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ABSTRACT: OBJECTIVE:: To introduce the World Health Organization Surgical Safety Checklist into every operating room within a severely resource-limited hospital located in a developing country and to measure its impact on surgical hazards and complications. BACKGROUND:: The checklist has been shown to reduce surgical morbidity and mortality, but the ability to successfully implement the checklist program hospital-wide in lower income settings without basic resources is unknown. METHODS:: We conducted a pre- versus postintervention study of the implementation of the checklist, including the introduction of universal pulse oximetry at a hospital in Chisinau, Moldova, where only 3 oximeters were available for their 22 operating stations. We supplied data-recording oximeters for all operating stations and trained a local checklist implementation team. The primary outcomes were process adherence, major complications, and rates of hypoxemia (SpO2 <90%). Propensity score weighing was conducted to adjust process and outcome measures. Regression models were used to evaluate adherence to process measures and hypoxemia trends over time. RESULTS:: Data from 2145 pre- and 2212 postintervention cases were collected. Adherence to all safety processes increased significantly from 0.0% to 66.9% (P < 0.001). After checklist implementation, the overall complication rate decreased from 21.5% to 8.8% (P < 0.001). Infectious and noninfectious complications decreased significantly after checklist implementation from 17.7% to 6.7% (P < 0.001) and from 2.6% to 1.5% (P = 0.018), respectively. The number of hypoxemic episodes lasting 2 minutes or longer per 100 hours of oximetry decreased from 11.5 to 6.4 (P < 0.002). CONCLUSIONS:: Successful hospital-wide Surgery Safety Checklist implementation can be achieved in a resource-limited setting and can significantly reduce surgical hazards and complications.
Annals of surgery 11/2012; · 7.90 Impact Factor
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ABSTRACT: Surgical care is a vital component of health care worldwide, yet there is no clinically meaningful measure of operative outcomes that could be applied globally. The Surgical Apgar Score, a simple metric derived from 3 intraoperative parameters, has been shown in U.S. academic medical centers to predict 30-day patient outcomes after operation, but has not been validated more broadly.
We collected the components of the Surgical Apgar Score at the time of operation for 5,909 adult patients undergoing noncardiac operative procedures under general anesthesia at 8 hospitals in diverse international settings and evaluated the relationship between patients' scores and the incidence of inpatient postoperative morbidity and mortality, using generalized estimating equations to adjust for clustering within sites.
During the first 30 days of postoperative hospitalization, 544 patients (9.2%) experienced ≥ 1 complications. Compared with patients with the median score of 7--whose complication rate was 9.1%-those with a Surgical Apgar Score <5 (n = 302) had an adjusted complication rate of 32.9% (relative risk [RR],3.6; 95% CI, 2.9-4.5), whereas those with a score of 10 (n = 238) had a 3.0% adjusted complication rate (RR, 0.3; 95% CI, 0.1-1.1). The score's c-statistic for prediction of any complication is 0.70; for death it is 0.77.
The Surgical Apgar Score is easily calculated, predictive, and moderately discriminative for major complications among adults undergoing inpatient noncardiac operative procedures. Such a score could provide objective indication of relative postoperative risk for inpatients and provide a potential target for quality improvement efforts, particularly in resource-limited settings.
Surgery 01/2011; 149(4):519-24. · 3.10 Impact Factor
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Alex B Haynes,
Thomas G Weiser,
William R Berry,
Stuart R Lipsitz,
Abdel-Hadi S Breizat,
E Patchen Dellinger, Gerald Dziekan,
Teodoro Herbosa,
Pascience L Kibatala,
Marie Carmela M Lapitan,
Alan F Merry,
Richard K Reznick,
Bryce Taylor,
Amit Vats,
Atul A Gawande
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ABSTRACT: To assess the relationship between changes in clinician attitude and changes in postoperative outcomes following a checklist-based surgical safety intervention.
Pre- and post intervention survey.
Eight hospitals participating in a trial of a WHO surgical safety checklist.
Clinicians actively working in the designated study operating rooms at the eight hospitals. SURVEY INSTRUMENT: Modified operating-room version Safety Attitudes Questionnaire (SAQ).
Change in mean safety attitude score and correlation between change in safety attitude score and change in postoperative outcomes, plus clinician opinion of checklist efficacy and usability.
Clinicians in the preintervention phase (n=281) had a mean SAQ score of 3.91 (on a scale of 1 to 5, with 5 representing better safety attitude), while the postintervention group (n=257) had a mean of 4.01 (p=0.0127). The degree of improvement in mean SAQ score at each site correlated with a reduction in postoperative complication rate (r=0.7143, p=0.0381). The checklist was considered easy to use by 80.2% of respondents, while 19.8% felt that it took a long time to complete, and 78.6% felt that the programme prevented errors. Overall, 93.4% would want the checklist used if they were undergoing operation.
Improvements in postoperative outcomes were associated with improved perception of teamwork and safety climate among respondents, suggesting that changes in these may be partially responsible for the effect of the checklist. Clinicians held the checklist in high regard and the overwhelming majority would want it used if they were undergoing surgery themselves.
BMJ quality & safety 01/2011; 20(1):102-7.
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ABSTRACT: The World Health Organization's Patient Safety Programme created an initiative to improve the safety of surgery around the world. In order to accomplish this goal the programme team developed a checklist with items that could and, if at all possible, should be practised in all settings where surgery takes place. There is little guidance in the literature regarding methods for creating a medical checklist. The airline industry, however, has more than 70 years of experience in developing and using checklists. The authors of the WHO Surgical Safety Checklist drew lessons from the aviation experience to create a safety tool that supports essential clinical practice. In order to inform the methodology for development of future checklists in health care, we review how we applied lessons learned from the aviation experience in checklist development to the development of the Surgical Safety Checklist and also discuss the differences that exist between aviation and medicine that impact the use of checklists in health care.
International Journal for Quality in Health Care 10/2010; 22(5):365-70. · 1.96 Impact Factor
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ABSTRACT: Surgery is an essential part of health care, but resources to ensure the availability of surgical services are often inadequate. We estimated the global distribution of operating theatres and quantified the availability of pulse oximetry, which is an essential monitoring device during surgery and a potential measure of operating theatre resources.
We calculated ratios of the number of operating theatres to hospital beds in seven geographical regions worldwide on the basis of profiles from 769 hospitals in 92 countries that participated in WHO's safe surgery saves lives initiative. We used hospital bed figures from 190 WHO member states to estimate the number of operating theatres per 100,000 people in 21 subregions throughout the world. To estimate availability of pulse oximetry, we sent surveys to anaesthesia providers in 72 countries selected to ensure a geographically and demographically diverse sample. A predictive regression model was used to estimate the pulse oximetry need for countries that did not provide data.
The estimated number of operating theatres ranged from 1·0 (95% CI 0·9-1·2) per 100,000 people in west sub-Saharan Africa to 25·1 (20·9-30·1) per 100,000 in eastern Europe. High-income subregions all averaged more than 14 per 100,000 people, whereas all low-income subregions, representing 2·2 billion people, had fewer than two theatres per 100,000. Pulse oximetry data from 54 countries suggested that around 77,700 (63,195-95,533) theatres worldwide (19·2% [15·2-23·9]) were not equipped with pulse oximeters.
Improvements in public-health strategies and monitoring are needed to reduce disparities for more than 2 billion people without adequate access to surgical care.
WHO.
The Lancet 09/2010; 376(9746):1055-61. · 38.28 Impact Factor
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ABSTRACT: To assess whether implementation of a 19-item World Health Organization (WHO) Surgical Safety Checklist in urgent surgical cases would improve compliance with basic standards of care and reduce rates of deaths and complications.
Use of the WHO Surgical Safety Checklist has been shown to be associated with significant reductions in complications and deaths. Before evaluation of this safety tool, concern was raised about whether its use would be practical or beneficial during urgent surgical procedures.
We prospectively collected clinical process and outcome data for 1750 consecutively enrolled patients 16 years of age or older undergoing urgent noncardiac surgery before and after introduction of the WHO Surgical Safety Checklist in 8 diverse hospitals around the world; 842 underwent urgent surgery-defined as an operation required within 24 hours of assessment to be beneficial-before introduction of the checklist and 908 after introduction of the checklist. The primary end point was the rate of complications, including death, during hospitalization up to 30 days following surgery.
The complication rate was 18.4% (n=151) at baseline and 11.7% (n=102) after the checklist was introduced (P=0.0001). Death rates dropped from 3.7% to 1.4% following checklist introduction (P=0.0067). Adherence to 6 measured safety steps improved from 18.6% to 50.7% (P<0.0001).
Implementation of the checklist was associated with a greater than one-third reduction in complications among adult patients undergoing urgent noncardiac surgery in a diverse group of hospitals. Use of the WHO Surgical Safety Checklist in urgent operations is feasible and should be considered.
Annals of surgery 05/2010; 251(5):976-80. · 7.90 Impact Factor
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ABSTRACT: Public health surveillance relies on standardised metrics to evaluate disease burden and health system performance. Such metrics have not been developed for surgical services despite increasing volume, substantial cost, and high rates of death and disability associated with surgery. The Safe Surgery Saves Lives initiative of WHO's Patient Safety Programme has developed standardised public health metrics for surgical care that are applicable worldwide. We assembled an international panel of experts to develop and define metrics for measuring the magnitude and effect of surgical care in a population, while taking into account economic feasibility and practicability. This panel recommended six measures for assessing surgical services at a national level: number of operating rooms, number of operations, number of accredited surgeons, number of accredited anaesthesia professionals, day-of-surgery death ratio, and postoperative in-hospital death ratio. We assessed the feasibility of gathering such statistics at eight diverse hospitals in eight countries and incorporated them into the WHO Guidelines for Safe Surgery, in which methods for data collection, analysis, and reporting are outlined.
The Lancet 09/2009; 374(9695):1113-7. · 38.28 Impact Factor
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ABSTRACT: Healthcare-associated infection is a major safety issue affecting the quality of care of hundreds of millions of patients every year in both developed and developing countries. To meet the goal of ensuring patient safety across healthcare settings around the globe, the World Health Organization launched the World Alliance for Patient Safety in October 2004. Healthcare-associated infections were identified as a fundamental work priority and selected as the topic of the First Global Patient Safety Challenge launched by the Alliance. Under the banner "Clean Care is Safer Care", the Challenge aims at implementing several actions to reduce healthcare-associated infections worldwide, regardless of the level of development of healthcare systems and the availability of resources. Implementation strategies include the integration of multiple interventions in the areas of blood safety, injection safety, clinical procedure safety, and water, sanitation and waste management, with the promotion of hand hygiene in healthcare as the cornerstone. Several initiatives have been undertaken to raise global awareness and to obtain country commitment to support action on this issue. The new Guidelines on Hand Hygiene in Health Care, including the most consistent scientific evidence available, have been issued in an advanced draft form. An implementation strategy is proposed therein to provide solutions to overcome obstacles to improvement in compliance with hand hygiene practices, together with a range of practical tools for use in healthcare settings. The latter are currently undergoing testing in several pilot sites to evaluate feasibility, acceptability and sustainability.
Journal of Hospital Infection 07/2007; 65 Suppl 2:115-23. · 3.39 Impact Factor
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ABSTRACT: Poor injection practices transmit potentially life-threatening pathogens. We modelled the cost-effectiveness of policies for the safe and appropriate use of injections in ten epidemiological subregions of the world in terms of cost per disability-adjusted life year (DALY) averted.
The incidence of injection-associated hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) infections was modelled for a year 2000 cohort over a 30-year time horizon. The consequences of a "do nothing" scenario were compared with a set of hypothetical scenarios that incorporated the health gains of effective interventions. Resources needed to implement effective interventions were costed for each subregion and expressed in international dollars (I dollars).
Worldwide, the reuse of injection equipment in the year 2000 accounted for 32%, 40%, and 5% of new HBV, HCV and HIV infections, respectively, leading to a burden of 9.18 million DALYs between 2000 and 2030. Interventions implemented in the year 2000 for the safe (provision of single-use syringes, assumed effectiveness 95%) and appropriate (patients-providers interactional group discussions, assumed effectiveness 30%) use of injections could reduce the burden of injection-associated infections by as much as 96.5% (8.86 million DALYs) for an average yearly cost of 905 million I dollars (average cost per DALY averted, 102; range by region, 14-2293). Attributable fractions and the number of syringes and needles required represented the key sources of uncertainty.
In all subregions studied, each DALY averted through policies for the safe and appropriate use of injections costs considerably less than one year of average per capita income, which makes such policies a sound investment for health care.
Bulletin of the World Health Organisation 02/2003; 81(4):277-85. · 4.64 Impact Factor
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ABSTRACT: OBJECTIVE: Poor injection practices transmit potentially life-threatening pathogens. We modelled the cost-effectiveness of policies for the safe and appropriate use of injections in ten epidemiological subregions of the world in terms of cost per disability-adjusted life year (DALY) averted. METHODS: The incidence of injection-associated hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) infections was modelled for a year 2000 cohort over a 30-year time horizon. The consequences of a "do nothing" scenario were compared with a set of hypothetical scenarios that incorporated the health gains of effective interventions. Resources needed to implement effective interventions were costed for each subregion and expressed in international dollars (I$). FINDINGS: Worldwide, the reuse of injection equipment in the year 2000 accounted for 32%, 40%, and 5% of new HBV, HCV and HIV infections, respectively, leading to a burden of 9.18 million DALYs between 2000 and 2030. Interventions implemented in the year 2000 for the safe (provision of single-use syringes, assumed effectiveness 95%) and appropriate (patients-providers interactional group discussions, assumed effectiveness 30%) use of injections could reduce the burden of injection-associated infections by as much as 96.5% (8.86 million DALYs) for an average yearly cost of I$ 905 million (average cost per DALY averted, 102; range by region, 14-2293). Attributable fractions and the number of syringes and needles required represented the key sources of uncertainty. CONCLUSION: In all subregions studied, each DALY averted through policies for the safe and appropriate use of injections costs considerably less than one year of average per capita income, which makes such policies a sound investment for health care.
Bulletin of the World Health Organization. 01/2003;
