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Richard C. Karl, M.D. Richard G. Connar Professor and Chairman Department of Surgery College of Medicine University of South Florida Founder, Surgical.

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Presentation on theme: "Richard C. Karl, M.D. Richard G. Connar Professor and Chairman Department of Surgery College of Medicine University of South Florida Founder, Surgical."— Presentation transcript:

1 Richard C. Karl, M.D. Richard G. Connar Professor and Chairman Department of Surgery College of Medicine University of South Florida Founder, Surgical Safety Institute Contributing Editor, Flying Magazine Tampa, FL Captain Robert Haynes Director of Flight Standards & Quality Assurance, Southwest Airlines Dallas, TX What Can the Operating Room Learn from the Cockpit?

2 What Can an Operating Room Learn from a Cockpit? What is realistic? What is realistic? What are the fundamental/immutable differences? What are the fundamental/immutable differences? What can be done now? What can be done now? What can be done in the future? What can be done in the future? What can you do tomorrow? What can you do tomorrow?

3 Is the cockpit model perfectly transferable to the OR?

4 Differences Unlikely to Change Regulation Regulation Employment Employment Number of people harmed per incident Number of people harmed per incident Harm to the team Harm to the team

5 Differences That Could Change…Eventually Credentialing and re-evaluation Credentialing and re-evaluation Simulators Simulators

6 Differences That Could Change…Now Limitation of hours Limitation of hours Teamwork and communication Teamwork and communication The culture in the OR The culture in the OR

7 Why Teamwork and Communication? To help compensate for the FACT that humans (even well-trained, highly experienced, good ones) make errors Stress Stress Fatigue Fatigue Overload Overload Emergency Emergency Unfamiliar Unfamiliar Distractions/interruptions Distractions/interruptions

8 From JCAHO website as of July, 2007

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11 100,000 die from medical errors Does not include: - wrong site - retained surgical item - surgical site infection with hypothermia - cancer recurrence with blood transfusion - consequences of hyperglycemia 15,000,000 harms - IHI Preventable Adverse Events

12 Clinical Reasons to Communicate

13 Temperature Mild hypothermia ( C vs C) Mild hypothermia ( C vs C) Increases surgical wound infections Increases surgical wound infections 18% hypothermia vs. 6% normothermia (p.0009)18% hypothermia vs. 6% normothermia (p.0009) Negative impact on all patients, but also significantly affected the uninfected patients Negative impact on all patients, but also significantly affected the uninfected patients Uninfected Patients NormothermiaHypothermia P value Days to first solid food <0.001 Days to suture removal Days of hospitalization Kurz, New England Journal of Medicine 1996;334:

14 Glucose Control Higher incidence of SSI in diabetic patients undergoing CABG with poor glucose control. Higher incidence of SSI in diabetic patients undergoing CABG with poor glucose control. Moderate hyperglycemia (200 mg/dL) at any time during the first postoperative day increases risk of SSI fourfold after noncardiac surgery. Moderate hyperglycemia (200 mg/dL) at any time during the first postoperative day increases risk of SSI fourfold after noncardiac surgery. Critically ill patients, tight glucose control Critically ill patients, tight glucose control 34% decrease in mortality 34% decrease in mortality Reduced blood stream infections by 44% Reduced blood stream infections by 44% Decreased renal failure and less likely to require prolonged mechanical ventilation Decreased renal failure and less likely to require prolonged mechanical ventilation Van Den Berghe, NEJM 2001;345: Pomposelli, JPEN 1998;22:77-81 Latham, ICHE 2001;22:607-12

15 Blood Transfusions Transfusion of any volume of red blood cell concentrates more than triples the risk of nosocomial infection. Transfusion of any volume of red blood cell concentrates more than triples the risk of nosocomial infection. Transfusion of critically ill patients Transfusion of critically ill patients Increases risk of nosocomial infection Increases risk of nosocomial infection Worsens organ dysfunction Worsens organ dysfunction Increases mortality Increases mortality Linked to cancer recurrence or cancer-related deaths Linked to cancer recurrence or cancer-related deaths Head and neck cancer, breast cancer, gastric cancer, lung cancer, and colon cancer Head and neck cancer, breast cancer, gastric cancer, lung cancer, and colon cancer Englesbe, JACS 2005;200(2): Burrows, Lancet 1982;2:662 Hill, J Trauma 2003;54: Taylor, CCM 2002;30:

16 Fluids

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19 Traditional Surgical Brief

20 Teamwork and Communication Have structured and clear team roles Have structured and clear team roles Use patterned communication Use patterned communication Brief and debrief Brief and debrief Plan for contingencies Plan for contingencies Know the game plan Know the game plan Invite input Invite input Know and use names Know and use names Assert: Speak up if something looks wrong or confusing Assert: Speak up if something looks wrong or confusing Read back all the time Read back all the time Watch out for each other/vigilance Watch out for each other/vigilance Identify and deal with red flags Identify and deal with red flags

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22 Key Skills by Crew Position Briefing Briefing Leadership Leadership Interpersonal Skill Interpersonal Skill Communication Communication Inquiry/Assertion Preparation, Planning, & Vigilance Technical Proficiency Leadership Captain First Officer Captain First Officer

23 Are Teamwork and Communication Enough? An integrated approach Create cohesive, clear, reliable policies Create cohesive, clear, reliable policies Ensuring no RSI or wrong surgery is a team function, not solely a nursing or surgeon function Ensuring no RSI or wrong surgery is a team function, not solely a nursing or surgeon function Make teamwork and communication the bedrock of safety in job descriptions Make teamwork and communication the bedrock of safety in job descriptions Hire for teamwork skills – ALL team members Hire for teamwork skills – ALL team members Deal with disruptive team members Deal with disruptive team members Align physician and nurse codes of conduct Align physician and nurse codes of conduct Regularly train team and practical skills Regularly train team and practical skills Commit to imbedding teamwork into the culture Commit to imbedding teamwork into the culture

24 Bringing Surgeons into the Team Everyone feels frustrated and powerless Everyone feels frustrated and powerless OR is now leaderless OR is now leaderless MD as solitary craftsman MD as solitary craftsman Anesthesia, prep and nursing as solitary craftsmen Anesthesia, prep and nursing as solitary craftsmen MDs are leaders, not just craftsmen – rise to the occasion, control their environment MDs are leaders, not just craftsmen – rise to the occasion, control their environment MD role is to provide leadership and create a functioning team MD role is to provide leadership and create a functioning team

25 Our Experience – Success Factors Have early and simultaneous MD training Insist on physician-to-physician training Separate MDs from the rest of the team initially Separate MDs from the rest of the team initially Start with an MD dinner Start with an MD dinner Win them over one by one Win them over one by one Emphasize the clinical and efficiency reasons to communicate Emphasize the clinical and efficiency reasons to communicate Emphasize how briefs can solve nagging frustrations: Emphasize how briefs can solve nagging frustrations: Travelers/temps Travelers/temps Ill-timed breaks Ill-timed breaks Interruptions and distractions Interruptions and distractions Equipment issues Equipment issues Respect for everyones critical times Respect for everyones critical times Use alpha dogs Use alpha dogs Spread MD testimonials of early successes Spread MD testimonials of early successes

26 Our Experience – Success Factors Use tools for support: Use tools for support: White boards White boards Observations Observations Show support from the top and the middle Exhibit dogged and determined leadership Integrate the effort Provide recurrent training

27 What you can do to make this happen tomorrow

28 Provide leadership – it can come from anywhere Provide leadership – it can come from anywhere Advocate for this – dont give up Advocate for this – dont give up Hand out articles on the topic Hand out articles on the topic Discuss the topic at managers meetings Discuss the topic at managers meetings Have a grand rounds or in-service on the topic Have a grand rounds or in-service on the topic Consider how communication played a role in every event Consider how communication played a role in every event Walk in and observe whats going on now Walk in and observe whats going on now Introduce white boards Introduce white boards What you can do to make this happen tomorrow

29 Start small with a willing group Start small with a willing group Use outsiders initially – aviation is sexy, engaging and convincing Use outsiders initially – aviation is sexy, engaging and convincing Use physician trainers Use physician trainers Do briefs Do briefs Spread anecdotes of success – believer to non-believer Spread anecdotes of success – believer to non-believer Develop killer item checklists Develop killer item checklists Stress function over form Stress function over form Incorporate teamwork and communication into all policies, job descriptions, by-laws Incorporate teamwork and communication into all policies, job descriptions, by-laws Be consistent in support of teamwork Be consistent in support of teamwork Commit to a coordinated approach – not just team training Commit to a coordinated approach – not just team training

30 Does it Work?

31 Aviation U.S. airline fatality rate 1/5 th of 1950 U.S. airline fatality rate 1/5 th of 1950 No one died in a domestic airliner in No one died in a domestic airliner in

32 Operating Rooms Preoperative brief results: WSS decreased from 3 to 0 per year Employee satisfaction increased 19% Nursing turnover decreased 16% Early resolution of equipment issues Reduced delays in receiving equipment Reduced case delay or cancellations The Permanente Journal Spring 2004 Vol 8 No 2 James DeFontes, MD, Stephanie Surbida, MPH

33 Medicine is a lot harder These techniques can make it easier, more efficient, and safer

34 Bibliography While there are increasing numbers of articles about the topic of crew resource management (or team training) in the health care literature, this is a quick list of several that may help to persuade others: Bulletin of the American College of Surgeons April 2007 Vol 92 No 4 Page Staying Safe: Simple Tools for Safe Surgery Karl RC Bulletin of the American College of Surgeons April 2007 Vol 92 No 4 Page Staying Safe: Simple Tools for Safe Surgery Karl RC The Permanente Journal Spring 2004 Vol 8 No 2 Preoperative Safety Briefing Project James DeFontes MD and Stephanie Surbida MPH The Permanente Journal Spring 2004 Vol 8 No 2 Preoperative Safety Briefing Project James DeFontes MD and Stephanie Surbida MPH Journal of the American College of Surgeons February 2007 Volume 204 No. 2 Operating Room Briefings and Wrong-Site Surgery Makary, Mukherjee, Sexton, Syin, et al Journal of the American College of Surgeons February 2007 Volume 204 No. 2 Operating Room Briefings and Wrong-Site Surgery Makary, Mukherjee, Sexton, Syin, et al British Medical Journal March Error, stress, and teamwork in medicine and aviation: cross sectional surveys Sexton JB, Thomas EJ, Helmreich RL British Medical Journal March Error, stress, and teamwork in medicine and aviation: cross sectional surveys Sexton JB, Thomas EJ, Helmreich RL

35 Bibliography Journal of the American College of Surgeons July 2007 Vol 205 No Briefing and Debriefing in the Operating Room Using Fighter Pilot Crew Resource Management J McGreevey, MD, T Otten, BS Journal of the American College of Surgeons July 2007 Vol 205 No Briefing and Debriefing in the Operating Room Using Fighter Pilot Crew Resource Management J McGreevey, MD, T Otten, BS Academic Medicine March 2002 Vol 77 No 3 Team Communications in the Operating Room: Talk Patterns, Sites of Tension, and Implications for Novices Lingard, Reznick, Espin, Regehr, DeVito Academic Medicine March 2002 Vol 77 No 3 Team Communications in the Operating Room: Talk Patterns, Sites of Tension, and Implications for Novices Lingard, Reznick, Espin, Regehr, DeVito American Journal of Surgery 2005 Nov 190(5) Bridging the communication gap in the operating room with medical team training Awad SS, Fagan SP, Bellows C, Albo D, Green-Rashad B, De la Garza M, Berger DH American Journal of Surgery 2005 Nov 190(5) Bridging the communication gap in the operating room with medical team training Awad SS, Fagan SP, Bellows C, Albo D, Green-Rashad B, De la Garza M, Berger DH Annals of Surgery May 2006 Vol 243 Issue 5 Page 628 Patient Safety in Surgery Martin A. Makary, MD, MPH; J Bryan Sexton, PhD; Julie A. Freischlag, MD; E Anne Millman, MS; David Pryor, MD; Christine Holzmueller, BLA; Peter J. Pronovost, MD, PhD Annals of Surgery May 2006 Vol 243 Issue 5 Page 628 Patient Safety in Surgery Martin A. Makary, MD, MPH; J Bryan Sexton, PhD; Julie A. Freischlag, MD; E Anne Millman, MS; David Pryor, MD; Christine Holzmueller, BLA; Peter J. Pronovost, MD, PhD

36 Richard C. Karl, MD Richard G. Connar Professor and Chairman Department of Surgery College of Medicine University of South Florida Founder, Surgical Safety Institute Contributing Editor, Flying Magazine Tampa, FL Captain Robert Haynes Director of Flight Standards & Quality Assurance, Southwest Airlines Dallas, TX What Can the Operating Room Learn from the Cockpit?


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