Analysis of observations and interviews identified three major themes: (1)Perceived usefullness, (2) Modification of implementation, and (3) Communication outside of the checklist. In the following sections, each of the themes are presented in detail. The identified themes and corresponding categories are presented in table 2, with representative verbatim quotes and observation notes (in italics) to illustrate the findings.
Perceived usefullness
Participants expressed various views related to SSC’s practical utility. The anaesthesia team (nurse anaesthetists and anaesthesiologists) perceived the SSC to lack practical value, especially the “Sign-In” part, which was perceived as not adding anything new to reduce anaesthetic risk. They reported that they had good control of procedures and tasks before induction of anaesthesia. Existing checking mechanisms and protocols were considered sufficient, as pre-anaesthetic patient risk assessments; e.g. difficult airways, medications, allergies were performed in advance, and safety tests and -checks of the anaesthesia machine, - equipment and -medications, were incorporated in existing routines and reviewed prior to induction of anaesthesia. Checks performed by the anaesthesia team during the preoperative phase were aligned with their roles and responsibilities, acknowledged by both the anaesthesia team and other perioperative members. In addition, some anaesthesiologists expressed a need of retrieving surgical information regardless of the SSC, which in their opinion made reviews of SSC “Sign- In” items superfluous. Yet, some anaesthesiologists expressed a need for more time to review and handle high-risk patients together with the nurse anaesthetists, during a pre-anaesthesia briefing.
Interestingly, however, other staff-members described situations where they experienced the SSC as being particularly useful i.e.; by confirmation of patient identity, as a reminder-list of important safety checks, especially for procedures that might vary according to types of surgeries, or patient specific conditions such as administration of surgical antibiotic prophylaxis. OT nurses described how surgical equipment reviews during “Time-Out” were advantageous, as well as tissue-sample labelling double checks at “Sign-Out”. SSC was also highly valued in order to provide predictability in the OT, e.g., logistics in OT scheduling, timing of anaesthesia, and for preparation and reports to post-anaesthesia ward. Nurses in particular, reported an ease of workflow when everybody in the team knew the surgical plan. In addition, the “Sign-Out” provided a sum-up of the surgery, which were reported being of help to understand exactly what procedures that had been performed. This was considered helpful in correct surgical procedure codings. Introduction of the team members during SSC “Time-Out” was also described by some surgeons as unifying the team to structure their focus before incision. This was especially useful for new and/or unexperienced team-members.
Modification of implementation
Observations identified variations in how different items and parts of the SSC were carried out – and also in how the electronic registration of the SSC was done (the latter is important as it is used to provide national compliance rates). Policy for hospital 1 mandated specific registration of each of the three parts of the SSC (so 3 separate registrations) whereas policy for hospital 2 mandated one SSC registration including all three parts (so 1 registration in total).
SSC utilisation varied across different SSC items and participants’ perception of challenges of actual use. Observations showed that induction of anaesthesia done in the OT in both units silenced and concentrated the team members present in OT. Yet, performance of the SSC “Sign-In” only few minutes earlier did not have at all the same effect: it failed to concentrate the teams’ attention.
Participants described how verbal SSC briefings rushed through the items, forgetting to include the whole team. Lack of team focus- and concentration during SSC performance was also described. When SSC checks interfered with existing workflow, the SSC was often partly or poorly performed, delayed, or left out as a result. Resistance within the team and verbal disturbances also influenced performance. As a result, SSC registration was often described as a “tick-off exercise”, which some of the participants vocally worried about its impact on safety.
Presence of the different team members in the OT also influenced how- and by whom the SSC items were checked. While nurse anaesthetists and OT nurses were present during all three parts of SSC, surgeons and cardiovascular perfusionists were not present in OT during “Sign-In”. Cardiovascular perfusionists also described being haphazardly included or not during “Time-Out”, unless they actively initiated communication themselves about specific items or equipment in use. Anaesthesiologists described that their presence in OT during “Time-Out” and “Sign-In” was more relevant in complex surgical cases, and for high-risk patients.
Communication outside of the checklist
Risk communication and critical information exchanges during perioperative care were performed in multiple, formal and informal micro-team constellations. The team members’ individual and professional perception of identified or potential patient safety challenges influenced SSC utilisation, and how, when, and to whom information on risk was passed in the perioperative phase of surgery. Their perceptions of safety challenges also influenced how the team members viewed and exerted influence on risk communication within the team.
In one of the study sites, according to participants, formal team constellations featured preoperative morning meetings where the surgical schedule of the day was presented by the surgeons in charge. Relevant safety issues were discussed amongst the present team members. Team members who had been present at the meeting then disseminated information of importance to their respective colleagues. Some of the interview participants described this information exchange as a “sub-optimal, second hand ad-hoc information transfer”. Instead, they would have preferred that team briefings were better structured prior to surgery, involving the actual team members scheduled for that specific surgical procedure. Aligning the SSC items and reviews according to specific risks related to the individual patients and their specialties was also suggested.
The local SSC version was scaled down to cover a minimum of items. This was explained by physicians in charge as being sufficient, partly due to factors such as strong organisational structures, a limited variety of surgical procedures and standardised operative environment with few OTs. Moreover, the required competencies, professional experience and good inter-staff relationships were also cited as elements justifying the reduction of SSC content. This was emphasised in terms of the highly qualified and experienced multidisciplinary perioperative team members and local practice of one-to-one relationship between the anaesthesiologist and the patient, throughout the perioperative pathway.
The formal planning of surgery and anaesthesia was performed by the respective surgeons and anaesthesiologists in charge. If somehow concerns about the patient needed to be discussed more thoroughly, i.e.; clarifications about the procedure, required equipment, laboratory tests, blood products, or patient medications, the different health care personnel directly contacted the responsible professionals. This form of patient specific communication and information exchange within micro-team constellations was observed throughout the perioperative phase – such that:
- the anaesthesia team reported to have an on-going dialogue about the patients’ risks, necessary equipment, fluids and medications.
- the OT nurses and surgeons had a continuing dialogue on maintaining a sterile field, possible risks and lack of equipment, specimen labelling and compress counts.
- cardiovascular perfusionists, anaesthesiologists and nurse anaesthetists had an ongoing dialogue on collaboration of the haemodynamic controlling.
- the anaesthesiologist had also ongoing dialogue with the surgeon in charge.
These interactive patterns of micro-team communication and information exchange clearly dominated and superseded any SSC checks.
Table 2: Themes and categories with illustrative participant quotes and observation notes (in italics)
THEME
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CATEGORY
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ILLUSTRATIVE QUOTES FROM PARTICIPANTS (Observation notes in italics)
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Perceived usefullness
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Lack of practical utility
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Anaesthesiologist: Before I anaesthetise the patient, I know all the parameters for my patients, I check their circulation, and I know about their vascular occlusions and specific arterial stenosis, and I feel I have complete control of the patient, so…. It is hard to think that the checklist will provide extra safety for me.
Anaesthesiologist: Patient safety is part of our training as anaesthesiologists from the very beginning! Eh- check of the anaesthesia machine, instruments, the patients, and practically checks of everything we do! Double control of every blood products provided, medications, everything! In addition to assessing the patient in person and talking to them prior to surgery. We have always performed these items; it is part of the standardised pre-operative anaesthesia assessment and preparations.
Nurse anaesthetist: The anaesthesia machine is not due to any variation, it should be checked prior to every anaesthesia. We do not admit patients into the OT unless the anaesthesia machine is OK.
Surgeon: Well, the SSC has a function, in a very simplistic way, but it does not have a proper control function, the way it is supposed to, because we have so many checks and control mechanisms incorporated. So, I don’t think that the SSC is as important to us, as to other surgical departments, which have other pre-operative assessment routines. We have so many points of assessment, where our patients are discussed and evaluated.
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Perceived benefits
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Operating theatre nurse: The SSC is useful as a reminder of double checks of labelling tissue samples, and to make sure the right surgical equipment is present. Surgical routines are complicated when you are a beginner…
Nurse anaesthetist: I value how the SSC may contribute in aligning the surgical and anaesthesia plan for the entire team.
Surgeon: The team introduction is a nice way to start team working; the “Time-Out” is in a way a mental team-calibration.
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Modification of implementation
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Review and confirmation of items
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Cardiovascular perfusionist: And occasionally, I may have to call out if there is something I believe is required or something has been omitted, i.e. that the patient has low haemoglobin levels, and I need to take action. In addition, during haemodilation, I avoid infusing too much fluid in the machine. Then I tell the surgeon and anaesthesiologist what I intend to do, to make them understand what I intend to do.
Operating theatre nurse: Some surgeons that are more reluctant than others, they just start to mumble through the SSC as soon as they enter the OT, and then proclaim to have performed time-out. Then, it is required from an OT nurse to be determined and speak up, and say, «no, this is not good enough! Everybody needs to know what you just said! » Sometimes I have to add: «No, this was not loud enough, you have to repeat the SSC! » However, to speak up requires some years of work experience.
Operating theatre nurse: I think the SSC is a good thing, but I miss team concentration during its performance Things have improved, from the beginning until now, but there is still too much disturbance during SSC performance. I really miss that everybody stops and pays attention. Due to the workflow in the OT, there is always someone who pursuits some kind of work, and does not stop. In addition, you need to pay full attention for the SSC to be advantageous.
Nurse anaesthetist: But it is obvious, the SSC performance is totally depending on the physicians participation. As soon as they became more involved, both performance and compliance increased.
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Presence of team members
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Nurse anaesthetist: Personally, I prefer to perform the sign-in with the anaesthesiologist being present in the OT, I think it is embarrassing to repeat the questions and items I have asked the patient previously, upon arrival in the OT. So I have almost stopped to ask the patients about their potential allergies, and so on. The anaesthetist repeats everything when they arrive in OT anyway.
Observation: The team compositions varied during the different parts of the SSC performance; The nurse anaesthetist, operating theatre nurse and anaesthesiologist were present during “Sign-In”. The nurse anaesthetist, operating theatre nurse, surgeon(s) and anaesthesiologist (occasionally) were present during “Time-Out”. The nurse anaesthetist, operating theatre nurse, surgeon(s) and anaesthesiologist (occasionally) were present during “Sign-Out”.
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Barriers of performance
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Nurse anaesthetist: Well, you don’t want a conflict within the OT, you’re in a way a bit tired of that, so you try once more to perform the SSC, and if you do not receive any attention, you just let it go and tick off the box, even though it has not been performed.
Nurse anaesthetist: It is so important to keep the SSC short, because it does in a way disturb our workflow.. You are about to start induction of anaesthesia, and then; «No, no, we have to stop and perform the SSC! » Our workflow is interrupted, and it is very disturbing and frustrating.
Operating theatre nurse: The anaesthesia team is responsible for the anaesthesia, medications…. It is their responsibility. Questioning them about this is like questioning them whether they have done their job or not. ….
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Registration practices
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Observation: At the surgical units in hospital 2, SSC performance was ticked off either after “Sign-In”, or the “Time-Out” part. There was only one box that needed to be ticked off electronically, in order for the SSC to be registered as performed. At the surgical unit at hospital 1, all three parts of the checklist had to be ticked off as three separate boxes in order for the SSC to be registered as performed.
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Communication outside of the checklist
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Patient specific risk communication
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Anaesthesiologist: In general, we have contact with the cardiovascular perfusionist prior to surgery, to inform them about patient specific details such as medications, because they don’t read the patient records the same way we do.
Operating theatre nurse: …. And if bleeding is involved, we need to notify the anaesthesia team about the estimations of blood volume collected in the surgical suction, before other fluids are added.
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Selected communication of risks
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Cardiovascular perfusionist: … and these preparations are being discussed between the surgeon and the cardiovascular perfusionist prior to surgery.
Operating theatre nurse: In most cases, we have direct communication with the anaesthesiologist during induction of anaesthesia, and ask permission to start our preparations, such as positioning the patient, or inserting the urinary tract catheter.
Anaesthesiologist: … and then, the surgeons talk about the details of the surgery they have performed, while rushing out of the OT, right? And then you have to talk with them afterwards anyway, due to potential considerations post-operatively, like the follow-up antibiotic prophylaxis. Then you have to initiate contact anyway, because certain things require a follow-up.
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