Behavioral sciences applied to acute care teams: a research agenda for the years ahead by a European research network.

BACKGROUND: Multi-disciplinary behavioral research on acute care teams has focused on understanding how teams work and on identifying behaviors characteristic of efficient and effective team performance. We aimed to define important knowledge gaps and establish a research agenda for the years ahead of prioritized research questions in this field of applied health research. METHODS: In the first step, high-priority research questions were generated by a small highly specialized group of 29 experts in the field, recruited from the multinational and multidisciplinary "Behavioral Sciences applied to Acute care teams and Surgery (BSAS)" research network - a cross-European, interdisciplinary network of researchers from social sciences as well as from the medical field committed to understanding the role of behavioral sciences in the context of acute care teams. A consolidated list of 59 research questions was established. In the second step, 19 experts attending the 2020 BSAS annual conference quantitatively rated the importance of each research question based on four criteria - usefulness, answerability, effectiveness, and translation into practice. In the third step, during half a day of the BSAS conference, the same group of 19 experts discussed the prioritization of the research questions in three online focus group meetings and established recommendations. RESULTS: Research priorities identified were categorized into six topics: (1) interventions to improve team process; (2) dealing with and implementing new technologies; (3) understanding and measuring team processes; (4) organizational aspects impacting teamwork; (5) training and health professions education; and (6) organizational and patient safety culture in the healthcare domain. Experts rated the first three topics as particularly relevant in terms of research priorities; the focus groups identified specific research needs within each topic. CONCLUSIONS: Based on research priorities within the BSAS community and the broader field of applied health sciences identified through this work, we advocate for the prioritization for funding in these areas.

Alone Together: Is Strain Experienced Concurrently by Members of Operating Room Teams?: An Event-based Study.

Objective: To identify which strain episodes are concurrently reported by several team members; to identify triggers of strain experienced by operating room (OR) team members during the intraoperative phase. Summary: OR teams are confronted with many sources of strain. However, most studies investigate strain on a general, rather than an event-based level, which does not allow to determine if strain episodes are experienced concurrently by different team members. Methods: We conducted an event-based, observational study, at an academic medical center in North America and included 113 operations performed in 5 surgical departments (general, vascular, pediatric, gynecology, and trauma/acute care). Strain episodes were assessed with a guided-recall method. Immediately after operations, participants mentally recalled the operation, described the strain episodes experienced and their content. Results: Based on 731 guided recalls, 461 strain episodes were reported; these refer to 312 unique strain episodes. Overall, 75% of strain episodes were experienced by a single team member only. Among different categories of unique strain episodes, those triggered by task complexity, issues with material, or others' behaviors were typically experienced by 1 team member only. However, acute patient issues (n = 167) and observations of others' strain (n = 12) (respectively, 58.5%; P < 0.001 and 83.3%; P < 0.001) were often experienced by 2 or more team members. Conclusions and relevance: OR team members are likely to experience strain alone, unless patient safety is at stake. This may jeopardize the building of a shared understanding among OR team members.

No signs of check-list fatigue - introducing the StOP? intra-operative briefing enhances the quality of an established pre-operative briefing in a pre-post intervention study.

Background: The team timeout (TTO) is a safety checklist to be performed by the surgical team prior to incision. Exchange of critical information is, however, important not only before but also during an operation and members of surgical teams frequently feel insufficiently informed by the operating surgeon about the ongoing procedure. To improve the exchange of critical information during surgery, the StOP?-protocol was developed: At appropriate moments during the procedure, the leading surgeon briefly interrupts the operation and informs the team about the current Status (St) and next steps/objectives (O) of the operation, as well as possible Problems (P), and encourages questions of other team members (?). The StOP?-protocol draws attention to the team. Anticipating the occurrence of StOP?-protocols may support awareness of team processes and quality issues from the beginning and thus support other interventions such as the TTO; however, it also may signal an additional demand and contribute to a phenomenon akin to "checklist fatigue." We investigated if, and how, the introduction of the StOP?-protocol influenced TTO quality. Methods: This was a prospective intervention study employing a pre-post design. In the visceral surgical departments of two university hospitals and one urban hospital the quality of 356 timeouts (out of 371 included operation) was assessed by external observers before (154) and after (202) the introduction of the StOP?-briefing. Timeout quality was rated in terms of timeout completeness (number of checklist items mentioned) and timeout quality (engagement, pace, social atmosphere, noise). Results: As compared to the baseline, after the implementation of the StOP?-protocol, observed timeouts had higher completeness ratings (F = 8.69, p = 0.003) and were rated by observers as higher in engagement (F = 13.48, p < 0.001), less rushed (F = 14.85, p < 0.001), in a better social atmosphere (F = 5.83, p < 0.016) and less noisy (F = 5.35, p < 0.022). Conclusion: Aspects of TTO are affected by the anticipation of StOP?-protocols. However, rather than harming the timeout goals by inducing "checklist fatigue," it increases completeness and quality of the team timeout.

StOP? II trial: cluster randomized clinical trial to test the implementation of a toolbox for structured communication in the operating room-study protocol.

BACKGROUND: Surgical care, which is performed by intensely interacting multidisciplinary teams of surgeons, anesthetists, and nurses, remains associated with significant morbidity and mortality. Intraoperative communication has been shown to be associated with surgical outcomes, but tools ensuring efficient intraoperative communication are lacking. In a previous study, we developed the StOP?-protocol that fosters structured intraoperative communication. Before the critical phases of the operation, the responsible surgeon initiates and leads one or several StOP?s. During a StOP?, the surgeon informs about the progress of the operation (status), next steps and proximal goals (objectives), and possible problems (problems) and encourages all team members to voice their observations and ask questions (?). In a before-after study performed mainly in visceral surgery, we found effects of the StOP?-protocol on mortality, length of hospital stay, and reoperation. We intend to assess the impact of the StOP?-protocol in a cluster randomized trial, in a wider variety of surgical specialties (i.e., general, visceral, thoracic, vascular surgery, surgical urology, and gynecology). The primary hypothesis is that the consistent use of the StOP?-protocol by the main surgeon reduces patient mortality within 30 days after the operation. The secondary hypothesis is that the consistent use of the StOP?-protocol by the main surgeon reduces unplanned reoperations, length of hospital stay, and unplanned hospital readmissions. METHODS: This study is designed as a multicenter, cluster-randomized parallel-group trial. Board-certified surgeons of participating clinical departments will be randomized 1:1 to the StOP? intervention group or to the standard of care (control) group. The intervention group will undergo a training to use the StOP?-protocol and receive regular feedback on their compliance with the protocol. The surgeons in the control group will communicate as usual during their operations. The unit of observation will be operations performed by cluster surgeons. Consecutive patients will be enrolled over 4 months per cluster. A total of 400 surgeons will be recruited, and we expect to collect patient outcome data for 14,000 surgical procedures. DISCUSSION: The StOP?-protocol was designed as a tool to structure communication during surgical procedures. Testing its effects on patient outcomes will contribute to implementing evidenced-based interventions to reduce surgical complications. TRIAL REGISTRATION: ClinicalTrials.gov NCT05356962. Registered on May 2, 2022.

Association Between Operating Room Noise and Team Cognitive Workload in Cardiac Surgery.

Excessive intra-operative noise in cardiac surgery has the potential to serve as source of distraction and additional cognitive workload for the surgical team, and may interfere with optimal performance. The separation from bypass phase is a technically complex phase of surgery, making it highly susceptible to communication breakdowns due to high cognitive demands and requiring tightly coupled team coordination. The objective of this study was to investigate team cognitive workload levels and communication in relation to intra-operative time periods representative of infrequent vs. frequent peaks in ambient noise. Compared to 5-minute segments with no peaks in noise at all, segments with the highest percentage of noise peaks (≥10%) were significantly associated with higher team members' heart rate before, during, and after noise segments analyzed. These noisier segments were also associated with a significantly higher level of case-irrelevant communication events. These data suggest that case-irrelevant conversations associated with a greater degree of excessive peaks in noise may be associated with team workload levels, warranting further investigation into efforts to standardize communication during critical surgical phases.

Effects of structured intraoperative briefings on patient outcomes: multicentre before-and-after study.

BACKGROUND: Operations require collaboration between surgeons, anaesthetia professionals, and nurses. The aim of this study was to determine whether intraoperative briefings influence patient outcomes. METHODS: In a before-and-after controlled trial (9 months baseline; 9 months intervention), intraoperative briefings were introduced in four general surgery centres between 2015 and 2018. During the operation, the responsible surgeon (most senior surgeon present) briefed the surgical team using the StOP? protocol about: progress of the operation (Status), next steps (Objectives), possible problems (Problems), and encouraged asking questions (?). Differences between baseline and intervention were analysed regarding surgical-site infections (primary outcome), mortality, unplanned reoperations, and duration of hospital stay (secondary outcomes), using inverse probability of treatment (IPT) weighting based on propensity scores. RESULTS: In total, 8256 patients underwent surgery in the study. Endpoint data were available for 7745 patients (93.8 per cent). IPT-weighted and adjusted intention-to-treat analyses showed no differences in surgical-site infections between baseline and intervention (9.8 versus 9.6 per cent respectively; adjusted difference (AD) -0.15 (95 per cent c.i. -1.45 to 1.14) per cent; odds ratio (OR) 0.92, 95 per cent c.i. 0.83 to 1.15; P = 0.797), but there were reductions in mortality (1.6 versus 1.1 per cent; AD -0.54 (-1.04 to -0.03) per cent; OR 0.60, 0.39 to 0.92; P = 0.018), unplanned reoperations (6.4 versus 4.8 per cent; AD -1.66 (-2.69 to -0.62) per cent; OR 0.72, 0.59 to 0.89; P = 0.002), and fewer prolonged hospital stays (21.6 versus 19.8 per cent; AD -1.82 (-3.48 to -0.15) per cent; OR 0.87, 0.77 to 0.98; P = 0.024). CONCLUSION: Short intraoperative briefings improve patient outcomes and should be performed routinely.

Outcomes of surgery depend on patient characteristics and surgeon expertise, but also on teamwork, notably communication. The present study introduces the StOP? protocol, in which the surgeon informs the team about the current status (St), objectives regarding next steps (O), and potential problems (P), and encourages the team to ask questions and raise concerns (?). The results suggest an effect of the StOP? intervention on patient mortality, risk of unplanned reoperation, and duration of hospital stay, but not on surgical-site infections. The study is promising regarding the effect of structured intraoperative communication on important patient outcomes. The study compared patient outcomes at baseline and after implementation of the StOP? protocol, which enhances exchange of structured information within the interdisciplinary surgical team during the course of the operation. The intention-to-treat analyses in this multicentre before-and-after study of 8256 patients undergoing general surgery showed no differences between baseline and intervention for surgical-site infections, but revealed reduced mortality and unplanned reoperations, and fewer prolonged hospital stays during the intervention period.

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

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.

Predictors and triggers of incivility within healthcare teams: a systematic review of the literature.

OBJECTIVES: To explore predictors and triggers of incivility in medical teams, defined as behaviours that violate norms of respect but whose intent to harm is ambiguous. DESIGN: Systematic literature review of quantitative and qualitative empirical studies. DATA SOURCES: Database searches according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline in Medline, CINHAL, PsychInfo, Web of Science and Embase up to January 2020. ELIGIBILITY CRITERIA: Original empirical quantitative and qualitative studies focusing on predictors and triggers of incivilities in hospital healthcare teams, excluding psychiatric care. DATA EXTRACTION AND SYNTHESIS: Of the 1397 publications screened, 53 were included (44 quantitative and 9 qualitative studies); publication date ranged from 2002 to January 2020. RESULTS: Based on the Medical Education Research Study Quality Instrument (MERSQI) scores, the quality of the quantitative studies were relatively low overall (mean MERSQI score of 9.93), but quality of studies increased with publication year (r=0.52; p<0.001). Initiators of incivility were consistently described as having a difficult personality, yet few studies investigated their other characteristics and motivations. Results were mostly inconsistent regarding individual characteristics of targets of incivilities (eg, age, gender, ethnicity), but less experienced healthcare professionals were more exposed to incivility. In most studies, participants reported experiencing incivilities mainly within their own professional discipline (eg, nurse to nurse) rather than across disciplines (eg, physician to nurse). Evidence of specific medical specialties particularly affected by incivility was poor, with surgery as one of the most cited uncivil specialties. Finally, situational and cultural predictors of higher incivility levels included high workload, communication or coordination issues, patient safety concerns, lack of support and poor leadership. CONCLUSIONS: Although a wide range of predictors and triggers of incivilities are reported in the literature, identifying characteristics of initiators and the targets of incivilities yielded inconsistent results. The use of diverse and high-quality methods is needed to explore the dynamic nature of situational and cultural triggers of incivility.

"Disruptive behavior" in the operating room: A prospective observational study of triggers and effects of tense communication episodes in surgical teams.

BACKGROUND: Tense communication and disruptive behaviors during surgery have often been attributed to surgeons' personality or hierarchies, while situational triggers for tense communication were neglected. Goals of this study were to assess situational triggers of tense communication in the operating room and to assess its impact on collaboration quality within the surgical team. METHODS AND FINDINGS: The prospective observational study was performed in two university hospitals in Europe. Trained external observers assessed communication in 137 elective abdominal operations led by 30 different main surgeons. Objective observations were related to perceived collaboration quality by all members of the surgical team. A total of 340 tense communication episodes were observed (= 0.57 per hour); mean tensions in surgeries with tensions was 1.21 per hour. Individual surgeons accounted for 24% of the variation in tensions, while situational aspects accounted for 76% of variation. A total of 72% of tensions were triggered by coordination problems; 21.2% by task-related problems and 9.1% by other issues. More tensions were related to lower perceived teamwork quality for all team members except main surgeons. Coordination-triggered tensions significantly lowered teamwork quality for second surgeons, scrub technicians and circulators. CONCLUSIONS: Although individual surgeons differ in their tense communication, situational aspects during the operation had a much more important influence on the occurrence of tensions, mostly triggered by coordination problems. Because tensions negatively impact team collaboration, surgical teams may profit from improving collaboration, for instance through training, or through reflexivity.

Comparison of Surveillance of Surgical Site Infections by a National Surveillance Program and by Institutional Audit.

BACKGROUND: Reported incidence of surgical site infections (SSI) after colonic surgery varies widely. These variations depend not only on patient- and surgery-related parameters but are influenced by type and quality of follow-up. The aim of the study was to compare SSI assessed by two independent prospective surveillance systems, a national surveillance program based on recommendations of the National Healthcare Safety Network (Swissnoso) versus an international audit system, the ERAS® Interactive Audit System (EIAS; Encare, Stockholm, Sweden). METHODS: Comparative study of a consecutive cohort of colonic resections at a single institution from September 2015 to March 2017. Independent prospective SSI monitoring was available from Swissnoso and EIAS. Inter-observer reliability was calculated using Cohen k. Sensitivity, specificity, and accuracy of EIAS in assessing SSI was compared with Swissnoso, considered as gold standard. RESULTS: The final sample included 143 patients. Of these, 136 (95.1%) were classified into the same category by both systems, identifying 17 patients (12.5%) with SSI and 119 patients (87.5%) without SSI, respectively. Discrepant results were found for the remaining seven patients (4.9%) with four SSI categorization according to Swissnoso but not EIAS, and three SSI categorization in EIAS but not in Swissnoso; all miscategorized patients presented superficial SSI. Sensitivity, specificity, and accuracy of EIAS for SSI recording was 81%, 97.5%, and 95.1%, respectively. Inter-observer agreement was high (Cohen k value of 0.801, p < 0.001). Case-by-case analysis of discrepant findings revealed mainly discrepant interpretation of clinical symptoms and erroneous labeling of non-procedure-related infections. CONCLUSIONS: Surgical site infection recording by two independent systems showed high concordance and good inter-rater reliability.

Assessing Perceptions of Teamwork Quality Among Perioperative Team Members.

Successful surgery depends on collaboration and mutual trust among interdisciplinary team members. We compared teamwork quality as perceived by surgeons, anesthesia care providers, and perioperative nurses using two surveys in the same hospital. The general survey sent to the homes of the OR personnel revealed teamwork climate scores in the medium to high range. Attending surgeons were significantly more satisfied than perioperative nurses and resident surgeons; anesthesiologists were significantly more satisfied than perioperative nurses. A second single-item survey administered immediately after elective open abdominal surgical procedures also showed relatively high satisfaction with teamwork. Results of the second survey, however, showed that attending surgeons were significantly less satisfied than the members of all the other professions, and perioperative nurses were significantly more satisfied than the members of all the other professions. We conclude that general surveys about teamwork quality among members of surgical teams may not necessarily reflect teamwork quality during actual surgical procedures.

Noise in the Operating Room Distracts Members of the Surgical Team. An Observational Study.

BACKGROUND: Noise pollution in operation rooms may distract the surgical team members. In particular during phases of high task complexity, noise can jeopardize concentration. Phases of high complexity are related to task specificities and may thus be different for different members of the surgical team. STUDY DESIGN: Noise exposure was measured during 110 open abdominal surgeries. Distinguishing three phases (opening, main phase, and closing), noise was related to self-report of distraction levels by main and secondary surgeons, scrub nurses and anesthetists. RESULTS: Noise pollution was higher than recommended levels for concentrated work. Adjusted for duration, surgical type, and difficulty of the surgery, results showed that second surgeons are more likely distracted when noise pollution was high in the main phase; and anesthetists are more likely distracted when noise pollution was high during the closing phase. Main surgeons' and scrub nurses' concentration was not impaired by measured noise levels. CONCLUSIONS: In phases with higher concentration demands, noise pollution was particularly distracting for second surgeons and anesthetist, corresponding to their specific task demands (anesthetists) and experience (second surgeons). Reducing noise levels particularly in the main and closing phase of the surgery may reduce concentration impairments.

More Than Talking About the Weekend: Content of Case-Irrelevant Communication Within the OR Team.

BACKGROUND: Case-irrelevant communication (CIC) is defined as "any conversation" irrelevant to the case. It includes small talk, but also communication related to other work issues besides the actual task. CIC during surgeries is generally seen as distracting, despite a lack of knowledge about the content of CIC and its regulation in terms of adjustments to the situation of CIC. Primary goal of the study was to evaluate CIC content; secondary goal was to evaluate whether surgical teams regulate CIC according to different concentration demands of surgical procedures. METHODS: In 125 surgeries, 1396 CIC events were observed. CIC were content coded into work-related CIC (pertaining to other tasks or work in general) and social CIC (pertaining to acquaintance talk, gossip, or private conversation). The impact of different phases and the difficulty of the surgical procedure on CIC were assessed. RESULTS: Work-related CIC were significantly more frequent (2.49 per hour, SD = 2.17) than social CIC (1.42 per hour, SD = 2.17). Across phases, frequency of work-related CIC was constant, whereas social CIC increased significantly across phases. In surgeries assessed as highly difficult by the surgeons, social CIC were observed at a lower frequency, and less work-related CIC were observed during the main phase compared to surgeries assessed as less difficult. CONCLUSION: The high proportion of work-related CIC indicates that surgical teams deal with other tasks during surgeries. Surgical teams adapt CIC according to the demands of the procedure. Hospital policies should support these adaptations rather than attempt to suppress CIC entirely.

Noise peaks influence communication in the operating room. An observational study.

Noise peaks are powerful distractors. This study focuses on the impact of noise peaks on surgical teams' communication during 109 long abdominal surgeries. We related measured noise peaks during 5-min intervals to the amount of observed communication during the same interval. Results show that noise peaks are associated with less case-relevant communication; this effect is moderated by the level of surgical experience; case-relevant communications decrease under high noise peak conditions among junior, but not among senior surgeons. However, case-irrelevant communication did not decrease under high noise level conditions, rather there was a trend to more case-irrelevant communication under high noise peaks. The results support the hypothesis that noise peaks impair communication because they draw on attentional resources rather than impairing understanding of communication. As case-relevant communication is important for surgical performance, exposure to high noise peaks in the OR should be minimised especially for less experienced surgeons. Practitioner Summary: This study investigated whether noise during surgeries influenced the communication within surgical teams. During abdominal surgeries, noise levels were measured and communication was observed. Results showed that high noise peaks reduced the frequency of patient-related communication, but did not reduce patient-irrelevant communication. Noise may negatively affect team coordination in surgeries.

Stem cell mobilization chemotherapy with gemcitabine is effective and safe in myeloma patients with bortezomib-induced neurotoxicity.

Vinorelbine chemotherapy with granulocyte-colony stimulating factor (G-CSF) stimulation is a widely applied non-myelosuppressive mobilization regimen in Switzerland for myeloma patients, but its neurotoxic potential limits its use in patients with bortezomib-induced polyneuropathy. In this single-center study, we alternatively evaluated safety and effectiveness of gemcitabine chemotherapy with G-CSF for mobilization of autologous stem cells. Between March 2012 and February 2013, all bortezomib-pretreated myeloma patients planned to undergo first-line high-dose melphalan chemotherapy received a single dose of 1250 mg/m2 gemcitabine, with G-CSF started on day 4. The 24 patients in this study had received a median of four cycles of bortezomib-dexamethason-based induction. Bortezomib-related polyneuropathy was identified in 21 patients (88%) by clinical evaluation and a standardized questionnaire. Administration of gemcitabine mobilization did not induce new or aggravate pre-existing neuropathy. Stem cell mobilization was successful in all 24 patients, with a single day of apheresis being sufficient in 19 patients (78%). The median yield was 9.51×10(6) CD34+ cells/kg. Stem collection could be accomplished at day 8 in 67%. Our data suggest that single-dose gemcitabine together with G-CSF is an effective mobilization regimen in myeloma patients and a safe alternative non-myelosuppressive mobilization chemotherapy for myeloma patients with bortezomib-induced polyneuropathy.

Neurotoxicity of stem cell mobilization chemotherapy with vinorelbine in myeloma patients after bortezomib treatment.

Vinorelbine chemotherapy with G-CSF stimulation is the standard mobilization regimen in Switzerland for multiple myeloma patients. However, with the increasing use of bortezomib during induction treatment, adding the neurotoxic compound vinorelbine for mobilization may aggravate bortezomib-induced polyneuropathy. In this retrospective single-center study, we aimed to explore vinorelbine mediated neuropathy in 106 consecutive bortezomib pretreated myeloma patients. We confirmed that vinorelbine with G-CSF represents a reliable and effective regimen for mobilization of autologous stem cells. However, the single administration of 35 mg/m(2) vinorelbine added significant neurotoxicity. We found that 24 patients (24%) reported vinorelbine mediated neurotoxicity: Aggravation of bortezomib-induced neuropathy was observed in 17 patients (17%), and vinorelbine mobilization induced first occurrence of polyneuropathy in additional 7 patients (7%). We observed that development of polyneuropathy was not associated with differing survival rates. Finally, affected patients reported polyneuropathy associated disease burden as "very high" in 13% and "high" in 50%. Our data indicate that a single administration of vinorelbine to mobilize autologous stem cells is associated with significant additional polyneuropathy in bortezomib pretreated myeloma patients. The efficacy of vinorelbine mobilization should be balanced against its neurotoxic potential.

Assessing distractors and teamwork during surgery: developing an event-based method for direct observation.

OBJECTIVE: To develop a behavioural observation method to simultaneously assess distractors and communication/teamwork during surgical procedures through direct, on-site observations; to establish the reliability of the method for long (>3 h) procedures. METHODS: Observational categories for an event-based coding system were developed based on expert interviews, observations and a literature review. Using Cohen's κ and the intraclass correlation coefficient, interobserver agreement was assessed for 29 procedures. Agreement was calculated for the entire surgery, and for the 1st hour. In addition, interobserver agreement was assessed between two tired observers and between a tired and a non-tired observer after 3 h of surgery. RESULTS: The observational system has five codes for distractors (door openings, noise distractors, technical distractors, side conversations and interruptions), eight codes for communication/teamwork (case-relevant communication, teaching, leadership, problem solving, case-irrelevant communication, laughter, tension and communication with external visitors) and five contextual codes (incision, last stitch, personnel changes in the sterile team, location changes around the table and incidents). Based on 5-min intervals, Cohen's κ was good to excellent for distractors (0.74-0.98) and for communication/teamwork (0.70-1). Based on frequency counts, intraclass correlation coefficient was excellent for distractors (0.86-0.99) and good to excellent for communication/teamwork (0.45-0.99). After 3 h of surgery, Cohen's κ was 0.78-0.93 for distractors, and 0.79-1 for communication/teamwork. DISCUSSION: The observational method developed allows a single observer to simultaneously assess distractors and communication/teamwork. Even for long procedures, high interobserver agreement can be achieved. Data collected with this method allow for investigating separate or combined effects of distractions and communication/teamwork on surgical performance and patient outcomes.

Flunarizine in prevention of headache, ataxia, and memory deficits during decompression to 4559 m.

Our purpose was to study the preventive effect of the calcium channel blocker flunarizine on headache, postural ataxia, and memory deficits occurring during decompression to high altitude in a randomized, placebo-controlled, double-blind study. After 7-day pretreatment with the study drugs, 20 healthy men were investigated at 490 m and 0.5, 2, 4, and 6 h later at a simulated altitude of 4559 m. Headache severity was evaluated on a 4-point scale. Sway path and anteroposterior and lateral sway were recorded with open and closed eyes by static posturography. Short- and long-term memory was studied by testing the recall of verbal and figural material immediately and 2 h after presentation, respectively. Blood pressure (BP) and arterial oxygen saturation (Sa(O2)) were also assessed. Headache scores showed a trend to be lower in the flunarizine group that was significant after 4 and 6 h. Headache scores expressed as difference from baseline values showed a nonsignificant trend to be lower at 4 and 6 h in subjects treated with flunarizine. Postural stance, memory, BP, and Sa(O2) were similar in both treatment groups. Although the low number of investigated subjects may have prevented the detection of a significant therapeutic effect of flunarizine, the present data do not show that flunarizine is effective for prevention of headache, postural ataxia, and neurocognitive deficits occurring at simulated high altitude.