Teamwork and Collaboration for Prevention of Surgical Site Infections

When we think about preventing surgical site infections (SSI), we commonly think first about the use of prophylactic antibiotics, and in this setting concentrate on which procedures should receive prophylaxis, which drug to use, how much, when to start, whether to redose, and how long to continue [1]. A more in depth look quickly proceeds to methods proven to reduce infection risk including maintaining normothermia [2], hair removal without razors [3], preventing hyperglycemia [4–6], skin antisepsis [7], and decolonizing Staphylococcus aureus carriers [8]. We may then move to items with strong theoretical rationale that currently lack strong enough evidence to warrant universal recommendation such as increased FiO₂ during and after the surgical procedure [9,10], wound protectors [11,12], antibacterial impregnated sutures [13,14], antiseptic-impregnated adherent drapes [15], pre-operative bathing with chlorhexidine [16], and “good” surgical technique (how do you measure that?) [17]. In this piece I make the case that there is an increasing body of evidence that suggests we should include teamwork, communication, and collaboration in the O.R. to this list.

Wiegmann points out that human error leading to complications in the O.R. is often caused by a combination of both active and latent failures, only the last of which is an unsafe act by an individual [18]. He points out that observation in the O.R. shows a strong correlation between increased numbers of teamwork disruptions and communication failures and surgical errors. However, whereas poor teamwork may predispose to surgical error, good teamwork, in turn, may facilitate the detection and remediation of errors [18]. In this study, errors discovered after a delay were more likely to be discovered by a person who had not committed the error. This would be another example of the value of teamwork.

The perceptions of teamwork and collaboration in the O.R. may differ dramatically depending on the role of the person asked. Makary et al. interviewed anesthesiologists, CRNAs, surgeons, and O.R. nurses regarding quality of collaboration. Each profession rated itself highly for collaboration within its own group (81%–96% rating quality of teamwork and collaboration as high or very high) and for its own collaboration with other professional groups. Surgeons also rated collaboration and teamwork of others highly (84%–88%). However, nurses and CRNAs rated surgeon collaboration as good only 48% and 58% of the time [19]. In another study nurses and surgeons gave substantially different ratings to the following statements [20]:

I am comfortable intervening in a procedure if I have concerns about what is occurring.

During surgical and diagnostic procedures, everyone on the team is aware of what is happening.

Morale on our team is high.

Everyone on our team is comfortable giving feedback to other team members.

Lingard et al. at the University of Toronto examined the value of a team briefing among surgeons, anesthesiologist, and surgeons at the beginning of a case in an effort to reduce communication failures. In a before and after study, they saw a reduction in communication failures per procedure from four to 1.3 (p < 0.001) and of communication failures with consequences from 2.4 to 0.9. The proportion of operations with no communication failures increased from 6% to 37% [21]. In a similar study, Henrickson et al. recorded miscommunications, knowledge disruptions, and trips to core by the circulating nurse before and after the institution of pre-operative briefings. They found a 47% reduction in total disruptions per case (p = 0.0002), a 46% reduction in disruptions tied to knowledge (p = 0.007), a 53% reduction in miscommunications (p = 0.03), a 53% reduction in trips to core, and 56% reduction in time spent by the circulator in core (p = 0.01) [22]. They also found that the time spent on the briefings decreased as the teams became more familiar with the process. Beldi et al. examined risk factors for SSI in an observational study and found that risk was increased by obesity, operations extended beyond 3 h, the performance of an intestinal anastomosis (all with p < 0.01), and also by a poor discipline score measuring hectic movement, change of personnel, visitors in the O.R., and loud noise (p < 0.04). Risk was not influenced by extended antiseptic measures such as frequent glove changes, more compulsive cover-up and scrub clothing, iodine-impregnated adherent drapes, changing instruments, and extensive irrigation [23]. In another study the same group found that recordings of noise level in the O.R. recorded substantially greater decibel levels in the O.R. in operations that subsequently resulted in an SSI than in cases that did not lead to an SSI [24].

Within this context the results of several recent publications on the use of a surgical safety checklist are relevant. Haynes et al. studied the introduction of the WHO Surgical Safety Checklist in hospitals in four developed countries (United Kingdom, Canada, United States, and New Zealand) and four developing countries (India, Jordan, Philippines, and Tanzania) and collected data on more than 7,600 patients [25]. They found a 45% reduction in SSI as well as substantial reductions in unplanned return to the O.R., any complication, and mortality rates. They measured safety attitudes in the participating hospitals and found a substantial correlation between changes in safety attitudes during the project and changes in complication rates [26].

Some commentaries on this paper suggested that most of the changes had occurred in the developing countries, which was in fact, not the case [27]. Follow-up studies in the Netherlands, definitely not a developing country, also demonstrated a 29% reduction in SSI as well as substantial reductions in patients with complications and mortality rates [28]. In this study where they tracked how much of the checklist had been completed they found that complications were lower for patients in whom more of the checklist had been done. This study was done in multiple hospitals, all of which were comparable institutions and all of which had an effective ongoing program for recording and following complications. The investigators also followed a second cohort of similar hospitals in which the checklist was not introduced during the same interval and found no changes in the measured outcomes. A second study in the Netherlands examined post-operative mortality rates before and after the introduction of a checklist and followed more than 25,000 patients. Among all patients studied before and after, there was a 15% reduction in mortality rates, but when they examined only operations in which the entire checklist had been completed the reduction was 56% [29].

It is not clear that simply checking items on a checklist substantially reduces SSIs and other complications unless it involves genuine communication, although it probably achieves some benefit from avoiding the omission of certain key process elements such as timely administration of prophylactic antibiotics and redosing for long cases. Neily et al. studied the implementation of a more ambitious program of team training within the VA system for everyone working in the operating rooms, which involved 2 mo of preparation and a full-day of training followed by four quarterly coaching interviews [30]. The training specifically mandated briefings and debriefings before and after each case and the use of checklists. The result was a sustained reduction in mortality rates that persisted and increased as time passed following introduction of the program. The program could not be rolled out to every hospital at the same time, so they were able to observe differences over time depending on participation in the program. In 2007, 42 hospitals underwent team training and 32 did not. Both groups demonstrated reductions in overall morbidity and in post-operative infections from 2006 to 2008. Hospitals with team training had a 20% greater reduction in morbidity (p < 0.001) and 17% greater reduction in infections than those that did not (p < 0.005) [31].

Clearly culture, communication, and teamwork in the O.R. have an enormous amount to do with patient outcomes including SSI risk. The culture of delivering safe, high-acuity peri-operative care depends on:

Clear central goals, widely shared across the organization;

A hierarchical structure that honors collegial decision making independent of rank;

A culture where vigilance is prized and safety is rewarded;

Databases the support safety goals; and

An environment where reporting and simulation enhance learning [32].

With these principles in mind, a multidisciplinary group at the University of Washington Medical Center (UWMC) composed of surgeons from multiple disciplines, anesthesiologists, CRNAs, nurses, scrub techs, and infection control personnel examined the checklist being used and introduced some modifications designed to improve communication, information sharing, vigilance, and teamwork. Inspection of the original WHO checklist reveals the following information at the bottom of the list, “This checklist is not intended to be comprehensive: Additions and modifications to fit local practice are encouraged” [33]. With this encouragement, and with information from the Surgical Care and Outcomes Assessment Program (SCOAP) of the State of Washington [34,35], UWMC had modified the original WHO checklist, taking off items that were always done reliably, such as checking the instrument sterility indicators and using a pulse oximeter. In their place the checklist added items, such as checking the dose of prophylactic antibiotic, calling out a plan for re-dosing for long cases, checking glucose levels for patients at risk for hyperglycemia and calling out a plan for correction, and confirming the existence of active warming. The checklist also specifically asks for input from the nursing team regarding whether they have the equipment and supplies that they need or any other questions. Similarly the anesthesia team is asked for any airway or other issues. Finally before the operation begins there is a request for any person in the O.R. who has concerns or questions of any kind to speak up at that time and an admonition for every member of the team to speak up promptly at any time during the procedure if any questions or concerns should arise. The checklist retains the important element from the original WHO checklist in which every member of the O.R. team introduces him/herself and indicates his/her role (Table 1). Despite all of these important elements, it is still possible to go through the mechanics of the checklist, checking off the elements without participating in the spirit of the checklist, and recent publications show that simple administrative requirements to check off a list does not result in improvements [36,37]. For this reason our multidisciplinary work group put together an “instruction manual” for the checklist which is available in every O.R. and contains the following points.

OPEN IN VIEWER

Table 1.

Checklist Used at University of Washington Medical Center

1. Before induction: Briefing
All Team Members - (Attending Surgeon or designee leads):
□ Confirm patient (at least 2 identifiers), procedure, site, Left/Right
□ Describe procedure, expected duration, & anticipated difficulties
□ Expected blood loss & blood availability
□ Need for special instruments/supplies/IV access beyond usual
□ Heparin given/not needed and/or SCDs in place and turned on
Nursing/Tech reviews:
□ Equipment issues (instruments ready, staff in-serviced, implants available)
Anesthesia reviews:
□ Airway or other concerns
□ Allergies
□ Special meds, other
All Team Members:
□ Questions/issues/concerns from any team member & duty to speak up at any time in the procedure

2. Before incision: Process control
Attending Surgeon reviews: (as applicable)
□ Attending Surgeon not present for SCOAP 1? Repeat SCOAP 1.
□ Each person introduces self by name & role
□ Personnel exchanges: timing, plan for announcing changes
□ Essential imaging displayed: right & left confirmed
□ Has patient positioning changed since SCOAP 1? Is marking still visible?
□ Antibiotic prophylaxis - drug, dose, time, redosing plan
□ Active warming - needed? In place, truned on?
□ Risk of hyperglycemia? Plan for insulin protocol if needed
□ Sharps management plan
□ Specialty-specific checklist

3. Just before closure of operative field or removal of trocars: No retained objects
Attending Surgeon:	Nursing/Tech:
□ Perform methodical visual & physical sweep of wound & report	□ All music, conversation, & distractions halted
	□ Perform preliminary count of needles/sponges/ instruments & report

4. After skin closure complete: No retained objects, debriefing, care transition
All Team Members (Attending Surgeon or designee leads):	Surgeon and Anesthesia:
□ Confirm final needles/sponges/instruments count correct	□ Does patient need special monitoring?
□ Surgeon views all sponges & laps in holders	□ Insulin drip needed?
□ Confirm name of procedure	□ Post-op beta blockers needed?
□ Any Specimens? Confirm label & instructions	□ Post-op anticoagulation needed?
□ Equipment issues to be addressed? If yes, response plan	□ Pain management by Surgery or Acute Pain Service?
□ Other issues? If yes, response plan	□ Other special concerns for patient recovery?

1. A poster or image of the checklist on a flat screen must be visible to and readable by every professional involved in the case in the O.R. for each stage of the checklist. The checklist should never be done from memory.

2. The checklist requires the participation of all persons in the operating room. The attending surgeon (or on rare occasions a designee) will lead. Leading means, first, requesting permission from the members of anesthesia and nursing, and second, addressing every single line by reading each line.

3. Recruitment of all personnel: For each of the four parts of the checklist, it is mandatory that the leader politely request permission from the other two disciplines and assures the participation of his/her team to begin the checklist. The checklist can only be run when all personnel in the O.R. are able to stop other things that they are doing and pay attention and contribute. If patient instability demands anesthesia team attention then the checklist must wait. If the telephone rings, it should be allowed to ring, or if it is an urgent patient care matter then the checklist must wait. For the checklist to be most effective, a member other than the leader should comment/respond at the end of every line.

4. As much as possible, the checklist should be run in a way that involves all of the professional disciplines in the room and generates responses to the items on the list.

5. A member of each of the three disciplines (Anesthesia, Nursing, Surgery) must be present for first portion of the checklist that occurs in the operating room before induction.

6. If the Surgery attending is not available, then the checklist will be initiated by a member of the primary surgical team who will be present and participating in the operation and who knows the operative plan and is familiar with the patient's clinical details and who has been specifically designated by the Surgery Attending through a direct communication with the circulating nurse.

7. Introduction of all persons may seem “silly” to some, but in a large academic medical center residents change frequently, new faculty often join a department, nurses turn over or are brought in from other teams. Introductions can be done quickly, and it is helpful to be sure that everyone knows everyone else's name and role and can get their attention quickly if needed. It has also been shown that this moment, albeit a little “uncomfortable” at times, is essential to break the ice and to establish from the beginning a “team” presence. Extensive research demonstrates an increase in post-operative morbidity and mortality rates when teamwork and communication are not optimized.

8. Any team member who observes deviation from the policies expressed in this document should consider it his or her obligation to call it out immediately. We assume that this will be accepted graciously. If not, the incident should be reported to your supervisor as soon as possible during or immediately after the case.

Discussion

Teamwork is crucially important for patient safety and the reduction of surgical site infections, but exactly how to introduce it into the tradition bound, hierarchical structure of the operating room is not entirely clear or well-studied. It clearly helps to have a clinical champion who is respected in the institution and it also requires commitment and support from the leadership structure of the hospital both in the medical and administrative divisions and in the nursing division. Time and effort spent on this goal will pay off in reduced complications for patients and in reduced expense for the institution.