Improving Surgical and Anaesthesia Practice: Review of the Use of the WHO Safe Surgery Checklist in Felege Hiwot Referral Hospital, Ethiopia

Abstract

Development of surgical and anaesthetic care globally has been consistently reported as being inadequate. The Lancet Commission on Global Surgery highlights the need for action to address this deficit. One such action to improve global surgical safety is the introduction of the WHO Surgical Checklist to Operating Rooms (OR) around the world. The checklist has a growing body of evidence supporting its ability to assist in the delivery of safe anaesthesia and surgical care. Here we report the introduction of the Checklist to a major Ethiopian referral hospital and low-resource setting and highlight the success and challenges of its implementation over a one year period.This project was conducted between July 2015 and August 2016, within a wider partnership between Felege Hiwot Hospital and The University of Aberdeen. The WHO Surgical Checklist was modified for appropriate and locally specific use within the OR of Felege Hiwot. The modified Checklist was introduced to all OR's and staff instructed on its use by local surgical leaders. Assessment of use of the Checklist was performed for General Surgical OR in three phases and Obstetric OR in two phases via observational study and case note review. Training was conduct between each phase to address challenges and promote use.Checklist utilisation in the general OR increased between Phase I and 2 from 50% to 97% and remained high at 94% in Phase 3. Between Phase I and 2 partial completion rose from 27% to 77%, whereas full completion remained unchanged (23% to 20%). Phase 3 resulted in an increase in full completion from 20% to 60%. After 1 year the least completed section was “Sign In” (53%) and “Time Out” was most completed (87%). The most poorly checked item was “Site Marked” (60%). Use of the checklist in Obstetrics OR increased between Phase I and Phase II from 50% to 100% with some improvement in partial completion (50% to 60%) and a notable increase in full completion (0% to 40%). The least completed section was “Time Out” (50%) and “Sign In” was the most completed (90%). The most poorly checked item was “Recovery Concerns” (70%). There was considerable enthusiasm for use of the checklist among staff. The greatest challenge was communication difficulties between teams and high staff turnover.This study records a locally driven, successful introduction of the WHO Surgical Safety Checklist modified for the specific locale and illustrates an increase in use of the checklist over a one year period in both General Surgical and Obstetric OR's. Local determination and ownership of the Checklist with regular intervention to promote use and train users contributed to this success.

Use of the WHO surgical safety checklist in low and middle income countries: A review of the literature

“…During previous work to evaluate the impact of the WHO checklist on theatre departments it was found that relatively little of the available literature retrieved from database searches provided information on the checklist's use in low and middle income countries (LMICs) (Cadman 2016). This has also been highlighted by others (Ellis et al 2017) who have also commented how variations in successful implementation will be context-dependent (Yuan et al 2012). It was therefore decided to pursue this area further to assess just how the checklist is being put into practice in such countries and any unique obstacles they face in comparison to high income countries (HICs).…”

“…However, they also commented that it is not representative of rural community hospitals, and once volunteers had left there was little or no support for continued use of the checklist. Leifso (2014) and Ellis et al (2017) both stated how economic migration following staff training increased staff turnover.…”

“…Mody et al (2014) reported that introperative counts were introduced as part of a quality improvement project surrounding the checklist, whilst Lilaonitkul et al (2015) commented on how there was no formal way of recording the counts. Ellis et al (2017) acknowledged that, whilst counts were done, they were poorly performed leading to the introduction of an instrument/swab count table on the reverse of the checklist to aid compliance. Lilaonitkul et al (2015) also described how, in addition to no formal record of counts, there was not only no instrument list to check against but also no standardised instrument pack for procedures.…”

Anaesthesia practices for Caesarean section amongst non-physician anaesthesia providers at an Ethiopian referral hospital

“…An earlier study at FHRH reported similar findings, with WHO SSC use in all obstetric surgical cases following phased implementation, and the surgical pause point the least completed component. 18…”

Reply to: Synoptic operative reports for quality improvement in pediatric cancer care

“…Presurgical timeouts and checklists have been shown to avoid errors and we agree with Cundy et al that the synoptic operative report has good evidence to be a tool to improve care and should be embraced and studied to see if it helps with adherence to protocols. 7 In addition, with the widespread use of electronic medical records, we now have the flexibility to develop smart templates that would allow for development of templates for pediatric renal tumors or other pediatric cancers. These templates could contain dropdown menus that incorporate the principles of synoptic operative notes.…”