Surgical Sabermetrics: A Scoping Review of Technology-enhanced Assessment of Nontechnical Skills in the Operating Room.

OBJECTIVE: To evaluate the current evidence for surgical sabermetrics: digital methods of assessing surgical nontechnical skills and investigate the implications for enhancing surgical performance. BACKGROUND: Surgeons need high-quality, objective, and timely feedback to optimize performance and patient safety. Digital tools to assess nontechnical skills have the potential to reduce human bias and aid scalability. However, we do not fully understand which of the myriad of digital metrics of performance assessment have efficacy for surgeons. METHODS: A systematic review was conducted by searching PubMed, EMBASE, CINAHL, and PSYCINFO databases following PRISMA-ScR guidelines. MeSH terms and keywords included "Assessment," "Surgeons," and "Technology". Eligible studies included a digital assessment of nontechnical skills for surgeons, residents, and/or medical students within an operative context. RESULTS: From 19,229 articles screened, 81 articles met the inclusion criteria. The studies varied in surgical specialties, settings, and outcome measurements. A total of 122 distinct objective, digital metrics were utilized. Studies digitally measured at least 1 category of surgical nontechnical skill using a single (n=54) or multiple objective measures (n=27). The majority of studies utilized simulation (n=48) over live operative settings (n=32). Surgical Sabermetrics has been demonstrated to be beneficial in measuring cognitive load (n=57), situation awareness (n=24), communication (n=3), teamwork (n=13), and leadership (n=2). No studies measured intraoperative decision-making. CONCLUSIONS: The literature detailing the intersection between surgical data science and operative nontechnical skills is diverse and growing rapidly. Surgical Sabermetrics may provide a promising modifiable technique to achieve desirable outcomes for both the surgeon and the patient. This study identifies a diverse array of measurements possible with sensor devices and highlights research gaps, including the need for objective assessment of decision-making. Future studies may advance the integration of physiological sensors to provide a holistic assessment of surgical performance.

An Open-Source, Interoperable Architecture for Generating Real-Time Surgical Team Cognitive Alerts from Heart-Rate Variability Monitoring.

Clinical alarm and decision support systems that lack clinical context may create non-actionable nuisance alarms that are not clinically relevant and can cause distractions during the most difficult moments of a surgery. We present a novel, interoperable, real-time system for adding contextual awareness to clinical systems by monitoring the heart-rate variability (HRV) of clinical team members. We designed an architecture for real-time capture, analysis, and presentation of HRV data from multiple clinicians and implemented this architecture as an application and device interfaces on the open-source OpenICE interoperability platform. In this work, we extend OpenICE with new capabilities to support the needs of the context-aware OR including a modularized data pipeline for simultaneously processing real-time electrocardiographic (ECG) waveforms from multiple clinicians to create estimates of their individual cognitive load. The system is built with standardized interfaces that allow for free interchange of software and hardware components including sensor devices, ECG filtering and beat detection algorithms, HRV metric calculations, and individual and team alerts based on changes in metrics. By integrating contextual cues and team member state into a unified process model, we believe future clinical applications will be able to emulate some of these behaviors to provide context-aware information to improve the safety and quality of surgical interventions.

Crew Autonomy During Simulated Medical Event Management on Long Duration Space Exploration Missions.

OBJECTIVE: Our primary aim was to investigate crew performance during medical emergencies with and without ground-support from a flight surgeon located at mission control. BACKGROUND: There are gaps in knowledge regarding the potential for unanticipated in-flight medical events to affect crew health and capacity, and potentially compromise mission success. Additionally, ground support may be impaired or periodically absent during long duration missions. METHOD: We reviewed video recordings of 16 three-person flight crews each managing four unique medical events in a fully immersive spacecraft simulator. Crews were randomized to two conditions: with and without telemedical flight surgeon (FS) support. We assessed differences in technical performance, behavioral skills, and cognitive load between groups. RESULTS: Crews with FS support performed better clinically, were rated higher on technical skills, and completed more clinical tasks from the medical checklists than crews without FS support. Crews with FS support also had better behavioral/non-technical skills (information exchange) and reported significantly lower cognitive demand during the medical event scenarios on the NASA-TLX scale, particularly in mental demand and temporal demand. There was no significant difference between groups in time to treat or in objective measures of cognitive demand derived from heart rate variability and electroencephalography. CONCLUSION: Medical checklists are necessary but not sufficient to support high levels of autonomous crew performance in the absence of real-time flight surgeon support. APPLICATION: Potential applications of this research include developing ground-based and in-flight training countermeasures; informing policy regarding autonomous spaceflight, and design of autonomous clinical decision support systems.

Measuring and Improving Emotional Intelligence in Surgery: A Systematic Review.

OBJECTIVE: Evaluate how emotional intelligence (EI) has been measured among surgeons and to investigate interventions implemented for improving EI. SUMMARY BACKGROUND: EI has relevant applications in surgery given its alignment with nontechnical skills. In recent years, EI has been measured in a surgical context to evaluate its relationship with measures such as surgeon burnout and the surgeon-patient relationship. METHODS: A systematic review was conducted by searching MEDLINE, EMBASE, CINAHL, and PSYCINFO databases using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. MeSH terms and keywords included "emotional intelligence," "surgery," and "surgeon." Eligible studies included an EI assessment of surgeons, surgical residents, and/or medical students within a surgical context. RESULTS: The initial search yielded 4627 articles. After duplicate removal, 4435 articles were screened by title and abstract and 49 articles proceeded to a full-text read. Three additional articles were found via hand search. A total of 37 articles were included. Studies varied in surgical specialties, settings, and outcome measurements. Most occurred in general surgery, residency programs, and utilized self-report surveys to estimate EI. Notably, EI improved in all studies utilizing an intervention. CONCLUSIONS: The literature entailing the intersection between EI and surgery is diverse but still limited. Generally, EI has been demonstrated to be beneficial in terms of overall well-being and job satisfaction while also protecting against burnout. EI skills may provide a promising modifiable target to achieve desirable outcomes for both the surgeon and the patient. Future studies may emphasize the relevance of EI in the context of surgical teamwork.

Maintaining health professional education during war: A scoping review.

PURPOSE: War negatively impacts health professional education when health care is needed most. The aims of this scoping review are to describe the scope of barriers and targeted interventions to maintaining health professional education during war and summarise the research. METHODS: We conducted a scoping review between 20 June 2018 and 2 August 2018. The search was restricted to English publications including peer-reviewed publications without date ranges involving war and health professional education (medical school, residency training and nursing school), with interventions described to maintain educational activities. Two independent reviewers completed inclusion determinations and data abstraction. Thematic coding was performed using an inductive approach allowing dominant themes to emerge. The frequency of barrier and intervention themes and illustrative quotes were extracted. Articles were divided into modern/postmodern categories to permit temporal and historical analysis of thematic differences. RESULTS: Screening identified 3271 articles, with 56 studies meeting inclusion criteria. Publication dates ranged from 1914-2018 with 17 unique wars involving 17 countries. The studies concerned medical students (61.4%), residents (28.6%) and nursing students (10%). Half involved the modern era and half the postmodern era. Thematic coding identified five categories of barriers and targeted interventions in maintaining health professions education during war: curriculum, personnel, wellness, resources, and oversight, with most involving curriculum and personnel. The distribution of themes among various health professional trainees was similar. The frequency and specifics changed temporally reflecting innovations in medical education and war, with increased focus on oversight and personnel during the modern era and greater emphasis on wellness, curriculum, and resources during the postmodern era. CONCLUSIONS: There are overarching categories of barriers and targeted interventions in maintaining health professional education during war which evolve over time. These may serve as a useful framework to strategically support future research and policy efforts.

Dissecting Cardiac Surgery: A Video-based Recall Protocol to Elucidate Team Cognitive Processes in the Operating Room.

OBJECTIVE: The aim of this study was to elucidate the cognitive processes involved in surgical procedures from the perspective of different team roles (surgeon, anesthesiologist, and perfusionist) and provide a comprehensive compilation of intraoperative cognitive processes. SUMMARY BACKGROUND DATA: Nontechnical skills play a crucial role in surgical team performance and understanding the cognitive processes underlying the intraoperative phase of surgery is essential to improve patient safety in the operating room (OR). METHODS: A mixed-methods approach encompassing semistructured interviews with 9 subject-matter experts. A cognitive task analysis was built upon a hierarchical segmentation of coronary artery bypass grafting procedures and a cued-recall protocol using video vignettes was used. RESULTS: A total of 137 unique surgical cognitive processes were identified, including 33 decision points, 23 critical communications, 43 pitfalls, and 38 strategies. Self-report cognitive workload varied substantially, depending on team role and surgical step. A web-based dashboard was developed, providing an integrated visualization of team cognitive processes in the OR that allows readers to intuitively interact with the study findings. CONCLUSIONS: This study advances the current body of knowledge by making explicit relevant cognitive processes involved during the intraoperative phase of cardiac surgery from the perspective of multiple OR team members. By displaying the research findings in an interactive dashboard, we provide trainees with new knowledge in an innovative fashion that could be used to enhance learning outcomes. In addition, the approach used in the present study can be used to deeply understand the cognitive factors underlying surgical adverse events and errors in the OR.

We Asked the Experts: The WHO Surgical Safety Checklist and the COVID-19 Pandemic: Recommendations for Content and Implementation Adaptations.

BACKGROUND: As surgical systems are forced to adapt and respond to new challenges, so should the patient safety tools within those systems. We sought to determine how the WHO SSC might best be adapted during the COVID-19 pandemic. METHODS: 18 Panelists from five continents and multiple clinical specialties participated in a three-round modified Delphi technique to identify potential recommendations, assess agreement with proposed recommendations and address items not meeting consensus. RESULTS: From an initial 29 recommendations identified in the first round, 12 were identified for inclusion in the second round. After discussion of recommendations without consensus for inclusion or exclusion, four additional recommendations were added for an eventual 16 recommendations. Nine of these recommendations were related to checklist content, while seven recommendations were related to implementation. CONCLUSIONS: This multinational panel has identified 16 recommendations for sites looking to use the surgical safety checklist during the COVID-19 pandemic. These recommendations provide an example of how the SSC can adapt to meet urgent and emerging needs of surgical systems by targeting important processes and encouraging critical discussions.

Analysis of Dynamic Changes in Cognitive Workload During Cardiac Surgery Perfusionists' Interactions With the Cardiopulmonary Bypass Pump.

OBJECTIVE: This novel preliminary study sought to capture dynamic changes in heart rate variability (HRV) as a proxy for cognitive workload among perfusionists while operating the cardiopulmonary bypass (CPB) pump during real-life cardiac surgery. BACKGROUND: Estimations of operators' cognitive workload states in naturalistic settings have been derived using noninvasive psychophysiological measures. Effective CPB pump operation by perfusionists is critical in maintaining the patient's homeostasis during open-heart surgery. Investigation into dynamic cognitive workload fluctuations, and their relationship with performance, is lacking in the literature. METHOD: HRV and self-reported cognitive workload were collected from three Board-certified cardiac perfusionists (N = 23 cases). Five HRV components were analyzed in consecutive nonoverlapping 1-min windows from skin incision through sternal closure. Cases were annotated according to predetermined phases: prebypass, three phases during bypass, and postbypass. Values from all 1min time windows within each phase were averaged. RESULTS: Cognitive workload was at its highest during the time between initiating bypass and clamping the aorta (preclamp phase during bypass), and decreased over the course of the bypass period. CONCLUSION: We identified dynamic, temporal fluctuations in HRV among perfusionists during cardiac surgery corresponding to subjective reports of cognitive workload. Not only does cognitive workload differ for perfusionists during bypass compared with pre- and postbypass phases, but differences in HRV were also detected within the three bypass phases. APPLICATION: These preliminary findings suggest the preclamp phase of CPB pump interaction corresponds to higher cognitive workload, which may point to an area warranting further exploration using passive measurement.

Medical Event Management for Future Deep Space Exploration Missions to Mars.

BACKGROUND: Long-duration exploration missions (LDEMs), such as voyages to Mars, will present unique medical challenges for astronaut crews, including communication delays and the inability to return to Earth early. Medical events threaten crewmember lives and increase the risk of mission failure. Managing a range of potential medical events will require excellent technical and nontechnical skills (NTSs). We sought to identify medical events with potential for rescue, range them according to the potential impact on crew health and mission success during LDEMs, and develop a list of NTSs to train for management of in-flight medical events. MATERIALS AND METHODS: Twenty-eight subject matter experts with specializations in surgery, medicine, trauma, spaceflight operations, NTS training, simulation, human factors, and organizational psychology completed online surveys followed by a 2-d in-person workshop. They identified and rated medical events for survivability, mission impact, and impact of crewmember NTSs on outcomes in space. RESULTS: Sudden cardiac arrest, smoke inhalation, toxic exposure, seizure, and penetrating eye injury emerged as events with the highest potential mission impact, greatest potential for survival, and that required excellent NTS for successful management. Key NTS identified to target in training included information exchange, supporting behavior, communication delivery, and team leadership/followership. CONCLUSIONS: With a planned Mars mission on the horizon, training countermeasures need to be developed in the next 3-5 y. These results may inform policy, selection, medical system design, and training scenarios for astronauts to manage in-flight medical events on LDEMs. Findings may extend to surgical and medical care in any rural and remote location.

Sensors for Continuous Monitoring of Surgeon's Cognitive Workload in the Cardiac Operating Room.

Monitoring healthcare providers' cognitive workload during surgical procedures can provide insight into the dynamic changes of mental states that may affect patient clinical outcomes. The role of cognitive factors influencing both technical and non-technical skill are increasingly being recognized, especially as the opportunities to unobtrusively collect accurate and sensitive data are improving. Applying sensors to capture these data in a complex real-world setting such as the cardiac surgery operating room, however, is accompanied by myriad social, physical, and procedural constraints. The goal of this study was to investigate the feasibility of overcoming logistical barriers in order to effectively collect multi-modal psychophysiological inputs via heart rate (HR) and near-infrared spectroscopy (NIRS) acquisition in the real-world setting of the operating room. The surgeon was outfitted with HR and NIRS sensors during aortic valve surgery, and validation analysis was performed to detect the influence of intra-operative events on cardiovascular and prefrontal cortex changes. Signals collected were significantly correlated and noted intra-operative events and subjective self-reports coincided with observable correlations among cardiovascular and cerebral activity across surgical phases. The primary novelty and contribution of this work is in demonstrating the feasibility of collecting continuous sensor data from a surgical team member in a real-world setting.

Surgery Task Load Index in Cardiac Surgery: Measuring Cognitive Load Among Teams.

Background. The most commonly used subjective assessment of perceived cognitive load, the NASA Task Load Index (TLX), has proven valuable in measuring individual load among general populations. The surgery task load index (SURG-TLX) was developed and validated to measure cognitive load specifically among individuals within a surgical team. Notably, the TLX lacks temporal sensitivity in its typical retrospective administration. Objective. This study sought to expand the utility of SURG-TLX by investigating individual measures of cognitive load over time during cardiac surgery, and the relationship between individual and team measures of cognitive load and proxies for surgical complexity. Materials & Methods. SURG-TLX was administered retrospectively in the operating room immediately following each case to approximate cognitive load before, during, and after cardiopulmonary bypass for cardiac surgery team members (surgeon, anesthesiologist, and perfusionist). Correlations were calculated to determine the relationship of individual and team measures of cognitive load over the entire procedure with bypass length and surgery length. Results. Results suggest that perceived cognitive load varies throughout the procedure such that cognitive load during bypass significantly differs compared to before or after bypass, across all 3 roles. While on bypass, results show that anesthesiologists experience significantly lower levels of perceived cognitive load than both surgeons and perfusionists. Correlational analyses reveal that perceived cognitive load of both the surgeon and the team had significant positive associations with bypass length and surgery length. Conclusion. Our findings support the utility of SURG-TLX in real cardiac cases as a measure of cognitive load over time, and on an individual and team-wide basis.

Physiological synchronization and entropy as measures of team cognitive load.

The operating room (OR) is a high-risk and complex environment, where multiple specialized professionals work as a team to effectively care for patients in need of surgical interventions. Surgical tasks impose high cognitive demands on OR staff and cognitive overload may have deleterious effects on team performance and patient safety. The aim of the present study was to investigate the feasibility and describe a novel methodological approach to characterize dynamic changes in team cognitive load by measuring synchronization and entropy of heart rate variability parameters during real-life cardiac surgery. Cognitive load was measured by capturing interbeat intervals (IBI) from three team members (surgeon, anesthesiologist and perfusionist) using an unobtrusive wearable heart rate sensor and transmitted in real-time to a smartphone application. Clinical data and operating room audio/video recordings were also collected to provide behavioral and contextual information. We developed symbolic representations of the transient cognitive state of individual team members (Individual Cognitive State - ICS), and overall team (Team Cognitive State - TCS) by comparing IBI data from each team member with themselves and with others. The distribution of TCS symbols during surgery enabled us to display and analyze temporal states and dynamic changes of team cognitive load. Shannon's entropy was calculated to estimate the changing levels of team organization and to detect fluctuations resulting from a variety of cognitive demands and/or specific situations (e.g. medical error, emergency, flow disruptions). An illustrative example from a real cardiac surgery team shows how cognitive load patterns shifted rapidly after an actual near-miss medication event, leading the team to a more organized and synchronized state. The methodological approach described in this study provides a measurement technique for the assessment of team physiological synchronization, which can be applied to many other team-based environments. Future research should gather additional validity evidence to support the proposed methods for team cognitive load measurement.

Adapting the World Health Organization's Surgical Safety Checklist to High-Income Settings: A Hybrid Effectiveness-Implementation Trial Protocol.

Objectives: The proposed study aims to assess users' perceptions of a surgical safety checklist (SSC) reimplementation toolkit and its impact on SSC attitudes and operating room (OR) culture, meaningful checklist use, measures of surgical safety, and OR efficiency at 3 different hospital sites. Background: The High-Performance Checklist toolkit (toolkit) assists surgical teams in modifying and implementing or reimplementing the World Health Organization's SSC. Through the explore, prepare, implement, and sustain implementation framework, the toolkit provides a process and set of tools to facilitate surgical teams' modification, implementation, training on, and evaluation of the SSC. Methods: A pre-post intervention design will be used to assess the impact of the modified SSC on surgical processes, team culture, patient experience, and safety. This mixed-methods study includes quantitative and qualitative data derived from surveys, semi-structured interviews, patient focus groups, and SSC performance observations. Additionally, patient outcome and OR efficiency data will be collected from the study sites' health surveillance systems. Data analysis: Statistical data will be analyzed using Statistical Product and Service Solutions, while qualitative data will be analyzed thematically using NVivo. Furthermore, interview data will be analyzed using the Consolidated Framework for Implementation Research and reach, effectiveness, adoption, implementation, maintenance implementation frameworks. Setting: The toolkit will be introduced at 3 diverse surgical sites in Alberta, Canada: an urban hospital, university hospital, and small regional hospital. Anticipated impact: We anticipate the results of this study will optimize SSC usage at the participating surgical sites, help shape and refine the toolkit, and improve its usability and application at future sites.

Data-driven coaching to improve statewide outcomes in CABG: before and after interventional study.

BACKGROUND: The impact of quality improvement initiatives program (QIP) on coronary artery bypass grafting surgery (CABG) remains scarce, despite improved outcomes in other surgical areas. This study aims to evaluate the impact of a package of QIP on mortality rates among patients undergoing CABG. MATERIALS AND METHODS: This prospective cohort study utilized data from the multicenter database Registro Paulista de Cirurgia Cardiovascular II (REPLICCAR II), spanning from July 2017 to June 2019. Data from 4018 isolated CABG adult patients were collected and analyzed in three phases: before-implementation, implementation, and after-implementation of the intervention (which comprised QIP training for the hospital team). Propensity Score Matching was used to balance the groups of 2170 patients each for a comparative analysis of the following outcomes: reoperation, deep sternal wound infection/mediastinitis ≤30 days, cerebrovascular accident, acute kidney injury, ventilation time >24 h, length of stay <6 days, length of stay >14 days, morbidity and mortality, and operative mortality. A multiple regression model was constructed to predict mortality outcomes. RESULTS: Following implementation, there was a significant reduction of operative mortality (61.7%, P =0.046), as well as deep sternal wound infection/mediastinitis ( P <0.001), sepsis ( P =0.002), ventilation time in hours ( P <0.001), prolonged ventilation time ( P =0.009), postoperative peak blood glucose ( P <0.001), total length of hospital stay ( P <0.001). Additionally, there was a greater use of arterial grafts, including internal thoracic ( P <0.001) and radial ( P =0.038), along with a higher rate of skeletonized dissection of the internal thoracic artery. CONCLUSIONS: QIP was associated with a 61.7% reduction in operative mortality following CABG. Although not all complications exhibited a decline, the reduction in mortality suggests a possible decrease in failure to rescue during the after-implementation period.

A tool to assess nontechnical skills of perfusionists in the cardiac operating room.

OBJECTIVES: This study aimed to develop the Perfusionists' Intraoperative Non-Technical Skills tool, specifically to the perfusionists' context, and test its inter-rater reliability. METHODS: An expert panel was convened to review existing surgical nontechnical skills taxonomies and develop the Perfusionists' Intraoperative Non-Technical Skills tool. During a workshop held at a national meeting, perfusionists completed the Perfusionists' Intraoperative Non-Technical Skills ratings after watching 4 videos displaying simulated cardiac operations. Two videos showed "good performance," and 2 videos showed "poor performance." Inter-rater reliability analysis was performed and intraclass correlation coefficient was reported. RESULTS: The final version of the Perfusionists' Intraoperative Non-Technical Skills taxonomy contains 4 behavioral categories (decision making, situation awareness, task management and leadership, teamwork and communication) with 4 behavioral elements each. Categories and elements are rated using an 8-point Likert scale ranging from 0.5 to 4.0. A total of 60 perfusionist raters were included and the comparison between rating distribution on "poor performance" and "good performance" videos yielded a statistically significant difference between groups, with a P value less than .001. A similar difference was found in all behavioral categories and elements. Reliability analysis showed moderate inter-rater reliability across overall ratings (intraclass correlation coefficient, 0.735; 95% confidence interval, 0.674-0.796; P < .001). Similar inter-rater reliability was found when raters were stratified by experience level. CONCLUSIONS: The Perfusionists' Intraoperative Non-Technical Skills tool presented moderate inter-rater reliability among perfusionists with varied levels of experience. This tool can be used to train and assess perfusionists in relevant nontechnical skills, with the potential to enhance safety and improve surgical outcomes.

Extended Reality Applications for Space Health.

INTRODUCTION: Spaceflight has detrimental effects on human health, imposing significant and unique risks to crewmembers due to physiological adaptations, exposure to physical and psychological stressors, and limited capabilities to provide medical care. Previous research has proposed and evaluated several strategies to support and mitigate the risks related to astronauts' health and medical exploration capabilities. Among these, extended reality (XR) technologies, including augmented reality (AR), virtual reality (VR), and mixed reality (MR) have increasingly been adopted for training, real-time clinical, and operational support in both terrestrial and aerospace settings, and only a few studies have reported research results on the applications of XR technologies for improving space health. This study aims to systematically review the scientific literature that has explored the application of XR technologies in the space health field. We also discuss the methodological and design characteristics of the existing studies in this realm, informing future research and development efforts on applying XR technologies to improve space health and enhance crew safety and performance.Ebnali M, Paladugu P, Miccile C, Park SH, Burian B, Yule S, Dias RD. Extended reality applications for space health. Aerosp Med Hum Perform. 2023; 94(3):122-130.

The impact of a smartphone-based cognitive aid on clinical performance during cardiac arrest simulations: A randomized controlled trial.

Objectives: In-hospital cardiac arrests are common and associated with high mortality. Smartphone applications offer quick access to algorithms and timers but often lack real-time guidance. This study assesses the impact of the Code Blue Leader application on the performance of providers leading cardiac arrest simulations. Methods: This open-label randomized controlled trial included Advanced Cardiac Life Support (ACLS)-trained medical doctors (MD) and registered nurses (RN). Participants were randomized to lead the same ACLS simulation with or without the app. The primary outcome, "performance score," was assessed by a trained rater using a validated ACLS scoring system. Secondary outcomes included percentage of critical actions performed, number of incorrect actions, and chest compression fraction (percentage of time spent performing chest compressions). A sample size of 30 participants was calculated to detect a difference of 20% at the 0.05 alpha level with 90% power. Results: Fifteen MDs and 15 RNs underwent stratified randomization. The median (interquartile range) performance score in the app group was 95.3% (93.0%-100.0%) compared to 81.4% (60.5%-88.4%) in the control group, demonstrating an effect size of r = 0.69 (Z = -3.78, r = 0.69, p = 0.0002). The percentage of critical actions performed in the app group was 100% (96.2%-100.0%) compared to 85.0% (74.1%-92.4%) in the control group. The number of incorrect actions performed in the app group was 1 (1) compared to 4 (3-5) in the control group. Chest compression fraction in the app group was 75.5% (73.0%-84.0%) compared to 75.0% (72.0%-85.0%) in the control group. Conclusions: The Code Blue Leader smartphone app significantly improved the performance of ACLS-trained providers in cardiac arrest simulations.

Temporally guided articulated hand pose tracking in surgical videos.

PURPOSE: Articulated hand pose tracking is an under-explored problem that carries the potential for use in an extensive number of applications, especially in the medical domain. With a robust and accurate tracking system on surgical videos, the motion dynamics and movement patterns of the hands can be captured and analyzed for many rich tasks. METHODS: In this work, we propose a novel hand pose estimation model, CondPose, which improves detection and tracking accuracy by incorporating a pose prior into its prediction. We show improvements over state-of-the-art methods which provide frame-wise independent predictions, by following a temporally guided approach that effectively leverages past predictions. RESULTS: We collect Surgical Hands, the first dataset that provides multi-instance articulated hand pose annotations for videos. Our dataset provides over 8.1k annotated hand poses from publicly available surgical videos and bounding boxes, pose annotations, and tracking IDs to enable multi-instance tracking. When evaluated on Surgical Hands, we show our method outperforms the state-of-the-art approach using mean Average Precision, to measure pose estimation accuracy, and Multiple Object Tracking Accuracy, to assess pose tracking performance. CONCLUSION: In comparison to a frame-wise independent strategy, we show greater performance in detecting and tracking hand poses and more substantial impact on localization accuracy. This has positive implications in generating more accurate representations of hands in the scene to be used for targeted downstream tasks.

Using Digital Biomarkers for Objective Assessment of Perfusionists' Workload and Acute Stress During Cardiac Surgery.

The cardiac operating room (OR) is a high-risk, high-stakes environment inserted into a complex socio-technical healthcare system. During cardiopulmonary bypass (CPB), the most critical phase of cardiac surgery, the perfusionist has a crucial role within the interprofessional OR team, being responsible for optimizing patient perfusion while coordinating other tasks with the surgeon, anesthesiologist, and nurses. The aim of this study was to investigate objective digital biomarkers of perfusionists' workload and stress derived from heart rate variability (HRV) metrics captured via a wearable physiological sensor in a real cardiac OR. We explored the relationships between several HRV parameters and validated self-report measures of surgical task workload (SURG-TLX) and acute stress (STAI-SF), as well as surgical processes and outcome measures. We found that the frequency-domain HRV parameter HF relative power - FFT (%) presented the strongest association with task workload (correlation coefficient: -0.491, p-value: 0.003). We also found that the time-domain HRV parameter RMSSD (ms) presented the strongest correlation with perfusionists' acute stress (correlation coefficient: -0.489, p-value: 0.005). A few workload and stress biomarkers were also associated with bypass time and patient length of stay in the hospital. The findings from this study will inform future research regarding which HRV-based biomarkers are best suited for the development of cognitive support systems capable of monitoring surgical workload and stress in real time.

Implementing ultrasound-guided nerve blocks in the emergency department: A low-cost, low-fidelity training approach.

Background: Managing acute pain is a common challenge in the emergency department (ED). Though widely used in perioperative settings, ED-based ultrasound-guided nerve blocks (UGNBs) have been slow to gain traction. Here, we develop a low-cost, low-fidelity, simulation-based training curriculum in UGNBs for emergency physicians to improve procedural competence and confidence. Methods: In this pre-/postintervention study, ED physicians were enrolled to participate in a 2-h, in-person simulation training session composed of a didactic session followed by rotation through stations using handmade pork-based UGNB models. Learner confidence with performing and supervising UGNBs as well as knowledge and procedural-based competence were assessed pre- and posttraining via electronic survey quizzes. One-way repeated-measures ANOVAs and pairwise comparisons were conducted. The numbers of nerve blocks performed clinically in the department pre- and postintervention were compared. Results: In total, 36 participants enrolled in training sessions, eight participants completed surveys at all three data collection time points. Of enrolled participants, 56% were trainees, 39% were faculty, 56% were female, and 53% self-identified as White. Knowledge and competency scores increased immediately postintervention (mean ± SD t0 score 66.9 ± 8.9 vs. t1 score 90.4 ± 11.7; p < 0.001), and decreased 3 months postintervention but remained elevated above baseline (t2 scores 77.2 ± 11.5, compared to t0; p = 0.03). Self-reported confidence in performing UGNBs increased posttraining (t0 5.0 ± 2.3 compared to t1 score 7.1 ± 1.5; p = 0.002) but decreased to baseline levels 3 months postintervention (t2 = 6.0 ± 1.9, compared to t0; p = 0.30). Conclusions: A low-cost, low-fidelity simulation curriculum can improve ED provider procedural-based competence and confidence in performing UGNBs in the short term, with a trend toward sustained improvement in knowledge and confidence. Curriculum adjustments to achieve sustained improvement in confidence performing and supervising UGNBs long term are key to increased ED-based UGNB use.