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Evidence-Based Nursing

I. Clinical Question

How effective is the impact of operating room briefings on coordination of

care and risk for wrong-site surgery?

II. Citation

Operating Room Briefings and Wrong-Site SurgeryMartin A Makary, MD, MPH, Arnab Mukherjee, BA, J Bryan Sexton, PhD, Dora Syin,BS,Emmanuelle Goodrich,MPH, Emily Hartmann, MSS, Lisa Rowen, RN, DScN, Drew CBehrens,Michael Marohn,DO, FACS, Peter J Pronovost, MD, PhD

III. Study Characteristics

1. Patients included

There were 11 surgeons (7 general surgeons, 2 plastic surgeons, and 2

neurosurgeons) who agreed to implement briefings after 2 months of baseline

data collection. A case-based OR SAQwas administered to OR staff, including

physicians and nurses, at an academic medical center for 2 months before

initiation of an OR briefing program. Sampling was not used because of small

sample sizes of diverse caregiver roles in the OR, which would threaten the

generalizability of the data. Instead, a high response rate was sought to capture

the representative perceptions of each caregiver type in the OR.

2. Interventions compared

We used a pre- and postdesign in which we measured perceptions of briefings

and awareness of the surgical site and side for 5 months: we implemented

ORbriefings for 3 months and then measured collaboration and awareness of

surgical site and side for 2 months. We used a case-based version of the Safety

Attitudes Questionnaire (SAQ, OR version) called the OR Briefing Assessment

Tool (ORBAT), starting in May 2005. To assess OR briefings, we surveyed

caregivers as they exited their first case of the day to capture the effectiveness of

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care coordination and wrong-site surgery prevention during that case. The study

site included the general operating rooms in an academic medical center.

3. Outcomes Monitored

The prebriefing response rate was 85% (306 of 360 respondents), and the

postbriefing responserate was 75% (116 of 154). Respondents included

surgeons (34.9%), anesthesiologists (14.0%), and nurses (44.4%). Briefings

were associated with caregiver perceptions of reduced risk for wrong-site surgery

and improved collaboration [F (6,390) 10.15, p 0.001]. Operating room

caregiver assessments of briefing and wrong-site surgery issues improved for 5

of 6 items, eg, Surgery and anesthesia worked together as a well-coordinated

team (67.9% agreed prebriefing, 91.5% agreed postbriefing, p 0.0001), and A

preoperative discussion increased my awareness of the surgical site and side

being operated on (52.4% agreed prebriefing, 64.4% agreed postbriefing, p

0.001).

4. Does the study focus on a significant problem in clinical practice

Yes, this studysignificantly aim to reduce perceived risk for wrong-site surgery

and improve perceived collaboration among OR personnel.

IV. Methodology/Design

Survey questions were developed by generating a case based version of the

SAQ teamwork and patient safety related items, which we have found to be

associated with outcomes and error rates. The 17-question survey consisted of

questions relating to the awareness and understanding of the surgical site,

willingness to speak up when problems were perceived, and the quality of

teamwork and communication between caregivers in the OR. Response options

for each item ranged from 1 (disagree strongly) to 5 (agree strongly). The

dependent variables were six survey questions related to briefings and wrong

site operations: 1) A preoperative discussion increased my awareness of the

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10.15, p 0.001, indicated that OR caregivers assessed briefings and wrong-site

surgery-related issues differently after the briefing intervention. OR caregiver

assessments of briefing and wrong-site surgery issues improved for five of the

six items: A preoperative discussion increased my awareness of the surgical site

and side being operated on (52.4% agreed pre, 64.4% agreed post); The

surgical site of the operation was clear to me before the incision (88.2% agreed

pre, 96.6% agreed post); Surgery and anesthesia worked together as a well -

coordinated team (67.9% agreed pre, 91.5% agreed post); Decision making

utilized input from relevant personnel (78.7% agreed pre, 89.6% agreed post);

Team discussions are common in the ORs here (37.4% agreed pre, 48.3%

agreed post). The only item that did not improve was, A team discussion before

a surgical procedure is important for patient safety, for which responses were

favourable both pre- and postintervention (94.0% versus 93.3%, respectively).

Table 2 presents the means and confidence intervals for each of the six items

pre- and post-groups, and Figure 2 presents the percent agreement and percent

disagreement for each item pre- and post-intervention.

VI. Authors conclusion/recommendations

OR briefings significantly reduce perceived risk for wrong-site surgery and

improve perceived collaboration among OR personnel. (J Am Coll Surg

2007;204:236243. 2007 by the American College of Surgeons)

We recognize that there are some important limitations to this study. First, we

used caregiver assessments of issues related to briefings and wrong-site

operations on the ORBAT, rather than rates of wrong-site surgery. The six items

reported here may not correlate with actual wrong-site operations. But scores on

the SAQ are associated with important clinical and operational outcomes in the

OR. Second, we used a pre- and postdesign without a control group, rather than

a more robust randomized design, and this could introduce bias. Because nurses

and anesthesiologists work with multiple surgeons, and the intervention required

training of staff, we believed a randomized design was not feasible in this early

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stage of the research, because teams would be contaminated with clinicians who

were trained in briefings.

VII. Applicability

In the future, we can study the impact of briefings on caregiver attitudes related

to teamwork and patient safety and care coordination behaviors. Briefings may

be beneficial before bedside procedures are performed in the inpatient setting, or

at the start of a day or shift to proactively plan for potential problems. Briefings

before procedures may also be valuable in reducing adverse events in the

outpatient setting. Although briefings are not a panacea for what ails care

coordination in healthcare, they do have the potential to fill many of the gaps

created by production pressures; staffing problems; high levels of acuity; and

lack of familiarity with environments, people, or procedures.

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