Teamwork in Airway Surgery

Abstract

The twentieth century saw the gradual disappearance of the heroic individual doctor and the emergence of specialities with distinct governance structures through colleges and societies. These defined training and issued qualifications. In our world, cardiothoracic surgery split from general surgery, pediatric surgery from general surgery and ear, nose and throat surgery emerged in parallel. The separation produced rapid advances in each field but, as an unexpected consequence, the disciplines grew apart, developing their own ways of working and their own tribal cultures. Our patients (and their conditions) did not recognize this, and they would find that the way in which their disease was treated varied widely–defined largely by the speciality with which they first came into contact. The management of complex airway disease in children exemplifies these problems, but also offers a solution. In the late twentieth century, patients were referred to individual surgeons who applied the skills of their own discipline to varying, but imperfect effect. Inter-discipline referral was rare, and sometimes difficult because the geographic location of services had become separated to different hospital sites in previous years. Sadly, and as we all now know, affected children often had problems which crossed the constrained boundaries which we physicians had drawn up. Tracheal stenosis is often combined with cardiovascular anomalies and genetic abnormalities are frequent. Upper gastro-intestinal tract issues including swallowing problems abound. Patients attending one speciality were referred to another for consultation on a transactional basis. Indeed, in dominantly private healthcare systems, this remains the case, as it can increase incomes to all parties. This slows decision making, fails to integrate views effectively and weights decision making in favor of the physician to whom primary referral is made. Our primary aim as physicians is “first, do no harm.” As Hull and Sevdalis pithily stated (1) “Teams create safety,” and as we hope to outline in this paper, teamwork also improve outcomes, creates efficiency, reduces cost and promotes research. Achieving these goals is good for patients and for the wider healthcare system. In the United Kingdom in the 1980s and 90s, referrals for small children with long segment congenital airway stenosis (LSCTS) passed through a series of gateways to pediatric or cardiac intensive care units, largely because of the resuscitative skills held by the staff there. Surgery tended to default to cardiac surgical teams because of the high incidence of associated cardiovascular anomalies and the need for cardiopulmonary bypass for repair. The incidence is low, and so each center saw a tiny number of patients, and experience was hard to acquire. There were only a few short case series in the literature upon which to base treatment choices, and few contained sufficient detail to be confident about all the relevant technical details and none had any long-term data. Several techniques had been described for repair, but patch tracheoplasty dominated, and mortality rates were high. At that time, relevant skills were distributed in such a way that individuals had to be consulted to manage specific problems. For example, endoscopic examination of the airway was largely done by ear, nose and throat (ENT) surgeons, cardiologists helped diagnose and manage cardiac issues, and the surgical reparative skills crossed boundaries. Intensive care was mandatory, but often seen as a “service” to other teams, and nursing was undervalued. Interventional radiology was embryonic, but increasingly seen to be relevant, and palliative care was only a consultative service. The interfaces between services were relatively formal; a consultative interface. As Reason pointed out many years ago (2), it is the interfaces which go wrong and lead to error because of failures in communication. Each discipline approached problems in its own way according to its own (often limited) experience. Those of us involved in the care of these children decided that this was not good enough and everyone involved met in 2000 to work out how we might better deal with complex airway cases. It was the birth of the GOSH¹ Tracheal Team, and a fantastic meeting of minds. Several key decisions were made; • The team should comprise all those coming into contact with such patients on a regular basis. Namely, but in no specific order of importance, cardiothoracic surgeons, ENT surgeons, interventional radiologists, specialist and intensive care unit (ICU) nurses, intensivists, respiratory physicians, pediatric general surgeons, anesthetists, diagnostic radiologists, speech therapists, physiotherapists, administrative staff, data managers, radiographers, cardiologists, and interested researchers and junior staff in training. • A leadership structure was created. • ALL referrals with complex airway problems would be reviewed by the Tracheal Team at a weekly multi-disciplinary team meeting (MDT). • ALL relevant decisions about both individual patient care and overall strategy would be taken at the MDT, recorded and stored in a database. • LSCTS would be treated by slide tracheoplasty on cardiopulmonary bypass or extracorporeal membrane oxygenation (ECMO), and where possible, cardiac lesions would be repaired at the same time. • The team should learn to cross-skill to avoid delays to patient care. Specifically, this related to skills in fibreoptic bronchoscopy and balloon dilatation. • All outcomes would be published, and attempts would be made over time to centralize care in the UK if results justified it. • Links would be created with other interested specialists throughout the world. Within just a few years we...