Associations of workflow disruptions in the operating room with surgical outcomes: a systematic review and narrative synthesis

Abstract

BackgroundPerformance in the operating room is an important determinant of surgical safety. Flow disruptions (FDs) represent system-related performance problems that affect the efficiency of the surgical team and have been associated with a risk to patient safety. Despite the growing evidence base on FDs, a systematic synthesis has not yet been published.ObjectiveOur aim was to identify, evaluate and summarise the evidence on relationships between intraoperative FD events and provider, surgical process and patient outcomes.MethodsWe systematically searched databases MEDLINE, Embase and PsycINFO (last update: September 2019). Two reviewers independently screened the resulting studies at the title/abstract and full text stage in duplicate, and all inconsistencies were resolved through discussion. We assessed the risk of bias of included studies using established and validated tools. We summarised effects from included studies through a narrative synthesis, stratified based on predefined surgical outcome categories, including surgical process, provider and patient outcomes.ResultsWe screened a total of 20 481 studies. 38 studies were found to be eligible. Included studies were highly heterogeneous in terms of methodology, medical specialty and context. Across studies, 20.5% of operating time was attributed to FDs. Various other process, patient and provider outcomes were reported. Most studies reported negative or non-significant associations of FDs with surgical outcomes.ConclusionApart from the identified relationship of FDs with procedure duration, the evidence base concerning the impact of FDs on provider, surgical process and patient outcomes is limited and heterogeneous. We further provide recommendations concerning use of methods, relevant outcomes and avenues for future research on associated effects of FDs in surgery.

Intraoperative dynamics of workflow disruptions and surgeons' technical performance failures: insights from a simulated operating room

“…Surgical errors can have a devastating effect on the surgical outcome [40]. The evidence base remains inconsistent concerning the ramifications of FDs on surgical performance and outcomes [15,41]. Notwithstanding, precarious sources of errors and patient harm associated with FD need to be mitigated [13,15,42,43].…”

“…The evidence base remains inconsistent concerning the ramifications of FDs on surgical performance and outcomes [15,41]. Notwithstanding, precarious sources of errors and patient harm associated with FD need to be mitigated [13,15,42,43]. We, therefore, set out a study assessing the effects of FDs on technical performance failures.…”

The Effects of Flow Disruptions on RN Circulators

“…As additional flow disruptions occur across different factors throughout the course of the surgery, the error space widens, allowing additional opportunities for errors to occur. A recent literature review exploring the effect of surgical flow disruptions found that perioperative team members spend approximately 20.5% of operating time managing flow disruptions 11 . A proactive approach to implementing safety measures may address the error space.…”

Effects of structured intraoperative briefings on patient outcomes: multicentre before-and-after study

“…However, several aspects threaten highquality intraoperative information exchange 18 . Surgeons perform difficult psychomotor tasks that require their full attention [20][21][22] ; at the same time, they lead the team and have to provide the information needed for team members to carry out their tasks appropriately 23,24 . Switching attention between psychomotor and communication tasks often induces additional mental load 25 , and can interrupt the surgical flow.…”

“…It was developed based on research into: the content of instructions needed to foster team situation awareness 29 ; the characteristics of the StOP? as a short step back from the operation [30][31][32] ; timing that avoids task disruptions 22,33 ; and the issue of speaking up 27 . Before the study, the procedure was tested and adapted in several operations.…”