Anesthesia Management: Team Creates Protocol for Handling OR Emergencies

The worst moments in the operating room, according to surgeon David Earle, MD, are the quiet ones that settle in during intraoperative emergencies, when seconds drag on for minutes and minutes for hours.

“Anyone involved in a surgical procedure knows those times, particularly when the patient is bleeding, the room is quiet, and the team is waiting for the circulator to return with the appropriate supplies and equipment,” said Dr. Earle, director of minimally invasive surgery at Baystate Medical Center, Springfield, Mass.

Dr. Earle believes that those moments should not occur. Operating room (OR) teams can prevent them by having a practiced plan of action for emergencies, similar to those for cardiac arrest and fire, he said. “All hospitals have codes for those emergencies, but almost none have formalized protocols for dealing with high-risk intraoperative emergencies.

“When there is an urgent, unexpected change in the operative plan, even the best teams are strained to perform efficiently, and that’s precisely when peak performance of the team is essential.”

He and his colleagues developed a protocol for intraoperative emergencies. Over several months, the team simulated emergencies in the OR to figure out what is needed during these events. The mock operations were videotaped and assessed by all members of the OR team. After extensive debriefs of the videos, the team created a protocol known as C-STAT.
The keystone of the C-STAT protocol is a rapid technical response team that can be summoned to the OR in an emergency. When an emergency alert is sounded, any OR staff not currently performing a critical patient care duty is expected to stop what they are doing and attend.

The primary circulating nurse quickly assigns roles to the first people to arrive. To eliminate confusion about who is responsible for what, every member of the rapid response team carries a card tucked into the back of his or her hospital identification badge.

The card outlines the assigned tasks for every person on the C-STAT team. For instance, the first nurse who comes to the OR and assumes the role of C-STAT RN sees the following on the back of his or her card: responsible for ordering blood and setting up additional equipment.

As members of the C-STAT team assume their duties, the primary operative team stays focused on the immediate needs of the operative field, said Dr. Earle, who presented details of C-STAT at a panel session on patient safety during the 2014 annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

The C-STAT protocol takes confusion out of emergencies, said Diane Betti, MSN, RN, CNOR, director of the Daly OR, who helped develop the program.

“When there’s an emergency, the first thing that happens is everybody’s attention is diverted away from the operative field just at the critical time when everybody’s attention needs to be on the patient.

“Now, there’s an increased ability to focus on the operative field because everyone in the room knows exactly what needs to be done,” Ms. Betti said.

Based on the results of their simulation exercises, the Baystate group also developed a conversion pack for cases that require switching from laparoscopic to open surgery. “It’s crazy that a conversion pack didn’t exist before, that we were running around every single time,” Dr. Earle said. “But I don’t think it’s that uncommon.”

Emilia Scala, RN, CNOR, service coordinator for Baystate operating rooms, said the C-STAT team typically gets called about once a month.

“We had an activation last week. … We were nearing the end of a long operation on a patient with a pancreatic tumor. There was tumor stuck to an artery, and the patient started bleeding. We called for the C-STAT team, and everyone knew exactly what to do,” Ms. Scala said.

The C-STAT team has been in existence at Baystate for about seven years. For that period, they have not tracked activations, patient outcomes and staff satisfaction with the program.
But even without supporting data, other surgeons say there is a role for programs like C-STAT.

“You don’t need to spend a lot of [research] dollars to understand that a team that’s practiced, rehearsed what they are going to do and are geared up together to address problems are going to be better than the folks caught off guard trying to manage that same situation in an operating room,” said Daniel B. Jones, MD, professor of surgery at Harvard Medical School, Boston.

In a crisis, OR team members often have different ideas “of what needs to be done next, where the supplies are, who is doing what,” Dr. Jones said. “But by practicing the drills, orchestrating the team, they are able to respond like Navy Seals in a very coordinated fashion. More likely than not, it would achieve a higher level of care.”

Anne Lidor, MD, MPH, associate professor of surgery at Johns Hopkins Hospital, Baltimore, said all hospitals should have programs like C-STAT and practice regularly, “just like we do for trauma and [advanced cardiovascular life support].”

But it poses a major challenge to take these programs from concept into reality, she added.

“This is something that people should think about and should do. But how to initiate it, how to get people to buy into it—that’s another story. It’s not just surgeons that need to be onboard. It’s everybody in the OR: nurses, techs, OR assistants. You’d have to have a lot of people willing to participate, and you need some sort of impetus to get this done.”