Adverse effect of noise in the operating theatre on surgical-site infection

Visual Mapping of Operating Theater Team Dynamics and Communication for Reflexive Feedback and Surgical Practice Optimization

Background

Effective operating theater (OT) communication and teamwork are essential to optimal surgical outcomes. We mapped the OT team dynamics and infection control practices using visual methods to guide reflexive feedback and optimize perioperative practices.

Methods

Data were gathered from adult gastrointestinal surgical teams at a tertiary hospital in India using observations, sociograms (communication mapping tool), and focus group discussions (FGDs). Our methods aimed to map team communication, roles and responsibilities in infection-related practices, and door openings. Qualitative data were thematically analyzed. Quantitative data were analyzed using descriptive statistics.

Results

Data were gathered from 10 surgical procedures (over 51 hours) using 16 sociograms, 15 traffic flow maps, and 3 FGDs. Senior surgeons directly influence team hierarchies, dynamics, and communication. While the surgeons, anesthetic residents, and technicians lead most tasks during procedures, the scrub nurse acts as a mediator coordinating activity among role players across hierarchies. Failing to provide the scrub nurse with complete details of the planned surgery leads to multiple door openings to fetch equipment and disposables. Traffic flow observed in 15-minute intervals corresponds to a mean frequency of 56 door openings per hour (min: 16; max: 108), with implications for infection control. Implementing the World Health Organization surgical safety checklist was inconsistent across pathways and does not match reported compliance data.

Conclusions

Human factors research is important in optimizing surgical teamwork. Using visual methods to provide feedback to perioperative teams on their communication patterns and behaviors, provided an opportunity for contextualized enhancement of infection prevention and control practices.

Operating Room Noise Environment and Behavior in Children Undergoing General Anesthesia: A Randomized Controlled Trial

Background

Excessive operating room noise impairs communication, distracts from monitoring equipment, and may increase patient and provider stress.

Aim

This study investigates the effects of reduced noise on perioperative behavior in children undergoing general anesthesia and on anesthesia provider response time.

Methods

Healthy children (the American Society of Anesthesiologists class I-II), 2-8 years of age, and their anesthesia providers were randomized into a control or treatment group exposed to reduced stimulation during induction and emergence. Primary outcomes were patient behavior and provider response time. Secondary outcomes were postoperative pain scores, provider responses exceeding 30 seconds, and median and maximum noise exposure.

Results

64 children (27 females and 37 males) were randomized into a control or treatment group, of whom 32 (50%) underwent tonsillectomy/adenoidectomy and 32 (50%) underwent dental procedures. The average age was 4.6 (SD 1.43) years. Children exposed to reduced noise were less likely to be "fussy about eating" (p=0.042), more "interested in what goes on around them" (p=0.008), and had fewer temper tantrums (p=0.004) on postoperative day one or two and on postoperative day five, six, or seven. No other differences were found between groups in behavioral assessment scores or provider response times.

Conclusions

Our study is the first to show that a low-stimulus environment improves postdischarge behavior. Provider response time was unaffected by reduced noise, and the average and peak noise exposure levels did not exceed national safety guidelines. This trial is registered with NCT03507855 and NCT03504553.

Effect of noise on the performance of arthroscopic simulator

Background

Noise is omnipresent in the operating room. The average noise in the operating room generally ranges between 60 and 65 dB and can sometimes exceed 100 dB, despite the ARS (Agence Régionale de Santé) and WHO (World Health Organization) recommending levels of 35 dB(A). This study aimed to evaluate the effect of different kinds of background auditory stimuli on the performance of surgeons during an arthroscopic simulation task.

Methods

Forty-seven surgeons with varying experience in arthroscopic surgery undertook different exercises under four different conditions: quiet, classical music, hard rock, and sustained chatter. All background auditory stimuli were set at 65 dB(A). Each participant underwent double randomization for the four sound stimuli and the four exercises to be performed. A musical questionnaire was also completed by each participant. Data related to each exercise included operating time in seconds, distance from the camera or instruments in centimeters, and an overall score automatically calculated by the simulator based on safety, economy of movement, and speed (scale: 0-20 points).

Results

Operative time in an environment with classical music was significantly lower than in an environment with hard rock (95.9 s vs. 128.7 s, p = 0.0003). The overall rating in an environment with chatter was significantly lower than in a silent environment (11.7 vs. 15.7, p < 0.0001). The overall rating in an environment with hard rock was significantly lower than in an environment with classical music (14.3 vs. 17.5, p = 0.0008).Surgeons who preferred listening to music in the operating room performed differently than those who did not. The mean operative time for surgeons who preferred music was 99.52 s (SD = 47.20), compared to 117.16 s (SD = 61.06) for those who did not prefer music, though this difference was not statistically significant (p = 0.082). The mean overall score for surgeons who preferred music was significantly higher at 17.46 (SD = 2.29) compared to 15.57 (SD = 3.49) for those who did not prefer music (p = 0.001).

Conclusions

Our study suggests that exposure to classical music and silence may confer greater benefits to the surgeon compared to the impact of hard rock and chatter. These conclusions are grounded in significant differences observed in operative time and overall evaluations, highlighting the potential advantages of an environment characterized by acoustic tranquility for surgical professionals. Preferences for music in the operating room also play a role, with those who prefer music demonstrating better performance scores.

Too loud to hear myself think: deleterious effects of noise in the operating room

Noise is part of daily life in the operating room, and too often is viewed as a necessary evil. However, much of the noise in operating rooms (ORs) is unnecessary, such as extraneous conversations and music, and could be reduced. At the least, noise is known to increase staff stress and to hamper effective communication; at the worst, it adversely affects patient outcomes. Every member of the OR team should be cognisant of this and work to reduce unnecessary noise.

The effect of music on the operating surgeon: a pilot randomized crossover trial (the MOSART study)

OBJECTIVE

The experience of stress is common among surgeons while working in the operating theatre (OT). Understanding and finding ways to mitigate this stress is important for optimizing surgical quality and maintaining clinician wellbeing. In this pilot study, we tested the feasibility and reported the outcomes of measuring the effect of background music on intra-operative surgeon stress in the clinical environment.

METHODS

The effect of Music on the Operating Surgeon: A pilot Randomized crossover Trial (the MOSART study) was conducted over a 9-month period in a single-centre. Vascular and general surgeons acting as primary operators (POs) performing elective, general anaesthetic operations were included. The intervention was surgeon-selected music, and the control was the absence of music. Outcome measures were feasibility (recruitment rate, practicability, and completeness of data), heart rate variability (HRV) indices, the Six-Item State-Trait Anxiety Inventory (STAI-6), and the Surgical Task-load Index (SURG-TLX).

RESULTS

Five POs performed 74 eligible randomized cases. The protocol was well tolerated, and no cases were abandoned. Data was incomplete in 8% of cases. The overall mean (SD) operative SURG-TLX score was 48 (±22). Mean HR increased and RMSSD decreased significantly from baseline, suggesting reduced parasympathetic activity while operating. The presence of intra-operative music was not found to affect the psychological or physiological outcomes.

CONCLUSIONS

A music interventional study of this nature is feasible in the operating theatre environment, though no difference was found between in the music and non-music conditions. Follow-up research in a simulated environment with intensive physiological monitoring could be considered.

Behavioral sciences applied to acute care teams: a research agenda for the years ahead by a European research network

BACKGROUND

Multi-disciplinary behavioral research on acute care teams has focused on understanding how teams work and on identifying behaviors characteristic of efficient and effective team performance. We aimed to define important knowledge gaps and establish a research agenda for the years ahead of prioritized research questions in this field of applied health research.

METHODS

In the first step, high-priority research questions were generated by a small highly specialized group of 29 experts in the field, recruited from the multinational and multidisciplinary "Behavioral Sciences applied to Acute care teams and Surgery (BSAS)" research network - a cross-European, interdisciplinary network of researchers from social sciences as well as from the medical field committed to understanding the role of behavioral sciences in the context of acute care teams. A consolidated list of 59 research questions was established. In the second step, 19 experts attending the 2020 BSAS annual conference quantitatively rated the importance of each research question based on four criteria - usefulness, answerability, effectiveness, and translation into practice. In the third step, during half a day of the BSAS conference, the same group of 19 experts discussed the prioritization of the research questions in three online focus group meetings and established recommendations.

RESULTS

Research priorities identified were categorized into six topics: (1) interventions to improve team process; (2) dealing with and implementing new technologies; (3) understanding and measuring team processes; (4) organizational aspects impacting teamwork; (5) training and health professions education; and (6) organizational and patient safety culture in the healthcare domain. Experts rated the first three topics as particularly relevant in terms of research priorities; the focus groups identified specific research needs within each topic.

CONCLUSIONS

Based on research priorities within the BSAS community and the broader field of applied health sciences identified through this work, we advocate for the prioritization for funding in these areas.

Noise level and surgeon stress during thyroidectomy in an endocrine surgery operating room

INTRODUCTION

Noise in the operating room is an ongoing problem that impacts the outcome of any surgery. Noise as a stressor can produce a startling reaction and activate the fight or flight response of the autonomic and endocrine systems. The psychobiology of stress as assessed by salivary cortisol level is a sensitive measure of allostatic load. This study aims to correlate, both subjectively and objectively, the salivary cortisol levels of the surgeon with noise level measurement in an endocrine surgery operating room (OR).

MATERIALS AND METHODS

A prospective observational study was conducted in the Endocrine surgery OR of a tertiary care center. We recorded the noise from the shifting in of patients in the OR to shifting out using a digital sound level meter. The operating surgeon (S) provided two salivary cortisol samples (normal salivary cortisol <5 nmol/L), one baseline and another after the procedure. The questionnaire for the assessment of distraction during thyroidectomy was filled in by the S at the end of the procedure. Salivary cortisol levels were analyzed using SLV-4635 (formerly SLV-2930) DRG Instruments GmbH German using the ELISA technique. Statistical analysis was performed using SPSS 22.0.

RESULTS

A total of 37 procedures with 74 salivary cortisol samples and 259 questionnaire responses from S were analyzed. All patients with only benign FNAC were operated upon (64.9% colloid). Mean TSH levels were 3.5 ± 6.7 mIU/L. The majority had a solitary thyroid nodule (STN) (25/37, 67.6%). Nineteen patients (51.3%) underwent open hemithyroidectomy, 10 patients total thyroidectomy, and eight patients endoscopic hemithyroidectomy. The mean noise level in the OR was 70 db. The maximum and minimum noise level in the OR was 90.06 and 51.81 dB, respectively. A total of 74 salivary cortisol samples from the S were collected (baseline and post-noise exposure) and mean cortisol levels were recorded. The surgeon was more significantly affected by surrounding noise, especially during critical phases 3 of surgery, mainly, RLN dissection and parathyroid dissection as recorded by their responses in the questionnaire (p = 0.003). The maximum value of post-operative salivary cortisol of surgeon was recorded as 23. 48 ng/mL and the minimum value recorded was 0.49 ng/mL. The difference in baseline cortisol and post-noise exposure cortisol levels of surgeon was found to be significant (p < 0.001). Maximum and mean noise levels were significantly associated with post-noise exposure salivary cortisol elevation in the surgeon (p = 0.032 and 0.014, respectively). The noise levels during RLN dissection were borderline significant with the post-noise exposure salivary cortisol of the surgeon (p = 0.055).

CONCLUSION

Our research is the first such study which has been done to assess noise levels and their effect on thyroidectomy using objective salivary cortisol measurement. It challenges the misconstrued notion that visceral surgeries requiring lesser instruments are not associated with noise-related stress. Noise is a major distraction and the effect of long-term effect on the entire surgical team needs to be studied.

Safety in Health Care: The Impact of Operating Room Design

The science of operating room design has grown over the past 20 years due to the realization that the physical environment influences health care provider performance and patient outcomes. Medical errors occur when the normal workflow in an operating room is disrupted as providers must overcome sub-optimal conditions. All aspects of the physical environment can impact operating room flow. Studying the layout, contents, ergonomics, and environmental parameters of the operating can lead improved work conditions resulting improved patient and provider safety. At the forefront of operating room design science is the use of simulation and the evaluation of new technologies.

Healthcare Professionals and Noise-Generating Tools: Challenging Assumptions about Hearing Loss Risk

Hearing loss is a significant global health concern, affecting billions of people and leading to various physical, mental, and social consequences. This paper focuses on the risk of noise-induced hearing loss (NIHL) among specific healthcare professionals, especially ear surgeons, orthopaedic surgeons, dentists, and dental hygienists, who frequently use noisy instruments in their professions. While studies on these professionals' noise exposure levels are limited, certain conditions and factors could pose a risk to their hearing. Measures such as engineering and administrative controls, regular audiometric testing, and the use of hearing protection devices are crucial in preventing NIHL. Early detection and intervention are also vital to mitigate further damage. This paper proposes the results of a modified screening protocol, including questionnaires, audiometry, and additional diagnostic tests to identify and address potential hearing disorders. Specific healthcare professionals should remain aware of the risks, prioritize hearing protection, and undergo regular monitoring to safeguard their long-term auditory well-being.

Effect of music on colonoscopy performance: A propensity score-matched analysis

BACKGROUND

Music has been used to reduce stress and improve task performance during medical therapy.

AIM

To assess the effects of music on colonoscopy performance outcomes.

METHODS

We retrospectively reviewed patients who underwent colonoscopy performed by four endoscopists with popular music. Colonoscopy performance outcomes, such as insertion time, adenoma detection rate (ADR), and polyp detection rate (PDR), were compared between the music and non-music groups. To reduce selection bias, propensity score matching was used.

RESULTS

After one-to-one propensity score matching, 169 colonoscopies were selected from each group. No significant differences in insertion time (4.97 vs 5.17 min, P = 0.795) and ADR (39.1% vs 46.2%, P = 0.226) were found between the two groups. Subgroup analysis showed that the insertion time (3.6 vs 3.8 min, P = 0.852) and ADR (51.1% vs 44.7%, P = 0.488) did not significantly differ between the two groups in experts. However, in trainees, PDR (46.9% vs 66.7%, P = 0.016) and ADR (25.9% vs 47.6%, P = 0.006) were significantly lower in the music than in the non-music group.

CONCLUSION

The current study found that listening to music during colonoscopy did not affect procedure performance. Moreover, it suggested that music may distract trainees from appropriately detecting adenomas and polyps.

Data-Driven Technologies as Enablers for Value Creation in the Prevention of Surgical Site Infections: a Systematic Review

Despite the advances in modern medicine, the use of data-driven technologies (DDTs) to prevent surgical site infections (SSIs) remains a major challenge. Scholars recognise that data management is the next frontier in infection prevention, but many aspects related to the benefits and advantages of using DDTs to mitigate SSI risk factors remain unclear and underexplored in the literature. This study explores how DDTs enable value creation in the prevention of SSIs. This study follows a systematic literature review approach and the PRISMA statement to analyse peer-reviewed articles from seven databases. Fifty-nine articles were included in the review and were analysed through a descriptive and a thematic analysis. The findings suggest a growing interest in DDTs in SSI prevention in the last 5 years, and that machine learning and smartphone applications are widely used in SSI prevention. DDTs are mainly applied to prevent SSIs in clean and clean-contaminated surgeries and often used to manage patient-related data in the postoperative stage. DDTs enable the creation of nine categories of value that are classified in four dimensions: cost/sacrifice, functional/instrumental, experiential/hedonic, and symbolic/expressive. This study offers a unique and systematic overview of the value creation aspects enabled by DDT applications in SSI prevention and suggests that additional research is needed in four areas: value co-creation and product-service systems, DDTs in contaminated and dirty surgeries, data legitimation and explainability, and data-driven interventions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41666-023-00129-2.

Investigating the attentional focus to workplace-related soundscapes in a complex audio-visual-motor task using EEG

Introduction

In demanding work situations (e.g., during a surgery), the processing of complex soundscapes varies over time and can be a burden for medical personnel. Here we study, using mobile electroencephalography (EEG), how humans process workplace-related soundscapes while performing a complex audio-visual-motor task (3D Tetris). Specifically, we wanted to know how the attentional focus changes the processing of the soundscape as a whole.

Method

Participants played a game of 3D Tetris in which they had to use both hands to control falling blocks. At the same time, participants listened to a complex soundscape, similar to what is found in an operating room (i.e., the sound of machinery, people talking in the background, alarm sounds, and instructions). In this within-subject design, participants had to react to instructions (e.g., "place the next block in the upper left corner") and to sounds depending on the experimental condition, either to a specific alarm sound originating from a fixed location or to a beep sound that originated from varying locations. Attention to the alarm reflected a narrow attentional focus, as it was easy to detect and most of the soundscape could be ignored. Attention to the beep reflected a wide attentional focus, as it required the participants to monitor multiple different sound streams.

Results and discussion

Results show the robustness of the N1 and P3 event related potential response during this dynamic task with a complex auditory soundscape. Furthermore, we used temporal response functions to study auditory processing to the whole soundscape. This work is a step toward studying workplace-related sound processing in the operating room using mobile EEG.

Effect of Background Music in the Operating Room on Surgical Outcomes: A Prospective Single-Blinded Case-Control Study

BACKGROUND

The effect of playing background music on surgical outcomes has been controversial. This prospective case-control study aims to evaluate the impact of music tempo in general surgical settings.

STUDY DESIGN

Six hundred consecutive patients with nonmetastatic breast cancer receiving breast cancer surgery have been recruited since April 2017. Patients were then assigned to 3 arms in consecutive order. The surgeon operated without music in study arm A; the surgeon operated with slow music in study arm B; and in study arm C, the surgeon operated with fast background music. Patients' clinical records were reviewed by an independent blinded assessor.

RESULTS

Baseline demographic data were comparable among the 3 study arms. Seven (3.5%) patients from study arm A developed minor complications (Clavien-Dindo class I and II); none developed major complications (Clavien-Dindo class III or above). Six (3.0%) patients from study arm B and C, respectively (slow/fast music groups), developed minor complications; none developed a major complication. Mean blood loss was also similar among the 3 study arms (5.1, 5.1, and 5.2 mL, respectively; p > 0.05). Operating time was significantly shorter in study arm C: 115 minutes (90-145), compared with 125 minutes (100-160) in study arm A (p < 0.0001) and 120 minutes (95-155) in study arm B (p = 0.0024). After a median follow-up of 40 months (3-56), 40 months (3-56), and 39.5 months (3-56), the local recurrence rates were 1.5%, 1%, and 1%, respectively (p > 0.05).

CONCLUSION

Playing music in the operating room is safe in general surgical settings in experienced hands.

Methods and Measures for Mental Stress Assessment in Surgery: A Systematic Review of 20 Years of Literature

Real-time mental stress monitoring from surgeons and surgical staff in operating rooms may reduce surgical injuries, improve performance and quality of medical care, and accelerate implementation of stress-management strategies. Motivated by the increase in usage of objective and subjective metrics for cognitive monitoring and by the gap in reviews of experimental design setups and data analytics, a systematic review of 71 studies on mental stress and workload measurement in surgical settings, published in 2001-2020, is presented. Almost 61% of selected papers used both objective and subjective measures, followed by 25% that only administered subjective tools - mostly consisting of validated instruments and customized surveys. An overall increase in the total number of publications on intraoperative stress assessment was observed from mid-2010 s along with a momentum in the use of both subjective and real-time objective measures. Cardiac activity, including heart-rate variability metrics, stress hormones, and eye-tracking metrics were the most frequently and electroencephalography (EEG) was the least frequently used objective measures. Around 40% of selected papers collected at least two objective measures, 41% used wearable devices, 23% performed synchronization and annotation, and 76% conducted baseline or multi-point data acquisition. Furthermore, 93% used a variety of statistical techniques, 14% applied regression models, and only one study released a public, anonymized dataset. This review of data modalities, experimental setups, and analysis techniques for intraoperative stress monitoring highlights the initiatives of surgical data science and motivates research on computational techniques for mental and surgical skills assessment and cognition-guided surgery.

Effects of noise and music on situation awareness, anxiety, and the mental workload of nurses during operations

This study aims to explore the effects of noise and music types on nurses' anxiety, mental workload and situation awareness during an operation. Participants included 20 circulating nurses (CNs) and 16 nurse anesthetists (NAs) who completed a total of 70 operations in which each operation required one CN and one NA. The experiment was separated into a control group (operating noise only) vs. an experimental group (3 different music types-between subjects and 2 music volume levels-within-subjects). Results showed that all participants had excellent situation awareness performance despite their mental workload showing significant differences in various phases of the surgery. Music at 55-60 dB caused lower mental workloads and anxiousness for nurses than those exposed to levels of 75-80 dB. When Mozart's music was played, the participants' mental workload and situation anxiety were lower than when exposed to other music types. Music played at 60 dB during an operation may be a feasible solution to mitigate the negative effects of extra noise and thus improve the nurses' performance.

Operating Room Noise and Team Communication during Facial Plastic and Reconstructive Surgery: A Multicenter Study

Operating room (OR) noise contributes to team miscommunication. In facial plastic and reconstructive surgery (FPRS), many cases are completed under sedation. This creates a unique environment wherein patients are aware of OR noise. The objectives of this study were to quantify noise and evaluate team members' perspectives on communication inside of FPRS ORs. This study was completed across three surgical institutions. Objective noise measurements were recorded with SoundMeter X. A communication questionnaire was delivered to OR team members following each case. Four hundred and twenty-three noise measurements were recorded during facelift/neck, eye/brow, rhinoplasty, and fat transfer/lip surgeries. The mean and maximum noise levels were 66.1 dB (dB) and 87.6 dB, respectively. Measurements during cases with general anesthetic (221/423, 52.2%) had higher noise measurements (70.3 dB) compared with those with sedation (202/423, 47.8%) (69.7 dB) (p = 0.04). The OR was louder with suction on (72.3 dB) versus off (69.3 dB) (p <0.00). Suction (34.5%) and music (22.4%) were the largest noise contributors according to questionnaire replies. Intraoperative noise, awake patients, and suctions/music may negatively impact FPRS OR communication. Innovation to improve FPRS intraoperative communication should be considered for effective patient care.

Noise in the operating room during induction of anesthesia: impact of a quality improvement initiative

PURPOSE

Noise in the operating room (OR) is common and associated with negative effects on anesthesiologists, surgeons, and patient outcomes. Induction of anesthesia is among the loudest perioperative periods. Despite its critical nature, there is little data on noise levels during induction, associated patient and anesthesiologist satisfaction, and the effects of noise reduction strategies.

METHODS

We conducted a two-part prospective interventional quality improvement project on the care of adult patients receiving general anesthesia for elective noncardiac surgery. For part A, we measured average and peak noise (dB[A]) levels during anesthesia induction in N = 100 cases and administered a satisfaction questionnaire to anesthesiologists. We then applied a multidisciplinary educational program to OR personnel on active noise reduction strategies and subsequently collected data during N = 109 cases in a post-intervention phase. For part B, we administered satisfaction questionnaires to N = 100 patients pre- vs postintervention, respectively.

RESULTS

Median [interquartile range] noise levels throughout induction were 66.0 [62.5-68.6] dB(A) preintervention vs 63.5 [60.1-65.4] dB[A] post-intervention (Hodges-Lehmann estimator of the difference, - 2.7 dB[A]; 95% confidence interval [CI], - 4.0 to - 1.5; P < 0.001). Peak noise levels during induction were 87.3 [84.0-90.5] dB(A) preintervention and 86.2 [81.8-89.3] dB(A) postintervention (Hodges-Lehmann estimator of the difference, - 1.8 dB[A]; 95% CI, - 3.3 to - 0.3; P = 0.02). Noise-related anesthesiologist satisfaction postintervention was significantly improved in multiple domains, including assessment of noise having distracted anesthesiologists. Patient satisfaction was high pre-intervention and did not significantly improve further.

CONCLUSION

In this quality improvement project, average noise levels during induction of anesthesia, anesthesiologist satisfaction, and anesthesiologists' perceived ability to perform were improved following a multidisciplinary educational program on noise reduction in the OR.

STUDY REGISTRATION

www.ClinicalTrials.gov (NCT04204785); registered 19 December 2019.

Are operating room distractions, interruptions and disruptions associated with performance and patient safety? A systematic review and meta-analysis

OBJECTIVE

The operating room is a complex environment in which distractions, interruptions and disruptions (DIDs) are frequent. Our aim was to synthesize research on the relationships between DIDs and (i) operative duration, (ii) team performance, (iii) individual performance and (iv) patient safety outcomes in order to better understand how interventions can be designed to mitigate the negative effects of DIDs.

METHODS

Electronic databases (MEDLINE, Embase, CINAHL and PsycINFO) and reference lists were systematically searched. Included studies were required to report the quantitative outcomes of the association between DIDs and team performance, individual performance and patient safety. Two reviewers independently screened articles for inclusion, assessed study quality and extracted data. A random-effects meta-analysis was performed on a subset of studies reporting total operative time and DIDs.

RESULTS

Twenty-seven studies were identified. The majority were prospective observational studies (n = 15) of moderate quality. DIDs were often defined, measured and interpreted differently in studies. DIDs were significantly associated with extended operative duration (n = 8), impaired team performance (n = 6), self-reported errors by colleagues (n = 1), surgical errors (n = 1), increased risk and incidence of surgical site infection (n = 4) and fewer patient safety checks (n = 1). A random-effects meta-analysis showed that the proportion of total operative time due to DIDs was 22.0% (95% confidence interval 15.7-29.9).

CONCLUSION

DIDs in surgery are associated with a range of negative outcomes. However, significant knowledge gaps exist about the mechanisms that underlie these relationships, as well as the potential clinical and non-clinical benefits that DIDs may deliver. Available evidence indicates that interventions to reduce the negative effects of DIDs are warranted, but current evidence is not sufficient to make recommendations about potentially useful interventions.

Noise Evaluation of Arthroplasty Theaters: Results From the NEAT Study

AIMS

The aim of this study was to define the levels of noise exposure for the surgeon, assistant, scrub nurse, and anesthetist during total hip and knee arthroplasty surgery. In addition, we sought to determine whether the noise exposure during these procedures reaches or exceeds the action values set out by the U.K. Noise at Work Regulations (2005).

MATERIALS AND METHODS

Individual noise exposure during arthroplasty hip and knee surgery was recorded using a personal noise Dosemeter System model 22 (DM22) (Pulsar instruments, Filey, U.K.). Recordings were taken in real-time during five separate theater sessions. Each theater session included two arthroplasty procedures and lasted approximately 4 hrs. Personal noise exposure was expressed in terms of peak sound pressure and an average noise exposure over an 8-hour time-period to reflect the noise experienced by the ear over a working day.

RESULTS

In all three sessions involving total hip replacement surgery, the peak sound pressure, for the operating surgeon exceeded the exposure action values set out by the U.K. Noise at Work Regulations. Theater sessions involving total knee replacement surgery did not exceed any exposure action values for LCPeak or LEPd.

CONCLUSION

Arthroplasty surgery is a working environment with significant noise exposure. We recommend any surgeon or theater member who is concerned about the noise generated in their theater to have noise levels formally assessed using appropriately positioned recording devices.

Fellows and Observers Are Not a Problem for Infection in the Operating Rooms of Teaching Centers

PURPOSE

The aim of the present study was to determine whether the risk of complications increases with the number of people in the operating room (OR). Several studies have stated that an increased number of people in the OR increases not only the risk of infection but also the risk of intraoperative complications due to distractions during the surgery.

MATERIALS AND METHODS

This retrospective study included all patients who had surgery between January 2017 and January 2018 in an OR with the usual surgical team and three or more observers. Patient demographic data, surgical details (duration of the surgery, the surgery being open or arthroscopic, and whether a graft was used), and intraoperative and postoperative complications were recorded.

RESULTS

A total of 165 surgeries were recorded, with a mean operating time of 70 min (40% open surgeries, 37% arthroscopic surgeries, and 23% combined open and arthroscopic procedures). The main intraoperative complications were vessel damage, nerve damage, premature cement setting, and leg-length discrepancy, with 1 case each. The main postoperative complications were rigidity (8 cases), unexplained pain (11 cases), failed meniscal suturing (3 cases), a postoperative stress fracture (1 case), correction loss in osteotomy (1 case), and wound problems not related to infection (1 case). There were no cases of infection.

DISCUSSION

The present study shows that the complication rate when having observers in the OR is comparable to the reported data. The key to avoiding complications is for everyone to comply with basic OR behavior.

The Perception and Attitude Toward Noise and Music in the Operating Room: A Systematic Review

BACKGROUND

Environmental noise pollution is regarded as a general stressor. Noise levels frequently exceed recommended noise levels by the World Health Organization in hospitals, especially in the operation room. The aim of this systematic review was to assess the effects of noise pollution on patient outcome and performance by operation room staff. In addition, the perception and attitude toward playing music in the operation room, which can increase noise levels, were assessed as well.

MATERIALS AND METHODS

A systematic literature search of the databases Embase, Medline Ovid, and Cochrane from date of database inception until October 16^th, 2020 using the exhaustive literature search method was performed. Prospective studies evaluating the effect of noise on the patient, surgeons, anesthesiologists, nurses, and other operation room staff, or perception and attitude toward playing music in the operation room, were included. This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines and was registered with PROSPERO (ID: 208282).

RESULTS

The literature search generated 4758 articles, and 22 prospective studies (3507 participants) were included. Three of the four studies that investigated the effect of noise on patient outcome reported a significant reduction of complication rate in surgical patients, when noise levels were lower. Six studies assessed the effect of noise in the operation room on the staff (1383 participants). Over half of the surveyed staff found noise levels to be a disturbing stressor and negatively impact performance. Although music increased decibel levels in the operation room, most surveyed staff was positively predisposed toward playing music during surgery, believing it to improve both individual and team performance. In general, music was not considered to be distracting or impairing communication.

CONCLUSIONS

Higher noise levels seem to have a negative effect on patient outcome and adversely affect performance by members in the operation room. Further research is needed to assess whether this knowledge can benefit patient outcome and surgical performance. Notably, attitude of surgical team members toward music during surgery is generally regarded favorable.

Noise in Otolaryngology - Head and Neck Surgery operating rooms: a systematic review

OBJECTIVE

Noise in operating rooms (OR) can have negative effects on both patients and surgical care workers. Noise can also impact surgical performance, team communication, and patient outcomes. Such implications of noise have been studied in orthopedics, neurosurgery, and urology. High noise levels have also been demonstrated in Otolaryngology-Head and Neck Surgery (OHNS) procedures. Despite this, no previous study has amalgamated the data on noise across all OHNS ORs to determine how much noise is present during OHNS surgeries. This study aims to review all the literature on noise associated with OHNS ORs and procedures.

METHODS

Ovid Medline, EMBASE Classic, Pubmed, SCOPUS and Cochrane databases were searched following PRISMA guidelines. Data was collected on noise measurement location and surgery type. Descriptive results and statistical analysis were completed using Stata.

RESULTS

This search identified 2914 articles. Final inclusion consisted of 22 studies. The majority of articles analyzed noise level exposures during mastoid surgery (18/22, 82%). The maximum noise level across all OHNS ORs and OHNS cadaver studies were 95.5 a-weighted decibels (dBA) and 106.6 c-weighted decibels (dBC), respectively (P = 0.2068). The mean noise level across all studies was significantly higher in OHNS cadaver labs (96.9 dBA) compared to OHNS ORs (70.1 dBA) (P = 0.0038). When analyzed together, the mean noise levels were 84.9 dBA.

CONCLUSIONS

This systematic review demonstrates that noise exposure in OHNS surgery exceeds safety thresholds. Further research is needed to understand how noise may affect team communication, surgical performance and patient outcomes in OHNS ORs.

The impact of noise in the operating theatre: a review of the evidence

INTRODUCTION

Noise has been recognised to have a negative impact on performance and wellbeing in many settings. Average noise levels have been found to range between 51dB and 79dB in operating theatres. Despite these levels of noise, there is little research investigating their effect on surgical team functioning.

METHODS

A literature review to look at the impact of noise in the operating theatre was performed on MEDLINE, which included the search terms 'noise' OR 'distraction' AND 'technical skill' OR 'Surgical skill' OR 'Operating Room'. Only 10 of 307 articles identified were deemed relevant.

FINDINGS

Eight of ten studies found noise to be detrimental to communication and surgical performance, particularly regarding total errors and time to task completion. No studies found noise to be beneficial. Two studies found case-irrelevant verbal communication to be a frequent form of noise pollution in operating theatres; this is both perceived by surgeons to be distracting and delays patient care.

CONCLUSION

Noise and irrelevant verbal communications were both found to be harmful to surgical performance, surgeon experience and team functioning.

The Selection of Main Surgical Work Factors in Operating Rooms

The main component of error minimization in operating rooms (ORs) is to maintain high reliability of surgical teams. The analysis of adverse events in the OR reveals deficiencies in cognitive and interpersonal skills as the main factors influencing surgeons’ errors. Therefore, research of these additional factors is necessary, besides factors related to surgeons’ clinical knowledge and technical skills. In this paper, the key factors for evaluating activities in surgical operating rooms are identified. Fuzzy analytic hierarchy process is used for identification of key factors. Fifteen key factors are identified for evaluating activities in surgical operating rooms to improve the efficiency of surgical operations. For each group of activities (surgical “capabilities,” operating room characteristics, and non-technical skills), five factors are identified. As the most important, the following factors are obtained: communication, indoor environment standardization, and tool handle design. The aim of the analysis of these key factors is surgeons’ work capability enhancement, rational design of operating rooms, and advancement of operators’ cognitive and interpersonal skills.

"Noise Factory": A qualitative study exploring healthcare providers' perceptions of noise in the intensive care unit

OBJECTIVES

This study aimed to explore healthcare providers' perceptions of noise in the intensive care unit.

DESIGN

A qualitative exploratory study was conducted using group interviews.

SETTING

The setting comprised a total of 15 participants (five physicians and ten registered nurses) working in an 18-bed medical surgical intensive care unit at a teaching hospital in Istanbul, Turkey. Semi-structured questions were formulated and used in focus group interviews, after which the recorded interviews were transcribed by the researchers. Thematic analysis was used to identify significant statements and initial codes.

FINDINGS

Four themes were identified: the meaning of noise, sources of noise, effects of noise and prevention and management of noise. It was found that noise was an inevitable feature of the intensive care unit. The most common sources of noise were human-induced. It was also determined that device-induced noise, such as alarms, did not produce a lot of noise; however, when staff were late in responding, the sound transformed into noise. Furthermore, it was observed that efforts to decrease noise levels taken by staff had only a momentary effect, changing nothing in the long term because the entire team failed to implement any initiatives consistently. The majority of nurses stated that they were now becoming insensitive to the noise due to the constant exposure to device-induced noise.

CONCLUSION

The data obtained from this study showed that especially human-induced noise threatened healthcare providers' cognitive task functions, concentration and job performance, impaired communication and negatively affected patient safety. In addition, it was determined that any precautions taken to reduce noise were not fully effective. A team approach should be used in managing noise in intensive care units with better awareness.

Too noisy to sleep safely?-An observational study of noise levels and distractions during critical phases of pediatric anesthesia

BACKGROUND

Noise and distraction are recognized as contributing factors in critical incidents associated with surgery and anesthesia. In addition, excessive noise exposure can have negative effects on patients and staff members in these environments.

AIMS

We aimed to quantify noise exposure of the anesthesiology team and patients in pediatric operating theaters, comparing them to adult studies, internationally recognized standards, and identifying factors contributing to noise and/or distraction.

METHODS

We measured noise levels during three phases of anesthesia (pre-induction, induction, and postinduction/maintenance) and recorded additional environmental sources of distraction and noise.

RESULTS

We included 49 theater cases. The median and interquartile range (IQR) of mean noise levels during pre-induction, induction, and maintenance were 61 (59.7-63.5), 61.9 (60.6-63.3), and 61.6 (60.4-63.7) dB, respectively, while the median (IQR) of maximal noise levels was 81.4 (77.3-86.8), 83.7 (78.5-87.4), and 86.3 (84.6-90.4), respectively. There was an average of 8.3 people present in the room during induction. In 23 cases, there were additional unnecessary conversations occurring within the room at induction. We noted the maintenance phase was the noisiest phase of anesthesia. We recorded frequent potential sources of distraction during pre-induction and induction, though no significant correlations between these distractions and recorded noise levels.

CONCLUSIONS

We documented noise levels well above recommended levels during all phases of pediatric anesthesia. We highlighted factors with potential to contribute to noise and distraction but found no statistically significant correlation with noise levels.

Noise in Endoscopic Sinus and Skull Base Surgery Operating Rooms

BACKGROUND

Noise in the operating room (OR) contributes to miscommunication among team members and may negatively impact patient outcomes.

OBJECTIVES

This study aimed to quantify noise levels during endoscopic sinus and skull base surgery. The secondary aim was to understand how OR team members perceive noise during endoscopic sinus and skull base surgery.

METHODS

Noise levels were measured using the validated phone application SoundMeter X 10.0.4 (r1865) (Faber Acoustical, Utah, USA) at the ear-level of the surgeon, scrub nurse, circulating nurse, and anesthesiologist. At the end of each surgery, OR team members were asked to complete a six-question questionnaire about noise during that surgery.

RESULTS

One thousand four hundred and two noise measurements were recorded across 353 trials. The loudest mean noise measurement was 84.51 dB and maximum noise measurement was 96.21 dB at the ear-level of the surgeon. Noise was significantly higher at the ear-level of the surgeon and scrub nurse in comparison to the circulating nurse (p = .000) and anesthesiologist (p = .000). Forty percent of questionnaire respondents believed noise was a problem and 38% stated that noise caused communication issues during surgery.

CONCLUSION

Surgeons and scrub nurses have significantly higher noise exposure in comparison to circulating nurses and anesthesiologists during endoscopic sinus and skull base surgery. For these members of the OR team, noise is also identified as problematic and causing issues with communication. Mechanisms to reduce potential noise may be implemented to improve communication and patient outcomes in endoscopic sinus and skull base surgery.

Impact of changing the surgical team for wound closure on surgical site infection: A matched case-control study

BACKGROUND

Wound closure is performed at the end of the procedure, when the attention of the surgical team may decrease due to tiredness. The aim of this study was to assess the influence of changing the surgical team for wound closure on the rate of surgical site infection (SSI).

METHODS

A two-armed observational monocentric matched case-control study was performed in a time series design. During the baseline period, closure of the abdominal wall was performed by the main surgical team. The intervention consisted of closure of the abdominal wall and skin by an independent surgical team. Matching was based on gender, BMI, length of surgery, type of surgery, elective versus emergency surgery and ASA score. The primary outcome was SSI rate 30 days after surgery.

RESULTS

A total of 72 patients in the intervention group were matched with 72 patients in the baseline group. The SSI rate after 30 days in the intervention group was 10% (n = 7) and in the baseline group 21% (n = 15) (p = 0.064). Redo-Surgery as result of infection (e.g. opening the wound, drainage or reoperation) was significantly higher in the baseline group (19.4% vs 2.7%; p = 0.014). Mortality, length of stay, rehospitalisation and complication rates 30 days after surgery did not differ significantly.

CONCLUSION

Changing the surgical team for wound closure did not reduce the overall rate of SSI, but the rate of redo-surgery as a result of SSI. Despite being potentially beneficial, organizational factors are a main limiting factor of changing the surgical team for the wound closure.

TRIAL REGISTRATION

Clinicaltrial.gov NCT04503642.

Impact of Acoustic and Interactive Disruptive Factors during Robot-Assisted Surgery-A Virtual Surgical Training Model

The use of virtual reality trainers for teaching minimally invasive surgical techniques has been established for a long time in conventional laparoscopy as well as robotic surgery. The aim of the present study was to evaluate the impact of reproducible disruptive factors on the surgeon's work. In a cross-sectional investigation, surgeons were tested with regard to the impact of different disruptive factors when doing exercises on a robotic-surgery simulator (Mimic Flex VR^TM). Additionally, we collected data about the participants' professional experience, gender, age, expertise in playing an instrument, and expertise in playing video games. The data were collected during DRUS 2019 (Symposium of the German Society for Robot-assisted Urology). Forty-two surgeons attending DRUS 2019 were asked to participate in a virtual robotic stress training unit. The surgeons worked in various specialties (visceral surgery, gynecology, and urology) and had different levels of expertise. The time taken to complete the exercise (TTCE), the final score (FSC), and blood loss (BL) were measured. In the basic exercise with an interactive disruption, TTCE was significantly longer (p < 0.01) and FSC significantly lower (p < 0.05). No significant difference in TTCE, FSC, or BL was noted in the advanced exercise with acoustic disruption. Performance during disruption was not dependent on the level of surgical experience, gender, age, expertise in playing an instrument, or playing video games. A positive correlation was registered between self-estimation and surgical experience. Interactive disruptions have a greater impact on the performance of a surgeon than acoustic ones. Disruption affects the performance of experienced as well as inexperienced surgeons. Disruption in daily surgery should be evaluated and minimized in the interest of the patient's safety.

Noise patterns in visceral surgical procedures: Analysis of second-by-second dBA data of 599 procedures over the course of one year

The objective of this study is to analyze noise patterns during 599 visceral surgical procedures. Considering work-safety regulations, we will identify immanent noise patterns during major visceral surgeries. Increased levels of noise are known to have negative health impacts. Based on a very fine-grained data collection over a year, this study will introduce a new procedure for visual representation of intra-surgery noise progression and pave new paths for future research on noise reduction in visceral surgery. Digital decibel sound-level meters were used to record the total noise in three operating theatres in one-second cycles over a year. These data were matched to archival data on surgery characteristics. Because surgeries inherently vary in length, we developed a new procedure to normalize surgery times to run cross-surgery comparisons. Based on this procedure, dBA values were adjusted to each normalized time point. Noise-level patterns are presented for surgeries contingent on important surgery characteristics: 16 different surgery types, operation method, day/night time point and operation complexity (complexity levels 1–3). This serves to cover a wide spectrum of day-to-day surgeries. The noise patterns reveal significant sound level differences of about 1 dBA, with the most-common noise level being spread between 55 and 60 dBA. This indicates a sound situation in many of the surgeries studied likely to cause stress in patients and staff. Absolute and relative risks of meeting or exceeding 60 dBA differ considerably across operation types. In conclusion, the study reveals that maximum noise levels of 55 dBA are frequently exceeded during visceral surgical procedures. Especially complex surgeries show, on average, a higher noise exposure. Our findings warrant active noise management for visceral surgery to reduce potential negative impacts of noise on surgical performance and outcome.

The impact of a wireless audio system on communication in robotic-assisted laparoscopic surgery: A prospective controlled trial

Background

Robotic surgery presents a challenge to effective teamwork and communication in the operating theatre (OR). Our objective was to evaluate the effect of using a wireless audio headset device on communication, efficiency and patient outcome in robotic surgery.

Methods and findings

A prospective controlled trial of team members participating in gynecologic and urologic robotic procedures between January and March 2015. In the first phase, all surgeries were performed without headsets (control), followed by the intervention phase where all team members used the wireless headsets. Noise levels were measured during both phases. After each case, all team members evaluated the quality of communication, performance, teamwork and mental load using a validated 14-point questionnaire graded on a 1–10 scale. Higher overall scores indicated better communication and efficiency. Clinical and surgical data of all patients in the study were retrieved, analyzed and correlated with the survey results. The study included 137 procedures, yielding 843 questionnaires with an overall response rate of 89% (843/943). Self-reported communication quality was better in cases where headsets were used (113.0 ± 1.6 vs. 101.4 ± 1.6; p < .001). Use of headsets reduced the percentage of time with a noise level above 70 dB at the console (8.2% ± 0.6 vs. 5.3% ± 0.6, p < .001), but had no significant effect on length of surgery nor postoperative complications.

Conclusions

The use of wireless headset devices improved quality of communication between team members and reduced the peak noise level in the robotic OR.

The influence of music on the surgical task performance: A systematic review

INTRODUCTION

Music is commonly played in operating theatres. Music was shown to diminish stress of the surgical team along with reducing the patient's anxiety before surgery. On the other hand, it has been revealed that music might give rise to negative effects of divided attention causing distraction in surgical routines. Therefore, we aimed to systematically review the effect of music on the surgeon's task performance.

METHODS

A systematic review was performed in compliance with the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) and AMSTAR (Assessing the methodological quality of systematic reviews) guidelines. A literature search using PubMed/Medline, ScienceDirect and Google Scholar, was performed by means of the search terms: "music and operating theatre", as well as "music and surgery". The search was limited to citations in English from year 2009-2018. Search items were considered from the nature of the articles, date of publication, forum of publication, aims and main findings in relation to use of music in operating theatres. Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria were applied. Studies were included based on predetermined inclusion criteria where after the papers' quality assessments and evidence grading were completed by two independent reviewers. The protocol was registered with the PROSPERO register of systematic reviews.

RESULTS

Out of 18 studies that formed the base for evidence evaluations, 6 studies were assessed as having high quality and 8 studies of moderate quality. Five studies, provided both strong and moderate scientific evidence for a positive effect of music on surgeon's task performance. In contrast, strong scientific evidence for a negative effect of music on surgeon's task performance also was revealed in 2 high-quality studies. Nevertheless, the positive effect of music on the surgical task performance was significantly higher when compared to its negative effect (p < 0.0001).

CONCLUSION

Certain music elements affect the surgical task performance in a positive or negative way. The total and significant outcome of the present study was that the positive effect of music on surgeon's task performance, overrides its negative effect. Classic music when played with a low to medium volume can improve the surgical task performance by increasing both accuracy and speed. The distracting effect of music should also be put in consideration when playing a loud or high-beat type of music in the operating theatres.

Environmental noise levels in hospital settings: A rapid review of measurement techniques and implementation in hospital settings

BACKGROUND

Hospitals provide treatment to improve patient health and well-being but the characteristics of the care environment receive little attention. Excessive noise at night has a negative impact on in-patient health through disturbed sleep. To address this hospital staff must measure night-time environmental noise levels. Therefore, an understanding of environmental noise measurement techniques is required. In this review, we aim to 1) provide a technical overview of factors to consider when measuring environmental noise in hospital settings; 2) conduct a rapid review on the equipment and approaches used to objectively measured noise in hospitals and identify methodological limitations.

DESIGN

: A rapid review of original research articles, from three databases, published since 2008. Studies were included if noise levels were objectively measured in a hospital setting where patients were receiving treatment.

RESULTS

1429 articles were identified with 76 included in the review. There was significant variability in the approaches used to measure environmental noise in hospitals. Only 14.5% of studies contained sufficient information to support replication of the measurement process. Most studies measured noise levels using a sound level meter positioned closed to a patient's bed area in an intensive care unit.

CONCLUSION

: Unwanted environmental noise in hospital setting impacts negatively on patient and staff health and well-being. However, this literature review found that the approaches used to objectively measure noise level in hospital settings have been inconsistent and poorly reported. Recommendations on best-practice methods to measure noise levels in hospital environments are provided.

The Impact of a Wireless Audio System on Communication in Robotic-Assisted Laparoscopic Surgery: A Prospective Controlled Trial.. [DOI: 10.1101/701078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background

Robotic surgery presents a challenge to effective teamwork and communication in the operating theatre (OR). Our objective was to evaluate the effect of using a wireless audio headset device on communication, efficiency and patient outcome in robotic surgery.

Methods and findings

A prospective controlled trial of team members participating in gynecologic and urologic robotic procedures between January and March 2015. In the first phase, all surgeries were performed without headsets (control), followed by the intervention phase where all team members used the wireless headsets. Noise levels were measured during both phases. After each case, all team members evaluated the quality of communication, performance, teamwork and mental load using a validated 14-point questionnaire graded on a 1-10 scale. Higher overall scores indicated better communication and efficiency. Clinical and surgical data of all patients in the study were retrieved, analyzed and correlated with the survey results.

The study included 137 procedures, yielding 843 questionnaires with an overall response rate of 89% (843/943). Self-reported communication quality was better in cases where headsets were used (113.0 ± 1.6 vs. 101.4 ± 1.6; p < .001). Use of headsets reduced the percentage of time with a noise level above 70 dB at the console (8.2% ± 0.6 vs. 5.3% ± 0.6, p < .001), but had no significant effect on length of surgery nor postoperative complications.

Conclusions

The use of wireless headset devices improved quality of communication between team members and reduced the peak noise level in the robotic OR.

Improvement in staff behavior during surgical procedures to prevent post-operative complications (ARIBO2): study protocol for a cluster randomised trial

BACKGROUND

Inappropriate staff behaviour during surgical procedures may disrupt the surgical performance and compromise patient safety. We developed an innovative monitoring and feedback system combined with an adaptive approach to optimise staff behaviour intraoperatively and prevent post-operative complications (POC) in orthopaedic surgery.

METHODS/DESIGN

This protocol describes a parallel-group, cluster randomised, controlled trial with orthopaedic centre as the unit of randomisation. The intervention period will last 6 months and will be based on the monitoring of two surrogates of staff behaviour: the frequency of doors opening and the level of noise. Both will be collected from incision to wound closure, using wireless sensors and sonometers, and recorded and analysed on a dedicated platform (Livepulse®). Staff from centres randomised to the intervention arm will be informed in real time on their own data through an interactive dashboard available in each operating room (OR), and a posteriori for hip and knee replacement POC. Aggregated data from all centres will also be displayed for benchmarking. A lean method will be applied in each centre by a local multidisciplinary team to analyse baseline situations, determine the target condition, analyse the root cause(s), and take countermeasures. The education and awareness of participants on the impact of their behaviour on patient safety will assist the quality improvement process. The control centres will be blinded to monitoring data and quality improvement approaches. The primary outcome will be any POC occurring during the 30 days post operation. We will evaluate this outcome using local and national routinely collected data from hospital discharge and disease databases. Thirty orthopaedic centres will be randomised for a total of 9945 hip and knee replacement surgical procedures.

DISCUSSION

The field of human factors and behaviour in the OR seems to offer potential room for improvement. An intervention providing goal-setting, monitoring, feedback and action planning may reduce the traffic flow and interruptions/distractions of the surgical team during procedures, preventing subsequent POCs. The results of this trial will provide important data on the impact of OR staff behaviour on patient safety, and promote best practice during surgical procedures.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03158181 .

Diagnostic error increases mortality and length of hospital stay in patients presenting through the emergency room

BACKGROUND

Diagnostic errors occur frequently, especially in the emergency room. Estimates about the consequences of diagnostic error vary widely and little is known about the factors predicting error. Our objectives thus was to determine the rate of discrepancy between diagnoses at hospital admission and discharge in patients presenting through the emergency room, the discrepancies' consequences, and factors predicting them.

METHODS

Prospective observational clinical study combined with a survey in a University-affiliated tertiary care hospital. Patients' hospital discharge diagnosis was compared with the diagnosis at hospital admittance through the emergency room and classified as similar or discrepant according to a predefined scheme by two independent expert raters. Generalized linear mixed-effects models were used to estimate the effect of diagnostic discrepancy on mortality and length of hospital stay and to determine whether characteristics of patients, diagnosing physicians, and context predicted diagnostic discrepancy.

RESULTS

755 consecutive patients (322 [42.7%] female; mean age 65.14 years) were included. The discharge diagnosis differed substantially from the admittance diagnosis in 12.3% of cases. Diagnostic discrepancy was associated with a longer hospital stay (mean 10.29 vs. 6.90 days; Cohen's d 0.47; 95% confidence interval 0.26 to 0.70; P = 0.002) and increased patient mortality (8 (8.60%) vs. 25(3.78%); OR 2.40; 95% CI 1.05 to 5.5 P = 0.038). A factor available at admittance that predicted diagnostic discrepancy was the diagnosing physician's assessment that the patient presented atypically for the diagnosis assigned (OR 3.04; 95% CI 1.33-6.96; P = 0.009).

CONCLUSIONS

Diagnostic discrepancies are a relevant healthcare problem in patients admitted through the emergency room because they occur in every ninth patient and are associated with increased in-hospital mortality. Discrepancies are not readily predictable by fixed patient or physician characteristics; attention should focus on context.

TRIAL REGISTRATION

https://bmjopen.bmj.com/content/6/5/e011585.

Do theatre staff use face masks in accordance with the manufacturers' guidelines of use?

Aim

Surgical face masks are worn by theatre staff to protect the surgical site from airborne contamination and the wearer from bodily fluid splash. This observational/audit aimed to assess whether theatre staff wear masks in accordance with manufacturers'/Centers for Disease Control and Prevention (CDC) guidelines of use.

Methods

A total of 1034 surgically scrubbed staff were assessed on their technique of applying surgical face masks, compared to the CDC guidelines as manufacturers' guidelines were not available as per Health and Safety Executive guidelines.

Results

Only 18% of surgically scrubbed staff fully complied with the CDC guidelines on the application of a face mask. Compliance was worst in urology, ophthalmology and vascular surgeons, whereas orthopaedic and plastic surgeons were the most compliant.

Discussion

Compliance with CDC face mask guidelines may have an impact on surgical site infections (SSI) and protection of staff from body fluid splash, but most staff do not comply with these guidelines.

Conclusions

Most operating theatre staff do not apply a face mask using correct technique, outlined in CDC guidance, which may increase SSI rates. Staff are not aware of existing guidelines for donning a mask.

Modifications of Surgical Suction Tip Geometry for Flow Optimisation: Influence on Suction-Induced Noise Pollution

Introduction

Suction devices for clearing the surgical field are among the most commonly used tools of every surgeon because a better view of the surgical field is essential. Forced suction may produce disturbingly loud noise, which acts as a nonnegligible stressor. Especially, in emergency situations with heavy bleeding, this loud noise has been described as an impeding factor in the medical decision-making process. In addition, there are reports of inner ear damage in patients due to suction noises during operations in the head area. These problems have not been solved yet. The purpose of this study was to analyse flow-dependent suction noise effects of different surgical suction tips. Furthermore, we developed design improvements to these devices.

Methods

We compared five different geometries of suction tips using an in vitro standardised setup. Two commercially available standard suction tips were compared to three adapted new devices regarding their flow-dependent (10–2000 mL/min) noise emission (dB, weighting filter (A), distance 10 cm) and acoustic quality of resulting noises (Hamilton fast Fourier analysis) during active suction at the liquid-air boundary. Noise maps at different flow rates were created for all five suction devices, and the proportion of extracted air was measured. The geometries of the three custom-made suction tips (new models 1, 2, and 3) were designed considering the insights after determining the key characteristics of the two standard suction models.

Results

The geometry of a suction device tip has significant impact on its noise emission. For the standard models, the frequency spectrum at higher flow rates significantly changes to high-frequency noise patterns (>3 kHz). A number of small side holes designed to prevent tissue adhesion lead to increased levels of high-frequency noise. Due to modifications of the tip geometry in our new models, we are able to achieve a highly significant reduction of noise level at low flow rates (new model 2 vs. standard models p < 0.001) and also the acoustic quality improved. Additionally, we attain a highly significant reduction of secondary air intake (new model 2 vs. the other models p < 0.001).

Conclusion

Improving flow-relevant features of the geometry of suction heads is a suitable way to reduce noise emissions. Optimized suction tips are significantly quieter. This may help us to reduce noise-induced hearing damage in patients as well as stress of medical staff during surgery and should lead to quieter operation theatres overall. Furthermore, the turbulence reduction and reduced secondary air intake during the suction process are expected to result in protective effects on the collected blood and thus could improve the quality of autologous blood retransfusions. We are on the way to evaluate potential benefits.

How noisy are total knee and hip replacements?

Orthopaedic theatre can be noisy. Fifty percent of orthopaedic theatre staff have features of noise-induced hearing loss (NIHL). In this study, decibel (dB) levels were recorded in 17 total knee replacements (TKRs) and 11 total hip replacements (THRs). Noise levels reached 105.6dB(A) using a hammer and 97.9dB(A) with an oscillating saw. Exposure to levels above 90dB (which occurred in every case) even for short time periods is proven to cause irreversible loss of hearing. Tools used in orthopaedic theatre produce impulse noises that can cause NIHL. Further investigation is required.

Research on Key Indicators in Modern Surgical Practice Assessment: Ergonomic Approach

It is undeniable that fundamental requirements in surgery refer to the adequate use of medical knowledge (eg, clinical knowledge and technical skills). However, this knowledge and skills of surgeons should be supplemented with synergetic research of capabilities of surgeons, operating rooms (ORs), and nontechnical skills. In this article, by using expert research, we presented 15 key indicators in surgical practice assessment. Communication efficiency in the OR has been ranked as the first and most important among indicators using the fuzzy analytic hierarchy process method. Within the analysis of this indicator, we have shown a new method that provided us with the results describing the extent of communication, the correlation in the communication system, surgeon workload uniformity, and isolation of individual surgeons in the OR. The goal of this research is aimed at the increase of operator efficiency in the OR. It is necessary that results of this kind of research find their practical use and become an obligatory element in the construction of new ORs as well as reconstruction of old ORs.

[Hazard assessment and occupational safety measures in surgery : Relevant knowledge on occupational medicine]

Surgeons routinely work in an environment with occupational risks and hazards about which they are often uninformed. Based on the currently available scientific literature this review article describes the various hazards in the operating theater and their effects on personnel, particularly from the surgical perspective. A further aim of this article is to describe the occupational safety measures to reduce the burdens and to maintain the long-term health of personnel. Ultimately, surgeons should be equipped with the necessary knowledge for implementing hazard assessments according to the German Occupational Health and Safety Act. Surgeons are exposed to increased risks and hazards by working in awkward positions with a high risk for musculoskeletal pain and injuries. They are also commonly exposed to inhalational anesthetics, surgical smoke, radiation, noise and infectious agents. Furthermore, the mental and emotional stress associated with these activities is also high. Meaningful occupational safety measures for reduction of burdens are from a technical aspect the installation of effective air extraction systems, measures to reduce exposure to radiation and noise and the use of safer instruments to prevent needle stick injuries. Furthermore, individual occupational safety measures, such as the use of personal protective equipment (e.g. radiation protective clothing and double gloves) must be observed. The consistent implementation and also adherence to these described occupational safety measures and regulations can reduce the burden on operating theater personnel and contribute to maintaining health. Furthermore, periodic preventive healthcare controls and health checks by the company medical officer and individually initiated additional prevention measures can be a sensible augmentation to these safety measures.

Novel approaches to surgical site infections: what recommendations can be made?

INTRODUCTION

Surgical site infections (SSI) are one of the most frequent healthcare-associated infections worldwide, representing a substantial burden on the healthcare system and the individual patient. Various risk factors for SSI have been identified, which can be separated into patient-related, procedure-related and other risk factors. Areas covered: Other risk factors relevant for SSI are the season in which surgery is performed, the volume of surgeries in a department, the working atmosphere in the operating room and the indications for surgery. Overall, the risk of SSI is higher during summertime. Higher-volume departments appear to be protective against SSI as does a calm working atmosphere. The frequency of certain types of surgery differs greatly among European countries. The decision to perform surgery appears to be dependent on the patient's condition as well as the healthcare system and financial incentives. Expert commentary: When possible, elective surgery should not be executed during summertime but during cooler times of year. Departments with a high volume of surgical procedures should be given preference. The establishment of a calm working atmosphere is beneficial to a surgeon's performance and can reduce SSI rates. The indications for performing surgery should be carefully reevaluated whenever possible.