“Analysis of medical errors has shown that more than two-thirds involve issues of team communication, and these are contributed to by issues of institutional and team culture. These errors can include missed communication, inaccurate communication, or inability or unwillingness of team members to speak up—all of which can be related to the culture of a team or institution and which are dramatically affected based on the tone and climate set by surgeon leaders, both in and out of the operating room. Every team and institution have a “safety culture”—the attitudes, behaviors, and expectations that affect patient outcomes for good or for ill. There is increasing evidence that this safety culture directly affects both morbidity and mortality. For example, in a study of 31 hospitals in South Carolina, institutional safety culture was directly related to patient death. For every 1-point change (on a 7-point scale) in the hospital-level scores for respect, clinical leadership, and assertiveness, 30-day mortality after surgery decreased from 29% to 14%. In another example, measures of safety culture across 22 hospitals in Michigan directly predicted patient outcomes after bariatric surgery. In that study, when nurses rated coordination of OR teams as acceptable, rather than excellent, serious complications were 22% more likely.
The Operating Room Team
The act of surgery is inherently team-based. Each operation requires the surgeon to work closely and effectively with their assistants, anesthesia providers, nursing staff, surgical technologists, and ancillary staff members to make the OR function. Team members frequently move in and out of the OR, with change of shift or for breaks, and additional team members may be required for specialty or emergency care. The key is to remember that the patient is at the center of the team, thus the phrase “patient-centered care.” Always keep in mind that patient safety and well-being are at the heart of all our efforts. It is especially important that all members of the team have a “shared mental model”—a common understanding of the issues, both medical and logistical, which might affect the course of an operation. This allows for improved efficiency, better situational awareness, and better ability to recognize and respond to issues. Here we describe the individuals commonly encountered in the operating room.
Every surgical team will consist of an attending surgeon, usually accompanied by one or more assistants. In the learning environment, it is important for the surgeons to discuss roles and responsibilities as well as educational goals for the case, which may vary depending on the level of training and experience of the team members. An important concept in surgical education is “progressive autonomy,” in which learners are allowed to take on more and more responsibility in an operation based on their level of competency. A preoperative discussion between the surgeon and the resident is critical to clear understanding of which parts of the operation the learner can be expected to perform and when the attending might need to take control of the case. It is the responsibility of every member of the surgeon’s team to review the patient’s case in detail to understand their past medical and surgical history, their current disease and how it has been managed to date, relevant medications, and review of all diagnostic studies to anticipate difficulties that may be encountered during the operation. Secondarily, it is incumbent on each member to discuss the case with other members of the team to ensure that all individuals have a shared mental model of the operative plan, the postoperative plan, and any anticipated difficulties. During the operation, the patient is the focus of the team. Each individual is expected to do their part to advance the operation while helping other team members to do the same. Following the operation, it is important to discuss postoperative care such as pain management, dietary restrictions, venous thromboembolism prophylaxis, and the need for new or existing prescription medications.
Scrub Nurse and Circulator
Working closely with every surgical team is the surgical technologist or scrub nurse, often referred to as the “scrub.” This individual will have various levels of training depending on their background—he or she may be a certified surgical technician or a nurse with extra training. The scrub is an integral part of the team as they are responsible for ensuring that all necessary equipment is open or readily available prior to the case starting, anticipating the needs of the surgeon to maximize efficiency, and troubleshooting when there are equipment problems or failures. Depending on the scope of practice as defined by state law and regulations, the scrub may or may not be authorized to assist with limited surgical tasks. It is the responsibility of the surgeon (or surgical resident in their place) to meet with the scrub ahead of time, confirm that all necessary equipment is available, and confirm this during the surgical pause or “time-out.” Doing so will foster a collegial environment while also helping the case run more smoothly. The circulator is typically a nurse by training who is responsible for maintaining the flow of the OR, while the surgeons are sterilely gowned and gloved. It is important (especially for new residents) to introduce yourself to the circulator to open the flow of communication for the day and to give them a baseline understanding of your skill level so that they can assist you as necessary. For example, the circulator may pay extra close attention to the medical student as they don their sterile gown and glove to ensure that they do not break the sterile field. Throughout the case, the circulator works to maintain the flow of the OR. As such, the circulator is not always available to assist in tasks not related to the direct care of the patient.
The Anesthesia Team
Without the anesthesia team, the surgeon cannot operate. The anesthesia team consists of either an attending anesthesiologist who is present for the duration of the case or an anesthesia resident or certified registered nurse anesthetist (CRNA) who is supervised by an attending anesthesiologist who may be overseeing several operations at once. In some states, depending on state law, a CRNA can also practice independently. The anesthesia provider is often helped by an anesthesia technician, much like the surgeon is helped by a surgical technician. The anesthesia team is responsible for providing pain control and sedation, managing the airway, medical and fluid management throughout the case, and monitoring the patient for any physiologic derangements that may or may not be related to the operation at hand. They should meet the patient ahead of time to evaluate for any risk factors such as underlying cardiovascular or pulmonary disease. Communication with the anesthesia team is critical for maintaining the safety and well-being of the patient. One of the most important tools to promote this communication is the surgical pause or “time-out”. Throughout the case, the surgical team must also alert the anesthesia team if they anticipate significant hemodynamic changes for the patient. This can range from events as common as insufflation of pneumoperitoneum during a laparoscopic operation to more uncommon events such as unexpected, significant hemorrhage. Conversely, it is imperative that the anesthesia team communicates with the surgeon about any significant changes in hemodynamic status or about other issues that may impact patient care. Finally, it is important to debrief with anesthesia at the end of the case, to ensure that all members of the team have the same situational awareness and understanding of the patient’s intraoperative course and postoperative plan. This includes issues such as fluid and electrolyte management, expected or potential postoperative issues, and a plan for pain management.