TASK, TEAM AND TECHNOLOGY INTEGRATION IN SURGICAL CARE

TASK, TEAM AND TECHNOLOGY INTEGRATION IN SURGICAL CARE Dr Ken Catchpole Director of Surgical Safety and Human Factors Research Department of Surgery Cedars-Sinai Medical Center Los Angeles

.WHERE I FINISHED LAST YEAR HF is changing healthcare. Human Factors will also be changed. There are unique challenges ahead: Practical: Level of complexity. Scientific: What is evidence? Personal: Acceptance & value of expertise. Ethical: Complicity, and lack of guidance & support.

METHOD OF ENQUIRY Is this consistent with achieving a high standard of care? Would this be acceptable for me or one of my family? Does it have to be like this? Is this the best it can be? Compare and Discuss Experiences Widely Get the message out healthcare Reflect back into

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VIGNETTE 1: NEURO SURGERY A V-P shunt was being given to a paediatric patient. The scrub nurse was new to the operation, but was being supported by an experienced nurse, and the consultant surgeon was joined by a semi-retired colleague and mentor. The operation did not immediately proceed smoothly, with several problems and stoppages due to equipment problems; the diathermy did not immediately function effectively; the pneumatic hose on the cranial drill was occluded when it was secured to the drapes, and took several minutes to rectify (with the nursing staff first changing several parts of the drill before another nurse solved the problem). The surgeons were also struggling with the equipment, some of which was an inappropriate size for the patient, and since this operation was being performed in another part of the hospital from usual, no alternatives were available. To rinse the incision site for passing the V-P shunt under the skin, the semi-retired surgeon requested saline, but the inexperienced and overloaded scrub nurse, also attending to the needs of the consultant surgeon, accidentally gave the previously used syringe of local anaesthetic (chirocaine). As the surgeon was about to squirt the contents of the syringe onto the incision site, the second (experienced) scrub nurse realised the error and very loudly shouted No don t do that, and the error was captured. Catchpole, Dale, Hirst, Smith, Giddings (2009). The Safer Theatre Teams Project: Final Report to the Health Foundation

Co-ordination / communication Absence Equipment failure Equipment Configuration failure atient-sourced procedural difficulties Safety consciousness Unintended effects on patient Equipment / Workspace management Distraction Perfusion difficulties Psychomotor-related surgical error External resource failure Cannulation difficulties Procedure-related Error Vigilance / awareness Team Conflict Perfusion difficulties: technical Expertise / skill failure Planning failure Temperature control difficulties Pre-operative diagnosis failure Psychomotor Error (general) Fault resolution Resource management Psychomotor-related perfusion error External pressures Fatigue Known problem Decision-related surgical error 0 0.5 1 1.5 2 2.5 3 3.5 4 Minor Problem Types 24 Operations 366 minor problems 29 different types PAEDIATRIC CARDIAC SURGERY Catchpole, K, Giddings, A, De Leval, M, Peek, G, Godden, P, Utley, M, Gallivan, S, Hirst, G, Dale, T (2006). Identification of systems failures in successful paediatric cardiac surgery. Ergonomics 49(5-6), pp.567-588. Mean number per operation

Number of Minor Problems Catchpole, K, Giddings, A, Wilkinson, M, Hirst, G, Dale, T, De Leval, M. (2007) Improving patient safety by identifying latent failures in successful operations. Surgery 142(1), pp.102-110.

Distraction Equipment / workspace management failure Safety consciousness Co-ordination / communication Expertise / skill failure Procedure-related Error Equipment Configuration failure Patient-sourced procedural difficulties Equipment failure Vigilance / awareness failure Absence Psychomotor Error (general) Planning failure External resource failure Team Conflict Psychomotor-related surgical error Resource management failure Unintended effects on patient Pre-operative diagnosis failure Decision-related surgical error Minor Problem Types 416 minor problems 20 different types ORTHOPAEDIC SURGERY 0 1 2 3 4 5 6 7 8 9 10 Mean number per operation

Minor Failures Minor Problems Per Operation (Orthopaedic Surgery) 60 50 40 THR Training Case 30 20 10 0 Risk level 1 Risk level 2 Risk level 3 Arthroscopy Primary THR and TKR Revision TKR

THE CARDIAC OR Catchpole K (2011). Task, Team and Technology Integration in the Paediatric Cardiac Operating Room. Progress in Pediatric Cardiology 32 (2), 85-88. Cardiac OR

THE ORTHOPEDIC OR CN SN 1A S Pump Drip Anaesthetic Workstation AC Catchpole, K (2009). Observing Failures in Successful Orthopaedic Surgery. In L. Mitchell and R Flin (eds), Safer Surgery Analysing Behaviour in the Operating Theatre.

SURGICAL NOTECHS Dimensions Leadership & Management Teamwork & Co-operation Problem Solving & Decision Making Situation Awareness Mishra, et al. (2009). The Oxford NOTECHS System: reliability and validity of a tool for measuring teamwork behaviour in the operating theatre. Quality and Safety in Healthcare, 18, pp. 104-108. Elements Leadership Maintenance of Standards Planning & Preparation Workload Management Authority & Assertiveness Team building & Maintaining Support of others Understanding team needs Conflict solving Definition & Diagnosis Option Generation Risk Assessment Outcome Review Notice Understand Think Ahead Below Standard (1) Basic Standard (2) Standard (3) Exceed(4) Behaviour directly compromises patient safety and effective teamwork. Behaviour in other conditions could directly compromise patient safety and effective teamwork. Behaviour maintains an effective level of patient safety and teamwork. Behaviour enhances patient safety and teamwork. A model for all other teams.

Intraoperative Duration (mins) Minor Problems Intraoperative Performance INFLUENCE OF TEAMWORK 16 14 12 10 Ineffective Teams Effective Teams 1 0.99 0.98 0.97 0.96 8 6 4 2 0 350 300 0.95 0.94 0.93 0.92 0.91 0.9 250 200 150 100 50 0 Pediatric Cardiac Surgery Orthopedic Surgery Catchpole et al. Improving patient safety by identifying latent failures in successful operations. Surgery 142(1),

DISRUPTONS AND NON-TECHNICAL SKILLS (PAEDIATRIC CARDIAC SURGERY) Most Effective Least Effective Spearman s Rho = 0.738, n=24, p<0.001 Mishra, A, et at. (2009). Rating Operating Theatre Teams - Surgical NOTECHS. In Safer Surgery Analysing Behaviour in the Operating Theatre. Aldershot: Ashgate.

NOTECHS SKILLS AND INTRAOPERATIVE PERFORMANCE Catchpole, K et al. (2008). A Method for Measuring Threats and Errors in Surgery. Cognition, Technology and Work 10(4), pp. 295-304. Rho n p Minor Failures 0.738 <0.001 Paediatric Cardiac Threats 0.584 <0.005 24 Technical Errors 0.286 0.175 Operative Duration 0.581 <0.005 Orthopaedic Minor Failures 0.400 0.081 Threats 0.249 0.290 20 Technical Errors 0.311 0.182 Operative Duration 0.270 0.250

Other Procedural Problems and Errors Errors in Surgical Technique 7 6 Ken Catchple 2012 Laparoscopic Cholecystectomy Carotid Endarerectomy Effective surgical situation awareness is associated with reduced technical errors 5 4 3 2 1 Laparoscopic Cholecystectomy Model Carotid Endarterectomy Model 0 Ineffective Standard Effective Basic (2) Standard (3) Exceed (4) Surgical Situation Awareness Effective nursing leadership and management is associated with reduced procedural hold ups 16 14 12 10 8 6 4 2 0 Laparoscopic Cholecystectomy Carotid Endarterectomy Laparoscopic Cholecystectomy Model Carotid Endarterectomy Model Ineffective Standard Effective Basic (2) Standard (3) Exceed (4) Nursing Leadership and Management Catchpole, K et al. (2008). Teamwork and Error in the Operating Room: Analysis of Skills and Roles. Annals of Surgery 247(4), pp.699-706.

Operating Time Operating Time 180 Ken Catchple 2012 Laparoscopic Cholecystectomy Carotid Endarterecomy Effective surgical leadership is associated with reduced operating time 160 140 120 100 80 60 40 20 BUT 0 180 Ineffective Standard Basic (2) Standard (3) Exceed (4) Surgical Leadership & Management Laparoscopic Cholecystectomy Effective Effective anaesthetic leadership is associated with increased operating time in CEA 160 140 120 100 80 60 40 20 0 Carotid Endarterectomy Ineffective Standard Effective Basic (2) Standard (3) Exceed (4) Anaesthetic Leadership & Management Catchpole, K et al. (2008). Teamwork and Error in the Operating Room: Analysis of Skills and Roles. Annals of Surgery 247(4), pp.699-706.

BENEFITS OF TEAM TRAINING Better perceived teamwork Better observed team skills Improved compliance with briefings Better processes Reduced error rates Better satisfaction with care Better organisational perceptions

SYSTEMATIC REVIEW The evidence for technical or clinical benefit from teamwork training in medicine is weak. There is some evidence of benefit from studies with more intensive training programmes, but. cost-benefit analysis are needed. McCulloch, Rathbone, Catchpole (2011). Interventions to improve teamwork and communications among healthcare staff. BJS 98(4), 469-479

Mean Dimension Score (%) BUILDING ON WEAK FOUNDATIONS 100 Site 1 Site 2 Site 3 90 80 70 60 50 40 30 20 10 0 Teamwork Climate Safety Climate Job Satisfaction Perceptions of Management Working Conditions Stress Recognition Catchpole, K, Dale, T, Hirst, G, Smith, P, Giddings, A.(2010). A multi-centre trial of aviation-style training for surgical teams. Journal of Patient Safety

SOME CHALLENGES Teamwork Fluidity Role Definition Training Professional diversity Recurrence Expense Tasks Surgical complexity Variation between surgeries Variation between teams & surgeons Technology Piecemeal Rarely replaced Storage Maintenance

SELECTED PUBLICATIONS Catchpole K, Gangi A, Blocker R, Ley E, Blaha J, Gewertz B, Wiegmann D. (2013) Flow disruptions in trauma care handoffs. Accepted to the Journal of Surgical Research, Feb 19 th 2013. Catchpole K, Wiegmann D (2012). Understanding safety and performance in the cardiac operating room: from sharp end to blunt end. BMJ Quality and Safety 21(10), 807-809. Catchpole K (2011). Task, Team and Technology Integration in the Paediatric Cardiac Operating Room. Progress in Pediatric Cardiology 32 (2), 85-88. McCulloch, P, Rathbone, J, Catchpole, K, (2011). The effects of interventions to improve teamwork and communications amongst healthcare staff. British Journal of Surgery 98 pp 469-479. Catchpole, K, Dale, T, Hirst, G, Smith, P, Giddings, A.(2010). A multi-centre trial of aviation-style training for surgical teams. Journal of Patient Safety 6(3),180-186 Catchpole, K, Giddings, A, Wilkinson, M, Hirst, G, Dale, T, De Leval, M. (2007) Improving patient safety by identifying latent failures in successful operations. Surgery 142(1), pp.102-110. Catchpole, K, Giddings, A, De Leval, M, Peek, G, Godden, P, Utley, M, Gallivan, S, Hirst, G, Dale, T (2006). Identification of systems failures in successful paediatric cardiac surgery. Ergonomics 49(5-6), pp.567-588.

ACKNOWLEDGEMENTS Great Ormond Street Hospital (2003-2005) Marc de Leval, Tony Giddings, Guy Hirst, Trevor Dale University of Oxford (2005-2011) Peter McCulloch, Ami Mishra, Simon Kreckler, Lauren Morgan, Eleanor Robertson, Mo Hadi, Sharon Pickering, Phil Smith Cedars-Sinai Medical Center (2011- ) Bruce Gewertz, Doug Wiegmann, Jen Blaha, Eric Ley, Ed Salas, Danny Shouhed, Alex Gangi, Shannon Webert, Renaldo Blocker

THANK YOU FOR LISTENING Dr Ken Catchpole Director of Surgical Safety and Human Factors Research Cedars-Sinai Medical Centre Los Angeles ken.catchpole@cshs.org ken.catchpole@safersurgery.co.uk