Effects of Flow Disruptions on Mental Workload and Surgical Performance in Robotic-Assisted Surgery

Robotic surgery governance structures: a systematic review

Since the Food and Drug Administration in the United States approved the first robotic platform for use in humans in 2000, there has been a steady increase in the popularity of robotic approaches to surgery. Robotic-assisted surgery (RAS) offers enhanced 3D visualisation of the operative field and increased flexibility and agility of the instruments, amongst other benefits. However, robotic platforms are complex systems and there is evidence that they may be associated with increased patient risk, particularly in the initial learning curve of a surgeon's robotic training. To ensure the continued safe use of RAS, adequate governance policies must be in place to regulate training, ensure patient safety and maximise the benefits of RAS programs. This systematic review synthesises all available evidence on RAS governance structures internationally for the first time. It was conducted and reported per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. This systematic review identified, for the first time, three guidelines offering recommendations on the Governance Structures for RAS programs. We extracted the key recommendations to provide a holistic set of guidelines. Through consensus, we offer recommendations for the composition of a RAS governance committee, the frequency with which the committee should sit, and the remit of the committee, including training, granting of privileges, quality assurance and continued professional development. We also stress future research needs in RAS team credentialing and vendor-agnostic training pathways. These recommendations may serve as a template for establishing future RAS programs.

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.

Validation of a Novel "Windshield Wiper" for Laparoscopes in Cadaver and Live Porcine Models

BackgroundDuring laparoscopic surgeries, laparoscopes are inserted through a trocar port into the body cavity, which is then insufflated with carbon dioxide. Laparoscope lens clarity frequently becomes compromised via condensation or smearing of blood and adipose. This problem is well-known in the field, yet a viable in vivo solution has yet to address the issue and be successfully clinically adopted.Research DesignA structured cadaveric study evaluated the cleaning performance and clinician satisfaction with a novel laparoscope lens cleaning device against 2 gold-standard lens cleaning products. The novel device was also tested in a live animal porcine model to assess cleaning performance in a warm body environment qualitatively. The validation in the porcine model did not have the same evaluation process and comparison with other lens clearing methods as the cadaveric experiment.ResultsCleaning events were timed individually and analyzed post hoc. Average times to clean scopes for the novel device, Clearify™, and Fred™ Anti-Fog solution were 5 ± 5, 16 ± 7, and 14 ± 6 seconds, respectively. In 100 cleaning events with the novel device, the laparoscope was removed from the body zero times, with an average of 2 ± 1.29 cleaning actuations per event. Clearify™ and Fred™ Anti-Fog were removed from the body 102 and 116 times, with an average number of cleaning actuations of 1.07 ± 0.26 and 1.19 ± 0.53 per event, respectively. In the live porcine model, the novel device consistently cleared all debris deposited on the lens, including fog, tissue, blood, and bile fluid.ConclusionThis study demonstrates the novel device's reduction in cleaning duration and scope removals compared to gold-standard technologies, suggesting a potential for improved workflow and reduced intra-operative interruptions.

Interruptions in multidisciplinary tumor conferences with patient participation: A video interaction analysis

OBJECTIVE

To identify a) interruptions (secondary activities disrupting the workflow of the main task) occurring during case discussions in multidisciplinary tumor conferences (MTCs) with patient participation, and b) observable reactions among patients and healthcare professionals (HCPs).

METHODS

Within the non-interventional mixed-methods study PINTU, we video-recorded five case discussions during MTCs with patient participation at one breast and gynecological cancer center. A qualitative sequential video interaction analysis was used to identify interruptions and related interactions.

RESULTS

Occurring interruptions resulted in reactions of patients and/or HCPs. Work organization and seating arrangement led to interruptions, e.g., turning around to face individuals. Some interruptions caused reactions only among patients and not among HCPs.

CONCLUSION

Interruptions occur regularly in case discussions during MTCs with patient participation. Certain interruptions, which did not cause observable reactions among HCPs and seem to be commonplace, attracted the patient's attention. As interruptions can be associated with patients' unmet need for information, HCPs' awareness of interruptions should be raised.

PRACTICE IMPLICATIONS

When patients participate in MTCs, interruptions should be reduced to improve HCP-patient interactions. Our findings can lead to recommendations for improving organization of MTCs with patient participation aiming to cause fewer interruptions and thus better quality of patient care.

Ambiguity in robotic surgical instruction: lessons from remote and in-person simulation

The rise of robotic surgery has been accompanied by numerous educational challenges as surgeons and trainees learn skills unique to the robotic platform. Remote instruction is a solution to provide surgeons ongoing education when in-person teaching is not feasible. However, surgical instruction faces challenges from unclear communication. We aimed to describe, examine, and compare ambiguities in remote and in-person robotic instruction. We designed a simulation scenario in which a standardized learner performed tasks in robotic surgery while making pre-scripted errors. Instructors provided remote or in-person instruction to the standardized learner. We applied tools from discourse analysis to transcribe sessions, identify instructional instances, classify ambiguities, and select passages for further review. We used tests of proportions to compare ambiguities between the settings. We conducted four simulation sessions, including two remote and two in-person sessions, and identified 206 instructional instances. Within these, we found 964 occurrences of three common semantic ambiguities, or ambiguities arising from words alone. Instructors used visual tools - thus employing multimodality - to clarify semantic ambiguities in 32% of instructional instances. We identified a similar degree of referential ambiguity, or ambiguity for which context from multimodality did not provide clarifying information, during remote (60%) and in-person (48%) instructional instances (p = 0.08). We described, examined, and compared ambiguities in remote and in-person instruction for simulated robotic surgery. Based on the high prevalence of ambiguity in both settings, we recommend that robotic instructors decrease referential ambiguity. To do so, instructors can reduce semantic ambiguity, harness multimodality, or both.

Learning curve analysis of extraperitoneal single-site robotic-assisted radical prostatectomy: a CUSUM-based approach

This study applied cumulative sum (CUSUM) analysis to evaluate trends in operative time and blood loss, It aims to identify key milestones in mastering extraperitoneal single-site robotic-assisted radical prostatectomy (ss-RARP). A cohort of 100 patients who underwent ss-RARP, performed by a single surgeon at the First Affiliated Hospital of Guangzhou Medical University between March 2021 and June 2023, was retrospectively analyzed. To evaluate the learning curve, the CUSUM (Cumulative Sum Control Chart) technique was applied, revealing the progression and variability over time. A cubic polynomial model was utilised to fit the non-linear data trends accurately. Key perioperative outcomes, such as operative duration and estimated blood loss, were assessed and compared between distinct learning stages to identify improvements and transitions during the surgeon's proficiency development. A total of 100 patients were included, with a mean age of 71.44 ± 5.46 years. The median operative time was 119.53 min (94, 144), and the best-fit equation for the CUSUM learning curve of operative time was y = 387.0373  - 3.4334x  - 0.2982x2 + 0.003x3 (R2 = 0.898), reaching its peak at the 11th case. The median blood loss was 49.9 ml (20, 50), and the best-fit equation for the CUSUM learning curve of blood loss was y = 444.9362 + 23.6787x  - 0.7719x2 + 0.0049x3 (R2 = 0.957), reaching its peak at the 27th case. The learning curve was divided into a learning phase (1-27 cases) and a proficient phase (28 cases onward). Intraoperative blood loss significantly decreased from 75.93 ± 79.19 mL to 40.27 ± 35.27 mL in the proficient phase (P < 0.05), while operative time remained similar between phases (P > 0.05).There were no statistically significant differences in pelvic drainage tube placement time, drainage volume, positive surgical margin rate, hospital stay duration, or postoperative pain scores (P > 0.05). The findings suggest that proficiency in ss-RARP is typically achieved after approximately 27 cases, indicating a manageable and safe learning curve. These insights can inform the design of surgical training programmes, optimising early learning and improving clinical outcomes for novice surgeons.

Comparative analysis of disruptive events in robotic and laparoscopic radical prostatectomy

This study compares laparoscopic (LRP) and robotic-assisted (RARP) radical prostatectomy to identify external and internal disruptive events, focusing on tasks that require heightened attention and coordination among the surgical team. Observations conducted across three hospitals in Australia and China. Data collection was rigorously ensured through the analysis of video recordings and consultations with surgeons, followed by statistical analysis using the Wilcoxon Signed Rank test. In a sample of 54 surgeries (27 RARP, 27 LRP), 15 activities were analysed, identifying 23 internal and 38 external disruption types. The findings indicate that RARP significantly reduces both external and internal disruptions compared to LRP, with decreases of around 41% and 33%, respectively. Notably, neurovascular bundle release showed the highest internal disruptions, with 123 events in RARP and 160 in LRP, and minor vessel bleeding led to the most internal disruptions, with 200 in RARP and 251 in LRP. RARP advantages include fewer disruptions due to pre-dissection inspections for visibility, improved blood management, and a skilled assistant, reducing the need for direct eye contact and repeated instructions. This study adds new dimensions to existing research by comparing internal and external disruptions in complex surgeries-specifically radical prostatectomy-performed using two approaches: robotic-assisted and laparoscopic.

Rethinking Surgical Safety: Investigating the Impact of Gamified Training on Severe Flow Disruptions in Surgery

OBJECTIVES

There is a need for effective and engaging training methods to enhance technical and nontechnical skills in robotic-assisted surgery (RAS), where deficiencies can compromise safety and efficiency. This study aims to evaluate the impact of a gamified team training intervention, the "RAS Olympics," on the safety and efficiency of RAS procedures.

METHODS

The study was conducted at a 958-bed tertiary care academic medical center in with a robust robotic surgery program. A total of 56 RAS procedures (general, urology, and gynecology) were included in the analysis, with a mix of procedure types representative of the surgical caseload at the medical center. A pretest posttest experimental design was employed, comparing the frequency and severity of flow disruptions (FD) between preintervention, postintervention without "RAS Olympics" participants, and postintervention with "RAS Olympics" participants. The "RAS Olympics" involved safety hazard identification, troubleshooting, workspace navigation, instrument retrieval, and turnover optimization.

RESULTS

Postintervention cases with "RAS Olympics" participants exhibited significantly lower overall FDs compared to the postintervention control group. The reduction was particularly notable during phase 3 (surgeon on console) and in cases involving more severe FDs.

CONCLUSIONS

Gamified team training interventions may improve the safety and efficiency of RAS procedures. The positive outcomes underscore the potential of innovative and engaging training methods to address the evolving challenges in surgical practice, emphasizing the relevance of gamification in healthcare education. As the healthcare landscape continues to advance, incorporating such interventions may be crucial in ensuring the adaptability and competence of surgical teams.

Nurses' experiences of working with robotic assisted surgery in an Irish healthcare setting: A qualitative descriptive design

AIM

To explore the experiences of nurses working with robotic assisted surgery patients.

BACKGROUND

Robotic assisted surgery has grown considerably since its introduction in the 1980's with more than 6500 da Vinci robots installed worldwide and over 55,000 surgeons trained to use these machines. Nurses play a major role in the successful completion of robotic surgery; however, minimal research has been conducted in the literature to date surrounding robotic assisted surgery nurses' experiences working in the perioperative department and beyond.

DESIGN

Qualitative descriptive design with thematic analysis.

METHOD

The study sample was recruited from three care settings where nurses work with robotic assisted surgery patients including: operating theatre, surgical ward and the community. Ten semi-structured face to face interviews were conducted. Interviews were audio recorded with data transcribed verbatim and analysed using thematic analysis.

RESULTS

Themes included - 1. Limited education specific to robotic assisted surgery, Subthemes: Robotic assisted surgery patient safety concerns; Lacking technical education and training; and Lacking patient postoperative care education. 2. Challenges for nurses working with robotic assisted surgery, Subthemes: Diverse dynamics in the robotic assisted surgery environment; Working with inexperienced staff; and Communication difficulties.

CONCLUSION

The key findings from this research are that nurses experience of working with robotic assisted surgery patients outside of the perioperative area is limited and all nurses require more education specific to caring for robotic assisted surgery patients to be competent in their roles. Further research from a national and international perspective is required to better understand the needs of nurses working with robotic assisted surgery patients.

Challenges With Robot-Assisted Surgery Setup for Complex Minimally Invasive Upper Gastrointestinal Surgery

BACKGROUND

The utilization of robot-assisted approaches to surgery has increased significantly over the last two decades. This has introduced novel complexities into the operating room environment, requiring management of new challenges and workflow adaptation. This study aimed to analyze challenges in the surgical setup for complex upper gastrointestinal robot-assisted surgery (UGI-RAS) and identify opportunities for solutions.

METHODS

Direct observations of surgical setup processes for UGI-RAS were performed by a trained Human Factors researcher at a non-profit academic medical center in Southern California. Setup tasks were subdivided into five phases: (1) before wheels-in; (2) patient transfer and anesthesia induction; (3) patient preparation; (4) surgery preparation; and (5) robot docking. Start/end times for each phase/task were documented along with workflow disruption (FD) narratives and timestamps. Setup tasks and FDs were analyzed using descriptive statistics.

RESULTS

Twenty UGI-RAS setup procedures were observed between May-November 2023: sleeve gastrectomy +/- hiatal hernia repair (n = 9, 45.00%); para-esophageal hernia repair +/- fundoplication (n = 8, 40.00%); revision to Roux-en-Y gastric bypass (n = 2, 10.00%); and gastric band removal (n = 1, 5.00%). Frequent FDs included planning breakdowns (n = 20, 29.85%), equipment/supply management (n = 17, 25.37%), patient care coordination (n = 8, 11.94%), and equipment challenges (n = 8, 11.94%). Eleven of 20 observations were first-start cases, of which 10 experienced delayed starts.

DISCUSSION

Interventions aimed at improving workflows during UGI-RAS setup include performing pre-operative team huddles and conducting trainings aimed at team coordination and equipment challenges. These solutions could result in improved teamwork, efficiency, and communication while reducing case start delays and turnover time.

Routine Automated Assessment Using Surgical Intelligence Reveals Substantial Time Spent Outside the Patient's Body in Minimally Invasive Gynecological Surgeries

OBJECTIVE

To demonstrate the use of surgical intelligence to routinely and automatically assess the proportion of time spent outside of the patient's body (out-of-body-OOB) in laparoscopic gynecological procedures, as a potential basis for clinical and efficiency-related insights.

DESIGN

A retrospective analysis of videos of laparoscopic gynecological procedures.

SETTING

Two operating rooms at the Gynecology Department of a tertiary medical center.

PARTICIPANTS

All patients who underwent laparoscopic gynecological procedures between January 1, 2021 and December 31, 2022 in those two rooms.

INTERVENTIONS

A surgical intelligence platform installed in the two rooms routinely captured and analyzed surgical video, using AI to identify and document procedure duration and the amount and percentage of time that the laparoscope was withdrawn from the patient's body per procedure.

RESULTS

A total of 634 surgical videos were included in the final dataset. The cumulative time for all procedures was 639 hours, of which 48 hours (7.5%) were OOB segments. Average OOB percentage was 8.7% (SD = 8.7%) for all the procedures and differed significantly between procedure types (p < .001), with unilateral and bilateral salpingo-oophorectomies showing the highest percentages at 15.6% (SD = 13.3%) and 13.3% (SD = 11.3%), respectively. Hysterectomy and myomectomy, which do not require the endoscope to be removed for specimen extraction, showed a lower percentage (mean = 4.2%, SD = 5.2%) than the other procedures (mean = 11.1%, SD = 9.3%; p < .001). Percentages were lower when the operating team included a senior surgeon (mean = 8.4%, standard deviation = 9.2%) than when it did not (mean = 10.1%, standard deviation = 6.9%; p < .001).

CONCLUSION

Surgical intelligence revealed a substantial percentage of OOB segments in laparoscopic gynecological procedures, alongside associations with surgeon seniority and procedure type. Further research is needed to evaluate how laparoscope removal affects postoperative outcomes and operational efficiency in surgery.

Intraoperative workload of the surgeon in robot-assisted radical prostatectomy: a systematic review

In the present study, we aimed to systematically evaluate the current evidence regarding the intraoperative workload of surgeons performing robot-assisted radical prostatectomy (RARP) for prostate cancer. A systematic search was carried out in the PubMed-MEDLINE and Web of Science databases through April 2024 using the following search terms: "workload AND robot assisted radical prostatectomy", "workload AND robotic radical prostatectomy", "task load AND robotic radical prostatectomy", "task load AND robot assisted radical prostatectomy" and "NASA-TLX AND robot assisted radical prostatectomy" by combining population, intervention, comparison, and outcome (PICO) terms, following preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. We therefore selected studies that included patients with prostate cancer (P) who underwent robotic radical prostatectomy (I) and reported a workload/task load questionnaire (C) to assess the intraoperative workload/task load of the surgeon performing robot-assisted radical prostatectomy (O). A total of 11 studies were identified. The surgeon's workload during RARP was assessed using the National Aeronautics and Space Administration task load index (NASA-TLX) and/or the surgery task load index (SURG-TLX) in the studies. Total NASA-TLX scores of the studies ranged from 22.7 ± 3.2 to 62.0 ± 6.4. Mental and physical demands, flow interruptions, surgeon experience, the use of single or multiple ports, and the relationship between the surgeon and other staff in the operating theater may play a role in the intraoperative workload of the console surgeon. The studies we reviewed suggest that RARP offers an acceptable workload for the console surgeon despite its mental demands.

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.

Surgical counting interruptions in operating rooms

BACKGROUND

Operating rooms are complex working environments with high workloads and high levels of cognitive demand. The first surgical count which occurs during the chaotic preoperative stage and is considered a critical phase, is a routine task in ORs. Interruptions often occur during the first surgical count; however, little is known about the first surgical counting interruptions. This study aimed to observe and analyse the sources, outcomes, frequency of the first surgical counting interruptions and responses to interruptions.

METHODS

A retrospective observational study was carried out to examine the occurrence of the first surgical counting interruptions between 1st August 2023 and 30th September 2023. The data were collected using the "Surgical Counting Interruption Event Form", which was developed by the researchers specifically for this study.

RESULTS

A total of 66 circulating nurses (CNs) and scrub nurses (SNs) were observed across 1015 surgeries, with 4927.8 min of surgical count. The mean duration of the first surgical count was 4.85 min, with a range of 1.03 min to 9.51 min. In addition, 697 interruptions were identified, with full-term interruptions occurring an average of 8.7 times per hour. The most frequent source of interruption during the first surgical counts was instruments (N = 144, 20.7%). The first surgical counting interruptions mostly affected the CN (336 times; 48.2%), followed by the ORNs (including CNs and SNs) (243 times; 34.9%) and the SN (118 times; 16.9%). Most of the outcomes of interruptions were negative, and the majority of the nurses responded immediately to interruptions.

CONCLUSIONS

The frequency of the first surgical counting interruption is high. Managers should develop interventions for interruptions based on different surgical specialties and different nursing roles.

An Adaptive Human-Robotic Interaction Architecture for Augmenting Surgery Performance Using Real-Time Workload Sensing-Demonstration of a Semi-autonomous Suction Tool

OBJECTIVE

This study developed and evaluated a mental workload-based adaptive automation (MWL-AA) that monitors surgeon cognitive load and assist during cognitively demanding tasks and assists surgeons in robotic-assisted surgery (RAS).

BACKGROUND

The introduction of RAS makes operators overwhelmed. The need for precise, continuous assessment of human mental workload (MWL) states is important to identify when the interventions should be delivered to moderate operators' MWL.

METHOD

The MWL-AA presented in this study was a semi-autonomous suction tool. The first experiment recruited ten participants to perform surgical tasks under different MWL levels. The physiological responses were captured and used to develop a real-time multi-sensing model for MWL detection. The second experiment evaluated the effectiveness of the MWL-AA, where nine brand-new surgical trainees performed the surgical task with and without the MWL-AA. Mixed effect models were used to compare task performance, objective- and subjective-measured MWL.

RESULTS

The proposed system predicted high MWL hemorrhage conditions with an accuracy of 77.9%. For the MWL-AA evaluation, the surgeons' gaze behaviors and brain activities suggested lower perceived MWL with MWL-AA than without. This was further supported by lower self-reported MWL and better task performance in the task condition with MWL-AA.

CONCLUSION

A MWL-AA systems can reduce surgeons' workload and improve performance in a high-stress hemorrhaging scenario. Findings highlight the potential of utilizing MWL-AA to enhance the collaboration between the autonomous system and surgeons. Developing a robust and personalized MWL-AA is the first step that can be used do develop additional use cases in future studies.

APPLICATION

The proposed framework can be expanded and applied to more complex environments to improve human-robot collaboration.

Human Factors Integration in Robotic Surgery

OBJECTIVE

Using the example of robotic-assisted surgery (RAS), we explore the methodological and practical challenges of technology integration in surgery, provide examples of evidence-based improvements, and discuss the importance of systems engineering and clinical human factors research and practice.

BACKGROUND

New operating room technologies offer potential benefits for patients and staff, yet also present challenges for physical, procedural, team, and organizational integration. Historically, RAS implementation has focused on establishing the technical skills of the surgeon on the console, and has not systematically addressed the new skills required for other team members, the use of the workspace, or the organizational changes.

RESULTS

Human factors studies of robotic surgery have demonstrated not just the effects of these hidden complexities on people, teams, processes, and proximal outcomes, but also have been able to analyze and explain in detail why they happen and offer methods to address them. We review studies on workload, communication, workflow, workspace, and coordination in robotic surgery, and then discuss the potential for improvement that these studies suggest within the wider healthcare system.

CONCLUSION

There is a growing need to understand and develop approaches to safety and quality improvement through human-systems integration at the frontline of care.Precis: The introduction of robotic surgery has exposed under-acknowledged complexities of introducing complex technology into operating rooms. We explore the methodological and practical challenges, provide examples of evidence-based improvements, and discuss the implications for systems engineering and clinical human factors research and practice.

The Distraction Perceptions of Health Care Professionals in the Operating Room: The Disruptions in Surgery Index (DiSI)

PURPOSE

The purpose of the study was to evaluate the psychometric properties of the Disruptions in Surgery Index (DiSI) in operating room health care professionals and to determine the frequency of distractions DESIGN: Methodological study.

METHODS

The sample consisted of 152 health care professionals. Data were collected online using the DiSI scale. The language validity was ensured, and the data were analyzed with the content validity index, Cronbach α coefficient, and item-total score correlation. Data on distractions of health care workers were given as percentages and averages.

FINDINGS

The mean age of health care professionals was 27.3 ± 6.0 years, and 77.0% of them were operating room nurses. The content validity index of the scale was found to be 0.95. The Cronbach α coefficient of the scale was 0.953 for frequency, 0.967 for contribution to error, and 0.971 for obstruction of goals. The correlation between the item and the total item was positive and significant (p < .001). Tiredness was determined as the most common distraction factor, causing errors and making it difficult to achieve goals.

CONCLUSIONS

The DiSI was found to be a valid and reliable tool. The most common distractions, contributing to errors and obstructing to goals, were related to individuals' skills, performance, and personality. Health care professionals perceived the distractions related to the surgical processes and the situations of the team members in the coordination and situational awareness subdimension as the least distracting factor.

Operating room organization and surgical performance: a systematic review

BACKGROUND

Organizational factors may influence surgical outcomes, regardless of extensively studied factors such as patient preoperative risk and surgical complexity. This study was designed to explore how operating room organization determines surgical performance and to identify gaps in the literature that necessitate further investigation.

METHODS

We conducted a systematic review according to PRISMA guidelines to identify original studies in Pubmed and Scopus from January 1, 2000 to December 31, 2019. Studies evaluating the association between five determinants (team composition, stability, teamwork, work scheduling, disturbing elements) and three outcomes (operative time, patient safety, costs) were included. Methodology was assessed based on criteria such as multicentric investigation, accurate population description, and study design.

RESULTS

Out of 2625 studies, 76 met inclusion criteria. Of these, 34 (44.7%) investigated surgical team composition, 15 (19.7%) team stability, 11 (14.5%) teamwork, 9 (11.8%) scheduling, and 7 (9.2%) examined the occurrence of disturbing elements in the operating room. The participation of surgical residents appeared to impact patient outcomes. Employing specialized and stable teams in dedicated operating rooms showed improvements in outcomes. Optimization of teamwork reduced operative time, while poor teamwork increased morbidity and costs. Disturbances and communication failures in the operating room negatively affected operative time and surgical safety.

CONCLUSION

While limited, existing scientific evidence suggests that operating room staffing and environment significantly influences patient outcomes. Prioritizing further research on these organizational drivers is key to enhancing surgical performance.

What do nurses experience in communication when assisting in robotic surgery: an integrative literature review

BACKGROUND

Communication in surgery is integral to the fundamentals of perioperative nursing practice and patient safety. Research exploring team communication in robotic-assisted surgery (RAS) is evident in the literature but little attention has been focused on how the experiences of operating room nurses' communication affect safety, practice and patient care outcomes.

OBJECTIVE

To synthesise current evidence regarding communication during robotic-assisted surgery as experienced by registered nurses.

DESIGN

An integrative literature review informed by Whittemore and Knafl's (2005) methodology was used to conduct a rigorous analysis and synthesis of evidence.

METHODS

A comprehensive database search was conducted using PRISMA guidelines. CINAHL, Pubmed, PsychINFO and British Nursing Web of Science databases were searched using a Boolean strategy.

RESULTS

Twenty-five relevant papers were included in this literature review. Thematic analysis revealed two main themes with four related subthemes. The two main themes are: 'Adaptive operating room nursing in RAS' and 'RAS alters team dynamics'. The four subthemes are: 'Navigating disruptions in RAS', 'RAS heightens interdependence on team working', 'Augmented communicative workflow in RAS', and 'Professional empowerment to speak up'.

CONCLUSIONS

This integrative review identifies how current research largely focuses on communication in the wider OR team. However, current evidence lacks the input of nurses. Therefore, further evidence is needed to explore nurses' experiences to highlight their perspectives.

CLINICAL RELEVANCE

Robotics significantly benefit patients, and this review identifies different challenges that robotic-assisted surgery nurses encounter. A better understanding of the communication from the perspective of nurses is needed to guide future research, practice education, policy development and leadership/management.

Impaired robotic surgical visualization: archaic issues in a modern operating room

While robotic-assisted surgery (RAS) has been revolutionizing surgical procedures, it has various areas needing improvement, specifically in the visualization sector. Suboptimal vision due to lens occlusions has been a topic of concern in laparoscopic surgery but has not received much attention in robotic surgery. This study is one of the first to explore and quantify the degree of disruption encountered due to poor robotic visualization at a major academic center. In case observations across 28 RAS procedures in various specialties, any lens occlusions or "debris" events that appeared on the monitor displays and clinicians' reactions, the cause, and the location across the monitor for these events were recorded. Data were then assessed for any trends using analysis as described below. From around 44.33 h of RAS observation time, 163 debris events were recorded. 52.53% of case observation time was spent under a compromised visual field. In a subset of 15 cases, about 2.24% of the average observation time was spent cleaning the lens. Additionally, cautery was found to be the primary cause of lens occlusions and little variation was found within the spread of the debris across the monitor display. This study illustrates that in 6 (21.43%) of the cases, 90% of the observation time was spent under compromised visualization while only 2 (7.14%) of the cases had no debris or cleaning events. Additionally, we observed that cleaning the lens can be troublesome during the procedure, interrupting the operating room flow.

Workflow disruptions in robot-assisted surgery

Surgical flow disruptions are unexpected deviations from the natural progression which can potentially compromise the safety of the operation. Separation of the surgeon from the patient and team members is the main contributor for flow disruptions (FDs) in robot-assisted surgery (RAS). FDs have been categorised as communication, coordination, surgeon task considerations, training, equipment/ technology, external factors, instrument changes, and environmental factors. There may be an association between FDs and task error rate. Intervention to counter FDs include training, operating room adjustments, checklists, teamwork, communication improvement, ergonomics, technology, guidelines, workflow optimisation, and team briefing. Future studies should focus on identifying the significant disruptive FDs and the impact of interventions on surgical flow during RAS.

Demands of surgical teams in robotic-assisted surgery: An assessment of intraoperative workload within different surgical specialties

BACKGROUND

Current approaches to assessing workload in robotic-assisted surgery (RAS) focus on surgeons and lack real-world data. Understanding how workload varies by role and specialty aids in identifying effective ways to optimize workload.

METHODS

SURG-TLX surveys with six domains of workload were administered to surgical staff at three sites. Staff reported workload perceptions for each domain on a 20-point Likert scale, and aggregate scores were determined per participant.

RESULTS

188 questionnaires were obtained across 90 RAS procedures. Significantly higher aggregate scores were reported for gynecology (Mdn ​= ​30.00) (p ​= ​0.034) and urology (Mdn ​= ​36.50) (p ​= ​0.006) than for general (Mdn ​= ​25.00). Surgeons reported significantly higher scores for task complexity (Mdn ​= ​8.00) than both technicians (Mdn ​= ​5.00) (p ​= ​0.007), and nurses (Mdn ​= ​5.00).

CONCLUSIONS

Staff reported significantly higher workload during urology and gynecology procedures, and experienced significant differences in domain workload by role and specialty, elucidating the need for tailored workload interventions.

Identifying Workflow Disruptions in Robotic-Assisted Bariatric Surgery: Elucidating Challenges Experienced by Surgical Teams

PURPOSE

Bariatric surgery is an effective and durable treatment for weight loss for patients with extreme obesity. Although traditionally approached laparoscopically, robotic bariatric surgery (RBS) has unique benefits for both surgeons and patients. Nonetheless, the technological complexity of robotic surgery presents new challenges for OR teams and the wider clinical system. Further assessment of the role of RBS in delivering quality care for patients with obesity is necessary and can be done through a human factors approach. This observational study sought to investigate the impact of RBS on the surgical work system via the study of flow disruptions (FDs), or deviations from the natural workflow progression.

MATERIALS AND METHODS

RBS procedures were observed between October 2019 and March 2022. FDs were recorded in real time and subsequently classified into one of nine work system categories. Coordination FDs were further classified into additional sub-categories.

RESULTS

Twenty-nine RBS procedures were observed at three sites. An average FD rate of 25.05 (CI =  ± 2.77) was observed overall. FDs were highest between insufflation and robot docking (M = 29.37, CI =  ± 4.01) and between patient closing and wheels out (M = 30.00, CI =  ± 6.03). FD rates due to coordination issues were highest overall, occurring once every 4 min during docking (M = 14.28, CI =  ± 3.11).

CONCLUSION

FDs occur roughly once every 2.4 min and happen most frequently during the final patient transfer and robot docking phases of RBS. Coordination challenges associated with waiting for staff/instruments not readily available and readjusting equipment contributed most to these disruptions.

Study protocol for the implementation and evaluation of a digital-robotic-based intervention for nurses and patients in a hospital: a quantitative and qualitative triangulation based on the Medical Research Council (MRC) framework for developing and evaluating complex interventions

BACKGROUND

Nurses spend part of their working time on non-nursing tasks. Unnecessary walking distances and the assumption of service activities and other non-care-related tasks take up a lot of space, which reduces the time for direct patient care and demonstrably increases the dissatisfaction of the persons involved. The REsPonSe project aims to relieve nursing staff by using a smartphone app for communication in combination with an autonomous service robot to reduce walking distances and service activities. The technical systems are tested on a nuclear medicine ward and are intended to reduce the radiation exposure of the staff. The aim of this study is to test and evaluate the use and intervention of the technical systems, the acceptance of the users and the change in the utilisation of the nursing service. In addition to findings on usability and manageability, effects on nursing practice, as well as facilitating and inhibiting contextual factors for implementation, will be identified.

METHODS

The Medical Research Council (MRC) Framework for Developing and Evaluating for Complex Interventions was chosen as the theoretical basis. The data collection in the Feasibility and Evaluation phase is a triangulation of quantitative and qualitative methods. Standardised observations are planned to collect data on non-care activities and walking distances, and a survey of utilisation by use of a questionnaire based on the NASA TLX. Qualitative individual interviews with patients and group discussions with nursing staff will be conducted. Statements on the subjective experiences, as well as the evaluation of the use of the digital-robotic system in the clinical setting, will be collected. The descriptive evaluation of the usage and retrieval data will provide information on duration, time, requests, and reduced contact times, as well as error and fault messages.

DISCUSSION

The evaluation study will make it possible to represent a variety of perspectives from different interest groups. The results should contribute to the definition of implementation and evaluation criteria and facilitate the integration of digital-robotic assistance systems in nursing acute inpatient settings.

TRIAL REGISTRATION

The trial was registered with the German Clinical Trials Register (DRKS) on 16.02.2022: DRKS00028127.

Factors affecting workflow in robot-assisted surgery: a scoping review

BACKGROUND

Robot-assisted surgery is expanding worldwide. Most research in this field concentrates on surgeons' technical skills and patient outcome, but research from open and laparoscopic surgery shows that teamwork is crucial for patient safety. Team composition is changed in robot-assisted surgery with the surgeon placed away from the bedside, potentially altering teamwork and workflow in the operating theatre. This scoping review aimed to explore how factors affecting workflow as well as team members' social and cognitive skills during robot-assisted surgery are reported in the literature.

METHODS

A systematic search was performed in the databases Medline, EMBASE, PsycINFO, and Web of Science. Reports were screened according to the Preferred Reporting Item for Systematic reviews and Meta-Analysis for Scoping Review guidelines. Inclusion criteria were robot-assisted surgery, multi-professional teams, and workflow, flow disruptions, or non-technical skills.

RESULTS

A total of 12,527 references were screened, and 24 articles were included in the review. Articles were heterogeneous in terms of aim, methods and focus. The studies concentrated on two main fields: flow disruptions and the categorization of their causes and incidences; and non-technical skills describing the challenges of communication and effects on situation awareness.

CONCLUSION

Many studies focused on flow disruptions and found that communication, coordination, training, and equipment/technology were the most frequent causes. Another focus of studies was non-technical skills-primarily communication and situation awareness. Future studies could focus on how to prevent the most harmful flow disruptions and develop interventions for improving workflow.

A real-time analysis of intraoperative interruptions in relation to use of simple preventive measures including a sign on the door and a checklist-based team brief

This study aimed to evaluate intraoperative interruptions by frequency, type, interference and source, and preventive measures. The interruptions in the operating theatre were evaluated for 52 surgical procedures based on real-time recordings and divided into routine operative procedures (ROP, n = 26, without intervention) and intervened operative procedures (IOP, n = 26, observed after team brief and placement of a warning sign for unnecessary door openings) groups. Intervened operative procedures vs. routine operative procedures was associated with a significantly lower number of interruptions (p = 0.014). Implementation of preventive measures was associated with a significantly lower number of entrances and exits (p = 0.001) and equipment issues (p = 0.003), interruptions that affected the circulating nurse or anaesthesia technician/associate (p = 0.003) and those caused by team members other than assisting surgeon and scrub nurse (p-value ranged from 0.015 to 0.009). Our findings revealed significantly reduced interruptions after a simple preventive measure including team brief and the placement of a warning sign for unnecessary door openings.

Operating room team strategies to reduce flow disruptions in high-risk task episodes: resilience in robot-assisted surgery

In healthcare work settings, flow disruptions (FDs) pose a potential threat to patient safety. Resilience research suggests that adaptive behavioural strategies contribute to preventing cognitive overload through FDs at crucial moments. We aimed to explore the nature and efficacy of operating room (OR) team strategies to prevent FDs in robot-assisted surgery. Within a mixed-methods design, we first asked surgical professionals, which strategies they apply, and secondly, identified behavioural strategies through direct observations. Findings were analysed using content analysis. Additionally, FDs were assessed through live observations in the OR. The sample included four interviewed experts and 15 observed surgical cases. Sixty originally received strategies were synthesised into 17 final OR team strategies. Overall, 658 FDs were observed with external FDs being the most frequent. During high-risk episodes, FDs were significantly reduced (p < 0.0001). The identified strategies reveal how OR teams deliberatively and dynamically manage and mitigate FDs during critical tasks. Our findings contribute to a nuanced understanding of adaptive strategies to safeguard performance in robot surgery services. Practitioner Summary: Flow disruptions (FDs) in surgical work may become a severe safety threat during high-risk situations. With interviews and observations, we explored team strategies applied to prevent FDs in critical moments. We obtained a comprehensive list of behavioural strategies and found that FDs were significantly reduced during a specific high-risk surgical task. Our findings emphasise the role of providers' and teams' adaptive capabilities to manage workflow in high-technology care environments.

A Novel Approach for Engagement in Team Training in High-Technology Surgery: The Robotic-Assisted Surgery Olympics

INTRODUCTION

There is ongoing interest in the development of technical and nontechnical skills in healthcare to improve safety and efficiency; however, barriers to developing and delivering related training programs make them difficult to implement. Unique approaches to training such as "serious games" may offer ways to motivate teams, reinforce skill acquisition, and promote teamwork. Given increased challenges to teamwork in robotic-assisted surgery (RAS), researchers aimed to develop the "RAS Olympics," a game-based educational competition to improve skills needed to successfully perform RAS.

METHODS

This pilot study was conducted at an academic medical center in Southern California. Robotic-assisted surgery staff were invited to participate in the "RAS Olympics" to develop their skills and identify opportunities to improve processes. Impact of the activity was assessed using surveys and debriefs.

RESULTS

Sixteen operating room team members participated and reacted favorably toward the RAS-Olympics (average score, 4.5/5). They enjoyed the activity, would recommend all staff participate, felt that it was relevant to their work, and believed that they practiced and learned new techniques that would improve their practice. Confidence in skills remained unchanged. Participants preferred the RAS Olympics to traditional training because it provided an interactive learning environment.

CONCLUSIONS

The successful implementation of the RAS Olympics provided insight into new opportunities to engage surgical staff members while also training technical and nontechnical skills. Furthermore, this shared experience allowed surgical staff members to gain a greater appreciation for their teammates and an understanding of the current challenges and methods to improve teamwork and communication while promoting safety and efficiency in RAS.

Barriers to safety and efficiency in robotic surgery docking

BACKGROUND

The introduction of new technology into the operating room (OR) can be beneficial for patients, but can also create new problems and complexities for physicians and staff. The observation of flow disruptions (FDs)-small deviations from the optimal course of care-can be used to understand how systems problems manifest. Prior studies showed that the docking process in robotic assisted surgery (RAS), which requires careful management of process, people, technology and working environment, might be a particularly challenging part of the operation. We sought to explore variation across multiple clinical sites and procedures; and to examine the sources of those disruptions.

METHODS

Trained observers recorded FDs during 45 procedures across multiple specialties at three different hospitals. The rate of FDs was compared across surgical phases, sites, and types of procedure. A work-system flow of the RAS docking procedure was used to determine which steps were most disrupted.

RESULTS

The docking process was significantly more disrupted than other procedural phases, with no effect of hospital site, and a potential interaction with procedure type. Particular challenges were encountered in room organization, retrieval of supplies, positioning the patient, and maneuvering the robot.

CONCLUSIONS

Direct observation of surgical procedures can help to identify approaches to improve the design of technology and procedures, the training of staff, and configuration of the OR environment, with the eventual goal of improving safety, efficiency and teamwork in high technology surgery.

Intraoperative dynamics of workflow disruptions and surgeons' technical performance failures: insights from a simulated operating room

INTRODUCTION

Flow disruptions (FD) in the operating room (OR) have been found to adversely affect the levels of stress and cognitive workload of the surgical team. It has been concluded that frequent disruptions also lead to impaired technical performance and subsequently pose a risk to patient safety. However, respective studies are scarce. We therefore aimed to determine if surgical performance failures increase after disruptive events during a complete surgical intervention.

METHODS

We set up a mixed-reality-based OR simulation study within a full-team scenario. Eleven orthopaedic surgeons performed a vertebroplasty procedure from incision to closure. Simulations were audio- and videotaped and key surgical instrument movements were automatically tracked to determine performance failures, i.e. injury of critical tissue. Flow disruptions were identified through retrospective video observation and evaluated according to duration, severity, source, and initiation. We applied a multilevel binary logistic regression model to determine the relationship between FDs and technical performance failures. For this purpose, we compared FDs in one-minute intervals before performance failures with intervals without subsequent performance failures.

RESULTS

Average simulation duration was 30:02 min (SD = 10:48 min). In 11 simulated cases, 114 flow disruption events were observed with a mean hourly rate of 20.4 (SD = 5.6) and substantial variation across FD sources. Overall, 53 performance failures were recorded. We observed no relationship between FDs and likelihood of immediate performance failures: Adjusted odds ratio = 1.03 (95% CI 0.46-2.30). Likewise, no evidence could be found for different source types of FDs.

CONCLUSION

Our study advances previous methodological approaches through the utilisation of a mixed-reality simulation environment, automated surgical performance assessments, and expert-rated observations of FD events. Our data do not support the common assumption that FDs adversely affect technical performance. Yet, future studies should focus on the determining factors, mechanisms, and dynamics underlying our findings.

Using flow disruptions to understand healthcare system safety: A systematic review of observational studies

This systematic review provides information on the methodologies, measurements and classification systems used in observational studies of flow disruptions in clinical environments. The PRISMA methodology was applied and authors searched two databases (PubMed and Web of Science) for studies meeting the following inclusion criteria: (a) were conducted in a healthcare setting, (b) explored systems-factors leading to deviations in care processes, (c) were prospective and observational, (d) classified observations, and (e) were original research studies published in peer-reviewed journals. Thirty studies were analyzed and a variety of methods were identified for observer training, data collection and observation classification. Although primarily applied in surgery, comparable research has been successfully conducted in other venues such as trauma care, and delivery rooms. The findings of this review were synthesized into a framework of considerations for conducting rigorous methodological studies aimed at understanding clinical systems.

A Concern for Intraoperative Distractions and Interference: An Observational Study Identifying, Measuring, and Quantifying Both within the Operating Theatre

Background

Modern surgical research has broadened to include an interest into the investigation of surgical workflow. Rigorous analysis of the surgical process has a particular focus on distractions. Operating theatres are inherently full of distractions, many not pertinent to the surgical process. Distractions have the potential to increase surgeon stress, operative time, and complications. Our study aims to objectively identify, classify, and quantify distractions during the surgical process.

Methods

46 general surgical procedures were observed within a tertiary Irish hospital between June 2019 and October 2019. An established observational tool was used to apply a structured observation to all operations. Additionally, a nine-point ordinal behaviourally anchor scoring scale was used to assign an interference level to each distraction.

Results

The total operative observation time was 4605 minutes (mean = 100.11 minutes, std. deviation: 45.6 minutes). Overall, 855 intraoperative distractions were coded. On average, 18.58 distractions were coded per operation (std. deviation: 6.649; range: 5–34), with 11.14 distractions occurring per hour. Entering/exiting (n = 380, 42.88%) and case irrelevant communication (n = 251, 28.32%) occurred most frequently. Disruption rate was highest within the first (n = 275, 32%) and fourth operative quartiles (n = 342, 41%). Highest interference rates were observed from equipment issue and procedural interruptions. Anaesthetists initiated CIC more frequently (2.72 per operation), compared to nurses (1.57) and surgeons (1.17).

Conclusion

Our results confirm that distractions are prevalent within the operating theatre. Distractions contribute to significant interferences of surgical workflow. Steps can be taken to reduce overall prevalence and interference level by drawing upon a systems-based perspective. However, due to the ubiquitous nature of distractions, surgeons may need to develop skills to help them resume interrupted primary tasks so as to negate the effects distraction has on surgical outcomes. Data for the above have been presented as conference abstract in 28th International Congress of the European Association for Endoscopic Surgery (EAES) Virtual Congress, 23–26 June 2020.

The Impact of Robotic-Assisted Surgery on Team Performance: A Systematic Mixed Studies Review

OBJECTIVE

The aim of this study is to describe the impact of robotic-assisted surgery on team performance in the operating room.

BACKGROUND

The introduction of surgical robots has improved the technical performance of surgical procedures but has also contributed to unexpected interactions in surgical teams, leading to new types of errors.

METHOD

A systematic literature search of Cumulative Index to Nursing and Allied Health Literature, PubMed, ProQuest, Cochrane, Web of Science, PsycINFO, and Scopus databases using key words and MeSH terms was conducted. Screening identified studies employing qualitative and quantitative methods published between January 2000 and September 2019. Two reviewers independently appraised the methodological quality of the articles using the Mixed Methods Appraisal Tool (2018). Discussions were held among authors to examine quality scores of the studies and emergent themes, and agreement was reached through consensus. Themes were derived using inductive content analysis.

RESULTS

Combined searches identified 1,065 citations. Of these, 19 articles, 16 quantitative and 3 qualitative, were included. Robotic-assisted surgeries included urology, gynecology, cardiac, and general procedures involving surgeons, anesthetists, nurses, and technicians. Three themes emerged: Negotiating the altered physical environs and adapting team communications to manage task and technology; managing the robotic system to optimize workflow efficiency; and technical proficiency depends on experience, team familiarity, and case complexity.

CONCLUSION

Inclusion of a robot as a team member adds further complexity to the work of surgery.

APPLICATION

These review findings will inform training programs specifically designed to optimize teamwork, workflow efficiency, and learning needs.

Are operating room distractions, interruptions and disruptions associated with performance and patient safety? A systematic review and meta-analysis

OBJECTIVE

The operating room is a complex environment in which distractions, interruptions and disruptions (DIDs) are frequent. Our aim was to synthesize research on the relationships between DIDs and (i) operative duration, (ii) team performance, (iii) individual performance and (iv) patient safety outcomes in order to better understand how interventions can be designed to mitigate the negative effects of DIDs.

METHODS

Electronic databases (MEDLINE, Embase, CINAHL and PsycINFO) and reference lists were systematically searched. Included studies were required to report the quantitative outcomes of the association between DIDs and team performance, individual performance and patient safety. Two reviewers independently screened articles for inclusion, assessed study quality and extracted data. A random-effects meta-analysis was performed on a subset of studies reporting total operative time and DIDs.

RESULTS

Twenty-seven studies were identified. The majority were prospective observational studies (n = 15) of moderate quality. DIDs were often defined, measured and interpreted differently in studies. DIDs were significantly associated with extended operative duration (n = 8), impaired team performance (n = 6), self-reported errors by colleagues (n = 1), surgical errors (n = 1), increased risk and incidence of surgical site infection (n = 4) and fewer patient safety checks (n = 1). A random-effects meta-analysis showed that the proportion of total operative time due to DIDs was 22.0% (95% confidence interval 15.7-29.9).

CONCLUSION

DIDs in surgery are associated with a range of negative outcomes. However, significant knowledge gaps exist about the mechanisms that underlie these relationships, as well as the potential clinical and non-clinical benefits that DIDs may deliver. Available evidence indicates that interventions to reduce the negative effects of DIDs are warranted, but current evidence is not sufficient to make recommendations about potentially useful interventions.

An Assessment of the Impact of Flow Disruptions on Mental Workload and Performance of Surgeons During Percutaneous Nephrolithotomy

Objective

The aim of this study was to assess the impact of intraoperative disruptions on surgeons’ workload and performance during percutaneous nephrolithotomy (PCNL).

Materials and methods

A structured and standardized tool was used to identify disruptions and interferences that occurred during 33 PCNL procedures. The surgical steps during PCNL were divided into four phases: ureteric catheter placement (phase I), puncture and tract dilation (phase II), intra-calyceal navigation and stone fragmentation (phase III), and tube placement (phase IV). Surgeons’ workload was evaluated using a validated tool: Surgery Task Load Index (SURG-TLX), and correlated with the mean observed intraoperative disruptions. All operating team members evaluated the teamwork immediately after the procedure. Statistical analysis was performed using SPSS Statistics version 22 (IBM, Armonk, NY).

Results

A total of 1,897 disturbances were observed, with an average of 57.48 ± 16.36 disruptions per case. The largest number of disruptions occurred during phase III of PCNL (32.06 ± 14.12). The most common cause of the disruption was people entering or exiting the operating room (OR) (29.1 ± 10.03/case), followed by the ringing of phones or pagers (6.42 ± 2.4). The mean observed intraoperative disruptions were significantly associated with the operating surgeon’s mental workload, and it had a significant impact on all domains of surgeons’ mental workload as measured by SURG-TLX. Compared to other team members, surgeons’ assistants experienced an inferior sense of teamwork (r=-0.433; p=0.012).

Conclusion

Significant intraoperative disruptions were observed during PCNL. They were observed to directly correlate with the surgeon's workload and had a detrimental effect on teamwork. Improving OR dynamics by reducing unnecessary disruptions would help establish an efficient and smooth surgical work environment for safe surgical care.

Work-system interventions in robotic-assisted surgery: a systematic review exploring the gap between challenges and solutions

BACKGROUND

The introduction of a robot into the surgical suite changes the dynamics of the work-system, creating new opportunities for both success and failure. An extensive amount of research has identified a range of barriers to safety and efficiency in Robotic Assisted Surgery (RAS), such as communication breakdowns, coordination failures, equipment issues, and technological malfunctions. However, there exists very few solutions to these barriers. The purpose of this review was to identify the gap between identified RAS work-system barriers and interventions developed to address those barriers.

METHODS

A search from three databases (PubMed, Web of Science, and Ovid Medline) was conducted for literature discussing system-level interventions for RAS that were published between January 1, 1985 to March 17, 2020. Articles describing interventions for systems-level issues that did not involve technical skills in RAS were eligible for inclusion.

RESULTS

A total of 30 articles were included in the review. Only seven articles (23.33%) implemented and evaluated interventions, while the remaining 23 articles (76.67%) provided suggested interventions for issues in RAS. Major barriers identified included disruptions, ergonomic issues, safety and efficiency, communication, and non-technical skills. Common solutions involved team training, checklist development, and workspace redesign.

CONCLUSION

The review identified a significant gap between issues and solutions in RAS. While it is important to continue identifying how the complexities of RAS affect operating room (OR) and team dynamics, future work will need to address existing issues with interventions that have been tested and evaluated. In particular, improving RAS-associated non-technical skills, task management, and technology management may lead to improved OR dynamics associated with greater efficiency, reduced costs, and better systems-level outcomes.

Associations of workflow disruptions in the operating room with surgical outcomes: a systematic review and narrative synthesis

BACKGROUND

Performance in the operating room is an important determinant of surgical safety. Flow disruptions (FDs) represent system-related performance problems that affect the efficiency of the surgical team and have been associated with a risk to patient safety. Despite the growing evidence base on FDs, a systematic synthesis has not yet been published.

OBJECTIVE

Our aim was to identify, evaluate and summarise the evidence on relationships between intraoperative FD events and provider, surgical process and patient outcomes.

METHODS

We systematically searched databases MEDLINE, Embase and PsycINFO (last update: September 2019). Two reviewers independently screened the resulting studies at the title/abstract and full text stage in duplicate, and all inconsistencies were resolved through discussion. We assessed the risk of bias of included studies using established and validated tools. We summarised effects from included studies through a narrative synthesis, stratified based on predefined surgical outcome categories, including surgical process, provider and patient outcomes.

RESULTS

We screened a total of 20 481 studies. 38 studies were found to be eligible. Included studies were highly heterogeneous in terms of methodology, medical specialty and context. Across studies, 20.5% of operating time was attributed to FDs. Various other process, patient and provider outcomes were reported. Most studies reported negative or non-significant associations of FDs with surgical outcomes.

CONCLUSION

Apart from the identified relationship of FDs with procedure duration, the evidence base concerning the impact of FDs on provider, surgical process and patient outcomes is limited and heterogeneous. We further provide recommendations concerning use of methods, relevant outcomes and avenues for future research on associated effects of FDs in surgery.

Eye-Tracking Metrics Predict Perceived Workload in Robotic Surgical Skills Training

OBJECTIVE

The aim of this study is to assess the relationship between eye-tracking measures and perceived workload in robotic surgical tasks.

BACKGROUND

Robotic techniques provide improved dexterity, stereoscopic vision, and ergonomic control system over laparoscopic surgery, but the complexity of the interfaces and operations may pose new challenges to surgeons and compromise patient safety. Limited studies have objectively quantified workload and its impact on performance in robotic surgery. Although not yet implemented in robotic surgery, minimally intrusive and continuous eye-tracking metrics have been shown to be sensitive to changes in workload in other domains.

METHODS

Eight surgical trainees participated in 15 robotic skills simulation sessions. In each session, participants performed up to 12 simulated exercises. Correlation and mixed-effects analyses were conducted to explore the relationships between eye-tracking metrics and perceived workload. Machine learning classifiers were used to determine the sensitivity of differentiating between low and high workload with eye-tracking features.

RESULTS

Gaze entropy increased as perceived workload increased, with a correlation of .51. Pupil diameter and gaze entropy distinguished differences in workload between task difficulty levels, and both metrics increased as task level difficulty increased. The classification model using eye-tracking features achieved an accuracy of 84.7% in predicting workload levels.

CONCLUSION

Eye-tracking measures can detect perceived workload during robotic tasks. They can potentially be used to identify task contributors to high workload and provide measures for robotic surgery training.

APPLICATION

Workload assessment can be used for real-time monitoring of workload in robotic surgical training and provide assessments for performance and learning.

Evaluation of the Impact of Intraoperative Distractions on Teamwork, Stress, and Workload

BACKGROUND

Within the operating rooms (ORs), distractions occur on a regular basis, which affect the surgical workflow and results in the interruption of urgent tasks. This study aimed to observe the occurrence of intraoperative distractions in Tunisian ORs and evaluate associations among distractions, teamwork, workload, and stress.

METHODS

This observational cross-sectional study was conducted in four different ORs (orthopedic, urology, emergency, and digestive surgery) of Sahloul University Hospital for a period of 3 mo in 2018. Distractions and teamwork were recorded and rated in real time during the intraoperative phase of each case using validated observation sheets. Besides, at the end of each operation, stress and workload of team members were measured.

RESULTS

Altogether, 50 cases were observed and 160 participants were included. Distractions happened in 100% of the included operations. Overall, we recorded 933 distractions that occurred once every 3 min, with a mean frequency of M = 18.66 (standard deviation [SD] = 8.24) per case. It is particularly noticeable that procedural distractions occurred significantly higher during teaching cases compared with nonteaching cases (M = 3.85, M = 0.60, respectively, P < 0.001). The mean global teamwork score was M = 3.85 (SD = 0.67), the mean workload score was M = 58.60 (SD = 24.27), and the mean stress score was M = 15.29 (SD = 4.00). Furthermore, a higher stress level among surgeons was associated with distractions related to equipment failures and people entering or exiting the OR (r = 0.206, P < 0.01 and r = 0.137, P < 0.01, respectively). Similarly, nurses reported a higher workload in the presence of distractions related to the work environment in the OR (r = 0.313, P < 0.05).

CONCLUSIONS

This study highlighted a serious problem, which often team members seem to ignore or underestimate. Taking our findings into consideration, we recommend the implementation of the Surgical Checklist and preoperative briefings to reduce the number of surgical distractions. Also, a continuous teamwork training should be adopted to ensure that OR staff can avoid or handle distractions when they happen.

Impact of flow disruptions in the delivery room

AIM

Flow disruptions (FDs) are deviations from the progression of care that compromise safety and efficiency of a specific process. The study aim was to identify the impact of FDs during neonatal resuscitation and determine their association with key process and outcome measures.

METHODS

Prospective observational study of video recorded delivery room resuscitations of neonates <32 weeks gestational age. FDs were classified using an adaptation of Wiegmann's FD tool. The primary outcome was target oxygenation saturation achievement at 5 min. Secondary outcomes included achieving target saturation at 10 min, time to positive pressure ventilation for initially apnoeic/bradycardic neonates, time to electrocardiogram signal, time to pulse oximetry signal, and time to stable airway. Multivariable logistic regression assessed association between FDs and achieving target saturations adjusting for gestational age and leader. Associations between FDs and time to event outcomes were assessed using Cox proportional hazards models.

RESULTS

Between 10/2017-7/2018, 32 videos were included. A mean of 52.6 FDs (standard deviation 17.9) occurred per resuscitation. Extraneous FDs were the most common FDs. FDs were associated with an adjusted odds ratio of 0.92 (95% confidence interval [CI] 0.80-1.05) of achieving target saturation at 5 min and 0.94 (95% CI 0.84-1.05) at 10 min. There was no significant evidence to show FDs were associated with time to event outcomes.

CONCLUSIONS

FDs occurred frequently during neonatal resuscitation. Measuring FDs is a feasible method to assess the impact of human factors in the delivery room and identify modifiable factors and practices to improve patient care.

Interruptions in Surgery: A Comprehensive Review

BACKGROUND

Recent literature showed that analysis of interruptions can contribute to evaluating the care process in the operating room, and thus, understanding potential errors that may occur during surgical procedures. The aim of this comprehensive review was to summarize current knowledge on the description and impact of interruptions in surgery.

MATERIAL AND METHODS

A literature search was conducted according to a set of criteria in the databases MEDLINE, BASE, Cochrane's Library, and PsycINFO.

RESULTS

41 articles were included. Two main methodological approaches were found, observational in the OR, or controlled in an experimental simulated environment. Interruptions in the OR were manifold, and several classifications were used. The severity of interruptions differed according to the category of the interruptions. Interruptions were influenced by team familiarity and the expertise of the surgical team; high team familiarity and a high level of expertise decreased the frequency of interruptions. However, our literature search lacked controlled studies carried out in the OR. Interruptions seemed to increase the workload and stress of the surgical team and impair nontechnical skills, but no clear evidence of this was advanced.

CONCLUSIONS

Interruptions are probably risk factors for errors in the operating room. However, there is as yet no clear evidence of the association of interruption frequency with errors in the operating room. There is a need to define and target interruptions, which should be reduced by putting safeguards in place, thereby allowing those which could be beneficial and neglecting those with no potential consequences.