Transcript Utilization of Operating Room Simulation and Debriefing to Enhance

Utilization of Operating Room
Simulation and Debriefing to Enhance
Surgical Resident Participation in the
Surgical Timeout Checklist
Edward Dominguez MD FACS
Riverside Methodist Hospital, Columbus, OH
Center for Medical Education and Innovation
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Introduction
 Surgical timeout checklist is a key component
of patient safety
– Encourages communication
– Verifies recommended practices
– Proven decreased morbidity and mortality
 Agency for Healthcare Research and Quality
recently identified Top 10 patient safety
strategies
– “preoperative and anesthesia checklists”
» Ann Internal Med 2013
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What is the Surgical Resident’s Role
in the Surgical Timeout Checklist?
 In teaching hospitals residents often have a diminished
role
 Reliance on attendings and other staff members
 Preoccupation on other aspects of the case
 “Passive participation”
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Operating Room Simulation
 Platform for residents to become comfortable with
technical and nontechnical aspects of patient care
 Objectives can be defined
 Errors are “allowable”
 Video Review
 Lends itself toward debriefing opportunities
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Debriefing and Simulation
 Encourages time for reflection of performance
 Critiques allowable errors
 Feedback from participants
 Time consuming and requires commitment
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Purpose of the Study
 In this pilot study does utilizing a simulated,
fully staffed operating room and debriefing
alter behaviors of surgical residents toward
the surgical timeout?
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Methods
• Simulated operating room at the Center of Medical
Education and Innovation at Riverside Methodist
Hospital, 2009-2010 academic year
• Arranged as standard setup for laparoscopic
cholecystectomy
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Operating Room Team
 Surgical Resident as “Attending”
 Board Certified Anesthesiologist
 Certified Scrub Technician
 Board Certified Operating Room Nurse as circulator
 “Control room” team behind the scenes
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Resident Participants
 Eleven General Surgery Residents (N =11)
– PGY 1-3 = 7
– PGY 4-5 = 4
 All signed informed consent for participation as
reviewed by the IRB
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Scenario
 Residents briefed on scenario prior to entering the OR
– Laparoscopic cholecystectomy
– Perioperative requirement of Beta blocker
 Gowned and gloved by nursing staff
 Video recording begins
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Surgical Timeout Checklist
 Initiated by circulator nurse as per our institution
standard “universal checklist”
 Purposely incomplete
 Patient’s identity (1), age (2), procedure (3), position
(4) and antibiotic administration (5)
 Omitted verifying sequential compression devices
(SCDs) (6), beta blocker administration (7)and
whether the team was ready to begin (8)
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Scenario
 Laparoscopic cholecystectomy
 Non technical aspects
 Communication techniques
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Debriefing Session
 One on one with resident and faculty investigator
 Video review of the individual’s session
 Errors and omissions reviewed
 Communication critiqued
 “What went well?”
 “What did not go well?”
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Post Debriefing Scenario
 Repeated weeks to months following the first session
 Same scenario and timeout checklist
 Also video recorded
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Video Observation Research Team
• Surgeon
• Hospital Patient Safety Officer
• Operating Room Nurse
• Statistician
• Medical Researcher
• Blinded to PGY level
• Videos randomized so pre or post debriefing was not
identifiable
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Video Scoring
• Research team scored timeout portion of sessions
based on completeness
• Scoring system
–
–
–
–
8
0
1
2
items on checklist
points if omitted
point if incomplete
points if completed correctly
• Scored data analyzed using the Wilcoxon sign rank test
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Results
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14.8
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Total Score
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10
9.3
p = 0.003
8
6
4
2
0
Pre
Post
Scenario
Notes:
Scores based on: 0 = not at all, 1 = incomplete, 2 = complete
Total Score on 8 questions: range 0 - 16
Analyses based on the Wilcoxon sign rank test
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Results
16
14
12
10
8
6
4
2
0
PGY IV-V
15.7
9.7
p = 0.017
Total Score
Total Score
PGY I-III
Pre
Post
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14
12
10
8
6
4
2
0
= 0.066
p =p0.066
13.3
8.5
Pre
Scenario
Post
Scenario
Notes:
Scores based on: 0 = not at all, 1 = incomplete, 2 = complete
Total Score on 8 questions: range 0 - 16
Analyses based on the Wilcoxon sign rank test
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Results
 For all resident levels significant improvement was
demonstrated in the areas of verifying:
– Patient position (p=0.008)
– Perioperative beta blocker administration
(p=0.002)
– Sequential compression devices (p=0.005)
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Discussion
 In this pilot study, utilization of a simulated surgical
scenario and video debriefing facilitated resident’s
involvement as active participants in the surgical
timeout checklist verification and completion when
items were specifically omitted
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Simulated Operating Room Team
 Board certified anesthesiologist
 Board certified nurse
 Clinical surgical scrub technician
 Simulation technicians in control room
 Generated a productive anxiety from the residents
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Video Observational
Research Team
 Surgeon, operating room nurse, hospital patient safety
officer, statistician, medical researcher
 Blinded to PGY level
 Blinded to pre or post debriefing
 Broader view and opinion of what is considered
appropriate communication in the OR
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Resident Communication
the in OR
 Our focus was on specific resident communication by
the resident and not by the team
 Resident to attending communication failure is a
significant source of medical malpractice
 Simulation may be a platform for practice of
communication skills
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Did These Simulations Make a
Clinical Difference?
 Hard to know for sure
 Anecdotally, YES!
 Feedback from OR nurses regarding resident
communication in the OR was revealing
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Resident Feedback
 Anonymous evaluations of the simulation collected by
the research staff were very positive
 One on one debriefing
– “Do I really sound like that?”
– “I need to be more vocal in the operating room
and be more of a team leader”
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Weaknesses
 Very small group of resident participants
 Times between simulation and debriefing varied based
on resident schedule
 Not all aspects of the surgical timeout were evaluated
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What We Learned From This
Operating Room Simulation
 Buy-in from hospital staff is crucial
 Be prepared for scheduling conflicts
 If an operating room team is assembled make it count
(i.e. have a series of experiences for the learners,
have multiple learners available)
 Ask the residents about the experience
 Ask your clinical staff about observed changes in
behavior or communication post simulation
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Special Thanks
 Video Observational Research Team
–
–
–
–
William D. Watson, MD FACS
Kathy Crea, Pharm D
John Elliott, MPH
Karen Hoffman, RN
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