Cardiothoracic Manual for Perioperative Practitioners

1

Healthcare professional roles within the operating room

Jean Hinton

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 addition, according to Tang and Hsiao (2013, p.1) ‘Multidisciplinary collaboration means a team consisting of members with different professional backgrounds and skills that can compensate each other and work together toward the same direction to achieve the same goals’. Working as a team is important in all aspects of primary, clinical and emergency care. However, the operating theatre is unique among healthcare settings in that it requires all members of the multidisciplinary team to be present at the same time, working together to treat patients requiring anaesthetic and surgical interventions. No single discipline can work in isolation within the perioperative environment; they all rely on each other’s expertise and knowledge to deliver successful patient outcomes.

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):

Never Events are defined as Serious Incidents that are wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers.

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.

The operating room personnel:

• 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.

Some examples of the anaesthetic practitioner’s responsibilities include:

• 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.

The role of the scrub practitioner is predominantly to:

• 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.

In Australia, the practitioner undertaking the scrub role is referred to as the scrub nurse or instrument nurse. The role predominantly focuses on the sterility of the instruments, and accounting for the instruments, swabs and sharps provided for the surgical team. They scrub nurse must have a good working knowledge of each procedure in order to pass and retrieve instruments safely while managing the introduction and disposal of items in a timely manner.

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.

• Nausea and vomiting may occur postoperatively and must also be managed.

• 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):

An Assistant Practitioner is defined as a worker who competently delivers health and social care to and for people. They have a required level of knowledge and skill beyond that of the traditional healthcare assistant or support worker.

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.

When delegating tasks to ATPs or any unregistered healthcare worker, it is crucial that registered practitioners are aware and understand that they are still professionally accountable for the appropriateness of the delegation of care. This requirement is explicit in both the Nursing and Midwifery Council (2015) Code of Professional Conduct: Standards of Conduct, Performance and Ethics and the Health and Care Professionals Council (2016) Standards of Conduct, Performance and Ethics. The PCC (2015, p. 2) position statement also highlights the fact that registered practitioners should understand that ATPs ‘are responsible in civil, criminal and contract law for their actions and thus are accountable to the patient and the employer’.

• 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.

Nevertheless, HCAs remain an integral part of the perioperative multiprofessional team and their main duty is circulating for the surgical team. Without the skilled and efficient support of the circulating team, the effectiveness of the scrub team is undermined, which could detract from optimum patient care and safety. All members of the scrub team also undertake circulating duties. This is because it is imperative that a scrub practitioner knows where everything that could possibly be required for a full operating list, is located. There is also a theatre saying that ‘A good scrub practitioner is only as good as his/her circulating team/person’.

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.

Table 1.1: The education and training requirements of the non-medical surgical team

Non-medical advanced surgical team

Introduction

Due to a range of political, economic, technological and sociological drivers impacting upon contemporary healthcare services, there is a continuing requirement for service evolution and workforce redesign that includes the development of advanced clinical roles within nursing and allied health professions.

This has led to the development of a plethora of advanced roles for non-medical practitioners. The Royal College of Surgeons (RCS) of England (2016, p. 1) states:

Non-medical practitioners, who do not regularly rotate through different organisations and who often build up significant expertise in their areas of work, can improve the coordination of patient care as they can provide a link between patients, consultants and trainees. There are also benefits to having highly experienced and trained non-medical practitioners on hand to answer questions and provide support. They provide a familiar face, help establish good relationships, and are key to developing trust between patients and staff.

The challenges in developing these advanced roles include a lack of standardisation and regulation across the UK. Health Education England and the RCSEng are working to standardise these roles and their responsibilities. This section briefly introduces some of the non-medical roles that may be included in cardiothoracic surgical teams to aid the delivery of safe and effective care to the patients.

Surgical first assistant (formerly advanced scrub practitioner)

Surgical first assistants are defined by the PCC (2018, p.1) as:

The role undertaken by the registered practitioner who provides continuous, competent and dedicated surgical assistance to the operating surgeon throughout the surgery; Surgical First Assistants practice as part of the surgical team, under the direct supervision of the operating surgeon.

Scrub practitioners traditionally covered elements of the SFA role, particularly as junior doctor numbers diminished, and they could no longer support theatre lists. This has led to confusion about the legalities, accountabilities and responsibilities of the SFA role. Recommendations from the PCC (2018) position statement state that any perioperative practitioner undertaking a surgical first assistant role must have the necessary skills and underpinning knowledge gained via a nationally recognised programme of study, which has been benchmarked against national standards.

In addition, surgical needs for a surgical first assistant should be highlighted in time to allow an extra relevant qualified practitioner to be rostered into the theatre. All SFAs should have appropriate job descriptions that clearly describe their role and all skills should be risk-assessed and covered by appropriate policies and procedures. Dual role (whereby the scrub practitioner acts as both the scrub practitioner and the surgical first assistant) should not be undertaken except when agreed within the Trust and where strict parameters are heeded and only for relatively minor procedures. The PCC (2018, p. 1) states:

In the event that an employer considers that a dual role is required in minor surgery, then this must only be undertaken by a registered practitioner and the decision should be endorsed by a policy that fully supports this practice and should also be based on a risk assessment of each situation to ensure patient safety.

Some examples of SFA responsibilities:

• Preoperative and postoperative visiting

• Whenever possible to facilitate, preoperative and postoperative visiting enhances communication links between the patient, theatre and ward.

• Positioning

• Being able to position the patient with knowledge of optimum safe positioning to give the surgeon best access for the procedure.

• Being aware of nerves, blood vessels that could be potentially damaged through malpositioning.

• Knowing the surgeon’s operation technique and preferences to aid optimum positioning.

• Male and female catheterisation

• This is a core skill undertaken by all trained SFAs.

• Prepping and draping

• The SFA must have knowledge of the operative technique, the surgeon’s approach and preferences in order to prep and drape appropriately to enhance the safety of the patient.

• Skin and tissue retraction

• The surgeon retains responsibility for placing all retractors as required.

• It is the SFA’s responsibility to know how much pressure to exert in order to avoid damage to the patient.

• Assisting with haemostasis, including indirect diathermy

• Having knowledge of wound healing, clotting factors and the different methods of maintaining haemostasis within surgery.

• Camera holding in minimal invasive surgery

• Being able to safely and knowledgeably maintain an optimum operative visual field during laparoscopic surgery.

• Cutting of sutures and ties

• Safely cutting sutures and ties to the optimum length and having an in-depth knowledge of suture materials.

Some SFAs are required by their Trusts to extend their skills and knowledge by undertaking further study. This may include the advanced skills of suturing skin, administering local anaesthetic and sewing in drains. However, it is imperative that practitioners stay within the boundaries of these roles and only undertake skills that are within their job description, risk assessed and for which there are written policies and procedures.

In the USA, when the RN is also performing the scrub role, they will often participate in the surgical procedure, both by assisting the surgeon as well as managing the sterile instruments during surgery. This is in contrast to the UK, where such a dual role would only be carried out under strict guidelines. However, in Australia and New Zealand the perioperative nurse surgeon’s assistant role is very similar to that of the UK’s surgical first assistant.

Surgical care practitioner (SCP)

According to the Royal College of Surgeons of England (2014, p. 13) National Curriculum definition, a surgical care practitioner is:

A registered non-medical practitioner who has completed a Royal College of Surgeons accredited programme (or other previously recognised course), working in clinical practice as a member of the extended surgical team, who performs surgical interventions, preoperative and postoperative care under the direction and supervision of a consultant surgeon.

SCPs tend to be employed as members of the extended surgical team, responsible to the consultant surgeon. The role provides patient care within the perioperative environment, on the wards, in clinics and departments within a specific surgical pathway, e.g. cardiothoracic. SCPs are registered healthcare professionals and abide by their registering body’s Code of Conduct (NMC 2015, HCPC 2016). Their scope of practice includes any areas that have been covered by training and education, as detailed in the Royal College of Surgeons of England (RCSEng 2014) national curriculum, clinical experience and the successful assessment of competency. SCPs are described by Jones, Arshad and Nolan (2012, p. 19) as ‘[working] within a consultant led extended surgical team, [who] work alongside a variety of healthcare practitioners to provide safe patient care, meet service demand and educate the future surgical workforce’.

Some examples of SCP responsibilities (RCSEng 2014) include:

• Clinics

• Seeing patients in clinic, listing them for surgery and taking consent where agreed within their surgical team, while working in line with local policies and guidelines.

• Preoperative assessment

• Undertaking clinical examinations and diagnostic procedures, adhering to enhanced recovery protocols as directed by the surgical team.

• Investigations (both preoperative and postoperative)

• Arranging appropriate investigations to enhance patient safety across all stages in the patient journey.

• Consent process

• Gaining informed consent from patients, adhering to the General Medical Council, Local Trust or healthcare provider guidelines.

• Liaison with the Multidisciplinary Team

• Supporting patient-centred care, the smooth running of the theatre lists and preoperative and postoperative care.

• World Health Organisation Checklist

• Participating in or leading the briefings for the Five Steps to Safer Surgery Checklist (WHO 2009).

• Preparation of patients for surgery

• Carrying out venepuncture and catheterisation.

• Surgical interventions

• Assisting the surgical team, e.g. harvesting a vein and/or performing some technical or operative procedures autonomously. Writing up operation and/or ward round notes.

• Postoperative patient care

• Recognising a deteriorating patient and knowing about the National Early Warning Score (NHS Improvement 2018) wound assessment, treatment and knowledge of discharge procedures and follow-up care.

• Supporting junior members of the surgical team

• As consistent members of the team, SCPs can support junior doctors by facilitating training sessions or carrying out duties so that the juniors can be released to attend training sessions.

In the USA, the physician assistant (PA) assists in the preoperative evaluation of patients and during surgery; they also follow up patients after surgery. They are the surgeon’s ‘right hand’, often writing the orders, medications and medical interventions that nurses use to care for hospital patients. The PA is often ‘on call’ with the surgeon and responsible for taking phone calls from patients in the postoperative period as well as assisting with emergency care for patients at night and at weekends.

Perfusionist

One of the most important roles on this team is the perfusionist (National Health Service Careers 2018b). Due to the nature of cardiac surgery, certain procedures require a heart that is not beating. It is therefore necessary to temporarily suspend a patient’s normal circulatory and respiratory functions. The perfusionist must use alternative means to maintain the function of the heart and lungs during the operative procedure.

According to Explore Healthcare Careers (2018, p. 1), the perfusionist’s role is to:

Operate a heart-lung machine, which is an artificial blood pump, which propels oxygenated blood to the patient’s tissues while the surgeon operates on the heart. The perfusionist manages the physiological and metabolic demands of the patient while the cardiac surgeon operates on the heart. It is also the perfusionist’s responsibility to deliver the drug that stops the heart.

As the perfusionist is responsible for diverting blood away from the heart and lungs during cardiothoracic procedures, they must ensure that oxygen is added to the blood and carbon dioxide is removed. They are responsible for maintaining the patient’s blood volume during the procedure to maintain perfusion of tissues and cells throughout the body. In addition, they constantly measure physiological changes during the procedure. With the agreement of the surgeon and anaesthetist, they may also administer medications via the cardiopulmonary bypass machine should the need arise.

In order to successfully undertake their role, a perfusionist must be able to communicate at all levels, from simple to complex, in addition to being a good team player. Like all other professionals, perfusionists rely on other members of the multidisciplinary team to be able to fulfil their role, especially within the perioperative environment. Another characteristic of a good perfusionist is their ability to work with, and understand, complex technical machinery and troubleshoot any problems that may occur.

Some examples of a perfusionist’s responsibilities include:

• Liaising with the surgeon and team

• Close communication is vital, between the surgeon, the anaesthetist and the perfusionist, to ensure optimum pharmacology and blood transfusion intervention during the surgery.

• The perfusionist will also keep the theatre team apprised of the patient’s condition.

• Cardiopulmonary equipment and techniques

• The perfusionist must be knowledgeable about all the equipment utilised in bypass. After consultation with the surgeon, the perfusionist is responsible for selecting all appropriate equipment for the planned procedure.

• Managing the patient’s physiological state

• The perfusionist will measure and interpret blood and other parameters to decide on the thermal, mechanical and pharmacological manipulation required to maintain the patient’s physiological state.

• It is essential for the perfusionist to have detailed knowledge of the patient’s medical history.

Table 1.2: A brief overview of the education and training requirements for the non-medical advanced surgical team

Medical surgical team

The medical surgical team consists of doctors and surgeons with varying degrees of experience and responsibility, as well as consultant anaesthetists and their juniors. In this section, there are brief descriptions of the roles and responsibilities of all grades of surgeons and anaesthetists, each of whom plays a key part in delivering safe and effective patient care.

The list below (RCSEng 2018) shows the seven training stages that would typically take a surgeon from medical degree to consultant:

1. Obtain medical degree from the university

2. F1 (Foundation Year 1)

3. F2 (Foundation Year 2)

4. Core Training (CT1 and CT2)

5. Specialist surgical registrar (SpR)

6. Associate specialist surgeon

7. Speciality surgical registrar (StR)

8. Speciality/Staff/Grade surgeons

9. Consultant surgeon.

Surgical team

Consultant cardiothoracic surgeon

Consultant cardiothoracic surgeons are doctors who have specialised in cardiothoracic surgery. They will have gone through a lengthy educational process (both theoretical and practical) to gain the knowledge and experience needed to become consultant surgeons. Their scope of practice covers a variety of conditions and surgical procedures, ranging from a coronary artery bypass to a heart and lung transplant.

In the UK, to become consultants in the NHS, their names must be on the specialist register of the General Medical Council. According to the Royal College of Surgeons in Ireland (RCSI 2018), the training to become a cardiothoracic surgeon is one of the longest of all the specialisms, taking approximately six years between the grades of ST3 and ST8. To become a consultant, the individual is expected to spend time in the various specialities and sub-specialities of cardiothoracic surgical practice. For example, ‘at a minimum Specialist Trainees will spend three years doing adult cardiac surgery, six months doing thoracic surgery and six months in Paediatric cardiothoracic surgery’ (RCSI 2018, p. 1).

A consultant surgeon must have manual dexterity, in addition to an excellent understanding of biology, physiology and other sciences. They also need to remain calm in stressful situations and be able to concentrate, even in adverse situations. Consultant surgeons must pay attention to detail and be able to cope with trauma and death. They also need to have physical and mental stamina, leadership qualities, and be up to date with evidence-based practices and apply them in their work.

The RCSEng (2009, p. 2) states that a consultant-led service must ensure best-quality care for patients:

In a consultant-delivered service the consultant surgeon is clinically responsible for the care the patient receives during the treatment. The consultant will either deliver or closely supervise in the clinical setting all aspects of the care the patient receives. Care may be delivered by other members of the surgical team but only under the supervision of the consultant who is always alert to the needs of the patient being treated.

The consultant cardiothoracic surgeon’s responsibilities can include:

• Treating patients using excellent levels of clinical judgement which complement a first-rate knowledge of cardiovascular, physiological and respiratory anatomy.

• Leading a surgical team and overseeing the training and assessment of junior members of the team.

• Consultant surgeons are responsible for training sufficient numbers of trainee surgeons to enable future workforce planning, as well as analysing and maintaining patient records.

• Physical examinations and diagnostics testing to include x-rays, magnetic resonance imaging, computed tomography scans and positron emission tomography scans

• Undertaking various surgical procedures, from minor to major surgery

• Postoperative care and treatment

• Managing patient expectations

• Consultant surgeons must be directly involved in all their designated patients’ care.

• This is believed to aid treatment decisions, maximise resources and ensure best practice for patients.

• Research responsibilities

• Consultants are responsible for their own professional development and are at the forefront of service development based on the best clinical practice.

• On-call commitments

• Transplant surgery, i.e. heart and lungs

• Attention to detail and excellent hand eye co-ordination are essential.

Trainee specialist registrar in surgery

A specialist registrar in cardiothoracic surgery is accountable to, and works under the supervision of, a consultant cardiothoracic surgeon. According to the General Medical Council (GMC 2014, p.13) training syllabus, this specialist registrar level equips the registrar to work to a high standard, demonstrating ‘knowledge, skills and professional behaviours’. Cardiothoracic registrars should be developing competencies in managing both elective and emergency situations and finalising their professional competencies in all aspects of cardiothoracic surgery (GMC, 2014).

Although specialist registrars do not have financial or budgetary controls, they should have an appreciation of how clinical requirements affect departmental resources and how costing is crucial. In addition to financial issues the registrars will be committed to observing safe working practices to protect their own and others’ health and safety. Another aspect of this role is to provide leadership and support for junior members of the team and to assist the consultant in ensuring that junior medical members of the team receive appropriate performance management, professional training and development opportunities.

A surgical trainee specialist registrar’s main responsibilities can include:

• Providing safe and high-quality person-centred care including patient assessment and management in consultation with the treating consultant

• Having good communication skills to aid extensive interaction within the multidisciplinary team

• Ensuring coordination of care for patients in the department

• Ensuring timely and clear clinical communication including clinical handover

• Ensuring timely escalation of care-related issues to the consultant when required

• Demonstrating commitment to quality and safety

• Teaching, supporting and supervising junior staff

• Providing clinical leadership to the multidisciplinary team

• Complying with all relevant health policies and procedures

• Demonstrating good self-management skills, such as time management and completing intercollegiate requirements.

Core/Surgical trainees (junior doctors)

Junior surgeons work directly under the supervision of the consultant, whose patients they are managing. Junior surgeons share responsibility with other team members for preoperative assessment, preparation, surgical care and postoperative care of all cardiothoracic surgery patients. This includes attendance at outpatient clinics, ward rounds and elective and emergency operating sessions. An important aspect of the role is to be able to communicate with both junior and senior medical colleagues, with ward and intensive care nurses, theatre nurses, ODPs, perfusionists and nurse practitioners, in addition to other relevant members of the multidisciplinary team.

A core/surgical trainee or junior doctor’s main responsibilities can include:

• Assisting the consultant or specialist registrar in treating patients presenting with a range of symptoms and elective conditions as specified in the core syllabus for the specialty of cardiothoracic surgery

• Gaining competence in a broad range of skills, including:

• Interpretation of both echocardiograms and cardiac catheterisation studies

• Insertion of temporary cardiac pacemakers

• Exercise testing

• Insertion of Swan-Ganz catheters

• Management of a broad range of cardiac cases, both acute and elective.

• Assisting the consultants and operating surgeons in the operating theatre

• Performing operative procedures under supervision as appropriate

• Postoperative follow-up of patients in the outpatient clinic

• Recording both written and electronic clinical data as outlined in the principles of Good Medical Practice described by the GMC

• Participating in postgraduate education activities

• Teaching and supporting medical students and junior members of the multidisciplinary team

• Managing own workload and study

• Complying with relevant policies and procedures.

In the USA, during their final year in medical school, the student will begin applying for a general residency programme. The Accreditation Council for Graduate Medical Education is the accrediting body of the Residency Review Committee for each specialty. The Residency Review Committee determines the rules and regulations under which the training programmes operate, and they maintain the overall quality of the accredited programmes. After general residency training, the doctor undertakes specialist cardiothoracic training. On completion of training, the resident is eligible to become certified by both the American Board of Surgery and the American Board of Thoracic Surgery. In addition, some institutions now offer an integrated six-year clinical programme that will match medical students directly with a cardiothoracic pathway. It is anticipated that more six-year integrated programmes will emerge in the near future (Society of Thoracic Surgeons 2015, p. 2).

In both Australia and New Zealand, independent standards bodies oversee medical education and training. The Australian Medical Council assesses and, if appropriate, accredits the medical courses offered by Australian university medical schools. It also assesses and, where appropriate, accredits postgraduate medical specialist training programmes and continuing professional development programmes. The Australian Medical Council collaborates with the Medical Council of New Zealand in the assessment and accreditation of specialist training programmes and continuing professional development programmes that involve medical practitioners or trainees from both countries. Among their responsibilities, the Australian Medical Council and MCNZ accredit the work of the Royal Australasian College of Surgeons in Australia and New Zealand (Royal Australasian College of Surgeons 2015).

In Europe admission to medical schools varies from country to country. Some, such as Belgium, Finland, Greece, Italy, Poland, Portugal, Romania, and Spain (Martinho 2012, p. 984), exclusively use academic criteria to allow admission to university programmes. This is mainly carried over to residency programmes. Other countries (such as Denmark) place most students on academic ability but do reserve a small proportion of places for students where other characteristics are considered. In Germany and the Czech Republic medical training admissions combine academic ability with other characteristics decided by individual universities (Martinho 2012).

Anaesthetic team

Consultant anaesthetist

A consultant anaesthetist is a medical specialist who looks after a patient before, during and after surgery (NHS Careers 2018d). This is a demanding speciality which requires excellent knowledge of anatomy, physiology and pharmacology to ensure that patients remain asleep during the surgery and for as long after as required. The consultant anaesthetist also needs to work very closely with the surgical team, the perfusionist and the wider multidisciplinary healthcare professionals in caring for cardiothoracic patients. The Royal College of Anaesthetists (2018a, p. 1) states:

Anaesthetists form the largest single hospital medical specialty and their skills are used in all aspects of patient care. While the perioperative anaesthetic care of the surgical patient is the core of specialty work (and this includes all types of surgery from simple body surface surgery in adults to the most complex surgery in patients of all ages, including the premature new-born) many anaesthetists have a much wider scope of practice.

The characteristics of a good consultant anaesthetist are varied and wide-ranging, including the ability to communicate in a variety of ways with people who have differing abilities and needs. In addition, being aware of patient concerns and anxieties can allow the anaesthetist to help patients understand their options better. A consultant anaesthetist needs to be able to work both independently and as part of a team, and to be able to make difficult clinical decisions promptly and confidently. Like all medical consultants, they will need to concentrate for long periods of time while maintaining strict attention to detail, especially during the perioperative phase of a patient’s journey. All consultant anaesthetists have a responsibility to actively teach junior anaesthetists and other healthcare professionals.

A consultant anaesthetist’s main responsibilities can include:

• Having overall responsibility for patients under their care

• Being involved in clinical governance, risk management and clinical audit – overseeing and maintaining systems or processes to ensure the continuation of optimum, safe patient care

• Taking responsibility for the professional supervision and development of trainee doctors within the specialty

• Providing a consultation service and advisory service to other clinical colleagues in other specialties within the Trust and primary care

• Participating in the development of the anaesthesia and critical care treatment protocols and guidelines

• Ensuring that their practice is current and evidence-based

• Cardiothoracic anaesthetists also have responsibilities in intensive care units, high dependency units, ward areas and other specialist areas (such as intraoperative transoesophageal echocardiography services) as required.

Trainee specialist registrar in anaesthetics

A specialist registrar in anaesthetics works under the supervision of a consultant anaesthetist. A specialist registrar describes their experiences (Royal College of Anaesthetists 2018b, p. 1):

Anaesthetics is a very varied speciality. You never know what each day is going to hold – relieving pain on a labour ward, resuscitating a sick patient in ITU or participating in an elective theatre list or chronic pain clinic. There is something for everyone.

Outside the operating theatres, specialist registrars would work with cardiac and thoracic patients in departments such as radiology and radiotherapy, using different types of anaesthetic such as:

• Local anaesthetic – for minor operations, working on a specific localised area of the body

• Regional anaesthetic – for example, an epidural anaesthetic to numb a larger surface area of the body (this is sometimes used when a general anaesthetic would be more dangerous for the patients because of their clinical condition)

• General anaesthetic – rendering the patient unconscious (used for operations where local and regional anaesthetics are not suitable).

An anaesthetics trainee registrar’s main responsibilities can include:

• Preoperative preparation of surgical patients

• Provision of sedation and anaesthesia for patients undergoing various cardiothoracic procedures

• Resuscitation and stabilisation of patients in the emergency department or in a stabilisation bay in a recovery area

• Administration of pain relief and monitoring its effects

• In obstetrics

• In postoperative pain relief

• In acute pain management

• In chronic and cancer pain management.

• Transporting acutely ill patients between departments and/or hospitals

• Pre-hospital emergency care

• Intensive care medicine

• Teaching junior medical and other healthcare professional staff

• Working closely with other MDT members, such as the perfusionist and the surgeon.

Core/anaesthetic trainee (junior anaesthetist)

Junior anaesthetists work full time under the direction of the various consultant anaesthetists on the team. The junior anaesthetist will be granted study leave to help them achieve higher examinations and is usually allowed to sit one examination every six months to try and minimise disruption to the department and their staffing levels. A change in the training of anaesthetists now often means that instead of entering the speciality two or three years following their postgraduate training, they now enter immediately after their foundation programmes. According to The Group of Anaesthetists in Training (GAT) (2016, p. 32):

Advanced training is vital to any trainee wishing to pursue a career in cardiothoracic anaesthesia and it is essential that trainees gain a wide and varied clinical experience but also build a CV for consultant appointment.

A junior anaesthetist’s main responsibilities can include:

• Allocation of patients to the intensive therapy unit (ITU)

• Assisting with the management of ITU patients

• Attending day-time emergencies and other out-of-hours’ emergencies with a consultant anaesthetist (can include on-call responsibilities, once a level of competence has been established)

• Allocation of patients to theatre sessions under the supervision of a more senior anaesthetist

• Assisting other departmental staff to maintain services – for example, working with the pain team.

In the USA anaesthesiologists are board-certified by a specialty medical board – either the American Board of Anaesthesiology or the American Osteopathic Board of Anaesthesiology. The American Board of Anaesthesiology is a member of the American Board of Medical Specialties, while the American Osteopathic Board of Anaesthesiology falls under the auspices of the American Osteopathic Association. Both boards are recognised by the major American insurance underwriters.

In the USA, approximately 60% of anaesthetics are provided by certified registered nurse anaesthetists (CRNAs). The CRNAs have similar responsibilities to anaesthesiologists and they provide safe anaesthetics for patients undergoing surgical procedures with oversight from an anaesthesiologist. This means there may be one anaesthesiologist responsible for providing support to a group of surgical rooms, each with a CRNA providing care to the patient.

In Australia and New Zealand, anaesthetists are physicians who are represented by the Australian Society of Anaesthetists and the New Zealand Society of Anaesthetists. Training is overseen by the Australian and New Zealand College of Anaesthetists.

In Europe anaesthetists are all physicians who, after medical school, undertake periods of specialised accredited anaesthetic training of between 4 and 5 years.

Table 1.3: A brief overview of education and training requirements for the surgical team.

Conclusion

The roles described in this chapter are constantly changing, developing and adapting, due to the many factors that affect the global healthcare environment. All over the world there is an ageing population, requiring more treatments, drugs and innovations in surgical techniques. The standardisation of roles is constantly being evaluated and, where possible, implemented as described in this chapter. The physician assistant (PA) role is gradually being introduced into the UK, although PAs do not currently work in cardiothoracic theatres. As described in this chapter, surgical care practitioners currently undertake that role in the UK. Physician assistants in anaesthesia are currently used in some hospitals, where they deliver anaesthetics and maintenance throughout the surgical episode with a consultant anaesthetist nearby (playing a similar role to an anaesthesia nurse in the USA).

Effective MDTs rely on good teamwork, excellent communication between all the staff and departments, and appropriate and relevant training and education. The MDT involved in delivering safe and effective patient care in cardiothoracic surgery is complex, diverse, knowledgeable and trained to react to any adverse situation that may occur during the cardiothoracic perioperative patient journey.

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2

Legal and ethical implications in the perioperative area

Richard Thompson and Bhuvaneswari Krishnamoorthy

Introduction

This chapter will discuss the legal and ethical considerations that govern