Australasian Anaesthesia 2011 - Australian and New Zealand ...

192 Australasian Anaesthesia 2011Teamwork: hard facts, soft skills. 193TRANSLATION TO THE OPERATING THEATRESalas suggests that before we can begin to work effectively as an operating room team we need to have developeda degree of trust in each other; we need to have a common understanding of the patient status, the operation andthe goals of treatment (shared mental model) and how the tasks of patient care will be managed between thedifferent team members; and we need good basic communication skills.Mutual trust: Developing trust in a new team member usually takes time. Working with someone over a periodof time, you get to know their skills, capabilities and limitations. In the operating room some teams have the luxuryof stability, but oftentimes we are working with new staff, and may not even know each others’ names. As anaesthetists,we have developed expertise in rapidly establishing respect and trust with our patients, due to the nature of ourbrief pre-operative encounters with patients before they place themselves in our care. According to Salas, applyingthis expertise to establishing similar relations with the staff in our theatre for the day may have equally importantresults for our patients. Speed dating comes to mind. To some extent the WHO Surgical Safety Checklist aims tointroduce the team to each other at the beginning of the day, but, anecdotally, in some theatres this can be a tokeneffort.Shared mental models: Developing a common understanding of issues for a patient, or indeed for the managementof the list, seems an obvious thing to do, but perhaps we don’t do it? Examples include wrong side surgery; listoverruns; wrong equipment; wrong anaesthetic; no warning about complicated patients coming in on day of surgeryadmissions; surgeon not present in theatre until the patient is anaesthetised. The hierarchical, undemocratic natureof the theatre team may discourage input or challenge from junior staff or some professional groups. A democraticteam briefing as a standard procedure at the start of the day is being tried as one component of “The ProductiveOperating Room” initiative in some NZ hospitals.Closed-loop communication: Communication skills, as championed by Gaba in “Crisis Management inAnesthesiology” 30 include clear, directed communication and closing the communication loop. Mnemonics havebeen proposed to assist communication clarity, including ISBAR 3 1 and SNAPPI 32 (Figures 1 and 2).Figure 1. ISBAR handover communication toolISBAR – handover toolIdentify who you areSituation – describe the problemBackground- clinical contextAssessment – what you think is going onRecommendation / requirement – what you think needs to be done, what you need the other person to doFigure 2: SNAPPI Call outSNAPPI Call out• Stand back and get the attention of the team• Notify the team of patient status (vital signs etc)• Assessment of the situation (what you think is going on)• Proposed plan for treatment• Priorities (what needs to be done first etc)• Invite ideas and suggestionsLingard noted failed communication in her observations of operating room teams. 22 Directing communication bystating a person’s name and avoiding making requests to “someone” requires that names are known. This suggeststhe need for systems to ensure names are known, for example the introduction of person and role in the WHOSurgical Safety Checklist; writing names on a whiteboard; readable name badges. Closing the communication loop(i.e. acknowledging hearing the communication) is clearly demonstrated in the military and aviation industries.Salas 29 proposes that the above three conditions are requirements for effective team leadership; mutualperformance monitoring; backup behaviour; adaptability; and team orientation.Leadership: In anaesthesia, the role of the leader is to centralise communication and co-ordinate tasks. If theteam has previously clarified their roles and capabilities, established a common understanding of the pertinentissues, and the goal of treatment, and has the skills to communicate efficiently, the leader’s job is facilitated.Mutual performance monitoring /Backup behaviour: A common understanding of others roles and clarity aboutthe goals of treatment enables team members to recognise when others are task overloaded, not coping or not onthe right track. Mutual trust and respect enables team members to speak up. A shared goal with whole teamresponsibility facilitates speaking across professional boundaries in the interests of achieving the goal.Adaptability: In the operating room, team members may not know each other, and the situation can changerapidly. Processes that support understanding of who is in the team and their tasks and responsibilities, andstructures to ensure information is shared and updated, enables the whole team to move rapidly to a newunderstanding of the changed situation and modify their actions accordingly.Team orientation: When making decisions about patient care, surgeons and/or anaesthetists with a teamorientation will take others views into consideration when determining what’s best for the patient or for the runningof the day.A SYSTEMS APPROACH TO TEAMWORK IN THE OPERATING ROOMFollowing the initial publication of the report “To Err is Human” with calls for doctors to improve the way they workedin healthcare teams, progress has been frustratingly slow. 33 Most effective public health interventions have takena systems approach. Roads are made safer not by asking drivers to be careful, but by installing traffic controllingfunctions such as speed humps, traffic lights, median barriers. Anaesthesia has become safer by, for example, theintroduction of pulse oximetry and capnography, and design of gas delivery systems. In the same way, to improvecollaboration between members of operating room team we are likely to require systems and organisational structuresthat support, or indeed require, collaboration by team members. These could include scheduling a brief and debriefinto the theatre day, implementing the WHO Surgical Safety Checklist, regular multidisciplinary departmental trainingdays.There is a problem and we need to fix it, working alongside our surgical and nursing colleagues to firstly betterunderstand the requirements of teamwork in the operating theatre, develop a more democratic operating roomenvironment, and hone up on some of those hard skills of teamwork.REFERENCES1. Weaver SJ, Lyons R, DiazGranados D, Rosen MA, Salas E, Oglesby J, et al. The anatomy of health care teamtraining and the state of practice: a critical review. 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