Introduction of briefing and debriefing system in operating theaters in Pakistan

Syed Shakir Hasan
Consultant Anaesthetist, UK.

Correspondence: Syed Shakir Hasan, West Temperley, Altrincham WA14544, UK. Phone: +447432605854; E-mail: shakirhasanpk@yahoo.com
Citation: Hasan SS. Introduction of briefing and debriefing system in operating theaters in Pakistan. Anaesth. pain intensive care 2021;25(2):129–131.

DOI: 10.35975/apic.v25i2.1460
Introduction
It has been observed worldwide that catastrophic events can occur in the operating theater because of human factors or errors, which in the past had resulted in a misjudgement of patient’s identity and operating site, lack of planning in using the effective theater time, lack of precision regarding individual’s specific role, lack of identifying or planning for those at risk & discussing them beforehand for an effective outcome. Therefore, there is a need to have a system of checklist through where such incidents can be avoided by having a brief meeting with all staff members and discussing each & every patient on the theater list along with detailed surgical and anesthesia plans before their arrival in theater.
To improve patient safety in the operating theater, a system of peri-operative briefing and debriefing should be introduced in Pakistan as well to avoid or reduce the chances of mishaps and human errors. Unfortunately, even the best in our hospitals in Pakistan do not seem to be following this, which has been a routine practice in elsewhere in the world.
This should work through an optimal collaboration between surgical team members. It has been observed that perioperative briefing and debriefing improve the team climate of surgical teams and the efficiency of their work within the operating theater. Checklists, briefings and debriefings have become widely used in operating theaters worldwide. The aim of these teamwork and communication tools is to improve the quality and safety of healthcare services for patients having surgery.
The use of surgical checklists has been shown to reduce adverse events and improve patient outcomes. Briefings and debriefing support improved communication, better identification of recurring issues and a reduction in unexpected delays.
In case of Aviation, Checklists had been developed for pilots to be sure of remembering & implementing everything on their list. Similarly, it can be applied to operating theaters due to the similarities of increasing complexity in aviation and delivery of surgery. The safety during surgery requires effective coordination among surgeons, anesthetists, nurses and technicians.

Briefing
The plan for the day needs to be discussed in the presence of all team members. It is initiated before the first case of the day once all team members are available in the department to ensure a shared understanding of the plan for the day & in anticipation and preparation for problems. Briefing can be led by any member of the staff & one should consider rotating the lead by including and encouraging the junior staff and trainees. Briefing is usually started with the introduction of all staff members, followed by their roles, responsibilities, actions and interactions. Everyone must feel comfortable about the day and has a valid role, perspective and opinion. The team can highlight any issues arising from the previous list’s debrief. The list for the day needs to be reviewed for any changes such as change in order of the patients or cancelation, any anticipated events such as fire alarm test, necessary changes in case of emergency procedures, details of each case, clear plans, expectations, special considerations for allergies such as latex allergy/positioning/equipment, any sterility or decontamination issues

Surgical safety checklist
WHO surgical checklist is available online, which can be downloaded and printed for implementation, checklist need to be done before the induction of anesthesia, before surgical incision and after the surgery before the patients go to the recovery room

Before the induction of anesthesia
(With at least nurse and anesthetist)

• Has the patient confirmed his/her identity, site, procedure, and consent?
• Is the site marked?
• Is the anesthesia machine and medication check complete?
• Is the pulse oximeter attached to the patient and functioning?
• Does the patient have a:
• Known allergy?
• Difficult airway or aspiration risk?
• The risk of more than 500ml blood loss (7ml/kg in children)?
  
  Before the skin incision
  (With nurse, anesthetist and surgeon)

• Confirm all team members have introduced themselves by name and role.
• Confirm the patient’s name, procedure, and where the incision will be made.
• Have antibiotic prophylaxis been given within the last 60 min?
• Anticipated Critical Events
  
  To Surgeon:

• What are the critical or non–routine steps? How long will the case take?
• What is the anticipated blood loss?
  
  To anesthetist:

• Are there any patient–specific concerns?
  
  To Nursing Team:

• Has sterility (including indicator results) been confirmed?
• Are there equipment issues or any concerns?
• Is essential imaging displayed?
  
  Before the patient leaves operating room
  
  (With nurse, anesthetist and surgeon)
  
  Nurse Verbally Confirms:
  
  The name of the procedure
  Completion of instrument, sponge and needle counts
  Specimen labeling (read specimen labels aloud, including patient name)
  Whether there are any equipment problems to be addressed
  
  To Surgeon, Anesthetist and Nurse:
  
  What are the key concerns for recovery and management of this patient?
  
  Debriefing
  Debriefing is a discussion of the day’s list and an opportunity to learn from what went well and what did not. It occurs at the end of an operating session and involves all the members of the theater. It allows the team to assess what they did well, what the challenges were and what they will do differently next time and if the team performed effectively, discussing any communication issues, discussing what might have been done differently and other learning points, appreciating of something, which went very well, review the timing of the operating list (was there enough time/was there too much time) and closing with checking whether the debriefing helped the team.
  The debrief should be performed before team members start leaving the theater/department
  Its aim is to improve rather than blame someone with an opportunity to feedback on team learning and capture problems and trends. It can be led by any member of the team and consider rotating the lead, including students and trainees. Preferably, it is better to give the lead role to the team member who is often the first to leave the theater. The purpose is to Reflect by sharing information and perspectives, having own personal views with no direct criticism or blame, with Openness and honesty. Ideally, everyone should be encouraged to contribute and should acknowledge glitches, mistakes, distractions and interruptions. One own work and others need to be reflected upon and to highlight the factor contributing to the events whether it is an individual, team or system failure. It needs to stress upon individuals to speak up in case of a need and must emphasize the importance of teamwork, on our preparation as a whole.
  The debriefing should finish on a positive or high learning note and the loop can be closed by recording learning points, highlighting the need to change anything in the future or anything requiring escalation after having the feedback and then forwarded to the management for implementation.
  
  Our practice
  It is a common practice in most of the hospital in the UK to brief before beginning of the theater list. We start the briefing with the introduction of the staff present on that list, each & every case on the list is discussed in detail including patient’s ASA status, any allergies, detailed anesthesia plan including enquiry about the possibility of difficult airway and a proposed plan, surgical plan including the proposed procedure and required surgical equipment, estimated blood loss, preventive measures of DVT, need of antibiotics. All these details are documented by the person with a leading role, on a paper prepared specifically for this purpose. Patient’s identity and the site of surgery is checked on arrival against the consent form and the patient’s bracelet and both the surgeon and anesthetist must sign the form. After the induction of anesthesia, it is ensured that patient’s condition is fine to go ahead along with the questions regarding patient’s temperature, glycemic control and antibiotics. At the end of surgery, the surgeons are asked as to what exact procedure they have done, count of swab, equipment and needles, the anesthetist is asked about any issue to be highlighted for the recovery room and whether intravenous lines have been flushed and fine to be used later. Then, it is asked from everyone if there is any need for a debrief?
  
  In Pakistan
  In comparison, there is no such system followed in Pakistan either due to nonexistence of such protocols or due to lack of interest even if it exists or it is not being followed properly according to guidelines. There are some of the Tertiary care hospitals, which have the checklists, but these may not be of the same standard and protocols and hence does not fulfill the purpose.
  I feel that it is an excellent system being practiced worldwide. There have been reports of errors when the checklist is not in use and there are studies, which have shown the efficacy and improvement in patient’s safety, especially in tertiary hospitals. This is something that is not new in our part of the world as well, but it is our need to implement it and stick to the guidelines and protocols so that we can practice it in Pakistan as it will certainly improve the quality of care and avoid the preventable errors and mishaps.
  
  Conflict of interest
  No conflict of interest is declared by the author
  
  Author’s contribution
  
  The author conceived the idea and prepared the manuscript.
  
  References

1. Checklists, briefing & debriefings. Health Quality and Safety Commission; 2016. Available from: https://www.hqsc.govt.nz/publications–and–resources/publication/2209/
2. Briefing and debriefings. Royal Australasian College of surgeon; 2016. Available from: https://www.surgeons.org/en/about–racs/position–papers/briefing–and–debriefing–2016
3. WHO surgical safety checklist and implementation manual; 2008. Available from: https://www.who.int/patientsafety/safesurgery/ss_checklist/en/
4. Leong KBMSL, Hanskamp–Sebregts M, van der Wal RA, Wolff AP. Effects of perioperative briefing and debriefing on patient safety: a prospective intervention study. BMJ Open. 2017 Dec 14;7(12):e018367. [PubMed] DOI: 1136/bmjopen–2017–018367