Lowndes, Bethany R.

The Stop The Bleed initiative was developed by the Department of Homeland Security to educate lay providers in bleeding reduction strategies. The current study evaluated: (1)three tourniquet instructions using a simulated tourniquet task and (2)participant confidence levels in tourniquet use and lay provider training. Thirty participants with limited clinical experience applied a tourniquet to a simulated limb using one of three instruction sets. Twelve of these participants (40%) participated in a tourniquet training session and focus group to discuss each instruction set. Participants preferred the most simple and pictoral instruction set, and identified opportunities for improvement in each set. Participant confidence in tourniquet use increased significantly following the task and the focus group. After the focus group, participant confidence in instructing lay providers on proper tourniquet use significantly increased. Adding key steps, contextual pictures, and indicators of success to instructions could support lay providers stop the bleed in life-threatening situations.

The purpose of this study was to validate a commercially available inertial measurement unit (IMU) system against a standard lab-based motion capture system for the measurement of shoulder elevation, elbow flexion, trunk flexion/extension, and neck flexion/extension kinematics. The validation analyses were applied to 6 surgical faculty members performing a standard, simulated surgical training task that mimics minimally invasive surgery. Three-dimensional joint kinematics were simultaneously recorded by an optical motion capture system and an IMU system with 6 sensors placed on the head, chest, and bilateral upper and lower arms. The sensor-to-segment axes alignment was accomplished manually. The IMU neck and trunk IMU flexion/extension angles were accurate to within 2.9 ± 0.9 degrees and 1.6 ± 1.1°, respectively. The IMU shoulder elevation measure was accurate to within 6.8 ± 2.7° and the elbow flexion measure was accurate to within 8.2 ± 2.8°. In the Bland-Altman analyses, there were no significant systematic errors present; however, there was a significant inversely proportional error across all joints. As the gold standard measurement increased, the IMU underestimated the magnitude of the joint angle. This study reports acceptable accuracy of a commercially available IMU system; however, results should be interpreted as protocol specific.

Abstract Background Surgical performance, provider health, and patient safety can be compromised when workload demands exceed individual capability on the surgical team. The purpose of this study is to quantify and compare intraoperative workload among surgical team members. Methods Observations were conducted for an entire surgical day for 33 participating surgeons and their surgical team at one medical institution. Workload (mental, physical, case complexity, distractions, and case difficulty) was measured for each surgical team member using questions from validated questionnaires. Statistical analyses were performed with a mixed effects model. Results A total of 192 surgical team members participated in 78 operative cases, and 344 questionnaires were collected. Procedures with high surgeon mental and physical workload included endovascular and gastric surgeries, respectively. Ratings did not differ significantly among surgeons and residents, but scrub nurses physical demand ratings were 14–22 (out of 100) points lower than the surgeons, residents, and surgical assistants. Residents reported the highest mental workload, averaging 19–24 points higher than surgical assistants, scrub nurses, and circulating nurses. Mental and physical demands exceeded 50 points 28–45 % of the time for surgeons and residents. Workload did not differ between minimally invasive and open techniques. Conclusion The workload questionnaires are an effective tool for quantifying intraoperative workload across the surgical team to ensure mental and physical demands do not exceed thresholds where performance may decrease and injury risk increase. This tool has the potential to measure the safety of current procedures and drive design of workload interventions.

Surgical trainees undergo demanding training to achieve high surgical task proficiency. Abounding clinical and educational responsibilities mandate efficient and effective training. This research measured resident workload during laparoscopic skills training to identify excessive workload and how workload impacted task performance. Twenty-eight surgical trainees performed a standardized surgical training task and completed a workload questionnaire while observers measured physiological stress, posture risk assessment, and task performance. Participants self-reported mental demands, physical demands, temporal demands, performance, effort, and frustration. Effort (12±4) and frustration (12±5) were the highest subscales while physical demand (8±4) was the lowest. All participants were observed performing the task in at-risk postures, with 21% exhibiting risk levels requiring immediate intervention. Physical demand was associated with posture risk assessment scores (p<0.05). Mental demand was positively (R 2 =0.20, p<0.05) and frustration was negatively (R 2 =0.18, p<0.05) associated with skin conductance range. A point increase in physical demand was associated with a six second increase in performance time (β=6.0, p=0.01). These results support the fact that human factors and ergonomic tools can be used to relate surgical skills performance with workload, stress, and posture risks.

Laparoendoscopic single site surgery (LESS) can provide potential patient benefits beyond conventional laparoscopy (CL). However, LESS further exacerbates current ergonomic disadvantages of CL. LESS practices to compensate for the constraints include intracorporeal crossing of instruments (UL) for improved manipulation of instrumentation and extracorporeal crossing of hands (PL) for illusion mitigation. Preliminary results from this study involving 12 medical students (7 males) performing a simulated surgical task found statistical difference between CL, PL, and UL for physical demand (P<0.001), task complexity (P=0.002) and performance times (P<0.001) with no difference for mental demand (P=0.106). These initial findings show that the PL technique cannot currently compensate for the limitations of LESS to make UL more similar to CL. Further research is needed to determine if PL or another LESS compensatory practice can allow surgeons to more effectively perform procedures with a single port and therefore ensure patients reap its benefits.

Objective The aim of this study was to define health care providers’ perceptions toward prone patient positioning for spine surgery using the Jackson Table, which has not been hitherto explored. Methods We analyzed open-ended questionnaire data and interviews conducted with the spine surgical team regarding the current process of spinal positioning/repositioning using the Jackson Table. Participants were asked to provide an open-ended explanation as to whether they think the current process of spinal positioning/repositioning is safe for the staff or patients. Follow-up qualitative interviews were conducted with 11 of the participants to gain an in-depth understanding of the challenges and safety issues related to prone patient positioning. Results Data analysis resulted in 6 main categories: general challenges with patient positioning, role-specific challenges, challenges with the Jackson Table and the “sandwich” mechanism, safety concerns for patients, safety concerns for the medical staff, and recommendations for best practices. Conclusions This study is relevant to everyday practice for spinal surgical team members and advances our understanding of how surgical teams qualitatively view the current process of patient positioning for spinal surgery. Providers recommended best practices for using the Jackson Table, which can be achieved through standardized practice for transfer of patients, educational tools, and checklists for equipment before patient transfer and positioning. This research has identified several important practice opportunities for improving provider and patient safety in spine surgery.

With various minimally invasive approaches in the field of surgery and new techniques entering rapidly, it is important to evaluate the effectiveness of these different practices. Information about the impact on both patient and provider can be gained through research investigations. Since the workload placed on the surgeon may influence patient outcomes, this study measured levels of stress and fatigue for the surgeon participating in an NIH randomized control trial of single incision versus 4-port laparoscopic cholecystectomy. Through the administration of the SURG-TLX for 22 Single-Incision Laparoscopic Cholecystectomies and 24 4-port cholecystectomies, physical workload was the only measure statistically different between 4-port and SILC (P=0.028). There was a significant difference in the duration (P=0.029) based on the procedure that was completed. Mental stress was highly correlated to many of the variables in the Surg-TLX and duration, degree of difficulty, and complexity were all highly correlated. This research shows how the SILC procedure can cause more stress on the surgeon. When the situation is combined with longer surgeries, higher complexity, and a higher degree of difficulty, the patient outcomes may be at risk.

The Institute of Medicine lists investigations of the comparative effectiveness for minimally invasive surgical procedures as a research priority. As new minimally invasive procedures are developed, comparisons of the resulting workload contribute valuable information about the impact of the new procedures. Recent reports suggest that surgeon workload can influence patient outcomes. Measurements of stress and fatigue for the surgical team participating in a randomized NIH supported trial of single incision versus traditional laparoscopic cholecystectomy were obtained. These stress measures showed that the SURG-TLX was sensitive to the difficulty of the surgery. The SURG-TLX and a surgical difficulty score was obtained from the surgical team for 16 laparoscopic surgeries by surgical approach (8 SILC and 8 4-port) showed that for this small sample size, there were no statistically significant differences in length of surgery, degree of difficulty, nor patient considerations such as post-operative pain scores. In addition, no statistically significant differences in the individual Surg-TLX subscale scores or Surg-TLX total for the surgical team overall or for the surgeon alone by surgical platform. This is likely due to the small sample size reducing the power of the tests.