Emergency responses to the operating room should be drilled to improve performance and patient safety. Infection prevention is a priority.

• Code teams may be unprepared for maintaining sterility.

• OR team members should manage those coming to the room.

• Practice variations on similar scenarios to better prepare clinicians.

Hospitals typically run drills for a wide range of emergency scenarios, everything from shoulder dystocia in childbirth to an active shooter. But not as many run drills for an emergency response to the operating room.

This shortcoming became apparent in a hospital where Charles Dinerstein, MD, MBA, FACS, FSVS, previously was surgical chair. He is now senior medical fellow at the American Council on Science and Health in New York City.

With more than 25 years of experience as a vascular surgeon, Dinerstein saw multiple instances in which a patient suffered cardiac arrest in the OR and a code team was summoned.

“The code team arrived, violating every possible sterile field in street clothes, without masks to assist in care already being delivered by anesthesia and OR staff. Everybody came running into that room, including the family practice residents who were doing the cardiac codes,” Dinerstein recalls. “All sorts of people were wandering into that room. It became abundantly clear that we had not had any practice, the staff was not familiar with standard routines, and that the surgeons had no plan for protecting the field.”

Dinerstein realized the clinical teams needed a better plan for maintaining sterility, accessing needed supplies, and identifying key team members.

“We arranged for a simulation in an OR environment so that we could review what communications broke down, where equipment was located, and how to respond. It was a very significant learning experience for everyone, and it might be worthwhile for hospitals to have a series of simulations throughout the year,” Dinerstein says. “Often times, continuing education closes the OR for an hour at the beginning of the day once a month or every other week, providing opportunities for drills without impacting routine care.”

Dinerstein’s hospital conducted drills in an available OR with a typical contingent of physicians and staff for surgery in the room. The drill started by declaring that the patient was in cardiac arrest and calling for a code team. After the simulation, the OR team debriefed and looked for ways to improve.

The drills made the OR team more confident about their roles in the emergency, highlighting the need for them to maintain control of the overall situation while allowing the code team members to do their jobs. The hospital also trained the code team in proper protocol for entering the OR and maintaining the sterile field.

“The roles of the CRNA [certified registered nurse anesthetist] and anesthesiologist were pretty straightforward, but we reassigned the roles of the scrub nurse and the surgeon to focus on caring for the patient, specifically to protect the sterile field, and we reassigned the circulating nurse to control the crowd coming and going,” he says. “Those needs had not been immediately apparent to us before.”

Drills should focus on issues such as who will be in charge, how to manage the room, and what decisions are being made by the team as the situation evolves. The drills should vary the situations, even in the same general topic such as cardiac arrest, so that participants can practice how to respond and change their assumptions.

“We have a habit of giving people an advanced life support card and telling them they’re good to go,” he says. “But what they encounter in actual situations may be different than what they’re expecting or what they’ve done before because every patient is different.”

The success of the drills led Dinerstein and colleagues at the hospital to develop similar simulations for other emergency scenarios like massive blood loss during surgery.

“The key insight is that this is another thing we can learn from the airline industry. The airlines require their teams to train regularly in simulators, with a focus on team management and communication,” Dinerstein says. “This is something that hospitals have been a little bit slow to think about. There is not enough of that required in our hospitals, and we could be getting a lot more benefit from that kind of training.”