Flow disruptions during trauma care

Human Factors Integration in Robotic Surgery

OBJECTIVE

Using the example of robotic-assisted surgery (RAS), we explore the methodological and practical challenges of technology integration in surgery, provide examples of evidence-based improvements, and discuss the importance of systems engineering and clinical human factors research and practice.

BACKGROUND

New operating room technologies offer potential benefits for patients and staff, yet also present challenges for physical, procedural, team, and organizational integration. Historically, RAS implementation has focused on establishing the technical skills of the surgeon on the console, and has not systematically addressed the new skills required for other team members, the use of the workspace, or the organizational changes.

RESULTS

Human factors studies of robotic surgery have demonstrated not just the effects of these hidden complexities on people, teams, processes, and proximal outcomes, but also have been able to analyze and explain in detail why they happen and offer methods to address them. We review studies on workload, communication, workflow, workspace, and coordination in robotic surgery, and then discuss the potential for improvement that these studies suggest within the wider healthcare system.

CONCLUSION

There is a growing need to understand and develop approaches to safety and quality improvement through human-systems integration at the frontline of care.Precis: The introduction of robotic surgery has exposed under-acknowledged complexities of introducing complex technology into operating rooms. We explore the methodological and practical challenges, provide examples of evidence-based improvements, and discuss the implications for systems engineering and clinical human factors research and practice.

Identifying Workflow Disruptions in Robotic-Assisted Bariatric Surgery: Elucidating Challenges Experienced by Surgical Teams

PURPOSE

Bariatric surgery is an effective and durable treatment for weight loss for patients with extreme obesity. Although traditionally approached laparoscopically, robotic bariatric surgery (RBS) has unique benefits for both surgeons and patients. Nonetheless, the technological complexity of robotic surgery presents new challenges for OR teams and the wider clinical system. Further assessment of the role of RBS in delivering quality care for patients with obesity is necessary and can be done through a human factors approach. This observational study sought to investigate the impact of RBS on the surgical work system via the study of flow disruptions (FDs), or deviations from the natural workflow progression.

MATERIALS AND METHODS

RBS procedures were observed between October 2019 and March 2022. FDs were recorded in real time and subsequently classified into one of nine work system categories. Coordination FDs were further classified into additional sub-categories.

RESULTS

Twenty-nine RBS procedures were observed at three sites. An average FD rate of 25.05 (CI =  ± 2.77) was observed overall. FDs were highest between insufflation and robot docking (M = 29.37, CI =  ± 4.01) and between patient closing and wheels out (M = 30.00, CI =  ± 6.03). FD rates due to coordination issues were highest overall, occurring once every 4 min during docking (M = 14.28, CI =  ± 3.11).

CONCLUSION

FDs occur roughly once every 2.4 min and happen most frequently during the final patient transfer and robot docking phases of RBS. Coordination challenges associated with waiting for staff/instruments not readily available and readjusting equipment contributed most to these disruptions.

Using Process Flow Disruption Analysis to Guide Quality Improvement

BACKGROUND

Process flow describes the efficiency and consistency with which a process functions. Disruptions in surgical flow have been shown to be associated with an increase in error. Despite this, little experience exists in using surgical flow analysis to guide quality improvement (QI).

STUDY DESIGN

In a 900-bed teaching hospital with an annual surgical volume of 24,000 cases, a 4-month observational study of process flow was done by experts in complex system evaluation. Identified flow disruptions were used to guide QI. Statistical analysis included descriptive and bivariate techniques.

RESULTS

More than 200 unique process data points were evaluated. There was a high degree of variability in completion of 79 individual intraoperative data elements. Lack of completion of all elements of the time out was associated with number of times the operating room door opened during case (19, 11-27; p = 0.01). Flow disruptions were used to direct surgical QI. One example was a disruption affecting the use of Sugammadex. Resolving this flow disruption resulted in a 59% reduction in the incidence of postoperative respiratory failure (p < 0.01) and a direct and variable cost savings of $447,200 and $313,160, respectively, in the first 12 months.

CONCLUSIONS

The use of process flow analysis to direct surgical quality initiatives is a novel approach that emphasizes system-level strategy. Resolving flow disruptions can lead to effective QI that embraces reliability by focusing attention on common processes rather than adverse events that may be unique and therefore difficult to apply broadly.

A Smartphone Application for Teamwork and Communication in Trauma: Pilot Evaluation "in the Wild"

OBJECTIVE

To evaluate the potential for a smartphone application to improve trauma care through shared and timely access to patient and contextual information.

BACKGROUND

Disruptions along the trauma pathway that arise from communication, coordination, and handoffs problems can delay progress through initial care, imaging diagnosis, and surgery to intensive care unit (ICU) disposition. Implementing carefully designed and evaluated information distribution and communication technologies may afford opportunities to improve clinical performance.

METHODS

This was a pilot evaluation "in the wild" using a before/after design, 3 month, and pre- post-intervention data collection. Use statistics, usability assessment, and direct observation of trauma care were used to evaluate the app. Ease of use and utility were assessed using the technology acceptance model (TAM) and system usability scale (SUS). Direct observation deployed measures of flow disruptions (defined as "deviations from the natural progression of an procedure"), teamwork scores (T-NOTECHS), and treatment times (total time in emergency department [ED]).

RESULTS

The app was used in 367 (87%) traumas during the trial period. Usability was generally acceptable, with higher scores found by operating room (OR), ICU, and neuro and orthopedic users. Despite positive trends, no significant effects on flow disruptions, teamwork scores, or treatment times were observed.

CONCLUSIONS

Pilot trials of a clinician-centered smartphone app to improve teamwork and communication demonstrate potential value for the safety and efficiency of trauma care delivery as well as benefits and challenges of "in-the-wild" evaluation.

Using flow disruptions to understand healthcare system safety: A systematic review of observational studies

This systematic review provides information on the methodologies, measurements and classification systems used in observational studies of flow disruptions in clinical environments. The PRISMA methodology was applied and authors searched two databases (PubMed and Web of Science) for studies meeting the following inclusion criteria: (a) were conducted in a healthcare setting, (b) explored systems-factors leading to deviations in care processes, (c) were prospective and observational, (d) classified observations, and (e) were original research studies published in peer-reviewed journals. Thirty studies were analyzed and a variety of methods were identified for observer training, data collection and observation classification. Although primarily applied in surgery, comparable research has been successfully conducted in other venues such as trauma care, and delivery rooms. The findings of this review were synthesized into a framework of considerations for conducting rigorous methodological studies aimed at understanding clinical systems.

When patients get stuck: A systematic literature review on throughput barriers in hospital-wide patient processes

Hospital productivity is of great importance to policymakers, and previous research demonstrates that improved hospital productivity can be achieved by directing more focus towards patient throughput at healthcare organizations. There is also a growing body of literature on patient throughput barriers hampering the flow of patients. These projects rarely, however, encompass complete hospitals. Therefore, this paper provides a systematic literature review on hospital-wide patient process throughput barriers by consolidating the substantial body of studies from single settings into a hospital-wide perspective. Our review yielded a total of 2207 articles, of which 92 were finally selected for analysis. The results reveal long lead times, inefficient capacity coordination and inefficient patient process transfer as the main barriers at hospitals. These are caused by inadequate staffing, lack of standards and routines, insufficient operational planning and a lack in IT functions. As such, this review provides new perspectives on whether the root causes of inefficient hospital patient throughput are related to resource insufficiency or inefficient work methods. Finally, this study develops a new hospital-wide framework to be used by policymakers and healthcare managers when deciding what improvement strategies to follow to increase patient throughput at hospitals.

The Role of the Physical Environment in Shaping Interruptions and Disruptions in Complex Health Care Settings: A Scoping Review

Interruptions and disruptions in complex healthcare environments, such as trauma rooms, can lead to compromised workflow and safety issues due to the physical environment's characteristics. This scoping review investigated the impact of the physical environment on interruptions and disruptions and the associated outcomes in complex environments, as they relate to the components of the Systems Engineering Initiative for Patient Safety. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was used to conduct the scoping review. CINAHL, Web of Science, and PubMed databases were searched. After removing duplicates and eligibility screening, quality assessment was conducted using the Mixed Methods Appraisal Tool (MMAT). Of 1,158 articles found, 20 were selected. Poor layout configurations, tripping hazards, and technology integration were common examples. More research must be conducted to unveil the impact of the physical environment on interruptions and disruptions.

Using Broken Windows Theory as the Backdrop for a Proactive Approach to Threat Identification in Health Care

OBJECTIVES

Historically, health care has relied on error management techniques to measure and reduce the occurrence of adverse events. This study proposes an alternative approach for identifying and analyzing hazardous events. Whereas previous research has concentrated on investigating individual flow disruptions, we maintain the industry should focus on threat windows, or the accumulation of these disruptions. This methodology, driven by the broken windows theory, allows us to identify process inefficiencies before they manifest and open the door for the occurrence of errors and adverse events.

METHODS

Medical human factors researchers observed disruptions during 34 trauma cases at a Level II trauma center. Data were collected during resuscitation and imaging and were classified using a human factors taxonomy: Realizing Improved Patient Care Through Human-Centered Operating Room Design for Threat Window Analysis (RIPCHORD-TWA).

RESULTS

Of the 576 total disruptions observed, communication issues were the most prevalent (28%), followed by interruptions and coordination issues (24% each). Issues related to layout (16%), usability (5%), and equipment (2%) comprised the remainder of the observations. Disruptions involving communication issues were more prevalent during resuscitation, whereas coordination problems were observed more frequently during imaging.

CONCLUSIONS

Rather than solely investigating errors and adverse events, we propose conceptualizing the accumulation of disruptions in terms of threat windows as a means to analyze potential threats to the integrity of the trauma care system. This approach allows for the improved identification of system weaknesses or threats, affording us the ability to address these inefficiencies and intervene before errors and adverse events may occur.

Characteristics of trauma patients that leave against medical advice: An eight-year survey analysis using the National Hospital Ambulatory Medical Care Survey, 2009-2016

BACKGROUND

Leaving against medical advice (AMA) is associated with increased readmission rates, fragmented patient care, and healthcare litigation. Understanding the factors associated with trauma patients leaving AMA from acute care settings will help guide better communication with trauma patients and improve patient satisfaction. This study aims to assess the sociodemographic and in-hospital care characteristics of trauma patients that leave AMA from acute care centers across the U.S.

METHODS

We pooled and analyzed eight years of data (2009-2016) from the National Hospital Ambulatory Medical Care Survey. The outcome variable was whether the patient left AMA or not. The main predictors were the triage class, weekend presentation, health insurance status, the presence of chronic diseases, and the receipt of therapeutic and diagnostic procedures. The sociodemographic characteristics -age, sex, and race/ethnicity, were measured as potential confounders in the developed model. We performed logistic regression and reported the unadjusted and adjusted odds of leaving AMA as well as the 95% confidence intervals.

RESULTS

The weighted percent of the trauma patient population that left AMA was 1.8%. The odds of leaving AMA decreased with advancing age, and increased among non-Hispanic Blacks, compared with non-Hispanic Whites. After adjusting for age, race, and gender, the odds of leaving AMA increased among patients that lacked health insurance (AOR: 1.86; 95% CI: 1.51-2.31), and had diagnostic procedures (AOR: 2.79; 95% CI: 2.32-3.36). The odds of leaving AMA reduced among trauma patients who were classified as emergent (AOR: 0.70; 95% CI: 0.50-0.98) and had therapeutic procedures (AOR: 0.39; 95% CI: 0.32-0.47).

CONCLUSION

Predicting trauma patients with increased odds of leaving AMA will inform intentional communication that may reduce leaving AMA rates and improve care.

Research and Exploratory Analysis Driven-Time-data Visualization (read-tv) software

MOTIVATION

Research & Exploratory Analysis Driven Time-data Visualization (read-tv) is an open source R Shiny application for visualizing irregularly and regularly spaced longitudinal data. read-tv provides unique filtering and changepoint analysis (CPA) features. The need for these analyses was motivated by research of surgical work-flow disruptions in operating room settings. Specifically, for the analysis of the causes and characteristics of periods of high disruption-rates, which are associated with adverse surgical outcomes.

MATERIALS AND METHODS

read-tv is a graphical application, and the main component of a package of the same name. read-tv generates and evaluates code to filter and visualize data. Users can view the visualization code from within the application, which facilitates reproducibility. The data input requirements are simple, a table with a time column with no missing values. The input can either be in the form of a file, or an in-memory dataframe- which is effective for rapid visualization during curation.

RESULTS

We used read-tv to automatically detect surgical disruption cascades. We found that the most common disruption type during a cascade was training, followed by equipment.

DISCUSSION

read-tv fills a need for visualization software of surgical disruptions and other longitudinal data. Every visualization is reproducible, the exact source code that read-tv executes to create a visualization is available from within the application. read-tv is generalizable, it can plot any tabular dataset given the simple requirements that there is a numeric, datetime, or datetime string column with no missing values. Finally, the tab-based architecture of read-tv is easily extensible, it is relatively simple to add new functionality by implementing a tab in the source code.

CONCLUSION

read-tv enables quick identification of patterns through customizable longitudinal plots; faceting; CPA; and user-specified filters. The package is available on GitHub under an MIT license.

A Human Factors Approach to Surgical Patient Safety

This article explores the role of human factors engineering in patient safety in surgery. The authors discuss the history and evolution of human factors and the role of human factors in patient safety and provide a description of human factors methods used to study and improve patient safety.

Surgical Flow Disruptions, a Pilot Survey with Significant Clinical Outcome Implications

PURPOSE OF REVIEW

Surgical flow disruptions (SFD) are deviations from the progression of a procedure which can be potentially compromising to the safety of the patient. Investigators have previously demonstrated that SFDs can increase the likelihood of error. To date, there has been no investigation into flow disruptions through the eyes of clinicians in the operating room. This study, therefore, attempted to better understand SFDs and their impact from the perspective of operating room team members.

RECENT FINDINGS

After Institutional Review Board approval, a survey was sent to operating room team members including surgeons, anesthesia providers, nurses, and surgical technologists. The survey was developed to assess the perceived frequency and consequences of SFDs, and the ability to report and perceive the efficacy of reporting to management. Among 111 survey participants, 65% reported that surgical flow disruptions happen either "several times a day" or "every procedure." Forty percent ranked poor communication as the most frequent cause of SFDs. Ten percent reported equipment failure was the most frequent cause of SFDs. Respondents who identified as attending surgeons felt impacts on patient safety and staff burnout was the most likely consequence of SFDs. Scrub technicians and nurses felt that economic consequences were the most likely result. Forty-four percent did not feel reporting led to effective change. Thirty-five percent did not believe they could report issues without adverse consequences. Flow disruptions represent patterns or accumulations of disruptions which may highlight weak points in surgical systems and potential causes of staff burnout and medical error. The data in the present investigation demonstrate that OR team members recognize surgical flow disruptions are an important issue and believe poor communication and equipment problems are a significant factor. Our data additionally suggest the groups surveyed do not feel safe or productive in reporting flow disruptions.

Associations of workflow disruptions in the operating room with surgical outcomes: a systematic review and narrative synthesis

Background

Performance in the operating room is an important determinant of surgical safety. Flow disruptions (FDs) represent system-related performance problems that affect the efficiency of the surgical team and have been associated with a risk to patient safety. Despite the growing evidence base on FDs, a systematic synthesis has not yet been published.

Objective

Our aim was to identify, evaluate and summarise the evidence on relationships between intraoperative FD events and provider, surgical process and patient outcomes.

Methods

We systematically searched databases MEDLINE, Embase and PsycINFO (last update: September 2019). Two reviewers independently screened the resulting studies at the title/abstract and full text stage in duplicate, and all inconsistencies were resolved through discussion. We assessed the risk of bias of included studies using established and validated tools. We summarised effects from included studies through a narrative synthesis, stratified based on predefined surgical outcome categories, including surgical process, provider and patient outcomes.

Results

We screened a total of 20 481 studies. 38 studies were found to be eligible. Included studies were highly heterogeneous in terms of methodology, medical specialty and context. Across studies, 20.5% of operating time was attributed to FDs. Various other process, patient and provider outcomes were reported. Most studies reported negative or non-significant associations of FDs with surgical outcomes.

Conclusion

Apart from the identified relationship of FDs with procedure duration, the evidence base concerning the impact of FDs on provider, surgical process and patient outcomes is limited and heterogeneous. We further provide recommendations concerning use of methods, relevant outcomes and avenues for future research on associated effects of FDs in surgery.

Impact of flow disruptions in the delivery room

AIM

Flow disruptions (FDs) are deviations from the progression of care that compromise safety and efficiency of a specific process. The study aim was to identify the impact of FDs during neonatal resuscitation and determine their association with key process and outcome measures.

METHODS

Prospective observational study of video recorded delivery room resuscitations of neonates <32 weeks gestational age. FDs were classified using an adaptation of Wiegmann's FD tool. The primary outcome was target oxygenation saturation achievement at 5 min. Secondary outcomes included achieving target saturation at 10 min, time to positive pressure ventilation for initially apnoeic/bradycardic neonates, time to electrocardiogram signal, time to pulse oximetry signal, and time to stable airway. Multivariable logistic regression assessed association between FDs and achieving target saturations adjusting for gestational age and leader. Associations between FDs and time to event outcomes were assessed using Cox proportional hazards models.

RESULTS

Between 10/2017-7/2018, 32 videos were included. A mean of 52.6 FDs (standard deviation 17.9) occurred per resuscitation. Extraneous FDs were the most common FDs. FDs were associated with an adjusted odds ratio of 0.92 (95% confidence interval [CI] 0.80-1.05) of achieving target saturation at 5 min and 0.94 (95% CI 0.84-1.05) at 10 min. There was no significant evidence to show FDs were associated with time to event outcomes.

CONCLUSIONS

FDs occurred frequently during neonatal resuscitation. Measuring FDs is a feasible method to assess the impact of human factors in the delivery room and identify modifiable factors and practices to improve patient care.

Proactive Safety Management in Trauma Care: Applying the Human Factors Analysis and Classification System

INTRODUCTION

This article examines the reliability of the Human Factors Analysis and Classification System (HFACS) for classifying observational human factors data collected prospectively in a trauma resuscitation center.

METHODS

Three trained human factors analysts individually categorized 1,137 workflow disruptions identified in a previously collected data set involving 65 observed trauma care cases using the HFACS framework.

RESULTS

Results revealed that the framework was substantially reliable overall (κ = 0.680); agreement increased when only the preconditions for unsafe acts were investigated (κ = 0.757). Findings of the analysis also revealed that the preconditions for unsafe acts category was most highly populated (91.95%), consisting mainly of failures involving communication, coordination, and planning.

CONCLUSION

This study helps validate the use of HFACS as a tool for classifying observational data in a variety of medical domains. By identifying preconditions for unsafe acts, health care professionals may be able to construct a more robust safety management system that may provide a better understanding of the types of threats that can impact patient safety.

Relationships Between Expertise, Crew Familiarity and Surgical Workflow Disruptions: An Observational Study

BACKGROUND

Teamwork is an essential factor in reducing workflow disruption (WD) in the operating room. Team familiarity (TF) has been recognized as an antecedent to surgical quality and safety. To date, no study has examined the link between team members' role and expertise, TF and WD in surgical setting. This study aimed to examine the relationships between expertise, surgeon-scrub nurse familiarity and WD.

METHODS

We observed a convenience sample of 12 elective neurosurgical procedures carried out by 4 surgeons and 11 SN with different levels of expertise and different degrees of familiarity between surgeons and SN. We calculated the number of WD per unit of coding time to control for the duration of operation. We explored the type and frequency of WD, and the differences between the surgeons and SN. We examined the relationships between duration of WD, staff expertise and surgeon-scrub nurse familiarity.

RESULTS

9.91% of the coded surgical time concerned WD. The most frequent causes of WD were distractions (29.7%) and colleagues' interruptions (25.2%). This proportion was seen for SN, whereas teaching moments and colleagues' interruptions were the most frequent WD for surgeons. The WD was less high among expert surgeons and less frequent when surgeon was familiar with SN.

CONCLUSIONS

The frequency of WD during surgical time can compromise surgical quality and patient safety. WD seems to decrease in teams with high levels of surgeon-scrub nurse familiarity and with development of surgical expertise. Favoring TF and giving feedback to the team about WD issues could be interesting ways to improve teamwork.

Decreased transport time to the surgical intensive care unit

INTRODUCTION

Extended stay in the emergency department (ED) is associated with worse outcomes in critically ill trauma patients. We conducted a human factors analysis to better understand impediments for patient flow when a surgical ICU (SICU bed is available in order to reduce ED LOS.

METHODS

This is a retrospective review of all trauma patients admitted to a protected SICU through the ED during 2011 and 2014. In 2010, a 24-hour protected SICU bed protocol was implemented to make a bed readily available. During 2013 human factors analysis helped to describe flow disruptions; related interventions were introduced to facilitate rapid transport from the ED to SICU. The interventions required the following prior to CT scanning: immediate ICU bed orders placed by the ED physician and ED to ICU personnel communication. Direct transport from the CT scanner to the ICU was mandated. Data including patient demographics, injury severity, ED LOS, ICU LOS, and hospital LOS was collected and compared between 2011 (PRE) and 2014 (POST).

RESULTS

A total of 305 trauma patients admitted from the ED to the SICU were analyzed; 174 patients in 2011 (PRE) and 131 in 2014 (POST). Average age was 46 years and patients had a mean admission GCS and injury severity score (ISS) of 12.3 and 15.9, respectively. The cohorts were similar in age, mechanism of injury, initial vital signs, and injury severity. After implementing the human factors interventions, decreases were noted in the mean ED LOS (2.4 v. 3.0 hours, p=0.005) and ICU LOS (4.0 v. 4.8 days, p=0.023). No differences in hospital LOS or mortality were observed.

CONCLUSIONS

While an open SICU bed protocol may facilitate rapid transport of trauma patients from the ED to the ICU, additional human factors interventions emphasizing improved communication and coordination can further reduce time spent in the ED.

LEVEL OF EVIDENCE

Level IV, Economic/Decision.

Nursing Interruptions in a Trauma Intensive Care Unit: A Prospective Observational Study

OBJECTIVE

The aims of this study were to identify and analyze elements that affect duration of an interruption and likelihood of activity switch as experienced by nurses in an ICU.

BACKGROUND

Although interruptions in the ICU impact patient safety, little is known regarding the complex situations that drive them.

METHODS

RNs were observed in a 23-bed surgical ICU. We observed 206 interruptions, and analyzed for duration and activity switch.

RESULTS

RNs were interrupted on the average every 21.8 minutes. Attending physicians/residents caused fewer, but longer, interruptions to the RN. Longer interruptions were more likely to result in an activity switch. During complex situations such as when an RN is documenting, interruptions by a physician led to longer durations. Interruptions by a device led to higher switches.

CONCLUSIONS

A deeper understanding of individual factors and their complex interactions related to interruptions experienced by ICU RNs are vital to understanding the clinical significance of these interruptions and intervention design.

Qualitative assessment of simulation-based training for pediatric trauma resuscitation

BACKGROUND

Effective teamwork is critical in the trauma bay, although there is a lack of consensus related to optimal training for these skills. We implemented in situ trauma simulations with debriefing as a possible training methodology to improve team-oriented skills.

METHODS

Focus groups were conducted with multidisciplinary clinicians who respond to trauma activations. The focus group questions were intended to elicit discussion on the clinicians' experiences during trauma activations and simulations with an emphasis on confidence, leadership, cooperation, communication, and opportunities for improvement. Thematic content analysis was conducted using Atlas.ti analytical software.

RESULTS

Ten focus groups were held with a total of 55 clinicians. Qualitative analysis of focus group feedback revealed the following selected themes: characteristics of a strong leader during a trauma, factors impacting trauma team members' confidence, and effective communication as a key component during trauma response. Participants recommended continued simulations to enhance trauma team trust and efficiency.

CONCLUSION

Clinicians responding to pediatric trauma resuscitations valued the practice they received during trauma simulations and supported the continuation of the simulations to improve trauma activation teamwork and communication. Findings will inform the development of future simulation-based training programs to improve teamwork, confidence, and communication between trauma team members.

Barriers to efficiency in robotic surgery: the resident effect

BACKGROUND

Robotic surgery offers advantages over conventional operative approaches but may also be associated with higher costs and additional risks. Analyzing surgical flow disruptions (FDs), defined as "deviations from the natural progression of an operation," can help target training techniques and identify opportunities for improvement.

MATERIALS AND METHODS

Thirty-two robotic surgery operations were observed over a 6-wk period at one 900-bed surgical center. FDs were recorded in detail and classified into one of 11 different categories. Procedure type, robot model, and resident involvement were also recorded. Linear regression analyses were used to evaluate the effects of these parameters on FDs and operative duration.

RESULTS

Twenty-one prostatectomies, eight sacrocolpopexies, and three nephrectomies were observed. The mean number of FDs was 48.2 (95% confidence interval [CI] 38.6-54.8 FDs), and mean operative duration was 163 min (95% CI 148-179 min). Each FD added 2.4 min (P = 0.025) to a case's total operative duration. The number and rate of FDs were significantly affected by resident involvement (P = 0.008 and P = 0.006, respectively). Resident cases demonstrated mostly training, equipment, and robot switch FDs, whereas nonresident cases demonstrated mostly equipment, instrument changes, and external factor FDs.

CONCLUSIONS

Although the FDs encountered in resident training are more frequent, they may not significantly increase operative duration. Other FDs, such as equipment or external factors, may be more impactful. Limiting these specific FDs should be the focus of performance improvement efforts.

Whatever happens to trauma patients who leave against medical advice?

BACKGROUND

Although trauma patients are frequently discharged against medical advice (AMA), the fate of these patients remains mostly unknown.

METHODS

Patients with traumatic injuries were identified in the California State Inpatient Database, 2007 to 2011. Readmission characteristics of patients discharged AMA were compared with patients discharged home.

RESULTS

There were 203,756 (75.65%) patients discharged home and 4,480 (1.66%) discharged AMA. Compared with those discharged home, patients discharged AMA had significantly higher 30-day readmission rates (17.12% vs 6.75%), rates of multiple readmissions (3.83% vs 1.12%), and likelihood of being readmitted at different hospitals (44.83% vs 33.82%) (all P < .001). The commonest reasons for readmission in patients discharged AMA were psychiatric conditions [adjusted odds ratio: 1.67 (1.21 to 2.27)].

CONCLUSIONS

Discharge AMA is associated with multiple readmissions and higher rates of readmissions at different hospitals. Early identification of vulnerable patients and improved modalities to prevent discharge AMA among these patients may reduce the negative outcomes associated with discharge AMA among trauma patients.

Safety, efficiency and learning curves in robotic surgery: a human factors analysis

BACKGROUND

Expense, efficiency of use, learning curves, workflow integration and an increased prevalence of serious incidents can all be barriers to adoption. We explored an observational approach and initial diagnostics to enhance total system performance in robotic surgery.

METHODS

Eighty-nine robotic surgical cases were observed in multiple operating rooms using two different surgical robots (the S and Si), across several specialties (Urology, Gynecology, and Cardiac Surgery). The main measures were operative duration and rate of flow disruptions-described as 'deviations from the natural progression of an operation thereby potentially compromising safety or efficiency.' Contextual parameters collected were surgeon experience level and training, type of surgery, the model of robot and patient factors. Observations were conducted across four operative phases (operating room pre-incision; robot docking; main surgical intervention; post-console).

RESULTS

A mean of 9.62 flow disruptions per hour (95 % CI 8.78-10.46) were predominantly caused by coordination, communication, equipment and training problems. Operative duration and flow disruption rate varied with surgeon experience (p = 0.039; p < 0.001, respectively), training cases (p = 0.012; p = 0.007) and surgical type (both p < 0.001). Flow disruption rates in some phases were also sensitive to the robot model and patient characteristics.

CONCLUSIONS

Flow disruption rate is sensitive to system context and generates improvement diagnostics. Complex surgical robotic equipment increases opportunities for technological failures, increases communication requirements for the whole team, and can reduce the ability to maintain vision in the operative field. These data suggest specific opportunities to reduce the training costs and the learning curve.

Differentiating between detrimental and beneficial interruptions: a mixed-methods study

INTRODUCTION

Efforts to understand interruptions now span much of the last decade and a half. Often thought to negatively impact patient safety, some now acknowledge that interruptions may be beneficial and actually necessary for safety and high quality care. This study seeks a framework for differentiating between interruptions that are detrimental and those that are beneficial.

METHODS

A mixed-methods approach at a US Level 1 trauma centre included direct observation of 13 registered nurses (RNs), survey of 47 RNs, retrospective observation of hands-free communication devices, and modelling of observed interruptions to key performance measures.

RESULTS

On average, RNs were interrupted every 11 min, with 20.3% of their workload triggered by interruptions. While 85% of RNs agreed that interruptions place their patients at risk, only 21% agreed that all should be eliminated. During one 90-min period, 18 original events spawned 68 interruptions, 50 of these repeat messages. A statistical model, with patient measures of time and comfort, revealed that alarms and call lights returning RN's attention to the patient outside the patient room are beneficial, while interruptions in the patient room are generally detrimental. Triangulating the results, we present an emerging framework for differentiating between beneficial and detrimental interruptions based on the impact of interruptions on the RN's steady treatment and attention to the patient.

CONCLUSIONS

A mixed-methods approach can help distinguish between detrimental and beneficial interruptions. While interruptions breaking the delivery of steady treatment and attention to the patient are detrimental, those returning the RN's focus to the patient, as well as those supporting patient-clinician and clinician-clinician communications are beneficial. This insight may be helpful to healthcare delivery teams tasked with improving interruption-laden processes.

Lost information during the handover of critically injured trauma patients: a mixed-methods study

BACKGROUND

Clinical information may be lost during the transfer of critically injured trauma patients from the emergency department (ED) to the intensive care unit (ICU). The aim of this study was to investigate the causes and frequency of information discrepancies with handover and to explore solutions to improving information transfer.

METHODS

A mixed-methods research approach was used at our level I trauma centre. Information discrepancies between the ED and the ICU were measured using chart audits. Descriptive, parametric and non-parametric statistics were applied, as appropriate. Six focus groups of 46 ED and ICU nurses and nine individual interviews of trauma team leaders were conducted to explore solutions to improve information transfer using thematic analysis.

RESULTS

Chart audits demonstrated that injuries were missed in 24% of patients. Clinical information discrepancies occurred in 48% of patients. Patients with these discrepancies were more likely to have unknown medical histories (p<0.001) requiring information rescue (p<0.005). Close to one in three patients with information rescue had a change in clinical management (p<0.01). Participants identified challenges according to their disciplines, with some overlap. Physicians, in contrast to nurses, were perceived as less aware of interdisciplinary stress and their role regarding variability in handover. Standardising handover, increasing non-technical physician training and understanding unit cultures were proposed as solutions, with nurses as drivers of a culture of safety.

CONCLUSION

Trauma patient information was lost during handover from the ED to the ICU for multiple reasons. An interprofessional approach was proposed to improve handover through cross-unit familiarisation and use of communication tools is proposed. Going beyond traditional geographical and temporal boundaries was deemed important for improving patient safety during the ED to ICU handover.

Intra-operative disruptions, surgeon's mental workload, and technical performance in a full-scale simulated procedure

BACKGROUND AND AIM

Surgical flow disruptions occur frequently and jeopardize perioperative care and surgical performance. So far, insights into subjective and cognitive implications of intra-operative disruptions for surgeons and inherent consequences for performance are inconsistent. This study aimed to investigate the effect of surgical flow disruption on surgeon's intra-operative workload and technical performance.

METHODS

In a full-scale OR simulation, 19 surgeons were randomly allocated to either of the two disruption scenarios (telephone call vs. patient discomfort). Using a mixed virtual reality simulator with a computerized, high-fidelity mannequin, all surgeons were trained in performing a vertebroplasty procedure and subsequently performed such a procedure under experimental conditions. Standardized measures on subjective workload and technical performance (trocar positioning deviation from expert-defined standard, number, and duration of X-ray acquisitions) were collected.

RESULTS

Intra-operative workload during simulated disruption scenarios was significantly higher compared to training sessions (p < .01). Surgeons in the telephone call scenario experienced significantly more distraction compared to their colleagues in the patient discomfort scenario (p < .05). However, workload tended to be increased in surgeons who coped with distractions due to patient discomfort. Technical performance was not significantly different between both disruption scenarios. We found a significant association between surgeons' intra-operative workload and technical performance such that surgeons with increased mental workload tended to perform worse (β = .55, p = .04).

CONCLUSIONS

Surgical flow disruptions affect surgeons' intra-operative workload. Increased mental workload was associated with inferior technical performance. Our simulation-based findings emphasize the need to establish smooth surgical flow which is characterized by a low level of process deviations and disruptions.

A Comprehensive Methodology for Examining the Impact of Surgical Team Briefings and Debriefings on Teamwork

The adoptions of briefing and debriefing protocols have evolved from the Joint Commission’s initiative to improve communication and safety in the operating room. Briefing normally occurs prior to incision and is used to discuss and confirm critical information, while debriefing occurs during or after surgery. Debriefing provides a unique opportunity for individuals and teams to immediately reflect on their performance, allowing them to more easily identify errors and develop plans to improve their next performance. Studies have shown that using briefings and debriefings improve communication and teamwork. However, there is still much to learn about the value of both for surgical teams. This paper presents a robust methodology for examining and measuring the impacts of surgical team briefings and debriefings on teamwork. The methodology includes (1) audio/video recording the surgical care process, (2) prospective observations using a validated electronic data collection tool, (3) pre- and post-surgery surveys, and (4) individual surgical team member interviews. The current paper describes the methodology to obtain a robust and comprehensive data set for analyzing the impacts of briefing and debriefing on teamwork; the results of the surgeries recorded using this methodology will be presented in subsequent papers.