A correlational analysis of COVID-19 incidence and mortality and urban determinants of vitamin D status across the London boroughs.

One of the biggest challenges of the COVID-19 pandemic is the heterogeneity in disease severity exhibited amongst patients. Among multiple factors, latest studies suggest vitamin D deficiency and pre-existing health conditions to be major contributors to death from COVID-19. It is known that certain urban form attributes can impact sun exposure and vitamin D synthesis. Also, long-term exposure to air pollution can play an independent role in vitamin D deficiency. We conducted a correlational analysis of urban form and air quality in relation to the demographics and COVID-19 incidence and mortality across 32 London boroughs between March 2020 and January 2021. We found total population, number of residents of Asian ethnicity, 4-year average PM10 levels and road length to be positively correlated with COVID-19 cases and deaths. We also found percentage of households with access to total open space to be negatively correlated with COVID-19 deaths. Our findings link COVID-19 incidence and mortality across London with environmental variables linked to vitamin D status. Our study is entirely based on publicly available data and provides a reference framework for further research as more data are gathered and the syndemic dimension of COVID-19 becomes increasingly relevant in connection to health inequalities within large urban areas.

Obesity, oxidative DNA damage and vitamin D as predictors of genomic instability in children and adolescents.

BACKGROUND/OBJECTIVES: Epidemiological evidence indicates obesity in childhood and adolescence to be an independent risk factor for cancer and premature mortality in adulthood. Pathological implications from excess adiposity may begin early in life. Obesity is concurrent with a state of chronic inflammation, a well-known aetiological factor for DNA damage. In addition, obesity has been associated with micro-nutritional deficiencies. Vitamin D has attracted attention for its anti-inflammatory properties and role in genomic integrity and stability. The aim of this study was to determine a novel approach for predicting genomic instability via the combined assessment of adiposity, DNA damage, systemic inflammation, and vitamin D status. SUBJECTS/METHODS: We carried out a cross-sectional study with 132 participants, aged 10-18, recruited from schools and paediatric obesity clinics in London. Anthropometric assessments included BMI Z-score, waist and hip circumference, and body fat percentage via bioelectrical impedance. Inflammation and vitamin D levels in saliva were assessed by enzyme-linked immunosorbent assay. Oxidative DNA damage was determined via quantification of 8-hydroxy-2'-deoxyguanosine in urine. Exfoliated cells from the oral cavity were scored for genomic instability via the buccal cytome assay. RESULTS: As expected, comparisons between participants with obesity and normal range BMI showed significant differences in anthropometric measures (p < 0.001). Significant differences were also observed in some measures of genomic instability (p < 0.001). When examining relationships between variables for all participants, markers of adiposity positively correlated with acquired oxidative DNA damage (p < 0.01) and genomic instability (p < 0.001), and negatively correlated with vitamin D (p < 0.01). Multiple regression analyses identified obesity (p < 0.001), vitamin D (p < 0.001), and oxidative DNA damage (p < 0.05) as the three significant predictors of genomic instability. CONCLUSIONS: Obesity, oxidative DNA damage, and vitamin D deficiency are significant predictors of genomic instability. Non-invasive biomonitoring and predictive modelling of genomic instability in young patients with obesity may contribute to the prioritisation and severity of clinical intervention measures.

Work conditions, mental workload and patient care quality: a multisource study in the emergency department.

BACKGROUND: Workflow interruptions, multitasking and workload demands are inherent to emergency departments (ED) work systems. Potential effects of ED providers' work on care quality and patient safety have, however, been rarely addressed. We aimed to investigate the prevalence and associations of ED staff's workflow interruptions, multitasking and workload with patient care quality outcomes. METHODS: We applied a mixed-methods design in a two-step procedure. First, we conducted a time-motion study to observe the rate of interruptions and multitasking activities. Second, during 20-day shifts we assessed ED staff's reports on workflow interruptions, multitasking activities and mental workload. Additionally, we assessed two care quality indicators with standardised questionnaires: first, ED patients' evaluations of perceived care quality; second, patient intrahospital transfers evaluated by ward staff. The study was conducted in a medium-sized community ED (16 600 annual visits). RESULTS: ED personnel's workflow was disrupted on average 5.63 times per hour. 30% of time was spent on multitasking activities. During 20 observations days, data were gathered from 76 ED professionals, 239 patients and 205 patient transfers. After aggregating daywise data and controlling for staffing levels, prospective associations revealed significant negative associations between ED personnel's mental workload and patients' perceived quality of care. Conversely, workflow interruptions were positively associated with patient-related information on discharge and overall quality of transfer. CONCLUSIONS: Our investigation indicated that ED staff's capability to cope with demanding work conditions was associated with patient care quality. Our findings contribute to an improved understanding of the complex effects of interruptions and multitasking in the ED environment for creating safe and efficient ED work and care systems.

A multicentre observational study to evaluate a new tool to assess emergency physicians' non-technical skills.

OBJECTIVE: To evaluate a new tool to assess emergency physicians' non-technical skills. METHODS: This was a multicentre observational study using data collected at four emergency departments in England. A proportion of observations used paired observers to obtain data for inter-rater reliability. Data were also collected for test-retest reliability, observability of skills, mean ratings and dispersion of ratings for each skill, as well as a comparison of skill level between hospitals. Qualitative data described the range of non-technical skills exhibited by trainees and identified sources of rater error. RESULTS: 96 assessments of 43 senior trainees were completed. At a scale level, intra-class coefficients were 0.575, 0.532 and 0.419 and using mean scores were 0.824, 0.702 and 0.519. Spearman's ρ for calculating test-retest reliability was 0.70 using mean scores. All skills were observed more than 60% of the time. The skill Maintenance of Standards received the lowest mean rating (4.8 on a nine-point scale) and the highest mean was calculated for Team Building (6.0). Two skills, Supervision & Feedback and Situational Awareness-Gathering Information, had significantly different distributions of ratings across the four hospitals (p<0.04 and 0.007, respectively), and this appeared to be related to the leadership roles of trainees. CONCLUSION: This study shows the performance of the assessment tool is acceptable and provides valuable information to structure the assessment and training of non-technical skills, especially in relation to leadership. The framework of skills may be used to identify areas for development in individual trainees, as well as guide other patient safety interventions.

Identifying nontechnical skills associated with safety in the emergency department: a scoping review of the literature.

STUDY OBJECTIVE: Understanding the nontechnical skills specifically applicable to the emergency department (ED) is essential to facilitate training and more broadly consider interventions to reduce error. The aim of this scoping review is to first identify and then explore in depth the nontechnical skills linked to safety in the ED. METHODS: The review was conducted in 2 stages. In stage 1, online databases were searched for published empirical studies linking nontechnical skills to safety and performance in the ED. Articles were analyzed to identify key ED nontechnical skills. In stage 2, these key skills were used to generate additional key words, which enabled a second search of the literature to be undertaken and expand on the evidence available for review. RESULTS: In stage 1, 11 articles were retrieved for data analysis and 9 core emergency medicine nontechnical skills were identified. These were communicating, managing workload, anticipating, situational awareness, supervising and providing feedback, leadership, maintaining standards, using assertiveness, and decisionmaking. In stage 2, a secondary search, using these 9 skills and related terms, uncovered a further 21 relevant articles. Therefore, 32 articles were used to describe the main nontechnical skills linked to safety in the ED. CONCLUSION: This article highlights the challenges of reviewing a topic for which the terms are not clearly defined in the literature. A novel methodological approach is described that provides a structured and transparent process for reviewing the literature in emerging areas of interest. A series of literature reviews focusing on individual nontechnical skills will provide a clearer understanding of how the skills identified contribute to safety in the ED.

Development and validation of a tool to assess emergency physicians' nontechnical skills.

STUDY OBJECTIVE: Nontechnical skills are "the cognitive, social and personal resource skills that complement technical skills, and contribute to safe and efficient task performance." Our research team developed and evaluated the task of developing and validating a behavioral marker system for the observational assessment of emergency physicians' nontechnical skills. METHODS: The development of the tool was divided into 3 phases and used triangulation of data from a number of sources. During phase 1, a provisional assessment tool was developed according to published literature and curricula. Phase 2 used analysis of staff interviews and field observations to determine whether the skill list contained any significant omissions. These studies were also used to identify behavioral markers linked to nontechnical skills in the context of the emergency department (ED) and establish whether skills included in the tool were observable. Phase 3 involved evaluating the content validity index of exemplar behaviors, using a survey of experts. RESULTS: A behavioral marker system was developed that comprised 12 emergency medicine-specific nontechnical skills, grouped into 4 categories. Content validity was assessed with a survey of 148 emergency medicine staff, and 75% of items achieved the recommended content validity index greater than 0.75. Data from the survey enabled further refinement of the behavioral markers to produce a final version of the tool. CONCLUSION: Although further evaluative studies are needed, this behavioral marker system provides a structured approach to the assessment and training of nontechnical skills in the ED.

The ABC of handover: a qualitative study to develop a new tool for handover in the emergency department.

OBJECTIVES: This study identifies best practice for shift handover and introduces a new tool used to hand over clinical and operational issues at the end of a shift in the emergency department (ED). METHODS: Literature review, semi-structured interviews and observations of handover were used to develop a standardised process for handover. Participants were ED middle grades, consultants and senior nurses. Interviews were used to identify agreed best practice and derive a tool to classify the information into relevant sections. RESULTS: Interviews identified a variety of perceived current deficits in handover including a lack of standardised practice and structure. Participants provided examples of poor handover that were thought to have led to adverse events; these included delay in investigations and treatment for patients who were handed over with brief or inaccurate information. There was wide variation in the understanding of the meaning and purpose of shift handover, and differences were apparent according to the level of experience of the middle grades interviewed. The experts' responses were used to reach a unifying 'best practice' for the content of handover. This was then grouped under ABCDE headings to develop the ABC of handover tool. CONCLUSIONS: A simple tool was developed to provide the basis for medical shift handover, which includes clinical and operational information necessary for efficiency and organisation of the next shift. The ABC of handover classifies shift information to be handed over under the ABCDE headings, which are easy to remember and highly relevant to emergency medicine.

Teams under pressure in the emergency department: an interview study.

OBJECTIVE: To identify key stressors for emergency department (ED) staff, investigate positive and negative behaviours associated with working under pressure and consider interventions that may improve how the ED team functions. METHODS: This was a qualitative study involving semistructured interviews. Data were collected from staff working in the ED of a London teaching hospital. A purposive sampling method was employed to recruit staff from a variety of grades and included both doctors and nurses. RESULTS: 22 staff members took part in the study. The most frequently mentioned stressors included the '4-hour' target, excess workload, staff shortages and lack of teamwork, both within the ED and with inpatient staff. Leadership and teamwork were found to be mediating factors between objective stress (eg, workload and staffing) and the subjective experience. Participants described the impact of high pressure on communication practices, departmental overview and the management of staff and patients. The study also revealed high levels of misunderstanding between senior and junior staff. Suggested interventions related to leadership and teamwork training, advertising staff breaks, efforts to help staff remain calm under pressure and addressing team motivation. CONCLUSIONS: This study highlights the variety of stressors that ED staff are subject to and considers a number of cost-efficient interventions. Medical education needs to expand to include training in leadership and other 'non-technical' skills in addition to traditional clinical skills.

The ABC of handover: impact on shift handover in the emergency department.

INTRODUCTION: A study was undertaken to test the impact of a new tool for shift handover, 'The ABC of Handover', in the emergency department (ED). The impact on shift handover following implementation of this structured tool, the effect on clinical and organisational aspects of the subsequent shift and the opinions of users of this new tool are reported. METHODS: A prospective observational before and after study was performed to explore the effect of implementing 'The ABC of Handover' on clinical and organisational practice using a questionnaire. RESULTS: 41 handovers were observed before implementation of 'The ABC of Handover' and 42 were observed after. The new tool was successfully implemented and resulted in a change of practice which led to a significant increase in the operational issues mentioned at handover from a mean of 34% to a mean of 86% of essential items with the ABC method. Over the study period, middle-grade staff demonstrated improved situational awareness as they adopted proactive management of operational issues such as staffing or equipment shortages. All participants reported that 'The ABC of Handover' improved handover regardless of the seniority of the doctor giving it, and found the ABC method easy to learn. CONCLUSIONS: Successful implementation of 'The ABC of Handover' led to a change of practice in the ED. Improving handover resulted in better organisation of the shift and heightened awareness of potential patient safety issues. The ABC method provides a framework for organising the shift and preparing for events in the subsequent shift.

Patient safety factors in children dying in a paediatric intensive care unit (PICU): a case notes review study.

OBJECTIVE: To identify patient safety factors in pre-hospital and hospital management of critically ill children dying in a paediatric intensive care unit (PICU). DESIGN: Retrospective case notes review. SETTING: Single tertiary regional PICU in London. PARTICIPANTS: 47 patients (7%) who died from a total of 679 children admitted during 2007 and 2008. Median age was 1.1 years and median predicted mortality from the Paediatric Index of Mortality 2 score was 39%. MAIN OUTCOME MEASURES: Adverse events contributing to death (AEds) and critical incidents (CIs). AEd was defined as an unintended injury or complication caused by health care management, contributing to death. CI was defined as an undesirable event in healthcare management, which could have led to harm or did lead to harm of the patient but did not contribute to the patient's death. RESULTS: 22 AEds occurred in 17 of 47 (36%) cases. Two AEds occurred in primary care, 20 in pre-PICU hospital care, and none in PICU. AEds were mainly problems in diagnosis and management of critical illness. 37 CIs occurred in 28 of 47 (60%) cases. Two CIs occurred prior to hospital admission, 17 occurred in pre-PICU hospital care, 1 during inter-hospital transport and 17 in PICU. CIs were predominantly medical management and procedure related. Individual, team and organisational factors caused the majority of AEds and CIs. CONCLUSION: Adverse events in pre-PICU hospital care were common in children who subsequently died in PICU. CIs occurred throughout the patient journey. Interventional studies of healthcare organisation and delivery are necessary to identify appropriate strategies to improve patient safety.

Stress management training for surgeons-a randomized, controlled, intervention study.

BACKGROUND: Stress and coping influence performance. In this study, we evaluate a novel stress management intervention for surgeons. METHODS: A randomized control group design was used. Sixteen surgeons were allocated to either the intervention or control group. The intervention group received training on coping strategies, mental rehearsal, and relaxation. Performance measures were obtained during simulated operations and included objective-structured assessment of technical skill, observational teamwork assessment for surgery, and end product assessment rated by experts. Stress was assessed using the state-trait-anxiety-inventory, observer rating, coefficient of heart rate variability (C_HRV), and salivary cortisol. The number of applied surgical coping strategies (number of coping strategies [NC]) was assessed using a questionnaire. A t test for paired samples investigated any within-subject changes, and multiple linear regression analysis explored between-subject effects. Interviews explored surgeons' perceptions of the intervention. RESULTS: The intervention group showed enhanced observational teamwork assessment for surgery performance (t = -2.767, P < 0.05), and increased coping skills (t = -4.690, P < 0.01), and reduced stress reflected inheart rate variability (t = -4.008, P < 0.01). No significant changes were identified in the control group. Linear regression analysis confirmed a significant effect on NC (ß = -0.739, P < 0.01). Qualitative data analysis revealed improved technical skills, decision making, and confidence. CONCLUSIONS: The intervention had beneficial effects on coping, stress, and nontechnical skills during simulated surgery.

The Imperial Stress Assessment Tool (ISAT): a feasible, reliable and valid approach to measuring stress in the operating room.

BACKGROUND: Stress can impair surgical performance and may compromise patient safety. This prospective, cross-sectional study describes the feasibility, reliability, and validity of the Imperial Stress Assessment Tool (ISAT) as an approach to measuring stress during surgery. METHODS: A total of 54 procedures were observed with 11 surgeons (4 attendings, 4 senior residents and 3 junior residents) in a large university teaching hospital in London, UK. Data collection involved physiological measures of operating surgeons [heart rate (HR) and salivary cortisol] and self-report questionnaires (State Trait Anxiety Inventory, or STAI). RESULTS: In all, 23 of 54 procedures were stressful, as identified by self-reporting. For stressful procedures compared to nonstressful ones, STAI was higher (mean +/- SD) 9.81 +/- 2.20 vs. 12.87 +/- 4.27, t (30.64) = 3.15 as was the HR (mean +/- SD) 79.94 +/- 8.55 vs. 93.17 +/- 14.94, t(32.57) = 3.81) (p < 0.05). Significant positive correlations were obtained between the measures indicating concurrent validity: Pearson's r = 0.47 (HR vs. STAI), 0.34 (cortisol vs. STAI), and 0.57 (HR vs. cortisol) (p < 0.05). Perfect correlation of subjective and objective measures was found for 70% of the procedures. HR and cortisol had specificities of 78% and 91% and sensitivities of 91% and 70% respectively for detecting stress during surgery. CONCLUSION: ISAT is a nonintrusive, feasible approach that combines subjective and objective methods for measuring stress in the operating room. The ISAT may increase understanding of the effects of stress on clinical performance and outcomes, leading to improved patient care.

Factors compromising safety in surgery: stressful events in the operating room.

BACKGROUND: Stressful events occur in the operating room (OR) with potentially severe consequences for patient safety. We recorded the incidence of these events in the OR, assessed the levels of stress that they caused, and investigated their detectability. METHODS: Stressful incidents in the OR were recorded and rated in real time by an observer in 55 general and orthopedic procedures. Operating surgeons also rated incident stressfulness and their stress (validated State Trait Anxiety Inventory). RESULTS: The total count of stressors/case ranged from 1 to 23.5 (mean, 5.87). Technical, patient, and equipment problems occurred frequently and were most stressful. Frequent but least severe stressors were distractions/interruptions, whereas least frequent/most severe stressors were teamwork problems. These events were associated with an increase in surgeons' self-reported stress. The observer was able to capture surgeons' stress accurately. CONCLUSIONS: Systematically occurring stressors in the OR affect surgeons and can be assessed accurately. Further research should investigate the impact of stress on surgical performance.

Reflective analysis of safety research in the hospital accident & emergency departments.

Providing health care in emergency settings is complex, hazardous work that is vulnerable to failure. Human factors and ergonomics studies of hazardous work in other settings have produced useful insights, innovations, and contributions to improving safety in those fields, so there is great interest in applying similar methods to the study of clinical work. However, the clinical environment presents some unique challenges to researchers. We discuss some of those challenges, based on our experience in conducting a variety of studies in the emergency setting in the US and UK, and offer suggestions for future work in this area.

The effects of stress and coping on surgical performance during simulations.

OBJECTIVE: This study investigates the effects of surgeons' stress levels and coping strategies on surgical performance during simulated operations. METHODS: Thirty surgeons carried out each a non-crisis and a crisis scenario of a simulated operation. Surgeons' stress levels were assessed by several measures: self-assessments and observer ratings of stress, heart rate, heart rate variability, and salivary cortisol. Coping strategies were explored qualitatively and quantified to a coping score. Experience in surgery was included as an additional predictor. Outcome measures consisted of technical surgical skills using Objective Structured Assessment of Technical Skill (OSATS), nontechnical surgical skills using Observational Teamwork Assessment for Surgery (OTAS), and the quality of the operative end product using End Product Assessment (EPA). Uni- and multivariate linear regression were used to assess the independent effects of predictor variables on each performance measure. RESULTS: During the non-crisis simulation, a high coping score and experience significantly enhanced EPA (beta1, 0.279; 0.009-0.460; P= 0.04; beta2, 0.571; 4.328-12.669, P< 0.001; respectively). During the crisis simulation, a significant beneficial effect of the interaction of high experience and low stress on all performance measures was found (EPA: beta, 0.537; 2.079-8.543; OSATS: beta, 0.707; 8.708-17.860; OTAS: beta, 0.654; 13.090-30.483; P< 0.01). Coping significantly enhanced nontechnical skills (beta, 0.302; 0.117-1.624, P= 0.03). CONCLUSIONS: Clinicians' stress and coping influenced surgical performance during simulated operations. Hence, these are critical factors for the quality of health care.

The impact of stress on surgical performance: a systematic review of the literature.

BACKGROUND: Safe surgical practice requires a combination of technical and nontechnical abilities. Both sets of skills can be impaired by intra-operative stress, compromising performance and patient safety. This systematic review aims to assess the effects of intra-operative stress on surgical performance. METHODS: A systematic search strategy was implemented to obtain relevant articles. MEDLINE, EMBASE, and PsycINFO databases were searched, and 3,547 abstracts were identified. After application of limits, 660 abstracts were retrieved for subsequent evaluation. Studies were included on the basis of predetermined inclusion criteria and independent assessment by 2 reviewers. RESULTS: In all, 22 articles formed the evidence base for this review. Key stressors included laparoscopic surgery (7 studies), bleeding (4 studies), distractions (4 studies), time pressure (3 studies), procedural complexity (3 studies), and equipment problems (2 studies). The methods for assessing stress and performance varied greatly across studies, rendering cross-study comparisons difficult. With only 7 studies assessing stress and surgical performance concurrently, establishing a direct link was challenging. Despite this shortfall, the direction of the evidence suggested that excessive stress impairs performance. Specifically, laparoscopic procedures trigger greater stress levels and poorer technical performance (3 studies), and expert surgeons experience less stress and less impaired performance compared with juniors (2 studies). Finally, 3 studies suggest that stressful crises impair surgeons' nontechnical skills (eg, communication and decision making). CONCLUSION: Surgeons are subject to many intra-operative stressors that can impair their performance. Current evidence is characterized by marked heterogeneity of research designs and variable study quality. Further research on stress and performance is required so that surgical training and clinical excellence can flourish.

Methodological variability in detecting prescribing errors and consequences for the evaluation of interventions.

PURPOSE: To compare four methods of detecting prescribing errors (PE) in the same patient cohorts before and after an intervention (computerised physician order entry; CPOE) and to determine whether the impact of CPOE is identified consistently by all methods. METHODS: PEs were identified using (1) prospective detection by ward pharmacist; (2) retrospective health record review; (3) retrospective use of a trigger tool and (4) spontaneous reporting over two separate 4-week periods on one surgical ward in a UK teaching hospital. RESULTS: We reviewed 93 patients pre- and 114 post-CPOE. Using all four methods, we identified 135 PE (10.7% of all medication orders) pre-CPOE, and 127 (7.9%) post-CPOE. There was little overlap in PE detected by the different methods: prospective detection identified 48 (36% of all PE) pre- and 30 (24%) post-CPOE; retrospective review (RR) revealed 93 (69%) pre- and 105 (83%) post-CPOE, trigger tool 0 pre- and 2 (2%) post-CPOE and spontaneous reporting 1 (1%) pre- and 1 (1%) post-CPOE. The calculated relative reduction in risk of PE was 50% using prospective data, 12% with RR and 26% using data from all four methods. CONCLUSIONS: In this study, each method predominantly identified different PE. A combination of methods may be required to understand the true effectiveness of different interventions.

Managing intraoperative stress: what do surgeons want from a crisis training program?

BACKGROUND: Current surgical training provides little opportunity for surgeons to recognize and manage intraoperative stress before it affects performance and compromises patient safety. We explored the perceived need for structured stress training and propose an intervention design that may be acceptable and appropriate. METHODS: Fifteen semistructured interviews identified stressors in the operating room, characterized coping strategies, and explored surgeons' views about a training intervention. Interviews were analyzed using standard qualitative methods. RESULTS: Stressors and coping strategies confirmed those identified in previous work. Key components of an intervention should include recognizing stress in oneself and in others; experiencing the impact of stress on performance; providing effective coping strategies; offering feedback; and providing opportunities to practice what has been taught in a safe, simulation-based environment. CONCLUSIONS: There is a need for structured training in management of intraoperative stress. Surgeons would welcome a simulation-based intervention to enhance performance and patient safety.

Communication patterns in a UK emergency department.

STUDY OBJECTIVE: Good communication is important in patient care and plays an essential part of teamwork and patient safety. Communication in the emergency department (ED) can be chaotic, with the potential for error resulting from communication overload and problems of communication. The nurse in charge of the ED plays a crucial role in maintaining communication flow. The aims of this study are to identify the features of the communication load on the nurse in charge of the ED. METHODS: This was an observational, nonexperimental study, building on the methods of observation and analysis developed by Coiera. It was carried out in an inner-city hospital ED in London. The nurse in charge of the ED was observed. The following factors were studied: the level of communication, interruptions, and simultaneous events; the channel and purpose of communication; interaction types; unresolved communications and annoying aspects of the observed periods; and the effect of weekday, staffing, and patient levels on the level of communication. RESULTS: Eleven nurses were observed during 18 observation periods during a total of 20 hours. Analysis revealed that there were 2,019 communication events in 20 hours and that 1,183 (59%) were initiated by the nurse in charge. Two hundred eighty-six (14%) simultaneous events/tasks were identified by the observer. One thousand five hundred twenty-eight (76%) communications involving the nurse in charge were face to face, 144 (7%) were by telephone, 107 (5%) concerned the use of the computer, and 104 (5%) concerned the use of the whiteboard. The largest purpose of communication events was related to patient management (48%). There was a slight relationship between junior medical staff and the level of communication and a moderate relationship between communication load and the number of patients in the ED. In addition, a greater number of nurses on duty were associated with fewer communication events with the nurse in charge. CONCLUSION: These findings are an important measure of communication load, which can disrupt memory and lead to mistakes. Improving communication between health care staff by reducing the levels of interruptions and minimizing the volume of irrelevant or unnecessary information exchange could therefore have important implications for patient safety.

The effects of stress on surgical performance.

BACKGROUND: Although the general literature on stress and performance is extensive, little is known about specific effects of stress in surgical practice. This qualitative study explored key surgical stressors, their impact on performance, and coping strategies used by surgeons. METHODS: Individual in-depth semistructured interviews with surgeons were analyzed by 2 researchers independently. Key themes were discussed within the research team. RESULTS: Sixteen interviews were performed, including interviews with consultants (n = 9) and surgeons in training (n = 7). A wide range of intraoperative stressors was identified. Although stress had both positive and negative effects, undue levels of stress impaired judgment, decision making, and communication. Although junior surgeons showed uncertainty about their ability to cope, senior surgeons had developed sophisticated strategies for controlling each situation. CONCLUSIONS: Although stress poses significant risks, coping strategies are not taught explicitly during surgical training. This article presents a framework for categorizing surgical stress and suggests key elements for effective coping strategies.