More Surgical Team Familiarity Could Trim Cardiopulmonary Bypass Time

The level of familiarity among a cardiac surgical team—including surgeons, anesthesiologists, and perfusionists—does not appear to reduce patient morbidity and mortality but is directly related to surgical efficiency as measured by time on cardiopulmonary bypass, especially for emergency or salvage operations, according to new registry data.

“Operative efficiency can lead to reduced expenditures and improved surgical team productivity, making it a critical aspect of modern healthcare,” write Tyler M. Bauer, MD (University of Michigan, Ann Arbor), and colleagues. “In the present study, team familiarity was found to have a significant inverse association with cardiopulmonary bypass time, suggesting that increasing the number of operations conducted together by critical team members in the year before surgery was associated with more efficient practices in the OR.”

In the study, published online this week in Circulation: Cardiovascular Quality and Outcomes, team familiarity was measured by tertiles based on the mean number of procedures each team member performed jointly each year. It was not significantly associated with safety as measured by the Society of Thoracic Surgeons (STS) composite major morbidity and operative mortality, but it was inversely linked with time on cardiopulmonary bypass after adjustment.

The research topic is one “that cardiac surgeons have thought about for a long time,” Daniel T. Engelman, MD (Baystate Medical Center, Springfield, MA), commented to TCTMD. “That’s why we are very much in favor of having a smaller cohort of perfusionists and anesthesiologists and nurses in our operating rooms, because we know that familiarity breeds success and this reinforces that.”

More Familiarity, Faster Bypass

For the study, Bauer and colleagues calculated team familiarity for 13,581 operations involving cardiopulmonary bypass from the STS adult cardiac surgery registry (median patient age 64 years; 31.9% women). All took place at one of three quaternary care academic medical centers between 2014 and 2021. CABG made up about one-third of operations with the remaining two-thirds involving valve repair or replacement, with almost half (45.7%) not captured by STS ACSD Operative Risk Calculator.

Researchers grouped the procedures into tertiles of familiarity: low (teams had done fewer than six operations together), moderate (six to less than 9.67 shared operations), and high (more than 9.67 shared operations). Median overall team familiarity was 7.67 shared operations.

Operative mortality was 3.2%, with the primary safety outcome of composite STS morbidity and mortality reported in 17.3%. The most common morbidities were prolonged ventilation (13.9%), renal failure (4.3%), and reoperation (3.9%). The median cardiopulmonary bypass time for the entire population was 129 minutes.

As a surgeon, if you work with the same team all the time, you can get to the point where you can just put your hand out and the correct instrument with the correct suture is placed in your hand. Daniel T. Engelman

Both observed STS morbidity and mortality rates were higher (P = 0.02) and cardiopulmonary bypass times were longer (P < 0.001) in operations with less team familiarity. After adjustment, however, increasing familiarity was no longer related to STS morbidity and mortality (P = 0.51), but bypass time continued to be linked (-2.02 minutes per 1 unite increase in team familiarity; P < 0.001).

Procedural acuity was found to have a significant interaction with team familiarity and bypass time: a stronger association was observed when surgeries were emergent or salvage compared with urgent or scheduled cases (P < 0.001). There was also a stronger association between familiarity and bypass duration in operations that were not captured by the STS ACSD Operative Risk Calculator.

‘Niche Teams’

Engelman said he wasn’t surprised that the study didn’t show a significant association between team familiarity and hard outcomes because “the predicted risk of a death or a complication after cardiac surgery is relatively low. You would have to have a real prolonged operation or a real miscommunication to result in an identifiable complication, difference, or death.”

Ram K. Subramanyan, MD, PhD (University of Nebraska Medical Center, Omaha), agreed, going as far as to suggest that mortality should no longer be an endpoint in surgical studies. “Because cardiothoracic surgery has come so far, we’re not able to do operations with mortality under 1% for the majority of the operations,” he told TCTMD. “When mortality is that low, it’s going to take tens of thousands of patients for us to demonstrate a mortality benefit by any of the interventions that we’re bringing forth.”

But the fact that such a strong association was noted between familiarity and bypass time is valuable in determining how surgical teams should be structured going forward.

“My conclusion is that we need to focus on not having a huge cohort of people doing these operations together,” Engelman said, noting that the size of the group is going to depend on the case volume of the hospital. “In smaller institutions with smaller groups, they actually have more familiarity and may benefit from that. The large institutions have tons of anesthesiologists, perfusionists, and nursing teams, and everybody’s moving around a lot and they probably have less familiarity.”

While some large hospitals might already have smaller cohorts of groups who are scheduled to work together, this isn’t always routine practice, he said. This study “really focuses the attention on the importance of people working together frequently to have better outcomes.”

I don’t think a successful team can have a scrub who does cardiac surgery in the morning, drains pus in the abdomen in the afternoon, and then in the evening gets called back to do neurosurgery. Ram K. Subramanyan

Specifically, Engelman explained, operations can take several hours and involve a wide variety of tools and steps. “If the team is familiar with each other, they can anticipate the needs of each other and not spend a lot of time explaining and second checking that things are correct, too,” he said. “As a surgeon, if you work with the same team all the time, you can get to the point where you can just put your hand out and the correct instrument with the correct suture is placed in your hand.”

Increased familiarity also lessens team member fatigue, he added. “If you’re familiar with the team, it’s less work to do the operation, which makes you more resilient, less tired, and you can perform the operation quicker.”

Similarly, Subramanyan said, “If every day I come into the operating room and I have to meet a new scrub or a new circulator or a new anesthesiologist, the team will fail.”

He urged hospitals to start forming “niche teams” of members who are dedicated to cardiothoracic surgery, or even a more specific subset of these surgeries depending on the institution’s case volume. “I don’t think a successful team can have a scrub who does cardiac surgery in the morning, drains pus in the abdomen in the afternoon, and then in the evening gets called back to do neurosurgery,” he said. “While those models exist, I don’t think that’s the model for the future.”

Case volume and available personnel will be the two, rather large, hurdles in the way of this happening, Subramanyan acknowledged. But handling these challenges can be done in a nuanced fashion depending on each institution’s need. One example of gaining expertise is to send team members to other high-volume institutions for a short period of time to gain experience, he said.

Another challenge to increasing team familiarity is the practice of hiring traveling nurses, technicians, or perfusionists who only stay for a limited period, according to Engelman. “Perhaps this suggests that the wide utilization of traveler nurses and perfusionists, and at some institutions even surgeons, may slow down the course of an operation and be somewhat inefficient,” he said. “And yet you’ll still get good outcomes. So it’s not necessarily correlated with a dangerous situation, but it’s certainly not an efficient practice for surgery.”

Future Research Avenues

The study opens the door to a wide array of issues regarding surgical teams that should be analyzed in the future.

Engelman suggested looking to see if teams with a high degree of familiarity are able to perform quicker operations or if increased familiarity over time improves efficiency.

“We’re a strange specialty where the speed of the operation really matters,” he said. “It’s not just the time under anesthesia. . . . The longer you’re in the operating room, the more chance you have for bleeding, blood utilization, problems with your end organs, with the cardiopulmonary bypass time, getting cold, hypothermia, infection, you can get pressure injuries.”

Engelman also noted that the range of familiarity in this study was “not that wide,” so potentially looking at surgical teams that work together more often might glean “even greater improvements in efficiency.”

For his part, Subramanyan said he’d like to see future studies look not just at bypass time but also the effects of familiarity on things like resources used, need for blood transfusion, hospital length of stay, OR time, and team attrition.

“We need to look at those kinds of systems-based research where we look at resource utilization and we look at people satisfaction and retention of staff in the teams to make sure that we establish the right teams where everybody feels that they belong to the team and they’re valued and appreciated, and therefore, longevity is improved in the team,” he said. “As longevity improves, by definition, experience improves.”