Simple surgical checklist cuts deaths and complications

Medical Tribune March 2009 P7
David Brill

Using a simple checklist for surgical procedures could dramatically reduce mortality and complication rates across the globe, the “unprecedented” results of a new study show.

Implementation of the WHO-developed list saw post-surgical death rates drop from 1.5 percent to 0.8 percent (P=0.003), and inpatient complications fall from 11 percent to 7 percent (P<0.001)> over 11 months.

The checklist was trialed at hospitals in eight diverse cities, ranging from London to Manila to Ifakara in Tanzania. Data were collected from 3,733 procedures conducted before implementation of the list, and 3,955 after. [N Engl J Med 2009 Jan 29;360(5):491-9]

“The concept of using a brief but comprehensive checklist is surprisingly new to us in surgery. Not everyone on the operating teams was happy to try it,” said Dr. Atul Gawande, senior author of the study. “But the results were unprecedented. And the teams became strong supporters.

“These findings have implications beyond surgery, suggesting that checklists could increase the safety and reliability of care in numerous medical fields. The checklists must be short, extremely simple, and carefully tested in the real world. But in specialties ranging from cardiac care to pediatric care, they could become as essential in daily medicine as the stethoscope,” added Gawande, an associate professor of surgery at Harvard Medical School, US, and team leader for the WHO project.

The checklist was first launched in 2008 as part of new “safe surgery” guidelines from the WHO. It comprises 19 items, and is used at three “critical junctures” in care: before anesthesia, before incision, and before the patient is taken from the operating room.

Rates of surgical site infection also dropped following implementation of the list – from 6.2 to 3.4 percent (P<0.001)> – and unplanned reoperation rates decreased from 2.4 to 1.8 percent (P=0.047).

Dr. Sophia Ang, patient safety officer and associate chairman of the medical board at National University Hospital (NUH), Singapore, said that similar checklists are already in use at NUH.

“Some of these have been in place for a long time, such as an instrument count, sponge count and needle count,” she said.

“There is no deliberate effort on our part to do this as a scientific research so we have no findings to conclusively show that the changes have brought about improved outcomes. Some of the elements were introduced in phases and over time and we are continually reviewing and improving on them to enable us to meet our patient safety needs,” she added.

Some 234 million operations are performed worldwide each year, according to Gawande and his colleagues. At least half of all complications arising from surgery are thought to be avoidable, they add.

The study, which was conducted between October 2007 and September 2008, included only patients aged over 16 who underwent noncardiac surgery. The other cities where the checklist was tested were New Delhi, India; Toronto, Canada; Amman, Jordan; Auckland, New Zealand; and Seattle, US.

Asia takes action on drug-resistant tuberculosis

David Brill
The Lancet Infectious Diseases October 2008
Article link

This article also appeared on the Stop TB homepage of the WHO's Western Pacific Region Office.

Africa and eastern Europe have largely dominated recent attention around strengthening tuberculosis control, but Asia could yet prove the decisive battleground in the international war on the disease. At a gathering of countries from WHO's Western Pacific Region (WPR) in Tokyo (July 22—24) Pieter van Maaren, regional advisor for tuberculosis (WHO, Manila, Philippines), accused Asian nations of complacency, saying: “if we are going to avoid a public-health disaster, we have to accelerate action”. Representatives from all eight of the countries that attended—representing around 95% of the region's multidrug-resistant (MDR) tuberculosis burden—acknowledged the issue and agreed to raise their commitment to it.

The WPR alone makes up a quarter of the world's tuberculosis cases—a similar proportion to Africa. Together with the South-East Asia Region (SEAR), more than 300 000 cases are estimated to be MDR, with only 1% of patients accessing appropriate treatment. The prevalence of MDR tuberculosis is highest in China (one in every ten new tuberculosis cases), which remains second only to the former Soviet Union in terms of prevalence.

Strengthening diagnostic laboratory facilities is a major component of WHO's strategy for the control of MDR tuberculosis in the region. Senior laboratory managers from the WPR will be attending a workshop in Hong Kong in October to discuss how to implement the latest technologies, including molecular line probe assays that can give a diagnosis of MDR tuberculosis in 2 days. These tests are being introduced through a UNITAID-funded project, announced in June. Laboratory capacity is a serious concern in the SEAR, which is home to only two of the 26 centres in WHO's global Supranational Laboratory Network, a network that provides assistance with MDR-tuberculosis testing to national facilities.

“For us in this region the emphasis is on using this window of opportunity to put in cost-effective interventions to prevent MDR tuberculosis. It's less about trying to catch people once they've developed MDR disease, which is what we are seeing in eastern Europe and in Africa, but rather building that barrier to stop people developing MDR tuberculosis in the first place”, said Nani Nair, SEAR's regional tuberculosis advisor (WHO, New Delhi, India).

In Tokyo, delegates also promised to commit to providing better access to treatment, with countries being encouraged to submit proposals to the Global Fund to finance the purchasing of drugs for MDR tuberculosis. Management programmes supported by the Green Light Committee are currently operating in six SEAR countries, while UNITAID funding is available for drug procurement in three.

Nair told TLID: “…if all current plans can be implemented successfully then the long-term outlook for control of MDR in the SEAR is very good”. At present, however, she estimates that only half the required budget has been raised. The region does not contain any major international donors, and to make up this shortfall countries must rely on funding from their own governments, donors from other regions, and international initiatives such as the Global Fund and UNITAID.

China meanwhile is looking into health-care reforms and how they can be integrated into scalable new programmes for MDR-tuberculosis treatment and control. In the wake of the severe acute respiratory syndrome epidemic in 2003 it became a legal requirement for health-care systems to report all new tuberculosis cases within 24 h. Individual patients from across the country are now entered into an online database and can be tracked centrally to ensure that they receive appropriate treatment.

The project has caught the attention of the Bill & Melinda Gates Foundation, who have pledged to spend some US$900 million on tuberculosis worldwide by 2015. Representatives from the Foundation have been in discussions with the Chinese government about how new diagnostic technologies can be integrated into this system to detect multidrug resistance at the first point of contact. “Their surveillance system is phenomenal, and they've scaled it up so that 90% of their referral hospitals are using it. Having these online mechanisms for tracking tuberculosis cases and ensuring that those patients get optimal therapy lays the foundation for a truly innovative programme for controlling MDR tuberculosis that goes beyond the standard interventions”, said Senior Program Officer for Tuberculosis Peter Small (Bill & Melinda Gates Foundation, Seattle, WA, USA), who recently returned from a fact-finding trip to the country. He added that he was “very impressed by the government's commitment” to tackling MDR tuberculosis.

How current efforts to control MDR tuberculosis in Asia will affect the longer-term global spread of the disease remains to be seen. Small is in no doubt, however, as to the importance of the task. “What the world is doing with MDR tuberculosis right now, through inaction, is committing ourselves to a future epidemic of much more complicated tuberculosis. I suspect that future generations will judge us harshly if we fail to intervene”, he said.

Images courtesy of WHO/P Virot.