Daniel Shouhed

Integrating Human Factors Research and Surgery: A Review

OBJECTIVE To provide a review of human factors research within the context of surgery. DATA SOURCES We searched PubMed for relevant studies published from the earliest available date through February 29, 2012. STUDY SELECTION The search was performed using the following keywords: human factors, surgery, errors, teamwork, communication, stress, disruptions, interventions, checklists, briefings, and training. Additional articles were identified by a manual search of the references from the key articles. As 2 human factors specialists, a senior clinician, and a junior clinician, we carefully selected the most appropriate exemplars of research findings with specific relevance to surgical error and safety. DATA EXTRACTION Seventy-seven articles of relevance were selected and reviewed in detail. Opinion pieces and editorials were disregarded; the focus was solely on articles based on empirical evidence, with a particular emphasis on prospectively designed studies. DATA SYNTHESIS The themes that emerged related to the development of human factors theories, the application of those theories within surgery, a specific interest in the concept of flow, and the theoretical basis and value of human-related interventions for improving safety and flow in surgery. CONCLUSIONS Despite increased awareness of safety, errors routinely continue to occur in surgical care. Disruptions in the flow of an operation, such as teamwork and communication failures, contribute significantly to such adverse events. While it is apparent that some incidence of human error is unavoidable, there is much evidence in medicine and other fields that systems can be better designed to prevent or detect errors before a patient is harmed. The complexity of factors leading to surgical errors requires collaborations between surgeons and human factors experts to carry out the proper prospective and observational studies. Only when we are guided by this valid and real-world data can useful interventions be identified and implemented.

Flow Disruptions in Trauma Surgery: Type, Impact, and Affect

The objective of this study was to identify and understand all components of the trauma care process to mitigate the systemic challenges faced by clinicians attempting to deliver the best trauma care. The study was conducted using a prospective data collection method. An interdisciplinary team of researchers observed 87 cases over a 10-week period and identified 1759 flow disruptions. There were a higher number of flow disruptions per case in the operating room (M=61.3, ±36.72) than in the emergency department (M=9.2, ±1.77) or radiology (M=7.5, ±2.01). Focusing on the OR, the majority of the flow disruptions identified in the OR were due to either coordination issues (28%) or communication breakdowns (24%). Roughly 12% of disruptions resulted in moderate delays or full case cessation. This study demonstrates the value of using flow disruptions as a surrogate for efficiency and quality outcome measures, and as a diagnostic method for understanding higher order problems in the system of trauma care.

Barriers to Trauma Patient Care Associated with CT Scanning

BACKGROUND Trauma care is often delivered to unstable patients with incomplete medical histories, under time pressure, and with a need for multidisciplinary collaboration. Trauma patient flow through radiology is particularly prone to deviations from optimal care. A better understanding of this process could reduce errors and improve quality, flow, and patient outcomes. STUDY DESIGN Disruptions to the flow of trauma care during trauma activations were observed over a 10-week period at a level I trauma center. Using a validated data collection tool, the type, nature, and impact of disruptions to the care process were recorded. Two physicians unaffiliated with the study conducted a post hoc, blinded review of the flow disruptions and assigned a clinical impact score to each. RESULTS There were 581 flow disruptions observed during the radiologic care of 76 trauma patients. An average of 30.5 minutes (95% CI, 27-34; median, 29; interquartile range, 20-38) was spent in the CT scanner, with a mean of 14.5 flow disruptions per hour (95% CI, 11.8-17.2). Coordination problems (34%), communication failures (19%), interruptions (13%), patient-related factors (12%), and equipment issues (8%) were the most frequent disruption types. Flow disruptions with the highest clinical impact were generally related to patient movements while in the scanner, problems with ordering systems, equipment unavailability, and ineffective teamwork. CONCLUSIONS Although flow disruptions cannot be eliminated completely, specific targeted interventions are available to address the issues identified.

Thromboprophylaxis and Major Oncologic Surgery Performed With Epidural Analgesia

OBJECTIVE To evaluate clinical outcomes in patients with cancer undergoing major abdominal surgery who received preoperative indwelling epidural catheters (ECs) and no postoperative thromboprophylaxis. DESIGN Retrospective analysis of a prospective database. SETTING Tertiary referral medical center. PATIENTS Between January 1, 2009, and July 31, 2011, 119 patients, with a mean age of 64.5 years (range, 34-95 years), underwent major abdominal oncologic surgery with an indwelling EC. MAIN OUTCOME MEASURES Records of all patients were reviewed for age, duration of surgery, hospital length of stay, and clinical outcomes. All patients underwent lower extremity venous duplex ultrasonography prior to hospital discharge. RESULTS The average operative time was 338 minutes. Mean (SD) intensive care unit stay was 2.8 (1.4) days (range, 1-7 days). Patients ambulated by postoperative day 1 or 2. Most ECs were removed on postoperative day 4. There were no major complications from the EC. Fifty-two patients (44%) were treated with deep venous thrombosis prophylaxis on postoperative day 4 after removal of the EC. Lower extremity duplex studies showed 8 patients (6.7%) had an acute thrombus. One patient (0.8%) developed an asymptomatic proximal deep venous thrombosis and 7 patients (5.9%) developed distal superficial thrombi. No patient developed a pulmonary embolus. CONCLUSIONS Thromboembolic complications following major abdominal surgery for cancer may be reduced with the use of ECs. Epidural catheters may directly prevent deep venous thrombosis through sympathetic blockade, resulting in increased blood flow to the lower extremities. This effect may also be attributable to earlier ambulation. These results suggest that patients who have an EC and do not receive concurrent postoperative thromboprophylaxis do not have an increased risk for thromboembolic events.

The role of bariatric surgery in nonalcoholic fatty liver disease and nonalcoholic steatohepatitis

ABSTRACT Introduction: Nonalcoholic fatty liver disease (NAFLD) affects between 25% and 33% of the population, is more common in obese individuals, and is the most common cause of chronic liver disease in the United States. However, despite rising prevalence, effective treatments remain limited. Areas covered: We performed a literature search across multiple databases (Pubmed, Medline, etc.) to identify significant original research and review articles to provide an up-to-date and concise overview of disease pathogenesis and diagnostic evaluation and to expand on available treatment options with a specific focus on the potential role of bariatric surgery. Here we provide the most comprehensive review of bariatric surgery for the management of NAFLD, noting benefits from different procedures and multiple reports showing improvements in steatosis, inflammation and fibrosis over the duration of follow-up. Expert commentary: The morbidity of NAFLD is significant as it may become the most common indication for liver transplantation within the next 5 years. In addition to known benefits of weight loss and diabetes resolution, bariatric surgery has the potential to halt and reverse disease progression and future controlled trials should be performed to further define its benefit in the treatment of NAFLD in morbidly obese patients.

Introduction and Overview of Current and Emerging Operations

All would agree that obesity has become a worldwide epidemic associated with drastic deleterious effects on the health and mortality of patients. A report by the World Health Organization (WHO) indicated that at least 400 million adults around the world were obese in 2005. Historical operations, such as the jejunoileal and jejunocolic bypass, paved the road for the development of the commonly performed operations, including the gastric bypass. With the advent of laparoscopy and significant reduction in perioperative morbidity and mortality, it is no surprise that the demand for bariatric surgery has exponentially grown. New technological advances intended to treat obesity are continually in the process of being developed and tested for use. Endoscopic interventions such as transoral gastroplasty, the intragastric balloon, and the endoluminal gastrointestinal liner are a few devices that have gained recognition and demonstrated promising results.