Arvid Steinar Haugen is a registered nurse and has clinical background as nurse anaesthetist. He is a postdoctoral researcher and head of a research and development section, at Haukeland University Hospital in Bergen, Norway. As principal investigator he studies effects of the WHO Surgical Safety Checklist implementation on patient outcome and safety culture. He was in 2015 awarded with a quality and safety prize in Norway, and also the European Society of Anaesthesiologists’ Baxter Prize for a publication of significant relevance on “Outcome improvement in perioperative medicine". His research interests are within implementation of patient safety and safety culture.
The World Health Organization globally launched the “Safe Surgery Saves Lives” campaign in 2008, including the Safe Surgery Checklist (SSC), to improve communication, teamwork and consistency of care. Implementation of the SSC significantly reduced overall major complications (including postoperative infections) from 19.9% to 12.4% (P<0.001) and length of in-hospital stay (7.8 to 7.0 days – P=0.022) in a stepped wedge cluster randomized controlled quality improvement trial.1 In a large Canadian study morbidity and mortality was not significantly improved 3 months after implementation of the SSC.2 To mitigate knowledgegap of SSC effects on surgical site infections (SSI) a systematic review of literature is required. We hypothesize that actual use of the checklist reducespostoperative SSI.
Material and methods
We conducted a systematic literature review of published studies on SSC effects on safety culture, postoperative complications (including SSI) and mortality. A comprehensive search was carried out by a librarian in the following databases: PubMed, Embase, Cochrane Central, and Database of Abstracts of Reviews of Effects (DARE). The search strategies combined Mesh and text terms to identify original studies, review articles, systematic reviews, and free hand searches for grey literature. Studies on SSC interventions or surgical safety checklists were included in the search. Patients undergoing elective or emergency surgery constituted the studies populations.
Initial systematic literature search was carried out in February 2014. We identified 2984 titles through data base screening. 2815 titles and abstractswerescreened, and 395 werereviewed in full text. A total of 31 papers investigated SSC effects on safety culture, morbidity and mortality. Of the studies, seven included postoperative SSI’s. In an updated literature search in October 2015, four new studies were identified. Of the 11 relevant studies, we found one randomized controlled trial and 10 observational studies with pre and post design. A meta-analysis of the studies was carried out. A total of 254,600 surgical patients were included in studies published in 2009-2015. Relative risk ratio for a postoperative SSI was significantly reduced when the SSC was utilized, 0.70 (95% confidence interval 0.54 to 0.90).
This meta-analysis indicate that implementation of the SSCsignificantly reducesthe risk of SSI’s in a large population. Using a checklist ensure equity in care for patients during surgery. Healthcare professionals tend to rely on memory and use of checklists introduces a new way to think about safety in perioperative care. The use of a checklist can influence on workflow and introduce changes in how tasks and procedures are carried out. When implementing SSC changes in care processes are necessary to improve patient outcome.
Audience take away
- Use of checklists - a new way to think in healthcare?
- Standardization of safe care
- Better communication and teamwork across professions
- New knowledge on how a simple tool like a checklist can have significant impact on patient outcome
- Improved care processes equals improved outcome