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Team Training in Anaesthesia

Jennifer Weller

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Acknowledgements

• Dr Jane Torrie• Dr Rob Frengley• Prof Brian Jolly• Prof Alan Merry• Dr Brian Robinson• Dr Boaz Shulruf• Dr Robert Henderson• Ms Kaylene Henderson• Dr Bevan Yee• Dr Pete Dzendrowskyj• Dr Adam Paul• ANZCA • Plus hosts of others

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A private Hospital: wrong side surgery (knee).

“A team is called a team for a very good reason; there is an expectation that there will be sufficient co-operation and communication amongst its members to minimise the risk of harm to the patient.”

A Report by the Health and Disability Commissioner. (Case 00/06857), 2002; Orthopaedic Surgeon/Anaesthetist/Theatre Nurse/Anaesthetic Nurse/Scrub Nurse

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“If you can’t measure it you can’t improve it.” Lord Kelvin

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Global performance measure

Behaviour 1 2 3 4 5

• Acquisition of all available information• Anticipates and plans • Calls for help appropriately• Reevaluates situation • Utilises team resources effectively• Allocates attention wisely• Prioritises• Concise, directed instructions, closes communication loop • Communicates problem clearly to team, Listens to team• Manages Conflict (if required)

Weller et al. Anaesthesia. 2005 Weller et al. British Journal of Anaesthesia. 2003

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WhenRole in

commun-ication

Who to Type of Communication

Situational content

Pre induction Initiation Tech Statement

Verbalises patient

parameters

Post induction

Response Surgeon Task assignment Assessment of

patient status

Circn.Nurse

Gave tech 2 or more instructions

Anticipates future problems

All Requests information

Proposes plan of action

Other Asks for suggestions

Unspecified Receiver

Responds to suggestions

Ignored suggestions

Requested helpRequest to surgeon

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Randomised scenario order

4 scenariosRespiratory / Cardiac

160 videos

Validation of the instrument

40 critical care teams

Scenario order randomised

Three trained assessors

independently rated the scenarios.

480 scores

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Exploratory Factor Analysis

Leadership and Team

Coordinationα = 0.917

Mutual Performance Monitoringα = 0.915

Verbalising Situational Informationα = 0.893

Internal consistency measured with Cronbach’s α

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Generalisability analysis

G-Coeff

Overall behaviour score 0.78

Leadership and Team Coordination 0.85

Mutual Performance Monitoring 0.4

Verbalising Situational Information 0.37

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Item Simulation Type Difference P value

Overall Teamwork Behavior

Airway 1.107 <0.005

Cardiac 0.826 <0.005

Leadership and Team

Co-ordination

Airway 0.849 <0.005

Cardiac 0.691 <0.005

Verbalizing Situational Information

Airway 0.747 <0.005

Cardiac 0.472 <0.005

Mutual Performance Monitoring

Airway 0.113 0.76

Cardiac -0.034 0.365

Improvement in teamwork and its components following training

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Participant’s evaluation of the team training intervention

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Recap

So far we’ve considered: • Different ways of looking at

teamwork• Need for robust measures• Evidence that teamwork behaviours

can be learnt

BUT

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“It is critical for a theatre team to operate as a team rather than as a group of individuals with separate and independent responsibilities.There must be an acknowledgment of the necessity of collective responsibility for a team of trained health professionals operating as a team within the operating theatre environment.”

HDC commenting further on case of wrong side surgery

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Understanding communication failures

Issues we identified

• Sharing goals

• Establishing capabilities of team members

• Challenging behaviour

Weller et al Interdisciplinary team interactions. Medical Education 2008

If you get a team leader who verbalises well, there’s no mixed messages going through and everybody knows what the .. objectives are

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Value of multidisciplinary team training

“The nurses can take some of the load from a doctor. The nurses are valuable members of the team and their ideas have value too.” [N]

“so they can both see from the other’s eyes what they are responsible for, what they’re going through” [N]

“new appreciation of the expert assistant role of the nurse” [D]

“It’s highlighted that doctors need to be able to take on information, process it and spit it out at a great rate of knots. But -just because they’re the doctor doesn’t mean that they can see absolutely everything -we have to work together as a team to get a desired outcome”. [N]

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Issues in Multidisciplinary Team training

Limited numbers of studies – McCulloch 2011

• MDT approach to training and assessment

• Real teams playing themselves• Meaningful engagement of all

players• Simulations of sufficient fidelity and

relevance to engage all

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Innovations in health professionals training in the management of the surgical patient.

We aim to: • Create realistic simulated

operating room environments to engage the whole team.

• Target identified communication problems.

• Evaluate change in practice in the workplace.

• Demonstrate improved outcomes for patients.

Innovations in health professionals training in the management of the surgical patient. J Weller et al (Health Workforce NZ Innovations funding)

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A SNAPPI Call-out

S top and gather the team Stand back and get the attention of the room

Notify team re patient status

Provide an overview of the situation e.g. Vital signs, blood results, events.

Assessment of the situation

Verbalise your assessment of the situation e.g. “I think this may be anaphylaxis” plus options

P roposed plan for treatment

Say what you think needs to be done

P riorities And in which order

I nvite ideas Invite suggestions, other ideas on diagnosis or treatment.

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Voice your concerns

Probe

Alert

Challenge

Emergency

Response

The two Challenge Rule

“If a pilot is clearly challenged twice about an unsafe situation during a flight without a satisfactory reply, the subordinate is empowered to take over the controls.”

Juniors are expected to express their concerns.

Seniors are expected to listen and reply.

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I dentify

S ituation

B ackground

A ssessment

R ecommendation

ISBAR – handover tool