Anesthesiolopgy

Background The Surgical Safety Checklist is widely used to improve the quality of perioperative care. However, clinicians continue to debate the clinical effectiveness of this tool. Methods Prospective analysis of data from the International Surgical Outcomes study (ISOS), an international observational study of elective in-patient surgery, accompanied by a systematic review and metaanalysis of published literature. The exposure was surgical safety checklist use. The primary outcome was in-hospital mortality and the secondary outcome was postoperative complications. In the ISOS cohort, a multivariable multi-level generalised linear model was used to test associations. To further contextualise these findings, we included the results from the ISOS cohort in a meta-analysis. Results are reported as odds ratios (OR) with 95% confidence intervals. Results We included 44,814 patients from 497 hospitals in 27 countries in the ISOS analysis. 40,245 (89.8%) patients were exposed to the checklist, whilst 7508 (16.8%) sustained ≥1 postoperative complications and 207 (0.5%) died before hospital discharge. Checklist exposure was associated with reduced mortality (OR 0.49 [0.32-0.77]; p<0.01), but no difference in complication rates (OR 1.02 [0.88-1.19]; p=0.75). In the systematic review, we screened 3,732 records and identified 11 eligible studies of 453,292 patients including the ISOS cohort. Checklist exposure was associated with both reduced postoperative mortality (OR 0.75 [0.62-0.92]; p<0.01; I 2 =87%) and reduced complication rates (OR 0.73 [0.61-0.88]; p<0.01; I 2 =89%). Conclusions Patients exposed to a surgical safety checklist experience better postoperative outcomes, but this could simply reflect wider quality of care in hospitals where checklist use is routine.

Background The Surgical Safety Checklist is widely used to improve the quality of perioperative care. However, clinicians continue to debate the clinical effectiveness of this tool. Methods Prospective analysis of data from the International Surgical Outcomes study (ISOS), an international observational study of elective in-patient surgery, accompanied by a systematic review and metaanalysis of published literature. The exposure was surgical safety checklist use. The primary outcome was in-hospital mortality and the secondary outcome was postoperative complications. In the ISOS cohort, a multivariable multi-level generalised linear model was used to test associations. To further contextualise these findings, we included the results from the ISOS cohort in a meta-analysis. Results are reported as odds ratios (OR) with 95% confidence intervals. Results We included 44,814 patients from 497 hospitals in 27 countries in the ISOS analysis. 40,245 (89.8%) patients were exposed to the checklist, whilst 7508 (16.8%) sustained ≥1 postoperative complications and 207 (0.5%) died before hospital discharge. Checklist exposure was associated with reduced mortality (OR 0.49 [0.32-0.77]; p<0.01), but no difference in complication rates (OR 1.02 [0.88-1.19]; p=0.75). In the systematic review, we screened 3,732 records and identified 11 eligible studies of 453,292 patients including the ISOS cohort. Checklist exposure was associated with both reduced postoperative mortality (OR 0.75 [0.62-0.92]; p<0.01; I 2 =87%) and reduced complication rates (OR 0.73 [0.61-0.88]; p<0.01; I 2 =89%). Conclusions Patients exposed to a surgical safety checklist experience better postoperative outcomes, but this could simply reflect wider quality of care in hospitals where checklist use is routine.

Aims: Previous research suggests that patients undergoing upper gastrointestinal surgery are at high risk of poor postoperative outcomes. The aim of our study was to describe patient outcomes after elective upper gastrointestinal surgery at a global level. Methods: Prospective analysis of data collected during an international seven-day cohort study of 474 hospitals in 27 countries. Patients undergoing elective upper gastrointestinal surgery were recruited. Outcome measures were in-hospital complications and mortality at 30-days. Results are presented as n(%) and odds ratios with 95% confidence intervals. Results: 2139 patients were included, of whom 498 (23.2%) developed one or more postoperative complications, with 30 deaths (1.4%). Patients with complications had longer median hospital stay 11 (6-18) days vs. 5 (2-10) days. Infectious complications were most frequent, affecting 368 (17.2%) patients. 328 (15.3%) patients were admitted to critical care postoperatively, of whom 161 (49.1%) developed a complication with 14 deaths (4.3%). In a multivariable logistic regression model we identified age (OR 1.02 [1.01-1.03]), American Society of Anesthesiologists physical status III (OR 2.12 [1.44-3.16]) and IV (OR 3.23 [1.72-6.09]), surgery for cancer (OR 1.63 [1.27-2.11]), open procedure (OR 1.40 [1.10-1.78]), intermediate surgery (OR 1.75 [1.12-2.81]) and major surgery (OR 2.65 [1.72-4.23]) as independent risk factors for postoperative complications. Patients undergoing major surgery for upper gastrointestinal cancer experienced twice the rate of complications compared to those undergoing other procedures (224/578 patients [38.8%] versus 274/1561 patients [17.6%]). Conclusions: Complications and death are common after upper gastrointestinal surgery. Patients undergoing major surgery for cancer are at greatest risk.

Background. The incidence and impact of postoperative complications are poorly described. Failure-to-rescue, the rate of death following complications, is an important quality measure for perioperative care but has not been investigated across multiple health care systems. Methods. We analysed data collected during the International Surgical Outcomes Study, an international 7-day cohort study of adults undergoing elective inpatient surgery. Hospitals were ranked by quintiles according to surgical procedural volume (Q1 lowest to Q5 highest). For each quintile we assessed in-hospital complications rates, mortality, and failure-to-rescue. We repeated this analysis ranking hospitals by risk-adjusted complication rates (Q1 lowest to Q5 highest). Results. A total of 44 814 patients from 474 hospitals in 27 low-, middle-, and high-income countries were available for analysis. Of these, 7508 (17%) developed one or more postoperative complication, with 207 deaths in hospital (0.5%), giving an overall failure-to-rescue rate of 2.8%. When hospitals were ranked in quintiles by procedural volume, we identified a threefold variation in mortality (Q1: 0.6% vs Q5: 0.2%) and a twofold variation in failure-to-rescue (Q1: 3.6% vs Q5: 1.7%). Ranking hospitals in quintiles by risk-adjusted complication rate further confirmed the presence of important variations in failureto-rescue, indicating differences between hospitals in the risk of death among patients after they develop complications. Conclusions. Comparison of failure-to-rescue rates across health care systems suggests the presence of preventable postoperative deaths. Using such metrics, developing nations could benefit from a data-driven approach to quality improvement, which has proved effective in high-income countries.