Teamwork and communication in the operating room: relationship to discrete outcomes and research challenges

Operating room organization and surgical performance: a systematic review

BACKGROUND

Organizational factors may influence surgical outcomes, regardless of extensively studied factors such as patient preoperative risk and surgical complexity. This study was designed to explore how operating room organization determines surgical performance and to identify gaps in the literature that necessitate further investigation.

METHODS

We conducted a systematic review according to PRISMA guidelines to identify original studies in Pubmed and Scopus from January 1, 2000 to December 31, 2019. Studies evaluating the association between five determinants (team composition, stability, teamwork, work scheduling, disturbing elements) and three outcomes (operative time, patient safety, costs) were included. Methodology was assessed based on criteria such as multicentric investigation, accurate population description, and study design.

RESULTS

Out of 2625 studies, 76 met inclusion criteria. Of these, 34 (44.7%) investigated surgical team composition, 15 (19.7%) team stability, 11 (14.5%) teamwork, 9 (11.8%) scheduling, and 7 (9.2%) examined the occurrence of disturbing elements in the operating room. The participation of surgical residents appeared to impact patient outcomes. Employing specialized and stable teams in dedicated operating rooms showed improvements in outcomes. Optimization of teamwork reduced operative time, while poor teamwork increased morbidity and costs. Disturbances and communication failures in the operating room negatively affected operative time and surgical safety.

CONCLUSION

While limited, existing scientific evidence suggests that operating room staffing and environment significantly influences patient outcomes. Prioritizing further research on these organizational drivers is key to enhancing surgical performance.

Standardization and Visualization of the Surgical Time-Out

INTRODUCTION

The time-out (TO) can prevent adverse events but is subject to TO engagement. We hypothesize transforming the TO to an auditable, active process will improve compliance and engagement.

METHODS

The passive nature of the current TO was identified as a potential safety issue on staff patient safety culture surveys. Subsequently, the Time Out Engagement and Standardization quality improvement initiative was developed and included a whiteboard checklist to be used in the operating room. As a baseline, 11 TOs were audited concerning engagement and content. Key stakeholders were engaged to determine potential interventions. A TO consisting of 15 elements using a TO whiteboard checklist with role-specific objectives was developed. Plan, Do, Study, Act cycles commenced. After implementation, 17 TOs were audited based on engagement and content.

RESULTS

Before intervention, engagement varied with nurse participating in 100% compared with anesthesia provider or surgeon participating in 18%. No TO included all 15 elements and only 13% of elements included in all TOs. After implementation of Time Out Engagement and Standardization, anesthesia and surgeon who participated increased to 100% and 76.5%, respectively (P < 0.0001, P = 0.006). The 15 standardized elements of the TO were discussed in 90% of cases. Overall, preintervention 88 elements (57.1%) were completed across all TOs, while postintervention 243 elements (98.8%) were completed (P < 0.001).

CONCLUSIONS

We identified a need for increased engagement of the TO based on staff concerns, which were verified through auditing. Implementation of a team-driven intervention and 3 rapid Plan, Do, Study, Act cycles led to measurable improvement of the surgical TO.

Analyzing interprofessional teamwork in the operating room: An exploratory observational study using conventional and alternative approaches

Intraoperative teamwork is vital for patient safety. Conventional tools for studying intraoperative teamwork typically rely on behaviorally anchored rating scales applied at the individual or team level, while others capture narrative information across several units of analysis. This prospective observational study characterizes teamwork using two conventional tools (Operating Theatre Team Non-Technical Skills Assessment Tool [NOTECHS]; Team Emergency Assessment Measure [TEAM]), and one alternative approach (modified-Systems Engineering Initiative for Patient Safety [SEIPS] model). We aimed to explore the advantages and disadvantages of each for providing feedback to improve teamwork practice. Fifty consecutive surgical cases at a Canadian academic hospital were recorded with the OR Black Box®, analyzed by trained raters, and summarized descriptively. Teamwork performance was consistently high within and across cases rated with NOTECHS and TEAMS. For cases analyzed with the modified-SEIPS tool, both optimal and suboptimal teamwork behaviors were identified, and team resilience was frequently observed. NOTECHS and TEAM provided summative assessments and overall pattern descriptions, while SEIPS facilitated a deeper understanding of teamwork processes. As healthcare organizations continue to prioritize teamwork improvement, SEIPS may provide valuable insights regarding teamwork behavior and the broader context influencing performance. This may ultimately enhance the development and effectiveness of multi-level teamwork interventions.

Guidelines and principles for the care of the cardiothoracic transplant patient in the intensive care unit

Heart and lung transplant recipients require care provided by clinicians from multiple different specialties, each contributing unique expertise and perspective. The period the patient spends in the intensive care unit is one of the most critical times in the perioperative trajectory. Various organizational models of intensive care exist, including those led by intensivists, surgeons, transplant cardiologists, and pulmonologists. Coordinating timely efficient intensive care is an essential and logistically difficult goal. The present work product of the American Society of Transplantation's Thoracic and Critical Care Community of Practice, Critical Care Task Force outlines operational guidelines and principles that may be applied in different organizational models to optimize the delivery of intensive care for the cardiothoracic organ recipient.

Why non-technical skills matter in surgery. New paradigms for surgical leaders

The surgical literature is paying more and more attention to the topic of soft or non-technical skills (NTS), defined as those cognitive and social skills that characterize high-performing individuals and teams. NTS are essential in supporting surgeons in dealing with unexpected situations. During the COVID-19 pandemic, NTS have been considered crucial in defining situation awareness, enhancing decision making, communicating among groups and teams, and fostering leadership. With a "looking back and planning forward" approach, the current perspective aims at deepening the contribution of NTS for surgeons to deal with the unexpected challenges posed by the COVID crisis, surgical emergencies, the introduction of new technologies in clinical practice, to understand how such skills may help shape the surgical leaders of the future.

Human Performance of Three Hands in Unimanual, Bimanual and Trimanual Tasks

Trimanual operation using a robotic supernumerary limb is a new and challenging mechanism for human operators that could enable a single user to perform tasks requiring more than two hands. Foot-controlled interfaces have previously proven able to be intuitively controlled, enabling simple tasks to be performed. However, the effect of going from unimanual to bimanual and then to trimanual tasks on subjects performance and coordination is not well understood. In this paper, unimanual, bimanual and trimanual teleoperation tasks were performed in a virtual reality scene to evaluate the impact of extending to trimanual actions. 15 participants were required to move their limbs together in a coordinated reaching activity. The results show that the addition of another hand resulted in an increase in operating time, where the time increased in going from unimanual to bimanual operation and then increased further when going from bimanual to trimanual. Moreover, the success rate for performing bimanual and trimanual tasks was strongly influenced by the subject's performance in ipsilateral hand-foot activities, where the ipsilateral combination had a lower success rate than contralateral limbs. The addition of a hand did not affect any two-hand coordination rate and even in some cases reduced coordination deviations. Clinical relevance - This work can contribute to build efficient training and learning framework on human multiple limbs motion control and coordination for both rehabilitation and augmentation.

Accountable Operating Room Teams

With Medicare reimbursement diminishing and the aging population consuming more health care, hospitals continue to push for reforms to improve the efficiency of health care delivery, decrease consumption, and elevate the quality of care. Operating rooms command a large share of hospital resources but are also major revenue generators. Surgical care has evolved to become more efficient and accountable. Defining the characteristics of an accountable operating room team has been more elusive and inconsistent. This review defines the characteristics of accountable operating room teams and recommends measures by which to evaluate them. [Orthopedics. 2021;44(4):e463-e470.].

A Three-Limb Teleoperated Robotic System with Foot Control for Flexible Endoscopic Surgery

Flexible endoscopy requires a lot of skill to manipulate both the endoscope and the associated instruments. In most robotic flexible endoscopic systems, the endoscope and instruments are controlled separately by two operators, which may result in communication errors and inefficient operation. Our solution is to enable the surgeon to control both the endoscope and the instruments. Here, we present a novel tele-operation robotic endoscopic system commanded by one operator using the continuous and simultaneous movements of their two hands and one foot. This 13-degree-of-freedom (DoF) system integrates a foot-controlled robotic flexible endoscope and two hand-controlled robotic endoscopic instruments, a robotic grasper and a robotic cauterizing hook. A dedicated foot-interface transfers the natural foot movements to the 4-DoF movements of the endoscope while two other commercial hand interfaces map the movements of the two hands to the two instruments individually. An ex-vivo experiment was carried out by six subjects without surgical experience, where the simultaneous control with foot and hands was compared with a sequential clutch-based hand control. The participants could successfully teleoperate the endoscope and the two instruments to cut the tissues at scattered target areas in a porcine stomach. Foot control yielded 43.7% faster task completion and required less mental effort as compared to the clutch-based hand control scheme, which proves the concept of three-limb tele-operation surgery and the developed flexible endoscopic system.

Operating room team training using simulation: Hope or hype?

BACKGROUND

This study sought to determine the long-term impact of multidisciplinary simulated operating room (OR) team training.

METHOD

Two-wave survey study (immediate post-training survey 2010-2017, follow-up 2018). Differences across time, specialty, and experience with adverse events were assessed using chi-square and t -tests.

RESULTS

Immediately after training, more than 90% of respondents found simulation scenarios realistic and reported team training would provide safer patient care. However, follow-up participants reported less enthusiasm toward training, with 58% stating they would like to take similar training again. A majority of participants (77%) experienced adverse events after training; those reporting adverse events reported more positive long-term evaluations.

CONCLUSIONS

Simulated OR team training is initially highly valued by participants and is perceived as contributing to patient safety. Diminution of participant enthusiasm over time suggests that repeat training requirements be reconsidered, and less costly, alternative methods (such as asynchronous learning or virtual reality) should be explored.

La définition des moments critiques et non critiques en salle d'opération : une étude de consensus Delphi modifiée

BACKGROUND

While the operating room (OR) has significantly benefited from aviation strategies to improve safety, the rate of avoidable human errors remains relatively high. One key aviation strategy that has yet to be formally established in the OR is the "sterile cockpit" rule, which prohibits all non-essential behaviours during critical moments of a flight. Applying this rule to the OR may enhance patient safety, but the critical moments of surgery need to be defined first.

METHODS

This study used a modified Delphi methodology to determine critical moments during surgery according to OR team members across institutions, professions, and specialties. Analysis occurred after each round. The stopping criterion was consensus on 80% of survey items or no change in the mean score for any individual item between two consecutive rounds.

RESULTS

The first round included 304 respondents. Of these, 115 completed the second-round survey, and 75 completed all three rounds (27 nurses, 29 anesthesiologists, 19 surgeons). Critical moments obtained by consensus were: induction of anesthesia; emergence from anesthesia; preoperative briefing; final counts at the end of the procedure; anesthesiologist- or surgeon-relevant intraoperative event; handovers; procedure-specific high-risk surgical moments; crisis resource management situations; medication and equipment preparation; and key medication administration.

CONCLUSIONS

By defining the most critical moments of surgery, future research can determine the relative importance of behaviour and actions at each stage and target interventions to these stages.

Measuring the teamwork performance of operating room teams: a systematic review of assessment tools and their measurement properties

Teamwork is fundamental to surgical patient safety but is inconsistently measured. While many tools have been developed for elective intraoperative situations, it is unclear which is the most robust. This systematic review aimed to identify tools to measure the teamwork of operating room teams. Studies were included if they examined the measurement properties of these tools. PsycINFO, Embase (via OVID), CINAHL, ERIC, Medline and Medline in Process (via OVID) were searched through to May 3, 2019, as were reference lists of included studies and previously published relevant reviews. Retrieved articles were screened and data extracted in duplicate by two independent reviewers. Quality was assessed using the COSMIN checklist. Of the 2121 references identified, 14 studies of six assessment tools were included. Tools were validated across various specialties, mostly in clinical rather than simulated settings. The Observational Teamwork Assessment for Surgery (OTAS) and Operating Theater Team Non-Technical Skills Assessment Tool (NOTECHS) were the most frequently investigated tools. Though acceptable for assessing teamwork, both NOTECHS and OTAS rely on the questionable assumption that the teamwork of a team is equivalent to the sum of individual performances. Future studies may investigate other assessment tools that assess the whole team as the unit of analysis along with the potential of these tools to provide healthcare providers with meaningful feedback in clinical practice.

"Disruptive behavior" in the operating room: A prospective observational study of triggers and effects of tense communication episodes in surgical teams

BACKGROUND

Tense communication and disruptive behaviors during surgery have often been attributed to surgeons' personality or hierarchies, while situational triggers for tense communication were neglected. Goals of this study were to assess situational triggers of tense communication in the operating room and to assess its impact on collaboration quality within the surgical team.

METHODS AND FINDINGS

The prospective observational study was performed in two university hospitals in Europe. Trained external observers assessed communication in 137 elective abdominal operations led by 30 different main surgeons. Objective observations were related to perceived collaboration quality by all members of the surgical team. A total of 340 tense communication episodes were observed (= 0.57 per hour); mean tensions in surgeries with tensions was 1.21 per hour. Individual surgeons accounted for 24% of the variation in tensions, while situational aspects accounted for 76% of variation. A total of 72% of tensions were triggered by coordination problems; 21.2% by task-related problems and 9.1% by other issues. More tensions were related to lower perceived teamwork quality for all team members except main surgeons. Coordination-triggered tensions significantly lowered teamwork quality for second surgeons, scrub technicians and circulators.

CONCLUSIONS

Although individual surgeons differ in their tense communication, situational aspects during the operation had a much more important influence on the occurrence of tensions, mostly triggered by coordination problems. Because tensions negatively impact team collaboration, surgical teams may profit from improving collaboration, for instance through training, or through reflexivity.

Exploring stakeholder perceptions around implementation of the Operating Room Black Box for patient safety research: a qualitative study using the theoretical domains framework

Background

Systematically observing clinical performance in the operating room (OR) to support patient safety initiatives faces numerous logistical and methodological challenges. These may be solved by new audio-video recording technologies like the OR Black Box, which is a tool similar to black boxes in aviation. This study aimed to identify barriers and enablers that may influence patients’, clinicians’ and senior leadership team members’ support of the OR Black Box in order to guide its future implementation.

Methods

Patients, clinicians and senior leadership team members were recruited to participate in semistructured interviews informed by the theoretical domains framework (TDF) to identify factors relevant to planning OR Black Box implementation. Deidentified interview transcripts were analysed in duplicate following a TDF coding structure.

Results

Data saturation was achieved at 15 patients, 17 clinicians and 9 senior leadership team members. Seven domains were relevant for patients, nine for clinicians and four for senior leadership. Knowledge and Beliefs about consequences were barriers and enablers for all three groups. Memory, attention and decision processes and Social influences were enablers for both clinicians and senior leadership. Environmental context and resources, Emotion and Behavioural regulation were found to be barriers and enablers for both clinicians and patients. Social/professional role and identity and Reinforcement were enablers for patients only and Optimism and Intentions were barriers and enablers to clinicians.

Conclusions

While most stakeholders were supportive of the OR Black Box, we identified many key areas that need to be addressed during its implementation. It is critical to ensure all stakeholders have adequate and accurate information about the OR Black Box system and research goals, and that the OR Black Box is positioned as a patient safety initiative for learning from and improving practice.

Perianesthesia Nurses Are My Second Family: A Qualitative Descriptive Study

PURPOSE

Identify the perceptions of perianesthesia nurses regarding behaviors that promote or detract from sustaining a safe, efficient, and satisfying work environment.

DESIGN

Two focus groups and seven individual interviews (n=14) were conducted exploring the perceptions regarding team behavior of registered nurses in one pediatric perianesthesia unit.

METHODS

Qualitative descriptive data collection, inductive content analysis.

FINDINGS

Nurses described a responsive, engaged health care team whose leadership is available and directive when needed, as creating an effective, satisfying work environment. Primary themes that emerged were Leadership Sets the Tone, Playing Fair, No One Gets Hurt, and Why We Stay. This nursing team acknowledged that inattentive, distracted team members cause frustration, work inequities, and care delays, potentially undermining patient safety.

CONCLUSIONS

Results demonstrate the need to create and sustain consistently respectful perianesthesia work cultures. Research focusing on unit specific approaches to work distribution, communication, leadership, and technology use is needed.

In Situ Operating Room-Based Simulation: A Review

OBJECTIVE

To systematically review the literature surrounding operating room-based in situ training in surgery.

METHODS

A systematic review was conducted of MEDLINE. The review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology, and employed the Population, Intervention, Comparator, Outcome (PICO) structure to define inclusion/exclusion criteria. The Kirkpatrick model was used to further classify the outcome of in situ training when possible.

RESULTS

The search returned 308 database hits, and ultimately 19 articles were identified that met the stated PICO inclusion criteria. Operating room-based in situ simulation is used for a variety of purposes and in a variety of settings, and it has the potential to offer unique advantages over other types of simulation. Only one randomized controlled trial was conducted comparing in situ simulation to off-site simulation, which found few significant differences. One large-scale outcome study showed improved perinatal outcomes in obstetrics.

CONCLUSIONS

Although in situ simulation theoretically offers certain advantages over other types of simulation, especially in addressing system-wide or environmental threats, its efficacy has yet to be clearly demonstrated.

Noise peaks influence communication in the operating room. An observational study

Noise peaks are powerful distractors. This study focuses on the impact of noise peaks on surgical teams' communication during 109 long abdominal surgeries. We related measured noise peaks during 5-min intervals to the amount of observed communication during the same interval. Results show that noise peaks are associated with less case-relevant communication; this effect is moderated by the level of surgical experience; case-relevant communications decrease under high noise peak conditions among junior, but not among senior surgeons. However, case-irrelevant communication did not decrease under high noise level conditions, rather there was a trend to more case-irrelevant communication under high noise peaks. The results support the hypothesis that noise peaks impair communication because they draw on attentional resources rather than impairing understanding of communication. As case-relevant communication is important for surgical performance, exposure to high noise peaks in the OR should be minimised especially for less experienced surgeons. Practitioner Summary: This study investigated whether noise during surgeries influenced the communication within surgical teams. During abdominal surgeries, noise levels were measured and communication was observed. Results showed that high noise peaks reduced the frequency of patient-related communication, but did not reduce patient-irrelevant communication. Noise may negatively affect team coordination in surgeries.

Are surgeons and anesthesiologists lying to each other or gaming the system? A national random sample survey about "truth-telling practices" in the perioperative setting in the United States

Background

The perioperative setting demands strong teamwork to ensure safe patient care, but anecdotally surgeons and anesthesiologists are not always fully truthful with each other. The present study sought to determine the frequency of misrepresentation of the truth in the perioperative setting.

Methods

Direct mailed survey in the United States about misrepresenting information to colleagues in a national random sample of 1130 anesthesiologists and 1130 surgeons.

Results

Reflecting the sensitive nature of these questions, only 252 (11 %) surveys were returned-128/1130 by anesthesiologists and 124/1130 by surgeons. While modest numbers of both anesthesiologists (34/128, 27 %) and surgeons (8/124, 7 %) acknowledged misreporting information at least once per month, misreporting was considerably more common among responding anesthesiologists. Among anesthesiologists the majority (68 %) were concerned that surgeons misreported information to them once a month or more often, though only 8 % of surgeons shared reciprocal concerns. More than a third of responding anesthesiologists (36 %) reported having seen their teachers misreport information to surgeons during their training.

Conclusions

These findings, though preliminary due to the small sample, raise concerns about a possible culture of misrepresentation, passed on between generations, in some perioperative environments. Misreporting of information should be examined in more detail and addressed at local levels whenever it is found. Further research is required to determine if the reported behaviors represent routine gaming of perioperative care systems or deliberate and intentional deception. Strategies aimed at fostering conditions in which open honest communication can thrive should be investigated.

Control of a Supernumerary Robotic Hand by Foot: An Experimental Study in Virtual Reality

In the operational theater, the surgical team could highly benefit from a robotic supplementary hand under the surgeon's full control. The surgeon may so become more autonomous; this may reduce communication errors with the assistants and take over difficult tasks such as holding tools without tremor. In this paper, we therefore examine the possibility to control a third robotic hand with one foot's movements. Three experiments in virtual reality were designed to assess the feasibility of this control strategy, the learning curve of the subjects in different tasks and the coordination of foot movements with the two natural hands. Results show that the limbs are moved simultaneously, in parallel rather than serially. Participants' performance improved within a few minutes of practice without any specific difficulty to complete the tasks. Subjective assessment by the subjects indicated that controlling a third hand by foot has been easy and required only negligible physical and mental efforts. The sense of ownership was reported to improve through the experiments. The mental burden was not directly related to the level of motion required by a task, but depended on the type of activity and practice. The most difficult task was moving two hands and foot in opposite directions. These results suggest that a combination of practice and appropriate tasks can enhance the learning process for controlling a robotic hand by foot.

Checklist usage decreases critical task omissions when training residents to separate from simulated cardiopulmonary bypass

OBJECTIVE

Separation from cardiopulmonary bypass (CPB) requires multiple preparatory steps, during which mistakes, omissions, and human errors may occur. Checklists have been used extensively in aviation to improve performance of complex, multistep tasks. The aim of this study was to (1) develop a checklist using a modified Delphi process to identify essential steps necessary to prepare for separation from CPB, and (2) compare the frequency of completed items with and without the use of a checklist in simulation. It was hypothesized that the use of a checklist would reduce the number of omissions.

DESIGN

High-fidelity simulation study.

SETTING

University-affiliated tertiary care facility.

PARTICIPANTS

Seven cardiac anesthesiologists created a checklist using a modified Delphi process. Ten residents participated in 4 scenarios separating from CPB in simulation.

INTERVENTIONS

Each scenario was performed first without a checklist and then again with a checklist. An observer graded participants' performance.

MEASUREMENTS AND MAIN RESULTS

A pre-separation checklist containing 9 tasks was created using the Delphi process. Without using this checklist, 4 tasks were completed in at least 75% of scenarios, and 8 tasks were completed at least 75% of the time when using the checklist. There was a significant improvement in completion of 5 of the 9 items (p< 0.01).

CONCLUSIONS

A modified Delphi process can be used to create a checklist of steps in preparing to separate from CPB. Using this checklist during simulation resulted in increased frequency of completing designated tasks in comparison to relying on memory alone. Checklists may reduce omission errors during complex periods of anesthesiologists' perioperative workflow.

Managing a surgical exsanguination emergency in the operating room through simulation: an interdisciplinary approach

OBJECTIVE

Operating room (OR) emergencies, such as fire, anaphylaxis, cardiac arrest, and exsanguination, are infrequent, but high-risk situations that can result in significant morbidity and mortality. An exsanguination scenario involving a pregnant trauma patient in the OR was developed for surgery residents with the objectives of improving overall team performance when activating an emergency response system, identifying a team leader, initiating an exsanguination protocol, following advanced cardiac life support guidelines, and recognizing the mother as the first patient.

STUDY DESIGN

During 6 months, 171 OR staff members of the Hospital of the University of Pennsylvania participated in a prospective study in which randomly selected groups of surgery residents, anesthesia residents, and perioperative nurses were trained in a simulated exsanguination and cardiac arrest emergency. Upon arrival to the simulation center, groups of trainees were assigned to a simulated OR equipped with a SimMan 3G (Laerdal, Norway) and a session moderator. The scenario started with a pregnant patient in hemorrhagic shock, bleeding from a carotid injury, ultimately leading to cardiac arrest. Each group did an initial "cold" simulation without any prior training or knowledge of the scenario, followed by a didactic training session, and ending with a "warm" simulation.

SETTING

Penn Medicine Clinical Simulation Center at 1800 Lombard Street, Philadelphia, Pennsylvania.

RESULTS

Among 156 participants, 50% reported understanding their role in an OR exsanguination emergency pretraining, compared with 98% who understood it posttraining (p < 0.001). For activation of the exsanguination protocol, 50% understood how to do it pretraining, compared with 98% posttraining (p = 0.004). The time needed to complete 8 clinically significant tasks was documented pre- and posttraining, with a statistically significant improvement in all tasks.

CONCLUSIONS

The results of this simulated exsanguination emergency demonstrate that team training using a high-fidelity mannequin is an effective way to train OR personnel, on how to manage exsanguinating traumatic patients in a high-risk surgical emergency.