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14 Teamwork andCommunication Simulation toImprove Safety intheOR
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Simulation in surgical specialties has been used largely for training and educational purposes; its growth has been driven not only by the patient safety movement,
but also by technological advances in imaging, computing, virtual reality, and threedimensional printing [13]. These changes have happened concurrently with restrictions placed on resident and fellow work hours in 1999 for ACGME (Accreditation
Council for Graduate Medical Education)-based training programs, which reduced
surgical case experience [14]. In part due to these factors, the American Residency
Review Committee for Surgery has mandated skills training labs for surgical residency programs since 2008 [15]. In neurosurgery, simulators are available for general surgical techniques, life-saving emergency procedures (e.g., ventriculostomy,
decompressive craniectomies), critical care emergencies (e.g., spinal shock, cerebral vasospasm), vascular neurosurgery, and minimally invasive neurosurgery [13].
Plastic surgery similarly has developed simulators for vascular anastomosis microsurgery, as well as sophisticated simulators for specic procedures such as craniosynostosis repair, which can simulate surgical bleeding and may even be imaged
pre- and post-operatively. A children’s hospital-based simulation program has
developed an extensive two-day-long simulation experience for their residents featuring 11 of the most common pediatric orthopedic procedures, using a combination
of cadavers and synthetic bones. (See https://www.youtube.com/watch?v=7fG_-
hRrBjE). While not used for teaching directly, computer simulation is also used
extensively to predict a desired outcome and establish surgical planning for cosmetic plastic surgery uses [16].
Simulation has similarly grown in its role in nursing education and in interdisciplinary team training involving nurses, physicians, and other healthcare practitioners.
In 2009, the Carnegie Foundation for Advancement of Teaching’s National Nursing
Education Study launched Educating Nurses: A Call for Radical Transformation
prompting curricular and pedagogic changes to nursing education programs nationwide, including increased incorporation of simulation [17]. The International Nursing
Association for Clinical Simulation and Learning (INACSL) publishes standards of
best practices for nursing simulation, for a variety of simulation types from task trainers (e.g., IV placement) to high-delity, in situ simulators [18, 19].
231
Applying Simulation toPatient Safety Issues
Numerous patient safety concerns may be addressed by simulation exercises:
• Communication failures
• Teamwork inadequacy
• Infrequency of critical event practice
• Patient risk in practicing technical skills
• Cognitive load during critical events (use of cognitive aids)
• Poor patient safety culture
• Identifying risks of new facilities and processes
• Root cause analysis
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J. L. Sparling and J. B. Cooper
Communication
Cross-disciplinary communication is essential for the delivery of safe patient care and
has been shown to be enhanced by simulation exercises [20]. Conversely, communication failures are a common contributing cause to patient harm [21]. Simply providing a safe environment for practice can reduce barriers in communication between
nursing, anesthesiology, and surgery practitioners, reducing dependence on situation
factors or individual personalities. Further, specic communication practices such as
closed-loop communication can be taught. Standardized communication tools are
increasingly being developed and utilized in the perioperative environment, and training on these handoff tools is enhanced by simulation [20, 22–24].
Teamwork
Teamwork concepts adapted from the aviation industry are critical to both preventing
and rescuing from unanticipated critical events. Crisis resource management (CRM),
also adapted from aviation, is now widely recognized as a process that can enable
effective teamwork in such events [25]. Effective teamwork requires that there is
clearly dened leadership, that team members have mutual respect, for one another
and that tasks, goals, and key information are shared to enable each member to do
their job well. Simulation-based CRM and teamwork training have been shown to
improve teamwork behaviors and reduce the rate of errors during event management
[26]. For example, a recent study of a post-operative OR-to-ICU handoff bundle in
the cardiac surgical ICU, consisting of a four-hour handoff simulation and debrieng
session, reported improvements in team leadership, communication, coordination,
and cooperation that were sustained 2.3 years following their initial deployment [27].
Critical Event Practice
In the perioperative environment, harmful critical events happen infrequently, yet
they demand our best performance and the utilization of many specialized resources.
Simulation aids in preparing for these events by allowing clinicians to practice and
to familiarize themselves with appropriate resources. Simulation-based practice
aims to make instinctive personal and team-based behaviors that will be essential
during a stressful, high-risk situation [28]. For example, pediatric OR staff, who
were largely untrained in pediatric advanced life support (PALS), were studied in a
two-part high-delity simulation experience. They underwent an initial high- delity
simulation with an intraoperative pediatric emergency involving airway management and recognition of an arrhythmia requiring debrillation. They subsequently
underwent an educational debrieng and hands-on training session with the debrillator. One month later, they again participated in a similar simulation session where
objective improvements in performance were achieved, including time to obtain the
code cart and time to debrillation [29]. Similarly, early simulation-based training
for recognizing and treating hypoxemia and hypotension among novice anesthesiology residents resulted in improved performance on a standardized checklist over a
14 Teamwork andCommunication Simulation toImprove Safety intheOR
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233
6-week time period. Thus, simulation can play a role not only in ongoing training
for critical events, but also in accelerating the acquisition of specic management
skills in learners new to the perioperative environment [30].
Technical Skills
Perioperative medicine involves procedures with inherent risk to the patient.
Simulation allows practitioners to practice these skills in a controlled environment, of
delity appropriate to the learning objectives, without exposing patients to risk.
Studies have shown improved outcomes with simulation-based placement of peripheral and central venous lines, [31, 32] sterile technique, [33] airway management,
[34–36] open and laparoscopic surgical skills, [37, 38] and blood pressure measurement [39]. In one surgical residency program, new interns participate in a day-long
simulation boot camp with hands-on practice in endoscopy, laparoscopy, bronchoscopy, and abdominal surgical access. After the one-day session, both mean skill
assessment and self-condence ratings improved signicantly across all four topics
[40]. Similarly, surgical personnel of different levels (medical student through attend-
ing) used a simulated model for preperitoneal mesh repair of an umbilical hernia; they
were assessed by blinded raters using a competency assessment tool (CAT).
Participation in the simulation experience was associated with statistically signicant
learning increase from the rst to the second surgery among beginners [41] (Fig.14.1).
Use ofCognitive Aids
Discussed elsewhere in Chap. 4, the use of checklists and cognitive aids, often
adapted from other high-risk industries such as nuclear power and aviation, has
been shown to improve patient outcomes in numerous environments. They can be
Fig. 14.1 A surgical
trainee practices robotic
knot-tying, courtesy of the
Massachusetts General
Hospital Surgical Skills
Laboratory
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J. L. Sparling and J. B. Cooper
applied for crisis management and for routine tasks. Perioperative cognitive aids are
increasingly being used as a tool to help manage acute situations, especially those
not commonly encountered. However, familiarity with the tool is necessary in order
for it to be useful during an emergency, and simulation using the tools helps to
achieve this. It is well known that cognition and memory may be blurred during
times of stress and can be degraded by distractions during emergent perioperative
events. An emergency manual consisting of numerous checklists for relatively infrequent, but still likely to be encountered, events has been demonstrated via simulation to be effective in improving event management, for example, reducing the
number of errors or missed critical steps [42, 43]. The Emergency Manual
Implementation Collaborative has assembled examples of such manuals and advice
for effective implementation [44]. The Stanford Emergency Manual contains guides
for management of 25 critical events in the OR, as well as tips for crisis resource
management. While these and other such cognitive aids are similar in concept, they
differ in the way they are organized and presented. It is not clear which approach is
optimal, but there is mounting evidence of the value of such tools (Fig.14.2).
Fig. 14.2 Cover and index
page for the Stanford
Emergency Manual, used
with permission from
D.Gaba, Stanford
Anesthesia Cognitive Aid
Group
14 Teamwork andCommunication Simulation toImprove Safety intheOR
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Cognitive aids have also been implemented for the many different situations
where responsibility for a patient is transferred from one provider or team to another,
the process known as a handover or handoff. Many different forms of handoffs and
cognitive aids for enabling them have been developed [45–47]. There is evidence
that the use of a standardized handoff tool decreases technical errors and handoff
omissions [48, 49]. Yet there is not yet good evidence for what format of cognitive
aid is best, nor have many other questions about the use of handoff processes or
tools been answered. A recent consensus process reported recommendations for
many aspects of handoff practices [50].
Research, evaluation, and training for the use of cognitive aids and processes like
handoffs are enabled, and greatly benet from the use of simulation.
235
Developing aPatient Safety Culture
Patient safety culture is dened as “an organization’s shared perceptions, beliefs,
values, attitudes, and competencies that combine to create a commitment to safety
and an effort to minimize harm.” [51] While safety culture is difcult to measure,
surveys of safety attitudes have been correlated with important outcomes such as
professional burn-out and engagement. Further, hospitals with better scores on
patient safety climate, as demonstrated on surveys, have better scores on patient
safety indicators, specically among frontline personnel [52].
It serves to reason that simulation enhances safety culture, for example, by
emphasizing an organization’s commitment to improvement and practicing for
emergencies; yet, to date little research has been performed examining the relationship between safety attitudes and participation in simulation [53]. Interdisciplinary
surveys have shown opportunity for improvement in safety culture through the use
of CRM simulation [54].
Forms ofSimulation
Medical simulation exists in many forms to meet diverse goals and suit difference
audiences. Gaba describes 11 dimensions of simulation applications which may be
tweaked to optimize outcomes and to derive maximal benet from the simulation
experience [2]. These 11 dimensions are described in Fig. 14.3. Some of these
dimensions represent a spectrum from one extreme to another, while other dimensions are simply categorical distinctions. While many permutations of options
across different dimensions have been described, many more options remain to be
explored.
For example, simulation may serve any of a number of different purposes,
including education, training, performance assessment, clinical rehearsal, and
human factors research. Medical students may participate in simulation as an initial learning exercise for procedural skills, such as intubation, arterial line placement, lumbar puncture, and central line insertion, [55] while surgical residents
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Fig. 14.3 The 11
dimensions of simulation
application. Used with
permission from Gaba [2]
J. L. Sparling and J. B. Cooper
may use simulation as training to hone technical surgical skills (Fig.14.4) [15].
Various medical organizations now use simulation as means of performance
assessment for licensure and board accreditations. The United States Medical
Licensing Exam (USMLE) Step 2 clinical skills (CS) exam was one such assessment that is required for physicians to gain initial licensure in the United States,
wherein medical students interviewed and examined standardized patients in
14 Teamwork andCommunication Simulation toImprove Safety intheOR
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Fig. 14.4 A simulation
mannequin, illustrating a
thoracoabdominal gunshot
wound. Courtesy, Center
for Medical Simulation
237
order to demonstrate clinical skills and come to a diagnosis and treatment plan
[56]. The USMLE Step 2 CS exam was discontinued during the COVID-19 pan-
demic, and replaced by computer-based case simulations in the Step 3 exam.
Clinical rehearsal includes simulations geared toward practicing use of emergency manuals and critical events [44]. Finally, simulation has been used broadly
in human factors research. For example, simulation experiences based on previously experienced real-life adverse events, including errors in drug infusion pump
programming, have been used to discern factors contributing to errors during the
simulation debrief sessions [57].
The unit of participation in simulation also varies from individual use through
a crew, team, or other work unit, all the way up to an entire organization. These
units may represent a single discipline focused on skills or behaviors specic to
their purview, such as a surgeon training to tie knots laparoscopically [58].
Alternatively, a unit may include several different disciplines working together
to optimize team performance and response to critical events as a team
[26, 59–63].
The site of simulation is another dimension across which experiences can vary
in order to suit particular needs. Simple simulations may be presented as a computer program-based case where the participant steps through clinical decisions
in a progression; indeed, some of the earliest medical simulations were of this
type [11]. In the surgical specialties, simulation tends to focus on technical skills
and thus may be more likely to take place in a skills lab. In a 2017 systematic
review, 41.9% of the simulation programs studied took place in a skills lab, while
only 6.5% took place in a dedicated simulation center [15]. However, the earliest
modern simulation was conducted in a replica of an OR, and today simulation
centers have developed high- delity simulators where participants train together
in a realistic replica of an operating room or in situ in a real operating or procedure room. Fig.14.5 is an example of one such simulator. Successful simulation
interventions may be conducted in a number of different sites; however, it is not
clear that training in a simulation center enhances outcomes compared with hospital-based simulations [59]. Fig. 14.6 illustrates simulation in an out-of-OR
environment.
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Fig. 14.5 View of a
high-delity simulated
operating room, from the
control room. Courtesy,
Center for Medical
Simulation
Fig. 14.6 Typical
out-of-OR simulation
environment and
illustrative pediatric
mannequin. Courtesy,
Center for Medical
Simulation
J. L. Sparling and J. B. Cooper
Debriefing
Debrieng is a, or perhaps the, critical element of simulation exercises. Debrieng
had its origins in the military where individuals reported back following a mission,
and the report was analyzed and strategy for ongoing missions developed. It was
further developed for psychological reasons as a way to defuse following a traumatic
event [64]. Since then, critical incident stress debrieng (CISB) was developed as a
facilitator-led approach to review facts, experiences, and reactions among emergency
rst responders [65]. The skill used in debrief simulation scenarios is easily extended
into debrieng following a critical event, both for the purpose of identifying causative factors, as well as for the purpose of supporting clinicians affected as second
victims [64]. Debriefs typically occur following the conclusion of a simulation session, but a “time-out” during the scenario may also provide an opportunity for
debrieng (see Table14.1). The conventional wisdom is that debriengs should be
led by a trained facilitator, but it has also been advocated that participants can debrief
themselves via self-reection using various conversational structures [66].
14 Teamwork andCommunication Simulation toImprove Safety intheOR
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Table 14.1 Overview of Healthcare Simulation Debrieng Methods. Used with permission from
Sawyer etal. [66]
Process elements
Conversational
techniques/
Timing and
facilitation
Facilitatorguided
postevent
debrieng
Self-guided
postevent
debrieng
Facilitatorguided
withinevent
debrieng
Conversational
structure
• 3-phase
• Multiphase
Cognitive aid
driven
Event/
performance
focused
Essential elements
• Psychological
safety
• Debrieng
stance or basic
assumption
• Establish
debrieng
rules
• Shared mental
model
• Address
learning
objectives
• Open-ended
questions
• Using silence
• Psychological
safety
• Debrieng
stance or basic
assumption
• Establish
debrieng
rules
• Shared mental
model
• Address
learning
objectives
• Open-ended
questions
• Using silence
• Psychological
safety
• Debrieng
stance or basic
assumption
• Establish
debrieng
rules
• Shared mental
model
• Address
learning
objectives
• Open-ended
questions
• Using silence
Educational
strategies
• Learner
selfassessment
• Directive
feedback
• Circular
questions
• Advocacy
inquiry
• Guided
team
selfcorrection
• Learner
selfassessment
• Guided
team
selfcorrection
• Learner
selfassessment
• Directive
feedback
• Circular
questions
• Advocacy
inquiry
Debrieng
adjuncts
• Codebriefer
• Debrieng
script
• Video
review
• Debrieng
script
• Video
review
• Codebriefer
• Video
review
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There are numerous approaches to debrieng [9]. There is no solid empirical
evidence for what method is best in general, nor exactly when to use each approach.
Yet there are generally accepted suggestions for what situations call for what type
of debrieng. Debrieng is a skill that requires great self-awareness of the debriefer
and for which many training programs are offered around the world. For example,
the Debrieng Assessment for Simulation in Healthcare (DASH) program is used to
develop debrieng skills and evaluate debrieng effectiveness; it takes into account
the evidence and theory behind adult experiential learning, and it provides frameworks that may be used across disciplines and courses [67].
J. L. Sparling and J. B. Cooper
Simulation inPerioperative Care
Perioperative care has many opportunities for improvement in patient safety through
simulation. All of the elements listed in previously (see “Applying Simulation to
Patient Safety Issues”) have application in the perioperative environment, from
when a patient rst enters the pre-operative preparation space to leaving from recovery or intensive care.
Crisis resource management (CRM) refers to the skills that contribute to effective leadership, teamwork, communication, resource utilization, task management,
situational awareness, problem-solving and decision-making used in a crisis [68–
71]. High- acuity settings such as perioperative medicine and emergency medicine
benet from practicing these skills in a simulated environment, as critical events are
rare. The goals of these simulations are to improve patient safety, and thus patient
outcomes. In a recent systematic review, simulation-based CRM training was more
effective than didactic sessions or no intervention in transferring CRM principles to
clinical care. Further, several studies have shown improved patient outcomes and
mortality with CRM simulation training [69]. One such example is Gallagher’s
Anesthesia Resident Emergency Scenarios Series (see https://www.youtube.com/
watch?v=IeObjHh5M7g). This video series is designed for anesthesia residents to
improve their capability to handle critical anesthesia emergencies in clinical practice and in preparation for the OSCE exam for primary anesthesia certication.
Once residents have prepared for sessions via watching the video, they complete a
live simulation session, demonstrating competence on that particular anesthesia
emergency. Another such example is the American Society of Anesthesiology’s
SimSTAT virtual reality training, which is available online to fulll MOCA® 2.0
requirements. SimSTAT is a high-delity, virtual operating room scenario in a gaming environment, focusing specically on management of anesthesia emergencies
[72]. It features virtual patients and operating theaters, interactive anesthesia equipment with live physiological data and performance tracking to allow the learner to
receive feedback and identify areas for improvement. An example video is available
at https://www.youtube.com/watch?v=cktrth6ejO0.
Teamwork is critical in the high-stakes perioperative setting, and team-based
simulation exercises are increasingly being used [60]. Studies have shown an
improvement in participant-reported post-simulation performance assessments
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