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The Royal Australasian College of Surgeons (RACS) supports briefing and debriefing of surgical teams. These processes ensure that all members of the surgical team have a shared understanding of the operative plan prior to the operation and so that post-operative discussions become a routine part of supporting quality improvement to protocols and patient safety. The process of briefing and debriefing is an important element of building respect and teamwork among staff, providing an opportunity for positive reinforcement and continuous improvement.
Briefing and debriefing processes, together with surgical checklists, aim to improve the quality and safety of healthcare services provided to patients undergoing surgery and to help prevent adverse events. Appropriate briefing and debriefing has been shown to reduce unexpected delays by 31% and surgeon-reported unexpected delays by 82%.1 Research2has further indicated that when surgical team briefings are implemented in the theatre environment the following positive effects are recorded:
- Communication failures are reduced by two-thirds
- Non-routine events are reduced by 25%
- Potential surgical safety hazards are identified
- It is perceived that risk is reduced, with an increased a sense of team collaboration
RACS recognises that there is no one correct way in which briefing and debriefing should take place in surgical settings. Individual surgeons, hospitals and health services will adapt these processes depending on the make-up of the surgical list, the context of the practice and the operations being undertaken. The underlying principle is to ensure that these processes are undertaken, and that it is in a manner appropriate to the circumstances.
Surgical safety checklist
Surgical safety checklists are widely used to support quality assurance and improvement in hospitals. RACS endorses the World Health Organisation (WHO) Surgical Safety Checklist3 as a minimum standard for supporting safe surgical procedures. The ten objectives outlined by WHO4 regarding surgical safety checklists are:
The team will:
- Operate on the correct patient at the correct site.
- Use methods known to prevent harm from administration of anaesthetics, while protecting the patient from pain.
- Recognise and effectively prepare for life-threatening loss of airway or respiratory function.
- Recognise and effectively prepare for risk of high blood loss.
- Avoid inducing an allergic or adverse drug reaction for which the patient is known to be at significant risk.
- Consistently use methods known to minimise the risk for surgical site infection.
- Prevent inadvertent retention of instruments or sponges in surgical wounds.
- Secure and accurately identify all surgical specimens.
- Effectively communicate and exchange critical information for the safe conduct of the operation.
- Undertake a risk assessment for venous thromboembolism (VTE).
And additionally, that hospitals and public health systems will establish routine surveillance of surgical capacity, volume and results.
The importance of adhering to surgical safety checklists is articulated in the RACS Code of Conduct, which states that a surgeon will ‘ensure that operation safety practices for patients and theatre staff are adhered to, including completing a surgical safety checklist’.5
A briefing is a short meeting between all theatre team members to ensure that there is a shared understanding of what is expected of them and the role of other team members. A briefing may be undertaken in conjunction with completion of an appropriate surgical safety checklist6 and does not replace or duplicate the checklist and/or monitoring the outcomes of surgical procedures through appropriate hospital meetings (i.e. morbidity and mortality meetings).
Briefings are a valuable opportunity to ensure that all members of the surgical team have a clear understanding of the plan for the operation, the type of anaesthesia, possible complications and contingencies. A briefing should provide the following opportunities for team members to:
- Gain clarity of direction
- Facilitate better coordination between team members
- Reduce the risk of problems and breakdowns in communication occurring
- Develop contingency plans for if unexpected events happen
- Clarify any misunderstanding of plan or approach
- Create a culture of open communication
- Make everyone feel part of a team7
At a minimum, briefings should include discussion around drug sensitivities, patient information relevant to the procedure, anaesthesia type, availability of blood products, equipment and planned stages of surgery.8
Briefing should be a routine part of both elective and emergency operative sessions. The briefing should be led by the team member who knows the most about the patient/s on the operating list – usually the surgeon.
Debriefing occurs at the end of a theatre session and should include all members of the surgical team. The meeting can be used to consider the good points of the operating process and teamwork, review any issues that occurred, answer concerns that the team may have and identify areas for improvement.9 It is often appropriate for the surgeon to thank the rest of the surgical team.
The opportunities that arise from regular participation in debriefing meetings include:
- Improved communication across all disciplines
- Practice improvement
- Equipment, personnel and technology issues to be identified and addressed10
To support these objectives, it is important that the surgical team engages in constructive dialogue that fosters an environment where members provide comments and raise issues in a non-threatening and non-confrontational manner.
In conjunction with surgical safety checklists, briefing and debriefing sessions are most successful when they are planned and integrated into the day-to-day practice of surgical teams. Ongoing education and consistent implementation of these protocols will improve the co-ordination of surgical teams and reduce the risk of poor patient outcomes.
1 Health Quality and Safety Commission – New Zealand, Checklists, briefings and debriefings: A summary of the evidence, available at http://www.hqsc.govt.nz/publications-and-resources/publication/2209/
2 Civil I & Shuker C. (2015), Briefings and debriefings in one surgeon’s practice, ANZ Journal of Surgery, 85: pp. 321–3.
3 World Health Organisation (WHO), Surgical Safety Checklist, available at http://www.who.int/patientsafety/safesurgery/ss_checklist/en/
5 Royal Australasian College of Surgeons, Code of Conduct (3rd ed.), available at http://www.surgeons.org/media/346446/2016-04-29_mnl_racs_code_of_conduct.pdf
6 WHO, Surgical Safety Checklist
7 National Health Service (NHS), Royal Cornwall Theatre Briefing Guide, available at http://www.nrls.npsa.nhs.uk/
9 Royal College of Surgeons, The High Performing Surgical Team, A Guide to best practice, 2014.
10 Marks, S, Loskove, J, Greenfield, A, Berlin, R, Kadis, J & Doss, R, Surgical Team Debriefing and Follow-Up: Creating an Efficient, Positive Operating Room Environment to Improve Patient Safety, available at http://www.apsf.org/newsletters/html/2014/June/04_surgicaldebrief.htm .