Developing an Intervention to Improve the Non-Technical Skills of the Cardiac Surgical Teams

Over 290,000 Coronary Artery Bypass Graft (CABG) and valve replacement surgeries are performed in the US annually. Around 30% of patients undergoing CABG experience a complication. Notably, hospitals and surgeons with high CABG and valve surgery volumes are more likely to achieve better outcomes. In other surgical specialties, more than 50% of surgical complications are attributable to ineffective non-technical skills for surgeons (NOTSS), defined as cognitive skills (situation awareness, decision making) and social skills (leadership, communication, and teamwork) underpinning medical knowledge and technical skills. The previous work and others found that better non-technical skills were associated with improved risk-adjusted rates of any post-operative complication, mortality, return to the operating room, and intraoperative performance. The investigator have also reported that non-technical skills training programs for general surgeons can effectively improve NOTSS and are associated with improved Operating Room (OR) performance metrics, fewer unplanned reoperations, decreased length of hospital stay, and lower mortality rate. Given our prior work, it is likely that Non-Technical Skills for Cardiac Surgery (NOTSCS) are also important contributors to better cardiac surgery outcomes.

Cardiac surgery procedures are technically challenging for the surgeons and physiologically disruptive for patients, e.g. circulatory arrest, cardiopulmonary bypass, with very little physiologic reserve as a result of their cardiac disease. Cardiac surgeries are conducted by different teams each composed for specialized medical professionals working in concert and relieving each other to support creation of new anatomical structures in the heart (surgery team), cardiopulmonary function (anesthesia team), perfusion to vital organs (perfusionist team), transfusion (blood management team), provision of medicines (operating room pharmacy team) and provision of tools and implants (nursing team). The dramatic and unexpected physiologic changes that occur, large number of medical professionals, extreme sub-specialization of medical professionals, ad-hoc nature of the teams, steep hierarchy between medical professionals and participation of learners all make cardiac surgery operating rooms highly stressful environments. Individuals working in this stressful environment are highly vulnerable to human errors that lead to complications. Yet most of the surgical education programs focus only on technical skills, and interventions to improve the non-technical skills of cardiac surgical teams are scarce. Therefore, there is an urgent need to develop tailored, cardiac surgery-specific interventions to improve the NOTSCS and to assess their effect on patient outcomes.

The goal of this K99/R00 is to develop and test an intervention to improve the non-technical skills of cardiac surgical teams. The investigators will develop, pilot test, refine, and assess the effect of a NOTSCS intervention by applying principles of simulation-based mastery learning (SBML). SBML allows learners to deliberately practice skills until they achieve a mastery level. Most importantly, this application will allow for my development as an independent investigator focused on improving NOTSCS, with a long-term goal of improving cardiac surgery outcomes. The aims of this application are:

K99 Aim 1: To adapt existing non-technical skills performance metrics to cardiac surgical teams. The investigators will identify the behavioral markers required to enhance intraoperative non-technical skills performance for the cardiac surgery teams at academic and community hospitals.

K99 Aim 2: To adapt refine and pilot test an existing NOTSS improvement intervention for cardiac surgery-specific skills, environments, and teams, and assess barriers and facilitators to its implementation.

R00 Aim 1: To assess the preliminary effectiveness of NOTSCS on OR times and patient outcomes.

The research team will implement the NOTSCS intervention to cardiac surgical teams from two academic hospitals. The hypothesis is that a non-technical skills improvement program will be associated with increased NOTSS behaviors, decreased OR time, cardiopulmonary bypass time, time on/off pump, intraoperative bleeding requiring transfusion, and unplanned return to the operating room.

R00 Aim 2: To examine implementation acceptability, feasibility, appropriateness of a SBML NOTSCS intervention. Using quantitative and qualitative feedback, the investigators will map barriers and facilitators to an implementation framework to address barriers to the NOTSCS intervention.