Our pilot site in Cambodia, WMEH, has the material resources necessary to implement the WHO surgical safety checklist. The staff readily engaged in the communication elements of the checklist, easily adopting new behaviors introduced through checklist implementation. After identification of readily correctable deficiencies such as lack of sterility indicators in surgical trays, the staff were able to quickly adopt specific improvements implemented by hospital management through a defined protocol.
Our experience with data collection demonstrated that there were inconsistencies between subjective perception that a checklist item has been completed and objective verification that the task had been performed. This was seen in confirmation of instrument sterility, peri-procedure sponge counting, and correct surgical site confirmation, suggesting that effective checklist implementation and assurance of perioperative quality of care demand a detailed understanding of the process of care, and not subjective interpretation of compliance. For example, for the question “was a post procedure sponge count performed?” the initial interpretation was whether or not a sponge had been left in the wound. This interpretation led to incongruent affirmative responses, when the count was not performed. Likewise, the question regarding confirmation of instrument sterility was interpreted as asking if the instruments were presumed to be sterile, not if there was objective, visual confirmation of sterility. These seemingly minute question interpretation differences can lead to challenges in accurate data collection and true quality assessment, and highlight the need for data collection tool validation and modification.
Checklist compliance variability arose almost exclusively in processes involving subjective clinical decision making. The timely administration of antibiotics, sponge counting, and site marking were all done inconsistently. Informative for future hospital improvement work, these processes were performed at the subjective discretion of the surgical team. Prophylactic antibiotics administration within 60 min prior to skin incision is recommended for “clean” or “clean-contaminated” cases, which often relies on the surgeon’s clinical assessment. While the clinical determination can be straightforward for some cases, such as orthopedic hardware implants, it can be more subjective for others, such as skin closures and wound management procedures.
These results indicate a need for further work in understanding, categorizing, and improving decision making with these complex perioperative processes and emphasize the importance of objective verification over subjective assessment. Notably, these potential areas for improvement do not require additional material resources, as is often the assumed need in public health issues. While resource constrained, the steady NGO financial support to WMEH provides the resources necessary for providing basic, quality perioperative care.
There are limitations to the study. First, given the perioperative observation by research members, the Hawthorne effect may have had an influence, particularly regarding communication elements such as estimating blood loss and case duration or behavior-based elements like surgical sponge counting. Second, ambiguity in the clinical determination of wound class could have led to inaccuracy in reporting on proper timing of prophylactic antibiotics. For example, all cases documented as “delayed primary closures” were considered to require antibiotics. However, often a small, superficial wound being closed in addition to other “dirty” procedures such as debridement were labeled as a delayed primary closure. Thus, it is possible that compliance with timely antibiotic administration is higher than the data indicate.
Third, the case observation schedule was reliant upon constrained nursing scheduling, and may have introduced a selection bias. The employed data collectors worked during the day and were instructed to preferentially observe “clean” cases if multiple cases were occurring. It is likely this potential bias is small as research team members did observe night cases over one week and observed primarily debridements and closed reductions, cases that do not require strict infection prevention measures. Furthermore, the surgical staff all perform both day and night shifts, so no staff work exclusively during the day or night, potentially biasing checklist habits.
Two questions, operative site marking and team introduction, were removed from the data analysis because of more fundamental issues; site marking was unknown to the surgical team and required separate education and training; thus, we felt it did not fit into an appropriate pattern for data analysis. Team introduction was deemed unnecessary early on in checklist introduction because the surgical team at WMEH is relatively small, and members knew each other well.
Coupling of the perioperative checklist adherence data to patient outcomes measurements has emerged as a focus for future work. There were attempts to record rates of surgical site infections at WMEH using indirect methods of patient chart review. However, data was found to be unreliable due to charting inconsistencies. Ongoing work includes the development and implementation of a robust and accurate infection surveillance program.
This work was conceived as a means to better understand how perioperative safety and infection prevention improvements can be achieved in low-resource settings. We found that lack of material resources was not a significant barrier to quality care at this pilot hospital in Cambodia; rather, checklist items that were open to subjective clinical decision making were the most difficult for surgical teams to perform consistently. Key lessons learned involved the importance of ongoing data collector training and contextually specific data collection tool improvement. Notably, institution-specific protocols and policies are needed to enhance consistency in perioperative tasks involving clinical decision making. Based on the pattern of checklist completion at WMEH, we emphasize the need for an in-depth evaluation of these complex perioperative processes in low-resource settings for improved surgical patient safety.