High Volume Multidisciplinary Surgical Team Experience: Reduced Operative Times and Better Patient Outcomes

Background: Teamwork is increasingly being recognized as an important factor in surgical outcomes, especially in rare procedures requiring advanced technical skills, such as the middle fossa craniotomy (MFC) approach to vestibular schwannoma resection. The MFC requires excellent communication, swift, yet collaborative, decision-making, and an understanding of the leadership structure in the operating room. Decision-making collaboration extends outside of the operating room (OR) to the choice of the particular type of patient characteristics which would most likely benefit from specific approaches. Examination of outcomes from a recently formed team provides an excellent context to explore team formation on patient outcome.

Hypothesis: In acoustic neuroma surgery, development of a specialized operative team that undergoes team-building exercises, collaborates in the choice of surgical approach, shares OR instrumentation, and conducts a relatively high rate of rare procedures will result in reduced operative times and improved patient outcomes.

Methods: A retrospective review of patient outcomes (operative time, total length of stay, discharge placement, complications, facial nerve and hearing outcomes, among other variables) in middle cranial fossa excisions was conducted. Qualitative measures, such as communication styles and collaborative decision-making, were reviewed.

Results: A multidisciplinary surgical team was recently formed, led by a neuro-otologist and neurosurgeon. Previously, both surgeons had performed the surgeries independently and were highly experienced in all craniotomy approaches in the cerebellar pontine angle. A total of 35 middle fossa procedures were performed between Sept 2013 and Aug 2016, at a rate of ~11 procedures each year. Average patient age and tumor size remained nearly constant over the 3 years, reflecting a consistency in the method of patient selection. Average operating time was significantly reduced from the first year to the second and third years (p=.006). Average OR time was 3.0 hours, reducing to 2.5 hours in the second and third years. Average length of hospital stay decreased from 3.0 days to 2.5 days (n.s.) and discharge was usually to home.

Of the 34 cases with full hearing data, hearing preservation was achieved in 28 cases (82%, significantly different from chance, p < .001). Post-operative word recognition scores increased with increasing team experience (Average = 58%, 73%, and 79% for years 1, 2, and 3). Similarly, in procedures that did not result in complete deafness, the difference between pre- and post-operative word recognition scores decreased with increased team experience (average reduction in score: 35%, 25%, and 18%). A House-Brackmann facial nerve grade of greater than 1 or 2 was too rare (1 instance each year) to detect differences with team expertise.

Discussion: The results suggest that formation of an effective team plays an important role in improving microsurgical outcomes, reducing time in the OR and trending toward better hearing outcomes. Improvements in communication during the first year, along with clear priorities as defined by the leadership team resulted in a cohesiveness which improved patient outcomes. The challenges of the MFC approach can effectively be managed through the development of a multidisciplinary team, ultimately benefitting the patient.