“Managing a Surgical Exsanguination Emergency in the Operating Room through Simulation:

An Interdisciplinary Approach”

Natalia Martinez Acero M.D, Greg Motuk, R.N, Josef Luba, R.N., Michael Murphy, M.S.N,

Susan McKelvey, R.N., Gretchen Kolb, M.S, Kristoffel Dumon M.D, Andrew S. Resnick, FACS, M.D,

M.B.A.

Hospital of the University of Pennsylvania

Nothing to Disclose

BACKGROUND

• Each year 234 million major operations are performed worldwide1

• 30 million surgical procedures are performed each year in the US alone 2,3

• ECRI - 550-650 surgical fires per year in the US 4

• AST – 1 in 4,500 patients has an anaphylactic reaction in the US 5

• Clinical and non-clinical OR emergencies are infrequent, but carry significant morbidity and mortality

• Previously presented initial studies – OR fire and anaphylaxis• No published team training work focusing on complex perinatal scenarios,

taking advantage of newer technology

1. World Health Organization : 10 Facts on Safe Surgery, June 25, 20082. Fires in the Operating Room. American College of Surgeons: Committee on Perioperative Care. Podnos YD,

Williams RA 3. American College of Surgeons: Statement on Health Care Reform4. Emergency Care Research Institute (ECRI). Clinical Guide to Surgical Fire Prevention (2009). Pennsylvania, USA.5. Association of Surgical Technologists. Standards of practice, Guideline Anaphylactic Reaction (2005). CO, USA.

MAIN OBJECTIVES

Train residents and OR staff in recognizing adverse events and responding to emergencies within the OR

Improve overall team performance during an OR exsanguination emergency using 8 clinical mitigation steps

Demonstrate an improvement in knowledge after training OR staff in an exsanguination emergency

SIMULATED SCENARIO• Study : Prospective • Duration: June- November 2011• Location: Penn Medicine Clinical Simulation Center (PMCSC)

– Hospital of the University of Pennsylvania (HUP)

• Participants: 171 OR staff members (residents, nurses, surgical technologists)• Design: Weekly one hour OR Team Training sessions• Scenario: Simulated exsanguination emergency in a

pregnantpatient (hidden carotid injury) after a MVC

Cardiac arrest

SESSION PARTICIPANTS

Anesthesia Res-idents20%

ENT Residents6%

OB GYN Residents7%

Oral Surg Res-idents

9%

PeriOp Nurses and Surgical

Technologists41%

Surgery Residents17%

TEAM TRAINING SESSION

• Informed consent obtained

• Cognitive assessment (3 questions): 1. Pregnant patient position and hand placement during CPR2. Recommended room temperature during an exsanguination3. Number of licensed personnel required to check blood

products prior to transfusion

Simulated Scenario: • Brief H&P on a pregnant patient who had unexpectedly arrived to

the OR• Each group was assigned to simulated OR (equipped with a

SimMan® 3G and a moderator)

SIMULATED SCENARIO

Simulations were recorded using advanced AV simulation software (B-Line Medical®)

TEAM TRAINING SESSION

“COLD” simulation(prior to training)

Didactic lecture(8 mitigation steps)

“WARM” simulation(after training)

8 MITIGATION STEPS • Supported by a systematic review of current literature 6,7,8,9

• Measured for both “cold” and “warm” simulations– Activate Emergency Response System– Identify a team leader – Mother is 1st patient to treat – Initiation of an exsanguination protocol– Raise room temperature to 80⁰F– Reposition mother on left lateral recumbent position– 2nd person to verify blood products– Initiate CPR

6. Levy DB. Neck Trauma: Treatment & Management, 2010.7. Chames MC, Pearlman MD. Trauma during pregnancy: Outcomes and clinical management. Clinical Obstetrics and Gynecology 2008; 51(2): 398-408.8. Mirza F, Devine PC, Gaddipati S. Trauma in Pregnancy: A systematic Approach. Am Journal of Perinatology 2010; 27(7): 579-586.9. McCunn M, Gordon EK, Scott TH. Anesthetic concerns in trauma victims requiring operative intervention: The patient too sick to anesthetize. Anesthesiology Clin 2010; 28: 97-116.

TEAM TRAINING SESSION

During the Simulated Scenarios:• Time intervals for completion of mitigation steps analyzed for

each COLD and WARM simulation was annotated • Paired t-test used to compare COLD and WARM scenario

performance

To finalize the session:• Repeat cognitive assessment (3 questions)• Session Survey

• How realistic was the scenario?• How realistic was the environment?• Was this relevant to your current clinical practice?

RESULTS: Overall Performance• Total # of participating groups: 26 • In the warm scenario, 7 groups (27%) performed all 8 mitigation steps• During the warm scenario, the mean number of mitigation steps

completed increased for all teams (p<0.001)

Cold Simulation Warm Simulation0

1

2

3

4

5

6

7

3.9

6.6

Mean Number of Mitigation Steps Completed During "Cold and Warm" Simulations

Number of Mitiga-tion Steps

RESULTS: Overall Performance

Call for H

elp

Identify Team Leader

Mom is 1st

Patient

Exsanguination Pro

tocol

Room Temperature 80F

Reposition M

other

2nd Person Check

RBCs

Start CPR

02468

101214161820222426

Mitigation Steps Completed in the "COLD" and "WARM" Scenarios

Cold ScenarioWarm Scenario

Number of Groups

RESULTS: Eight Mitigation Steps

All groups performed all mitigation steps faster during the “warm” scenario (p<0.03)

Mitigation StepMean Cold

Duration (sec)Mean Warm

Duration (sec)Mean Change in Time to Perform Step (sec)

Reduction in Time (%) p-value

Call for Help 110 35 75 68.2 < 0.001

Identify a Team Leader 112 46 66 59 0.004

Mom is 1st Patient 429 123 306 71.3 0.009

Activate Exsanguination Protocol 127 42 85 67 < 0.001

Raise Room temperature to 80F 122 41 81 66.4 0.007

Reposition Mother to LAD 244 83 161 66 0.0003

2nd Person to Verify Blood Products 163 93 70 43 0.03

Start CPR 226 135 91 40.3 < 0.001

RESULTS: Cognitive Assessment (n=161)• Pregnant patient positioning and hand placement for CPR:

– 60% vs. 99% after training• Recommended room temperature in an exsanguination:

– 79% vs. 99%• Number of licensed personnel required to verify blood products:

– 76% vs. 94%

SURVEY RESULTS

• After doing both the “COLD” and “WARM” simulations, trainees completed a session survey using a Likert scoring scale where:

1 2 3 4 5

Completely Disagree Neither Agree Completely

Disagree Agree Nor AgreeDisagree

RESULTS: Role in an Exsanguination (n=156)

Only 50% of participants agreed or completely agreed knowing their role in an exsanguination before training vs. 98% after training (p <0.001)

RESULTS: Exsanguination Protocol (n=152)

Only 50% agreed or completely agreed they knew how to activate an exsanguination protocol prior to training vs. 98% after training (p= 0.004)

RESULTS: Relevance and Realism (n=154)• 100% agreed and completely agreed that the scenario was

relevant to their current clinical practice• 83% found the environment to be realistic• 91% felt the patient scenario was realistic

CONCLUSIONS

Team training using high fidelity simulation is an effective way to train surgical residents and OR staff in the management of a

high-risk surgical emergency in the OR

Team training allowed surgical residents and OR staff to perform the basic goals of therapy in a complex

exsanguination scenario in the OR

Team training allowed teams to achieve faster response times in a complex exsanguination scenario in the OR

THANK YOU

Dr. Jon Morris: General Surgery Residency Program Director,

Hospital of the University of Pennsylvania

Dr. Noel Williams: General Surgery Preliminary Program Director,

Hospital of the University of Pennsylvania

QUESTIONS?

COST OF TEAM TRAINING USING SIMULATION

• Facilities• OR equipment• High fidelity mannequin

- Sim Man 3G® $80,000• AV simulation software

- B-Line Medical® $200,000 - $250,000 (1 Operating Room)

• OR staff time outside the OR

SURVEY ANSWERS

• MDs vs. RNs:– 3 cognitive questions: MDs (N=96) RNs

(N=63)• Pt positioning/ hand placement for CPR: 64.6%/ 97.9% 52.4%/ 100%• Room temperature: 69.8%/ 98.9% 91.9%/ 100%• Licensed personnel to check blood: 67.4%/ 92.7% 88.9%/ 95%

– Survey: MDs (N=94) RNs (N=59)

• My role in an exsanguination: 41.4%/ 96.8% 62.7%/ 100%• Exsanguination protocol: 50%/ 100% 56.2%/ 100%• Relevant to current practice: 100% 100%• Simulated environment was realistic: 77.4% 91.4%• Simulated patient scenario was realistic: 91.2% 91.6%