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Title: The effect of surgical checklists on the laparoscopic task performance
Author: El Boghdady, Michael
ISNI:       0000 0004 5994 7389
Awarding Body: University of Dundee
Current Institution: University of Dundee
Date of Award: 2016
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Background: Surgical checklists are in use as means to reduce errors for safer surgery. Checklists are infrequently applied during procedures and have been limited to lists of procedural steps as aid memoires. Aims: We aimed to formulate a performance based checklist and to study its effect on the surgical task performance of novice surgeons when applied during both, routine knot tying and simulated emergency laparoscopic tasks. We also aimed to study the effect of the performance based intra-procedural checklist in clinical environments during elective laparoscopic procedures as a way of error reduction mechanism and improvement of patient safety. Methods: The study was conducted in two settings, lab-based and clinical-based environments. The lab-based study was conducted during both routine and emergency tasks. Lab-based study- routine task: Twenty novices were randomised into two equal groups, those receiving paper feedback (control group), and those receiving paper feedback and the checklist that was applied at 20 seconds intervals (checklist group). The task involved performing laparoscopic double knots which were repeated over 5 separate stages. Human reliability assessment technique was used for error analysis on unedited video recordings of the tasks. Endpoints included number of errors, error probability (number of errors/number of knots), error types and number of completed knots. Non-parametric statistics were used for data analysis. Lab-based- emergency task: Thirty consented laparoscopic novices were exposed unexpectedly to a bleeding vessel in a laparoscopic virtual reality simulator as an emergency surgical scenario. The task consisted of using laparoscopic clips to achieve haemostasis. Subjects were randomly allocated into 2 equal groups; those using the checklist (checklist group) and those without (control group). The checklist was applied by the trainees in the checklist group at 20 seconds intervals. The surgical performance was computed on eight predetermined technical factors. Clinical-based study: Surgical trainees in the general surgery at Tayside NHS were included in this study and required the attendance of a trainer during the procedure as per routine practice. Record year of trainees and previous experience on laparoscopic cholecystectomy were noted. Two elective laparoscopic cholecystectomies for each trainee were video-recorded without the use of the checklist, directly followed by 2 further operations after the introduction of the checklist. The unedited videos were analysed for error detection using human reliability analysis technique. Total number of errors per time during each procedure, total number of errors per number of instrument movements, total number of instrument movements per time and number of trainer intervention while per time were noted as assessment points. Results: Lab-based- routine task: 2341 errors were detected in 141 tasks, 408 subtasks and 2249 steps during the 5 stages. During the first stage, the errors were not significantly different between groups. The checklist group committed significantly fewer errors as compared to the control group during all the later 4 stages (p < 0.01). The checklist group had an enhanced learning curve as the last 4 stages showed significant fewer errors compared to the first stage (p < 0.05), while the control group showed no improvement. Error probability was significantly higher in the control group compared to the checklist group: median [IQR] 32.6 [25.89] vs 11.7 [10.72] (p < 0.01). Individual error types during each step of the laparoscopic task were identified. The checklist group performed better with fewer errors for all the error types. While, there was no significant difference in each of 'the lack of supination', 'tissue bite' and 'out of vision'; the differences in all the rest of error types were highly statistically significant (p < 0.01). Number of completed knots was not statistically different between the 2 groups. Lab-based- emergency task: The checklist group performed significantly better in 6 out of 8 technical factors when compared to the control group median [IQR]: Right instrument path length (m) 1.44 [1.22] vs 2.06 [1.70] (p= 0.029), and right instrument angular path (degree) 312.10 [269.44] vs 541.80 [455.16] (p= 0.014), left instrument path length (m) 1.20 [0.60] vs 2.08 [2.02] (p= 0.004), left instrument angular path (degree) 277.62 [132.11] vs 385.88 [428.42] (p= 0.017). The checklist group committed significantly fewer number of errors in the number of badly placed clips (p= 0.035) and number of dropped clips (p= 0.012). Although statistically not significant, total blood loss (lit) decreased in the checklist group from 0.83 [1.23] to 0.78 [0.28] (p= 0.724), and total time (sec) from 186.51 [145.69] to 125.14 [101.46] (p=0.165). Clinical-based study: Participants performed statistically better with fewer number of errors per time with the application of the checklist compared to when no checklist was used respectively: Median [IQR] total number of errors 1.51 [0.80] vs 3.84 [1.42] (p=0.002), consequential errors 0.20 [0.12] vs 0.45 [0.42] (P=0.005), inconsequential errors 1.32 [0.75] vs 3.27 [1.48] (p=0.006) and total number of errors per number of instrument movements 0.16 [0.04] vs 0.29 [0.16] (p= 0.003). With the introduction of the checklist, the number of interventions by the trainer per time decreased from 2.79 [1.85] to 0.43 [1.208] (p=0.003) and the number of instrument movements per time decreased from 11.90 [5.34] to 10.38 [5.16] (p=0.04). Conclusions: We have developed standardised checklists to be applied during elective and emergency laparoscopic tasks. The performance based self-administered intra-procedural checklist had a significant accelerating effect on the acquisition of technical skills when applied by novices during a standardised laparoscopic lab-based routine task and improved the task performance during a simulated laparoscopic emergency scenario. The checklist enhanced the performance of surgical trainees and decreased the number of interventions of the trainer during laparoscopic cholecystectomy.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (M.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available
Keywords: Checklist ; Task performance ; Training and education ; Laparoscopic ; Surgery