"Going through introductions at the beginning of the surgery and planning out parts of the case is really helpful. I find it immensely useful when everyone knows everyone's name - makes for a much better personal team that works together, fosters respect. Also, during the brief, we talk about what we might find, how long the surgery might take, how to accommodate needs like Trendelenburg positioning, etc. We identify all the instruments we might need...TeamSTEPPS has also taught to be more aware personally of the things I bring to the OR, to think more carefully about being fed, hydrated, rested, and ready. If pages come through for myself or for the residents, I now more frequently just take a second and stop the case while the information is being conveyed rather than try to multitask as most of us impatient surgeons do. If the case isn't going well, sometimes I'll just take 5, pause, put the endoscope down, take a deep breath and, when ready, start going again...These are some of the ways TeamSTEPPS has influenced me. Overall, I have a very positive impression of the program and it's impact on my operating room."
"We did a multidisciplinary TeamSTEPPS briefing/debriefing on Tuesday morning prior to beginning fetal surgery. This involved a team of approximately 15 members, it was awesome. I was so proud to be a part of this process!"
"Kudos and High Fives! to several Family Medicine, Orange County Emergency EMS, and Emergency Department staff for facilitating the care of a patient who walked into the Family Medicine Center (Corner of Manning Drive and Fordham Boulevard) this morning. Ninety one minutes after the patient walked into the Family Medicine Center complaining of jaw pain she was in UNC's Cardiac Cath Lab. It is not a stretch at all to say that this episode was in part due to FMC staff going to TeamSTEPPS training a month ago. We’ve started to debrief after every transfer to the ED and the suggestions and learnings from those debriefs helped improve this patient’s experience."
There was a patient that I was caring for on the PICU that was on an unconventional mode of ventilation. It was unusual for me to be in the PICU but I was there to monitor a patient on the VDR-4 ventilator, which is common in the BICU but not the PICU. While I was in my patient’s room, I noticed a bit of activity in the room next door. There was an infant on a ventilator and I noticed concern on the face of the nurse caring for the infant so I left my patient and went to see if I could help her. For some reason, the patient was not oxygenating, her saturations were trending downward and her heart rate was starting to slow down. I increased the oxygen on the ventilator and the nurse called for help from others on the PICU team. One respiratory therapist, another nurse, the PICU attending, PICU Fellow and two residents entered the room immediately. Within 2 minutes, the patient had desaturated to a dangerous level and her heart rate was below 70.
The attending physician immediately took control as the team leader and in a calm and reassuring manner he asked direct questions actually using the names of the caregivers he was directing the questions to in order to figure out what may have happened to the patient to cause the desaturations. Other caregivers were shouting out vital signs as they were needed without being questioned; as if there was a shared mental model already at work with the staff who were used to working together in the PICU. When the attending physician asked for medication doses, there were check backs by the nursing staff. When he asked for the nurse to give another dose, there were always check backs by the nursing staff without hesitation. When ventilator parameters needed to be changed, the RT would tell the team what she was doing and the attending physician acknowledged the changes and said them back and said thank-you after each check back. It was truly like watching a well oiled machine-all to save a very sick infant under their care.
Within about 3-5 minutes, the medications that had to be given to get this patient back to her normal situation had been given. Tests to make sure she was okay had been ordered and done. Before I knew it, the team had completed their work using all the Team STEPPS skills that had been taught and then some! By the time I left the room, the patient was fine.
Just before Thanksgiving there was a 30 YOM who was admitted form an outside hospital to the MICU with H1N1. He was deteriorating very quickly and within 2 hours of being admitted to the MICU, it was determined that the only thing that would save him was ECMO. Very quickly he was moved to the SICU so that he could be cannulated and placed on ECMO. The cannulation process is extremely complicated and the procedure can have many complications associated with it if it is not done by experienced care givers which include physicians, nurses, respiratory therapists and perfusionists. Due to the complicated procedure and the fact that it can be very nerve racking, the ECMO caregivers involved with the cannulation process all need to be in control of the situation once a decision is made to start ECMO.
Immediately after the patient arrived to the SICU, even though everyone was scurrying to get their equipment ready, the attending physician informed all that were involved that he planned to have a huddle at 10pm and that everyone involved with the cannulation had to be there. Shortly after informing everyone of the exact time for the huddle, he went to speak to the family members.
At 10 pm, all nurses, RTs and residents listened to the attending physician who was considered the leader of the ECMO cannulation process. He dictated which residents would be assisting him and where they would stand at the bedside. Each responded that they understood. He asked one nurse to record what was going on and the other was to assist the physicians with the cannulation. He asked the ECMO specialists to continue to build and maintain the circuit until he was ready for them to make the necessary connections. So, everyone was told their role before the attending physician did the time out to check patient identification.
During the cannulation, the attending physician was the only one in the room who would call out instructions, (using staff names). He was in total control, being calm but serious during the cannulation calling out what he needed at any given time. The nurses would do check backs for every call out, being very smooth and efficient throughout the procedure which I am sure made the attending physician confident that she was always doing the right thing. His focus had to be on inserting the cannulas so he could not look up from the insertion sites. When the physicians were ready to make the tubing connections, a call out was made to the respiratory therapists who seemed to know already what was expected of them at the crucial time they made the connections from the ECMO pump to the cannulas which were now inserted into the patient. Since the team has done this quite a few times, there was clearly a shared mental model happening at this time between the nurses, the attending physician and the respiratory therapists.
Watching the attending physician and the patient’s caregivers was like watching a conductor lead musicians in an orchestra in a perfect rendition of Beethoven’s 5th symphony. I believe that the staff’s commitment to Team STEPPS skills led to a very calm and effective cannulation process lead by an attending who used all the Team STEPPS skills during the procedure and with staff assisting who did the same.