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Checklists can help in surgical crises, too: study


By Andis Robeznieks
Posted: January 21, 2013 - 7:00 pm ET
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By using simulation technology, researchers were able to show something previously thought impossible to prove: the benefits of using surgical checklists in an operating room emergency.

In an Agency for Healthcare Research and Quality-funded study, a team of researchers observed 17 surgical teams participating in 106 staged crises. The researchers found there was stricter adherence to critical steps in “life-saving processes” when a set of crisis checklists was available.

According to a report in the New England Journal of Medicine, there was a 75% reduction in “failure to adhere to critical steps” when checklists were used. In these instances, 6% (24 of 371) of the critical steps were missed, compared to 23% (89 of 379) when teams were working from memory. Each session was recorded, and physician researchers observed and scored adherence to the established, evidence-based response guidelines.

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“We know that checklists work to improve safety during routine surgery,” AHRQ Director Dr. Carolyn Clancy said in news release. “Now, we have compelling evidence that checklists also can help surgical teams perform better during surgical emergencies.”

Surgical teams from three Boston-area institutions, including two community hospitals and one academic medical center, spent six hours in a “high fidelity simulated operating room” where they were presented with emergency scenarios in which half the time they had access to a checklist booklet and half the time they went from memory. Simulated emergencies included gas bubbles in the bloodstream, severe allergic reaction, irregular heart rhythms associated with bleeding, or an unexplained drop in blood pressure, according to the AHRQ news release.

Four years ago, we showed that completing a routine checklist before surgery can substantially reduce the likelihood of a major complication,” said lead researcher Dr. Atul Gawande, checklist champion and a general and endocrine surgeon at Brigham & Women's Hospital in Boston. He is also a professor at the Harvard School of Public Health and Harvard Medical School.

“For decades, we in surgery have believed that surgical crisis situations are too complex for simple checklists to be helpful,” Gawande said in the release. “This work shows that assumption is wrong.”

The study's main measure was failure to adhere to the life-saving processes of care. In an e-mail, Gawande said it would be too hard to speculate which simulations would have resulted in death or injury to the patient.

Participants in the study were surveyed, and 97% agreed with the statement: “If I were having an operation and experienced this intraoperative emergency, I would want the checklist to be used.”

The report noted that the results of the scenarios were similar across all three institutions, but also added that a limitation of the study was that a surgeon was not present at most of the sessions.

“Their participation would have been preferable, but it was difficult to enlist volunteers,” the authors wrote. “However, we found no evidence that the presence of a surgeon reduced the benefit of the checklist intervention.”

The key processes being tracked, according to the report, “were primarily the responsibility of nursing and anesthesiology staff.”

In an e-mail, Gawande explained that it was easier to recruit anesthesiologists and nurses who were on salary to participate. But for surgeons, participating in a six-hour study represented lost income.

It was also mentioned that these types of emergencies are rarely experienced by individual practitioners, but that roughly 145 such events are estimated to occur annually at hospitals performing 10,000 operations a year.

“A shift in the medical culture may be necessary if healthcare providers are expected to pull out a cognitive aid during an intraoperative (or any other) emergency,” the authors concluded. “Several studies have shown that the retention of memorized knowledge of accepted clinical algorithms is poor during crises.”


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