title: Sustainability and long-term effectiveness of the WHO surgical safety checklist combined with pulse oximetry in a resource-limited setting: two-year update from Moldova.
abstract: OBJECTIVE
  Little is known about the sustainability and long-term effect of surgical safety checklists when implemented in resource-limited settings. A previous study demonstrated the marked, short-term effect of a structured hospital-wide implementation of a surgical safety checklist in Moldova, a lower-middle-income country, as have studies in other low-resource settings.
  
  
  OBJECTIVE
  To assess the long-term reduction in perioperative harm following the introduction of a checklist-based surgical quality improvement program in a resource-limited setting and to understand the long-term effects of such programs.
  
  
  METHODS
  Twenty months after the initial implementation of a surgical safety checklist and the provision of pulse oximetry at a referral hospital in Moldova, a lower-middle-income, resource-limited country in Eastern Europe, we conducted a prospective study of perioperative care and outcomes of 637 consecutive patients undergoing noncardiac surgery (the long-term follow-up group), and we compared the findings with those from 2106 patients who underwent surgery shortly after implementation (the short-term follow-up group). Preintervention data were collected from March to July 2010. Data collection during the short-term follow-up period was performed from October 2010 to January 2011, beginning 1 month after the implementation of the launch period. Data collection during the long-term follow-up period took place from May 25 to July 6, 2012, beginning 20 months after the initial intervention.
  
  
  METHODS
  The primary end points of interest were surgical morbidity (ie, the complication rate), adherence to safety process measures, and frequency of hypoxemia.
  
  
  RESULTS
  Between the short- and long-term follow-up groups, the complication rate decreased 30.7% (P = .03). Surgical site infections decreased 40.4% (P = .05). The mean (SD) rate of completion of the checklist items increased from 88% (14%) in the short-term follow-up group to 92% (11%) in the long-term follow-up group (P < .001). The rate of hypoxemic events continued to decrease (from 8.1 events per 100 hours of oximetry for the short-term follow-up group to 6.8 events per 100 hours of oximetry for the long-term follow-up group; P = .10).
  
  
  CONCLUSIONS
  Sustained use of the checklist was observed with continued improvements in process measures and reductions in 30-day surgical complications almost 2 years after a structured implementation effort that demonstrated marked, short-term reductions in harm. The sustained effect occurred despite the absence of continued oversight by the research team, indicating the important role that local leadership and local champions play in the success of quality improvement initiatives, especially in resource-limited settings.
authors: Ariadne Labs, Harvard School of Public Health, Boston, Massachusetts2Department of Surgery, Stanford University School of Medicine, Boston, Massachusetts.
authors: Rebecca Y
authors: RY
authors: Kim
authors: Ariadne Labs, Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
authors: Gifty
authors: G
authors: Kwakye
authors: Department of Surgery, University of Utah School of Medicine, Salt Lake City.
authors: Alvin C
authors: AC
authors: Kwok
authors: National Scientific and Practical Centre of Emergency Medicine, Anaesthesiology Intensive Care "Valeriu Ghereg," State University of Medicine and Pharmacy "Nicolae Testemitanu," Chisinau, Republic of Moldova.
authors: Ruslan
authors: R
authors: Baltaga
authors: National Scientific and Practical Centre of Emergency Medicine, State University of Medicine and Pharmacy "Nicolae Testemitanu," Chisinau, Republic of Moldova.
authors: Gheorghe
authors: G
authors: Ciobanu
authors: Department of Anesthesia, University of Auckland and Auckland City Hospital, Auckland, New Zealand.
authors: Alan F
authors: AF
authors: Merry
authors: Department of Surgery, University of Wisconsin, Madison.
authors: Luke M
authors: LM
authors: Funk
authors: Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.
authors: Stuart R
authors: SR
authors: Lipsitz
authors: Ariadne Labs, Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
authors: Atul A
authors: AA
authors: Gawande
authors: Ariadne Labs, Harvard School of Public Health, Boston, Massachusetts.
authors: William R
authors: WR
authors: Berry
authors: Ariadne Labs, Codman Center for Clinical Effectiveness in Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.
authors: Alex B
authors: AB
authors: Haynes
mesh_terms: D057189:Checklist / Q000706:statistics & numerical data*; D005260:Female; D005500:Follow-Up Studies; D019983:Guideline Adherence; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D008966:Moldova / Q000453:epidemiology; D010092:Oximetry / Q000592:standards*; D061214:Patient Safety / Q000592:standards*; D011183:Postoperative Complications / Q000453:epidemiology*; D012189:Retrospective Studies; D013514:Surgical Procedures, Operative / Q000401:mortality*; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D014944:World Health Organization