Preoperative Checklist Research Articles

Principles of surgical care: preoperative care

This article discusses the care of people prior to their undergoing a surgical procedure. For many, the thought of having to undergo surgery can cause distress and anxiety. The healthcare assistant and assistant practitioner (HCA and AP), understanding the issues that people may face, are in an ideal position to offer support to patients, both from a physical and a psychological perspective. This article outlines the principles of preoperative care, describing the categories and types of surgery. There is a discussion regarding the concerns that patients might have prior to surgery, preoperative information-giving and teaching and the importance of a preoperative checklist.

The Role of Smile Train and the Partner Hospital Model in Surgical Safety, Collaboration, and Quality in the Developing World.

The partner hospital model identifies hospitals in the developing world to educate and enable local surgeons to deliver effective cleft care. This study aimed to determine the outcomes of this model on safety, education, and quality of surgical care. Twelve partner hospitals, sponsored by Smile Train for 5 or more years and distributed over 4 continents, were selected. Activities at each institution were evaluated using cleft surgical data, and surveys were completed by hospital leadership. A mean of 82% of cleft patients at partner hospitals underwent sponsored surgeries. After partnership, all 12 hospitals implemented preoperative checklists for cleft surgery, and 5 implemented checklists for other surgeries. All hospitals had personnel who received safety training as a result of partnership. There was no change in 30-day reoperations or readmissions. Follow-up rate increased by 18% (P = 0.03). Facilities recruited 1.8 additional cleft surgeons (P < 0.01) and increased the number of cleft surgical trainees by a mean of 13.3 annually (P = 0.012); 2.5 ± 1.7 additional ancillary services were added, resulting in 75% of partner hospitals having a basic multidisciplinary cleft team (surgery, speech, and dental) compared with 25% prior to partnership (P < 0.01). Total cleft surgeries, alveolar bone grafts, and percentage of secondary surgeries increased significantly as length of partnership progressed (P < 0.01). Smile Train's partner hospital model increases both the volume and quality of cleft care delivered at these institutions. Safety initiatives for cleft care demonstrate effects extending to global surgical care delivered at partner hospitals.

A call centre and extended checklist for pre-screening elective surgical patients – a pilot study.

BackgroundNovel approaches to preoperative assessment and management before elective surgery are warranted to ensure that a sustainable high quality service is provided. The benefits of a call centre incorporating an extended preoperative electronic checklist and phone follow-up as an alternative to a clinic attendance were examined.MethodsThis was a pilot study of a new method of patient assessment in patients scheduled for elective non-cardiac surgery and who attended a conventional preoperative clinic. A call centre assessment, using a Computer-assisted Health Assessment by Telephone (CHAT), paper review by an anaesthetist, and a follow-up phone call if the anaesthetist wished more information, preceded the conventional preoperative clinic. Summaries from the call centre and clinic assessments were independently produced.The times spent by call centre staff were recorded. The ‘procedural anaesthetist’ (who provided anaesthesia for each patient’s actual surgery/procedure) documented an opinion on whether the call centre assessment alone would have been sufficient to bypass the preoperative clinic if the patient were hypothetically undergoing laparoscopic cholecystectomy. This opinion was also sought from a panel of four senior anaesthetists, based on patient summaries from both the call centre and preoperative clinic, but expanded to three hypothetical operations of different complexity – cataract removal, laparoscopic cholecystectomy, and total hip replacement.ResultsCall centre assessment followed by clinic attendance was studied in 193 patients. The mean time for CHAT was 19.8 (SD 7.5) minutes and, after review of CHAT summaries, anaesthetists telephoned 45.6 % of cases for follow-up information. The mean time spent by anaesthetists on summary review and phone calls was 3.8 (SD 3.9) minutes. Procedural anaesthetists considered 89 % of the patients under their care suitable to have bypassed the preoperative clinic if they were to have undergone cholecystectomy. The panel of senior anaesthetists judged 95-97 % of patients suitable to have bypassed preoperative clinic for cataract surgery, 81-85 % for cholecystectomy and 79-82 % for hip replacement.ConclusionsA call centre to pre-screen elective surgical patients might substantially reduce patient numbers attending preoperative anaesthetic assessment clinics. Further studies to assess the quality of such an approach are indicated.Trial registrationANZCTRACTRN12614000199617.

Acute Kidney Injury Subsequent to Cardiac Surgery

Acute kidney injury (AKI) after cardiac surgery is a common and underappreciated syndrome that is associated with poor short- and long-term outcomes. AKI after cardiac surgery may be epiphenomenon, a signal for adverse outcomes by virtue of other affected organ systems, and a consequence of multiple factors. Subtle increases in serum creatinine (SCr) postoperatively, once considered inconsequential, have been shown to reflect a kidney injury that likely occurred in the operating room during cardiopulmonary bypass (CPB) and more often in susceptible individuals. The postoperative elevation in SCr is a delayed signal reflecting the intraoperative injury. Preoperative checklists and the conduct of CPB represent opportunities for prevention of AKI. Newer definitions of AKI provide us with an opportunity to scrutinize perioperative processes of care and determine strategies to decrease the incidence of AKI subsequent to cardiac surgery. Recognizing and mitigating risk factors preoperatively and optimizing intraoperative practices may, in the aggregate, decrease the incidence of AKI. This review explores the pathophysiology of AKI and addresses the features of patients who are the most vulnerable to AKI. Preoperative strategies are discussed with particular attention to a readiness for surgery checklist. Intraoperative strategies include minimizing hemodilution and maximizing oxygen delivery with specific suggestions regarding fluid management and plasma preservation.

Improving Education and Standards for Cleft Care in the Developing World

INTRODUCTION The partner hospital model identifies hospitals in the developing world to educate and enable local surgeons to deliver effective cleft care. This study aimed to determine the outcomes of this model on safety, education, and quality of surgical care. MATERIALS AND METHODS Twelve partner hospitals, sponsored by Smile Train for 5 or more years and distributed over 4 continents, were selected. Activities at each institution were evaluated using cleft surgical data, and electronic surveys were completed by hospital leadership. RESULTS A mean of 82% of patients with cleft at partner hospitals underwent sponsored surgeries. After partnership, all 12 hospitals implemented preoperative checklists for cleft surgery, and 5 hospitals implemented checklists for other surgeries. All hospitals had personnel who received safety training as a result of partnership. There was no change in 30-day reoperations or readmissions. Follow-up rate increased by 18% (P = 0.03). Facilities recruited 1.8 additional cleft surgeons (P < 0.01) and increased the number of cleft surgical trainees by a mean of 13.3 annually (P = 0.012); 2.5 ± 1.7 additional ancillary services were added, resulting in 75% of partner hospitals having a basic multidisciplinary cleft team (Surgery, Speech, and Dental), compared with 25% prior to partnership (P < 0.01). Total cleft surgeries, alveolar bone grafts, and percentage of secondary surgeries increased significantly as the length of partnership progressed (P < 0.01). CONCLUSIONS A model to enhance global education and delivery of cleft care through development and support of local hospitals increases both the volume and the quality of cleft care delivered at these institutions. Safety initiatives for cleft care demonstrate effects extending to global surgical care delivered at partner hospitals.

A Checklist for Endonasal Transsphenoidal Anterior Skull Base Surgery

Introduction: Approximately 250 million surgical procedures are performed annually around the world, and data suggest that major complications occur in 3 to 17%. Many of these complications can be classified as avoidable, and previous studies have demonstrated that preoperative checklists and improved OR teamwork decrease complication rates. Although our institution has instituted a general preoperative “time-out” designed to streamline communication, flatten vertical authority gradients, and decrease procedural errors, there is no specific checklist for endonasal transsphenoidal anterior skull base surgery, with or without endoscopy. Such minimally invasive cranial surgery includes a completely different conceptual approach, setup, instrumentation, and operative procedures, and subsequently can be associated with different types of complications as compared with open cranial surgery. We hypothesize that a detailed, procedure-specific preoperative checklist would be useful to reduce errors, improve outcomes, decrease delays, and to maximize both team building and operational efficiency.

Initial Utilization of an Electronic Medical Record Living-Donor Kidney Transplant Preoperative Checklist.

Purpose: We created an electronic medical record(EMR) living-donor kidney transplant(LDKT) preoperative checklist used to enhance patient safety and prevent “never” events such as transplant with incompatible (ABO)blood type, positive (XM)cross match, infectious disease(ID) transmission, or an anatomically inappropriate kidney. Methods: Recipient preoperative EMR checklists from September 2011 deployment until present were retrospectively reviewed. The checklist included both recipient and donor information: demographics, ABO, XM / panel reactive antibody(PRA) results, ID status(Hepatitis B, Hepatitis C, Human Immunodeficiency Virus), and kidney anatomy(laterality, arteries, veins, ureters). Attestation statements acknowledging compatibility in each domain were required. The checklist used auto-populated recipient data directly from the EMR and donor data manually entered from source documentation. This ensured critical review of source documentation and facilitated identification of incompatibility by the recipient surgeon. Checklists were completed 1-7 days pre-transplant. Completion rates of the entire document and individual sections were assessed. Results: A total 157 LDKT checklists were reviewed. Mean recipient age was 48.4 years with 56.6% male and 43.5% female. Checklist completion rate was 87.9% across 5 surgeons. All completed checklists contained recipient ABO while 5.1% lacked donor data, but 98.6% noted ABO compatibility. Similarly, XM results were omitted in 7.2% of checklists(up to 18.1% lacked virtual PRA data) but overall XM was acceptable in 93.5% with 1 erroneously noting incompatibility. Risk of ID was completed in all but 6.52% of checklists while 98.5% were deemed acceptable. Anatomic details were present in all but 3.6% of checklists with only 1(paired donor organ from another hospital) not confirming donor and recipient surgeon discussion. The checklist identified 1 instance of inadequate ID screening, which cancelled transplantation 1 day pre-operatively. No “never” events occurred. Conclusions: This novel EMR-based preoperative LDKT checklist enhanced patient safety by preventing “never” events. It operated by facilitating critical review and referencing of source documentation to confirm ABO, XM, ID risk, and anatomic organ compatibility. It is easy to use with high compliance rates and is available to all healthcare team members. Further means to ensure completeness and 100% compliance are being evaluated.

Parental involvement in the preoperative surgical safety checklist is welcomed by both parents and staff.

We involved the parents of paediatric patients in the first part of the three-stage WHO Surgical Safety Checklist (SSC) process. Forty-two parents took part in the study. They came to the theatre suite with their child and into the induction room. Immediately before induction of anaesthesia they were present at, and took part in, the first stage of the three-stage SSC process, confirming with staff the identity of their child, the procedure to be performed, the operating site, and the consent being adequately obtained and recorded. We asked parents and theatre staff later whether they thought that parental involvement in the SSC was beneficial to patient safety. Both parents and staff welcomed parental involvement in the WHO Surgical Safety Checklist and felt that it improved patient safety.

Use of a Preoperative Checklist Reduces Risk of Penile Prosthesis Infection

Infection of a penile prosthesis is a devastating complication that necessitates the removal of all device components. Many aspects of preoperative and intraoperative infection prophylaxis practices have been examined but the specific relevant factors remain unknown. We determined whether use of a mandatory checklist of perioperative practices believed to reduce the risk of prosthesis infection would impact patient safety. We retrospectively reviewed men with erectile dysfunction who underwent penile prosthesis insertion. Only patients who had not previously undergone penile prosthesis surgery were included in the study. After an outbreak of infections, a mandatory checklist comprised of best infection prophylaxis practices was developed and was required for all subsequent implant surgeries. Patient cohorts were divided into 3 groups of baseline period, outbreak period and intervention period. Statistical analysis was performed using the chi-square test, Fisher's exact test and ANOVA. During the baseline period 2 of 68 (2.9%) inflatable penile prosthesis devices became infected. During the outbreak period 6 of 11 (54.5%) devices became infected, representing an incidence risk ratio 18.55 times that of the baseline period. After the implementation of the preoperative checklist the incidence risk ratio decreased to 0.0 in the intervention period with 0 of 52 devices (0%) becoming infected. After an outbreak of an unusually high number of penile prosthesis infections, implementation of a required checklist brought the rate down to zero. Although the specific factors that led to the infection outbreak and subsequent cessation of infections are unknown, we have shown that use of a checklist was associated with a dramatic impact on patient safety.

Safe pediatric surgery: development and validation of preoperative interventions checklist

This study was aimed at developing and validating a checklist of preoperative pediatric interventions related to the safety of surgical patients. Methodological study concerning the construction and validation of an instrument with safe preoperative care indicators. The checklist was subject to validation through the Delphi technique, establishing a consensus level of 80%. Five professional specialists in the area conducted the validation and a consensus on the content and the construct was reached after two applications of the Delphi technique. The "Safe Pediatric Surgery Checklist", simulating the preoperative trajectory of children, is an instrument capable of contributing to the preparation and promotion of safe surgery, as it identifies the presence or absence of measures required to promote patient safety.

Improving operating room first start efficiency – value of both checklist and a pre‐operative facilitator

There are multiple components leading to improved operating room efficiency. We undertook a project focusing on first case starts; accounting for each delay component on a global basis. Our hypothesis was there would be a reduction in first start delays after we implemented strategies to address the issues identified through this accounting process. An orange sheet checklist was implemented, with specific items that needed to be clear prior to roll back to the operating room (OR), and an OR facilitator was employed to intervene whenever there were any missing items needed for a specific patient. We present the data from this quality improvement project over an 18-month period. Initially, 10.07 (± 0.73) delayed first starts occurred per day but declined steadily over time to a low of 4.95 (± 0.38) per day after 6 months (-49.2 %, P < 0.001). By the end of the project, the most common reasons for delay still included late surgical attending (19%), schedule changes (14%) as well as 'other reasons' (13%), but with an overall reduction per day of each. Total anaesthesia delay initially totalled 11% of the first start delays, but was negligible (< 1%) at the project's completion. While we have a challenging operating room environment based on our patient population, multiple trainees in both the surgery and anaesthesiology teams: an orange sheet - pre-operative checklist in addition to a dedicated pre-operative facilitator; allowed us to make a substantial improvement in our first start on time starts.

Educational Value of a Preoperative CT Sinus Checklist: A Resident's Perspective

The objective of this study is to evaluate the educational value and effectiveness of a preoperative computed tomography (CT) sinus anatomy checklist as a teaching method from the perspective of otolaryngology residents. Between 2009 and 2011, 15 otolaryngology residents completed a CT sinus anatomy checklist prior to the start of sinus surgery cases. A cross-sectional brief Likert-type questionnaire assessed the resident experience with the checklist. Nine items explored its perceived utility, role in the preoperative setting, incorporation into practice, and recall. St. Michael's Hospital, tertiary care hospital. Otolaryngology residents rotating through St. Michael's Hospital between 2009 and 2011 were enrolled into this study. A total of 15 residents entered and finished the study. Overall, all residents strongly agreed that the checklist was useful. It ensured that the CT imaging was properly reviewed and increased their comfort level with the relevant anatomy. Nearly all the residents continue to use this checklist even after completing the rotation with the senior author (JML). The CT sinus anatomy checklist was perceived as useful overall by otolaryngology residents. In the future, checklists should be applied to other areas of head and neck surgical training to further standardize preoperative planning.

QR-Code Patienten-Tracking: eine kostengünstige Möglichkeit zur Verbesserung der Patientensicherheit

Hospitals are implementing a risk management system to avoid patient or surgery mix-ups. The trend is to use preoperative checklists. This work deals specifically with a type of patient identification, which is realized by storing patient data on a patient-fixed medium. In 127 ENT surgeries data relevant for patient identification were encrypted in a 2D-QR-Code. The code, as a separate document coming with the patient chart or as a patient wristband, has been decrypted in the OR and the patient data were presented visible for all persons. The decoding time, the compliance of the patient data, as well as the duration of the patient identification was compared with the traditional patient identification by inspection of the patient chart. A total of 125 QR codes were read. The time for the decrypting of QR-Code was 5.6 s, the time for the screen view for patient identification was 7.9 s, and for a comparison group of 75 operations traditional patient identification was 27.3 s. Overall, there were 6 relevant information errors in the two parts of the experiment. This represents a ratio of 0.6% for 8 relevant classes per each encrypted QR code. This work allows a cost effective way to technically support patient identification based on electronic patient data. It was shown that the use in the clinical routine is possible. The disadvantage is a potential misinformation from incorrect or missing information in the HIS, or due to changes of the data after the code was created. The QR-code-based patient tracking is seen as a useful complement to the already widely used identification wristband.

A Journey to Action Research in a Clinical Nursing Context

Purpose: The purpose of this study was to examine the effectiveness of Action Research (AR) approach in nursing. Methods: Participants were 64 perioperative nurses recruited from C hospital in Gwangju, Korea. The nurses were en gaged in the project through 2 cycles of planning, acting, observing, and reflecting. A mixed-methods design was used to examine changes in participants and their knowledge management practice. Quantitative data were analyzed using SPSS 20.0 program and qualitative reflection data underwent content analysis. Results: During the project, participants developed standardized pre-operative checklists and opened an Internet Cafe to better manage their perioperative nursing information. At the end of the project, t here was a significant increase in nurses' knowledge management ( p =.015) and the rate of surgical material prescription errors decreased from 8.0% to 2.9%. Core AR project team members' teamwork skills and organizational commitment increased significantly (p=.040, p=.301, respectively). The main themes that emerged from the qualitative data were learning how to solve problems in practice, facilitating team activities through motivation, barriers of large participation, and rewarded efforts and inflated expectations. Conclusion: The AR project contributed to empowering participants to solve local p roblems. AR is a useful methodology to promote changes in practices and research participants.

In response: simulation-based trial of surgical-crisis checklists.

1 Arriaga AF, Bader AM, Wong JM, et al. Simulation-Based Trial of Surgical-Crisis Checklists. N Eng J Med. 2013;368:246–53. 2 Hales BM, Pronovost PJ. The checklist—a tool for error management and performance improvement. J Crit Care. 2006;21(3):231–5. 3 Lingard L, Regehr G, Orser B, et al. Evaluation of a preoperative checklist and team briefing among surgeons, nurses and anaesethsiologists to reduce failure in communication. Archives of Surgery. 2008;143(1):12–17. 4 Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpa-tient surgery. N Eng J Med. 2009;361:1368–75. 5 Martin Bromiley. Just a Routine Operation [online]. Available at: http://www.youtube.com/watch?v=JzlvgtPIof4 (accessed 6 February 2013). 6 Conley DM, Singer SJ, Edmondson L, Berry WR, Gawande AA. Effective surgical safety checklist implementation. J Am Coll Surg. 2011;212(5):873–9. 7 Rydenfalt C, Johansson G, Odenrick P, Akerman K, Larsson PA. Compliance with the WHO surgical safety checklist: deviations and possible improvements. Int J Qual Health Care 2013[Ahead of print] doi: 10.1093/intqhc/mzt004.

Value of a preoperative checklist for laparoscopic appendectomy and cholecystectomy

Laparoscopy is a complex technique where incidents related to equipment failure/malfunction commonly occur. The purpose of the WHO preoperative safety checklist is to significantly reduce surgically associated complications and mortality. The goal of this study was to show that a preoperative checklist for laparoscopy could improve procedure efficiency by reducing lost time due to these incidents. This prospective study compared the occurrence of incidents related to equipment, patient installation and the time loss attributed to these incidents, before and after the initiation of a preoperative checklist. Two hundred consecutive laparoscopic procedures (appendectomies and cholecystectomies) were studied; the first hundred without the preoperative checklist and the second hundred after the initiation of this laparoscopic checklist. The risk of at least one incident to occur during the procedure was increased 3-fold ([1.36 vs. 6.64], P=0.007) when the checklist was not used compared to when the preoperative checklist was used. Likewise, the number of incidents increased 2.4-fold ([1.15; 5.01], P=0.02), compared to when the preoperative checklist was used. The checklist significantly reduced the proportion of incidences during which time was lost from 22% to 10% (P=0.03). A preoperative checklist for laparoscopic procedures is feasible and seems useful to prevent adverse events in the operating room.

Intraoperative neurophysiological monitoring in spine surgery: indications, efficacy, and role of the preoperative checklist

Spine surgery carries an inherent risk of damage to critical neural structures. Intraoperative neurophysiological monitoring (IONM) is frequently used to improve the safety of spine surgery by providing real-time assessment of neural structures at risk. Evidence-based guidelines for safe and efficacious use of IONM are lacking and its use is largely driven by surgeon preference and medicolegal issues. Due to this lack of standardization, the preoperative sign-in serves as a critical opportunity for 3-way discussion between the neurosurgeon, anesthesiologist, and neuromonitoring team regarding the necessity for and goals of IONM in the ensuing case. This analysis contains a review of commonly used IONM modalities including somatosensory evoked potentials, motor evoked potentials, spontaneous or free-running electromyography, triggered electromyography, and combined multimodal IONM. For each modality the methodology, interpretation, and reported sensitivity and specificity for neurological injury are addressed. This is followed by a discussion of important IONM-related issues to include in the preoperative checklist, including anesthetic protocol, warning criteria for possible neurological injury, and consideration of what steps to take in response to a positive alarm. The authors conclude with a cost-effectiveness analysis of IONM, and offer recommendations for IONM use during various forms of spine surgery, including both complex spine and minimally invasive procedures, as well as lower-risk spinal operations.

Improving patient safety in perioperative care for major surgeries

The Helsinki Declaration was created and signed by the European Board of Anaesthesiology (EBA) and the European Society of Anaesthesiology (ESA). It was initiated in June 2010, and it implies a European consensus on those medical practices which improve patient safety and provide higher quality perioperative care. Authors focus on four elements of this initiative, which can be easily implemented, and provide almost instant benefit: use of preoperative checklist, prevention of perioperative infections, goal-directed fluid therapy and perioperative nutrition. The literature review emphasizes that well organized perioperative care plays the most important role in improving patient safety.

Placenta Accreta: A New Take on an Old Problem

To disseminate information about a multidisciplinary approach to the management of patients with placenta accreta and its variants: increta and percreta. This program will define accreta and its variants and also identify the incidence of accreta in the population. The development of preoperative and intraoperative checklists will be presented along with an in-depth educational plan. The use of erythropoietin and iron sucrose injection also will be discussed.

The Effect of Preoperative Checklists on Final Histology and Rates of Hysterectomy for Benign Conditions

Our null hypothesis was that the introduction of preoperative hysterectomy checklists for fibroids, dysfunctional uterine bleeding (DUB), and chronic pelvic pain (CPP) would not affect the rate of hysterectomy or the proportion of cases with nonconfirmable final pathology. Using a prospective 6-month cohort, we compared the rate of hysterectomy (using ambulatory current procedural terminology codes for all eligible patients) and the preoperative diagnoses to final histologic diagnoses, to a baseline 6-month retrospective cohort. We also sought to determine the proportion of completed preoperative checklists among eligible cases. Checklist implementation was associated with a significant decrease in the hysterectomy rate for DUB: 25 (15.2%) of 165 fell to 12 (6.5%) of 185 (P = 0.014): for CPP: 11 (10.9%) of 101 to 3 (2.9%) of 105 (P = 0.044), as well as for the combined total rate: 86 (25.2%) of 341 to 52 (15.2%) of 342 (P = 0.002). There was a 50% decrease in nonconfirmable pathology for all cases: 21 of 86 at baseline compared to 6 of 52 after intervention (P = 0.049). In this 6-month pilot analysis, the use of preoperative hysterectomy checklists for 3 common nonmalignant conditions (fibroids, DUB, and CPP) was associated with a statistically significant decrease in hysterectomy rates and overall nonconfirmable pathology.