Impact of WHO's Surgical Safety Checklist-Based Program on Cleft-lip and Palate Repair Outcomes in LMICs

Abstract

Background

“Clean Cleft” (CC) is an adaptation of the Lifebox Clean Cut program, designed to reduce surgical site infections (SSIs) in cleft lip and palate repairs. It focuses on 6 key processes: hand and site decontamination, surgical linen integrity, instrument sterility, timely antibiotic use, gauze counting, and WHO Surgical Safety Checklist compliance. The study explores CC's effectiveness in reducing infections, other complications, and enhancing early recovery.

Methods

CC was piloted in 2 Ethiopian hospitals and 1 in Côte d'Ivoire, the primary public cleft care centers in each country. Baseline data were collected through direct observation in the operating room, with patients monitored postoperatively for infections and complications through daily ward visits and follow-up calls or clinic visits at 30 days. Post-intervention data were collected for 5 months. Data was captured in DHIS2 software and analyzed using SPSS version 26.

Results

The program enrolled 275 patients, with 156 during baseline and 119 post-implementation. Complications significantly dropped from 21.7% to 8.7% (P = .008), a 60% decrease. SSI rates fell from 18.1% to 8.0% (P = .03), while palatal fistulas decreased from 13.0% to 6.1% (P = .1) and wound dehiscence from 18.0% to 8.0% (P = .03). Adherence to perioperative standards improved, except for hand and skin preparation while pain management remained effective throughout the program.

Conclusion

CC improved perioperative practices, significantly reducing infections, palatal fistulas, and wound dehiscence, supporting the broader program expansion to any subspecialty.

Keywords

surgical site infection cleft lip & palate quality improvement LMIC infection prevention outcome

Get full access to this article

View all access options for this article.

References

Hlongwa

Levin

Rispel

. Epidemiology and clinical profile of individuals with cleft lip and palate utilizing specialized academic treatment centers in South Africa. PLoS One. 2019;14(5):e0215931. doi: https://doi.org/10.1371/journal.pone.0215931

Shkoukani

Lawrence

Liebertz

Svider

. Cleft palate: A clinical review. Birth Defects Res C Embryo Today. 2014;102(4):333–342. doi: https://doi.org/10.1002/bdrc.21083

Yılmaz

Özbilen

EÖ

Stunk

. The prevalence of cleft lip and palate patients: A single-center experience for 17 years. Turk J Orthod. 2019;32(3):139–144. doi: https://doi.org/10.5152/TurkJOrthod.2019.18094

Naidu

Yao

Chong

Magee

. Cleft Palate Repair: A History of Techniques and Variations. Plast Reconstr Surg Glob Open. 2022;10(3):e4019. doi: https://doi.org/10.1097/GOX.0000000000004019

Fillies

Homann

Meyer

Reich

Joos

Werkmeister

. Perioperative complications in infant cleft repair. Head Face Med. 2007;3(1):1–5. doi: https://doi.org/10.1186/1746-160X-3-9

Schönmeyr

Wendby

Campbell

. Early surgical complications after primary cleft lip repair: A report of 3108 consecutive cases. Cleft Palate-Craniofacial Journal. 2015;52(6):706–710. doi: https://doi.org/10.1597/14-158

Andersen

. Prevention of postoperative wound infections. In Prevention and control of infections in hospitals. Springer International Publishing, 2019, pp. 377–437. doi: https://doi.org/10.1007/978-3-319-99921-0_33

Schönmeyr

Restrepo

Wendby

Gillenwater

Campbell

. Lessons learned from two consecutive cleft lip and palate missions and the impact of patient education. J Craniofacial Surg. 2014;25(5):1610–1613. doi: https://doi.org/10.1097/SCS.0000000000000999

Massenburg

Hopper

Crowe

, et al. Global burden of orofacial clefts and the world surgical workforce. Plast Reconstr Surg. 2021;148(4):568e–580e. doi:https://doi.org/10.1097/PRS.0000000000008334

10.

Mammo

, Feyssa MD, Haile ST, Fikre T, Shiferaw MA, Woldeamanuel H, Temesgen F, Gebeyehu N, Starr N, Fernandez K, et al. Evaluation of an adaptive, multimodal intervention to reduce postoperative infections following cesarean delivery in Ethiopia: study protocol of the CLEAN-CS cluster-randomized stepped wedge interventional trial. Trials. 2022;23(1):692. doi: https://doi.org/10.1186/s13063-022-06500-9

11.

Mattingly

, Starr N, Bitew S, Forrester JA, Negussie T, Bereknyei Merrell S, Weiser TG. Qualitative outcomes of Clean Cut: Implementation lessons from reducing surgical infections in Ethiopia. BMC Health Serv Res. 2019;19(1):1–10. doi: https://doi.org/10.1186/s12913-019-4383-8

12.

Forrester

, Koritsanszky L, Parsons BD, Hailu M, Amenu D, Alemu S, Jiru F, Weiser TG. Development of a surgical infection surveillance program at a tertiary hospital in Ethiopia: Lessons learned from two surveillance strategies. Surg Infect (Larchmt). 2018;19(1):25–32. doi: https://doi.org/10.1089/sur.2017.136

13.

Schönmeyr

Wendby

Campbell

. Early surgical complications after primary cleft lip repair: A report of 3108 consecutive cases. Cleft Palate-Craniofacial J. 2015;52(6):706–710. doi: https://doi.org/10.1597/14-158

14.

Abdurrazaq

Micheal

Lanre

Olugbenga

Akin

. Surgical outcome and complications following cleft lip and palate repair in a teaching hospital in Nigeria. Afr J Paediatr Surg. 2013;10(4):345–357. doi: https://doi.org/10.4103/0189-6725.125447

15.

Al-Thunyan

Aldekhayel

Al-Meshal

Al-Qattan

. Ambulatory cleft lip repair. Plast Reconstr Surg. 2009;124(6):2048–2053. doi: https://doi.org/10.1097/PRS.0b013e3181bcf305

16.

Jones

JLP

, Canady JW, Brookes JT, Wehby GL, L'Heureux J, Schutte BC, Murray JC, Dunnwald M. Wound complications after cleft repair in children with Van der Woude syndrome. J Craniofacial Surg. 2010;21(5):1350–1353. doi: https://doi.org/10.1097/SCS.0b013e3181ec6aad

17.

Lees

Pigott

. Early postoperative complications in primary cleft lip and palate surgery-how soon may we discharge patients from hospital? Br J Plast Surg. 1992 Jan 1;45(3):232–234. doi: https://doi.org/10.1016/0007-1226(92)90084-B

18.

Katusabe

Hodges

Galiwango

Mulogo

. Challenges to achieving low palatal fistula rates following primary cleft palate repair: Experience of an institution in Uganda. BMC Res Notes. 2018;11(1):1–6. doi: https://doi.org/10.1186/s13104-018-3459-6

19.

Skinner

Arvedson

Jones

Spinner

Rockwood

. Post-operative feeding strategies for infants with cleft lip. Int J Pediatr Otorhinolaryngol. 1997 Dec 10;42(2):169–178. doi: https://doi.org/10.1016/S0165-5876(97)00127-8

20.

Matsunaka

Ueki

Makimoto

. Impact of breastfeeding or bottle-feeding on surgical wound dehiscence after cleft lip repair in infants: A systematic review protocol. JBI Database System Rev Implement Rep. 2015;13(10):3–11. doi: https://doi.org/10.11124/jbisrir-2015-2336

21.

Duarte

Ramos

Cardoso

MCdeAF

. “Métodos de alimentação para crianças com fissura de lábio e/ou palato: Uma revisão sistemática,” Braz J Otorhinolaryngol., vol. 82, no. 5. Elsevier Editora Ltda, pp. 602–609, 2016. doi: https://doi.org/10.1016/j.bjorl.2015.10.020

22.

Melhem

, Ramly EP, Al Abyad OS, Chahine EM, Teng S, Vyas RM, Hamdan US. Enhanced recovery after cleft lip repair: Protocol development and implementation in outreach settings. Cleft Palate Craniofacial J. 2022;60(6):724–733. doi: https://doi.org/10.1177/10556656221078744

23.

Paine

, Paliga JT, Tahiri Y, Fischer JP, Wes AM, Wink JD, Gelder CA, Taylor JA. An assessment of 30-day complications in primary cleft palate repair: A review of the 2012 ACS NSQIP pediatric. Cleft Palate Craniofacial J. 2016;53(3):357–362. doi: https://doi.org/10.1597/14-193

Impact of WHO's Surgical Safety Checklist-Based Program on Cleft-lip and Palate Repair Outcomes in LMICs—The CLEAN CLEFT Program

Abstract

Background

Methods

Results

Conclusion

Keywords

Get full access to this article

References