Crew Resource Management Training for Surgical Teams, A Fragmented Landscape.

OBJECTIVE: Medical Crew Resource Management (CRM) training courses are designed to increase patient safety by reducing the effects of human errors. These training courses are most popular in surgery and a wide range of medical CRM training courses for surgical teams is now available. However, the effects of these CRM training courses on patient outcomes are inconclusive. Although surgical teams feel the need to be trained in team collaboration skills, they are often puzzled about what criteria to apply when choosing a medical CRM training course. This study aimed to compare CRM training courses on didactic components and simulation-exercises to explore if these courses are interchangeable. METHODS: In this qualitative study, semi-structured interviews were conducted among 10 main CRM training providers of surgical teams in the Netherlands. RESULTS: Although a large variety was found in the content of CRM training courses, the most substantial differences were found in the simulation-exercises. Nine out of 10 trainers stated that standard simulation-exercises would be a step forward to ensure quality in CRM trainings. According to the trainers, the implementation of medical CRM can reduce human errors and as a result, preventable patient complications. They suggested a quality standard for CRM trainers in the medical field to ensure the quality of medical team training as a way to reach this. CONCLUSIONS: Medical CRM training courses are diverse and noninterchangeable. Trainers expect that if CRM becomes part of surgical training and is embedded in operating theatre culture, it could be of great value for patients and professionals.

Availability, procurement, training, usage, maintenance and complications of electrosurgical units and laparoscopic equipment in 12 African countries.

BACKGROUND: Strategies are needed to increase the availability of surgical equipment in low- and middle-income countries (LMICs). This study was undertaken to explore the current availability, procurement, training, usage, maintenance and complications encountered during use of electrosurgical units (ESUs) and laparoscopic equipment. METHODS: A survey was conducted among surgeons attending the annual meeting of the College of Surgeons of East, Central and Southern Africa (COSECSA) in December 2017 and the annual meeting of the Surgical Society of Kenya (SSK) in March 2018. Biomedical equipment technicians (BMETs) were surveyed and maintenance records collected in Kenya between February and March 2018. RESULTS: Among 80 participants, there were 59 surgeons from 12 African countries and 21 BMETs from Kenya. Thirty-six maintenance records were collected. ESUs were available for all COSECSA and SSK surgeons, but only 49 per cent (29 of 59) had access to working laparoscopic equipment. Reuse of disposable ESU accessories and difficulties obtaining carbon dioxide were identified. More than three-quarters of surgeons (79 per cent) indicated that maintenance of ESUs was available, but only 59 per cent (16 of 27) confirmed maintenance of laparoscopic equipment at their centre. CONCLUSION: Despite the availability of surgical equipment, significant gaps in access to maintenance were apparent in these LMICs, limiting implementation of open and laparoscopic surgery.

ANTECEDENTES: En países de bajos y medianos ingresos (low- and middle-income countries, LMIC) hay que desarrollar estrategias de futuro para incrementar la disponibilidad de equipos quirúrgicos, adquisición, capacitación, uso, mantenimiento y complicaciones relacionadas con las unidades electroquirúrgicas (electrosurgical unit, ESU) y los equipos de laparoscopia. MÉTODOS: Se realizó una encuesta entre los cirujanos que asistieron a la reunión anual del Colegio de Cirujanos de África Oriental, Central y Meridional (College Of Surgeons of East, Central and Southern Africa, COSECSA) en diciembre de 2017 y a la reunión anual de la Sociedad Quirúrgica de Kenia (Surgical Society of Kenya, SSK) en marzo de 2018. Se encuestaron también a los técnicos de equipos biomédicos (Biomedical Equipment Technicians, BMET) y se recopilaron los registros de mantenimiento en Kenia entre febrero y marzo de 2018. RESULTADOS: Participaron 80 sujetos, 59 cirujanos de 11 países africanos y 21 BMET de Kenia. Se recopilaron 36 registros de mantenimiento. Todos los cirujanos de COSECSA y SSK disponían de ESU, pero menos de la mitad (49%) disponían de equipos de laparoscopia. Como principales problemas se detectaron la reutilización de accesorios desechables en las ESU y las dificultades para disponer de CO2. Más de las tres cuartas partes (78%) de los cirujanos contaban con equipos de mantenimiento para las ESU, pero solo el 59% disponía de mantenimiento para los equipos de laparoscopia en su centro. CONCLUSIÓN: A pesar de la disponibilidad de equipos quirúrgicos, en estos LMIC se detectaron serias dificultades en su mantenimiento, hecho que limita la implementación de la cirugía abierta y laparoscópica.

'It is Time to Prepare the Next patient' Real-Time Prediction of Procedure Duration in Laparoscopic Cholecystectomies.

Operating Room (OR) scheduling is crucial to allow efficient use of ORs. Currently, the predicted durations of surgical procedures are unreliable and the OR schedulers have to follow the progress of the procedures in order to update the daily planning accordingly. The OR schedulers often acquire the needed information through verbal communication with the OR staff, which causes undesired interruptions of the surgical process. The aim of this study was to develop a system that predicts in real-time the remaining procedure duration and to test this prediction system for reliability and usability in an OR. The prediction system was based on the activation pattern of one single piece of equipment, the electrosurgical device. The prediction system was tested during 21 laparoscopic cholecystectomies, in which the activation of the electrosurgical device was recorded and processed in real-time using pattern recognition methods. The remaining surgical procedure duration was estimated and the optimal timing to prepare the next patient for surgery was communicated to the OR staff. The mean absolute error was smaller for the prediction system (14 min) than for the OR staff (19 min). The OR staff doubted whether the prediction system could take all relevant factors into account but were positive about its potential to shorten waiting times for patients. The prediction system is a promising tool to automatically and objectively predict the remaining procedure duration, and thereby achieve optimal OR scheduling and streamline the patient flow from the nursing department to the OR.

Safety challenges of medical equipment in nurse anaesthetist training in Haiti.

Safety challenges related to the use of medical equipment were investigated during the training of nurse anaesthetists in Haiti, using a systems approach to Human Factors and Ergonomics (HFE). The Observable Performance Obstacles tool, based on the Systems Engineering Initiative for Patient Safety (SEIPS) model, was used in combination with exploratory observations during 13 surgical procedures, to identify performance obstacles created by the systemic interrelationships of medical equipment. The identification of performance obstacles is an effective way to study the accumulation of latent factors and risk hazards, and understand its implications in practice and behaviour of healthcare practitioners. In total, 123 performance obstacles were identified, of which the majority was related to environmental and organizational aspects. These findings show how the performance of nurse anaesthetists and their relation to medical equipment is continuously affected by more than user-related aspects. The contribution of systemic performance obstacles and coping strategies to enrich system design interventions and improve healthcare system is highlighted. In addition, methodological challenges of HFE research in low-resource settings related to professional culture and habits, and the potential of community ergonomics as a problem-managing approach are described.

A RFID specific participatory design approach to support design and implementation of real-time location systems in the operating room.

Information technology, such as real-time location (RTL) systems using Radio Frequency IDentification (RFID) may contribute to overcome patient safety issues and high costs in healthcare. The aim of this work is to study if a RFID specific Participatory Design (PD) approach supports the design and the implementation of RTL systems in the Operating Room (OR). A RFID specific PD approach was used to design and implement two RFID based modules. The Device Module monitors the safety status of OR devices and the Patient Module tracks the patients' locations during their hospital stay. The PD principles 'multidisciplinary team', 'participation users (active involvement)' and 'early adopters' were used to include users from the RFID company, the university and the hospital. The design and implementation process consisted of two 'structured cycles' ('iterations'). The effectiveness of this approach was assessed by the acceptance in terms of level of use, continuity of the project and purchase. The Device Module included eight strategic and twelve tactical actions and the Patient Module included six strategic and twelve tactical actions. Both modules are now used on a daily basis and are purchased by the hospitals for continued use. The RFID specific PD approach was effective in guiding and supporting the design and implementation process of RFID technology in the OR. The multidisciplinary teams and their active participation provided insights in the social and the organizational context of the hospitals making it possible to better fit the technology to the hospitals' (future) needs.

Operative notes do not reflect reality in laparoscopic cholecystectomy.

BACKGROUND: Operative notes represent an essential element in safe patient care and should therefore be clear and accurate. This comparative study examined whether operative notes accurately represented the laparoscopic cholecystectomy (LC) as performed. METHODS: Nine Dutch teaching and non-teaching hospitals were invited to record 20 successive LCs each and to collect the corresponding operative notes. The main outcome measures were overall differences and correspondence between video recordings and notes based on the Dutch guideline for LC and the occurrence of iatrogenic gallbladder perforation. A comparison was made of the cumulative results of recordings and operative notes, and individual recordings were compared with the corresponding notes. RESULTS: Seven hospitals participated in the study; 125 video recordings and operative notes were fully analysed. Recordings showed more steps of the procedure than did notes. Individual comparisons showed significant differences (P≤0·001) between the recording and the corresponding note for the steps 'Introducing trocars under vision', 'Condition of the gallbladder', 'Critical view of safety' and 'Removing first and second trocar under vision'. Iatrogenic gallbladder perforation with spilled bile occurred in 31 patients (24·8 per cent), and was both recorded and reported in 29 patients. Iatrogenic gallbladder perforation with spilled bile and spilled stones occurred in 15 patients (12·0 per cent), and was recorded and reported in 11 patients. CONCLUSION: Operative notes do not adequately represent the actual LCs performed as they describe fewer important procedural steps. It is suggested that operative notes should include video recordings.

Discrepant perceptions of communication, teamwork and situation awareness among surgical team members.

OBJECTIVE: To assess surgical team members' differences in perception of non-technical skills. DESIGN: Questionnaire design. SETTING: Operating theatres (OTs) at one university hospital, three teaching hospitals and one general hospital in the Netherlands. PARTICIPANTS: Sixty-six surgeons, 97 OT nurses, 18 anaesthetists and 40 nurse anaesthetists. METHODS: All surgical team members, of five hospitals, were asked to complete a questionnaire and state their opinion on the current state of communication, teamwork and situation awareness at the OT. RESULTS: Ratings for 'communication' were significantly different, particularly between surgeons and all other team members (P ≤ 0.001). The ratings for 'teamwork' differed significantly between all team members (P ≤ 0.005). Within 'situation awareness' significant differences were mainly observed for 'gathering information' between surgeons and other team members (P < 0.001). Finally, 72-90% of anaesthetists, OT nurses and nurse anaesthetists rated routine team briefings and debriefings as inadequate. CONCLUSIONS: This study shows discrepancies on many aspects in perception between surgeons and other surgical team members concerning communication, teamwork and situation awareness. Future research needs to ascertain whether these discrepancies are linked to greater risk of adverse events or to process as well as systems failures. Establishing this link would support implementation and use of complex team interventions that intervene at multiple levels of the healthcare system.

Non-invasive measurement of intra-abdominal pressure: a preliminary study.

The importance of measuring intra-abdominal pressure (IAP) has increased since the negative effects of sustained increased IAP, also known as intra-abdominal hypertension (IAH), have become known. The relation between IAP and abdominal wall tension has been included in several reports. We have developed a device to measure abdominal wall tension by measuring force and distance. This device enables us to investigate the correlation between the abdominal wall tension and IAP. The abdomens of two corpses (one female, one male) were insufflated with air. IAP was increased and measured at intervals by means of a laparoscopic set-up. Abdominal tension was measured at seven points on the abdominal wall at each interval. Pearson's correlation coefficients were used to determine the relationship between IAP and tension for each point measured. ANOVA was used to assess relations between measured tensions versus applied pressure, locations and subjects. In both corpses, all points showed significant (p < 0.001) correlations between IAP and abdominal wall tension. The points along the mid transverse plane appear to be more similar compared to more cranial and caudal points. We have assessed the feasibility of a device that non-invasively can track changes in IAP. Measurements performed with the device are preliminary results, and further investigation is needed.

Application of ergonomic guidelines during minimally invasive surgery: a questionnaire survey of 284 surgeons.

BACKGROUND: This study aimed to obtain an answer for the question: Are ergonomic guidelines applied in the operating room and what are the consequences? METHODS: A total of 1,292 questionnaires were sent by email or handed out to surgeons and residents. The subjects worked mainly in Europe, performing laparoscopic and/or thoracoscopic procedures within the digestive, thoracic, urologic, gynecologic, and pediatric disciplines. RESULTS: In response, 22% of the questionnaires were returned. Overall, the respondents reported discomfort in the neck, shoulders, and back (almost 80%). There was not one specific cause for the physical discomfort. In addition, 89% of the 284 respondents were unaware of ergonomic guidelines, although 100% stated that they find ergonomics important. CONCLUSIONS: The lack of ergonomic guidelines awareness is a major problem that poses a tough position for ergonomics in the operating room.