Cath Lab Checklists a Means to Prevent Errors and Anticipate Problems Before They Arise

Safety checklists work, experts said in a EuroPCR discussion, but few attendees there reported using them.

Cath Lab Checklists a Means to Prevent Errors and Anticipate Problems Before They Arise

PARIS, France—Focusing on the technical aspects of interventional cases is no doubt crucial, but so too is making sure that the entire team is prepared for the worst-case scenario. Cath lab professionals need to know what could happen and how each team member will individually respond to emergencies, experts asserted at a EuroPCR 2019 session dedicated to cath lab crises.

“It might seem a lot, but if you get it done systematically and everyone is doing every case, every day, it becomes second nature and it becomes part of your routine,” said Jaydeep Sarma, MD, PhD (Wythenshawe Hospital, Manchester, England).

“We go into every case thinking: what happens if there is a cardiac arrest in this case? Whether it's a routine diagnostic angiogram or a primary angioplasty, or a TAVI, it's about fielding your players and making sure each and every one feels comfortable doing the roles they are being asked to do,” Sarma urged. “If someone, for example, does not feel confident leading the arrest, I would never ask them to lead the arrest, but I might ask them to take notes, give adrenaline, or administer CPR under supervision.”

Speaking at EuroPCR, Sarma said safety checklists in cath labs have been widely embraced in the United Kingdom.

“We use them because the surgeons use them for general surgery and the cardiac surgeons are now using them, but also because research into minimizing error has shown that they work,” he said, adding that much of the validity of checklist systems has come from the civil aviation field and its attempts to improve airline safety.

Because mistakes most commonly stem from poor communication and lack of preparation, Sarma said cath lab checklists should be fairly simple, quick, and "bulletproof," even though they serve multiple purposes. In short, the goal should be to ensure that patient and staff are in agreement, necessary checks are carried out, there is a correct skill mix among the staff, correct equipment is available for the procedure, unforeseen circumstances are anticipated, and correct handover to recovery staff occurs.

At the outset of the session, Sarma emphasized to attendees that they could speak candidly without having to identify themselves or their institutions. "You're not going to breach any confidence. You don't have to name any names or your own name,” he said, encouraging those there to share their personal experiences.

Minimal Time, Big Payoff

Sarma and Martin Oberhoff, MD (Kreisklinikum Calw-Nagold, Calw, Germany), who moderated the session together, agreed that in most situations the 30 or 60 seconds needed to consult the checklist is not going to change the outcome for the worse. Not consulting it, on the other hand, could lead to error, injury, and even death.

You shouldn’t [ignore] other things that are your responsibility because you are doing the checklist, but it can help give you a framework for smooth, standardized working and [allow you] to eliminate any errors. Jaydeep Sarma

"That . . . relatively short period of time may be the difference between recognizing and understanding the story of an individual patient versus another patient," Sarma said. While the cath lab’s objective is always to get the patient on the table and open the artery, the checklist helps prepare the team by providing important details about the person in their care, such as allergies, medications, past medical history, last meal eaten, and details of any recent acute events and where they occurred (eg, “VF in ambulance”).  

"Even while you’re getting the patient on the table, we can still do a checklist. We might have a senior nurse, or a radiographer, or a consultant or trainee doctor just reading off a laminate that has their name, age, territory of infarction, events; basic stuff,” he explained. Once the checklist is read, Sarma said there should be an allocation of roles in whatever way makes sense for the workflow of the team.

"The checklist isn't something you should become obsessed with and you shouldn’t [ignore] other things that are your responsibility because you’re doing the checklist, but it can help give you a framework for smooth, standardized working and [allow you] to eliminate any errors," he added.

One nurse in the audience noted that she takes it upon herself to be proactive before procedures begin and make it clear to others in the room that consulting the checklist is a priority among her duties.

According to Sarma, the World Health Organization (WHO)'s surgical safety checklist has been an example of how a simple tool can effectively reduce morbidity and mortality. In one study of the surgical checklist’s use in over 3,700 patients at six hospitals, complications decreased overall, as did the number of complications per patient and the rate of in-hospital mortality.

“The WHO has clearly shown that checklists save human lives tremendously,” Oberhoff said. “It’s proven that [they] will make you work better.”

Creating a ‘Culture’ of Safety in the Lab

Despite the known benefits of checklists, when Oberhoff asked the audience of approximately 30 nurses and allied health professionals how many were currently using them in their cath labs, only two people raised their hands.

One of them, the “proactive” nurse, agreed with Sarma and Oberhoff that the only way to make checklists work consistently is to have the entire team actively engaged in precautionary thinking at all times. She described how cath lab teams at her hospital have mandatory preprocedural “safety huddles” for the entire room staff. Each member states their designated emergency role, so everyone knows what the others are doing. No individual staff member, regardless of their role, she added, is exempt from the safety huddle.

While the idea of safety checklists can be a challenge for those who do not adapt well to change or for hospitals with limited resources, the other audience member whose hospital uses these tools said sometimes it takes falling back into old habits for people to realize that lack of use can result in unnecessary errors and problems.

“Sometimes resistance comes from quite high up,” Sarma agreed. “Making sure that this becomes part of the culture in your lab oftentimes is just a process of keeping going and insisting [that it is] the only way we’re going to get this case done.”

You wouldn’t board a plane where the pilot [hadn’t] done his checklist. Martin Oberhoff

To TCTMD, Sarma said he was disappointed to see so few people in the session acknowledge the use of safety checklists, attributing it to outdated thinking where the focus is on getting patients "on the table and out the door."

"Checklists can be very difficult to integrate into the culture of an organization because people perceive them as a time delay, and that's not the case at all," he said.

During his presentation, Oberhoff noted that when safety is “sidelined” due to emphasis on speed and caseload, it can compromise medical care. Beyond that, it can leave operators and hospitals open to legal ramifications if something does go wrong.

“You wouldn’t board a plane where the pilot [hadn’t] done his checklist,” Oberhoff pointed out. “In areas where there is very high demand for safety, there is no question about using these [kinds of] tools.”

  • Oberhoff M, Sarma J. Crash course on cathlab emergencies: how to manage the patient, how to manage the relatives? Presented at: EuroPCR 2019. May 21, 2019. Paris, France.

  • Oberhoff and Sarma report no relevant conflicts of interest.