Developing a Preoperative Briefing Protocol for Cardiovascular Surgery Objective: Design a protocol for conducting preoperative briefings within the context of cardiovascular surgery. Method: A combined questionnaire and semi-structured focus group approach involving four subspecialties of surgical staff (n = 55) was conducted to gather information concerning (1) attitudes towards preoperative briefings, (2) logistical issues related to the conduct and content of briefings and (3) potential barriers that might impede implementation. Results: Analyses revealed consensus among surgical staff concerning briefing benefits (majority were very positive), duration (< 10 min), location (in the OR), content (procedure, patient, and equipment issues) and potential barriers (staff availability, attitudes, case scheduling, and lack of resources). Differences in opinions arose concerning timing of the brief (e.g., before vs. after patient enters OR) and the role of key participants. Discussion:A prototype checklist for conducting preoperative briefings was developed based on these results. Additional research is needed to implement and validate its effectiveness.
INTRODUCTION Effective communication and teamwork have long been recognized as imperative drivers of quality and safety in almost every industry. Like most industries, healthcare is a team-based profession. However, as more data become available, there is increasing recognition that poor communication and/or teamwork are causal factors in a large percentage of sentinel events within healthcare systems. In fact, the Joint Commission (2006) reports “Communication” as the number one root cause (65%) of reported sentinel events between 1995-2004. In studies of errors during cardiac surgery, several factors have been identified that impact surgical performance (Wiegmann, ElBardissi, Derani, and Sundt, 2006). One of the most important factors is teamwork. In one study, teamwork factors alone accounted for roughly 45% of the variance in the errors committed by surgeons during cardiac cases. Teamwork issues generally clustered around issues of miscommunication, lack of coordination, failures in monitoring, and lack of team familiarity.
These findings are not specific to one institution. Poor staff communication has been linked to poor surgical outcomes in general (de Leval, Carthey, Wright, Farewell, and Reason, 2000; Carthey, de Leval, and Reason, 2001). For example, a study by Gawande, Zinner, Studdert, and Brenner, (2003) focused on the dangers of incomplete, nonexistent or erroneous communication in the OR and found that that communication was the causal factor in 43% of errors made during surgery. Another study by Lingard, Espin, Whyte, Regehr, Baker, Reznick, Bohnen, Orser, Doran, and Grober, (2004) found that 36% of communication errors in the operating room resulted in visible effects on system processes which include inefficiency, team tension, resource waste, work-around, delay, patient inconvenience, and procedural error.
Many teamwork problems during surgery could be ameliorated by team meetings (preoperative briefings) prior to conducting the operation. For example, DeFontes & Surbida (2004) developed a preoperative safety briefing for use by general surgical teams that was similar to a preflight checklist used by the airline industry. A six-month pilot of the briefing protocol indicated that wrong-site surgeries decreased, employee satisfaction increased, nursing personnel turnover decreased, and perception of the safety climate in the operating room improved from "good" to "outstanding.” Operating suite personnel perception of teamwork quality also improved substantially.
Despite the potential benefits of preoperative briefings, there utilization remains relatively low within many surgical specialties. This is likely do to multiple reasons. For example, there are no standardized protocols for conducting preoperative briefings. Each surgical specialty has unique “issues” that may need to be addressed prior to each operation. Therefore, a generic off-the-shelf checklist may not suffice. This is not to say that the development of a common template for designing briefing protocols is untenable, rather the specific content will need to be tailored to each surgical specialty. Other barriers impeding the utilization of preoperative briefings include individual attitudes or resistance to change by surgical staff, as well as organizational barriers such as case schedules, lack of facilities and limited resources. As documented by DeFontes & Surbida (2004), the successful development of a preoperative briefing protocol takes several months of research and development, beginning with first understanding the needs and views of key stakeholders (i.e., surgical staff) and the nuances of the organization in which such briefings are to take place.
Purpose of the present study.
Given the results of previous human factors (HF) studies within the cardiovascular surgical suits (Wiegmann et al., 2006), our HF team was asked by cardiac surgeons to develop a protocol for conducting preoperative briefings. Currently, formal briefings do not take place within our institution. There are also no published, standardized methods for conducting such briefings within cardiovascular surgery. The goal of this study, therefore, was to take the first step in the design of a preoperative briefing protocol by gathering information concerning (1) attitudes of surgical staff towards preoperative briefings, (2) logistical issues related to the conduct and content of preoperative briefings and (3) potential barriers that could impede the implementation of a preoperative briefing protocol. Data from this initial study served as the foundation for designing a prototype protocol for conducting preoperative briefings within the context of cardiovascular surgery.
Participants (n = 55) included surgical personnel involved in patient care within the cardiac surgery operating room at a large medical teaching institution. The targeted specialty groups were surgical staff, including surgical assistants, surgical technicians (scrub technicians), registered nurses (circulating nurses), perfusionists, and certified registered nurse anesthetists.
A combined questionnaire and semi-structured focus group methodology was used in this study. At the beginning of each session, participants were informed that the purpose of the study was explore the possible content, procedure, and feasibility of performing a preoperative briefing prior to cardiovascular surgical operations. They were then given a “preoperative brief” questionnaire and asked to complete the questionnaire concerning preoperative briefings (10 min.) This questionnaire was developed to examine surgical staffs’ attitudes about pre-operative briefings, information about briefing logistics (when, where, who and how long,), the key topics that should be discussed during the briefings, and barriers that might exist in establishing a briefing protocol and/or implementing the protocol.
Upon completion of the questionnaire, a short question/answer focus group session then occurred to discuss participants’ answers to the questionnaire. A human factors expert facilitated each group. The facilitator began the focus group session by asking the staff to share their answers to each question in a sequential fashion. For each question, a separate researcher took notes to capture the comments provided by the staff, the nature of any disagreements/discussions among staff members, and answers to follow-up questions posed by the facilitator. The entire session lasted less than 1 hr.
Questionnaire administration and focus group sessions took place during each group’s normal monthly division meeting and each surgical specialty group was assembled and queried separately. This was done because the surgical environment is very hierarchical in nature. Therefore, some individuals among the specialties may be intimidated or reluctant to discuss their opinions in the presence of others outside their specialty and/or to debate, criticize or disagree with opinions offered by others. Consequently, conducting focused groups independently for each specialty was intended to result in more information being collected and more informative discussions during each session.
A combined approached (questionnaire and focus group) was utilized for several reasons (Berg, 2007). First, most participants had not heard of the term “pre-operative briefing,” prior this study; therefore, the questionnaire provided them with an opportunity to think about the topic and brainstorm in a pertinent manner prior to the focused group discussion. Second, the questionnaire provided an opportunity for subsequent analyses of responses on an individual basis. The focus group component, however, will also allow for additional data to be collected on a group level that individuals might not have created on their own.
RESULTS Analysis of the data involved the use of both qualitative and quantitative methods. Specifically, a grounded theory approach was used to analyze the content of participants’ statements for each of the questions on the preoperative survey and subsequent focus group discussion (Berg 2007). Specific quotes were also included to better illustrate the nature of these themes. Descriptive and summary statistics were used (e.g., means and frequencies) to quantify the number of participants who voiced similar concerns/ideas or the differences between specialties in terms of the types of concerns/ideas they may have had.
Attitudes about Briefings Participants were asked the question “Would you like some sort of preoperative briefing to be implemented?” As illustrated in Figure 1, the majority (65%) of surgical staff answered this question affirmatively. Roughly, 22% indicated that they did not want such a procedure to be implemented and 13% expressed no opinion. Of those who said “no,” the majority indicated that either 1) they were already doing some sort of informal briefing with other staff and they feared that formalizing the process would detract from it, and/or 2) they simply did not think it was a feasible or practical option. Of those that expressed no opinion, the majority indicated that they would be in favor if the briefing met certain specifications, such as timeliness and location and proper staff availability.
Figure 1. Response distribution to the question “Would you like to see some sort of preoperative briefing implemented?
Duration (how long?). There was a high level of agreement among staff concerning the maximum duration of a preoperative briefing, as illustrated in Figure 2. Roughly 74% indicated that it should be less than 10 min, with 44% of the participants indicating that the briefing should last between 5-10 minutes, while approximately 30% of participants said that less than 5 minutes would be best. The other 20% either indicated that the duration of the brief should be “as long as it takes” or voiced no opinion.