The impact of team familiarity and surgical experience on operative efficiency: a retrospective analysis

Evaluating the Impact of Operative Team Familiarity on Cardiac Surgery Outcomes: A Retrospective Cohort Study of Medicare Beneficiaries

OBJECTIVE

To associate surgeon-anesthesiologist team familiarity (TF) with cardiac surgery outcomes.

BACKGROUND

TF, a measure of repeated team member collaborations, has been associated with improved operative efficiency; however, examination of its relationship to clinical outcomes has been limited.

METHODS

This retrospective cohort study included Medicare beneficiaries undergoing coronary artery bypass grafting (CABG), surgical aortic valve replacement (SAVR), or both (CABG+SAVR) between January 1, 2017, and September 30, 2018. TF was defined as the number of shared procedures between the cardiac surgeon and anesthesiologist within 6 months of each operation. Primary outcomes were 30- and 90-day mortality, composite morbidity, and 30-day mortality or composite morbidity, assessed before and after risk adjustment using multivariable logistic regression.

RESULTS

The cohort included 113,020 patients (84,397 CABG; 15,939 SAVR; 12,684 CABG+SAVR). Surgeon-anesthesiologist dyads in the highest [31631 patients, TF median (interquartile range)=8 (6, 11)] and lowest [44,307 patients, TF=0 (0, 1)] TF terciles were termed familiar and unfamiliar, respectively. The rates of observed outcomes were lower among familiar versus unfamiliar teams: 30-day mortality (2.8% vs 3.1%, P =0.001), 90-day mortality (4.2% vs 4.5%, P =0.023), composite morbidity (57.4% vs 60.6%, P <0.001), and 30-day mortality or composite morbidity (57.9% vs 61.1%, P <0.001). Familiar teams had lower overall risk-adjusted odds of 30-day mortality or composite morbidity [adjusted odds ratio (aOR) 0.894 (0.868, 0.922), P <0.001], and for SAVR significantly lower 30-day mortality [aOR 0.724 (0.547, 0.959), P =0.024], 90-day mortality [aOR 0.779 (0.620, 0.978), P =0.031], and 30-day mortality or composite morbidity [aOR 0.856 (0.791, 0.927), P <0.001].

CONCLUSIONS

Given its relationship with improved 30-day cardiac surgical outcomes, increasing TF should be considered among strategies to advance patient outcomes.

Evaluation of operating room inefficiencies and their impact on operating room duration using a surgical app

BACKGROUND

Efficient utilization of the operating room (OR) is essential. Inefficiencies are thought to cause preventable delays. Our goal was to identify OR incidents causing delays and estimate their impact on the duration of various general surgery procedures.

MATERIALS

Three trained observers prospectively collected intraoperative data using the ExplORer Surgical app, a tool that helped capture incidents causing delays. The impact of each incident on case duration was assessed using multivariable analysis.

RESULTS

151 general surgery procedures were observed. The mean number of incidents was 2.7 per each case that averaged 109min. On average, each incident caused a 2.8 ​min delay (p ​< ​0.001), however, some incidents were associated with longer delays. The procedural step of each procedure most susceptible to incidents was also defined.

CONCLUSION

The identification of the type of incidents and the procedural step during which they occur may allow targeted interventions to optimize OR efficiency and decrease operative time.

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

BACKGROUND

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Exploring the Challenges of Using Minimal Invasive Surgery to Treat Stress Urinary Incontinence: Insights from a Retrospective Case-Control Study

Stress urinary incontinence (SUI) is a significant global health issue that particularly affects females, leads to notable societal and economic challenges and significantly affects the quality of life. This study focuses on the comparative analysis of two established surgical interventions, tension-free vaginal tape (TVT) and transobturator tape (TOT), at a single center and applied to 455 women suffering from SUI, with a mean follow-up period of 102 ± 30 months for TVT and 80.4 ± 13 months for TOT. Our findings indicate that, in comparison to TVT, the TOT procedure demonstrates fewer early and late post-operative complications in patient outcomes (1.41% vs. 17.64% and; 5.66% vs. 12.74%, both respectively). However, the TVT procedure shows a modestly favorable outcome in the risk of recurrence of SUI, compared to TOT (0% vs. 3.7%); the TOT procedure has also proven to be more effective in alleviating of urgency symptoms, although not at a statistically significant level (p = 0.072). Univariable and multivariable analysis of factors that predict late complications showed that only obesity can predict a worse outcome [OR]: 1.125 CI 95%: 1.105-1.533, p = 0.037), when adjustments are made for symptoms presented before surgery and procedure type. While both methods are safe and effective, the choice between them should be based on the specific characteristics of each case.

Team-based care of the thoracic surgical patient

PURPOSE OF REVIEW

Although team-based care has been shown in many sectors to improve outcomes, very little work has been done with the thoracic surgical patient. This review article focuses on this and, extrapolating from other closely related surgical fields, teamwork in thoracic surgery will be reviewed for outcome efficacy and substance.

RECENT FINDINGS

The optimal team has been shown to display behaviors that allow them to model future needs, predict disaster, be adaptable to change, and promote team cohesiveness all with a positive effect on perioperative outcome. The suboptimal team will have transactional leadership, poor communication, ineffective conflict resolution, and hold rigid beliefs about other team members.

SUMMARY

To improve outcome, the thoracic surgical team, centered on the anesthesiologist and surgeon, will display the 'Big 5' attributes of highly effective teams. There are attributes of poor teams, which the dyad should avoid in order to increase the team's function and thus outcome.

Operating room organization and surgical performance: a systematic review

BACKGROUND

Organizational factors may influence surgical outcomes, regardless of extensively studied factors such as patient preoperative risk and surgical complexity. This study was designed to explore how operating room organization determines surgical performance and to identify gaps in the literature that necessitate further investigation.

METHODS

We conducted a systematic review according to PRISMA guidelines to identify original studies in Pubmed and Scopus from January 1, 2000 to December 31, 2019. Studies evaluating the association between five determinants (team composition, stability, teamwork, work scheduling, disturbing elements) and three outcomes (operative time, patient safety, costs) were included. Methodology was assessed based on criteria such as multicentric investigation, accurate population description, and study design.

RESULTS

Out of 2625 studies, 76 met inclusion criteria. Of these, 34 (44.7%) investigated surgical team composition, 15 (19.7%) team stability, 11 (14.5%) teamwork, 9 (11.8%) scheduling, and 7 (9.2%) examined the occurrence of disturbing elements in the operating room. The participation of surgical residents appeared to impact patient outcomes. Employing specialized and stable teams in dedicated operating rooms showed improvements in outcomes. Optimization of teamwork reduced operative time, while poor teamwork increased morbidity and costs. Disturbances and communication failures in the operating room negatively affected operative time and surgical safety.

CONCLUSION

While limited, existing scientific evidence suggests that operating room staffing and environment significantly influences patient outcomes. Prioritizing further research on these organizational drivers is key to enhancing surgical performance.

Novel Application of a Dynamic, In-room Survey Platform to Measure Surgical Team Satisfaction

OBJECTIVE

To elucidate the potential usage of continuous feedback regarding team satisfaction and correlations with operative performance and patient outcomes.

BACKGROUND

Continuous, actionable assessment of teamwork quality in the operating room (OR) is challenging. This work introduces a novel, data-driven approach to prospectively and dynamically assess health care provider satisfaction with teamwork in the OR.

METHODS

Satisfaction with teamwork quality for each case was assessed utilizing a validated prompt displayed on HappyOrNot Terminals placed in all ORs, with separate panels for circulators, scrub nurses, surgeons, and anesthesia providers. Responses were cross-referenced with OR log data, team familiarity indicators, efficiency parameters, and patient safety indicator events through continuous, semiautomated data marts. Deidentified responses were analyzed through logistic regression modeling.

RESULTS

Over a 24-week period, 4123 responses from 2107 cases were recorded. The overall response rate per case was 32.5%. Greater scrub nurse specialty experience was strongly associated with satisfaction (odds ratio: 2.15, 95% CI: 1.53-3.03, P < 0.001). Worse satisfaction was associated with longer than expected procedure time (odds ratio: 0.91, 95% CI: 0.82-1.00, P = 0.047), nighttime (0.67, 95% CI: 0.55-0.82, P < 0.001), and add-on cases (0.72, 95% CI: 0.60-0.86, P < 0.001). Higher material costs (22%, 95% CI: 6-37, P = 0.006) were associated with greater team satisfaction. Cases with superior teamwork ratings were associated with a 15% shorter length of hospital stay (95% CI: 4-25, P = 0.006).

CONCLUSIONS

This study demonstrates the feasibility of a dynamic survey platform to report actionable health care provider satisfaction metrics in real-time. Team satisfaction is associated with modifiable team variables and some key operational outcomes. Leveraging qualitative measurements of teamwork as operational indicators may augment staff engagement and measures of performance.

Intraoperative Challenges in Hand Surgery

A wide array of intraoperative issues can arise during surgery involving the hand and upper extremity. An understanding of the common pitfalls within hand surgery may help practicing hand surgeons circumvent such issues. Within this manuscript, we first identify problems with the increasingly popular technique of wide-awake local anesthesia no tourniquet (WALANT). Achieving appropriate hemostasis and anesthetic can be bothersome, especially for procedures proximal to the distal palmar crease. We discuss our local anesthetic timing and concentrations to help mitigate such issues, as well as other problems that may arise in WALANT procedures. There also lies a barrier in connecting the traumatized patient to care in the outpatient/ambulatory setting. Additionally, the polytraumatized patient increases the complexity of care coordination for not just the hand surgeon, but all surgical providers involved. The order in which multidisciplinary surgical procedures are performed is influenced by both the complexity of the patient's case as well as the institution's current protocol. All academic institutions are faced with challenges in providing optimal intraoperative education to trainees. We acknowledge that there should be a balance between the attending surgeon executing key portions of the procedure and the trainee gaining the appropriate hands-on experience. This manuscript elaborates on the issues of intraoperative education provided to residents and anecdotal methods that may help overcome such challenges. Resources within hand surgery can often be limited and become particularly problematic in the operative setting. Specific examples include but are not limited to the lack of dedicated teams, inability to obtain appropriate intraoperative imaging, access to appropriate hardware, and intraoperative complications in an ambulatory surgery center setting.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Identifying Factors of Operative Efficiency in Head and Neck Free Flap Reconstruction

Importance

Head and neck oncological resection and reconstruction is a complex process that requires multidisciplinary collaboration and prolonged operative time. Numerous factors are associated with operative time, including a surgeon's experience, team familiarity, and the use of new technologies. It is paramount to evaluate the contribution of these factors and modalities on operative time to facilitate broad adoption of the most effective modalities and reduce complications associated with prolonged operative time.

Objective

To examine the association of head and neck cancer resection and reconstruction interventions with operative time.

Design, Setting, and Participants

This large cohort study included all patients who underwent head and neck oncologic resection and free flap-based reconstruction in Calgary (Alberta, Canada) between January 1, 2007, and March 31, 2020. Data were analyzed between November 2021 and May2022.

Interventions

The interventions that were implemented in the program were classified into team-based strategies and the introduction of new technology. Team-based strategies included introducing a standardized operative team, treatment centralization in a single institution, and introducing a microsurgery fellowship program. New technologies included use of venous coupler anastomosis and virtual surgical planning.

Main Outcomes and Measures

The primary outcome was mean operative time difference before and after the implementation of each modality. Secondary outcomes included returns to the operating room within 30 days, reasons for reoperation, returns to the emergency department or readmissions to hospital within 30 days, and 2-year and 5-year disease-specific survival. Multivariate regression analyses were performed to examine the association of each modality with operative time.

Results

A total of 578 patients (179 women [30.9%]; mean [SD] age, 60.8 [12.9] years) undergoing 590 procedures met inclusion criteria. During the study period, operative time progressively decreased and reached a 32% reduction during the final years of the study. A significant reduction was observed in mean operative time following the introduction of each intervention. However, a multivariate analysis revealed that team-based strategies, including the use of a standardized nursing team, treatment centralization, and a fellowship program, were significantly associated with a reduction in operative time.

Conclusions

The results of this cohort study suggest that among patients with head and neck cancer, use of team-based strategies was associated with significant decreases in operative time without an increase in complications.

Operative Team Familiarity and Specialization at an Academic Medical Center

OBJECTIVE

To propose a framework for quantification of surgical team familiarity.

BACKGROUND

Operating room (OR) teamwork quality is associated with familiarity among team members and their individual specialization. We describe novel measures of OR team familiarity and specialty experience.

METHODS

Surgeon-scrub (SS) and surgeon-circulator (SC) teaming scores, defined as the pair's proportion of interactions relative to the surgeon's total cases in the preceding 6 months were calculated between 2017 and 2021 at an academic medical center. Nurse service-line (SL) experience scores were defined as the proportion of a nurse's cases performed within the given specialty. SS, SC, and nurse-SL scores were analyzed by specialty, case urgency, robotic approach, and surgeon academic rank. Two-sample Kolmogorov-Smirnov tests were used to determine heterogeneity between distributions.

RESULTS

A total of 37,364 operations involving 150 attending surgeons and 222 nurses were analyzed. Median SS and SC scores were 0.08 (interquartile range: 0.03-0.19) and 0.06 (interquartile range: 0.03-0.13), respectively. Higher margin SLs, senior faculty rank, elective, and robotic cases were associated with greater SS, SC, and nurse-SL scores ( P <0.001).

CONCLUSIONS

These novel measures of teaming and specialization illustrate the low levels of OR team familiarity and objectively highlight differences that necessitate a deliberate evaluation of current OR scheduling practices.

Association Between Familiarity of the Surgeon-Anesthesiologist Dyad and Postoperative Patient Outcomes for Complex Gastrointestinal Cancer Surgery

Importance

The surgeon-anesthesiologist teamwork and relationship is crucial to good patient outcomes. Familiarity among work team members is associated with enhanced success in multiple fields but rarely studied in the operating room.

Objective

To examine the association between surgeon-anesthesiologist dyad familiarity-as the number of times working together-with short-term postoperative outcomes for complex gastrointestinal cancer surgery.

Design, Setting, and Participants

This population-based retrospective cohort study based in Ontario, Canada, included adults undergoing esophagectomy, pancreatectomy, and hepatectomy for cancer from 2007 through 2018. The data were analyzed January 1, 2007, through December 21, 2018.

Exposures

Dyad familiarity captured as the annual volume of procedures of interest done by the surgeon-anesthesiologist dyad in the 4 years before the index surgery.

Main Outcomes and Measures

Ninety-day major morbidity (any Clavien-Dindo grade 3 to 5). The association between exposure and outcome was examined using multivariable logistic regression.

Results

Seven thousand eight hundred ninety-three patients with a median age of 65 years (66.3% men) were included. They were cared for by 737 anesthesiologists and 163 surgeons who were also included. The median surgeon-anesthesiologist dyad volume was 1 (range, 0-12.2) procedures per year. Ninety-day major morbidity occurred in 43.0% of patients. There was a linear association between dyad volume and 90-day major morbidity. After adjustment, the annual dyad volume was independently associated with lower odds of 90-day major morbidity, with an odds ratio of 0.95 (95% CI, 0.92-0.98; P = .01) for each incremental procedure per year, per dyad. The results did not change when examining 30-day major morbidity.

Conclusions and Relevance

Among adults undergoing complex gastrointestinal cancer surgery, increasing familiarity of the surgeon-anesthesiologist dyad was associated with improved short-term patient outcomes. For each additional time that a unique surgeon-anesthesiologist dyad worked together, the odds of 90-day major morbidity decreased by 5%. These findings support organizing perioperative care to increase the familiarity of surgeon-anesthesiologist dyads.

The implications of fragmented practice in hepatopancreatic surgery

BACKGROUND

Familiarity with the surgical work environment has been demonstrated to improve outcomes. We sought to investigate the impact of the rate of fragmented practice on textbook outcomes, a validated composite outcome representing an "optimal" postoperative course.

METHODS

Patients who underwent a hepatic or pancreatic surgical procedure between 2013 and 2017 were identified from the Medicare Standard Analytic Files. The rate of fragmented practice was defined as the surgeon's volume over the study period relative to the number of facilities practiced at. The association between the rate of fragmented practice and textbook outcomes was assessed using multivariable logistic regression.

RESULTS

A total of 37,599 patients were included (pancreatic: n = 23,701, 63.0%; hepatic: n = 13,898, 37.0%). After controlling for relevant characteristics, patients who underwent surgery by surgeons in higher rate of fragmented practice categories had lower odds of achieving a textbook outcome (reference: low rate of fragmented practice; intermediate rate of fragmented practice: odds ratio = 0.88 [95% confidence interval 0.84-0.93]; high rate of fragmented practice: odds ratio = 0.58 [95% confidence interval 0.54-0.61]) (both P < .001). Of note, the adverse effect of a high rate of fragmented practice on the achievement of textbook outcomes remained substantial, regardless of the county-level social vulnerability index [high rate of fragmented practice; low social vulnerability index: odds ratio = 0.58 (95% confidence interval 0.52-0.66); intermediate social vulnerability index: odds ratio = 0.56 (95% confidence interval 0.52-0.61); high social vulnerability index: odds ratio = 0.60 (95% confidence interval 0.54-0.68)] (all P < .001). Patients in intermediate and high social vulnerability index counties had 19% and 37% greater odds of undergoing surgery by a high rate of fragmented practice surgeon (reference: low social vulnerability index; intermediate social vulnerability index: odds ratio = 1.19 [95% confidence interval 1.12-1.26]; high social vulnerability index: odds ratio = 1.37 [95% confidence interval 1.28-1.46]).

CONCLUSION

Owing to the impact of the rate of fragmented practice on postoperative outcomes, decreasing fragmentation of care may be an important target for quality initiatives and a means to alleviate social disparities in surgical care.

Determinants of Operative Time in Arthroscopic Rotator Cuff Repair

Arthroscopic rotator cuff repairs have been reported to take between 72 and 113 min to complete. This team has adopted its practice to reduce rotator cuff repair times. We aimed to determine (1) what factors reduced operative time, and (2) whether arthroscopic rotator cuff repairs could be performed in under 5 min. Consecutive rotator cuff repairs were filmed with the intent of capturing a <5-min repair. A retrospective analysis of prospectively collected data of 2232 patients who underwent primary arthroscopic rotator cuff repair by a single surgeon was performed using Spearman's correlations and multiple linear regression. Cohen's f² values were calculated to quantify effect size. Video footage of a 4-min arthroscopic repair was captured on the 4th case. Backwards stepwise multivariate linear regression found that an undersurface repair technique (f² = 0.08, p < 0.001), fewer surgical anchors (f² = 0.06, p < 0.001), more recent case number (f² = 0.01, p < 0.001), smaller tear size (f² = 0.01, p < 0.001), increased assistant case number (f² = 0.01, p < 0.001), female sex (f² = 0.004, p < 0.001), higher repair quality ranking (f² = 0.006, p < 0.001) and private hospital (f² = 0.005, p < 0.001) were independently associated with a faster operative time. Use of the undersurface repair technique, reduced anchor number, smaller tear size, increased surgeon and assistant surgeon case number, performing repairs in a private hospital and female sex independently lowered operative time. A <5-min repair was captured.

A dedicated surgical team for posterior spinal fusion in patients with adolescent idiopathic scoliosis improves OR efficiency

PURPOSE

Standardized care pathways for adolescent idiopathic scoliosis (AIS) patients undergoing PSF improve clinical outcomes. We hypothesized that having dedicated spine personnel would decrease surgical time and improve clinical outcomes.

METHODS

367 patients with AIS had a PSF within a standardized perioperative care pathway. Cases with 1-3 dedicated spine team members (any combination of circulating nurse, surgical technologist, and anesthesiologist) were compared to teams with none. The impact of individual members was also analyzed. Parametric or non-parametric tests were used for each outcome based on the distribution of the data points. These included one-way ANOVA models, Kruskal-Wallis tests, and Fisher's exact tests.

RESULTS

Surgical time and total OR time were significantly decreased with the participation of each additional dedicated team member resulting in 43.86 min less surgical time and 50.8 min less total OR time when three team members were present compared to no team members. If the nurse was a spine member, the surgical time was lower (p = 0.037). If the technologist was a team member, the surgical time and total OR time were lower (p = 0.002 and p = 0.001, respectively). Lastly, if the anesthesiologist was a member of the team, the anesthesia time was lower (p = 0.003). No significant clinical differences were observed.

CONCLUSION

Having dedicated surgical team members decreases surgical and total OR time for AIS patients undergoing PSF, and this OR efficiency improves as the dedicated team is more robust. OR surgical teams did not influence clinical outcomes. Hospitals should strongly consider developing surgical teams to improve OR efficiency of PSF cases.

Leveraging large, real-world data through machine-learning to increase efficiency in robotic-assisted total knee arthroplasty

PURPOSE

Increased operative time can be due to patient, surgeon and surgical factors, and may be predicted by machine learning (ML) modeling to potentially improve staff utilization and operating room efficiency. The purposes of our study were to: (1) determine how demographic, surgeon, and surgical factors affected operative times, and (2) train a ML model to estimate operative time for robotic-assisted primary total knee arthroplasty (TKA).

METHODS

A retrospective study from 2007 to 2020 was conducted including 300,000 unilateral primary TKA cases. Demographic and surgical variables were evaluated using Wilcoxon/Kruskal-Wallis tests to determine significant factors of operative time as predictors in the ML models. For the ML analysis of robotic-assisted TKAs (> 18,000), two algorithms were used to learn the relationship between selected predictors and operative time. Predictive model performance was subsequently assessed on a test data set comparing predicted and actual operative time. Root mean square error (RMSE), R² and percentage of predictions with an error < 5/10/15 min were computed.

RESULTS

Males, BMI > 40 kg/m² and cemented implants were associated with increased operative time, while age > 65yo, cementless, and high surgeon case volume had reduced operative time. Robotic-assisted TKA increased operative time for low-volume surgeons and decreased operative time for high-volume surgeons. Both ML models provided more accurate operative time predictions than standard time estimates based on surgeon historical averages.

CONCLUSIONS

This study demonstrated that greater surgeon case volume, cementless fixation, manual TKA, female, older and non-obese patients reduced operative time. ML prediction of operative time can be more accurate than historical averages, which may lead to optimized operating room utilization.

LEVEL OF EVIDENCE

III.

Fragmentation of practice: The adverse effect of surgeons moving around

BACKGROUND

Whether surgical team familiarity is associated with improved postoperative outcomes remains unknown. We sought to characterize the impact of fragmented surgical practice on the likelihood that a patient would experience a textbook outcome, which is a validated patient-centric composite outcome representing an "ideal" postoperative outcome.

METHOD

Medicare beneficiaries aged 65 and older who underwent elective inpatient abdominal aortic aneurysm repair, coronary artery bypass graft, cholecystectomy, colectomy, or lung resection were identified. Rate of fragmented practice was calculated based on the total number of surgical procedures of interest performed over the study period (2013-2017) divided by the number of different hospitals in which the surgeon operated. Surgeons were categorized into "low," "average," "above average," or "high" rate of fragmented practice categories using an unsupervised machine learning technique known k-medians cluster analysis.

RESULTS

Among 546,422 Medicare beneficiaries who underwent an elective surgical procedure of interest (coronary artery bypass graft: n = 156,384, 28.6%; lung resection: n = 83,164, 15.2%; abdominal aortic aneurysm: n = 112,578, 20.6%; cholecystectomy: n = 42,955, 7.9%; colectomy: n = 151,341, 27.7%), median patient age was 74 years (interquartile range: 69-80), and most patients were male (n = 319,153, 58.4%). Machine learning identified 3 cutoffs to categorize rate of fragmented practice: 2.8%, 5.6%, and 10.6%. Overall, the majority of surgical procedures were performed by surgeons with a low rate of fragmented practice (n = 382,504, 70.0%); other surgical procedures were performed by surgeons with average (n = 109,141, 20.0%), above average (n = 44,249, 8.1%), or high (n = 10,528, 1.9%) rate of fragmented practice. On multivariable analyses, after controlling for patient demographics, individual surgeon volume, procedure type, and a random effect for hospital, patients who underwent a surgical procedure by a high versus low rate of fragmented practice surgeon had lower odds to achieve a postoperative textbook outcome (odds ratio 0.71, 95% confidence interval 0.77-0.84). Patients who underwent a procedure by a high rate of fragmented practice surgeon also had increased odds of a perioperative complication (odds ratio 1.30, 95% confidence interval: 1.23-1.37), extended length of stay (odds ratio 1.17, 95% confidence interval: 1.11-1.24), 90-day readmission (odds ratio 1.17, 95% confidence interval: 1.11-1.23), and 90-day mortality (odds ratio 1.29, 95% confidence interval: 1.17-1.42) (all P < .05).

CONCLUSION

Patients undergoing a surgical procedure by a surgeon with a high rate of fragmented practice had lower odds of achieving an optimal postoperative textbook outcome. Surgical team familiarity, measured by a surgeon rate of fragmented practice, may represent a modifiable mechanism to improve surgical outcomes.

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

PURPOSE

To examine the key factors impacting surgical team performance in a military medical center.

DESIGN

A retrospective, exploratory, cross-sectional design.

METHODS

We reviewed 751 orthopedic surgical cases to determine the association of surgical team familiarity, surgical complexity, team size, and the presence of student registered nurse anesthetists (SRNAs) with the surgical performance measures of total operative time, turnover time, and on-time surgical start.

FINDINGS

We found increases in surgical team familiarity significantly reduced turnover time by 7.84% (1-0.9216 = 0.0784; P = .0260) after controlling for surgical complexity and the presence of an SRNA on the team. Familiarity did not significantly impact total operative time or the odds of a first case on-time start. With a significant interaction of surgical complexity and team size on total operative time, the surgical complexity marginal effect (at the mean of team size) showed that a one-point increase prolonged total operative time by 6.89% (P < .0001), after controlling for team familiarity and an SRNA. The team size marginal effect (at the mean of surgical complexity) showed that adding one member to the surgical team prolonged total operative time by 6.45% (P < .0001), after controlling for team familiarity and an SRNA. Higher surgical complexity not only increased turnover time by 1.46% (P = .0265) while holding surgical complexity and an SRNA presence constant, but also reduced the likelihood of an on-time surgical start by 0.9359 (P = .0060). Larger teams decreased the odds of an on-time start by 0.7750 (P = .0363). We found that SRNAs potentially offer efficiency benefits, as their presence on a surgical team was associated with a 0.82% (1-0.9185 = 0.0815; P = .0007) decrease in total operative time, and a 21.01% (1-0.7899=0.2101; P = .0002) reduction in expected turnover time, after adjusting for confounding variables.

CONCLUSIONS

Surgical efficiency is a modifiable function of surgical teams. Although we suggest additional research, surgical leaders can potentially improve team performance by improving familiarity and forming small and cohesive surgical teams. As OR inefficiencies degrade the financial vitality of healthcare systems, surgical leaders should engage in a multifaceted program to improve efficiency by building familiarity and optimizing team size.

The opportunity cost of arthroplasty training in orthopaedic surgery

INTRODUCTION

Training the next generation of surgeons is a crucial role fulfilled by consultant orthopaedic surgeons. However we are increasingly constrained by limited time and resources. We sought to compare operative time and length of stay (LOS) for total hip and total knee arthroplasties (THA, TKA) performed by a consultant orthopaedic surgeon with those performed by supervised trainees.

MATERIALS AND METHODS

A prospective database of arthroplasty procedures performed from 2015 to 2018 was collated. Primary surgeon grade was recorded. Patient demographics, ASA grade, LOS and operative time were recorded. For THA both cemented and uncemented arthroplasties were used. SPSS version 23 was used for statistical analysis.

RESULTS

394 arthroplasty procedures were carried out during the study period. Trainee surgeons performed a high proportion of both THA (53.2%, n = 123) and TKA (44.8%, n = 73) surgeries. Trainees performed 57% of cemented THA procedures. LOS did not differ between consultant and trainee surgeons for THA (5.9 ± 4.8 days) or TKA (5.6 ± 4.1 days). Age had a significant effect on LOS (p < 0.001). For THA the mean operative time for trainees was 90.3 ± 19.23 min, 18.2 min longer than the consultant group. For TKA the mean operative time was 89.06 ± 18.87 min for trainees, 24.4 min longer than the consultant group.

DISCUSSION

At our institution trainee surgeons can be expected to take between 18 and 24 min longer to perform arthroplasty procedures. This should be factored into resource planning, as the training of orthopaedic surgeons is crucial to sustaining and improving health service provision.

The Effect of RN Circulator-Scrub Person Dyad Consistency on Total OR Time and Turnover Time

Operating room efficiency is an important consideration for perioperative nurse leaders because it can affect their facilities' revenue and provider and patient satisfaction. Using consistent perioperative teams, including the same RN circulator and scrub person, for consecutive procedures may improve OR efficiency. This retrospective cross-sectional cohort study assessed the effects of a consistent team in the form of RN circulator-scrub person dyads on the total OR and turnover times for 310 surgical procedures using electronic OR records data from the National Surgical Quality Improvement Program that was collected in 2008. Controlling for relevant variables (eg, procedure type consistency, number of staff members present, procedure complexity), the association between RN circulator-scrub person dyads and total OR time and turnover time was not significant.

Rapid standardized operating rooms (RAPSTOR) in thyroid and parathyroid surgery

OBJECTIVE

To evaluate the impact of a high efficiency rapid standardized OR (RAPSTOR) for hemithyroid/parathyroid surgery using standardized equipment sets (SES) and consecutive case scheduling (CCS) on turnover times (TOT), average case volumes, patient outcomes, hospital costs and OR efficiency/stress.

METHODS

Patients requiring hemithyroidectomy (primary or completion) or unilateral parathyroidectomy in a single surgeon's practice were scheduled consecutively with SES. Retrospective control groups were classified as sequential (CS) or non-sequential (CNS). A survey regarding OR efficiency/stress was administered. Phenomenography and descriptive statistics were conducted for time points, cost and patient outcome variables. Hospital cost minimization analysis was performed.

RESULTS

The mean TOT of RAPSTOR procedures (16 min; n = 27) was not significantly different than CS (14 min, n = 14) or CNS (17 min, n = 6). Mean case number per hour was significantly increased in RAPSTOR (1.2) compared to both CS (0.9; p < 0.05) and CNS (0.7; p < 0.05). Average operative time was significantly reduced in RAPSTOR (32 min; n = 28) compared to CNS (48 min; p < 0.05) but not CS (33 min; p = 0.06). Time to discharge was reduced in RAPSTOR (595 min) compared to CNS (1210 min, p < 0.05). There was no difference in complication rate between all groups (p = 0.27). Survey responses suggested improved efficiency, teamwork and workflow. Furthermore, there is associated decrease in direct operative costs for RAPSTOR vs. CS.

CONCLUSION

A high efficiency standardized OR for hemithyroid and parathyroid surgery using SES and CCS is associated with improved efficiency and, in this study, led to increased capacity at reduced cost without compromising patient safety.

LEVEL OF EVIDENCE

Level 2.

The impact of team familiarity on intra and postoperative cardiac surgical outcomes

BACKGROUND

Familiarity among cardiac surgery team members may be an important contributor to better outcomes and thus serve as a target for enhancing outcomes.

METHODS

Adult cardiac surgical procedures (n = 4,445) involving intraoperative providers were evaluated at a tertiary hospital between 2016 and 2020. Team familiarity (mean of prior cardiac surgeries performed by participating surgeon/nonsurgeon pairs within 2 years before the operation) were regressed on cardiopulmonary bypass duration (primary-an intraoperative measure of care efficiency) and postoperative complication outcomes (major morbidity, mortality), adjusting for provider experience, surgeon 2-year case volume before the surgery, case start time, weekday, and perioperative risk factors. The relationship between team familiarity and outcomes was assessed across predicted risk strata.

RESULTS

Median (interquartile range) cardiopulmonary bypass duration was 132 minutes (91-192), and 698 (15.7%) patients developed major postoperative morbidity. The relationship between team familiarity and cardiopulmonary bypass duration significantly differed across predicted risk strata (P = .0001). High (relative to low) team familiarity was associated with reduced cardiopulmonary bypass duration for medium-risk (-24 minutes) and high-risk (-27 minutes) patients. Increasing team familiarity was not significantly associated with the odds of major morbidity and mortality.

CONCLUSION

Team familiarity, which was predictive of improved intraoperative efficiency without compromising major postoperative outcomes, may serve as a novel quality improvement target in the setting of cardiac surgery.

Surgical team familiarity and waste generation in the operating room

BACKGROUND

Wastage of surgical supplies results from inappropriate anticipation of surgical needs in the operating room and contributes to avoidable healthcare costs.

METHODS

A retrospective, cross-sectional analysis of 28,768 elective cases at the University of Chicago Medical Center from 2016 through 2018 was conducted. Attending surgeon-scrub nurse and surgeon-circulating nurse familiarity scores were calculated. Odds of surgical waste generation based on surgeon-scrub nurse and surgeon-circulating nurse familiarity were estimated through multivariate logistic regression modeling.

RESULTS

Teams in the third and fourth quartiles of surgeon-scrub familiarity were significantly associated with reduced odds of waste (odds ratios 0.80 [p = 0.003] and 0.83 [p = 0.030], respectively). There was no significant reduction of odds of waste generation as surgeon-circulator familiarity increased.

CONCLUSIONS

Greater surgeon-scrub familiarity was associated with lower risk of waste generation. Cost savings may be realized through supporting staffing schedules that promote consistency of surgeon-scrub teams.

Characterizing the Surgeon Learning Curve in Instrumented Minimally Invasive Spinal Surgery: Does the Evidence Account for Training and Experience? A Systematic Literature Review

STUDY DESIGN

This was a systematic literature review.

OBJECTIVE

The purpose of this systematic literature review was to aggregate all evidence characterizing the learning curve of instrumented minimally invasive surgery (MIS) techniques in spinal surgery and summarize what, if any, consideration has been given to surgeon training and experience.

SUMMARY OF BACKGROUND DATA

MIS techniques have become prevalent in spine surgery given the ability to diminish the intraoperative footprint, translating to quicker patient recovery, and improved long-term outcomes. However, technical demand on the surgeon can be significant, particularly during the procedural adoption (learning curve) phase. Many studies have sought to quantify the duration and severity of these learning curve phases, with the intent to characterize MIS procedural appropriateness and safety. However, while these studies are robust regarding outcome metrics, it is not well understood whether they adequately characterize surgeon training and experience.

METHODS

A systematic literature review was performed in the PubMed and MEDLINE databases in accordance with the PRISMA guidelines. All inclusion articles were screened for statements regarding surgeon experience/training. Statements were further classified by the types of metrics/variables utilized to establish a contextual history of experience/training. Descriptive statistics were reported.

RESULTS

Initial search criteria yielded 458 articles, 12 met final inclusion. Seven articles (58.3%) attempted a summary statement of experience which acknowledged at least one of the following metrics: total years in practice (41.7%), years/number of cases performed using the traditional/gold-standard technique (16.7%), specification of residency/fellowship training (16.7%), use/nonuse of cadaveric or course/lab training (16.7%), and/or design of operating team (8.3%). No articles considered experience as a quantitative variable in their study analyses.

CONCLUSIONS

Spine MIS learning curve studies for instrumented fusion procedures provide inadequate context/characterization of surgeon experience and training. Future efforts leveraging learning curve methodology utilized in other surgical specialties would be beneficial.

BISMICS consensus statement: implementing a safe minimally invasive mitral programme in the UK healthcare setting

Disseminating the practice of minimally invasive mitral surgery (mini-MVS) can be challenging, despite its original case reports a few decades ago. The penetration of this technology into clinical practice has been limited to centres of excellence, and mitral surgery in most general cardiothoracic centres remains to be conducted via sternotomy access as a first line. The process for the uptake of mini-MVS requires clearer guidance and standardisation for the processes involved in its implementation. In this statement, a consensus agreement is outlined that describes the benefits of mini-MVS, including reduced postoperative bleeding, reduced wound infection, enhanced recovery and patient satisfaction. Technical considerations require specific attention and can be introduced through simulation and/or use in conventional cases. Either endoballoon or aortic cross clamping is recommended, as well as femoral or central aortic cannulation, with the use of appropriate adjuncts and instruments. A coordinated team-based approach that encourages ownership of the programme by the team members is critical. A designated proctor is also recommended. The organisation of structured training and simulation, as well as planning the initial cases, is an important step to consider. The importance of pre-empting complications and dealing with adverse events is described, including re-exploration, conversion to sternotomy, unilateral pulmonary oedema and phrenic nerve injury. Accounting for both institutional and team considerations can effectively facilitate the introduction of a mini-MVS service. This involves simulation, team-based training, visits to specialist centres and involvement of a designated proctor to oversee the initial cases.

La cirugía como una sinfonía. Un proyecto para el trabajo en equipo y coordinado

La seguridad del paciente es uno de los aspectos de mayor relevancia en la atención en un quirófano. El trabajo en equipo y coordinado, sumado al liderazgo, permite que los errores sean menos. Mantener un equipo estable en el quirófano, que conozca bien los procedimientos, y donde cada participante sabe el rol que juega, es uno de los factores más importantes para lograr un trabajo eficiente, con disminución de las complicaciones y del tiempo quirúrgico. Comparar el trabajo en el quirófano con una orquesta sinfónica, nos ayuda a entender la importancia del trabajo coordinado.

International expert consensus on laparoscopic pancreaticoduodenectomy

IMPORTANCE

While laparoscopic pancreaticoduodenectomy (LPD) is being adopted with increasing enthusiasm worldwide, it is still challenging for both technical and anatomical reasons. Currently, there is no consensus on the technical standards for LPD.

OBJECTIVE

The aim of this consensus statement is to guide the continued safe progression and adoption of LPD.

EVIDENCE REVIEW

An international panel of experts was selected based on their clinical and scientific expertise in laparoscopic and open pancreaticoduodenectomy. Statements were produced upon reviewing the literature and assessed by the members of the expert panel. The literature search and its critical appraisal were limited to articles published in English during the period from 1994 to 2019. The Web of Science, Medline, and Cochrane Library and Clinical Trials databases were searched, The search strategy included, but was not limited to, the terms 'laparoscopic', 'pancreaticoduodenectomy, 'pancreatoduodenectomy', 'Whipple's operation', and 'minimally invasive surgery'. Reference lists from the included articles were manually checked for any additional studies, which were included when appropriate. Delphi method was used to establish expert consensus and the AGREE II-GRS Instrument was applied to assess the methodological quality and externally validate the final statements. The statements were further discussed during a one-day face-to-face meeting at the 1st Summit on Minimally Invasive Pancreatico-Biliary Surgery in Wuhan, China.

FINDINGS

Twenty-eight international experts from 8 countries constructed the expert panel. Sixteen statements were produced by the members of the expert panel. At least 80% of responders agreed with the majority (80%) of statements. Other than three randomized controlled trials published to date, most evidences were based on level 3 or 4 studies according to the AGREE II-GRS Instrument.

CONCLUSIONS AND RELEVANCE

The Wuhan international expert consensus meeting on LPD has produced a set of clinical practice statements for the safe development and progression of LPD. LPD is currently in its development and exploration stages, as defined by the international IDEAL framework for surgical innovation. More robust randomized controlled trial and registry study are essential to proceed with the assessment of LPD.

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.

Barriers to Revision Total Hip Service Lines: A Surgeon's Perspective Through a Deterministic Financial Model

BACKGROUND

Revision THA represents approximately 5% to 10% of all THAs. Despite the complexity of these procedures, revision arthroplasty service lines are generally absent even at high-volume orthopaedic centers. We wanted to evaluate whether financial compensation is a barrier for the development of revision THA service lines as assessed by RVUs.

QUESTIONS/PURPOSES

Therefore, we asked: (1) Are physicians fairly compensated for revision THA on a per-minute basis compared with primary THA? (2) Are physicians fairly compensated for revision THA on a per-day basis compared with primary THA?

METHODS

Our deterministic financial model was derived from retrospective data of all patients undergoing primary or revision THA between January 2016 and June 2018 at an academic healthcare organization. Patients were divided into five cohorts based on their surgical procedure: primary THA, head and liner exchange, acetabular component revision THA, femoral component revision THA, and combined femoral and acetabular component revision THA. Mean surgical times were calculated for each cohort, and each cohort was assigned a relative value unit (RVU) derived from the 2018 Center for Medicaid and Medicare assigned RVU fee schedule. Using a combination of mean surgical time and RVUs rewarded for each procedure, three models were developed to assess the financial incentive to perform THA services for each cohort. These models included: (1) RVUs earned per the mean surgical time, (2) RVUs earned for a single operating room for a full day of THAs, and (3) RVUs earned for two operating rooms for a full day of primary THAs versus a single rooms for a full day of revision THAs. A sixth cohort was added in the latter two models to more accurately reflect the variety in a typical surgical day. This consisted of a blend of revision THAs: one acetabular, one femoral, and one full revision. The RVUs generated in each model were compared across the cohorts.

RESULTS

Compared with primary THA by RVU per minute, in revision THA, head and liner exchange demonstrated a 4% per minute deficit, acetabular component revision demonstrated a 29% deficit, femoral component revision demonstrated a 32% deficit, and full revision demonstrated a 27% deficit. Compared with primary service lines with one room, revision surgeons with a variety of revision THA surgeries lost 26% potential relative value units per day. Compared with a two-room primary THA service, revision surgeons lost 55% potential relative value units per day.

CONCLUSIONS

In a comparison of relative value units of a typical two-room primary THA service line versus those of a dedicated revision THA service line, we found that revision specialists may lose between 28% and 55% of their RVU earnings. The current Centers for Medicare and Medicaid Services reimbursement model is not viable for the arthroplasty surgeon and limits patient access to revision THA specialists.

LEVEL OF EVIDENCE

Level III, economic and decision analysis.

Determinants of hospital variability in perioperative red blood cell transfusions during coronary artery bypass graft surgery

OBJECTIVE

To identify to what extent distinguishing patient and procedural characteristics can explain center-level transfusion variation during coronary artery bypass grafting surgery.

METHODS

Observational cohort study using the Perfusion Measures and Outcomes Registry from 43 adult cardiac surgical programs from July 1, 2011, to July 1, 2017. Iterative multilevel logistic regression models were constructed using patient demographic characteristics, preoperative risk factors, and intraoperative conservation strategies to progressively explain center-level transfusion variation.

RESULTS

Of the 22,272 adult patients undergoing isolated coronary artery bypass surgery using cardiopulmonary bypass, 7241 (32.5%) received at least 1 U allogeneic red blood cells (range, 10.9%-59.9%). When compared with patients who were not transfused, patients who received at least 1 U red blood cells were older (68 vs 64 years; P < .001), were women (41.5% vs 15.9%; P < .001), and had a lower body surface area (1.93 m² vs 2.07 m²; P < .001), respectively. Among the models explaining center-level transfusion variability, the intraclass correlation coefficients were 0.07 for model 1 (random intercepts), 0.12 for model 2 (patient factors), 0.14 for model 3 (intraoperative factors), and 0.11 for model 4 (combined). The coefficient of variation for center-level transfusion rates were 0.31, 0.29, 0.40, and 0.30 for models 1 through 4, respectively. The majority of center-level variation could not be explained through models containing both patient and intraoperative factors.

CONCLUSIONS

The results suggest that variation in center-level red blood cells transfusion cannot be explained by patient and procedural factors alone. Investigating organizational culture and programmatic infrastructure may be necessary to better understand variation in transfusion practices.

Dedicated spine nurses and scrub technicians improve intraoperative efficiency of surgery for adolescent idiopathic scoliosis

STUDY DESIGN

Retrospective comparative study.

OBJECTIVE

To determine how the use of dedicated spine surgical nurses and scrub technicians impacted surgical outcomes of posterior spinal fusions for adolescent idiopathic scoliosis (AIS). Dedicated team approaches to surgery have been shown to improve surgical outcomes. However, their study on orthopaedics and spine surgery is limited.

METHODS

A retrospective review of all patients who underwent a primary posterior spinal fusion of seven or more levels for AIS at a tertiary care pediatric hospital with a minimum of 2 years of follow-up from 2006 to 2013 was conducted. Our institution had dedicated spine surgeons and anesthesiologists throughout the study period, but use of dedicated spine nurses and scrub technicians was variable. The relationship between the proportion of nurses and scrub technicians that were dedicated spine and surgical outcome variables was examined. A multiple regression was performed to control for the surgeon performing the case and the start time.

RESULTS

A total of 146 patients met criteria. When teams were composed of < 60% dedicated spine nurses and scrub technicians, there was 34 min more total OR time (p = .008), 27 min more surgical time (p = .037), 7 min more nonsurgical OR time (p = .030), 30% more estimated blood loss (EBL) (p = .013), 27% more EBL per level instrumented (p = .020), 113% more allogeneic transfusion (p = .006), and 104% more allogeneic transfusion per level instrumented (p = .009). There was no significant difference in length of stay, unplanned staged procedures, surgical site infection, reoperation, or major medical complications.

CONCLUSIONS

Performing posterior spinal fusions for AIS patients with dedicated spine nurses and scrub technicians is associated with a significant decrease in total OR time, blood loss, and transfusion rates.

LEVEL OF EVIDENCE

III.

Impact of First Assistant Surgeon Experience on the Perioperative Outcomes of Laparoscopic Hepatectomies

Introduction: This study aims to evaluate the impact of first assistant surgeon experience on the outcomes of laparoscopic hepatectomies in a university-affiliated teaching hospital. Methods: This is a retrospective study comparing outcomes of laparoscopic hepatectomies with first assistant surgeons of varying experience levels. Three hundred and eighty-five consecutive laparoscopic hepatectomies performed in a tertiary university-affiliated teaching hospital from 2012 to 2018 were included and stratified into three cohorts-Group 1 in which assistants were residents, Group 2 for fellows, and Group 3 for attendings. Baseline clinicopathologic variables and outcome measures were analyzed using the augmented inverse probability of treatment weighting approach, which is a propensity score-based method that combines aspects of covariate adjustment and inverse probability weighting. Results: Group 3 comprised a greater proportion of advanced- and expert-level surgeries based on the Iwate criteria; 33.8%, 32.2%, and 46.0% of patients underwent advanced- and expert-level surgeries in Groups 1, 2, and 3, respectively. Group 3 had consistently higher operative times as well as more frequent use and longer duration of Pringle's maneuver (P < .05). The median operative times for Groups 1, 2, and 3 were 195, 195, and 290 minutes, respectively. Pringle's maneuver was applied in 26.9%, 33.9%, and 60.2% of patients with a corresponding median duration of 35, 36, and 45 minutes, respectively. None of the other perioperative and postoperative outcomes demonstrated statistically significant differences. Conclusion: With an appropriate selection of cases, participation of residents as first assistants in laparoscopic hepatectomies can be encouraged without compromise in perioperative outcomes.

Interruptions in Surgery: A Comprehensive Review

BACKGROUND

Recent literature showed that analysis of interruptions can contribute to evaluating the care process in the operating room, and thus, understanding potential errors that may occur during surgical procedures. The aim of this comprehensive review was to summarize current knowledge on the description and impact of interruptions in surgery.

MATERIAL AND METHODS

A literature search was conducted according to a set of criteria in the databases MEDLINE, BASE, Cochrane's Library, and PsycINFO.

RESULTS

41 articles were included. Two main methodological approaches were found, observational in the OR, or controlled in an experimental simulated environment. Interruptions in the OR were manifold, and several classifications were used. The severity of interruptions differed according to the category of the interruptions. Interruptions were influenced by team familiarity and the expertise of the surgical team; high team familiarity and a high level of expertise decreased the frequency of interruptions. However, our literature search lacked controlled studies carried out in the OR. Interruptions seemed to increase the workload and stress of the surgical team and impair nontechnical skills, but no clear evidence of this was advanced.

CONCLUSIONS

Interruptions are probably risk factors for errors in the operating room. However, there is as yet no clear evidence of the association of interruption frequency with errors in the operating room. There is a need to define and target interruptions, which should be reduced by putting safeguards in place, thereby allowing those which could be beneficial and neglecting those with no potential consequences.

Operating Room Personnel Determine Efficiency of Pediatric Spinal Fusions for Scoliosis

STUDY DESIGN

Retrospective chart review.

OBJECTIVES

To investigate the effect of different surgeons, anesthesiologists, and cRNAs individually and in teams on various perioperative and operative time intervals in a large, high-volume children's hospital.

SUMMARY OF BACKGROUND DATA

Along with individual factors, studies have indicated that team factors play a role in efficiency, with larger teams leading to increased procedure times. An operating room (OR) staff dedicated to orthopedics has been reported to decrease turnover time; however, the characteristics and behaviors of surgical team members, to our knowledge, have not been analyzed as possible factors contributing to pediatric OR efficiency, and limited research has been conducted in the field of orthopedic personnel.

METHODS

Chart review identified consecutive pediatric and adolescent patients who had primary posterior spinal fusion (PSF) of ≥7 levels for correction of spinal deformity. Time intervals and delays were recorded based on previous studies looking at OR efficiency and adjusted to the specific time points available in our perioperative nursing records.

RESULTS

Adjusted for etiology, osteotomy, fusion levels, distance from hospital, staff switch, and body mass index, there was a significant difference in patient wait time among anesthesiologists, surgeon-anesthesiologist, and anesthesiologist-certified registered nurse anesthetist (cRNA) teams; in surgery prep time and total prep among surgeons and SA teams; and in surgery time and total room time among surgeons. There were no significant differences among cRNAs, individually, in any time interval.

CONCLUSIONS

Anesthesiologists have a significant effect before and surgeons have a significant effect after entry into the OR. Identification of this variability provides an opportunity to study the differences in habits and processes of high- and low-efficiency teams, which can then be applied to all teams with the goal of improving performance of all surgical teams.

LEVEL OF EVIDENCE

Level IV, case series.

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.

A 15-Minute Incremental Increase in Operative Duration Is Associated With an Additional Risk of Complications Within 30 Days After Arthroscopic Rotator Cuff Repair

Background:

Operative time is a risk factor for short-term complications after orthopaedic procedures; however, it has yet to be investigated as an independent risk factor for postoperative complications after arthroscopic rotator cuff repair.

Purpose:

To determine whether operative time is an independent risk factor for complications, readmissions, and extended hospital stays within 30 days after arthroscopic rotator cuff repair.

Study Design:

Descriptive epidemiology study.

Methods:

The American College of Surgeons National Surgical Quality Improvement Program was queried for all hospital-based inpatient and outpatient arthroscopic rotator cuff repairs (Current Procedural Terminology code 29827) from 2005 to 2016. Concomitant procedures such as subacromial decompression, biceps tenodesis, superior labrum anterior and posterior (SLAP) repair, labral repair, and distal clavicle excision were also included, whereas patients undergoing arthroplasty were excluded from the study. Operative time was correlated with patient demographics, comorbidities, and concomitant procedures. All adverse events were correlated with operative time, while controlling for the above preoperative variables, using multivariate Poisson regression with a robust error variance.

Results:

A total of 27,524 procedures met inclusion and exclusion criteria. The mean age of patients was 58.4 ± 10.9 years, the mean operative time was 86.9 ± 37.4 minutes, and the mean body mass index was 30.4 ± 7.0 kg/m². Concomitant biceps tenodesis, glenohumeral debridement, SLAP repair, labral repair, and distal clavicle excision significantly increased operative time (P < .001) but not the risk of adverse events (P > .05). The overall rate of adverse events was 0.88%. After adjusting for demographic and procedural characteristics, a 15-minute increase in operative duration was associated with an increased risk of anemia requiring transfusion (relative risk [RR], 1.27 [95% CI, 1.14-1.42]; P < .001), venous thromboembolism (RR, 1.17 [95% CI, 1.02-1.35]; P = .029), surgical site infection (RR, 1.13 [95% CI, 1.03-1.24]; P = .011), and extended length of hospital stay (RR, 1.07 [95% CI, 1.00-1.14]; P = .036).

Conclusion:

Although the rate of short-term complications after arthroscopic rotator cuff repair is low, incremental increases in operative time are associated with an increased risk of adverse events such as surgical site infection, pulmonary embolism, transfusion, and extended length of hospital stay. Efforts should be made to maximize surgical efficiency in the operating room through optimal coordination of the staff or increased preoperative planning.

Relationships Between Expertise, Crew Familiarity and Surgical Workflow Disruptions: An Observational Study

BACKGROUND

Teamwork is an essential factor in reducing workflow disruption (WD) in the operating room. Team familiarity (TF) has been recognized as an antecedent to surgical quality and safety. To date, no study has examined the link between team members' role and expertise, TF and WD in surgical setting. This study aimed to examine the relationships between expertise, surgeon-scrub nurse familiarity and WD.

METHODS

We observed a convenience sample of 12 elective neurosurgical procedures carried out by 4 surgeons and 11 SN with different levels of expertise and different degrees of familiarity between surgeons and SN. We calculated the number of WD per unit of coding time to control for the duration of operation. We explored the type and frequency of WD, and the differences between the surgeons and SN. We examined the relationships between duration of WD, staff expertise and surgeon-scrub nurse familiarity.

RESULTS

9.91% of the coded surgical time concerned WD. The most frequent causes of WD were distractions (29.7%) and colleagues' interruptions (25.2%). This proportion was seen for SN, whereas teaching moments and colleagues' interruptions were the most frequent WD for surgeons. The WD was less high among expert surgeons and less frequent when surgeon was familiar with SN.

CONCLUSIONS

The frequency of WD during surgical time can compromise surgical quality and patient safety. WD seems to decrease in teams with high levels of surgeon-scrub nurse familiarity and with development of surgical expertise. Favoring TF and giving feedback to the team about WD issues could be interesting ways to improve teamwork.

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.

Perioperative Safety: Keeping Our Children Safe in the Operating Room

The entire operating room team is responsible for the safety of children in the operating room. As a leader in the operating room, the surgeon is impactful in ensuring that all team members are committed to providing this safe environment. This is achieved by the use of perioperative huddles or briefings, the use of appropriate surgical checklists, operating room standardization, surgeons proficient in the care they provide, and team members that embrace Just Culture.

Do not break up the surgical team! Familiarity and expertise affect operative time in complex surgery

BACKGROUND

The effects of replacing a surgeon's familiar, experienced certified surgical assistant (CSA) on perioperative outcomes in complex surgery were investigated.

METHODS

An interrupted time series of totally laparoscopic pancreatoduodenectomies performed by a single surgeon was retrospectively studied. Segmented regression analysis estimated replacement effects on estimated blood loss (EBL) and operative time.

RESULTS

The cohort was composed of the last 100 cases with the familiar CSA and the first 100 cases with the replacement CSA. Study groups were similar. Unadjusted segmented regression of operative time and EBL predicted replacement effects of 70 min (95%CI, 18-122; p = 0.008) and 114 cc (95%CI, -93-320; p = 0.3), respectively. Adjusted regression predicted replacement effects of 40 min (95%CI, 0.9-78; p = 0.04) and 27 cc (95%CI, -156-210; p = 0.3).

CONCLUSIONS

The replacement of a familiar, experienced CSA was associated with longer operative times. Despite confinement to a single surgeon and procedure, these results suggest what all surgeons know: excellent help is priceless.

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.

Anticipation, teamwork and cognitive load: chasing efficiency during robot-assisted surgery

INTRODUCTION

Robot-assisted surgery (RAS) has changed the traditional operating room (OR), occupying more space with equipment and isolating console surgeons away from the patients and their team. We aimed to evaluate how anticipation of surgical steps and familiarity between team members impacted efficiency.

METHODS

We analysed recordings (video and audio) of 12 robot-assisted radical prostatectomies. Any requests between surgeon and the team members were documented and classified by personnel, equipment type, mode of communication, level of inconvenience in fulfilling the request and anticipation. Surgical team members completed questionnaires assessing team familiarity and cognitive load (National Aeronautics and Space Administration - Task Load Index). Predictors of team efficiency were assessed using Pearson correlation and stepwise linear regression.

RESULTS

1330 requests were documented, of which 413 (31%) were anticipated. Anticipation correlated negatively with operative time, resulting in overall 8% reduction of OR time. Team familiarity negatively correlated with inconveniences. Anticipation ratio, per cent of requests that were non-verbal and total request duration were significantly correlated with the console surgeons' cognitive load (r=0.77, p=0.006; r=0.63, p=0.04; and r=0.70, p=0.02, respectively).

CONCLUSIONS

Anticipation and active engagement by the surgical team resulted in shorter operative time, and higher familiarity scores were associated with fewer inconveniences. Less anticipation and non-verbal requests were also associated with lower cognitive load for the console surgeon. Training efforts to increase anticipation and team familiarity can improve team efficiency during RAS.