- Department of Neurosurgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio, United States,
- Department of Neurosurgery, Neurosurgery Teaching Hospital, Baghdad, Iraq.
Zahraa F. Al-Sharshahi, Department of Neurosurgery, Neurosurgery Teaching Hospital, Baghdad, Iraq.
DOI:10.25259/SNI_1118_2021Copyright: © 2022 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Hoz SS1, Arkawazi AH2, Al-Sharshahi ZF2, Al-Rawi MA2, Al-Taweel MM2, Sadik H2, Salih HR2. A customized checklist for microsurgical clipping of intracranial aneurysms. Surg Neurol Int 27-May-2022;13:226
How to cite this URL: Hoz SS1, Arkawazi AH2, Al-Sharshahi ZF2, Al-Rawi MA2, Al-Taweel MM2, Sadik H2, Salih HR2. A customized checklist for microsurgical clipping of intracranial aneurysms. Surg Neurol Int 27-May-2022;13:226. Available from: https://surgicalneurologyint.com/surgicalint-articles/11616/
“To Err is Human” is the core principle behind the introduction of checklists in critical procedures.[
The release of the report, “To Err Is Human: Building A Safer Health System” by the institute of health in the fall of 1999, has established the cornerstone for the incorporation of checklists in the medical field.[
Surgical adverse events constitute 50–67% of all medical errors and it is estimated that 50% of these events are preventable.[
Vascular neurosurgery has unique demands given its unforgiving nature, the complexity of the procedural tasks, the numerous instrumental sets required, the diversity of the personnel involved in a single surgery, the inherent vulnerability of its patients, and the dire nature of its potential complications. Furthermore, it involves many additional key steps that are not routinely required in other surgeries calling for special focus [
Modified intracranial aneurysm clipping safety checklist. ID: Identification, VTE: Venous thromboembolism, ASA: American Society of Anesthesiologists, ICP: Intracranial Pressure, LP: Lumbar puncture, IV: Intravenous, CV: Central venous, AEDs: Antiepileptic drugs, U/S: Ultrasound, DSA: Digital subtraction angiography, EVD: External ventricular drain, IOM: Intraoperative monitoring, UOP: Urine output, BP: Blood pressure, CP: Cardiopulmonary, ICU: Intensive care unit, IOR: Intraoperative rupture.
In this paper, we present a role-based checklist tailored specifically for the unique demands of cerebral aneurysm surgery [
The success of a surgical procedure is related to the performance of all personnel who participate in this patient procedure that includes those preparing the instruments for surgery, preparing the operating room for a procedure, nursing, scrub nurses, anesthesiologists, residents, and the surgeon his/herself. To make a procedure, a success requires that all understand the goals of the surgery and the steps during that procedure. This success requires constant communication among all of the staffs involved in this operation. It requires an understanding of the personalities involve with each staff member to achieve that success. Most often these principles are ignored by the attending surgeon as if they are not part of the operation.
The checklist consists of three parts and an additional [X] section addressing the steps to be followed during temporary clipping, should the surgeon opt for it, and intraoperative aneurysm rupture, should this complication occur.
The checklist was applied for 14 months with a compliance rate of 97% for a total of 60 cases involving three neurosurgeons. The 3% noncompliance rate was attributed to the initial hesitancy with the acceptance of the checklist by the various team members and the time of significant staff shifts. At the conclusion of the study period, the postimplementation adverse incident rates were contrasted with those of another 46 patients who had been operated on before the implementation of the checklist. Overall, 106 aneurysms were included in the study, of which 92.6% were ruptured. Besides, the effect of the checklist on team communication was assessed by double-blinded staff surveys.
The introduction of the checklist into neurosurgical practice was facilitated by a series of institutional amendments mandating the use of the checklist in all upcoming aneurysm clipping surgeries to test its practical validity. Furthermore, all prospective users were trained to use the checklist 1 month in advance through the Hospital’s Continuous Medical Education program.
Overall mortality and morbidity rates have decreased by 2.2% and 6.8%, respectively (P < 0.00001 for both).
Given the multifactorial nature of intraoperative rupture (IOR) and its related complications, estimation of the precise impact of the checklist in such cases was challenged by a set of confounding variables. However, the average time from onset to control of the IOR was significantly reduced following the introduction of the checklist; with ranges of 13 and 7 min, for pre- and postimplementation cases, respectively.
The impact of the checklist was noted during the following surgical steps: intraoperative administration and correct dosing of papaverine, hematoma evacuation, intended lamina terminalis, and Lilliquist membrane fenestration – performed in all cases with ruptured aneurysms at our institution – aneurysm muscle wrapping and accurate timing of temporary clipping. The respective reduction rates of the time required to administer these steps were as follows: 15.2%, 4.3%, 4.3%, 8.6%, 10.9%, and 6.5% (P < 0.05), respectively.
Key anesthetic complications that were significantly (P < 0.05) reduced following the administration of the checklist include cessation of muscle relaxant to enable intraoperative monitoring (15.2%), intraoperative antibiotic and anti-epileptic prophylaxis administration, 4.3% and 8.3%, accordingly, and allergic and transfusion reactions, 4.3%, and 2.1%, respectively.
Delays are commonplace in everyday neurosurgical practice here due to several factors, including personnel shortages, unreliable task assignments, and hardware failure, and failure of the surgeon to prepare adequately for the multiple alternative outcomes and abnormalities in the conduct of the surgery. Our checklist was designed to reflect the following “typical” time consuming and often missed steps: proper surgical set and aneurysmal clip preparation, availability of a second suction system, timely preparation, draping, and “white balance” check of the microscope. On average, with the exclusion of the disparity in surgical experience, the estimated range of surgical delay due to these mundane steps is approximately 60–90 min in up to 70% of cases. Postimplementation, the sequence of these steps has been guaranteed, eliminating interruptions, and ensuring intraoperative flow at an untraceable rate.
A total of 34 staff members were surveyed, including two neurosurgeons, 13 neurosurgery residents, 10 nurses, two anesthetists and five anesthesia assistants, and two intraoperative monitoring personnel, with the main objective of determining the impact of the checklist on the level of interdisciplinary team communication within the operating room. In addition, the postimplementation survey asked the staff to indicate if they would recommend the continuous application of the checklist and to rate its ease of use.
The questionnaires were circulated before and after the launch of the checklist and, to reduce observer and reporting bias, responders were informed that the survey was part of a quality improvement project. Overall, the team graded the checklist favorably, with 96% encouraging its continued application. Specifically, 94% “agreed” or “strongly agreed” that the safety culture in the operating room had been enforced by the checklist. A significant improvement in communication was also seen, with a 50% increase in participants who scored communication as “excellent” (P < 0.05).
A checklist devised specifically for intracranial aneurysm clipping surgery has the potential to improve team communication and maximize surgical outcomes, specifically in low-volume centers.
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