1. 1 Utilization of Operating Room Simulation and Debriefing to Enhance Surgical Resident Participation in the Surgical Timeout Checklist Edward Dominguez MD FACS Riverside Methodist Hospital, Columbus, OH Center for Medical Education and Innovation

2. 2 Introduction  Surgical timeout checklist is a key component of patient safety –Encourages communication –Verifies recommended practices –Proven decreased morbidity and mortality  Agency for Healthcare Research and Quality recently identified Top 10 patient safety strategies –“preoperative and anesthesia checklists” »Ann Internal Med 2013

3. 3 What is the Surgical Resident’s Role in the Surgical Timeout Checklist?  In teaching hospitals residents often have a diminished role  Reliance on attendings and other staff members  Preoccupation on other aspects of the case  “Passive participation”

4. 4 Operating Room Simulation  Platform for residents to become comfortable with technical and nontechnical aspects of patient care  Objectives can be defined  Errors are “allowable”  Video Review  Lends itself toward debriefing opportunities

5. 5 Debriefing and Simulation  Encourages time for reflection of performance  Critiques allowable errors  Feedback from participants  Time consuming and requires commitment

6. 6 Purpose of the Study  In this pilot study does utilizing a simulated, fully staffed operating room and debriefing alter behaviors of surgical residents toward the surgical timeout?

7. 7 Methods Simulated operating room at the Center of Medical Education and Innovation at Riverside Methodist Hospital, 2009-2010 academic year Arranged as standard setup for laparoscopic cholecystectomy

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9. 9 Operating Room Team  Surgical Resident as “Attending”  Board Certified Anesthesiologist  Certified Scrub Technician  Board Certified Operating Room Nurse as circulator  “Control room” team behind the scenes

10. 10 Resident Participants  Eleven General Surgery Residents (N =11) –PGY 1-3 = 7 –PGY 4-5 = 4  All signed informed consent for participation as reviewed by the IRB

11. 11 Scenario  Residents briefed on scenario prior to entering the OR –Laparoscopic cholecystectomy –Perioperative requirement of Beta blocker  Gowned and gloved by nursing staff  Video recording begins

12. 12 Surgical Timeout Checklist  Initiated by circulator nurse as per our institution standard “universal checklist”  Purposely incomplete  Patient’s identity (1), age (2), procedure (3), position (4) and antibiotic administration (5)  Omitted verifying sequential compression devices (SCDs) (6), beta blocker administration (7)and whether the team was ready to begin (8)

13. 13 Scenario  Laparoscopic cholecystectomy  Non technical aspects  Communication techniques

14. 14 Debriefing Session  One on one with resident and faculty investigator  Video review of the individual’s session  Errors and omissions reviewed  Communication critiqued  “What went well?”  “What did not go well?”

15. 15 Post Debriefing Scenario  Repeated weeks to months following the first session  Same scenario and timeout checklist  Also video recorded

16. 16 Video Observation Research Team Surgeon Hospital Patient Safety Officer Operating Room Nurse Statistician Medical Researcher Blinded to PGY level Videos randomized so pre or post debriefing was not identifiable

17. 17 Video Scoring Research team scored timeout portion of sessions based on completeness Scoring system – 8 items on checklist – 0 points if omitted – 1 point if incomplete – 2 points if completed correctly Scored data analyzed using the Wilcoxon sign rank test

18. 18 Results p = 0.003 Notes: Scores based on: 0 = not at all, 1 = incomplete, 2 = complete Total Score on 8 questions: range 0 - 16 Analyses based on the Wilcoxon sign rank test

19. 19 Results p = 0.017 p = 0.066 Notes: Scores based on: 0 = not at all, 1 = incomplete, 2 = complete Total Score on 8 questions: range 0 - 16 Analyses based on the Wilcoxon sign rank test

20. 20 Results  For all resident levels significant improvement was demonstrated in the areas of verifying: –Patient position (p=0.008) –Perioperative beta blocker administration (p=0.002) –Sequential compression devices (p=0.005)

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22. 22 Discussion  In this pilot study, utilization of a simulated surgical scenario and video debriefing facilitated resident’s involvement as active participants in the surgical timeout checklist verification and completion when items were specifically omitted

23. 23 Simulated Operating Room Team  Board certified anesthesiologist  Board certified nurse  Clinical surgical scrub technician  Simulation technicians in control room  Generated a productive anxiety from the residents

24. 24 Video Observational Research Team  Surgeon, operating room nurse, hospital patient safety officer, statistician, medical researcher  Blinded to PGY level  Blinded to pre or post debriefing  Broader view and opinion of what is considered appropriate communication in the OR

25. 25 Resident Communication the in OR  Our focus was on specific resident communication by the resident and not by the team  Resident to attending communication failure is a significant source of medical malpractice  Simulation may be a platform for practice of communication skills

26. 26 Did These Simulations Make a Clinical Difference?  Hard to know for sure  Anecdotally, YES!  Feedback from OR nurses regarding resident communication in the OR was revealing

27. 27 Resident Feedback  Anonymous evaluations of the simulation collected by the research staff were very positive  One on one debriefing –“Do I really sound like that?” –“I need to be more vocal in the operating room and be more of a team leader”

28. 28 Weaknesses  Very small group of resident participants  Times between simulation and debriefing varied based on resident schedule  Not all aspects of the surgical timeout were evaluated

29. 29 What We Learned From This Operating Room Simulation  Buy-in from hospital staff is crucial  Be prepared for scheduling conflicts  If an operating room team is assembled make it count (i.e. have a series of experiences for the learners, have multiple learners available)  Ask the residents about the experience  Ask your clinical staff about observed changes in behavior or communication post simulation

30. 30 Special Thanks  Video Observational Research Team –William D. Watson, MD FACS –Kathy Crea, Pharm D –John Elliott, MPH –Karen Hoffman, RN