The flip side of speaking up: a new model to facilitate positive responses to speaking up in the operating theatre.

BACKGROUND: Speaking up is important for patient safety, but only if the concern raised is acknowledged and responded to appropriately. While the power to change the course of events rests with those in charge, research has focussed on supporting those in subordinate positions to speak up. We propose responsibility also rests with senior clinical staff to respond appropriately. We explored the perceptions of senior staff on being spoken up to in the operating theatre (OT), and factors moderating their response. METHODS: We undertook interviews and focus groups of fully qualified surgeons, anaesthetists, nurses, and anaesthetic technicians working in OTs across New Zealand. We used grounded theory to analyse and interpret the data. RESULTS: With data from 79 participants, we conceptualise three phases in the speaking up interaction: 1) the content of the speaker's message and the tone of delivery; 2) the message interpreted through the receiver's filters, including beliefs on personal fallibility and leadership, respect for the speaker, understanding the challenges of speaking up, and personal cultural and professional norms around communication; and 3) the receiver's subsequent response and its effects on the speaker, the observing OT staff, and patient care. CONCLUSIONS: The speaking up interaction can be high stakes for the whole OT team. The receiver response can strengthen team cohesion and function, or cause distress and tension. Our grounded theory uncovers multiple influences on this interaction, with potential for re-framing and optimising the speaker/receiver interaction to improve team function and patient safety.

Sustaining multidisciplinary team training in New Zealand hospitals: a qualitative study of a national simulation-based initiative.

AIM: Healthcare is delivered by teams, but the training of healthcare staff is commonly undertaken in professional silos. This study investigated local perspectives on the sustainability of NetworkZ, a New Zealand national simulation-based multi-disciplinary operating room team training programme. METHOD: Local course instructors and managers were invited to participate in semi-structured interviews. Diffusion of innovations theory was utilised to frame deductive thematic analysis of interview data. RESULTS: Twenty-seven people participated. Interviewees described valuing NetworkZ for its multi-disciplinary orientation, in-situ delivery, scenario realism, relevance to teamwork and communication and potential for generalisability to other settings. Interviewees also identified NetworkZ as generating improvements in teamwork and crisis management. NetworkZ was described as complex, due to multidisciplinary participation and the multiple roles and skillsets of instructors needed to run simulations smoothly, making the programme resource intensive to deliver. CONCLUSION: NetworkZ is appreciated as a valuable and unique programme for developing important teamwork and communication skills. Its sustainability is dependent on adequate resourcing and funding.

Towards a safer culture: implementing multidisciplinary simulation-based team training in New Zealand operating theatres - a framework analysis.

AIM: NetworkZ is a simulation-based multidisciplinary team-training programme designed to enhance patient safety by improving communication and teamwork in operating theatres (OTs). In partnership with the Accident Compensation Corporation, its implementation across New Zealand (NZ) began in 2017. Our aim was to explore the experiences of staff - including the challenges they faced - in implementing NetworkZ in NZ hospitals, so that we could improve the processes necessary for subsequent implementation. METHOD: We interviewed staff from five hospitals involved in the initial implementation of NetworkZ, using the Organising for Quality model as the framework for analysis. This model describes embedding successful quality improvement as a process of overcoming six universal challenges: structure, infrastructure, politics, culture, motivation and learning. RESULTS: Thirty-one people participated. Structural support within the hospital was considered essential to maintain staff enthusiasm, momentum and to embed the programme. The multidisciplinary, simulation-based approach to team training was deemed a fundamental infrastructure for learning, with participants especially valuing the realistic in situ simulations and educational support. Participants reported positive changes to the OT culture as a result of NetworkZ and this realisation motivated its implementation. In sites with good structural support, NetworkZ implementation proceeded quickly and participants reported rapid cultural change towards improved teamwork and communication in their OTs. CONCLUSION: Implementation challenges exist and strategies to overcome these are informing future implementation of NetworkZ. Embedding the programme as business as usual across a nation requires significant and sustained support at all levels. However, the potential gains in patient safety and workplace culture from widespread multidisciplinary team training are substantial. Trial registration number ACTRN12617000017325.

Building the evidence on simulation validity: comparison of anesthesiologists' communication patterns in real and simulated cases.

BACKGROUND: Effective teamwork is important for patient safety, and verbal communication underpins many dimensions of teamwork. The validity of the simulated environment would be supported if it elicited similar verbal communications to the real setting. The authors hypothesized that anesthesiologists would exhibit similar verbal communication patterns in routine operating room (OR) cases and routine simulated cases. The authors further hypothesized that anesthesiologists would exhibit different communication patterns in routine cases (real or simulated) and simulated cases involving a crisis. METHODS: Key communications relevant to teamwork were coded from video recordings of anesthesiologists in the OR, routine simulation and crisis simulation and percentages were compared. RESULTS: The authors recorded comparable videos of 20 anesthesiologists in the two simulations, and 17 of these anesthesiologists in the OR, generating 400 coded events in the OR, 683 in the routine simulation, and 1,419 in the crisis simulation. The authors found no significant differences in communication patterns in the OR and the routine simulations. The authors did find significant differences in communication patterns between the crisis simulation and both the OR and the routine simulations. Participants rated team communication as realistic and considered their communications occurred with a similar frequency in the simulations as in comparable cases in the OR. CONCLUSION: The similarity of teamwork-related communications elicited from anesthesiologists in simulated cases and the real setting lends support for the ecological validity of the simulation environment and its value in teamwork training. Different communication patterns and frequencies under the challenge of a crisis support the use of simulation to assess crisis management skills.

Anaesthetic drug administration as a potential contributor to healthcare-associated infections: a prospective simulation-based evaluation of aseptic techniques in the administration of anaesthetic drugs.

OBJECTIVE: To evaluate the possibility that anaesthetists are administering potentially pathogenic micro-organisms to their patients. DESIGN: Prospective microbiological and observational study in a realistic simulated setting. PARTICIPANTS: Ten anaesthetists supported by 10 anaesthetic technicians. PRIMARY OUTCOME MEASURE: The presence or absence of organisms cultured from sterile intravenous bags used to collect drugs injected during the simulated cases and from the needles and the contents of the syringes used. The authors also observed the aseptic techniques used. RESULTS: Organisms were isolated from five of 38 (13%) bags from five of 20 simulated cases anaesthetised by four of 10 anaesthetists, 10 of 197 (5%) syringes and six of 17 (35%) needles. None of the anaesthetists washed their hands prior to entry, used the hand gel provided, disinfected the phial septa before drawing up drugs or disinfected the intravenous ports on the intravenous administration set before use. One was seen to recap a needle left on a syringe for possible reuse. Three participants were observed to place equipment such as stethoscopes, drug charts and pens on top of their inuse drug trays. CONCLUSION: The administration of intravenous drugs during anaesthesia may be an important factor in the genesis (or potentially the prevention) of healthcare-associated infection. These observations suggest room for improvement in the aseptic techniques of at least some anaesthetists when preparing and administering intravenous drugs. Confirmation of these findings in clinical settings is needed. STUDY REGISTRY NUMBER (FOR THE VASER STUDY): Australian New Zealand Clinical Trials Registry: Ref: ACTRN 12609000530224, https://www.anzctr.org.au/registry/trial_review.aspx?ID=308128; note that the work presented here is a subset of the registered trial and its outcomes were not included in this registration.

The effect of a simulation-based training intervention on the performance of established critical care unit teams.

OBJECTIVE: We evaluated the effectiveness of a simulation-based intervention on improving teamwork in multidisciplinary critical care teams managing airway and cardiac crises and compared simulation-based learning and case-based learning on scores for performance. DESIGN: Self-controlled randomized crossover study design with blinded assessors. SETTING: A simulated critical care ward, using a high-fidelity patient simulator, in a university simulation center. SUBJECTS: Forty teams from critical care units within the region comprising one doctor and three nurses. INTERVENTION: At the beginning and end of the 10-hr study day, each team undertook two preintervention and two postintervention assessment simulations (one airway, one cardiac on both occasions). The study day included presentations and discussions on human factors and crisis management, and airway and cardiac skills stations. For the intervention, teams were randomized to case-based learning or simulation-based learning for cardiac or airway scenarios. MEASUREMENTS AND MAIN RESULTS: Each simulation was recorded and independently rated by three blinded expert assessors using a structured rating tool with technical and behavioral components. Participants were surveyed 3 months later. We demonstrated significant improvements in scores for overall teamwork (p ≤ .002) and the two behavioral factors, "Leadership and Team Coordination" (p ≤ .002) and "Verbalizing Situational Information" (p ≤ .02). Scores for clinical management also improved significantly (p ≤ .003). We found no significant difference between simulation-based learning and case-based learning in the context of this study. Survey data supported the effectiveness of study day with responders reporting retention of learning and changes made to patient management. CONCLUSIONS: A simulation-based study day can improve teamwork in multidisciplinary critical care unit teams as measured in pre- and postcourse simulations with some evidence of subsequent changes to patient management. In the context of a full-day course, using a mix of simulation-based learning and case-based learnings seems to be an effective teaching strategy.

Analyser position for end-tidal carbon dioxide monitoring in a rebreather circuit.

INTRODUCTION: A diving rebreather currently nearing release incorporates an infra-red CO2 analyser at the end of the exhale hose and uses the expired gas CO2 measurement made at this position to detect hypercapnia. This configuration may allow exhaled anatomic and mouthpiece dead space gas to mix with alveolar gas in the exhale hose thus falsely lowering the CO2 measurement, especially at low tidal volumes. METHODS: A test circuit was constructed using a typical rebreather mouthpiece and exhale hose connected into an anaesthetic machine breathing loop. True end-tidal PCO2 was measured in gas sampled from the mouth and compared breath-by-breath to the PCO2 measured in gas sampled at the end of the exhale hose. Two subjects each completed 60 breaths at tidal volumes of 500, 750, 1000, 1500 and 2000 ml. RESULTS: There was a small (≤ 0.21 kPa) mean difference between true end-tidal CO2 and end-of-hose CO2 at tidal volumes of 1000 ml or more. However, at lower tidal volumes, the mean difference increased and, at 500 ml, it was 1.04 kPa and 0.70 kPa in subjects 1 and 2 respectively. CONCLUSION: Measurement of the peak exhaled PCO2 at the end of a rebreather exhale hose may provide a reasonable estimation of the true end-tidal CO2 at large tidal volumes, but may significantly underestimate the true end-tidal CO2 at low tidal volumes.