Improving operating room coordination: communication pattern assessment

Objective Measures of Surgeon Non-Technical Skills in Surgery: A Scoping Review

OBJECTIVE

The purpose of this study was to identify, synthesize, and discuss objective behavioral or physiological metrics of surgeons' nontechnical skills (NTS) in the literature.

BACKGROUND

NTS, or interpersonal or cognitive skills, have been identified to contribute to safe and efficient surgical performance; however, current assessments are subjective, checklist-based tools. Intraoperative skill evaluation, such as technical skills, has been previously utilized as an objective measure to address such limitations.

METHODS

Five databases in engineering, behavioral science, and medicine were searched following PRISMA reporting guidelines. Eligibility criteria included studies with NTS objective measurements, surgeons, and took place within simulated or live operations.

RESULTS

Twenty-three articles were included in this review. Objective metrics included communication metrics and measures from physiological responses such as changes in brain activation and motion of the eye. Frequencies of content-coded communication in surgery were utilized in 16 studies and were associated with not only the communication construct but also cognitive constructs of situation awareness and decision making. This indicates the underlying importance of communication in evaluating the NTS constructs. To synthesize the scoped literature, a framework based on the one-way communication model was used to map the objective measures to NTS constructs.

CONCLUSION

Objective NTS measurement of surgeons is still preliminary, and future work on leveraging objective metrics in parallel with current assessment tools is needed.

APPLICATION

Findings from this work identify objective NTS metrics for measurement applications in a surgical environment.

Non-technical skills and device-related interruptions in minimally invasive surgery

BACKGROUND

Device-related interruptions in the operating room (OR) may create stress among health care providers and delays. Although non-technical skills (NTS) of the OR teams, such as situational awareness and communication, are expected to influence device-related interruptions, empirical data on this relationship are limited.

METHODS

We performed a prospective cohort study of 144 consecutive elective laparoscopic operations during 13 months. A data capture system called the OR Black Box® was used to characterize device-related interruptions, NTS, and distractions. Device-related interruptions were classified according to a priori established categories. Positive and negative NTS instances were identified according to validated measurement tools specific for nurses and surgeons. We assessed the relationship between NTS and device-related interruptions after adjusting for potential confounders.

RESULTS

A total of 86 device-related interruptions occurred in 48 of 144 operations (33%). They were most frequently classified as device failure (54%) followed by improper assembly (19%) and disconnection (14%). Medians of 1 [interquartile range (IQR) 0-3] and 1 (IQR 0-2) negative NTS instance per operation were demonstrated by nurses and surgeons, respectively. Medians of 28 (IQR 15-38) and 40 (IQR 28-118) positive NTS instances per operation were demonstrated by nurses and surgeons. In a multivariable analysis, a higher frequency of negative NTS instances demonstrated by nurses was associated with device-related interruptions after risk adjustment (Odds Ratio 1.33, p = 0.02).

CONCLUSIONS

In elective laparoscopic operations, an increased likelihood of device-related interruptions in the OR was associated with more frequent negative NTS demonstrations by nursing teams.

A Practical Approach to Artificial Intelligence in Plastic Surgery

Understanding the intersection of technology and plastic surgery has been and will be essential to positioning plastic surgeons at the forefront of surgical innovation. This account of the current and future applications of artificial intelligence (AI) in reconstructive and aesthetic surgery introduces us to the subset of issues amenable to support from this technology. It equips plastic surgeons with the knowledge to navigate technical conversations with peers, trainees, patients, and technical partners for collaboration and to usher in a new era of technology in plastic surgery. From the mathematical basis of AI to its commercially viable applications, topics introduced herein constitute a framework for design and execution of quantitative studies that will better outcomes and benefit patients. Finally, adherence to the principles of quality data collection will leverage and amplify plastic surgeons’ creativity and undoubtedly drive the field forward.

The nurse manager's role in perioperative settings: An integrative literature review

AIM

To describe the nurse manager's role in perioperative settings.

BACKGROUND

The nurse manager's role is complex and its content unclear. Research in this area is scarce. We need to better understand what this role is to support the nurse manager's work and decision-making with information systems.

EVALUATION

An integrative literature review was conducted in May 2018. Databases CINAHL, Cochrane, PubMed and Web of Science were used together with a manual search. The review followed a framework especially designed for integrative reviews. Quality of the literature was analysed with an assessment tool. Nine studies published between 2001 and 2016 were included in the final review.

KEY ISSUE

The findings from the review indicate that the nurse manager's role requires education and experience, and manifests in skills and tasks. A bachelor's degree with perioperative specialisation is the minimum educational requirement for a nurse manager.

CONCLUSION

Research lacks a clear description of the nurse manager's role in perioperative settings. However, the role evolves by education. More education provides advanced skills and, thereby, more demanding tasks. Information technology could provide useful support for task management.

IMPLICATIONS FOR NURSING MANAGEMENT

These findings can be used to better answer the current and future demands of the nurse manager's work.

Compared efficiency of trauma versus scheduled orthopaedic surgery operating rooms in a university hospital

BACKGROUND

The objective of this study was to contribute to an OR efficiency optimisation effort by comparing a trauma OR versus a scheduled surgery OR in a lower limb orthopaedic surgery department.

HYPOTHESIS

The main hypothesis is that efficiency is lower in the trauma OR than in the scheduled surgery OR. The secondary hypothesis is that efficiency of the trauma OR is lower during weekends.

MATERIAL AND METHODS

This prospective study was conducted in 2016 in the orthopaedic surgery department of a university hospital. Patients were divided into three groups based on whether they underwent scheduled surgery (SchOS), trauma surgery on a weekday (TSwk), or trauma surgery on a weekend (TSwkend). Actual OR occupancy time, allocated OR block time (BT), OR occupancy rate, patient entrance-to-incision time, incision-to-closure time, closure-to-post-anaesthesia care unit (PACU) entrance time, and clean-up/set-up time (T4) were measured.

RESULTS

We included 691 patients in the SchOS group, 819 in the TSwk group, and 327 in the TSwkend group. OR efficiency was lower in the TSwk group compared to the SchOS group (occupancy rate, 86% vs. 88%; p=10^-4). All occupancy time components were longer in the TSwk group. However, each component accounted for similar total occupancy time proportions in the two groups, except for clean-up/set-up time, which was longer in the TSwk group (p<0.05). On average, entrance-to-incision time accounted for 31%, incision-to-closure time for 34%, closure-to-PACU time for 18%, and clean-up/set-up time for 17% of total occupancy time. Efficiency was lower in the TSwkend group than in the TSwk group (occupancy rate, 75% vs. 86%; p=10^-4). The TSwkend group had shorter entrance-to-incision and incision-to-closure times (p<0.05) and a nearly 10% longer clean-up/set-up time (p<0.05).

CONCLUSION

Efficiency of the trauma OR, although lower compared to the scheduled orthopaedic surgery OR, was nevertheless satisfactory as assessed based on standard indicators. Of the four total occupancy time components, the first three accounted for similar proportions of the total; differences occurred only for clean-up/set-up time. Efforts to improve OR efficiency should focus on arrival of the first patient and turnover time.

LEVEL OF EVIDENCE

II, prospective cohort study.

Using an integrative mock-up simulation approach for evidence-based evaluation of operating room design prototypes

This paper describes the process and tools developed as part of a multidisciplinary collaborative simulation-based approach for iterative design and evaluation of operating room (OR) prototypes. Full-scale physical mock-ups of healthcare spaces offer an opportunity to actively communicate with and to engage multidisciplinary stakeholders in the design process. While mock-ups are increasingly being used in healthcare facility design projects, they are rarely evaluated in a manner to support active user feedback and engagement. Researchers and architecture students worked closely with clinicians and architects to develop OR design prototypes and engaged clinical end-users in simulated scenarios. An evaluation toolkit was developed to compare design prototypes. The mock-up evaluation helped the team make key decisions about room size, location of OR table, intra-room zoning, and doors location. Structured simulation based mock-up evaluations conducted in the design process can help stakeholders visualize their future workspace and provide active feedback.

Nurses' Perceptions of Patient Care Continuity in Day Surgery

PURPOSE

The increase in day surgery has brought about a significant change in patient care and care continuity. The purpose of this study was to analyze nurses' perceptions of the realization of continuity of care in day surgery. Continuity of care is examined from the perspectives of time, flow, co-ordination flow, caring relationship flow, and information flow.

DESIGN

Descriptive study.

METHODS

A questionnaire including demographics and questions about continuity of care was completed by 83 of the 120 eligible nurses (response rate, 69%) in one hospital district in Finland.

FINDINGS

According to the nurses, continuity of patient care is mostly well realized. On the day of surgery, information flow was the domain that was best realized. In the opinion of the nurses, continuity of care was least realized at home before surgery and at home during the period after surgery.

CONCLUSIONS

Based on nurses' perceptions, continuity of care was relatively well realized.

The documentation practice of perioperative nurses: a literature review

AIMS AND OBJECTIVE

To explore and present the existing knowledge of the documentation practices of perioperative nurses in the operating room.

BACKGROUND

Studies demonstrate that the documentation of nursing care provided is important for the continuity of patient care as well as patient safety. Nurses find that documenting their perioperative services is important to the surgical pathway; however, a number of studies indicate that the documentation practices of perioperative nurses are characterised by subjectivity, randomness and poor quality.

DESIGN

A literature review with a systematic search of scientific material.

METHOD

The content of the studies included was analysed using content analysis as suggested by Krippendorff. The materials were acquired by searching electronic databases. The search was performed for the period 1995-2015 and resulted in 12 studies.

RESULTS

Three general themes were found to be important for perioperative nurses' documentation practices: (1) the documentation tool must be adapted to the clinical practice; (2) nurses document to improve patient safety and protect themselves legally; and (3) traditions and conditions for documentation.

CONCLUSION

Nurses considered documenting their perioperative practices very important. It was of vital importance that the tool used be adapted to the actual clinical practice and to relevant regulations regarding form and content. Nurses' subjective perceptions of and opinions on the effect of documentation influenced their documentation practices, which were widely governed by habits and traditions. Nurses document to safeguard patients against errors but also to protect their own legal status. Nurses also use documentation as proof of their nursing and as 'a window' to gain recognition for their professional practice.

RELEVANCE TO CLINICAL PRACTICE

Our review demonstrates that a focus on the documentation traditions of perioperative nurses combined with training, structure and improved technical tools may facilitate the documentation and thereby improve patient safety.

Centralized and Decentralized Nurse Station Design: An Examination of Caregiver Communication, Work Activities, and Technology

The healthcare construction boom requires evidence for effective design of nurse stations, including evidence supporting workflow processes, computerization, integration of technology, communication of caregivers, and optimal patient outcomes. This article describes the examination of a traditional centralized nursing station using a total patient care delivery model and minimal computerization and a highly computerized, decentralized nursing station using a team nursing model. Results specific to communication activities, time with patients, number of patient visits per registered nurse, and patient satisfaction with response time are reported.

Video Technology to Advance Safety in the Operating Room and Perioperative Environment

Video is a powerful medium and is underused for patient safety in several areas: education, real-time consultation, process improvement, research, and workflow coordination. We illustrate this point through an overview of uses of video in health care by the authors and others in several institutions. These uses were in the context of team work training, operating room coordination, technical skills of invasive procedures, process improvement, telementoring, and multimedia video records. Also described are several key issues associated with the use of video, such as ethics and legal concerns. Technology advances and new methods will make video an important tool for improving patient safety.

Observation for assessment of clinician performance: a narrative review

BACKGROUND

Video recorded and in-person observations are methods of quality assessment and monitoring that have been employed in high risk industries. In the medical field, observations have been used to evaluate the quality and safety of various clinical processes. This review summarises studies utilising video recorded or in-person observations for assessing clinician performance in medicine and surgery.

METHODS

A search of MEDLINE (PubMed) was conducted using a combination of medical subject headings (MeSH) terms. Articles were included if they described the use of in-person or video recorded observations to assess clinician practices in three categories: (1) teamwork and communication between clinicians; (2) errors and weaknesses in practice; and (3) compliance and adherence to interventions or guidelines.

RESULTS

The initial search criteria returned 3215 studies, 223 of which were identified for full text review. A total of 69 studies were included in the final set of literature. Observations were most commonly used in data dense and high risk environments, such as the emergency department or operating room. The most common use was for assessing teamwork and communication factors.

CONCLUSIONS

Observations are useful for the improvement of healthcare delivery through the identification of clinician lapses and weaknesses that affect quality and safety. Limitations of observations include the Hawthorne effect and the necessity of trained observers to capture and analyse the notes or videos. The comprehensive, subtle and sensitive information observations provided can supplement traditional quality assessment methods and inform targeted interventions to improve patient safety and the quality of care.

Operation room tool handling and miscommunication scenarios: an object-process methodology conceptual model

OBJECTIVE

Errors in the delivery of medical care are the principal cause of inpatient mortality and morbidity, accounting for around 98,000 deaths in the United States of America (USA) annually. Ineffective team communication, especially in the operation room (OR), is a major root of these errors. This miscommunication can be reduced by analyzing and constructing a conceptual model of communication and miscommunication in the OR. We introduce the principles underlying Object-Process Methodology (OPM)-based modeling of the intricate interactions between the surgeon and the surgical technician while handling surgical instruments in the OR. This model is a software- and hardware-independent description of the agents engaged in communication events, their physical activities, and their interactions. The model enables assessing whether the task-related objectives of the surgical procedure were achieved and completed successfully and what errors can occur during the communication.

METHODS AND MATERIAL

The facts used to construct the model were gathered from observations of various types of operations miscommunications in the operating room and its outcomes. The model takes advantage of the compact ontology of OPM, which is comprised of stateful objects - things that exist physically or informatically, and processes - things that transform objects by creating them, consuming them or changing their state. The modeled communication modalities are verbal and non-verbal, and errors are modeled as processes that deviate from the "sunny day" scenario. Using OPM refinement mechanism of in-zooming, key processes are drilled into and elaborated, along with the objects that are required as agents or instruments, or objects that these processes transform. The model was developed through an iterative process of observation, modeling, group discussions, and simplification.

RESULTS

The model faithfully represents the processes related to tool handling that take place in an OR during an operation. The specification is at various levels of detail, each level is depicted in a separate diagram, and all the diagrams are "aware" of each other as part of the whole model. Providing ontology of verbal and non-verbal modalities of communication in the OR, the resulting conceptual model is a solid basis for analyzing and understanding the source of the large variety of errors occurring in the course of an operation, providing an opportunity to decrease the quantity and severity of mistakes related to the use and misuse of surgical instrumentations. Since the model is event driven, rather than person driven, the focus is on the factors causing the errors, rather than the specific person. This approach advocates searching for technological solutions to alleviate tool-related errors rather than finger-pointing. Concretely, the model was validated through a structured questionnaire and it was found that surgeons agreed that the conceptual model was flexible (3.8 of 5, std=0.69), accurate, and it generalizable (3.7 of 5, std=0.37 and 3.7 of 5, std=0.85, respectively).

CONCLUSION

The detailed conceptual model of the tools handling subsystem of the operation performed in an OR focuses on the details of the communication and the interactions taking place between the surgeon and the surgical technician during an operation, with the objective of pinpointing the exact circumstances in which errors can happen. Exact and concise specification of the communication events in general and the surgical instrument requests in particular is a prerequisite for a methodical analysis of the various modes of errors and the circumstances under which they occur. This has significant potential value in both reduction in tool-handling-related errors during an operation and providing a solid formal basis for designing a cybernetic agent which can replace a surgical technician in routine tool handling activities during an operation, freeing the technician to focus on quality assurance, monitoring and control of the cybernetic agent activities. This is a critical step in designing the next generation of cybernetic OR assistants.

Continuous interprofessional coordination in perioperative work: an exploratory study

Coordination of perioperative work is challenging. Advancements in diagnostic and therapeutic possibilities have not been followed by similar advancements in the ability to coordinate care. In this paper, we report on a study that explored the nature of continuous coordination as practiced by perioperative staff in order to coordinate their own activities with respect to those of their colleagues. We conducted in-depth interviews (n = 14), and combined observations and focused interviews (n = 31) with perioperative staff (physicians, nurses, technicians, and cleaners) at a major university hospital in Norway. Data were analysed qualitatively with systematic text condensation. The results indicated that a surgical schedule was important for informing staff members about the cases and tasks they had been assigned. Staff also depended on ad hoc, explicit communication to ensure timeliness of particular perioperative activities. This, however, left little room for adjustments of other activities. Hence, to be able to proactively coordinate their own work some staff tried to predict future perioperative activities by observing the workplace, monitoring the surgical scheduling software for changes, and sharing their colleagues' progress updates and predictions. These findings could be important for those developing support for perioperative coordination.

Continuity of care in day surgical care - perspective of patients

BACKGROUND

The realisation of continuity in day surgical care is analysed in this study. The term 'continuity of care' is used to refer to healthcare processes that take place in time (time flow) and require coordination (coordination flow), rapport (caring relationship flow) and information (information flow). Patients undergoing laparoscopic cholecystectomy or inguinal hernia day surgery are ideal candidates for studying the continuity of care, as the diseases are very common and the treatment protocol is mainly the same in different institutions, in addition to which the procedure is elective and most patients have a predictable clinical course.

AIM

The aim of the study was to describe, from the day surgery patients' own perspective, how continuity of care was realised at different phases of the treatment, prior to the day of surgery, on the day of surgery and after it.

METHOD

The study population consisted of 203 day surgical patients 10/2009-12/2010 (N = 350, response rate 58%). A questionnaire was developed for this study.

RESULTS

Based on the results, the continuity of care was well realised as a rule. Continuity is improved by the fact that patients know the nurse who will look after them in the hospital before the day of surgery and have a chance to meet the nurse even after the operation. Meeting the surgeon who performed the operation afterwards also improves patients' perception of continuation of care.

CONCLUSIONS

Continuity of care may be improved by ensuring that the patient meets caring staff prior to the day of operation and after the procedure. An important topic for further research would be how continuation of care is realised in the case of other patient groups (e.g. in internal medicine). On the other hand, realisation of continuation of care should also be studied from the viewpoint of those taking part in patient care in order to find similarities/differences between patients' perceptions and professionals' views. Studying interventions aimed to promote continuity of care, for example in patient guidance, would also be of great importance.

Human Factors in Critical Care Medical Environments

The purpose of this chapter on human factors in critical care medical environments is to provide a systematic review of the human factors and ergonomics contributions that led to significant improvements in patient safety over the last five decades. The review will focus on issues that contributed to patient injury and fatalities and how human factors and ergonomics can improve performance of providers in critical care. Given the complexity of critical care delivery, a review needs to cover a wide range of subjects. In this review, I take a sociotechnical systems perspective on critical care and discuss the people, their technical and nontechnical skills, the importance of teamwork, technology, and ergonomics in this complex environment. After a description of the importance of a safety climate, the chapter will conclude with a summary on how human factors and ergonomics can improve quality in critical care delivery.

Instant messaging at the hospital: supporting articulation work?

INTRODUCTION

Clinical work is increasingly fragmented and requires extensive articulation and coordination. Computer systems may support such work. In this study, we investigate how instant messaging functions as a tool for supporting articulation work at the hospital.

PURPOSE

This paper aims to describe the characteristics of instant messaging communication in terms of number and length of messages, distribution over time, and the number of participants included in conversations. We also aim to determine what kind of articulation work is supported by analysing message content.

METHODS

Analysis of one month's worth of instant messages sent through the perioperative coordination and communication system at a Danish hospital.

RESULTS

Instant messaging was found to be used extensively for articulation work, mostly through short, simple conversational exchanges. It is used particularly often for communication concerning the patient, specifically, the coordination and logistics of patient care. Instant messaging is used by all actors involved in the perioperative domain.

CONCLUSION

Articulation work and clinical work are hard to separate in a real clinical setting. Predefined messages and strict workflow design do not suffice when supporting communication in the context of collaborative clinical work. Flexibility is of vital importance, and this needs to be reflected in the design of supportive communication systems.

Co-ACT--a framework for observing coordination behaviour in acute care teams

BACKGROUND

Acute care teams (ACTs) represent action teams, that is, teams in which members with specialised roles must coordinate their actions during intense situations, often under high time pressure and with unstable team membership. Using behaviour observation, patient safety research has been focusing on defining teamwork behaviours-particularly coordination-that are critical for patient safety during these intense situations. As one result of this divergent research landscape, the number, scope and variety of applied behaviour observation taxonomies are growing, making comparison and convergent integration of research findings difficult.

AIM

To facilitate future ACT research by presenting a framework that provides a shared language of teamwork behaviours, allows for comparing previous and future ACT research and offers a measurement tool for ACT observation.

METHOD

Based on teamwork theory and empirical evidence, we developed Co-ACT-the Framework for Observing Coordination Behaviour in ACT. Integrating two previous, extensive taxonomies into Co-ACT, we also suggested 12 behavioural codes for which we determined inter-rater reliability by analysing the teamwork of videotaped anaesthesia teams in the clinical setting.

RESULTS

The Co-ACT framework consists of four quadrants organised along two dimensions (explicit vs implicit coordination; action vs information coordination). Each quadrant provides three categories for which Cohen's κ overall value was substantial; but values for single categories varied considerably.

CONCLUSIONS

Co-ACT provides a framework for organising behaviour codes and offers respective categories for succinctly measuring teamwork in ACTs. Furthermore, it has the potential to allow for guiding and comparing ACTs study results. Future work using Co-ACT in different research and training settings will show how well it can generally be applied across ACTs.

Event-based knowledge elicitation of operating room management decision-making using scenarios adapted from information systems data

Background

No systematic process has previously been described for a needs assessment that identifies the operating room (OR) management decisions made by the anesthesiologists and nurse managers at a facility that do not maximize the efficiency of use of OR time. We evaluated whether event-based knowledge elicitation can be used practically for rapid assessment of OR management decision-making at facilities, whether scenarios can be adapted automatically from information systems data, and the usefulness of the approach.

Methods

A process of event-based knowledge elicitation was developed to assess OR management decision-making that may reduce the efficiency of use of OR time. Hypothetical scenarios addressing every OR management decision influencing OR efficiency were created from published examples. Scenarios are adapted, so that cues about conditions are accurate and appropriate for each facility (e.g., if OR 1 is used as an example in a scenario, the listed procedure is a type of procedure performed at the facility in OR 1). Adaptation is performed automatically using the facility's OR information system or anesthesia information management system (AIMS) data for most scenarios (43 of 45). Performing the needs assessment takes approximately 1 hour of local managers' time while they decide if their decisions are consistent with the described scenarios. A table of contents of the indexed scenarios is created automatically, providing a simple version of problem solving using case-based reasoning. For example, a new OR manager wanting to know the best way to decide whether to move a case can look in the chapter on "Moving Cases on the Day of Surgery" to find a scenario that describes the situation being encountered.

Results

Scenarios have been adapted and used at 22 hospitals. Few changes in decisions were needed to increase the efficiency of use of OR time. The few changes were heterogeneous among hospitals, showing the usefulness of individualized assessments.

Conclusions

Our technical advance is the development and use of automated event-based knowledge elicitation to identify suboptimal OR management decisions that decrease the efficiency of use of OR time. The adapted scenarios can be used in future decision-making.

Examination of Wireless Technology to Improve Nurse Communication, Response Time to Bed Alarms, and Patient Safety

Objective:

A medical-surgical unit in a southwestern United States hospital examined the results of adding wireless communication technology to assist nurses in identifying patient bed status changes and enhancing team communication. Following the addition of wireless communication, response time to patient calls and the number of nurse-initiated communications were compared to pre-wireless calls and response time sampling period.

Background:

In the baseline study, nurse-initiated communications and response time to patient calls were investigated for a team nursing model ( Guarascio-Howard & Malloch, 2007 ). At this time, technology consisted of a nurse call system and telephones located at each decentralized nurse station and health unit coordinator (HUC) station. For this follow-up study, a wireless device was given to nurses and their team members following training on device use and privacy issues.

Method:

Four registered nurses (RNs) were shadowed for 8 hours (32 hours total) before and after the introduction of the wireless devices. Data were collected regarding patient room visits, number of patient calls, bed status calls, response time to calls, and the initiator of the communication episodes.

Results:

Follow-up study response time to calls significantly decreased ( t-test p = .03). RNs and licensed practical nurses responded to bed status calls in less than 1 minute—62% of the 37 calls. Communication results indicated a significant shift (One Proportion Z Test) in RN-initiated communications, suggesting an enhanced ability to communicate with team members and to assist in monitoring patient status. Patient falls trended downward, although not significantly ( p > .05), for a 6-month period of wireless technology use compared to the same period the previous year.

Conclusions:

The addition of a wireless device has advantages in team nursing, namely increasing communication with staff members and decreasing response time to patient and bed status calls. Limitations of the study included a change in caregiver team members and issues regarding wireless device and locator badge compliance. Administrative issues that arose during this field study included bed and cable maintenance, device battery charging, and the training of new and floating team members.

Information needs in operating room teams: what is right, what is wrong, and what is needed?

BACKGROUND

Safe surgical care requires effective information transfer between members of the operating room (OR) team. The present study aims to assess directly, systematically, and comprehensively, information needs of all OR team-members.

METHODS

Thirty-three OR team-members (16 surgeons/anesthesiologists, 17 nurses) took part in a mixed-method interview. Participants indicated what information they need, their problems accessing it, and potential interventions to improve information transfer. They also rated the importance of different sources of information and the quality (accuracy, availability, timeliness, completeness, and clarity) of the information that they typically receive. Theme extraction and statistical analyses (descriptive and inferential) were used to analyze the data.

RESULTS

The patient emerged as the top source of information. Surgeons and anesthesiologists relied more on information from fellow clinicians, as well as information originating from diagnostic and imaging labs. They were also more critical about the quality of the information than nursing personnel. Anesthesiologists emerged as the most reliable source of information, whereas information coming from surgeons was deemed lacking in quality (even by surgeons themselves). Finally, the more time participants had spent working in ORs, the more negative views they had about the information that they receive-an unexpected finding. Communication skills training, standardized communication protocols, and information technology (IT) systems to function as a central information repository were the top three proposed interventions.

CONCLUSIONS

This study comprehensively maps information sources, problems, and solutions expressed by OR end-users. Recent developments in skills training modules and patient safety interventions for the OR (Surgical Safety Checklist) are discussed as potential interventions that will ameliorate communication in ORs, with a view to enhance patient safety and surgical care.

Information transfer and communication in surgery: a systematic review

OBJECTIVES

We conducted a systematic review of published literature to gain a better understanding of interprofessional information transfer and communication (ITC) in hospital setting in the field of surgical and anesthetic care.

BACKGROUND

Communication breakdowns are a common cause of surgical errors and adverse events.

DATA SOURCES

Medline, Embase, PsycINFO, Cochrane Database of Systematic Reviews, and hand search of articles bibliography.

STUDY SELECTION

Of the 4027 citations identified through the initial electronic search and screened for possible inclusion, 110 articles were retained following title and abstract reviews. Of these, 38 were accepted for this review.

DATA EXTRACTION

Data were extracted from the studies about objectives, clinical domain, methodology including study design, sample population, tools for assessing communication, results, and limitations.

RESULTS

Information transfer failures are common in surgical care and are distributed across the continuum of care. They not only lead to errors in care provision but also lead to patient harm. Most of the articles have focused on ITC process in different phases especially in operating room. None of the studies have looked at whole of the surgical care process. No standard tool has been developed to capture the ITC process in different teams and to evaluate the effect of various communication interventions. Uses of standardized communication through checklist, proformas, and technology innovations have improved the ITC process, with an effect on clinical and patient outcomes.

CONCLUSIONS

ITC deficits adversely affect patient care. There is a need for standard measures to evaluate this process. Effective and standardized communication among healthcare professionals during the perioperative process facilitates surgical safety.

Communication and team situation awareness in the OR: Implications for augmentative information display

Team Situation Awareness (TSA) is one of the critical factors in effective Operating Room (OR) teamwork and can impact patient safety and quality of care. While previous research showed a relationship between situation awareness, as measured by communication events, and team performance, the implications for developing technology to augment and facilitate TSA were not examined. This research aims to further study situation-related communications in the cardiac OR in order to uncover potential degradation in TSA which may lead to adverse events. The communication loop construct-the full cycle of information flow between the participants in the sequence-was used to assess susceptibility to breakdown. Previous research and the findings here suggest that communication loops that are open, non-directed, or with delayed closure, can be susceptible to information loss. These were quantitatively related to communication indicators of TSA such as questions, replies, and announcements. Taken together, both qualitative and quantitative analyses suggest that a high proportion of TSA-related communication (63%) can be characterized as susceptible to information loss. The findings were then used to derive requirements and design a TSA augmentative display. The design principles and potential benefits of such a display are outlined and discussed.

Care coordination in intensive care units: communicating across information spaces

OBJECTIVE

This study explores the interactions among phases of team coordination, patient-related information, decision-making levels, and role holders in intensive care units (ICUs).

BACKGROUND

The effects of communication improvement initiatives on adverse patient events or improved outcomes have been difficult to establish. Conceptual inconsistencies and methodological shortcomings suggest insufficient understanding about clinical communication and care coordination.

METHOD

Data were collected by shadowing a charge nurse, fellow, resident, and nurse in each of eight ICUs and recording each of their conversations during 12 hrs (32 role holders during 350 hrs).

RESULTS

Hierarchical log linear analyses show statistically significant three-way interactions between the patient information, phases of team coordination, and decision levels, chi2(df = 75) = 212, p < .0001; between roles, phases of team coordination, and decision levels, chi2(df = 60) = 109, p < .0001; and between roles, patient information, and decision levels, chi2(df = 60) = 155, p < .0001. Differences among levels of the variables were evaluated with the use of standardized parameter estimates and 95% confidence intervals.

CONCLUSION

ICU communication and care coordination involve complex decision structures and role interactions across two information spaces. Different role holders mediate vertical and lateral process flows with goals and directions representing an important conceptual transition. However, lateral isolation within decision levels (charge nurses) and information overload (residents) are potential communication and care coordination vulnerabilities. Results are consistent with and extend the findings of previous studies.

APPLICATION

The profile of ICU communication and care coordination provides a systemic framework that may inform future interventions and research.

Prospective trial of thoracic and spine surgeons' updating of their estimated case durations at the start of cases

BACKGROUND

Surgeon estimates of case durations are important for operating room (OR) management decision making because many cases are rare combinations of procedures with few or no historical data. Thoracic and spine surgeons updated their scheduled OR times on the day of surgery just before the "time out" in the OR.

METHODS

All elective (scheduled) general thoracic (n = 39) and spine surgery (n = 48) cases at 1 hospital were studied over 3-month and 1.5-month periods, respectively.

RESULTS

Among cases with a change in predicted duration, most changes were made based on updates to the surgical or anesthetic procedures (thoracic 85%, spine 86%). For thoracic surgery, there was overall no significant median reduction in absolute prediction error (median 0 minutes, 95% confidence interval [CI] 0-0 minutes). Among the 37% of cases with changed predicted durations, there was a significant reduction in absolute error (median 38 minutes, 95% CI >7.5 minutes). For spine surgery, there was overall no reduction in the absolute error (median 0 minutes, 95% CI 0-0 minutes). Among the 29% of cases with changed predicted durations, absolute error was no worse, but not significantly better (point estimate of median reduction 34 minutes, 95% CI >0 minutes). Secondary observations made were no effect of updates on bias, frequent rounding of scheduled durations to the nearest half hour, and increased predictive error caused by decisions that reduced expected overutilized OR time.

CONCLUSIONS

A systematic program of routinely and/or always asking for updated case duration predictions will not substantively improve OR management decision making. However, when a change in surgical approach, surgical procedure, or anesthetic procedure is identified (e.g., at the intraoperative briefing before case start), the updated estimate of case duration should be used, because such updates are not worse and often better than original estimates.

Decoding the perioperative process breakdowns: a theoretical model and implications for system design

BACKGROUND

Breakdowns in communication and coordination are situations of mismatch between actual and expected conditions in joint activities. Breakdowns have been identified as the leading cause of adverse events in healthcare, especially in the Operating Room environment. As a result, researchers have started to examine breakdowns in healthcare as emergent dynamics of teamwork. However, the occurrence and consequences of breakdowns related to inter-team processes are yet to be addressed at a fine level of detail. In this paper we seek understanding of breakdowns at the systemic level, and its relevance to design.

OBJECTIVES

The objective of this study is to bring forward an in-depth understanding of the impact of breakdowns on the surgical process by expanding the focus of analysis beyond teamwork dynamics, to the level of hospital system processes. This study also aims to examine the implications of such understanding of breakdowns for the design of clinical systems.

METHODS

Properties of breakdowns and repairs were inductively derived, and developed into a formal coding scheme, which was applied over a set of observed breakdowns from an elective surgery unit in a North American hospital. Systematic content analysis was employed to quantify qualitative data spanning 79 h of observations, followed by statistical hypotheses testing for relationships between variables of breakdowns and repairs.

MEASURES

Breakdown type, theme, tangibility, coordination scale, breakdown lifetime, repair strategy, and repair cost.

RESULTS

The results reveal that properties of breakdowns determine properties of repairs. The majority of breakdowns were outside the scope of teamwork--at the inter-team coordination level. The results also demonstrate that breakdowns usually propagate downstream in the surgical process, affecting the work of multiple teams, and the longer they propagate the higher the communication cost associated with the respective repair. The implications are two-fold: in terms of theory we develop a conceptual framework of breakdowns in perioperative work, and in terms of system design we propose a design framework informed by the acquired understanding of breakdowns.

CONCLUSIONS

This study achieved an initial understanding of the deep features of breakdowns from a process-oriented perspective, which allowed us to build the groundwork for a theoretical model of breakdowns in perioperative activities and to propose a design approach that tackles breakdowns during early stages of system development. The direct association between breakdowns and repairs can be exploited in both IT-system design and organizational design. The patterns of repair work can inform design so as to provide clinicians with the types of information that will prevent breakdowns from occurring or to mitigate the impact of breakdowns. The results reveal that preventing breakdown propagation should be a prime target in surgical applications design.

Performance in Nursing

Nurses spend more time with patients than do any other health care providers, and patient outcomes are affected by nursing care quality. Thus, improvements in patient safety can be achieved by improving nurse performance. We review the literature on nursing performance, including cognitive, physical, and organizational factors that affect such performance, focusing on research studies that reported original data from nurse participants. Our review indicates that the nurse's work system often does not accommodate human limits and capabilities and that nurses work under cognitive, perceptual, and physical overloads. Specifically, nurses engage in multiple tasks under cognitive load and frequent interruptions, and they encounter insufficient lighting, illegible handwriting, and poorly designed labels. They spend a substantial amount of their time walking, work long shifts, and experience a high rate of musculoskeletal disorders. Research is overdue in the areas of cognitive processes in nursing, effects of interruptions on nursing performance, communications during patient handoffs, and situation awareness in nursing. Human factors and ergonomics (HF/E) professionals must play a key role in the redesign of the nurses' work system to determine how overloads can be reduced and how the limits and capabilities of performance can be accommodated. Collaboration between nurses and HF/E specialists is essential to improve nursing performance and patient safety.

Shifting the sterile processing department paradigm: a mandate for change

Sterile processing department (SPD) staff members have the difficult task of processing complicated instrumentation, containing costs, and managing limited resources; and how they face these challenges has a direct effect on patient care. Recent technological advances require SPD staff members to be more knowledgeable about what instrument trays are used together and the conditions in which they are used to help prevent costly delays in processing. This article explores how one health care system was successful in facing these challenges by implementing a solid orientation and education program.

Simulated laparoscopic operating room crisis: An approach to enhance the surgical team performance

OBJECTIVE

Diminishing human error and improving patient outcomes is the goal of task training and simulation experience. The fundamentals of laparoscopic surgery (FLS) is a validated tool to assess technical laparoscopic skills. We hypothesize that performance in a crisis depends on technical skills and team performance. The aim of this study was to develop and validate a high-fidelity simulation model of a laparoscopic crisis scenario in a mock endosuite environment.

METHODS

To establish the feasibility of the model as well as its face and construct validity, the scenario evaluated the performances of FLS-certified surgeon experts (n = 5) and non-FLS certified novices (n = 5) during a laparoscopic crisis scenario, in a mock endosuite, on a simulated abdomen. Likert scale questionnaires were used for validity assessments. Groups were compared using previously validated rating scales on technical and nontechnical performance. Objective outcome measures assessed were: time to diagnose bleeding (TD), time to inform the team to convert (TT), and time to conversion to open (TC). SAS software was used for statistical analysis.

RESULTS

Median scores for face validity were 4.29, 4.43, 4.71 (maximum 5) for the FLS, non-FLS, and nursing groups, respectively, with an inter-rater reliability of 93%. Although no difference was observed in Veress needle safety and laparoscopic equipment set up, there was a significant difference between the two groups in their overall technical and nontechnical abilities (p < 0.05), specifically in identifying bleeding, controlling bleeding, team communication, and team skills. There was a trend towards a difference between the two groups for TD, TT, and TC. While experts controlled bleeding in a shorter time, they persisted longer laparoscopically.

CONCLUSIONS

Our evidence suggests that face and construct validity are established for a laparoscopic crisis simulation in a mock endosuite. Technical and nontechnical performance discrimination is observed between novices and experts. This innovative multidisciplinary simulation aims at improving error/problem recognition and timely initiation of appropriate and safe responses by surgical teams.

A Psychological Basis for Anesthesiologists’ Operating Room Managerial Decision-Making on the Day of Surgery

BACKGROUND

We investigated whether, without prompting, anesthesiologists tend to make managerial decisions to increase the clinical work per unit time of the sites to which they are assigned during their scheduled time present. Although a sound basis for decision-making involving individual ORs, the heuristic is often suboptimal economically when applied to decisions involving multiple ORs.

METHODS

Two studies were performed at one hospital. 1) A retrospective analysis was made of anesthesiologists' managerial decisions when caring for sequential lists of patients. 2) Patients' and surgeons' waiting on nights and weekends were studied before/after education on optimal decision-making.

RESULTS

1) Anesthesiologists' decisions resulted in an increase in their clinical work per unit time, not a reduction in patient waiting. 2) Paradoxically, such efforts on nights and weekends caused increased patient and surgeon waiting. Decisions were unchanged after education on a different way to assign cases.

CONCLUSIONS

In a companion article, we showed that clinicians tended to make decisions that increased the clinical work per unit time at each moment in each OR, even when doing so resulted in an increase in overutilized OR time, higher staffing costs, unpredictable work hours, and/or mandatory overtime. The current studies show that such efforts to work fast cannot be explained as a consequence of efforts to reduce surgeon and patient waiting. Rather, the heuristic followed is consistent with increasing one's personal clinical work per unit time at one's assigned anesthetizing location.

Operating Room Managerial Decision-Making on the Day of Surgery With and Without Computer Recommendations and Status Displays

BACKGROUND

There are three basic types of decision aids to facilitate operating room (OR) management decision-making on the day of surgery. Decision makers can rely on passive status displays (e.g., big screens or whiteboards), active status displays (e.g., text pager notification), and/or command displays (e.g., text recommendations about what to do).

METHODS

Anesthesiologists, OR nurses, and housekeepers were given nine simulated scenarios (vignettes) involving multiple ORs to study their decision-making. Participants were randomized to one of four groups, all with an updated paper OR schedule: with/without command display and with/without passive status display.

RESULTS

Participants making decisions without command displays performed no better than random chance in terms of increasing the predictability of work hours, reducing over-utilized OR time, and increasing OR efficiency. Status displays had no effect on these end-points, whereas command displays improved the quality of decisions. In the scenarios for which the command displays provided recommendations that adversely affected safety, participants appropriately ignored advice.

CONCLUSIONS

Anesthesia providers and nursing staff made decisions that increased clinical work per unit time in each OR, even when doing so resulted in an increase in over-utilized OR time, higher staffing costs, unpredictable work hours, and/or mandatory overtime. Organizational culture and socialization during clinical training may be a cause. Command displays showed promise in mitigating this tendency. Additional investigations are in our companion paper.

Evaluation of a Hands-Free Wireless Communication Device in the Perioperative Environment

The objective of this study was to evaluate the efficiency and reliability of a hands-free voice over Internet protocol (VOIP) communication system in the perioperative environment. Two surveys were administered to anesthesiologists and operating room (OR) nurses working at an academic medical center. Providers were queried by alphanumeric pages or VOIP queries during OR work shifts to measure communication response times. Providers, responding to the query, were asked to verbally complete a system performance survey to capture information regarding their workload and work environment at the time of the query. A user feedback survey was independently administered in writing to a convenience sample of OR providers to obtain information regarding provider communication preferences, concerns, and recommendations. OR providers responded to communication queries four times faster when using VOIP compared to alphanumeric pagers. Providers found VOIP to be much less reliable than conventional pager-telephone systems. Dead spots in the 802.11b network and errors in speaker recognition were frequently cited as sources of system failures. Providers also expressed concern in maintaining confidentiality of patient data or other clinical data communicated using this system. The results of this study suggest that VOIP is still a developing technology but one that is currently viable in the clinical setting. The technology can be used efficiently and securely in health care if users are given the proper training its functions and capabilities.

An Algorithm for Processing Vital Sign Monitoring Data to Remotely Identify Operating Room Occupancy in Real-Time

We developed an algorithm for processing networked vital signs (VS) to remotely identify in real-time when a patient enters and leaves a given operating room (OR). The algorithm addresses two types of mismatches between OR occupancy and VS: a patient is in the OR but no VS are available (e.g., patient is being hooked up), and no patient is in the OR but artifactual VS are present (e.g., because of staff handling of sensors). The algorithm was developed with data from 7 consecutive days (122 cases) in a 6 OR trauma center. The algorithm was then tested on data from another 7 consecutive days (98 cases), against patient in- and out-times captured by OR surveillance videos. When pulse oximetry, electrocardiogram, and temperature readings were used, OR occupancy was correctly identified 96% (95% confidence interval [CI] 95%-97%) and OR vacancy >99% of the time. Identified patient in- and out-times were accurate within 4.9 min (CI 4.2-5.7) and 2.8 min (CI 2.3-3.5), respectively, and were not different in accuracy from times reported by staff on OR records. The algorithm's usefulness was demonstrated partly by its continued operational use. We conclude that VS can be processed to accurately report OR occupancy in real-time.

Informatics challenges for the impending patient information explosion

As we move toward an era when health information is more readily accessible and transferable, there are several issues that will arise. This article addresses the challenges of information filtering, context-sensitive decision support, legal and ethical guidelines regarding obligations to obtain and use the information, aligning patient and health professionals' expectations in regard to the use and usefulness of the information, and enhancing data reliability. The authors discuss the issues and offer suggestions for addressing them.