Surgical Checklist

[geogil]

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I just saw a bit in the news about a study conducted by Atul Gawande and some others showing that a checklist used before operating reduced post surgical mortality by 40%. Any of you guys have any experience using something like this? Thoughts?

here's the abstract from NEJM:

A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population
Alex B. Haynes, M.D., M.P.H., Thomas G. Weiser, M.D., M.P.H., William R. Berry, M.D., M.P.H., Stuart R. Lipsitz, Sc.D., Abdel-Hadi S. Breizat, M.D., Ph.D., E. Patchen Dellinger, M.D., Teodoro Herbosa, M.D., Sudhir Joseph, M.S., Pascience L. Kibatala, M.D., Marie Carmela M. Lapitan, M.D., Alan F. Merry, M.B., Ch.B., F.A.N.Z.C.A., F.R.C.A., Krishna Moorthy, M.D., F.R.C.S., Richard K. Reznick, M.D., M.Ed., Bryce Taylor, M.D., Atul A. Gawande, M.D., M.P.H., for the Safe Surgery Saves Lives Study Group





More Information
- PubMed Citation
ABSTRACT

Background Surgery has become an integral part of global health care, with an estimated 234 million operations performed yearly. Surgical complications are common and often preventable. We hypothesized that a program to implement a 19-item surgical safety checklist designed to improve team communication and consistency of care would reduce complications and deaths associated with surgery.

Methods Between October 2007 and September 2008, eight hospitals in eight cities (Toronto, Canada; New Delhi, India; Amman, Jordan; Auckland, New Zealand; Manila, Philippines; Ifakara, Tanzania; London, England; and Seattle, WA) representing a variety of economic circumstances and diverse populations of patients participated in the World Health Organization's Safe Surgery Saves Lives program. We prospectively collected data on clinical processes and outcomes from 3733 consecutively enrolled patients 16 years of age or older who were undergoing noncardiac surgery. We subsequently collected data on 3955 consecutively enrolled patients after the introduction of the Surgical Safety Checklist. The primary end point was the rate of complications, including death, during hospitalization within the first 30 days after the operation.

Results The rate of death was 1.5% before the checklist was introduced and declined to 0.8% afterward (P=0.003). Inpatient complications occurred in 11.0% of patients at baseline and in 7.0% after introduction of the checklist (P<0.001).

Conclusions Implementation of the checklist was associated with concomitant reductions in the rates of death and complications among patients at least 16 years of age who were undergoing noncardiac surgery in a diverse group of hospitals.

 

[jwk]

Interesting study. Similar articles have been in the APSF Newsletter recently. However, I would hate to think our perioperative mortality rate is anywhere close to even the 0.008 rate they quoted as the "improved" rate. If we had that we'd be losing a patient each day.

It's also I interesting since I seem to remember reading that all the "time out" stuff has had a negligible effect on wrong side/site surgery.

 

[Bertelman]

We began using this at our institution a few months ago. I'm not sure it will decrease mortality at all. It will possibly decrease wrong-side surgery.

Things it will do:
1) Increase chart size- 2%
2) Increase snide remarks by surgeons- 150%
3) Increase bureaucratic inefficiency- 15%
4) Increase rules bypassed by half-assed efforts- 68%
5) Increase OR circulator tasks- 85%

 

[fakin' the funk]

There should be a checklist to make sure we complete all these checklists.

 

[geauxg8rs]

sounds like something good for a white coat nurse to add to her titles

Chief of OR Checklists (RN CORC)

 

[tranman]

I read this on the plane this morning; interesting study. In the discussion section it reads:

In addition, an evaluation of the American College of Surgeons' National Surgical Quality Improvement Program cohort in the United States during 2007 did not reveal a substantial change in the rate of death and complications (Ashley S. personal communication, http://acsnsqip.org).

It makes you think that the current safeguards and "checklists" are already adequate in the United States and that the rest of the world is catching up.

 

[pgg]

It's also I interesting since I seem to remember reading that all the "time out" stuff has had a negligible effect on wrong side/site surgery.

Color me absolutely shocked that deliberate dilution of responsibility for errors didn't have positive effects!

 

[Planktonmd]

Sometimes I wish Atul Gawande never had caused that pneumothorax while trying to place a central line as an Intern or at least he would stop trying to make us pay for his traumatic experience.
We get it, you feel guilty and the world is not perfect, can we move on??

 

[nutmegs]

I really found part of this study interesting - NOT the part about 8 million people participating in the time out, but the part before and after the surgery where the surgeon and anesthesiologist were "forced" to communicate about potential critical portions of the surgery, special concerns about the patient, and key points of the postoperative recovery. I for one think having this communication standardized (at least at the beginning) would be a really interesting exercise for both us and our surgical colleagues.

 

[proman]

We do this: It's called a Briefing, and time out is just a part of it. It really does improve communication for those operations where critical steps might get neglected (ie transplant, neurosurgery). We're also supposed to do a Debriefing at the end of a case to go over problems or issues that came up. Debriefing is less frequently done.

 

[Carmengia]

There's also always the problem of bias in non-blinded studies. Did they have better mortality rates due to the checklist or because they knew outcomes were being measured? I'd love to see a similar study in which the surgical team knows vs. doesn't know that outcomes are being measured. Actually this probably has been done.

 

[jwk]

Color me absolutely shocked that deliberate dilution of responsibility for errors didn't have positive effects!

👍👍👍

 

[Buckeye Anes]

sounds like something good for a white coat nurse to add to her titles

Chief of OR Checklists (RN CORC)

Awesome...just awesome

 

[doerun]

I read this on the plane this morning; interesting study. In the discussion section it reads:

In addition, an evaluation of the American College of Surgeons’ National Surgical Quality Improvement Program cohort in the United States during 2007 did not reveal a substantial change in the rate of death and complications (Ashley S. personal communication, http://acsnsqip.org).

It makes you think that the current safeguards and "checklists" are already adequate in the United States and that the rest of the world is catching up.

The statement that a checklist used before operating reduced post surgical mortality by 40% does not apply to U.S. hospitals but only seems to apply to third world hospitals.

 

[2ndyear]

This study sure made the news, and I did have a few patients ask if we used a checklist. Headlines proclaiming 50% reduction in morbidity😱 Of course we have the mandatory site and side marking, times outs before incision, and sponge and instrument counts. I'd venture a guess that 99% of US hospitals do. Media sensationalism at work. Not that it was a bad idea for a study, but I'm sure the results surprised the investigators a bit.

I think the 'critical portion of case' parts are interesting. Airline pilots do this, in cockpit briefs about takeoff rejection speeds, weather, and route. I just don't see all of our surgeons complying with this. For some major procedures, maybe. Like a redo heart a simple reminder that things may go south quickly, do we have blood available, can we crash onto bypass if we need to. Or a liver transplant, something like: we expect major bleeding with the MELD score being high, lets have the blood bank get extra FFP and cryo, we are not planning to use V-V bypass but the option is there if we need it, is it ready to go?