HHE Emergency care supplement 2018 - Page 25

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 Patient simulation and debriefing techniques can enhance individual and team performance 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%). 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 of expertise and training Important cognitive mechanisms for the development of SA as well as knowledge bases and task skills are gained with experience. Many studies have shown that experienced subjects develop SA in a shorter time and with less effort than novices. These differences may be attributable to several factors that determine the achievement of good SA, such as correct distribution of attention, prioritising information, dynamic switching between goal-driven processing and data-driven processing, automaticity, which can provide good performance with very low level of attention demand, learned skills, pattern-matching with prototypical situations, and development of mental models that help in the integration of information and projection of future states. 2 Patient simulation and related debriefing techniques can enhance individual and team performance by focusing on skills and behaviours related to good SA, such as prioritisation, and coordination and communication that are essential for the effective treatment of critical incidents. 3–10 SA errors There can be failures at each level of SA, leading to low performance. 13 In the first level (perception), relevant information may not be correctly detected or if too much data are perceived at a time, we become overloaded, focusing on just part of the information (‘tunnel vision’) and missing parts that matter. It is widely recognised that more data does not equal more information. Today’s systems’ problems are not the lack of information but finding what is needed when it is needed; therefore, a critical part of SA level I is learning the cues to watch for (proper distribution of attention). 2 An outside view sometimes helps to reveal what we cannot see or give additional information that might help highlight that something has been missed. In the second level (comprehension), the situation might not be understood correctly, Assessment of SA Several direct and indirect methods have been developed to assess SA and can be summarised as query-, rating- and performance-based techniques. In query techniques, the subjects are asked directly about their perception of certain aspects of the situation. The Situation Awareness Global Assessment Technique (SAGAT) has been validated as an objective and direct method to evaluate different levels of SA during a simulated scenario, and consists of stopping at random points to ask the participants to complete a questionnaire regarding what is occurring at that specific time. This technique can be perceived as intrusive due to freezes in a simulation but many studies have shown it does not affect performance. 3,14 In rating techniques, the subjects or observers are asked to rate SA directly along a few dimensions (SA Rating Technique) or indirectly through 25 HHE 2018 | hospitalhealthcare.com