“Managing a Surgical Exsanguination Emergency in the
Operating Room through Simulation:
An Interdisciplinary Approach”
Natalia Martinez Acero M.D, Greg Motuk, R.N,
Josef Luba, R.N., Michael Murphy, M.S.N,
Susan McKelvey, R.N., Gretchen Kolb, M.S,
Kristoffel Dumon M.D, Andrew S. Resnick, FACS, M.D, M.B.A.
Hospital of the University of Pennsylvania
Nothing to Disclose
BACKGROUND
•
•
•
•
•
Each year 234 million major operations are performed worldwide1
30 million surgical procedures are performed each year in the US alone 2,3
ECRI - 550-650 surgical fires per year in the US 4
AST – 1 in 4,500 patients has an anaphylactic reaction in the US 5
Clinical and non-clinical OR emergencies are infrequent, but carry
significant morbidity and mortality
• Previously presented initial studies – OR fire and anaphylaxis
• No published team training work focusing on complex perinatal scenarios,
taking advantage of newer technology
1. World Health Organization : 10 Facts on Safe Surgery, June 25, 2008
2. Fires in the Operating Room. American College of Surgeons: Committee on Perioperative Care. Podnos YD,
Williams RA
3. American College of Surgeons: Statement on Health Care Reform
4. Emergency Care Research Institute (ECRI). Clinical Guide to Surgical Fire Prevention (2009). Pennsylvania, USA.
5. Association of Surgical Technologists. Standards of practice, Guideline Anaphylactic Reaction (2005). CO, USA.
MAIN OBJECTIVES
Train residents and OR staff in recognizing adverse
events and responding to emergencies within the OR
Improve overall team performance during an OR exsanguination emergency
using 8 clinical mitigation steps
Demonstrate an improvement in knowledge after training OR staff in an
exsanguination emergency
SIMULATED SCENARIO
• Study :
• Duration:
• Location:
Prospective
June- November 2011
Penn Medicine Clinical Simulation Center (PMCSC) –
Hospital of the University of Pennsylvania (HUP)
• Participants: 171 OR staff members (residents, nurses, surgical
technologists)
• Design:
Weekly one hour OR Team Training sessions
• Scenario: Simulated exsanguination emergency in a pregnant
patient (hidden carotid injury) after a MVC
Cardiac arrest
SESSION PARTICIPANTS
Surgery
Residents
17%
Anesthesia
Residents
20%
ENT Residents
6%
PeriOp Nurses
and Surgical
Technologists
41%
OB GYN
Residents
7%
Oral Surg
Residents
9%
TEAM TRAINING SESSION
• Informed consent obtained
• Cognitive assessment (3 questions):
1. Pregnant patient position and hand placement during CPR
2. Recommended room temperature during an exsanguination
3. Number of licensed personnel required to check blood
products prior to transfusion
Simulated Scenario:
• Brief H&P on a pregnant patient who had unexpectedly arrived to
the OR
• Each group was assigned to simulated OR (equipped with a
SimMan® 3G and a moderator)
SIMULATED SCENARIO
Simulations were recorded using advanced AV simulation software
(B-Line Medical®)
TEAM TRAINING SESSION
“COLD” simulation
(prior to training)
Didactic lecture
(8 mitigation steps)
“WARM” simulation
(after training)
8 MITIGATION STEPS
• Supported by a systematic review of current literature 6,7,8,9
• Measured for both “cold” and “warm” simulations
– Activate Emergency Response System
– Identify a team leader
– Mother is 1st patient to treat
– Initiation of an exsanguination protocol
– Raise room temperature to 80⁰F
– Reposition mother on left lateral recumbent position
– 2nd person to verify blood products
– Initiate CPR
6. Levy DB. Neck Trauma: Treatment & Management, 2010.
7. Chames MC, Pearlman MD. Trauma during pregnancy: Outcomes and clinical management. Clinical Obstetrics and Gynecology
2008; 51(2): 398-408.
8. Mirza F, Devine PC, Gaddipati S. Trauma in Pregnancy: A systematic Approach. Am Journal of Perinatology 2010; 27(7): 579-586.
9. McCunn M, Gordon EK, Scott TH. Anesthetic concerns in trauma victims requiring operative intervention: The patient too sick to
anesthetize. Anesthesiology Clin 2010; 28: 97-116.
TEAM TRAINING SESSION
During the Simulated Scenarios:
• Time intervals for completion of mitigation steps analyzed for
each COLD and WARM simulation was annotated
• Paired t-test used to compare COLD and WARM scenario
performance
To finalize the session:
• Repeat cognitive assessment (3 questions)
• Session Survey
• How realistic was the scenario?
• How realistic was the environment?
• Was this relevant to your current clinical practice?
RESULTS: Overall Performance
• Total # of participating groups: 26
• In the warm scenario, 7 groups (27%) performed all 8 mitigation steps
• During the warm scenario, the mean number of mitigation steps
completed increased for all teams (p<0.001)
7
Mean Number of Mitigation Steps Completed
During "Cold and Warm" Simulations
6.6
6
5
4
3.9
Number of
Mitigation Steps3
2
1
0
Cold Simulation
Warm Simulation
RESULTS: Overall Performance
Mitigation Steps Completed in the "COLD" and "WARM"
Scenarios
26
24
22
20
18
16
Number 14
of Groups 12
10
8
6
4
2
0
Cold Scenario
Warm Scenario
RESULTS: Eight Mitigation Steps
All groups performed all mitigation steps faster during the “warm” scenario
(p<0.03)
Mean Cold
Duration (sec)
Mean Warm
Duration (sec)
Mean Change in Time
to Perform Step (sec)
Reduction
in Time (%)
p-value
Call for Help
110
35
75
68.2
< 0.001
Identify a Team Leader
112
46
66
59
0.004
Mom is 1st Patient
429
123
306
71.3
0.009
Activate Exsanguination
Protocol
127
42
85
67
< 0.001
Raise Room temperature
to 80F
122
41
81
66.4
0.007
Reposition Mother to LAD
244
83
161
66
0.0003
2nd Person to Verify Blood
Products
163
93
70
43
0.03
Start CPR
226
135
91
40.3
< 0.001
Mitigation Step
RESULTS: Cognitive Assessment (n=161)
• Pregnant patient positioning and hand placement for CPR:
– 60% vs. 99% after training
• Recommended room temperature in an exsanguination:
– 79% vs. 99%
• Number of licensed personnel required to verify blood products:
– 76% vs. 94%
SURVEY RESULTS
• After doing both the “COLD” and “WARM” simulations,
trainees completed a session survey using a Likert scoring scale
where:
1
Completely
Disagree
2
Disagree
3
Neither
Agree Nor
Disagree
4
Agree
5
Completely
Agree
RESULTS: Role in an Exsanguination (n=156)
Only 50% of participants agreed or completely agreed knowing
their role in an exsanguination before training vs. 98% after
training (p <0.001)
RESULTS: Exsanguination Protocol (n=152)
Only 50% agreed or completely agreed they knew how to
activate an exsanguination protocol prior to training vs. 98%
after training (p= 0.004)
RESULTS: Relevance and Realism (n=154)
• 100% agreed and completely agreed that the scenario was
relevant to their current clinical practice
• 83% found the environment to be realistic
• 91% felt the patient scenario was realistic
CONCLUSIONS
Team training using high fidelity simulation is an effective way to
train surgical residents and OR staff in the management of a
high-risk surgical emergency in the OR
Team training allowed surgical residents and OR staff
to perform the basic goals of therapy in a complex
exsanguination scenario in the OR
Team training allowed teams to achieve faster response times in
a complex exsanguination scenario in the OR
THANK YOU
Dr. Jon Morris:
General Surgery Residency Program Director,
Hospital of the University of Pennsylvania
Dr. Noel Williams:
General Surgery Preliminary Program Director,
Hospital of the University of Pennsylvania
QUESTIONS?
COST OF TEAM TRAINING
USING SIMULATION
• Facilities
• OR equipment
• High fidelity mannequin
- Sim Man 3G® $80,000
• AV simulation software
- B-Line Medical® $200,000 - $250,000
(1 Operating Room)
• OR staff time outside the OR
SURVEY ANSWERS
• MDs vs. RNs:
– 3 cognitive questions:
• Pt positioning/ hand placement for CPR:
• Room temperature:
• Licensed personnel to check blood:
– Survey:
•
•
•
•
•
My role in an exsanguination:
Exsanguination protocol:
Relevant to current practice:
Simulated environment was realistic:
Simulated patient scenario was realistic:
MDs (N=96) RNs (N=63)
64.6%/ 97.9% 52.4%/ 100%
69.8%/ 98.9% 91.9%/ 100%
67.4%/ 92.7% 88.9%/ 95%
MDs (N=94) RNs (N=59)
41.4%/ 96.8%
50%/ 100%
100%
77.4%
91.2%
62.7%/ 100%
56.2%/ 100%
100%
91.4%
91.6%