Publications

Importance: 

Sacral neuromodulation (SNM) requires removal for infectious complications in 3-11%.

Objective: Does preoperative antibiotic choice impact device removal rates?

Study Design: 

This was a retrospective cohort analysis, using the Health Facts® Database, representing >750 hospitals. We included female patients undergoing SNM
implantation 2010-2018. Univariate and multivariate logistic regression identified factors associated with removal. 35 comorbidities were evaluated. Those with p<0.2 on univariate analysis were included in the multivariate analysis. We decided a priori to include prophylactic antibiotic choice in the final model.

Results: 

Of 1,433 patients, 170 (11.9%) had device removal. Subjects were 70.0 ± 14.9 years old, predominantly Caucasian (90.0%), treated in urban hospitals (94.1%),
and married (54.2%). 11.8% were obese, and 18.0% smoked. Those in the removal cohort were more likely from the Northeastern U.S. 52.3% received 1st gen cephalosporins (CPSN), 7.4% 2nd or 3rd gen CPSNs, 9.1% vancomycin, 13.4% aminoglycosides, 4.6% clindamycin, and 13.3% fluoroquinolones. Compared to vancomycin, more removals were associated with first generation CPSNs (OR=3.1, 95% confidence interval [1.4, 6.8]); clindamycin (OR=3.2, [1.2, 8.4]); second/third generation CPSNs (OR=3.1, [1.3, 7.6]); and aminoglycosides (OR = 3.1, [1.3, 7.4]). Additionally, patients treated in the Northeast were more likely to undergo removal (OR = 1.9, [1.0, 3.7]).

Conclusions: Vancomycin as a prophylactic antibiotic was associated with fewer device removals compared to most antibiotics in this retrospective cohort analysis. While prospective trials could confirm this benefit, low removal rates may make this impractical.

Keywords: Sacral Neuromodulation, antibiotics, urinary incontinence, postoperative complications, device removal, infection

Miscommunication in the OR is a threat to patient safety and surgical efficiency. Our objective was to measure the frequency and causes of communication interference between robotic team members. We observed 78 robotic surgeries over 215 h. 65.4% were General Surgery, most commonly cholecystectomy, identifying Speech Communication Interference (SCI) events, defined as “surgery-related group discourse that is disrupted according to the goals of the communication or the physical and situational context of the exchange”. We noted the causes and strategies to correct the miscommunication, near misses, and case delays associated with each SCI event. Post-surgery interviews supported observations and were analyzed thematically. Overall, we observed 687 SCI events (mean 8.8 ± 6.5 per case, 3.2 per hour), ranging from one to 28 per case. 48 (7.0%) occurred during docking and 136 (19.8%) occurred during a critical moment. The most common causes were concurrent tasks (66.1%); loud noises (10.8%) from patient cart, lightbox fan, and suction machine; and overlapping conversations (4.2%). 94.8% resulted in a case delay. These events distracted from monitoring patient safety and resulted in near misses. Mitigating strategies included leaning out of the surgeon console to repeat the message and employing a messenger. These findings help characterize miscommunication in robotic surgery. Possible interventions include microphones and headsets, positioning the surgeon console closer to the bedside, moving loud equipment further away, and upgrading the patient cart speaker.

Keywords: Anesthesia; Communication; Interprofessional teamwork; OR nursing staff; Robotic surgery; Surgical error.

PURPOSE:

The surgical clerkship provides medical students with valuable hands-on experience. This study examined why medical students speak or remain silent in the OR to improve progression from novice to engaged surgical team member.

METHODS:

Using Constructivist Grounded Theory 37 interviews were conducted concerning expectations and behaviors that encourage or discourage students from speaking during their clerkship. Transcripts were coded, analyzed, and triangulated to develop a conceptual model.

RESULTS:

Students' decision to speak or remain silent was based on their perception of the OR as a safe learning space. Our findings suggest that better preparation, awareness of critical moments, and informal communication with team members encouraged student speech.

CONCLUSIONS:

Medical students remain conflicted about their speaking in the OR and their evaluation. Key to improving students' psychological safety is establishment of interpersonal relationships, awareness of OR mood, and assignment of case-related tasks to assist with OR assimilation and improved learning.

Introduction and hypothesis:

Surgeon kinematics play a significant role in the prevention of patient injury. We hypothesized that elbow extension and ulnar wrist deviation are associated with bladder injury during simulated midurethral sling (MUS) procedures.

Methods:

We used motion capture technology to measure surgeons’ flexion/extension, abduction/adduction, and internal/external rotation angular time series for shoulder, elbow, and wrist joints. Starting and ending angles, minimum and maximum angles, and range of motion (ROM) were extracted from each time series. We created anatomical multibody models and applied linear mixed modeling to compare kinematics between trials with versus without bladder penetration and attending versus resident surgeons. A total of 32 trials would provide 90% power to detect a difference.

Results:

Out of 85 passes, 62 were posterior to the suprapubic bone and 20 penetrated the bladder. Trials with versus without bladder penetration were associated with more initial wrist dorsiflexion (−27.32 vs −9.03°, p = 0.01), less final elbow flexion (39.49 vs 60.81, p = 0.03), and greater ROM in both the wrist (27.48 vs 14.01, p = 0.02), and elbow (20.45 vs 12.87, p = 0.04). Wrist deviation and arm pronation were not associated with bladder penetration. Compared with attendings, residents had more ROM in elbow flexion (14.61 vs 8.35°, p < 0.01), but less ROM in wrist dorsiflexion (13.31 vs 20.33, p = 0.02) and arm pronation (4.75 vs 38.46, p < 0.01).

Conclusions:

Bladder penetration during MUS is associated with wrist dorsiflexion and elbow flexion but not internal wrist deviation and arm supination. Attending surgeons exerted control with the wrist and forearm, surgical trainees with the elbow. Our findings have direct implications for MUS teaching.

Keywords: Biomedical engineering; Kinematics; Midurethral sling; Motion capture; Patient safety; Surgical education; Surgical simulation.

Objective: 

In our previous work, teaching surgeons used potentially ambiguous language in the OR 12.3 times per minute. Our objectives were to examine ambiguous examples featuring Directional Frame of Reference (DFoR), which involves instructions containing directional terms like "up" or "left," and to uncover what contributes to understanding or misunderstanding of such instruction.

Design: 

We videorecorded the critical moments of 6 surgeries, as chosen by the surgeons. With a semanticist, we applied constructs from formal semantics to choose potentially ambiguous DFoR terms commonly flagged in our previous work. We separately interviewed attending and resident surgeons, asking each to describe the meaning of those DFoR terms while they viewed case recordings alongside transcripts. We compared their responses, analyzing them for agreement in direction. We performed thematic analysis on case and interview transcripts for themes related to DFoR.

Setting: 

Midwestern academic university teaching hospital.

Participants: 

Six attending and 6 resident surgeons.

Results: 

Attending and resident surgeons disagreed on direction in 9 of the 26 (34.6%) DFoR examples. Misunderstanding arose from using linear direction to describe three-dimensional space, e.g., "up" for anterior/cephalad/right. It also arose when combining degree modifiers with DfoR, e.g., "we're far enough back" combines the ambiguities of "back" (DfoR) and "far enough" (degree modifier). Use of axial parts (noun-like directional terms), e.g., "bottom," and confusing "left" for "right" also provoked misunderstanding. Misunderstanding was associated with lack of experience and mitigated by pointing with a finger or instrument, concurrent with speech.

Conclusions: 

Use of ambiguous language with DFoR incurs a high potential for misunderstanding, especially with novice surgeons. We recommend avoiding linear directions and axial parts, and instead physically pointing to represent complex 3D directions. Degree modifiers can be replaced with exact distances e.g., replace "little more anterior" with "1 centimeter anterior," and semaphores can be used to clarify direction.

Keywords: communication; linguistics; semantics; surgery; surgical education.

Highlights

• This is the first study applying linguistic inquiry and word count to intraoperative spoken language.

• Attending surgeons spoke more words and used more language of clout.

• Residents used more informal speech with an emotional tone and assent.

• There were no meaningful differences in language use according to gender.

Objective

Previous work has analyzed residency letters of recommendation for agentic and communal language, but this has not been applied to spoken language. Our objective was to analyze intraoperative spoken language by attending and resident surgeons for the use of agentic and communal language.

Design

We completed a linguistic inquiry and word count (LIWC) analysis on 16 operating room transcripts (total time 615 minutes) between attendings and resident surgeons for categories associated with agentic and communal speech. Wilcoxon signed rank and Mann-Whitney U tests were used to compare attending versus resident and male versus female speech patterns for word count; “I,” clout, and power (agentic categories); and “we,” authentic, social (communal categories).

Setting

Midwestern academic university teaching hospital.

Participants

Sixteen male (9 attendings, 7 residents) and 16 female (7 attendings, 9 residents) surgeons, from 6 surgical specialties, most commonly from General Surgery.

Results

Attending surgeons used more words per minute than residents (40.01 vs 16.92, p < 0.01), were less likely to use “I” (3.18 vs 5.53, p < 0.01), and spoke more language of “clout” (75.82 vs 55.47, p < 0.01). There were no significant differences between attendings and residents in use of analytic speech (23.72 vs 24.67, p = 0.32), “causation” (1.20 vs 1.08, p = 0.72), or “cognitive processing” (10.20 vs 10.54, p = 0.74). Residents used more speech with “emotional tone” (92.91 vs 79.92, p = 0.03), “positive emotion” (4.98 vs 3.86, p = 0.04), more “assent” language (4.89 vs 3.09, p < 0.01), and more “informal” language (9.27 vs 6.77, p < 0.01). There were no gender differences, except for male residents speaking with greater certainty than female residents, although by less than 1% of the total word count.

Conclusions

In the operating room, attending surgeons were more likely to use agentic language compared to resident surgeons based on LIWC analysis. These differences did not depend on gender and likely relate to surgeon experience and confidence, learning versus teaching, and power dynamics.

Key words

communication, surgery, surgical education, gender, language

BACKGROUND: Our objective was to compare the use of agentic ("I") and communal ("we") spoken intraoperative discourse between male and female attending and resident surgeons.

METHODS: We analyzed transcripts involving attending and resident surgeons from 5 specialties at a single Midwestern academic teaching hospital. We adapted and expanded Grebelsky-Lichtman's codes, assessed rater agreement, and systematically coded transcripts for agentic and communal terms. Differences between genders and roles were evaluated using Mann-Whitney U tests.

RESULTS: In the operating room, attendings used significantly more Action Demands, Rationality, Collective Speech, Passive Speech, Nurturing Speech, and Degree Modifiers. Conversely, residents used significantly more Assertive Speech, and Display Solution. Attendings were also more likely to use Action Demands combined with Passive Speech. No significant gender differences were found in any categories.

CONCLUSIONS: Language use in the OR is more closely associated with professional role rather than gender and may reflect underlying power dynamics and the nature of the surgical teaching environment.

Importance: 

Few studies compare the link between hemogobin A1c (HbA1c) and urogynecologic surgical complications.

Objective: 

The objective of this study was to determine the association between HbA1c and reoperation in women undergoing surgery for stress urinary incontinence (SUI) or pelvic organ prolapse (POP).

Study design: 

We performed 2 separate retrospective cohort analyses using Cerner's HealthFacts Database (750 hospitals; 519,000,000 patient encounters from January 1, 2010, to November 30, 2018). We included women undergoing surgery for (1) SUI or (2) apical POP by International Classification of Diseases coding who had HbA1c at the initial procedure. Each analysis compared those undergoing reoperation for complications or recurrence and those who did not. Multivariable logistic regression assessed the association between reoperation and HbA1c both as a continuous variable and comparing the commonly accepted cutoff ≥8.

Results: 

Of 30,180 SUI surgical procedures and 26,389 POP surgical procedures, 1,625 (5.4%) and 805 (3.1%) had HbA1c. Median (interquartile range) HbA1c in grams per deciliter was similar by reoperation status (SUI: 6.0 [5.6-6.8] vs 6.1 [5.6-6.9], P = 0.35; POP: 6.2 [5.6-6.6] vs 6.1 [5.7-6.8], P = 0.60). Reoperation was also similar using the HbA1c ≥8% cutoff (SUI: 6.9% vs 7.4%, P = 0.79; POP: 6.3% vs 5.4%, P = 0.77). On multivariate analysis, HbA1c value was not a significant predictor of reoperation either as a continuous (SUI: odds ratio [OR] = 0.966, 95% CI = 0.833-1.119; POP: OR = 1.040, 95% CI = 0.801-1.350) or dichotomous variable ≥8 (SUI: OR = 0.767, 95% CI = 0.407-1.446; POP: OR = 0.988, 95% CI = 0.331-2.951). Mean follow-up was 4.28-5.13 years.

Conclusion: 

Although other studies have shown a link between diabetes and complications, we were unable to show an association between HbA1c values and rates of reoperation.

Introduction: 

Operating room communication is frequently disrupted, raising safety concerns. We used a Speech Interference Instrument to measure the frequency, impact, and causes of speech communication interference (SCI) events.

Methods:

 In this prospective study, we observed 40 surgeries, primarily general surgery, to measure the frequency of SCI, defined as "group discourse disrupted according to the participants, the goals, or the physical and situational context of the exchange." We performed supplemental observations, focused on conducting postsurgery interviews with SCI event participants to identify contextual factors. We thematically analyzed notes and interviews.

Results: 

The observed 103 SCI events in 40 surgeries (mean 2.58) mostly involved the attending (50.5%), circulating nurse (44.6%), resident (44.6%), or scrub tech (42.7%). The majority (82.1%) of SCI events occurred during another patient-related task. 17.5% occurred at a critical moment. 27.2% of SCI events were not acknowledged or repeated and the message was lost. Including the supplemental observations, 97.0% of SCI events caused a delay (mean 5 s). Inter-rater reliability, calculated by Gwet's AC¹ was 0.87-0.98. Postsurgery interviews confirmed miscommunication and distractions. Attention was most commonly diverted by loud noises (e.g., suction), conversations, or multitasking (e.g., using the electronic health record). Successful strategies included repetition or deferment of the request until competing tasks were complete.

Conclusions: 

Communication interference may have patient safety implications that arise from conflicts with other case-related tasks, machine noises, and other conversations. Reorganization of workflow, tasks, and communication behaviors could reduce miscommunication and improve surgical safety and efficiency.

Keywords: Anesthesia; Communication; Interprofessional teamwork; OR nursing staff; Surgery; Surgical error.

Background

Instructions form a vital part of OR communication, yet ambiguous language is common. This study compares attending and resident understanding of ambiguous intraoperative instructions using concepts from formal semantics.

Methods

We filmed attending and resident surgeons during intraoperative critical moments, the portion most crucial for safe, effective surgery. We transcribed all communication and with a semanticist, analyzed transcripts for instructions that could be interpreted ambiguously, while simultaneously viewing case video for context. We distinguished explicit instruction from implicit instruction as delivered only by implicature. Afterward, we interviewed the surgeons independently about their interpretation of each implicit instruction. We compared their answers, noted misunderstanding, and conducted thematic analysis to explore what makes instruction semantically clear versus misunderstood.

Results

The team recorded 169 min of critical moments from 6 cases, involving 6 attending and 8 resident surgeons, and interviewed 12 surgeons. We identified 334 instructions, 79.9% from the attendings and 20.1% from residents: 113 (33.8%) were explicit and 267 (66.2%) implicit. 7% of potential ambiguities provoked misunderstanding, including one not recovered. Attending and resident understanding of implicit instruction was context-dependent, involving high degrees of tacit knowledge. Some instructions allowed the resident to practice decision-making. Many implicit instructions involved highly varied ways to instruct someone to begin a motion, prepare to stop, or stop. Many were constructed with polite formulas.

Conclusion

The majority of instruction to residents is implicitly stated or contains lexical ambiguities, yet is well-understood. Future research should examine the impact of misunderstood instruction on resident educational and patient safety.

Keywords Communication· Surgery· Surgical education· Linguistics· Semantics