Dynamics of surgical teams

This important topic is evolving daily in operating rooms (ORs) around the world. Patients are living longer because of complex operations performed on a routine basis. Older and sicker patients are being treated. The margin for error to achieve excellent outcomes is smaller than ever before. Yet results are good and improving. This is largely due to teams working in a unified and coordinated fashion year after year.

There is evidence that surgical outcomes including quality and safety are largely related to teamwork including nontechnical skills of communication, collaboration, and coordination of care. Better teamwork is associated with fewer errors. ^,

Surgery is a team sport with outcomes depending on multiple players performing their roles both independently and in unison. A smooth operation means fewer postoperative problems and better outcomes. This includes morbidity and mortality.

As primarily a cardiac surgeon, I will use examples from cardiovascular surgery to discuss the dynamics of surgical teams. Cardiac surgery is particularly dependent on teamwork. It is a highly precise group of processes with many steps, and steps within steps. It requires decision-making and action with little margin for error. All of this is done under significant time constraint.

The cardiopulmonary bypass circuit used to maintain perfusion has fewer deleterious effects with shorter pump times. The longer the pump run, the greater the negative consequences. This puts all cardiac surgeons on a time clock to perform highly skilled intricate processes.

Teamwork makes efficiency and safety possible. Under time constraint a well-practiced team will perform complex processes more efficiently. Cardiac surgery often looks like a dance with many people moving in concert. Minor workflow disruptions are common. Most do not affect the outcome. However, as minor disruptions increase in frequency, operative performance is reduced, increasing the operative duration. In addition, the accumulation of minor problems also reduces the surgical team's ability to compensate for major errors. It is said that “little things matter.”

Teamwork reduces the number and mitigates the consequences of minor disruptions. In this way teamwork enhances safety. A well-trained team can see a cardiac surgical procedure from many angles. There are many trained eyes watching for problems. There are many minds available to anticipate and avoid problems. Team familiarity prevents minor problems as there is smooth communication at each step.

The University of Michigan studied 460,000 doctors caring for 251,000 heart bypass patients. They reported that a 25% increase in teamwork was associated with 17 fewer readmissions for every 1000 patients treated. “Our findings show that physician teamwork influences patient outcomes, even more than some measures of comorbid illness,” John Hollingsworth, MD, MS.

The importance of developing specialized and experienced teams in cardiac surgery have been shown around the world to make an impact on survival. Having a cardiac surgery team available for emergency cardiopulmonary bypass in place saved the lives of drowning victims in Switzerland. After many unsuccessful attempts it was found that giving emergency medical services the ability to call to mobilize a cardiac surgery team greatly improved the outcomes. Outcomes had been poor until the dedicated team was built, having the right people together at the right time with proper communication created the ability to improve outcomes and save lives.

Most will agree that in general teamwork is a good idea. It seems obvious to anyone asked about the subject. Yet there is a large gap between a good idea and execution of an excellent performance. An example of this is the reduction of central line infections by Dr. Peter Pronovost in the intensive care unit (ICU) at the Johns Hopkins Hospital and later in ICUs in the state of Michigan. Everyone thought that everything was being done well to avoid line infections. Yet the problem persisted. It was only when permission was given for any team member to call out deviations from standardized practice was there an improvement in outcomes. This principle of “nontechnical teamwork skills” applies to surgical teams as well. Unlike an ICU procedure, OR procedures involve multiple people in specific roles over a longer period of time. Surgical quality depends upon the effective interaction of these team members ( Fig. 5.1 ).

Team components and responsibilities

Surgeon

The surgeon is the team Captain in the sense that he or she is responsible for bringing the patient to surgery, choosing the appropriate operation, and managing the patient after surgery. The most effective way to perform this task is to lead with understanding of the components of the team. Each part of the team is working on its portion of the task with its own expertise. One major role of the surgeon is to coordinate the efforts of all team members in the room.

A surgeon should always check-in with the team in the room to make sure they know which operation is being done and if they are ready with the required staff and equipment. For example, in cardiac surgery cases requiring cardiopulmonary bypass, a check-in with perfusion is essential. This is especially true for cases done infrequently. Knowing the expectation for cannulation, myocardial protection strategy, and special equipment needs are key to good outcomes. Miscommunication or lack of communication leads to delays that worsen outcomes. The captain's responsibility is to ensure that everyone involved has a voice and is on the same page.

Anesthesia

Communication with anesthesia is critical. Setting expectations at the beginning of the case includes discussion of comorbid factors such as renal insufficiency, neurologic deficits, and dysrhythmias. Ongoing communication about the management of blood pressure, blood products, and management of air are examples of issues that must be handled as a team.

One author said “An anesthesiologist that looks into the wound is worth his weight in gold” emphasizing the importance of having everyone anticipating and on the same page.

Scrub nurse

The scrub nurse (or scrub technician in many hospitals) is the surgeon's closest ally. Communication with the scrub before, during, and after the case is paramount to success. Preoperative clarification of the operation about to be performed, presence of equipment, and any potential or anticipated deviation from usual practice is necessary to ensure excellent performance.

Collaboration with an experienced scrub nurse can avoid mistakes. The team in the OR needs to have the opportunity to express concerns openly. Ongoing communication is vital. Moments lost with miscommunication end up as costing minutes and then hours. In addition, miscommunication can lead to the wrong instrument passed at the wrong time. It can lead to an incorrect needle or instrument count. A well-trained team can perform an entire operation with few words as each team member anticipates the next step. This level of expertise requires that you intentionally train your team to understand not only the steps of the operation but also the reason for each step. If this is set as the expectation, the team will rise to that level of expectation.

There are times when it is necessary to work with an unfamiliar team. Those include starting a new program or working with new people in an established program. During these times meticulous communication is paramount.

Circulating nurse

The circulating nurse is the surgical team member who is not scrubbed in sterile fashion at the table. They are responsible for assessing the patient immediately before surgery and facilitating a smooth transfer into the OR. Along with the scrub nurse they are responsible for setting up and breaking down the OR. During the procedure they pass supplies up to the table as needed in the order that is planned and expected. Coordination with the surgeon is essential so that the correct instruments and supplies are available at the right time.

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