after all, anesthesia is the profession in which we put our patients to sleep! is communication...
TRANSCRIPT
AFTER ALL, ANESTHESIA IS THE PROFESSION IN WHICH WE PUT OUR
PATIENTS TO SLEEP!
Is Communication Really Necessary?
By: Danielle Boggio, CRNA, MSA
Communication… What is it?
Definition of COMMUNICATION:
The imparting or exchanging of information or news. The act of transmitting thoughts, opinions, or information by speech, writing, symbols, signs or behavior.
“Everything becomes a little different as soon as it is spoken out loud.”
Hermann Hess
Famous Quote
Failed Communication in the OR
Communication failures are a well-characterized source of errors in the Operating Room.
A study by the Agency for Healthcare Research and Quality in 2011 used direct observation of surgical procedures to assess the incidence, types and consequences of surgical communication problems>>>
FAILURE to DISCUSS equipment problems and progress of the procedure were common, resulting in delays, inefficiency and medical errors.
Operating Room Communication
Teamwork training - All providers practice the same guidelines; Pre/Intra/Post Op Guidelines
Checklists - All providers use same check and balances; Surgical Safely Checklist
Universal Protocol: Time Out - All providers identify correct patient identity, correct site, procedure to be done.
Cockpit Checklists in Aviation
Aircraft checklists: Are regarded as the foundation for
guidance of standardization of many high-risk industries such as maritime transportation, nuclear industry, weapons systems, space flight and medical care.
Human factor professions: Are all at risk from several limitations in
humans such as culture of the environment, resource management and production pressures.
OR Check Procedures are similar to Aviation
The Check Procedures must include:
1. Each crew (team member) check for safety 2. This should be done before starting engines
(pre-op requirements/OR equipment and staff)
3. Take off Checks (induction and incision), 4. Landing Secured (extubation and closing) 5. Preparation for an event of engine and
system emergencies in place (patient instability, surgical complications, equipment failure)
Time Out - Before draping and skin incision
Introduction of people in ORConfirm patient, Surgical site and side,
Procedure and PositionMedications labeledNeed for Antibiotic/IrrigationImagesAvailability of implants, equipment, monitorsSafety Considerations: Blood products, X-Ray
protectionRelevant documentation: H&P, Pertinent
labs/medical conditions, Consents
Proper Time out requires Change in Culture
The Difficulty involves
1~ changing culture of hospitals and surgery centers
2~ getting doctors – who typically prize their autonomy, resist checklists and underestimate their propensity for error –
3~ to follow standardized procedures and work in teams
“To Err is Human”, 1999 in Institute of Medicine
Could have been prevented: >50% of adverse events resulted from preventable medical errors
Medical errors: up to 98,000 Americans die each year as a result of medical errors
Famous Quote
“Words should be used as tools of communication and not as a substitute for action”
Martin Luther King, Jr.
Case 1: Nasal Reconstruction
Patient: Female, 60 yo, 70kg, skin cancer, nasal defect
Surgery: Repair Nasal defect, booked 2.5 hrsSurgeon’s office contacted Anesthesia
department to change booking from general to MAC. Email sent to anesthesiologist and CRNA.
Anesthesiologist did pre-op with patient and discussed GETA. CRNA comes out and explains Anesthetic plan with Ologist, Patient and Surgical Team (including Otolaryngology Plastic Surgeon.
Case 1: Nasal Reconstruction Continued
Resident/fellow/attending confirms 2.5 hours and taking flap transfer, septum repair etc. GETA advised.
New Plastic attending comes in and ready for MAC, Nasal cannula, explains patient will be fine and walks away.
CRNA discusses with ologist and patient we will proceed with MAC
In OR team confirms 2.5 hours and they leave. MAC begins, case lasts 10minutes and all is well!
Case 2: HHT (Hereditary Hemorrhagic
Telangiectasia)
Patient: male, 47 yo, 250 lbs, HHT complicated by significant epistaxis. He underwent sphenopalatine ligation and control of epistaxis in right nasal passage, then re-bleeding 1 year later and had Youngs Procedure to completely occlude the nasal passage.
Surgery: Bronchoscopy to evaluate coughing up blood.
Case 2: HHT Continued
Anesthesia team had discussions about airway management with LMA vs ETTLMA: Potentially will not protect stomach/airway
if bleeding, suctioning is difficult, Less traumatic and may cause less bleeding, airway does not sit in trachea and therefore trachea can be evaluated
ETT: Potentially may cause more bleeding, case may be EUA and short time, may inhibit view of trachea, may assist with decreasing bleeding by pressure of tube, may be difficult airway and trauma may be induced.
Case 2: HHT Continued
Discussions between Surgical team, patient, wife, CRNA, Anesthesiologist.
Case was done with LMA, HOB elevated, bleeding immediately, suctioned, assisted ventilation, patient protected his own reflexes by coughing, procedure aborted. Patient safe.
Case 3: Breast Reduction
Patient 44 yo, 190 lb, h/o Asthma on several inhalers
Surgery Breast reduction
Pre-op: CRNA told pre-op was done by Anesthesiologist and it was a healthy patient with no medical issues. Surgeon and nurses rushing because room running late. No physical exam including pre-op assessment of breath sounds.
Case 3: Breast Reduction Continued
Intra-op:
~~ EMT trainee intubated: no discussion about airway confirmation and time out being done at same time
~~ Patient moved when folly catheter inserted: Rocuronium given.
~~ Patient desaturated : no communication ~~ Anesthesiologist treated with albuterol ~~ Assessed for leak, depth, BS, patient color…
Case 3: Breast Reduction Continued
Stat anesthesia help was called and it was noted that the ETT was not in the trachea, patient was re-intubated and case was held for reversal of non-depolarizer and case was cancelled.
GI Cases
Patient stated she sleeps 2 days after one beer. Scheduled for EGD, Propofol 100mg for 30 min EGD, Asleep for 4 hours in PACU, stumbled into car with assist.
Patient h/o Afib (successful ablation) and CVA, 60 yo, plays tennis. Scheduled for Colonoscopy, Propofol 200mg titrated and after scope pressure, abdominal pressure and air, patient had 4 episodes of asystole for 2 screens about 3-4 seconds.
Importance of OR Plan Communicated
Neuromuscular blockade –necessary or notLength of case – observing surgery progressSite of surgery (BP cuff, IV, pulse ox, ECG leads)Type of anesthetic discussion among teamsENT: use of scope at beginning or end of caseGI: anatomy, retroflex, cecum, NPO split prep,
cases out of order and wrong procedureOpthamology: Local anesthetic, block, type of
anesthesia surgeon requests vs anesthesia team Thyroplasty- need pt cooperation to speak
during pint in case: clarity, volume, pitch
$ Value of CRNA Communication
Billing Diagnosis and Surgery (ICD and CPT)Medical ModifiersStart/End timesPQRS: Physician Quality Reporting System
Payment adjustments Required to report Beta blockers for CABG sx,
prevention of catheter-related bloodstream infections and perioperative temperature management
Report at least one cost cutting measureMedicare Billing:
QK: Medical direction of up to 4 concurrent cases QZ: CRNA service: without medical direction
Sources
Agency for Healthcare Research and Quality Communication failure in the operating room. Halverson AL, Casey JT, Anderson J, et al. Surgery. 2011;49:305-316
Helath.belgium.be/internet2prd/groups/public/@acutecare/documents/ie2: Surgical Safety Checklist Time-out. Anesthesia Safety, Vancermeersch E. UZ Kuleuven
Human factors 35(2), pp. 28-43, Cockpit Checklists: Concepts, Design, and Use. Asaf Degani and Earl Wiener
www.asahq.org/resources/quality-improvement/physicians-quality-reporting-systems/2015-pqrs-faqs
How many die from medical mistakes in US Hospitals? Sept 20, 2013. Marshall Allen, Propublica, Shots Health News From NPR
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