Realistic Simulations Improve Teamwork and Care Processes in the Operating Room
Realistic Simulations Improve Teamwork and Care Processes in the Operating Room
The Louisiana State University Health Sciences Center seeks to improve surgical teamwork and communication by practicing simulated surgical situations in real hospital operating rooms. Year one preliminary results show that the program provided a realistic environment and led to better teamwork and positive changes in actual care delivery processes during surgical cases.
New Orleans, LA
Date First Implemented
Effective communication and teamwork are required for safe surgical care, but evidence suggests that they seldom occur, leading to many adverse events. Practicing care processes in simulated surgical cases has been shown to help.
- Miscommunication and suboptimal teamwork as a common problem: One recent study found that communication failures occurred in approximately 30 percent of surgical team exchanges, with the most common failures being poor timing, missing or inaccurate information, lack of issue resolution, and exclusion of key individuals.1
- Leading to adverse events and medical errors: The operating room (OR) experiences more adverse events than any other hospital site,2 with approximately one-half of all adverse events affecting surgical patients and at least one-half of these being preventable. Often, these preventable events occur as a result of poor communication and suboptimal teamwork, which has been found to lead to higher rates of medical errors.3
- Complexity as a root cause of communication errors: Surgical care involves teams of individuals from multiple disciplines who must closely coordinate their work while working in an environment where there are multiple opportunities for miscommunication, differing motivations and perspectives, and varying communication skills across team members.4
- Potential benefits of simulations: Improvements in communication and teamwork can be achieved through practicing critical events in the OR.5
Description of the Innovative Activity
Multidisciplinary teams at the Louisiana State University Health Sciences Center by practicing simulated surgical situations in real hospital ORs, with the goal of improving care processes and clinical outcomes during actual cases. Teams use a “mobile mock operating room” as an authentic, dynamic clinical environment in which to practice, with the goal of improving care delivery. Because the mobile mock operating room is situated in an actual OR used by clinicians, the program provides a highly realistic environment that helps ensure that clinicians retain and apply what they learn in everyday practice. Key elements of the program include the following:
- Multidisciplinary participation: Team participants typically include surgeons and residents, anesthesiologists, surgical technologists, nurse anesthetists, and circulating nurses. Teams practice a laparoscopic cholecystectomy procedure, a common general surgical procedure conducted at Louisiana State University and elsewhere.
- Real-world equipment and setting: Teams practice at a scheduled time during elective surgery hours (7 a.m. to 3 p.m.) in a real OR, with the hospital's own equipment and supplies, thus making the environment as realistic as possible. OR teams are scheduled for a “mock” surgery just as they would be for a real surgical case. The mobile mock operating room itself consists of additional portable equipment (which can be set up and taken down in roughly 20 minutes) designed to closely mimic a real patient in an actual OR setting. The equipment can be stored in a small area and transported to other institutions in a moderately sized sport-utility vehicle. Equipment includes the following:
- Computerized mannequin: The mannequin is placed on the OR table and connected to a laptop computer; the computer monitor displays the mannequin's vital signs and serves as the anesthesia machine monitor.
- Cholecystectomy torso model: A separate inanimate torso connected to the mannequin contains a model of physiological components to allow clinicians to mimic the cholecystectomy procedure. Thus, the surgical incision and procedure occur within the torso while the mannequin exhibits physiological responses to treatment.
- Air compressor: The mannequin is attached to an air compressor that prompts the mannequin to open and shut its eyes, breathe, alter airway size, and maintain palpable pulses.
- Computer software: Computer software includes preprogrammed algorithms that guide clinical training scenarios. The software allows the mannequin to mimic complex and spontaneous physiological responses to team interventions, medication administration, and treatments. As a result, team decisions and actions directly influence the mannequin's outcome.
- Audio/visual equipment: Audio/visual equipment records the training sessions.
- Realistic cases focused on appropriate response to potential complications: The team members report to the OR, are reoriented to the equipment, and given a general introduction by the facilitator. Clinicians conduct a preoperative “interview” in which the mannequin offers preset responses to questions related to name, medical history, and other information. The team transports the mannequin to the OR and begins surgery. The session consists of two separate, realistic patient scenarios (lasting 20 to 30 minutes each), each a crisis that requires the team to interact and communicate while performing the appropriate care processes in response to the situation presented. The scenarios used to date include the following: onset of malignant hyperthermia, unstable cardiac arrhythmias, anaphylactic shock, and septic shock.
- Debriefing on care processes, communication, and teamwork: A 15-minute structured debriefing is held in the OR immediately after each scenario. Team members reflect on specific behaviors and incidents during the simulated case and discuss their performance in the context of nine teamwork competencies (e.g., situational awareness, resource management, role clarity) that have been shown to promote high reliability in team functionality.
Context of the Innovation
Louisiana State University Health Sciences Center Health Care Services Division comprises eight hospitals with roughly 600 staffed inpatient beds located across the southern region of the state. Between 2006 and 2007, these hospitals managed a total of 18,703 surgical cases. Three of the hospitals participated in the System for Teamwork Effectiveness and Patient Safety program (commonly known as “STEPS”), with the program being implemented at two sites and the third serving as a control. The mobile mock operating room is an adaptation of a previous concept called the virtual operating room, established at the Isidore Cohn, Jr. Learning Center at Louisiana State University. After the virtual operating room was destroyed in Hurricane Katrina, program developers began rebuilding the model, adapting it so that it could be transported easily to other locations. The mobile mock operating room serves as a key component of Louisiana State University's effort to develop an interdisciplinary, simulation-based training model to improve OR teamwork and patient safety. The STEPS model, supported by a grant from the Agency for Healthcare Research and Quality (AHRQ), involves simulations conducted at the point of care, with staff learning to overcome latent conditions that can lead to suboptimal teamwork and communication, and working with change agents at the hospital to develop and implement strategies so that improvements in teamwork can be sustained.
To date, 22 sessions have been completed with surgical teams at Earl K. Long Medical Center in Baton Rouge (about 80 miles from the main campus), and 18 at the University Medical Center in Lafayette (about 140 miles from the main campus). Year one results show that the program provided a realistic training environment and led to better teamwork and positive changes in actual care delivery processes.
- Highly realistic environment: Participants rated the environment as highly realistic on seven items related to authenticity and the overall value of the sessions.
- Better teamwork: Results from questionnaires (the Operating Room Teamwork Assessment Scale6 ) administered before and after training show that the program yielded statistically significant gains in 14 of 15 items related to teamwork.
- Improved care processes in everyday practice: Results from the Operating Room Teamwork Assessment Scale-Department Form strongly suggest that learning has transferred to everyday practice in real patient cases. Statistically significant gains were observed for four of the five scales and subscales, including the preoperative briefing, overall teamwork/shared mental model, teamwork behavior, and adaptive communication and response. These early results suggest positive and statistically significant improvements in teamwork during everyday care delivery. Early qualitative analyses support these quantitative findings and explain further the influence of leadership and an organizational culture committed to excellence and receptivity to change and improvement.
Planning and Development Process
Key elements of the planning and development process included the following:
- Adaptation of equipment: Louisiana State University purchased a commercially available simulation mannequin and torso and worked with vendors to adapt the equipment so that the simulations could be more realistic (e.g., by allowing for scenarios such as hemorrhage).
- Development of computer software: A Louisiana State University physician developed computer software with preprogrammed algorithms to guide clinical scenarios; a patent is pending on this software.
- Development of debriefing structure: Program developers structured a debriefing session based on research on the nine teamwork competencies that lead to effective teamwork.
- Pilot testing: Louisiana State University conducted pilot tests of the simulated sessions with residents at the University Hospital in New Orleans; the tests identified “kinks” in the system that were then fixed.
- Rollout: Program developers worked with senior leaders and OR managers at other institutions to win approval to run onsite sessions.
- Continued use and expansion: Information provided in November 2010 indicates that the simulation-based training model has been applied and is in continued use with an inter-professional education component. Inter-professional teamwork training is being conducted in the on-campus learning center with teams comprised of fourth-year medicine and nursing students, second-year nurse anesthesia students, and physical therapy doctoral students, with teamwork training occurring in simulated surgical and ICU environments. Additional grant funding has been received to further develop the teamwork training model. The model has also been the foundation for two new simulation-based pediatrics residency training programs: one program focused on unannounced mock codes and in situ simulation-based training of interdisciplinary code teams, and a second program focused on neonatal resuscitation in the hospital setting. The university is also engaged with colleagues at the Imperial College of Surgeons in London to further examine the effectiveness of debriefing in simulation-based training.
Resources Used and Skills Needed
- Staffing: Running the practices involves three Louisiana State University physicians: one who oversees and monitors the computerized scenarios and operates the mannequin (this physician developed the computer algorithm), one who handles research administration and data collection tasks and observes the team training sessions, and one who facilitates and observes the team training. These individuals, along with several other Louisiana State University faculty, are also involved in the research investigation.
- Costs: Staff time and travel expenses for a 2-year period were approximately $560,000. Equipment costs (e.g., for the mannequin and torso) ran approximately $100,000.
The staffing for this project is funded by a $560,000, 2-year grant from AHRQ (grant #RHS016680-01). The Louisiana State University Alumni Association funded the purchase of the equipment.
Tools and Resources
The Emergency Care Simulator mannequin is available from Medical Education Technologies, Incorporated in Sarasota, FL. Available at: http://www.meti.com
The Torso Trainer is available from Simulab Corporation in Seattle, WA. Available at: http://www.simulab.com
Getting Started with This Innovation
- Gain administrator buy-in: Administrator support is critical to getting the program up and running. Administrators who support a culture of safety are most likely to quickly see the value of the program.
- Elicit clinician support by focusing on safety benefits: Educate participants on the potential benefits of the program by sharing data on the link between poor communication/teamwork and adverse events and medical errors. These data should convince clinicians of the opportunity that exists to improve communication patterns and work styles.
- Schedule sessions at convenient times: Scheduling sessions during elective surgery hours ensures convenience for professionals across the multiple disciplines involved in surgical care.
- Keep debriefings short and structured: Short, focused debriefings will help to ensure that participants understand and retain the main lessons. Short sessions may also encourage clinicians to engage in debriefing sessions after real cases.
Contact the Innovator
Note: Innovator contact information is no longer being updated and may not be current.
Sheila W. Chauvin, MEd, PhD
Director, Office of Medical Education Research and Development (OMERAD)
Professor, Department of Internal Medicine and School of Public Health
Louisiana State University Health Sciences Center
2020 Gravier Street, Room 657
New Orleans, LA 70112
Phone: (504) 568-2140
Fax: (504) 988-1453
Dr. Chauvin has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
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Paragi R, Yang T, Paige JT, et al. Examining the effectiveness of debriefing at the point of care in simulation-based operating room team training. Advances in Patient Safety: New Directions and Alternative Approaches . Vol. 3 (AHRQ Publication No. 08-0034, 1-4). Rockville, MD: U.S. Department of Health and Human Services, Agency for Health Care Research and Quality; August 2008. [PubMed]
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