Surgical Patients Want to See Docs Complete Pre-op Checklists

Veronica Hackethal, MD

December 19, 2019

Surgical safety checklists improve patient safety and even save lives. Yet anesthesiologists may be reluctant to use them in front of patients because they worry that doing so may increase patient anxiety.

Now a study has found the opposite: Patients overwhelmingly preferred that surgical checklists be completed in their presence. In fact, doing so actually decreased patient anxiety, according to results published online December 19 in the European Journal of Anaesthesiology.

"Patients experience far less discomfort observing the use of pre-induction checklists directly before induction of anaesthesia in the operating room than anaesthesia providers expect," Sabine Nabecker MD, Bern University Hospital, Bern, Switzerland, and colleagues write.

"[Patients] acknowledge the importance of pre-induction checklists to reduce errors and mortality and demand that anaesthesia providers use the pre-induction checklist for safety reasons," they add.

In 2008, the World Health Organization started the Safe Surgery Saves Lives program, which includes a perioperative checklist that double-checks the patient's identity, known allergies, medications, type of procedure, and incision site, among other factors. Such checklists take as few as 38 seconds to complete, yet adherence to them is low. One study reported that as few as 39% of checklists were filled out completely. Anesthesiologists may skip items that they think increase patient anxiety or may think using a checklist will delay anesthesia and surgery.

The researchers conducted a prospective observational study that included 110 anesthesia providers (50% female; 48% anaesthesiologists; 52% anaesthesia nurses; 29% overall had fewer than 5 years of experience in their profession). It also included 125 German-, English-, and French-speaking patients who had elective ear, nose and throat, or maxillofacial surgery between June and August 2016, were not premedicated, and had a signed general research consent form (44% female; median age, 53 years). Researchers excluded patients younger than 18 years, patients in daycare, and those with premedication, dementia, or other mental illnesses.

Researchers asked anesthesia providers and patients to rate the following three statements on a 0-to-100 visual analogue scale (VAS), with 0 meaning no agreement and 100 meaning total agreement:

  1. Anesthesia providers should use checklists in the presence of the patient.

  2. Using a checklist prior to anesthesia induction causes discomfort for the patient.

  3. The use of checklists prior to induction of anesthesia reduces the risk of errors.

Researchers asked providers these questions at a weekly departmental meeting. They asked patients immediately after arriving in the operating room, and again on the first postoperative day, while their memory was still fresh. They also asked patients if they recalled whether the checklist had been used.

Only six patients were lost to follow-up, and 119 patients answered the second questionnaire.

Patients overwhelmingly agreed that providers should use checklists in front of them (statement 1), with a median VAS of 100 both before surgery and on postoperative day 1. Providers rated this question significantly lower than patients, with a median of 81 (P < .001).

For statement 2, providers rated patient discomfort with checklists significantly higher than did patients, both before surgery (median VAS 43 and 7, respectively; P < .001) and on postoperative day 1 (median VAS 7 and 0, respectively; P = .001).

Providers and patients agreed that checklists decrease errors (statement 3), though providers rated this question slightly lower (providers median VAS 93 vs patients before surgery VAS 97 [P = .039] and vs patients on postoperative day 1 VAS 100 [P < .001]).

Ninety-four percent of patients remembered that providers used the checklist.

"Anaesthesia providers estimate patient discomfort significantly higher than it is actually perceived by the patients themselves. In fact, our study suggests that although anaesthesia providers agree that checklists reduce risks, they are reluctant to use them, solely based on the wrongly assumed discomfort for patients," the authors write.

They mention several limitations. The study was relatively small and took place at a single hospital in Switzerland. Patients were mostly healthy and underwent specialty surgery, so results may not apply to other settings. Also, the accuracy of the VAS scale has not been tested for the statements used in this study.

The study was supported by a grant from the Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Bern, Switzerland. The authors have disclosed no relevant financial relationships.

Eur J Anaesthesiol. Published online December 19, 2019. Abstract

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