Intra-operative Decision-Making in Surgery

Dr Keryn Pauley

University of Aberdeen

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?

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

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).

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

Surgical Decision Making – Preliminary FrameworkOn-going situation awareness

Situation AssessmentWhat is the Problem?

Level of Risk?Available Time?

Decision Making Strategy

Intuitive/recognition-

primed

Rule-based

Analytical Creative

High Risk Little Time

Variable risk More time

Flin, R., Youngson, G., & Yule, S. (2007). How do surgeons make intraoperative decisions? Quality and Safety in Healthcare, 16, 235-239. Page 236

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)

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

Surgical Risk Management• Like aviation, surgery is a high risk

domain:– Relatively high likelihood of an adverse event– Potentially severe consequence of errorImportance of risk management

• But research to date has only concerned pre-operative risk assessment.

Research Questions:

How do consultant surgeons make intra-operative decisions? Is this consistent with Flin et al’s preliminary framework?

• Do these processes differ across types of operation (laparoscopic and open surgery) and contexts (emergency and elective)?

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.

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.

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?

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 < 1 year ago).

• A range of specialities: orthopaedics, general, vascular, transplant, urology

CasesOpen Laparoscopic

Emergency

• Laparotomy (6) • Investigative laparoscopy (2)• Laparoscopic cholecystectomy (2)• Laparoscopic ulcer repair• Laparoscopic cyst removal

Elective • Hip replacement• Percutaneous nephrostomy•Aortobifemoral bypass•Liver resection•Open cholecystectomy•Sphinterectomy

• Laparoscopic cholecystectomy (3)• Esophagectomy •Laparoscopic incisional hernia repair•Laparoscopic rephrectomy

DecisionsOpen Laparoscopic

Emergency

• Intra-operative treatment? (3)• Accept intra-operative findings? • Call for help?•Take over from Trainee?

• Convert/Continue /Stop? (5)•Intra-operative treatment?

Elective • Intra-operative treatment? (5)•Accept intra-operative findings?

• Convert/Continue

/Stop (3)•How much to organ to take?•Accept intra-operative findings?•Adapt equipment?

Strategies for Decision Making

• Intuitive: “... it was an instant decision, almost instant, quick decision. There wasn’t really an option, you know, it wasn’t 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?

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”.

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

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 can’t 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

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

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.

Questions?

k.pauley@abdn.ac.uk