Introduction

This chapter focuses on the individual roles and professions that make up the perioperative multidisciplinary team (MDT) working in cardiothoracic theatres nationally and internationally. This chapter covers training and education in the UK, the USA, Australia and New Zealand for each of the different roles within the MDT. European countries have slightly different requirements in terms of level and standard of training. However, although titles and roles may differ from one country to another, there are many similarities in training, and the skills and knowledge required are comparable.

Background

One of the main aims of perioperative team work is to develop and maintain a culture of safe, good-quality care in order to reduce any potential patient harm within the perioperative environment and beyond. To ensure the maximum safety of surgical patients within the perioperative environment, multidisciplinary teamwork is key in delivering best practice and optimum patient care.

Teamwork has been recognised as a vital aspect of healthcare practice. In the UK, prior to the establishment of the National Health Service (NHS) and as early as 1920, the Dawson Report suggested that working together as a team was the most productive way forward for primary care (Colin-Thormé et al. 2016). A report issued by the International Association of Physicians in Aids Care (IAPAC 2011) describes the MDT as ‘a partnership among healthcare workers of different disciplines inside and outside the health sector and the community with the goal of providing quality continuous, comprehensive and efficient health services’.

In the current global healthcare climate, with increasing technical innovations, financial constraints and the challenges of caring for aging populations, healthcare services are under unprecedented pressure. Protecting patients from avoidable harm is a paramount goal internationally and the World Health Organisation’s Surgical Checklist is an example of a global initiative for emergency and essential surgical care. It promotes safer surgery and is made up of different phases, corresponding to specific stages in the perioperative process. This checklist is used internationally. Whilst there are local, regional, national variances and additions, the original version included three main areas (WHO 2009):

1. ‘Sign in’ before the induction of anaesthesia

2. ‘Time out’ before the incision of the skin

3. ‘Sign out’ before the patient leaves the operating room.

As a result of feedback following the implementation of the WHO Surgical Checklist, the Five Steps to Safer Surgery were introduced in 2010 (WHO 2016). Two phases were added to the original checklist: the team brief (held at the beginning of the operating list) and the debrief (held at the end of each operation). At the end of each phase the designated leader signs off and confirms that all the listed tasks (such as correct identification of site of operation, prior to commencing the incision) have been completed (WHO 2016).

The WHO Surgical Checklist is one of the methods introduced to reduce the incidence of ‘adverse events’ or ‘never event’ reporting. ‘Never event’ is the term used in the UK and defined by NHS Improvement (2018, p. 4):

It is therefore the MDT’s responsibility, through training and education, to ensure that these ‘never events’ are kept to a minimum and, where possible, eradicated.

The non-medical surgical team

Operating room personnel are key to the outcomes of all patients undergoing surgical procedures. They mainly spend their time working within the perioperative area, preparing the environment and instrumentation, and caring for the patients before, during and after their surgical procedures. The roles and responsibilities of operating room personnel are highlighted below. Together with non-medical specialists and medical staff, operating room personnel make up the MDT, who collectively ensure the best practice is followed and the safety of surgical patients remains paramount.

• Provide effective management of the operating theatres/suites

• Communicate with all departments and staff via the MDT

• Maintain and update staff training, and education as needed for their role

• Maintain and provide appropriate operating theatre resources

• Maintain and provide all operating theatre equipment and instrumentation, maintaining sterility as required.

Anaesthetic practitioner

In the UK, the anaesthetic practitioner can be either a qualified theatre nurse or a qualified operating department practitioner (ODP). The Association of Anaesthetists of Great Britain and Ireland (2010, p. 3) states that ‘Anaesthetists must have dedicated qualified assistance wherever anaesthesia is administered, whether in the operating department, the obstetric unit or any other area.’

The anaesthetic theatre nurse (or ODP) assists the anaesthetist in all aspects of the planning, delivery and maintenance of the cardiothoracic patient’s anaesthetic care. This care begins when the patient is admitted to the theatre area. There is then a handover of care from the ward nurse directly to the anaesthetic practitioner, or from the forward waiting team who have already accepted the patient from the ward. The anaesthetic care continues from the anaesthetic room, where the patient is anaesthetised, to the theatre, when they are transferred for the surgical procedure.

The anaesthetic practitioner’s main responsibilities are to ensure the smooth running of the list from an anaesthetic perspective. This includes checking the availability of all equipment that may be needed, including emergency anaesthetic equipment, and performing the required preoperative checks thoroughly in both the anaesthetic room and the operating theatre before starting the list.

During the anaesthetic phase, the anaesthetic practitioner assists the anaesthetist to maintain the patient’s airway, while constantly observing and monitoring the patient’s physical and physiological responses to the anaesthetic and surgery. This requires a high level of skill, underpinning knowledge and experience when caring for cardiothoracic patients who are undergoing a variety of procedures. These procedures will extend over a wide range of patient dependency and they could be major or minor procedures, and range from dire emergencies to elective surgery, covering all age groups.

The anaesthetic practitioner usually holds the drug cupboard keys for their anaesthetic room and theatre, which means they are responsible for checking, recording and signing for controlled drugs, such as morphine and fentanyl. The anaesthetic practitioner will also organise and prepare any intravenous fluids prescribed by the anaesthetist and set up specialist monitoring equipment (such as arterial lines and central venous pressure lines) which is frequently used in major surgical cases.

After surgery, the anaesthetic theatre nurse or ODP will hand care over to a recovery practitioner in the recovery room, a nurse on a high dependency unit, or a nurse on the intensive care unit, depending on the severity of the cardiac procedure and/or the patient’s state of health.

• Anaesthetic machines/ventilators

• Checking the anaesthetic machines and ventilators in both the anaesthetic room and theatre before commencing every theatre list.

• Modern anaesthetic machines have sophisticated, computerised controls incorporating a few modifications that enable the treatment of patients with complex and adverse anaesthetic issues.

• A fault occurring perioperatively with the anaesthetic machine or ventilator can be potentially life-threatening for the patient.

• Airway management/intubation aids and items

• Airway management is crucial in ensuring a safe outcome for any patient undergoing general anaesthesia.

• All equipment must be collected and checked prior to starting the list.

• The anaesthetic practitioner has to anticipate any potential problems and have relevant supplementary/emergency equipment checked and present in the theatre should it be required.

• Monitoring equipment

• Various types of monitoring equipment may be required during cardiothoracic surgery. The anaesthetic practitioner has to ensure that all monitoring equipment is cleaned, regularly calibrated and maintained in working order.

• Basic monitoring includes checks on blood pressure (non-invasive), temperature, respiratory rate, oxygen saturation and capnography (this measures the amount of CO2 the patient exhales).

• Depending on the type, length or comorbidities of a patient undergoing cardiothoracic surgery, the anaesthetic practitioner may have to prepare equipment to measure arterial blood pressure, central venous pressure and/or oesophageal Doppler ultrasonography to measure the cardiac output.

In the USA, there is no equivalent to the anaesthetic support available in the UK. Instead, the registered nurse provides nursing care, assisting the anaesthesiologist during the delivery and with the maintenance of anaesthesia, the positioning of the patient, and all the documentation required for the surgical procedure. In Australia and New Zealand, the anaesthetic technician’s role is like that of an ODP or anaesthetic nurse. However, they are not currently registered, and the training is not uniform throughout these countries. In Europe, this role is carried out by the registered nurse and is not always considered a separate role. In some European countries, an anaesthetic nurse delivers the anaesthetic with an anaesthetist in the vicinity, but not under direct supervision.

Scrub practitioner

The scrub practitioner can be a qualified theatre nurse, a qualified operating department practitioner or a theatre assistant practitioner.

• Maintain and update their skills and knowledge

• Check all the surgical equipment prior to starting the list, and ensure that all equipment is in working order and present in the operating theatre

• Maintain a strict scrubbing up regime, wearing surgical masks, goggles, sterile gowns and gloves appropriately

• Check for any patient allergies, gain consent for the operation and undertake the WHO Surgery Checklist (WHO 2016) before surgery commences

• Complete all counts with the circulating practitioner before the start of surgery, during the surgery as necessary and prior to final skin closure

• Manage the instruments and supplementary equipment required for the surgical team to perform the required cardiothoracic procedure in order to keep both the patient and the MDT team safe

• Maintain and monitor the sterile field and ensure the sterility of all instruments used (e.g. check that the sterile instruments sets have no obvious holes in their wrapping to avoid the risk of using unsterile or contaminated instruments during the procedure)

• Managing and account for all instruments, swabs, needles and sundries used in the surgical procedure

• Have a good understanding of the operative procedure in order to anticipate the needs of the surgical team as they progress through the surgical procedure

• Monitor and manage the circulating team, giving clear instructions and requests in a timely manner so as not to delay the surgical operating team

• Save and pass out to the circulating team any specimens needed, clearly and accurately identifying the specimen(s) for documentation purposes, and checking accuracy with the operating surgeon before the specimen(s) are documented and sent out of theatre

• Anticipate any potential complications and have equipment available, close at hand, should it be required.

An important responsibility of a scrub practitioner is to ensure that all relevant information pertaining to a patient is accurately recorded on the relevant documentation within the patient’s notes. This is necessary for the safety of the patient and for legal purposes.

In the USA, the registered nurse (RN) is responsible for providing safe and effective care for patients undergoing surgical procedures. This includes preoperative investigations, such as electrocardiogram, blood for cross matching and checking haemoglobin, urea and electrolytes to ensure the patients are fit and ready for surgery. The RN is responsible for ensuring the surgical theatre has everything necessary for the procedure (such as the appropriate instrumentation and surgical implants) and providing support to the surgical team by opening additional items as required during the surgical procedure.

Post-anaesthetic care unit or recovery practitioner

In the UK, the recovery practitioner can be either a qualified nurse or a qualified operating department practitioner. The role of the recovery practitioner involves caring for patients individually, on a one-to- one basis. In cardiothoracic surgery this can include adults, children and patients with learning difficulties or other special needs.

Smedley (2009) highlights the complexity and responsibility of the role and recognises the constantly changing priorities for the practitioner, requiring a high level of flexibility, knowledge and skill.

The responsibilities of the recovery practitioner are varied and demanding. There are some similarities with the responsibilities of the intensive care unit (ICU) and high dependency unit (HDU) nurse, especially where the recovery practitioner is allocated to the resuscitation bay(s) found in some recovery areas. However, the ICU and HDU nurses are usually allocated one or two patient(s) for the whole shift, whereas the recovery practitioner is allocated many patients during their shift, who may have widely differing conditions, requiring the recovery practitioner’s knowledge, skills and competence.

One of the recovery practitioner’s most important responsibilities is to check that all areas are fully equipped and clean before the patient arrives in the post-anaesthetic care unit (PACU) following their surgery. The main priority is to maintain the patient’s airway, as most patients (having received a general anaesthetic with muscle relaxants) will still be unable to maintain their own airway safely. This maintenance is required until the patient has fully reversed from the anaesthetic and is fully conscious.

Some examples of the recovery practitioner’s responsibilities include:

• Monitoring

• Initially, five-minute checks on the patient’s respiratory rate, pulse rate, oxygen saturation, blood pressure and patient responses are crucial. The recovery practitioner needs to be vigilant in recognising any potential problems swiftly, as some can be life-threatening.

• Pain management

• Constant monitoring of the patient’s pain threshold is required, and the recovery practitioner must manage the patient’s pain relief before they can go back to the ward.

• This means dealing with controlled drugs, knowing the contra-indications and how to manage adverse situations that could result from administering pain relief to a variety of patients.

• Fluid maintenance

• Monitoring all fluid loss and intake throughout the recovery period, including urinary catheters, wounds and wound drains to ensure the patient is adequately hydrated.

• Mobility and perfusion

• The patient needs to be observed and monitored to ensure that they are gradually regaining their preoperative mobility and that their circulatory system is accurately perfusing their body, especially following cardiothoracic surgery.

• Record-keeping

• Maintaining records of the care and treatment delivered to the patient during their recovery period.

• This is essential in order to carry out a comprehensive handover to the ward nurse, which ensures continuity of care.

• Reassurance

• Patients are often distressed and disorientated when emerging from a general anaesthetic.

• The recovery practitioner’s skill and calm manner can reassure the patient and provide a smoother, less stressful recovery experience.

Assistant theatre practitioner (ATP)

According to Skills for Health (2011, p.4):

The concept of role expansion for healthcare assistants (HCAs) was first discussed in 2004 as a result of the NHS Changing Workforce Programme (DH 2000, 2001, 2002). Initially there was strong resistance to this concept; and the introduction of these roles in the operating theatre is still spasmodic, with some areas embracing the concept and others still resistant. The Perioperative Care Collaborative (2015) position statement has clearly identified the different roles from which ATPs are recruited, such as support worker, healthcare assistant and auxiliary nurse, in their caveat at the beginning of the document.

The Perioperative Care Collaborative defines a healthcare support worker ‘as a non-registered staff member of the perioperative team’ (PCC 2015, p. 1). There is some confusion with HCAs, who have undergone a two-year foundation degree at a university, regarding their accountability and responsibilities within the perioperative team. However, as ATPs are non-registered staff, they are always expected to be supervised by a registered individual and certain checks must be undertaken with a registered professional. For example, an ATP cannot check swabs or instruments with another HCA; this task has to be performed with a registered practitioner (PCC 2015). The ATP’s role is therefore limited and must be practised within strict parameters. While some staff equate ATPs with State Enrolled Nurses, the key difference is that State Enrolled Nurses are registered nurses and their role therefore has a much wider remit than that of ATPs.

• All swab, instrument and needle counts must be conducted with a registered practitioner who is a member of the scrub team.

• The supervising registered practitioner should be present in the operating theatre for the duration of the operative procedure as part of the scrub team.

• A registered practitioner must ensure that the patient care record and other documentation have been completed satisfactorily by the ATP. Good practice would be for the registered practitioner to countersign all records completed by the ATP.

The PCC (2015) emphasises that no support worker, HCA or auxiliary nurse should undertake any of these tasks unless they have undertaken training in line with the Perioperative Care Support and the Perioperative Care Surgical Support units of the National Occupational Standards for Perioperative Care and have been assessed via National Qualification Frameworks.

In the USA, surgical technicians manage the surgical instruments during the procedure to assist the surgeon. This includes making sure that all necessary instruments and implants are present prior to the surgical procedure as well as preparing the operating room. In Australia, the operating room technician or technologist carries out similar duties to those of the surgical technician in the USA and the ATP in the UK.

Healthcare assistant

Healthcare assistants (HCAs) work in all hospital departments, providing assistance to qualified healthcare practitioners, including nurses, ODPs, doctors and the wider multidisciplinary team (National Health Service Careers 2018a). In cardiothoracic theatres, the HCAs assist in providing safe and effective patient care and contribute to the smooth running of the operating list in a variety of ways. Their work is always supervised by qualified, registered staff who can delegate tasks to the HCAs, providing they have had adequate training and are competent to undertake any delegated task safely and efficiently.

A negative factor that is often raised regarding HCAs is that they are untrained and unregistered. Although all HCAs should be able to access the Skills for Health competencies and be assessed as competent in carrying out any delegated skills, some managers do not provide access to this training for their workforce, or other factors prevent them accessing it. This can lead to a workforce with little or no standardisation of knowledge and skills, especially recognisable transferable skills.

Some examples of the perioperative HCA’s responsibilities include:

• Chaperoning female patients in the anaesthetic room with a male anaesthetic team

• Patients arriving in a theatre department can be extremely nervous.

• Female patients may feel vulnerable when they find themselves with a male anaesthetic team.

• A female HCA can provide support both for the patient and the anaesthetic team.

• Theatre checks

• The HCA will assist in the cleaning (damp dusting if carried out) and setting up of the theatre at the start of the list.

• This will include making sure that the theatre prep rooms are fully stocked and everything is ready and available for the list.

• Circulating duties

• Helping set up for the scrub team by opening instrument trays, arranging drapes and sundry equipment, needles, swabs, blades and prep solutions.

• Assisting with the transfer of the patient from the trolley onto the operating table – if the transfer is not performed in the anaesthetic room.

• Assisting in placing pressure-relieving devices.

• Using the theatre computer to log the patient into theatre and help to complete patient documentation where appropriate. (Note: a registered, qualified practitioner must countersign all documentation.)

• Always contributing to maintaining the sterile field.

• Accepting specimens and labelling them correctly under the direction of the scrub practitioner or operating surgeon.

• Handling contaminated instruments, sundries and specimens correctly, following local policies and protocols.

• Cleaning the theatre area thoroughly between patients.