Publications

2021
Lauren R Kennedy-Metz, Roger D Dias, Ronald H Stevens, Steven J Yule, and Marco A Zenati. 2021. “Analysis of Mirrored Psychophysiological Change of Cardiac Surgery Team Members During Open Surgery.” J Surg Educ, 78, 2, Pp. 622-629.Abstract
OBJECTIVE: Mirrored psychophysiological change in cognitive workload indices may reflect shared mental models and effective healthcare team dynamics. In this exploratory analysis, we investigated the frequency of mirrored changes, defined as concurrent peaks in heart rate variability (HRV) across team members, during cardiac surgery. DESIGN: Objective cognitive workload was evaluated via HRV collected from the primary surgical team during cardiac surgery cases (N = 15). Root mean square of the successive differences (RMSSD) was calculated as the primary HRV measure. Procedures were divided into consecutive nonoverlapping 5-minute segments, and RMSSD along with deviations from RMSSD were calculated for each segment. Segments with positive deflections represent above-average cognitive workload. Positive deflections and peaks across dyads within the same segment were counted. SETTING: Data collection for this study took place in the cardiovascular operating room during live surgeries. PARTICIPANTS: Physiological data were collected and analyzed from the attending surgeon, attending anesthesiologist, and primary perfusionist involved with the recorded cases. RESULTS: Of the 641 five-minute segments analyzed, 325 (50.7%) were positive deflections above average, concurrently across at least 2 team members. Within the 325 positive deflections, 26 (8%) represented concurrent peaks in HRV across at least 2 active team members. Mirrored peaks across team members were observed most commonly during the coronary anastomoses or valve replacement phase (N = 12). CONCLUSIONS: In this pilot study, mirrored physiological responses representing peaks in cognitive workload were observed uncommonly across dyads of cardiac surgery team members (1.73 peaks/case on average). Almost half of these occurred during the most technically demanding phases of cardiac surgery, which may underpin teamwork quality. Future work should investigate interactions between technical and nontechnical performance surrounding times of mirrored peaks and expand the sample size.
Lauren Kennedy-Metz, Roger Dias, and Marco Zenati. 2021. “The Cognitive Relevance of a Formal Pre-Incision Time-out in Surgery.” In European Conference on Cognitive Ergonomics 2021. New York, NY, USA: Association for Computing Machinery. Publisher's VersionAbstract
Surgical time-outs are designed to promote situation awareness, teamwork, and error prevention. The pre-incision time-out in particular aims to facilitate shared mental models prior to incision. Objective, unbiased measures to confirm its effectiveness are lacking. We hypothesized that providers’ mental workload would reveal team psychophysiological mirroring during a formal, well-executed pre-incision time-out. Heart rate variability was collected during cardiac surgery cases from the surgeon, anesthesiologist, and perfusionist. Data were analyzed for six cases from patient arrival until sternal closure. Annotation of surgical phases was completed according to previously developed standardized process models of aortic valve replacement and coronary artery bypass graft procedures, producing thirteen total surgical phases. Statistical analysis revealed significant main effects. Tukey HSD post hoc tests revealed significant differences across provider roles within various phases, including Anesthesia Induction, Heparinization, Initiation of Bypass, Aortic Clamp and Cardioplegia, Anastomoses or Aortotomy, Separation from Bypass, and Sternal Closure. Despite these observed differences between providers over various surgical phases, the Pre-incision Time-out phase revealed almost negligible differences across roles. This preliminary work supports the utility of the pre-incision safety checklist to focus the attention of surgical team members and promote shared team mental models, measured via psychophysiological mirroring, using an objective mental workload measure. Future studies should investigate the relationship between psychophysiological mirroring among surgical team members and the effectiveness of the pre-incision time-out checklist.
Marco A Zenati, Roger D Dias, and Lauren R Kennedy-Metz. 2021. “Commentary: Nontechnical skills redux.” J Thorac Cardiovasc Surg.
L. R. Kennedy-Metz, P. Mascagni, A. Torralba, R. D. Dias, P. Perona, J. A. Shah, N. Padoy, and M. A. Zenati. 2021. “Computer Vision in the Operating Room: Opportunities and Caveats.” IEEE Transactions on Medical Robotics and Bionics, 3, 1, Pp. 2-10.Abstract
Effectiveness of computer vision techniques has been demonstrated through a number of applications, both within and outside healthcare. The operating room environment specifically is a setting with rich data sources compatible with computational approaches and high potential for direct patient benefit. The aim of this review is to summarize major topics in computer vision for surgical domains. The major capabilities of computer vision are described as an aid to surgical teams to improve performance and contribute to enhanced patient safety. Literature was identified through leading experts in the fields of surgery, computational analysis and modeling in medicine, and computer vision in healthcare. The literature supports the application of computer vision principles to surgery. Potential applications within surgery include operating room vigilance, endoscopic vigilance, and individual and team-wide behavioral analysis. To advance the field, we recommend collecting and publishing carefully annotated datasets. Doing so will enable the surgery community to collectively define well-specified common objectives for automated systems, spur academic research, mobilize industry, and provide benchmarks with which we can track progress. Leveraging computer vision approaches through interdisciplinary collaboration and advanced approaches to data acquisition, modeling, interpretation, and integration promises a powerful impact on patient safety, public health, and financial costs.
João Gabriel Rosa Ramos, Otavio Tavares Ranzani, Roger Daglius Dias, and Daniel Neves Forte. 2021. “Impact of nonclinical factors on intensive care unit admission decisions: a vignette-based randomized trial (V-TRIAGE).” Rev Bras Ter Intensiva, 33, 2, Pp. 219-230.Abstract
OBJECTIVE: To assess the impact of intensive care unit bed availability, distractors and choice framing on intensive care unit admission decisions. METHODS: This study was a randomized factorial trial using patient-based vignettes. The vignettes were deemed archetypical for intensive care unit admission or refusal, as judged by a group of experts. Intensive care unit physicians were randomized to 1) an increased distraction (intervention) or a control group, 2) an intensive care unit bed scarcity or nonscarcity (availability) setting, and 3) a multiple-choice or omission (status quo) vignette scenario. The primary outcome was the proportion of appropriate intensive care unit allocations, defined as concordance with the allocation decision made by the group of experts. RESULTS: We analyzed 125 physicians. Overall, distractors had no impact on the outcome; however, there was a differential drop-out rate, with fewer physicians in the intervention arm completing the questionnaire. Intensive care unit bed availability was associated with an inappropriate allocation of vignettes deemed inappropriate for intensive care unit admission (OR = 2.47; 95%CI 1.19 - 5.11) but not of vignettes appropriate for intensive care unit admission. There was a significant interaction with the presence of distractors (p = 0.007), with intensive care unit bed availability being associated with increased intensive care unit admission of vignettes inappropriate for intensive care unit admission in the distractor (intervention) arm (OR = 9.82; 95%CI 2.68 - 25.93) but not in the control group (OR = 1.02; 95%CI 0.38 - 2.72). Multiple choices were associated with increased inappropriate allocation in comparison to the omission group (OR = 5.18; 95%CI 1.37 - 19.61). CONCLUSION: Intensive care unit bed availability and cognitive biases were associated with inappropriate intensive care unit allocation decisions. These findings may have implications for intensive care unit admission policies.
Michael R Mathis, Steven Yule, Xiaoting Wu, Roger D Dias, Allison M Janda, Sarah L Krein, Milisa Manojlovich, Matthew D Caldwell, Korana Stakich-Alpirez, Min Zhang, Jason Corso, Nathan Louis, Tongbo Xu, Jeremy Wolverton, Francis D Pagani, and Donald S Likosky. 2021. “The impact of team familiarity on intra and postoperative cardiac surgical outcomes.” Surgery.Abstract
BACKGROUND: Familiarity among cardiac surgery team members may be an important contributor to better outcomes and thus serve as a target for enhancing outcomes. METHODS: Adult cardiac surgical procedures (n = 4,445) involving intraoperative providers were evaluated at a tertiary hospital between 2016 and 2020. Team familiarity (mean of prior cardiac surgeries performed by participating surgeon/nonsurgeon pairs within 2 years before the operation) were regressed on cardiopulmonary bypass duration (primary-an intraoperative measure of care efficiency) and postoperative complication outcomes (major morbidity, mortality), adjusting for provider experience, surgeon 2-year case volume before the surgery, case start time, weekday, and perioperative risk factors. The relationship between team familiarity and outcomes was assessed across predicted risk strata. RESULTS: Median (interquartile range) cardiopulmonary bypass duration was 132 minutes (91-192), and 698 (15.7%) patients developed major postoperative morbidity. The relationship between team familiarity and cardiopulmonary bypass duration significantly differed across predicted risk strata (P = .0001). High (relative to low) team familiarity was associated with reduced cardiopulmonary bypass duration for medium-risk (-24 minutes) and high-risk (-27 minutes) patients. Increasing team familiarity was not significantly associated with the odds of major morbidity and mortality. CONCLUSION: Team familiarity, which was predictive of improved intraoperative efficiency without compromising major postoperative outcomes, may serve as a novel quality improvement target in the setting of cardiac surgery.
Lauren R Kennedy-Metz, Atilio Barbeito, Roger D Dias, and Marco A Zenati. 2021. “Importance of high-performing teams in the cardiovascular intensive care unit.” J Thorac Cardiovasc Surg.
Joanne G Abi-Jaoudé, Lauren R Kennedy-Metz, Roger D Dias, Steven J Yule, and Marco A Zenati. 2021. “Measuring and Improving Emotional Intelligence in Surgery: A Systematic Review.” Ann Surg.Abstract
OBJECTIVE: Evaluate how emotional intelligence (EI) has been measured among surgeons and to investigate interventions implemented for improving EI. SUMMARY BACKGROUND: EI has relevant applications in surgery given its alignment with non-technical skills. In recent years, EI has been measured in a surgical context to evaluate its relationship with measures such as surgeon burnout and the surgeon-patient relationship. METHODS: A systematic review was conducted by searching MEDLINE, EMBASE, CINAHL, and PSYCINFO databases using PRISMA guidelines. MeSH terms and keywords included "emotional intelligence," "surgery," and "surgeon." Eligible studies included an EI assessment of surgeons, surgical residents, and/or medical students within a surgical context. RESULTS: The initial search yielded 4,627 articles. After duplicate removal, 4,435 articles were screened by title and abstract and 49 articles proceeded to a full-text read. Three additional articles were found via hand search. A total of 37 articles were included. Studies varied in surgical specialties, settings, and outcome measurements. Most occurred in general surgery, residency programs, and utilized self-report surveys to estimate EI. Notably, EI improved in all studies utilizing an intervention. CONCLUSIONS: The literature entailing the intersection between EI and surgery is diverse but still limited. Generally, EI has been demonstrated to be beneficial in terms of overall well-being and job satisfaction while also protecting against burnout. EI skills may provide a promising modifiable target to achieve desirable outcomes for both the surgeon and the patient. Future studies may emphasize the relevance of EI in the context of surgical teamwork.
Donald Likosky, Steven J Yule, Michael R Mathis, Roger D Dias, Jason J Corso, Min Zhang, Sarah L Krein, Matthew D Caldwell, Nathan Louis, Allison M Janda, Nirav J Shah, Francis D Pagani, Korana Stakich-Alpirez, and Milisa M Manojlovich. 2021. “Novel Assessments of Technical and Nontechnical Cardiac Surgery Quality: Protocol for a Mixed Methods Study.” JMIR Res Protoc, 10, 1, Pp. e22536.Abstract
BACKGROUND: Of the 150,000 patients annually undergoing coronary artery bypass grafting, 35% develop complications that increase mortality 5 fold and expenditure by 50%. Differences in patient risk and operative approach explain only 2% of hospital variations in some complications. The intraoperative phase remains understudied as a source of variation, despite its complexity and amenability to improvement. OBJECTIVE: The objectives of this study are to (1) investigate the relationship between peer assessments of intraoperative technical skills and nontechnical practices with risk-adjusted complication rates and (2) evaluate the feasibility of using computer-based metrics to automate the assessment of important intraoperative technical skills and nontechnical practices. METHODS: This multicenter study will use video recording, established peer assessment tools, electronic health record data, registry data, and a high-dimensional computer vision approach to (1) investigate the relationship between peer assessments of surgeon technical skills and variability in risk-adjusted patient adverse events; (2) investigate the relationship between peer assessments of intraoperative team-based nontechnical practices and variability in risk-adjusted patient adverse events; and (3) use quantitative and qualitative methods to explore the feasibility of using objective, data-driven, computer-based assessments to automate the measurement of important intraoperative determinants of risk-adjusted patient adverse events. RESULTS: The project has been funded by the National Heart, Lung and Blood Institute in 2019 (R01HL146619). Preliminary Institutional Review Board review has been completed at the University of Michigan by the Institutional Review Boards of the University of Michigan Medical School. CONCLUSIONS: We anticipate that this project will substantially increase our ability to assess determinants of variation in complication rates by specifically studying a surgeon's technical skills and operating room team member nontechnical practices. These findings may provide effective targets for future trials or quality improvement initiatives to enhance the quality and safety of cardiac surgical patient care. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/22536.
Sang Won Seo, Lauren R. Kennedy-Metz, Marco A. Zenati, Julie A. Shah, Roger D. Dias, and Vaibhav V. Unhelkar. 2021. “Towards an AI Coach to Infer Team Mental Model Alignment in Healthcare.” In 2021 IEEE Conference on Cognitive and Computational Aspects of Situation Management (CogSIMA), Pp. 39-44.
Egide Abahuje, Andrew Bartuska, Rachel Koch, George Youngson, George Ntakiyiruta, Wendy Williams, Roger D Dias, Claudia Rosu, Steven Yule, and Robert Riviello. 2021. “Understanding Barriers and Facilitators to Behavior Change After Implementation of an Interdisciplinary Surgical Non-Technical Skills Training Program in Rwanda.” J Surg Educ.Abstract
OBJECTIVE: Nontechnical skills, such as situation awareness, decision making, leadership, communication, and teamwork play a crucial role on the quality of care and patient safety in the operating room (OR). In our previous work, we developed an interdisciplinary training program, based on the NOTSS (Non-Technical Skills for Surgeons) taxonomy. The aim of this study was to understand the challenges faced by Rwandan surgical providers, who had undergone NOTSS training, to apply these nontechnical skills during subsequent operative surgery. SETTING DESIGN: A sequential exploratory mixed method study design was used to assess how participants who took the NOTSS in Rwanda applied nontechnical skills in surgical care delivery. The qualitative phase of this study deployed a constructivist grounded theory approach. Findings from the qualitative phase were used to build a quantitative survey tool that explored themes that emerged from the first phase. PARTICIPANTS: Participants were nurses and resident from the departments of Surgery, Anesthesia, Obstetric, and Gynecology, from the University of Rwanda who attended the NOTSS course in March 2018. RESULTS: A total of 25 participants and 49 participants were respectively enrolled in the qualitative phase and quantitative phase. Participants noted that nontechnical skills implementation in clinical practice was facilitated by working with other personnel also trained in NOTSS, anticipation, and preparation ahead of the time; while lack of interdisciplinary communication, hierarchy, work overload, and an inconsistently changing environment compromised nontechnical skills implementation. Nontechnical skills were useful both inside and outside the operating. Participants reported that nontechnical skills implementation resulted in improved team dynamics, safer patient care, and empowerment. CONCLUSION: Surgical care providers who took the NOTSS course subsequently implemented nontechnical skills both inside and outside of the OR. Human and system-based factors affected the implementation of nontechnical skills in the clinical setting.
Nikhil Panda, James C Etheridge, Takshveer Singh, Yves Sonnay, George Molina, Barbara K Burian, Nina Capo-Chichi, Christy E Cauley, David AH de Beer, Miliard Derbew, Roger D Dias, Mary C Fearon, Mekdes Daba Feyssa, Kathryn Hagen, Manoj Kumar, Tihitena Negussie Mammo, Edward R Mariano, Alan Merry, Barbara Mushayandebvu, Mary T Nabukenya, Milind Shah, Lisa Spruce, Thomas G Weiser, and Mary E Brindle. 2021. “We Asked the Experts: The WHO Surgical Safety Checklist and the COVID-19 Pandemic: Recommendations for Content and Implementation Adaptations.” World J Surg, 45, 5, Pp. 1293-1296.Abstract
BACKGROUND: As surgical systems are forced to adapt and respond to new challenges, so should the patient safety tools within those systems. We sought to determine how the WHO SSC might best be adapted during the COVID-19 pandemic. METHODS: 18 Panelists from five continents and multiple clinical specialties participated in a three-round modified Delphi technique to identify potential recommendations, assess agreement with proposed recommendations and address items not meeting consensus. RESULTS: From an initial 29 recommendations identified in the first round, 12 were identified for inclusion in the second round. After discussion of recommendations without consensus for inclusion or exclusion, four additional recommendations were added for an eventual 16 recommendations. Nine of these recommendations were related to checklist content, while seven recommendations were related to implementation. CONCLUSIONS: This multinational panel has identified 16 recommendations for sites looking to use the surgical safety checklist during the COVID-19 pandemic. These recommendations provide an example of how the SSC can adapt to meet urgent and emerging needs of surgical systems by targeting important processes and encouraging critical discussions.
2020
Joao Gabriel Rosa Ramos, Roger Daglius Dias, Rogerio Hora da Passos, Paulo Benigno Pena Batista, and Daniel Neves Forte. 8/2020. “Prognostication in urgent intensive care unit referrals: a cohort study.” BMJ Support Palliat Care, 10, 1, Pp. 118-121.Abstract
OBJECTIVES: Prognostication is an essential ability to clinicians. Nevertheless, it has been shown to be quite variable in acutely ill patients, potentially leading to inappropriate care. We aimed to assess the accuracy of physician's prediction of hospital mortality in acutely deteriorating patients referred for urgent intensive care unit (ICU) admission. METHODS: Prospective cohort of acutely ill patients referred for urgent ICU admission in an academic, tertiary hospital. Physicians' prognosis assessments were recorded at ICU referral. Prognosis was assessed as survival without severe disabilities, survival with severe disabilities or no survival. Prognosis was further dichotomised in good prognosis (survival without severe disabilities) or poor prognosis (survival with severe disabilities or no survival) for prediction of hospital mortality. RESULTS: There were 2374 analysed referrals, with 2103 (88.6%) patients with complete data on mortality and physicians' prognosis. There were 593 (34.4%), 215 (66.4%) and 51 (94.4%) deaths in the groups ascribed a prognosis of survival without disabilities, survival with severe disabilities or no survival, respectively (p<0.001). Sensitivity was 31%, specificity was 91% and the area under the receiver operating characteristic curve was 0.61 for prediction of mortality. After multivariable analysis, severity of illness, performance status and ICU admission were associated with an increased likelihood of incorrect classification, while worse predicted prognosis was associated with a lower chance of incorrect classification. CONCLUSIONS: Physician's prediction was associated with hospital mortality, but overall accuracy was poor, mainly due to low sensitivity to detect risk of poor prognosis.
Lauren R Kennedy-Metz, Roger D Dias, Rithy Srey, Geoffrey C Rance, Heather M Conboy, Miguel E Haime, Jacquelyn A Quin, Steven J Yule, and Marco A Zenati. 2020. “Analysis of Dynamic Changes in Cognitive Workload During Cardiac Surgery Perfusionists' Interactions With the Cardiopulmonary Bypass Pump.” Hum Factors, Pp. 18720820976297.Abstract
OBJECTIVE: This novel preliminary study sought to capture dynamic changes in heart rate variability (HRV) as a proxy for cognitive workload among perfusionists while operating the cardiopulmonary bypass (CPB) pump during real-life cardiac surgery. BACKGROUND: Estimations of operators' cognitive workload states in naturalistic settings have been derived using noninvasive psychophysiological measures. Effective CPB pump operation by perfusionists is critical in maintaining the patient's homeostasis during open-heart surgery. Investigation into dynamic cognitive workload fluctuations, and their relationship with performance, is lacking in the literature. METHOD: HRV and self-reported cognitive workload were collected from three Board-certified cardiac perfusionists (N = 23 cases). Five HRV components were analyzed in consecutive nonoverlapping 1-min windows from skin incision through sternal closure. Cases were annotated according to predetermined phases: prebypass, three phases during bypass, and postbypass. Values from all 1min time windows within each phase were averaged. RESULTS: Cognitive workload was at its highest during the time between initiating bypass and clamping the aorta (preclamp phase during bypass), and decreased over the course of the bypass period. CONCLUSION: We identified dynamic, temporal fluctuations in HRV among perfusionists during cardiac surgery corresponding to subjective reports of cognitive workload. Not only does cognitive workload differ for perfusionists during bypass compared with pre- and postbypass phases, but differences in HRV were also detected within the three bypass phases. APPLICATION: These preliminary findings suggest the preclamp phase of CPB pump interaction corresponds to higher cognitive workload, which may point to an area warranting further exploration using passive measurement.
Roger D Dias, Julie A Shah, and Marco A Zenati. 2020. “Artificial intelligence in cardiothoracic surgery.” Minerva Cardioangiol, 68, 5, Pp. 532-538.Abstract
The tremendous and rapid technological advances that humans have achieved in the last decade have definitely impacted how surgical tasks are performed in the operating room (OR). As a high-tech work environment, the contemporary OR has incorporated novel computational systems into the clinical workflow, aiming to optimize processes and support the surgical team. Artificial intelligence (AI) is increasingly important for surgical decision making to help address diverse sources of information, such as patient risk factors, anatomy, disease natural history, patient values and cost, and assist surgeons and patients to make better predictions regarding the consequences of surgical decisions. In this review, we discuss the current initiatives that are using AI in cardiothoracic surgery and surgical care in general. We also address the future of AI and how high-tech ORs will leverage human-machine teaming to optimize performance and enhance patient safety.
L. R. Kennedy-Metz, A. Bizzego, R. D. Dias, C. Furlanello, G. Esposito, and M. A. Zenati. 2020. “Autonomic Activity and Surgical Flow Disruptions in Healthcare Providers during Cardiac Surgery.” In 2020 IEEE Conference on Cognitive and Computational Aspects of Situation Management (CogSIMA), Pp. 200-204.Abstract
Cardiac surgery represents a complex sociotechnical environment relying on a combination of technical and non-technical team-based expertise. Surgical flow disruptions (SFDs) may be influenced by a variety of sources, including social, environmental, and emotional factors affecting healthcare providers (HCPs). Many of these factors can be readily observed, except for emotional factors (i.e. distress), which represents an underappreciated yet critical source of SFDs. The aim of this study was to demonstrate the sensitivity of autonomic activity metrics to detect an SFD during cardiac surgery. We integrated heart rate variability (HRV) analysis with observation-based annotations to allow data triangulation. Following a critical medication administration error by the anesthesiologist in-training, data sources were consulted to identify events precipitating this near-miss event. Using pyphysio, an open-source physiological signal processing package, we analyzed the attending anesthesiologists' HRV, specifically the low frequency (LF) power, high frequency (HF) power, LF/HF ratio, standard deviation of normal-to-normal (SDNN), and root mean square of the successive differences (RMSSD) as indicators of ANS activity. A heightened SNS response in the attending anesthesiologists' physiological arousal was observed as elevations in LF power and LF/HF ratio, as well as depressions in HF power, SDNN, and RMSSD prior to the near-miss event. The attending anesthesiologist subjectively confirmed a state of high distress induced by task-irrelevant environmental factors during this time. Qualitative analysis of audio/video recordings objectively revealed that the autonomic nervous system (ANS) activation detected was temporally associated with an argument over operating room management. This study confirms that it is possible to recognize detrimental psychophysiological influences in cardiac surgery procedures via advanced HRV analysis. To our knowledge, ours is the first such case demonstrating ANS activity coinciding with strong self-reported emotion during live surgery using HRV. Despite extensive experience in the cardiac OR, transient but intense emotional changes may have the potential to disrupt attention processes in even the most experienced HCP. A primary implication of this work is the possibility to detect real-time ANS activity, which could enable personalized interventions to proactively mitigate downstream adverse events. Additional studies on our large database of surgical cases are underway and new studies are actively being planned to confirm this preliminary observation.
Marco A Zenati, Lauren Kennedy-Metz, and Roger D Dias. 2020. “Cognitive Engineering to Improve Patient Safety and Outcomes in Cardiothoracic Surgery.” Semin Thorac Cardiovasc Surg, 32, 1, Pp. 1-7.Abstract
Cognitive engineering is focused on how humans can cope and master the complexity of processes and technological environments. In cardiothoracic surgery, the goal is to support safe and effective human performance by preventing medical errors. Strategies derived from cognitive engineering research could be introduced in cardiothoracic surgery practice in the near future to enhance patient safety and outcomes.
H. M. Conboy, L. R. Kennedy-Metz, G. S. Avrunin, L. A. Clarke, L. J. Osterweil, R. D. Dias, and M. A. Zenati. 2020. “Digital Cognitive Aids to Support Adaptation of Surgical Processes to COVID-19 Protective Policies.” In 2020 IEEE Conference on Cognitive and Computational Aspects of Situation Management (CogSIMA), Pp. 205-210.Abstract
Surgical processes are rapidly being adapted to address the COVID-19 pandemic, with changes in procedures and responsibilities being made to protect both patients and medical teams. These process changes put new cognitive demands on the medical team and increase the likelihood of miscommunication, lapses in judgment, and medical errors. We describe two process model driven cognitive aids, referred to as the Narrative View and the Smart Checklist View, generated automatically from models of the processes. The immediate perceived utility of these cognitive aids is to support medical simulations, particularly when frequent adaptations are needed to quickly respond to changing operating room guidelines.
Lauren R. Kennedy-Metz, Andrea Bizzego, Roger D. Dias, Cesare Furlanello, Gianluca Esposito, and Marco A. Zenati. 2020. “Feasibility of Healthcare Providers' Autonomic Activation Recognition in Real-Life Cardiac Surgery Using Noninvasive Sensors.” In HCI International 2020 – Late Breaking Posters, edited by Constantine Stephanidis, Margherita Antona, and Stavroula Ntoa, Pp. 402–408. Cham: Springer International Publishing.Abstract
Cardiac surgery is one of the most complex specialties in medicine, akin to a complex sociotechnical system. Patient outcomes are vulnerable to surgical flow disruptions (SFDs), a source of preventable harm. Healthcare providers' (HCPs) sympathetic activation secondary to emotional states represent an underappreciated source of SFDs. This study's objective was to demonstrate the feasibility of detecting elevated sympathetic nervous system (SNS) activity as a proxy for emotional distress associated with a medication error using heart rate variability (HRV) analysis. After obtaining informed consent, audio/video and HRV data were captured intraoperatively during cardiac surgery from multiple HCPs. Following a critical medication administration error by the anesthesiologist in-training, the attending anesthesiologists' recorded HRV data was analyzed using pyphysio, an open-source signal analysis package, to identify events precipitating this near-miss event. We considered elevated low-frequency/high-frequency (LF/HF) HRV ratio (normal value <2) as a primary indicator of SNS activity and emotional distress. A heightened SNS response by the attending anesthesiologist, observed as an LF/HF ratio value of 3.39, was detected prior to the near-miss event. The attending anesthesiologist confirmed a state of significant SNS activity/distress induced by task-irrelevant environmental factors, which led to a temporarily ineffective mental model. Qualitative analysis of audio/video recordings revealed that SNS activation coincided with an argument over operating room management causing SFD. This preliminary study confirms the feasibility of recognizing potentially detrimental psychophysiological states during cardiac surgery in the wild using HRV analysis. To our knowledge, this is the first case demonstrating SNS activation coinciding with self-reported and observable emotional distress during live surgery using HRV. Irrespective of the HCP's expertise, transient but intense emotional changes may disrupt attention processes leading to SFDs and preventable errors. This work supports the possibility to detect real-time SNS activation, which could enable interventions to proactively mitigate errors. Additional studies on our large database of surgical cases are underway to confirm this observation.
João Carlos Pereira Gomes, Roger Daglius Dias, Jacson Venancio de Barros, Irineu Tadeu Velasco, and Wilson Jacob Filho. 2020. “The growing impact of older patients in the emergency department: a 5-year retrospective analysis in Brazil.” BMC Emerg Med, 20, 1, Pp. 47.Abstract
BACKGROUND: The average age of the global population is rising at an increasing rate. There is a disproportional increase in Emergency Department (ED) visits by older people worldwide. In the Brazilian health system, complex and severely ill patients and those requiring specialized urgent procedures are referred to tertiary level care. As far as we know, no other study in Latin America has analyzed the impact of demographic changes in tertiary ED attendance. AIM: To describe the sociodemographic characteristics and outcomes of tertiary Brazilian ED users. METHODS: Design: Observational cross-sectional analytic study. SETTING: Emergency Department, tertiary university hospital, São Paulo, Brazil. PARTICIPANTS: patients aged 18 years or older attending a tertiary ED (2009-2013). The primary outcomes were hospitalization and mortality; the secondary outcome was ICU admission. Age was categorized as 'young adults' (18-39y), 'adults' (40-59y), 'young-older adults' (60-79y), and 'old-older adults' (80-109y). Other variables included sex, reason for attendance, time of ED visit, mode of presentation, type of hospitalization, main procedure, length of hospital stay (LOS) and length of ICU stay (ICU-LOS). We calculated descriptive statistics, built generalized linear mixed models for each outcome and estimated Odds Ratios (95% CI) for the independent categorical variables. The significance level was 5% with Bonferroni correction. RESULTS: Older age-groups represented 26.6% of 333,028 ED visits, 40.7% of admissions, 42.7% of ICU admissions and 58% of all deaths. Old-older patients accounted for 5.1% of ED visits, 9.5% of admissions and 10.1% of ICU admissions. Hospitalization, ICU admission and mortality rates increased with older age in both sexes. LOS and ICU-LOS were similar across age-groups. The proportions of visits and admissions attributed to young adults decreased annually, while those of people aged 60 or over increased. The ORs for hospitalization, ICU admission and mortality associated with the old-older group were 3.49 (95% CI = 3.15-3.87), 1.27 (1.15-1.39) and 5.93 (5.29-6.66) respectively, with young adults as the reference. CONCLUSIONS: In tertiary ED, age is an important risk factor for hospitalization and mortality, but not for ICU admission. Old-older people are at the greatest risk and demand further subgroup stratification.

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