HHE Cardiovascular supplement 2018 - Page 2

Hospital Healthcare Europe Cardiovascular Emergency and critical care Haematology and oncology Neurology Pathology and diagnostics Radiology and imaging Rheumatology and musculoskeletal Theatre and surgery The Official HOPE Reference Book hospitalhealthcare.com p1_HHE2018_cover_v2.indd 1 23/08/2018 13:26 Re-register to continue receiving Hospital Healthcare Europe emergency and critical care Situation awareness during crisis in the OR The operating room is a complex environment and knowledge and improvement of situation awareness can increase the performance in this domain, leading to better patient outcomes Diana Zamudio Penko PhD Daniel Arnal Velasco MD Department of Anaesthesia and Critical Care, The Alcorcon Foundation University Hospital, Spain Situation awareness (SA) can be defined as ‘the perception of elements of the environment within a volume of time and space, the comprehension of their meaning and the projection of their status in the near future’. 1 In simple terms, it is knowing what is going on around you by extracting information from the environment and then integrating that information to create a notion of the situation and anticipate future events. Therefore, SA is important for effective decision-making, performance and teamwork. 2 Understanding the meaning of SA and how to improve it in a complex work environment, such as the operating room (OR), is essential for patient safety. Individual SA According to the definition, SA is subdivided into three levels: perception (level I), comprehension (level II) and projection (level III). 2 The first level comprises the identification of the key elements that assess the ongoing situation; in the OR, the perception of the patient’s state is provided by the patient (for example, through verbal communication or appearance), monitors, patient charts, communication within the team, anaesthesia machines, respirators, and the surgical field. 3 The second level comprises the comprehension and integration of multiple pieces of information and the determination of their relevance to the situation to form a coherent mental picture. Finally, the highest level entails the ability to forecast the future development of the patient’s state and determine the best way to proceed. Generating SA and maintaining it at a high level can reduce the probability of patient injury, because the healthcare provider can respond more quickly to an emerging problem and it can allow proactive management of human and material resources during a crisis. 3,4 Team SA (TSA) TSA is ‘the degree to which every team member possesses the SA required for his or her responsibilities’. 5 Teamwork is characteristic to the OR, where an interdisciplinary team of individuals is engaged in the common project of ‘patient treatment’. 2 In a highly effective team approach, decisions should be based on information derived from all team members. This allows for an efficient plan of action; otherwise, a breakdown of performance would occur when team members are not able to anticipate what help is needed by the others. 6,7 However, not all members of the team should be aware of the same thing at the same time and nor does all the information need to be shared with every individual involved. Rather, it is necessary that each person be aware of circumstances that are relevant to their respective roles and responsibilities and to create a system where the right information reaches the right person at the right time, and this involves team coordination. 3,8,9 Team processes and behaviours that can improve TSA include closed-loop communication, group prioritisation, contingency planning and actively sharing SA about the patient, planned procedure and potential critical events. 6,10 despite all the relevant information being detected. This is due to an inappropriate or absent mental model; with time pressure and high cognitive workload we may get drawn into bias by selecting a mental model that we prefer based on our experience. 3 In the third level (projection), the future is not correctly anticipated, although the situation is understood. As errors on SA levels II and III necessarily involve long-term memory content for the processing of basic data, this may be due to a lack of training and experience. 3,4 Schulz et al reviewed 200 reports from the German anaesthesia critical incident reporting system and found that SA errors were involved in 81.5% of the cases; in addition, more errors on the levels of perception (38%) and comprehension (31.5%) were identified. 4 With a similar methodology, we reviewed 100 incidents reported to the Spanish anaesthesia and intensive care incident reporting system (SENSAR; Safety Reporting System in Anaesthesia and Rescuscitation) and found comparable results. SA errors were identified in 65% of the cases and the majority were on the levels of perception (51%) and comprehension (8%). Patient simulation and debriefing techniques can enhance individual and team performance Distributed SA (DSA) DSA is a concept that recognises the contribution of technical systems. The entire system including human and non-human subsystems, and the interactions between them, is considered to develop SA. Hence, cognitive processes occur at a system level rather than an individual level. 11 The DSA approach allows a better overall understanding of the operating theatre interactions where a group of people (anaesthetist, surgeon, nurse, patient) interact with external objects (for example, equipment, monitors, charts) in a dynamic explicit and implicit way, and it is only when the interactions between all the individual components are compiled that a coherent picture emerges. 12 The role o bWW'F6RBG&p'FB6vFfRV662f"FPFWfVVBb42vV2vVFvP&6W2BF662&RvVBvFWW&V6R7GVFW2fR6vFBWW&V6V@7V&V7G2FWfV46'FW"FRBvFW72Vff'BFf6W2FW6RFffW&V6W2&RGG&'WF&RF6WfW&f7F'2FBFWFW&֖PFR6WfVVBbvB47V626'&V7@F7G&'WFbGFVF&&F6rf&FG֖27vF6r&WGvVVvG&fV&6W76rBFFG&fV&6W76rWFF6Gv66&fFRv@W&f&6RvFfW'rWfVbGFVFFVBV&VB62GFW&F6rvF&FG66GVF2BFWfVVB`VFFV2FBVFRFVw&F`f&FB&V7FbgWGW&R7FFW2 FVB6VFB&VFVBFV'&VfpFV6VW26V6RFfGVBFVЧW&f&6R'f7W6r62B&VfW'0&VFVBFvB47V62&&F6F@6&FFB6V6FFB&RW76VFf"FRVffV7FfRG&VFVBb7&F66FVG2>( 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