End Notes
The Surgical Prebrief as Part of a Five-Point Comprehensive Approach to Improving Pediatric Cardiac Surgical Team Communication
World Journal for Pediatric and Congenital Heart Surgery 2014, Vol. 5(4) 640-642 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/2150135114544753 pch.sagepub.com
David M. Hoganson, MD1, Umar S. Boston, MD1, Peter B. Manning, MD1, and Pirooz Eghtesady, MD, PhD1
Abstract Communication is essential to the safe conduct of any critical task including cardiac surgery. After inspiration by airline crew resource management training, a communication system for the care plans of pediatric cardiac patients was developed and refined over time that encompasses the entire heart center team. Five distinct communication points are used to ensure preoperative, intraoperative, and postoperative care, which is transitioned efficiently and maintained at the highest level. Keywords intensive care, patient safety, perioperative care, comorbidity Submitted March 11, 2014; Accepted July 02, 2014.
Communication is a central aspect of any successful teambased organization. The airline industry, military, and nuclear power plants are a few examples of team-based activities, where communication systems have been implemented at a very high level, focusing on a safe outcome. Cardiac surgery parallels these team-based activities, yet the periprocedural communication is often inconsistent. Formalizing the structure of periprocedural communication of the cardiac surgical team may result in more efficiency in the operating room (OR), improved patient safety, and higher quality patient handoffs in the intensive care unit (ICU). We have developed a comprehensive communication system for pediatric cardiac surgery and all cardiovascular procedures which focuses on optimizing the preoperative (preop), intraoperative, and postoperative (postop) strategies to ensure the procedures are carried out in the safest way possible with attention to every detail that might impact the care of the patient. Other cardiac surgery groups have developed and studied briefings and safety checklists that occur within the OR and concluded that they improve communication and reduce disruptions.1-3 In one study, communication failures occurred in 30% of OR team exchanges and a third of these resulted in effects which jeopardized patient safety by increasing cognitive load, interrupting routine, and increasing tension in the OR.4 Postop debriefing in the OR3 can identify potential problems for improvement and enhance communication. Formal
handoffs in the cardiac ICU further facilitate team communication.5 Creation of high-reliability teams focused on closed loop communication, mutual performance monitoring, error management, and feedback, and team self-correction may be the best approach to address this clear need for improved communication.6 The communication strategy reported here originated after the senior author (PE) attended a quality and safety course that taught the fundamental aspects of the crew resource management communication system of the airlines. Over a period of several years, the prebriefing and postbriefing concepts have been developed into a methodology of perioperative communication. This communication strategy is centered on five communication time points: the prebrief, the pretime-out review, the intraoperative postbrief, the care plan review in the ICU, and the full team postbrief.
1 Department of Surgery, Section of Pediatric Cardiothoracic Surgery, Saint Louis Children’s Hospital and Washington University in Saint Louis, St. Louis, MO, USA
Corresponding Author: Pirooz Eghtesady, One Children’s Place Suite 5S50, Saint Louis, MO 63110, USA. Email: [email protected]
Downloaded from pch.sagepub.com at Uniwersytet Warszawski on June 9, 2015
Hoganson et al
641
Care Plan Review in the ICU
Abbreviations and Acronyms OR ICU Preop Postop
operating room intensive care unit preoperative postoperative
Prebrief The day prior to the planned operation, an e-mail (created from a preexisting word document template) is distributed by the attending cardiac surgeon who reviews the pertinent history of the patient, indications for planned operative approach, expected sequence of operation, equipment required, any planned implants, details of cardiopulmonary bypass strategy, extubation strategy, and any particular potential complications (Supplemental file 1). This document is distributed to all of the staff physicians, fellows and residents from cardiac surgery, cardiology, anesthesia, the ICU, the perfusionists, and the cardiac surgery nursing team. Any unusual elective case that requires additional preop planning is discussed in a prebrief that takes place one to two weeks prior to surgery to allow adequate planning from the entire operating team. Urgent or emergency cases on occasion do not get a prebrief e-mail circulated.
Pretime-out Review Once the patient is in the OR, the nursing and anesthesia staff complete a checklist confirming supplies and communication details. Prior to the surgeon scrubbing, a pretime-out review (or preflight checklist) is done where the attending surgeon briefly reviews the operative plan and a checklist of operative details is reviewed (Supplemental file 2). Although some of these details may seem overly basic, many have made the list as a result of instances where complications have occurred in situations where these details had not been managed correctly. The standard time-out follows the pretime-out review with added details of confirming that any new team members have been introduced. Finally, there is an opportunity for questions and comments prior to proceeding.
Intraoperative Postbrief When the attending surgeon scrubs out at the end of the case, he briefly asks the team for feedback about the operation. All team members are asked to weigh in with respect to what went right, what went wrong, and what could be done better next time. This frequently initiates conversation regarding any issues that arose regarding cardiopulmonary bypass, available instruments, or any unexpected patient instability during the case. It is designed to be brief, on the order of 1 to 5 minutes in length. Significant issues raised may be tabled for further discussion so the patient’s care is not unduly interrupted.
Upon arrival in the cardiac ICU, the surgical team is joined by the intensive care nurses and physicians. After the patient has been connected to the monitors, there is a review of the intraoperative care and postop care plan that enlists the undivided attention of all of the above-mentioned parties. The anesthesiologist begins and reviews the course of the operation from the anesthesia perspective including medications, operative times, and most recent laboratory values. The surgeon then reviews the details of the operation, the chest tubes, lines, pacing wires, and the postop goals including medications, blood pressure goals, and any anticipated postop events or concerns. The ICU attending then briefly reviews their postop care plan. The communication is guided by a checklist card (Supplemental file 3), so the information is reviewed for each patient in a uniform way.
Full Team Postbrief After the patient has arrived in the ICU, a second short e-mail is distributed to the entire team who previously received the prebrief e-mail. This second e-mail details the operative findings and outcome of the operation. The e-mail postbrief reviews the anatomy and course of the procedure, the cardiopulmonary bypass details, and postbypass findings as well as key postop concerns (Supplemental file 4). This postbrief e-mail is very short, often three to seven lines and completed by the attending surgeon in minutes immediately following the care plan review. This is the most recent communication point added to the communication plan and has been in place for about one and a half years at our institution. This process aims to insure a high degree of continuity of care throughout the perioperative period. With these communication events, the entire team is very well aware of the details of the patient and their care plan as they progressed through the perioperative sequence. This communication strategy is now used for all pediatric cardiac catheterization and electrophysiology procedures in the institution, so it is a uniform approach for all cardiac procedural care. After the early introduction of this communication tool, many other team members requested to be added to the e-mail distribution list, highlighting the benefit of such a simple tool for widespread communication. As well, the dialogue generated in response to the e-mail allows ‘‘all’’ to participate in the discussion of potential concerns or other thoughts related to the planned procedure. The widely distributed prebriefing using e-mail is an efficient way of communicating with a larger audience. Finally, these communications are protected and can be used as part of quality improvement/quality assurance activities subsequently. In development of this process, early approaches were just a phone call to the clinical perfusionist and maybe to the anesthesiologist the day before the case and that was occurring in 79% of the cases. Postbriefs were occurring in 71% of the cases and 100% of the staff surveyed noted that more communication was needed (n ¼ 15 data points for each). After development of this
Downloaded from pch.sagepub.com at Uniwersytet Warszawski on June 9, 2015
642
World Journal for Pediatric and Congenital Heart Surgery 5(4)
strategy, 98% of cases had e-mailed prebriefs, 85% had postbriefs, and just 30% of the staff noted that more communication was needed preop (n ¼ 26 data points for each). The staff comment after implementation was ‘‘we can’t live without the prebriefs.’’ Insights and directions for evaluation of the efficacy and impact of single-center quality improvement initiatives were recently reviewed and discussed by Gaies.7 Certainly, structured data collection is important in the assessment of quality improvement initiatives. We acknowledge that a plan to collect more data on the staff impressions, quality outcomes, and efficiency improvements before and after these changes were put in place would have been a good idea. At this point in time, the collective opinion of the staff concerning the value of this process and the level of satisfaction expressed by participants is sufficiently high that the possibility of ‘‘turning the clock back’’ for the sake of a before-and-after comparison has no appeal. Quality measures for congenital and pediatric cardiac surgery have been formulated and approved by the Society of Thoracic Surgeons and endorsed by the Congenital Heart Surgeons Society.8 These measures include a detailed multistep process of preop, intraoperative, and postop team briefings and checklists as well as a handoff protocol and checklist for transfer of care to the postop ICU team. Our approach mirrors the principle features of that process, although our approach has been in development for over five years. As a result, detailed templates for each phase of team communication have evolved and have stood the test of time. Importantly, our process adds the e-mailed prebrief prior to the operation. This is felt to be a critical step, as it allows review of the plan by the entire cardiovascular staff who then have a detailed understanding of the approach when the child enters the OR and enters the ICU. It gets everyone ‘‘on the same page’’ and invites comment at a time when comments can be processed and implemented. An alternative approach wherein the perfusionist or anesthesiologist suggests major changes to the approach at the time of the pretime-out review may not be ideal. Pediatric cardiac surgery is inherently complex and many cases have a significant perioperative mortality risk. In this, as well as all of surgery, success is in the details. The diversity of procedures to repair complex congenital cardiac defects nullifies the notion that any series of similar patients will have the same operative and perioperative care plan. A comprehensive communication strategy that includes all of the individuals who
care for these patients enhances the continuity of care and increases the safety and quality of these procedures. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
Supplemental Material The online supplemental files are available at http://pch.sagepub.com/ supplemental.
References 1. Henrickson SE, Wadhera RK, Elbardissi AW, Wiegmann DA, Sundt TM III. Development and pilot evaluation of a preoperative briefing protocol for cardiovascular surgery. J Am Coll Surg. 2009; 208(6): 1115-1123. 2. Clark SC, Dunning J, Alfieri OR, et al. EACTS guidelines for the use of patient safety checklists. Eur J Cardiothorac Surg. 2012; 41(5): 993-1004. 3. Papaspyros SC, Javangula KC, Adluri RK, O’Regan DJ. Briefing and debriefing in the cardiac operating room. Analysis of impact on theatre team attitude and patient safety. Interact Cardiovasc Thorac Surg. 2010;10(1): 43-47. 4. Lingard L, Espin S, Whyte S, et al. Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care. 2004;13(5): 330-334. 5. Joy BF, Elliott E, Hardy C, Sullivan C, Backer CL, Kane JM. Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit. Pediatr Crit Care Med. 2011;12(3): 304-308. 6. Wilson KA, Burke CS, Priest HA, Salas E. Promoting health care safety through training high reliability teams. Qual Saf Health Care. 2005;14(4): 303-309. 7. Gaies MG. Maximizing the value of single-center quality improvement reports. World J Pediatr Congenit Heart Surg. 2012;3(4): 419-420. 8. Jacobs JP, Jacobs ML, Austin EH, III, et al. Quality measures for congenital and pediatric cardiac surgery. World J Pediatr Congenit Heart Surg. 2012;3(1): 32-47.
Downloaded from pch.sagepub.com at Uniwersytet Warszawski on June 9, 2015
The Surgical Prebrief as Part of a Five-Point Comprehensive Approach to Improving Pediatric Cardiac Surgical Team Communication
World Journal for Pediatric and Congenital Heart Surgery 2014, Vol. 5(4) 640-642 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/2150135114544753 pch.sagepub.com
David M. Hoganson, MD1, Umar S. Boston, MD1, Peter B. Manning, MD1, and Pirooz Eghtesady, MD, PhD1
Abstract Communication is essential to the safe conduct of any critical task including cardiac surgery. After inspiration by airline crew resource management training, a communication system for the care plans of pediatric cardiac patients was developed and refined over time that encompasses the entire heart center team. Five distinct communication points are used to ensure preoperative, intraoperative, and postoperative care, which is transitioned efficiently and maintained at the highest level. Keywords intensive care, patient safety, perioperative care, comorbidity Submitted March 11, 2014; Accepted July 02, 2014.
Communication is a central aspect of any successful teambased organization. The airline industry, military, and nuclear power plants are a few examples of team-based activities, where communication systems have been implemented at a very high level, focusing on a safe outcome. Cardiac surgery parallels these team-based activities, yet the periprocedural communication is often inconsistent. Formalizing the structure of periprocedural communication of the cardiac surgical team may result in more efficiency in the operating room (OR), improved patient safety, and higher quality patient handoffs in the intensive care unit (ICU). We have developed a comprehensive communication system for pediatric cardiac surgery and all cardiovascular procedures which focuses on optimizing the preoperative (preop), intraoperative, and postoperative (postop) strategies to ensure the procedures are carried out in the safest way possible with attention to every detail that might impact the care of the patient. Other cardiac surgery groups have developed and studied briefings and safety checklists that occur within the OR and concluded that they improve communication and reduce disruptions.1-3 In one study, communication failures occurred in 30% of OR team exchanges and a third of these resulted in effects which jeopardized patient safety by increasing cognitive load, interrupting routine, and increasing tension in the OR.4 Postop debriefing in the OR3 can identify potential problems for improvement and enhance communication. Formal
handoffs in the cardiac ICU further facilitate team communication.5 Creation of high-reliability teams focused on closed loop communication, mutual performance monitoring, error management, and feedback, and team self-correction may be the best approach to address this clear need for improved communication.6 The communication strategy reported here originated after the senior author (PE) attended a quality and safety course that taught the fundamental aspects of the crew resource management communication system of the airlines. Over a period of several years, the prebriefing and postbriefing concepts have been developed into a methodology of perioperative communication. This communication strategy is centered on five communication time points: the prebrief, the pretime-out review, the intraoperative postbrief, the care plan review in the ICU, and the full team postbrief.
1 Department of Surgery, Section of Pediatric Cardiothoracic Surgery, Saint Louis Children’s Hospital and Washington University in Saint Louis, St. Louis, MO, USA
Corresponding Author: Pirooz Eghtesady, One Children’s Place Suite 5S50, Saint Louis, MO 63110, USA. Email: [email protected]
Downloaded from pch.sagepub.com at Uniwersytet Warszawski on June 9, 2015
Hoganson et al
641
Care Plan Review in the ICU
Abbreviations and Acronyms OR ICU Preop Postop
operating room intensive care unit preoperative postoperative
Prebrief The day prior to the planned operation, an e-mail (created from a preexisting word document template) is distributed by the attending cardiac surgeon who reviews the pertinent history of the patient, indications for planned operative approach, expected sequence of operation, equipment required, any planned implants, details of cardiopulmonary bypass strategy, extubation strategy, and any particular potential complications (Supplemental file 1). This document is distributed to all of the staff physicians, fellows and residents from cardiac surgery, cardiology, anesthesia, the ICU, the perfusionists, and the cardiac surgery nursing team. Any unusual elective case that requires additional preop planning is discussed in a prebrief that takes place one to two weeks prior to surgery to allow adequate planning from the entire operating team. Urgent or emergency cases on occasion do not get a prebrief e-mail circulated.
Pretime-out Review Once the patient is in the OR, the nursing and anesthesia staff complete a checklist confirming supplies and communication details. Prior to the surgeon scrubbing, a pretime-out review (or preflight checklist) is done where the attending surgeon briefly reviews the operative plan and a checklist of operative details is reviewed (Supplemental file 2). Although some of these details may seem overly basic, many have made the list as a result of instances where complications have occurred in situations where these details had not been managed correctly. The standard time-out follows the pretime-out review with added details of confirming that any new team members have been introduced. Finally, there is an opportunity for questions and comments prior to proceeding.
Intraoperative Postbrief When the attending surgeon scrubs out at the end of the case, he briefly asks the team for feedback about the operation. All team members are asked to weigh in with respect to what went right, what went wrong, and what could be done better next time. This frequently initiates conversation regarding any issues that arose regarding cardiopulmonary bypass, available instruments, or any unexpected patient instability during the case. It is designed to be brief, on the order of 1 to 5 minutes in length. Significant issues raised may be tabled for further discussion so the patient’s care is not unduly interrupted.
Upon arrival in the cardiac ICU, the surgical team is joined by the intensive care nurses and physicians. After the patient has been connected to the monitors, there is a review of the intraoperative care and postop care plan that enlists the undivided attention of all of the above-mentioned parties. The anesthesiologist begins and reviews the course of the operation from the anesthesia perspective including medications, operative times, and most recent laboratory values. The surgeon then reviews the details of the operation, the chest tubes, lines, pacing wires, and the postop goals including medications, blood pressure goals, and any anticipated postop events or concerns. The ICU attending then briefly reviews their postop care plan. The communication is guided by a checklist card (Supplemental file 3), so the information is reviewed for each patient in a uniform way.
Full Team Postbrief After the patient has arrived in the ICU, a second short e-mail is distributed to the entire team who previously received the prebrief e-mail. This second e-mail details the operative findings and outcome of the operation. The e-mail postbrief reviews the anatomy and course of the procedure, the cardiopulmonary bypass details, and postbypass findings as well as key postop concerns (Supplemental file 4). This postbrief e-mail is very short, often three to seven lines and completed by the attending surgeon in minutes immediately following the care plan review. This is the most recent communication point added to the communication plan and has been in place for about one and a half years at our institution. This process aims to insure a high degree of continuity of care throughout the perioperative period. With these communication events, the entire team is very well aware of the details of the patient and their care plan as they progressed through the perioperative sequence. This communication strategy is now used for all pediatric cardiac catheterization and electrophysiology procedures in the institution, so it is a uniform approach for all cardiac procedural care. After the early introduction of this communication tool, many other team members requested to be added to the e-mail distribution list, highlighting the benefit of such a simple tool for widespread communication. As well, the dialogue generated in response to the e-mail allows ‘‘all’’ to participate in the discussion of potential concerns or other thoughts related to the planned procedure. The widely distributed prebriefing using e-mail is an efficient way of communicating with a larger audience. Finally, these communications are protected and can be used as part of quality improvement/quality assurance activities subsequently. In development of this process, early approaches were just a phone call to the clinical perfusionist and maybe to the anesthesiologist the day before the case and that was occurring in 79% of the cases. Postbriefs were occurring in 71% of the cases and 100% of the staff surveyed noted that more communication was needed (n ¼ 15 data points for each). After development of this
Downloaded from pch.sagepub.com at Uniwersytet Warszawski on June 9, 2015
642
World Journal for Pediatric and Congenital Heart Surgery 5(4)
strategy, 98% of cases had e-mailed prebriefs, 85% had postbriefs, and just 30% of the staff noted that more communication was needed preop (n ¼ 26 data points for each). The staff comment after implementation was ‘‘we can’t live without the prebriefs.’’ Insights and directions for evaluation of the efficacy and impact of single-center quality improvement initiatives were recently reviewed and discussed by Gaies.7 Certainly, structured data collection is important in the assessment of quality improvement initiatives. We acknowledge that a plan to collect more data on the staff impressions, quality outcomes, and efficiency improvements before and after these changes were put in place would have been a good idea. At this point in time, the collective opinion of the staff concerning the value of this process and the level of satisfaction expressed by participants is sufficiently high that the possibility of ‘‘turning the clock back’’ for the sake of a before-and-after comparison has no appeal. Quality measures for congenital and pediatric cardiac surgery have been formulated and approved by the Society of Thoracic Surgeons and endorsed by the Congenital Heart Surgeons Society.8 These measures include a detailed multistep process of preop, intraoperative, and postop team briefings and checklists as well as a handoff protocol and checklist for transfer of care to the postop ICU team. Our approach mirrors the principle features of that process, although our approach has been in development for over five years. As a result, detailed templates for each phase of team communication have evolved and have stood the test of time. Importantly, our process adds the e-mailed prebrief prior to the operation. This is felt to be a critical step, as it allows review of the plan by the entire cardiovascular staff who then have a detailed understanding of the approach when the child enters the OR and enters the ICU. It gets everyone ‘‘on the same page’’ and invites comment at a time when comments can be processed and implemented. An alternative approach wherein the perfusionist or anesthesiologist suggests major changes to the approach at the time of the pretime-out review may not be ideal. Pediatric cardiac surgery is inherently complex and many cases have a significant perioperative mortality risk. In this, as well as all of surgery, success is in the details. The diversity of procedures to repair complex congenital cardiac defects nullifies the notion that any series of similar patients will have the same operative and perioperative care plan. A comprehensive communication strategy that includes all of the individuals who
care for these patients enhances the continuity of care and increases the safety and quality of these procedures. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
Supplemental Material The online supplemental files are available at http://pch.sagepub.com/ supplemental.
References 1. Henrickson SE, Wadhera RK, Elbardissi AW, Wiegmann DA, Sundt TM III. Development and pilot evaluation of a preoperative briefing protocol for cardiovascular surgery. J Am Coll Surg. 2009; 208(6): 1115-1123. 2. Clark SC, Dunning J, Alfieri OR, et al. EACTS guidelines for the use of patient safety checklists. Eur J Cardiothorac Surg. 2012; 41(5): 993-1004. 3. Papaspyros SC, Javangula KC, Adluri RK, O’Regan DJ. Briefing and debriefing in the cardiac operating room. Analysis of impact on theatre team attitude and patient safety. Interact Cardiovasc Thorac Surg. 2010;10(1): 43-47. 4. Lingard L, Espin S, Whyte S, et al. Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care. 2004;13(5): 330-334. 5. Joy BF, Elliott E, Hardy C, Sullivan C, Backer CL, Kane JM. Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit. Pediatr Crit Care Med. 2011;12(3): 304-308. 6. Wilson KA, Burke CS, Priest HA, Salas E. Promoting health care safety through training high reliability teams. Qual Saf Health Care. 2005;14(4): 303-309. 7. Gaies MG. Maximizing the value of single-center quality improvement reports. World J Pediatr Congenit Heart Surg. 2012;3(4): 419-420. 8. Jacobs JP, Jacobs ML, Austin EH, III, et al. Quality measures for congenital and pediatric cardiac surgery. World J Pediatr Congenit Heart Surg. 2012;3(1): 32-47.
Downloaded from pch.sagepub.com at Uniwersytet Warszawski on June 9, 2015
