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Checklists in the OR can help caregivers avert crises, study finds

Crises in the operating room are common, but caregivers often fail to save the patient because they do not recall the necessary steps quickly enough. An experiment at Brigham and Women’s Hospital suggests that surgeons, nurses, and other staff members can vastly improve their handling of these critical situations by reviewing checklists, an approach used by pilots during airplane mishaps.

When checklists were available to surgical teams, they missed just 6 percent of life­saving steps, compared with 23 percent when the tool was not available, according to results published online Wednesday in the New England Journal of Medicine.

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The study was one of the first large clinical trials ­conducted in a simulated operating room — the Brigham’s STRATUS Center for Medical Simulation — where teams work on life-like mannequins that bleed synthetic fluid and produce vital signs. Researchers said it would be unwieldy and expensive to test checklists during actual surgery crises, because these situations — when patients suffer heart attacks or massive bleeding, for example — are hard to predict.

“You might be watching for years to get enough critical mass to make statistical ­calculations,” said Dr. Charles Pozner, one of the authors and medical director of the ­STRATUS center.

A hospital that has 10,000 operations a year will experience about 145 operating-room crises on average. Failure to rescue these patients is the most significant source of variation in surgical mortality among hospitals.

Dr. Atul Gawande, a Brigham surgeon who led the study, helped popularize the use of checklists prior to surgery to make sure teams are performing the intended operation at the correct site on the right patient. He believes this new study will help overcome the skepticism that exists among surgeons about relying on written guides.

“There is a general belief that you just need to rely on expertise and seat-of-the-pants thinking and on the people in the room,” Gawande said in an interview. “That is in distinct contrast to how you handle the crisis in a crashing airplane. Having a playbook is a lot better than not having a playbook.”

The checklists used in the study included information such as potential diagnoses, whom to page for additional help, and when to start chest compressions.

Gawande said he has kept a crisis checklist in his briefcase for a year, and has pulled it out three times.

In one case a patient’s heart rate dropped and caregivers did not know why.

The checklist reminded them that the combination of anesthesia and calcium channel blockers, used to treat high blood pressure and which the patient took, could be risky.

When they gave the patient calcium, the heart rate rebounded.

Gawande said the Brigham plans to develop and use crises checklists in its operating rooms and will publish them online for other hospitals to adopt.

Liz Kowalczyk can be reached at kowalczyk@globe.com. Follow her on twitter at @GlobeLizK
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