Dr. Jennifer Arnold - Teamwork and Communication – Mission Critical for Patient Safety

Sorry everyone for some technical difficulties but we'll go ahead and get started now that I think they're all sorted out fortunately. So I have the pleasure of introducing Dr. Jennifer Arnold. So I think for many people Dr. Arnold needs no introduction but I will do that anyway. In terms of her academic history as she went to medical school, Johns Hopkins and then state in Pittsburgh for quite some time I learned for residency fellowship in neonatology and graduate school. And so she's now our program director for immersive design systems and this as I sort of learned about your history I think you speak and are insightful in this area from so many perspectives from both some celebrity and from some personal experiences in medicine. And I saw they were even inspired by a neurosurgeon and so that's always nice to hear on our side. You have decades of experiences in pediatric simulation and we look forward to hearing what we can learn about teamwork and communication, what you call mission critical for patient safety, which we all know and believe and want to learn how we can improve in and with that. Thanks very much. Thank you so much for that lovely introduction and let me see if I can just bring up my slides. I apologize for the delay. Zoom was not my friend this morning. Hopefully I've downloaded this very large presentation. There's a lot of videos. I wouldn't be a simulation educator without sharing some videos and so it took a little bit here. How many of you actually while I'm here waiting for this to open up have participated in the Krico simulation program here at Boston Children's and Immersive Design Systems. I love seeing all those hands excellent. Thank you. Well, you know, coming from another organization having been here at Boston Children's now for almost two years, the program here is really impressive and there are really very few other programs that have the support of, you know, an insurer to fund and offer these types of opportunities and an amazing simulation program. But Dr. Weinstad who is in the audience here and the rest of the team have built to be able to offer team training on a regular basis embedded into your daily work and that's really impressive because ultimately that is the goal of simulation based training and that's the goal of improving teamwork. There's no other better way to train. And we're very slow. So my apologies. So really, I'm going to just go ahead and get started in terms of the background because you all have gone through simulation based training for Krico and teamwork skills. We're not going to, you know, really talk a lot about the theory behind it. I think everyone's pretty familiar. We will have a quick overview, but I really want to spend some time doing an exercise and interactive exercise where we'll engage the audience you all. And so have out your phones, please. There'll be an opportunity to use a QR code, all right. And we'll talk about teamwork skills. And when we talk about teamwork skills, I'll share with you that the videos you see were made for the movies, so to speak. They're a little exaggerated, but they get the point across about how these specific skills can really impact care. And again, you all know this, but as we go through this, you'll get to see how those teamwork skills when they're used not so well can negatively impact patient care and how when they're used well, how they can positively impact patient care. Oh, yeah. Okay. Okay. We're going to share screen. My apologies. I forgot was zoom. Okay. Hopefully everyone on zoom can see too. Okay. So conflict of interest. I do have a grant that with colleagues here through cry co, which is related to using simulation as a patient safety tool. And really our goals as I mentioned are to review CRM skills. So it's a little bit of a review, I apologize, but I think it'll be a lot of fun because we're going to do an activity where we get to talk about and explore CRM skills and the impact. And then last, I'm going to sort of end with a little bit of the future. So thinking ahead, you all have again, very experienced in what these teamwork skills are, the importance of them. But how do we take what we've learned today and move it forward to becoming even safer in healthcare? Because we still have some work to do. So again, teamwork skills that we're going to talk about, you know how important they are. They can improve patient care specifically. When we do them well, it allows us to have a better safety climate and culture. We actually can see decreases in error rates, improve processes, and ultimately again improve our outcomes of our patients. Again, many of you know this, but we've taken these teamwork skills and applied them to healthcare based on what we've learned from other heights. And what we've learned from other high risk industries and specifically aviation. Many of you may know NASA way back in the 1980s to the study looking at the black box recordings of in-flight crises. And they actually found that almost 70% of the time, the leading causes of those incidents were related to deficiencies in teamwork, communication, leadership, team training. And similarly, about 10 years later, the Institute of Medicine identified in healthcare, 70% of mistakes in medicine, preventable harm, have implicated deficiencies in those teamwork skills. And so again, in the aviation and other high risk industries, like nuclear power and the military, focusing on and training on those teamwork skills, factors or non-technical skills have made those industries safer. And similarly, we know that it can make healthcare safer as well. So where do these skills come from? You're probably familiar with the work by Dr. David Gabbah. He's a simulationist. He's also an anesthesiologist who really figured out how to adapt those skills from aviation and other high risk industries, which you see here on the left, those 15, what they called crew resource management skills, and translated them into healthcare into what we call crisis resource management skills. And here, as part of your program, you focus in the Crico program on five of those skills, role clarity, communication, personal support, resources, and global assessment. So why is this so important? Well, the literature is continuing to grow, showing that CRM does help improve outcomes. It is cost effective. I love this study that came out in 2019 by Moffat and Bruce that actually showed CRM training is a financially viable way to improve patient safety, with an overall ROI of $9 to $24 million when you compare the actual reduction in observed versus expected adverse events from these trainings and comparing that to the cost of training. So, you know, those that sort of say, okay, it's too expensive to put folks into simulation training, put them into this time. It actually is worth every penny. And then of course, there's literature that showed improvements in culture of safety survey data and institutions up to two years post training, which I thought was pretty impressive. There's also other data that shows decreases in out bad versus outcomes and medical error rates, which is pretty exciting. And of course, ultimately the main goal to decrease patient mortality. So the program here, congratulations on all the work that you have done. This program has been around since 2010. It is includes a three year cycle, which you all know better than me, where you rotate with one year of simulation training, another year of the chief's choice. And other types of learning opportunities all related to CRM. And since 2020, Kreiko has actually saved foundations over $1.2 million because by your participation, there is a now practice premium reduction, which is really exciting to see an organization support this financially. All right, so little background. Now I'm curious who wants to be a crisis resource. All right, I'm going to have to hear the audio. I hope my videos work. All right, so you all talk about five CRM skills. For the purposes of this exercise, we're going to focus on four, which are really similar to the five that you focus on your Kreiko program. World clarity. Again, it's all about having specific roles and making sure that team members are able to focus on their roles in any situation that no team member is multitasking, right? And that we have good handoff of roles as appropriate, which is not unusual in a crisis situation. Effective communication. I'm sure you're also very familiar with this is the idea that we maintain a common professional environment. We used good communication techniques, such as closed loop communication. We clearly communicate, especially during a crisis or when critical events occur as a team leader. We are effectively communicating the plan and that all team members are empowered to speak up. And so those are all the aspects we want to look at with communication. Situation awareness is again very similar to the global assessment that you oftentimes utilize in the CRM courses here. This is the idea that team members utilize all the information that they have. We're anticipating, we're monitoring, we're looking ahead for the crisis so that we're ready and prepared to handle that crisis. And even during a situation, we're using what I like to refer to as effective mental modeling, which is the idea that we are constantly recapping and talking about where we're at and where we need to go so that we can all have a shared understanding of what that situation is when we're working as a team. And so that helps each person in their role to be able to better perform their job duties because we're all in the same page. And then last but not least, this is concept of resource utilization, which is again where we use all of our resources, well people, information, technology, equipment that we're optimizing, how to use those resources and also how to minimize overload of workload or under workload. And again, all the different resources that are involved in a team are able to be functioning at their optimal. So I'm sure you all have heard of these skills. You've utilized these skills in your daily practice and then obviously trained to them in simulation. We're going to sort of explore a little deeper dive because sometimes I think talking about these skills doesn't necessarily sink in as well as when we see them. And we're going to start off with a case and we're going to do a little discussion here of a teenager admitted to a pediatric acute care floor with respiratory illness. And this patient is essentially going to have a decomposition, an event. And there is a team that will come in and you know waves, right? Typically when we're in a situation, a lot of times there's the first responders and then we have second responders. A little different I understand in the OR setting where most of the team members are likely already there. But I imagine there are times where you have to call for additional resources. And so we're going to go through this case. And as I mentioned in these videos, sometimes it can be a little hard to watch because they really show poor crisis resource management skills. But we're going to talk about them and I want you to, as you watch each clip, help me identify where the deficiencies in CRMR. I don't think you can hear. Can you all hear on the back? No. Okay, I'm really concerned. The heart rate is very low by the mesaccurations you're dropping. Well, you know, there's my envy friend. We did? He says we're good. Can you hear? No. I can't hear something. You can't hear. You can get the laser can. You don't have to put it on too late. I don't think we can hear in the auditorium. He's working on it. Well, this will be a really quick lecture if we don't get to listen to the videos. I'm going to pause it. No. Dr. Rammurly concerned. The heart rate is very low by the mesaccurations. All right. Well, if this doesn't work, we'll just keep going. See? He said, he from last night checked out to me that this is the way he spent the saturation's or continuing to drop. And the heart rate's continuing to elevate. I'm very concerned. You can get the news. No. Can hear it on Zoom, but not out loud. Okay. Well, anybody? Yeah, they can hear it on Zoom, but not here. Has anybody else had that problem? Thank you. Why? Thank you. I'm going to come down to that. I'm here. I'm going to come into your own. That's for the video. Thank you. Dr. Rammurly concerned. The heart rate's very low by the mesaccurations are dropping. Well, you know, the team from last night checked out to me that this is the way he spent the saturation's or continuing to drop. The heart rate's continuing to elevate. We're very concerned. Okay. You can get the news. Okay. No. I'm putting on two later. Some people have to listen. They've got to be right down. This is the way they're going to turn. I'm not sure what else to do. Let me see. I'm not sure what else to do. Let me call my finger at you. Okay. Can you get your help? What's going on? He's trying to put the oxygen, but it's not helping. Can you call me for that? Yeah. I'm worrying about it now. So you've got to call me for this. That's my name. I get it. I'm going to get it. Oh, I'm going to do this. He's on two later. Can I put him up to four or five? It's great and fine. That's a big noise online. Yeah, this is the way he went. I'm going to put the team on these. I'm going to put him here. And now he's going to open up the hospital. He's going to close the hospital. He's going to close the hospital. He's going to close the hospital. I'm just going to pause with you since the audio is not... They just stay there. Not very easy. So I'd love for you all to get out your phone if you can and grab this QR code. And we're going to have a vote. This is where you get to be a CRM millionaire. And I'd like you to tell me what CRM skilled you think was most efficient as they were evaluating this patient who was decompensating. And essentially standing there. That's not very helpful. See more. Nope. Okay. I'm just going to tell you the answers. A is role clarity. B is... Should be resource utilization. Oh goodness. Nothing is working for me today, huh? All right. So, let's see. Nope. All right. It's been flagged already. Tell me the audience. We're going to give up on the role. They are poll. Tell me what CRM skilled you think was most efficient in that scenario. Anybody? Any guesses? Yes. I love that. Can you tell me why? I don't know. Exactly. They knew things weren't going well, but they really weren't thinking about what can they do to help advance, you know, increasing care level of support quickly. Great. And I might argue personnel, even equipment and supplies, right? So, there's other respiratory support that they could have provided, monitoring things of that nature. Great. And any other CRM skills that folks thought might have been lacking in that situation thus far? Yes. Thank you. So, fixation, lack of situational awareness, right? They were very focused on one aspect of that patient, the desaturation, and really not thinking globally about what else could be going on. Which leads to delays in care. Great. All right. Thank you. All right. So, I'm just going to advance, and we're going to see a little bit of the care here. We, in this situation, what you're going to see is, now the team is in the room. So, they call for help. They did call for help. They've gotten a little bit of a code team there, and it's a little bit chaotic. So, I'm hoping you can hear a little bit of this so we can have a little bit further dialogue. All right. It's been splashed already? 30, 70, 80. 14. Oh my goodness. Thank you in the back. Mact 2. Okay. What are you having the luck? You all here? Whatever. We need to hurry. Blade. What? Aito. You got men? Ready? Okay. All right. Entitle. You got the entitle? No, I don't know. We need an entitle CO2. Just go. I'm trying to push them out. I can't wait to have a minute. I'm just kidding. How do you get so sick? I'm just starting to be standing with Cole here. You guys took some time to make here, right? Right, whatever. All right. We're going to integrate an entitle on its way. Okay, let's push the meds. Kelly, I'm ready for the meds. I'm looking for the entitle. Hold on. It's on its way. Where? All right. All right. I'm just going to activate. Okay, well, but you like me to push first. We don't need anything. He's out. Do you think someone will be fine? You're right. You just need to get him into baited. Two. This is on it. We're not getting that. I just got it in. Okay, I'm not feeling a hole. We're in. I just need to bag it a little bit. No, not going to. Well, then start compression. Do you want to make sure you have the pulse? I don't know. All right. Start compression. You start compression. All right. So there we go. The team is starting to move. So there we go. The team is starting their resuscitation. What CRM skills did you see lacking in that progression of the case? Again, like I said, this is a little painful. It's exaggerated for demonstration. It is a simulation inscripted. Roll clarity. Tell me more. Who would die here, DeFram? Not clear who's supposed to do what and multiple jobs. Yes. So again, not calling out assigning roles. You're exactly right. Folks are doing too much. Others are not doing anything. And that's not really a good utilization of resources either by not assigning roles. Any other thoughts on? Can you give me an example or just a little bit more? Yeah, he was just sort of barking out into the atmosphere, but not specifically talking and addressing people by names that they knew exactly what they needed to do. He was clearly very anxious and he was making sure everyone felt that anxiety. Yes. I agree. 100%. Yes. And also, I think when it comes to the poor communication, it was almost a lack of professionalism at times as well under that stress. So that also again, as you mentioned, spreads across the whole room. All right. So there are multiple CRM skills missing in that scenario. This last case, I think we'll drive home. Really, I think when you start off challenge when it comes to CRM, it's hard to recover and not impossible, but it really can impact the outcome of our patient. This is our last. We need another round of COVID. I need FBE calcium, bike harm. So it should call the family. First, which was the last we gave? Who's documenting? Document. Document. You document? I don't know. I had neurodentative. Well, figure it out. So which one did we give last? I don't know. Let's just give FBE. Let's give another dose of FBE. How much of FBE sugar? Don't you have a cheat sheet or something to give the total dose? I don't have that cheat. How much do I give? You give one amp. One amp. A VE. All of it. Did you give it? I'll let it. Are we gonna give you a high five? Yes, yes. The whole thing. Okay. Can you go a little faster? I'm losing him. We're gonna hire him. So how many doses of FBE have we given? I don't know, like, maybe four or five? No, I have any idea yet. Four or five? This is useless. Just call it. So little dramatic, but our patient did not survive. Needless to say. So what happened in that situation? Any other, anyone want to comment on some other CRM skills? I feel like every CRM skill is sufficient in that case. But any particular ones that stand out for you that someone would like to to comment on. Thanks, Monica. I think they actually did a good job stating what their limitations were. They knew their limitations, but they didn't know how to then get additional resources to help them. So I give them credit for speaking up and saying, I don't know how to do that, but they didn't problem solve. They didn't problem solve exactly. I would agree utilizing those resources and calling for help. Other other thoughts? Peter, on my phone, thank you. There was sort of a subtle pick up, I think, that actually seemed quite obvious. There was the compressor who was getting frustrated because I think he was getting exhausted and didn't actually know what he was doing and didn't speak up to say I need to be relieved or to be instructed. And I think that speaks to sort of another topic that's related to all of this, which is psychological safety. I mean, there was no way that the event manager ran the room. The tone was just so poor that no one would speak up and express, you know, if there were deficiencies and so on. I thought the compressor was a nice example of that. Yeah, I think that's the same thing about the pulse. The first person said there's no pulse. And clearly the implication was shouldn't we start compressions, but she didn't feel safe suggesting we need to give compressions. She had reiterated several times. And then he asked somebody else to check the pulse as if he didn't believe her. Exactly. Yeah. Now, I think that's psychological safety piece inhibits everyone's ability to speak up and then act. And then I mean, I think the other piece of this in that whole environment is that by not being afraid to speak up, your teen leader who was multitasking, you know, who probably should have been hands off the patient, instead of trying to manage the airway also was fixated. By not speaking up, he was never aware of the things that others in the room knew needed to happen. So again, all of those contributing factors lead to potentially an unnecessary bad outcome. So the team debriefed and they talked all about these CRM skills that you all have nicely pointed out at different moments. And after that case, they actually had an opportunity to do it over. I feel like it would be very nice for you all to see a little bit of improvement. So I'm going to show a little bit of this video. Hopefully you can hear OK. And you're going to see I think some CRM skills that really are demonstrated effectively. Again, always opportunities for improvement, but I think much has improved. So we're going to start in the middle of the case. That with the code team, what's the situation here? So this is 16 year olds with pneumonia and we're concerned that these audiences severe respiratory failure and... Can you turn the volume on? I would agree. It looks like he's decompensated. So everyone's OK. I'm going to take over as a teen leader and reassign roles. Julie, if you could take the airway as my RT and Carla if you could take circulation. A lot to mind, if you could be ready to push them as, and if you could document for us. Do we have medication available? We need to anticipate them. Yes, I've got a lot of people from Toronto who have been first to here and they're all labeled. Karen, do you think you could drop some SNF run in an atropine just in case you decompensate further? Do you feel comfortable calling the family and letting them know that he's getting worse? Sure, OK. I appreciate it. Julie, I think that we're having trouble with just the face mask. If we could bag him and take over his brand. I think we're going to have to prepare to anticipate him. Do we still have a Paul's car left? Yes. Karen, do you have the epinepinepin an atropine? Yes, I do. OK. Let's get him ready to anticipate and bring the vets to the bedside. OK, are we ready to anticipate? Yes. OK, what meds do we have? I have four milligrams of horse sed, 200 milligrams of ketamine, and one milligrams of rockerolium. Perfect. Julie, do you have all your spline needed? I have an 802 blade and an title. I get and Carly is still on good pulses. Good pulse. OK, I think we're ready. Fought to me and why don't you go ahead and push the vets and the ketamine, please. OK. Four milligrams of vets going in. Vets going in. In. 200 milligrams of ketamine. Ketamine is in. Perfect. Is he still easy to bag, Julia? Yes. OK, and you have good pulses still. Still good pulses. Push the rocky ronium. One milligrams of rocky ronium in. Rocker ronium in. All right, let's give that some time to work. Bitals are stable. Any movement? Tatumun? No movement. OK, Julie, why don't you go ahead and anticipate? OK. And that much? And just hold this getting weaker. All right. Everything OK, Julia? Yes, I'm through the court. Confirm. Let's verify if I should know if you could listen for breast sounds bilaterally. I don't feel it all sunny on that. This heart is dropping. I start CPR. OK. I start compressions. Carries, you can get our 1 milagame of epi over to the bedside. Here we go. 1 milligram of epi. And then we're going to need the backboard too, please. A little harder in Carla. 100 times a minute. And Julia, remember to bag it 10 times a minute, please. Good chest compressions. Carla, you get tired? I can take over chest compressions after this. Next pulse check. Yeah, great. Then two minutes, time for a pulse check. OK. And we're about 1 minute away from the next epi dose. OK, here you can get that ready. Carla, do you have a pulse? No pulse. Let's resume compression spots. Carla, if you can come over and push meds for us. Pressure 1 milligram of epi. It's been 3 minutes since the last epi. OK. Go ahead and give Carla. Doing the epi? Epi? Everything. All right, let's recap. We have a 16 year old pneumonia in shock who are rested during intubation. We don't really have a good cause. Is there anything that we're missing? I'm not concerned about it. If you had some hypobusity a day yesterday, and we're not really sure why. OK, let's get that blood gas. Because then we could check for glucose, potassium, acidosis, some of the other causes. And then Carla, maybe you can listen for bilateral breast sound. Sure. I've got this up in C. That C. That C. That C. Perfect. You're doing great chest compression spots. But just a little bit deeper with full recoil. Thank you very much. Good breast sound. That's fine. If you're into macidosis and the glucose was 16. OK, I think we have a cause. Let's treat that. Carried to you to get the dextrose? Carried to your amp with D15. Great. So we might as well drop the next dose of that napord and be ready with that. D50s and D50? Perfect. Continue compressions. It's been tremendous in your log pulse check. OK. Carla, if you could check the pulses, you hold compressions with your pump to them? He's got a pulse. Excellent. I confirm. All right. Excellent. Yay. So you, sorry for the little bit of the long video, but it's I think it's helpful to see some of those skills in action. I'm curious from the audience. What specific improvements did you see in terms of CRM skills? If I could just have folks just throughout a few, you know, definitely better team leadership, even where he was standing. He had a better situation awareness and better communication. And people were actually responding. So when he would ask for something, they would verbalize what they were delivering. And then the person that was documenting this then confirming it. So there was much better mental model of what's going on. Yeah, and closed loop. Yeah, closed loop and mental modeling. Great. Any other comments in terms of good effective CRM skill usage? Yes, in the back. Thank you. He wasn't as angry. And he actually sought input from the others rather than call it and then walks away. So I thought that was different. Yes. So much more professional, much more calm leads to that psychological safety that Peter is talking about and allowed everyone to contribute and do their roles effectively. Right? He called her by name, which I think is often the biggest challenge because it's hard to order his name, the situation like that. It is very hard. And sometimes we work not as, you know, familiar teams and new teams. And so taking a moment to figure out individual's names or what I sometimes call as, you know, sort of professional rudeness to be like you. Make sure that closes that loop if you don't know someone's name. It's worth it. Great. Well, thank you. I think I wanted to add is, you know, nice role clarity to assigning roles help them. So this was just, you know, meant to be an exercise to refresh our knowledge related to CRM skills. And you all have been training to them. The question is, you know, if the, you know, good use of CRM skills training to CRM skills makes patients safety better. Why are we still having healthcare errors today? Clearly, this is making a difference, but we still have a ways to go when it comes to preventable harm. And so despite, again, years of CRM training here, we are probably much, in a much better spot, the most institutions that don't have the opportunity to train as frequently to these skills. But how might we also think, okay, what's next? What else can I do to add on? And this is where I'm thinking future here. And I think one of the things that we need to now embed into our trainings and in our focus of effective teamwork is how we as a team can be more adaptable and more resilient. Again, you all know better than I do that the OR is a complex, dynamic environment that requires time and resource constraint actions to manage both expected and unexpected events. And obviously, I'm a simulationist, so simulation, I feel, is a great tool for training not only on CRM skills and when we do simulation focusing on where we go wrong and how we can improve that thinking about that safety one lens, but also learning from our successes in that safety two lens. The ability to succeed under varying conditions because whether it's real life or simulation, the reason patients do as well as they do is because we as a team are constantly adapting and responding to the situations and the inputs that we're getting. And so really what I think the future is in terms of where we need to go to improve safety is to think about how we can be more adaptive because the OR really is a complex adaptive system. And it's only, it's truly only by focusing not only on standardized practice and best practice, but also adaptation, especially during unexpected events that we can ultimately improve patient care. So why is, you know, why do I think this sort of idea of resilience and adaptability is so important for us as clinicians really there's a growing amount of work that shows teams that have higher ratings of teamwork, which again relates to our CRM training, but also higher levels of resiliency and adaptability have better safety culture and lower medical errors. And this is a what I thought a great study that came out of topic and colleagues in 2017 looking at NICU teams. And so again, our CRM simulation training that you're already doing is helping to improve our teamwork skills, something that you know 20 years ago we weren't even talking about in healthcare. But then how can we think about how do we train resilience, can we train to resiliency, can we make ourselves more resilient to ultimately I think lead to better outcomes. So what are what what is resiliency look like? Well, Eric, all sort of felt like there are four major abilities or key aspects of resilient organizations. And this is where we need to think about moving forward and those are anticipating monitoring, responding and learning. And so the idea is that as a healthcare team and very complex systems, we are constantly anticipating and thinking ahead about where we might go wrong. And what is our plan when things go right as well? And some of our strategies could be preoperative huddles, which you do, surgical checklist and even potentially something called just at time simulation where we're rehearsing before we actually provide care. And that helps us to anticipate for where things might go wrong so that we're ready when they do. It also includes monitoring. So this is the idea that we're constantly surveilling and looking for, you know, what could go wrong, but also things and inputs as they happen, because we're constantly adapting to our patient status and situation during care. And then ultimately our ability to respond, particularly when things don't go as expected. And that's that adaptive coordination that we're able to pivot as a team based on hopefully some of the anticipatory work that we've done thinking ahead. And that's where effective CRN skills is really a really critical. And then last but not least, in order to constantly improve and to be more resilient in all of the care we deliver is to constantly learn both from real events and from simulated events. And so that's where your postoperative debriefings can really help us to learn from not only the things that, you know, unexpected and how we either did well or didn't do well in an unexpected event. But even how we do well when things go right when things are routine. Because the factors that oftentimes lead to failures in this work of safety climate today is not are really the same factors that lead to things that go well. And so we really need to understand both. And so this is I think our potential for a safer OR. This is a nice study by Gora recently that actually looked at so you know if we think about with routine and adverse situations when things go well. What are the things in an OR setting that contribute to things going well again thinking with that safety to lens. And they found that there were three main categories that nurses, physicians and other caretakers in the operating room setting felt were important for things to essentially go well in both routine and adverse safety. And adverse situations are unexpected situations these included preconditions and resources. So again, did we set ourselves up for success that we have a shared mental model. Did we all have the experience and confidence needed to care for the patient. Did we have respect and psychological safety. And then another factor was planning and preparing again creating that plan doing our pre surgical checklist and talking about our equipment looking at all of our equipment and supplies and procedures. So it's that preparation piece. And then last but not least is the adapting piece right. So when things happen can we adapt and prioritize patient cares appropriately as needed, especially during unexpected events. And so if we think about those three major buckets of categories as being really key for being a resilient OR surgical team. How can we how can we improve those how can we be aware of them just like we were talking about 20 years ago about CRM now we need to be think about how what are the aspects of resiliency that we need to be trying to focus on improve and train to. And so I'm just going to as we get near the end here show an example of a team that is essentially preparing for a high risk situation a baby coming in with ECMO. And this is a little bit of how they might prepare in the moment thinking about that do they have the skill sets do they have the right resources and then are they prepared for what may happen. So I'm going to let you hopefully you'll be able to hear a little bit of this discussion and see those strategies in action. Hey guys, unfortunately we had a patient come in for an outline hospital for ECMO consultation who we just got where to rest in the ambulance. So I wanted us to huddle before they get here and I expect many minutes just to talk about goals of care and how we're going to coordinate the chaos. All right. We've already reached out to the OR team. They're here and they're getting ready and we resets perfusion. So we've just in the Tom here any issues so far in terms of getting circuit ready or blood availability anything like that. I just want to talk about some goals up front after some resident history. So 39 week five kilo baby found hemicony mass operation. Intubated in the D. R. U. A. and UV lines were placed. I think in addition to that they they cool they did give surfactant escalator from conventional to high frequency with addition nitric oxide had an echo that was super systemic. So really no improvement there on Dopa Fee and Miller known infusions. I don't have any human dynamic data. I don't have like this is unfortunately. I just know that they're actively doing compressions. Okay. In terms of goals. I think let's get the backboard on early. Let's get this old pads on early. Let's make sure that we have all the personnel that we need. So if there's anybody that you can think of that isn't here that needs to be here. Let's let's get that moving quickly. Death of compression should be one and a half inches. Diastolic holes are going to be greater than 28 corner perfusion goals greater than 20 and total goals greater than 20 questions about. Okay. So that continues on. But I hope you saw in that moment while they're thankfully having a little bit of time we don't always have that time. They're preparing for this obviously this very sick critically ill patient. You sell them talking about goals goals of care simple things backboard what are our you know CPR goals in the resuscitation. They're talking about having all the personnel in the OR team ready to cannulate for ECMO. So you know sometimes these things just happen. But if we take a moment to really think ahead. Then all of that preparation can potentially help them when things go unexpectedly to have those things front of mind and to be able to adapt in the moment. And I'm just going to show it to you a little bit about how when the moment happens how that adaptation can occur as well. So you hear. So now they're. We're in time for our patient. We did a step so for Dr. Stone please. One minute. You hear one minute. Step still for the compressor. It's relatively quiet. Okay. So again some of that quiet might just be a little bit of an artifact of simulation. But that team was prepared they were able to know their roles and they were able to essentially adapt when things change something is simple as the compressors having trouble needs a step still right they forgot that they were able to adapt and obviously adaptation continues from there. So thinking about these skills and how they've applied here. I do want to share a quick case that recently happened at Boston Children's which is not a critical event like you saw before but something you know that is still very important and that was related to a specimen handling event where we had a 16 year old undergoing gender transition who was scheduled for planned bilateral and then we had a different type of activity with a nipple area complex graph and in a in that graph. Time out happened. The graphs were kept on the surgical field covered in separate containers and labeled as left and right with a pre-painted label. The breast tissue was removed and was kept in a separate large containers and also labeled as left and right. The first thing that was being placed the nursing team was told that they could bag and tag the tissue for specimen. Breast tissue was placed in a container with formalin and transported back to pathology. The circulator asked the scrub to pass off the tissue remaining on the field and the scrub passes off when the surgical team asked for the graph an error was identified. So essentially they couldn't find what they had mixed up between the resection and the graph. The immediate response at this time was that the tissues for the graph were rinsed multiple times and so before being placed in the patient there was a disclosure to the family and the patient did well. So they identified from that but what can we learn from that's you know example even in a non you know sort of high risk resuscitation type event is that there were CRM related contributing factors related to communication around the language of passing and the field like of closed communication when handling specimens off the field and a failure to speak up for safety when the circulator asked the scrub to pass off the containers holding the graph tissue. So if you think about you know the CRM skills they are critical the critical and high risk acute situations in their critical and everyday patient care. Of course there were also system levels and this is where again not only thinking about resiliency but the systems that we create being able to make it harder for errors to happen is really important for us to get at a safer healthcare environment. So it's not just CRM skills and but it's not just even resiliency it's how we can make our system support better care. So with that I'm going to wrap up I apologize for all of the technical issues I have a huge thanks to all the teams that I've had the opportunity to work with in simulation and learn from how simulation and crisis resource management and really resiliency can make healthcare safer both of here Boston Children's Johns Hopkins and Texas Children's thank you. I'm open to questions. Well despite all the technical challenges that was really spectacular Jen and we're really appreciative of you demonstrating for us with video and your expertise how we can. I think we all sort of live through those videos and realize we've all been in some of those situations and made some of those mistakes. The caucus a little bit ahead so we have one or two minutes for questions. This is more of opportunity to comment if you would. And I just think our situations here are so unique in the OR you know our codes occurred during a trache in a small child with lost airway our codes occurred during Scoliosis repair and a kid with fontan physiology and massive blood loss etc. Trying to do sort of standardized care is really difficult because the situations are so different. I guess I'd ask everybody to continue the good work that we've been doing to try to make yourself available for insight to team oriented simulation that occurs with the teams that actually work together on a regular basis. I think that's where the really good stuff is for us and I don't know if you have any comments from the simulation or IDS team perspective. Yeah, I think you've got a really good point that in tech team training to really get teams to be more active. I think we can figure out how to pivot and I sort of call it my team's where we say it a lot lately. Hi dose low. I'm sorry. Hi frequency low dose simulation. See you in a second. We want to probably make that happen in your environment. So much. Thank you. Thank you. Oh, I don't know. Thank you. Thank you. Yeah. I would have made you like that.