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Corresponding author. Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, One Brigham Circle 1620 Tremont Street, 4-020, Boston, MA 02120. Tel.: +1 617 525 7300; fax: +1 617 525 7723.
Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MassachusettsBrigham and Women's Hospital, Division of Trauma, Burns and Surgical Critical Care, Boston, MassachusettsAriadne Labs, Boston, Massachusetts
Emergency general surgery (EGS) is characterized by high rates of morbidity and mortality. Though checklists and associated communication-based huddle strategies have improved outcomes, these tools have never been specifically examined in EGS. We hypothesized that use of an evidence-based communication tool aimed to trigger intraoperative discussion could improve communication in the EGS operating room (OR).
Materials and methods
We designed a set of discussion prompts based on modifiable factors identified from previously published studies aimed to encourage all team members to speak up and to centralize awareness of patient disposition and intraoperative transfusion practices. This tool was pilot-tested using OR human patient simulators and was then rolled out to EGS ORs at an academic medical center. The perceived effect of our tool's implementation was evaluated through mixed-methodologic presurvey and postsurvey analysis.
Results
Preimplementation and postimplementation survey-based data revealed that providers reported the EGS-focused discussion prompts as improving team communication in EGS. A trend toward shared awareness of intraoperative events was observed; however, nurses described cultural impedance of discussion initiation. Providers described a need for further reinforcement of the tool and its indications during implementation.
Conclusions
Use of a discussion-based communication tool is perceived as supporting team communication in the EGS OR and led to a trend toward improving a shared understanding of intraoperative events. Analyses suggest the need for enhanced reinforcement of use during implementation and improvement of team-based education regarding EGS. Furthermore work is needed to understand the full impact of this evidence-based tool on OR team dynamics and EGS patient outcomes.
In 2010, emergency general surgery (EGS) adult hospital admissions composed 8.1% of total hospital admissions nationwide, with estimated costs of EGS hospitalizations during that same year reaching $28 billion.
Following adjustment for patient-specific factors, EGS patients remain 31% more likely to experience a major postoperative complication and are 39% more likely to die than those undergoing the same procedure electively.
Improved understanding of contributory factors and corresponding targeted quality interventions aimed to address the disparities by which EGS is presently characterized are urgently needed.
Breakdowns in communication between operating room (OR) team members are associated with adverse surgical events and postoperative malpractice claims.
Use of the World Health Organization (WHO) surgical safety checklist (SSC) has improved multidisciplinary communication practices, provider perceptions of surgical safety, and has reduced rates of morbidity and mortality in a variety of surgical settings.
Safe Surgery Saves Lives Study Group. Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention.
Derived from principles first studied in the airline industry, the checklist tool is aimed to enhance team completion of critical tasks, which might increase risk or be deadly if missed, at junctures where detection of omission is still possible.
Through further study, the WHO SSC has been tailored to fit the specific needs of several medical specialties, inclusive of obstetrics and vascular surgery, to good effect.
Identification of patient safety improvement targets in successful vascular and endovascular procedures: analysis of 251 hours of complex arterial surgery.
In conjunction with checklist tools, team huddle strategies, which are purposeful exchanges of information intended to be used at any point in the continuum of patient care, have been shown to enhance communication between providers of varied disciplines.
Neither of these tools, which have advanced modern patient safety practices, has been explicitly examined in EGS.
In this study, we sought to develop and implement an evidence-based surgical safety communication tool aimed at encouraging the use of huddle strategies centered on identified modifiable factors associated with EGS patient outcomes for use in the operative care of the EGS patient. The intent of this work was not to replace the existing WHO SSC in the EGS OR; instead, we sought to enhance it by introducing points aimed to enhance multidisciplinary team discussion regarding points key to patient safety in EGS. We intended not only to create an easy-to-use tool but also to render it readily reproducible for use in a variety of hospital settings. Ultimately, by encouraging use of an intervention targeted toward communication, we aim to improve EGS outcomes.
Material and methods
We created and tested a communication tool targeted toward the care of EGS patients through three phases of work (Fig. 1): identification of modifiable huddle points, pilot testing of our developed preliminary adjunct, and subsequent implementation of the tool into the OR. All elements of this project were approved by the Partners Healthcare institutional review board.
Fig. 1Phases of communication tool development and implementation. (Color version of figure is available online).
Phase 1: identification of evidence-based modifiable huddle points
To develop huddle points relevant to the care of EGS patients, modifiable factors linked to EGS patient outcomes were identified through literature review and separate, previously published, quantitative and qualitative analyses.
Explaining the excess morbidity and mortality of emergency general surgery: packed red blood cell and fresh frozen plasma transfusion practices are associated with major complications in nonmassiely transfused patients.
Identified huddle points were validated through review by an expert panel of nine acute care surgeons.
Phase 2: pilot testing of preliminary communication tool
The feasibility of our tool's use in an OR setting was tested through development of a simulation-based curriculum. Training sessions were held at the Simulation, Training, Research, and Technology Utilization System Center for Medical Simulation at Brigham and Women's Hospital from April through November 2016. Each training session aimed to simulate a true EGS OR and thus was composed of a team of at least one anesthesiologist, nurse, and surgeon. Participants were recruited through emails directed at all OR staff active in the care of EGS patients; willing participants were scheduled based on availability.
At the commencement of each training session, participants were surveyed using questions from the International Personality Item Pool (IPIP) for the purpose of gauging preexisting attitudes on team performance and predisposition to speak up in the instance of concern.
(Appendix A). Participate responses are scaled in five-point Likert fashion (1 = strongly disagree, 2 = moderately disagree, 3 = neither agree nor disagree, 4 = moderately agree, 5 = strongly agree); a total maximum score for the 13 scaled questions posed to participants is 65. A single additional question regarding professional discipline was asked; no further demographic information was examined. Validation of our survey was performed through additional consultation of our panel of acute care surgical providers. Following completion of the preexercise survey, participants then underwent a simulation-based exercise in which unexpected surgical bleeding was encountered. Following this first exercise, participants were given the opportunity to debrief and then participated in an interactive teaching session. An introduction to EGS, inclusive of the conditions and disparate outcome rates by which it is defined, was presented along with the tool itself.
A second simulation event followed, offering participants to apply the communication tool to a clinical exercise in which a patient's clinical status abruptly changes while on the OR table. Following the second case, a debriefing was performed and participant's feedback was solicited with regard to clarity of teaching presentation, perceived risks or benefits, potential barriers to use, and how use of the huddle points would fit into existing work flows. The teaching curriculum was modified based on feedback from each simulation session. Following this debriefing, posttraining surveys including questions from the IPIP along with questions aimed to identify perceived barriers to checklist-adjunct application in the true OR setting were administered (Appendix B). Each participant was assigned a deidentified study number that allowed for matched analysis of pretraining and posttraining survey data. Survey data collected underwent response frequency analysis, t-testing for comparison of response means, and Wilcoxon rank sum and Kruskal–Wallis testing to examine for response differences within and across professional disciplines, respectively. Alpha level was set at 0.05. All computations for this phase of work were made using STATA 14 by STATA Corp College Station, TX.
Phase 3: implementation: introduction of the EGS communication tool and team huddle strategy into the OR
Following pilot testing, the EGS communication tool was implemented into all 43 OR's at our institution. The teaching curriculum developed during pilot testing was presented at anesthesia, nursing, and surgical grand rounds, with the intent of familiarizing all relevant staff with the huddle points and indications for adjunct use (specifically, for use in every EGS case booked to the OR either emergently or urgently; elective cases were not included). In addition to identification of participants' professional discipline, preimplementation and postimplementation surveys based on the IPIP scales were developed, with the aim of assessing attitudes regarding intraoperative communication practices, perceptions of tool utility, and intraoperative patient status awareness in five-point Likert scale format (1 = strongly agree, 2 = moderately agree, 3 = neither agree or disagree, 4 = moderately disagree, 5 = strongly disagree). These surveys were validated by an expert panel of nine acute care surgeons. Further demographic information was not sought. One month before checklist-adjunct posting, preimplementation surveys were distributed in hard copy form and via email to all EGS staff (Appendix C). Following closure of this survey, the huddle points were physically posted on the OR wall, next to the WHO SSC, in each OR. A wash-in period of approximately 6 wks was issued to ensure ample opportunity for staff practice with the checklist; wash-in was continued until checklist compliance was reported to be at a target level of 80%. During this time period, following each EGS case that was booked under emergent or urgent status (elective cases were excluded), an email was sent to the surgical team to assess for communication tool use; qualifying cases were identified through classification previously defined by the American Association for the Surgery of Trauma Committee on Severity Assessment and Patient Outcomes.
Then, for a period of approximately 9 wks, following each EGS case that occurred, a survey link was sent via email to each assigned provider, including staff and trainee anesthesiologists, nurses, and surgeons (Appendix D). In addition to IPIP-based and communication tool-specific questions, five open-ended questions were added to the postimplementation survey to assess for perceived barriers to the tool's use and to offer participants the opportunity to describe how the tool might be improved. With the exception of professional discipline, all data were deidentified to preserve participant anonymity. Convergent parallel analyses were performed for mixed-methods evaluation of survey implementation. Quantitatively, frequency analysis was used for descriptive statistics within and across disciplines; Kruskal–Wallis testing with post hoc Dunn testing was employed for analysis of response differences between professional disciplines. Alpha level was set at 0.05. Qualitative grounded theory was used to analyze the open-ended components of this survey. Once all surveys had been completed, open-ended data were iteratively coded and analyzed within and across question responses to consensus by two members of our research team (A.B.C. and M.C.A.) to identify collective emergent themes. All computations for the quantitative components of this work were made using STATA 14 by STATA Corp., College Station, TX. Qualitative analysis was aided through the use of Atlas.ti by Atlas.ti Scientific Software Development GmbH.
Results
Phase 1
The results of our analyses revealed significant differences in team members’ reported awareness of preoperative patient status and planned postoperative disposition, in spite of strong consensus that consistent, interdisciplinary communication is essential in the care of EGS patients.
Explaining the excess morbidity and mortality of emergency general surgery: packed red blood cell and fresh frozen plasma transfusion practices are associated with major complications in nonmassiely transfused patients.
These results, reviewed in the context of a growing body of literature regarding the importance of a shared, multidisciplinary understanding of patient status in the prevention of adverse perioperative complications, led to the identification of speaking-up behavior, blood product transfusions, and patient disposition (post-anesthesia care unit or intensive care unit) as targets for inclusion in the checklist adjunct.
Explaining the excess morbidity and mortality of emergency general surgery: packed red blood cell and fresh frozen plasma transfusion practices are associated with major complications in nonmassiely transfused patients.
These results represent critical, modifiable factors in EGS patient care and served as the key points on which our communication tool was built.
Our brief communication tool was designed to standardize communication practices within EGS. Just before surgical incision, in addition to use of the standard WHO SSC, EGS teams are directed to verbally acknowledge if the case is classified as EGS and to state the anticipated postoperative disposition of the patient. Multidisciplinary team members are additionally empowered to call a team huddle for discussion of any concerns for changes in patient safety, inclusive of suspected indication for blood product transfusion, and a change in patient status that might alter anticipated disposition. (Fig. 2).
Fig. 2EGS communication tool. (Color version of figure is available online).
A total of 19 participants were trained in seven pilot sessions (seven surgeons, four anesthesiologists, and eight nurses). In the event of a specialty's absence, a member of our research team played the role of that discipline to enhance authenticity of the OR environment.
Survey data were collected only from recruited participants. Analysis of our collected survey data revealed that, regardless of specialty, our participants exhibited above average IPIP scores on both their pretraining and posttraining surveys (Presurvey mean score 50.68, postsurvey mean score 51.08, P = 0.257), indicating a predisposition toward speaking out behavior that was unchanged by training. After training, participant responses demonstrated an increase in perceived bravery (P = 0.049) and trended toward a likelihood to take control (P = 0.05). After training, 94.7% of participants either agreed or strongly agreed that the EGS communication tool was easy to use, would improve communication in the EGS OR, and ought to be implemented into the EGS OR, with no differences appreciated between professional disciplines (Table 1).
Table 1Training results.
Statement: the EGS checklist…
Strongly disagree or disagree
Neutral
Strongly agree or agree
% Strongly agree or Agree
Interdisciplinary P value
Is easy to use
0
1
18
94.7%
0.512
Will help improve communication between OR team members
A total of 103 preimplementation surveys were collected over a period of approximately 7 wks (January 23, 2017-March 23, 2017): 42 surgeons, 38 anesthesiologists, and 23 nurses responded with an overall response rate of 20% (77 surgeons, 269 Anesthesiologists, 168 nurses) (Table 2). Central tendency analyses indicated that participants perceived team communication as essential in EGS patient care. Participants reported SSCs to be helpful and nonobstructive in the OR and, across disciplines, participants reported that they were empowered to speak up in regard to concerns regarding patient safety to all other team members. When asked to scale awareness of changes in patient disposition status during EGS cases, a significant difference was found to exist between professional disciplines (P = 0.05), with post hoc analysis revealing anesthesiologists reporting themselves as more aware than surgeons (P = 0.008). Regarding reported awareness of intraoperative blood product transfusion during EGS cases, a significant difference was appreciated between professional disciplines (P < 0.0001). Post hoc analyses revealed significant differences between all three professional disciplines, with surgeons describing themselves as less aware than either anesthesiologists or nurses (surgery versus anesthesia P < 0.0001, surgery versus nursing P = 0.004, anesthesia versus nursing P = 0.0009) (Table 3). There were no differences appreciated amongst respondent training levels.
Table 2Preimplementation and postimplementation cohorts.
Forty qualifying EGS cases were performed during the wash-in period. Fifty four percent of these cases were booked emergently. An overall EGS communication tool compliance rate of 72.5% was recorded increasing from 63% during first half of the wash-in period to 86% during second half. A 100% compliance rate was observed during the last week of wash-in (Fig. 3).
Fig. 3Checklist implementation compliance rates: from wash-in to postimplementation. (Color version of figure is available online).
A total of 81 postimplementation surveys were collected over a period of approximately 9 wks (March 24-May 30, 2017). Forty eight EGS cases, 50% of which were booked emergently, were tracked during this time period (Appendix E). Surveys were collected from 22 surgeons, 31 anesthesiologists, and 28 nurses (Table 2). Reported postimplementation communication tool use rate was 67.5% (Fig. 2). A majority of respondents either strongly or moderately agreed that use of the EGS communication tool improved team communication in EGS cases (87.34%) with no significant differences detected across professional disciplines (P = 0.44). 66% of respondents reported experiencing no barriers to communication tool use.
After implementation, participants continued to report that they felt empowered to speak up with concerns regarding patient safety to all other team members with a notable trend toward assimilation in perceived empowerment between professional disciplines (Pre: P = 0.25 post: P = 0.98, Δ = 0.73). Following introduction of our tool in the OR, surgeons reported themselves to be significantly more empowered to speak up than before implementation (Premean: 1.64, postmean 1.27 P = 0.05). Responses from anesthesiologists (Premean: 1.47, postmean 1.31, P = 0.70) and nurses (Premean: 1.56, postmean: 1.30, P = 0.65) indicated a similar tendency toward improved empowerment.
In regard to reported intraoperative awareness of changes in patient disposition, a difference was again appreciated between professional disciplines postimplementation, (P = 0.05). Post hoc analysis revealed the significant difference to be between anesthesia and nursing (Anesthesia versus nursing P = 0.007), with nurses reporting themselves as less aware of a change in patient disposition. The previously appreciated difference between surgery and anesthesia was eradicated postimplementation, (Post hoc surgery versus anesthesia P = 0.15) suggesting an improvement in the shared understanding of intraoperative events between surgeons and anesthesiologists. While there was no statistically significant difference appreciated, surgeons' (Premean: 2.4, postmean: 1.96, P = 0.10) and anesthesiologists' (Premean: 1.89, postmean: 1.77, P = 0.84) responses indicated an improved awareness of patient disposition changes postimplementation, while nurses’ responses indicated a trend toward decreased awareness (Premean: 2.12, postmean 2.52, P = 0.22).
After implementation, continued interdisciplinary differences were also appreciated in regard to reported awareness of intraoperative blood product transfusion during EGS cases (P <0.0001). Post hoc analyses revealed significant differences between anesthesia and both surgery (Anesthesia versus surgery P ≤ 0.0001) and nursing (Anesthesia versus nursing P = 0.002), with surgeons and nurses reporting themselves less aware of intraoperative blood transfusion than their anesthesiologist colleagues. After implementation, there existed no reported difference in blood transfusion awareness between surgeons and nurses (Surgery versus anesthesia P = 0.09), suggesting an improvement in a shared understanding of intraoperative events. Surgeons' (Premean: 2.45, postmean: 2.14, P = 0.31) and anesthesiologists' (Premean: 1.14, postmean: 1.10, P = 0.55) responses indicated a trend toward improved awareness of blood product transfusion postimplementation, whereas nurses’ responses indicated a trend toward decreased awareness (Premean: 1.67, postmean 1.93, P = 0.51). Again, no significant differences were associated with respondent training level (Table 3).
Open-ended feedback was offered by 61.7% of participants in their survey responses. Qualitative analysis revealed two major emergent themes: barriers to communication tool use and positive feedback (Table 4). While most of the participants indicated through closed-ended response that they had not experienced barriers to communication tool use in the EGS OR, several barriers were discussed in participants' written testimony. Prominent subthemes represented described barriers to communication tool use and included forgetting to employ the tool, a lack of knowledge of the tool, a lack of understanding of indications for use of the tool, lack of adequate visualization of the tool, distractions associated with the OR environment, and a lack of shared empowerment for huddle initiation. While other themes were consistent across disciplines, this final barrier was described most prominently in nurse's responses and suggested that if the huddle points were not broached by surgery before incision, they would not be broached at all. In spite of these significant barriers, participants did describe the tool as helpful and as improving team communication dynamics when employed.
Table 4Major themes of open-ended responses.
Theme: barriers to EGS checklist adjunct use
Forgetting to use the tool
“We did not remember to use it.”—Surgeon
“Forgetting to initiate the checklist is the main barrier.”—Anesthesiologist
Lack of knowledge of the tool
“We did not use it in the OR. I'm not sure how aware the OR staff was about this huddle.”—Anesthesiologist
“I am not familiar with the EGS checklist adjunct.”—Nurse
Lack of understanding of indications for tool use
“The case was booked as emergent when in truth it probably did not need to be.”—Anesthesiologist
“Did not know it was an EGS case. It was just an appendectomy.”—Anesthesiologist
Lack of adequate tool visualization
“The print needs to be bigger on the poster.”—Nurse
Distracting OR environment
“Everyone should actually be ready to pause, no activity or background talking, to clearly establish climate and to establish the tone of the case.”—Nurse
Lack of shared empowerment for huddle initiation
“Attending surgeon did not mention it before the case started so I did not say anything.”–Nurse
“Some personalities are very intimidating in a room and people are afraid to speak up.”—Nurse
Theme: positive feedback
“It's good. Brief, but hits high points. Never obtrusive.”—Anesthesiologist
“After huddle, we decided not to transfuse and the patient did well without an unnecessary blood transfusion.”—Surgeon
In this study, we have designed and implemented an EGS-specific communication tool encouraging an intraoperative huddle strategy that is perceived as beneficial in the ORs of a large academic medical center. Ultimate compliance with checklist adjunct use was below our target rate of 80%, with a notable drop in reported compliance in appropriate cases postimplementation. Analysis of open-ended participant responses indicated that participants sometimes simply forgot to use the tool, were not aware of its introduction, did not understand its intended indications, or needed a larger print sign. This lends insight into a need for continuous reinforcement when introducing a new element into OR protocol. The need for iterative teaching in the context of intervention implementation has been previously described; while our research team made efforts to engage EGS teams regarding communication tool use during implementation, this represents an area for methodological improvement.
Safe Surgery Saves Lives Study Group. Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention.
This work has identified baseline differences between anesthesiologists, surgeons, and nurses with regard to significant events in the EGS OR including blood product transfusion and change in disposition status. The use of the EGS communication tool and huddle strategy did not entirely remedy these differences. In this single-center pilot study, we did not anticipate adequate power to demonstrate a statistical difference when comparing preimplementation and postimplementation responses. We were however able to demonstrate improvement in surgery and anesthesia's awareness of intraoperative patient disposition status and eradicate differences between surgeons- and nurses-reported awareness of intraoperative blood transfusion. At present, these conclusions should be considered tendencies toward improvement in communication through shared understanding of the patient's condition and intraoperative events.
Providers who encountered our tool reported it to be helpful in the care of EGS patients. Use of targeted tools such as this may represent a means of reducing the detrimental, system variability by which EGS is plagued and may help to enhance awareness of compounding patient variability.
However, the qualitative component of our implementation analysis reveals that there is still work to be done; amongst our cohort, cultural barriers may currently impede shared awareness of patient factors and use of this new tool. In spite of a consistently delivered teaching curriculum, including instruction on the American Association for the Surgery of Trauma definitions of EGS,
the checklist adjunct was sometimes cited as being omitted in cases that fall under the taxonomy of EGS because providers felt that the case was not adequately emergent, indicating that our multidisciplinary cohort does not reliably define relevant conditions as EGS.
Nursing, in particular, continued to describe a perceived lack of ownership over huddle initiation with deference to surgery to broach topics that may critically impact patient care. Further work is needed to comprehend the impact of cultural barriers on nurses’ responses and practice; such barriers may be related to Phase 3 nursing responses reflecting decreased awareness of blood transfusion practices following implementation of our tool. Given that improvements in perceived teamwork and OR safety climate are associated with improved patient outcomes, our results suggest that while implementation of our EGS checklist adjunct may serve as an important step in improving communication in EGS, enhancement of the shared understanding of EGS patient care across disciplines, including its definition and factors that may affect EGS patient safety, along with establishment of consistent, open channels of communication in the OR are still necessary.
Safe Surgery Saves Lives Study Group. Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention.
Future steps toward enhancing team dynamics may include team training paradigms specifically designed for groups of multidisciplinary EGS providers. While we employed an EGS-focused simulation-based curriculum for a limited number of participants in phase 2 of this work, opportunity for all OR staff to participate may have been beneficial.
The strengths of this study include its multistaged, evidence-based processes, which sought to employ high quality methods to identify and address factors contributing to morbidity and mortality in EGS. In conjunction with the development of the EGS communication tool points, we have authored a reproducible curriculum that can be used to instruct relevant, multidisciplinary providers on the tool's use. Through deidentification of survey-based evaluations of multidisciplinary participants' impressions of the communication tool's utility, we sought to minimize bias, thus theoretically maximizing the accuracy of participants' responses. Use of mixed methods allowed for evaluation from more than one perspective. While we did not collect baseline demographics, by surveying the same pool of providers within a limited time frame, we believe that we maintained a reasonably consistent cohort of representative providers. Each survey link could be accessed only once by a given participant, preventing redundant responses.
This single-institution pilot study of this tool is limited in the size of its cohort. A larger, multicenter study is needed to achieve adequate power to comprehensively evaluate the impact on operative team dynamics attributable to implementation of this tool. No objective communication measurement was performed. Our focus on preservation of anonymity of participants responding to phase 3 preimplementation and postimplementation surveys through deidentification rendered us unable to perform a matched analysis of our final results, making it impossible to identify provider level differences. Our qualitative analysis is, by nature, nondefinitive and should be further examined in other multidisciplinary cohorts. Though attempts to limit bias, including the anonymity of survey responses, were made, as members of our research team were familiar to members of our cohort and only a selection of total providers offered the surveys elected to participate (20% and 55% for preimplementation and postimplementation, respectively. In the preimplementation cohort, response rates were 55% for surgeons, 13% for anesthesiologists, and 15% for nurses; in the postimplementation cohort, response rates were 62% for surgeons, 65% for anesthesiologists, and 43% for nurses), we cannot fully estimate the impact through which reporting bias may have affected our results. Variance between individual OR cases, including patient acuity, that were not controlled for in our overview data, may have affected reported perceptions of use of our tool effectiveness. Means of eliminating this potential source of bias for future study may include focusing on a more limited selection of cases or including patient level data in an efficacy analysis. While our checklist and corresponding curriculum may serve as a foundation on which EGS providers may enhance their practice, EGS providers are encouraged to apply our reproducible methods to optimize tailoring of huddle-based tools toward their own patients and hospital systems. External validation of this tool and of our results in other settings is, in fact, necessary to better understand its applicability. Currently, this study does not include a postimplementation chart review for evaluation of our tool's impact on patient outcomes. Furthermore work is needed to identify the generalized and long-term effects of this tools implementation on EGS patient morbidity and mortality.
Though this single-center study was not powered to evaluate the comprehensive statistical impact of this intervention, our cohort of providers serves as a representative, multidisciplinary sample of EGS providers whose relatively favorable response toward this tool's introduction may indicate that this tool, in turn, can be introduced to other cohorts of EGS providers without difficulty. Qualitative analysis elucidated barriers to our tool's use, including a need for continued enforcement of our tool's presence and indications for its intended use. Furthermore, our cohort of providers indicated that there remains a need for enhanced multidisciplinary education regarding the conditions that fall under the purview of EGS along with the vulnerabilities that characterize this population of patients. Improvements in EGS team training and successful implementation of tools such as ours may aid to empower all OR team members, regardless of professional discipline, to initiate channels of communication regarding key elements of patient care. While study is needed to examine the generalizability of this tool and its effect on EGS patient outcomes, we propose that this intervention may serve as an easy-to-use means of improving intraoperative communication and patient safety in a vulnerable patient population.
Conclusions
In conclusion, our study represents the first application of a tailored, evidence-based communication intervention that focuses on speaking-up behavior along with awareness of transfusions and changes in postoperative patient disposition in the EGS setting. Evaluation of its pilot implementation into the OR's of a large academic medical center have demonstrated that this adjunct to the WHO SSC, focused on previously described huddle strategies and focused toward EGS, can improve communication and can be feasibly adapted to the EGS population.
Acknowledgment
Authors' contributions: A.B.C. was involved in all stages of this work, including study conception and design, data acquisition and interpretation, article drafting and review, and article finalization. M.C.A. made substantial contributions to this work, including data acquisition and interpretation, article drafting and review, and article finalization. W.R.B. made substantial contributions to this work, including study conception and design, article drafting and review, and article finalization. A.H.H. made substantial contributions to this work, including study conception and design, article drafting and review, and article finalization. A.S. made substantial contributions to this work, including study conception and design, article drafting and review, and article finalization. J.M.H. was involved in all stages of this work, including study conception and design, data acquisition and interpretation, article drafting and review, and article finalization.
Funding: This study was supported by a grant from CRICO/Risk Management Foundation of the Harvard Medical Institutions.
Safe Surgery Saves Lives Study Group. Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention.
Identification of patient safety improvement targets in successful vascular and endovascular procedures: analysis of 251 hours of complex arterial surgery.
Explaining the excess morbidity and mortality of emergency general surgery: packed red blood cell and fresh frozen plasma transfusion practices are associated with major complications in nonmassiely transfused patients.
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