Together with increasing awareness for patient safety in general, the seminal Institute of Medicine report “To Err Is Human” 10 was one of the first publications that highlighted the importance of team performance in healthcare and inspired subsequent research. One of the predominant definitions of a team is “a set of two or more individuals interacting adaptively, interdependently and dynamically towards a common and valued goal” 11. Manser 12 further highlights aspects that are especially relevant for healthcare, among them task-specific competencies and specialized work roles while using shared resources. In anesthesiology, due to the domain’s dynamic nature and coupled with the fact that teams have changing membership and are often assembled “ad-hoc”, this reinforces the need for high quality coordination and communication 12,13. In this context, the concept of shared team mental models (TMM) is used to describe complex human interaction that includes anticipating each other’s actions, simplifying coordination and improving collaboration 3,5. The present study explores the application of a semi-structured briefing as one possible tool often used for the alignment of TMMs in various high-consequence industries to anesthesiology.
Contrary to our hypothesis, our study showed no significant difference between groups in the time spent on the decision to perform an emergency cricothyroidotomy. This may be due to several reasons. It has to be stressed that none of the SG teams explicitly discussed this procedure during the briefing. For those parts of the airway algorithm that participants chose to discuss, usually a supraglottic airway device as first alternative (Plan B) and mask ventilation as second alternative (Plan C), we noted a significant difference between groups in the time spent with those alternatives and in the advancement in the algorithm. However, this effect did not implicitly “spill over” to the rest of the airway algorithm. These findings further add to contradictory results on the impact of structured mental rehearsal of activity on subsequent performance: A study by Hayter et al. demonstrated that a structured mental practice did not lead to any difference in observed nontechnical skills and no difference in time to perform chest compressions, administer epinephrine, and give blood in a simulated cardiac arrest 14. However, Lorello et al. demonstrated significantly improved teamwork according to a validated team-based behavioral rating scale after structured mental rehearsal 15.
Emergency cricothyroidotomies remain rare events (approximately 1:50.000 anesthetics) that anesthesiologists do not necessarily feel comfortable or experienced with, and that are not trained on a regular basis 16. The ensuing doubts and hesitation associated with an invasive, unfamiliar and potentially risky procedure are apparently not overcome by a semi-structured pre-induction briefing that discusses various contingencies, but that is primarily designed for the individually adaptive alignment of mental models and not specifically for review of complete difficult airway guidelines.
One of the key findings of this study is that a team briefing in anesthesiology that is adaptively focused on the management of certain contingencies can significantly improve the efficiency of the ensuing actions, provided that these aspects are explicitly discussed during the briefing. In our example, after failed endotracheal intubation, while SG teams primarily reverted to a supraglottic airway device and quickly moved on after realizing that this alternative did also not lead to sufficient oxygenation (as discussed in their briefing), CG teams initially reverted to mask ventilation while discussing and coordinating the teams’ next move. Consequently, the investment of a few minutes before induction that included discussion of initial alternative airway strategies lead to a smoother, more focused initial approach to airway management in a simulated airway emergency, since most necessary team coordination had already taken place during the briefing. This could potentially save precious seconds in a real-life situation where the patient cannot be oxygenated.
While guidelines provide a good frame of reference for a certain situation, the exact course of action is still dependent on individual decisions that need to be communicated within the team. The explicit communication in form of instructions or orders commonly used to coordinate the team has been shown to be impaired in dynamic, stressful situations 17. Successful joint activity is dependent on interpredictability and “common ground”, or “pertinent knowledge, beliefs and assumptions that are shared among the involved parties” 18. Through anticipation and deliberate, proactive communication strategies, teams with shared mental models have been shown to work faster and more effectively. This implicit form of coordination can help to facilitate team interaction 19.
In this regard, it is important to reinforce the difference between semi-structured briefings and checklists, as we have previously done 9. Checklists, another tool that has been proposed as a pre-induction measure to improve safety 20, are used to verify critical steps in a procedural workflow. On the other hand, briefings are a more informal addition that serve a multitude of purposes. They help with the alignment of mental models within the team, while facilitating, or “opening up”, communication. But more importantly, briefings introduce an element of adaptability that complements the rigid content found in checklists. They help to harness the adaptive capacity of humans collaborating towards a common goal by providing an opportunity to highlight special considerations in a given situation or case, direct attention and focus on peculiarities and exceptions to the usual routine. By doing so, they foster a more resilient style of work that can help advance patient safety efforts from the traditional, reactive focus on “fixing things that went wrong” to a more proactive, vigilant state where things “keep on going right” 21. Briefings support the incorporation of properties such as education, training, experience or intuition into applied patient safety in a collective rather than merely individual fashion.
In the current study, increased work efficiency and quicker decision making were observed in the areas covered by the briefing, usually the first and sometimes second alternative approach to airway management. This was achieved with an investment in training of around 10 minutes that could be considered minimal, further hinting at the potential benefit of briefings when implemented on a larger, more robust scale. The exchange of information that could be observed in the control group, while mostly unstructured, shows that communication and collaboration are central, intuitive components of teamwork. However, in current anesthesia practice heavily focused on proceduralised (read checklist) work, this remains unsupported and is left to be taken care of by individual chance.
Particularly interesting is the lack of difference between groups regarding the call for help. Considering how the provision of anesthesia is generally organized, managing and optimizing resources could be considered a key feature in managing adverse events, in marked contrast to industries traditionally associated with briefings (e.g. aviation) where additional help is rarely available. Although the majority of teams explicitly reviewed emergency contact information, this did not result in an earlier call for help. One possible explanation is that in certain departmental cultures, help is called as the result of running out of options or a perceived loss of control rather than in an effort to utilize all available resources. In this regard, briefings could potentially further delay an early call for help by scripting and organizing actions for a team, thereby giving team members a better sense of control. Special care needs to be taken when implementing and training the use of briefings to emphasize the benefit that can be harnessed from an early call for help.
Our study has several limitations. First and foremost, as this was a simulator study, there is always the expectancy bias that an adverse event is about to occur. As participants were observed outside of their normal work environment and routine, one has to be cautious with the interpretation of behavior in relation to real-life situations. This simulator bias might have had a significant effect on the decisions to perform a cricothyroidotomy, and when to call for help.
Second, the training and familiarization time with the TEAM-briefing tool was relatively short. While our results showed promising effects, after the video explanation a disappointingly small number of study group teams discussed alternative airway management despite this being the A in TEAM. Semi-structured briefings are designed with ample leeway for individual interpretation; however, a modified instructional strategy might help teams follow the TEAM tool more closely. A more thorough implementation might help improve teamwork significantly through a more complete alignment of TMMs. It has to be noted, however, that actions and behaviors do not necessarily equate with understanding of the situation.
Third, our study was an exploratory pilot trial, hence, no power calculation could be conducted in the planning phase. The sample size was instead based on considerations of feasibility. Consequently, our trial might not have been adequately powered to detect differences between treatment groups.
Fourth, due to the study design, we singularly focused on a difficult airway scenario, and evaluated the briefing effects accordingly. This does not represent or capture the diverse and complex web of human interactions taking place in a dynamic work environment. A more ethnographical approach might be better suited to evaluate the intricate subtleties found in multi-professional teamwork, and could further our understanding of the complex process that is human everyday work.
While our study showed mixed results in the areas affected by the briefing, we had no indication that communication, collaboration and crisis management were impaired, or worsened, in the study group. Consequently, the results of this study warrant a larger follow-up investigation into the effects of anesthesiologic briefings in an actual work environment.