Intraoperative dynamics of workflow disruptions and surgeons' technical performance failures: insights from a simulated operating room

Introduction Flow disruptions (FD) in the operating room (OR) have been found to adversely affect the levels of stress and cognitive workload of the surgical team. It has been concluded that frequent disruptions also lead to impaired technical performance and subsequently pose a risk to patient safety. However, respective studies are scarce. We therefore aimed to determine if surgical performance failures increase after disruptive events during a complete surgical intervention. Methods We set up a mixed-reality-based OR simulation study within a full-team scenario. Eleven orthopaedic surgeons performed a vertebroplasty procedure from incision to closure. Simulations were audio- and videotaped and key surgical instrument movements were automatically tracked to determine performance failures, i.e. injury of critical tissue. Flow disruptions were identified through retrospective video observation and evaluated according to duration, severity, source, and initiation. We applied a multilevel binary logistic regression model to determine the relationship between FDs and technical performance failures. For this purpose, we compared FDs in one-minute intervals before performance failures with intervals without subsequent performance failures. Results Average simulation duration was 30:02 min (SD = 10:48 min). In 11 simulated cases, 114 flow disruption events were observed with a mean hourly rate of 20.4 (SD = 5.6) and substantial variation across FD sources. Overall, 53 performance failures were recorded. We observed no relationship between FDs and likelihood of immediate performance failures: Adjusted odds ratio = 1.03 (95% CI 0.46–2.30). Likewise, no evidence could be found for different source types of FDs. Conclusion Our study advances previous methodological approaches through the utilisation of a mixed-reality simulation environment, automated surgical performance assessments, and expert-rated observations of FD events. Our data do not support the common assumption that FDs adversely affect technical performance. Yet, future studies should focus on the determining factors, mechanisms, and dynamics underlying our findings.

THE PANDEMIC AND THE ECONOMIC CONUNDRUM: HOW ISLAMIC FINANCE CAN HELP

This paper examines the economic and financial impact of the COVID-19 pandemic and the responses that governments undertook. Though large and unprecedented in size, policy response has mostly been the same. Huge monetary stimulus, rate cuts, direct market intervention like bond purchases and debt moratoriums. Many of these were techniques used in the previous global financial of 2007–2009. Economies were already fragile and in a vulnerable state when the pandemic struck in late 2019. Continued use of the same policies did prevent a potential meltdown but has increased system vulnerability. The global debt burden is now much larger but governments may have fully expended all their monetary ammunition. Fiscal stimulus though much needed and more appropriate is seriously constrained by budget deficits and lack of fiscal space. Adding more debt to fund fiscal expansion is not really an option. Yet, the pandemic has made vulnerable, several parts of the economy that need to be salvaged. The SME sector which forms the spine of most developing economies is verging on collapse due to cash flow disruptions arising from lockdowns. The domestic banking sector which had funded these SMEs is exposed to a potential meltdown unless restructuring is done. The loan moratoriums widely adapted do not solve but merely postpone the problem. Governments, given their precarious fiscal position are in no position to provide the huge financial infusion needed to shore up the SMEs and banks. Islamic finance, which has risk-sharing alternatives can provide a way out of this conundrum. The paper proposes a shariah compliant risk sharing alternative to resolve this problem.

Impact of Surgical Table Orientation on Flow Disruptions and Movement Patterns during Pediatric Outpatient Surgeries

(1) Background: The surgical table within a typical ambulatory surgery operating room is frequently rotated and placed in different orientations to facilitate surgery or in response to surgeon preferences. However, different surgical table orientations can impact access to different work zones, areas and equipment in the OR, potentially impacting workflow of surgical team members and creating patient safety risks; (2) Methods: This quantitative observational study used a convenience sample of 38 video recordings of the intraoperative phase of pediatric outpatient surgeries to study the impacts of surgical table orientation on flow disruptions (FDs), number of contacts between team members and distance traveled; (3) Results: This study found that the orientation of the surgical table significantly influenced staff workflow and movement in the OR with an angled surgical table orientation being least disruptive to surgical work. The anesthesia provider, scrub nurse and circulating nurse experienced more FDs compared to the surgeon; (4) Conclusions: The orientation of the surgical table matters, and clinicians and architects must consider different design and operational strategies to support optimal table orientation in the OR.

A Smartphone Application for Teamwork and Communication in Trauma: Pilot Evaluation “in the Wild”

Objective To evaluate the potential for a smartphone application to improve trauma care through shared and timely access to patient and contextual information. Background Disruptions along the trauma pathway that arise from communication, coordination, and handoffs problems can delay progress through initial care, imaging diagnosis, and surgery to intensive care unit (ICU) disposition. Implementing carefully designed and evaluated information distribution and communication technologies may afford opportunities to improve clinical performance. Methods This was a pilot evaluation “in the wild” using a before/after design, 3 month, and pre- post-intervention data collection. Use statistics, usability assessment, and direct observation of trauma care were used to evaluate the app. Ease of use and utility were assessed using the technology acceptance model (TAM) and system usability scale (SUS). Direct observation deployed measures of flow disruptions (defined as “deviations from the natural progression of an procedure”), teamwork scores (T-NOTECHS), and treatment times (total time in emergency department [ED]). Results The app was used in 367 (87%) traumas during the trial period. Usability was generally acceptable, with higher scores found by operating room (OR), ICU, and neuro and orthopedic users. Despite positive trends, no significant effects on flow disruptions, teamwork scores, or treatment times were observed. Conclusions Pilot trials of a clinician-centered smartphone app to improve teamwork and communication demonstrate potential value for the safety and efficiency of trauma care delivery as well as benefits and challenges of “in-the-wild” evaluation.

Prevalence of Surgical Flow Disruptions Across Intra-operative High- and Low-Workload Phases in Cardiac Surgery

While the influence of surgical flow disruptions (SFDs) on surgical performance has been observed in live cardiovascular surgery and their influence on cognitive workload has been evaluated in high-fidelity simulations, the relationship between SFDs and cognitive workload of surgical providers in the live cardiac surgery operating room has yet to be explored. Recent evidence suggests that preventable surgical errors often have a cognitive basis, warranting investigation into the association between SFDs and workload. This study aimed to characterize SFDs according to auditory and cognitive domains and further to compare the frequency and nature of SFDs within periods of high team cognitive workload and low team cognitive workload. Overall, the presence of cognitive distractions was associated more with high team cognitive workload states, while the frequency of auditory distractions was significantly higher during periods of low team cognitive workload states. Future work should consider the types, frequency, and sources of SFDs as well as their impact on surgical procedures and outcomes in order to devise appropriate methods to mitigate or manage potential disruptions to surgical workflow.