AHA: Strategies to improve safety during heart surgery

Among the biggest threats to patient safety during cardiac surgery are failures in teamwork and deficiencies in nontechnical skills such as communication, according to a statement written by an American Heart Association (AHA) committee. The group makes several recommendations for future research as well as ways to cultivate and maintain a “culture of safety.”

Although cardiac surgery has saved countless lives, in the years since the 1999 Institute of Medicine report that discussed ways to reduce preventable medical errors, “there is little evidence that much progress has been achieved in reducing or preventing errors,” wrote the committee, led by Joyce A. Wahr, MD, of the University of Michigan Medical Center in Ann Arbor. The report was published online Aug. 5 in Circulation.

The team reviewed evidence-based literature focusing on communication between members of the surgical team, the workspace and the operating room (OR) culture.

Several studies have found ineffective communication to be the most common cause of problems in the OR. Breakdowns during patient handoff were also frequent study findings, with most occurring during the preoperative and postoperative phases.

Data from one study, for example, found that only 30 percent of surgical information was communicated verbally, and it was mostly done by anesthesiology personnel.

Communication is only one of the “six ‘C’s,’” the authors explained, the others being cooperation, coordination, cognition—consisting of collective knowledge and mutual understanding—conflict resolution and coaching. Research has found communication to be the most problematic facet of teamwork.

“Formal handoff protocols should be implemented during transfer of the care of cardiac surgical patients to new medical personnel,” the committee recommended. Protocols should include timeouts, checklists, briefings and debriefings.

They also suggested formal teamwork training focused on improving communication, leadership and situational awareness involving all team members. In addition to staff training, there should also be future research that assesses the most effective communication models and what communication barriers exist as well as studies of the outcomes of new training.

There must also be changes to the OR culture in order to reduce disruptive behaviors—such as verbal outbursts, physical threats and refusal to perform job duties—and to eliminate the belief that surgeons deserve “hero” status.

“Local institutional policies that define disruptive behavior in medical professionals in all hospital settings should be implemented immediately, with transparent and formal procedures for addressing unacceptable behaviors and interventions to eliminate such behaviors,” they recommended.

Another vital part of the culture of safety is the utilization of quality improvement measures that continuously work to identify potential hazards and ways to eliminate them.

The physical makeup of the OR also impacts patient safety. If the room is too small or not organized well, there can be significant disruptions.

“Optimal OR design ensures standardization of the location of the head of the patient bed and surgical table, adequate space for equipment and staff movement, maintenance of focus on the patient, and use of technology to help workflow,” the authors wrote.

Noise levels and excessive traffic can be distracting and should also be controlled. Simulation scenarios and real-time testing can help determine the optimal OR design and layout.

The authors hope their work will lead to more research that will help improve patient safety, but they also hope future study will extend beyond cardiac ORs.

“Such research should be widely applicable to all ORs, as well as to interventional cardiology and electrophysiologoy procedural settings,” they wrote.