SURGICALTEAMCOMMUNICATION

November26,2008www.perspect.ca

Defini>on:

‐aprocessbywhichinforma>onisexchangedbetweenindividualsthroughacommonsystemofsymbols,signs,orbehavior

Communica>on

Outline

  Importanceofeffec>vecommunica>oninsurgicalteams

  CurrentpiPallsinORcommunica>on  Newcommunica>ontools

 SBAR ORbriefings

 Medicalteamtraining

  Implementa>on

Preventablemedicalerrors

  Ins>tuteofMedicine’s1999report“ToErrisHuman”

  preventablemedicalerrorsresultin: 44,000‐98,000deaths/yearinUShospitals

Primaryrootcauseanalysisofsen>nelevents

  delayintreatment  84%‐breakdownincommunica>on

  wrongsitesurgery  >50%‐breakdownincommunica>onbetweensurgicalteammembers

andthepa>entandfamily  opera>veandpost‐opcomplica>ons

  66%‐failureincommunica>on   ven>lator‐relateddeathsandinjuries

  70%‐communica>onbreakdown  infantdeathandinjuryduringdelivery

  72%involvedcommunica>onissues(with55percentci>ngorganiza>oncultureasabarriertoeffec>vecommunica>onandteamwork)

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

TeamworkintheOR

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

TeamworkintheOR

  Makaryetal.,JAMCollSurg,2006 surveyedORpersonnelregardingaftudestowardteamworkandcollabora>on

 60hospitalsinvolved 2769ques>onnaires

 77.1%responserate

MakaryMA,SextonJB,FreischlagJA,HolzmuellerCG,MillmanEA,RowenL,PronovostPJ.Opera>ngRoomTeamworkamongPhysiciansandNurses:TeamworkintheEyeoftheBeholder.JAmCollSurg2006;202:746‐752

Samplesurveyitems

  ratedona5‐pointLikertscale  thephysiciansandnurseshereworktogetherasawell‐coordinatedteam

  Iamfrequentlyunabletoexpressdisagreementwiththestaffphysicianshere

  importantissuesarewellcommunicatedatshijchange  Iamsa>sfiedwiththequalityofcollabora>onIexperiencewith(staffphysicians/nurses)inthisclinicalarea

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ratings of teamwork (3.68 of 5.00) and OR nurses(scrub and circulating) were given the highest ratings ofteamwork (4.20 of 5.00). This, despite the fact that sur-geons and anesthesiologists rated teamwork within theirown discipline the highest, their group received the low-est ratings overall. In addition, OR nurses, who weregiven the highest overall ratings of teamwork, ratedteamwork with surgeons as only 3.52 of 5.00, relative tothe higher ratings surgeons gave OR nurses (4.42 of5.00).

Each OR caregiver rated teamwork with their owncolleagues highly within their peer group at their hospi-tal. Surgeons rated teamwork among surgeons highly,with 85.2% describing the teamwork with surgeons as“high” or “very high” (Fig. 1). Similarly, anesthesiologistsrated teamwork among anesthesiologists very highly andCRNAs rated CRNAs very well (scores were 95.8 and92.7, respectively). In fact, surgeons perceived thateveryone in the OR is doing a good job in terms ofteamwork (Fig. 2). Figures 3A, 3B, and 3C display thecontrast between surgeons and nurses, surgeons and an-esthesiologists, and anesthesiologists and nurses, respec-tively, and Figures 4A and 4B demonstrate interpositiondifferences in teamwork among all members of the OR.Such differences underscore the disconnect in teamworkand the methodological barrier in aggregating measuresof teamwork in surgery.

DISCUSSIONSubstantial discrepancies in perceptions of teamwork ex-ist in the OR, with physicians rating the teamwork ofothers as good, and at the same time, nurses perceiveteamwork as poor. These findings mirror similar resultsof discrepant attitudes about collaboration betweenphysicians and nurses in intensive care units.18

Based on our findings, surgeons and anesthesiologistsappear more satisfied with physician!nurse collabora-tion than nurses. Nurses did not reciprocate the highratings of teamwork given by physicians. This mighthave been a result of fundamental and long-standingdifferences between nurses and physicians, includingstatus, authority, gender, training, and patient-care re-sponsibilities. It might also be a result of different ideasof what constitutes effective teamwork. Discussionswith respondents during survey feedback presentationshighlighted that nurses often describe good collabora-tion as having their input respected, and physicians of-ten describe good collaboration as having nurses whoanticipate their needs and follow instructions. Histori-cally, there are differences between the expectations thatphysicians and nurses bring to a communication en-counter. Nurses are trained to communicate more holis-tically, using the “story” of the patient, and physiciansare trained to communicate succinctly using the “head-

Table 1. Characteristics of Respondents Surveyed and Response Rates by Operating Room Caregiver Position

Position

Response rate

Age (y)*Women Experience in

position (y)*

Working atcurrent

hospital (y)*%Returned/

administered n %Surgeon 73 222/305 48.3 " 9.92 8.6 19 17.4 " 9.41 12.3 " 9.20Anesthesiologist 77 170/220 45.8 " 9.31 12.7 21 15.8 " 8.18 10.6 " 8.60CRNA 67 121/181 44.6 " 10.71 50.0 63 14.7 " 12.32 9.5 " 9.35OR nurse 79 1,058/1,335 43.3 " 10.85 89.0 942 13.9 " 10.04 10.7 " 8.69Total 77 2,135/2,769 42.6 " 11.3 68.5 1,462 13.7 " 10.47 10.0 " 9.08

*Values are mean " SD.CRNA, certified registered nurse anesthetist; OR, operating room.

Table 2. ANOVA Results for Teamwork Ratings by and of Each Operating Room Provider Type

Ratings of df F p ValueMean ratings* of teamwork by

OverallSurgeons Anesthesiologists CRNAs OR nurses†

Surgeons 4, 2058 41.73 ! 0.001 4.38 4.03 3.72 3.52 3.68Anesthesiologists 4, 1990 53.15 ! 0.001 4.39 4.80 4.25 3.85 3.96CRNAs 4, 1571 37.36 ! 0.001 4.37 4.58 4.67 3.94 4.04OR nurses 4, 2061 12.93 ! 0.001 4.42 4.31 4.10 4.25 4.20Surgical technicians 4, 2044 6.17 ! 0.001 4.36 4.17 3.95 4.07 4.10

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

748 Makary et al Teamwork in the Operating Room J Am Coll Surg

Percentage(rounded)ofopera>ngroom(OR)caregiversrepor>nga“high”or“veryhigh”levelofcollabora>onwithothermembersoftheORteam.

Barrierstoeffec>veteamcommunica>onintheOR

  ORsefng masks noise

  hierarchicalstructure

  workoverload

  distrac>ngcommunica>on

  communica>onplan  accountability

TypesofCommunica>onFailures

  Occasion occurredtoolate

  Content  inaccurateorincomplete

  Audience significantindividualsexcluded

  Purpose  issueslejunresolved

LingardL,EspinS,WhyteS,RegehrG,BakerGR,ReznickR,BohnenJ,OrserB,DoranD,GroberE.Communica>onFailuresintheOpera>ngRoom:anobserva>onalclassifica>onofrecurrenttypesandeffects.QualSafHealthCare2004;13:330‐334

Communica>onfailures(cont’d)

  31%ofcommunica>oneventsfail usuallydueto>mingorcontent

  one‐thirdresultinimmediateeffects delay  inefficiency  teamtension

  Mayleadtofalsesenseofsecurityandmigra>onintopoten>aldangerzone

CrewResourceManagement

  history originated1979 NASAresearchshowedthatmajorityofavia>onaccidentswerecausedbyhumanerror

 specificallyfailuresofcommunica>on,leadershipanddecision‐making

CRMTraining

  encompassesknowledge,skillsandaftudes

  includes: communica>on  leadership problem‐solving situa>onalawareness decision‐making

  teamworkskills conflictresolu>on

CRMinMedicine

  SBAR

  Opera>ngRoomBriefings

  MedicalTeamTraining

SITUATION Whatisgoingonwiththepa>ent?

BACKGROUND Whatisthekeyclinicalbackgroundorcontext?

ASSESSMENT WhatdoIthinktheproblemis?

RECOMMENDATION WhatdoIthinkyoushoulddoandwhen?

SBAR

  communica>ontechniqueprovidingaframeworkforadiscussionaboutapa>ent

  usesastandardizedformat  enhancesclarityandefficiencyofcommunica>on

PossibleusesofSBAR

  anesthesiahand‐offs

  crisismanagement

  reques>ngaconsult  hand‐oversatshijchangeorforwardtransfers

  nurse‐physiciancommunica>onsregardingpa>entstatus

ExampleofSBAR

  Dr.Jones,thisisNurseMcDonald,IamcallingfromABCHospitalaboutyourpa>entJaneSmith.

  Situa&on:Here'sthesitua>on:Mrs.Smithishavingincreasingdyspneaandiscomplainingofchestpain.

  Background:Thesuppor>ngbackgroundinforma>onisthatshehadatotalkneereplacementtwodaysago.Abouttwohoursagoshebegancomplainingofchestpain.Herpulseis120andherbloodpressureis128/54.Sheisrestlessandshortofbreath.

  Assessment:Myassessmentofthesitua>onisthatshemaybehavingacardiaceventorapulmonaryembolism.

  Recommenda&on:Irecommendthatyouseeherimmediatelyandthatwestartheron02stat.

Opera>ngRoomBriefings

  alsocalledateamchecklist

  addressessafetyissuesby: decreasingrelianceonmemory standardizingprocesses  increasingaccesstoinforma>on providingfeedback

Developmentandpilotimplementa>onofachecklist

  Lingardetal.2005

  developedownchecklist

  studieditsusein18vascularsurgeryprocedures  elicitedfeedbackfrompar>cipants

LingardL,EspinS,RubinB,WhiteS,ColmenaresM,BagerGR,DoranD,GroberE,OrserB,BohnenJ,ReznickR.GefngTeamstoTalk:developmentandpilotimplementa>onofachecklisttopromoteinterprofessionalcommunica>onintheOR.QualSafHealthCare2005;14:340‐346

Developmentandpilotimplementa>onofachecklist

  dura>on averaged3.5minutes(range1‐6min)

  >ming (numberofchecklistsdone)

 beforepa>entarrival 9 ajerarrival,beforeinduc>on 5 ajerinduc>on 4

  loca>on  inOR 13  inhallway 4

  inholdingarea 1

Developmentandpilotimplementa>onofachecklist

  not>meconsumingoronerous

  increasednursingknowledgeofhistoryandplan

  improvedORefficiency

  reducedequipmentdelays

  inconvenienttosurgeons

  interruptedworkflow

  iftoolate,redundant

Pros Cons

Studyofpre‐opera>vechecklisttoreducecommunica>onfailures

  13monthprospec>vestudy

  #ofcommunica>onfailurespre‐andpost‐checklistinterven>on

  func>onalu>lityofchecklist

LingardL,RegehrG,OrserB,ReznickR,BakerGR,DoranD,EspinS,BohnenJ,WhyteS.Evalua>onofaPreopera>veChecklistandTeamBriefingAmongSurgeons,Nurses,andAnesthesiologiststoReduceFailuresinCommunica>on.ArchSurg2008;143:12‐17

Studyofpre‐opera>vechecklisttoreducecommunica>onfailures

  observed302checklistbriefings 1–4minutes 8%beforepa>entarrivaltoOR 34%ajerpa>entarrival,beforeinduc>on 47%ajerinduc>onofgeneralanesthesia

  (11%>mingwasnotdocumented)

Studyofpre‐opera>vechecklisttoreducecommunica>onfailures

  observed86eachpre‐andpost‐interven>onprocedures

  #ofcommunica>onfailuresperprocedure 3.95beforeintroduc>onofchecklist

 1.31ajerintroduc>onofchecklist P<0.001

Func>onalu>lityofchecklistbriefings

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

 promptedafollow‐upac>on

  44%hadadirectimpactonpa>entcare

Implementa>on

BARRIERS  ORprofessionalsaccustomedtoindependence

  “individualexcellenceshouldbesufficient”

  overwhelmedandmaypriori>zeotherdu>es

ASSETS  engagingteammembers

  stake‐holdermee>ngs

  surgeon“champions”

MedicalTeamTraining

  usesinterdisciplinaryteamtraining

  surgicalteamsworkinahigh‐stress,high‐workload,>me‐pressuredenvironment needflexible,opencommunica>on

 mustan>cipateothermembers’needs

GOAL:

  totransformateamofexpertsintoan“expertteam”

MedicalTeamTraining

  teamtrainingfocusesonnon‐technicalskills  leadership decisionmakingability situa>onawareness communica>on

  teamskills coordina>on vigilance

ApproachestoTeamTraining

CLASSROOM‐BASEDTEACHING

  lectures

  videos

  case‐reviews  problem‐solving

  exams

MEDICALSIMULATION

  high‐fidelitysimulatedOR

  prac>cenewprotocolsinworksefng

ApproachestoTeamTraining

CLASSROOM‐BASEDTEACHING

  noexpensiveequipment

  teachmanystaffsimultaneously

  canupdateandorientnewstaffasneeded

MEDICALSIMULATION

  hands‐onprac>ce  deploynewskillsincomplexenvironment

  enhancecross‐roleunderstanding

  immediatefeedback

MedicalTeamTraining

  difficulttocausepermanentchangewithonlyasingleinterven>on

  peopleneedrepe>>vetrainingandprac>cetochangebehaviours

  workplacere‐inforcementisbeneficial

  “champions”ofthenewbehavioursareideal

  classroomteachingandmedicalsimula>oncouldbeusedtogether

WHO’s“SafeSurgerySavesLives”

  beganinJanuary2007

  officiallylaunchedJune2008

  iden>fiedfourareasrequiringimprovementinordertoincreasepa>entsafetyduringsurgery surgicalsiteinfec>onpreven>on safeanesthesia

 safesurgicalteams measurementofsurgicalservices

Pilotevalua>onofWHO“SurgicalSafetyChecklist”

Pilotevalua>onofWHO“SurgicalSafetyChecklist”  1000pa>ents

  8sitesworldwide

  adherencetoprovenstandardsofsurgicalcare hasincreasedfrom36%to68%

  reducedcomplica>onsanddeaths

WorldHealthOrganiza0on.Safesurgerysaveslives.Availableonlinefrom,hdp://www.who.int/pa>entsafety/safesurgery/tes>ng/pilot_sites/en/index.html

SafeSurgicalTeams

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9THE SECOND GLOBAL PATIENT SAFETY CHALLENGE: SAFE SURGERY SAVES LIVES

WHO has undertaken a number of global and regional initiatives to address surgical

safety. The Global Initiative for Emergency and Essential Surgical Care and the Guidelines

for Essential Trauma Care focussed on access and quality. The second Global Patient

Safety Challenge: Safe Surgery Saves Lives addresses the safety of surgical care. The

World Alliance for Patient Safety initiated work on this Challenge in January 2007.

The goal of this Challenge is to improve the safety of surgical care around the world

by defining a core set of safety standards that can be applied in all WHO Member

States. To this end, working groups of international experts were convened to review

the literature and the experiences of clinicians around the world. They reached

consensus on four areas in which dramatic improvements could be made in the safety

of surgical care. These are: surgical site infection prevention, safe anaesthesia, safe

surgical teams and measurement of surgical services (see box 4).

THE SECONDGLOBAL PATIENTSAFETY

CHALLENGE:SAFE SURGERY

SAVES LIVES

8 THE SECOND GLOBAL PATIENT SAFETY CHALLENGE: SAFE SURGERY SAVES LIVES

2

Box 4: Working groups of the second Global Patient Safety Challenge

• Surgical site infection prevention: Surgical site infections remain one of the

most common causes of serious surgical complications. Evidence shows that

proven measures — such as antibiotic prophylaxis within the hour before

incision and effective sterilization of instruments — are inconsistently followed.

This is often not because of the cost or lack of resources but because of poor

systematization. Antibiotics, for example, are given perioperatively in both

developed and developing countries but they are often administered too early,

too late or simply erratically, making them ineffective in reducing patient harm.

• Safe anaesthesia: Anaesthetic complications remain a substantial cause of

surgical death globally, despite safety and monitoring standards which have

significantly reduced unnecessary deaths and disability in developed countries.

Three decades ago a patient undergoing general anaesthesia had an estimated

one in 5000 chance of death. With improvements in knowledge and basic

standards of care the risk has dropped to one in 200 000 in the developed

world— a 40-fold improvement. Unfortunately the rate of anaesthesia-associated

mortality in developing countries appears to be 100–1000 times higher, indicating

a serious, sustained lack of safe anaesthesia for surgery in these settings.

• Safe surgical teams: Teamwork is the core of all effectively functioning systems

involving multiple people. In the operating room, where tension may be high

and lives are at stake, teamwork is an essential component of safe practice. The

quality of teamwork depends on the culture of the team and its communication

patterns, as well as the clinical skills and situational awareness of the team

members. Improving team characteristics should aid communication and reduce

patient harm.

• Measurement of surgical services: A major problem in surgical safety has

been a shortage of basic data. Efforts to reduce maternal and neonatal mortality

during childbirth have been critically reliant on routine surveillance of mortality

rates and systems of obstetric care to monitor successes and failures. Similar

surveillance has generally not been undertaken for surgical care. Data on

surgical volume are available for only a minority of countries and are not

standardized. Routine surveillance to evaluate and measure surgical services

must be established if public health systems are to ensure progress in improving

the safety of surgical care.

0859_WHO_BROCHURE_10 17/6/08 15:50 Page 8

Globalsupportandendorsements

  Accredita>onCanada  AmericanAcademyofOrthopaedicSurgeons/AmericanAssocia>onof

OrthopaedicSurgeons  AmericanAcademyofOtolaryngology‐Head&Necksurgery  AmericanAssocia>onofNeurologicalSurgeons(AANS)  AmericanCollegeofSurgeons  AmericanOrthopaedicAssocia>on  AmericanSocietyofAnesthesiologists  AnesthesiaPa>entSafetyFounda>on  CanadianAnesthesiologists'Society  CanadianAssocia>onofGeneralSurgeons  CanadianMedicalAssocia>on  CanadianPa>entSafetyIns>tute  RoyalCollegeofPhysiciansandSurgeonsofCanada

FrameworkforHarmPreven>on

BodomLine

  IOMandJCAHOhavebothrecommendedadop>onofavia>onsafetyprinciples

  WHOsupportsimprovedsurgicalsafetyanduseofanORchecklist  theWHOini>a>veisendorsedworldwide

NextSteps…

  Howbesttoimplementandmaintainnewini>a>ves?

  Par>cipa>oniscrucial–considerbecomingachampion

  Nextmee>ngofORsafetycommideeisJanuary21,2009

  ContactDr.CraigBosenbergforfurtherinforma>on

Contact:

Dr. O McAllister BSc, MD, FRCP(C) Managing Partner

Colin McAllister PEng, PMP, MBA Managing Principal

Perspect Management Consulting www.perspect.ca (Contact Us)