ACC.14: Workflow disruptions drag down surgical quality

WASHINGTON, D.C.—Human factor issues and not just a cardiac surgeon’s skills may dictate excellence or failure in the operating room (OR). Applying insights from aviation to cardiac care, an engineer showed on March 30 at the American College of Cardiology (ACC) scientific session how minimizing disruptions can facilitate quality care.

Traditionally, the cardiac surgeon’s skills, balanced against patient risk factors, are considered pivotal for good or poor outcomes in cardiovascular surgical procedures. The human factors perspective takes another approach, said Douglas A. Wiegmann, PhD, an engineer at the University of Wisconsin in Madison and an expert in aviation safety. Human factors research looks at how the work environment, ergonomics, equipment, decision making, communication and team performance contribute to errors.

“These may be more important than skill when reaching truly high performance,” he said during a presentation on quantifying workflow in cardiac surgery.

Human factor researchers first conduct interviews to identify issues, observe the workplace and identify workflow disruptions. Wiegmann listed the steps as observe, analyze, measure and intervene.

In the cardiac surgical setting, he observed that the OR was cluttered with technology and people with many barriers to communication, including clamor from pagers and smart phones. Observing 31 cases, he and his team counted eight disruptions per hour.

As an example of communication issues, he described a cardiac surgeon requesting something be done only to learn it had not. “These breaks in communication in the case disrupt the workflow and disrupt the mental workflow as well” because the surgeon begins to worry about other tasks that may not have been addressed.

Their analysis showed that 52 percent of disruptions were related to teamwork; 17 percent were external, such as someone entering the room; 12 percent involved training medical students; 11 percent dealt with equipment; and 7 percent had to do with accessibility of resources.

There were five errors per case, most of them minor. As flow disruption increased, the ability for surgeons to perform at their peak decreased, he said.

Their intervention included a briefing protocol, standardizing communications to include acknowledgment when a task was completed and consistency of teams to build familiarity. When teams work together often “they know each other and can anticipate each other’s movements and actions,” Wiegmann said.