Quantifying Intraoperative Workloads Across the Surgical Team Roles: Room for Better Balance?

A novel multimodal, intraoperative cognitive workload assessment of cardiac surgery team members

OBJECTIVE

To characterize cognitive workload (CWL) of cardiac surgery team members in a real-world setting during coronary artery bypass grafting (CABG) surgery using providers' heart rate variability (HRV) data as a surrogate measure of CWL.

METHODS

HRV was collected from the surgeon, anesthesiologist, perfusionist, and scrub nurse, and audio/video recordings were made during isolated, nonemergency CABG surgeries (n = 27). Eight surgical phases were annotated by trained researchers, and HRV was calculated for each phase.

RESULTS

Significant differences in CWL were observed within a given role across surgical phases. Results are reported as predicted probability (95% confidence interval [CI]). CWL was significantly higher for anesthesiologists during "preparation and induction" (0.57; 95% CI, 0.42-0.71) and "anastomoses" (0.44; 95% CI, 0.30-0.58) compared to other phases, and the same held for nurses during the "opening" (0.51; 95% CI, 0.37-0.65) and "postoperative" (0.68; 95% CI, 0.42-0.86) phases. Additional significant differences were observed between roles within a given surgical phase. For example, surgeons had significantly higher CWL during "anastomoses" (0.81; 95% CI, 0.69-0.89) compared to all other phases, and the same was true of perfusionists during the "opening" (0.79; 95% CI, 0.66-0.88) and "prebypass preparation" (0.50; 95% CI, 0.36-0.64) phases.

CONCLUSIONS

Our innovative analysis demonstrates that CWL fluctuates across surgical procedures by role and phase, which may reflect the distribution of primary tasks. This corroborates earlier findings from self-report measures. The data suggest that team-wide, peak CWL during a phase decreases from early phases of surgery through initiation of cardiopumonary bypass (CPB), rises during anastomosis, and decreases after termination of CPB. Knowledge of these trends could encourage the adoption of behaviors to enhance team dynamics and performance.

Intraoperative workload of the surgeon in robot-assisted radical prostatectomy: a systematic review

In the present study, we aimed to systematically evaluate the current evidence regarding the intraoperative workload of surgeons performing robot-assisted radical prostatectomy (RARP) for prostate cancer. A systematic search was carried out in the PubMed-MEDLINE and Web of Science databases through April 2024 using the following search terms: "workload AND robot assisted radical prostatectomy", "workload AND robotic radical prostatectomy", "task load AND robotic radical prostatectomy", "task load AND robot assisted radical prostatectomy" and "NASA-TLX AND robot assisted radical prostatectomy" by combining population, intervention, comparison, and outcome (PICO) terms, following preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. We therefore selected studies that included patients with prostate cancer (P) who underwent robotic radical prostatectomy (I) and reported a workload/task load questionnaire (C) to assess the intraoperative workload/task load of the surgeon performing robot-assisted radical prostatectomy (O). A total of 11 studies were identified. The surgeon's workload during RARP was assessed using the National Aeronautics and Space Administration task load index (NASA-TLX) and/or the surgery task load index (SURG-TLX) in the studies. Total NASA-TLX scores of the studies ranged from 22.7 ± 3.2 to 62.0 ± 6.4. Mental and physical demands, flow interruptions, surgeon experience, the use of single or multiple ports, and the relationship between the surgeon and other staff in the operating theater may play a role in the intraoperative workload of the console surgeon. The studies we reviewed suggest that RARP offers an acceptable workload for the console surgeon despite its mental demands.

How ready is the health care system in Northeast India for surgical delivery? a mixed-methods study on surgical capacity and need

BACKGROUND

Surgical services are scarce with persisting inequalities in access across populations and regions globally. As the world's most populous county, India's surgical need is high and delivery rates estimated to be sub-par to meet need. There is a dearth of evidence, particularly sub-regional data, on surgical provisioning which is needed to aid planning.

AIM AND METHOD

This mixed-methods study examines the state of surgical care in Northeast India, specifically health care system capacity and barriers to surgical delivery. It involved a facility-based census and semi-structured interviews with surgeons and patients across four states in the region.

RESULTS

Abdominal conditions constituted a large portion of the overall surgeries across public and private facilities in the region. Workloads varied among surgical providers across facilities. Task-shifting occurred, involving non-specialist nursing staff assisting doctors with surgical procedures or surgeons taking on anaesthetic tasks. Structural factors dis-incentivised facility-level investment in suitable infrastructure. Facility functionality was on average higher in private providers compared to public providers and private facilities offer a wider range of surgical procedures. Facilities in general had adequate laboratory testing capability, infrastructure and equipment. Public facilities often do not have surgeon available around the clock while both public and private facilities frequently lack adequate blood banking. Patients' care pathways were shaped by facility-level shortages as well as personal preferences influenced by cost and distance to facilities.

DISCUSSION AND CONCLUSION

Skewed workloads across facilities and regions indicate uneven surgical delivery, with potentially variable care quality and provider efficiency. The need for a more system-wide and inter-linked approach to referral coordination and human resource management is evident in the results. Existing task-shifting practices, along with incapacities induced by structural factors, signal the directions for possible policy action.

Revision Total Joint Arthroplasty Places a Disproportionate Burden on Surgeons: A Comparison Using the National Aeronautics and Space Administration Task Load Index (NASA TLX)

BACKGROUND

Perceived surgeon workload of performing primary and revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) is challenging to quantify. The National Aeronautics and Space Administration Task Load Index (NASA TLX) survey was developed to quantify experiences following aviation and has been applied to healthcare fields. Our purposes were to 1) quantify the workload endured by surgeons who are performing primary and revision TKA and THA and 2) compare these values to their Center for Medicare & Medicaid Services (CMS) reimbursement.

METHODS

A prospective cohort of 5 fellowship-trained adult reconstruction surgeons completed NASA TLX surveys following primary and revision TKA/THA cases. A total of 122 surveys consisting of 70 TKA (48 primaries and 22 revisions) and 55 THA surveys (38 primaries and 17 revisions) were completed. Patient demographics and surgical variables were recorded. Final NASA TLX workloads were compared to 2021 CMS work relative value units.

RESULTS

Compared to primary TKA, revision TKA had 176% increased intraoperative workload (P < .001), 233% increased mental burden (P < .001), and 150% increased physical burden (P < .001). Compared to primary THA, revision THA had 106% increased intraoperative workload (P < .001), 96% increased mental burden (P < .001), and 91% increased physical burden (P < .001). Operative time was higher in revision versus primary TKA (118 versus 84.5 minutes, P = .05) and THA (150 versus 115 minutes, P = .001). Based upon 2021 CMS data, revision TKA and THA would need to be compensated by an additional 36% and 12.3%, respectively, to parallel intraoperative efforts.

CONCLUSIONS

Revision hip and knee arthroplasty places a major mental and physical workload upon surgeons and is disproportionately compensated by CMS.

The compatibility of exoskeletons in perioperative environments and workflows: an analysis of surgical team members' perspectives and workflow simulation

Surgical team members in perioperative environments experience high physical demands. Interventions such as exoskeletons, external wearable devices that support users, have the potential to reduce these work-related physical demands. However, barriers such as workplace environment and task compatibility may limit exoskeleton implementation. This study gathered the perspectives of 33 surgical team members: 12 surgeons, four surgical residents, seven operating room (OR) nurses, seven surgical technicians (STs), two central processing technicians (CPTs), and one infection control nurse to understand their workplace compatibility. Team members were introduced to passive exoskeletons via demonstrations, after which surgical staff (OR nurses, STs, and CPTs) were led through a simulated workflow walkthrough where they completed tasks representative of their workday. Five themes emerged from the interviews (workflow, user needs, hindrances, motivation for intervention, and acceptance) with unique subthemes for each population. Overall, exoskeletons were largely compatible with the duties and workflow of surgical team members.

Team Stress and Its Impact on Interprofessional Teams: A Narrative Review

Phenomenon: Interprofessional healthcare team (IHT) collaboration can produce powerful clinical benefits for patients; however, these benefits are difficult to harness when IHTs work in stressful contexts. Research about stress in healthcare typically examines stress as an individual psychological phenomenon, but stress is not only a person-centered experience. Team stress also affects the team's performance. Unfortunately, research into team stress is limited and scattered across many disciplines. We cannot prepare future healthcare professionals to work as part of IHTs in high-stress environments (e.g., emergency medicine, disaster response) unless we review how this dispersed literature is relevant to medical education. Approach: The authors conducted a narrative review of the literature on team stress experienced by interprofessional teams. The team searched five databases between 1 Jan 1990 and 16 August 2021 using the search terms: teams AND stress AND performance. Guided by four research questions, the authors reviewed and abstracted data from the 22 relevant manuscripts. Findings: Challenging problems, time pressure, life threats, environmental distractors, and communication issues are the stressors that the literature reports that teams faced. Teams reacted to team stress with engagement/cohesion and communication/coordination. Stressors impact team stress by either hindering or improving team performance. Critical thinking/decision-making, team behaviors, and time for task completion were the areas of performance affected by team stress. High-quality communication, non-technical skills training, and shared mental models were identified as performance safeguards for teams experiencing team stress. Insights: The review findings adjust current models explaining drivers of efficient and effective teams within the context of interprofessional teams. By understanding how team stress impacts teams, we can better prepare healthcare professionals to work in IHTs to meet the demands placed on them by the ever-increasing rate of high-stress medical situations.

The effect of music on the operating surgeon: a pilot randomized crossover trial (the MOSART study)

OBJECTIVE

The experience of stress is common among surgeons while working in the operating theatre (OT). Understanding and finding ways to mitigate this stress is important for optimizing surgical quality and maintaining clinician wellbeing. In this pilot study, we tested the feasibility and reported the outcomes of measuring the effect of background music on intra-operative surgeon stress in the clinical environment.

METHODS

The effect of Music on the Operating Surgeon: A pilot Randomized crossover Trial (the MOSART study) was conducted over a 9-month period in a single-centre. Vascular and general surgeons acting as primary operators (POs) performing elective, general anaesthetic operations were included. The intervention was surgeon-selected music, and the control was the absence of music. Outcome measures were feasibility (recruitment rate, practicability, and completeness of data), heart rate variability (HRV) indices, the Six-Item State-Trait Anxiety Inventory (STAI-6), and the Surgical Task-load Index (SURG-TLX).

RESULTS

Five POs performed 74 eligible randomized cases. The protocol was well tolerated, and no cases were abandoned. Data was incomplete in 8% of cases. The overall mean (SD) operative SURG-TLX score was 48 (±22). Mean HR increased and RMSSD decreased significantly from baseline, suggesting reduced parasympathetic activity while operating. The presence of intra-operative music was not found to affect the psychological or physiological outcomes.

CONCLUSIONS

A music interventional study of this nature is feasible in the operating theatre environment, though no difference was found between in the music and non-music conditions. Follow-up research in a simulated environment with intensive physiological monitoring could be considered.

Quantifying Workload and Stress in Intensive Care Unit Nurses: Preliminary Evaluation Using Continuous Eye-Tracking

OBJECTIVE

(1) To assess mental workloads of intensive care unit (ICU) nurses in 12-hour working shifts (days and nights) using eye movement data; (2) to explore the impact of stress on the ocular metrics of nurses performing patient care in the ICU.

BACKGROUND

Prior studies have employed workload scoring systems or accelerometer data to assess ICU nurses' workload. This is the first naturalistic attempt to explore nurses' mental workload using eye movement data.

METHODS

Tobii Pro Glasses 2 eye-tracking and Empatica E4 devices were used to collect eye movement and physiological data from 15 nurses during 12-hour shifts (252 observation hours). We used mixed-effect models and an ordinal regression model with a random effect to analyze the changes in eye movement metrics during high stress episodes.

RESULTS

While the cadence and characteristics of nurse workload can vary between day shift and night shift, no significant difference in eye movement values was detected. However, eye movement metrics showed that the initial handoff period of nursing shifts has a higher mental workload compared with other times. Analysis of ocular metrics showed that stress is positively associated with an increase in number of eye fixations and gaze entropy, but negatively correlated with the duration of saccades and pupil diameter.

CONCLUSION

Eye-tracking technology can be used to assess the temporal variation of stress and associated changes with mental workload in the ICU environment. A real-time system could be developed for monitoring stress and workload for intervention development.

Examining workload variations among different surgical team roles, specialties, and techniques: a multicenter cross-sectional descriptive study

BACKGROUND

A high workload may negatively impact the surgical team's performance and jeopardize patient safety. The aim of this study was to measure the workload of the surgical team across different surgical roles, specialties, and techniques in several hospitals.

METHODS

This cross-sectional multicenter study was performed in the operating rooms of eight teaching hospitals affiliated with Isfahan University of Medical Sciences, Iran. At the conclusion of each surgical procedure, all members of the surgical team completed the Surgery Task Load Index (SURG-TLX) questionnaire to assess workload levels. Descriptive statistics, analysis of variance (ANOVA), and Pearson correlations, were performed to compare surgical roles, specialties, techniques, and surgical time on workload overall and by subscale.

RESULTS

A total of 409 workload questionnaires were obtained from 76 surgical teams or cases, involving 346 surgical team members. The total workload among all participants was 32.41 ± 17.21. Surgical complexity, physical demands, and mental demands were the highest workload subscales and distraction was the lowest workload subscale. Cardiovascular specialty had a higher workload compared to other specialties. Open techniques resulted in a higher workload compared to minimally invasive techniques. Surgical technologists who act in both the role of circulating and scrub nurse (C&Ss) experienced the highest workload, followed by surgical residents and surgeons.

CONCLUSIONS

The results of the study showed that the workload for some members of the surgical team is disproportionately high and is influenced by factors such as specialty, technique, role, and surgical duration. By knowing the distribution of workload among the members of the surgical team, efforts can be made to optimize the team members' workload.

Impact of preferred surgical modality on surgeon wellness: a survey of workload, physical pain/discomfort, and neuromusculoskeletal disorders

BACKGROUND

We compared surgeons' workload, physical discomfort, and neuromusculoskeletal disorders (NMSDs) across four surgical modalities: endoscopic, laparoscopic, open, and robot-assisted (da Vinci Surgical Systems).

METHODS

An electronic survey was sent to the surgeons across an academic hospital system. The survey consisted of 47 questions including: (I) Demographics and anthropometrics; (II) The percentage of the procedural time that the surgeon spent on performing each surgical modality; (III) Physical and mental demand and physical discomfort; (IV) Neuromusculoskeletal symptoms including body part pain and NMSDs.

RESULTS

Seventy-nine out of 245 surgeons completed the survey (32.2%) and 65 surgeons (82.2%) had a dominant surgical modality: 10 endoscopic, 15 laparoscopic, 26 open, and 14 robotic surgeons. Physical demand was the highest for open surgery and the lowest for endoscopic and robotic surgeries, (all p < 0.05). Open and robotic surgeries required the highest levels of mental workload followed by laparoscopic and endoscopic surgeries, respectively (all p < 0.05 except for the difference between robotic and laparoscopic that was not significant). Body part discomfort or pain (immediately after surgery) were lower in the shoulder for robotic surgeons compared to laparoscopic and open surgeons and in left fingers for robotic surgeons compared to endoscopic surgeons (all p < 0.05). The prevalence of NMSD was significantly lower in robotic surgeons (7%) compared to the other surgical modalities (between 60 and 67%) (all p < 0.05).

CONCLUSIONS

The distribution of NMSDs, workload, and physical discomfort varied significantly based on preferred surgical approach. Although robotic surgeons had fewer overall complaints, improvement in ergonomics of surgery are still warranted.

Demands of surgical teams in robotic-assisted surgery: An assessment of intraoperative workload within different surgical specialties

BACKGROUND

Current approaches to assessing workload in robotic-assisted surgery (RAS) focus on surgeons and lack real-world data. Understanding how workload varies by role and specialty aids in identifying effective ways to optimize workload.

METHODS

SURG-TLX surveys with six domains of workload were administered to surgical staff at three sites. Staff reported workload perceptions for each domain on a 20-point Likert scale, and aggregate scores were determined per participant.

RESULTS

188 questionnaires were obtained across 90 RAS procedures. Significantly higher aggregate scores were reported for gynecology (Mdn ​= ​30.00) (p ​= ​0.034) and urology (Mdn ​= ​36.50) (p ​= ​0.006) than for general (Mdn ​= ​25.00). Surgeons reported significantly higher scores for task complexity (Mdn ​= ​8.00) than both technicians (Mdn ​= ​5.00) (p ​= ​0.007), and nurses (Mdn ​= ​5.00).

CONCLUSIONS

Staff reported significantly higher workload during urology and gynecology procedures, and experienced significant differences in domain workload by role and specialty, elucidating the need for tailored workload interventions.

Human Factors Approach to Assess Physician Workload in Elective Plastic Surgery Breast Procedures

Background

Human factors research involves the study of work system interactions, physician workload, cognitive effort, and performance. This pilot study incorporated a human factor approach and other surgery-based metrics to assess cognitive workload among plastic surgeons during elective plastic surgery breast procedures.

Methods

In this prospective study of plastic surgery breast procedures over a 3-month period, surgeon and patient demographics and procedural details were collected. The lead surgeon assessed each procedure using a validated workload questionnaire (National Aeronautics and Space Administration Task Load Index [NASA-TLX]) that included 6 subscales (ie, mental, physical, temporal demand, performance, effort, and frustration), a question on distraction, and their expectation of procedural difficulty.

Results

Fifty-seven cases were included in this study. Surgical duration had a positive correlation with increased mental demand (P < .001), physical demand (P < .001), and degree of distractions (P < .001). Free flap reconstruction, breast reduction, and transgender mastectomy had the highest average mental, physical demands, and perceived effort. Bilateral cases had significantly higher workload than unilateral ones (P = .002). NASA-TLX scores between immediate and delayed reconstructions were comparable, but delayed cases had higher degree of distractions (P = .04). There was a strong correlation between degree of distractions and increased mental workload (R = 0.68; P < .001), increased physical demand (P = 0.61; P < .001), and increased temporal demand (R = 0.78; P < .001). More difficult procedures were associated with greater procedural duration than those rated as difficult as expected or less difficult than expected (P = .02).

Conclusions

These preliminary data demonstrated multiple factors that may influence and govern perceived physician workload and may provide insight for targeted quality improvement to plan procedures safely and effectively.

Biomechanical Load of Neck and Lumbar Joints in Open-Surgery Training

The prevalence of musculoskeletal symptoms (MSS) like neck and back pain is high among open-surgery surgeons. Prolonged working in the same posture and unfavourable postures are biomechanical risk factors for developing MSS. Ergonomic devices such as exoskeletons are possible solutions that can reduce muscle and joint load. To design effective exoskeletons for surgeons, one needs to quantify which neck and trunk postures are seen and how much support during actual surgery is required. Hence, this study aimed to establish the biomechanical profile of neck and trunk postures and neck and lumbar joint loads during open surgery (training). Eight surgical trainees volunteered to participate in this research. Neck and trunk segment orientations were recorded using an inertial measurement unit (IMU) system during open surgery (training). Neck and lumbar joint kinematics, joint moments and compression forces were computed using OpenSim modelling software and a musculoskeletal model. Histograms were used to illustrate the joint angle and load distribution of the neck and lumbar joints over time. During open surgery, the neck flexion angle was 71.6% of the total duration in the range of 10~40 degrees, and lumbar flexion was 68.9% of the duration in the range of 10~30 degrees. The normalized neck and lumbar flexion moments were 53.8% and 35.5% of the time in the range of 0.04~0.06 Nm/kg and 0.4~0.6 Nm/kg, respectively. Furthermore, the neck and lumbar compression forces were 32.9% and 38.2% of the time in the range of 2.0~2.5 N/kg and 15~20 N/kg, respectively. In contrast to exoskeletons used for heavy lifting tasks, exoskeletons designed for surgeons exhibit lower support torque requirements while additional degrees of freedom (DOF) are needed to accommodate combinations of neck and trunk postures.

A randomised control trial study of early post-operative pain and intraoperative surgeon workload following laparoscopic mesh repair of midline ventral hernia by enhanced-view totally extraperitoneal and intraperitoneal onlay mesh plus approach

Introduction

The aim of this study was to compare the peri-operative outcomes, especially intraoperative surgeon workload and early post-operative pain, following midline ventral hernia repair by laparoscopic enhanced-view totally extraperitoneal (eTEP) approach and laparoscopic intraperitoneal onlay mesh plus (IPOM plus) approach.

Patients and Methods

This single-centre randomised control trial study was conducted from January 2020 to June 2022. A total of 60 adult patients undergoing elective ventral hernia surgery with small- and medium-sized midline defects were included. Intraoperative surgeon workload and early post-operative pain were systematically recorded and analysed for each procedure.

Results

Out of 30 patients assigned to each group, 29 patients underwent eTEP mesh repair and 27 patients underwent successful IPOM plus repair. The intraoperative surgeon's workload, especially mental demand, physical demand, task complexity and degree of difficulty as reported and felt by the operating surgeon, was significantly higher in the eTEP mesh repair group compared to IPOM plus group (P < 0.001) with comparable operating room distractions (P = 0.039). The mean overall post-operative pain score on post-operative day 1 was slightly less in eTEP mesh repair (4.28 ± 1.12) group compared to IPOM plus group (4.93 ± 1.17), which was statistically insignificant (P = 0.042). The eTEP group had significantly longer operative time and length of hospital stay compared to the IPOM plus group.

Conclusion

Our study revealed significantly longer operative time, higher surgical workload and increased length of hospital stay in the eTEP group with comparable early post-operative pain in both groups, thus making eTEP mesh repair a more difficult and challenging procedure.

Intraoperative workload in elective open vascular and endovascular surgery: A study of procedural drivers

This study investigated vascular surgeon workload and its association with specific procedural drivers over different procedure types. Thirteen attending vascular surgeons (two females) were emailed a survey over a 3-month period. Data from 253 surgical procedures (118 open, 85 endovascular, 18 hybrid, and 32 venous) revealed high physical and cognitive workload among vascular surgeons. Based on the statistically significant findings and similar non-significant trends in the data (significance level of 0.01), open and hybrid vascular procedures showed higher levels of physical and cognitive workload compared to venous cases, while endovascular procedures were relatively more moderate. Additionally, the workload subscales for five subcategories of open procedures (e.g., arteriovenous access) as well as three subcategories of endovascular procedures (e.g., aortic) were compared. The granularity of the intraoperative workload drivers across various vascular procedure types and adjunct equipment could be the key to create targeted ergonomic interventions to reduce workload during vascular surgeries.

Stress in surgical educational environments: a systematic review

BACKGROUND

The effects of stress on surgical residents and how stress management training can prepare residents to effectively manage stressful situations is a relevant topic. This systematic review aimed to analyze the literature regarding (1) the current stress monitoring tools and their use in surgical environments, (2) the current methods in surgical stress management training, and (3) how stress affects surgical performance.

METHODS

A search strategy was implemented to retrieve relevant articles from Web of Science, Scopus, and PubMed. The 787 initially retrieved articles were reviewed for further evaluation according to the inclusion/exclusion criteria (Prospero registration number CRD42021252682).

RESULTS

Sixty-one articles were included in the review. The stress monitoring methods found in the articles showed heart rate analysis as the most used monitoring tool for physiological parameters while the STAI-6 scale was preferred for psychological parameters. The stress management methods found in the articles were mental-, simulation- and feedback-based training, with the mental-based training showing clear positive effects on participants. The studies analyzing the effects of stress on surgical performance showed both negative and positive effects on technical and non-technical performance.

CONCLUSIONS

The impact of stress responses presents an important factor in surgical environments, affecting residents' training and performance. This study identified the main methods used for monitoring stress parameters in surgical educational environments. The applied surgical stress management training methods were diverse and demonstrated positive effects on surgeons' stress levels and performance. There were negative and positive effects of stress on surgical performance, although a collective pattern on their effects was not clear.

Characterizing exposure to physical risk factors during veterinary surgery with wearable sensors: a pilot study

Occupational ApplicationsVeterinarians provide comprehensive health services for animals, but despite exposure to similar occupational and safety hazards as medical physicians, physical risk factors for these doctors and healthcare teams have not been characterized. In this pilot study, we used wearable sensor technology and showed that veterinary surgeons commonly experience static and demanding postures while performing soft tissue and orthopedic surgeries. Observations showed that muscle activation was highest in the right trapezius. Job factors such as surgical role (attending vs. assisting) and surgical specialty (soft tissue vs. orthopedics) appeared to influence exposure to physical risk factors. These findings suggest a need to consider the unique demands of surgical specialties in order to address the key risk factors impacting injury risks among veterinarians. For example, static postures may be a priority for soft tissue surgeons, while tools that reduce force requirements are more pressing for orthopedic surgeons.Technical AbstractBackground: Although musculoskeletal fatigue, pain, and injuries are commonly reported among surgeons in veterinary medicine, few studies have objectively characterized the exposure to physical risk factors among veterinary surgeons.Purpose: This study aimed to characterize muscle activation and postures of the neck and shoulders during live veterinary surgeries in the soft tissue and orthopedic specialties.Methods: Forty-four ergonomic exposure assessments (exposures) were collected during 26 surgical procedures across five surgeons. Exposures were collected from both soft tissue (n = 23) and orthopedic (n = 21) specialties. Physical risk factors were characterized by: 1) directly measuring muscle activation and posture of the neck and shoulders, using surface electromyography and inertial measurement units, respectively; and 2) collecting self-reported workload, pain, and stiffness.Results: Across the 44 exposures, neck and back symptoms respectively worsened after the surgery in 27% and 14% of the exposures. Veterinary surgeons exhibited neck postures involving a mean of 17° flexion during the surgical procedures. Static postures were common, occurring during 53-80% of the procedures. Compared to soft tissue procedures (e.g., 13.2% MVC in the right trapezius), higher muscle activity was observed during orthopaedic procedures (e.g., 27.6% MVC in the right trapezius).Conclusions: This pilot study showed that physical risk factors (i.e., muscle activity and posture of the neck/shoulder) can be measured using wearable sensors during live veterinary surgeries. The observed risk factors were similar to those documented for medical physicians. Further studies are needed to bring awareness to opportunities for improving workplace ergonomics in veterinary medicine and surgery.

Auswirkungen der COVID-19-Pandemie auf die robotische Viszeralchirurgie in Deutschland

Einleitung

Der Einsatz roboterassistierter Operationen verzeichnet in der Viszeralchirurgie gegenwärtig einen stetigen Zuwachs. Im Jahr 2020 hat die COVID-19-Pandemie den klinischen und chirurgischen Alltag unerwartet wesentlich verändert. Wir haben in einer Umfrage den Status der roboterassistierten Viszeralchirurgie in Deutschland sowie die gegenwärtigen Ausbildungskonzepte evaluiert und deren Veränderungen unter dem Einfluss der COVID-19-Pandemie untersucht.

Material und Methoden

In einer umfangreichen Recherche wurden 89 Kliniken identifiziert, welche ein Robotersystem für die Viszeralchirurgie 2020 einsetzten. Diese Kliniken wurden über eine webbasierte anonyme Umfrage mit 35 Fragen dreimal kontaktiert. Die Fragen bezogen sich auf die Einsatzgebiete eines Operationsroboters in der Viszeralchirurgie, die dazugehörige klinische Ausbildung und den Einfluss der COVID-19-Pandemie auf das bestehende Programm.

Ergebnisse

Von den angeschriebenen Kliniken haben 22 (24,7%) eine Rückmeldung gegeben. Hiervon waren 17 (19,1%) Fragebögen auswertbar. Es beteiligten sich 58,8% Universitätsklinika, 17,6% Maximalversorger und 23,5% Schwerpunktkrankenhäuser an der Studie. Der Operationsroboter wurde am oberen Gastrointestinaltrakt (OGIT; 88,2%), am hepatopankreatikobiliären System (HPB; 82,4%) und im kolorektalen Bereich (KRK; 94,1%) sowie bei der Hernienversorgung (35,3%) eingesetzt. Der relative Anteil robotischer Eingriffe am operierten Gesamtkollektiv lag dabei zwischen 0,3% und 15,4%. Die Konversionsraten für 2020 lag im Mittel bei 4,6 ± 3,2%. Die Operationsroboter wurden zum Großteil im interdisziplinären Setting wechselweise mit anderen chirurgischen Disziplinen (82,4%) genutzt. Zu Lehrzwecken stand in sieben Kliniken (41,2%) eine zweite Konsole zur Verfügung. Die Ausbildungsstrukturen waren sehr heterogen und nur 13,2 ± 6,5% der Chirurg*innen pro Klinik waren in das Roboterprogramm involviert. In 82,4% existierten feste Teams, die sich aus Ober‑, Fach- und Assistenzärzt*innen zusammensetzen und in 76,5% wurden Ärzt*innen und Pflegepersonal über klinikinterne Ausbildungsprogramme geschult. Die COVID-19-Pandemie hatte einen Fallzahlrückgang robotischer Eingriffe im Vergleich zu 2019 bei 70% der Kliniken vor allem im zweiten Jahresquartal 2020 (64,7%) zur Folge. Dies wurde auf Personalmangel nichtchirurgischer Disziplinen (Anästhesie 35,3%, OP-Pflege 35,3%, Intensivmedizin 17,6%), interne Regularien (58,8%) und begrenzte Intensiv- oder Überwachungskapazitäten (47,1%) zurückgeführt. Die COVID-19-Pandemie führte in der robotischen Ausbildung teilweise bei der Assistenz am OP-Tisch (23,5%) und der Assistenz an der zweiten Konsole (42,9%) zu einem kompletten Ausbildungsstopp. Ausschlaggebend für diese Entwicklung war überwiegend der Rückgang der Operationszahlen.

Schlussfolgerung

Die Robotik wird mittlerweile in einem breiten Spektrum der Viszeralchirurgie an Kliniken mit unterschiedlichen Versorgungsschwerpunkten in Deutschland eingesetzt. Der relative Anteil der Eingriffe am Gesamtspektrum ist allerdings noch gering. Roboterassistierte Eingriffe sind expertenfokussiert und es bestehen sehr heterogene Ausbildungskonzepte. Ein Lernerfolg mit konstanten und niedrigen Konversionsraten ist nach wenigen Jahren mit zunehmender Erfahrung zu erkennen. Die COVID-19-Pandemie hatte insgesamt einen negativen Einfluss auf die robotischen OP-Fallzahlen und die damit verbundenen Ausbildungsmöglichkeiten bei freien chirurgischen Personalressourcen. Hier ist eine kreative Gestaltung optimierter Ausbildungsmodalitäten erforderlich.

Effect of Manual versus Robotic-Assisted Total Knee Arthroplasty on Cervical Spine Static and Dynamic Postures

This study compared surgeon cervical (C) spine postures and repetitive motions when performing traditional manual total knee arthroplasty (MTKA) versus robotic-assisted TKA (RATKA). Surgeons wore motion trackers on T3 vertebra and the occiput anatomical landmarks to obtain postural and repetitive motion data during MTKA and RATKA performed on cadavers. We assessed (1) flexion-extension at T3 and the occiput anatomical landmarks, (2) range of motion (ROM) as the percentage of time in the flexion-extension angle, (3) repetition rate, defined as the number of the times T3 and the occiput flexion-extension angle exceeded ±10°; and (4) static posture, where T3 or occiput postures exceed 10° for more than 30 seconds. The average T3 flexion-extension angle for MTKA cases was 5-degree larger than for RATKA cases (19 ± 8 vs. 14 ± 8 degrees). The surgeons who performed MTKA cases spent 15% more time in nonneutral C-spine ROM than those who performed RATKA cases (78 ± 25 vs. 63 ± 36%, p < 0.01). The repetition rate at T3 was 4% greater for MTKA than RATKA (14 ± 5 vs. 10 ± 6 reps/min). The percentage of time spent in static T3 posture was 5% greater for overall MTKA cases than for RATKA cases (15 ± 3 vs. 10 ± 3%). In this cadaveric study, we found differences in cervical and thoracic ergonomics between manual and robotic-assisted TKA. Specifically, we found that RATKA may reduce a surgeon's ergonomic strain at both the T3 and occiput locations by reducing the time the surgeon spends in a nonneutral position.

Design and Implementation of an Emergency Undocking Curriculum for Robotic Surgery

INTRODUCTION

Current training for robotic surgery crisis management, specifically emergency robotic undocking protocol (ERUP), remains limited to anecdotal experience. A curriculum to impart the skills and knowledge necessary to recognize and complete a successful ERUP was developed using an education approach then evaluated.

METHODS

Baseline knowledge and confidence regarding ERUP were established for 5 robotic teams before completing 2 full-immersion simulations separated by an online self-paced learning module. In each simulation, teams operated on a perfused hydrogel model and were tasked to dissect a retroperitoneal tumor abutting a major vessel. During vascular pedicle ligation, a major vascular bleed and nonrecoverable robotic fault were remotely induced, necessitating ERUP with open conversion. After the simulation, participants completed surgery task load index (cognitive load assessment) and realism surveys. Weighted checklists scored participants' actions during each simulation. Surgical metrics including estimated blood loss, time to control bleeding, and undocking time were recorded. Curriculum retention was assessed by repeating the exercise at 6 months.

RESULTS

Participants experienced high levels of cognitive demand and agreed that the simulation's realism and stress mimicked live surgery. Longitudinal analysis showed significant knowledge (+37.5 points, p = 0.004) and confidence (+15.3 points, p < 0.001) improvements from baseline to completion. Between simulations, checklist errors, undocking time, and estimated blood loss decreased (38⇾17, -40 seconds, and -500 mL, respectively), whereas action scores increased significantly (+27 points, p = 0.008). At 6 months, insignificant changes from curriculum completion were seen in knowledge (-4.8 points, p = 0.36) and confidence (+3.7 points, p = 0.1).

CONCLUSIONS

This simulation-based curriculum successfully improves operative team's confidence, knowledge, and skills required to manage robotic crisis events.

Influence of Perioperative Practice on Cognitive Function of Scrub Nurses: A Cross-Sequential Study

BACKGROUND

The operating room is a sophisticated, dynamic environment, with advanced technology. The goal of our study is to evaluate the effect of peri-operative practice on the cognitive functions of scrub nurses.

METHOD

This study included a total of 75 scrub nurses. The d2 Test of Attention was used for evaluation of cognitive function. The test was conducted with participants on three different working shifts.

RESULTS

A significant difference was found between overall mean values for total number of items processed, number of errors, total number of items processed minus number of errors, and concentration performance scores for the posttest compared with the pretest.

CONCLUSION

Perioperative practice has a significantly positive effect on cognitive function of scrub nurses, although this positive effect has a downward trend with increasing age as well as increasing workload. [J Contin Educ Nurs. 2021;52(12):565-574.].

Development of a local model for measuring the work of surgeons

Objective: The Relative Value Unit (RVU) is the main method of calculating surgeons’ reimbursements and a tool for measuring the work of surgeons. Existing evidence shows that the work Relative Value Unit (wRVU) does not accurately represent surgeon’s work. Therefore, the current study attempted to develop a local model to measure surgeons’ work.

Material and Methods: This study was conducted in two main phases of determining the metrics and model development using quantitative and qualitative approaches from December 2019 to April 2021. Literature review, focused group discussions, and interviews were used to collect data. Con- tent analysis and Exploratory Data Analysis techniques were applied to analyze data.

Results: The findings demonstrated that patient’s conditions (age, severity of disease at referring time, and comorbidities), disease specifications (time, complexity, physical effort, and risk), and provider characteristic (surgeon’s willingness, imposed stress, and surgeon’s skill) were important by 17, 51, and 32%, respectively, in determining surgeons’ work.

Conclusion: Determining a fixed value for each procedure does not accurately estimate the amount of required surgeon’s work for any procedure. Many factors, such as the patient’s condition, surgeon’s characteristics, and disease specification affect surgeons’ work in the operation room. Proper measurement of the surgeon’s work is an important step towards establishing equity in payment in the health system.

Analysis of Dynamic Changes in Cognitive Workload During Cardiac Surgery Perfusionists' Interactions With the Cardiopulmonary Bypass Pump

OBJECTIVE

This novel preliminary study sought to capture dynamic changes in heart rate variability (HRV) as a proxy for cognitive workload among perfusionists while operating the cardiopulmonary bypass (CPB) pump during real-life cardiac surgery.

BACKGROUND

Estimations of operators' cognitive workload states in naturalistic settings have been derived using noninvasive psychophysiological measures. Effective CPB pump operation by perfusionists is critical in maintaining the patient's homeostasis during open-heart surgery. Investigation into dynamic cognitive workload fluctuations, and their relationship with performance, is lacking in the literature.

METHOD

HRV and self-reported cognitive workload were collected from three Board-certified cardiac perfusionists (N = 23 cases). Five HRV components were analyzed in consecutive nonoverlapping 1-min windows from skin incision through sternal closure. Cases were annotated according to predetermined phases: prebypass, three phases during bypass, and postbypass. Values from all 1min time windows within each phase were averaged.

RESULTS

Cognitive workload was at its highest during the time between initiating bypass and clamping the aorta (preclamp phase during bypass), and decreased over the course of the bypass period.

CONCLUSION

We identified dynamic, temporal fluctuations in HRV among perfusionists during cardiac surgery corresponding to subjective reports of cognitive workload. Not only does cognitive workload differ for perfusionists during bypass compared with pre- and postbypass phases, but differences in HRV were also detected within the three bypass phases.

APPLICATION

These preliminary findings suggest the preclamp phase of CPB pump interaction corresponds to higher cognitive workload, which may point to an area warranting further exploration using passive measurement.

Intraoperative posture and workload assessment in vascular surgery

Quantifying the workload and postural demand on vascular surgeons provides valuable information on the physical and cognitive factors that predispose vascular surgeons to musculoskeletal pain and disorders. The aim of this study was to quantify the postural demand, workload, and discomfort experienced by vascular surgeons and to identify procedural factors that influence surgical workload. Both objective (wearable posture sensors) and subjective (surveys) assessment tools were used to evaluate intraoperative workload during 47 vascular surgery procedures. Results demonstrate unfavorable neck and low back postures as well as high pain scores for those body segments. Additionally, workload from subjective surveys increased significantly as a function of operative duration, and mental workload was high across all procedure types. Neck postural risk exposure and physical demand were among the variables that increased with surgical duration, procedure type, and loupes used by the surgeons. Correlations among postural angles and pain scores showed consistency between the objective assessment and the subjective surveys for neck and trunk. The authors believe that the results of this study highlight the need for developing mitigating measures such as ergonomic interventions for vascular surgery.

Sensor-based indicators of performance changes between sessions during robotic surgery training

Training of surgeons is essential for safe and effective use of robotic surgery, yet current assessment tools for learning progression are limited. The objective of this study was to measure changes in trainees' cognitive and behavioral states as they progressed in a robotic surgeon training curriculum at a medical institution. Seven surgical trainees in urology who had no formal robotic training experience participated in the simulation curriculum. They performed 12 robotic skills exercises with varying levels of difficulty repetitively in separate sessions. EEG (electroencephalogram) activity and eye movements were measured throughout to calculate three metrics: engagement index (indicator of task engagement), pupil diameter (indicator of mental workload) and gaze entropy (indicator of randomness in gaze pattern). Performance scores (completion of task goals) and mental workload ratings (NASA-Task Load Index) were collected after each exercise. Changes in performance scores between training sessions were calculated. Analysis of variance, repeated measures correlation, and machine learning classification were used to diagnose how cognitive and behavioral states associate with performance increases or decreases between sessions. The changes in performance were correlated with changes in engagement index (rrm=-.25,p<.001) and gaze entropy (rrm=-.37,p<.001). Changes in cognitive and behavioral states were able to predict training outcomes with 72.5% accuracy. Findings suggest that cognitive and behavioral metrics correlate with changes in performance between sessions. These measures can complement current feedback tools used by medical educators and learners for skills assessment in robotic surgery training.

Evaluation of the occurrence of work-related musculoskeletal pain among anesthesiology, intensive care, and surgical nurses: An observational and descriptive study

Clinical nurses can encounter musculoskeletal pain episodes stemming from regular exposure to workplace risk factors that contribute to overloads. This study aimed to evaluate the occurrence and location of work-related musculoskeletal pain among Polish nurses. An observational and descriptive survey study was conducted among 136 nurses working in the anesthesiology, intensive care, and surgery units. An extended version of the Nordic Musculoskeletal Questionnaire was used to investigate musculoskeletal pain. Only 8% of the participating nurses experienced no musculoskeletal pain, while 85% suffered from pain in more than one location. The lower back (67%), upper back (59%), and neck (66%) were the most common pain locations. In summary, nurses experienced multiple musculoskeletal pain episodes, occurring most frequently in the spinal region (lower and upper back and neck). It is crucial to determine the real causes of musculoskeletal pain and to take appropriate preventive measures to improve workplace ergonomics.

Eye-Tracking Metrics Predict Perceived Workload in Robotic Surgical Skills Training

OBJECTIVE

The aim of this study is to assess the relationship between eye-tracking measures and perceived workload in robotic surgical tasks.

BACKGROUND

Robotic techniques provide improved dexterity, stereoscopic vision, and ergonomic control system over laparoscopic surgery, but the complexity of the interfaces and operations may pose new challenges to surgeons and compromise patient safety. Limited studies have objectively quantified workload and its impact on performance in robotic surgery. Although not yet implemented in robotic surgery, minimally intrusive and continuous eye-tracking metrics have been shown to be sensitive to changes in workload in other domains.

METHODS

Eight surgical trainees participated in 15 robotic skills simulation sessions. In each session, participants performed up to 12 simulated exercises. Correlation and mixed-effects analyses were conducted to explore the relationships between eye-tracking metrics and perceived workload. Machine learning classifiers were used to determine the sensitivity of differentiating between low and high workload with eye-tracking features.

RESULTS

Gaze entropy increased as perceived workload increased, with a correlation of .51. Pupil diameter and gaze entropy distinguished differences in workload between task difficulty levels, and both metrics increased as task level difficulty increased. The classification model using eye-tracking features achieved an accuracy of 84.7% in predicting workload levels.

CONCLUSION

Eye-tracking measures can detect perceived workload during robotic tasks. They can potentially be used to identify task contributors to high workload and provide measures for robotic surgery training.

APPLICATION

Workload assessment can be used for real-time monitoring of workload in robotic surgical training and provide assessments for performance and learning.

Intraoperative musculoskeletal discomfort and risk for surgeons during open and laparoscopic surgery

BACKGROUND

Surgeon workload is significant both mentally and physically and may differ by procedure type. When comparing laparoscopic surgery and open surgery, studies have reported contrasting results on the physical and mental workload assessed.

METHODS

Wearable posture sensors and pre-/post-surgical questionnaires were employed to assess intraoperative workload and to identify risk factors for surgeons using objective and subjective measures.

RESULTS

Data from 49 cases (27 open and 22 laparoscopic surgeries performed by 13 male and 11 female surgeons) were assessed. More than half the surgeons reported a clinically relevant post-surgical fatigue score. The surgeons also self-reported a significant increase in pain for the neck, upper back, and lower back during/after surgery. Procedural time had significant impacts on fatigue, body part pain, and subjective (NASA-TLX) workload. The objectively assessed intraoperative work postures using wearable sensors showed a high musculoskeletal risk for neck and lower back based on their posture overall. Open surgeries had significantly larger neck angles (median [IQR]: 40 [28-47]°) compared with laparoscopic surgeries (median [IQR]: 23 [16-29]°), p < 0.001) and torso (median [IQR]: 17 [14-22]° vs. 13 [10-17]°, p = 0.006).

CONCLUSION

Surgeons reported significantly higher levels of fatigue and pain in the neck and lower back during or after performing a surgical case. Longer procedural time resulted in more self-rated fatigue, pain, and subjective workload. Open surgery had higher postural risk. Overall, surgeons spent a disturbingly high percentage of time during surgery in high-risk musculoskeletal postures, especially the neck. These results show that intraoperative postural risk is very high and that interventions are necessary to protect surgeon musculoskeletal health for optimal surgeon performance and career longevity.

Surgery Task Load Index in Cardiac Surgery: Measuring Cognitive Load Among Teams

Background. The most commonly used subjective assessment of perceived cognitive load, the NASA Task Load Index (TLX), has proven valuable in measuring individual load among general populations. The surgery task load index (SURG-TLX) was developed and validated to measure cognitive load specifically among individuals within a surgical team. Notably, the TLX lacks temporal sensitivity in its typical retrospective administration. Objective. This study sought to expand the utility of SURG-TLX by investigating individual measures of cognitive load over time during cardiac surgery, and the relationship between individual and team measures of cognitive load and proxies for surgical complexity. Materials & Methods. SURG-TLX was administered retrospectively in the operating room immediately following each case to approximate cognitive load before, during, and after cardiopulmonary bypass for cardiac surgery team members (surgeon, anesthesiologist, and perfusionist). Correlations were calculated to determine the relationship of individual and team measures of cognitive load over the entire procedure with bypass length and surgery length. Results. Results suggest that perceived cognitive load varies throughout the procedure such that cognitive load during bypass significantly differs compared to before or after bypass, across all 3 roles. While on bypass, results show that anesthesiologists experience significantly lower levels of perceived cognitive load than both surgeons and perfusionists. Correlational analyses reveal that perceived cognitive load of both the surgeon and the team had significant positive associations with bypass length and surgery length. Conclusion. Our findings support the utility of SURG-TLX in real cardiac cases as a measure of cognitive load over time, and on an individual and team-wide basis.

NASA-TLX Assessment of Surgeon Workload Variation Across Specialties

OBJECTIVE

With advancements in surgical equipment and procedures, human-system interactions in operating rooms affect surgeon workload and performance. Workload was measured across surgical specialties using surveys to identify potential predictors of high workload for future performance improvement.

SUMMARY BACKGROUND DATA

Surgical instrumentation and technique advancements have implications for surgeon workload and human-systems interactions. To understand and improve the interaction of components in the work system, NASA-Task Load Index can measure workload across various fields. Baseline workload measurements provide a broad overview of the field and identify areas most in need of improvement.

METHODS

Surgeons were administered a modified NASA-Task Load Index survey (0 = low, 20 = high) following each procedure. Patient and procedural factors were retrieved retrospectively.

RESULTS

Thirty-four surgeons (41% female) completed 662 surgery surveys (M = 14.85, SD = 7.94), of which 506 (76%) have associated patient and procedural data. Mental demand (M = 7.7, SD = 5.56), physical demand (M = 7.0, SD = 5.66), and effort (M = 7.8, SD = 5.77) were the highest rated workload subscales. Surgeons reported difficulty levels higher than expected for 22% of procedures, during which workload was significantly higher (P < 0.05) and procedural durations were significantly longer (P > 0.001). Surgeons reported poorer perceived performance during cases with unexpectedly high difficulty (P < 0.001).

CONCLUSIONS

When procedural difficulty is greater than expected, there are negative implications for mental and physical demand that result in poorer perceived performance. Investigations are underway to identify patient and surgical variables associated with unexpected difficulty and high workload. Future efforts will focus on re-engineering the surgical planning process and procedural environment to optimize workload and performance for improved surgical care.

Supporting Surgical Teams: Identifying Needs and Barriers for Exoskeleton Implementation in the Operating Room

OBJECTIVE

The objective of this study was to identify potential needs and barriers related to using exoskeletons to decrease musculoskeletal (MS) symptoms for workers in the operating room (OR).

BACKGROUND

MS symptoms and injuries adversely impact worker health and performance in surgical environments. Half of the surgical team members (e.g., surgeons, nurses, trainees) report MS symptoms during and after surgery. Although the ergonomic risks in surgery are well recognized, little has been done to develop and sustain effective interventions.

METHOD

Surgical team members (n = 14) participated in focus groups, performed a 10-min simulated surgical task with a commercial upper-body exoskeleton, and then completed a usability questionnaire. Content analysis was conducted to determine relevant themes.

RESULTS

Four themes were identified: (1) characteristics of individuals, (2) perceived benefits, (3) environmental/societal factors, and (4) intervention characteristics. Participants noted that exoskeletons would benefit workers who stand in prolonged, static postures (e.g., holding instruments for visualization) and indicated that they could foresee a long-term decrease in MS symptoms with the intervention. Specifically, raising awareness of exoskeletons for early-career workers and obtaining buy-in from team members may increase future adoption of this technology. Mean participant responses from the System Usability Scale was 81.3 out of 100 (SD = 8.1), which was in the acceptable range of usability.

CONCLUSION

Adoption factors were identified to implement exoskeletons in the OR, such as the indicated need for exoskeletons and usability. Exoskeletons may be beneficial in the OR, but barriers such as maintenance and safety to adoption will need to be addressed.

APPLICATION

Findings from this work identify facilitators and barriers for sustained implementation of exoskeletons by surgical teams.

Interruptions in Surgery: A Comprehensive Review

BACKGROUND

Recent literature showed that analysis of interruptions can contribute to evaluating the care process in the operating room, and thus, understanding potential errors that may occur during surgical procedures. The aim of this comprehensive review was to summarize current knowledge on the description and impact of interruptions in surgery.

MATERIAL AND METHODS

A literature search was conducted according to a set of criteria in the databases MEDLINE, BASE, Cochrane's Library, and PsycINFO.

RESULTS

41 articles were included. Two main methodological approaches were found, observational in the OR, or controlled in an experimental simulated environment. Interruptions in the OR were manifold, and several classifications were used. The severity of interruptions differed according to the category of the interruptions. Interruptions were influenced by team familiarity and the expertise of the surgical team; high team familiarity and a high level of expertise decreased the frequency of interruptions. However, our literature search lacked controlled studies carried out in the OR. Interruptions seemed to increase the workload and stress of the surgical team and impair nontechnical skills, but no clear evidence of this was advanced.

CONCLUSIONS

Interruptions are probably risk factors for errors in the operating room. However, there is as yet no clear evidence of the association of interruption frequency with errors in the operating room. There is a need to define and target interruptions, which should be reduced by putting safeguards in place, thereby allowing those which could be beneficial and neglecting those with no potential consequences.

Human-based dynamics of mental workload in complicated systems

As a dynamic system in which different factors affect human performance via dynamic interactions, mental workload needs a dynamic measure to monitor its factors and evidence in a complicated system, an approach that is lacking in the literature. The present study introduces a system dynamics-based model for designing feedback mechanisms related to the mental workload through literature review and content analysis of the previous studies. A human-based archetype of mental workload was detected from the data collection process. The archetype is presented at various stages, including dynamic theory, behavior over time, leverage points and model verification. The real validation of the dynamic model was confirmed in an urban train simulator. The dynamic model can be used to analyze the long-term behavior of the mental workload. Decision-makers can benefit from the developed archetypes in evaluating the dynamic impact of their decisions on accident prevention in the complicated systems.

Detecting Mental Workload in Surgical Teams Using a Wearable Single-Channel Electroencephalographic Device

OBJECTIVE

To assess the sensitivity of an electroencephalographic (EEG)-based index, the prefrontal beta power, to quantify the mental workload in surgeons in real scenarios. Such EEG-based index might offer unique and unbiased measures of overload, a crucial factor when designing learning and training surgical programs.

DESIGN

The experiment followed a 2 × 2 × 2 within subjects design with 3 factors: (1) Surgical Role during the surgery (primary surgeon vs. assistant surgeon), (2) the Surgical Procedure (laparo-endoscopic single-site [LESS] surgery vs. multiport laparoscopic surgery [MPS]), and (3) the Suturing Techniques (interrupted vs. continuous suture).

SETTING

The study was carried out at the Advanced Multi-Purpose Simulation and Technological Innovation Complex situated at IAVANTE (Granada, Spain).

METHODS

Four surgical teams (primary surgeon and assistant surgeon, experts in MPS) performed 8 surgical exercises on porcine models, under different task complexities. They performed 2 suturing techniques (continuous and interrupted), employing a low complex procedure (MPS) and a high complex procedure (LESS). Surgeons acted as the primary surgeon during half of the exercises, and, as the assistant surgeon, during the rest of them. Simultaneously, we monitored EEG prefrontal EEG beta power spectra of both surgeons, using 2 synchronized wearable EEG devices. We also collected performance and subjective data.

RESULTS

Surgical complexity modulated prefrontal beta power. LESS surgery caused significant higher prefrontal beta power for both suturing techniques for both surgical roles which indicates higher demands than MPS. Perceived task complexity, overall surgical evaluation, and laparoscopic execution time confirmed EEG-based results. Finally, subjective ratings of surgical complexity differentiated between surgical roles within the same exercise, even when prefrontal beta power did not.

CONCLUSIONS

To detect mental overload when surgeons are engaged with complex surgeries, real or simulated, is still guesswork. EEG-based indices have great potential as objective and nonintrusive measures to assess mental overload in surgeons. Furthermore, EEG-based indices might play a relevant role in monitoring surgeons and residents' cognitive state during their training.

Quantitative Evaluations of the Effects of Noise on Mental Workloads Based on Pupil Dilation during Laparoscopic Surgery

Noise can exert undeniable pressure on human minds, especially during tasks that require high precision and attention, such as those performed during surgery. To investigate whether auditory stimuli increases mental loads during laparoscopic surgery, we examined the effects of operating room (OR) noises and music by measuring mean changes in pupil sizes and subjectively assessing performances during surgery. We recruited 24 subjects with varying laparoscopic surgery experience levels to perform complete appendectomy using a laparoscopic simulator. Wearable eye trackers were worn by all subjects to monitor pupil sizes during surgery, and surgical tasks were performed under conditions of silence, background OR noise, and music. National Aeronautics and Space Administration-Task Load Index scores and performance parameters were also recorded during surgical tasks. Noise distractions were associated with significant increases in pupil sizes compared with those observed in silence, and the related increases in mental loads may have affected surgical performance. However, more experienced operators had smaller changes in pupil sizes because of auditory disturbances than moderately experienced surgeons. Noise stimulation in the OR increases surgeon's mental workload and performance. Auditory regulation of the OR may be better standardized using data from studies of the effects of acoustic stimulation in the OR, and mental stresses during surgery could be considered in a more humane manner. Further investigations are necessary to determine the cognitive consequences of various auditory stimuli.

Research on Key Indicators in Modern Surgical Practice Assessment: Ergonomic Approach

It is undeniable that fundamental requirements in surgery refer to the adequate use of medical knowledge (eg, clinical knowledge and technical skills). However, this knowledge and skills of surgeons should be supplemented with synergetic research of capabilities of surgeons, operating rooms (ORs), and nontechnical skills. In this article, by using expert research, we presented 15 key indicators in surgical practice assessment. Communication efficiency in the OR has been ranked as the first and most important among indicators using the fuzzy analytic hierarchy process method. Within the analysis of this indicator, we have shown a new method that provided us with the results describing the extent of communication, the correlation in the communication system, surgeon workload uniformity, and isolation of individual surgeons in the OR. The goal of this research is aimed at the increase of operator efficiency in the OR. It is necessary that results of this kind of research find their practical use and become an obligatory element in the construction of new ORs as well as reconstruction of old ORs.

Systematic review of measurement tools to assess surgeons' intraoperative cognitive workload

BACKGROUND

Surgeons in the operating theatre deal constantly with high-demand tasks that require simultaneous processing of a large amount of information. In certain situations, high cognitive load occurs, which may impact negatively on a surgeon's performance. This systematic review aims to provide a comprehensive understanding of the different methods used to assess surgeons' cognitive load, and a critique of the reliability and validity of current assessment metrics.

METHODS

A search strategy encompassing MEDLINE, Embase, Web of Science, PsycINFO, ACM Digital Library, IEEE Xplore, PROSPERO and the Cochrane database was developed to identify peer-reviewed articles published from inception to November 2016. Quality was assessed by using the Medical Education Research Study Quality Instrument (MERSQI). A summary table was created to describe study design, setting, specialty, participants, cognitive load measures and MERSQI score.

RESULTS

Of 391 articles retrieved, 84 met the inclusion criteria, totalling 2053 unique participants. Most studies were carried out in a simulated setting (59 studies, 70 per cent). Sixty studies (71 per cent) used self-reporting methods, of which the NASA Task Load Index (NASA-TLX) was the most commonly applied tool (44 studies, 52 per cent). Heart rate variability analysis was the most used real-time method (11 studies, 13 per cent).

CONCLUSION

Self-report instruments are valuable when the aim is to assess the overall cognitive load in different surgical procedures and assess learning curves within competence-based surgical education. When the aim is to assess cognitive load related to specific operative stages, real-time tools should be used, as they allow capture of cognitive load fluctuation. A combination of both subjective and objective methods might provide optimal measurement of surgeons' cognition.

Improving Teamwork: Evaluating Workload of Surgical Team During Robot-assisted Surgery

OBJECTIVE

To investigate the cognitive and physical workload experienced by each operating room team member for different types of urologic procedures.

METHODS

Surgeons, anesthesiologists, surgical fellows, bedside assistants, circulating nurses, and scrub nurses completed the National Aeronautics and Space Administration Task Load Index questionnaire for various urologic robot-assisted surgery procedures. A total of 338 questionnaires from 55 unique individuals were collected. Workload differences by role, type of procedure, and surgery duration were analyzed using analysis of variance for each of the 6 domains of the National Aeronautics and Space Administration Task Load Index. The effects of trainees' participation on their perceived workload and the workloads of the lead surgeon and bedside assistant were analyzed with correlation.

RESULTS

The role of the surgical team was significant for all the scales of workload, and there was a main effect type of surgery on temporal demand and frustration. Frustration was higher for prostatectomy in comparison to cystectomy for the trainee surgeon. On the other hand, it was lower for the anesthesiologist, bedside assistant, and the circulating nurse. There was no effect of procedural complexity on workload. Regardless of surgical complexity, the trainees performed approximately 40% of the procedure without significantly impacting their perceived workload.

CONCLUSION

This study provides an analysis of variations and contributors to workload parameters and serves as a platform to optimize team members' workload during robot-assisted surgery.

Nursing Project Management to Reduce the Operating Room Infection

BACKGROUND

Nursing project management is widely used in different aspects of the society. However, whether the nursing project management can control the infections in the operation room (OR) is rarely reported. We evaluated the outcomes of surgical patients after implementing a nursing project management program to provide new scientific ways to manage the OR infections.

METHODS

Overall, 382 patients, who underwent surgical treatment in Qilu Hospital of Shandong University, Shandong, China from May 2015 to January 2016, were enrolled as observation group. Besides, 347 cases were selected as control group. Patients in the observation group were treated with the nursing project management plan, while patients in the control group were treated with the routine operation-room nursing measures. The infection control rates in the OR, and the patient satisfaction with the nursing team postoperatively were both compared between the two groups of patients.

RESULTS

The OR air, the surgical and personnel's hands surfaces were sampled for colony forming units, and all were found to be significantly of better quality (indicated by less colony forming units) in the observation group (P<0.001). In addition, there were 3 cases (0.79%) of post-operation infections in the observation group, while 12 cases (3.46%) occurred in the control group. The overall infection rate of the observation group was significantly lower than that of the control group (P = 0.011); and the satisfaction of patients with the nursing team in the observation group was significantly higher than that of the patients in the control group (P = 0.001).

CONCLUSION

It is worth popularizing and applying a good nursing project management plan for surgical patients in hospitals.