Checklists, Communication May Reduce Surgical Complications

Larry Hand

December 07, 2012

Training surgical teams in communication and using a procedure checklist before, during, and after surgery may significantly decrease 30-day postoperative complications such as surgical site infections and bleeding requiring transfusions, according to a study conducted at 2 Connecticut medical centers.

Lindsay A. Bliss, MD, general surgery resident at the University of Connecticut Health Center, Farmington, and colleagues report their results in an article, published in the December issue of the Journal of the American College of Surgery.

The investigators compared the outcomes for 3 sets of surgeries: 73 in which the surgical team had participated in communications training and used a surgical checklist, 246 in which the team had not received the training but used a checklist, and 2079 that were drawn from the American College of Surgeons National Surgical Quality Improvement Program database for use as a baseline comparator. The surgeries were performed at the University of Connecticut Health Center, a teaching hospital, and St. Francis Hospital and Medical Center, a tertiary care center in Hartford, Connecticut, between January 2007 and June 2010.

The surgical teams completed checklist sections in 97.26% of the checklist cases and achieved a statistically significant decrease in overall 30-day adverse events. The adverse event rates were 23.60% for historical control patients, 15.90% for cases with only training and no checklist use, and 8.20% for checklist cases. The rates of serious adverse events were 11.9%, 13%, and 5.5% (P = .205), respectively, whereas the rates for minor adverse events were 6.9%, 7.3%, and 4.1% (P = .620), respectively.

In addition, the researchers write, checklist cases produced a small reduction of time in the operating room, a factor correlated with reduction in adverse events.

The communications training consisted of 3 sessions on issues such as "crucial conversations." For the checklist cases, surgical teams used the Association of Perioperative Registered Nurses 2010 surgical checklist, which is based on the World Health Organization's surgical safety checklist.

Although previous research has documented benefits of using a checklist, the researchers write, this is the first study to use the American College of Surgeons National Surgical Quality Improvement Program database as an outcomes-reporting tool. The program database is an evidence-based, standardized surgical outcomes database.

Complete Process

"With rigorous team training centered on the checklist as a compliance tool, stakeholders could freely advocate for patients," the authors write. "In addition, the checklist and the strategies to engage team members in a collegial framework helped to improve patient outcomes by establishing a plan of care to ensure proper handoffs throughout the perioperative process."

In the 73 checklist cases, of 511 possible safety-compromising events that could have occurred, observers recorded 186 (37%) that did occur. More than half of such cases were attributed to "impaired communication and deviation from sterile technique." Of 27 cases with 4 or more safety-compromising events, 4 patients developed surgical site infections serious enough for readmission. According to the Society of Actuaries, postoperative infections can average $14,500 in excess care costs per case.

Limitations of the study include the low number of actual checklist cases compared with historical cases, which hinders the possible identification of trends in types of adverse events.

"Despite the limitations of this study, it demonstrates a considerable improvement in risk-adjusted 30-day postoperative morbidity," the researchers conclude.

Even just knowing who else is working on the surgical team can help, according to a journal news release. "The theory is that this brings a sense of accountability and makes sure that everyone's voice can be heard," Dr. Bliss explained in the release. "No one on the surgical team is a nameless, faceless body. The checklist makes sure everyone is advocating for the patient."

"There is an ethical and financial obligation tied to both tools," she added.

Dr. Bliss pointed out that the checklist is available online, adding, "The cost of a photo copy in exchange for reducing patient morbidity is a fabulous return on investment."

The authors have disclosed no relevant financial relationships.

J Am Coll Surg. 2012:215:766-776. Abstract