An observational study of distractions in the operating theatre

Mapping Distractions in the Hybrid Operating Room During Elective Endovascular Aortic Procedures

BACKGROUND

The hybrid operating room (OR) is a complex environment where numerous auditory and visual stimuli are encountered, potentially affecting team performance and postoperative outcomes. This study aimed to quantify distractions during elective endovascular aortic procedures in a hybrid OR using audiovisual data collected with a medical data recorder.

METHODS

This retrospective, observational, single-center study analyzed elective endovascular procedures for aneurysmal or occlusive atherosclerotic disease in a hybrid OR using the OR Black Box (Surgical Safety Technologies Inc., Toronto, Canada). Distractions were characterized using a modified Disruptions in Surgery Index. Descriptive and nonparametric statistics were used to describe the number of distractions per procedural phase. Associations of distractions with total surgical time and observed number of healthcare workers present in the OR were examined.

RESULTS

Twenty-two endovascular procedures were analyzed with good to excellent interrater (ICC 0.86) and intrarater (ICC 0.89, 0.96) reliability. Median surgical time was 110 min (IQR 73-138). Distractions were observed at a median rate of 81 per hour (IQR 67-94), with internal traffic being most frequent (36 per hour; IQR 31-46). Significantly more distractions occurred during the closing phase (p < 0.001). Total surgical time and number of healthcare workers were not associated with the number of distractions per hour.

CONCLUSIONS

Distractions occur frequently in the hybrid OR and can be mapped with a medical data recorder. Further research is needed to unravel the impact of distractions on clinical outcomes and to evaluate quality improvement initiatives to reduce distractions during surgery.

The Impact of COVID-19 on Healthcare Services, Risk Management, and Infection Prevention in Surgical Settings: A Qualitative Study

Background/Objective In every surgical environment, the prevention of surgical site infections is not merely desirable but essential, given their profound impact on patient health and healthcare costs. To optimize patient care during surgery, a thorough exploration and assessment of all intraoperative nursing practices are necessary, guided by empirical evidence. The aim of this study was to explore nurses' experiences with surgical site infection prevention practices in the intraoperative setting. Methods Twenty-one nurses working in clinical settings in Hong Kong participated in semi-structured interviews for this qualitative study. Data were analyzed using Colaizzi's seven-step method. Results Four main themes were identified from the interview data: ensuring safety and minimizing threats; facing silent, intangible, and hidden risks; team collaboration in eliminating risks; and persistent knowledge acquisition. Conclusions Nurses encountered diverse obstacles tied to teamwork, updated knowledge, communication, and patient safety. Enhanced quality of care in clinical settings can be achieved through strategic implementations. Focusing on quality improvement initiatives, establishing consistent teams, and recognizing the vital role of nurses strengthen care delivery. These actions contribute significantly to preventing surgical site infections and ensuring patient safety during intraoperative nursing practices.

Noise, Distractions, and Hazards in the Operating Room

Anesthesiologists are perioperative leaders of patient and health care team safety. The anesthesiologist needs to remain vigilant in the perioperative setting and while caring for patients. The ability to navigate increased noise levels, distractions, and hazards is crucial for maintaining a safe environment. While some noise, such as music, can have benefits, overall noise levels can distract from patient care and have adverse effects on patient care and intraoperative staff. This study provides an overview of noise, distractions, and hazards in the perioperative environment.

The Effect of External Distractions on Simulated Laparoscopic Performance

Background: Surgeons are exposed to unavoidable distractions while operating. Distractions can cause stress, and stress can impair cognition and motor skills to the detriment of surgeon performance. This study assessed the impact of distractions on surgeon stress levels and surgeon performance during simulated laparoscopic tasks. Methods: Twelve surgical trainees completed a peg-thread transfer task three times on a laparoscopic simulator in a neutral environment. Six trainees then completed the task three more times in an environment overlain with distractions commonly found in the operating theatre. Six others completed three more tasks in a neutral environment. Stress was measured by recording heart rate and by assessing responses to the NASA Task Load Index. Performance was measured using instrument tracking metrics and time to complete the task. Results: The distracted participants reported significantly higher effort, frustration, and physical demand than the neutral group, as measured by the NASA Task Load Index, (P = .001, .031, and .044, respectively). The neutral group completed their final task significantly faster compared with baseline (P = .049), while the distracted group failed to show this improvement. The distracted group showed higher hand discordance, suggesting reduced ambidexterity. Conclusion: Distraction negatively impacted some aspects of performance and resulted in subjective increased stress. In future, simulation may have a role in "stress inoculation," enabling surgeons to maintain performance, despite distractions.

Using mobile EEG to study auditory work strain during simulated surgical procedures

Surgical personnel face various stressors in the workplace, including environmental sounds. Mobile electroencephalography (EEG) offers a promising approach for objectively measuring how individuals perceive sounds. Because surgical performance does not necessarily decrease with higher levels of distraction, EEG could help guide noise reduction strategies that are independent of performance measures. In this study, we utilized mobile EEG to explore how a realistic soundscape is perceived during simulated laparoscopic surgery. To examine the varying demands placed on personnel in different situations, we manipulated the cognitive demand during the surgical task, using a memory task. To assess responses to the soundscape, we calculated event-related potentials for distinct sound events and temporal response functions for the ongoing soundscape. Although participants reported varying degrees of demand under different conditions, no significant effects were observed on surgical task performance or EEG parameters. However, changes in surgical task performance and EEG parameters over time were noted, while subjective results remained consistent over time. These findings highlight the importance of using multiple measures to fully understand the complex relationship between sound processing and cognitive demand. Furthermore, in the context of combined EEG and audio recordings in real-life scenarios, a sparse representation of the soundscape has the advantage that it can be recorded in a data-protected way compared to more detailed representations. However, it is unclear whether information get lost with sparse representations. Our results indicate that sparse and detailed representations are equally effective in eliciting neural responses. Overall, this study marks a significant step towards objectively investigating sound processing in applied settings.

Visual Mapping of Operating Theater Team Dynamics and Communication for Reflexive Feedback and Surgical Practice Optimization

Background

Effective operating theater (OT) communication and teamwork are essential to optimal surgical outcomes. We mapped the OT team dynamics and infection control practices using visual methods to guide reflexive feedback and optimize perioperative practices.

Methods

Data were gathered from adult gastrointestinal surgical teams at a tertiary hospital in India using observations, sociograms (communication mapping tool), and focus group discussions (FGDs). Our methods aimed to map team communication, roles and responsibilities in infection-related practices, and door openings. Qualitative data were thematically analyzed. Quantitative data were analyzed using descriptive statistics.

Results

Data were gathered from 10 surgical procedures (over 51 hours) using 16 sociograms, 15 traffic flow maps, and 3 FGDs. Senior surgeons directly influence team hierarchies, dynamics, and communication. While the surgeons, anesthetic residents, and technicians lead most tasks during procedures, the scrub nurse acts as a mediator coordinating activity among role players across hierarchies. Failing to provide the scrub nurse with complete details of the planned surgery leads to multiple door openings to fetch equipment and disposables. Traffic flow observed in 15-minute intervals corresponds to a mean frequency of 56 door openings per hour (min: 16; max: 108), with implications for infection control. Implementing the World Health Organization surgical safety checklist was inconsistent across pathways and does not match reported compliance data.

Conclusions

Human factors research is important in optimizing surgical teamwork. Using visual methods to provide feedback to perioperative teams on their communication patterns and behaviors, provided an opportunity for contextualized enhancement of infection prevention and control practices.

Improving Team Members' Attention During the OR Briefing or Time Out

Effective coordination among health care professionals is crucial to achieving optimal outcomes. In the OR, even minor errors can have catastrophic consequences. To mitigate the risk of error, health care professionals have adopted a briefing culture like that used in the aviation industry. Briefings are essential to ensure that everyone involved in a procedure knows the plan and potential risks and is prepared to perform their duties safely and effectively. The fundamental human sense involved in briefings is auditory perception; although important, hearing alone does not equate to focused attention. To enhance the efficacy of briefings, engaging the use of a second sense by adding a visual checklist may increase attentiveness and the chances of early error detection and prevention. Using a projection device may enhance all team members' engagement and participation during the briefing or time-out process and can be an effective tool for improving communication and reducing errors.

A Quantitative Analysis of Intraoperative Distractions and When They Occur During General Surgical Operations

Introduction Distractions in operating theatres prevent team members from concentrating on the complex tasks required for a successful operation. This can be a potential hazard to care for, and previously, correlations have been made between increased theatre distractions and adverse events. However, it remains unclear how frequently such events occur during routine care in theatres. The present study aims to quantify distractions and analyse any differences between staff groups, operative stages, and modes of operation. Methods A single-centre prospective study was conducted to assess disruptions in general surgical theatres. Events were recorded using a previously described categorization system on a proforma by a single researcher. The source and severity of distraction were recorded, as well as the mode of operation (elective/emergency), stage of operation, and staff team (scrubbed/floor). Results A total of 4,219 minutes of surgery were observed over four weeks, and 1,095 distraction events were recorded. Of the 14 elective and nine emergency procedures recorded, there was a mean of 54.8 distractions per procedure and a frequency of one distraction every three minutes and 51 seconds (15.6 hr-1). Irrelevant communication relating to the patient's case was the most common source, accounting for 24.7% of all distractions. The most frequently disrupted stage of the procedure for scrubbed staff was during anastomosis/resection for both elective and emergency procedures, with 16.9 and 32.6 distractions occurring per hour, respectively. Scrubbed staff were significantly more susceptible to distraction in emergency procedures than the floor staff. Discussion Our study reflects previous assessments with irrelevant communications and emergency procedures yielding the highest prevalence of distraction. This investigation provides novel information about the different stages of general surgery and the frequency of distractions that occur.

Effects of colour-coded compartmentalised syringe trays on anaesthetic drug error detection under cognitive load

BACKGROUND

Anaesthetic drug administration is complex, and typical clinical environments can entail significant cognitive load. Colour-coded anaesthetic drug trays have shown promising results for error identification and reducing cognitive load.

METHODS

We used experimental psychology methods to test the potential benefits of colour-coded compartmentalised trays compared with conventional trays in a simulated visual search task. Effects of cognitive load were also explored through an accompanying working memory-based task. We hypothesised that colour-coded compartmentalised trays would improve drug-detection error, reduce search time, and reduce cognitive load. This comprised a cognitive load memory task presented alongside a visual search task to detect drug errors.

RESULTS

All 53 participants completed 36 trials, which were counterbalanced across the two tray types and 18 different vignettes. There were 16 error-present and 20 error-absent trials, with 18 trials presented for each preloaded tray type. Syringe errors were detected more often in the colour-coded trays than in the conventional trays (91% vs 83%, respectively; P=0.006). In signal detection analysis, colour-coded trays resulted in more sensitivity to the error signal (2.28 vs 1.50, respectively; P<0.001). Confidence in response accuracy correlated more strongly with task performance for the colour-coded tray condition, indicating improved metacognitive sensitivity to task performance (r=0.696 vs r=0.447).

CONCLUSIONS

Colour coding and compartmentalisation enhanced visual search efficacy of drug trays. This is further evidence that introducing standardised colour-coded trays into operating theatres and procedural suites would add an additional layer of safety for anaesthetic procedures.

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part I

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

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

PURPOSE

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

METHODS

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

FINDINGS

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

CONCLUSIONS

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

The Effects of an Order-Assist Mobile Application on Pediatric Anesthesia Safety: An Observational Study

Pediatric anesthesia requires the rapid creation, communication, and execution of anesthesia orders, and there is a risk of human error. The authors developed an order-assisted mobile application (app) to reduce human error during pediatric anesthesia preparation. The authors conducted an observational study that compared the effects of the application by comparing anesthesiologists' errors, nurses' errors, nurses leaving the operating room, and delays in surgery, between the Conventional group (n = 101) and the App group (n = 101). The app was associated with reduced human error by anesthesiologists and nurses, and it lowered the frequency and duration of nurses leaving the operating room during anesthesia. In addition, the authors surveyed anesthesia nurses regarding the effectiveness of the app. The nurses confirmed that the app was convenient and reduced human error. This study revealed that the order-assisted mobile app developed by a pediatric anesthesiologist could reduce human errors by anesthesiologists and nurses during pediatric anesthesia preparation.

Human factors in anaesthesia: a narrative review

Healthcare relies on high levels of human performance, as described by the 'human as the hero' concept. However, human performance varies and is recognised to fall in high-pressure situations, meaning that it is not a reliable method of ensuring safety. Other safety-critical industries embed human factors principles into all aspects of their organisations to improve safety and reduce reliance on exceptional human performance; there is potential to do the same in anaesthesia. Human factors is a broad-based scientific discipline which aims to make it as easy as possible for workers to do things correctly. The human factors strategies most likely to be effective are those which 'design out' the chance of an error or adverse event occurring. When errors or adverse events do happen, barriers are in place to trap them and reduce the risk of progression to patient and/or worker harm. If errors or adverse events are not trapped by these barriers, mitigations are in place to minimise the consequences. Non-technical skills form an important part of human factors barriers and mitigation strategies and include: situation awareness; decision-making; task management; and team working. Human factors principles are not a substitute for proper investment and appropriate staffing levels. Although applying human factors science has the potential to save money in the long term, its proper implementation may require investment before reward can be reaped. This narrative review describes what is known about human factors in anaesthesia to date.

Standardised colour-coded compartmentalised syringe trays improve anaesthetic medication visual search and mitigate cognitive load

BACKGROUND

Anaesthetic procedures are complex and subject to human error. Interventions to alleviate medication errors include organised syringe storage trays, but no standardised methods for drug storage have yet been widely implemented.

METHODS

We used experimental psychology methods to explore the potential benefits of colour-coded compartmentalised trays compared with conventional trays in a visual search task. We hypothesised that colour-coded compartmentalised trays would reduce search time and improve error detection for both behavioural and eye-movement responses. We recruited 40 volunteers to identify syringe errors presented in pre-loaded trays for 16 trials in total: 12 error present and four error absent, with eight trials presented for each tray type.

RESULTS

Errors were detected faster when presented in the colour-coded compartmentalised trays than in conventional trays (11.1 s vs 13.0 s, respectively; P=0.026). This finding was replicated for correct responses for error-absent trays (13.3 s vs 17.4 s, respectively; P=0.001) and in the verification time of error-absent trays (13.1 s vs 17.2 s, respectively; P=0.001). On error trials, eye-tracking measures revealed more fixations on the drug error for colour-coded compartmentalised trays (5.3 vs 4.3, respectively; P<0.001), whilst more fixations on the drug lists for conventional trays (8.3 vs 7.1, respectively; P=0.010). On error-absent trials, participants spent longer fixating on the conventional trials (7.2 s vs 5.6 s, respectively; P=0.002).

CONCLUSIONS

Colour-coded compartmentalisation enhanced visual search efficacy of pre-loaded trays. Reduced fixations and fixation times for the loaded tray were shown for colour-coded compartmentalised trays, indicating a reduction in cognitive load. Overall, colour-coded compartmentalised trays were associated with significant performance improvements when compared with conventional trays.

Investigating the attentional focus to workplace-related soundscapes in a complex audio-visual-motor task using EEG

Introduction

In demanding work situations (e.g., during a surgery), the processing of complex soundscapes varies over time and can be a burden for medical personnel. Here we study, using mobile electroencephalography (EEG), how humans process workplace-related soundscapes while performing a complex audio-visual-motor task (3D Tetris). Specifically, we wanted to know how the attentional focus changes the processing of the soundscape as a whole.

Method

Participants played a game of 3D Tetris in which they had to use both hands to control falling blocks. At the same time, participants listened to a complex soundscape, similar to what is found in an operating room (i.e., the sound of machinery, people talking in the background, alarm sounds, and instructions). In this within-subject design, participants had to react to instructions (e.g., "place the next block in the upper left corner") and to sounds depending on the experimental condition, either to a specific alarm sound originating from a fixed location or to a beep sound that originated from varying locations. Attention to the alarm reflected a narrow attentional focus, as it was easy to detect and most of the soundscape could be ignored. Attention to the beep reflected a wide attentional focus, as it required the participants to monitor multiple different sound streams.

Results and discussion

Results show the robustness of the N1 and P3 event related potential response during this dynamic task with a complex auditory soundscape. Furthermore, we used temporal response functions to study auditory processing to the whole soundscape. This work is a step toward studying workplace-related sound processing in the operating room using mobile EEG.

The frequency and effects of distractions in operating theatres

BACKGROUND

Operating theatres (OTs) are complex environments where team members complete difficult tasks under stress. Distractions in these environments can lead to errors that compromise patient safety. A range of potential distractions exist in OTs and previous research suggests they are common. This study assesses the nature, frequency and impact of distracting events in the OT at a tertiary New Zealand hospital.

METHODS

Prospective observational study of the frequency, type and impact of OT distractions during a 3-month period. Two observational methods - the frequency of door openings and a validated tool - were used to categorize OT distractions for a range of acute and elective, paediatric and adult surgical procedures according to their cause and effect.

RESULTS

There were 57 procedures (2037 intraoperative minutes) observed. During this time, 721 door openings and 1152 other distracting events were recorded. On average, either a door opening or other distracting event was recorded 56 times per hour of intraoperative time. The frequency of distractions did not vary in relation to acute versus elective or paediatric versus adult procedures but were more common in the morning. Communication unrelated to the case was the most common distracting event: these and equipment issues had the greatest effect on the entire surgical team, usually by causing some interruption to operative flow.

CONCLUSION

Distractions in OTs were common, occurring nearly every minute. Most were trivial, but some had the potential to disrupt the operative procedure and result in patient harm. Reducing distractions in surgery could reduce patient harm and improve resource use.