use of the who surgical safety checklist on surgical management

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USE OF THE WHO SURGICAL SAFETY CHECKLIST ON SURGICAL
MANAGEMENT PROCEDURE IN OPERATING ROOM
BLUD RSUD MEURAXA BANDA ACEH CITY
THESIS SUMMARY
POSTGRADUATE IN HOSPITAL MANAGEMENT
Written by:
Merina CH
10/308478/PKU/11741
MAGISTER <strong>of</strong> PUBLIC HELATH
FACULTY <strong>of</strong> MEDICINE
GADJAH MADA UNIVERSITY
YOGYAKARTA
2011

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USE OF THE WHO SURGICAL SAFETY CHECKLIST ON SURGICAL
MANAGEMENT PROCEDURE IN OPERATING ROOM
BLUD RSUD MEURAXA BANDA ACEH CITY
Merina CH
10/308478/PKU/11741
Approved by:
Supervisor
Pr<strong>of</strong>. dr. Iwan Dwiprahasto., MMedSc., PhD
Tanggal:

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USE OF THE WHO SURGICAL SAFETY CHECKLIST ON SURGICAL MANAGEMENT
PROCEDURE IN OPERATING ROOM
BLUD RSUD MEURAXA BANDA ACEH CITY
Merina CH 1 , Iwan Dwiprahasto 2
ABSTRACT
Background: A surgery is one <strong>of</strong> medical treatments aimed to save one’s live, prevent
from disability and complication. However, <strong>the</strong> effect <strong>of</strong> surgery can ca<strong>use</strong> death and
handicap such as from <strong>surgical</strong> wound infection. RSUD Meuraxa Banda Aceh city in 2010,
<strong>the</strong>re were 4 post <strong>surgical</strong> patients suffered from dehiscence in <strong>the</strong> suture <strong>surgical</strong>
operation. There have been rarely prophylaxis antibiotic adductions to pre <strong>surgical</strong>
patients. There have also been latency and cancellation for <strong>the</strong> surgery. One <strong>of</strong> <strong>the</strong> efforts
to decrease <strong>the</strong> number <strong>of</strong> infections to <strong>surgical</strong> wound is by using WHO <strong>surgical</strong> <strong>safety</strong>
<strong>checklist</strong>.
Objectives: To find out to what extent is <strong>the</strong> suitability <strong>of</strong> <strong>surgical</strong> operations in operating
room RSUD Meuraxa Banda Aceh City with WHO <strong>surgical</strong> <strong>safety</strong> <strong>checklist</strong>s and <strong>the</strong>
impact toward <strong>the</strong> <strong>surgical</strong> outcomes.
Method: This is an observational research using sectional cross design. The dependent
variable is <strong>the</strong> number <strong>of</strong> surgery wound infections and <strong>the</strong> independent variables are <strong>the</strong>
characteristics <strong>of</strong> <strong>surgical</strong> patients, prophylaxis antibiotics and WHO <strong>surgical</strong> <strong>safety</strong>
<strong>checklist</strong>. The data were collected through observation using <strong>checklist</strong> toward <strong>surgical</strong> and
prophylaxis antibiotics operational procedure. The data <strong>the</strong>n were analyzed by using
frequency distribution, percentage and chi square test. The subjects <strong>of</strong> this research are all
<strong>surgical</strong> patients from 1 nd <strong>of</strong> June to 15 th <strong>of</strong> July 2011 in RSUD Meuraxa Banda Aceh city.
Analysis and results: The variable <strong>of</strong> subject characteristics <strong>of</strong> age and education are
significant to <strong>surgical</strong> wound infection occurrence (p value

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INTRODUCTION
Surgery is an integral part <strong>of</strong> health care and is one <strong>of</strong> <strong>the</strong> important actions
in medical. This surgery is one <strong>of</strong> <strong>the</strong> medical act which aims to save lives,
prevent disability and complications. However, <strong>surgical</strong>ly performed can also
engender a complication may endanger <strong>the</strong> life. 1
Data 56 (29%) surgery <strong>of</strong> <strong>the</strong> 192 countries members <strong>of</strong> <strong>the</strong> WHO and <strong>the</strong>
estimated 234.2 dissection (95% CI-281.2 187.2) take place each year around <strong>the</strong>
world. One million patients died <strong>of</strong> surgery, ei<strong>the</strong>r during surgery or after surgery
and 7 o<strong>the</strong>r million patients experienced complications. 2
Wound infection is <strong>the</strong> third largest operation that ca<strong>use</strong> nosocomial
infections. Wound infection led to operation morbditas, mortality and extend <strong>the</strong>
period <strong>of</strong> inpatient in <strong>the</strong> Hospital thus increasing maintenance costs between 10%
to 20% are wound infection surgery. The costs incurred by <strong>the</strong> patient and <strong>the</strong>
patient's family when it is not <strong>the</strong> occurrence <strong>of</strong> infections <strong>of</strong> wounds operations is $
31.523 but with <strong>the</strong> existence <strong>of</strong> operation wound infection becomes $ 75007. This
has resulted in material losses and imateril in patients and <strong>the</strong>ir families. 3.4.5
In <strong>the</strong> Act <strong>of</strong> surgery, <strong>the</strong> patient characteristics allow <strong>the</strong> occurrence <strong>of</strong>
infection with surgery wounds. The characteristics <strong>of</strong> <strong>the</strong>se patients include:
diabetes, smoking, steroids long-term, obesity, age, status and lack <strong>of</strong> nutrients by
<strong>the</strong> transfusion <strong>of</strong> operation. 5 Education is very influential on <strong>the</strong> subject <strong>of</strong> healthy
behavior, withhigher education level <strong>the</strong> higher <strong>the</strong> knowledge. As for o<strong>the</strong>r factors
that affect wound infections in Obstetrics and surgery SMF content <strong>of</strong>. Dr. Sardjito
Hospital Yogyakarta, that <strong>the</strong> quality and skills <strong>of</strong> <strong>the</strong> operator <strong>of</strong> <strong>the</strong> resident OR =
6,03 (95% CI: 12,03-18.02) statistically meaningful with P & Lt; 0.05. 6 Good
collaboration between surgeons, anes<strong>the</strong>sia and nurses very important in <strong>the</strong>
management <strong>surgical</strong> room. 7 Communication errors in <strong>surgical</strong> team is <strong>the</strong> ca<strong>use</strong> <strong>of</strong>
<strong>the</strong> occurrence <strong>of</strong> an error in surgery, ei<strong>the</strong>r on <strong>the</strong> side <strong>of</strong> <strong>the</strong> surgery as well as in

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o<strong>the</strong>r <strong>surgical</strong> procedures <strong>the</strong>refore need good communication and cooperation in
<strong>surgical</strong> teamwork to improve patient <strong>safety</strong>.
Surgical wound infection rates (ILO) can be scaled with antibioticprophylaxis
and timing <strong>of</strong> administration should be appropriate. One way for granting an
antibiotic prophylactic at <strong>the</strong> proper time is by a guide <strong>surgical</strong> <strong>safety</strong> <strong>checklist</strong>. <strong>the</strong>
<strong>use</strong> <strong>of</strong> <strong>surgical</strong> <strong>safety</strong> <strong>checklist</strong> can optimize <strong>the</strong> time <strong>of</strong> <strong>the</strong> granting <strong>of</strong> an antibiotic
prophylactic before <strong>the</strong> dissection. 8
Surgical <strong>safety</strong> <strong>checklist</strong> contains 19 items WHO is to be done in three
stages, before induction <strong>of</strong> anes<strong>the</strong>sia (sign in), before <strong>the</strong> skin incisions (time out)
and leave <strong>the</strong> operating room before <strong>the</strong> patient (sign out). The <strong>use</strong> <strong>of</strong> <strong>surgical</strong>
<strong>safety</strong> <strong>checklist</strong> <strong>who</strong> is adjusted to <strong>the</strong> condition <strong>of</strong> a hospital. 9
Function <strong>of</strong> <strong>the</strong> <strong>surgical</strong> <strong>safety</strong> <strong>checklist</strong> is providing information that details
about <strong>the</strong> case which is being worked on, confirm <strong>the</strong> details, <strong>the</strong> focus <strong>of</strong>
discussion and <strong>the</strong> formation <strong>of</strong> <strong>the</strong> penyuaraan team. Besides that discussion
ceklist also gives <strong>the</strong> opportunity for education and decision maker. Of members <strong>of</strong>
a team <strong>the</strong> operation <strong>of</strong> emphasized <strong>the</strong> importance <strong>of</strong> information and cooperation
<strong>the</strong> team as a function most important <strong>of</strong> ceklist. 10
In indonesia has issued a decree health minister No
382/menkes/SK/III/2007 concerning <strong>the</strong> implementation <strong>of</strong> <strong>the</strong> prevention and
control infections in hospitals and health care facilities ano<strong>the</strong>r as an attempt to
decide cycle <strong>the</strong> contagion <strong>of</strong> disease and protect <strong>the</strong> patient, medic, visitors and
<strong>the</strong> people <strong>who</strong> receives health services, ei<strong>the</strong>r in a hospital or facility o<strong>the</strong>r health
services. 11
Regional General Hospital (RSUD) meuraxa <strong>the</strong> city <strong>of</strong> banda aceh is a
hospital a public service agancy <strong>the</strong> area <strong>of</strong> class B <strong>who</strong> became a hospital <strong>the</strong>
referent <strong>of</strong> in <strong>the</strong> area <strong>of</strong> a city Banda Aceh and had a duty carry out <strong>the</strong> service <strong>of</strong>
<strong>the</strong> treatment, <strong>the</strong> recovery <strong>of</strong> an increase in health and <strong>the</strong> prevention <strong>of</strong> disease
that is executed through <strong>the</strong> service <strong>of</strong> inpatient, outpatient, emergency room, and
<strong>the</strong> act <strong>of</strong> medical based on <strong>the</strong> regulation.

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This hospital having a number <strong>of</strong> a bed 136, and have service between
o<strong>the</strong>rs: <strong>surgical</strong> poliklinik 1, 1 space <strong>surgical</strong> man, 1 space <strong>surgical</strong> woman, 1
installation <strong>surgical</strong> middlemost having 3 chamber operations (2 <strong>the</strong> operating
room large rooms small operations and 1), recovery room and space sterility
instrument. The number <strong>of</strong> operations in 2009 is 655 operations and 715 operation
in 2010. The incidence <strong>of</strong> <strong>surgical</strong> wound infections in Meuraxa hospitals
Banda Aceh not in <strong>the</strong> know beca<strong>use</strong> it has never been any research or data
on nosocomial infections and<strong>surgical</strong> wound infections. Nosocomial infection
control team is newly formed at <strong>the</strong> end <strong>of</strong> 2010. in 2010 as much as 4 patients
after an operation that experiencing dehisiensi at a seam scrapes operation so as
to need done operation re xamined. Delivery <strong>of</strong> antibiotic prophylaxis in patients
before surgery was rarely performed, it is still a delay and <strong>the</strong> cancellation <strong>of</strong>
surgery.
RESEARCH OBJECTIVES
The general objective <strong>of</strong> this research is to know <strong>the</strong> extent <strong>of</strong> compliance
action surgery in Meuraxa hospital Banda Aceh City with <strong>surgical</strong> <strong>safety</strong> <strong>checklist</strong>
WHO and <strong>the</strong>ir impact on <strong>the</strong> outcome <strong>of</strong> surgery.
MATERIALS AND RESEARCH METHOD
The research was conducted at a Meuraxa hospital in Banda Aceh, <strong>of</strong> this
research is observasional plan cross sectional. This research is subject to <strong>the</strong>
patients <strong>who</strong> underwent surgery on a planned from June 1 to July 15, 2011. The
collection <strong>of</strong> data with <strong>the</strong> data in <strong>the</strong> <strong>checklist</strong> can <strong>the</strong>n examine, through <strong>the</strong>
analysis <strong>of</strong> <strong>the</strong> data in two stages, i.e. univariate and bivariate. Univariate analysis
was conducted to find out <strong>the</strong> frequency distribution <strong>of</strong> each independent variable.
Analysis <strong>of</strong> bivariat to see <strong>the</strong> influence <strong>of</strong> <strong>the</strong> dependent variable for each
independent variable.

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RESEARCH AND DISCUSSIONS
1. Characteristic subject
Based on <strong>the</strong> results <strong>of</strong> an analysis <strong>of</strong> <strong>the</strong> relation <strong>of</strong> characteristic <strong>of</strong>
<strong>the</strong> subject with <strong>the</strong> occurrence <strong>of</strong> an infection in a wound <strong>the</strong> operation <strong>of</strong>
that has been carried at 60 <strong>the</strong> subject <strong>of</strong> study, from <strong>the</strong> eighth variable
characteristic <strong>of</strong> <strong>the</strong> subject (age, education, sex, a class <strong>of</strong> care, diagnose
<strong>surgical</strong>, a comorbidities, <strong>the</strong> day <strong>of</strong> care and <strong>the</strong> operator <strong>surgical</strong>) visible
two characteristic <strong>of</strong> a subject that are meaningful increase my risk <strong>of</strong> <strong>the</strong>
occurrence <strong>of</strong> an infection <strong>of</strong> a wound <strong>the</strong> operation <strong>of</strong> ie sub characteristic
<strong>of</strong> <strong>the</strong> subject <strong>of</strong> aged and sub karakteriktik education with magnitudes p<
0.005. Risk factors <strong>of</strong> infection <strong>of</strong> operation wound, namely: <strong>the</strong> <strong>surgical</strong> risk
factors (age, sex, diagnosis, complication surgery, intra venous attached,
long day pre surgery ca<strong>the</strong>ter is inserted, <strong>the</strong> time <strong>of</strong> urine antibiotic
prophylaxis and hair shearing time pubis), risk factors during surgery
(surgery, complications <strong>of</strong> old surgery, complications <strong>of</strong> anes<strong>the</strong>sia and
antibiotics added) and risk factors <strong>of</strong> post surgery (antibiotics, wound care
and nursing care <strong>of</strong> old). 9 The characteristics <strong>of</strong> <strong>the</strong> subject sub class
variables do not care to <strong>the</strong>ir risk factors to <strong>the</strong> occurrence <strong>of</strong> wound
infection is likely due to <strong>the</strong> operation in Meuraxa hospital Banda Aceh, <strong>the</strong>
level <strong>of</strong> hygiene diruangan aseptiknya good care and techniques and
existing standard operating procedural (SOP) to replace <strong>the</strong> wrap cuts post
operation. Supervision in replacing <strong>the</strong> wrap <strong>of</strong> post operative already done
periodically by <strong>the</strong> head <strong>of</strong> <strong>the</strong> chamber and chairman <strong>of</strong> <strong>the</strong> implementation
<strong>of</strong> <strong>the</strong> orphanage team daily nursing.

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Table 2. Relationship Between Characteristics <strong>of</strong> Subjects With Wound
Infection Occurrence <strong>of</strong> Operations
Characteristics subjects ILO events N=60 P OR crude
ILO
N (%)
Tidak ILO
N (%)
(95%CI)
Age
• < 21
• 21-35
• 36-50
• ≥ 51
Education
• Basic
middle to upper
0 (0)
0 (0)
2 (15,4)
10 (100)
11 (52,46)
1 (2,6)
11 (100)
26 (100)
11 (84,6)
0 (0)
10 (47,6)
38 (97,4)
11 (18,3)
26 (43,3)
13 (21,7)
10 (16,7)
21 (35,0)
39 (65,0)
0,000
0,000 41,80
(4,8-363,3)
2. Granting <strong>of</strong> antibiotic prophylaxis
Table 2. Relationship between pr<strong>of</strong>ilaksis antibiotics (AP) with <strong>the</strong> wound
operation infections
Pr<strong>of</strong>ilaksis antibiotics ILO events N=60 P OR crude
ILO
N (%)
Tidak ILO
N (%)
(95%CI)
AP Given
• Yes
• No
2 (5,1)
10 (47,6)
37 (94,6)
11 (52,4)
39 (65,0)
21 (35,0)
0.000
16,8
(3,2-88,5)
The time <strong>of</strong>
granting AP
• ≤ 60 minute
• > 60 minute
1 (4,0)
1 (7,1)
24 (96,0)
13 (92,9)
N=39
25 (64,1)
14 (35,9)
0,669
1,8
(0,1-32,0)
From a statistical analysis <strong>of</strong> this research was to find <strong>the</strong> meaning <strong>of</strong>
significant (p

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Prophylaxis antibiotics are given to help prevent <strong>the</strong> occurrence <strong>of</strong>
infections. Administering an antibiotic prophylaxis 30 minutes before
surgery. The granting <strong>of</strong> antibiotics prophylaxis is <strong>the</strong> main thing must be
considered, <strong>the</strong> granting <strong>of</strong> antibiotics pr<strong>of</strong>ilasis advised 60 minutes before
incision is <strong>the</strong> first <strong>of</strong> lea<strong>the</strong>r is carried, <strong>the</strong> <strong>use</strong> <strong>of</strong> antibiotics prophylaxis an
hour before incisions first on <strong>the</strong> skin can be lowered infection scrapes
operations. 13
Administering an antibiotic prophylaxis prior to surgery performed in
are still rarely performed Meuraxa Hospital Banda Aceh city, is due to <strong>the</strong>
presence <strong>of</strong> SOP and yet <strong>the</strong> provisions concerning antibiotic prophylaxis
and administering prophylaxis antibiotic timing.
3. Surgical <strong>safety</strong> cheklist (SSCL) WHO
Confirmation <strong>of</strong> <strong>the</strong>
<strong>surgical</strong> procedure
• Yes
• No
Team nurse review
Steril <strong>surgical</strong>
equipment
• Yes
• No
Antibiotics are given 60
minutes before surgery
• Yes
• No
Table 3.
Relationship Between <strong>the</strong> Use <strong>of</strong> Surgical suitability
Safety Checklist (SSCL) WHO The occurrence <strong>of</strong> <strong>the</strong> ILO
SSCL ILO N=60 P OR crude
ILO Tidak ILO
N (%) N (%)
1 (5,3)
11 (26,8)
1 (2,4)
11 (57,9)
1 (4,0)
11 (31,4)
18 (94,7)
30 (73,2)
40 (97,6)
8 (42,1)
24 (96,0)
24 (68,6)
19 (31,7)
41 (68,3)
41 (68,3)
19 (31,7)
25 (41,2)
35 (58,3)
0,052
0,000
0,009
6,6
(0,7-55,4)
55,0
(6,19-488,1)
11,0
(1,3-91,9)
The results showed most <strong>of</strong> <strong>the</strong> <strong>surgical</strong> <strong>safety</strong> <strong>checklist</strong> WHO
variable does not mean significantly with <strong>the</strong> wound infection <strong>of</strong> sub

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operations but variable confirm <strong>surgical</strong> procedures, <strong>surgical</strong> team sub
variable review <strong>surgical</strong> equipment is sterile and sub antibotik variables are
given 60 minutes before prophylactic surgery means significant (p

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poliklinik, <strong>the</strong> room and do <strong>surgical</strong>ly in a <strong>surgical</strong>, so that <strong>of</strong>ten occurs delay
operations.
4. Incident wound operation infections
Digit gen infection operation post dissection (20, %), mostly found on
<strong>the</strong> seventh day ie at a visit to poliklinik (58, 3). Of research results type
infection scrapes operation that is superficial SSI most (83, 3), <strong>the</strong> deep SSI
(16,7) and organs/ space does not occur. Wound infections nosocomial
infections third operation is <strong>of</strong>ten reported, <strong>of</strong> <strong>the</strong> total patients are cared for
hospitalization are exposed to infections nosocomial 14-16% are wound
infection surgery. Based on <strong>the</strong> level <strong>of</strong> contamination <strong>of</strong> wounds which
were operating clean contaminated (53.3), while net classification (36.7) and
<strong>the</strong> lowest classification <strong>of</strong> contaminated (5.0) and klasfikasi dirty (5.0).
Wound infection in general surgery is 2% to 5% <strong>of</strong> <strong>the</strong> 27 million patients
<strong>who</strong> undergo surgery around <strong>the</strong> world each year 16 . Event operations post
surgery infections were presented in table 4.

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Table 4.
Event Operations Post Surgery Wounds Infection
Physica scene infections wound operation N (%)
N (total samples)
60
<strong>the</strong> occurrence <strong>of</strong> wound surgery
• Yes
12 (20,0)
• No
48 (80,0)
N (total samples)
• Time <strong>of</strong> operation wound infection
• Day 3
• Day 7
• Day 21
The detected infections wound operation
• At Inpatient
• At <strong>the</strong> polyclinic during <strong>the</strong> control
• Readmision
Type wound operation infections
• Superficial SSI
• Deep SSI
• Organ/ space SSI
Classification wound operation based
mortalitas contamination
• Clean
• Clean contaminated
• Contaminated
• Gross
12
5 (41,7)
7 (58,3)
0 (0)
5 (41,7)
7 (58,3)
0 (0)
10 (83,3)
2 (16,7)
0 (0)
22 (36,7)
32 (53,3)
3 (5,0)
3 (5,0)
CONCLUSIONS AND RECOMMENDATIONS
The conclusions can be drawn from <strong>the</strong> results <strong>of</strong> research are: 1.
characteristics <strong>of</strong> <strong>the</strong> subject sub, education, variable age <strong>of</strong> antibiotic prophylaxis,
<strong>the</strong> provision <strong>of</strong> <strong>the</strong> antibiotic prophylaxis, confirmation <strong>of</strong> <strong>surgical</strong> procedures,
<strong>surgical</strong> nurse review team equipment is sterile and providing prophylaxis
antibiotics before surgery effect 60 minutes statistically meaningful significantly
(p

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Suggestion that can be given is: 1. Development mechanism in <strong>the</strong> form <strong>of</strong>
monitoring and reporting structured: digit gen infection scrapes operations, granting
antibiotic prophylactic and <strong>the</strong> granting <strong>of</strong> antibiotics in a hospital, 2. The need for
attention to <strong>the</strong> improvement <strong>of</strong> quality management in facilitating service with <strong>the</strong>
<strong>use</strong> <strong>of</strong> <strong>surgical</strong> <strong>safety</strong> <strong>checklist</strong> WHO in <strong>surgical</strong> procedures in order to lower <strong>the</strong>
incidence <strong>of</strong> infection wound surgery; 3. Activating <strong>the</strong> role <strong>of</strong> nosocomial infection
in a team doing a continuous evaluation and monitoring, 4. Do adopting SSCL
WHO.

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