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ECONOMICS, EDUCATION, AND POLICY

Coordination Patterns Related to High Clinical Performance in a Simulated Anesthetic Crisis

Tanja Manser, PhD^*, Thomas Kyle Harrison, MD, David M. Gaba, MD, and Steven K. Howard, MD

From the *Center for Organizational and Occupational Sciences, ETH Zurich, Switzerland; and VA Palo Alto Health Care System, Palo Alto, Department of Anesthesia, School of Medicine, Stanford University, and Patient Simulation Center of Innovation, VA Palo Alto Health Care System, Palo Alto, California.

Address correspondence and reprint requests to Tanja Manser, PhD, ETH Zurich, Center for Organizational and Occupational Sciences, Kreuzplatz 5, CH-8032 Zurich, Switzerland. Address e-mail to tmanser{at}ethz.ch.

Abstract

BACKGROUND: Teamwork is an integral component in the delivery of safe patient care. Several studies highlight the importance of effective teamwork and the need for teams to respond dynamically to changing task requirements, for example, during crisis situations. In this study, we address one of the many facets of "effective teamwork" in medical teams by investigating coordination patterns related to high performance in the management of a simulated malignant hyperthermia (MH) scenario. We hypothesized that (a) anesthesia crews dynamically adapt their work and coordination patterns to the occurrence of a simulated MH crisis and that (b) crews with higher clinical performance scores (based on a time-based scoring system for critical MH treatment steps) exhibit different coordination patterns.

METHODS: This observational study investigated differences in work and coordination patterns of 24 two-person anesthesia crews in a simulated MH scenario. Clinical and coordination behavior were coded using a structured observation system consisting of 36 mutually exclusive observation categories for clinical activities, coordination activities, teaching, and other communication. Clinical performance scores for treating the simulated episode of MH were calculated using a time-based scoring system for critical treatment steps. Coordination patterns in response to the occurrence of a crisis situation were analyzed using multivariate analysis of variance and the relationship between coordination patterns and clinical performance was investigated using hierarchical regression analyses. Qualitative analyses of the three highest and lowest performing crews were conducted to complement the quantitative analysis.

RESULTS: First, a multivariate analysis of variance revealed statistically significant changes in the proportion of time spent on clinical and coordination activities once the MH crisis was declared (F [5,19] = 162.81, P < 0.001, _p² = 0.98). Second, hierarchical regression analyses controlling for the effects of cognitive aid use showed that higher performing anesthesia crews exhibit statistically significant less task distribution (β = –0.539, P < 0.01) and significantly more situation assessment (β = 0.569, P < 0.05). Additional qualitative video analysis revealed, for example, that lower scoring crews were more likely to split into subcrews (i.e., both anesthesiologists worked with other members of the perioperative team without maintaining a shared plan among the two-person anesthesia crew).

CONCLUSIONS: Our results of the relationship of coordination patterns and clinical performance will inform future research on adaptive coordination in medical teams and support the development of specific training to improve team coordination and performance.