some one posted this on one of my groups and I thought it was pretty interesting and know the nascar fans especially would, Lyn
A Hospital Races To Learn Lessons Of Ferrari Pit Stop
Auto Crew Teaches Surgeons Small Errors Can Add Up On the Track, or in the ICU
WALL ST. JOURNAL November 14, 2006
LONDON -- After surgeons completed a six-hour operation to fix the hole in a
boy's heart, Angus McEwan supervised one of the more dangerous phases of the
procedure: transferring the fragile three-year-old from surgery to the intensive
care unit.
Thousands of such "handoffs" occur in hospitals every day, and devastating
mistakes can happen during them. This one went off without a hitch, thanks to
pit-stop techniques of the Ferrari race-car team.
"It was smooth. We didn't miss anything," said Dr. McEwan, a senior
anesthesiologist at Great Ormond Street Hospital for Children. His role as
leader of the handoff was partly modeled after Ferrari's "lollipop man," who
uses a large paddle to direct drivers to the pit.
In one of the more unlikely collaborations of modern medicine, Britain's largest
children's hospital has revamped its patient handoff techniques by copying the
choreographed pit stops of Italy's Formula One Ferrari racing team. The hospital
project has been in place for two years and has already helped reduce the number
of mishaps.
The challenge of moving a patient to another unit, or to a new team during a
shift change, is an old one. In 1995, one man in Florida had the wrong leg
amputated after a flubbed handoff. "If you transfer a patient to the ICU after
surgery and the ventilator isn't ready, you're really riding on the edge" of
patient safety, says Allan Goldman, head of the pediatric intensive care unit at
Great Ormond Street Hospital and a chief architect of the hospital's
collaboration with Ferrari.
A 2005 study found that nearly 70% of preventable hospital mishaps occurred
because of communication problems, and other studies have shown that at least
half of such breakdowns occur during handoffs.
American hospitals are starting to improve the way they transfer patients. As in
Britain, they are borrowing ideas from fields more skilled in the art of
high-risk handoffs, including aviation, spaceflight and the military. Last week
the Royal College of Surgeons of England and Dr. Goldman's hospital held an
international conference on the subject. One of the speakers was a British
submarine commander who spoke about lessons from the Kursk, the Russian
submarine that sank in 2000.
Kaiser Permanente of California, a health system with 37 medical centers and 8.6
million members, has a handoff method based on a change-of-command system
developed for nuclear submarines. At Trinity Medical Center in Rock Island,
Ill., nurses and doctors actually "pass the baton": They place documents with
key patient information inside a plastic baton and pass it on during a patient
handoff.
A facility in St. Joseph's Health System in Orange, Calif., uses a method it
calls "Ticket to Ride" -- a series of questions about the patient's medications,
infections and other medical issues, that have to be asked of a person
transferring the patient between departments. Blount Memorial Hospital in
Maryville, Tenn., encourages its staff to "Just Go NUTS," an acronym for a
four-step handoff routine it recommends (Name, Unique issues, Tubes, Safety).
Recent trends have increased the risk during handoffs. A nurse shortage means
more hospitals are hiring temporary staff. Because of new rules, medical interns
are also working fewer hours, which makes shift changes -- and therefore
handoffs -- more frequent. At the same time, some surgeons work in larger teams
and connect patients to an ever-growing tangle of wires and tubes.
Earlier this year, the Joint Commission on Accreditation of Healthcare
Organizations began requiring U.S. hospitals to standardize their approach for
handoff communications or risk losing their accreditations. Without
accreditation, hospitals can find it harder to get reimbursed by Medicare and
private insurers.
Founded in 1852, the Great Ormond Street Hospital was one of the first
children's hospitals in the English-speaking world. In 1929, J.M. Barrie gave
the hospital full copyright and royalties of his children's classic, Peter Pan.
The facility treats 100,000 children each year and is known for its expertise in
infant heart surgery, a field where a lot can go wrong. Two decades ago, a lot
did go wrong.
Between 1987 and 1993, surgeon Marc de Leval performed 104 "arterial switches"
at Great Ormond Street Hospital. The operation corrects a congenital heart
defect and is often done within the first two weeks of a newborn's life. At one
stage, seven of Dr. de Leval's patients died in quick succession. Horrified, he
decided to retrain at another institution before returning to Great Ormond
Street Hospital. He didn't have such an alarming run of failures again.
Soon after, in 1994, Dr. de Leval published an unusually forthright paper about
what had gone wrong. His key insight was that the infant deaths couldn't
entirely be explained by the riskiness of the procedure or blatant failures such
as a machine breaking down. Instead, he pointed to general "suboptimal
performance" by himself and his team.
Dr. de Leval then persuaded 21 surgeons across Britain to allow "human-factor"
specialists to observe their arterial-switch operations. The specialists use
scientific techniques to study how people interact in a particular environment,
including areas where technology is heavily used.
Unexpected Finding
The study found, not surprisingly, that big mistakes can lead to bad outcomes.
Its unexpected finding was about small mistakes: The study revealed that they
often went unnoticed and unrectified. What's more, "if you added them up they
correlated strongly" with bad outcomes, says Dr. de Leval.
The paper caused a stir when it appeared in the Journal of Thoracic and
Cardiovascular Surgery, in 2000. At Great Ormond Street Hospital, it prompted
doctors to take a harder look at how their teams were working together and
transferring patients. "Our handovers were haphazard," says Dr. Goldman, the
pediatric ICU chief.
Sometimes a patient, still in a precarious condition after an operation, was
moved before the ventilator in the ICU had been properly set up. Or a key
component of the blood-pressure monitor went missing and a nurse had to scramble
to find it -- a loss of valuable minutes.
One Sunday in 2003, after a particularly tough day in the operating theater, Dr.
Goldman and surgeon Martin Elliot slumped before a TV set and watched a Formula
One race unfold. Both were racing fans, and they noticed striking similarities
between patient handovers at their hospital and the interchange of tasks at a
racing pit stop. But while a 20-member crew could switch a car's tires, adjust
its front wing, clean the air vents and send the car roaring off in seven
seconds, hospital handovers seemed downright clunky by comparison.
The duo invited members of McLaren, a British team that fields race cars in
Formula One contests, to provide insights into pit-stop maneuvers. Armed with
videos and slides, the racing team described how they used a human-factors
expert to study the way their pit crews performed. They also explained how their
system for recording errors stressed the small ones that might go unnoticed, not
the big ones that everyone knew about.
That point struck a chord with Dr. de Leval. He immediately saw that pit-stop
handovers were successful precisely because of an obsession with tiny mistakes,
a conclusion similar to the one he had reached in his 2000 paper about
arterial-switch operations.
Dr. de Leval then hired Ken Catchpole, a human-factors expert, to do a more
detailed study of patient safety in the hospital's cardiac-surgery unit. The
hospital also got in touch with Ferrari, which invited a team of doctors from
the hospital to attend practice sessions at the British Grand Prix in order to
get a closer look at pit stops. The Ferrari Formula One team is operated by the
same company, Ferrari SpA, that makes sports cars for the general public.
There were skeptics. "I did think that the whole idea was a bit kooky," says Dr.
McEwan, the anesthesiologist.
In early 2005, Dr. Elliot, Dr. Goldman and Mr. Catchpole traveled to Ferrari's
headquarters in Maranello, Italy, and sat down with Nigel Stepney, the racing
team's technical director. As a test car roared around a nearby track, the
visitors played a video of a hospital handover and described the process in
pictures.
The Ferrari man wasn't impressed. "In fact, he was amazed" at how clumsy and
informal the hospital handover process appeared to be, recalls Mr. Catchpole,
now a researcher at Oxford University.
In that meeting, Mr. Stepney described how each member of the Ferrari crew is
required to do a specific job, in a specific sequence, and usually in silence.
By contrast, he noted, the hospital handover was often chaotic. Several
conversations between nurses and doctors went on at once. Meanwhile, different
members of the team disconnected or reconnected equipment to a patient, but in
no particular order.
In a Formula One race, the "lollipop man" with a paddle ushers the car in and
signals the driver when it's safe to go. But in the hospital setting, it wasn't
always clear who was in charge. Though the anesthesiologist had nominal
responsibility to take the lead during a handover, sometimes the surgeon assumed
that role -- or no one at all.
The crew at Ferrari trained for the worst contingencies. "If Michael Schumacher
comes in five laps early because it's raining and he wants wet-weather tires,
they're prepared," says Mr. Catchpole, referring to the Ferrari driver and
seven-time world champion, who recently retired. The hospital team dealt with
problems as they came up.
Back in London, Dr. Goldman and his colleagues began to incorporate Ferrari's
lessons, along with advice from two jumbo-jet pilots, into the hospital handover
process. They wrote up a seven-page protocol describing every step in the
procedure. Between December 2003 and December 2005, they also did a careful
study to see if those changes made any real difference to patient safety.
Dr. Goldman and his colleagues recently submitted a paper to a peer-reviewed
journal that describes 50 patient handovers at Great Ormond Street Hospital over
that two-year period. The study looked at 23 handovers before the
Ferrari-inspired changes were put in place, and 27 after.
Errors Fall
After the changes, the average number of technical errors per handover fell 42%
and "information handover omissions" fell 49%. It also took slightly less time
to execute each handover, though, unlike the Ferrari team, the doctors weren't
trying to speed up their process. The study didn't attempt to measure whether
the changes reduced deaths.
Not everything has gone smoothly. Mr. Catchpole says that some cardiac doctors
at Great Ormond Street Hospital chose not to adopt the new handover process,
arguing that there was nothing wrong with the old method.
At one point, Drs. Goldman and Elliot considered having their surgical team
stand in prearranged places around the patient, just as Ferrari organizes
technicians around a pit stop. "But I thought it was a step too far," says Dr.
McEwan. The idea was dropped.
Nonetheless, cardiac-surgery handovers at the hospital are now systematic. One
recent afternoon, three-year-old Faizaan Hussain lay sedated on an operating
table, his chest open and his tiny heart pumping solidly. The six-hour operation
to save his life was coming to a close.
Faizaan suffered from tetralogy of Fallot, a congenital condition that includes
a hole in the heart and thickened heart muscle that reduces the normal flow of
blood. Such infants are often blue. Each year in the U.S., about 3,000 babies
are born with the condition. If untreated, about 25% of patients die within the
first year of life and about 40% by age 10.
As a pair of surgeons closed the boy's chest, Dr. McEwan took the lead role in
preparing for the handover, mimicking the job done by Ferrari's lollipop man.
Dr. McEwan dispatched a member of the team to the ICU with a document describing
the state of the patient and what equipment was needed at the ICU end -- a
contingency-planning idea learned from the Italian racing team. The patient was
then moved from the operating table to a mobile bed. Dr. McEwan and his
colleagues systematically disconnected a mess of tubes and wires from a large
refrigerator-size unit in the operating room and replugged them into smaller
devices on the mobile bed.
"We call it the spaghetti effect," said Dr. McEwan, as he untangled a pair of
tubes draining blood and fluid from the boy's chest. Other wires led to monitors
measuring the boy's blood pressure, heart rate, oxygen saturation level,
temperature and respiration. The process lasted several minutes; it was
completed in near silence.
At the ICU, where a new group of doctors and nurses awaited the patient, the
surgical team went through a three-step procedure to complete the handover.
First, key instruments were replugged into the ICU's wall units. Dr. McEwan
noticed that the boy's blood pressure had jumped, so he asked a nurse to
increase the anesthetic.
Because of the efficient transfer, "we could pick that up immediately instead of
10 minutes later," said Dr. McEwan.
Next, the anesthesiologist went through a two-page handover checklist, including
the patient's name, age, weight and medical history. "Before he came to us, he
was very blue," he said. When a pair of doctors at the back of the room started
up a conversation, Dr. McEwan shushed them.
The senior ICU doctor listened carefully, while an ICU nurse wrote down
everything. Finally, a surgeon described the operation. Only 15 minutes had
elapsed since Faizaan was wheeled in. Even so, the new ICU team now knew almost
as much about the boy's medical condition as did the surgeons, who had been with
him for six hours. The surgical team's work was done.
Faizaan made a quick recovery and, less than a week later, his parents took him
home
A Hospital Races To Learn Lessons Of Ferrari Pit Stop
Auto Crew Teaches Surgeons Small Errors Can Add Up On the Track, or in the ICU
WALL ST. JOURNAL November 14, 2006
LONDON -- After surgeons completed a six-hour operation to fix the hole in a
boy's heart, Angus McEwan supervised one of the more dangerous phases of the
procedure: transferring the fragile three-year-old from surgery to the intensive
care unit.
Thousands of such "handoffs" occur in hospitals every day, and devastating
mistakes can happen during them. This one went off without a hitch, thanks to
pit-stop techniques of the Ferrari race-car team.
"It was smooth. We didn't miss anything," said Dr. McEwan, a senior
anesthesiologist at Great Ormond Street Hospital for Children. His role as
leader of the handoff was partly modeled after Ferrari's "lollipop man," who
uses a large paddle to direct drivers to the pit.
In one of the more unlikely collaborations of modern medicine, Britain's largest
children's hospital has revamped its patient handoff techniques by copying the
choreographed pit stops of Italy's Formula One Ferrari racing team. The hospital
project has been in place for two years and has already helped reduce the number
of mishaps.
The challenge of moving a patient to another unit, or to a new team during a
shift change, is an old one. In 1995, one man in Florida had the wrong leg
amputated after a flubbed handoff. "If you transfer a patient to the ICU after
surgery and the ventilator isn't ready, you're really riding on the edge" of
patient safety, says Allan Goldman, head of the pediatric intensive care unit at
Great Ormond Street Hospital and a chief architect of the hospital's
collaboration with Ferrari.
A 2005 study found that nearly 70% of preventable hospital mishaps occurred
because of communication problems, and other studies have shown that at least
half of such breakdowns occur during handoffs.
American hospitals are starting to improve the way they transfer patients. As in
Britain, they are borrowing ideas from fields more skilled in the art of
high-risk handoffs, including aviation, spaceflight and the military. Last week
the Royal College of Surgeons of England and Dr. Goldman's hospital held an
international conference on the subject. One of the speakers was a British
submarine commander who spoke about lessons from the Kursk, the Russian
submarine that sank in 2000.
Kaiser Permanente of California, a health system with 37 medical centers and 8.6
million members, has a handoff method based on a change-of-command system
developed for nuclear submarines. At Trinity Medical Center in Rock Island,
Ill., nurses and doctors actually "pass the baton": They place documents with
key patient information inside a plastic baton and pass it on during a patient
handoff.
A facility in St. Joseph's Health System in Orange, Calif., uses a method it
calls "Ticket to Ride" -- a series of questions about the patient's medications,
infections and other medical issues, that have to be asked of a person
transferring the patient between departments. Blount Memorial Hospital in
Maryville, Tenn., encourages its staff to "Just Go NUTS," an acronym for a
four-step handoff routine it recommends (Name, Unique issues, Tubes, Safety).
Recent trends have increased the risk during handoffs. A nurse shortage means
more hospitals are hiring temporary staff. Because of new rules, medical interns
are also working fewer hours, which makes shift changes -- and therefore
handoffs -- more frequent. At the same time, some surgeons work in larger teams
and connect patients to an ever-growing tangle of wires and tubes.
Earlier this year, the Joint Commission on Accreditation of Healthcare
Organizations began requiring U.S. hospitals to standardize their approach for
handoff communications or risk losing their accreditations. Without
accreditation, hospitals can find it harder to get reimbursed by Medicare and
private insurers.
Founded in 1852, the Great Ormond Street Hospital was one of the first
children's hospitals in the English-speaking world. In 1929, J.M. Barrie gave
the hospital full copyright and royalties of his children's classic, Peter Pan.
The facility treats 100,000 children each year and is known for its expertise in
infant heart surgery, a field where a lot can go wrong. Two decades ago, a lot
did go wrong.
Between 1987 and 1993, surgeon Marc de Leval performed 104 "arterial switches"
at Great Ormond Street Hospital. The operation corrects a congenital heart
defect and is often done within the first two weeks of a newborn's life. At one
stage, seven of Dr. de Leval's patients died in quick succession. Horrified, he
decided to retrain at another institution before returning to Great Ormond
Street Hospital. He didn't have such an alarming run of failures again.
Soon after, in 1994, Dr. de Leval published an unusually forthright paper about
what had gone wrong. His key insight was that the infant deaths couldn't
entirely be explained by the riskiness of the procedure or blatant failures such
as a machine breaking down. Instead, he pointed to general "suboptimal
performance" by himself and his team.
Dr. de Leval then persuaded 21 surgeons across Britain to allow "human-factor"
specialists to observe their arterial-switch operations. The specialists use
scientific techniques to study how people interact in a particular environment,
including areas where technology is heavily used.
Unexpected Finding
The study found, not surprisingly, that big mistakes can lead to bad outcomes.
Its unexpected finding was about small mistakes: The study revealed that they
often went unnoticed and unrectified. What's more, "if you added them up they
correlated strongly" with bad outcomes, says Dr. de Leval.
The paper caused a stir when it appeared in the Journal of Thoracic and
Cardiovascular Surgery, in 2000. At Great Ormond Street Hospital, it prompted
doctors to take a harder look at how their teams were working together and
transferring patients. "Our handovers were haphazard," says Dr. Goldman, the
pediatric ICU chief.
Sometimes a patient, still in a precarious condition after an operation, was
moved before the ventilator in the ICU had been properly set up. Or a key
component of the blood-pressure monitor went missing and a nurse had to scramble
to find it -- a loss of valuable minutes.
One Sunday in 2003, after a particularly tough day in the operating theater, Dr.
Goldman and surgeon Martin Elliot slumped before a TV set and watched a Formula
One race unfold. Both were racing fans, and they noticed striking similarities
between patient handovers at their hospital and the interchange of tasks at a
racing pit stop. But while a 20-member crew could switch a car's tires, adjust
its front wing, clean the air vents and send the car roaring off in seven
seconds, hospital handovers seemed downright clunky by comparison.
The duo invited members of McLaren, a British team that fields race cars in
Formula One contests, to provide insights into pit-stop maneuvers. Armed with
videos and slides, the racing team described how they used a human-factors
expert to study the way their pit crews performed. They also explained how their
system for recording errors stressed the small ones that might go unnoticed, not
the big ones that everyone knew about.
That point struck a chord with Dr. de Leval. He immediately saw that pit-stop
handovers were successful precisely because of an obsession with tiny mistakes,
a conclusion similar to the one he had reached in his 2000 paper about
arterial-switch operations.
Dr. de Leval then hired Ken Catchpole, a human-factors expert, to do a more
detailed study of patient safety in the hospital's cardiac-surgery unit. The
hospital also got in touch with Ferrari, which invited a team of doctors from
the hospital to attend practice sessions at the British Grand Prix in order to
get a closer look at pit stops. The Ferrari Formula One team is operated by the
same company, Ferrari SpA, that makes sports cars for the general public.
There were skeptics. "I did think that the whole idea was a bit kooky," says Dr.
McEwan, the anesthesiologist.
In early 2005, Dr. Elliot, Dr. Goldman and Mr. Catchpole traveled to Ferrari's
headquarters in Maranello, Italy, and sat down with Nigel Stepney, the racing
team's technical director. As a test car roared around a nearby track, the
visitors played a video of a hospital handover and described the process in
pictures.
The Ferrari man wasn't impressed. "In fact, he was amazed" at how clumsy and
informal the hospital handover process appeared to be, recalls Mr. Catchpole,
now a researcher at Oxford University.
In that meeting, Mr. Stepney described how each member of the Ferrari crew is
required to do a specific job, in a specific sequence, and usually in silence.
By contrast, he noted, the hospital handover was often chaotic. Several
conversations between nurses and doctors went on at once. Meanwhile, different
members of the team disconnected or reconnected equipment to a patient, but in
no particular order.
In a Formula One race, the "lollipop man" with a paddle ushers the car in and
signals the driver when it's safe to go. But in the hospital setting, it wasn't
always clear who was in charge. Though the anesthesiologist had nominal
responsibility to take the lead during a handover, sometimes the surgeon assumed
that role -- or no one at all.
The crew at Ferrari trained for the worst contingencies. "If Michael Schumacher
comes in five laps early because it's raining and he wants wet-weather tires,
they're prepared," says Mr. Catchpole, referring to the Ferrari driver and
seven-time world champion, who recently retired. The hospital team dealt with
problems as they came up.
Back in London, Dr. Goldman and his colleagues began to incorporate Ferrari's
lessons, along with advice from two jumbo-jet pilots, into the hospital handover
process. They wrote up a seven-page protocol describing every step in the
procedure. Between December 2003 and December 2005, they also did a careful
study to see if those changes made any real difference to patient safety.
Dr. Goldman and his colleagues recently submitted a paper to a peer-reviewed
journal that describes 50 patient handovers at Great Ormond Street Hospital over
that two-year period. The study looked at 23 handovers before the
Ferrari-inspired changes were put in place, and 27 after.
Errors Fall
After the changes, the average number of technical errors per handover fell 42%
and "information handover omissions" fell 49%. It also took slightly less time
to execute each handover, though, unlike the Ferrari team, the doctors weren't
trying to speed up their process. The study didn't attempt to measure whether
the changes reduced deaths.
Not everything has gone smoothly. Mr. Catchpole says that some cardiac doctors
at Great Ormond Street Hospital chose not to adopt the new handover process,
arguing that there was nothing wrong with the old method.
At one point, Drs. Goldman and Elliot considered having their surgical team
stand in prearranged places around the patient, just as Ferrari organizes
technicians around a pit stop. "But I thought it was a step too far," says Dr.
McEwan. The idea was dropped.
Nonetheless, cardiac-surgery handovers at the hospital are now systematic. One
recent afternoon, three-year-old Faizaan Hussain lay sedated on an operating
table, his chest open and his tiny heart pumping solidly. The six-hour operation
to save his life was coming to a close.
Faizaan suffered from tetralogy of Fallot, a congenital condition that includes
a hole in the heart and thickened heart muscle that reduces the normal flow of
blood. Such infants are often blue. Each year in the U.S., about 3,000 babies
are born with the condition. If untreated, about 25% of patients die within the
first year of life and about 40% by age 10.
As a pair of surgeons closed the boy's chest, Dr. McEwan took the lead role in
preparing for the handover, mimicking the job done by Ferrari's lollipop man.
Dr. McEwan dispatched a member of the team to the ICU with a document describing
the state of the patient and what equipment was needed at the ICU end -- a
contingency-planning idea learned from the Italian racing team. The patient was
then moved from the operating table to a mobile bed. Dr. McEwan and his
colleagues systematically disconnected a mess of tubes and wires from a large
refrigerator-size unit in the operating room and replugged them into smaller
devices on the mobile bed.
"We call it the spaghetti effect," said Dr. McEwan, as he untangled a pair of
tubes draining blood and fluid from the boy's chest. Other wires led to monitors
measuring the boy's blood pressure, heart rate, oxygen saturation level,
temperature and respiration. The process lasted several minutes; it was
completed in near silence.
At the ICU, where a new group of doctors and nurses awaited the patient, the
surgical team went through a three-step procedure to complete the handover.
First, key instruments were replugged into the ICU's wall units. Dr. McEwan
noticed that the boy's blood pressure had jumped, so he asked a nurse to
increase the anesthetic.
Because of the efficient transfer, "we could pick that up immediately instead of
10 minutes later," said Dr. McEwan.
Next, the anesthesiologist went through a two-page handover checklist, including
the patient's name, age, weight and medical history. "Before he came to us, he
was very blue," he said. When a pair of doctors at the back of the room started
up a conversation, Dr. McEwan shushed them.
The senior ICU doctor listened carefully, while an ICU nurse wrote down
everything. Finally, a surgeon described the operation. Only 15 minutes had
elapsed since Faizaan was wheeled in. Even so, the new ICU team now knew almost
as much about the boy's medical condition as did the surgeons, who had been with
him for six hours. The surgical team's work was done.
Faizaan made a quick recovery and, less than a week later, his parents took him
home
