COVID-19 and Your Surgical Safety Checklist

When a surgical patient tests positive or is suspected to have the SARS CoV2 virus that causes COVID-19, standard surgical practices such as intubation and extubation become high-risk transmission events to spread the virus. Changes to donning and doffing PPE for these procedures and cleaning the OR has required new considerations to reduce transmission risks.

Surgical staffing and team communication have also been disrupted through the pandemic.

Knowing these new dangers, surgical teams across the world have had to adapt their checklist—including those who helped create the original Surgical Safety Checklist—to increase team communication, reduce the risk of virus transmission and continue to prevent safety events such as wrong site surgery.

Last year, team members from Ariadne Labs, including Mary Brindle, MP, MPH, and Lifebox established by well-known checklist advocate Atul Gawande, MD, MPH, convened virtually with Lisa Spruce, DNP, RN, ACNP, CNOR, CNS-CP, ACNS, FAA, AORN Director of Evidence-Based Perioperative Practice, and other experts representing surgical team roles to recommend COVID-19-specific checklist updates.

“We all faced the very real risks that our usual safety measures might be overlooked given the concerns around COVID,” notes Brindle, a pediatric surgeon in Alberta, Canada and director of Safe Surgery and Safe Surgery Systems for Ariadne Labs at Brigham and Women’s Hospital in Boston.

This team published these eight recommended checklist changes for COVID-19 in February

• Review the patient's COVID-19 test results, symptoms, and/or risk factors
• Review the plan for intubation
• Review the aerosolization risks of the procedure
• Confirm that all members of the operating room are wearing appropriate PPE
• Ensure in-room availability of all necessary equipment to minimize the number of times individuals enter or leave the operating room
• Discuss handling, packaging, and transport of laboratory or pathology specimens
• Confirm appropriate postoperative bed availability
• Sign out prior to extubation

The team also noted recommendations for implementing checklist changes and performance, including identifying local leaders from surgery, anesthesia, and nursing as part of an implementation team to guide site-specific content changes and implementation efforts, and conducting more formal and frequent teamwork and communication training with COVID-19 specific simulation.

In ongoing work as a team to refine the Surgical Safety Checklist for COVID-19 or any other highly infectious virus, “we must recognize that we have a tool, right there that is designed for this very purpose—to ensure that there is good communication between team members, a shared understanding of the case (including risks and mitigating strategies), and to make sure that critical processes are not forgotten,” Brindle notes.

Some of these COVID-19-specific changes make sense for teams to consider adopting on an ongoing basis.

That’s why Brindle and AORN’s Spruce suggest surgical team’s take time to compare their own COVID-19 checklist changes to these recommended changes, as part of efforts to ensure the Surgical Safety Checklist remains most effective for patients and team members.

Revising the Checklist for COVID

When the COVID-19 pandemic emerged, surgical safety experts including Brindle saw from the experiences of colleagues in places like Italy and a number of locations in Asia, that the operating room can be a high-risk area for transmission.

“The concerns I saw in my hospital were the same concerns I saw across my province and the same concerns shared by my colleagues in Boston and around the world—the need for COVID-specific recommendations were pretty clear to me,” Brindle explains.

One concern she saw was the need to have the team Sign Out before extubation, because COVID-19 protocols require non-essential team members to leave during this high transmission-risk action.

She says, “having the team quickly discuss the case and ensure that there is a good plan in place will not only ensure that the patient gets the best care after surgery but will also help the team identify issues that need debugging and opportunities to improve.”

Brindle explains that some of the recommended changes for a COVID-19 checklist are critically important when the team is starting to adapt to the pandemic but may become less critical when processes become more entrenched or if they become unnecessary.

The COVID-19 checklist changes also include recommendations for de-implementation, as COVID evolves differently in individual communities.

“Remember, it’s important that the checklist remains easily usable and relevant—we don’t want to load it up with items that are not critical or retain items that become obsolete,” Brindle says. “The Surgical Safety Checklist is our checklist and if we use it well, we can ensure that our teams are all on the same page and performing at the top of our game.”