Patient safety in the cardiac operating room: human factors and teamwork: a scientific statement from the American Heart Association

Perfusionist education in Japan: A survey of challenges and current status

IntroductionThis study aimed to examine the educational challenges faced by perfusionists in Japan. Although Japan has over 400 cardiovascular surgery centers, it performs fewer surgeries than by countries such as Germany and the United States. We focused on challenges related to varying caseloads and working conditions.MethodsWe conducted an online survey containing 24 questions using Google Forms from January to June 2022, targeting perfusionists in Japan. The 24-question survey spanned various educational topics and was approved by the Morinomiya University of Medical Sciences Ethics Committee.ResultsResponses were received from 129 perfusionists across 77 institutions. Approximately 70% of these centers managed less than 200 cardiopulmonary bypass (CPB) cases per year, with a similar proportion of perfusionists handling under 50 CPB cases annually. Challenges in Japanese perfusionist education include enhancing communication and troubleshooting skills and the need for instructors with a broad teaching experience.ConclusionsThis study emphasizes the significant differences in caseload and work environments for perfusionists among Japanese institutions. Perfusionists, who often work in clinical engineering, have various responsibilities. These findings highlight the need for improved communication, problem-solving skills, and the implementation of modern teaching technologies. Additionally, this study highlights the complexities of training Japanese perfusionists and underscores the need for more practical, technology-driven educational methods. Addressing these issues is crucial for improving Japan's healthcare standards and could influence global perfusionist education.

Exploring the Impact of the Physical Environment on Robotic-Assisted Surgery Outcomes and Processes: A Scoping Review

ObjectiveThe purpose of this scoping review is to identify physical environmental facilitators and barriers related to performing robotic-assisted surgery (RAS) in operating rooms (ORs).BackgroundAs new robotic surgery technology is developed and brought to market, there is a need to understand how existing and future operating rooms are adapted and designed to support patient safety, surgical workflow, and teamwork. This review will focus on literature related to physical environment factors that impact workflow and communication, as well as the adoption of RAS technology.MethodThe scoping review search was conducted during November 2022, following the PRISMA guidelines. An independent reviewer screened articles for inclusion and exclusion and two independent reviewers completed a quality appraisal was on the included articles.ResultsOf the 9325 texts screened, 28 articles were included for analysis. The primary physical environment and outcome variables were extracted and synthesized under the following categories: RAS process or task-related, environmental features, environmental qualities, and staff or patient outcomes.ConclusionThe physical environment of the OR, such as OR layout, OR size, environmental noise, and dedicated robotic ORs played a significant role in efficiency and workflow outcomes for RAS, as well as workload measures, staff and patient safety, and surgical performance.ApplicationSince there are minimal evidence-based resources available for the application of RAS, this review provides distinct connections between RAS outcomes and specific environmental features for considerations among design researchers, architects, human factors professionals, hospital administrators, and practitioners to aid in decision making during and after implementation of RAS technology.

Enhancing patient safety: identifying fall risks during patient transfers in operating rooms

BACKGROUND

Transfers within operating rooms present significant risks to patient safety, with falls potentially leading to serious consequences for both patients and staff. The aim of this study is to explore the factors contributing to falls during transfers and strategies to enhance patient safety in operating rooms.

METHODS

This is a qualitative study conducted using semi-structured interviews with fifteen operating room staff including nurse (n = 7), anaesthesia technician (n = 7) and scrub person (n = 1). Their ages ranged from 28 to 39 years, with experience years in the operating room ranging from two to ten years. The data were analysed using a thematic analysis approach based on the grounded theory.

RESULTS

The thematic analysis identified six key factors contributing to falls during patient transfers: human error, team coordination, patient condition, staffing challenges, equipment issues, and inadequate training. Participants recommended improving team collaboration, pre-operative patient education, better infrastructure (e.g., private elevators), hands-on training, and increased staffing. Additionally, policy changes to limit complex outpatient transfers were suggested to reduce risks.

CONCLUSIONS

This study provides valuable insights into the risk factors and potential prevention strategies regarding falls during patient transfers in operating rooms. Future research should incorporate multidisciplinary observational studies involving human factors to provide deeper insights. It is recommended to create systems for anonymous incident reporting and implement comprehensive training programs.

Quality Improvement Methodologies: An Application in Cardiac Anesthesiology

Quality improvement (QI) in medicine serves as the cornerstone of best practices. It enhances medical care by maximizing safety and efficiency while minimizing errors and waste. For a QI initiative to succeed it requires careful strategizing and effective change management plans, including the application of established QI methodologies to ensure sustainable success. Today, QI processes are integral to foundational learning for students and trainees, as well as for maintaining board certification for anesthesiologists. However, many anesthesiologists, including those actively pursuing QI efforts, are often unaware of these methodologies and their associated tools. A successful QI program that leads to sustainable improvement in outcomes relies on methodologies that assess the true current state, define value-added measures, evaluate defects and opportunities for enhancement, implement solutions through a robust change management plan, and ensure the sustainability of the process. This document provides a concise summary of methodologies that can be effectively led and executed by process improvement teams. We examine these methods within the context of cardiac anesthesiology, highlighting one institution's experience in reducing surgical site infections following coronary artery bypass graft surgery. However, these principles are applicable to various healthcare situations and beyond.

Entrapment of Pulmonary Artery Catheters in Cardiac Surgery: A Structured Literature Review and Analysis of Published Case Reports

OBJECTIVES

This systematic review aims to tabulate and analyze the published literature regarding pulmonary artery catheter (PAC) entrapment during cardiac surgery.

DESIGN

Systematic review.

SETTING

Case reports and series.

PARTICIPANTS

Adults undergoing cardiac surgery.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

223 distinct incidents of PAC entrapment were published across 77 case reports and 3 retrospective studies. The reported incidence of an entrapped PAC was 137/200,831 (0.068%, 95% confidence interval: 0.067%, 0.069%). Reported PAC entrapment was most seen in the setting of mitral valve surgery and was not discovered until the postoperative period in 77% of cases. Inadvertent fixation to cardiac structures was the most common mechanism of PAC entrapment. A total of 75% of patients with an entrapped PAC required an immediate redo sternotomy for PAC retrieval. After PAC retrieval, these patients still had longer hospital length of stay compared with the Society of Thoracic Surgeons Adult Cardiac Surgery Database averages.

CONCLUSIONS

Although PAC entrapment during cardiac surgery is rare, an entrapped PAC increases patient morbidity, delays recovery, and increases hospital length of stay. Surgeons and anesthesiologists are encouraged to be attentive to PAC entrapment before chest closure.

2024 EACTS/EACTAIC/EBCP Guidelines on cardiopulmonary bypass in adult cardiac surgery

Clinical practice guidelines consolidate and evaluate all pertinent evidence on a specific topic available at the time of their formulation. The goal is to assist physicians in determining the most effective management strategies for patients with a particular condition. These guidelines assess the impact on patient outcomes and weigh the risk-benefit ratio of various diagnostic or therapeutic approaches. While not a replacement for textbooks, they provide supplementary information on topics relevant to current clinical practice and become an essential tool to support the decisions made by specialists in daily practice. Nonetheless, it is crucial to understand that these recommendations are intended to guide, not dictate, clinical practice, and should be adapted to each patient's unique needs. Clinical situations vary, presenting a diverse array of variables and circumstances. Thus, the guidelines are meant to inform, not replace, the clinical judgement of healthcare professionals, grounded in their professional knowledge, experience and comprehension of each patient's specific context. Moreover, these guidelines are not considered legally binding; the legal duties of healthcare professionals are defined by prevailing laws and regulations, and adherence to these guidelines does not modify such responsibilities. The European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) and the European Board of Cardiovascular Perfusion (EBCP) constituted a task force of professionals specializing in cardiopulmonary bypass (CPB) management. To ensure transparency and integrity, all task force members involved in the development and review of these guidelines submitted conflict of interest declarations, which were compiled into a single document available on the EACTS website (https://www.eacts.org/resources/clinical-guidelines). Any alterations to these declarations during the development process were promptly reported to the EACTS, EACTAIC and EBCP. Funding for this task force was provided exclusively by the EACTS, EACTAIC and EBCP, without involvement from the healthcare industry or other entities. Following this collaborative endeavour, the governing bodies of EACTS, EACTAIC and EBCP oversaw the formulation, refinement, and endorsement of these extensively revised guidelines. An external panel of experts thoroughly reviewed the initial draft, and their input guided subsequent amendments. After this detailed revision process, the final document was ratified by all task force experts and the leadership of the EACTS, EACTAIC and EBCP, enabling its publication in the European Journal of Cardio-Thoracic Surgery, the British Journal of Anaesthesia and Interdisciplinary CardioVascular and Thoracic Surgery. Endorsed by the EACTS, EACTAIC and EBCP, these guidelines represent the official standpoint on this subject. They demonstrate a dedication to continual enhancement, with routine updates planned to ensure that the guidelines remain current and valuable in the ever-progressing arena of clinical practice.

Safety Interventions in Cardiac Anesthesia: A Systematic Review

BACKGROUND

The cardiac operating room is a complex, high-risk, sociotechnical system. Risks in cardiac surgery and anesthesiology have been extensively categorized, but less is known about effective risk reduction strategies. A comprehensive understanding of effective, evidence-based risk reduction strategies is necessary to improve patient safety in cardiac anesthesia.

METHODS

An advanced literature search of MEDLINE, CINAHL, Embase, and Web of Science databases was conducted to identify studies involving the introduction of a tool or intervention to improve patient safety and human factors in cardiac anesthesia. Studies were screened independently by two authors applying prespecified inclusion and exclusion criteria. Risk reduction strategies and safety initiatives identified were classified according to the Systems Engineering Initiative for Patient Safety model. Data were extracted using a standardized form and were narratively synthesized.

RESULTS

A total of 18 studies were identified for inclusion using preoperative briefing tools, intraoperative checklists, and postoperative handover tools. Preoperative briefing tools were associated with a significant reduction in patient mortality and length of hospital stay and also led to adaptations to planned operation. Intraoperative checklists demonstrated decreased bleeding, mortality, and blood transfusion requirements. Postoperative handover tools were associated with improved information transfer and teamwork.

CONCLUSION

This review identified three categories of tools that may be used to improve patient and organizational outcomes. Many of these tools are simple to introduce and sustainable in the long term and can be readily adapted to different centers.

Impact of intraoperative anesthesia handover on major adverse cardiovascular events after thoracic surgery: A propensity-score matched retrospective cohort study

STUDY OBJECTIVE

Handover of anesthesia care is often required in busy clinical settings. Herein, we investigated whether intraoperative anesthesia handover was associated with an increased risk of major adverse cardiovascular events (MACEs) after thoracic surgery.

DESIGN

A retrospective cohort study.

SETTING

A tertiary hospital.

PATIENTS

Adult patients who underwent elective thoracic surgery.

EXPOSURES

A complete handover of intraoperative anesthesia care was defined when the outgoing anesthesiologist transferred patient care to the incoming anesthesiologist and no longer returned.

MEASUREMENTS

Our primary endpoint was a composite of MACEs, including acute myocardial infarction, new-onset congestive heart failure, non-fatal cardiac arrest, and cardiac death, that occurred within 7 days after surgery. The impact of complete anesthesia handover on postoperative MACEs was analyzed using propensity score matching.

MAIN RESULTS

Of 6962 patients (mean age 59.7 years; 57.4 % female) included in the analysis, 2319 (33.3 %) surgeries were conducted with anesthesia handover whereas 4643 (66.7 %) were conducted without. After propensity score matching, 2165 (50.0 %) surgeries were conducted with anesthesia handover whereas the other half were conducted without. Patients with anesthesia handover developed more MACEs when compared with those without (10.4 % [225/2165] vs. 8.4 % [181/2165]; relative risk 1.24, 95 % CI 1.03 to 1.50, P = 0.022). Specifically, myocardial infarction was more common in patients with anesthesia handover than in those without (9.2 % [199/2165] vs. 7.4 % [160/2165]; relative risk 1.24, 95 % CI 1.02 to 1.52, P = 0.032).

CONCLUSIONS

For adult patients undergoing thoracic surgery, a complete handover of intraoperative anesthesia care was associated with an increased risk of MACEs after surgery.

Developing Proficiency in Robotic Cardiac Surgery

BACKGROUND

The purpose of this review is to provide recommendations for cardiac surgeons interested in adopting a robotic platform into their programs.

METHODS

The recommendations are based on the experience of the authors and cover a diverse array of cardiac surgical procedures that are currently performed with robotic assistance. The focus, as with any innovative surgical approach, is to ensure patient safety, maximize quality and efficacy, and set realistic expectations about what is required to achieve proficiency in robotic cardiac surgery.

RESULTS

Even though there may be steady growth in robotic cardiac procedures, it is possible that these procedures will be concentrated in higher-volume programs that already offer expertise in mitral valve or coronary surgery. Once success and proficiency with robotic cardiac approaches to coronary or valvular heart disease is achieved, as outlined in this review, surgeons may wish to embark on more complex robotic procedures, such as reoperative mitral valve surgery, totally endoscopic coronary artery bypass, or aortic valve replacement.

CONCLUSIONS

Maintaining the same principles and techniques for coronary surgery or intracardiac procedures and maintaining the fundamentals of myocardial protection and cardiopulmonary bypass are essential to ensure excellent technical and clinical outcomes and to optimize patient safety.

Trauma video review analysis: Increased provider movement impedes trauma team performance

INTRODUCTION

Trauma team performance, measured by the non-technical skills scale T-NOTECHS, has been shown to impact patient outcomes. We assess how personnel movements affect non-technical skills and time of resuscitation(TOR) using trauma video review.

METHODS

A prospective study of blunt and/or penetrating trauma activations recorded between May and November 2023 ​at a Level-I trauma center. Regressions controlling for confounders were used to measure the association between foot traffic and the outcomes of interest1: TOR2 T-NOTECHS score(Smith et al., 2015; Mackenzie et al., 2007; Maiga et al., 2024; Vella et al., 2024; Pucher et al., 2014; Dumas et al., 2020; Succar et al., 2024; Steinemann et al., 2012; Andersson et al., 2012; Conrad et al., 2010; Lies and Zhang, 2015) .5-155-15 RESULTS: We identified 77 trauma activations, with 40 ​%(n ​= ​32/77) penetrating injuries. There was a median of 17[14-18] individuals at the start of trauma activations. During resuscitations, individuals entered the room a median of 12[8-18] times and exited the room 17[11-22] times. The median TOR was 8[6-10] min and the median T-NOTECHS was 7[6-8]. Regression analysis showed foot traffic was independently associated with increased TOR(β 0.34, p-value <0.01) and worse total T-NOTECHS score(β 0.06, p ​< ​0.01).

CONCLUSIONS

Higher foot traffic is associated with poorer team performance and delays in resuscitation. Future directions should further explore environmental and personal factors that may impede performance metrics.

Compliance with care standards and professional knowledge of operating theatre personnel before, during and after laparoscopic bariatric surgery: A study in public hospitals in Iran

INTRODUCTION

By adhering to care standards, many adverse outcomes for patients, such as pressure injuries, tissue necrosis and patient falls, can be prevented. The aim of this study was to investigate the level of compliance with care standards before, during and after various types of bariatric surgeries.

MATERIALS AND METHODS

This study was a cross-sectional descriptive study conducted in the operating theatres of selected teaching hospitals in Isfahan (Iran). The study sample consisted of all operating theatre personnel in the selected teaching hospitals who met the inclusion criteria. Compliance with care standards was measured using a researcher-developed checklist. A researcher-developed questionnaire with 43 true/false questions was used to evaluate the operating theatre personnel's professional knowledge. The data were analysed using SPSS version 20 and descriptive and inferential statistics.

RESULTS

The mean score of adherence to care standards and the mean score of professional knowledge of operating theatre personnel regarding care of laparoscopic bariatric surgery were 78.35 ± 9.49 and 29.45 ± 6.17, respectively. There is no significant relationship between these two variables, with a two-tailed significance (Sig.) of 0.056 and a correlation coefficient (r) of 0.199.

DISCUSSION AND CONCLUSION

In general, it can be concluded that the specific knowledge of the local operating theatre personnel regarding minimally invasive laparoscopic surgery care is at an intermediate level. Requirements for training in this area were therefore successfully identified. In addition, not all operating theatre personnel adhere to the standards of care for patients undergoing laparoscopic bariatric surgery. This non-adherence could be due to insufficient training or the absence of established standards in hospitals.

Quality and Simulation Professionals Should Collaborate

Simulation is underutilized as a tool to improve healthcare quality and safety despite many examples of its effectiveness to identify and remedy quality and safety problems, improve teamwork, and improve various measures of quality and safety that are important to healthcare organizations, eg, patient safety indicators. We urge quality and safety and simulation professionals to collaborate with their counterparts in their organizations to employ simulation in ways that improve the quality and safety of care of their patients. These collaborations could begin through initiating conversations among the quality and safety and simulation professionals, perhaps using this article as a prompt for discussion, identifying one area in need of quality and safety improvement for which simulation can be helpful, and beginning that work. (Sim Healthcare 19(5):319-325, 2024).

Call to Action: Quality and Simulation Professionals Should Collaborate

SUMMARY STATEMENT

Simulation is underutilized as a tool to improve healthcare quality and safety despite many examples of its effectiveness to identify and remedy quality and safety problems, improve teamwork, and improve various measures of quality and safety that are important to healthcare organizations, eg, patient safety indicators. We urge quality and safety and simulation professionals to collaborate with their counterparts in their organizations to employ simulation in ways that improve the quality and safety of care of their patients. These collaborations could begin through initiating conversations among the quality and safety and simulation professionals, perhaps using this article as a prompt for discussion, identifying one area in need of quality and safety improvement for which simulation can be helpful, and beginning that work.

Effect of standardized EHR-integrated handoff report on intraoperative communication outcomes

OBJECTIVES

We evaluated the effectiveness and implementability of a standardized EHR-integrated handoff report to support intraoperative handoffs.

MATERIALS AND METHODS

A pre-post intervention study was used to compare the quality of intraoperative handoffs supported by unstructured notes (pre) to structured, standardized EHR-integrated handoff reports (post). Participants included anesthesia clinicians involved in intraoperative handoffs. A mixed-method approach was followed, supported by general observations, shadowing, surveys, and interviews.

RESULTS

One hundred and fifty-one intraoperative permanent handoffs (78 pre, 73 post) were included. One hundred percent of participants in the post-intervention cohort utilized the report. Compared to unstructured, structured handoffs using the EHR-integrated handoff report led to: (1) significant increase in the transfer of information about airway management (55%-78%, P < .001), intraoperative course (63%-86%, P < .001), and potential concerns (64%-88%, P < .001); (2) significant improvement in clinician satisfaction scores, with regards to information clarity and succinctness (4.5-4.7, P = .002), information transfer (3.8-4.2, P = .011), and opportunities for fewer errors reported by senders (3.3-2.5, P < .001) and receivers (3.2-2.4, P < .001); and (3) significant decrease in handoff duration (326.2-262.3 s, P = .016). Clinicians found the report implementation highly acceptable, appropriate, and feasible but noted a few areas for improvement to enhance its usability and integration within the intraoperative workflow.

DISCUSSION AND CONCLUSION

A standardized EHR-integrated handoff report ensures the effectiveness and efficiency of intraoperative handoffs with its structured, consistent format that-promotes up-to-date and pertinent intraoperative information transfer; reduces opportunities for errors; and streamlines verbal communication. Handoff standardization can promote safe and high-quality intraoperative care.

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.

A novel multimodal, intraoperative cognitive workload assessment of cardiac surgery team members

OBJECTIVE

To characterize cognitive workload (CWL) of cardiac surgery team members in a real-world setting during coronary artery bypass grafting (CABG) surgery using providers' heart rate variability (HRV) data as a surrogate measure of CWL.

METHODS

HRV was collected from the surgeon, anesthesiologist, perfusionist, and scrub nurse, and audio/video recordings were made during isolated, nonemergency CABG surgeries (n = 27). Eight surgical phases were annotated by trained researchers, and HRV was calculated for each phase.

RESULTS

Significant differences in CWL were observed within a given role across surgical phases. Results are reported as predicted probability (95% confidence interval [CI]). CWL was significantly higher for anesthesiologists during "preparation and induction" (0.57; 95% CI, 0.42-0.71) and "anastomoses" (0.44; 95% CI, 0.30-0.58) compared to other phases, and the same held for nurses during the "opening" (0.51; 95% CI, 0.37-0.65) and "postoperative" (0.68; 95% CI, 0.42-0.86) phases. Additional significant differences were observed between roles within a given surgical phase. For example, surgeons had significantly higher CWL during "anastomoses" (0.81; 95% CI, 0.69-0.89) compared to all other phases, and the same was true of perfusionists during the "opening" (0.79; 95% CI, 0.66-0.88) and "prebypass preparation" (0.50; 95% CI, 0.36-0.64) phases.

CONCLUSIONS

Our innovative analysis demonstrates that CWL fluctuates across surgical procedures by role and phase, which may reflect the distribution of primary tasks. This corroborates earlier findings from self-report measures. The data suggest that team-wide, peak CWL during a phase decreases from early phases of surgery through initiation of cardiopumonary bypass (CPB), rises during anastomosis, and decreases after termination of CPB. Knowledge of these trends could encourage the adoption of behaviors to enhance team dynamics and performance.

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.

Robotic surgery and work-related stress: A systematic review

Despite robot-assisted surgery (RAS) becoming increasingly common, little is known about the impact of the underlying work organization on the stress levels of members of the operating room (OR) team. To this end, assessing whether RAS may impact work-related stress, identifying associated stress factors and surveying relevant measurement methods seems critical. Using three databases (Scopus, Medline, Google Scholar), a systematic review was conducted leading to the analysis of 20 articles. Results regarding OR team stress levels and measurement methods were heterogeneous, which could be explained by differing research conditions (i.e., lab. vs. real-life). Relevant stressors such as (in)experience with RAS and quality of team communication were identified. Development of a common, more reliable methodology of stress assessment is required. Research should focus on real-life conditions in order to develop valid and actionable knowledge. Surgical teams would greatly benefit from discussing RAS-related stressors and developing team-specific strategies to handle them.

Quality Improvement and Patient Safety Rounds-A New Paradigm in Cardiothoracic Surgery

Background

The delivery of cardiothoracic health care is complex, and despite best efforts, adverse patient outcomes do occur. There is significant heterogeneity in morbidity and mortality rounds within and between institutions as well as undertones of a "blame and shame" culture prohibitive to meaningful quality assessment and improvement of patient care. The Quality Improvement and Patient Safety (QIPS) program was designed to address these issues.

Methods

QIPS is built on the Donabedian model of quality and established phase-of-care adverse event analysis. It focuses on cultivating a culture of transparency. Every case review yields important demographic data, event factors, and the case inflection point, creating an institution-specific QIPS database. The QIPS format was presented by The Society of Thoracic Surgeons Workforce on Patient Safety at 2 Society of Thoracic Surgeons webinar series in December 2021 and August 2022. Descriptive data on both presentations were collected.

Results

The December 2021 webinar had 75 unique viewers from 13 countries, and there were 343 asynchronous playbacks. The August 2022 webinar had 38 unique viewers from 9 countries and 310 asynchronous playbacks.

Conclusions

The standardized QIPS methods allow consistent recording of event factors and the inflection point, which are root causes of case morbidity or mortality. Dedication to the program will build a granular databank and identify recurring individual or system issues to launch quality improvement initiatives that address institution-specific needs. QIPS is simple, effective, and reproducible and seeks to create a culture of patient-centered quality and excellence in cardiothoracic surgery programs.

Do two operators improve outcomes in left main percutaneous coronary intervention? Insights from the ORPKI Registry

BACKGROUND

Significant left main coronary artery (LMCA) disease is prevalent in 7% of patients undergoing angiography. Limited data exists on the impact of double scrubbing in LMCA PCI. We sought to assess periprocedural outcomes in two-operator LMCA percutaneous coronary intervention (PCI).

METHODS

Using data from the Polish National Registry of PCI (ORPKI), we collected data on 28,745 patients undergoing LMCA PCI from 154 centers. Patients were divided into two groups based on the number of operators performing PCI (one vs. two operators).

RESULTS

LMCA PCI was performed by a single operator in 86% of the cases and by two operators in 14% of cases. Patients treated by two operators had a greater comorbidity burden including diabetes mellitus, arterial hypertension, previous myocardial infarction, and previous revascularization. In addition, these were more likely to be treated in high-volume centers, by operators with higher volume of LMCA PCIs. The risk of periprocedural death (2.37% vs. 2.44%; P=0.78), as well as cardiac arrest, coronary artery perforation, no-reflow, and puncture site bleeding was comparable between the two groups. On multivariable analysis, we found that a two-operator strategy was an independent predictor of periprocedural death, with this effect being much more profound in an elective setting (OR=5.13 [1.37-19.26]; P=0.015), compared to an urgent (ACS) setting (OR=1.32 [1.00-1.73]; P=0.047).

CONCLUSIONS

Our study suggests that a two-operator approach is not necessarily routinely recommended for LMCA interventions, although it can be considered for more complex cases.

Certified Registered Nurse Anaesthetists' and Critical Care Registered Nurses' perception of knowledge/power in teamwork with Anaesthesiologists in Sweden: a mixed-method study

Efficient teamwork is crucial to provide optimal health care. This paper focuses on teamwork between Anaesthesiologists (ANES), Certified Registered Nurse Anaesthetists' (CRNA) and Critical Care Registered Nurses (CCRN) working in challenging environments such as the intensive care unit (ICU) and the operating room (OR). Conflicts are common between physicians and nurses, negatively impacting teamwork. Social hierarchies based on professional status and power inequalities between nurses and physicians plays a vital role in influencing teamwork. Foucault was a famous thinker especially known for his reasoning regarding power/knowledge. A Foucauldian perspective was therefore incorporated into this paper and the overall aim was to explore CCRN/CRNA perception of knowledge/power in teamwork with ANES.Methods A mixed-method approach was applied in this study. Data was collected using a web-based questionnaire containing both closed-end and open-ended questions. A total of 289 CCRNs and CRNAs completed the questionnaire. Data analysis was then conducted through five stages as outlined by Onwuebugzie and Teddlie; analysing quantitative data in SPSS 27.0 and qualitative data with a directed content analysis, finally merging data together in ATLAS.ti v.23.Results The result reveals a dissonance between quantitative and qualitative data; quantitative data indicates a well-functioning interdisciplinary teamwork between CCRN/CRNA and ANES - qualitative data highlights that there are several barriers and inequalities between the two groups. Medicine was perceived as superior to nursing, which was reinforced by both social and organisational structures at the ICU and OR.Conclusion Unconscious rules underlying current power structures in the ICU and OR works in favour of the ANES and biomedical paradigm, supporting medical knowledge. To achieve a more equal power distribution between CCRN/CRNAs and ANES, the structural hierarchies between nursing and medicine needs to be addressed. A more equal power balance between the two disciplines can improve teamwork and thereby reduce patient mortality and improve patient outcomes.

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.

Beyond the self: a novel framework to enhance non-technical team skills for anesthesiologists

Human factors and non-technical skills (NTS) have been identified as essential contributors to both the propagation and prevention of medical errors in the operating room. Despite extensive study and interventions to nurture and enhance NTS in anesthesiologists, gaps to effective team practice and patient safety remain. Furthermore, the link between added NTS training and clinically significant improved outcomes has not yet been demonstrated. We performed a narrative review to summarize the literature on existing systems and initiatives used to measure and nurture NTS in the clinical operating room setting. Controlled interventions performed to nurture NTS (N.=13) were identified and compared. We comment on the body of current evidence and highlight the achievements and limitations of interventions published thus far. We then propose a novel education and training framework to further develop and enhance non-technical skills in both individual anesthesiologists and operating room teams. We use the cardiac anesthesiology environment as a starting point to illustrate its use, with clinical examples. NTS is a key component of enhancing patient safety. Effective framing of its concepts is central to apply individual characteristics and skills in team environments in the OR and achieve tangible, beneficial patient outcomes.

Crisis Scenarios for Simulation-Based Nontechnical Skills Training for Cardiac Surgery Teams: A National Survey Among Cardiac Anesthesiologists, Cardiac Surgeons, Clinical Perfusionists, and Cardiac Operating Room Nurses

BACKGROUND

Nontechnical skills in cardiac surgery are vital in ensuring patient safety in the operating room (OR). To train these skills in a simulation-based scenario, a collection of commonly accepted crisis scenarios is needed to serve as a framework for a simulation-based training program.

OBJECTIVE

The objective of this study was to identify and reach consensus on a collection of relevant crisis scenarios in cardiac surgery suitable for simulation-based team training focusing on nontechnical skills.

METHODS

Using the Delphi method, a national assessment was performed among cardiac surgeons, cardiac anesthesiologists, clinical perfusionists, and cardiac OR nurses in the Netherlands. In the first Delphi round, potential crisis scenarios for simulation-based team training in cardiac surgery were identified. In the second round, the identified scenarios were rated using a 5-point Likert scale. Finally, based on consensus (two-thirds majority), scenarios were prioritized and explored for feasibility.

RESULTS

One hundred fourteen experts participated in the study (26 cardiac anesthesiologists, 24 cardiac surgeons, 25 clinical perfusionists, and 39 OR nurses), representing all 16 cardiac surgical centers in the Netherlands. In the first round, 237 scenarios were identified. After eliminating duplicates and grouping similar scenarios, 44 scenarios were scored in round 2, which finally resulted in 13 relevant crisis scenarios with an expert consensus higher than 67%.

CONCLUSIONS

Thirteen crisis scenarios relevant to simulation-based team training were identified by an expert panel consisting of all members of the cardiac surgical team. Further research is needed to evaluate the educational value of the respective scenarios.

Team Dynamics in the Operating Room: How Is Team Performance Optimized?

Health care requires the effort of a team, and nowhere is this more evident than in the care of the surgical patient. No single clinician can perform all aspects of the continuum of surgical care. The basic operating room (OR) team consists of nurses, technicians, surgeons, and anesthesiologists with unique and well-defined roles and expertise in perioperative care. The modern OR team continues to grow and evolve in size, diversity, and complexity to meet the needs of growing patient and procedural complexity. This growing complexity makes achieving optimal team performance paramount and challenging.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Alone Together: Is Strain Experienced Concurrently by Members of Operating Room Teams?: An Event-based Study

Objective

To identify which strain episodes are concurrently reported by several team members; to identify triggers of strain experienced by operating room (OR) team members during the intraoperative phase.

Summary

OR teams are confronted with many sources of strain. However, most studies investigate strain on a general, rather than an event-based level, which does not allow to determine if strain episodes are experienced concurrently by different team members.

Methods

We conducted an event-based, observational study, at an academic medical center in North America and included 113 operations performed in 5 surgical departments (general, vascular, pediatric, gynecology, and trauma/acute care). Strain episodes were assessed with a guided-recall method. Immediately after operations, participants mentally recalled the operation, described the strain episodes experienced and their content.

Results

Based on 731 guided recalls, 461 strain episodes were reported; these refer to 312 unique strain episodes. Overall, 75% of strain episodes were experienced by a single team member only. Among different categories of unique strain episodes, those triggered by task complexity, issues with material, or others' behaviors were typically experienced by 1 team member only. However, acute patient issues (n = 167) and observations of others' strain (n = 12) (respectively, 58.5%; P < 0.001 and 83.3%; P < 0.001) were often experienced by 2 or more team members.

Conclusions and relevance

OR team members are likely to experience strain alone, unless patient safety is at stake. This may jeopardize the building of a shared understanding among OR team members.

Mastering the Best Practices: A Comprehensive Look at the European Guidelines for Cardiopulmonary Bypass in Adult Cardiac Surgery

The successful outcome of a cardiac surgery procedure is significantly dependent on the management of cardiopulmonary bypass (CPB). Even if a cardiac operation is technically well-conducted, a patient may suffer CPB-related complications that could result in severe comorbidities, reduced quality of life, or even death. However, the role of clinical perfusionists in perioperative patient care, which is critical, is often overlooked. Therefore, the European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Cardiothoracic Anaesthesiology (EACTA), and the European Board of Cardiovascular Perfusion (EBCP) have agreed to develop joint clinical practice guidelines (CPGs) for CPB due to its significant impact on patient care and significant variations in practice patterns between countries. The European guidelines, based on the EACTS standardized framework for the development of CPGs, cover the entire spectrum of CPB management in adult cardiac surgery. This includes training and education of clinical perfusionists, machine hardware, disposables, preparation for initiation of CPB, a complete set of procedures during CPB to help maintain end-organ function and anticoagulation, weaning from CPB, and the gaps in evidence and future research directions. This comprehensive coverage ensures that all aspects of CPB management are addressed, providing clinicians with a standardized approach to CPB management based on the latest evidence and best practices. To ensure better integration of these evidence-based recommendations into daily practice, this review aims to provide a general understanding of guideline development and an overview of essential treatment recommendations for CPB management.

A sensor-based framework for layout and workflow assessment in operating rooms

Due to their large sizes and impediments to personnel workflows, integrating robotic technologies into the existing operating rooms (OR) is a challenge. In this study, we developed an ultra-wideband sensor-based human-machine-environment framework for layout and workflow assessments within the OR. In addition to providing best practices for use of the framework, we also demonstrated its effectiveness in understanding layout and workflow inefficiencies in 12 robotic-assisted surgeries (RAS) across 4 different surgical specialties. We found avoidable movements as the circulating nurse covers at least twice the distance of any other OR personnel before the patient cart (robot) is docked. OR areas of congestion and undesirable personnel-pair proximities across RAS phases that impose extra non-technical skill challenges were determined. Our findings highlight several implications for the added complexity of integrating robotic technologies into the OR, which can serve as drivers for objective evidence-based recommendations to combat RAS OR layout and workflow inefficiencies.

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

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Implications of equipment failure occurring during surgery

INTRODUCTION

Few formal studies have been performed investigating the frequency of equipment failure during surgery. Surgeons are unable to operate without the plethora of instruments and equipment surrounding them in the operating theatre. As with any mechanical component, instruments and equipment are subject to time- and use-dependent degradation in their performance. Yet no formal requirements exist for the routine inspection or maintenance of instruments. Owing to this lack of information regarding equipment failure we undertook the first investigation of intraoperative equipment malfunction occurring during cardiac surgical procedures.

METHODS

Over a 12-month period cardiac surgeons were required to report equipment malfunction during each procedure. Operating theatre equipment was divided into three categories broadly based on equipment portability and function: group 1, theatre infrastructure and components; group 2, large medical equipment; and group 3, surgical instruments.

RESULTS

In a highly significant proportion of operations performed (92%) there was an issue with equipment. The most common issues occurred in group 3 with fine surgical instrument malfunctions; most commonly worn-out needle holders and blunt scissors. Theatre infrastructure and large medical equipment failures (groups 1 and 2) resulted in the cancellation of four cases. Some intraoperative instrument failures were potentially catastrophic.

CONCLUSIONS

The incidence of equipment failure during cardiac surgery is unacceptably high. In some instances, cases were cancelled and revenue lost owing to equipment malfunction. A balance between the safety and quality of equipment and cost effectiveness is required. These findings suggest that surgical instruments warrant an annual compulsory inspection.

Analyzing and Discussing Human Factors Affecting Surgical Patient Safety Using Innovative Technology: Creating a Safer Operating Culture

INTRODUCTION

Surgical errors often occur because of human factor-related issues. A medical data recorder (MDR) may be used to analyze human factors in the operating room. The aims of this study were to assess intraoperative safety threats and resilience support events by using an MDR and to identify frequently discussed safety and quality improvement issues during structured postoperative multidisciplinary debriefings using the MDR outcome report.

METHODS

In a cross-sectional study, 35 standard laparoscopic procedures were performed and recorded using the MDR. Outcome data were analyzed using the automated Systems Engineering Initiative for Patient Safety model. The video-assisted MDR outcome report reflects on safety threat and resilience support events (categories: person, tasks, tools and technology, psychical and external environment, and organization). Surgeries were debriefed by the entire team using this report. Qualitative data analysis was used to evaluate the debriefings.

RESULTS

A mean (SD) of 52.5 (15.0) relevant events were identified per surgery. Both resilience support and safety threat events were most often related to the interaction between persons (272 of 360 versus 279 of 400). During the debriefings, communication failures (also category person) were the main topic of discussion.

CONCLUSIONS

Patient safety threats identified by the MDR and discussed by the operating room team were most frequently related to communication, teamwork, and situational awareness. To create an even safer operating culture, educational and quality improvement initiatives should aim at training the entire operating team, as it contributes to a shared mental model of relevant safety issues.

Development of a management protocol for internal carotid artery injury during endoscopic surgery: a modified Delphi method and single-center multidisciplinary working group

BACKGROUND

Intra-operative internal carotid artery (ICA) injury during transnasal endoscopic surgery is a potentially catastrophic event. Such an injury is life-threatening in the immediate setting, with a reported peri-operative mortality rate of 10%. Nasal packing, muscle patches, direct vessel closure, and endovascular techniques have been described as useful strategies for managing ICA bleeds. The objective of this study was to develop a formalized management protocol for intra-operative ICA injury through engagement with a multi-disciplinary panel.

METHODS

A modified Delphi method including literature review, iterative rounds of stakeholder feedback, and expert panel discussions was used to develop a management protocol for ICA injury during transnasal endoscopic surgery. The 10-person multi-disciplinary panel included otolaryngologists, neurosurgeons, interventional neuroradiologists, anesthesiologists, and operating room nursing staff.

RESULTS

After three rounds of stakeholder engagement with the expert panel, consensus was reached on important elements to include within the protocol. The protocol was divided in three categories: Alert, Control, and Transfer. 'Alert' focusses on early communication with anesthesia and nursing staff. 'Control' focusses on techniques to expose the injury and obtain hemostasis or adequate tamponade. Lastly, 'Transfer' describes the process of contacting neuro-interventional radiology and safely transferring the patient. A one-page handout of the protocol was developed for placement in operating theatres.

CONCLUSION

Due to the life-threatening nature of ICA injury, it is imperative that endoscopic sinus and skull base surgeons are prepared to manage this complication. Using a modified Delphi method with a multidisciplinary expert panel, a protocol for management of intra-operative ICA injury was developed.

Considerations for a Holistic Model in Evaluating Medical Students for Cardiothoracic Surgical Residency

Program directors are tasked with selecting whom they think will be the best fit for residency and the next leaders of the field. While numerical metrics have played a vital role in this process, recent changes to student evaluation are reducing the availability of these metrics. This poses unique challenges for both applicants and program directors. Here we discuss how this will likely shift the focus on other parts of the application and the consequences (good and bad) of doing so.

Adherence to the cardiac surgery checklist decreased mortality at a teaching hospital: A retrospective cohort study

OBJECTIVE

To evaluate the impact of adherence to the cardiac surgical checklist on mortality at the teaching hospital.

METHODS

A retrospective cohort study after the implementation of the cardiac surgical safety checklist in a reference hospital in Latin America. All patients undergoing coronary artery bypass surgery and/or heart valve surgery from 2013 to 2019 were analyzed. After the implementation of the project InCor-Checklist "Five steps to safe cardiac surgery" in 2015, the correlation between adherence and completeness of this instrument with surgical mortality was assessed. The EuroSCORE II was used as a reference to assess the risk of expected mortality for patients. Cross-sectional questionnaires were during the implementation of the InCor-Checklist. To perform the correlation, Pearson's coefficient was calculated using R software.

RESULTS

Since 2013, data from 8139 patients have been analyzed. The average annual mortality was 5.98%. In 2015, the instrument was used in only 58% of patients; in contrast, it was used in 100% of patients in 2019. There was a decrease in surgical mortality from 8.22% to 3.13% for the same group of procedures. The results indicate that the greater the checklist use, the lower the surgical mortality (r = 88.9%). In addition, the greater the InCor-Checklist completeness, the lower the surgical mortality (r = 94.1%).

CONCLUSION

In the formation of the surgical patient safety culture, the implementation and adherence to the InCor-Checklist "Five steps to safe cardiac surgery" was associated with decreased mortality after cardiac surgery.

Artificial Intelligence for Surgical Safety: Automatic Assessment of the Critical View of Safety in Laparoscopic Cholecystectomy Using Deep Learning

OBJECTIVE

To develop a deep learning model to automatically segment hepatocystic anatomy and assess the criteria defining the critical view of safety (CVS) in laparoscopic cholecystectomy (LC).

BACKGROUND

Poor implementation and subjective interpretation of CVS contributes to the stable rates of bile duct injuries in LC. As CVS is assessed visually, this task can be automated by using computer vision, an area of artificial intelligence aimed at interpreting images.

METHODS

Still images from LC videos were annotated with CVS criteria and hepatocystic anatomy segmentation. A deep neural network comprising a segmentation model to highlight hepatocystic anatomy and a classification model to predict CVS criteria achievement was trained and tested using 5-fold cross validation. Intersection over union, average precision, and balanced accuracy were computed to evaluate the model performance versus the annotated ground truth.

RESULTS

A total of 2854 images from 201 LC videos were annotated and 402 images were further segmented. Mean intersection over union for segmentation was 66.6%. The model assessed the achievement of CVS criteria with a mean average precision and balanced accuracy of 71.9% and 71.4%, respectively.

CONCLUSIONS

Deep learning algorithms can be trained to reliably segment hepatocystic anatomy and assess CVS criteria in still laparoscopic images. Surgical-technical partnerships should be encouraged to develop and evaluate deep learning models to improve surgical safety.

Safety gaps in medical team communication: Closing the loop on quality improvement efforts in the cardiac catheterization lab

Closed-loop communication (CLC) is a fundamental aspect of effective communication, critical in the cardiac catheterization laboratory (cath lab) where physician orders are verbal. Complete CLC is typically a hospital and national mandate. Deficiencies in CLC have been shown to impair quality of care. Single center observational study, CLC for physician verbal orders in the cath lab were assessed by direct observation during a 5-year quality improvement effort. Performance feedback and educational efforts were used over this time frame to improve CLC, and the effects of each intervention assessed. Responses to verbal orders were characterized as complete (all important parameters of the order repeated, the mandated response), partial, acknowledgment only, or no response. During the first observational period of 101 cases, complete CLC occurred in 195 of 515 (38%) medication orders and 136 of 235 (50%) equipment orders. Complete CLC improved over time with various educational efforts, (p < 0.001) but in the final observation period of 117 cases, complete CLC occurred in just 259 of 328 (79%) medication orders and 439 of 581 (76%) equipment orders. Incomplete CLC was associated with medication and equipment errors. CLC of physician verbal orders was used suboptimally in this medical team setting. Baseline data indicate that physicians and staff have normalized weak, unreliable communication methods. Such lapses were associated with errors in order implementation. A subsequent 5-year quality improvement program resulted in improvement but a sizable minority of unacceptable responses. This represents an opportunity to improve patient safety in cath labs.

Physicians' perspectives and attitudes toward surgical bailout in transcatheter aortic valve replacement

OBJECTIVES

The incidence of surgical bailout during transcatheter aortic valve replacement (TAVR) is ∼1%, with an associated 50% in-hospital mortality. We performed an exploratory qualitative study of TAVR team perceptions regarding routine surgical bailout planning with patients.

METHODS

We developed a semistructed interview guide to explore clinician perspectives on the TAVR consent process, managing intraoperative emergencies, and involving patients in surgical contingency planning. We interviewed surgeons, cardiologists, and anesthesiologists involved with TAVR in 4 hospitals. We performed qualitative thematic analysis via independent coding of salient quotations from the transcribed texts. Codes were categorized based on shared meaning and the final themes were derived by identifying key content, and examining its relational nature.

RESULTS

Thirteen interviews were conducted, identifying 4 major themes. Participants agreed that eliciting patient preference for bailout is crucial, particularly when surgical outcome is ambiguous. In those cases, participants offered criteria for determining which patients should be engaged in a more nuanced discussion. The ethos of specialty clinicians impacted anticipation and response to procedural emergencies. Finally, physician attitudes reflected strong emotional responses to patient death/morbidity, particularly in iatrogenic injury. Participants expressed anxiety with performing TAVR without surgical backup, while also demonstrating willingness to respect patients' wishes.

CONCLUSIONS

The TAVR team supports engaging patients regarding potential surgical bailout and honoring their preferences in the event of complication. However, clinical judgment about the expected outcome of bailout would frame that discussion. Participants described the emotional weight of not pursuing bailout if indicated and the importance of good coping mechanisms.

Professionalism of Admitting and Consulting Services and Trauma Patient Outcomes

OBJECTIVE

To determine whether trauma patients managed by an admitting or consulting service with a high proportion of physicians exhibiting patterns of unprofessional behaviors are at greater risk of complications or death.

SUMMARY BACKGROUND DATA

Trauma care requires high-functioning interdisciplinary teams where professionalism, particularly modeling respect and communicating effectively, is essential.

METHODS

This retrospective cohort study used data from nine level I trauma centers that participated in a national trauma registry linked with data from a national database of unsolicited patient complaints. The cohort included trauma patients admitted January 1, 2012 through December 31, 2017. The exposure of interest was care by one or more high-risk services, defined as teams with a greater proportion of physicians with high numbers of patient complaints. The study outcome was death or complications within 30 days.

RESULTS

Among the 71,046 patients in the cohort, 9,553 (13.4%) experienced the primary outcome of complications or death, including 1,875 of 16,107 patients (11.6%) with 0 high-risk services, 3,788 of 28,085 patients (13.5%) with one high-risk service, and 3,890 of 26,854 patients (14.5%) with 2+ high-risk services (p < .001). In logistic regression models adjusting for relevant patient, injury, and site characteristics, patients who received care from one or more high-risk services were at 24.1% (95% CI 17.2% to 31.3%; P < 0.001) greater risk of experiencing the primary study outcome.

CONCLUSIONS

Trauma patients who received care from at least one service with a high proportion of physicians modeling unprofessional behavior were at an increased risk of death or complications.

Communication and Teamwork During Telemedicine-Enabled Stroke Care in an Ambulance

OBJECTIVE

The purpose of this study is to understand the communication among care teams during telemedicine-enabled stroke consults in an ambulance.

BACKGROUND

Telemedicine can have a significant impact on acute stroke care by enabling timely intervention in an ambulance before a patient reaches the hospital. However, limited research has been conducted on understanding and supporting team communication during the care delivery process for telemedicine-enabled stroke care in an ambulance.

METHOD

Video recordings of 13 simulated stroke telemedicine consults conducted in an ambulance were coded to document the tasks, communication events, and flow disruptions during the telemedicine-enabled stroke care delivery process.

RESULTS

The majority (82%) of all team interactions in telemedicine-enabled stroke care involved verbal interactions among team members. The neurologist, patient, and paramedic were almost equally involved in team interactions during stroke care, though the neurologist initiated 48% of all verbal interactions. Disruptions were observed in 8% of interactions, and communication-related issues contributed to 44%, with interruptions and environmental hazards being other reasons for disruptions in interactions during telemedicine-enabled stroke care.

CONCLUSION

Successful telemedicine-enabled stroke care involves supporting both verbal and nonverbal communication among all team members using video and audio systems to provide effective coverage of the patient for the clinicians as well as vice versa.

APPLICATION

This study provides a deeper understanding of team interactions during telemedicine-enabled stroke care that is essential for designing effective systems to support teamwork.

Improving teamwork and communication in the operating room by introducing the theatre cap challenge

Objective

One of the steps of the Surgical Safety Checklist is for the team members to introduce themselves. The objective of this study was to implement a tool to help remember and use each other’s names and roles in the operating theatre.

Methods

This study was part of a pilot study in which a video and medical data recorder was implemented in one operating theatre and used as a tool for postoperative multidisciplinary debriefings. During these debriefings, name recall was evaluated. Following the implementation of the medical data recorder, this study was started by introducing the theatre cap challenge, meaning the use of name (including role) stickers on the surgical cap in the operating theatre.

Findings

In total, 41% (n = 40 out of 98) of the operating theatre members were able to recall all the names of their team at the team briefings. On average 44.8% (n = 103) was wearing the name sticker.

Conclusions

The time-out stage of the Surgical Safety Checklist might be inadequate for correctly remembering and using your operating theatre team members’ names. For this, the theatre cap challenge may help.