#TheatreCapChallenge - where's the evidence?

TheatreCapChallenge - where's the evidence?

We’ve put some quick links together at the start of this post:

General communication errors

70% of adverse events related to communication errors 

Communication failures in 30% of theatre team exchanges, 1/3 of which lead to inefficiency and increased tension 

Staff misidentification 

Numerous cases of adversity including death from wrong blood transfusion.

4 out of 5 female doctors report being misidentified

Increased staff engagement through knowing names

Cocktail party effect 

Hearing one’s own name has unique brain functioning activation

A person’s name, to that person, is the sweetest and most important sound in any language.

Staff poor at introductions

How good are doctors at introducing themselves? 

Poor compliance with name and role introduction part of Surgical safety checklist 

Only a small fraction of patients could successfully identify at least 1 physician or trainee on their inpatient team in charge of their hospital care.

Difficulty for staff to recall names

Even when not distracted humans only remember 30% of names after first introduction then we readily forget them 

Social stress-induced cortisol elevation acutely impairs social memory in humans.

Humans poor at remembering names good at remembering faces

Surgeons only knew 44% of names 

Even after time out introductions performed 25% of surgeons did not know the scrub nurses name and 30% of surgeons did not know the anaesthetists name

Number of different combinations of team coming together to manage an obstetric emergency 381 million

BJA – name recall worst in Emergency theatres 

Studies indicating benefit in using names for communication

Knowing and recognising team members by name has been quantitatively and qualitatively associated with increased trust, work engagement and clinical improvement. 

Studies have shown that knowing the names of other team members greatly improves prevention of adverse outcomes.

Only 32% of communications during paediatric resuscitation were directed (ie at a named individual). This significantly inhibits the performance of closed loop communication. Orders completed using closed loop communication were performed 3.6 times sooner than those completed using open loop communication.

Supportive policy

Garling Enquiry 2008 – all healthcare staff should wear badges or similar bearing in large print the person’s name and title or role. 

NSW Policy 2008 – Nurse in charge will ensure all staff are easily identifiable 

Why use a theatre cap and not just use a badge, lanyard, whiteboard?

Despite policies staff displaying their name and role in theatre is not common

What’s in a name – Fantastic presentation by Dr Rhys Thomas – Quality & Safety Fellow John Hunter Hospital. He discusses how name badges on tops in theatre are often covered up by sterile, lead or warming gowns, how writing names on a whiteboard is often ineffectual and much more.

Survey data

#TheatreCapChallenge led to increased name & role introductions from 38 to 90%, increased name recall from 42 to 85% and increased propensity to speak up from 45 to 85%.

Overwhelming support from staff  – Imperial College London 

Overwhelming support from patients – Queen Elizabeth Hospital 

86.5% support on social media survey 

88% support on twitter poll 

80% agreed that names and roles on hats either did or could improve communication – Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust

Qualitative data suggests introductions help with identification of roles, improve morale and team performance  (and see here). However emerging data indicate these introductions have little impact on name recall amongst staff.

British Medical Journal – Name & Role Theatre Caps led to ‘statistically significant increase in OR staff knowledge of the anaesthesia resident’s name (66% vs 100%, p=<0.001), an increase in the mean number of times the surgical providers addressed the anaesthesia residents (3.6 vs 7.8, p=0.0074) and an increase in the mean number of times the surgical providers addressed them by their first name (0.7 vs 4, p=0.0067). Comments received during the intervention were positive with overwhelming support.’

Simulation data

Stanford University simulation – The response during this simulation was the most efficient and effective of any simulation we had ever run. In particular, we found communicating directly by first names enhanced the participant’s ability to have closed-loop communication.’ 

Awaiting publication of data from Marlies Schivjen – Professor of Surgery, Amsterdam 

Grant from ACI – working group progressing on obtaining outline & data

Support from associations

Endorsed by Australian Society of Anaesthetists 

Endorsed by American Association of Surgical Physician Assistants 

Australia and New Zealand College of Anaesthetists Bulletin 

Support from the European Society of Anaesthesiology and the American Society of Anesthetisology 

Chris Pointon #hellomynameis 

where's the evidence

Infection Control

Haskins IN, et al. Hernia. 2017.‘There is no association between the type of surgical hat worn and the incidence of postoperative wound events.’

Hussain S, et al. Neurosurgery, Volume 82, Issue 4, 1 April 2018, Pages 548–554.‘Mandatory Change From Surgical Skull Caps to Bouffant Caps Among Operating Room Personnel Does Not Reduce Surgical Site Infections in Class I Surgical Cases.’

Markel T et al, Journal of the American College of Surgeons. October 2017. Volume 225, Issue 4, Supplement 2, Pages e29–e30‘When compared to cloth skull caps, disposable bouffants had greater permeability, greater particulate contamination, and greater passive microbial shed.’

Kothari SN, et al. Journal of the American College of Surgeons. 2018.‘Attending surgeon preference for bouffant vs skull cap does not significantly impact SSI rates after accounting for surgical procedure type.’

Elmously et al. Journal of the American College of Surgeons. 2018.Implementation of the AORN guidelines has not decreased SSIs and has increased healthcare costs.

Journal of Hospital Infection 2002 – There is no need for non scrubbed theatre staff to wear disposable headgear 

Policy review

Collaborative statement from AORN, ACS, ASA, APIC, AST and TJC – at present available scientific evidence does not demonstrate any association between the type of hat and SSI rates. 

ACORN standards reference Australian Standards which don’t actually relate to headwear. 

Excellent review of ACORN Standards as they relate to theatre caps by Dr Rhys Thomas 

Information for Trusts about TheatreCapChallenge hats – Draft policy presented to Royal College of Surgeons by Mrs Scarlett McNally

Environmental Benefit

20 theatre hospital discards approximately 100,000 disposable theatre hats every year. These hats are made from viscose – a substance whose production is particularly harmful to the environment: 

From ANZCA PS64 (Statement on Environmental Sustainability in Anaesthesia):Use of reusable surgical gowns, dedicated operating theatre footwear and freshly laundered lint free hats will reduce the amount of single use gowns, caps and overshoes that are discarded and add to waste.

Results showed that that the reusable scrubs have considerably lower environmental impact within the studied categories. The main reason for this is the longer lifespan of the reusable garments, which results in substantially decreased environmental impacts per use within all phases of the lifecycle except usage.

Financial benefit

‘I looked at the number of hats that were purchased over a 12 month period. This came to >93,000 hats per year at a cost of NZ$14,600 (AUD 13,410). We have 15 theatres and 430 staff members (includes all surgeons / anaesthetists and surg/anaes registrars).’ – Broadbent J.

Mainstream media support

BBC World News 4.2million likes 

Covered by mainstream media throughout the world 

If you would like to purchase name and role personalised TheatreCaps please check out our website TheatreCaps.com. All profits from the sale of our caps go towards supporting other patient safety initiatives.

where's the evidence?