Surgical checklists: a systematic review of impacts and implementation

The surgical safety checklist: a quantitative study on attitudes and barriers among gynecological surgery teams

Background

Implementation of the surgical safety checklist (SSC) plays a significant role in improving surgical patient safety, but levels of compliance to a SSC implementation by surgical team members vary significantly. We aimed to investigate the factors affecting satisfaction levels of gynecologists, anesthesiologists, and operating room registered nurses (OR-RNs) with SSC implementation.

Methods

We conducted a survey based on 267 questionnaires completed by 85 gynecologists from 14 gynecological surgery teams, 86 anesthesiologists, and 96 OR-RNs at a hospital in China from March 3 to March 16, 2020. The self-reported questionnaire was used to collect respondent’s demographic information, levels of satisfaction with overall implementation of the SSC and its implementation in each of the three phases of a surgery, namely sign-in, time-out, and sign-out, and reasons for not giving a satisfaction score of 10 to its implementation in all phases.

Results

The subjective ratings regarding the overall implementation of the SSC between the surgical team members were different significantly. “Too many operations to check” was the primary factor causing gynecologists and anesthesiologists not to assign a score of 10 to sign-in implementation. The OR-RNs gave the lowest score to time-out implementation and 82 (85.42%) did not assign a score of 10 to it. “Surgeon is eager to start for surgery” was recognized as a major factor ranking first by OR-RNs and ranking second by anesthesiologists, and 57 (69.51%) OR-RNs chose “Too many operations to check” as the reason for not giving a score of 10 to time-out implementation. “No one initiates” and “Surgeon is not present for ‘sign out’” were commonly cited as the reasons for not assigning a score of 10 to sign-out implementation.

Conclusion

Factors affecting satisfaction with SSC implementation were various. These factors might be essentially related to heavy workloads and lack of ability about SSC implementation. It is advisable to reduce surgical team members’ excessive workloads and enhance their understanding of importance of SSC implementation, thereby improving surgical team members’ satisfaction with SSC implementation and facilitating compliance of SSC completion.

Impact of the WHO Surgical Safety Checklist Relative to Its Design and Intended Use: A Systematic Review and Meta-Meta-Analysis

BACKGROUND

The aim of this study was to identify what parts of the World Health Organization Surgical Safety Checklist (WHO SSC) are working, what can be done to make it more effective, and to determine if it achieved its intended effect relative to its design and intended use.

STUDY DESIGN

We conducted a qualitative thematic analysis and meta-meta-analyses of findings in WHO SSC systematic reviews following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.

RESULTS

Twenty systematic reviews were included for qualitative thematic analysis. Narrative information was coded in 4 primary areas with a focus on impact of the WHO SSC. Four themes-Clinical Outcomes, Process Measures, Team Dynamics and Communication, and Safety Culture-pertained directly to the aims or purposes behind the development of the SSC. The other 2 themes-Efficiency and Workload involved in using the checklist and Checklist Impact on Institutional Practices-are associated with SSC use, but were not focal areas considered during its development. Included in the 20 systematic reviews were 24 unique observational cohort studies that reported pre-post data on a total of 18 clinical outcomes. Mortality, morbidity, surgical site infection, pneumonia, unplanned return to the operating room, urinary tract infection, blood loss requiring transfusion, unplanned intubation, and sepsis favored the use of the WHO SSC. Deep vein thrombosis was the only postoperative outcome assessed that did not favor use of the WHO SSC.

CONCLUSIONS

The WHO SSC positively impacts the things it was explicitly designed to address and does not positively impact things it was not explicitly designed for.

"Attention Everyone, Time Out!": Safety Attitudes and Checklist Practices in Anesthesiology in Germany. A Cross-Sectional Study

BACKGROUND

The use of perioperative checklists has generated a growing body of evidence pointing toward reduction of mortality and morbidity, improved compliance with guidelines, reduction of adverse events, and improvements in human factor-related areas. Usual quality management metrics generally fall short in assessing compliance with their perioperative application. Our study assessed application attitudes and compliance with safety measures centered around the World Health Organization (WHO) "Safe Surgery Saves Lives" campaign as perceived by anesthesia professionals in Germany.

METHODS

Three hundred sixteen physicians and nurses participated in our cross-sectional survey, and 304 completed all 35 questions.

RESULTS

Only 59.5% of participants had knowledge of the theoretical framework behind the WHO campaign. During the "sign-in," patient ID and surgical site were checked in 99.6% and 95.1% as recommended by the WHO. Allergies were addressed by 89.2%, expected difficult airway by 65.7%, and the availability of blood products by 70.5%. A total of 84.9% of participants advocated for the time-out to include all persons present in the operating room, which was the case in 57.0%. A total of 40.8% stated that the time-out was only performed between anesthetist and surgeon; in 17.0% of cases, the patient was simultaneously draped and/or surgically scrubbed. No significant differences between hospital types were observed.

CONCLUSIONS

Our study paints a heterogeneous picture of the implementation, usage, and safety attitudes concerning the Safe Surgery Checklist as promoted by the WHO. The lack of standardized execution and team-mindedness can be taken as further evidence for the importance of interdisciplinary training focusing on human factors, communication, and collaboration rather than the mere implementation by decree.

Impact of an educational intervention on WHO surgical safety checklist and pre-operative antibiotic use at a referral hospital in southwestern Uganda

INTRODUCTION

The World Health Organization (WHO) recommends adherence to its surgical safety checklist (SSC) to optimize patient safety and reduce cesarean surgical site infection (SSI). Educational interventions combined with audit and feedback mechanisms on the checklist use by clinicians have the potential to improve adherence and clinical outcomes. Despite the increase in cesarean delivery rates, there is a paucity of data on how such interventions can improve adherence in resource-limited settings.

OBJECTIVE

We performed a quality improvement project to measure the impact of an educational intervention with daily audit and feedback procedures on rates of WHO SSC adherence, including pre-operative antibiotic administration and SSI at Mbarara Regional Referral Hospital maternity ward in Uganda.

METHODS

The study involved chart abstraction of WHO SSC and pre-operative antibiotic use during cesarean deliveries and signs of subsequent SSI in three phases. First, we conducted a retrospective review of all charts from May to June 2018 (pre-intervention phase). Second, we instituted an educational intervention on the WHO SSC and pre-operative antibiotics use, followed by a daily audit of charts and feedback to clinicians from July to August 2018 (the intervention phase). Third, we reviewed charts from September to October 2018 (the post-intervention phase). The WHO SSC adherence, pre-operative antibiotic administration and SSI rates were measured as the proportion of the total cesarean deliveries per study phase and then compared across the three phases.

RESULTS

We reviewed 678 patients' charts (200 in the pre-intervention phase, 230 in the intervention phase and 248 in the post-intervention phase). The mean patient age was 25 years. The use of the WHO SSC was 7% in the pre-intervention phase compared to 92% in the intervention phase (P < 0.001), and 77% in the post-intervention phase (P < 0.001). Pre-intervention antibiotic receipt was 18% compared to 90% in the intervention phase (P < 0.001) and 84% in the post-intervention phase (P < 0.001). The documented SSI rate in the pre-intervention phase was 15% compared to 7% in the intervention phase (P = 0.02) and 11% in the post-intervention phase (P = 0.20).

CONCLUSIONS

An educational intervention, daily audit and feedback to clinicians increased the use of the WHO SSC and prophylactic antibiotics for cesarean delivery-although the rates waned with time. Research to understand factors influencing the checklist use and antibiotic prophylaxis including prescriber knowledge, motivation and clinical process is required. Implementation interventions to sustain usage and impact on clinical outcomes need to be explored.

Perioperative antimicrobial decision making: Focused ethnography study in orthopedic and cardiothoracic surgeries in an Australian hospital

OBJECTIVE

Antimicrobial use in the surgical setting is common and frequently inappropriate. Understanding the behavioral context of antimicrobial use is a critical step to developing stewardship programs.

DESIGN

In this study, we employed qualitative methodologies to describe the phenomenon of antimicrobial use in 2 surgical units: orthopedic surgery and cardiothoracic surgery.

SETTING

This study was conducted at a public, quaternary, university-affiliated hospital.

PARTICIPANTS

Healthcare professionals from the 2 surgical unit teams participated in the study.

METHODS

We used focused ethnographic and face-to-face semi-structured interviews to observe antimicrobial decision-making behaviors across the patient's journey from the preadmission clinic to the operating room to the postoperative ward.

RESULTS

We identified 4 key themes influencing decision making in the surgical setting. Compartmentalized communication (theme 1) was observed with demarcated roles and defined pathways for communication (theme 2). Antimicrobial decisions in the operating room were driven by the most senior members of the team. These decisions, however, were delegated to more junior members of staff in the ward and clinic environment (theme 3). Throughout the patient's journey, communication with the patient about antimicrobial use was limited (theme 4).

CONCLUSIONS

Approaches to decision making in surgery are highly structured. Although this structure appears to facilitate smooth flow of responsibility, more junior members of the staff may be disempowered. In addition, opportunities for shared decision making with patients were limited. Antimicrobial stewardship programs need to recognize the hierarchal structure as well as opportunities to engage the patient in shared decision making.

Checklists in Femur Fractures: High Adherence After Implementation of Computer-based Pediatric Femur Guidelines

The American Academy of Orthopaedic Surgeons (AAOS) created an evidence-based clinical practice guideline for the care of pediatric diaphyseal femur fractures in 2010. Our institution implemented checklists based off these guidelines embedded in a standardized EMR order. The purpose of this study was to describe compliance with checklist completion and to assess safety improvement in a large urban pediatric hospital.

A Scoping Review of Strategies Used to Implement the Surgical Safety Checklist

In 2007, the World Health Organization initiated the Surgical Safety Checklist (SSC) as part of an initiative to improve patient outcomes. After publication of the SSC, perioperative nurses identified challenges with implementing it and questioned its effectiveness. We desired to summarize the state of the science on the effectiveness of strategies that perioperative personnel have used to implement and assess the SSC; therefore, we conducted a scoping review. We searched several databases and identified 28 articles that described the three key stages of SSC implementation (ie, before, during, and after). Half of the identified articles addressed intervention strategies and most articles provided strategies for SSC implementation. The literature also indicated that effective implementation occurred when there was adequate planning. Perioperative leaders should work with nurses when implementing the SSC and monitor its use after implementation to verify compliance and help prevent negative patient outcomes.

Litigation in breast surgery: unique insights from the English National Health Service experience

BACKGROUND

The increase in medical negligence claims against the National Health Service (NHS) over the past decade has had a detrimental impact on limited financial and human resources that could otherwise be available for direct clinical care. The aim of this study was to review litigation claims in breast surgery as part of the national Getting It Right First Time quality improvement initiative, with the aim of identifying opportunities to improve clinical practice and patient safety.

METHODS

All general and plastic surgical claims notified to NHS Resolution between April 2012 and April 2018 were reviewed. Claims related specifically to breast surgery were retrieved manually, and case summaries were analysed independently by two breast surgeons.

RESULTS

From 6915 claims, 449 relating to breast surgery were identified and reviewed. The mean(s.d.) claimant age was 46(13) years. The median number of claims over the 6-year period per NHS trust was 2 (range 0-22). The most frequent causes of litigation were dissatisfaction with cosmetic outcome (121 claims, 26.9 per cent) and patient-reported delays in diagnosis (121, 26.9 per cent). A large proportion of claims related to breast implant surgery (78, 17.4 per cent), and issues regarding consent/communication were common (69, 15.4 per cent). The estimated annual cost of breast surgery litigation claims ranged from £5.57 to £9.59 million (€6.35-11.02 million).

CONCLUSION

Patient-reported delays in diagnosis and dissatisfaction with cosmetic outcome are the most common causes of litigation related to breast surgery. These key themes should be the focus for workforce learning, with the aim of improving patient care and experience.

Time-Out and Its Role in Neurosurgery

BACKGROUND

Safety checklists have improved surgical outcomes; however, much of the literature comes from general surgery.

OBJECTIVE

To identify the role of time-outs in neurosurgery, understand neurosurgeons' attitudes toward time-out, and highlight areas for improvement.

METHODS

A cross-sectional study using a 15-item survey to evaluate how time-outs were performed across 5 hospitals affiliated with a single neurosurgery training program.

RESULTS

Surveys were sent to 51 neurosurgical faculty, fellows, and residents across 5 hospitals with a 72.5% response rate. At all hospitals, surgeons, anesthesiologists, registered nurses, and circulators were involved in time-outs. Although all required time-out before incision, there was no consensus regarding the precise timing of time-out, in policy or in practice. Overall, respondents believed the existing time-out was adequate for neurosurgical procedures (H1: 17, 65.4%; H2: 19, 86.4%; H3: 14, 70.0%; H4: 20, 80.0%; and H5: 18, 78.3%). Of the respondents, 97.2% believed time-out made surgery safe, 94.6% agreed that time-outs reduce the risk of wrong-side or wrong-level neurosurgery, and 17 (45.9%) saw a role for a neurosurgery-specific safety checklist. Pragmatic challenges (n = 20, 54.1%) and individual beliefs and attitudes (n = 20, 54.1%) were common barriers to implementation of standardized time-outs.

CONCLUSION

Multidisciplinary time-outs have become standard of care in neurosurgery. Despite proximity and overlapping personnel, there is considerable variability between hospitals in the practice of time-outs. This lack of uniformity, allowed for by flexible World Health Organization guidelines, may reflect the origins of surgical time-outs in general surgery, rather than neurosurgery, underscoring the potential for time-out optimization with neurosurgery-specific considerations.

Safer outcomes for placenta accreta spectrum disorders: A decade of quality improvement

OBJECTIVE

To describe the evolution and evaluation of protocol-based multidisciplinary quality improvement (QI) in women undergoing cesarean hysterectomy for radiologically suspected and pathologically confirmed placenta accreta spectrum (PAS) disorders.

METHODS

A single-center, retrospective cohort study was conducted of all patients undergoing cesarean hysterectomy for PAS disorders between March 2009 and June 2018. Two distinct periods were defined to compare outcomes: 2009-2011 (initial period) and 2017-2018 (current period). Primary outcomes included blood loss and administration of blood products. Secondary outcomes included perioperative levels of hemoglobin, adverse events and complications, time to mobilization, and length of hospitalization.

RESULTS

Among the 105 consecutive patients identified, there were 26 in the initial period and 32 in the current period. With the implementation of all QI care bundles, median estimated surgical blood loss halved from 2000 ml in the initial period to 1000 ml in the current period, and fewer patients required allogenic blood transfusion (61.5% vs 25%). Patients in the current period demonstrated improved postoperative levels of hemoglobin compared to those in the initial period (101 g/L vs 89 g/L) and had a shorter median postoperative hospital stay (3 days vs 5 days).

CONCLUSION

These results support the implementation of a multifaceted QI and patient care initiative for women with PAS disorders.

How Much and What Local Adaptation Is Acceptable? A Comparison of 24 Surgical Safety Checklists in Switzerland

OBJECTIVES

In 2009, the World Health Organization (WHO) published the WHO Surgical Safety Checklist, and 3 years later, the Swiss Patient Safety Foundation adapted it for Switzerland. Several meta-analyses and systematic reviews showed ambiguous results on the effectiveness of surgical checklists. Most of them assume that the study checklists are almost identical, but in fact they are quite heterogeneous due to adaptations to local settings. This study aims to investigate the extent to which the checklists currently used in Switzerland differ and to discuss the consequences of local adaptations.

METHODS

For the analysis, 24 checklists used in 18 Swiss hospitals are analyzed. First, general checklist characteristics are examined. Second, the checklist items are compared with the checklist items of the WHO and the Swiss Patient Safety Foundation.

RESULTS

The checklists contain a median of 34.5 items (range, 15-76). Compared with the checklists of WHO and Patient Safety Switzerland, which contain 12 and 21 process checks and 10 and 9 conversation prompts, respectively, the study checklists contain a median of 15.5 process checks (range, 3-25) and a median of 4 conversation prompts (range, 0-10).

CONCLUSIONS

There are major differences between the study checklists and the reference checklists that raise doubts about the comparability of checklists. More resources must be invested in proper checklist adaptions and better guidance on how to adapt safety tools such as the surgical safety checklist needed to local conditions. In any case, details of the checklists used need to be clearly described in studies on checklist effectiveness.

Surgical service monitoring and quality control systems at district hospitals in Malawi, Tanzania and Zambia: a mixed-methods study

BACKGROUND

In low-income and middle-income countries, an estimated one in three clinical adverse events happens in non-complex situations and 83% are preventable. Poor quality of care also leads to inefficient use of human, material and financial resources for health. Improving outcomes and mitigating the risk of adverse events require effective monitoring and quality control systems.

AIM

To assess the state of surgical monitoring and quality control systems at district hospitals (DHs) in Malawi, Tanzania and Zambia.

METHODS

A mixed-methods cross-sectional study of 75 DHs: Malawi (22), Tanzania (30) and Zambia (23). This included a questionnaire, interviews and visual inspection of operating theatre (OT) registers. Data were collected on monitoring and quality systems for surgical activity, processes and outcomes, as well as perceived barriers.

RESULTS

53% (n=40/75) of DHs use more than one OT register to record surgical operations. With the exception of standardised printed OT registers in Zambia, the register format (often handwritten books) and type of data collected varied between DHs. Monthly reports were seldom analysed by surgical teams. Less than 30% of all surveyed DHs used surgical safety checklists (n=22/75), and <15% (n=11/75) performed surgical audits. 73% (n=22/30) of DHs in Tanzania and less than half of DHs in Malawi (n=11/22) and Zambia (n=10/23) conducted surgical case reviews. Reports of surgical morbidity and mortality were compiled in 65% (n=15/23) of Zambian DHs, and in less than one-third of DHs in Tanzania (n=9/30) and Malawi (n=4/22). Reported barriers to monitoring and quality systems included an absence of formalised guidelines, continuous training opportunities as well as inadequate accountability mechanisms.

CONCLUSIONS

Surgical monitoring and quality control systems were not standard among sampled DHs. Improvements are needed in standardisation of quality measures used; and in ensuring data completeness, analysis and utilisation for improving patient outcomes.

Checklists for image-guided interventions: a systematic review

OBJECTIVES

Safety checklists have improved safety in patients undergoing surgery. Checklists have been designed specifically for use in image-guided interventions. This systematic review aimed to identify checklists designed for use in radiological interventions and to evaluate their efficacy for improving patient safety. Secondary aims were to evaluate attitudes toward checklists and barriers to their use.

METHODS

OVID, MEDLINE, CENTRAL and CINAHL were searched using terms for "interventional radiology" and "checklist". Studies were included if they described pre-procedural checklist use in vascular/body interventional radiology (IR), paediatric IR or interventional neuro-radiology (INR). Data on checklist design, implementation and outcomes were extracted.

RESULTS

Sixteen studies were included. Most studies (n = 14, 87.5%) focused on body IR. Two studies (12.5%) measured perioperative outcome after checklist implementation, but both had important limitations. Checklist use varied between 54 and 100% and completion of items on the checklists varied between 28 and 100%. Several barriers to checklist use were identified, including a lack of leadership and education and cultural challenges unique to radiology.

CONCLUSIONS

We found few reports of the use of checklists in image-guided interventions. Approaches to checklist implementation varied, and several barriers to their use were identified. Evaluation has been limited. There seems to be considerable potential to improve the effective use of checklists in radiological procedures.

ADVANCES IN KNOWLEDGE

There are few reports of the use of checklists in radiological interventions, those identified reported significant barriers to the effective use of checklists.

Widespread gaps in the quality of care for primary biliary cholangitis in UK

OBJECTIVE

Primary biliary cholangitis (PBC) is a progressive, autoimmune, cholestatic liver disease affecting approximately 15 000 individuals in the UK. Updated guidelines for the management of PBC were published by The European Association for the Study of the Liver (EASL) in 2017. We report on the first national, pilot audit that assesses the quality of care and adherence to guidelines.

DESIGN

Data were collected from 11 National Health Service hospitals in England, Wales and Scotland between 2017 and 2020. Data on patient demographics, ursodeoxycholic acid (UDCA) dosing and key guideline recommendations were captured from medical records. Results from each hospital were evaluated for target achievement and underwent χ² analysis for variation in performance between trusts.

RESULTS

790 patients' medical records were reviewed. The data demonstrated that the majority of hospitals did not meet all of the recommended EASL standards. Standards with the lowest likelihood of being met were identified as optimal UDCA dosing, assessment of bone density and assessment of clinical symptoms (pruritus and fatigue). Significant variations in meeting these three standards were observed across UK, in addition to assessment of biochemical response to UDCA (all p<0.0001) and assessment of transplant eligibility in high-risk patients (p=0.0297).

CONCLUSION

Our findings identify a broad-based deficiency in 'real-world' PBC care, suggesting the need for an intervention to improve guideline adherence, ultimately improving patient outcomes. We developed the PBC Review tool and recommend its incorporation into clinical practice. As the first audit of its kind, it will be used to inform a future wide-scale reaudit.

OR black box and surgical control tower: Recording and streaming data and analytics to improve surgical care

Effective and safe surgery results from a complex sociotechnical process prone to human error. Acquiring large amount of data on surgical care and modelling the process of surgery with artificial intelligence's computational methods could shed lights on system strengths and limitations and enable computer-based smart assistance. With this vision in mind, surgeons and computer scientists have joined forces in a novel discipline called Surgical Data Science. In this regard, operating room (OR) black boxes and surgical control towers are being developed to systematically capture comprehensive data on surgical procedures and to oversee and assist during operating rooms activities, respectively. Most of the early Surgical Data Science works have focused on understanding risks and resilience factors affecting surgical safety, the context and workflow of procedures, and team behaviors. These pioneering efforts in sensing and analyzing surgical activities, together with the advent of precise robotic actuators, bring surgery on the verge of a fourth revolution characterized by smart assistance in perceptual, cognitive and physical tasks. Barriers to implement this vision exist, but the surgical-technical partnerships set by ambitious efforts such as the OR black box and the surgical control tower are working to overcome these roadblocks and translate the vision and early works described in the manuscript into value for patients, surgeons and health systems.

Establishment and implementation of safety check project for invasive procedures outside the operating room

Objective

This study aimed to describe the implementation of the surgical safety check policy and the surgical safety checklist for invasive procedures outside the operating room (OR) and evaluate its effectiveness.

Methods

In 2017, to improve the safety of patients who underwent invasive procedures outside of the OR, the hospital quality and safety committee established the surgery safety check committee responsible for developing a new working plan, revise the surgery safety check policy, surgery safety check form, and provide training to the related staff, evaluated their competency, and implemented the updated surgical safety check policy and checklist. The study compared the data of pre-implementation (Apr to Sep 2017) and two post-implementation phases (Apr to Sep 2018, Apr to Sep 2019). It also evaluated the number of completed surgery safety checklist, correct signature, and correct timing of signature.

Results

The results showed an increase in the completion rate of the safety checklist after the program implementation from 41.7% (521/1,249) to 90.4% (3,572/3,950), the correct rates of signature from 41.9% (218/521) to 99.0% (4,423/4,465), and the correct timing rates of signature from 34.4% (179/521) to 98.5% (4,401/4,465), with statistical significance (P < 0.01).

Conclusion

Implementing the updated surgery safety check significantly is a necessary and effective measure to ensure patient safety for those who underwent invasive procedures outside the OR. Implementing surgical safety checks roused up the clinical staff’s compliance in performing safety checks, and enhanced team collaboration and communication.

Strong for Surgery: Association Between Bundled Risk Factors and Outcomes After Major Elective Surgery in the VA Population

BACKGROUND

Strong for Surgery (S4S) is a public health campaign focused on optimizing patient health prior to surgery by identifying evidence-based modifiable risk factors. The potential impact of S4S bundled risk factors on outcomes after major surgery has not been previously studied. This study tested the hypothesis that a higher number of S4S risk factors is associated with an escalating risk of complications and mortality after major elective surgery in the VA population.

METHODS

The Veterans Affairs Surgical Quality Improvement Program (VASQIP) database was queried for patients who underwent major non-emergent general, thoracic, vascular, urologic, and orthopedic surgeries between the years 2008 and 2015. Patients with complete data pertaining to S4S risk factors, specifically preoperative smoking status, HbA1c level, and serum albumin level, were stratified by number of positive risk factors, and perioperative outcomes were compared.

RESULTS

A total of 31,285 patients comprised the study group, with 16,630 (53.2%) patients having no S4S risk factors (S4S0), 12,323 (39.4%) having one (S4S1), 2,186 (7.0%) having two (S4S2), and 146 (0.5%) having three (S4S3). In the S4S1 group, 60.3% were actively smoking, 35.2% had HbA1c > 7, and 4.4% had serum albumin < 3. In the S4S2 group, 87.8% were smokers, 84.8% had HbA1c > 7, and 27.4% had albumin < 3. Major complications, reoperations, length of stay, and 30-day mortality increased progressively from S4S0 to S4S3 groups. S4S3 had the greatest adjusted mortality risk (adjusted odds radio [AOR] 2.56, p = 0.04) followed by S4S2 (AOR 1.58, p = 0.02) and S4S1 (AOR 1.34, p = 0.02).

CONCLUSION

In the VA population, patients who had all three S4S risk factors, namely active smoking, suboptimal nutritional status, and poor glycemic control, had the greatest risk of postoperative mortality compared to patients with fewer S4S risk factors.

Implementation and adherence to a speciality-specific checklist for neurosurgery and its influence on patient safety

Background and Aims

Neurosurgery involves a high level of expertise coupled with enduring and long duration of working hours. There is a paucity of published literature about the experience with a speciality-specific checklist in neurosurgery. We conducted a cross-sectional observational study to identify the adherence to various elements of the Modified World Health Organization Surgical Safety Checklist (WHO SSC) for neurosurgery by the operating room (OR) team.

Methods

We implemented an intra-operative Modified WHO SSC consisting of 40 tools for neurosurgery, in 200 consecutive elective cases. Trained anaesthesiologists assumed the role of checklist co-ordinator. The checklist divided the surgery into 5 phases, each corresponding to a specific time-period. The adherence rates to various tools were evaluated and areas where the checklist prompted a corrective measure were analysed.

Results

A total of 131 cases undergoing craniotomy and 69 cases undergoing spine surgery were studied. With the 40-point modified SSC applied in 200 cases, we analysed a total of 8000 observations. The modified checklist prompted the OR team to adhere to speciality-specific safety practices about application of compression stockings (9.5%); airway precautions in unstable cervical spine (2.5%); precautions for treatment of raised intracranial pressure (10.5%); and intraoperative neuro-monitoring (5%).

Conclusion

The implementation of Modified WHO SSC for Neurosurgery, by a designated checklist co-ordinator, can rectify anaesthetic and surgical facets promptly, without increasing the OR time. The anaesthesiologist as SSC coordinator can effectively implement an intraoperative checklist ensuring excellent participation of operating room team members.

Operating room team training using simulation: Hope or hype?

BACKGROUND

This study sought to determine the long-term impact of multidisciplinary simulated operating room (OR) team training.

METHOD

Two-wave survey study (immediate post-training survey 2010-2017, follow-up 2018). Differences across time, specialty, and experience with adverse events were assessed using chi-square and t -tests.

RESULTS

Immediately after training, more than 90% of respondents found simulation scenarios realistic and reported team training would provide safer patient care. However, follow-up participants reported less enthusiasm toward training, with 58% stating they would like to take similar training again. A majority of participants (77%) experienced adverse events after training; those reporting adverse events reported more positive long-term evaluations.

CONCLUSIONS

Simulated OR team training is initially highly valued by participants and is perceived as contributing to patient safety. Diminution of participant enthusiasm over time suggests that repeat training requirements be reconsidered, and less costly, alternative methods (such as asynchronous learning or virtual reality) should be explored.

Improving surgical quality in low-income and middle-income countries: why do some health facilities perform better than others?

BACKGROUND

Evidence on heterogeneity in outcomes of surgical quality interventions in low-income and middle-income countries is limited. We explored factors driving performance in the Safe Surgery 2020 intervention in Tanzania's Lake Zone to distil implementation lessons for low-resource settings.

METHODS

We identified higher (n=3) and lower (n=3) performers from quantitative data on improvement from 14 safety and teamwork and communication indicators at 0 and 12 months from 10 intervention facilities, using a positive deviance framework. From 72 key informant interviews with surgical providers across facilities at 1, 6 and 12 months, we used a grounded theory approach to identify practices of higher and lower performers.

RESULTS

Performance experiences of higher and lower performers differed on the following themes: (1) preintervention context, (2) engagement with Safe Surgery 2020 interventions, (3) teamwork and communication orientation, (4) collective learning orientation, (5) role of leadership, and (6) perceived impact of Safe Surgery 2020 and beyond. Higher performers had a culture of teamwork which helped them capitalise on Safe Surgery 2020 to improve surgical ecosystems holistically on safety practices, teamwork and communication. Lower performers prioritised overhauling safety practices and began considering organisational cultural changes much later. Thus, while also improving, lower performers prioritised different goals and trailed higher performers on the change continuum.

CONCLUSION

Future interventions should be tailored to facility context and invest in strengthening teamwork, communication and collective learning and facilitate leadership engagement to build a receptive climate for successful implementation of safe surgery interventions.

Association Between Implementing Comprehensive Learning Collaborative Strategies in a Statewide Collaborative and Changes in Hospital Safety Culture

Importance

Hospital safety culture remains a critical consideration when seeking to reduce medical errors and improve quality of care. Little is known regarding whether participation in a comprehensive, multicomponent, statewide quality collaborative is associated with changes in hospital safety culture.

Objective

To examine whether implementation of a comprehensive, multicomponent, statewide surgical quality improvement collaborative is associated with changes in hospital safety culture.

Design, Setting, and Participants

In this survey study, the Safety Attitudes Questionnaire, a 56-item validated survey covering 6 culture domains (teamwork, safety, operating room safety, working conditions, perceptions of management, and employee engagement), was administered to a random sample of physicians, nurses, operating room staff, administrators, and leaders across Illinois hospitals to assess hospital safety culture prior to launching a new statewide quality collaborative in 2015 and then again in 2017. The final analysis included 1024 respondents from 36 diverse hospitals, including major academic, community, and rural centers, enrolled in ISQIC (Illinois Surgical Quality Improvement Collaborative).

Exposures

Participation in a comprehensive, multicomponent statewide surgical quality improvement collaborative. Key components included enrollment in a common standardized data registry, formal quality and process improvement training, participation in collaborative-wide quality improvement projects, funding support for local projects, and guidance provided by surgeon mentors and process improvement coaches.

Main Outcomes and Measures

Perception of hospital safety culture.

Results

The overall survey response rate was 43.0% (580 of 1350 surveys) in 2015 and 39.0% (444 of 1138 surveys) in 2017 from 36 hospitals. Improvement occurred in all the overall domains, with significant improvement in teamwork climate (change, 3.9%; P = .03) and safety climate (change, 3.2%; P = .02). The largest improvements occurred in individual measures within domains, including physician-nurse collaboration (change, 7.2%; P = .004), reporting of concerns (change, 4.7%; P = .009), and reduction in communication breakdowns (change, 8.4%; P = .005). Hospitals with the lowest baseline safety culture experienced the largest improvements following collaborative implementation (change range, 11.1%-14.9% per domain; P < .05 for all). Although several hospitals experienced improvement in safety culture in 1 domain, most hospitals experienced improvement across several domains.

Conclusions and Relevance

This survey study found that hospital enrollment in a statewide quality improvement collaborative was associated with overall improvement in safety culture after implementing multiple learning collaborative strategies. Hospitals with the poorest baseline culture reported the greatest improvement following implementation of the collaborative.

The design and evaluation of a pre-procedure checklist specific to the cardiac catheterisation laboratory

BACKGROUND

With the increasing complexity of procedures being performed in the cardiac catheterisation laboratory, the multidisciplinary team has the challenge of providing safe care to patients who present with a multitude of healthcare needs. Although the use of a surgical safety checklist has become standard practice in operating theatres worldwide, the use of a pre-procedure checklist has not been routinely adopted into interventional cardiology.

OBJECTIVE

The aim of this study was to design and evaluate a pre-procedure checklist specific to the cardiac catheterisation laboratory.

METHOD

A descriptive, exploratory design was used to develop a specifically designed pre-procedure checklist for use in the cardiac catheterisation laboratory in a private hospital in Melbourne, Australia. The pre-procedure checklist was developed by exploring the multidisciplinary team's opinion regarding the organisation's previous surgical pre-procedure checklist through a pre-implementation survey and focus groups. Following an expert review, and implementation of the proposed pre-procedure checklist, a post-implementation survey was completed.

RESULTS

Thirty-five (70%) cardiac catheterisation laboratory healthcare professionals completed the pre-implementation survey, with 31 (62%) completing the post-implementation survey. Ninety-one per cent of participants agreed that important clinical information required for interventional procedures was not documented on the previous surgical checklist. A specific checklist was developed from the results of the survey and six focus groups (N = 25) and implemented in the cardiac catheterisation laboratory. In the post-implementation survey, participants identified that the cardiac catheterisation laboratory specific pre-procedure checklist included all relevant clinical information and improved documentation of patient information.

CONCLUSION

The development of a specific cardiac catheterisation laboratory pre-procedure checklist has led to an improved transfer of pertinent clinical information required prior to procedures being performed in the unit. The outcome of this study has implications for other cardiac catheterisation laboratories with the potential to standardise practice within interventional cardiology practice and improve patient safety outcomes.

Introducing the FATLIPS acronym for assessing the red flag clinical features of dental infection

Introduction Dental infection can progress to life-threatening cervicofacial and deep space infections. Therefore, safe management requires early identification of serious infections in primary care with appropriate referral to secondary care. We have developed an acronym to aid assessment of the red flag clinical features for serious dental infection in primary care by general dental practitioners.Materials and methods Literature review and focus group discussions.Results We introduce the FATLIPS acronym for assessment of red flag features of dental infection: failed previous treatment(s), airway compromise, trismus, look (lower border mandible, orbit, oral, neck), immunosuppression, pyrexia, swallowing difficulties.Conclusion We propose the FATLIPS red flags acronym to help dentists assess the red flag features of dental infections in primary care.

Why industrial methods do not work in healthcare: an analytical approach

Healthcare professionals and managers in hospitals are frequently suggested to learn from industry and business to improve quality and efficiency. However, evidence that the implementation of industrial techniques and business methods has a meaningful effect on patient outcomes is often lacking. An explanation for this phenomenon is thought to be the complexity of the hospital organisation and the diversity of patients. In this article, we use the practice approach to discuss the application of industrial techniques and business methods in healthcare. We employ a practice model that offers three perspectives to understand professional practices: Identity and intrinsic values, Interests of stakeholders, and Ideals and basic beliefs (Triple I). This model demonstrates that the nature of healthcare practices differs strongly from the nature of industrial and business practices. Healthcare has a moral nature that does not let itself be easily organised along technological or business categories. This may provide a fundamental explanation of why industrial techniques and business methods in general will be less successful in healthcare. At the same time, this model invites hospitals to develop innovative approaches that do justice to the identity and intrinsic values of healthcare. In this process, insights from industry and business cannot be copied but have to be used as sources of inspiration.

[Safe surgery and COVID-19: A narrative review]

Fundamentos

La interrupción de la actividad asistencial quirúrgica en España provocada por la pandemia debe finalizar. La recuperación de esta actividad ha de realizarse de forma electiva y en convivencia con posibles casos de COVID-19. El objetivo de esta revisión fue la incorporación de criterios de buenas prácticas relacionados con la COVID-19 al contexto de cirugía segura, que permitiesen desarrollar una propuesta de lista de verificación de seguridad quirúrgica adaptada a pacientes con esta enfermedad.

Métodos

Revisión bibliográfica narrativa, siguiendo el protocolo PRISMA, en los repertorios Medline y Cochrane, utilizando los términos MeSH (coronavirus, infections, safety, surgical procedures, operative, checklist) y el operador booleano AND. Además, se revisaron recomendaciones de organismos y sociedades científicas (literatura gris).

Resultados

Se incluyeron 33 estudios finales con recomendaciones para la cirugía segura y lista de verificación de seguridad quirúrgica adaptada para COVID-19, siendo los más frecuentes los aspectos relacionados con el tratamiento (41,3%) y medidas de prevención y control (27,6%).

Conclusiones

La existencia de un amplio consenso en buenas prácticas recomendadas a pacientes COVID quirúrgicos permite realizar una propuesta de lista de verificación de seguridad quirúrgica a estos enfermos.

Safe surgery checklist: content validation proposal for liver transplantation

OBJECTIVES

to develop the safe surgery checklist for liver transplantation according to the original model of the World Health Organization and perform content validation.

METHODS

a methodological research developed in four stages: integrative review; expert participation; consensus among researchers; and content validation using the Delphi technique in two rounds, by five judges. For data analysis, the Content Validation Index was used.

RESULTS

the first version of the checklist consisted of four surgical moments with 64 items of verification, with an average Content Validation Index of 0.80. After adjustments, in the second round the checklist maintained four surgical moments with 76 items and a Content Validation Index of 0.87.

CONCLUSIONS

the checklist was validated and adequate for the safety of liver transplantation in the surgical environment, given that each item established must be mapped and managed for the success and effectiveness of the procedure.

National implementation of a pragmatic quality improvement skills curriculum for urology residents in the UK: Application and results of 'theory-of-change' methodology

BACKGROUND

There is global momentum to establish scalable Quality Improvement (QI) skills training curricula. We report development of an implementation plan for national scale-up of the 'Education in Quality Improvement' program (EQUIP) in UK urology residencies.

MATERIALS & METHODS

Theory-of-Change (ToC) methodology was used, which engaged EQUIP stakeholders in developing a single-page implementation 'Logic Model' in 4 study phases (2 stakeholder workshops (N = 20); 10 stakeholder interviews). The framework method was used for analysis.

RESULTS

Core elements of the EQUIP Logic Model include: (i) QI curriculum integration into national surgical curricula; (ii) resident-led, modular, team-based QI projects; (iii) development of a national web-platform as QI projects library; (iv) a train-the-trainers module to develop attendings as QI mentors; and (v) knowledge transfer activities (e.g., peer-reviewed publications of residents' QI projects).

CONCLUSIONS

ToC methodology was useful in developing a stakeholder-driven, actionable implementation plan for the national scale-up of EQUIP in the UK.

Changes in Racial Disparities in Mortality After Cancer Surgery in the US, 2007-2016

IMPORTANCE

Racial disparities are well documented in cancer care. Overall, in the US, Black patients historically have higher rates of mortality after surgery than White patients. However, it is unknown whether racial disparities in mortality after cancer surgery have changed over time.

OBJECTIVE

To examine whether and how disparities in mortality after cancer surgery have changed over 10 years for Black and White patients overall and for 9 specific cancers.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional study, national Medicare data were used to examine the 10-year (January 1, 2007, to November 30, 2016) changes in postoperative mortality rates in Black and White patients. Data analysis was performed from August 6 to December 31, 2019. Participants included fee-for-service beneficiaries enrolled in Medicare Part A who had a major surgical resection for 9 common types of cancer surgery: colorectal, bladder, esophageal, kidney, liver, ovarian, pancreatic, lung, or prostate cancer.

EXPOSURES

Cancer surgery among Black and White patients.

MAIN OUTCOMES AND MEASURES

Risk-adjusted 30-day, all-cause, postoperative mortality overall and for 9 specific types of cancer surgery.

RESULTS

A total of 870 929 cancer operations were performed during the 10-year study period. In the baseline year, a total of 103 446 patients had cancer operations (96 210 White patients and 7236 Black patients). Black patients were slightly younger (mean [SD] age, 73.0 [6.4] vs 74.5 [6.8] years), and there were fewer Black vs White men (3986 [55.1%] vs 55 527 [57.7%]). Overall national mortality rates following cancer surgery were lower for both Black (-0.12%; 95% CI, -0.17% to -0.06% per year) and White (-0.14%; 95% CI, -0.16% to -0.13% per year) patients. These reductions were predominantly attributable to within-hospital mortality improvements (Black patients: 0.10% annually; 95% CI, -0.15% to -0.05%; P < .001; White patients: 0.13%; 95% CI, -0.14% to -0.11%; P < .001) vs between-hospital mortality improvements. Across the 9 different cancer surgery procedures, there was no significant difference in mortality changes between Black and White patients during the period under study (eg, prostate cancer: 0.35; 95% CI, 0.02-0.68; lung cancer: 0.61; 95% CI, -0.21 to 1.44).

CONCLUSIONS AND RELEVANCE

These findings offer mixed news for policy makers regarding possible reductions in racial disparities following cancer surgery. Although postoperative cancer surgery mortality rates improved for both Black and White patients, there did not appear to be any narrowing of the mortality gap between Black and White patients overall or across individual cancer surgery procedures.

Perioperative nurses' experiences in relation to surgical patient safety: A qualitative study

Surgical patient safety remains a concern worldwide as, despite World Health Organization recommendations and implementation of its Surgical Safety Checklist, adverse events continue to occur. The aim of this qualitative study was to explore the views and experiences of perioperative nurses regarding the factors that impact surgical patient safety. Data were collected through five focus groups involving a total of 50 perioperative nurses recruited from four public hospitals in Spain. Content analysis of the focus groups yielded four main themes: personal qualities of the perioperative nurse, the surgical environment, safety culture, and perioperative nursing care plans. One of the main findings concerned barriers to the exercise of leadership by nurses, especially regarding completion of the Surgical Safety Checklist. Some of the key factors that impacted the ability of perioperative nurses to fulfil their duties and ensure patient safety were the stress associated with working in the operating room, time pressures, and ineffective communication in the multidisciplinary team. Targeting these aspects through training initiatives could contribute to the professional development of perioperative nurses and reduce the incidence of adverse events by enhancing the surgical safety culture.

Standardized Care Pathways as a Means to Improve Patient Safety

The literature overwhelmingly supports standardized, evidence-based care to improve patient safety in the surgical setting, including checklists and enhanced recovery programs. Although local culture, patient complexity, and hospital setting can represent barriers to implanting standardized practices, they can be overcome with thoughtful strategies.

Using Process Improvement and Systems Redesign to Improve Rheumatology Care Quality in a Safety Net Clinic

OBJECTIVE

To develop and evaluate interventions to improve quality of care in 4 priority areas in an urban safety net adult rheumatology clinic serving a racially/ethnically and socioeconomically diverse patient population.

METHODS

The Institute for Healthcare Improvement's Model for Improvement was used to redesign clinical processes to achieve prespecified benchmarks in the following areas from 2015 to 2017: 13-valent pneumococcal conjugate vaccine (PCV13) administration among immunocompromised patients; disease activity monitoring with the Clinical Disease Activity Index (CDAI) for patients with rheumatoid arthritis; latent tuberculosis infection (LTBI) screening for new biologic users with RA; and reproductive health counseling among women receiving potentially teratogenic medications. We measured performance for each using standardized metrics, defined as the proportion of eligible patients receiving recommended care.

RESULTS

There were 1205 patients seen in the clinic between 2015 and 2017. Regarding demographics, 71% were women, 88% identified as racial/ethnic minorities, and 45% were eligible for at least 1 of the quality measures. Shewart charts for the PCV13 and CDAI measures showed evidence of improved healthcare delivery over time. Benchmarks were achieved for the CDAI and LTBI measures with 93% and 91% performance, respectively. Performance for the PCV13 and reproductive health counseling measures was 78% and 46%, respectively, but did not meet prespecified improvement targets.

CONCLUSION

Through an interprofessional approach, we were able to achieve durable improvements in key rheumatology quality measures largely by enhancing workflow, engaging nonphysician providers, and managing practice variation.

Anesthesia Professionals' Perspectives of Teamwork During Robotic-Assisted Surgery

Robotic-assisted surgery (RAS) presents unique teamwork challenges for perioperative team members, including anesthesia professionals. The purpose of this study was to explore anesthesiologists' and nurse anesthetists' teamwork experiences during RAS using an exploratory qualitative study design involving individual semistructured interviews. Study participants expressed that teamwork during RAS is both positive and challenging, and the start-up phase is the most demanding phase of RAS in terms of teamwork. Anesthesia professionals believe that both technical and nontechnical skills are necessary to provide excellent patient care and maintain patient safety during RAS. Furthermore, they believe that a more concentrated focus on nontechnical skills than is traditional is an essential component of teamwork.

Strategies to Prevent Healthcare-Associated Infections: A Narrative Overview

Healthcare-associated infections (HCAIs) are a major source of morbidity and mortality and are the second most prevalent cause of death. Furthermore, it has been reported that for every one-hundred patients admitted to hospital, seven patients in high-income economies and ten in emerging and low-income economies acquire at least one type of HCAI. Currently, almost all pathogenic microorganisms have developed antimicrobial resistance, and few new antimicrobials are being developed and brought to market. The literature search for this narrative review was performed by searching bibliographic databases (including Google Scholar and PubMed) using the search terms: "Strategies," "Prevention," and "Healthcare-Associated Infections," followed by snowballing references cited by critical articles. We found that although hand hygiene is a centuries-old concept, it is still the primary strategy used around the world to prevent HCAIs. It forms one of a bundle of approaches used to clean and maintain a safe hospital environment and to stop the transmission of contagious and infectious microorganisms, including multidrug-resistant microbes. Finally, antibiotic stewardship also has a crucial role in reducing the impact of HCAIs through conserving currently available antimicrobials.

Identifying optimal program structure, motivations for and barriers to peer coaching participation for surgeons in practice: a qualitative synthesis

BACKGROUND

Continuous advancement of surgical skills is of utmost importance to surgeons in practice, but traditional learning activities without personalized feedback often do not translate into practice changes in the operating room. Peer coaching has been shown to lead to very high rates of practice changes and utilization of new skills. The purpose of this study was to explore the opinions of practicing surgeons regarding the characteristics of peer coaching programs, in order to better inform future peer coaching program design.

METHODS

Using a convenience sample, practicing general surgeons were invited to participate in focus group interviews. Allocation into groups was according to years in practice. The interviews were conducted using open-ended questions by trained facilitators. Audio recordings were transcribed and coded into themes by two independent reviewers using a grounded theory approach.

RESULTS

Of 52 invitations, 27 surgeons participated: 74% male; years in practice: < 5 years: 33%; 5-15 years: 26%; > 15 years: 41%. Three main themes emerged during coding: ideal program structure, motivations for participation, and barriers to implementation. For the ideal structure of a peer coaching program all groups agreed coaching programs should be voluntary, involve bidirectional learning, and provide CME credits. Live, in situ coaching was preferred. Motivations for coaching participation included: desire to learn new techniques (48%), remaining up to date with the evolution of surgical practice (30%) and improvement of patient outcomes (18%). Barriers to program implementation were categorized as: surgical culture (42%), perceived lack of need (26%), logistical constraints (23%) and issues of coach-coachee dynamics (9%).

CONCLUSION

Peer coaching to refine or acquire new skills addresses many shortcomings of traditional, didactic learning modalities. This study revealed key aspects of optimal program structure, motivations and barriers to coaching which can be used to inform the design of successful peer coaching programs in the future.

[Implementation of the G-BA Quality Management Guideline Regarding Surgical Checklist at a University Maximum Care Hospital - Claim and Reality]

Surgical treatment pathways can favor the development of Adverse Events (AE) due to the inherent complexity of their service delivery. The World Health Organization (WHO) Surgical Safety Checklist (SSC) is an instrument that effectively reduces perioperative morbidity and mortality. Against this background, in 2016 the Federal Joint Committee (G-BA) issued a Quality Management Directive (QM-RL) making the use of checklists mandatory for surgical procedures. The aim of this study was to compare the checklist compliance of all ten surgical organizational units of the University Medical Center Mainz in the second half of 2017 and 2018. In addition to the annex of the SSC, the processing of the subitems »Sign-In«, »Team-Time-Out« and »Sign-Out« was evaluated. A comparison of 2017 with 2018 showed an increase in all parameters (»Creation of checklist« (94.2 / 96.5%), »Sign-In« (81.4 / 84.4%), »Team-Time-Out« (56.8 / 62.4%) and »Sign-Out« (50.7 / 57.9%), without, however, statistical significance (p>0.05). In contrast, there were significant differences between certified and non-certified surgical operating units. The parameters showing significant differences were found to be »Sign-In« (87.9 / 71.8%; p=0.034), »Team-Time-Out« (68.4 / 39.4%; p=0.029) and »Sign-Out« (62.1 / 33.6%; p=0.029) for 2017 and »Team-Time-Out« (76.2 / 41.7%); p=0.019) and the »Sign-Out« (71.3 / 37.9%; p=0.019) for 2018. From 2017 to 2018, there was increased implementation of the SCC, particularly in certified facilities. Therefore, the external control of prescribed quality features, for instance, as part of a certification procedure, appears to be a suitable tool for increasing checklist compliance.

The Management Script: A Practical Tool for Teaching Management Reasoning

Management reasoning, a component of clinical reasoning, has become an important area for medical education research given its inherent complexity, role in medical decision making, and association with high-value care. Teaching management reasoning requires characterizing its core concepts and identifying strategies to teach them. In this Perspective, the authors propose the term "management script" to describe the mental schema that clinicians develop and use in medical decision making. Management scripts are high-level, precompiled, conceptual knowledge structures of the courses of action that a clinician may undertake to address a patient's health care problem(s). Like illness scripts, management scripts have foundational elements that are shared by most clinicians but are ultimately idiosyncratic based on each clinician's unique history of learning and experience. Applying management scripts includes 2 steps-(1) management script activation and (2) management option selection-which can occur reflexively (unconsciously) or deliberately (consciously), similar to, respectively, the System 1 thinking and System 2 thinking of dual process theory. Management scripts can be taught for different conditions by using management script templates, educational scaffolds that provide possible courses of action to address a health care problem at any stage. Just as learners use system-based or organ-based frameworks to generate a differential diagnosis, students can use a generic management script template early in training to develop management scripts for specific problems. Future research directions include exploring the role of management scripts in medical education and quality improvement practices.

Safe surgeries: elaboration and validation of a checklist for outpatient surgical procedures

PURPOSE

To prepare and validate the content of a checklist in order to assure the safety for outpatient surgical procedures.

METHOD

Methodological research, performed between May and December 2018, as per three stages: 1) preparation of the checklist; 2) validation of content by five judges; and 3) preliminary testing of the instrument. The concord, among the judges, was measured by the Content Validity Index and the values over 0.9 were considered as being satisfactory.

RESULTS

Initially the instrument was prepared having 58 items, considering the heading and six topics. In the first round, two topics and 27 items had an index below 0.9. After reformulations, in the second round, only two items had values below 0.9 and, in the third, all items reached an index of 1.0. Along the preliminary testing, modifications were realized. The final version it has 43 items, distributed as per five topics.

CONCLUSION

The "Checklist for Safe Surgery regarding Ambulatory Surgical Procedures" was prepared and its contents were validated.

Okay, let's talk - short debriefings in the operating room

INTRODUCTION

Debriefing is increasingly used to enhance learning and reflection in clinical practice. Nevertheless, barriers to implementing debriefings in the operating room (OR) include lack of time, the availability of trained facilitators, and difficulty gathering the full team after surgery. Spending five minutes on a debriefing during skin closure or between procedures may enhance learning and reflection on practice, generating to improve patient safety. The aim of this study was to explore characteristics, feasibility and content of short debriefings in the OR.

METHODS

This was a mixed-method study of short debriefings, analyzing audio-recordings, field notes and relevance ratings from multi-professional teams, that conducted short debriefings in the OR at two University Hospitals in Denmark.

RESULTS

A total of 135 debriefings were conducted, with a median duration of five minutes (range 1:19 min-12:05 min). A total of 477 team members participated in the debriefings. The teams' median rating of relevance was 6 (range 1-10). The rating was higher following challenging events and in debriefings where the surgeon actively participated in the conversation. The teams discussed non-technical skills in all the debriefings and verbalized reflections on practice in 75 percent of the debriefings.

CONCLUSION

It was feasible to conduct short debriefings in a production-focused, complex work environment. In all the debriefings, the teams discussed various non-technical skills (NTS) and reflected on practice. The majority of team members rated the debriefings as relevant for their task management.

A BEME realist synthesis review of the effectiveness of teaching strategies used in the clinical setting on the development of clinical skills among health professionals: BEME Guide No. 61

Background: Literature describing the effectiveness of teaching strategies in the clinical setting is limited. This realist synthesis review focuses on understanding the effectiveness of teaching strategies used in the clinical setting.Methods: We searched ten databases for English language publications between 1 January 1970 and 31 May 2017 reporting effective teaching strategies, used in a clinical setting, of non-procedural skills. After screening, we used consensus to determine inclusion and employed a standardised instrument to capture study populations, methodology, and outcomes. We summarised what strategies worked, for whom, and in what settings.Results: The initial search netted 53,642 references after de-duplication; 2037 were retained after title and abstract review. Full text review was done on 82 references, with ultimate inclusion of 25 publications. Three specific teaching strategies demonstrated impact on educational outcomes: the One Minute Preceptor (OMP), SNAPPS, and concept mapping. Most of the literature involves physician trainees in an ambulatory environment. All three have been shown to improve skills in the domains of medical knowledge and clinical reasoning.Discussion/conclusions: Apart from the OMP, SNAPPS, and concept mapping, which target the formation of clinical knowledge and reasoning skills, the literature establishing effective teaching strategies in the clinical setting is sparse.

Checklist design and implementation: critical considerations to improve patient safety for low-frequency, high-risk patient events

Purpose: This pilot project describes the development and implementation of two specialised aviation-style checklist designs for a low-frequency high-risk patient population in a cardiac intensive care unit. The effect of the checklist design as well as the implementation strategies on patient outcomes and adherence to best practice guidelines were also explored. The long-term objective was to improve adherence to accepted processes of care by establishing the checklists as standard practice thereby improving patient safety and outcomes.

Methods: During this project, 10specialised crisis checklists using two specific aviation-style designs were developed. A quasiexperimental prospective pre-post repeated measure design including surveys along with repetitive simulations were used to evaluate self-confidence and self-efficacy over time as well as the perceived utility, ease of use, fit into workflow and benefits of the checklists use to patients. Performance, patient outcomes and manikin outcomes were also used to evaluate the effectiveness of the crisis checklists on provider behaviours and patient outcomes.

Results: Overall self-confidence and self-confidence related to skills and knowledge while not significant demonstrated clinically relevant improvements that were sustained over time. Perceptions of the checklists were positive with consistent utilisation sustained over time. More importantly, use of the checklists demonstrated a reduction in errors both in the simulated and clinical setting.

Conclusion: Recommendations from this study consist of key considerations for development and implementation of checklists including: utilisation of stakeholders in the development phase; implementation in real and simulated environments; and ongoing reinforcement and training to sustain use.

Combination of National Quality Assurance Data Collection With a Standard Operating Procedure in Community-Acquired Pneumonia: A Win-Win Strategy?

PURPOSE

The primary contact for German physicians with national quality assurance in community-acquired pneumonia (CAP) is frequently experienced as time-consuming obligatory documentation. Since the regular feedback loop stretches up to 18 months, the immediate impact on quality is perceived as rather low. Ultimately, a method leading to increase in the quality of data collection, clarification on expected clinical treatment standards, and improvement in the acceptance and feedback mechanism is needed.

METHODS

We developed a form merging data collection for quality indicators with a standard operating procedure (SOP) in CAP and implemented it in the daily routine of a university's department for internal medicine. Fulfillment of quality indicators before and after the implementation of the new form was measured.

RESULTS

Critical parameters such as the documentation of breathing rate and clinical parameters at discharge strongly improved after implementation of the intervention. Uncritical parameters showed slight improvement or stable results at a high level.

CONCLUSION

The combination of collection of quality data with a clinical SOP and context information may improve the impact of quality measures by increasing acceptance, quality of data capture, short-loop feedback, and possibly quality of care.