Mt. View CT Surgery 2017
and in the future

Timeframe N Observed
Mortality
Expected
Mortality
O/E
ratio
Jan 2016 – Sep 2016 17 5.9% 2.2% 2.9
Timeframe N Observed
Complications
Expected
Complications
O/E
ratio
Jan 2016 – Sep 2016 17 17% 13% 1.1
Timeframe N Observed
Blood Use
Expected
Blood Use
O/E
ratio
Jan 2016 – Sep 2016 17 88% 43% 2.0
Timeframe N Observed
Operative
Time
Expected
Operative
Time
Jan 2016 – Sep 2016 17 355 min 309 min
MORTALITY
MAJOR COMPLICATIONS
BLOOD USE
OPERATIVE TIME

0
10
20
30
40
50
60
5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% More
0
5
10
15
20
25
Mortality Mortality and Morbidity
Outcomes for Heart
Surgery at Mt. View
Dec ‘16 – Dec ‘17 (n=202)
17%
16.5
16
15.5
15
14.5
14
13.5
13
12.5
12
11.5
11
10%
8
6
4
2
0
Observed Expected
O/E
0.75
O/E
0.83
Histogram of M&M Risk for CT Patients at Mt. View
frequency
Morbidity and Mortality Risk

Time
Performance
Low
High
Rapid Improvements
1st case …Nth case
Robotic program
introduced
Trial and error
Status quo
Team Learning of Less Invasive Surgery
Novice Proficient Expert

Expectations
Time
Low
High
1st case …Nth case
Status quo
Organizational Learning of Less Invasiveness
Novice Proficient Expert

Expectations
Low
High
Status quo
“The minimally invasive…much less traumatic. By the time you go home, you're
pretty much ready to go back to work.“ LA Times, story by T Maugh
Sept 2011May 1997 May 1999
“…backed away from minimally invasive after poor outcomes,
concerns about difficulty, and high cost of the equipment.”
Wall Street Journal, story by Ralph King
“Our experience with the DaVinci robot…
continues to be positive and satisfying,
encompassing more than 200 patients with
1 death and 2 permanent strokes.”
Editorial, Mayo Clinic Proceedings

Expectations
Time
Performance
Low
High
Low
High
Rapid Improvements
1st case …Nth case
Robotic program
introduced
Trial and error
Status quo
Organizational Learning of Robotic CABG
Novice Proficient Expert
STEP 1: Uncovering the Expectations – Reality Gap
Expectations-
reality gap

Concerns about the Safety of Less Invasive
1. Limited field of view slows response to
adverse events
2. Case selection is both challenging and
critical to success
3. Existing training does not address # 1
and #2
http://www.roboticctsurgery.com/2016/02/07/the-scandal-of-robotic-heart-surgery-training-and-what-to-do-about-it/

Learning Curve Challenges
• Communication
• Learning from failures
• Teamwork
• Prepare for safety threats
Edmondson, Amy et al. Speeding Up Team Learning. Harvard Business Review 2001: 125-132.

Less costly More costly
More Costly Categories
Inhaled nitric oxide/flolan
Intraop mentoring for TEE
Anesthesia assistants for CT cases
ECMO (two CT surgeons/perfusionists)
Less Costly Categories
Employee training: HRO
Time-outs/OR briefings
Debriefings in OR, ICU and IMC
Participate in the STS database
Safety Investments

Improvements
• IT issues
• Margo/Robin: Angiograms
• Margo: Echo images sent via text
• Matt: vital signs in robotic console
• Equipment/supplies
• Tim/Ray: IABP (cables, helium, working with cath
lab), EKG troubleshooting
• Carla/Melinda: esophageal pacing, fibrilator box,
vital signs screen, cerebrox, cinch Medtronic MV,
aortic cannula without stopcock, two iron
interns
• Jennifer: ABG vs. lab Hct, hemolyzed samples
• Bob: Factor VII dosing
• Tim: pleurovac/cell saving
• Robin/Chelsie: abx dosing for wound infection
• Communication
• Mark: implicit vs. explicit (closed loop), safety of open RA/RV
while on CPB
• Chad: cerebral oximetry
• Deannette: pacing wire/CO2 in the field
• Robin: postop issues (SBP, reintubating)
• Anesthesia: one-lung and pulm HTN
• Dee: sterility, sponge counts, motherly advice
• Matt: expertise with Everest patch, looking for bleeding sites
• Tim/Roberto: reminders about unique patient issues
(subclavian occlusion, femoral disease, IVC filter)
• Becky: difficult airway
• Safety
• Matt/Carla: groin a-line
• Tim: emergency bypass pack
• Margo: new habits (time outs x 2 and at 6 hr)
• Rhiana, Ann: TEE support
• Robin/Chelsea: risk assessments
• David: routine on-table CXR
• Pericardial effusion prior to TEE removal, extubation checklist
• Jim/Pat/Katt: flolan
• David: de facto ICU director

Expectations
Time
Performance
Low
High
Low
High
Rapid Improvements
1st case …Nth case
Expectations-
reality gap
Robotic program
introduced
Trial and error
Status quo
Organizational Learning of Robotic CABG
Novice Proficient Expert
STEP 2: DILEMMA OF INFORMATION ASYMMETRY

Stakeholders outside the robotic OR:
Administrators
Referring physicians
ICU nurses/managers
Ancillary staff
QA/Peer review
Surgeon colleagues/competitors

Perfect Information
CABG
Imperfect Information
Robotic CABG
George A. Akerlof. The Market for "Lemons": Quality Uncertainty and the Market Mechanism. The Quarterly Journal of Economics, 1970; 84(3):488-500.

Improvements: ICU RN in the Operating Room
• Rationale
• Improve ICU nurse performance in the early postop phase
• Provide assistance to anesthesia in high workload period
• Metrics of success
• Evaluate hemodynamics and ischemia effectively
• Troubleshoot drips and lines
• Give protamine, fluid and blood products and describe response
• Empathy
• Announce their arrival
• Give them a break at 30 minutes

Near Misses
• Severe protamine reaction
• Off CPB without awareness
• Low AUC for cerebral oximetry
• Off CPB with ongoing surgical bleeding
• Occlude coronary with no heparin
• Large ptx noted after extubation
• Retained heartstring

Dealing with Conflict
• Administering protamine
• Responding to intraop critique
• Scheduling cases/room assignment
• Changes in the arrangement of the room
• Overreact to equipment problems
• Staffing of valve cases
• OR extubations
• SBAR – “poor respiratory status”
• Concerns about doing cases robots/off-pump

Expectations
Time
Performance
Low
High
Low
High
Rapid Improvements
1st case …Nth case
Expectations-
reality gap
Robotic program
introduced
Trial and error
Status quo
Organizational Learning of Robotic CABG
Novice Proficient Expert
STEP 3: ADAPTING TO A NEW WAY

1940 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000
CHANGE IN FATAL AIRLINE ACCIDENTS OVER TIME

1940 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000
CHANGE IN FATAL AIRLINE ACCIDENTS OVER TIME

Things to Watch Out For
• Old habits
• Noise in the OR (ventilation, too many people)
• Work overload (anesthesia, perfusion)
• Accountability (echo training, high risk cases)
• Situational awareness
• Cognitive tunneling/High stress decisions
• Administration
• Follow-up: TEG, CVVH machine
• Involvement in clinical decisions

Robotics Increases the Risk of Blame
• Adverse event: Loss vs. foregone gain
• Poor morale – judgment calls go the wrong way
Criteria for Blame Before Adverse Event After Adverse Event Blameworthy
Planning
Safety
Risk unforeseeable
Persistence = grit
Negligent planning
Persistence = disregard of
safety
Could’ve
Type of program
Type of surgeon
Program is innovative
Highly skilled
Program is unsafe
Skills are idiosyncratic
Should’ve
Cause of event
Accountability
Pioneering effort
Team learning curve
Reckless behavior
Surgeon unable to learn
Didn’t
https://robpostonblog.wordpress.com/2017/12/26/the-real-reason-most-cardiac-surgeons-dont-use-robotics-its-not-about-patients/

Unique value
of less invasiveness
OPCAB results