Reducing surgical mortality in Scotland by use of the WHO Surgical Safety Checklist

Abstract

Background The WHO Surgical Safety Checklist has been implemented widely since its launch in 2008. It was introduced in Scotland as part of the Scottish Patient Safety Programme (SPSP) between 2008 and 2010, and is now integral to surgical practice. Its influence on outcomes, when analysed at a population level, remains unclear. Methods This was a population cohort study. All admissions to any acute hospital in Scotland between 2000 and 2014 were included. Standardized differences were used to estimate the balance of demographics over time, after which interrupted time‐series (segmented regression) analyses were performed. Data were obtained from the Information Services Division, Scotland. Results There were 12 667 926 hospital admissions, of which 6 839 736 had a surgical procedure. Amongst the surgical cohort, the inpatient mortality rate in 2000 was 0·76 (95 per cent c.i. 0·68 to 0·84) per cent, and in 2014 it was 0·46 (0·42 to 0·50) per cent. The checklist was associated with a 36·6 (95 per cent c.i. –55·2 to –17·9) per cent relative reduction in mortality (P < 0·001). Mortality rates before implementation were decreasing by 0·003 (95 per cent c.i. –0·017 to +0·012) per cent per year; annual decreases of 0·069 (–0·092 to –0·046) per cent were seen during, and 0·019 (–0·038 to +0·001) per cent after, implementation. No such improvement trends were seen in the non‐surgical cohort over this time frame. Conclusion Since the implementation of the checklist, as part of an overall national safety strategy, there has been a reduction in perioperative mortality.

Author response to: Reducing postoperative mortality rates in England

“…In our study, we noted a significant reduction in mortality rates in patients undergoing surgical intervention in Scotland after the introduction and implementation of the WHO Surgical Checklist. This reduction in mortality was not seen in patients who did not undergo surgical intervention.…”

“…We thank Nepogodiev et al . for their correspondence about our recent publication. By their analysis on patients operated upon in England, they further add to the body of evidence demonstrating improvement in mortality rates over time.…”

Good intra‐operative anaesthesia is more than an ‘airway, breathing, circulation, drugs with a three, two and a one’

“…Jelacic et al. 's study complements work recently published by Ramsey et al., finding a reduction in surgical mortality in Scotland associated with the introduction of the WHO Surgical Safety Checklist . However, not all studies of checklist implementation at scale have been able to demonstrate clinical benefits, particularly when evaluating implementation outside the research setting and at scale across multiple centres .…”

Reducing postoperative mortality rates in England

“…Ramsay et al . report that a key driver for the 39 per cent relative reduction in inpatient postoperative mortality in Scotland in 2000–2014 was the introduction of the WHO Surgical Safety Checklist. The checklist has been demonstrated to reduce postoperative mortality rates (POMR) at an individual patient level, but this is the first evidence for its potential to improve outcomes at a national level.…”