Preparing Anesthesiology Residents for Operating Room Communication Challenges: A New Approach for Conflict Resolution Training.

BACKGROUND: The hierarchical culture in high-stake areas such as operating rooms (ORs) may create volatile communication challenges. This unfunded exploratory study sought to establish whether a conflict resolution course was effective in preparing anesthesiology residents to handle and deescalate disagreements that may arise in the clinical environment, especially when challenging a surgeon. METHODS: Thirty-seven anesthesiology residents were assessed for ability to deescalate conflict. Nineteen had completed a conflict resolution course, and 18 had not. The 2-hour course used 10 videotaped vignettes that showed attending anesthesiologists, patients, and surgeons challenging residents in a potentially confrontational situation. Guided review of the videos and discussions was focused on how the resident could optimally engage in conflict resolution. To determine efficacy of the conflict resolution course, we used simulation-based testing. The setting was a simulated OR with loud music playing (75-80 dB) under the control of the surgeon. The music was used as a tool to create a potential, realistic confrontation with the surgeon to test conflict resolution skills. The initial evaluation of the resident was whether they ignored the music, asked for the surgeon to turn it off, or attempted to turn it off themselves. The second evaluation was whether the resident attempted to deescalate (eg, calmly negotiate for the music to be turned off or down) when the surgeon was scripted to adamantly refuse. Two trained observers evaluated residents' responses to the surgeon's refusal. RESULTS: Of the residents who experienced the confrontational situation and had not yet taken the conflict resolution course, 1 of 5 (20.0%; 95% CI, 0.5-71.6) were judged to have deescalated the situation. In comparison, of those who had taken the course, 14 of 15 (93.3%; 95% CI, 68.1-99.8) were judged to have deescalated the situation (P = .002). Only 2 of 19 (10.5%; 95% CI, 1.3-33.1) of those who completed the course ignored the music on entering the OR versus 10 of 18 (55.6%; 95% CI, 30.8-78.5) who did not complete the course (P = .004). CONCLUSIONS: This study suggests that a conflict resolution course may improve the ability of anesthesiology residents to defuse clinical conflicts. It also demonstrated the effectiveness of a novel, simulation-based assessment of communication skills used to defuse OR confrontation.

A new approach to infection prevention: A pilot study to evaluate a hand hygiene ambassador program in hospitals and clinics.

BACKGROUND: A pilot study was conducted to assess the perceptions of visitors, patients, and staff to the presence of a hand hygiene ambassador (HHA). METHODS: Two hundred and twenty-five entrants to various health care settings were surveyed. Only entrants who failed to clean their hands at the alcohol-based handrub (ABHR) station on entry to the lobby were offered application of ABHR by an HHA. Several questions were also asked to assess their attitudes about the presence of an HHA. RESULTS: When asked whether they think it is a good idea to have an HHA place ABHR on an entrant's hands, the majority of staff, visitors, and patients agreed. No one refused administration of handrub by the HHA. DISCUSSION: HHA programs have direct and indirect benefits. Although the cost of such an initiative should be considered prior to implementation, it should be weighed against the annual spending for health care-associated infections. CONCLUSIONS: Considering that hand hygiene compliance and health care-associated infection are clearly linked, a new approach using an HHA may help reduce infection, acting as a source of hand hygiene on entry to the hospital and possibly as a reminder to perform hand hygiene elsewhere in the hospital and clinics.

Targeted Use of Alcohol-Based Hand Rub on Gloves During Task Dense Periods: One Step Closer to Pathogen Containment by Anesthesia Providers in the Operating Room.

BACKGROUND: Anesthesia providers' hand hygiene practices in the operating room may contribute to the transmission of bacteria. There is a debate, however, over the best approaches for pathogen containment during task dense periods (induction and extubation) of anesthesia care. A novel approach to reducing pathogen spread during these task dense periods is the use of alcohol-based hand rub on gloves when it may be difficult to either change gloves or clean hands. METHODS: To evaluate the impact of alcohol-based hand rub on gloves, we estimated perforation rates of 50 gloves that were worn as pairs by volunteers for 2 hours at a time applying alcohol-based hand rub every 15 minutes (total of 8 alcohol-based hand rub applications per pair of gloves). We also identified perforation rates of 50 new, unused gloves. To evaluate the ability to perform routine anesthesia functions, volunteers were asked to pick up a coin from a table top and document whether the gloves felt normal or sticky at each 15-minute period. RESULTS: Fifty new gloves (not exposed to alcohol-based hand rub) were tested for integrity using the Food and Drug Administration-approved process, and one was found to have a microperforation. Of the 50 gloves that had been applied with alcohol-based hand rub 8 times, no microperforations were identified. All volunteers demonstrated tactile competence by picking up a coin from a table top after 8 alcohol-based hand rub applications; in addition, as the number of alcohol-based hand rub applications progressed, the volunteers reported increased stickiness. CONCLUSIONS: This study suggests that the use of alcohol-based hand rub on commonly used nitrile examination gloves does not compromise glove integrity or hamper the ability to safely perform routine anesthesia functions.

Does Adherence to World Health Organization Hand Hygiene Protocols in the Operating Room Have the Potential to Produce Irritant Contact Dermatitis in Anesthesia Providers?

Anesthesia providers have the burden of constant hand hygiene during task dense periods. The requirement for hand hygiene often demands frequent application of alcohol-based hand rub. To assess whether frequent alcohol-based hand rub use leads to skin changes or irritant contact dermatitis, volunteers cleaned their hands with alcohol-based hand rub every 15 minutes for 8 hours for 5 sequential days. They were examined by a dermatologist before and after and asked about subjective skin changes. Results suggest an increase in irritant contact dermatitis scores and subjective complaints.

Current hand hygiene education is suboptimal.

BACKGROUND: To address the low levels of hand hygiene compliance (HHC) at our academic medical centre, we developed an annual patient safety course required for all incoming third-year medical students. Based on previous observations of medical students, it was determined that hand hygiene (HH) would be a central component of the course. METHODS: Over a 1-year period (2015/16), we observed third- and fourth-year medical students who had participated in the annual patient safety course entering three intensive care units (ICUs) at two teaching hospitals. A total of 150 medical students failed to perform HH on entry and were subsequently asked why they did not comply. RESULTS: Of the 150 medical students observed entering an ICU without performing HH, 74.7% were male and 25.3% were female. Males cited inadequate time (21.4%), lack of role models (10.7%) and provided incorrect information regarding HH requirements (58.9%). Females cited concerns about dry or cracked skin (34.2%) and forgetting (23.7%). DISCUSSION: Our study demonstrates that even when medical students receive intensive HH education, compliance remains low. Of note, males and females offered different reasons for why they failed to perform HH. To address the suboptimal HHC, we developed an annual patient safety course required for all third-year medical students immediately prior to beginning clinical rotations. In this study, we sought to understand why medical students' HH remains suboptimal even after an intensive course.

Why Money Alone Can't (Always) "Nudge" Physicians: The Role of Behavioral Economics in the Design of Physician Incentives.

Behavioral economics seeks to define how humans respond to incentives, how to maximize desired behavioral change, and how to avoid perverse negative impacts on work effort. Relatively new in their application to physician behavior, behavioral economic principles have primarily been used to construct optimized financial incentives. This review introduces and evaluates the essential components of building successful financial incentive programs for physicians, adhering to the principles of behavioral economics. Referencing conceptual publications, observational studies, and the relatively sparse controlled studies, the authors offer physician leaders, healthcare administrators, and practicing anesthesiologists the issues to consider when designing physician incentive programs to maximize effectiveness and minimize unintended consequences.

Introductions During Time-outs: Do Surgical Team Members Know One Another's Names?

BACKGROUND: Introductions are the first item of the time-out in the World Health Organization Surgical Safety Checklist (SSC). It has yet to be established that surgical teams use colleagues' names or consider the use of names important. A study was conducted to determine if using the SSC has a measurable impact on name retention and to assess if operating room (OR) personnel believe it is important to know the names of their colleagues or for their colleagues to know theirs. METHODS: All OR personnel were individually interviewed at the end of 25 surgical cases in which the SSC was used. They were asked (1) to name each OR participant, and (2) if they believed it is important to know the names of their team members and (3) for their team members to know their name. RESULTS: Of the 150 OR personnel interviewed, 147 (98%) named the surgery attending correctly. The surgery attending named only 44% of other OR staff (p <0.001). Only 62% of the OR staff correctly named the anesthesiology attending. The anesthesiology resident was the least well known but was able to name 82% of the others. The anesthesiology attending named his or her resident 100% of the time; the surgery attending correctly named his or her resident only 68% of the time (p = 0.002). CONCLUSION: This study suggests that OR personnel may consider introductions to be another bureaucratic hurdle instead of the safety check they were designed to be. It appears that this first step of the time-out is often being performed perfunctorily.

A ubiquitous but ineffective intervention: Signs do not increase hand hygiene compliance.

Proper hand hygiene is critical for preventing healthcare-associated infection, but provider compliance remains suboptimal. While signs are commonly used to remind physicians and nurses to perform hand hygiene, the content of these signs is rarely based on specific, validated health behavior theories. This observational study assessed the efficacy of a hand hygiene sign disseminated by the Centers for Disease Control and Prevention in an intensive care unit compared to an optimized evidence-based sign designed by a team of patient safety experts. The optimized sign was developed by four patient safety experts to include known evidence-based components and was subsequently validated by surveying ten physicians and ten nurses using a 10 point Likert scale. Eighty-two physicians and 98 nurses (102 females; 78 males) were observed for hand hygiene (HH) compliance, and the total HH compliance rate was 16%. HH compliance was not significantly different among the signs (Baseline 10% vs. CDC 18% vs. OIS 20%; p=0.280). The findings of this study suggest that even when the content and design of a hand hygiene reminder sign incorporates evidence-based constructs, healthcare providers comply only a fraction of the time.

An assessment of CPR skills using simulation: Are first responders prepared to save lives?

The American Heart Association's (AHA) recommendation for biyearly recertification and annual mandatory CPR training may be suboptimal for first responders (nurses and technicians) working in outpatient clinics (American Heart Association, 2013). To determine the efficacy of the AHA guidelines, 40 simulated sudden cardiac arrest (SCA) encounters were conducted followed by debriefing and a subsequent SCA to determine a basic level of CPR proficiency. First responders' CPR skills were evaluated using a 19-item assessment form to quantify the event. A comparison of scores using two different viewing modalities was performed to provide an assessment of the training program. Of the 40 sessions, group mean performance scores for the first encounter were just above the organization's minimum required score of 24. Performance scores increased slightly (27-28) after the second encounter. Proficiency of skills was poor and frequent basic life support training may be indicated to help first responders provide high-quality CPR.

The influence of high fidelity simulation on first responders retention of CPR knowledge.

INTRODUCTION: The purpose of this study was to identify the impact of high-fidelity simulation on the retention of basic life support cardiopulmonary resuscitation (CPR) knowledge among a group of healthcare providers (HCPs). METHODS: A twenty-five question exam was completed by nurses and nurse technicians over a two-year period before and after mandatory CPR training with high-fidelity simulation. RESULTS: Most HCPs scored near 50% or below the passing score (80%) with a mean range of scores between 28% and 84%. HCPs missed questions on the exam that requested specific details related to technique or human physiology during CPR. CONCLUSION: The current teaching method for basic life support may be enhanced by using high-fidelity simulation, but this modality alone is not enough to support HCPs retention of CPR knowledge. Additional studies are needed to identify strategies that will help HCPs remember specific and detailed information in the CPR algorithm.

A New Approach to Pathogen Containment in the Operating Room: Sheathing the Laryngoscope After Intubation.

BACKGROUND: Anesthesiologists may contribute to postoperative infections by means of the transmission of blood and pathogens to the patient and the environment in the operating room (OR). Our primary aims were to determine whether contamination of the IV hub, the anesthesia work area, and the patient could be reduced after induction of anesthesia by removing the risk associated with contaminants on the laryngoscope handle and blade. Therefore, we conducted a study in a simulated OR where some of the participants sheathed the laryngoscope handle and blade in a glove immediately after it was used to perform an endotracheal intubation. METHODS: Forty-five anesthesiology residents (postgraduate year 2-4) were enrolled in a study consisting of identical simulation sessions. On entry to the simulated OR, the residents were asked to perform an anesthetic, including induction and endotracheal intubation timed to approximately 6 minutes. Of the 45 simulation sessions, 15 were with a control group conducted with the intubating resident wearing single gloves, 15 with the intubating resident using double gloves with the outer pair removed and discarded after verified intubation, and 15 wearing double gloves and sheathing the laryngoscope in one of the outer gloves after intubation. Before the start of the scenario, the lips and inside of the mouth of the mannequin were coated with a fluorescent marking gel. After each of the 45 simulations, an observer examined the OR using an ultraviolet light to determine the presence of fluorescence on 25 sites: 7 on the patient and 18 in the anesthesia environment. RESULTS: Of the 7 sites on the patient, ultraviolet light detected contamination on an average of 5.7 (95% confidence interval, 4.4-7.2) sites under the single-glove condition, 2.1 (1.5-3.1) sites with double gloves, and 0.4 (0.2-1.0) sites with double gloves with sheathing. All 3 conditions were significantly different from one another at P < 0.001. Of the 18 environmental sites, ultraviolet light detected fluorescence on an average of 13.2 (95% confidence interval, 11.3-15.6) sites under the single-glove condition, 3.5 (2.6-4.7) with double gloves, and 0.5 (0.2-1.0) with double gloves with sheathing. Again, all 3 conditions were significantly different from one another at P < 0.001. CONCLUSIONS: The results of this study suggest that when an anesthesiologist in a simulated OR sheaths the laryngoscope immediately after endotracheal intubation, contamination of the IV hub, patient, and intraoperative environment is significantly reduced.

An evaluation of hand hygiene in an intensive care unit: Are visitors a potential vector for pathogens?

Patients in an intensive care unit (ICU) are frequently immunocompromised and might be highly susceptible to infection. Visitors to an ICU who do not adequately clean their hands could carry pathogenic organisms, resulting in risk to a vulnerable patient population. This observational study identifies pathogens carried on the hands of visitors into an ICU and investigates the effect of hand hygiene. Two observers, one stationed outside and one inside the ICU, evaluated whether visitors performed hand hygiene at any of the wall-mounted alcohol-based hand sanitizer dispensers prior to reaching a patient's room. Upon reaching a patient's room, the dominant hand of all of the participants was cultured. Of the 55 participating visitors, 35 did not disinfect their hands. Among the cultures of those who failed to perform hand hygiene, eight cultures grew Gram-negative rods and one grew methicillin-resistant Staphylococcus aureus. Of the cultures of the 20 individuals who performed hand hygiene, 14 (70%) had no growth on the cultures, and the remaining six (30%) showed only the usual skin flora. The visitors who do not perform hand hygiene might carry pathogens that pose a risk to ICU patients.

Using simulation technology to identify gaps between education and practice among new graduate nurses.

Applied knowledge was observed among nurse groups from a medical-surgical residency program to measure clinical performance during simulation training. Twenty groups of new graduate nurses were observed during five simulated clinical scenarios, and their performances were scored on a 24-item checklist. Nurse groups showed significant improvement (p < 0.001) in applied knowledge in four clinical domains from week 1 to week 5, and the results provided valuable information of the groups' overall performances. In two of the five scenarios, poor decisions and prioritization of competing tasks were factors associated with lower performance group scores. Complex patient conditions may pose a challenge for new graduate nurses, and standardized training during the residency program may help instructors recognize specific factors to address during the transition from education to practice.

Double gloves: a randomized trial to evaluate a simple strategy to reduce contamination in the operating room.

BACKGROUND: Oral flora, blood-borne pathogens, and bacterial contamination pose a direct risk of infection to patients and health care workers. We conducted a study in a simulated operating room using a newly validated technology to determine whether the use of 2 sets of gloves, with the outer set removed immediately after endotracheal intubation, may reduce this risk. METHODS: Forty-one anesthesiology residents (PGY 2-4) were enrolled in a study consisting of individual or group simulation sessions. On entry to the simulated operating room, the residents were asked to perform an anesthetic induction and tracheal intubation timed to approximately 6 minutes; they were unaware of the study design. Of the 22 simulation sessions, 11 were conducted with the intubating resident wearing single gloves, and 11 with the intubating resident using double gloves with the outer pair removed after verified intubation. Before the start of the scenario, we coated the lips and inside of the mouth of the mannequin with a fluorescent marking gel as a surrogate pathogen. After the simulation, an observer examined 40 different sites using a handheld ultraviolet light in the operating room to determine the transfer of surrogate pathogens to the patient and the patient's environment. Residents who wore double gloves were instructed by a confederate nurse to remove the outer set immediately after completion of the intubation. Forty sites of potential intraoperative pathogen spread were identified and assigned a score. RESULTS: The difference in the rate of contamination between anesthesiology residents who wore single gloves versus those with double gloves was clinically and statistically significant. The number of sites that were contaminated in the operating room when the intubating resident wore single gloves was 20.3 ± 1.4 (mean ± SE); the number of contaminated sites when residents wore double gloves was 5.0 ± 0.7 (P < 0.001). CONCLUSIONS: The results of this study suggest that when an anesthesiologist wears 2 sets of gloves during laryngoscopy and intubation and then removes the outer set immediately after intubation, the contamination of the intraoperative environment is dramatically reduced.

The use of a novel technology to study dynamics of pathogen transmission in the operating room.

Pathogenic organisms have been found in the intraoperative environment, potentially posing a risk of infection that could cause morbidity and mortality. In an effort to understand how a patient's bacteria can be spread throughout the operating room with the anesthesia provider as a vector, we conducted a study using recently developed experimental technology in a simulated operating room environment with a high-fidelity human patient simulator.

Do hospital visitors wash their hands? Assessing the use of alcohol-based hand sanitizer in a hospital lobby.

BACKGROUND: Reports regarding hand hygiene compliance (HHC) among hospital visitors are limited. Although there is an implicit assumption that the availability of alcohol-based hand sanitizer (AHS) promotes visitor HHC, the degree of AHS use by visitors remains unclear. To assess AHS use, we observed visitor HHC and how it is affected by visual cues in a private university hospital. METHODS: Using an observational controlled study, we tested 3 interventions: a desk sign mandating all visitors to use AHS, a free-standing AHS dispenser directly in front of a security desk, and a combination of a freestanding AHS dispenser and a sign. RESULTS: HHC was 0.52% at baseline and did not improve significantly when the desk sign was provided as a cue 0.67% (P = .753). However, HHC did improve significantly with use of the freestanding AHS dispenser (9.33%) and the sign and dispenser combination (11.67%) (P < .001 for all comparisons of dispenser alone and sign and dispenser with baseline and sign alone). The degree of improvement with the sign and dispenser combination over the dispenser was not statistically significant. CONCLUSIONS: Hospital visitors represent an important factor in infection prevention. A coordinated effort is needed to increase visitor HHC, including an evaluation of the AHS placement, education of visitors on the importance of HHC, and evaluation of corresponding changes in hand hygiene behavior.

A novel educational programme to improve knowledge regarding health care-associated infection and hand hygiene.

Lack of hand hygiene by health-care workers is the most significant cause of health care-associated infection. This programme was designed to make health-care workers want to wash their hands, to change their knowledge regarding hand hygiene and health care-associated infection, and influence practice. Improvement between pre- and post-test scores was statistically significant. Compliance is a multifactorial problem that involves knowledge and behaviour. Educational awareness and frequent reminders are critical to maintain high rates of hand hygiene compliance.