N. Y. Garland1, H. Eap2, S. Kheng2, J. Forrester1, T. Uribe-Leitz1, M. M. Esquivel1, G. Lucas2, O. Palritha2, T. G. Weiser1 1Stanford University,Department Of Surgery, Section Of Acute Care Surgery,Stanford, CA, USA 2World Mate Emergency Hospital,Battambang, BATTAMBANG, Cambodia
Introduction: The WHO Surgical Safety Checklist (SSC) has been proven to reduce post operative morbidity and mortality, however it remains difficult to implement, particularly in low resource settings. We aimed to better characterize both the barriers to checklist implementation and subsequent improvement in patient safety measures by assessing compliance with specific checklist items and evaluating root causes of compliance failures. We hypothesized that a better understanding of barriers to quality improvement will lead to a more effective implementation strategy.
Methods: The SSC was introduced at a 109 bed orthopedic trauma hospital in Battambang, Cambodia. After two half-day training sessions for the operating theatre (OT) staff in checklist use, intraoperative data were collected by trained nurses via a paper form for the first 2 months, and later a mobile REDCap data collection tool. Our tool focused on identifying performance of specific checklist items, including both communication and perioperative processes. Process-level data were compiled and presented to hospital administration and the surgical team.
Results:We collected information from direct observations of 308 surgical cases. Following initiation of the checklist all communication elements of the checklist (discussing case length, confirming the correct patient, and estimating blood loss) were performed 100% (308/308) of the time with the exception of team introductions, which the surgical team found unnecessary as they had a small staff and were familiar with each other. Several elements that required material resources were also performed with great consistency; for example, appropriate imaging was present in the OT during 100% (278/278) of cases. Other processes that were initially done poorly or not done at all were quickly brought to 100% compliance when resource barriers were overcome, such as the presence of a sterile indicator in instrument trays, which increased from 0% to 100% by the end of the observational period. However, complex processes that required clinical decision-making, such as antibiotic administration within 60 minutes of skin incision for clean cases, were performed inconsistently.
Conclusion:The primary barriers to checklist compliance in this low resource setting were not communication factors or material resources, but rather inconsistently functioning processes. Complex processes that involve clinical decision-making were more difficult to perform consistently, but appear likely to improve over time with ongoing data feedback to the team. This study highlights the importance of understanding barriers to checklist compliance as part of a checklist implementation strategy.
