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J Thorac Cardiovasc Surg 2010;139:312-319
© 2010 The American Association for Thoracic Surgery

Acquired Cardiovascular Disease

Is the "sterile cockpit" concept applicable to cardiovascular surgery critical intervals or critical events? The impact of protocol-driven communication during cardiopulmonary bypass

^a Mayo Clinic, Rochester, Minn
^b University of Aberdeen, Aberdeen, Scotland
^c University of Wisconsin–Madison, Madison, Wis

Read at the Thirty-fifth Annual Meeting of The Western Thoracic Surgical Association, Banff Springs, Alberta, Canada, June 24–27, 2009.

Received for publication June 29, 2009; revisions received October 4, 2009; accepted for publication October 25, 2009.

^_* Address for reprints: Thoralf M. Sundt III, MD, Division of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905. (Email: sundt.thoralf{at}mayo.edu).

Objective: There is general enthusiasm for applying strategies from aviation directly to medical care; the application of the "sterile cockpit" rule to surgery has accordingly been suggested. An implicit prerequisite to the evidence-based transfer of such a concept to the clinical domain, however, is definition of periods of high mental workload analogous to takeoff and landing. We measured cognitive demands among operating room staff, mapped critical events, and evaluated protocol-driven communication.

Methods: With the National Aeronautics and Space Administration Task Load Index and semistructured focus groups, we identified common critical stages of cardiac surgical cases. Intraoperative communication was assessed before (n = 18) and after (n = 16) introduction of a structured communication protocol.

Results: Cognitive workload measures demonstrated high temporal diversity among caregivers in various roles. Eight critical events during cardiopulmonary bypass were then defined. A structured, unambiguous verbal communication protocol for these events was then implemented. Observations of 18 cases before implementation including 29.6 hours of cardiopulmonary bypass with 632 total communication exchanges (average 35.1 exchanges/case) were compared with observations of 16 cases after implementation including 23.9 hours of cardiopulmonary bypass with 748 exchanges (average 46.8 exchanges/case, P = .06). Frequency of communication breakdowns per case decreased significantly after implementation (11.5 vs 7.3 breakdowns/case, P = .008).

Conclusions: Because of wide variations is cognitive workload among caregivers, effective communication can be structured around critical events rather than defined intervals analogous to the sterile cockpit, with reduction in communication breakdowns.

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