Introduction Team work, communication, and efficiency in the operating theatre are widely recognised to be suboptimal. Poor communication is the single biggest cause of medical error. The surgical operating theatre is a potentially highly stressed environment where poor communication can lead to fatal errors. The objectives of this study were to assess the effects briefings and debriefings had on theatre start time, list lengths, and the staff's impression of these meetings.
Materials and methods Briefings and debriefings were conducted before the start of theatre lists over a 6 month period in 2007 in a district general hospital in north Bristol, UK. Both quantitative and qualitative data were collected. Using the hospital theatre database, theatre start and finish time was found and list length calculated. A questionnaire was devised and used to assess staff attitude to the briefings and debriefings.
Results Staff felt that the briefings highlighted potential problems, improved the team culture, and led to organisational change. Theatre start times tended to be earlier and lists lengths were shorter when briefings were conducted, although this only reached statistical significance on one type of list.
Discussion Briefings and debriefings had a positive impact on teamwork and communication. The lists ran more efficiently and briefings did not delay the theatre start times—in fact, the lists tended to start earlier.
- change management
- adult surgery
- adverse events
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During the 1970s the aviation industry responded to a series of high profile crashes involving poor communication by implementing a communication training programme called Crew Resource Management (CRM).1 One of the important components of this was the use of briefings and debriefings before and after flights. The current study attempted to emulate this by assessing the effect that briefings would have on communication and team work in the operating theatre. It was conducted before the introduction of the World Health Organization Surgical Safety Checklist.
Medical errors cause between 44 000 and 98 000 deaths in the USA a year,2 3 and the single biggest factor underlying these errors is poor communication between health professionals.4 In multiple studies of operating room performance4–7 up to 30% of all communication events are considered failures. Further analysis showed that one third of these failed communication events resulted in visible effects on system processes, including inefficiency, team tension, resource waste, delay, and procedural error.
Assessing communication and teamwork within medicine is difficult. The two main methods used are observational recording and questionnaire based studies. The observational tools, such as Observational Teamwork Assessment for Surgery,8 9 require a designated observer and this was not available for this project. Questionnaires have been used in many studies to assess the effect of team working interventions. One example (on which this study's questionnaire is based) is the Safety Attitude Questionnaire (SAQ),10 11 which evolved out of the airline equivalent—the Cockpit Management Attitudes Questionnaire.
Briefings have been used before in the operating theatre environment. Published evidence of these is relatively limited. One study12 attempted to use briefings to reduce wrong site surgery, and although the questionnaire responses showed an increase in caregiver's perception of reduced risk, no overall reduction in wrong site surgery was demonstrated. In a more complex study11 a series of structured educational interventions, including briefings, had an impact on staff attitude towards teamwork. Both of these were conducted in teaching hospitals.
The aims of this study were to determine the effect briefings had on theatre start times and theatre list length, and to study the effect of briefings on the staff's attitude to safety and team work. Ideally the primary outcome would be a reduction in adverse events and mortality. A recent study has shown a reduction in mortality with safety checklists and briefings,13 but it would be extremely difficult in a study of this size to demonstrate truly an improved patient outcome, so surrogate markers had to be used.
Materials and methods
The study was conducted during a 6 month period in 2007 in a busy district general hospital in north Bristol. The hospital is split over two sites: on one site the major operations were conducted and the briefings were run on an all day colorectal surgery list; on the other site day cases were undertaken and here the study was carried out on a half day breast surgery list. The first 3 months were used as a control period, and the briefings and debriefings were conducted for the next 3 months. Approval was sought and was received from the medical director, the head of the theatre complexes, as well as the heads of anaesthesia and surgery.
Box 1 highlights the important aspects of all the briefings; however, the two list types needed slightly different formats. For the day case list, the briefing would be conducted at 08:30. This would give the anaesthetist and surgeon time to see the patients and obtain their consent (usually 3–4) before the briefing. The meeting took place in the coffee room adjacent to the operating theatre. It was almost always attended by: two staff nurses, the healthcare assistant (HCA), the operating department practitioner (ODP), the porter, the anaesthetist (registrar or consultant), the consultant surgeon, and the registrar. Initially, and occasionally thereafter, the theatre manager and recovery nurses would attend.
Briefings were conducted before the theatre list and took place in the coffee room next to theatres.
All members of the team attended.
The first part of the meeting would address feedback from the previous list and a discussion of relevant external factors.
A focused discussion on each patient on the list that day would be conducted by the team leader (usually surgeon, anaesthetist or theatre sister).
This discussion highlighted, among other things, any particular patient factors as well as extra equipment needed.
The meeting lasted between 5–10 min and would consist of a general discussion regarding external factors. This would sometimes relate to problems from the last theatre list or feedback if anything had changed in the external environment. Then a focused discussion about that day's list would take place. The order would be discussed and each operation explained. The anaesthetist would discuss any anaesthetic problems and tell the ODP what agents he or she was going to use. The surgeons would point out any problems and extra equipment needed. If there were nursing issues, such as different staff, these were then mentioned. Once everyone was satisfied the porter would leave and get the patient.
In a similar manner briefings were carried out on the all day colorectal list. This was a more complicated list and several different procedures were carried out. The briefing was again carried out in the theatre coffee room, but was able to be at 08:15 as some of the patients would have come in the night before and so could be seen and their consent obtained then.
A debriefing would be carried out at the end of the list. The main points are highlighted in box 2. Occasionally this would be held in the coffee room. However, most often it would occur in the theatre room itself as the nursing staff would have to clean the room at the end of the list and found it easier to have the debrief there. The team leader would run through the day's list and ask for any comments from the group about what went well and what could be improved for the next list. Often points regarding the external environment would be brought up and an individual could be allocated to ensure the issue was addressed.
Debriefing occurred at the end of the list.
It was difficult to do these formally in the staff room.
They tended to happen in the empty theatre once the last patient had left.
Points, both positive and negative, from the day were discussed
At the end of the study, questionnaires were given to all staff members. The questions are listed in box 3. The questionnaire had been previously trialled in another district general hospital during a brief pilot study for this project. It used a Likert scoring system and was similar in nature to other safety questionnaires.10 There was a section at the end of the questionnaire for general comments. The results were tabulated.
The questions asked about team briefings
Made you aware of the cases?
Highlighted potential problem?
Lead to organisational change?
Were a waste of time?
Made you feel part of the team?
Allowed the list to start more punctually?
Should carry on?
Data were collected for theatre start and finish time, and thereby list length. These data were recorded by the theatre team separately from this research study. This is a mandatory computer field filled in for all patients. This was routine practice before the start of the briefings and was therefore not influenced by the presence or absence of briefings. The data were analysed for significance using the Student t test for probability.
The results of the questionnaire are show in table 1. The questionnaires were completed by all members of the team; anaesthetists, surgeons, nurses, HCAs, and ODAs (in total 13 questionnaires were returned).
Staff attitude to briefings and debriefings
In the extra comment section at the bottom of the questionnaire a variety of positive comments were left:
“An extremely useful way of involving all team members in planning ahead the tasks of the day”
“All lists should have team briefings”
“… these briefings helped ensure the good communication needed for individualised patient care; however, other forces, ie, transportation, no beds available, overrunning lists, no porters, did not allow these briefings to prevent delays”
The latter comment makes the reasonable point that although these team briefings do seem to improve the running of the lists they are by no means creating a perfect system.
At the first two briefings (in the breast day case list) both the anaesthetists and surgeons complained that the patients were not ready to be seen at 08:00, so there was no way theatre could start on time. The admitting nurses from the day case unit were at the briefing and explained that the patients were told to come in at 08.00, even though the nursing staff were ready from 07:15. This had not been noticed before as a reason why the lists started late. One of the members of the team was allocated after the briefing to talk to the admission secretaries and bring the patients in for 07:30 so that they would be ready to be seen at 08:00. By the third week this was in place and the difference was readily noticed.
During one briefing the anaesthetist and recovery nurse had a discussion about the postoperative fentanyl protocol and cleared up several issues for each other; this is a discussion that would not normally take place as there is little communication between these two members of staff. This is a good example of how the briefing system allows more communication and can help with patient safety.
At one of the all day colorectal lists, a porter (who attended the briefings) asked at the end of the briefing whether any of the patients would have intravenous fluids running. When asked why, he explained that often they would go to the ward to collect the patient, find that they needed an intravenous drip stand and that there may not be one available. They would spend some time looking before returning to the theatre suite to pick up one from their store and return to the ward. They said this had been going on for years and was often a reason why the patients were delayed. If they were told beforehand, they could take their own drip stand and so there would be no delay.
At all the briefings there were issues that needed to be cleared up regarding the list order or what operations were actually involved, and any special equipment needed that day. A regular example would be the theatre list with an incorrect procedure written on it, so without the briefing the theatre staff would not know until later on what operation would actually be taking place.
Theatre start time: data analysis
Tables 2 and 3 present the data for list length and theatre start times (defined for this study as the entry of the patient to the operating theatre, already under anaesthesia). Time data were recorded as the length of time after the theoretical start of the list; 08:15 for the all day list and 08:30 for the day case list. This is displayed as a mean time, together with ranges and p values calculated using the Student t test. Fifty data entries were recorded in the control phase and 37 data points were recorded once the briefings were being conducted. The lists tended to start earlier and have shorter list times, but this only reached statistical significance for the day case breast list. This may be a result of the all day operating list already being efficient in the first place; it tended to start almost on time before the study and so there was less room for improvement, whereas the day case breast list was relatively inefficient (starting 41 min late before) so the effect of the briefing was more dramatic.
The crucial observation, however, is that briefings do not delay the start of the list. This has often been a criticism of running briefings.
The debriefings happened after most of the day case lists and after some of the all day lists. There were problems getting all the staff together after lists. Both the surgeons and anaesthetists would be rushing to get away to their other commitments, and the nurses would be preparing the operating theatre for the next list. This meant that it was rarely possibly to get all members of staff together for a formal debrief in the coffee room. What was possible was a brief meeting that took place in the operating theatre, almost immediately after the patient had been taken to the recovery room. Although debriefings were particularly useful in the aviation industry, in this study they did not seem to be crucial. The start of the next briefing can be used as the debrief from the list before.
Briefings are liked by staff and have an impact (although not significantly) on theatre efficiency, as judged by reduced theatre list length and start time. As a quality improvement project it has the huge advantage of being completely free (apart from a few doughnuts). Briefings engender a feeling of ‘team’ among the staff and so improve the working environment; for that reason alone it is worth conducting briefings.
Throughout the programme there were problems with implementation. Many senior staff (particularly consultants) were cynical of the idea of briefings, and it was occasionally difficult to coerce them into coming to the briefings. The most common argument was that there is not time to attend them. This study has at least shown that this argument is untrue. Along with the cynicism comes the ‘boomerang’ effect. This phrase was coined when team building was implemented in the aviation industry during the 1980s and refers to the effect seen in some senior pilots (in our case consultants) who became more distant and less interested in the ‘team’ after briefings or team training. This has been observed during some implementation of patient safety methods, where staff members were forced into conducting the briefings. As such it is crucial when bringing preoperative briefings into place that all members of the team are involved beforehand and brought on board with the idea. If it is seen to being forced upon them then some will turn away.
Theatre lists tend to start earlier when briefings are conducted.
Staff enjoy briefings, and feel more part of the team when they are run.
Staff should be fully involved in implementation.
Do not force staff to conduct briefings.
It is difficult to get staff to attend debriefings.
Current research questions
Should formal checklists be used in briefings, like the WHO checklist?
What is the state of the patient safety culture in theatre?
In this study the questionnaires were given after the briefings were initiated; it would be better to have used a standard questionnaire, such as the 27 point Safety Attitude Questionnaire,10 11 before and after implementing the intervention. Since this study was undertaken, a multicentred trial of the WHO Surgical Safety Checklist13 has demonstrated the effect improved communication can have on patient outcome; although the focus of that study was the perioperative checklist, in addition they used preoperative team briefings. This study shows further the benefit of these briefings and demonstrates that they do not delay theatre start times.
The evidence for activities for enhancing team work is well established. The next area of study will be to make these interventions ‘stick’. For example, a year after this study was conducted the briefings were still occurring on the all day colorectal list, but stopped almost immediately on the breast day case list as the main author had left the hospital.
The authors thank Cathy Braybrook and her team for her help organising the meetings in the day case setting.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.