“Managing a Surgical Exsanguination Emergency in the Operating Room through Simulation: An Interdisciplinary Approach” Natalia Martinez Acero M.D, Greg Motuk, R.N, Josef Luba, R.N., Michael Murphy, M.S.N, Susan McKelvey, R.N., Gretchen Kolb, M.S, Kristoffel Dumon M.D, Andrew S. Resnick, FACS, M.D, M.B.A. Hospital of the University of Pennsylvania
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“Managing a Surgical Exsanguination Emergency in the Operating Room through Simulation: An Interdisciplinary Approach” Natalia Martinez Acero M.D, Greg.
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“Managing a Surgical Exsanguination Emergency in the Operating Room through Simulation:
An Interdisciplinary Approach”
Natalia Martinez Acero M.D, Greg Motuk, R.N, Josef Luba, R.N., Michael Murphy, M.S.N,
Susan McKelvey, R.N., Gretchen Kolb, M.S, Kristoffel Dumon M.D, Andrew S. Resnick, FACS, M.D,
• Each year 234 million major operations are performed worldwide1
• 30 million surgical procedures are performed each year in the US alone 2,3
• ECRI - 550-650 surgical fires per year in the US 4
• AST – 1 in 4,500 patients has an anaphylactic reaction in the US 5
• Clinical and non-clinical OR emergencies are infrequent, but carry significant morbidity and mortality
• Previously presented initial studies – OR fire and anaphylaxis• No published team training work focusing on complex perinatal scenarios,
taking advantage of newer technology
1. World Health Organization : 10 Facts on Safe Surgery, June 25, 20082. Fires in the Operating Room. American College of Surgeons: Committee on Perioperative Care. Podnos YD,
Williams RA 3. American College of Surgeons: Statement on Health Care Reform4. Emergency Care Research Institute (ECRI). Clinical Guide to Surgical Fire Prevention (2009). Pennsylvania, USA.5. Association of Surgical Technologists. Standards of practice, Guideline Anaphylactic Reaction (2005). CO, USA.
SIMULATED SCENARIO• Study : Prospective • Duration: June- November 2011• Location: Penn Medicine Clinical Simulation Center (PMCSC)
– Hospital of the University of Pennsylvania (HUP)
• Participants: 171 OR staff members (residents, nurses, surgical technologists)• Design: Weekly one hour OR Team Training sessions• Scenario: Simulated exsanguination emergency in a
pregnantpatient (hidden carotid injury) after a MVC
• Cognitive assessment (3 questions): 1. Pregnant patient position and hand placement during CPR2. Recommended room temperature during an exsanguination3. Number of licensed personnel required to check blood
products prior to transfusion
Simulated Scenario: • Brief H&P on a pregnant patient who had unexpectedly arrived to
the OR• Each group was assigned to simulated OR (equipped with a
8 MITIGATION STEPS • Supported by a systematic review of current literature 6,7,8,9
• Measured for both “cold” and “warm” simulations– Activate Emergency Response System– Identify a team leader – Mother is 1st patient to treat – Initiation of an exsanguination protocol– Raise room temperature to 80⁰F– Reposition mother on left lateral recumbent position– 2nd person to verify blood products– Initiate CPR
6. Levy DB. Neck Trauma: Treatment & Management, 2010.7. Chames MC, Pearlman MD. Trauma during pregnancy: Outcomes and clinical management. Clinical Obstetrics and Gynecology 2008; 51(2): 398-408.8. Mirza F, Devine PC, Gaddipati S. Trauma in Pregnancy: A systematic Approach. Am Journal of Perinatology 2010; 27(7): 579-586.9. McCunn M, Gordon EK, Scott TH. Anesthetic concerns in trauma victims requiring operative intervention: The patient too sick to anesthetize. Anesthesiology Clin 2010; 28: 97-116.
RESULTS: Overall Performance• Total # of participating groups: 26 • In the warm scenario, 7 groups (27%) performed all 8 mitigation steps• During the warm scenario, the mean number of mitigation steps
completed increased for all teams (p<0.001)
Cold Simulation Warm Simulation0
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3.9
6.6
Mean Number of Mitigation Steps Completed During "Cold and Warm" Simulations
• MDs vs. RNs:– 3 cognitive questions: MDs (N=96) RNs
(N=63)• Pt positioning/ hand placement for CPR: 64.6%/ 97.9% 52.4%/ 100%• Room temperature: 69.8%/ 98.9% 91.9%/ 100%• Licensed personnel to check blood: 67.4%/ 92.7% 88.9%/ 95%
– Survey: MDs (N=94) RNs (N=59)
• My role in an exsanguination: 41.4%/ 96.8% 62.7%/ 100%• Exsanguination protocol: 50%/ 100% 56.2%/ 100%• Relevant to current practice: 100% 100%• Simulated environment was realistic: 77.4% 91.4%• Simulated patient scenario was realistic: 91.2% 91.6%