The influence of non-technical performance on technical outcome in laparoscopic cholecystectomy

Analysis of patient safety event report categories at one large academic hospital

Given the persistent safety incidents in operating rooms (ORs) nationwide (approx. 4,000 preventable harmful surgical errors per year), there is a need to better analyze and understand reported patient safety events. This study describes the results of applying the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) supported by the Teamwork Evaluation of Non-Technical Skills (TENTS) instrument to analyze patient safety event reports at one large academic medical center. Results suggest that suboptimal behaviors stemming from poor communication, lack of situation monitoring, and inappropriate task prioritization and execution were implicated in most reported events. Our proposed methodology offers an effective way of programmatically sorting and prioritizing patient safety improvement efforts.

Improving Situation Awareness to Advance Patient Outcomes: A Systematic Literature Review

Improving nurses' situation awareness skills would likely improve patient status recognition and prevent adverse events. Technologies such as electronic health record dashboards can be a promising approach to support nurses' situation awareness. However, the effect of these dashboards on this skill is unknown. This systematic literature review explores the evidence around interventions to improve nurses' situation awareness at the point of care. Current research on this subject is limited. Studies that examined the use of electronic health record dashboards as an intervention had weak evidence to support their effectiveness. Other interventions, including communication interventions and structured nursing assessments, may also improve situation awareness, but more research is needed to confirm this. It is important to carefully consider the design and content of situation awareness interventions, as well as the specific outcomes being measured, when designing situation awareness interventions. Overall, there is a need for higher-quality research in this area to determine the most effective interventions for improving nurse situation awareness. Future studies should focus on developing dashboards that follow a theoretical situation awareness model information and represent all situation awareness levels.

Comparison of cognitive workload and surgical outcomes between a three-dimensional and conventional microscope macular hole surgery

BACKGROUND

Performing a surgical task subjects the surgeon to multitudinal stressors, especially with the newer 3D technology. The quantum of cognitive workload using this modern surgical system in comparison to the Conventional microscope system remains unexplored. We evaluate the surgeon's cognitive workload and the surgical outcomes of macular hole(MH) surgery performed on a 3D versus a Conventional microscope operating system.

METHODS

50 eyes of 50 patients with MH undergoing surgery using the 3D or Conventional microscope visualization system. Cognitive workload assessment was done by real-time tools(Surgeons' heart rate [HR] and oxygen saturation[SPO2]) and self-report tool(Surgery Task Load Index[SURG-TLX] questionnaire) of three Vitreoretinal surgeons. Based on the SURG-TLX questionnaire, an assessment of the workload was performed.

RESULTS

Of the 50 eyes, 30 eyes and 20 eyes underwent surgery with the Conventional microscope and the 3D system, respectively. No difference was noted in the MH basal-diameter(p = 0.128), total surgical-duration(p = 0.299), internal-limiting membrane(ILM) peel time(p = 0.682), and the final visual acuity (VA; p = 0.515) between the two groups. Both groups showed significant improvement in VA(p < 0.001) with a 90% closure rate at one-month post-surgery. Cognitive workload comparison, the intraoperative HR(p = 0.024), total workload score(P = 0.005), and temporal-demand dimension(p = 0.004) were significantly more in Conventional microscope group as compared to 3D group. In both the groups, the HR increased significantly from the baseline while performing ILM peeling and at the end.

CONCLUSION

The surgeon's cognitive workload is markedly reduced while performing macular hole surgery with a 3D viewing system. Moreover, duration of surgery including ILM peel time, MH closure rates, and visual outcomes remains unaffected irrespective of the operating microscope system.

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.

Collaborative Team Training in Virtual Reality is Superior to Individual Learning For Performing Complex Open Surgery: A Randomized Controlled Trial

OBJECTIVE

To assess whether multiplayer immersive Virtual Reality (iVR) training was superior to single-player training for the acquisition of both technical and nontechnical skills in learning complex surgery.

BACKGROUND

Superior teamwork in the operating room (OR) is associated with improved technical performance and clinical outcomes. iVR can successfully train OR staff individually; however, iVR team training has yet to be investigated.

METHODS

Forty participants were randomized to individual or team iVR training. Individually trained participants practiced alongside virtual avatar counterparts, whereas teams trained live in pairs. Both groups underwent 5 iVR training sessions over 6 weeks. Subsequently, they completed a real-life assessment in which they performed anterior approach total hip arthroplasty surgery on a high-fidelity model with real equipment in a simulated OR. Teams performed together, and individually trained participants were randomly paired up. Videos were marked by 2 blinded assessors recording the 'Non-Operative Technical Skills for Surgeons, Oxford NOn-TECHnical Skills II and Scrub Practitioners' List of Intraoperative Non-Technical Skills' scores. Secondary outcomes were procedure duration and the number of technical errors.

RESULTS

Teams outperformed individually trained participants for nontechnical skills in the real-world assessment (Non-Operative Technical Skills for Surgeons: 13.1±1.5 vs 10.6±1.6, P = 0.002, Non-TECHnical Skills II score: 51.7 ± 5.5 vs 42.3 ± 5.6, P = 0.001 and Scrub Practitioners' List of Intraoperative Non-Technical Skills: 10 ± 1.2 vs 7.9 ± 1.6, P = 0.004). They completed the assessment 33% faster (28.2 minutes ± 5.5 vs 41.8 ± 8.9, P < 0.001), and made fewer than half the number of technical errors (10.4 ± 6.1 vs 22.6 ± 5.4, P < 0.001).

CONCLUSIONS

Multiplayer training leads to faster surgery with fewer technical errors and the development of superior nontechnical skills.

Utilizing Eye Tracking to Assess Medical Student Non-Technical Performance During Scenario-Based Simulation: Results of a Pilot Study

Background

Non-technical skills (NTS) are essential for safe surgical patient management. However, assessing NTS involves observer-based ratings, which can introduce bias. Eye tracking (ET) has been proposed as an effective method to capture NTS. The purpose of the current study was to determine if ET metrics are associated with NTS performance.

Methods

Participants wore a mobile ET system and participated in two patient care simulations, where they managed a deteriorating patient. The scenarios featured several challenges to leadership, which were evaluated using a 4-point Likert scale. NTS were evaluated by trained raters using the Non-Technical Skills for Surgeons (NOTSS) scale. ET metrics included percentage of fixations and visits on areas of interest.

Results

Ten medical students participated. Average visit duration on the patient was negatively correlated with participants' communication and leadership. Average visit duration on the patient's intravenous access was negatively correlated with participants' decision making and situation awareness.

Conclusions

Our preliminary data suggests that visual attention on the patient was negatively associated with NTS and may indicate poor comprehension of the patient's status due to heightened cognitive load. In future work, researchers and educators should consider using ET to objectively evaluate and provide feedback on their NTS.

Beyond the Surgical Safety Checklist: Using Intraoperative Handoff to Facilitate Team Situation Awareness in the OR

BACKGROUND

The surgical safety checklist (SSC) has been credited with improving team situation awareness (SA) in the operating room. Although the SSC may support team SA at the outset of the operative case, intraoperative handoff provides an opportunity for either SA breakdown or, more preferably, SA reinforcement. High-functioning surgical teams demonstrate a high level of continued SA, whereas teams deficient in SA are more likely to be affected by surgical errors and adverse events. To date, no interprofessional intraoperative tools exist to support team SA beyond the SSC.

METHODS

This study was divided into 2 phases. The first used qualitative methods to (1) characterize intraoperative handoff processes across surgery, nursing, anesthesia, and perfusion, and (2) identify cultural factors that shaped handoff practices. Data for phase one were collected over 38 observation days and 41 brief interviews. Phase 2, informed by phase 1, used a modified Delphi process to create a tool for use during intraoperative handoff. Data were analyzed iteratively.

RESULTS

Handoff practices were not standardized and rarely involved the entire team. In addition we uncovered cultural factors-specifically assumptions held by participants-that hindered team communication during handoff. Assumptions included: (1) team members are interchangeable, (2) trained individuals are able to determine when it is appropriate to handoff without consulting the OR team. Despite claims of improved teamwork resulting from the SSC, many participants held a fragmented view of the OR team, resulting in communication challenges during handoff. Findings from both phases of our study informed the development of multidisciplinary intraoperative handoff tools to facilitate shared team situation awareness and a shared mental model.

CONCLUSIONS

Intraoperative handoff occurs frequently, and offers the opportunity for either renewed or fractured team SA beyond the SSC.

Analyzing interprofessional teamwork in the operating room: An exploratory observational study using conventional and alternative approaches

Intraoperative teamwork is vital for patient safety. Conventional tools for studying intraoperative teamwork typically rely on behaviorally anchored rating scales applied at the individual or team level, while others capture narrative information across several units of analysis. This prospective observational study characterizes teamwork using two conventional tools (Operating Theatre Team Non-Technical Skills Assessment Tool [NOTECHS]; Team Emergency Assessment Measure [TEAM]), and one alternative approach (modified-Systems Engineering Initiative for Patient Safety [SEIPS] model). We aimed to explore the advantages and disadvantages of each for providing feedback to improve teamwork practice. Fifty consecutive surgical cases at a Canadian academic hospital were recorded with the OR Black Box®, analyzed by trained raters, and summarized descriptively. Teamwork performance was consistently high within and across cases rated with NOTECHS and TEAMS. For cases analyzed with the modified-SEIPS tool, both optimal and suboptimal teamwork behaviors were identified, and team resilience was frequently observed. NOTECHS and TEAM provided summative assessments and overall pattern descriptions, while SEIPS facilitated a deeper understanding of teamwork processes. As healthcare organizations continue to prioritize teamwork improvement, SEIPS may provide valuable insights regarding teamwork behavior and the broader context influencing performance. This may ultimately enhance the development and effectiveness of multi-level teamwork interventions.

Relationship between stress and resident non-technical skills during interdisciplinary trauma simulations

BACKGROUND

Non-technical skills, such as communication and situation awareness, are vital for patient care and effective surgical team performance. Previous research has found that residents' perceived stress is associated with poorer non-technical skills; however, few studies have investigated the relationship between objectively assessed stress and non-technical skills. Accordingly, the purpose of this study was to assess the relationship between objectively assessed stress and non-technical skills.

METHODS

Emergency medicine and surgery residents voluntarily participated in this study. Residents were randomly assigned to trauma teams to manage critically ill patients. Acute stress was assessed objectively using a chest-strap heart rate monitor, which measured average heart rate and heart rate variability. Participants also evaluated perceived stress and workload using the 6-item version of the State-Trait Anxiety Inventory and the Surgery Task Load Index. Non-technical skills were assessed by faculty raters using the non-technical skills scale for trauma. Pearson's correlation coefficients were used to examine relationships between all variables.

RESULTS

Forty-one residents participated in our study. Heart rate variability (where higher values reflect lower stress) was positively correlated with residents' non-technical skills overall and leadership, communication, and decision-making. Average heart rate was negatively correlated with residents' communication.

CONCLUSION

Higher objectively assessed stress was associated with poorer non-technical skills in general and nearly all non-technical skills domains of the T-NOTECHS. Clearly, stress has a deleterious effect on residents' non-technical skills during trauma situations, and given the importance of non-technical skills in surgical care, educators should consider implementing mental skills training to reduce residents' stress and optimize non-technical skills during trauma situations.

Understanding ultrarare adverse events - Lessons learned from a twelve-year review of intraoperative deaths at an academic medical center

BACKGROUND

Intraoperative death (ID) is rare, the incidence remains challenging to quantify and learning opportunities are limited. We aimed to better define the demographics of ID by reviewing the longest single-site series.

METHODS

Retrospective chart reviews, including a review of contemporaneous incident reports, were performed on all ID between March 2010 to August 2022 at an academic medical center.

RESULTS

Over 12 years, 154 IDs occurred (∼13/year, average age: 54.3 years, male: 60%). Most occurred during emergency procedures (n = 115, 74.7%), 39 (25.3%) during elective procedures. Incident reports were submitted in 129 cases (84%). 21 (16.3%) reports cited 28 contributing factors including challenges with coordination (n = 8, 28.6%), skill-based errors (n = 7, 25.0%), and environmental factors (n = 3, 10.7%).

CONCLUSIONS

Most deaths occurred in patients admitted from the ER with general surgical problems. Despite expectations for incident reporting, few provided actionable information on ergonomic factors which might help identify improvement opportunities.

Surgeons' Leadership Style and Team Behavior in the Hybrid Operating Room: Prospective Cohort Study

OBJECTIVE

This study aimed to assess the relationship between surgeons' leadership style and team behavior in the hybrid operating room through video coding. Secondly, possible fluctuations possible fluctuations in leadership styles and team behavior during operative phases were studied.

BACKGROUND

Leadership is recognized as a key component to successful team functioning in high-risk industries. The 'full range of leadership' theory is commonly used to evaluate leadership, marking transformational, transactional, and passive. Few studies have examined the effects of these leadership styles on team behavior in surgery and/or their fluctuations during surgery.

METHODS

A single-center study included patients planned for routine endovascular procedures. A medical data capture system was used to allow post hoc video coding through Behavior Anchored Rating Scales. Multilevel statistical analysis was performed to assess possible correlations between leadership style and 3 team behavior indicators (speaking up, knowledge sharing, and collaboration) on an operative phase level.

RESULTS

Twenty-two cases were analyzed (47 hours recording). Transformational leadership is positively related to the extent to which team members work together (γ=0.20, P <0.001), share knowledge (γ=0.45, P <0.001), and speak up (γ=0.64, P <0.001). Passive leadership is significantly positively correlated with speaking up (γ=0.29, P =0.004). Leadership style and team behavior clearly fluctuate during a procedure, with similar patterns across different types of endovascular procedures.

CONCLUSIONS

Consistent with other professional fields, surgeons' transformational leadership enhances team behavior, especially during the most complex operative phases. This suggests that encouraging surgeons to learn and actively implement a transformational leadership style is meaningful to enhance patient safety and team performance.

Technical, Non-Technical, or Both? A Scoping Review of Skills in Simulation-Based Surgical Training

OBJECTIVE

Technical and non-technical skills are traditionally investigated separately in simulation-based surgical training (SBST). Recent literature has indicated an interrelation of these skills, but a clear relationship is yet to be established. This scoping review aimed to identify published literature on the use of both technical and non-technical learning objectives in SBST and investigate how the entities are related. Additionally, this scoping study reviewed the literature with the aim of mapping how publications on technical and non-technical skills within SBST have changed over time.

DESIGN

We conducted a scoping review using the 5 step framework by Arksey and O'Malley and reported our results according to the PRISMA guidelines for scoping reviews. Four databases, PubMed, Web of Science, Embase and Cochrane Library, were systematically searched for empirical studies on SBST. Studies within surgical training addressing both technical and non-technical learning objectives and presenting primary data were included for further analysis.

RESULTS

Our scoping review identified 3144 articles on SBST published between 1981 and 2021. During our analysis, an emphasis on technical skills training in published literature was identified. However, recent years have seen an immense increase of publications within either technical or non-technical skills. A similar trend is seen in publications addressing both technical and non-technical. In total, 106 publications addressed both technical and non-technical learning objectives and were included for further analysis. Only 45 of the included articles addressed the relationship between technical and non-technical skills. These articles mainly focused on the effect of non-technical skills on technical skills.

CONCLUSIONS

Though literature on the relationship between technical and non-technical skills remains scarce, the included studies on technical skills and non-technical skills such as mental training suggest such a relationship exists. This implies that the separation of the skill sets is not necessarily beneficial for the outcome of SBST. A shift towards seeing technical and non-technical skills as intertwined may enhance learning outcomes from SBST.

Video-based training of situation awareness enhances minimally invasive surgical performance: a randomized controlled trial

BACKGROUND

Many training curricula were introduced to deal with the challenges that minimally invasive surgery (MIS) presents to the surgeon. Situational awareness (SA) is the ability to process information effectively. It depends on general cognitive abilities and can be divided into three steps: perceiving cues, linking cues to knowledge and understanding their relevance, and predicting possible outcomes. Good SA is crucial to predict and avoid complications and respond efficiently. This study aimed to introduce the concept of SA into laparoscopic training.

METHODS

This is a prospective, randomized, controlled study conducted at the MIS Training Center of Heidelberg University Hospital. Video sessions showing the steps of the laparoscopic cholecystectomy (LC) were used for cognitive training. The intervention group trained SA with interposed questions inserted into the video clips. The identical video clips, without questions, were presented to the control group. Performance was assessed with validated scores such as the Objective Structured Assessment of Technical Skills (OSATS) during LC.

RESULTS

72 participants were enrolled of which 61 were included in the statistical analysis. The SA-group performed LC significantly better (OSATS-Score SA: 67.0 ± 11.5 versus control: 59.1 ± 14.0, p value = 0.034) and with less errors (error score SA: 3.5 ± 1.9 versus control: 4.7 ± 2.0, p value = 0.027). No difference in the time taken to complete the procedure was found. The benefit assessment analysis showed no difference between the groups in terms of perceived learning effect, concentration, or expediency. However, most of the control group indicated retrospectively that they believed they would have benefitted from the intervention.

CONCLUSION

This study suggests that video-based SA training for laparoscopic novices has a positive impact on performance and error rate. SA training should thus be included as one aspect besides simulation and real cases in a multimodal curriculum to improve the efficiency of laparoscopic surgical skills training.

Impact of sleep deficiency on surgical performance: a prospective assessment

STUDY OBJECTIVES

Sleep deficiency can adversely affect the performance of resident physicians, resulting in greater medical errors. However, the impact of sleep deficiency on surgical outcomes, particularly among attending surgeons, is less clear.

METHODS

Sixty attending surgeons from academic and community departments of surgery or obstetrics and gynecology were studied prospectively using direct observation and self-report to explore the effect of sleep deprivation on patient safety, operating room communication, medical errors, and adverse events while operating under 2 conditions, post-call (defined as > 2 hours of nighttime clinical duties) and non-post-call.

RESULTS

Each surgeon contributed up to 5 surgical procedures post-call and non-post-call, yielding 362 cases total (150 post-call and 210 non-post-call). Most common were caesarian section and herniorrhaphy. Hours of sleep on the night before the operative procedure were significantly less post-call (4.98 ± 1.41) vs non-post-call (6.68 ± 0.88, P < .01). Errors were infrequent and not related to hours of sleep or post-call status. However, Non-Technical Skills for Surgeons ratings demonstrated poorer performance while post-call for situational awareness, decision-making, and communication/teamwork. Fewer hours of sleep also were related to lower ratings for situational awareness and decision-making. Decreased self-reported alertness was observed to be associated with increased procedure time.

CONCLUSIONS

Sleep deficiency in attending surgeons was not associated with greater errors during procedures performed during the next day. However, procedure time was increased, suggesting that surgeons were able to compensate for sleep loss by working more slowly. Ratings on nontechnical surgical skills were adversely affected by sleep deficiency.

CITATION

Quan SF, Landrigan CP, Barger LK, et al. Impact of sleep deficiency on surgical performance: a prospective assessment. J Clin Sleep Med. 2023;19(4):673-683.

Leadership Development Among Junior Surgery Residents: Communication and Perception

INTRODUCTION

Leadership is necessary for effective health care teams, particularly for surgeons. Trainees similarly must acquire foundational leadership skills to maximize effectiveness. However, surgical leadership is rarely formally assessed, particularly for junior trainees. We aimed to establish themes of communication, perception and engagement styles, as well as strengths and weaknesses among junior surgical residents at a single institution.

METHODS

The Data Dome Inc. (datadome.com) DISC personality assessment was administered in 2018-2021 to junior residents at an academic general surgery training program at a single institution. Resident demographics were recorded, and themes from deidentified reports were analyzed by year (PGY-1 and PGY-2) using JMP 16 Pro Text Explorer.

RESULTS

PGY-1 communication was most frequently described as "accomplished best by well-defined avenues" with "duties and responsibilities of others who will be involved explained" in "friendly terms." PGY-2 communication involved "deal [ing] with people," "strong feelings about a particular problem," and being "good at giving verbal and nonverbal feedback." In ideal environments, PGY-1s self-perceived as "good listener [s]," "good-natured," and "team player [s]." However, under stress, PGY-1s were perceived by others as "poor listener [s]," "self-promoter [s]," "detached," and "insensitive." In ideal environments, PGY-2s were also "good listener [s]," "good-natured," and "team player [s]." However, under stress, PGY-2 external perception was "overly confident," "poor listener [s]," and "self-promoter [s]."

CONCLUSIONS

Clear expectations, friendly work environments, and opportunities to succeed are key to effectively train junior surgical residents. In environments where time is often a limited resource, surgical simulation, stress training, and standardized teaching methods from attending surgeons are needed to develop competent trainees.

How Do Resident Surgeons Identify Operative Case Complexity? An Analysis of Resident versus Attending Perceptions

OBJECTIVE

Accurate recognition of patient-related complexity of an operation is critical for appropriate surgical decision making. It is not yet understood whether general surgery residents are able to accurately assess the relative complexity of a given operative case. This study investigates the agreement of case complexity ratings between residents and attending surgeons and explores whether resident-related factors correlate with any discordance in perception of patient-related operative complexity.

DESIGN

Residents and attending surgeons rated the relative complexity of completed cases on a 3 point scale via the SIMPL (Society for Improving Medical Professional Learning) operative assessment smartphone app. Additional trainee demographic data, autonomy ratings, and performance ratings were also obtained from the SIMPL registry for each rated case. Complexity agreement was defined as an equal rating between the resident and attending and assigned a value of zero. Over-estimate ratings were assigned a positive value and under-estimate ratings were assigned a negative value. Trends in complexity agreement were analyzed using descriptive statistics and mixed-effects models.

RESULTS

A total of 43,179 general surgery cases were rated by 1946 categorical general surgery residents and 1520 attending surgeons between 2015 and 2020. Residents and attendings agreed on case complexity in 63.23% of cases, while the residents overestimated complexity in 13.37% of cases and underestimated complexity in 23.40% of cases. Every level of resident except post-graduate year 2 had similar rates of agreement about the complexity of a procedure, while residents who received a higher autonomy rating were more likely to be in agreement with the faculty raters (OR 1.12, 95% CI 1.06-1.19).

CONCLUSIONS

The results of this study suggest that general surgery residents inaccurately perceive the patient-related complexity of a given case approximately one third of the time. Greater experience and operative autonomy appear to be associated with higher complexity agreement. Future research into factors influencing perceived case complexity may provide insight into how to best implement new teaching for surgical residents regarding the concept of case complexity.

Chairless Chairs for Orthopedic Surgery Purpose – A Literature Review

Musculoskeletal disorders are often found in various types of work, including surgeons. Standing working position is immobile and rigid when performing surgical operations. The equipment used is less ergonomic which is the main parameter. The surgeon profession belongs to the category of the high-risk profession and has the potential to experience musculoskeletal disorders. Surgeons who suffer musculoskeletal disorders sense disease start from mild-to-severe due to the muscles receiving static loads frequently in the long-term. The emergence of musculoskeletal disorders can be caused by working environment conditions and standing position while working, causing injury to joints, vertebral discs, nerves, cartilage, tendons, and muscles. This paper describes in extensive the potential for reducing musculoskeletal problems with the use of a chairless chair for surgeons in carrying out operations. Musculoskeletal problems in surgery and the use of chairless chairs have been further explored to close the existing research gap.

Effects of shared mental models in teams performing video-assisted thoracoscopic surgery lobectomy

BACKGROUND

Important non-technical skills enable operating teams to establish shared mental models (SMMs). The importance of SMMs in regards to surgical performance and peri-operative outcomes remains to be investigated. The aim of this study was to explore whether shared mental models (SMMs) of team resources and the current situation, respectively, were predictive of technical skills, duration of surgery, and amount of intra-operative bleeding in video-assisted thoracoscopic surgery (VATS).

METHODS

A prospective multi-center observational study was conducted at four tertiary academic hospitals during VATS lobectomy procedures. Data included pre-operative and post-operative questionnaires answered by each of the six team members to measure the SMMs; thoracoscopic video recordings assessed using the previously validated VATS lobectomy Assessment Tool (VATSAT); surgery-related time stamps; and amount (volume) of intra-operative bleeding. Linear regression analyses were conducted to adjust for confounders.

RESULTS

Fifty-eight lobectomy procedures were included. Median (interquartile range) VATSAT score was 33.3 (scale 8-40) duration of surgery 101 min (88-123), and amount of intra-operative bleeding 100 ml (20-150). The mean (± SD) of teams' SMMs of the current situation was 20 (± 5). They were not predictive of the surgeons' technical skills, but every one point increase in SMM score significantly predicted a 1 min 52 s decrease in duration of surgery and an 11% decrease in amount of bleeding. The SMMs of team resources were not predictive of any outcomes.

CONCLUSION

VATS teams' superior SMMs of the current situation related to significantly shorter duration of surgery and decreased intra-operative bleeding, indicating an effect on team performance and patient care.

TRIAL REGISTRATION

NCT02999113 at http://www.clinicaltrials.gov .

Virtual non-technical skills assessment training is an effective, scalable approach for novice raters

OBJECTIVES

The COVID-19 pandemic has forced a creative transition to virtual platforms due to physical distancing and travel restrictions. We designed and tested a highly scalable virtual training curriculum for novice raters using the Oxford NOTECHS non-technical skills rating system.

DESIGN

A three-day training course comprising virtual didactics, virtually facilitated simulations, and independent live observations was implemented. NOTECHS scores were submitted for eleven standardized video simulations and four live operations. Intraclass correlation coefficients (ICCs) were calculated for total NOTECHS scores and subcomponent scores. Raters previously trained in-person with the same standardized videos served as a comparator group for equivalence testing.

SETTING

All study activities were conducted in a large academic tertiary referral center in Singapore as part of an ongoing surgical safety initiative.

PARTICIPANTS

Seven staff members underwent training (three virtually and four in-person).  None had prior surgical experience or non-technical skills assessment training.

RESULTS

ICCs for total NOTECHS scores were 0.85 (95% CI, 0.73-0.98) for virtually trained raters and 0.83 for those trained in-person (95% CI, 0.68-0.99).  Scores were equivalent between groups within a 10% margin.

CONCLUSIONS

Non-technical skills assessment can be reliably taught in a highly scalable virtual format. Virtual NOTECHS training is a valuable tool for educational and quality improvement initiatives during the COVID-19 pandemic and for centers that lack ready access to onsite non-technical skills training expertise.

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.

Cognitive workload, complications and visual outcomes of phacoemulsification cataract surgery: Three-dimensional versus conventional microscope

PURPOSE

To compare the surgical workload, complications, and visual outcomes using the three-dimensional visualization system with the conventional microscope in phacoemulsification cataract surgery.

DESIGN

Prospective, non-randomized, open-label interventional study.

METHODS

All patients underwent phacoemulsification cataract surgery using the three-dimensional visualization system or conventional microscope.

RESULTS

Of the 203 eyes, 80 underwent surgery with the three-dimensional system while 123 underwent with the conventional microscope. No difference was noted in the total surgical duration, complication rates, and visual outcomes between the two groups. However, capsulorhexis was significantly faster using the conventional microscope while posterior chamber intraocular lens insertion was quicker using the three-dimensional system. In terms of cognitive workload comparison, no difference was seen in the surgeons' heart rate, oxygen saturation levels, and surgery task load index total workload score and workload score for all six dimensions of the questionnaire, between the three-dimensional system and conventional microscope groups. As compared to baseline, the heart rate increased significantly during all surgical steps and at the end in both groups. When compared to baseline, the oxygen saturation levels were significantly raised during capsulorhexis, irrigation, and aspiration and posterior chamber intraocular lens insertion and at the end of the surgery in the three-dimensional group and during incision and at the end of the surgery in the conventional microscope group.

CONCLUSIONS

The duration of surgery, complications, and visual acuity outcomes remain unaffected while performing phacoemulsification cataract surgeries with the three-dimensional viewing system when compared to the conventional microscopes. Moreover, the surgeons' cognitive workload too remains unaffected while utilizing this revolutionary three-dimensional surgical technology.

Human factors application for healthcare teams in low- and medium-income countries (LMIC) to help improve patient safety and performance

Mistakes will always happen whether at work or in our personal lives. We can never completely eliminate error, but learning and disseminating lessons from these mistakes to others is essential. Human factors application for colleagues in healthcare, particularly in low- and medium-income countries (LMIC) can greatly improve patient safety and aid better team working and staff morale. Factors such as hunger, dehydration anger, and tiredness, all reduce personal performance and can raise the risk of personal error. It is vital that we understand and optimize interaction within the healthcare team members. As part of this, ineffective communication, steep hierarchy and loss of situational awareness can lead to compromised patient safety and potentially serious error. In this paper, we provide a brief overview of human factors for healthcare colleagues in LMIC. We highlight ways to reduce the chances of error and improve patient safety by recognizing and applying various human factors to our day to day practices.

European Association of Oral Medicine 2021 Conference - Crispian Scully Lecture: Applying Human Factors to Improve Patient Safety and Performance

BACKGROUND

This paper is a synopsis of the Crispian Scully Lecture, presented by one of the authors (PAB), at the 2021 European Association of Oral Medicine (EAOM) Conference in Lisbon, Portugal. It provides an overview of human factors that affect individuals and teams, highlighting ways to reduce the chances of error and improve patient safety.

DISCUSSION AND CONCLUSION

Error is an inevitable and 'normal' part of being human, and it can never be completely eliminated, though learning from mistakes is essential. Human factor application in health care can greatly improve patient safety and lead to better team working and staff morale. Personal factors including tiredness, hunger, dehydration and stress can all reduce performance and raise the risk of clinical error. It is also important to understand and optimise interaction within the clinical team. Poor communication, steep hierarchy and loss of situational awareness can all potentially compromise patient safety.

Situation awareness and the mitigation of risk associated with patient deterioration: A meta-narrative review of theories and models and their relevance to nursing practice

BACKGROUND

Accurate situation awareness has been identified as a critical component of effective deteriorating patient response systems and an essential patient safety skill for nursing practice. However, situation awareness has been defined and theorised from multiple perspectives to explain how individuals, teams and systems maintain awareness in dynamic task environments.

AIM

Our aim was to critically analyse the different approaches taken to the study of situation awareness in healthcare and explore the implications for nursing practice and research as it relates to clinical deterioration in ward contexts.

METHODS

We undertook a meta-narrative review of the healthcare literature to capture how situation awareness has been defined, theorised and studied in healthcare. Following an initial scoping review, we conducted an extensive search of ten electronic databases and included any theoretical, empirical or critical papers with a primary focus on situation awareness in an inpatient hospital setting. Included papers were collaboratively categorised in accordance with their theoretical framing, research tradition and paradigm with a narrative review presented.

RESULTS

A total of 120 papers were included in this review. Three overarching narratives reflecting philosophical, patient safety and solution focussed framings of situation awareness and seven meta-narratives were identified as follows: individual, team and systems perspectives of situation awareness (meta-narratives 1-3), situation awareness and patient safety (meta-narrative 4), communication tools, technologies and education to support situation awareness (meta-narratives 5-7). We identified a concentration of literature from anaesthesia and operating rooms and a body of research largely located within a cognitive engineering tradition and a positivist research paradigm. Endsley's situation awareness model was applied in over 80% of the papers reviewed. A minority of papers drew on alternative situation awareness theories including constructivist, collaborative and distributed perspectives.

CONCLUSIONS

Nurses have a critical role in identifying and escalating the care of deteriorating patients. There is a need to build on prior studies and reflect on the reality of nurse's work and the constraints imposed on situation awareness by the demands of busy inpatient wards. We suggest that this will require an analysis that complements but goes beyond the dominant cognitive engineering tradition to reflect the complex socio-cultural reality of ward-based teams and to explore how situation awareness emerges in increasingly complex, technologically enabled distributed healthcare systems.

Are Trauma Surgery Simulation Courses Beneficial in Low- and Middle-Income Countries—A Systematic Review and Meta-Analysis

Despite trauma-related injuries being a leading cause of death worldwide, low- and middle-income countries (LMICs) lack the infrastructure and resources required to offer immediate surgical care, further perpetuating the risk of morbidity and mortality. In high-income countries, trauma surgery simulation courses are routinely delivered to surgeons, teaching the fundamental skills of operative trauma. This study aimed to assess whether similar courses are beneficial in LMICs and how they can be improved. We performed a systematic review and meta-analysis using MEDLINE, Embase and Google Scholar, analysing studies evaluating trauma surgery simulation in LMICs. The outcomes measured included clinical knowledge improvement, participant confidence and general course-feedback. The review was carried out in-line with PRISMA guidelines. Five studies were included, summating a population of 172 participants. In three studies, meta-analysis showed an overall significant weighted mean improvement of knowledge post-course by 22.91% (95%CI 19.53, 26.29; p < 0.00001; I2 = 0%). One study reported a significant increase in participant confidence for 20/22 of operative skills taught (p < 0.04). We conclude that these courses are beneficial in LMICs; however, further research is necessary to establish the optimum course design, and whether patient outcomes are improved following their implementation. Collaboration between international trauma institutions is essential for closing the educational resource inequality gap between higher- and lower-income countries.

Teaching and Evaluating Nontechnical Skills for General Surgery

Surgical training programs have long used quantitative measures of knowledge, as well as subjective evaluation of technical skills, to define the competence of trainees. However, a growing body of literature has shown the importance of nontechnical surgical skills as vital components of quality surgical care. Institutions must train nontechnical surgical skills, including leadership, communication, teamwork, situational awareness, and decision making, and incorporate these attributes into their evaluative processes to maximally enhance surgical performance at every career stage.

Stress and resident interdisciplinary team performance: Results of a pilot trauma simulation program

BACKGROUND

Excessive stress negatively impacts surgical residents' technical performance. The effect of stress on trainee nontechnical skills, however, is less well studied. Given that nontechnical skills are known to impact clinical performance, the purpose of this study was to assess the relationship between residents' perceived stress and nontechnical skills during multidisciplinary trauma simulations.

METHODS

First-year surgery and emergency medicine residents voluntarily participated in this study. Residents participated in 3 trauma simulations across 2 training sessions in randomly assigned teams. Each team's nontechnical skills were evaluated by faculty using the Trauma Nontechnical Skills scale. The Trauma Nontechnical Skills scale consists of 5 items: leadership, cooperation, communication, assessment, and situation awareness/coping with stress. After each scenario, residents completed the 6-item version of the State-Trait Anxiety Inventory and the Surgery Task Load Index to detail their perceived stress and workload during scenarios. Linear regressions were run to assess relationships between stress, workload, and nontechnical skills.

RESULTS

Twenty-five residents participated in the first simulation day, and 24 residents participated in the second simulation day. Results from regressions revealed that heightened stress and workload predicted significantly lower nontechnical skills performance during trauma scenarios. In regard to specific aspects of nontechnical skills, residents' heightened stress and workload predicted statistically significant lower situation awareness and decision-making during trauma scenarios.

CONCLUSION

Residents' perceived stress and workload significantly impaired their nontechnical skills during trauma simulations. This finding highlights the need to offer stress management and performance-optimizing mental skills training to trainees to lower their stress and optimize nontechnical skills performance during challenging situations.

Non-Technical Skill Assessment and Mental Load Evaluation in Robot-Assisted Minimally Invasive Surgery

BACKGROUND: Sensor technologies and data collection practices are changing and improving quality metrics across various domains. Surgical skill assessment in Robot-Assisted Minimally Invasive Surgery (RAMIS) is essential for training and quality assurance. The mental workload on the surgeon (such as time criticality, task complexity, distractions) and non-technical surgical skills (including situational awareness, decision making, stress resilience, communication, leadership) may directly influence the clinical outcome of the surgery. METHODS: A literature search in PubMed, Scopus and PsycNet databases was conducted for relevant scientific publications. The standard PRISMA method was followed to filter the search results, including non-technical skill assessment and mental/cognitive load and workload estimation in RAMIS. Publications related to traditional manual Minimally Invasive Surgery were excluded, and also the usability studies on the surgical tools were not assessed. RESULTS: 50 relevant publications were identified for non-technical skill assessment and mental load and workload estimation in the domain of RAMIS. The identified assessment techniques ranged from self-rating questionnaires and expert ratings to autonomous techniques, citing their most important benefits and disadvantages. CONCLUSIONS: Despite the systematic research, only a limited number of articles was found, indicating that non-technical skill and mental load assessment in RAMIS is not a well-studied area. Workload assessment and soft skill measurement do not constitute part of the regular clinical training and practice yet. Meanwhile, the importance of the research domain is clear based on the publicly available surgical error statistics. Questionnaires and expert-rating techniques are widely employed in traditional surgical skill assessment; nevertheless, recent technological development in sensors and Internet of Things-type devices show that skill assessment approaches in RAMIS can be much more profound employing automated solutions. Measurements and especially big data type analysis may introduce more objectivity and transparency to this critical domain as well. SIGNIFICANCE: Non-technical skill assessment and mental load evaluation in Robot-Assisted Minimally Invasive Surgery is not a well-studied area yet; while the importance of this domain from the clinical outcome's point of view is clearly indicated by the available surgical error statistics.

Clinical Evaluation of Intraoperative Near Misses in Laparoscopic Rectal Cancer Surgery

OBJECTIVE

To investigate the frequency, nature, and severity of intraoperative adverse near miss events within advanced laparoscopic surgery and report any associated clinical impact.

BACKGROUND

Despite implementation of surgical safety initiatives, the intraoperative period is poorly documented with evidence of underreporting. Near miss analyses are undertaken in high-risk industries but not in surgical practice.

METHODS

Case video and data from 2 laparoscopic total mesorectal excision randomized controlled trials were analyzed (ALaCaRT ACTRN12609000663257, 2D3D ISRCTN59485808). Intraoperative adverse events were identified and categorized using the observational clinical human reliability analysis technique. The EAES classification was applied by 2 blinded assessors. EAES grade 1 events (nonconsequential error, no damage, or need for correction) were considered near misses. Associated clinical impact was assessed with early morbidity and histopathology outcomes.

RESULTS

One hundred seventy-five cases contained 1113 error events. Six hundred ninety-eight (62.7%) were near misses (median 3, IQR 2-5, range 0-15) with excellent inter-rater and test-retest reliability (κ=0.86, 95% CI 0.83-0.89, P < 0.001 and κ=0.88, 95% CI 0.85-0.9, P < 0.001 respectively). Significantly more near misses were seen in patients who developed early complications (4 (3-6) vs. 3 (2-4), P < 0.001). Higher numbers of near misses were seen in patients with more numerous (P = 0.002) and more serious early complications (P = 0.003). Cases containing major intraoperative adverse events contained significantly more near misses (5 (3-7) vs. 3 (2-5), P < 0.001) with a major event observed for every 19.4 near misses.

CONCLUSION

Intraoperative adverse events and near misses can be reliably and objectively captured in advanced laparoscopic surgery. Near misses are commonplace and closely associated with morbidity outcomes.

Attending Surgeons Demonstrate Greater Correlations of Skill Assessment and Anticipation of Adverse Events Than Residents During Laparoscopic Cholecystectomy

BACKGROUND

Surgical training includes the development of technical and nontechnical skills. While technical skills are more easily quantified, nontechnical skills such as situation awareness (SA) are more difficult to measure and quantify. This study investigated the relationships between different SA elements and expertise.

METHODS

Twenty attending and resident surgeons rated their anticipation of an impending adverse event while watching 20 videos of laparoscopic cholecystectomies with and without adverse events. After watching each video, they assessed surgeon skills and self-assessed their anticipation ratings. All participants answered a general confidence questionnaire before and after the study.

RESULTS

Videos with adverse events led to significantly higher anticipation of adverse events (P < 0.001), lower surgeon skill rating (P < 0.001), and higher self-assessment in their anticipation ratings (P < 0.001) across both participant groups. General confidence was significantly lower for residents than that for attending surgeons (P < 0.001). Compared with the residents, attendings exhibited stronger and more stable correlations between measurements of SA. When viewing videos with adverse events, attendings showed significantly higher correlation between anticipation of an impending adverse event and skill assessment of the surgeon (P = 0.005).

CONCLUSIONS

This study investigated how different elements of SA and their relationships were influenced by experience. The results indicated that attendings had stronger and more stable correlations between SA elements than residents, demonstrating how measurement correlations could be meaningful and sensitive indicators of expertise and autonomy readiness.

Surgeon stress negatively affects their non-technical skills in the operating room

BACKGROUND

Poor surgeons' non-technical skills (NTS) and excessive stress and workload are known contributors to surgical errors. Our aim was to examine the relationship between surgeons' stress and workload, and their observed NTS intraoperatively.

METHODS

Surgeon's NTS were rated in the operating room (OR) by trained observers. Surgeon stress, workload, familiarity with the OR team, prior experience, and case difficulty were captured. Relationships between variables were assessed.

RESULTS

Fifteen surgeons participated in our study. Agreement among raters was high for NTS observations (ICC range = 0.56-0.96). Stress was negatively correlated with situation awareness, and workload was negatively correlated with decision making. Less familiarity among the team was correlated with higher stress.

CONCLUSIONS

Surgeons' stress and workload negatively affected their NTS in the OR. Further, unfamiliarity with the surgical team contributed to surgeon's stress. Methods to reduce surgeons' stress and workload such as mental skills training should be considered.

Immersive virtual reality enables technical skill acquisition for scrub nurses in complex revision total knee arthroplasty

INTRODUCTION

Immersive Virtual Reality (iVR) is a novel technology which can enhance surgical training in a virtual environment without supervision. However, it is untested for the training to select, assemble and deliver instrumentation in orthopaedic surgery-typically performed by scrub nurses. This study investigates the impact of an iVR curriculum on this facet of the technically demanding revision total knee arthroplasty.

MATERIALS AND METHODS

Ten scrub nurses completed training in four iVR sessions over a 4-week period. Initially, nurses completed a baseline real-world assessment, performing their role with real equipment in a simulated operation assessment. Each subsequent iVR session involved a guided mode, where the software taught participants the procedural choreography and assembly of instrumentation in a simulated operating room. In the latter three sessions, nurses also undertook an assessment in iVR. Outcome measures were related to procedural sequence, duration of surgery and efficiency of movement. Transfer of skills from iVR to the real world was assessed in a post-training simulated operation assessment. A pre- and post-training questionnaire assessed the participants knowledge, confidence and anxiety.

RESULTS

Operative time reduced by an average of 47% across the 3 unguided sessions (mean 55.5 ± 17.6 min to 29.3 ± 12.1 min, p > 0.001). Assistive prompts reduced by 75% (34.1 ± 16.8 to 8.6 ± 8.8, p < 0.001), dominant hand motion by 28% (881.3 ± 178.5 m to 643.3 ± 119.8 m, p < 0.001) and head motion by 36% (459.9 ± 99.7 m to 292.6 ± 85.3 m, p < 0.001). Real-world skill improved from 11% prior to iVR training to 84% correct post-training. Participants reported increased confidence and reduced anxiety in scrubbing for rTKA procedures (p < 0.001).

CONCLUSIONS

For scrub nurses, unfamiliarity with complex surgical procedures or equipment is common. Immersive VR training improved their understanding, technical skills and efficiency. These iVR-learnt skills transferred into the real world.

Teamwork and Surgical Team-Based Training

Effective teamwork, both in and out of the operating room, is an essential component of safe and efficient surgical performance. There are multiple available assessment tools for evaluating teamwork and important contributors to teamwork such as safety culture and nontechnical skills. Multiple types of interventions exist to improve and train providers on teamwork, and many have been demonstrated to improve not only teamwork but also patient outcomes. Teamwork strategies can be adapted to different contexts, based on provider needs and resources.

Key components of a hepatobiliary surgery curriculum for general surgery residents: results of the FULCRUM International Delphi consensus

BACKGROUND

In general surgery residency, hepatobiliary training varies significantly across the world. The aim of this study was to establish an international consensus among hepatobiliary surgeons on components of a hepatobiliary curriculum for general surgery residents.

METHODS

A three-round modified Delphi technique was employed. Fifty-two hepatobiliary surgeons involved in general surgery training programs were invited. An initial questionnaire was developed by a group of experts in hepatobiliary and educational research after a systematic literature review. It comprised 90 statements about knowledge, technical skills, attitudes, and postoperative care. Panelists could add or alter items. The survey was delivered electronically and the panel was instructed to score the items based on 5-point Likert scale. Consensus was reached when at least 80% of panelists agreed on a statement with Cronbach's alpha value >0.8.

RESULTS

Forty-one (79%) experts have participated. Sixteen panelists are based in Asia, 14 in Europe, and 11 in the Americas. Eighty percent of all proposed skills (81/101) were considered fundamental including knowledge (39/43), technical skills (16/32), attitude (15/15), and postoperative care (11/11).

CONCLUSION

An international consensus was achieved on components of a hepatobiliary curriculum. Acquiring broad knowledge is fundamental during residency. Advanced liver resection techniques require specialized hepatobiliary training.

Optimizing the robotic surgery team: an operations management perspective

INTRODUCTION AND HYPOTHESIS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Accuracy and usefulness in assessing proficiency of the observational clinical human reliability assessment checklist of the open inguinal hernia repair procedure: A cross-sectional study

BACKGROUND

The Observational Clinical Human Reliability Assessment (OCHRA) can be used to score errors during surgical procedures. To construct an OCHRA-checklist, steps, substeps, and hazards of a surgical procedure need to be defined. A step-by-step framework was developed to segment surgical procedures into steps, substeps, and hazards. The first aim of this study was to investigate if the step-by-step framework could be used to construct an accurate Lichtenstein open inguinal hernia repair (LOIHR) stepwise description. The second aim was to investigate if the OCHRA-checklist based on this stepwise description was accurate and useful for surgical training and assessment.

MATERIALS AND METHODS

Ten expert surgeons rated statements regarding the accuracy of the LOIHR stepwise description, the accuracy, and the usefulness of the LOIHR OCHRA-checklist (eight, seven, and six statements, respectively) using a 5-point Likert scale. One-sample Wilcoxon signed-rank test was used to compare the outcomes to the neutral value of 3.

RESULTS

The accuracy of the stepwise description and the accuracy and usefulness of the OCHRA-checklist were rated statistically significantly higher than the neutral value of 3 (median 4.75 [5.00-4.00] with p = .009, median 5.00 [5.00-4.00] with p = .012, median 4.00 [5.00-4.00] with p = .047, respectively). The experts rated the OCHRA-checklist to be useful for the training (5.00 [5.00-4.00], p = .009), and assessment (4.50 [5.00-4.00], p = .010) of surgical residents.

CONCLUSION

This preliminary study showed that the stepwise LOIHR description constructed using the step-by-step framework was found to be accurate. The LOIHR OCHRA-checklist developed using the stepwise description was also accurate, and particularly useful for the training and assessment of proficiency of surgical residents.

Physiological correlates of cognitive load in laparoscopic surgery

Laparoscopic surgery can be exhausting and frustrating, and the cognitive load experienced by surgeons may have a major impact on patient safety as well as healthcare economics. As cognitive load decreases with increasing proficiency, its robust assessment through physiological data can help to develop more effective training and certification procedures in this area. We measured data from 31 novices during laparoscopic exercises to extract features based on cardiac and ocular variables. These were compared with traditional behavioural and subjective measures in a dual-task setting. We found significant correlations between the features and the traditional measures. The subjective task difficulty, reaction time, and completion time were well predicted by the physiology features. Reaction times to randomly timed auditory stimuli were correlated with the mean of the heart rate (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$r = - 0.29$$\end{document}r=-0.29) and heart rate variability (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$r = 0.4$$\end{document}r=0.4). Completion times were correlated with the physiologically predicted values with a correlation coefficient of 0.84. We found that the multi-modal set of physiology features was a better predictor than any individual feature and artificial neural networks performed better than linear regression. The physiological correlates studied in this paper, translated into technological products, could help develop standardised and more easily regulated frameworks for training and certification.

Association of Coworker Reports About Unprofessional Behavior by Surgeons With Surgical Complications in Their Patients

Importance

For surgical teams, high reliability and optimal performance depend on effective communication, mutual respect, and continuous situational awareness. Surgeons who model unprofessional behaviors may undermine a culture of safety, threaten teamwork, and thereby increase the risk for medical errors and surgical complications.

Objective

To test the hypothesis that patients of surgeons with higher numbers of reports from coworkers about unprofessional behaviors are at greater risk for postoperative complications than patients whose surgeons generate fewer coworker reports.

Design, Setting, and Participants

This retrospective cohort study assessed data from 2 geographically diverse academic medical centers that participated in the National Surgical Quality Improvement Program (NSQIP) and recorded and acted on electronic reports of safety events from coworkers describing unprofessional behavior by surgeons. Patients included in the NSQIP database who underwent inpatient or outpatient operations at 1 of the 2 participating sites from January 1, 2012, through December 31, 2016, were eligible. Patients were excluded if they were younger than 18 years on the date of the operation or if the attending surgeon had less than 36 months of monitoring for coworker reports preceding the date of the operation. Data were analyzed from August 8, 2018, through April 9, 2019.

Exposures

Coworker reports about unprofessional behavior by the surgeon in the 36 months preceding the date of the operation.

Main Outcomes and Measures

Postoperative surgical or medical complications, as defined by the NSQIP, within 30 days of the operation.

Results

Among 13 653 patients in the cohort (54.0% [7368 ] female; mean [SD] age, 57 [16] years) who underwent operations performed by 202 surgeons (70.8% [143] male), 1583 (11.6%) experienced a complication, including 825 surgical (6.0%) and 1070 medical (7.8%) complications. Patients whose surgeons had more coworker reports were significantly more likely to experience any complication (0 reports, 954 of 8916 [10.7%]; ≥4 reports, 294 of 2087 [14.1%]; P < .001), any surgical complication (0 reports, 516 of 8916 [5.8%]; ≥4 reports, 159 of 2087 [7.6%]; P < .01), or any medical complication (0 reports, 634 of 8916 [7.1%]; ≥4 reports, 196 of 2087 [9.4%]; P < .001). The adjusted complication rate was 14.3% higher for patients whose surgeons had 1 to 3 reports and 11.9% higher for patients whose surgeons had 4 or more reports compared with patients whose surgeons had no coworker reports (P = .05).

Conclusions and Relevance

Patients whose surgeons had higher numbers of coworker reports about unprofessional behavior in the 36 months before the patient's operation appeared to be at increased risk of surgical and medical complications. These findings suggest that organizations interested in ensuring optimal patient outcomes should focus on addressing surgeons whose behavior toward other medical professionals may increase patients' risk for adverse outcomes.

An observational study of technical and non-technical skills in advanced life support in the clinical setting

OBJECTIVE

Technical skills (TS) and non-technical skills (NTS) are the primary elements ensuring patient safety during advanced life support (ALS) and effective crisis resource management (CRM). Both skills are needed to perform high-quality ALS, though they are traditionally practiced separately. The evidence of the association between NTS and TS in high-quality ALS performance is insufficient. Hence, we aimed to evaluate the association between the skills in real-life in-hospital ALS situations.

METHODS

We video recorded real-life in-hospital ALS situations, analyzed TS and NTS demonstrated in them with an instrument measuring TS and NTS, and tested the linear association between NTS and TS using a linear mixed model.

RESULTS

Among 50 real-life in-hospital ALS situations that we recorded, 20 had adequate data for analysis. NTS and TS total scores were associated with one another (slope 0.48, P < 0.001). All NTS subcategories were associated with the TS total score (slopes ranging from 0.29 to 0.39, P < 0.001). The NTS total score and TS subcategories (chest compression quality, ventilation quality, rhythm control and defibrillation quality) were associated with one another (slopes ranging from 0.37 to 0.56, P < 0.01).

CONCLUSIONS

The resuscitation teams who demonstrated good NTS also performed the technical aspects of ALS better. The results suggest that NTS and TS have an association with one another in real-life in-hospital ALS situations. NTS performance had the most evident association with chest compression quality and rhythm control and defibrillation quality; these are considered the most crucial elements affecting outcomes of ALS. The findings of the study present novel information of what and why to emphasize in ALS training.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT03017144.

Validity of the Medi-StuNTS behavioural marker system: assessing the non-technical skills of medical students during immersive simulation

Background

The Medical Students’ Non-Technical Skills (Medi-StuNTS) behavioural marker system (BMS) is the first BMS to be developed specifically for medical students to facilitate training in non-technical skills (NTS) within immersive simulated acute care scenarios. In order to begin implementing the tool in practice, validity evidence must be sought. We aimed to assess the validity of the Medi-StuNTS system with reference to Messick’s contemporary validity framework.

Methods

Two raters marked video-recorded performances of acute care simulation scenarios using the Medi-StuNTS system. Three groups were marked: third-year and fourth-year medical students (novices), final-year medical students (intermediates) and core medical trainees (experts). The scores were used to make assessments of relationships to the variable of clinical experience through expert–novice comparisons, inter-rater reliability, observability, exploratory factor analysis, inter-rater disagreements and differential item functioning.

Results

A significant difference was found between the three groups (p<0.005), with experts scoring significantly better than intermediates (p<0.005) and intermediates scoring significantly better than novices (p=0.001). There was a strong positive correlation between the two raters’ scores (r=0.79), and an inter-rater disagreement of more than one point in less than one-fifth of cases. Across all scenarios, 99.7% of skill categories and 84% of skill elements were observable. Factor analysis demonstrated appropriate grouping of skill elements. Inconsistencies in test performance across learner groups were shown specifically in the skill categories of situation awareness and decision making and prioritisation.

Conclusion

We have demonstrated evidence for several aspects of validity of the Medi-StuNTS system when assessing medical students’ NTS during immersive simulation. We can now begin to introduce this system into simulation-based education to maximise NTS training in this group.

Objective assessment of surgical operative performance by observational clinical human reliability analysis (OCHRA): a systematic review

Background

Both morbidity and mortality data (MMD) and learning curves (LCs) do not provide information on the nature of intraoperative errors and their mechanisms when these adversely impact on patient outcome. OCHRA was developed specifically to address the unmet surgical need for an objective assessment technique of the quality of technical execution of operations at individual operator level. The aim of this systematic review was to review of OCHRA as a method of objective assessment of surgical operative performance.

Methods

Systematic review based on searching 4 databases for articles published from January 1998 to January 2019. The review complies with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines and includes original publications on surgical task performance based on technical errors during operations across several surgical specialties.

Results

Only 26 published studies met the search criteria, indicating that the uptake of OCHRA during the study period has been low. In 31% of reported studies, the operations were performed by fully qualified consultant/attending surgeons and by surgical trainees in 69% in approved training programs. OCHRA identified 7869 consequential errors (CE) during the conduct of 719 clinical operations (mean = 11 CEs). It also identified ‘hazard zones’ of operations and proficiency–gain curves (P-GCs) that confirm attainment of persistent competent execution of specific operations by individual trainee surgeons. P-GCs are both surgeon and operation specific.

Conclusions

Increased OCHRA use has the potential to improve patient outcome after surgery, but this is a contingent progress towards automatic assessment of unedited videos of operations. The low uptake of OCHRA is attributed to its labor-intensive nature involving human factors (cognitive engineering) expertise. Aside from faster and more objective peer-based assessment, this development should accelerate increased clinical uptake and use of the technique in both routine surgical practice and surgical training.

Measuring the teamwork performance of operating room teams: a systematic review of assessment tools and their measurement properties

Teamwork is fundamental to surgical patient safety but is inconsistently measured. While many tools have been developed for elective intraoperative situations, it is unclear which is the most robust. This systematic review aimed to identify tools to measure the teamwork of operating room teams. Studies were included if they examined the measurement properties of these tools. PsycINFO, Embase (via OVID), CINAHL, ERIC, Medline and Medline in Process (via OVID) were searched through to May 3, 2019, as were reference lists of included studies and previously published relevant reviews. Retrieved articles were screened and data extracted in duplicate by two independent reviewers. Quality was assessed using the COSMIN checklist. Of the 2121 references identified, 14 studies of six assessment tools were included. Tools were validated across various specialties, mostly in clinical rather than simulated settings. The Observational Teamwork Assessment for Surgery (OTAS) and Operating Theater Team Non-Technical Skills Assessment Tool (NOTECHS) were the most frequently investigated tools. Though acceptable for assessing teamwork, both NOTECHS and OTAS rely on the questionable assumption that the teamwork of a team is equivalent to the sum of individual performances. Future studies may investigate other assessment tools that assess the whole team as the unit of analysis along with the potential of these tools to provide healthcare providers with meaningful feedback in clinical practice.

Technical and Nontechnical Skills in Surgery: A Simulated Operating Room Environment Study

STUDY DESIGN

Observational simulation study.

OBJECTIVE

The goal of this study was to investigate the relationship between technical and nontechnical skills (NTS) in a simulated surgical procedure.

SUMMARY OF BACKGROUND DATA

Although surgeons' technical and NTS during surgery are crucial determinants for clinical outcomes, little literature is available in spine surgery. Moreover, evidence regarding how surgeons' technical and NTS are related is limited.

METHODS

A mixed-reality and full-scale simulated operating room environment was employed for the surgical team. Eleven surgeons performed the vertebroplasty procedure (VP). Technical skills (TS) were assessed using Objective Structured Assessment of Technical Skill scores and senior expert-evaluated VP outcome assessment. NTS were assessed with the Observational Teamwork Assessment for Surgery. Kendall-Tau-b tests were performed for correlations. We further controlled the influence of surgeons' experience (based on professional tenure and number of previous VPs performed).

RESULT

Surgeons' NTS correlated significantly with their technical performance (τ = 0.63; P = 0.006) and surgical outcome scores (τ = 0.60; P = 0.007). This association was attenuated when controlling for surgeons' experience.

CONCLUSION

Our results suggest that spine surgeons with higher levels of TS also apply better communication, leadership, and coordination behaviors during the procedure. Yet, the role of surgeons' experience needs further investigation for improving surgeons' intraoperative performance during spine surgery.

LEVEL OF EVIDENCE

3.

How do team experience and relationships shape new divisions of labour in robot-assisted surgery? A realist investigation

Safe and successful surgery depends on effective teamwork between professional groups, each playing their part in a complex division of labour. This article reports the first empirical examination of how introduction of robot-assisted surgery changes the division of labour within surgical teams and impacts teamwork and patient safety. Data collection and analysis was informed by realist principles. Interviews were conducted with surgical teams across nine UK hospitals and, in a multi-site case study across four hospitals, data were collected using a range of methods, including ethnographic observation, video recording and semi-structured interviews. Our findings reveal that as the robot enables the surgeon to do more, the surgical assistant's role becomes less clearly defined. Robot-assisted surgery also introduces new tasks for the surgical assistant and scrub practitioner, in terms of communicating information to the surgeon. However, the use of robot-assisted surgery does not redistribute work in a uniform way; contextual factors of individual experience and team relationships shape changes to the division of labour. For instance, in some situations, scrub practitioners take on the role of supporting inexperienced surgical assistants. These changes in the division of labour do not persist when team members return to operations that are not robot-assisted. This study contributes to wider literature on divisions of labour in healthcare and how this is impacted by the introduction of new technologies. In particular, we emphasise the need to pay attention to often neglected micro-level contextual factors. This can highlight behaviours that can be promoted to benefit patient care.

How effective is teamwork really? The relationship between teamwork and performance in healthcare teams: a systematic review and meta-analysis

OBJECTIVES

To investigate the relationship between teamwork and clinical performance and potential moderating variables of this relationship.

DESIGN

Systematic review and meta-analysis.

DATA SOURCE

PubMed was searched in June 2018 without a limit on the date of publication. Additional literature was selected through a manual backward search of relevant reviews, manual backward and forward search of studies included in the meta-analysis and contacting of selected authors via email.

ELIGIBILITY CRITERIA

Studies were included if they reported a relationship between a teamwork process (eg, coordination, non-technical skills) and a performance measure (eg, checklist based expert rating, errors) in an acute care setting.

DATA EXTRACTION AND SYNTHESIS

Moderator variables (ie, professional composition, team familiarity, average team size, task type, patient realism and type of performance measure) were coded and random-effect models were estimated. Two investigators independently extracted information on study characteristics in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

The review identified 2002 articles of which 31 were included in the meta-analysis comprising 1390 teams. The sample-sized weighted mean correlation was r=0.28 (corresponding to an OR of 2.8), indicating that teamwork is positively related to performance. The test of moderators was not significant, suggesting that the examined factors did not influence the average effect of teamwork on performance.

CONCLUSION

Teamwork has a medium-sized effect on performance. The analysis of moderators illustrated that teamwork relates to performance regardless of characteristics of the team or task. Therefore, healthcare organisations should recognise the value of teamwork and emphasise approaches that maintain and improve teamwork for the benefit of their patients.