Randomized clinical trial of the impact of surgical ward-care checklists on postoperative care in a simulated environment

Background: Complications are a common and accepted risk of surgery. Failure to optimize the management of patients who suffer postoperative morbidity may result in poorer surgical outcomes. This study aimed to evaluate a checklist-based tool to improve and standardize care of postoperative complications.

Methods: Surgical trainees conducted baseline ward rounds of three patients with common postoperative complications in a high-fidelity simulated ward environment. Subjects were randomized to intervention or control groups, and final ward rounds were conducted with or without the aid of checklists for management of postoperative complications. Adherence to critical care processes was assessed, in addition to technical (Surgical Ward-care Assessment Tool, SWAT) and non-technical (Ward NOn-TECHnical Skills (W-NOTECHS) scale) performance. Subjects completed a feedback questionnaire regarding their perception of the checklists.

Results: Twenty trainees completed 120 patient assessments. All intervention group subjects opted to use the checklists, resulting in significantly fewer critical errors compared with controls (median (i.q.r.) 0 (0-0) versus 60 (40-73) per cent; P < 0·001). The intervention group demonstrated improved patient management (SWAT-M) (P < 0·001) and non-technical skills (P = 0·043) between baseline and final ward rounds, whereas controls did not (P = 0·571 and P = 0·809 respectively). A small learning effect was seen with improvement in patient assessment (SWAT-A) in both groups (P < 0·001). Intervention group subjects found checklists easy and effective to use, and would want them used for their own care if they were to experience postoperative complications.

Conclusion: Checklist use resulted in significantly improved standardization, evidence-based management of postoperative complications, and quality of ward rounds. Simulation-based piloting aided appropriate use of checklists and staff engagement. Checklists represent a low-cost intervention to reduce rates of failure to rescue and to improve patient care.