Surveying work-as-done in post-operative delirium risk factors collection and diagnosis monitoring
Introduction
Post-operative delirium (POD) is a syndrome characterized by an acute modification in patient's cognition and attention after a surgical intervention associated with increased peri-operative morbidity, mortality, delayed functional recovery, increased hospital stay, and higher healthcare costs (Hempenius et al., 2013; Whitlock et al., 2011). Reported incidence of POD ranges between 5% and 50% and it is related to characteristics of the patients, of the surgical procedure and of perioperative management. It is higher in elderly and fragile patients and it is steadily increasing over recent years (Bilotta et al., 2011; Dasgupta and Dumbrell, 2006; Etzioni et al., 2003). As emerged from literature, the occurrence of POD is often underrecognized and consequently untreated, since it is associated with: specific risk factors not entirely included in the routine pre-operative evaluation; fluctuating symptoms; sometime subtle neuropsychological changes (Aldecoa et al., 2017; Robinson et al., 2011). Clinical attention to POD has dramatically increased in the last 2 decades (Janssen et al., 2019).
Generally, medical protocols are based on guidelines and evidence medicine insights for the design of a procedural pathway feasible only in an “ideal work” environment. This latter is frequently labelled as “work-as-imagined” (WAI) (Carvalho et al., 2018; Catchpole and Alfred, 2018; Moppett and Shorrock, 2018). Due to the complex nature of healthcare settings, staff members adapt continuously to pursue contrasting and concurrent goals under unpredictable demanding conditions, often with inadequate/degraded resources (Jalonen et al., 2020; Patriarca et al., 2018b). Such adaptation leads to a work practice that deviates from the WAI, leading to the so-called “work-as-done” (WAD). Resilience engineering, accounting for the actual dynamic nature of socio-technical systems, allows to compare WAI and WAD to improve safety and efficiency, and to promote organizational awareness on systemic risk recognition (Bueno et al., 2019; Son et al., 2020). This topic has been widely discussed in previous literature on systems theory, with conferences dedicating particular attention to this comparison in multiple domains (Chatzimichailidou and Karanikas, 2018).
The measure of organizational awareness is an open and challenging task that might extent to clinical practice of POD diagnosis and treatment (Aldecoa et al., 2017; Fioratou et al., 2016). The Risk Situation Awareness Provision (RiskSOAP) belongs to the corpora of systems theory methodologies and it is particularly suited to clarify the systemic relationships between safety and awareness (Canham et al., 2018; Chatzimichailidou and Dokas, 2015a). The RiskSOAP approach integrates “Early Warning Sign Analysis based on the STPA” (EWaSAP) with a dissimilarity measure between binary sets, and provides a reproducible measure of the distance between WAD and WAI (Dokas et al., 2013).
The present study adopts a system-theoretic perspective for WAI vs WAD comparison in order to design a questionnaire intended to identify how POD risk factors collection and diagnosis monitoring are accomplished in WAD. The recorded results were analyzed with RiskSOAP method.
The next section explains in detail the methods used in this study; section 3 illustrates the results, then discussed in section 4; section 5 draws the conclusions of the study.
Section snippets
Research team and initial setting
The research group included 8 members: 1 staff anesthesiologist and 3 residents, that routinely work in an Italian University Hospital, and 4 industrial engineers with background in risk, safety and resilience management. The various contributors to the present project have a consolidated common experience in resilient health care which facilitated remarkably the establishment of a fruitful communication environment (Tiferes and Bisantz, 2018).
Moreover, the growing clinical interest in POD drew
Sample composition
Out of 97 anesthetists who received the invitation to fill the questionnaire, 61 replies were received and 58 were considered valid. About the three discarded ones: one respondent submitted twice her/his answers and both submissions were discarded; a third invalid submission was rejected because of being incomplete. Given the limited numerosity of the sample, data have not been further disaggregated by city of work, affiliation, or department.
Demography of respondents
As observable from Table 1, the questionnaire does
Discussion
This survey aimed at recording real work practices (WAD) for POD risk factors collection and monitoring. The low number of the sample, as well as the method chosen for its composition, does not allow us to make assumptions related to its demography with regard to safety management. To achieve such results, a larger randomized sample is required.
The distinctive result of our research is that most of the information, that are proven to specifically associate with POD, are routinely recorded but
Conclusions
There is a growing academic interest around the POD, as it seems to be still an underestimated phenomenon, although its potential wide incidence on patient safety.
Health care systems have several means possibly useable to detect and to manage the POD. However, complex underlying structures and relations of a health care socio-technical system does not allow for putting in place these means on the POD structure. On the contrary, it emerges a sort of system's blindness to the POD, i.e. there is
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgements
The authors ought to acknowledge Stefano Fresilli for his efforts in a preliminary stage of this survey. Furthermore, the authors wish to thank all the interviewees and the neurosurgery department staff, where this research have been started.
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