Distraction in the urology operating theatre.
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Attention↗
Biomedical subjects
Shabnam Undre
Publications and source records attributed to Shabnam Undre.
Observational assessment of surgical teamwork: a feasibility study.
BACKGROUND: Teamwork is fundamental to effective surgery, yet there are currently no measures of teamwork to guide training, evaluate team interventions or assess the impact of teamwork on outcomes. We report the first steps in the development of an observational assessment of teamwork and preliminary findings. METHOD: We observed 50 operations in general surgery from a single operating theater using a measure of teamwork specifically developed for use in the operating theater. The OTAS (Observational Teamwork Assessment for Surgery) comprises a procedural task checklist centered on the patient, equipment and communications tasks and ratings on team behavior constructs, namely: communication, co-operation, co-ordination, shared-leadership and monitoring. RESULTS: Ratings of overall team performance were reasonably high, though variable, but there was evidence that clinically significant steps were being missed which at the very least eroded safety margins. There was, for instance, a frequent failure to check both surgical and anesthetic equipment and a failure to confirm the procedure verbally, patient notes were missing in about one-eighth of the cases and delays or changes occurred in over two-thirds of the cases. CONCLUSIONS: This study takes an initial step towards developing measures of team performance in surgery that are defined in relation to tasks and behaviors of the team. The observational method of assessment is feasible and can provide a wealth of potentially valuable research data. However, for these measures to be used for formal assessment, more research is needed to make them robust and standardized.
Adult↗
Training junior operative residents in laparoscopic suturing skills is feasible and efficacious.
BACKGROUND: Laparoscopic suturing has been regarded as an advanced operative task, and courses to develop this skill are aimed at senior trainees and consultants. This study evaluates the role of laparoscopic suturing courses in the modern operative training curriculum. METHODS: The performance of 9 senior operative trainees (course A) was compared to that of 14 junior operative trainees (course B) at identical, 2-day laparoscopic suturing courses. Pre- and post-course assessments measured time taken, dexterity, and quality for the placement of 1 intracorporeal suture on synthetic bowel. Post-course data was compared to the performance of a group of 6 experts. RESULTS: The median number of laparoscopic procedures carried out unassisted was 130 for surgeons on course A, and 0 for those on course B. At the pre-course assessment, senior trainees (course A) were significantly faster, more dexterous, and had higher checklist scores then those on course B. Both groups had improved significantly by the end of each the course. Post-course comparison between the 2 groups showed equivalent path length and checklist scores, although group A remained faster (P = .003) and made fewer movements (P = .033). Senior trainees had similar performance data to the group of expert surgeons, although this was not the case for junior trainees. CONCLUSIONS: Endoscopic suturing is a task that can be learned by operative trainees during short skills courses, regardless of baseline laparoscopic experience. Skills training in laparoscopic suturing should thus not be reserved only for those contemplating advanced laparoscopic operation.
General Surgery↗
The complexity of measuring interprofessional teamwork in the operating theatre.
Surgery depends on interprofessional teamwork, which is becoming increasingly specialized. If surgery is to become a highly reliable system, it must adapt and professionals must learn from, and share, tested models of interprofessional teamwork. Trainers also need valid measures of teamwork to assess individual and team performance. However, measurement and assessment of interprofessional teamwork is lacking and interprofessional team training is scarce in the surgical domain. This paper addresses the complexity of measuring interprofessional teamwork in the operating theatre. It focuses mainly on the design and properties of observational assessment tools. The report and analysis serves to inform the researcher or clinician of the issues to consider when designing or choosing from alternative measures of team performance for training or assessment.
Humans↗
Surgical crisis management skills training and assessment: a simulation[corrected]-based approach to enhancing operating room performance.
BACKGROUND: Intraoperative surgical crisis management is learned in an unstructured manner. In aviation, simulation training allows aircrews to coordinate and standardize recovery strategies. Our aim was to develop a surgical crisis simulation and evaluate its feasibility, realism, and validity of the measures used to assess performance. METHODS: Surgical trainees were exposed to a bleeding crisis in a simulated operating theater. Assessment of performance consisted of a trainee's technical ability to control the bleeding and of their team/human factors skills. This assessment was performed in a blinded manner by 2 surgeons and one human factors expert. Other measures consisted of time measures such as time to diagnose the bleeding (TD), inform team members (TT), achieve control (TC), and close the laceration (TL). Blood loss was used as a surrogate outcome measures. RESULTS: There were considerable variations within both senior (n = 10) and junior (n = 10) trainees for technical and team skills. However, while the senior trainees scored higher than the juniors for technical skills (P = 0.001), there were no differences in human factors skills. There were also significant differences between the 2 groups for TD (P = 0.01), TC (P = 0.001), and TL (0.001). The blood loss was higher in the junior group. CONCLUSIONS: We have described the development of a novel simulated setting for the training of crisis management skills and the variability in performance both in between and within the 2 groups.
Blood Loss, Surgical↗
Teamwork in the operating theatre: cohesion or confusion?
RATIONALE: The aim of the research that we report here was to empirically assess the cohesiveness of the multidisciplinary operating theatre (OT) team. METHOD: We used concepts from the team performance and team mental models literature to assess OT professionals' perceptions of their teamwork, the structure of their teams and their respective roles within them and their teams' performance. RESULTS: Team structure: OT professionals would welcome a change from the current structure of the team, although there was no agreement on what that structure is. Nurses perceived the team as unitary, surgeons and anaesthetists perceived it as comprising multiple subteams. Team roles: OT professionals tended to overrate their own understanding of their colleagues' role in the OT relative to the role understanding that the colleagues attributed to them. This tendency was especially marked for the surgeons. Team communication and team performance: OT professionals agreed on the relative importance of the various communicating pairs in the OT. Moreover, they were satisfied with the quality of communication among them, except for the communication between the surgeon and the anaesthetist, which received lower ratings. Finally, the quality of the teamwork in the OT was deemed acceptable, although there is room for improvement. CONCLUSIONS: The OT environment need not be as cohesive as previously assumed--a finding that carries implications for the effectiveness of team training interventions. Further research is needed in order to fully comprehend the dynamics of the OT as a working environment and, most importantly, their relation to patient safety.
Communication↗
Assessment of psychomotor skills acquisition during laparoscopic cholecystectomy courses.
BACKGROUND: Standardized short courses in laparoscopic cholecystectomy aim to teach laparoscopic skills to surgical trainees, although end-of-course assessments of performance remain subjective. The current study aims to objectively assess psychomotor skills acquisition of trainees attending laparoscopic cholecystectomy courses. METHODS: Thirty-seven junior surgical trainees had their laparoscopic skills assessed before and after attending 1 of 3 separate 2-day courses (A, B, and C), all with identical format. Assessments were comprised of a standardized simulated laparoscopic task, with performance measured using a valid electromagnetic hand-motion tracking device. RESULTS: Overall, trainees made significant improvements in path length (P=.006), number of movements (P<.001), and time taken (P<.001). Analyzing the 3 courses separately, only trainees attending courses A and C made significant improvements. DISCUSSION: Objective validated methods can be used to assess learning of psychomotor skills on courses. In addition to providing participants with an insight into their skills, these data can be used to demonstrate course efficacy.
Cholecystectomy, Laparoscopic↗
Simultaneous combined use of flexible ureteroscopy and percutaneous nephrolithotomy to reduce the number of access tracts in the management of complex renal calculi.
OBJECTIVE: To present early experience in managing complex renal calculi using a combined ureteroscopic and percutaneous approach, as complex and branched renal calculi often require multiple access tracts during percutaneous nephrolithotomy (PNL), and the combined use of flexible ureteroscopy and PNL has the potential to reduce the inherent morbidity of several tracts. PATIENTS AND METHODS: The study included seven patients (mean age 54 years) with multiple, branched, large-volume renal calculi suitable for management with PNL. Preoperative data, including patient demographics, stone location and stone surface area, were recorded. After informed consent, the patients underwent combined PNL and ureteroscopy in one session. Intraoperative data, including the location of PNL puncture sites, operative duration and complications, were analysed. Stone-free rates were determined by follow-up imaging at 3 months. RESULTS: All patients had either two or more stones in separate locations in the collecting system, or staghorn stones involving multiple calyces. The mean stone burden was 666 mm(2). All patients had only one percutaneous access tract. The mean operative duration was 142 min and the mean blood loss 79 mL. Two patients had small residual stones (< 3 mm), that required ureteroscopic intervention as they failed to pass spontaneously by 3 months after the initial combined procedure. The convalescence was similar to that in our current PNL practice; imaging showed that five of the patients were stone-free. CONCLUSIONS: Combined PNL and ureteroscopic management can effectively reduce the number of percutaneous access tracts which would otherwise be required for managing complex and branched renal calculi, as stones in an unfavourable location relative to the access tract can be relocated and fragmented within easy reach of the single nephrostomy tract. This manoeuvre reduces potential patient morbidity and blood loss but with no significant effect on stone-free rates and operative durations.
Adult↗
Laparoscopic task recognition using Hidden Markov Models.
Surgical skills assessment has been paid increased attention over the last few years. Stochastic models such as Hidden Markov Models have recently been adapted to surgery to discriminate levels of expertise. Based on our previous work combining synchronized video and motion analysis we present preliminary results of a HMM laparoscopic task recognizer which aims to model hand manipulations and to identify and recognize simple surgical tasks.
Clinical Competence↗
"Pass the ball!" Simultaneous flexible nephroscopy and retrograde intrarenal surgery for large residual upper-pole staghorn stone.
Complex staghorn calculi have conventionally been treated with percutaneous nephrolithotomy, extracorporeal lithotripsy, or, occasionally, open surgery. Access to branched calculi is difficult through a single percutaneous track. We tested and make a case for a synchronous bidirectional technique combining the use of flexible instruments through percutaneous and retrograde approaches. We present a case of "pass the ball," which may have a place in tackling large, complex, or branched staghorn calculi without the need for multiple percutaneous punctures, removing larger fragments than is possible through the ureter and avoiding multiple passes through the ureter, saving time and decreasing the possibility of iatrogenic ureteral injury.
Adult↗