‘Play to the conditions’: optimizing the operating theatre environment through lessons from elite performance domains

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In 2014, a judicial court in Brazil was an unusual setting for a defining moment in the relationship between elite sport and the physical environment1. In response to athlete demands, the court required water breaks in football World Cup games when the wet-globe temperature (WGBT) exceeded 32°C. Despite initial concerns this would disrupt the flow of the game, the requirement has since become the global standard in professional football. Elite tennis has taken this further. The US and Australian Opens feature high temperatures, but the humidity in New York is greater than in Melbourne. A uniform approach would not work for both and once this difference was recognized, different solutions were implemented; the use of fans and water to accelerate conductive heating loss for players in dry conditions, rather than multiple iced towels in humid conditions. Indeed, standardization of the physical environment (requirements for temperature, illumination, and noise in addition to measures to address humidity) is common across elite sport as a means to support athlete performance. Like elite sport, surgical performance is affected by environmental factors. Unlike sport, the performance effects and optimization of the operating theatre environment is an underexplored and underutilized area of surgical research that extends across multiple domains. Surgeons and surgical leaders must recognize environmental control as an opportunity to optimize team performance and patient outcomes. The effects of thermodynamics on human performance are equally applicable in an operating theatre and a football pitch. Operative staff, for example, have reported decreased subjective performance in higher temperatures, with reduced response time and cognition2, but methods to counteract it (without impacting patient temperature), such as cooling vests, have had limited research with no widespread adoption. Hydration breaks are inconsistent and team dependent. Emergency response teams provide a marked contrast to this. Firefighters require protection from temperatures that can exceed 250°C. Personal protective equipment has improved to the extent that firefighters experience no significant decrease in mobility or performance when compared to their normal clothing3. Compliance with rehab and hydration standards is high. Task completion in fluctuating temperatures is not limited to emergency services; in space exploration and sport, such as Formula 1, it is an area of continual investigation and incremental improvement. Lighting is another underappreciated variable. In surgery we often emphasize lux, with a target at least three times brighter than general room lighting. However, we fail to mitigate the potential negative performance and physiological effects of illumination. On the International Space Station (ISS), astronauts operate under lighting conditions specifically designed to aid both visual acuity and neuroendocrine behaviour4. In baseball, cricket, and American football, players wear anti-glare paste under the eyes (known as ‘eye black’), a simple yet effective intervention to improve contrast sensitivity. Noise, although inevitable for members of the operating theatre team, may signal operative complexity and has been associated with surgical complications5. Performance in elite footballers is demonstrably affected by stadium crowd noise6, so players train under representative conditions to acclimatize, with proven benefits. Surgery could adopt similar strategies, given practical difficulties in eliminating noise. In simulation or virtual reality training it is important the actual environment is recreated, not simply the operative task itself. Recreating the acoustic environment in training may better prepare surgical teams for clinical situations. High-performance domains demonstrate the benefit of small improvements in control of the environment into an overall strategy for performance outcomes (Fig. 1). The operating theatre should be no exception. Recognizing and mitigating suboptimal conditions, whether temperature, lighting or noise not only aligns with a human factors approach, but is crucial to optimizing surgical team performance and patient outcomes. Strategies from other high-performance domains that could optimize surgical performance C.P.B. is supported by a research fellowship from Edinburgh Surgery Online. R.J.E.S. is funded by an NHS Research Scotland (NRS) clinician post. Connor Boyle (Conceptualization, Data curation, Formal analysis, Methodology, Resources, Software, Writing—original draft, Writing—review & editing), James Crichton (Data curation, Writing—review & editing), Alessandro Sgrò (Data curation, Writing—review & editing), Sarah Michael (Supervision, Writing—review & editing), Stephen Wigmore (Supervision, Writing—review & editing), Richard Skipworth (Conceptualization, Supervision, Writing—review & editing), and Steven Yule (Conceptualization, Supervision, Writing—review & editing) There are no other conflicts of interest to disclose. Not applicable.

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