Patient flow modeling and simulation to study HAI incidence in an Emergency Department.

Healthcare-associated infections (HAIs), or nosocomial infections, refer to patients getting new infections while getting treatment for an existing condition in a healthcare facility. HAI poses a significant challenge in healthcare delivery that results in higher rates of mortality and morbidity as well as a longer duration of hospital stay. While the real cause of HAI in a hospital varies widely and in most cases untraceable, it is popularly believed that patient flow in a hospital-which hospital units patients visit and where they spend the most time since their admission into the hospital-can trace back to HAI incidence in the hospital. Based on this observation, we, in this paper, model and simulate patient flow in an emergency department of a hospital and then utilize the developed model to study HAI incidence therein. We obtain (a) a flowchart of patient movement (admission to discharge) and (b) anonymous patient data from University Health Medical Center for a duration of 11 months (Aug 2022-June 2023). Based on these data, we develop and validate the patient flow model. Our model captures patient movement in different areas of a typical emergency department, such as triage, waiting room, and minor procedure rooms. We employ the discrete-event simulation (DES) technique to model patient flow and associated HAI infections using the simulation software, Anylogic. Our simulation results show that the rates of HAI incidence are proportional to both the specific areas patients occupy and the duration of their stay. By utilizing our model, hospital administrators and infection control teams can implement targeted strategies to reduce the incidence of HAI and enhance patient safety, ultimately leading to improved healthcare outcomes and more efficient resource allocation.

Surgeon Upper Extremity Kinematics During Error and Error-Free Retropubic Trocar Passage.

INTRODUCTION AND HYPOTHESIS: Surgeon kinematics play a significant role in the prevention of patient injury. We hypothesized that elbow extension and ulnar wrist deviation are associated with bladder injury during simulated midurethral sling (MUS) procedures. METHODS: We used motion capture technology to measure surgeons' flexion/extension, abduction/adduction, and internal/external rotation angular time series for shoulder, elbow, and wrist joints. Starting and ending angles, minimum and maximum angles, and range of motion (ROM) were extracted from each time series. We created anatomical multibody models and applied linear mixed modeling to compare kinematics between trials with versus without bladder penetration and attending versus resident surgeons. A total of 32 trials would provide 90% power to detect a difference. RESULTS: Out of 85 passes, 62 were posterior to the suprapubic bone and 20 penetrated the bladder. Trials with versus without bladder penetration were associated with more initial wrist dorsiflexion (-27.32 vs -9.03°, p = 0.01), less final elbow flexion (39.49 vs 60.81, p = 0.03), and greater ROM in both the wrist (27.48 vs 14.01, p = 0.02), and elbow (20.45 vs 12.87, p = 0.04). Wrist deviation and arm pronation were not associated with bladder penetration. Compared with attendings, residents had more ROM in elbow flexion (14.61 vs 8.35°, p < 0.01), but less ROM in wrist dorsiflexion (13.31 vs 20.33, p = 0.02) and arm pronation (4.75 vs 38.46, p < 0.01). CONCLUSIONS: Bladder penetration during MUS is associated with wrist dorsiflexion and elbow flexion but not internal wrist deviation and arm supination. Attending surgeons exerted control with the wrist and forearm, surgical trainees with the elbow. Our findings have direct implications for MUS teaching.

"Right Into the Center": A Semantic Analysis of Direction in Operating Room Instruction.

OBJECTIVE: In our previous work, teaching surgeons used potentially ambiguous language in the OR 12.3 times per minute. Our objectives were to examine ambiguous examples featuring Directional Frame of Reference (DFoR), which involves instructions containing directional terms like "up" or "left," and to uncover what contributes to understanding or misunderstanding of such instruction. DESIGN: We videorecorded the critical moments of 6 surgeries, as chosen by the surgeons. With a semanticist, we applied constructs from formal semantics to choose potentially ambiguous DFoR terms commonly flagged in our previous work. We separately interviewed attending and resident surgeons, asking each to describe the meaning of those DFoR terms while they viewed case recordings alongside transcripts. We compared their responses, analyzing them for agreement in direction. We performed thematic analysis on case and interview transcripts for themes related to DFoR. SETTING: Midwestern academic university teaching hospital. PARTICIPANTS: Six attending and 6 resident surgeons. RESULTS: Attending and resident surgeons disagreed on direction in 9 of the 26 (34.6%) DFoR examples. Misunderstanding arose from using linear direction to describe three-dimensional space, e.g., "up" for anterior/cephalad/right. It also arose when combining degree modifiers with DfoR, e.g., "we're far enough back" combines the ambiguities of "back" (DfoR) and "far enough" (degree modifier). Use of axial parts (noun-like directional terms), e.g., "bottom," and confusing "left" for "right" also provoked misunderstanding. Misunderstanding was associated with lack of experience and mitigated by pointing with a finger or instrument, concurrent with speech. CONCLUSIONS: Use of ambiguous language with DFoR incurs a high potential for misunderstanding, especially with novice surgeons. We recommend avoiding linear directions and axial parts, and instead physically pointing to represent complex 3D directions. Degree modifiers can be replaced with exact distances e.g., replace "little more anterior" with "1 centimeter anterior," and semaphores can be used to clarify direction.

Language in the Teaching Operating Room: Expressing Confidence Versus Community.

OBJECTIVE: Previous work has analyzed residency letters of recommendation for agentic and communal language, but this has not been applied to spoken language. Our objective was to analyze intraoperative spoken language by attending and resident surgeons for the use of agentic and communal language. DESIGN: We completed a linguistic inquiry and word count (LIWC) analysis on 16 operating room transcripts (total time 615 minutes) between attendings and resident surgeons for categories associated with agentic and communal speech. Wilcoxon signed rank and Mann-Whitney U tests were used to compare attending versus resident and male versus female speech patterns for word count; "I," clout, and power (agentic categories); and "we," authentic, social (communal categories). SETTING: Midwestern academic university teaching hospital. PARTICIPANTS: Sixteen male (9 attendings, 7 residents) and 16 female (7 attendings, 9 residents) surgeons, from 6 surgical specialties, most commonly from General Surgery. RESULTS: Attending surgeons used more words per minute than residents (40.01 vs 16.92, p < 0.01), were less likely to use "I" (3.18 vs 5.53, p < 0.01), and spoke more language of "clout" (75.82 vs 55.47, p < 0.01). There were no significant differences between attendings and residents in use of analytic speech (23.72 vs 24.67, p = 0.32), "causation" (1.20 vs 1.08, p = 0.72), or "cognitive processing" (10.20 vs 10.54, p = 0.74). Residents used more speech with "emotional tone" (92.91 vs 79.92, p = 0.03), "positive emotion" (4.98 vs 3.86, p = 0.04), more "assent" language (4.89 vs 3.09, p < 0.01), and more "informal" language (9.27 vs 6.77, p < 0.01). There were no gender differences, except for male residents speaking with greater certainty than female residents, although by less than 1% of the total word count. CONCLUSIONS: In the operating room, attending surgeons were more likely to use agentic language compared to resident surgeons based on LIWC analysis. These differences did not depend on gender and likely relate to surgeon experience and confidence, learning versus teaching, and power dynamics.

Speech Communication Interference in the Operating Room.

INTRODUCTION: Operating room communication is frequently disrupted, raising safety concerns. We used a Speech Interference Instrument to measure the frequency, impact, and causes of speech communication interference (SCI) events. METHODS: In this prospective study, we observed 40 surgeries, primarily general surgery, to measure the frequency of SCI, defined as "group discourse disrupted according to the participants, the goals, or the physical and situational context of the exchange." We performed supplemental observations, focused on conducting postsurgery interviews with SCI event participants to identify contextual factors. We thematically analyzed notes and interviews. RESULTS: The observed 103 SCI events in 40 surgeries (mean 2.58) mostly involved the attending (50.5%), circulating nurse (44.6%), resident (44.6%), or scrub tech (42.7%). The majority (82.1%) of SCI events occurred during another patient-related task. 17.5% occurred at a critical moment. 27.2% of SCI events were not acknowledged or repeated and the message was lost. Including the supplemental observations, 97.0% of SCI events caused a delay (mean 5 s). Inter-rater reliability, calculated by Gwet's AC1 was 0.87-0.98. Postsurgery interviews confirmed miscommunication and distractions. Attention was most commonly diverted by loud noises (e.g., suction), conversations, or multitasking (e.g., using the electronic health record). Successful strategies included repetition or deferment of the request until competing tasks were complete. CONCLUSIONS: Communication interference may have patient safety implications that arise from conflicts with other case-related tasks, machine noises, and other conversations. Reorganization of workflow, tasks, and communication behaviors could reduce miscommunication and improve surgical safety and efficiency.

"Black Women Don't Always Put Our Healthcare First": Facilitators and Barriers to Cervical Cancer Screening and Perceptions of Human Papillomavirus Self-Testing Among Church-Affiliated African American Women.

Background: African American women are at greater risk for cervical cancer incidence and mortality than White women. Up to 90% of cervical cancers are caused by human papillomavirus (HPVs) infections. The National Institutes of Health (NIH) co-developed HPV self-test kits to increase access to screening, which may be critical for underserved populations. Purpose/Research Design: This mixed methods study used the Theory of Planned Behavior to examine attitudes, barriers, facilitators, and intentions related to receipt of cervical cancer screening and perceptions of HPV self-testing among church-affiliated African American women. Study Sample/Data Collection: Participants (N = 35) aged 25-53 participated in focus groups and completed a survey. Results: Seventy-four percent of participants reported receipt of cervical cancer screening in the past 3 years. Healthcare providers and the church were supportive referents of screening. Past trauma and prioritizing children's healthcare needs were screening barriers. Concerns about HPV self-testing included proper test administration and result accuracy. Conclusions: Strategies to mitigate these concerns (e.g., delivering HPV self-test kits to the health department) are discussed.

Hemoglobin A1c and Reoperation After Surgery for Stress Incontinence or Prolapse.

IMPORTANCE: Few studies compare the link between hemogobin A1c (HbA1c) and urogynecologic surgical complications. OBJECTIVE: The objective of this study was to determine the association between HbA1c and reoperation in women undergoing surgery for stress urinary incontinence (SUI) or pelvic organ prolapse (POP). STUDY DESIGN: We performed 2 separate retrospective cohort analyses using Cerner's HealthFacts Database (750 hospitals; 519,000,000 patient encounters from January 1, 2010, to November 30, 2018). We included women undergoing surgery for (1) SUI or (2) apical POP by International Classification of Diseases coding who had HbA1c at the initial procedure. Each analysis compared those undergoing reoperation for complications or recurrence and those who did not. Multivariable logistic regression assessed the association between reoperation and HbA1c both as a continuous variable and comparing the commonly accepted cutoff ≥8. RESULTS: Of 30,180 SUI surgical procedures and 26,389 POP surgical procedures, 1,625 (5.4%) and 805 (3.1%) had HbA1c. Median (interquartile range) HbA1c in grams per deciliter was similar by reoperation status (SUI: 6.0 [5.6-6.8] vs 6.1 [5.6-6.9], P = 0.35; POP: 6.2 [5.6-6.6] vs 6.1 [5.7-6.8], P = 0.60). Reoperation was also similar using the HbA1c ≥8% cutoff (SUI: 6.9% vs 7.4%, P = 0.79; POP: 6.3% vs 5.4%, P = 0.77). On multivariate analysis, HbA1c value was not a significant predictor of reoperation either as a continuous (SUI: odds ratio [OR] = 0.966, 95% CI = 0.833-1.119; POP: OR = 1.040, 95% CI = 0.801-1.350) or dichotomous variable ≥8 (SUI: OR = 0.767, 95% CI = 0.407-1.446; POP: OR = 0.988, 95% CI = 0.331-2.951). Mean follow-up was 4.28-5.13 years. CONCLUSION: Although other studies have shown a link between diabetes and complications, we were unable to show an association between HbA1c values and rates of reoperation.

Cognitive models for mentally visualizing a sharp instrument in a blind procedure.

Purpose: Our objective was to understand the cognitive strategies used by surgeons to mentally visualize navigation of a surgical instrument through blind space. Methods: We conducted semi-structured interviews with 15 expert and novice surgeons following simulated retropubic trocar passage on 3D-printed models of pelvises segmented from preop MRIs. Midurethral sling surgery involves blind passage of a trocar among the urethra, bladder, iliac vessels, and bowel while relying primarily on haptic feedback from the suprapubic bone (SPB) for guidance. Our conceptual foundation was based on Lahav's study on blind people's mental mapping of spaces using haptic cues. Participants detailed how they mentally pictured the trocar's location relative to vital anatomy. We coded all responses and used constant comparative analysis to generate themes, confirmed with member checking. Results: Expert and novice participants utilized multiple cognitive strategies combined with haptic feedback to accomplish safe trocar passage. Some used a step-by-step route strategy, visualizing sequential 2D axial images of anatomy adjacent to the SPB. Others used a map strategy, forming global 3D pictures. Although these mental pictures vanished when they were "lost," a safe zone could be reestablished by touching the SPB. Experts were more likely to relate their body position to the trocar path and rely on minor variations in resistance. Novices were more inclined toward backtracking of the trocar. Conclusions: Our findings may be extended to any blind surgical procedure. Teaching visualization strategies and incorporating tactile feedback can be used intraoperatively to help learners navigate their instrument safely around vital organs.

Surgeon estimation of retropubic trocar position in blind 3D space.

INTRODUCTION AND HYPOTHESIS: Retropubic midurethral sling surgery involves the blind passage of trocars near vital organs. We quantified the proximity of surgeons' mental representation of trocar position relative to actual position using a pelvis simulation platform. We hypothesized that novice surgeons, compared with experts, would estimate the trocar's location to be further from the actual location. METHODS: Novice and expert surgeons performed bilateral retropubic trocar passes of a Gynecare TVT trocar (#810041B-#810,051) on the simulation platform. We measured the trocar tip's position using a motion capture system, and recorded vocalizations when they perceived contacting the bone and crossing three landmark-oriented planes. We calculated differences (∆Bone, ∆Turn, ∆Top, ∆Pop) between vocalization times and when the trocar crossed the corresponding plane. We performed Mann-Whitney and Chi-squared tests to investigate differences between novices and experts and Levene's test to assess equality of variances for subject-level variation. RESULTS: A total of 34 trials, including 22 expert and 12 novice trials, were performed by six participants. ∆Bone was significantly smaller among novice surgeons (1.27 vs 2.81 s, p=0.013). There were no significant differences in the remaining three deltas or in vocalizing early versus late. Levene's test revealed no significant differences in within-subject variability for any of the four deltas. Novices passed the trocar anterior to the pubic bone on three passes. CONCLUSIONS: Novices were similar to expert surgeons in their estimation of the trocar's location and may have relied more heavily on anticipatory mechanisms to compensate for lack of experience. Teaching surgeons should make sure the novice surgeon trocar pass starts posterior to the bone.

The Impact of Facial Personal Protective Equipment on Speech Intensity.

IMPORTANCE: Facial personal protective equipment (FPPE) filters small particles in the operating room (OR) but also affects speech production, diminishing the effective transfer of information among OR team members. OBJECTIVE: The aim of the study is to assess the attenuating effects of different combinations of layered FPPE on speech intensity, including potential differences in the effect of talkers with varying backgrounds and speaking volumes. STUDY DESIGN: We recruited 30 speakers from health and nonhealth occupations with English as either their first or second language. All participants spoke unmasked, at varying voice levels into a portable Zoom H4n device 12 inches from the microphone. These no-mask recordings were played from a Styrofoam head, fitted with 7 combinations of FPPE commonly worn in the COVID-19 era, with the attenuated signals assessed for digital average signal levels. We submitted these attenuation values to an omnibus mixed analysis of variance and performed a spectral analysis on signal attenuation stratified by typical speech frequency bands. RESULTS: Signal attenuation was strongly determined by FPPE combination, regardless of talker sex, first language, and occupation ( P < 0.01, η 2p = 0.881). The effects of vocal output were also significant ( P < 0.01, η 2p = 0.881). Soft talkers experienced particularly high attenuation at frequency bands higher than 2,000 Hz. The signal of the softest talkers, when asked to speak loudly, was similar to the loud talkers' signal. CONCLUSIONS: Layered FPPE in the OR protects the surgical team from small particle exposure but may increase communication failures. Our data can help OR staff choose FPPE and alter their vocal volume accordingly.

Reoperation rates of stress incontinence surgery in rural vs urban hospitals.

BACKGROUND: XXX. OBJECTIVE: This study aimed to determine the impact of a rural vs urban hospital location on the risk of undergoing a second surgery for stress urinary incontinence. STUDY DESIGN: Using the Cerner Health Facts nationwide electronic medical record database, we identified patients who underwent surgeries for stress incontinence between January 1, 2010 and November 30, 2018. Stress incontinence surgeries included synthetic midurethral slings, fascial slings, retropubic urethral suspension, and other surgeries for stress urinary incontinence, such as the laparoscopic sling or the Pereyra procedure. Patients were divided into 2 cohorts, namely those who had a single operation and those who had a reoperation, defined as any second stress incontinence surgery or revision after initial incontinence surgery. Logistic regression analysis was performed to determine whether urban vs rural hospital location impacted reoperation rates. We adjusted for significant sociodemographic variables identified in the univariate analysis with a P value <.1. RESULTS: Of the 25,085 women who underwent stress incontinence procedures, 669 (2.7%) underwent a second surgery. Of these, 346 (51.7%) patients underwent were a second stress incontinence procedure, 307 (45.9%) underwent revisions of the index case, and 16 (2.4%) underwent both. Women in the single surgery cohort were older (median age, 54 vs 53 years; P=.029). In the total sample, 85.5% identified as White and 4.5% identified as Black. Of the study cohort, 7720 (30.8%) had obesity and 2660 (10.6%) had diabetes. There was a higher rate of reoperation among patients with obesity (3.0% vs 2.5%; P=.017). Among patients who underwent a concomitant prolapse surgery with their index surgery, there were fewer reoperations (2.2% vs 2.8%; P=.012). In the univariate analysis, we did not detect a difference between women who lived in rural vs urban areas (3.0% vs 2.6%; P=.16). After adjusting for confounders, we still did not see a significant association between rural hospital location and the risk for repeat surgery (odds ratio, 1.00; 95% confidence interval, 0.76-1.31). In this multivariable regression, obesity increased the risk for having a reoperation (odds ratio, 1.20; 95% confidence interval, 1.02-1.41), whereas patients who had concomitant prolapse procedures with their index surgery had a reduced risk for having a reoperation (odds ratio, 0.80; 95% confidence interval, 0.66-0.98). CONCLUSION: We did not detect an association between hospital location (rural vs urban) and the risk for reoperation among women undergoing stress incontinence surgery. With low reoperation rates, patients can be reassured that they are receiving excellent care in either setting.

Retropubic trocar modified with a load cell to verify contact with pubic bone.

BACKGROUND: Vital injuries during midurethral sling surgery are avoided by maintaining constant trocar contact with bone, and yet this is challenging for a teaching surgeon to monitor during this blind procedure. We modified a retropubic trocar with a load cell to distinguish on-bone and off-bone movement and tested it on a midurethral sling surgery 3-dimensional surgery simulator. METHODS: Two experts and 3 novice surgeons performed retropubic trocar passage on the physical pelvic floor model using the modified trocar. Biofidelity was assessed comparing expert performance on a Thiel-embalmed cadaver and the physical model. The test-retest was assessed comparing performance on the physical pelvic model 2 weeks apart. The force variables were analyzed with paired and independent t tests. We performed post hoc analyses comparing the experts to novices on the physical model. RESULTS: The root-mean-squared force was similar between the cadaver and model (24.3 vs 21.1 pounds, P = .62), suggesting biofidelity. Root-mean-squared force was also similar between the test and retest (14.0 vs 19.1 pounds, P =. 30). The expert surgeons exhibited a larger maximum force amplitude (51.2 vs 22.7 pounds, P = .03), shorter time to maximum force (2.7 vs 9.5 seconds, P = .03) and larger maximum rate of force development (171.5 vs 54.0 pounds/second, P = .01). CONCLUSION: This study suggested high test-retest reliability and adequate biofidelity of the modified trocar used on our midurethral sling surgery 3-dimensional surgery simulator. This innovative trocar can be used both in simulation and in the operating room to help the novice surgeons stay on the bone and to help the attending surgeon monitor safe surgery.

Risk factors for the development of acute pyelonephritis in women with a positive urine culture.

INTRODUCTION: In treating lower urinary tract symptoms (LUTS), the risk of overtreatment with antibiotics must be reconciled with the risk of an untreated urinary tract infection (UTI) progressing to acute pyelonephritis (APN). Using Cerner HealthFacts, a longitudinal clinical informatics database, we aimed to determine risk factors associated with the development of APN from UTI in an effort to guide the initiation of empiric antibiotics. METHODS: We queried the Cerner HealthFacts database for women over age 18 with a positive urine culture. Any patient with an International Classification of Disease (ICD) code indicating chronic pyelonephritis was excluded. Development of APN within 30 days of the positive culture, specified by ICD coding, was our primary outcome. Patient and facility factors were assessed as potential risk factors for the development of APN using multivariable regression. RESULTS: Out of 58 344 women with a positive urine culture, 3.9% (2296) developed APN. Mean patient age was 54.4 ± 25.3 years. Overall, 12 variables were predictive for APN and 11 variables were protective against APN. Presence of obstructive and reflux uropathies (OR 4.58), presentation to an acute care facility (OR 3.19), urinary retention (OR 2.30), history of UTI (OR 2.19), and renal comorbidities (OR 2.07) conferred the highest odds of APN development. The most protective variable against APN development was cognitive impairment (OR 0.49). CONCLUSIONS: Identified risk factors associated with APN development may aid decisions regarding empiric antibiotic initiation for patients presenting with LUTS while awaiting urine culture results. The relationship between cognitive impairment and progression to APN deserves further study.

Optimizing surgical teaching through the lens of sociocultural learning theory.

BACKGROUND: The objective of this study was to identify intraoperative instructional strategies that embody the ways that learning occurs in the social contexts of surgery. METHODS: We performed a qualitative review of examples of intraoperative teaching from transcripts of ten videotaped surgeries, coupled with interviews with surgical attendings and residents. We coded the examples according to the key tenets of sociocultural learning theories and used these codes to develop instructional strategies aimed at improving resident surgical autonomy. RESULTS: The sociocultural learning theories prompted six intraoperative teaching strategies (Assess Learner Needs, Inquire, Coach, Permit, Entrust, and Debrief) to address residents' learning needs in specific surgical tasks. The six strategies involve identifying procedure-specific learning needs; discussing interventions based on strategies successful with other learners; providing in-the-moment, interactive coaching; allowing the resident to struggle; increasing the resident's graduated responsibility; debriefing about successes and struggles. CONCLUSIONS: We argue that these six strategies should improve the quality of intraoperative teaching, and therefore, enhance progression to autonomous practice.

Human-Caused Sound Distractors and their Impact on Operating Room Team Function.

BACKGROUND: Patient safety in the Operating Room (OR) depends on unobstructed team communication. Yet the typical OR is loud, containing numerous sounds from surgical machinery overlayed with human-caused sounds. Our objective was to compare machine vs human-caused sounds for their loudness and distraction, and potential impact on team communication. METHODS: After surveying OR staff about sounds that interfere with job performance and team communication, we recorded 19 machine and 48 human-caused sounds measuring their acoustical intensity. We compared peak measures of machine vs human-caused sound loudness, using Student's t-test. We observed the effect of these sounds on OR staff in 59 live surgeries, rating level of interference with team function. We visually depicted competing sounds through a spectral analysis. RESULTS: The survey response rate was 62.8%. 93% of respondents indicated that OR noise, especially human-caused sounds such as irrelevant conversations, interfere with team communication, hearing, and focus. OR peak decibel levels ranged from 56.8 dB (surgical packaging) to 105.0 dB (kicked metal stepstool). Human-caused sounds were comparable to machine-caused sounds in terms of mean peak dB levels (77.0 versus 73.8 dB, p = 0.32), yet were rated as more interfering with surgical team function. The spectral analysis illustrated both machine and human-caused sound sources obscuring the surgeon's instructions. CONCLUSIONS: Avoidable human-caused sounds are a major source of disruption in the OR and interfere with communication and job performance. We recommend surgical team training to minimize these distractions.

Mental 3D Visualization: Building Surgical Resilience for Performing High-Risk Procedures.

OBJECTIVE: Psychological resilience has been studied in several demanding professions, including the military and competitive sports, yet specific strategies for managing stress are not commonly addressed during surgical training. The objective of this study was to investigate how surgeons view performance under pressure during high-risk surgical steps. DESIGN: Using constructivist grounded theory, we conducted 12 individual semi-structured interviews with a theoretical sample teaching surgeons, representing 10 different specialties and a range of experience. We drew on Luthar's concept of resilience as positive adaptation, an active and flexible process in which critical choices are made in stressful situations. We asked about both protective and vulnerability factors contributing to resilience in high-risk surgery. We coded transcripts, transforming each category of codes into a visual schematic highlighting our findings related to performance under pressure and resilience, which we transformed into a conceptual model. SETTING: Truman Medical Center, Kansas City, MO, tertiary hospital. PARTICIPANTS: Twelve teaching surgeons from 10 different surgical specialties. RESULTS: Mental 3D visualization is necessary for proper preoperative planning, enacting contingency plans in the face of intra-operative challenges, and managing emotions during high-risk surgery. Each of these factors informs staying calm under pressure and is necessary for building long-term surgical resilience. Negotiating challenges in high-risk surgery is contingent upon adapting to risk developed over time through surgical experience, mental 3D visualization, intentionality, and self-reflection. CONCLUSIONS: Mental 3D visualization informs processes for staying calm under pressure and is essential for building long-term surgical resilience. We recommend that residency curricula offer progressive education on mental 3D visualization and foster intraoperative environments that promote adapting to risk.

Semantically Ambiguous Language in the Teaching Operating Room.

OBJECTIVE: Teaching and training surgeons work hard in the OR to understand each other, yet miscommunication is an important cause of preventable adverse events in surgery. Our objective was to perform a formal semantic analysis of language in authentic teaching surgical cases, identify the prevalence and typology of ambiguous or potentially ambiguous language, and describe their potential for miscommunication. DESIGN: In this secondary analysis of qualitative data, we collaborated with a semanticist, categorizing linguistic phenomena often associated with miscommunication. We defined an ambiguous phenomenon as a string of language that could be reasonably interpreted in more than one way. We analyzed transcripts of 319 minutes of surgery, coding for 14 linguistic categories. Cohen's kappa was calculated. We determined the prevalence and rate of each linguistic category and chose illustrative examples. PARTICIPANTS AND SETTING: Six surgical attendings, four fellows, and six residents, ranging from PGY1 to PGY4, at the University of Pittsburgh Medical Center, a tertiary medical center in Pittsburgh, Pennsylvania. RESULTS: We found 3912 examples of potentially ambiguous language, 12.3 per minute. Percentage agreement between two expert raters was 76.3%. The most common phenomena were deixis (3.1 per minute), directional (2.6), anaphora (1.3), implicit instruction (1.3), and degree modifiers (0.7). Restatements/reframing occurred 1.4 times per minute. We identified 131 near misses associated with potentially ambiguous language. Cohen's kappa was 0.70 among expert semanticists. CONCLUSIONS: Potentially ambiguous language is common and has the potential to jeopardize safe teaching surgery. We postulate that the high amount of potentially ambiguous language use in the operating room places a burden on the training surgeon to comprehend surgical instruction.

The Risk of Primary Uterine and Cervical Cancer After Hysteropexy.

OBJECTIVE: The aim of the study was to determine the rate of subsequent uterine/cervical cancer after hysteropexy compared with hysterectomy with apical prolapse repair. METHODS: The study used a retrospective cohort of women with uterovaginal prolapse using the Cerner Health Facts database between 2010 and 2018. We identified sacrospinous or uterosacral ligament suspensions or sacral colpopexy/hysteropexy and excluded those with previous hysterectomy. We used the International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision codes for endometrial cancer/hyperplasia and cervical cancer and then reviewed each case, excluding those whose cancer existed at time of prolapse repair. Given that 0 cancer cases were identified, we used Wilson, Jeffreys, Agresti-Coull, Clopper-Pearson, and Rule of 3 to define 95% confidence intervals to estimate the highest possible rate of cancer in each cohort. RESULTS: A total of 8,927 patients underwent apical prolapse surgery. Of 4,510 with uterovaginal prolapse, 755 (16.7%) underwent hysteropexy. Seventy one with hysterectomy and 5 with hysteropexy had codes for subsequent gynecologic cancer but were excluded on further review. This left 0 gynecologic cancer cases with the largest 95% confidence interval of 0%-0.61% for hysteropexy versus 0%-0.13% for hysterectomy (P > 0.05). The hysteropexy cohort was older (62.6 years vs 57.3 years, P < 0.0001), more likely to have public insurance (51.0% vs 37.9%, P < 0.0001), and less likely to smoke (4.5% vs 7.6%, P = 0.0026). Median follow-up was longer after hysteropexy (1,480 days vs 1,164 days, P < 0.0009). CONCLUSIONS: We can say with 95% certainty that uterine or cervical cancer will develop after hysteropexy in fewer than 0.61% of women, which was not different if hysterectomy was performed. This should be included in preoperative counseling for hysteropexy. Studying longer follow-up after hysteropexy may capture more cases of subsequent cancer development.

The Complexity of the Retropubic Midurethral Sling: A Cognitive Task Analysis.

OBJECTIVE: The primary aim of this study was to use cognitive task analysis to expand the retropubic midurethral sling into smaller steps, reflecting a surgeon's internal thought processes during the surgery. METHODS: Two surgeons and a cognitive psychologist collaborated with expert urogynecologic surgeons in structured discussions and semistructured interviews, iteratively creating a list of clinical steps for the midurethral sling. They primarily considered 2 questions: (1) what action does the expert perform for this step, and (2) what information does the expert need to complete the step? We defined each additional piece of detail within a step as a microstep. The cognitive task analysis list was further reviewed by 4 external expert urogynecologic surgeons to obtain further detail. The process was repeated for every step until the maximum level of detail was reached. We used multiple methods to explore the relationship between microsteps and the cognitive load associated with various portions of the surgery. RESULTS: Cognitive task analysis expanded the midurethral sling from 23 to 197 microsteps. Steps with the greatest number of microsteps included retropubic advancement with the trocar (19 microsteps) and ventral advancement of the trocar through the skin (17 microsteps). CONCLUSIONS: The retropubic midurethral sling is a complex surgery with multiple microsteps embedded within in each step. Identification of these steps can lead to strategies to minimize cognitive load encouraging both efficacy and safety. Surgical training interventions and competency assessment can be developed based on this content.

Absence or presence: Silent discourse in the operating room and impact on surgical team action.

BACKGROUND: Our objective was to examine the influence of silence on team action in the operating room. METHODS: We conducted a constructed grounded theory study with semi-structured interviews with 25 interprofessional surgical team members. Using a framework of silence as communication and performance, transcripts were iteratively team-coded to develop themes and a conceptual model. RESULTS: OR silence is expressed verbally and nonverbally. Two contexts of silence were identified: homogenous as collective action, and disparate, as disengagement. Complex and dynamic, two primary themes emerged, Power that often shuts down communication, and Focus during critical moments. Five additional sub-themes included critical moments, respect, self-reflection, personal preference, and, bad mood. CONCLUSION: OR silence is not an absence of communication and requires a response. Whether homogenous through cohesiveness, or desperate as a solitary act, OR silence is a call to action. Examining silence as a part discourse has important implications on surgical team function.