Physiological synchronization and entropy as measures of team cognitive load

Prospects for Augmenting Team Interactions with Real-Time Coordination-Based Measures in Human-Autonomy Teams

Complex work in teams requires coordination across team members and their technology as well as the ability to change and adapt over time to achieve effective performance. To support such complex interactions, recent efforts have worked toward the design of adaptive human-autonomy teaming systems that can provide feedback in or near real time to achieve the desired individual or team results. However, while significant advancements have been made to better model and understand the dynamics of team interaction and its relationship with task performance, appropriate measures of team coordination and computational methods to detect changes in coordination have not yet been widely investigated. Having the capacity to measure coordination in real time is quite promising as it provides the opportunity to provide adaptive feedback that may influence and regulate teams' coordination patterns and, ultimately, drive effective team performance. A critical requirement to reach this potential is having the theoretical and empirical foundation from which to do so. Therefore, the first goal of the paper is to review approaches to coordination dynamics, identify current research gaps, and draw insights from other areas, such as social interaction, relationship science, and psychotherapy. The second goal is to collate extant work on feedback and advance ideas for adaptive feedback systems that have potential to influence coordination in a way that can enhance the effectiveness of team interactions. In addressing these two goals, this work lays the foundation as well as plans for the future of human-autonomy teams that augment team interactions using coordination-based measures.

From Teams to Teamness: Future Directions in the Science of Team Cognition

OBJECTIVE

We review the current state-of-the-art in team cognition research, but more importantly describe the limitations of existing theories, laboratory paradigms, and measures considering the increasing complexities of modern teams and the study of team cognition.

BACKGROUND

Research on, and applications of, team cognition has led to theories, data, and measures over the last several decades.

METHOD

This article is based on research questions generated in a spring 2022 seminar on team cognition at Arizona State University led by the first author.

RESULTS

Future research directions are proposed for extending the conceptualization of teams and team cognition by examining dimensions of teamness; extending laboratory paradigms to attain more realistic teaming, including nonhuman teammates; and advancing measures of team cognition in a direction such that data can be collected unobtrusively, in real time, and automatically.

CONCLUSION

The future of team cognition is one of the new discoveries, new research paradigms, and new measures.

APPLICATION

Extending the concepts of teams and team cognition can also extend the potential applications of these concepts.

Surgical Sabermetrics: A Scoping Review of Technology-enhanced Assessment of Nontechnical Skills in the Operating Room

OBJECTIVE

To evaluate the current evidence for surgical sabermetrics: digital methods of assessing surgical nontechnical skills and investigate the implications for enhancing surgical performance.

BACKGROUND

Surgeons need high-quality, objective, and timely feedback to optimize performance and patient safety. Digital tools to assess nontechnical skills have the potential to reduce human bias and aid scalability. However, we do not fully understand which of the myriad of digital metrics of performance assessment have efficacy for surgeons.

METHODS

A systematic review was conducted by searching PubMed, EMBASE, CINAHL, and PSYCINFO databases following PRISMA-ScR guidelines. MeSH terms and keywords included "Assessment," "Surgeons," and "Technology". Eligible studies included a digital assessment of nontechnical skills for surgeons, residents, and/or medical students within an operative context.

RESULTS

From 19,229 articles screened, 81 articles met the inclusion criteria. The studies varied in surgical specialties, settings, and outcome measurements. A total of 122 distinct objective, digital metrics were utilized. Studies digitally measured at least 1 category of surgical nontechnical skill using a single (n=54) or multiple objective measures (n=27). The majority of studies utilized simulation (n=48) over live operative settings (n=32). Surgical Sabermetrics has been demonstrated to be beneficial in measuring cognitive load (n=57), situation awareness (n=24), communication (n=3), teamwork (n=13), and leadership (n=2). No studies measured intraoperative decision-making.

CONCLUSIONS

The literature detailing the intersection between surgical data science and operative nontechnical skills is diverse and growing rapidly. Surgical Sabermetrics may provide a promising modifiable technique to achieve desirable outcomes for both the surgeon and the patient. This study identifies a diverse array of measurements possible with sensor devices and highlights research gaps, including the need for objective assessment of decision-making. Future studies may advance the integration of physiological sensors to provide a holistic assessment of surgical performance.

A Typology for the Application of Team Coordination Dynamics Across Increasing Levels of Dynamic Complexity

OBJECTIVE

This review and synthesis examines approaches for measuring and assessing team coordination dynamics (TCD). The authors advance a system typology for classifying TCD approaches and their applications for increasing levels of dynamic complexity.

BACKGROUND

There is an increasing focus on how teams adapt their coordination in response to changing and uncertain operational conditions. Understanding coordination is significant because poor coordination is associated with maladaptive responses, whereas adaptive coordination is associated with effective responses. This issue has been met with TCD approaches that handle increasing complexity in the types of TCD teams exhibit.

METHOD

A three-level system typology of TCD approaches for increasing dynamic complexity is provided, with examples of research at each level. For System I TCD, team states converge toward a stable, fixed-point attractor. For System II TCD, team states are periodic, which can appear complex, yet are regular and relatively stable. In System III TCD, teams can exhibit periodic patterns, but those patterns change continuously to maintain effectiveness.

RESULTS

System I and System II are applicable to TCD with known or discoverable behavioral attractors that are stationary across mid-to long-range timescales. System III TCD is the most generalizable to dynamic environments with high requirements for adaptive coordination across a range of timescales.

CONCLUSION

We outline current challenges for TCD and next steps in this burgeoning field of research.

APPLICATION

System III approaches are becoming widespread, as they are generalizable to time- and/or scale-varying TCD and multimodal analyses. Recommendations for deploying TCD in team settings are provided.

Wearable heart rate variability and atrial fibrillation monitoring to improve clinically relevant endpoints in cardiac surgery-a systematic review

Background

This systematic review aims to highlight the untapped potential of heart rate variability (HRV) and atrial fibrillation (AF) monitoring by wearable health monitoring devices as a critical diagnostic tool in cardiac surgery (CS) patients. We reviewed established predictive capabilities of HRV and AF monitoring in specific cardiosurgical scenarios and provide a perspective on additional predictive properties of wearable health monitoring devices that need to be investigated.

Methods

After screening most relevant databases, we included 33 publications in this review. Perusing these publications on HRV's prognostic value, we could identify HRV as a predictor for sudden cardiac death, mortality after acute myocardial infarction (AMI), and post operative atrial fibrillation (POAF). With regards to standard AF assessment, which typically includes extensive periods of unrecorded cardiac activity, we demonstrated that continuous monitoring via wearables recorded significant cardiac events that would otherwise have been missed.

Results

Photoplethysmography and single-lead electrocardiogram (ECG) were identified as the most useful and convenient technical assessment modalities, and their advantages and disadvantages were described in detail. As a call to further action, we observed that the scientific community has relatively extensively explored wearable AF screening, whereas HRV assessment to improve relevant clinical outcomes in CS is rarely studied; it still has great potential to be leveraged.

Conclusions

Therefore, risk assessment in CS would benefit greatly from earlier preoperative and postoperative AF detection, comprehensive and accurate assessment of cardiac health through HRV metrics, and continuous long-term monitoring. These should be achievable via commercially available wearables.

Surgical Team Structure: How Familiarity and Team Size Influence Communication Effectiveness in Military Surgical Teams

INTRODUCTION

Preventable patient harm has persisted in health care despite recent advances to reduce errors. There is increasing recognition that non-technical skills, including communication and relationships, greatly impact interprofessional team performance and health care quality. Team familiarity and size are critical structural components that potentially influence information flow, communication, and efficiency.

METHODS

In this exploratory, prospective, cross-sectional study, we investigated the key structural components of surgical teams and identified how surgical team structure shapes communication effectiveness. Using total population sampling, we recruited surgical clinicians who provide direct patient care at a 138-bed military medical center. We used statistical modeling to characterize the relationship between communication effectiveness and five predictors: team familiarity, team size, surgical complexity, and the presence of surgical residents and student anesthesia professionals.

RESULTS

We surveyed 137 surgical teams composed of 149 multidisciplinary clinicians for an 82% response rate. The mean communication effectiveness score was 4.61 (SD = 0.30), the average team size was 4.53 (SD = 0.69) persons, and the average surgical complexity was 10.85 relative value units (SD = 6.86). The surgical teams exhibited high variability in familiarity, with teams co-performing 26% (SD = 0.16) of each other's surgeries. We found for every unit increase in team familiarity, communication effectiveness increased by 0.36 (P ≤ .05), whereas adding one additional member to the surgical team decreased communication effectiveness by 0.1 (P ≤ .05). Surgical complexity and the influence of residents and students were not associated with communication effectiveness.

CONCLUSIONS

For military surgical teams, greater familiarity and smaller team sizes were associated with small improvements in communication effectiveness. Military leaders can likely enhance team communication by engaging in a thoughtful and concerted program to foster cohesion by building familiarity and optimizing team size to meet task and cognitive demands. We suggest leaders develop bundled approaches to improve communication by integrating team familiarity and team size optimization into current evidence-based initiatives to enhance performance.

The Impact of Training on Human-Autonomy Team Communications and Trust Calibration

OBJECTIVE

This work examines two human-autonomy team (HAT) training approaches that target communication and trust calibration to improve team effectiveness under degraded conditions.

BACKGROUND

Human-autonomy teaming presents challenges to teamwork, some of which may be addressed through training. Factors vital to HAT performance include communication and calibrated trust.

METHOD

Thirty teams of three, including one confederate acting as an autonomous agent, received either entrainment-based coordination training, trust calibration training, or control training before executing a series of missions operating a simulated remotely piloted aircraft. Automation and autonomy failures simulating degraded conditions were injected during missions, and measures of team communication, trust, and task efficiency were collected.

RESULTS

Teams receiving coordination training had higher communication anticipation ratios, took photos of targets faster, and overcame more autonomy failures. Although autonomy failures were introduced in all conditions, teams receiving the calibration training reported that their overall trust in the agent was more robust over time. However, they did not perform better than the control condition.

CONCLUSIONS

Training based on entrainment of communications, wherein introduction of timely information exchange through one team member has lasting effects throughout the team, was positively associated with improvements in HAT communications and performance under degraded conditions. Training that emphasized the shortcomings of the autonomous agent appeared to calibrate expectations and maintain trust.

APPLICATIONS

Team training that includes an autonomous agent that models effective information exchange may positively impact team communication and coordination. Training that emphasizes the limitations of an autonomous agent may help calibrate trust.

Exploring objective measures for assessing team performance in healthcare: an interview study

Introduction

Effective teamwork plays a critical role in achieving high-performance outcomes in healthcare. Consequently, conducting a comprehensive assessment of team performance is essential for providing meaningful feedback during team trainings and enabling comparisons in scientific studies. However, traditional methods like self-reports or behavior observations have limitations such as susceptibility to bias or being resource consuming. To overcome these limitations and gain a more comprehensive understanding of team processes and performance, the assessment of objective measures, such as physiological parameters, can be valuable. These objective measures can complement traditional methods and provide a more holistic view of team performance. The aim of this study was to explore the potential of the use of objective measures for evaluating team performance for research and training purposes. For this, experts in the field of research and medical simulation training were interviewed to gather their opinions, ideas, and concerns regarding this novel approach.

Methods

A total of 34 medical and research experts participated in this exploratory qualitative study, engaging in semi-structured interviews. During the interview, experts were asked for (a) their opinion on measuring team performance with objective measures, (b) their ideas concerning potential objective measures suitable for measuring team performance of healthcare teams, and (c) their concerns regarding the use of objective measures for evaluating team performance. During data analysis responses were categorized per question.

Results

The findings from the 34 interviews revealed a predominantly positive reception of the idea of utilizing objective measures for evaluating team performance. However, the experts reported limited experience in actively incorporating objective measures into their training and research. Nevertheless, they identified various potential objective measures, including acoustical, visual, physiological, and endocrinological measures and a time layer. Concerns were raised regarding feasibility, complexity, cost, and privacy issues associated with the use of objective measures.

Discussion

The study highlights the opportunities and challenges associated with employing objective measures to assess healthcare team performance. It particularly emphasizes the concerns expressed by medical simulation experts and team researchers, providing valuable insights for developers, trainers, researchers, and healthcare professionals involved in the design, planning or utilization of objective measures in team training or research.

Entropy for team communication pattern recognition

This work aims to demonstrate entropy as a method that can be used to analyze team coordination using naturalistic team communication content. Much of team coordination happens through communication; understanding team communication is vital to better formulate and train teams for successful performance outcomes. Several decades of team communication research have led to various methods for analyzing team communication patterns. Many existing methods for team communication analysis have not been tested with naturalistic communication or only consider the frequency or flow of communication. Sliding-window entropy is used to analyze team coordination dynamics with team communication as a proxy. The resulting time series are evaluated using nonlinear dynamical systems analysis and clustering. Various team coordination patterns are identified using communication entropy at the team level. Entropy can be used to identify team communication patterns and their relation to team performance. While team coordination happens at the team level, a posteriori analysis indicates members' individual characteristics affect the overall team coordination patterns. In teams where the contribution is unequal, some members disproportionately affect the overall team coordination, which may undermine the team impact and affect team performance.

A Methodological Framework to Study Change in Team Cognition Under the Dynamical Hypothesis

The dynamical hypothesis claims that cognitive systems, such as teams, are dynamical systems (i.e., an interdependent collection of individuals and their technology that change together over time). Following this hypothesis, team researchers have adopted dynamical approaches to better understand the team cognitive processes and states that form team cognition, as well as how they emerge over time. One approach focuses on team coordination dynamics, which examines the coupling of signals between interacting individuals in various modalities, and has been shown to reflect aspects of team functioning including team cognition. However, how changes in team coordination relate to high-level team cognitive processes and states, as well as important events, are not yet fully understood. To this end, we advance a methodological framework for researching team cognition under the dynamical hypothesis. Subsequently, we provided an empirical case-study application of this framework. Thereby, this work contributes methodologically and empirically to a deeper understanding of team cognition, the dynamical hypothesis, and the synergy between them.

Measuring teamwork for training in healthcare using eye tracking and pose estimation

Teamwork is critical for safe patient care. Healthcare teams typically train teamwork in simulated clinical situations, which require the ability to measure teamwork via behavior observation. However, the required observations are prone to human biases and include significant cognitive load even for trained instructors. In this observational study we explored how eye tracking and pose estimation as two minimal invasive video-based technologies may measure teamwork during simulation-based teamwork training in healthcare. Mobile eye tracking, measuring where participants look, and multi-person pose estimation, measuring 3D human body and joint position, were used to record 64 third-year medical students who completed a simulated handover case in teams of four. On one hand, we processed the recorded data into the eye contact metric, based on eye tracking and relevant for situational awareness and communication patterns. On the other hand, the distance to patient metric was processed, based on multi-person pose estimation and relevant for team positioning and coordination. After successful data recording, we successfully processed the raw videos to specific teamwork metrics. The average eye contact time was 6.46 s [min 0 s - max 28.01 s], while the average distance to the patient resulted in 1.01 m [min 0.32 m - max 1.6 m]. Both metrics varied significantly between teams and simulated roles of participants (p < 0.001). With the objective, continuous, and reliable metrics we created visualizations illustrating the teams' interactions. Future research is necessary to generalize our findings and how they may complement existing methods, support instructors, and contribute to the quality of teamwork training in healthcare.

An Open-Source, Interoperable Architecture for Generating Real-Time Surgical Team Cognitive Alerts from Heart-Rate Variability Monitoring

Clinical alarm and decision support systems that lack clinical context may create non-actionable nuisance alarms that are not clinically relevant and can cause distractions during the most difficult moments of a surgery. We present a novel, interoperable, real-time system for adding contextual awareness to clinical systems by monitoring the heart-rate variability (HRV) of clinical team members. We designed an architecture for real-time capture, analysis, and presentation of HRV data from multiple clinicians and implemented this architecture as an application and device interfaces on the open-source OpenICE interoperability platform. In this work, we extend OpenICE with new capabilities to support the needs of the context-aware OR including a modularized data pipeline for simultaneously processing real-time electrocardiographic (ECG) waveforms from multiple clinicians to create estimates of their individual cognitive load. The system is built with standardized interfaces that allow for free interchange of software and hardware components including sensor devices, ECG filtering and beat detection algorithms, HRV metric calculations, and individual and team alerts based on changes in metrics. By integrating contextual cues and team member state into a unified process model, we believe future clinical applications will be able to emulate some of these behaviors to provide context-aware information to improve the safety and quality of surgical interventions.

A tool to assess nontechnical skills of perfusionists in the cardiac operating room

OBJECTIVES

This study aimed to develop the Perfusionists' Intraoperative Non-Technical Skills tool, specifically to the perfusionists' context, and test its inter-rater reliability.

METHODS

An expert panel was convened to review existing surgical nontechnical skills taxonomies and develop the Perfusionists' Intraoperative Non-Technical Skills tool. During a workshop held at a national meeting, perfusionists completed the Perfusionists' Intraoperative Non-Technical Skills ratings after watching 4 videos displaying simulated cardiac operations. Two videos showed "good performance," and 2 videos showed "poor performance." Inter-rater reliability analysis was performed and intraclass correlation coefficient was reported.

RESULTS

The final version of the Perfusionists' Intraoperative Non-Technical Skills taxonomy contains 4 behavioral categories (decision making, situation awareness, task management and leadership, teamwork and communication) with 4 behavioral elements each. Categories and elements are rated using an 8-point Likert scale ranging from 0.5 to 4.0. A total of 60 perfusionist raters were included and the comparison between rating distribution on "poor performance" and "good performance" videos yielded a statistically significant difference between groups, with a P value less than .001. A similar difference was found in all behavioral categories and elements. Reliability analysis showed moderate inter-rater reliability across overall ratings (intraclass correlation coefficient, 0.735; 95% confidence interval, 0.674-0.796; P < .001). Similar inter-rater reliability was found when raters were stratified by experience level.

CONCLUSIONS

The Perfusionists' Intraoperative Non-Technical Skills tool presented moderate inter-rater reliability among perfusionists with varied levels of experience. This tool can be used to train and assess perfusionists in relevant nontechnical skills, with the potential to enhance safety and improve surgical outcomes.

Cognitive Load Management: An Invaluable Tool for Safe and Effective Surgical Training

This article highlights the importance of considering Cognitive Load (CL) and Cognitive Load Theory (CLT) during surgical training, focusing on the acquisition of intra-operative skills. It describes the basis of CLT with the overarching aim of describing CLT-based techniques to enhance current training strategies and surgical performance, many of which are instinctively already employed in surgical practice. Currently, methods of feedback and assessment are imperfect - typically subjective, unsystematic, opportunistic, or retrospective, and at risk of human bias. Surgical Sabermetrics, the advanced analytics of surgical and audio-visual data, aims to enhance this feedback by providing objective, real-time, digital-based feedback. This article introduces the benefit of real-time measurement of CL to enhance feedback and its applications to surgical performance that follow the ethos of Surgical Sabermetrics.¹ The 2022 theme for ICOSET was "Making it Better." Cognitive Load and Surgical Sabermetrics principles provide tools to make Surgical training better, with the goal of higher quality care for patients.

multiSyncPy: A Python package for assessing multivariate coordination dynamics

In order to support the burgeoning field of research into intra- and interpersonal synchrony, we present an open-source software package: multiSyncPy. Multivariate synchrony goes beyond the bivariate case and can be useful for quantifying how groups, teams, and families coordinate their behaviors, or estimating the degree to which multiple modalities from an individual become synchronized. Our package includes state-of-the-art multivariate methods including symbolic entropy, multidimensional recurrence quantification analysis, coherence (with an additional sum-normalized modification), the cluster-phase 'Rho' metric, and a statistical test based on the Kuramoto order parameter. We also include functions for two surrogation techniques to compare the observed coordination dynamics with chance levels and a windowing function to examine time-varying coordination for most of the measures. Taken together, our collation and presentation of these methods make the study of interpersonal synchronization and coordination dynamics applicable to larger, more complex and often more ecologically valid study designs. In this work, we summarize the relevant theoretical background and present illustrative practical examples, lessons learned, as well as guidance for the usage of our package - using synthetic as well as empirical data. Furthermore, we provide a discussion of our work and software and outline interesting further directions and perspectives. multiSyncPy is freely available under the LGPL license at: https://github.com/cslab-hub/multiSyncPy , and also available at the Python package index.

Better forbearance, lower depression: Evidence based on heart rate variability

Background

The relationship between forbearance, a psychological resource, and depression has to date remained inconclusive. The present study investigated heart rate variability (HRV) reactivity to acute stressor tasks in participants with different levels of forbearance to discover how forbearance influences depressive emotions when facing adversity.

Method

The study examined the relationship between forbearance and depression, comparing HRV reactivity to stressor tasks in participants with different levels of forbearance. The levels of reported forbearance were assessed by the Forbearance Scale (FS). The Patient Health Questionnaire-9 (PHQ-9) was used to assessed depression severity. HRV reactivity was evaluated at five stages: baseline, the active stressor task, the period of recovery after the active stressor task, the passive stressor task, the period of recovery after the passive stressor task.

Results

FS scores had a significant negative correlation with PHQ-9 and a significant positive correlation with HRV; significant differences existed between the basal HRV in the higher and lower FS groups. In the passive stressor task and the period of recovery after the active stressor task, significantly different HRV responses were identified between the two groups.

Discussion

Forbearance was correlated with depression and HRV. The present research found differences in HRV among subjects with different levels of forbearance in the baseline as well as stressor and recovery periods, suggesting that self-regulation dysfunction may exist among persons with lower levels of forbearance. Because of the higher levels of forbearance, the negative emotions of individuals caused by adversity are mitigated.

Westerink JHD, Rispens S. A Review of Using Wearable Technology to Assess Team Functioning and Performance

Wearable technology enables collecting continuous in situ data from multiple people in various modalities, which can enhance team research and support, as the dynamic coupling of signals between interacting individuals (i.e., team coordination dynamics) is believed to reflect underlying processes and states of team functioning and performance. We conducted a systematic review on existing literature to evaluate the prospective use of wearable technology in research and practice. Using the IMOI framework as an organizing tool, our review revealed considerable support linking team coordination dynamics in different modalities to team functioning and performance, but also explicated the field’s nascent status.

Assessing Team Situational Awareness in the Operating Room via Computer Vision

Situational awareness (SA) at both individual and team levels, plays a critical role in the operating room (OR). During the pre-incision time-out, the entire OR team comes together to deploy the surgical safety checklist (SSC). Worldwide, the implementation of the SSC has been shown to reduce intraoperative complications and mortality among surgical patients. In this study, we investigated the feasibility of applying computer vision analysis on surgical videos to extract team motion metrics that could differentiate teams with good SA from those with poor SA during the pre-incision time-out. We used a validated observation-based tool to assess SA, and a computer vision software to measure body position and motion patterns in the OR. Our findings showed that it is feasible to extract surgical team motion metrics captured via off-the-shelf OR cameras. Entropy as a measure of the level of team organization was able to distinguish surgical teams with good and poor SA. These findings corroborate existing studies showing that computer vision-based motion metrics have the potential to integrate traditional observation-based performance assessments in the OR.

Military Surgical Team Performance: The Impact of Familiarity, Team Size, and Nurse Anesthesia Students

PURPOSE

To examine the key factors impacting surgical team performance in a military medical center.

DESIGN

A retrospective, exploratory, cross-sectional design.

METHODS

We reviewed 751 orthopedic surgical cases to determine the association of surgical team familiarity, surgical complexity, team size, and the presence of student registered nurse anesthetists (SRNAs) with the surgical performance measures of total operative time, turnover time, and on-time surgical start.

FINDINGS

We found increases in surgical team familiarity significantly reduced turnover time by 7.84% (1-0.9216 = 0.0784; P = .0260) after controlling for surgical complexity and the presence of an SRNA on the team. Familiarity did not significantly impact total operative time or the odds of a first case on-time start. With a significant interaction of surgical complexity and team size on total operative time, the surgical complexity marginal effect (at the mean of team size) showed that a one-point increase prolonged total operative time by 6.89% (P < .0001), after controlling for team familiarity and an SRNA. The team size marginal effect (at the mean of surgical complexity) showed that adding one member to the surgical team prolonged total operative time by 6.45% (P < .0001), after controlling for team familiarity and an SRNA. Higher surgical complexity not only increased turnover time by 1.46% (P = .0265) while holding surgical complexity and an SRNA presence constant, but also reduced the likelihood of an on-time surgical start by 0.9359 (P = .0060). Larger teams decreased the odds of an on-time start by 0.7750 (P = .0363). We found that SRNAs potentially offer efficiency benefits, as their presence on a surgical team was associated with a 0.82% (1-0.9185 = 0.0815; P = .0007) decrease in total operative time, and a 21.01% (1-0.7899=0.2101; P = .0002) reduction in expected turnover time, after adjusting for confounding variables.

CONCLUSIONS

Surgical efficiency is a modifiable function of surgical teams. Although we suggest additional research, surgical leaders can potentially improve team performance by improving familiarity and forming small and cohesive surgical teams. As OR inefficiencies degrade the financial vitality of healthcare systems, surgical leaders should engage in a multifaceted program to improve efficiency by building familiarity and optimizing team size.

Stress and autonomic nerve dysfunction monitoring in perioperative gastric cancer patients using a smart device

Background

Heart rate variability (HRV), a sensitive marker of stress and autonomic nervous disorders, was significantly decreased in cardiovascular disease, inflammation, and surgical injury. However, the effect of radical gastrectomy on HRV parameters needs to be further investigated.

Methods

A prospective, observational study including 45 consecutive enrolled patients undergoing radical gastrectomy in our enhanced recovery after surgery (ERAS) programs was conducted. Frequency‐ and time‐domain parameters of HRV from 1 day prior to operation to 4 days postoperatively were continuously measured. Meanwhile, plasma cortisol and inflammatory markers were recorded and correlated to HRV parameters.

Results

Heart rate variability showed a solidly circadian rhythm. Anesthesia severely disturbed HRV parameters, resulting in a reduction of most of the HRV parameters. Frequency‐domain parameter (including VLF) and time‐domain parameters (including the SDNN, SDANN, and triangular index) of HRV demonstrated a significant reduction compared to preoperative values on the postoperative day 1 (Pod1), and these HRV parameters could return to baseline on Pod2 or Pod3, indicating surgical stress and autonomic nerve dysfunction existed in the early postoperative period. Inflammatory biomarkers were significantly elevated on Pod1 and Pod3. Plasma cortisol decreased significantly on Pod1 and Pod3. Both inflammatory biomarkers and plasma cortisol had no significant correlation with HRV parameters.

Conclusions

Compared with plasma cortisol and inflammation biomarkers, HRV is more sensitive to detect surgical stress and autonomic nervous dysfunction induced by radical gastrectomy in patients with gastric cancer.

Analysis of Mirrored Psychophysiological Change of Cardiac Surgery Team Members During Open Surgery

OBJECTIVE

Mirrored psychophysiological change in cognitive workload indices may reflect shared mental models and effective healthcare team dynamics. In this exploratory analysis, we investigated the frequency of mirrored changes, defined as concurrent peaks in heart rate variability (HRV) across team members, during cardiac surgery.

DESIGN

Objective cognitive workload was evaluated via HRV collected from the primary surgical team during cardiac surgery cases (N = 15). Root mean square of the successive differences (RMSSD) was calculated as the primary HRV measure. Procedures were divided into consecutive nonoverlapping 5-minute segments, and RMSSD along with deviations from RMSSD were calculated for each segment. Segments with positive deflections represent above-average cognitive workload. Positive deflections and peaks across dyads within the same segment were counted.

SETTING

Data collection for this study took place in the cardiovascular operating room during live surgeries.

PARTICIPANTS

Physiological data were collected and analyzed from the attending surgeon, attending anesthesiologist, and primary perfusionist involved with the recorded cases.

RESULTS

Of the 641 five-minute segments analyzed, 325 (50.7%) were positive deflections above average, concurrently across at least 2 team members. Within the 325 positive deflections, 26 (8%) represented concurrent peaks in HRV across at least 2 active team members. Mirrored peaks across team members were observed most commonly during the coronary anastomoses or valve replacement phase (N = 12).

CONCLUSIONS

In this pilot study, mirrored physiological responses representing peaks in cognitive workload were observed uncommonly across dyads of cardiac surgery team members (1.73 peaks/case on average). Almost half of these occurred during the most technically demanding phases of cardiac surgery, which may underpin teamwork quality. Future work should investigate interactions between technical and nontechnical performance surrounding times of mirrored peaks and expand the sample size.

Sensors for Continuous Monitoring of Surgeon's Cognitive Workload in the Cardiac Operating Room

Monitoring healthcare providers’ cognitive workload during surgical procedures can provide insight into the dynamic changes of mental states that may affect patient clinical outcomes. The role of cognitive factors influencing both technical and non-technical skill are increasingly being recognized, especially as the opportunities to unobtrusively collect accurate and sensitive data are improving. Applying sensors to capture these data in a complex real-world setting such as the cardiac surgery operating room, however, is accompanied by myriad social, physical, and procedural constraints. The goal of this study was to investigate the feasibility of overcoming logistical barriers in order to effectively collect multi-modal psychophysiological inputs via heart rate (HR) and near-infrared spectroscopy (NIRS) acquisition in the real-world setting of the operating room. The surgeon was outfitted with HR and NIRS sensors during aortic valve surgery, and validation analysis was performed to detect the influence of intra-operative events on cardiovascular and prefrontal cortex changes. Signals collected were significantly correlated and noted intra-operative events and subjective self-reports coincided with observable correlations among cardiovascular and cerebral activity across surgical phases. The primary novelty and contribution of this work is in demonstrating the feasibility of collecting continuous sensor data from a surgical team member in a real-world setting.

Application of the Structure Function in the Evaluation of the Human Factor in Healthcare

A structure function is one of the possible mathematical models of systems in reliability engineering. A structure function maps sets of component states into system performance levels. Methods of system reliability evaluation based on structure function representation are well established. A structure function can be formed based on completely specified data about system behavior. Such data for most real-world systems are incomplete and uncertain. The typical example is analysis and evaluation of the human factor. Therefore, the structure function is not used in human reliability analysis (HRA) typically. In this paper, a method for structure function construction is proposed based on incomplete and uncertain data in HRA. The proposed method application is considered for healthcare to evaluate medical error. This method is developed using a fuzzy decision tree (FDT), which allows all possible component states to be classified into classes of system performance levels. The structure function is constructed based on the decision table, which is formed according to the FDT. A case study for this method is considered by evaluating the human factor in healthcare: complications in the familiarization and exploitation of a new device in a hospital department are analyzed and evaluated. This evaluation shows the decreasing of medical errors in diagnosis after one year of device exploitation and a slight decrease in quality of diagnosis after two months of device exploitation. Numerical values of probabilities of medical error are calculated based on the proposed approach.

Cognitive Engineering to Improve Patient Safety and Outcomes in Cardiothoracic Surgery

Cognitive engineering is focused on how humans can cope and master the complexity of processes and technological environments. In cardiothoracic surgery, the goal is to support safe and effective human performance by preventing medical errors. Strategies derived from cognitive engineering research could be introduced in cardiothoracic surgery practice in the near future to enhance patient safety and outcomes.