From the Flight Deck to the Operating Room: An Initial Pilot Study of the Feasibility and Potential...

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rom the Flight Deck to the Operating Room:n Initial Pilot Study of the Feasibility andotential Impact of True Interdisciplinaryeam Training using High-Fidelity Simulation

ohn Paige, MD,* Valeriy Kozmenko, MD,† Barbara Morgan, MD,† D. Shannon Howell, BA,‡heila Chauvin, MEd,‡ Charles Hilton, MD,‡ Isidore Cohn, Jr, MD,* and J. Patrick O’Leary, MD*

Department of Surgery, †Department of Anesthesia, and ‡Office of Medical Education, Louisiana State
niversity Health Sciences Center, New Orleans, Louisiana
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ACKGROUND: The operating room is a dynamic environ-ent in which proper teamwork is essential. After piloting a

imulation-based interdisciplinary operative team trainingrogram, we examined the impact of these sessions on thearticipants.

ETHODS: Three interdisciplinary operating room teamsarticipated in the training model. Each team of 3 or 4 mem-ers completed the training in a virtual minimally invasive op-rating room using a standardized operative scenario. Uponompletion of the training, participants completed a voluntarynd anonymous training effectiveness questionnaire.

ESULTS: All 10 participants completed the training evalua-ion questionnaires. Across the 3 teams, all participants felt thathe training was worthwhile and would participate again. Eightarticipants said that the session would change their practices inhe operating room. All participants felt that the session wasffective in promoting team communication skills and crisis-elated teamwork. Nine of the 10 felt that the training modelas effective in recognizing operating room errors.

ONCLUSIONS: Implementing true interdisciplinary teamraining with a high-fidelity simulation can be accomplishedffectively. Team training has the potential for facilitating pos-tive behavioral changes in operating room personnel that aremportant for adaptive team function in a crisis situation. (Jurg 64:369-377. Published by Elsevier Inc. on behalf of thessociation of Program Directors in Surgery.)

EY WORDS: interdisciplinary team training, operatingoom, simulation, human factors, error reduction, patient safety

OMPETENCY: Patient Care, Systems Based Practice

torrespondence: Inquiries to John Paige, MD, 503 Bolivar Street, Room 508, New Orleans,A 70112, fax: (504) 568-4633; e-mail: [email protected]

ournal of Surgical Education • Published by Elsevier Inc. on behalf ofAssociation of Program Directors in Su

ACKGROUND

he operating room is a high-risk environment requiring closeoordination among all team members. In such a dynamic set-ing, lapses in team function can negatively impact patient care.eliable teamwork, therefore, is paramount. Important charac-

eristics of a highly reliable team include the ability to adapt tohanges within the work environment, to maintain open andexible communication, and to anticipate the needs of eachember of the team.1 These characteristics allow team coordi-

ation in high-stress, high-workload situations and facilitatedaptive responses that produce superior performance.1

Unfortunately, operating room teams often fail to perform inn ideal manner. Although these teams comprise well-trainedndividuals with expertise in their particular field, the interac-ion between members is frequently problematic. Trained ob-ervers in 1 study2 found that the teamwork between surgeonsnd anesthesiologists in the operating room was poor to mini-al up to 50% of the time. In contrast, poor team interaction

ccurred approximately 15% of the time between pilots on theight deck.2 The self-assessment of teamwork also reveals majorroblems in the operating room as 86% of consultant anesthe-iologists rated teamwork between themselves and their peersery high, whereas only 36% of this group gave similar markshen comparing teamwork between themselves and surgeons.3

In an effort to address this lack of teamwork within theealth-care system, the Institute of Medicine (IOM) includedhe recommendation of creating interdisciplinary team trainingrograms in To Err is Human: Building a Safer Healthcare Sys-em.4 In 2003, the IOM again stressed the importance of team-ork in healthcare by listing the ability to work in interdisci-linary teams as 1 of its 5 core competencies for all healthrofessionals.5 Spurred by the IOM recommendations, theoint Commission on Accreditation of Healthcare Organiza-
ions (JCAHO) has included team training as part of its sug-
the 1931-7204/07/$30.00rgery doi:10.1016/j.jsurg.2007.03.009

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ested comprehensive patient safety curriculum for institu-ions.6 In fact, it has pushed for Congressional action to helpmphasize greater focus on interdisciplinary team education.7

Although the health-care profession has taken significant stepsver the last decade in developing high-fidelity, simulation-basedraining of operating room professionals, most work thus far hasocused on training particular crews within the operating room,uch as anesthesiologists8,9 or surgical trainees.10,11 Interdisci-linary training has received little attention. One notable ex-eption is the Team Oriented Medical Simulator (TOMS)rogram developed in the 1990s at the University of Baselantonsspital in collaboration with the University of Texas.12,13

A simulation-based interdisciplinary team training programor the operating room was developed by the authors, whichocuses on the behavioral competencies associated with highlyffective teams. Two primary hypotheses guided this work: (1)perating room team member participants would perceive theimulated scenarios as authentic and worthwhile; (2) partici-ants would perceive the interdisciplinary simulation trainings effective methods for enhancing communication and team-ork during an operating room crisis. The training model wasiloted in the summer of 2005.

ETHODS

raining Setting

ll scenarios took place within a Virtual Operating RoomVOR) developed for team training at the Isidore Cohn, Jr.,

D Learning Center in the School of Medicine. The spaceonsisted of a modern minimally invasive surgery (MIS) oper-ting room suite containing boom technology and flat-paneliewing monitors (Fig. 1). This suite was developed in partner-hip with Stryker Communications (Flower Mound, Texas).n affiliated workstation housed a main router, touch-screenanel control, digital capture device, and voice control system.he router allowed for transmission of audio and video material

iIGURE 1. The VOR is a modern minimally invasive surgical suite with aETI Human Patient Simulator (HPS) and Simbionix LapMentor machine.

70 Journal of Surgical

rom the suite to a viewing/control room adjacent to the suitend to outside locations, which included remote classrooms orperating rooms with appropriate technology.

The simulation equipment consisted of a full-scale computer-perated mannequin (Medical Education Technologies Incorpo-ated [METI], Sarasota, Florida) as well as a virtual reality chole-ystectomy machine (Simbionix Ltd, Lod, Israel) (Fig. 1). The

ETI mannequin simulates human physiologic responseso treatment interventions, medications, and anestheticgents. A bar-code system allows for manual administrationf “medications” during sessions. The mannequin connectso an anesthetic machine within the simulation suite that isapable of interpreting the gas composition during the sim-lated intubation. The virtual reality machine allows an op-rator to perform a cholecystectomy from start to finishithout prompting. This type of experience is described as

free training.”A novel quad screen system was developed to support simul-

aneous monitoring and recording of important activity withinhe suite (Fig. 2). For example, 1 section of the quad screen cane used by participants to track team member interaction via anverhead room camera, whereas another section can be used byarticipants to track the progress of the virtual cholecystectomy.third screen can be used by participants to monitor the vital

igns of the mannequin during the scenario, and a fourth screenan be devoted to any additional monitoring or informationeeded for the session. Interchangeability between screens ofhe quad system allows for customization to fit the teaching,earning, and assessment needs of the training session. An in-ight camera housed within the handle of the overhead operat-ng room light can also be used by the participants for viewingctivity in the suite, especially in relation to a closer view of theperative field. The recording of multiple, simultaneous viewss particularly useful for enhancing the after-action debriefingiscussions, facilitating professional reflection and critique, andeinforcing teaching points with direct observation of specificerformance.

raining Format

raining sessions occurred in the morning and lasted up to 3ours, depending on the length of time spent working throughhe scenario and completing the video-facilitated debriefing dis-ussion. Upon arrival, team members were briefly oriented tohe VOR and how it functioned. After orientation, team mem-ers were assembled together and had the goals and objectives ofhe training explained. The background for the patient case thatas the focus of the training scenario was reviewed in a way thatas authentic to the operating room setting, and the team wasiven the patient chart to review before starting the scenario.pon completion of the scenario, the team engaged in a video-

acilitated debriefing discussion guided by the trainer. Threeeople were required to run the training session: a programmero oversee mannequin function, a person to assist with record-
ng the session, and a trainer/facilitator who helped with orien-
Education • Volume 64/Number 6 • November/December 2007

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ation and debriefing. The Institutional Review Board approvalt an exempt status was obtained before initiating the trainingnd research activities.

raining Participants

n interdisciplinary operating room team was assembled forach of the 3 pilot sessions. Each team consisted of a senioreneral surgery resident (PGY IV), a certified registered nursenesthetist (CRNA) or CRNA student, and a circulating regis-ered nurse (RN). The RNs came from an operating roomhere the surgery residents and CRNA/CRNA students ro-

ated during their training. The team reflected a group thatould actually occur in the clinical setting. As the members wereelected based on rotation schedule, willingness, and availabil-ty, the team created was in essence a random grouping withoutignificant prior experience or training together as a unit. Threeeams involving a total of 10 participants were assembled for the

IGURE 2. The quad-screen system allows for simultaneous monitoring ofo the overhead room camera, another to the LapMentor screen, a third

ilot program (Table 1).

ournal of Surgical Education • Volume 64/Number 6 • November/D

raining Scenario

ach of the 3 teams underwent the same standardized trainingcenario involving 1 or more intraoperative cardiac arrhyth-ias. The patient scenario included a preprogrammed algo-

ithm (Fig. 3) that responds to team interactions. For example,f the team did not recognize at the beginning of the scenario thextremely low potassium level of the mannequin before surgery,hen the mannequin would develop atrial fibrillation with rapidesponse after the surgeon began the cholecystectomy. If the

nt activities within the VOR. During a session, 1 quadrant can be devotedETI HPS vital signs, and a fourth for any additional information.

ABLE 1. Composition of Interdisciplinary Teams

SessionTeamSize Team Composition

1 4 RN, CRNA student x 2, surgical resident(PGY IV)

2 3 RN, CRNA, surgical resident (PGY IV)3 3 RN, CRNA student, surgical resident

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eam did not properly diagnose or treat the atrial fibrillation,hen the arrhythmia would deteriorate into ventricular tachy-ardia. However, if the operating room team recognized the lowotassium level and initiated adequate treatment, then theannequin would not develop atrial fibrillation during the pro-

edure. Thus, while the patient case remained the same, thecenario became dynamic and unique to the team in training.

The other aspect of the training session included specificpportunities for every operating room team to engage in team-ork competencies. Each patient case included a specific set of

IGURE 3. The patented software interface supports the development ofyocardial infarction, PEA � pulseless electrical activity, NSR � normal

esponses, regardless of the intraoperative scenario that un- p


olded. For example, the mannequin in the patient case used byhe participants for the pilot training sessions always developedradycardia with the creation of pneumoperitoneum, regardlessf the actions of the team.

The effectiveness of teamwork during the training scenarioas assessed based on process and patient outcome measures.he actions of the team were judged on features of communi-

ation, coordination, situational awareness, and adaptive re-ponse, as well as on a set of patient outcomes. A checklist waseveloped as part of the patient scenario that reflected expected

gically complex scenarios involving the mannequin. BL � baseline, MI �ythm, K � potassium, VTach � ventricular tachycardia, J � joules.

atient outcomes and appropriate clinical actions for the intra-


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perative event encountered in the training. Specific actionsere identified as necessary or “critical” for successful teamerformance in addressing the patient problem (Fig. 3). Onemportant critical performance indicator comprising patientutcome measures of the training included administering po-assium intravenously to treat the low preoperative value. Thisction avoided further arrhythmias during the scenario. An-ther important critical performance indicator involved releas-ng the pneumoperitoneum to resolve completely the bradycar-ia. Treating the bradycardia with pharmacologic agents wouldnly partially resolve it.

raining Debriefing and Questionnaire

ach team participated in a debriefing activity immediatelyfter their completion of the scenario. An important compo-ent included observation of their video-taped performancesing the quad-screen recording system. Guided by the trainer/acilitator, the team used the videos to identify and discusspecific performances regarding teamwork, communication,nd situational awareness. The debriefing activity was designedo provide only formative assessment and feedback to the par-icipants regarding team behavioral skills in crisis situations.he assessment checklist was used by the trainer/facilitator

olely as a guide for enhancing reflective practice and learninguring the debriefing activity and not to implement a scoringystem for evaluating the performance of the team.

After completion of the debriefing activity, participants weresked to complete a voluntary and anonymous questionnaireocusing on the effectiveness of the training session. Threepen-ended questions solicited both yes/no and narrative re-ponses regarding overall satisfaction with, and perceptions of,raining effectiveness for specific elements. Another 3 itemsere included about specific attributes of teamwork and used a-point Likert-type response scale (A � Not effective at all to� Very effective) (Fig. 4). Questionnaire data were collated

nd analyzed after completion of all pilot sessions to assurenonymity of responses. The mean scores for the Likert-typeesponses were determined by assigning numerical values toach response (A � 1, B � 2, C � 3, D � 4, E � 5). Frequencyounts of positive (yes)/negative (no) responses of the 3 open-nded questions were determined. Results were used to assesshe feasibility and effectiveness of the training model based onhe perceptions of trainees of the pilot training sessions, interestn ongoing interdisciplinary operating room team training, anduggestions for future refinement.

ESULTS

he response rate for the questionnaire across the 3 pilot train-ng sessions was 100% (total n � 10). The average age of theenior surgical residents was 31.3 years, with a female-to-maleatio of 1:2. They had an average of 5 years of experience overallnd within the institution. One surgical resident reported un-
ergoing prior team training. The average age of the CRNA/ d

RNA students was 30.5 years. The female-to-male ratio was:1 (1 team had 2 CRNA students). The CRNA/CRNA stu-ents had an average of 6 years of experience overall and 1.5ears within the institution. One CRNA reported participatingn prior team training. The average age of the RNs was 58 years.he female-to-male ratio was 2:1. Overall, they had an averagef 23.7 years of experience and 10 years of experience at thenstitution. Two RNs reported having had prior team training.

The frequency counts of the affirmative and negative answerso the open-ended questions revealed that all 10 participantsound the training session worthwhile and would attend an-ther session. Eight out of 10 participants said that the trainingession would change the way they practiced within the oper-ting room. One RN did not think that the session wouldnfluence how this RN practiced. One CRNA student did notive an affirmative or negative response to whether the trainingould influence how this student practiced.Mean scores for items targeting the perceived effectiveness by

he participants of the training session were examined. Ashown in Table 2, item mean scores for the total respondentroup were 4.5 for improving communication and 4.7 for im-roving teamwork, and 4.4 for recognizing errors in the oper-ting room. In fact, every participant thought that the sessionsere effective (rating � 4) to very effective (rating � 5) for

mproving teamwork and communication. Nine of the 10 re-pondents felt that the training model was effective (4) to veryffective (5) for recognizing problems and errors in the operat-ng room, and the remaining response was neutral (CRNA, 3n the 5-point scale). As shown in Table 2, disciplinary sub-roup scores were consistent with the total group scores. Thetem mean scores for each discipline support the training asffective in all 3 of the above domains. Item mean scores for theNs were overall the highest for all 3 domains. The view ofRNA/CRNA students of the effectiveness of the session inromoting teamwork was the highest ratings mean score acrosstems and disciplinary subgroups. In fact, the teamwork do-

ain had the highest average score for each subgroup and theotal group. Error recognition had the lowest item mean scoreor general surgery residents and CRNA/CRNA students. Ad-itionally, it was the lowest item mean score for the total groupesponses.

OMMENTS

his pilot study focused on the receptivity of the participants torue interdisciplinary operating room team training and theeasibility of conducting ongoing training in an academicealth center environment. As with any study, limitations to theesearch design are important considerations in drawing con-lusions and suggest implications for future directions. Severalimitations should be considered. First, the pilot study consistedf only 3 iterations of implementing the training model andnvolved only 10 participants (ie, 3 to 4 individuals per trainingeam). Second, the research design was descriptive, based on
ata from a post-session participant questionnaire to obtain
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ormative feedback from participants about training effective-ess and supplemented by direct faculty observation and post-raining session debriefings. Consequently, the descriptive na-ure of the research design, the small number of iterations andraining participants, and training implementation at only 1nstitution precludes drawing definitive conclusions or general-zing to other settings.

Que

Items were included to obtain participant

gender, age, profession, overall and local

institution), prior team training experienc

Open-ended questions included the follow

• Was today’s session worthwhile?

• Will it change your practice?

• Would you attend this session aga

Items requiring responses to a 5-point Lik

E/5=Very effective)

Please rate the effectiveness of

• Promoting team communi

• Promoting teamwork in a

• Recognizing and addressin

FIGURE 4. Q

ABLE 2. Interdisciplinary Team Training Effectiveness

Training EffectivenessOverall M

Score

romotes team communication 4.5romotes teamwork in crises 4.7acilitates recognition of problems and errors 4.4
Includes CRNA students.

Evaluation of training effectiveness was based on the resultsf the participant questionnaire data that reflected perceptionsnd self-reported learning and intention to change behaviornly—not evidence of actual learning, behavior change, or im-act resulting from the training. The goal of this pilot was tossess participant receptiveness and overall feasibility of theraining model and not to try to assess actual behavioral change.

naire Content

cteristics for the following categories:

rience (years in training, years at

ype scale A/1=Not effective at all to

session in

skills

ors and problems in the operating room

naire content.

RN MeanScore

CRNA* MeanScore

Resident MeanScore

4.7 4.5 4.34.7 4.8 4.74.7 4.3 4.3

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ccepting these limitations, several conclusions can be madeased on this model and other teamwork simulation reports.This operating room team training model was designed spe-

ifically to enhance interdisciplinary team interactions. The op-rating room is a dynamic, complex environment that bringsogether an interdisciplinary team of professionals who musteamlessly coordinate their expertise and activities to provideafe, effective care to the patient. This group of experts oftenoes not act like a team.2 Each member has a clear picture ofhat s/he does but does not approach his/her tasks with a clearnderstanding of what each of the others will do or may needo do.14 The members do not have a shared image or “mentalodel” of how the team should work and interact.14

A shared mental model is necessary for team members tonticipate, adapt, and respond effectively to each other and tohe situation (ie, adaptive response) in the dynamic and high-tress situation of the operating room.1 The lack of a sharedental model among team members is reflected in a survey of

perating room teams in which members rated the degree ofeamwork among disciplines.2 Whereas 73% of surgical resi-ents and 64% of attending surgeons reported high levels ofeamwork with other attending surgeons, only 39% of attend-ng anesthesiologists, 28% of surgical nurses, 25% of anesthesiaurses, and 10% of anesthesia residents reported similar levelsf teamwork with surgeons. A similar disconnect was presenthen comparing teamwork between disciplines within the op-

rating room. Sixty-two percent of the surgical staff rated theeamwork with the anesthesia staff highly, but only 41% ofhe anesthesia staff held the same view toward teamwork withhe surgical staff. Such disparity suggests a failure among oper-ting room members to create a common understanding of howhe team members, individually and collectively, should inter-ct and work together effectively. The lack of a common un-erstanding impacts the effectiveness of team communicationnd the awareness of members of the unfolding situationhroughout an operative procedure.

Another factor that seems to contribute to ineffective team-ork is related to the concept of a shared mental model and

nvolves a lack of professional role clarity among operatingoom team members. Results based on focus group interviewsnvolving 52 operating room team members revealed a strikingissonance between how surgeons and nurses define their ownrofessional roles in the operating room versus how each disci-line would define the role of the other.15 This finding is attrib-ted to a lack of interdisciplinary training resulting in a poornderstanding of the culture, skills, and roles across the variousperating room disciplines and reinforces the “silo” effectithin team members.Ineffective communication is a third factor commonly cited

n the literature as leading to a breakdown in team functioningithin the operating room. In a follow-up study, 48 general

urgical and vascular procedures were observed and communi-ation events were categorized.16 Of 421 events deemed proce-urally relevant, 129 (30.6%) were classified as a communica-
ion failure. These failures were grouped into 4 categories: i

ccasion, content, purpose, and audience. Importantly, 36.4%f the communication failures had an apparent negative impactn the system function within the operating room. Of theseegative impacts, the top 3 were inefficiency (17.8%), teamension (12.3%), and delay (7.7%).

The lack of teamwork within the operating room createshat James Reason called a latent condition within the team for

he commission of errors.17 These team-based errors fall intoour main categories: procedural errors, communication errors,ecision errors, and intentional noncompliance errors.18 Ac-ording to the University of Texas Threat and Error Manage-ent Model (TEMM), a team error can result in 1 of 3 distinct

utcomes.18 The most benign outcome is one in which therror is inconsequential. Alternately, an error can result in anndesired state or condition. Finally, it can lead to anotherrror, which becomes part of an error chain.

Improving teamwork within the operating room has the po-ential for enhancing patient safety. A team training session forperating room personnel at 1 institution significantly im-roved communication for anesthesiologists and surgeons.19

he improved communication, coupled with the introductionf a preoperative briefing protocol, increased the rate of on-timedministration of prophylactic antibiotics and applicationf sequential compression stockings for deep vein thrombosisrophylaxis.Because of the similarities in team dynamics, breakdowns,

nd organizational cultures, the operating room and flighteck possess strong parallels.20 The success of high-fidelityimulation-based team training within the flight deck hasttracted the attention of health-care professionals workingithin the operating room. Anesthesia was the first discipline

o adapt crew resource management (CRM) principles. Anes-hesia Crisis Resource Management is their training module.8,9

ore recently, surgeons have begun using high-fidelity simula-ion and CRM principles. At the Imperial College in London,nited Kingdom, a realistic mock operating room has beeneveloped to evaluate the responses of surgical trainees torises.10,11

Unfortunately, CRM is effective at teaching and evaluatinghe behavioral skills of professionals within a discipline, but itoes not provide appropriate focus on interdisciplinary team

nteractions. Also, CRM does not provide sufficient opportu-ities to engage in realistic scenarios followed by cycles of de-

iberate and focused reflection, feedback, and practice related tomproving how an operating room team can function as a unit.uch clinical team training has never been described in thenited States, and the world literature contains only 1 descrip-

ion of a now-defunct program (TOMS).12,13

High-fidelity simulation-based training has been expandedrom a discipline-specific, crew-based experience to a new gen-ration of team training that reflects interdisciplinary interac-ions in an actual operating room. The highly consistent andositive results of the initial pilot study involving the experi-nces of 3 teams with the new training model provides convinc-
ng evidence of both receptivity to and feasibility of team train-
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ng. Participants viewed the training context and the scenarioss authentic and the training activities as valuable. The pilotesults demonstrated that simulation-based operating roomeam training is effective without the addition of embeddedctors that has been typical of previous training models usingRM simulation-based approaches. The use of actual interdis-

iplinary teams in a highly authentic simulation environmentllowed participants to enhance their understanding of the rolef each other and improve their abilities to communicate effec-ively with team members of other disciplines. Feedback fromarticipants revealed that such training can be accomplished in“safe” environment where members can use deliberate prac-

ice and feedback to hone important teamwork competencies,ncluding the use of a shared mental model, situational aware-ess, anticipatory and adaptive response, effective communica-ion, and leadership. The goal was not to define outcome-basedvidence of actual behavior change but to examine the receptiv-ty of health professionals to the simulation model. Evaluationesults revealed positive attitudes and suggest it is perceived asaluable by the participants.

These results suggest that this training model could be incor-orated into the educational mission for in-training and con-inuing education programs and could be accomplished effec-ively. Therefore, as the program is refined, opportunities tontegrate training sessions into appropriate curricula will beesearched. The training activities and patient scenarios will bexpanded to develop a comprehensive, interdisciplinary teamraining curriculum. A specific area of current study includesevelopment of a competency-based assessment system foroth the operating room team21 and the individual team mem-ers22-24 that can be used in both simulated and real-life oper-ting room settings. The importance of evaluating changes inctual learning, behavior, and outcomes is all recognized. Theseesearch goals must be integrated into future investigations.

In conclusion, results of this pilot study support the recep-ivity to and the feasibility of implementing a high-fidelityimulation-based interdisciplinary team training program at aarge academic health sciences center. Participants involved inhis pilot program found it worthwhile. Additionally, they in-icated that it is effective in promoting teamwork in a crisis,

mproving communication among team members, and recog-izing errors in the operating room. The results support con-ucting additional research and development into high-fidelityimulation-based interdisciplinary operating room team train-ng to examine the extent to which this innovative approach cannhance behavioral skills that are important for effective oper-ting room teamwork in high workload environments.

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From the Flight Deck to the Operating Room: An Initial Pilot Study of the Feasibility and Potential...

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