WHO Surgical Checklist in Transplant Surgery: Still another tick box exercise? Results from a Closed Loop Audit at a Medium-Sized Transplant Centre

doi:10.21203/rs.3.rs-3300360/v1

Download PDF

Short Report

WHO Surgical Checklist in Transplant Surgery: Still another tick box exercise? Results from a Closed Loop Audit at a Medium-Sized Transplant Centre

https://doi.org/10.21203/rs.3.rs-3300360/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

Background: There is compelling evidence that effective teamwork can significantly reduce adverse events in medical settings. Our 2014 audit revealed that the adherence to the WHO Surgical Checklist for renal transplant and vascular access procedures was less than optimal.

Objective: The aim of this re-audit was to quantitatively evaluate any changes in practice since the 2014 findings and recommendations.

Methods: Theatre personnel, comprising surgeons, nurses, and anaesthetists, were spontaneously queried regarding patient and staff details both intra-operatively and post-operatively, as outlined in the WHO Checklist. This was done across 54 surgical sessions with the Transplant Team. Importantly, staff were unaware of this impromptu survey, mitigating the potential for the Hawthorne effect.

Results: The Checklist was rigorously adhered to in 100% of the operations (N=54) across all specified phases (Pre-anaesthesia induction - "Check-in"; Pre-skin incision - "Time out"; Prior to patient exiting the theatre - "Sign out"). These results were benchmarked against the 2014 study. While there was a statistically significant improvement in the recall of the patient's ID and the primary surgeon's name, the name of the assisting surgeon was not remembered in 78% of the queries. Moreover, full retention of the anaesthetist's and scrub nurse's IDs was not achieved. Notably, no intraoperative "never events" or near-miss incidents were recorded in either cohort.

Conclusions: While there was complete adherence to reading the checklist in all operations, the retention of specific details by staff was inconsistent. Although there has been noticeable progress in information retention since 2014, there remains a considerable need for enhancement.

Worldwide, an estimated 312 million surgical procedures are conducted annually, with a significant proportion of associated complications being potentially preventable (1, 2). Global figures suggest that major perioperative complications range from 3–17%, and mortality rates for inpatient surgeries fall between 1.5% and 4% (2, 3, 4, 5, 6). Critical errors, such as misidentification of patients, surgical site or procedure discrepancies, equipment shortages, unanticipated haemorrhage, use of unsterile instruments, and retention of surgical instruments post-surgery, contribute significantly to these figures. A considerable body of evidence highlights that the majority of these errors emanate from inadequate communication and teamwork in the operating room (OR) (4–6). Over the past decade, these insights have catalysed the creation and adoption of safety checklists in ORs to mitigate the risk of patient complications and mortality (1–4).

The WHO Surgical Safety Checklist (SSC)

In 2007, the World Health Organisation's (WHO) Patient Safety Program embarked on an initiative to develop the WHO Surgical Safety Checklist (SSC) (7). This tool was meticulously designed to enhance communication, teamwork, and the uniformity of patient care during the pre-operative, intra-operative, and immediate post-operative phases. A 2008 pilot study of the SSC yielded impressive results, showing a reduction in patient mortality from 1.5–0.8% and a decrease in complications from 11–7% (6). These outcomes remained consistent across healthcare institutions of varying sizes and financial capacities. Some institutions have even reported a staggering 57% reduction in complications post-SSC adoption (8, 9, 10).

The SSC, a 19-item list, fosters interdisciplinary communication within OR teams (4, 5, 6, 7). It is segmented into three distinct sections, each aligned with specific junctures in the surgical process: the "sign-in" prior to anaesthesia induction, the "time-out" just before the skin incision, and the "sign-out" immediately following skin closure. This structured approach ensures all vital information is cross-verified and relayed to all OR team members. Interestingly, merely introducing team members, as facilitated by the SSC, has been shown to be one of the most effective interventions to boost an individual's engagement and sense of accountability, thus empowering them to voice concerns or flag potential issues (5, 6, 7). Given the fluidity of OR team compositions, fostering such familiarization is paramount to optimize communication and collaboration.

From its inception, the WHO emphasized the SSC's adaptability, encouraging institutions to tailor it to their specific contexts (11–13). Although over 2000 ORs globally utilize the SSC, its implementation isn't devoid of challenges (9). Numerous studies have pinpointed a potential pitfall: the perception of the SSC as a mere administrative task, rather than an integral component of surgical safety (11, 12). If used superficially, the SSC's potential is nullified, possibly introducing new risks, such as omitted checks or dismissive responses from senior staff (12). For the SSC to truly revolutionize patient safety, its implementation demands more than rote compliance. Effective utilization hinges on the OR staff's genuine commitment to the checklist's principles and their empowerment to actively engage with, question, and act upon the items therein (14).

Objective:

The principal objective of our research was to investigate adherence to the World Health Organization Surgical Safety Checklist (WHO SSC) during renal transplant and vascular access procedures. Following an initial 2014 audit that highlighted discernible gaps in the transmission of information, it was recommended for the operating room (OR) staff to be more engaged with the checklist. Consequently, the purpose of the subsequent 2020 re-audit was to ascertain if there had been any enhancement in the engagement levels with the checklist over the intervening period.

Data Collection and Sample

In 2020, replicating the data collection strategy from 2014, we selected a consecutive series of 54 transplant and vascular access surgeries performed at The Royal Liverpool University Hospital. The consultant surgeon was responsible for data gathering. Questions derived from the WHO SSC were directed at both the transplant team and the OR staff pre- and post-operation.

Engagement and Compliance Metrics

To gauge engagement, the extent to which staff retained information from the SSC when queried a subsequent time was evaluated. Furthermore, compliance was ascertained by determining whether checklist items were deliberated upon at any juncture during the surgical procedure.

Items Assessed: The following checklist components were posed to the staff both prior to and following the surgical procedure: Patient's Name/ID, chief surgeon's name, first assistant's name, anaesthetist's name, scrub nurse's name, operation side/site (post-operative query only), specific operation title, sponge count, and specimen labelling.

Survey Approach

To curtail the potential influence of the Hawthorne effect—wherein an individual's performance might be enhanced simply due to the awareness of being observed—the queries were informally presented, ensuring the staff remained unaware of this impromptu survey. The project was exempted from the formal ethical approval process as it was categorized as a clinical audit of standard practice and a quality improvement initiative.

Statistical Analysis

In the study, we used DATA tab Statistics for our calculations. A p-value of < 0.05 was regarded as statistically significant.

Utilization of the Surgical Safety Checklist

In 2020, a comprehensive examination of the WHO Surgical Safety Checklist (SSC) was conducted across 54 sequential renal transplant and vascular surgical procedures. This assessment focused on nine specific elements from the SSC, as delineated in Table 1. These results were juxtaposed with those obtained in a prior study conducted in 2014, as outlined in both Table 1 and Fig. 1.

Table 1

Results of the Snapshot WHO Checklist Audit 2020
Question	Aware − 2014 (%)	Aware- 2020 (%)	Not Aware – 2014 (%)	Not Aware – 2020 (%)	p- value Chi Sq test
Name/ID of the Patient	12/30 (40%)	32/54 (59%)	18/30 (60%)	22/54 (41%)	< 0.01
Name of Surgeon	11/21 (52%)	39/54 (72%)	10/21 (48%)	15/54 (28%)	< 0.01
Name of the First Surgical Assistant	07/16 (43%)	12/54 (22%)	09/16 (57%)	42/54 (78%)	< 0.01
Name of Anesthetist	09/15 (60%)	36/54 (66%)	06/15 (40%)	18/54 (34%)	0.42
Name of Scrub Nurse	17/22 (77%)	41/54 (75%)	05/22 (23%)	13/54 (25%)	0.57
Side/site of operation (asked post operatively)	9/11 (81%)	49/54 (89%)	02/11 (19%)	5/54 (11%)	0.33
Name of the operation	17/21 (81%)	44/54 (81%)	05/21 (19%)	10/54 (19%)	0.75
Surgical Sponge count	22/22 (100%)	54/54 (100%)	-	-	1
Labeling of the specimen	19/21 (90%)	6/7(85%)	02/21 (10%)	1/7( 15%)	0.19

Comparative Assessment of Checklist Adherence: Consistently across the years 2014 and 2020, the SSC was rigorously adhered to in every operation under scrutiny. This involved three critical phases: pre-anaesthetic induction (referred to as 'check in'), immediately prior to the surgical incision ('time out'), and right before the patient's exit from the operating room ('sign out').

Detailed Observations from 2020 vs. 2014 Data

A comparative analysis revealed marked enhancements in specific domains. By 2020, there was a significant surge in the awareness levels related to the identification of the patient's name and the primary surgeon. In the 2014 cohort, a mere 40% of the OR staff could accurately recall the patient's name or ID upon inquiry. This metric saw a commendable escalation to 59% by 2020. Similarly, the recognition rate of the chief surgeon's name rose from 52% in 2014 to 72% in 2020.

However, not all parameters experienced advancement. Intriguingly, the recognition of the first surgical assistant's name dwindled considerably from 43% in 2014 to just 22% in 2020, a decline that was statistically significant (p < 0.01). Another element that saw a slight decrement was the accuracy in labelling specimens, which regressed from 90% in 2014 to 85% in 2020.

In terms of maximal awareness among the OR staff, the count of surgical sponges stood out with a consistent 100% recognition in both study years. In stark contrast, the least recognized item was the name of the first surgical assistant.

Clinical Implications

It is noteworthy to highlight that across both research cohorts, there were no reported instances of intraoperative "never events" or near-miss scenarios, underscoring the crucial role of stringent procedural checks.

Re-assessment of WHO SSC Engagement

The focal point of this re-audit was to evaluate the extent of our surgical team's engagement with the WHO Surgical Safety Checklist (SSC) since its introduction in 2011 and subsequent assessment in 2014. After adopting the WHO SSC into our operative protocols, data from 2014 revealed suboptimal retention of checklist information. Despite this realization and the subsequent feedback provided to the surgical team, there was negligible evolution in both the perception and implementation of the WHO SSC from 2014 to 2020, as illustrated in Table 1.

Preliminary Observations

An overarching theme from the 2020 data suggests a possible superficial adherence to the SSC, hinting at a potential "tick box" approach to its utilization. This perception arises from the observed limited retention of the checklist information by the OR staff. Such limited engagement might be attributed to an insufficient comprehension of the checklist's intrinsic value and its pivotal role in enhancing patient safety. Efficacious application of the checklist not only fortifies communication within the surgical team but also fosters an environment where concerns can be candidly articulated. (4) Importantly, it's not merely the act of ticking off items that enhances safety; it's the resulting actions and discussions that genuinely mitigate complications.

Criticality of Effective Implementation

Evidence suggests that the efficacy of any clinical intervention, checklists included, is intrinsically tied to its meticulous implementation. (11, 12, 15) The lacklustre recall of the SSC items could be symptomatic of a superficial understanding of its core purpose. Prior research underscores the imperative of a comprehensive explication of the checklist's rationale and its optimal utilization strategy. (10) To foster genuine engagement, a unified comprehension of the SSC's essence is vital, as disparities in understanding can exacerbate interpersonal dynamics and amplify hierarchical tensions. (4)

Imperatives for Successful Implementation

Reflecting upon the insights from the prior audit (17), the foundational pillars for successful SSC deployment include the identification of local champions, unwavering organizational leadership, and robust training mechanisms. Emphasis must be accorded to training, ensuring clarity in checklist execution, especially regarding the leadership of checklist segments. Concurrently, for sustainable implementation, senior leadership endorsement is paramount. Continuous audits and feedback loops are indispensable for refining compliance.

Need for Enhanced Research

There is an evident gap in correlating SSC utilization with tangible surgical outcomes, specifically morbidity and mortality rates. Comprehensive audits that transcend mere checklist recitation and delve deeper into the real-time application and its consequent impact on team dynamics are quintessential. An in-depth questionnaire to unearth the underlying reasons for subpar checklist recall, akin to the suggestions by Haugen et al., (10) could offer valuable insights.

Potential Solutions

To bolster engagement, innovative strategies such as wall-mounted WHO SSC posters or digital platforms (6) (currently in use at Liverpool) could be pivotal in minimizing risk events and enhancing patient safety.

Limitations

This study, while insightful, has its constraints. The operations evaluated were primarily from the transplant unit, and thus, the findings might not be universally applicable across all surgical domains. Furthermore, the cross-sectional nature of the study limits its ability to draw robust causal inferences.

In both reviewed periods, the teams consistently filled out the WHO SSC, but we noticed some lack of commitment and memory of its details. Research clearly shows that the WHO SSC is crucial for preventing surgical mistakes. Because of this, we urgently need better ways to help our team understand and use the checklist effectively. In conclusion, further studies are required to assess the impact the WHO SSC has had on patient morbidity and mortality. This would give us more evidence to conclude if the checklist is more than a simple tick-box exercise.

Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflicts of Interest: The authors declare no conflicts of interest associated with this manuscript.

Ethics Approval: The project was exempted from the formal ethical approval process as it was categorized as a clinical audit of standard practice and a quality improvement initiative as per the Trust’s Guidelines.

Consent for Publication: Not applicable.

Availability of Data and Materials: The datasets generated and/or analysed during the current study are available from the corresponding author upon reasonable request.

Dobson GP. Trauma of major surgery: A global problem that is not going away. Int J Surg (London England). 2020;81:47–54.
Gawande AA, Thomas EJ, Zinner MJ et al. The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery, 126(1), 66–75.
Kable AK, Gibberd RW, Spigelman AD. Adverse events in surgical patients in Australia. Int J Qual health care: J Int Soc Qual Health Care. 2002;14(4):269–76.
Fudickar A, Hörle K, Wiltfang J, et al. The effect of the WHO Surgical Safety Checklist on complication rate and communication. Deutsches Arzteblatt international. 2020;109(42):695–701.
Russ SPhD, Rout, Shantanus MRCS, Sevdalis NPhD et al. Do safety Checklists Improve Teamwork and Communication in the Operating Room? A systematic review, Annals of Surgery: December 2014- Volume 258- Issue 6 – p 856–71.
Haynes AB, Weiser TG, Berry, Safe Surgery Saves Lives Study Group, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491–9.
Willassen ET, Jacobsen I, Tveiten S. Safe Surgery Checklist, Patient Safety, Teamwork, and Responsibility-Coequal Demands? A Focus Group Study. Global qualitative nursing research. 2018;5:2333393618764070.
Urbach DR, Govindarajan A, Saskin R, Wilton AS, Baxter NN. Introduction of surgical safety checklists in Ontario, Canada. N Engl J Med. 2014;370(11):1029–38.
Vats A, Vincent CA, Nagpal K, Davies RW, Darzi A, Moorthy K. Practical challenges of introducing WHO surgical checklist: UK pilot experience. BMJ. 2010;340:b5433.
Haugen AS, Sevdalis N, Søfteland E. Impact of the World Health Organization Surgical Safety Checklist on Patient Safety. Anesthesiology. 2019;131(2):420–5.
Weiser TG, Haynes AB. Ten years of the Surgical Safety Checklist. Br J Surg. 2018;105(8):927–9.
Emond YEJJM, Calsbeek H, Peters YAS, Bloo GJA, et al. Increased adherence to perioperative safety guidelines associated with improved patient safety outcomes: a stepped-wedge, cluster-randomised multicentre trial. Br J Anaesth. 2022;128(3):562–73.
Department of Health. An organisation with a memory. Report of an expert group on learning from adverse events in the NHS. London: The Stationery Office., 2000. http://patientsafety.health.org.uk/resources/organisation-memory [Accessed 30 July 2021].
Lucian LLMD. (2014). The Checklist Conundrum, N engl j med 370;11.
White MC, Daya L, Karel FK et al. Using the Knowledge to Action Framework to Describe a Nationwide Implementation of the WHO Surgical Safety Checklist in Cameroon, Anesthesia & Analgesia: May 2020 - Volume 130 - Issue 5 - p 1425–34.
Cushley C, Knight T, Murray H et al. Writing's on the wall: improving the WHO Surgical Safety Checklist. BMJ open quality, 10(1), e001086.
Sharma H et al. WHO Surgical Checklist in renal transplant: Is it another tick box exercise? https://bts.org.uk/wp-content/uploads/2016/09/BTS_Abstract_pdf_2014.pdf.

No competing interests reported.

Download PDF

Version 1

posted

You are reading this latest preprint version

WHO Surgical Checklist in Transplant Surgery: Still another tick box exercise? Results from a Closed Loop Audit at a Medium-Sized Transplant Centre

Status:

Version 1

Abstract

Figures

Introduction

Objective:

Methodology

Results

Discussion

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1