Multidisciplinary Teams: Better Together

Abstract

It can be estimated that the human heart will contract over 2.5 billon times in a lifespan of 70 years; blood is thusly propelled into the aorta over 2.5 million times in a lifetime as the initial conduit to systemic tissue perfusion. It is difficult to overstate the importance of a healthy aorta – when aortic disease manifests itself, its management can prove to be a challenging clinical endeavor, with high risk for potential morbidity and mortality when intervention is required. To this end, the American College of Cardiology (ACC) and the American Heart Association (AHA) sponsored an expert panel of authors to create a guideline document that offers recommendations for the diagnosis and management of a wide spectrum of aortic diseases. This ACC/AHA report was published in December of 2022.1 While an expansive range of topics and presentations related to aortic diseases are covered in the 111 page manuscript, these updated Guidelines (which replace a 2010 document) now explicitly highlight the benefits that are conferred when a team-based approach is used in caring for patients with aortic diseases: specific mentions are made regarding the importance of the use of the Multidisciplinary Aortic Team (MAT) and aortic disease care provision at a high volume aortic center.1,2 This acknowledgement of the importance of multidisciplinary teams at those centers caring for patients with aortic diseases within the aforementioned Guideline is consistent with much of the published data from multiple other cardiac interventions, including transcatheter aortic valve replacement, mitral valve interventions, heart failure, and cardiogenic shock, where improvements in patient outcomes and safety have been noted.3,4 The very writing committee that was convened to create the Aortic Disease Guidelines is in fact reflects a multidisciplinary cohort, represented by cardiac surgeons, cardiologists, vascular surgeons, a geneticist, radiologist, cardiovascular anesthesiologist, and an emergency medicine physician.1 The ACC and AHA are to be commended for explicitly stating the importance of multidisciplinary teams in these Guidelines; an argument may be made that a firm statement is even overdue. The “team approach” to address that management of complex clinical issues has large potential upside of desirable benefits, including broadening of patient-focused considerations and identification (and reduction!) of errors in patient evaluation and management. A team is a “group of people who perform interdependent tasks to work toward accomplishing a common mission or specific objective”.5 Moreover, a health care team should be “professionals from various disciplines who enter a collaborative relationship with the patient to deliver coordinated, high-value, and patient-centered healthcare”.6 In advanced clinical practice teams, like those associated with high risk conditions like aortic diseases, these definitions may be melded and refocused; such a team should be a multidisciplinary group of professionals who use their respective backgrounds, education, experiences and expertise to offer opinion, insight, perspective and nuance toward a unified management goal. It is from this perspective that the MAT should be created in centers that treat aortic diseases. While an in-depth commentary on the overall quality of healthcare provided to patients with aortic diseases is beyond the scope of this manuscript, it is suffice to that patients and physician alike want the best possible experience and outcomes. To this end, it is acknowledged that “old habits die hard”. Historically, patient care could be disparate – the diagnosis and offered treatment of a particular condition might have been left entirely at the discretion of the physician who saw the patient initially, or to whichever specialist received a referral or consultation request. This, of course, left the evaluation and management of patients open to a greater tendency for error. Error is acknowledged to be significant contributor to suboptimal patient outcomes, and, unfortunately, all physicians are at risk to commit one (or more) type of well-described sources of error.7 Attribution error, anchoring error, and availability error to occur, which are due to the bias that exists when only one perspective is applied. Attribution error describes a mistake made due to an association of a patient's condition with stereotypes or prior experiences. Anchoring error occurs when a single symptom, sign or fact in a clinical scenario is inappropriately considered, wrongly influencing further decision making. Availability error is the tendency to apply what is familiar or commonly seen to clinical situations, instead of considering novel diagnoses or approaches to care.8 It must be underscored that these errors are mistakes can occur even when physicians are applying their undivided attention to the patients and issues at hand; the risk of considerable error is even greater when we account for the seemingly unending interruptions, alerts, and mandates that compete for our time while trying to care for patients.9 Multidisciplinary teams can serve as a means of support, redirection, and focus when the aforementioned opportunities for error arise. Unfortunately, there is a dearth of literature that “proves” that the multidisciplinary team improves outcomes; much of the literature is observational, but some compelling support exists.10 In a simulated environment, it has been shown that clinical errors among healthcare teams decrease as scores on a validated measure of teamwork increase.11 In 1997, a post-hoc analysis of registry of the Emory Angioplasty versus Surgery Trial (which compared outcomes between angioplasty and coronary bypass surgery for treatment of coronary artery disease) found that patients who had a revascularization strategy created by a multidisciplinary team had better survival than those simply randomized into one cohort or the other.12 More recently, a retrospective study of an Australian TAVR registry study showed robust reduction in 5 year risk-adjusted mortality after a multidisciplinary heart team was implemented in TAVR care.13 Aortic diseases often represent a complex clinical entity in which a multifaceted, team approach to evaluation and management is now formally sponsored by updated ACC/AHA guidelines, in the form of a MAT. Anesthesiologists are key stakeholders in these teams, given their role in perioperative teams spanning the preoperative, intraoperative and postoperative continuum. As historical leaders of perioperative safety and focused team participation (e.g.: “Code Blue” response teams, Difficult Airway Teams, etc), we have yet another opportunity to step into MAT provide meaningful support those impacted by, and caring for, persons with aortic diseases.14,15 1Isselbacher EM, Preventza O, Hamilton Black J 3rd, et al. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology joint committee on clinical practice guidelines. Circulation. 2022;146(24):e334-e4822ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the diagnosis and management of patients with thoracic aortic disease. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine [published correction appears in J Am Coll Cardiol. 2013 Sep 10;62(11):1039-40]. J Am Coll Cardiol. 2010;55(14):e27-e1293Writing Committee Members, Otto CM, Nishimura RA, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg. 2021;162(2):e183-e3534Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the management of heart failure: Executive summary: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2022;79(17):1757-1780, Papolos AI, Kenigsberg BB, Berg DD, et al. Management and outcomes of cardiogenic shock in cardiac ICUs with versus without shock teams. J Am Coll Cardiol. 2021;78(13):1309-13175https://asq.org/quality-resources/teams, date last accessed 8 May 20236Martin AK, Green TL, McCarthy AL, Sowa PM, Laakso EL. Healthcare teams: Terminology, confusion, and ramifications. J Multidiscip Healthc. 2022;15:765-7727Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016;353:i21398McGrath BM. How doctors think. Can Fam Physician. 2009;55(11):11139Grissinger M. Sidetracks on the safety express: interruptions lead to errors and … wait, what was I doing?. P T. 2015;40(3):145-19010Batchelor W, Anwaruddin S, Wang D, et al. The multidisciplinary heart team in cardiovascular medicine. JACC Adv. 2023 Jan, 2 (1). https://doi.org/10.1016/j.jacadv.2022.10016011Herzberg S, Hansen M, Schoonover A, et al. Association between measured teamwork and medical errors: an observational study of prehospital care in the USA. BMJ Open. 2019;9(10):e02531412King S.B., Barnhart H.X., Kosinski A.S., et al. Angioplasty or surgery for multivessel coronary artery disease: comparison of eligible registry and randomized patients in the EAST trial and influence of treatment selection on outcomes. Emory Angioplasty versus Surgery Trial investigators. Am J Cardiol . 1997;79:1453-145913Jones D.R., Chew D.P., Horsfall M.J., et al. "Multidisciplinary transcatheter aortic valve replacement heart team programme improves mortality in aortic stenosis". Open Heart . 2019;6:e0009814Price JW, Applegarth O, Vu M, Price JR. Code blue emergencies: A team task analysis and educational initiative. Can Med Educ J. 2012;3(1):e4-e2015Mark LJ, Herzer KR, Cover R, et al. Difficult airway response team: a novel quality improvement program for managing hospital-wide airway emergencies. Anesth Analg. 2015;121(1):127-139 I am submitting a free-standing editorial (requested by Dr. Augoustides), entitled “Multidisciplinary Team: Better Together”, related to the subsections on Multidisciplinary Aortic Teams and High Volume Aortic Centers within the 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Diseases (Isselbacher EM, Preventza O, Hamilton Black J 3rd, et al. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology joint committee on clinical practice guidelines. Circulation. 2022;146(24):e334-e482), an important manuscript published in Circulation. I confirm I have no conflict of interest associated with this editorial submission.