Surgeons' dominant surgical modality: Impacts on wellbeing, burnout, and interventions for neuromusculoskeletal disorders

BACKGROUND

This study investigated the impact of surgical modalities on surgeon wellbeing with a focus on burnout, job satisfaction, and interventions used to address neuromusculoskeletal disorders (NMSDs).

METHODS

An electronic survey was sent to surgeons across an academic integrated multihospital system. The survey consisted of 47 questions investigating different aspects of surgeons' wellbeing.

RESULTS

Out of 245 thoracic and abdominopelvic surgeons, 79 surgeons (32.2 ​%) responded, and 65 surgeons (82 ​%) were able to be categorized as having a dominant surgical modality. Compared to robotic surgeons, laparoscopic (p ​= ​0.042) and open (p ​= ​0.012) surgeons reported more frequent feelings of burnout. The number of surgeons who used any treatment/intervention to minimize the operative discomfort/pain was lower for robotic surgeons than the other three modalities (all p ​< ​0.05).

CONCLUSIONS

NMSDs affect different aspects of surgeons' lives and occupations. Robotic surgery was associated with decreased feelings of burnout than the other modalities.

Using the Operating Room Black Box to Assess Surgical Team Member Adaptation Under Uncertainty: An Observational Study

OBJECTIVE

Identify how surgical team members uniquely contribute to teamwork and adapt their teamwork skills during instances of uncertainty.

SUMMARY/BACKGROUND DATA

The importance of surgical teamwork in preventing patient harm is well documented. Yet, little is known about how key roles (nurse, anesthesiologist, surgeon, medical trainee) uniquely contribute to teamwork during instances of uncertainty, particularly when adapting to and rectifying an intraoperative adverse event (IAE).

METHODS

Audio-visual data of 23 laparoscopic cases from a large community teaching hospital were prospectively captured using OR Black Box®. Human factors researchers retrospectively coded videos for teamwork skills (backup behaviour, coordination, psychological safety, situation assessment, team decision making, leadership) by team role under two conditions of uncertainty: associated with an IAE versus no IAE. Surgeons identified IAEs.

RESULTS

1015 instances of teamwork skills were observed. Nurses adapted to IAEs by expressing more backup behaviour skills (5.3x increase; 13.9 instances/h during an IAE vs. 2.2 instances/h when no IAE) while surgeons and medical trainees expressed more phycological safety skills (surgeons:3.6x increase; 30.0 instances/h vs. 6.6 instances/h and trainees 6.6x increase; 31.2 instances/h vs. 4.1 instances/h). All roles expressed less situation assessment skills during an IAE versus no IAE.

CONCLUSIONS

ORBB enabled the assessment of critically important details about how team members uniquely contribute during instances of uncertainty. Some teamwork skills were amplified, while others dampened, when dealing with IAEs. Knowledge of how each role contributes to teamwork and adapts to IAEs should be used to inform the design of tailored interventions to strengthen interprofessional teamwork.

Impact of preferred surgical modality on surgeon wellness: a survey of workload, physical pain/discomfort, and neuromusculoskeletal disorders

BACKGROUND

We compared surgeons' workload, physical discomfort, and neuromusculoskeletal disorders (NMSDs) across four surgical modalities: endoscopic, laparoscopic, open, and robot-assisted (da Vinci Surgical Systems).

METHODS

An electronic survey was sent to the surgeons across an academic hospital system. The survey consisted of 47 questions including: (I) Demographics and anthropometrics; (II) The percentage of the procedural time that the surgeon spent on performing each surgical modality; (III) Physical and mental demand and physical discomfort; (IV) Neuromusculoskeletal symptoms including body part pain and NMSDs.

RESULTS

Seventy-nine out of 245 surgeons completed the survey (32.2%) and 65 surgeons (82.2%) had a dominant surgical modality: 10 endoscopic, 15 laparoscopic, 26 open, and 14 robotic surgeons. Physical demand was the highest for open surgery and the lowest for endoscopic and robotic surgeries, (all p < 0.05). Open and robotic surgeries required the highest levels of mental workload followed by laparoscopic and endoscopic surgeries, respectively (all p < 0.05 except for the difference between robotic and laparoscopic that was not significant). Body part discomfort or pain (immediately after surgery) were lower in the shoulder for robotic surgeons compared to laparoscopic and open surgeons and in left fingers for robotic surgeons compared to endoscopic surgeons (all p < 0.05). The prevalence of NMSD was significantly lower in robotic surgeons (7%) compared to the other surgical modalities (between 60 and 67%) (all p < 0.05).

CONCLUSIONS

The distribution of NMSDs, workload, and physical discomfort varied significantly based on preferred surgical approach. Although robotic surgeons had fewer overall complaints, improvement in ergonomics of surgery are still warranted.

Optimizing ergonomics during open, laparoscopic, and robotic-assisted surgery: A review of surgical ergonomics literature and development of educational illustrations

BACKGROUND

The surgical profession is plagued with a high prevalence of work-related musculoskeletal disorders. While numerous interventions have been tested over the years, surgical ergonomics education is still uncommon.

METHODS

The available literature on surgical ergonomics was reviewed, and with input from surgeons, recommendations from the review were used to create pictorial reminders for open, laparoscopic, and robot-assisted surgical modalities. These simple pictorial ergonomic recommendations were then assessed for practicality by residents and surgeons.

RESULTS

A review of the current literature on surgical ergonomics covered evidence-based ergonomic recommendations on equipment during open and laparoscopic surgery, as well as proper adjustment of the surgical robot for robot-assisted surgeries. Ergonomic operative postures for the three modalities were examined, illustrated, and assessed.

CONCLUSIONS

The resulting illustrations of ergonomic guidelines across surgical modalities may be employed in developing ergonomic education materials and improving the identification and mitigation of ergonomic risks in the operating room.

Intraoperative workload in elective open vascular and endovascular surgery: A study of procedural drivers

This study investigated vascular surgeon workload and its association with specific procedural drivers over different procedure types. Thirteen attending vascular surgeons (two females) were emailed a survey over a 3-month period. Data from 253 surgical procedures (118 open, 85 endovascular, 18 hybrid, and 32 venous) revealed high physical and cognitive workload among vascular surgeons. Based on the statistically significant findings and similar non-significant trends in the data (significance level of 0.01), open and hybrid vascular procedures showed higher levels of physical and cognitive workload compared to venous cases, while endovascular procedures were relatively more moderate. Additionally, the workload subscales for five subcategories of open procedures (e.g., arteriovenous access) as well as three subcategories of endovascular procedures (e.g., aortic) were compared. The granularity of the intraoperative workload drivers across various vascular procedure types and adjunct equipment could be the key to create targeted ergonomic interventions to reduce workload during vascular surgeries.

Intraoperative Ergonomic Assessment of Exoscopes versus Conventional DIEP Flap

BACKGROUND

 This study compared the ergonomics of surgeons during deep inferior epigastric perforator (DIEP) flap surgery using either baseline equipment (loupes, headlights, and an operating microscope) or an exoscope. Plastic surgeons may be at high risk of musculoskeletal problems. Recent studies indicate that adopting an exoscope may significantly improve surgeon postures and ergonomics.

METHODS

 Postural exposures, using inertial measurement units at the neck, torso, and shoulders, were calculated in addition to the surgeons' subjective physical and cognitive workload. An ergonomic risk score on a scale of 1 (lowest) to 4 (highest) was calculated for each of the postures observed. Data from 23 bilateral DIEP flap surgeries (10 baseline and 13 exoscope) were collected.

RESULTS

 The neck and torso risk scores decreased significantly during abdominal flap harvest and chest dissection, while right shoulder risk scores increased during the abdominal flap harvest for exoscope DIEP flap procedures compared with. Exoscope anastomoses demonstrated higher neck, right shoulder, and left shoulder risk scores. The results from the survey for the "surgeon at abdomen" showed that the usage of exoscopes was associated with decreased performance and increased mental demand, temporal demand, and effort. However, the results from the "surgeon at chest" showed that the usage of exoscopes was associated with lower physical demand and fatigue, potentially due to differences in surgeon preference.

CONCLUSION

 Our study revealed some objective evidence for the ergonomic benefits of exoscope; however, this is dependent on the tasks the surgeon is performing. Additionally, personal preferences may be an important factor to be considered in the ergonomic evaluation of the exoscope.

Course Design and Learning Outcomes of a Practical Online Ergonomics Course for Surgical Residents

OBJECTIVE

Course content was designed and the learning outcomes assessed for an online ergonomics course for surgical residents. This course could fulfill an optional Surgical Council on Resident Education (SCORE) curriculum on Surgical Ergonomics.

DESIGN

The online course included five 5-minute modules within the residents' learning system, each ending with an ungraded knowledge question, and a final 5-question multiple-choice retention quiz that allowed infinite attempts. The course was designed by ergonomists and surgeons at a quaternary academic hospital system. Participants were given two weeks to complete the modules. An electronic survey with questions assessing ergonomics knowledge and understanding on a 5-point Likert scale (strongly disagree - strongly agree) was distributed both before and after the course. The post-course survey included three additional questions to elicit feedback regarding learning experience and course design. Descriptive statistics and nonparametric paired comparisons were used to evaluate learning outcomes.

SETTING

General surgery residency program at an academic medical center in the U.S.

PARTICIPANTS

Twenty-two general surgery post graduate year 1 residents (PGY1s) were recruited to participate and completed the pre-course survey. Eight out of the 22 participants (36%) completed the online course and quiz; seven (32%) completed the course, quiz, and the post-course survey.

RESULTS

Participants had high pre-course awareness of the importance of surgical ergonomics, benefits of work-related musculoskeletal disorder (WMSD) prevention, as well as awkward intraoperative postures being an WMSD risk factor. Participants' confidence increased significantly from pre- to post-course in ability to assess risk (p = 0.021), but not in ability or willingness to mitigate risky surgical postures. Participants who completed the quiz answered a median of 4 (IQR: [4, 5]) questions correctly. All participants indicated that they would recommend this course to other residents.

CONCLUSIONS

These short practical ergonomics online learning modules increased surgical residents' confidence in assessing surgical WMSD risks.

Creating a Practical Transformational Change Management Model for Novel Artificial Intelligence-Enabled Technology Implementation in the Operating Room

Objective

To identify change management (CM) strategies for implementing novel artificial intelligence and similar novel technologies in operating rooms and create a new CM model for future trials and applications inspired by the abovementioned strategies and established models.

Methods

Key phases of technology implementation were defined, and strategies for transformational CM were created and applied in a recent CM experience at our institution between October 15, 2020 and October 15, 2021. We appraised existing CM models and propose the newly created model.

Results

The key phases of the technology implementation were as follows: (1) team assembly; (2) committee approvals; (3) CM; and (4) system installation and go-live. Key strategies were (1) assemble team with necessary expertise; (2) anticipate potential institutional cultural and regulatory hurdles; (3) add agility to project planning and execution; (4) accommodate institutional culture and regulations; (5) early clinical partner buy-in and stakeholder engagement; and (6) consistent communication, all of which contributed to the new CM model creation.

Conclusion

Key CM strategies and a new CM model addressing the unique needs and characteristics of operating room novel technology implementation were identified and created. The new model may be customized and tested for individual institution and project’s needs and characteristics.

Postsurgical Remote Patient Monitoring Outcomes and Perceptions: A Mixed-Methods Assessment

Objective

To determine how postsurgical remote patient monitoring (RPM) influences readmissions and emergency visits within 30 days of discharge after operation and to understand patient and surgeon perspectives on postsurgical RPM.

Patients and Methods

This study was conducted at a US tertiary academic medical center between April 1, 2021, and December 31, 2021. This mixed-methods evaluation included a randomized controlled trial evaluation of RPM after operation and a qualitative assessment of patients' and surgeons' perceptions of RPM's acceptability, feasibility, and effectiveness.

Results

A total of 292 patients participated in the RPM trial, and 147 were assigned to the RPM intervention. Despite a good balance between the groups, results indicated no difference in primary or secondary outcomes between the intervention and control groups. The qualitative component included 11 patients and 9 surgeons. The overarching theme for patients was that the program brought them peace of mind. Other main themes included technological issues and perceived benefits of the RPM platform. The major themes for surgeons included identifying the best patients to receive postsurgical RPM, actionable data collection and use, and improvements in data collection needed.

Conclusion

Although quantitative results indicate no difference between the groups, postsurgical RPM appears well-accepted from the patient's perspective. However, technological issues could eliminate the benefits. Hospitals seeking to implement similar programs should carefully evaluate which populations to use the program in and seek to collect actionable data.

Intraoperative workload during robotic radical prostatectomy: Comparison between multi-port da Vinci Xi and single port da Vinci SP robots

The goal of this study was to quantify and compare prospective self-reported intraoperative workload and teamwork during robot-assisted radical prostatectomy (RARP) for multi-port da Vinci Xi (MP) and single-port da Vinci SP (SP) robots. The self-reported workload (surgeon and surgical team) and teamwork (surgeon) measures were collected and compared between MP and SP RARPs, as well as the learning curve. Results from 25 MP and SP RARPs showed that overall, the NASA-TLX workload subscales were lower, and the teamwork modified NOTECHS subscales were higher for the MP RARPs compared to the SP RARPs. The underlying reason for the significant differences between these two RARP surgical procedures could be other factors (e.g., robot design factors) in addition to the surgeon and surgical team's experience. The results also suggested learning effects through the 25 SP RARPs; however, twenty-five procedures may not be enough to achieve proficiency with the SP system.

Procedural and anthropometric factors associated with musculoskeletal injuries among gastroenterology endoscopists

BACKGROUND AND AIMS

Musculoskeletal (MSK) injuries among gastroenterologists are common. Our study describes risk factors and consequences of injury by comparing provider-specific anthropometric and objective procedural data to self-reported injury patterns.

METHODS

A validated MSK symptom survey was sent to gastroenterologists to gauge prevalence, distribution, and severity of active injury. Respondents' procedural activities over 7 years were collected via an endoscopic database.

RESULTS

64 surveys were completed. 54 respondents had active pain; 53.1% reported activity-limiting injury. Activity-limiting injuries lead to longer colonoscopy times (25.3 vs. 22.1 min, P = 0.03) and lower procedural volumes (532 vs. 807, P = 0.01). Hand/wrist injuries yielded longer colonoscopy insertion times (9.35 vs. 8.21 min, P = 0.03) and less hands-on scope hours (81.2 vs. 111.7 h, P = 0.04). Higher esophagogastroduodenoscopy volume corelated with shoulder injury (336.5 vs. 243.1 EGDs/year, P = 0.04). Females had more foot injuries (P = 0.04).

CONCLUSION

Activity-limiting MSK symptoms/injuries affect over 50% of endoscopists with negative impact on procedural volume and efficiency.

Effects of passive exoskeleton support on EMG measures of the neck, shoulder and trunk muscles while holding simulated surgical postures and performing a simulated surgical procedure

Exoskeletons have shown significant impact at reducing the biomechanical demand on muscles during repetitive lifting and overhead tasks in non-healthcare industries. However, the benefits of exoskeletons are yet to be realized in the operating room, particularly as work-related musculoskeletal disorders continue to be a concern for surgeons. This study quantified the effect of using neck, arm, and trunk exoskeletons on muscle activity while assuming typical postures held in the operating room. Fourteen participants were recruited to participate in this study. In this two-part experiment participants were asked to 1) hold a series of neck flexion, arm abduction and trunk flexion postures seen in surgical procedures, and 2) perform a simulated surgical task requiring five different trunk flexion posture levels. Participants were required to complete these tasks with and without passive exoskeleton(s). This study showed that even for postures held short time periods, exoskeletons are beneficial at reducing the demand on muscles; however, the reduction in muscle demand depends on body segment and postural angle, as intended with these passive exoskeletons. Furthermore, for the simulated surgical task with awkward trunk flexion postures (10-65°), the trunk exoskeletons showed a significant reduction in the rate of rise in back muscle sEMG (+1.365%MVC/min vs. +0.769%MVC/min for non-dominant lumbar extensor muscles, p = 0.0108; +1.377%MVC/min vs. +0.770%MVC/min for the dominant lumbar extensor muscles, p = 0.0196) over 25 min, consequently resulting in improved trunk subjective discomfort scores (7.34 vs. 4.30, p < 0.05), with no impact on the neck and shoulder biomechanical demand. The results from this study indicate that exoskeletons may be a potential intervention to reduce biomechanical loading during surgery.

Exploring the relationship between neck flexion and neck problems in occupational populations: a systematic review of the literature

A systematic review was conducted to evaluate the relationship between occupational neck flexion angles and neck problems. The synthesised findings were used to answer three research questions: (1) Is there a positive/negative relationship between neck flexion and neck problems? (2) What is the appropriate angular threshold for neck flexion as a risk factor for neck problems? (3) What are the gaps in our current knowledge? A review of 21 papers revealed (1) a consistent positive correlation between neck flexion and neck problems, and (2) a neck flexion angle of 20° as the most evidence-based (not necessarily the best) cut-off angle separating high- and low-risk neck flexion postures. Future research should focus on the (1) continuous collection of three-dimensional neck postures through longitudinal studies to quantify cumulative exposures of neck postures, and (2) development of standard descriptions of 'neck problems' and 'neck flexion' to facilitate the development of a dose-response relationship. Practitioner summary: Practitioners depend on thresholds for evaluating neck postural exposure using work assessment tools; however, the scientific basis for this is unclear. This systematic review investigated the angular threshold for neck flexion and found 20° of neck flexion with the greatest evidence-based support as the threshold for high-risk neck postural exposure.

NASA-TLX assessment of workload in resident physicians and faculty surgeons covering trauma, surgical intensive care unit, and emergency general surgery services

BACKGROUND

Higher workload is associated with burnout and lower performance. Therefore, we aim to assess shift-related factors associated with higher workload on EGS, ICU, and trauma surgery services.

METHODS

In this prospective cohort study, faculty surgeons and surgery residents completed a survey after each EGS, ICU, or trauma shift, including shift details and a modified NASA-TLX.

RESULTS

Seventeen faculty and 12 residents completed 174 and 48 surveys after working scheduled 12-h and 24-h shifts, respectively (response rates: faculty - 62%, residents - 42%). NASA-TLX was significantly increased with a higher physician subjective fatigue level. Further, seeing more consults or performing more operations than average significantly increased workload. Finally, NASA-TLX was significantly higher for faculty when they felt their shift was more difficult than expected.

CONCLUSIONS

Higher volume clinical responsibilities and higher subjective fatigue levels are independently associated with higher workload. Designing shift coverage to expand on busier days may decrease workload, impacting burnout and shift performance.

Malpractice Allegations Against Vascular Surgeons:Prevalence, Risk Factors, and Impact on Surgeon Wellness

OBJECTIVES

The contemporary medicolegal environment has been linked to procedure overuse, healthcare variation, and higher costs. For physicians accused of malpractice, there is also a personal toll. The objective of this study was to evaluate the prevalence of and risk factors for involvement in medical malpractice lawsuits among US vascular surgeons, and to examine the association between these allegations with surgeon wellness.

METHODS

In 2018, the Society of Vascular Surgery (SVS) Wellness Task Force conducted a confidential survey of active members using a validated burnout assessment (Maslach Burnout Index) embedded into a questionnaire. This survey included questions related to medical errors and malpractice litigation. De-identified demographic, personal, and practice-related characteristics were assessed in respondents who reported malpractice allegations in the preceding two years, then compared to those without recent medicolegal litigation. Risk factors for malpractice allegations were identified (chi-square, Kruskal-Wallis tests), and the association between malpractice allegations with wellness was examined. Multivariate logistic regression models were developed to identify independent risk factors for malpractice accusations.

RESULTS

Of 2905 active SVS members, 871 responses from practicing vascular surgeons were analyzed. 161 (18.5%) were named in a malpractice lawsuit within two years. Malpractice allegations were significantly associated with surgeon burnout [OR 1.47 (1.01, 2.15), p=0.041], but not with self-reported depression or suicidal ideation. The nature of malpractice claims included procedural errors (23.1%), failure to treat (18.8%) and error/delay in diagnosis (16.9%). 20% of claims were settled prior to trial and 19% were dismissed. Defendant vascular surgeons reported a "fair" resolution in 26.4% of closed cases. By unadjusted analysis, factors significantly associated with recent malpractice claims included mean age (51.7+/-10.0 vs. 49.3+/-11.2; p=0.0044) and mean years in practice (18.0+/-10.7 vs. 15.2+/-11.8; p=0.0007). Multivariate analysis revealed independent variables associated with malpractice allegations, including on-call frequency (p=0.0178), recent medical errors (p=0.0189), and male surgeons (p=0.045).

CONCLUSIONS

Malpractice allegations are common for vascular surgeons and are significantly associated with surgeon burnout. Nearly 20% of survey respondents reported being named in a lawsuit within the preceding two years. Our findings underscore the need for SVS initiatives to provide counseling and peer support for vascular surgeons facing litigation.

Mechanical Assessment of Tissue Properties During Tourniquet Application

INTRODUCTION

Successful tourniquet application increases survival rate of exsanguinating extremity hemorrhage victims. Tactile feedback during tourniquet application training should reflect human tissue properties in order to increase success in the field. This study aims to understand the mechanical properties of a human limb during tourniquet application.

METHOD

Six cadaveric extremities-three uppers and three lowers-were tested from three body mass index groups: low (<19) healthy (19-24), and overweight (>24). Each specimen donned with a tourniquet and mounted to a servo-hydraulic testing machine, which enabled controlled tightening of the tourniquet while recording the tourniquet tension force and strap displacement. A thin-film pressure sensor placed between the specimen and the tourniquet recorded contact pressure. Each limb was tested with the tourniquet applied at two different sites resulting in testing at the upper arm, forearm, thigh, and shank.

RESULTS

The load displacement curves during radial compression were found to be nonlinear overall, with identifiable linear regions. Average contact pressure under the tourniquet strap at 200N and 300N of tension force was 126.3 (σ = 41.2) mm Hg and 205.3 (σ = 75.3) mm Hg, respectively. There were no significant differences in tissue stiffness or contact pressure at 300N of tension force between limb (upper vs. lower) or body mass index. At 200N of tension, the upper limb had significantly higher contact pressure than the lower limb (P = 0.040). Relative radial compression was significantly different between upper (16.74, σ = 4.16%) and lower (10.15, σ = 2.25%) extremities at 200N tension (P = 0.005).

CONCLUSIONS

Simulation of tissue compression during tourniquet application may be achieved with a material exhibiting elastic properties to mimic the force-displacement behavior seen in cadaveric tissue or with different layers of material. Different trainers for underweight, healthy, and overweight limbs may not be needed. Separate tourniquet training fixtures should be created for the upper and lower extremities.

Effects of break scheduling strategies on subjective and objective measures of neck and shoulder muscle fatigue in asymptomatic adults performing a standing task requiring static neck flexion

Sustained non-neutral postures of the head/neck are related to transient neck discomfort and longer-term disorders of the neck. Periodic breaks can help but the ideal length and frequency of breaks are yet to be determined. The current study aimed to quantify the effects of three work-rest strategies on fatigue development. Participants maintained a 45-degree neck flexion posture for a total of 60 min and were provided 3 min of rest distributed in different ways throughout the experiment [LONG (one, 3-min break), MEDIUM (two, 1.5-min breaks), or SHORT (five, 36-s breaks)]. Surface electromyography data were collected from the bilateral neck extensors and trapezius. Subjective discomfort/fatigue ratings were also gathered. Results of the analysis of the EMG data revealed that the SHORT condition did not show increased EMG activity, while LONG [21%] and MEDIUM [10%] did (p < 0.05), providing objective data supporting the guidance of short, frequent breaks to alleviate fatigue.

Intraoperative posture and workload assessment in vascular surgery

Quantifying the workload and postural demand on vascular surgeons provides valuable information on the physical and cognitive factors that predispose vascular surgeons to musculoskeletal pain and disorders. The aim of this study was to quantify the postural demand, workload, and discomfort experienced by vascular surgeons and to identify procedural factors that influence surgical workload. Both objective (wearable posture sensors) and subjective (surveys) assessment tools were used to evaluate intraoperative workload during 47 vascular surgery procedures. Results demonstrate unfavorable neck and low back postures as well as high pain scores for those body segments. Additionally, workload from subjective surveys increased significantly as a function of operative duration, and mental workload was high across all procedure types. Neck postural risk exposure and physical demand were among the variables that increased with surgical duration, procedure type, and loupes used by the surgeons. Correlations among postural angles and pain scores showed consistency between the objective assessment and the subjective surveys for neck and trunk. The authors believe that the results of this study highlight the need for developing mitigating measures such as ergonomic interventions for vascular surgery.

Intraoperative musculoskeletal discomfort and risk for surgeons during open and laparoscopic surgery

BACKGROUND

Surgeon workload is significant both mentally and physically and may differ by procedure type. When comparing laparoscopic surgery and open surgery, studies have reported contrasting results on the physical and mental workload assessed.

METHODS

Wearable posture sensors and pre-/post-surgical questionnaires were employed to assess intraoperative workload and to identify risk factors for surgeons using objective and subjective measures.

RESULTS

Data from 49 cases (27 open and 22 laparoscopic surgeries performed by 13 male and 11 female surgeons) were assessed. More than half the surgeons reported a clinically relevant post-surgical fatigue score. The surgeons also self-reported a significant increase in pain for the neck, upper back, and lower back during/after surgery. Procedural time had significant impacts on fatigue, body part pain, and subjective (NASA-TLX) workload. The objectively assessed intraoperative work postures using wearable sensors showed a high musculoskeletal risk for neck and lower back based on their posture overall. Open surgeries had significantly larger neck angles (median [IQR]: 40 [28-47]°) compared with laparoscopic surgeries (median [IQR]: 23 [16-29]°), p < 0.001) and torso (median [IQR]: 17 [14-22]° vs. 13 [10-17]°, p = 0.006).

CONCLUSION

Surgeons reported significantly higher levels of fatigue and pain in the neck and lower back during or after performing a surgical case. Longer procedural time resulted in more self-rated fatigue, pain, and subjective workload. Open surgery had higher postural risk. Overall, surgeons spent a disturbingly high percentage of time during surgery in high-risk musculoskeletal postures, especially the neck. These results show that intraoperative postural risk is very high and that interventions are necessary to protect surgeon musculoskeletal health for optimal surgeon performance and career longevity.

Ergonomic Robotic Console Configuration in Gynecologic Surgery: An Interventional Study

STUDY OBJECTIVE

The objectives of this study were to (1) pilot a robotic console configuration methodology to optimize ergonomic posture, and (2) determine the effect of this intervention on surgeon posture and musculoskeletal discomfort.

DESIGN

This was an institutional review board-approved prospective cohort study conducted from February 2017 to October 2017.

SETTING

A single tertiary care midwestern academic medical center.

PARTICIPANTS

Six fellowship-trained gynecologic surgeons, proficient in robotic hysterectomy, were recruited: 3 men and 3 women.

INTERVENTIONS

Each surgeon performed 3 robotic hysterectomies using their self-selected robotic console settings (preintervention). Then, a robotic console ergonomic intervention protocol was implemented by trained ergonomists to improve posture and decrease time in poor ergonomic positions. Each surgeon then performed 3 robotic hysterectomies using the ergonomic intervention settings (postintervention). All surgeries used the da Vinci Xi surgical system (Intuitive Surgical, Inc., Sunnyvale, CA) and were the first case of the day. The surgeons wore inertial measurement unit (IMU) sensors on their head, chest, and bilateral upper arms during surgery. The IMU sensors are equipped with accelerometers, gyroscopes, and magnetometers to give objective measurements of body posture. IMU data were then analyzed to determine the percentage of time spent in ergonomically risky postures as categorized using a modified rapid upper limb assessment. Before and after each hysterectomy, the surgeons completed identical questionnaires for an assessment of musculoskeletal pain/discomfort. The outcome measurements were compared pre- versus postintervention on the basis of fitting generalized linear mixed models that handled the individual surgeon as a random effect and "setting" as a fixed effect.

MEASUREMENTS AND MAIN RESULTS

With regard to the IMU posture results, there was a significant decrease in time spent in the moderate- to high-risk neck position and a decrease in average neck angle after the ergonomic intervention. The average percentage of time spent in moderate- to high-risk categories was significantly lower for the neck (mean, 54.3% vs 21.0%; p = .008) and right upper arm (mean, 15.5% vs 0.9%; p = .02) when using the intervention settings compared with the surgeons' settings. Pain score results: There were fewer reported increases in neck (4 [22%] vs 1 [6%]) and right shoulder (4 [22%] vs 2 [11%]) pain or discomfort after completion of robotic hysterectomy postintervention versus preintervention; however, these differences did not attain statistical significance (p = .12 and p = .37, respectively).

CONCLUSION

An ergonomic robotic console intervention demonstrated effectiveness and improved objective surgeon posture at the console when compared with the surgeons' self-selected settings.

Intraprocedural ergonomics of vascular surgeons

OBJECTIVE

The objective of this study was to estimate the ergonomic postural risk (EPR) for musculoskeletal posture of vascular surgeons performing open and endovascular procedure types and with various adjunctive equipment using wearable inertial measurement unit (IMU) sensors. The hypothesis was that EPR will increase with increased physical and mental demand as well as with procedural complexity.

METHODS

A prospective, observational study was conducted at a large, quaternary academic hospital located at two sites. Sixteen vascular surgeons (13 male) participated in the study. Participants completed a presurgery and postsurgery survey consisting of a body part discomfort scale and a modified NASA-Task Load Index. Participants wore IMU sensors on the head and upper body to measure EPR during open and endovascular procedures.

RESULTS

Vascular surgeons have increased EPR scores of the neck as measured by the IMUs and increased lower back pain when performing open surgery compared with non-open surgery (P < .05). Open procedures were rated as more physically demanding. The use of loupes resulted in increased EPR scores for the neck and torso (P < .05), and they were significantly associated with higher levels of lower back pain during procedures (P < .05) as well as with higher levels of physical demand (P < .05). The use of headlights also resulted in increased subjectively measured levels of physical demand and lower back pain. In comparing survey responses with IMU data, surveyed physical demand was strongly and significantly correlated with the neck (r = 0.61; P < .0001) and torso (r = 0.59; P < .0001) EPR scores. The use of lead aprons did not affect EPR or most surveyed measures of workload but resulted in significantly higher levels of distraction (P < .01). The data presented highlight the potential of using wearable sensors to measure the EPR of surgeons during vascular surgical procedures.

CONCLUSIONS

Vascular surgeons should be aware of EPR during the performance of their duties. Procedure type and surgical adjuncts can alter EPR significantly.

Effect of surgical radiation personal protective equipment on EMG-based measures of back and shoulder muscle fatigue: A laboratory study of novices

Interventional radiologists are at increased risk for musculoskeletal discomfort/disorders and this has been linked to the use of radiation personal protective equipment (rPPE). This study examined the effects of rPPE on the development of fatigue of the erector spinae and trapezius muscles. Surface electromyography (EMG) was used to capture muscle activity, and both time domain (average rectified value) and frequency domain (median frequency) measures were considered in the assessment of localized muscle fatigue. Sixteen participants performed a simulated surgical procedure requiring intermittent 30° flexed static trunk posture with and without rPPE on separate days. The results showed that the rPPE condition demonstrated significantly greater (p < 0.05) downward shift in median frequency in the left lumbar erector spinae and left lower thoracic erector spinae consistent with task-induced localized muscle fatigue. Ergonomic intervention strategies are discussed.

Impact of Procedure Type, Case Duration, and Adjunctive Equipment on Surgeon Intraoperative Musculoskeletal Discomfort

BACKGROUND

Surgeons are at high risk of developing musculoskeletal disorders.

STUDY DESIGN

This study was designed to identify risk factors and assess intraoperative physical stressors using subjective and objective measures, including type of procedure and equipment used. Wearable sensors and pre- and postoperation surveys were analyzed.

RESULTS

Data from 116 cases (34 male and 19 female surgeons) were collected across surgical specialties. Surgeons reported increased pain in the neck, upper, and lower back both during and after operations. High-stress intraoperative postures were also revealed by the real-time measurement in the neck and back. Surgical duration also impacted physical pain and fatigue. Open procedures had more stressful physical postures than laparoscopic procedures. Loupe usage negatively impacted neck postures.

CONCLUSIONS

This study highlights the fact that musculoskeletal disorders are common in surgeons and characterizes surgeons' intraoperative posture as well as surgeon pain and fatigue across specialties. Defining intraoperative ergonomic risk factors is of paramount importance to protect the well-being of the surgical workforce.

Workload Differentiates Breast Surgical Procedures: NSM Associated with Higher Workload Demand than SSM

Background

Breast surgery has evolved with more focus on improving cosmetic outcomes, which requires increased operative time and technical complexity. Implications of these technical advances in surgery for the surgeon are unclear, but they may increase intraoperative demands, both mentally and physically. We prospectively evaluated mental and physical demand across breast surgery procedures, and compared surgeon ergonomic risk between nipple-sparing (NSM) and skin-sparing mastectomy (SSM) using subjective and objective measures.

Methods

From May 2017 to July 2017, breast surgeons completed modified NASA-Task Load Index (TLX) workload surveys after cases. From January 2018 to July 2018, surgeons completed workload surveys and wore inertial measurement units to evaluate their postures during NSM and SSM cases. Mean angles of surgical postures, ergonomic risk, survey items, and patient factors were analyzed.

Results

Procedural duration was moderately related to surgeon frustration, mental and physical demand, and fatigue (p < 0.001). NSMs were rated 23% more physically demanding (M = 13.3, SD = 4.3) and demanded 28% more effort (M = 14.4, SD = 4.6) than SSMs (M = 10.8, SD = 4.7; M = 11.8, SD = 5.0). Incision type was a contributing factor in workload and procedural difficulty. Left arm mean angle was significantly greater for NSM (M = 30.1 degrees, SD = 6.6) than SSMs (M = 18.2 degrees, SD = 4.3). A higher musculoskeletal disorder risk score for the trunk was significantly associated with higher surgeon physical workload (p = 0.02).

Conclusion

Nipple-sparing mastectomy required the highest surgeon-reported workload of all breast procedures, including physical demand and effort. Objective measures identified the surgeons’ left upper arm as being at the greatest risk for a work-related musculoskeletal disorder, specifically from performing NSMs.

Attitudes and Behavior of Health Care Workers Before, During, and After Implementation of Real-Time Location System Technology

Objective

To assess how staff attitudes before, during, and after implementation of a real-time location system (RTLS) that uses radio-frequency identification tags on staff and patient identification badges and on equipment affected staff’s intention to use and actual use of an RTLS.

Participants and Methods

A series of 3 online surveys were sent to staff at an emergency department with plans to implement an RTLS between June 1, 2015, and November 29, 2016. Each survey corresponded with a different phase of implementation: preimplementation, midimplementation, and postimplementation. Multiple logistic regression with backward elimination was used to assess the relationship between demographic variables, attitudes about RTLSs, and intention to use or actual use of an RTLS.

Results

Demographic variables were not associated with intention to use or actual use of the RTLS. Before implementation, poor perceptions about the technology’s usefulness and lack of trust in how employers would use tracking data were associated with weaker intentions to use the RTLS. During and after implementation, attitudes about the technology’s use, not issues related to autonomy and privacy, were associated with less use of the technology.

Conclusion

Real-time location systems have the potential to assess patterns of health care delivery that could be modified to reduce costs and improve the quality of care. Successful implementation, however, may hinge on how staff weighs attitudes and concerns about their autonomy and personal privacy with organizational goals. With the large investments required for new technology, serious consideration should be given to address staff attitudes about privacy and technology in order to assure successful implementation.

Crossover Assessment of Intraoral and Cuffed Ventilation by Emergency Responders

OBJECTIVES

A cuffed bag valve mask (BVM) is the most common device used by emergency medical responders to ventilate patients. The BVM can be difficult for users to seal around the patient's mouth and nose. An intraoral mask (IOM) with snorkel-like design may facilitate quicker and better ventilation particularly under austere conditions.

METHODS

Both a BVM and IOM were utilized by 27 trained emergency medical technicians and paramedics to ventilate a lightly embalmed cadaver. Ventilation efficacy, workload, and usability were assessed for both devices across four study conditions.

RESULTS

The IOM was superior to the BVM in delivered tidal volume ratio (measure of leak, p < 0.03) and minute ventilation (p < 0.0001). Workload, ergonomic and usability assessments indicated that the IOM facilitated gripping through the reduced hand interface size (p < 0.01), decreased user effort (p < 0.001), and reduced upper limb workload (p = 0.0088).

CONCLUSIONS

In the assessed model, the IOM represented a better choice for airway management than the standard cuffed BVM. An emergency medical device that is intuitive, efficacious and less demanding has the potential to reduce responder stress and improve resuscitation efforts, especially during austere rescue and patient transport.

Sweating the Little Things: Tourniquet Application Efficacy in Two Models of Pediatric Limb Circumference

BACKGROUND

Current military recommendations include the use of tourniquets (TQ) in appropriate pediatric trauma patients. Although the utility of TQs has been well documented in adult patients, the efficacy of TQ application in pediatric patients is less clear. The current study attempted to identify physical constraints for TQ use in two simulated pediatric limb models.

METHODS

Five different TQ (Combat Application Tourniquet (CAT) Generation 6 and Generation 7, SOFTT (SOF Tactical Tourniquet), SOFTT-W (SOF Tactical Tourniquet - Wide), SWAT-T (Stretch Wrap and Tuck - Tourniquet) and a trauma dressing were evaluated in two simulated pediatric limb models. Model one employed four cardiopulmonary resuscitation (CPR) manikins simulating infant (Simulaids SaniBaby), 1 year (Gaumard HAL S3004), and 5 years (Laerdal Resusci Junior, Gaumard HAL S3005). Model two utilized polyvinyl chloride (PVC) piping with circumferences ranging from 4.25" to 16.5". Specific end-points included tightness of the TQ and ability to secure the windlass (where applicable).

RESULTS

In both models, the ability to successfully apply and secure the TQ depended upon the simulated limb circumference. In the 1-year-old CPR manikin, all windlass TQs failed to tighten on the upper extremity, while all TQs successfully tightened at the high leg and mid-thigh. With the exception of the CAT7 and the SOFTT-W at the mid-thigh, no windlass TQ was successfully tightened at any extremity location on the infant. The SWAT-T was successfully tightened over all sites of all CPR manikins except the infant. No windlass TQ was able to tighten on PVC pipe 5.75" circumference or smaller (age < 24 months upper extremity). All windlass TQs were tightened and secured on the 13.25" and 15.5" circumference PVC pipes (age 7-12 years lower extremity, age >13 years upper extremity). The SWAT-T was tightened on all PVC pipes.

DISCUSSION

The current study suggests that commercial windlass TQs can be applied to upper and lower extremities of children aged 5 years and older at the 50%th percentile for limb circumference. In younger children, windlass TQ efficacy is variable. Further study is required to better understand the limitations of TQs in the youngest children, and to determine actual hemorrhage control efficacy.

Characteristics of team briefings in gynecological surgery

Preoperative briefings have been proven beneficial for improving team performance in the operating room. However, there has been minimal research regarding team briefings in specific surgical domains. As part of a larger project to develop a briefing structure for gynecological surgery, the study aimed to better understand the current state of pre-operative team briefings in one department of an academic hospital. Twenty-four team briefings were observed and video recorded. Communication was analyzed and social network metrics were created based on the team member verbal interactions. Introductions occurred in only 25% of the briefings. Network analysis revealed that average team briefings exhibited a hierarchical structure of communication, with the surgeon speaking the most frequently. The average network for resident-led briefings displayed a non-hierarchical structure with all team members communicating with the resident. Briefings conducted without a standardized protocol can produce variable communication between the role leading and the team members present.

Surgical team workload comparison for 4-port and single-port laparoscopic cholecystectomy procedures

Advanced minimally invasive procedures may cause postural constraints and increased workload and stress for providers. This study compared workload and stress across surgical team roles for 48 laparoscopic cholecystectomies (4-port vs single-port) using a task load index (NASA-TLX), a procedural difficulty question, and salivary stress hormones. Statistical analyses were performed based on the presence intra-cluster correlation within team roles, at α=0.05. The single-port technique resulted in an 89% increase in physical workload for the surgeon and 63% increase for the assistant (both p<0.05). The surgeon had significantly higher salivary stress hormones during single-port surgeries. The degree of procedural difficulty was positively correlated between the surgeon and most roles: resident (r=0.67), assistant (r=0.81), and technician (r=0.81). There was a statistically significant positive correlation between the surgeon and assistant for all selfreported workload measures (p<0.05). The single-port technique requires further improvement to balance surgical team workload for optimal patient safety and satisfaction.

Human factors in robotic assisted surgery: Lessons from studies 'in the Wild'

This article reviews studies conducted "in the wild" that explore the "ironies of automation" in Robotic Assisted Surgery (RAS). Workload may be reduced for the surgeon, but increased for other team members, with postural stress relocated rather than reduced, and the introduction of a range of new challenges, for example, in the need to control multiple arms, with multiple instruments; and the increased demands of being physically separated from the team. Workflow disruptions were not compared with other surgeries; however, the prevalence of equipment and training disruptions differs from other types of surgeries. A consistent observation is that communication and coordination problems are relatively frequent, suggesting that the surgical team may need to be trained to use specific verbal and non-verbal cues during surgery. RAS also changes the necessary size of the operating room instrument cleaning processes. These studies demonstrate the value of clinically-based human factors engineers working alongside surgical teams to improve the delivery of RAS.

Preliminary Investigation of Civilian Clinician Perspectives & Just-in-Time Guidance for Tourniquet Use to “Stop the Bleed”

Objective

The American College of Surgeons (ACS) encourages clinicians to provide training to laypeople on tourniquet application. It is unclear whether clinicians are confident in their abilities and equipped with adequate knowledge, skills, and resources. This study aimed to determine surgical trainee knowledge and attitudes regarding tourniquet application and compare the effectiveness of instructions.

Methods

Thirty surgical trainees performed a tourniquet application simulation using a Combat Application Tourniquet and one of the three instructions sets developed by ACS, Department of Homeland Security, and the tourniquet manufacturer. Participants reported tourniquet knowledge, attitudes, and confidence and discussed the instructions. One instruction set was updated and compared to the original set with 20 new trainees.

Results

Participants with ACS instructions passed the greatest number of steps (p &lt; 0.01) and completed the task significantly faster compared to those with manufacturer instructions (p &lt; 0.01). Participants (80%) reported favorable views toward tourniquets but 30–60% did not align with to ACS tourniquet guidelines. Focus group participants suggested revisions to the ACS instructions. Comparing the original and revised version of these instructions resulted in no significant improvements.

Conclusions

ACS instructions provide guidance; however, improvements to tourniquet instruction are needed for success in controlling exsanguinating hemorrhage.

A pilot study of non-routine events in gynecological surgery: Type, impact, and effect

OBJECTIVE

Quantifying non-routine events (NREs) assists with identify underlying sociotechnical factors that could lead to adverse events. NREs are considered any event that is unusual or atypical during surgical procedures. This study aimed to use prospective observations to characterize the occurrence of non-routine events in gynecological surgeries.

METHODS

Observational data were collected prospectively within one surgical gynecology department over a five month period. Researchers captured NREs in real time using a validated tablet PC-based tool according to the NRE type, impact, whom was affected, and duration. Researchers also noted what surgical approach (i.e. open, laparoscopic, robotic) was used.

RESULTS

Across 45 surgical cases, 554 non-routine events (M = 12.31 NREs per case, SD = 9.81) were identified. The majority of non-routine events were external interruptions (40.3%), teamwork (26.7%), or equipment (21.3%). The circulating nurse was most frequently affected by NREs (43.2%) followed by the entire surgical team (13.7%). There was no statistically significant difference in non-routine events based on surgical approach.

CONCLUSION

Non-routine events are prevalent in the gynecological surgical setting. Identifying the sociotechnical factors that influence non-routine events are important in determining interventions that will combat the associated risks. Interventions focusing on teamwork, managing external interruptions, and coordinating equipment may have the greatest impact to reduce or eliminate NREs in gynecological surgeries.

Mini Breaks, Many Benefits: Development and Pilot Testing of an Intraoperative Microbreak Stretch Web-Application for Surgeons

Periodic intraoperative microbreaks with calesthenic exercises performed within the sterile field improved self-reported mental focus (38%) and physical performance (57%) for 56 surgeons. Therefore, targeted stretching exercises and a web-application (web-app) leading the stretches with a reminder system were developed and piloted using user-centered design principles. A focus group with 10 users was conducted to refine the developed app. Seven surgeons (4 females) at a quaternary medical institute piloted the periodic stretching web-app in their operating rooms. At the end of each surgical day, the surgeons completed a short survey about the intraoperative stretching exercises web-app impact on their physical performance, mental focus and workflow disruption. Non-Routine Events were captured during the procedures. Twelve surgical days were followed with a median of 6 microbreaks/day/surgeon. Results showed that better physical performance and lower fatigue were reported (91.7%) across the surgical days, also better mental focus was reported (83.3%) across the surgical days, and less pain/discomfort was reported (100%) across the surgical days, with others reporting no change. The web-app leading sterile field microbreak stretches helped reduce physical pain, discomfort/pain, fatigue, and improve mental focus with minimal disruption for a small sample. The web-app is a promising tool for improving surgeon mental focus and physical performance and potentially musculoskeletal health.

Improving Accuracy of Noninvasive Hemoglobin Monitors: A Functional Regression Model for Streaming SpHb Data

OBJECTIVE

The purpose of this paper is to develop a method for improving the accuracy of SpHb monitors, which are noninvasive hemoglobin monitoring tools, leading to better critical care protocols in trauma care.

METHODS

The proposed method is based on fitting smooth spline functions to SpHb measurements collected over a time window and then using a functional regression model to predict the true HgB value for the end of the time window.

RESULTS

The accuracy of the proposed method is compared to traditional methods. The mean absolute error between the raw SpHb measurements and the gold standard hemoglobin measurements was 1.26 g/Dl. The proposed method reduced the mean absolute error to 1.08 g/Dl. [1] Conclusion: Fitting a smooth function to SpHb measurements improves the accuracy of Hgb predictions.

SIGNIFICANCE

Accurate prediction of current and future HgB levels can lead to sophisticated decision models that determine the optimal timing and amount of blood product transfusions.

Validation of a Novel Inverted Peg Transfer Task: Advancing Beyond the Regular Peg Transfer Task for Surgical Simulation-Based Assessment

OBJECTIVE

To evaluate the validity of a novel inverted peg transfer (iPT) task for assessing laparoscopic skills of novices and experts and compare iPT to the regular PT (rPT) task to ensure surgical trainee acquisition of an adequate advanced laparoscopic skills level for safe laparoscopic practice in the operating room.

DESIGN

Prospective crossover study.

SETTING

Multidisciplinary simulation center and motion analysis laboratory, Mayo Clinic.

PARTICIPANTS

Novices were medical students and surgical interns without laparoscopic experience. Experts were surgeons with at least 3 years of experience in laparoscopic surgery.

METHODS

This was the first exposure to iPT for both groups. Completion time and performance metrics were recorded. A scoring rubric was used to calculate a normalized performance score between 0 and 100. Wilcoxon rank sum and Mann-Whitney tests were performed with α = 0.05. Receiver-operating characteristic curves were graphed for the 2 task scores to assess the tasks' sensitivity and specificity in differentiating laparoscopic experience level.

MAIN OUTCOME MEASURES

Performance measures of completion time, transferred triangles, dropped triangles (errors), and the overall performance score on both tasks between- and within-subjects (i.e., novices and experts).

RESULTS

Thirty-six novices and eight experts participated. Both experts and novices had longer completion time and lower scores during iPT than rPT (p < 0.05). Within iPT, novice completion times were 144 seconds longer (p = 0.04), and performance score was 35 points lower than experts (p < 0.01). No differences between novices and experts were observed for completion time or performance scores (p > 0.05) for rPT. The iPT scores had a higher sensitivity and specificity than the rPT (area under the receiver-operating characteristic curve: iPT = 0.91; rPT = 0.69).

CONCLUSIONS

iPT is a valid assessment of advanced laparoscopic skills for surgical trainees with higher specificity and sensitivity than rPT. As advanced minimally invasive surgery becomes more common, it is important that tasks such as iPT be included in surgical simulation curricula and training assessment.

Physician, Interrupted: Workflow Interruptions and Patient Care in the Emergency Department

BACKGROUND

It is unclear how workflow interruptions impact emergency physicians at the point of care.

OBJECTIVES

Our study aimed to evaluate interruption characteristics experienced by academic emergency physicians.

METHODS

This prospective, observational study collected interruptions during attending physician shifts. An interruption is defined as any break in performance of a human activity that briefly requires attention. One observer captured interruptions using a validated tablet PC-based tool that time stamped and categorized the data. Data collected included: 1) type, 2) priority of interruption to original task, and 3) physical location of the interruption. A Kruskal-Wallis H test compared interruption priority and duration. A chi-squared analysis examined the priority of interruptions in and outside of the patient rooms.

RESULTS

A total of 2355 interruptions were identified across 210 clinical hours and 28 shifts (means = 84.1 interruptions per shift, standard deviation = 14.5; means = 11.21 interruptions per hour, standard deviation = 4.45). Physicians experienced face-to-face physician interruptions most frequently (26.0%), followed by face-to-face nurse communication (21.7%), and environment (20.8%). There was a statistically significant difference in interruption duration based on the interruption priority, χ²(2) = 643.98, p < 0.001, where durations increased as priority increased. Whereas medium/normal interruptions accounted for 53.6% of the total interruptions, 53% of the interruptions that occurred in the patient room (n = 162/308) were considered low priority (χ² [2, n = 2355] = 78.43, p < 0.001).

CONCLUSIONS

Our study examined interruptions over entire provider shifts and identified patient rooms as high risk for low-priority interruptions. Targeting provider-centered interventions to patient rooms may aid in mitigating the impacts of interruptions on patient safety and enhancing clinical care.

Iterative Implementation of a Remote Cardiac Patient Monitoring Device using Qualitative Analysis and Human Factors Engineering

Remote monitoring has the potential to improve patient care and satisfaction while reducing the cost of care and burden on the healthcare system for Congestive Heart Failure (CHF) and Atrial Fibrillation (AF) patients. However, the device must be convenient and easy for the population to use correctly. In this study, human factors and qualitative researchers evaluated the use of a remote cardiac monitoring device during a clinical trial with 74 CHF and AF patients. Human factors usability concerns centered on device use and the information presented in the manual. The key themes identified during the qualitative analysis were related to patient education. These findings were incorporated into device design, user manual, or education material updates. This study illustrates how these methods can infuse patient experience into device design to inform continued quality improvement and usability refinement specifically in devices to aid CHF and AF patients without added burden.

Kinematic and ergonomic assessment of laparoendoscopic single-site surgical instruments during simulator training tasks

While laparoendoscopic single-site surgery (LESS) appears to be feasible and safe, instrument triangulation, tissue handling, and other bimanual tasks are difficult even for experienced surgeons. Novel technologies emerged to overcome LESS' procedural and ergonomic difficulties of "tunnel vision" and "instrument clashing." Surgeon kinematics, self-reported workload and upper body discomfort were used to compare straight, bent and two articulating instruments while performing two basic surgical tasks in a LESS simulator. All instruments resulted in bilateral elevation and rotation of the shoulders, excessive forearm motion and flexion and ulnar deviation of wrists. Surgeons' adopted non-neutral upper extremity postures and performed excessive joint excursions to compensate for reduced freedom of movement at the single insertion site and to operate the instrument mechanisms. LESS' cosmetic benefits continue to impact laparoscopic surgery and by enabling performance through improved instruments, ergonomic improvement for LESS can reduce negative impact on surgeon well-being and patient safety.

The impact of intraoperative microbreaks with exercises on surgeons: A multi-center cohort study

Recent literature has demonstrated ergonomic risk to surgeons in the operating room. One method used in other industries to mitigate these ergonomic risks is the incorporation of microbreaks. Thus, intraoperative microbreaks with exercises in a non-crossover design were studied. Fifty-six attending surgeons from 4 Medical Centers volunteered first in a day of their regular surgeries and then second day where there were microbreaks with exercises that could be performed in the sterile field, answering questions after each case, without significantly increasing the duration of their surgeries. Surgeons self-reported improvement or no change in their mental focus (88%) and physical performance (100%) for the surgical day incorporating microbreaks with exercises. Discomfort in the shoulders was significantly reduced while distractions and flow impact was minimal. Eighty-seven percent of the surgeons wanted to incorporate the microbreaks with exercises into their OR routine. Intraoperative microbreaks with exercises may be a way to mitigate work-related musculoskeletal fatigue, pain and injury.

Ergonomic Laparoscopic Tool Handle Design

Twenty-two subjects were tested and categorized according to hand size (small, medium, or large). Each subject selected the best location for a trackball and a trigger on a handle. Each subject specified the optimum diameter/size of the handle that he or she preferred. Additionally, subjects selected their preferred pivot range for opening and closing the handle. Finally, each subject exerted his or her preferred force for the trackball and trigger controls in the selected positions. Based on the data collected in this experiment, the recommended handle diameter is in the range of 4.3 to 5.7 cm. The recommended handle pivot is the range of 8.1 to 17.3 degrees for the open and closed positions. The recommended trackball actuation force is 3.0 lbs and the recommended ratchet actuation force is 0.6 lbs, on average.

The Effects of Instruction, Verbal Encouragement, and Visual Feedback on Static Handgrip Strength

The objective of this study was to evaluate the effects of instruction, verbal encouragement, and real-time visual feedback on static handgrip strength. Sixteen subjects participated in this study and a computerized wrist dynamometer was used for the measurement of grip strength. The independent variables were five different instructions including the Caldwell Regimen, use of verbal encouragement and visual feedback. According to the results of ANOVA, there were significant differences in main effects. Therefore, the employment of verbal encouragement or visual feedback should be noted in any paper if used while measuring static strength. Since the comparison between peak forces showed that fast contraction and immediate release upon maximal contraction instruction had greater peak forces than all other instruction sets, it can be suggested for the standard of peak force measurement that the static strength should be reached within 1.5 seconds and immediately released when reaching the maximum force and the greatest force can be designated as the peak force.