Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background: The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods: In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results: Of 12,296 patients included from 76 countries, 4,843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2,455 of 2,741, 89.6%) compared with countries with a middle (753 of 1,242, 60.6%; odds ratio (OR) 0.17, 95% c.i. 0.14 to 0.21, P<0.001) or low (363 of 860, 42.2%; OR 0.08, 0.07 to 0.10, P<0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference −9.4% (95% c.i. −11.9 to −6.9); P<0.001), but the relationship was reversed in low-HDI countries (+12.1% (7.0 to 17.3); P<0.001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 0.73; P<0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion: Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.