Using a checklist helped assure compliance with processes set up to handle a crisis situation -- such as a cardiac arrest or massive hemorrhage -- in the operating room, researchers found.
Teams using checklists were 75% less likely to miss a critical step in resolving a simulated crisis than teams that relied on memory to recall what they should do, a group of researchers that included one of the most well-known proponents of checklists -- Atul Gawande, MD, MPH, of Brigham & Women's Hospital -- reported in the Jan. 17 issue of the New England Journal of Medicine.
"Under these simulated circumstances, teams did substantially better with the checklist," Gawande said in an interview with MedPage Today -- although he acknowledged that the study couldn't assess whether using the checklist translated to better patient outcomes.
"These events happen so rarely, you won't get randomized controlled trials to test them," Gawande said. "But the simulation was enough to convince [some centers] to move forward with implementing [the crisis checklist] in the real world."
Those centers include Brigham & Women's and the Kaiser Permanente health system, which will be monitoring to see whether the crisis checklists indeed translate to better care, Gawande said.
Evidence has been accumulating that using checklists in the operating room can lead to lower morbidity and mortality rates. Gawande and colleagues have argued that other high-risk industries, such as aviation and nuclear power, have used checklists to boost performance during "rare and unpredictable" emergencies.
For this study, the team expanded the checklist concept to crisis situations in the OR, including cardiac arrest, air embolism, anaphylaxis, and hemorrhage.
Given how rarely such events happen, the researchers used a high-fidelity simulation of surgical-crisis scenarios in a simulated OR. The 17 teams came from three institutions -- one academic medical center and two community hospitals -- and were tested in 106 simulated scenarios.
Each team was randomly assigned to manage half the scenarios with a set of checklists, while the remaining scenarios were to be done from memory alone.
The primary outcome was failure to adhere to critical processes of care. There were a total of 47 key processes.
Gawande and colleagues found that not adhering to the specific processes of care was less common during simulations when the checklists were available -- 6% of steps were missed with checklists in hand compared with 23% when a team had to manage the situation from memory alone.
That translated to about a 75% difference, the researchers reported (P<0.001).
Those results remained largely the same in multivariate models that accounted for potential confounders such as clustering within teams, institution type, the specific scenario, and learning and fatigue effects (aRR 0.28, 95% CI 0.18 to 0.42, P<0.001).
The researchers noted that every single team performed better when the crisis checklists were available than when they weren't.
And in a survey, nearly all team members (97%) said that if one of these crises occurred while they were having surgery themselves, they would want the checklist used.
Gawande acknowledged that there's been some resistance to the use of checklists in the OR even though "in many ways it is now the standard of care."
"When you visit ORs to see whether surgeons and teams are following through on the full checklist, you find that many are not," he told MedPage Today. There are many reasons for that, including the simple fact that it takes time to incorporate the lists into the job, he said.
It's also a "conflict of values," he said. "The core values of using the checklist are humility, teamwork, and discipline. But often values in medicine are about autonomy and the feeling that the surgeon should make whatever decision they wish -- including not having to deal with this kind of thing."
Indeed, for this study, surgeon participation was low. But Gawande said that had more to do with payment systems, since nurses and anesthesiologists are salaried and could be freed to participate in the trial. Surgeons, on the other hand, are paid per operation and thus had a disincentive to spend their time participating in the simulations.
"Few people are excited to have a checklist," Gawande said, "but at the end of the day, there wasn't a single person who did not want that checklist used" when they were on the operating table.
by Kristina Fiore
Staff Writer, MedPage Today