Deep Learning Analysis of Surgical Video Recordings to Assess Nontechnical Skills

Importance

Assessing nontechnical skills in operating rooms (ORs) is crucial for enhancing surgical performance and patient safety. However, automated and real-time evaluation of these skills remains challenging.

Objective

To explore the feasibility of using motion features extracted from surgical video recordings to automatically assess nontechnical skills during cardiac surgical procedures.

Design, Setting, and Participants

This cross-sectional study used video recordings of cardiac surgical procedures at a tertiary academic US hospital collected from January 2021 through May 2022. The OpenPose library was used to analyze videos to extract body pose estimations of team members and compute various team motion features. The Non-Technical Skills for Surgeons (NOTSS) assessment tool was employed for rating the OR team's nontechnical skills by 3 expert raters.

Main Outcomes and Measures

NOTSS overall score, with motion features extracted from surgical videos as measures.

Results

A total of 30 complete cardiac surgery procedures were included: 26 (86.6%) were on-pump coronary artery bypass graft procedures and 4 (13.4%) were aortic valve replacement or repair procedures. All patients were male, and the mean (SD) age was 72 (6.3) years. All surgical teams were composed of 4 key roles (attending surgeon, attending anesthesiologist, primary perfusionist, and scrub nurse) with additional supporting roles. NOTSS scores correlated significantly with trajectory (r = 0.51, P = .005), acceleration (r = 0.48, P = .008), and entropy (r = -0.52, P = .004) of team displacement. Multiple linear regression, adjusted for patient factors, showed average team trajectory (adjusted R2 = 0.335; coefficient, 10.51 [95% CI, 8.81-12.21]; P = .004) and team displacement entropy (adjusted R2 = 0.304; coefficient, -12.64 [95% CI, -20.54 to -4.74]; P = .003) were associated with NOTSS scores.

Conclusions and Relevance

This study suggests a significant link between OR team movements and nontechnical skills ratings by NOTSS during cardiac surgical procedures, suggesting automated surgical video analysis could enhance nontechnical skills assessment. Further investigation across different hospitals and specialties is necessary to validate these findings.

Healthcare Professionals' Perceptions of Function-Focused Care Education for Nursing Home Practitioners

A nursing home (NH) care environment necessitates a shared cognition-based education model that maintains effective function-focused care (FFC). This study’s aim was to explore healthcare professionals’ perceptions of function-focused care education for the development of an education model using a shared mental model (SMM) in NHs. Semi-structured interviews with 30 interdisciplinary practitioners from four different professions (nurses, physical therapists, occupational therapists, and social workers) and focus group interviews with 12 experts were conducted. Data were analyzed using content analysis, and the education model development was guided by the shared mental models for data interpretation and formation. Our FFC interdisciplinary educational model incorporates four key learning components: learning contents, educational activities, educational goals/outcome, and environment, and four types of SMMs: team, task, team interaction, and equipment. As for educational contents, a team’s competencies with FFC were found to be team knowledge (physical and psychosocial functional care), team skills to perform FFC successfully (motivation, coaching and supporting, managing discomfort), and team attitude (possessing philosophy perceptions regarding FFC). As for learning outcomes, the shared cognition-based education model suggests not only the evaluation of practitioners, but also the assessment of residents’ aspects.

Medication review and reconciliation in older adults

Older people are frequently exposed to polypharmacy, inappropriate prescribing, and adverse drug events. Two clinical processes can help geriatricians to optimize and increase the safety of drug prescriptions for older adults: medication reconciliation and medication review. Medication reconciliation provides the best possible medication history and identifies and resolves discrepancies in drug prescriptions. During the medication review, the best possible medication history is crosschecked against other data, including morbidities, patient's preferences, or geriatric syndromes, to produce a personalized medication strategy. Alignment of treatment recommendations with patient preferences and goals through shared decision-making is particularly important in medication review. Medication reconciliation and medication review have proven to be effective, but their broad implementation remains difficult. Indeed, these procedures are time-consuming and require specific skills, coordination between different healthcare professionals, organizations and dedicated means. The involvement of geriatricians therefore remains essential for the successful implementation of medication reconciliation and medication review in geriatric settings and among frail older people.

Optimizing the robotic surgery team: an operations management perspective

INTRODUCTION AND HYPOTHESIS

To assess the critical threshold to optimize operating room (OR) time for each surgical team member in robotically assisted sacrocolpopexy (RASCP) and to evaluate the most efficient team compositions.

METHODS

All women who underwent RASCP for pelvic organ prolapse (POP) were prospectively entered in a database. Patients having unrelated concomitant surgery were excluded. Our primary outcome measure was total OR time. We utilized factor analysis, regression analysis, and analysis of variance, OR time mapping, and stochastic optimization to identify 'optimal' surgical team configuration.

RESULTS

The database included 359 consecutive RASCPs, all performed for stage III-IV POP: 156 (43%) were with total and 44 (12%) supracervical hysterectomies and 159 (44%) post-hysterectomy. Mean age was 58.6 ± 9.3 years. Mean parity was 2.8 ± 1.4, and mean body mass index was 28 ± 4.7 kg/m². A total of 4 surgeons, 34 first assistants, 20 circulating nurses, 15 surgical technologists, and 59 anesthesiologist/nurse anesthetists were involved. Optimal experience levels for each team member were achieved at the following number of robotic procedures: surgeon 44; first assistant 13; surgical technologist 66; circulating nurse 56; anesthesia provider 46. Our analysis revealed that the surgical technologist and first assistant played the most significant roles within the team. The surgeon was ranked third followed by the circulating nurse and anesthesia provider, respectively.

CONCLUSION

Operating time in robotic surgery is multifactorial. Experience of each member of a robotic surgery team is critical. An optimal team can be composed of a variety of combinations of experience levels among the robotic team members.

SEIPS 3.0: Human-centered design of the patient journey for patient safety

The Systems Engineering Initiative for Patient Safety (SEIPS) and SEIPS 2.0 models provide a framework for integrating Human Factors and Ergonomics (HFE) in health care quality and patient safety improvement. As care becomes increasingly distributed over space and time, the "process" component of the SEIPS model needs to evolve and represent this additional complexity. In this paper, we review different ways that the process component of the SEIPS models have been described and applied. We then propose the SEIPS 3.0 model, which expands the process component, using the concept of the patient journey to describe the spatio-temporal distribution of patients' interactions with multiple care settings over time. This new SEIPS 3.0 sociotechnical systems approach to the patient journey and patient safety poses several conceptual and methodological challenges to HFE researchers and professionals, including the need to consider multiple perspectives, issues with genuine participation, and HFE work at the boundaries.

Clarifying workforce flexibility from a division of labor perspective: a mixed methods study of an emergency department team

BACKGROUND

The need for greater flexibility is often used to justify reforms that redistribute tasks through the workforce. However, "flexibility" is never defined or empirically examined. This study explores the nature of flexibility in a team of emergency doctors, nurse practitioners (NPs), and registered nurses (RNs), with the aim of clarifying the concept of workforce flexibility. Taking a holistic perspective on the team's division of labor, it measures task distribution to establish the extent of multiskilling and role overlap, and explores the behaviors and organizational conditions that drive flexibly.

METHODS

The explanatory sequential mixed methods study was set in the Fast Track area of a metropolitan emergency department (ED) in Sydney, Australia. In phase 1, an observational time study measured the tasks undertaken by each role (151 h), compared as a proportion of time (Kruskal Wallis, Mann-Whitney U), and frequency (Pearson chi-square). The time study was augmented with qualitative field notes. In phase 2, 19 semi-structured interviews sought to explain the phase 1 observations and were analyzed thematically.

RESULTS

The roles were occupationally specialized: "Assessment and Diagnosis" tasks consumed the largest proportion of doctors' (51.1%) and NPs' (38.1%) time, and "Organization of Care" tasks for RNs (27.6%). However, all three roles were also multiskilled, which created an overlap in the tasks they performed. The team used this role overlap to work flexibly in response to patients' needs and adapt to changing demands. Flexibility was driven by the urgent and unpredictable workload in the ED and enabled by the stability provided by a core group of experienced doctors and nurses.

CONCLUSION

Not every healthcare team requires the type of flexibility found in this study since that was shaped by patient needs and the specific organizational conditions of the ED. The roles, tasks, and teamwork that a team requires to "be flexible" (i.e., responsive and adaptable) are highly context dependent. Workforce flexibility therefore cannot be defined as a particular type of reform or role; rather, it should be understood as the capacity of a team to respond and adapt to patients' needs within its organizational context. The study's findings suggest that solutions for a more flexible workforce may lay in the organization of healthcare work.

An ontology-driven framework to support the dynamic formation of an interdisciplinary healthcare team

BACKGROUND AND PURPOSE

Teamwork has become a modus operandi in healthcare and delivery of patient care by an interdisciplinary healthcare team (IHT) is now a prevailing modality of care. We argue that a formal and automated support framework is needed for an IHT to properly leverage information technology resources. Such a framework should allow for patient preferences and expand a representation of a clinical workflow with a formal model of dynamic formation of a team, especially with regards to team leader- and membership, and the assignment of tasks to team members. Our goal was to develop such a support framework, present its prototype software implementation and verify the implementation using a proof-of-concept use case. Specifically, we focused on clinical workflows for in-patient tertiary care and on patient preferences with regards to selecting team members and team leaders.

MATERIALS AND METHODS

Drawing on the research on clinical teamwork we defined the conceptual foundations for the proposed framework. Then, we designed its architecture and used ontology-driven design and first-order logic with associated reasoning methods to create and operationalize architectural elements. Finally, we incorporated existing solutions for business workflow modeling and execution as a backend for implementing the proposed framework.

RESULTS

We developed a Team and Workflow Management Framework (TWMF) with semantic components that allow for formalizing and operationalizing team formation in in-patient tertiary care setting and support provider-related patient preferences. We also created a prototype software implementation of TWMF using the IBM Business Process Manager platform. This implementation was evaluated in several simulated patient scenarios.

CONCLUSIONS

TWMF integrates existing workflow technologies and extends them with the capabilities to support dynamic formation of an IHT. Results of this research can be used to support real-time execution of clinical workflows, or to simulate their execution in order to assess the impact of various conditions (e.g., patterns of work shifts, staffing) on IHT operations.

Surgical team workload comparison for 4-port and single-port laparoscopic cholecystectomy procedures

Advanced minimally invasive procedures may cause postural constraints and increased workload and stress for providers. This study compared workload and stress across surgical team roles for 48 laparoscopic cholecystectomies (4-port vs single-port) using a task load index (NASA-TLX), a procedural difficulty question, and salivary stress hormones. Statistical analyses were performed based on the presence intra-cluster correlation within team roles, at α=0.05. The single-port technique resulted in an 89% increase in physical workload for the surgeon and 63% increase for the assistant (both p<0.05). The surgeon had significantly higher salivary stress hormones during single-port surgeries. The degree of procedural difficulty was positively correlated between the surgeon and most roles: resident (r=0.67), assistant (r=0.81), and technician (r=0.81). There was a statistically significant positive correlation between the surgeon and assistant for all selfreported workload measures (p<0.05). The single-port technique requires further improvement to balance surgical team workload for optimal patient safety and satisfaction.

Test results management and distributed cognition in electronic health record-enabled primary care

Managing abnormal test results in primary care involves coordination across various settings. This study identifies how primary care teams manage test results in a large, computerized healthcare system in order to inform health information technology requirements for test results management and other distributed healthcare services. At five US Veterans Health Administration facilities, we interviewed 37 primary care team members, including 16 primary care providers, 12 registered nurses, and 9 licensed practical nurses. We performed content analysis using a distributed cognition approach, identifying patterns of information transmission across people and artifacts (e.g. electronic health records). Results illustrate challenges (e.g. information overload) as well as strategies used to overcome challenges. Various communication paths were used. Some team members served as intermediaries, processing information before relaying it. Artifacts were used as memory aids. Health information technology should address the risks of distributed work by supporting awareness of team and task status for reliable management of results.

Enhancing teamwork using a creativity-focussed learning intervention for undergraduate nursing students - A pilot study

A cohort of year two students (n = 181) was exposed to a transformational and experiential learning intervention in the form of team-led poster development workshops to enhance competence and interpersonal skills for working in teams. The aims of this study were to test the suitability of an amended TeamSTEPPS teamwork perceptions questionnaire (T-TPQ) for measuring the impact of the intervention on students' perceptions of team working, and to ascertain students' views about the experience. This was a two phase pilot study. Phase 1 was a repeated measures design to test the T-TPQ for evaluating the impact of the experiential intervention, and Phase 2 was a survey of students' views and opinions. Descriptive and statistical analysis of the data were performed. Our findings suggest that age and part-time employment mediate towards more positive teamwork perceptions. Teamwork perceptions increased from week 3 to week 9 of the experiential intervention, and students viewed the experience positively. This was the first time that the T-TPQ was tested for suitability for measuring the impact of an experiential learning intervention among nursing students. Despite limitations, our study indicates that the amended T-TPQ is sensitive to changes in teamwork perceptions in repeated measures design studies among nursing students.

"Do you see what I mean?" staff collaboration in eating disorder units during mealtimes

Background

Eating disorders are psychiatric illnesses with potentially life-threatening consequences. Inpatient treatment is typically required for the most severely ill patients, who are often emaciated or significantly malnourished. A core therapeutic objective is to normalize eating patterns and facilitate weight gain. These goals guide the efforts of milieu therapeutic staff working with this patient group, who support renourishment through the positive manipulation of a structured environment, as well via relational aspects. However, there is a lack of empirical research exploring inpatient staff members’ perspectives concerning various aspects of this work. This article explore staff’s teamwork during mealtimes on inpatient eating disorder units. Specifically, we investigated the collaborative strategies employed to support core therapeutic goals of meal completion and normalized eating behavior, while concurrently maintaining a supportive, friendly atmosphere during mealtimes.

Methods

This was a exploratory qualitative study. Data was collected through 20 semi-structured in-depth interviews with staff members working on a specialized eating disorder unit. The interviews were performed after the conduction of meal time support. Cultural historical activity theory was used as the key theoretical tool for analysis.

Results

The analysis revealed three main themes: 1) strategic seating arrangements mediates division of labor, 2) the use of verbal and nonverbal communication as collaborative tools, and 3) the importance of experience as a collaborative resource.

Conclusions

The present study found that mealtime collaborative strategies on inpatient EDUs were mainly of non-verbal nature, with level of experience as an important premise for staff collaboration. Greater awareness about how collegial collaboration is practiced may help staff members to learn routines and regulate scripts for mealtime practices.

Noise peaks influence communication in the operating room. An observational study

Noise peaks are powerful distractors. This study focuses on the impact of noise peaks on surgical teams' communication during 109 long abdominal surgeries. We related measured noise peaks during 5-min intervals to the amount of observed communication during the same interval. Results show that noise peaks are associated with less case-relevant communication; this effect is moderated by the level of surgical experience; case-relevant communications decrease under high noise peak conditions among junior, but not among senior surgeons. However, case-irrelevant communication did not decrease under high noise level conditions, rather there was a trend to more case-irrelevant communication under high noise peaks. The results support the hypothesis that noise peaks impair communication because they draw on attentional resources rather than impairing understanding of communication. As case-relevant communication is important for surgical performance, exposure to high noise peaks in the OR should be minimised especially for less experienced surgeons. Practitioner Summary: This study investigated whether noise during surgeries influenced the communication within surgical teams. During abdominal surgeries, noise levels were measured and communication was observed. Results showed that high noise peaks reduced the frequency of patient-related communication, but did not reduce patient-irrelevant communication. Noise may negatively affect team coordination in surgeries.

Multimodal team interactions in Robot-Assisted Surgery

Communication gaps have been systematically linked to failures during surgery; however few studies have addressed challenges related to the remoteness of the surgeon during robot-assisted surgery (RAS). While studies on team communication in the Operating Room (OR) rarely report on nonverbal aspects, our initial work has shown that the vast majority of interaction events between the console surgeon and the right bed side assistant is nonverbal. This study focuses on improving our understanding of the nature of the multimodal interactions between surgeons and right bed side assistants. Six robot-assisted radical prostatectomies were recorded and the interaction events between the surgeon and the right bed side assistant were categorized by type (verbal/nonverbal), topic, and sender. The proportion of verbal and nonverbal events varied with the topic of the interaction. Strategies to improve team communication during surgery should take into account both the use of nonverbal communication means and the change in communication strategies based on purpose.

Differential impact of student behaviours on group interaction and collaborative learning: medical students' and tutors' perspectives

BACKGROUND

Collaboration is of increasing importance in medical education and medical practice. Students' and tutors' perceptions about small group learning are valuable to inform the development of strategies to promote group dynamics and collaborative learning. This study investigated medical students' and tutors' views on competencies and behaviours which promote effective learning and interaction in small group settings.

METHODS

This study was conducted at UNSW Australia. Five focus group discussions were conducted with first and second year medical students and eight small group tutors were interviewed. Data were transcribed verbatim and thematic analysis was conducted.

RESULTS

Students and tutors identified a range of behaviours that influenced collaborative learning. The main themes that emerged included: respectfulness; dominance, strong opinions and openness; constructiveness of feedback; active listening and contribution; goal orientation; acceptance of roles and responsibilities; engagement and enthusiasm; preparedness; self- awareness and positive personal attributes. An important finding was that some of these student behaviours were found to have a differential impact on group interaction compared with collaborative learning. This information could be used to promote higher quality learning in small groups.

CONCLUSION

This study has identified medical students' and tutors' perceptions regarding interactional behaviours in small groups, as well as behaviours which lead to more effective learning in those settings. This information could be used to promote learning in small groups.

Robotic surgery and its impact on teamwork in the operating theatre

Effective teamwork in the operating theatre is important for safe patient care. In robotic surgery, the surgeon is physically separated from the operating theatre team, which could potentially have an impact on teamwork. With robotic surgery increasing internationally, this article reviews relevant published literature on teamwork in the operating theatre and reflects on how this might be impacted by robotic surgery. We conclude by describing a research study we are currently undertaking on this topic.

Knowledge integration, teamwork and performance in health care

Purpose

– Knowledge integration is the process of building shared mental models. The integration of the diverse knowledge of the health professions in shared mental models is a precondition for effective teamwork and team performance. As it is known that different groups of health care professionals often tend to work in isolation, the authors compared the perceptions of knowledge integration. It can be expected that based on this isolation, knowledge integration is assessed differently. The purpose of this paper is to test these differences in the perception of knowledge integration between the professional groups and to identify to what extent knowledge integration predicts perceptions of teamwork and team performance and to determine if teamwork has a mediating effect.

Design/methodology/approach

– The study is a multi-center cross-sectional study with a descriptive-explorative design. Data were collected by means of a staff questionnaire for all health care professionals working in the rehabilitation clinics.

Findings

– The results showed that there are significant differences in knowledge integration within interprofessional health care teams. Furthermore, it could be shown that knowledge integration is significantly related to patient-centered teamwork as well as to team performance. Mediation analysis revealed partial mediation of the effect of knowledge integration on team performance through teamwork.

Practical/implications

– In practice, the results of the study provide a valuable starting point for team development interventions.

Originality/value

– This is the first study that explored knowledge integration in medical rehabilitation teams and its relation to patient-centered teamwork and team performance.