Does using the WHO surgical checklist improve compliance to venous thromboembolism prophylaxis guidelines?
Introduction
Venous thromboembolism (VTE) is the largest cause of in hospital preventable death in the UK with an estimated 25,000 deaths per annum. Surgery carries a high risk of venous thromboembolic disease with studies estimating the innate risk to be at high as 25% in general surgery patients.1, 2 This risk persists for at least 3 months.3
Prophylactic measures including mechanical stockings and pharmacological to reduce this risk have been recommended in NICE guidelines. Compliance to these guidelines is routinely measured in most trusts as part of ongoing clinical governance. Different strategies have been used to improve compliance however re-audit and teaching is often not shown to improve compliance alone. Interventions such as pre- printed drug charts, specialist nurses and formal risk assessment sheets have been shown to improve compliance in various audits across different specialities.2, 4, 5
In June 2009 the World Health Organisation (WHO) launched the Safe Surgery Saves Lives campaign.6 This included the safe surgical checklist known as the WHO checklist. This was based on a study that showed a 47% reduction in deaths after its implementation across 8 hospitals in countries with different economic resources.7 The WHO safe surgical checklist has been adapted for use within the NHS.8 This adaptation contains a checklist item requiring the whole multidisciplinary team to acknowledge that VTE prophylaxis measures are applied before the operation commences.
The effect of the introduction of WHO checklist on compliance to NICE VTE prophylaxis guidelines has not been established. Our study investigated whether routine use of the surgical checklist improved compliance of general surgical patients to NICE pharmacological VTE prophylaxis guidelines.
Section snippets
Materials and methods
The WHO checklist was introduced to our trust in December 2008 and became routinely used in all general surgery theatres in April 2009. General surgery inpatients were assessed for compliance to NICE VTE prophylaxis guidelines before and after the establishment of the WHO checklist.
There were 2 audits before and one after 6 months of routine use of the WHO safe surgical checklist. All other measures to improve compliance were kept constant including a teaching session for foundation doctors at
Results
370 patients (173 [47%] male, 197 [53%] female, mean age 61.6 yrs) were assessed throughout all audit periods. Pre checklist baseline non compliance to VTE guidelines was 16/233 (6.9%). After 6 months of routine use to the WHO checklist the non compliance improved from 16/233 (6.9%) to 3/137 (2.1%). Relative Risk Reduction 3.2 (p = 0.046) (Table 1).
Non compliance to NICE VTE guidelines in the two audits performed before the checklist was established were similar at 7/107 (6.5%) and 9/126 (7.2%)
Discussion
The addition of the surgical checklist to our existing strategies has significantly improved compliance to NICE VTE prophylaxis guidelines in our department. Overall non compliance improved from 6.2% to 2.1% after introduction of the checklist.
The checklist was designed to improve patient safety. The original study, which led to the recommendation by the WHO for a universal checklist, showed a reduction in mortality of 47%7 across a variety of healthcare systems. The study was not designed to
Conclusion
This study confirms that the WHO checklist benefits patients but also adds a new dimension to the evidence by considering its effect of VTE prophylaxis. It demonstrates that establishment of the WHO checklist for routine use in all surgical cases significantly improves VTE guideline compliance. This may be the mechanism that accounts for some of the reduction in mortality observed in other studies when using the WHO checklist.
Financial support
None.
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