White Michelle C, Randall Kirsten, Ravelojaona Vaonandianina A, Andriamanjato Hery H, Andean Vanessa, Callahan James, Shrime Mark G, Russ Stephanie, Leather Andrew J M, Sevdalis Nick
Centre for Global Health and Health Partnerships, King's College London, London, UK.
Department of Medical Capcity Building, Mercy Ships Africa Bureau, Cotonou, Benin.
BMJ Glob Health. 2018 Dec 20;3(6):e001104. doi: 10.1136/bmjgh-2018-001104. eCollection 2018.
The WHO Surgical Safety Checklist reduces postoperative complications by up to 50% with the biggest gains in low-income and middle-income countries (LMICs). However in LMICs, checklist use is sporadic and widespread implementation has hitherto been unsuccessful. In 2015/2016, we partnered with the Madagascar Ministry of Health to undertake nationwide implementation of the checklist. We report a longitudinal evaluation of checklist use at 12-18 months postimplementation.
Hospitals were identified from the original cohort using purposive sampling. Using a concurrent triangulation mixed-methods design, the primary outcome was self-reported checklist use. Secondary outcomes included use of basic safety processes, assessment of team behaviour, predictors of checklist use, impact on individuals and organisational culture and identification of barriers. Data were collected during 1-day hospital visits using validated questionnaires, WHO Behaviourally Adjusted Rating Scale (WHOBARS) assessment tool and focus groups and analysed using descriptive statistics, multivariate linear regression and thematic analysis.
175 individuals from 14 hospitals participated. 74% reported sustained checklist use after 15 months. Mean WHOBARS scores were high, indicating good team engagement. Sustained checklist use was associated with an improved overall understanding of patient safety but not with WHOBARS, hospital size or surgical volume. 87% reported improved understanding of patient safety and 83% increased job satisfaction. Thematic analysis identified improvements in hospital culture (teamwork and communication, preparation and organisation, trust and confidence) and hospital practice (pulse oximetry, timing of antibiotic prophylaxis, introduction of a surgical count). Lack of time in an emergency and obstructive leadership were the greatest implementation barriers.
74% of participants reported sustained checklist use 12-18 months following nationwide implementation in Madagascar, with associated improvements in job satisfaction, culture and compliance with safety procedures. Further work is required to examine this implementation model in other countries.
世界卫生组织手术安全核对表可将术后并发症减少多达50%，在低收入和中等收入国家（LMICs）成效最为显著。然而在LMICs，核对表的使用并不稳定，迄今为止广泛实施均未成功。2015/2016年，我们与马达加斯加卫生部合作在全国范围内实施核对表。我们报告了实施后12至18个月核对表使用情况的纵向评估。
采用目的抽样法从原始队列中确定医院。使用并行三角测量混合方法设计，主要结果是自我报告的核对表使用情况。次要结果包括基本安全流程的使用、团队行为评估、核对表使用的预测因素、对个人和组织文化的影响以及障碍识别。在为期1天的医院访视期间，使用经过验证的问卷、世界卫生组织行为调整评分量表（WHOBARS）评估工具和焦点小组收集数据，并使用描述性统计、多元线性回归和主题分析进行分析。
来自14家医院的175人参与。74%的人报告在15个月后持续使用核对表。WHOBARS平均得分较高，表明团队参与度良好。持续使用核对表与对患者安全的总体理解改善相关，但与WHOBARS、医院规模或手术量无关。87%的人报告对患者安全的理解有所改善，83%的人工作满意度提高。主题分析确定了医院文化（团队合作与沟通、准备与组织、信任与信心）和医院实践（脉搏血氧饱和度测定、抗生素预防时机、引入手术清点）方面的改善。紧急情况下时间不足和领导阻碍是最大的实施障碍。
74%的参与者报告在马达加斯加全国实施后12至18个月持续使用核对表，同时工作满意度、文化和安全程序合规性也有相关改善。需要进一步开展工作以在其他国家检验这种实施模式。
