Surgical Safety Checklist Reduces Post-Op Deaths

Diana Swift

June 28, 2019

Implementation of the World Health Organization (WHO) Surgical Safety Checklist at surgical centers in England led to a 37.2% relative reduction (from 1.21 to 0.76) in inpatient postoperative mortality during the years after implementation, a study has found.

"The checklist has been demonstrated to reduce postoperative mortality rates (POMR) at an individual patient level, but this is the first evidence for its potential to improve outcomes at a national level," the researchers write.

The study, by Dmitri Nepogodiev, MBChB, from the National Institute for Health Research Global Health Research Unit on Global Surgery, University of Birmingham, United Kingdom, and colleagues was published online June 25 in a research letter in the British Journal of Surgery.

"With an estimated 4.2 million people worldwide dying within 30 days of surgery each year, identification of strategies to reduce postoperative mortality has been identified as a global research priority," they explain.

Previous population research in Scotland found that use of the checklist resulted in a 39% relative reduction in inpatient POMRs from 2000 to 2014. The checklist was phased in from 2008 to 2010 as part of the Scottish Patient Safety Programme. In the Birmingham study, investigators sought to replicate those findings.

"Most of the estimated 4.2 million postoperative deaths each year occur in low- and middle-income countries, where the WHO checklist is often inconsistently used," Nepogodiev told Medscape Medical News.

The 16 years from 1998 to 2014 saw a general downward trend in postoperative deaths, with a more than 30% relative reduction in POMR across all specialties except otorhinolaryngology, cardiology, colorectal oncology, and plastic surgery. In England, which already had low baseline POMRs, the greatest decrease was observed in the 2 years preceding checklist implementation in 2008. During that period, there was an absolute POMR reduction of 0.71% per year, after which the annual pace of decrease fell.

The greatest reductions occurred in esophagogastric (68.8%) and breast surgery (69.3%). During the implementation and postimplementation periods, 10 of 14 specialties had a better than 5% relative reduction in POMRs; POMRs remained stable in plastic and cardiac surgery and increased in obstetrics and otorhinolaryngology.

The study data cannot explain why some specialties saw no decline in POMRs. "One key factor that may contribute to this is changes in case mix, such as age of patients, how many other medical conditions patients have, how frail they are, what type of surgery they are having. We have not controlled for in this study," Nepogodiev explained.

The greatest benefit has been seen in patients undergoing emergency surgery in low- and middle-income countries. Earlier this year, Nepogodiev's group reported data on 12,296 patients who underwent major abdominal surgery in 76 countries. "We found that in high-income countries, the checklist was used in 85%, but this dropped to 59% of cases in middle-income countries and to 47% of cases in low-income countries," he said. "Across all settings, the patients for whom the checklist was used had a lower likelihood of dying postoperatively than those patients for whom the checklist was not used."

Multiple factors likely contribute to the nonuse of the checklist — lack of staff training, limited resources, and time constraints in filling out the list, for example. To shed light on these, Nepogodiev's unit has funded collaborating surgeons in Rwanda and Malawi to study use of the current WHO checklist in their countries, as well as barriers to use and solutions.

"The improvements in postoperative mortality rates in Scotland and England could be replicated across low- and middle-income countries, but investment is urgently needed to identify and roll out successful strategies that improve surgical safety, including the WHO checklist, which is an important adjunct to making surgery safer," Nepogodiev said.

The study was funded by the National Institute for Health Research Global Health Research Unit at the University of Birmingham. The authors have disclosed no relevant financial relationships.

Br J Surg. Published online June 25, 2019. Abstract

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