OR Briefings Reduce Surgical Errors, Improve Outcomes

Norra MacReady

July 11, 2014

A preoperative briefing lasting 2 minutes or less improves safety and communication in the operating room (OR) and reduces delays by more than 80%, say the authors of a new review.

Briefings and debriefings can improve teamwork in the OR, lead author Caitlin W. Hicks, MD, and colleagues write in an article published online July 9 in JAMA Surgery. Several prospective studies have shown that "[u]se of preoperative briefings improves team communication, decreases disruptions to surgical workflow, improves compliance with antibiotic and deep vein thrombosis prophylaxis, and improves overall perceptions about the safety climate in the OR." Teamwork training also was associated with an 18% mortality reduction compared with a 7% reduction among sites that did not receive this training, according to a recent analysis conducted at Veterans Administration facilities. In another study cited by the authors, the annual decline in surgical morbidity was 20% greater after the staff underwent teamwork training compared with teams that were not trained.

Preoperative briefings consist of more than just the standard preoperative time-out, Dr. Hicks, from the Department of Surgery, Johns Hopkins University, Baltimore, Maryland, and coauthors write. "In a briefing, team members introduce themselves by name and role; a traditional time-out is performed; and then a formal review by the anesthesiological, surgical, and nursing staff is performed." It may sound time-consuming, but effective briefings can be accomplished in less than 2 minutes.

One of the biggest challenges to establishing a routine briefing is making it compatible with the hospital culture: local workflows often must be changed, and expectations of interactions among OR team members must be adjusted to accommodate the briefing. The hospital's preexisting culture of safety also plays an important role. Checklists are essential to the briefing process, but their greatest benefit is seen in units that already have a high safety culture. "This indicates that, not surprisingly, the degree to which staff value and prioritize the briefing and debriefing process influences how effective it is," the authors write. Some units will require training and reinforcement on the value of briefings and debriefings to strengthen their culture of safety. Consistent support from clinical and administrative leaders also is essential to making briefings and debriefings a permanent part of the OR routine.

At Johns Hopkins, the authors recently introduced an OR comprehensive unit-based safety program (CUSP) in the colorectal suite as part of an effort to reduce surgical site infections and improve OR culture and teamwork. "The goal of CUSPs is to educate providers on the science of safety and then empower, with the support of hospital leadership, frontline staff to identify and address preventable harm," they write.

Using evidence-based practices, the team charged with developing the CUSP, consisting of nurses, surgeons, technicians, anesthesiologists, and certified registered nurse anesthetists, created a colorectal CUSP briefing checklist tailored to patients undergoing colorectal surgery. For example, the checklist has a section on steroid coverage as part of the preoperative time out. Also, during the briefing and debriefing, team members are encouraged to note any defects that might have affected the success of the case. Each week, a frontline nurse, supported by a nurse manager and an administrator, spends 4 to 6 hours reviewing and correcting the defects and communicating the results to the team members. As a result of these measures, the team was able to improve their procedure for isolating dirty surgical instruments used for bowel anastomosis, thus reducing the risk for surgical site infections.

Effective briefings and debriefings enhance OR safety and may be associated with better patient outcomes, the authors conclude. "Commitment by the participating providers is essential for effective briefings, which include discussion of relevant information pertaining to the procedure."

The authors have disclosed no relevant financial relationships.

JAMA Surg. Published online July 9, 2014. Full text

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