title: The impact of intra-operative interruptions on surgeons' perceived workload: an observational study in elective general and orthopedic surgery.
abstract: OBJECTIVE
  Surgeons' intra-operative workload is critical for effective and safe surgical performance. Detrimental conditions in the operating room (OR) environment may add to perceived workload and jeopardize surgical performance and outcomes. This study aims to evaluate the impact of different intra-operative workflow interruptions on surgeons' capacity to manage their workload safely and efficiently.
  
  
  METHODS
  This was an observational study of intra-operative interruptions and self-rated workload in two surgical specialties (general, orthopedic/trauma surgery). Intra-operative interruptions were assessed via expert observation using a well-validated observation tool. Surgeons, nurses, and anesthesiologists assessed their intra-operative workload directly after case completion based on three items of the validated Surgery Task Load Index (mental demand, situational stress, distraction).
  
  
  RESULTS
  A total of 56 elective cases (35 open, 21 laparoscopic) with 94 workload ratings were included. Mean intra-operative duration was 1 h 37 min. Intra-operative interruptions were on average observed 9.78 times per hour. People who entered/exited the OR (30.6 %) as well as telephone-/beeper-related disruptions (23.6 %) occurred most often. Equipment and OR environment-related interruptions were associated with highest interference with team functioning particularly in laparoscopic procedures. After identifying task and procedural influences, partial correlational analyses revealed that case-irrelevant communications were negatively associated with surgeons' mental fatigue and situational stress, whereas surgeons' reported distraction was increased by case-irrelevant communication and procedural disruptions. OR nurses' and anesthesiologists' perceived workload was also related to intra-operative interruption events.
  
  
  CONCLUSIONS
  Our study documents the unique contribution of different interruptions on surgeons' workload; whereas case-irrelevant communications may be beneficial for mental fatigue and stress in routine cases, procedural interruptions and case-irrelevant communication may contribute to surgeons' mental focus deteriorating. Well-designed OR environments, surgical leadership, and awareness can help to control unnecessary interruptions for effective and safe surgical care.
authors.affiliation: Institute and Outpatient Clinic for Occupational, Social, and Environmental Medicine, Ludwig-Maximilians-University Munich, Ziemssenstrasse 1, 80336, Munich, Germany, matthias.weigl@med.lmu.de.
authors.forename: Matthias
authors.initials: M
authors.lastname: Weigl
authors.forename: Sophia
authors.initials: S
authors.lastname: Antoniadis
authors.forename: Costanza
authors.initials: C
authors.lastname: Chiapponi
authors.forename: Christiane
authors.initials: C
authors.lastname: Bruns
authors.forename: Nick
authors.initials: N
authors.lastname: Sevdalis
mesh_terms: D003142:Communication; D003430:Cross-Sectional Studies; D017558:Elective Surgical Procedures; D013502:General Surgery; D006801:Humans; D007400:Interprofessional Relations; D007432:Intraoperative Period; D009873:Operating Rooms; D009985:Orthopedics; D010465:Perception; D057566:Self Report; D013315:Stress, Psychological; D066231:Surgeons / Q000523:psychology*; D057188:Workflow; D016526:Workload / Q000523:psychology*; D017132:Workplace