The role of teamwork and non-technical skills for improving emergency surgical outcomes: an international perspective

The World Society of Emergency Surgery (WSES) was founded in 2007 with the mission of promoting research, education, clinical quality and patient safety, interdisciplinary networking, and ultimately the global advancement of emergency surgery [1]. The WSES held its 8^th International Conference at the historic McEwan Hall in Edinburgh, Scotland, on September 7–10, 2021. The congress was designed as a “hybrid” meeting with the options of in-person and virtual attendance. The congress was hosted by the University of Edinburgh and sponsored by the Royal College of Surgeons of Edinburgh (RCSEd). The challenges of organizing an international hybrid meeting during the resurgence of the COVID-19 pandemic cannot be understated. In spite of the logistic obstacles, the congress had a record number of submissions for both oral and poster presentations, attracting delegates from 42 countries from all continents. The local organizing committee had the pleasure of welcoming more than 100 delegates in person at the McEwan Hall. The Chair of Behavioural Sciences at the University of Edinburgh has been leading cutting-edge research in the field of non-technical skills, surgical sabermetrics, coaching, global surgery, and space medicine. Furthermore, the MSc in Patient Safety & Clinical Human Factors (www.​edinburghsurgery​online.​com/​courses), run in partnership with the RCSEd, further added to the distinguished expertise of the patient safety panel in attendance at WSES. This forum allowed for a unique opportunity of international experts to convene in a variety of panels that focused around human factors, non-technical skills, and other pertinent aspects related to surgical patient safety. This review article evolved from an expert panel discussion at the 8^th International WSES Congress in Edinburgh and was designed to provide an international consensus opinion on the role of team dynamics and non-technical skills in improving patient safety and patient outcomes in emergency surgery.

More than 200 million surgeries are performed worldwide each year [2]. Any patient admitted to a hospital to undergo a surgical procedure should rightfully expect to be better off after the intervention than before [3]. However, recent reports reveal that adverse event rates for surgical conditions remain unacceptably high, despite multiple nationwide and global patient safety initiatives over the past decade [4]. These include the “100,000 Lives Campaign” and ensuing “5 Million Lives Campaign” by the Institute for Healthcare Improvement, the “Surgical Care Improvement Project” (SCIP) and “Universal Protocol” implementation by the Joint Commission, and the WHO “Safe Surgery Saves Lives” campaign which rolled out the surgical safety checklist on a global scale [5, 6].

In spite of the multitude of patient safety initiatives designed to protect surgical patients, the current regulatory mandates and safety checklists continue to fall short of protecting surgical patients from suffering preventable harm [7]. Two recent studies from Colorado revealed that “never events” such as wrong-site and wrong-patient surgery continue to occur, albeit at a low incidence, in spite of the availability of modern surgical safety checklists [8, 9]. Contrary to other high-risk industries, patient safety in surgery has historically suffered from a lack of standardized protocols aimed at recognizing and preventing medical errors and surgical complications [10‐13]. Ironically, the high standard of regulatory compliance-mandated patient safety protocols in the United States originates from decades of work by lawyers, legislators, and patient advocacy groups, rather than from a physician-driven approach of owning patient safety as a surgical responsibility [4]. A study from the American College of Surgeons’ closed claims database revealed that most surgical complications which lead to malpractice claims do not originate from intraoperative technical errors, but rather from deficiencies in non-technical skills, such as communication breakdown [14]. The success of high-reliability organizations (HROs) is based on high-performing teams, standardized communication, and redundant fail-safe backup options which prevent an error from causing harm [15‐18].

The context of emergency and trauma surgery is complicated and characterized by high pressure, stress, and time restraints. Lack of knowledge about the trauma causes, the identity of the patients, and their existing circumstances or conditions can negatively affect surgical decision making, leading to less effective clinical choices. Moreover, the situation may not allow the engagement with the patients or their families in order to understand their treatment preferences or wishes. While shared decision making and co-production dynamics in a multistakeholder scenario stand today among the most relevant pillars of the patient-centric healthcare system, such processes may appear particularly challenging or even not be possible at all [19‐21]. Furthermore, time constraints may not allow consulting the clinical guidelines or conferring with specialists for second opinions. In such a scenario, non-technical or soft skills look as relevant as technical abilities, as they allow multidisciplinary team members to work together smoothly [22]. Ensuring surgical patients’ safety and satisfactory clinical outcomes is a priority in emergency surgery. Still, while the surgical community has employed several efforts on the technical side, innovating the surgical techniques and summarizing valuable clinical guidelines, a new approach should emerge. Therefore, as it happens in other fields (for example, sports), team performance and outcomes may also be increased leveraging on more intangible aspects, including non-technical skills and team assembly decisions [23].

Starting from this premise, the “Team Dynamics” initiative [24, 25], endorsed by the WSES, stood as a multidisciplinary research project to investigate the role of non-technical skills [26, 27], knowledge translation dynamics [28, 29], and ethics [30, 31] in emergency and trauma surgery teams. An online questionnaire following the CHERRIES checklist for online medical surveys was conducted from January to February 2021, gathering more than 400 fully-filled questionnaires (response rate > 45%) by surgeons from 72 countries [32]. Results underline the perceived importance of non-technical skills, especially leadership and teamwork. Still, just a few surgeons declare to engage with the patients in share-decision making processes actively. While clinical guidelines and training are widely used among the participants, only half of them report using online tools and electronic medical records. Regarding ethical matters, some interesting results arise. The project investigated the role of surgical consent as a tool to engage and talk to the patient about the clinical options, the possible outcomes, and the pros and cons of the treatment, the perceived importance of the team leader as an ethical leader, and the relevance of ethical training [31, 33]. Interesting enough, team members who declared to belong to a diverse group, meaning which members have different features (in terms of gender, age, education, nationality, values) paid the most significant attention to ethical-related matters.

Starting from the Team Dynamics initiative, some takeaways emerge. Two relevant topics, namely the importance of shared-decision making and the adoption of advanced technological tools to empower surgical decision-making, should be on the agenda of the scientific societies to support the surgical community in ensuring the best possible outcomes for their patients [34]. Moreover, diversity in teams may boost the sensitiveness towards patients’ engagement and shared decision making. Therefore, team assembly decisions may represent a valuable strategy to be pursued by those institutions more engaged towards a patient-centric philosophy.

The teaching of non-technical skills for medical students and trainees remains a challenge on a global scale. The total number and distribution of medical schools worldwide is not matched with existing physician numbers and distribution. India, Brazil, USA, and China, make up more than one-third of the world’s total number of medical schools [61]. In many countries, only a few selected medical schools have disciplines directed to trauma care and EGS [62]. The simulation assumes growing importance in the field of medical education. Many medical schools work with simulators or even have their own simulation center. Classic emergency training at the hospital or in classrooms are increasingly being replaced by simulation case scenarios. There are many challenges in undergraduate medical education: the need for adjustability and repeatability, high risk of adverse events, limited student’s experience, and students’ fear of the patient. Medical simulation is an effective method of practical education: standardized, objective, adjustable, repeatable, safe, and attractive for the students, avoiding risks to patients and learners. Critical life skills can be controlled and adjusted during simulation scenarios, such as: leadership, collaboration, organization, critical thinking, problem-solving skills, independent learning skills, empathy, tolerance, communication skills, teamwork, and accountability [63, 64]. It is essential to work with NTS concepts with the medical students since the beginning of the course. In the experience at the University of Campinas in Brazil, the skills of medical students have been improved by moving from a predominantly theoretical to a more practical basic life support course (BLS), which included activities on which students were assessed on their ability to teach the principles of BLS to laypeople in the community. Assessing students on their ability to teach improves communication and team work, and can enhance both learning and medical school social accountability [65, 66]. As an extracurricular activity, the medical students in the second year can apply to join the Trauma League, in which they gather with a supervising faculty physician, with the intent to improve their knowledge in the areas of surgery and emergency care; have early contact with environments such as the emergency room, and operating room; observe the surgeons at work (apprenticeship); develop research; organize meetings (regional and national), and work with trauma prevention. It was observed in Brazil the capacity of the Trauma Leagues to bring the students to their actions could be a way to attract new general surgeons and expose them to NTS [67].

The “European Trauma Course” (ETC) brings together different specialists like surgeons, emergency physicians, anaesthetists, intensivists, and others engaged in the initial evaluation of major trauma patients to learn and teach together as a team, including the technical and non-technical skills [68]. The ETC was launched in 2008 during an international conference of the European Resuscitation Council (ERC), composed of members of the European Society of Trauma and Emergency Surgery (ESTES), the European Society of Emergency Medicine (EuSEM), and the European Society of Anaesthesiology (ESA). The ETC course runs over 2.5 days and is predominantly practical based learning assessed on technical, non-technical skills, and team leadership, provided in more than 20 countries around the world [69, 70]. The “Non-Technical Skills for Surgeons” (NOTSS) course has been running for more than a decade in many countries, raising the awareness of the importance of communication in surgical teams, as outlined in detail above.

The adherence to evidence-based practice protocols and patient safety checklists represents a global trend in EGS [47]. The 19-item WHO “Surgical Safety Checklist” has been implemented worldwide in the past decade and resulted in significant reduction of perioperative morbidity and mortality [6]. However, there remains a wide variability in compliance and adherence to established evidence-based safety checklists [8]. Surgeon ownership and leadership will be required to consistently eradicate preventable complications and adverse events in EGS. The knowledge and proficiency in mastering non-technical skills and endorsing shared decision-making with patients, in conjunction with teaching these non-technical humanistic traits to the next generation of surgeons will hopefully help improve surgical patient outcomes with consistency on a global scale.