Checklists in Surgery


P (patients)

I (intervention)

C (comparator)

O (outcomes)

All adult patients undergoing colon resection

Use of checklists for quality improvement

Historical management systems without checklists

Mortality

Morbidity

Errors (wrong site, procedure, etc)

Cost

Efficiency

Attitudes and barriers





Results



Question 1:

Do surgical checklists reduce perioperative morbidity & mortality?

The WHO surgical safety checklist was implemented in 2008. In 2009, Haynes’ et al. published a landmark study which began a growing mountain of evidence to support the use of these checklists [2]. This study prospectively collected data on approximately 4000 patients from a diverse group of eight hospitals worldwide before and after implementation of the SSC. The authors demonstrated reductions in death (1.5–0.8 %, p = 0.003) and inpatient complications (11.0–7.0 %, p < 0.001) with checklist use. Many of the studies that followed have been prospective or retrospective observational studies to evaluate the results of SCC implementation in more specific clinical settings (Table 40.1).


Table 40.1
Question 1: Do surgical checklists reduce perioperative mortality & mortality?





































































































































































Author/year

Study design

n/type of procedure

Outcome measures

Conclusions

Quality of evidence

Gillespie et al. (2014) [4]

Meta-analysis

37,339/general

Major complications, mortality, minor complications

Use of a SSC reduces all complications, wound infections, blood loss. No significant reductions in mortality, pneumonia, or unplanned reoperation.

High

Kwok et al. (2013) [5]

Prospective cohort

2145/general

Process adherence, major 30 days complications, intraoperative hypoxemia

SSC implementation resulted in a decrease in overall, infectious, and noninfectious complications in a resource-limited setting

Moderate

Bliss et al. (2012) [6]

Prospective cohort

319/general

Checklist completion, 30 days morbidity, adverse events

Implementation of SSC results in reduction in adverse events from expected (NSQIP data) rates.

Moderate

Weiser et al. (2010) [7]

Prospective cohort

1750/general

30 day morbidities and mortality

SSC implementation reduces overall complication rate and mortality

Moderate

Haynes et al. (2009) [2]

Prospective cohort

7688/general

30 day morbidities and mortality

SSC implementation significantly reduced inpatient morbidity and mortality in a group of 8 international hospitals

Moderate

Haugen et al. (2015) [8]

Prospective cohort

2212/general

30 day morbidities and mortality

SSC implementation significantly reduced inpatient morbidity and mortality using a model to adjust for possible confounders

Moderate

Tillman et al. (2013) [9]

Prospective cohort

824/general

Compliance with SCIP Measures

Implementation of SSC improves compliance with SSI reduction strategies and may reduce SSI rates in colorectal procedures

Moderate

Askarian et al. (2011) [10]

Prospective cohort

294/general

Any complication

SSC implementation decreases perioperative complications in a small Iranian hospital

Moderate

Sewell et al. (2011) [3]

Prospective cohort

965/orthopedics

Any complication, mortality

SSC was not associated with a significant reduction in early complications and mortality in patients undergoing orthopaedic surgery

Moderate

Yuan et al. (2012) [11]

Prospective cohort

481/general

Any complication, mortality

SSC implementation is associated with variable improvements in surgical process compliance and surgical outcomes

Moderate

McCarroll et al. (2015) [12]

Retrospective cohort

89/laparoscopic/robotic

30 day readmission Length of stay Operative time

Decreased readmissions (13.5 % vs 4.1 %), no difference in LOS or OR time

Very low

Garcia-Paris et al. (2015) [13]

Retrospective cohort

134/podiatric

LOS, SSI, antibiotic use in podiatric surgery

Use of a SSC improves correct use of antibiotics, reduces SSI’s, and reduces LOS

Very low

Reames et al. (2015) [14]

Retrospective cohort

64,891/general

SSI, wound complications, all complications, 30 day mortality

Implementation of a checklist tool did not affect adverse outcomes, potentially due to failed implementation

Low

Loor et al. (2012) [15]

Retrospective cohort

5812/cardiac

Reoperation for bleeding

Implementation of SSC significantly reduces operations for rebleeding

Moderate

van Klei et al. (2012) [16]

Retrospective cohort

25,513/general

mortality

SSC implementation reduces in-hospital mortality, and effect is related to checklist compliance

Moderate

Kim et al. (2015) [17]

Retrospective cohort

637/general

Overall complications, hypoxemia, adherence to safety processes

SSC implementation at a resource-limited hospital improves communication, adherence to safety processes, and complications with no reduction in mortality. Improvements were greater after two years than after 6 months

Low

Dell’Atti et al. (2013) [18]

Retrospective cohort

324/urologic

All complications, intrahospital mortality

SSC implementation led to a reduction in overall complication rate and mortality

Very low

Haynes et al. (2015) [19]

Opinion

n/a/general

n/a

Checklists are effective if barriers to implementation are overcome

Very low

Garg et al. (2013) [20]

Opinion

n/a/general

n/a

Intraoperative crisis checklist is perceived to fascilitate response to massive hemorrhage

Very low

Ladak et al. (2014) [21]

Opinion

n/a/general

n/a

Perceived need for checklists to improve preoperative workup and planning

Very low

Panesar et al. (2009) [22]

Opinion

n/a/general

n/a

Adoption of SSC is effective and should be adopted throughout the UK

Very low

While no prospective randomized control studies have been (or likely will be) done, Gillespie et al. performed a robust meta-analysis including seven prospective cohort studies of 37,339 patients, concluding that SSC’s significantly reduce postoperative complications [4]. Van Klei et al. reported a significant reduction in mortality when checklists were fully completed [16]. Lastly, in an attempt to remove confounders, Haugen et al. described an elaborate protocol for SSC implementation, finding significant reductions in morbidity and length of stay [8]. Collectively, these studies indicate that implementation of surgical safety checklists likely improves post-operative outcomes including mortality rates.

However, the benefits above have not been demonstrated in all studies. Several investigators have suggested necessary conditions under which morbidity and mortality can be reduced. Surgical safety checklists are designed primarily to prevent deaths from perioperative errors, which are rare events. Therefore, the intervention of introducing checklists should be with the expectation of population-level benefits, and that a large cohort size will be required to demonstrate effectiveness. Second, some authors have demonstrated effectiveness by examining higher-risk populations (e.g., complicated procedures, unplanned procedures, colorectal operations, and procedures at limited-resource hospitals [3, 5, 9, 10, 12, 15, 17]) or by studying more common or impactful outcomes (e.g., re-operation, infection rates, length of stay [5, 9, 10, 1218]). Safety culture and attitudes may also play a role in checklists and patient outcome. Haynes et al. updated their original work with a survey of attitudes toward the SSC and found essentially a dose-response curve in which changes in outcomes were directly associated with team perceptions of successful checklist implementation [23]. Fidelity of checklist use and completion has been shown to have a direct correlation with reduction in morbidity [16]. Therefore, the evidence clearly indicates that checklists reduce morbidity and mortality effectively, as long as they are being used as intended.


Question 2:

Do surgical checklists have other costs or benefits?

In addition to preventing morbidity and mortality, other indirect measures of quality have been shown to improve with SSC use (Table 40.2). Standardized perioperative processes of care have been shown to improve outcomes. Performance measures including antibiotic timing, intraoperative hypothermia management, and hypoxemia have all been shown to improve with checklist implementation [5, 9, 17]. As a further indication of SSC success, implementation has improved perceptions of perioperative patient safety and communication among operative teams [17, 23].


Table 40.2
Question 2: Do surgical checklists offer other benefits?














































Author/year

Study design

n/type of procedure

Outcome measures

Conclusions

Quality of evidence

Tillman et al. (2013) [9]

Prospective cohort

824/general procedures

Compliance with SCIP measures

Implementation of SSC improves compliance with SSI reduction strategies and may reduce SSI rates in colorectal procedures

Moderate

Kim et al. (2015) [17]

Prospective cohort

637/general procedures

Overall complications, hypoxemia, adherence to safety processes

SSC implementation at a resource-limited hospital improves communication, adherence to safety processes, and complications with no reduction in mortality. Improvements were greater after 2 years than after 6 months

Low

Semel et al. (2010) [24]

Prospective cohort

n/a

Cost of SSC implementation

Theoretical hospital cost of SSC implementation is recovered if five major complications are prevented

Low

McCarroll et al. (2015) [12]

Meta-analysis

89/robotic/laparoscopic

30 day readmission Length of stay Operative time

Decreased readmissions (13.5 % vs 4.1 %), no difference in LOS or OR time

Very low

The vocal critics who oppose the conception of surgical safety checklists have expressed concerns and negative perceptions in the form of anecdotal evidence, surveys, and opinion papers. Some believe that use of a checklist in the operating room is ineffective, unnecessary, and reduces operating room efficiency [25]. Even though there are studies that have failed to demonstrate effectiveness, the concerns brought forth by these critics have not been objectively validated and in some cases directly refuted. Two cohort studies have shown no difference in operative times before and after SSC implementation [12, 26]. This seems intuitive since the checklist itself takes only a few minutes. Results from our institution indicate that SSC implementation did not affect first-start in room on time performance or same day cancellations [9]. Furthermore, the cost of SSC has been investigated. Semel et al. calculated a cost-savings of $103,829 per year assuming prevention of five major complications during 4000 non-cardiac operations [24]. Therefore, checklists have the added benefit of improving performance of standardized care, perception of patient safety, and communication among team members without adversely affecting operating room efficiency or cost.


Question 3:

Are there costs or barriers to use of surgical checklists?

From the inception of checklist utilization, barriers to their use have been present (Table 40.3). The most obvious of these is non-use or failure to complete the checklist [6, 27]. However, “checklist mentality” leads to misuse even after a high completion rate is achieved. Several investigators have audited checklists and team behavior, universally finding poor checklist fidelity [16, 37, 39]. This may be a direct result of checkbox fatigue where the process turns from one of patient safety and benefit to one of mundane automatic (or mindless) checking of a box.


Table 40.3
Question 3: Are there costs or barriers to use of surgical checklists?































Author/year

Study design

n/type of procedure

Outcome measures

Conclusions

Quality of evidence

Oak et al. (2015) [27]

Prospective case series

3000/general

Pediatric surgery: major errors, “near misses”, checklist compliance

0 major errors, 0.3 % near misses, high rate of incompletion or errors

Low

Biskup et al. (2015) [28]

Retrospective cohort

2166/plastics

30 days complications

Checklist does not reduce complication rates, likely due to checklist item applicability

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Jul 13, 2018 | Posted by in ABDOMINAL MEDICINE | Comments Off on Checklists in Surgery
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