TNO Human Factors, 3769 ZG Soesterberg, The Netherlands.
BMJ Qual Saf. 2011 Jul;20(7):599-603. doi: 10.1136/bmjqs.2010.048983. Epub 2011 Apr 13.
Paediatric cardiac surgery has a low error tolerance and demands high levels of cognitive and technical performance. Growing evidence suggests that further improvements in patient outcomes depend on system factors, in particular, effective team skills. The hypotheses that small intraoperative non-routine events (NREs) can escalate to more serious situations and that effective teamwork can prevent the development of serious situations were examined to develop a method to assess these skills and to provide evidence for improvements in training and performance.
This mixed-method design, using both quantitative and qualitative measures, relied on trained human factor observers who observed and coded NREs and teamwork elements from the time of patient arrival into the operating room to patient handover to the intensive care unit. Real-time teamwork observations were coupled with microsystem preparedness measures, operative duration, assessed difficulty of the operation and patient outcome measures. Behaviour was rated based on whether it hindered or enhanced teamwork.
40 paediatric cardiac surgery cases were observed. Surgeons displayed better teamwork during complicated procedures, particularly during the surgical bypass/repair epoch. More procedural NREs were associated with a more complicated postoperative course (M(uncomplicated)=9.08; M(minor complications)=11.11; M(major morbidity)=14.60, F(2,26)=3.46, p<0.05). Procedural NREs decreased substantially over time (M₁=13.5; M₂=7.1, F(1,37)=33.07, p<0.001).
Structured observation of effective teamwork in the operating room can identify substantive deficiencies in the system and conduct of procedures, even in otherwise successful operations. High performing teams are more resilient displaying effective teamwork when operations become more difficult.
儿科心脏手术的容错率很低，需要高水平的认知和技术表现。越来越多的证据表明，进一步提高患者的预后取决于系统因素，特别是有效的团队技能。本研究假设术中的小非例行事件（NREs）可能会升级为更严重的情况，有效的团队合作可以防止严重情况的发生，因此研究旨在开发一种评估这些技能的方法，并为培训和绩效的改进提供证据。
该混合方法设计同时使用定量和定性措施，依赖于经过培训的人为因素观察员，他们从患者进入手术室到移交给重症监护病房的时间内观察和编码 NREs 和团队合作要素。实时团队合作观察与微观系统准备措施、手术时间、手术难度评估和患者预后措施相结合。行为的评分依据是它是否阻碍或增强了团队合作。
观察了 40 例儿科心脏手术病例。外科医生在复杂手术中表现出更好的团队合作，特别是在手术旁路/修复阶段。更多的手术 NREs与更复杂的术后过程相关（无并发症组 M（uncomplicated）=9.08；轻微并发症组 M（minor complications）=11.11；主要发病率组 M（major morbidity）=14.60，F（2,26）=3.46，p<0.05）。手术 NREs 随时间显著减少（M₁=13.5；M₂=7.1，F（1,37）=33.07，p<0.001）。
在手术室中对有效团队合作进行结构化观察可以识别系统和手术过程中的实质性缺陷，即使在其他方面成功的手术中也是如此。表现出色的团队在手术变得更加困难时更具弹性，能够展示有效的团队合作。
