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17 January 2013

Checklists help doctors in emergencies

Having step-by-step checklists on hand may help doctors and nurses manage emergencies in the operating room, a new study suggests.

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Having step-by-step checklists on hand may help doctors and nurses manage emergencies in the operating room, a new study suggests.

In situations when a person's heart stops beating on the operating table or a patient begins bleeding uncontrollably, those lists can save time and brain power, researchers said.

"The standard practice across the country has just been, you work from memory and reason your way through a crisis," said Dr Atul Gawande, from Brigham and Women's Hospital in Boston, who worked on the study.

"People have called (checklists) 'dumbing down' medicine, but what we showed is that even in this incredibly stressful, high-complexity situation, the teams that worked from a kind of pre-planned set of steps had three quarters lower likelihood of missing critical lifesaving steps," he said.

For example, in the case where a patient's heart slowed way down, "you weren't racking your brain to remember what the setting was supposed to be on that external pacemaker," Gawande said. "Instead you were focusing on, 'What else am I not thinking about here?'"

For the study, he and his colleagues arranged 17 operating room teams to go through 106 simulated surgical crises, with or without the checklists. They found that with the lists, the proportion of essential steps missed during emergencies dropped from 23% to 6%.

Every OR team did better when it had the crisis checklists on hand, the researchers reported.

Standard procedure

Gawande said his own hospital and a few others have started making such emergency checklists standard procedure in the OR. Past research by his team showed using pre-surgery checklists also helped prevent problems in the first place.

"Previous checklists made sure things went well for cases we do every day," said Dr Douglas Paull, a surgeon at the Veterans Health Administration's National Center for Patient Safety in Ann Arbor, Michigan.

"Now (there are) checklists for crisis to make sure critical actions occur in timely fashion," added Paull, who wasn't involved in the new study.

Some doctors and hospitals may still be hesitant to start using the lists, researchers said.

"Checklists are totally part of the landscape everywhere else, but they are not what we're trained to use in healthcare," said Dr Paul Preston, an anaesthesiologist from Kaiser Permanente San Francisco.

"There is a huge issue of, 'Good people would remember this, they don't need a checklist,'" said Preston, who is leading efforts to get checklists into Kaiser Permanente ORs and train people to use them.

The study authors noted that their research was done in simulated situations, so they can't be sure what would happen in a real-world emergency. Still, they found almost all doctors and nurses involved in the simulations said they would want a checklist if one of those crises occurred during an operation.

And that could end up benefiting patients, researchers said.

"The biggest difference in the survival from surgery between hospitals is in whether they're able to rescue people from complications," Gawande said.

(Reuters Health, January 2013)

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