Checklists May Save Lives During Surgical Crises

Neil Osterweil

January 16, 2013

Taking a few extra seconds to follow a checklist during an intraoperative crisis such as a massive hemorrhage or cardiac arrest may quite literally mean the difference between life and death, investigators say.

In a series of simulated operating room (OR) crises, operative teams missed only 6% of potentially life-saving processes of care when checklists were available compared with 23% of steps missed when there were no checklists immediately at hand, Alexander F. Arriaga, MD, MPH, ScD, from the Department of Health Policy and Management, Harvard School of Public Health, and the Center for Surgery and Public Health; the Department of Anesthesiology, Perioperative, and Pain Medicine; and the Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, and colleagues report in the January 17 issue of the New England Journal of Medicine.

"In this high-fidelity simulation-based study, we found that the use of crisis checklists was associated with a significant improvement in adherence to recommended procedures for the most common intraoperative emergencies. After participation, 97% of the participants agreed that they would want these checklists used if they had an intraoperative crisis as a patient," Dr. Arriaga and colleagues write.

A surgeon who was not involved in the study told Medscape Medical News that the value of checklists is most evident when rare but potentially life-threatening events occur.

"It's in these crises where checklists are even more important," said David R. Flum, MD, MPH, associate director of research and director of the Surgical Outcomes Research Center at the University of Washington in Seattle.

"You don't need to look much further than the aviation industry to look at what happens in crisis moments," he said. "Think about when a flock of geese flies into your airplane's engines and you have to make a landing in the Hudson River: You use checklists in that environment because things are moving so quickly and there are so many other things going on, the checklists give you the essentials much quicker than seat-of-the-pants flying."

He notes that in his institution they have checklists available in the OR for rare but potentially devastating events such as fires or malignant hyperthermia.

"Malignant hyperthermia happens rarely enough that if you relied on memory to make sure that we got the right things to happen every time, it would be a big mistake," he said.

Team Challenge

Individual surgeons, nurses, anesthesiologists, or technicians may encounter intraoperative crises only rarely during their careers, but in large hospitals such events are fairly common, yet still complex and difficult to manage, Dr. Arriaga and colleagues note.

To determine whether the use of checklists could improve the odds that clinicians would follow evidence-based best practices during a crisis in the OR, the authors assembled teams composed of anesthesia staff, OR nurses, surgical technologists, and surgeon stand-ins, because of the difficulties in getting a sufficient number of surgeon volunteers.

The teams were then submitted to the rigors of simulated but highly realistic OR crises during 6-hour sessions. The crises included air embolism, anaphylaxis, asystolic cardiac arrest, hemorrhage followed by ventricular fibrillation, malignant hyperthermia, unexplained hypotension and hyoxemia followed by unstable bradycardia, and unstable tachycardia.

Each team was assigned at random to respond to half the scenarios with checklists available, and half relying on training and memory alone.

The authors found that when checklists were in the operating room, the surgical team failed to carry out only 6% of 47 key processes identified by the investigators as life-saving processes, based on evidence based guidelines.

In contrast, left to their own devices, the teams omitted 23% of the processes (P < .0001).

Similarly, in a multivariate model adjusted for clustering with teams, institution, scenario, learning effects, and fatigue, the availability of checklists was associated with a relative risk of 0.28 (95% confidence interval, 0.18 - 0.42; P < .0001).

"Participants reported that the checklists were easy to use, that the checklists helped them feel better prepared, and that they would use the checklists if presented with these operative emergencies in real life," the authors write.

They add that the study was limited by the use of a simulated OR rather than real-world setting and by the dearth of surgeon volunteers, but added that "we found no evidence that the presence of a surgeon reduced the benefit of the checklist intervention. The key processes tracked for this study, which were developed by a multidisciplinary panel that included surgeons, were primarily the responsibility of nursing and anesthesiology staff."

Dr. Flum pointed out that although it would have been preferable to have greater participation by actual surgeons in the experiments, the investigators controlled for the presence of surgeons and still had robust results.

The study was supported by a grant from the Agency for Healthcare Research and Quality. One coauthor reported receiving speaking fees from myriad professional medical associations and for-profit entities in the United States and Europe, as well as royalties from publishers in the United States, Europe, and Asia. One coauthor provided expert review of a variety of medical malpractice cases for both plaintiffs and defendants. The other authors and Dr. Flum have disclosed no relevant financial relationships.

N Engl J Med. 2013;368:246-253.