Improving the emergency prompt-card process in operating theatres

Our Human Factors and Team Resource Management Programme (known as SCReaM), developed and implemented the UK's first set of emergency prompt cards in operating theatres [1] Due to team leaders' anticipated perceptual blindness to the cards, often encountered during high cognitive loading, a Reader of the Cards (ROC) role within the operating team was introduced The ROC's role is to get the cards from the wall and bring them to the team's attention;however, anecdotal reports suggest that the prompt cards are not always used when emergencies present themselves A quality-improvement (QI) project was therefore undertaken to identify the reasons behind this and to try to implement changes to improve the frequency of their use Methods A fishbone root cause analysis using the 'five whys' approach was undertaken to identify reasons why the cards were not being used This was carried out via one-to-one interviews and focus groups In addition, observations were carried out to capture baseline data to establish current practices The data highlighted that although the prompt cards were always present, there were limitations around the ROC role It seemed the name of the ROC was seldom allocated and the badge used to identify the ROC rarely worn As a result of the initial data gathering exercise, the QI project focussed on the role of the ROC, with the assumption that improving the ROC role would lead to the outcome measure of 'increased use of prompt cards' The process measures were the frequency with which the ROC was allocated and knowledge of the ROC role Results A number of interventions were proposed and prioritised using an action priority matrix (Fig 1) to determine a rough order in which they should be carried out: 'quick wins' were carried out first in order to realise benefit as quickly as possible and maintain momentum Consequently, the following interventions were made:-Amending the wording on the WHO checklist-Replacement ROC badge clips-Rename and re-launch of the ROC name: 'reminder', rather than 'reader' of the cards-Promoting awareness of the role of the ROC and prompt cards Initial findings suggest the ROC role is now more widely known by staff and the badge is being worn more Discussion Allocation and knowledge of the ROC role appears to be an important factor in increasing the use of the prompt cards A number of interventions have been identified Due to COVID-19, further data gathering and implementation are being resumed