Monday, October 25, 2010

Team Work

Updated 3/2017-- all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

There’s an article in the Oct 20, 2010 issue of the Journal of the American Medical Association (JAMA) which discusses surgical team training and team work in the operating room.
Most surgeons have crews or individuals in the operating rooms they prefer to work along side.  Things just go smoother.  We work more as a team, more as one.
Why?  Personalities.  Communication styles that work well together.  Skills that compliment.  Each person knows and does their job, not trying to do someone else’s.  Each knowing that even the smallest task is important to the whole.
Ideally, we could create teams like this at all times in the operating room.  In reality, its not so easy.  Change in personnel happens.  Team members get sick, so there is great need for cross-training and flexibility.  Personnel (including surgeons) need to be able to work with these changes.
I know currently the comparison is to racecar teams that change the tires, etc with great efficiency or the aviation industry with their check lists.  While we should learn from these industries, we must not forget that medicine is far more diverse. 
Surgeries are not all the same.  The cars are.
Ask your personnel.  I know OR nurses and scrub techs who detest certain surgeries and try very hard not to be in those rooms.  Some like eye surgeries.  Some like orthopedics.  Some like the laparoscopic cases.  Others do not.  Others even after doing similar cases with you multiple times, never seem to pay enough attention to be able to “anticipate” what comes next.
The really good OR nurses and scrub techs will put aside their distaste for the procedure (or surgeon) and function within the team framework.  Others will let their boredom distract them.
In the racecar industry, the guys changing the tires are thrilled to be there.  Thrilled to be part of it all. 
We should strive to work as a team.  We should each learn our job and give it our best.  Like all teams, there have to be second and possibly third strings for backup when a team member is absent (personal sickness, family illness, jury duty, etc). 
The study’s lead author Dr. James Bagian is a former NASA astronaut.  The VA training took a page from the aviation and the nuclear power industries, which have used checklists and improved communication to reduce risks.  The adoption of surgical team training saw a mortality rates drop from 17 deaths per 1,000 cases to 14 deaths per 1,000 cases.
The Medical Team Training program includes 2 months of preparation and planning with each facility's implementation surgical care team. This is followed by a day-long onsite learning session. To allow surgical staff to attend as a team (surgeons, anesthesiologists, nurse anesthetists, nurses, and technicians), the operating room (OR) is closed.
Using the crew resource management theory from aviation adapted for health care, clinicians were trained to work as a team; challenge each other when they identify safety risks; conduct checklist-guided preoperative briefings and postoperative debriefings; and implement other communication strategies such as recognizing red flags, rules of conduct for communication, stepping back to reassess a situation, and how to conduct effective communication between clinicians during care transitions.
The learning session included lecture, group interaction, and videos. After the learning session, 4 quarterly follow-up structured telephone interviews were conducted with the team for 1 year to support, coach, and assess the Medical Team Training implementation. Follow-up calls were usually conducted with the OR nurse manager or an OR nurse, a surgeon or chief of surgery, and other staff nurses, and administrative support staff also frequently participated.

Association Between Implementation of a Medical Team Training Program and Surgical Mortality; Julia Neily; Peter D. Mills; Yinong Young-Xu; Brian T. Carney; Priscilla West; David H. Berger; Lisa M. Mazzia; Douglas E. Paull; James P. Bagian; JAMA. 2010;304(15):1693-1700.; doi:10.1001/jama.2010.1506
Improving Teamwork to Reduce Surgical Mortality; Peter J. Pronovost, MD, PhD; Julie A. Freischlag, MD; JAMA. 2010;304(15):1721-1722. doi:10.1001/jama.2010.1542


Elaine Schattner, M.D. said...

Nice post on what should be a trivial point but isn't: As a patient, I very much like the idea of knowing the doctors and nurses are cooperating while I'm under anesthesia.

BrainDame said...

I worked to get some team training (less extensive) set up at one of my hospitals and so far they haven't taken it on-the expense is high on many levels. Perhaps a study like this can make resources for such training more available. This is just the kind of project that can never "pay for itself" because the savings are in lives and things which insurance companies don't reimburse...
Having said that, I do REALLY appreciate your points about how medicine differs from aviation, racetracks, etc.

Cynthia Bailey MD said...

This is a perfect example of why health care needs not to become commoditized. Thanks for bringing it front and center with your post.