Richard C. Karl, M.D.Richard C. Karl, M.D.

Richard G. Connar Professor and ChairmanRichard G. Connar Professor and ChairmanDepartment of SurgeryDepartment of Surgery

College of MedicineCollege of MedicineUniversity of South FloridaUniversity of South Florida

Founder, Surgical Safety InstituteFounder, Surgical Safety Institute

Contributing Editor, Flying MagazineContributing Editor, Flying MagazineTampa, FLTampa, FL

Captain Robert HaynesCaptain Robert Haynes

Director of Flight Standards & Quality Assurance, Southwest AirlinesDirector of Flight Standards & Quality Assurance, Southwest AirlinesDallas, TXDallas, TX

What Can the Operating What Can the Operating Room Learn from the Room Learn from the

Cockpit?Cockpit?

What Can an Operating What Can an Operating Room Learn from a Room Learn from a

Cockpit?Cockpit?

What is realistic?What is realistic? What are the What are the

fundamental/immutable fundamental/immutable differences?differences?

What can be done now?What can be done now? What can be done in the future?What can be done in the future? What can you do tomorrow?What can you do tomorrow?

Is the cockpit model Is the cockpit model perfectly transferable to the perfectly transferable to the

OR?OR?

Differences Unlikely to Differences Unlikely to ChangeChange

RegulationRegulation EmploymentEmployment Number of Number of

people harmed people harmed per incidentper incident

Harm to the teamHarm to the team

Differences That Could Differences That Could Change…EventuallyChange…Eventually

Credentialing and re-Credentialing and re-evaluationevaluation

SimulatorsSimulators

Differences That Could Differences That Could Change…NowChange…Now

Limitation of hoursLimitation of hours Teamwork and Teamwork and

communicationcommunication The culture in the ORThe culture in the OR

Why Teamwork and Why Teamwork and Communication?Communication?

To help compensate for the FACT that To help compensate for the FACT that humans humans (even well-trained, highly (even well-trained, highly

experienced, good ones)experienced, good ones) make errors make errors StressStress FatigueFatigue OverloadOverload EmergencyEmergency UnfamiliarUnfamiliar Distractions/interruptionsDistractions/interruptions

From JCAHO website as of From JCAHO website as of July, 2007July, 2007

From JCAHO website as of July, From JCAHO website as of July, 20072007

100,000 die from medical errors

Does not include:- wrong site- retained surgical item- surgical site infection with

hypothermia- cancer recurrence with blood

transfusion- consequences of hyperglycemia

15,000,000 harms - IHI

Preventable Adverse EventsPreventable Adverse Events

Clinical Reasons to Clinical Reasons to CommunicateCommunicate

Glucose ControlGlucose Control Higher incidence of SSI in diabetic patients Higher incidence of SSI in diabetic patients

undergoing CABG with poor glucose control.undergoing CABG with poor glucose control.

Moderate hyperglycemia (200 mg/dL) at any Moderate hyperglycemia (200 mg/dL) at any time during the first postoperative day time during the first postoperative day increases risk of SSI increases risk of SSI fourfoldfourfold after noncardiac after noncardiac surgery.surgery.

Critically ill patients, tight glucose controlCritically ill patients, tight glucose control 34% decrease in mortality34% decrease in mortality Reduced blood stream infections by 44%Reduced blood stream infections by 44% Decreased renal failure and less likely to require Decreased renal failure and less likely to require

prolonged mechanical ventilation prolonged mechanical ventilation Van Den Berghe, NEJM 2001;345:1359-67

Pomposelli, JPEN 1998;22:77-81

Latham, ICHE 2001;22:607-12

Blood TransfusionsBlood Transfusions Transfusion of any volume of red blood cell Transfusion of any volume of red blood cell

concentrates more than triples the risk of concentrates more than triples the risk of nosocomial infection.nosocomial infection.

Transfusion of critically ill patients Transfusion of critically ill patients Increases risk of nosocomial infectionIncreases risk of nosocomial infection Worsens organ dysfunctionWorsens organ dysfunction Increases mortalityIncreases mortality

Linked to cancer recurrence or cancer-related Linked to cancer recurrence or cancer-related deaths deaths Head and neck cancer, breast cancer, gastric Head and neck cancer, breast cancer, gastric

cancer, lung cancer, and colon cancercancer, lung cancer, and colon cancerEnglesbe, JACS 2005;200(2):249-54

Burrows, Lancet 1982;2:662

Hill, J Trauma 2003;54:908-14

Taylor, CCM 2002;30:2249-54

Fluids

Traditional Traditional Surgical BriefSurgical Brief

Teamwork and Teamwork and CommunicationCommunication

Have structured and clear team rolesHave structured and clear team roles Use patterned communicationUse patterned communication Brief and debriefBrief and debrief Plan for contingenciesPlan for contingencies Know the game planKnow the game plan Invite inputInvite input Know and use namesKnow and use names Assert: Speak up if something looks wrong Assert: Speak up if something looks wrong

or confusingor confusing Read back all the timeRead back all the time Watch out for each other/vigilanceWatch out for each other/vigilance Identify and deal with red flagsIdentify and deal with red flags

Key Skills by Crew PositionKey Skills by Crew Position

BriefingBriefing LeadershipLeadership Interpersonal SkillInterpersonal Skill CommunicationCommunication

Inquiry/AssertionInquiry/Assertion Preparation, Preparation,

Planning, & Planning, & VigilanceVigilance

Technical Technical ProficiencyProficiency

LeadershipLeadership

Captain Captain First Officer First Officer

Are Teamwork and Are Teamwork and Communication Enough?Communication Enough?An integrated approachAn integrated approach

Create cohesive, clear, reliable policiesCreate cohesive, clear, reliable policies Ensuring no RSI or wrong surgery is a team Ensuring no RSI or wrong surgery is a team

function, not solely a nursing or surgeon function, not solely a nursing or surgeon functionfunction

Make teamwork and communication the Make teamwork and communication the bedrock of safety in job descriptions bedrock of safety in job descriptions

Hire for teamwork skills – ALL team membersHire for teamwork skills – ALL team members Deal with disruptive team membersDeal with disruptive team members Align physician and nurse codes of conductAlign physician and nurse codes of conduct Regularly train team and practical skillsRegularly train team and practical skills Commit to imbedding teamwork into the cultureCommit to imbedding teamwork into the culture

Bringing Surgeons into Bringing Surgeons into the Teamthe Team

Everyone feels frustrated and powerlessEveryone feels frustrated and powerless OR is now leaderlessOR is now leaderless MD as solitary craftsmanMD as solitary craftsman Anesthesia, prep and nursing as solitary Anesthesia, prep and nursing as solitary

craftsmencraftsmen

MDs are leaders, not just craftsmen – rise MDs are leaders, not just craftsmen – rise

to the occasion, control their environmentto the occasion, control their environment MD role is to provide leadership and create MD role is to provide leadership and create

a functioning teama functioning team

Our Experience – Success Our Experience – Success FactorsFactors

Have early and simultaneous MD training Insist on physician-to-physician training Separate MDs from the rest of the team initially Separate MDs from the rest of the team initially Start with an MD dinnerStart with an MD dinner Win them over one by oneWin them over one by one Emphasize the clinical and efficiency reasons to Emphasize the clinical and efficiency reasons to

communicatecommunicate Emphasize how briefs can solve nagging frustrations:Emphasize how briefs can solve nagging frustrations:

Travelers/tempsTravelers/temps Ill-timed breaksIll-timed breaks Interruptions and distractionsInterruptions and distractions Equipment issuesEquipment issues Respect for everyone’s critical timesRespect for everyone’s critical times

Use alpha dogsUse alpha dogs Spread MD testimonials of early successesSpread MD testimonials of early successes

Our Experience – Success Our Experience – Success FactorsFactors

Use tools for support:Use tools for support: White boardsWhite boards ObservationsObservations

Show support from the top and the middle

Exhibit dogged and determined leadership

Integrate the effort

Provide recurrent training

What you can do to What you can do to make this happen make this happen

tomorrowtomorrow

Provide leadership – it can come from Provide leadership – it can come from anywhereanywhere

Advocate for this – don’t give upAdvocate for this – don’t give up Hand out articles on the topicHand out articles on the topic Discuss the topic at managers’ meetingsDiscuss the topic at managers’ meetings Have a grand rounds or in-service on the Have a grand rounds or in-service on the

topictopic Consider how communication played a role in Consider how communication played a role in

every eventevery event Walk in and observe what’s going on nowWalk in and observe what’s going on now Introduce white boardsIntroduce white boards

What you can do to make this happen What you can do to make this happen tomorrowtomorrow

What you can do to make this happen What you can do to make this happen tomorrowtomorrow

Start small with a willing groupStart small with a willing group Use outsiders initially – aviation is sexy, engaging Use outsiders initially – aviation is sexy, engaging

and convincing and convincing Use physician trainersUse physician trainers Do briefsDo briefs Spread anecdotes of success – believer to non-Spread anecdotes of success – believer to non-

believerbeliever Develop “killer” item checklistsDevelop “killer” item checklists Stress function over formStress function over form Incorporate teamwork and communication into all Incorporate teamwork and communication into all

policies, job descriptions, by-lawspolicies, job descriptions, by-laws Be consistent in support of teamworkBe consistent in support of teamwork Commit to a coordinated approach – not just team Commit to a coordinated approach – not just team

trainingtraining

Does it Work?Does it Work?

AviationAviation

U.S. airline fatality rate U.S. airline fatality rate 1/5 th1/5 th of 1950 of 1950 No one died in a domestic airliner in 2002-No one died in a domestic airliner in 2002-

20042004

Operating Rooms

Preoperative brief results:

WSS decreased from 3 to 0 per year

Employee satisfaction increased 19%

Nursing turnover decreased 16%

Early resolution of equipment issues

Reduced delays in receiving equipment

Reduced case delay or cancellationsThe Permanente Journal Spring 2004 Vol 8 No 2 James DeFontes, MD, Stephanie Surbida, MPH

Medicine is a lot harderMedicine is a lot harder

These techniques can make it easier,

more efficient,

and safer

BibliographyBibliographyWhile there are increasing numbers of articles about the topic While there are increasing numbers of articles about the topic

of crew resource management (or team training) in the of crew resource management (or team training) in the health care literature, this is a quick list of several that may health care literature, this is a quick list of several that may help to persuade others:help to persuade others:

Bulletin of the American College of Surgeons Bulletin of the American College of Surgeons April 2007 April 2007 Vol 92 No 4 Page 16-22 “Staying Safe: Simple Tools for Vol 92 No 4 Page 16-22 “Staying Safe: Simple Tools for Safe Surgery” Karl RCSafe Surgery” Karl RC

The Permanente Journal The Permanente Journal Spring 2004 Vol 8 No 2 Spring 2004 Vol 8 No 2 “Preoperative Safety Briefing Project” James DeFontes MD “Preoperative Safety Briefing Project” James DeFontes MD and Stephanie Surbida MPHand Stephanie Surbida MPH

Journal of the American College of Surgeons Journal of the American College of Surgeons February 2007 February 2007 Volume 204 No. 2 “Operating Room Briefings and Wrong-Volume 204 No. 2 “Operating Room Briefings and Wrong-Site Surgery” Makary, Mukherjee, Sexton, Syin, et alSite Surgery” Makary, Mukherjee, Sexton, Syin, et al

British Medical JournalBritish Medical Journal March 18 2000 “Error, stress, and March 18 2000 “Error, stress, and teamwork in medicine and aviation: cross sectional surveys” teamwork in medicine and aviation: cross sectional surveys” Sexton JB, Thomas EJ, Helmreich RL Sexton JB, Thomas EJ, Helmreich RL

BibliographyBibliography

Journal of the American College of Surgeons Journal of the American College of Surgeons July 2007 July 2007 Vol 205 No 1 169-176 “Briefing and Debriefing in the Vol 205 No 1 169-176 “Briefing and Debriefing in the Operating Room Using Fighter Pilot Crew Resource Operating Room Using Fighter Pilot Crew Resource Management J McGreevey, MD, T Otten, BSManagement J McGreevey, MD, T Otten, BS

Academic Medicine March Academic Medicine March 2002 Vol 77 No 3 “Team 2002 Vol 77 No 3 “Team Communications in the Operating Room: Talk Patterns, Communications in the Operating Room: Talk Patterns, Sites of Tension, and Implications for Novices” Lingard, Sites of Tension, and Implications for Novices” Lingard, Reznick, Espin, Regehr, DeVitoReznick, Espin, Regehr, DeVito

American Journal of Surgery American Journal of Surgery 2005 Nov 190(5) 770-4 2005 Nov 190(5) 770-4 “Bridging the communication gap in the operating room “Bridging the communication gap in the operating room with medical team training” Awad SS, Fagan SP, Bellows with medical team training” Awad SS, Fagan SP, Bellows C, Albo D, Green-Rashad B, De la Garza M, Berger DHC, Albo D, Green-Rashad B, De la Garza M, Berger DH

Annals of Surgery Annals of Surgery May 2006 Vol 243 Issue 5 Page 628 May 2006 Vol 243 Issue 5 Page 628 “Patient Safety in Surgery” Martin A. Makary, MD, MPH; “Patient Safety in Surgery” Martin A. Makary, MD, MPH; J Bryan Sexton, PhD; Julie A. Freischlag, MD; E Anne J Bryan Sexton, PhD; Julie A. Freischlag, MD; E Anne Millman, MS; David Pryor, MD; Christine Holzmueller, Millman, MS; David Pryor, MD; Christine Holzmueller, BLA; Peter J. Pronovost, MD, PhDBLA; Peter J. Pronovost, MD, PhD

Richard C. Karl, MDRichard C. Karl, MD

Richard G. Connar Professor and ChairmanRichard G. Connar Professor and ChairmanDepartment of SurgeryDepartment of Surgery

College of MedicineCollege of MedicineUniversity of South FloridaUniversity of South Florida

Founder, Surgical Safety InstituteFounder, Surgical Safety Institute

Contributing Editor, Flying MagazineContributing Editor, Flying MagazineTampa, FLTampa, FL

Captain Robert HaynesCaptain Robert Haynes

Director of Flight Standards & Quality Assurance, Southwest AirlinesDirector of Flight Standards & Quality Assurance, Southwest AirlinesDallas, TXDallas, TX

What Can the Operating What Can the Operating Room Learn from the Room Learn from the

Cockpit?Cockpit?