title: Point prevalence of surgical checklist use in Europe: relationship with hospital mortality.
abstract: BACKGROUND
  The prevalence of use of the World Health Organization surgical checklist is unknown. The clinical effectiveness of this intervention in improving postoperative outcomes is debated.
  
  
  METHODS
  We undertook a retrospective analysis of data describing surgical checklist use from a 7 day cohort study of surgical outcomes in 28 European nations (European Surgical Outcomes Study, EuSOS). The analysis included hospitals recruiting >10 patients and excluding outlier hospitals above the 95th centile for mortality. Multivariate logistic regression and three-level hierarchical generalized mixed models were constructed to explore the relationship between surgical checklist use and hospital mortality. Findings are presented as crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs).
  
  
  RESULTS
  A total of 45 591 patients from 426 hospitals were included in the analysis. A surgical checklist was used in 67.5% patients, with marked variation across countries (0-99.6% of patients). Surgical checklist exposure was associated with lower crude hospital mortality (OR 0.84, CI 0.75-0.94; P=0.002). This effect remained after adjustment for baseline risk factors in a multivariate model (adjusted OR 0.81, CI 0.70-0.94; P<0.005) and strengthened after adjusting for variations within countries and hospitals in a three-level generalized mixed model (adjusted OR 0.71, CI 0.58-0.85; P<0.001).
  
  
  CONCLUSIONS
  The use of surgical checklists varies across European nations. Reported use of a checklist was associated with lower mortality. This observation may represent a protective effect of the surgical checklist itself, or alternatively, may be an indirect indicator of the quality of perioperative care.
  
  
  BACKGROUND
  The European Surgical Outcomes Study is registered with ClinicalTrials.gov, number NCT01203605.
authors.affiliation: Department of Clinical Medicine, University of Bergen, Bergen 5021, Norway Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen 5021, Norway.
authors.forename: I
authors.initials: I
authors.lastname: Jammer
authors.affiliation: Queen Mary University of London, London E1 4NS, UK.
authors.forename: T
authors.initials: T
authors.lastname: Ahmad
authors.affiliation: Department of Anesthesia and Surgical Critical Care, Hospital Universitario Rio Hortega, Valladolid 47012, Spain.
authors.forename: C
authors.initials: C
authors.lastname: Aldecoa
authors.affiliation: 2nd Critical Care Department, Attikon University Hospital, Athens 12462, Greece Burns, Trauma and Critical Care Research Centre, University of Queensland, Brisbane, QLD 4006, Australia.
authors.forename: D
authors.initials: D
authors.lastname: Koulenti
authors.affiliation: Department of Anaesthesiology and Intensive Care Medicine, University Hospital Sveti Duh, Zagreb 10000, Croatia.
authors.forename: T
authors.initials: T
authors.lastname: Goranović
authors.affiliation: Anesthesia and Intensive Care Department, Regional Institute of Oncology, University of Medicine and Pharmacy 'Gr. T. Popa', Iasi 700483, Romania.
authors.forename: I
authors.initials: I
authors.lastname: Grigoras
authors.affiliation: Department of Anaesthesiology and Intensive Care Medicine, University Hospital Sveti Duh, Zagreb 10000, Croatia Medical School of J.J. Strossmayer University, Osijek 31000, Croatia.
authors.forename: B
authors.initials: B
authors.lastname: Mazul-Sunko
authors.affiliation: UCINC, Hospital de São José, Centro Hospitalar de Lisboa Central, EPE, Lisboa 1150-199, Portugal.
authors.forename: R
authors.initials: R
authors.lastname: Matos
authors.affiliation: UCINC, Hospital de São José, Centro Hospitalar de Lisboa Central, EPE, Lisboa 1150-199, Portugal.
authors.forename: R
authors.initials: R
authors.lastname: Moreno
authors.affiliation: Landspitali Unversity Hospital, University of Iceland, 101 Reykjavik, Iceland.
authors.forename: G H
authors.initials: GH
authors.lastname: Sigurdsson
authors.affiliation: Anaesthesia and Intensive Care, Odense University Hospital, Odense 5000, Denmark.
authors.forename: P
authors.initials: P
authors.lastname: Toft
authors.affiliation: Postanaesthesia and Intermediate Care Unit, University Hospitals of Geneva, Geneva 1211, Switzerland.
authors.forename: B
authors.initials: B
authors.lastname: Walder
authors.affiliation: Critical Care, St George's Healthcare NHS Trust and St George's University of London, London SW17 0QT, UK.
authors.forename: A
authors.initials: A
authors.lastname: Rhodes
authors.affiliation: Queen Mary University of London, London E1 4NS, UK r.pearse@qmul.ac.uk.
authors.forename: R M
authors.initials: RM
authors.lastname: Pearse
mesh_terms: D057189:Checklist / Q000379:methods / Q000706:statistics & numerical data*; D015331:Cohort Studies; D005060:Europe; D005260:Female; D017052:Hospital Mortality; D006761:Hospitals / Q000706:statistics & numerical data; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D016017:Odds Ratio; D017063:Outcome Assessment, Health Care / Q000379:methods* / Q000706:statistics & numerical data*; D015995:Prevalence; D012189:Retrospective Studies; D012307:Risk Factors; D013514:Surgical Procedures, Operative / Q000706:statistics & numerical data*; D014944:World Health Organization
keywords: checklist; hospital mortality; outcome assessment (health care)