Communicatie op de operatiekamer - Dr. Anne van Dalen

Welcome to Anders Tezie Praatjes, I am Koen and in this podcast I talk to people who want to tell you everything about our wonderful specialist. Hello everyone, nice that you are listening to Anders Tezie Praatjes. Today I am here with Dr. Anne Van Dalen and we are going to talk about communication on the operating room. Anne has studied in Amsterdam, a university in Amsterdam. She has started her PhD there and is a master's degree in teaching. After receiving the master's degree, she has been in the Anders Tezie Faculty for a number of years and has been in the Tintents of Care. After that, she has been in the Anders Tezie Faculty for a number of years and has been in the Tintents of Care for a number of years and has been in the Tintents of Care. Anne, welcome. Thank you Koen. Nice that you are here. Two A's as under each other. That doesn't happen very often. Anne, why have you ever chosen Anders Tezie Faculty? I have chosen Anders Tezie Faculty because it is a very diverse and technical department. You work with all the specialists in the nursing home and it is also nice to adapt the physiological knowledge of the human body and the action and reaction aspect. So actually, with every treatment you do, you immediately see a result, which I always like. And of course the fact that you always have to be prepared for what may happen. Most of course everything goes well, but the fact that you have to prepare for what may be wrong, I like it very much. So you work together with the whole operation team. Yes, we will talk about that later. You never know what is going to happen during a service. Why can we wake you up at night during a service? Of course, I just love to sleep. But I always think it's very nice when there is a trauma, or an eczema or reanimation is on the spine and help. Because also there you can see that everyone has already woken up. As soon as that patient comes in, everybody puts a button on it and then it is done very well. And then everyone has one goal in mind, and that is to receive the patient as well as possible, which I always like to see. So again that cooperation. Yes, exactly. Do you also think there are disadvantages to our clinic? Yes, I think the advantage is that you work in a service. Of course, the surgeon has to finish the operation, but we can solve each other. For the work life balance, I think that is very nice, but you also have a very facilitating role, so you can sometimes see that as a disadvantage. And of course the job perspective is not so good for all the young doctors now, but I hope that when I am finally ready that it is a little better. Yes, exactly. We are going to see that. As soon as you promote an operation that you do not hear so often, communication on the operating room and then especially with the use of a sort of black box, a recorder. How do you come up with that challenge? What is the background of it? Yes, the background of it is that despite having a lot of safety systems on the operating room, such as the checklist at the beginning of the operation, there are still a lot of things that are not so good on the operating room. And what we saw from earlier studies was that a large part of it is actually forbidden. But how can you analyze that? You can actually do it by taking things up. Yes, and then look back. Yes, yes, because when I was a little bit in the numbers, I was a little shocked. There were studies that came across from Harvard, a number of years ago, where it was said that actually 3.7% of the recordings were seen. Of which actually more than half, 58%, were actually fake, which were forbidden. Was that one of the instructions to say, well, then we have to take them up and see if the forbidden mistakes come across? What is the idea behind making those recordings? First of all, of course, a large part of the mistakes in the hospital came from the operating room. But actually, from the outside, the operating room is also a bit of a black box. Nobody knows what exactly happened. We have already taken a lot from the airplane industry. So it's actually a professor from Canada, Dr. Gwentroff, who thought that we could also install a black box in an operating room in the airplane industry. He takes up everything that happens there and analyzes it, and thus gives objective data to the team, so that the team can look back at its own performance. Yes, precisely, the training that I did at the same time with the air force. Of course, we also know that. So the black box, where we recorded everything was black. Of course, there it is very often only about accidents. I always thought, if an accident happens and the airplane crashes down, then we go in search of that black box. And then they go and see how it can be that the airplane is crashed down. What I also found out now was that the black box also serves to track data about the maintenance of the airplane. Or the parts that are no longer functioning well. So it's actually a black box, so not only for when the fault has gone, but precisely to prevent the fault. Yes, that's right. Most people think that it's only a black box that is used to destroy the airplane, but that's no longer the case. How should we call it now in the airplane industry is the cockpit data recorder. And it also takes up the sound and the conversations in the cockpit. And actually all that data has been analysed for a number of years. And also used for team training for the pilots and the rest of the team in the airplane. Okay, yes. And well, you can track the parallel between the air force and the operating room. And of course we can also say that the human factor actually has the biggest influence on what is happening there. The pilot has to get up, land and make decisions in between. We have to do that as well as the geologists. What do you have now before you started your research on the communication factor? How important is that communication? Yes, actually from all studies that you find about faults, both in the air force and in hospitals, to lead to the communication fault. So that's really a very important factor when it comes to the increase in safety. Yes, but what kind of fault can that lead to in the operating room that can lead to complications? Well, it's actually about things that are very open. So indeed, with the name of the wrong names. The fact that the surgeon, for example, thinks that everyone can understand him or her, but that is often not the case. Because everyone wears mouth masks, there are all pimples, phones that go off, doors that open. So that's already a very common feature. And also the feature that everyone always has everything through what happens. So that the nurse always continues to have, for example, the surgeon has a bleeding. And of course also, that the nurse thinks that the surgeon continues to have the bleeding. Or that there is a problem on the other side of the roof. Yes, so actually there are two islands, you don't want that either. You have all communicated with the islands. But now it's important that they understand each other and understand what they mean. Yes, exactly. Yes, you just mentioned those pimples. Of course, we are constantly busy with signal sending, but also reception as an anesthesiologist. Of course, all the sounds around us, the parameters, we have to look at the patient and so on. You call that a beautiful wolf, I have already taught you situational awareness. At what moments does that take off? Yes, situational awareness is of course a ability that is very important as an anesthesiologist. You have to keep everything going. But yes, what they also see is that especially under stressful situations, or if you are having a difficult treatment or for example in a night service, when you are tired, that it takes off very well. So then it is extra important to communicate very well with each other. Yes, exactly. Those complications that you came across during your promotion research, can you share them in certain blocks? Are there main groups of complications? Or can you put all the complications on the operating room in one big hope? How exactly is that? Yes, the Black Box Performance Report that we got back. We were actually from technical events and non-technical, so non-technical events. Technical events were mainly about surgical treatments, but non-technical events actually turned out to be much more relevant. And then it is about communication, cooperation and the situation awareness and instructions. Distractions. Okay, and technical versus non-technical? What do you think about technical mistakes? Yes, that is, for example, the pressure that is too hard on the arm, that kind of things. Okay, but does the Black Box also make a difference? Yes, yes, that's right. And how did he do that? Yes, there is a lot of software behind the Black Box system with Artificial Intelligence and also Machine Learning, which of course constantly improves itself. The analyses are getting better and better. Okay, yes, good. Yes, good, the Black Box, yes, it constantly takes data on the operating room. I read that in the airfield, there has been a lot of resistance with pilots. When that black box was introduced, 15, 60 years ago, I said, yes, then it is continuously looked at how we function, how we talk. If we discuss something in the cockpit, then you can listen to that again. This will cost us a lot of money. How was it reacted in your hospital when you said, well, we are going to install things here and everything is recorded, what is said here is done. Yes, it is of course a very logical reaction that people will react. So yes, we also saw that in the beginning. So that is of course very important, to get that right, the legal and medical medical, what do you say? Medicalical, yes. Yes, it is very important to get that right. So we have also done that. The Black Box system analyzes data according to the privacy by design principles. So that means that all data is analyzed immediately. The heads of the team members are blurred, the voices are formed and all data is analyzed. Then a report was made. And the original data was then disappeared as soon as the report was made. So it can no longer be led back to the team members and the patient. Above all, it is a quality instrument. It is really about the use of the team. It is no part of the treatment of the patient. So it is so that it does not have to be added to the patient's file. No, but I assume that the patient had to give the previous application that you would need this work. The patients received a so-called opt-out option. So of course they were informed that there was going to be a recording. And if they did not want that, they could choose not to be operated on that day on that operating room. But the patients were very enthusiastic and said that it is strange that it does not happen before. No, I can also imagine that it has a safe feeling. If you look at how it works on an operating room. And that is only the source of the good. If a patient had received a complication during his research. And he had said that he wanted the research to be done. What exactly went wrong during the operation? Did they then have the use of the black box at that moment? At that moment, yes, the report is not because that is the quality instrument. And that is not part of the patient's file. But if something goes wrong, then it will be according to the normal standards. So yes, we assume that everyone is adhering to the procedure. So everything is well documented. In that way analyzed what went wrong. I think that is also a factor that gave more confidence to the people who participate. So the anesthesiologist, the surgeon, the operating assistant and so on. That this could not be used against them if there was a complication. Yes, we have indeed made sure that there was a kind of agreement, in which the data was not used against the participants. Was the black box the only instrument that you used or implemented to investigate the communication protocol? Or were there more things that you wanted to include? Well, we received the report and of course we used it to discuss it afterwards with the whole team. Because, as footballers can also look back at the game to see how we can improve. It is of course very logical that you also want to do that as an operating team. But how do you discuss something afterwards? So there we also developed a model. And if you dive into literature, then you find that that actually... Yes, you have two kinds of negotiations. The hot debriefing and cold debriefing. It means that you really do it directly. So that's what is often done, for example, on the patient's file. Directly after it has happened. But in this situation, I think it's better to do it a few days later. And to be able to cool off, if something really happened. But that actually feels very much like that. Okay. And how do you sit down at such a moment, if you do a cold debriefing with a recalled bias and so on? Of course, everything is in there and you let it go for days. How do people still remember something? Well, that is the beauty of the report. There were also videos. So we went and looked at the report with the videos. And then everyone was like, oh yeah, oh yeah, that was it. And then it was important that the hierarchy is as low as possible. So that you can actually sit on a round table. And we had an independent person who accompanied the debriefing. It was not the surgeon or the anesthesiologist. So that everyone feels safe to say something. And I think that's the most important thing. And that's what we got back from the participants. For example, that everyone, that it was nice, for example, that the staff also liked it. That they once got room to give their opinion. Exactly, exactly. Yes, fine. Do you notice now that it was also difficult to get everyone around the table? I can imagine that surgeons who are on certain days, on certain occasions, the anesthesiologist, we all have a very busy schedule. But otherwise, of course, it is not one solid team, because every day the same people exist. So how are you going to get the people around the table for the debriefing? Yes, that has indeed turned out to be very difficult. So it was of course a pilot study to see if it is possible to do this. And for the future it would indeed be very nice if there really would be a solid moment. So there are also a number of hospitals in Canada and America that have the Black Box. And they then have so-called M&M meetings. So morbidity, mortality meetings. And that there is just a solid moment, once a month, when a number of surgeries are discussed. You just put all your hopes into it and then you take them all off. Yes, exactly. And because it is anonymous, it is possible and therefore a no-blame, no-shame environment. No, yes, beautiful. Hey Anne, of course you get a tremendous amount of data from the Black Box. You just said that you can use that for a debriefing to learn from each other's communication. What have you been able to learn from that data from the Black Box? As I said, it was a pilot study, so we all included relatively simple operations. But despite all the operations where everything went well, the Black Box found 50 relevant events per operation. I think it was also a story to see that even if everything goes well, then you can still learn a lot from an operation. Then you put 50 events per operation. With simple operations, I think of a goldblast extension, an appendix, which is removed. And the average surgeon in an academic center does that for three quarters of an hour. So you have about one event per minute which marks the Black Box as remarkable. Yes, we also had hemicolectomies. Operations on the body are well-groomed. But also appendectomies, indeed. But these are relevant events, so they are as good as safety threats, as the Black Box marked. Of course, it is also about making almost false agreements. Because before there is really an adverse event, so an adverse event means that there is really a damage, that it really results in damage, then there is always a number of almost false agreements. I think it is important to make those agreements, so that an adverse event is prevented, and especially in the future, of course. Yes, exactly. Of course, you also show those images to the visitors during such debriefing. What was their reaction when they saw themselves back? What is their perception of what they should get? Of course, in the beginning everyone was a bit nervous, but what we saw was that the Black Box did not fit into the operating room. We used the cameras that were already there, and then small microphones. So actually everyone was just in such a normal role. There were also just jokes made. And the music was also just allowed to stand on. So that all went very well. And actually everyone was very enthusiastic. Everyone thought it was very nice to look back in this way. We also saw that in the study, or the data that we analyzed with the help of questions, that 98% would also advise to participate in their colleagues. So actually you would advise every surgeon and anesthesiologist once a week to watch his own video of himself, to see how I actually do things. For me, if you do something very self-sufficient, you just do some things in your routines. And if you see it from the outside, as a third person, you think, hey, why am I actually doing this? And couldn't it be much more efficient or better or something else? Yes, exactly. Of course, during your clinical training, you do that of course more often. We had, during the bachelor, that you then assume that you first have a talk with a patient. But as soon as you're done with your training, you never do that again. So of course that's pretty weird. And I think, yes, top athletes do that. So why don't we do that? It's also top sport on the operating room. Yes, sure, sure. And what were the main points that came out of such a team meeting, such a debriefing? What were the most striking things? Well, we did a sub-analysis to see how well everyone knows each other's name. Because in principle, you write at least in our case, always the name on the whiteboard on the operating room. And yes, it is also part of the surpass, of the time-out procedure to do a preview round. But we analysed that, that was almost never done, that preview round. I don't know how that will be done here in Maastricht. Yes, at the beginning of the day. Yes, we try to keep that in mind. Yes, exactly. That's very good, I think. But we say that that was often not done, and then you hear from the team members that it's just weird if the patient is still going to introduce themselves to each other, if they don't know each other. But if you ask a patient, they don't think that's easy at all. But then you did that when the patient was in the room? Yes, exactly. Because not every operation is done with the same team, in principle, of course. You operate with the same team the whole day, but that's not always the case. So we went to see the negotiations, everyone can still write down all the names of all the team members, with whom they were standing all day. But then we saw that 40% couldn't do that at all. The operator only knew 5% of the cases, the name of the other nurse. And the other nurse knew in 65% of the cases, the name of the operator. Okay. So how can you solve that simply? I think it's good to get the team spirit in at the beginning of the day. If you have a moment with all of them, and that the task distribution is also clear, but to keep the name, it's just difficult. We already know that for a long time. So then we thought, just like in the dressing room, why don't we just put a name sticker on our head? Also anesthesiologists in Australia have introduced that with the fourth cap challenge. Okay. So it's a very simple solution. Yes, actually it's a matter of thought, that 15% of the surgery, but the name of the other nurse knows from the day, turns out to be 75% only. Yes. If I were to tell you again that the success rate is also very crazy, if the pilot and the co-pilot don't know each other's names. No, exactly. The two captains are also on the operating room. Yes, exactly. Okay, so then a sticker was put on the head, so that everyone heard each other's name well, and heard the function. Have you also looked at whether that actually resulted in a better communication experience? We would like to indeed investigate that in a follow-up study. We also looked at the implementation of those name stickers at the beginning, but a few years ago we did that. And everyone in the operating room, in the Amsterdam emergency room, just wore those stickers. Okay. And now that's just the state. And why did you wear those stickers? Because your name has been with you for ten years already. So why is it a problem to put on your hat? Yes, people thought it was childish. Or they said, yes, everyone knows my name. And yes, that's strange for the patient. But yes, that's also true. Yes, it's a bit more complicated. Yes, exactly. Yes, that's what I could imagine. So, then you had about the operation muts with the name, an imagine round, at the beginning of the day, or at the beginning of the operation, like changing teams. Are there still things that you can get out of it? Yes, to improve that communication even more. Yes, also a well-known term, also from the airport, is of course the closed-loop communication. I think that is the most important principle, actually. So that means that if you give an assignment, or if you ask someone that you first call someone's name, that he or she gets the assignment, and that then the one who gives the assignment is also connected again, that he has done the assignment. So that you make the round. And I think that, what you may have recognized yourself, that that communication often does not happen that way. And then you get the names that people think that you understand each other and understand each other. And that is often not the case. No, exactly. I know that closed-loop very well, from within the closed-loop itself. So with your closed-loop partner, or your staff member, or your co-workers. I have given this medium, and then you get back, okay, you have given this medium, or I write in the system, or something like that. But you say, well, then we would also have to look at it more, between the operating specialist and the closed-loop, to get that closed-loop more. Exactly, because there is often a gap between the surgeon team and the other team, and what I have already said, there are just a lot of instructions on the operating room. And yes, that is just, it just remains difficult. Yes, yes, sure. And I can certainly also imagine, if of course the pressure is increased at difficult operations, at critical moments, that that communication will only become more important. Yes, exactly. Are there still techniques or tricks to improve that? Yes, what they do in the air is the sterile cockpit rule. So at the stairs and at the landing, then there really shouldn't be any instructions for the pilot. So I think that we could also adapt that to the operating room. So yes, of course, at the training, and at the training, that the radio will not go out, that there will not be clenched, and that the door will not open three times, because those are just important moments. And that gives the surgeon, for example, that I am now going to do an important part of the operation. Can everyone, I have a good focus needed, to silence for a moment. So that you give that way when it is a stressful moment, so that everyone knows, OK, now we have to communicate well, and ensure that there are as few instructions as possible. Yes, that is actually a summary. It is just important to communicate on an operating room, with a closed-loop communication. The surgeon says something, otherwise the doctor will give it back, that he has heard it. We know with which team you are on the operating room, that you know each other's names, that you know each other with short instructions, that you can draw the name with it. But also really at difficult moments, the introduction, the introduction, difficult moments, the tennis operation for the surgeon. Because then just to give a listen. At this moment, we just have to be quiet for a moment. No extra tricks, so that we can actually have all the focus on how to deal with it. Yes, exactly what we also saw from the data that we analysed, was that for example during the important moment for the ocassistent, so counting the gases, that that was often not seen as a important moment for the rest of the team. So that the ocassistent was counting, but the surgeon did not go through, that they were doing it, and they just continued to give orders and talk, so that the counting can actually not be done well, and that is of course also a critical moment of the operation. Yes, exactly. So that was also such an announcement and a realisation moment. And is it then the task of the surgeon to be more alert there, or is it then the task of the operating assistant to say, "Listen, I'm going to start this now. I no longer have space to get instructions for other things." I think both sides. So the surgeon also does not express that, he does not continue that. So I think that the ocassistent has to say, "We are going to count now," and then that clearly communicates with the rest of the team. And so the surgeon indeed realizes, "Oh yes, this is an important moment for him. Now I'm going to keep my mouth shut." Yes, good, nice. Hey Anne, you mentioned it a few times, we want to go and investigate some things. We are now perhaps in the direction of this and this and this. What is actually the future of that black box? I'm going to see this in my career in 20 years, in every operating room where I come from. Yes, that would of course be the most beautiful thing. So in the Amsterdam University, the new black box system is now installed in two operating rooms. So yes, it is the future, I think. And what I have already said, the artificial intelligence software ensures that the data analysis is only getting better and better. And yes, the possibilities are actually endless. You can research everything you want. Yes, research, but in the end you may also just use it in your daily practice. Yes, so the goal, what we have for now, is that you can actually use it for three things. So one for standard team training, for example, once in a while you must get your ALS in a simulation setting, that if you work in the hospital where a black box is, you are obligated to do one or two times a year to do such a black box operation, and to look back on your own operation with the team. So just in that way. And second, of course, if there really is a calamity, where there is real damage to the patient, then you would rather use the data you want to use if that helps. And third, of course, for research related things. Yes, exactly. How far can you now pull out the black box or the artificial intelligence? What I still have to think about is, how more training you, for example, have as an anesthesiologist in your daily work, how more difficult it is to have your attention on both things that you really have to do. So it is of course important, especially if there are complications, that you write a system, how much do you think your friends have given you for propofol or for chronium, what then also. But I sometimes notice at the operating room that it is quite a distraction to always, if you have given something, or to say otherwise to the nurse, write it down for a moment, and take it out of her concentration, what she is doing with me, or to the computer itself to walk and to carry it in the state. You can also insert a black box to just notice it with voice recognition. Okay, the anesthesiologist has now said, I have given 150 milligrams of propofol, and that it is just in the system. Because if you work really hard over it, and at difficult moments, as you call it yourself, you call it the sterile cockpit rule, then the black box would be able to support us a lot. Yes, for sure. Administration of course can generally cause problems with the whole hospital. That would certainly be very nice if we could work together more, indeed. You don't have to spend unnecessary time on the administration. For example, now it still can't, but there is also a black box specially developed for the trauma room, which is installed in the American hospital. And it already has some of the features that it can document. Okay, so over 20, 30 years, if you have a fixed track somewhere, and the track market is very optimal for all of us, then we can support each operation with a black box, which is also done with research, and which keeps us safe. Yes, that would be very nice. So, hey Anne, thank you very much for your time. Thank you for wanting to keep this story. And thank you for listening too, thank you for listening to us, and see you next time. you