Faculty of Medicine, Islamic University-Gaza Can the use of “WHO Surgical safety checklist” Save lives? Gathering Evidence. Dr Khamis Elessi Head of EBM Unit- Faculty of Medicine, Islamic University-Gaza

WHO Surgical safety checklist Background: Published by WHO in 2009 & focuses on teamwork, communication, adherence to good practice, and anticipation of adverse events. It aims to ensure that teams consistently follow few critical safety steps and thereby minimize the most common and avoidable risks endangering the lives and well-being of surgical patients worldwide.

WHO’s 10 Objectives for Safe Surgery Team will operate on the correct patient at the correct site. Team will use methods known to prevent harm from administration of anesthetics, while protecting the patient from pain. Team will recognize & effectively prepare for life-threatening loss of respiratory function. Team will recognize and effectively prepare for risk of high blood loss. Team will avoid inducing an allergic or adverse drug reaction for which the patient is known to be at significant risk.

WHO’s 10 Objectives for Safe Surgery (con’t) Team will consistently use methods known to minimize the risk for surgical site infection. Team will prevent inadvertent retention of instruments or sponges in surgical wounds. Team will secure and accurately identify all surgical specimens. Team will effectively communicate and exchange critical information for safe conduct of operations. Hospitals and health systems will establish routine surveillance of surgical capacity, volume and results.

Ex. Modified Checklist for England & Wales

Why safe surgery is important: The facts Surgical Patient safety has been a persistent topic in the health care systems. Still, many avoidable mistakes — such as operating on the wrong body part or giving an improper medication continue to occur (Prof. Nick Markham). In 2004 alone, Worldwide, about 234 million operations were done. A rate of 0.4 - 0.8% deaths & 3-16% complications were recorded globally, meaning, at least 1 million deaths & 7 million complications /year

Why safe surgery is important: The facts In England and Wales, 129,419 surgery-related incidents were reported to National Reporting and Learning Service (NRLS) in 2007 including 271 deaths. Previous studies reported crude mortality rate after major surgery between 0.5 and 5%; while post-surgical complications occur in up to 25% of patients;

Why safe surgery is important: The facts Gen. anesthesia alone is reported to cause 1 in 150 deaths in some parts of sub-Saharan Africa. In developed nations, half of all recorded adverse events among surgical patients occur in operating rooms. In developing countries, death rates are estimated to be between 5-10% for major surgeries and half of these adverse events were preventable.

Methodology: A literature review was conducted to ascertain the evidence of efficacy of the WHO-Surgical Safety checklist in saving lives.

Results:1 A pilot testing of WHO-checklist in 8 countries (Seattle, Toronto, London, Auckland, Amman, New Delhi, Manila, and Tanzania revealed : Reduction in major complications from 11% before to 7% after checklist introduction . Dramatic fall of post-Sx deaths by more than 40 % (1.5% to 0.8%) after checklist implementing. NB: Reductions were of equal magnitude in high income and low-income sites in the study.

The Checklist was piloted in 8 cities… EURO EMRO PAHO I London, UK Amman, Jordan Toronto, Canada WPRO I Manila, Philippines PAHO II Seattle, USA WPRO II Auckland, Neozeland AFRO Ifakara, Tanzania SEARO New Delhi, India

Results – All 8 Sites 3733 3955 - 1.5% 0.8% 0.003 11.0% 7.0% <0.001 Baseline Checklist P value Cases 3733 3955 - Death 1.5% 0.8% 0.003 Any Complication 11.0% 7.0% <0.001 Unplanned Re-operation 2.4% 1.8% 0.047 Haynes et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. New England Journal of Medicine 360:491-9. (2009)

Change in Death & Complications by Site Income Classification Change in Complications Change in Death High Income sites 10.3% -> 7.1%* 0.9% -> 0.6% Low and Middle Income sites 11.7% -> 6.8%* 2.1% -> 1.0%* Haynes et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. New England Journal of Medicine 360:491-9. (2009) * p<0.05

Results:2 Financial Burden: The famous Harvard surgeon Dr. Gawande’s & his research team has estimated that if WHO Surgical Safety Checklist were implemented in all operating rooms in the U.S., then, the annual cost-savings from the prevention of major complications would range between $15 billion to $25 billion/ year.

Results:2 A research by Dr. Ellner et al, compared post-operative complications before & after team members participated in three 60-minute training sessions on Using the WHO- safety checklist and to improve OR communication. They found that this combination has reduced complications for the 30-day period after high-risk surgery by more than 15.9%. This only tell us that implementing the surgical checklists alone is not enough; there must be effective communication and team building.

Results:3 Another survey by National Center for Patient Safety found significantly better surgery outcomes for hospitals that put their staff through team training re-affirmed the findings of other studies. It showed that About 80% of adverse events are attributable to failed team communication. A new study on WHO checklist Usefulness in orthopedics, described the checklist as one major weapon in the armamentarium of the orthopaedic surgeons.

Results:4 A Cochrane review (2017) on various surgical Safety tools showed that combining checklist integration in systems Plus teamwork training are more effective than adopting either approach alone. Despite high acceptance of WHO checklist among professional, Some gaps on when & how to use it still exist which can threaten its implementation. Therefore, efforts should focus on universal awareness and complete knowledge on when and how to use this checklist.

Conclusions & Recommendation When coupled with team training, WHO-surgical safety checklist was able to reduce complications and save more lives. We call upon all hospitals to train their surgical teams on when & how to use, modify & adopt the use of WHO-safety Checklist. We ask all hospital to take part in the WHO-checklist Audit that we plan to conduct in few months time.