Photo By Douglas Stutz | Coordinating and communicating through a crisis ... Naval Hospital Bremerton Main...... read more read more
BREMERTON, Wash. - When Sim Lab Junior came into Naval Hospital Bremerton’s Main Operating Room (OR) for a routine appendectomy operation; it turned out to be anything but a normal procedure.
Under the on-scene tutelage of Anesthesiology Department provider Lt. Cmdr. Shawn Bowdoin, Main OR surgeons, nurses, and surgical technicians used TeamSTEPPS to train on handling the emergency case of pediatric malignant hyperthermia, a serious complication that statistically happens one in 10,000 to 40,000 surgical cases.
But happens it does.
The Main OR staff not only honed their craft in handling such a time-sensitive emergency, but improved on their TeamSTEPPS ability, which is a teamwork-based program designed to improve patient safety, enhance performance, augment overall communication and advance teamwork skills.
“This was a good TeamSTEPPS training evolution. We stopped when a definite problem was noticed. There was communication and there was solicitation for input which was very good because it’s easy to get tunnel vision when dealing with an emergency like this,” said Cmdr. Brent Bushey, Anesthesiology Department and training coordinator for the exercise.
According to Cmdr. Annie Case, NHB Quality Management Department head, the Main OR environment is a high-risk area that relies on every member to function as an efficient part of the team.
“Communication is key to the success of each surgery. Teamwork is essential to ensure that not only is the correct equipment and instrumentation available and ready for the procedures, but also communication of any information that could assist or alter the procedure due to the patient’s condition or availability of items,” Case said.
Ongoing communication is a central tenet of TeamSTEPPS where information is clearly and accurately exchanged amongst every team member. Every member of the team is involved, especially so when it’s an emergency.
Bowdoin immediately noticed complications setting in when administering anesthesia to the patient. He immediately called out to hold off on the surgery. He called out to the "floor walker" that there was a concern. He verbally took stock of the patient, checking off what had was done, what needed to be started, and which potential steps would be rapidly required.
“Can anyone think of anything else we need to do? What am I missing?” Bowdoin asked to the assembled team in a quick huddle as the rapid sequence of events unfolded concerning their patient.
Verbalizing questions out loud by Bowdoin is considered a significant strategic part of communication by exchanging information clearly and accurately between team members. It is also one of the key principles of TeamSTEPPS that includes team structure; leadership; situation monitoring and cross monitoring; and mutual support.
“Leadership is also needed, as their support is required when staff members need to raise concerns and come up against team members who disagree or won’t listen to the concerns. Mutual support and situation monitoring are equally important concepts, as each demonstrate the need to work together to ensure that teamwork is the driving concept and safety is the utmost goal for each and every patient and surgical procedure,” said Case.
The TeamSTEPPS communication principle is patterned on what is known as SBAR, the acronym for Situation (what’s going on with the patient?); Background (what is the clinical background or context?); Assessment (what is the problem thought to be?); and Recommendation/Request (what needs to be done to correct the problem?).
“All team members are aware of a patient’s status. Everyone knows who is on the team. A combination of the anesthesia, surgeon, and perioperative nurse work together to ensure that the surgical environment is in the top notch condition for the patient; the right environmental/facility factors are in place, the right team members have been trained, and the right equipment and right paperwork is in line. Everything works together towards the safest care possible,” explained Case.
The acknowledgement of a time sensitive order is a prime example of TeamSTEPPS communication used in the Main OR. Acknowledgment is also known as the "call-back" tool. When an order is given, team members respond and then call-back when completed. The call-back process ensures that the information conveyed by the sender is understood by the receiver as intended.
An example of a call-back would have the sender initiating a message with the receiver who accepts the message and provides feedback. The sender then double-checks to ensure that the message was received.
“Call-backs are encouraged. A call-back helps make it clear that an order was understood and is being taken for action. This is especially important during communication when an order is shared out loud and immediate delegation is needed,” said Lt. Cmdr. Jeffrey Peterson of NHB’s Main OR.
In dealing with pediatric malignant hyperthermia, which is potentially a fatal metabolic disorder, the aim for medical providers is to keep treating until the case is proven otherwise.
“This is why Main OR has a cart reserved specifically for malignant hyperthermia. Resuscitation and treating for this condition is very labor intensive. It takes a lot of people. Everyone has to help and that help is vital. That’s why everyone communicating – listening and acknowledging – is so important,” Bushey said.
Just as the Main OR staff uses the Team STEPPS format of always having a check list in place to go over before surgery, there is also another check list with references affixed to the malignant hyperthermia cart.
“We take nothing to chance. That check list is our friend and very important,” Bushey said.
Bowdoin attests that TeamSTEPPS is also "all about recognizing risk factors and then immediately sharing on what needs to be done."
“Knowing signs and symptoms is critical but also so is being able to be part of the team,” Bowdoin said.
The TeamSTEPPS concept of team structure revolves around assembling the team; establishing a leader; identifying the team goals and vision; assigning roles and responsibilities; actively sharing information and holding everyone accountable.
Leadership as a performance tool includes utilizing resources to maximize performance; balancing the workload within the team; delegating tasks as appropriate; conducting briefs, huddles and debriefs; and empowering the team to speak freely and ask questions.
Case attests that an effective TeamSTEPPS leader is also a strong patient advocate.
“Someone who, regardless of rank or position or job title, is cognizant and aware of each team member, respects their roles and contributions, and recognizes when someone who needs to say something, but is too shy to say it,” Case said.
Situation monitoring fosters communication to ensure that all team members are on the same page and know what is going on around them. The patient and family are also included in the process.
Mutual support provides task-related assistance; provides timely and constructive feedback; effectively advocates for the patient; encourages team collaboration; and uses such available as the two-challenge rule to resolve conflict.
Case stressed the importance of situational monitoring and cross monitoring noting that during a surgical procedure, at all phases, from pre-operative to post-operative, there is a lot going on in various sections. Anesthesia nurses is prepping the patient for induction of the anesthetic state; the surgical techs are setting up the sterile field and the surgeon is reading over the chart to verify the surgical plan. Multiple systems are going on at once.
“Each team member is focused on their section, but also keenly aware of the other aspects of the room and what the various teams are doing, and most importantly, how they are doing. An urgency or question from one will divert the essential team members to that aspect of the patient’s surgical care to ensure things are addressed,” said Case, adding that thanks to the openness concepts within TeamSTEPPS, problem solving happens as a group through teamwork.
The two-challenge rule – which empowers all team members to stop action if they sense or discover an essential safety breach - can come into play when an initial assessment is ignored. If that happens to a team member, they have the responsibility to assertively voice their concern at least two times to ensure they have been heard. The team member being challenged must acknowledge. If the outcome is still not acceptable, a stronger course of action must be taken by utilizing the supervisor or chain of command.
Case says that putting TeamSTEPPS principles into practice lessens any stress in an emergency scenario and helps achieve a successful outcome. Patient-safety is the bottom line of TeamSTEPPS with everyone is part of the team, not only the Main OR staff, but also the patient and even their family.
“TeamSTEPPS is extremely important for the staff and even more so for the patient. Patient safety succeeds with programs like TeamSTEPPS to ensure that the right thing is done each and every time,” said Case. “By having everyone on the same page the patient is in the best situation possible. If something is out of place, the patient can rest assured that someone will speak up, so corrective actions can be taken and safety maintained.”
NHB’s Quality Management team conducts periodic training in TeamSTEPPS, a three-step process that initially starts with a pre-training assessment, followed with training for onsite trainers and staff members that segues into actual implementation and sustainment of the program with the main goal of maintaining the continuous culture of patient safety.
| Date Taken: | 07.28.2015 |
| Date Posted: | 07.30.2015 12:55 |
| Story ID: | 171591 |
| Location: | BREMERTON, WA, US |
| Web Views: | 209 |
| Downloads: | 0 |
This work, TeamSTEPPS a preparation process for patient safety at Naval Hospital Bremerton, by Douglas Stutz, identified by DVIDS, must comply with the restrictions shown on https://www.dvidshub.net/about/copyright.
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