Realistic Simulations Improve Teamwork and Care Processes in the Operating Room

Service Delivery Innovation Profile

Realistic Simulations Improve Teamwork and Care Processes in the Operating Room

Snapshot

Summary

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.

Evidence Rating

Moderate: The evidence consists of pre- and post-implementation survey results and a post-implementation OR teamwork assessment scale. Results for publication are not yet available; current evidence represents preliminary findings.

Developing Organizations

Louisiana State University Health Sciences Center

New Orleans, LA

Date First Implemented

2005

August

Problem Addressed

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.

Results

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.

Evidence Rating

Moderate: The evidence consists of pre- and post-implementation survey results and a post-implementation OR teamwork assessment scale. Results for publication are not yet available; current evidence represents preliminary findings.

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.

Funding Sources

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
E-mail: schauv@lsuhsc.edu



Innovator Disclosures

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.

References/Related Articles

Paige JT, Kozmenko V, Yang T, et al. The mobile mock operating room: bringing team training to the point of care. 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]

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]

Paige JT, Kozmenko V, Yang T, et al. High fidelity, simulation-based training at the point-of-care improves teamwork in the operating room. J Am Coll Surg. 2008;207(3):587-8. [PubMed]

Paige JT, Aaron DL, Yang T, et al. Implementation of a preoperative briefing protocol improves accuracy of teamwork assessment in the operating room. Am Surg. 2008;74(9):817-23. [PubMed]

Footnotes

  1. 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):330-4. [PubMed]

  2. Leape LL. Error in medicine. JAMA. 1994;272:1851-7. [PubMed]

  3. Catchpole K, Mishra A, Handa A, et al. Teamwork and error in the operating room: analysis of skills and roles. Ann Surg. 2008;247(4):699-706. [PubMed]

  4. Lingard L, Reznick R, Espin S, et al. Team communications in the operating room: talk patterns, sites of tension, and implications for novices. Acad Med. 2002;77:232-7. [PubMed]

  5. Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004;13 Suppl 1:i85-90. [PubMed]

  6. Paige JT, Aaron DL, Yang T, et al. Improved operating room teamwork via SAFETY prep: a rural community hospital's experience. World J Surg. 2009;33(6):1181-7. [PubMed]

Funding Sources

Agency for Healthcare Research and Quality
Louisiana State University Alumni Association

Developers

Louisiana State University Health Sciences Center

New Orleans, LA

Comments

By Tara Vitale OR Nurse Resident ORMC on
To be an effective Nurse requires team work. Communication and collaboration with staff members are vital components of working in an OR. The patients safety is in the hands of the OR team. When members do not effectively communicate, or perform as a team, adverse events occur. It is often difficult to educate individuals on effective communication as they cannot see how they communicate. Utilizing a simulation is a great way for staff to evaluate themselves in a mock scenario. Having the ability to visualize the simulation afterwards highlights the key components that were effective, and the areas that require improvement. Although simulations are costly, I truly believe that they are the most effective tools for educating healthcare staff.

By Matthew Adams on
While I support the use the simulation you did not offer any concrete data to support your position. To state that your results were 'strongly supported' or 'statistically significant' without data does not allow practioners to measure and evaluate your process and in essence makes the study null and void for future reference. Trust but verify!!! Matthew Adams, BSN, RN OR Nurse Resident Orange Regional Medical Center

By Melissa Anderson RN, BSN, CMSRN, OR RN student on
This innovation appears to be of great value becuase it allows the staff to be in a real OR setting with serious health complications scenarios but without the stress of a "real live" patient. Having the stress removed allows staff to ask questions that they might not have if it were a real scenerio, seek ways of improving communication, learn better ways of handling the situation, and to enjoy the learning experience. Is there a recommended way to rotate the staff through the program, frequency in which they should attend a mock OR, or a formal evaluation form to improve the process?

By Arthur on
There is significant importance to team work in all medical settings. The operating room has a special interest in teamwork, and communication. There is difficulty understanding and evaluation of communication skills. With the new technology available it is helpful to get an outside view of your personal team building, and use the new skills to improve operation room areas for everyone.
Original Publication: 11/11/09

Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last Updated: 11/06/13

Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: 10/30/13

Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read Health Care Innovations Exchange Disclaimer.

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