Intraoperative DecisionMaking in Surgery

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Intra-operative Decision-Making in Surgery

• Dr Keryn Pauley
• University of Aberdeen

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Outline

• Decision making in surgery
• Preliminary model of surgical decision-making
  (Flin et al., 2007)
• Risk management in surgery
• Current study intra-operative surgical
  decision-making and risk management
• Where to next?

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Decision Making

• A vital aspect of minimising error in high risk
  domains
• Involves 4 basic components
• Detection
• Situation assessment (diagnosing the situation,
  assessment of risk and time available)
• Generating options
• Choosing a course of action
• Decisions can go wrong at any stage
• Sound decision-making is an important for expert
  performance
• Especially in high risk situations

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Surgical Decision Making

• Good decision making is an important aspect of
  expert surgical performance
• Surgical judgement and decision making were rated
  as important by most chief residents and
  directors of surgical residency programs
  (Martella Santos, 1995).
• Surgical adverse events have been linked to
  failures in cognitive skills, such as situation
  awareness and decision-making (e.g., Rogers et
  al., 2006).
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

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Phases of Surgery

• Different phases of surgery involving different
  cognitive skills for accessing and acting on
  information pre-operative, intra-operative, and
  post-operative
• Most decision-making research involves the
  pre-operative phase diagnosing illness and
  disease and deciding on a treatment or whether to
  operate at all.
• Many important decisions made pre-operatively but
  intra-operative decision-making is important in
• Emergency Surgery
• Elective cases when something does not go to pan

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Surgical Decision Making Preliminary Framework
On-going situation awareness

Situation Assessment What is the Problem? Level
of Risk? Available Time?
Variable risk More time
High Risk Little Time
Decision Making Strategy
Intuitive/ recognition- primed
Rule- based
Analytical
Creative
Flin, R., Youngson, G., Yule, S. (2007). How do
surgeons make intraoperative decisions? Quality
and Safety in Healthcare, 16, 235-239. Page 236
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Methods of Studying On-Task Decision-Making

• Observation tools (e.g., NOTSS)
• Verbal Protocol Analysis
• Judgement Analysis
• Cognitive Task Analysis (Critical Decision
  Method/Critical Incident Technique)

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Critical Decision Method

• Knowledge elicitation technique that uses
  interview questions to elicit information
  regarding expert decision-making (Klein et al.,
  1989)
• Experts recall a real-life incident from their
  experience, and then reconstruct (i.e. describe)
  and explain their decision-making actions
• Allows researchers to access information not
  available from more observational / experimental
  techniques

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Surgical Risk Management

• Like aviation, surgery is a high risk domain
• Relatively high likelihood of an adverse event
• Potentially severe consequence of error
• Importance of risk management
• But research to date has only concerned
  pre-operative risk assessment.

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Research Questions

• How do consultant surgeons make intra-operative
  decisions? Is this consistent with Flin et als
  preliminary framework?
• Do these processes differ across types of
  operation (laparoscopic and open surgery) and
  contexts (emergency and elective)?

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Current Research

• Critical decision method interviews with 24
  consultant surgeons in Scotland
• Emergency vs. elective cases
• Laparoscopic vs. open cases
• Interviews focused on the Decision Making process
• Aim of the study is to identify how experts make
  decisions during operations and to test the
  assumptions of Flin et al.s (2007) model.

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Protocol

• Sweep 1 Description of incident.
• The surgeon was asked to provide an account of
  the incident from the beginning to the end.
• E.g., Parts of the anatomy were abnormal during
  key-hole surgery. Do we need to call for help?
• Sweep 2 Construction a time line.
• The case was repeated back to the surgeon.
• A timeline was constructed to indicate where the
  key decision points occurred.
• A decision was selected to concentrate on.

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Protocol

• Sweep 3 Deepening.
• What information was available to you at the time
  of the decision?
• Were you reminded of any previous experiences?
• Does this case fit a standard or typical
  scenario?
• What were your specific goals and objectives at
  this time?
• What other courses of action were considered?
• What specific training or experience was helpful
  in making this decision?
• How did you arrive at your chosen course of
  action?
• Did you seek any guidance?
• What were some of the risks associated with the
  various options?

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Participants

• 21 males, 3 females
• 35 62 years (M 46, SD 7.5)
• 6 months 28 years consultancy experience
• Incident occurred 1 day 12 years ago (Median
  4 months, 17/24 lt 1 year ago).
• A range of specialities orthopaedics, general,
  vascular, transplant, urology

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Cases
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Decisions
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Strategies for Decision Making

• Intuitive ... it was an instant decision,
  almost instant, quick decision. There wasnt
  really an option, you know, it wasnt as if there
  was a balance of, you know, do I do this or do I
  do that?
• Analytical I assessed some options, and this
  seemed to be the most elegant at the time, with
  the potential to do the least harm to him, and to
  give him the best outcome.
• But some contradiction e.g., discussing pattern
  recognition then describing an analytical
  decision-making strategy.
• Moderators experience, time pressure,
  risk/complications of procedure, type of
  procedure?

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Risk Management

• Risk perception The risks were major bleeding
  and the consequences of that to the patient,
  i.e., death.
• Risk tolerance So I thought that it was
  probably a safe enough risk to take, a small
  enough risk to take to not put the patient at
  risk of having an open operation.

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Decision to Convert

• A common decision made during laparoscopic
  procedures was the decision to convert
• Analogous to the decision to divert in aviation
• Laparoscopic is usually safer than open surgery
• Open surgery scarring and a longer recovery
  time
• But sometimes it is too dangerous to continue
  laparoscopically ? must convert to open surgery

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Decision to Convert...

• How do surgeons make this decision?
• They will not convert if the surgery is
  progressing
• Sometimes it is very obvious that a conversion is
  required (e.g., if so much bleeding that cant
  see anything)
• Otherwise, decision is made by weighing up the
  risks associated with converting and continuing
• Different surgeons have different criteria for
  converting. Some surgeons accept a higher level
  of risk before converting (e.g., more bleeding)
• This seems to be dependent on experience

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Where to next?

• Transcripts will be coded and reliability checks
  will be performed
• Contribute to the development of a model of
  Surgical Decision Making across different
  operations (open and laparoscopic) and contexts
  (elective and emergency)
• Why do surgeons sometimes make decisions that end
  adversely? E.g., converting too late. The role of
  risk perception and risk tolerance

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Conclusion

• Surgical intra-operative decision-making and risk
  management are under-researched topics.
• The current research will add to our
  understanding of intra-operative decision-making
  and risk management.

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Questions?

• k.pauley_at_abdn.ac.uk