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July 22, 2014
More on Operating Room Briefings and Debriefings
When we work on improving surgical safety and OR efficiency one of the first things we look at is whether the organization is doing briefings and debriefings. Preoperative briefings (sometimes called “huddles”) and postoperative debriefings are tools we have strongly recommended since we first began talking about the TeamSTEPPS™ training program back in 2007 (see our our May 22, 2007 Patient Safety Tip of the Week “More on TeamSTEPPS™” and our March 2009 What’s New in the Patient Safety World column “Surgical Team Training”). Briefings and debriefings are also core components of many of the crew resource management programs such as the VA’s Medical Team Training Program (see our January 11, 2011 Patient Safety Tip of the Week “NPSA (UK) ‘How to Guide’: Five Steps to Safer Surgery”).
Our April 2012 What’s New in the Patient Safety World column “Operating Room Briefings and Debriefings” focused on structuring OR briefings and debriefings and use of tools such as checklists to facilitate these. Now a new study from Johns Hopkins (Hicks 2014) provides further evidence of successful implementation of OR briefings and debriefings and emphasizes some key points that we always stress:
(1) though standardization of briefings is helpful, the briefings must be customized for the service(s) and disciplines involved in the surgery
(2) you have to have a culture of safety in order to be successful with such programs
(3) you have to demonstrate that action is taken on issues identified at the debriefings
Hicks and colleagues used their OR CUSP (Comprehensive Unit-Based Safety Program) to develop and implement OR briefings and debriefings tailored for colorectal surgery. In our own experience the patient safety and quality improvement projects that are most successful are those done in relatively small settings where the key participants all know each other and work closely together as affinity groups. CUSP’s are prime examples of such affinity groups. We discussed CUSP’s in our March 2011 What’s New in the Patient Safety World column “Michigan ICU Collaborative Wins Big” and referred readers to Pronovost 2006 and Timmel 2010 for good descriptions of the CUSP model. The CUSP model is also nicely described in Peter Pronovost’s book “Safe Patients, Smart Hospitals” (see our July 6, 2010 Patient Safety Tip of the Week “Book Reviews: Pronovost and Gawande”).
Through their briefing and debriefings their colorectal team was able to identify and improve several aspects of patient care. They better identified which patients needed steroids prior to surgery and they developed better ways to identify and separate out tools from the “dirty” parts of procedures to help improve surgical site infection rates. Also, their CUSP identified an issue with availability of interpreter services for patients not speaking English and developed a system to ensure the interpreter appointments the day prior to surgery.
One vital thing they did was to assign a frontline nurse to spend 4 to 6 hours a week addressing defects that were revealed during the briefings and debriefings and provide feedback to all parties that those defects were fixed. Nothing can kill a debriefing program faster than failure to fix those things you found wrong at these debriefings. Fortunately at Hopkins the OR management and hospital leadership provide the resources necessary to fix such issues.
Hicks and colleagues describe another phenomenon we see all too often at hospitals when briefings and debriefings are implemented: they are often nurse-driven in the beginning and do not become fully successful until there is buy-in from surgery and anesthesiology leadership.
The Hicks article provides examples of their briefing and debriefing tools and checklists. Other examples of such checklists for the preoperative briefings may be found on either the NHS Patient Safety First website or the VA website. Video examples of preoperative briefings may also be found at the NHS website or the VA website. The online version of a study (Bandari 2012) we highlighted in our April 2012 What’s New in the Patient Safety World column “Operating Room Briefings and Debriefings” also provides copies of the tools they used.
The Hicks article also discusses the need to take into account the workflows of all the participants so they can all be freed up at the same time to convene a pre-op briefing.
Some of the issues we’ve previously pointed out that might be discussed in a pre-op briefing/huddle are:
But it’s very important not to make the process too complicated. Your pre-op briefing should probably take no more than about 2-3 minutes. Be sure to customize them. A briefing for an orthopedic surgery case is likely to be significantly different than one for a gynecological procedure.
In debriefings you are basically asking “What went well?”, “What didn’t go well?” and “What could we do better next time?”. You’ll often identify the need to fix broken equipment or ensure the availability of appropriate backup instruments. Sometimes it’s something simple like tray set-ups or equipment set-ups that interfered with the surgeon’s movements during the procedure. But, again, be sure that someone follows up on issues identified and communicates back to the group when they are fixed. Also, make sure you identify at the debriefing any problems you had with team communication during the procedure.
A structured debriefing tool may also be useful. An example of one such tool used at Florida’s Memorial Health System was published recently in the Anesthesia Patient Safety Foundation (APSF) Newsletter (Marks 2014). At Memorial the tool records action items identified at the debriefing. The circulator is the “owner” who is responsible for referring any action items identified to the appropriate person for followup. Corrective action on those identified issues usually takes place within 12-48 hours. They also recommend that a list of the action items and their resolution status be sent to hospital administration on a weekly or monthly basis. (Note that the Marks paper also has some excellent examples of issues identified at debriefings and notes how physician satisfaction improved considerably after implementation of debriefings, even among those surgeons and anesthesiologists who were originally concerned that debriefings would add too much time to procedures).
Importantly, the mere performance of the briefings and debriefings fosters a sense of belonging to teams, empowerment for all members, and better communication. These lead not only to a culture of safety but they also significantly improve job satisfaction for all involved.
Our December 9, 2008 Patient Safety Tip of the Week “Huddles in Healthcare” also discussed how huddles and briefings can be useful in a variety of healthcare situations, not just the preoperative one.
Some of our prior articles on OR briefings and debriefings:
Hicks CW, Rosen M, Hobson DB, et al. Improving Safety and Quality of Care With Enhanced Teamwork Through Operating Room Briefings. JAMA Surg 2014; Published online July 09, 2014. doi:10.1001/jamasurg.2014.172
Pronovost PJ, King J, Holzmueller CG, et al. A Web-based Tool for the Comprehensive Unit-based Safety Program (CUSP). Joint Commission Journal on Quality and Patient Safety 2006; 32(3): 119-129
Timmel J, Kent PS, Holzmueller CG, et al. Impact of the Comprehensive Unit-Based Safety Program (CUSP) on Safety Culture in a Surgical Inpatient Unit.
Joint Commission Journal on Quality and Patient Safety 2010; 36(6): 252-260
Pronovost P, Vohr E. Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out. Hudson Street Press 2010
NHS Patient Safety First. video demonstrating sample pre-op briefings
NHS Patient Safety First. Quick guide to briefing and debriefing.
Veterans Health Administration. Preoperative Briefing Guide for Use in the Operating Room.
Veterans Health Administration. Postoperative Briefing Guide for Use in the Operating Room.
Veterans Health Administration. Preoperative Briefing Video.
Bandari J, Schumacher K, Simon M, et al. Surfacing Safety Hazards Using Standardized Operating Room Briefings and Debriefings at a Large Regional Medical Center. The Joint Commission Journal on Quality and Patient Safety 2012; 38(4): 154-160
Marks SW, Loskove J, Greenfield A, et al. Surgical Team Debriefing and Follow-Up: Creating an Efficient, Positive Operating Room Environment to Improve Patient Safety. Experience from the Memorial Healthcare System, Florida. APSF Newsletter 2014; 29(1): 7-12 June 2014
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We’ve done several columns in the past year about patients being potentially exposed to blood-borne pathogens from misuse of insulin pens in hospitals (see February 26, 2013 Patient Safety Tip of the Week “Insulin Pen Re-Use Incidents: How Do You Monitor Alerts?” and our What’s New in the Patient Safety World columns for April 2013 “More Tips on Insulin Pen Safety” and April 2014 “Insulin Pens - Again”).
But a far more common risk is exposing patients to infection by misuse of single-use vials and even multi-dose vials. So much so that the Joint Commission has just issued a sentinel event alert on preventing infection from misuse of vials. The sentinel event alert notes that vials intended for single use do not have preservatives so they are especially prone to bacterial contamination and spread of infection.
Occurrences and outbreaks of blood-borne pathogens and associated infections, including hepatitis B and C virus, meningitis, and epidural abscesses. Adverse events caused by this misuse have occurred in both inpatient and outpatient settings but 2 outpatient settings seem to be especially vulnerable: pain management clinics and cancer clinics.
The biggest contributing factor is failure to adhere to safe injection practices and aseptic techniques. Joint Commission cites statistics that 6% of healthcare providers surveyed admitted using single-dose or single-use vials on multiple patients and 15% using multiple-dose vials used the same syringe to re-enter the vial numerous times for the same patient or used the vial for multiple patients.
The alert goes on to provide recommendations for standardized policies pertaining to single-dose/single-use, multi-dose, and all vials. It also recommends doing audits looking for open vials on various units. That’s an important recommendation. In addition to formal audits, we’d recommend you add this to the activities you do on your Patient Safety Walk Rounds. And the alert discusses the importance of training and education, safety culture and reporting.
Call us skeptics. You can do all the education and training in the world. But if you have vials and syringes in patient care areas it is inevitable that someone will at some time misuse those vials. The fewer people that have access to vials, the lower the likelihood that such misuse will occur. Absent some changes in product design at the manufacturer/supplier level, the best way to reduce the risk would be to have the pharmacy prepare all such doses and provide them to the patient care areas in pre-filled syringes. That solution might work in hospitals and hospital-based outpatient clinics but is problematic in those office and clinic settings that do not have access to a pharmacy.
We know that sometimes the misuse of vials is done with the good intention of cost containment. There is no question that our suggestion above or a change at the manufacturer/supplier level would increase supply costs (and perhaps personnel costs). But you have to weigh that against the costs (both financial and PR) you’d incur if you have to notify many patients of potential exposure, do testing for pathogen exposure, and cover costs for treatment of such exposure. In our April 2014 What’s New in the Patient Safety World column “Insulin Pens - Again” we noted that the cost of one full course of hepatitis C treatment with the newer drugs just on the market is about $84,000.
This is a real problem. It deserves an industry-wide solution. We only solved the unintentional lethal KCl injection problem by taking vials of concentrated KCl off patient care units. We similarly need to avoid enabling well-intentioned healthcare workers from unintentionally exposing patients to infection through misuse of vials.
The Joint Commission. Sentinel Event Alert. Preventing infection from the misuse of vials. Sentinel Event Alert 2014; 52: 1-6 June 16, 2014
CDC. Injection Safety.
CDC. One & Only Campaign.
We’ve long known that wrong-site procedures outside the OR are frequent. We discussed them in our Patient Safety Tips of the Week for December 6, 2010 “More Tips to Prevent Wrong-Site Surgery” and June 6, 2011 “Timeouts Outside the OR” and our August 2011 What’s New in the Patient Safety World column “New Wrong-Site Surgery Resources”. These included links to some excellent resources (Neily 2011, Stahel 2010).
In our Patient Safety Tip of the Week November 25, 2008 “Wrong-Site Neurosurgery” we noted that chest tube inserted on the wrong side was the most frequent wrong-site occurrence in New York State in the past. Wrong-side chest tube insertions and wrong-side thoracenteses continue to occur. Now a new study (Miller 2014) has analyzed factors associated with wrong-side thoracenteses. The researchers searched the VA’s extensive root cause analysis database from 2004 through 2011 and found 14 cases of thoracenteses performed on the wrong side outside the OR setting. These were complicated by pneumothorax in 4 cases, bleeding in 3, and attributable death in 2. Length of stay was increased for 8 cases where reported (by an average of 2.6 days, including 1.9 ICU days).
A resident performed the procedure in 10 of the cases and an attending performed 2. An attending was present in 6 cases and a nurse was present in just 3 cases.
The most frequent associated factor was failure to perform a timeout (12 of the 14 cases). Laterality was missing from the consent form in 10 cases and the site was not marked in 12 cases. Medical image verification was not done in 7 of the 10 cases where information was available.
They found 30 root causes in the 14 cases (average 2.1 root causes per event). These most often included communication issues, failure to follow policy or procedures, and equipment issues. In several cases, the images were not available at the time of the procedure. That is particularly problematic in today’s computerized environment. If the PACS system is down you may not have immediate access to the images. In the old days we’d bring the actual films with us to the bedside. Today there are no films, only the images on the computer system.
Of interest, most of the wrong-side thoracenteses were performed on the patient’s right side when the pleural effusion was on the left. The authors note that right-left confusion is a common human error in many scenarios. They note one resident knew the pleural effusion was on the left side on the x-ray but when he went behind the patient the x-ray image in his mind reversed.
Miller et al. note a number of strategies that are helpful in preventing such events. First is formal standardization of Universal Protocol and timeouts for invasive procedures anywhere, not just in the OR. Checklists, site marking, and ultrasound localization are also useful. Learning and practicing the procedures in a simulation environment is also encouraged. Development of a culture of patient safety and good communication is also critical.
We prefer to use forcing functions or constraints as actions whenever possible (see our March 27, 2012 Patient Safety Tip of the Week “Action Plan Strength in RCA’s” including our illustrative slides of strong vs. weak actions). Particularly for thoracenteses, there are two good ways to ensure that a timeout gets done and force all the appropriate elements to prevent a wrong-site, wrong-side, or wrong-patient procedure. One is to prevent a physician from accessing a thoracentesis tray all alone. That is best done by requiring an order for the tray, which would require a nurse to access the tray and accompany the physician to the patient’s room (or other site where the thoracentesis will be performed) and participate in the procedure. Second is to include on the outside of the sterile tray a checklist that must be completed prior to opening the sterile tray. That checklist, of course, would include the items typically in the Universal Protocol and timeouts (things like consent, verification of the patient, procedure, laterality including review of relevant imaging studies, etc.).
The Miller paper is a reminder that wrong-site procedures continue to occur and that we must put in place system interventions to help reduce the risk of their occurrence, not only in the OR but everywhere in our facilities.
Some of our prior columns related to wrong-site surgery:
Patient Safety Tip of the Week columns:
September 23, 2008 “Checklists and Wrong Site Surgery”
June 5, 2007 “Patient Safety in Ambulatory Surgery”
March 11, 2008 “Lessons from Ophthalmology”
July 1, 2008 “WHO’s New Surgical Safety Checklist”
January 20, 2009 “The WHO Surgical Safety Checklist Delivers the Outcomes”
September 14, 2010 “Wrong-Site Craniotomy: Lessons Learned”
November 25, 2008 “Wrong-Site Neurosurgery”
January 19, 2010 “Timeouts and Safe Surgery”
June 8, 2010 “Surgical Safety Checklist for Cataract Surgery”
December 6, 2010 “More Tips to Prevent Wrong-Site Surgery”
June 6, 2011 “Timeouts Outside the OR”
October 30, 2012 “Surgical Scheduling Errors”
January 1, 2013 “Don’t Throw Away Those View Boxes Yet”
August 27, 2013 “Lessons on Wrong-Site Surgery”
September 10, 2013 “Informed Consent and Wrong-Site Surgery”
What’s New in the Patient Safety World columns:
July 2007 “Pennsylvania PSA: Preventing Wrong-Site Surgery”
August 2011 “New Wrong-Site Surgery Resources”
December 2011 “Novel Technique to Prevent Wrong Level Spine Surgery”
January 2013 “How Frequent are Surgical Never Events?”
Neily J, Mills PD, Eldridge N, et al. Incorrect Surgical Procedures Within and Outside of the Operating Room. A Follow-up Report. Arch Surg 2011; Published online July 18, 2011
Stahel PF, Sabel AL, Victoroff MS, et al. Wrong-Site and Wrong-Patient Procedures in the Universal Protocol Era. Analysis of a Prospective Database of Physician Self-reported Occurrences. Arch Surg. 2010; 145(10): 978-984
Miller KE, Mims M, Paull DE, et al. Wrong-Side Thoracentesis. Lessons Learned From Root Cause Analysis. JAMA Surg 2014; Published online June 11, 2014
We’ve done many columns on the controversy over use of beta blockers in patients undergoing surgery. On the other hand, beta blockers have been a mainstay of treatment in patients who have had an MI. Studies have clearly demonstrated the long-term benefit of chronic beta blockers in patients with a history of MI. But recently questions have been raised about the acute short-term benefits of beta blockers, noting that prior studies demonstrating an acute benefit were largely done in the era before coronary reperfusion strategies became widespread.
A new analysis of data (Park 2014) from the large Global Registry of Acute Coronary Events (GRACE) has raised issues regarding the timing and route of administration of beta blockers in patients with ST-segment elevation MI (STEMI). It must be kept in mind that this is a retrospective analysis of data from a registry, not a randomized controlled trial. In such analyses it is always impossible to determine whether there were confounding factors (eg. the patient may have had clinical factors that led to certain decisions about the use, route, and timing of beta blockers) that may have impacted outcomes.
Nevertheless, the new analysis raises interesting questions. They classified patients as receiving early (within the first 24 hours) or delayed (after 24 hours) beta blocker therapy and further differentiated IV from oral early beta blocker therapy. Early IV beta blockers and delayed beta blockers were associated with higher rates of some adverse outcomes (cardiogenic shock, ventricular arrhythmias, acute heart failure). But in-hospital mortality was significantly increased with IV beta blockers but reduced with delayed beta blockers. On the other hand, early oral beta blocker therapy was associated with reduced rates of cardiogenic shock, ventricular arrhythmias, acute heart failure but was associated with higher in-hospital mortality rates.
Again, it is difficult to use data from registries to conclusively change practice recommendations. What the analysis really tells us is that we need further randomized trials to answer the question about optimal timing of beta blocker therapy in patients with acute MI.
Park KL, Goldberg RJ, Anderson FA, et al. Beta-blocker Use in ST-segment Elevation Myocardial Infarction in the Reperfusion Era (GRACE). The American Journal of Medicine 2014; 127(6): 503–511
We’ve done lots of columns on adverse effects on patients in the Radiology suite and MRI suite (see the list at the end of today’s column). But we’ve never before done one on adverse effects on MRI staff! And it turns out that there are symptoms that staff may develop after exposure to MRI.
A pilot study done on Swedish nurses exposed to MRI (Wilén 2011) showed that 15% of nurses responding to a survey reported regularly experiencing at least one health complaint attributed to arise or be aggravated by their presence in the MRI scanning room.
Now researchers in The Netherlands (Schaap 2014) reviewed diaries from 361 employees of 14 clinical and research MRI facilities and attempted to correlate reported symptoms with exposure and scanner strength. Symptoms were reported in 16-39% of MRI shifts worked. They found a positive association between scanner strength and reported symptoms among healthcare and research staff working with closed-bore MRI scanners of 1.5 Tesla(T) and higher. This finding was mainly driven by reporting of vertigo and a metallic taste. Other symptoms included nausea, tinnitus, seeing light spots or light flashes, tingling sensations, and a host of more general symptoms. They conclude that there is an exposure-response association between exposure to strong static magnetic fields and reporting of transient symptoms on the same day of exposure. But the authors do postulate that there may be a possible underlying trait of personal sensitivity that may influence whether a person develops symptoms on exposure to a static magnetic field.
While the study does not report on any permanent sequellae to exposure to MRI fields and the transient symptoms do not appear to be particularly debilitating, we suspect it may lead to further research on the effects of working in MRI suites. It is a reminder that we need to consider staff as well as patients in our patient safety efforts.
Some of our prior columns on patient safety issues in the radiology suite:
Some of our prior columns on the “Ticket to Ride” concept:
Some of our previous columns on the issue of radiation risk:
Wilén J, De Vocht F. Health complaints among nurses working near MRI
Scanners - a descriptive pilot study. Eur J Radiol 2011; 80: 510-513
Schaap K, Christopher-de Vries Y, Mason CK, et al. Occupational exposure of healthcare and research staff to static magnetic stray fields from 1.5–7 Tesla MRI scanners is associated with reporting of transient symptoms. Occup Environ Med 2014; published online April 8, 2014 doi:10.1136/oemed-2013-101890
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