What is the recommended checklist for surgical clearance?

Surgical Clearance Checklist

Use an institution-approved surgical safety checklist that includes three critical pause points (sign-in, time-out, and sign-out) to verify patient identity, procedure, operative site, and essential safety measures before, during, and after surgery. 1, 2

Pre-Operative Checklist Components

Patient Verification and Consent

• Verify the informed consent form explicitly describes the procedure and operative site without abbreviations 3
• Ask the patient which site is to be operated on before administering any medications 3
• Confirm that the patient's response, informed consent, and physician's orders all match for the operative site 3
• For bilateral sites, use standardized coding (Right=1, Left=2, Bilateral=3) 3

Site Marking and Verification

• The surgeon must discuss the planned procedure with the patient and mark the appropriate site 3
• Office chart notes must be physically available in the operating room 3
• Write the patient's name, operative site, and any implant information on a visible whiteboard in the operating room 3

Patient Optimization Screening

• Screen for smoking, alcohol usage, hypertension, diabetes, and anemia 1
• Perform nutritional assessment 1
• Conduct delirium screening 1
• Perform preoperative HIV testing in countries with high HIV/AIDS prevalence 1
• Complete clinical cardiorespiratory assessment 1

Specific Pre-Operative Protocols

• Fasting: Allow oral clear fluids up to 2 hours before induction; light meals up to 6 hours; full meals (meat, fatty foods) require 8+ hours 1
• Carbohydrate loading: Give 400ml complex carbohydrate drink (50g CHO, 12g/100ml, osmolality <300 mOsm/kg) 2 hours before surgery 1
• Bowel preparation: Do NOT routinely use mechanical bowel preparation for elective colonic or gynecologic surgery 1
• Premedication: Avoid routine premedication; consider short-acting anxiolytic only for severe anxiety 1

For Elderly Patients (Age >75 Years)

• Allow additional time for preparation 1
• Keep functional aids (glasses, hearing aids, dentures) in place until just before induction 1
• Complete a specific elderly patient checklist after WHO sign-in but before induction 1

Intra-Operative Checklist Components

Formal Time-Out Procedure

• Conduct structured closed-loop communication where information is stated and verbally confirmed by all team members 3
• Verify patient identity, planned procedure, operative site, and any implants or special equipment required 3
• Acknowledge completion of the perfusion checklist during the surgical safety checklist "team time out" 1
• Ensure the operative plan is visible so the surgeon can read it while gowned and gloved 3

Essential Safety Measures

• Antimicrobial prophylaxis: Administer first-generation cephalosporin within 1 hour of incision; do NOT continue postoperatively 1, 2
• PONV prophylaxis: Assess all patients for risk; give 2-3 antiemetics to high-risk patients and continue postoperatively as needed 1
• VTE prophylaxis: Use combination of compression stockings and/or intermittent pneumatic compression with LMWH or unfractionated heparin; continue in hospital 1
• Temperature management: Maintain core temperature ≥36°C; use active warming for all operations >30 minutes 1

Monitoring Requirements

• Use standard AAGBI monitoring guidelines 1
• For elderly or high-risk patients: Consider intra-arterial blood pressure monitoring before induction to prevent hypotension (defined as >20% drop from baseline systolic BP) 1

Anesthesia Protocol

• Use short-acting anesthetic agents 1
• Implement lung-protective ventilation 1
• Ensure complete reversal of neuromuscular blockade 1
• Use multimodal opioid-sparing analgesia combined with local/regional blocks 1
• For open abdominal surgery, use mid-thoracic epidural analgesia 1

COVID-19 Specific Measures (When Applicable)

• Perform PCR test for suspected cases 1
• Use dedicated OR with negative pressure (5 Pa) 1
• Reduce OR personnel to strict minimum and establish traceability 1
• All staff must wear: head cover, shoe cover, surgical gowns, surgical goggles, 2 pairs of gloves, FFP2 masks 1
• Limit circuit disconnections during positioning 1

Post-Operative Checklist Components

Immediate Post-Operative Review

• Review RV and LV function, especially septal motion, within first 24 hours postoperatively 1
• Check cardiac-specific enzyme release within first 24 hours 1
• Maintain temperature monitoring during transport and in recovery area 1

Documentation and Follow-Up

• Document all CPB-related incidents using perioperative checklist 1
• Establish clear emergency contact details and transport plans for discharge 1
• Provide postoperative education in oral, written, and/or pictorial format to patient and caregiver 1

Implementation Requirements

The checklist must be used meaningfully, not as a "tick-box" exercise, with multidisciplinary team involvement and regular auditing of compliance. 2, 4

Key Success Factors

• Obtain leadership support and commitment 2
• Include all team members in implementation to increase buy-in 2
• Conduct regular audits and provide feedback on compliance 2
• Integrate with existing workflows to avoid overburdening clinicians 2
• Adapt to local context while maintaining core safety elements 2

Common Pitfalls to Avoid

• Checklist fatigue: Do not implement too many checklists simultaneously 2
• Superficial compliance: Ensure meaningful use rather than perfunctory completion 2
• Lack of training: Provide adequate training for new staff and use simulation-based practice 3
• Poor communication: Use structured closed-loop communication, not passive reading 3

This comprehensive approach has demonstrated reduction in surgical complications from 27.3% to 16.7% and mortality from 1.5% to 0.8% in high-quality studies. 5, 6