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.

Early warning model for passenger disturbance due to flight delays.

Disruptive behavior by passengers delayed at airport terminals not only affects personal safety but also reduces civil aviation efficiency and passenger satisfaction. This study investigated the causal mechanisms of disruptive behavior by delayed passengers in three aspects: environmental, managerial, and personal. Data on flight delays at Shenzhen Airport in 2018 were collected and analyzed. The main factors leading to disruptive behavior by delayed passengers were identified, and an early warning model for disturbances was developed using multiple logistic regression and a back-propagation(BP) neural network. The results indicated that the proposed model and method were feasible. Compared to the logistic regression model, the BP neural network model had advantages in predicting disturbances by delayed passengers, showing higher prediction accuracy. The BP network weight analysis method was used to obtain the influence weight of each factor on behavior change of delayed passengers. The influence weight of different factors was obtained, providing an assistant decision-making method to address disruption from flight-delayed passengers.

Accounting for product impact in the airlines industry

We apply the product impact measurement framework of the Impact-Weighted Accounts Initiative (IWAI) in two competitor companies within the airlines industry. We design a monetization methodology that allows us to calculate monetary impact estimates of fare affordability, timeliness and gate control, among other factors. Our results indicate substantial differences in the impact that competitors have through their products. These differences demonstrate how impact reflects corporate strategy and informs decision-making on industry-specific areas, including airline route structure choices.(AU)

Asthma and Rotary-Wing Military Aircrew Selection.

BACKGROUND: From a population-based perspective, reports in the peer-reviewed medical literature suggest an increase in the overall prevalence of asthma in recent decades. Applicants for military aviation training with a current or past history of asthma are generally excluded in the United Kingdom.METHODS: In order to assess the impact of the prevalence of asthma on the available pool of military service candidates, the authors collected data on annual live births between 1916 and 2016 as well as peer-reviewed publications that provided insight into asthma prevalence trends within the United Kingdom across the last century (covering birth-year population cohorts ranging from 1924 to 1995). Regression techniques were used to estimate the prevalence of individuals who could reasonably expect to be found unfit for military aviation service due to asthma-like conditions within the birth-year cohorts between 2001 and 2016.RESULTS: Between 1916 and 2016, the number of live births in the United Kingdom has averaged approximately 802,000 per year. The reported prevalence of asthma, based on the assimilated data points, ranged from 2.3 cases per 1000 individuals among the 1924 birth-year cohort, to 29.8 cases per 1000 individuals among the 1990 birth-year cohort.DISCUSSION: Based on the data and analysis presented above, asthma continues to constitute a significant public health issue in the United Kingdom. Military services must base risk mitigation decisions on accurate and precise diagnostic categorizations, and prudently balance the benefits of allowing affected individuals to participate in military service with the potential for mission degradation or compromise.Porter WD, Powell-Dunford N, Wilde GD, Bushby AJR. Asthma and rotary-wing military aircrew selection. Aerosp Med Hum Perform. 2019; 90(7):606-612.

Safety in the nonoperating room anesthesia suite is not an accident: lessons from the National Transportation Safety Board.

PURPOSE OF REVIEW: To review the findings of National Transportation Safety Board-related aviation near misses and catastrophes and apply these principles to the nonoperating room anesthesia (NORA) suite. RECENT FINDINGS: NORA is a specialty that has seen tremendous growth. In 2019, NORA contributes to a larger proportion of anesthesia practice than ever before. With this growth, the NORA anesthesiologist and team are challenged to provide safe, high-quality care for more patients, often with complex comorbidities, and are forced to utilize deeper levels of sedation and anesthesia than ever before. These added pressures create new avenues for human error and adverse outcomes. SUMMARY: Safety in modern anesthesia practice often draws comparison to the aviation industry. From distinct preoperational checklists, defined courses of action, safety monitoring and the process of guiding individuals through a journey, there are many similarities between the practice of anesthesia and flying an airplane. Consistent human performance is paramount to creating safe outcomes. Although human errors are inevitable in any complex process, the goal for both the pilot and physician is to ensure the safety of their passengers and patients, respectively. As the aviation industry has had proven success at managing human error with a dramatic improvement in safety, a deeper look at several key examples will allow for comparisons of how to implement these strategies to improve NORA safety.

Video Game Play as a Fatigue Countermeasure in Air Traffic Controllers.

BACKGROUND: Extensive research has demonstrated that shift-work and time of day affect one's ability to maintain alertness and vigilance. Research has also sought to determine ways to increase alertness and decrease the effects of fatigue in high vigilance environments, such as air traffic control. This study was designed to assess the effectiveness of video game play as a fatigue countermeasure in air traffic controllers.METHODS: We tested 22 military air traffic controllers to ascertain whether video game play prior to time in the air traffic control room heightened their alertness during their shift. An oculometer, which is an objective measure of physiological arousal and visual alertness, was used to measure pupillary diameter, amplitude, latency, and velocity. Perceived alertness was assessed using the Stanford Sleepiness Scale. Over a 4-wk period, the air traffic controllers participated in a counterbalanced, within-subjects design study with experimental (video gaming prior to control room) and control (no video gaming prior to control) conditions.RESULTS: We used a within-subjects, repeated measures MANOVA to compare differences in physiological and perceived alertness of individuals in the two conditions. Results indicated that video game play significantly increased physiological alertness in air traffic controllers, especially pupil diameter and velocity, and this effect was sustained for at least 30 min after they stopped playing. Perceived alertness was also increased by video game play.DISCUSSION: These results indicate that video game play could be an effective fatigue countermeasure in high vigilance occupations such as air traffic control.Fowler LA, Gustafson D. Video game play as a fatigue countermeasure in air traffic controllers. Aerosp Med Hum Perform. 2019; 90(6):540-545.

The training and practice of crew resource management: recommendations from an inductive in vivo study of the flight deck.

Crew resource management (CRM) is credited with saving 185 lives at Sioux City. While the theory behind CRM is well documented, there are few studies of how CRM manifests on the line. This inductive in vivo study had three objectives. First, to describe how CRM manifests. Secondly, to evaluate the efficacy of CRM vis-à-vis flight safety. Thirdly, to suggest improvements to the CRM training syllabus. The study produced five conclusions: First, CRM is durable under conditions of moderate strain. Secondly, crews embed and refine CRM through reflection and action. Thirdly, CRM facilitates and shapes social relations. Fourthly, mindlessness (Langer 1989 ) undermines CRM. Finally, the interruption of flight-deck routines by third-parties poses a threat to flight-safety. The paper recommends multi-profession CRM training as a means of improving communication and co-ordination in and around aircraft. The study's limitations include a monocultural flight-deck: flights were operated by pilots with European backgrounds. Mindful of Hofstede's ( 1980 ), Engle's ( 2000 ) and Helmreich and Merritt's ( 2001 ) examination of the relationship between culture and performance, the author suggests the study be repeated with carriers that employ pilots from a variety of cultures. Practitioner Summary: This in vivo study evaluates the efficacy of CRM vis-à-vis flight safety and supports a critique of the CRM syllabus. The author observed twenty sectors and attended a CRM training day. To improve safety and efficiency, it is recommended that airlines run multi-profession (inclusive) CRM training courses.

Factores humanos en aviación: CRM (crew resource management-gestión de recursos de la tripulación) / Human factors in aviation: CRM (crew resource management)

Uno de los campos aplicados a los que más ha contribuido la ciencia psicológica es, sin lugar a dudas, el de la aviación. El análisis y estudio de los factores humanos constituye actualmente uno de los puntos fuertes en el sector aeronáutico de cara a la reducción de los accidentes aéreos. Desde su aparición en 1979, los programas de Gestión de Recursos de la Tripulación (CRM) han sido una de las herramientas que con mayor éxito han gestionado el denominado "error humano". El presente artículo realiza un breve recorrido por la historia de estos programas globales de entrenamiento que suponen uno de los grandes logros de la Psicología Aplicada

One of the applied fields to which psychological science has most contributed is, without doubt, aviation. The analysis and study of human factors is currently one of the strong points in the aeronautical sector in order to reduce accidents in aviation. Since its appearance in 1979, the Crew Resource Management (CRM) programs have been one of the most successful tools that have managed the so-called "human error". This paper makes a brief tour through the history of these global training programs that represent one of the great achievements of Applied Psychology

Selecting trainee pilots: Predictive validity of the WOMBAT situational awareness pilot selection test.

The WOMBAT pilot selection test is widely used to select candidates for pilot training programs. Despite use in many countries, little information is available regarding the predictive validity of the test. This study was designed to test the ability of the WOMBAT test to predict performance outcomes in a sample of ab-initio pilots. Sixty students commenced the study in 3 cohorts, and completed the WOMBAT test before their performance in the training program was evaluated through flight time to solo, flight time to licence level achievement, and instructor ratings of performance. Higher WOMBAT total scores were significantly related to reduced time to solo, achieving flight licences, as well as some early ratings of performance by flight instructors. Further research now needs to examine the exact nature of the skills and abilities that the test indexes in order to further improve pilot selection and training procedures.

Principles of Automation for Patient Safety in Intensive Care: Learning From Aviation.

BACKGROUND: The transition away from written documentation and analog methods has opened up the possibility of leveraging data science and analytic techniques to improve health care. In the implementation of data science techniques and methodologies, high-acuity patients in the ICU can particularly benefit. The Principles of Automation for Patient Safety in Intensive Care (PASPIC) framework draws on Billings's principles of human-centered aviation (HCA) automation and helps in identifying the advantages, pitfalls, and unintended consequences of automation in health care. THE FRAMEWORK AND ITS KEY CHARACTERISTICS: Billings's HCA principles are based on the premise that human operators must remain "in command," so that they are continuously informed and actively involved in all aspects of system operations. In addition, automated systems need to be predictable, simple to train, to learn, and to operate, and must be able to monitor the human operators, and every intelligent system element must know the intent of other intelligent system elements. In applying Billings's HCA principles to the ICU setting, PAPSIC has three key characteristics: (1) integration and better interoperability, (2) multidimensional analysis, and (3) enhanced situation awareness. RECOMMENDATIONS: PAPSIC suggests that health care professionals reduce overreliance on automation and implement "cooperative automation" and that vendors reduce mode errors and embrace interoperability. CONCLUSION: Much can be learned from the aviation industry in automating the ICU. Because it combines "smart" technology with the necessary controls to withstand unintended consequences, PAPSIC could help ensure more informed decision making in the ICU and better patient care.

Can the Aviation Industry be Useful in Teaching Oncology about Safety?

Healthcare practitioners have long considered aviation as a domain from which much can be learned about safety. Over the past 30 years, attempts have been made to apply aviation safety-related concepts to healthcare. Although some applications have been successful, a few decades later, many healthcare safety experts have learned that the appeal of the aviation-healthcare analogy is an illusion. Both domains are so basically dissimilar that simple adoption of aviation concepts will not be successful. However, what has succeeded is healthcare's adaptation of specific aviation safety concepts. Three concepts, investment in safety, human factors and safety management systems, are described and examples are given of adapted applications to healthcare/clinical oncology. Finally, there is a need to ensure that these concepts are applied systematically throughout healthcare rather than sporadically and without a centralised mandate, to help ensure success and improved patient and provider safety.

[The criteria for the relationship between hearing impairment and professional occupation and the criteria for professional suitability in terms of hearing among the aeronautical personnel engaged in civilian aviation]. / Kriterii sviazi narushenii slukha s professiei i kriterii profprigodnosti po slukhu u aviatsionnogo personala grazhdanskoi aviatsii.

This article describes the main clinical features associated with the development and manifestations of disturbed sound perception in the members of the aeronautical personnel engaged in the Russian civilian aviation. The main expert criteria for the relationship between the diseases of the organs of hearing (as exemplified by chronic sensorineural hearing impairment) and professional occupation have been developed based on the results of the clinical and diagnostic examination with the use of whispered and loud speech acumetry, tonal threshold audiometry, speech audiometry, impedancometry and evoked optoacoustic emission. Civilian aviation sectoral approaches to the evaluation of professional suitability in terms of hearing among the aeronautical personnel are considered in accordance with the criteria adopted by the International Civil Aviation Organization (ICAO), a specialized UN agency that sets the international standards for the civilian aviation and co-ordinates its development with the purpose of enhancing the safety and effectiveness of flights. The criteria are formulated for the solution of the expert problems arising from the relationship between the professional occupation and the diseases of the organs of hearing and for the evaluation of the professional suitability in terms of hearing among the aeronautical personnel engaged in civilian aviation.

Elvira López Maurín, la primera enfermera militar de la aviación sanitaria española. La historia de un acto heroico olvidado / Elvira López Maurín, the first female soldier of Spanish healthcare aviation. Story of a heroic, forgotten act

La noche del día 1 de noviembre de 1922 marcaría el inicio de las actividades de la Aviación Sanitaria de España. En esta noche se desplazaría por primera vez un equipo quirúrgico completo, en tres aviones de guerra, desde el aeródromo de Nador (Melilla) hasta Dar-Drius con el propósito de atender a los múltiples heridos que acudían después de los combates en el frente de Tizzi Azza. A la importancia histórica de este vuelo se sumó el hecho de presentarse voluntaria la enfermera Elvira López Maurín, que por su condición de mujer, no tenía la obligación de volar en un avión de guerra en esta época. Esta valerosa actitud junto con su afán por socorrer a los heridos más allá de su deber fueron recogidos como una acción heroica en todos los medios de comunicación. En los días posteriores fue felicitada en distintas audiencias por el Rey Alfonso XIII, la Reina Victoria Eugenia, el presidente del Gobierno, Ministro de la Guerra y Comisario Regio de la Cruz Roja, distinguida y recompensada por dicha acción. Por este hecho heroico el impacto en los medios de comunicación del comienzo de esta nueva forma de trasporte sanitario fue mayor. La trayectoria de esta enfermera coincide con el comienzo de la enfermería profesional en España. Este suceso transcendente para la historia de la Medicina, la Aviación y la Enfermería española ha quedado en el olvido por los profesionales sanitarios de esta disciplina no habiéndose recogido en profundidad en ninguna publicación

The night of November, 1 1922 represented the starting point of Healthcare Aviation in Spain. Fort the first time, a full surgical team travelled, by three military aircraft, from the aerodrome of Nador (Melilla) to Dar-Drius in order to attend the numerous wounded resulting from the combats along the Tizzi Azza front line. The historic importance of the flight was coupled by the fact of counting on the voluntary nurse Elvira López Maurín who, due to her gender, did not have to fly in the aircraft at that time. Her brave attitude and her eagerness to help the wounded beyond the limits of duty were considered a heroic action by the media. Some days later, she was both congratulated in several ceremonies (by their Majesties King Alfonso XIII and Queen Victoria Eugenia, the President of the Government, the Ministre of War and the Red Cross Royal Deputy), distinguished and rewarded. Her heroism was directly responsible for the increasing impact in the media of this new way of transportation. The vital trajectory of this nurse coincides with the initial development of professional nursing in Spain, this event being essential for the Spanish History of Medicine, Aviation and Nursing although it has remained obscured and forgotten by healthcare professionals for it has not been recorded in any publication so far

Johnny was here: From airmanship to airlineship.

In this article we explore the phenomenon of airmanship in commercial passenger flights, in a context of increasing standardisation of procedures and technologies. Through observation studies in cockpits and interviews we have studied pilots' practices and how they relate to the larger system of procedures and the technical environment. We find that practices are to a large extent guided by standard operating procedures, and that interchangeability of pilots and aircrafts is both a prerequisite for and enabled by this standardised regime. However, since sociotechnical systems in general - and operation of aircrafts is no exception - are inherently underspecified, the pilots' exercise of discretion in their context-sensitive adaptation of the procedures and technical environments is another prerequisite for well-functioning systems. Mastering these adaptations - and recognising the absolute delimitations of adaptations - is a central aspect of airmanship. Outside this space of manoeuvre for the pilots, the aircrafts are managed by what we call airlineship: The inter-organisational efforts to create predictability and safe practices through de-identification and interchangeability of personnel and aircrafts. Pilots are actors in sociotechnical systems that are not demarcated by the cockpits. To understand pilots' work, studies must account also for the wider sociotechnical context of organisational, regulative and techno-material structures. The article is a contribution to the a generic attempt in the field of ergonomics to contribute with models and theories that portray individuals, groups, organisations and systems in ways that keep sight of the individuals in the systems and the systems in the individuals at the same time.

De la cabina al quirófano / From the cockpit to the operating room

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