News

Study eyes impact of surgical safety checklists on mortality

Key clinical point: Implementation of surgical safety checklists (SSCs) at a hospital led to reduced risk of mortality at 90 days, but not at 30 days.

Major finding: Ninety-day all-cause mortality was 2.4% before implementation of SSCs, compared with 2.2% after implementation, for an adjusted odds ratio (AOR) of 0.73 (P = .02).

Data source: A retrospective evaluation of surgical procedures performed on 10,741 patients during the 6 months before and 6 months after implementation of SSCs at the 715-bed Central Hospital of Bolzano in Italy.

Disclosures: The study was supported by the Public Health Care Company of South Tyrol, Italy, and by the Autonomous Province of Bolzano, Italy. The researchers reported having no financial disclosures.

View on the News

Study highlights challenges of implementation

We commend the authors for choosing to focus on the 90-day postoperative all-cause mortality rate, and we are reassured that they saw a statistically significant decrease. However, we should also consider why no statistically significant change in the 30-day postoperative all-cause mortality rate was observed. This finding could be attributable to inherent differences in the population studied, to the case mix, or to insufficient power to detect change related to sample size.

This article also highlights the ongoing challenges of checklist implementation and measurement of the impact of the SSC. First, whether SSC performance underwent direct observation during implementation and whether that observation compared with reported performance are unclear. Checklist performance appears to be measured primarily by checking whether a form was completed. Significant discordance between paper checklist completion and actual completion has been described. Second, 80% completion was considered the threshold for complete implementation in this study, whereas recent literature supports that full rather than partial checklist completion provides an opportunity for significant improvement of the effect of the SSC on the quality of patient care and surgical safety. With more effective implementation and full SSC use in every case, the improvement in outcomes seen could have been even. If the SSC is not used, it cannot help.

These comments were extracted from an editorial that appeared online in JAMA Surgery (JAMA Surg. 2016 Feb 3. doi:10.1001/jamasurg.2015.5551). Dr. William Berry is with the department of health policy and management at Harvard School of Public Health, Boston; Dr. Alex Haynes is with the department of surgical oncology at Massachusetts General Hospital, Boston; and Dr. Janaka Lagoo is with the Harvard School of Public Health and Brigham and Women’s Hospital, Boston. The authors reported having no financial disclosures.


 

FROM JAMA SURGERY

References

After implementation of surgical safety checklists in a tertiary care hospital, researchers observed a 27% reduction of risk-adjusted all-cause 90-day mortality, but adjusted all-cause 30-day mortality remained unchanged.

In addition, length of stay was reduced but 30-day readmission rate was not, according to the study published online in JAMA Surgery. Those key findings are from an effort to assess the association between the implementation of surgical safety checklists (SSCs) and rates of all-cause 90- and 30-day mortality.

checklist ©PixelEmbargo/Thinkstock

Previous studies have analyzed in-hospital mortality or 30-day mortality “but not intermediate-term outcome variables,” said lead author Dr. Matthias Bock of the department of anesthesiology and intensive care medicine at Merano Hospital, Merano, Italy. “Almost one-quarter (23.6%) of the deaths within 30 days after surgery occurred after discharge, and 39.7% of patients undergoing surgery experienced only post-discharge complications. Ninety-day mortality often doubles 30-day mortality. In-hospital mortality and 30-day mortality might therefore underreport the real risk to these patients, especially after tumor surgery or among the elderly. Studies of the effect or the association of the implementation of surgical safety checklists (SSCs) on 90-day mortality are lacking.”

Dr. Bock and his associates retrospectively evaluated the outcomes of surgical procedures performed during the six months before and six months after implementation of SSCs at the 715-bed Central Hospital of Bolzano (CHB) in Italy (Jan. 1-June 30, 2010, and Jan. 1-June 30, 2013, respectively). The key outcome measures were risk-adjusted rates of 90- and 30-day mortality, readmission rate, and LOS (JAMA Surg. 2016 Feb 3. doi:10.1001/jamasurg.2015.5490).

The study sample consisted of 10,741 patients, including 5,444 pre-intervention and 5,297 post-intervention patients. Of these, 53% were female and their mean age was 53 years.

The researchers reported that 90-day all-cause mortality was 2.4% before SSC implementation, compared with 2.2% after implementation, for an adjusted odds ratio (AOR) of 0.73 (P = .02). However, 30-day all-cause mortality was 1.36% before SSC implementation, compared with 1.32% after implementation, for an AOR of 0.79 (P = .17), remaining essentially unchanged.

Dr. Bock and his associates also found that 30-day readmission rates were similar in the pre-implementation and post-implementation groups (14.6% vs. 14.5%, respectively: P = .90), but the adjusted length of stay favored the post-implementation group (a mean of 9.6 days, compared with a mean of 10.4 days in the in the pre-implementation group; P less than .001).

The researchers acknowledged certain limitations of the study, including its single-center design and the lack of a control group. “The study design highly reduces the risk for observation bias (Hawthorne effect),” they wrote. “Furthermore, we did not inform the staff about the purpose of our study. We analyzed only objective outcome data to reduce reporting bias as much as possible.”

The finding of a decline in LOS “suggests potential cost savings after the implementation of SSCs,” they concluded. “Further trials should address this hypothesis and the effect on quality of care owing to a reduction of the costs of complications or unplanned reoperations.”

The study was supported by the Public Health Care Company of South Tyrol, Italy, and by the Autonomous Province of Bolzano, Italy. The researchers reported having no financial disclosures.

dbrunk@frontlinemedcom.com

Next Article:

   Comments ()