Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation

A Delphi-based exploration of factors impacting blood loss and operative time in robotic prostatectomy

This study aims to investigate factors influencing the implementation of robotic-assisted radical surgery, with a specific focus on their effects on blood loss and operative time. Radical prostatectomy was chosen as the case study due to its complexity and diverse surgical activities. The study employed a three-round Delphi approach involving 25 surgeons from three countries: UK, Australia, and China. The collected data were analysed using non-parametric tests. The Delphi study showed significant correlations between the degree of difficulty and blood loss (Z = 2.698, ρ < 0.007), as well as between team coordination and blood loss (Z = 3.499, ρ < 0.0001). However, no significant relationship was found between operative time and blood loss. Surgeons reported that neurovascular bundle (NVB) release and pelvic lymph node dissection require high team coordination. NVB release is particularly challenging and poses a higher risk of blood loss. Additionally, a large prostate increases the difficulty of prostate dissection, prolongs operative time for bladder neck and NVB dissection, and leads to a considerable overall increase in operative time. The manuscript shows that effective team coordination plays a crucial role in reducing blood loss and operative time during surgical activities. When the team coordinates well, clear and efficient verbal communication suffices, reducing the need for physical proximity during robotic-assisted surgeries.

Challenges With Robot-Assisted Surgery Setup for Complex Minimally Invasive Upper Gastrointestinal Surgery

BACKGROUND

The utilization of robot-assisted approaches to surgery has increased significantly over the last two decades. This has introduced novel complexities into the operating room environment, requiring management of new challenges and workflow adaptation. This study aimed to analyze challenges in the surgical setup for complex upper gastrointestinal robot-assisted surgery (UGI-RAS) and identify opportunities for solutions.

METHODS

Direct observations of surgical setup processes for UGI-RAS were performed by a trained Human Factors researcher at a non-profit academic medical center in Southern California. Setup tasks were subdivided into five phases: (1) before wheels-in; (2) patient transfer and anesthesia induction; (3) patient preparation; (4) surgery preparation; and (5) robot docking. Start/end times for each phase/task were documented along with workflow disruption (FD) narratives and timestamps. Setup tasks and FDs were analyzed using descriptive statistics.

RESULTS

Twenty UGI-RAS setup procedures were observed between May-November 2023: sleeve gastrectomy +/- hiatal hernia repair (n = 9, 45.00%); para-esophageal hernia repair +/- fundoplication (n = 8, 40.00%); revision to Roux-en-Y gastric bypass (n = 2, 10.00%); and gastric band removal (n = 1, 5.00%). Frequent FDs included planning breakdowns (n = 20, 29.85%), equipment/supply management (n = 17, 25.37%), patient care coordination (n = 8, 11.94%), and equipment challenges (n = 8, 11.94%). Eleven of 20 observations were first-start cases, of which 10 experienced delayed starts.

DISCUSSION

Interventions aimed at improving workflows during UGI-RAS setup include performing pre-operative team huddles and conducting trainings aimed at team coordination and equipment challenges. These solutions could result in improved teamwork, efficiency, and communication while reducing case start delays and turnover time.

Endoscopic Robotic Mitral Operating Room as a Microsystem for Safety and Sustainability

OBJECTIVE

Safety and sustainability are key elements of a robotic mitral valve (MV) program at any stage of development. Challenges include the positioning of the surgeon at the robotic console, increasing patient complexity, and upstream administrative staffing difficulties. We instituted a systems approach to maximize patient safety and maintain robotic service viability.

METHODS

A single dedicated robotic operating room (OR) was equipped as a microsystem with team training in the operative steps, ergonomics, digital tools, and an explicit culture of safety. Outcomes of all robotic mitral procedures including concomitant procedures in the microsystem OR by a single surgeon were retrospectively reviewed.

RESULTS

From January 2014 through December 2023, 1,529 consecutive MV patients were operated with an endoscopic robotic approach. Ten patients (0.65%) were converted to conventional approaches. Overall, 1,300 MV repairs (85%) were performed with residual MV regurgitation of none to trace in 1,205 patients (92.7%), mild in 92 patients (7.1%), and moderate in 3 patients (0.23%). MV replacements were performed in 229 patients (15%) with no paravalvular leaks. Mortality was 0.08% in the repair group and 0.87% in the replacement group. No deaths have occurred in the last 38 months. Stroke occurred in 0.31% of repair patients and 1.3% of replacement patients. One patient developed transient renal failure.

CONCLUSIONS

Organization of the robotic OR as a microsystem is associated with surgical efficacy and very low morbidity and mortality. A comparable microsystem approach using all or select components may promote safety and sustainability for robotic MV programs at all levels.

Human Factors: Do They Impact Surgical Performance?

INTRODUCTION

Human factors in surgery relate to the environmental, organisational, and human factors that can impact performance in the operating theatre. This study assesses whether various factors such as music, counting backwards, and attempting to do simultaneous tasks impact surgical time and performance.

METHODS

Ten orthopaedic surgical staff were asked to guide a metal loop around a metal maze in a 'don't buzz the wire' game. The primary outcomes were the course completion time and the number of times the loop touched the wire. They were asked to do the course four times: one control run, with music, whilst counting backwards from a hundred in increments of three, and whilst simultaneously verbalising the steps of a dynamic hip screw (DHS) fixation.

RESULTS

The average time to complete the course for the control was 33.8 seconds. This was similar to when music was played (33.4 seconds) but increased when counting backwards (38.7 seconds) and verbalising the steps of a DHS (69.8 seconds, p = 0.0039). The average number of touches for the control was 4.3. Similar findings were obtained when counting backwards (four touches), but the number of touches decreased when music was played (2.2 touches). The average number of touches increased to 10.6 when verbalising the steps of a DHS (p = 0.0078).

CONCLUSION

Human factors can affect surgical performance, and an awareness of this is vital to take necessary steps to minimise the impact this has on behaviour and performance in the operating theatre.

Mastering multicasualty trauma care with the Trauma Non-technical Skills Scale

BACKGROUND

Multicasualty events present complex medical challenges. This is the first study to investigate the role of nontechnical skills in prehospital multicasualty trauma care. We assessed the feasibility of using the Trauma Nontechnical Skills Scale (T-NOTECHS) instrument, which has not yet been investigated to evaluate these scenarios.

METHODS

We conducted an observational study involving military medical teams with Israel Defense Forces Military Trauma Life Support training to assess the T-NOTECHS' utility in predicting prehospital medical team performance during multicasualty event simulations. These teams were selected from a pool of qualified military Advanced Life Support providers. Simulations were conducted in a dedicated facility resembling a field setting, with video recordings to ensure data accuracy. Teams faced a single multicasualty scenario, assessed by two instructors, and were evaluated using a 37-item checklist. The T-NOTECHS scores were analyzed using regression models to predict simulation performance.

RESULTS

We included 27 teams for analysis, led by 28% physicians and 72% paramedics. Interrater reliability for simulation performance and T-NOTECHS scores showed good agreement. Overall T-NOTECHS scores were positively correlated with simulation performance scores ( R = 0.546, p < 0.001). Each T-NOTECHS domain correlated with simulation performance. The Communication and Interaction domain explained a unique part of the variance ( β = 0.406, p = 0.047). Assessment and Decision Making had the highest correlation ( R = 0.535, p < 0.001). These domains significantly predicted specific items on the simulation performance checklist. Cooperation and Resource Management showed the least correlation with checklist items.

CONCLUSION

This study confirms the T-NOTECHS' reliability in predicting prehospital trauma team performance during multicasualty scenarios. Key nontechnical skills, especially Communication and Interaction, and Assessment and Decision Making, play vital roles. These findings underscore the importance of training in these skills to enhance trauma care in such scenarios, offering valuable insights for medical team preparation.

LEVEL OF EVIDENCE

Diagnostic Tests or Criteria; Level III.

Can Operating Room Design Make Orthopedic Surgeries Shorter, Safer, and More Efficient?: A Quasi-Experimental Study

OBJECTIVES

The study aimed to fill the knowledge gap about how operating room (OR) design could reduce orthopedic surgery duration and contribute to surgical care safety and efficiency.

BACKGROUND

Long surgery duration may lead to delays and cancellations of surgeries, deteriorated patient experiences, postoperative complications, and waste of healthcare resources. The OR physical environment may contribute to the reduction of surgery duration by minimizing workflow disruptions and personnel movements during surgeries.

METHODS

Unobtrusive observations were conducted of 70 unilateral total knee or hip replacement surgeries in two differently designed ORs at a community hospital in the United States. A set of computer-based forms adapted from recent research was used to measure the surgery duration, environment-related disruptions, and ambulatory movements involving circulators. Potential confounding factors like surgery type were controlled in statistical analyses.

RESULTS

Significantly shorter surgery durations were recorded in the larger OR with more clearances on both sides of the operating table, a wider door located on the sidewall, more cabinets, and more clearance between the circulator workstation and the sterile field (p =.019). The better-designed OR was also associated with less frequent disruptions and fewer movements per case (p < .001). Significant correlations existed between surgery duration, the number of disruptions, and the number of movements (rs = .576-.700, ps < .001).

CONCLUSIONS

The study demonstrated the important role of OR physical environment in supporting the safe and efficient delivery of surgical care, which should be further enhanced through research and design innovations.

Comparative Analysis of Endoscope Obscuration With Utilization of an Endonasal Access Guide for Endonasal Skull Base Surgery

BACKGROUND AND OBJECTIVES

In endoscopic endonasal approaches (EEAs) for skull base pathologies, endoscope view obscuration remains a persistent, time-consuming, and distracting issue for surgeons and may result in increased operative time. The endonasal access guide (EAG) has been demonstrated as a possible adjunct to minimize these events. However, to date, there have been no comparative studies performed and the potential time savings by using EAGs have yet to be quantified. This cohort study aimed to determine the operative efficiency benefits of the EAG in EEA operations.

METHODS

Analysis of EEA operative videos from an EAG cohort (n = 20) and a control cohort (n = 20) was performed, assessing 12-minute segments in the first, middle, and last third of each operation. The first segment in each cohort was selected before EAG placement, serving as an internal control. Every endoscope lens soiling instance was counted (measured as cleaning actions per minute), timed (obscuration time %), and identified as a withdrawal, irrigation, or other cleaning action. Perioperative variables including skull base repair and postoperative cerebrospinal fluid leakage were assessed.

RESULTS

Within the EAG cohort, obscuration time was reduced in the middle and last third compared with the first third (3.73% [CI: 2.39-5.07] vs 12.97% [CI: 10.24-15.70], P < .001; 4.19% [CI: 2.83-5.55] vs 12.97% [CI: 10.24-15.70], P < .001) and cleaning actions were also significantly reduced by EAG (0.69/min [CI: 0.39-0.99] vs 1.67/min [CI: 1.34-2.00], P = .001; 0.66/min [CI: 0.35-0.97] vs 1.67/min [CI: 1.34-2.00], P < .001). Between the control and EAG cohorts, there was no significant difference between obscuration time and cleaning actions in the first third (9.33% vs 12.97%, P = .086; 1.34/min vs 1.67/min, P = .151) or in the middle third (6.24% vs 3.73%, P = .140; 0.80/min vs 0.69/min, P = .335), but there was a significant difference in the last third (9.25% [CI: 6.95-11.55] vs 4.19% [CI: 2.83-5.55], P < .001; 0.95/min [CI: 0.73-1.17] vs 0.66/min [CI: 0.35-0.97], P = .018).

CONCLUSION

EAG significantly reduces lens obscurations and cleaning events, particularly during the intradural portion of operations. This technology may offer a greater time-saving impact with patients undergoing long EEA operations.

Quantitative assessment of the troCarWash™ system for automated laparoscopic camera cleaning

BACKGROUND

Soilage of the surgical endoscope occurs frequently during minimally invasive surgery. The resultant impairment of visualization of the surgical field compromises patient safety, prolongs operative times, and frustrates surgeons. The standard practice for cleaning the surgical camera involves a disruption in the conduct of surgery by completely removing the endoscope from the field, manually cleaning its lens, treating it with a surfactant, and reinserting it into the patient; after which the surgeon resumes the procedure.

METHODS

We developed an automated solution for in vivo endoscope cleaning in minimally invasive surgery- a port that detects the position of the endoscope in its distal lumen, and precisely and automatically delivers a pressurized mist of cleaning solution to the lens of the camera. No additions to the scope and minimal user interaction with the port are required. We tested the efficacy of this troCarWash™ device in a porcine model of laparoscopy. Four board-certified general surgeons were instructed to soil and then clean the laparoscope using the device. Representative pre- and post-clean images were exported from the surgical video and clarity was graded (1) digitally by a canny edge detection algorithm, and (2) subjectively by 3 blinded, unbiased observers using a semi-quantitative scale.

RESULTS

We observed statistically significant improvements in clarity by each method and for each surgeon, and we noted significant correlation between digital and subjective scores.

CONCLUSION

Based on these data, we conclude that the troCarWash™ effectively restored impaired visualization in a large animal model of laparoscopy.

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.

A Quantitative Analysis of Intraoperative Distractions and When They Occur During General Surgical Operations

Introduction Distractions in operating theatres prevent team members from concentrating on the complex tasks required for a successful operation. This can be a potential hazard to care for, and previously, correlations have been made between increased theatre distractions and adverse events. However, it remains unclear how frequently such events occur during routine care in theatres. The present study aims to quantify distractions and analyse any differences between staff groups, operative stages, and modes of operation. Methods A single-centre prospective study was conducted to assess disruptions in general surgical theatres. Events were recorded using a previously described categorization system on a proforma by a single researcher. The source and severity of distraction were recorded, as well as the mode of operation (elective/emergency), stage of operation, and staff team (scrubbed/floor). Results A total of 4,219 minutes of surgery were observed over four weeks, and 1,095 distraction events were recorded. Of the 14 elective and nine emergency procedures recorded, there was a mean of 54.8 distractions per procedure and a frequency of one distraction every three minutes and 51 seconds (15.6 hr-1). Irrelevant communication relating to the patient's case was the most common source, accounting for 24.7% of all distractions. The most frequently disrupted stage of the procedure for scrubbed staff was during anastomosis/resection for both elective and emergency procedures, with 16.9 and 32.6 distractions occurring per hour, respectively. Scrubbed staff were significantly more susceptible to distraction in emergency procedures than the floor staff. Discussion Our study reflects previous assessments with irrelevant communications and emergency procedures yielding the highest prevalence of distraction. This investigation provides novel information about the different stages of general surgery and the frequency of distractions that occur.

Call me Ishmael: addressing the white whale of team communication in the operating room with labelled surgical caps at an academic medical centre

INTRODUCTION

Effective communication in the operating room (OR) is crucial. Addressing a colleague by their name is respectful, humanising, entrusting and associated with improved clinical outcomes. We aimed to enhance team communication in the perioperative environment by offering personalised surgical caps labelled with name and provider role to all OR team members at a large academic medical centre.

MATERIALS AND METHODS

This was a quasi-experimental, uncontrolled, before-and-after quality improvement study. A survey regarding perceptions of team communication, knowledge of names and roles, communication barriers, and culture was administered before and after cap delivery. Survey results were measured on a 5-point Likert Scale; descriptive statistics and mean scores were compared. All cause National Surgical Quality Improvement Project (NSQIP) morbidity and mortality outcomes for surgical specialties were examined.

RESULTS

1420 caps were delivered across the institution. Mean survey scores increased for knowing the names and roles of providers around the OR, feeling that people know my name and feeling comfortable communicating without barriers across disciplines. The mean score for team communication around the OR is excellent was unchanged. The highest score both before and after was knowing the name of an interdisciplinary team member is important for patient care. A total of 383 and 212 providers participated in the study before and after cap delivery, respectively. Participants agreed or strongly agreed that labelled surgical caps made it easier to talk to colleagues (64.9%) while improving communication (66.0%), team culture (60.5%) and patient care (56.8%). No significant differences were noted in NSQIP outcomes.

CONCLUSIONS

Personalised labelled surgical caps are a simple, inexpensive tool that demonstrates promise in improving perioperative team communication. Creating highly reliable surgical teams with optimal communication channels requires a multifaceted approach with engaged leadership, empowered front-line providers and an institutional commitment to continuous process improvement.

Application of broken windows theory to identify flow disruptions in neurosurgery procedure

Addressing flow disruptions (FDs) in neurosurgery requires a multifaceted approach. Strategies like improved communication protocols, minimizing interruptions, improving coordination among team, optimizing operating room layout, and promoting user-centered design can help mitigate the challenges and enhance the overall flow and safety of neurosurgical procedures. Thirty neurosurgery cases were observed at two tertiary care facilities. The data collected were from wheels into the operating room to wheels out from the operating room. Data points were categorized using a human factors taxonomy known as RIPCHORD-TWA (Realizing Improved Patient Care Through Human-Centered Operating Room Design for Threat Window Analysis). Of the 541 total disruptions observed, coordination issues were the most prevalent (26.25%), followed by layout issues (26.06%), issues related to interruption (22.55%), communication (22.37%), equipment issues (2.40%) and usability issues (0.37%) comprised the remainder of the observations. This translated into one disruption every 2.7 min. Instead of focusing exclusively on errors and adverse events, we propose conceptualizing the accumulation of disruptions as "threat windows" to analyze potential threats to the integrity of the care system. This perspective allows for the improved identification of system weaknesses or threats, affording us the ability to address these inefficiencies and intervene before errors and adverse events may occur.

Prevention of complications in endourological management of stones: What are the basic measures needed before, during, and after interventions?

Objective

This narrative review aims to describe measures to minimise the risk of complications during percutaneous nephrolithotomy (PCNL), ureteroscopy, and retrograde intrarenal surgery.

Methods

A literature search was conducted from the PubMed/PMC database for papers published within the last 10 years (January 2012 to December 2022). Search terms included "ureteroscopy", "retrograde intrarenal surgery", "PCNL", "percutaneous nephrolithotomy", "complications", "sepsis", "infection", "bleed", "haemorrhage", and "hemorrhage". Key papers were identified and included meta-analyses, systematic reviews, guidelines, and primary research. The references of these papers were searched to identify any further relevant papers not included above.

Results

The evidence is assimilated with the opinions of the authors to provide recommendations. Best practice pathways for patient care in the pre-operative, intra-operative, and post-operative periods are described, including the identification and management of residual stones. Key complications (sepsis and stent issues) that are relevant for any endourological procedure are then be discussed. Operation-specific considerations are then explored. Key measures for PCNL include optimising access to minimise the chance of bleeding or visceral injury. The role of endoscopic combined intrarenal surgery in this regard is discussed. Key measures for ureteroscopy and retrograde intrarenal surgery include planning and technique to minimise the risk of ureteric injury. The role of anaesthetic assessment is discussed. The importance of specific comorbidities on each step of the pathway is highlighted as examples.

Conclusion

This review demonstrates that the principles of meticulous planning, interdisciplinary teamworking, and good operative technique can minimise the risk of complications in endourology.

Perceived Pager Burden Among Trainees Across Medical Specialties

BACKGROUND

The experiences of pager use among trainees across medical specialties is underexplored. The aim of this study was to assess experiences of pager burden and communication preferences among trainees in different specialties.

METHODS

An online survey was developed to assess perceived pager burden (eg, pager volume, mistake pages, sleep, and off-time interruptions) and communication preferences at a tertiary center in the United States. All residents and fellows were eligible to participate. Responses were grouped by specialty: General surgery [GS], Surgical subspecialty [SS], Medicine, Anesthesiology, and Psychiatry. Multivariable linear regression was used to assess factors associated with pager burden. Free text responses were analyzed using open coding methods.

RESULTS

Of the total 306 responses, the majority were female (58.8%), 30-39 years (59.2%), and White (70.6%). Specialty breakdown was: Medicine (40.2%), Psychiatry (10.8%), SS (18.0%), GS (5.6%), and Anesthesiology (3.6%). GS respondents reported receiving more mistake pages (P < .001), spending more time redirecting mistake pages (P = .003), and having the highest sleep time disruptions (P < .001). For urgent communications, surgical trainees preferred physical pagers, while nonsurgical trainees preferred smartphone pagers (P = .001). "Receive fewer nonurgent pages" was the most common change respondents desired.

DISCUSSION

In this single center study, subjective experiences of pager burden were disproportionately high among GS trainees. Reducing nonurgent and mistake pages are potential targets for improving trainee communication experiences. Hospitals should consider incorporating trainee preferences into paging systems. Additional studies are warranted to increase the sample size, assess generalizability of the findings, and contextualize trainee experiences with objective hospital-level paging data.

Human Factors Integration in Robotic Surgery

OBJECTIVE

Using the example of robotic-assisted surgery (RAS), we explore the methodological and practical challenges of technology integration in surgery, provide examples of evidence-based improvements, and discuss the importance of systems engineering and clinical human factors research and practice.

BACKGROUND

New operating room technologies offer potential benefits for patients and staff, yet also present challenges for physical, procedural, team, and organizational integration. Historically, RAS implementation has focused on establishing the technical skills of the surgeon on the console, and has not systematically addressed the new skills required for other team members, the use of the workspace, or the organizational changes.

RESULTS

Human factors studies of robotic surgery have demonstrated not just the effects of these hidden complexities on people, teams, processes, and proximal outcomes, but also have been able to analyze and explain in detail why they happen and offer methods to address them. We review studies on workload, communication, workflow, workspace, and coordination in robotic surgery, and then discuss the potential for improvement that these studies suggest within the wider healthcare system.

CONCLUSION

There is a growing need to understand and develop approaches to safety and quality improvement through human-systems integration at the frontline of care.Precis: The introduction of robotic surgery has exposed under-acknowledged complexities of introducing complex technology into operating rooms. We explore the methodological and practical challenges, provide examples of evidence-based improvements, and discuss the implications for systems engineering and clinical human factors research and practice.

A Combined Assessment Tool of Teamwork, Communication, and Workload in Hospital Procedural Units

Teamwork, communication, and workload issues continue to contribute to patient safety events. The authors developed a diagnostic mixed methods toolkit combining a behavior observation tool, semistructured interview guide, and surveys to proactively identify relevant gaps. Applied across 14 units at three hospitals, this toolkit yielded 344 findings with 156 associated recommendations and took, on average, four days of observation. On a scale from 1 (not at all helpful) to 6 (substantially helpful), leaders indicated that the assessment and its recommendations were very helpful (median 5, interquartile range 5-6, 34 survey respondents, 47.9% individual-level response rate, 85.7% unit-level response rate). Integrating this tool into a broader safety strategy can help inform organizational improvement efforts.

A Narrative Review on Intraoperative Adverse Events: Risks, Prevention, and Mitigation

INTRODUCTION

Adverse events from surgical interventions are common. They can occur at various stages of surgical care, and they carry a heavy burden on the different parties involved. While extensive research and efforts have been made to better understand the etiologies of postoperative complications, more research on intraoperative adverse events (iAEs) remains to be done.

METHODS

In this article, we reviewed the literature looking at iAEs to discuss their risk factors, their implications on surgical care, and the current efforts to mitigate and manage them.

RESULTS

Risk factors for iAEs are diverse and are dictated by patient-related risk factors, the nature and complexity of the procedures, the surgeon's experience, and the work environment of the operating room. The implications of iAEs vary according to their severity and include increased rates of 30-day postoperative morbidity and mortality, increased length of hospital stay and readmission, increased care cost, and a second victim emotional toll on the operating surgeon.

CONCLUSIONS

While transparent reporting of iAEs remains a challenge, many efforts are using new measures not only to report iAEs but also to provide better surveillance, prevention, and mitigation strategies to reduce their overall adverse impact.

Team-based care of the thoracic surgical patient

PURPOSE OF REVIEW

Although team-based care has been shown in many sectors to improve outcomes, very little work has been done with the thoracic surgical patient. This review article focuses on this and, extrapolating from other closely related surgical fields, teamwork in thoracic surgery will be reviewed for outcome efficacy and substance.

RECENT FINDINGS

The optimal team has been shown to display behaviors that allow them to model future needs, predict disaster, be adaptable to change, and promote team cohesiveness all with a positive effect on perioperative outcome. The suboptimal team will have transactional leadership, poor communication, ineffective conflict resolution, and hold rigid beliefs about other team members.

SUMMARY

To improve outcome, the thoracic surgical team, centered on the anesthesiologist and surgeon, will display the 'Big 5' attributes of highly effective teams. There are attributes of poor teams, which the dyad should avoid in order to increase the team's function and thus outcome.

Surgical complications: errors and adverse events

Complications are a recognized hazard of surgery. The term is confusing; it has multiple meanings, including surgical error and adverse surgical outcomes. I propose the latter two terms are used. Grading of 'complications' is difficult but made easier by grading errors and outcomes separately, though they are not always linked. The exact grades are not established.Error avoidance requires efforts at a personal (surgeon) level, including training, learning and preparation, and at a systems level. Understanding human factors is important.The perspective of patients about adverse outcomes is not well understood. There is evidence that, unsurprisingly, patient perspectives may be different to surgeon perspectives. There are a range of surgeon responses to error and adverse outcomes; many are negative. These need to be understood better in order to protect patients and surgeons in the immediate aftermath and in the potentially prolonged 'recovery time', both for patients and surgeons.Level of evidence: V.

Examining the surgical stress effects (SSE) framework in practice: A qualitative assessment of perceived sources and consequences of intraoperative stress in surgical teams

BACKGROUND

Surgical adverse events persist despite extensive improvement efforts. Emotional and behavioral responses to stressors may influence intraoperative performance, as illustrated in the surgical stress effects (SSE) framework. However, the SSE has not been assessed using "real world" data.

METHODS

We conducted semi-structured interviews with all surgical team roles at one midwestern VA hospital and elicited narratives involving intraoperative stress. Two coders inductively identified codes from transcripts. The team identified themes among codes and assessed concordance with the SSE framework.

RESULTS

Throughout 28 interviews, we found surgical stress was ubiquitous, associated with a variety of factors, including adverse events. Stressors often elicited frustration, anger, fear, and anxiety; behavioral reactions to negative emotions frequently were perceived to degrade individual/team performance and compromise outcomes. Narratives were consistent with the SSE framework and support adding a process outcome (efficiency) and illustrating how adverse events can feedback and acutely increase job demands and stress.

CONCLUSION

This qualitative study describes narratives of intraoperative stress, finding they are consistent with the SSE while also allowing minor improvements to the current framework.

Transforming Team Performance Through Reimplementation of the Surgical Safety Checklist

Importance

Patient safety interventions, like the World Health Organization Surgical Safety Checklist, require effective implementation strategies to achieve meaningful results. Institutions with underperforming checklists require evidence-based guidance for reimplementing these practices to maximize their impact on patient safety.

Objective

To assess the ability of a comprehensive system of safety checklist reimplementation to change behavior, enhance safety culture, and improve outcomes for surgical patients.

Design, Setting, and Participants

This prospective type 2 hybrid implementation-effectiveness study took place at 2 large academic referral centers in Singapore. All operations performed at either hospital were eligible for observation. Surveys were distributed to all operating room staff.

Intervention

The study team developed a comprehensive surgical safety checklist reimplementation package based on the Exploration, Preparation, Implementation, Sustainment framework. Best practices from implementation science and human factors engineering were combined to redesign the checklist. The revised instrument was reimplemented in November 2021.

Main Outcomes and Measures

Implementation outcomes included penetration and fidelity. The primary effectiveness outcome was team performance, assessed by trained observers using the Oxford Non-Technical Skills (NOTECH) system before and after reimplementation. The Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture was used to assess safety culture and observers tracked device-related interruptions (DRIs). Patient safety events, near-miss events, 30-day mortality, and serious complications were tracked for exploratory analyses.

Results

Observers captured 252 cases (161 baseline and 91 end point). Penetration of the checklist was excellent at both time points, but there were significant improvements in all measures of fidelity after reimplementation. Mean NOTECHS scores increased from 37.1 to 42.4 points (4.3 point adjusted increase; 95% CI, 2.9-5.7; P < .001). DRIs decreased by 86.5% (95% CI, -22.1% to -97.8%; P = .03). Significant improvements were noted in 9 of 12 composite areas on culture of safety surveys. Exploratory analyses suggested reductions in patient safety events, mortality, and serious complications.

Conclusions and Relevance

Comprehensive reimplementation of an established checklist intervention can meaningfully improve team behavior, safety culture, patient safety, and patient outcomes. Future efforts will expand the reach of this system by testing a structured guidebook coupled with light-touch implementation guidance in a variety of settings.

Identifying Built Environment Risk Factors to Provider Workflow and Patient Safety Using Simulation-Based Evaluation of a Pediatric ICU Room

OBJECTIVE

This study aimed to identify latent conditions in a pediatric intensive care unit (PICU) by analyzing characteristics of flow disruptions (FD) during a simulation of a three-phased scenario.

BACKGROUND

The built environment of healthcare facilities contributes to FD that can lead to clinical errors and patient harm. In the facility design process, there is an opportunity to identify built environment features that cause FD and pose safety risks. Simulation-based evaluation of proposed designs may help in identifying and mitigating safety concerns before construction and occupancy.

METHODOLOGY

During design development for a new 400-bed children's hospital, a series of simulations were conducted using physical mock-ups in a large warehouse. A three-phased scenario, (1) admission and intubation, (2) cardiac arrest, and (3) bedside surgery involving a cannulation to extracorporeal membrane oxygenation, was conducted in a PICU room mock-up. Each scenario was video recorded from four angles. The videos were systematically coded to identify FD.

RESULTS

Analysis identified FDs in three ICU zones: respiratory therapists (RT) zone, nurse zone, and head of the patient. Challenges in these zones were related to spatial constraints in the RT zone and head of the bed, equipment positioning in the RT zone and nurse zone, and impeded visibility related to the location of the boom monitor in the nurse zone.

CONCLUSION

Simulation-based evaluation of prototypes of patient care spaces can help identify characteristics of minor and major FD related to the built environment and can provide valuable information to inform the iterative design process.

Enhancing Quality of Congenital Heart Care Within Resource-Limited Settings

Over 90% of the world's children with congenital heart disease (CHD) are born in the resources poor settings of low- to middle-income countries (LMICs). The shortfall in human and material resources and dysfunctional health systems leads to poor quality of care (QoC) which contributes substantially to suboptimal outcomes of patients with CHD in LMICs. Notwithstanding these challenges, it is possible to develop a quality improvement (QI) framework that can have a significant impact on outcomes and prevent a number of deaths. In this review, we examine the common barriers to implementing effective QI processes in LMICs. Using examples of successful QI initiatives in LMIC, we propose a broad framework that focuses on simple, yet effective measures involving cohesive efforts of all key participants guided and nurtured by a leadership that strongly values QoC.

Utilizing Eye Tracking to Assess Medical Student Non-Technical Performance During Scenario-Based Simulation: Results of a Pilot Study

Background

Non-technical skills (NTS) are essential for safe surgical patient management. However, assessing NTS involves observer-based ratings, which can introduce bias. Eye tracking (ET) has been proposed as an effective method to capture NTS. The purpose of the current study was to determine if ET metrics are associated with NTS performance.

Methods

Participants wore a mobile ET system and participated in two patient care simulations, where they managed a deteriorating patient. The scenarios featured several challenges to leadership, which were evaluated using a 4-point Likert scale. NTS were evaluated by trained raters using the Non-Technical Skills for Surgeons (NOTSS) scale. ET metrics included percentage of fixations and visits on areas of interest.

Results

Ten medical students participated. Average visit duration on the patient was negatively correlated with participants' communication and leadership. Average visit duration on the patient's intravenous access was negatively correlated with participants' decision making and situation awareness.

Conclusions

Our preliminary data suggests that visual attention on the patient was negatively associated with NTS and may indicate poor comprehension of the patient's status due to heightened cognitive load. In future work, researchers and educators should consider using ET to objectively evaluate and provide feedback on their NTS.

Safety in Health Care: The Impact of Operating Room Design

The science of operating room design has grown over the past 20 years due to the realization that the physical environment influences health care provider performance and patient outcomes. Medical errors occur when the normal workflow in an operating room is disrupted as providers must overcome sub-optimal conditions. All aspects of the physical environment can impact operating room flow. Studying the layout, contents, ergonomics, and environmental parameters of the operating can lead improved work conditions resulting improved patient and provider safety. At the forefront of operating room design science is the use of simulation and the evaluation of new technologies.

Workflow disruptions in robot-assisted surgery

Surgical flow disruptions are unexpected deviations from the natural progression which can potentially compromise the safety of the operation. Separation of the surgeon from the patient and team members is the main contributor for flow disruptions (FDs) in robot-assisted surgery (RAS). FDs have been categorised as communication, coordination, surgeon task considerations, training, equipment/ technology, external factors, instrument changes, and environmental factors. There may be an association between FDs and task error rate. Intervention to counter FDs include training, operating room adjustments, checklists, teamwork, communication improvement, ergonomics, technology, guidelines, workflow optimisation, and team briefing. Future studies should focus on identifying the significant disruptive FDs and the impact of interventions on surgical flow during RAS.

LAST: LAtent Space-Constrained Transformers for Automatic Surgical Phase Recognition and Tool Presence Detection

When developing context-aware systems, automatic surgical phase recognition and tool presence detection are two essential tasks. There exist previous attempts to develop methods for both tasks but majority of the existing methods utilize a frame-level loss function (e.g., cross-entropy) which does not fully leverage the underlying semantic structure of a surgery, leading to sub-optimal results. In this paper, we propose multi-task learning-based, LAtent Space-constrained Transformers, referred as LAST, for automatic surgical phase recognition and tool presence detection. Our design features a two-branch transformer architecture with a novel and generic way to leverage video-level semantic information during network training. This is done by learning a non-linear compact presentation of the underlying semantic structure information of surgical videos through a transformer variational autoencoder (VAE) and by encouraging models to follow the learned statistical distributions. In other words, LAST is of structure-aware and favors predictions that lie on the extracted low dimensional data manifold. Validated on two public datasets of the cholecystectomy surgery, i.e., the Cholec80 dataset and the M2cai16 dataset, our method achieves better results than other state-of-the-art methods. Specifically, on the Cholec80 dataset, our method achieves an average accuracy of 93.12±4.71%, an average precision of 89.25±5.49%, an average recall of 90.10±5.45% and an average Jaccard of 81.11 ±7.62% for phase recognition, and an average mAP of 95.15±3.87% for tool presence detection. Similar superior performance is also observed when LAST is applied to the M2cai16 dataset.

Relationship between stress and resident non-technical skills during interdisciplinary trauma simulations

BACKGROUND

Non-technical skills, such as communication and situation awareness, are vital for patient care and effective surgical team performance. Previous research has found that residents' perceived stress is associated with poorer non-technical skills; however, few studies have investigated the relationship between objectively assessed stress and non-technical skills. Accordingly, the purpose of this study was to assess the relationship between objectively assessed stress and non-technical skills.

METHODS

Emergency medicine and surgery residents voluntarily participated in this study. Residents were randomly assigned to trauma teams to manage critically ill patients. Acute stress was assessed objectively using a chest-strap heart rate monitor, which measured average heart rate and heart rate variability. Participants also evaluated perceived stress and workload using the 6-item version of the State-Trait Anxiety Inventory and the Surgery Task Load Index. Non-technical skills were assessed by faculty raters using the non-technical skills scale for trauma. Pearson's correlation coefficients were used to examine relationships between all variables.

RESULTS

Forty-one residents participated in our study. Heart rate variability (where higher values reflect lower stress) was positively correlated with residents' non-technical skills overall and leadership, communication, and decision-making. Average heart rate was negatively correlated with residents' communication.

CONCLUSION

Higher objectively assessed stress was associated with poorer non-technical skills in general and nearly all non-technical skills domains of the T-NOTECHS. Clearly, stress has a deleterious effect on residents' non-technical skills during trauma situations, and given the importance of non-technical skills in surgical care, educators should consider implementing mental skills training to reduce residents' stress and optimize non-technical skills during trauma situations.

Understanding ultrarare adverse events - Lessons learned from a twelve-year review of intraoperative deaths at an academic medical center

BACKGROUND

Intraoperative death (ID) is rare, the incidence remains challenging to quantify and learning opportunities are limited. We aimed to better define the demographics of ID by reviewing the longest single-site series.

METHODS

Retrospective chart reviews, including a review of contemporaneous incident reports, were performed on all ID between March 2010 to August 2022 at an academic medical center.

RESULTS

Over 12 years, 154 IDs occurred (∼13/year, average age: 54.3 years, male: 60%). Most occurred during emergency procedures (n = 115, 74.7%), 39 (25.3%) during elective procedures. Incident reports were submitted in 129 cases (84%). 21 (16.3%) reports cited 28 contributing factors including challenges with coordination (n = 8, 28.6%), skill-based errors (n = 7, 25.0%), and environmental factors (n = 3, 10.7%).

CONCLUSIONS

Most deaths occurred in patients admitted from the ER with general surgical problems. Despite expectations for incident reporting, few provided actionable information on ergonomic factors which might help identify improvement opportunities.

Surgery and Anesthesia Preoperative "Virtual Huddle": A Pilot Trial to Enhance Communication across the Drape

OBJECTIVES

 Effective communication between surgeons and anesthesiologists is critical for high-quality, safe, and efficient perioperative patient care. Despite widespread implementation of surgical safety checklists and time-outs, ineffective team communication remains a leading cause of patient safety events in the operating room. To promote effective communication, we conducted a pilot trial of a "virtual huddle" between anesthesiologists and surgeons.

METHODS

 Attending anesthesiologists and surgeons at an academic medical center were recruited by email to participate in this feasibility trial. An electronic health record-based smartphone application was utilized to create secure group chats among trial participants the day before a surgery. Text notifications connected a surgeon/anesthesiologist pair in order to introduce colleagues, facilitate a preoperative virtual huddle, and enable open-ended, text message-based communication. A 5-point Likert scale-based survey with a free-text component was used to evaluate the utility of the virtual huddle and usability of the electronic platform.

RESULTS

 A total of 51 unique virtual huddles occurred between 16 surgeons and 12 anesthesiologists over 99 operations. All postintervention survey questions received a positive rating (range: 3.50/5.00-4.53/5.00) and the virtual huddle was considered to be easy to use (4.47/5.00), improve attending-to-attending communication (4.29/5.00), and improve patient care (4.22/5.00). There were no statistically significant differences in the ratings between surgery and anesthesia. In thematic analysis of qualitative survey results, Participants indicated the intervention was particularly useful in interdisciplinary relationship-building and reducing room turnover. The huddle was less useful for simple, routine cases or when participation was one sided.

CONCLUSION

 A preoperative virtual huddle may be a simple and effective intervention to improve communication and teamwork in the operating room. Further study and consideration of broader implementation is warranted.

Identifying Workflow Disruptions in Robotic-Assisted Bariatric Surgery: Elucidating Challenges Experienced by Surgical Teams

PURPOSE

Bariatric surgery is an effective and durable treatment for weight loss for patients with extreme obesity. Although traditionally approached laparoscopically, robotic bariatric surgery (RBS) has unique benefits for both surgeons and patients. Nonetheless, the technological complexity of robotic surgery presents new challenges for OR teams and the wider clinical system. Further assessment of the role of RBS in delivering quality care for patients with obesity is necessary and can be done through a human factors approach. This observational study sought to investigate the impact of RBS on the surgical work system via the study of flow disruptions (FDs), or deviations from the natural workflow progression.

MATERIALS AND METHODS

RBS procedures were observed between October 2019 and March 2022. FDs were recorded in real time and subsequently classified into one of nine work system categories. Coordination FDs were further classified into additional sub-categories.

RESULTS

Twenty-nine RBS procedures were observed at three sites. An average FD rate of 25.05 (CI =  ± 2.77) was observed overall. FDs were highest between insufflation and robot docking (M = 29.37, CI =  ± 4.01) and between patient closing and wheels out (M = 30.00, CI =  ± 6.03). FD rates due to coordination issues were highest overall, occurring once every 4 min during docking (M = 14.28, CI =  ± 3.11).

CONCLUSION

FDs occur roughly once every 2.4 min and happen most frequently during the final patient transfer and robot docking phases of RBS. Coordination challenges associated with waiting for staff/instruments not readily available and readjusting equipment contributed most to these disruptions.

Effects of wide-angle laparoscopy on surgical workflow in laparoscopic cholecystectomies

INTRODUCTION

Laparoscopy is now the gold standard approach to many surgical procedures thanks to its many advantages. Minimizing distractions is essential to a safe and successful surgery and an undisrupted surgical workflow. The SurroundScope, a wide angle (270°) laparoscopic camera system has the potential to decrease surgical distractions and increase workflow.

METHODS

Forty-two laparoscopic cholecystectomies were performed by a single surgeon, 21 with the SurroundScope and 21 with standard angle laparoscope. Video recordings of surgeries were reviewed for calculating the number of entries of surgical tools into the field of view, relative time of tools and ports viewed in surgical field and number of times camera was removed due to fog or smoke.

RESULTS

The usage of the SurroundScope resulted in a significantly lower number of entries to the field of view compared to the standard scope (58.50 versus 102; P < 0.0001). Usage of SurroundScope resulted in a significantly higher appearance ratio of tools, with a value of 1.87 compared to 1.63 for standard scope (P-value < 0.0001), and the appearance ratio of ports was also significantly higher, measuring 1.84 compared to 0.27 for the standard scope (P-value < 0.0001). In addition, the SurroundScope had to be removed and reinserted due to smoke or fog in only 2 cases (9.5%), compared to 12 cases (57.1%) in the standard scope group (P-value < 0.01).

CONCLUSIONS

The SurroundScope camera system improves surgical workflow in laparoscopic cholecystectomy. This conceivably increase the safety of the operation due to the utilization of the wide-angle view and "chip on the tip" technology.

Kindness Isn't Just about Being Nice: The Value Proposition of Kindness as Viewed through the Lens of Incivility in the Healthcare Workplace

The healthcare workplace is a high-stress environment. All stakeholders, including patients and providers, display evidence of that stress. High stress has several effects. Even acutely, stress can negatively affect cognitive function, worsening diagnostic acumen, decision-making, and problem-solving. It decreases helpfulness. As stress increases, it can progress to burnout and more severe mental health consequences, including depression and suicide. One of the consequences (and causes) of stress is incivility. Both patients and staff can manifest these unkind behaviors, which in turn have been shown to cause medical errors. The human cost of errors is enormous, reflected in thousands of lives impacted every year. The economic cost is also enormous, costing at least several billion dollars annually. The warrant for promoting kindness, therefore, is enormous. Kindness creates positive interpersonal connections, which, in turn, buffers stress and fosters resilience. Kindness, therefore, is not just a nice thing to do: it is critically important in the workplace. Ways to promote kindness, including leadership modeling positive behaviors as well as the deterrence of negative behaviors, are essential. A new approach using kindness media is described. It uplifts patients and staff, decreases irritation and stress, and increases happiness, calmness, and feeling connected to others.

Real-time estimation of the remaining surgery duration for cataract surgery using deep convolutional neural networks and long short-term memory

PURPOSE

Estimating the surgery length has the potential to be utilized as skill assessment, surgical training, or efficient surgical facility utilization especially if it is done in real-time as a remaining surgery duration (RSD). Surgical length reflects a certain level of efficiency and mastery of the surgeon in a well-standardized surgery such as cataract surgery. In this paper, we design and develop a real-time RSD estimation method for cataract surgery that does not require manual labeling and is transferable with minimum fine-tuning.

METHODS

A regression method consisting of convolutional neural networks (CNNs) and long short-term memory (LSTM) is designed for RSD estimation. The model is firstly trained and evaluated for the single main surgeon with a large number of surgeries. Then, the fine-tuning strategy is used to transfer the model to the data of the other two surgeons. Mean Absolute Error (MAE in seconds) was used to evaluate the performance of the RSD estimation. The proposed method is compared with the naïve method which is based on the statistic of the historical data. A transferability experiment is also set to demonstrate the generalizability of the method.

RESULT

The mean surgical time for the sample videos was 318.7 s (s) (standard deviation 83.4 s) for the main surgeon for the initial training. In our experiments, the lowest MAE of 19.4 s (equal to about 6.4% of the mean surgical time) is achieved by our best-trained model for the independent test data of the main target surgeon. It reduces the MAE by 35.5 s (-10.2%) compared to the naïve method. The fine-tuning strategy transfers the model trained for the main target to the data of other surgeons with only a small number of training data (20% of the pre-training). The MAEs for the other two surgeons are 28.3 s and 30.6 s with the fine-tuning model, which decreased by -8.1 s and -7.5 s than the Per-surgeon model (average declining of -7.8 s and 1.3% of video duration). External validation study with Cataract-101 outperformed 3 reported methods of TimeLSTM, RSDNet, and CataNet.

CONCLUSION

An approach to build a pre-trained model for estimating RSD estimation based on a single surgeon and then transfer to other surgeons demonstrated both low prediction error and good transferability with minimum fine-tuning videos.

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.

Implementation of a Device Briefing Tool reduces interruptions in surgery: A nonrandomized controlled pilot trial

BACKGROUND

Interruptions in operative flow are known to increase team stress and errors in the operating room. Device-related interruptions are an increasing area of focus for surgical safety, but common safety processes such as the Surgical Safety Checklist do not adequately address surgical devices. We assessed the impact of the Device Briefing Tool, a communication instrument for surgical teams, on device-related interruptions in a large academic referral center in Singapore.

METHODS

The Device Briefing Tool was implemented in 4 general surgery departments, with 4 additional departments serving as a comparator group. Trained observers evaluated device-related interruption incidence in live operations at baseline and after implementation. Changes in device-related interruption frequency were assessed in each group using Poisson regression, with and without adjustment for surgical department and device complexity. Subgroup analyses assessed the impact of the Device Briefing Tool by device type.

RESULTS

A total of 210 operations were evaluated by observers. In the Device Briefing Tool group, there were 38.6 and 27.2 device-related interruptions per 100 cases at baseline and after Device Briefing Tool implementation, respectively (difference -23%, P = .0047, adjusted difference -28%, P = .0013). Device-related interruption frequency in the comparator group remained stable across study periods. Point estimates indicated reductions in device-related interruptions for all device types, reaching statistical significance for circular staplers (-26%, P = .0049).

CONCLUSION

Implementation of the Device Briefing Tool was associated with a 28% reduction in device-related interruptions. Proactive approaches to improving surgical device safety are crucial in the technology-driven landscape of modern surgical care. Future efforts will assess formal integration of the Device Briefing Tool into institution-wide surgical safety processes.

Impact of sleep deficiency on surgical performance: a prospective assessment

STUDY OBJECTIVES

Sleep deficiency can adversely affect the performance of resident physicians, resulting in greater medical errors. However, the impact of sleep deficiency on surgical outcomes, particularly among attending surgeons, is less clear.

METHODS

Sixty attending surgeons from academic and community departments of surgery or obstetrics and gynecology were studied prospectively using direct observation and self-report to explore the effect of sleep deprivation on patient safety, operating room communication, medical errors, and adverse events while operating under 2 conditions, post-call (defined as > 2 hours of nighttime clinical duties) and non-post-call.

RESULTS

Each surgeon contributed up to 5 surgical procedures post-call and non-post-call, yielding 362 cases total (150 post-call and 210 non-post-call). Most common were caesarian section and herniorrhaphy. Hours of sleep on the night before the operative procedure were significantly less post-call (4.98 ± 1.41) vs non-post-call (6.68 ± 0.88, P < .01). Errors were infrequent and not related to hours of sleep or post-call status. However, Non-Technical Skills for Surgeons ratings demonstrated poorer performance while post-call for situational awareness, decision-making, and communication/teamwork. Fewer hours of sleep also were related to lower ratings for situational awareness and decision-making. Decreased self-reported alertness was observed to be associated with increased procedure time.

CONCLUSIONS

Sleep deficiency in attending surgeons was not associated with greater errors during procedures performed during the next day. However, procedure time was increased, suggesting that surgeons were able to compensate for sleep loss by working more slowly. Ratings on nontechnical surgical skills were adversely affected by sleep deficiency.

CITATION

Quan SF, Landrigan CP, Barger LK, et al. Impact of sleep deficiency on surgical performance: a prospective assessment. J Clin Sleep Med. 2023;19(4):673-683.

An exploratory study of distractions during the induction phase of pediatric procedural sedation with propofol

INTRODUCTION

Distractions are a leading cause of disturbance to workflow during medical care. Distractions affecting the anesthetic team in the operating room are frequent and have a negative impact on patient care one-fifth of the time. The objective of this study was to evaluate the frequency, source, target, and impact of distractions during the induction phase of pediatric procedural sedation outside the operating room.

METHODS

Distractions were analyzed during propofol induction for oncology procedures from 45 video recordings. Distraction was defined as any event that disturbs or has potential to disturb the sedation team from performing their primary tasks. The type of distraction was cataloged into communication, coordination, extraneous events, equipment, layout, and usability. A five-point Likert scale was used to quantify the impact on the sedation team or its members.

RESULTS

All patients had a diagnosis of acute lymphocytic leukemia and had a mean age of 8.4 years. Five hundred and sixty-seven distractions occurred and averaged 12.6 events (±5.6) per induction (mean induction time 3 min 12 s). Extraneous events were most common, accounting for 55% (312/567) of all distractions. Most distractions had an impact on the sedation team's workflow, resulting in multitasking (46%, n = 262), and in either brief or complete disruption from a primary task (17%). Sedation nurses were impacted most often, 62% of the time. Coordination and usability issues resulted in the greatest negative impact, mean ± SD, 3.7 ± 1.0 and 3.5 ± 0.9, respectively. There was no significant association between distractions and adverse events or induction length.

DISCUSSION

Distractions are common during procedural sedation, with extraneous events being most frequent. Coordination issues within the team and usability problems had the greatest negative impact on sedation team workflow. Nurses were the most frequent target.

CONCLUSION

Distractions impacted sedation team workflow but had no association with patient outcomes.

A distractions capture tool for cardiac surgery and lung transplantation: impact on outcomes

OBJECTIVES

Surgical distractions are associated with worse patient outcomes. Lung transplantation and cardiac surgery's multi-disciplinary nature, and their inherent complexities render them more vulnerable to distractions. We aim to use a novel distractions capture tool to evaluate the severity of distractions during cardiac surgery (CS) and lung transplantation (LTx) and assess its impact on post-operative complications.

METHODS

A prospective 'blinded' study was undertaken by direct observation of distractions during CS and LTx. Events were identified using the Imperial College Error Capture tool (ICECAP). Number and severity of distractions were correlated with post-operative outcomes (ICU & hospital stay, bleeding and anastomotic complications).

RESULTS

In LTx, we observed 2059 distractions within 287 h across 41 surgeries. In CS, we observed 1089 distractions within 192 h across 62 surgeries. Surgeons were consciously aware of 19.2% (LTx) and 21.3% (CS) of recorded events. Distractions consisted of procedure-independent pressures (61% LTx vs 56% CS), equipment problems (15% LTx vs 23%CS), communication (12% LTx vs 12% CS), technical problems or patient safety concerns (12% LTx vs 9% CS). In CS, 91% of procedure-independent pressures were non-operative distractions whilst LTx recorded 83%. Staff absences at a critical moment of surgery were recorded at 9% (LTx) and 7% (CS). The number and severity of distractions correlated with bleeding (CS p < 0.001, LTx p < 0.01), prolonged ICU stay (CS p = 0.002, LTx p = 0.002), hospital stay (CS p < 0.001) and anastomotic complications(LTx p < 0.03).

CONCLUSIONS

ICECAP as a novel surgical distractions capture tool was effective & applicable to both elective cardiac and urgent transplant surgeries. Surgeons were unaware of a large number of distractions & interruptions. Distractions were associated with longer ICU stay and higher rate of bleeding.

The Association Between Catheter Type and Dialysis Treatment: A Retrospective Data Analysis at Two U.S.-Based ICUs

Dialysis catheter type may be associated with differences in continuous renal replacement therapy (CRRT) treatment in the critically ill, with potential implications for patient outcomes and healthcare costs.

OBJECTIVES

To evaluate the association between the catheter type and multiple dialysis treatment outcomes among the critically ill.

DESIGN

Retrospective, observational study.

SETTING

Two U.S.-based ICUs.

PARTICIPANTS

Critically ill patients receiving CRRT between April 1, 2018, and July 1, 2020. A total of 1,037 CRRT sessions were analyzed.

MAIN OUTCOMES AND MEASURES

Circuit life, alarm interruption frequency (including a subset of vascular access [VA]-related alarms), termination type (elective vs nonelective), and blood flow rates. Pre- (n = 530) and post-catheter change (n = 507) periods were assessed, and the post-change period was further divided into intervals of pre-COVID (n = 167) and COVID contemporaneous (n = 340) to account for the pandemic's impact.

RESULTS

Compared with pre-change sessions, post-change sessions had 31% longer circuit life (95% CI, 1.14-1.49; p < 0.001), 3% higher blood flow rate (1.01-1.05; p < 0.01), and lower proportion of nonelective terminations (adjusted odds ratio [OR], 0.42 [0.28-0.62]; p < 0.001). There were fewer interruptions for all alarms (adjusted count ratio, 0.95 [0.87-1.05]; p = 0.31) and VA-related alarms (0.80 [0.66-0.96]; p = 0.014). The sessions during COVID period were statistically similar to pre-COVID sessions for all outcomes except a lower proportion of nonelective terminations (adjusted OR, 0.39 [0.22-0.70]; p < 0.01).

CONCLUSIONS

A change in catheter type was associated with longer CRRT sessions with fewer interruptions and unexpected terminations in a population of critical patients.

Health care professionals' perceptions of unprofessional behaviour in the clinical workplace

BACKGROUND

Unprofessional behaviour undermines organizational trust and negatively affects patient safety, the clinical learning environment, and clinician well-being. Improving professionalism in healthcare organizations requires insight into the frequency, types, sources, and targets of unprofessional behaviour in order to refine organizational programs and strategies to prevent and address unprofessional behaviours.

OBJECTIVE

To investigate the types and frequency of perceived unprofessional behaviours among health care professionals and to identify the sources and targets of these behaviours.

METHODS

Data was collected from 2017-2019 based on a convenience sample survey administered to all participants at the start of a mandatory professionalism course for health care professionals including attending physicians, residents and advanced practice providers (APPs) working at one academic hospital in the United States.

RESULTS

Out of the 388 participants in this study, 63% experienced unprofessional behaviour at least once a month, including failing to respond to calls/pages/requests (44.3%), exclusion from decision-making (43.0%) and blaming behaviour (39.9%). Other monthly experienced subtypes ranged from 31.7% for dismissive behaviour to 4.6% for sexual harassment. Residents were more than twice as likely (OR 2.25, p<0.001)) the targets of unprofessional behaviour compared to attending physicians. Female respondents experienced more discriminating behaviours (OR 2.52, p<0.01). Nurses were identified as the most common source of unprofessional behaviours (28.1%), followed by residents from other departments (21%).

CONCLUSIONS

Unprofessional behaviour was experienced frequently by all groups, mostly inflicted on these groups by those outside of the own discipline or department. Residents were most frequently identified to be the target and nurses the source of the behaviours. This study highlights that unprofessional behaviour is varied, both regarding types of behaviours as well as targets and sources of such behaviours. This data is instrumental in developing training and remediation initiatives attuned to specific professional roles and specific types of professionalism lapses.

Operating room design using agent-based simulation to reduce room obstructions

This study seeks to improve the safety of clinical care provided in operating rooms (OR) by examining how characteristics of both the physical environment and the procedure affect surgical team movement and contacts. We video recorded staff movements during a set of surgical procedures. Then we divided the OR into multiple zones and analyzed the frequency and duration of movement from origin to destination through zones. This data was abstracted into a generalized, agent-based, discrete event simulation model to study how OR size and OR equipment layout affected surgical staff movement and total number of surgical team contacts during a procedure. A full factorial experiment with seven input factors - OR size, OR shape, operating table orientation, circulating nurse (CN) workstation location, team size, number of doors, and procedure type - was conducted. Results were analyzed using multiple linear regression with surgical team contacts as the dependent variable. The OR size, the CN workstation location, and team size significantly affected surgical team contacts. Also, two- and three-way interactions between staff, procedure type, table orientation, and CN workstation location significantly affected contacts. We discuss implications of these findings for OR managers and for future research about designing future ORs.

Face, content, and construct validity of the virtual immersive operating room simulator for training laparoscopic procedures

BACKGROUND

The aim of this work is to present the face, content, and construct validation of the virtual immersive operating room simulator (VIORS) for procedural training of surgeons' laparoscopic psychomotor skills and evaluate the immersive training experience.

METHODS

The VIORS simulator consists of an HMD Oculus Rift 2016 with a visor on a 1080 × 1200 pixel OLED screen, two positioning sensors with two adapted controls to simulate laparoscopic instruments, and an acrylic base to simulate the conventional laparoscopic setup. The immersion consists of a 360° virtual operating room environment, based on the EndoSuite at Hospital Infantil de Mexico Federico Gomez, which reproduces a configuration of equipment, instruments, and common distractions in the operating room during a laparoscopic cholecystectomy procedure. Forty-five surgeons, residents, and medicine students participated in this study: 27 novices, 13 intermediates, and 5 experts. They completed a questionnaire on the realism and operating room immersion, as well as their capabilities for laparoscopic procedural training, scored in the 5-point Likert scale. The data of instrument movement were recorded and analyzed using 13 movement analysis parameters (MAPs). The experience during training with VIORS was evaluated through NASA-TLX.

RESULTS

The participants were enthusiastic about the immersion and sensation levels of the VIORS simulator, with positive scores on the realism and its capabilities for procedural training using VIORS. The results proved that the VIORS simulator was able to differentiate between surgeons with different skill levels. Statistically significant differences were found in nine MAPs, demonstrating their construct validity for the objective assessment of the procedural laparoscopic performance. At cognitive level, the inversion experience proves a moderate mental workload when the laparoscopic procedure is carried out.

CONCLUSION

The VIORS simulator has been successfully presented and validated. The VIORS simulator is a useful and effective device for the training of procedural laparoscopic psychomotor skills.

Factors affecting workflow in robot-assisted surgery: a scoping review

BACKGROUND

Robot-assisted surgery is expanding worldwide. Most research in this field concentrates on surgeons' technical skills and patient outcome, but research from open and laparoscopic surgery shows that teamwork is crucial for patient safety. Team composition is changed in robot-assisted surgery with the surgeon placed away from the bedside, potentially altering teamwork and workflow in the operating theatre. This scoping review aimed to explore how factors affecting workflow as well as team members' social and cognitive skills during robot-assisted surgery are reported in the literature.

METHODS

A systematic search was performed in the databases Medline, EMBASE, PsycINFO, and Web of Science. Reports were screened according to the Preferred Reporting Item for Systematic reviews and Meta-Analysis for Scoping Review guidelines. Inclusion criteria were robot-assisted surgery, multi-professional teams, and workflow, flow disruptions, or non-technical skills.

RESULTS

A total of 12,527 references were screened, and 24 articles were included in the review. Articles were heterogeneous in terms of aim, methods and focus. The studies concentrated on two main fields: flow disruptions and the categorization of their causes and incidences; and non-technical skills describing the challenges of communication and effects on situation awareness.

CONCLUSION

Many studies focused on flow disruptions and found that communication, coordination, training, and equipment/technology were the most frequent causes. Another focus of studies was non-technical skills-primarily communication and situation awareness. Future studies could focus on how to prevent the most harmful flow disruptions and develop interventions for improving workflow.

The future of artificial intelligence in neurosurgery: A narrative review

Background:

Artificial intelligence (AI) and machine learning (ML) algorithms are on the tremendous rise for being incorporated into the field of neurosurgery. AI and ML algorithms are different from other technological advances as giving the capability for the computer to learn, reason, and problem-solving skills that a human inherits. This review summarizes the current use of AI in neurosurgery, the challenges that need to be addressed, and what the future holds.

Methods:

A literature review was carried out with a focus on the use of AI in the field of neurosurgery and its future implication in neurosurgical research.

Results:

The online literature on the use of AI in the field of neurosurgery shows the diversity of topics in terms of its current and future implications. The main areas that are being studied are diagnostic, outcomes, and treatment models.

Conclusion:

Wonders of AI in the field of medicine and neurosurgery hold true, yet there are a lot of challenges that need to be addressed before its implications can be seen in the field of neurosurgery from patient privacy, to access to high-quality data and overreliance on surgeons on AI. The future of AI in neurosurgery is pointed toward a patient-centric approach, managing clinical tasks, and helping in diagnosing and preoperative assessment of the patients.

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.

Operating room team strategies to reduce flow disruptions in high-risk task episodes: resilience in robot-assisted surgery

In healthcare work settings, flow disruptions (FDs) pose a potential threat to patient safety. Resilience research suggests that adaptive behavioural strategies contribute to preventing cognitive overload through FDs at crucial moments. We aimed to explore the nature and efficacy of operating room (OR) team strategies to prevent FDs in robot-assisted surgery. Within a mixed-methods design, we first asked surgical professionals, which strategies they apply, and secondly, identified behavioural strategies through direct observations. Findings were analysed using content analysis. Additionally, FDs were assessed through live observations in the OR. The sample included four interviewed experts and 15 observed surgical cases. Sixty originally received strategies were synthesised into 17 final OR team strategies. Overall, 658 FDs were observed with external FDs being the most frequent. During high-risk episodes, FDs were significantly reduced (p < 0.0001). The identified strategies reveal how OR teams deliberatively and dynamically manage and mitigate FDs during critical tasks. Our findings contribute to a nuanced understanding of adaptive strategies to safeguard performance in robot surgery services. Practitioner Summary: Flow disruptions (FDs) in surgical work may become a severe safety threat during high-risk situations. With interviews and observations, we explored team strategies applied to prevent FDs in critical moments. We obtained a comprehensive list of behavioural strategies and found that FDs were significantly reduced during a specific high-risk surgical task. Our findings emphasise the role of providers' and teams' adaptive capabilities to manage workflow in high-technology care environments.

StOP? II trial: cluster randomized clinical trial to test the implementation of a toolbox for structured communication in the operating room-study protocol

Background

Surgical care, which is performed by intensely interacting multidisciplinary teams of surgeons, anesthetists, and nurses, remains associated with significant morbidity and mortality. Intraoperative communication has been shown to be associated with surgical outcomes, but tools ensuring efficient intraoperative communication are lacking. In a previous study, we developed the StOP?-protocol that fosters structured intraoperative communication. Before the critical phases of the operation, the responsible surgeon initiates and leads one or several StOP?s. During a StOP?, the surgeon informs about the progress of the operation (status), next steps and proximal goals (objectives), and possible problems (problems) and encourages all team members to voice their observations and ask questions (?). In a before-after study performed mainly in visceral surgery, we found effects of the StOP?-protocol on mortality, length of hospital stay, and reoperation. We intend to assess the impact of the StOP?-protocol in a cluster randomized trial, in a wider variety of surgical specialties (i.e., general, visceral, thoracic, vascular surgery, surgical urology, and gynecology). The primary hypothesis is that the consistent use of the StOP?-protocol by the main surgeon reduces patient mortality within 30 days after the operation. The secondary hypothesis is that the consistent use of the StOP?-protocol by the main surgeon reduces unplanned reoperations, length of hospital stay, and unplanned hospital readmissions.

Methods

This study is designed as a multicenter, cluster-randomized parallel-group trial. Board-certified surgeons of participating clinical departments will be randomized 1:1 to the StOP? intervention group or to the standard of care (control) group. The intervention group will undergo a training to use the StOP?-protocol and receive regular feedback on their compliance with the protocol. The surgeons in the control group will communicate as usual during their operations. The unit of observation will be operations performed by cluster surgeons. Consecutive patients will be enrolled over 4 months per cluster. A total of 400 surgeons will be recruited, and we expect to collect patient outcome data for 14,000 surgical procedures.

Discussion

The StOP?-protocol was designed as a tool to structure communication during surgical procedures. Testing its effects on patient outcomes will contribute to implementing evidenced-based interventions to reduce surgical complications.

Trial registration

ClinicalTrials.gov NCT05356962. Registered on May 2, 2022

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06775-y.

To page or not to page? A qualitative study of communication practices of general surgery residents and nurses

BACKGROUND

Communication errors contribute to preventable adverse hospital events; however, communication between general surgery residents and nurses remains insufficiently studied. The purpose of our study was to use qualitative methods to characterize communication practices of surgical residents and nurses on inpatient general and intermediate care units to inform best practices and future interprofessional interventions.

METHODS

Our study cohort consisted of 14 general surgery residents and 13 inpatient nurses from a tertiary academic medical center. Focus groups were conducted via a secure video platform, recorded, and transcribed. Two authors performed open coding of transcripts for qualitative analysis. Codes were reviewed iteratively with themes generated via abductive analysis, contextualizing results within 3 domains of an established communication space framework: organizational, cognitive, and social complexity.

RESULTS

Communication practices of general surgery residents and inpatient nurses are affected by workflow differences, disruptive communication patterns, and communication technology. Barriers to effective communication, as well as strategies used to mitigate challenges, were characterized, with select communication practices found to negatively affect the well-being of patients, nurses, and residents.

CONCLUSION

Communication practices of general surgery residents and inpatient nurses are influenced by entrenched and interrelated organizational, technological, and interpersonal factors. Given that current communication practices negatively affect patient and provider well-being, collaboration between surgeons, nurses, systems engineers, health information technology experts, and other stakeholders is critical to (1) establish communication best practices, and (2) design interventions to assess and improve multiple areas (rather than isolated domains) of surgical interprofessional communication.