A Qualitative Study of the Work Systems and Culture Around End-of-Day Intraoperative Anesthesia Handoffs in a Tertiary Care Center

BACKGROUND

Intraoperative handoffs have been implicated as a contributing factor in many perioperative adverse events. Despite conflicting data around their impact on perioperative outcomes, they remain a vulnerable point in the perioperative system with significant attention focused on improving them. This study aimed to understand the processes in place surrounding the point of information transfer in intraoperative handoffs.

METHODS

We used semistructured interviews with anesthesia clinicians to understand the processes and systems surrounding intraoperative handoffs. Interview data were coded deductively using the Systems Engineering Initiative for Patient Safety model as a framework, with subthemes developed inductively.

RESULTS

Clinicians do a significant amount of work before and after the point of information transfer to ensure a smooth handoff and safe patient care. Despite not having standardization of handoffs, most clinicians have a typical handoff organization and largely agree on content that should be included. However, there is variability based on clinician and patient characteristics, including clinician discipline and patient acuity. These handoffs are additionally impacted by the overall culture in the operating room, including the teamwork and hierarchies present among the surgical and anesthesia teams. Finally, the broader operating room logistics, including scheduling practices for surgical cases and anesthesia teams, impact the quality of intraoperative handoffs and the ability of clinicians to prepare for these handoffs.

CONCLUSIONS

Handoffs involve processes beyond the point of information transfer and are embedded in the systems and culture of the operating rooms. These considerations are important when seeking to improve the quality of intraoperative handoffs.

Emergency manual peri-crisis use six years following implementation: Sustainment of an intervention for rare crises

STUDY OBJECTIVE

Use of cognitive aids during emergencies increases key actions and decreases omissions, both known to save lives. With little known about emergency manual (EM) clinical use, we aimed to help answer "Will EMs be used peri-crisis at a meaningful frequency?" and to explore clinical sustainment.

DESIGN

Prospective, observational study.

SETTING

Operating Rooms.

PATIENTS

All patients undergoing anesthesia at a major academic medical center during the study periods; ∼75,000 cases.

INTERVENTION & MEASUREMENTS

To understand the initial and sustainment phases of EM implementation, we placed a question regarding EM use at the end of every anesthetic case to prospectively measure EM use at: implementation, one-year later, and six years post-implementation.

MAIN RESULTS

For more than twenty-four thousand cases in each approximately 6-month study period, EMs were used peri-crisis (before, during or after a perioperative crisis) in 145 cases initially (0.55%; SE 0.045%), 42 cases one-year later (0.17%; SE 0.026%), and 57 cases (0.21%; SE 0.028%) six years post-implementation. Peri-crisis EM uses dropped 0.38% (97.5% CI: 0.26%, 0.49%) from initial to one-year post-implementation. After that, peri-crisis EM uses did not differ significantly from one-year to six years post-implementation, showing sustainment [increased 0.04% (97.5% CI: -0.05%, 0.12%)]. Among cases with cardiac arrest or CPR, as a subset proxy for relevant crises, EMs were used in 7/13 such cases initially (54%, SE 13.6%), 8/20 one-year later (40%; SE 10.9%) and 7/13 six years later (54%; SE 13.6%).

CONCLUSIONS

After an initial expected drop, EM peri-crisis use six years post-implementation was: sustained without intensive additional efforts, averaged ∼10 times per month at a single institution, and was reported in more than half of cases with cardiac arrest or CPR. Peri-crisis use of EMs is appropriately rare, though for relevant crises can have substantial positive impacts as described in prior literature. The sustained use of EMs may be related to increasing cultural acceptance of EMs, as reflected in survey result trends and broader cognitive aid literature.

Setting the stage for speaking up: psychological safety and directing care in acute care collaboration

Managing a safe and efficient anaesthetic induction within a team involves the challenge of when, if, and how to surface, discuss, and implement the best plan on how to proceed. The Lemke and colleagues study in this issue of the British Journal of Anaesthesia is a unique view into real-world conversations that naturally occur in anaesthesia teams in moments of high task and cognitive load, such as induction of anaesthesia. The study spotlights important small moments of physician, nurse, and trainee team coordination. It illuminates key patterns of conversation in naturally occurring anaesthesia teams, and raises important questions about what the speaking up standard should be and the psychological safety-shaping role consultants play in setting the norms for speaking up.

Supporting Caregivers During COVID-19: Transforming Compassionate Care From a Way of Doing to Being

The expectation by colleagues that fellow clinicians deftly manage the stresses of practice often predisposes healthcare professionals involved in an adverse event to experience isolation, blame, and shame. The peer support model has since been recognized as an important component of institutional wellness and follows a well-described and structured method. Although peer support programs have traditionally been established to support caregivers involved in adverse medical events, the relevance and applicability of these programs have found substantial traction across broader crisis domains. Interventions, including peer support, help mitigate the 3 components of burnout: emotional exhaustion, depersonalization (cynicism), and reduced efficacy.

Huddles and Debriefings: Improving Communication on Labor and Delivery

Interprofessional teams work together on the labor and delivery unit, where clinical care is often unscheduled, rapidly evolving, and fast paced. Effective communication is key for coordinated delivery of optimal care and for fostering a culture of community and safety in the workplace. The preoperative huddle allows for information sharing, cross-checking, and preparation before the start of surgery. Postoperative debriefings allow the operative team to engage in ongoing process improvement. Debriefings after adverse events allow for shared understanding, mutual healing, and help mitigating the harm to potential "second victims."

Improving Anesthesiologists' Ability to Speak Up in the Operating Room: A Randomized Controlled Experiment of a Simulation-Based Intervention and a Qualitative Analysis of Hurdles and Enablers

PURPOSE

The authors addressed three questions: (1) Would a realistic simulation-based educational intervention improve speaking-up behaviors of practicing nontrainee anesthesiologists? (2) What would those speaking-up behaviors be when the issue emanated from a surgeon, a circulating nurse, or an anesthesiologist colleague? (3) What were the hurdles and enablers to speaking up in those situations?

METHOD

The authors conducted a simulation-based randomized controlled experiment from March 2008-February 2011 at the Center for Medical Simulation, Boston, Massachusetts. During a mandatory crisis management course for practicing nontrainee anesthesiologists from five Boston institutions, a 50-minute workshop on speaking up was conducted for intervention (n = 35) and control (n = 36) groups before or after, respectively, an experimental scenario with three events. The authors analyzed videos of the experimental scenarios and debriefing sessions.

RESULTS

No statistically significant differences between the intervention and control group subjects with respect to speaking-up actions were observed in any of the three events. The five most frequently mentioned hurdles to speaking up were uncertainty about the issue, stereotypes of others on the team, familiarity with the individual, respect for experience, and the repercussion expected. The five most frequently mentioned enablers were realizing the speaking-up problem, having a speaking-up rubric, certainty about the consequences of speaking up, familiarity with the individual, and having a second opinion or getting help.

CONCLUSIONS

An educational intervention alone was ineffective in improving the speaking-up behaviors of practicing nontrainee anesthesiologists. Other measures to change speaking-up behaviors could be implemented and might improve patient safety.

Practicality of using galvanic skin response to measure intraoperative physiologic autonomic activation in operating room team members

BACKGROUND

Physiologic and psychological stress are commonly experienced by operating room (OR) personnel, yet there is little research about the stress levels in OR teams and their impact on performance. Previously published procedures to measure physiologic activation are invasive and impractical for the OR. The purpose of this study was to determine the practicality of a new watch-sized device to measure galvanic skin response (GSR) in OR team members during high-fidelity surgical simulations.

METHODS

Interprofessional OR teams wore sensors on the wrist (all) and ankle (surgeons and scrub nurses/technicians) during the orientation, case, and debriefing phases for 17 simulations of a surgical airway case. Data were compared across all simulation phases, collectively and for each professional group.

RESULTS

Forty anesthesiology residents, 35 surgery residents, 27 OR nurses, 12 surgical technicians, and 7 CRNAs participated. Collectively, mean wrist GSR levels significantly increased from orientation phase to the case (0.40-0.62 μS; P < .001) and remained elevated even after the simulation was over (0.40-0.67 μS; P < .001). Surgery residents were the only group that demonstrated continued increases in wrist GSR levels throughout the entire simulation (change in GSR = 0.21 to 0.32 to 0.11 μS; P < .01). Large intraindividual differences (≤ 200 times) were found in both wrist and ankle GSR. There was no correlation between wrist and ankle data.

CONCLUSION

Continuous GSR monitoring of all professionals during OR simulations is feasible, but would be difficult to implement in an actual OR environment. Large variation in individual levels of physiologic activation suggests complementary qualitative research is needed to better understand how people respond to stressful OR situations.

The relationship between intraoperative teamwork and management skills in patient care

BACKGROUND

Optimal team performance in the operating room (OR) requires a combination of interactions among OR professionals and adherence to clinical guidelines. Theoretically, it is possible that OR teams could communicate very well but fail to follow acceptable standards of patient care and vice versa. OR simulations offer an ideal research environment to study this relationship. The goal of this study was to determine the relationship between ratings of OR teamwork and communication with adherence to patient care guidelines in a simulated scenarios of malignant hyperthermia (MH).

METHODS

An interprofessional research team (2 anesthesiologists, 1 surgeon, an OR nurse, and a social scientist) reviewed videos of 5 intraoperative teams managing a simulated patient who manifested MH while undergoing general anesthesia for an epigastric herniorraphy in a high-fidelity, in situ OR. Participant teams consisted of 2 residents from anesthesiology, 1 from surgery, 1 OR nurse, and 1 certified surgical technician. Teamwork and communication were assessed with 4 published tools: Anesthesiologists' Non-Technical Skills (ANTS), Scrub Practitioners List of Intra-operative Non-Technical Skills (SPLINTS), Non-Technical Skills for Surgeons (NOTSS), and Objective Teamwork Assessment System (OTAS). We developed an evidence-based MH checklist to assess overall patient care.

RESULTS

Interrater agreement for teamwork tools was moderate. Average rater agreement was 0.51 For ANTS, 0.67 for SPLINTS, 0.51 for NOTSS, and 0.70 for OTAS. Observer agreement for the MH checklist was high (0.88). Correlations between teamwork and MH checklist were not significant. Teams were different in percent of the MH actions taken (range, 50-91%; P = .006).

CONCLUSION

In this pilot study, intraoperative teamwork and communication were not related to overall patient care management. Separating nontechnical and technical skills when teaching OR teamwork is artificial and may even be damaging, because such an approach could produce teams with excellent communication skills as they unsuccessfully manage the patient. OR simulations offer a unique opportunity to research how to best integrate both of these domains to improve patient care.

Practicality of intraoperative teamwork assessments

BACKGROUND

High-quality teamwork among operating room (OR) professionals is a key to efficient and safe practice. Quantification of teamwork facilitates feedback, assessment, and improvement. Several valid and reliable instruments are available for assessing separate OR disciplines and teams. We sought to determine the most feasible approach for routine documentation of teamwork in in-situ OR simulations. We compared rater agreement, hypothetical training costs, and feasibility ratings from five clinicians and two nonclinicians with instruments for assessment of separate OR groups and teams.

MATERIALS AND METHODS

Five teams of anesthesia or surgery residents and OR nurses (RN) or surgical technicians were videotaped in simulations of an epigastric hernia repair where the patient develops malignant hyperthermia. Two anesthesiologists, one OR clinical RN specialist, one educational psychologist, one simulation specialist, and one general surgeon discussed and then independently completed Anesthesiologists' Non-Technical Skills, Non-Technical Skills for Surgeons, Scrub Practitioners' List of Intraoperative Non-Technical Skills, and Observational Teamwork Assessment for Surgery forms to rate nontechnical performance of anesthesiologists, surgeons, nurses, technicians, and the whole team.

RESULTS

Intraclass correlations of agreement ranged from 0.17-0.85. Clinicians' agreements were not different from nonclinicians'. Published rater training was 4 h for Anesthesiologists' Non-Technical Skills and Scrub Practitioners' List of Intraoperative Non-Technical Skills, 2.5 h for Non-Technical Skills for Surgeons, and 15.5 h for Observational Teamwork Assessment for Surgery. Estimated costs to train one rater to use all instruments ranged from $442 for a simulation specialist to $6006 for a general surgeon.

CONCLUSIONS

Additional training is needed to achieve higher levels of agreement; however, costs may be prohibitive. The most cost-effective model for real-time OR teamwork assessment may be to use a simulation technician combined with one clinical rater to allow complete documentation of all participants.

Altered arterial compliance in hypertensive pregnant women is associated with preeclampsia

BACKGROUND

Vascular alterations are present in pregnant women affected by preeclampsia. In this study, we assessed arterial compliance in women affected by hypertensive disorders of pregnancy. We hypothesized that arterial compliance is reduced in women affected by preeclampsia.

METHODS

Forty-three hypertensive pregnant women undergoing evaluation for preeclampsia were studied. Clinical data about each patient and pregnancy were collected. Large (C1) and small (C2) artery compliance were assessed by radial tonometry, while the patients underwent laboratory tests to diagnose preeclampsia. At the time of delivery, gestational age and newborn data were recorded.

RESULTS

Eighteen women were diagnosed with preeclampsia. C2 levels were lower among preeclamptic versus hypertensive aproteinuric women (mean ± SD, 4.5 ± 1.3 vs 5.9 ± 2.3 mL/mm Hg · 100, P = 0.013, 95% confidence interval [CI] of difference 0.32-2.55), whereas C1 levels did not differ. In the preeclampsia group, C2 levels correlated with urine total protein concentrations measured the same day (Spearman ρ = -0.49, P = 0.047, upper 95% CI -0.01) and with gestational age at first occurrence of hypertension (Spearman ρ = 0.59, P = 0.010, lower 95% CI 0.17). Among singleton gestations, C2 also correlated with newborn birth weight measured at delivery (Spearman ρ = 0.43, P = 0.009, lower 95% CI 0.11). Women who were hypertensive but aproteinuric at the time of compliance assessment, but who subsequently developed preeclampsia (n = 6), had C2 levels similar to those with an early diagnosis of preeclampsia (mean difference 0.37 mL/mm Hg · 100, 95% CI -2.42 to 1.67) and lower C2 levels than women diagnosed with gestational hypertension (P = 0.019, 95% CI 0.33-4.42 mL/mm Hg · 100).

CONCLUSIONS

The noninvasive assessment of arterial elasticity may contribute toward characterization of the nature of the pathophysiology in pregnancy-induced hypertensive disorders. The vascular alterations of the small arteries, as assessed by C2, may reflect the extent of vascular alterations present with preeclampsia.

Severe glottic stenosis in a parturient with ectodermal dysplasia

Airway stenosis in pregnancy is challenging and the literature does not offer consensus regarding its evaluation and anesthetic management. A 21-year-old nulliparous woman with ectodermal dysplasia and severe glottic stenosis was referred to the obstetric anesthesia team for evaluation and peripartum management recommendations. She had a history of a congenital complete glottic web that required a tracheostomy at birth. After decannulation at age four, she was lost to follow-up. On examination in early pregnancy, she was found to have a dangerously narrow airway with fixed vocal cords and a glottic aperture of 2-3mm. At nine weeks of gestation an elective tracheostomy was performed under local anesthesia. She later underwent an uneventful cesarean delivery under spinal anesthesia. Ultimately, early interdisciplinary planning for an elective tracheostomy helped assure patient safety during advancing pregnancy and delivery.

Stop Hypertension With the Acupuncture Research Program (SHARP)

Case studies and small trials suggest that acupuncture may effectively treat hypertension, but no large randomized trials have been reported. The Stop Hypertension with the Acupuncture Research Program pilot trial enrolled 192 participants with untreated blood pressure (BP) in the range of 140/90 to 179/109 mm Hg. The design of the trial combined rigorous methodology and adherence to principles of traditional Chinese medicine. Participants were weaned off antihypertensives before enrollment and were then randomly assigned to 3 treatments: individualized traditional Chinese acupuncture, standardized acupuncture at preselected points, or invasive sham acupuncture. Participants received < or = 12 acupuncture treatments over 6 to 8 weeks. During the first 10 weeks after random assignment, BP was monitored every 14 days, and antihypertensives were prescribed if BP exceeded 180/110 mm Hg. The mean BP decrease from baseline to 10 weeks, the primary end point, did not differ significantly between participants randomly assigned to active (individualized and standardized) versus sham acupuncture (systolic BP: -3.56 versus -3.84 mm Hg, respectively; 95% CI for the difference: -4.0 to 4.6 mm Hg; P=0.90; diastolic BP: -4.32 versus -2.81 mm Hg, 95% CI for the difference: -3.6 to 0.6 mm Hg; P=0.16). Categorizing participants by age, race, gender, baseline BP, history of antihypertensive use, obesity, or primary traditional Chinese medicine diagnosis did not reveal any subgroups for which the benefits of active acupuncture differed significantly from sham acupuncture. Active acupuncture provided no greater benefit than invasive sham acupuncture in reducing systolic or diastolic BP.