A Prepared Team is a Successful Team

How one Operating Room Nurse created a forum for team alignment and preparedness.

Pre-Op Surgical Lecture and Walk-Through

Ensuring team alignment, preparedness and expectations.

Justine is a CRNFA on the high-risk open aortic surgical team at a tier-1 teaching institution and felt that there was something missing when it came to team preparedness for these cases that are likely the most treacherous elective and emergent procedures performed. Her service covers aortic dissections, repairs of aortic arch aneurysms, the David procedure, Bentall procedures, repairs of thoracoabdominal aortic aneurysms (aneurysms often spanning both the ascending and descending aorta), open aortic graft infection debridement and replacement, and aortoesophageal fistulae. These cases are often marathons (10+ hours), require a well-coordinated team, involve the use of Deep Hypothermic Circulatory Arrest (DHCA), aortic cross-clamping, and no room for error. Many patients undergoing open aortic surgery have underlying connective tissue disorders such as Marfan Syndrome (MFS) or the Vascular Variant of Ehlers-Danlos Syndrome (EDS). These connective tissue disorders weaken the aortic tissue making them more susceptible to stretching, tearing and aneurysms.

Time is everything in Open Aortic Surgery as there is often a period of time where perfusion may be cut off to vital organs such as the spinal cord and kidneys. As techniques continue to improve with volume at Aortic Centers of Excellence, clinical outcomes have become better, which both affords open aortic surgery to more patients who may have previously been deemed too high-risk and has reduced the incidence of adverse events including paraplegia (due to spinal cord ischemia), and intraoperative mortality.

Justine met with the two surgeons who run her institution’s Aortic Center of Excellence and discussed her idea of doing a pre-op walk-through with the full surgical team to improve both the efficiency and efficacy of surgical intervention for these high-risk patients. The two surgeons felt it was a great idea and Justine did her first pre-op surgical lecture on the afternoon of September 26, 2019, one day prior to an open debridement and repair of a descending aortic graft that had been unresponsive to medical management including broad spectrum antibiotics. Since then, this formal team preparation has become a standard for all high-risk elective open aortic surgical cases.

The Pre-Op Surgical Lecture - Sample

The Pre-Op Surgical Lecture will vary in-length, but is typically around 2 hours and is prepared and delivered by the CRNFA. All Open Aortic Surgeries have at least one attending (most have two) and if available, the attending or a senior fellow will attend to provide any additional context for the team.

Introduction & Background - 30 min.

  • Team member introductions (role on team, etc.)

  • Overview of patient and procedure

  • Review of patient’s scans and surgical history

  • Review of surgeons’ preference cards

Operative Approach - 1 hr.

  • Patient positioning and incision

  • Retraction type and variations

  • Outline of key operative steps

  • Identification of key points of potential complications

  • Key “hand-off” communications to CVICU team

Team Expectations - 15 min.

  • Expectations of the team

  • Reinforcement of best practices to be utilized such as closed-loop communication

  • Discussion of key learnings from prior missteps

Q&A - 30 min.

  • Provides opportunity for each team member to ask any questions about the case.