

Auckland, NZ

PAHO II

Seattle, USA

The Checklist was piloted in 8 cities…

VENTAJAS

• Adaptable a las necesidades específicas

• Implementación incremental?• Soportado por evidencia científica• Evaluado en diferentes condiciones• Asegura adherencia a prácticas

seguras• Mínimo consumo de recursos

POR QUE?POR QUE?

• SALVAVIDASSALVAVIDAS• Previene COMPLICACIONESCOMPLICACIONES• Disminuye COSTOSCOSTOS médicos por el

error• Participación institucional la red de

SOPORTESOPORTE internacional de LA LISTA DE LA LISTA DE CHEQUEOCHEQUEO

• Reconocimiento institucional como LIDERLIDER en SEGURIDAD DEL PACIENTESEGURIDAD DEL PACIENTE

BIBLIOGRAFIARealizar el Paciente y la cirugía CORRECTOS

• American Academy of Orthopaedic Surgery. "AAOS Advisory Statement on Wrong-Site Surgery." Retrieved 25 January, 2008, from http://www.aaos.org/about/papers/advistmt/1015.asp.

• American College of Surgeons (2002). "Statement on ensuring correct patient, correct site, and correct procedure surgery." Bulletin of the American College of Surgeons 87(12).

• Australian Commission on Safety and Quality in Healthcare. "Ensuring Correct Patient, Correct Site, Correct Procedure." Retrieved 23 August, 2007, from http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/content/former-pubs-archive-correct.

BIBLIOGRAFIARealizar el Paciente y la cirugía CORRECTOS

• Joint Commission. "Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery." Retrieved 15 February, 2007, from http://www.jointcommission.org/PatientSafety/UniversalProtocol/.

• Kwaan, M. R., D. M. Studdert, et al. (2006). "Incidence, patterns, and prevention of wrong-site surgery." Arch Surg 141(4): 353-7; discussion 357-8.

• Joint Commission. "A follow-up review of wrong site surgery." Retrieved 3 May, 2007, from http://www.jointcommission.org/SentinelEvents/sentineleventalert/sea_24.htm

BIBLIOGRAFIAPrevenir los RIESGOS ANESTÉSICOS y evitar el DOLOR• Arbous, M. S., A. E. Meursing, et al. (2005). "Impact of

anesthesia management characteristics on severe morbidity and mortality." Anesthesiology 102: 257-68.

• Cooper, J. B., R. S. Newbower, et al. (1978). "Preventable anesthesia mishaps: a study of human factors." Anesthesiology 49(6): 399-406.

• Eichhorn, J. H., J. B. Cooper, et al. (1986). "Standards for patient monitoring during anesthesia at Harvard Medical School." Jama 256(8): 1017-20.

• Gaba, D. M., K. J. Fish, et al. (1994). Crisis Management in Anesthesiology. New York, Churchill Livingston.

• Hodges, S. C., C. Mijumbi, et al. (2007). "Anaesthesia services in developing countries: defining the problems." Anaesthesia 62(1): 4-11.

BIBLIOGRAFIAPrevenir los RIESGOS ANESTÉSICOS y evitar el DOLOR• International Task Force on Anaesthesia Safety (1993).

"International standards for a safe practice of anaesthesia." European Journal of Anaesthesiology 10 (Suppl. 7): 12-15.

• Runciman, W. B. (1993). "Risk assessment in the formulation of anaesthesia safety standards." European Journal of Anaesthesiology - Supplement 7: 26-32.

• Runciman, W. B. (2005). "Iatrogenic harm and anaesthesia in Australia." Anaesthesia & Intensive Care 33(3): 297-300.

• World Federation of Societies of Anaesthesiologists (WFSA). (Endorsed by the General Assembly of the WFSA at the 14th World Congress of Anaesthesiologists on 7 March 2008). "2008 International Standards for Safe Practice of Anaesthesia." Retrieved 26 May 2008, from http://www.anaesthesiologists.org

BIBLIOGRAFIAPrevenir y manejar los RIESGOS DE VÍA AÉREA: Difícil–

Aspiración

• (1993). "Practice Guidelines for Management of the Difficult Airway. A Report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway." Anesthesiology 78: 597-602.

• Cormack, R. S. and J. Lehane (1984). "Difficult tracheal intubation in obstetrics." Anaesthesia 39(11): 1105-11.

• Crosby, E. T., R. M. Cooper, et al. (1998). "The unanticipated difficult airway with recommendations for management." Can J Anaesth 45(8): 757-76.

• Mallampati, S., S. Gatt, et al. (1985). "A clinical sign to predict difficult tracheal intubation: a prospective study." Can Anaesth Soc J 32: 429-434.

BIBLIOGRAFIAPrevenir y manejar los RIESGOS DE VÍA AÉREA: Difícil–

Aspiración

• Murphy, M. and D. J. Doyle (2008). Airway evaluation. Management of the Difficult and Failed Airway. O. Hung and M. Murphy. New York, McGraw Hill: 3-15.

• Paix, A. D., J. A. Williamson, et al. (2005). "Crisis management during anaesthesia: difficult intubation." Qual Saf Health Care 14(3): e5.

• Samsoon, G. and J. Young (1987). "Difficult tracheal intubation: a retrospective study. ." Anaesthesia 42: 487-490.

• Shiga, T., Z. Wajima, et al. (2005). "Predicting difficult intubation in apparently normal patients: a meta-analysis of bedside screening test performance." Anesthesiology 103(2): 429-37.

BIBLIOGRAFIAReconocer y preparar el manejo de SANGRADO MAYOR• American College of Surgeons: Committee on Trauma

(1997). Advanced Trauma Life Support for Doctors. Chicago, ACS.

• Feliciano, D., K. Mattox, et al. (2008). Trauma. New York, McGraw Hill.

• Gaba, D. M., K. J. Fish, et al. (1994). Crisis Management in Anesthesiology. New York, Churchill Livingston.

• Rivers, E., B. Nguyen, et al. (2001). "Early goal-directed therapy in the treatment of severe sepsis and septic shock." N Engl J Med 345(19): 1368-77.

• Rotondo, M. F., C. W. Schwab, et al. (1993). "'Damage control': an approach for improved survival in exsanguinating penetrating abdominal injury." J Trauma 35(3): 375-82; discussion 382-3.

• Shires, T., D. Coln, et al. (1964). "Fluid Therapy in Hemorrhagic Shock." Arch Surg 88: 688-93.

BIBLIOGRAFIAEvitar REACCIONES ALERGÍCAS y EFECTOS

FARMACOLÓGICOS ADVERSOS

• Baker, G. R., P. G. Norton, et al. (2004). "The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada." CMAJ Canadian Medical Association Journal 170(11): 1678-86.

• Bowdle, T. A. (2003). "Drug administration errors from the ASA Closed Claims Project." ASA Newsletter 67: 11-3.

• Jensen, L. S., A. F. Merry, et al. (2004). "Evidence-based strategies for preventing drug administration errors during anaesthesia." Anaesthesia 59(5): 493-504.

• Webster, C. S., A. F. Merry, et al. (2001). "The frequency and nature of drug administration error during anaesthesia." Anaesth Intensive Care 29(5): 494-500.

BIBLIOGRAFIAMinimizar riesgo de INFECCIÓN DE HERIDA

QUIRÚRGICA• Astagneau, P., C. Rioux, et al. (2001). "Morbidity and

mortality associated with surgical site infections: results from the 1997-1999 INCISO surveillance." J Hosp Infect 48(4): 267-74.

• Bratzler, D. W. and P. M. Houck (2004). "Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project." Clin Infect Dis 38(12): 1706

• Bratzler, D. W., P. M. Houck, et al. (2005). "Use of antimicrobial prophylaxis for major surgery: baseline results from the national surgical infection prevention project." Arch Surg 140(2): 174-82.-15.


QUIRÚRGICA

• Classen, D. C., R. S. Evans, et al. (1992). "The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection." N Engl J Med 326(5): 281-6.

• Dellinger, E. (1997). Surgical infections and choice of antibiotics. Textbook of surgery: the biological basis of modern surgical practice. D. Sabiston. Philadelphia, W.B. Saunders: 264-280.

• Dellinger, E. (1999). Nosocomial infection. American College of Surgeons. Care of the surgical patient. D. Wilmore, M. Brennan, A. Harken, J. Holcroft and J. Meakins. New York, Scientific American.

• Dellinger, E. P. (2007). "Prophylactic antibiotics: administration and timing before operation are more important than administration after operation." Clin Infect Dis 44(7): 928-30.

BIBLIOGRAFIA

Minimizar riesgo de INFECCIÓN DE HERIDA QUIRÚRGICA

• Dellinger, E. P., P. A. Gross, et al. (1994). "Quality standard for antimicrobial prophylaxis in surgical procedures. The Infectious Diseases Society of America." Infect Control Hosp Epidemiol 15(3): 182-8.

• Dellinger, E. P., S. M. Hausmann, et al. (2005). "Hospitals collaborate to decrease surgical site infections." Am J Surg 190(1): 9-15.

• Fry, D. (2003) Surgical site infection: Pathogenesis and prevention. Medscape Volume, DOI:

• Fry, D. E. (1995). Surgical Infections. Boston, Little, Brown and Company.


QUIRÚRGICA• Garibaldi, R. A., D. Skolnick, et al. (1988). "The impact of

preoperative skin disinfection on preventing intraoperative wound contamination." Infect Control Hosp Epidemiol 9(3): 109-13.

• Gaynes, R. P. (1998). Surveillance of nosocomial infections. Hospital Infections. J. V. Bennett and P. S. Brachman. Philadelphia, Lippincott-Raven Publishers: 65-84.

• Horan, T. C., D. H. Culver, et al. (1993). "Nosocomial infections in surgical patients in the United States, January 1986-June 1992. National Nosocomial Infections Surveillance (NNIS) System." Infection Control and Hospital Epidemiology 14(2): 73-80.


QUIRÚRGICA• Horan, T. C., R. P. Gaynes, et al. (1992). "CDC

definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections." Am J Infect Control 20: 271-274.

• Kurz, A., D. I. Sessler, et al. (1996). "Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group [see comments]." N Engl J Med 334(19): P 1209-15.

• Moro, M. L., F. Morsillo, et al. (2005). "Rates of surgical-site infection: an international comparison." Infect Control Hosp Epidemiol 26(5): 442-8.


QUIRÚRGICA• Rioux, C., B. Grandbastien, et al. (2007). "Impact of a six-

year control programme on surgical site infections in France: results of the INCISO surveillance." J Hosp Infect 66(3): 217-23.

• Smaill, F. and G. J. Hofmeyr (2002). "Antibiotic prophylaxis for cesarean section." Cochrane Database Syst Rev(3): CD000933. Stone, H. H., B. B. Haney, et al. (1979). "Prophylactic and preventive antibiotic therapy: timing, duration and economics." Ann Surg 189: 691-699.

• Sullivan, S. A., T. Smith, et al. (2007). "Administration of cefazolin prior to skin incision is superior to cefazolin at cord clamping in preventing postcesarean infectious morbidity: a randomized, controlled trial." Am J Obstet Gynecol 196(5): 455 e1-5.

BIBLIOGRAFIAMinimizar riesgo de INFECCIÓN DE HERIDA QUIRÚRGICA

• Van den Berghe, G., P. Wouters, et al. (2001). "Intensive insulin therapy in the critically ill patients.[see comment]." New England Journal of Medicine 345(19): 1359-67.

• Washington, J. A., 2nd, W. H. Dearing, et al. (1974). "Effect of preoperative antibiotic regimen on development of infection after intestinal surgery: Prospective, randomized, double-blind study." Ann Surg 180(4): 567-72.

• Wilson, A. P., T. Treasure, et al. (1986). "A scoring method (ASEPSIS) for postoperative wound infections for use in clinical trials of antibiotic prophylaxis." Lancet 1(8476): 311-3.

BIBLIOGRAFIAPrevenir la RETENCIÓN inadvertida de GASAS –

INSTRUMENTOS

• American College of Surgeons. "American College of Surgeons: Statement on the Prevention of Retained Foreign Bodies after Surgery." Retrieved 5 February, 2008, from http://www.facs.org/fellows_info/statements/st-51.html.

• Australian College of Operating Room Nurses and Association of peri-Operative Registered Nurses (2006). Counting of Accountable Items used during Surgery. Standards for Perioperative Nurses. ACORN: 1-12.

• Gawande, A. A., D. M. Studdert, et al. (2003). "Risk factors for retained instruments and sponges after surgery." N Engl J Med 348(3): 229-35.

BIBLIOGRAFIAIdentificar adecuadamente TODAS LAS MUESTRAS DE

PATOLOGÍA

• Howanitz, P. J. (2005). "Errors in laboratory medicine: practical lessons to improve patient safety." Arch.Pathol.Lab Med. 129(10): 1252-1261.

• Makary, M. A., J. Epstein, et al. (2007). "Surgical specimen identification errors: a new measure of quality in surgical care." Surgery 141(4): 450-455.

• Troxel, D. B. (2004). "Error in surgical pathology." Am.J.Surg.Pathol. 28(8): 1092-1095.

• Wagar, E. A., L. Tamashiro, et al. (2006). "Patient safety in the clinical laboratory: a longitudinal analysis of specimen identification errors." Arch.Pathol.Lab Med. 130(11): 1662-1668.

BIBLIOGRAFIAComunicación adecuada para realizar una CIRUGÍA

SEGURA

• Greenberg, C. C., S. E. Regenbogen, et al. (2007). "Patterns of communication breakdowns resulting in injury to surgical patients." J Am Coll Surg 204(4): 533-40.

• Lingard, L., S. Espin, et al. (2005). "Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR." Qual.Saf Health Care 14(5): 340-346.

• Lingard, L., S. Espin, et al. (2004). "Communication failures in the operating room: an observational classification of recurrent types and effects." Qual.Saf Health Care 13(5): 330-334.

BIBLIOGRAFIAComunicación adecuada para realizar una

CIRUGÍA SEGURA

• Makary, M. A., C. G. Holzmueller, et al. (2006). "Operating room debriefings." Jt.Comm J.Qual.Patient.Saf 32(7): 407-10, 357.

• Makary, M. A., A. Mukherjee, et al. (2007). "Operating room briefings and wrong-site surgery." J.Am.Coll.Surg. 204(2): 236-243.

• Makary, M. A., J. B. Sexton, et al. (2006). "Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder." J.Am.Coll.Surg. 202(5): 746-752.


CIRUGÍA SEGURA

• Pronovost, P., D. Needham, et al. (2006). "An

intervention to decrease catheter-related

bloodstream infections in the ICU." N Engl J Med

355(26): 2725-32.• Reason, J. (1992). Human Error. Cambridge, Mass,

Cambridge University Press.• Reason, J. (1995). "Understanding adverse events:

human factors." Qual.Health Care 4(2): 80-89.• Reason, J. (2000). "Human error: models and

management." Bmj 320(7237): 768-70.


CIRUGÍA SEGURA

• Sexton, J. B., M. A. Makary, et al. (2006). "Teamwork

in the operating room: frontline perspectives among

hospitals and operating room personnel."

Anesthesiology 105(5): 877-884.

• Sexton, J. B., E. J. Thomas, et al. (2000). "Error,

stress, and teamwork in medicine and aviation: cross

sectional surveys." BMJ 320(7237): 745-749.


CIRUGÍA SEGURA

• Reason, J. (2002). "Combating omission errors

through task analysis and good reminders." Qual Saf

Health Care 11(1): 40-4.

• Thomas, E. J., J. B. Sexton, et al. (2003). "Discrepant

attitudes about teamwork among critical care nurses

and physicians." Crit Care Med. 31(3): 956-959.

BIBLIOGRAFIAEstablecer y difundir por las INSTITUCIONES y EL

SISTEMA DE SALUD INDICADORES DE GESTIÓN • Berwick, D. M. (1989). "Continuous improvement as

an ideal in health care." N Engl J Med 320(1): 53-6.• Berwick, D. M. (2003). "Disseminating innovations in

health care." Jama 289(15): 1969-75.• Berwick, D. M. (2008). "The science of improvement."

Jama 299(10): 1182-4.• Berwick, D. M., D. R. Calkins, et al. (2006). "The

100,000 lives campaign: setting a goal and a deadline for improving health care quality." Jama 295(3): 324-7.

• Burke, J. P. (2003). "Infection control - a problem for patient safety." N Engl J Med 348(7): 651-6.


SISTEMA DE SALUD INDICADORES DE GESTIÓN

• Donabedian, A. (1966). "Evaluating the Quality of Medical Care." Milbank Memorial Fund Quarterly 44:: 166—203.

• Donabedian, A. (1988). "The quality of care: how can it be assessed?" JAMA 260(12): 1743-1748.

• Gawande, A. A., M. R. Kwaan, et al. (2007). "An Apgar

score for surgery." J Am Coll Surg 204(2): 201-8.

• Health Metrics Network (2006). Framework and

standards for the development of country health

information systems, World Health Organisation.


SISTEMA DE SALUD INDICADORES DE GESTIÓN

• Regenbogen, S. E., R. T. Lancaster, et al. (2008). "Does the Surgical Apgar Score measure intraoperative performance?" Ann Surg (in press).

• Ronsmans, C. and W. J. Graham (2006). "Maternal mortality: who, when, where, and why." Lancet 368(9542): 1189-200.

• Weiser, T., S. Regenbogen, et al. "An estimation of

the global volume of surgery." (submitted).

Sadea Cirugía Segura

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