Researchers in the US found that surgical deaths dropped in hospitals where operating room (OR) staff had taken part in a training program that taught them the practices of aviation crews, including aspects of teamwork and communication skills such as being prepared to challenge each other about safety risks and conducting briefings before and after operations, compared to hospitals whose OR teams had not taken part in the program.

The study was the work of Dr Julia Neily of the National Center for Patient Safety, Department of Veterans Affairs in Hanover, New Hampshire, and colleagues, and was published online in the 20 October issue of JAMA, Journal of the American Medical Association.

The study examined the impact of a formalized medical team training program that the Veterans Health Administration (VHA) implemented across the US. The VHA has the largest integrated health care system in the US, including 130 hospitals.

The authors wrote in their background information that despite the best efforts of clinicians, OR deaths and adverse events continue to occur. So in 2006, the VHA designed the Medical Team Training program and started implementing it.

At the hospital level, the program includes 2 months of preparation and planning with the surgical care team, followed by a one-day on-site session where the medical team learn about crew resource management theories taught to aviation crews and adapted for use with surgical care teams. The staff then had one year of quarterly coaching interviews.

The researchers wrote that the program covers a number of key skills and approaches for improving teamwork, such as: challenging each other when you spot safety risks; observing rules of conduct for effective communication; spotting red flags; conducting checklisted briefings before and after surgical operations; stepping back and reassessing situations; and communicating effectively when handing over to other teams.

All the OR staff went through the training together: nurses, technicians, anesthesiologists and surgeons.

Neily said in an interview that one of the key elements of the program was "flattening the hierarchy in the operating room" so "everybody, the scrub tech, the nurse, the surgeon, the anesthesiologist, whoever it is in the operating room could bring up any concerns they had about the patient".

The researchers used the data that accumulated from participating hospitals between the fiscal years 2006 and 2008. Also during this time, there were some hospitals that had not yet entered the program, they were scheduled to receive it later, thus affording the researchers the opportunity to carry out a "retrospective health services study with a contemporaneous control group".

They got the outcome data from the VHA Surgical Quality Improvement Program (VASQIP) and from structured interviews.

Altogether they analyzed 182,409 samples procedures from 108 VHA hospitals.

The main variable they examined was the mortality rate 1 year before and 1 year after the program, both for the participating hospitals and the time-matched controls.

The results showed that:
  • The 74 hospitals that underwent the training showed an 18% drop in annual mortality (rate ratio RR = 0.82, 95% confidence interval CI ranged from 0.76 to 0.91, P=0.01).

  • This compared with a 7% drop in the 34 hospitals that did not have the training (RR=0.93; 95% CI=0.80-1.06; P = .59).

  • The risk-adjusted mortality rate at the start of the study (baseline: the year before the training) for the trained hospitals was 17 per 1,000 procedures per year.

  • For the non-trained hospitals this figure was 15 per 1,000.

  • At the end of the study the risk-adjusted rate was 14 per 1,000 for both groups.

  • After adjusting for differences in surgical risk and volume, the drop in risk-adjusted surgical mortality was about 50% bigger in the trained group (RR=1.49; 95% CI=1.10-2.07; P = .01) than in the non-trained group.

  • There was also a dose-response relationship: for each quarter of the training program, there was a reduction of 0.5 deaths per 1,000 procedures, and for every increase in the degree of briefing and debriefings, they went down by 0.6 per 1,000.
The researchers concluded that:

"Participation in the VHA Medical Team Training program was associated with lower surgical mortality."

They wrote that conducting preoperative briefings appears to be a "key component in reducing mortality because it provides a final chance to correct problems before starting the case".

Briefings and debriefings are not the same as just using a checklist: they require more "active participation", said the researchers. Teams get to voice problems and resolve them in a timely manner, which the researchers believe contribute to the improvements.

During the follow up interviews, the staff also gave examples of where briefings had prevented adverse events.

It should be noted, as already mentioned, that this study was a retrospective study, so the groups were not randomly assigned to receive the training program. This could have inadvertently allowed a number of things to bias the results, as the researchers themselves were first to admit when they discussed the limitations of their work.

For example, there is a chance that the hospitals thought to most need the training may have been first in the queue.

Neily and colleagues also noted that the patients in VA hospitals may not be representative of the population at large, so it would not be wholly reasonable to generalize these results to all US hospitals that carry out surgical procedures.

"Association Between Implementation of a Medical Team Training Program and Surgical Mortality."
Julia Neily; Peter D. Mills; Yinong Young-Xu; Brian T. Carney; Priscilla West; David H. Berger; Lisa M. Mazzia; Douglas E. Paull; James P. Bagian.
JAMA, Vol 304, No 15, pp 1693-1700, published online 20 October 2010
DOI:10.1001/jama.2010.1506

Sources: JAMA and Archives Journals .

Written by: Catharine Paddock, PhD