Exploring challenges and solutions in the preparation of surgical patients

Perioperative handovers and patient safety are attracting increasing attention [1-3]. Handover from surgical wards to operating rooms is a vulnerable situation in which quality depends much on completion of tasks related to the preparation of patients, including the planning of the surgical trajectory, completion of prescribed tasks and sufficient information transfer to the receiving surgery and anaesthesia team. One study found that information degraded from one perioperative phase to another, the preoperative period being the most sensible point for information and communication failures [4]. Another study found communication breakdown in 60 of 444 surgical procedures with malpractice claims, 38% of those occurring during the preoperative handover [5]. Insufficient preparation can lead to adverse events, ultimately harming the patients. Cancellation of surgical procedures is one example of an unfortunate consequence that delays or impedes necessary treatment and interrupts the operating room schedule [6].

In our hospital, guidelines for preparation of surgical patients and pre-operative handover were developed based on best evidence and in accordance with a political demand for accreditation of Danish hospitals [7]. Yet, no evaluation of the implementation of the guidelines was performed. The anaesthesia team expressed a trend towards insufficient adherence and an increase in inadequately prepared patients. However, they lacked data to support their arguments and methods for developing ideas for solutions.

Interactive methods such as full-scale simulation have proven effective in identifying discrepancies in institutional policies and practice [8]. Table-top simulation using a small-scale set-up and simple models is used to involve health professionals in innovative solutions when designing new facilities [9]. Team processes are accepted as an important factor influencing clinical performance [10]. The handover process involves team members from different professions and specialties. Hence, a common understanding of each team member’s responsibilities is important. We speculated that simulation with handover teams could be used to identify challenges and solutions in preoperative handover situations.

The aims of the study were: 1) to explore if surgical patients are sufficiently prepared for surgery according to local guidelines; and 2) to identify challenges and solutions in the various work processes related to the preparation of surgical patients through interactive table simulation-based workshops involving the various professions and specialties.

METHODS

The project was divided into two phases:

1) Specific tasks in the hospital guidelines for preparation of surgical patients were monitored for all surgical procedures during one week. 2) Workshops with table simulations involving participants from the various professions and specialties were held.

The study was initiated by the Department of Anaesthesiology and Intensive Care in a large university hospital in Denmark. The department covers six surgical specialties: gynaecology, abdominal surgery, orthopaedic surgery, urology, plastic surgery, and mamma surgery, with approximately 17,000 procedures performed annually.

Data collection in the operation theatre

To explore gaps and challenges in the preoperative preparation of the patient, we conducted a one-week (Week 38, 2011) monitoring of the completion of mandatory tasks according to the guidelines, which are presented in Table 1. We used a data collection scheme based on tasks contained in those guidelines. It contained 19 questions organised into five main categories: electronic patient management system (EPM), patient medication, blood tests, anaesthesia record and patient record. The scheme had to be filled out by the anaesthetist for all surgical procedures regardless of time at day and type of procedure.

Workshop participants

The workshop participants in the second part of the study were selected by the managers of the involved departments (abdominal, orthopaedic, urology and gynaecology) and represented the multi-professional team involved in the preoperative handover: surgeons, surgical ward nurses, anaesthesiologists, nurse anaesthetists and scrub nurses.

Workshops with table simulation

We used workshops with table simulation to map procedures related to the preparation of surgical patients and to identify challenges and solutions in the various work processes in this context. We started the workshops by presenting data from the data collection week in order to highlight and pinpoint the problems and motivate the participants to explore the underlying causes and find ideas for solutions. A floor plan of the hospital was placed on a table, and mini-mannequins represented patients and hospital staff. This set-up allowed visualisation of the patient flow and the procedures in preoperative preparation of elective and emergency surgical patients (Figure 1).

For each of the participating surgical specialties, the preparation of surgical patients was investigated by the team in two-hour workshops. The process mapping was facilitated by experienced simulation instructors, but predominantly performed by the staff. Two workshops were held at a one-month interval.

Workshop 1: Mapping of patient flow

In this workshop, we aimed at mapping the workflow for patients’ ideal preoperative preparation. Special focus was given to the previously investigated categories of mandatory tasks. The flow of the surgical patient trajectory started at the emergency department or outpatient clinic and ended in the recovery room. The mini-mannequins were placed on the hospital floor plan on the table, one person drew the journey indicating each step taken, and sticky notes in different colours were used to demonstrate specific tasks related to the individual
step. The colour of the sticky notes represented either
a human, technical or organisational task. After the workshop, a comprehensive resume was written and
e-mailed to all participants for approval. Figure 1 illustrates the process.

Workshop 2: Identification of challenges and solutions

Prior to workshop 2, the participants received the accepted resume of workshop 1 so that all could recall the achieved consensus on the ideal patient flow before continuing the innovative process. Again, table simulation was the method used. In this workshop, we aimed at seeking a more in-depth understanding of existing problems and barriers to sufficient preparation according to guidelines. The participants identified steps in the patient flow where challenges were present and reflected on specific solutions to these challenges. Afterwards, another comprehensive resume was prepared and e-mailed to all participants for approval.

Analysis

For the data collection, absolute numbers and percentages were calculated for emergency/elective procedures and completed/not-completed tasks. We excluded cases with no indication of whether the procedure was emergency or elective. For each question in the data collection scheme, the possible answer categories were “yes”, “no”, “don’t know” or “not relevant.” In each data collection scheme, a main category of task completion was considered “not completed” if the answer was “no” to a single question within this specific main category. For a synthesis of the workshop reflections and conclusions, we grouped elements from the resumes according to point in time in the patient trajectory and according to problems identified in the data collection phase.

Trial registration: not relevant.

RESULTS

Data collection from surgical procedures in a one-week period

In all, 314 surgical procedures were performed at the hospital in the data collection week. A total of 196 data collection schemes were eligible for analysis (62%). The proportion of elective and emergency procedures was 74% and 26%, respectively. Figure 2 presents the answers from the data collection schemes for all included procedures in total and proportions of completed main task categories within emergency and elective procedures. The poorest results were seen for emergency procedures, where the proportion of not completed tasks was 58% of EPM tasks, 26% of anaesthesia record tasks, 24% of medication tasks, 14% of blood test tasks and 12% of patient record tasks.

Workshops with table simulation

Two workshops were held for each of the four specialties (abdominal, orthopaedic, urology and gynaecology) with a total of 21 participants from surgical and anaesthesiological departments. Table 2 presents the synthesis of the workshop resumes. A description of challenges and suggestions for solutions is given for each time point in the surgical patient flow and according to the problems identified in the data collection phase. In workshop 1, the preoperative patient flow with related responsibilities, tasks and written documentation was mapped. In workshop 2, challenges and suggestions for solutions were identified within eight areas. Overall, the challenges represented organisational, technical and human aspects. Unclear understanding of tasks and responsibility and unclear communication were some of the human aspects mentioned. General solutions were: Education of staff and development of tools to facilitate a safe and structured communication including a clear understanding of work processes.

DISCUSSION

Overall, completion of mandatory tasks for preparation of surgical patients was poor indicating an insufficient implementation of guidelines. The poorest results were seen for EPM and medication-related tasks. Elective patients were better prepared for surgery than were emergency patients. Our findings are in line with the challenges in preoperative handovers identified by Nagpal et al [4, 11]. Examples of known barriers to guideline adherence in general are lack of agreement, lack of awareness, or lack of outcome expectancy [12]. We aimed at identifying reasons behind these challenges in the workshops and at developing a common understanding [10].

The analysis of the workshops underlined that preoperative handover was a complex situation, which implies that there is no simple solution to this challenge. Several initiatives are needed to increase patient safety in this context. Challenges and solutions were identified within eight areas representing organisational, technical and human aspects. Blood-test-related issues such as long latency and unclear procedures were mentioned as organisational aspects, whereas EPM-related issues were technical challenges. Lack of competence was addressed, including lacking awareness of own responsibility, uncertainty of how to prepare patients or poor understanding of the consequences of insufficient preparation. The possible reasons for this comprise inadequate introduction or no available checklists. The most important reason was unclear communication. We find the simulations successful as they made the participants discover the situation from the perspectives of others. This is one of the most important elements that may help improve interventions [13]. The table simulations actively involved the participants in the process and gave them ownership to the solutions. Interaction between groups is considered very important where multiple stakeholders are involved. The quality of the relations and the debate are essential to understand the process, especially in transitions [14]. Our intention of bringing professionals from various departments together is in agreement with a paper arguing that this can have a profound effect on diffusion of new initiatives or innovations [15]. The innovative mapping process evoked an obvious need for further elaboration of the challenges and solutions. The hospital and department heads initiated a change in work processes and established working groups to refine and implement the solutions accordingly. One thought worth exploring is the development of a common checklist for preoperative handover. Studies have demonstrated a better outcome for patients for whom a surgical checklist has been used [16, 17]. The potential benefits of checklists in general are also described [18, 19].

Methodological discussion

In the data collection phase, we aimed at presenting the problems quantitatively rather than at investigating causal relations. Therefore, the method was simple and without calculation of effect measures. Data collection schemes were filled out by nurse anaesthetists or anaesthesiologists, who might be the group most frustrated by insufficient patient preparation, and this approach entails a risk of reporting bias. We chose table simulation as a method to identify challenges and solutions in the work processes. Table simulation has previously been used as a method to analyse the tasks and the organisation of work in an ambulatory, and the benefits of bringing different professionals together to develop a common picture of the situation have been described previously [9]. The drawback of simulation is that it involves only few representatives from each profession and specialty. Hence, it might not have identified all relevant challenges and solutions. Nor did we analyse the possible impact of each solution. Other methods, such as failure mode effect analysis (FEMA) have been used to identify challenges in the perioperative handover [11]. This method identifies the steps in a given process and provides thorough process insight, whereas table simulation provides a broader view on a process, but less detail.

We included health-care professionals with daily patient contact to ensure that they had insight into the contextual workflow and every-day challenges. Involving health professionals at an early stage builds ownership to solutions and may facilitate later implementation.

CONCLUSIONS

Overall, completion of mandatory tasks for preparation of surgical patients was poor indicating an insufficient implementation of guidelines. Workshops with table simulations actively involved the health-care stakeholders from the various professions and specialties in describing the patient trajectory and the mandatory tasks according to hospital guidelines in addition to identifying challenges and solutions for improvement.

Correspondence: Thea Palsgaard Møller, Brådervej 4, 3500 Værløse, Denmark. E-mail: thea.palsgaard.moeller@regionh.dk

Accepted: 25 June 2015

Conflicts of interest:Disclosure forms provided by the authors are available with the full text of this article at www.danmedj.dk