The surgical safety checklist and patient outcomes after surgery: a prospective observational cohort study, systematic review and meta-analysis

Safety of surgery: quality assessment of meta-analyses on the WHO checklist

Objectives

To assess the quality of the meta-analyses that review the WHO surgical safety checklist.

Methods

A systematic review of meta-analysis studies was undertaken using the search terms "World Health Organization Surgical Safety Checklist" in PubMed, Embase, and Lilacs databases. The selected meta-analyses were rated using the AMSTAR 2 assessment tool.

Results

In the three meta-analyses evaluated, the checklist was associated with a decrease in the rates of complications and mortality. Overall confidence in the results of the evaluated meta-analysis was critically low.

Conclusions

The meta-analysis coincides with obtaining lower complications and mortality rates with the WHO surgical safety checklist. However, the studies included in the meta-analyses were mostly observational, with potential biases, and according to the AMSTAR 2 tool, the overall confidence in the results of the evaluated studies was critically low.

A Process Evaluation of a Fall Prevention Intervention Using the RE-AIM Framework

BACKGROUND

Home hazard removal programs are effective in reducing falls among older adults, but delivery in the United States is limited.

OBJECTIVES

We completed a process evaluation of the Home Hazard Removal Program (HARP), an intervention delivered by occupational therapists.

METHODS

Using the RE-AIM framework (reach, effectiveness, adoption, implementation, maintenance), we examined outcomes using descriptive statistics and frequency distribution. We examined differences between covariates using Pearson correlation coefficients and two-sample t tests.

RESULTS

79.1% of eligible older adults participated (reach); they experienced a 38% reduction in fall rates (effectiveness). Ninety percent of recommended strategies were completed (adoption), 99% of intervention elements were delivered (implementation), and 91% of strategies were still used at 12 months (maintenance). Participants received an average of 258.6 minutes of occupational therapy. An average of US$765.83 was spent per participant to deliver the intervention.

CONCLUSIONS

HARP has good reach, effectiveness, adherence, implementation, and maintenance and is a low-cost intervention.

Psychological Safety and Hierarchy in Operating Room Debriefing: Reflexive Thematic Analysis

INTRODUCTION

Debriefing is a team discussion in a constructive, supportive environment. Barriers exist to consistent, effective team debriefing in the clinical setting, especially in operating theaters. The purpose of this study was to gain insights from frontline workers on how to set up an effective debriefing policy for our operating room.

METHODS

This was a qualitative study in which we interviewed operating room workers in a tertiary children's hospital. Interviews were audio-recorded, transcribed, and coded. Data were analysed using the reflexive thematic analysis technique within a critical realism paradigm.

RESULTS

Interviews were analysed from 40 operating room staff: 14 nurses, seven anesthetic technicians, seven anaesthetists, and 12 surgeons; 25 (65%) were female. The three key themes were (1) "commitment to learning"-healthcare workers are committed to teamwork and quality improvement; (2) "it is a safe space"-psychological safety is a prerequisite for, and is enhanced by, debriefing; and (3) "natural leader"-the value of leadership, but also constructs around leadership that maintain hierarchies.

CONCLUSIONS

Psychological safety is both a prerequisite for and a product of debriefing. Leadership, if viewed as a collective responsibility, could help break down power structures. Given the results of this study and evidence in the literature, it is likely that routine debriefing, if well done, will improve psychological safety, facilitate team learning, reduce errors, and improve patient safety.

Remote Assessment of Real-World Surgical Safety Checklist Performance Using the OR Black Box: A Multi-Institutional Evaluation

BACKGROUND

Large-scale evaluation of surgical safety checklist performance has been limited by the need for direct observation. The operating room (OR) Black Box is a multichannel surgical data capture platform that may allow for the holistic evaluation of checklist performance at scale.

STUDY DESIGN

In this retrospective cohort study, data from 7 North American academic medical centers using the OR Black Box were collected between August 2020 and January 2022. All cases captured during this period were analyzed. Measures of checklist compliance, team engagement, and quality of checklist content review were investigated.

RESULTS

Data from 7,243 surgical procedures were evaluated. A time-out was performed during most surgical procedures (98.4%, n = 7,127), whereas a debrief was performed during 62.3% (n = 4,510) of procedures. The mean percentage of OR staff who paused and participated during the time-out and debrief was 75.5% (SD 25.1%) and 54.6% (SD 36.4%), respectively. A team introduction (performed 42.6% of the time) was associated with more prompts completed (31.3% vs 18.7%, p < 0.001), a higher engagement score (0.90 vs 0.86, p < 0.001), and a higher percentage of team members who ceased other activities (80.3% vs 72%, p < 0.001) during the time-out.

CONCLUSIONS

Remote assessment using OR Black Box data provides useful insight into surgical safety checklist performance. Many items included in the time-out and debrief were not routinely discussed. Completion of a team introduction was associated with improved time-out performance. There is potential to use OR Black Box metrics to improve intraoperative process measures.

Barriers and facilitators associated with the implementation of surgical safety checklists: A qualitative systematic review

AIM

Despite the documented benefits of the World Health Organisation Patient Safety Checklist compliance rates with implementation continue to cause risk to patient safety. This qualitative systematic review aimed to explore the reported factors that impact compliance and implementation processes related to surgical safety checklists in perioperative settings.

DESIGN

A qualitative systematic review.

METHODS

A systematic review using the Joanna Briggs Institute (JBI) approach to synthesize qualitative studies was conducted and reported according to PRISMA guidelines. Electronic databases were expansively searched using keywords and subject headings. Articles were assessed using a pre-selected eligibility criterion. Data extraction and quality appraisal was undertaken for all included studies and a meta-aggregation performed.

DATA SOURCES

The CINAHL, Medline and Scopus databases were searched in August 2022 and the search was repeated in June 2023.

RESULTS

34 studies were included. Following the synthesis of the findings there were multiple interrelating barriers to checklist compliance that impacted implementation. There were more barriers than enablers reported in existing studies. Enablers included effective leadership, education and training, timely use of audit and feedback, local champions, and the option for local modifications to the surgical checklist. Further research should focus on targeted interventions that improve observed compliance rates to optimize patient safety.

CONCLUSION

This qualitative systematic review identified multiple key factors that influenced the uptake of the Surgical Safety Checklist in operating theatres.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Surgeon participation, hierarchical culture, complacency, and duplication of existing safety processes were identified which impacted the use and completion of the checklist.

Team Dynamics in the Operating Room: How Is Team Performance Optimized?

Health care requires the effort of a team, and nowhere is this more evident than in the care of the surgical patient. No single clinician can perform all aspects of the continuum of surgical care. The basic operating room (OR) team consists of nurses, technicians, surgeons, and anesthesiologists with unique and well-defined roles and expertise in perioperative care. The modern OR team continues to grow and evolve in size, diversity, and complexity to meet the needs of growing patient and procedural complexity. This growing complexity makes achieving optimal team performance paramount and challenging.

Facilitators and barriers to the implementation of surgical safety checklist: an integrative review

Surgical procedures pose an immense risk to patients, which can lead to various complications and adverse events. In order to safeguard patients' safety, the World Health Organization initiated the implementation of the Surgical Safety Checklist (SSC) in operating theatres worldwide. The aim of this integrative review was to summarize and evaluate the use and implementation of SSC, focusing on facilitators and barriers at the individual, professional, and organizational levels. This review followed closely the integrative review method by Whittemore and Knafl. An English literature search was conducted across three electronic databases (PubMed, CINAHL, and EMBASE) and other hand search references. Keywords search included: 'acute care', 'surgical', 'adult patients', 'pre-operative', 'intra-operative', and 'post-operative'. A total of 816 articles were screened by two reviewers independently and all articles that met the pre-specified inclusion criteria were retained. Data extracted from the articles were categorized, compared, and further analysed. A total of 34 articles were included with the majority being observational studies in developed and European countries. Checklists had been adopted in various surgical specialities. Findings indicated that safety checklists improved team cohesion and communication, resulting in enhanced patient safety. This resulted in high compliance rates as healthcare workers expressed the benefits of SSC to facilitate safety within operating theatres. Barriers included manpower limitations, hierarchical culture, lack of staff involvement and training, staff resistance, and appropriateness of checklist. Common facilitators and barriers at individual, professional, and organizational levels have been identified. Staff training and education, conducive workplace culture, timely audits, and appropriate checklist adaptations are crucial components for a successful implementation of the SSC. Methods have also been introduced to counter barriers of SSC.

Markers for Major Complications at Day-One Postoperative in Fast-Track Metabolic Surgery: Updated Metabolic Checklist

INTRODUCTION

In fast-track metabolic surgery, the window to identify complications is narrow. Postoperative checklists can be useful tools in the decision-making of safe early discharge. The aim of this study was to evaluate the predictive value of a checklist used in metabolic surgery.

METHODS

Retrospective data from June 2018 to January 2021 was collected on all patients that underwent metabolic surgery in a high-volume bariatric hospital in the Netherlands. Patients without an available checklist were excluded. The primary outcome was major complications and the secondary outcomes were minor complications, readmission, and unplanned hospital visits within 30 days postoperatively.

RESULTS

Major complications within 30 days postoperatively occurred in 62/1589 (3.9%) of the total included patients. An advise against early discharge was significantly more seen in patients with major complications compared to those without major complications (90.3% versus 48.1%, P < 0.001, respectively), and a negative checklist (advice for discharge) had a negative predictive value of 99.2%. The area under the curve for the total checklist was 0.80 (P < 0.001). Using a cut-off value of ≥3 positive points, the sensitivity and specificity were 65% and 82%, respectively. Individual parameters from the checklist: oral intake, mobilization, calf pain, willingness for discharge, heart rate, drain (>30 ml/24 h), hemoglobin, and leukocytes count were also significantly different between groups.

CONCLUSION

This checklist is a valuable tool to decide whether patients can be safely discharged early. Heart rate appeared to be the most predictive parameter for the development of major complications. Future studies should conduct prediction models to identify patients at risk for major complications.

Use of Technology to Improve the Adherence to Surgical Safety Checklists in the Operating Room

BACKGROUND

Although checklists can improve safety in the operating room (OR), compliance with their use is variable. Use of a forcing function, a principle of human factors engineering, has not been reported earlier as a method of increasing checklist use. The authors conducted this study to determine the feasibility and effects of introducing a forcing function on OR surgical safety checklist implementation and adherence.

METHODS

The authors developed and introduced the use of an electronic version of the surgical safety checklist on an Android application, provided on a personal device available in the OR. This application was linked by Bluetooth to electrocautery equipment, which could not be started before the electronic checklist was completed on the screen of the personal device. In the same OR, retrospective data from use of the traditional (paper-based) checklist were compared with data from the new electronic checklist for frequency of use, and completeness (percentage of all checklist items completed) at three stages of the surgical process-sign-in, time-out, and sign-out.

RESULTS

The frequency of use was 100.0% for the electronic checklist, compared with 97.9% for the traditional checklist. The frequency of completeness was 27.1% for the traditional vs. 100.0% for the electronic (p < 0.001).The manual checklist's sign-out component was completed only 37.0% of the time.

CONCLUSION

Although checklist use in some form was already high with the traditional checklist, completion rate was low and significantly increased with the use of the electronic checklist with a forcing function.

Trends in perioperative practices of high-risk surgical patients over a 10-year interval

INTRODUCTION

In Brazil, data show an important decrease in morbi-mortality of high-risk surgical patients over a 10-year high. The objective of this post-hoc study was to evaluate the mechanism explaining this trend in high-risk surgical patients admitted to Brazilian ICUs in two large Brazilian multicenter cohort studies performed 10 years apart.

METHODS

The patients included in the 2 cohorts studies published in 2008 and 2018 were compared after a (1:1) propensity score matching. Patients included were adults who underwent surgeries and admitted to the ICU afterwards.

RESULTS

After matching, 704 patients were analyzed. Compared to the 2018 cohort, 2008 cohort had more postoperative infections (OR 13.4; 95%CI 6.1-29.3) and cardiovascular complications (OR 1.5; 95%CI 1.0-2.2), as well as a lower survival ICU stay (HR = 2.39, 95% CI: 1.36-4.20) and hospital stay (HR = 1.64, 95% CI: 1.03-2.62). In addition, by verifying factors strongly associated with hospital mortality, it was found that the risk of death correlated with higher intraoperative fluid balance (OR = 1.03, 95% CI 1.01-1.06), higher creatinine (OR = 1.31, 95% CI 1.1-1.56), and intraoperative blood transfusion (OR = 2.32, 95% CI 1.35-4.0). By increasing the mean arterial pressure, according to the limits of sample values from 43 mmHg to 118 mmHg, the risk of death decreased (OR = 0.97, 95% CI 0.95-0.98). The 2008 cohort had higher fluid balance, postoperative creatinine, and volume of intraoperative blood transfused and lower mean blood pressure at ICU admission and temperature at the end of surgery.

CONCLUSION

In this sample of ICUs in Brazil, high-risk surgical patients still have a high rate of complications, but with improvement over a period of 10 years. There were changes in the management of these patients over time.

No signs of check-list fatigue - introducing the StOP? intra-operative briefing enhances the quality of an established pre-operative briefing in a pre-post intervention study

Background

The team timeout (TTO) is a safety checklist to be performed by the surgical team prior to incision. Exchange of critical information is, however, important not only before but also during an operation and members of surgical teams frequently feel insufficiently informed by the operating surgeon about the ongoing procedure. To improve the exchange of critical information during surgery, the StOP?-protocol was developed: At appropriate moments during the procedure, the leading surgeon briefly interrupts the operation and informs the team about the current Status (St) and next steps/objectives (O) of the operation, as well as possible Problems (P), and encourages questions of other team members (?). The StOP?-protocol draws attention to the team. Anticipating the occurrence of StOP?-protocols may support awareness of team processes and quality issues from the beginning and thus support other interventions such as the TTO; however, it also may signal an additional demand and contribute to a phenomenon akin to "checklist fatigue." We investigated if, and how, the introduction of the StOP?-protocol influenced TTO quality.

Methods

This was a prospective intervention study employing a pre-post design. In the visceral surgical departments of two university hospitals and one urban hospital the quality of 356 timeouts (out of 371 included operation) was assessed by external observers before (154) and after (202) the introduction of the StOP?-briefing. Timeout quality was rated in terms of timeout completeness (number of checklist items mentioned) and timeout quality (engagement, pace, social atmosphere, noise).

Results

As compared to the baseline, after the implementation of the StOP?-protocol, observed timeouts had higher completeness ratings (F = 8.69, p = 0.003) and were rated by observers as higher in engagement (F = 13.48, p < 0.001), less rushed (F = 14.85, p < 0.001), in a better social atmosphere (F = 5.83, p < 0.016) and less noisy (F = 5.35, p < 0.022).

Conclusion

Aspects of TTO are affected by the anticipation of StOP?-protocols. However, rather than harming the timeout goals by inducing "checklist fatigue," it increases completeness and quality of the team timeout.

The EUPEMEN (EUropean PErioperative MEdical Networking) Protocol for Bowel Obstruction: Recommendations for Perioperative Care

Mechanical bowel obstruction is a common symptom for admission to emergency services, diagnosed annually in more than 300,000 patients in the States, from whom 51% will undergo emergency laparotomy. This condition is associated with serious morbidity and mortality, but it also causes a high financial burden due to long hospital stay. The EUPEMEN project aims to incorporate the expertise and clinical experience of national clinical specialists into development of perioperative rehabilitation protocols. Providing special recommendations for all aspects of patient perioperative care and the participation of diverse specialists, the EUPEMEN protocol for bowel obstruction, as presented in the current paper, aims to provide faster postoperative recovery and reduce length of hospital stay, postoperative morbidity and mortality rate.

Surgical safety checklists in UK veterinary practice: Current implementation and attitudes towards their use

BACKGROUND

Surgical safety checklist (SSC) use benefits veterinary patients, but endorsement and implementation are essential for these benefits to be observed.

METHODS

A cross-sectional survey assessed UK veterinary professionals' attitudes towards and usage of SSCs and identified factors associated with poorer attitude or failure to use SSCs.

RESULTS

Of 513 respondents, 70% used SSCs. Of these, 87.1% used SSCs for every surgical procedure, 19.1% adapted SSCs for different procedures and 61.1% had a standard operating procedure detailing how to use SSCs. Attitudes towards SSC use were favourable, with increased positive attitude associated with employing at least one registered veterinary nurse with a post-qualifying qualification (p < 0.001), current SSC use (p < 0.001), undertaking self-directed reading (p = 0.033) or completing SSC-relevant post-qualification continuing professional development (p = 0.005). Factors associated with veterinary practices not using SSCs included Practice Standards Scheme (PSS) non-membership (odds ratio [OR] 2.0, 1.1-3.4), no RCVS hospital status (OR 1.9, 1.1-3.5) or being a mixed first-opinion veterinary practice (OR 2.4, 1.2-5.0).

LIMITATIONS

Study limitations include sampling methodology and non-validated attitudinal scale usage.

CONCLUSION

Most respondents used SSCs. Familiarity, education and the RCVS PSS were associated with improved uptake and attitudes, but mixed practice was associated with reduced usage.

Implementation Strategies for Preventing Healthcare-Associated Infections across the Surgical Pathway: An Italian Multisociety Document

Healthcare-associated infections (HAIs) result in significant patient morbidity and can prolong the duration of the hospital stay, causing high supplementary costs in addition to those already sustained due to the patient’s underlying disease. Moreover, bacteria are becoming increasingly resistant to antibiotics, making HAI prevention even more important nowadays. The public health consequences of antimicrobial resistance should be constrained by prevention and control actions, which must be a priority for all health systems of the world at all levels of care. As many HAIs are preventable, they may be considered an important indicator of the quality of patient care and represent an important patient safety issue in healthcare. To share implementation strategies for preventing HAIs in the surgical setting and in all healthcare facilities, an Italian multi-society document was published online in November 2022. This article represents an evidence-based summary of the document.

Difference in prioritization of patient safety interventions between experts and patient safety managers in Japan

Although a variety of patient safety interventions have been implemented, prioritizing them in a limited resource environment is important. The intervention priorities of patient safety managers may differ from those of patient safety experts. This study aimed to clarify the difference in prioritization of interventions between experts and safety managers to better identify interventions that should be promoted in Japan. We performed a secondary data analysis of two surveys: the Delphi survey for Japanese experts and a nationwide questionnaire survey for safety managers in hospitals. Regarding the 32 interventions constituting 14 organizational-level and 18 clinical-level interventions examined in the previous studies, we assessed three correlations to examine the difference in prioritization between experts and safety managers: correlations between experts and safety managers in the three perspectives (contribution, dissemination, and priority), those between priorities of experts and safety managers at the clinical and organizational level, and those among the three perspectives in experts and safety managers. Contribution (r = 0.768) and dissemination (r = 0.689) of patient safety interventions evaluated by experts and safety managers were positively correlated, but priorities were not. Interventions with priorities that differed between experts and safety managers were identified. In experts, there was no significant correlation between contribution and priority or between dissemination and priority. For safety managers, contributions (r = 0.812) and dissemination (r = 0.691) were positively correlated with priority. Our results suggest that patient safety managers evaluated future priority based on past contributions and current dissemination, whereas experts evaluated future priority based on other factors, such as expected impacts in the future, as mentioned in the previous study. In health policymaking, promotion of patient safety interventions that were given high priority by experts, but low priority by safety managers, should be considered with possible incentives.

Visual Blood, a 3D Animated Computer Model to Optimize the Interpretation of Blood Gas Analysis

Acid–base homeostasis is crucial for all physiological processes in the body and is evaluated using arterial blood gas (ABG) analysis. Screens or printouts of ABG results require the interpretation of many textual elements and numbers, which may delay intuitive comprehension. To optimise the presentation of the results for the specific strengths of human perception, we developed Visual Blood, an animated virtual model of ABG results. In this study, we compared its performance with a conventional result printout. Seventy physicians from three European university hospitals participated in a computer-based simulation study. Initially, after an educational video, we tested the participants’ ability to assign individual Visual Blood visualisations to their corresponding ABG parameters. As the primary outcome, we tested caregivers’ ability to correctly diagnose simulated clinical ABG scenarios with Visual Blood or conventional ABG printouts. For user feedback, participants rated their agreement with statements at the end of the study. Physicians correctly assigned 90% of the individual Visual Blood visualisations. Regarding the primary outcome, the participants made the correct diagnosis 86% of the time when using Visual Blood, compared to 68% when using the conventional ABG printout. A mixed logistic regression model showed an odds ratio for correct diagnosis of 3.4 (95%CI 2.00–5.79, p < 0.001) and an odds ratio for perceived diagnostic confidence of 1.88 (95%CI 1.67–2.11, p < 0.001) in favour of Visual Blood. A linear mixed model showed a coefficient for perceived workload of −3.2 (95%CI −3.77 to −2.64) in favour of Visual Blood. Fifty-one of seventy (73%) participants agreed or strongly agreed that Visual Blood was easy to use, and fifty-five of seventy (79%) agreed that it was fun to use. In conclusion, Visual Blood improved physicians’ ability to diagnose ABG results. It also increased perceived diagnostic confidence and reduced perceived workload. This study adds to the growing body of research showing that decision-support tools developed around human cognitive abilities can streamline caregivers’ decision-making and may improve patient care.

Surgical provider-reported reasons for utilization of the World Health Organization's Surgical Safety Checklist at a tertiary hospital in Ghana

Despite the established positive benefits, LMICs' adoption of the WHO Surgical Safety Checklist (SSC) is inadequate, with as little as 20% use. This study assessed the utilization and beliefs that drive the non-utilization of the WHO SSC among surgical providers at Korle Bu Teaching Hospital (KBTH) in Accra, Ghana. A cross-sectional study was conducted among 186 surgical providers at the KBTH in Ghana. Data collected included the category of personnel, awareness of the SSC, training received, previously identified barriers, and staff perceptions. Utilization and drivers associated with non-utilization of the SSC were assessed using bivariate log-binomial regression. Out of 190 surgical professionals invited, 186 gave their consent and participated in the survey, giving a response rate of 97.9%. Respondents comprised 69 (37%) surgeons, 66 (36%) anesthetists, and 51 (27%) nurses. Only 30.4% of surgical professionals always use the SSC, as advised by WHO. The majority (67.7%) of surgical professionals had received no formal training on using the WHO SSC. The proportion was highest among surgeons (81.2%) compared to anesthetists (66.7%) and nurses (51%). Surgeons were perceived by other professionals to be the least supportive of checklist use (87.6%), in contrast to nurses (96.1%) and anesthetists (93.9%). Significant drivers associated with checklist usage among surgical professionals included the SSC taking too long to complete, poor communication between anesthetist and surgeon, checklist not covering all perioperative risks, difficulty finding a coordinator, poor attitude of team members toward questions, surgical specialty/unit and training status of professionals. The checklist was always used by only a small (30%) proportion of surgical professionals at the KBTH. Improving checklist use will necessitate its careful application to all surgical operations and a cycle of periodic training that includes context-specific adjustments, checklist auditing, and feedback from local coordinators.

Nurses' Priorities for Perioperative Research in Africa

BACKGROUND

Mortality rates among surgical patients in Africa are double those of surgical patients in high-income countries. Internationally, there is a call to improve access to and safety of surgical and perioperative care. Perioperative research needs to be coordinated across Africa to positively impact perioperative mortality.

METHODS

The aim of this study was to determine the top 10 perioperative research priorities for perioperative nurses in Africa, using a research priority-setting process. A Delphi technique with 4 rounds was used to establish consensus on the top 10 perioperative research priorities. In the first round, respondents submitted research priorities. Similar research priorities were amalgamated into single priorities when possible. In round 2, respondents ranked the priorities using a scale from 1 to 10 (of which 1 is the first/highest priority, and 10 is the last/lowest priority). The top 20 (of 31) were determined after round 2. In round 3, respondents ranked their top 10 priorities. The final round was an online discussion to reach consensus on the top 10 perioperative research priorities.

RESULTS

A total of 17 perioperative nurses representing 12 African countries determined the top research priorities, which were: (1) strategies to translate and implement perioperative research into clinical practice in Africa, (2) creating a perioperative research culture and the tools, resources, and funding needed to conduct perioperative nursing research in Africa, (3) optimizing nurse-led postoperative pain management, (4) survey of operating theater and critical care resources, (5) perception of, and adherence to sterile field and aseptic techniques among surgeons in Africa (6) surgical staff burnout, (7) broad principles of infection control in surgical wards, (8) the role of interprofessional communication to promote clinical teamwork when caring for surgical patients, (9) effective implementation of the surgical safety checklist and measures of its impact, and (10) constituents of quality nursing care.

CONCLUSIONS

These research priorities provide the structure for an intermediate-term research agenda for perioperative research in Africa.

Extension of patient safety initiatives to perioperative care

PURPOSE OF REVIEW

Patient safety has significantly improved during the intraoperative period thanks to the anesthesiologists, surgeons, and nurses. Nowadays, it is within the perioperative period where most of the preventable harm happened to the surgical patient. We aim to highlight the main issues and efforts to improve perioperative patient safety focusing and the relation to intraoperative safety strategies.

RECENT FINDINGS

There is ongoing research on perioperative safety strategies aiming to initiate multidisciplinary interventions on early stages of the perioperative period as well as an increasing focus on preventing harm from postoperative complications.

SUMMARY

Any patient safety strategy to be implemented needs to be framed beyond the operating room and include in the intervention the whole perioperative period.

Lariboisiere Hospital pre-operative surgical checklist to improve safety during transpetrosal approaches

BACKGROUND

Transpetrosal approaches are technically complex and require a complete understanding of surgical and radiological anatomy. A careful evaluation of pre-operative magnetic resonance imaging and computed tomography scan is mandatory, because anatomical or pathological variations are common and may increase the risk of complications related with the approach.

METHODS

Pre-operative characteristics of venous and petrous bone anatomy were analysed and correlated with intraoperative findings, using injected magnetic resonance imaging and thin-slices computed tomography scan. These data regularly checked before each transpetrosal approach were progressively included in the presented checklist.

RESULTS

Transpetrosal approaches have been used in 101 patients. Items included in the checklist were petrous bone pneumatization, angle between petrous apex and clivus, dehiscence of petrous carotid artery, dehiscence of geniculate ganglion, distance between superior semicircular canal and middle fossa floor, distance between cochlea and middle fossa floor, sigmoid sinus dominance, transverse sigmoid sinus junction depth to the outer cortical bone, jugular bulb height (high or low), location of the vein of Labbé, characteristics of superior petrosal vein complex.

CONCLUSION

The presented checklist provides a systematic scheme of consultation of characteristic of venous and petrous bone anatomy for transpetrosal approaches. In our experience, the use of this checklist reduces the risk of complications related with approach, by minimizing the neglect of crucial information.

Surgical safety checklists for dental implant surgeries-a scoping review

OBJECTIVES

In both elective surgeries and aviation, a reduction of complications can be expected by paying attention to the so-called human factors. Checklists are a well-known way to overcome some of these problems. We aimed to evaluate the current evidence regarding the use of checklists in implant dentistry.

METHODS

An electronic literature search was conducted in the following databases: CINHAL, Medline, Web of Science, and Cochrane Library until March 2022. Based on the results and additional literature, a preliminary checklist for surgical implant therapy was designed.

RESULTS

Three publications dealing with dental implants and checklists were identified. One dealt with the use of a checklist in implant dentistry and was described as a quality assessment study. The remaining two studies offered suggestions for checklists based on literature research and expert opinion.

CONCLUSIONS

Based on our results, the evidence for the use of checklists in dental implantology is extremely low. Considering the great potential, it can be stated that there is a need to catch up. While creating a new implant checklist, we took care of meeting the criteria for high-quality checklists. Future controlled studies will help to place it on a broad foundation.

CLINICAL RELEVANCE

Checklists are a well-known way to prevent complications. They are especially established in aviation, but many surgical specialties and anesthesia adopt this successful concept. As implantology has become one of the fastest-growing areas of dentistry, it is imperative that checklists become an integral part of it.

Effective communication and patient safety among nurses in perioperative settings: a best practice implementation project

OBJECTIVES

The aim of this implementation project was to promote evidence-based best practice regarding effective communication and patient safety amongst nurses in perioperative settings.

INTRODUCTION

One of the main causes of surgical errors is inadequate communication. To address this issue, published research has shown that effective communication among healthcare professionals (HCPs) within and between all phases of perioperative care, as well as the proper transfer of all patient information at all transition points, are essential for ensuring patient safety and quality of care.

METHODS

This best practice implementation project was conducted based on the JBI implementation model and included three phases of activity: a baseline audit, a strategies implementation stage and a follow-up audit. The audit criteria used were based on a JBI evidence summary and referred to: education, interdisciplinary team, conflict resolution, team communication, transfer of patient information and safety intraoperative processes. The project was carried out in the perioperative environment of a university hospital, and the sample included 52 nurses.

RESULTS

Eleven audit criteria were used in the baseline audit. For four of these criteria (on education and information transfer) the compliance was zero, for five criteria (on intraoperative processes) the compliance had values between 31 and 66% and for two criteria (on interdisciplinary team/conflict resolution documentation and team communication monitoring), the identified compliance was maximum (100%). Following the identification of four barriers to compliance and the implementation of targeted strategies, the follow-up audit showed complete compliance (100%) for all criteria except three, for which the identified compliance values were 96, 95 and 25%.

CONCLUSION

The implementation of appropriate strategies in this project has led to a significant improvement in nurses' compliance with all audit criteria except one, regarding the verbal transfer of patient information. However, future audits and strategies are needed not only to support the improvements obtained but also to significantly increase the compliance rate for the audit criterion for which only a slight increase in compliance was recorded.

Barriers and enablers to utilisation of the WHO surgical safety checklist at the university teaching hospital in Lusaka, Zambia: a qualitative study

Background

Surgical perioperative deaths and major complications are important contributors to preventable morbidity, globally and in sub-Saharan Africa. The surgical safety checklist (SSC) was developed by WHO to reduce surgical deaths and complications, by utilising a team approach and a series of steps to ensure the safe transit of a patient through the surgical operation. This study explored barriers and enablers to the utilisation of the Checklist at the University Teaching Hospital (UTH) in Lusaka, Zambia.

Methods

A qualitative case study was conducted involving members of surgical teams (doctors, anaesthesia providers, nurses and support staff) from the UTH surgical departments. Purposive sampling was used and 16 in-depth interviews were conducted between December 2018 and March 2019. Data were transcribed, organised and analysed using thematic analysis.

Results

Analysis revealed variability in implementation of the SSC by surgical teams, which stemmed from lack of senior surgeon ownership of the initiative, when the SSC was introduced at UTH 5 years earlier. Low utilisation was also linked to factors such as: negative attitudes towards it, the hierarchical structure of surgical teams, lack of support for the SSC among senior surgeons and poor teamwork. Further determinants included: lack of training opportunities, lack of leadership and erratic availability of resources. Interviewees proposed the following strategies for improving SSC utilisation: periodic training, refresher courses, monitoring of use, local adaptation, mobilising the support of senior surgeons and improvement in functionality of the surgical teams.

Conclusion

The SSC has the potential to benefit patients; however, its utilisation at the UTH has been patchy, at best. Its full benefits will only be achieved if senior surgeons are committed and managers allocate resources to its implementation. The study points more broadly to the factors that influence or obstruct the introduction and effective implementation of new quality of care initiatives.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08257-y.

A Quality Improvement Initiative Using Peer Audit and Feedback to Improve Compliance with the Surgical Safety Checklist

Background

The Surgical Safety Checklist (SSC) published by the WHO in 2009 is used as standard in surgery worldwide to reduce perioperative patient mortality. However, compliance with the SSC and quality of its application are often not satisfactory. Internal audits and feedbacks seem promising for improving SSC application.

Objective

The purpose of this study is to investigate whether an intervention consisting of peer observation and immediate peer feedback can be implemented with high fidelity and acceptance.

Method

Data were obtained from a national pilot programme that was initiated in Switzerland in 2018 to measure and improve compliance with the SSC using peer audit and feedback. A total of 11 hospitals with 14 sites implemented the full intervention. Each hospital formed an interprofessional project team that should perform at least 30 observations with feedback on SSC application documented in an observation tool developed specifically for this programme. Since the SSCs of the study hospitals differ greatly regarding checklist items, for each of the three SSC sections standard items were defined: four at Sign In, five at Team Time Out and two at Sign Out. Frequency analyses were performed for initiation characteristics, SSC application at item level, feedback characteristics and programme evaluation.

Results

The 11 hospitals documented 715 valid observations, and feedback on SSC application was provided for 79% of the observations. In 61%, all team members stopped their work for the SSC application, and in 71%, the items were read off from the checklist (instead of recalled from memory). On average, 86% of the standard items were read out by the checklist coordinator, whilst the two items at Sign Out were read out only in 60% and 74%. Additional visual checks with another source (e.g. patient wristband) took place in only 41%, and verbal confirmation of the items (by someone else other than the checklist coordinator) was obtained on an average of 76% across all three checklist sections. The surgical teams reacted positively in 64% to the peer feedback.

Conclusion

Both implementation fidelity and acceptability of the intervention were high—the present intervention seems suitable for regular monitoring of the quality of SSC application with internal resources. Peer observation facilitated identifying weaknesses regarding the SSC process and application at item level. Across all hospitals, the Sign Out section in general, visual control for item checks and lack of work interruption of all team members during SSC application showed up as the main areas of improvement.

Surgical team perceptions of the surgical safety checklist in a tertiary hospital in Jordan: a descriptive qualitative study

Purpose

The purpose of this paper is to explore the perceptions of operating room staff towards the use of the World Health Organization Surgical Safety Checklist in a tertiary hospital in Jordan.

Design/methodology/approach

This was a qualitative descriptive study. Semi-structured interviews were conducted with a purposeful sample of 21 healthcare staff employed in the operating room (nurses, residents, surgeons and anaesthesiologists). The interviews were conducted in the period from October to December 2021. Thematic analysis was used to analyse the data.

Findings

Three main themes emerged from data analysis namely compliance with the surgical safety checklist, the impact of surgical safety checklist, and barriers and facilitators to the use of the surgical safety checklist. The use of the checklist was seen as enabling staff to communicate effectively and thus to accomplish patient safety and positive outcomes. The perceived barriers to compliance included excessive workload, congestion and lack of training and awareness. Enhanced training and education were thought to improve the utilization of the surgical safety checklist, and help enhance awareness about its importance.

Originality/value

While steps to utilize the surgical safety checklist by the operation room personnel may seem simple, the quality of its administration is not necessarily robust. There are several challenges for consistent, complete and effective administration of the surgical safety checklist by the surgical team members. Healthcare managers must employ interventions to eliminate barriers to and offer facilitators of adherence to the application of the surgical safety checklist, therefore promoting quality healthcare and patient safety.

Role of regional anesthesia and analgesia in enhanced recovery after colorectal surgery: a systematic review of randomized controlled trials

BACKGROUND

Effective analgesia is an important element of enhanced recovery after surgery (ERAS), but the clinical impact of regional anesthesia and analgesia for colorectal surgery remains unclear.

OBJECTIVE

We aimed to determine the impact of regional anesthesia following colorectal surgery in the setting of ERAS.

EVIDENCE REVIEW

We performed a systematic review of nine databases up to June 2020, seeking randomized controlled trials comparing regional anesthesia versus control in an ERAS pathway for colorectal surgery. We analyzed the studies with successful ERAS implementation, defined as ERAS protocols with a hospital length of stay of ≤5 days. Data were qualitatively synthesized. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool.

FINDINGS

Of the 29 studies reporting ERAS pathways, only 13 comprising 1170 patients were included, with modest methodological quality and poor reporting of adherence to ERAS pathways. Epidural analgesia had limited evidence of outcome benefits in open surgery, while spinal analgesia with intrathecal opioids may potentially be associated with improved outcomes with no impact on length of stay in laparoscopic surgery, though dosing must be further investigated. There was limited evidence for fascial plane blocks or other regional anesthetic techniques.

CONCLUSIONS

Although there was variable methodological quality and reporting of ERAS, we found little evidence demonstrating the clinical benefits of regional anesthetic techniques in the setting of successful ERAS implementation, and future studies must report adherence to ERAS in order for their interventions to be generalizable to modern clinical practice.

PROSPERO REGISTRATION NUMBER

CRD42020161200.

Improving emergency treatment for patients with acute stroke: the PEARS research programme, including the PASTA cluster RCT

Background

Intravenous thrombolysis and intra-arterial thrombectomy are proven emergency treatments for acute ischaemic stroke, but they require rapid delivery to selected patients within specialist services. National audit data have shown that treatment provision is suboptimal.

Objectives

The aims were to (1) determine the content, clinical effectiveness and day 90 cost-effectiveness of an enhanced paramedic assessment designed to facilitate thrombolysis delivery in hospital and (2) model thrombectomy service configuration options with optimal activity and cost-effectiveness informed by expert and public views.

Design

A mixed-methods approach was employed between 2014 and 2019. Systematic reviews examined enhanced paramedic roles and thrombectomy effectiveness. Professional and service user groups developed a thrombolysis-focused Paramedic Acute Stroke Treatment Assessment, which was evaluated in a pragmatic multicentre cluster randomised controlled trial and parallel process evaluation. Clinicians, patients, carers and the public were surveyed regarding thrombectomy service configuration. A decision tree was constructed from published data to estimate thrombectomy eligibility of the UK stroke population. A matching discrete-event simulation predicted patient benefits and financial consequences from increasing the number of centres.

Setting

The paramedic assessment trial was hosted by three regional ambulance services (in north-east England, north-west England and Wales) serving 15 hospitals.

Participants

A total of 103 health-care representatives and 20 public representatives assisted in the development of the paramedic assessment. The trial enrolled 1214 stroke patients within 4 hours of symptom onset. Thrombectomy service provision was informed by a Delphi exercise with 64 stroke specialists and neuroradiologists, and surveys of 147 patients and 105 public respondents.

Interventions

The paramedic assessment comprised additional pre-hospital information collection, structured hospital handover, practical assistance up to 15 minutes post handover, a pre-departure care checklist and clinician feedback.

Main outcome measures

The primary outcome was the proportion of patients receiving thrombolysis. Secondary outcomes included day 90 health (poor status was a modified Rankin Scale score of > 2). Economic outputs reported the number of cases treated and cost-effectiveness using quality-adjusted life-years and Great British pounds.

Data sources

National registry data from the Sentinel Stroke National Audit Programme and the Scottish Stroke Care Audit were used.

Review methods

Systematic searches of electronic bibliographies were used to identify relevant literature. Study inclusion and data extraction processes were described using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Results

The paramedic assessment trial found a clinically important but statistically non-significant reduction in thrombolysis among intervention patients, compared with standard care patients [197/500 (39.4%) vs. 319/714 (44.7%), respectively] (adjusted odds ratio 0.81, 95% confidence interval 0.61 to 1.08; p = 0.15). The rate of poor health outcomes was not significantly different, but was lower in the intervention group than in the standard care group [313/489 (64.0%) vs. 461/690 (66.8%), respectively] (adjusted odds ratio 0.86, 95% confidence interval 0.60 to 1.2; p = 0.39). There was no difference in the quality-adjusted life-years gained between the groups (0.005, 95% confidence interval –0.004 to 0.015), but total costs were significantly lower for patients in the intervention group than for those in the standard care group (–£1086, 95% confidence interval –£2236 to –£13). It has been estimated that, in the UK, 10,140–11,530 patients per year (i.e. 12% of stroke admissions) are eligible for thrombectomy. Meta-analysis of published data confirmed that thrombectomy-treated patients were significantly more likely to be functionally independent than patients receiving standard care (odds ratio 2.39, 95% confidence interval 1.88 to 3.04; n = 1841). Expert consensus and most public survey respondents favoured selective secondary transfer for accessing thrombectomy at regional neuroscience centres. The discrete-event simulation model suggested that six new English centres might generate 190 quality-adjusted life-years (95% confidence interval –6 to 399 quality-adjusted life-years) and a saving of £1,864,000 per year (95% confidence interval –£1,204,000 to £5,017,000 saving per year). The total mean thrombectomy cost up to 72 hours was £12,440, mostly attributable to the consumables. There was no significant cost difference between direct admission and secondary transfer (mean difference –£368, 95% confidence interval –£1016 to £279; p = 0.26).

Limitations

Evidence for paramedic assessment fidelity was limited and group allocation could not be masked. Thrombectomy surveys represented respondent views only. Simulation models assumed that populations were consistent with published meta-analyses, included limited parameters reflecting underlying data sets and did not consider the capital costs of setting up new services.

Conclusions

Paramedic assessment did not increase the proportion of patients receiving thrombolysis, but outcomes were consistent with improved cost-effectiveness at day 90, possibly reflecting better informed treatment decisions and/or adherence to clinical guidelines. However, the health difference was non-significant, small and short term. Approximately 12% of stroke patients are suitable for thrombectomy and widespread provision is likely to generate health and resource gains. Clinician and public views support secondary transfer to access treatment.

Future work

Further evaluation of emergency care pathways will determine whether or not enhanced paramedic assessment improves hospital guideline compliance. Validation of the simulation model post reconfiguration will improve precision and describe wider resource implications.

Trial registration

This trial is registered as ISRCTN12418919 and the systematic review protocols are registered as PROSPERO CRD42014010785 and PROSPERO CRD42015016649.

Funding

The project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 4. See the NIHR Journals Library website for further project information.

Perceptions from nurses, surgeons, and anesthetists about the use and benefits of the surgical checklist in a teaching hospital

OBJECTIVE

To assess attitudes and perceptions from nursing staff, surgeons and anesthetists about compliance, utility, and impact on patient's safety of the surgical checklist in a teaching hospital. We also aimed to identify improvement opportunities for strengthening the usefulness of the checklist in the operating theater.

METHODS

We carried out a questionnaire-based an observational cross-sectional study. A questionnaire was distributed to operating room staff, including nursing staff, surgeons, and anesthetists. In addition to the information about surgical checklist, We also collected information regarding years of experience in the operating theater. Fisher's exact was used to compare proportions in each statement. Group discussion meetings with key professionals were held to jointly assess the results, propose improvement actions, and evaluate their feasibility.

RESULTS

The overall response rate was 36.2% (131/362). Nursing staff was perceived as the most supportive group in the use of surgical checklist. A 64.3% of surgeons considered that using the checklist prevented adverse events vs 84.2% and 85.7% among anesthetists and nurses, respectively; p=0.028. Junior staff showed a supportive attitude toward the use of surgical checklist, considering it as a tool that gives them confidence. We ended up with a list of improvement actions aiming at strengthening the surgical checklist reliability and compliance.

CONCLUSIONS

The perception of the surgical checklist usefulness as a tool to prevent adverse events was moderate among surgeons, but well appreciated by junior staff. Nursing staff were especially critical regarding compliance and support by other professionals. To reinforce the usefulness perception of the surgical checklist it is needed to increase the involvement of all professionals, especially senior staff and surgical leaders.

Reducing surgical site infections and mortality among obstetric surgical patients in Tanzania: a pre-evaluation and postevaluation of a multicomponent safe surgery intervention

INTRODUCTION

Despite ongoing maternal health interventions, maternal deaths in Tanzania remain high. One of the main causes of maternal mortality includes postoperative infections. Surgical site infection (SSI) rates are higher in low/middle-income countries (LMICs), such as Tanzania, compared with high-income countries. We evaluated the impact of a multicomponent safe surgery intervention in Tanzania, hypothesising it would (1) increase adherence to safety practices, such as the WHO Surgical Safety Checklist (SSC), (2) reduce SSI rates following caesarean section (CS) and (3) reduce CS-related perioperative mortality rates (POMRs).

METHODS

We conducted a pre-cross-sectional/post-cross-sectional study design to evaluate WHO SSC utilisation, SSI rates and CS-related POMR before and 18 months after implementation. Our interventions included training of inter-professional surgical teams, promoting use of the WHO SSC and introducing an infection prevention (IP) bundle for all CS patients. We assessed use of WHO SSC and SSI rates through random sampling of 279 individual CS patient files. We reviewed registers and ward round reports to obtain the number of CS performed and CS-related deaths. We compared proportions of individuals with a characteristic of interest during pre-implementation and post implementation using the two-proportion z-test at p≤0.05 using STATA V.15.

RESULTS

The SSC utilisation rate for CS increased from 3.7% (5 out of 136) to 95.1% (136 out of 143) with p<0.001. Likewise, the proportion of women with SSI after CS reduced from 14% during baseline to 1% (p=0.002). The change in SSI rate after the implementation of the safe surgery interventions is statistically significant (p<0.001). The CS-related POMR decreased by 38.5% (p=0.6) after the implementation of safe surgery interventions.

CONCLUSION

Our findings show that our intervention led to improved utilisation of the WHO SSC, reduced SSIs and a drop in CS-related POMR. We recommend replication of the interventions in other LMICs.

Compliance with the Surgery Safety Checklist: An Update on the Status

WHO has recommended the implementation of the Surgery Safety Checklist (SSC) to reign in often simple logistic errors that lead to numerous complications, some of them being fatal, in the perioperative period. This study aims to discuss doubts presented in the medical literature concerning the effectiveness of SSC in the currently existing form. The article is based on the literature search performed in PubMed using the command phrase "Surgery Safety Checklist". The search yielded 1,476 articles up to March 2021. Out of this group, we selected 811 articles for further detailed analysis. The selection was based on the meritorious SSC-related topicality and scrutinized content of the articles. Out of these articles, we identified 59 studies that specifically raised the issue of the effectiveness of SSC use in its current form, which we discussed herein in detail. The review distinctly indicates that the SSC reduces perioperative complications including fatalities. However, there are issues reported with the itemized content of the checklist that hardly corresponds to the diverseness of patients' conditions and operating room settings. Further, it is unclear if a reduction in the complications stems from the use of SSC or the algorithms for performing procedures it contains. The consensus arises that SSC should be periodically updated so that it would catch up with the advances in medical knowledge and the emerging technologies, which would safeguard the SSC from becoming just another paperwork nuisance for the operating room staff.

The surgical safety checklist: a quantitative study on attitudes and barriers among gynecological surgery teams

Background

Implementation of the surgical safety checklist (SSC) plays a significant role in improving surgical patient safety, but levels of compliance to a SSC implementation by surgical team members vary significantly. We aimed to investigate the factors affecting satisfaction levels of gynecologists, anesthesiologists, and operating room registered nurses (OR-RNs) with SSC implementation.

Methods

We conducted a survey based on 267 questionnaires completed by 85 gynecologists from 14 gynecological surgery teams, 86 anesthesiologists, and 96 OR-RNs at a hospital in China from March 3 to March 16, 2020. The self-reported questionnaire was used to collect respondent’s demographic information, levels of satisfaction with overall implementation of the SSC and its implementation in each of the three phases of a surgery, namely sign-in, time-out, and sign-out, and reasons for not giving a satisfaction score of 10 to its implementation in all phases.

Results

The subjective ratings regarding the overall implementation of the SSC between the surgical team members were different significantly. “Too many operations to check” was the primary factor causing gynecologists and anesthesiologists not to assign a score of 10 to sign-in implementation. The OR-RNs gave the lowest score to time-out implementation and 82 (85.42%) did not assign a score of 10 to it. “Surgeon is eager to start for surgery” was recognized as a major factor ranking first by OR-RNs and ranking second by anesthesiologists, and 57 (69.51%) OR-RNs chose “Too many operations to check” as the reason for not giving a score of 10 to time-out implementation. “No one initiates” and “Surgeon is not present for ‘sign out’” were commonly cited as the reasons for not assigning a score of 10 to sign-out implementation.

Conclusion

Factors affecting satisfaction with SSC implementation were various. These factors might be essentially related to heavy workloads and lack of ability about SSC implementation. It is advisable to reduce surgical team members’ excessive workloads and enhance their understanding of importance of SSC implementation, thereby improving surgical team members’ satisfaction with SSC implementation and facilitating compliance of SSC completion.

Impact of the WHO Surgical Safety Checklist Relative to Its Design and Intended Use: A Systematic Review and Meta-Meta-Analysis

BACKGROUND

The aim of this study was to identify what parts of the World Health Organization Surgical Safety Checklist (WHO SSC) are working, what can be done to make it more effective, and to determine if it achieved its intended effect relative to its design and intended use.

STUDY DESIGN

We conducted a qualitative thematic analysis and meta-meta-analyses of findings in WHO SSC systematic reviews following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.

RESULTS

Twenty systematic reviews were included for qualitative thematic analysis. Narrative information was coded in 4 primary areas with a focus on impact of the WHO SSC. Four themes-Clinical Outcomes, Process Measures, Team Dynamics and Communication, and Safety Culture-pertained directly to the aims or purposes behind the development of the SSC. The other 2 themes-Efficiency and Workload involved in using the checklist and Checklist Impact on Institutional Practices-are associated with SSC use, but were not focal areas considered during its development. Included in the 20 systematic reviews were 24 unique observational cohort studies that reported pre-post data on a total of 18 clinical outcomes. Mortality, morbidity, surgical site infection, pneumonia, unplanned return to the operating room, urinary tract infection, blood loss requiring transfusion, unplanned intubation, and sepsis favored the use of the WHO SSC. Deep vein thrombosis was the only postoperative outcome assessed that did not favor use of the WHO SSC.

CONCLUSIONS

The WHO SSC positively impacts the things it was explicitly designed to address and does not positively impact things it was not explicitly designed for.

Implementation Strategies and the Uptake of the World Health Organization Surgical Safety Checklist in Low and Middle Income Countries: A Systematic Review and Meta-analysis

OBJECTIVES

To identify the implementation strategies used in World Health Organization Surgical Safety Checklist (SSC) uptake in low- and middle-income countries (LMICs); examine any association of implementation strategies with implementation effectiveness; and to assess the clinical impact.

BACKGROUND

The SSC is associated with improved surgical outcomes but effective implementation strategies are poorly understood.

METHODS

We searched the Cochrane library, MEDLINE, EMBASE and PsycINFO from June 2008 to February 2019 and included primary studies on SSC use in LMICs. Coprimary objectives were identification of implementation strategies used and evaluation of associations between strategies and implementation effectiveness. To assess the clinical impact of the SSC, we estimated overall pooled relative risks for mortality and morbidity. The study was registered on PROSPERO (CRD42018100034).

RESULTS

We screened 1562 citations and included 47 papers. Median number of discrete implementation strategies used per study was 4 (IQR: 1-14, range 0-28). No strategies were identified in 12 studies. SSC implementation occurred with high penetration (81%, SD 20%) and fidelity (85%, SD 13%), but we did not detect an association between implementation strategies and implementation outcomes. SSC use was associated with a reduction in mortality (RR 0.77; 95% CI 0.67-0.89), all complications (RR 0.56; 95% CI 0.45-0.71) and infectious complications (RR 0.44; 95% CI 0.37-0.52).

CONCLUSIONS

The SSC is used with high fidelity and penetration is associated with improved clinical outcomes in LMICs. Implementation appears well supported by a small number of tailored strategies. Further application of implementation science methodology is required among the global surgical community.

A Systematic Review of Interventions Used to Enhance Implementation of and Compliance With the World Health Organization Surgical Safety Checklist in Adult Surgery

The focus of this systematic review is to identify and synthesize the evidence for effectiveness of interventions to increase compliance with the World Health Organization Surgical Safety Checklist (SSC) for adult surgery. We searched a variety of databases and identified 24 peer-reviewed articles of either a quantitative (n = 17), qualitative (n = 4), or mixed-methods design (n = 3) published in English from January 1, 2008, to July 8, 2020. Interventions included modifying the ways of delivering the SSC, integrating or tailoring the SSC to local context or existing practice, promoting clinician awareness and engagement, and managing policies. Despite a lack of common outcome measures, all quantitative and mixed-methods study results showed a significant positive effect on SSC compliance. A few researchers reported nonsignificant or negative changes in certain aspects with the interventions. Additional research is needed to address SSC compliance measures globally and outcomes in developing countries.

A retrospective audit of postoperative days alive and out of hospital, including before and after implementation of the WHO surgical safety checklist

We implemented the World Health Organization surgical safety checklist at Auckland City Hospital from November 2007. We hypothesised that the checklist would reduce postoperative mortality and increase days alive and out of hospital, both measured to 90 postoperative days. We compared outcomes for cohorts who had surgery during 18-month periods before vs. after checklist implementation. We also analysed outcomes during 9 years that included these periods (July 2004-December 2013). We analysed 9475 patients in the 18-month period before the checklist and 10,589 afterwards. We analysed 57,577 patients who had surgery from 2004 to 2013. Mean number of days alive and out of hospital (95%CI) in the cohort after checklist implementation was 1.0 (0.4-1.6) days longer than in the cohort preceding implementation, p < 0.001. Ninety-day mortality was 395/9475 (4%) and 362/10,589 (3%) in the cohorts before and after checklist implementation, multivariable odds ratio (95%CI) 0.93 (0.80-1.09), p = 0.4. The cohort changes in these outcomes were indistinguishable from longer-term trends in mortality and days alive and out of hospital observed during 9 years, as determined by Bayesian changepoint analysis. Postoperative mortality to 90 days was 228/5686 (4.0%) for Māori and 2047/51,921 (3.9%) for non-Māori, multivariable odds ratio (95%CI) 0.85 (0.73-0.99), p = 0.04. Māori spent on average (95%CI) 1.1 (0.5-1.7) fewer days alive and out of hospital than non-Māori, p < 0.001. In conclusion, our patients experienced improving postoperative outcomes from 2004 to 2013, including the periods before and after implementation of the surgical checklist. Māori patients had worse outcomes than non-Māori.

Safe surgery checklist: evaluation in a neotropical region

OBJECTIVE

assess patient responses and associated factors of items on a safe surgery checklist, and identify use before and after protocol implementation from the records.

METHODS

a cohort study conducted from 2014 to 2016 with 397 individuals in stage I and 257 in stage II, 12 months after implementation, totaling 654 patients. Data were obtained in structured interviews. In parallel, 450 checklist assessments were performed in medical records from public health institutions in the Southwest II Health Region of Goiás state, Brazil.

RESULTS

six items from the checklist were evaluated and all of these exhibited differences (p < 0.000). Of the medical records analyzed, 69.9% contained the checklist in stage I and 96.5% in stage II, with better data completeness. In stage II, after training, the checklist was associated with surgery (OR; 1.38; IC95%: 1.25-1.51; p < 0.000), medium-sized hospital (OR; 1.11; CI95%; 1.0-1.17; p < 0.001), male gender (OR; 1.07; CI95%; 1.0-1.14; p < 0.010), type of surgery (OR; 1.7; CI95%: 1.07-1.14; p < 0.014) and antibiotic prophylaxis 30 to 60 min after incision (OR; 1.10; CI95%: 1.04-1.17; p < 0.000) and 30 to 60 min after surgery (OR; 1.23; CI95%: 1.04-1.45; p = 0.015).

CONCLUSIONS

the implementation strategy of the safe surgery checklist in small and medium-sized healthcare institutions was relevant and associated with better responses based on patient, data availability and completeness of the data.

Cost-effectiveness of an enhanced Paramedic Acute Stroke Treatment Assessment (PASTA) during emergency stroke care: Economic results from a pragmatic cluster randomized trial

Background

The Paramedic Acute Stroke Treatment Assessment (PASTA) trial evaluated an enhanced emergency care pathway which aimed to facilitate thrombolysis in hospital. A pre-planned health economic evaluation was included. The main results showed no statistical evidence of a difference in either thrombolysis volume (primary outcome) or 90-day dependency. However, counter-intuitive findings were observed with the intervention group showing fewer thrombolysis treatments but less dependency.

Aims

Cost-effectiveness of the PASTA intervention was examined relative to standard care.

Methods

A within trial cost-utility analysis estimated mean costs and quality-adjusted life years over 90 days’ time horizon. Costs were derived from resource utilization data for individual trial participants. Quality-adjusted life years were calculated by mapping modified Rankin scale scores to EQ-5D-3L utility tariffs. A post-hoc subgroup analysis examined cost-effectiveness when trial hospitals were divided into compliant and non-compliant with recommendations for a stroke specialist thrombolysis rota.

Results

The trial enrolled 1214 patients: 500 PASTA and 714 standard care. There was no evidence of a quality-adjusted life year difference between groups [0·007 (95% CI: −0·003 to 0·018)] but costs were lower in the PASTA group [−£1473 (95% CI: −£2736 to −£219)]. There was over 97.5% chance that the PASTA pathway would be considered cost-effective. There was no evidence of a difference in costs at seven thrombolysis rota compliant hospitals but costs at eight non-complaint hospitals costs were lower in PASTA with more dominant cost-effectiveness.

Conclusions

Analyses indicate that the PASTA pathway may be considered cost-effective, particularly if deployed in areas where stroke specialist availability is limited.

Trial Registration: ISRCTN12418919 www.isrctn.com/ISRCTN12418919

Expert commentary on the challenges and opportunities for surgical site infection prevention through implementation of evidence-based guidelines in the Asia-Pacific Region

INTRODUCTION

Surgical site infections (SSIs) are a significant source of morbidity and mortality in the Asia-Pacific region (APAC), adversely impacting patient quality of life, fiscal productivity and placing a major economic burden on the country's healthcare system. This commentary reports the findings of a two-day meeting that was held in Singapore on July 30-31, 2019, where a series of consensus recommendations were developed by an expert panel composed of infection control, surgical and quality experts from APAC nations in an effort to develop an evidence-based pathway to improving surgical patient outcomes in APAC.

METHODS

The expert panel conducted a literature review targeting four sentinel areas within the APAC region: national and societal guidelines, implementation strategies, postoperative surveillance and clinical outcomes. The panel formulated a series of key questions regarding APAC-specific challenges and opportunities for SSI prevention.

RESULTS

The expert panel identified several challenges for mitigating SSIs in APAC; (a) constraints on human resources, (b) lack of adequate policies and procedures, (c) lack of a strong safety culture, (d) limitation in funding resources, (e) environmental and geographic challenges, (f) cultural diversity, (g) poor patient awareness and (h) limitation in self-responsibility. Corrective strategies for guideline implementation in APAC were proposed that included: (a) institutional ownership of infection prevention strategies, (b) perform baseline assessments, (c) review evidence-based practices within the local context, (d) develop a plan for guideline implementation, (e) assess outcome and stakeholder feedback, and (f) ensure long-term sustainability.

CONCLUSIONS

Reducing the risk of SSIs in APAC region will require: (a) ongoing consultation and collaboration among stakeholders with a high level of clinical staff engagement and (b) a strong institutional and national commitment to alleviate the burden of SSIs by embracing a safety culture and accountability.

Early protein C activation is reflective of burn injury severity and plays a critical role in inflammatory burden and patient outcomes

BACKGROUND

Navigating the complexities of a severe burn injury is a challenging endeavour where the natural course of some patients can be difficult to predict. Straddling both the coagulation and inflammatory cascades that feature strongly in the burns systemic pathophysiology, we propose the pleiotropic protein C (PC) system may produce a viable biomarker to assist traditional evaluation methods for diagnostic and prognostic purposes.

METHODS

We enrolled 86 patients in a prospective observational cohort study. Over three weeks, serial blood samples were taken and measured for PC, activated (A)PC, their receptor endothelial protein C receptor (EPCR), and a panel of inflammatory cytokines including C-reactive protein (CRP), tumour necrosis factor-α, interleukin (IL)-1β, IL-6, IL-8, and IL-17. Their temporal trends were analysed alongside clinical factors including burn size, burn depth, presence of inhalational injury, and a composite outcome of requiring increased support.

RESULTS

(i) APC increased from a nadir on Day 3 (2.3±2.1ng/mL vs 4.1±2.5ng/mL by Day 18, p<0.0005), only becoming appropriately correlated to PC from Day 6 onwards (r=0.412-0.721, p<0.05 for all Days 6-21). (ii) This early disturbance in the PC system was amplified in the more severe burns (≥30% total body surface area, predominantly full thickness, or with inhalational injury), which were characterised by a marked fall in PC activation (approximated by APC/PC ratio) and APC levels during Days 0-3 with low unchanged PC levels. Critically low levels of this cytoprotective agent was associated with greater inflammatory burden, as reflected by significantly elevated CRP, IL-6, and IL-8 levels in the more severe compared to less severe burns, and by negative correlations between both PC and APC with most inflammatory cytokines. (iii) Alongside clinical markers of severity at admission (burn size, burn depth, and presence of inhalational injury), only Day 0 APC/PC ratio (OR 1.048 (1.014-1.083), p=0.006), APC (OR 1.364 (1.032-1.803), p=0.029), PC (OR 0.899 (0.849-0.953), p<0.0005), and not any inflammatory cytokines were predictive markers of requiring increased support. Uniquely, decreased Day 0 PC was further individually associated with each increased total length of stay, ICU length of stay, intravenous fluid resuscitation, and total surgeries, as well as possibly mortality.

CONCLUSION

An early functional depletion of the cytoprotective PC system provides a physiological link between severe burns and the cytokine storm, likely contributing to worse outcomes. Our findings on the changes in APC, PC and PC activation during this pathological state support APC and PC as early diagnostic and prognostic biomarkers, and provides a basis for their therapeutic potential in severe burn injuries.

Postoperative infectious complications in elderly patients after elective surgery in China: results of a 7-day cohort study from the International Surgical Outcomes Study

AIM

Despite initiatives to increase elderly patients' access to surgical treatments, the prevalence and impact of postoperative infectious complications (PICs) in elderly patients in China are poorly described. The aim of our study was to describe PICs and associated mortality in elderly patients undertaking elective surgery in China.

METHODS

We analyzed data about elderly patients from China during the International Surgical Outcomes Study (ISOS), a 7-day prospective cohort study of outcomes after elective surgery in in-patient adults. All elderly patients (age ≥60 years) from 28 hospitals in China included in the ISOS study were included in this study as well. A review of 2014 elderly patients who underwent elective surgery in April 2014 was conducted.

RESULTS

Of 2014 elderly patients, 209 (10.4%) developed at least one postoperative complication. Infectious complications were most frequent, affecting 154 patients (7.6%); there was one death, or 0.6% 30-day mortality, which was a significantly higher rate than among patients without PICs (0%). The most frequent infectious complication was superficial surgical-site infection (3.3%). The length of hospital stay was longer in elderly patients with PICs than in those without PICs. Moreover, a total of 142 elderly patients (7.1%) were routinely sent to critical care after surgery, of whom 97 (68.3%) developed PICs. Compared to elderly patients admitted to a standard ward, those admitted to critical care immediately after surgery had a higher postoperative complication rate and critical care admission rate to treat complications.

CONCLUSIONS

The present prospective, multicentre study found that 7.6% of elderly patients in China had PICs after elective surgery that could prolong hospital stay and increase 30-day mortality. The clinical effectiveness of admission to critical care after surgery on elderly patients is not identified. Initiatives to increase elderly patients' access to surgical interventions should also enhance safe perioperative care to reduce PICs in China.

Effect of an Enhanced Paramedic Acute Stroke Treatment Assessment on Thrombolysis Delivery During Emergency Stroke Care: A Cluster Randomized Clinical Trial

Question

Can hospital stroke thrombolysis treatment rates be increased by an enhanced paramedic assessment that includes additional prehospital information collection, a structured hospital handover, practical assistance after handover, a predeparture care checklist, and clinician feedback?

Findings

In this cluster randomized clinical trial, fewer patients in the intervention group (39.4%) received thrombolysis vs those in the standard care group (44.7%), but there were fewer poor health outcomes (disability or death) after 90 days (intervention group, 64.0% vs standard care group, 66.8%). The results were not statistically significant.

Meaning

This study found that the enhanced paramedic assessment should not be used to increase thrombolysis volume but may influence the quality of treatment decisions.

Importance

Rapid thrombolysis treatment for acute ischemic stroke reduces disability among patients who are carefully selected, but service delivery is challenging.

Objective

To determine whether an enhanced Paramedic Acute Stroke Treatment Assessment (PASTA) intervention increased hospital thrombolysis rates.

Design, Setting, and Participants

This multicenter, cluster randomized clinical trial took place between December 2015 and July 2018 in 3 ambulance services and 15 hospitals. Clusters were paramedics based within ambulance stations prerandomized to PASTA or standard care. Patients attended by study paramedics were enrolled after admission if a hospital specialist confirmed a stroke and paramedic assessment started within 4 hours of onset. Allocation to PASTA or standard care reflected the attending paramedic’s randomization status.

Interventions

The PASTA intervention included additional prehospital information collection, a structured hospital handover, practical assistance up to 15 minutes after handover, a predeparture care checklist, and clinician feedback. Standard care reflected national guidelines.

Main Outcomes and Measures

Primary outcome was the proportion of patients receiving thrombolysis. Secondary outcomes included time intervals and day 90 health (with poor status defined as a modified Rankin Score >2, to represent dependency or death).

Results

A total of 11 478 patients were screened following ambulance transportation; 1391 were eligible and approached, but 177 did not consent. Of 1214 patients enrolled (mean [SD] age, 74.7 [13.2] years; 590 women [48.6%]), 500 were assessed by 242 paramedics trained in the PASTA intervention and 714 were assessed by 355 paramedics continuing with standard care. The paramedics trained in the PASTA intervention took a mean of 13.4 (95% CI, 9.4-17.4) minutes longer (P < .001) to complete patient care episodes. There was less thrombolysis among the patients in the PASTA group, but this was not significant (PASTA group, 197 of 500 patients [39.4%] vs the standard care group, 319 of 714 patients [44.7%]; adjusted odds ratio, 0.81 [95% CI, 0.61-1.08]; P = .15). Time from a paramedic on scene to thrombolysis was a mean of 8.5 minutes longer in the PASTA group (98.1 [37.6] minutes) vs the standard care group (89.4 [31.1] minutes; P = .01). Poor health outcomes did not differ significantly but occurred less often among patients in the PASTA group (313 of 489 patients [64.0%]) vs the standard care group (461 of 690 patients [66.8%]; adjusted odds ratio, 0.86 [95% CI, 0.60-1.20]; P = .39).

Conclusions and Relevance

An enhanced paramedic assessment did not facilitate thrombolysis delivery. The unexpected combination of thrombolysis and health outcomes suggests possible alternative influences on treatment decisions by the intervention, requiring further evaluation.

Trial Registration

ISRCTN Registry Identifier: ISRCTN12418919

Clinical Efficacy of Combined Surgical Patient Safety System and the World Health Organization's Checklists in Surgery: A Nonrandomized Clinical Trial

Question

Does patient safety improve when adding the preoperative and postoperative Surgical Patient Safety System checklists to the World Health Organization’s established surgical safety checklist?

Findings

In this stepped-wedge cluster nonrandomized clinical trial with parallel controls that included 9009 surgical procedures, reductions in complications and emergency reoperations occurred when the preoperative Surgical Patient Safety System was added to the surgical safety checklist. The postoperative Surgical Patient Safety System reduced readmissions, whereas overall increased complications were found in the 9678 parallel controls.

Meaning

These findings suggest that joint use of the preoperative and postoperative Surgical Patient Safety System with the intraoperative surgical safety checklist is beneficial for patients.

Importance

Checklists have been shown to improve patient outcomes in surgery. The intraoperatively used World Health Organization surgical safety checklist (WHO SSC) is now mandatory in many countries. The only evidenced checklist to address preoperative and postoperative care is the Surgical Patient Safety System (SURPASS), which has been found to be effective in improving patient outcomes. To date, the WHO SSC and SURPASS have not been studied jointly within the perioperative pathway.

Objective

To investigate the association of combined use of the preoperative and postoperative SURPASS and the WHO SSC in perioperative care with morbidity, mortality, and length of hospital stay.

Design, Setting, and Participants

In a stepped-wedge cluster nonrandomized clinical trial, the preoperative and postoperative SURPASS checklists were implemented in 3 surgical departments (neurosurgery, orthopedics, and gynecology) in a Norwegian tertiary hospital, serving as their own controls. Three surgical units offered additional parallel controls. Data were collected from November 1, 2012, to March 31, 2015, including surgical procedures without any restrictions to patient age. Data were analyzed from September 25, 2018, to March 29, 2019.

Interventions

Individualized preoperative and postoperative SURPASS checklists were added to the intraoperative WHO SSC.

Main Outcomes and Measures

Primary outcomes were in-hospital complications, emergency reoperations, unplanned 30-day readmissions, and 30-day mortality. The secondary outcome was length of hospital stay (LOS).

Results

In total, 9009 procedures (5601 women [62.2%]; mean [SD] patient age, 51.7 [22.2] years) were included, with 5117 intervention procedures (mean [SD] patient age, 51.8 [22.4] years; 2913 women [56.9%]) compared with 3892 controls (mean [SD] patient age, 51.5 [21.8] years; 2688 women [69.1%]). Parallel control units included 9678 procedures (mean [SD] patient age, 57.4 [22.2] years; 4124 women [42.6%]). In addition to the WHO SSC, adjusted analyses showed that adherence to the preoperative SURPASS checklists was associated with reduced complications (odds ratio [OR], 0.70; 95% CI, 0.50-0.98; P = .04) and reoperations (OR, 0.42; 95% CI, 0.23-0.76; P = .004). Adherence to the postoperative SURPASS checklists was associated with decreased readmissions (OR, 0.32; 95% CI, 0.16-0.64; P = .001). No changes were observed in mortality or LOS. In parallel control units, complications increased (OR, 1.09; 95% CI, 1.01-1.17; P = .04), whereas reoperations, readmissions, and mortality remained unchanged.

Conclusions and Relevance

In this nonrandomized clinical trial, adding preoperative and postoperative SURPASS to the WHO SSC was associated with a reduction in the rate of complications, reoperations, and readmissions.

Trial Registration

ClinicalTrials.gov Identifier: NCT01872195

Improving surgical quality in low-income and middle-income countries: why do some health facilities perform better than others?

BACKGROUND

Evidence on heterogeneity in outcomes of surgical quality interventions in low-income and middle-income countries is limited. We explored factors driving performance in the Safe Surgery 2020 intervention in Tanzania's Lake Zone to distil implementation lessons for low-resource settings.

METHODS

We identified higher (n=3) and lower (n=3) performers from quantitative data on improvement from 14 safety and teamwork and communication indicators at 0 and 12 months from 10 intervention facilities, using a positive deviance framework. From 72 key informant interviews with surgical providers across facilities at 1, 6 and 12 months, we used a grounded theory approach to identify practices of higher and lower performers.

RESULTS

Performance experiences of higher and lower performers differed on the following themes: (1) preintervention context, (2) engagement with Safe Surgery 2020 interventions, (3) teamwork and communication orientation, (4) collective learning orientation, (5) role of leadership, and (6) perceived impact of Safe Surgery 2020 and beyond. Higher performers had a culture of teamwork which helped them capitalise on Safe Surgery 2020 to improve surgical ecosystems holistically on safety practices, teamwork and communication. Lower performers prioritised overhauling safety practices and began considering organisational cultural changes much later. Thus, while also improving, lower performers prioritised different goals and trailed higher performers on the change continuum.

CONCLUSION

Future interventions should be tailored to facility context and invest in strengthening teamwork, communication and collective learning and facilitate leadership engagement to build a receptive climate for successful implementation of safe surgery interventions.

Postoperative Outcomes Following Elective Surgery in India

Introduction

The incidence of complications and mortality in patients undergoing elective surgery in India are unknown. We contributed Indian data to ISOS. Since there were fewer than ten centers, Indian data were not included in the primary analysis. We report postoperative outcomes in the Indian data set of patients following elective surgery.

Materials and methods

In this prospective 7-day observational study, after obtaining a waiver of informed consent, data were collected for 30 days from consecutive patients >18 years undergoing elective surgery. The primary outcome was in-hospital postoperative complications. The secondary outcomes were in-hospital all-cause mortality, the relationship between postoperative complications and admission to critical care, and the duration of hospital stay. Complications were graded as mild, moderate, and severe. Failure to rescue was defined as mortality in patients admitted to an intensive care unit (ICU) for the treatment of complications.

Results

Complications occurred in 57 (27.5%) patients, who were older (53 vs 47 years, p < 0.001) and had American Society of Anaesthesiologists grades III and IV physical status (p = 0.029). One hundred and thirty-eight (65.7%) patients underwent a major surgical procedure of which 132 (62.8%) procedures were done for malignancy. Postoperative complications were significantly higher (41.5% vs 22.7%) in patients electively admitted to ICU. The overall mortality rate was 2.4%, whereas the mortality rate was 8.8% in those who developed complications.

Conclusion

We found that 28% of patients developed postoperative complications. The overall mortality was 2.4% but was higher (8.8%) in those who developed complications. Age and complex surgical procedures independently predicted complications, while lower preoperative hemoglobin appeared to be protective.

Study Registration

ISRCTN51817007.

How to cite this article

Agarwal V, Muthuchellappan R, Shah BA,Rane PP, Kulkarni AP, et al. Postoperative Outcomes Following Elective Surgery in India. Indian J Crit Care Med 2021;25(5):528-534.

Safer Surgical Practice: a Guide for Surgeons (not just for pandemics)

The surgical working environment has changed considerably since the World Health Organisation (WHO) declared the coronavirus outbreak, COVID-19 (SARS-CoV-2), a pandemic on 11 March 2020. Measures remain in place to reduce the risk of spread from patients to surgeons, nosocomial infection and amongst healthcare workers. However, despite these protective measures, healthcare staff are at risk with the number of health workforce deaths increasing worldwide. This article sets out to explore the roles and responsibilities of the surgeon during these extraordinary times and discuss how we can improve our practice to reduce the risk of harm to patients, surgical staff, and ourselves.

Advantages of, and Adaptations to, Enhanced Recovery Protocols for Perioperative Care during the COVID-19 Pandemic

Objective

This review formulates the rationale for using enhanced recovery protocols (ERPs) to standardize and optimize perioperative care during this high-risk time to minimize poor outcomes owing to provider, patient, and system vulnerabilities.

Data Sources

n/a

Methods of Study Selection

A literature review using key Medical Subject Headings terms was performed—according to methods described by the Cochrane Collaboration and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines—on studies that described enhanced recovery and coronavirus disease (COVID-19).

Tabulation, Integration, and Results

Modifications to our existing ERPs related to the COVID-19 pandemic should include new accommodations for patient education, preoperative COVID-19 testing, prehabilitation, and intraoperative infection as well as thromboembolism risk reduction.

Conclusion

ERPs are evidence-based, best practice guidelines applied across the perioperative continuum to mitigate surgical stress, decrease complications, and accelerate recovery. These benefits are part of the high-value–care equation needed to solve the clinical, operational, and financial challenges of the current COVID-19 pandemic. The factors driving outcomes on ERPs, such as the provision of minimally invasive surgery, warrant careful consideration. Tracking patient outcomes and improving care in response to outcomes data are key to the success of clinical care protocols such as ERPs. Numerous emerging clinical registries and reporting systems have been activated to provide outcomes data on the impact of COVID-19. This will inform and change surgical practice as well as provide opportunity to learn if the advantages that surgeons, patients, and the healthcare system might gain from using ERPs during a pandemic are meaningful.

A Health Economic Evaluation of the World Health Organization Surgical Safety Checklist: A Single Center Assessment

OBJECTIVES

To evaluate cost-effectiveness of the WHO Surgical Safety Checklist.

BACKGROUND

The clinical effectiveness of surgical checklists is largely understood. Few studies to-date have evaluated the cost-effectiveness of checklist use.

METHODS

An economic evaluation was carried out using data from the only available randomized controlled trial of the checklist. Analyses were based on 3702 procedures. Costs considered included checklist implementation costs and length and cost of hospital stay, costs of warming blanket use, blood transfusions and antibiotics used in the operating room, and the cost of clinical time in the operating room - all calculated for each procedure and its associated admission. Nonparametric bootstrapping was used to simulate an empirical distribution of the mean effect of the checklist on total admission costs and the probability of observing a complication-free admission and to quantify sampling uncertainty around mean cost estimates.

RESULTS

The overall cost of checklist implementation was calculated to be $900 per 100 admissions. Implementation of the WHO checklist resulted in an additional 5.9 complication-free admissions per 100 admissions and an average of 110 bed-days saved per 100 admissions. Accounting for all costs included in the analysis, for every 100 admissions, use of the WHO checklist was estimated to save $55,899.

CONCLUSIONS

Implementation of the WHO checklist was a cost-effective strategy for improving surgical safety.

Economic Case for Scale-up of the WHO Surgical Safety Checklist at the National Level in Sub-Saharan Africa

OBJECTIVES

To evaluate the economic case for nationwide scale-up of the World Health Organisation (WHO) Surgical Safety Checklist using cost-effectiveness and benefit-cost analyses.

BACKGROUND

The Checklist improves surgical outcomes but the economic case for widespread use remains uncertain. For perioperative quality improvement interventions to compete successfully against other worthwhile health and non-health interventions for limited government resources they must demonstrate cost-effectiveness and positive societal benefit.

METHODS

Using data from three countries, we estimated the benefits as the total years of life lost (YLL) due to post-operative mortality averted over a 3 year period; converted the benefits to dollar equivalent values using estimates of the economic value of an additional year of life expectancy; estimated total implementation costs; and determined incremental cost-effectiveness ratios (ICER) and benefit-cost-ratios (BCR). Costs are reported in international dollars using Word Bank purchasing power parity conversion factors at 2016 price-levels.

RESULTS

In Benin, Cameroon and Madagascar ICERs were: $31, $138 and $118 per additional YLL averted; and BCRs were 62, 29, and 9, respectively. Sensitivity analysis demonstrated that the associated mortality reduction and increased usage due to Checklist scale-up would need to deviate approximately 10-fold from published data to change our main interpretations.

CONCLUSIONS

According to WHO criteria, Checklist scale-up is considered "very cost-effective" and for every $1 spent the potential return on investment is $9-62. These results compare favourably with other health and non-health interventions and support the economic argument for investing in Checklist scale-up as part of a national strategy for improving surgical outcomes.