Table 1.
Summary of literature review
| Citations | N | Study location | Type of Surgery | Checklist used | Population | Impact of checklist |
|---|---|---|---|---|---|---|
| Moore et al. 2022 [9] | Before checklist: 9475 18 months after: 10,589 9 years after 57,577 | Auckland City Hospital, New Zealand | Majority MSK: 27%, GI: 25%, Urinary: 12% Neurological: 11%, Cardiovascular: 10%, Derm and plastics: 6%, Male genital organs: 5%, Other: 5% | WHO surgical safety checklist | Adult | Mean number of days alive and out of hospital after checklist implementation was 1.0 (0.4–1.6) days longer than in the cohort preceding implementation. 90-day mortality was 4% before and 3% after SSC, not statistically significant |
| Healey et al. 2022 [10] | 3702, control: 1398, checklist: 2304 | Norway | Orthopedic: 61.5%, thoracic: 18.5%, Neuro: 20%. 53.1% elective and 46.9% emergency. General anesthesia in 59.3% and regional in 40.7% | WHO surgical safety checklist | Adult | Implementation of the WHO checklist resulted in an additional 5.9 complication-free admissions per 100 admissions |
| Wurdeman et al. 2022 [11] | 1341 | Tanzania, 20 facilities in Lake Zone | Cesarian section | WHO surgical safety checklist | Adult women | Higher SSC adherence was associated with lower rates of maternal sepsis: < 25% adherence: 5.0%; > 75% adherence: 0.7%. Adjusted OR of 0.17 per percentage point increase in SSC adherence. Wound class significantly associated with maternal sepsis: Clean-Contaminated 3.7% vs Contaminated/Dirty 20% |
| de Almeida et al. 2021 [12] | 1025, 486 before implementation and 539 after implementation | Brazil | Elective and acute surgery | WHO surgical safety checklist | Adult | Significant reduction in SSI, OR 0.33. Reduction of SSI for contaminated and infected wounds, and for those in whom antimicrobial prophylaxis was discontinued < 48 h. Reduced antimicrobial resistance. Reduction in hospital deaths 6.4% to 3.2% |
| Ngonzi et al. 2021 [13] | 678 (pre-intervention: 200, intervention: 230, post-intervention: 248) | Uganda, referral hospital | Cesarian section | WHO surgical safety checklist | Adult women | Pre-intervention antibiotic use was 18% versus 90% in intervention phase and 84% post-intervention phase. SSI rate in the pre-intervention phase was 15% versus 7% in intervention phase and 11% post-intervention |
| Storesund et al. 2020 [14] | checklist: 9009, controls: 9678 | Norway, tertiary hospital | Control: 16.3%, neurosurgery, 46.9% orthopedics, 36.7% gynecology. Regional: 33.7%, general: 66.3%. Checklist: 37.2%, neurosurgery, 51.0% orthopedics, 11.8% gynecology. Regional: 35.1%, general: 64.9% | Adapted WHO surgical safety checklist (preoperative and postoperative checklists) | All ages | Reductions in complications with OR 0.70 and emergency reoperations with OR 0.42. Reduced readmissions, OR 0.32. No changes in mortality or LOS. Overall increased complications for parallel controls |
| Yu et al. 2020 [15] | 1072 (checklist: 556, control: 526) | China, tertiary referral hospital | Surgery for gastric cancer | Perioperative Safety Checklist for Gastric Cancer (designed by researchers) | Adult | Reduction in postop intestinal fistula formation, unplanned secondary surgery, and total hospitalization expenses. Intraoperative blood loss in the complete and partial implementation groups significantly lower than in no implementation group, hospitalization cost showed an opposite trend |
| Chhabra et al. 2019 [16] | Control: 250, Checklist: 250 | India | Urology, breast, gall bladder, hernia stoma reversal, anorectal malformations, other abdominal and thyroid surgeries | WHO surgical safety checklist | All ages | Major wound disruption: 10.8% control and 5.2% checklist group. Control group 29.2% SSI vs 13.6% in checklist group. 2% patients in the control group developed sepsis while no patients in the checklist group did |
| de Jager et al. 2019 [17] | 21,306 | Australia, tertiary hospital | Variety of procedures. Both general and regional anesthesia | WHO surgical safety checklist | All ages | Postoperative mortality rates decreased from 1.2 to 0.92% OR 0.74, and length of admission decreased from 5.2 to 4.7 days. Reduction in mortality reached significance after 2–3 years. Independent of surgery duration |
| Gama et al. 2019 [18] | Brazil: 518 (control: 171, SSC: 347), Canada: 842 (control: 177, SSC: 665) | Canada and Brazil, university hospitals | Elective and urgent | Altered WHO surgical safety checklist (by each institution) | Adult | SSI rate decreased from 27.7%-25.9% in Canada and from 17.0%-14.4% in Brazil, not statistically significant. In Canada, no SSI in incomplete SSC and in Brazil 20% SSI in incomplete SSC, statistically significant difference |
| GlobalSurg Collaborative 2019 [19] | 4843 | 76 countries | Emergency laparotomy | WHO surgical safety checklist | All ages | SSC associated with a lower 30-day perioperative mortality with OR 0·60, statistically significant. Greatest absolute benefit for emergency surgery in low- and middle-HDI countries |
| Haugen et al. 2019 [20] | 3702 (control: 1398, SSC: 2304) | Norway | Control: orthopedic 51.6%, thoracic 21.0%, neuro 27.5%, elective 49.6%, emergency 50.4%. SSC: orthopedic 67.6%, thoracic 17.0%, neuro 15.4%, elective 55.3%, emergency 44.7% | WHO SSC | All ages | SSI decreased from 7.4% to 3.6% (OR 0.52). Antibiotics post incision decreased 12.5 to 9.8%, pre-incision increase from 54.5 to 63.1% and non-administration decreased 33% to 27.1%. Blood transfusion costs reduced by 40% |
| Ramsay et al. 2019 [21] | 6,839,736 | Scotland | General surgery: pre-SSC 34.3%, SSC 31.7%, post-SSC 32.7%. Orthopedics: pre-SSC 15.3%, SSC 17.5%, post-SSC 17.6%. Other: pre-SSC 50.4%, SSC 50.8%, post-SSC 49.7%. Non-elective: pre-SSC 23.6%, SSC 18.8%, post-SSC 17.4% | WHO surgical safety checklist | All ages | Before SSC, inpatient mortality rate was 0.76%, after it was 0.46%. SSC associated with 36.6% reduction in mortality. Before, SSC mortality rates were decreasing by 0.003% per year, during implementation annual decrease was 0.069% and after 0.019% |
| Wang et al. 2019 [22] | 7209 (SSC: 3971, control: 3238) | China | Elective surgery to remove GI tumor: partial/ total gastrectomy, right/left hemicolectomy, Dixon, Hartmann, Miles, small bowel resection. General anesthesia 58.34% control and 79.93% SSC | WHO surgical safety checklist | Age > 16 yrs | The rates of morbidity and in-hospital mortality before and after SSC implementation were 16.43% vs 14.33% and 0.46% vs 0.18% respectively. Postoperative hospital stay in SSC group was shorter than that in control group (8 vs 9 days). SSC was an independent factor influencing postoperative complications (OR = 0.860) |
| Anderson et al. 2018 [23] | 591 | United States, children's hospital | Pediatric surgery (burn dental, fetal, GI, OMFS, pulmonology and transplant surgeries) | WHO SSC | Pediatric | 19% cases had 1 or more intraoperative delay (majority due to missing/malfunctioning equipment). No difference in adherence but increased fidelity for cases without delay (80.5% vs 77.1%) |
| Rodella et al. 2018 [24] | 1,166,424 | Italy, 48 public hospitals | MSK: 20.4–22.2%, GI: 9.3–11.6%, Ob/gyn: 7.3–8.8%, urinary: 6.9–7.9% | WHO surgical safety checklist | All ages | Statistically significant differences between surgical interventions performed in hospitals with higher adherence to the checklist and in other hospitals with 30-days readmissions rate OR: 0.96 and LOS ⩾ 8 days rate (OR: 0.88). No association with mortality, |
| Schmitt et al. 2018 [25] | 80 (SSC: 40, control: 40) | Germany | OMFS procedures: routine dental extractions and biopsies, multiple extractions and osteotomies, routine/multiple implant placement and complicated implant placement and bone graft | Adapted WHO SSC (created by institution) | All ages | Statistically significantly higher frequency of incidents without the use of the checklist (n = 43) than with the use of the checklist (n = 10) |
| Shankar et al. 2018 [26] | 1778 | India, teaching hospital | Majority cases Ob/Gyn (223), general (226) and orthopedics (137). Some plastic surgery, pediatric surgery, urology, neurosurgery, dental. General anesthesia (626) and regional anesthesia (1152) | WHO surgical safety checklist | All ages | 4.1% surgeries had complications with more than half being surgical wound infections. All patients received prophylactic antibiotics, SSC identified a deficit and corrected it in 27 patients |
| Westman et al. 2018 [27] | 4678 | Finland | Neurosurgery | WHO surgical safety checklist | All ages | Time from operation to infection shorter before than after checklist, effect in the onset of early HAIs. Overall incidence of SSIs of all patients did not differ at 4.1% vs 4.5%. No differences in superficial SSIs, deep SSIs, and deep organ SSIs |
| Haynes et al. 2017 [28] | 22,514 | United States, 14 hospitals (rural and urban, most were not teaching hospitals) | Adult inpatient surgery, obstetric excluded. Neurosurgery, head and neck, thoracic, cardiac, GI/abdominal, urology, gyn, ortho, vascular, skin/soft tissue | Adapted WHO SSC | Adult | Risk-adjusted 30-day mortality among SSC hospitals was 3.38% before SSC and 2.84% after, while mortality at other hospitals was 3.50% and 3.71% in those same years. There is a 22% difference between the groups on DID analysis |
| Naidoo et al. 2017 [29] | 3785 | South Africa, 18 hospitals in public health sector | Maternal surgery consisting of CDs, laparotomies for ectopic pregnancies, uterine evacuations, removal of placentas and unplanned returns to OR | Modified World Health Organization surgical safety checklist for maternity care (MSSCL) | Adult | Significant improvements per 1000 patients in adverse incident rates (IRR 0.805), post op sepsis (IRR 0.619) and unscheduled return to OR (IRR 0.719). Greater reductions in maternal mortality in hospitals implementing MSSCL |
| Anwer et al. 2016 [30] | 3638 | Pakistan | Elective surgery | WHO SSC | All ages | SSI in laparoscopic cholecystectomies was 20.8%, 13%, 5.68% and 1.12% in 1st, 2nd, 3rd and 4th year respectively as SSC use progressively increased from 20.4% to 89.9% |
| Lacassie et al. 2016 [31] | 58,500 | Chile | Emergency in 22.7% control and 23.5% SSC | WHO SSC | Age > 15yrs | Mortality in hospital decreased from 0.82% before SSC to 0.65% after (OR 0.73). LOS also decreased from 3 days before to 2 days after |
| García-París et al. 2015 [32] | 134, control: 100, SSC: 34 | Spain | Podiatric surgery: nail/skin surgery (66.4%), osteoarticular surgeries with implants (23.1%), osteoarticular surgeries without implants (10.4%) | WHO SSC | All ages | Statistically significant relationship between correct use of antibiotic prophylaxis and SSC use, reduction in LOS |
| Toor et al. 2015 [33] | 613, control: 303, SSC: 310 | United States | Similar rates for both control and SSC. Largest group was GI, 45 and 40%. Some hepatobiliary, gyn, urology, breast, skin cases | WHO SSC | All ages | Optimal administration of antibiotic increased from 37.6 to 91% with SSC. Post-op infections decreased from 32.7 to 15.2%. LOS reduced from 7.8 to 6.5 mean |
| Baradaran Binazir et al. 2015 [34] | Iran | Modified WHO SSC | All ages | Complications pre-checklist 30% vs 12% post. Complications decreased by 58% | ||
| Kim et al. 2015 [35] | Long term follow up: 637, Short term follow up: 2106 | Moldova, state general and trauma referral hospital | Similar cases for short and long term. Majority non-urgent, regional anesthesia, largest group general surgery (38.9% short vs 44.7% long term). Some OMFS, OB/Gyn, orthopedics, neurosurgery | WHO SSC, also implemented widespread use of pulse oximetry | All ages | Complication rate decreased 30.7%, SSI decreased 40.4%. Rate of hypoxemic events also decreased |
| Lepänluoma et al. 2015 [36] | 175, control: 103, SSC: 72 | Finland | Neurosurgery | WHO SSC | Adult | Preventable complication requiring reoperations decreased from 3.3 to 2%. Mainly due to infection, 46% before and 39% after checklist. Infection related reoperations were 2.5% before vs 1.6% after. Adherence to checklist 78% |
| Helmiö et al. 2015 [37] | 223 | Finland, tertiary, central, local and primary hospitals | ENT, 6.3% urgent | n/a | All ages | 9.6% error in checklist item, 4.8% of injuries could have been prevented with properly used checklist |
| Biskup et al. 2016 [38] | Control: 2166, SSC:2310 | United States | Plastics: 22% inpatient, 78% outpatient, 22% hand, 21% breast, 18% tegumentary, 13.5% head and neck, 10% aesthetic, 8% head & neck, 5% trunk, 1.5% micro, 1% LE | Modified WHO SSC (by surgeons at Loma Linda University Medical Center) | All ages | No significant decrease in complications (total or specific) for plastic surgery, found need for a more specific checklist |
| Chaudhary et al. 2015 [39] | 700, Control: 264, SSC: 271 | India | GI surgery | WHO SSC with preoperative imaging and postoperative DVT modifications | Age > 16yrs | Wound related, abdominal, and bleeding complications lower with checklist. High grade complications and mortality reduced. Number of complications per patient was higher for those with incomplete checklists than fully completed |
| Haugen et al. 2015 [40] | 5295, control: 1305, SSC: 1671 | Norway | Similar case distribution for control and SSC. Majority elective cases. Largest group was orthopedics (control 32.7%, SSC 55.3%). Other cases: thoracic, neurosurgery, general, urology | All ages | Complication rates decreased from 19.9% to 11.5%, absolute risk reduction 8.4. SSC effect on complications significant with OR 1.95 even with adjustments for confounding factors. LOS decreased by 0.8. Mortality in hospital decreased from 1.9% to 0.2% in 1 out of 2 hospitals but overall, not significant | |
| Urbach et al. 2014 [41] | Control: 109,341, SSC: 106,370 | Canada, all acute care hospitals in Ontario | Similar case distribution for both groups. Vast majority elective, majority outpatient. Mix of neuro, eye, ear, ENT, respiratory, CV, lymphatic, GI, GU, MSK, skin and breast | CPSI, own design, WHO SSC | All ages | No significant reduction in mortality or complications. Risk of death 0.71% before SSC, 0.65% after. Risk of complications 3.86% before, 3.82% after implementation |
| Boaz et al. 2014 [42] | 760, Control: 380, SSC:380 | Israel | Orthopedic | WHO SSC | Adult | Postoperative fever in 5.3% with vs 10.6% without checklist. 34% decrease in the rate of surgical wound infection after SSC |
| Lepänluoma et al. 2013 [43] | Control: 83, SSC: 67 | Finland | Neurosurgery | WHO SSC | Adult | Unplanned readmissions 25% vs 10% after checklist. Wound complications decreased from 19 to 8%. Consistency of documentation improved |
| Kwok et al. 2013 [44] | Control: 2145, SSC: 2212 | Moldova | General surgery, gynecology, neurosurgery, ophthalmology and oral-maxillofacial surgery, orthopedics. Control: urgent 50.5%, SSC: urgent 46.8% | WHO SSC | All ages | Complication rate decreased from 21.5 to 8.8%, infectious complications decreased from 17.7 to 6.7% and non-infectious from 2.6 to 1.5%, hypoxemic episodes decreased from 11.5 to 6.4% |
| Lubbeke et al. 2013 [45] | Control: 609, SSC: 1818 | Switzerland, tertiary hospital | Control: 53% elective, SSC: 52% elective | WHO SSC (French version) | Adult | Unplanned return to OR in 7.4% before vs 6.0% after, RR 0.82; reoperation for SSI in 3.0% before vs 1.7% after, RR 0.56; unplanned admission to ICU in 2.8% before vs 2.6% after, RR 0.90; in-hospital death in 4.3% before vs 5.9% after, RR 1.44. Checklist use during 77 cases prevented 1 reoperation for SSI |
| Tillman et al. 2013 [46] | Control: 10,126, SSC: 9676 | United States | Cardiac, colorectal, general, gyn, thoracic, vascular, orthopedic | WHO SSC (Scott and White version) | All ages | Significant reduction in patients with post-anesthesia care unit temperature < 98.6°F from 9.7% to 6.9%. SSI rates decreased from 3.13% to 2.96% overall, not significant. SSI rates similar for all services except colorectal surgery (24.1% vs 11.5%) |
| Rosenberg et al. 2012 [47] | Control: 212, SSC: 180 | United States | Plastic surgery | Office-based surgical checklist (based on WHO SSC) | All ages | Total number of complications per 100 patients decreased from 15.1 to 2.72, absolute risk reduction 12.4. Site marking increased from 69.9% to 97.8%, complications decreased from 11.9 to 2.72% |
| Bliss et al. 2012 [48] | Control: 246, SSC: 73 | United States | Elective cases | WHO SSC | Adult | 30-day morbidity: reduction in adverse event rates—23.6% for control, 15.9% for team training, 8.2% for checklist use |
| van Klei et al. 2012 [49] | Total participants: 25,513; SSC: 11,151 | Netherlands | Similar rates. Most frequent: 16.6% control vs 17% SSC emergency surgery, 18.3% control vs 17.3% SSC general surgery. Some CT surgery, neurosurgery, ENT, orthopedic, gynecology, plastics, vascular, eye surgery, dental and urology | WHO SSC | Adult | Mortality decreased from 3.13 to 2.85% (OR 0.85) and related to checklist compliance. Full compliance association is 0.44 while association is 1.09 and 1.16 for partial and noncompliance |
| Yuan et al. 2012 [50] | Control: 232, SSC: 249 | Liberia, 2 hospitals |
Similar anesthesia for both groups. Majority general anesthesia (62.4% control, 54.6% SSC), some spinal, local, and conscious sedation Control: 24.8% emergency general, 33.9% emergency OB, 29.1% other general, 12.2% other OB. SSC: 14.5% emergency general, 45.2% emergent OB, 21.8% other general, 18.5% other OB |
WHO SSC | Adult | Introduction of checklist was significantly associated with reduced surgical site infections (adjusted OR: 0.28) and a reduced surgical complication (adjusted OR: 0.45). Association was significant only for Hospital 2 (OR: 0.12 and 0.35) and not for Hospital 1 (OR: 0.74 and 0.75) |