This is a very difficult paper to present because of the complex data analysis but the findings are very interesting. This work suggests that even complex behavioral interactions can be examined. Basically the authors had trained observers record predefined elements of team behavior during 293 general surgery operations at 2 medical centers and 2 ambulatory surgery centers affiliated with the Kaiser Foundation Health Plan. After discharge, a medical record review for 30 day postsurgical outcomes was performed by a trained reviewer who did not know the results of the OR observations. The markers of team behavior used were as follows: Briefing – situation/relevant background is shared including patient name, procedure, site/side, plans are stated, questions are asked, and ongoing monitoring and communication is encouraged. Information sharing – Information is shared, intentions are stated, mutual respect is evident, social conversations are appropriate. Inquiry – Members of the team ask for input and other relevant information. Vigilance and awareness – Tasks are prioritized, attention is focused, patient/equipment monitoring is maintained, tunnel vision is avoided, and red flags are identified. The observers scored the surgical teams on a zero to four scale (never observed to frequently observed) during induction of anesthesia, intraoperatively and at handoff to the post operative care givers. The ratings were used to create a univariate behavioral marker called the Behavioral Marker Risk Index (BMRI) with values ranging from 0 to 1. A BMRI of zero represented good team behavior and 1 represented poor team behavior.
The authors found that the patients in this study were mostly middle aged with low to intermediate risk based on the ASA and the American College of Cardiology/American Heart Association classifications. Only four patients were ASA 4 and none were ASA 5. More than half (54%) of the procedures had “no complications” as the outcome rating but 24% had one or more post operative indicators of potential harm, 16 % had a minor complication, and 4% had a major complication. Three patients in the last group had an outcome of death or disability. In about 25% of the patients the BMRI was more than 0.50 indicating a high proportion of operative phases with infrequent observations of good team behavior. After significant data manipulation the authors found a strong association between teamwork behaviors and death or a major complication; specifically when teamwork behaviors were relatively infrequent the patient was more likely to experience death or a major complication. Clearly a study of this complexity has limitations as acknowledged by the authors. First, it is observational and does not provide mechanism. Second, it does not allow a determination of which behaviors, at which times during the procedure would be the most beneficial with respect to minimizing complications or death. Mazzocco K et al: Surgical team behaviors and patient outcomes. Am J Surg 2009;197:678-685
David S. Smith, M.D., Ph.D.