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

Artificial intelligence automated surgical phases recognition in intraoperative videos of laparoscopic pancreatoduodenectomy

BACKGROUND

Laparoscopic pancreatoduodenectomy (LPD) is one of the most challenging operations and has a long learning curve. Artificial intelligence (AI) automated surgical phase recognition in intraoperative videos has many potential applications in surgical education, helping shorten the learning curve, but no study has made this breakthrough in LPD. Herein, we aimed to build AI models to recognize the surgical phase in LPD and explore the performance characteristics of AI models.

METHODS

Among 69 LPD videos from a single surgical team, we used 42 in the building group to establish the models and used the remaining 27 videos in the analysis group to assess the models' performance characteristics. We annotated 13 surgical phases of LPD, including 4 key phases and 9 necessary phases. Two minimal invasive pancreatic surgeons annotated all the videos. We built two AI models for the key phase and necessary phase recognition, based on convolutional neural networks. The overall performance of the AI models was determined mainly by mean average precision (mAP).

RESULTS

Overall mAPs of the AI models in the test set of the building group were 89.7% and 84.7% for key phases and necessary phases, respectively. In the 27-video analysis group, overall mAPs were 86.8% and 71.2%, with maximum mAPs of 98.1% and 93.9%. We found commonalities between the error of model recognition and the differences of surgeon annotation, and the AI model exhibited bad performance in cases with anatomic variation or lesion involvement with adjacent organs.

CONCLUSIONS

AI automated surgical phase recognition can be achieved in LPD, with outstanding performance in selective cases. This breakthrough may be the first step toward AI- and video-based surgical education in more complex surgeries.

The Impact of Neuroanesthesia Fellowship Training and Anesthesiologist-Surgeon Dyad Volume on Patient Outcomes in Adult Spine Surgery: A Population-Based Study

INTRODUCTION

Extensive research has explored the impact of surgeons' characteristics on patient outcomes; however, the influence of anesthesiologists remains understudied. We performed a population-based retrospective cohort study to investigate the impact of anesthesiologists' characteristics on in-hospital morbidity after spine surgery.

METHODS

Adult patients who underwent spine surgery at the London Health Science Centre, Ontario, Canada between January 1, 2010 and June 30, 2023 were included in this study. Data was extracted from the local administrative database. Five anesthesiologists' characteristics (neuroanesthesia fellowship and residency training backgrounds, surgeon familiarity, annual case volume, and sex) were examined as primary exposures. The primary outcome was composite in-hospital morbidity, encompassing 141 complications. Multivariable logistic regression was performed to assess the association between anesthesiologists' characteristics and postoperative morbidity with adjustment of patients' sex, Charlson Comorbidities Index, surgical complexity, and surgeon characteristics.

RESULTS

A total of 7692 spine surgeries were included in the analysis. Being a neuroanesthesia fellowship-trained anesthesiologist and high anesthesiologist-surgeon annual dyad volume were associated with reduction in in-hospital comorbidity; adjusted odds ratio (95% CI) of 0.58 (0.49-0.69; P<0.001) and 0.93 (0.91-0.95; P<0.001), respectively. Conversely, anesthesiologist annual case volume, characteristics of residency training and anesthesiologist sex showed only nuanced associations with outcomes.

CONCLUSIONS

Neuroanesthesia fellowship training and high surgeon-anesthesiologist dyad familiarity was associated with a reduction in in-hospital morbidity following spine surgery. These findings underscore the superiority of structured fellowship education over case exposure experience alone, advocate for dedicated neuroanesthesia teams with high surgeon-anesthesiologist dyad volume and recognize neuroanesthesia as a crucial subspecialty in spine surgery.

Evaluating the Impact of Operative Team Familiarity on Cardiac Surgery Outcomes: A Retrospective Cohort Study of Medicare Beneficiaries

OBJECTIVE

To associate surgeon-anesthesiologist team familiarity (TF) with cardiac surgery outcomes.

BACKGROUND

TF, a measure of repeated team member collaborations, has been associated with improved operative efficiency; however, examination of its relationship to clinical outcomes has been limited.

METHODS

This retrospective cohort study included Medicare beneficiaries undergoing coronary artery bypass grafting (CABG), surgical aortic valve replacement (SAVR), or both (CABG+SAVR) between January 1, 2017, and September 30, 2018. TF was defined as the number of shared procedures between the cardiac surgeon and anesthesiologist within 6 months of each operation. Primary outcomes were 30- and 90-day mortality, composite morbidity, and 30-day mortality or composite morbidity, assessed before and after risk adjustment using multivariable logistic regression.

RESULTS

The cohort included 113,020 patients (84,397 CABG; 15,939 SAVR; 12,684 CABG+SAVR). Surgeon-anesthesiologist dyads in the highest [31631 patients, TF median (interquartile range)=8 (6, 11)] and lowest [44,307 patients, TF=0 (0, 1)] TF terciles were termed familiar and unfamiliar, respectively. The rates of observed outcomes were lower among familiar versus unfamiliar teams: 30-day mortality (2.8% vs 3.1%, P =0.001), 90-day mortality (4.2% vs 4.5%, P =0.023), composite morbidity (57.4% vs 60.6%, P <0.001), and 30-day mortality or composite morbidity (57.9% vs 61.1%, P <0.001). Familiar teams had lower overall risk-adjusted odds of 30-day mortality or composite morbidity [adjusted odds ratio (aOR) 0.894 (0.868, 0.922), P <0.001], and for SAVR significantly lower 30-day mortality [aOR 0.724 (0.547, 0.959), P =0.024], 90-day mortality [aOR 0.779 (0.620, 0.978), P =0.031], and 30-day mortality or composite morbidity [aOR 0.856 (0.791, 0.927), P <0.001].

CONCLUSIONS

Given its relationship with improved 30-day cardiac surgical outcomes, increasing TF should be considered among strategies to advance patient outcomes.

From Aviation to Pediatric Surgery

Aviation is a tremendously complex process involving multiple factors that can be subsidiary to human error. The implementation of checklists, tools that reduce this risk, has often been extrapolated to other fields, especially medicine. Through this reflection, we comment on the critical and relevant aspects of pediatric surgical patient safety, briefly discussing the existing literature and analyzing potential areas for improvement.

Boosting teamwork between scrub nurses and neurosurgeons: exploring the value of a role-played hands-on, cadaver-free simulation and systematic review of the literature

Background

Recently, non-technical skills (NTS) and teamwork in particular have been demonstrated to be essential in many jobs, in business as well as in medical specialties, including plastic, orthopedic, and general surgery. However, NTS and teamwork in neurosurgery have not yet been fully studied. We reviewed the relevant literature and designed a mock surgery to be used as a team-building activity specifically designed for scrub nurses and neurosurgeons.

Methods

We conducted a systematic review by searching PubMed (Medline) and CINAHL, including relevant articles in English published until 15 July 2023. Then, we proposed a pilot study consisting of a single-session, hands-on, and cadaver-free activity, based on role play. Scrub nurses were administered the SPLINTS (Scrub Practitioners' List of Intraoperative Non-Technical Skills) rating form as a self-evaluation at baseline and 20-30 days after the simulation. During the experiment, surgeons and scrub nurses role-played as each other, doing exercises including a simulated glioma resection surgery performed on an advanced model of a cerebral tumor (Tumor Box, UpSurgeOn®) under an exoscope. At the end, every participant completed an evaluation questionnaire.

Results

A limited number of articles are available on the topic. This study reports one of the first neurosurgical team-building activities in the literature. All the participating scrub nurses and neurosurgeons positively evaluated the simulation developed on a roleplay. The use of a physical simulator seems an added value, as the tactile feedback given by the model further helps to understand the actual surgical job, more than only observing and assisting. The SPLINTS showed a statistically significant improvement not only in "Communication and Teamwork" (p = 0.048) but also in "Situation Awareness" (p = 0.031).

Conclusion

Our study suggests that team-building activities may play a role in improving interprofessional teamwork and other NTS in neurosurgery.

A comparison between a maximum care university hospital and an outpatient clinic - potential for optimization in arthroscopic workflows?

BACKGROUND

Due to the growing economic pressure, there is an increasing interest in the optimization of operational processes within surgical operating rooms (ORs). Surgical departments are frequently dealing with limited resources, complex processes with unexpected events as well as constantly changing conditions. In order to use available resources efficiently, existing workflows and processes have to be analyzed and optimized continuously. Structural and procedural changes without prior data-driven analyses may impair the performance of the OR team and the overall efficiency of the department. The aim of this study is to develop an adaptable software toolset for surgical workflow analysis and perioperative process optimization in arthroscopic surgery.

METHODS

In this study, the perioperative processes of arthroscopic interventions have been recorded and analyzed subsequently. A total of 53 arthroscopic operations were recorded at a maximum care university hospital (UH) and 66 arthroscopic operations were acquired at a special outpatient clinic (OC). The recording includes regular perioperative processes (i.a. patient positioning, skin incision, application of wound dressing) and disruptive influences on these processes (e.g. telephone calls, missing or defective instruments, etc.). For this purpose, a software tool was developed ('s.w.an Suite Arthroscopic toolset'). Based on the data obtained, the processes of the maximum care provider and the special outpatient clinic have been analyzed in terms of performance measures (e.g. Closure-To-Incision-Time), efficiency (e.g. activity duration, OR resource utilization) as well as intra-process disturbances and then compared to one another.

RESULTS

Despite many similar processes, the results revealed considerable differences in performance indices. The OC required significantly less time than UH for surgical preoperative (UH: 30:47 min, OC: 26:01 min) and postoperative phase (UH: 15:04 min, OC: 9:56 min) as well as changeover time (UH: 32:33 min, OC: 6:02 min). In addition, these phases result in the Closure-to-Incision-Time, which lasted longer at the UH (UH: 80:01 min, OC: 41:12 min).

CONCLUSION

The perioperative process organization, team collaboration, and the avoidance of disruptive factors had a considerable influence on the progress of the surgeries. Furthermore, differences in terms of staffing and spatial capacities could be identified. Based on the acquired process data (such as the duration for different surgical steps or the number of interfering events) and the comparison of different arthroscopic departments, approaches for perioperative process optimization to decrease the time of work steps and reduce disruptive influences were identified.

Effect of Surgical Care Team Consistency During Urologic Procedures on Surgical Efficiency and Perioperative Outcomes

OBJECTIVE

To evaluate the effect of urologic surgical care team consistency on surgical efficiency and patient outcomes.

METHODS

Patients undergoing major urologic surgery (prostatectomy, nephrectomy, or cystectomy) at a single institution from 2010 to 2019 were identified. A surgical care team comprised a certified surgical assistant, certified surgical technologist, and circulating nurse. Primary team member status was assigned on a quarterly basis to team members present for the highest proportion of a surgeon's cases. Surgical efficiency outcomes included time to first incision, procedure duration, and turnover time. Perioperative clinical outcomes included hospital length of stay and 30-day readmission and reoperation rates. Outcomes were compared according to team consistency and assessed via univariate and multivariable analyses.

RESULTS

Overall, 11,213 surgical procedures were included. Time to first incision, procedure duration, and turnover time were significantly lower in procedures performed with high-consistency teams (2-3 primary members) versus low-consistency teams (0-1 primary members) (all P <.001). After adjusting for patient-related variables, high-consistency teams were significantly associated with decreased time to first incision (estimate, -2.04 minutes; 95% CI, -2.68 to -1.41 minutes; P <.001) and turnover time (estimate, -7.23 minutes; 95% CI, -9.8 to -4.66 minutes; P <.001). For minimally invasive nephrectomy, high-consistency teams were associated with significantly decreased odds of prolonged hospitalization (odds ratio, 0.63; 95% CI, 0.47-0.84; P = .001). For robotic prostatectomy, high-consistency teams were associated with decreased procedure duration (estimate, -4.55 minutes; 95% CI, -7.48 to -1.62 minutes; P = .002).

CONCLUSION

Highly consistent surgical care teams were associated with improved surgical efficiency and patient outcomes.

Association Between Familiarity of the Surgeon-Anesthesiologist Dyad and Postoperative Patient Outcomes for Complex Gastrointestinal Cancer Surgery

Importance

The surgeon-anesthesiologist teamwork and relationship is crucial to good patient outcomes. Familiarity among work team members is associated with enhanced success in multiple fields but rarely studied in the operating room.

Objective

To examine the association between surgeon-anesthesiologist dyad familiarity-as the number of times working together-with short-term postoperative outcomes for complex gastrointestinal cancer surgery.

Design, Setting, and Participants

This population-based retrospective cohort study based in Ontario, Canada, included adults undergoing esophagectomy, pancreatectomy, and hepatectomy for cancer from 2007 through 2018. The data were analyzed January 1, 2007, through December 21, 2018.

Exposures

Dyad familiarity captured as the annual volume of procedures of interest done by the surgeon-anesthesiologist dyad in the 4 years before the index surgery.

Main Outcomes and Measures

Ninety-day major morbidity (any Clavien-Dindo grade 3 to 5). The association between exposure and outcome was examined using multivariable logistic regression.

Results

Seven thousand eight hundred ninety-three patients with a median age of 65 years (66.3% men) were included. They were cared for by 737 anesthesiologists and 163 surgeons who were also included. The median surgeon-anesthesiologist dyad volume was 1 (range, 0-12.2) procedures per year. Ninety-day major morbidity occurred in 43.0% of patients. There was a linear association between dyad volume and 90-day major morbidity. After adjustment, the annual dyad volume was independently associated with lower odds of 90-day major morbidity, with an odds ratio of 0.95 (95% CI, 0.92-0.98; P = .01) for each incremental procedure per year, per dyad. The results did not change when examining 30-day major morbidity.

Conclusions and Relevance

Among adults undergoing complex gastrointestinal cancer surgery, increasing familiarity of the surgeon-anesthesiologist dyad was associated with improved short-term patient outcomes. For each additional time that a unique surgeon-anesthesiologist dyad worked together, the odds of 90-day major morbidity decreased by 5%. These findings support organizing perioperative care to increase the familiarity of surgeon-anesthesiologist dyads.

A real-time analysis of intraoperative interruptions in relation to use of simple preventive measures including a sign on the door and a checklist-based team brief

This study aimed to evaluate intraoperative interruptions by frequency, type, interference and source, and preventive measures. The interruptions in the operating theatre were evaluated for 52 surgical procedures based on real-time recordings and divided into routine operative procedures (ROP, n = 26, without intervention) and intervened operative procedures (IOP, n = 26, observed after team brief and placement of a warning sign for unnecessary door openings) groups. Intervened operative procedures vs. routine operative procedures was associated with a significantly lower number of interruptions (p = 0.014). Implementation of preventive measures was associated with a significantly lower number of entrances and exits (p = 0.001) and equipment issues (p = 0.003), interruptions that affected the circulating nurse or anaesthesia technician/associate (p = 0.003) and those caused by team members other than assisting surgeon and scrub nurse (p-value ranged from 0.015 to 0.009). Our findings revealed significantly reduced interruptions after a simple preventive measure including team brief and the placement of a warning sign for unnecessary door openings.

Fragmentation of practice: The adverse effect of surgeons moving around

BACKGROUND

Whether surgical team familiarity is associated with improved postoperative outcomes remains unknown. We sought to characterize the impact of fragmented surgical practice on the likelihood that a patient would experience a textbook outcome, which is a validated patient-centric composite outcome representing an "ideal" postoperative outcome.

METHOD

Medicare beneficiaries aged 65 and older who underwent elective inpatient abdominal aortic aneurysm repair, coronary artery bypass graft, cholecystectomy, colectomy, or lung resection were identified. Rate of fragmented practice was calculated based on the total number of surgical procedures of interest performed over the study period (2013-2017) divided by the number of different hospitals in which the surgeon operated. Surgeons were categorized into "low," "average," "above average," or "high" rate of fragmented practice categories using an unsupervised machine learning technique known k-medians cluster analysis.

RESULTS

Among 546,422 Medicare beneficiaries who underwent an elective surgical procedure of interest (coronary artery bypass graft: n = 156,384, 28.6%; lung resection: n = 83,164, 15.2%; abdominal aortic aneurysm: n = 112,578, 20.6%; cholecystectomy: n = 42,955, 7.9%; colectomy: n = 151,341, 27.7%), median patient age was 74 years (interquartile range: 69-80), and most patients were male (n = 319,153, 58.4%). Machine learning identified 3 cutoffs to categorize rate of fragmented practice: 2.8%, 5.6%, and 10.6%. Overall, the majority of surgical procedures were performed by surgeons with a low rate of fragmented practice (n = 382,504, 70.0%); other surgical procedures were performed by surgeons with average (n = 109,141, 20.0%), above average (n = 44,249, 8.1%), or high (n = 10,528, 1.9%) rate of fragmented practice. On multivariable analyses, after controlling for patient demographics, individual surgeon volume, procedure type, and a random effect for hospital, patients who underwent a surgical procedure by a high versus low rate of fragmented practice surgeon had lower odds to achieve a postoperative textbook outcome (odds ratio 0.71, 95% confidence interval 0.77-0.84). Patients who underwent a procedure by a high rate of fragmented practice surgeon also had increased odds of a perioperative complication (odds ratio 1.30, 95% confidence interval: 1.23-1.37), extended length of stay (odds ratio 1.17, 95% confidence interval: 1.11-1.24), 90-day readmission (odds ratio 1.17, 95% confidence interval: 1.11-1.23), and 90-day mortality (odds ratio 1.29, 95% confidence interval: 1.17-1.42) (all P < .05).

CONCLUSION

Patients undergoing a surgical procedure by a surgeon with a high rate of fragmented practice had lower odds of achieving an optimal postoperative textbook outcome. Surgical team familiarity, measured by a surgeon rate of fragmented practice, may represent a modifiable mechanism to improve surgical outcomes.

Intraoperative dynamics of workflow disruptions and surgeons' technical performance failures: insights from a simulated operating room

INTRODUCTION

Flow disruptions (FD) in the operating room (OR) have been found to adversely affect the levels of stress and cognitive workload of the surgical team. It has been concluded that frequent disruptions also lead to impaired technical performance and subsequently pose a risk to patient safety. However, respective studies are scarce. We therefore aimed to determine if surgical performance failures increase after disruptive events during a complete surgical intervention.

METHODS

We set up a mixed-reality-based OR simulation study within a full-team scenario. Eleven orthopaedic surgeons performed a vertebroplasty procedure from incision to closure. Simulations were audio- and videotaped and key surgical instrument movements were automatically tracked to determine performance failures, i.e. injury of critical tissue. Flow disruptions were identified through retrospective video observation and evaluated according to duration, severity, source, and initiation. We applied a multilevel binary logistic regression model to determine the relationship between FDs and technical performance failures. For this purpose, we compared FDs in one-minute intervals before performance failures with intervals without subsequent performance failures.

RESULTS

Average simulation duration was 30:02 min (SD = 10:48 min). In 11 simulated cases, 114 flow disruption events were observed with a mean hourly rate of 20.4 (SD = 5.6) and substantial variation across FD sources. Overall, 53 performance failures were recorded. We observed no relationship between FDs and likelihood of immediate performance failures: Adjusted odds ratio = 1.03 (95% CI 0.46-2.30). Likewise, no evidence could be found for different source types of FDs.

CONCLUSION

Our study advances previous methodological approaches through the utilisation of a mixed-reality simulation environment, automated surgical performance assessments, and expert-rated observations of FD events. Our data do not support the common assumption that FDs adversely affect technical performance. Yet, future studies should focus on the determining factors, mechanisms, and dynamics underlying our findings.

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.

Intraoperative Scrub Nurse Handoffs Are Associated With Increased Operative Times for Total Joint Arthroplasty Patients

BACKGROUND

Surgeons typically remain scrubbed in for the duration of a surgical case, while scrub nurses are shift-workers who handoff mid-operation. These handoffs can intuitively create inefficiencies, but currently, no orthopedic research has studied the impact of these handoffs. This study analyzed the effect of intraoperative scrub nurse handoffs on operative times for total joint arthroplasties (TJAs).

METHODS

A retrospective chart review was performed for primary total hip (THA) and total knee arthroplasties (TKA) performed between May 2014 and May 2018. Operative times, number of scrub nurse handoffs, surgeon, and patient information were collected. A multivariable linear regression was performed to assess the association between patient and surgeon characteristics, intraoperative handoffs, and operative times.

RESULTS

A total of 1109 TKA and 1032 THA patients were identified. Multivariable linear regression demonstrated that for TKAs, 1 handoff was associated with a 3.89-minute longer operative time (P value = .02), and 2+ handoffs were associated with a 15.99-minute longer case (P value < .001). For THA patients, 1 handoff was associated with a 6.20-minute longer operative time (P value < .001), and 2+ handoffs were associated with an 18.52-minute longer case (P value < .001).

CONCLUSIONS

Although causation cannot be established, when controlling for multiple confounders, intraoperative scrub nurse handoffs were associated with statistically significant increases in operative times for TJAs. Optimizing scrub nurse staffing models to decrease intraoperative handoffs could thus have practical ramifications on TJA patients.

Surgical Team Familiarity: An Integrative Review

The dynamic nature of perioperative care often brings unfamiliar clinicians together yet requires them to collectively provide complex health care in a challenging environment. In this review, we comprehensively evaluated evidence regarding surgical team familiarity and its relationship to surgical team performance. Using a comprehensive and iterative search strategy, we searched PubMed, Web of Science, PsycInfo, and EMBASE for surgical team familiarity manuscripts. We identified 598 manuscripts, 16 of which met our inclusion criteria. We found that surgical team familiarity is associated with improved performance for many metrics, including shorter total operative time, team member safety, decreased surgical errors and disruptions, reduced miscommunication, and fewer patient readmissions. Although additional research would be helpful, surgical managers should consider team familiarity and consistency in team membership when assigning staff members to surgical teams to optimize surgical care, decrease inefficiencies, and promote safe patient outcomes.

Rapid standardized operating rooms (RAPSTOR) in thyroid and parathyroid surgery

OBJECTIVE

To evaluate the impact of a high efficiency rapid standardized OR (RAPSTOR) for hemithyroid/parathyroid surgery using standardized equipment sets (SES) and consecutive case scheduling (CCS) on turnover times (TOT), average case volumes, patient outcomes, hospital costs and OR efficiency/stress.

METHODS

Patients requiring hemithyroidectomy (primary or completion) or unilateral parathyroidectomy in a single surgeon's practice were scheduled consecutively with SES. Retrospective control groups were classified as sequential (CS) or non-sequential (CNS). A survey regarding OR efficiency/stress was administered. Phenomenography and descriptive statistics were conducted for time points, cost and patient outcome variables. Hospital cost minimization analysis was performed.

RESULTS

The mean TOT of RAPSTOR procedures (16 min; n = 27) was not significantly different than CS (14 min, n = 14) or CNS (17 min, n = 6). Mean case number per hour was significantly increased in RAPSTOR (1.2) compared to both CS (0.9; p < 0.05) and CNS (0.7; p < 0.05). Average operative time was significantly reduced in RAPSTOR (32 min; n = 28) compared to CNS (48 min; p < 0.05) but not CS (33 min; p = 0.06). Time to discharge was reduced in RAPSTOR (595 min) compared to CNS (1210 min, p < 0.05). There was no difference in complication rate between all groups (p = 0.27). Survey responses suggested improved efficiency, teamwork and workflow. Furthermore, there is associated decrease in direct operative costs for RAPSTOR vs. CS.

CONCLUSION

A high efficiency standardized OR for hemithyroid and parathyroid surgery using SES and CCS is associated with improved efficiency and, in this study, led to increased capacity at reduced cost without compromising patient safety.

LEVEL OF EVIDENCE

Level 2.

Evaluation of Operative Waste in a Military Medical Center: Analysis of Operating Room Cost and Waste during Surgical Cases

Operating rooms (ORs) contribute to at least 40 per cent of hospital costs. There is an existing cost waste in ORs for surgical devices that are opened without being used. There is a paucity of data evaluating the hospital cost of opened but unused OR supplies. The goal of this observational study is to examine the cost of opened but unused OR supplies for general surgery cases. We performed a quality improvement project of OR cost waste by observing 30 cases. Surgical cases of a senior surgeon who had been at the institution for more than five years were evaluated for items opened appropriately and whether the items are used. The cases evaluated ranged from open hernia repairs to robotic-assisted hernia repairs. We found that the cost of instruments opened but not used was $4528.18. Of the cases evaluated, we found that a range of 0 per cent to 27 per cent of total items were wasted, an average of 8.3 per cent. We found that for the open inguinal hernia case, there was minimal waste. The highest waste was among complex cases such as the robotic-assisted inguinal hernia with an average waste and cost of 15.8 per cent and $379. We found that on average for less complex cases such as open inguinal hernia repairs, $1.44 was potentially wasted per case, whereas for more complex cases up to $379 was wasted per case. We identified the outdated preference cards, lack of instrument knowledge, circulating nurse, and surgical technician distractions as reasons for contributing to waste.

Role of requests and communication breakdowns in the coordination of teamwork: a video-based observational study of hybrid operating rooms

OBJECTIVES

This study investigated the functional role of 'requests' in the coordination of surgical activities in the operating room (OR). A secondary aim was to describe, closely, instances of potential miscommunication to scrutinise how so-called conversational repairs were used to address and prevent mistakes.

DESIGN

Non-participant video-based observations.

SETTING

Team coordination around image acquisitions (digital subtraction angiography) done during endovascular aortic repair (EVAR) procedures in a hybrid OR.

METHODS

The study followed and documented a total of 72 EVAR procedures, out of which 12 were video-recorded (58 hours). The results were based on 12 teams operating during these recorded surgeries and specifically targeted all sequences involving controlled apnoea. In total, 115 sequences were analysed within the theoretical framework of conversation analysis.

RESULTS

The results indicated a simple structure of communication that can enable the successful coordination of work between different team members. Central to this analysis was the distinction between immediate requests and pre-requests. The results also showed how conversational repairs became key in establishing joint understanding and, therefore, how they can function as crucial resources in safety management operations.

CONCLUSION

The results suggest the possibility of devising an interactional framework to minimise problems with communication, thereby enabling the advancement of patient safety. By making the distinction between different types of requests explicit, certain ambiguities can be mitigated and some misunderstandings avoided. One way to accomplish this practically would be to tie various actions to clearer and more distinct forms of expression.

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 the complexity of surgical procedures and intraoperative interruptions on neurosurgical team workload

BACKGROUND

Neurosurgical teams are exposed to various stressors: complexity of surgical procedures, environment, time pressure and interruptions contribute to increasing the perceived workload.

OBJECTIVE

This study aimed to evaluate the impact of interruptions and surgical complexity on neurosurgical team workload.

METHODS

A prospective observational study was conducted on thirty surgical procedures of graduated complexity recorded in our Department of Neurosurgery. A scale was created and used by neurosurgeons to evaluate the perceived complexity of the surgical procedure. Interruptions and severity of interruptions were noted. The workloads of the neurosurgeon, surgical assistant, scrub nurse and circulating nurse were measured on the Surgery Task Load Index (SURG-TLX) at the end of the procedure.

RESULTS

A mean 24.6 interruptions per hour were recorded. The mean interference level of the interruptions was 3.5/7. Mean surgical complexity was 4.3/10. Mean sterile team workload was 43.4/100. The multiple linear regression model showed that sterile team workload increased with surgical complexity (β=6.692, P=.0002) but decreased in spite of increases in the number of interruptions per hour (β=-0.855, P=.027). Neurosurgeon and surgical assistant workload increased with surgical complexity (β=11.53, P<0.0001 and β=7.42, P=0.0007, respectively). Scrub nurse workload decreased in spite of increases in the number of interruptions per hour (β=-1.11, P=.026).

CONCLUSION

Our study suggests positive effects of some interruptions during elective neurosurgical procedures with strong team familiarity.

Performance Optimization Strategies for Complex Endourologic Procedures

OBJECTIVE

To identify and address factors that may impact a surgeon's performance during endourologic procedures.

METHODS

A literature review was performed for articles focusing on surgical ergonomics, education, sports and performance psychology.

RESULTS

As urologists and trainees have become more comfortable approaching complex pathology endoscopically, there remains an opportunity to refine surgeon-related factors and optimize extrinsic factors to maximize efficiency and provide patients with the highest quality outcomes and safety.

CONCLUSION

Medical centers and training programs should strive to include formal lessons on stress-coping mechanisms, communication, and dedicated ergonomic training, as these all play a role in physician well-being and may lead to improved clinical outcomes.

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.