Introduction
Methods
Protocol and registration
Search criteria
Eligibility criteria
Data extraction and analysis
Quality
Results
Search results
Author/year/country (developed nations bolded) | Study Design | Length of review | Sample size | Type of procedures included/excluded | Type of Intervention | Outcome measures | Pre/post, %, P value, [% change if significant] |
---|---|---|---|---|---|---|---|
Askarian et al. (2011), Iran [43] | Prospective cohort | Pre: 3 months Post: 3 months | 294 | Elective general surgery > 16 years |
Total complications
|
Pre: 22.9, Post: 10
p = 0.03 [-56]
| |
SSI | Pre: 10.4, Post: 5.3 p = 0.1 | ||||||
Pneumonia | Pre: 7.6, Post: 3.3 p = 0.1 | ||||||
Acute renal failure | Pre: 4.9, Post: 2.0 p = 0.17 | ||||||
Baradaran et al. (2015), Iran [44] | Prospective cohort | NR | 200 | Elective general surgery > 16 years/end stage & immunocompromised patients |
Any complication
|
Pre: 30, Post 12
p = 0.002 [-60]
| |
Unplanned readmission to the OT
|
Pre: 9, Post: 2,
p = 0.03 [-67]
| ||||||
SSI | Pre: 13, Post: 7 p = 0.157 | ||||||
Pneumonia | Pre: 8, Post: 3 p = 0.121 | ||||||
Biskup et al. (2015), United states of America [25] | Retrospective cohort | Pre: 39 months Post: 39 months | 4476 | Plastic surgery | Total complications | Pre: 5.95, Post: 5.75 p = 0.799 | |
Mortality | Pre: 0.05, Post: 0.04 p = 0.549 | ||||||
Infection | Pre: 1.75, Post: 2.29 p = 0.206 | ||||||
Wound dehiscence | Pre: 1.20, Post: 1.47 p = 0.439 | ||||||
Respiratory failure | Pre: 0.09, Post: 0.04 p = 0.613 | ||||||
Pneumonia | Pre: 0.05, Post: 0 p = 0.484 | ||||||
Bliss et al. (2012), Unites states of America [33] | Pre: Retrospective historical control Post: Prospective cohort | 32 months | 2398 | Specific high risk electively scheduled procedures, > 18 years/traumatic injuries | Three session team training program |
Any adverse event
|
Pre: 23.6, Post: 8.2
p = 0.000 [-65]
|
Infectious | Pre: 11.1, Post: 6.8 p = 0.514 | ||||||
Sepsis | Pre: 2.5, Post: 2.7 p = 0.355 | ||||||
Septic shock | Pre: 2.3, Post: 0 p = 0.411 | ||||||
SSI | Pre: 6.2, Post: 5.5 p = 0.845 | ||||||
Pneumonia | Pre: 2.4, Post: 0 p = 0.362 | ||||||
All pulmonary events | Pre: 6.1, Post: 0 p = 0.087 | ||||||
All cardiac events | Pre: 1.9, Post: 0 p = 0.124 | ||||||
Acute renal failure
|
Pre: 0.4, Post: 0
p = 0.045 [-100]
| ||||||
Bleeding | Pre: 6.1, Post: 2.7 p = 0.392 | ||||||
Surgical wound disruption | Pre: 0.5, Post: 0 p = 0.325 | ||||||
DVT/PE | Pre: 0.7, Post: 0 p = 0.074 | ||||||
Ventilator use > 48 h | Pre: 3, Post: 0 p = 0.311 | ||||||
Boaz et al. (2014), Israel [35] | Retrospective review | Pre: 6 months Post: 6 months | 760 | Adult Orthopaedics |
Mortality
|
Pre: 0.8, Post: 2.7
p = 0.049 [
+238]
| |
Total complications
|
Pre 25.9 Post 18.9
p = 0.02 [-27]
| ||||||
Length of hospital stay | Pre: 7.3 Post 7.4 p = 0.132 | ||||||
Septic shock | Pre: 0, Post: 0.3 p = 0.316 | ||||||
SIRS | Pre 0.5, Post 0.3 p = 0.564 | ||||||
SSI | Pre: 3.2, Post: 2.1 p = 0.368 | ||||||
Post operative fever
|
Pre: 10.6, Post: 5.3
p = 0.008 [-50]
| ||||||
Wound infections at discharge
|
Pre: 0.3, Post: 2.4
p = 0.01 [+700]
| ||||||
Chaudhary et al. (2015), India [26] | Randomised control trial | 13 months | 700 | Gastroenterology > 16 years |
Mortality
|
Pre: 10, Post: 5.7
p = 0.004 [-43]
| |
Complications per patient | Pre: 0.97, Post: 0.8 p = 0.06 | ||||||
High grade complications per patient
|
Pre: 0.33, Post: 0.23
p = 0.004 [-30]
| ||||||
Total complication rate | Pre: 52, Post: 46 p = 0.15 | ||||||
Sepsis | Pre: 30, Post: 26 p = 0.31 | ||||||
Wound related
|
Pre: 8.5, Post: 4.5
p = 0.04 [-47]
| ||||||
Respiratory complication | Pre: 3.7, Post: 4 p = 1 | ||||||
Cardiac complication | Pre: 2.5, Post: 3.4 p = 0.65 | ||||||
Renal complication | Pre: 2.2, Post: 0.5 p = 0.1 | ||||||
Abdominal complication
|
Pre: 28, Post: 19.7
p = 0.01 [-30]
| ||||||
Bleeding
|
Pre: 2.8, Post: 0.5
p = 0.03 [-82]
| ||||||
Length of hospital stay | Pre and Post = 9 days p = 0.54 | ||||||
Haughen et al. (2015), Norway [23] | Stepped wedge randomised control trial | 10 months | 5295 | Cardiothoracic, neurosurgery, orthopaedic, general & urological | Educational program with standardised lectures and information materials. | Mortality | Pre: 1.6, Post: 1 p = 0.151 |
Any complication
|
Pre: 19.9, Post: 11.5
p = 0.001 [-42]
| ||||||
Unplanned readmission to theatre
|
Pre: 1.7, Post: 0.6
p < 0.001 [-65]
| ||||||
Infectious complications
|
Pre: 6, Post: 3.4
p < 0.001 [-43]
| ||||||
Sepsis | Pre: 0.6, Post: 0.3 p = 0.075 | ||||||
SSI | Pre: 2.2, Post: 1.5 p = 0.149 | ||||||
Pneumonia
|
Pre: 3.7, Post: 1.9
p < 0.001 [-48]
| ||||||
Respiratory complication
|
Pre: 6.4, Post: 3.2
p < 0.001 [-50]
| ||||||
Cardiac complication
|
Pre: 6.4, Post: 4.3
p < 0.004 [-33]
| ||||||
Bleeding
|
Pre: 2.3, Post: 1.2
p < 0.008 [-48]
| ||||||
Anaesthetic complication | Pre: 0.3, Post: 0.2 p = 0.772 | ||||||
Embolism | Pre: 0.5, Post: 0.2 p = 0.092 | ||||||
Hayes et al. (2009), Multinational [38] | Pre: Retrospective historical control Post: Prospective cohort | Pre: 3 months Post: 3 months | 7688 | Local study team introduced the checklist using lectures, written materials and direct guidance. |
Total Mortality
|
Pre: 1.5, Post: 0.8
p = 0.003 [-47]
| |
Any complication
|
Pre: 11, Post: 7
p < 0.001 [-36]
| ||||||
SSI
|
Pre: 6.2, Post: 3.4
p < 0.001 [-45]
| ||||||
Unplanned return to OT
|
Pre: 2.4, Post: 1.8
p = 0.047 [-25]
| ||||||
Pneumonia | Pre: 1.1, Post: 1.3 p = 0.46 | ||||||
India, United states of America, Tanzania, Canada, New Zealand
| No statistically significant changes | ||||||
Jordan
| |||||||
Mortality
|
Pre: 1, Post: 0
p < 0.05 [-100]
| ||||||
Any complication
|
Pre: 11.6, Post: 7
p < 0.05 [-40]
| ||||||
SSI
|
Pre: 4, Post: 2
p < 0.05 [-50]
| ||||||
Unplanned return to OT
|
Pre: 4.6, Post: 1.8
p < 0.05 [-61]
| ||||||
Pneumonia | Pre: 0.8, Post: 1.2 P > 0.05 | ||||||
Philippines
| |||||||
Mortality
|
Pre: 1.4, Post: 0
p < 0.05 [-100]
| ||||||
Any complication
|
Pre: 21.4, Post: 5.5
p < 0.05 [-74]
| ||||||
SSI
|
Pre: 20.5, Post: 3.6
p < 0.05
[-82]
| ||||||
Unplanned return to OT | Pre: 1.4, Post: 1.8 P > 0.05 | ||||||
Pneumonia | Pre: 0.3, Post: 0 P > 0.05 | ||||||
England
| |||||||
Mortality | Pre: 2.1, Post: 1.7 P > 0.05 | ||||||
Any complication
|
Pre: 12.4, Post: 8.0
p < 0.05 [-35]
| ||||||
SSI
|
Pre: 9.5, Post: 5.8
p < 0.05 [-38]
| ||||||
Unplanned return to OT
|
Pre: 1.3, Post: 0.2
p < 0.05 [-84]
| ||||||
Pneumonia | Pre: 1, Post: 1.7 p > 0.05 | ||||||
Jammer et al. (2015), 28 European nations [51] | Prospective cohort | 7 days | 45,591 from 426 sites | Non-cardiac surgery > 16 years | No clear relationship between patterns of checklist use and mortality rates in individual countries | ||
Crude mortality | Pre: NR, Post: NR p = 0.002 | ||||||
→ Adjusting for confounders |
p < 0.06 | ||||||
Lepatuma et al. (2013), Finland [36] | Pre: Retrospective historical control Post: Prospective cohort | Pre: 6 wks Post: 6 wks | 150 | Neurosurgery, > 18 years | Total complication | Pre: 58, Post: 46 p = 0.16 | |
All unplanned readmissions (ICU, OT, hospital 30 days)
|
Pre: 25.3, Post: 10.4
p = 0.02 [-58]
| ||||||
Readmission to operating room | Pre: 19.3, Post: 9 p = 0.076 | ||||||
Infectious | Pre: 13.3, Post: 13.4 p = 0.94 | ||||||
SSI | Pre: 9.6, Post: 4.5 p = 0.347 | ||||||
Pneumonia | Pre: 4.8, Post: 3 p = 0.69 | ||||||
Bleeding | Pre: 14.5, Post: 11.9 p = 0.652 | ||||||
Wound dehiscence | Pre: 3.6, Post: 0 p = 0.254 | ||||||
DVT | Pre: 1.2, Post: 0 p = 1 | ||||||
Mechanical ventilation > 48 h | Pre: 10.8, Post: 7.5 p = 0.479 | ||||||
Wound combined
|
Pre: 19.3, Post: 7.5
p = 0.038 [−61]
| ||||||
Duration of hospital stay (Days) | Pre 6.65, Post 6.76 p = 0.46 | ||||||
Prospective cohort | Pre: 3 months Post: 3 months immediate 3 months 1 year after 3 months 2 years after | 2427 | High risk surgical patients > 16 years, ASA 3-5/emergency, gynaecological & obstetric surgery, ambulatory surgery & minor urological surgery | Baseline to post combined | |||
Unplanned return to OT | Pre: 7.4, Post: 6 RR = 0.82 CI(0.59-1.14) | ||||||
Unplanned return to OT for SSI
|
Pre: 3, Post: 1.7 RR = 0.56 CI(0.32-1)
[-43]
| ||||||
Unplanned readmission to ICU | Pre: 2.8, Post: 2.6 RR = 0.9 CI(0.52-1.55) | ||||||
In hospital mortality | Pre: 4.3, Post: 5.9 RR = 1.44 CI(0.97-2.14) | ||||||
Baseline to post period 1 | |||||||
Unplanned return to OT | Pre: 7.4, Post: 5.8 p = NR | ||||||
Unplanned return to OT for SSI
|
Pre: 3, Post: 1.6
p = NR
| ||||||
Unplanned readmission to ICU | Pre: 2.8, Post: 3.1 p = NR | ||||||
In hospital mortality
|
Pre: 4.3, Post: 7.4
p = NR
| ||||||
Baseline to post period 2 | |||||||
Unplanned return to OT | Pre: 7.4, Post: 6.3 p = NR | ||||||
Unplanned return to OT for SSI
|
Pre: 3, Post: 1.6
p = NR
| ||||||
Unplanned readmission to ICU | Pre: 2.8, Post: 2.3 p = NR | ||||||
In hospital mortality | Pre: 4.3, Post: 4.8 p = NR | ||||||
Baseline to post period 3 | |||||||
Unplanned return to OT | Pre: 7.4, Post: 5.9 p = NR | ||||||
Unplanned return to OT for SSI
|
Pre: 3, Post: 1.7
p = NR
| ||||||
Unplanned readmission to ICU | Pre: 2.8, Post: 2.5 p = NR | ||||||
In hospital mortality | Pre: 4.3, Post: 5.6 p = NR | ||||||
Mayer et al. (2015), United Kingdom [37] | Retrospective review | 14 months | 6714 | General, urological, orthopaedic elective & emergency >16 years | Examined checklist completion vs. not completing the checklist and linked this to postoperative outcomes | Mortality | Pre: 1.4, Post: 0.9 p = 0.67 |
Complication
|
Pre: 16.9, Post: 11.2
p < 0.01 [-33]
| ||||||
Morgan et al. (2015), United kingdom [39] | Retrospective review Concurrent control group | Pre: 6 months Post: 6 months | 2352 | Pre: vascular and general surgery Post: Orthopaedic surgery | One day teamwork-training course, six weekly in service coaching |
Complication rate
|
Pre: 21.5, Post: 26.8
p = 0.05 [+ 25] → in concurrent control group during this time period complication rates decreased (27.1 to 25.7) |
Length of stay
|
Pre: 11.1, Post: 13.2
p = 0.0371 [+ 19]
| ||||||
Readmission rate | Pre: 13, Post: 11 p = 0.25 | ||||||
Morgan et al. (2015), United kingdom [40] | Retrospective review Controlled interrupted time series Concurrent control group | Pre: 6 months Post: 6 months | 2221 | Elective orthopaedic surgery | Teamwork training, plus training and follow-up support in developing standardised operating procedures | Complication rate | Pre: 14, Post: 18 p = 0.33 |
Length of stay | Pre: 11, Post: 7.2 p = 0.372 | ||||||
Readmission rate | Pre: 13, Post: 11 p = 0.29 | ||||||
Nelson et al. (2014), United states [41] | Prospective cohort | 3 months | NR | NR | Mortality | No change | |
Total complications | No change | ||||||
Oszvald et al. (2012), Germany [52] | Retrospective cohort | Pre: 4 years Post: 18 months | 12,390 | All neurosurgery cases | Improved compliance to advanced checklist modified to suit local needs and addition of checklist in emergency settings | Number of errors (wrong sided) | Pre: 0.03, Post: 0 p = 0.74 |
Prakash et al. (2014), India [45] | Prospective cohort Concurrent cohort comparison | NR | 152 | General, obstetrics and gynaecology |
Mortality
|
Pre: 1.38, Post: 0
p < 0.05 [-100]
| |
Total AE
|
Pre: 15.27, Post: 5
p < 0.001 [-67]
| ||||||
SSI
|
Pre: 8.33, Post: 1.25
p < 0.001
[-85]
| ||||||
Wrong side surgery
|
Pre: 1.38, Post: 0
p < 0.05 [-100]
| ||||||
Excessive bleeding | Pre: 1.38, Post: 1.25 P > 0.05 | ||||||
Rodrigo-Rincon et al. (2015), Spain [24] | Retrospective cohort | Pre: 12 months Post: 12 months | 1602 | Adults with a minimum hospital stay of 24 h | 22 team training sessions | Mortality | Pre: 1.5, Post: 0.9 p = 0.356 |
Total complications | Pre: 18.1, Post: 16.2 p = 0.35 | ||||||
Reinterventions | Pre: 5.5, Post: 4.4 p = 0.356 | ||||||
Total complication rates non- elective
|
Pre: 31.8, Post: 20.4
p = 0.006 [-36]
| ||||||
Total complication rates elective | Pre: 12.9, Post 14.7 p = 0.42 | ||||||
Infections
|
Pre: 13.9, Post: 9.6
p = 0.037 [-31]
| ||||||
Sepsis
|
Pre: 2, Post: 0.5
p = 0.011 [-75]
| ||||||
SSI | Pre: 7.1, Post: 6 p = 0.419 | ||||||
Wound disruption | Pre: 4.7, Post: 6.5 p = 0.158 | ||||||
Pneumonia | Pre: 2.8, Post: 1.4 p = 0.077 | ||||||
PE | Pre: 0.1, Post: 0 p = 1 | ||||||
MI | Pre: 0, Post: 0.1 p = 0.317 | ||||||
Renal insufficiency | Pre: 0.05, Post: 0.01 p = 0.374 | ||||||
Bleeding | Pre: 1.5, Post: 1.7 p = 0.844 | ||||||
Thrombophlebitis | Pre: 0.5, Post: 0.4 p = 1 | ||||||
Ventilator use | Pre: 2.2, Post: 1.2 p = 0.181 | ||||||
Sewell et al. (2011), United Kingdom [6] | Pre: Retrospective historical control Post: Prospective cohort | Pre: 4 months Post: 5 months | 965 | Orthopaedic procedures | Training video, small and large group education sessions | Mortality | Pre: 1.9, Post: 1.6 P > 0.05 |
Total complications | Pre: 8.5, Post: 7.6 P > 0.05 | ||||||
Unplanned readmission to theatre | Pre: 1, Post: 1 P > 0.05 | ||||||
SSI | Pre: 4.4, Post: 3.5 P > 0.05 | ||||||
Tillman et al. (2013), United states [48] | Retrospective review | Pre: 1 yr Post: 1 yr | 6935 | Cardiac, colorectal, general, gynaecological, orthopaedic, thoracic & vascular | Multidisciplinary team development, surgical team training, education, monitoring and coaching | Mortality | Pre: 0.9, Post: 1 p = 0.79 |
SSI | Pre: 3.13, Post: 2.96 p = 0.72 | ||||||
Colorectal SSI
|
Pre: 24.1, Post: 11.5
p < 0.05 [-52]
| ||||||
Orthopaedic SSI | Pre: 1.7, Post: 0.7 p = 0.06 | ||||||
Cardiac SSI | Pre: 7.4, Post: 13.9 p = 0.22 | ||||||
General SSI | Pre: 6.2, Post: 6.1 p = 0.92 | ||||||
Gynaecology SSI | Pre: 2.1, Post: 2.7 p = 0.77 | ||||||
Thoracic SSI | Pre: 2.4, Post: 7 p = 0.62 | ||||||
Vascular SSI | Pre: 2.5, Post: 4.7 p = 0.50 | ||||||
Urbach et al. (2014), Canada [22] | Retrospective cohort | Pre: 3 months Post: 3 months | 215,741 in 101 hospitals | All surgical procedures | Some hospitals used specific intervention or educational programs for the checklist implementation | Mortality | Pre: 0.71, Post: 0.65 p = 0.07 |
Total complications | Pre: 3.86, Post: 3.82 p = 0.53 | ||||||
Length of stay (days)
|
Pre: 5.11, Post: 5.07
p = 0.003 [-1]
| ||||||
Readmission to theatre
|
Pre: 1.94, Post: 1.78
p = 0.001 [-8]
| ||||||
Readmission to hospital within 30 days | Pre: 3.11, Post: 3.14 p = 0.76 | ||||||
ED visits in 30 days | Pre: 10.44, Post: 10.55 p = 0.37 | ||||||
Emergency procedure mortality | Pre: 4.51, Post 4.12 p = 0.11 | ||||||
Sepsis | Pre: 0.1, Post: 0.09 p = 0.73 | ||||||
Septic shock | Pre: 0.05 Post 0.05 p = 0.83 | ||||||
Shock | Pre: 0.07 Post 0.09 p = 0.26 | ||||||
SSI | Pre: 0.61, Post: 0.64 p = 0.30 | ||||||
Major wound disruption | Pre: 0.14, Post: 0.13 p = 0.61 | ||||||
Pneumonia | Pre: 0.31, Post: 0.31 p = 0.80 | ||||||
Acute renal failure | Pre: 0.1, Post: 0.13 p = 0.08 | ||||||
Bleeding | Pre: 0.64, Post: 0.63 p = 0.76 | ||||||
DVT
|
Pre: 0.03, Post: 0.07
p < 0.001 [+ 133]
| ||||||
PE | Pre: 0.03, Post: 0.03 p = 0.58 | ||||||
MI | Pre: 0.29 Post: 0.29 p = 0.91 | ||||||
Ventilator use
|
Pre: 0.08, Post: 0.12
p = 0.007 [+ 50]
| ||||||
Van Klei et al. (2012), Netherlands [42] | Retrospective cohort | 18 months | 25,513 | All adult patients that underwent a surgery | Team meeting, compliance monitored monthly | Crude mortality | Pre: 3.13, Post: 2.85 p = 0.19 |
Mortality adjusted for baseline differences
|
OR 0.85 CI (0.73-0.98)
| ||||||
Vats et al. (2010), United Kingdom [49] | Pre: Retrospective historical control Post: Prospective cohort | 6 months | 729 | Trauma & orthopaedic, gastrointestinal, gynaecology | Research team meetings with operating theatre staff and local supervision | Mortality | No significant change |
Total complications | No significant change | ||||||
Weissner et al. (2010), Multinational [50] | Pre: Retrospective historical control Post: Prospective cohort | <12 months | 1700 | Emergency procedures | Local study team introduced the checklist to the operating room staff through lectures, written materials and direct mentoring |
Mortality
|
Pre: 3.7, Post: 1.4
p = 0.0067 [-62]
|
Total complications
|
Pre: 18.4, Post: 11.7
p = 0.0001 [-36]
| ||||||
SSI
|
Pre: 11.2, Post: 6.6
p = 0.008 [-41]
| ||||||
Estimated blood loss > 500 mL
|
Pre: 20.2, Post: 13.2
p < 0.001 [-34]
| ||||||
Yuan et al. (2012), Liberia [46] | Prospective cohort | Pre: 2 months Post: 2 months | 481 | >16 years surgical patients | Lectures, written materials, direct guidance, team meetings |
Total
| |
Mortality | Pre: 2.2, Post: 2.8 p = 0.334 | ||||||
Total complications
|
Pre: 32.9, Post: 19.1
p = 0.005 [-42]
| ||||||
SSI
|
Pre: 28.6, Post: 9.9
p = 0.001 [-65]
| ||||||
Site 1
| |||||||
Mortality | Pre: 0.9, Post: 4.6 p = 0.191 | ||||||
Total complications | Pre: 16.2, Post: 13.6 p = 0.488 | ||||||
SSI | Pre: 13.1, Post: 9.6 p = 0.506 | ||||||
Site 2
| |||||||
Mortality | Pre: 3.4, Post: 1.4 p = 0.909 | ||||||
Total complications | Pre: 50, Post: 23.2 p = 0.008 | ||||||
SSI
|
Pre: 43.4, Post: 10.1
p < 0.001
[-77]
|