Publications

2022
Mohamed Alsabri, Zoubir Boudi, Dominique Lauque, Roger Daglius Dias, Julia S Whelan, Linda Östlundh, Guillaume Alinier, Churchill Onyeji, Philippe Michel, Shan W Liu, Carlos A Jr Camargo, Tobias Lindner, Anna Slagman, David W Bates, Karim Tazarourte, Sara J Singer, Anita Toussi, Shamai Grossman, and Abdelouahab Bellou. 2022. “Impact of Teamwork and Communication Training Interventions on Safety Culture and Patient Safety in Emergency Departments: A Systematic Review.” J Patient Saf, 18, 1, Pp. e351-e361.Abstract
OBJECTIVES: This study aimed to narratively summarize the literature reporting on the effect of teamwork and communication training interventions on culture and patient safety in emergency department (ED) settings. METHODS: We searched PubMed, EMBASE, Psych Info CINAHL, Cochrane, Science Citation Inc, the Web of Science, and Educational Resources Information Centre for peer-reviewed journal articles published from January 1, 1988, to June 8, 2018, that assessed teamwork and communication interventions focusing on how they influence patient safety in the ED. One additional search update was performed in July 2019. RESULTS: Sixteen studies were included from 8700 screened publications. The studies' design, interventions, and evaluation methods varied widely. The most impactful ED training interventions were End-of-Course Critique, Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), and crisis resource management (CRM)-based training. Crisis resource management and TeamSTEPPS CRM-based training curriculum were used in most of the studies. Multiple tools, including the Kirkpatrick evaluation model, the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture, the TeamSTEPPS Teamwork Attitudes Questionnaire, the Safety Attitudes Questionnaire, and the Communication and Teamwork Skills Assessment, were used to assess the impact of such interventions. Improvements in one of the domains of safety culture and related domains were found in all studies. Four empirical studies established improvements in patient health outcomes that occurred after simulation CRM training (Kirkpatrick 4), but there was no effect on mortality. CONCLUSIONS: Overall, teamwork and communication training interventions improve the safety culture in ED settings and may positively affect patient outcome. The implementation of safety culture programs may be considered to reduce incidence of medical errors and adverse events.
Lauren R Kennedy-Metz, Atilio Barbeito, Roger D Dias, and Marco A Zenati. 2022. “Importance of high-performing teams in the cardiovascular intensive care unit.” J Thorac Cardiovasc Surg, 163, 3, Pp. 1096-1104.
Valerie A Dobiesz, Madeline Schwid, Roger D Dias, Benjamin Aiwonodagbon, Baraa Tayeb, Adrienne Fricke, Phuong Pham, and Timothy B Erickson. 2022. “Maintaining Health Professional Education During War: A Scoping Review.” Med Educ.Abstract
PURPOSE: War negatively impacts health professional education when healthcare is needed most. The aims of this scoping review are to describe the scope of barriers and targeted interventions to maintaining health professional education during war and summarize the research. METHODS: We conducted a scoping review between June 20, 2018, and August 2, 2018. The search was restricted to English publications including peer reviewed publications without date ranges involving war and health professional education (medical school, residency training, and nursing school), with interventions described to maintain educational activities. Two independent reviewers completed inclusion determinations and data abstraction. Thematic coding was performed using an inductive approach allowing dominant themes to emerge. The frequency of barrier and intervention themes and illustrative quotes were extracted. Articles were divided into modern/postmodern categories to permit temporal and historical analysis of thematic differences. RESULTS: Screening identified 3,271 articles, with 56 studies meeting inclusion criteria. Publication dates ranged from 1914-2018 with 16 unique wars involving 17 countries. The studies concerned medical students (61.4%), residents (28.6%) and nursing students (10%). Half involved the modern era and half the postmodern era. Thematic coding identified 5 categories of barriers and targeted interventions in maintaining health professions education during war: curriculum, personnel, wellness, resources, and oversight, with most involving curriculum and personnel. The distribution of themes among various health professional trainees was similar. The frequency and specifics changed temporally reflecting innovations in medical education and war, with increased focus on oversight and personnel during the modern era and greater emphasis on wellness, curriculum, and resources during the postmodern era. CONCLUSIONS: There are overarching categories of barriers and targeted interventions in maintaining health professional education during war which evolve over time. These may serve as a useful framework to strategically support future research and policy efforts.
Joanne G Abi-Jaoudé, Lauren R Kennedy-Metz, Roger D Dias, Steven J Yule, and Marco A Zenati. 2022. “Measuring and Improving Emotional Intelligence in Surgery: A Systematic Review.” Ann Surg, 275, 2, Pp. e353-e360.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 nontechnical 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 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (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 4627 articles. After duplicate removal, 4435 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.
Omar Asdrúbal Vilca Mejia, Bruno Mahler Mioto, Gabrielle Barbosa Borgomoni, Juliana Mendanha Camilo, Danielle Misumi Watanabe, Sirlei Pereira Nunes, Vanessa Santos Sallai, Maraina Pegorini Libório de Lima, Jurema Silva Herbas da Palomo, Helenice Moreira da Costa, Elisandra Trevisan Arita, Maria Ignêz Zanetti Feltrim, Vera Coimbra, Roger Daglius Dias, Filomena Regina Barbosa Gomes Galas, José Otávio Costa Auler Junior, and Fabio Biscegli Jatene. 2022. “Preparing Patients And Optimizing Processes In The Perioperative Period Of Cardiac Surgery: How To Redesign The Flow Of Care After COVID-19.” Arq Bras Cardiol, 118, 1, Pp. 110-114.
Steven Yule, Jamie M Robertson, Benjamin Mormann, Douglas S Smink, Stuart Lipsitz, Egide Abahuje, Lauren Kennedy-Metz, Sandra Park, Christian Miccile, Charles N Pozner, Thomas Doyle, David Musson, and Roger D Dias. 2022. “Research Article in Revision for Human Factors Special Issue: Human Factors and Ergonomics in Space Exploration Crew Autonomy During Simulated Medical Event Management on Long Duration Space Exploration Missions.” Hum Factors, Pp. 187208211067575.Abstract
OBJECTIVE: Our primary aim was to investigate crew performance during medical emergencies with and without ground-support from a flight surgeon located at mission control. BACKGROUND: There are gaps in knowledge regarding the potential for unanticipated in-flight medical events to affect crew health and capacity, and potentially compromise mission success. Additionally, ground support may be impaired or periodically absent during long duration missions. METHOD: We reviewed video recordings of 16 three-person flight crews each managing four unique medical events in a fully immersive spacecraft simulator. Crews were randomized to two conditions: with and without telemedical flight surgeon (FS) support. We assessed differences in technical performance, behavioral skills, and cognitive load between groups. RESULTS: Crews with FS support performed better clinically, were rated higher on technical skills, and completed more clinical tasks from the medical checklists than crews without FS support. Crews with FS support also had better behavioral/non-technical skills (information exchange) and reported significantly lower cognitive demand during the medical event scenarios on the NASA-TLX scale, particularly in mental demand and temporal demand. There was no significant difference between groups in time to treat or in objective measures of cognitive demand derived from heart rate variability and electroencephalography. CONCLUSION: Medical checklists are necessary but not sufficient to support high levels of autonomous crew performance in the absence of real-time flight surgeon support. APPLICATION: Potential applications of this research include developing ground-based and in-flight training countermeasures; informing policy regarding autonomous spaceflight, and design of autonomous clinical decision support systems.
2021
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. 2021. “Analysis of Dynamic Changes in Cognitive Workload During Cardiac Surgery Perfusionists' Interactions With the Cardiopulmonary Bypass Pump.” Hum Factors, 63, 5, Pp. 757-771.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.
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.
Lauren R Kennedy-Metz, Roger D Dias, and Marco A Zenati. 2021. “The Cognitive Relevance of a Formal Pre-incision Time-out in Surgery.” ECCE, 2021.Abstract
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.
Lauren R Kennedy-Metz, Pietro Mascagni, Antonio Torralba, Roger D Dias, Pietro Perona, Julie A Shah, Nicolas Padoy, and Marco A Zenati. 2021. “Computer Vision in the Operating Room: Opportunities and Caveats.” IEEE Trans Med Robot 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.
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.
Roger D Dias, Marco A Zenati, Heather M Conboy, Lori A Clarke, Leon J Osterweil, George S Avrunin, and Steven J Yule. 2021. “Dissecting Cardiac Surgery: A Video-based Recall Protocol to Elucidate Team Cognitive Processes in the Operating Room.” Ann Surg, 274, 2, Pp. e181-e186.Abstract
OBJECTIVE: The aim of this study was to elucidate the cognitive processes involved in surgical procedures from the perspective of different team roles (surgeon, anesthesiologist, and perfusionist) and provide a comprehensive compilation of intraoperative cognitive processes. SUMMARY BACKGROUND DATA: Nontechnical skills play a crucial role in surgical team performance and understanding the cognitive processes underlying the intraoperative phase of surgery is essential to improve patient safety in the operating room (OR). METHODS: A mixed-methods approach encompassing semistructured interviews with 9 subject-matter experts. A cognitive task analysis was built upon a hierarchical segmentation of coronary artery bypass grafting procedures and a cued-recall protocol using video vignettes was used. RESULTS: A total of 137 unique surgical cognitive processes were identified, including 33 decision points, 23 critical communications, 43 pitfalls, and 38 strategies. Self-report cognitive workload varied substantially, depending on team role and surgical step. A web-based dashboard was developed, providing an integrated visualization of team cognitive processes in the OR that allows readers to intuitively interact with the study findings. CONCLUSIONS: This study advances the current body of knowledge by making explicit relevant cognitive processes involved during the intraoperative phase of cardiac surgery from the perspective of multiple OR team members. By displaying the research findings in an interactive dashboard, we provide trainees with new knowledge in an innovative fashion that could be used to enhance learning outcomes. In addition, the approach used in the present study can be used to deeply understand the cognitive factors underlying surgical adverse events and errors in the OR.
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, 170, 4, Pp. 1031-1038.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 (91-192) minutes, 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.
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.
Roger D Dias, William Riley, Kenneth Shann, Donald S Likosky, David Fitzgerald, and Steven Yule. 2021. “A tool to assess nontechnical skills of perfusionists in the cardiac operating room.” J Thorac Cardiovasc Surg.Abstract
OBJECTIVES: This study aimed to develop the Perfusionists' Intraoperative Non-Technical Skills tool, specifically to the perfusionists' context, and test its inter-rater reliability. METHODS: An expert panel was convened to review existing surgical nontechnical skills taxonomies and develop the Perfusionists' Intraoperative Non-Technical Skills tool. During a workshop held at a national meeting, perfusionists completed the Perfusionists' Intraoperative Non-Technical Skills ratings after watching 4 videos displaying simulated cardiac operations. Two videos showed "good performance," and 2 videos showed "poor performance." Inter-rater reliability analysis was performed and intraclass correlation coefficient was reported. RESULTS: The final version of the Perfusionists' Intraoperative Non-Technical Skills taxonomy contains 4 behavioral categories (decision making, situation awareness, task management and leadership, teamwork and communication) with 4 behavioral elements each. Categories and elements are rated using an 8-point Likert scale ranging from 0.5 to 4.0. A total of 60 perfusionist raters were included and the comparison between rating distribution on "poor performance" and "good performance" videos yielded a statistically significant difference between groups, with a P value less than .001. A similar difference was found in all behavioral categories and elements. Reliability analysis showed moderate inter-rater reliability across overall ratings (intraclass correlation coefficient, 0.735; 95% confidence interval, 0.674-0.796; P < .001). Similar inter-rater reliability was found when raters were stratified by experience level. CONCLUSIONS: The Perfusionists' Intraoperative Non-Technical Skills tool presented moderate inter-rater reliability among perfusionists with varied levels of experience. This tool can be used to train and assess perfusionists in relevant nontechnical skills, with the potential to enhance safety and improve surgical outcomes.
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.” IEEE CogSIMA (2021), 2021, Pp. 39-44.Abstract
Shared mental models are critical to team success; however, in practice, team members may have misaligned models due to a variety of factors. In safety-critical domains (e.g., aviation, healthcare), lack of shared mental models can lead to preventable errors and harm. Towards the goal of mitigating such preventable errors, here, we present a Bayesian approach to infer misalignment in team members' mental models during complex healthcare task execution. As an exemplary application, we demonstrate our approach using two simulated team-based scenarios, derived from actual teamwork in cardiac surgery. In these simulated experiments, our approach inferred model misalignment with over 75% recall, thereby providing a building block for enabling computer-assisted interventions to augment human cognition in the operating room and improve teamwork.
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, 78, 5, Pp. 1618-1628.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.

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