Behavioral sciences applied to acute care teams: a research agenda for the years ahead by a European research network.

BACKGROUND: Multi-disciplinary behavioral research on acute care teams has focused on understanding how teams work and on identifying behaviors characteristic of efficient and effective team performance. We aimed to define important knowledge gaps and establish a research agenda for the years ahead of prioritized research questions in this field of applied health research. METHODS: In the first step, high-priority research questions were generated by a small highly specialized group of 29 experts in the field, recruited from the multinational and multidisciplinary "Behavioral Sciences applied to Acute care teams and Surgery (BSAS)" research network - a cross-European, interdisciplinary network of researchers from social sciences as well as from the medical field committed to understanding the role of behavioral sciences in the context of acute care teams. A consolidated list of 59 research questions was established. In the second step, 19 experts attending the 2020 BSAS annual conference quantitatively rated the importance of each research question based on four criteria - usefulness, answerability, effectiveness, and translation into practice. In the third step, during half a day of the BSAS conference, the same group of 19 experts discussed the prioritization of the research questions in three online focus group meetings and established recommendations. RESULTS: Research priorities identified were categorized into six topics: (1) interventions to improve team process; (2) dealing with and implementing new technologies; (3) understanding and measuring team processes; (4) organizational aspects impacting teamwork; (5) training and health professions education; and (6) organizational and patient safety culture in the healthcare domain. Experts rated the first three topics as particularly relevant in terms of research priorities; the focus groups identified specific research needs within each topic. CONCLUSIONS: Based on research priorities within the BSAS community and the broader field of applied health sciences identified through this work, we advocate for the prioritization for funding in these areas.

When Illegitimate Tasks Threaten Patient Safety Culture: A Cross-Sectional Survey in a Tertiary Hospital.

Objectives: The current study investigates the prevalence of illegitimate tasks in a hospital setting and their association with patient safety culture outcomes, which has not been previously investigated. Methods: We conducted a cross-sectional survey in a tertiary referral hospital. Patient safety culture outcomes were measured using the Hospital Survey on Patient Safety Culture questionnaire; the primary outcome measures were a low safety rating for the respondent's unit and whether the respondent had completed one or more safety event reports in the last 12 months. Analyses were adjusted for hospital department and staff member characteristics relating to work and health. Results: A total of 2,276 respondents answered the survey (participation rate: 35.0%). Overall, 26.2% of respondents perceived illegitimate tasks to occur frequently, 8.1% reported a low level of safety in their unit, and 60.3% reported having completed one or more safety event reports. In multivariable analyses, perception of a higher frequency of illegitimate tasks was associated with a higher risk of reporting a low safety rating and with a higher chance of having completed event reports. Conclusion: The prevalence of perceived illegitimate tasks was rather high. A programme aiming to reduce illegitimate tasks could provide support for a causal effect of these tasks on safety culture outcomes.

No signs of check-list fatigue - introducing the StOP? intra-operative briefing enhances the quality of an established pre-operative briefing in a pre-post intervention study.

Background: The team timeout (TTO) is a safety checklist to be performed by the surgical team prior to incision. Exchange of critical information is, however, important not only before but also during an operation and members of surgical teams frequently feel insufficiently informed by the operating surgeon about the ongoing procedure. To improve the exchange of critical information during surgery, the StOP?-protocol was developed: At appropriate moments during the procedure, the leading surgeon briefly interrupts the operation and informs the team about the current Status (St) and next steps/objectives (O) of the operation, as well as possible Problems (P), and encourages questions of other team members (?). The StOP?-protocol draws attention to the team. Anticipating the occurrence of StOP?-protocols may support awareness of team processes and quality issues from the beginning and thus support other interventions such as the TTO; however, it also may signal an additional demand and contribute to a phenomenon akin to "checklist fatigue." We investigated if, and how, the introduction of the StOP?-protocol influenced TTO quality. Methods: This was a prospective intervention study employing a pre-post design. In the visceral surgical departments of two university hospitals and one urban hospital the quality of 356 timeouts (out of 371 included operation) was assessed by external observers before (154) and after (202) the introduction of the StOP?-briefing. Timeout quality was rated in terms of timeout completeness (number of checklist items mentioned) and timeout quality (engagement, pace, social atmosphere, noise). Results: As compared to the baseline, after the implementation of the StOP?-protocol, observed timeouts had higher completeness ratings (F = 8.69, p = 0.003) and were rated by observers as higher in engagement (F = 13.48, p < 0.001), less rushed (F = 14.85, p < 0.001), in a better social atmosphere (F = 5.83, p < 0.016) and less noisy (F = 5.35, p < 0.022). Conclusion: Aspects of TTO are affected by the anticipation of StOP?-protocols. However, rather than harming the timeout goals by inducing "checklist fatigue," it increases completeness and quality of the team timeout.

Effects of team leaders' position in cardiopulmonary resuscitation teams on leadership behavior and team performance: A prospective randomized interventional cross-over simulation-based trial.

BACKGROUND: Leadership is an important performance factor in resuscitation teams. Medical guidelines for cardiopulmonary resuscitation (CPR) advise team leaders to keep hands off patients. There is little evidence for this recommendation that is based purely on observational data. Accordingly, the aim of this trial was to investigate the effect of leaders' position during CPR on leadership behavior and team performance. METHOD: This is a prospective randomized interventional crossover simulation-based single center trial. Teams of 3 to 4 physicians each, representing a rapid response team, were confronted with a simulated cardiac arrest. Team leaders were randomly assigned and assigned team leaders were 1:1 randomized to 2 leadership positions: position at the patient's head; and hands-off position. Data analysis was performed from video-recordings. All utterances during the first 4 minutes of CPR were transcribed and coded based on a modified "Leadership Description Questionnaire." The primary endpoint was the number of leadership statements. Secondary outcomes included CPR related performance markers like hands-on time and chest compression rate, and the behavioral related endpoints Decision Making, Error Detection, and Situational Awareness. RESULTS: Data from 40 teams (143 participants) was analyzed. Leaders in hands-off position made more leadership statements (28 ± 8 vs 23 ± 8; P <.01) and contributed more to their team's leadership (59 ± 13% vs 50 ± 17%; P = .01) than leaders in the head position. Leaders' position had no significant effect on their teams' CPR performance, Decision Making, and Error Detection. Increased numbers of leadership statements lead to improved hands-on time ( R = 0.28; 95% confidence interval 0.05-0.48; P = .02). CONCLUSIONS: Team leaders in a hands-off position made more leadership statements and contributed more to their teams' leadership during CPR than team leaders actively involved in the head position. However, team leaders' position had no effect on their teams' CPR performance.

ILC3s restrict the dissemination of intestinal bacteria to safeguard liver regeneration after surgery.

It is generally believed that environmental or cutaneous bacteria are the main origin of surgical infections. Therefore, measures to prevent postoperative infections focus on optimizing hygiene and improving asepsis and antisepsis. In a large cohort of patients with infections following major surgery, we identified that the causative bacteria are mainly of intestinal origin. Postoperative infections of intestinal origin were also found in mice undergoing partial hepatectomy. CCR6+ group 3 innate lymphoid cells (ILC3s) limited systemic bacterial spread. Such bulwark function against host invasion required the production of interleukin-22 (IL-22), which controlled the expression of antimicrobial peptides in hepatocytes, thereby limiting bacterial spread. Using genetic loss-of-function experiments and punctual depletion of ILCs, we demonstrate that the failure to restrict intestinal commensals by ILC3s results in impaired liver regeneration. Our data emphasize the importance of endogenous intestinal bacteria as a source for postoperative infection and indicate ILC3s as potential new targets.

StOP? II trial: cluster randomized clinical trial to test the implementation of a toolbox for structured communication in the operating room-study protocol.

BACKGROUND: Surgical care, which is performed by intensely interacting multidisciplinary teams of surgeons, anesthetists, and nurses, remains associated with significant morbidity and mortality. Intraoperative communication has been shown to be associated with surgical outcomes, but tools ensuring efficient intraoperative communication are lacking. In a previous study, we developed the StOP?-protocol that fosters structured intraoperative communication. Before the critical phases of the operation, the responsible surgeon initiates and leads one or several StOP?s. During a StOP?, the surgeon informs about the progress of the operation (status), next steps and proximal goals (objectives), and possible problems (problems) and encourages all team members to voice their observations and ask questions (?). In a before-after study performed mainly in visceral surgery, we found effects of the StOP?-protocol on mortality, length of hospital stay, and reoperation. We intend to assess the impact of the StOP?-protocol in a cluster randomized trial, in a wider variety of surgical specialties (i.e., general, visceral, thoracic, vascular surgery, surgical urology, and gynecology). The primary hypothesis is that the consistent use of the StOP?-protocol by the main surgeon reduces patient mortality within 30 days after the operation. The secondary hypothesis is that the consistent use of the StOP?-protocol by the main surgeon reduces unplanned reoperations, length of hospital stay, and unplanned hospital readmissions. METHODS: This study is designed as a multicenter, cluster-randomized parallel-group trial. Board-certified surgeons of participating clinical departments will be randomized 1:1 to the StOP? intervention group or to the standard of care (control) group. The intervention group will undergo a training to use the StOP?-protocol and receive regular feedback on their compliance with the protocol. The surgeons in the control group will communicate as usual during their operations. The unit of observation will be operations performed by cluster surgeons. Consecutive patients will be enrolled over 4 months per cluster. A total of 400 surgeons will be recruited, and we expect to collect patient outcome data for 14,000 surgical procedures. DISCUSSION: The StOP?-protocol was designed as a tool to structure communication during surgical procedures. Testing its effects on patient outcomes will contribute to implementing evidenced-based interventions to reduce surgical complications. TRIAL REGISTRATION: ClinicalTrials.gov NCT05356962. Registered on May 2, 2022.

No impact of sex on surgical site infections in abdominal surgery: a multi-center study.

OBJECTIVE: Male sex is controversially discussed as a risk factor for surgical site infections (SSI). The aim of the present study was to evaluate the impact of sex on SSI in abdominal surgery under elimination of relevant confounders. METHODS: Clinicopathological data of 6603 patients undergoing abdominal surgery from a multi-center prospective database of four Swiss hospitals including patients between 2015 and 2018 were assessed. Patients were stratified according to postoperative SSI and risk factors for SSI were identified using univariate and multivariate analysis. RESULTS: In 649 of 6603 patients, SSI was reported (9.8%). SSI was significantly associated with reoperation (22.7% vs. 3.4%, p < 0.001), increased mortality rate (4.6% vs. 0.9%, p < 0.001), and increased rate of length of hospital stay > 75th percentile (57.0% vs. 17.9%, p < 0.001). In univariate analysis, male sex was a significant risk factor for SSI (p = 0.01). In multivariate analysis including multiple confounders' such as comorbidities and perioperative factors, there was no association between male sex and risk of SSI (odds ratio (OR) 1.1 [CI 0.8-1.4]). Independent risk factors for SSI in multivariate analysis were BMI ≥ 30 kg/m2 (OR 1.8 [CI 1.3-2.3]), duration of surgery > 75th percentile (OR 2.3 [1.8-2.9]), high contamination level (OR 1.3 [1.0-1.6]), laparotomy (OR 1.3 [1.0-1.7]), previous laparotomy (OR 1.4 [1.1-1.7]), blood transfusion (OR 1.7 [1.2-2.4]), cancer (OR 1.3 [1.0-1.8] and malnutrition (OR 2.5 [1.8-3.4]). CONCLUSION: Under elimination of relevant confounders, there is no significant correlation between sex and risk of SSI after abdominal surgery.

Impact of family presence during cardiopulmonary resuscitation on team performance and perceived task load: a prospective randomised simulator-based trial.

OBJECTIVES: Guidelines recommend family presence to be offered during cardiopulmonary resuscitation (CPR). Data on the effects of family presence on the quality of CPR and rescuers' workload and stress levels are sparse and conflicting. This randomised trial investigated the effects of family presence on quality of CPR, and rescuers' perceived stress. DESIGN: Prospective randomised single-blind trial. SETTING: Voluntary workshops of educational courses. PARTICIPANTS: 1085 physicians (565 men) randomised to 325 teams entered the trial. 318 teams completed the trial without protocol violation. INTERVENTIONS: Teams were randomised to a family presence group (n=160) or a control group (n=158) and to three versions of leadership: (a) designated at random, (b) designated by the team or (c) left open. Thereafter, teams were confronted with a simulated cardiac arrest which was video-recorded. Trained actors played a family member according a scripted role. MAIN OUTCOME MEASURES: The primary endpoint was hands-on time. Secondary outcomes included interaction time, rescuers' perceived task load and adherence to CPR algorithms. RESULTS: Teams interacted with the family member during 24 (17-36) % of the time spent for resuscitation. Family presence had no effect on hands-on time (88% (84%-91%) vs 89% (85%-91%); p=0.18). Family presence increased frustration (60 (30-75) vs 45 (30-70); p<0.001) and perceived temporal (75 (55-85) vs 70 (50-80); p=0.001) and mental demands (75 (60-85) vs 70 (55-80); p=0.009), but had no relevant effect on CPR performance markers. Leadership condition had no effects. CONCLUSIONS: Interacting with a family member occupied about a quarter of the time spent for CPR. While this additional task was associated with an increase in frustration and perceived temporal and mental demands, family presence had no relevant negative effect on the quality of CPR. TRIAL REGISTRATION NUMBER: DRKS00024759.

Gender-focused training improves leadership of female medical students: A randomised trial.

OBJECTIVES: Recent research suggests that the gender of health care providers may affect their medical performance. This trial investigated (1) the effects of the gender composition of resuscitation teams on leadership behaviour of first responders and (2) the effects of a brief gender-specific instruction on leadership behaviour of female first responders. METHODS: This prospective randomised single-blinded trial, carried out between 2008 and 2016, included 364 fourth-year medical students of two Swiss universities. One hundred and eighty-two teams of two students each were confronted with a simulated cardiac arrest, occurring in the presence of a first responder while a second responder is summoned to help. The effect of gender composition was assessed by comparing all possible gender-combinations of first and second responders. The gender-specific instruction focused on the importance of leadership, gender differences in self-esteem and leadership, acknowledgement of unease while leading, professional role, and mission statement to lead was delivered orally for 10 min by a staff physician and tested by randomising female first responders to the intervention group or the control group. The primary outcome, based on ratings of video-recorded performance, was the first responders' percentage contribution to their teams' leadership statements and critical treatment decision making. RESULTS: Female first responders contributed significantly less to leadership statements (53% vs. 76%; P = 0.001) and critical decisions (57% vs. 76%; P = 0.018) than male first responders. For critical treatment decisions, this effect was more pronounced (P = 0.007) when the second responder was male. The gender-specific intervention significantly increased female first responder's contribution to leadership statements (P = 0.024) and critical treatment decisions (P = 0.034). CONCLUSIONS: Female first responders contributed less to their rescue teams' leadership and critical decision making than their male colleagues. A brief gender-specific leadership instruction was effective in improving female medical students' leadership behaviours.

Effects of structured intraoperative briefings on patient outcomes: multicentre before-and-after study.

BACKGROUND: Operations require collaboration between surgeons, anaesthetia professionals, and nurses. The aim of this study was to determine whether intraoperative briefings influence patient outcomes. METHODS: In a before-and-after controlled trial (9 months baseline; 9 months intervention), intraoperative briefings were introduced in four general surgery centres between 2015 and 2018. During the operation, the responsible surgeon (most senior surgeon present) briefed the surgical team using the StOP? protocol about: progress of the operation (Status), next steps (Objectives), possible problems (Problems), and encouraged asking questions (?). Differences between baseline and intervention were analysed regarding surgical-site infections (primary outcome), mortality, unplanned reoperations, and duration of hospital stay (secondary outcomes), using inverse probability of treatment (IPT) weighting based on propensity scores. RESULTS: In total, 8256 patients underwent surgery in the study. Endpoint data were available for 7745 patients (93.8 per cent). IPT-weighted and adjusted intention-to-treat analyses showed no differences in surgical-site infections between baseline and intervention (9.8 versus 9.6 per cent respectively; adjusted difference (AD) -0.15 (95 per cent c.i. -1.45 to 1.14) per cent; odds ratio (OR) 0.92, 95 per cent c.i. 0.83 to 1.15; P = 0.797), but there were reductions in mortality (1.6 versus 1.1 per cent; AD -0.54 (-1.04 to -0.03) per cent; OR 0.60, 0.39 to 0.92; P = 0.018), unplanned reoperations (6.4 versus 4.8 per cent; AD -1.66 (-2.69 to -0.62) per cent; OR 0.72, 0.59 to 0.89; P = 0.002), and fewer prolonged hospital stays (21.6 versus 19.8 per cent; AD -1.82 (-3.48 to -0.15) per cent; OR 0.87, 0.77 to 0.98; P = 0.024). CONCLUSION: Short intraoperative briefings improve patient outcomes and should be performed routinely.

Outcomes of surgery depend on patient characteristics and surgeon expertise, but also on teamwork, notably communication. The present study introduces the StOP? protocol, in which the surgeon informs the team about the current status (St), objectives regarding next steps (O), and potential problems (P), and encourages the team to ask questions and raise concerns (?). The results suggest an effect of the StOP? intervention on patient mortality, risk of unplanned reoperation, and duration of hospital stay, but not on surgical-site infections. The study is promising regarding the effect of structured intraoperative communication on important patient outcomes. The study compared patient outcomes at baseline and after implementation of the StOP? protocol, which enhances exchange of structured information within the interdisciplinary surgical team during the course of the operation. The intention-to-treat analyses in this multicentre before-and-after study of 8256 patients undergoing general surgery showed no differences between baseline and intervention for surgical-site infections, but revealed reduced mortality and unplanned reoperations, and fewer prolonged hospital stays during the intervention period.

Hacking teamwork in health care: Addressing adverse effects of ad hoc team composition in critical care medicine.

BACKGROUND: The continued need for improved teamwork in all areas of health care is widely recognized. The present article reports on the application of a hackathon to the teamwork problems specifically associated with ad hoc team formation in rapid response teams. PURPOSES: Hackathons-problem-solving events pioneered in computer science-are on the rise in health care management. The focus of these events tends to be on medical technologies, however, with calls for improvements in management practices as general recommendations. The hackathon reported here contributes to health care management practice by addressing improvements in teamwork as the focal problem. METHODOLOGY: The hackathon event took place over 2.5 days in conjunction with an academic conference focused on group research. Three teams comprised of practicing healthcare professionals, academic researchers and students developed solutions to problems of ad hoc team formation in rapid response teams. FINDINGS: The event fulfilled several goals. The teams produced three distinct, yet complementary solutions that were backed by both field-based experience and solid research evidence. The event provided the opportunity for two-way translation of research and practice through direct collaboration among key stakeholders. The hackathon produced long term effects through establishing or strengthening collaborations, dissemination of the ideas through presentations, workshops, and publications, and changes in participantsâ work practices. PRACTICE IMPLICATION: The event demonstrated that hackathons, classically focused on technology, can also offer a spur to innovation around organizational processes. The article provides advice for organizing other hackathons focused on similar topics. The solutions offered by the participants in the event yields the clear insight that multipronged solutions for emergency-oriented teamwork are needed. The hackathon highlighted the scaled of collaboration and effort needed to tackle the many complexities in health care that impact outcomes for providers, patients, and health organizations.

Does stress influence the performance of cardiopulmonary resuscitation? A narrative review of the literature.

Cardiopulmonary resuscitation represents a major physical and psychological challenge for all involved health care workers because survival of the patients is closely related to the timely and accurate actions of rescuers. Consequently, rescuers may experience high levels of acute mental stress. Stress, in turn, may influence attentional resources and distractibility, which may affect the quality of resuscitation. This narrative review summarizes the current state of research concerning the influence of stress on resuscitation performance. Peer-reviewed studies retrieved in scientific databases were eligible. We found that rescuers experience high levels of stress and some associations of higher levels of stress with lower resuscitation performance. Finally, few interventional studies assessed whether interventions aiming at reducing levels of stress may have a beneficial effect on resuscitation performance, but results are variable. Although the mechanisms linking stress to performance of emergency teams are still not fully understood, factors such as individual experience and self-confidence of rescuers, gender composition and hierarchy within resuscitation teams may play an important role. This review provides a targeted overview of how stress can be defined and measured, how it may influence emergency situations such as a cardiopulmonary resuscitation, and which interventions have the potential to reduce overwhelming stress.

Impact of changing the surgical team for wound closure on surgical site infection: A matched case-control study.

BACKGROUND: Wound closure is performed at the end of the procedure, when the attention of the surgical team may decrease due to tiredness. The aim of this study was to assess the influence of changing the surgical team for wound closure on the rate of surgical site infection (SSI). METHODS: A two-armed observational monocentric matched case-control study was performed in a time series design. During the baseline period, closure of the abdominal wall was performed by the main surgical team. The intervention consisted of closure of the abdominal wall and skin by an independent surgical team. Matching was based on gender, BMI, length of surgery, type of surgery, elective versus emergency surgery and ASA score. The primary outcome was SSI rate 30 days after surgery. RESULTS: A total of 72 patients in the intervention group were matched with 72 patients in the baseline group. The SSI rate after 30 days in the intervention group was 10% (n = 7) and in the baseline group 21% (n = 15) (p = 0.064). Redo-Surgery as result of infection (e.g. opening the wound, drainage or reoperation) was significantly higher in the baseline group (19.4% vs 2.7%; p = 0.014). Mortality, length of stay, rehospitalisation and complication rates 30 days after surgery did not differ significantly. CONCLUSION: Changing the surgical team for wound closure did not reduce the overall rate of SSI, but the rate of redo-surgery as a result of SSI. Despite being potentially beneficial, organizational factors are a main limiting factor of changing the surgical team for the wound closure. TRIAL REGISTRATION: Clinicaltrial.gov NCT04503642.

Hands-On Times, Adherence to Recommendations and Variance in Execution among Three Different CPR Algorithms: A Prospective Randomized Single-Blind Simulator-Based Trial.

BACKGROUND: Alternative cardiopulmonary resuscitation (CPR) algorithms, introduced to improve outcomes after cardiac arrest, have so far not been compared in randomized trials with established CPR guidelines. METHODS: 286 physician teams were confronted with simulated cardiac arrests and randomly allocated to one of three versions of a CPR algorithm: (1) current International Liaison Committee on Resuscitation (ILCOR) guidelines ("ILCOR"), (2) the cardiocerebral resuscitation ("CCR") protocol (3 cycles of 200 uninterrupted chest compressions with no ventilation), or (3) a local interpretation of the current guidelines ("Arnsberg", immediate insertion of a supraglottic airway and cycles of 200 uninterrupted chest compressions). The primary endpoint was percentage of hands-on time. RESULTS: Median percentage of hands-on time was 88 (interquartile range (IQR) 6) in "ILCOR" teams, 90 (IQR 5) in "CCR" teams (p = 0.001 vs. "ILCOR"), and 89 (IQR 4) in "Arnsberg" teams (p = 0.032 vs. "ILCOR"; p = 0.10 vs. "CCR"). "ILCOR" teams delivered fewer chest compressions and deviated more from allocated targets than "CCR" and "Arnsberg" teams. "CCR" teams demonstrated the least within-team and between-team variance. CONCLUSIONS: Compared to current ILCOR guidelines, two alternative CPR algorithms advocating cycles of uninterrupted chest compressions resulted in very similar hands-on times, fewer deviations from targets, and less within-team and between-team variance in execution.

Association of self-esteem, personality, stress and gender with performance of a resuscitation team: A simulation-based study.

BACKGROUND: Gender composition, stress and leadership of a resuscitation team influence CPR performance. Whether psychological variables such as self-esteem, motivation and personality traits are associated with resuscitation performance, stress levels and gender of rescuers during a cardiac arrest scenario remains uncertain. METHODS: We included 108 medical students in this prospective, observational simulator study. We videotaped the resuscitation performance and assessed self-esteem, perceived stress-overload and personality traits using validated questionnaires. In addition, we analysed leadership utterances and ECG data of all participants during the simulation. The primary endpoint was cardiopulmonary resuscitation performance, defined as hands-on time within the first 180 sec. Secondary outcomes included first meaningful measure of resuscitation, leadership statements of group leaders and physiological stress parameters of rescuers. RESULTS: Adjusted for group size and leadership designation, mean self-esteem of students was significantly associated with hands-on time (adjusted regression coefficient 7.94 (95%CI 2.61 to 13.27), p<0.01). The personality trait conscientiousness was positively associated with hands-on time (adjusted regression coefficient 38.4, [95%CI 7.41 to 69.38, p = 0.02]). However, after additional adjustment for self-esteem, this association was no longer significant. Further, agreeableness of team leaders was significantly associated with longer hands-on time (adjusted regression coefficient 20.87 [95%CI 3.81 to 37.94], p = 0.02). Openness to experience was negatively associated with heart rate reactivity (-5.92 (95%CI -10 to -1.85), p<0.01). Male students showed significantly higher (mean, [±SD]) self-esteem levels (24.6 [±3.8] vs. 22.0 [±4.4], p<0.01), expressed significantly more leadership statements (7.9 [±7.8] vs. 4.6 [±3.8], p<0.01) and initiated first resuscitation measures more often (n, [%]) compared to female students (16, [23] vs. 7, [12], p = 0.01). CONCLUSION: This simulator study found that self-esteem of resuscitation teams and agreeableness of team leaders of inexperienced students was associated with cardiopulmonary resuscitation performance. Whether enhancing these factors during resuscitation trainings serve for better performance remains to be studied.

More than experience: a post-task reflection intervention among team members enhances performance in student teams confronted with a simulated resuscitation task-a prospective randomised trial.

Background: Teams that regularly step back from action and deliberately reflect on their performance and strategies show higher performance. Ad hoc emergency teams with changing team composition cannot develop such habits but may engage in short postaction reflection to discuss shortcomings of past performance and potential adaptations of their strategies for future similar tasks. This study aimed to test the effect of a short postaction self-led reflective team briefing on resuscitation performance in a simulator setting in terms of three performance parameters: hands-on time, coordination between chest compression and ventilation, and defibrillation. Methods: We performed a randomised controlled trial including 56 ad hoc formed teams of three fourth-year medical students each. All groups performed a resuscitation task, followed by a self-guided reflective briefing, based on a general instruction (n=28 teams), or an unrelated discussion session (control condition; n=29), followed by a second resuscitation task in the same team composition. Results: Adjusted for performance in the first task, teams in the reflection condition showed higher performance gain in the second resuscitation than teams in the control condition (6.21 percentage points (95% CI 1.31 to 11.10, p<0.001)) for basic hands-on performance; 15.0 percentage points (95% CI 2 to 28, p<0.001) for coordinative performance but non-significantly lower performance for defibrillation (-9%, 95% CI -27% to -9%, p=0.312). Conclusion: Even very short self-led postaction reflective briefings enhance basic resuscitation performance in ad hoc groups but may not influence more complex aspects of the task. We recommend including short self-led team debriefings as part of simulator training.

"Disruptive behavior" in the operating room: A prospective observational study of triggers and effects of tense communication episodes in surgical teams.

BACKGROUND: Tense communication and disruptive behaviors during surgery have often been attributed to surgeons' personality or hierarchies, while situational triggers for tense communication were neglected. Goals of this study were to assess situational triggers of tense communication in the operating room and to assess its impact on collaboration quality within the surgical team. METHODS AND FINDINGS: The prospective observational study was performed in two university hospitals in Europe. Trained external observers assessed communication in 137 elective abdominal operations led by 30 different main surgeons. Objective observations were related to perceived collaboration quality by all members of the surgical team. A total of 340 tense communication episodes were observed (= 0.57 per hour); mean tensions in surgeries with tensions was 1.21 per hour. Individual surgeons accounted for 24% of the variation in tensions, while situational aspects accounted for 76% of variation. A total of 72% of tensions were triggered by coordination problems; 21.2% by task-related problems and 9.1% by other issues. More tensions were related to lower perceived teamwork quality for all team members except main surgeons. Coordination-triggered tensions significantly lowered teamwork quality for second surgeons, scrub technicians and circulators. CONCLUSIONS: Although individual surgeons differ in their tense communication, situational aspects during the operation had a much more important influence on the occurrence of tensions, mostly triggered by coordination problems. Because tensions negatively impact team collaboration, surgical teams may profit from improving collaboration, for instance through training, or through reflexivity.

The workday of hospital surgeons: what they do, what makes them satisfied, and the role of core tasks and administrative tasks; a diary study.

BACKGROUND: Many surgeons report passion for their work, but not all tasks are likely to be satisfying. Little is known about how hospital surgeons spend their days, how they like specific tasks, and the role of core tasks (i.e. surgery-related tasks) versus tasks that may keep them from core tasks (e.g., administrative work). This study aimed at a more detailed picture of hospital surgeons' daily work - how much time they spend with different tasks, how they like them, and associations with satisfaction. METHODS: Hospital surgeons (N = 105) responded to a general survey, and 81 of these provided up to five daily questionnaires concerning daily activities and their attractiveness, as well as their job satisfaction. The data were analyzed using t-tests, analysis of variance, as well as analysis of covariance and repeated measures analysis of variance for comparing means across tasks. RESULTS: Among 14 tasks, surgery-related tasks took 21.2%, patient-related tasks 21.7% of the surgeons' time; 10.4% entailed meetings and communicating about patients, and 18.6% documentation and administration. The remaining time was spent with teaching, research, leadership and management, and not task-related activities (e.g. walking between rooms). Surgery was rated as most (4.25; SD = .66), administration as least attractive (2.63; SD = .78). A higher percentage of administration predicted lower perceived legitimacy; perceived legitimacy of administrative work predicted job satisfaction (r = .47). Residents were least satisfied; there were few gender differences. CONCLUSIONS: Surgeons seem to thrive on their core tasks, most notably surgery. By contrast, administrative duties are likely perceived as keeping them from their core medical tasks. Increasing the percentage of medical tasks proper, notably surgery, and reducing administrative duties may contribute to hospital surgeons' job satisfaction.

Comparison of Surveillance of Surgical Site Infections by a National Surveillance Program and by Institutional Audit.

BACKGROUND: Reported incidence of surgical site infections (SSI) after colonic surgery varies widely. These variations depend not only on patient- and surgery-related parameters but are influenced by type and quality of follow-up. The aim of the study was to compare SSI assessed by two independent prospective surveillance systems, a national surveillance program based on recommendations of the National Healthcare Safety Network (Swissnoso) versus an international audit system, the ERAS® Interactive Audit System (EIAS; Encare, Stockholm, Sweden). METHODS: Comparative study of a consecutive cohort of colonic resections at a single institution from September 2015 to March 2017. Independent prospective SSI monitoring was available from Swissnoso and EIAS. Inter-observer reliability was calculated using Cohen k. Sensitivity, specificity, and accuracy of EIAS in assessing SSI was compared with Swissnoso, considered as gold standard. RESULTS: The final sample included 143 patients. Of these, 136 (95.1%) were classified into the same category by both systems, identifying 17 patients (12.5%) with SSI and 119 patients (87.5%) without SSI, respectively. Discrepant results were found for the remaining seven patients (4.9%) with four SSI categorization according to Swissnoso but not EIAS, and three SSI categorization in EIAS but not in Swissnoso; all miscategorized patients presented superficial SSI. Sensitivity, specificity, and accuracy of EIAS for SSI recording was 81%, 97.5%, and 95.1%, respectively. Inter-observer agreement was high (Cohen k value of 0.801, p < 0.001). Case-by-case analysis of discrepant findings revealed mainly discrepant interpretation of clinical symptoms and erroneous labeling of non-procedure-related infections. CONCLUSIONS: Surgical site infection recording by two independent systems showed high concordance and good inter-rater reliability.

Stress as Offense to Self: a Promising Approach Comes of Age.

Stress is related to goals being thwarted. Arguably, protecting one's self, both in terms of personal self-esteem and in terms of social self-esteem, is among the most prominent goals people pursue. Although this line of thought is hardly disputed, it does not play the prominent role in occupational health psychology that we think it deserves. Stress-as-Offense-to-Self theory focuses on threats and boosts to the self as important aspects of stressful, and resourceful, experiences at work. Within this framework we have developed the new concepts of illegitimate tasks and illegitimate stressors; we have investigated appreciation as a construct in its own right, rather than as part of larger constructs such as social support; and we propose that the threshold for noticing implications for the self in one's surroundings typically is low, implying that even subtle negative cues are likely to be appraised as offending, as exemplified by the concept of subtly offending feedback. Updating the first publication of the SOS concept, the current paper presents its theoretical rationale as well as research conducted so far. Research has covered a variety of phenomena, but the emphasis has been (a) on illegitimate tasks, which now can be considered as an established stressor, and (b) on appreciation, showing its importance in general and as a core element of social support. Furthermore, we discuss implications for further research as well as practical implications of an approach that is organized around threats and boosts to the self, thus complementing approaches that are organized around specific conditions or behaviors.