Measurement of Nontechnical Skills During Robotic-Assisted Surgery Using Sensor-Based Communication and Proximity Metrics

This cohort study uses sensor-based communication and proximity metrics to assess surgeon nontechnical skills during robotic-assisted surgery.


Introduction
Nontechnical skills (NTS) include cognitive and interpersonal (eg, teamwork) skills 1 ; they are linked to patient outcomes in surgery. 2,3Currently, NTS assessment in surgery relies on behavior ratings that are subjective, potentially biasing assessments, and requires trained raters, a limited resource.
This study demonstrates a sensing-based system for objectively measuring intraoperative NTS.We hypothesized that objective, sensor-derived communication and proximity metrics are associated with NTS scores assessed with existing tools and can accurately predict exemplar NTS scores that promote patient safety and teamwork.

Methods
This cohort study, conducted between January 1 and December 31, 2019, was approved by the Indiana University institutional review board and followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for observational studies.No race or ethnicity data were collected because those details might identify participants.The Non-Technical Skills for Surgeons (NOTSS) tool with reported validity evidence was used as the gold standard NTS assessment.Two raters assessed surgeon NTS, and interrater reliability was determined. 4Three categories of objective metrics were captured with wearable sensors and video (Table ): communication, speech (Praat version 6.1.01),and proximity of surgical team member location (Figure).
Surgical teams performing robotic-assisted surgeries (RAS) from general, colorectal, and urology specialties were recruited.After surgeons provided written consent, sensors and video were captured during RAS.Data were segmented into 5 phases: patient-side cart docking, 5 minutes before the critical phase, critical phase, 5 minutes after the critical phase, and 10 minutes before patient-side cart undocking.

Results
Thirty-four cases were observed, with the participation of 16 nurses (6 men [38%]; 10 women

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Open Access.This is an open access article distributed under the terms of the CC-BY License.Nonverbal communication metrics between surgeons with both circulating nurses and technicians were also associated with NOTSS scores, which may indicate anticipation during tasks such as instrument exchange, previously identified to contribute to team effectiveness. 6Nonlinear behavior metric models estimated NOTSS scores better than linear models, suggesting that there may be optimal ranges of behaviors, such as maintaining appropriate loudness instead of consistently increasing or decreasing speech intensity.

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Study limitations include moderate interrater reliability, missing sensor data, small singleinstitution sample, and inclusion of male surgeons only.These limitations indicate directions for future work.
In conclusion, this work presents a starting point for research on sensor-based metrics during RAS to objectively assess NTS.With additional supporting evidence, such sensor-based metrics could be used for effective team performance assessment in the operating room for developing personalized training for team members and to improve patient safety.