Amid Resistance, Support Growing for Safety Checklists in the Cath Lab

Patient safety checklists, long a mainstay in surgical operating rooms, still are inconsistently designed and unevenly applied among cardiac catheterization labs. Yet a paper published in the January 2015 issue of Heart asserts that checklists can and do benefit patients undergoing interventional procedures.

“With appropriate implementation and guarding against complacency or a ‘tick-box’ exercise, checklists have the potential to promote a culture of effective team-based communication and reform patient safety in the cath lab,” write Thomas J. Cahill, MA, MBBS, of the University of Oxford (Oxford, England), and colleagues. Working under the auspices of the British Cardiovascular Society (BCS), they have developed a checklist specifically designed for use by interventional cardiologists.

Sunil V. Rao, MD, of Duke University Medical Center (Durham, NC), agreed that checklists are “extremely useful, particularly when considering high-risk patients who are undergoing PCI.” Dr. Rao coauthored the 2012 Society for Cardiovascular Angiography and Interventions (SCAI) consensus statement on best practices in the cath lab, which recommended use of a preprocedure checklist and provided an example of one tailored to the cath lab setting.

When TCTMD surveyed its readers on the topic, however, it emerged that even as checklists become more routine in practice, many interventionalists remain unconvinced that they are necessary.

TCTMD Readers Speak

Responding to the Heart paper, Stephen Clark, DM, of Freeman Hospital (Newcastle upon Tyne, England), cautions against indifference.

“[A]s is clear from the introduction of safety checklists in the surgical arena, the most significant hurdle to overcome is one of apathy following their introduction,” he writes in correspondence published online March 2, 2015, ahead of print in the journal. “If this can be overcome and the motivation of those using it maintained through strong leadership, then this will surely be an effective contribution to patient safety.”

Indeed, only 220 subscribers to TCTMD’s weekly newsletter clicked on the link to an online survey called “Safety Checklists in the Cath Lab: What’s Your Take?” this January. Among them, 44 actually completed it—66% were located in North America, 18% in Europe, and 16% in Asia.

The majority (95%) of those 44 respondents said their cath lab had a standard safety checklist. Three-quarters (74%) reported using the checklist for every case, with 12% saying they “rarely” used it and the remainder indicating they used it most or half of the time.

Most (79%) categorized their checklist as “simply a ‘time-out’ before the procedure,” while 17% used the World Health Organization (WHO) surgical checklist. Approximately half (55%) completed only verbal checklists, while 29% had printed and 16% had electronic versions.

Improving patient care was the top goal for those using a checklist at 42%. Additional reasons for using one were the Joint Commission requirement for a “time-out” (33%), the need to fulfill a safety committee requirement (15%), and reduction in the cost of liability insurance (5%). One physician added that checklists are simply the “right thing to do,” although others were unconvinced.

“It’s a total waste of time,” said one respondent, who nonetheless reported using a checklist for every case.

Several commented that the cath lab environment did not necessitate checklists. “It seems a bit silly,” a physician said, noting that the practice is a “solution to a problem that didn't exist in the cath lab, [which is] a little different situation than the OR.”

Another noted: “For specific procedures such as TAVR it is useful. For day-to-day stuff it hurts, as it desensitizes to what is important.”

Do Checklists Work?

“I am convinced that [checklists] help,” Dr. Rao said, adding, “The data from the airline industry and surgical specialties support their utility.”

First used more than 75 years ago as a precaution against pilot error, safety checklists entered the field of medicine relatively recently. Research studies on preoperative checklists began to appear in the literature in the mid-1990s. Then, in 2008, the well-known WHO surgical safety checklist debuted; according to an article published by the New England Journal of Medicine in 2009, its implementation at 8 test sites was associated with reductions in death and complications.

Dr. Cahill and colleagues, however, acknowledge that it is unclear exactly how checklists work. “At the most basic level there is a ‘shopping list effect’—a reminder to check, for example, the patient’s hemoglobin result, like picking up the milk,” they write. “This improves the reliability of a process and sets out an expected standard for practice. Perhaps more importantly, checklists modify team behavior, bringing a focus to patient safety and communication and empowering junior members.”

Kishore J. Harjai, MD, of Geisinger Wyoming Valley (Wilkes-Barre, PA), told TCTMD in an email that checklists also “encourage the ‘broken window’ phenomenon; ie, when small errors are identified and corrected appropriately…, larger errors are less likely to occur.”

But, he added, “Like any good thing, checklists can be overdone and become a waste of time.” Extending a surgical checklist to the cath lab “may bring in many irrelevant items,” he said, such as preprocedural antibiotics or beta-blockers and postprocedural swab count.

Ted E. Feldman, MD, of NorthShore University Health System (Evanston, Illinois), told TCTMD in a telephone interview that his center does a time-out for every case in the cath lab. “Personally I find at least some value in our verbal pre-op, but a big checklist, I think, is wasteful for cath procedures,” he said. There is little worry in this setting that the wrong procedure will be performed, Dr. Feldman added. Instead, checklists are more helpful in regards to the dosing of medications and avoidance of allergic reactions.

“All of us practitioners have different opinions [about whether checklists are worthwhile],” he said. “Some people think these are useful because it doesn’t really take much time and if you avoid one omission or commission in every couple hundred cases, it may be worth it. Some people think these are a complete waste of time.”

Dr. Feldman noted that evidence in the literature is sparse and “mixed about whether these things actually reduce complications.”

A PubMed search of the terms catheterization, laboratory, and checklist turns up, as of March 2015, only 12 related papers. In addition, Dr. Harjai highlighted The Checklist Manifesto, a book by Atul Gawande.

“So far the data are limited, but this will change,” Dr. Cahill predicted in an email interview with TCTMD. “The surgical operating theater is not a million miles away from the cath cab, and the evidence supporting the use of the [WHO checklist] is compelling.

How to Overcome Resistance

Dr. Cahill described the response to the newly developed BCS checklist as “fantastic.”

“There’s huge demand for a cath lab safety checklist that has been designed with our patients, our procedures, and our teams specifically in mind,” he said, noting that the BCS checklist was created to meet that demand. “Since the release we’ve had great responses from cardiologists, nurses, physiologists and radiographers both in the United Kingdom and overseas,” Dr. Cahill reported. “In particular, the team brief and modifiable fields on the checklist (for customization in house) have gone down very well.”

Asked whether practicing interventionalists are enthusiastic toward checklists in general, he was more circumspect. “In principle—almost always. In practice—a little encouragement is required!

“Checklists change working practice and as such will always meet with some resistance,” Dr. Cahill continued. “What’s important is that there is backing from clinical leads and the whole cath lab team—the checklist should be the expected norm rather than the personal choice of some cardiologists. For a checklist to be most effective, you need a culture of every patient, every time—including emergencies and primary angioplasty.”

He emphasized “that there are very few circumstances when the team cannot pause for the brief period required for safety checks and an informative briefing—and this process changes the team dynamic and promotes a focus on safety.

One telling detail, Dr. Cahill said, is that “[a]n overwhelming majority of clinical staff tell us they would want a checklist used if they were having a procedure in the cath lab. Engaging with the ‘human factors’ aspect of cardiology—team leadership, structured communication, and resource management—has great potential to improve safety. Checklists and team briefing are a step in that direction.”

The Motivation for Use

In the United States, the Joint Commission requires clinicians at accredited hospitals to conduct time-outs before doing invasive procedures, Dr. Feldman pointed out.

SCAI President-Elect James C. Blankenship, MD, MSc, of Geisinger Medical Center (Danville, PA), noted that another factor encouraging checklist use is participation in the National Cardiovascular Data Registry (NCDR).

“Ninety percent of cath labs in the United States report to the NCDR CathPCI Registry and that means we routinely collect lots of the information,” Dr. Blankenship said. “[W]ith our own lab, we know we will have to report it in to the NCDR so we just collect it before the procedure.”

Although he described the scenario as unlikely, Dr. Blankenship acknowledged that checklists—or the lack thereof—could, in general, “be used against you in a legal case.

“If you did not go through the checklist and then something bad happened, then the allegation could be that you were practicing substandard medicine—that if you had put everything on the checklist, then the bad thing wouldn’t have happened,” he said.

What to Include

A strength of the BCS checklist published in Heart, Dr. Blankenship said, is that it catalogues information “all in one place—from starting to during and after the procedure—to make sure it’s all done.” Yet one of the paper’s key principles is that lists “should be customizable,” he noted.

Dr. Blankenship suggested adding a specific entry for allergies as well as a spot for calculating the best volume of contrast media given the patients estimated glomerular filtration rate. A “big one” missing in the BCS version is a box for whether the case fulfills appropriate use criteria (AUC), he added. “For an ‘inappropriate’ rating, another item would be whether you consulted with another cardiologist before deciding to proceed.”

According to Dr. Rao, AUC and checklists “are related, and in labs where there are noninterventional invasive cardiologists, this is essential. The interventional cardiologist who comes in to do the PCI should make sure that the procedure is appropriate.”

Dr. Harjai agreed that AUC “will eventually have to be part of any checklist prior to invasive or noninvasive procedures. Starting in 2016, legislation will mandate the documentation of appropriateness prior to obtaining CT scans or other expensive radiology tests.” He predicted that similar record keeping will eventually be required by law before cardiac testing.

Additional items suggested by Dr. Rao were bleeding risk, candidacy for DES, any prior reaction to contrast dye, and consent. Dr. Harjai proposed taking note of when patients on enoxaparin or novel oral anticoagulants took their most recent dose, as well as whether STEMI patients were given any medications in the ED. And for patients likely to require stenting, checklists should address any contraindications to dual antiplatelet therapy, he added.



Cahill TJ, Clarke SC, Simpson IA, Stables RH. A patient safety checklist for the cardiac catheterization laboratory. Heart. 2015;101:91-93.

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