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For Safety, Are Intact Surgical Teams Possible?

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For Safety, Are Intact Surgical Teams Possible?

By Tom A. Augello, CRICO

Related to: Communication, Nursing, Surgery, Teamwork Training

A gathering of surgeons confronts rotating personnel in operating rooms as a barrier to using team methods for patient safety.

Commentators

  • William Berry, MD, MPH CRICO/RMF Cambridge, MA
  • Andrew Freiberg, MD Massachusetts General Hospital Boston, MA
  • David Hanscom, MD Swedish Hospital Seattle, WA
  • Daniel Jones, MD, FACS Beth Israel Deaconess Medical Center Boston, MA
  • James Mandell, MD Children’s Hospital Boston, MA

Transcript

In November 2007, nearly 100 surgeons from across the country spent a highly interactive day with a series of panels to discuss top barriers to making care safer in the surgical environment.

It was called a “Surgery Summit,” and a key challenge that quickly emerged involves the concept of teams and team processes. Typical hospital units do not organize surgical procedures with intact surgical teams.

As the “lone ranger” model of surgery done by a highly skilled surgeon surrounded by people responding to commands gives way to a safer model of an integrated professional team, there’s a problem: The scrub techs, the nurses, the circulators, are rarely the same from day to day or procedure to procedure. Many attendees at the conference felt that this undermines efforts to use team methodology to improve outcomes.

Panelist Andrew Freiberg, Chief of Adult Reconstructive Unit at Massachusetts General Hospital, recognized the issue when an audience member raised it.

“One of the mistakes I think we make is that we assume that any scrub nurse, any scrub tech, any circulator, they are equivalent. The fact is, it is not true. We always like to say this to our administrative leaders, ‘You know, I tell you what, we’ll change your secretary every day because we are going to give you a good secretary, we are going to give you a good legal assistant. We are going to change it every day. We are going to give you new ones once in a while, and we are going to let you teach them because it is important to have new ones.”

“It is really wild when you are in the operating room and you show up, and you’re operating on the CEO of blank, and it’s ‘Bring Your Scrub Tech Student to School Day,’ and you’re ‘what?’ You have to think about this because the person that I usually work with is the person that I prefer to work with and when I work with her, my environment is different. She sees things that I don’t see. …it’s a very dynamic environment. And who you work with and how that is structured is very important to the safety and success of the whole day”

One of the symposium’s panelists runs Children’s Hospital in Boston. Dr. James Mandel is President and CEO, as well as a Professor of Surgery at Harvard Medical School. An audience member asked him directly:

“I’d like to go back to the teamwork and ask Jim to comment on whether it is in fact practical to have these dedicated teams in the operating room or is that not practical from a hospital standpoint? Because if it is not practical, we shouldn’t be dreaming of it because we will create physicians who can’t operate unless they have their perfect team together.”

[new voice, Dr. Mandel]:

“I think it is practical in some cases but not in all. And what we have done at least around our center of excellence, we have tried to get a whole dedicated team both intraoperative, postoperative, etc. So whether in the Neurosurgical Services, in the Cardiac Services, in the Orthopedic Services, we have tried to get dedicated teams that extend both from the entryway all the way to the postoperative period.

“It is not going to be possible in all cases. In my specialty, there are nurses and staff that tend to work there because they like to work there and we have known each other for decades, but I don’t think from an institutional point of view you can have a dedicated team for every specialty. But I do think for those high volume, high risk it is perfectly possible to get the continuum of care both pre, intra, and postoperatively. Certainly, our cardiology team is the most representative where you have virtually everybody on the team, whether it’s preoperative, intraoperative, postoperative, etc., all of which are members of the team that are quite separate and distinct. We are getting there with orthopedics. We have not done quite as well in some of the other subspecialties.”

Dr. William Berry was a cardiothoracic surgeon in California who now does research in patient safety and serves as a surgical consultant for CRICO/RMF, the patient safety and malpractice company for the Harvard medical system. Dr. Berry’s former institution pursued intact teams for his specialty.

“In the last hospital that I worked, this came to a head and we got our team. Not circulators; no one could be in the heart room, number one, who didn’t want to be in the heart room, because that was a huge problem, people who would get put in there who didn’t want to be in there, and no one would be in there who wasn’t taught. I empathized totally with the student-of-the-day thing, and it used to drive me crazy. Another piece that drove me nuts with that was the fact that, again, administrators, God love them, they have to be there, but administrators would have very little appreciation for the value of someone who had been trained. So very small salary increments or improvement in job benefits or whatever would be put aside, to lose someone with 15 or 20 years of experience who was going to cost a half a million dollars to retrain in terms of the efficiencies that were induced and those kinds of things, so I am a big supporter of intact teams whenever it is possible.”

Dr. Berry noted that simulation centers in the Harvard system are working with intact teams to improve team skills that they are already good at. Panelist Dan Jones runs a surgical simulation center at Beth Israel Deaconess Medical Center, and he suggested one concept to help with surgical teams that are not intact.

“Our nurses have set up in the simulation environment a proficiency rating for our nurses and our scrub techs. So recognition rather than money being the end result, of saying you’re a ‘Level 5’ at a lap/chole case and you’re a ‘MIS super user,’ whereas someone who is a 1 or 2 is a ‘needs improvement’ if they want to do minimally invasive surgery cases. So there is at least a concept of nurses assessing nurses as ongoing evaluation to sort of see who knows what, so that that information can be used to see who could go into a room and who should not go into say our endo suite MIS rooms.”

[new voice, Jo Shapiro]

“Jo Shapiro, Surgery at the Brigham. To the point about intact teams, though I think we should work towards that, it is the ideal, I think it is probably impractical in all situations. And what we can do is we can try to change the culture so that when you walk into an operating room, whatever your role is, you know that in that operating room your input will be welcomed, that you will be part of a team, that everyone will know your name because it will be part of a briefing, and that you will have an opportunity afterwards to learn from how the operation went in a very safe environment. I think that’s what many of our institutions are trying to do.

It is the concept of a just culture. For example, we are always going to have new trainees with us, but they will understand that this is the environment that they are going to walk into. So I think we can try to have intact teams because they are wonderful, but in the situations where they are not, if we change the culture enough, it will be almost irrelevant really because everybody will have a shared mental model of what it means to operate at the Brigham or operate at any of our hospitals.”

[new voice, David Roberson]

“David Roberson, Otolaryngology at Children’s. I am going to just echo and expand. If you walk in a room and there are a bunch of strangers there, one response that I’ve adopted in the past was to roll my eyes at my residents, and say, ‘oh my God another day.’ And the other response as to whether the culture has changed or not is stop and say ‘we’re doing this operation, do you understand?’ The nurse may know 90 percent of what he or she needs to know, but if you give them the chance to say, ‘well this part here, Dr. Roberson, I don’t understand what is going to happen there,’ talk about it before. I think you can get an awful lot of the benefits of team by having the right pre-op briefing and the right conversation before the surgery.”

A surgeon who attended the conference from Swedish Hospital in Seattle saw how he could plug these concepts into a new program that he’s been developing at his institution.

Dr. David Hanscom is an orthopedic spine surgeon. For more than a year, Dr. Hanscom and his colleagues have been using a protocol designed to promote the view of surgery as a performance, rather than a series of tasks that lead to an outcome. Now, instead of a rushed entrance right before the operation, Dr. Hanscom spends up to 45 minutes getting the room ready and briefing the personnel on every stage of the surgery. It’s something that he calls “Team Building on the Run.”

He describes a recent spine surgery, where he added to his process the concept of an “extended time out,” a concept that he brought back with him from the conference in Boston.

“So the patient is now asleep on the table. I pulled the entire team together. I have been talking to them for 45 minutes, and I went around the room and asked everybody, I said ‘we are going to do the extended time-out.’ I had everybody say their first name and last name, and we reviewed the process with each person that I had gone through. This includes x-ray tech, the spinal cord monitor, the reps from the instrument companies who are going to be there.

So I went through in detail what we are going to do. That took about three minutes. Everybody’s name was already written on the board per myself. Then we turned the patient over and then we did the final safety pauses before we did the incision. So we took a whole day of 9 hours that could have been really quite chaotic and turned into a really nice smooth performance.”

That also reflects a trend Dr. Hanscom has seen, of steadily declining complication rates since turning to a performance paradigm and “team-building-on-the-run.” Beyond the implications for improved patient safety, Dr. Hanscom reports that nurses, anesthesiologists, and staff are embracing the change in their work environment. The increased efficiency that results—with fewer distractions and missing equipment—may reduce error, but it definitely improves the provider’s work life.

“In the 20 years I’ve done this, this has never happened. I’ve never gone through cases like this without being frustrated and not finding instruments and people were in and out of the room, and it just changed my entire surgical experience.”


January 1, 2008
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