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Is The “Sterile Cockpit” Concept Applicable To Cardiovascular Surgery? Critical Intervals or Critical Events?
Sarah Henrickson1, Rishi Wadhera1, Douglass Wiegmann2, Thoralf M Sundt, III1
1Mayo Clinic, Rochester, MN;2University of Wisconsin, Madison, WI
BACKGROUND:
The concept of maintaining a ”sterile cockpit” strictly free of conversation not directly pertinent to the task at hand during periods of high cognitive workload is widely adopted in high consequence industries such as aviation; its transfer to the discipline of surgery has been advocated. An implicit pre-requisite to the feasibility of evidence-based transfer of such a concept to the clinical domain, however, is the clear definition of the period(s) of high cognitive workload for the entire operating room team. We therefore mapped the cognitive workload among team members in the cardiovascular surgical operating room.
METHODS:
The NASA Task Load Index (NASA TLX), a validated tool to measure mental workload was administered to a diverse sample of cardiovascular operating room staff (n=30), including perfusionists, certified registered nurse anesthetists, surgical assistants, surgical technicians, and circulating nurses. Subjects were asked to assess mental workload for 8 different stages of surgery (preparation, induction, opening, initiation of bypass, surgical repair, termination of bypass, closure, and post-op).
RESULTS:
The NASA TLX demonstrated widely divergent cognitive workload measures over the course of a typical case (figure). At each stage there were striking differences among care-givers in different roles such that during critical phases for one group (eg endotracheal intubation for anesthesia) others were at low work loads, while at other stages other groups were at high levels (e.g. postop for circulating nurses).
Figure 1: NASA Task Load Index scores for mental workload across stages of CVS
CONCLUSIONS:
While data such as these are dependent upon subjective assessment, cognitive workload itself is inherently subjective emerging at the intersection of task load and individual subjective assessment of task complexity. The divergence of results among team members reflects the complexity of the tasks at hand and the diversity of team member background and roles. Furthermore, although individual staff (e.g. surgeons) have a sense of their own cognitive workload and when they feel sterile cockpit would be valuable for them, if the “sterile cockpit” is to be of value it must respect the needs of all members of the team. These results suggest that definition of “critical events” rather than a discreet “critical interval” may be more appropriate and confirms that many aviation concepts need significant adaptation before adoption in medicine. 
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