Neurosurgical checklists: a review

Quality and patient safety research in pediatric neurosurgery: a review

BACKGROUND

In 2001, the National Academy of Medicine, formerly known as the Institute of Medicine (IOM), published their seminal work, Crossing the Quality Chasm: A New Health System for the 21st Century. In this work, the authors called for improved safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity in the United States' healthcare system. Two decades after the publication of this work, healthcare costs continue to rise, but outcomes lag other nations. The objective of this narrative review is to describe research efforts in pediatric neurosurgery with respect to the six quality aims proposed by the IOM, and highlight additional research opportunities.

METHODS

PubMed, Google Scholar, and EBSCOhost were queried to identify studies in pediatric neurosurgery that have addressed the aims proposed by the IOM. Studies were summarized and synthesized to develop a set of research opportunities to advance quality of care.

RESULTS

Twenty-three studies were reviewed which focused on the six quality aims proposed by the IOM. Out of these studies, five research opportunities emerged: (1) To examine performance of tools of care, (2) To understand processes surrounding care delivery, (3) To conduct cost-effectiveness analyses for a broader range of neurosurgical conditions, (4) To identify barriers driving healthcare disparities, and (5) To understand patients' and caregivers' experiences receiving care, and subsequently develop tools and programs to address their needs and preferences.

CONCLUSION

There is a growing body of literature examining quality in pediatric neurosurgical care across all aims proposed by the IOM. However, there remains important gaps in the literature that, if addressed, will advance the quality of pediatric neurosurgical care delivery.

Safety and Quality in Syndromic Neurosurgery

The developing field of syndromic neurosurgery has significant challenges and opportunities in quality and safety. Quality care must be safe, effective, patient-centered, timely, efficient, and equitable; the Donabedian model focused on system structures, processes, and outcomes is a helpful framework to guide improvement in these areas. Ultimately, a successful syndromic neurosurgery program will bring together an interested multidisciplinary team of experts who will grow care through open communication and steady improvement efforts.

The Neurosurgical Intraoperative Checklist for Surgery of the Craniocervical Junction and Spine

Many sectors within healthcare have adapted checklists to improve quality control. Notwithstanding the reported successful implementation of surgical checklists in the operating theater, a dearth of literature addresses the specific challenges posed by complex surgery in the craniocervical junction and spine. The authors devised an intraoperative checklist to address the common errors and verify the completion of objectives unique to these surgeries. The data over six years is presented retrospectively; no historical control for comparison is available, as those omissions and surgical errors addressed by the checklist are not generally registered in any morbidity and mortality reports. Through six years and approximately 1200 surgeries, the checklist was implemented with 98% compliance. The checklist eliminated the occurrences of mundane surgical errors, minimized iatrogenic complications, and ensured completion of specific objectives. We discuss that preoperative checklists, now in general use in all hospitals, have not addressed the most common, intraoperative omissions. These technical omissions result in part from the complexity of spine surgery and directly impact the surgical outcome. The Neurosurgical Intraoperative Checklist is a practical, rapid, and comprehensive means to prevent common, avoidable errors and iatrogenic complications inherent to spine surgery.

UC Care Check-A Postoperative Neurosurgery Operating Room Checklist: An Interrupted Time Series Study

BACKGROUND

The effectiveness of neurosurgical operating room (OR) checklists to improve communication, safety attitudes, and clinical outcomes is uncertain.

PURPOSE

To develop, implement, and evaluate a post-operative neurosurgery operating room checklist.

METHODS

Four large academic medical centers participated in this study. We developed an evidence-based checklist to be performed at the end of every adult-planned or emergent surgery in which all team members pause to discuss key elements of the case. We used a prospective interrupted time series study design to assess trends in clinical and cost outcomes. Safety attitudes and communication among OR providers were also assessed.

RESULTS

There were 11,447 neurosurgical patients in the preintervention and 10,973 in the postintervention periods. After implementation, survey respondents perceived that postoperative checklists were regularly performed, important issues were communicated at the end of each case, and patient safety was consistently reinforced. Observed to expected (O/E) overall mortality rates remained less than one, and 30-day readmission rate, length of stay index, direct cost index, and perioperative venous thromboembolism and hematoma rates remained unchanged as a result of checklist implementation.

CONCLUSION

A neurosurgical checklist can improve OR team communication; however, improvements in safety attitudes, clinical outcomes, and health system costs were not observed.

The Need for Surgical Safety Checklists in Neurosurgery Now and in the Future-A Systematic Review

Safety checklists have been studied among various surgical patient groups, but evidence of their benefits in neurosurgery remains sparse. Since the implementation of the World Health Organization's Surgical Safety Checklist, their use has become widespread. The aim of this review was to systematically review the state of the literature on surgical safety checklists in neurosurgery. Also, in the new era of robotics and artificial intelligence, there is a need to re-evaluate patient safety procedures in neurosurgery. A systematic review was conducted on PubMed, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials, Embase, and MEDLINE for articles published between 2008 and 2016 using MeSH (medical subject heading) terms and keywords describing postoperative complications and surgical adverse events, and some additional searches were carried out until January 2019. Twenty-six original studies or reviews were eligible for this review. They were categorized into studies with patient-related outcomes, personnel-related outcomes, or previous reviews. Checklist use in neurosurgery was found to reduce hospital-acquired infectious complications and to enhance operating room safety culture. Checklists seem to improve patient safety in neurosurgery, although the amount of evidence is still limited. Despite their shortcomings, checklists are here to stay, and new research is required to update checklists to meet the requirements of the transforming working environment of the neurosurgery operating room.

The Zurich Checklist for Safety in the Intraoperative Magnetic Resonance Imaging Suite: Technical Note

BACKGROUND

Recently, the use of intraoperative magnetic resonance imaging (ioMRI) has evolved in neurosurgery. Challenges related to ioMRI-augmented procedures are significant, since the magnetic field creates a potentially hazardous environment. Strict safety guidelines in the operating room (OR) are necessary. Checklists can minimize errors while increasing efficiency and improving workflow.

OBJECTIVE

To describe the Zurich checklists for safety in the ioMRI environment.

METHODS

We summarize the checklist protocol and the experience gained from over 300 surgical procedures performed over a 4-yr period using this new system for transcranial or transsphenoidal surgery in a 2-room high-field 3 Tesla ioMRI suite.

RESULTS

Particularities of the 2-room setting used at our institution can be summarized as (1) patient transfer from a sterile to a nonsterile environment and (2) patient transfer from a zone without to a zone with a high-strength magnetic field. Steps on the checklist have been introduced for reasons of efficient workflow, safety pertaining to the strength of the magnetic field, or sterility concerns. Each step in the checklist corresponds to a specific phase and particular actions taken during the workflow in the ioMRI suite. Most steps are relevant to any 2-room ioMRI-OR suite.

CONCLUSION

The use of an ioMRI-checklist promotes a zero-tolerance attitude for errors, can lower complications, and can help create an environment that is both efficient and safe for the patient and the OR personnel. We highly recommend the use of a surgical checklist when applying ioMRI.

Patient safety improvement interventions in children's surgery: A systematic review

BACKGROUND

Adult surgical patient safety literature is plentiful; however, there is a disproportionate paucity of published safety work in the children's surgical literature. We sought to systematically evaluate the nature and quality of patient safety evidence pertaining to pediatric surgical practice.

METHODS

Systematic search of MEDLINE and EMBASE databases and gray literature identified 1399 articles. Data pertaining to demographics, methodology, interventions, and outcomes were extracted. Study quality was assessed utilizing formal criteria.

RESULTS

20 studies were included. 14 (70%) comprised peer-reviewed articles. 18 (90%) were published in the last 4years. 13 (65%) described a novel intervention, and 7 (35%) described a modification of an existing intervention. Median patient sample size was 79 (29-1210). A large number (n=55) and variety (n=35) of measures were employed to evaluate the effect of interventions on patient safety. 15 (75%) studies utilized a checklist tool as a component of their intervention. 9 (45%) studies [comprising handoff tools (n=7); checklists (n=1); and multidimensional quality improvement initiatives (n=1)] reported a positive effect on patient safety. Quality assessment was undertaken on 14 studies. Quantitative studies had significantly higher quality scores than qualitative studies (61 [0-89] vs 44 [11-78], p=0.03).

CONCLUSIONS

Pediatric surgical patient safety evidence is in its early stages. Successful interventions that we identified were typically handoff tools. There now ought to be an onus on pediatric surgeons to develop and apply bespoke pediatric surgical safety interventions and generate an evidence base to parallel the adult literature.

LEVEL OF EVIDENCE

Level IV, Case series with no comparison group.

Internal Audit of Compliance with a Perioperative Checklist in a Tertiary Care Neurosurgical Unit

BACKGROUND

In 1999, the Institute of Medicine reported that, in the United States, 44,000 to 98,000 people die annually as a result of avoidable medical errors. Among the many initiatives undertaken to stem avoidable surgical errors, the World Health Organization (WHO) Surgical Safety Checklist has certainly been one of the most successful. Many surgical units have implemented adapted versions of the WHO Surgical Safety Checklist, audited their performance and discussed issues relating to the implementation process. However, such literature is still lacking in neurosurgery.

METHODS

A prospective observational study of 171 neurosurgical cases was conducted over an 8-week period. An independent observer assessed compliance with and completeness of the three steps in the perioperative checklist: Sign-in, Time-out and Sign-out. Factors that may reduce compliance were also analyzed.

RESULTS

Compliance with the Sign-in, Time-out and Sign-out steps was 82%, 99% and 93% respectively. On average, 92% of the Time-out elements were verified. The emergent nature of a surgery was the only factor that caused a statistically significant reduction in compliance with the checklist. Overall compliance diminished during the observation period.

CONCLUSION

In this internal audit study, compliance with the preoperative checklist reached a satisfactory level. Further work is still needed, however, on some aspects of our surgical strategy, namely, a relatively low compliance rate with the Sign-in process was recorded and emergent cases were associated with decreased performance.

A checklist for endonasal transsphenoidal anterior skull base surgery

OBJECT Approximately 250 million surgical procedures are performed annually worldwide, and data suggest that major complications occur in 3%-17% of them. Many of these complications can be classified as avoidable, and previous studies have demonstrated that preoperative checklists improve operating room teamwork and decrease complication rates. Although the authors' institution has instituted a general preoperative "time-out" designed to streamline communication, flatten vertical authority gradients, and decrease procedural errors, there is no specific checklist for transnasal transsphenoidal anterior skull base surgery, with or without endoscopy. Such minimally invasive cranial surgery uses a completely different conceptual approach, set-up, instrumentation, and operative procedure. Therefore, it can be associated with different types of complications as compared with open cranial surgery. The authors hypothesized that a detailed, procedure-specific, preoperative checklist would be useful to reduce errors, improve outcomes, decrease delays, and maximize both teambuilding and operational efficiency. Thus, the object of this study was to develop such a checklist for endonasal transsphenoidal anterior skull base surgery. METHODS An expert panel was convened that consisted of all members of the typical surgical team for transsphenoidal endoscopic cases: neurosurgeons, anesthesiologists, circulating nurses, scrub technicians, surgical operations managers, and technical assistants. Beginning with a general checklist, procedure-specific items were added and categorized into 4 pauses: Anesthesia Pause, Surgical Pause, Equipment Pause, and Closure Pause. RESULTS The final endonasal transsphenoidal anterior skull base surgery checklist is composed of the following 4 pauses. The Anesthesia Pause consists of patient identification, diagnosis, pertinent laboratory studies, medications, surgical preparation, patient positioning, intravenous/arterial access, fluid management, monitoring, and other special considerations (e.g., Valsalva, jugular compression, lumbar drain, and so on). The Surgical Pause is composed of personnel introductions, planned procedural elements, estimation of duration of surgery, anticipated blood loss and fluid management, imaging, specimen collection, and questions of a surgical nature. The Equipment Pause assures proper function and availability of the microscope, endoscope, cameras and recorders, guidance systems, special instruments, ultrasonic microdoppler, microdebrider, drills, and other adjunctive supplies (e.g., Avitene, cotton balls, nasal packs, and so on). The Closure Pause is dedicated to issues of immediate postoperative patient disposition, orders, and management. CONCLUSIONS Surgical complications are a considerable cause of death and disability worldwide. Checklists have been shown to be an effective tool for reducing preventable errors surrounding surgery and decreasing associated complications. Although general checklists are already in place in most institutions, a specific checklist for endonasal transsphenoidal anterior skull base surgery was developed to help safeguard patients, improve outcomes, and enhance teambuilding.

The science of medical decision making: neurosurgery, errors, and personal cognitive strategies for improving quality of care

During the last 2 decades, there has been a shift in the U.S. health care system towards improving the quality of health care provided by enhancing patient safety and reducing medical errors. Unfortunately, surgical complications, patient harm events, and malpractice claims remain common in the field of neurosurgery. Many of these events are potentially avoidable. There are an increasing number of publications in the medical literature in which authors address cognitive errors in diagnosis and treatment and strategies for reducing such errors, but these are for the most part absent in the neurosurgical literature. The purpose of this article is to highlight the complexities of medical decision making to a neurosurgical audience, with the hope of providing insight into the biases that lead us towards error and strategies to overcome our innate cognitive deficiencies. To accomplish this goal, we review the current literature on medical errors and just culture, explain the dual process theory of cognition, identify common cognitive errors affecting neurosurgeons in practice, review cognitive debiasing strategies, and finally provide simple methods that can be easily assimilated into neurosurgical practice to improve clinical decision making.