Ashok Handa

The effects of aviation-style non-technical skills training on technical performance and outcome in the operating theatre

Unintended harm to patients in operating theatres is common. Correlations have been demonstrated between teamwork skills and error rates in theatres. This was a single-institution uncontrolled before–after study of the effects of “non-technical” skills training on attitudes, teamwork, technical performance and clinical outcome in laparoscopic cholecystectomy (LC) and carotid endarterectomy (CEA) operations. The setting was the theatre suite of a UK teaching hospital. Attitudes were measured using the Safety Attitudes Questionnaire (SAQ). Teamwork was scored using the Oxford Non-Technical Skills (NOTECHS) method. Operative technical errors (OTEs), non-operative procedural errors (NOPEs), complications, operating time and length of hospital stay (LOS) were recorded. A 9 h classroom non-technical skills course based on aviation “Crew Resource Management” (CRM) was offered to all staff, followed by 3 months of twice-weekly coaching from CRM experts. Forty-eight procedures (26 LC and 22 CEA) were studied before intervention, and 55 (32 and 23) afterwards. Non-technical skills and attitudes improved after training (NOTECHS increase 37.0 to 38.7, tu200a=u200a−2.35, pu200a=u200a0.021, SAQ teamwork climate increase 64.1 to 69.2, tu200a=u200a−2.95, pu200a=u200a0.007). OTEs declined from 1.73 to 0.98 (uu200a=u200a1071, pu200a=u200a0.009), and NOPEs from 8.48 to 5.16 per operation (tu200a=u200a4.383, p<0.001). These effects were stronger in the LC group than in CEA procedures. The operating time was unchanged, and a non-significant reduction in LOS was observed. Non-technical skills training improved technical performance in theatre, but the effects varied between teams. Considerable cultural resistance to adoption was encountered, particularly among medical staff. Debriefing and challenging authority seemed more difficult to introduce than other parts of the training. Further studies are needed to define the optimal training package, explain variable responses and confirm clinical benefit.

Teamwork and Error in the Operating Room : Analysis of Skills and Roles

Objective:To analyze the effects of surgical, anesthetic, and nursing teamwork skills on technical outcomes. Summary Background Data:The value of team skills in reducing adverse events in the operating room is presently receiving considerable attention. Current work has not yet identified in detail how the teamwork and communication skills of surgeons, anesthetists, and nurses affect the course of an operation. Methods:Twenty-six laparoscopic cholecystectomies and 22 carotid endarterectomies were studied using direct observation methods. For each operation, teams’ skills were scored for the whole team, and for nursing, surgical, and anesthetic subteams on 4 dimensions (leadership and management [LM]; teamwork and cooperation; problem solving and decision making; and situation awareness). Operating time, errors in surgical technique, and other procedural problems and errors were measured as outcome parameters for each operation. The relationships between teamwork scores and these outcome parameters within each operation were examined using analysis of variance and linear regression. Results:Surgical (F(2,42) = 3.32, P = 0.046) and anesthetic (F(2,42) = 3.26, P = 0.048) LM had significant but opposite relationships with operating time in each operation: operating time increased significantly with higher anesthetic but decreased with higher surgical LM scores. Errors in surgical technique had a strong association with surgical situation awareness (F(2,42) = 7.93, P < 0.001) in each operation. Other procedural problems and errors were related to the intraoperative LM skills of the nurses (F(5,1) = 3.96, P = 0.027). Conclusions:Detailed analysis of team interactions and dimensions is feasible and valuable, yielding important insights into relationships between nontechnical skills, technical performance, and operative duration. These results support the concept that interventions designed to improve teamwork and communication may have beneficial effects on technical performance and patient outcome.

Effect of a “Lean” intervention to improve safety processes and outcomes on a surgical emergency unit

PROBLEMnEmergency surgical patients are at high risk for harm because of errors in care. Quality improvement methods that involve process redesign, such as “Lean,” appear to improve service reliability and efficiency in healthcare.nnnDESIGNnInterrupted time series.nnnSETTINGnThe emergency general surgery ward of a university hospital in the United Kingdom.nnnKEY MEASURES FOR IMPROVEMENTnSeven safety relevant care processes.nnnSTRATEGY FOR CHANGEnA Lean intervention targeting five of the seven care processes relevant to patient safety.nnnEFFECTS OF CHANGEn969 patients were admitted during the four month study period before the introduction of the Lean intervention (May to August 2007), and 1114 were admitted during the four month period after completion of the intervention (May to August 2008). Compliance with the five process measures targeted for Lean intervention (but not the two that were not) improved significantly (relative improvement 28% to 149%; P<0.007). Excellent compliance continued at least 10 months after active intervention ceased. The proportion of patients requiring transfer to other wards fell from 27% to 20% (P<0.000025). Rates of adverse events and potential adverse events were unchanged, except for a significant reduction in new safety events after transfer to other wards (P<0.028). Most adverse events and potential adverse events were owing to delays in investigation and treatment caused by factors outside the ward being evaluated.nnnLESSONS LEARNTnLean can substantially and simultaneously improve compliance with a bundle of safety related processes. Given the interconnected nature of hospital care, this strategy might not translate into improvements in safety outcomes unless a system-wide approach is adopted to remove barriers to change.

Factors influencing incident reporting in surgical care

Objectives: To evaluate the process of incident reporting in a surgical setting. In particular: the influence of event outcome on reporting behaviour; staff perception of surgical complications as reportable events. Design: Anonymous web-based questionnaire survey. Setting: General Surgical Department in a UK teaching hospital. Population: Of 203 eligible staff, 55 (76.4%) doctors and 82 (62.6%) nurses participated. Main outcome measures: Knowledge and use of local reporting system; propensity to report incidents which vary by outcome (harm, no harm, harm prevented); propensity to report surgical complications; practical and psychological barriers to reporting. Results: Nurses were significantly more likely to know of the local reporting system and to have recently completed a report than doctors. The level of harm (F(1.8,246)u200a=u200a254.2, p<0.001), incident type (F(1.9,258)u200a=u200a64.4, p<0.001) and profession (F(1,135)u200a=u200a20.7, p<0.001) all significantly affected the likelihood of reporting. Staff were most likely to report an incident when harm occurred. Doctors were significantly less likely to report surgical complications than other types of incident (15% vs 53%, zu200a=u200a4.633, p<0.001). Fear was a significantly less important barrier to reporting than other reasons (zu200a=u200a−3.49, p<0.0002). Conclusion: An incident is more likely to be reported if harm results. Surgical complications are not generally perceived to be “reportable incidents,” but they are addressed in Mortality and Morbidity meetings (M&M). Integrating M&M and incident reporting data will result in more comprehensive healthcare safety systems.

Quality and safety on an acute surgical ward: an exploratory cohort study of process and outcome.

Objective:To evaluate patient safety in an emergency surgical unit using process and outcome measures in parallel. Background:Patient harm from errors in care is common in modern surgical practice. Measurement of the problem is essential to any solution, but current methods of evaluating patient harm are either impractical or inadequate. We have therefore analyzed compliance with safety-relevant care processes, with the aim of developing a process-based system for evaluating ward safety. Methods:Adverse events (AE), potential adverse events (PAE), and 7 safety-relevant processes were measured on a 38-bed surgical emergency unit over a 16-week period. AE, PAE, and process measures were studied by prospective direct observation in large convenience samples, using objective measures. Possible influences on AE and PAE risk were analyzed. Results:Compliance with the 7 processes studied ranged from 23% to 89%. The AE and PAE rates were 11.9% and 13.8% in a 63% sample of admissions (n = 607). Length of stay was significantly associated with both AE (P < 0.001) and PAE (P < 0.001). Having an operation was also associated with AE (P = 0.001) but not with PAE. No other factors appeared to influence AE/PAE rates. Delays were the commonest causes of both AE and PAE. Conclusions:Compliance with individual care processes on a ward with average levels of patient harm is poor. Length of hospital stay increases the risk of both AE and PAE, suggesting a system defect. A bundle of care processes may be useful for monitoring safety improvement.

Effective prevention of thromboembolic complications in emergency surgery patients using a quality improvement approach.

Objective To assess the effectiveness of a multifaceted intervention based on industrial process improvement to identify and sustainably correct deficiencies in thromboprophylaxis delivery. Summary background data Deep vein thrombosis and pulmonary embolism are major causes of morbidity and mortality in surgical patients, but effective prophylactic treatments are available. Ensuring reliable delivery of the intended thromboprophylaxis is, however, a long-standing problem. Methods Delivery of thromboprophylactic treatment on an emergency general surgery admissions ward was targeted during a multidisciplinary intervention to improve process reliability using industrial quality improvement approaches. Delivery was audited against guidelines before and after 3-u2005month intervention. Clinical outcome was evaluated by reviewing all radiological investigations for suspected Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE) from patients admitted to the unit in the 1u2005year immediately before and that immediately after intervention. Results Delivery of thromboprophylaxis according to guidelines was improved from 35% before to 87% 3u2005months after intervention (χ2=87.412, p<0.0001) and sustained at 86% 10u2005months after intervention. Radiologically identified thromboembolic events occurring up to 60u2005days after admission in patients admitted for over 48u2005h fell from 23/3075 (0.75%) before to 9/3080 (0.29%) after intervention (HR 0.39, CI 0.29 to 0.53, χ2=6.18, p=0.01292). The risk of thromboembolism in the two groups diverged during follow-up to 60u2005days, before converging again. Conclusions A quality improvement process resulted in major sustainable improvements in the delivery of thromboprophylaxis associated with a 61% reduction in radiologically detected clinical episodes of thromboembolism 2u2005months after admission. Further study of this approach to improving care quality is warranted.