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Surgery in Simulation Center Has Real Effect on Teamwork

The "patient" in the simulation was a life-size, computer-controlled mannequin.

For the team working on the surgical repair of a ventricular septal defect in the Cedars-Sinai Women's Guild Simulation Center for Advanced Clinical Skills, the focus was on the tiny "patient."

The infant was a life-size, computer-controlled mannequin, anatomically correct from its synthetic skin (complete with fat and fascia planes) to its articulated joints, sculpted bones, and pliable muscles and tendons; and from its respiratory system that "breathed" to its circulatory system that maintained blood pressure and pumped ersatz blood. The mannequin's heart had holes between its upper chambers, and another between its lower chambers (atrial and ventricular septal defects).

But no matter how technically dazzling the mannequin was, the surgical team approached it simply as a tool for reaching a crucial goal: to improve patient safety in the complex and fast-paced environment of cardiac surgery by working as a seamless unit.

"The challenge is that we are all exceptionally well-trained as individual practitioners, but too often the integration of the individual into team delivery of healthcare is poorly done," said Alistair Phillips, MD, co-director of the Guerin Family Congenital Heart Program and chief of the division of Congenital Heart Surgery at Cedars-Sinai.

"The beauty of the sim center is that it has real, live information that is communicated to us exactly as we would see it in the O.R.," said Alistair Phillips, MD (left).

"We all agree that the No. 1 focus is a healthy child at the end of surgery," Phillips said. "Along the road to getting there, though, we each have different goals that we personally think are the most important."

According to a report by the American Heart Association published in August 2013, most preventable surgical errors in cardiac operating rooms arose not from failures in technical skills but from breakdowns in teamwork and communication.

To address these potential communication failures, and to give the Congenital Heart Program's surgical team a real-time, high-stakes arena in which to practice, Phillips turned to the Women's Guild Simulation Center, commonly referred to as the sim center.

The sim center includes two operating rooms, an intensive care unit, an Ob-Gyn room, a trauma bay and a neonatal intensive care unit. All are fully functioning and, when needed, can be pressed into immediate service. Each environment is connected to one of two control rooms, where technicians use computers to create and control an infinite range of medical scenarios for teaching or practice purposes.

Phillips designed a simulation in which an infant exhibiting symptoms of failure to thrive undergoes surgery for repair of a large ventricular septal defect. Working with Russell Metcalfe Smith, the sim center's manager, Phillips crafted a meticulous scenario for the surgery and a subsequent scenario for the Congenital Cardiac Intensive Care Unit.

"We had a prototype congenital heart baby designed specifically for the scenario, which makes it that much more immersive for the people in the O.R.," Metcalfe Smith said. "It takes a significant amount of time for a team to learn to function together, which is why simulations like this need to take place on a regular basis."

Phillips' approach to honing the congenital cardiac team's interpersonal skills starts with erasing traditional hierarchical markers. To his team he is "Alistair," not "Dr. Phillips," a distinction he believes makes it easier for team members to participate fully in discussions and critiques.

Each simulation begins with a "pre-brief," a document that lays out each participant's goals for the surgery, the order in which the surgery will proceed, and the after-care duties of nursing staff.

"We start with a team huddle" in which the team members state the goal and the procedures by which the goal will be met, Phillips said.

In the simulation with the infant mannequin, the goal was the closure of the septal defect with a Gore-Tex patch, the surgical procedure was a sternotomy, and the main concern was ensuring that all holes (known medically as shunts) were closed to control postoperative bleeding and improve heart function. After the anesthesiologist, perfusionist, O.R. nursing team and ICU teams stated their goals and procedures, the team was ready to begin.

Each environment in the sim center is connected to a control room, where technicians use computers to create and control an infinite range of medical scenarios for teaching or practice purposes.

In the sim center's operating room, with team members scrubbed in and gowned, the surgery proceeded in real time. As the mannequin's heart was stopped and circulatory function moved to bypass, the perfusionist quietly answered queries about heart rate, blood pressure and oxygen saturation.

Meanwhile, on the other side of the operating room's large window, Metcalfe Smith and his team huddled over a bank of keyboards, monitors and readouts.

Planning for this simulation took a few weeks. Setting up the operating room, which included programming the scenario, took 72 hours. As the operation proceeded, the sim center team made sure that each step of the surgery, including prearranged complications for the O.R. team to react to, was executed as planned.

"What makes this special is the collection of professionals running through the sequence, training together to perfect the surgical experience," Metcalfe Smith said. "When you're all training together, when you're continually working toward a common goal, then you can improve communication, which has a significant impact on safety and outcomes."

After surgery, the patient was prepared for transport and then transferred to the ICU, where the team handoff is conducted. The handoff is a crucial part of the medical care transition — the operating room team has to efficiently and accurately communicate what is going on with the patient. Cedars-Sinai has found that an enhanced handoff can dramatically reduce medical care issue during the first 24 hours after surgery, improving patient safety.

In the ICU, the team was tested with changing clinical scenarios that allow for very unusual but potentially very harmful clinical events.

After the procedure, Phillips and the O.R. and ICU teams met in a conference room for a step he considers as important as the surgery itself — the debriefing. Seated in a circle, team members asked and answered questions and raised issues they encountered during the simulation.

The general consensus from the surgical team: The simulation went well.

Discussion included technical glitches for the sim center team to deal with before the next simulation, and ways the surgical team could improve. From seemingly small changes, such as moving a medical device a few inches, to refining the information to offer when asked a direct question, the Congenital Heart Program's surgical team honed its approach.

In congenital heart surgery, where at any one time 10 people may be taking care of a patient, the team trumps the individual, Phillips said.

"After the scenario, you can adjust where people stand, change the position of the bypass machine, adjust where the scrub nurse stands in relation to the surgeon, and you get to see how each change affects communication," Phillips said. "The beauty of the sim center is that it has real, live information that is communicated to us exactly as we would see it in the O.R., and we can, in the safest way, review how it affects the patient."

The goal of the simulation was to improve patient safety through better teamwork.