Developing an Awake Spine Program

Speaker 1So, it was interesting about a year ago, um, I got a call from, uh, um, Helen and her, um, Helen's an anesthesiologist, and Mthusa, who's a neurosurgeon. And in England, they were getting crushed with the whole COVID crisis and they wanted to move towards more Outpatient spine surgery. And so we worked over the past year to over a one-year time period to put together a whole program for them.

Speaker 1And not only was it clinically amazing, but they really went through a tremendous amount of behavioral change with their nurses over in England. So, I'm really excited to have them both join us today and speak about their experiences about how they developed an awake Spine Pro program.

Speaker 1Helen, with this is it's good to see you.

Speaker 2Hi Alec, thanks for inviting us. So just a little bit about us, I'm an anesthetist uh at the John Radcliffe Hospital and I work my um.

Speaker 2My NHS practice with Mr. Sekanda, who's a neurosurgeon by background, um, but mainly now focuses on Spine. Um, I, um, had this idea to, um, start doing Awake spine surgery about 12 years ago, but, um.

Speaker 2Couldn't find a surgeon to um to buy in to help me along with this, um, and um I was lucky enough to meet Mausa um during the um COVID Pandemic and um he did some Research and found you, Alok, um, and you gladly agreed to mentor us and that's really where this, um, journey started. Um, so what this talk is about, just a bit of, bit about, uh, about our experience here in Oxford, um.

Speaker 2We're not gonna tell you what to do. Every institute is different, but we'll just share a few of our experiences.

Speaker 2Um, we based our, um, Approach on McKinsey's 7S framework, which I'm sure you're all aware about, um, and I won't go into detail, um, it's just the sort of philosophy when managing change which we found quite effective.

Speaker 2So first of all, we wanted to look at our needs and motivations. Um, why did we want to do this? I mean, I think our Primary reason was for better patient outcome, um, and we've heard a lot about that today. Um, there's also, um, of health economic benefits in terms of no on the day cancellations because of no beds, um, lower environmental impact, um, and everything that we've heard about today.

Speaker 2Um, interestingly, I think that this actually widens patient eligibility. Um, we've done a number of, um, very sick patients who would never go home on the same day after a general anesthetic. Um, we did a chap with a BMI of 48, uh, who had obstructive sleep apnea. We turned him upside down, popped his CPAP mask on, and he was home the same day playing with his children. So, you know, I really do think that we can offer this service to more patients.

Speaker 2As we've seen, um,

Speaker 2We can probably get 3 more patients in a day doing them awake. So is this a solution to tackle some long waiting lists? Well, it's part of a solution.

Speaker 2So we obviously found mentorship extremely useful. um Obviously Awake Surgery was established in Other centers which gave us the courage to carry on. Um, Alec was very helpful along with his anesthetist um Nicola, um, in providing remote mentorship, not only via um sort of WhatsApp chats, but we sent a lot of videos when we were training, which he was able to feed back to us about.

Speaker 2Um, and also, uh, the doc Social platform provided a lot of learning opportunities, and we're since, since been in touch with, um, a number of Other centers who are doing this. Um, and that's, that's been really, really helpful to sort of compare, um, experiences and learn from, um, Other people's, you know, mistakes, hopefully not.

Speaker 2Um

Speaker 2Governance for us in the NHS and I think, you know, any healthcare system is very important. Um, we went to our um institute's new procedures committee to get permission to carry out this new procedure.

Speaker 2Um,

Speaker 2Sorry.

Speaker 3Sorry, can you hear me now?

Speaker 2We

Speaker 2can hear you now, and I can hear you on WhatsApp. Hold on, I need to turn you off.

Speaker 3Sorry.

Speaker 2I'm back.

Speaker 2So, from, from our point of view, um, it was, it was imperative to get the backing from the trust, um.

Speaker 2To get guidance from the trust about how to do this, so that we were indemnified, um, and so that we made sure our program aligned with trust values.

Speaker 2Um, we started initially with 10 patients who had simple single level pathologies, um, in order to sort of, I suppose, build some muscle memory in there. Um, and the trust luckily, um, allowed us to go ahead and then we went back to them and presented our results, including, um, patient feedback and some very raw data such as opioid uses, length of stay, etc.

Speaker 2Um, they then set us some goals, um, as we were continuing along the program and have asked us to go back to be reevaluated when we've achieved those goals. So, I, I think it's very important for us to have the backing of our institutions, certainly here in the NHS.

Speaker 2Um,

Speaker 2When we were thinking about um how we were going to build this team, we actually asked our um new procedures committee if we could select a bespoke team. But that's quite unusual in the NHS where really you just sort of get who you're given on the day. And we were delighted that they actually approved our plan. Um, so who did we include? Well, naturally, I think the surgeon and the anesthetist got slotted into the lead roles, um, quite naturally.

Speaker 2We then chose several senior perioperative specialist nurses and an anesthetic assistant. So these were pre-op assessment nurses, advanced nurse practitioners on the ward and um theater staff.

Speaker 2We also recruited a pharmacist who helped us with our electronic prescribing um bundle so that the awake spines um get the same protocol.

Speaker 2And we also recruited a physiotherapist for preemptive strikes and for post-operative advice. Not on the slide, but I think super important. We're also our management, um, so various different managers, so the theater manager, an aesthetic manager, but we also have something called an Innovation lead in our trust, who we're delighted to say bought in, um, and has helped us with a few ideas along the way. So that was really helpful.

Speaker 2And we also got directly in touch with our um Primary um musculoskeletal referrals, um.

Speaker 2So that we could, um, sort of tell them what type of patients we needed and get the message out there going forward to get a larger referral base.

Speaker 2Um, and that's actually led to some teaching and feedback as well, which has been great.

Speaker 2What were we looking for in our team members? Everybody knows change management brings stresses, so the mindset of all our um team members was of paramount importance. Somebody who has an appropriate transferable skill set and is willing to transfer those skills to make that change happen. Um, and I have to say our team has been fabulous. We have had some pushback, um.

Speaker 2But it's not lasted very long, so, um, yeah, super proud of the team.

Speaker 2Um

Speaker 2We are great believers in stakeholder buy-in and building Protocols from the ground up. So what we did when we assembled our team was gave, sort of gave everybody a very, very broad brush outline of what we wanted to achieve, sent them away to build their own Protocols, their own buy-in, and their own, um,

Speaker 2Protocols, their own checklists.

Speaker 2And then we came back and we did 3 days of simulated training across the whole patient journey. Everybody went away, they modified their Protocols and checklists, and on our last training session, um, Matthusa will talk a little bit more about this shortly, but our last training session, I think went fabulously. Everybody was able to use the skills to, to the best of their abilities because they'd written their own Protocols.

Speaker 2Um, it was appropriate to the working environment, um, and obviously our last training session we realized we had actually achieved what we set out to do and tailored it to the actual overarching goal of the team. So I really would encourage, um.

Speaker 2You know, the the ground up Approach, not, not the top down kind of.

Speaker 2Um

Speaker 2I suppose dictatorial um Approach.

Speaker 2Um, Matisa, do you want to talk a little bit more about the human factors training we did?

Speaker 3Yeah, can you hear me now? Yes, OK, great, excellent. So yeah, so, um,

Speaker 3I, I think as, as, as this is echoed throughout the entire talk today is this is a paradigm change, both for surgeons, anesthetists, for theater staff, and for patients. Now, from our perspective, when, when we looked at this and, and as Helen said, and as Giorgio said in this.

Speaker 3In his talk before, for us, it was uh coming, we started this pathway when COVID was active. So for us, it was a change in paradigm, establishing a new pathway, looking at every system involved. And what we quickly found out was speaking to alo was that uh it was different for everyone. The challenges were different, all centrally related to human factors and things, but.

Speaker 3It was very different in, from a governance point of view, from a structure, organizational point of view. And that's where we had the challenges, and that's where we wanted to share things. So, like Helen said, we, we used, we created a bespoke team, and we used, we actually went and trained from human factors training.

Speaker 3Uh, Helen and I went to the British Airways and trained with their pilots and their crew, uh, on simulation training to understand human factors and where we could improve. We stripped down everything we did in theater to try to reanalyze everything to the point where we brought in a Le Mans driver to try to pit stop our Approach to harness maximum time from Surgery, and just to make things efficiently.

Speaker 3In terms of cross pollination, what we also did was we had interchangeable roles. Now that Lego model does have a purpose apart from being uh quite playful and interactive, is that uh we divided it into four steps. And what we did is everyone knew where they were supposed to stand, when they were supposed to stand, what they could do, what each person was doing.

Speaker 3We talked a lot about the theater environment, so we divided it into theater etiquette. So we developed languages and gestures that we could communicate with each Other without the patient sort of understanding or being upset by verbal communication. We also did a theater choreography and we rehearsed that with videos, and, and that's how we brought down our timing. So we know.

Speaker 3That when the spinal goes in, the patient is going to be on the table in the prone position in 10 minutes. We know by 28 minutes that we're going to be draped and set to go. We know by, you know, 1 hour, 45 minutes that we're beginning to close, and we know by 2 hours we're out of the theater.

Speaker 3That's how we, that's how we planned our Surgery. And that was the, as Alok was saying, that was the, the technical aspect of how to do things and set up the service, and it, it generated a lot of interest.

Speaker 3In terms of the pathway itself, it's just an overview of what we decided the pathway should look like. And interestingly enough with the human factors, so our institute has got about 17 Spine surgeons in total. Now some of them are senior colleagues, some of them are new, and changing a mindset was a tough thing. We had a lot of.

Speaker 3Uh, constructive criticism, to put it mildly, we had a lot of Other things, but we changed that. We changed it and we moved forward, and the people who were criticizing us from all aspects of the pathway were then our greatest advertisers or advocates for the, for the thing because our philosophy that we generated was that the patient is at the center and we used.

Speaker 3This pathway, not as a change in paradigm of Surgery, but as a change in the paradigm of how we think about patient care. And that was very attractive, and that's something that in a setting of a large institute is very difficult to do.

Speaker 3Um, as Helen was saying, safety netting was extremely important to us.

Speaker 2She keeps I'm slide

Speaker 2hopping. I'm sorry.

Speaker 3That's all right.

Speaker 3And the safety netting and the patient education was extremely important for us. Uh, we developed, uh, according to the trust guidelines, daycare leaflets. We went to the trust media, we set up, um, you know, uh, articles in the local paper, and lo and behold, people were coming to us to ask us about Awake spine surgery, and who were the people? They were the patients themselves who were quite.

Speaker 3Uh, enthusiastic about having options for Surgery and especially having an option to go home. We've done

Speaker 2just, uh, sorry, can I just add a little bit more about the safety netting? Um, so we've actually developed a one-stop clinic, um, where the patient's seen on the same day by the surgeon and the anesthetist and in the future by the pre-op assessment nurse. Um, I think that has implications for Patient experience and I also think that has implications for health economics.

Speaker 2As Matthusa said, the information leaflet is given to the patient at the pre-op assessment clinic. Then they are consented there.

Speaker 2Um,

Speaker 2And they're sent away with, obviously you can see the contact numbers here and they get a personal follow up call the next day either from myself or from Matusa, and I think we've both slept better knowing that this is sort of taking care of our patients.

Speaker 2So it, it was really important that we had that in place.

Speaker 3The audit was quite self-explanatory when we presented it, so apart from younger patients, what we clearly observed that we were able to discharge patients who, who fell outside the spectrum of general anesthetic daycare Surgery. Uh, we've had elderly people who have mobilized and gone home, well in their 80s. Um, we've had a gentleman who was two people, I believe, Helen, who had obstructive sleep apnea, who on previous occasions from general anesthetics.

Speaker 3Spent a couple of days in the high care unit, so they were, uh, they were very happy to go home the same day, Pain free.

Speaker 3So it, it was, it was quite an eye opener for us as well, uh, in, in where, where we practice in Oxford, uh, we have uh quite a senior population there, and we find that the benefits in that age group are significantly larger than the young, fit, healthy person who can go home on the same day with a general anesthetic. We also found along our journey that the psychological aspect of uh operating on patients.

Speaker 3Uh, while they're awake was, was huge and it, it, it's, it's unexplored, to be honest. So we've had patients who've either slept and woken up refreshed, or we've had patients who've been taking photographs of the operating screen of their anatomy, and I'll let Helen explain where the psychological benefits of one patient.

Speaker 3Uh, was, uh, was, uh, what's the word.

Speaker 3Emphasized by her actually seeing a decompressed nerve root.

Speaker 3So she psychologically um sort of hyped herself up into, um, uh, a better outcome on table, saying my Pain is gone because I can see the pressure gone.

Speaker 3And those are, those are, those are aspects of patient care that we have not studied.

Speaker 2Uh, yeah, so, um,

Speaker 2In summary, I think

Speaker 2Setting up a new program for Awake spine surgery, I think you need to ask yourself, why do you want to do it? What's your motivation to change, um, and try to keep revisiting that. Um, does your institute have the resources? Is it feasible, um, get as much help and get as much buy-in as possible and recruit the right team and keep training, keep moving forward, um.

Speaker 2And we're very lucky to have had the team that we've had.

Speaker 2Um, and, uh, you just want to tell, uh, tell them what rewards it's for reward.

Speaker 3Yeah, I, I think the, the, the change is difficult to accept.

Speaker 3But uh I think a good change will be welcomed, and we have recently received an excellence award from the trust, uh, the entire team, uh, we call it the SAS team, Spine Awake Surgery. Uh, we have received an excellence award from our trust, and we have received a lot of inquiries from surgeons in the country, and we are now currently in the process of helping them set up a similar service.

Speaker 3Thank you for listening.

Speaker 2Yeah, thank you very much for having

Speaker 1us. Thank you. That, you know, I think it was really interesting because, um, a lot of times when we learn new surgical techniques, we don't talk about the change management aspect of it. And, uh, if you get the buy-in from your team, it just makes the process easier. I was, I've been fortunate that I've always had, I've been fortunate to have good teams to work with. And so getting buy-in was, was, uh, easy, um.

Speaker 1But it, Amanda is a race car driver who's good friends with Helen Han. She um actually came to their operating room and sort of helped them understand uh how to work together as a team.

Speaker 1And what Amanda actually educated me about was this, um, uh, the pit stops. Do you know what's the fastest time it takes to replace 4 tires in a Formula One race?

Speaker 1This is fascinating.

Speaker 22.2 seconds.

Speaker 12.0, 2.0, 2.0 seconds.

Speaker 2Yeah,

Speaker 2I mean, yeah, Amanda's amazing talking about marginal gains and um sort of economy of movement and things like that. She was fantastic, yeah.

Speaker 1And so she, what she did was basically like you're talking about, about iterative improvements, essentially took apart the team and then iteratively looked at each step and basically got them beyond the psychological aspects, the behavioral part of it. And pits, these pit stop drivers, they, there's no time, 2.0 seconds, there's no time for inefficiency. So we've learned a lot. So I really appreciate how um you've been able to put together this program. And so I think that going forward in the future, we're gonna sort of call you in to help us understand.

Speaker 1How you're able to overcome the British nurses to actually change their behavior.

Speaker 1I know it's been a challenge. So we,

Speaker 3uh, we, we, we work in a system where we work in a system where we don't have the luxury of the same team. We work in a system where, um, uh, you know, it's extremely stressed. So for example, if we were to stop taking in new, um, surgical cases in our trust, it'll take us 3 years to catch up, and that's, you know, that, that's, that's the, that's the story of things, um, and the nurses actually the end were the nurses who nominated the team.

Speaker 3Was the nurse who nominated the team was the nurse who was the biggest, um, she, she was the most skeptical about the whole thing from the beginning.

Speaker 1So if you could do it in England, you could do it anywhere.

Speaker 3Oh, absolutely.