Surgical crisis checklists improve performance during operating-room crisis simulations

Feb 8th – NEJM – Failure to adhere to life-saving processes during operating-room crisis simulation dropped 75% after the use of a surgical crisis checklist.

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1. Failure to adhere to life-saving processes during operating-room crisis simulation dropped 75% with the use of surgical crisis checklist.

2. 97% of participants that they would want the checklist used if they were a patient in an operating-room crisis situation.

This well-designed simulation based study of operating room crisis has proven the efficacy of surgical crisis checklists in improving adherence to life-saving process measures. Furthermore, by the end of the study, the checklist had gained the confidence of nearly all the study participants. The main limitation of this study was that it is simulation based, and thus extrapolation of the results into real-world situations is tenuous. This work does support the use of a crisis checklist in operating rooms, and paves the way for a study of the actual effectiveness in real-world scenarios. Another key limitation was the absence of surgeons in most of the simulations due to low volunteer interest. Most of the processes measured in the study were the domain of nurses and anesthesiologists, and no evidence was found that surgeon participation impact the study results in any way.

Click to read the study in NEJM

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1. Failure to adhere to life-saving processes during operating-room crisis simulation dropped 75% with the use of surgical crisis checklist.

2. 97% of participants that they would want the checklist used if they were a patient in an operating-room crisis situation.

Dr. Angela Bader, MD, MPH and Dr. Alex Arriaga, MD, MPH, Sc.D. talk to 2 Minute Medicine: Brigham and Women’s Hospital, Department of Anesthesiology, Perioperative and Pain Medicine 

Why is this study relevant to physicians?

“Operating room crises are high-acuity events that require rapid and coordinated care in a time critical setting.  In our simulation-based study, we found that use of crisis checklists was associated with a significant reduction in failure to adhere to best practices for common intraoperative emergencies.  After participation, 97% of study participants agreed that they would want these checklists used if experiencing an intraoperative crisis as a patient.”

Why is this study relevant to students?

“The earlier in one’s career that physicians are exposed to tools such as these, the easier it can be for them to integrate the tools into their daily practice and customize them to their clinical routine.  As we mention in the manuscript, a shift in medical culture may be necessary if health care providers are expected to pull out a cognitive aid during an intraoperative (or any other) emergency.  Medical students are critical drivers of the future of medical culture.”

Future implications?

“Our findings suggest that checklists for use during intraoperative crises have the potential to improve surgical care and should be considered for implementation by hospitals and ambulatory surgical centers.  Future work in this area should include mechanisms for training and implementation, processes to update the checklists as evidence evolves, and determining the best user interface (e.g. paper, electronic) for different institutions.”

This [randomized, controlled, simulation-based] study: involved 17 operating room teams from three different institutions in 106 simulated surgical crisis scenarios. Each team conducted half of their scenarios with and without the checklist. A pair of independent reviewers scored the video replays of each simulation with excellent inter-rater reliability. Failure to adhere to life-saving process measures decreased from 23% to 6% with use of the checklist (P<0.001). Participants were then surveyed about the checklist. A total of 97% of the participants would want the checklist used if they were the patient in a similar intraoperative crisis.  

In sum: This well-designed simulation based study of operating room crisis has proven the efficacy of surgical crisis checklists in improving adherence to life-saving process measures. Furthermore, by the end of the study, the checklist had gained the confidence of nearly all the study participants. The main limitation of this study was that it is simulation based, and thus extrapolation of the results into real-world situations is tenuous. This work does support the use of a crisis checklist in operating rooms, and paves the way for a study of the actual effectiveness in real-world scenarios. Another limitation was the absence of surgeons in most of the simulations due to low volunteer interest. Most of the processes measured in the study were the domain of nurses and anesthesiologists, and no evidence was found that surgeon participation impact the study results in any way.

Click to read the study in NEJM

By Allen Ho and Marc Succi

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