According to recent estimates, roughly 350,000 to 500,000 patients undergo cardiac surgery each year. Thousands of patient lives have been saved or significantly improved with the advent of modern cardiac surgery. Studies demonstrate that mortality and morbidity for CABG surgery have decreased during the past decade. At the same time, however, the highly skilled and dedicated personnel in cardiac operating rooms (ORs) are human and will make errors. Studies show that about 12% of cardiac surgery patients will experience an adverse event, and about one-third of deaths associated with CABG operations may be preventable.
Efforts have been made to refine techniques, use advanced technologies, and enhance the coordination of care to improve cardiac surgery outcomes. Studies assessing the impact of these interventions on patient safety have suggested that little progress has been made in reducing or preventing errors. “It appears that preventable errors are often not related to failures in technical skills, training, or knowledge,” says Joyce A. Wahr, MD. “Instead, they typically represent cognitive, systematic, or teamwork failures. Communication, cooperation, coordination, and leadership among physicians are critical non-technical components that deserve greater emphasis.”
A Scientific Statement
In 2013, the American Heart Association (AHA) commissioned a scientific statement to summarize the evidence regarding risks to patient safety and clarify interventions that can help reduce perioperative risks and human error in cardiac surgery. The statement involved clinicians from key cardiac surgery specialties, including surgeons, anesthesiologists, nurses, and others. The comprehensive review focuses primarily on the human, environmental, and cultural factors that affect teamwork. In particular, it addresses how cardiac surgery teams can enhance communication within the OR and with other unit teams.
“Breakdowns in teamwork are exceedingly common and can lead to disruptions,” explains Dr. Wahr, who was co-chair of the AHA scientific statement. “These disruptions may be minor, but they do accumulate and can increase technical errors and adverse patient outcomes. The majority of flow disruptions are related to teamwork failures. Minor events in cardiac surgical procedures reduce the team’s ability to recover from major events. In short, little things matter.”
Several approaches to improving communication are emphasized throughout the AHA’s scientific statement, including checklists, preoperative and postoperative briefings, and team training in communication skills, but these are rarely used (Table 1). “Communication skills have been measured as the worst aspect of teamwork behavior in the OR,” says Dr. Wahr. “To improve teamwork, OR teams should use checklists and/or briefings and debriefings in every cardiac surgery case. These teamwork tools have been shown in trials to reduce operative mortality.”
“Concerted, organized efforts are needed to enhance patient safety and quality of care.”
The AHA statement also recommends training to improve communication, leadership, and situational awareness involving all members of the cardiac OR team. “Formal handoff protocols for transfer of cardiac surgical patients are also important,” Dr. Wahr says. “Ultimately, efforts are needed to improve information flow and avoid the omission or misinterpretation of data. Studies have showed us that formal training in teamwork improves communication skills and translates into better patient outcomes.”
Other key areas to improving care in the cardiac OR are enhancing the physical design of the OR and encouraging an organizational culture of safety. According to the AHA statement, many cardiac ORs have poor ergonomics, which can result in hazards for both patients and staff (Table 2). Studies suggest that noise levels are also an important consideration because a combination of music, alarms, and multiple conversations can be hazardous. Small, crowded rooms can increase the risk of OR personnel tripping over equipment or power cords.
“Concerted, organized efforts are needed to enhance patient safety and quality of care,” says Dr. Wahr. “More studies are needed to determine how cardiac ORs can cut down on distractions and improve clinicians’ ability to integrate knowledge from multiple sources.” She notes that an innovative area of future studies may be to find ways to avoid expensive design errors and test optimal OR design and layout.
More research is needed to assess interventions intended to enhance communication within the cardiac OR. For now, teams should focus on implementing those interventions that have been shown to be effective, such as team training and operative briefings. “In addition, institutions throughout the country should develop policies that define disruptive behaviors,” says Dr. Wahr. “There is a need for transparent, formal procedures that address unacceptable behaviors and promote an institutional culture of safety. By establishing quality improvement systems with input from all team members, we’ll hopefully identify the hazards and fix them accordingly.”