1. AFTER ALL, ANESTHESIA IS THE PROFESSION IN WHICH WE PUT OUR PATIENTS TO SLEEP! Is Communication Really Necessary? By: Danielle Boggio, CRNA, MSA

2. Communication… What is it? Definition of COMMUNICATION: The imparting or exchanging of information or news. The act of transmitting thoughts, opinions, or information by speech, writing, symbols, signs or behavior.

5. Words With Different Meanings

6. “Everything becomes a little different as soon as it is spoken out loud.” Hermann Hess Famous Quote

7. Failed Communication in the OR Communication failures are a well-characterized source of errors in the Operating Room. A study by the Agency for Healthcare Research and Quality in 2011 used direct observation of surgical procedures to assess the incidence, types and consequences of surgical communication problems>>> FAILURE to DISCUSS equipment problems and progress of the procedure were common, resulting in delays, inefficiency and medical errors.

8. Operating Room Communication Teamwork training - All providers practice the same guidelines; Pre/Intra/Post Op Guidelines Checklists - All providers use same check and balances; Surgical Safely Checklist Universal Protocol: Time Out - All providers identify correct patient identity, correct site, procedure to be done.

9. Cockpit Checklists in Aviation Aircraft checklists: Are regarded as the foundation for guidance of standardization of many high-risk industries such as maritime transportation, nuclear industry, weapons systems, space flight and medical care. Human factor professions: Are all at risk from several limitations in humans such as culture of the environment, resource management and production pressures.

10. OR Check Procedures are similar to Aviation The Check Procedures must include : 1. Each crew (team member) check for safety 2. This should be done before starting engines (pre-op requirements/OR equipment and staff) 3. Take off Checks (induction and incision), 4. Landing Secured (extubation and closing) 5. Preparation for an event of engine and system emergencies in place (patient instability, surgical complications, equipment failure)

11. Time Out - Before draping and skin incision Introduction of people in OR Confirm patient, Surgical site and side, Procedure and Position Medications labeled Need for Antibiotic/Irrigation Images Availability of implants, equipment, monitors Safety Considerations: Blood products, X-Ray protection Relevant documentation: H&P, Pertinent labs/medical conditions, Consents

12. Proper Time out requires Change in Culture The Difficulty involves 1~ changing culture of hospitals and surgery centers 2~ getting doctors – who typically prize their autonomy, resist checklists and underestimate their propensity for error – 3~ to follow standardized procedures and work in teams

14. “To Err is Human”, 1999 in Institute of Medicine Could have been prevented: >50% of adverse events resulted from preventable medical errors Medical errors: up to 98,000 Americans die each year as a result of medical errors

15. Famous Quote “Words should be used as tools of communication and not as a substitute for action” Martin Luther King, Jr.

16. Case 1: Nasal Reconstruction Patient: Female, 60 yo, 70kg, skin cancer, nasal defect Surgery: Repair Nasal defect, booked 2.5 hrs Surgeon’s office contacted Anesthesia department to change booking from general to MAC. Email sent to anesthesiologist and CRNA. Anesthesiologist did pre-op with patient and discussed GETA. CRNA comes out and explains Anesthetic plan with Ologist, Patient and Surgical Team (including Otolaryngology Plastic Surgeon.

17. Case 1: Nasal Reconstruction Continued Resident/fellow/attending confirms 2.5 hours and taking flap transfer, septum repair etc. GETA advised. New Plastic attending comes in and ready for MAC, Nasal cannula, explains patient will be fine and walks away. CRNA discusses with ologist and patient we will proceed with MAC In OR team confirms 2.5 hours and they leave. MAC begins, case lasts 10minutes and all is well!

18. Case 2: HHT (Hereditary Hemorrhagic Telangiectasia) Patient: male, 47 yo, 250 lbs, HHT complicated by significant epistaxis. He underwent sphenopalatine ligation and control of epistaxis in right nasal passage, then re-bleeding 1 year later and had Youngs Procedure to completely occlude the nasal passage. Surgery: Bronchoscopy to evaluate coughing up blood.

19. Case 2: HHT Continued Anesthesia team had discussions about airway management with LMA vs ETT  LMA: Potentially will not protect stomach/airway if bleeding, suctioning is difficult, Less traumatic and may cause less bleeding, airway does not sit in trachea and therefore trachea can be evaluated  ETT: Potentially may cause more bleeding, case may be EUA and short time, may inhibit view of trachea, may assist with decreasing bleeding by pressure of tube, may be difficult airway and trauma may be induced.

20. Case 2: HHT Continued Discussions between Surgical team, patient, wife, CRNA, Anesthesiologist. Case was done with LMA, HOB elevated, bleeding immediately, suctioned, assisted ventilation, patient protected his own reflexes by coughing, procedure aborted. Patient safe.

21. Case 3: Breast Reduction Patient 44 yo, 190 lb, h/o Asthma on several inhalers Surgery Breast reduction Pre-op: CRNA told pre-op was done by Anesthesiologist and it was a healthy patient with no medical issues. Surgeon and nurses rushing because room running late. No physical exam including pre- op assessment of breath sounds.

22. Case 3: Breast Reduction Continued Intra-op: ~~ EMT trainee intubated: no discussion about airway confirmation and time out being done at same time ~~ Patient moved when folly catheter inserted: Rocuronium given. ~~ Patient desaturated : no communication ~~ Anesthesiologist treated with albuterol ~~ Assessed for leak, depth, BS, patient color…

23. Case 3: Breast Reduction Continued Stat anesthesia help was called and it was noted that the ETT was not in the trachea, patient was re-intubated and case was held for reversal of non-depolarizer and case was cancelled.

24. GI Cases Patient stated she sleeps 2 days after one beer. Scheduled for EGD, Propofol 100mg for 30 min EGD, Asleep for 4 hours in PACU, stumbled into car with assist. Patient h/o Afib (successful ablation) and CVA, 60 yo, plays tennis. Scheduled for Colonoscopy, Propofol 200mg titrated and after scope pressure, abdominal pressure and air, patient had 4 episodes of asystole for 2 screens about 3-4 seconds.

25. Importance of OR Plan Communicated Neuromuscular blockade –necessary or not Length of case – observing surgery progress Site of surgery (BP cuff, IV, pulse ox, ECG leads) Type of anesthetic discussion among teams ENT: use of scope at beginning or end of case GI: anatomy, retroflex, cecum, NPO split prep, cases out of order and wrong procedure Opthamology: Local anesthetic, block, type of anesthesia surgeon requests vs anesthesia team Thyroplasty- need pt cooperation to speak during pint in case: clarity, volume, pitch

26. $ Value of CRNA Communication Billing Diagnosis and Surgery (ICD and CPT) Medical Modifiers Start/End times PQRS: Physician Quality Reporting System  Payment adjustments  Required to report Beta blockers for CABG sx, prevention of catheter-related bloodstream infections and perioperative temperature management  Report at least one cost cutting measure Medicare Billing:  QK: Medical direction of up to 4 concurrent cases  QZ: CRNA service: without medical direction

28. Sources Agency for Healthcare Research and Quality Communication failure in the operating room. Halverson AL, Casey JT, Anderson J, et al. Surgery. 2011;49:305-316 Helath.belgium.be/internet2prd/groups/public/@acutecare/doc uments/ie2: Surgical Safety Checklist Time-out. Anesthesia Safety, Vancermeersch E. UZ Kuleuven Helath.belgium.be/internet2prd/groups/public/@acutecare/doc uments/ie2 Human factors 35(2), pp. 28-43, Cockpit Checklists: Concepts, Design, and Use. Asaf Degani and Earl Wiener www.asahq.org/resources/quality-improvement/physicians- quality-reporting-systems/2015-pqrs-faqs www.asahq.org/resources/quality-improvement/physicians- quality-reporting-systems/2015-pqrs-faqs How many die from medical mistakes in US Hospitals? Sept 20, 2013. Marshall Allen, Propublica, Shots Health News From NPR http://weknowmemes.com/wp-content/uploads/2012/02/this- sentence-has-7-different-meanings.jpg