First Reported Use of Team Cognitive Workload for Root Cause Analysis in Cardiac Surgery

Zenati, Marco A.; Leissner, Kay B.; Zorca, Suzana; Kennedy-Metz, Lauren R.; Yule, Steven; Dias, Roger D.

doi:10.1053/j.semtcvs.2018.12.003

Cited by 26 publications

(17 citation statements)

References 11 publications

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“…New technological developments allow to measure strain in terms of physiological changes over time, in particular in relation to the stress experienced by the OR teams (e.g. heart rate variability) [1,9]. Although, these new technologies are not likely to replace data collected based on subjective experiences of OR team members, they may measure complementary facets of strain [27].…”

Section: Guided Reports To Measure Strainmentioning

confidence: 99%

“…For OR team members, strain can emerge from multiple sources, including task, collaboration, technology, ambiguity and patient care related time pressure [7,8]. It is crucial to identify phases of high strain in the OR because strain through high workload or stress was found to decrease surgical technical performance, non technical skills and to impair anesthesiologists' perceptions of relevant information [9][10][11][12] Because strain is influenced by tasks and interactions in OR teams, strain is not constant during surgery. Phases of high strain may be followed by routine, low strain phases.…”

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confidence: 99%

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Episodes of strain experienced in the operating room: impact of the type of surgery, the profession and the phase of the operation

et al. 2020

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Background Strain episodes, defined as phases of higher workload, stress or negative emotions, occur everyday in the operating room (OR). Accurate knowledge of when strain is most intense for the different OR team members is imperative for developing appropriate interventions. The primary goal of the study was to investigate temporal patterns of strain across surgical phases for different professionals working in the OR, for different types of operations. Methods We developed a guided recall method to assess the experience of strain from the perspective of operating room (OR) team members. The guided recall was completed by surgeons, residents, anesthesiologists, circulating nurses and scrub technicians immediately after 113 operations, performed in 5 departments of one hospital in North America. We also conducted interviews with 16 surgeons on strain moments during their specific operation types. Strain experiences were related to surgical phases and compared across different operation types separately for each profession in the OR. Results We analyzed 693 guided recalls. General linear modeling (GLM) showed that strain varied across the phases of the operations (defined as before incision, first third, middle third and last third) [quadratic (F = 47.85, p < 0.001) and cubic (F = 8.94, p = 0.003) effects]. Phases of operations varied across professional groups [linear (F = 4.14, p = 0.001) and quadratic (F = 14.28, p < 0.001) effects] and surgery types [only cubic effects (F = 4.92, p = 0.001)]. Overall strain was similar across surgery types (F = 1.27, p = 0.28). Surgeons reported generally more strain episodes during the first and second third of the operations; except in vascular operations, where no phase was associated with significantly higher strain levels, and emergency/trauma surgery, where strain episodes occurred primarily during the first third of the operation. Other professional groups showed different strain time patterns. Conclusions Members of the OR teams experience strain differently across the phases of an operation. Thus, phases with high concentration requirements may highly vary across OR team members and no single phase of an operation can be defined as a “sterile cockpit” phase for all team members.

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Section: Guided Reports To Measure Strainmentioning

confidence: 99%

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confidence: 99%

Episodes of strain experienced in the operating room: impact of the type of surgery, the profession and the phase of the operation

et al. 2020

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“…MWL is important in the context of surgery due to growing evidence of the influence of cognition and cognitive errors on surgical performance [ 12 , 13 ], and can be accurately and reliably measured via objective means. Heart rate variability (HRV) is the most extensively utilized measure of workload during surgery [ 14 ], and evidence supports its accuracy in reflecting mental workload and procedure workload levels in complex systems [ 15 , 16 ], including surgery [ 17 ].…”

Section: Introductionmentioning

confidence: 99%

“…The aim of this study is to investigate the relationship between providers’ MWL and surgical phases within aortic valve replacement (AVR) and coronary artery bypass graft (CABG) surgeries at a tertiary academic hospital, with special interest in the pre-incision time-out phase. Given recent evidence suggesting that mirrored changes in team workload reflect the presence of shared team-wide mental models [ 17 , 18 ], we hypothesized that providers’ MWL would reveal mirrored team workload states across individuals during a formal, well-executed pre-incision time-out.…”

Section: Introductionmentioning

confidence: 99%

The Cognitive Relevance of a Formal Pre-incision Time-out in Surgery

Kennedy-Metz

Dias

Zenati

2021

European Conference on Cognitive Ergonomics 2021

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Surgical time-outs are designed to promote situation awareness, teamwork, and error prevention. The pre-incision time-out in particular aims to facilitate shared mental models prior to incision. Objective, unbiased measures to confirm its effectiveness are lacking. We hypothesized that providers’ mental workload would reveal team psychophysiological mirroring during a formal, well-executed pre-incision time-out. Heart rate variability was collected during cardiac surgery cases from the surgeon, anesthesiologist, and perfusionist. Data were analyzed for six cases from patient arrival until sternal closure. Annotation of surgical phases was completed according to previously developed standardized process models of aortic valve replacement and coronary artery bypass graft procedures, producing thirteen total surgical phases. Statistical analysis revealed significant main effects. Tukey HSD post hoc tests revealed significant differences across provider roles within various phases, including Anesthesia Induction, Heparinization, Initiation of Bypass, Aortic Clamp and Cardioplegia, Anastomoses or Aortotomy, Separation from Bypass, and Sternal Closure. Despite these observed differences between providers over various surgical phases, the Pre-incision Time-out phase revealed almost negligible differences across roles. This preliminary work supports the utility of the pre-incision safety checklist to focus the attention of surgical team members and promote shared team mental models, measured via psychophysiological mirroring, using an objective mental workload measure. Future studies should investigate the relationship between psychophysiological mirroring among surgical team members and the effectiveness of the pre-incision time-out checklist.

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“…Our Medical Robotics and Computer Assisted Surgery (MRCAS) Lab team has previously described the use of HRV to monitor cognitive workload of surgical team members in a real-world setting [ 15 , 16 , 17 ], while other groups have used functional NIRS (fNIRS) in conjunction with HR during experimental surgical tasks [ 18 , 19 ]. The pilot study reported here is novel in the use for the first time of both HRV and NIRS to simultaneously monitor providers’ cognitive workload during real-world complex surgery.…”

Section: Introductionmentioning

confidence: 99%

Sensors for Continuous Monitoring of Surgeon’s Cognitive Workload in the Cardiac Operating Room

Kennedy-Metz

Dias

Srey

et al. 2020

Sensors

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Monitoring healthcare providers’ cognitive workload during surgical procedures can provide insight into the dynamic changes of mental states that may affect patient clinical outcomes. The role of cognitive factors influencing both technical and non-technical skill are increasingly being recognized, especially as the opportunities to unobtrusively collect accurate and sensitive data are improving. Applying sensors to capture these data in a complex real-world setting such as the cardiac surgery operating room, however, is accompanied by myriad social, physical, and procedural constraints. The goal of this study was to investigate the feasibility of overcoming logistical barriers in order to effectively collect multi-modal psychophysiological inputs via heart rate (HR) and near-infrared spectroscopy (NIRS) acquisition in the real-world setting of the operating room. The surgeon was outfitted with HR and NIRS sensors during aortic valve surgery, and validation analysis was performed to detect the influence of intra-operative events on cardiovascular and prefrontal cortex changes. Signals collected were significantly correlated and noted intra-operative events and subjective self-reports coincided with observable correlations among cardiovascular and cerebral activity across surgical phases. The primary novelty and contribution of this work is in demonstrating the feasibility of collecting continuous sensor data from a surgical team member in a real-world setting.

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First Reported Use of Team Cognitive Workload for Root Cause Analysis in Cardiac Surgery

Cited by 26 publications

References 11 publications

Episodes of strain experienced in the operating room: impact of the type of surgery, the profession and the phase of the operation

Episodes of strain experienced in the operating room: impact of the type of surgery, the profession and the phase of the operation

The Cognitive Relevance of a Formal Pre-incision Time-out in Surgery

Sensors for Continuous Monitoring of Surgeon’s Cognitive Workload in the Cardiac Operating Room

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