Radiology Management, ICU Management, Healthcare IT, Cardiology Management, Executive Management

IntroductionIt has been nearly a decade since seminal reports and associated research documenting the surprising frequency of accidental injury in healthcare were published in the UK and around the world (Vincent, Neale and Woloshynowych 2001). Around that time, complex and systemic causes of a sequence of probable accidental deaths at the Bristol Royal Infirmary were emerging, while research at Great Ormond Street Hospital was finding that small, seemingly innocuous events could accumulate to affect mortality and morbidity (de Leval et al. 2000). In these incidents, the technical challenges of complex surgery in very high risk patients meant that teams were sometimes unable to prevent errors that subsequently affected patients.All complex systems are faced with the same problem: although humans are fallible and make mistakes, they cannot be designed out. This is not just because humans design, maintain, operate and promulgate technology, tools and tasks that allow regular systems function, but also because they keep all these disparate components together. Complex systems themselves are naturally unsafe. It is the people and teams within them that allow them to achieve high standards (Dekker 2002).      It is with this in mind that there has been much speculation on how to learn from other industries to address safety issues. We at Great Ormond Street Hospital were able to learn from the Ferrari F1 team, which comprises a complex system, and apply this knowledge to improving a critical handover process, thus developing new ways to think about safety in high risk surgical care.High Risk HandoversProviding continuity of care between frequently changing teams is an area of vulnerability in any complex system. With the increasing transfer of patients between clinical areas, and the reduction in working hours following the European Working Time Directive, continuity of care has vastly increased in importance in the clinical field. The transfer from the operating theatre to the intensive care unit is one of the most difficult stages in the care of a child, concluded Kennedy (2001). These children, often only days old and having had a hugely invasive surgical operation, can be extremely unstable and will require support from a wide number of inotropes, vasoactive agents, other drugs and several invasive monitoring lines. They need to be moved from safe ventilation and monitoring to portable equipment while they are transported a short distance into the ICU (in Great Ormond Street Hospital this was only 30 or 40 meters). Here they are returned to safe monitoring and ventilation.

Bed space is configured around these patients, with infusion pumps placed on a stand and plugged into the power socket, and monitoring lines plugged into the monitors, which are then appropriately zeroed. During the same period, the surgeon and anaesthetist hand over to the receiving doctors and nurses in the ICU the vital information required for the care of the patient, which they have gathered during pre-operative assessments and several hours of surgery. At this point, the ICU staff may have little knowledge of the patient.      Thus, there are two critical safety tasks that occur at the same time: the transfer of the monitoring and life support equipment, and the transfer of information. Our early observations suggested that things did not always go smoothly in this risky stage of operations. Sometimes the patient was on portable monitoring and support equipment longer than they needed to be because either the teams did not know which bed space was being used; the bed space was not prepared; the correct monitoring lines or data interfaces were not immediately available; or the ICU ventilator needed configuration before the patient could be safely put onto it. Sometimes the infusion and monitoring lines were cluttered or tangled, and sometimes the infusion pumps were not plugged in and eventually ran out of battery power. Also, the receiving ICU staff may not have been aware of a patient's imminent arrival so they were not always immediately available. Another important issue was that sometimes the verbal handover was conducted at the same time as the equipment was set up, thus stretching human cognitive resources and inviting information degradation. At other times, the full set of information was not handed over.Though it is possible to argue that these small problems were not affecting patient care, our research (Catchpole et al. 2006), and the work of others in the growing field of patient safety, was starting to suggest that the small things really do matter. The high risk of handovers was identified in the Bristol Royal Infirmary enquiry, while previous research at Great Ormond Street Hospital found problems in handovers, with several recent events and near misses identified to be partly attributable to this poor performance. We felt that these risks could relatively easily be reduced by small process changes, but we needed to understand how.Learning From Other IndustriesHigh risk industries usually manage to function effectively and to a high degree of safety in extremely adverse environments, with a huge literature covering the field.

Nevertheless, serious accidents can be found in all these industries: Piper Alpha (Oil), Chernobyl and Three Mile Island (Nuclear), Challenger and Columbia (Space exploration), Tenerife and Kegworth (Aviation), Aryton Senna (Formula 1). The key is that in all areas, it is possible and necessary to learn from past tragedies. Rather than blame individuals, we need to understand how teams came to make the critical mistakes that they did, and build better systems of work around people to encourage the avoidance, identification and mitigation of errors before they can lead to more serious consequences.      Indeed, the notion that is conveyed through these industrial analogies is that the optimisation of human performance at the centre of every system can be approached through the application of science to the design of technology, the working environment, tasks, training, and even organisations. This approach is known as human factors, and it has helped make high- and low-risk industrial processes, and a wide range of consumer products, including cell phones, software, and even toothbrushes, more reliable, easier to operate, and safer to use. The key to learning from other industries is in translating their positive principles to the new context.     While researching ICU handovers, intensive care specialists Allan Goldman and Nick Pigott, and surgeon Martin Elliott, recognised through their shared interest in motor racing that a handover might have similarities to a pit stop. Just like a handover, a pit-stop requires a team of specialists to co-ordinate and work together under time pressure, to perform a complex technical task to a high degree of accuracy, in a changing and rapidly evolving situation. Learning From FerrariI, Dr. Ken Catchpole, author of this article, joined the project team, and the two ICU doctors and I were invited to the Ferrari headquarters in Maranello, Italy to discuss pit stops with the race technical director. We showed him a video of our process and discussed at great length how Ferrari achieved the performance levels in pit stops that we sought. Upon return to the UK, we were also able to obtain the views of two British Airways pilots on approaches to structuring teamwork and communications.      Earlier, a Failure Modes and Effects Analysis had been conducted to understand where the biggest risks in the process might lie.

After deliberating at some length over the lessons learned and how we might translate them into the highly technical tasks of ICU handovers, we eventually derived a process that included the entire range of elements that we had learned.The New Handover ProcessThe new handover was a four stage process. First, we asked the anaesthetist to fill in a standard form that detailed the ventilator settings and bed space configuration that would be required for the patient upon arrival in the ICU. They would contact the ICU approximately 30 minutes before the patient was due to be transferred so that the receiving nurse could collect this form from theatre. This meant that the bed space, ventilation and all required monitoring interfaces could be prepared beforehand, minimising the time that the patient was off stable monitoring and ventilation. It also meant that the receiving ICU team knew exactly when to expect the patient.     Upon arrival in the ICU, the equipment was set up without any verbal handover. Each team member had been assigned a specific role, so everyone knew exactly what should be happening. The lead anaesthetist then made a safety check to ensure that all the monitoring was reading as expected, the ventilation was appropriately configured, and the infusion lines were untangled.The third stage of the process was the verbal handover, which was given a specific order and rhythm. The outgoing surgical team and the receiving ICU team all grouped at the patient’s bed to listen to the anaesthetist, followed by the surgeon, provide information. The entire team was then provided the opportunity to pose questions and discuss the situation. The receiving doctor used an information transfer aide memoire, a form or checklist specifically designed for this process, to prompt and record the transfer of the appropriate information. Once all the blanks on the form were filled (or discussed where missing), the form was placed in the patient’s notes and acted as the admission note to the ICU, saving everyone time.At this point, transfer of responsibility of the patient to the ICU team was complete, so in the fourth stage, the team (still including the surgery team) discussed the expectations for this patient. These were grouped into one of four categories of risk and further treatment, from immediate waking and extubation through six-hour and overnight reviews, to the expectation of high risk for extracorporeal membrane oxygenation (ECMO).     Importantly, and in contrast to both aviation and motor racing, the new process could be trained in 20-30 minutes.