Publications

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.

OBJECTIVES:

The objective of this study was to identify risk factors for having to return to the operating room for a second surgery after midurethral sling (MUS).

METHODS:

We used a case-control design. Cases return to operating room were a composite of 6 surgical complications or recurrent stress urinary incontinence because we believed that women would consider return to the operating room (OR) a similar MUS-related complication regardless of indication. Cases were obtained from Cerner Health Facts database, including 213 hospitals, using current procedural technology codes 57288 (repeat sling), 57287 (sling revision), and 53500 (urethrolysis) for procedures after index MUS. Controls no return to OR were randomly selected in 4:1 ratio from the remaining slings without these procedures. Multivariable regression analysis included all variables with P < 0.10 on univariable analysis.

RESULTS:

Between January 1, 2010, and December 31, 2016, 1247 patients returned to the OR of 17,953 patients who underwent initial MUS (6.9%). After adjusting for confounders, white race (OR, 1.47 [1.20-1.81]), lack of concomitant prolapse surgery (OR, 1.37 [1.18-1.59]), immunosuppressant drugs (OR, 1.27 [1.12-1.45]), and blood thinner use (OR, 1.38 [1.18-1.62]) significantly impacted the odds for returning to the OR. Anticholinergic use and smoking tobacco or marijuana, although significant on univariable analysis, were no longer significant after adjusting for confounders.

CONCLUSIONS: The rate of a second surgery after MUS using a composite outcome, over a 7-year period including multiple diagnoses, is 6.9%. White race, using immunosuppressant drugs, using blood thinners, and not having concomitant prolapse surgery are all risk factors for having second surgery after MUS.

BACKGROUND:

Surgical residents desire independent operating experience but recognize that attendings have a responsibility to keep cases as short as possible.

METHODS:

We analyzed video and interviews of attending surgeons related to more than 400 moments in which the resident was the primary operator. We examined these moments for themes related to timing and pace.

RESULTS:

Our surgeons encouraged the residents to speed up when patient safety could be jeopardized by the case moving too slowly. In contrast, they encouraged the residents to slow down when performing a crucial step or granting independence. Attending surgeons encouraged speed through economical language, by substituting physical actions for words, and through the use of Intelligent Cooperation. Conversely, they encouraged slowing down via just-in-time mini-lectures and by questioning the trainee.

CONCLUSIONS:

We present recommendations for safe teaching in the operating room while simultaneously maintaining overall surgical flow. Teaching residents to operate quickly can save time and is likely based on an automaticity in teaching. Slowing a resident down is vital for trainee skill development and patient safety.

Keywords: Pace; Patient safety; Qualitative research; Surgery; Surgical teaching; Videotape.