“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 worldwide 1 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, 2008 2. 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 Reform 4. 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 : Duration: Location: June- November 2011 Penn Medicine Clinical Simulation Center (PMCSC) – Hospital of the University of Pennsylvania (HUP) Participants: 171 OR staff members (residents, nurses, surgical technologists) Design: Scenario: Prospective Weekly one hour OR Team Training sessions Simulated exsanguination emergency in a pregnant patient (hidden carotid injury) after a MVC Cardiac arrest

SESSION PARTICIPANTS

Surgery Residents 17% PeriOp Nurses and Surgical Technologists 41% Anesthesia Residents 20% ENT Residents 6% OB GYN Residents 7% Oral Surg Residents 9%

TEAM TRAINING SESSION

• Informed consent obtained • Cognitive assessment (3 questions): 1. Pregnant patient position and hand placement during CPR 2. Recommended room temperature during an exsanguination 3. 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 1 st patient to treat – – Initiation of an exsanguination protocol Raise room temperature to 80⁰F – Reposition mother on left lateral recumbent position – 2 nd 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)

5

Number of Mitigation Steps

4 3 2 1 0 6 7

Mean Number of Mitigation Steps Completed During "Cold and Warm" Simulations 6,6 3,9

Cold Simulation Warm Simulation

RESULTS: Overall Performance

Number of Groups

12 10 8 6 4 2 0 26 24 22 20 18 16 14

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

Cold Scenario Warm Scenario

RESULTS: Eight Mitigation Steps

All groups performed all mitigation steps faster during the “warm” scenario

(p<0.03) Mitigation Step Call for Help Identify a Team Leader Mom is 1st Patient Activate Exsanguination Protocol Raise Room temperature to 80F Reposition Mother to LAD 2nd Person to Verify Blood Products Start CPR Mean Cold Duration (sec) 110 112 429 Mean Warm Duration (sec) 35 46 123 Mean Change in Time to Perform Step (sec) 75 Reduction in Time (%) 68.2

66 306 59 71.3

p-value < 0.001

0.004

0.009

127 122 244 163 226 42 41 83 93 135 85 81 161 70 91 67 66.4

66 43 40.3

< 0.001

0.007

0.0003

0.03

< 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 Disagree Neither Agree Nor Disagree Agree Completely Agree

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: • • • Pt positioning/ hand placement for CPR: Room temperature: Licensed personnel to check blood: MDs (N=96) RNs (N=63) 64.6%/ 97.9% 52.4%/ 100% 69.8%/ 98.9% 91.9%/ 100% 67.4%/ 92.7% 88.9%/ 95% – Survey: • My role in an exsanguination: • • • • Exsanguination protocol: Relevant to current practice: Simulated environment was realistic: Simulated patient scenario was realistic: MDs (N=94) RNs (N=59) 41.4%/ 96.8% 62.7%/ 100% 50%/ 100% 56.2%/ 100% 100% 100% 77.4% 91.2% 91.4% 91.6%