Leading article

Checklists and crisis management in surgical emergenciesK. Ram and M. A. Boermeester

Department of Surgery, Academic Medical Centre, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands (e-mail: m.a.boermeester@amc.uva.nl)

Published online 13 November 2013 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9339

Changes in healthcare culture haveresulted in a number of initiativesdesigned to improve patient safety andquality of care. Besides doctors, gov-ernments, healthcare providers, qual-ity improvement organizations, healthinsurers and the media have all shownan interest in these developments. Thesurgical community should, however,improve care by considering the factsand scientific evidence. Safety inter-ventions should be selected for imple-mentation based on effectiveness notpopularity. There is already evidencethat this can be achieved for patientswith sepsis1. The extent to which thiscan be applied to patients with surgicalemergencies is still a challenge.

The SURgical PAtient SafetySystem (SURPASS) checklist demon-strated a clear effect on mortalityreduction. In the study2 using thiscomprehensive perioperative check-list, about 20 per cent of patientsunderwent emergency surgery. Oneyear later, a specific SURPASSchecklist for emergency surgery wasdeveloped that based the selectionof checklist items on prevalenceof intercepted incidents with thechecklist. For emergency surgery thischecklist is lean, focusing on the mostfrequent incidents.

In emergency settings, checklistsand safety management may seemtrivial, although initiatives such asearly warning scores (EWSs) andthe medical emergency team (MET)enjoy considerable popularity, withthe intention of improving healthcarequality, despite a lack of convincingevidence of effect on outcome.

In the management of medicalemergencies, EWSs are used to

identify physiological deterioration inpatients at an early stage, to alert theMET. The consistent effect of thissystem has been to reduce the num-ber of patients who need resuscitation.A recent study3 of 1058 consultationstriggered by EWSs in 981 patientsover 5 years showed that 57 per centof patients had their care escalated,usually through transfer to a criticalcare environment. Despite this, one-quarter of patients died.

A MET may already be part ofdaily patient care in many hospitals,but to what extent and in whatform does a MET really contributeto better and safer care? There islimited evidence to prove that rapidresponse systems save lives. It isnoteworthy that there is an extremelylow number of MET consultations atnight-time and relatively few duringthe day at weekends. These are timeswhen supervision may be absent orsuboptimal, but when a MET seemsmost needed. It seems improbable thatpatients would generally be healthierand less likely to deteriorate duringthe night or at weekends.

Reliably identifying patients at riskbefore a life-threatening event occursthrough an EWS system seems ade-quate, as many patients are trans-ferred to the intensive care unit(ICU) after MET evaluation. EWSsare relatively good predictors ofevents such as death, unexpected ICUadmission, emergency surgery andsevere complications. The questionremains whether the course of diseasewould have been any different withoutan EWS-triggered MET intervention.Where are the data to support thehypothesis that a system of care that

includes a MET produces better out-comes than standard care? Are mor-tality rates, for example, lower thanthe expected mortality calculated froman organ failure score? In a cluster-randomized trial (MERIT study)4 inAustralia, a MET was introduced in 12of 23 participating hospitals, whereasthe remaining 11 hospitals contin-ued functioning as usual and servedas controls. This study showed that,although the team was consulted fre-quently, there was no in-hospital effecton the incidence of cardiac arrest,unplanned ICU admissions and unex-pected mortality. The authors notedthat almost half of calls to the teamswere ‘early’ calls (before a cardiacarrest). As the proportion of early callsincreased, the rate of cardiac arrestsand unexpected deaths decreased. Forevery 10 per cent increase in the pro-portion of early calls, there was a 2·2(95 per cent confidence interval (c.i.)–2·9 to –1·6) reduction per 10 000admissions in overall cardiac arrests,and a 0·94 (–1·4 to –0·5) per 10 000reduction in unexpected deaths. Thiswas not reflected, however, in a sta-tistical reduction in overall deaths orunplanned ICU admissions5.

Systematic reviews6,7 on the subjecthave come to similar conclusions. Theeffect of a MET on patient outcomehas not been demonstrated clearly.The most recent meta-analysis7 eval-uated 18 studies involving METs andshowed a 33·8 per cent reduction inrates of cardiopulmonary arrest out-side the ICU (relative risk (RR) 0·66,95 per cent c.i. 0·54 to 0·80), but thiswas not associated with lower hospi-tal mortality rates (RR 0·96, 0·84 to1·09). A large prospective study8 of

2013 BJS Society Ltd BJS 2014; 101: e5–e6Published by John Wiley & Sons Ltd

e6 K. Ram and M. A. Boermeester

24 193 admissions before and 24 978after introduction of a MET indicatedthat the team was called for 376 times,with no effect on mortality (3·22 versus3·09 per 100 hospital admissions).

Beyond an impression that theMET is probably a good initia-tive that deserves support, it seemsthat an effect on patient outcomecannot be demonstrated, or sub-optimal implementation of a METconsistently obscures any effect onoutcome.

Besides identification of deteriorat-ing patients, an EWS can also beused as a triage tool in the emer-gency department for acute medicalpatients. The modified early warn-ing score (MEWS) and Rapid Emer-gency Medicine Score are useful toolsfor identifying hospitalized patients inneed of a higher level of care andthose at risk of in-hospital death. Pulserate, systolic blood pressure, respira-tory rate, oxygen saturation, temper-ature and neurological status (level ofconsciousness) are used to calculate anEWS for medical admissions. For eachrise in score category, an increased riskof admission to the ICU (odds ratio(OR) 3·35, 95 per cent c.i. 1·52 to 7·40)and death (OR 2·19, 1·41 to 3·39) isfound. An improvement in serial EWSwithin 4 h of presentation to hospitalpredicts improved clinical outcomes9.The MEWS, near-patient-test lactatelevels and the abbreviated Mortality inEmergency Department Sepsis scorepredict 28-day mortality with reason-

able accuracy in adult patients withsepsis in the emergency department10.

METs are still at the end of the line,and this must limit the extent of theireffectiveness. Training, organization,response time and availability deter-mine the effect on outcome, but firstof all the team must be called in timeto patients who are in need of criticalcare outreach.

Disclosure

M.A.B.’s medical institution dis-tributes the SURPASS Digital webapplication on a non-profit basis.

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2013 BJS Society Ltd www.bjs.co.uk BJS 2014; 101: e5–e6Published by John Wiley & Sons Ltd