Factors that influence the expected length of operation: results of a prospective study

The frequency and reasons for missed nursing care in Australian perioperative nurses: A national survey

AIM

To describe Australian perioperative nurses' reported frequency and reasons for missed nursing care in the operating room.

DESIGN

Cross-sectional online survey conducted in March-April 2022.

METHODS

A census of Australian perioperative nurses who were members of a national professional body were invited to complete a survey that focussed on their reported frequency of missed nursing care and the reasons for missed nursing care in the operating room using the MISSCare Survey OR.

RESULTS

In all, 612 perioperative nurses completed the survey. The perioperative and intraoperative nursing care tasks reported as most frequently missed included time-intensive tasks and communication with multiple surgical team members present. The most frequently reported reasons for missed care were staffing-related (e.g. staff number, skill mix, fatigue and complacency) and affected teamwork. There were no significant differences in the frequency of missed care based on perioperative nurse roles. However, there were statistically significant differences between nurse management, circulating/instrument nurses and recovery room nurses in reasons for missed care.

CONCLUSIONS

Much of the missed care that occurs in the operating room is related to communication practices and processes, which has implications for patient safety.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Understanding the types of nursing care tasks being missed and the reasons for this missed care in the operating room may offer nurse managers deeper insights into potential strategies to address this situation.

REPORTING METHOD

Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Nontechnical Skills for Intraoperative Team Members

Nontechnical skills, defined as the set of cognitive and social skills used by individuals and teams to reduce error and improve performance in complex systems, have become increasingly recognized as a key contributor to patient safety. Efforts to characterize, quantify, and teach nontechnical skills in the context of perioperative care continue to evolve. This review article summarizes the essential behaviors for safety, described in taxonomies for nontechnical skills assessments developed for intraoperative clinical team members (eg, surgeons, anesthesiologists, scrub practitioners, perfusionists). Furthermore, the authors describe emerging methods to advance understanding of the impact of nontechnical skills on perioperative outcomes.

Instrument shank-assisted ovariohysterectomy: a randomized clinical trial of surgical and pain alleviation efficiency of a single-person modified technique

Objectives

To evaluate a modified ovariohysterectomy (OHE) technique performed by a single person and compare it with the conventional method based on time efficiency, trauma, and postoperative pain.

Methods

In a prospective, randomized, experimental study, 18 healthy, large, deep-chested, mixed-breed intact female dogs were randomly allocated to conventional (n = 9) and instrument shank-assisted (n = 9) groups. On the basis of video recordings, the various surgical step durations were analyzed: total surgery time (TST), pedicle intervention time (PIT), suspensory release time (SRT), shanking time (ShT), clamping time (ClpT), ligating time (LigT), and closure time (CT). The Glasgow composite pain scale short-form (GCMPS-SF), university of Melbourne pain scale (UMPS), and Visual Analogue Scales (VAS) were used to measure pain. C-reactive protein (CRP) fluctuation was also investigated. These evaluations were completed before and 6, 24, 48, and 72 h postoperatively.

Results

Instrument shank-assisted OHE was less time-consuming than conventional OHE (p = 0.005), improved PIT by 30.7% (6.44 min for both pedicles, p = 0.014), and correlated strongly with TST (ρ = 0.862, p = 0.003 and ρ = 0.955, p = 0.000, respectively). The two method's surgical step durations were also TST = 47.40 ± 9.9 vs. 34.70 ± 6.7 min, PIT = 20.96 ± 5.78 vs. 14.52 ± 3.73 min, SRT = 78.97 ± 69.10 vs. ShT = 20.39 ± 8.18 s (p = 0.035), ClpT = 50.66 ± 45.04 vs. 63.55 ± 37.15 s (p = 0.662), LigT = 12.82 ± 3.37 vs. 8.02 ± 3.11 min (p = 0.005), and CT = 16.40 ± 4.5 vs. 11.60 ± 2.5 min (p = 0.013), respectively. While both techniques inflicted pain on the animals, the novel approach resulted in a reduction of pain at T6 (GCMPS-SF, p = 0.015 and VAS, p = 0.002), T24 (UMPS, p = 0.003), and T48 (GCMPS-SF, p = 0.015 and UMPS, p = 0.050). Both methods exhibited a peak in CRP level after 24 h, which subsequently returned to baseline after 48 h. However, the shank-assisted method demonstrated a significantly lower reduction in CRP level at the 48-h compared to the other group (p = 0.032).

Conclusion

Instrument shank-assisted technique permitted ovarian removal without an assistant, less damage to animals and reducing its time when compared to a conventional technique, and resulting in an alternative that causes less surgical stress and fatigue. Further research with a larger population size is required to determine the serum CRP levels as an alternative pain biomarker.

Thematic mapping of perioperative incident reporting data to relational coordination domains

Communication failure is a common root cause of adverse clinical events. Problematic communication domains are difficult to decipher, and communication improvement strategies are scarce. This study compared perioperative incident reports (IR) identifying potential communication failures with the results of a contemporaneous peri-operative Relational Coordination (RC) survey. We hypothesised that IR-prevalent themes would map to areas-of-weakness identified in the RC survey. Perioperative IRs filed between 2018 and 2020 (n = 6,236) were manually reviewed to identify communication failures (n = 1049). The IRs were disaggregated into seven RC theory domains and compared with the RC survey. Report disaggregation ratings demonstrated a three-way inter-rater agreement of 91.2%. Of the 1,049 communication failure-related IRs, shared knowledge deficits (n = 479, 46%) or accurate communication (n = 465, 44%) were most frequently identified. Communication frequency failures (n = 3, 0.3%) were rarely coded. Comparatively, shared knowledge was the weakest domain in the RC survey, while communication frequency was the strongest, correlating well with our IR data. Linking IR with RC domains offers a novel approach to assessing the specific elements of communication failures with an acute care facility. This approach provides a deployable mechanism to trend intra- and inter-domain progress in communication success, and develop targeted interventions to mitigate against communication failure-related adverse events.

A real-time analysis of intraoperative interruptions in relation to use of simple preventive measures including a sign on the door and a checklist-based team brief

This study aimed to evaluate intraoperative interruptions by frequency, type, interference and source, and preventive measures. The interruptions in the operating theatre were evaluated for 52 surgical procedures based on real-time recordings and divided into routine operative procedures (ROP, n = 26, without intervention) and intervened operative procedures (IOP, n = 26, observed after team brief and placement of a warning sign for unnecessary door openings) groups. Intervened operative procedures vs. routine operative procedures was associated with a significantly lower number of interruptions (p = 0.014). Implementation of preventive measures was associated with a significantly lower number of entrances and exits (p = 0.001) and equipment issues (p = 0.003), interruptions that affected the circulating nurse or anaesthesia technician/associate (p = 0.003) and those caused by team members other than assisting surgeon and scrub nurse (p-value ranged from 0.015 to 0.009). Our findings revealed significantly reduced interruptions after a simple preventive measure including team brief and the placement of a warning sign for unnecessary door openings.

Automatic Surgery and Anesthesia Emergence Duration Prediction Using Artificial Neural Networks

Cost control is becoming increasingly important in hospital management. Hospital operating rooms have high resource consumption because they are a major part of a hospital. Thus, the optimal use of operating rooms can lead to high resource savings. However, because of the uncertainty of the operation procedures, it is difficult to arrange for the use of operating rooms in advance. In general, the durations of both surgery and anesthesia emergence determine the time requirements of operating rooms, and these durations are difficult to predict. In this study, we used an artificial neural network to construct a surgery and anesthesia emergence duration-prediction system. We propose an intelligent data preprocessing algorithm to balance and enhance the training dataset automatically. The experimental results indicate that the prediction accuracies of the proposed serial prediction systems are acceptable in comparison to separate systems.

Communication Patterns During Routine Patient Care in a Pediatric Intensive Care Unit: The Behavioral Impact of In Situ Simulation

OBJECTIVE

Effective communication minimizes medical errors and leads to improved team performance while treating critically ill patients. Closed-loop communication is routinely applied in high-risk industries but remains underutilized in healthcare. Simulation serves as an educational tool to introduce, practice, and appreciate the efficacy of closed-loop communication.

METHODS

This observational before-and-after study investigates behavioral changes in communication among nurses brought on by simulation team training in a pediatric intensive care unit (PICU). The communication patterns of PICU nurses, who had no prior simulation experience, were observed during routine bedside care before and after undergoing in situ simulation.One month before and 1 and 3 months after simulation (intervention), 2 trained raters recorded nurse communications relative to callouts, uttered by the sender, and callbacks, reciprocated by the recipient. The impact of simulation on communication patterns was analyzed quantitatively.

RESULTS

Among the 15 PICU nurses included in this study, significant changes in communication behavior were observed during patient care after communication-focused in situ simulation. The PICU nurses were significantly less likely to let a callout go unanswered during clinical routine. The effect prevailed both 1 month (P = 0.039) and 3 months (P = 0.033) after the educational exposure.

CONCLUSIONS

This observational before-and-after study describes the prevalence and pattern of communication among PICU nurses during routine patient care and documents PICU nurses transferring simulation-acquired communication skills into their clinical environment after a single afternoon of in situ simulation. This successful transfer of simulation-acquired skills has the potential to improve patient safety and outcome.

The Impact of Robotic-Assisted Surgery on Team Performance: A Systematic Mixed Studies Review

OBJECTIVE

The aim of this study is to describe the impact of robotic-assisted surgery on team performance in the operating room.

BACKGROUND

The introduction of surgical robots has improved the technical performance of surgical procedures but has also contributed to unexpected interactions in surgical teams, leading to new types of errors.

METHOD

A systematic literature search of Cumulative Index to Nursing and Allied Health Literature, PubMed, ProQuest, Cochrane, Web of Science, PsycINFO, and Scopus databases using key words and MeSH terms was conducted. Screening identified studies employing qualitative and quantitative methods published between January 2000 and September 2019. Two reviewers independently appraised the methodological quality of the articles using the Mixed Methods Appraisal Tool (2018). Discussions were held among authors to examine quality scores of the studies and emergent themes, and agreement was reached through consensus. Themes were derived using inductive content analysis.

RESULTS

Combined searches identified 1,065 citations. Of these, 19 articles, 16 quantitative and 3 qualitative, were included. Robotic-assisted surgeries included urology, gynecology, cardiac, and general procedures involving surgeons, anesthetists, nurses, and technicians. Three themes emerged: Negotiating the altered physical environs and adapting team communications to manage task and technology; managing the robotic system to optimize workflow efficiency; and technical proficiency depends on experience, team familiarity, and case complexity.

CONCLUSION

Inclusion of a robot as a team member adds further complexity to the work of surgery.

APPLICATION

These review findings will inform training programs specifically designed to optimize teamwork, workflow efficiency, and learning needs.

Effects of a Brief Team Training Program on Surgical Teams' Nontechnical Skills: An Interrupted Time-Series Study

BACKGROUND

Up to 60% of adverse events in surgery are the result of poor communication and teamwork. Nontechnical skills in surgery (NOTSS) are critical to the success of surgery and patient safety. The study aim was to evaluate the effect of a brief team training intervention on teams' observed NOTSS.

METHODS

Pretest-posttest interrupted time-series design with statistical process control analysis was used to detect longitudinal changes in teams' NOTSS. We evaluated NOTSS using the revised NOTECHS weekly for 20 to 25 weeks before and after implementation of a team training program.

RESULTS

We observed 179 surgical procedures with cardiac, vascular, upper gastrointestinal, and hepatobiliary teams. Mean posttest NOTECHS scores increased across teams, showing special cause variation. There were also significant before and after improvements in NOTECHS scores in respect to professional role and in the use of the Surgical Safety Checklist.

CONCLUSIONS

Our results suggest associated improvements in teams' NOTSS after implementation of the team training program.

Impact of Surgical Table Orientation on Flow Disruptions and Movement Patterns during Pediatric Outpatient Surgeries

(1) Background: The surgical table within a typical ambulatory surgery operating room is frequently rotated and placed in different orientations to facilitate surgery or in response to surgeon preferences. However, different surgical table orientations can impact access to different work zones, areas and equipment in the OR, potentially impacting workflow of surgical team members and creating patient safety risks; (2) Methods: This quantitative observational study used a convenience sample of 38 video recordings of the intraoperative phase of pediatric outpatient surgeries to study the impacts of surgical table orientation on flow disruptions (FDs), number of contacts between team members and distance traveled; (3) Results: This study found that the orientation of the surgical table significantly influenced staff workflow and movement in the OR with an angled surgical table orientation being least disruptive to surgical work. The anesthesia provider, scrub nurse and circulating nurse experienced more FDs compared to the surgeon; (4) Conclusions: The orientation of the surgical table matters, and clinicians and architects must consider different design and operational strategies to support optimal table orientation in the OR.

Are operating room distractions, interruptions and disruptions associated with performance and patient safety? A systematic review and meta-analysis

OBJECTIVE

The operating room is a complex environment in which distractions, interruptions and disruptions (DIDs) are frequent. Our aim was to synthesize research on the relationships between DIDs and (i) operative duration, (ii) team performance, (iii) individual performance and (iv) patient safety outcomes in order to better understand how interventions can be designed to mitigate the negative effects of DIDs.

METHODS

Electronic databases (MEDLINE, Embase, CINAHL and PsycINFO) and reference lists were systematically searched. Included studies were required to report the quantitative outcomes of the association between DIDs and team performance, individual performance and patient safety. Two reviewers independently screened articles for inclusion, assessed study quality and extracted data. A random-effects meta-analysis was performed on a subset of studies reporting total operative time and DIDs.

RESULTS

Twenty-seven studies were identified. The majority were prospective observational studies (n = 15) of moderate quality. DIDs were often defined, measured and interpreted differently in studies. DIDs were significantly associated with extended operative duration (n = 8), impaired team performance (n = 6), self-reported errors by colleagues (n = 1), surgical errors (n = 1), increased risk and incidence of surgical site infection (n = 4) and fewer patient safety checks (n = 1). A random-effects meta-analysis showed that the proportion of total operative time due to DIDs was 22.0% (95% confidence interval 15.7-29.9).

CONCLUSION

DIDs in surgery are associated with a range of negative outcomes. However, significant knowledge gaps exist about the mechanisms that underlie these relationships, as well as the potential clinical and non-clinical benefits that DIDs may deliver. Available evidence indicates that interventions to reduce the negative effects of DIDs are warranted, but current evidence is not sufficient to make recommendations about potentially useful interventions.

Surgical Team Familiarity: An Integrative Review

The dynamic nature of perioperative care often brings unfamiliar clinicians together yet requires them to collectively provide complex health care in a challenging environment. In this review, we comprehensively evaluated evidence regarding surgical team familiarity and its relationship to surgical team performance. Using a comprehensive and iterative search strategy, we searched PubMed, Web of Science, PsycInfo, and EMBASE for surgical team familiarity manuscripts. We identified 598 manuscripts, 16 of which met our inclusion criteria. We found that surgical team familiarity is associated with improved performance for many metrics, including shorter total operative time, team member safety, decreased surgical errors and disruptions, reduced miscommunication, and fewer patient readmissions. Although additional research would be helpful, surgical managers should consider team familiarity and consistency in team membership when assigning staff members to surgical teams to optimize surgical care, decrease inefficiencies, and promote safe patient outcomes.

Surgical benchmarks, mid-term oncological outcomes, and impact of surgical team composition on simultaneous enbloc robot-assisted radical cystectomy and nephroureterectomy

Background

Simultaneous urothelial cancer manifestation in the lower and upper urinary tract affects approximately 2% of patients. Data on the surgical benchmarks and mid-term oncological outcomes of enbloc robot-assisted radical cystectomy and nephro-ureterectomy are scarce.

Methods

After written informed consent was obtained, we prospectively enrolled consecutive patients undergoing enbloc radical cystectomy and nephro-ureterectomy with robotic assistance from the DaVinci Si-HD® system in a prospective institutional database and collected surgical benchmarks and oncological outcomes. Furthermore, as one console surgeon conducted all the procedures, whereas the team providing bedside assistance was composed ad hoc, we assessed the impact of this approach on the operative duration.

Results

Nineteen patients (9 women), with a mean age of 73 (SD: 7.5) years, underwent simultaneous enbloc robot-assisted radical cystectomy and nephro-ureterectomy. There were no cases of conversion to open surgery. In the postoperative period, we registered 2 Clavien-Dindo class 2 complications (transfusions) and 1 Clavien-Dindo class 3b complication (port hernia). After a median follow-up of 23 months, there were 3 cases of mortality and 1 case of metachronous urothelial cancer (contralateral kidney).The total operative duration did not decrease with increasing experience (r = 0.174, p = 0.534). In contrast, there was a significant, inverse, strong correlation between the console time relative to the total operative duration and the number of conducted procedures after adjusting for the degree of adhesions and the type of urinary diversion(r = -0.593, p = 0.02).

Conclusions

These data suggest that en bloc simultaneous robot-assisted radical cystectomy and nephro-ureterectomy can be safely conducted with satisfactory mid-term oncological outcomes. With increasing experience, improved performance was detectable for the console surgeon but not in terms of the total operative duration. Simulation training of all team members for highly complex procedures might be a suitable approach for improving team performance.

Trial registration: Not applicable.

Fellows and Observers Are Not a Problem for Infection in the Operating Rooms of Teaching Centers

PURPOSE

The aim of the present study was to determine whether the risk of complications increases with the number of people in the operating room (OR). Several studies have stated that an increased number of people in the OR increases not only the risk of infection but also the risk of intraoperative complications due to distractions during the surgery.

MATERIALS AND METHODS

This retrospective study included all patients who had surgery between January 2017 and January 2018 in an OR with the usual surgical team and three or more observers. Patient demographic data, surgical details (duration of the surgery, the surgery being open or arthroscopic, and whether a graft was used), and intraoperative and postoperative complications were recorded.

RESULTS

A total of 165 surgeries were recorded, with a mean operating time of 70 min (40% open surgeries, 37% arthroscopic surgeries, and 23% combined open and arthroscopic procedures). The main intraoperative complications were vessel damage, nerve damage, premature cement setting, and leg-length discrepancy, with 1 case each. The main postoperative complications were rigidity (8 cases), unexplained pain (11 cases), failed meniscal suturing (3 cases), a postoperative stress fracture (1 case), correction loss in osteotomy (1 case), and wound problems not related to infection (1 case). There were no cases of infection.

DISCUSSION

The present study shows that the complication rate when having observers in the OR is comparable to the reported data. The key to avoiding complications is for everyone to comply with basic OR behavior.

Influence of team composition on turnover and efficiency of total hip and knee arthroplasty

AIMS

Surgical costs are a major component of healthcare expenditures in the USA. Intraoperative communication is a key factor contributing to patient outcomes. However, the effectiveness of communication is only partially determined by the surgeon, and understanding how non-surgeon personnel affect intraoperative communication is critical for the development of safe and cost-effective staffing guidelines. Operative efficiency is also dependent on high-functioning teams and can offer a proxy for effective communication in highly standardized procedures like primary total hip and knee arthroplasty. We aimed to evaluate how the composition and dynamics of surgical teams impact operative efficiency during arthroplasty.

METHODS

We performed a retrospective review of staff characteristics and operating times for 112 surgeries (70 primary total hip arthroplasties (THAs) and 42 primary total knee arthroplasties (TKAs)) conducted by a single surgeon over a one-year period. Each surgery was evaluated in terms of operative duration, presence of surgeon-preferred staff, and turnover of trainees, nurses, and other non-surgical personnel, controlling cases for body mass index, presence of osteoarthritis, and American Society of Anesthesiologists (ASA) score.

RESULTS

Turnover among specific types of operating room staff, including the anaesthesiologist (p = 0.011), circulating nurse (p = 0.027), and scrub nurse (p = 0.006), was significantly associated with increased operative duration. Furthermore, the presence of medical students and nursing students were associated with improved intraoperative efficiency in TKA (p = 0.048) and THA (p = 0.015), respectively. The presence of surgical fellows (p > 0.05), vendor representatives (p > 0.05), and physician assistants (p > 0.05) had no effect on intraoperative efficiency. Finally, the presence of the surgeon's 'preferred' staff did not significantly shorten operative duration, except in the case of residents (p = 0.043).

CONCLUSION

Our findings suggest that active management of surgical team turnover and composition may provide a means of improving intraoperative efficiency during THA and TKA. Cite this article: Bone Joint J 2021;103-B(2):347-352.

Positive communication behaviour during handover and team-based clinical performance in critical situations: a simulation randomised controlled trial

BACKGROUND

Positive communication behaviour within anaesthesia teams may decrease stress response and improve clinical performance. We aimed to evaluate the effect of positive communication during medical handover on the subsequent team-based clinical performance in a simulated critical situation. We also assessed the effect of positive communication behaviour on stress response.

METHODS

This single-centre RCT involved anaesthesia teams composed of a resident and a nurse in a high-fidelity scenario of anaesthesia-related paediatric laryngospasm after a standardised handover. During the handover, similar information was provided to all teams, but positive communication behaviour was adopted only for teams in the intervention group. Primary outcome was team-based clinical performance, assessed by an independent blinded observer, using video recordings and a 0-to 100-point scenario-specific scoring tool. Three categories of tasks were considered: safety checks before the incision, diagnosis/treatment of laryngospasm, and crisis resource management/non-technical skills. Individual stress response was monitored by perceived level of stress and HR variability.

RESULTS

The clinical performance of 64 anaesthesia professionals (grouped into 32 teams) was analysed. The mean (standard deviation) team-based performance score in the intervention group was 44 (10) points vs 35 (12) in the control group (difference: +8.4; CI_95% [0.4-16.4]; P=0.04). The effects were homogeneous over the three categories of tasks. Perceived level of stress and HR variability were not significantly different between groups.

CONCLUSIONS

Positive communication behaviour between healthcare professionals during medical handover improved team-based performance in a simulation-based critical situation.

CLINICAL TRIAL REGISTRATION

NCT03375073.

Research and Exploratory Analysis Driven-Time-data Visualization (read-tv) software

MOTIVATION

Research & Exploratory Analysis Driven Time-data Visualization (read-tv) is an open source R Shiny application for visualizing irregularly and regularly spaced longitudinal data. read-tv provides unique filtering and changepoint analysis (CPA) features. The need for these analyses was motivated by research of surgical work-flow disruptions in operating room settings. Specifically, for the analysis of the causes and characteristics of periods of high disruption-rates, which are associated with adverse surgical outcomes.

MATERIALS AND METHODS

read-tv is a graphical application, and the main component of a package of the same name. read-tv generates and evaluates code to filter and visualize data. Users can view the visualization code from within the application, which facilitates reproducibility. The data input requirements are simple, a table with a time column with no missing values. The input can either be in the form of a file, or an in-memory dataframe- which is effective for rapid visualization during curation.

RESULTS

We used read-tv to automatically detect surgical disruption cascades. We found that the most common disruption type during a cascade was training, followed by equipment.

DISCUSSION

read-tv fills a need for visualization software of surgical disruptions and other longitudinal data. Every visualization is reproducible, the exact source code that read-tv executes to create a visualization is available from within the application. read-tv is generalizable, it can plot any tabular dataset given the simple requirements that there is a numeric, datetime, or datetime string column with no missing values. Finally, the tab-based architecture of read-tv is easily extensible, it is relatively simple to add new functionality by implementing a tab in the source code.

CONCLUSION

read-tv enables quick identification of patterns through customizable longitudinal plots; faceting; CPA; and user-specified filters. The package is available on GitHub under an MIT license.

The Impact of Surgical Team Familiarity on Length of Procedure and Length of Stay: Inconsistent Relationships Across Procedures, Team Members, and Sites

BACKGROUND

Team familiarity has been shown to be important for operative efficiency and number of complications, but it is unclear for which types of operations and for which team members familiarity matters the most. The objective of this study is to further our understanding of familiarity in the OR by quantifying the relative importance of familiarity among all possible core team dyads, and defining the impact of team level familiarity on outcomes.

MATERIALS AND METHODS

Using a retrospective chart and administrative data review, five years of data from two health systems (14 hospitals) and across two procedures, (knee arthroplasty and lumbar laminectomy) were included. Multilevel modeling approach and a dominance analysis were conducted.

RESULTS

For each previous surgery that any two members of the core surgical team had participated in together, the length of surgery decreased significantly. The familiarity of the scrub and the surgeon was the most significant relationship for knee arthroplasty across the two hospitals, and laminectomies at one hospital.

CONCLUSIONS

The relationship between familiarity of the surgical team and surgical efficiency may be more complex than previously articulated. Familiarity may be more important for certain types of procedures. The familiarity of certain dyads may be more important for certain types of procedures.

Associations of workflow disruptions in the operating room with surgical outcomes: a systematic review and narrative synthesis

Background

Performance in the operating room is an important determinant of surgical safety. Flow disruptions (FDs) represent system-related performance problems that affect the efficiency of the surgical team and have been associated with a risk to patient safety. Despite the growing evidence base on FDs, a systematic synthesis has not yet been published.

Objective

Our aim was to identify, evaluate and summarise the evidence on relationships between intraoperative FD events and provider, surgical process and patient outcomes.

Methods

We systematically searched databases MEDLINE, Embase and PsycINFO (last update: September 2019). Two reviewers independently screened the resulting studies at the title/abstract and full text stage in duplicate, and all inconsistencies were resolved through discussion. We assessed the risk of bias of included studies using established and validated tools. We summarised effects from included studies through a narrative synthesis, stratified based on predefined surgical outcome categories, including surgical process, provider and patient outcomes.

Results

We screened a total of 20 481 studies. 38 studies were found to be eligible. Included studies were highly heterogeneous in terms of methodology, medical specialty and context. Across studies, 20.5% of operating time was attributed to FDs. Various other process, patient and provider outcomes were reported. Most studies reported negative or non-significant associations of FDs with surgical outcomes.

Conclusion

Apart from the identified relationship of FDs with procedure duration, the evidence base concerning the impact of FDs on provider, surgical process and patient outcomes is limited and heterogeneous. We further provide recommendations concerning use of methods, relevant outcomes and avenues for future research on associated effects of FDs in surgery.

An observational study of ad-hoc anaesthesia teams

BACKGROUND

Anaesthesia teams are temporarily assembled to cooperate with teams in emergency departments in the immediate management of events compromising patients’ airway, ventilation and circulation.

PURPOSE

The aim was to describe a temporary ad-hoc anaesthesia team’s performance.

DESIGN

An observational study was conducted.

METHODS

Data, collected with 12 non-participatory observations, were analysed using both an thematic method, and a validated assessment tool, the Team Emergency Assessment Measure.

RESULTS

Three themes were identified: (1) flexibility in assuming varying roles, (2) expertise in verbal and non-verbal communication and (3) skills dealing with the challenges of working in unfamiliar dynamic environments. Ninety per cent of anaesthesia teams scored 7.6 (0–10) on the overall assessment according to the Team Emergency Assessment Measure rating.

CONCLUSION

Ad-hoc anaesthesia team members communicated in various ways and the anaesthesia team adapted well to the unpredictable environment in the emergency department.

What attributes define excellence in a trauma team? A qualitative study

Background

Hospital trauma teams consist of a diverse spectrum of health care professionals who work together to deliver quality care. Although the qualities of a well-performing trauma team are often believed to be self-evident, there is little objective information about the most desirable personal and professional characteristics associated with quality trauma care. The aim of this study was to determine the traits and characteristics deemed of greatest value for a trauma team leader and a trauma team member in the adult trauma care setting.

Methods

Semistructured interviews were conducted with trauma team leaders and trauma team members at a tertiary Canadian trauma centre. Standard qualitative research methodology was used. Interviews were recorded, transcribed and analyzed via an inductive analysis approach.

Results

Thematic saturation was achieved after 5 interviews, and 6 further interviews were conducted to ensure that a breadth of trauma care disciplines were included. Six attributes were identified to be of greatest value for trauma team leaders: communication, role clarity, experience, anticipation, management and decisiveness. Four attributes were identified to be of greatest value for trauma team members: engagement, efficiency, experience and collaboration. We further characterized the language defining the ranking of performance for each of these attributes.

Conclusion

Results of this qualitative study involving an experienced and diverse spectrum of trauma team practitioners provide insight into the characteristics that are critical to establishing a “good” trauma team. These findings can be used to inform future determinations of the quality of trauma teams, the education of trauma practitioners and continuing medical education training and assessment tools.

Improving Operating Room Efficiency: Machine Learning Approach to Predict Case-Time Duration

BACKGROUND

Accurate estimation of operative case-time duration is critical for optimizing operating room use. Current estimates are inaccurate and earlier models include data not available at the time of scheduling. Our objective was to develop statistical models in a large retrospective data set to improve estimation of case-time duration relative to current standards.

STUDY DESIGN

We developed models to predict case-time duration using linear regression and supervised machine learning. For each of these models, we generated an all-inclusive model, service-specific models, and surgeon-specific models. In the latter 2 approaches, individual models were created for each surgical service and surgeon, respectively. Our data set included 46,986 scheduled operations performed at a large academic medical center from January 2014 to December 2017, with 80% used for training and 20% for model testing/validation. Predictions derived from each model were compared with our institutional standard of using average historic procedure times and surgeon estimates. Models were evaluated based on accuracy, overage (case duration > predicted + 10%), underage (case duration < predicted - 10%), and the predictive capability of being within a 10% tolerance threshold.

RESULTS

The machine learning algorithm resulted in the highest predictive capability. The surgeon-specific model was superior to the service-specific model, with higher accuracy, lower percentage of overage and underage, and higher percentage of cases within the 10% threshold. The ability to predict cases within 10% improved from 32% using our institutional standard to 39% with the machine learning surgeon-specific model.

CONCLUSIONS

Our study is a notable advancement toward statistical modeling of case-time duration across all surgical departments in a large tertiary medical center. Machine learning approaches can improve case duration estimations, enabling improved operating room scheduling, efficiency, and reduced costs.

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

OBJECTIVES

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

DESIGN

Systematic review and meta-analysis.

DATA SOURCE

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

ELIGIBILITY CRITERIA

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

DATA EXTRACTION AND SYNTHESIS

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

RESULTS

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

CONCLUSION

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

A novel team Familiarity Score for operating teams is a predictor of length of a procedure: A retrospective Bayesian analysis

OBJECTIVE

The aim of our retrospective study was to assess whether a novel team Familiarity Score (FS) is associated with the length of procedure (LOP), postoperative length of stay (LOS), and complication rate after vascular procedures.

METHODS

We retrospectively analyzed 326 vascular procedures performed at a tertiary care vascular surgery center between April 2012 and September 2014. Data collected included patients' age, American Society of Anesthesiologists grade, LOP, type and urgency of procedure, LOS, and complications. Familiarity Score (FS) was defined as the sum of the number of times that each possible pair of the team (vascular consultant, vascular registrar, scrub nurse, anesthetic consultant) within the team had worked together during the previous 6 months, divided by the number of possible combinations of pairs in the team. Bayesian statistics was used to analyze the data.

RESULTS

FS was significantly associated with type and urgency of the procedure (Bayes factor [BF] >1000). Emergency procedures were performed by less familiar teams, and the least familiar teams were involved in the emergency aortic procedures-endovascular and open. FS was strongly associated with LOP (BF = 37) but not with LOS (BF = 4.0) and complication rate.

CONCLUSIONS

FS in vascular teams was shown to be strongly associated with LOP, suggesting that more familiar teams might collaborate more efficiently.

Surgical team: improving teamwork, a review

Teams within surgery have been through countless cycles of refinement with an ever-increasing list of surgical team members. This results in a more dispersed team, making effective teamwork harder to achieve. Furthermore, the ad hoc nature of surgical teams means that team familiarity is not always given. The impact of this is seen across the field, with inadequacies leading to disastrous outcomes. This is a review of research that has been done into the topic of surgical teams. It will investigate barriers and consider the evidence available on how to improve the current system. Studies show an increased effectiveness of surgical teams with structures that allowed consistency in team members. The research advocates that advancements made in improving teamwork and efficiency can prove to be a low-cost but high-yield strategy for development. This can be in terms of simulated training, staff turnover management and fixed team allocation.

Minor flow disruptions, traffic-related factors and their effect on major flow disruptions in the operating room

BACKGROUND

Studies in operating rooms (OR) show that minor disruptions tend to group together to result in serious adverse events such as surgical errors. Understanding the characteristics of these minor flow disruptions (FD) that impact major events is important in order to proactively design safer systems OBJECTIVE: The purpose of this study is to use a systems approach to investigate the aetiology of minor and major FDs in ORs in terms of the people involved, tasks performed and OR traffic, as well as the location of FDs and other environmental characteristics of the OR that may contribute to these disruptions.

METHODS

Using direct observation and classification of FDs via video recordings of 28 surgical procedures, this study modelled the impact of a range of system factors-location of minor FDs, roles of staff members involved in FDs, type of staff activities as well as OR traffic-related factors-on major FDs in the OR.

RESULTS

The rate of major FDs increases as the rate of minor FDs increases, especially in the context of equipment-related FDs, and specific physical locations in the OR. Circulating nurse-related minor FDs and minor FDs that took place in the transitional zone 2, near the foot of the surgical table, were also related to an increase in the rate of major FDs. This study also found that more major and minor FDs took place in the anaesthesia zone compared with all other OR zones. Layout-related disruptions comprised more than half of all observed FDs.

CONCLUSION

Room design and layout issues may create barriers to task performance, potentially contributing to the escalation of FDs in the OR.

Team talk and team decision processes: a qualitative discourse analytical approach to 10 real-life medical emergency team encounters

OBJECTIVES

Explore the function of three specific modes of talk (discourse types) in decision-making processes.

DESIGN

Ten real-life admissions of patients with critical illness were audio/video recorded and transcribed. Activity-type analysis (a qualitative discourse analytical method) was applied.

SETTING

Interdisciplinary emergency teams admitting patients with critical illness in a Norwegian university hospital emergency department (ED).

PARTICIPANTS

All emergency teams consisted of at least two internal medicine physicians, two ED nurses, one anaesthetist and one nurse anaesthetist. The number of healthcare professionals involved in each emergency team varied between 11 and 20, and some individuals were involved with more than one team.

RESULTS

The three discourse types played significant roles in team decision-making processes when negotiating meaning. Online commentaries (ONC) and metacommentaries (MC) created progression while offline commentaries (OFC) temporarily placed decisions on hold. Both ONC and MC triggered action and distributed tasks, resources and responsibility in the team. OFC sought mutual understanding and created a broader base for decisions.

CONCLUSION

A discourse analytical perspective on team talk in medical emergencies illuminates both the dynamics and complexity of teamwork. Here, we draw attention to the way specific modes of talk function in negotiating mutual understanding and distributing tasks and responsibilities in non-algorithm-driven activities. The analysis uncovers a need for an enhanced focus on how language can trigger safe team practice and integrate this knowledge in teamwork training to improve communication skills in ad hoc emergency teams.

Evaluation of a patient safety programme on Surgical Safety Checklist Compliance: a prospective longitudinal study

BACKGROUND

Surgical Safety Checklists (SSC) have been implemented widely across 132 countries since 2008. Yet, despite associated reductions in postoperative complications and death rates, implementation of checklists in surgery remains a challenge. The aim of this study was to assess the impact of a patient safety programme over time on SSC use and incidence of clinical errors.

DESIGN

A prospective longitudinal design over three time points and a retrospective secondary analysis of clinical incident data was undertaken.

METHODS

We implemented a patient safety programme over 4 weeks to improve surgical teams' use of the SSC. We undertook structured observations to assess surgical teams' checklist use before and after programme implementation and conducted a retrospective audit of clinical incident data 12 months before and 12 months following implementation of the programme.

RESULTS

There were significant improvements in the observed use of the SSC across all phases, particularly in sign-out where completion rates ranged from 79.3% to 94.5% (p<0.0001) following programme implementation. Across clinical incident audit periods, 33 019 surgical procedures were performed. Based on a subsample of 64 cases, clinical incidents occurred in 22/16 264 (0.13%) before implementation and 42/16 755 (0.25%) cases after implementation. The most predominant incident after programme implementation was inadequate tissue specimen labelling (23/42, 54.8%). Clinical incidents resulted in minimal or no harm to the patient.

CONCLUSIONS

The benefit in using a surgical checklist lies in the potential to enhance team communications and the promotion of a team culture in which safety is the priority.

Operating list composition and surgical performance

BACKGROUND

Recent reviews suggest that the way in which surgeons prepare for a procedure (warm up) can affect performance. Operating lists present a natural experiment to explore this phenomenon. The aim was to use a routinely collected large data set on surgical procedures to understand the relationship between case list order and operative performance.

METHOD

Theatre lists involving the 35 procedures performed most frequently by senior surgeons across 38 private hospitals in the UK over 26 months were examined. A linear mixed-effects model and matched analysis were used to estimate the impact of list order and the cost of switching between procedures on a list while controlling for key prognosticators. The influence of procedure method (open versus minimally invasive) and complexity was also explored.

RESULTS

The linear mixed-effects model included 255 757 procedures, and the matched analysis 48 632 pairs of procedures. Repeating the same procedure in a list resulted in an overall time saving of 0·98 per cent for each increase in list position. Switching between procedures increased the duration by an average of 6·48 per cent. The overall reduction in operating time from completing the second procedure straight after the first was 6·18 per cent. This pattern of results was consistent across procedure method and complexity.

CONCLUSION

There is a robust relationship between operating list composition and surgical performance (indexed by duration of operation). An evidence-based approach to structuring a theatre list could reduce the total operating time.

Quantifying team cooperation through intrinsic multi-scale measures: respiratory and cardiac synchronization in choir singers and surgical teams

A highly localized data-association measure, termed intrinsic synchrosqueezing transform (ISC), is proposed for the analysis of coupled nonlinear and non-stationary multivariate signals. This is achieved based on a combination of noise-assisted multivariate empirical mode decomposition and short-time Fourier transform-based univariate and multivariate synchrosqueezing transforms. It is shown that the ISC outperforms six other combinations of algorithms in estimating degrees of synchrony in synthetic linear and nonlinear bivariate signals. Its advantage is further illustrated in the precise identification of the synchronized respiratory and heart rate variability frequencies among a subset of bass singers of a professional choir, where it distinctly exhibits better performance than the continuous wavelet transform-based ISC. We also introduce an extension to the intrinsic phase synchrony (IPS) measure, referred to as nested intrinsic phase synchrony (N-IPS), for the empirical quantification of physically meaningful and straightforward-to-interpret trends in phase synchrony. The N-IPS is employed to reveal physically meaningful variations in the levels of cooperation in choir singing and performing a surgical procedure. Both the proposed techniques successfully reveal degrees of synchronization of the physiological signals in two different aspects: (i) precise localization of synchrony in time and frequency (ISC), and (ii) large-scale analysis for the empirical quantification of physically meaningful trends in synchrony (N-IPS).

Oncoplastic round block technique has comparable operative parameters as standard wide local excision: a matched case-control study

BACKGROUND

Although oncoplastic breast surgery is used to resect larger tumors with lower re-excision rates compared to standard wide local excision (sWLE), criticisms of oncoplastic surgery include a longer-albeit, well concealed-scar, longer operating time and hospital stay, and increased risk of complications. Round block technique has been reported to be very suitable for patients with relatively smaller breasts and minimal ptosis. We aim to determine if round block technique will result in operative parameters comparable with sWLE.

METHODS

Breast cancer patients who underwent a round block procedure from 1st May 2014 to 31st January 2016 were included in the study. These patients were then matched for the type of axillary procedure, on a one to one basis, with breast cancer patients who had undergone sWLE from 1st August 2011 to 31st January 2016. The operative parameters between the 2 groups were compared.

RESULTS

22 patients were included in the study. Patient demographics and histologic parameters were similar in the 2 groups. No complications were reported in either group. The mean operating time was 122 and 114 minutes in the round block and sWLE groups, respectively (P=0.64). Length of stay was similar in the 2 groups (P=0.11). Round block patients had better cosmesis and lower re-excision rates. A higher rate of recurrence was observed in the sWLE group.

CONCLUSION

The round block technique has comparable operative parameters to sWLE with no evidence of increased complications. Lower re-excision rate and better cosmesis were observed in the round block patients suggesting that the round block technique is not only comparable in general, but may have advantages to sWLE in selected cases.

A realist process evaluation of robot-assisted surgery: integration into routine practice and impacts on communication, collaboration and decision-making

Background

The implementation of robot-assisted surgery (RAS) can be challenging, with reports of surgical robots being underused. This raises questions about differences compared with open and laparoscopic surgery and how best to integrate RAS into practice.

Objectives

To (1) contribute to reporting of the ROLARR (RObotic versus LAparoscopic Resection for Rectal cancer) trial, by investigating how variations in the implementation of RAS and the context impact outcomes; (2) produce guidance on factors likely to facilitate successful implementation; (3) produce guidance on how to ensure effective teamwork; and (4) provide data to inform the development of tools for RAS.

Design

Realist process evaluation alongside ROLARR. Phase 1 – a literature review identified theories concerning how RAS becomes embedded into practice and impacts on teamwork and decision-making. These were refined through interviews across nine NHS trusts with theatre teams. Phase 2 – a multisite case study was conducted across four trusts to test the theories. Data were collected using observation, video recording, interviews and questionnaires. Phase 3 – interviews were conducted in other surgical disciplines to assess the generalisability of the findings.

Findings

The introduction of RAS is surgeon led but dependent on support at multiple levels. There is significant variation in the training provided to theatre teams. Contextual factors supporting the integration of RAS include the provision of whole-team training, the presence of handpicked dedicated teams and the availability of suitably sized operating theatres. RAS introduces challenges for teamwork that can impact operation duration, but, over time, teams develop strategies to overcome these challenges. Working with an experienced assistant supports teamwork, but experience of the procedure is insufficient for competence in RAS and experienced scrub practitioners are important in supporting inexperienced assistants. RAS can result in reduced distraction and increased concentration for the surgeon when he or she is supported by an experienced assistant or scrub practitioner.

Conclusions

Our research suggests a need to pay greater attention to the training and skill mix of the team. To support effective teamwork, our research suggests that it is beneficial for surgeons to (1) encourage the team to communicate actions and concerns; (2) alert the attention of the assistant before issuing a request; and (3) acknowledge the scrub practitioner’s role in supporting inexperienced assistants. It is beneficial for the team to provide oral responses to the surgeon’s requests.

Limitations

This study started after the trial, limiting impact on analysis of the trial. The small number of operations observed may mean that less frequent impacts of RAS were missed.

Future work

Future research should include (1) exploring the transferability of guidance for effective teamwork to other surgical domains in which technology leads to the physical or perceptual separation of surgeon and team; (2) exploring the benefits and challenges of including realist methods in feasibility and pilot studies; (3) assessing the feasibility of using routine data to understand the impact of RAS on rare end points associated with patient safety; (4) developing and evaluating methods for whole-team training; and (5) evaluating the impact of different physical configurations of the robotic console and team members on teamwork.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Attempted Development of a Tool to Predict Anesthesia Preparation Time From Patient-Related and Procedure-Related Characteristics

BACKGROUND

Operating room (OR) utilization generally ranges from 50% to 75%. Inefficiencies can arise from various factors, including prolonged anesthesia preparation time, defined as the period from induction of anesthesia until patients are considered ready for surgery. Our goal was to use patient-related and procedure-related factors to develop a model predicting anesthesia preparation time.

METHODS

From the electronic medical records of adults who had noncardiac surgery at the Cleveland Clinic Main Campus, we developed a model that used a dozen preoperative factors to predict anesthesia preparation time. The model was based on multivariable regression with "Least Absolute Shrinkage and Selection Operator" and 10-fold cross-validation. The overall performance of the final model was measured by R, which describes the proportion of the variance in anesthesia preparation time that is explained by the model.

RESULTS

A total of 43,941 cases met inclusion and exclusion criteria. Our final model had only moderate discriminative ability. The estimated adjusted R for prediction model was 0.34 for the training data set and 0.27 for the testing data set.

CONCLUSIONS

Using preoperative factors, we could explain only about a quarter of the variance in anesthesia preparation time-an amount that is probably of limited clinical value.

Correlates of non-technical skills in surgery: a prospective study

BACKGROUND

Communication and teamwork failures have frequently been identified as the root cause of adverse events and complications in surgery. Few studies have examined contextual factors that influence teams' non-technical skills (NTS) in surgery. The purpose of this prospective study was to identify and describe correlates of NTS.

METHODS

We assessed NTS of teams and professional role at 2 hospitals using the revised 23-item Non-TECHnical Skills (NOTECHS) and its subscales (communication, situational awareness, team skills, leadership and decision-making). Over 6 months, 2 trained observers evaluated teams' NTS using a structured form. Interobserver agreement across hospitals ranged from 86% to 95%. Multiple regression models were developed to describe associations between operative time, team membership, miscommunications, interruptions, and total NOTECHS and subscale scores.

RESULTS

We observed 161 surgical procedures across 8 teams. The total amount of explained variance in NOTECHS and its 5 subscales ranged from 14% (adjusted R² 0.12, p<0.001) to 24% (adjusted R² 0.22, p<0.001). In all models, inverse relationships between the total number of miscommunications and total number of interruptions and teams' NTS were observed.

CONCLUSIONS

Miscommunications and interruptions impact on team NTS performance.

Team talk and team activity in simulated medical emergencies: a discourse analytical approach

Background

Communication errors can reduce patient safety, especially in emergency situations that require rapid responses by experts in a number of medical specialties. Talking to each other is crucial for utilizing the collective expertise of the team. Here we explored the functions of “team talk” (talking between team members) with an emphasis on the talk-work relationship in interdisciplinary emergency teams.

Methods

Five interdisciplinary medical emergency teams were observed and videotaped during in situ simulations at an emergency department at a university hospital in Norway. Team talk and simultaneous actions were transcribed and analysed. We used qualitative discourse analysis to perform structural mapping of the team talk and to analyse the function of online commentaries (real-time observations and assessments of observations based on relevant cues in the clinical situation).

Results

Structural mapping revealed recurring and diverse patterns. Team expansion stood out as a critical phase in the teamwork. Online commentaries that occurred during the critical phase served several functions and demonstrated the inextricable interconnections between team talk and actions.

Discussion

Discourse analysis allowed us to capture the dynamics and complexity of team talk during a simulated emergency situation. Even though the team talk did not follow a predefined structure, the team members managed to manoeuvre safely within the complex situation. Our results support that online commentaries contributes to shared team situation awareness.

Conclusions

Discourse analysis reveals naturally occurring communication strategies that trigger actions relevant for safe practice and thus provides supplemental insights into what comprises “good” team communication in medical emergencies.

Trauma team leaders' non-verbal communication: video registration during trauma team training

BACKGROUND

There is widespread consensus on the importance of safe and secure communication in healthcare, especially in trauma care where time is a limiting factor. Although non-verbal communication has an impact on communication between individuals, there is only limited knowledge of how trauma team leaders communicate. The purpose of this study was to investigate how trauma team members are positioned in the emergency room, and how leaders communicate in terms of gaze direction, vocal nuances, and gestures during trauma team training.

METHODS

Eighteen trauma teams were audio and video recorded during trauma team training in the emergency department of a hospital in northern Sweden. Quantitative content analysis was used to categorize the team members' positions and the leaders' non-verbal communication: gaze direction, vocal nuances, and gestures. The quantitative data were interpreted in relation to the specific context. Time sequences of the leaders' gaze direction, speech time, and gestures were identified separately and registered as time (seconds) and proportions (%) of the total training time.

RESULTS

The team leaders who gained control over the most important area in the emergency room, the "inner circle", positioned themselves as heads over the team, using gaze direction, gestures, vocal nuances, and verbal commands that solidified their verbal message. Changes in position required both attention and collaboration. Leaders who spoke in a hesitant voice, or were silent, expressed ambiguity in their non-verbal communication: and other team members took over the leader's tasks.

DISCUSSION

In teams where the leader had control over the inner circle, the members seemed to have an awareness of each other's roles and tasks, knowing when in time and where in space these tasks needed to be executed. Deviations in the leaders' communication increased the ambiguity in the communication, which had consequences for the teamwork. Communication cannot be taken for granted; it needs to be practiced regularly just as technical skills need to be trained. Simulation training provides healthcare professionals the opportunity to put both verbal and non-verbal communication in focus, in order to improve patient safety.

CONCLUSIONS

Non-verbal communication plays a decisive role in the interaction between the trauma team members, and so both verbal and non-verbal communication should be in focus in trauma team training. This is even more important for inexperienced leaders, since vague non-verbal communication reinforces ambiguity and can lead to errors.

Trauma teams and time to early management during in situ trauma team training

OBJECTIVES

To investigate the association between the time taken to make a decision to go to surgery and gender, ethnicity, years in profession, experience of trauma team training, experience of structured trauma courses and trauma in the trauma team, as well as use of closed-loop communication and leadership styles during trauma team training.

DESIGN

In situ trauma team training. The patient simulator was preprogrammed to represent a severely injured patient (injury severity score: 25) suffering from hypovolemia due to external trauma.

SETTING

An emergency room in an urban Scandinavian level one trauma centre.

PARTICIPANTS

A total of 96 participants were divided into 16 trauma teams. Each team consisted of six team members: one surgeon/emergency physician (designated team leader), one anaesthesiologist, one registered nurse anaesthetist, one registered nurse from the emergency department, one enrolled nurse from the emergency department and one enrolled nurse from the operating theatre.

PRIMARY OUTCOME

HRs with CIs (95% CI) for the time taken to make a decision to go to surgery was computed from a Cox proportional hazards model.

RESULTS

Three variables remained significant in the final model. Closed-loop communication initiated by the team leader increased the chance of a decision to go to surgery (HR: 3.88; CI 1.02 to 14.69). Only 8 of the 16 teams made the decision to go to surgery within the timeframe of the trauma team training. Conversely, call-outs and closed-loop communication initiated by the team members significantly decreased the chance of a decision to go to surgery, (HR: 0.82; CI 0.71 to 0.96, and HR: 0.23; CI 0.08 to 0.71, respectively).

CONCLUSIONS

Closed-loop communication initiated by the leader appears to be beneficial for teamwork. In contrast, a high number of call-outs and closed-loop communication initiated by team members might lead to a communication overload.

Optimizing Operating Room Scheduling

This article reviews the management of an operating room (OR) schedule and use of the schedule to add value to an organization. We review the methodology of an OR block schedule, daily OR schedule management, and post anesthesia care unit patient flow. We discuss the importance of a well-managed OR schedule to ensure smooth patient care, not only in the OR, but throughout the entire hospital.

The relationship between intraoperative teamwork and management skills in patient care

BACKGROUND

Optimal team performance in the operating room (OR) requires a combination of interactions among OR professionals and adherence to clinical guidelines. Theoretically, it is possible that OR teams could communicate very well but fail to follow acceptable standards of patient care and vice versa. OR simulations offer an ideal research environment to study this relationship. The goal of this study was to determine the relationship between ratings of OR teamwork and communication with adherence to patient care guidelines in a simulated scenarios of malignant hyperthermia (MH).

METHODS

An interprofessional research team (2 anesthesiologists, 1 surgeon, an OR nurse, and a social scientist) reviewed videos of 5 intraoperative teams managing a simulated patient who manifested MH while undergoing general anesthesia for an epigastric herniorraphy in a high-fidelity, in situ OR. Participant teams consisted of 2 residents from anesthesiology, 1 from surgery, 1 OR nurse, and 1 certified surgical technician. Teamwork and communication were assessed with 4 published tools: Anesthesiologists' Non-Technical Skills (ANTS), Scrub Practitioners List of Intra-operative Non-Technical Skills (SPLINTS), Non-Technical Skills for Surgeons (NOTSS), and Objective Teamwork Assessment System (OTAS). We developed an evidence-based MH checklist to assess overall patient care.

RESULTS

Interrater agreement for teamwork tools was moderate. Average rater agreement was 0.51 For ANTS, 0.67 for SPLINTS, 0.51 for NOTSS, and 0.70 for OTAS. Observer agreement for the MH checklist was high (0.88). Correlations between teamwork and MH checklist were not significant. Teams were different in percent of the MH actions taken (range, 50-91%; P = .006).

CONCLUSION

In this pilot study, intraoperative teamwork and communication were not related to overall patient care management. Separating nontechnical and technical skills when teaching OR teamwork is artificial and may even be damaging, because such an approach could produce teams with excellent communication skills as they unsuccessfully manage the patient. OR simulations offer a unique opportunity to research how to best integrate both of these domains to improve patient care.

The influence of anesthesia-controlled time on operating room scheduling in Dutch university medical centres

BACKGROUND

Predicting total procedure time (TPT) entails several elements subject to variability, including the two main components: surgeon-controlled time (SCT) and anesthesia-controlled time (ACT). This study explores the effect of ACT on TPT as a proportion of TPT as opposed to a fixed number of minutes. The goal is to enhance the prediction of TPT and improve operating room scheduling.

METHODS

Data from six university medical centres (UMCs) over seven consecutive years (2005-2011) were included, comprising 330,258 inpatient elective surgical cases. Based on the actual ACT and SCT, the revised prediction of TPT was determined as SCT × 1.33. Differences between actual and predicted total procedure times were calculated for the two methods of prediction.

RESULTS

The predictability of TPT improved when the scheduling of procedures was based on predicting ACT as a proportion of SCT.

CONCLUSIONS

Efficient operating room (OR) management demands the accurate prediction of the times needed for all components of care, including SCT and ACT, for each surgical procedure. Supported by an extensive dataset from six UMCs, we advise grossing up the SCT by 33% to account for ACT (revised prediction of TPT = SCT × 1.33), rather than employing a methodology for predicting ACT based on a fixed number of minutes. This recommendation will improve OR scheduling, which could result in reducing overutilized OR time and the number of case cancellations and could lead to more efficient use of limited OR resources.

Perioperative process errors and delays in otolaryngology at a Veterans Hospital: prospective study

OBJECTIVES/HYPOTHESIS

To understand the leading causes for process errors and delays in the otolaryngology operating room and recognize the impact of process errors and delays on patient safety, operating room resources and hospital costs.

STUDY DESIGN

Prospective, observational study.

METHODS

A 4-week study was conducted during 1 calendar month in 2012, evaluating 23 elective otolaryngology cases. A standardized data collection tool was developed and refined based on prestudy pilot observations. Two trained observers recorded relevant times and actions from patient check-in time in the preoperative holding area to the "wheels out" time.

RESULTS

The mean case observation time was 220.0 ± 167.8 minutes, with mean duration of operation length being 107.0 ± 146.2 minutes. The perioperative period was divided into six stages: patient holding, room preparation, preintubation, postintubation, intraoperative, and postextubation. One hundred process errors were recorded (average of 4.3 per case), 34% of which were due to communication failures. Forty delays were observed, resulting in 336 minutes of standstill delay. Again, communication failures represented the most common etiology, with 17 communication failures resulting in 146 minutes of standstill delay. The preintubation stage was most affected by delay, with 1 in 6 minutes comprising standstill delay.

CONCLUSION

Process errors and significant delays were common in cases performed at our institution; communication errors were the most common etiology. There is opportunity for preoperative team discussion and the use of technology to minimize communication-related process errors and standstill delays. Further work is currently being undertaken to study this critical issue across specialties.