The operating room’s (OR) complex workflow requires a carefully coordinated plan to ensure both safe and efficient processes. The potential for video recording to promote surgical quality improvement and patient safety, eliminate surgical “never events,” and enhance communication and teamwork among providers has been documented. In a large multicenter trial, the use of a surgical safety checklist was shown to reduce mortality and complication rates and improve outcomes during simulated events. We hypothesized that remote video auditing (RVA) with nonpunitive, real-time feedback would improve compliance with safety processes and OR efficiency and prove to be an innovative harm-reduction strategy by enhancing accountability and communication of feedback to the OR team.
As part of a pilot study, staff at Northwell Health engaged a commercial company that provides RVA services to promote safety and efficiency in fast food, meatpacking, and other industries, to audit 23 ORs in real-time in a large OR suite at one of its main tertiary hospitals. One of its key objectives was to study the impact of RVA with feedback on compliance of OR staff with the sign-in, time-out, and sign-out elements of the World Health Organization (WHO) surgical safety checklist. Video, through a camera placed in each OR suite and viewed remotely, was audited every two minutes by a 10-person audit team and feedback metrics (pass/fail) were posted to display boards in each suite and sent as email or text alerts to the OR team within three minutes of each audit start.
For the OR team to receive a “pass” for sign-in, time-out, and sign-out, auditors looked for the surgeon, circulating nurse, and anesthesia provider to (1) read the script from a checklist, clearly visible on camera, (2) be engaged and participate without distraction, (3) take the minimum amount of time required to complete the checklist, and (4) complete each element in the proper order. Results of the initial pilot demonstrated an increase in compliance with time-out procedures from 16% during baseline (n=1886) to 84% for feedback ORs and 77% for no feedback ORs during the intervention phase (n=2693).
These positive results led to the further launch of video auditing in nine ORs at one of its community hospitals in 2013 and further expansion of its use through 2020 to 137 ORs, including three endoscopy, three ambulatory, and one labor and delivery unit in 13 locations, impacting over 505,000 cases. At each site, OR time-out with RVA compliance remained or increased to greater than or equal to 90% following implementation—apart from one endoscopy and one labor and delivery unit (currently 88% and 82% respectively). Data is further analyzed based on sign-in, time-out, and sign-out failures, e.g., abbreviated or distracted time-outs.
In summary, improved efficiency and compliance to safety protocols in a complex environment such as the OR can result from direct observation, measurement, and immediate feedback to the OR team. The team believes that acceptance among staff was facilitated by their emphasis on individual privacy, teamwork, and nonpunitive reinforcement when metrics diverge from targets.
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