Surgical Checklists Improve Patient Outcomes

Anette Storesund, RN, PhD

Findings of a new nonrandomized clinical trial showed that adding a preoperative and postoperative Surgical Patient Safety System (SURPASS) to the World Health Organization (WHO) surgical safety checklist was associated with a reduction in the rate of complications, reoperations, and readmissions.

The findings from Anette Storesund, RN, PhD, and a team of investigators suggested that the use of SURPASS with the safety checklist was beneficial for patients.

Storesund, from the Department of Anesthesia and Intensive Care at Haukeland University Hospital in Norway, and colleagues investigated the association of combined use of the preoperative and postoperative SURPASS and the WHO surgical safety checklist in perioperative care with morbidity, mortality, and length of hospital stay. The team saw a decrease in hospital readmissions and reduced reoperations and complications.

The investigators implemented the SURPASS checklists in 3 surgical departments in a tertiary hospital in Norway, along with the WHO surgical safety checklist. The system was developed to include known risk factors described in the literature and validated against actual registered adverse events.

The SURPASS checklists were individualized to be performed by key clinicians in the surgical pathway. The checklists were supposed to be used as a last point of check before transfer to the next segment of the pathway to ensure good planning and compliance with protocols at all transfer points.

Before implementation of the SURPASS checklists, frontline clinicians participated in educational sessions to learn why the checklists should be used, their evidence, and the practicalities of how to apply them. There was also an information campaign in the trial departments through distribution of printed posters and emails.

Storesund and the team’s primary outcomes were in-hospital morbidity consisting of complications, emergency reoperations, and 30-day readmissions, and all-cause 30-day postoperative mortality. An additional outcome was length of stay.

The team included in-hospital patients of all ages who were undergoing an elective or emergency surgical procedure. Patients were excluded if they were undergoing a radiological intervention, donor surgery, or extracorporeal membrane oxygenation procedures.

Overall, the investigators included 3892 procedures at baseline and 5117 procedures in the intervention period during the 29 months. The 9009 procedures accounted for 7772 unique patients in 8515 admissions with a mean age of 51.7 years old. There were more women in the study (62.2%) due to the inclusion of gynecology as 1 of the departments.

Among the 9009 procedures, 15.7% were associated with >1 complication. In an adjusted intention-to-treat analyses, the number decreased (OR, .73; 95% CI, .54-.98; P=.04).

The investigators found that when adherence to the preoperative SURPASS checklists was achieved, there was a decrease in in-hospital complications (OR, .7; 95% CI, .5-.98; P=.04) and emergency reoperations (OR, .42; 95% CI, .23-.76; P=.004). Adherence to the 3 postoperative SURPASS checklists was linked with a reduction of unplanned 30-day readmissions (OR, .32; 95% CI, .16-.64; P=.001).

Using the preoperative SURPASS checklist for 30-day in-hospital mortality was nonsignificant (OR, .28; 95% CI, .04-1.78; P=.17). For postoperative, the association was also nonsignificant (OR, .86; 95% CI, .68-1.08; P=.18).

There was also no change in 30-day mortality after discharge associated with using the preoperative (OR, 1.67; 95% CI, .38-7.44; P=.5) or the postoperative SURPASS (OR, .64; 95% CI, .17-2.45; P=.51) in all adjusted analyses.

The findings demonstrated that adding the SURPASS checklists to the intraoperative WHO surgical safety checklist could be clinically advantageous. The joint application of the 2 checklists led to a reduction of in-hospital complications, emergency reoperations, and hospital readmissions. What's more, checklists can make surgical care safer.

The study, “Clinical Efficacy of Combined Surgical Patient Safety System and the World Health Organization’s Checklists in Surgery,” was published online in JAMA Surgery.