Written by: Dr C. Williams

Systematic review of psychological, emotional and behavioural impacts of surgical incidents on operating theatre staff. Sera N, Sahota A, Husband AK et al. British Journal of Surgery Open 2017 doi:10.1002/bjs5.21

Evidence suggests that medical errors affect up to 16% of patients admitted to hospital with 50% of those errors occurring during surgery or other invasive procedures. The operating theatre is an environment uniquely characterised by acute stress, heavy workload and quick decision-making. With more and more healthcare institutions worldwide considering strategies for promoting a safety culture and staff well-being, the purpose of this review was to provide potentially transferable insights into how best to support staff following a surgical incident.

Surgical incidents may or may not result in patient harm but yet may still affect the health professionals involved. Studies looking at the effects on surgeons have found that they report depression and emotional distress symptoms likened to those of post-traumatic stress disorder. Evidence shows that operating theatre nurses and allied health professionals can also suffer loss of self-confidence and job dissatisfaction. The UK Care Quality Commission recommend that organisational support be offered to staff at this time and stressed the importance of actively supporting the health and well-being of staff.

The studies reviewed reported a range of emotional impact on staff and a variety of different coping mechanisms used. It also showed that surgical incidents occurring during elective surgery appeared to have more of an impact on operating staff that those occurring during emergency surgery. What is clear is that the majority of operating theatre staff felt that there is inadequate support from their managers within their organisation after a surgical incident. Surgeons in particular reported a blame culture and therefore a reluctance to disclose or discuss incidents for fear of consequences. Morbidity and mortality meetings are designed to encourage informal and constructive discussions about surgical incidents but there are reports of surgeons becoming ‘defensive and aggressively pursuing angles that put them in the best possible light’ during these meetings.

There are a variety of ways in which healthcare professionals can be supported. But what is evident is that health professionals can suffer severe emotional distress following surgical incidents. This must not be ignored and ideally tools should be developed to help the team deconstruct surgical incidents that occur in a blame-free culture to encourage open discussion and promote shared learning within organisations. Organisations themselves need to actively cultivate a culture of ‘psychological safety’ and in this way they can potentially reduce the impact of incidents on individuals and promote learning. Clearly we still a lot to learn.

Enhancing the quality and safety of the perioperative patient. Stander S, Smith A. Current Opinion in Anaesthesiology 2017;30(6):730-735 doi:10.1097/ACO.0000000000000517 

Although the anaesthetists work is still concentrated mainly in the operating theatre, the spectrum of our job is evolving with work ranging from pre-clinical emergency medicine, preoperative optimisation clinics, treating patients throughout the whole journey from operating room to postoperative care in recovery rooms, intensive and intermediate care facilities, normal wards and acute and chronic pain services. This broad spectrum means that the role of her perioperative physician is firmly linked to the anaesthetist. This review focuses on some aspects of perioperative management where the patient’s quality and safety can be enhanced.

There are many hazards that threaten perioperative outcomes for patients and this review focuses on three areas. The first is pre-operative assessment. We know that optimisation and risk stratification using risk-scores are important early steps in safety management. Secondly, checklists and cognitive aids are becoming more widely used in perioperative care, but vary considerably in quality and usability. Proper design, implementation and recurrent training is crucial to their success.

Finally, addressing the burden of complications in the postoperative period is a future challenge. This can possibly be addressed by proper patients’ preparation and complication management avoiding the so called ‘failure-to’rescue’ concept where complications are not recognised or treated in a timely manner.

Can lung ultrasound be the first-line tool for evaluation of intraoperative hypoxemia? Díaz-Gómez JL, Renew JR, Ratzlaff RA et al. Anaesthesia & Analgesia 2017 doi:10.1213/ANE.0000000000002578 

The use of ultrasound in perioperative settings is becoming more and more popular. ‘Traditional’ evaluation of intraoperative hypoxaemia involves assessing technical factors such as gas mixture, mechanical ventilator function and settings, anaesthetic machine and circuit issues and patient factors with the use of techniques such as auscultation, chest radiography and flexible bronchoscopy. The authors argue that the inherent qualities of lung ultrasound (the wide availability, lack of radiation, portability and immediate interpretation) make it attractive for use in the intraoperative period.

Lung ultrasound has emerged as a timely non-invasive bedside tool and evidence shows that it demonstrates a higher diagnostic accuracy compared to chest radiography and auscultation for many conditions. Currently the evidence for intraoperative use of lung ultrasound to diagnose hypoxaemia is scarce. The arguments for incorporating lung ultrasound into clinical practice are reasonable but it does rely on it being widely available, being able to access the patient to obtain appropriate images in the middle of surgery and that the user has the appropriate skills to interpret images. It remains to be seen how widespread lung ultrasound will become as a first line use for intraoperative diagnosis of causes of hypoxaemia.

Acute physiologic stress and subsequent anxiety among family members of ICU patients. Beesley SJ, Hopkins RO, Holt-Lunstad J et al. Critical Care Medicine 2017 doi:10.1097/CCM.0000000000002835

It is well established that patients who survive critical illness experience high rates of anxiety, depression and post traumatic stress disorder that persist for months to years after hospital discharge. As doctors our focus is often on the patient, however the impact of having a relative on the critical care unit must not be forgotten. Studies have shown that family members of intensive care patients commonly suffer from psychologic disorders including persistent anxiety, depression and PTSD and may experience a decrease in quality of life that persists for 2 or more years associated with significant financial and emotional burden.

Studies have begun to look at risk factors among family members for developing psychological problems and ones elucidated so far include female sex, age of family member or patient, history of anxiety and levels of social support. Persistent psychologic distress also seemed to be more common if family members were involved in medical decision making or perceived that communication with clinicians was inadequate. This study hypothesised that measuring salivary cortisol early in an ICU admission was associated with subsequent anxiety levels among ICU family members.

Family members provided five salivary cortisol samples over 24 hours at the time of the patients admission to critical care. They were then followed up at 3 months primarily looking at anxiety but also depression and post traumatic stress disorder. The results appear to show that higher cortisol levels are associated with anxiety in family members 3 months after ICU admission with roughly one-third of family members affected. There are confounding factors that are not accounted for and this study includes a small sample size so further studies would be needed to confirm this finding. However, being able to identify ICU family members who may be at higher risk of adverse psychologic outcomes may enable early targeted therapies to mitigate post-ICU anxiety.

Improve postoperative sleep: what can we do? Xian S; Dong-Xin W. Current Opinion in Anaesthesiology 2017 doi: 10.1097/ACO.0000000000000538 

Sleep disturbances are common in patients after surgery and they can affect postoperative recovery. Recent evidence points towards multiple perioperative factors that are related to the development of postoperative sleep disturbances – some of these factors can potentially be managed to reduce the severity of sleep disturbances and possibly improve postoperative recovery.

Patients having major surgery often develop significant sleep disturbances in the immediate postoperative period. Severe sleep deprivation and sleep fragmentation is often seen during the night after surgery. For the majority of people their sleep structure gradually returns to normal within a week.

Factors associated with an increased risk of sleep disturbance include:

  • Increasing age
  • Preoperative comorbidity – including obstructive sleep apnoea and coronary artery disease
  • Type of anaesthesia – patients having hysterectomies under spinal anaesthesia had less disturbed sleep than those having general anaesthesia.
  • Pain – pain affects sleep but so does the use of opioid analgesia
  • Severity of surgical trauma – the bigger the surgery the more severe the sleep disturbance
  • Postoperative factors – including noise and light levels on the wards, disturbances from healthcare staff and disturbances by other patients

There are several recognised harmful effects of sleep disturbances on postoperative outcomes including the development of delirium, increased pain levels, increased risk of cardiovascular events in high risk patients, longer hospital stays, poorer functional recovers, poorer emotional state and a lower quality of life.

There are many strategies to reduces sleep disturbance both pharmacological and non pharmacological, both of which may help to improve postoperative recovery. Sleep-promotion strategies are helpful for the recovery of postoperative patients. Although research is still needed what is clear is that sleep is an essential factor to consider when looking to improve patient perioperative outcomes.

Restoration of resident sleep and wellness with block scheduling. Bordet J, Agustin AG, Ahmed MA et al. Medical Education 2017;51(12):1241-1249 doi:10.1111/medu.13392

Sleep deprivations and the effects of fatigue on anaesthetic trainees has been highlighted recently in journals and mainstream media (Journal watch July 2017). Following on from this has been a campaign to raise fatigue awareness by both the AAGBI and the RCoA. The hazards of sleep deprivation have been consistently demonstrated including reduced memory capacity, impaired reaction time and reduced vigilance with increased incidences of medical errors. Trainees in anaesthesia have also been shown to be at higher risks of burnout, depression and be involved n motor vehicle accidents. Although much of the work has been in looking at anaesthetic trainees, all healthcare professionals and indeed non-healthcare professionals are at risk from sleep deprivation.

This paper is an observational study of intensive care residents looking at how changing work schedules may have a positive impact in residents sleep and wellness. The ICU in this study looked at whether using a block scheduling meant that trainees had better sleep and wellness compared to traditional scheduling. The paper describes in detail what ‘block scheduling’ entails but briefly over a 4 week period residents work 3 weeks in ICU and have one week of ‘ambulatory’ work. Although it is difficult to work out exactly what ‘ambulatory work entails it is made up of a week of 8am-5pm days as opposed to the 12-13 hour shifts (day or night) while working on ICU.

All residents wore wrist actigraphy which measured total sleep time, sleep latency, sleep efficiency, light exposure, steps and activity levels. Residents also filled out weekly questionnaires including the Epworth Sleepiness Scale and the Perceived Stress Scale. Residents slept significantly longer during their week away from ICU (ambulatory week). Their Sleepiness Scale and Stress Scale scores worsened the longer they spent working ICU shifts but improved significantly during their ‘ambulatory week’. Residents who stayed on ICU for the whole 4 week block continued to show a trend with a decline in perceived wellness.

Although further studies are needed this type of ‘block’ scheduling may have some benefits in repaying sleep debt, correcting circadian misalignment and improving wellness.