A multicentric study of practice of surgical site marking

Abstract

Objective: The objective of this study was to evaluate the process of surgical site marking (SSM) and compare the actual practice with the recommended practices. Methodology: This was a prospective study involving 768 patients from 19 accredited hospitals located in different regions of India and are members of the Consortium of Accredited Healthcare Organizations. The study was performed over a period of 45 days. While performing the study, proportionate to size sampling methodology was used. The total number of surgeries performed per month in the top six specialties (in terms of volume) of the participating hospitals were considered. Further, in a particular specialty out of the six top specialties of the hospital, the auditors randomly selected the top three most frequently performed surgeries and studied the SSM process as per the predefined Pro forma. The observations of the study were then compared (and analyzed) with the recommended practices as per the guide to SSM, High 5 S by Haute Autorite d e Sante and CEPPRAL, October 2012. Results: In this study, the actual side marking was done in 85% of the surgeries that required side marking and 81% had site marking done. Surgical site in majority of the patients was marked in preoperative bay (43.8%). Moreover, surgical sites in 57.9% of the patients were marked by operating surgeons themselves, while others were delegated to nurses or technicians. Surgical side marking was done on 88.3% of the surgeries performed on paired organs. In surgeries with laterality such as hernia repair, the marking was done in 90% when the open surgery was performed and 70% for laparoscopic surgeries. Surgical site markings were visible before and after the site preparation in 63.2% and 46.5% of patients, respectively. It was pertinent to note that the SSM markings were not visible in 17.8% and 34.5% of the cases before and after skin preparation and 19% did not have the site marking. This percentage is quite high and thus an important area of concern. In addition, only in 36.1% of the patients, the SSM was visible within 6 inches from the incision. Crosses (27.7%) were the most common markings used. It is crucial that the nurses checked the patient's SSM only in 42.7% of cases in the wards and 74.1% of cases preoperatively in operation theater (OT), thereby a strong need to strengthening, streamlining, and standardization of the process of SSM to avoid missing out of cases. The surgical site marks were verbally and physically checked in 6.8% and 67.3% of the patients and not checked for 25.9% of the cases. Similarly, the surgical team inside the OT checked the surgical site marks verbally and physically in 17.6% and 77.7% of the patients, respectively. Conclusions: The findings of this study demonstrate that SSM procedure is practiced in majority of the hospital audited, but operating surgeons involved in this procedure were far from desired. Surgeons should be sensitized and educated and specialty-based protocols are to be framed so that they are strictly followed. There is a need to bring about national guidelines on the safe practice of SSM. Once protocols are in place and implemented, further studies will be required in future to assess their practice.