Background: The World Health Organization (WHO) Surgical Safety Checklist has fostered safe
practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim
of this study was to evaluate reported checklist use in emergency settings and examine the relationship
with perioperative mortality in patients who had emergency laparotomy.
Methods: In two multinational cohort studies, adults undergoing emergency laparotomy were compared
with those having elective gastrointestinal surgery. Relationships between reported checklist use and
mortality were determined using multivariable logistic regression and bootstrapped simulation.
Results: Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After
adjusting for patient and disease factors, checklist use before emergency laparotomy was more common
in countries with a high Human Development Index (HDI) (2455 of 2741, 89⋅6 per cent) compared
with that in countries with a middle (753 of 1242, 60⋅6 per cent; odds ratio (OR) 0⋅17, 95 per cent c.i. 0⋅14
to 0⋅21, P < 0⋅001) or low (363 of 860, 42⋅2 per cent; OR 0⋅08, 0⋅07 to 0⋅10, P < 0⋅001) HDI. Checklist
use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk
difference −9⋅4 (95 per cent c.i. −11⋅9 to −6⋅9) per cent; P < 0⋅001), but the relationship was reversed in
low-HDI countries (+12⋅1 (+7⋅0 to +17⋅3) per cent; P < 0⋅001). In multivariable models, checklist use was
associated with a lower 30-day perioperative mortality (OR 0⋅60, 0⋅50 to 0⋅73; P < 0⋅001). The greatest
absolute benefit was seen for emergency surgery in low- and middle-HDI countries.
Conclusion: Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.