Posts Tagged ‘Transfer’

Hearts in the fast lane!

September 17, 2010

Life in the fast lane

Surely make you lose your mind

Life in the fast lane

Everything, all the time!

Life in the Fast Lane, The Eagles (1977)

I found this information through Facebook friend Mary Ellen:

London’s Great Ormond Street Hospital (which has the unusual acronym GOSH) had a problem. One of the most critical times in heart surgery is the transfer – the process of moving a patient from the operating room to the recovery room. It is not a simple task of just moving the patient from the operating table to a gurney and rolling it down to the recovery unit; monitors have to be unplugged and reconnected to portable equipment, IV’s have to be prepared for transport, and any life support must be switched to portable units. It is a complicated, involved job that has to be done perfectly – the first time, and every time.

Patients weren’t doing so well, and some were running into real problems after surgery, so GOSH Surgeon Marc De Leval asked a group of “Human Factor Specialists” to study a series of Arterial Switch operations and try to determine what the problem was. The Arterial Switch is one of the more difficult Congenital Heart Surgeries and one that seemed to be causing more than its fair share of problems.

The evaluators determined that both the surgical unit and the recovery team was up to the task; the problem was based in the transfer. Too many things to do, too many things that could be missed, and it could be slow. But it had to be done slowly and carefully, because if you missed something, things could go very wrong for the patient. So even though they recognized the problem, the surgeons of GOSH seemed to be unable to do anything about it.

Until the day when a surgeon and the head of the Pediatric Intensive Care Unit were watching TV. What they needed, they realized, was a team approach – a group of people who could work together to get the job done correctly and the patient on their way to Recovery.

So they asked a Formula One race team for help.

Americans (especially those of us in the South) are more familiar with NASCAR racing. A Formula One pit crew is just as fast as their NASCAR counterparts – and considering that Formula One allows more people working on the car simultaneously, they are probably better.  So the race team came in, and spent some time with the hospital staff. The speedsters made many suggestions, and while not all of them could be implemented, several important ones were: One person was placed in charge of the transfer process and everyone involved was trained on their new task. Problems don’t just happen, they learned. A small error that slips by can turn into a larger problem, which can become an even larger problem. So if the small problems are eliminated, the larger problems should not occur.  They were also trained to have clear, concise plans on what to do if something went wrong. “Plan B” works best when everyone is familiar with what Plan B involves.

So far, the “Pit Stop” approach is working. GOSH reports medical errors that occur during the transfer period are down 30%!