Hospital operating rooms (OR) are spaces in which medical personnel performs often complex surgeries and tasks with many interactions between humans and equipment. Even though to the casual observer an operating room may come across as organised chaos, it is meant to be a well-choreographed sequence of procedures.
Any issues regarding teamwork, communication, workflow, and equipment design are known to lead to complications and increased mortality. Observational studies can identify these issues, leading to a better understanding in how to improve teamwork and team performance, which can lead to better care for patients and save lives. Dr Anjali Joseph and her team conducted such an observational study.
The team used a Portable Noldus Observation Lab, behavioural coding with The Observer XT, and computer modelling to qualify and quantify the goings on during surgeries in real operating rooms, not simulated versions of one. Their goal was to identify flow disruptions, determine what is causing them, and come up with solutions to minimise them and make ORs as safe and efficient as possible.
Direct observation and behavioural coding reveals disruptions
The research team used a Portable Noldus Observation Lab (with four cameras and microphones) to record activity during 28 surgeries in three operating rooms. The locations, roles, and activities of all medical personnel, along with any flow disruptions (FD), were then coded in detail with The Observer XT software. Across all surgeries a total of 2.504 FDs were observed, 26% of which were major ones.
The researchers found that the rate of major FDs increases with the rate of minor FDs, especially when they are related to particular equipment and its positioning in the room, and certain specific locations in the OR. More FDs were observed in the anaesthesia zone than any other zones.
The central role of the circulating nurse
In another study, Neyens et al. and Bayramzadeh et al. looked at the role of the circulating nurse (CN) in more detail. Across 25 surgeries, in three different ORs, the CN spent 34 hours performing 1.471 tasks, each categorised as patient, equipment, material, and information related. CNs were more likely to be involved in layout and environmental hazard FDs when involved in patient, material, or equipment-related tasks compared to information tasks, while the latter tasks involve the least movement.
The OR was divided up in multiple zones, each of which was categorised as functional (workstations, preparation zones, surgery, etc.) or transitional. The CN travelled through multiple zones during the vast majority of activities. Of all flow disruptions, 58% happened in the transitional zones, while behavioural coding revealed that even though the layout of the three ORs varied, the flow disruption patterns were quite similar: certain zones will always be adjacent to each other.
Digging deeper: Simulation modelling to analyse traffic flow in the OR
To dig deeper into what all is going on in an operating room, Taaffe et al. used the behavioural data set generated with The Observer XT to model the traffic flow during surgery. They looked at the effect of the size and shape of the room, the orientation of the surgery table, and the location of the workstation of the circulating nurse.
A larger room reduced the number of contacts and transitions, even though it required more movement. Positioning the table at an angle into the centre of the room with the workstation at the foot of the table resulted in a reduction of undesired contacts among medical personnel in the surgical zone and sterile areas.
Communication and teamwork in telemedicine care
Dr Joseph and her team also used the Noldus Portable lab and The Observer XT to observe and code telemedicine sessions for stroke patients conducted in an ambulance. These sessions, where remotely located patients are connected to medical professionals, provide timely assessment and interventions that are critical for preventing death and improving patient outcomes. Therefore, effective communication among team members is critical for developing a shared understanding of the patient’s condition and for conducting the stroke care evaluation.
They aimed to answer three research questions:
- How do team members communicate with one another using verbal and nonverbal means during telemedicine-enabled stroke evaluations in an ambulance?
- How do team members obtain the information required to complete specific tasks associated with stroke care evaluation?
- How do disruptions during telemedicine-enabled stroke evaluations impact communication among team members?
Record – Code – Analyse
In the study of Joseph et al., all team members – a remote neurologist, remote nurse, paramedic, and patient – completed normal tasks for a stroke evaluation during simulated stroke care delivery sessions. The sessions (n=13) were being recorded. The video recordings included the interior of the ambulance, nursing station, nursing computer screen, neurologist workspace, and neurologist computer screen.
The recordings were used to analyse the communication structure and disruptions to team communications. In The Observer XT, the tasks of the paramedic, the flow disruptions, the communication type, and the communication-pairs were coded.
Measuring flow disruptions during team interactions
The researchers found that in many instances, the paramedic’s role was to be the ears and eyes of the neurologist in the ambulance to help complete patient care evaluation tasks that the neurologist could not easily do remotely due to a limited field of view. The verbal communication with the paramedic was critical in helping the neurologist develop a shared mental model about the patient’s condition.
In the 1.897 communication events that were recorded, the most frequent type of verbal communication (40%) involved one team member giving information to another, followed by requests for information and requests for action.
Flow disruptions occurred at 156 instances (=8%) of which the majority happened during the verbal interactions among team members, mostly between the neurologist and the paramedic. The flow disruptions included communication-related disruptions, interruptions, environmental hazards, usability issues, and layout issues.
Verbal and nonverbal communication
As the paramedic and the patient were in the same room (the ambulance), most nonverbal communication occurred during the interaction between these two. Nevertheless, the neurologist communicated nonverbally with the patient as well. It was used to evaluate the patient’s condition including sensation, ataxia, arm movements, and visual field. Only 22 flow disruptions occurred during nonverbal interactions.
The researcher conclude that successful telemedicine stroke care involves supporting both verbal and nonverbal communication among all team members using video and audio systems that provide effective coverage of the patient for the providers as well as vice versa.
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Joseph, A.; Khoshkenar, A.; Taaffe, K.M.; Catchpole, K.; Machry, M.; Bayramzadeh, S. & RIPCHD.OR study group. (2019). Minor flow disruptions, traffic-related factors and their effect on major flow disruptions in the operating room. BMJ Quality & Safety. http://dx.doi.org/10.1136/bmjqs-2018-007957
Bayramzadeh, S.; Joseph, A.; San, D.; Khoshkenar, A.; Taaffe, K.; Jafarifiroozabadi, R.; Neyens, D.M. & RIPCHD.OR Study Group (2018). The Impact of Operating Room Layout on Circulating Nurse’s Work Patterns and Flow Disruptions: A Behavioural Mapping Study. Health Environments Research & Design Journal, 11, 124-138. https://doi.org/10.1177/1937586717751124
Neyens, D.M.; Bayramzadehb, S.; Catchpole, K.; Joseph, A.; Taaffe, K.; Jurewicza, K.; Khoshkenara, A.; San, D.; RIPCHD. OR Study Group (2019). Using a systems approach to evaluate a circulating nurse’s work patterns and workflow disruptions. Applied Ergonomics, 78, 293-300. https://doi.org/10.1016/j.apergo.2018.03.017
Taaffe, K.; Joseph, A.; Khoshkenar, A.; Machry, H.; Allison, D.; Reeves, S.T. & RIPCHD.OR Study Group (2020). Proactive Evaluation of an Operating Room Prototype: A Simulation-Based Modeling Approach. Journal of Patient Safety. https://doi.org/10.1097/PTS.0000000000000693
Joseph, A.; Chalil Madathil, K.; Jafarifiroozabadi, R.; Rogers, H.; Mihandoust, S.; Khasawneh, A.; McNeese, N.; Holmstedt, C. & McElligott, J. T. (2021). Communication and Teamwork During Telemedicine-Enabled Stroke Care in an Ambulance. Human Factors. https://doi.org/10.1177/0018720821995687