Intra-operative decision making by ophthalmic surgeons

Decision-Making During High-Risk Events: A Systematic Literature Review

Effective decision-making in crisis events is challenging due to time pressure, uncertainty, and dynamic decisional environments. We conducted a systematic literature review in PubMed and PsycINFO, identifying 32 empiric research papers that examine how trained professionals make naturalistic decisions under pressure. We used structured qualitative analysis methods to extract key themes. The studies explored different aspects of decision-making across multiple domains. The majority (19) focused on healthcare; military, fire and rescue, oil installation, and aviation domains were also represented. We found appreciable variability in research focus, methodology, and decision-making descriptions. We identified five main themes: (1) decision-making strategy, (2) time pressure, (3) stress, (4) uncertainty, and (5) errors. Recognition-primed decision-making (RPD) strategies were reported in all studies that analyzed this aspect. Analytical strategies were also prominent, appearing more frequently in contexts with less time pressure and explicit training to generate multiple explanations. Practitioner experience, time pressure, stress, and uncertainty were major influencing factors. Professionals must adapt to the time available, types of uncertainty, and individual skills when making decisions in high-risk situations. Improved understanding of these decisional factors can inform evidence-based enhancements to training, technology, and process design.

Applied convolutional neural network framework for tagging healthcare systems in crowd protest environment

Healthcare systems constitute a significant portion of smart cities infrastructure. The aim of smart healthcare is two folds. The internal healthcare system has a sole focus on monitoring vital parameters of patients. The external systems provide proactive health care measures by the surveillance mechanism. This system utilizes the surveillance mechanism giving impetus to healthcare tagging requirements on the general public. The work exclusively deals with the mass gatherings and crowded places scenarios. Crowd gatherings and public places management is a vital challenge in any smart city environment. Protests and dissent are commonly observed crowd behavior. This behavior has the inherent capacity to transform into violent behavior. The paper explores a novel and deep learning-based method to provide an Internet of Things (IoT) environment-based decision support system for tagging healthcare systems for the people who are injured in crowd protests and violence. The proposed system is intelligent enough to classify protests into normal, medium and severe protest categories. The level of the protests is directly tagged to the nearest healthcare systems and generates the need for specialist healthcare professionals. The proposed system is an optimized solution for the people who are either participating in protests or stranded in such a protest environment. The proposed solution allows complete tagging of specialist healthcare professionals for all types of emergency response in specialized crowd gatherings. Experimental results are encouraging and have shown the proposed system has a fairly promising accuracy of more than eight one percent in classifying protest attributes and more than ninety percent accuracy for differentiating protests and violent actions. The numerical results are motivating enough for and it can be extended beyond proof of the concept into real time external surveillance and healthcare tagging.

Effect of virtual reality simulation training on real-life cataract surgery complications: systematic literature review

Virtual reality simulation (VRS) has become progressively popular as a training tool in ophthalmology. However, debate continues as to whether VRS has resulted in better outcomes for patients after cataract surgery. Accordingly, a qualitative systematic literature review was conducted to identify whether VRS training results in a reduced complication rate after real-life cataract surgery. Included studies measured the effect of VRS on real-life patient outcomes after cataract surgery. Databases searched included MEDLINE (Ovid), The Cochrane Library, Web of Science, PubMed, and CINAHL. A total of 1917 studies were identified, of which 10 studies were included, spanning from 2011 to 2020. The studies comprised 471 ophthalmological residents, with their complication rates assessed after 30 462 cataract surgery procedures. This systematic literature review indicates that VRS seems to be most helpful in reducing the rate of posterior capsular rupture or errant curvilinear capsulorrhexis and had limited evidence in reducing the rate of other complications.

Value of Nontechnical Skills in Minimally Invasive Surgery

Nontechnical skills are of increasing importance in surgery and surgical training. The main studies on its impact on the safety and effectiveness of surgical interventions were mainly published in the first decade of the 2000s. Due to the significant technical complexity and great diversity of instruments for nontechnical skills evaluation, the interest in training and in measuring the impact on surgical safety has relatively decreased. However, the advent of minimally invasive surgery and its peculiar technical characteristics of sophisticated technique and constant innovation through the adoption of new materials and drugs has rekindled interest in this expertise area. In the present review, we have revisited the main instruments available to measure nontechnical skill of surgical teams and analyzed the role of the main competencies on which they are based, such as situational awareness, leadership and communication skills, and the consistency of the intraoperative decision-making process. We conclude that despite the great consensus that exists among all members of the health team on the importance of nontechnical skills for the surgical team in minimally invasive surgery, the reproducible evidence on the subject is scarce and laborious to obtain. To the extent that protecting and expanding nontechnical skills is fundamental to the path toward the high reliability of health institutions, it is possible to anticipate here the role of these institutions as promoters of continuity and new research models in this area of knowledge, especially in minimally invasive surgery, an access route to which more and more patients undergoing surgical treatment in these same institutions are submitted.

How Do Pediatric Neurosurgeons Make Intraoperative Decisions?

OBJECTIVE

The purpose of this research was to explore the processes by which pediatric neurosurgeons make intraoperative decisions when they encounter something unexpected or uncertain while they are operating.

METHODS

The study used the grounded theory method of data collection and analysis. Twenty-six pediatric neurosurgeons (PNs) from 12 countries were interviewed about the process by which they make intraoperative decisions. Data were analyzed line by line, and constant comparison was used to examine relationships within and across codes and categories.

RESULTS

PNs described a complex process that existed along a spectrum in making intraoperative decisions. Three types of response processes emerged from the analysis: 1) internal processing, with the themes of getting oneself under control and performing control for the surgical team; 2) action processes that included the themes of stabilizing the patient, responding intuitively/automatically when making decisions, and shifting surgical strategies; and 3) analytical processing that involved assessing the situation, consulting with colleagues and the family of the patient when making intraoperative decisions.

CONCLUSIONS

The findings from this study contribute novel information on PNs' intraoperative decision making processes and can be used to train resident neurosurgeons about the various components involved in these processes. This research suggests that new models of decision making are needed within the medical and neurosurgical context and inspire a new set of questions about the process by which surgeons make life and death decisions in the operating room.

Choice and consequence: A naturalistic analysis of least-worst decision-making in critical incidents

Individuals responsible for decision-making during critical incidents must wrestle with uncertainty, complexity, time pressure, and accountability. Critical incidents are defined as rare events where demand outstrips resources and where there are high stakes, uncertainty, and dynamic and ever-shifting elements that frustrate clear predictions. This paper argues that critical-incident decision-making is highly complex because many critical incidents have no such analogue, and thus there is no prior experience to draw upon. Further, while prescriptive models argue for a selection of a "best" outcome, rarely in critical incidents is there a "best" outcome and, instead, more likely a "least-worst" one. Most options are high risk, most will carry negative consequences, and many will be immutable and irreversible once committed to. This paper analyzes data collected from critical decision method interviews with members of the United States Armed Forces to explore the psychological processes of making (or not making) least-worst decisions in high-consequence situations. Specifically, and based on thematic analysis of interviews with those who have made least-worst decisions while serving as part of the Armed Forces, we identify a host of exogenous (external to the incident such as resources, political agendas) and endogenous factors (features of the incident itself-size, scale, duration) that affect the decision-making process. These factors have, to date, not been factored into theoretical models of how high-stakes decisions are made under conditions of uncertainty.

Decision-Making in the Catheter Laboratory: The Most Important Variable in Successful Outcomes

Increasingly the importance of how and why we make decisions in the medical arena has been questioned. Traditionally the aeronautical and business worlds have shed a light on this complex area of human decision-making. In this review we reflect on what we already know about the complexity of decision-making in addition to directing particular focus on the challenges to decision-making in the high-intensity environment of the pediatric cardiac catheterization laboratory. We propose that the most critical factor in outcomes for children in the catheterization lab may not be technical failures but rather human factors and the lack of preparation and robust shared decision-making process between the catheterization team. Key technical factors involved in the decision-making process include understanding the anatomy, the indications and objective to be achieved, equipment availability, procedural flow, having a back-up plan and post-procedural care plan. Increased awareness, pre-catheterization planning, use of standardized clinical assessment and management plans and artificial intelligence may provide solutions to pitfalls in decision-making. Further research and efforts should be directed towards studying the impact of human factors in the cardiac catheterization laboratory as well as the broader medical environment.

Decision-centred design in healthcare: The process of identifying a decision support tool for airway management

Current decision support interventions for airway management in anaesthesia lack the application of Human Factors Engineering; leading to interventions that can be disruptive, inefficient and error-inducing. This study followed a decision-centred design process to identify decision support that can assist anaesthesia teams with challenging airway management situations. Field observations, Critical Decision Method interviews and focus groups were conducted to identify the most difficult decisions and their requirements. Data triangulation narrowed the focus to key decisions related to preparation and planning, and the transitioning between airway techniques during difficulties. Five decision-support interventions were identified and positively rated by anaesthesia team members in relation to their perceived effectiveness. An organized airway equipment trolley was chosen as the most beneficial decision support intervention. This study reiterated the key importance of both Human Factors Engineering and data triangulation when designing for healthcare.

Head, heart or checklist? How self-reported decision-making strategies change according to speciality and grade: a cross-sectional survey of doctors

PURPOSE

To identify and analyse variations in self-reported decision-making strategies between medical professionals of different specialty and grade.

STUDY DESIGN

We conducted a cross-sectional survey of doctors of different specialities and grades at St. George's Hospital, London, UK. We administered 226 questionnaires asking participants to assign proportions of their clinical decision-making behaviour to four strategies: intuitive, analytical, rule-based and creative.

RESULTS

We found that physicians said they used rule-based decision-making significantly more than did surgeons and anaesthetists (p = 0.025) and analytical decision-making strategies significantly less (p = 0.003). In addition, we found that both intuitive (p = 0.0005) and analytical (p = 0.0005) decision-making had positive associations with increasing experience, whereas rule-based decision-making was negatively associated with greater experience (p = 0.0005).

CONCLUSIONS

Decision-making strategies may evolve with increasing clinical experience from a predominant use of rule-based approaches towards greater use of intuitive or analytical methods depending on the familiarity and acuity of the clinical situation. Rule-based strategies remain important for delivering evidence-based care, particularly for less experienced clinicians, and for physicians more than surgeons, possibly due to the greater availability and applicability of guidelines for medical problems. Anaesthetists and intensivists tend towards more analytical decision-making than physicians; an observation which might be attributable to the greater availability and use of objective data in the care environment. As part of broader training in non-technical skills and human factors, increasing awareness among trainees of medical decision-making models and their potential pitfalls might contribute to reducing the burden of medical error in terms of morbidity, mortality and litigation.

Human factors enablers and barriers for successful airway management - an in-depth interview study

Human factors are the individual, team, environmental and organisational aspects of the anaesthetic environment that affect performance and decision-making of anaesthesia teams. This study aimed to identify which human factors were enablers and/or barriers to anaesthesia teams during airway management challenges. Sixteen interviews were conducted with experienced anaesthetists and anaesthetic nurses using an in-depth interview technique (the Critical Decision Method) to identify human factors enablers and/or barriers during successful management of a significant airway challenge. Thematic analysis identified three overarching enablers: equipment location and storage; experience and learning; teamwork and communication. Five overarching barriers were also identified: time and resource limitations; teamwork and communication; equipment location and storage; experience and learning; insufficient back-up planning; and equipment preparation. This study showed that a variety of human factors issues affect the handling of airway challenges, ranging from individual and team to organisational and environmental aspects. Recommendations for the design of airway management decision support tools that relate to equipment standardisation, decision support complexity, inclusive mutual learning and teamwork are discussed.

Acquisition and maintenance of medical expertise: a perspective from the expert-performance approach with deliberate practice

As a part of a special collection in this issue of Academic Medicine, which is focused on mastery learning in medical education, this Perspective describes how the expert-performance approach with deliberate practice is consistent with many characteristics of mastery learning. Importantly, this Perspective also explains how the expert-performance approach provides a very different perspective on the acquisition of skill. Whereas traditional education with mastery learning focuses on having students attain an adequate level of performance that is based on goals set by the existing curricula, the expert-performance approach takes an empirical approach and first identifies the final goal of training-namely, reproducibly superior objective performance (superior patient outcomes) for individuals in particular medical specialties. Analyzing this superior complex performance reveals three types of mental representations that permit expert performers to plan, execute, and monitor their own performance. By reviewing research on medical performance and education, the author describes evidence for these representations and their development within the expert-performance framework. He uses the research to generate suggestions for improved training of medical students and professionals. Two strategies-designing learning environments with libraries of cases and creating opportunities for individualized teacher-guided training-should enable motivated individuals to acquire a full set of refined mental representations. Providing the right resources to support the expert-performance approach will allow such individuals to become self-regulated learners-that is, members of the medical community who have the tools to improve their own and their team members' performances throughout their entire professional careers.