Using a checklist in the operating theatre could save lives and money
SURGICAL TEAMS that followed a basic cockpit-style checklist in the operating room, from confirming the patient’s name to discussing expected blood loss, reduced the rate of deaths and complications by more than one-third, according to a year-long, eight-nation project.
Surgeons, it seems, are discovering what airline pilots learned decades ago: The human brain can’t remember everything, so it’s best to focus on the complicated challenges and leave the simple reminders to a cheat sheet.
“You take something as complex as surgery, and you think there isn’t a lot that can be done to make it better,” says Atul Gawande, a Boston physician who led the study being published in the New England Journal of Medicine. “A checklist seems like a no-brainer, but the size of the benefit is dramatic.”
The low-cost, low-tech intervention tested in eight hospitals around the globe could have enormous financial implications as well. If every operating room in the US adopted the surgical checklist, the nation could save $15-$25 billion a year in the cost of treating avoidable complications, according to calculations by the authors.
In the one-year pilot study involving 7,600 patients, the hospitals saw the rate of serious complications fall from 11 per cent to 7 per cent. Inpatient deaths fell by more than 40 per cent overall, with the most drastic reductions occurring in hospitals with fewer resources.
More than 234 million surgeries are performed worldwide each year, with 3-17 per cent resulting in major complications such as a life-threatening infection. In the US, the average surgical complication costs $12,000 to treat, though as many as half are preventable, according to several studies over the past 15 years.
Even as modern medicine becomes increasingly sophisticated, “we’re not great at doing the simple things all the time”, says Gawande, a surgeon at Boston’s Brigham and Women’s hospital and a medical writer for the New Yorker magazine.
For the study, which was prompted by the World Health Organisation, hospitals in eight countries adopted a 19-step checklist in non-cardiac surgeries. The project involved rural and urban hospitals with diverse populations in cities such as Seattle, London, New Delhi, Manila and Ifakara, Tanzania.
According to the checklist, before an operation begins, the team members introduce themselves, review the patient’s name and the procedure to be done. They discuss allergies, confirm that all equipment has been sterilised and necessary antibiotics administered, and assess potential problems such as blood loss. After the surgery but before the patient leaves the operating room, the team returns to the checklist, labelling specimens and ensuring that all equipment has been removed from the patient.
Though the steps are routine, an astonishing number of doctors and nurses miss at least one, Gawande says. “If you miss a few per cent here and a few per cent there, it adds up,” he says. The central premise of a checklist “is making sure that nothing is missed. It’s an all-or-none phenomenon.”
Donald Berwick, the physician president of the Institute for Healthcare Improvement, which promotes high-quality advances in the delivery of care, says: “I cannot recall a clinical care innovation in the past 30 years that has shown results of the magnitude demonstrated by the surgical checklist.”
Very few US hospitals are using the surgical safety checklist, though Berwick aims to introduce it in the 4,000 hospitals participating in his institute’s programmes. The major barrier to widespread adoption is physician attitudes, several experts say. “If you ask surgeons, they’ll say, ‘oh, we do this stuff’,” Gawande says.
According to David Flum, a surgeon at the University of Washington Medical Center, the few minutes it takes to read down a checklist “are well worth it in order to save a patient from having a horrible complication”.
Peter Pronovost, a physician at Johns Hopkins University and a longtime proponent of medical checklists, agrees. But he is sceptical of the study’s reported huge drop in post-surgery deaths, and observes that the study did not reveal equally dramatic improvements in sub-categories such as pneumonia.
– (LA Times/Washington Post)