Endoscopic sinus surgery checklist

Authors

  • Zachary M. Soler MD, MSc,

    1. Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina
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  • Timothy L. Smith MD, MPH

    Corresponding author
    1. Division of Rhinology and Sinus Surgery, Oregon Sinus Center, Department of Otolaryngology–Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, U.S.A.
    • Division of Rhinology and Sinus Surgery, Department of Otolaryngology–Head and Neck Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd., PV-01, Portland, OR 97239
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  • Zachary M. Soler, MD, is a consultant for Ora (Andover, MA). Timothy L. Smith, MD, is funded by grant support from the NIH/NIDCD for research unrelated to this effort. Dr. Smith is also a consultant for Intersect ENT (Palo Alto, CA), which did not provide financial or material support for this manuscript. The authors have no other funding, financial relationships, or conflicts of interest to disclose.

Abstract

Over 250,000 endoscopic sinus surgeries are performed yearly in the United States alone. Although overall complication rates are low, errors can lead to significant morbidity due to the close proximity of the sinuses to the orbit and skull base and the resultant potential for blindness, cerebrospinal fluid leak, and catastrophic bleeding. Surgical checklists are endorsed by the World Health Organization and have been incorporated into most U.S. operating rooms as a measure to minimize avoidable errors. Standardized surgical checklists were developed with general and/or orthopedic procedures in mind, but in many instances they fail to incorporate concerns specific to endoscopic sinus surgery (ESS). In response to this clinical problem, we sought to develop and institute an ESS surgical checklist. This checklist can serve as a template for physicians who perform ESS and wish to prevent avoidable adverse events.

INTRODUCTION

Over 250,000 endoscopic sinus surgeries are performed yearly in the United States alone.1 Although overall complication rates are low, surgical errors can lead to significant morbidity due to the close proximity of the sinuses to the orbit and skull base and the resultant potential for blindness, cerebrospinal fluid leak, and catastrophic bleeding. This reality is reflected in U.S. malpractice litigation, wherein rhinology claims represent 70% of the total indemnity compensation for otolaryngology lawsuits, with sinusitis being the most common diagnosis.2

Surgical checklists are endorsed by the World Health Organization (WHO) and have been incorporated into most U.S. operating rooms as a measure to minimize avoidable errors. Substantial data exist acknowledging that a simple, basic checklist can improve outcomes such as infection rates and overall mortality.3 However, standardized surgical checklists were developed with general and/or orthopedic procedures in mind and in many instances fail to incorporate concerns specific to endoscopic sinus surgery (ESS). In response to this clinical problem, we sought to develop and institute an ESS surgical checklist. This ESS-specific checklist would seek to preemptively address those errors that are unique to endoscopic sinonasal procedures.

ESS-Specific Checklist

This ESS checklist is designed as a supplement to existing generic surgical checklists, which are likely to already be in place in most operating rooms. These additional steps are surgeon led and can easily be incorporated regardless of surgical setting or nature of the existing checklists. The ESS checklist is broken down into sections centered around definable time points common to all procedures: 1) prior to intubation, 2) prior to instrumentation, and 3) prior to extubation (Figure 1). Prior to intubation, the surgeon confirms that the necessary imaging study (usually computed tomography scan or magnetic resonance image) is available, displayed in the operating room (OR), and matches the correct patient and date. As prior studies have shown, radiographic errors contribute to the majority of wrong-site sinus procedures. Proper left-right orientation of the films should be confirmed.4 If image guidance is required for the case, the machine should be present in the OR suite, with necessary images properly loaded into the system. Last, the surgeon(s) reviews and articulates specific anatomic variations that may predispose to complications and must be accounted for in the operative plan (e.g., skull base erosion, dehiscent lamina papyracea, sphenoethmoid [Onodi] cell). Although many surgeons review scans in detail prior to the operative case, this last step is best repeated at the outset of each individual case, as it can be difficult to remember the specific anatomy in the midst of a busy surgical caseload.

Figure 1.

Sample endoscopic sinus surgery checklist. Supplemental items are surgeon led, allowing them to be readily integrated into standardized checklists without additional training of surgical staff. *ESS-specific initiatives that supplement the standard perioperative checklist.

The traditional surgical time-out or pause occurs just prior to instrumentation of the patient. Most operating rooms have adopted a single generic checklist to which all surgical teams must adhere (e.g., medication allergies, important comorbidities, antibiotics). After completion of the generic checklist, we have added several additional statements that cover unique and critical elements of ESS. First, the surgeon informs the team that a topical vasoconstricting agent will be used (often high-dose epinephrine, cocaine, or oxymetazoline), and that this agent has been stained (usually fluorescein or marking ink), is labeled appropriately, and is not to be used for injection. This step is critical, as injection of these potent agents is a genuine risk and can precipitate hypertension, arrhythmia, and even stroke, myocardial infarction, or death.5 The step also serves to inform the anesthesiologist that this medication is being used and reiterates the potential danger to the nursing and tech teams. In a similar fashion, the surgeon informs the team of the medication to be used for injection and confirms it has been properly labeled. The surgeon also confirms that necessary specialized equipment to control bleeding is sterilized and available (endoscopic cautery and hemostatic materials). Last, the surgeon should inform the team whether specimens will be taken and the methodology of collection. This is especially important during bilateral cases and when instrumentation requires special setup to collect specimen, such as with a microdebrider.

The last aspect of the checklist occurs at the completion of the surgical case. The surgeon confirms with the nursing and tech teams that the pledget count is correct and specimens, if collected, have been properly labeled. If nonabsorbable synthetic materials have been placed in situ (spacers, stents, packing), these items are properly documented in the medical record along with their projected date of removal.

DISCUSSION

A recent report estimated that over 2,600 episodes of major morbidity and 165 deaths may occur annually due to avoidable medical errors in otolaryngology patients.6 The avoidance of these errors are major initiatives of the Institute of Medicine, WHO, and The Joint Commission, especially never events such as wrong-patient surgery and wrong-site surgery.7–9 The ESS-specific checklist detailed herein is an attempt to identify errors and prevent adverse outcomes in patients undergoing ESS.

Surgical checklists are now endorsed by most major surgical societies, including the American Academy of Otolaryngology–Head and Neck Surgery. A wealth of evidence documents the ability of checklists to enhance optimal practices, such as routine delivery of preoperative antibiotics, and to reduce adverse outcomes such as infection and perioperative mortality.3, 10 These same studies show that checklists have a negligible impact on overall operative time.11 However, despite this evidence, some surgeons remain skeptical and even unreceptive to the concept of a checklist. Some portion of this hostility may reflect generic checklists not addressing the concerns unique to surgeons performing specialized surgeries such as ESS. Others may feel that checklists interfere with OR efficiency. According to developers of the WHO checklist, the most effective checklists are short, simple, and situation specific.12 With this in mind, we developed the ESS checklist to be brief, surgeon led, and to cover those topics specific to ESS but unlikely to be addressed in generic checklists.

The checklist outlined above serves as a basic template that can be molded to fit an individual surgeon's distinct practice, whether it is academic, private, hospital based, or at an outpatient surgical center. The checklist would be especially useful in emergent surgeries wherein supporting personnel may be unfamiliar with the specific perils of ESS or the surgeon's standard routine. This template covers those items identified as important sources of error in the literature, but practitioners are encouraged to incorporate unique steps (such as specialized equipment or medications) that they feel are critical aspects of their surgical approach and could predispose to error. The more relevant the checklist is to a specific surgeon, the greater the buy-in, and ultimately greater the overall efficacy.

CONCLUSION

Surgical checklists are a proven means to decrease avoidable surgical errors. The ESS checklist supplements existing standardized checklists with items critical to the safe performance of ESS. This checklist can serve as a template for physicians who perform ESS and wish to prevent avoidable adverse events.

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