Table 3 Intra-operative demands for surgeon, nurse, and anesthetist (example sub-step “inject cement”)
Categories | Profession | ||
|---|---|---|---|
Surgeon | Nurse | Anesthetist | |
Objective Objectives for this sub-step? | Inject cement evenly and adequately to stabilize fractured vertebral body | Assist surgeon to inject cement | Ensure patient safety |
Party responsible Who is responsible? | Surgeon | Surgeon | Anesthetist |
Course of action How do you proceed? | Inject cement slowly under lateral C-Arm guidance | Hand over injection system to surgeon; provide feedback on cement’s time status | Monitoring vital signs |
Decisions What decisions do you need to take? | (1) When to apply cement (2) Amount of cement to inject (3) Pressure and speed of injection | (1) Can cement be applied (2) How long can cement be applied | (1) Increase oxygen saturation |
Basis for decisions On what base do you take these decisions? | (1) Time since cement was mixed, tactile cement probing (like “chewing gum”), experience; (2) Volume of vertebral body, type of fracture; (3) Leakages, experience | (1) Cement should “curl” instead of falling down (2) Depends on type, temperature, and mixing container | (1) Existing risk factors |
Attention Focus of attention? | C-arm guidance, cement amount and flow direction, fracture line | Time | Vital signs; signs of reactions to cement |
Information Important information? | X-ray picture, injected amount (in mm2) on syringe | – | Pitch of oxygen saturation |
Feedback What feedback do you get? | No haptic feedback through injection, vital signs from anesthetist | – | – |
Equipment Tools and equipment in use? | Syringe or filler, trocar, C-arm, 2nd monitor | Applicators or syringes | Monitoring devices (ECG, blood pressure, oxygen saturation, temperature) |
Communication What communication is necessary? | To anesthetist that cement injection starts, to circulating nurse to reposition C-arm, to scrub nurse how long since cement has been mixed | Scrub nurse asks what material is needed for the step “cutaneous suture” (if not already arranged) | To surgeon if vital signs change significantly |
Coordination What coordination takes place? | Handing of syringe from scrub nurse to surgeon | Handing of syringe from surgeon to scrub nurse; empty syringes into waste | If surgeon needs longer, anesthetist may give medication that supports circulation |
Time-sensitive Is this sub step time-sensitive? | Yes, as cement can only be injected within a limited duration | Yes, cement hardening needs to be monitored | – |
Importance/patient risks Is this a high-risk sub step? | Critical phase with higher patient risks | Higher risk | Critical phase with higher patient risks |
Automated action Is this action automated? | Non-automated action | Time has to be monitored actively | – |
Potential complications What kind of complications could occur? | Cement leakage into vessels, spinal canal, or intervertebral disk; too much injected cement; pulmonary embolism | – | Blood pressure may fall if surgical stimulus is missing for too long |
Variations Are there any variations to your approach? | Different types of cement, different cement injection systems | – | – |