Operating room staff SSC use and attitude survey (Table 2):
A total of 846 individuals from 138 hospitals representing all mainland Chinese provinces responded to the survey. 74.3% were working in a Level 3 hospital (most advanced level), 15.5% in a Level 2 hospital, 1.9% in a Level 1 hospital and 8.3% in private hospitals. We obtained responses from staff with a representative distribution of roles in the SSC process (39.2% surgeons, 35.3% anaesthetists and 25.4% Operating room nurses).
The mean safety attitude score was 4.06 (minimum score = 1, maximum score = 5). Negative questions were reverse-scored. The 4 items asking a positive question scored well, with mean 85.6% affirming their environment as safe and collegiate, however the two negative items ‘it is difficult for me to speak up’ and ‘personnel frequently disregard the rules’ scored less well with mean 73.4% disagreeing with these statements (X2 = 42.50, p < 0.0001). 88.1% of all responders stated that they would feel safe being treated there as a patient.
Following its universal implementation from 2010 it was assumed that the MoH SSC was used in all hospitals. For the domain ‘attitudes towards the checklist’, only 12.7% of responders deemed that the checklist ‘took a long time to complete’. 78.8% agreed it was ‘easy to use’. A large majority agreed that the checklist improved operating room safety and communication (90.4% and 85.6% respectively) and 89.5% thought that the checklist helped prevent errors in the operating room. Only 3.4% disagreed with the statement that they would want the checklist used if they were having an operation.
Questions about anxiety induced in patients revealed that over 40% considered that a conscious patient might become anxious during repetitive confirmation of her/his identity, the procedure and operation site, or discussion of potential airway hazards and blood loss in their hearing. Over half claimed that they had experience of a patient becoming anxious because of this. Furthermore, the most common open comment was that potential blood loss and airway risk should not be discussed in the presence of a conscious patient.
Implementation and compliance study.
At all sites completion of checklists was paper-based and these were archived in the patient’s medical record after completion of the operation. Complete information was obtained from 860 checklist processes in the five hospitals. Hospital characteristics and cases by surgical specialty are reported in Table 3. Just over half of the cases were orthopaedic, with general surgery, gynaecology and thoracic surgery contributing 16%, 12% and 11% respectively.
Compliance with the WHO SSC ‘ sign-in ’ items:
As shown in Table 4, compliance with the sign-in items varies from hospital to hospital, but the five items of the WHO SSC which remain part of the MoH SSC achieved over 95% compliance. The remaining two items which are omitted from the MoH SSC were discussed less than 90% of the time. These were ‘Difficult airway or aspiration risk’ (84%) and ‘Risk of > 500 ml blood loss’ (90%).
Different professionals were responsible for leading the ‘sign-in’ phase at different sites (table 5). Depending on local policy checklist leaders were a combination of professionals although at three sites anaesthetists were not involved.
Compliance with the WHO SSC ‘ time-out ’ items:
Table 4 shows that the WHO SSC checklist item ‘introducing team members by name and role’ which is not part of the MoH SSC was rarely completed at any site (< 2%). The other nine items all remain part of the MoH SSC. These steps were completed well in some centres but not in others. Five items scored over 90% compliance (patient identification /incision site, confirmation of antibiotic prophylaxis, confirmation of sterility, equipment issues, display of essential imaging). Three items achieved less than 60% compliance (identification of critical / non-routine steps, length of surgery and anticipated blood loss). From Table 4 all professional groups engaged in the time-out process at each site, although overall compliance according to professional groups ranged from 86–100%. Leadership role varied (nurses at two sites, and anaesthetists at three sites). Staff engagement in an actual ‘time-out’ (where staff stop what they are doing to listen and participate) varied greatly; two sites achieved total compliance, whereas the other three had very poor engagement from at least one of doctors, nurses or anaesthetists. The ‘time-out’ checklist was not seen to be done at all in 6% of cases at Site C (Table 4).
The WHO Guidelines for Safe Surgery 2009 states that certain information should be sought specifically from the surgeon (critical stages, length of surgery, anticipated blood loss) and from the nurse (sterility and equipment issues)(5). Surgeon compliance with their responsible items averaged 52.3%, whereas nurse compliance averaged 91.7%. Surgeons were significantly worse than all other group and nurses significantly better (X2 = 735.5 and 744.4 respectively, both p < 0.0001).
Table 5 shows levels of engagement from doctors and nurses at different sites during the timeout phase. There was no clear association between doctors or nurses who failed to engage or to stop their activity during the timeout process and lack of compliance with items which are usually within their sphere of knowledge. On the other hand, the three hospitals in which anaesthetists took the lead in completing the checklist showed a significant association with the three surgeon-related items being better performed, in contrast to nurse-led processes in which these items were not done well (X2 = 315.6, 433.6 & 426.6 respectively, all p < 0.0001).
Compliance with the WHO SSC ‘ sign-out ’ items:
Table 4 shows that the three items which remained part of the MoH SSC achieved a high rate of compliance (over 97%). However, the two items encompassing equipment problems and patient recovery plans and concerns were discussed less frequently (66% and 28% respectively).
Participation rates across disciplines were high (Table 5), however anaesthetists were infrequently represented at two of the five sites. Overall, checklists were completed before the patient left the operation suite 97% of the time (range 80–100%).
Overall Compliance With Who Ssc Items:
Overall compliance rates of all 17 items which remained part of the MoH SSC was 87% (Table 4). The other five items removed from the MoH SSC were discussed in 54% of cases overall. One hospital (site D) achieved 100% compliance in 21/22 of their checklist items (the next best hospital achieved 15/22). At site D overall compliance was 96%, significantly better than any of the other hospitals (site D compared with next best site X2 = 567.3, p < 0.0001).
Adverse Pre-operative Events:
These event categories and incidences varied among hospitals (Table 6). At most sites overall frequency was less than 3%. However, nearly 30% of cases from site D had missing instruments which led to an operative delay.