Ethan D. Grober

Communication failures in the operating room: an observational classification of recurrent types and effects

Background: Ineffective team communication is frequently at the root of medical error. The objective of this study was to describe the characteristics of communication failures in the operating room (OR) and to classify their effects. This study was part of a larger project to develop a team checklist to improve communication in the OR. Methods: Trained observers recorded 90 hours of observation during 48 surgical procedures. Ninety four team members participated from anesthesia (16 staff, 6 fellows, 3 residents), surgery (14 staff, 8 fellows, 13 residents, 3 clerks), and nursing (31 staff). Field notes recording procedurally relevant communication events were analysed using a framework which considered the content, audience, purpose, and occasion of a communication exchange. A communication failure was defined as an event that was flawed in one or more of these dimensions. Results: 421 communication events were noted, of which 129 were categorized as communication failures. Failure types included “occasion” (45.7% of instances) where timing was poor; “content” (35.7%) where information was missing or inaccurate, “purpose” (24.0%) where issues were not resolved, and “audience” (20.9%) where key individuals were excluded. 36.4% of failures resulted in visible effects on system processes including inefficiency, team tension, resource waste, workaround, delay, patient inconvenience and procedural error. Conclusion: Communication failures in the OR exhibited a common set of problems. They occurred in approximately 30% of team exchanges and a third of these resulted in effects which jeopardized patient safety by increasing cognitive load, interrupting routine, and increasing tension in the OR.

Teaching surgical skills: What kind of practice makes perfect? : A randomized, controlled trial

Objective:Surgical skills laboratories have become an important venue for early skill acquisition. The principles that govern training in this novel educational environment remain largely unknown; the commonest method of training, especially for continuing medical education (CME), is a single multihour event. This study addresses the impact of an alternative method, where learning is distributed over a number of training sessions. The acquisition and transfer of a new skill to a life-like model is assessed. Methods:Thirty-eight junior surgical residents, randomly assigned to either massed (1 day) or distributed (weekly) practice regimens, were taught a new skill (microvascular anastomosis). Each group spent the same amount of time in practice. Performance was assessed pretraining, immediately post-training, and 1 month post-training. The ultimate test of anastomotic skill was assessed with a transfer test to a live, anesthetized rat. Previously validated computer-based and expert-based outcome measures were used. In addition, clinically relevant outcomes were assessed. Results:Both groups showed immediate improvement in performance, but the distributed group performed significantly better on the retention test in most outcome measures (time, number of hand movements, and expert global ratings; all P values <0.05). The distributed group also outperformed the massed group on the live rat anastomosis in all expert-based measures (global ratings, checklist score, final product analysis, competency for OR; all P values <0.05). Conclusions:Our current model of training surgical skills using short courses (for both CME and structured residency curricula) may be suboptimal. Residents retain and transfer skills better if taught in a distributed manner. Despite the greater logistical challenge, we need to restructure training schedules to allow for distributed practice.

The educational impact of bench model fidelity on the acquisition of technical skill: The use of clinically relevant outcome measures

Objective:To evaluate the impact of bench model fidelity on the acquisition of technical skill using clinically relevant outcome measures. Methods:Fifty junior surgery residents participated in a 1-day microsurgical training course. Participants were randomized to 1 of 3 groups: 1) high-fidelity model training (live rat vas deferens; n = 21); 2) low-fidelity model training (silicone tubing; n = 19); or 3) didactic training alone (n = 10). Following training, all participants were assessed on the high- and low-fidelity bench models. Immediate outcome measures included procedure times, blinded, expert assessment of videotaped performance using checklists and global rating scales, anastomotic patency, suture placement precision, and final product ratings. Delayed outcome measures (obtained from the live rat vas deferens 30 days following training) included anastomotic patency, presence of a sperm granuloma, and the presence of sperm on microscopy. Results:Following training, checklist (P < 0.001) and global rating scores (P < 0.001) on the bench model simulators were higher among subjects who received hands-on training, irrespective of model fidelity. Immediate anastomotic patency rates of the rat vas deferens were higher with increasing model fidelity training (P = 0.048). Delayed anastomotic patency rates were higher among subjects who received bench model training, irrespective of model fidelity (P = 0.02). Rates of sperm presence on microscopy were higher among subjects who received high-fidelity model training compared with subjects who received didactic training (P = 0.039) but did not differ among subjects in the high- and low-fidelity groups. Conclusions:Surgical skills training on low-fidelity bench models appears to be as effective as high-fidelity model training for the acquisition of technical skill among novice surgeons.

Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR

Background: Pilot studies of complex interventions such as a team checklist are an essential precursor to evaluating how these interventions affect quality and safety of care. We conducted a pilot implementation of a preoperative team communication checklist. The objectives of the study were to assess the feasibility of the checklist (that is, team members’ willingness and ability to incorporate it into their work processes); to describe how the checklist tool was used by operating room (OR) teams; and to describe perceived functions of the checklist discussions. Methods: A checklist prototype was developed and OR team members were asked to implement it before 18 surgical procedures. A research assistant was present to prompt the participants, if necessary, to initiate each checklist discussion. Trained observers recorded ethnographic field notes and 11 brief feedback interviews were conducted. Observation and interview data were analyzed for trends. Results: The checklist was implemented by the OR team in all 18 study cases. The rate of team participation was 100% (33 vascular surgery team members). The checklist discussions lasted 1–6 minutes (mean 3.5) and most commonly took place in the OR before the patient’s arrival. Perceived functions of the checklist discussions included provision of detailed case related information, confirmation of details, articulation of concerns or ambiguities, team building, education, and decision making. Participants consistently valued the checklist discussions. The most significant barrier to undertaking the team checklist was variability in team members’ preoperative workflow patterns, which sometimes presented a challenge to bringing the entire team together. Conclusions: The preoperative team checklist shows promise as a feasible and efficient tool that promotes information exchange and team cohesion. Further research is needed to determine the sustainability and generalizability of the checklist intervention, to fully integrate the checklist routine into workflow patterns, and to measure its impact on patient safety.

Visual-spatial ability correlates with efficiency of hand motion and successful surgical performance

BACKGROUND This study examines the influence of visual-spatial ability and manual dexterity on surgical performance across 3 levels of expertise. METHODS Dental students, surgical residents, and staff surgeons completed standardized tests of manual dexterity and visual-spatial ability and were assessed objectively while performing the rigid fixation of an anterior mandible on bench model simulations. Outcome variables included expert assessment of technical performance and efficiency of hand motion during the procedure (recorded using electromagnetic sensors). RESULTS Visual-spatial scores correlated significantly with surgical performance scores within the group of dental students (r=.40 to.73), but this was not the case for residents or staff surgeons. For all groups, manual dexterity did not correlate with hand motion parameters. There were no differences between groups in visual-spatial ability or manual dexterity, but highly significant differences were seen in surgical performance scores (P<.001), in that surgeons outperformed residents, who in turn outperformed students. CONCLUSIONS Among novices, visual-spatial ability is associated with skilled performance on a spatially complex surgical procedure. However, advanced trainees and experts do not score any higher on carefully selected visual-spatial tests, suggesting that practice and surgical experience may supplant the influence of visual-spatial ability over time. Thus, the use of these tests for the selection of residents is not currently recommended; they may be of more use in identifying those novice trainees (ie, those with lower test scores) who might benefit most from brief supplementary instruction on specific technical tasks.

Testosterone Replacement Therapy Following Radical Prostatectomy

INTRODUCTION Controversy exists regarding testosterone replacement therapy (TRT) in men following radical prostatectomy (RP). Many clinicians are hesitant to offer patients TRT after an RP, out of concern that the increased androgen levels may promote tumor progression or recurrence from residual tumor. Recently, several small studies have demonstrated the use of TRT in men following an RP and have shown an improvement in serum testosterone levels with no increase in prostate-specific antigen (PSA) values. AIMS The aim of this article is to assess changes in PSA and testosterone values in hypogonadal patients on TRT after RP and also to evaluate the impact of pathologic Gleason grade on ultimate PSA values. METHODS All hypogonadal men who were treated with TRT by members of our department following RP were retrospectively reviewed. PSA values before RP, after RP, and after TRT were evaluated. Serum testosterone levels before and after TRT were also examined. Only patients with undetectable PSA values and negative surgical margins on pathologic specimen were offered TRT and included in the study. MAIN OUTCOME MEASURES Main outcome measures were changes in PSA and testosterone values after initiation of TRT. RESULTS Fifty-seven men, ages 53-83 years (mean 64), were identified as having initiated TRT following RP. Men received TRT for an average of 36 months following RP (range 1-136 months). Patients were followed an average of 13 months after initiation of TRT (range 1-99 months). The mean testosterone values rose from 255 ng/dL before TRT to 459 ng/dL after TRT (P < 0.001). There was no increase in PSA values after initiation of TRT and thus no patient had a biochemical PSA recurrence. CONCLUSION TRT is effective in improving testosterone levels, without increasing PSA values, in hypogonadal men who have undergone RP.

Proteomic analysis of seminal plasma from normal volunteers and post-vasectomy patients identifies over 2000 proteins and candidate biomarkers of the urogenital system.

Seminal plasma is a fluid that originates from the testis, epididymis,prostate, and seminal vesicles, and hence, proteomic studies may identify potential markers of infertility and other diseases of the genito-urinary tract. We profiled the proteomes of pooled seminal plasma from fertile Control and post-vasectomy (PV) men. PV seminal plasma samples are void of proteins originating from the testis and the epididymis due to ligation of the vas deferens, and hence, comparative analysis of Control and PV data sets allows for identification of proteins originating from these tissues. Utilizing offline MudPIT and high-resolution mass spectrometry, we were able to identify over 2000 proteins in Control and PV pools each and over 2300 proteins all together. With semiquantitative analysis using spectral counting, we catalogued 32 proteins unique to Control, 49 at lower abundance in PV, 3 unique to PV, and 25 at higher abundance in PV. We believe that proteins unique to Control or at lower abundance in PV have their origin in the testis and the epididymis. Public databases have confirmed that many of these proteins originate from the testis and epididymis and are linked to the reproductive tract. These proteins may serve as candidate biomarkers for future studies of infertility and urogenital diseases.

The incidence and effect of bacteriospermia and elevated seminal leukocytes on semen parameters

OBJECTIVE To determine the incidence of bacteriospermia and elevated seminal leukocytes (ESL) in a subfertile male population and correlate these results with semen parameters. DESIGN Retrospective cohort study. SETTING Canadian tertiary-level male infertility clinic and university-affiliated andrology and microbiology laboratories. PATIENT(S) Four thousand nine hundred thirty-five nonazoospermic subfertile men. INTERVENTION(S) Analysis and concurrent culture of 7,852 semen samples. MAIN OUTCOME MEASURE(S) Incidence of bacteriospermia and ESL and comparison of semen parameters between these groups. RESULT(S) The rate of bacteriospermia was 15% (22 species), and the rate of ESL was 19%, with no statistical correlation between these groups. Bacteriospermic patients (without ESL) had a statistically significant deterioration in DNA fragmentation index (DFI) only, compared with patients without bacteriospermia and ESL (24.1 vs. 21.8%). ESL alone was associated with a statistically significant deterioration in sperm concentration (20.6 vs. 55.3 × 10(6)/mL), motility (21.8 vs. 26.9%), normal morphology (12.3 vs. 17.4%), and DFI (26.5 vs. 21.8%), with no additional deterioration identified with bacteriospermia. CONCLUSION(S) Bacteriospermia and ESL were prevalent, but not statistically associated, in subfertile men. Bacteriospermia alone was associated with an increase in DFI only, but the presence of ESL was the dominant factor associated with deterioration in semen parameters.

Analysis of seminal plasma from patients with non-obstructive azoospermia and identification of candidate biomarkers of male infertility.

Infertility affects approximately 15% of couples with equivalent male and female contribution. Absence of sperm in semen, referred to as azoospermia, accounts for 5-20% of male infertility cases and can result from pretesticular azoospermia, non-obstructive azoospermia (NOA), and obstructive azoospermia (OA). The current clinical methods of differentiating NOA cases from OA ones are indeterminate and often require surgical intervention for a conclusive diagnosis. We catalogued 2048 proteins in seminal plasma from men presented with NOA. Using spectral-counting, we compared the NOA proteome to our previously published proteomes of fertile control men and postvasectomy (PV) men and identified proteins at differential abundance levels among these clinical groups. To verify spectral counting ratios for candidate proteins, extracted ion current (XIC) intensities were also used to calculate abundance ratios. The Pearson correlation coefficient between spectral counting and XIC ratios for the Control-NOA and NOA-PV data sets is 0.83 and 0.80, respectively. Proteins that showed inconsistent spectral counting and XIC ratios were removed from analysis. There are 34 proteins elevated in Control relative to NOA, 18 decreased in Control relative to NOA, 59 elevated in NOA relative to PV, and 16 decreased in NOA relative to PV. Many of these proteins have expression in the testis and the epididymis and are linked to fertility. Some of these proteins may be useful as noninvasive biomarkers in discriminating NOA cases from OA.

Intraoperative assessment of technical skills on live patients using economy of hand motion: establishing learning curves of surgical competence

BACKGROUND On surgical simulators, measures of economy of hand motion have been shown to be reliable, valid, and objective measures of technical competence. Our goal was to validate hand-motion analysis (HMA) as an objective measure of surgical skill on real patients. METHODS HMA (hand movement frequency, hand travel distance) was evaluated serially on 2 standardized, live patient surgeries (vasectomy, vasectomy reversal) for both a novice and experienced surgeon. HMA parameters were correlated with blinded, case-matched assessments of technical skill using previously validated global rating scales and surgical checklist scores applied to unedited surgical videos. Serial hand-motion data from the novice and experienced surgeon were plotted to establish competency-based learning curves over time. RESULTS Intraoperative HMA correlated significantly with case-matched global rating and checklist scores. Meaningful improvements in the number of hand movements and hand travel distance were shown over time for the novice surgeon, but remained stable for the experienced surgeon. CONCLUSIONS Intraoperative assessment of economy of hand motion represents a feasible, objective, and valid measure of technical skill and can be used to establish competency-based surgical learning curves.