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Simulation-Based Trial of Surgical-Crisis Checklists

Arriaga, Alexander F.; Bader, Angela M.; Wong, Judith M.; Lipsitz, Stuart R.; Berry, William R.; Ziewacz, John E.; Hepner, David L.; Boorman, Daniel J.; Pozner, Charles N.; Smink, Douglas S.; Gawande, Atul A.

Obstetrical & Gynecological Survey: May 2013 - Volume 68 - Issue 5 - p 336–338
doi: 10.1097/01.ogx.0000430375.22369.87
Obstetrics: Ethics, Medicolegal Issues, and Public Policy

ABSTRACT Crises in operating rooms (ORs) require rapid, coordinated care. Checklists have been accepted in other high-risk industries to improve performance during rare and unpredictable critical events. The use of checklists during routine operative care has led to significant reductions in morbidity and mortality. This randomized controlled trial was undertaken to determine the effect of using a crisis checklist during simulations of life-threatening events.

Participants were recruited from 1 academic medical center and 2 community hospitals and included teams of anesthesia staff, OR nurses, surgical technologists, and a mock surgeon participant. Each team spent a 6-hour day in a high-fidelity simulated OR where they were presented with crisis scenarios and tested for adherence to 47 key processes derived from evidence-based guidelines. In half the scenarios, the team had access to a set of checklists for crisis events. In the other half, they worked from memory, as usual. The crises included air embolism, anaphylaxis, asystolic cardiac arrest, hemorrhage followed by ventricular fibrillation, malignant hyperthermia, unexplained hypotension and hypoxemia followed by unstable bradycardia, and unstable tachycardia. The checklists were placed adjacent to the anesthesia machine and the circulating nurse’s work area. The primary outcome was failure to adhere to lifesaving processes of care for each crisis. All simulation sessions were recorded, observed, and scored. Study participants were surveyed regarding their perceptions of the usefulness and clinical relevance of the checklists. Data were analyzed using SAS software; P < 0.05 was considered significant.

Seventeen OR teams, with wide-ranging experience, participated in 106 simulated crisis scenarios. Use of the checklist led to a 75% reduction in failure to adhere to critical steps in management; 6% of steps were missed with checklists available compared with 23% without checklists available (P < 0.001). Results were similar in a multivariate analysis adjusting for institution, scenario, and simulation learning or fatigue. The effect of the checklists did not differ among participants from academic or community hospitals. The significant effect of checklist use was also seen when results were stratified according to scenario. The scenarios were grouped into 3 categories: those directly related to algorithms for advanced cardiac life support, those related to algorithms for advanced cardiac life support and preceded by a precode condition, and other crisis scenarios. In all strata, failure rates were significantly lower in scenarios in which the crisis checklists were used. The effect of the checklist was significant (P < 0.001) in all secondary analyses. Participants reported that the checklists were easy to use and helped them feel better prepared, and they would use the checklists if presented with these operative emergencies in real life.

The use of crisis checklists led to a significant improvement in adherence to recommended procedures for common intraoperative emergencies. After participation, 97% of the participants said they would want checklists used if they had an intraoperative crisis as a patient. Events undoubtedly occur in more varied circumstances than possible to simulate, but these results suggest that hospitals and ambulatory surgical centers should consider implementation of checklists to increase the safety of surgical care.

Department of Health Policy and Management, Harvard School of Public Health (A.F.A., A.M.B., J.M.W., S.R.L., W.R.B., J.E.Z., D.S.S., A.A.G.) and the Center for Surgery and Public Health (A.F.A., A.M.B., J.M.W., S.R.L., W.R.B., J.E.Z., A.A.G.), Department of Anesthesiology, Perioperative, and Pain Medicine (A.F.A., A.M.B., D.L.H.), and Department of Neurosurgery (J.M.W.), Simulation, Training, Research, and Technology Utilization System (STRATUS) Center for Medical Simulation (C.N.P., D.S.S.), and Department of Surgery (A.F.A., D.S.S., A.A.G.), Brigham and Women’s Hospital, Boston, MA; University of Michigan Health Systems (J.E.Z.), Department of Neurosurgery, Ann Arbor, MI; and Boeing Aircraft (D.J.B.), Seattle, WA

© 2013 by Lippincott Williams & Wilkins.