Association Between Familiarity of the Surgeon-Anesthesiologist Dyad and Postoperative Patient Outcomes for Complex Gastrointestinal Cancer Surgery

Safety amid the scalpels: creating psychological safety in the operating room

PURPOSE OF REVIEW

We briefly review the concept of psychological safety and discuss the actions that can create it in the anesthesiologist's work environment.

RECENT FINDINGS

The interest in psychological safety has grown in popularity since the publication of Amy Edmondson's book The Fearless Organization in 2018. While the concept and its benefits are described in the healthcare literature, the specific actions necessary to create it are often not.

SUMMARY

To ensure patient safety, we want members of the teams we lead to be comfortable sharing emerging problems that they see before we become aware of them. As educators, we want trainees to approach us when they do not understand something and openly participate and contribute without the fear of how others will perceive them. These scenarios require an environment of psychological safety - the ability to ask for help, admit mistakes, and be respectfully forthright with unpopular beliefs without the fear of being ostracized or ignored. Methods for creating an environment of psychological safety will be discussed.

Triphasic Learning Curve of Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is an effective but costly procedure for select patients with peritoneal malignancies. The impact of progression along a learning curve on the cost of these procedures is unknown.

PATIENTS AND METHODS

We performed a retrospective cohort study of patients undergoing CRS-HIPEC from 2016 to 2022 at a single quaternary center. Our study cohort was temporally divided into four equally sized volume quartiles (A, B, C, and D). We utilized cumulative sum plots and split-group analysis to characterize the institutional learning curve based on cost, operative time, length of stay, and morbidity. Multivariable linear regression was performed to estimate costs after adjusting for covariates. Bivariate analysis was performed using a Kruskal-Wallis test to compare continuous variables and a χ2 test to compare categorical variables.

RESULTS

Of 201 patients, the median age [interquartile range (IQR)] was 57 (47-65) years, 113 (56%) patients were female, 143 (71%) were white, and 107 (53%) had private insurance. Median operating room charge [US$42,639 (US$32,477-54,872), p < 0.001] varied between volume quartiles, peaking in quartile C. Stabilization was achieved for 86 cases for operating room cost, 88 cases for routine cost, 96 cases for length of stay, 103 cases for operative time, 120 cases for intensive care unit length of stay, and 150 cases for overall and serious morbidity. The actual operating room and routine costs were similar to predicted costs at the end of the study period.

CONCLUSIONS

The CRS-HIPEC learning curve is triphasic, with cost stability achieved relatively early compared with other markers of surgical proficiency.

The Operating and Anesthetic Reference Assistant (OARA): A fine-tuned large language model for resident teaching

OBJECTIVE

This study aimed to fine-tune a large language model (LLM) for domain-specific text generation in surgical and anesthesia residency education.

SUMMARY BACKGROUND DATA

With growing interest in artificial intelligence (AI) for medical training, the potential of LLMs to transform residency education is explored.

METHODS

The 7-billion parameter base model "Vicuna v1.5" was trained on 266,342 lines of text from 821 peer-reviewed documents. We evaluated the model with 150 surgical or anesthesia queries and assessed accuracy, token count, and inference speed across various reasoning tasks. Tests of significance were conducted using ANOVA and chi-square analysis.

RESULTS

Our model achieved 65.3% accuracy, excelling in surgical case-based tasks. We found no significant difference in accuracy between knowledge domains (P=0.081), though longer response generation demonstrated poorer accuracy, with significant accuracy variation based on output length (P ​= ​0.002).

CONCLUSIONS

LLMs show potential in enhancing residency education. Our model's efficiency and task-specific accuracy highlights such promise, though limits in parameter count diminishes accuracy of longer response generation. Our findings showcase how AI may be integrated effectively within future residency training.

Ambulance professionals' experiences of teamwork in the context of a team training programme - a qualitative study

BACKGROUND

Teamwork in the context of ambulance services exhibits unique characteristics, as this environment involves a small core team that must adapt to a dynamic team structure that involves health care professionals and emergency services. It is essential to acquire a deeper understanding of how ambulance teams operate. Therefore, this study aimed to explore the experiences of ambulance professionals with teamwork and how they were influenced by the implementation of a team training programme.

METHODS

A qualitative descriptive study was conducted involving ambulance professionals who took part in focus group interviews carried out both before and after the implementation of a team training program across seven ambulance stations within a Norwegian hospital trust. The data were analysed using reflexive thematic analysis based on a deductive-inductive approach.

RESULTS

Our analysis revealed 15 subthemes that characterised ambulance professionals' experiences with teamwork and a team training programme, which were organised according to the five main themes of team structure, communication, leadership, situation monitoring, and mutual support. Ambulance professionals' experiences ranged from the significance of team composition and interpersonal and professional relationships to their preferences regarding different communication styles and the necessity of team leaders within the ambulance service. The team training programme raised awareness of teamwork, while the adoption of teamwork tools was influenced by both individual and contextual factors. The Introduction/Identity, Situation, Background, Assessment and Recommendation (ISBAR) communication tool was identified as the most beneficial aspect of the programme due to its ease of use, which led to improvements in the structure and quality of consultations and information handover.

CONCLUSIONS

This study documented the diverse characteristics and preferences associated with teamwork among ambulance professionals, emphasising the particular importance of proficient partnerships in this context. Participation in a team training programme was perceived as a valuable reminder of the significance of teamwork, thus providing a foundation for the enhancement of communication skills.

TRIAL REGISTRATION

ClinicalTrials.gov-ID: NCT05244928.

The Impact of Neuroanesthesia Fellowship Training and Anesthesiologist-Surgeon Dyad Volume on Patient Outcomes in Adult Spine Surgery: A Population-Based Study

INTRODUCTION

Extensive research has explored the impact of surgeons' characteristics on patient outcomes; however, the influence of anesthesiologists remains understudied. We performed a population-based retrospective cohort study to investigate the impact of anesthesiologists' characteristics on in-hospital morbidity after spine surgery.

METHODS

Adult patients who underwent spine surgery at the London Health Science Centre, Ontario, Canada between January 1, 2010 and June 30, 2023 were included in this study. Data was extracted from the local administrative database. Five anesthesiologists' characteristics (neuroanesthesia fellowship and residency training backgrounds, surgeon familiarity, annual case volume, and sex) were examined as primary exposures. The primary outcome was composite in-hospital morbidity, encompassing 141 complications. Multivariable logistic regression was performed to assess the association between anesthesiologists' characteristics and postoperative morbidity with adjustment of patients' sex, Charlson Comorbidities Index, surgical complexity, and surgeon characteristics.

RESULTS

A total of 7692 spine surgeries were included in the analysis. Being a neuroanesthesia fellowship-trained anesthesiologist and high anesthesiologist-surgeon annual dyad volume were associated with reduction in in-hospital comorbidity; adjusted odds ratio (95% CI) of 0.58 (0.49-0.69; P<0.001) and 0.93 (0.91-0.95; P<0.001), respectively. Conversely, anesthesiologist annual case volume, characteristics of residency training and anesthesiologist sex showed only nuanced associations with outcomes.

CONCLUSIONS

Neuroanesthesia fellowship training and high surgeon-anesthesiologist dyad familiarity was associated with a reduction in in-hospital morbidity following spine surgery. These findings underscore the superiority of structured fellowship education over case exposure experience alone, advocate for dedicated neuroanesthesia teams with high surgeon-anesthesiologist dyad volume and recognize neuroanesthesia as a crucial subspecialty in spine surgery.

Optimising operating theatre (OT) efficiency while maintaining the standardised patient care in adolescent idiopathic scoliosis (AIS) surgery with the dedicated spine team approach: a specialised spine unit experience

PURPOSE

To report the efficiency of OT utilisation and perioperative outcomes with a dedicated spine team approach in AIS patients who underwent posterior spinal fusion (PSF) surgeries in a consecutive case operation list.

METHODS

Three AIS patients operated in a day (8:00 AM-8:00 PM) by a dedicated spine team were recruited between 2021 and 2022. The dedicated team comprised of three senior spine consultants who operated using a dual attending surgeon strategy, an anaesthetic consultant, dedicated surgical scrub nurses, anaesthesiology nurses, radiographers, and neuromonitoring technicians. Patients were categorised according to the sequence of operation list of the day (Case 1, Case 2, and Case 3). OT efficiency was represented by OT time in five stages (preoperative time, operative time, postoperative time, total OT time, and turnover time). OT time and perioperative outcomes were compared.

RESULTS

102 cases were analysed. On average, Case 1 began at 8:38 AM whereas Case 3 ended by 5:54 PM. OT efficiency was consistent throughout the day of operation with comparable OT time in all five stages between groups (p > 0.05). The mean turnover time was 15.1 ± 13.5 min and the mean operative time was 123.0 ± 28.1 min. Intraoperative arterial blood gas (ABG) parameters were maintained in an optimal range. The complication rate was 2.0% (N = 2/102).

CONCLUSION

Consistent OT efficiency was demonstrated with a dedicated spine team approach. Despite performing three AIS cases in a consecutive case operation list, patients' safety was not compromised as perioperative outcomes between groups were comparable.

2023 Clinical Update in Liver Transplantation

Liver transplantation continues to provide life-saving treatment for patients with end-stage liver disease. Advances in the field of transplant anesthesia continue to support the care of more complex patients. The use of extracorporeal membrane oxygenation has been described in critical care settings and cardiac surgery but may be a valuable option for specific conditions for patients undergoing liver transplantation. Changes to the allocation process for liver grafts now focus on acuity circles to reduce regional disparities. As the number of life-saving transplant surgeries increases, so does the need for specialty knowledge in the anesthetic considerations of these procedures. The specialty of transplant anesthesia continues to grow and develop to meet the demands of complex patients and the increased number of transplants performed. Liver transplantation can be a resource-demanding procedure, and predicting the need for massive transfusion can aid in planning and preparing for significant blood loss.

Locum doctor working and quality and safety: a qualitative study in English primary and secondary care

BACKGROUND

The use of temporary doctors, known as locums, has been common practice for managing staffing shortages and maintaining service delivery internationally. However, there has been little empirical research on the implications of locum working for quality and safety. This study aimed to investigate the implications of locum working for quality and safety.

METHODS

Qualitative semi-structured interviews and focus groups were conducted with 130 participants, including locums, patients, permanently employed doctors, nurses and other healthcare professionals with governance and recruitment responsibilities for locums across primary and secondary healthcare organisations in the English NHS. Data were collected between March 2021 and April 2022. Data were analysed using reflexive thematic analysis and abductive analysis.

RESULTS

Participants described the implications of locum working for quality and safety across five themes: (1) 'familiarity' with an organisation and its patients and staff was essential to delivering safe care; (2) 'balance and stability' of services reliant on locums were seen as at risk of destabilisation and lacking leadership for quality improvement; (3) 'discrimination and exclusion' experienced by locums had negative implications for morale, retention and patient outcomes; (4) 'defensive practice' by locums as a result of perceptions of increased vulnerability and decreased support; (5) clinical governance arrangements, which often did not adequately cover locum doctors.

CONCLUSION

Locum working and how locums were integrated into organisations posed some significant challenges and opportunities for patient safety and quality of care. Organisations should take stock of how they work with the locum workforce to improve not only quality and safety but also locum experience and retention.

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.

Tips and tricks in gynaecological robotic surgery

It was the dawn of a new era for robotic surgery when the Food and Drug Administration (FDA) approved da Vinci robotic surgical system for general laparoscopic procedures in 2000. The surgical practice saw a transformative breakthrough towards minimally invasive approach with the ever-increasing uptake of advanced robots proven to benefit patients and surgeons in various ways. However, these innovative machines only complement and enhance a surgeon's operating skills, and with such privilege come responsibilities and new challenges. Heavy reliance on such advanced devices while operating on humans necessitates thorough training and supervision to ensure safe and efficient applications. It is the surgeon's responsibility to direct the procedure constantly and lead other team members who assist during the surgery. In this chapter, we provide miscellaneous tips and tricks that can help beginners navigate through robotic surgery with more confidence and enthusiasm.

Team-based care of the thoracic surgical patient

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Social science and teams: a patient perspective

Teamwork is fundamental for providing high quality care and providing positive experiences for patients. Concepts from organisational behaviour and social science are integrated with a patient perspective to elucidate how various aspects of teams impact on the patient experience. Particular attention is devoted to the team composition, the interaction and communication patterns among team members, how teams are structured, coordination among team members, facilitating a positive team climate, and considering patients as a member of the team.

Perspectives on Perioperative Team-Based Morbidity and Mortality Conferences: A Mixed Methods Study

BACKGROUND

Morbidity and mortality conferences (MMCs) are quality improvement mechanisms during which adverse events are reviewed, often by physicians within a single discipline. There is a growing desire to include nonphysicians and physicians from other disciplines in team-based morbidity and mortality conferences (TBMMs). This mixed methods study investigates perioperative perspectives on MMCs generally and TBMMs specifically.

METHODS

A national survey of perioperative health care professionals, including surgeons, anesthesiologists, and nurses, was used to explore opinions about MMCs and TBMMs. Semistructured qualitative interviews and focus groups were conducted with health care professionals and leaders at a single study site. Quantitative data were compared using a Kruskal-Wallis test. Interview transcripts were inductively analyzed. Data were analyzed using a concurrent mixed methods approach, triangulating both sources of data.

RESULTS

Survey respondents (N = 1,466) were generally positive about both MMCs and TBMMs, agreeing that conferences were respectful, affected practice, and were educational. Nurses, compared to surgeons and anesthesiologists, were more likely to find conferences educational (p = 0.004) and were less comfortable speaking up in conferences (p < 0.001). Attendees who had more experience with TBMMs rated conferences as having significantly higher utility in achieving educational and safety goals. Qualitative data from 14 participants identified barriers and facilitators at the micro, meso, and macro level. Barriers include negative personal interactions, unsupportive leadership, and legal and regulatory issues. Facilitators include interpersonal relationships between professionals, buy-in from leadership, and external motivators.

CONCLUSION

Perceptions of TBMMs were overall positive, but significant barriers to implementation remain. Team members may be invited to the table, but more effort is needed to make the entire team feel included in the discussion and optimize the value of these conferences. Strategies for overcoming identified barriers remains an open area of research.

Barriers and Facilitators to Clinical Practice Development in Men and Women Surgeons

Importance

Many early-career surgeons struggle to develop their clinical practices, leading to high rates of burnout and attrition. Furthermore, women in surgery receive fewer, less complex, and less remunerative referrals compared with men. An enhanced understanding of the social and structural barriers to optimal growth and equity in clinical practice development is fundamental to guiding interventions to support academic surgeons.

Objective

To identify the barriers and facilitators to clinical practice development with attention to differences related to surgeon gender.

Design, Setting, and Participants

A multi-institutional qualitative descriptive study was performed using semistructured interviews analyzed with a grounded theory approach. Interviews were conducted at 5 academic medical centers in the US between July 12, 2022, and January 31, 2023. Surgeons with at least 1 year of independent practice experience were selected using purposeful sampling to obtain a representative sample by gender, specialty, academic rank, and years of experience.

Main Outcomes and Measures

Surgeon perspectives on external barriers and facilitators of clinical practice development and strategies to support practice development for new academic surgeons.

Results

A total of 45 surgeons were interviewed (23 women [51%], 18 with ≤5 years of experience [40%], and 20 with ≥10 years of experience [44%]). Surgeons reported barriers and facilitators related to their colleagues, department, institution, and environment. Dominant themes for both genders were related to competition, case distribution among partners, resource allocation, and geographic market saturation. Women surgeons reported additional challenges related to gender-based discrimination (exclusion, questioning of expertise, role misidentification, salary disparities, and unequal resource allocation) and additional demands (related to appearance, self-advocacy, and nonoperative patient care). Gender concordance with patients and referring physicians was a facilitator of practice development for women. Surgeons suggested several strategies for their colleagues, department, and institution to improve practice development by amplifying facilitators and promoting objectivity and transparency in resource allocation and referrals.

Conclusions and Relevance

The findings of this qualitative study suggest that a surgeon's external context has a substantial influence on their practice development. Academic institutions and departments of surgery may consider the influence of their structures and policies on early career surgeons to accelerate practice development and workplace equity.

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.

Enhanced perioperative care in emergency general surgery: the WSES position paper

Enhanced perioperative care protocols become the standard of care in elective surgery with a significant improvement in patients' outcome. The key element of the enhanced perioperative care protocol is the multimodal and interdisciplinary approach targeted to the patient, focused on a holistic approach to reduce surgical stress and improve perioperative recovery. Enhanced perioperative care in emergency general surgery is still a debated topic with little evidence available. The present position paper illustrates the existing evidence about perioperative care in emergency surgery patients with a focus on each perioperative intervention in the preoperative, intraoperative and postoperative phase. For each item was proposed and approved a statement by the WSES collaborative group.

Novel Interdisciplinary Enhanced Recovery after Surgery Protocol Implementation in Paediatric Orthopaedics

The enhanced recovery after surgery (ERAS) protocol is not routine management in paediatric orthopaedics. Cultural differences or assumptions about the financing of medical care in different countries encourage creative adaptation of general assumptions in local communities. The aim of this study was to compare the quality of the perioperative period before and after the introduction of an interdisciplinary protocol adopted to organisational conditions. A group of 4098 children were included in the "before-after" observational study. The data of 1553 patients (BEFORE group) were analysed in terms of compliance with the enhanced recovery after surgery protocol guidelines and the time and cost of hospitalisation over a 20-month period. A novel interdisciplinary protocol was developed, including an education and training app called BackOnFeet (BOF®), standardised hospital management, and the introduction of methods novel to Poland (intraoperative nerve cryoanalgesia in children). A further 2545 patients (AFTER group) were reassessed over a period of 20 months. It was found that the groups differed in hospitalisation time (p < 0.001), type of procedures, and percentage ratio of costs incurred to revenue generated. The usefulness of the BOF® app as an effective educational tool was demonstrated. The optimisation of perioperative management in paediatric orthopaedics based on novel tools and the interdisciplinary ERAS protocol is possible and brings tangible benefits in psychological, organisational, and financial terms.