A threshold of 100 or more colony-forming units on the anesthesia machine predicts bacterial pathogen detection: a retrospective laboratory-based analysis

PURPOSE

Preventing the spread of pathogens in the anesthesia work area reduces surgical site infections. Improved cleaning reduces the percentage of anesthesia machine samples with ≥ 100 colony-forming units (CFU) per surface area sampled. Targeting a threshold of < 100 CFU when cleaning anesthesia machines may be associated with a lower prevalence of bacterial pathogens. We hypothesized that anesthesia work area reservoir samples returning < 100 CFU would have a low (< 5%) prevalence of pathogens.

METHODS

In this retrospective cohort study of bacterial count data from nine hospitals, obtained between 2017 and 2022, anesthesia attending and assistants' hands, patient skin sites (nares, axilla, and groin), and anesthesia machine (adjustable pressure-limiting valve and agent dials) reservoirs were sampled at case start and at case end. The patient intravenous stopcock set was sampled at case end. The isolation of ≥ 1 CFU of Staphylococcus aureus, methicillin-resistant Staphylococcus aureus, Enterococcus, vancomycin-resistant Enterococcus, gram-negative (i.e., Klebsiella, Acinetobacter, Pseudomonas, and Enterobacter spp.) or coagulase-negative Staphylococcus was compared for reservoir samples returning ≥ 100 CFU vs those returning < 100 CFU.

RESULTS

Bacterial pathogens were isolated from 24% (7,601/31,783) of reservoir samples, 93% (98/105) of operating rooms, and 83% (2,170/2,616) of cases. The ratio of total pathogen isolates to total CFU was < 0.0003%. Anesthesia machine reservoirs returned ≥ 100 CFU for 44% (2,262/5,150) of cases. Twenty-three percent of samples returning ≥ 100 CFU were positive for ≥ 1 bacterial pathogen (521/2,262; 99% lower confidence limit, 22%) vs 3% of samples returning < 100 CFU (96/2,888; 99% upper limit, 4%).

CONCLUSIONS

Anesthesia machine reservoir samples returning < 100 CFU were associated with negligible pathogen detection. This threshold can be used for assessment of terminal, routine, and between-case cleaning of the anesthesia machine and equipment. Such feedback may be useful because the 44% prevalence of ≥ 100 CFU was comparable to the 46% (25/54) reported earlier from an unrelated hospital.

Quantitative measurement of airborne particles during endoscopic and microscopic ear surgery in the operating room

OBJECTIVE

This study aimed to quantitatively investigate airborne particle load in the operating room during endoscopic or microscopic epitympanectomy or mastoidectomy.

METHOD

In the transcanal endoscopic ear surgery group, drilling was performed underwater. A particle counter was used to measure the particle load before, during and after drilling during transcanal endoscopic ear surgery or microscopic ear surgery. The device counted the numbers of airborne particles of 0.3, 0.5 or 1.0 μm in diameter.

RESULTS

The particle load during drilling was significantly higher in the microscopic ear surgery group (n = 5) than in the transcanal endoscopic ear surgery group (n = 11) for all particle sizes (p < 0.01). In the transcanal endoscopic ear surgery group, no significant differences among the particle load observed before, during and after drilling were seen for any of the particle sizes.

CONCLUSION

Bone dissection carries a lower risk of airborne infection if it is performed using the endoscopic underwater drilling technique.

The effects of hierarchical relationship on well-being of surgical team members in operating theaters: Prospective cohort study

Although there are many studies about wellbeing on healthcare professionals, the relationship between hierarchy and well-being has not been studied much. In this study, we focused on surgical branch professionals (anesthesiologists, surgeons, nurses) as organized in a strict hierarchy. We explored the association between the position within the organizational hierarchy in operating theaters and well-being. Data were collected in 2 parts as cross-sectional (baseline) and daily surveys (for 15 days). A total of 226 participants participated in the baseline study and 156 participants in the daily surveys. How hierarchical positions, in-group identification and personality traits were related to the well-being and experiences of surgical team members were investigated. System justification, social dominance orientation, and personality theories were used to investigate personality traits. Emotional stability and identification with other healthcare professionals were positively associated with positive experience and well-being. Daily hierarchical relationship when the team members were in a superior position was positively associated with that day's well-being, positive experience, enjoying working, and motivation to work on the following day. Conversely, the negative effects of daily hierarchical relationships on outcomes were not seen when the participants were in a subordinate position. Our findings were parallel to the literature that perceived autonomy in the workplace has positive impacts on the well-being. Furthermore, we found that in-group identification can protect surgical branch professionals from the adverse effects of the organizational hierarchy. We suppose our findings can contribute to the literature to evaluate organizational structure of operating theaters.

Influence of surgical scrubs outside the operation theatre on post-operative infections - A systematic review

Background and Aims

Healthcare workers (HCWs), which include surgeons, anaesthesiologists, nurses, technicians, and other non-medical staff working in the operation theatre (OT), change to surgical scrubs for providing designated services. This study was intended to investigate the association of moving in and out of OT to other hospital areas without changing scrubs and its impact on bacterial infection.

Methods

After PROSPERO registration, we performed a systematic review to compare the occurrence of surgical site infections (SSIs) with or without the movement of HCWs outside OT. We searched PubMed, Scopus, and Cochrane Library using relevant keywords. RoB-2 and ROBINS-E tools were used to assess the risk of bias in randomised controlled trials (RCTs) and observational studies, respectively.

Results

We identified six articles that fulfilled the inclusion criteria: three RCTs and three observational studies. A risk of bias assessment revealed an overall low bias in the RCTs and an overall high bias in the observational studies. The analysis revealed a comparable incidence of bacterial infection in terms of colony-forming units when scrubs when HCWs moved in and out of OT with the same scrubs. A meta-analysis was not performed due to heterogeneity in participants and the OT set-up, as well as fewer studies and sample size.

Conclusion

The evidence is insufficient to suggest that wearing scrubs outside the OT could increase the incidence of SSI in surgical patients or transmit the organisms to patients, causing infection. The present review neither supports nor is against wearing surgical scrubs outside OT premises.

Evaluation of a Course to Teach Medical Students Latent Hazard Identification in the Operating Room

INTRODUCTION

To improve situational awareness in the operating room (OR), a virtual online operating room of hazards (ROH) with deliberately placed risks was created. We hypothesized that subjects first participating in the virtual online ROH would identify more hazards during an in-person ROH exercise in a physical OR than those in the control group who only received didactic training.

METHODS

We conducted a randomized controlled trial at a major academic medical center, enrolling 48 pre-clinical medical students with no previous OR exposure during their classes. Control and experimental group subjects participated in a brief, online didactic orientation session conducted live over Zoom (Zoom Video Communications, Inc., San Jose, CA) to learn about latent hazards in the OR. Experimental group subjects further interacted with a virtual online operating ROH in which latent hazards were present. The fraction of deliberately created latent hazards placed in a physical, in-person OR identified by subjects was calculated.

RESULTS

Experimental group subjects identified a significantly larger fraction of the created hazards (41.3%) than the control group (difference = 16.4%, 95% CI: 11.3% to 21.4%, P < 0.0001). There was no difference in the number of non-hazards misidentified as hazards between the groups.

CONCLUSIONS

Participation in the virtual online environment resulted in greater recognition of latent operating room hazards during a simulation conducted in a physical, in-person OR than in a didactic experience alone. Because creating an in-room experience to teach the identification of latent hazards in an OR is resource-intensive and requires removing the OR from clinical use, we recommend the virtual online approach described for training purposes. Adding items most misidentified as hazards is suggested for future implementation.

Access to Surgery for Endometrial Cancer Patients During the COVID-19 Pandemic in Ontario, Canada: A Population-Based Study

OBJECTIVES

To assess the impact of the COVID-19 pandemic on endometrial cancer stage and surgical treatment in Ontario, Canada.

METHODS

This descriptive study identified cases from January 1, 2017 to December 31, 2021 from endometrial cancer hysterectomy specimens in the Ontario Health-Cancer Care Ontario, ePath system. Endometrial biopsy records from January 1, 2016 to December 31, 2021 were matched to surgical specimens by provincial health card number. Time to surgery and surgical stage were compared before (2017-2019) and during (2020-2021) the COVID-19 pandemic.

RESULTS

There were 10 446 women treated with hysterectomy for endometrial cancer in Ontario from 2017-2021. In April and May 2020, corresponding with the provincial state of emergency, there was a 56% relative reduction in endometrial biopsies. Despite this 2-month reduction in endometrial biopsy volume, there was no change in surgical volume for endometrial cancer treatment. The median time from endometrial biopsy to surgery was 56 days (IQR 40, 80) during the pandemic (2020-2021) compared to 58 days (IQR 43, 82) prior to the pandemic (2017-2019) (P < 0.001). There was no upstaging of endometrial cancer during the COVID-19 pandemic.

CONCLUSIONS

The Ontario healthcare system continued to prioritize service delivery to endometrial cancer patients during the COVID-19 pandemic, despite the increase in virtual care and decrease in operating room time. There were no significant surgical delays or upstaging of endometrial cancer.

Experiences of Operating Room Professionals During the 2020 Izmir Earthquake: A Qualitative Approach

OBJECTIVE

In the aftermath of earthquakes, the availability of emergency units and operating rooms (OR) in hospitals can make a difference in the survival of those injured. OR professionals' experience during earthquakes is vital for ensuring safe and effective surgical procedures. This study was conducted to explore perceptions and describe the experiences of OR professionals, aiming to improve OR processes during and after earthquakes.

METHODS

This phenomenological study employed semi-structured interviews to collect qualitative data from 16 OR professionals who experienced the earthquake. Purposeful sampling was utilized for face-to-face interviews, and MAXQDA20 was used for content analysis.

RESULTS

The primary themes included workplace perspectives, during-earthquake experiences, ethical considerations, and post-earthquake experiences. The workplace was described as unique, dynamic, stressful, and disciplined. Participants experienced fear and panic during the earthquake. Abandoning patients was deemed unethical, resulting in ethical quandaries for professionals when their safety was at risk.

CONCLUSION

Participants displayed responsibility and ethical conduct while remaining with the patients during the tremor. Implementing practices is crucial in mitigating fear and chaos and improving information management. As such, it is highly recommended that hospital disaster plans incorporate the active participation of OR professionals.

Barriers and Solutions in Implementing Evidence-Based Recommendations to Prevent Intraoperative Inadvertent Hypothermia: A Qualitative Study

In this study, it was aimed to understand the barriers and solutions for operating room (OR) nurses and anesthesiologists to implement evidence-based recommendations to prevent intraoperative inadvertent hypothermia (IIH). A qualitative, inductive, and descriptive study was conducted. This qualitative interview study was conducted face-to-face with 19 participants working in OR units between February and March 2023. The interviews were analyzed using qualitative content analysis. The COREQ checklist was followed. Two main themes and five sub-themes were identified as a result of content analysis. According to the participants, barriers to IIH prevention interventions are caused by individual and organizational inefficiencies and personal opinions, and the main solution is education. Participants reported many factors that hinder IIH prevention practices. The individual characteristics of OR staff and the opinions and behavior of the institution are very important for IIH prevention.

Knowledge and practices about safe handling regarding the risk of exposure to antineoplastic drugs for caregivers in compounding units and in operating rooms performing HIPEC/PIPAC

INTRODUCTION

Ever since the late 1970s, occupational exposure associated with the handling of antineoplastic drugs (ADs) in the healthcare environment has been highlighted and demonstrated. Contamination was detected in both operating rooms (OR) and compounding units (CU), where healthcare workers handle and are exposed to ADs in different ways. In the OR, the risk of exposure is higher and the staff receives less training in handling ADs than in the CU. This study aimed to assess and compare knowledge and practices about the safe handling of ADs by caregivers working in these two locations, namely the CU and OR.

METHODS

Two questionnaires (one each for the OR and CU) were created by two investigator pharmacists and were completed during a personal interview of 20 min. The questions were related to the following topics: training, knowledge about occupational exposure and questions related to protective practices. A scoring system was implemented to assess the knowledge and practices of each participant.

RESULTS

In total, 38 caregivers working in the OR and 39 in the CU were included in our study. Significantly more CU staff had specific initial training (p < 0.001) and ongoing training (p < 0.001) in handling ADs. Concerning the knowledge score, OR caregivers had a significantly lower median score for contamination routes (p < 0.001), contamination surfaces (p < 0.001), existing procedures (p < 0.001) and total knowledge (p < 0.001) than CU caregivers. Concerning protective handling practices of ADs, the two locations had nonsignificantly different median scores (p = 0.892).

CONCLUSION

This study suggests that there is still room for improvement in terms of knowledge and protection practices when handling ADs. An appropriate and tailored training program should be developed and provided to all caregivers who handle or come in contact with ADs.Clinical trial registrationStudy CONTACT, ref. 19-504.

Awareness of healthcare providers on environment-friendly practices in operating rooms in selected hospitals in Riyadh, Saudi Arabia

Climate change will have a great impact on humanity in upcoming years and will affect the health of all living creatures. Hospitals play a significant role in climate change due to their substantial waste production and they are considered a profound pollution source, with the Operating Theater as a main contributor. This study was aimed to examine the level of knowledge among healthcare professionals in Saudi Arabia concerning the proper implementation of operating room (OR) environmental procedures and efficient management of hospital waste. This is a cross sectional study performed across 3 hospitals in Riyadh, Saudi Arabia. The hospitals included are Prince Sultan military hospital, National guard hospital and King Salman hospital. The study included all the staff and health workers in OR (operating room), excluding all staff and health workers not in OR. The study took place between September 1 and November 1, 2022. None of the study participants mentioned that their institute or hospital fully engaged in Greenhealth Greening the OR initiative. Almost 1 to 3rd of the study participants (38.1%) mentioned that endorsement and participation in the practice of Greenhealth Greening the OR initiative was not implemented at all, and 45% of the participants were completely unaware of such an initiative. The study's findings suggest that healthcare providers in Saudi Arabia are not fully aware of environmentally friendly practices. Further, the current initiatives undertaken by the hospital administration fall short in attaining environmentally sustainable benchmarks.

Internet of Things and New Technologies for Tracking Perioperative Patients With an Innovative Model for Operating Room Scheduling: Protocol for a Development and Feasibility Study

BACKGROUND

Management of operating rooms is a critical point in health care organizations because surgical departments represent a significant cost in hospital budgets. Therefore, it is increasingly important that there is effective planning of elective, emergency, and day surgery and optimization of both the human and physical resources available, always maintaining a high level of care and health treatment. This would lead to a reduction in patient waiting lists and better performance not only of surgical departments but also of the entire hospital.

OBJECTIVE

This study aims to automatically collect data from a real surgical scenario to develop an integrated technological-organizational model that optimizes operating block resources.

METHODS

Each patient is tracked and located in real time by wearing a bracelet sensor with a unique identifier. Exploiting the indoor location, the software architecture is able to collect the time spent for every step inside the surgical block. This method does not in any way affect the level of assistance that the patient receives and always protects their privacy; in fact, after expressing informed consent, each patient will be associated with an anonymous identification number.

RESULTS

The preliminary results are promising, making the study feasible and functional. Times automatically recorded are much more precise than those collected by humans and reported in the organization's information system. In addition, machine learning can exploit the historical data collection to predict the surgery time required for each patient according to the patient's specific profile. Simulation can also be applied to reproduce the system's functioning, evaluate current performance, and identify strategies to improve the efficiency of the operating block.

CONCLUSIONS

This functional approach improves short- and long-term surgical planning, facilitating interaction between the various professionals involved in the operating block, optimizing the management of available resources, and guaranteeing a high level of patient care in an increasingly efficient health care system.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05106621; https://clinicaltrials.gov/ct2/show/NCT05106621.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/45477.

Immunotoxicity induced by occupational inhalation exposure to waste anesthetic gases: a historical cohort study

This study was undertaken to ascertain whether long-term occupational exposure to inhalational anesthetic, was associated with any significant alteration in the parameters of immune function.

Materials and methods

This was a historical cohort study in which 30 male participants with at least one year of work experience in the operating room at the time of the study and 30 unexposed referent subjects were investigated. Exposure levels were quantified by measuring the urinary concentrations of nitrous oxide (N2O), isoflurane, and sevoflurane gases by headspace gas chromatography-mass spectrometry. Serum concentrations of interleukin-4 (IL-4), Th2-type cytokines, and interferon-gamma (IFN-γ) were measured by the ELISA method. Additionally, an automated hematology analyzer was used for the white blood cell count and white blood cell differential test. The data were analyzed using SPSS software for Windows version 21.

Results

Mean urinary concentrations of N2O, isoflurane, and sevoflurane were found to be 211.57±75.15, 4.06±0.96, and 19.51±12.96  ppb, respectively. In simplistic statistical data analysis, significant differences were noted between exposed and control groups as far as the mean serum cytokines levels (IFN-γ, IL-4) were concerned. Furthermore, after adjusting for important confounders, statistical analysis showed that the IFN-γ, IL-4, and the ratio of IFN-γ/IL-4 were significantly higher in the exposed group than in the referent subjects.

Conclusion

These findings provide corroborative evidence to further substantiate the contention that exposure to anesthetics agents (N2O, isoflurane, and sevoflurane) is associated with subtle, subclinical, prepathological changes in the parameters of immune function. The long-term ramification of these changes requires further investigation.

Genetic Algorithm for Solving the No-Wait Three-Stage Surgery Scheduling Problem

In this research, we consider a deterministic three-stage operating room surgery scheduling problem. The three successive stages are pre-surgery, surgery, and post-surgery. The no-wait constraint is considered among the three stages. Surgeries are known in advance (elective). Multiple resources are considered throughout the surgical process: PHU (preoperative holding unit) beds in the first stage, ORs (operating rooms) in the second stage, and PACU (post-anesthesia care unit) beds in the third stage. The objective is to minimize the makespan. The makespan is defined as the maximum end time of the last activity in stage 3. Minimizing the makespan not only maximizes the utilization of ORs but also improves patient satisfaction by allowing treatments to be delivered to patients in a timely manner. We proposed a genetic algorithm (GA) for solving the operating room scheduling problem. Randomly generated problem instances were tested to evaluate the performance of the proposed GA. The computational results show that overall, the GA deviated from the lower bound (LB) by 3.25% on average, and the average computation time of the GA was 10.71 s. We conclude that the GA can efficiently find near-optimal solutions to the daily three-stage operating room surgery scheduling problem.

Trends in pediatric non-operating room anesthesia: Data from the National Anesthesia Clinical Outcomes Registry

BACKGROUND

Modern pediatric anesthetic encounters occur in operating rooms and non-operating room settings. Most anesthesia providers have cared for children in radiology, endoscopy, and other interventional settings at some point in their training and career. There is an absence of published data on the frequency, timing, and demographics of these pediatric anesthesia encounters.

AIMS

The primary goal of our study is to present data spanning a variety of institutions and practice settings in the United States to define the percentage of non-operating room anesthetic encounters in children. We also set out to characterize the frequency of the most common procedures in the non-operating room setting within the United States.

METHODS

Using the National Anesthesia Clinical Outcomes Registry data from 2015-2019, we analyzed and reported data on current trends in non-operating room anesthesia including patient demographics, encounter setting, procedure type, and the time at which anesthetic encounters occurred.

RESULTS

2 236 788 pediatric anesthetic encounters (patient age <18 y.o.) were analyzed revealing that 22.7% of all pediatric anesthetics occur in non-operating room settings. Patients were more likely to have higher American Society of Anesthesiologists Physical Status classifications in the non-operating room anesthesia group. Gastroenterological suites are the most common setting reported for pediatric non-operating room anesthesia.

CONCLUSIONS

Non-operating room anesthesia in the United States is a prominent segment of pediatric anesthetic practice. Pediatric patients encountered in the non-operating room setting have more comorbidities, though further studies are needed to characterize the implication of this finding.

Long-term capacity planning for obstetric surgical suites using quantile linear regression

Obstetric surgical suites differ from most inpatient surgical suites, serving one specialty, and often small. We evaluated long-term capacity planning for these operating rooms. The retrospective cohort study included all caesarean births in three operating rooms over 28 years, 1994 through 2021, plus all other obstetric procedures over the latter 19 years. We calculated the obstetric anaesthesia activity index, 0.5 × neuraxial labour analgesia placement + 1.0 × caesarean births. Annual caesarean births from one year to the next had a Pearson linear correlation coefficient of 0.993. Therefore, linear regression can be used for long-term capacity planning. However, the difference between 0.9 and 0.1 quantiles in weekly caseloads was greater than tenfold larger than the annual rate of growth in births per week. Therefore, clinicians likely would be unable to distinguish, by experience, between growth versus being busy due to variability, suggesting value of the modelling. Over 19 years, the fraction of the obstetric workload from caesarean births was unchanging, Pearson correlation coefficient of 0.04. Therefore, use of the obstetric anaesthesia activity index to judge changes in workload was appropriate. The annual total for the index increased linearly, Pearson correlation coefficient of 0.98, supporting validity of the finding that long-term capacity can be planned with linear regression. The difference between 0.9 and 0.1 quantiles in weekly totals of the index exceeded annual rate of growth, supporting validity of the finding that variability week to week is very large relative to growth. These results help decision-makers ensure that operating rooms and staff meet referring hospitals' needs.

Comparison of the Effects of Surgical Smoke on the Air Quality and on the Physical Symptoms of Operating Room Staff

BACKGROUND

Surgical smoke can be a hazard because e it contains toxic gases with carcinogenic effects that may threaten health. This study aims to determine the effect of surgical smoke containing toxic chemicals on indoor air quality and examine employees' physical symptoms in the operating room.

METHOD

The study was conducted in the operating room between June 2020 and July 2020. In the study, 45 air samples were taken before, during, and after surgery using the active sampling method. Nineteen employees working in the operating room were asked about their physical complaints and their throat cultures were taken before and after surgery. These results were compared with those of the employees working in internal units.

RESULTS

The Total Volatile Organic Compounds value at the time of surgery was significantly higher (p ≤ 0.05). Benzene concentrations remained constantly high (p ≤ 0.05) throughout the surgery, exceeding the limit values. Other VOCs (Volatile Organic Compounds) were significantly higher during surgery and remained below the limit values (p ≤ 0.05). When compared in terms of open and laparoscopic surgery, no difference between VOC concentrations was observed (p ≤ 0.05). The physical symptoms of the surgical team increased during the operation, and they experienced more complaints of tearing, burning in the eyes, hair odor, nausea, and cough than those working in the internal units (e.g., internal medicine, dermatology; (p ≤ 0.05).

CONCLUSIONS

Surgical smoke was an important contaminant for indoor air quality in the operating room.

Occupational Exposure to Halogenated Anaesthetic Gases in Hospitals: A Systematic Review of Methods and Techniques to Assess Air Concentration Levels

Objective During the induction of gaseous anaesthesia, waste anaesthetic gases (WAGs) can be released into workplace air. Occupational exposure to high levels of halogenated WAGs may lead to adverse health effects; hence, it is important to measure WAGs concentration levels to perform risk assessment and for health protection purposes. Methods A systematic review of the scientific literature was conducted on two different scientific databases (Scopus and PubMed). A total of 101 studies, focused on sevoflurane, desflurane and isoflurane exposures in hospitals, were included in this review. Key information was extracted to provide (1) a description of the study designs (e.g., monitoring methods, investigated occupational settings, anaesthetic gases in use); (2) an evaluation of time trends in the measured concentrations of considered WAGs; (3) a critical evaluation of the sampling strategies, monitoring methods and instruments used. Results Environmental monitoring was prevalent (68%) and mainly used for occupational exposure assessment during adult anaesthesia (84% of cases). Real-time techniques such as photoacoustic spectroscopy and infrared spectrophotometry were used in 58% of the studies, while off-line approaches such as active or passive sampling followed by GC-MS analysis were used less frequently (39%). Conclusions The combination of different instrumental techniques allowing the collection of data with different time resolutions was quite scarce (3%) despite the fact that this would give the opportunity to obtain reliable data for testing the compliance with 8 h occupational exposure limit values and at the same time to evaluate short-term exposures.

Acoustic Biotopes, Listeners and Sound-Induced Action: A Case Study of Operating Rooms

As socio-technological environments shape and direct listener behaviour, an ecological account is needed that encompasses listening in complexity (i.e., multiple listeners, multiple sounds and their sources, and multiple sound-induced actions that ensure the success of a mission). In this study, we explored sound-induced action under the framework of "acoustic biotopes" (a notion of ecological acoustics by Smolders, Aertsen, and Johanessma, 1979 and 1982) in a specific socio-technological environment, i.e., the context of an orthopaedic operating room. Our approach is based on literature research into the topics of environmental psychology and auditory perception and action and in situ observations in healthcare with field recordings, participatory observations, and interviews on the spot. The results suggest a human-centered definition of sound-induced action in acoustic biotopes: Acoustic biotope is an active and shared sound environment with entangled interactions and sound-induced actions taking place in a specific space that has a critical function. Listening in highly functional environments is an individual experience and is influenced by hearing function, physical position and role in an environment, and the task at hand. There is a range of active and passive sound listeners as a function of their attentive state and listeners as sound sources within the acoustic biotope. There are many different sound sources and sound locals in socio-technological environments and sounds have great potential to serve critical information to operators. Overall, our study provides a holistic, multi-layered and yet a listener-centric view on the organisation of complex spaces and the results can immediately be applicable for rethinking the acoustic environment for ORs for better listening and sound-induced action.

Competency assessment of the operating room staff and some related factors: A multi-center cross-sectional study

Background

Operating Rooms (ORs) are complicated environments that necessitate the improvement of OR staff's knowledge and skills to remain clinically competent and secure patient safety. The aim of this study was to assess clinical competence of OR staff in accordance with some related factors.

Materials and Methods

This descriptive analytical cross-sectional study was conducted on 227 OR staff in nine academic hospitals. Sampling was performed from the beginning to the end of May 2019 and the samples were selected by quota sampling. Data were collected using a researcher-made questionnaire encompassing six dimensions of competency including general knowledge, specialized knowledge, general practical skills, specific practical skills, personality, and motivation. Data analysis was performed using descriptive and interpretive statistics.

Results

The mean (SD) total score of competence was 80.99, which was optimal (11.28). The lowest score was related to the dimension of general practical skills with the mean (SD) score of 53.32 (10.26). The mean score of specialized practical skills was significantly higher in single-specialty ORs (F = 21.53, p < 0.001). Based on multiple linear regression test, it was possible to predict clinical competency through the age and work experience (R-squared = 0.96, beta = 0.31, p = 0.022).

Conclusions

Specialized training has overshadowed the general practical skills that are related to the observation of basic principles of patient safety apart from surgical specialization. Strengthening of competence in general practical skills need to be prioritized in empowerment programs. We need a fixed and permanent space for the continuation of educational programs designed to promote perioperative general practical skills.

The Experiences of Operating Room Nurses During COVID-19 Pandemic: A Qualitative Study

PURPOSE

The aim of this study was to determine the changes in the physical, mental, and social conditions of operating room nurses and their personal experiences during the COVID-19 pandemic.

DESIGN

The study applied a qualitative research design that included the content analysis method.

METHODS

Face-to-face interviews were conducted online with 26 operating room nurses. Analysis of the data was completed in six steps using the content analysis method.

FINDINGS

Four main themes emerged from the interviews: physical effect of the COVID-19 pandemic on operating room nurses, psychological effect of the COVID-19 pandemic on operating room nurses, operating room nurses' perceptions on the training given to them during the COVID-19 pandemic, and effects of the COVID-19 pandemic on health care worker and patient safety and nursing care.

CONCLUSIONS

This study contributes new findings on the experiences of operating nurses during the COVID-19 pandemic to the relevant literature. The results of the study indicated that the nurses were negatively affected both physically and psychologically during this period, and that this directly affected patient care.

Nursing Care during the Perioperative within the Surgical Context

The study describes basic nursing care during the perioperative. Introduces the origins of perioperative nursing, general care that must be practiced with patient in this context. During the preoperative, care related with risk assessment and preparation of patient from the emotional and physical point of view are important. The trans-operative is related with the anesthesia used, surgical position, preparation of the skin, maintenance of normothermia, among many others. The postoperative depends on the type of anesthesia and surgical procedure, emphasizing on airway permeability, hemodynamic stability, pain, and symptomatology being presented by patients until they are stable and suitable for transfer to another service or their home.

The who, what, and how of teamwork research in medical operating rooms: A scoping review

Despite the importance of teamwork in the operating room (OR), teamwork can often be conflated with teamwork components (e.g., communication, cooperation). We reviewed the existing literature pertaining to OR teamwork to understand which teamwork components have been assessed. Following PRISMA guidelines for scoping reviews, 4,233 peer-reviewed studies were identified using MEDLINE and Embase. Eighty-seven studies were included for synthesis and analysis. Using the episodic model of teamwork as an organizing framework, studies were grouped into the following teamwork categories: (a) transition processes (e.g., goal specification), (b) action processes (e.g., coordination), (c) interpersonal processes (e.g., conflict management), (d) emergent states (e.g., psychological safety), or (e) omnibus topics (a combination of higher-order teamwork processes). Results demonstrated that action processes were most frequently explored, followed by transition processes, omnibus topics, emergent states, and interpersonal processes. Although all studies were framed as investigations of teamwork, it is important to highlight that most explored only one or a few constructs under the overarching umbrella of teamwork. We advocate for enhanced specificity with descriptions of OR teamwork, reporting practices pertaining to interprofessional demographics and outcomes, and increased diversity in study design and surgery type to advance understanding of teamwork and its implications.

Damage control surgery for thoracic outlet vascular injuries: the new resuscitative median sternotomy plus REBOA

Thoracic vascular trauma is associated with high mortality and is the second most common cause of death in patients with trauma following head injuries. Less than 25% of patients with a thoracic vascular injury arrive alive to the hospital and more than 50% die within the first 24 hours. Thoracic trauma with the involvement of the great vessels is a surgical challenge due to the complex and restricted anatomy of these structures and its association with adjacent organ damage. This article aims to delineate the experience obtained in the surgical management of thoracic vascular injuries via the creation of a practical algorithm that includes basic principles of damage control surgery. We have been able to show that the early application of a resuscitative median sternotomy together with a zone 1 resuscitative endovascular balloon occlusion of the aorta (REBOA) in hemodynamically unstable patients with thoracic outlet vascular injuries improves survival by providing rapid stabilization of central aortic pressure and serving as a bridge to hemorrhage control. Damage control surgery principles should also be implemented when indicated, followed by definitive repair once the correction of the lethal diamond has been achieved. To this end, we have developed a six-step management algorithm that illustrates the surgical care of patients with thoracic outlet vascular injuries according to the American Association of the Surgery of Trauma (AAST) classification.

Is a Video Worth a Thousand Words? Educating Preclinical Medical Students on Sterile Scrubbing, Gowning, and Gloving Virtually and In-Person

Introduction

Programs that offer early exposure to surgery for medical students foster interest in and positive perceptions of surgery. The COVID-19 pandemic led to suspension of these activities at our institution, the University of Kansas School of Medicine. In response to the lack of virtual alternatives, a pilot virtual surgery enrichment program was implemented for first-year students in place of in-person surgical exposure. The aim of this study was to compare the efficacy of in-person and virtual-based surgical education programs to expose preclinical medical students about the surgical realm of medicine.

Methods

First-year medical students participated in either a virtual (Group A) or in-person (Group B) week-long surgical enrichment program. Group assignments were dictated by COVID restrictions on each of our three medical school campuses: Salina, Wichita, and Kansas City. Pre- and post-surveys with a 14-question multiple-choice assessment of surgical knowledge were distributed to participants. Paired Wilcoxon Signed Rank tests and Mann-Whitney-U tests were used for statistical analysis.

Results

There were 14 participants in Group A and 7 participants in Group B. Both groups improved significantly from pre- to post-assessment score. (Group A, p = 0.01; Group B, p = 0.04). There was no difference between groups in the magnitude of score improvement from pre- to post-assessment (p = 0.59).

Conclusions

This pilot program demonstrated that virtual platforms can be a method to provide meaningful clinical experiences in surgery to preclinical medical students restricted from clinical activities. Further development of mentorship in virtual surgical programs and assessment of subjective experience is needed.

Association of dexmedetomidine with recovery room and hospital discharge times: A retrospective cohort analysis

BACKGROUND

Dexmedetomidine is a useful anesthetic adjunct, increasingly popular during pediatric surgery and procedural sedation. Its half-life of 2-3 hours might prolong recovery and discharge times when compared with an un-supplemented propofol anesthetic. This may create an additional burden in a busy post-anesthetic care unit (PACU).

AIM

To investigate whether intraoperative adjuvant dexmedetomidine delays PACU discharge in patients undergoing propofol anesthesia for day surgery or procedural investigations with minimal anticipated post-procedural pain.

METHODS

We conducted a retrospective review of outpatient procedures performed during a six-month period including pediatric patients, ASA physical status I-III, who underwent intravenous anesthesia with propofol and remifentanil for magnetic resonance imaging (MRI), strabismus repair, upper gastrointestinal endoscopy, or combined upper/lower gastrointestinal endoscopy. Patients receiving a sedative premedication, long-acting opioids, or volatile anesthetics for maintenance of anesthesia, were excluded. Duration of PACU stay was compared for patients who did or did not receive intraoperative dexmedetomidine in the four procedure groups.

RESULTS

Charts were reviewed for 359 patients; 130 (36%) received dexmedetomidine. Median differences in duration of PACU stay for dexmedetomidine versus non-dexmedetomidine cases were: 5 minutes (95%CI 0 to 10, p=0.037) for MRI; 5 minutes (95%CI -3 to 15, p=0.258) for strabismus surgery; 7 minutes (95%CI 3 to 10, p<0.001) for upper endoscopy; and 5 minutes (95%CI 1 to 12, p=0.021) for combined upper/lower endoscopy. Linear regression (F=61.1, adjusted R² =0.40) indicated a significant relationship between dexmedetomidine dose (estimate 14.6 minutes per μg/kg, 95%CI 8.2 to 21.1, p<0.001) and duration of PACU stay.

CONCLUSION

We found evidence for a small association of intraoperative dexmedetomidine with duration of recovery from propofol anesthesia for a set of common outpatient procedures, with a potential dose relationship equivalent to approximately 15 minutes delay per μg/kg dexmedetomidine administered. Future research into the benefits of dexmedetomidine in pediatric anesthesia should further evaluate this relationship.

Strategic planning of operating room session allocation using stability analysis

Operating room (OR) resources are limited, and for this reason there is usually a competition among surgeons to win them. However, the methods developed for allocating OR sessions are mostly based on optimisation methods which compensate the preferences of surgeons or surgical specialities in favour of the productivity of the entire OR department. This leads to conflict and dissatisfaction among surgeons. To overcome this problem, a methodology based on game theoretic solutions is presented in this paper that formulates the allocation problem as a simple game. The surgeons or specialities as players then jointly pursue the goal of achieving overall stability. Stability is defined and measured using a method called Power Index. The proposed method is then combined with the Monte-Carlo technique to deal with uncertainties. To demonstrate the capability of the suggested procedures, they are applied to a case study from the literature and a set of hypothetical scenarios.

It's Not Over Till It's Over: A Prospective Cohort Study and Analysis of "Anesthesia Stat!" Emergency Calls in the Pediatric Post-Anesthesia Care Unit (PACU)

Background

Emergency "Anesthesia Stat!" (AS!) calls remain a common practice in medical centers even when advanced communication infrastructures are available. We hypothesize that the analysis of post-procedure "AS!" calls will lead to actionable insights which may enhance patient safety.

Methods

After institutional review board approval, we prospectively collected data from April 2015 through May 2018 on "AS!" calls throughout the pediatric operating rooms (OR), off-site locations, and post-anesthesia care unit (PACU) at a tertiary university medical center. Data recorded included demographic information, location, time of the event, event duration, vital signs, medications, anesthesia staff, attending anesthesiologist, and staff responding to the call. A narrative account of the event was also documented.

Results

A total of 82 "AS!" calls occurred, with ages ranging from 11 days old to 17 years old. Forty-nine of the 82 calls (60%) occurred at emergence. Seventy-one of the 82 calls (87%) were solely respiratory-related. Thirty-five of 49 emergence calls (71%) occurred in the PACU. Further, 34 of 35 PACU calls (97%) were respiratory-related, with 30 of 35 PACU calls (86%) associated with desaturation requiring intervention by anesthesia staff. Finally, 31 of 35 PACU calls (89%) occurred within 30 minutes of patient arrival to PACU.

Conclusion

Analysis of "AS!" events from our PACU continues to support the need for the prompt and continuous availability of at least one staff member with advanced airway management skills. Further, pediatric patients undergoing general anesthesia and surgery should likely be monitored for a minimum of 30 minutes following arrival in the PACU.

Strategies for improvement of blood consumption management in the operating rooms: experts´ suggestions

Background: In operating rooms, blood product wastage occurs with various reasons especially over-demand ordering during elective surgeries. Consequently, it imposes a heavy financial burden on health system. Therefore, managing blood consumption in the operating rooms is of special importance. Surgeons and anesthesiologists play a key role in blood transfusion practice in operating rooms.

Objective: To investigate surgeons´ and anesthesiologists´ perspectives in regard to the effective strategies for better management of blood transfusion practice in operating rooms.

Method: In this qualitative cross-sectional study, from January to March 2020, 60 surgeons and anesthesiologists were participated. All of them were working in surgical departments of the general hospitals affiliated with Shiraz University of Medical Sciences, in Shiraz, Southern Iran. Their viewpoints regarding the improvement of blood consumption management in operating rooms were recorded through interviews and several focus group sessions.

Results: After content analysis, the most important recommendations with the highest scores were regular training programs for surgical team (23.3%), collaboration of surgeons, anesthesiologists, and managers of the surgical departments by arrangement of monthly meetings to estimate the number of required blood bags more accurately (23.3%), establishing a well-organized electronic requesting and registration system (13.3%), promoting the ordering process by a comprehensive preoperative evaluation (11.6%), and updating transfusion protocols based on the standards and monitoring the adherence to these standards (10%).

Conclusion: Implementing the proposed policies, which are based on the invaluable experiences of related experts would be effective in improving blood consumption management in operating rooms.

Association between genotoxic properties of inhalation anesthetics and oxidative stress biomarkers

Exposure to inhalation anesthetics (IAs) has been associated with DNA damage as reflected in the increased frequency of micronuclei (MN) and chromosomal aberrations (CAs). The present study was undertaken to ascertain whether there was any correlation between increased MN and CA and the extent of oxidative stress as well as the antioxidant status of a group of operating room personnel exposed to a mixture of IAs, including nitrous oxide, isoflurane, and sevoflurane. In this cross-sectional study, 60 operating room personnel (exposed group) in whom the frequencies of MN and CA had already been shown to be significantly higher than those of a referent group, as well as 60 unexposed nurses, were studied. Venous blood samples were taken from all participants, and malondialdehyde (MDA) levels as an index of oxidative stress (OS) and the activity of superoxide dismutase (SOD) and levels of total antioxidant capacity (TAC) as indices of antioxidant status were measured. The level of TAC (1.76 ± 0.59 mM vs. 2.13 ± 0.64 mM, p = 0.001) and the activity of SOD (11.22 ± 5.11 U/ml vs. 13.36 ± 4.12 U/ml, p = 0.01) were significantly lower, while the mean value of MDA was significantly higher (2.46 ± 0.66 µM vs. 2.19 ± 0.68 µM, p = 0.03) in the exposed group than in the nonexposed group. After adjusting for potential confounders, there were statistically significant associations between exposure to IAs, gender, SOD, and TAC with MN frequency and between exposure to IAs and SOD with numbers of CA. The findings of the present study indicated that exposure to IAs was associated with OS, and this, in turn, may be causally linked with DNA damage.

Spread of Multidrug-Resistant Bacteria by Moth Flies from Hospital Waste Water System

We documented and analyzed moth fly occurrence and spread of multidrug-resistant bacteria in a tertiary care hospital in Germany. The moth flies (Clogmia albipunctata) bred in the sewage system, then moved into the hospital, carrying biofilm and multidrug-resistant bacteria on their feet. Subsequently, the hospital developed a pest control protocol.

Perioperative anxiety in pediatric surgery: Induction room vs. operating room

BACKGROUND

Perioperative anxiety can have a profound and lasting effect on children and their parents, with up to 70 percent of children undergoing outpatient surgery experiencing significant physiologic and/or psychological manifestations of anxiety throughout the ambulatory surgical process. The physical healthcare environment itself can contribute to these feelings, substantially impacting the level of anxiety experienced by both the child and their parent.

OBJECTIVE

This study sought to examine whether a difference exists between utilization of an induction room vs. the operating room on child and parent perioperative anxiety for parent present induction.

METHODS

A single institution multi-site prospective observational study was conducted with a cohort of 51 healthy children aged 6-12 years, receiving an outpatient tonsillectomy and/or adenoidectomy and their parent. The methodological approach utilized for this study was Ecological Momentary Assessment. Two psychological measures of anxiety, (i) momentary and (ii) environmental, and one physiologic measure of anxiety (i) electrodermal activity were used. Data were captured separately for child and parent.

RESULTS

For children who underwent anesthetic induction in the induction room, all three anxiety responses were significantly lower and exhibited a large positive effect [momentary (P = .0002, d = 1.984, induction room = 3.76, operating room = 7.07), environmental (P = .018, d = 1.160, induction room = 1.72, operating room = 0.85), and electrodermal activity (P = .039, d = 1.007, induction room = 0.76, operating room = 1.51)], as compared to children who were induced in the operating room. Electrodermal activity was also statistically significantly lower, with a large positive effect, in the postoperative environment (P = .004, d = 1.454, induction room = 0.21, operating room = 0.60) for Children who were induced in the induction room, as compared to the operating room cohort. No significant differences were found between parents for momentary and environmental anxiety, and electrodermal anxiety.

CONCLUSIONS

The nonpharmacological strategy of using an induction room for anesthetic induction of children may be clinically effective in reducing anxiety as compared to an operating room.

Implementation of the Operating Room Black Box Research Program at the Ottawa Hospital Through Patient, Clinical, and Organizational Engagement: Case Study

Background

A large proportion of surgical patient harm is preventable; yet, our ability to systematically learn from these incidents and improve clinical practice remains limited. The Operating Room Black Box was developed to address the need for comprehensive assessments of clinical performance in the operating room. It captures synchronized audio, video, patient, and environmental clinical data in real time, which are subsequently analyzed by a combination of expert raters and software-based algorithms. Despite its significant potential to facilitate research and practice improvement, there are many potential implementation challenges at the institutional, clinician, and patient level. This paper summarizes our approach to implementation of the Operating Room Black Box at a large academic Canadian center.

Objective

We aimed to contribute to the development of evidence-based best practices for implementing innovative technology in the operating room for direct observation of the clinical performance by using the case of the Operating Room Black Box. Specifically, we outline the systematic approach to the Operating Room Black Box implementation undertaken at our center.

Methods

Our implementation approach included seeking support from hospital leadership; building frontline support and a team of champions among patients, nurses, anesthesiologists, and surgeons; accounting for stakeholder perceptions using theory-informed qualitative interviews; engaging patients; and documenting the implementation process, including barriers and facilitators, using the consolidated framework for implementation research.

Results

During the 12-month implementation period, we conducted 23 stakeholder engagement activities with over 200 participants. We recruited 10 clinician champions representing nursing, anesthesia, and surgery. We formally interviewed 15 patients and 17 perioperative clinicians and identified key themes to include in an information campaign run as part of the implementation process. Two patient partners were engaged and advised on communications as well as grant and protocol development. Many anticipated and unanticipated challenges were encountered at all levels. Implementation was ultimately successful, with the Operating Room Black Box installed in August 2018, and data collection beginning shortly thereafter.

Conclusions

This paper represents the first step toward evidence-guided implementation of technologies for direct observation of performance for research and quality improvement in surgery. With technology increasingly being used in health care settings, the health care community should aim to optimize implementation processes in the best interest of health care professionals and patients.

Solving Operating Room Scheduling Problem Using Artificial Bee Colony Algorithm

Many healthcare institutions are interested in reducing costs and in maintaining a good quality of care. The operating room department is typically one of the most costly units in a hospital. Hospital managers are always interested in finding effective ways of using operating rooms to minimize operating costs. In this research, we study the operating room scheduling problem. We consider the use of a weekly surgery schedule with an open scheduling strategy that takes into account the availabilities of surgeons and operating rooms. The objective is to minimize the total operating cost while maximizing the utilization of the operating rooms but also minimizing overtime use. A revised mathematical model is proposed that can provide optimal solutions for a surgery size up to 110 surgical cases. Next, two modified heuristics, based on the earliest due date (EDD) and longest processing time (LPT) rules, are proposed to quickly find feasible solutions to the studied problem. Finally, an artificial bee colony (ABC) algorithm that incorporates the initial solutions, a recovery scheme, local search schemes, and an elitism strategy is proposed. The computational results show that, for a surgery size between 40 and 100 surgical cases, the ABC algorithm found optimal solutions to all of the tested problems. For surgery sizes larger than 110 surgical cases, the ABC algorithm performed significantly better than the two proposed heuristics. The computational results indicate that the proposed ABC is promising and capable of solving large problems.

Quality improvement in the surgery-related processes: Managerial challenges and solutions from hospitals of Iran

BACKGROUND

There is a growing global movement toward quality and safety in healthcare and quality improvement (QI) in general surgery. The first step in any QI initiative is identifying the challenges and barriers to achieve such goals and then to define appropriate actions. This study aims to provide an overview of the QI challenges in Iranian hospitals' surgery-related processes and suggest applied solutions accordingly.

METHODS

This is a sequential (qual-quant) mixed-method study from November 2019 to January 2020, involving 21 face-to-face interviews with hospital managers, quality officers, and surgery-related clinicians and staff, followed by a Delphi consensus-seeking stage to finalize solutions. MAXQDA software was applied for organizing the concepts, and thematic content analysis was used for analyzing the data as an inductive approach to extract the emerging themes and sub-themes.

RESULTS

The managerial problems were classified into four groups of (I) defects and delays in completing patient medical records, (II) irregularity and the lack of transparency in the direction of processes in the hospital, (III) inappropriate and unrealistic operating scheduling, and (IV) poor safety considerations. The proposed solutions included imposing stricter regulations for competing for medical records, such as reduction of payments, development of guiding brochures or protocols for patients on their arrival, assigning a certain number of experienced nurses and surgeons for schedule management, rewarding the report of medical and surgical error cases, and developing a regular monitoring program for the proper implementation of surgical safety guidelines.

CONCLUSION

There are various managerial barriers that hamper QI in hospitals' surgery-related processes. Implementing simple but agreed solutions can lead to saving patients' lives, reduction of the unnecessary use of resources, and enhance of patient and staff satisfaction.

Impact of physician's sex/gender on processes of care, and clinical outcomes in cardiac operative care: a systematic review

OBJECTIVES

This systematic review aimed to assess the role of physician's sex and gender in relation to processes of care and/or clinical outcomes within the context of cardiac operative care.

DESIGN

A systematic review.

DATA SOURCES

Searches were conducted in PsycINFO, Embase and Medline from inception to 6 September 2018. The reference lists of relevant systematic reviews and included studies were also searched.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Quantitative studies of any design were included if they were published in English or French, involved patients of any age undergoing a cardiac surgical procedure and specifically assessed differences in processes of care or clinical patient outcomes by physician's sex or gender. Studies were screened in duplicate by two pairs of independent reviewers.

OUTCOME MEASURES

Processes of care, patient morbidity and patient mortality.

RESULTS

The search yielded 2095 publications after duplicate removal, of which two were ultimately included. These studies involved various types of surgery, including cardiac. One study found that patients treated by female surgeons compared with male surgeons had a lower 30-day mortality. The other study, however, found no differences in patient outcomes by surgeon's sex. There were no studies that investigated anaesthesiologist's sex/gender. There were also no studies investing physician's sex or gender exclusively in the cardiac operating room.

CONCLUSIONS

The limited data surrounding the impact of physician's sex/gender on the outcomes of cardiac surgery inhibits drawing a robust conclusion at this time. Results highlight the need for primary research to determine how these factors may influence cardiac operative practice, in order to optimise provider's performance and improve outcomes in this high-risk patient group.

[Recommendations for reopening elective surgery services during the SARS-CoV-2 pandemic]

Dada la incertidumbre que acompaña a la pandemia por SARS-CoV-2 y ante la necesidad de dar respuesta a múltiples problemas de salud crónicos y agudos que afectan a la población general, incluidos aquellos que precisan de una intervención quirúrgica, se presentan las recomendaciones implementadas en clínicas y hospitales de Colombia como guía para lograr una reapertura de los servicios de cirugía electiva de forma segura, escalonada y monitoreada acorde a la dinámica que impone la pandemia, la regulación nacional e internacional y la velocidad en la producción de evidencia científica relacionada con la COVID-19.

Building a Brain Tumor Practice: Objective Analysis of Referral Patterns and Implications for the Growth of a Subspecialty Surgical Program

Introduction Growth of surgical caseload among specialties with a large contribution margin is an important financial objective for hospitals. In this study, we examined the diversity of referral patterns to a neurosurgeon over an eight-year interval and examined practice attributes related to surgical growth. Methods The electronic records of all patients undergoing an intracranial surgical procedure between August 2011 and August 2019 by an academic neurosurgeon were reviewed retrospectively. The Herfindahl-Hirschman index (HHI) was used to assess the distribution of referrals among community physicians who referred such patients; a value of HHI <0.15 indicates diversity. The yearly HHI trend was evaluated using meta-regression. Results The neurosurgeon's brain surgery caseload progressively increased on an annual basis from 1.4 to 12.5 cases per week between 2012 and 2018. Among the 1540 cases referred by 1775 different physicians, 78% were from three counties in southeast Florida and 8.1% from two counties in southwest Florida. The HHI declined between 2013 and 2018 by 0.023 per year (0.0046 standard error [SE], p = 0.0073) with the estimated value 0.0063 (0.0014 SE) < 0.15 in 2018 (p < 0.0001). The findings indicate that the base of referring physicians was highly diverse and that growth in caseload was accompanied by significantly less concentration of referrals. Conclusion Surgical growth in the neurosurgeon's practice resulted from a small number of referrals from many physicians, not from many referrals from a small number of physicians. Few physicians referred a sufficient number of patients to warrant attribution of the referral itself to personal knowledge of their patients' eventual outcomes. Rather, factors promoting timely access to patient care appear to have been the driving force for growth.

Assessment of anesthetic gases in a central hospital

Introduction:

Adverse health effects related with chronic exposure to waste anesthetic gases remain controversial. Strict threshold values are recommended to minimize possible health risks. The objective of our study was to measure the concentration of waste anesthetic gases in different hospital settings in an 11-year period.

Materials and methods:

Six-monthly assessment of nitrous oxide, sevoflurane, and desflurane was made between 2005 and 2016 in different hospital departments. Trace gas analysis was performed by infrared spectroscopy.

Results:

An anesthetic gas concentration above the upper limit of the threshold value was found in computed tomography/magnetic resonance imaging (CT/MRI) (45.5%), ambulatory operating room (34.5%), and in the burn unit (31.6%). Desflurane assessment was more frequently above the upper limit of threshold value (12.37%).

Discussion:

In the CT/MRI department, the small number of air cycling per hour and the frequent use of a face mask with the associated risk of leakage may explain the results. In burn unit patients inhalatory route is also frequent. Desflurane is widely used for its rapid elimination and rapid recovery, which is compatible with the results. Being odorless, it may be connected to undetected escape.

Conclusion:

The places with more anesthetic agents exposure were the CT/MRI, the ambulatory operating room, and the burn unit. Desflurane was the anesthetic agent more frequently above the upper limit of threshold value. To complement environmental surveillance, it is essential to establish a health surveillance system for professionals exposed to anesthetic agents.

Association of intraoperative anaesthesia handovers with patient morbidity and mortality: a systematic review and meta-analysis

BACKGROUND

Handover of anaesthesia patient care during surgery is common; however, its association with patient outcome is unclear. This systematic review aimed to assess the impact of anaesthesia handover during surgery on patient outcome.

METHODS

All prospective and retrospective clinical studies specifically investigating the association of intraoperative transfer of anaesthesia care between anaesthesia providers in the operating room with patient morbidity and mortality were included. Searches were conducted from inception to April 24, 2019 in Medline, Medline in Process, CINAHL, and Embase. Reference lists of included studies were searched. Studies were assessed for eligibility and data were extracted by independent reviewers in duplicate with disagreements resolved by consensus or a third reviewer. Risk of bias was assessed in duplicate using the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Data were summarised narratively given substantial heterogeneity. An exploratory meta-analysis was conducted using a random-effects model for a subset of comparable studies.

RESULTS

Eight studies met the inclusion criteria. Six studies focused on patients as the unit of analysis (n_patients=605 678) and two focused on anaesthesia providers as the unit of analysis (n_providers=307). Seven studies identified a relationship between anaesthesia handovers and adverse patient outcomes, whereas one suggested that handover may be beneficial to error detection or rectification. Included studies were of fair or good quality. Meta-analysis of four studies found a 40% increased risk of patients experiencing an adverse event when an anaesthesia handover occurs during the procedure (pooled risk ratio=1.40; 95% confidence interval, 1.19 to 1.65; P<0.001; I²=98%).

CONCLUSIONS

Intraoperative anaesthesia handovers generally increase morbidity and mortality for surgical patients but could have the potential to improve safety in certain contexts. Future research should determine the specific handover characteristics that impact safety.

Cardiac surgeons between apprehension and ethical duty in the COVID-19 pandemic

Background

Cardiothoracic surgeons are facing a big challenge in their surgical practice in the era of the COVID-19 pandemic. The attitude towards performing surgery is influenced by the pandemic. Setting special recommendations for safe cardiothoracic surgery is of extreme importance.

Methods

This was an observational cross-sectional survey that included 77 Egyptian cardiothoracic surgeons. The survey consisted of a self-administered constructed questionnaire with six sections, and was delivered as a Google Forms questionnaire (https://www.google.com/forms/about) that was sent to individuals via social networks and email.

Results

More than 80% of Egyptian cardiothoracic surgeons believe they and their patients are at risk. Out of all participants, none had actually been infected with COVID-19 but 26% had encountered a positive COVID-19 person in their surgical team. Although 51% were testing patients before surgery, they reported 9 confirmed cases postoperatively. Computed tomography was the most recommended investigation prior to surgery (by 69%). Most had postponed elective surgeries and only one-third of all surgeons recommended performing elective surgeries cautiously with pretesting for COVID-19 and maximizing protective measures, while more than 40% recommended not performing high-risk elective surgeries.

Conclusion

We are committed to the safety of our patients, ourselves, our staff, and our families. Planning for the new phase of reopening, whether total reopening or step-by-step reopening, should carefully consider how we should utilize our resources, respect social distancing, and prevent exposure to untested patients or health workers who might turn out to be an undetected positive case.

Use of a Low-Cost Portable 3D Virtual Reality Gesture-Mediated Simulator for Training and Learning Basic Psychomotor Skills in Minimally Invasive Surgery: Development and Content Validity Study

Background

Simulation in virtual environments has become a new paradigm for surgeon training in minimally invasive surgery (MIS). However, this technology is expensive and difficult to access.

Objective

This study aims first to describe the development of a new gesture-based simulator for learning skills in MIS and, second, to establish its fidelity to the criterion and sources of content-related validity evidence.

Methods

For the development of the gesture-mediated simulator for MIS using virtual reality (SIMISGEST-VR), a design-based research (DBR) paradigm was adopted. For the second objective, 30 participants completed a questionnaire, with responses scored on a 5-point Likert scale. A literature review on the validity of the MIS training-VR (MIST-VR) was conducted. The study of fidelity to the criterion was rated using a 10-item questionnaire, while the sources of content-related validity evidence were assessed using 10 questions about the simulator training capacity and 6 questions about MIS tasks, and an iterative process of instrument pilot testing was performed.

Results

A good enough prototype of a gesture-based simulator was developed with metrics and feedback for learning psychomotor skills in MIS. As per the survey conducted to assess the fidelity to the criterion, all 30 participants felt that most aspects of the simulator were adequately realistic and that it could be used as a tool for teaching basic psychomotor skills in laparoscopic surgery (Likert score: 4.07-4.73). The sources of content-related validity evidence showed that this study’s simulator is a reliable training tool and that the exercises enable learning of the basic psychomotor skills required in MIS (Likert score: 4.28-4.67).

Conclusions

The development of gesture-based 3D virtual environments for training and learning basic psychomotor skills in MIS opens up a new approach to low-cost, portable simulation that allows ubiquitous learning and preoperative warm-up. Fidelity to the criterion was duly evaluated, which allowed a good enough prototype to be achieved. Content-related validity evidence for SIMISGEST-VR was also obtained.

The interactive effect of preoperative consultation and operating room admission by a counselor on anxiety level and vital signs in patients undergoing Coronary Artery Bypass Grafting surgery. A clinical trial study

OBJECTIVES

The purpose of this study was to provide appropriate preoperative supportive conditions to improve anxiety and vital signs for patients undergoing Coronary Artery Bypass Grafting -CABG- surgery.

METHODS

This clinical trial study was performed on 90 patients undergoing CABG surgery in Farshchian Hospital of Hamadan, Iran in 2019. Sample was selected by convenience and were randomly divided into three groups: control (n=30), intervention1 (n=30), and intervention2 (n=30). The control group received only the routine preoperative counseling of ward and admitted to the operating room as usual; the intervention1 and intervention2 groups in addition received another two counseling sessions, then the intervention1 group was admitted in the operating room as usual, but the intervention2 group was admitted by the counselor in the operating room. Data were collected using a three-part questionnaire including demographic characteristics, vital signs chart, and the Spielberger's State-Trait Anxiety Inventory.

RESULTS

The results showed that there was a significant difference in the mean anxiety of the three groups after admission in the operating room (intervention2 was lower than intervention1 and control groups, p<0.001; and intervention 1 group was lower than control group, p<0.001) and also there was a significant difference between the mean systolic blood pressure, heart rate and respiratory rate of the three groups (p <0.001) but the mean of the variables of temperature and diastolic blood pressure in the three groups were not significantly different (p=0.59 and p=0.225, respectively).

CONCLUSIONS

Our results revealed preoperative consultation and admission in the operating room by the consultant can reduce the level of anxiety and stability of vital signs of patients undergoing CABG.

Methods of Orienting New Anesthesiology Residents to the Operating Room Environment: A National Survey of Residency Program Directors

BACKGROUND

The initial weeks of clinical anesthesiology are a formative period for new residents. Trainees may be clinically educated by a variety of individuals, and introductory didactic structure likely differs between institutions. This study was undertaken to define current orientation practices in US anesthesiology residency programs.

METHODS

A survey was created using Qualtrics© software and distributed to all US anesthesiology residency program directors through the Society of Academic Associations of Anesthesiology & Perioperative Medicine email newsletter and through direct email to program directors.

RESULTS

Fifty-six unique survey responses were received of 156 total programs. Eighty-nine percent of programs with an integrated intern year begin anesthesia-related orientation before the first year of clinical anesthesiology. Sixty-three percent of programs pair trainees with more than one specific individual during orientation. Programs most frequently pair trainees with anesthesiologists (75%) and/or senior residents (70%). Forty-six percent maintain this pairing for 4 weeks and 30% for 6 weeks or longer. Forty-three percent provide education on teaching practices to trainers. Introductory didactics last a median of 30 hours. Programs may blend lectures, simulations/workshops, digital content, problem-based learning, pocket references, and/or checklists into a cohesive introductory curriculum. Fifty-six percent begin call responsibilities in the sixth week of orientation or later.

CONCLUSIONS

Orientation practices for clinical anesthesia training vary across residency programs in the United States. We hope this information will help program directors compare their orientation practices to other programs and identify best practices and potentially useful variations.

The Impact of Patient, Procedural, and Staffing Factors Upon Ureteroscopy Cost

Introduction: The purpose of this study was to evaluate factors during ureteroscopy that can potentially impact procedure cost. Materials and Methods: A retrospective review of 129 consecutive elective ureteroscopy cases was performed to determine direct procedure cost. Direct cost was defined as cost incurred because of operating room expenses, including operating room time, staffing expenses, equipment, and supply costs. Data regarding patient, procedural, and operating room staffing characteristics were compared between the most and least expensive cases. Univariate and logistic regression analysis were performed to identify factors predictive of higher costs. Results: The average direct ureteroscopy cost was $3298/case. On univariate analysis, ureteroscopies in the highest 50th cost percentile had larger stone burden (170.1 vs 146 mm²; p = 0.03) and longer operative times (95.3 vs 49.9 minutes; p < 0.01), were more likely performed for non-stone indications (21.4% vs 7.2%; p = 0.03), more likely to include a resident (65.5% vs 43.6%; p = 0.02), and less likely to have a dedicated urology scrub technician (38.2% vs 61.8%; p = 0.01) compared to cases in the lowest 50th percentile. The presence of a resident, larger stone burden, absence of a dedicated scrub technician, and longer operative time were associated with an average cost increase of $516, $700, $1122, and $1401, respectively. Logistic regression analysis showed that operating room time was the only factor predicting higher cost (OR [odds ratio] 12.8, 95% confidence interval [CI] 2.0-84.0). A post-hoc logistic regression analysis demonstrated that the presence of a resident during ureteroscopy (OR 2.9, 95% CI 1.1-8.0) and larger stone burden (OR 1.01, 95% CI 1.0-1.013) were significantly associated with longer operative times. Conclusion: Operating room time is the primary determinant of ureteroscopy case cost. All efforts should be made to decrease operative time, although balancing patient safety and maintaining a quality training environment.

A qualitative study of how inter-professional teamwork influences perioperative nursing

Aim

To explore Norwegian operating room nurses' perceptions of how team skills in the inter-professional operating room team influence perioperative nursing in relation to patient safety.

Design

A qualitative, descriptive study based on interviews.

Methods

Ten operating room nurses (N = 10) employed in four Norwegian hospitals were interviewed individually. A qualitative inductive content analysis was conducted. The study was reported adhering to the Consolidated Criteria for Reporting Qualitative Research Checklist.

Results

Three generic categories, containing three subcategories each, were identified illuminate the operating room nurses' perceptions. The operating room team's team skills influence on (a) the quality of perioperative nursing, about task performance, result for the patient and learning; (b) the progress of perioperative nursing, by keeping focus on the task, being prepared and task distribution and (c) the operating room nurses' work environment in the operating room, including confidence, stress and energy use and irritation or job satisfaction.

Reducing preoperative anxiety with Child Life preparation prior to intravenous induction of anesthesia: A randomized controlled trial

BACKGROUND

Induction of anesthesia can be stressful: Up to 60% of children suffer significant anxiety immediately before surgery. Anxiety is associated with higher postoperative analgesia requirements, higher incidence of emergence delirium, and detrimental effects on sleep and behavior. Child Life preparation includes role-play, expectation-setting, and teaching coping strategies. AIM : The aim of this trial was to determine whether preoperative Child Life preparation reduces anxiety prior to intravenous induction of anesthesia.

METHODS

Children aged 3-10 years, with no known preexisting anxiety and no preoperative anxiolytics, undergoing elective day surgery lasting ≤ 2 hours, were enrolled in a randomized controlled trial. Each child's baseline anxiety was assessed in the anesthetic care unit, using the modified Yale Preoperative Anxiety Scale-Short Form (mYPAS-SF, observational scores from 22.9, minimal anxiety, to 100, maximal anxiety) as the primary outcome. The child was randomly assigned to intervention (minimum 15 minutes Child Life preparation) or control (standard practice without Child Life preparation). Participants entered the operating room with one parent. A researcher (blinded to group allocation) scored the child's operating room anxiety using mYPAS-SF, up to the first attempt at intravenous cannulation.

RESULTS

Fifty-nine children completed the study, aged median [interquartile range] 5 [3-7] years. Baseline mYPAS-SF anxiety was 29.2 [22.9-37.5] for all children, and operating room anxiety was 29.2 [22.9-49.0]. Operating room anxiety was higher than baseline in 16/31 (52%) children in the control group and 6/28 (21%) in the Child Life preparation group. ANCOVA revealed a significant effect of baseline mYPAS-SF anxiety and group on operating room anxiety (F = 10.31, P < .001, adjusted R²  = .24); individual parameter estimates indicated that Child Life preparation reduced operating room anxiety by 13.8 (95% CI 4.4-23.1) points compared to control, P = .005.

CONCLUSION

A brief, targeted Child Life preparation session had a statistically significant effect on reducing preoperative anxiety prior to intravenous induction of anesthesia in young children, with no known preexisting anxiety. This effect may be clinically important and suggests that Child Life can be a valuable component of pediatric surgical care. Further research is required in specific populations.

Evaluating Usability of a Touchless Image Viewer in the Operating Room

BACKGROUND

Availability of patient-specific image data, gathered from preoperatively conducted studies, like computed tomography scans and magnetic resonance imaging studies, during a surgical procedure is a key factor for surgical success and patient safety. Several alternative input methods, including recognition of hand gestures, have been proposed for surgeons to interact with medical image viewers during an operation. Previous studies pointed out the need for usability evaluation of these systems.

OBJECTIVES

We describe the accuracy and usability of a novel software system, which integrates gesture recognition via machine learning into an established image viewer.

METHODS

This pilot study is a prospective, observational trial, which asked surgeons to interact with software to perform two standardized tasks in a sterile environment, modeled closely to a real-life situation in an operating room. To assess usability, the validated "System Usability Scale" (SUS) was used. On a technical level, we also evaluated the accuracy of the underlying neural network.

RESULTS

The neural network reached 98.94% accuracy while predicting the gestures during validation. Eight surgeons with an average of 6.5 years of experience participated in the usability study. The system was rated on average with 80.25 points on the SUS.

CONCLUSION

The system showed good overall usability; however, additional areas of potential improvement were identified and further usability studies are needed. Because the system uses standard PC hardware, it made for easy integration into the operating room.

A comparative study on patient safety attitude between nurses and doctors in operating rooms

OBJECTIVE

To investigate and compare the attitudes of operating room nurses and doctors regarding patient safety, performance of surgical time-out and recognition of count error.

METHODS

This cross-sectional study recruited operating room nurses, surgeons and anaesthesiologists between 1 August 2015 and 5 February 2016. A Safety Attitude Questionnaire was used to analyse the three elements in both groups of operating room staff (nurses and doctors).

RESULTS

The study analysed the questionnaires from 171 participants; 95 nurses (55.6%) and 76 doctors (44.4%). Differences exist between doctors and nurses regarding teamwork climate, working conditions, perception of management and the recognition of stress. On the performance of surgical time-out, nurses showed higher scores on way of counting, while doctors showed higher scores on the time-out procedure itself. Also, doctors believed they actively cooperated with the nurses, while nurses believed they did not receive cooperation. Scores for the recognition of count error were higher in nurses than in doctors. More experienced operating room staff showed higher scores than younger less experienced staff.

CONCLUSIONS

Perceptual differences among doctors and nurses need to be minimized for the safety of the patient in the operating room.

Measuring the teamwork performance of operating room teams: a systematic review of assessment tools and their measurement properties

Teamwork is fundamental to surgical patient safety but is inconsistently measured. While many tools have been developed for elective intraoperative situations, it is unclear which is the most robust. This systematic review aimed to identify tools to measure the teamwork of operating room teams. Studies were included if they examined the measurement properties of these tools. PsycINFO, Embase (via OVID), CINAHL, ERIC, Medline and Medline in Process (via OVID) were searched through to May 3, 2019, as were reference lists of included studies and previously published relevant reviews. Retrieved articles were screened and data extracted in duplicate by two independent reviewers. Quality was assessed using the COSMIN checklist. Of the 2121 references identified, 14 studies of six assessment tools were included. Tools were validated across various specialties, mostly in clinical rather than simulated settings. The Observational Teamwork Assessment for Surgery (OTAS) and Operating Theater Team Non-Technical Skills Assessment Tool (NOTECHS) were the most frequently investigated tools. Though acceptable for assessing teamwork, both NOTECHS and OTAS rely on the questionable assumption that the teamwork of a team is equivalent to the sum of individual performances. Future studies may investigate other assessment tools that assess the whole team as the unit of analysis along with the potential of these tools to provide healthcare providers with meaningful feedback in clinical practice.

Minimax c th percentile of makespan in surgical scheduling

In this paper, we address the problem of finding an assignment of n surgeries to be performed in one of m parallel identical operating rooms (ORs), given each surgery has a stochastic duration with a known mean and standard deviation. The objective is to minimise the maximum of the c^th percentile of makespan of any OR. We formulate this problem as a nonlinear integer program, and small-sized instances are solved using the GAMS BONMIN solver. We develop a greedy heuristic and a genetic algorithm procedure for solving large-sized instances. Using real data from a major U.S. teaching hospital and benchmarking datasets from the literature, we report on the performance of the heuristics as compared to the GAMS BONMIN solver.