May 27, 2009 A short, preoperative team briefing prior to cardiac surgery — where each person on the team speaks — improves communication and reduces errors and costs, according to a pilot study conducted at Mayo Clinic.
Mayo researchers believe this is the first such study to use real-time observations to measure the effect of preoperative briefings on specific disruptions to surgery. Disruptions were categorized as patient-related issues, equipment or resource issues, procedural knowledge issues and miscommunication events.
"The goal of the briefings was to get everyone used to talking when there wasn't a problem, so they would be more likely to speak up when problems occur," says Thoralf Sundt, M.D., Mayo Clinic cardiac surgeon who volunteered his surgery team for the study. "We know that miscommunication is a major cause of sentinel events, an unexpected death or serious injury."
Fifty-six surgical staff members filled out questionnaires and participated in focus groups to develop the format for the briefings. Among the participants were surgical assistants and technicians, registered nurses, nurse anesthetists, and perfusionists, who operate the heart-lung machine during most cardiac surgeries.
The briefings were conducted in the operating room immediately prior to the first surgical procedure of the day, before the patient arrived in the room. Each team member discussed his or her role in the procedure and any concerns specific to the patient. The briefings lasted from one to eight minutes.
"The briefing was not a checklist review," says Dr. Sundt. Checklists are most helpful in preventing predictable errors, such as confirming if and when medications are administered prior to surgery. No checklist can cover the unexpected scenarios that might occur in surgery.
"Because of the complexity of what we do, errors do happen," says Dr. Sundt. "Each team member needs to feel comfortable enough to identify errors. Then we catch them and correct them."
Pre-procedure briefings are not common in operating rooms, but they are standard in other high-risk industries such as aviation and in the military, according to Douglas Wiegmann, Ph.D., the lead researcher on the Mayo study.
"This approach reflects a change in culture in the surgical field - that everyone has a unique contribution to the outcome and care of the patient," says Dr. Wiegmann, who has since moved to the University of Wisconsin as an associate professor of human factors engineering.
While staff are expected to speak up during surgery, they don't or don't always, according to Dr. Wiegmann. Other research has shown that information conveyed in the operating room is often shared in a tense, ad hoc manner that is not conducive to comfortable communication. Previous Mayo Clinic research found that only 32 percent of nonphysician caregivers in cardiovascular surgery thought that surgeon communication was effective. In the same study, 59 percent of nonphysician respondents thought that surgeon attitudes and personalities negatively impacted teamwork.
To measure the briefings' effectiveness, a trained observer monitored six surgeries where briefings were conducted and 10 surgeries where no briefing occurred. The observer was a medical student who was familiar with cardiac surgery and trained to record errors and flow disruptions.
When the briefings were conducted:
- Miscommunication events were reduced by 53 percent. None of the miscommunication events observed during the study resulted in adverse events. Examples include the surgeon asking for a medication to be given the anesthesiologist not hearing the request. There were significantly fewer delays, with fewer interruptions to clarify procedures. And, nurses made fewer trips outside the operating room to retrieve supplies.
- Waste of medical supplies was reduced because the team better anticipated specific needs for each surgery.
Dr. Sundt says his team has embraced the briefings and continues to conduct them prior to the first procedure of the day. Other surgical teams have since requested implementation of the briefings.
"It's time well spent that tunes us in to the specific patient's needs," says Dr. Sundt. In addition to specific concerns about the surgery, the briefings include information about the patient's prior procedures, other diagnoses, risks and emotional concerns, such as the patient's biggest worry regarding surgery.
"It sets the tone for the day. Now, I'm uncomfortable when we don't do it," says Dr. Sundt, who was initially skeptical about the benefits of the briefings.
There are barriers to conducting briefings for every procedure. "The structure of the operating room is not conducive to this," says Dr. Sundt. With multiple surgical suites, surgery times overlap, creating difficulty in assembling the team prior to each procedure. During long, complex surgeries, shift and staff changes occur.
Results from the Mayo Clinic pilot are published online in the Journal of the American College of Surgeons. Additional study and pilots are needed to determine ways to incorporate the briefings more broadly, researchers say.
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