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SURGICALTEAMCOMMUNICATION
November26,2008www.perspect.ca
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Defini>on:
‐aprocessbywhichinforma>onisexchangedbetweenindividualsthroughacommonsystemofsymbols,signs,orbehavior
Communica>on
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Outline
Importanceofeffec>vecommunica>oninsurgicalteams
CurrentpiPallsinORcommunica>on Newcommunica>ontools
SBAR ORbriefings
Medicalteamtraining
Implementa>on
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Preventablemedicalerrors
Ins>tuteofMedicine’s1999report“ToErrisHuman”
preventablemedicalerrorsresultin: 44,000‐98,000deaths/yearinUShospitals
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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/
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TeamworkintheOR
posi>veaftudestowardsteamwork reducederrorsinavia>onandICUs increasedjobsa>sfac>on lesssick>meusedbyemployees decreasedemployeeturnover
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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
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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
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Percentage(rounded)ofopera>ngroom(OR)caregiversrepor>nga“high”or“veryhigh”levelofcollabora>onwithothermembersoftheORteam.
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Barrierstoeffec>veteamcommunica>onintheOR
ORsefng masks noise
hierarchicalstructure
workoverload
distrac>ngcommunica>on
communica>onplan accountability
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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
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Communica>onfailures(cont’d)
31%ofcommunica>oneventsfail usuallydueto>mingorcontent
one‐thirdresultinimmediateeffects delay inefficiency teamtension
Mayleadtofalsesenseofsecurityandmigra>onintopoten>aldangerzone
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CrewResourceManagement
history originated1979 NASAresearchshowedthatmajorityofavia>onaccidentswerecausedbyhumanerror
specificallyfailuresofcommunica>on,leadershipanddecision‐making
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CRMTraining
encompassesknowledge,skillsandaftudes
includes: communica>on leadership problem‐solving situa>onalawareness decision‐making
teamworkskills conflictresolu>on
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CRMinMedicine
SBAR
Opera>ngRoomBriefings
MedicalTeamTraining
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SITUATION Whatisgoingonwiththepa>ent?
BACKGROUND Whatisthekeyclinicalbackgroundorcontext?
ASSESSMENT WhatdoIthinktheproblemis?
RECOMMENDATION WhatdoIthinkyoushoulddoandwhen?
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SBAR
communica>ontechniqueprovidingaframeworkforadiscussionaboutapa>ent
usesastandardizedformat enhancesclarityandefficiencyofcommunica>on
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PossibleusesofSBAR
anesthesiahand‐offs
crisismanagement
reques>ngaconsult hand‐oversatshijchangeorforwardtransfers
nurse‐physiciancommunica>onsregardingpa>entstatus
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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.
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Opera>ngRoomBriefings
alsocalledateamchecklist
addressessafetyissuesby: decreasingrelianceonmemory standardizingprocesses increasingaccesstoinforma>on providingfeedback
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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
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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
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Developmentandpilotimplementa>onofachecklist
not>meconsumingoronerous
increasednursingknowledgeofhistoryandplan
improvedORefficiency
reducedequipmentdelays
inconvenienttosurgeons
interruptedworkflow
iftoolate,redundant
Pros Cons
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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
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Studyofpre‐opera>vechecklisttoreducecommunica>onfailures
observed302checklistbriefings 1–4minutes 8%beforepa>entarrivaltoOR 34%ajerpa>entarrival,beforeinduc>on 47%ajerinduc>onofgeneralanesthesia
(11%>mingwasnotdocumented)
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Studyofpre‐opera>vechecklisttoreducecommunica>onfailures
observed86eachpre‐andpost‐interven>onprocedures
#ofcommunica>onfailuresperprocedure 3.95beforeintroduc>onofchecklist
1.31ajerintroduc>onofchecklist P<0.001
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Func>onalu>lityofchecklistbriefings
34%(100/295)showedsomefunc>onalu>lity iden>fiedaproblem revealedanambiguity exposedacri>calknowledgegap provokedachangeinplan
promptedafollow‐upac>on
44%hadadirectimpactonpa>entcare
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Implementa>on
BARRIERS ORprofessionalsaccustomedtoindependence
“individualexcellenceshouldbesufficient”
overwhelmedandmaypriori>zeotherdu>es
ASSETS engagingteammembers
stake‐holdermee>ngs
surgeon“champions”
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MedicalTeamTraining
usesinterdisciplinaryteamtraining
surgicalteamsworkinahigh‐stress,high‐workload,>me‐pressuredenvironment needflexible,opencommunica>on
mustan>cipateothermembers’needs
GOAL:
totransformateamofexpertsintoan“expertteam”
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MedicalTeamTraining
teamtrainingfocusesonnon‐technicalskills leadership decisionmakingability situa>onawareness communica>on
teamskills coordina>on vigilance
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ApproachestoTeamTraining
CLASSROOM‐BASEDTEACHING
lectures
videos
case‐reviews problem‐solving
exams
MEDICALSIMULATION
high‐fidelitysimulatedOR
prac>cenewprotocolsinworksefng
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ApproachestoTeamTraining
CLASSROOM‐BASEDTEACHING
noexpensiveequipment
teachmanystaffsimultaneously
canupdateandorientnewstaffasneeded
MEDICALSIMULATION
hands‐onprac>ce deploynewskillsincomplexenvironment
enhancecross‐roleunderstanding
immediatefeedback
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MedicalTeamTraining
difficulttocausepermanentchangewithonlyasingleinterven>on
peopleneedrepe>>vetrainingandprac>cetochangebehaviours
workplacere‐inforcementisbeneficial
“champions”ofthenewbehavioursareideal
classroomteachingandmedicalsimula>oncouldbeusedtogether
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WHO’s“SafeSurgerySavesLives”
beganinJanuary2007
officiallylaunchedJune2008
iden>fiedfourareasrequiringimprovementinordertoincreasepa>entsafetyduringsurgery surgicalsiteinfec>onpreven>on safeanesthesia
safesurgicalteams measurementofsurgicalservices
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Pilotevalua>onofWHO“SurgicalSafetyChecklist”
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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
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SafeSurgicalTeams
!
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
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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
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FrameworkforHarmPreven>on
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BodomLine
IOMandJCAHOhavebothrecommendedadop>onofavia>onsafetyprinciples
WHOsupportsimprovedsurgicalsafetyanduseofanORchecklist theWHOini>a>veisendorsedworldwide
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NextSteps…
Howbesttoimplementandmaintainnewini>a>ves?
Par>cipa>oniscrucial–considerbecomingachampion
Nextmee>ngofORsafetycommideeisJanuary21,2009
ContactDr.CraigBosenbergforfurtherinforma>on
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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)