Maureen Hemingway

Practicality of using galvanic skin response to measure intraoperative physiologic autonomic activation in operating room team members

BACKGROUND Physiologic and psychological stress are commonly experienced by operating room (OR) personnel, yet there is little research about the stress levels in OR teams and their impact on performance. Previously published procedures to measure physiologic activation are invasive and impractical for the OR. The purpose of this study was to determine the practicality of a new watch-sized device to measure galvanic skin response (GSR) in OR team members during high-fidelity surgical simulations. METHODS Interprofessional OR teams wore sensors on the wrist (all) and ankle (surgeons and scrub nurses/technicians) during the orientation, case, and debriefing phases for 17 simulations of a surgical airway case. Data were compared across all simulation phases, collectively and for each professional group. RESULTS Forty anesthesiology residents, 35 surgery residents, 27 OR nurses, 12 surgical technicians, and 7 CRNAs participated. Collectively, mean wrist GSR levels significantly increased from orientation phase to the case (0.40-0.62 μS; P < .001) and remained elevated even after the simulation was over (0.40-0.67 μS; P < .001). Surgery residents were the only group that demonstrated continued increases in wrist GSR levels throughout the entire simulation (change in GSR = 0.21 to 0.32 to 0.11 μS; P < .01). Large intraindividual differences (≤ 200 times) were found in both wrist and ankle GSR. There was no correlation between wrist and ankle data. CONCLUSION Continuous GSR monitoring of all professionals during OR simulations is feasible, but would be difficult to implement in an actual OR environment. Large variation in individual levels of physiologic activation suggests complementary qualitative research is needed to better understand how people respond to stressful OR situations.

Board 400 - Research Abstract Integrating Technical and Team Training Skills in an In-Situ Simulation Operating Room (Submission #1193)

Introduction/Background Cricothyrotomy is an essential, life-saving procedure that is taught to our general surgery interns using task trainers. Unfortunately, the task trainers lack clinical context to know when to perform the procedure and how to work in the environment where the skill will be utilized. We hypothesized that practicing this skill in an in-situ operating room scenario fosters integration of technical and team-training skills for all participants. Methods Interprofessional teams (general surgery interns, anesthesiology residents and operating room nurses) were asked to manage a simulated intraoperative patient who progresses from a difficult intubation to a “cannot mask/cannot ventilate” situation requiring cricothyrotomy. Participants were then debriefed following the session. Results Four general surgery interns, eight anesthesia residents (PGY2-4) and eight OR nurses (5-30 years of experience) participated. Anesthesia residents notified the rest of the OR team about the possibility for cricothyrotomy in 25% of cases. A patent secured airway was not achieved in any cases and average time to attempted cricothyrotomy was late in 75% (>20 minutes of severe hypoxia) and early in 25% (patient not severely hypoxic). Fifty percent of nurses recognized the need and prepared for cricothyrotomy before requested but there was no physician-to-nurse communication prior to cricothyrotomy in any case. Ninety percent of participants agreed or strongly agreed that the simulation was realistic, clinically applicable and improved teamwork skills. The program also led to the discovery of real system issues such as variable contact information for the surgical airway team, unclear equipment locations and postcricothyrotomy management. Conclusion This in-situ operating room team-training program emphasized the utility of practicing cricothyrotomies in actual clinical environments and improved interdisciplinary communication. These programs may be a platform to develop and enhance intraoperative protocols or systems. Disclosures Gordon Center, University of Miami School of Medicine.

Identifying and Managing Intraoperative Arrhythmia: A Multidisciplinary Operating Room Team Simulation Case

Introduction Resuscitation of a critically ill patient is challenging for both novice learners and experienced health care providers. During a critical event, not only is it important to identify the correct underlying diagnosis, it is equally crucial that the appropriate Advance Cardiac Life Support algorithm, medications, and defibrillator modality are implemented. This scenario features a 56-year-old female who presents for excisional biopsy of an inguinal lymph node to evaluate lymphadenopathy concerning for lymphoma. Intraoperatively, she goes into cardiopulmonary arrest. Participants must identify and manage three different scenarios: (1) ventricular fibrillation, (2) unstable ventricular tachycardia, and (3) bradycardia, including the use of the defibrillator. Method Weekly simulation sessions were conducted in the in situ simulation operating room at Massachusetts General Hospital. Surgical residents, anesthesiology residents, nurses, and surgical technicians participated in a multidisciplinary operating room team. Each approximately 60-minute session included an orientation, the case, and the debriefing. Equipment included a simulation operating room with general surgery supplies, general anesthesia equipment, a high-fidelity SimMan patient simulator, a code cart, and a defibrillator. Results Ninety-one multidisciplinary participants completed this scenario from September to December 2015. Participants reported that the scenario was applicable to their clinical practice (96%), promoted teamwork skills (88%), and encouraged interprofessional learning (94%). Discussion Intraoperative cardiac arrest is a devastating event that can result in poor patient outcomes if the care team is not thoroughly prepared for crisis management. This simulation case scenario was implemented to train multidisciplinary learners in the identification and management of such an event.

Multidisciplinary planning teams crucial for creating effective simulation scenarios

A ll health care personnel should be aware that they are part of a diverse multidisciplinary team. It is important for each team member to understand his or her professional role, capabilities, and responsibilities, as well as those of other team members to limit unnecessary redundancies and prevent gaps in care. Well-functioning teams across many industries share common traits that can be used in the surgical environment to provide high-quality care, including having shared goals, trust in each other, respect for professional and personal strengths and weaknesses, and a sense of confidence that the team can achieve its goals.1

Board 401 - Research Abstract What is the Best Instrument to Assess Interprofessional Operating Room Performance? (Submission #1239)

Introduction/Background Simulations for improving interprofessional team work are very resource intense in terms of financial and personnel costs. Although participant feedback is often strongly positive, the desired outcome is evidence of learning and improvement in clinical practice. Interprofessional operating room simulations include a surgeon, an anesthesiologist and nurses. A number of tools have been rigorously developed to assess performance of individuals and teams in operating rooms. Unfortunately, many of these tools were designed for research purposes only or require intense observer training. This development includes training observers to high inter-rater agreement before having them assess actual individual or team performance. Translational research is needed to assess the efficacy of these tools in everyday situations. Methods This mixed-Methods study investigated use of four published tools to assess specialty-specific and team behaviors in OR simulations; Anesthesiologists Non-Technical Skills (ANTS), Scrub Practitioners List of Intra-operative Non-Technical Skills (SPLINTS), Non-Technical Skills for Surgeons (NOTSS) and Objective Teamwork Assessment System (OTAS). Three of the tools, ANTS, SPLINTS and NOTSS, ask raters for one mark on each of 4 to 12 elements to characterize overall performance on a scale of poor, marginal, acceptable or good. OTAS is much more complex, with five dimensions and seven points on a scale indicating the degree of positive or negative impact of behavior from each dimension on overall team function. The scenario was a patient experiencing malignant hyperthermia during an epigastric hernia repair. Participants in each simulation included two junior residents in anesthesiology and one in surgery and three to five practicing OR nurses. Our interprofessional research team (one surgeon, one nurse, one social scientist, one research assistant and two anesthesiologists) used each of the four tools while watching a video replay of one of our interprofessional team training scenarios. The order of the videos and sequence of utilizing each tool was identical for each rater. After completing the tools for all of the videos, raters were asked several feasibility questions on a Likert scale from 1=Very low to 7=Very high. Results Inter-rater agreement was generally high. For ANTS, average rater agreement was 0.81, SPLINTS was 0.90, NOTSS was 0.96 and the average rater agreement for OTAS was 0.93. All of the instruments were felt to have similar elements and category clarity (mean=4.2). Raters were equally moderately confident that their assessments would be similar to another rater (mean=4.1). Interestingly, the OTAS instrument was felt to require the most time and mental energy to complete (mean=6.7) but most likely to result in the same ratings if used on the same video a week later (mean=4.5). All of the tools were felt to be suitable for both real-time observation and video replay. However, OTAS was felt to be the least useful for real-time observation (mean=2.4). Conclusion Rater agreement among raters with diverse backgrounds was generally very good across five videos without any training sessions. All of the instruments were felt to be suitable to assess team function but only the OTAS instrument was felt to result in consistent evaluations over raters and time. Disclosures Gordon Center, University of Miami School of Medicine.