Enhancing patient safety in trauma: Understanding adverse events, assessment tools, and the role of trauma video review.

OBJECTIVES: This study aimed to investigate adverse events (AEs) in trauma resuscitation, evaluate contributing factors, and assess methods, such as trauma video review (TVR), to mitigate AEs. BACKGROUND: Trauma remains a leading cause of global mortality and morbidity, necessitating effective trauma care. Despite progress, AEs during trauma resuscitation persist, impacting patient outcomes and the healthcare system. Identifying and analyzing AEs and their determinants are crucial for improving trauma care. METHODS: This narrative review explored the definition, identification, and assessment of AEs associated with trauma resuscitation within the trauma system. It includes various studies and assessment tools such as STAT Taxonomy and T-NOTECHs. Additionally, it assessed the role of TVR in detecting AEs and strategies to enhance patient safety. CONCLUSION: Integrated with standardized tools, TVR shows promise for identifying AEs. Challenges include ensuring reporting consistency and integrating approaches into existing protocols. Future research should prioritize linking trauma team performance to patient outcomes, and develop sustainable TVR programs to enhance patient safety.

Strategies to support maternal and early childhood wellness: insight from parent and provider qualitative interviews during the COVID-19 pandemic.

OBJECTIVES: The COVID-19 pandemic resulted in rapid changes to the delivery of maternal and newborn care. Our aim was to gain an understanding from parents and healthcare professionals (HCPs) of how the pandemic and associated public health restrictions impacted the peripartum and postpartum experience, as well as longer-term health and well-being of families. DESIGN: Qualitative study through focus groups. SETTING: Ontario, Canada. PARTICIPANTS: HCPs and parents who had a child born during the COVID-19 pandemic. INTERVENTIONS: Semistructured interview guide, with questions focused on how the pandemic impacted their care/their ability to provide care, and strategies to improve care and support now or in future situations with similar healthcare restrictions. OUTCOME MEASURES: Thematic analysis was used to describe participant experiences and recommendations. RESULTS: We included 11 HCPs and 15 parents in 6 focus groups. Participants described their experiences as 'traumatic', with difficulties in accessing prenatal and postpartum services, and feelings of distress and isolation. They also noted delays in speech and development in children born during the pandemic. Key recommendations included the provision of partner accompaniment throughout the course of care, expansion of available services for young families (particularly postpartum), and special considerations for marginalised groups, including access to technology for virtual care or the option of in-person visits. CONCLUSIONS: Our findings may inform the development of healthcare system and organisational policies to ensure the provision of maternal and newborn care in the event of future public health emergencies. Of primary importance to the participants was the accommodation of antenatal, intrapartum and postpartum partner accompaniment, and the provision of postpartum services.

Consensus Statement No. 434: Simulation in Obstetrics and Gynaecology.

OBJECTIVE: To provide a comprehensive and current overview of the evidence for the value of simulation for education, team training, patient safety, and quality improvement in obstetrics and gynaecology, to familiarize readers with principles to consider in developing a simulation program, and to provide tools and references for simulation advocates. TARGET POPULATION: Providers working to improve health care for Canadian women and their families; patients and their families. OUTCOMES: Simulation has been validated in the literature as contributing to positive outcomes in achieving learning objectives, maintaining individual and team competence, and enhancing patient safety. Simulation is a well-developed modality with established principles to maximize its utility and create a safe environment for simulation participants. Simulation is most effective when it involves interprofessional collaboration, institutional support, and regular repetition. BENEFITS, HARMS, AND COSTS: This modality improves teamwork skills, patient outcomes, and health care spending. Upholding prescribed principles of psychological safety when implementing a simulation program minimizes harm to participants. However, simulation can be an expensive tool requiring human resources, equipment, and time. EVIDENCE: Articles published between 2003 and 2022 were retrieved through searches of Medline and PubMed using the keywords "simulation" and "simulator." The search was limited to articles published in English and French. The articles were reviewed for their quality, relevance, and value by the SOGC Simulation Working Group. Expert opinion from relevant seminal books was also considered. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE: All health care professionals working to improve Canadian women's health, and relevant stakeholders, including granting agencies, physician/nursing/midwifery colleges, accreditation bodies, academic centres, hospitals, and training programs.

Defining ferritin clinical decision limits to improve diagnosis and treatment of iron deficiency: A modified Delphi study.

BACKGROUND: Iron deficiency is highly prevalent worldwide and is an issue of health inequity. Despite its high prevalence, uncertainty on the clinical applicability and evidence-base of iron-related lab test cut-offs remains. In particular, current ferritin decision limits for the diagnosis of iron deficiency may not be clinically appropriate nor scientifically grounded. METHODS: A modified Delphi study was conducted with various clinical experts who manage iron deficiency across Canada. Statements about ferritin decision limits were generated by a steering committee, then distributed to the expert panel to vote on agreement with the aim of achieving consensus and acquiring feedback on the presented statements. Consensus was reached after two rounds, which was defined as 70% of experts rating their agreement for a statement as 5 or higher on a Likert scale from 1 to 7. RESULTS: Twenty-six clinical experts across 10 different specialties took part in the study. Consensus was achieved on 28 ferritin decision limit statements in various populations (including patients with multiple comorbid conditions, pediatric patients, and pregnant patients). For example, there was consensus that a ferritin <30 µg/L rules in iron deficiency in all adult patients (age ≥ 18 years) and warrants iron replacement therapy. CONCLUSION: Consensus statements generated through this study corresponded with current evidence-based literature and guidelines. These statements provide clarity to facilitate clinical decisions around the appropriate detection and management of iron deficiency.

Modeling Technical Skills Learning Curves of Incoming Surgical Trainees.

OBJECTIVE: Not all trainees reach technical competency even after completing surgical training. While assessment of technical skill is not part of the residency interview process, identifying under-performers early on may help identify opportunities for individualized, targeted training. The objectives of this study were to (1) create predictive learning curve (LC) models for each of 3 basic laparoscopic tasks to identify performers versus underperformers and (2) evaluate the use of LCs to identify underperformers during selection into surgical training. DESIGN: Predictive LC models were created for laparoscopic pattern cutting (PC), peg transfer (PT) and intra-corporeal knots (IC) over 40 repetitions by 65 novice trainees in 2014. Trainees were categorized as performers and underperformers. Receiver operator characteristic analysis determined the minimum number of repetitions required to predict individual LCs, which were then used to determine the proportion of underperformers. SETTING: Technical performance was assessed onsite at the Canadian Residence Matching Service (CaRMS) interviews, after interview completion (January 2015). PARTICIPANTS: Applicants to general surgery (GS) and gynecology (OBGYN) participated in a skills assessment during. RESULTS: The PC, PT and IC tasks required a minimum of 8, 10, and 5 repetitions respectively, to predict overall performance. Predictive values for each task had excellent sensitivity and specificity: 1.00, 1.00 (PC); 1.00, 1.00 (PT); and 0.94, 1.00 (IC). Eighty applicants completed 8 PC repetitions; 16% were identified as underperformers. CONCLUSIONS: Individual LCs for three different laparoscopic tasks can be predicted with excellent sensitivity and specificity based on 10 repetitions or less. This information can be used to identify trainees who may have difficulty with laparoscopic technical skills early on.

Healthcare professionals' perception of safety culture and the Operating Room (OR) Black Box technology before clinical implementation: a cross-sectional survey.

INTRODUCTION: Comprehensive data capture systems such as the Operating Room Black Box (OR Black Box) are becoming more widely implemented to access quality data in the complex environment of the OR. Prior to installing an OR Black Box, we assessed perceptions on safety attitudes, impostor phenomenon and privacy concerns around digital information sharing among healthcare professionals in the OR. A parallel survey was conducted in Canada, hence, this study also discusses cultural and international differences when implementing new technology in healthcare. METHODS: A cross-sectional survey using three previously validated questionnaires (Safety Attitudes Questionnaire (SAQ), Clance Impostor Phenomenon Scale, Dispositional Privacy Concern) was distributed through Research Electronic Data Capture to 145 healthcare professionals from the OR (July to December 2019). Analysis of variance and analysis of covariance were used to test for differences. RESULTS: 124 responded (86%): 100 completed the survey (69%) (38 nurses, 10 anaesthesiologists, 36 obstetricians/gynaecologists, 16 residents). Significant variability in all six SAQ domains, safety climate and teamwork being the lowest ranked and job satisfaction ranked highest for all groups. The SAQ varied in all domains in Canada. Moderate to frequent impostor phenomenon was experienced by 71% predominantly among residents (p=0.003). 72% in the Canadian study. Residents were most comfortable with digital information sharing (p<0.001), only 13% of all healthcare professionals were concerned/heavy concerned compared with 45% in Canada. CONCLUSIONS: The different healthcare professional groups had diverse perceptions about safety culture, but were mainly concerned about safety climate and teamwork in the OR. Impostor phenomenon decreased with age. All groups were unconcerned about digital information sharing. The Canadian study had similar findings in terms of impostor phenomenon, but a variety within the SAQ and were more concerned about data safety, which could be due to medical litigation per se and is not widespread in Scandinavia compared with North America.

Perceptions of safety culture and recording in the operating room: understanding barriers to video data capture.

OBJECTIVE: Recording in the operating room is an important tool to help surgical teams improve their performance. This is becoming more feasible using the Operating Room Black Box, a comprehensive data capture platform. Operating room (OR) staff, however, may voice reasonable concerns as recording initiatives are implemented. The objective of this study was to assess pre-implementation attitudes of OR staff toward operative recording and explore the relationship of these attitudes to the themes of (1) safety culture, (2) impostor syndrome, and (3) privacy concerns. METHODS: This cross-sectional survey study measured staff members' beliefs and opinions of operative recording and used three previously validated tools (safety attitudes questionnaire, clance impostor phenomenon scale, and dispositional privacy concern) to assess personal and professional factors. Concepts were correlated using Pearson's correlation coefficient. RESULTS: Forty-three staff members participated in this study, with a response rate of 45% (n = 43/96, 20/22 nurses, 9/11 gynecologists, 14/63 anesthesiologists). Opinions of operative data capture were generally positive (5-point Likert scale, mean = 3.81, SD = 0.91). Nurses tended to have more favorable opinions of the OR Black Box as compared to gynecologists and anesthesiologists, though this did not reach statistical significance (4.15 vs. 3.67 vs 3.43, p = 0.06). Impostor syndrome characteristics correlated with concerns about litigation related to recording (r = - 0.32, p = 0.04). CONCLUSION: There are personal and professional attributes of the OR team that impact perceptions of the OR Black Box and implications around privacy and litigation. Addressing these concerns may facilitate successful implementation of the OR Black Box and improve team communication and patient safety in the OR.

Health Care Practitioners' Attitudes and Knowledge Regarding Trial of Labour After Cesarean Delivery (TOLAC): A Survey of Canadian Obstetrical Care Providers.

OBJECTIVES: To understand current attitudes and practice patterns of obstetrical care providers regarding trial of labour after cesarean (TOLAC) and to assess misconceptions regarding eligibility for and risks associated with TOLAC. METHODS: A survey was developed based on published literature, validated by a statistician, and piloted with Canadian obstetricians. French and English versions were distributed via the mailing list of the Society of Obstetricians and Gynaecologists of Canada and social media. Practising obstetrical care providers with an office antenatal practice were eligible to participate. Data were analyzed using descriptive statistics and correlational and multiple regression analyses. RESULTS: A total of 381 people responded, with representation from every Canadian province and territory. Obstetrician-gynaecologists (239, 63%), family physicians (100, 26%), and midwives (42, 11%) responded. Most participants (277, 78%) thought that TOLAC should be actively encouraged. Only 141 (40%) used a decision aid when counselling patients, although most respondents (250, 71%) thought it would be useful. Providers were less comfortable offering oxytocin induction compared with cervical foley or amniotomy (P < 0.001) and offering TOLAC to patients with an unknown uterine scar (P < 0.001). Providers in western Canada reported more comfort offering TOLAC to patients with more than 1 previous cesarean delivery compared with other regions. Two hundred nine participants (62%) reported that they had had at least 1 patient with a uterine rupture, with the minority of cases (13, 6%) resulting in litigation. CONCLUSIONS: This study offers new information on current national practice patterns and provider attitudes regarding TOLAC. These results can be used to guide future educational initiatives to increase TOLAC rates.

Key concerns among pregnant individuals during the pandemic: Online cross-sectional survey.

OBJECTIVE: To determine common sources of concern among pregnant individuals during the coronavirus disease 2019 (COVID-19) pandemic. DESIGN: A cross-sectional, open, online electronic survey from May 9, 2020, to June 14, 2020. SETTING: Electronic survey open internationally and advertised through Canadian-based social media platforms. PARTICIPANTS: Eligible participants understood English and had been pregnant during the COVID-19 pandemic (ie, were pregnant at the time of survey completion or had delivered an infant on or after March 11, 2020). MAIN OUTCOME MEASURES: Potential sources of concern related to the pandemic, calculated as the proportion of participants who endorsed each concern among those for whom the concern was relevant. Differences in the proportion of individuals endorsing each concern were compared by parity using modified Poisson regression. Frequency of concerns was examined in terms of level of distress, as per the Kessler Psychological Distress Scale (K6), using multivariable linear regression. RESULTS: Out of 1477 participants, 87.3% were Canadian. Top concerns included the following: hospital policies related to support persons during labour (80.9%), not being able to introduce the baby to family and friends (80.1%), and developing COVID-19 while pregnant (79.2%). Primiparous participants were more likely than multiparous participants to be concerned about accessing in-person prenatal classes (51.5% vs 13.3%; relative risk = 3.88; 95% CI 2.02 to 4.98) and cancellation of hospital tours (35.0% vs 5.6%, relative risk = 6.26; 95% CI 4.25 to 9.20), among other concerns. The mean (SD) K6 score was 6.7 (3.8) within the moderate to high distress range. Number of concerns reported was associated with K6 score in both primiparous (ß = 0.24; 95% CI 0.20 to 0.29; P < .0001) and multiparous (ß = 0.30; 95% CI 0.24 to 0.36; P < .0001) individuals. CONCLUSION: Pregnant individuals have unique concerns during the COVID-19 pandemic and the findings indicate the importance of targeted support strategies to meet the particular needs of both primiparous and multiparous pregnant individuals.

Utilizing the Operating Room Black Box to Characterize Intraoperative Delays, Distractions, and Threats in the Gynecology Operating Room: A Pilot Study.

Introduction Operating Room Black Box (ORBB) technology can be used to capture information during surgery for analysis and potential identification of root causes that jeopardize safety and efficiency. In this study, our objective was to identify and characterize procedural steps, intraoperative distractions, errors, and threats, as well as the non-technical skills of the team during a common minimally invasive gynecologic procedure. Methodology This was a cross-sectional pilot study of 25 patients undergoing total laparoscopic hysterectomy between May 2019 and February 2020 at a Canadian tertiary care academic hospital. Video, audio, and patient physiologic data from all procedures were obtained through a multichannel synchronized recording device (ORBB). Trained analysts reviewed and coded the recordings. Results The median total case time was 165 minutes (interquartile range [IQR]: 160-178 minutes) with the shortest step being cystoscopy and the longest being vaginal cuff closure. Time pressure and device absence or malfunction occurred in 48% of the cases, and a median of 262 (IQR: 228-304) auditory distractions were noted per case. There was a median of 3 (IQR: 2-4) safety threats identified per case and at least one error was identified in 11/25 cases (44%). Only two adverse events were noted among all 25 cases. Observed non-technical skills were mainly positive, and observations were the highest for situational awareness and leadership among the surgical team and communication and teamwork among the nursing/scrub technician and anesthesia teams. Conclusions This study is a novel application of the ORBB in the gynecology operating room to capture information regarding procedure times, intraoperative distractions, errors, and non-technical skills of the team. Frequent intraoperative cognitive and auditory distractions were noted. Although adverse events were rare, safety threats were identified. Ongoing and future research from our group will aim to identify key areas for organizational, technological, and team improvement to minimize inefficiencies and optimize patient safety in the operating room.

Predictors of Persistent Postsurgical Pain After Hysterectomy-A Prospective Cohort Study.

STUDY OBJECTIVE: To determine sociodemographic, surgical, and psychologic risk factors, including pain sensitivity, for persistent postsurgical pain (PPSP) after hysterectomy. DESIGN: A prospective cohort study. SETTING: Canadian academic medical center. PATIENTS: Patients (N = 200) who underwent hysterectomy (vaginal, laparoscopic, robotic, or open) between 2013 and 2014. INTERVENTIONS: Participants completed preoperative questionnaires assessing baseline pain scores and psychologic factors, including the Pain Sensitivity Questionnaire, Brief Pain Inventory Interference Items, the Beck Depression Inventory, the Numeric Rating Scale (NRS), and the Pain Catastrophizing Scale. Pain was recorded 1 and 24 hours postoperatively using the NRS. Patients were reassessed at 6 weeks postoperatively and completed the Brief Pain Inventory Interference Items, Patient Global Impression of Change, and the NRS. Patients who reported pain at 6 weeks were reassessed at 12 weeks using the above-mentioned questionnaires. MEASUREMENTS AND MAIN RESULTS: Of 200 study participants, 58 (32%) met the definition for PPSP (NRS ≥ 1 at 12 weeks), and 11 (6.1%) met the definition for moderate to severe postsurgical pain (NRS ≥ 4 at 12 weeks). Risk factors for PPSP included baseline pain scores, depression, pain catastrophizing, uterine mass, open surgical approach, acute postoperative pain, history of chronic pain, and having a hysterectomy due to pain. Multivariate regression analysis revealed that depression, pain catastrophizing, open surgical approach, and acute postoperative pain at 1 hour represent independent predictors of PPSP. Pain sensitivity was not associated with PPSP but was associated with acute and severe acute (NRS≥4) pain at 24 hours. CONCLUSION: Patients at risk for PPSP after hysterectomy can be identified preoperatively using validated questionnaires. This information can be used to guide targeted perioperative interventions to mitigate their risk.

The Use of In Situ Simulation to Enhance COVID-19 Pandemic Preparedness in Obstetrics.

Simulation's benefits in medical education are well established. However, its use for pandemic preparedness in obstetrics is lacking. Management of obstetrical patients with suspected COVID-19 infection is a complex task with safety considerations for mother, fetus and healthcare workers. Implementation of new workflow algorithms to ensure safety is critical but is challenging to implement in real-time. We sought to improve pandemic preparedness by designing and deploying a high-fidelity simulation exercise involving the admission of a labouring obstetrical patient with suspected COVID-19 into a labour room, urgent transfer to the operating room and neonatal resuscitation. The creation of the simulation scenario was a multi-disciplinary effort with input from a focus group of key clinical stakeholders from within and outside of our centre to ensure clinical validity. Simulations were performed on the clinical unit during regular work hours so workflow could be observed in real-time with access to the equipment and personnel in which this clinical scenario would occur. We completed a total of 11 simulation sessions involving 42 participants. Feedback, obtained from debrief sessions and anonymous surveys, was categorized based on the human factors framework, and used as part of an iterative process to adapt, revise and improve the simulation scenario. The result of this iterative process was the creation of validated departmental infection control protocols that continue to be implemented through the second wave of the COVID-19 pandemic.

Validating an Obstetrics and Gynaecology Longitudinal Integrated Clerkship Curriculum at the University of Toronto: A Four-Year Review.

The University of Toronto launched a longitudinal integrated clerkship (LIC) pilot project in 2014. Our aim was to evaluate LIC student outcomes in obstetrics and gynaecology compared with those of traditional block students. LIC and block students underwent identical evaluations, including written and oral exams, as well as clinical assessments from the ward. LIC student scores in each domain were compared with those of the traditional block students over 4 years. There were no differences in overall pass/fail status between LIC and block students. Thus, our LIC design could be appropriately modeled at other teaching institutions contemplating introducing an LIC stream.

Decreasing Cesarean Delivery Rates Using a Trial of Labour After Cesarean (TOLAC) Bundle.

OBJECTIVE: To develop and implement a trial of labour after cesarean delivery (TOLAC) bundle-a group of interventions aimed at decreasing cesarean delivery (CD) for women who have had a prior CD (Robson group 5). METHODS: A TOLAC bundle was developed that included: (1) educational rounds for health care providers, (2) a physician-patient TOLAC discussion aid, and (3) patient-centred educational resources. A before-and-after study design was employed. A one-year chart review determined baseline CD rates in Robson group 5 patients at a tertiary care academic centre. Following this, from February 1, 2018 until May 31, 2019, each bundle intervention was sequentially introduced every four to six months and modified based on provider feedback. Obstetricians were provided with their individual CD rates using an audit-and-feedback approach prior to the introduction of the next intervention. RESULTS: The baseline CD rate for Robson group 5 patients was 71% (175/247 eligible patients). Following the introduction of the bundle, the CD rate decreased to 61% (131/214 eligible patients). This was a 10% decrease in the CD rate (P = 0.029). A significant increase in rate of induction was noted, from 5% pre-intervention to 11% post-intervention (p = 0.017). There were no significant decreases in the rate of vaginal birth after CD or increases in the rates of uterine rupture or NICU admission. CONCLUSIONS: A TOLAC bundle, consisting of provider education, a TOLAC discussion aid, and patient resources, combined with audit and feedback, decreased CD for Robson group 5 patients.

Effect of a Surgical Teaching Video on Resident Performance of a Laparoscopic Salpingo-oophorectomy: A Randomized Controlled Trial.

STUDY OBJECTIVE: To assess the effect of a surgical teaching video on junior resident knowledge and performance of a laparoscopic salpingo-oophorectomy (LSO). DESIGN: Randomized controlled trial. SETTING: Urban tertiary care academic obstetrics and gynecology department. PATIENTS: First- and second-year gynecology residents. INTERVENTIONS: Access to an education video on LSO for 1 week before performing this surgery in the operating room. MEASUREMENTS AND MAIN RESULTS: Twenty-four junior residents were recruited and randomized to either the educational video group or traditional residency training group. All participants completed a demographic survey and knowledge questionnaire before performing an LSO, which was video-recorded. Video recordings of surgical performance were analyzed using the Objective Structured Assessment of Technical Skills (OSATS; 20 points) and an LSO-specific tool (30 points). Participants completed a self-assessment questionnaire before completing the procedure. The primary outcome measure was the difference in OSATS scores. The secondary outcomes were the knowledge questionnaire scores and self-assessed confidence scores. There were no significant differences between demographic variables of the 2 groups. The primary outcome revealed no significant differences in mean (standard deviation) OSATS scores (10.64 [2.05] vs 11.55 [1.85], p = .3) or LSO-specific tool scores (16.45 [2.68] vs 17.85 [2.63], p = .24). However, there was a significant difference in mean knowledge scores between the video and the traditional training (8.42 [0.79] vs 7.11 [1.36], p = .01) groups. In addition, residents in the video group had more confidence in their knowledge of pelvic anatomy (3.83 [0.39] vs 3.00 [1.00] out of 5.00, p = .04). CONCLUSION: For junior learners, the use of an LSO video improved knowledge and confidence in anatomy but did not translate to improved surgical performance in the operating room. Surgical videos are a useful adjunct and complement hands-on technical teaching.

Delphi Approach for the Design of an Intraoperative Blood Conservation Pathway for Open Myomectomy.

OBJECTIVE: Myomectomy is offered for treatment of symptomatic uterine fibroids in women who desire to maintain fertility. An open approach, sometimes necessitated by the size or number of fibroids, is associated with a high rate of perioperative blood transfusion. Our goal was to obtain expert consensus on interventions aimed at reducing blood loss and subsequent transfusion in open myomectomy for inclusion in an intraoperative care pathway. METHODS: A two-round modified Delphi approach was used to generate consensus on a pathway of interventions to reduce blood loss in open myomectomy. A multidisciplinary expert panel consisting of anaesthesiologists, hematologists, and gynaecologic surgeons rated interventions for inclusion in or exclusion from the pathway (Canadian Task Force Classification III). RESULTS: Twenty-three expert panel members participated in the Delphi. Consensus was achieved in both the Delphi's first (Cronbach α = 0.92) and second (Cronbach α = 0.94) rounds. Of 11 proposed interventions, five (dilute vasopressin, tranexamic acid, pericervical tourniquet, cell saver, and restrictive transfusion practice) reached consensus for inclusion in the pathway. CONCLUSION: A modified Delphi consensus approach was used to inform the development of an intraoperative pathway to reduce blood loss and subsequent transfusion in women undergoing open myomectomy. Future studies will investigate the effect of this intraoperative blood conservation pathway on reducing intraoperative blood loss and blood transfusion rates among women undergoing open myomectomy.