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SAN FRANCISCO – Training residents to notify attending surgeons of any significant change in a patient’s condition greatly reduced the proportion of critical events that were not communicated to attending surgeons, from 33% to 2%, in a prospective study of four hospitals.
The current study was undertaken in response to a previous study by the same research group showing that ambiguity about who is responsible for communications contributed to communication breakdowns between attending surgeons and other members of the team at any point in patient care, Dr. Caprice C. Greenberg said at the annual clinical congress of the American College of Surgeons.
In the previous study, 444 malpractice claims were reviewed, and this process identified 60 cases in which communication breakdown resulted in harm to a patient. Dr. Greenberg and colleagues found that communication breakdowns related to surgery are equally likely to happen during preoperative, intraoperative, and postoperative care, and most commonly involve communications attempted between an attending surgeon and another attending surgeon, a resident, or the patient or family.
Ambiguity about who is responsible for communicating played a role in 58% of communication breakdowns, said Dr. Greenberg, director of the Wisconsin Surgical Outcomes Research Program at the University of Wisconsin, Madison.
Handoffs of patient care from one provider to another contributed to 43% of communication breakdowns, and transferring a patient to a different location contributed to 39% of communication breakdowns. The data also showed that an asymmetry in status between the two communicating parties contributed to 74% of message breakdowns ( J. Am. Coll. Surg. 2007;204:533-40).
Dr. Greenberg and her associates identified "triggers" that should prompt residents or nurses to contact attending surgeons, including a patient’s admission to a hospital, discharge, or a visit to an emergency department, transfer into or out of the ICU, unplanned intubation, or the development of cardiac arrest, new arrhythmia, or hemodynamic instability.
Significant neurologic changes, major wound complications, unplanned blood transfusion, an invasive procedure or operation, or errors in medication or treatment necessitating an intervention also should trigger communication with the attending surgeon. Even simply concern by a surgical trainee or a request from a nurse or another physician to contact the attending surgeon were considered triggers for communication.
The triggers were included in guidelines created by representatives of the four hospitals in Harvard University’s system in a collaboration organized by the system’s malpractice insurers. Under the new guidelines, residents were to notify attending surgeons of any significant changes in a patient’s condition regardless of the day or time. The residents would be trained to understand what qualifies as "significant changes" based in part on specialty-specific definitions, she said.
"What a urologist cares about is probably a little bit different from what a neurosurgeon or cardiac surgeon cares about," she explained.
A study of previous practices found that residents thought that 61 of 80 critical patient events (76%) did not need to be communicated to attending surgeons for safe patient care, and 26 events were not communicated (33%). Of the 54 events that were communicated, discussions with the attending surgeons changed management in 18 cases (33%). Attending surgeons responded to calls 100% of the time ( Ann. Surg. 2009;250:861-5).
"It wasn’t that the attendings didn’t want to be called. It was that residents either felt unempowered to call or they felt that it wasn’t necessary," she said.
Breakdowns in communication are common and play a significant role in adverse events, prior data suggest. One study of 48 surgeries found that 31% of 421 attempted communications between surgical team members failed, and approximately a third of these communication failures potentially jeopardized patient safety (Qual. Saf. Health Care 2004;13:330-4).
Other strategies to reduce the risk of errors during surgery include "workload leveling," Dr. Greenberg added. This means the attending surgeon should communicate frequently to members of the interdisciplinary surgical team about the status of the case and expected progression of the case, so that team members can manage their time and plan to do auxiliary tasks at the appropriate times. It’s probably impossible to avoid all errors, so surgeons need to find the right balance of error prevention and error mitigation through "resilience" – the ability to anticipate, cope with, recover from, and learn from unforeseen developments, she added. "To start to increase resilience, we really need to teach people adaptability and flexibility," she said.
Dr. Mary Klingensmith, a professor of surgery at Washington University, St. Louis, and Dr. John Hanks, a professor of surgery at the University of Virginia, Charlottesville, commented, "The conclusion of this study may seem obvious to those of us no longer in training – namely that residents should communicate critical patient events to attendings. Yet the imperative nature of such communication is not stressed adequately in our surgical training culture. In many training programs, there are some time-honored but outdated concepts in play, such as it is a "sign of weakness" to call the attending. Dr. Greenberg describes residents in this position as feeling "unempowered" to place such a call.
"We need to debunk this myth and explicitly instruct our residents about what we want and expect. Under the new paradigm, this accountability must include rapid and accurate transmittal of information with confidence on both the sending and receiving ends.
"The intervention put into place by Dr. Greenberg’s group did just that, laying out for trainees the patient events that should trigger a call to the attending. Interestingly, they reported that change in patient management, as a result of attending input, occurred in only 33% of cases in which the attending was called – a result suggesting that information transfer was merely that of the "FYI" variety. Yet in all instances, the attending wanted to be called.
"If the patient safety aspect of these communication triggers can be stressed, we can more effectively shape trainee behavior." ☐
Effective communication continues to be a problem as medical teams become more modular in their approach to patient care. Although methods of communication for residents have become ubiquitous, communication to the attending often does not occur in a reliable manner.
This study is an excellent example of improving patient safety by removing potential communication breakdowns. This prospective study by Dr. Greenberg created clear, documented expectations on when the attending should be notified by either a resident or nurse. As such, critical patient events were more effectively delivered to the attending. In a third of these notifications, the patient care plan was then changed. An interesting component of this study was the setting of expectations on both ends; when to call and when to be open to receiving a call.
This study is also a microcosm of the dilemma surgical education finds itself in when attempting to merge ideals of graded resident autonomy with safe patient care. Grey-haired residency stories abound of feats of technical magnificence as their attending slept. Yet, over time, increased scrutiny on accountability and improved outcomes has shortened if not changed the leash trainees are given. Resident autonomy though is based on effective, bi-directional communication guided by an attending.
More hospitals are adopting critical pathways which cause a mandatory notification to the attending. Potential exists for the resident to be marginalized, becoming an outsider in patient care. It is imperative that safety measures implemented in hospital programs include an educational component. Integrating the resident into algorithms that emphasizes their role in diagnosis and implementing a treatment plan is crucial.
Dr. Robroy MacIver is a pediatric cardiothoracic surgery fellow at Seattle Children’s Hospital and a resident editor of Thoracic Surgery News.
Effective communication continues to be a problem as medical teams become more modular in their approach to patient care. Although methods of communication for residents have become ubiquitous, communication to the attending often does not occur in a reliable manner.
This study is an excellent example of improving patient safety by removing potential communication breakdowns. This prospective study by Dr. Greenberg created clear, documented expectations on when the attending should be notified by either a resident or nurse. As such, critical patient events were more effectively delivered to the attending. In a third of these notifications, the patient care plan was then changed. An interesting component of this study was the setting of expectations on both ends; when to call and when to be open to receiving a call.
This study is also a microcosm of the dilemma surgical education finds itself in when attempting to merge ideals of graded resident autonomy with safe patient care. Grey-haired residency stories abound of feats of technical magnificence as their attending slept. Yet, over time, increased scrutiny on accountability and improved outcomes has shortened if not changed the leash trainees are given. Resident autonomy though is based on effective, bi-directional communication guided by an attending.
More hospitals are adopting critical pathways which cause a mandatory notification to the attending. Potential exists for the resident to be marginalized, becoming an outsider in patient care. It is imperative that safety measures implemented in hospital programs include an educational component. Integrating the resident into algorithms that emphasizes their role in diagnosis and implementing a treatment plan is crucial.
Dr. Robroy MacIver is a pediatric cardiothoracic surgery fellow at Seattle Children’s Hospital and a resident editor of Thoracic Surgery News.
Effective communication continues to be a problem as medical teams become more modular in their approach to patient care. Although methods of communication for residents have become ubiquitous, communication to the attending often does not occur in a reliable manner.
This study is an excellent example of improving patient safety by removing potential communication breakdowns. This prospective study by Dr. Greenberg created clear, documented expectations on when the attending should be notified by either a resident or nurse. As such, critical patient events were more effectively delivered to the attending. In a third of these notifications, the patient care plan was then changed. An interesting component of this study was the setting of expectations on both ends; when to call and when to be open to receiving a call.
This study is also a microcosm of the dilemma surgical education finds itself in when attempting to merge ideals of graded resident autonomy with safe patient care. Grey-haired residency stories abound of feats of technical magnificence as their attending slept. Yet, over time, increased scrutiny on accountability and improved outcomes has shortened if not changed the leash trainees are given. Resident autonomy though is based on effective, bi-directional communication guided by an attending.
More hospitals are adopting critical pathways which cause a mandatory notification to the attending. Potential exists for the resident to be marginalized, becoming an outsider in patient care. It is imperative that safety measures implemented in hospital programs include an educational component. Integrating the resident into algorithms that emphasizes their role in diagnosis and implementing a treatment plan is crucial.
Dr. Robroy MacIver is a pediatric cardiothoracic surgery fellow at Seattle Children’s Hospital and a resident editor of Thoracic Surgery News.
SAN FRANCISCO – Training residents to notify attending surgeons of any significant change in a patient’s condition greatly reduced the proportion of critical events that were not communicated to attending surgeons, from 33% to 2%, in a prospective study of four hospitals.
The current study was undertaken in response to a previous study by the same research group showing that ambiguity about who is responsible for communications contributed to communication breakdowns between attending surgeons and other members of the team at any point in patient care, Dr. Caprice C. Greenberg said at the annual clinical congress of the American College of Surgeons.
In the previous study, 444 malpractice claims were reviewed, and this process identified 60 cases in which communication breakdown resulted in harm to a patient. Dr. Greenberg and colleagues found that communication breakdowns related to surgery are equally likely to happen during preoperative, intraoperative, and postoperative care, and most commonly involve communications attempted between an attending surgeon and another attending surgeon, a resident, or the patient or family.
Ambiguity about who is responsible for communicating played a role in 58% of communication breakdowns, said Dr. Greenberg, director of the Wisconsin Surgical Outcomes Research Program at the University of Wisconsin, Madison.
Handoffs of patient care from one provider to another contributed to 43% of communication breakdowns, and transferring a patient to a different location contributed to 39% of communication breakdowns. The data also showed that an asymmetry in status between the two communicating parties contributed to 74% of message breakdowns ( J. Am. Coll. Surg. 2007;204:533-40).
Dr. Greenberg and her associates identified "triggers" that should prompt residents or nurses to contact attending surgeons, including a patient’s admission to a hospital, discharge, or a visit to an emergency department, transfer into or out of the ICU, unplanned intubation, or the development of cardiac arrest, new arrhythmia, or hemodynamic instability.
Significant neurologic changes, major wound complications, unplanned blood transfusion, an invasive procedure or operation, or errors in medication or treatment necessitating an intervention also should trigger communication with the attending surgeon. Even simply concern by a surgical trainee or a request from a nurse or another physician to contact the attending surgeon were considered triggers for communication.
The triggers were included in guidelines created by representatives of the four hospitals in Harvard University’s system in a collaboration organized by the system’s malpractice insurers. Under the new guidelines, residents were to notify attending surgeons of any significant changes in a patient’s condition regardless of the day or time. The residents would be trained to understand what qualifies as "significant changes" based in part on specialty-specific definitions, she said.
"What a urologist cares about is probably a little bit different from what a neurosurgeon or cardiac surgeon cares about," she explained.
A study of previous practices found that residents thought that 61 of 80 critical patient events (76%) did not need to be communicated to attending surgeons for safe patient care, and 26 events were not communicated (33%). Of the 54 events that were communicated, discussions with the attending surgeons changed management in 18 cases (33%). Attending surgeons responded to calls 100% of the time ( Ann. Surg. 2009;250:861-5).
"It wasn’t that the attendings didn’t want to be called. It was that residents either felt unempowered to call or they felt that it wasn’t necessary," she said.
Breakdowns in communication are common and play a significant role in adverse events, prior data suggest. One study of 48 surgeries found that 31% of 421 attempted communications between surgical team members failed, and approximately a third of these communication failures potentially jeopardized patient safety (Qual. Saf. Health Care 2004;13:330-4).
Other strategies to reduce the risk of errors during surgery include "workload leveling," Dr. Greenberg added. This means the attending surgeon should communicate frequently to members of the interdisciplinary surgical team about the status of the case and expected progression of the case, so that team members can manage their time and plan to do auxiliary tasks at the appropriate times. It’s probably impossible to avoid all errors, so surgeons need to find the right balance of error prevention and error mitigation through "resilience" – the ability to anticipate, cope with, recover from, and learn from unforeseen developments, she added. "To start to increase resilience, we really need to teach people adaptability and flexibility," she said.
Dr. Mary Klingensmith, a professor of surgery at Washington University, St. Louis, and Dr. John Hanks, a professor of surgery at the University of Virginia, Charlottesville, commented, "The conclusion of this study may seem obvious to those of us no longer in training – namely that residents should communicate critical patient events to attendings. Yet the imperative nature of such communication is not stressed adequately in our surgical training culture. In many training programs, there are some time-honored but outdated concepts in play, such as it is a "sign of weakness" to call the attending. Dr. Greenberg describes residents in this position as feeling "unempowered" to place such a call.
"We need to debunk this myth and explicitly instruct our residents about what we want and expect. Under the new paradigm, this accountability must include rapid and accurate transmittal of information with confidence on both the sending and receiving ends.
"The intervention put into place by Dr. Greenberg’s group did just that, laying out for trainees the patient events that should trigger a call to the attending. Interestingly, they reported that change in patient management, as a result of attending input, occurred in only 33% of cases in which the attending was called – a result suggesting that information transfer was merely that of the "FYI" variety. Yet in all instances, the attending wanted to be called.
"If the patient safety aspect of these communication triggers can be stressed, we can more effectively shape trainee behavior." ☐
SAN FRANCISCO – Training residents to notify attending surgeons of any significant change in a patient’s condition greatly reduced the proportion of critical events that were not communicated to attending surgeons, from 33% to 2%, in a prospective study of four hospitals.
The current study was undertaken in response to a previous study by the same research group showing that ambiguity about who is responsible for communications contributed to communication breakdowns between attending surgeons and other members of the team at any point in patient care, Dr. Caprice C. Greenberg said at the annual clinical congress of the American College of Surgeons.
In the previous study, 444 malpractice claims were reviewed, and this process identified 60 cases in which communication breakdown resulted in harm to a patient. Dr. Greenberg and colleagues found that communication breakdowns related to surgery are equally likely to happen during preoperative, intraoperative, and postoperative care, and most commonly involve communications attempted between an attending surgeon and another attending surgeon, a resident, or the patient or family.
Ambiguity about who is responsible for communicating played a role in 58% of communication breakdowns, said Dr. Greenberg, director of the Wisconsin Surgical Outcomes Research Program at the University of Wisconsin, Madison.
Handoffs of patient care from one provider to another contributed to 43% of communication breakdowns, and transferring a patient to a different location contributed to 39% of communication breakdowns. The data also showed that an asymmetry in status between the two communicating parties contributed to 74% of message breakdowns ( J. Am. Coll. Surg. 2007;204:533-40).
Dr. Greenberg and her associates identified "triggers" that should prompt residents or nurses to contact attending surgeons, including a patient’s admission to a hospital, discharge, or a visit to an emergency department, transfer into or out of the ICU, unplanned intubation, or the development of cardiac arrest, new arrhythmia, or hemodynamic instability.
Significant neurologic changes, major wound complications, unplanned blood transfusion, an invasive procedure or operation, or errors in medication or treatment necessitating an intervention also should trigger communication with the attending surgeon. Even simply concern by a surgical trainee or a request from a nurse or another physician to contact the attending surgeon were considered triggers for communication.
The triggers were included in guidelines created by representatives of the four hospitals in Harvard University’s system in a collaboration organized by the system’s malpractice insurers. Under the new guidelines, residents were to notify attending surgeons of any significant changes in a patient’s condition regardless of the day or time. The residents would be trained to understand what qualifies as "significant changes" based in part on specialty-specific definitions, she said.
"What a urologist cares about is probably a little bit different from what a neurosurgeon or cardiac surgeon cares about," she explained.
A study of previous practices found that residents thought that 61 of 80 critical patient events (76%) did not need to be communicated to attending surgeons for safe patient care, and 26 events were not communicated (33%). Of the 54 events that were communicated, discussions with the attending surgeons changed management in 18 cases (33%). Attending surgeons responded to calls 100% of the time ( Ann. Surg. 2009;250:861-5).
"It wasn’t that the attendings didn’t want to be called. It was that residents either felt unempowered to call or they felt that it wasn’t necessary," she said.
Breakdowns in communication are common and play a significant role in adverse events, prior data suggest. One study of 48 surgeries found that 31% of 421 attempted communications between surgical team members failed, and approximately a third of these communication failures potentially jeopardized patient safety (Qual. Saf. Health Care 2004;13:330-4).
Other strategies to reduce the risk of errors during surgery include "workload leveling," Dr. Greenberg added. This means the attending surgeon should communicate frequently to members of the interdisciplinary surgical team about the status of the case and expected progression of the case, so that team members can manage their time and plan to do auxiliary tasks at the appropriate times. It’s probably impossible to avoid all errors, so surgeons need to find the right balance of error prevention and error mitigation through "resilience" – the ability to anticipate, cope with, recover from, and learn from unforeseen developments, she added. "To start to increase resilience, we really need to teach people adaptability and flexibility," she said.
Dr. Mary Klingensmith, a professor of surgery at Washington University, St. Louis, and Dr. John Hanks, a professor of surgery at the University of Virginia, Charlottesville, commented, "The conclusion of this study may seem obvious to those of us no longer in training – namely that residents should communicate critical patient events to attendings. Yet the imperative nature of such communication is not stressed adequately in our surgical training culture. In many training programs, there are some time-honored but outdated concepts in play, such as it is a "sign of weakness" to call the attending. Dr. Greenberg describes residents in this position as feeling "unempowered" to place such a call.
"We need to debunk this myth and explicitly instruct our residents about what we want and expect. Under the new paradigm, this accountability must include rapid and accurate transmittal of information with confidence on both the sending and receiving ends.
"The intervention put into place by Dr. Greenberg’s group did just that, laying out for trainees the patient events that should trigger a call to the attending. Interestingly, they reported that change in patient management, as a result of attending input, occurred in only 33% of cases in which the attending was called – a result suggesting that information transfer was merely that of the "FYI" variety. Yet in all instances, the attending wanted to be called.
"If the patient safety aspect of these communication triggers can be stressed, we can more effectively shape trainee behavior." ☐
Major Finding: Residents failed to inform attending surgeons of critical patient events in 26 of 80 cases (33%) before adoption of new guidelines, and in only 1 of 47 cases (2%) after the intervention.
Data Source: Prospective studies at four hospitals before and after adoption of guidelines requiring residents to inform attending surgeons of any significant change in patient status.
Disclosures: Dr. Greenberg said she has no relevant conflicts of interest.