Wednesday, December 21, 2016

No improvement in complication rates after instituting an operating room checklist

A before and after study at the University of Vermont Medical Center found that a 24-item operating room checklist did not significantly reduce the incidence of any of nine postoperative adverse outcomes.

More than 12,000 cases were studied, and outcomes included mortality, death among surgical in patients with serious treatable complications, sepsis, respiratory failure, wound dehiscence, postoperative venous thromboembolic events (VTE), postoperative hemorrhage or hematoma, transfusion reaction, and retained foreign body (FB).

After the checklist was established, respiratory failure rates decreased significantly on the initial analysis, but the difference disappeared when the Bonferroni correction* was applied to the data set.

Why didn’t the checklist work? I have discussed this in previous blog posts here and here. As was true in previous papers of this nature, many of the complications studied—respiratory failure, wound dehiscence, transfusion reaction, postoperative hemorrhage or hematoma—could not have been prevented by a checklist.

The hospital probably had a reasonable VTE prophylaxis protocol before the checklist was adopted in 2012 making it unlikely to have had much of an impact on that problem. Similarly, measures to prevent retained FBs existed well before the OR checklist was invented, and retained FBs occur too infrequently to have resulted in a meaningful difference in this setting.

Another possible explanation for the lack of efficacy of the checklist is that in a university teaching hospital in the United States, most preventable adverse outcomes were already occurring at a low rate.

As part of the study, a survey of operating room personnel including surgeons, anesthesiologists, and nurses found most of the staff understood why the checklist was used and felt it improved patient safety and communication and decreased errors.

The study did not look at either the compliance with checklist use or completeness of the documents. However, the survey revealed that the staff disagreed about the level of completeness of the checklist. About 70% of nurses and anesthesiologists believe that the checklist process was rushed compared with only 42% of surgeons. [Rushed? Not us. ;-)]

Over 80% of those who completed the survey said they would like to have a check list used if they were to undergo surgery.

My view of checklists is they may not prevent complications, but the minute or two spent on going over them is probably worth the effort.

For example, I know a surgeon who found out in the middle of an operation that the type of mesh he wanted to use for a hernia repair was not available. Attention to the checklist would have allowed him to cancel the case or plan from the start to use another product.

So go ahead with your OR checklist, but don’t be surprised if it doesn’t prevent complications.

*An adjustment made to p values when several dependent or independent statistical tests are being performed simultaneously on a single data set.


Autumn said...

I too read checklist manifesto and, while airline checklists have 27 items, Dr Gawande himself said to beware of creating too long a checklist. UVM missed that fundamentally. My unit clerk friend in Plattsburgh now has to say, when she answers the phone "University of Vermont Health Network, Champlain Valley Physicians Hospital" Yes, really!

Not sure why 24 items were needed to establish Right patient, right site, right surgery, consent and preop abx as ordered. the more items you put on the list the more likely people are just going to go through the motions!

Skeptical Scalpel said...

I agree that 24 items are too many. That's what happens when a committee designs a checklist. Everyone has their own pet thing that simply must be on the list. I agree that too many items leads to noncompliance too.

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