Training Teams for the Perioperative Environment: A Research Agenda

Perioperative crisis resource management simulation training in anaesthesia

Simulation-based education is now recognised to be a valuable tool to impart both technical and non-technical skills to healthcare professionals of all levels. Simulation is an well accepted educational tool for cultivating teamwork skills among residents globally. Simulation-based education encompasses diverse modalities, ranging from task trainers and simulated patients to sophisticated high-fidelity patient simulators. Notably, anaesthesiologists globally were early advocates of integrating simulation into education, particularly to instruct anaesthesia residents about the intricacies of perioperative crisis resource management and collaborative interdisciplinary teamwork. Given the inherent high-risk nature of anaesthesia, where effective teamwork is pivotal to averting adverse patient outcomes, and also to improve overall outcome of the patient, simulation training becomes imperative. This narrative review delves into the contemporary landscape of simulation training in perioperative anaesthesia management, examining the pedagogical approaches, simulators, techniques and technologies employed to facilitate this training.

Postgraduate training in anaesthesiology - A modular curriculum

The primary objective of postgraduate medical education is to produce specialists who provide highest quality of health care to suffering patients and return them to the community in the most functional capability. The secondary objective is to advance the cause of science through research and training. A postgraduate, after undergoing the required training in anaesthesiology, should be able to recognise the health needs of the community and apply cognitive and psychomotor skills to provide optimal anaesthetic care. Additionally, the anaesthesiologist should function as a perioperative physician being adept in perioperative care, pain medicine and critical care medicine. The 3-year postgraduate curriculum comprises experience in basic, subspeciality and advanced anaesthesia training. This structured training programme with a curriculum of increasing difficulty and learning incorporates ascending grades of difficulty, posing a challenge to the trainee's intellect and technical skills. Experience in basic anaesthesia training is aimed to lay stress on basic and fundamental aspects of anaesthetic management. Subspeciality anaesthesia training is needed to lay stress on the theory, special considerations and practice of subdisciplines of anaesthesiology. This document proposes a modular-structured, continuous, objectively evaluated, systematic training process that is monitored frequently and periodically, such that the trainee, at the end of training, is capable of appropriate anaesthetic management of disease conditions in a wide variety of situations.

Improving Operating Room and Perioperative Safety: Background and Specific Recommendations

The 1999 Institute of Medicine report To Err Is Human put a spotlight on death from preventable medical errors. Surgically related errors are second only to medication errors as the most frequent cause of error-related death. Although many hospitals have ongoing programs to improve medication safety, most hospitals are not focused in a meaningful way on operating room (OR) safety despite the import of the OR to the hospital's finances and despite clearly efficacious available technologies. The perioperative environment is a high-risk area with high velocity, high complexity, and high stakes. OR errors lead to disproportionately more harm than errors elsewhere in the hospital. Actual adverse events are relatively rare in any given OR suite, but near misses are rather common. It is possible to learn much from evaluating near misses (along with adverse events) with root-cause analyses and then instituting changes in processes and systems to assist humans from making their inevitable errors. This article outlines approaches that when combined can markedly improve safety in the OR.

Optimizing Operating Room Scheduling

This article reviews the management of an operating room (OR) schedule and use of the schedule to add value to an organization. We review the methodology of an OR block schedule, daily OR schedule management, and post anesthesia care unit patient flow. We discuss the importance of a well-managed OR schedule to ensure smooth patient care, not only in the OR, but throughout the entire hospital.

Creating an environment for patient safety and teamwork training in the operating theatre: A quasi-experimental study

INTRODUCTION

Positive safety and a teamwork climate in the training environment may be a precursor for successful teamwork training. This pilot project aimed to implement and test whether a new interdisciplinary and team-based approach would result in a positive training climate in the operating theatre.

METHOD

A 3-day educational module for training the complete surgical team of specialist nursing students and residents in safe teamwork skills in an authentic operative theatre, named Co-Op, was implemented in a university hospital. Participants' (n=22) perceptions of the 'safety climate' and the 'teamwork climate', together with their 'readiness for inter-professional learning', were measured to examine if the Co-Op module produced a positive training environment compared with the perceptions of a control group (n=11) attending the conventional curriculum.

RESULTS

The participants' perceptions of 'safety climate' and 'teamwork climate' and their 'readiness for inter-professional learning' scores were significantly higher following the Co-Op module compared with their perceptions following the conventional curriculum, and compared with the control group's perceptions following the conventional curriculum.

CONCLUSION

The Co-Op module improved 'safety climate' and 'teamwork climate' in the operating theatre, which suggests that a deliberate and designed educational intervention can shape a learning environment as a model for the establishment of a safety culture.

Improving clinical performance using rehearsal or warm-up: an advanced literature review of randomized and observational studies

PURPOSE

To determine whether rehearsal (the deliberate practice of skills specific to a procedure) or warm-up (the act or process of warming up by light exercise or practice) prior to performing complex clinical procedures on patients can improve the task performance of operators and operating teams.

METHOD

The authors performed an advanced literature search for clinical studies published between 1975 and October 2012 using MEDLINE, EMBASE, the Cochrane Controlled Trials Register, ISI Web of Knowledge, and clinicaltrials.gov. They identified randomized controlled trials and observational studies that evaluated the effects of physical rehearsal or warm-up prior to performing complex clinical procedures. Two reviewers independently reviewed titles and abstracts and then full texts before abstracting data using a standardized form. They resolved disagreements by consensus.

RESULTS

The authors identified 1,886 potential articles and included 7 in their review (2 randomized controlled trials and 5 observational studies). All reported that rehearsal or warm-up by operators or operating teams is feasible. Only two clinical studies objectively demonstrated that warm-up can improve overall technical performance. Other objective evidence supporting the positive effects of rehearsal or warm-up for other team or nontechnical outcomes was limited.

CONCLUSIONS

The potential benefits of and optimal techniques for performing physical rehearsal and warm-up have not been established. Preliminary findings suggest that preoperative rehearsal or warm-up can improve the performance of operators or operating teams, but there is a paucity of objective evidence and comparative clinical studies in the existing literature to support their routine use.

Development of our TAVI protocol for emergency initiation of cardiopulmonary bypass

All transcatheter aortic valve implantation (TAVI) cases are done in our hybrid operating room with a multidisciplinary team and a primed cardiopulmonary bypass (CPB) circuit on pump stand-by. We decided that we would resuscitate all patients undergoing a TAVI procedure via a transfemoral, transapical or transaortic approach, if required. Perfusion plays an essential role in providing rescue CPB for patient salvage when catastrophic complications occur. To coordinate the multidisciplinary effort, we have developed a written safety checklist that assigns a pre-determined role for team members for the rapid sequence initiation of CPB. Although many TAVI patients are not candidates for conventional aortic valve replacements, we feel strongly that rescue CPB should be offered to all TAVI patients to allow the correction of potentially reversible complications. This protocol is included in every surgical "Time Out" involving a TAVI procedure (Figure 1). The protocol has led to rapid and safe CPB initiation in less than five minutes of cardiac arrest. It has also led to a coordinated and consistent team, with pre-specified roles and improved communication. We discuss a case series of four TAVI patients who required emergent use of CPB. The first few cases did not have a written protocol. The experience from these cases led to the development of our protocol. We identified a lack of coordination, wasted movements, unnecessary delayed resuscitation and overall chaos, each of which was targeted for correction with the protocol. We will discuss the merits of the protocol in two recent TAVI cases which required emergent CPB.

Can we make postoperative patient handovers safer? A systematic review of the literature

Postoperative patient handovers are fraught with technical and communication errors and may negatively impact patient safety. We systematically reviewed the literature on handover of care from the operating room to postanesthesia or intensive care units and summarized process and communication recommendations based on these findings. From >500 papers, we identified 31 dealing with postoperative handovers. Twenty-four included recommendations for structuring the handover process or information transfer. Several recommendations were broadly supported, including (1) standardize processes (e.g., through the use of checklists and protocols); (2) complete urgent clinical tasks before the information transfer; (3) allow only patient-specific discussions during verbal handovers; (4) require that all relevant team members be present; and (5) provide training in team skills and communication. Only 4 of the studies developed an intervention and formally assessed its impact on different process measures. All 4 interventions improved metrics of effectiveness, efficiency, and perceived teamwork. Most of the papers were cross-sectional studies that identified barriers to safe, effective postoperative handovers including the incomplete transfer of information and other communication issues, inconsistent or incomplete teams, absent or inefficient execution of clinical tasks, and poor standardization. An association between poor-quality handovers and adverse events was also demonstrated. More innovative research is needed to define optimal patient handovers and to determine the effect of handover quality on patient outcomes.

Implementing a pediatric surgical safety checklist in the OR and beyond

An international study about implementation of the World Health Organization Surgical Safety Checklist showed that use of the checklist reduced complication and death rates in adult surgical patients. Clinicians at Children's Hospital Boston, Massachusetts, modified the Surgical Safety Checklist for pediatric populations. We pilot tested the Pediatric Surgical Safety Checklist and created a large checklist poster for each OR to allow the entire surgical team to view the checklist simultaneously and to promote shared responsibility for conducting the time out. Results of the pilot test showed improvements in teamwork, communication, and adherence to process measures. Parallel efforts were made in other areas of the hospital where invasive procedures are performed. Compliance with the checklist at our facility has been good, and team members have expressed satisfaction with the flow and content of the checklist.

Patient safety: latent risk factors

The person-centred analysis and prevention approach has long dominated proposals to improve patient safety in healthcare. In this approach, the focus is on the individual responsible for making an error. An alternative is the systems-centred approach, in which attention is paid to the organizational factors that create precursors for individual errors. This approach assumes that since humans are fallible, systems must be designed to prevent humans from making errors or to be tolerant to those errors. The questions raised by this approach might, for example, include asking why an individual had specific gaps in their knowledge, experience, or ability. The systems approach focuses on working conditions rather than on errors of individuals, as the likelihood of specific errors increases with unfavourable conditions. Since the factors that promote errors are not directly visible in the working environment, they are described as latent risk factors (LRFs). Safety failures in anaesthesia, in particular, and medicine, in general, result from multiple unfavourable LRFs, so we propose that effective interventions require that attention is paid to interactions between multiple factors and actors. Understanding how LRFs affect safety can enable us to design more effective control measures that will impact significantly on both individual performance and patient outcomes.

Teaching teamwork in medical education

Teamwork has become a major focus in healthcare. In part, this is the result of the Institute of Medicine report entitled To Err Is Human: Building a Safer Health System, which details the high rate of preventable medical errors, many of which are the result of dysfunctional or nonexistent teamwork. It has been proposed that a healthcare system that supports effective teamwork can improve the quality of patient care and reduce workload issues that cause burnout among healthcare professionals. Few clear guidelines exist to help guide the implementation of all these recommendations in healthcare settings. In general, training programs designed to improve team skills are a new concept for medicine, particularly for physicians who are trained largely to be self-sufficient and individually responsible for their actions. Outside of healthcare, research has shown that teams working together in high-risk and high-intensity work environments make fewer mistakes than individuals. This evidence originates from commercial aviation, the military, firefighting, and rapid-response police activities. Commercial aviation, an industry in which mistakes can result in unacceptable loss, has been at the forefront of risk reduction through teamwork training. The importance of teamwork has been recognized by some in the healthcare industry who have begun to develop their own specialty-driven programs. The purpose of this review is to discuss the current literature on teaching about teamwork in undergraduate medical education. We describe the science of teams, analyze the work in team training that has been done in other fields, and assess what work has been done in other fields about the importance of team training (ie, aviation, nonmedical education, and business). Additionally, it is vital to assess what work has already been done in medicine to advance the skills required for effective teamwork. Much of this work has been done in fields in which medical professionals deal with crisis situations (ie, anesthesia, trauma, and labor and delivery). We describe the current programs for teaching medical students these essential skills and what recommendations have been made about the best ways to introduce teaching this skill set into the curriculum. Finally, we include a review on assessing teamwork because one cannot teach team training without implementing an assessment to ensure that the skills are being learned.

What do surgical nurses know about surgical residents?

OBJECTIVE

A fundamental premise of establishing collaborative relationships between residents and nurses is a basic understanding of the attributes of each group. The intent of this study was to determine what surgical nurses know about surgical residents.

DESIGN

A piloted survey tool was administered to a cross-section of nurses working in 3 surgical intensive care units, a surgical intermediate unit, and 2 general surgical floors. Surgical residents completed the same survey tool. The percentage of residents giving the most frequent response was compared with the percentage of nurses giving the same response.

SETTING

A university, teaching hospital.

PARTICIPANTS

One hundred twenty-four of 129 surgical nurses and 24 of 25 surgical residents who completed the survey tool.

RESULTS

The response rate for nurses on the 2 survey days was 94%, or 54% of all surgical nurses employed by the hospital, and 96% for residents. The nurses surveyed were equally distributed between the units. Ninety-nine percent of nurses did not have a surgical resident as a significant other, 55% of nurses had greater than 5 years experience, and 95% were licensed registered nurses. Seventy-eight percent of nurses correctly indicated that a medical doctorate is the highest degree required to start residency (p = 0.01), but only 57% accurately identified the length of surgical residency (p = 0.02). Nurses perceived residents devoted less time to patient care (p < 0.01) and more time to studying (p < 0.01). Forty percent of nurses do not think interns are legally physicians (p < 0.01) or hold a medical license (p < 0.01). Forty percent of nurses are aware of the 80-hour work week restriction (p < 0.01). Eighteen percent of nurses have the perception that residents are not allowed to perform bedside procedures without an attending physician present (p = 0.03), while 56% have the perception that residents are not allowed to perform any part of an operation without an attending physician (p < 0.01). There is a misperception among 32% of nurses that residents pay tuition for residency (p < 0.01), while only 52% accurately identified the range of a resident's salary (p = 0.01) and 11% the amount of resident debt (p < 0.01).

CONCLUSIONS

Despite the importance of the collaborative relationship in surgical patient care, surgical nurses have a limited understanding of surgical residents. Educating nurses about the education, roles, and responsibilities of surgical residents might improve collaborative relationships and ultimately patient care.

Examining communication and team performance during clinical handover in a complex environment: the private sector post-anaesthetic care unit

Threats to patient safety during clinical handover have been identified as an ongoing problem in health care delivery. In complex handover situations, organisational, cultural, behavioural and environmental factors associated with team performance can affect patient safety by undermining the stability of team functioning and the effectiveness of interprofessional communication. We present a practical framework for promoting systematic, comprehensive measurement of the factors involved in clinical handover. The framework can be used to develop viable solutions to the problems of clinical handover. The framework was devised and used in a recent project examining interprofessional communication and team performance during clinical handover in post-anaesthetic care units. The framework combines five key concepts: clinical governance, clinician engagement, ecological validity, safety culture and team climate, and sustainability. We believe that use of this framework will help overcome the limitations of previous research that has not taken into account the complex and multifaceted influences on clinical handover and interprofessional communication.