The myth of communication in OR

ByUSAMA ELSAYED

Lecturer of anesthesia and intensive care

Outlines

• Skills needed for Anesthetists

• Effective communication skills in OR

• Communication failure in OR

For Anaesthetists

• Scientific background

Technical skills

Non technical skills

ANTS

ANTS• Two categoriesCognitive &mental skills: planning, situational awareness &decision making

Social &interpersonal skills :coordinated team work, communication &leadership

Task management

• Planning &preparation

• Prioritisation

• Identifing &utilising resources

• Providing & maintaining standards

Situational awareness

Gathering information

Recognizing & understanding

Anticipating

Situational awareness

Reduces level of monitoring becauseof distractions

Does not ask questions to orient selfto situation during hand-over

Decision making

• Identifying options

• Balancing risks & benefits

• Re evaluation

Causes of error in anesthesia primarily related to deficiencies in nontechnical skills, rather than a lack of technical expertise.

• Surgeons v. Anaesthetists : Why the Tensions?

• The Anaesthetists is often called the 'captain of the ship,' but the surgeon has a crucial role in how smooth the sailing is.

Why Is This Needed?

• We as anesthesiologists sensed a need for improvement in mutual communication skills

• Poor teamwork and communication are key factors responsible for medical errors

Team communication in OR

Safe: communication reduces morbidity and mortality

Accessible: communication skills can be demonstrated by all team members

Team communication in OR

Feasible: communication can be accomplished with practice but without difficulty.

Effective: communication improves team function(s).

Right: communication saves not only lives but also time and money

Can Communication Be Taught?• Communication skills is natural ability and cannot be t

aught .

• Some might say “you can’t teach an old dog new tricks,”

we enter medical school knowing that communication is important, but it seems to be lost on us later in our training

How to improve communication in OR ?

• Have mutual respect• Mutual respect between the two specialists is

the number one way to reduce friction in the OR

• Egos need to be checked in at the door, avoid talking-down to the OR team

How to improve communication in OR ?

A good surgeon will also respect an

anesthestist’s instructions inside the O.R.

when safety is at issue.

The command is not personal; the patient’s

safety is at issue; and no surgeon wants a

patient coding on the table.

Explain potential issues

Both surgeon and anesthetist need to be assertive and

preemptive when explaining potential issues, whether it's

during, immediately prior to or even days before the surgical

procedure

Get to know each other.

• "Say hi, shake hands, express your appreciation for working together today and ask the surgeon if there are any issues about this particular patient, this particular case

• The first communication of the day should never be 'the blood pressure is falling'."

• The more comfortable the surgeon and anesthesiologist are with each other, the more likely they will be to address their thoughts and concerns about the procedure in an open manner.

• Getting to know each other personally outside the OR can help surgeons and anesthesiologists develop that comfort level.

• "Learn something about the physician — where they live, kids, hobbies and remember it for future interactions. Who knows, you may make a lifelong friend,

SharingActive involvement in the progress of the operation by the anaesthetic, nursing and surgical crews that make up the OperatingRoom team. This involvement should include, atminimum, the anaesthetic crew being able to see over the ‘ether screen’ and communicate easily with the surgeon. In turn, the surgical crew should be able to see the anaesthetic monitors

Closed loop communication

Don't forget the goal

• It's essential that both physicians remember why they are in the operating room in the first place — to ensure the best care for the patient

• Over time, faith develops between the two and both trust that the other is doing their best for the patient."

Communication ptterns

• Jokes• Stories• Commands• Questions• Social chat• Rebukes• Silences.• Nonverbal signals (nodding, gesturing, facial

movements such as eyes rolling)

Communication topics

• Time (room turnover, patient cancellation, sending for the next patient),

• ▪ Resources (equipment allocation and distribution, personnel distribution),

• ▪ Roles (responsibilities, constraints) and relationships,

• Safety and sterility (aseptic technique), and• Situation control (temperature regulation,

recording activities).

Communication and Conflict

• Breakdowns in communication are one of the most frequent causes of conflict in health care

• The OR is at risk for conflict because:– There are many different professionals with overlapping

and sometimes poorly delineated responsibilities– Two physicians sharing equal responsibility for patient– Complex, high-pressure work environment– Sleep deprivation and stress affect interactions– Ethical conflicts and conflicts of interest may emerge

Surgeon anesthetist conflict

Hospital or patient pressure on surgeons

Lack of regard to anesthesiologists’ instructions

Patients’ unawareness of the role of anesthesiologists

Surgeon anesthetist conflict

Decision about the urgency of operations

Lack of an out-patient anesthesia clinic

Shortage of work facilities

Conflict Resolution in General

• Five basic mechanisms of conflict resolution– Avoidance – unlikely to be useful in the OR because

conflict is prevalent in this environment– Yielding – one side acquiesces to the other; appropriate

when one party recognizes that they are in error– Collaboration – the preferred approach, which focuses

on achieving goals together and is a “win-win” system– Compromise – both sides make trade-offs– Competition – conflict is seen as a zero-sum game that

is won by one party and lost by the other

• The surgeon and anesthesiologist also set the

tone in the operating room If they remain calm

when things go wrong and discuss the issue in a

rational manner, the nurses, technicians and

other members of the OR staff will feel at ease

and perform their job better. But if they are

hostile or passive aggressive, it makes for a

more difficult work environment.

How to De-Escalate Aggression

• Stay calm and respectful

• Approach in a warm, friendly,

open manner and avoid

closed body language (crossed

arms, standing too close)

• Speak softly and clearly in

short sentences while

avoiding taiking down

• Avoid distracting activities

such as writing or looking at

the computer

• Maintain nonthreatening eye

contact

• Use facial expressions or

nodding to convey

attentiveness & understanding

Communication failure

Communication failure

• Occasion

• Suboptimal timing of an information exchange such that information was requested or provided too late to be maximally useful

• The staff surgeon asks the anesthesiologist whether the antibiotics have beenadministered. At the point of this question, the procedure has been underway for overan hour.

Communication failure

• Content

• Relevant information was missing or inaccurate information was

exchanged

• The anesthesia fellow asks the staff surgeon if the patient has an ICU bed.

The staff surgeon replies that the ‘‘bed is probably not needed, and there

isn’t likely one available anyway, so we’ll just go ahead.’

Communication failure

• Purpose

Communication events in which purpose is unclear, not achieved, or inappropriate

During a living donor liver resection, the nurses discuss whether ice is needed in the basin they are preparing for the liver.

Communication failure

Audienceabsence of a key team member during the communication event, most frequently the absence of a surgical representative indiscussions regarding the preparation for surgery such as the set up of equipment and the positioning and draping of the patient

Effects of communication failure

• Tension: Emotional responses to a communication failure;

Failure of communication among surgeon , scrub nurse and circulating nurse about equipements preparation make all irritated and frustration spread among all

Effects of communication failure

Delay:

Communication failure results in a delay in the surgical procedure

In instances in which the surgical staff or resident has not been present

for discussions of positioning or draping, these activities occasionally

need to be redone to accommodate the particular needs of the

surgical team.

Effects of communication failure

• Resource waste:

Communication failure results in the use ofequipment or personnel that is not requiredA cell saver kit opened then discovered it is a cancer case

Effects of communication failure

• Procedural error:

• Insertion of an inappropriate line necessitating removal and reinsertion, each step of which raises the risk to the patient.

Example of communication failure

After the patient has been anesthetized, the nurse tells the

surgeon that the consent form used an abbreviation instead of

the full procedure name, and adds that this is against regulations.

The surgeon responds: ‘‘The key is, do you think he knew what he

was coming for this morning ?’’ The nurse assures: ‘‘Well, we

didn’t delay the case because of it

Silence in OR• Fear of exposing a lack of knowledge is one possible motivation for some silences

observed in the OR

• After the patient has arrived in the OR, the anesthesiologist asks thesurgical resident if the surgical team will want the patient’s arms to betucked in for the surgery.Surgical resident says he does not know, but will ask, and then leavesthe room.Circulating nurse: ‘Arms out?’Anesthesiologist: ‘He said he didn’t know’.After the patient is anesthetized the surgical resident returns to theroom and begins catheter insertion. He does not report back aboutarm positioning

Messages

• Take a time-out before every case• Communicate constantly during the

procedure• If u have been asked if u are concerned

about anything don’t always say GOOD

GOOD unless if really good احناكويسين احنا كويسين

TO SUM UPCommunication among OR team

members should be subtle and complex not like the openly combative style that is the stuff of OR myth.

The goal of effective communication in OR is to reduce tension