July 31, 2012
Surgical Case Duration and Miscommunications
Surgical case duration is one of the few modifiable risk factors for surgical infections. A number of studies in the past have demonstrated an association between perioperative infection and the duration of the surgical procedure. In our January 2010 What’s New in the Patient Safety World column “” we noted a study ( ) which looked at a large database of general surgical procedures and demonstrated a linear relationship between duration of surgery and infectious complications. The infectious complication rate increased by 2.5% per half hour and hospital length of stay (LOS) also increased geometrically by 6% per half hour.
But prolonged surgeries also increase risks other than that of infection. Our March 10, 2009 Patient Safety Tip of the Week “Prolonged Surgical Duration and Time Awareness” discussed time unawareness during many surgeries. In addition to the potential impact on infectious complications, we noted that there are other potential patient safety issues related to prolonged surgical duration such as DVT, decubiti, hypothermia, fluid/electrolyte shifts, nerve compression, compartment syndromes, and rhabdomyolysis. Long-duration cases also increase the likelihood of personnel changes that increase the chance of retained foreign objects. And the fatigue factor comes into play with longer cases, increasing the likelihood of a variety of other errors.
There are many factors that may lead to increased surgical durations, including case type and complexity, emergency vs. elective nature, and proficiency of the surgeon, lack of team familiarity, presence of trainees and poor communication.
A recent article (Gillespie 2012) looked at various factors involved in prolonging surgery. They looked at the above factors plus intraoperative interruptions and whether or not pre-op huddles/briefings were done. The mean duration of surgery for all cases was 85 minutes, compared to an expected mean duration of 60 minutes. They noted that preoperative briefings occurred in only 12.5% of cases, despite that practice having been “mandated” at the study hospital. Some of their teams were set teams that had worked together for many years. Others were teams that came together on a more ad hoc basis. Communication failures occurred in 57% of the cases, an average of 1.9 per case. Interruptions occurred in 66.9% of cases (mean number of interruptons per case = 2.3). But when they did regression analyses the only factor that independently predicted deviation from expected duration of surgery was the number of miscommunications. Such miscommunications were more frequent when some members of the OR team had less experience. They also had examples where insufficient or inaccurate information was conveyed but the recipient did not seek clarification. Interestingly, interruptions did not appear to predict prolonged surgery. And there did not appear to be a correlation with lack of team familiarity nor with out of hours surgery.
There is not enough we can say about the value of team training programs like TeamSTEPPS™ or any of a number of crew resource management programs that focus on ways to improve communication among team members. Assuring that standard nomenclature is used and that hearback is routinely used are fundamental to good team communication. Bucking the hierarchical structure of the OR is also crucial.
Gillespie et al. spend a good deal of time discussing the value of preop briefings. We, of course, are big fans of the preop huddle. See our prior columns:
· April 9, 2007 “Make Your Surgical Timeouts More Useful”
· May 22, 2007 “More on TeamSTEPPS™”
· December 9, 2008 “Huddles in Healthcare”
· March 10, 2009 “Prolonged Surgical Duration and Time Awareness”
· January 11, 2011 “NPSA (UK) ‘How to Guide’: Five Steps to Safer Surgery”
· March 2009 “Surgical Team Training”
· April 2012 “Operating Room Briefings and Debriefings”
During a preop huddle the team will often recognize that a piece of important equipment is missing, avoiding the considerable delay that might have occurred if that had been discovered well into the case. Checklists have been utilized more often for the preoperative briefings or huddles. We previously noted a study by Lingard et al (Lingard 2008) that used a checklist to structure short team briefings and documented reduction in the number of communication failures. Our December 9, 2008 Patient Safety Tip of the Week “Huddles in Healthcare” discussed an article by Nundy and colleagues at Johns Hopkins (Nundy 2008). They used a very simple format for pre-operative briefings that led to a 31% reduction in unexpected delays in the OR and a 19% reduction in communication breakdowns that lead to delays.
We recommend that the OR team, during the presurgical huddle, should discuss issues related to prolonged cases. For example, they should discuss whether intraoperative DVT prophylaxis should begin if the procedure lasts beyond a certain duration. Or discuss at what duration a repositioning of the patient (to avoid nerve compression, compartment syndrome, or rhabdomyolysis) might be wise. And it would be very useful to have an estimate of time remaining to again trigger some discussion on the above issues. In addition to the DVT prophylaxis and repositioning issues, it might raise questions about the need to temporarily ease up on traction. It might direct attention to maintenance of the patient’s body temperature. In a very prolonged case it might raise questions about the need for further doses of prophylactic antibiotics.
So good communication begins before the patient has actually entered the OR and is necessary throughout the case to ensure more efficient and safe performance of surgery. And don’t forget that the postop debriefing may help you save time during your next case as well!
No one is happy with surgical cases that take too long. And, by the way, ask your CFO what that extra 20 minutes per case translates to in financial terms over the course of a year!
And while the Gillespie study did not find interruptions as an independent predictor of surgical case duration, the impact of distractions and interruptions on surgical errors is significant. A new study (Feuerbacher 2012) of surgical residents in an OR simulator environment clearly demonstrates the impact of OR distractions and interruptions (ORDI’s) in producing surgical errors. Because most prior research on ORDI’s had used somewhat artificial distractions and interruptions (such as mental arithmetic) the authors sought to use realistic ORDI’s that they had previously observed in real OR’s. The ORDI’s included an unexpected reaching movement by an observer, a ringing cell phone answered by an observer, an unrelated side conversation, a noise from a dropped metal tray, a question about management of a previous surgical patient in the recovery room, and a question about why the resident chose that profession. Eight of eighteen participants committed significant surgical errors during simulated laparoscopic cholecystectomy when distracted or interrupted, compared to only one of eighteen who were not interrupted or distracted. Moreover, 56% forgot to make a scheduled announcement when distracted or interrupted vs. 22% in the uninterrupted group. Interestingly, time of day was important. Virtually all the errors occurred after 1 PM. And the latter could not be explained by fatigue factors or time of duty (these were measured separately).
The time of day phenomenon is also interesting. Recall that the polyp detection rate in colonoscopies also shows a pattern in which fewer polyps are detected later in the day (see our May 3, 2011 Patient Safety Tip of the Week “It’s All in the Timing”). Since the data collected in the Feuerbacher study seems to exclude fatigue as the key factor, there may well be other important factors that have yet to be delineated in this observational phenomenon of more errors later in the day.
We’ve done a number of columns on the deleterious effects of interruptions and distractions for physicians, nurses, pharmacists and others:
Procter LD, Davenport DL, Bernard AC, Zwischenberger JB. General Surgical Operative Duration Is Associated with Increased Risk-Adjusted Infectious Complication Rates and Length of Hospital Stay, Journal of the Amercican College of Surgeons 2010; 210: 60-65
Gillespie BM, Chaboyer W, Fairweather N. Factors that influence the expected length of operation: results of a prospective study. BMJ Qual Saf 2012; 21(1): 3-12 Published Online First: 14 October 2011 doi:10.1136/bmjqs-2011-000169
Lingard L, Regehr G, Orser B, et al. Evaluation of a Preoperative Checklist and Team Briefing Among Surgeons, Nurses, and Anesthesiologists to Reduce Failures in Communication. Arch Surg, Jan 2008; 143: 12-17
Nundy S, Mukherjee A, Sexton JB, et al. Impact of Preoperative Briefings on Operating Room Delays: A Preliminary Report. Arch Surg 2008; 143(11): 1068-1072
Feuerbacher RL, Funk KH, Spight DH, et al. Realistic Distractions and Interruptions That Impair Simulated Surgical Performance by Novice Surgeons. Arch Surg 2012; (): 1-5 published online first July 2012