Stress measurement in surgeons and residents using a smart patch

Part of this work was presented at the Academic Surgical Congress in Jacksonville, USA (February 2–4, 2016) and at the Association for Surgical Education in Boston, USA (April 12–14, 2016).
https://doi.org/10.1016/j.amjsurg.2017.05.015Get rights and content

Abstract

Background

Stress may negatively affect surgeons' performance during surgical procedures, jeopardizing patient safety. For measuring stress, complex methods are used that cannot record stress real time. This study reports stress measurements in surgeons and residents using a novel patch sensor to identify activities and risk factors of stress.

Methods

In this explorative study, surgeons and residents wore the HealthPatch™ during all daily activities for 2–3 days. The patch recorded heart rate variability (HRV), and real time stress percentage using a validated algorithm of heart rate (HR) and HRV. The patch was compared with self perceived stress reporting using STAI.

Results

A significant increase in HRV and stress percentage was shown in twenty surgeons and residents during surgery in comparison with other activities. Consultants showed lower stress levels while operating compared to fellows and residents. Stress according to the patch did not correlate with STAI outcome.

Conclusions

Continuous stress monitoring using a wearable sensor patch reveals relevant data on actual stress of surgeons and residents. Stress was highest performing an operation, particularly in fellows and residents.

Introduction

Surgery is a stressful profession.1 Long and continuous working hours, high workload, dealing with life and death,1 and technically challenging procedures2 are common contributors to stress in surgeons and surgical residents. Chronic stress can lead to relational issues, depression, and burnout,3, 4, 5 and also increases the risk of cardiovascular disease and decreases life expectancy.6, 7, 8, 9

Surgeons and residents spend a large part of their time in the operating room. Stress can both positively and negatively affect surgeon's performance in the operating room. While moderate levels of stress are necessary to improve alertness, focus, efficiency of action and thus overall performance (‘good stress’),10 excessive and long lasting stress is known to compromise technical11, 12, 13 and non-technical skills (‘bad stress’).13 During surgical procedures, excessive levels of stress are mainly caused by technical problems, complexity of the procedure, equipment failures, patient complications, interruptions, and high workload.10, 14, 15 During laparoscopic procedures, stress is associated with a prolonged operation time,11, 12 poorer motion efficiency, and an increased number of errors.12, 16 Excessive levels of stress also impair non-technical skills such as communication,10, 17, 18 teamwork, judgment, and decision-making.10, 17 Loss of these abilities is associated with undesirable events in the operating room and could compromise patient safety.13, 14, 15, 18, 19, 20, 21, 22

Research of surgical stress has been focused on the operating room environment and stress has rarely been studied during other activities.23, 24 However, ward rounds and seeing patients in the Emergency Room, the Intensive Care Unit and outpatient clinic may also elicit stress, of which the consequences for the quality of work are unknown.

Heart rate (HR), heart rate variability (HRV), skin conductance, eye blinks, and salivary cortisol13 are objective markers for stress response. HRV in particular has shown to be a reliable and more time related measure for stress than the other markers.25 Several studies showed changes in HRV recordings in surgeons during surgical procedures, indicating an increase in intra-operative stress.24, 26, 27, 28, 29, 30, 31 Qualitative measurement of stress is commonly by self-reporting questionnaires, such as the State Trait Anxiety Inventory (STAI).32 Arora et al.33 developed a method to measure surgeons' stress during surgical procedures using the so-called Imperial Stress Assessment Tool (ISAT). By combining heart rate, salivary cortisol and STAI data, they were able to measure intra-operative stress in a reliable and valid manner. Drawbacks of this tool are the complexity, the time consuming and expensive cortisol analyses, and the inability to obtain real-time stress levels and for a longer period.

Recently, wearable sensors became available for use in healthcare, which can continuously measure vital signs such as HR in an easy and reliable way. The HealthPatch™ (Vital Connect, Campbell, CA, USA) is a small, lightweight and comfortable patch, which is attached to the chest. The patch is unique in measuring stress continuously and depicting stress real time, using a validated algorithm that computes stress as a combination of HRV and HR.34, 35 Because of these features the patch has potential to be used in training situations and to assess chronic stress.

An exploratory study was conducted determining the value of the patch in continuously measuring stress levels in surgeons and surgical residents during all work activities in comparison to usual self perceived stress scoring. Important objective was to evaluate to what extent demographic and surgical factors, surgical experience level in particular, affect this stress.

Section snippets

Participants

Consultants, fellows and residents were recruited from the surgical department of the Radboud university medical center in the Netherlands between July 2014 and December 2014. A sample size calculation was not deemed necessary because of the exploratory nature of this study. Demographics including gender, age, level of surgical experience and concurrent use of medication affecting heart rate were noted. Participants gave verbal consent after being informed about the study and the anonymous

Results

Five consultants, seven fellows and senior residents, and eight junior residents (11 men and 9 women) participated. The mean age (±SD) of the consultants, fellows and senior residents, and junior residents were respectively 46.20 (±7.16) years, 35.43 (±4.44) years, 32.25 (±1.83) years. The mean (±SD) years of experience at consultant level was 11.80 (±6.91) years. At the time of data collection, one fellow and one junior resident were pregnant for six weeks. One male fellow used beta-blockers.

Discussion

Continuous stress monitoring in surgeons and surgical residents using a new, small and light weighted, wearable sensor patch reveals relevant and almost complete data on stress levels of surgeons and residents during their workday. Performing an operation was more stressful than other daily activities, particularly for fellows and residents, and based on different stress calculations. The patch did not interfere with the activities and was well tolerated by most participants, and measured

Conclusion

Continuous stress monitoring in surgeons and residents using a simple, easy to wear sensor patch reveals real time data on different stress levels of surgeons and residents during the day. With this new technique we could demonstrate that performing an operation is more stressful than other daily activities in the hospital, particularly with less surgical experience. The stress percentage allows for real time feedback of the stress level making the sensor patch suitable for a widespread

Funding sources

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Acknowledgments

We gratefully acknowledge Mr. Mats Koeneman (MSc) for his technical support and proof reading the manuscript.

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