Microbial surface contamination after standard operating room cleaning practices following surgical treatment of infection

At the authors' institution, some joint arthroplasty surgeons require the operating room to be terminally cleaned before using the room after infected cases, in theory to decrease exposure to excessive microbial contamination for the subsequent patient. The authors found no guidance in the literature to support this practice. To test this theory, the authors measured microbial surface contamination from 9 surfaces in operating rooms after standard operating room turnover following 14 infected cases vs 16 noninfected cases. A check was made for an association between organisms isolated intraoperatively from infected surgical patients immediately preceding standard cleaning and organisms isolated from common operating room surfaces. Colony counts were made at 24 and 48 hours, and organisms were identified. No significant difference was noted in colony counts between infected and noninfected cases, and no relationship was found between organisms isolated from infected cases and those from operating room surfaces. Furthermore, the largest colony count from both groups (0.08 cfu/cm(2)) was an order of magnitude less than the recently proposed 5 cfu/cm(2) threshold for surface hygiene in hospitals. This finding indicates that standard operating room turnover results in minimal surface contamination, regardless of the previous case's infection status, and that there is no need for a more extensive terminal cleaning after an infected case.

[Introduction to qualitative research: the main approaches and designs]

Introduction to qualitative research: the main approaches and designs. The main methods (phenomenology, ethnography, Grounded, narrative enquiry and case studies) and sampling technique of qualitative research are briefly outlined. A practical example is presented for each method.

Attitudes, risk of infection and behaviours in the operating room (the ARIBO Project): a prospective, cross-sectional study

INTRODUCTION

Inappropriate staff behaviours can lead to environmental contamination in the operating room (OR) and subsequent surgical site infection (SSI). This study will focus on the continued assessment of OR staff behaviours using a motion tracking system and their impact on the SSI risk during surgical procedures.

METHODS AND ANALYSIS

This multicentre prospective cross-sectional study will include 10 ORs of cardiac and orthopaedic surgery in 12 healthcare facilities (HCFs). The staff behaviour will be assessed by an objective, continued and prolonged quantification of movements within the OR. A motion tracking system including eight optical cameras (VICON-Bonita) will record the movements of reflective markers placed on the surgical caps/hoods of each person entering the room. Different configurations of markers positioning will be used to distinguish between the staff category. Doors opening will be observed by means of wireless inertial sensors fixed on the doors and synchronised with the motion tracking system. We will collect information on the OR staff, surgical procedures and surgical environment characteristics. The behavioural data obtained will be compared (1) to the 'best behaviour rules' in the OR, pre-established using a Delphi method and (2) to surrogates of the infectious risk represented by microbiological air counts, particle counts, and a bacteriological sample of the wound at closing. Statistics will be performed using univariate and multivariate analysis to adjust on the aerolic and architectural characteristics of the OR. A multilevel model will allow including surgical specialty and HCFs effects. Through this study, we will develop an original approach using high technology tools associated to data processing techniques to evaluate 'automatically' the behavioural dynamics of the OR staff and their impact on the SSI risk.

ETHICS AND DISSEMINATION

Approbation of the Institutional Review Board of Paris North Hospitals, Paris 7 University, AP-HP (no 11-113, 6 April 2012). The findings will be disseminated through peer-reviewed journals, and national and international conference presentations.

Trends in evolving technologies in the operating room of the future

Technology has much to offer the surgical disciplines. However, teamwork, open communication, and a willingness to adapt and adopt new skills and processes are critical to achieving improved clinical outcomes.

Ergonomic status of laparoscopic urologic surgery: survey results from 241 urologic surgeons in china

Background

The prolonged and frequent use of laparoscopic equipment raises ergonomic risks that may cause physical distress for surgeons. We aimed to assess the prevalence of urologic surgeons’ physical distress associated with ergonomic problems in the operating room (OR) and their awareness of the ergonomic guidelines in China.

Methods

A sample of 300 laparoscopic urologists in China was assessed using a questionnaire on demographic information, ergonomic issues in the OR, musculoskeletal symptoms, and awareness of the ergonomic guidelines for the OR.

Results

There were 241 survey respondents (86.7%) with valid questionnaires. Among the respondents, only 43.6% placed the operating table at pubic height during the actual operation. The majority of the respondents (63.5%) used only one monitor during the procedure. Only 29.9% placed the monitor below the eye level. More than half of the respondents (50.6%) preferred to use manual control instead of the foot pedal. Most of the respondents (95.0%) never used the body support. The respondents experienced discomfort in the following regions, in ascending order: leg (21.6%), hand (30.3%), wrist (32.8%), shoulder (33.6%), back (53.1%), and neck (58.1%). The respondents with over 250 total operations experienced less discomfort than those with less than 250 total operations. Most of the respondents (84.6%) were unaware of the ergonomic guidelines. However, almost all of the respondents (98.3%) regarded the ergonomic guidelines to be important in the OR.

Conclusions

Most of the laparoscopic urologists were not aware of the ergonomic guidelines for the OR; hence, they have been suffering from varying degrees of physical discomfort caused by ergonomic issues. There is an urgent need for education regarding ergonomic guidelines in the OR for laparoscopic urologists in China.

Recommended standards for newborn ICU design, eighth edition

This is the eighth edition of the Recommended Standards for Newborn ICU Design. It contains substantive changes in recommendations for patient room size and feeding preparation areas, and a number of refinements of previous Recommended Standards with respect to family space, hand hygiene, lighting and other aspects of the newborn intensive care unit (NICU) design.

Pioneer surgeon drove ultra clean technology

On the 50th anniversary of the development of his ground-breaking hip replacement surgical technique, Amanda Parkin, communications consultant with clean air technology specialist, Howorth Air Technology, examines Professor Sir John Charnley's influence on orthopaedic surgery, and explains how his realisation that any subsequent infection may not appear until long after the operation, and that keeping bacteria away from the wound during the procedure is the the key to minimising the risk, led to the emergence of 'ultra clean' operating theatre technology - within which Howorth was an early pioneer.

Choice of loco-regional anesthetic technique affects operating room efficiency for carpal tunnel release

Intravenous regional anesthesia (Bier block) is indicated for minor procedures such as carpal tunnel release but must be performed in the operating room. We hypothesize that preoperative peripheral nerve blocks decrease anesthesia-controlled time compared to Bier block for carpal tunnel release. With IRB approval, we reviewed surgical case data from a tertiary care university hospital outpatient surgery center for 1 year. Unilateral carpal tunnel release cases were grouped by anesthetic technique: (1) preoperative nerve blocks, or (2) Bier block. The primary outcome was anesthesia-controlled time (minutes). Secondary outcomes included surgical time and time for nerve block performance in minutes, when applicable. Eighty-nine cases met criteria for analysis (40 nerve block and 49 Bier block). Anesthesia-controlled time [median (10th-90th percentiles)] was shorter for the nerve block group compared to Bier block [11 (6-18) vs. 13 (9-20) min, respectively; p = 0.02). Surgical time was also shorter for the nerve block group vs. the Bier block group [13 (8-21) and 17 (10-29) min, respectively; p < 0.01), but nerve blocks took 10 (5-28) min to perform. Ultrasound-guided nerve blocks performed preoperatively reduce anesthesia-controlled time compared to Bier block and may be a useful anesthetic modality in some practice environments.

Implementing a perpetual anesthesia setup standardized for the trauma room in a level I trauma center

The trauma room in a level I trauma center is a dynamic environment that provides little room for error. Significant variability can exist if anesthesia providers set up the room differently. Standardization provides a system that is consistent, reliable, and cost-effective. This study examines the process of creating and implementing a standardized anesthesia setup in the trauma room of a level I trauma center. As a result of this study, the medication cart and airway setups have been standardized. Providers are encouraged to only draw up medications that will be immediately used and to ensure that prefilled syringes have been incorporated into the pharmacy formulary. Using the EZ Endo prestyleted endotracheal tube (ETT) vs a regular ETT with stylet has yielded an annual cost savings of $2,673. Ensuring that items such as an esophageal temperature probe, humidifier, and nasogastric tube are available but unopened has provided a savings of $1,989.25 per year. The reservoir bag has been changed to a latex-free bag, and 3 central line kits including an arterial line kit are routinely stocked. An ultrasound machine dedicated for central line access, GlideScope, rapid fluid infuser, and Airtraq laryngoscope have all been incorporated into the permanent setup in the trauma room.

Team communication during patient handover from the operating room: more than facts and figures

OBJECTIVE

This study was aimed at examining team communication during postoperative handover and its relationship to clinicians' self-ratings of handover quality.

BACKGROUND

Adverse events can often be traced back to inadequate communication during patient handover. Research and improvement efforts have mostly focused on the information transfer function of patient handover. However, the specific mechanisms between handover communication processes among teams of transferring and receiving clinicians and handover quality are poorly understood.

METHOD

We conducted a prospective, cross-sectional observation study using a taxonomy for handover behaviors developed on the basis of established approaches for analyzing teamwork in health care. Immediately after the observation, transferring and receiving clinicians rated the quality of the handover using a structured tool for handover quality assessment. Handover communication during 117 handovers in three postoperative settings and its relationship to clinicians' self-ratings of handover quality were analyzed with the use of correlation analyses and analyses of variance.

RESULTS

We identified significantly different patterns of handover communication between clinical settings and across handover roles. Assessments provided during handover were related to higher ratings of handover quality overall and to all four dimensions of handover quality identified in this study. If assessment was lacking, we observed compensatory information seeking by the receiving team.

CONCLUSION

Handover quality is more than the correct, complete transmission of patient information. Assessments, including predictions or anticipated problems, are critical to the quality of postoperative handover.

APPLICATION

The identification of communication behaviors related to high-quality handovers is necessary to effectively support the design and evaluation of handover improvement efforts.

[When the health care inspectorate closes the operating theatres: a case study]

BACKGROUND

The topic of 'quality of care' is subject to intense interest from the media, the public and the government. One of the key roles of the Dutch Health Care Inspectorate (IGZ) is the supervision and monitoring of quality of care. When the IGZ pays a visit, this generally has many consequences for the hospital concerned.

CASE STUDY

Following an unannounced inspection of a hospital, the IGZ closed the operating department due to shortcomings in the quality of care. The IGZ and the hospital proved to have different ideas concerning the norms of quality. Using a theoretical framework we have tried to provide some insight into the consequences of this situation.

CONCLUSION

A hospital comprises a number of different domains each with its own value system (market, governmental and political, societal, medical profession). To prevent these differences standing in the way of good care, we advise all parties to look outside their own domain in order to overcome the boundaries and connect to other domains and value systems.

Can particulate air sampling predict microbial load in operating theatres for arthroplasty?

Several studies have proposed that the microbiological quality of the air in operating theatres be indirectly evaluated by means of particle counting, a technique derived from industrial clean-room technology standards, using airborne particle concentration as an index of microbial contamination. However, the relationship between particle counting and microbiological sampling has rarely been evaluated and demonstrated in operating theatres. The aim of the present study was to determine whether particle counting could predict microbiological contamination of the air in an operating theatre during 95 surgical arthroplasty procedures. This investigation was carried out over a period of three months in 2010 in an orthopedic operating theatre devoted exclusively to prosthetic surgery. During each procedure, the bacterial contamination of the air was determined by means of active sampling; at the same time, airborne particulate contamination was assessed throughout the entire procedure. On considering the total number of surgical operations, the mean value of the total bacterial load in the center of the operating theatre proved to be 35 CFU/m(3); the mean particle count was 4,194,569 no./m(3) for particles of diameter ≥0.5 µm and 13,519 no./m(3) for particles of diameter ≥5 µm. No significant differences emerged between the median values of the airborne microbial load recorded during the two types of procedure monitored. Particulates with a diameter of ≥0.5 µm were detected in statistically higher concentrations (p<0.001) during knee-replacement procedures. By contrast, particulates with a diameter of ≥5 µm displayed a statistically higher concentration during hip-replacement procedures (p<0.05). The results did not reveal any statistically significant correlation between microbial loads and particle counts for either of the particle diameters considered (≥0.5 µm and ≥5 µm). Consequently, microbiological monitoring remains the most suitable method of evaluating the quality of air in operating theatres.

A tool and index to assess surgical capacity in low income countries: an initial implementation in Sierra Leone

BACKGROUND

A first step toward improving surgical care in many low and middle income countries is to document the need. To facilitate the collection and analysis of surgical capacity data and measure changes over time, Surgeons OverSeas (SOS) developed a tool and index based on personnel, infrastructure, procedures, equipment, and supplies (PIPES).

METHODS

A follow-up assessment of 10 government hospitals in Sierra Leone was completed 42 months after an initial survey in 2008 using the PIPES tool. An index based on number of operating rooms, personnel, infrastructure, procedures, equipment, and supplies was calculated. An index was also calculated, using the 2008 data for comparison.

RESULTS

Most hospitals demonstrated an increased index that correlated with site visits that verified improved conditions. Connaught Hospital in Sierra Leone had the highest score (9.2), consistent with its being the best equipped and staffed Ministry of Health and Sanitation facility. Makeni District Hospital had the greatest increase, from 3.8 to 7.5, consistent with a newly constructed facility.

DISCUSSION

The PIPES tool was easily administered at hospitals in Sierra Leone and an index was found useful. Surgical capacity in Sierra Leone improved between 2008 and 2011, as demonstrated by an increase in the overall PIPES indices.

Customization of a tool to assess Danish surgeons´ non-technical skills in the operating room

INTRODUCTION

Errors in surgery often stem from failure related to non-technical skills such as communication and teamwork. Tools for training and assessment of non-technical skills are needed to ensure safe surgery. The aim of this study was to customize the Non-Technical Skills for Surgeons (NOTSS) rating system for Danish general surgeons.

MATERIAL AND METHODS

Eight group interviews were conducted at two hospitals with consultant general surgeons, trainee surgeons, scrub nurses and anaesthesia staff (n = 72). Interviews were transcribed and analysed by two coders identifying surgeons´ non-technical skills. Skills were sorted according to NOTSS and behavioural examples were written. The prototype of NOTSSdk was discussed with a panel of surgeons (n = 12) to ensure face validity.

RESULTS

The skills identified in a Danish context fitted NOTSS's four categories: situation awareness, decision making, leadership, communication and teamwork and the 12 underlying elements. Only one element was added to the NOTSSdk; "monitoring own performance." A total of 3-8 good and 3-6 poor behavioural examples were written for each element. Respecting team members, creating a good working atmosphere and discussing options in the surgical team were distinct themes.

DISCUSSION

The tool, which was customized for Danish surgeons, comprises four categories, 13 elements and numerous behavioural examples. The distinct themes regarding respect, discussing options and creating a good working atmosphere are more prominent than in the Scottish NOTSS, which may be explained by cultural differences or the fact that the present study included the perspectives of the entire surgical team.

CONCLUSION

NOTSSdk holds potential as a tool for the guiding of assessment and feedback on surgeons´ non-technical performance.

FUNDING

not relevant.

TRIAL REGISTRATION

The study was registered with clinicaltrials.gov (NCT01334411).

The effect of the WHO Surgical Safety Checklist on complication rate and communication

BACKGROUND

In 2009, the World Health Organisation issued a worldwide recommendation for the use of its Surgical Safety Checklist in all operative procedures. In this review, we present the available data on the implementation of this checklist and its effect on perioperative morbidity and mortality and on operating-room safety culture. We also survey the experience with the checklist to date and give some recommendations for its practical implementation.

METHODS

We reviewed pertinent original publications retrieved by a selective search in the PubMed and Medline databases on the search term "Surgical Safety Checklist". All papers published before February 2012 were analyzed.

RESULTS

The 20 studies that we analyzed included a single prospective randomized trial concerning the effect of the WHO checklist on safety-related behavior in the operating room. The two surgical outcome studies documented a relative improvement of perioperative mortality by 47% in one study (from 56 in 3733 cases [1.5%] to 32 in 3955 cases [0.8%]) and by 62% in the other (from 31 in 842 cases [3.7%] to 13 in 908 cases [1.4%]), as well as a relative improvement of perioperative morbidity by 36% in one study (from 411 in 3733 cases [11.0%] to 288 in 3,955 cases [7.3%]) and by 37% in the other (from 151 in 842 cases [17.9%] to 102 in 908 cases [11.2%]). Improved interdisciplinary communication was also found. Factors that aided effective use of the checklist included exemplary implementation by team leaders and structured training.

CONCLUSION

These results support the WHO's recommendation to use the Surgical Safety Checklist in all operative procedures. The checklist should be understood not merely as a list of items to be checked off, but as an instrument for the improvement of communication, teamwork, and safety culture in the operating room, and it should be implemented accordingly.

Traffic flow in the operating room: an explorative and descriptive study on air quality during orthopedic trauma implant surgery

BACKGROUND

Understanding the protective potential of operating room (OR) ventilation under different conditions is crucial to optimizing the surgical environment. This study investigated the air quality, expressed as colony-forming units (CFU)/m(3), during orthopedic trauma surgery in a displacement-ventilated OR; explored how traffic flow and the number of persons present in the OR affects the air contamination rate in the vicinity of surgical wounds; and identified reasons for door openings in the OR.

METHODS

Data collection, consisting of active air sampling and observations, was performed during 30 orthopedic procedures.

RESULTS

In 52 of the 91 air samples collected (57%), the CFU/m(3) values exceeded the recommended level of <10 CFU/m(3). In addition, the data showed a strongly positive correlation between the total CFU/m(3) per operation and total traffic flow per operation (r = 0.74; P = .001; n = 24), after controlling for duration of surgery. A weaker, yet still positive correlation between CFU/m(3) and the number of persons present in the OR (r = 0.22; P = .04; n = 82) was also found. Traffic flow, number of persons present, and duration of surgery explained 68% of the variance in total CFU/m(3) (P = .001).

CONCLUSIONS

Traffic flow has a strong negative impact on the OR environment. The results of this study support interventions aimed at preventing surgical site infections by reducing traffic flow in the OR.

Thirty-day outcomes support implementation of a surgical safety checklist

BACKGROUND

Thirty-day postoperative complications from unintended harm adversely affect patients and their families and increase institutional health care costs. A surgical checklist is an inexpensive tool that will facilitate effective communication and teamwork. Surgical team training has demonstrated the opportunity for stakeholders to professionally engage one another through leveling of the authority gradient to prevent patient harm. The American College of Surgeons National Surgical Quality Improvement Program database is an outcomes reporting tool capable of validating the use of surgical checklists.

STUDY DESIGN

Three 60-minute team training sessions were conducted and participants were oriented to the use of a comprehensive surgical checklist. The surgical team used the checklist for high-risk procedures selected from those analyzed for the American College of Surgeons National Surgical Quality Improvement Program. Trained observers assessed the checklist completion and collected data about perioperative communication and safety-compromising events.

RESULTS

Data from the American College of Surgeons National Surgical Quality Improvement Program were compared for 2,079 historical control cases, 246 cases without checklist use, and 73 cases with checklist use. Overall completion of the checklist sections was 97.26%. Comparison of 30-day morbidity demonstrated a statistically significant (p = 0.000) reduction in overall adverse event rates from 23.60% for historical control cases and 15.90% in cases with only team training, to 8.20% in cases with checklist use.

CONCLUSIONS

Use of a comprehensive surgical safety checklist and implementation of a structured team training curriculum produced a statistically significant decrease in 30-day morbidity. Adoption of a comprehensive checklist is feasible with team training intervention and can produce measurable improvements in patient outcomes.

Building global capacity for patient safety: a training program for surgical safety research in developing and transitional countries

BACKGROUND

Recent studies show a significant rate of adverse events in hospitalized patients in developing/transitional countries--with approximately 18% of them related to surgical procedures. Understanding and preventing these errors requires adequate training in patient safety research methods--however, relevant training programs are currently lacking. We developed, delivered and evaluated a training program to address this gap.

METHODS

A one-day training program was developed based on the recently published WHO core competencies for patient safety research. The focus was on surgical patient safety research - including human factors, operating room (OR) teamwork, the OR environment, and safety culture. Feasibility, relevance and preliminary evaluation of the program ('proof of concept' testing) was conducted in Bogotá, Colombia in July 2011. A validated evaluation framework was utilized, assessing participants' objective knowledge, attitudes, and observational skills.

RESULTS

30 postgraduate students from a range of clinical/non-clinical disciplines signed up and 17 attended the program. Participants' knowledge of surgical patient safety significantly improved upon program completion (Mean pre-course=55% vs. Mean post-course=68%, P<0.01), as did their confidence and understanding of problems and methodologies to assess OR patient safety, and teamwork issues (P<0.05). Observational skills in recognizing safety-related behaviors using OTAS (i.e., quality of teamwork) improved on qualitative evaluation.

CONCLUSIONS

We have developed a viable, WHO-driven training program that can be delivered to clinical and non-clinical researchers to develop their competencies and thereby build capacity in developing/transitional countries to carry out surgical safety research. All program materials are available in English and Spanish for research, training and dissemination.

[Operating room during natural disaster: lessons from the 2011 Tohoku earthquake]

OBJECTIVES

Objective of this study is to clarify damages in operating rooms after the 2011 Tohoku Earthquake.

METHOD

To survey structural and non-structural damage in operating theaters, we sent questionnaires to 155 acute care hospitals in Tohoku area.

RESULTS

Questionnaires were sent back from 105 hospitals (70.3%). Total of 280 patients were undergoing any kinds of operations during the earthquake and severe seismic tremor greater than JMA Seismic Intensity 6 hit 49 hospitals. Operating room staffs experienced life-threatening tremor in 41 hospitals. Blackout occurred but emergency electronic supply unit worked immediately in 81 out of 90 hospitals. However, emergency power plant did not work in 9 hospitals. During earthquake some materials fell from shelves in 44 hospitals and medical instruments fell down in 14 hospitals. In 5 hospitals, they experienced collapse of operating room wall or ceiling causing inability to maintain sterile operative field. Damage in electric power and water supply plus damage in logistics made many operating rooms difficult to perform routine surgery for several days.

CONCLUSIONS

The 2011 Tohoku earthquake affected medical supply in wide area of Tohoku district and induced dysfunction of operating room. Supply-chain management of medical goods should be reconsidered to prepare severe natural disaster.