109 Compliance Rates of the WHO’s Surgical Safety Checklist, Within a District General Hospital’s ENT Department

Abstract Background The WHO’s Surgical Safety Checklist (SSC) is a required component of surgical procedures. It has been proven to decrease patient mortality. This audit’s objective was to assess the compliance with the timeout segment (specifically, the confirmation of all team members) of the SSC, at a district general hospital’s ENT department in comparison to WHO guidance. Method A prospective audit analysing elective and emergency theatres was undertaken over four months (1st cycle: 12/05/23- 21/06/23 and 2nd cycle: 27/07/23-20/08/23) with 19 patients for each cycle. The assessment focused on the completion of the segment’s names section, which included the names of the surgeon, surgical assistants, anaesthetic consultant, and registrar, and team leader for each case. Results During the first cycle, the Trust’s compliance rate for filling the sections was 4%. However, following our interventions of email communications and face-to-face staff meetings to theatre personnel on the importance of completing the theatre board with the categories’ names, there was an improvement resulting in a 100% compliance for all sections. To ensure compliance continued, we presented our findings within clinical governance meetings as our secondary intervention. Conclusions This audit demonstrated that simple measures could help to ensure compliance to WHO protocols as well as illustrating our Trust’s compliance to WHO guidance. To ensure ongoing compliance, a third cycle with interventions ensuring that new rotating staff are informed about the significance of the WHO SSC is needed. Furthermore, it may be beneficial to conduct analysis across various surgical specialties for comparative studies.