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Opinions on Practice Management

June Robinson, MD

“Code Red: Left Side of Head”?

June Robinson

Friday, October 16, 2009

Team training among airline crew helped passengers survive the plane crash into the Hudson River, New York after a bird struck the airplane engine in 2009.1 Equally important, surgical team training is vital to avert potential problems when a split second of hesitation or a misunderstanding can result in injury or even death.

In 2000, the Institute of Medicine recommended team training programs to improve patient safety.2 Additionally in 2007, the Joint Commission prioritized improved communication as a patient safety goal among caregivers.3 Two major organizations have now designated team training as an important way to improve patient safety.

The Northwestern Memorial Hospital in Chicago, USA, initiated a team training program led by 40 trainers.4 The educational intervention was a 4 hour team-training class led by an operating room physician and a non-physician. Each of the 36 training classes were conducted with approximately 30 trainees.

The main goals of the training were to achieve the following:

  • Develop leadership expertise and mutual performance monitoring;
  • To create a shared mental model;
  • To emphasize individual accountability;
  • To learn how to create pre-operative brief and post-operative debrief formats; 
  • To develop standard communication techniques, such as which words to repeat, and;
  • To develop standard terminology to indicate severity of the condition if it escalates.

The program was assessed by hospital metrics for surgical cases performed in the operating room where patients were under general anesthesia. The assessment looked at issues such as:

  • Administration of drugs at the wrong side and/or site;
  • Timely administration of antibiotics, and;
  • Cases which started on time and turn-over time between cases.

In addition, the program looked at teamwork attitude surveys and intra-operative observation using a checklist which consisted of patient identification, time-out before the commencement of a procedure, and debrief performance.

Among the 1,150 people trained, 37% felt that pre-operative briefs helped reduce patient risk and reduced delays in starting cases.4 Additionally, operating room efficiency was enhanced as the number of 'on-time' starts of procedures increased. Of note, teamwork attitude improvement was greater among nurses than among surgeons. The errors observed during the procedures were improper patient positioning and lack of equipment availability. At the end of a 6-month observation period, there was decreased performance of pre-operative briefs.4 This shows that pre-operative briefs might not be sustainable because people do not receive frequent reinforcement by perceiving that a disaster could have been averted by working together as a team. While there are an insufficient number of "near misses" in order to determine if team training is effective, the institution is continuing the program.

How Can Team Training in a Dermatology Office be Beneficial?

Attitude of Team Members

There is an immediate benefit in the team members' attitudes. When you consider the time and effort that it takes to train a surgical assistant or other members of staff, dermatologists might choose to use any possible means to improve attitude in order to retain personnel. Reduction in turn-over time of procedure rooms could be a major benefit to the busy practice. Lastly, there is the possibility that performance of team training could reduce malpractice premiums just as office accreditation lowers liability insurance premiums.

Emergency Plan

Team training exercises might specify the phrases to be used in case of an emergency, such as when a fire occurs in a procedure room. For example, say a laser ignites an alcohol sponge left near the head of the patient. What do you say to alert staff to the flame?

"Code red: left side of head"?

The team needs to know what "code red" means as well as knowing that the location given is with respect to the patient's head and not the doctor's head. After staff are alerted, the laser is switched off, and the flames are smothered. What happens if the flames start to spread? Who calls 911? Who stabilizes the patient, escorts the patient from the procedure room, and makes the decision to continue to monitor the patient? Where is the nearest exit? Does the office staff know how to evacuate the exam rooms and the waiting area? Who makes a sweep of the office to be sure that everyone is out of the suite? Where do the staff and patients assemble outside the building?

Team training with someone assuming the role of the patient helps people review, practice, and execute the plan. A fire drill demonstrating how to use the fire extinguisher once a year is also important. For new members of staff, fire drill training should be part of the orientation. Other team training exercises could be developed around cardiac arrest, obstructed airway, and difficulty controlling bleeding (see Table 1 below).

Table 1. Suggestions for dermatology office safety.


Emergency drills for hazards such as fire or floods. Record the date and those in attendance. 
Review and modify patient post-operative care handouts.
Physicians should monitor the laboratory log. The log notes the day the specimen is submitted, results received and results provided to patient and recommended action. If a report is missing, action is taken.
Equipment maintenance logs with inspection notes shown on hang tags.
Review and modify the risk management program. 

The training program should include the following tasks to keep the office functioning smoothly every day: 

Common Patient Situations in the Office

Alleviating anxiety in the pre-operative patient, and escorting and calming the complaining patient from the premises out the side door rather than through the waiting room are two common events that are managed with as little "drama" as possible by the team working together to develop scenarios.  Role playing by members of the team can make the experience meaningful . Staff can share "tips" with each other. The staff and physicians on the receiving end of verbal abuse from angry patients might experience anxiety and this can be relieved by sharing their experiences, being comforted by others, and by having a good laugh.

Office Maintenance

Lastly, there are the necessary tasks that keep the office running. Who performs equipment checks? How frequently are large pieces of equipment maintained? Does the suction instrument have a hang tag with maintenance inspections noted?  Equipment that is rarely used and often stored in out of the way places is easily overlooked when performing routine maintenance. For instance the crash cart, which is tucked away in a closet, may be forgotten. When a patient has an acute allergic or vasovagal reaction, it is important for the team to react swiftly with a crash cart that contains diphenhydramine, epinephrine for subcutaneous injection, blood pressure cuff, stethoscope, intravenous needles, lines and fluids, glucometer. Where is the oral sugar bolus? Is the oxygen tank easily opened? Is the tank full? Are the staff trained in the use of these items and can the patient be placed in Trendelenberg position rapidly with the examination table? Has the team practiced using the crash cart? Who checks the expiration dates on the medications, replaces them, and affixes a sticker to the cart noting the date that the maintenance was performed?

Surgical instruments need routine maintenance by the person who cleans the instruments. Scissors need to be checked for sharpness by cutting a piece of paper without undue force or leaving jagged edges. Clamps need to have their tips checked for alignment during closing. The fluid movement of needle drivers can be preserved by hand-brushing debris from the lock boxes during cleaning.

Most of those who read this article will think that the office manager already does all of this. Perhaps it would be a good idea to ask the office manager to see the emergency evacuation plan. Have you ever participated in a team training session? If yes, then give yourself a pat on the back. If not, why not? The physician is an integral part of the team.

References

  1. Helmreich RL, Wilhelm JA. Outcomes of crew resource management training. Int J Aviat Psychol 1991:1(4):287-300.
  2. Institute of Medicine: Kohn LT, Corrigan JM, Donaldson MS, eds.  To err is human: building a safer health system. Washington, DC. National Academy Press; 2000.
  3. The Joint Commission National Patient Safety Goals. Accessed August 2009.
  4. Halverson AL, Andersson JL, Anderson K, et al. Surgical team training: The Northwestern Memorial Hospital experience. Arch Surg 2009;144:107-112.
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