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Koch A, Quartucci C, Buchner A, Schlenker B, Becker A, Catchpole K, Weigl M. Associations of flow disruptions with patient, staff, and process outcomes: a prospective observational study of robotic-assisted radical prostatectomies. Surg Endosc 2023; 37:6964-6974. [PMID: 37336845 PMCID: PMC10462499 DOI: 10.1007/s00464-023-10162-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 05/28/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Technological advancements in the operating room (OR) have sparked new challenges for surgical workflow, OR professionals, and patient safety. Disruptive events are frequent across all surgical specialties, but little is known about their effects on patient outcomes and the influence of systemic factors. The aim was to explore the associations of intraoperative flow disruptions (FDs) with patient outcomes, staff workload, and surgery duration. METHODS Prospective, single-center, and multi-source study comprising direct and standardized OR observations of urologic surgical procedures, clinical patient outcomes, and staff- and patient-reported outcome data (PROMs; 3-month follow-up). All data were recorded between 01/2020 and 10/2021. FDs were assessed using standardized procedure observations. Linear and logistic regression analyses including multiple system factors were used to explore the effects of FDs on surgical outcomes. RESULTS 61 robotic-assisted radical prostatectomy procedures were captured (with 61 patients and 243 staff reports). High rates of FDs were observed; however, our analyses did not show significant relationships with patient complication rates. Equipment- and patient-related FDs were associated with increased staff workload. No association was found between higher rates of FDs and procedure duration. CONCLUSIONS FDs were not related to inferior patient outcomes. Our findings may inform future OR investigations that scrutinize the complex interplay of human, team, process, and technological components that mitigate the effects of FDs during surgery.
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Affiliation(s)
- Amelie Koch
- Institute for Patient Safety, University Hospital, University of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
- Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, Munich, Germany.
| | - Caroline Quartucci
- Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, Munich, Germany
- Bavarian Health and Food Safety Authority, Institute for Occupational Health and Product Safety, Environmental Health, Munich, Germany
| | - Alexander Buchner
- Department of Urology, University Hospital, LMU Munich, Munich, Germany
| | - Boris Schlenker
- Department of Urology, University Hospital, LMU Munich, Munich, Germany
| | - Armin Becker
- Department of Urology, University Hospital, LMU Munich, Munich, Germany
| | - Ken Catchpole
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, USA
| | - Matthias Weigl
- Institute for Patient Safety, University Hospital, University of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
- Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, Munich, Germany
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Hughes AM, Riska K, Farmer MJS, Krishnakumar D, Shea CM, Hess DR, Lindenauer PK, Stefan MS. Analysis of shared cognitive tasks in the application of non-invasive ventilation to patients with COPD exacerbation. J Interprof Care 2023; 37:576-587. [PMID: 36264072 PMCID: PMC10983066 DOI: 10.1080/13561820.2022.2118681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 08/22/2022] [Accepted: 08/22/2022] [Indexed: 12/24/2022]
Abstract
Interprofessional teamwork plays a key role in the uptake of evidence-based interventions, such as noninvasive ventilation (NIV) for patients with exacerbated Chronic Obstructive Pulmonary Disease (COPD). We aimed to identify the shared cognitive tasks in interprofessional teams using NIV for patients with COPD exacerbation. We used a cognitive task analysis approach (CTA) to engage nurses, rapid response team members, respiratory therapists, and physicians involved in the use of NIV to treat patients with COPD exacerbation. Clinicians participated in a semi-structured interview (n = 21) that elicited cognitions needed to treat COPD exacerbation. Three shared cognitive tasks were identified: Complete a thorough assessment, Formulate a care plan, and Continuously monitor patient status. Findings attest to the importance of having access to up-to-date information and expertise necessary to make accurate clinical inferences for patient assessment. Shared understanding of the formulated care plan among all members of the care team was important to its execution. Continuous monitoring was crucial; however, this cognitive task relied on patient assessment skills and ongoing collaboration within the clinical care team. Application of NIV for patients with COPD exacerbation may require enhancing collaboration through nontechnical skills and interprofessional training.
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Affiliation(s)
- Ashley M Hughes
- Department of Biomedical and Health Information Sciences, University of Illinois at Chicago, Chicago
- Center for Innovations in Chronic, Complex Healthcare, Edward Hines JR VA Medical Center, Hines
| | - Karen Riska
- Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School - Baystate, Springfield
| | - Mary Jo S Farmer
- Department of Medicine, University of Massachusetts Chan Medical School - Baystate, Springfield
- Division of Pulmonary and Critical Care, Department of Medicine, University of Massachusetts Chan Medical School - Baystate, Springfield
| | | | - Christopher M Shea
- Department of Health Policy and Management, Gilling's School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, NC, United States
| | - Dean R Hess
- College of Professional Studies, Respiratory Care Leadership, Northeastern University, Boston MS, United States
- Department of Respiratory Care, Massachusetts General Hospital, Boston, MS, United States
| | - Peter K Lindenauer
- Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School - Baystate, Springfield
- Department of Medicine, University of Massachusetts Chan Medical School - Baystate, Springfield
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MS, United States
| | - Mihaela S Stefan
- Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School - Baystate, Springfield
- Department of Medicine, University of Massachusetts Chan Medical School - Baystate, Springfield
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Koch A, Schlenker B, Becker A, Weigl M. Operating room team strategies to reduce flow disruptions in high-risk task episodes: resilience in robot-assisted surgery. ERGONOMICS 2022:1-14. [PMID: 36285451 DOI: 10.1080/00140139.2022.2136406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 10/10/2022] [Indexed: 06/16/2023]
Abstract
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.
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Affiliation(s)
- Amelie Koch
- Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU, Munich, Germany
- Institute for Patient Safety, University Hospital, University of Bonn, Bonn, Germany
| | - Boris Schlenker
- Department of Urology, University Hospital, LMU, Munich, Germany
| | - Armin Becker
- Department of Urology, University Hospital, LMU, Munich, Germany
| | - Matthias Weigl
- Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU, Munich, Germany
- Institute for Patient Safety, University Hospital, University of Bonn, Bonn, Germany
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Abraham J, Meng A, Montes de Oca A, Politi M, Wildes T, Gregory S, Henrichs B, Kannampallil T, Avidan MS. An ethnographic study on the impact of a novel telemedicine-based support system in the operating room. J Am Med Inform Assoc 2022; 29:1919-1930. [PMID: 35985294 PMCID: PMC10161534 DOI: 10.1093/jamia/ocac138] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/07/2022] [Accepted: 08/04/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The Anesthesiology Control Tower (ACT) for operating rooms (ORs) remotely assesses the progress of surgeries and provides real-time perioperative risk alerts, communicating risk mitigation recommendations to bedside clinicians. We aim to identify and map ACT-OR nonroutine events (NREs)-risk-inducing or risk-mitigating workflow deviations-and ascertain ACT's impact on clinical workflow and patient safety. MATERIALS AND METHODS We used ethnographic methods including shadowing ACT and OR clinicians during 83 surgeries, artifact collection, chart reviews for decision alerts sent to the OR, and 10 clinician interviews. We used hybrid thematic analysis informed by a human-factors systems-oriented approach to assess ACT's role and impact on safety, conducting content analysis to assess NREs. RESULTS Across 83 cases, 469 risk alerts were triggered, and the ACT sent 280 care recommendations to the OR. 135 NREs were observed. Critical factors facilitating ACT's role in supporting patient safety included providing backup support and offering a fresh-eye perspective on OR decisions. Factors impeding ACT included message timing and ACT and OR clinician cognitive lapses. Suggestions for improvement included tailoring ACT message content (structure, timing, presentation) and incorporating predictive analytics for advanced planning. DISCUSSION ACT served as a safety net with remote surveillance features and as a learning healthcare system with feedback/auditing features. Supporting strategies include adaptive coordination and harnessing clinician/patient support to improve ACT's sustainability. Study insights inform future intraoperative telemedicine design considerations to mitigate safety risks. CONCLUSION Incorporating similar remote technology enhancement into routine perioperative care could markedly improve safety and quality for millions of surgical patients.
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Affiliation(s)
- Joanna Abraham
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
- Institute for Informatics, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
- Division of Biology and Biomedical Sciences, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Alicia Meng
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Arianna Montes de Oca
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Mary Politi
- Department of Surgery, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Troy Wildes
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Stephen Gregory
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Bernadette Henrichs
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
- Goldfarb School of Nursing, Barnes-Jewish College, St. Louis, Missouri, USA
| | - Thomas Kannampallil
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
- Institute for Informatics, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
- Division of Biology and Biomedical Sciences, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
- Department of Computer Science & Engineering, McKelvey School of Engineering, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Michael S Avidan
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
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France DJ, Schremp E, Rhodes EB, Slagle J, Moroz S, Grubb PH, Hatch LD, Shotwell M, Lorinc A, Robinson J, Crankshaw M, Newman T, Weinger MB, Blakely ML. A pilot study to determine the incidence, type, and severity of non-routine events in neonates undergoing gastrostomy tube placement. J Pediatr Surg 2022; 57:1342-1348. [PMID: 34839947 PMCID: PMC9050962 DOI: 10.1016/j.jpedsurg.2021.10.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 10/13/2021] [Accepted: 10/20/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Non-routine events (NRE) are defined as any suboptimal occurrences in a process being measured in the opinion of the reporter and comes from the field of human factors engineering. These typically occur well up-stream of an adverse event and NRE measurement has not been applied to the complex context of neonatal surgery. We sought to apply this novel safety event measurement methodology to neonates in the NICU undergoing gastrostomy tube placement. METHODS A prospective pilot study was conducted between November 2016 and August 2020 in the Level IV NICU and the pediatric operating rooms of an urban academic children's hospital to determine the incidence, severity, impact, and contributory factors of clinician-reported non-routine events (NREs, i.e., deviations from optimal care) and 30-day NSQIP occurrences in neonates receiving a G-tube. RESULTS Clinicians reported at least one NRE in 32 of 36 (89%) G-tube cases, averaging 3.0 (Standard deviation: 2.5) NRE reports per case. NSQIP-P review identified 7 cases (19%) with NSQIP-P occurrences and each of these cases had multiple reported NREs. One case in which NREs were not reported was without NSQIP-P occurrences. The odds ratio of having a NSQIP-P occurrence with the presence of an NRE was 0.695 (95% CI 0.06-17.04). CONCLUSION Despite being considered a "simple" operation, >80% of neonatal G-tube placement operations had at least one reported NRE by an operative team member. In this pilot study, NRE occurrence was not significantly associated with the subsequent reporting of an NSQIP-P occurrence. Understanding contributory factors of NREs that occur in neonatal surgery may promote surgical safety efforts and should be evaluated in larger and more diverse populations. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Daniel J. France
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA,Center for Research and Innovation in Systems Safety, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Emma Schremp
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA,Center for Research and Innovation in Systems Safety, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Evan B. Rhodes
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA,Center for Research and Innovation in Systems Safety, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jason Slagle
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA,Center for Research and Innovation in Systems Safety, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sarah Moroz
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA,Center for Research and Innovation in Systems Safety, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Peter H. Grubb
- Department of Pediatrics, Division of Neonatology, University of Utah, Salt Lake City,UT,USA
| | - Leon D. Hatch
- Department of Pediatrics, Division of Neonatology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amanda Lorinc
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA,Center for Research and Innovation in Systems Safety, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jamie Robinson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA,Department of Pediatric Surgery, Monroe Carell Jr. Children’s Hospital at Vanderbilt, TN, USA
| | - Marlee Crankshaw
- Neonatal Intensive Care Unit, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN, USA
| | - Timothy Newman
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA,Center for Research and Innovation in Systems Safety, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew B. Weinger
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA,Center for Research and Innovation in Systems Safety, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Martin L. Blakely
- Department of Pediatric Surgery, Monroe Carell Jr. Children’s Hospital at Vanderbilt, TN, USA
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Hu L, Chen X. Clinical Analysis of Laparoscopic Imaging Technique-assisted Vaginal Resection in Gynecological Operations. J Imaging Sci Technol 2021. [DOI: 10.2352/j.imagingsci.technol.2021.65.6.060401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Abstract In recent years, the incidence of diseases such as uterine fibroids in women in China has increased, which has raised people’s attention to the clinical effects and postoperative recovery effects of medical gynecological surgery. Regarding gynecological surgery,
there are many types of myomectomy, and among them, vaginectomy is receiving widespread attention in gynecological surgery. This article studies the clinical effects of laparoscopic imaging technology-assisted vaginal resection and the functional status, mental status, and hormone levels of
women during the recovery period, and analyzes the postoperative ovarian function and immune function of women. In this article, 111 patients with uterine fibroids were divided into the observation group and the reference group, of which 56 cases were in the reference group and 55 cases were
in the observation group. The hospital stay, ovarian function status, immune status, uterine recovery, and tibia recovery of the control group and the experimental group were respectively analyzed. In the experiment, laparoscopic imaging technology-assisted vaginal resection surgery has no
incision pain. It can be moved early on the ground and can be discharged within 2‐4 days after surgery. This reduces medical expenses to a certain extent and can be performed at the same time without changing the position. This also performs other operations on the perineum or vagina,
such as repairing the front and back walls of the vagina. Experimental results show that laparoscopic imaging technology-assisted vaginal resection can reduce pain and speed up the recovery of ovarian function. Three months after surgery, 59.6% of patients resumed ovulation, much higher than
42.3% in the control group. Vaginectomy using laparoscopic imaging technology can improve immunity by adjusting hormone levels in the body in a short time.
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Affiliation(s)
- Linyi Hu
- Department of Gynaecology, Huai’an Maternal and Child Health-Care Center, Huai’an 223000, Jiangsu, China
| | - Xiaoqin Chen
- Department of Gynaecology, Huai’an Maternal and Child Health-Care Center, Huai’an 223000, Jiangsu, China
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Mastrianni A, Sarcevic A, Chung LS, Zakeri I, Alberto EC, Milestone ZP, Burd RS, Marsic I. Designing Interactive Alerts to Improve Recognition of Critical Events in Medical Emergencies. DIS. DESIGNING INTERACTIVE SYSTEMS (CONFERENCE) 2021; 2021:864-878. [PMID: 35330919 PMCID: PMC8941664 DOI: 10.1145/3461778.3462051] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Vital sign values during medical emergencies can help clinicians recognize and treat patients with life-threatening injuries. Identifying abnormal vital signs, however, is frequently delayed and the values may not be documented at all. In this mixed-methods study, we designed and evaluated a two-phased visual alert approach for a digital checklist in trauma resuscitation that informs users about undocumented vital signs. Using an interrupted time series analysis, we compared documentation in the periods before (two years) and after (four months) the introduction of the alerts. We found that introducing alerts led to an increase in documentation throughout the post-intervention period, with clinicians documenting vital signs earlier. Interviews with users and video review of cases showed that alerts were ineffective when clinicians engaged less with the checklist or set the checklist down to perform another activity. From these findings, we discuss approaches to designing alerts for dynamic team-based settings.
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Alberto EC, Jagannath S, McCusker ME, Keller S, Marsic I, Sarcevic A, O’Connell KJ, Burd RS. Classification strategies for non-routine events occurring in high-risk patient care settings: A scoping review. J Eval Clin Pract 2021; 27:464-471. [PMID: 33249690 PMCID: PMC7961264 DOI: 10.1111/jep.13456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 07/10/2020] [Accepted: 07/13/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Non-routine events (NREs) are atypical or unusual occurrences in a pre-defined process. Although some NREs in high-risk clinical settings have no adverse effects on patient care, others can potentially cause serious patient harm. A unified strategy for identifying and describing NREs in these domains will facilitate the comparison of results between studies. METHODS We conducted a literature search in PubMed, CINAHL, and EMBASE to identify studies related to NREs in high-risk domains and evaluated the methods used for event observation and description. We applied The Joint Commission on Accreditation of Healthcare Organization (JCAHO) taxonomy (cause, impact, domain, type, prevention, and mitigation) to the descriptions of NREs from the literature. RESULTS We selected 25 articles that met inclusion criteria for review. Real-time documentation of NREs was more common than a retrospective video review. Thirteen studies used domain experts as observers and seven studies validated observations with interrater reliability. Using the JCAHO taxonomy, "cause" was the most frequently applied classification method, followed by "impact," "type," "domain," and "prevention and mitigation." CONCLUSIONS NREs are frequent in high-risk medical settings. Strengths identified in several studies included the use of multiple observers with domain expertise and validation of the event ascertainment approach using interrater reliability. By applying the JCAHO taxonomy to the current literature, we provide an example of a structured approach that can be used for future analyses of NREs.
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Affiliation(s)
- Emily C. Alberto
- Division of Trauma and Burns, Children’s National Hospital, Washington, DC, USA
| | - Swathi Jagannath
- College of Computing and Informatics, Drexel University, Philadelphia, PA, USA
| | - Maureen E. McCusker
- Office of Institutional Research and Decision Support, Virginia Commonwealth University, Richmond, VA, USA
| | - Susan Keller
- Department of Nursing Science Professional Practice and Quality, Children’s National Hospital, Washington, DC, USA
| | - Ivan Marsic
- Department of Electrical and Computer Engineering, Rutgers University, Piscataway, NJ, USA
| | - Aleksandra Sarcevic
- College of Computing and Informatics, Drexel University, Philadelphia, PA, USA
| | - Karen J. O’Connell
- Division of Emergency Medicine, Children’s National Hospital, Washington, DC, USA
| | - Randall S. Burd
- Division of Trauma and Burns, Children’s National Hospital, Washington, DC, USA
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Alberto EC, Harvey AR, Amberson MJ, Zheng Y, Thenappan AA, Oluigbo C, Marsic I, Sarcevic A, O'Connell KJ, Burd RS. Assessment of Non-Routine Events and Significant Physiological Disturbances during Emergency Department Evaluation after Pediatric Head Trauma. Neurotrauma Rep 2021; 2:39-47. [PMID: 33748812 PMCID: PMC7962792 DOI: 10.1089/neur.2020.0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Outcomes following pediatric traumatic brain injury (TBI) are dependent on initial injury severity and prevention of secondary injury. Hypoxia, hypotension, and hyperventilation following TBI are associated with increased mortality. The purpose of this study was to determine the association of non-routine events (NREs) during the initial resuscitation phase with these physiological disturbances. We conducted a video review of pediatric trauma resuscitations of patients with suspected TBI and Glasgow Coma Scale (GCS) scores <13. NREs were rated as "momentary" if task progression was delayed by <1 min and "moderate" if delayed by >1 min. Vital sign monitor data were used to identify periods of significant physiological disturbances. We calculated the association between the rate of overall and moderate NREs per case and the proportion of cases with abnormal vital signs using multi-variate linear regression, controlling for GCS score and need for intubation. Among 26 resuscitations, 604 NREs were identified with a median of 23 (interquartile range [IQR] 17-27.8, range 5-44) per case. Moderate delay NREs occurred in 19 resuscitations (n = 32, median 1 NRE/resuscitation, IQR 0.3-1, range 0-5). Oxygen desaturation and respiratory depression were associated with a greater rate of moderate NREs (p = 0.008, p < 0.001, respectively). We observed no association between duration of hypotension, desaturation, and respiratory depression and overall NRE rate. NREs are common in the initial resuscitation of children with moderate to severe TBI. Episodes of hypoxia and respiratory depression are associated with NREs that cause a moderate delay in task progression. Conformance with resuscitation guidelines is needed to prevent physiological events associated with adverse outcomes following pediatric TBI.
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Affiliation(s)
- Emily C. Alberto
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington DC, USA
| | - Allison R. Harvey
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington DC, USA
| | | | - Yinan Zheng
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington DC, USA
| | | | - Chima Oluigbo
- Division of Neurosurgery, Children's National Hospital, Washington DC, USA
| | - Ivan Marsic
- Department of Electrical and Computer Engineering, Rutgers University, Piscataway, New Jersey, USA
| | - Aleksandra Sarcevic
- College of Computing and Informatics, Drexel University, Philadelphia, Pennsylvania, USA
| | - Karen J. O'Connell
- Division of Emergency Medicine, Children's National Hospital, Washington DC, USA
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington DC, USA
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10
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Assessment of Nonroutine Events During Intubation After Pediatric Trauma. J Surg Res 2020; 259:276-283. [PMID: 33138986 DOI: 10.1016/j.jss.2020.09.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 08/28/2020] [Accepted: 09/22/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Intubation in the early postinjury phase can be a high-risk procedure associated with an increased risk of mortality when delayed. Nonroutine events (NREs) are workflow disruptions that can be latent safety threats in high-risk settings and may contribute to adverse outcomes. MATERIALS AND METHODS We reviewed videos of intubations of injured children (age<17 y old) in the emergency department occurring between 2014 and 2018 to identify NREs occurring between the decision to intubate and successful intubation ("critical window"). RESULTS Among 34 children requiring intubation, the indications included GCS≤8 (n = 20, 58.8%), cardiac arrest (n = 6, 17.6%), airway protection (n = 5, 14.7%), and respiratory failure (n = 3, 8.8%). The median duration of the "critical window" was 7.5 min (range 1.4-27.5 min), with a median of six NREs per case in this period (range 2-30). Most NREs (n = 159, 61.9%) delayed workflow, with 31 (12.1%) of these delays each lasting more than one minute. Eighty-seven NREs (33.9%) had a potential for harm but did not lead to direct patient harm. The most common NREs directly related to the intubation process were poor positioning for intubation (n = 23, 8.9%) and difficulty passing the endotracheal tube (n = 5, 1.9%), with most being attributed to the anesthesiologist performing the intubation (n = 51, range 0-7). CONCLUSIONS Workflow disruptions related to nonroutine events were frequent during pediatric trauma intubation and were often associated with delays and potential for patient harm. Interventions for improving the efficiency and timeliness of the critical window should focus on adherence to intubation protocol and improving communication and teamwork related to tasks in this phase.
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