Military Surgical Team Performance: The Impact of Familiarity, Team Size, and Nurse Anesthesia Students

Increased team familiarity for surgical time savings: Effective primarily in complex surgical cases

BACKGROUND

Cohesion between team members is critical for surgical performance. Our previous study has shown that the experience of working together (measured by Team Familiarity Score, TFS) helps reduce procedure time (PT). However, that conclusion was found in a relatively small sample size. With a large dataset including mixed general surgical procedures, we hypothesize that team familiarity makes a significant contribution to the improvement of team performance in complex cases, rather than in medium or basic surgical cases, measured by the procedure time, length of hospital stays (LOS), and surgical cost (COST).

STUDY DESIGN

Patient demographics, operation, and patient outcome data of 922 general surgery cases were included. The cases were divided into three subgroups, including basic, medium, and complex surgical procedures. TFS and an Index of Difficulty of Surgery (IDS) were calculated for each procedure. Simple linear regression and random forest regressions were performed to analyze the association between surgical outcomes and all included independent variables (TFS, IDS, patient age, patient weight, and team size).

RESULTS

When applied to complex cases, procedure time (r = -0.21) and cost (r = -0.23) dropped as TFS increases. In basic and medium surgical cases, increasing team familiarity failed to shorten the procedure time on average.

CONCLUSION

Team familiarity is more important in complex cases because there is greater potential for improvement through team collaboration compared to basic and medium cases. Caution will be needed when applying team familiarity scores for examining surgical team performance in large databases with skewed to basic surgical cases.

Surgical Safety Does Not Happen By Accident: Learning From Perioperative Near Miss Case Studies

Adverse surgical events cause negative patient health outcomes and harm that can often overshadow the safe and effective patient care provided daily by nurses as members of interprofessional healthcare teams. Near misses occur far more frequently than adverse events and are less visible to nurse leaders because patient harm is avoided due to chance, prevention, or mitigation. However, near misses have comparable root causes to adverse events and exhibit the same underlying patterns of failure. Reviewing near misses provides nurses with learning opportunities to identify patient care weaknesses and build appropriate solutions to enhance care. As the operating room is one of the most complex work settings in healthcare, identifying potential weaknesses or sources for errors is vital to reduce healthcare-associated risks for patients and staff. The purpose of this manuscript is to educate, inform, and stimulate critical thinking by discussing perioperative near miss case studies and the underlying factors that lead to errors. Our authors discuss 15 near miss case studies occurring across the perioperative patient experience of care and discuss barriers to near miss reporting. Nurse leaders can use our case studies to stimulate discussion among perioperative and perianesthesia nurses in their hospitals to inform comprehensive risk reduction programs.

Periop 101: Improving Perioperative Nursing Knowledge and Competence in Labor and Delivery Nurses Through an Evidence-Based Education and Training Program

INTRODUCTION

To reach the highest levels of health care quality, all nurses providing intraoperative care to surgical patients should have a firm grasp of the complex knowledge, skills, and guidelines undergirding the perioperative nursing profession. In military treatment facilities, either perioperative registered nurses or labor and delivery (L&D) nurses provide skilled intraoperative nursing care for cesarean deliveries. However, L&D and perioperative nurses occupy vastly different roles in the continuum of care and may possess widely differing levels of surgical training and experience.

MATERIALS AND METHODS

The purpose of this project was to improve surgical care quality by standardizing and strengthening L&D nurse perioperative training, knowledge, and competence. Our population, intervention, comparative, and outcome question was, "For labor and delivery nurses of a regional military medical center (P), does implementing an evidence-based training program (I), as compared to current institutional nursing practices (C), increase nursing knowledge and perioperative nursing competence (O)?" We implemented Periop 101: A Core Curriculum-Cesarean Section training for 17 L&D nurses, measured knowledge using product-provided testing, and assessed competence using the Perceived Perioperative Competence Scale-Revised.

RESULTS

We found that perioperative nursing knowledge and competence significantly improved and were less varied among the nurses after completing the training program. Nurses demonstrated the greatest knowledge area improvements in scrubbing, gowning, and gloving; wound healing; and sterilization and disinfection, for which median scores improved by more than 100%. Nurses reported significantly greater perceived competence across all six domains of the Perioperative Competence Scale-Revised, with the largest improvements realized in foundational skills and knowledge, leadership, and proficiency.

CONCLUSIONS

We recommend that health care leaders develop policies to standardize perioperative education, training, and utilization for nurses providing intraoperative care to reduce clinician role ambiguity, decrease inefficiencies, and enhance care.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Surgical Capability Utilization Time for Military Casualties at Role 2 and Role 3 Facilities

INTRODUCTION

Operative capability utilization time for casualties is an important metric for trauma planning in the military. Operative capabilities can be a choke point resulting in multiple patients waiting for the asset to become available during mass casualty events. The objective measurement of how long deployed operative capabilities are utilized for various categories of injury has not been described. This study provides the measurements for role 2 and role 3 facilities.

MATERIALS AND METHODS

The Department of Defense Trauma Registry was sampled for each composite injury severity score (ISS) category in the registry (mild, moderate, severe, and critical). Thirty randomly selected samples for role 2 and role 3 facilities for each composite ISS category with an anesthesia record including a start and end time for the index surgical case were included.

RESULTS

There were no statistical differences between role 2 and role 3 facility operative capability utilization times for any composite ISS category. The mean time (min) for mild, moderate, severe, and critical for role 2 and role 3 was 93.9 and 96.3, 142.2 and 144.3, 177.4 and 171.1, 182.9 and 205.6, respectively. The proportion of Department of Defense Trauma Registry surgical patients who were mild, moderate, severe, or critical were 57.5%, 18.2%, 13.6%, and 10.7%, respectively.

CONCLUSION

There is no statistical difference between roles of care in operative asset utilization time. The provided operative capability utilization times will be useful for casualty management planning and improvement initiatives.

Associations of Surgical Team Communication With the Layout of Physical Space: A Network Analysis of the Operating Room in a Military Medical Center

AIM

To examine how the spatial topology of the operating room (OR) within the medical center impacts surgical team communication.

BACKGROUND

Understanding the complex association between surgical team communication and the OR's spatial network location is critical to patient safety. Effective surgical communication is associated with fewer adverse events and medical errors.

METHODS

We employed a cross-sectional, quantitative, case study, and network-centric study design. We studied the population of 204 clinicians in a large military medical center (36 perioperative nurses, 34 surgical technicians, 62 anesthesia providers, and 72 surgeons), focusing on surgical teams with cases completed within duty hours. Data were collected from December 2020 to June 2021 using an electronic survey. Spatial network analysis was done using electronic floor plans. Statistical analysis was done with descriptive statistics and linear regressions. The outcomes were general and task-specific communication, and team-level variables were aggregated from scores for all team members. Spatial effects were assessed with network centrality (degree, Laplacian, and betweenness).

RESULTS

The individual-level survey response rate was 77% (157 of 204). Data were collected on 137 surgical teams. On a 5-point scale, general and task-specific communication ranged from 3.4 to 5.0 and 3.5 to 5.0, respectively (for both, median = 4.7). Team size ranged from 4 to 6 individuals (median = 4). Surgical suites with higher network centralities were associated with significantly lower communication scores.

CONCLUSIONS

The OR's spatial network location has important impacts on surgical team communication. Our findings have design and workflow implications for ORs and even surgical care in combat zones.

No signs of check-list fatigue - introducing the StOP? intra-operative briefing enhances the quality of an established pre-operative briefing in a pre-post intervention study

Background

The team timeout (TTO) is a safety checklist to be performed by the surgical team prior to incision. Exchange of critical information is, however, important not only before but also during an operation and members of surgical teams frequently feel insufficiently informed by the operating surgeon about the ongoing procedure. To improve the exchange of critical information during surgery, the StOP?-protocol was developed: At appropriate moments during the procedure, the leading surgeon briefly interrupts the operation and informs the team about the current Status (St) and next steps/objectives (O) of the operation, as well as possible Problems (P), and encourages questions of other team members (?). The StOP?-protocol draws attention to the team. Anticipating the occurrence of StOP?-protocols may support awareness of team processes and quality issues from the beginning and thus support other interventions such as the TTO; however, it also may signal an additional demand and contribute to a phenomenon akin to "checklist fatigue." We investigated if, and how, the introduction of the StOP?-protocol influenced TTO quality.

Methods

This was a prospective intervention study employing a pre-post design. In the visceral surgical departments of two university hospitals and one urban hospital the quality of 356 timeouts (out of 371 included operation) was assessed by external observers before (154) and after (202) the introduction of the StOP?-briefing. Timeout quality was rated in terms of timeout completeness (number of checklist items mentioned) and timeout quality (engagement, pace, social atmosphere, noise).

Results

As compared to the baseline, after the implementation of the StOP?-protocol, observed timeouts had higher completeness ratings (F = 8.69, p = 0.003) and were rated by observers as higher in engagement (F = 13.48, p < 0.001), less rushed (F = 14.85, p < 0.001), in a better social atmosphere (F = 5.83, p < 0.016) and less noisy (F = 5.35, p < 0.022).

Conclusion

Aspects of TTO are affected by the anticipation of StOP?-protocols. However, rather than harming the timeout goals by inducing "checklist fatigue," it increases completeness and quality of the team timeout.

Operative time tracking for umbilical hernia patients

BACKGROUND

Army medical treatment facilities (MTFs) use a surgery scheduling system that reviews historical OR times to dictate expected procedural time when posting new cases. At a single military institution there was a noted inflation to umbilical hernia repair (UHR) times that was leading to issues with under-utilized operating rooms.

METHODS

This is a retrospective review determining what variables correlate with longer UHR operative time. Umbilical, ventral, epigastric, and incisional hernia repairs (both open and laparoscopic) were pulled from the local OR scheduling system at Dwight D. Eisenhower Army Medical Center from January 2013 to June 2018.

RESULTS

A total of 442 patients were included in the study with a mean age of 45.74 years and 54.98% male. Patient ASA level (p 0.045), primary vs. mesh repair (p < 0.001), number of hernias repaired (p 0.05), hernia size (p < 0.001), and absence of student nurse anesthetist (SRNA) (p 0.05) all correlated with longer UHR OR times. For the aggregated open hernia repair data, almost all independent variables of interest were statistically significant including age, PGY level, history of DM, case acuity, presence of SRNA, patient ASA level, patient's BMI, hernia defect size, number of hernias, history of prior repair, and history prior abdominal surgery. Multivariate regression analysis was done on the open hernia repair variables with only age and size of hernia being significant.

CONCLUSION

This data were used to create a new case request option (open UHR without mesh and open UHR with mesh) to more effectively utilize available OR time.