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Assessment of results of the Surgical Checklist in the surgical care process

Natalia Pérez Fuillerat
Área Quirúrgica, Hospital de Montilla. Agencia Sanitaria Alto Guadalquivir (APESHAG). Córdoba, España

Manuscrito recibido el 27.3.2014
Manuscrito aceptado el
27.7.2014

Evidentia 2015 abr-jun; 12(50)

 

 

 

Cómo citar este documento

Pérez Fuillerat, Natalia. Assessment of results of the Surgical Checklist in the surgical care process. Evidentia. 2015 abr-jun; 12(50). Disponible en: <https://www.index-f.com/evidentia/n50/ev9759e.php> Consultado el

 

 

 

Abstract

Objective: To find out about the mortality associated to the implementation of the Surgical Check-list Score in surgical patients from Alto Guadalquivir Health Agency (APESHAG). Methods: We have developed a mixed ecological study using the indicators proposed by WHO, the Patient Safety Indicators (PSI) and the Elixhauser Index. We compared the results obtained in 2008 (not score) and 2012. Results: There were no relevant differences in resources used and services given. The Elixhauser Index in 2008 is higher than in 2012. Deaths on the same day of surgery and Postoperative hospital mortality have decreased (0.02 % and 0.55 % respectively). There are three PSIs which have reduced their values. Conclusions: The use of the score is associated with an improvement in the mortality rates and the PSIs studied.
Key-words: Surgical Check-list Score/ Safety Indicators/ Elixhauser Index.

 

 

 

Introduction

    The comparison and verification of evidences from several studies carried out by the World Health Assembly in 20021 highlighted the needs and inequities in the health care process regarding to patient safety. It also urged the World Health Organization (WHO) to take the lead in the development of standardized patient safety procedures.

The World Alliance of Health addressed the second Global Patient Safety Challenge, setting in the years 2007-2008, a guide to procedures targeted by WHO2 recommendations.

This guide of good practices proposed the implementation and realization of the "Surgical checklist score", known in our country as Surgical Checklist (SC).3-5

There have been several studies focused on the evaluation and results of SC in different contexts. In the review by Tang et al.,6 real SC results in Australia are analyzed by comparing to other worldwide results. Torres and Gonzalez3 explain the need for the implementation of a list of results obtained in different studies made in Spain and the current policies about this subject.

The review by Fudickar et al.7 corroborates the significant relation in the use of SC and the improve of safety culture emphasizing interdisciplinary communication obtained by an exemplary implementation of team leaders and a structured training. They also identify a significant decrease in mortality and morbidity.

The study by Haynes et al.8 confirm the decline in mortality and morbidity, emphasizing the need for conducting further research to determine the exact mechanism and the duration of effects in specific contexts. De Vries et al.9 obtained a decrease in hospital mortality of 1.5% to 0.8% in hospitals identified with a high level in care quality. In turn, they identified the upgrading and standardization of existing protocols as a result of the SC establishment.

However, studies have detected inconsistencies and failures in completing the list due to the multidisciplinary nature of the procedure and the involvement of the heads of service and patient safety committee10 to the success of the SC.

This situation has increased due to the multifactorial nature of patient safety and its difficulty of measuring and monitoring.11

In the Guidelines for Safe Surgery, WHO proposed ten goals in the development of the surgical care process. This study is focused on the goal number 102: "Hospitals and public health systems will establish routine surveillance of surgical capacity, volume and results."

For this purpose, WHO has developed a set of core indicators ("surgical vital statistics") adopted by all Member States in their annual reports of public health,1 related to the monitoring and evaluation of the program "Safe Surgery Saves Lives" in which the implementation of the SC is included, as well as the indicators for monitoring and evaluating the program at the hospital level to provide leadership and supervision.

Thus, the surgical care process modifies its development from the priorities identified in its evaluation.12

In Spain, the Quality Plan for the National Health System in 200613 developed by the Spanish Ministry of Health, contains in its number eight the following strategy: "to improve the safety of patients attending health facilities in the NHS"; justified as international priority of this issue in the policies and strategies of health.14

In 2005, the National Study of Adverse Events related to hospitalization (NSAE)15 is conducted. It was reported that 55.6% of adverse events were produced during surgery, and 42.8% of them could have been avoided.

The importance of creating indicators of surgical safety assessment, validation, registration and universality is an issue previously addressed the Surgical Checklist.

In 2001, the NHS R & D Health Technology Assessment (HTA)16 conducted a review of the measurement and monitoring of surgical adverse events by detecting the high variability of procedures and definitions that sustained the hospital records of UK; describing the need to develop standard definitions and identify existing adverse events.

Since 2003, the Agency for Healthcare Research and Quality (AHRQ)17 is working in the Patient Safety Indicators (PSI), worldwide18 recognized for evaluating hospital safety. The PSI have been approved19 and they are used in the evaluation of our hospitals centers20 in particular, and our National Health System in general.

In addition to these indicators, it also incorporated the use of the Elixhauser index21,22 to study comorbidities and their influence on the measurement of indicators and analysis axes for the Basic Set Hospital Data (BSHD).23

The Andalusian Health Service (AHS), as essential element in assessing our health care activity, annually publishes a guide/report where the BSHD discharge records24,25 are collected and further develops the Patient Safety Indicators, the last one published in 2011 by the Agency for Healthcare Quality belonging to the Andalusian Regional Ministry of Health.26

From the establishment in 2009 of the "Safe Surgery Saves Lives" programme to 2012 in Alto Guadalquivir Health Agency (AGHA), this agency has taken steps to correct transposition and applicability about SC. Among them, we can highlight the description of the specific procedure of the company, the production of two types of SC depending on the type of surgery, updating the reporting systems "security incidents", the beginning of the Plan for Patient Safety 2012-2013, and a continued collaboration with the Agency for Health Quality of Andalusia in the development of security Indicators and recommendations for improving patient safety in health centers.

Similarly, the policy of the Alto Guadalquivir Health Agency follows the guidelines of the second Quality plan 2010-201427 conducted by the Andalusian Regional Ministry of Health.

According to the WHO recommendations and the policies pursued by the Alto Guadalquivir Health Agency, the hypothesis in this research is described as follows:
The SC implementation decreases operative mortality in surgical care processes in 2012 compared to 2008 in the AGHA.

The main objective of the study is to know the main differences in surgical mortality associated with the implementation of the Surgical Checklist.
 

Methodology

Population and sample

    The study of population consists of patients whose surgical care process has been conducted at the Montilla Hospital and the Alto Guadalquivir Hospital (field of study) belonging to the Alto Guadalquivir Health Agency(AGHA), in 2012 and in 2008 considering the implementation and development of the SC that agency has done since 2009.

The inclusion criteria are:
Group 1: Members of AGHA whose surgical care process has been performed with the SC in 2012.
Group 2: Members of AGHA whose surgical care process has been performed in 2008.

It was carried out a non-probability convenience sampling including all surgical care processes performed during these years in the hospitals mentioned above.

Design Type

    This is an ecological study mixed.28,29 This design was chosen because firstly we work with aggregate, environmental and global measurements. It is a mixed study as it has been developed using the database of two hospitals in two time sequences.

Study variables

    The independent variable in our study is "Performing Surgical Checklist (Yes/No)".

Our dependent variables are: Deaths on the same day of surgery, being the numerator the number of deaths on the day of the intervention and the denominator the total number of surgical cases; Hospital Postoperative mortality rate, being the numerator the number of deaths admitted after surgery and the denominator the total number of surgical cases; Elixhauser Index and Patient Safety Indicators.

Elixhauser Index (EI) measures the comorbidity of patient understood as "a diseased condition of the patient, already present on admission and not as a consequence of the care process during hospitalization."21 This is an alternative indicator to the classical Charlson - Deyo index that includes thirty diagnostic categories identified by CIE code accompanying the primary diagnosis of each of the patients analyzed.30 For its calculation, we used the Comorbidity Software version 3.7.

The "Patient Safety Indicators" (PSI),16,18 set by AHRQ and validated in our National Health System as Patient Safety Indicators, are designed for the screening of administrative databases for problems of patient safety and medical errors.

For identification and registration, version 3.2 has been used for 2008 PSI and version 4.3 for 2012 PSI.

The surgical PSI used in the study were classified as follows: Death in Low-Mortality DRGs (PSI 2), complications of anesthesia (PSI 1), Death Rate among Surgical patients with Serious Treatable Complications (PSI 4), Retained Surgical Item or Unretrieved Device Fragment Count (PSI 5) Postoperative Hip Fracture Rate (PSI 8), Perioperative Hemorrhage or Hematoma Rate (PSI 9), Postoperative Physiologic and Metabolic Derangement Rate (PSI 10), Postoperative Respiratory Failure Rate (PSI 11), Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate (PSI 12), Postoperative Sepsis Rate (PSI 13) and Postoperative Wound Dehiscence Rate (PSI 14).

The variables description for the contrasted groups are: Variables description of the groups being compared are: Exchange Checklist (Checklist Safety Minor Surgery (CSMS) and Checklist Safety Ambulatory Surgery and Major Surgery (CSAMS)); sociodemographic variables (age and sex), Hospital (Montilla Hospital/ Alto Guadalquivir Hospital), year (2008/2012), surgical specialty (traumatology, gynecology, obstetrics, urology, general surgery, ophthalmology, dermatology and otolaryngology), type of income and type of surgery (process scheduled or urgently surgical care turn classified in Ambulatory Surgery, Major Surgery and Surgery Minor),30 mean hospital stay, number of operating rooms, number of operations performed in the operating room, number of surgical procedures (Diagnostic Related Groups surgical (DRGs)31) performed in the operating room of the ten most common procedures in AGHA, number of trained surgeons and anesthetists and number of surgical nurses.

Procedure and data collection

    Through the Alto Guadalquivir Health Agency and the collaboration of the Area Management and Assessment, we have collected the data recorded in our variables of study belonging to 2008 and 2012.

Data have been obtained from the HIS database (Hospital Information System), the implementation of the National Health System for data collection; and the IA metrics, application contracted by AGHA.

Data analysis

    We performed a descriptive analysis of the characteristics of our population in the years of study. The relation between the use of SC and mortality rates were calculated using the confidence interval at 95% of the PSI, given the index value corresponding Elixhauser.

For these calculations we used the IBM SPSS v.19 statistical program (average and total percentages) and Epidat v.3.1 (confidence interval).

Ethical considerations and limitations of the study

    The research was carried out with the approval of the Ethics Committee of the AGHA where has been executed the study, and the Ethics Committee of the University of Jaen.

Members of the research team have guaranteed confidentiality and anonymity of the participants.

Due to performing ecological study and work with group data, we cannot explain the association between exposure and effect in an individual level (ecological fallacy).

The biases assessed and controlled are: selection bias due to possible incorrect definition of the target population and data loss; the classification bias and confusion bias. By analyzing the results, we evaluate the possible relation of the elapsed time to study, describing the projects and action plans developed in patient safety.
 

Results

    The study population has similar characteristics in 2008 and 2012 in terms of mean age (where the confidence interval of the mean age of 53,28 to 52,36 in 2008 and for 2012 from 55,43 to 54,49) and sex distribution. Both surgical care processes don't present a great variability for the variables of the number of surgical procedures (11,81% less between 2008 and 2012) and the percentage of type of income (1,9% more than scheduled surgery between 2008 and 2012).

In Table 1 we can observe some decreasing in emergency surgery in 2012 compared to 2008.

Regarding the days of Main Hospital Stay (MHS) in 2012 has obtained a slight decrease in its value.

The value of MHS is characterized as an indicator of low rate of complications and adverse events as well as a good effective and decisive clinical practice accompanied by adequate continuity of care.

In this study we cannot determine whether the decrease in days of MHS is significant.

Table 1. Descriptive variables: population and surgical care process

Table 1

The number of health professionals involved in the surgical care activity has not changed [Table 2]. The number of Otolaryngologists has a value of 2.5 people due to computation time setting and substitutions made.

Table 2. List of healthcare professionals (doctors and nurses) in the surgical process

Table 2

In the Montilla Hospital and the Alto Guadalquivir Hospital there are four operating rooms. Both hospitals have shown the "OR Two" as the operating room with the more operations per year, being 1628 operations in Montilla and 1336 operations in the Alto Guadalquivir.

In 2012 there has been a decrease: 7,5% in minor surgery and 9.2% major surgery, offset by the increasing of ambulatory surgery in 10.5%. In particular, we could say that the decrease in the frequency of major surgery has helped to decline the value of the Main Hospital Stay, highlighting that minor and ambulatory surgery patients count as 0 days.

For the 2012 recorded data, 6% of surgical operations were classified as indeterminate, 0% in the year 2008.

Regarding to specialties, in 2012 the incidence rate decreases in Dermatology, Orthopedic surgery and Obstetrics; it increases in specialties such as Gynaecology, Ophthalmology, General Surgery, Urology and Otorhinolaryngology.

The frequency of surgical DRGs in 2012 was slightly higher than in 2008. The specialties in which we can group the most frequent surgical DRGs are those of obstetrics, gynecology, general surgery and urology in which there is a variation in the order between 2008 and 2012, and trauma which is maintained in both years representing four of the 10 most frequent DRGs, being the specialty which has a higher level of representation but not in terms of frequency of hospital discharges.

These data reflect the priority needs in the surgical care process AGHA. Among the specialties mentioned, Obstetrics, Gynaecology and Orthopedic surgery have specific PSI (Obstetrics-Gynecology: PSI 2, 18, 19; Orthopedic surgery: PSI 8)32 which highlights their importance at the international level.

The low incidence of mortality hinders the analysis of descriptive variables, the Surgical Intervention day Mortality Rate and Postoperative Hospital Mortality Rate as a whole. However, the consistency of the data obtained is given by the amplitude of time studied (four years in the present study).

The values analyzed in 2008 and 2012 show a decrease in both population rates. Specifically, the decrease in Hospital Postoperative Mortality Rate (0.55%).

In the calculation of confidence intervals for Patient Safety indicators [Table 3], we found variations of PSI analyzed.

Registration of PSI 5 has not been made in any of the two years of study.

Those PSI in which have an improvement (decrease) in value in 2012 compared to 2008 are: Complications of anesthesia, Death in low-mortality DRGs, Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate, Postoperative Sepsis Rate, and Postoperative Wound Dehiscence Rate.

PSIs whose value has increased in 2012 as compared to the value it had in 2008 are: Death Rate among Surgical Inpatients with serious treatable complications, Postoperative Hip Fracture, Perioperative Hemorrhage or Hematoma Rate, Postoperative Physiologic and Metabolic Derangement Rate and Postoperative Respiratory Failure Rate.

Surgical PSI whose confidence intervals at 95% reflect a significant decrease are PSI 2 (Death Low-Mortality DRGs), PSI 12 (Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate) and PSI 14 (Postoperative Wound Dehiscence Rate).

However, it has been also identified the PSI 4 (Death Rate among Surgical Inpatients with serious treatable complications) with a confidence interval not overlapped and whose value has increased.

Table 3. PSI relation studied by year and hospital study

Table 3

Comorbidity associated with these processes has been registered by Elixhauser Index (EI). Its value was higher in 2008 (1.65) compared to 2012 (1.41). That is, the population in 2012 had lower risk of death than the population of 2008.
 

Discussion

    In the analysis of the given results, we have taken into account the inherent limitations of the study due to the design type and the use of administrative databases.

One of the most important points of the limitations used in this work was the low frequency of mortality and registration of PSIs whose sensitivity and specificity must continue improving33 and the precariousness or no control of it in some PSI (PSI 1, 2, 5, 8 and 10).

In AGHA should work strengthened support and maintenance "OR Two" in Montilla and Alto Guadalquivir Hospitals, and establish a system of evaluation from the majority care processes, which belong to the specialties of general surgery, orthopedics and ophthalmology, emphasizing the representation of these specialties in the frequency of surgical DRGs and measurement of security related to the PSI.

Regarding human resources, new indicators should be incorporated in the monitoring, which provide information about the level of accreditation, motivation, satisfaction with the company, work environment,33 etc., pursuing thereby assessing qualitative and quantitative quality of services.

One option would be to use the staff turnover rate, which would allow us to know if the service staff is comprised of former and stable staff or there is the need to cover different positions with new and unstable staff. This index is used by the National Institute of Statistics as operational indicator.

Studies focusing on reducing the frequency of emergency surgery reflected as common causes lack of early diagnosis and prevention of postoperative complications in cardiac pathologies and mainly in general surgery, which highlights cholecystectomy. The latter represents the second most frequent DRGs in 2012 and the fourth most frequent DRG in 2008 in AGHA.

The decrease in urgently surgeries may orient toward a possible improvement in the management of this condition in particular and all surgical DRGs in general. Would require a specific study of the prevalence of urgent elective surgery in each surgical DRGs to obtain meaningful results.

The decrease in MHS between 2008 and 2012, is produced in accordance with that obtained in more than half of the hospitals belonging to MHS of AHS in their hospital (MHS of AHS includes the surgical MHS calculated in this study).24,25 Moreover, said decrease (1.7%), coincides with the increased frequency of CMA (10.5%). However, it is still a good indicator of quality of care.

In relation to comorbidity associated with these processes, as already mentioned, it has been higher for the year 2008 than for 2012.

The study on cardiac mortality and cardiac morbidity conducted by Gili M et al.,34 they observed an increase of EI associated with population aging while identifying a decrease in the mortality rate. However, in this study there has been a decrease in morbidity and mortality.

In the original study of Elixhauser and the study done in our midst by the National Health System, conclude that the categories in which this index decomposes must comply with each subtype (in our case for each type of rate mortality and/or PSI). This is due to variability with this index is characterized and its relation with the mortality rate. Is needed more research to provide this data and adjust the calculation of results or extrapolated values for intervals.

Regarding the values of PSI, PSI five of the ten studied have shown a decrease in their values being three of them significant.

These results are consistent with the values obtained for the Surgical Intervention Day Mortality Rate and Hospital Postoperative Mortality Rate, whose values have declined in the four years between the years of study.

Although it has not been possible to perform statistical analysis of these variables, we found consistency in our results with studies conducted in the same materia.7,9

Decreasing the frequency of identified emergency surgery reflected improvements in the performance of early diagnosis and prevention of postoperative complications.

According to the value obtained for the PSI 4 should be analyzed as a whole in a comprehensive manner for handling and subsequent decrease in value.

Among the variables related to these results we find the increasing and ongoing work at international, national, autonomous and entrepreneurial level for patient safety. This has created a "culture of safety" in professional groups involved in clinical surgical practice35 identified as a significant factor in improving the quality of care.9

We can say that the study conducted involves an initial assessment of the quality improvement of patient safety following the implementation of the SC giving us a global vision to focus and prioritize the evaluation of clinical practice in this area.

In the search results a greater force looking for more noteworthy results, we propose the systematization of logging specific indicators for the surgical procedure, as well as their evaluation and development of action plans, initiating a positive spiral towards achieving excellence.

"Awareness, commitment and evidence for safe practice" is the phrase that summarized the International Meeting on Evidence-Based Nursing in 2009.36

In this study, in addition to the evidence provided, the commitment to the evaluation of the projects initiated towards security patient37,38 based on nurse care39 (coordinators in the implementation of SC) is promoted; reinforcing awareness integrated into the culture security developed in the company AGHA.
 

Conclusion

    No significant differences were found between years of study in terms of resources used and services rendered. However, we have identified a reduction of MHS and a change in the distribution of surgical DRGs, the type of income and type of surgery. There have been a decrease in mortality rates and three of the ten studied PSI. The Elixhauser index values require adjustment to study its relation to these indicators.

Necessary must be implemented of the evaluation of the monitored elements, adding new elements and the systematic evaluation of them and their relation to the SC in order to achieve real and progressive benefits.
 

Acknowledgements

    I thank Diego Angel Sevilla, head of the Department of Management and Services APESHAG, for her invaluable collaboration in the preparing the database of this study.


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