Efficacy and safety of mesh closure in preventing wound failure following emergency laparotomy: a systematic review and meta-analysis.

AIMS: To evaluate comparative outcomes of emergency laparotomy closure with and without prophylactic mesh. METHODS: A systematic review was performed via literature databases: PubMed, Cochrane Library, Science Direct, and Google Scholar. Studies were examined for eligibility and included if they compared prophylactic mesh closure to the conventional laparotomy closure following emergency abdominal surgery. Both acute wound failure and incisional hernia (IH) occurence were our primary outcomes. Secondary outcomes included surgical site infection (SSI), seroma/hematoma formation, Clavien-Dindo complications (score ≥ 3), total operative time, and length of hospital stay (LOS). RESULTS: Two randomised controlled trials (RCTs) and four comparative studies with a total of 817 patients met the inclusion criteria. Overall acute wound failure and incisional hernia rate was significantly lower in the mesh group compared to non-mesh group (odd ratio (OR) 0.23, p = 0.002) and (OR 0.21, p = 0.00001), respectively. There was no significant difference between the two groups regarding the following outcomes: total operative time (mean difference (MD) 21.44, p = 0.15), SSI (OR 1.47, p = 0.06), seroma/haematoma formation (OR 2.74, p = 0.07), grade ≥ 3 Clavien-Dindo complications (OR 2.39, p = 0.28), and LOS (MD 0.26, p = 0.84). CONCLUSION: The current evidence for the use of prophylactic mesh in emergency laparotomy is diverse and obscure. Although the data trends towards a reduction in the incidence of IH, a reliable conclusion requires further high-quality RCTs to fully assess the efficacy and safety of mesh use in an emergency setting.

Surgical Checklist Implementation Project: The Impact of Variable WHO Checklist Compliance on Risk-adjusted Clinical Outcomes After National Implementation: A Longitudinal Study.

OBJECTIVE: To evaluate impact of WHO checklist compliance on risk-adjusted clinical outcomes, including the influence of checklist components (Sign-in, Time-out, Sign-out) on outcomes. BACKGROUND: There remain unanswered questions surrounding surgical checklists as a quality and safety tool, such as the impact in cases of differing complexity and the extent of checklist implementation. METHODS: Data were collected from surgical admissions (6714 patients) from March 2010 to June 2011 at 5 academic and community hospitals. The primary endpoint was any complication, including mortality, occurring before hospital discharge. Checklist usage was recorded as checklist completed in full/partly. Multilevel modeling was performed to investigate the association between complications/mortality and checklist completion. RESULTS: Significant variability in checklist usage was found: although at least 1 of the 3 components was completed in 96.7% of cases, the entire checklist was only completed in 62.1% of cases. Checklist completion did not affect mortality reduction, but significantly lowered risk of postoperative complication (16.9% vs. 11.2%), and was largely noticed when all 3 components of the checklist had been completed (odds ratio = 0.57, 95% confidence interval: 0.37-0.87, P < 0.01). Calculated population-attributable fractions showed that 14% (95% confidence interval: 7%-21%) of the complications could be prevented if full completion of the checklist was implemented. CONCLUSIONS: Checklist implementation was associated with reduced case-mix-adjusted complications after surgery and was most significant when all 3 components of the checklist were completed. Full, as opposed to partial, checklist completion provides a health policy opportunity to improve checklist impact on surgical safety and quality of care.

A qualitative evaluation of the barriers and facilitators toward implementation of the WHO surgical safety checklist across hospitals in England: lessons from the "Surgical Checklist Implementation Project".

OBJECTIVES: To evaluate how the World Health Organization (WHO) surgical safety checklist was implemented across hospitals in England; to identify barriers and facilitators toward implementation; and to draw out lessons for implementing improvement initiatives in surgery/health care more generally. BACKGROUND: The WHO checklist has been linked to improved surgical outcomes and teamwork, yet we know little about the factors affecting its successful uptake. METHODS: A longitudinal interview study with operating room personnel was conducted across a representative sample of 10 hospitals in England between March 2010 and March 2011. Interviews were audio recorded over the phone. Interviewees were asked about their experience of how the checklist was introduced and the factors that hindered or aided this process. Transcripts were submitted to thematic analysis. RESULTS: A total of 119 interviews were completed. Checklist implementation varied greatly between and within hospitals, ranging from preplanned/phased approaches to the checklist simply "appearing" in operating rooms, or staff feeling it had been imposed. Most barriers to implementation were specific to the checklist itself (eg, perceived design issues) but also included problematic integration into preexisting processes. The most common barrier was resistance from senior clinicians. The facilitators revealed some positive steps that can been taken to prevent/address these barriers, for example, modifying the checklist, providing education/training, feeding-back local data, fostering strong leadership (particularly at attending level), and instilling accountability. CONCLUSIONS: We identified common themes that have aided or hindered the introduction of the WHO checklist in England and have translated these into recommendations to guide the implementation of improvement initiatives in surgery and wider health care systems.

Measuring variation in use of the WHO surgical safety checklist in the operating room: a multicenter prospective cross-sectional study.

BACKGROUND: Full implementation of safety checklists in surgery has been linked to improved outcomes and team effectiveness; however, reliable and standardized tools for assessing the quality of their use, which is likely to moderate their impact, are required. STUDY DESIGN: This was a multicenter prospective study. A standardized observational instrument, the "Checklist Usability Tool" (CUT), was developed to record precise characteristics relating to the use of the WHO's surgical safety checklist (SSC) at "time-out" and "sign-out" in a representative sample of 5 English hospitals. The CUT was used in real-time by trained assessors across general surgery, urology, and orthopaedic cases, including elective and emergency procedures. RESULTS: We conducted 565 and 309 observations of the time-out and sign-out, respectively. On average, two-thirds of the items were checked, team members were absent in more than 40% of cases, and they failed to pause or focus on the checks in more than 70% of cases. Information sharing could be improved across the entire operating room (OR) team. Sign-out was not completed in 39% of cases, largely due to uncertainty about when to conduct it. Large variation in checklist use existed between hospitals, but not between surgical specialties or between elective and emergency procedures. Surgical safety checklist performance was better when surgeons led and when all team members were present and paused. CONCLUSIONS: We found large variation in WHO checklist use in a representative sample of English ORs. Measures sensitive to checklist practice quality, like CUT, will help identify areas for improvement in implementation and enable provision of comprehensive feedback to OR teams.

The WHO surgical safety checklist: survey of patients' views.

BACKGROUND: Evidence suggests that full implementation of the WHO surgical safety checklist across NHS operating theatres is still proving a challenge for many surgical teams. The aim of the current study was to assess patients' views of the checklist, which have yet to be considered and could inform its appropriate use, and influence clinical buy-in. METHOD: Postoperative patients were sampled from surgical wards at two large London teaching hospitals. Patients were shown two professionally produced videos, one demonstrating use of the WHO surgical safety checklist, and one demonstrating the equivalent periods of their operation before its introduction. Patients' views of the checklist, its use in practice, and their involvement in safety improvement more generally were captured using a bespoke 19-item questionnaire. RESULTS: 141 patients participated. Patients were positive towards the checklist, strongly agreeing that it would impact positively on their safety and on surgical team performance. Those worried about coming to harm in hospital were particularly supportive. Views were divided regarding hearing discussions around blood loss/airway before their procedure, supporting appropriate modifications to the tool. Patients did not feel they had a strong role to play in safety improvement more broadly. CONCLUSIONS: It is feasible and instructive to capture patients' views of the delivery of safety improvements like the checklist. We have demonstrated strong support for the checklist in a sample of surgical patients, presenting a challenge to those resistant to its use.

Do safety checklists improve teamwork and communication in the operating room? A systematic review.

OBJECTIVES: The aim of this systematic review was to assess the impact of surgical safety checklists on the quality of teamwork and communication in the operating room (OR). BACKGROUND: Safety checklists have been shown to impact positively on patient morbidity and mortality following surgery, but it is unclear whether this clinical improvement is related to an improvement in OR teamwork and communication. METHODS: A systematic search strategy of MEDLINE, EMBASE, PsycINFO, Google Scholar, and the Cochrane Database for Systematic Reviews was undertaken to obtain relevant articles. After de-duplication and the addition of limits, 315 articles were screened for inclusion by 2 researchers and all articles meeting a set of prespecified inclusion criteria were retained. Information regarding the type of checklist, study design, assessment tools used, outcomes, and study limitations was extracted. RESULTS: Twenty articles formed the basis of this systematic review. All articles described an empirical study relating to a case-specific safety checklist for surgery as the primary intervention, with some measure of change/improvement in teamwork and/or communication relating to its use. The methods for assessing teamwork and communication varied greatly, including surveys, observations, interviews, and 360° assessments. The evidence suggests that safety checklists improve the perceived quality of OR teamwork and communication and reduce observable errors relating to poor team skills. This is likely to function through establishing an open platform for communication at the start of a procedure: encouraging the sharing of critical case-related information, promoting team coordination and decision making, flagging knowledge gaps, and enhancing team cohesion. However, the evidence would also suggest that when used suboptimally or when individuals have not bought in to the process, checklists may conversely have a negative impact on the function of the team. CONCLUSIONS: Safety checklists are beneficial for OR teamwork and communication and this may be one mechanism through which patient outcomes are improved. Future research should aim to further elucidate the relationship between how safety checklists are used and team skills in the OR using more consistent methodological approaches and utilizing validated measures of teamwork such that best practice guidelines can be established.

Observational teamwork assessment for surgery: feasibility of clinical and nonclinical assessor calibration with short-term training.

OBJECTIVES: To assess the feasibility of training clinical and nonclinical novice assessors to rate teamwork behavior in the operating room with short-term structured training using the observational teamwork assessment for surgery (OTAS) tool. BACKGROUND: Effective teamwork is fundamental to the delivery of optimal patient care in the operating room (OR). OTAS provides a comprehensive and robust measure of teamwork in surgery. To date, assessors with a background in psychology/human factors have been shown to be able to use OTAS reliably after training. However, the feasibility of observer training over a short timescale and accessibility to the wider clinical community (ie, OTAS use by clinicians) are yet to be empirically demonstrated. METHODS: Ten general surgery cases were observed and assessed using OTAS in real-time by an expert in rating OTAS behaviors (100+ cases rated) and 4 novices: 2 psychologists and 2 surgeons. Assessors were blinded to each other's scores during observations. After each observation, scores were compared and discussed between expert and novice assessors in a debriefing session. RESULTS: All novices were reliable with the expert to a acceptable degree at rating all OTAS behaviors by the end of training (intraclass correlation coefficients ≥0.68). For 3 of the 5 behaviors (communication, cooperation, and leadership), calibration improved most rapidly across the first 7 observed cases. For monitoring/situational awareness, calibration improved steadily across the 10 observed cases. For coordination, no significant improvement in calibration over time was observed because of high interrater reliability from the outset (ie, a ceiling effect). There was no significant difference between surgeons and psychologists in their calibration with the expert. CONCLUSIONS: It is feasible to train both clinicians and nonclinicians to use OTAS to assess teamwork behaviors in ORs over a short structured training period. OTAS is an accessible tool that can be used robustly (ie, reliably) by assessors from both clinical and nonclinical backgrounds.

Endoscopic ultrasound guided transgastric stenting of traumatic pancreatic pseudocyst.

CONTEXT: Although there exists multiple modalities of managing traumatic pancreatic pseudocysts it remains a diagnostic and therapeutic challenge. We report herein a case that was successfully managed by endoscopic ultrasound guided transgastric stent placement. CASE REPORT: A 28-year-old female jockey presented with abdominal pain after being kicked by a horse. Computerised tomography and magnetic resonance imaging revealed pancreatitis which resolved with conservative treatment. She proceeded to develop a pancreatic pseudocyst demonstrated on a magnetic resonance cholangiopancreatogram. This was managed by transgastric placement of two double pigtail stents into the pseudocyst by endoscopic ultrasound guidance. Rapid recovery followed with the patient remaining well on follow up. CONCLUSIONS: EUS guided transgastric stent placement for drainage of pancreatic pseudocysts is recommended particularly if they are in close proximity to the stomach.