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Original Study

The development, implementation, and efficacy of a perioperative briefing communication and treatment planning tool and its adaptation to the COVID-19 pandemic

Rassekh, Christopher H. MDa,; Atkins, Joshua H. MD, PhDa,b; O’Malley, Bert W. Jr MDa; Chalian, Ara A. MDa; Brody, Robert M. MDa; Basu, Devraj MDa; Paul, Ellen A. BSEa; Weinstein, Gregory S. MDa

Author Information
Journal of Head & Neck Anesthesia: May 2021 - Volume 5 - Issue 1 - p e36
doi: 10.1097/HN9.0000000000000036
  • Open

Abstract

Ineffective communication, lack of team alignment, and overall poor preparedness for surgery increases delays, cancellations, and clinical errors1. In fact, the majority of hospital errors can be attributed to the convergence of multiple factors which requires a systems-based approach2. Furthermore, teamwork is a key component of both wellness of the health care team and patient safety and quality of care3. One of the most important relationships in the realm of operating room (OR) patient safety is the surgeon-anesthesiologist relationship4.

An institutional policy for a preoperative “huddle” process was developed to bring the care team together to review and finalize the preoperative, intraoperative, and postoperative plans for the surgical procedure. The original concept was an in-person meeting at 0700 on the morning of surgery for each OR that includes all members of the team. However, difficulty bringing together members of the care team who were busy performing other tasks limited the feasibility of this approach. Execution and documentation of the huddle also proved difficult to standardize, and the meeting often occurred too late on the day of surgery to maximally benefit preparedness. We proposed a quality improvement risk reduction initiative involving an email approach and sought to investigate its efficacy by providers.

Materials and methods

The head and neck surgery division of the Department of Otorhinolaryngology-Head and Neck Surgery designed a risk reduction initiative to evaluate the efficacy of perioperative email communication to facilitate a “huddle” process first piloted by the senior author (G.S.W.) (Fig. 3). This “perioperative briefing” email from the surgeon disseminated the key preoperative, intraoperative, and postoperative planning information along with relevant co-morbidities that add risk to the airway management or other aspects of the surgical procedure. The concept was to transmit this key information by email while still leaving the option of an in-person huddle just before the case. The expectation was that some sort of in-person huddle would always occur even if it did not convene all members at the exact same time. The email would provide a point of discussion for clarification that all members could refer to.

The University of Pennsylvania Institutional review board designated this study as a quality improvement project and thus it was exempted. An initial quality improvement tool was designed using a Survey Monkey questionnaire regarding visibility and adoption of the tool. Subsequently, a second survey was used to assess the perceived risk reduction impact of the briefing tool. When 2 additional faculty members were recruited, we asked them to utilize the tool and assessed the integration of new faculty in the email huddle process. Modifications to the briefings were made as staff made suggestions, and the tool was further adapted at the onset of the COVID-19 pandemic. Relevant changes were made to communicate essential COVID-19-related patient information for essential oncologic cases still being performed after elective surgeries were halted and during a subsequent resurgence of elective head and neck surgery.

Process for efficiently creating perioperative briefing

The goal was to create a workable process that would be minimally time-consuming for the surgeon which would ensure ease of use and adoption into the daily routine of busy surgeons. The concept was that the time savings in terms of communication for special equipment alone would more than offset the time spent by the surgeon preparing the briefing.

It was recommended that the briefing be prepared by the surgeon the day before or the morning of surgery depending on the surgeon’s work routine. All involved members of the surgery, perioperative (circulating and scrub nurses), and anesthesia teams are sent the email. In addition, the neuromonitoring team and any consultants (such as general surgeons or neurosurgeons, reconstructive surgeons, and radiologists) who are performing procedures in that room on that day are also copied on the briefing. The goal is to make this one of the first emails seen by the recipients in the morning. Every team member is very busy so the timing of the briefing in the early morning was thought to be optimal as it allowed the team to read them with fewer email distractions and allowed the room assignments to be more finalized. A generic template of categories for different types of cases (TORS, salivary, thyroid, endoscopy, neck dissection, flaps, and so on) is used that can then be modified for different specific cases. The surgeon then modifies the generic briefing to fit the specifics of the individual patients. For instance, do they have an infectious disease? Do they have a difficult airway? Does the surgeon need special instrumentation unique to this case? The process ensures that the surgeon has thought thoroughly about the planning of each case for the day, and this process and the communication of these thoughts ensures improvements in safety and efficiency for the day.

The following is a summary of the process with examples of both the template and final email.

  • List of routine emails to be copied and pasted to the Perioperative Briefing email.
  • List of less common emails for occasional use (such as reconstructive surgeons, co-surgeons, back-up attendings, or neurosurgery that may participate).
  • The anesthesiology faculty and resident email addresses can also be found in the directory and added to the email briefing once assignments are made.
  • The words “Perioperative Briefing” to allow for cut a paste to the subject line of the email followed by the date of surgery, the name of the surgeon, and the OR number(s).
  • Introductory statement—which includes new information about surgeon preferences that apply to all cases.
  • Next in the email is a list of the specific briefing for a particular patient.

Results

After 6 months, all 4 head and neck surgeons in the division had adopted the formatted email and utilization was nearly 100% of cases. During the first 6 months, the total number of head and neck surgical cases was 606 among the 4 surgeons who initially adopted the approach with 314 of the procedures being inpatient and 292 being outpatient.

We obtained responses from 48 individuals (Table 1) including faculty surgeons and anesthesiologists (11), circulating nurses (n=11), scrub nurses (n=4), residents (n=17) and fellows (n=2), and other providers (n=3). Seventy-five percent of respondents work in the division daily.

Table 1 - Initial questionnaire responses (n=48).
Question Always Most of the Time Sometimes/Half the Time Seldom/Never No Response
Have you read the perioperative briefing? 36 (75) 8 (16.7) 3 (6.25) 1 (2.2) 0
Did you find the perioperative briefings useful? 25 (54.4) 17 (37) 2 (4.35) 2 (4.35) 2 (4.35)
Do you have opportunity to ask questions and do real-time live huddle following briefings? 17 (35.4) 17 (35.4) 4 (8.3) 10 (4.17) 0
Values are presented as n (%).

More than 90% of the respondents indicated that they read the emails >80% of the time and >70% indicated they read them every time. Over 90% found them overall to be helpful >80% of the time. Of all respondents, 98% felt the process should continue, with about 30% indicating that minor or major improvements were desirable.

On the basis of the results of the first survey, a follow-up survey (Table 2) was designed to assess the potential safety impact of the briefing process and to get a surrogate measure of risk reduction. We received 36 responses to the second survey. In all, 88.9% of the respondents perceived briefings to reduce the risk of serious errors, near misses, and complications, and all respondents stated that it prevented start time delays. All respondents indicated that the briefing made their jobs easier. In all, 72% of respondents felt that an email briefing tool could definitely be used for other surgical teams and not just head and neck surgery, and another 22% said it probably could be adapted by other teams.

Table 2 - Follow-up questionnaire (n=36).
Question Always More Than 80% of the Time Between 50% and 80% of the Time Between 25% and 50% of the Time Less than 25% of the Time
Do you think the Perioperative Email Briefing Tool helps prevent start time delays? 8 (22.2) 16 (44.4) 8 (22.2) 4 (11.11) 0
Do you think the Perioperative Email Briefing Tool decreases intraoperative delays resulting from equipment issues, miscommunication or lack of information about the true surgical procedure? 9 (25) 19 (52.8) 6 (16.7) 2 (5.6) 0
Question Definitely/Completely Probably/Mostly Not sure/Partly Unlikely/Not much No
Does the Briefing tool decrease the risk of errors, near misses or complications? 16 (44.4) 16 (44.4) 4 (11.1) 0 0
Has the Periop Briefing tool decreased the likelihood of safety net reports for OR cases? 7 (19.4) 16 (44.4) 11 (30.6) 2 (5.6) 0
Do you think the Perioperative Briefing Could be effective for other surgical teams besides just head and neck? 26 (72.2) 8 (22.2) 2 (5.6) 0 0
Does the Periop Briefing Tool make your job easier? 20 (55.6) 11 (30.6) 4 (11.1) 1 (2.8) 0
Values are presented as n (%).

Tables 1 and 2 show the results from the 2 surveys.

Figures 1 and 2 show some specific results in graphic form.

F1
Figure 1:
Attitudes of respondents about continuing perioperative briefings.
F2
Figure 2:
Opinion of respondents on who should send the briefing.

Following the survey, we noted that each faculty member made some changes in the way they delivered the briefings, some involved the residents in creating the briefing and some allowed the residents to send the briefings after faculty review but other faculty continued to do the briefings themselves. Two new faculty quickly achieved 100% utilization of the tool within 2 weeks of joining the division. Figure 3 shows the briefing tool that was ultimately modified for COVID and the perception of the team is that the compliance with the briefing followed by face-to-face huddles has improved consistently over time.

F3
Figure 3:
Generic example of a briefing template.

Discussion

There is considerable evidence1–10 to support the use of a preoperative huddle as an element of surgical care delivery. More specifically, types effects of communication failure include inefficiency, tension, delay, workaround, resource waste, patient inconvenience, and procedural error1. However, the team of surgeons, the anesthetists, and OR staff involved in the cases are often staggered in the timing of performing critical tasks which made the timing of an in-person huddle challenging at our institution. While there is always a safety “time out” and we have preserved that concept with the perioperative briefing tool we created, the actual “huddle” did not allow transmission of vital information critical to the flow of the operative day and relevant to all the stakeholders. Our standard procedural “safety time out” includes the patient’s identity, surgeon’s identity, site and laterality of the procedure, specific procedure, DVT prophylaxis, antibiotic prophylaxis. The “time out” is done just before induction of anesthesia and again just before incision or endoscopy. In contrast, a preoperative huddle must occur before the patient entering the OR. While there was often a huddle of most or all of the team, this could be abbreviated or even modified because the email “virtual” huddle was a great supplement to it. Our implementation of an email instrument for this purpose added to both the efficiency of the preoperative huddle and its likely dividend for patient safety. Our approach maintains the ability for any team member to request an in-person meeting if there is a lack of clarity in the perioperative huddle email or concerns arises about the plan as communicated therein. As an alternative to routine in-person team huddles, our structured email format provides multiple benefits. First, it uses a checklist format that likely reduces the omission of pertinent case-specific details while being fast and easy for the attending surgeon to fill out. It is also less disruptive to the varied workflows of team members and less taxing to their memories. In addition, the tool facilitates the transfer of information to newcomers joining the team and for other individuals not normally included in the huddle. The trial of this novel approach to the perioperative huddle produced universal enthusiasm for its continued use among all those providing head and neck surgical care at our institution.

The time management guru David Allen, author of the best-selling time management book Getting Things Done: The Art of Stress Free Productivity11 advocates creating a trusted system with a project list where everything on your mind is parked there for use when working on a particular project. Surgeons, as a group, think that if they do something routinely it behooves their team members to memorize their specific needs for their cases. However, even staff who work with us all the time found that having the email was of great value because to assume too much even when something seems routine has been found to add risk and stress. We chose to create an email platform as a starting point because it was universally accessible to all team members. We chose the categories of information to help all members of the team. Then, the focus is on each room that is running and the cases are listed for each room in order.

First, we list the expected procedure(s) and surgeons and the duration of the procedure. In addition, if there are multiple surgeons from one service or multiple services, this is indicated and if there are multiple rooms, the backup attending surgeon for the rooms that need this are listed. This can be checked against the scheduling and the consent to give us multiple things to match up. At the conclusion of the procedure, during the debriefing, the nurses can simply ask if there were changes to the planned procedure which can then be documented in the “procedures” section of the electronic intraoperative record.

We also list the case classification. Not only does the nurse need to document infectious precautions but all should be aware so by sending it out in the email everyone is aware always. Also, nurses now do not have to ask about wound classification they always have it in the email.

A major value of the briefing is the interaction with our Anesthesiology colleagues. This tool informs them about what we know about the airway. For example, both the faculty Anesthesiologist and the resident or CRNA are copied on the briefing and now always are aware if we believe this is an easy or more challenging airway which can avoid mishaps with securing the airway—the process of classifying it at the beginning of the day forces the attending surgeon to put thought into this critical issue as well for every case which is especially important for endoscopy and head and neck tumor cases. This was an adjunct to an already robust airway team collaboration and a scheduling process that allowed for the designation of special intubation needs such as nasal intubation or difficult airway.

We also found that by listing the equipment needed for a case, if there were anticipated shortages or unavailability of specific items, the briefing would prompt a call before the patient was brought back to the OR. This combined with using a preoperative scheduling system where special items could be requested made for multiple sequential steps optimizing the care and minimizing the chances of equipment not being ready.

In head and neck surgery, we often do nerve monitoring and while this is always scheduled in advance and ordered during the scheduling process, this provides assurance that there has not been a change but also lets everyone in the room know that we are going to monitor nerves and which ones.

We also added important components such as the postop disposition and the expected pathology specimens. During the portion of a procedure when resection is completed, certain things can be confusing like the name of a specimen when given across the room when there are multiple other activities going on (such as 2 teams still operating during a free flap, for example). By describing in advance the nurse can simply ask for changes when receiving the specimen. There is less potential for error in the specimen processing request. So, for instance, the nurses must always document prior radiation and chemo on the path sheet—here they have the information so do not have to look in the chart and fewer errors occur. This also improves flow and minimizes the chances of error. Planned disposition can allow for preparations to be made for the arrival of the patient to the postoperative setting.

As COVID-19 impacted our hospital, we were required to eliminate nonurgent elective surgery for ~2 months. During that time, we were able to continue to do cancer surgery but we made some changes. For example, we excluded routine panendoscopy and only did laryngoscopy on head and neck cancer cases. We also avoided doing patients who were severely immunocompromised12. We had to make some changes early on to accommodate tracheostomy for patients under investigation for COVID-1913. We developed guidelines for tracheostomy in COVID-19 patients14.

Initially, during COVID-19, we did not have sufficient testing to do routine preoperative testing so we took some special precautions, mainly the use of N-95 masks. Thus, the PPE needed for cases was added to the briefing communication. We also became aware of an oral prepping protocol which we implemented and this was added as an “ALL NEW” category of importance in the briefing15.

Eventually, we did have COVID-19 testing and this became routine, so we subsequently added this bullet point. Our routine was to use N-95 masks and eye protection for all aerodigestive tract cases during COVID-19. We did not change our practice when testing became available because we were concerned there might be false negatives.

During the COVID-19 surge, resident participation in cases was limited so as we began doing more surgery including the resurgence to elective surgery, we added some information about perceived resident educational benefit and need for assistance. For some time before that, only faculty and fellows attended mucosal cases unless there was a significant need for assistance.

Finally, during resurgence, a service line protocol that had been developed for the COVID crisis16 was amended slightly to now allow for us to bring our backlog of cases such as benign salivary gland tumors and other less urgent tumor and head and neck cases. In scheduling cases, we had to be cautious not to take risks of overburdening our health care system so we employed the Medically Necessary, Time-Sensitive Procedures Scoring (MeNTS) System that was recently described in the literature17. We calculated the MeNTS score for all patients and set a projected moving target over time depending on how the COVID patient volume evolved. The MeNTS calculator was incorporated into EPIC and the score could be added to the briefing as well for clarity.

Most of the literature to date has been in the general surgical literature and the focus in Otolaryngology has been on checklists18. We also hope to implement an emergency surgical tool19. Such a tool would potentially be an adaptation of the current strategy. Incentives to perform have been suggested but we believe the reduced stress and job satisfaction and patient outcomes are sufficient motivators by themselves20,21.

As the success with this initiative has been proven in our institution, the perioperative briefing tool is now being employed by our newly recruited head and neck surgeons and also by a newly recruited sleep surgeon. Many other surgeons have expressed interest in the tool both in our department and outside the department and we use it for collaborative cases with Neurosurgery such as skull base surgery as well.

The process approach we have recommended was initially used by the senior author but, just as each surgeon modifies surgical techniques after learning the basics of the approach, the same was done by our surgical team members. Each surgeon has implemented the briefing tool in a way that best accommodates his practice and it has become a way of life in the head and neck division in our hospital.

Further, 2 additional head and neck surgeons have joined the division and have implemented the perioperative briefing and we are now seeing this being used in other divisions within our department.

While the study has some limitations in that we have not been able to do a formal calculation of risk reduction, this is planned as a subsequent investigation as more divisions and departments come on board with this quality improvement program. In contrast to some existing literature22, our email communication was preferred as the initial method of transmitting case information in our institution. One possible explanation for our success is that we have a team that works together regularly and another is that we did not do away with the in-person huddle or the procedural time-out, we simply augmented it. Our anesthesiology and nursing colleagues came to rely on this method and we believe it will likely eventually become the standard in many departments in our institution.

Limitations of this study include that it is a survey of our team and has not yet been rigorously subjected to safety outcomes measures and plans are underway to do that. In addition, there is a risk that the briefing tool being only from the faculty surgeon does not bring in the evaluation of the anesthesiologist until later. Finally, there remains some difference of opinion among members of the OR team as to the best timing of the briefing. There are advantages of doing it the day before as well as doing it very early in the morning on the day of surgery. The first author (C.H.R.) has varied his approach to this a bit depending on what is known the day prior and both have worked very well if done correctly. It should be noted that the email is a supplement to the medical record and while it is not contained in the medical record, it is transmissible to other team members should the case be moved to another room or another team and it is complementary to the medical record but focuses on the key points to allow the OR team to streamline the amount of information.

In addition, the process could be augmented perhaps by including the postanesthesia care unit and intensive care unit staff but we should state specifically that all patients who were deemed COVID-19 positive or patients under investigation were managed independently and were done in a COVID-specific OR with negative pressure and were not done in the same room so they would not appear in a standard briefing for a room with multiple cases. Communication with personnel in the intensive care unit and COVID units is handled using a different mechanism.

Conclusions

An email perioperative briefing survey is feasible and well-received by all members of the team and is believed by team members to improve patient safety, flow, and satisfaction.

On the basis of the results of these surveys, the successful integration of all faculty into this initiative, and the overall impact of the briefing, we intend to work to incorporate the suggestions for improvement and will try to pilot an online “living” briefing, possibly using a mobile platform.

Finally, the briefing served as a powerful platform for us to incorporate critical elements as we saw rapidly evolving and dramatic changes in many aspects of the care of our patients and this allowed us to continue to care for patients with emergent and urgent (particularly cancer) problems and then quickly transition to going back to less urgent once we had demonstrated that the surge was on the decline. While the attitudes of our team suggest that this email instrument may improve patient safety, future studies are needed to validate this opinion and quantify the quality improvement capacity of the perioperative briefing tool.

Conflict of interest disclosures

The authors declare that they have no financial conflict of interest with regard to the content of this report.

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Keywords:

Electronic communication; OR preparation; Patient safety; Teamwork in surgery

Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The Society for Head and Neck Anesthesia.