REVIEW ARTICLE ANZJSurg.com

Improving operating theatre communication between the orthopaedics surgeon and radiographer Cheng Hong Yeo,*† Robert Gordon* and Iulian Nusem† *Department of Orthopaedic Surgery, Toowoomba Hospital, Toowoomba, Queensland, Australia and †Department of Orthopaedic Surgery, Logan Hospital, Meadowbrook, Queensland, Australia

Key words communication, image intensifier, orthopaedic surgery, trauma. Correspondence Dr Cheng Hong Yeo, Department of Orthopaedic Surgery, Toowoomba Hospital, Perchey’s Street, Toowoomba, QLD 4350, Australia. Email: [email protected] C. H. Yeo MBChB; R. Gordon MBBS; I. Nusem MD, FRACS. Accepted for publication 28 October 2013. doi: 10.1111/ans.12482

Abstract Objectives: This study was designed to assess the importance of communication between surgeons and radiographers in the operation of image intensifiers during orthopaedic surgery. Methods: This study was designed and conducted as single-centre, observational study. Fifteen medical officers and 15 radiographers were involved in this study. Each of the 15 radiographers was assigned to a medical officer. The 15 pairs were then each given a task to simulate achieving ‘perfect circles’ on fluoroscopy for distal locking of an intramedullary nail. The time taken for the surgeon to verbally instruct the radiographer how to position the image intensifier in order to achieve ‘perfect circles’ was recorded. The overall time taken to perform the task, and total number of images taken was recorded before and after a terminology system to manoeuvre image intensifier was introduced to the pairs. Results: The mean time taken for the pairs to achieve perfect circles after the introduction of the manoeuvre terminology showed statistically significant reduction from 212 to 97 s (t = 4.212, df = 88, P < 0.05) after the introduction of the terminology. The mean number of fluoroscopy exposures taken also showed a statistically significant reduction from 12 to 6 (t = 6.791, df = 88, P < 0.05). Conclusion: The implementation of a clear and unambiguous set of commands to control the image intensifier, which are common to both surgeon and radiographer, can reduce the time to acquire the desired images, and requires less radiation exposure in the process.

Introduction Good communication within the surgical team is imperative for a functional operating theatre environment and for optimal patient care. The surgical team comprises the surgeons, scrub staff, scout nurses, anaesthetic personnel, and when required a radiographer. The mobile image intensification (II or C-arm) is an essential tool in orthopaedic trauma surgery. The IIs are used frequently to assess fracture configuration, guide the surgical reduction and verify surgical fixation (i.e. the correct placement of instrumentation during internal fixation).1 Despite not operating the image intensifier themselves, the orthopaedic surgeons must have an adequate knowledge of the image intensifier positioning and manoeuvrability and be able to communicate this. Good understanding of this between the surgeon and the radiographer can avoid confusion, and has the potential to improve theatre utilization.2 It is well known that communication breakdown ANZ J Surg 84 (2014) 316–319

can lead to procedural delays and inefficiencies.3 We believe that a mutual understanding among the surgical team with respect to the goals of the procedure and requirements throughout will improve efficiency. This study assesses the importance of communication between surgeons and radiographers in the operation of image intensifiers during orthopaedic surgery. We believe that improved communication between surgeons and radiographers can reduce the overall time and radiation exposure during orthopaedic cases. We hypothesized that by introducing clear, unambiguous terminology, time spent by surgeons directing and radiographers positioning an image intensifier to produce a desired view can be significantly reduced.

Methods This study was designed and conducted as single-centre, observational study. A total of 15 medical officers (four consultant © 2013 Royal Australasian College of Surgeons

Swing, rock and roll

Fig. 1. Two large metal washers taped onto a basketball on two surfaces at either pole.

orthopaedics surgeons, six orthopaedics registrars and five orthopaedic junior medical officers) and 15 radiographers were involved in the study. An independent observer randomly assigned each of the 15 radiographers to a particular medical officer (the experimental pair). To simulate achieving ‘perfect circles’ for distal locking of an intramedullary nail, two large metal washers with differing diameters were taped onto a spherical object (a basketball) on two surfaces at either pole (Fig. 1). Three of these simulated limbs were positioned in differing orientations by an independent party on an operating table and covered with a sheet. The experimental pairs were blinded to the orientation of the simulated limbs. The time taken for the surgeon to verbally instruct the radiographer how to position the image intensifier in order to achieve ‘perfect circles’ (one washer silhouette contained within the other washer) (Fig. 2) was recorded. The overall time taken to perform the task and the total number of images taken were recorded. Subsequently, a new terminology system for II positioning was introduced to the experimental pairs with the aim of improving time to acquire the desired image and decreasing exposures. An independent observer, prior to data recollection, modified the orientation of the simulated limbs. The experimental pairs were blinded to this. The exercise of achieving perfect circles was repeated. The time taken and number of exposures were recorded. At all times protective lead garments were worn to ensure radiation safety of the staffs.

The manoeuvre terms The following terms to describe II positioning were introduced prior to the second round of data collection. Pictorial representations of these terms, together with a written explanation were given to the pairs. © 2013 Royal Australasian College of Surgeons

317

Fig. 2. One washer silhouette contained within the other washer.

Graphical explanations (Fig. 3) Swing The term for an orbital rotational movement of the C-arm. The term of ‘swing up’ and ‘swing down’ are made in reference to the movement of the receiver end of the C-arm. Rock The term for the horizontal movements of the C-arm. The term of ‘rock up’ and ‘rock down’ are made in reference to the movement of the receiver along the operating table. The receiver towards the head end of the table is up while towards the foot end is down. Roll The term for the radial rotational movements of the C-arm. The term of ‘roll up’ and ‘roll down’ are made in reference to the level of the receiver end of the C-arm. Arm up/down The term for the vertical movement of the C-arm. The term of ‘arm up’ and ‘arm down’ are made in reference to level of the receiver of the C-arm. Arm in/out The term for vertical movement of the whole C-arm machine. The term of ‘Arm in’ ‘Arm out’ are made in reference to the relationship between the machine and operating table. ‘In’ is the movement towards patient and ‘out’ away from the patient. Base up/down The term for movement of the whole C-arm machine moving along the operating table. The machine moving towards the head end of the table is up while towards the foot end is down.

318

Yeo et al.

Table 1 Time(s) taken by each surgeon to complete test before and after interventions. Each surgeon had three readings taken

Number of observation (n) Mean Standard deviation Variance

Time (seconds) before

Time (seconds) after

45 180.467 117.288 32568.218

45 99.822 52.323 9964.476

*t = 4.212, df = 88, P < 0.05, mean difference = −80.645 (95% confidence interval: −118.692 to −42.598).

Table 2 Total number of imaging taken by each surgeon before and after interventions. Each surgeon had three readings taken

Number of observation (n) Mean Standard deviation Variance

Number of imaging Before

Number of imaging After

45 12.067 4.754 22.610

45 6.444 2.873 8.253

*t = 6.791, df = 88, P < 0.05, mean difference: −5.623 (95% confidence interval: −7.268 to −3.977).

Table 3 Comparing average time improvement of surgeons whom first language is English and whom is not

Number of observation (n) Mean Standard deviation Variance

Non-English

English

6 151.333 35.251 1242.667

9 91.566 39.687 1575.028

*t = 2.981, df = 13, P < 0.05, mean difference: 59.777 (95% confidence interval: 16.462 to 103.092).

Fig. 3. Graphical demonstration of each of the five commands.

Statistical analysis There were a total of 45 readings recorded pre- and postintroduction of manoeuvre terminology, with each experimental pair of surgeon and radiographer having produced three sets of readings. The average of each set of three was calculated in seconds. The 15 averaged readings pre- and post-terminology introduction were compared using the Student’s t-test. The time required for surgeons and radiographers to become familiar with the manoeuvre commands was also recorded.

The mean number of II exposures taken reduced from 12 to 6 after the introduction of the manoeuvre commands. This was a statistically significant decrease after the introduction of the new terminologies (t = 6.791, df = 88, P < 0.05) (Supporting Information Fig. S2 and Table 2). The average time taken for surgeons and radiographers to become familiar with the terminology was 109 s. The pre- and post-values for pairs, which included an individual to whom English was not their first language, were evaluated. The improvements in time taken to acquire images, and the number of exposures taken were more significant than those to whom English was their first language (Supporting Information Figs S3,S4 and Tables 3,4).

Discussion Results The mean time taken for the pairs to achieve perfect circles prior to the introduction of the manoeuvre terminology was 212 s. After the introduction of the common terminology, this time was reduced to a mean of 97 s. This is a statistically significant reduction in overall time after the introduction of a common manoeuvre commands (t = 4.212, df = 88, P < 0.05) (Supporting Information Fig. S1 and Table 1).

The aim of this study was to demonstrate the importance of good communication between surgeons and radiographers during orthopaedic surgery. We hypothesized that the use of unambiguous terminology common to both the surgeon and radiographer would improve theatre efficiency and reduce radiation exposures. Our results demonstrate significant improvements in terms of reducing overall time taken to acquire adequate images with a lower number of images taken. © 2013 Royal Australasian College of Surgeons

Swing, rock and roll

319

Table 4 Comparing average improvement in number of imaging taken by surgeons whom first language is English and whom is not

Number of observation (n) Mean Standard deviation Variance

Non-English

English

6 8.167 1.329 1.767

9 3.778 4.295 18.444

*t = 2.401, df = 13, P < 0.05, mean difference: 4.389 (95% confidence interval: 0.440 to 8.338).

It has previously been shown that there is lack of consensus among orthopaedic surgeons, and between surgeons and radiographers with regard to what commands should be used to perform a specific movement of the image intensifier.4 Webster et al. has demonstrated that scripted communication was more efficient than a ‘no-rules’ approach.5 That is, without a structure to communication, more dialogue is necessary to achieve a common goal, resulting in a slower performance. Williams et al. has previously demonstrated that with a single experienced surgeon matched with a single radiographer using a pre-prepared communication strategy could significantly improve efficiency and safety of fluoroscopic C-arm use.6 However, this study involved just a single pair of surgeons and radiographer with repetitive manoeuvre. Our study demonstrates that use of a common vernacular can result in similar improvements in efficiency with staff of varied seniority and experience. The commands to manoeuvre the C-arm need to be short and clear. An average time of 109 s was recorded for the experimental pair to become familiar with, and able to implement the commands. Throughout the study period, there were two occasions where the surgeon, or radiographer needed to refer to the pictorial representations of the terminologies for the C-arm manoeuvre. With increasing diversity within our medical workforce, English as a second language is becoming more common among both surgeons and radiographers. The introduction of unambiguous, common terminology helps to overcome some potential language barriers and improve theatre efficiency. During part one of the study, surgeons and radiographers used various descriptors to manoeuvres of the C-arm. Surgeons tended to use short and simple terms when describing movements of the C-arm. This has the potential to be ambiguous and confusing for some radiographers. Radiographers had a good understanding regarding the manoeuvrability of the C-arm as compared to surgeons. The terminology relating to C-arm movements in the user manual have been found to be complex and cumbersome by radiographers and surgeons alike. This was noted throughout the first exercise when these terminologies and created confusion between the two parties. The terminology proposed in this study is simple and concise. Willams et al.6 had shown that amalgamation of commonly used terms with simple commands makes for easy instruction. The terminologies used in the study fulfilled these qualities. With increasing applications for minimally invasive orthopaedic surgery, reliance on image intensification is increasing.7 Awareness of radiation exposure to the surgical team is important and needs to be reduced where possible. Minimizing unnecessary images taken due to miscommunication between surgeons and radiographers helps to © 2013 Royal Australasian College of Surgeons

achieve this. We have shown that clear, unambiguous commands reduce the number of exposures and time to acquire the desired images. The study demonstrates that common terminology helps to improve theatre efficacy by improving mutual understanding between radiographers and surgeons. We recognize that this may not be appropriate in all institutions; however, it highlights that the implementation of a common vernacular to surgeons and radiographers has this potential. We recognize that we have not included a radiographer in the preparation of this manuscript; however, they were heavily involved in the planning and execution of the study. The clear improvement in time to acquire images, with less radiation use, would be welcome in any surgeon–radiographer relationship.

Conclusion The implementation of a clear and unambiguous set of commands to control the C-arm, which are common to both surgeon and radiographer, can reduce the time to acquire the desired images, and requires less exposure in the process. Overall, this results in a more efficient operating environment with less radiation exposure to the surgical team.

References 1. Bott OJ, Dresing K, Wagner M, Raab BW, Teistler M. Use of a C-arm fluoroscopy simulator to support training in intraoperative radiography. Radiographics 2011; 31: E65–76. 2. Chaganti S, Kumar D, Patil S, Alderman P. A language for effective communication between surgeons and radiographers in trauma Theatre. Ann. R. Coll. Surg. Engl. 2009; 91: 509–12. 3. Halverson AL, Casey JT, Andersson J et al. Communication failure in the operating room. Surgery 2011; 149: 305–10. 4. Trehan R, Tennent TD. Which way is up? The control of image of image intensifier movement in the operating theatre. J. Bone Joint Surg. Br. 2006; 88-B (Suppl. II): 277. 5. Webster JL, Cao CG. Lowering communication barriers in operating room technology. Hum. Factors 2006; 48: 747–58. 6. Williams THD, Syrett AG, Brammar TJ. W.S.B. – a fluoroscopy C-arm communication strategy. Injury 2009; 40: 840–3. 7. Giordano BD, Grauer JN, Miller CP, Morgan TL, Rechtine GR. Radiation exposure issues in orthopaedics. J. Bone Joint Surg. Am. 2011; 93: e69 (1–10).

Supporting information Additional Supporting Information may be found in the online version of this article at the publisher’s web-site: Figure S1. Time (s) taken by each surgeon to complete test before and after interventions. Each surgeon had three readings taken. *C = Consultant, R = Registrar, J = Resident Figure S2. Total number of imaging taken by each surgeon before and after interventions. Each surgeon had three readings taken. *C = Consultant, R = Registrar, J = Resident Figure S3. Comparing average time improvement of surgeons whom first language is English and whom is not. Figure S4. Comparing average improvement in number of imaging taken by surgeons whom first language is English and whom is not.

Improving operating theatre communication between the orthopaedics surgeon and radiographer.

This study was designed to assess the importance of communication between surgeons and radiographers in the operation of image intensifiers during ort...
297KB Sizes 0 Downloads 0 Views