Jarrod Shapiro, DPM Practice Perfect Editor Mountain View Medical & Surgical Associates, Madras, Oregon

Part Two, Surgical Checklists — Doing It Better

In our last Practice Perfect, I began a discussion about the use of the WHO’s Surgical Safety Checklist.  I attempted to lay out the current situation — an unnecessarily high number of surgical complications — and provide some historical perspective on the use of checklists in highly complex endeavors such as the airline industry.  Hopefully, I’ve successfully convinced you that something needs to be done to improve our surgical complication rates.  I’d like to conclude this two-part series discussing the ways in which checklists are revolutionizing patient safety practices in surgery, introduce you to the WHO’s Surgical Safety Checklist and hopefully spark your interest in using this method at your local hospital or surgery center.

		Tonight's Premier Lecture is Cutaneous Lesions of the Lower Extremity Marc Brenner, DPM

One problem that has been quite amenable to the use of checklists is the issue of catheter-related blood stream infections.  We’re talking here about PICC lines — something most of us have some interaction with, especially those involved in wound care.  There are an estimated 80,000 catheter-related blood stream infections per year and up to 28,000 deaths in the ICU from this problem.¹  To combat this epidemic, the Michigan Health Alliance Keystone ICU Project was undertaken and reported on in 2006.²  They studied whether a series of interventions (a standardized catheter insertion protocol with a checklist to ensure adherence) would decrease the number of infections. This study involved 103 ICUs with 375,757 catheter-days and examined the number of infections per 1000 catheter-days. Remarkably, their median infection rate went from 2.7/1000 catheter-days (prechecklist) to 0/1000 catheter-days with a 66% overall reduction of infections at 18 months!  Their overall rate dropped from 4% to zero, with an estimated 1500 lives and $200 million saved.  Clearly the use of a checklist greatly improved patient safety. But what about surgery?

Checklists in Surgery

Early this year, January 2010, a landmark article was published in The New England Journal of Medicine that demonstrated the efficacy of a surgical checklist in reducing intraoperative complications.³  Sponsored by the WHO, this study examined a 19 step surgical checklist performed at three different points during a procedure. The study included patients age > 16 years undergoing noncardiac surgery at eight pilot hospitals internationally (with various socioeconomic locations), including 3733 pre-intervention patients and 3955 post-intervention procedures. They followed patients until hospital discharge or 30 days, looking for any major complication or death. 

For the sake of brevity I’ll boil down the results. The researchers found a 36% decrease in “any complication,” 45% decrease in surgical site infections, 25% decrease in returns to the OR, and 47% decrease in surgery-related mortality.  All values were statistically significant.  These remarkable results were thought to be due to several issues.  First, fewer mistakes were made.  Second, the effective use of the checklist lead to changes in surgical team behaviors.  Third, institutional policies, such as when to administer antibiotics, changed, thereby reducing delays.³  Again, the use of a checklist significantly reduced surgical complications.

Nonsense … Or Is It?

So am I just wasting my breath on this subject?  Isn’t it enough that we do our surgical time out?  No, it’s not. The evidence shows clearly that a simple time out is not effective enough in reducing the potential for surgical complications.  We’ve seen thus far that initiation of checklists successfully and significantly reduces airplane complications, PICC line infections, and surgical complications.  It has additionally been shown that checklists improve adherence to clinical pathways for treatment of ST segment elevation myocardial infarction and stroke⁴ and improves OR efficiency by reducing unexpected delays by 31%.⁵

Oh yeah.  By the way, we’re already using them in podiatry!  Don’t think so?  Ever use a wound care documentation form?  This is simply another checklist to avoid errors and supply clear documentation.  How about point-and-click EMR programs?  This is simply a computerized version of a checklist.  Ever admit a patient to the hospital with a premade admission form?  Yup – another checklist.  They’re all over the place!

What Do I Do Now?

Whether you like it or not, checklists are here to stay and are likely to become the industry standard.  In fact, as of February 2010 the Surgical Safety Checklist is becoming mandated in England and Wales.⁶  So for those interested in bringing this checklist to their hospital (and decreasing the risk of surgical complications), the question becomes “what do I do now?”

Here are some suggestions:

• Perform multiple trials before going “live.”
• Modify the checklist as necessary.  The WHO’s checklist is made to be changed to fit the specific hospital situation. 
• Keep it simple.  The tendency is to enlarge the checklist to incorporate more steps.  Fight the urge and focus on the key steps of the procedure.
• Create an atmosphere of acceptance.  One doctor cannot implement this program alone.  Hospital administration must be supportive.  Educate all potential players (nurses, doctors, scrub techs, CRNA’s, etc).
• Empower all levels of participants.  Teach staff that it is permissible to voice concerns without feeling there will be repercussions from an angry doctor.  Emphasize “no fault” reporting.  A nonputative environment will foster the teamwork necessary for success.
• Track results/progress when possible.
• Appoint someone to “champion” the checklist, preferably a surgeon.
• Observe the performance of the checklist once widely instituted and re-educate as necessary.
• Go to www.safesurg.org which has all the tools necessary to get started.
  

Remember, it’s not about egos.  Recognize that medicine and surgery are highly complex undertakings with the potential for significant error, and no one is 100% consistent.  We can all have attention and memory lapses.  That’s excusable.  What’s inexcusable is when a mistake in the presence of ego leads to a poor patient outcome.  Welcome to the world of checklists, coming to hospital near you!  Best wishes.

Keep writing in with your thoughts and comments or our eTalk discussion forum on PRESENT Podiatry and start or get in on the discussion. Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

REFERENCES:

Sign up today and receive up to $60 Credit for CME

Major Sponsors