The impact of resident training on robotic operative times: is there a July Effect?

It is unknown whether the July Effect (a theory that medical errors and organizational inefficiencies increase during the influx of new surgical residents) exists in urologic robotic-assisted surgery. The aim of this study was to investigate the impact of urology resident training on robotic operative times at the beginning of the academic year. A retrospective chart review was conducted for urologic robotic surgeries performed at a single institution between 2008 and 2019. Univariate and multivariate mix model analyses were performed to determine the association between operative time and patient age, estimated blood loss, case complexity, robotic surgical system (Si or Xi), and time of the academic year. Differences in surgery time and non-surgery time were assessed with/without resident presence. Operative time intervals were included in the analysis. Resident presence correlated with increased surgery time (38.6 min (p < 0.001)) and decreased non-surgery time (4.6 min (p < 0.001)). Surgery time involving residents decreased by 8.7 min after 4 months into the academic year (July-October), and by an additional 5.1 min after the next 4 months (p = 0.027, < 0.001). When compared across case types stratified by complexity, surgery time for cases with residents significantly varied. Cases without residents did not demonstrate such variability. Resident presence was associated with prolonged surgery time, with the largest effect occurring in the first 4 months and shortening later in the year. However, resident presence was associated with significantly reduced non-surgery time. These results help to understand how new trainees impact operating room times.

Challenges With Robot-Assisted Surgery Setup for Complex Minimally Invasive Upper Gastrointestinal Surgery.

BACKGROUND: The utilization of robot-assisted approaches to surgery has increased significantly over the last two decades. This has introduced novel complexities into the operating room environment, requiring management of new challenges and workflow adaptation. This study aimed to analyze challenges in the surgical setup for complex upper gastrointestinal robot-assisted surgery (UGI-RAS) and identify opportunities for solutions. METHODS: Direct observations of surgical setup processes for UGI-RAS were performed by a trained Human Factors researcher at a non-profit academic medical center in Southern California. Setup tasks were subdivided into five phases: (1) before wheels-in; (2) patient transfer and anesthesia induction; (3) patient preparation; (4) surgery preparation; and (5) robot docking. Start/end times for each phase/task were documented along with workflow disruption (FD) narratives and timestamps. Setup tasks and FDs were analyzed using descriptive statistics. RESULTS: Twenty UGI-RAS setup procedures were observed between May-November 2023: sleeve gastrectomy +/- hiatal hernia repair (n = 9, 45.00%); para-esophageal hernia repair +/- fundoplication (n = 8, 40.00%); revision to Roux-en-Y gastric bypass (n = 2, 10.00%); and gastric band removal (n = 1, 5.00%). Frequent FDs included planning breakdowns (n = 20, 29.85%), equipment/supply management (n = 17, 25.37%), patient care coordination (n = 8, 11.94%), and equipment challenges (n = 8, 11.94%). Eleven of 20 observations were first-start cases, of which 10 experienced delayed starts. DISCUSSION: Interventions aimed at improving workflows during UGI-RAS setup include performing pre-operative team huddles and conducting trainings aimed at team coordination and equipment challenges. These solutions could result in improved teamwork, efficiency, and communication while reducing case start delays and turnover time.

Why can't we improve turnover time? A systematic review.

BACKGROUND: Despite substantial efforts to reduce operating room (OR) turnover time (TOT), delays remain a frustration to physicians, staff, and hospital leadership. These efforts have employed many systems and human factor-based approaches with variable results. A deeper dive into methodologies and their applicability could lead to successful and sustained change. The aim of this study was to conduct a systematic review to evaluate relevant research focused on improving OR TOT and clearly defining measures of successful intervention. MATERIAL AND METHODS: A systematic review of OR TOT interventions implemented between 1980 through October 2022 was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. Research databases included: 1) PubMed; 2) Web of Science; and 3) OVID Medline. RESULTS: A total of 38 articles were appropriate for analysis. Most employed a pre/post intervention approach (29, 76.3%), the remaining utilized a control/intervention approach. Nine intervention methods were identified: the majority included a process redesign bundle (24, 63%), followed by overlapping induction, dedicated unit/team/space feedback, financial incentives, team training, education, practice guidelines, and redefinition of roles/responsibilities. Studies were further categorized into one of two groups: (1) those that utilized predetermined interventions based on anecdotal experience or prior literature (18, 47.4%) and (2) those that conducted a prospective analysis on baseline data to inform intervention development (20, 52.6%). DISCUSSION: There are significant variability in the methodologies utilized to improve OR TOT; however, the most effective solutions involved process redesign bundles developed from a prospective investigation of the clinical work-system.

Rehabilitation Treatment Specification System for Voice Therapy: Application to Everyday Clinical Care.

PURPOSE: Rehabilitation intervention descriptions often do not explicitly identify active ingredients or how those ingredients lead to changes in patient functioning. The Rehabilitation Treatment Specification System (RTSS) provides guidance to identify the critical aspects of any rehabilitation therapy and supported the development of standardly named ingredients and targets in voice therapy (Rehabilitation Treatment Specification System for Voice Therapy [RTSS-Voice]). This study sought to test the content validity of the RTSS-Voice and determine if the RTSS-Voice can be used to identify commonalities and differences in treatment (criterion validity) across clinicians in everyday clinical practice. METHOD: Five speech-language pathologists from different institutions videotaped one therapy session for 59 patients diagnosed with a voice or upper airway disorder. Specifications were created for each video, and iterative rounds of revisions were completed with the treating clinician and two RTSS experts until consensus was reached on each specification. RESULTS: All 59 sessions were specified without the addition of any targets or ingredients. There were two frequent targets: (a) increased volition and (b) decreased strained voice quality. There were three frequent ingredients: (a) information regarding the patient's capability and motivation to perform a therapeutic behavior, (b) knowledge of results feedback, and (c) opportunities to practice voicing with improved resonance and mean airflow. Across sessions treating vocal hyperfunction, there was large variability across clinicians regarding the types and number of treatment components introduced, types of feedback provided, and vocal practice within spontaneous speech and negative practice. CONCLUSIONS: The RTSS and the RTSS-Voice demonstrated strong content validity, as they comprehensively characterized 59 therapy sessions. They also demonstrated strong criterion validity, as commonalities and differences were identified in everyday voice therapy for vocal hyperfunction across multiple clinicians. Future work to translate RTSS principles and RTSS-Voice terms into clinical documentation can help to understand how clinician and patient variability impacts outcomes and bridge the research-practice gap. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.24796875.

Medication Safety Event Reporting: Factors That Contribute to Safety Events During Times of Organizational Stress.

BACKGROUND: Incident reports submitted during times of organizational stress may reveal unique insights. PURPOSE: To understand the insights conveyed in hospital incident reports about how work system factors affected medication safety during a coronavirus disease-2019 (COVID-19) surge. METHODS: We randomly selected 100 medication safety incident reports from an academic medical center (December 2020 to January 2021), identified near misses and errors, and classified contributing work system factors using the Human Factors Analysis and Classification System-Healthcare. RESULTS: Among 35 near misses/errors, incident reports described contributing factors (mean 1.3/report) involving skill-based errors (n = 20), communication (n = 8), and tools/technology (n = 4). Reporters linked 7 events to COVID-19. CONCLUSIONS: Skill-based errors were the most common contributing factors for medication safety events during a COVID-19 surge. Reporters rarely deemed events to be related to COVID-19, despite the tremendous strain of the surge on nurses. Future efforts to improve the utility of incident reports should emphasize the importance of describing work system factors.