A 65-year-old man is undergoing a right knee replacement operation at a major U.S. hospital. The orthopedic surgeon has successfully inserted the hardware and is getting ready to close up the incision. Everything is going well until suddenly, the patient’s pulse jumps to 150 beats per minute and his blood pressure is no longer detectable with an inflatable arm cuff. Suddenly, a routine surgery has turned into an acute medical crisis. The operating room team will have to think quickly and make the right moves to save the life of the patient.
Fortunately, surgical crisis situations are rare occurrences. Yet, because they happen so infrequently, many providers go years without ever encountering an acute surgical crisis. When an operating room team finally experiences such a crisis, the team members may not remember to perform all of the critical steps that have been shown to improve patient outcomes. One option to help providers with management of surgical crises is to have a surgical crisis checklist available in the operating room.
A number of years ago, the Safe Surgery Saves Lives Initiative of the World Health Organization brought together a group of experts on surgery and patient safety, and they developed a 19-point checklist for use during all surgical procedures. Items on the checklist include verification of patient identity and allergies, correctly identifying the surgical site prior to initiation of the surgery, placing a pulse oxygen monitor on the patient prior to initiating anesthesia, and counting the number of sponges and surgical instruments at the end of the case to ensure that no foreign bodies were left inside the patient. A pilot program performed between 2007 and 2008 in eight cities around the world demonstrated that use of the checklist reduced rates of major surgical complications from 11% to 7% and reduced post-operative mortality from 1.5% to 0.8%. Three hundred professional societies, health organizations, ministries, and NGOs have endorsed the surgical checklist put forth by the Safe Surgery Saves Lives Program.
This week’s NEJM features a study which builds on the success of the WHO 19-point surgical checklist and examines a new surgical checklist for use during surgical crises such as cardiac arrest, ventricular fibrillation, and anaphylaxis. Because such events are infrequent, the study design relies on the performance of medical professionals during mock surgical crises using a surgical simulator. Teams consisted primarily of anesthesiologists, nurses, and surgical technologists. They spent half a day in a simulated operating room and were presented with a series of crisis scenarios. Success was measured based on adherence to evidence-based practices deemed most appropriate for each scenario. During half of the scenarios the team had access to crisis checklists containing protocols for appropriate management of the relevant scenarios, while the other half of the time the team did not have the checklists and had to rely on their memory to guide their decision making.
The study results showed that each of the 17 operating room teams performed better when the crisis checklists were available. Overall, the checklists helped the teams stick to best practice guidelines 75% more often than without the checklists. Especially telling is the fact that 97% of participants expressed the view that if they were to undergo an operation they would want these checklists available to operating room staff.
There are some major limitations to this study. Most importantly, the research was conducted in a simulation center rather than an actual operating room with real patients. Results measured in the study were adherence to evidence-based processes rather than true clinical outcomes such as patient survival. Due to scheduling conflicts, the study organizers were only able to include surgeons in two of the 17 study dates, thus the study teams were not entirely representative of true operating room teams.
According to NEJM Deputy Editor Mary Beth Hamel, “Despite these limitations, the results of this study suggest that surgical crisis checklists can help clinicians manage rare surgical emergencies.” Of course, the real test of these checklists will be to put them into practice and measure the effects that they have on actual patient outcomes.
One day, surgical crisis checklists may be available in all operating rooms not only in the United States, but also worldwide. That way, when a patient suddenly becomes tachycardic with a loss of blood pressure, the team caring for him can look to the checklist to ensure that they follow evidence-based practices to give the patient the best chance of making it through the surgery alive and healthy enough to enjoy the benefits of having a new knee.