A retrospective audit of postoperative days alive and out of hospital, including before and after implementation of the WHO surgical safety checklist.

We implemented the World Health Organization surgical safety checklist at Auckland City Hospital from November 2007. We hypothesised that the checklist would reduce postoperative mortality and increase days alive and out of hospital, both measured to 90 postoperative days. We compared outcomes for cohorts who had surgery during 18-month periods before vs. after checklist implementation. We also analysed outcomes during 9 years that included these periods (July 2004-December 2013). We analysed 9475 patients in the 18-month period before the checklist and 10,589 afterwards. We analysed 57,577 patients who had surgery from 2004 to 2013. Mean number of days alive and out of hospital (95%CI) in the cohort after checklist implementation was 1.0 (0.4-1.6) days longer than in the cohort preceding implementation, p < 0.001. Ninety-day mortality was 395/9475 (4%) and 362/10,589 (3%) in the cohorts before and after checklist implementation, multivariable odds ratio (95%CI) 0.93 (0.80-1.09), p = 0.4. The cohort changes in these outcomes were indistinguishable from longer-term trends in mortality and days alive and out of hospital observed during 9 years, as determined by Bayesian changepoint analysis. Postoperative mortality to 90 days was 228/5686 (4.0%) for Maori and 2047/51,921 (3.9%) for non-Maori, multivariable odds ratio (95%CI) 0.85 (0.73-0.99), p = 0.04. Maori spent on average (95%CI) 1.1 (0.5-1.7) fewer days alive and out of hospital than non-Maori, p < 0.001. In conclusion, our patients experienced improving postoperative outcomes from 2004 to 2013, including the periods before and after implementation of the surgical checklist. Maori patients had worse outcomes than non-Maori.

Use of a Transfusion Checklist by Student Nurses to Improve Patient Safety.

Better education around the recognition of transfusion-associated adverse events is warranted. It is unknown if checklist use improves recognition by student nurses. This study examined whether using a checklist could improve transfusion-associated adverse event recognition behaviors. There was an increased frequency of transfusion-associated adverse event management behaviors in the checklist group, but overall recognition was no greater than other groups. A transfusion-associated adverse event checklist may increase patient safety by promoting identification behaviors.

Obtaining and Modeling Variability in Travel Times From Off-Site Satellite Clinics to Hospitals and Surgery Centers for Surgeons and Proceduralists Seeing Office Patients in the Morning and Performing a To-Follow List of Cases in the Afternoon.

BACKGROUND: Hospitals achieve growth in surgical caseload primarily from the additive contribution of many surgeons with low caseloads. Such surgeons often see clinic patients in the morning then travel to a facility to do 1 or 2 scheduled afternoon cases. Uncertainty in travel time is a factor that might need to be considered when scheduling the cases of to-follow surgeons. However, this has not been studied. We evaluated variability in travel times within a city with high traffic density. METHODS: We used the Google Distance Matrix application programming interface to prospectively determine driving times incorporating current traffic conditions at 5-minute intervals between 9:00 AM and 4:55 PM during the first 4 months of 2018 between 4 pairs of clinics and hospitals in the University of Miami health system. Travel time distributions were modeled using lognormal and Burr distributions and compared using the absolute and signed differences for the median and the 0.9 quantile. Differences were evaluated using 2-sided, 1-group t tests and Wilcoxon signed-rank tests. We considered 5-minute signed differences between the distributions as managerially relevant. RESULTS: For the 80 studied combinations of origin-to-destination pairs (N = 4), day of week (N = 5), and the hour of departure between 10:00 AM and 1:55 PM (N = 4), the maximum difference between the median and 0.9 quantile travel time was 8.1 minutes. This contrasts with the previously published corresponding difference between the median and the 0.9 quantile of 74 minutes for case duration. Travel times were well fit by Burr and lognormal distributions (all 160 differences of medians and of 0.9 quantiles <5 minutes; P < .001). For each of the 4 origin-destination pairs, travel times at 12:00 PM were a reasonable approximation to travel times between the hours of 10:00 AM and 1:55 PM during all weekdays. CONCLUSIONS: During mid-day, when surgeons likely would travel between a clinic and an operating room facility, travel time variability is small compared to case duration prediction variability. Thus, afternoon operating room scheduling should not be restricted because of concern related to unpredictable travel times by surgeons. Providing operating room managers and surgeons with estimated travel times sufficient to allow for a timely arrival on 90% of days may facilitate the scheduling of additional afternoon cases especially at ambulatory facilities with substantial underutilized time.

Lipoprotein(a) in Patients Undergoing Transcatheter Aortic Valve Replacement.

Lipoprotein(a) [Lp(a)] is a genetically determined risk factor for calcific aortic valve stenosis (CAVS) for which transcatheter aortic valve replacement (TAVR) is increasingly utilized as treatment. We evaluated the effect of a program to increase testing of and define the prevalence of elevated Lp(a) among patients undergoing TAVR. Educational efforts and incorporation of a "check-box" Lp(a) order to the preoperative TAVR order set were instituted. Retrospective chart review was performed in 229 patients requiring TAVR between May 2013 and September 2018. Of these patients, 57% had an Lp(a) level measured; testing rates increased from 0% in 2013 to 96% in 2018. Lipoprotein(a) testing occurred in 11% of patients before and in 80% of patients after the "check-box" order set ( P < .001). The prevalence of elevated Lp(a) (≥30 mg/dL) was 35%; these patients had a higher incidence of coronary artery disease requiring revascularization compared with patients with normal Lp(a) (65% vs 47%; P = .047). Patients with Lp(a) ≥30 mg/dL also had higher incidence of paravalvular leak compared with those with normal Lp(a) (13% vs 4%; P = .04). This study defines the prevalence of elevated Lp(a) in advanced stages of CAVS and provides a practice pathway to assess procedural complications and long-term outcomes of TAVR in patients with elevated Lp(a) levels.

The Impact of a Pediatric Shunt Surgery Checklist on Infection Rate at a Single Institution.

BACKGROUND: Shunt infections remain a significant challenge in pediatric neurosurgery. Numerous surgical checklists have been introduced to reduce infection rates. OBJECTIVE: To introduce an evidence-based shunt surgery checklist and its impact on our shunt infection rate. METHODS: Between January 1, 2008 and December 31, 2015, pediatric patients who underwent shunt surgery at our institution were indexed in a prospectively maintained database. All definitive shunt procedures were included. Shunt infection was defined according to the Center for Disease Control and Prevention's National Hospital Safety Network surveillance definition for surgical site infection. Clinical and procedural variables were abstracted per procedure. Infection data were compared for the 4 year before and 4 year after protocol implementation. Compliance was calculated from retrospective review of our checklists. RESULTS: Over the 8-year study period, 1813 procedures met inclusion criteria with a total of 37 shunt infections (2%). Prechecklist (2008-2011) infection rate was 3.03% (28/924) and decreased to 1.01% (9/889; P = .003) postchecklist (2012-2015), representing an absolute risk reduction of 2.02% and relative risk reduction of 66.6%. One shunt infection was prevented for every 50 times the checklist was used. Those patients who developed an infection after protocol implementation were younger (0.95 years vs 3.40 years (P = .027)), but there were no other clinical or procedural variables, including time to infection, that were significantly different between the cohorts. Average compliance rate among required checklist components was 97% (range 85%-100%). CONCLUSION: Shunt surgery checklist implementation correlated with lower infection rates that persisted in the 4 years after implementation.

Assessing the similarity of mental models of operating room team members and implications for patient safety: a prospective, replicated study.

BACKGROUND: Patient safety depends on effective teamwork. The similarity of team members' mental models - or their shared understanding-regarding clinical tasks is likely to influence the effectiveness of teamwork. Mental models have not been measured in the complex, high-acuity environment of the operating room (OR), where professionals of different backgrounds must work together to achieve the best surgical outcome for each patient. Therefore, we aimed to explore the similarity of mental models of task sequence and of responsibility for task within multidisciplinary OR teams. METHODS: We developed a computer-based card sorting tool (Momento) to capture the information on mental models in 20 six-person surgical teams, each comprised of three subteams (anaesthesia, surgery, and nursing) for two simulated laparotomies. Team members sorted 20 cards depicting key tasks according to when in the procedure each task should be performed, and which subteam was primarily responsible for each task. Within each OR team and subteam, we conducted pairwise comparisons of scores to arrive at mean similarity scores for each task. RESULTS: Mean similarity score for task sequence was 87 % (range 57-97 %). Mean score for responsibility for task was 70 % (range = 38-100 %), but for half of the tasks was only 51 % (range = 38-69 %). Participants believed their own subteam was primarily responsible for approximately half the tasks in each procedure. CONCLUSIONS: We found differences in the mental models of some OR team members about responsibility for and order of certain tasks in an emergency laparotomy. Momento is a tool that could help elucidate and better align the mental models of OR team members about surgical procedures and thereby improve teamwork and outcomes for patients.

[Intraoperative crisis and surgical Apgar score].

Intraoperative crisis is an inevitable event to anesthesiologists. The crisis requires effective and coordinated management once it happened but it is difficult to manage the crises properly under extreme stressful situation. Recently, it is reported that the use of surgical crisis checklists is associated with significant improvement in the management of operating-room crises in a high-fidelity simulation study. Careful preoperative evaluation, proper intraoperative management and using intraoperative crisis checklists will be needed for safer perioperative care in the future. Postoperative complication is a serious public health problem. It reduces the quality of life of patients and raises medical cost. Careful management of surgical patients is required according to their postoperative condition for preventing postoperative complications. A 10-point surgical Apgar score, calculated from intraoperative estimated blood loss, lowest mean arterial pressure, and lowest heart rate, is a simple and available scoring system for predicting postoperative complications. It undoubtedly predicts higher than average risk of postoperative complications and death within 30 days of surgery. Surgical Apgar score is a bridge between proper intraoperative and postoperative care. Anesthesiologists should make effort to reduce the postoperative complication and this score is a tool for it.

Application of the American Heart Association/American College of Sports Medicine Adult Preparticipation Screening Checklist to a nationally representative sample of US adults aged >=40 years from the National Health and Nutrition Examination Survey 2001 to 2004.

BACKGROUND: Although the American Heart Association/American College of Sports Medicine's Preparticipation Questionnaire (AAPQ) is a recommended preexercise cardiovascular screening tool, it has never been systematically evaluated. The purpose of this research is to provide preliminary evidence of its effectiveness among adults aged ≥40 years. METHODS AND RESULTS: Under the assumption that participants would respond to AAPQ items as they responded to a general health survey, we calculated the sex- and age-specific proportions of adult participants in the National Health and Nutrition Examination Survey 2001 to 2004 who would receive a recommendation for physician consultation based on AAPQ referral criteria. Additionally, we compared recommended AAPQ referrals to a similar assessment using the Physical Activity Readiness Questionnaire in the study sample. AAPQ referral proportions were higher with older age. Across all age groups ≥40 years, 95.5% (94.3% to 96.8%) of women and 93.5% (92.2% to 94.7%) of men in the United States would be advised to consult a physician before exercise. Prescription medication use and age were the most commonly selected items. When referral based on AAPQ was compared with that of the Physical Activity Readiness Questionnaire, the 2 screening tools produced similar results for 72.4% of respondents. CONCLUSIONS: These results suggest that >90% of US adults aged ≥40 years would receive a recommendation for physician consultation by the AAPQ. Excessive referral may present an unnecessary barrier to exercise adoption and stress the healthcare infrastructure.

Screening children for autism in an urban clinic using an electronic M-CHAT.

BACKGROUND: The Modified Checklist for Autism in Toddlers (M-CHAT) is a screening tool for autism spectrum disorders in the clinic. However, the follow-up questions in the M-CHAT are difficult to implement on a paper format. OBJECTIVE: To compare the effectiveness of the M-CHAT on an electronic format versus paper format in an outpatient clinic setting. Methods. A prospective study used electronic M-CHAT on the iPad. A retrospective review of paper M-CHATs 6 months prior to implementation was used as the comparison group. RESULTS: A total of 176 participants completed the electronic M-CHAT format and 197 paper M-CHATs were retrospectively reviewed. The electronic format (3%) resulted in a significant difference in the frequency of children found to be at risk for autism compared with the paper version (11%); 99% of parents rated the experience as "good" or "excellent." CONCLUSION: The electronic format lowered both false at-risk screens and false not-at-risk screens and had higher parental satisfaction.

Incidence of neurosurgical wrong-site surgery before and after implementation of the universal protocol.

BACKGROUND: Although exceedingly rare, wrong-site surgery (WSS) remains a persistent problem in the United States. The incidence is thought to be 2 to 3 per 10 000 craniotomies and about 6 to 14 per 10 000 spine surgeries. In July 2004, the Joint Commission mandated the Universal Protocol (UP) for all accredited hospitals. OBJECTIVE: To assess the effect of UP implementation on the incidence of neurosurgical WSS at the University of Illinois College of Medicine at Peoria/Illinois Neurological Institute. METHODS: The Morbidity and Mortality Database in the Department of Neurosurgery was reviewed to identify all recorded cases of WSS since 1999. This was compared with the total operative load (excluding endovascular procedures) of all attending neurosurgeons to determine the incidence of overall WSS. A comparison was then made between the incidences before and after UP implementation. RESULTS: Fifteen WSS events were found with an overall incidence of 0.07% and Poisson 95% confidence interval of 8.4 to 25. All but one of these were wrong-level spine surgeries (14/15). There was only 1 recorded case of wrong-side surgery and this occurred after implementation of the UP. A statistically greater number of WSS events occurred before (n = 12) in comparison with after (n = 3) UP implementation (P < .001). CONCLUSION: A statistically significant reduction in overall WSS was seen after implementation of the UP. This reduction can be attributed to less frequent wrong-level spine surgery. There was no case of wrong procedure or patient surgery and the 1 case of wrong-side surgery occurred after UP implementation.

University of California, Los Angeles, surgical time-out process: evolution, challenges, and future perspective.

Since the development of the WHO Safe Surgery Saves Lives initiative and Surgical Safety Checklist, numerous hospitals across the globe have adopted the use of a surgical checklist. The UCLA Health System developed its first extended Surgical Safety Checklist in 2008. Authors of the present paper describe how the time-out checklist used before skin incision was implemented and how it progressed to its current form. Compliance with the most recent version of the checklist has been closely monitored via documentation and observance audits. In addition, the surgical team's appreciation of the current time-out has been assessed. Cultural, practice, and human resource challenges are discussed, as are potential future avenues for innovations in the emerging field of the surgical checklist in neurosurgery.