A novel integration of observational and physiological data for an in-depth analysis into team communication during routine surgical practice.

Surgeons are less likely to use directed exchanges and readback communication during high workload.

Other team members adapt their communication according to the surgeon’s workload and situational task demands.

Safety-relevant communication qualities are influenced by varying cognitive demands during surgery.

Data-recorders can provide actionable feedback that may benefit the training of non-technical skills.

To examine how intraoperative communication qualities differ during periods of high and low workload to identify possible gaps in surgical training.

A prospective observational study. Over 100 hours of surgical procedures were recorded and all communication between the surgeon, anaesthesia team and perfusionist transcribed. Surgeons’ heart rate variability was measured to determine periods of high and low workload. Communication quality standards were assessed across workload conditions, including exchange loop-types, substantive responses, directed exchanges and communication errors.

A cardio-thoracic surgery department at a university medical centre in the Netherlands.

Twenty four operating room teams during elective adult open-heart cardiac surgeries.

Compared to periods of low workload, surgeons were significantly less likely to respond in open loop (i.e. no verbal response) (IRR = 0.75, 95% CI: 0.63-0.88) and more likely to respond in call-back during periods of high workload (IRR = 1.14, 95% CI: 1.01-1.29). Surgeons were also less likely to give a substantive response during high workload (IRR = 1.23, 95% CI: 1.04-1.46) and less likely to address others by their name (IRR = 0.84, 95% CI: 0.71-0.99). Other team members addressed the surgeon less frequently when the surgeon was experiencing high workload (IRR = 0.64, 95% CI: 0.53-0.79). They were also more likely to address the surgeon by name (IRR = 0.74, 95% CI: 0.56-0.99) and reply substantively during high workload (IRR = 1.50, 95% CI: 1.12-2.02).

Intraoperative communication qualities varied across workload levels, with less directed and less substantive communication exchanges from the surgeon during high workload. Other team members appeared to adapt their communication behaviours accordingly, which contribute to the resilience in OR teams during high stress situations. These results highlight the importance of online measurements of workload for the assessment and training non-technical skills in the OR.

cardiac surgery

cognitive workload

heart-rate variability

intraoperative communication quality

stress

teamwork

© 2025 The Authors. Published by Elsevier Inc. on behalf of Association of Program Directors in Surgery.