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Figure.
HUB System Display Screen
HUB System Display Screen

A, HUB system display screen demonstrating surgical team on left (highlighted if checked in), procedural algorithm in the center (highlighted if completed), and progress bar on right. B, Example of an alert message displayed by HUB system secondary to omitted step.

Table.  
Procedure Algorithm for Conventional Coronary Artery Bypass Grafting
Procedure Algorithm for Conventional Coronary Artery Bypass Grafting
1.
Wahr  JA, Prager  RL, Abernathy  JH  III,  et al; American Heart Association Council on Cardiovascular Surgery and Anesthesia, Council on Cardiovascular and Stroke Nursing, and Council on Quality of Care and Outcomes Research.  Patient safety in the cardiac operating room: human factors and teamwork: a scientific statement from the American Heart Association.  Circulation. 2013;128(10):1139-1169.PubMedGoogle ScholarCrossref
2.
Gurses  AP, Kim  G, Martinez  EA,  et al.  Identifying and categorising patient safety hazards in cardiovascular operating rooms using an interdisciplinary approach: a multisite study.  BMJ Qual Saf. 2012;21(10):810-818.PubMedGoogle ScholarCrossref
3.
Wiegmann  DA, ElBardissi  AW, Dearani  JA, Daly  RC, Sundt  TM  III.  Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation.  Surgery. 2007;142(5):658-665.PubMedGoogle ScholarCrossref
4.
Allers  JC, Hussein  AA, Ahmad  N,  et al.  Evaluation and impact of workflow interruptions during robot-assisted surgery.  Urology. 2016;92:33-37.PubMedGoogle ScholarCrossref
5.
Conboy  HM, Maron  JK, Christov  SC,  et al. Process modeling of aortic cannulation in cardiac surgery: towards a smart checklist to mitigate the risk of stroke. Presented at: MICCAI International Conference on Medical Image Computing and Computer-Assisted Intervention; September 14, 2014; Boston, MA.
Research Letter
December 2016

Computer-Assisted Process Modeling to Enhance Intraoperative Safety in Cardiac Surgery

Author Affiliations
  • 1Harvard School of Public Health, Boston, Massachusetts
  • 2Harvard Medical School, Boston, Massachusetts
  • 3Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts
 

Copyright 2016 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.

JAMA Surg. 2016;151(12):1183-1186. doi:10.1001/jamasurg.2016.2839

The operating room is a common site for adverse events in the hospital, which are largely related to communication breakdowns and surgical flow disruptions leading to error cycles.1-4 To reduce the rate of preventable adverse events and enhance patient safety, we present what is, to our knowledge, the first clinical use of the HUB,5 a computer-assisted system designed to support intraoperative team performance.

Methods

We designed a single-site, prospective pilot investigation to determine the feasibility of the HUB5 mobile workflow management system (3Si Systems LLC), which uses speech-recognition technology to support intraoperative team communication and adherence to best-practice guidelines. Based on prior audio recordings of 9 cardiac procedures, process models composed of major procedural steps were developed onto software and preloaded on the HUB preoperatively (Table). The HUB recognizes voice commands (derived from the audio recordings and specific to each team member) by key team members fitted with high-fidelity microphones (earpiece or clip-on) that correspond to procedural steps that initiate appropriate algorithms (Figure, A) or alert the team if inadvertently omitted (Figure, B).

Functionality of the HUB was tested between May 2015 and March 2016 during 5 procedures: minimally invasive coronary artery bypass grafting, 2 conventional coronary artery bypass graftings, aortic valve replacement/coronary artery bypass grafting, and isolated aortic valve replacement. The primary outcome measured was the qualitative ability of the HUB to distinguish commands from conversational speech. The study was approved by the Veterans Affairs Boston Healthcare System institutional review board, and all research participants provided written informed consent.

Results

The HUB system registered key surgical team members using the phrase “check-in [team member name].” Collectively, 62 major steps and 216 subtasks were tested in the procedural algorithms. All task phrases were distinguished from conversational speech and recorded appropriately by the HUB; however, 62 steps required repetition before system acknowledgment.

During the procedures, the potential for 3 errors occurred: 2 recommended surgical steps were omitted, and 1 communication loop was not closed. In each instance, the HUB appropriately displayed alerts, successfully prompting the surgical team to correct the errors.

Discussion

Surgical safety interventions often fail to account for the multidisciplinary nature of surgery. The HUB is designed to facilitate multidisciplinary team communication, recognize sentinel steps of high-consequence surgical procedures, and alert the operating room team to communication failures and procedural omissions. The feasibility test we present is encouraging and supports further intraoperative analysis of the HUB, particularly speech recognition, because standard Microsoft speech recognition software was used in this investigation and requires upgrade for a marketed system. Although false-step recognition did not occur in this investigation, future speech recognition software may use a command to prompt the system to distinguish commands directed toward the HUB from commands uttered in conversational speech. Furthermore, should an intraoperative complication occur, the HUB user can request a preloaded surgical checklist to assist with correcting the complication. This does not interfere with the procedure algorithm, although a pause function may be introduced.

Although we tested the HUB in cardiac surgery, HUB algorithms can be developed and applied across all surgical specialties. Unique algorithms can also be tailored for complex procedures involving multiple surgical teams, where communication is critical and susceptible to error. Each team member may check in and check out of the procedure at any time, provided their profile is uploaded to the system preoperatively. Although no final product cost can be estimated at this time, use of the HUB across multiple surgical specialties may reduce the additional cost per case.

Ultimately, surgical safety interventions endeavor to reduce morbidity and mortality. The logical next step is to apply the HUB to a larger series of cardiac surgical procedures to determine whether the HUB achieves this goal.

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Article Information

Corresponding Author: Christopher L. Tarola, MD, MPH, Veterans Affairs Boston Healthcare System, Division Cardiac Surgery, 1400 VFW Pkwy, Mail Code 112, West Roxbury, MA 02132 (christopher.tarola@londonhospitals.ca).

Published Online: October 5, 2016. doi:10.1001/jamasurg.2016.2839

Author Contributions: Drs Tarola and Zenati had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Tarola, Haime, Leissner, Zenati.

Acquisition, analysis, or interpretation of data: All Authors.

Drafting of the manuscript: Tarola, Haime, Gabany, Zenati.

Critical revision of the manuscript for important intellectual content: Quin, Haime, Taylor, Leissner, Zenati.

Statistical analysis: Tarola.

Obtaining funding: Zenati.

Administrative, technical, or material support: Haime, Gabany, Taylor, Leissner, Zenati.

Study supervision: Quin, Gabany, Zenati.

Conflict of Interest Disclosures: Dr Zenati is the inventor of the original intellectual property, the HUB System, a communication management system that is licensed by Harvard University to Surgical Safety Solutions LLC. Dr Zenati additionally owns founder’s shares. No other disclosures are reported.

Additional Contributions: We thank Annette Phillips, RN, Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts, for her clerical assistance and Michael Grumbine of 3si Surgical Safety Solutions (http://www.3sisystems.com) for technical assistance in HUB operations. Neither party received financial compensation for their efforts.

References
1.
Wahr  JA, Prager  RL, Abernathy  JH  III,  et al; American Heart Association Council on Cardiovascular Surgery and Anesthesia, Council on Cardiovascular and Stroke Nursing, and Council on Quality of Care and Outcomes Research.  Patient safety in the cardiac operating room: human factors and teamwork: a scientific statement from the American Heart Association.  Circulation. 2013;128(10):1139-1169.PubMedGoogle ScholarCrossref
2.
Gurses  AP, Kim  G, Martinez  EA,  et al.  Identifying and categorising patient safety hazards in cardiovascular operating rooms using an interdisciplinary approach: a multisite study.  BMJ Qual Saf. 2012;21(10):810-818.PubMedGoogle ScholarCrossref
3.
Wiegmann  DA, ElBardissi  AW, Dearani  JA, Daly  RC, Sundt  TM  III.  Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation.  Surgery. 2007;142(5):658-665.PubMedGoogle ScholarCrossref
4.
Allers  JC, Hussein  AA, Ahmad  N,  et al.  Evaluation and impact of workflow interruptions during robot-assisted surgery.  Urology. 2016;92:33-37.PubMedGoogle ScholarCrossref
5.
Conboy  HM, Maron  JK, Christov  SC,  et al. Process modeling of aortic cannulation in cardiac surgery: towards a smart checklist to mitigate the risk of stroke. Presented at: MICCAI International Conference on Medical Image Computing and Computer-Assisted Intervention; September 14, 2014; Boston, MA.
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