Information needs in operating room teams: what is right, what is wrong, and what is needed?

BACKGROUND: Safe surgical care requires effective information transfer between members of the operating room (OR) team. The present study aims to assess directly, systematically, and comprehensively, information needs of all OR team-members. METHODS: Thirty-three OR team-members (16 surgeons/anesthesiologists, 17 nurses) took part in a mixed-method interview. Participants indicated what information they need, their problems accessing it, and potential interventions to improve information transfer. They also rated the importance of different sources of information and the quality (accuracy, availability, timeliness, completeness, and clarity) of the information that they typically receive. Theme extraction and statistical analyses (descriptive and inferential) were used to analyze the data. RESULTS: The patient emerged as the top source of information. Surgeons and anesthesiologists relied more on information from fellow clinicians, as well as information originating from diagnostic and imaging labs. They were also more critical about the quality of the information than nursing personnel. Anesthesiologists emerged as the most reliable source of information, whereas information coming from surgeons was deemed lacking in quality (even by surgeons themselves). Finally, the more time participants had spent working in ORs, the more negative views they had about the information that they receive-an unexpected finding. Communication skills training, standardized communication protocols, and information technology (IT) systems to function as a central information repository were the top three proposed interventions. CONCLUSIONS: This study comprehensively maps information sources, problems, and solutions expressed by OR end-users. Recent developments in skills training modules and patient safety interventions for the OR (Surgical Safety Checklist) are discussed as potential interventions that will ameliorate communication in ORs, with a view to enhance patient safety and surgical care.

Annoyances, disruptions, and interruptions in surgery: the Disruptions in Surgery Index (DiSI).

BACKGROUND: Recent studies have investigated disruptions to surgical process via observation. We developed the Disruptions in Surgery Index (DiSI) to assess operating room professionals' self-perceptions of disruptions that affect surgical processes. MATERIALS: The DiSI assesses individual issues, operating room environment, communication, coordination/situational awareness, patient-related disruptions, team cohesion, and organizational issues. Sixteen surgeons, 26 nurses, and 20 anesthetists/operating departmental practitioners participated. Participants judged for themselves and for their colleagues how often each disruption occurs, its contribution to error, and obstruction of surgical goals. RESULTS: We combined the team cohesion and organizational disruptions to improve reliability. All participants judged that individual issues, operating room environment, and communication issues affect others more often and more severely than one's self. Surgeons reported significantly fewer disruptions than nurses or anesthetists. CONCLUSION: Although operating room professionals acknowledged disruptions and their impact, they attributed disruptions related to individual performance and attitudes more to their colleagues than to themselves. The cross-professional discrepancy in perceived disruptions (surgeons perceiving fewer than the other two groups) suggests that attempts to improve the surgical environment should always start with thorough assessment of the views of all its users. DiSI is useful in that it differentiates between the frequency and the severity of disruptions. Further research should explore correlations of DiSI-assessed perceptions and other observable measures.

Which doctors are influenced by a patient's age? A multi-method study of angina treatment in general practice, cardiology and gerontology.

BACKGROUND: Elderly patients with cardiovascular disease are relatively undertreated and undertested. OBJECTIVES: To investigate whether, and how, individual doctors are influenced by a patient's age in their investigation and treatment of angina. DESIGN: Process-based judgment analysis using electronic patients, semistructured interviews. SETTING: Primary Care, Care of the Elderly and Cardiology in England. PARTICIPANTS: Eighty five doctors: 29 cardiologists, 28 care of the elderly specialists and 28 general practitioners (GPs). MAIN OUTCOME MEASURES: Testing and treatment decisions on hypothetical patients. RESULTS: Forty six per cent of GPs and care of the elderly doctors, and 48% of cardiologists treated patients aged 65+ differently to those under 65, independent of comorbidity. This effect was evident on several decisions: elderly patients were less likely to be prescribed a statin given a cholesterol test, referred to a cardiologist, given an exercise tolerance test, angiography and revascularisation; more likely to have their current prescriptions changed and to be given a follow-up appointment. There was no effect of specialty, gender or years of training on influence of patient age. Those doctors who were influenced by age were on average five years older than those who were not. Interviews revealed that some doctors saw old age as a contraindication to treat. CONCLUSIONS: Age, independent of comorbidity, presentation and patients' wishes, directly influenced decision-making about angina investigation and treatment by half of the doctors in the primary and secondary care samples. Doctors explicitly reasoned about the direct influence of age and age-associated influences.

Variations in cardiac interventions: doctors' practices and views.

OBJECTIVES: To investigate referral rates for cardiac interventions by clinical specialty, to document doctors' reasons for referrals and to explore doctors' perceptions of the factors that influenced their clinical decisions. STUDY DESIGN: Doctors completed a clinical decision-making exercise involving, in total, 6093 electronic patients with cardiac disease, and subsequently took part in the semi-structured interviews about influences on their decisions. Interviews were audio-recorded, transcribed and coded using a thematic approach, with the coding categories derived from the data. STUDY SETTING: Eighty-eight doctors (GPs, care-of-the-elderly specialists, cardiologists) participated in the full study, in seven areas in southern, central and northern England. Complete interview data were analysed for 76 of these. PRINCIPAL FINDINGS: Not all patients who were eligible for specific investigations or treatment received these. The extent of variations in clinical decisions differed by type of intervention. Apart from the general reasons for referrals, doctors raised nine main influences on their actual decision making. The most commonly reported influence ('barrier') was poor access to equipment for intervention, which increased thresholds for investigation and treatment. CONCLUSIONS: The current emphasis on achieving targets in the British NHS has led to a focus on easily measurable, but crude, process targets such as waiting lists. This study points to the need to include a broader quality assurance element to investigate the cluster of system failures which lead to variations in clinical decisions and thereby to inequitable treatment.

Surgical crisis management skills training and assessment: a simulation[corrected]-based approach to enhancing operating room performance.

BACKGROUND: Intraoperative surgical crisis management is learned in an unstructured manner. In aviation, simulation training allows aircrews to coordinate and standardize recovery strategies. Our aim was to develop a surgical crisis simulation and evaluate its feasibility, realism, and validity of the measures used to assess performance. METHODS: Surgical trainees were exposed to a bleeding crisis in a simulated operating theater. Assessment of performance consisted of a trainee's technical ability to control the bleeding and of their team/human factors skills. This assessment was performed in a blinded manner by 2 surgeons and one human factors expert. Other measures consisted of time measures such as time to diagnose the bleeding (TD), inform team members (TT), achieve control (TC), and close the laceration (TL). Blood loss was used as a surrogate outcome measures. RESULTS: There were considerable variations within both senior (n = 10) and junior (n = 10) trainees for technical and team skills. However, while the senior trainees scored higher than the juniors for technical skills (P = 0.001), there were no differences in human factors skills. There were also significant differences between the 2 groups for TD (P = 0.01), TC (P = 0.001), and TL (0.001). The blood loss was higher in the junior group. CONCLUSIONS: We have described the development of a novel simulated setting for the training of crisis management skills and the variability in performance both in between and within the 2 groups.