Integrating Cerebrospinal Fluid Shunt Quality Checks into the World Health Organization's Safe Surgery Checklist: A Pilot Study

doi:10.1016/j.wneu.2016.06.064

World Neurosurgery

Volume 92, August 2016, Pages 491-498.e3

https://doi.org/10.1016/j.wneu.2016.06.064 Get rights and content

Background

Despite efforts for improvement, cerebrospinal fluid (CSF) shunt failure rates remain high. Recent studies have shown promising reductions in failure rates and infection rates with the routine use of perioperative checklists. This study was conducted to pilot test the feasibility and efficacy of integrating specific CSF shunt surgery quality checks into the World Health Organization (WHO) Surgical Safety Checklist.

Methods

We designed CSF shunt checklist quality items according to a previously established methodology, including solicitation of best practices by a national multidisciplinary expert panel. We examined adherence to key processes before and after implementation as a measure of the efficacy of the integrated checklist. We then surveyed users regarding perceived checklist utility.

Results

Overall adherence to shunt-specific key processes increased from 8.6 (95% confidence interval [CI], 7.9–9.2) to 9.9 (95% CI, 9.3–10.4; P = 0.0070) per 12 items, driven by the infection control items (4.7 [95% CI, 4.1–5.3] to 6.0 [95% CI, 5.4–6.4] per 8 items; P = 0.0056). All of the survey respondents indicated that the checklist was easy to use. The majority stated that it helped them feel better prepared to perform the procedure consistently according to evidence-based practice, and that if they were to adhere to the checklist consistently, their rate of shunt failure would be expected to decrease.

Conclusions

The integration of specialty-specific checks into the WHO Safe Surgery Checklist improved adherence to quality processes and generally was well accepted in our pilot study. A larger clinical trial is needed to assess whether this approach could improve shunt outcomes.

Section snippets

Methods

The study was performed at Brigham and Women's Hospital (BWH) and Boston Children's Hospital (BCH) with approval from their respective Institutional Review Boards. The project consisted of 2 parts: development of an intraoperative shunt checklist prototype, and pilot testing and local implementation of the prototype. The primary outcome measure was adherence to key processes and behavioral changes resulting from use of the checklist. The secondary outcome was checklist utility as perceived by

Results

The integrated CSF shunt checklist is presented in Figure 2. Seventeen cases were collected before checklist implementation, 12 cases contributed to checklist development, and 16 cases were collected after checklist implementation. There were no significant differences in the number of procedures performed at the 2 institutions, the urgency of the procedures, or type of procedure between the preimplementation and postimplementation groups (Table 1).

Overall adherence to shunt-specific key

Discussion

This study was designed to examine the potential for improving the quality of shunt surgery through the integration of specialty-specific checks into the WHO Safe Surgery Checklist. The goal was to create a tool for intervention without disturbing the integrity of the already successful Safe Surgery Checklist. The Hydrocephalus Clinical Research Network has reported that adherence to certain key measures reduces the risk of shunt infection.¹⁰ Several of these steps are already routinely

Conclusion

Our results support the feasibility of integrating carefully designed shunt quality checks with the WHO Safe Surgery Checklist to improve adherence to processes believed to reduce shunt failure. A larger clinical trial is needed to evaluate whether use of the integrated shunt checklist clearly improves shunt outcomes. Additional pilot studies also are needed to assess whether this approach could be applied to other device or procedure-specific checklists as well.

Acknowledgment

The authors thank Kristin Alt Styer, Chris Barnes, Judie Jackson, Jeanne Richard, Dr. Alan Cohen, Sue Lovell, Beth Norton, Pearl Cunningham, Joan Vitello, Peggy Knowles, Carole Kubiak, Christine Smith, and staff at the Departments of Neurosurgery, Nursing, and Anesthesia at Boston Children's Hospital and Brigham and Women's Hospital for their expertise and assistance with this project.

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Safety checklists have been studied among various surgical patient groups, but evidence of their benefits in neurosurgery remains sparse. Since the implementation of the World Health Organization's Surgical Safety Checklist, their use has become widespread. The aim of this review was to systematically review the state of the literature on surgical safety checklists in neurosurgery. Also, in the new era of robotics and artificial intelligence, there is a need to re-evaluate patient safety procedures in neurosurgery. A systematic review was conducted on PubMed, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials, Embase, and MEDLINE for articles published between 2008 and 2016 using MeSH (medical subject heading) terms and keywords describing postoperative complications and surgical adverse events, and some additional searches were carried out until January 2019. Twenty-six original studies or reviews were eligible for this review. They were categorized into studies with patient-related outcomes, personnel-related outcomes, or previous reviews. Checklist use in neurosurgery was found to reduce hospital-acquired infectious complications and to enhance operating room safety culture. Checklists seem to improve patient safety in neurosurgery, although the amount of evidence is still limited. Despite their shortcomings, checklists are here to stay, and new research is required to update checklists to meet the requirements of the transforming working environment of the neurosurgery operating room.
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: Conflict of interest statement: This work was supported by a grant from the Agency for Healthcare Research and Quality (1R18 HS018537-01). Dr. Gawande has received royalties from multiple publishers and media outlets globally for writing on health care, including checklists. In the last 12 months, these organizations include Alpina Non-Fiction (Russia), Antoni Bosch Editor (Spanish worldwide), Arjmand Press (Iran), Asa Editore (Portugal), BBC, Bookie Publishing House (Korea), Book21 (Korea), CBS Television, Codecs (Romania), Cheers Publishing Company (China), Commonwealth Publishing Co. (China), Conde Nast Inc. (USA), Crete University Press (Greece), Dokoran (Czech Republic), Editions Domingo Publishing (Turkey), Editorial Empuries (Spain), Einaudi Editore (Italy), First News-Tn Viet Publishing Co. (Vietnam), Gramedia Pustaka Utama (Indonesia), Grup Media Litera (Romania), Harper Collins (World), Henry Holt (USA), Houghton Mifflin, Harvard Business School Press, Janis Roze Publishers (Latvia), Jesenski & Turk (Croatia), Koton Kitap (Turkey), Libraire Arthème Fayard (France), Lindhart og Rinhoft Forlag (Denmark), Lua de Papel (Portugal), Matichon (Thailand), McGraw Hill, Mehta Publishing House (India), Mime Forlag (Norway), Misuzu Shobo (Japan), Mizaik Knjiga (Croatia), Mladinska Knjiga (Slovenia), Modan (Israel), Moyen-Courrier (France), Objetiva (Brazil), Pearson Publishing, Penguin Random House Books (India), Pilgrim Group (Estonia), Profile Books Ltd. (British Commonwealth), Public Broadcasting Service, Picador USA, Radarami (Georgia), Random House GmbH (Germany), S. Fischer (Germany), Serambi Ilmu Semesta (Indonesia), Sextante (Brazil), Shinyusha Co, Ltd (Japan), Slovant Publishers (Slovak Republic), Streamland LTD (Romania), Tericam Kindo (Hungary), Uitgeverij De Arbeiderspers (Netherlands), Uitgeverij Nieuwezijds (Netherlands), Verlagsgruppe Vivat (Ukraine), Volante (Sweden), and Znak (Poland).

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Original ArticleIntegrating Cerebrospinal Fluid Shunt Quality Checks into the World Health Organization's Safe Surgery Checklist: A Pilot Study

Background

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

Conclusion

Acknowledgment

Jt Comm J Qual Patient Saf

Twenty-year outcome in young adults with childhood hydrocephalus: assessment of surgical outcome, work participation, and health-related quality of life

J Neurosurg Pediatr

Patterns in neurosurgical adverse events: cerebrospinal fluid shunt surgery

Neurosurg Focus

Long-term analysis of cerebrospinal fluid shunt infections: a 25-year experience

J Neurosurg

Effect of a comprehensive surgical safety system on patient outcomes

N Engl J Med

A surgical safety checklist to reduce morbidity and mortality in a global population

N Engl J Med

Original Article
Integrating Cerebrospinal Fluid Shunt Quality Checks into the World Health Organization's Safe Surgery Checklist: A Pilot Study