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Original Investigation
July 2016

A Comparative Effectiveness Analysis of the Implementation of Surgical Safety Checklists in a Tertiary Care Hospital

Author Affiliations
  • 1Department of Anesthesiology and Intensive Care Medicine I, Bolzano Central Hospital, Bolzano, Italy
  • 2Department of Anesthesiology, Perioperative Medicine and Intensive Care, Paracelsus Medical University, Salzburg, Austria
  • 3Currently with Department of Anesthesiology and Intensive Care Medicine, Merano Hospital “Franz Tappeiner,” Merano, Italy
  • 4Epidemiologic Observatory, Department of Health, Province of Bolzano, Bolzano, Italy
  • 5Hospital Management, Bolzano Central Hospital, Bolzano, Italy
  • 6Clinical Governance, Department of Health, Province of Bolzano, Bolzano, Italy
  • 7Department of Urology, Bolzano Central Hospital, Bolzano, Italy
JAMA Surg. 2016;151(7):639-646. doi:10.1001/jamasurg.2015.5490

Importance  The appropriately coached implementation of surgical safety checklists (SSCs) reduces the incidence of perioperative complications and 30-day mortality of patients undergoing surgery. The association of the introduction of SSCs with 90-day mortality remains unclear.

Objective  To assess the association between the implementation of SSCs and all-cause 90- and 30-day mortality rates.

Design, Setting, and Participants  Evaluation of the outcomes of surgical procedures performed during the 6 months before (January 1 to June 30, 2010) and after (January 1 to June 30, 2013) the introduction of SSCs by retrospective analysis of administrative databases. The study was conducted in a public, regional, university-affiliated hospital in Italy. Data were collected from October 23, 2013, to November 12, 2014, including 90-day all-cause mortality, 30-day all-cause mortality, length of hospital stay, and 30-day readmission rate among patients undergoing noncardiac surgery. Patients undergoing surgery during the 6-month periods before and after the implementation of SSCs were compared. Data were analyzed from September 17, 2014, to July 31, 2015.

Main Outcomes and Measures  Risk-adjusted rates of 90- and 30-day mortality, readmission rate, and length of stay.

Results  The total study sample of 10 741 patients included 5444 preintervention and 5297 postintervention patients (5093 [47.4%] male and 5648 [52.6%] female patients; mean [SD] age, 53.0 [23.0] years). Ninety-day all-cause mortality was 2.4% (129 patients) before compared with 2.2% (118 patients) after the SSC implementation, for an adjusted odds ratio (AOR) of 0.73 (95% CI, 0.56-0.96; P = .02). Thirty-day all-cause mortality was 1.36% (74 patients) before compared with 1.32% (70 patients) after the SSC implementation, for an AOR of 0.79 (95% CI, 0.56-1.11; P = .17). Thirty-day readmission occurred in 797 patients (14.6%) in the preimplementation group vs 766 patients (14.5%) in the postimplementation group, for an AOR of 0.90 (95% CI, 0.81-1.01; P = .79). The adjusted length of stay was 10.4 (95% CI, 10.3-10.6) days in the preimplementation group compared with 9.6 (95% CI, 9.4-9.7) days in the postimplementation group (P < .001).

Conclusions and Relevance  The data cannot prove causality owing to the study design. The implementation of SSCs was associated with a 27% reduction of the adjusted risk for all-cause death within 90 days but not within 30 days. The adjusted length of stay was reduced after implementation of SSCs.