Environmental sustainability and gynaecological surgery: Which factors influence behaviour? An interview study

OBJECTIVE

To assess the various factors that influence environmentally sustainable behaviour in gynaecological surgery and examine the differences between gynaecologists and residents.

DESIGN

An interview study.

SETTING

Academic and non-academic hospitals in the Netherlands.

POPULATION

Gynaecologists (n = 10) and residents (n = 6).

METHODS

Thematic analysis of semi-structured interviews to determine the various factors that influence environmentally sustainable behaviour in gynaecological surgery and to examine the differences between gynaecologists and residents. By using the Desmond framework and the COM-B BCW, both organisational and individual factors related to behaviour were considered.

MAIN OUTCOME MEASURES

Factors that influence environmentally sustainable behaviour.

RESULTS

Awareness is increasing but practical knowledge is insufficient. It is crucial to integrate education on the environmental impact of everyday decisions for residents and gynaecologists. Gynaecologists make their own choices but residents' autonomy is limited. There is the necessity to provide environmentally sustainable surgical equipment without compromising other standards. There is a need for a societal change that encourages safe and open communication about environmental sustainability. To transition to environmentally sustainable practices, leadership, time, collaboration with the industry and supportive regulatory changes are essential.

CONCLUSION

This study lays the groundwork for promoting more environmentally sustainable behaviour in gynaecological surgery. The key recommendations, addressing hospital regulations, leadership, policy revisions, collaboration with the industry, guideline development and education, offer practical steps towards a more sustainable healthcare system. Encouraging environmentally sustainable practices should be embraced to enhance the well-being of both our planet and our population, driving us closer to a more environmentally sustainable future in healthcare.

The Incidence and Nature of Adverse Medical Device Events in Dutch Hospitals: A Retrospective Patient Record Review Study

OBJECTIVES

Despite widespread use of medical devices and their increasing complexity, their contribution to unintended injury caused by healthcare (adverse events, AEs) remains relatively understudied. The aim of this study was to gain insight in the incidence and types of AEs involving medical devices (AMDEs).

METHODS

Data from two patient record studies for the identification of AEs were used. Identification of AMDEs was part of these studies. Patient records of 6894 admissions of a random sample of 20 hospitals in 2011/2012 and 19 hospitals in 2015/2016 were reviewed for AMDEs by trained nurses and physicians.

RESULTS

In 98.7% of the admissions, a medical device was used. Adverse events involving medical devices were present in 2.8% of the admissions, with 24% of the AMDEs being potentially preventable. Of all AEs, in 40%, medical devices were involved. Of all potentially preventable AEs, in 44%, medical devices were involved. Implants were most often involved in potentially preventable AMDEs.

CONCLUSIONS

Medical devices are substantially involved in potentially preventable AEs in hospitals. Research into AMDEs is of great importance because of the increasing use and complexity of medical devices. Based on patient records, most improvements could be made for placement of implants and prevention of infections related to medical devices. Safety and safe use of medical devices should be a subject of attention and further research.

Proficient until proven unproficient? Exploring attitudes and perceptions of medical specialists on proficiency, proficiency requirements and proficiency tests for electrosurgery

BACKGROUND

The correct and safe use of electrosurgery requires medical specialists to be proficient. Minimum proficiency requirements and proficiency tests are a manner to structurally assure proficiency. The objective of this study is to explore attitudes and perceptions of medical specialists on proficiency, proficiency requirements and proficiency tests for the safe use of electrosurgery.

METHODS

A qualitative study among medical specialists using semi-structured interviews.

RESULTS

The participants recognized that the use of electrosurgery poses risks to the safety of patients and perioperative staff. According to some participants, increased awareness on the risks of electrosurgery is required. Most medical specialists however thought that proficiency of users of electrosurgery is sufficiently assured. Medical specialists stated to support proficiency requirements when they are endorsed by their scientific association. Proficiency tests encountered much resistance. Medical specialists argued that electrosurgery should not be tested as a single device but should be embedded in a larger entity, for example in a broader course or proficiency test.

CONCLUSIONS

When assuring proficiency of users of electrosurgery, the positive attitude towards proficiency requirements and the more negative attitude towards proficiency tests should be taken into account.

The value of a 1-day multidisciplinary robot surgery training for novice robot surgeons

INTRODUCTION

To fulfil the need for a basic level of competence in robotic surgery (Brinkman et al., Surg Endosc Other Interv Tech 31(1):281-287, 2017; Dutch Health inspectorate (Inspectie voor de gezondheidszorg), Insufficient carefulness at the introduction of surgical robots (in Dutch: Onvoldoende zorgvuldigheid bij introductie van operatierobots), Igz, Utrecht, 2010), the NIVEL (Netherlands Institute for Healthcare Research) developed the 'Basic proficiency requirements for the safe use of robotic surgery' (BPR). Based on the BPR a 1-day robotic surgery training was organised to answer the following research questions: (1) Are novice robot surgeons able to accurately self-assess their knowledge and dexterity skills? (2) Is it possible to include the teaching of all BPRs in a 1-day training?

MATERIALS AND METHODS

Based on the BPR, a robot surgery course was developed for residents and specialists (surgery, gynaecology and urology). In preparation, the participants completed an online e-module. The 1-day training consisted of a practical part on robot set-up, a theoretical section, and hands-on exercises on virtual reality robot simulators. Multiple online questionnaire was filled out by the participants at the end of the training to evaluate the perceived educational value of the course and to self-assess the degree to which BPRs were reached.

RESULTS

20 participants completed the training during the conference of the Dutch Association for Endoscopic Surgery (NVEC) in 2017. Participants indicated nearly all competency requirements were mastered at the end of the training. The competency requirements not mastered were, however, critical requirements for the safe use of the surgical robot. Skill simulation results show a majority of participants are unable to reach a proficient simulation score in basic skill simulation exercises.

CONCLUSION

Results show novice robot surgeons are too positive in the self-assessment of their own dexterity skills after a 1-day training. Self-assessment revealed uncertainty of the obtained knowledge level on requirements for the safe use of the surgical robot. Basic courses on robotic training should inform trainees about their results to enhance learning and inform them of their competence levels.

Cerebral metabolism and electrocortical activity in the chronically hyperglycemic fetal lamb

Previous studies in the fetal lamb have demonstrated that hyperglycemia stimulates the fetal metabolic rate. The present study examined the effects of chronic fetal hyperglycemia on fetal cerebral metabolic rate and electrocortical activity. Nine chronically instrumented fetal lambs had measurements of cerebral blood flow and cerebral uptake/excretion of oxygen, glucose, lactate, and beta-hydroxybutyrate taken before and during a 48-h fetal glucose infusion. Electrocortical activity was also recorded. The fetal arterial glucose concentration was 19.8 +/- 2.0 mg/dl before glucose infusion and 48 +/- 4.5 to 54.6 +/- 6.6 mg/dl during the infusion period. Cerebral blood flow and cerebral glucose and oxygen uptake increased by 219, 209, and 171%, respectively, by the end of the infusion period. There was a linear relationship between the fetal arterial glucose concentration and cerebral blood flow and cerebral glucose and oxygen uptakes. The electroencephalogram showed significant slowing with increases in the cerebral metabolic rate. These findings suggest that fetal hyperglycemia is associated with significant metabolic stimulation of the brain.

Regulation of cerebral glucose metabolism in normal and polycythemic newborn lambs

In contrast to previous investigations, a recent study of polycythemic lambs suggested that cerebral glucose delivery (concentration x blood flow), not arterial glucose concentration, determined cerebral glucose uptake. In the present study, the independent effects of arterial glucose concentration and delivery on cerebral glucose uptake were examined in two groups of chronically catheterized newborn lambs (control and polycythemic). Arterial glucose concentration was varied by an infusion of insulin. CBF was reduced in one group of lambs (polycythemic) by increasing the hematocrit. At all arterial glucose concentrations, the cerebral glucose delivery of the polycythemic group was 59.6% of the control group. At arterial glucose concentrations of greater than 1.6 mmol/L, cerebral glucose uptake was constant and similar in both groups. At arterial glucose concentrations of less than or equal to 1.6 mmol/L, cerebral glucose uptake was unchanged in the control group, but was significantly decreased in the polycythemic group. In contrast, the cerebral glucose uptake was similar in both groups over a broad range of cerebral glucose delivery values. At cerebral glucose delivery values less than or equal to 83 mumols/min/100 g, there was a significant decrease in cerebral glucose uptake in both groups. During periods of low cerebral glucose delivery and uptake, cerebral oxygen uptake fell in the control group but remained unchanged in the polycythemic group. Maintenance of cerebral oxygen uptake in the polycythemic group was associated with an increased extraction and uptake of lactate and beta-hydroxybutyrate. We conclude that cerebral glucose delivery, not arterial glucose concentration alone, determines cerebral glucose uptake.

Insulin-induced alterations in amino acid metabolism in the fetal lamb

To investigate the role of insulin in modulation of fetal amino acid metabolism, insulin infusions were performed in 10 chronically-catheterized fetal lambs. Fetal insulin infusion caused a dose related fall in the arterial blood concentrations of 13 of 15 amino acids studied as well as a 15-25% decrease in total amino acid concentration. Fetal lambs exhibited a biphasic response of umbilical total amino acid uptake when compared to fetal blood insulin concentration, i.e., at achieved fetal insulin concentrations less than 100 microU/ml, umbilical uptake of 9 specific amino acids as well as summed amino acid uptake from the umbilical circulation were depressed, but at insulin concentrations of 100-350 microU/ml, amino acid uptakes were similar to or above control values. Insulin infusion also caused a drastic diminution in the rate of fetal urea excretion. These findings suggest that insulin acts in the fetus to depress amino acid catabolism, thus altering amino acid extraction and uptake. Depressed protein catabolism with or without enhanced amino acid uptake would have the theoretical effect of stimulation of net protein synthesis with a shift toward use of nonprotein substrates for energy purposes.

Intrauterine growth retardation after long-term maternal salicylate administration in the rabbit

The effects of chronic maternal salicylism on fetal growth were studied in chronically catheterized pregnant rabbits. Graded intravenous infusions of sodium salicylate were given continuously between days 22 and 29 of gestation. Maternal plasma salicylate concentrations (mean +/- SD) of 12.0 +/- 1.6 mg/dl (low-dose group) or 24.1 +/- 5.3 mg/dl (high-dose group) were achieved. Control rabbits were infused with saline solution. Pups were delivered by hysterotomy on day 29. Fetal/maternal salicylate concentration ratios were near unity for both infusion groups. There were significant dose-related reductions (mean +/- SD) in fetal weight (control, 39.7 +/- 6.7 gm; low-dose group, 34.4 +/- 6.4 gm; high-dose group, 22.2 +/- 7.1 gm; p less than 0.001) and in crown-rump length (control, 9.7 +/- 0.45 cm; low-dose group, 9.1 +/- 0.68 cm; high-dose group, 7.7 +/- 0.86 cm; p less than 0.001). There was a significant reduction in fetal brain weight only in the high-dose group, and brain weight/fetal weight ratios were increased, suggesting relative sparing of brain growth. Liver weight was significantly reduced in both low- and high-dose groups. In contrast to results in previous animal studies, standardized intravenous maternal salicylate administration in rabbits induced a reproducible and dose-dependent asymmetrical fetal growth retardation.

Effects of fetal insulin secretory deficiency on metabolism in fetal lamb

Fetal insulin secretion may be of importance in determining both fetal metabolic rate and glucose homeostasis in the resting state. To investigate this question, streptozocin (STZ) was injected into 10 late-gestation fetal lambs, and the effects of STZ on fetal pancreatic insulin storage and secretion, fetal metabolic rate, and umbilical glucose uptake were then studied. Fetal STZ injection caused a relative fetal hyperglycemia by 24 h after injection. Fetal hyperglycemia reached a maximum by 72 h and persisted for at least 10 days after injection. Neonates delivered after fetal injection were frankly diabetic. Fetal STZ injection was associated with complete suppression of both glucose- and tolbutamide-stimulated insulin release, although no changes in peripheral insulin concentration were observed when compared with controls. Fetal pancreatic insulin content was only 13% of that expected on the basis of gestational age. In a subgroup of 7 STZ-treated fetal lambs, fetal hyperglycemia was related to decrements in umbilical venoarterial difference of glucose, umbilical glucose uptake, and glucose-O2 quotient. No changes in maternal glucose homeostasis or in fetal O2 consumption were noted. The data suggest that deficient fetal insulin storage and secretion are associated with a decrement in exogenous fetal glucose entry but not in fetal metabolic rate. Whether the observed fetal changes relate to enhanced endogenous fetal glucose production with a passive decrease in maternofetal glucose transfer or are simply due to a decrease in overall fetal glucose utilization is not known. It is speculated that a quantitative decrease in pancreatic insulin secretion is responsible for the observed changes.

The effects of chronic fetal hyperglycemia on substrate uptake by the ovine fetus and conceptus

Hyperglycemia in fetal sheep has been shown to increase the fetal metabolic rate. Fetal venous glucose infusion was performed in eight late gestation, chronically catheterized fetal lambs to assess any changes in substrate uptake by the ovine uterus and conceptus. Fetal glucose infusion (11.9 +/- 0.6 mg glucose X kg-1 X min-1) caused a stable increase in fetal plasma glucose concentration approximately 3-fold above baseline. The fetal glucose entry rate increased from 6.6 +/- 0.7 to 9.3 +/- 0.6 mg X kg-1 X min-1 by day 3 of infusion (p less than 0.01) despite a net umbilical glucose excretion during the period of fetal hyperglycemia. Due to a concomitant increase in fetal oxygen consumption, no change in fetal glucose/O2 quotient was observed. A significant relationship was noted (p less than 0.02) between the fetal glucose entry rate and the rate of fetal oxygen consumption. Fetal glucose infusion caused a decrease in uterine glucose uptake as well. No changes were observed in calculated net placental glucose uptake although the relative fetal contribution increased from net placental exit to fetus to a placental uptake amounting to 20.8 +/- 5.8% of the total placental glucose uptake (p less than 0.01). Although no changes in fetal lactate concentration occurred, both maternal and fetal lactate entry rates increased, the magnitude of increase being significantly related to fetal glucose concentration. Both maternal and fetal insulin concentrations rose during the period of fetal hyperglycemia and were related to the respective increases of maternal or fetal substrate uptakes but not to fetal oxygen consumption.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of chronic fetal hyperglycemia upon oxygen consumption in the ovine uterus and conceptus

Hyperglycemia has been shown to induce arterial hypoxemia in the chronically catheterized fetal sheep. To investigate the mechanism behind this glucose-induced hypoxemia, eight pregnant ewes and their fetuses were studied. Fetal glucose infusion (11.9 +/- 0.6 mg glucose/kg per min) was associated with a doubling of the fetal plasma glucose concentration with concomitant elevation of the umbilical vein-distal arterial O2 content difference by 24 h of infusion (P less than 0.01). Calculated fetal O2 consumption increased from 8.1 +/- 0.4 ml/kg per min in the control period to a maximum value of 10.6 +/- 0.3 ml/kg per min by third infusion day (P less than 0.01), which is an increase of approximately 30%. The degree of stimulation of fetal O2 consumption was related to the degree of fetal hyperglycemia but not to the degree of fetal hyperinsulinemia. The increase in fetal O2 consumption was accompanied by a significant increase in fetal O2 extraction with no change in either fetal O2 delivery or fetal blood O2 affinity. In addition, fetal hypercapnea with a mild fetal respiratory acidosis was induced by fetal hyperglycemia. The increase in fetal arterial PCO2 was linearly related (P less than 0.001) to the magnitude of increase in fetal O2 consumption. These studies suggest that chronic fetal hyperglycemia induces a state of accelerated fetal oxidative metabolism and may be important in explaining the etiology behind certain unusual findings in human infants of diabetic mothers.

Inhibition of glucose-induced insulin secretion by indomethacin and sodium salicylate in the fetal lamb

The modulation of fetal insulin secretion by prostaglandins was studied with the aid of the prostaglandin synthesis inhibitors indomethacin and sodium salicylate in 10 chronically catheterized fetal lambs. Glucose-induced fetal insulin secretion was inhibited within 60 minutes by preinjection of either indomethacin or sodium salicylate in the fetal lambs. In the sodium salicylate experiments a significant (p less than 0.01) dose-related response (degree of insulin suppression) was noted between doses of 100 to 350 mg/kg of fetal weight. In a selected group of sodium salicylate injections prostaglandin levels were found to fall to 58% of control by 2 hours after injection. Five neonatal lambs exposed to a similar regimen were noted to have an exaggerated insulin response to glucose infusion when compared to fetal lambs. However, indomethacin or sodium salicylate pretreatment resulted in no suppression of glucose-induced insulin release. This finding may be of importance in explaining the observation of an increased incidence of fetal growth retardation after long-term exposure to salicylates in humans and in animal models.