WHO Guidelines for Safe Surgery - Atul Gawande

World Alliance for Patient Safety

WHO Guidelines for Safe Surgery

(First Edition)

The WHO Guidelines for Safe Surgery, First Edition, is intended to be issued as a Second Edition in 2009.

At present it is important for countries and organizations to note that the guidelines represent a consensus of international experts and up to date technical information on safe surgery across the world.

The guidelines are being implemented for testing purposes in several hospitals across the six WHO regions and changes may be made to some of the technical content of the chapters in light of results.

We welcome formal feedback on these guidelines. Feedback is invited using the AGREE methodology

WHO/IER/PSP/2008.08-1E

? World Health Organization 2008

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Table of contents

Section I. Introduction

7

The problem: Complications of surgical care have become a major cause of death and

disability worldwide

8

The Safe Surgery Saves Lives Challenge: Identifying solutions

10

Transformation of risk during anaesthesia

The `time out' or `surgical pause'

Use of a checklist for central line insertion

The Safe Surgery Saves Lives approach

12

Improvement through the Safe Surgery Saves Lives programme

13

Organization of the guidelines

15

Section II. Ten essential objective for safe surgery: Review of the evidence and

recommendations

19

Objective 1: The team will operate on the correct patient at the correct site.

21

The Universal Protocol

Step 1. Verification

Step 2. Marking

Step 3. `Time out'

Recommendations

Objective 2: The team will use methods known to prevent harm from administration of

anaesthetics, while protecting the patient from pain.

27

Patterns of avoidable morbidity and mortality during anaesthesia

Approaches to improving the safety of anaesthesia

Evidence on monitoring with pulse oximetry and capnography

Expert opinion

Controlled trials

Incident reporting

Inference from data on anaesthesia mortality

Other considerations on oximetry and capnography

Conclusion

Preparation for and delivery of anaesthesia

Facilities

Anaesthesia equipment

Gas supplies in anaesthesia

Monitoring

Ancillary equipment and medications

Infrastructure, supplies and care standards

Recommendations

Objective 3: The team will recognize and effectively prepare for life-threatening loss of airway

or respiratory function.

45

Incidence of difficult and failed airway management

Airway assessment

Thyromental distance

Mallampati classification

Management of the airway

Face-mask ventilation

Supraglottic airway ventilation

Endotrachial intubation

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Fibre-optic intubation Aspiration of gastric contents Recommendations

Objective 4: The team will recognize and effectively prepare for risk of high blood loss. 57 Resuscitation of hypovolaemic patients Prevention of blood loss Management of blood loss Recommendations

Objective 5: The team will avoid inducing an allergic or adverse drug reaction for which the

patient is known to be at significant risk.

63

Types of adverse reactions

Causes of error in delivery of perioperative medications

Recommendations

Objective 6: The team will consistently use methods known to minimize the risk for surgical

site infection.

69

Pathogenesis and microbiology

Prevention and surveillance of surgical site infections

Definitions of surgical site infection

Superficial incisional surgical site infection

Deep incisional surgical site infection

Organ?space surgical site infection

Methods of scoring infection

Surveillance of surgical site infections

Inpatients

Post-discharge

Risk factors

Blood glucose and risk of infection

Oxygen tension and temperature in the perioperative period

Presurgical skin disinfection

Alcoholic compounds

Chlorhexidine

Iodophors

Triclosan and chloroxylenol

Octenidine

Special cases for decontamination

Vaginal and uterine surgery

Digestive-tract surgery

Antibiotic prophylaxis

Prophylaxis in children

Subacute bactieral endocarditis prophylaxis in patients undergoing

surgical procedures

Minimizing contamination in the operating room

Guaranteeing sterility of surgical instruments: sterility indicators

Recommendations

Objective 7: The team will prevent inadvertent retention of instruments or sponges in

surgical wounds.

115

General criteria for counting

Sponge count

Sharps count

Instrument count

Documentation of counts

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Count discrepancies Methodical wound exploration before closure Recommendations

Objective 8: The team will secure and accurately identify all surgical specimens.

121

Recommendations

Objective 9: The team will effectively communicate and exchange critical information on the

patient.

123

Team culture and its effects on safety

Patterns of communication breakdown

Reducing communication breakdown during surgery

Use of checklists to improve safety and communication

Record-keeping

Recommendations

Objective 10: Hospitals and public health systems will establish routine surveillance of

surgical capacity, volume and results.

133

Feasibility and implications of measurement

Infrastructure

Economic considerations

Positive incentives

Negative incentives

Case mix and risk adjustment

Current measures in surgery

Volume

Outcome

Capacity

Surgical surveillance: Surgical vital statistics for systems-level evaluation

Basic surgical vital statistics

The number of operating rooms in each country

The number of surgical procedures performed in operating rooms in

each country

The numbers of trained surgeons and trained anaesthesia

professionals in each country

Number of deaths on the day of surgery

Number of in-hospital deaths after surgery

Intermediate surgical vital statistics

Advanced surgical vital statistics

Surgical surveillance: Basic patient measures at hospital and practitioner

levels

Day-of-surgery and postoperative in-hospital mortality rates

Surgical site infections

The Surgical Apgar Score: a simple outcome score for surgery

Findings from international pilot site

Future directions of surgical surveillance

Recommendations

Summary of Recommendations

151

Section III. WHO Surgical Safety Checklist

153

Section IV. Implementation manual for the WHO Surgical Safety Checklist

157

Authors and contributors

167

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