Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Abstract

Background: The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy.

Methods: In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation.

Results: Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89·6 per cent) compared with that in countries with a middle (753 of 1242, 60·6 per cent; odds ratio (OR) 0·17, 95 per cent c.i. 0·14 to 0·21, P < 0·001) or low (363 of 860, 42·2 per cent; OR 0·08, 0·07 to 0·10, P < 0·001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -9·4 (95 per cent c.i. -11·9 to -6·9) per cent; P < 0·001), but the relationship was reversed in low-HDI countries (+12·1 (+7·0 to +17·3) per cent; P < 0·001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0·60, 0·50 to 0·73; P < 0·001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries.

Conclusion: Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.

Figure 1

Flow chart of study population. HDI, Human Development Index

Figure 2

Odds ratio plots of WHO Surgical Safety Checklist use and 30‐day mortality. a Use of WHO checklist and b 30‐day mortality for surgery type and Human Development Index (HDI) group from multivariable logistic regression models. Odds ratios are shown with 95 per cent confidence intervals and P values. Checklist use was adjusted for age, ASA score, diabetes status, disease classification, bowel resection and wound contamination. For full models, see Tables S7 and S8 (supporting information). Mortality (b) is adjusted for WHO surgical safety checklist use, age, ASA, disease classification, bowel resection and wound contamination

Figure 3

Adjusted probability of 30‐day mortality by surgery type, Human Development Index group and WHO Surgical Safety Checklist use. a Emergency laparotomy; b elective surgery. The multivariable logistic regression model for 30‐day mortality (Fig. 2; Table S8, supporting information) was used to generate adjusted predicted probabilities of death using bootstrap replication, with other co‐variable levels specified: age 52 years, ASA grade less than III, malignancy disease classification, and contamination. Absolute risk differences for 30‐day mortality are presented with 95 per cent confidence intervals, and two‐sided P values for the absolute risk difference (Table S9, supporting information). HDI, Human Development Index