Abstract
BackgroundThe World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy.MethodsIn two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation.ResultsOf 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89·6 per cent) compared with that in countries with a middle (753 of 1242, 60·6 per cent; odds ratio (OR) 0·17, 95 per cent c.i. 0·14 to 0·21, P < 0·001) or low (363 of 860, 42·2 per cent; OR 0·08, 0·07 to 0·10, P < 0·001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high‐HDI countries (risk difference −9·4 (95 per cent c.i. −11·9 to −6·9) per cent; P < 0·001), but the relationship was reversed in low‐HDI countries (+12·1 (+7·0 to +17·3) per cent; P < 0·001). In multivariable models, checklist use was associated with a lower 30‐day perioperative mortality (OR 0·60, 0·50 to 0·73; P < 0·001). The greatest absolute benefit was seen for emergency surgery in low‐ and middle‐HDI countries.ConclusionChecklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low‐HDI countries was half that in high‐HDI countries.
Highlights
The volume of surgical procedures performed worldwide is large[1] and, many advances have been made in the past several decades, surgical care exposes patients to substantial risk of morbidity and mortality
In this large multinational prospective cohort study, reported use of the World Health Organization (WHO) Surgical Safety Checklist was associated with a significant reduction in 30-day perioperative mortality
Checklist use in low-Human Development Index (HDI) countries was half that of high-HDI countries, and this effect persisted after accounting for differences in patient and disease characteristics
Summary
The volume of surgical procedures performed worldwide is large[1] and, many advances have been made in the past several decades, surgical care exposes patients to substantial risk of morbidity and mortality. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89⋅6 per cent) compared with that in countries with a middle (753 of 1242, 60⋅6 per cent; odds ratio (OR) 0⋅17, 95 per cent c.i. 0⋅14 to 0⋅21, P < 0⋅001) or low (363 of 860, 42⋅2 per cent; OR 0⋅08, 0⋅07 to 0⋅10, P < 0⋅001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries Checklist use in low-HDI countries was half that in high-HDI countries. ∗Members of the GlobalSurg Collaborative are listed in Appendix S1 (supporting information)
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