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Structured perioperative team communication
Structured and effective communication is critical to a successful operation and perioperative care. It plays an essential role in facilitating teamwork. We define communication as the transfer of information from one person to another or to a group of individuals, either via verbal language, gestures or cues, or written messages. Effective communication allows a message or concern to be efficiently and clearly delivered to and understood by the intended recipient. Structured communication describes frameworks in which systems are put in place to allow for the delivery of this message or concern.
In the operating room and perioperative setting, the surgical care team must be able to clearly convey the plan of care, discuss obstacles, and debrief. The operating room, however, presents unique challenges to accomplish this, such as the physical barriers of surgical masks and sterile drapes, handoffs of care between team members, the potential for unexpected adversity or stress, and the traditional hierarchical structure of the medical team. Ultimately poor communication can result in the most dreaded complications: wrong procedure, wrong site surgery, use of incorrect or expired implants, increased morbidity, and even mortality.
This chapter will examine the importance of perioperative team communication. We will summarize the history behind formalizing and mandating surgical time-outs. We will also present evidence to support other interventions that enhance structured communication, including preoperative briefings, surgical checklists, postoperative debriefings, and handoffs. We will review the benefits and perceived limitations in implementing these interventions. Finally, we will outline strategies to help you achieve structured and effective communication in your operating room.
The need for structured and effective perioperative team communication
The perioperative surgical team consists of surgical members in three different locations: the preoperative, intraoperative, and postoperative areas. Team members include preoperative nurses and clinical technicians, the anesthesia care team, the operating room nurse, the scrub technician, the surgeon and their assistants, postoperative nurses, and the postoperative care team in the intensive care unit or the inpatient ward. Each team member provides a different skill set, all of which are crucial to patient care. Not only are multiple team members involved, but there are also multiple transitions of care inherent in the operative care of a patient. Effective teamwork entails cooperation and communication among the various care providers with the common goal of providing the best possible patient care. Its value is highlighted by evidence showing that poor teamwork results in errors, adverse events, and poor patient outcomes.
Despite a team's best intentions, the operating room presents several distinct challenges that can potentially limit effective communication. Many of the visual and auditory cues inherent to communication are precluded or dampened by the very nature of the operating room. For instance, the operating surgeon may not be able to look up from the patient for any visual cues while communicating with the first assistant, the scrub technician, the circulating nurse, or the anesthesiologist, who is additionally behind the curtain of the sterile drapes. Facemasks further cover nonverbal facial expressions and muffle verbal speech. The environment can be chaotic, such as during an unplanned, emergent operation in an unstable patient or an unexpected adverse event during the course of a planned operation. Such high stress, high stakes environments are associated with cognitive overload and breakdown of communication. This only helps to fuel a traditionally hierarchical team structure, both between the various health professionals and within the same category of healthcare professional based on level of experience. This hierarchy can breed an unsafe environment where team members might not speak up regarding a safety concern or question out of fear or formality. ,
Poor communication has been linked to many adverse outcomes, including wrong procedure, wrong site surgery, retained foreign objects, and use of incorrect or expired implants. Beyond individual adverse events, the evidence suggests that ineffective communication is independently associated with poorer overall outcomes for patients. For instance, Mazzocco et al. observed surgical teams in the operating room and found when teamwork behavior was infrequently observed, patients were statistically significantly more likely to experience a complication within 30 days of surgery, with an adjusted odds ratio of 4.82. Complications included in this analysis included death, intraoperative complications such as surgical burn, adverse drug reaction, wrong laterality or procedure, and retained foreign objects, and postoperative complications including respiratory failure, wound dehiscence, myocardial infarction, and cerebrovascular accident. As such, the need for effective and structured perioperative team communication is ever present.
The Joint Commission's surgical time-out
In 2004, The Joint Commission introduced the universal protocol to prevent wrong site, wrong procedure, and wrong person surgery as a mandatory quality standard. This is arguably the first time a structure was put in place to mandate a perioperative team communication initiative. The protocol includes a preprocedure verification process, surgical site marking, and a surgical time-out prior to starting the procedure. The time-out component of the universal protocol was initially defined as a designated time during which all members of the team pause to confirm the correct patient, operation, and laterality ( Table 6.1 ). All members of the operative team, including the anesthesiologist, surgeon, circulating nurse, and technician, must be present and engaged during the time-out.
Table 6.1
Components of The Joint Commission's surgical time-out. a
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a Source: The Joint Commission. “The Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery: Guidance for health care professionals.” https://www.jointcommission.org/assets/1/18/UP_Poster1.PDF . Accessed: July 5, 2019.
Since it was first implemented, The Joint Commission's surgical time-out has expanded to include verification of patient positioning, availability of equipment, patient allergies, and the need for essential medications including antibiotics, beta-blockers, and venous thromboembolism prophylaxis. The expanded time-out also includes the introduction of all team members by both name and role. The Joint Commission mandates that this is not only implemented before every invasive procedure, but that the procedure does not start until all questions and concerns are addressed. Failure to comply may result in the loss of accreditation of the medical center.
Unfortunately, despite The Joint Commission's universal protocol, operative errors still occur. Between 2005, when the time-out was first mandated, and 2016, 1281 wrong patient, wrong site, or wrong procedure sentinel events were reported to The Joint Commission. In 2018 alone, 94 wrong site surgeries were reported. This highlights that The Joint Commission's surgical time-out is a starting point, and not end point, to achieve structured and effective perioperative communication. The remainder of this chapter will focus on initiatives put forth by the World Health Organization (WHO) and other researchers that support preoperative briefings, surgical checklists, postoperative debriefings, and handoffs ( Fig. 6.1 ).
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