The Power of Pre-op and Surgical Checklists

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By Debra Wood, RN, contributor 

January 25, 2013 - Surgical teams learned several years ago that adhering to proven standards can improve safety and quality of care and employed checklists before starting a procedure to ensure nothing is missed. Now, research shows using checklists during crises situations can enhance clinicians’ response to the emergency, and teams in Washington State are investigating the use of pre-operative checklists in the clinic or surgeon’s office to improve outcomes.

“Nurses have been doing checklists for a long time, and I agree there is value,” said Tanya Lecompte, MSN, ACNS-BS, CPAN, a clinical nurse specialist in perianesthesia at Mercy Medical Center in Baltimore. “But I am concerned we sometimes over-use them. However, I was very impressed with the critical elements checklist.”

Boston researchers found while conducting a randomized clinical trial that when doctors, nurses and other hospital operating room staff, on 17 teams, follow a written safety checklist when responding to a simulation patient’s cardiac arrest, severe allergic reaction, bleeding followed by an irregular heartbeat or other crises during surgery, they were nearly 75 percent less likely to miss a critical clinical step than teams relying on memory alone.

The Power of Pre-op and Surgical Checklists
Marc D. Horton, MD, FACS, said that checklists are proven to improve patient outcomes and can ensure that key steps are done consistently.

“Checklists are well proven to improve outcomes,” added Marc D. Horton, MD, FACS, who serves as medical director of surgery and program director of the general surgery residency program at Swedish Medical Center in Seattle, attending surgeon with Swedish Surgical Specialists and a clinical associate professor of surgery at the University of Washington School of Medicine.

Horton is leading the hospital’s participation in Washington State’s Strong for Surgery initiative. He added that checklists “aid in making sure key things that will help us be successful are done every time.”

Swedish Medical Center’s operating teams always start cases with an introduction to each other and a two-minute run-through to identify the patient and confirm administration of an antibiotic, patient warmth and other variables that evidence indicates affect successful results.

“Strong for Surgery takes the same concept, but it’s completed before the patient gets to the hospital,” said Horton, who uses the evidence-based checklists to optimize patients’ health and reduce risks before surgery.

The Strong for Surgery checklists address four target areas: (1) nutritional support to prevent infections; (2) reducing cigarette smoking; (3) reviewing and coordinating potentially dangerous medications; and (4) improving diabetes care before surgery. The checklists are available online at no cost, but the initiative seeks feedback from users and would like to collaborate to benchmark results.

“We are looking at checklists for standardization, education about why do these steps, and communication,” said Thomas K. Varghese, Jr., MD, MS, FACS, medical director of Strong for Surgery, an initiative of Washington State’s CERTAIN program that is designed to create a learning health care system and includes nurses among the multidisciplinary team. Both are programs of the University of Washington.

Patients also can review the checklist and assume ownership.

“This is the type of program where we can increase patient engagement and get them ready for their surgical intervention,” said Varghese, who added, “Surgical preparedness now becomes part of the basic conversation about planning for surgery, and the patient shares in that process. It empowers patients.”

Lecompte said she liked the Strong for Surgery checklist for patients but felt that the items to be reviewed should already be on clinicians’ radar.

Items on the checklist may appear familiar or common sense, Varghese acknowledged, but the checklists remind clinicians about the minimum things they should ask and put everything in a standard, reproducible format.

Nurses can complete the checklists and inform patients about steps they can take that might improve their outcome.

“Nurses are key in the education efforts,” Varghese said. “There’s no question that people on the front lines, like nurses, be involved in a program like this.”

Identifying patients at risk also can alert perioperative and post-op nurses to watch for complications related to nutrition, smoking, glucose management and medication use. 

Varghese added, “Having nurses in our corner and being collaborators and advocates in the program will go a long way to improving outcomes and the health care team experience.”

Another specific application of checklists in the surgical setting is the new best practice guidelines that were recently released for the preoperative care of older adults by the American College of Surgeons (ACS) and the American Geriatrics Society (AGS), with support from the John A. Hartford Foundation. The joint guidelines, presented in the form of a checklist, apply to patients 65 years and older.

Barbara Resnick, PhD, CRNP, chair of the AGS board, said the guidelines help raise awareness about what nurses and physicians must keep in mind with elders, such as cognitive and physical functioning. The pre-op assessment should include a screen for depression and substance abuse, cardiac and pulmonary risks factors, nutritional status and treatment goals.

Although checklists serve a purpose, Lecompte worries that they may cause nurses to focus more on tasks than on individual patients’ needs.

“Checklists can be very valuable,” she said. But “we need to remember these are patients, and every patient is different and every situation is different.”

Links for additional information:
Strong for Surgery
ACS NSQIP®/AGS Best Practice Guidelines
Simulation-Based Trial of Surgical-Crisis Checklists 



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