A widely promoted checklist to reduce complications and
deaths during surgery is not straightforward to implement in either high- or
low-income countries, says new research. It is especially unlikely to be used as
intended in countries where the electricity supply is unreliable, there is a
lack of basic materials such as gauze, and shifts can last for up to 36
hours.
A study carried out by Dr Emma-Louise Aveling and Professor Mary
Dixon-Woods in the Department of Health Sciences at the University of Leicester,
and Peter McCulloch in the Nuffield Department of Surgical Science at the
University of Oxford, has compared how the checklist was used in operating
theatres in two English hospitals and one sub-Saharan African
hospital.
The results of the study, which was funded by a Higher
Education Innovation Fund Impact Award, the Wellcome Trust, and the Department
of Health Policy Research Programme, are published today in BMJ Open, an
open-access online journal. They are likely to foster debate worldwide.
Policy-makers and the World Health Organization have supported the checklist
since it was reported to have reduced the rate of deaths and complications by
more than a third across eight diverse hospitals in different countries in a
2009 pilot study.
Dr Aveling, who carried out the field research, says:
"An important feature of the checklist is its claim to universality: it is meant
to be as simple to use in a rural hospital in Namibia as it is in a private
medical centre in New Zealand."
Now used in 1,800 institutions worldwide,
the checklist combines checks for technical items such as administering of
antibiotics and use of pulse oximeters (a device that is attached to the finger
to measure oxygen to the brain) with non-technical items such as team
introductions.
Use of the checklist has been mandatory in UK hospitals
since 2010. But so-called 'never events' - patient safety incidents that the
checklist is designed to catch - have continued to occur in the UK and around
the world.
The research team conducted extensive observations in
operating theatres in the UK and an African country, and interviewed clinicians
and managers to see whether the checklist was used at all, used properly and
used fully. They found some similarities between the UK and African settings.
Though many staff welcomed the checklist, they did complain about some items.
And not all staff were wholly enthusiastic, or they were very resistant to using
the checklist properly. If these individuals were in senior positions or very
powerful in their local environments, their attitudes could undermine checks
designed to promote teamwork and reduce hierarchies.
Dr Aveling says:
"The checklist was designed not only to improve patient safety by increasing the
reliability of technical steps, but also by strengthening communication. But if
checklist implementation is not handled well, it is precisely where technical
and communication issues are most problematic that the checklist, by itself, is
least likely to resolve them."
The research found that in the UK settings
use of the checklist was high, although not 100%, for most procedures. In the
African setting it was highly inconsistent - there, during staff shortages,
emergencies or busy periods, the checklist was abandoned altogether. Checkboxes
were ticked without tasks such as equipment counts being
undertaken.
Differences were particularly marked where material resources
were concerned: there was a limited range of antibiotics and no hospital policy
regarding their administration; there were also too few pulse oximeters yet
operations were rarely cancelled if one was not available.
Dr Aveling
commented that: "Things we take for granted in the West - reliable
sterilisation, the availability of basic equipment - are rare in some low-income
countries. This made the checklist difficult to implement and use correctly and
completely."
Particularly disquieting was the finding that poor checklist
implementation in low-income countries might not only fail to reduce patient
safety risks, but introduce new risks for staff and patients.
The
researchers cite the case of two staff members at the African hospital who were
threatened at gunpoint and then arrested after a patient died during surgery
from lack of oxygen to the brain. No pulse oximeter had been available, even
though the checklist stipulates its use. Criminal charges were brought against
one of the accused, who was not provided with legal representation for some
weeks.
Professor Dixon-Woods, who is a Wellcome Trust Senior Investigator
in Society & Ethics, says: "Without adequate resources, efficient systems,
and the right culture in place, hospitals adopting the checklist can introduce
new risks for their staff and their patients. It is disturbing that the
checklist can encourage unethical behaviour, as staff feel under pressure to
tick the boxes even though they cannot comply. The principles underlying the
surgical checklist are good ones, but only now are we waking up to the serious
challenges associated with implementation. On its own, the checklist is no magic
bullet."
The team has made a number of recommendations that it hopes will
make the checklist more effective across the world: surgical teams should be
trained together on the use of the checklist, not separately within their
disciplines; collection and feedback of data has to be improved, with further
support if necessary; and senior staff need to be called on to act as
'champions' of the checklist where there is resistance to use. Most importantly,
the checklist needs to be part of a broader, institution-wide campaign to
improve patient safety, not just introduced in isolation.
