Maybe file this under: “Geez dude, everyone knows that” except for the fact that they don’t. How many foul shots do you have to shoot before you get good at foul shots? Ten? Ten thousand? Choose whatever analogy (sports or otherwise) that you prefer, but the relationship remains the same: with virtually no exceptions the more of something you do the better you get at it. This relationship has been shown to be especially true in orthopaedic surgery, both for surgeons and the teams supporting them. Recently, several researchers have focused on the impact that the operating room support team has on the work performed by the orthopaedic surgeon.
Xiao and his fellow researchers from Baylor University looked at two years of data regarding team consistency for surgeons performing at least 50 elective unilateral primary total hip and knee arthroplasties. If the scrub nurse / scrub tech and circulating nurse were among the top three most frequent folks to work with the surgeon, they were considered a consistent team. Using this definition, only 39% of the cases involved consistent teams. Inconsistent teams were an independent predictor of increased OR time, longer length of stay, and increased 30 day readmission rates.
Maruthappu and his coauthors from Harvard and Oxford looked at over ten years of total knee arthroplasty data with an eye for surgeon experience and first assistant familiarity. They referred to this as the attending–resident dyad. Not surprisingly, the more frequently that even this two member team worked together the better they got…
| Number of Collaborations | Average Operative Time |
| None | 121.9 min |
| 1 to 5 | 114.6 min |
| 6 to 10 | 105.6 min |
| >10 | 83.4 min |
Maruthappu also showed that surgeons with > 25 yrs experience were an average of 51 minutes faster than those with less experience AND that when the same two person team had > 40 cases together they were an average of 21 minutes faster than team with less familiarity. I like to summarize this one by saying that playing basketball with the exact same team for 40 games begins to challenge the value of 25 yrs of playing basketball with strangers.
We performed two similar studies at my own hospital aimed at determining how often high frequency team members supported pediatric orthopaedic surgical cases. High frequency was defined as scrub nurses / scrub techs and circulating nurses who had participated in > 10 of the cases of interest. In one study we looked at one year’s worth of pediatric orthopaedic trauma cases and found that at least 40% of these cases were supported by low frequency teams. The data was even worse when we looked at 100 scoliosis posterior spine fusion cases as 66% of cases were supported by low frequency teams. The safety and efficiency and general good feelings generated by a high frequency team is what we (and our patients) would like to experience every time.
If you work at a small hospital or surgi-center this discussion may strike you as odd, because you already work with the same support team most of the time and they know your routines, easily anticipate next steps, and troubleshoot seamlessly. However, there is almost always an inverse relationship between institutional size and the traits outlined in the previous sentence. In fact, it is the dirty little secret of many large and exceptionally well known hospitals that in many cases, the orthopaedic surgeon performing a relatively complicated procedure is doing so with a team that knows almost nothing about what’s going on. If you’re lucky, a sales rep is guiding them with a laser pointer.
Charles T. Mehlman, DO, MPH
References:
- Maruthappu M, Duclos A, Zhou CD, et al. The impact of team familiarity and surgical experience on operative efficiency: a retrospective analysis. J Roy Soc Med 2016;109:147-153.
- Xiao Y, Jones A, Zhang B, et al. Team consistency and occurrences of prolonged operative time prolonged hospital stay and hospital readmission: a retrospective analysis. World J Surg 2015;39:890-896.