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Emergency Theatre Prompt Cards

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There are around 234 million operations performed worldwide each year and it is estimated that 3 million patients experience intraoperative harm worldwide every year. Theatre team performance in the management of operating theatre emergencies and adverse incidents, is a major source of variation in surgical mortality and morbidity. At times of high stress, such as intraopertive cardiac arrest, key processes are often omitted, particulalry in a culture where clincians'memory of these potential life saving steps is relied upon. Taking from other high risk industries, such as aviation,  cognitive aids are embedded in their practice and safety culture to promote improved team performance and maintain situational awareness during emergencies.


In 2015, supported by Health Education England KSS, and in collaboration with the University of Surrey and colleagues at Ashford St Peters Trust, we developed and implemented the first UK Emergency Theatre Prompt Cards across 2 NHS acute trusts to improve team performance during theatre emergencies. We are grateful to Dr David Gaba and his team at Stanford University, California, USA for hosting us, sharing their implementation experience, and their support during development of this first UK version.

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In Oct 2016, SCReaM hosted a launch evening attended by trust executives, managers and theatre healthcare workers across both trusts at Brooklands Motor Museum supported by Maclaren, Ambu, Intersurgical and GE. Our thanks to our speakers, Andrew Blackie, senior inspector (Operations) Air Accidents Investigation Branch (AAIB), and Dr Kevin Fong, Consultant Anaesthetist, Expert in Major Incident Planning and Presenter of Horizon and Channel 4 "Extreme A&E".

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Following the launch of the prompt cards and training for theatre healthcare workers at RSCH and ASPH, we received media attention from BBC South today and BBC Radio Surrey and gained the interest of Martin Bromiley, chair of the Clinical Human Factors Group (CHFG).


Analogous to the Emergency SCreaM prompt cards, The Association of Anaesthetists released in early 2018, the Quick Reference Handbook by the Association of Anaesthetists which we fully support and are aligned to.


We have previously worked in partnership with the University of Surrey and the Quality Improvement Clinic, and continue to have a number of Research and Quality Improvement Projects underway in the use of the prompt cards and implementation of SCReaM. 

We have a number of opportunities for trainees and other healthcare workers including a SCReaM fellowship for senior anaesthetic trainees. If you are interested or have similar research interests, please contact us to find out more information.

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