High vs. low entrustment behaviors in the operating room

BackgroundOperative experience with an appropriate degree of supervised autonomy is critical to resident training. Progressively greater intraoperative entrustment has been associated with gradually higher levels of resident autonomy. This study attempts to identify consistently observed intraoperative behaviors that are linked with higher resident entrustment.MethodsThis qualitative study analyzed observational notes recorded by trained raters who provided entrustment scores for 204 surgical cases at Michigan Medicine from 2015 to 2017. Notes were coded in NVivo12. Thematic analysis was used to identify themes and patterns within the data.ResultsThe analysis generated 144 codes. Codes were clustered into 10 themes. These themes manifested differently in intraoperative behaviors strongly associated with high entrustment versus low entrustment.ConclusionThis study demonstrates key differences in intraoperative behaviors exhibited by residents and faculty in high and low entrustment interactions. Awareness of behaviors that enhance entrustment can help faculty augment resident learning and enable higher resident operative autonomy.     

Bridging the gap: The intersection of entrustability and perceived autonomy for surgical residents in the OR

Background

Faculty entrustment decisions affect resident entrustability behaviors and surgical autonomy. The relationship between entrustability and autonomy is not well understood. This pilot study explores that relationship.

A comparison of faculty and resident perception of resident learning needs in the operating room

OBJECTIVES: The purpose of this study was to gain an understanding of faculty and resident perception of residents' learning needs regarding operative management. Our hypothesis is that surgical faculty and residents have significantly different perceptions of residents' learning needs. DESIGN: This study used a 27-item survey designed to determine (1) the extent to which traditional learning resources are used by residents when preparing for cases in the operating room, (2) which Web-based resources residents use for operating room preparation, and (3) which operative management topics residents were deficient in despite preoperative preparation. SETTING: The settings for this study were the exhibit hall area during the 90th American College of Surgeons' Clinical Congress Meeting and a weekly resident conference. PARTICIPANTS: Participants for this study included a convenience sample of faculty and resident volunteers from the Clinical Congress and residents of our program (N = 246). RESULTS: On a scale of 1-5, with 5 indicating frequent use, residents rated their most frequently used resources as Major Surgical Texts (3.99) and Advice from colleagues (3.97). The top 3 operative management topics residents felt least prepared for after studying were "instrument use" (67.7%), "suture selection" (65.3%), and "operative field exposure" (50.0%). The top 3 operative management topics faculty felt residents were least prepared for were "anatomy" (73.9%), "natural history of disease" (73.9%), and "procedure choices" (69.6%). Chi-square analysis comparing faculty and resident perceptions of resident learning needs showed significant differences (p < 0.05) in 12 of the 12 operative management topics rated. CONCLUSION: A critical step in guiding development and proper use of learning technologies for surgical education is the conduct of needs assessments. The disparity between faculty and resident perception of residents' learning needs in the operating room underscores the need for residents to be included in needs assessments relating to surgical training.     

Teaching and learning in the operating room is a two-way street: resident perceptions

BACKGROUND: The transformation of a trainee into a surgeon is influenced strongly by communication patterns in the operating room (OR). In the current era of limited educational opportunities, elucidation of teaching and learning strategies in this environment is critical. The aim of this study was to further understand the elements of an effective communicative instructional interaction (CII) as perceived by surgical residents. METHODS: Qualitative research methodology was used to explore University of British Columbia surgery residents' perceptions of what constitutes an effective CII in the OR. Purposeful sampling was used to select participants from various years of training. Eighteen residents participated in semistructured interviews to facilitate reflection of their OR experiences. Interviews were transcribed, analyzed, and fed back to residents to confirm their accuracy. Independent coding and analysis led to the development of key emergent themes. RESULTS: Themes represented the interplay of ideals expressed by the residents. The primary emergent theme was that both teacher and learner play a major role in the creation of an effective CII. The ideal teacher had an instructional plan, facilitated surgical independence, and showed support and empathy for the surgical resident. The ideal resident was receptive, prepared, and acknowledged limitations. The contextual constraints of the OR played a central role in learning, and residents identified ways to maintain educational value despite primarily nonmodifiable contextual elements (ie, time constraints). CONCLUSIONS: In a unique environment such as the OR, both teacher and learner may benefit by an enhanced understanding of the elements of an effective CII.     

Role of the surgeon in quality and safety in the operating room environment

Medical errors in the OR can result in substantial morbidity, poor functional outcomes and mortality. They are associated with significant increases in direct and indirect healthcare costs. In addition, errors in the OR associated with harm often have a profound negative impact on the patient, their family, and the medical providers’ psychological and social well being. The majority of medical errors are believed to be preventable. Rarely, an error is the result of an isolated single failure in the delivery of care. More commonly, multiple linked processes contribute to the error. Poorly designed systems of care delivery, poor information and knowledge transfer, ambiguous communication between providers and poor coordination of care are frequently identified as the underlying drivers of errors. Solving the problem is as complex as the causes. Raising awareness that an error is more than an individual’s problem or behavior is the first step toward a solution. Thoughtful planning in developing systems of care delivery through optimizing and leveraging the knowledge of the team members that provide care is the single most important defense against medical errors. Surgeons play an important role in facilitating the development of and empowering the teams they work through their active participation and effective leadership within the operating room team.     

Surgical resident supervision in the operating room and outcomes of care in Veterans Affairs hospitals

BACKGROUND: There has been concern that a reduced level of surgical resident supervision in the operating room (OR) is correlated with worse patient outcomes. Until September 2004, Veterans' Affairs (VA) hospitals entered in the surgical record level 3 supervision on every surgical case when the attending physician was available but not physically present in the OR or the OR suite. In this study, we assessed the impact of level 3 on risk-adjusted morbidity and mortality in the VA system. METHODS: Surgical cases entered into the National Surgical Quality Improvement Program database between 1998 and 2004, from 99 VA teaching facilities, were included in a logistic regression analysis for each year. Level 3 versus all other levels of supervision were forced into the model, and patient characteristics then were selected stepwise to arrive at a final model. Confidence limits for the odds ratios were calculated by profile likelihood. RESULTS: A total of 610,660 cases were available for analysis. Thirty-day mortality and morbidity rates were reported in 14,441 (2.36%) and 63,079 (10.33%) cases, respectively. Level 3 supervision decreased from 8.72% in 1998 to 2.69% in 2004. In the logistic regression analysis, the odds ratios for mortality for level 3 ranged from .72 to 1.03. Only in the year 2000 were the odds ratio for mortality statistically significant at the .05 level (odds ratio, .72; 95% confidence interval, .594-.858). For morbidity, the odds ratios for level 3 supervision ranged from .66 to 1.01, and all odds ratios except for the year 2004 were statistically significant. CONCLUSIONS: Between 1998 and 2004, the level of resident supervision in the OR did not affect clinical outcomes adversely for surgical patients in the VA teaching hospitals.     

Identification of teaching excellence in operating room and clinic settings

BACKGROUND: A system for obtaining learner feedback on surgical faculty teaching is a program-specific resource for recognizing faculty accomplishments as well as being a requirement of the Accreditation Council for Graduate Medical Education (ACGME). This investigation uses 5 years of feedback from residents to identify surgical teaching behaviors that define teaching excellence. METHODS: Between 1995 and 1999 full-time surgeons in a division of general surgery were evaluated biannually by every resident on their services, using two 10-item Likert scales to assess frequency of performing selected teaching behaviors. Response categories ranged from 0 (does not demonstrate) to 4 (demonstrates the behavior to a very high degree). Mean scores > or =3.7 (1 SD above the mean) were categorized as evidence of superior teaching, whereas mean scores < or =2.4 (1 SD below the mean) were categorized as mediocre. Residents wrote statements identifying teaching strengths. RESULTS: There were 753 individual resident assessments of 16 faculty. The overall mean rating for operating room and clinic teaching was 3.1, with 24% of the ratings > or =3.7 and 14% of the ratings < or =2.4. For operating room, discriminant behaviors were: demonstrates sensitivity to resident learning needs (3.85 versus 1.62, P <0.01) and provides direct feedback (3.60 versus 1.27, P <0.01). Residents' statements yielded themes tied to superior teaching: demonstrates technical expertise, allows resident participation, and maintains a learning climate of respect. CONCLUSIONS: A resident-based teaching assessment system can offer a reasonable and valid form of feedback to academic surgeons. The use of mixed methods to identify teaching behaviors that characterize excellence informs faculty of how they are perceived as educators and provides examples of specific behaviors that merit commendation.     

The pretrained novice: using simulation-based training to improve learning in the operating room

Enabling trainees to acquire advanced technical skills before they begin the operating room experience benefits both trainee and patient. Whether medical students who had received exclusively simulation-based training could perform laparoscopic suturing and knot-tying as well as senior surgery residents was determined. Simulators were used to train 11 fourth-year medical students with no previous suturing experience to perform intracorporeal suturing and to successfully tie a free-hand intracorporeal knot. Students' skills were assessed by the performance of the fundal suturing portion of a Nissen fundoplication in a porcine model. Their operative performance was evaluated for time, needle manipulations, and total errors. Results were compared to those of 11 senior-level surgery residents performing the same task. The study concluded that trainees could learn advanced technical skills such as laparoscopic suturing and knot tying by using simulation exclusively. The trainees and senior level surgery residents had a similar number of needle manipulations.     

Fires in the operating room and intensive care unit: awareness is the key to prevention

Recent recommendations from the Centers for Disease Control (CDC) to use alcohol-based substances for hand hygiene and skin antisepsis could introduce new fire hazards in the operating room (OR). This potential for an increase in the number of fires in the hospital setting with wide spread use of alcohol-based agents warrants heightened awareness of the risks and implementation of safety measures when using these agents. Here, we report a patient who, during a tracheostomy, sustained severe burns resulting from a fire in the OR. In this case, the use of an alcohol-based antiseptic was the major contributing factor to the surgical fire.     

新型冠状病毒肺炎疫情后期手术室感染防控管理

目的探讨新型冠状病毒肺炎疫情后期手术室预防医院感染、保证手术患者及医护人员安全的有效方法。方法成立手术室新型冠状病毒肺炎疫情后期感染防控专职小组,制定手术人员健康准入、办公区感染防控、患者入室筛查、手术患者家属管理、疑似或确诊新型冠状病毒肺炎手术感染防控等管理策略并严格实施。结果 2020年3月9～18日实施择期手术36例,急诊手术71例,其中9例按疑似/确诊病例实施手术,无医护人员感染事件发生。结论新型冠状病毒肺炎疫情后期感染防控管理策略的制定与实施,有利于手术室工作科学、有序开展,保障患者和医护人员安全。     

A systematic review of the effect of distraction on surgeon performance: directions for operating room policy and surgical training

Background

Distractions during surgical procedures have been linked to medical error and team inefficiency. This systematic review identifies the most common and most significant forms of distraction in order to devise guidelines for mitigating the effects of distractions in the OR.

Methods

In January 2015, a PubMed and Google Scholar search yielded 963 articles, of which 17 (2 %) either directly observed the occurrence of distractions in operating rooms or conducted a laboratory experiment to determine the effect of distraction on surgical performance.

Results

Observational studies indicated that movement and case-irrelevant conversation were the most frequently occurring distractions, but equipment and procedural distractions were the most severe. Laboratory studies indicated that (1) auditory and mental distractions can significantly impact surgical performance, but visual distractions do not incur the same level of effects; (2) task difficulty has an interaction effect with distractions; and (3) inexperienced subjects reduce their speed when faced with distractions, while experienced subjects did not.

Conclusion

This systematic review suggests that operating room protocols should ensure that distractions from intermittent auditory and mental distractions are significantly reduced. In addition, surgical residents would benefit from training for intermittent auditory and mental distractions in order to develop automaticity and high skill performance during distractions, particularly during more difficult surgical tasks. It is unclear as to whether training should be done in the presence of distractions or distractions should only be used for post-training testing of levels of automaticity.

     

A strategy to decide whether to move the last case of the day in an operating room to another empty operating room to decrease overtime labor costs

We examined how to program an operating room (OR) information system to assist the OR manager in deciding whether to move the last case of the day in one OR to another OR that is empty to decrease overtime labor costs. We first developed a statistical strategy to predict whether moving the case would decrease overtime labor costs for first shift nurses and anesthesia providers. The strategy was based on using historical case duration data stored in a surgical services information system. Second, we estimated the incremental overtime labor costs achieved if our strategy was used for moving cases versus movement of cases by an OR manager who knew in advance exactly how long each case would last. We found that if our strategy was used to decide whether to move cases, then depending on parameter values, only 2.0 to 4.3 more min of overtime would be required per case than if the OR manager had perfect retrospective knowledge of case durations. The use of other information technologies to assist in the decision of whether to move a case, such as real-time patient tracking information systems, closed-circuit cameras, or graphical airport-style displays can, on average, reduce overtime by no more than only 2 to 4 min per case that can be moved. Implications: The use of other information technologies to assist in the decision of whether to move a case, such as real-time patient tracking information systems, closed-circuit cameras, or graphical airport-style displays, can, on average, reduce overtime by no more than only 2 to 4 min per case that can be moved.     

Identification of mandibular fracture epidemiology in Canada: Enhancing injury prevention and patient evaluation

BACKGROUND:

Mandibular fractures can lead to significant functional and aesthetic sequelae if treated improperly. They may act as an indicator of concomitant trauma and are very demanding on the public health care system. Thus, knowledge of mandibular fracture epidemiology is critical to effective prevention, as well the establishment of accurate trauma evaluation protocols.

OBJECTIVES:

To identify the epidemiology of mandibular fractures treated at a level 1 Canadian trauma centre, clarify the pathogenesis of these epidemiological patterns and suggest potential targets for preventive efforts.

METHODS:

A retrospective review of all mandibular fracture patients presenting to the Montreal General Hospital between 1998 and 2003 was performed. Medical records and digitized radiographic imaging were used to collect patient demographics and injury data.

RESULTS:

The chart review identified 181 patients with 307 mandibular fractures. Fifty-two per cent of the fractures occurred in individuals 21 to 40 years of age, 78% of patients were male, and there was wide ethnic diversity. Sixty percent of patients had multiple mandibular fractures; 29% were symphyseal/parasymphyseal fractures, 25% were condylar fractures and 23% were angle fractures. Assault was the most common mechanism of injury, with 29% of fractures involving alcohol or illegal drug use. Thirty percent of patients had an associated facial fracture, and more than one-third had another major injury.

CONCLUSIONS:

The present epidemiological review reveals several potential prevention targets as well as significant trends. Further research into the impact of these preventive measures could more objectively identify their impact on mandibular trauma.     

Safety,hazards and ergonomics in the operating room

Objective The objective for this study was to address the lack of information regarding the working conditions in the operating room (OR). Safety issues in the OR need to be discussed not only for the sake of patients, but also for personnel, as hazards may occur for all persons within the OR. Methods To evaluate the workplace conditions in the operating room, a survey was conducted among surgeons working in German hospitals. Sixty questions were asked regarding the personal profile, the architectural situation, the devices and instruments as well as working posture and associated pain. Results The survey showed elementary ergonomic deficiencies within all fields. Surgeons stated that these deficiencies lead to potential hazards for patients and personnel, potentially on a frequent basis. 97% of the surveyed surgeons see ergonomic improvement in the operating room as necessary. Conclusion The survey results display a high potential for improvement within all fields. Therefore, industry, surgeons and their professional organizations are asked to work on the optimization of the workplace conditions in the operating room in terms of improvement of quality and efficiency.     

四川省手术室专科护士培训基地学员自主学习能力调查

目的 调查四川省手术室专科护士培训基地学员自主学习能力水平现状及其影响因素。方法 方便抽样选取四川省手术室专科护士培训基地343名学员为调查对象,应用自主学习能力测评量表进行调查。结果 手术室专科护士培训学员的自主学习能力总分为(113.39±18.26)分。多元线性回归分析显示,婚姻状况、最高学历、平均月工资、参加专科护士培训及外出参加学习或交流次数是学员自主学习能力的主要影响因素(P<0.05,P<0.01)。结论 手术室专科护士培训学员自主学习能力总体水平一般。护理管理者应鼓励学员提高自身学历水平、积极参加专科护士培训或学习,培训基地负责人应探索创新培训模式,多措并举提升学员自主学习能力。