Lowndes, Bethany R.

Operating room throughput variability with spinal procedures revealed task inefficiency and potential safety concerns. Using the DMAIC framework (Define, Measure, Analyze, Improve, Control), a transdisciplinary team conducted a quality improvement (QI) research project to identify and address safety concerns with prone patient positioning. The main problem with patient positioning was undefined standard practice. Clinicians reported prone patient positioning for spinal surgery patients is physically demanding. Thus, the team conducted a rapid upper limb assessment for injury risk during patient positioning and identified a greater risk of clinician injury in the manual transfer process. The QI research team recommended the mechanical process of rotating patients with the Jackson Table to improve workload for the Surgical Team and developed training and design enhancements to support this workflow. The DMAIC quality framework enabled clinician collaboration with researchers to develop interventions to support a standardized process during prone patient positioning with the Jackson Table.

ABSTRACTIntroductionSuccessful tourniquet application increases survival rate of exsanguinating extremity hemorrhage victims. Tactile feedback during tourniquet application training should reflect human tissue properties in order to increase success in the field. This study aims to understand the mechanical properties of a human limb during tourniquet application.MethodSix cadaveric extremities—three uppers and three lowers—were tested from three body mass index groups: low (<19) healthy (19-24), and overweight (>24). Each specimen donned with a tourniquet and mounted to a servo-hydraulic testing machine, which enabled controlled tightening of the tourniquet while recording the tourniquet tension force and strap displacement. A thin-film pressure sensor placed between the specimen and the tourniquet recorded contact pressure. Each limb was tested with the tourniquet applied at two different sites resulting in testing at the upper arm, forearm, thigh, and shank.ResultsThe load displacement curves during radial compression were found to be nonlinear overall, with identifiable linear regions. Average contact pressure under the tourniquet strap at 200N and 300N of tension force was 126.3 (σ = 41.2) mm Hg and 205.3 (σ = 75.3) mm Hg, respectively. There were no significant differences in tissue stiffness or contact pressure at 300N of tension force between limb (upper vs. lower) or body mass index. At 200N of tension, the upper limb had significantly higher contact pressure than the lower limb (P = 0.040). Relative radial compression was significantly different between upper (16.74, σ = 4.16%) and lower (10.15, σ = 2.25%) extremities at 200N tension (P = 0.005).ConclusionsSimulation of tissue compression during tourniquet application may be achieved with a material exhibiting elastic properties to mimic the force-displacement behavior seen in cadaveric tissue or with different layers of material. Different trainers for underweight, healthy, and overweight limbs may not be needed. Separate tourniquet training fixtures should be created for the upper and lower extremities.

Studies utilizing a systems perspective show that individual work system elements impact surgeon workload. However, limited work has shown how multiple elements together can affect perceived workload in the healthcare domain. Using NASA-Task Load Index (NASA-TLX), this study aimed to compare operating room workload across two work system factors (surgical specialty and case number of the day) using a large set of self-reported surgeon workload data. Thirty-two surgeons completed 545 workload surveys across a three month period. Surgeons reported significant differences in composite workload scores across the surgical specialties (F(7,544)=3.622, p=0.001). Significant interactions were identified between surgical specialty and case number for composite workload, F(20,534)=1.72, p=0.027. While such findings are promising, future work is needed across multiple institutions to establish baseline workload values across specialties with different patient characteristics and work systems.

There is a growing awareness of the physical demands of performing surgery and the need for ergonomic education and training, extending beyond the primary surgeon to other members of the surgical team who are also at risk for musculoskeletal injury. In this study, nine Surgical First Assistants received knowledge-based ergonomic education before their body postures were evaluated using inertial measurement units in an anatomy training lab setting and again in the operating room (OR). Five of those trainees comprised the intervention group, receiving a personalized report detailing their level of ergonomic risk, while the other four did not receive this individual feedback. The intervention group significantly improved their neck and left arm posture during the anatomy lab training with carryover into the OR, indicating some retention of ergonomic concepts, while the control group did not. The integration of wearable technology and individualized feedback into traditional educational settings helped trainees learn about their own behaviors and practice strategies for reducing risks in the OR with greater retention compared to knowledge-based education alone.

Background: Laparoendoscopic single site surgery (LESS) is feasible for more complex procedure types, but the technical challenges and learning curve posed by LESS makes traditional multi-incision laparoscopy still the preferred technique. The aims of this study were to understand the restricted mobility and positional requirements of these more complex procedures and to generate innovative instrument designs to overcome these restrictions. Methods: A two-phase study was conducted where three lightly-embalmed (fresh tissue) cadavers were utilized to estimate in vivo mobility restriction and positional requirements. These data were combined to quantifying instrument force and positional requirements to develop a novel design for a LESS-specific grasper. Results: The LESS-specific has an ergonomic curved axial handle and locking mechanism that enables surgeons to relax their grip without the grasper releasing. Conclusion: Further design adaptations are needed to optimize the size, angles, and curvature of the tool, as well as to add two points of articulation for rapid intracorporeal adjustment.

Abstract Objective The American College of Surgeons (ACS) encourages clinicians to provide training to laypeople on tourniquet application. It is unclear whether clinicians are confident in their abilities and equipped with adequate knowledge, skills, and resources. This study aimed to determine surgical trainee knowledge and attitudes regarding tourniquet application and compare the effectiveness of instructions. Methods Thirty surgical trainees performed a tourniquet application simulation using a Combat Application Tourniquet and one of the three instructions sets developed by ACS, Department of Homeland Security, and the tourniquet manufacturer. Participants reported tourniquet knowledge, attitudes, and confidence and discussed the instructions. One instruction set was updated and compared to the original set with 20 new trainees. Results Participants with ACS instructions passed the greatest number of steps (p < 0.01) and completed the task significantly faster compared to those with manufacturer instructions (p < 0.01). Participants (80%) reported favorable views toward tourniquets but 30–60% did not align with to ACS tourniquet guidelines. Focus group participants suggested revisions to the ACS instructions. Comparing the original and revised version of these instructions resulted in no significant improvements. Conclusions ACS instructions provide guidance; however, improvements to tourniquet instruction are needed for success in controlling exsanguinating hemorrhage.

AbstractObjectivesA cuffed bag valve mask (BVM) is the most common device used by emergency medical responders to ventilate patients. The BVM can be difficult for users to seal around the patient’s mouth and nose. An intraoral mask (IOM) with snorkel-like design may facilitate quicker and better ventilation particularly under austere conditions.MethodsBoth a BVM and IOM were utilized by 27 trained emergency medical technicians and paramedics to ventilate a lightly embalmed cadaver. Ventilation efficacy, workload, and usability were assessed for both devices across four study conditions.ResultsThe IOM was superior to the BVM in delivered tidal volume ratio (measure of leak, p < 0.03) and minute ventilation (p < 0.0001). Workload, ergonomic and usability assessments indicated that the IOM facilitated gripping through the reduced hand interface size (p < 0.01), decreased user effort (p < 0.001), and reduced upper limb workload (p = 0.0088).ConclusionsIn the assessed model, the IOM represented a better choice for airway management than the standard cuffed BVM. An emergency medical device that is intuitive, efficacious and less demanding has the potential to reduce responder stress and improve resuscitation efforts, especially during austere rescue and patient transport.