Analysis of observations and interviews identified three major themes: (1) Assessing utility, (2) Customising implementation, and (3) Interactive micro-team communication. 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.
Assessing utility
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.
Customising 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.
Interactive micro-team communication
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 specialities 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.