Surgical Team Stability and Risk of Sharps-Related Blood and Body Fluid Exposures During Surgical Procedures

Team Consistency in Reducing Operative Time in Head and Neck Surgery with Microvascular Free Flap Reconstruction

OBJECTIVE(S)

To evaluate the impact of consistent surgical teams on procedure duration in head and neck free tissue transfer, and to evaluate the length of stay and readmission rates with consistent teams.

METHODS

A retrospective chart review of head and neck microvascular reconstruction by a single surgeon between August 2017 and November 2021 was performed. Procedure duration, wound complications, length of stay, and 30-day readmissions were analyzed. One circulating nurse (CN) and surgical technologist (ST) were considered "consistent" due to their prior work with the primary surgeon. All others were considered "ad hoc." Teams were "Consistent CN + ST," "Consistent ST," "Consistent CN," or "Ad hoc." Procedure duration between groups was compared via analysis of variance. Multivariate linear regression was performed to predict procedure duration.

RESULTS

A total of 135 patients were included. Age, sex, and American Society of Anesthesiologists status did not significantly differ across groups (p = 0.963; p = 0.467; p = 0.908, respectively). The mean procedure duration was 339.3 min and differed significantly across all groups (p = 0.006, Cohen d = 0.32). Compared to the Ad hoc group, consistent teams demonstrated significant reductions in mean procedure duration (Consistent CN + ST: 58.4 min, p = 0.001, Cohen d = 0.67; Consistent ST: 51.6 min, p = 0.013, Cohen d = 0.61; Consistent CN: 44.5 min, p = 0.031, Cohen d = 0.52). Controlling for other factors, the ad hoc team predicted increased procedure duration on multivariate analysis ( β 57.38, 19.92-94.85, p < 0.003). Wound complications, length of stay, and readmission rates did not differ significantly across groups (p = 0.940; p = 0.174; p = 0.935, respectively).

CONCLUSION

Consistent CN and ST improve operative efficiency in head and neck-free tissue transfer. Future studies may evaluate the impact of team consistency on complications, physician burnout, and health systems costs.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:2154-2159, 2023.

An exploratory project to develop an effective educational system to teach mastery of assistant laparoscopic gynecologic surgery skills

INTRODUCTION

In laparoscopic surgery, the cooperation of the first assistant surgeon is essential for the creation and maintenance of an appropriate and safe surgical field. The aim of this study is a validation of the impact of our educational system for first assistant laparoscopic surgeon residency in a single university-affiliated teaching hospital.

METHODS

Five residents were recruited for this study. We created a slide-set as an educational tool using Microsoft's PowerPoint that was in line with our surgical procedure to master the assistant skills of laparoscopic gynecologic surgery. Immediately after surgery, the attending doctor and residents reviewed videos of the first assistant's operative procedures. This study evaluated the effect of our educational checklist against the transition of evaluation scores before and after training in two groups of residents, those with minimal experience (Group 1) or with high experience (Group 2).

RESULTS

Before receiving our training tool, there was an expected significant difference in the review scores of the two experience groups (29.1 ± 3.1 vs 48.7 ± 3.9, P = .01). After our modified training, the inexperienced residents of Group 1 received review scores comparable to or higher than those of the experienced residents of Group 2 (81.9 ± 5.9 vs 70.4 ± 7.5, P = .23). As they assisted with more surgeries, the concordance between the resident's self-assessment and the attending doctor's assessment scores significantly increased (P < .001).

CONCLUSIONS

Our educational system for first assistant surgeons is effective for new residents, as it proved capable of imparting them with many of the same skill sets as much more experienced attending doctors.

Fragmentation of practice: The adverse effect of surgeons moving around

BACKGROUND

Whether surgical team familiarity is associated with improved postoperative outcomes remains unknown. We sought to characterize the impact of fragmented surgical practice on the likelihood that a patient would experience a textbook outcome, which is a validated patient-centric composite outcome representing an "ideal" postoperative outcome.

METHOD

Medicare beneficiaries aged 65 and older who underwent elective inpatient abdominal aortic aneurysm repair, coronary artery bypass graft, cholecystectomy, colectomy, or lung resection were identified. Rate of fragmented practice was calculated based on the total number of surgical procedures of interest performed over the study period (2013-2017) divided by the number of different hospitals in which the surgeon operated. Surgeons were categorized into "low," "average," "above average," or "high" rate of fragmented practice categories using an unsupervised machine learning technique known k-medians cluster analysis.

RESULTS

Among 546,422 Medicare beneficiaries who underwent an elective surgical procedure of interest (coronary artery bypass graft: n = 156,384, 28.6%; lung resection: n = 83,164, 15.2%; abdominal aortic aneurysm: n = 112,578, 20.6%; cholecystectomy: n = 42,955, 7.9%; colectomy: n = 151,341, 27.7%), median patient age was 74 years (interquartile range: 69-80), and most patients were male (n = 319,153, 58.4%). Machine learning identified 3 cutoffs to categorize rate of fragmented practice: 2.8%, 5.6%, and 10.6%. Overall, the majority of surgical procedures were performed by surgeons with a low rate of fragmented practice (n = 382,504, 70.0%); other surgical procedures were performed by surgeons with average (n = 109,141, 20.0%), above average (n = 44,249, 8.1%), or high (n = 10,528, 1.9%) rate of fragmented practice. On multivariable analyses, after controlling for patient demographics, individual surgeon volume, procedure type, and a random effect for hospital, patients who underwent a surgical procedure by a high versus low rate of fragmented practice surgeon had lower odds to achieve a postoperative textbook outcome (odds ratio 0.71, 95% confidence interval 0.77-0.84). Patients who underwent a procedure by a high rate of fragmented practice surgeon also had increased odds of a perioperative complication (odds ratio 1.30, 95% confidence interval: 1.23-1.37), extended length of stay (odds ratio 1.17, 95% confidence interval: 1.11-1.24), 90-day readmission (odds ratio 1.17, 95% confidence interval: 1.11-1.23), and 90-day mortality (odds ratio 1.29, 95% confidence interval: 1.17-1.42) (all P < .05).

CONCLUSION

Patients undergoing a surgical procedure by a surgeon with a high rate of fragmented practice had lower odds of achieving an optimal postoperative textbook outcome. Surgical team familiarity, measured by a surgeon rate of fragmented practice, may represent a modifiable mechanism to improve surgical outcomes.

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

PURPOSE

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

DESIGN

A retrospective, exploratory, cross-sectional design.

METHODS

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

FINDINGS

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

CONCLUSIONS

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

Surgical Team Familiarity: An Integrative Review

The dynamic nature of perioperative care often brings unfamiliar clinicians together yet requires them to collectively provide complex health care in a challenging environment. In this review, we comprehensively evaluated evidence regarding surgical team familiarity and its relationship to surgical team performance. Using a comprehensive and iterative search strategy, we searched PubMed, Web of Science, PsycInfo, and EMBASE for surgical team familiarity manuscripts. We identified 598 manuscripts, 16 of which met our inclusion criteria. We found that surgical team familiarity is associated with improved performance for many metrics, including shorter total operative time, team member safety, decreased surgical errors and disruptions, reduced miscommunication, and fewer patient readmissions. Although additional research would be helpful, surgical managers should consider team familiarity and consistency in team membership when assigning staff members to surgical teams to optimize surgical care, decrease inefficiencies, and promote safe patient outcomes.

Impact of First Assistant Surgeon Experience on the Perioperative Outcomes of Laparoscopic Hepatectomies

Introduction: This study aims to evaluate the impact of first assistant surgeon experience on the outcomes of laparoscopic hepatectomies in a university-affiliated teaching hospital. Methods: This is a retrospective study comparing outcomes of laparoscopic hepatectomies with first assistant surgeons of varying experience levels. Three hundred and eighty-five consecutive laparoscopic hepatectomies performed in a tertiary university-affiliated teaching hospital from 2012 to 2018 were included and stratified into three cohorts-Group 1 in which assistants were residents, Group 2 for fellows, and Group 3 for attendings. Baseline clinicopathologic variables and outcome measures were analyzed using the augmented inverse probability of treatment weighting approach, which is a propensity score-based method that combines aspects of covariate adjustment and inverse probability weighting. Results: Group 3 comprised a greater proportion of advanced- and expert-level surgeries based on the Iwate criteria; 33.8%, 32.2%, and 46.0% of patients underwent advanced- and expert-level surgeries in Groups 1, 2, and 3, respectively. Group 3 had consistently higher operative times as well as more frequent use and longer duration of Pringle's maneuver (P < .05). The median operative times for Groups 1, 2, and 3 were 195, 195, and 290 minutes, respectively. Pringle's maneuver was applied in 26.9%, 33.9%, and 60.2% of patients with a corresponding median duration of 35, 36, and 45 minutes, respectively. None of the other perioperative and postoperative outcomes demonstrated statistically significant differences. Conclusion: With an appropriate selection of cases, participation of residents as first assistants in laparoscopic hepatectomies can be encouraged without compromise in perioperative outcomes.

Do not break up the surgical team! Familiarity and expertise affect operative time in complex surgery

BACKGROUND

The effects of replacing a surgeon's familiar, experienced certified surgical assistant (CSA) on perioperative outcomes in complex surgery were investigated.

METHODS

An interrupted time series of totally laparoscopic pancreatoduodenectomies performed by a single surgeon was retrospectively studied. Segmented regression analysis estimated replacement effects on estimated blood loss (EBL) and operative time.

RESULTS

The cohort was composed of the last 100 cases with the familiar CSA and the first 100 cases with the replacement CSA. Study groups were similar. Unadjusted segmented regression of operative time and EBL predicted replacement effects of 70 min (95%CI, 18-122; p = 0.008) and 114 cc (95%CI, -93-320; p = 0.3), respectively. Adjusted regression predicted replacement effects of 40 min (95%CI, 0.9-78; p = 0.04) and 27 cc (95%CI, -156-210; p = 0.3).

CONCLUSIONS

The replacement of a familiar, experienced CSA was associated with longer operative times. Despite confinement to a single surgeon and procedure, these results suggest what all surgeons know: excellent help is priceless.