Eye-tracking analysis of skilled performance in clinical extracorporeal circulation

Eye Tracking Use in Surgical Research: A Systematic Review

INTRODUCTION

Eye tracking (ET) is a popular tool to study what factors affect the visual behaviour of surgical team members. To our knowledge, there have been no reviews to date that evaluate the broad use of ET in surgical research. This review aims to identify and assess the quality of this evidence, to synthesize how ET can be used to inform surgical practice, and to provide recommendations to improve future ET surgical studies.

METHODS

In line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic literature review was conducted. An electronic search was performed in MEDLINE, Cochrane Central, Embase, and Web of Science databases up to September 2020. Included studies used ET to measure the visual behaviour of members of the surgical team during surgery or surgical tasks. The included studies were assessed by two independent reviewers.

RESULTS

A total of 7614 studies were identified, and 111 were included for data extraction. Eleven applications were identified; the four most common were skill assessment (41%), visual attention assessment (22%), workload measurement (17%), and skills training (10%). A summary was provided of the various ways ET could be used to inform surgical practice, and three areas were identified for the improvement of future ET studies in surgery.

CONCLUSIONS

This review provided a comprehensive summary of the various applications of ET in surgery and how ET could be used to inform surgical practice, including how to use ET to improve surgical education. The information provided in this review can also aid in the design and conduct of future ET surgical studies.

Correlating Personal Resourcefulness and Psychomotor Skills: An Analysis of Stress, Visual Attention and Technical Metrics

Modern surgical education is focused on making use of the available technologies in order to train and assess surgical skill acquisition. Innovative technologies for the automatic, objective assessment of nontechnical skills are currently under research. The main aim of this study is to determine whether personal resourcefulness can be assessed by monitoring parameters that are related to stress and visual attention and whether there is a relation between these and psychomotor skills in surgical education. For this purpose, we implemented an application in order to monitor the electrocardiogram (ECG), galvanic skin response (GSR), gaze and performance of surgeons-in-training while performing a laparoscopic box-trainer task so as to obtain technical and personal resourcefulness' metrics. Eight surgeons (6 nonexperts and 2 experts) completed the experiment. A total of 22 metrics were calculated (7 technical and 15 related to personal resourcefulness) per subject. The average values of these metrics in the presence of stressors were compared with those in their absence and depending on the participants' expertise. The results show that both the mean normalized GSR signal and average surgical instrument's acceleration change significantly when stressors are present. Additionally, the GSR and acceleration were found to be correlated, which indicates that there is a relation between psychomotor skills and personal resourcefulness.

Simulation-based training of critical events during cardiopulmonary bypass: importance of a critical events checklist

Objectives:

Evaluation of critical events training for clinical perfusionists is necessary to improve this educational approach. Critical events checklists are effective in reducing clinical complications, but should be tested in a simulation environment first. Individual behavior and stress response of clinical perfusionists during simulated critical events on cardiopulmonary bypass have not been evaluated yet. This study focuses on the evaluation of critical events training and critical events checklists in simulated cardiopulmonary bypass.

Methods:

A total of 19 clinical perfusionists from a single hospital took part in two simulated critical event scenarios. Clinical perfusionist behavior and physiological responses were recorded using eye tracking, heart rate variability, video, and audio. In addition, workloads were determined and participants were interviewed.

Results:

Relevant areas of interest were identified for each simulation phase. During critical event detection and subsequent decision-making, areas of interest hits and fixation durations varied with the use of a critical events checklist. Times to decision were shorter, decision quality was higher, and temporal workload was increased when the checklist was used. Evaluation of selected heart rate variability measures revealed a good correlation with pupil diameters.

Conclusion:

Evaluation of critical events during simulated cardiopulmonary bypass shows that the scenario is realistic and relevant for clinical practice. Integrating a critical events checklist improves the probability of correct decision-making and shortens the correct decision time. Temporal workload is increased when using a checklist. Eye tracking and heart rate variability are well suited to evaluate participants’ behaviors and stress levels. All participants welcomed simulation training for critical incidents.

Simulation in perfusion: evaluating the efficacy of a specific training with eye-tracking

BACKGROUND

With the aim of integrating simulation training into the training of perfusionists, we examined whether the participants were able to transfer a specific learning content to the same and different situations and assessed their feedback on the simulation training. Eye-tracking was tested as a measure and supplemented by additional measures.

METHODS

A 2 × 2 mixed design was used, with test time (pre- and post-test) and training group (same and different content training) as factors. In the pre- and post-test, the participant had to handle a critical situation on the cardiopulmonary bypass, namely, a drop in arterial partial oxygen pressure. Between the two test times, the participant practised under guidance the handling of either the same critical situation (Group 1) or a different one, that is, impaired venous return (Group 2). Dependent measures were fixations of the eyes on specific areas of interest on the heart-lung machine, measures of latency and subjective assessments. Moreover, participants gave feedback on the simulation training.

RESULTS

Fixation analyses showed that the training led to an increased gaze on areas of interest relevant to the drop in arterial partial oxygen pressure in both groups, with a significant increase only for Group 1. The surveys revealed a great interest in the integration of simulation training into education.

CONCLUSION

In combination with other measures, eye-tracking is suitable for the evaluation of simulation training. Due to the positive training effects and positive participant feedback, the integration of simulation into the training of perfusionists is advocated. Concerning transfer of learning content, more research is needed.

Visual attention on a respiratory function monitor during simulated neonatal resuscitation: an eye-tracking study

OBJECTIVE

A respiratory function monitor (RFM) may improve positive pressure ventilation (PPV) technique, but many providers do not use RFM data appropriately during delivery room resuscitation. We sought to use eye-tracking technology to identify RFM parameters that neonatal providers view most commonly during simulated PPV.

DESIGN

Mixed methods study. Neonatal providers performed RFM-guided PPV on a neonatal manikin while wearing eye-tracking glasses to quantify visual attention on displayed RFM parameters (ie, exhaled tidal volume, flow, leak). Participants subsequently provided qualitative feedback on the eye-tracking glasses.

SETTING

Level 3 academic neonatal intensive care unit.

PARTICIPANTS

Twenty neonatal resuscitation providers.

MAIN OUTCOME MEASURES

Visual attention: overall gaze sample percentage; total gaze duration, visit count and average visit duration for each displayed RFM parameter. Qualitative feedback: willingness to wear eye-tracking glasses during clinical resuscitation.

RESULTS

Twenty providers participated in this study. The mean gaze sample captured wa s 93% (SD 4%). Exhaled tidal volume waveform was the RFM parameter with the highest total gaze duration (median 23%, IQR 13-51%), highest visit count (median 5.17 per 10 s, IQR 2.82-6.16) and longest visit duration (median 0.48 s, IQR 0.38-0.81 s). All participants were willing to wear the glasses during clinical resuscitation.

CONCLUSION

Wearable eye-tracking technology is feasible to identify gaze fixation on the RFM display and is well accepted by providers. Neonatal providers look at exhaled tidal volume more than any other RFM parameter. Future applications of eye-tracking technology include use during clinical resuscitation.

Evaluation of attention, perception, and stress levels of clinical cardiovascular perfusionists during cardiac operations: a pilot study

BACKGROUND

Performing cardiopulmonary bypass is a complex task which involves evaluating visual input from patient monitors and technical parameters displayed at the heart-lung machine console as well as reacting to other sensory input. Only few studies are available concerning the competency requirements for clinical cardiovascular perfusionists, including attention, perception, and coping with mental stress. This study aims at evaluating attention, perception, and stress levels of clinical cardiovascular perfusionists during cardiopulmonary bypass.

METHODS

Nine clinical cardiovascular perfusionists voluntarily offered to participate in the study. Participants were asked to wear Tobii 2 eye-tracking glasses throughout the procedures. Specific time points were analyzed (cardiopulmonary bypass on, initial cardioplegia delivery, steady state, cross-clamp off, and weaning from cardiopulmonary bypass). Data acquisition was supplemented by participants' self-evaluation regarding their stress levels and by National Aeronautics and Space Administration Task Load Index (NASA TLX) questionnaires.

RESULTS

Seven datasets were sufficient to be evaluated. The clinical cardiovascular perfusionists' professional experience ranged from 0.5 to 24 years. Evaluation of eye-tracking data revealed large variations in areas of interest hits, fixation, and dwell times. Across all phases, the venous reservoir, mean arterial pressure, arterial pump display, cardioplegia control, and data management system received the highest levels of attention. Pupil diameter measurements increased at start of cardiopulmonary bypass, cardioplegia delivery, and weaning off, but returned to base level during steady state. Clinical cardiovascular perfusionists' self-evaluation showed that subjective stress level was highest at the start and the end of the procedure. NASA TLX questionnaires revealed medium-to-high mental and temporal workloads, but low physical workloads. Performance, effort, and frustration indices showed medium workloads.

CONCLUSION

During cardiopulmonary bypass, perfusionists are subjected to stress. Peak stress levels were highest during start and end of cardiopulmonary bypass. Furthermore, visual attention and perception varied between the operative phases. Further studies are indicated to evaluate the design of heart-lung machines and stress-coping strategies during cardiopulmonary bypass.

Emerging applications of eye-tracking technology in dermatology

Eye-tracking technology has been used within a multitude of disciplines to provide data linking eye movements to visual processing of various stimuli (i.e., x-rays, situational positioning, printed information, and warnings). Despite the benefits provided by eye-tracking in allowing for the identification and quantification of visual attention, the discipline of dermatology has yet to see broad application of the technology. Notwithstanding dermatologists' heavy reliance upon visual patterns and cues to discriminate between benign and atypical nevi, literature that applies eye-tracking to the study of dermatology is sparse; and literature specific to patient-initiated behaviors, such as skin self-examination (SSE), is largely non-existent. The current article provides a review of eye-tracking research in various medical fields, culminating in a discussion of current applications and advantages of eye-tracking for dermatology research.

Optimal eye movement strategies: a comparison of neurosurgeons gaze patterns when using a surgical microscope

BACKGROUND

Previous studies have consistently demonstrated gaze behaviour differences related to expertise during various surgical procedures. In micro-neurosurgery, however, there is a lack of evidence of empirically demonstrated individual differences associated with visual attention. It is unknown exactly how neurosurgeons see a stereoscopic magnified view in the context of micro-neurosurgery and what this implies for medical training.

METHOD

We report on an investigation of the eye movement patterns in micro-neurosurgery using a state-of-the-art eye tracker. We studied the eye movements of nine neurosurgeons while performing cutting and suturing tasks under a surgical microscope. Eye-movement characteristics, such as fixation (focus level) and saccade (visual search pattern), were analysed.

RESULTS

The results show a strong relationship between the level of microsurgical skill and the gaze pattern, whereas more expertise is associated with greater eye control, stability, and focusing in eye behaviour. For example, in the cutting task, well-trained surgeons increased their fixation durations on the operating field twice as much as the novices (expert, 848 ms; novice, 402 ms).

CONCLUSIONS

Maintaining steady visual attention on the target (fixation), as well as being able to quickly make eye jumps from one target to another (saccades) are two important elements for the success of neurosurgery. The captured gaze patterns can be used to improve medical education, as part of an assessment system or in a gaze-training application.

Perioperative Nurses' Work Experience With Robotic Surgery: A Focus Group Study

The aim of this study was to explore the work experience of perioperative nurses involved in robotic surgery. A qualitative descriptive study was conducted. Participants were 15 nurses who had been on a robotic surgery team at one of five major university hospitals in Seoul, South Korea. Participants were one male and 14 female nurses (mean age, 31.33 [SD, 4.19] years; range, 25-41 years). Their experience as robotic surgery nurses ranged from 8 months to 6 years. Nurses' experiences with robotic surgery were categorized within four main themes: (1) constant checking on patients' safety and the robot's functions; (2) unexpected robotic machine errors or malfunctions; (3) feelings of burden in a robotic surgical team; and (4) need and desire for more information and education. This study showed that there are common concerns about patient safety and the possibility of emergencies related to robot system failure among nurses. Offering more support for nurses involved in robotic surgery should be a priority to empower them to play an extended role in robotic surgery.