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Evidence-Based Nursing I.

Clinical Question How effective is the impact of operating room briefings on coordination of care and risk for wrong-site surgery? II. Citation Operating Room Briengs and Wrong-Site Surgery
Martin A Makary, MD, MPH, Arnab Mukherjee, BA, J Bryan Sexton, PhD, Dora Syin, BS,Emmanuelle Goodrich,MPH, Emily Hartmann, MSS, Lisa Rowen, RN, DScN, Drew C Behrens,Michael Marohn,DO, FACS, Peter J Pronovost, MD, PhD

III. Study Characteristics 1. Patients included There were 11 surgeons (7 general surgeons, 2 plastic surgeons, and 2 neurosurgeons) who agreed to implement briefings after 2 months of baseline data collection. A case-based OR SAQwas administered to OR staff, including physicians and nurses, at an academic medical center for 2 months before initiation of an OR briefing program. Sampling was not used because of small sample sizes of diverse caregiver roles in the OR, which would threaten the generalizability of the data. Instead, a high response rate was sought to capture the representative perceptions of each caregiver type in the OR. 2. Interventions compared We used a pre- and postdesign in which we measured perceptions of briefings and awareness of the surgical site and side for 5 months: we implemented ORbriefings for 3 months and then measured collaboration and awareness of surgical site and side for 2 months. We used a case-based version of the Safety Attitudes Questionnaire (SAQ, OR version) called the OR Briefing Assessment Tool (ORBAT), starting in May 2005. To assess OR briefings, we surveyed caregivers as they exited their first case of the day to capture the effectiveness of

care coordination and wrong-site surgery prevention during that case. The study site included the general operating rooms in an academic medical center. 3. Outcomes Monitored The prebriefing response rate was 85% (306 of 360 respondents), and the postbriefing responserate was 75% (116 of 154). Respondents included surgeons (34.9%), anesthesiologists (14.0%), and nurses (44.4%). Briefings were associated with caregiver perceptions of reduced risk for wrong-site surgery and improved collaboration [F (6,390) 10.15, p 0.001]. Operating room

caregiver assessments of briefing and wrong-site surgery issues improved for 5 of 6 items, eg, Surgery and anesthesia worked together as a well-coordinated team (67.9% agreed prebriefing, 91.5% agreed postbriefing, p 0.0001), and A preoperative discussion increased my awareness of the surgical site and side being operated on (52.4% agreed prebriefing, 64.4% agreed post briefing, p 0.001). 4. Does the study focus on a significant problem in clinical practice Yes, this study significantly aim to reduce perceived risk for wrong-site surgery and improve perceived collaboration among OR personnel. IV. Methodology/Design Survey questions were developed by generating a case based version of the SAQ teamwork and patient safety related items, which we have found to be associated with outcomes and error rates. The 17-question survey consisted of questions relating to the awareness and understanding of the surgical site, willingness to speak up when problems were perceived, and the quality of teamwork and communication between caregivers in the OR. Response options for each item ranged from 1 (disagree strongly) to 5 (agree strongly). The dependent variables were six survey questions related to briefings and wrong site operations: 1) A preoperative discussion increased my awareness of the

surgical site and side being operated on; 2) The surgical site of the operation was clear to me before the incision; 3) A team discussion before a surgical procedure is important for patient safety; 4) Team discussions are common in the ORs here; 5) Decision making used input from relevant personnel; and 6) Surgery and anesthesia worked together as a well-coordinated team. 6,9 The OR briefing is a tool to enhance communication among the OR team members and improve patient safety. Our 2-minute OR briefing includes 3 critical components: each member of the OR team states his or her name and role, the surgeon leads the time-out, as required by the Joint Commission on Accreditation of Healthcare Organizations to identify critical components of the operation, including surgical site, and the care teams discuss and mitigate potential safety hazards (Fig. 1). The staff was trained to perform the briefing after anesthesia was achieved and before incision. Using MANOVA, we tested for pre- and post-differences in responses to the six briefing and wrong-site surgery items on the ORBAT survey instrument. In addition to the response means compared with MANOVA, we also reported the percent agreement (agree slightly plus agree strongly) for items pre- and postOR briefings. All statistical analyses were performed using SPSS version 13.0 (SPSS Inc). V. Results of the study The prebriefing ORBAT response rate was 85% (306 of 360 respondents), and the postbriefing response rate was 75% (116 of 154). There were 422 total respondents, including surgical attending physicians (20.4%), surgical residents (14.5%), anesthesia attending physicians (9.5%), anesthesia residents (4.5%), certified registered nurse anesthetists (8.1%), scrub nurses (17.3%), circulating nurses (19%), medical students (3.8%), nurse assistants (1.0%), and other (2.0%) (Table 1). MANOVA of the six items yielded a significant omnibus F result. An omnibus F to test for changes in caregiver assessments, F (6,390)

10.15, p 0.001, indicated that OR caregivers assessed briefings and wrong-site surgery-related issues differently after the briefing intervention. OR caregiver assessments of briefing and wrong-site surgery issues improved for five of the six items: A preoperative discussion increased my awareness of the surgical site and side being operated on (52.4% agreed pre, 64.4% agreed post); The surgical site of the operation was clear to me before the incision (88.2% agreed pre, 96.6% agreed post); Surgery and anesthesia worked together as a well coordinated team (67.9% agreed pre, 91.5% agreed post); Decision making utilized input from relevant personnel (78.7% agreed pre, 89.6% agreed post); Team discussions are common in the ORs here (37.4% agreed pre, 48.3% agreed post). The only item that did not improve was, A team discussion before a surgical procedure is important for patient safety, for which responses were favourable both pre- and postintervention (94.0% versus 93.3%, respectively). Table 2 presents the means and confidence intervals for each of the six items pre- and post-groups, and Figure 2 presents the percent agreement and percent disagreement for each item pre- and post-intervention. VI. Authors conclusion/recommendations OR briefings significantly reduce perceived risk for wrong-site surgery and improve perceived collaboration among OR personnel. (J Am Coll Surg 2007;204:236243. 2007 by the American College of Surgeons) We recognize that there are some important limitations to this study. First, we used caregiver assessments of issues related to briefings and wrong-site operations on the ORBAT, rather than rates of wrong-site surgery. The six items reported here may not correlate with actual wrong-site operations. But scores on the SAQ are associated with important clinical and operational outcomes in the OR. Second, we used a pre- and postdesign without a control group, rather than a more robust randomized design, and this could introduce bias. Because nurses and anesthesiologists work with multiple surgeons, and the intervention required training of staff, we believed a randomized design was not feasible in this early

stage of the research, because teams would be contaminated with clinicians who were trained in briefings. VII. Applicability In the future, we can study the impact of briefings on caregiver attitudes related to teamwork and patient safety and care coordination behaviors. Briefings may be beneficial before bedside procedures are performed in the inpatient setting, or at the start of a day or shift to proactively plan for potential problems. Briefings before procedures may also be valuable in reducing adverse events in the outpatient setting. Although briefings are not a panacea for what ails care coordination in healthcare, they do have the potential to fill many of the gaps created by production pressures; staffing problems; high levels of acuity; and lack of familiarity with environments, people, or procedures.

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