Presentation on theme: "What Can the Operating Room Learn from the Cockpit?"— Presentation transcript:
1What Can the Operating Room Learn from the Cockpit? Richard C. Karl, M.D.Richard G. Connar Professor and ChairmanDepartment of SurgeryCollege of MedicineUniversity of South FloridaFounder, Surgical Safety InstituteContributing Editor, Flying MagazineTampa, FLCaptain Robert HaynesDirector of Flight Standards & Quality Assurance, Southwest AirlinesDallas, TX
2What Can an Operating Room Learn from a Cockpit? What is realistic?What are the fundamental/immutable differences?What can be done now?What can be done in the future?What can you do tomorrow?WHAT IS REALISTIC?BUNCH OF PILOTS USELESS YAHOOS.
3Is the cockpit model perfectly transferable to the OR? FAA regulates the industry and the pilotsState boards, ACS, credentialing, JCAHOPilots work for the airlineSurgeons are largely independent and important to a hospital’s bottom lineA crash kills several at onceErrors kill/harm one at a timePilot is the first to the scene of the accidentClinician not hurt, except by reputation
4Differences Unlikely to Change RegulationEmploymentNumber of people harmed per incidentHarm to the teamFAA regulates the industry and the pilotsState boards, ACS, credentialing, JCAHOPilots work for the airlineSurgeons are largely independent and important to a hospital’s bottom lineA crash kills several at onceErrors kill/harm one at a timePilot is the first to the scene of the accidentClinician not hurt, except by reputation
5Differences That Could Change…Eventually Credentialing and re-evaluationSimulatorsAdd facts of sim prof and ck rides Strict re-evaluation process:Sim proficiency ADD FACTSCheck rides ADD FACTSSophisticated simulatorsCRM is mandated by the FAAWritten exam every 10 years – pass rate 97%Rudimentary med/surg simulators
6Differences That Could Change…Now Limitation of hoursTeamwork and communicationThe culture in the ORFederally limited duty flight hours OF WHAT?CRM is mandated by the FAAResidents only HOURS?Flawless performance of individual practitioners – the culture CAN change
7Why Teamwork and Communication? To help compensate for the FACT that humans (even well-trained, highly experienced, good ones) make errorsStressFatigueOverloadEmergencyUnfamiliarDistractions/interruptions
11Preventable Adverse Events 100,000 die from medical errorsDoes not include:- wrong site- retained surgical item- surgical site infection with hypothermia- cancer recurrence with blood transfusion- consequences of hyperglycemia15,000,000 harms - IHI
13Temperature Mild hypothermia (34.70C vs. 36.60C) Increases surgical wound infections18% hypothermia vs. 6% normothermia (p.0009)Negative impact on all patients, but also significantly affected the uninfected patientsUninfected PatientsNormothermiaHypothermiaP valueDays to first solid food5.26.1<0.001Days to suture removal9.610.60.003Days of hospitalization11.813.50.01Kurz, New England Journal of Medicine 1996;334:
14Glucose ControlHigher 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.Critically ill patients, tight glucose control34% decrease in mortalityReduced blood stream infections by 44%Decreased renal failure and less likely to require prolonged mechanical ventilationLatham, ICHE 2001;22:607-12Pomposelli, JPEN 1998;22:77-81Van Den Berghe, NEJM 2001;345:
15Blood TransfusionsTransfusion of any volume of red blood cell concentrates more than triples the risk of nosocomial infection.Transfusion of critically ill patientsIncreases risk of nosocomial infectionWorsens organ dysfunctionIncreases mortalityLinked to cancer recurrence or cancer-related deathsHead and neck cancer, breast cancer, gastric cancer, lung cancer, and colon cancerHill, J Trauma 2003;54:908-14Taylor, CCM 2002;30:Englesbe, JACS 2005;200(2):249-54Burrows, Lancet 1982;2:662
20Teamwork and Communication Have structured and clear team rolesUse patterned communicationBrief and debriefPlan for contingenciesKnow the game planInvite inputKnow and use namesAssert: Speak up if something looks wrong or confusingRead back all the timeWatch out for each other/vigilanceIdentify and deal with red flags
22Key Skills by Crew Position Captain First OfficerBriefingLeadershipInterpersonal SkillCommunicationInquiry/AssertionPreparation, Planning, & VigilanceTechnical ProficiencyLeadershipROB STARTS HERE.AMAZEMENT.ROLE OF REGULATIONAIRPLANE IS HEALTHYThis is from the NASA/University of Texas Research Project. For Captains, notice that the key skills are all teamwork and non-technical in nature.
23Are Teamwork and Communication Enough? An integrated approach Create cohesive, clear, reliable policiesEnsuring no RSI or wrong surgery is a team function, not solely a nursing or surgeon functionMake teamwork and communication the bedrock of safety in job descriptionsHire for teamwork skills – ALL team membersDeal with disruptive team membersAlign physician and nurse codes of conductRegularly train team and practical skillsCommit to imbedding teamwork into the cultureNot get along for the safe of being nice, cultural mandate. Critical to safe and effective performance of your duties
24Bringing Surgeons into the Team Everyone feels frustrated and powerlessOR is now leaderlessMD as solitary craftsmanAnesthesia, prep and nursing as solitary craftsmenMDs are leaders, not just craftsmen – rise to the occasion, control their environmentMD role is to provide leadership and create a functioning teamRICHARD STARTS HERE AGAIN
25Our Experience – Success Factors Have early and simultaneous MD trainingInsist on physician-to-physician trainingSeparate MDs from the rest of the team initiallyStart with an MD dinnerWin them over one by oneEmphasize the clinical and efficiency reasons to communicateEmphasize how briefs can solve nagging frustrations:Travelers/tempsIll-timed breaksInterruptions and distractionsEquipment issuesRespect for everyone’s critical timesUse alpha dogsSpread MD testimonials of early successesROB – EARLY CRM ADOPTION HURDLES??STORY: “not talk to anyone but a surgeon”ALPHA DOGS – USE HELICOPTER STORYTESTIMONIALS – USE DAVID CULBER, IMPASSIONED SPEECH TO MEC – CHANGED HIS RELATION NOT JUST WITH TEMPS BUT WITH 20 YR STAFF.
26Our Experience – Success Factors Use tools for support:White boardsObservationsShow support from the top and the middleExhibit dogged and determined leadershipIntegrate the effortProvide recurrent trainingROB – EARLY CRM ADOPTION HURDLES??STORY: “not talk to anyone but a surgeon”ALPHA DOGS – USE HELICOPTER STORYTESTIMONIALS – USE DAVID CULBER, IMPASSIONED SPEECH TO MEC – CHANGED HIS RELATION NOT JUST WITH TEMPS BUT WITH 20 YR STAFF.
28What you can do to make this happen tomorrow Provide leadership – it can come from anywhereAdvocate for this – don’t give upHand out articles on the topicDiscuss the topic at managers’ meetingsHave a grand rounds or in-service on the topicConsider how communication played a role in every eventWalk in and observe what’s going on nowIntroduce white boards
29What you can do to make this happen tomorrow Start small with a willing groupUse outsiders initially – aviation is sexy, engaging and convincingUse physician trainersDo briefsSpread anecdotes of success – believer to non-believerDevelop “killer” item checklistsStress function over formIncorporate teamwork and communication into all policies, job descriptions, by-lawsBe consistent in support of teamworkCommit to a coordinated approach – not just team training
31Aviation U.S. airline fatality rate 1/5 th of 1950 No one died in a domestic airliner in
32Operating Rooms WSS decreased from 3 to 0 per year Preoperative brief results:WSS decreased from 3 to 0 per yearEmployee satisfaction increased 19%Nursing turnover decreased 16%Early resolution of equipment issuesReduced delays in receiving equipmentReduced case delay or cancellationsThe Permanente Journal Spring 2004 Vol 8 No 2 James DeFontes, MD, Stephanie Surbida, MPH
33Medicine is a lot harder These techniques can make it easier,more efficient,and safer
34BibliographyWhile 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 Vol 92 No 4 Page “Staying Safe: Simple Tools for Safe Surgery” Karl RCThe Permanente Journal Spring Vol 8 No 2 “Preoperative Safety Briefing Project” James DeFontes MD and Stephanie Surbida MPHJournal of the American College of Surgeons February Volume 204 No. 2 “Operating Room Briefings and Wrong-Site Surgery” Makary, Mukherjee, Sexton, Syin, et alBritish Medical Journal March “Error, stress, and teamwork in medicine and aviation: cross sectional surveys” Sexton JB, Thomas EJ, Helmreich RL
35BibliographyJournal of the American College of Surgeons July Vol 205 No “Briefing and Debriefing in the Operating Room Using Fighter Pilot Crew Resource Management J McGreevey, MD, T Otten, BSAcademic Medicine March Vol 77 No 3 “Team Communications in the Operating Room: Talk Patterns, Sites of Tension, and Implications for Novices” Lingard, Reznick, Espin, Regehr, DeVitoAmerican Journal of Surgery 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 DHAnnals of Surgery May 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
36What Can the Operating Room Learn from the Cockpit? Richard C. Karl, MDRichard G. Connar Professor and ChairmanDepartment of SurgeryCollege of MedicineUniversity of South FloridaFounder, Surgical Safety InstituteContributing Editor, Flying MagazineTampa, FLCaptain Robert HaynesDirector of Flight Standards & Quality Assurance, Southwest AirlinesDallas, TX