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Cohen TN, Wang AS, Seferian EG, Sax HC, Gewertz BL. Assessment of Emotional Outcomes of Intraoperative Death on Surgical Team Members. JAMA Surg. 2021;156(7):683–685. doi:10.1001/jamasurg.2021.0704
Surgical team members are exposed to many challenging experiences, including intraoperative death (ID). The influence of these very rare incidents on staff morale is poorly defined; the few published studies1,2 are highly focused on specific clinical specialties and service roles, not the full range of surgical staff members.
We sought to define the current experiences at our institution, which is a level 1 trauma center and regional referral site for cardiovascular and neurosurgical emergencies. We hoped to identify ways in which team members can be better supported when IDs occur.
Multidisciplinary operating room team members were asked if they would be willing to describe their experiences and thoughts on IDs. A cross-section of surgeons, anesthesiologists, residents, nurses, and technicians were invited to respond to an online REDCap3 survey. The project was approved by the institutional review board at Cedars-Sinai Medical Center. On receipt of the REDCap survey, potential participants received a written summary of the research as outlined in an attached written study information sheet and indicated consent by completing the survey. Data were collected from September 2020 to October 2020. Descriptive statistics were used to analyze the data; data analysis was completed with Excel version 2102 (Microsoft).
One hundred twenty operating room team members completed the survey (50 women [41.7%]; 66 men [55.0%]; 4 who preferred not to state their sex [3.3%]; mean [SD] age, 45.6 [12.7] years). Of 120 participants, 82 (68.3%) indicated prior experience with ID, referencing more than 300 experiences. The same IDs were likely reported multiple times, because only 140 IDs had occurred at our institution over the past 10 years (incidence, 140 IDs in >300 000 operations, or approximately 0.04%). Twenty participants (24.4%) believed that at least 1 of the IDs they experienced could have been prevented by “not doing the surgery at all” (n = 5), “better planning/coordination” (n = 4), “timelier arrival to the operating room” (n = 3), “better focus from the team” (n = 2), “more procedure experience” (n = 3), “lack of resources” (n = 1), “more training/education” (n = 1), or “earlier recognition of bleeding” (n = 1).
Participants were asked to report which of the 5 stages of grief4 they experienced following IDs. Acceptance (n = 58 of 82 [71%]), denial (41 of 82 [50%]), and depression (n = 33 of 82 [40%]) were most commonly reported. Most participants (n = 50 [61%]) indicated that they continued working within 24 hours of an ID and wished to do so; however, 20 (24%) continued working despite not wanting to. Eleven of these 20 (13%) indicated that their professional abilities were compromised after experiencing an ID, citing an inability to focus on the next patient (n = 5 [46%]), feeling mentally and physically exhausted (n = 4 [36%]), or feeling unsettled (n = 2 [18%]) (Table).
When asked, “What can the hospital do to better support staff?” participants said formalized debriefing (n = 26 [21.7%]), staff check-ins (n = 15 [12.5%]), counseling (n = 12 [10.0%]), and specific training/education (n = 10 [8.3%]) would be most helpful. Most participants (n = 80 [66.7%]) said they felt that they would be supported by the institution if they were to observe an ID in the future; however, 38 (31.7%) said they were concerned they would not be supported appropriately.
Intraoperative deaths may reflect the severity and acuity of disease or occur as results of medical errors. These differences were not specifically assessed in our study and likely influence the outcomes on staff. That said, irrespective of cause, it is clear that IDs negatively affect team members. A considerable portion of participants experienced feelings of anger and depression. Depression has been associated with increased harmful errors5 and burnout, a condition that has been found to negatively affect professional performance.6 Most concerning, 13% indicated that their professional abilities were compromised after their most recent ID experience. This finding has implications for patient safety, given that most participants continued working immediately after an ID, even if 24.4% did not wish to do so.
These observations argue that sustainable tools must be designed and implemented to support staff after IDs. Debriefings, time off to decompress, and training/education may be helpful. Lessons learned from debriefings should be regularly analyzed to identify systemic breakdowns that may contribute to these disturbing, if rare, events.
Accepted for Publication: February 5, 2021.
Published Online: April 28, 2021. doi:10.1001/jamasurg.2021.0704
Corresponding Author: Tara N. Cohen, PhD, Department of Surgery, Cedars-Sinai Medical Center, 8687 Melrose Ave, Ste G-555, West Hollywood, CA 90069 (firstname.lastname@example.org).
Author Contributions: Dr Cohen had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: All authors.
Acquisition, analysis, or interpretation of data: Cohen, Seferian.
Drafting of the manuscript: Cohen, Gewertz.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Cohen.
Administrative, technical, or material support: All authors.
Supervision: Cohen, Seferian, Sax, Gewertz.
Conflict of Interest Disclosures: Drs Seferian and Cohen reported grants from Agency for Healthcare Research and Quality outside the submitted work. No other disclosures were reported.