Christine S. Park

Communication failure in the operating room

BACKGROUND Communication errors contribute to the occurrence of adverse events in various domains of health care. Recent studies surveying perceptions of communication in the operating room have found disparities in the perceived quality of communication among members of the operating room team. Our aim was to characterize the nature of communication failures observed in the operating room and to assess whether a Team Training curriculum had any impact on observed communication errors. METHODS Intraoperative observation was performed and communication errors were identified according to predetermined criteria. Observed errors were classified according to the type of error, subject matter, and observed effect. RESULTS Seventy-six communication failures were observed over 150 hours of observation. Overall, communication errors relating to equipment and keeping team members informed of the progress of an operation comprised 36% and 24% of all observed communication errors, respectively. Prior to the introduction of a Team Training curriculum, 56 errors were observed over 76 hours (rate,737 errors per hour; standard error, 0.098). After Team Training, 20 errors over 74 hours were observed (rate .270 errors per hour; standard error, 0.060; P < .001). CONCLUSION Communication failures related most frequently to equipment and keeping team members updated as to the progress of an operation. These failures can lead to procedural delay and inefficiencies. A program that teaches teamwork and communication skills is one strategy that may improve communication among members of the operating room team.

Acquisition of critical intraoperative event management skills in novice anesthesiology residents by using high-fidelity simulation-based training.

Background:Early acquisition of critical competencies by novice anesthesiology residents is essential for patient safety, but traditional training methods may be insufficient. The purpose of this study was to determine the effectiveness of high-fidelity simulation training of novice residents in the initial management of critical intraoperative events. Methods:Twenty-one novice residents participated in this 6-week study. Three hypoxemia and three hypotension scenarios were developed and corresponding checklists were validated. Residents were tested in all scenarios at baseline (0 weeks) and divided into two groups, using a randomized crossover study design. Group 1 received simulation-based training in hypoxemic events, whereas Group 2 was trained in hypotensive events. After intermediate (3 weeks) testing in all scenarios, the groups switched to receive training in the other critical event. Final testing occurred at 6 weeks. Raters blinded to subject identity, group assignment, and test date scored videotaped performances by using checklists. The primary outcome measure was composite scores for hypoxemia and hypotension scenarios, which were compared within and between groups. Results:Baseline performance between groups was similar. At the intermediate evaluation, the mean hypoxemia score was higher in Group 1 compared with Group 2 (65.5% vs. 52.4%, 95% CI of difference 6.3–19.9, P < 0.003). Conversely, Group 2 had a higher mean hypotension score (67.4% vs. 45.5%, 95% CI of difference 14.6–29.2, P < 0.003). At Week 6, the scores between groups did not differ. Conclusions:Event-specific, simulation-based training resulted in superior performance in scenarios compared with traditional training and simulation-based training in an alternate event.

Surgical Team Training The Northwestern Memorial Hospital Experience

OBJECTIVES To develop and implement a team-training curriculum. We hypothesized that better interactions between personnel would lead to improved patient safety, increased efficiency, and better staff satisfaction. DESIGN Prospective assessment of a team-training program. SETTING University-affiliated hospital. PARTICIPANTS Operating room physicians, nurses, technicians, and other personnel. INTERVENTIONS Four-hour classroom curriculum, intraoperative coaching on team-related behaviors, and follow-up feedback sessions. MAIN OUTCOME MEASURES Baseline metrics and observational data were collected for 3 months before implementing the team-training program and 6 months after a designated implementation date. A questionnaire regarding perceptions of teamwork was completed at the beginning of and 6 weeks following the team-training classroom session. RESULTS Six months after implementation of team training, compliance with preoperative briefings was 66%. No changes in hospital metrics were observed. An improved perception of teamwork among the participants was demonstrated in pretraining and posttraining surveys. Perceptions of teamwork and the utility of a preoperative briefing differed among nurses, surgeons, and anesthesiologists. CONCLUSIONS Our team-training program resulted in moderate compliance with behaviors taught in the curriculum. Even with only moderate compliance, we demonstrated improved perceptions of teamwork.

The Berlin Questionnaire for assessment of sleep disordered breathing risk in parturients and non-pregnant women

BACKGROUND Pregnancy is associated with alteration in sleep patterns and quality. We wished to investigate whether pregnant women have a higher likelihood of a positive Berlin Questionnaire than non-pregnant women. METHODS Pregnant women ages 18-45 years (n=4074) presenting for delivery, and non-pregnant women ages 18-45 years (n=490) presenting for outpatient surgery provided demographic information and completed the Berlin Questionnaire evaluating self-reported snoring and daytime sleepiness. For the pregnant patients, the infants birth weight and Apgar scores were also recorded. RESULTS Of the 1439 patients with a positive Berlin Questionnaire, 96 were in the non-pregnant control population versus 1343 in the pregnant population (20% vs. 33%, respectively, P<0.001; odds ratio 2.0 [95% CI: 1.6-2.5]). There was a positive correlation between infant weight and a positive Berlin Questionnaire. The incidence of preeclampsia was greater (odds ratio 3.9) in the pregnant patients with a positive Berlin Questionnaire as compared with the parturients with a negative Berlin Questionnaire (odds ratio 1.1). CONCLUSION Parturients are more likely to have a positive Berlin Questionnaire than non-pregnant women. This may indicate an increased likelihood of sleep disordered breathing.

Simulation and Quality Improvement in Anesthesiology

Simulation, a strategy for improving the quality and safety of patient care, is used for the training of technical and nontechnical skills and for training in teamwork and communication. This article reviews simulation-based research, with a focus on anesthesiology, at 3 different levels of outcome: (1) as measured in the simulation laboratory, (2) as measured in clinical performance, and (3) as measured in patient outcomes. It concludes with a discussion of some current uses of simulation, which include the identification of latent failures and the role of simulation in continuing professional practice assessment for anesthesiologists.

Two-photon confocal microscopy: A nondestructive method for studying wound healing

Two-photon confocal microscopy is a new technology useful in nondestructive analysis of tissue. The pattern generated from laser-excited autofluorescence and second harmonic signals can be analyzed to construct a three-dimensional, microanatomical, structural image. The healing of full-thickness guinea pig skin wounds was studied over a period of 28 days using two-photon confocal microscopy. Three-dimensional data were rendered from two-dimensional images and compared with conventional, en face, histologic sections. Two-photon confocal microscopy images show resolution of muscle, fascia fibers, collagen fibers, inflammatory cells, blood vessels, and hair. Although these images do not currently have the resolution of standard histology, the ability to noninvasively acquire three-dimensional images of skin promises to be an important tool in wound-healing studies.

Simulation-based Assessment of the Management of Critical Events by Board-certified Anesthesiologists.

Background: We sought to determine whether mannequin-based simulation can reliably characterize how board-certified anesthesiologists manage simulated medical emergencies. Our primary focus was to identify gaps in performance and to establish psychometric properties of the assessment methods. Methods: A total of 263 consenting board-certified anesthesiologists participating in existing simulation-based maintenance of certification courses at one of eight simulation centers were video recorded performing simulated emergency scenarios. Each participated in two 20-min, standardized, high-fidelity simulated medical crisis scenarios, once each as primary anesthesiologist and first responder. Via a Delphi technique, an independent panel of expert anesthesiologists identified critical performance elements for each scenario. Trained, blinded anesthesiologists rated video recordings using standardized rating tools. Measures included the percentage of critical performance elements observed and holistic (one to nine ordinal scale) ratings of participant’s technical and nontechnical performance. Raters also judged whether the performance was at a level expected of a board-certified anesthesiologist. Results: Rater reliability for most measures was good. In 284 simulated emergencies, participants were rated as successfully completing 81% (interquartile range, 75 to 90%) of the critical performance elements. The median rating of both technical and nontechnical holistic performance was five, distributed across the nine-point scale. Approximately one-quarter of participants received low holistic ratings (i.e., three or less). Higher-rated performances were associated with younger age but not with previous simulation experience or other individual characteristics. Calling for help was associated with better individual and team performance. Conclusions: Standardized simulation-based assessment identified performance gaps informing opportunities for improvement. If a substantial proportion of experienced anesthesiologists struggle with managing medical emergencies, continuing medical education activities should be reevaluated.

Using simulation to study speaking up and team performance

May 2013 • Volume 116 • Number 5 www.anesthesia-analgesia.org 1183 Using Simulation to Study Speaking Up and Team Performance to a different threshold, but our general conclusion is that length of ICU stay remains a factor to take into consideration before using succinylcholine for critically ill patients. We performed a clinical not a pharmacologic study2 and found it impossible to precisely measure the peak potassium concentration. The resulting bias however should be an observed lower peak concentration and thus an underestimated ΔK and underestimated correlation between ΔK and length of ICU stay. In some cases, ΔK was surprisingly negative, independent of ΔpH, but these data are actual clinical observations with the usual assay and interspecimen variability. Finally, some points are superimposed in the scatter plot, and all 153 results were analyzed. In conclusion, we continue to consider that the length of ICU stay is an additional risk factor for hyperkalemia after administration of succinylcholine in critically ill patients.

Comments on ‘Emotion, cognitive load and learning outcomes during simulation training’

Editor – The recent report by Fraser et al. represents pioneering work in developing understanding of cognitive load within simulation education. We applaud this effort and wish to offer comments on its interpretation. Firstly, the authors state ‘...training must be considered suboptimal when 25–30% of students fail to recognise a cardiac murmur...’ Thereafter, this standard is presumably the basis for restatements of simulation’s ‘failure to improve’. This is problematic. Without a comparator pre-experience assessment, it is not possible to know the actual effect of the simulation encounter. These Year 1 medical students actually fared remarkably well in comparison with previously reported advanced learners and clinicians. The implied expectation that Year 1 students should perform better than doctors in training or practice requires justification.

An institution-wide approach to submission, review, and funding of simulation-based curricula

This article describes the development, implementation, and modification of an institutional process to evaluate and fund graduate medical education simulation curricula. The goals of this activity were to (a) establish a standardized mechanism for proposal submission and evaluation, (b) identify simulation-based medical education (SBME) curricula that would benefit from mentored improvement before implementation, and (c) ensure that funding decisions were fair and defensible. Our intent was to develop a process that was grounded in sound educational principles, allowed for efficient administrative oversight, ensured approved courses were high quality, encouraged simulation education research and scholarship, and provided opportunities for medical specialties that had not previously used SBME to receive mentoring and faculty development.