Surgical Team Communication - Perspect Management Consulting

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SURGICALTEAM COMMUNICATION

www.perspect.ca

November26,2008

Communica>onDeni>on: aprocessbywhichinforma>onisexchanged betweenindividualsthroughacommonsystem ofsymbols,signs,orbehavior

OutlineImportanceofeec>vecommunica>oninsurgical teams CurrentpiPallsinORcommunica>on Newcommunica>ontools

SBAR ORbriengs Medicalteamtraining

Implementa>on

PreventablemedicalerrorsIns>tuteofMedicines1999reportToErris Human preventablemedicalerrorsresultin: 44,00098,000deaths/yearinUShospitals

Primaryrootcauseanalysisofsen>nel events

delayintreatment

84%breakdownincommunica>on >50%breakdownincommunica>onbetweensurgicalteammembers andthepa>entandfamily 66%failureincommunica>on 70%communica>onbreakdown 72%involvedcommunica>onissues(with55percentci>ng organiza>oncultureasabarriertoeec>vecommunica>onand teamwork)

wrongsitesurgery

opera>veandpostopcomplica>ons

ven>latorrelateddeathsandinjuries

infantdeathandinjuryduringdelivery

JointCommissiononAccredita0onofHealthcareOrganiza0ons.Sen$neleventsta$s$cs:Availableonline from,hdp://www.jointcomission.ort/Sen>nelEvents/Sen>nelEventAlert/

TeamworkintheOR

posi>veaftudestowardsteamwork reducederrorsinavia>onandICUs increasedjobsa>sfac>on lesssick>meusedbyemployees decreasedemployeeturnover

TeamworkintheOR

Makaryetal.,JAMCollSurg,2006 surveyedORpersonnelregardingaftudestoward

teamworkandcollabora>on 60hospitalsinvolved 2769ques>onnaires 77.1%responserate

MakaryMA,SextonJB,FreischlagJA,HolzmuellerCG,MillmanEA,RowenL,PronovostPJ.Opera>ngRoom TeamworkamongPhysiciansandNurses:TeamworkintheEyeoftheBeholder.JAmCollSurg2006;202: 746752

Samplesurveyitems

ratedona5pointLikertscale thephysiciansandnurseshereworktogetherasawell

coordinatedteam Iamfrequentlyunabletoexpressdisagreementwiththe staphysicianshere importantissuesarewellcommunicatedatshijchange Iamsa>sedwiththequalityofcollabora>onI experiencewith(staphysicians/nurses)inthisclinicalarea

92.7, respectively). In fact, surgeons perceived that everyone in the OR is doing a good job in terms of teamwork (Fig. 2). Figures 3A, 3B, and 3C display the contrast between surgeons and nurses, surgeons and anesthesiologists, and anesthesiologists and nurses, respectively, and Figures 4A and 4B demonstrate interposition differences in teamwork among all members of the OR. Such differences underscore the disconnect in teamwork and the methodological barrier in aggregating measures of teamwork in surgery.

with respondents during survey feedback presentations highlighted that nurses often describe good collaboration as having their input respected, and physicians often describe good collaboration as having nurses who anticipate their needs and follow instructions. Historically, there are differences between the expectations that physicians and nurses bring to a communication encounter. Nurses are trained to communicate more holistically, using the story of the patient, and physicians are trained to communicate succinctly using the headMean ratings* of teamwork by Anesthesiologists CRNAs

Table 2. ANOVA Results for Teamwork Ratings by and of Each Operating Room Provider TypeRatings of df F p Value Surgeons OR nurses Overall

Surgeons Anesthesiologists CRNAs OR nurses Surgical technicians

4, 2058 4, 1990 4, 1571 4, 2061 4, 2044

41.73 53.15 37.36 12.93 6.17

0.001 0.001 0.001 0.001 0.001

4.38 4.39 4.37 4.42 4.36

4.03 4.80 4.58 4.31 4.17

3.72 4.25 4.67 4.10 3.95

3.52 3.85 3.94 4.25 4.07

3.68 3.96 4.04 4.20 4.10

*1 very low; 5 very high. Scrub and circulating. CRNAs, certified registered nurse anesthetists; df, degrees of freedom; OR, operating room.

!

Percentage(rounded)ofopera>ngroom(OR)caregiversrepor>nga highorveryhighlevelofcollabora>onwithothermembersofthe ORteam.

Barrierstoeec>veteamcommunica>on intheOR

ORsefng masks noise

hierarchicalstructure workoverload distrac>ngcommunica>on communica>onplan accountability

TypesofCommunica>onFailures

Occasion occurredtoolate

Content inaccurateorincomplete

Audience signicantindividualsexcluded

Purpose issueslejunresolved

LingardL,EspinS,WhyteS,RegehrG,BakerGR,ReznickR,BohnenJ,OrserB,DoranD,GroberE. Communica>onFailuresintheOpera>ngRoom:anobserva>onalclassica>onofrecurrenttypesandeects. QualSafHealthCare2004;13:330334

Communica>onfailures(contd)

31%ofcommunica>oneventsfail usuallydueto>mingorcontent

onethirdresultinimmediateeects delay ineciency teamtension

Mayleadtofalsesenseofsecurityandmigra>on intopoten>aldangerzone

CrewResourceManagement

history originated1979 NASAresearchshowedthatmajorityofavia>on

accidentswerecausedbyhumanerror specicallyfailuresofcommunica>on,leadershipand decisionmaking

CRMTrainingencompassesknowledge,skillsandaftudes includes:

communica>on leadership problemsolving situa>onalawareness decisionmaking teamworkskills conictresolu>on

CRMinMedicineSBAR Opera>ngRoomBriengs MedicalTeamTraining

SITUATION Whatisgoingonwiththepa>ent?

BACKGROUND Whatisthekeyclinicalbackgroundor

context?

ASSESSMENT WhatdoIthinktheproblemis?

RECOMMENDATION WhatdoIthinkyoushoulddoandwhen?

SBARcommunica>ontechniqueprovidingaframework foradiscussionaboutapa>ent usesastandardizedformat enhancesclarityandeciencyofcommunica>on

PossibleusesofSBARanesthesiahandos crisismanagement reques>ngaconsult handoversatshijchangeorforwardtransfers nursephysiciancommunica>onsregardingpa>ent status

ExampleofSBAR

Dr.Jones,thisisNurseMcDonald,Iamcallingfrom ABCHospitalaboutyourpa>entJaneSmith. Situa&on:Here'sthesitua>on:Mrs.Smithishaving increasingdyspneaandiscomplainingofchestpain. Background:Thesuppor>ngbackgroundinforma>on isthatshehadatotalkneereplacementtwodaysago. Abouttwohoursagoshebegancomplainingofchest pain.Herpulseis120andherbloodpressureis 128/54.Sheisrestlessandshortofbreath. Assessment:Myassessmentofthesitua>onisthat shemaybehavingacardiaceventorapulmonary embolism. Recommenda&on:Irecommendthatyouseeher immediatelyandthatwestartheron02stat.

Opera>ngRoomBriengsalsocalledateamchecklist addressessafetyissuesby:

decreasingrelianceonmemory standardizingprocesses increasingaccesstoinforma>on providingfeedback

Developmentandpilotimplementa>onof achecklistLingardetal.2005 developedownchecklist studieditsusein18vascularsurgeryprocedures elicitedfeedbackfrompar>cipants

LingardL,EspinS,RubinB,WhiteS,ColmenaresM,BagerGR,DoranD,GroberE,OrserB,BohnenJ,Reznick R.GefngTeamstoTalk:developmentandpilotimplementa>onofachecklisttopromoteinterprofessional communica>onintheOR.QualSafHealthCare2005;14:340346

Developmentandpilotimplementa>onof achecklist

dura>on averaged3.5minutes(range16min)

9 5 4 13 4 1

>ming

(numberofchecklistsdone)

beforepa>entarrival

ajerarrival,beforeinduc>on ajerinduc>on

loca>on inOR

inhallway inholdingarea

Developmentandpilotimplementa>onof achecklistPros

Cons

not>meconsumingor onerous increasednursing knowledgeofhistoryand plan improvedOReciency reducedequipmentdelays

inconvenienttosurgeons interruptedworkow iftoolate,redundant

Studyofpreopera>vechecklisttoreduce communica>onfailures13monthprospec>vestudy #ofcommunica>onfailurespreandpost checklistinterven>on func>onalu>lityofchecklist

LingardL,RegehrG,OrserB,ReznickR,BakerGR,DoranD,EspinS,BohnenJ,WhyteS.Evalua>onofa Preopera>veChecklistandTeamBriengAmongSurgeons,Nurses,andAnesthesiologiststoReduceFailuresin Communica>on.ArchSurg2008;143:1217

Studyofpreopera>vechecklisttoreduce communica>onfailures

observed302checklistbriengs 14minutes 8%beforepa>entarrivaltoOR 34%ajerpa>entarrival,beforeinduc>on 47%ajerinduc>onofgeneralanesthesia (11%>mingwasnotdocumented)

Studyofpreopera>vechecklisttoreduce communica>onfailuresobserved86eachpreandpostinterven>on procedures #ofcommunica>onfailuresperprocedure

3.95beforeintroduc>onofchecklist 1.31ajerintroduc>onofchecklist Ponalu>lityofchecklistbriengs

34%(100/295)showedsomefunc>onalu>lity iden>edaproblem revealedanambiguity exposedacri>calknowledgegap provokedachangeinplan promptedafollowupac>on

44%hadadirectimpactonpa>entcare

Implementa>onBARRIERSORprofessionals accustomedto independence individualexcellence shouldbesucient overwhelmedand maypriori>zeother du>es

ASSETSengagingteam members stakeholdermee>ngs surgeonchampions

MedicalTeamTrainingusesinterdisciplinaryteamtraining surgicalteamsworkinahighstress,high workload,>mepressuredenvironment

needexible,opencommunica>on mustan>cipateothermembersneeds

GOAL: totransformateamofexpertsintoan expertteam

MedicalTeamTraining

teamtrainingfocusesonnontechnicalskills leadership decisionmakingability situa>onawareness communica>on teamskills coordina>on vigilance

ApproachestoTeamTrainingCLASSROOMBASED TEACHINGlectures videos casereviews problemsolving exams

MEDICALSIMULATIONhighdelitysimulated OR prac>cenewprotocols inworksefng

ApproachestoTeamTrainingCLASSROOMBASED TEACHINGnoexpensive equipment teachmanysta simultaneously