Effective Communication in Surgery Could Reduce Deaths by 2/3
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A communication tool first created for the nuclear submarine industry and later more widely used by the military and aviation sectors has been highlighted by Britain’s oldest surgical Royal College as an effective technique to avoid adverse events and improve patient safety – cutting mortality by as much as two thirds.
Whilst there is published guidance and literature by organisations such as the General Medical Council on physician communication, there is little in the way of recommendations for dialogue with patients, colleagues and supervisors specific to the surgical world. Studies have shown this area to have vastly different requirements and constraints, structurally distinct to primary care.
With this in mind, the Royal College of Surgeons of Edinburgh (www.rcsed.ac.uk); which in early 2014 opened its first base of operations in Birmingham to cater for the 80% of its UK membership based in England and Wales; launched a groundbreaking competition inviting trainee surgeons to submit videos showcasing communication techniques across a variety of circumstances encountered in their daily work. Submissions covered themes ranging from the delivery of bad news to patients, to clear handover to colleagues and phone calls to outside consultants when raising an alarm or seeking advice out-of-hours.
The competition was won by a team of female junior doctors based in Sheffield, who submitted a video on utilising the ‘SBAR’ technique to avoid errors and delays when escalating a concern to a consultant outside the hospital, for example when a patient might be deteriorating. SBAR – which stands for Situation, Background, Assessment and Recommendation – is a mnemonic system for prompt communication first developed by the US Navy and eventually adopted by medical ‘rapid response teams’ to promote a short, predictable flow of critical information.
A 2013 study in journal Resuscitation evaluated close to 40,000 patient admissions across 16 hospital wards, and the implementation of SBAR in nurse-doctor communication alone cut unexpected deaths by a staggering 66%. Another, more recent (2014) study in the British Medical Journal (BMJ) also showed that the adoption of SBAR within a number of anaesthetic clinics reduced the number of ‘serious incidents due to communication errors’ from 31% to 11% (-65%).
SBAR has become a recognised as a useful tool in nursing, and the Royal College of Physicians recommends its use in shift handovers. Uniquely, the winning video applied SBAR to phoning a senior outside the hospital – a circumstance which may involve waking them up in the middle of the night, or communicating a perceived urgency which less confident juniors might be hesitant to stress. According to competition winner and trainee surgeon (CT1 level) Anna Watts, who is 27;
“We've all been in a frustrating situation where someone is trying to pass on information about an unwell patient but nothing is in a logical order. It makes it extremely difficult for the recipient to make a judgement, so SBAR is a great way of ensuring that a clear picture of what is happening is created and that no information is missed.We chose to focus on SBAR because communicating over the telephone is part of our daily practice yet little emphasis is put on making sure you can do correctly. It's a really clear method of communicating that can be used by all members of the multidisciplinary team.”
In December 2013 a 10 year-old girl died from an epileptic seizure in Basildon Hospital, when the on-call consultant failed to note the urgency of the situation and stayed at home.
The College has previously made healthcare history through identifying the vital importance of non-technical skills in surgeons (‘NOTSS’) such as situational awareness, teamwork and leadership. It has developed highly tailored training and assessment programmes based on these human factors, not only used in the UK curriculum but which have become widespread internationally, including in the US, Japan and Australia. The College; the only in the UK to have a Faculty of Surgical Trainers, also recently launched the first-ever official standards for helping coach juniors as they progress through their careers. It’s known that surgical trainees consistently have the lowest job satisfaction and are three times more likely to experience bullying and undermining than other healthcare professions.
Other submissions to the competition covered the delivery of bad news – for example the need for empathy and clarity when informing a patient they have a serious illness, or when forced to explain a clerical error has meant a delay in test results. Some included a humorous approach (not dissimilar to the John Cleese infamous ‘Management training’ videos) on how not to communicate. Others covered the importance of clear, face-to-face handovers and briefings between teams during shift changes.
According to consultant plastic surgeon Judy Evans, who is on the Council of the Royal College of Surgeons of Edinburgh and who led the competition initiative;
“Effective communication is vital for patient safety. Studies have shown that whilst surgeons tend to be generally thorough in providing details about surgical conditions and treatments, they often don’t explore patients’ emotional concerns or express empathy in as much depth as they could. Equally, the pressures of the current shift system place a lot of emphasis on handover clarity, and it was fantastic to see through this competition how the next generation of surgeons propose communication solutions and techniques in a creative way, even through the simple use of a smartphone video.
“The winning team submitted an excellent video depicting the use of SBAR in an original way – it puts out a powerful message and a reminder that this effective tool can help cut errors and ensure the healthcare team covers all the salient and necessary features when providing patient history.”
A 2013 study in BMJ Palliative Care showed that poor communication, particularly with cancer patients, is associated with worse clinical outcomes, including worse pain control, worse adherence to treatment, confusion over prognosis and dissatisfaction at not being involved in decision making.
In a 2010 survey by the RCP, over three out of five (60%) young physicians said they had been given no education or induction in in the handover process at their hospital.
- S – Situation: identifying the site, patient and reason for report
- B – Background: reason for admission, significant medical history, prior procedures
- A – Assessment: vital signs, impressions and concerns
- R – Recommendation: explain what’s needed, clarify expectations, make suggestions
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