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Surgical checklist cuts complications by a third

A simple operating room checklist, similar to the one pilots use in the cockpit before takeoff, can dramatically reduce major complications in patients and even save lives, according to a just published study.

Performing that brief task in eight hospitals in as many countries caused an overall drop in the death rate by more than 40 per cent and major complications by more than a third, according to the New England Journal of Medicine study released online today and in print later this month.

While death rates in high-income countries such as Canada, England, United States and New Zealand were not deemed statistically significant from a research point of view - like those in low-income countries of Jordan, the Philippines, Tanzania and India - all hospitals saw comparable drops in complication rates after using the World Health Organization's Surgical Safety Checklist.

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With an estimated 1.3 million operations performed in Canadian hospitals and clinics each year that means some 40,000 major complications - including bleeding, cardiac arrest, pneumonia, stroke and blood clots - could be prevented if the checklist was used.

"We know that many surgical complications are preventable," said Bryce Taylor, surgeon-in-chief and director of surgical services for the University Health Network. One of its hospitals - Toronto General - was the only Canadian hospital to take part in the study that ran from October 2007 to September 2008.

The results were so impressive that the checklist was quickly adapted by the network's two other facilities - Toronto Western and Princess Margaret - so that it is done for every one of the 23,000 operations performed each year.

"I would not undergo surgery," said Dr. Taylor "Unless I knew the checklist was being done."

Data collected from 3,733 patients before implementation of the checklist and 3,955 after the checklist was implemented, showed an overall drop in major complications from 11 per cent to 7 per cent. Inpatient deaths following major operations dropped from 1.5 per cent to 0.8 per cent.

While the drop in death rates in hospitals in higher-income hospitals of Seattle, Washington, London, England, Auckland, New Zealand and Toronto were not statistically significant, the drop in complication rates was: from 10.3 per cent to 7.1 per cent, representing a decrease of nearly one-third.

The results were so compelling that the United Kingdom, Ireland, Jordan and the Philippines have already established nationwide programs to implement the checklist in its operating rooms.

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In the U.S., the Institute for Healthcare Improvement announced it will introduce the checklist to 4,000 hospitals, representing two thirds of American hospitals that took part in its 5 Million Lives Campaign, a national effort to improve quality and safety.

What makes this checklist different is the type of checks and the consistency with which they are being done. Checks are done in three groupings: before anesthesia is administered, before the skin is cut and before the patient is removed at the operating room.

Some of the checks include ensuring the correct surgery site is marked, that prophylactic antibiotics are given, blood loss is closely monitored, and sponge and needle counts are done.

A seemingly innocuous check - having the surgical team introducing themselves by name to each other - is crucial as it makes them more likely to speak up when something is going wrong.

Atul Gawande, leader of the WHO safe surgery program and lead investigator of the study, said the results are remarkable, saying when it began he only expected to see a 10 to 15 per cent drop in complications.

About a year ago, Dr. Gawande, a surgical oncologist, would use it in his operating room, not expecting much of a change, as he thought the biggest improvements would be in hospitals in the developing world.

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"The striking thing was, using it in my own cases, where I thought it would not make much difference, I would catch something that we missed every week," said Dr. Gawande, who is also associate professor of the Harvard School of Public Health.

He pegged the annual cost-savings from the prevention of major complications in the U.S. to be $15 to $25-billion U.S. per year.

Though no similar figures were available in Canada, preventing an estimated 40,000 complications would spell enormous savings to the health care system.

That's because by reducing complications - especially ones as serious as those measured in the study - it reduces the length of stay to the health care system, not to mention the patient's personal costs of pain, disability and economic losses for time off work.

Indeed, the complications measured can turn what was to be short hospital stay into a lengthy one: acute renal failure, unplanned intubation, ventilator use for 48 hours or more, blood poisoning, vascular graft failure and pulmonary embolism, which occurs when an artery in the lungs becomes blocked usually by a blood clot.

With 230 million operations performed annually worldwide and at least seven million complications resulting from them, this initiative "could save millions of people from major disability or death," said Dr. Gawande.

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