Atul Gawande has published his "checklist paper" in the latest NEJM. Last year he wrote a profile in the New Yoker on the efforts of Peter Pronovost at Johns Hopkins who had implemented a strict protocol algorithm (or checklist) to be followed for the insertion of central venous catheters, which almost completely eradicated the incidence of catheter-associated infectious complications. So this paper has been eagerly anticipated.
The paper is a prospective collection of 30 day complication data from hospitals around the world for patients undergoing non-cardiac surgery. Half the patients were subjected to a 19-item Surgical Safety Checklist during the peri-operative period. The checklist includes such items as making sure the correct surgical site is marked, noting allergies, making sure peri-op antibiotics have been given appropriately, and confirming that sponge and instrument counts are correct before closing the incision.
The results are rather astounding. According to the study, death rates were reduced by almost 50% when patients were subjected to this magical checklist. Now that's an amazing achievement. So much so that even Dr. Pronovost is a little suspicious. Surgical teams participating in the study were not blinded to the the study and the patients had not been randomized to either arm. So it's hard to make definitive, standard-of-care conclusions. Closer inspection of the data demonstrates that the biggest improvements were seen in hospitals from third world countries. This makes sense because in the United States, we've already been marking surgical sites and calling pre-op "time-outs" for several years.
Certainly, there is something to be said for meticulous routines when it comes to surgery or other procedures. But do we need mandatory 19 item checklists? Why stop there? Why not make it a 40 item checklist? Why not make the attending surgeon write an essay on how to avoid complications before every case? Or how about having the surgeon and all assistants read the chapter corresponding to the proposed operation from the textbook out loud together (alternating paragraphs) prior to making the incision?
It's good to be organized and precise in surgery. Limited checklists are useful in this regard. We ought to mark our initials on the correct side of the hernia repair. Point taken. Nothing groundbreaking here. We don't want to be operating on the wrong leg or leaving sponges inside bellies. But it's rather a ridiculous leap to think that death rates can be halved just by following a series of irritating instructions on a laminated list.