Surgical Safety Checklist Associated with Reduced 90-day Mortality

EBM Focus - Volume 11, Issue 31

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Reference - JAMA Surg 2016 Jul 1;151(7):639 (level 2 [mid-level] evidence)

  • Surgical safety checklists have been shown to reduce in-hospital and 30-day complications and mortality, but their effect on 90-day outcomes is unknown.
  • A before-and-after study in Italy evaluating 5,444 patients having noncardiac surgery before the implementation of a surgical safety checklist and 5,297 patients having surgery after high compliance with use of a checklist was reached found a reduction in 90-day mortality during the postintervention period.
  • A reduction in 30-day mortality was observed as well, but the result was not statistically significant.

Surgical safety checklists applied by the surgical team before, during, and after surgery have been associated with reduced mortality and complications (Ann Surg 2012 Dec;256(6):925). Previous studies evaluating the performance of these checklists have reported in-hospital or 30-day outcomes (N Engl J Med 2009 Jan 29;360(5):491, N Engl J Med 2010 Nov 11;363(20):1928); however, approximately 25% of deaths and 33% of all complications occur after discharge (Ann Surg 2010 Jul;252(1):183). To determine whether surgical safety checklists affect 90-day outcomes, a before-and-after study assessed 10,741 patients (mean age 53 years) having elective or emergency noncardiac surgery at a single hospital in Italy.

The surgical safety checklist was introduced at this hospital in September 2010 and by October 2012 ≥ 80% of checklists were correctly executed. The preintervention cohort included 5,444 patients having surgery from January through June 2010 and the postintervention cohort included 5,297 patients having surgery from January through June 2013. Several baseline characteristics were significantly different between these cohorts, including factors influencing postoperative mortality such as procedure type, age, and comorbidities. The analysis was adjusted to account for these differences. Compared to the preintervention periods, implementation of the surgical safety checklist was associated with reduced 90-day mortality (adjusted odds ratio 0.73, 95% CI 0.56-0.96), but the reduction in 30-day mortality was not significant. The surgical safety checklist was also associated with a significant reduction in the length of hospital stay and a nonsignificant reduction in 30-day readmission.

While previous studies have found reduced 30-day mortality after the introduction of surgical safety checklists, the current study only found a significant reduction at 90-days. The first study evaluating the introduction of the World Health Organization (WHO) surgical safety checklist found an overall reduction in mortality from 1.5% before introduction of the checklist to 0.8% afterward (N Engl J Med 2009 Jan 29;360(5):491). The WHO study included 8 hospitals in 8 countries and a subgroup analysis showed the reduction in 30-day mortality was only significant in low-income countries. High-income countries had lower mortality at baseline, making a statistically significant impact difficult to achieve. Therefore, the results of the current study evaluating a single hospital in Italy using an adaptation of the WHO checklist are consistent with previous data. This study from Italy did find a significant reduction in 90-day mortality, showing that even in settings with low rates of post-surgical mortality, the introduction of a surgical safety checklist can still have a significant impact.

For more information, see the Surgical Safety Checklist topics for more information.


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