Publications

Background:

Vital injuries during midurethral sling surgery are avoided by maintaining constant trocar contact with bone, and yet this is challenging for a teaching surgeon to monitor during this blind procedure. We modified a retropubic trocar with a load cell to distinguish on-bone and off-bone movement 1and tested it on a midurethral sling surgery 3-dimensional surgery simulator.

Methods:

Two experts and 3 novice surgeons performed retropubic trocar passage on the physical pelvic floor model using the modified trocar. Biofidelity was assessed comparing expert performance on a Thiel-embalmed cadaver and the physical model. The test-retest was assessed comparing performance on the physical pelvic model 2 weeks apart. The force variables were analyzed with paired and independent tests. We performed post hoc analyses comparing the experts to novices on the physical model.

Results:

The root-mean-squared force was similar between the cadaver and model (24.3 vs 21.1 pounds, P ¼ .62), suggesting biofidelity. Root-mean-squared force was also similar between the test and retest (14.0 vs 19.1 pounds, P ¼. 30). The expert surgeons exhibited a larger maximum force amplitude (51.2 vs 22.7 pounds, P ¼ .03), shorter time to maximum force (2.7 vs 9.5 seconds, P ¼ .03) and larger maximum rate of force development (171.5 vs 54.0 pounds/second, P ¼ .01).

Conclusion:

This study suggested high test-retest reliability and adequate biofidelity of the modified trocar used on our midurethral sling surgery 3-dimensional surgery simulator. This innovative trocar can be used both in simulation and in the operating room to help the novice surgeons stay on the bone and to help the attending surgeon monitor safe surgery.

Background:

African American women are at greater risk for cervical cancer incidence and mortality than White women. Up to 90% of cervical  cancers are caused by human papillomavirus (HPVs)  infections. The National Institutes of Health (NIH) co- developed HPV self-test kits to increase access to screening, which may be critical for underserved populations.

Purpose/Research Design:

This mixed methods study used the Theory of Planned Behavior to examine attitudes, barriers, facilitators, and intentions related to receipt of cervical cancer screening and perceptions of HPV self-testing among church- affiliated African American women. Study 
Sample/Data Collection: Participants (N = 35) aged 25–53 participated in focus groups and completed a survey.

Results:

Seventy-four percent of participants reported receipt of cervical cancer screening in the past 3 years. Healthcare providers and the church were supportive referents of screening. Past trauma and prioritizing children’s healthcare needs were screening barriers. Concerns about HPV self-testing included proper test administration and result accuracy.

Conclusions:

Strategies to mitigate these concerns (e.g., delivering HPV self-test kits to the health department) are discussed.
 

Keywords: African American women; HPV self-testing; cervical cancer disparities; community-engaged research; theory of planned behavior.

OBJECTIVE:

This study aimed to determine the impact of a rural vs urban hospital location on the risk of undergoing a second surgery for stress urinary incontinence.

STUDY DESIGN:

Using the Cerner Health Facts nationwide electronic medical record database, we identified patients who underwent surgeries for stress incontinence between January 1, 2010 and November 30, 2018. Stress incontinence surgeries included synthetic midurethral slings, fascial slings, retropubic urethral suspension, and other surgeries for stress urinary incontinence, such as the laparoscopic sling or the Pereyra procedure. Patients were divided into 2 cohorts, namely those who had a single operation and those who had a reoperation, defined as any second stress incontinence surgery or revision after initial incontinence surgery. Logistic regression analysis was performed to determine whether urban vs rural hospital location impacted reoperation rates. We adjusted for significant sociodemographic variables identified in the univariate analysis with a P value <.1.

RESULTS:

Of the 25,085 women who underwent stress incontinence procedures, 669 (2.7%) underwent a second surgery. Of these, 346 (51.7%) patients underwent were a second stress incontinence procedure, 307 (45.9%) underwent revisions of the index case, and 16 (2.4%) underwent both. Women in the single surgery cohort were older (median age, 54 vs 53 years; P=.029). In the total sample, 85.5% identified as White and 4.5% identified as Black. Of the study cohort, 7720 (30.8%) had obesity and 2660 (10.6%) had diabetes. There was a higher rate of reoperation among patients with obesity (3.0% vs 2.5%; P=.017). Among patients who underwent a concomitant prolapse surgery with their index surgery, there were fewer reoperations (2.2% vs 2.8%; P=.012). In the univariate analysis, we did not detect a difference between women who lived in rural vs urban areas (3.0% vs 2.6%; P=.16). After adjusting for confounders, we still did not see a significant association between rural hospital location and the risk for repeat surgery (odds ratio, 1.00; 95% confidence interval, 0.76−1.31). In this multivariable regression, obesity increased the risk for having a reoperation (odds ratio, 1.20; 95% confidence interval, 1.02−1.41), whereas patients who had concomitant prolapse procedures with their index surgery had a reduced risk for having a reoperation (odds ratio, 0.80; 95% confidence interval, 0.66−0.98).

CONCLUSION:

We did not detect an association between hospital location (rural vs urban) and the risk for reoperation among women under- going stress incontinence surgery. With low reoperation  rates, patients can be reassured that they are receiving excellent care in either setting.

Keywords: hospital status; incontinence; reoperation; repeat operation; rural; stress incontinence; urban; urogynecology

Importance

Facial personal protective equipment (FPPE) filters small particles in the operating room (OR) but also affects speech production, diminishing the effective  transfer of information among OR team members.

Objective

The aim of the study is to assess the attenuating effects of different combinations of layered FPPE on speech intensity,  including potential differences in the effect of talkers with varying backgrounds and speaking volumes.

Study Design

We recruited 30 speakers from health and nonhealth occupations with English as either their first or second language. All participants spoke unmasked, at varying voice levels into a portable Zoom H4n device 12 inches from the microphone. These no-mask recordings were played from a Styrofoam head, fitted with 7 combinations of FPPE commonly worn in the COVID-19 era, with the attenuated signals assessed for digital average signal levels. We submitted these attenuation values to an omnibus mixed analysis of variance and performed a spectral analysis on signal attenuation stratified by typical speech frequency bands.

Results

Signal attenuation was strongly determined by FPPE combination, regardless of talker sex, first language, and occupation (P < 0.01, η² = 0.881). The effects of vocal output were also significant (P < 0.01, η² = 0.881). Soft talkers experienced particularly high attenuation at frequency bands higher than 2,000 Hz. The signal of the softest talkers, when asked to speak loudly, was similar to the loud talkers’ signal.

Conclusions

Layered FPPE in the OR protects the surgical team from small particle exposure but may increase communication failures. Our data can help OR staff choose FPPE and alter their vocal volume accordingly.
 

OBJECTIVE:

Teaching and training surgeons work hard in the OR to understand each other, yet miscommunication is an important cause of preventable adverse events in surgery. Our objective was to perform a formal semantic analysis of language in authentic teaching surgical cases, identify the prevalence and typology of ambiguous or potentially ambiguous language, and describe their potential for miscommunication.

DESIGN:

In this secondary analysis of qualitative data, we collaborated with a semanticist, categorizing linguistic phenomena often associated with miscommunication. We defined an ambiguous phenomenon as a string of language that could be reasonably interpreted in more than one way. We analyzed transcripts of 319 minutes of surgery, coding for 14 linguistic categories. Cohen's kappa was calculated. We determined the prevalence and rate of each linguistic category and chose illustrative examples.

PARTICIPANTS AND SETTING:

Six surgical attendings, four fellows, and six residents, ranging from PGY1 to PGY4, at the University of Pittsburgh Medical Center, a tertiary medical center in Pittsburgh, Pennsylvania.

RESULTS:

We found 3912 examples of potentially ambiguous language, 12.3 per minute. Percentage agreement between two expert raters was 76.3%. The most common phenomena were deixis (3.1 per minute), directional (2.6), anaphora (1.3), implicit instruction (1.3), and degree modifiers (0.7). Restatements/reframing occurred 1.4 times per minute. We identified 131 near misses associated with potentially ambiguous language. Cohen's kappa was 0.70 among expert semanticists.

CONCLUSIONS:

Potentially ambiguous language is common and has the potential to jeopardize safe teaching surgery. We postulate that the high amount of potentially ambiguous language use in the operating room places a burden on the training surgeon to comprehend surgical instruction.

Keywords: Communication; Medical education; Patient safety; Semantics; Surgery

OBJECTIVE:

The aim of the study was to determine the rate of subsequent uterine/cervical cancer after hysteropexy compared with hysterectomy with apical prolapse repair.

METHODS:

The study used a retrospective cohort of women with uterovaginal prolapse using the Cerner Health Facts database between 2010 and 2018. We identified sacrospinous or uterosacral ligament suspensions or sacral colpopexy/hysteropexy and excluded those with previous hysterectomy. We used the International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision codes for endometrial cancer/hyperplasia and cervical cancer and then reviewed each case, excluding those whose cancer existed at time of prolapse repair. Given that 0 cancer cases were identified, we used Wilson, Jeffreys, Agresti-Coull, Clopper-Pearson, and Rule of 3 to define 95% confidence intervals to estimate the highest possible rate of cancer in each cohort.

RESULTS:

A total of 8,927 patients underwent apical prolapse surgery. Of 4,510 with uterovaginal prolapse, 755 (16.7%) underwent hysteropexy. Seventy one with hysterectomy and 5 with hysteropexy had codes for subsequent gynecologic cancer but were excluded on further review. This left 0 gynecologic cancer cases with the largest 95% confidence interval of 0%-0.61% for hysteropexy versus 0%-0.13% for hysterectomy (P > 0.05). The hysteropexy cohort was older (62.6 years vs 57.3 years, P < 0.0001), more likely to have public insurance (51.0% vs 37.9%, P < 0.0001), and less likely to smoke (4.5% vs 7.6%, P = 0.0026). Median follow-up was longer after hysteropexy (1,480 days vs 1,164 days, P < 0.0009).

CONCLUSIONS:

We can say with 95% certainty that uterine or cervical cancer will develop after hysteropexy in fewer than 0.61% of women, which was not different if hysterectomy was performed. This should be included in preoperative counseling for hysteropexy. Studying longer follow-up after hysteropexy may capture more cases of subsequent cancer development.

BACKGROUND:

Preventable intraoperative errors have the potential to lead to adverse events. Our objective was to build a conceptual model of the relationship between minute technical errors performed by the surgeon and adverse patient outcomes.

MATERIALS AND METHODS:

We used constructivist grounded theory methodology to build a model for the avoidance of technical errors. We used the Observational Clinical Human Reliability Assessment system, which categorizes granular, technical intraoperative errors, as our conceptual framework. We iteratively interviewed surgeons from multiple adult and pediatric surgical specialties, refined our semi-structured interview, and developed a conceptual model. Our model remained stable after interviewing 11 surgeons, and we reviewed it with earlier interviewed surgeons.

RESULTS:

Our conceptual model helps us understand how technical errors can be associated with adverse outcomes and is applicable to a broad range of surgical steps. Each technical error is defined by a unique improper technical motion that without a compensatory response, it may lead to 1 or more discreet adverse outcomes. Our model includes 5 primary defenses against an adverse outcome, including perfect technique, recognizing imperfect technique, adequately correcting imperfect technique, recognizing an adverse event, and adequately compensating for an adverse event. It includes multiple examples of compensating for a technical error, resulting in a near miss.

DISCUSSION:

Our conceptual model suggests that adverse patient outcomes can be related to minute technical deviations in surgical technique and provides a basis to study these preventable errors. Our model can also be used to develop intraoperative strategies to prevent these technical surgical errors.

Keywords: adverse events; adverse outcomes; medical education; patient safety; qualitative research; surgery; surgical errors.

BACKGROUND:

Our objective was to examine the influence of silence on team action in the operating room.

METHODS:

We conducted a constructed grounded theory study with semi-structured interviews with 25 interprofessional surgical team members. Using a framework of silence as communication and performance, transcripts were iteratively team-coded to develop themes and a conceptual model.

RESULTS:

OR silence is expressed verbally and nonverbally. Two contexts of silence were identified: homogenous as collective action, and disparate, as disengagement. Complex and dynamic, two primary themes emerged, Power that often shuts down communication, and Focus during critical moments. Five additional sub-themes included critical moments, respect, self-reflection, personal preference, and, bad mood.

CONCLUSION:

OR silence is not an absence of communication and requires a response. Whether homogenous through cohesiveness, or desperate as a solitary act, OR silence is a call to action. Examining silence as a part discourse has important implications on surgical team function.

OBJECTIVE:

The primary aim of this study was to use cognitive task analysis to expand the retropubic midurethral sling into smaller steps, reflecting a surgeon s internal thought processes during the surgery.

METHODS:

Two surgeons and a cognitive psychologist collaborated with expert urogynecologic surgeons in structured discussions and semistructured interviews, iteratively creating a list of clinical steps for the midurethral sling. They primarily considered 2 questions: (1) what action does the expert perform for this step, and (2) what information does the expert need to complete the step? We defined each additional piece of detail within a step as a microstep. The cognitive task analysis list was further reviewed by 4 external expert urogynecologic surgeons to obtain further detail. The process was repeated for every step until the maximum level of detail was reached. We used multiple methods to explore the relationship between microsteps and the cognitive load associated with various portions of the surgery.

RESULTS:

Cognitive task analysis expanded the midurethral sling from 23 to 197 microsteps. Steps with the greatest number of microsteps included retropubic advancement with the trocar (19 microsteps) and ventral advancement of the trocar through the skin (17 microsteps).

CONCLUSIONS:

The retropubic midurethral sling is a complex surgery with multiple microsteps embedded within in each step. Identification of these steps can lead to strategies to minimize cognitive load encouraging both efficacy and safety. Surgical training interventions and competency assessment can be developed based on this content.

CONTEXT:

In the high-stakes, time-critical environment of the operating room (OR), attendings and residents strive to complete safe, effective surgeries and ensure that learning occurs. Yet meaningful resident participation often receives less attention, and that impedes residents ability to learn and achieve autonomous operative practice. We need a new conceptual framework for understanding progression to autonomous practice that can guide both faculty and residents. Thus, we sought a new conceptualisation of intraoperative teaching and learning (IOT&L) through the lens of Eraut's notion of informal workplace learning and Billett's theory of relational interdependence between social and individual agency.

METHODS:

We viewed authentic examples of IOT&L in video and transcripts of live OR cases and interviews with participating attendings and residents. By systematically applying Eraut and Billet's theories to the transcripts and interviews, we developed concrete descriptions about how IOT&L occurs, categorised them into theory-based principles and derived a conceptualisation and related research ideas about IOT&L.

RESULTS:

Established workplace learning theories frame IOT&L as socially negotiated processes transpiring in distinct interdependent interactions between residents individual cognitive experiences and their OR social experiences that direct their learning. As the surgery unfolds, spontaneous events and the rules of surgery create opportunities for unplanned and informal learning. These authentic interrelated cognitive and social experiences are stimulated when residents reveal a learning need or attendings recognise a learning gap, and efforts ensue to bridge that gap. Through these minute distinct exchanges, labelled here as atomic IOT&L, residents gain crucial knowledge and skill.

CONCLUSION:

Framing authentic OR interactions between attendings and residents in terms of micro-relational interdependencies shows how granular teaching/learning exchanges yield high-value informal learning. To improve IOT&L, we must examine and change it at this fundamental level by using and testing this new theoretical conceptualisation. These insights produced ideas about IOT&L to test and research.