‘Email Huddle’ Prior to Surgery Improves Efficiency

Deployment of a preoperative huddle email improved in-room time and overall team satisfaction in elective cardiac operations, new study results indicate.

Cardiothoracic surgery workflow rarely goes as planned, according to Zachary Tyerman, a post doctoral fellow at the University of Virginia in Charlottesville, who presented his team’s results at the 65th Annual Meeting & Exhibition of the Southern Thoracic Surgical Association. Any number of variables—pages during rounds, an upset attending physician, urgent and emergent cases, and delayed/missing equipment—could all interrupt the chain of events. According to Tyerman, late starts are very common; previous studies have shown, that 96% of OR procedures start late and that this can be costly on two fronts: and associated increase in mortality and morbidity, and increased costs in the operating room (OR) of about $37 per minute. Regarding elective cases, late starts could decrease patient satisfaction and OR employee morale.

To solve this common problem, Tyerman and his colleagues tested the efficacy of the preoperative “Huddle” email. The Huddle email is composed on the eve of surgery by the cardiothoracic surgery fellow, who distributes the message to all staff members involved in patient care, including the OR nurse, anesthesiologist, and ICU staff. Generally, a Huddle email includes the patient’s name, patient history, the operative plan, any potential paperwork considerations, bypass plan, imaging equipment, dressings, and any allergies.

Researchers stratified 1,165 first start, elective, cardiac surgery (CABG and/or valve) by Pre-Huddle era (July 2012-June 2016) and Huddle era (July 2015-June 2017), as well as preoperative risk (PROMM), the abstract stated. They only included open cases; LVAD, TAVR, and emergent procedures were not included. The Wilcoxon rank-sum test was used to evaluate differences between scheduled start to in-room time, in-room to incision time, and total OR minutes. Tyerman’s team defined “delay time” as the time in between “scheduled in room” and “actual in room”; zero minutes was considered on time, and anything longer than 15 minutes was considered a long delay. Time to incision was the time spent in the OR until incision. OR minutes utilized was defined as the actual in room time until the patient is out of the room.

According to the abstract, there were 688 Pre-Huddle and 497 Huddle cases available for analysis. PROMM was not significantly different between the groups (PROMM: Pre-Huddle 14.7% [IQR:8.9-26.1] vs. Huddle 15.3% [IQR:9.7-23.2], P = 0.4205). During the Huddle era, OR arrival was three minutes earlier (Huddle 6 min delay [IQR: 2-11] vs. Pre-Huddle 9 min delayed [IQR: 4-15], P < 0.0001). Time to incision was longer in the Huddle group (Pre-Huddle 70 min [IQR:62-80] vs. Huddle 72 min [IQR:66-82], P = 0.0002), as was OR minutes utilized (Pre-Huddle 367 min [IQR: 318-426] vs. Huddle 391 min [IQR: 347- 439], P < 0.0001). Researchers attributed this difference to an increase in less experienced trainees performing components of the operation.

During discussion, Tyerman noted that the surgery teams did not know they were being timed for this reason, since the data were collected retrospectively, so this would not have impacted results.

“We found that urgent cases, on average, were worth about 10 minutes of delay time,” Tyerman said. “The only thing that was protective against delays was the primary surgeon’s years of experience.”

The study authors concluded that increased case complexity was associated with long delays and delay time.

“Trough the implementation of a relatively, simple, straightforward, and inexpensive intervention, we saw improvement in OR entry times, a 48% increase in our OR on time starts, as well as a 26% decrease in long delays,” Tyerman said. “Given the fact that this intervention is relatively easy and non-costly, we recommend that all surgery centers consider something like the preoperative huddle email.”