“Managing a Surgical Exsanguination - PowerPoint Presentation

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“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

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Nothing to Disclose

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BACKGROUND

Each year 234 million major operations are performed worldwide130 million surgical procedures are performed each year in the US alone 2,3ECRI - 550-650 surgical fires per year in the US 4AST – 1 in 4,500 patients has an anaphylactic reaction in the US 5Clinical and non-clinical OR emergencies are infrequent, but carry significant morbidity and mortalityPreviously presented initial studies – OR fire and anaphylaxisNo published team training work focusing on complex perinatal scenarios, taking advantage of newer technology

World Health Organization : 10 Facts on Safe Surgery, June 25, 2008Fires in the Operating Room. American College of Surgeons: Committee on Perioperative Care. Podnos YD, Williams RA American College of Surgeons: Statement on Health Care ReformEmergency Care Research Institute (ECRI). Clinical Guide to Surgical Fire Prevention (2009). Pennsylvania, USA.Association of Surgical Technologists. Standards of practice, Guideline Anaphylactic Reaction (2005). CO, USA.

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MAIN OBJECTIVES

Train residents and OR staff in recognizing adverse

events and responding to emergencies within the ORImprove 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

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SIMULATED SCENARIO

Study : Prospective Duration: June- November 2011Location: 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 sessionsScenario: Simulated exsanguination emergency in a pregnant patient (hidden carotid injury) after a MVC Cardiac arrest

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SESSION PARTICIPANTS

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TEAM TRAINING SESSION

Informed consent obtainedCognitive assessment (3 questions): Pregnant patient position and hand placement during CPRRecommended room temperature during an exsanguinationNumber of licensed personnel required to check blood products prior to transfusionSimulated Scenario: Brief H&P on a pregnant patient who had unexpectedly arrived to the OREach group was assigned to simulated OR (equipped with a SimMan® 3G and a moderator)

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SIMULATED SCENARIO

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

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TEAM TRAINING SESSION

“COLD” simulation

(prior to training)

Didactic lecture(8 mitigation steps)“WARM” simulation(after training)

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8 MITIGATION STEPS

Supported by a systematic review of current literature 6,7,8,9Measured for both “cold” and “warm” simulationsActivate Emergency Response SystemIdentify a team leader Mother is 1st patient to treat Initiation of an exsanguination protocolRaise room temperature to 80⁰FReposition mother on left lateral recumbent position2nd person to verify blood productsInitiate 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.

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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 performanceTo 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?

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RESULTS: Overall Performance

Total # of participating groups: 26 In the warm scenario, 7 groups (27%) performed all 8 mitigation stepsDuring the warm scenario, the mean number of mitigation steps completed increased for all teams (p<0.001)

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RESULTS: Overall Performance

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RESULTS: Eight Mitigation Steps

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

Mitigation Step

Mean Cold Duration (sec)

Mean Warm Duration (sec)Mean Change in Time to Perform Step (sec)Reduction in Time (%)p-valueCall for Help110357568.2< 0.001Identify a Team Leader1124666590.004Mom is 1st Patient42912330671.30.009Activate Exsanguination Protocol127428567< 0.001Raise Room temperature to 80F122418166.40.007Reposition Mother to LAD24483161660.00032nd Person to Verify Blood Products1639370430.03Start CPR2261359140.3< 0.001

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RESULTS: Cognitive Assessment (n=161)

Pregnant patient positioning and hand placement for CPR: 60% vs. 99% after trainingRecommended room temperature in an exsanguination: 79% vs. 99%Number of licensed personnel required to verify blood products: 76% vs. 94%

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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 Agree Disagree

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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)

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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)

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RESULTS: Relevance and Realism (n=154)

100% agreed and completely agreed that the scenario was relevant to their current clinical practice83% found the environment to be realistic91% felt the patient scenario was realistic

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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 ORTeam 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

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THANK YOU

Dr. Jon Morris: General Surgery Residency Program Director, Hospital of the University of PennsylvaniaDr. Noel Williams: General Surgery Preliminary Program Director, Hospital of the University of Pennsylvania

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QUESTIONS?

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COST OF TEAM TRAINING USING SIMULATION

FacilitiesOR equipmentHigh fidelity mannequin - Sim Man 3G® $80,000AV simulation software- B-Line Medical® $200,000 - $250,000 (1 Operating Room)OR staff time outside the OR

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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%