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Surgery Checklists Help OR Teams in a Crisis, Study Finds

WEDNESDAY Jan. 16, 2013 -- Perhaps you've seen the nail-biter episodes of "Grey's Anatomy" or another medical drama: One moment a surgery is progressing smoothly and the next, a patient's heart stops beating or he begins bleeding uncontrollably, and havoc breaks out in the operating room.

It happens in real life, too, said Dr. Atul Gawande, author of a new study that shows that if surgical teams follow a checklist when crises hit, important life-saving steps are less likely to be skipped.

"We've always believed you stay away from checklists and algorithms for these, that surgery is complicated and takes judgment and seat-of-the-pants thinking," Gawande said. "But when we tested surgical teams with crisis checklists, having a playbook proved majorly beneficial."

Gawande, a surgeon at Brigham and Women's Hospital in Boston and a professor in the department of health policy and management at Harvard School of Public Health, said that although it's rare for an individual doctor or nurse to experience an operating room crisis, such events are not uncommon for large hospitals. A hospital with 10,000 operations a year logs an estimated 145 such surgical emergencies annually, according to the study, which was published in the Jan. 17 issue of the New England Journal of Medicine.

"The major problem is a failure to rescue people when something goes wrong," Gawande said.

"Serious complications, such as when the patient stops breathing, the heart stops, blood pressure changes, massive bleeding -- when things hit the fan, it's total chaos. It's incredibly stressful," he said. "But it doesn't happen every day for someone handling it, so you're calling on skills that have been laying dormant."

Gawande conducted research four years ago that shows using pre-surgery checklists cuts down on complications during a procedure, but he and his colleagues wanted to explore whether using a checklist mid-emergency makes a difference too.

The study found that operating room teams who used surgical checklists when a life-threatening event arose were 74 percent less likely to skip pivotal life-saving steps compared to those who worked from memory.

For the study, Gawande's team recruited 17 surgical teams from three hospitals in the Boston area and simulated more than 100 operating room emergencies using a robotic patient.

"We tested surgical teams in a high-fidelity simulator. It looked like an operating room but with a fake, electronic patient, and in every operation something went wrong," Gawande said. "It was like the worst operating day you ever had."

Each team used a surgical checklist in half of the simulations and worked from memory alone in the other half. The failure rate for following proven life-saving processes fell from 23 percent to 6 percent, Gawande reported.

Afterward, nearly all of the participants said they would want a checklist used while handling a crisis during surgery.

Gawande said that to help develop surgical checklist protocols he and his colleagues collaborated with airline crisis experts who follow similar checklists for emergencies such as engine failures or in-flight fires.

Hospitals and surgical teams should tailor checklists to their own environments, he said.

Dr. Harry Papaconstantinou, interim chairman of the department of surgery at Scott and White Healthcare in Temple, Texas, called the study "fantastic" and said it highlights the importance of being prepared in the operating room.

"If you're in a really stressful situation and there are 10 steps that you have to memorize, essentially what this study is showing is that if you don't have a checklist, the likelihood is that you are going to miss steps," Papaconstantinou said.

Those missed steps can affect patient recovery and survival, he said.

"The checklist makes sure the patient receives the optimal treatment for the surgery and makes sure the team adheres to and performs the necessary recommended steps in a rapid, coordinated manner in spite of the chaotic, stressful environment," Papaconstantinou said.

Key staff members who run down the checklist typically include the anesthesiologist and the nurse, Gawande said.

Papaconstantinou said some surgery teams may be slower to adopt such checklists for a variety of reasons, including an attitude that these events don't happen to them or the belief that they don't need a checklist to do the right thing for patients. Some may be overconfident in their ability to perform under these stressful conditions, he said.

The authors of an accompanying journal editorial acknowledged that checklists are improving patient care in hospital operating rooms, and said the same consideration is due to patients undergoing outpatient procedures in endoscopy suites, cardiac catheter labs and interventional radiology rooms.

"These patients are deserving of the same safety considerations that are being afforded to those undergoing an operation," wrote the authors, from Imperial College London and Harvard University.

More information

The Nemours Foundation explains what surgery is like.

Posted: January 2013


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