Safe surgery prevents infection

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One of the great ironies of medical practice is that attempts to provide care can all too often compromise patients' safety; and infection is perhaps the biggest source of disease burden resulting inadvertently from health care. In 2005, WHO established the World Association for Patient Safety (WAPS) to tackle illnesses resulting from health care. The 2006 initiative Clean Care is Safer Care promotes cleanliness in health-care facilities as a simple inexpensive approach to improve patients' safety. Last year, WAPS launched its second initiative, Safe Surgery Saves Lives, which led to a checklist designed to improve surgical practice and reduce surgery-related disease burden. The Surgical Safety Checklist focuses on basic procedures to enable its use in any setting, whatever the resources. One surprising finding of the pilot study of the checklist is that, despite there being only two items directly related to infection, the rates of surgical-site infection decreased substantially. Not only do great disparities exist in the availability of treatment for surgical diseases, but also there is a dearth of information on surgical treatment in developing countries. Although almost 35% of people live in countries where yearly health-care expenditure is less than $100 per person, less than 3·5% of the 234 million surgical procedures that take place worldwide each year are in these settings; and outcomes from procedures are poorly documented and understood. In a Newsdesk item, Kath Senior discusses the global burden of surgical disease, the WHO checklist, and other initiatives to improve surgery in resource-limited settings. Despite apparent unmet surgical needs in developing countries, surgery is one of the largest sources of nosocomial infection in such settings—contrasting with developed countries in which urinary and respiratory infections predominate. Important risk factors for surgical-site infections are characteristics of patients (eg, an infection at another site, malnutrition, having a compromised immune system), the facility (eg, funding, equipment), and experience of the surgical team. Thus, simple measures to reduce risks of surgical-site infection are essential for developing countries, where many adverse risk factors are prevalent. But can a checklist based on data from developed countries and common sense help to reduce infection and other complications as poor countries strive to meet surgical needs? The Surgical Safety Checklist comprises 19 items in three parts to be completed in a total of 3 min at key points in surgical procedures. The items include measures such as confirming patients' names and procedures, introducing theatre staff to patients, and ensuring that prophylactic antibiotics to prevent surgical-site infection are used appropriately. The pilot trial of the checklist took place in eight hospitals, one in each of Canada, India, Jordan, New Zealand, Philippines, Tanzania, the UK, and the USA, covering all six WHO regions. Encouragingly, the proportion of procedures leading to surgical-site infection fell from 6·2% to 3·4%, overall, and decreased from 20·5% before the checklist was introduced to 3·6% in one site in a developing country where appropriate antibiotic use rose from 30% to 96%. The checklist is naturally not without its critics. Some specialists are sceptical of the proliferation of checklists, claiming that care increasingly becomes focused on the ticking of boxes rather than patients' needs. Another group believe that the checklist is not complete and should be extended to the period before patients enter the operating theatre, and to discharge and follow-up care. Finally, some feel that inclusion of requirements for pulse oximetry and imaging might not be applicable in some settings and that these items could be replaced in checklists tailored to developing countries with more items related to infection control and basic surgical technique. Before changes are made, developing countries should be encouraged to implement the checklist to ascertain its benefits, applicability, and weaknesses. Although the checklist has been shaped by information from developed countries, wider experience should help to refine it. The next WAPS initiative in 2010 is to tackle the spread of resistance to antimicrobials. Indeed, without success in tackling this problem, advances in reducing surgical-site infection or improved cleanliness in hospitals might become worthless. Although the WAPS again faces the problems of limited information from resource-poor settings, results from the previous two campaigns augur well. The Safe Surgery Saves Lives initiative has set a tone for practical and achievable interventions based on limited experience and common sense that can make a real difference in a diversity of settings. WHO Surgical Safety Checklist has value worldwideA recent study evaluating WHO's Surgical Safety Checklist has reported beneficial outcomes in hospitals in countries of high, middle, and low income. The 19-item surgical checklist is designed to reduce postoperative complications that themselves cause substantial morbidity and mortality. Full-Text PDF