How Does Surgeons' Autonomic Physiology Vary Intraoperatively?: A Real-time Study of Cardiac Reactivity.

OBJECTIVE: To measure the physiological responses of surgical team members under varying levels of intraoperative risk. BACKGROUND: Measurement of intraoperative physiological responses provides insight into how operation complexity, phase of surgery, and surgeon seniority impact stress. METHODS: Autonomic nervous system responses (interbeat intervals, IBIs) were measured continuously during different surgical operations of various complexity. The study investigated whether professional role (eg attending surgeon), operative risk (high vs. low), and type of primary operator (attending surgeon vs. resident) impacted IBI reactivity. Physiological synchrony captured the degree of correspondence between individuals' physiological responses at any given time point. RESULTS: A total of 10,005 observations of IBI reactivity were recorded in 26 participants during 16 high-risk (renal transplant and laparoscopic donor nephrectomy) and low-risk (arteriovenous fistula formation) operations. Attending surgeons showed greater IBI reactivity (faster heart rate) than residents and nurses during high-risk operations and while actively operating (Ps<0.001). Residents showed lower reactivity during high-risk (relative to low-risk) operations (P<0.001) and similar reactivity regardless of whether they or the attending surgeon was operating (P=0.10). Nurses responded similarly during low-risk and high-risk operations (P=0.102) but were more reactive when the resident was operating compared to when the attending surgeon was the primary operator (P<0.001). In high-risk operations, attending surgeons had negative physiological covariation with residents and nurses (P<0.001). In low-risk operations, only attending surgeons and nurses were synchronized (P<0.001). CONCLUSION: Attending surgeons' physiological responses were well-calibrated to operative demands. Residents' and nurses' responses were not callibrated to the same extent. This suggests that risk sensitivity is an adaptive response to stress that surgeons acquire.

Surgical leadership in a culture of safety: An inter-professional study of metrics and tools for improving clinical practice.

BACKGROUND: Leadership in a safety culture environment is essential in avoiding patient harm. However, leadership in surgery is not routinely taught or assessed. This study aims to identify a framework, metrics and tools to improve surgical leadership and safety outcomes. METHODS: Qualitative interviews were performed with leadership experts from safety-critical professions. Non-probability-based sampling was undertaken in major international airlines. Data underwent thematic analysis and clinical adaptation by multiple surgeon-analysts using the framework method. RESULTS: 583 codes were synthesised into 10 themes. Leaders were identified as 'threat and error managers' who placed safety first. Their core attribute was humble confidence. This allowed them to set the tone for high standards of practice, whilst empowering individuals to speak up about safety issues. Safety-oriented leaders assumed complete responsibility and applied their authority discerningly to obtain optimal outcomes. Finally, effective leaders rallied support for their mission by instilling confidence, building collaborations and managing conflict. CONCLUSIONS: Surgical leadership requires the ability to manage risk, opportunity and people. The study provides an assessment matrix and deliverable tools for improving surgical safety.

Donating a Kidney to a Stranger: Are Healthcare Professionals Facilitating the Journey? Results From the BOUnD Study.

Unspecified kidney donors (UKDs) are approached cautiously by some transplant professionals. The aim of this study was to interrogate the views of UK transplant professionals towards UKDs and identify potential barriers. A purposely designed questionnaire was validated, piloted and distributed amongst transplant professionals at each of the 23 UK transplant centres. Data captured included personal experiences, attitudes towards organ donation, and specific concerns about UKD. 153 responses were obtained, with representation from all UK centres and professional groups. The majority reported a positive experience with UKDs (81.7%; p < 0.001) and were comfortable with UKDs undergoing major surgery (85.7%; p < 0.001). 43.8% reported UKDs to be more time consuming and 52% felt that a mental health assessment should take place before any medical tests. 77% indicated the need for a lower age limit. The suggested age range was broad (16-50 years). Adjusted mean acceptance scores did not differ by profession (p = 0.68) but higher volume centres were more accepting (46.2 vs. 52.9; p < 0.001). This is the first quantitative study of acceptance by transplant professionals to a large national UKD programme. Support is broad, however potential barriers to donation have been identified, including lack of training. Unified national guidance is needed to address these.

Pediatric renal transplantation-A UNOS database analysis of donor-recipient size mismatch.

BACKGROUND: We used the BSAi (Donor BSA/Recipient BSA) to assess whether transplanting a small or large kidney into a pediatric recipient relative to his/her size influences renal transplant outcomes. METHODS: We included 14 322 single-kidney transplants in pediatric recipients (0-17 years old) (01/2000-02/2020) from the United Network for Organ Sharing database. We divided cases into four BSAi groups (BSAi ≤ 1, 1 < BSAi ≤ 2, 2 < BSAi ≤ 3, BSAi > 3). RESULTS: There were no differences concerning delayed graft function (DGF) or primary non-function (PNF) rates, whether the grafts were from living or brain-dead donors. In both transplants coming from living donors and brain-dead donors, cases with BSAi > 3 and cases with 2 < BSAi ≤ 3 had similar graft survival (p = .13 for transplants from living donors, p = .413 for transplants from brain-dead donors), and both groups had longer graft survival than cases with 1 < BSAi ≤ 2 and cases with BSAi ≤ 1 (p < .001). The difference in 10-year graft survival rates between cases with BSAi > 3 and cases with BSAi ≤ 1 reached around 25% in both donor types. The better graft survival in transplants with BSAi > 2 was confirmed in multivariable analysis. CONCLUSIONS: There is no significant impact of donor-recipient size mismatch on DGF and PNF rates in pediatric renal transplants. However, graft survival is significantly improved when the donor's size is more than twice the pediatric recipient's size.

Crisis Preparedness: A Systems-Based Framework for Avoiding Harm in Surgery.

BACKGROUND: Highly performing healthcare organizations benefit from robust failure management systems. This involves the ability to respond and recover from critical events, as well avoiding harm in the first place (crisis preparedness). Currently, the surgical community may lack an integrated toolbox for crisis readiness. The study aims to create a practical framework for crisis preparedness in surgery. STUDY DESIGN: A multimethod qualitative study was designed to identify and translate crisis preparedness interventions from high-reliability industries to clinical practice. The tools and strategies identified were subsequently developed and clinically adapted for healthcare use. The study used (1) observational fieldwork in commercial aviation; (2) semi-structured interviews with senior airline pilots, and (3) mixed focus groups with healthcare and aviation safety experts. A crisis preparedness framework was derived by thematic analysis using the framework method. Clinical adaptation was achieved using expert consensus methodology. RESULTS: Twenty-two aviation and healthcare experts participated in 17 interviews and 3 focus groups. A framework for crisis preparedness was derived, consisting of 6 behavioral interventions: (1) anticipate threats and errors by building situational awareness using cognitive tools; (2) brief teams about goals, deviations, operational risks, and contingency plans; (3) implement standard operating procedures using checklists; (4) rehearse emergency drills before critical phases of work; (5) set the tone for a positive working environment by establishing cultural norms and empowering individuals to speak up about safety issues; and (6) debrief performance outcomes to derive learning lessons. CONCLUSIONS: Surgical crisis preparedness requires integrated systems rather than isolated safety interventions. This study provides a framework and the tools to achieve this.

How crises work: A model of error cause and effect in surgical practice.

INTRODUCTION: Surgical crises have major consequences for patients, staff and healthcare institutions. Nevertheless, their aetiology and evolution are poorly understood outside the remit of root-cause analyses. AIMS: To develop a crisis model in surgery in order to aid the reporting and management of safety critical events. METHODS: A narrative review surveyed the safety literature on failure causes, mechanisms and effects in the context of surgical crises. Sources were identified using non-probability sampling, with selection and inclusion being determined by author panel consensus. The data underwent thematic analysis and reporting followed the recommendation of the SALSA framework. RESULTS: Data from 133 sources derived five principal themes. Analysis suggested that surgical care processes become destabilized in a step-wise manner. This crisis chain is initiated by four categories of threat or risk: (i) the systems in which surgeons operate; (ii) surgeons' technical, cognitive and behavioural skills; (iii) surgeons' physiological and psychological state (operational condition); and (iv) professional culture. Once triggered, the crisis chain is driven by only three types of errors: Type I. Performance errors consist of failures to diagnose, plan or execute tasks; Type II. Awareness errors are failures to recognise, comprehend or extrapolate the impact of performance failures; Type III. Rescue errors represent failures to correct faulty performance. The co-occurrence of all three error types gives rise to harm, which can lead to a crisis in the absence of mitigating actions. CONCLUSION: Surgical crises may be triggered by four categories of threat and driven by only three types of error. These may represent universal targets for safety interventions that create new opportunities for crisis management.

Crisis recovery in surgery: Error management and problem solving in safety-critical situations.

BACKGROUND: Surgical crises, both clinical and executive, carry risk of harm to patients, staff, and organizations. Once stabilized and contained, crisis recovery requires complex decision-making and problem-solving to address primary failures (errors) and their consequences. In contrast to other safety-critical professions, surgeons may lack access to crisis recovery strategies and tools that go beyond the technical aspects of clinical practice. This study aims to develop a framework for surgical crisis recovery based on problem-solving interventions used by pilots in commercial aviation. METHODS: This study undertook observational fieldwork, semistructured interviews, and focus groups with senior airline pilots and health care safety experts. Thematic analysis using the framework method identified key interventions applicable to surgical crisis recovery. Subsequently, expert group consensus adapted and content validated this model for clinical use. RESULTS: Qualitative data from 22 aviation and health care safety experts informed surgical crisis resolution. This consisted of 3 strategies: (1) building cognitive capacity by improving situational awareness and workload management; (2) using checklists in abnormal situations to implement emergency operating procedures; (3) undertaking structured decision-making using analysis-based problem-solving cycles (eg, T-DODAR framework). Twelve tools were validated and adapted to aid implementation of these strategies. CONCLUSION: Once stabilized, surgical crises may be resolved using 3 sequential strategies derived from commercial aviation.

Simultaneous Kidney and Parathyroid Transplantation in the Management of Genetic Hypoparathyroidism in a Child.

Background: Genetically determined hypoparathyroidism can lead to life-threatening episodes of hypocalcemia and, more rarely, to end-stage kidney disease at a young age. Parathyroid allotransplantation is the only curative treatment, and in patients already receiving immunosuppression for kidney transplantation, there may be little additional risk involved. We report the first such case in a child. Methods: An 11-y-old girl, known to have hypoparathyroidism secondary to an activating pathogenic variant in the calcium-sensing receptor, developed end-stage kidney disease and was started on intermittent hemodialysis. Since the age of 2.5 y, she had been receiving treatment with exogenous synthetic parathyroid hormone (PTH). In June 2019, at the age of 11.8 y, she received a living-donor kidney and simultaneous parathyroid gland transplant from her father. The kidney was implanted into the right iliac fossa, followed by implantation of the parathyroid gland into the exposed rectus muscle. Results: The kidney graft showed immediate function while the intrinsic serum PTH level remained low at 3 ng/L. Exogenous PTH infusion was reduced on day 6 posttransplantation to stimulate PTH production by the new gland, which resulted in improving intrinsic PTH concentrations of 28 ng/L by day 9. Twelve months after transplantation, PTH levels remain in normal range and the kidney graft function is stable with a serum creatinine of 110 µmol/L. Conclusions: Simultaneous living donation and transplantation of a kidney and a parathyroid gland into a child is safe and feasible and has the potential to cure primary hypoparathyroidism as well as kidney failure.

Crisis Containment: Tools for Harm Mitigation in Surgery.

BACKGROUND: Surgical crises represent unrecognized opportunities for improving patient safety and adding value in healthcare. The first step in a crisis response is to contain and mitigate harm. While the principles of damage control are well established in surgery, methods of containing harm on broader clinical and organizational levels are not clearly defined. STUDY DESIGN: A multimethods qualitative study identified crisis containment strategies and tools in commercial aviation. These were translated and clinically adapted in 3 stages: semi-structured observational fieldwork with commercial airlines, interviews with senior pilots, and focus groups with both healthcare and aviation safety experts. Thematic analysis and expert consensus methods were used to derive a framework for crisis containment. RESULTS: Fieldwork with 2 commercial airlines identified 2 crisis containment concepts: the detrimental impact of surprising or startling events on operator performance; and the use of prioritization tools to take basic but critical actions (Aviate, Navigate and Communicate model). Twenty-two experts in aviation and healthcare practice informed the topic of crisis containment in 17 interviews and 3 focus groups. Three strategies were identified and used to form a crisis containment algorithm: 1. Manage the operators' startle response to facilitate meaningful mitigating actions (STOP tool); 2. Take priority actions to secure core functions. These included managing patients' physiologic shock, optimizing environmental risks, and mobilizing resources (Perfuse, Move and Communicate tool); 3. Deploy well-rehearsed drills targeting case-specific harms or errors (Memory Actions). This model requires validation in clinical practice. CONCLUSIONS: Crisis containment can be achieved by controlling operators' startle response, applying prioritization tools, and deploying drills against specific failures. The application of this model may extend to healthcare areas outside surgery.

Avoid, Trap, and Mitigate: Development of an Evidence-Based Crisis Management Framework in Surgery.

BACKGROUND: Increasingly, surgeons are adopting broader roles in emergency response, on both clinical and executive levels. These have highlighted the need to develop healthcare-specific crisis management systems. Cross-professional research between safety-critical industries is a valuable method for learning crisis control. Commercial aviation, in particular, has been used to drive innovation in surgical safety. This study aimed to identify, adapt, and operationalize a surgical crisis management framework based on current practice in commercial aviation. STUDY DESIGN: A multimethod qualitative study interrogated safety experts in commercial aviation and healthcare. Stage I used immersive observational fieldwork in commercial aviation practice. Stage II performed semi-structured interviews with senior airline pilots. "Snowball" sampling targeted professional networks, recruiting 17 pilots from 4 airlines. Thematic analysis was used to derive a model of crisis management. Stage III undertook 3 focus groups with 5 pilots and 5 healthcare safety specialists. Expert consensus methods were used to adapt the model to clinical practice. RESULTS: Interview data provided 2,698 verbatim quotes on crisis management from aviation experts with a combined flying experience of 188,000 hours. Aviation crisis management was structured in 3 phases: avoid, trap, and mitigate. Adapted to clinical practice, these translated to crisis preparedness, recovery, and containment interventions. Additionally, the study identified 7 types of implementation tools and 9 crisis management skills that could be used to operationalize this framework in surgical practice. CONCLUSIONS: Surgical crisis management can follow the avoid, trap, and mitigate framework used in commercial aviation. Implementation relies on the combined use of crisis skills and performance tools. Crisis management should be delivered as part of a systems-based approach that relies on well-integrated failure management models. Simulation and in-situ validation of this framework is needed.

Surgeons Are Not Pilots: Is the Aviation Safety Paradigm Relevant to Modern Surgical Practice?

Error in surgery is common, although not always consequential. Surgical outcomes are often compared to safety data from commercial aviation. This industry's performance is frequently referenced as an example of high-reliability that should be reproduced in clinical practice. Consequently, the aviation-surgery analogy forms the conceptual framework for much patient safety research, advocating for the translation of aviation safety tools to the healthcare setting. Nevertheless, overuse or incorrect application of this paradigm can be misleading and may result in ineffective quality improvement interventions. This article discusses the validity and relevance of the aviation-surgery comparison, providing the necessary context to improve its application at the bedside. It addresses technical and human factors training, as well as more novel performance domains such as professional culture and optimization of operators' condition. These are used to determine whether the aviation-surgery analogy is a valuable source of cross-professional learning or simply another safety cliché.

Donating a Kidney to a Stranger: A Review of the Benefits and Controversies of Unspecified Kidney Donation.

OF BACKGROUND DATA: Unspecified kidney donation (UKD) describes living donation of a kidney to a stranger. The practice is playing an increasingly important role within the transplant programme in the United Kingdom, where these donors are commonly used to trigger a chain of transplants; thereby amplifying the benefit derived from their donation. The initial reluctance to accept UKD was in part due to uncertainty about donor motivations and whether the practice was morally and ethically acceptable. OBJECTIVES: This article provides an overview of UKD and answers common questions regarding the ethical considerations, clinical assessment, and how UKD kidneys are used to maximize utility. Existing literature on outcomes after UKD is also discussed, along with current controversies. CONCLUSIONS: We believe UKD is an ethically acceptable practice which should continue to grow, despite its controversies. In our experience, these donors are primarily motivated by a desire to help others and utilization of their kidney as part of a sharing scheme means that many more people seek to benefit from their very generous donation.

Endovascular intervention in the maintenance and rescue of paediatric arteriovenous fistulae for hemodialysis.

BACKGROUND: Arteriovenous fistulae (AVF) provide superior primary vascular access for children on chronic dialysis compared to central venous catheters (CVC). However, AVFs inevitably develop complications and will require some intervention to maintain long-term functional patency. METHODS: We report an 'endovascular-first' approach to the maintenance and rescue of paediatric AVFs. Thirty interventions targeting 46 lesions in 18 children (median age 11 years [range 5-17]) were performed. Sixty-eight percent of the AVFs were brachio-cephalic fistulae, 26% brachio-basilic fistulae and 5% radio-cephalic fistulae. Immediate functional success was 86% with good dialysis adequacy (mean urea reduction ratio > 70%) at 3 months post procedure. RESULTS: There was one significant complication, consisting of an AVF rupture which was managed with a covered stent. CONCLUSIONS: Repeated interventions may be necessary to maintain AVF patency and avoid central venous catheters. This is the largest series reported to date.

A novel 3D-printed hybrid simulation model for robotic-assisted kidney transplantation (RAKT).

Robotic-assisted kidney transplantation (RAKT) offers key benefits for patients that have been demonstrated in several studies. A barrier to the wider uptake of RAKT is surgical skill acquisition. This is exacerbated by the challenges of modern surgery with reduced surgical training time, patient safety concerns and financial pressures. Simulation is a well-established method of developing surgical skill in a safe and controlled environment away from the patient. We have developed a 3D printed simulation model for the key step of the kidney transplant operation which is the vascular anastomosis. The model is anatomically accurate, based on the CT scans of patients and it incorporates deceased donor vascular tissue. Crucially, it was developed to be used in the robotic operating theatre with the operating robot to enhance its fidelity. It is portable and relatively inexpensive when compared with other forms of simulation such as virtual reality or animal lab training. It thus has the potential of being more accessible as a training tool for the safe acquisition of RAKT specific skills. We demonstrate this model here.