Implementation of the World Health Organization surgical safety checklist, including introduction of pulse oximetry, in a resource-limited setting

Abstract

OBJECTIVE: To introduce the World Health Organization Surgical Safety Checklist into every operating room within a severely resource-limited hospital located in a developing country and to measure its impact on surgical hazards and complications. BACKGROUND: The checklist has been shown to reduce surgical morbidity and mortality, but the ability to successfully implement the checklist program hospital-wide in lower income settings without basic resources is unknown. METHODS: We conducted a pre- versus postintervention study of the implementation of the checklist, including the introduction of universal pulse oximetry at a hospital in Chisinau, Moldova, where only 3 oximeters were available for their 22 operating stations. We supplied data-recording oximeters for all operating stations and trained a local checklist implementation team. The primary outcomes were process adherence, major complications, and rates of hypoxemia (SpO2 <90%). Propensity score weighing was conducted to adjust process and outcome measures. Regression models were used to evaluate adherence to process measures and hypoxemia trends over time. RESULTS: Data from 2145 pre- and 2212 postintervention cases were collected. Adherence to all safety processes increased significantly from 0.0% to 66.9% (P < 0.001). After checklist implementation, the overall complication rate decreased from 21.5% to 8.8% (P < 0.001). Infectious and noninfectious complications decreased significantly after checklist implementation from 17.7% to 6.7% (P < 0.001) and from 2.6% to 1.5% (P = 0.018), respectively. The number of hypoxemic episodes lasting 2 minutes or longer per 100 hours of oximetry decreased from 11.5 to 6.4 (P < 0.002). CONCLUSIONS: Successful hospital-wide Surgery Safety Checklist implementation can be achieved in a resource-limited setting and can significantly reduce surgical hazards and complications.