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

Abstract

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.

Surgical Sabermetrics

“…High CogL decreases SA by affecting attention, increasing reaction time, and negatively impacting recognition skills 24,103,104 . Measuring overall team CogL through individual team member measurements can show psychophysiological mirroring and dynamic CogL changes occurring during unexpected or expected, task-specific events and provide evidence of effective teamwork 7,24,64,105,106 . Social proximity is a predictor of behavior as it influences the opportunities available for effective teamwork and communication through nonverbal interactions and is suggestive of a shared mental model 33,37 .…”

“…24,103,104 Measuring overall team CogL through individual team member measurements can show psychophysiological mirroring and dynamic CogL changes occurring during unexpected or expected, task-specific events and provide evidence of effective teamwork. 7,24,64,105,106 Social proximity is a predictor of behavior as it influences the opportunities available for effective teamwork and communication through nonverbal interactions and is suggestive of a shared mental model. 33,37 Studies have shown that computer vision techniques and proximity sensors for movement analysis can demonstrate an association between movement and teams with "poor" and "good" SA in the OR.…”