Innovations towards achieving environmentally sustainable operating theatres: A systematic review

INTRODUCTION

The NHS accounts for 5.4% of the UK's total carbon footprint, with the perioperative environment being the most resource hungry aspect of the hospital. The aim of this systematic review was to assimilate the published studies concerning the sustainability of the perioperative environment, focussing on the impact of implemented interventions.

METHODS

A systematic review was performed using Pubmed, OVID, Embase, Cochrane database of systematic reviews and Medline. Original manuscripts describing interventions aimed at improving operating theatre environmental sustainability were included.

RESULTS

675 abstracts were screened with 34 manuscripts included. Studies were divided into broad themes; recycling and waste management, waste reduction, reuse, reprocessing or life cycle analysis, energy and resource reduction and anaesthetic gases. This review summarises the interventions identified and their resulting effects on theatre sustainability.

DISCUSSION

This systematic review has identified simple, yet highly effective interventions across a variety of themes that can lead to improved environmental sustainability of surgical operating theatres. Combining these interventions will likely result in a synergistic improvement to the environmental impact of surgery.

Recommendations for Orthopedic Surgeons during the COVID-19 Pandemic

BACKGROUND

Toward the end of 2019, the coronavirus disease-2019 (COVID-19) pandemic began to create turmoil for global health organizations. The illness, caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), spreads by droplets and fomites and can rapidly lead to life-threatening lung disease, especially for the old and those with health co-morbidities. Treating orthopedic patients, who presented with COVID-19 while avoiding nosocomial transmission, became of paramount importance.

OBJECTIVES

To present relevant methods for pandemic control and hospital accommodation with emphasis on orthopedic surgery.

METHODS

We searched search PubMed and Google Scholar electronic databases using the following keywords: COVID-19, SARS-CoV-2, screening tools, personal protective equipment, and surgery triage.

RESULTS

We included 25 records in our analysis. The recommendations from these records were divided into the following categories: COVID-19 disease, managing orthopedic surgery in the COVID-19 era, general institution precautions, triage of orthopedic surgeries, preoperative assessment, surgical room setting, personal protection equipment, anesthesia, orthopedic surgery technical precautions, and department stay and rehabilitation.

CONCLUSIONS

Special accommodations tailored for each medical facility, based on disease burden and available resources can improve patient and staff safety and reduce elective surgery cancellations. This article will assist orthopedic surgeons during the COVID-19 medical crisis, and possibly for future pandemics.

Improvement in student-led debriefing analysis after simulation-based team training using a revised teamwork assessment tool

BACKGROUND

Team debriefing is an important teamwork development intervention for improving team outputs in healthcare. Debriefing is a key component of experiential team training teamwork development interventions such as simulation-based training. Improving the quality of debriefing of healthcare teams, therefore, has multiple benefits. We investigated whether the quality of student-led debriefing improved using a shortened guide.

METHODS

Senior medical students, nurse anesthesia students, and senior undergraduate nursing students participated in student operating room team training at a health sciences center in the southeastern United States. Student teams participated in a dual-scenario simulation-based training session with immediate after-action debriefings after each scenario. In 2018, student teams conducted the second debriefing using as a guide the teamwork assessment scale, an 11-item, 3-subscale, 6-point Likert-type instrument. In 2019, they used a shortened, revised, 5-item version of the teamwork assessment scale, the quick teamwork assessment scale. Trained observers rated the quality of the student-led debriefings using the Objective Structured Assessment of Debriefing, an 8-item, 5-point instrument. The Wilcoxon-Mann-Whitney test was used to compare the teamwork assessment scale-guided and the quick teamwork assessment scale-guided mean item debriefing scores.

RESULTS

Two observers rated 3 student-led team debriefings using the teamwork assessment scales as a guide in 2018, and 6 such debriefings happened using the quick teamwork assessment scale as a guide in 2019. For each debriefing, observer scores were averaged for each Objective Structured Assessment of Debriefing item; these mean scores were then averaged with other mean scores for each year. The use of the quick teamwork assessment scale resulted in a statistically significant higher mean score for the Analysis Objective Structured Assessment of Debriefing item compared with the use of the teamwork assessment scale (4.92 [standard deviation 0.20] versus 3.83 [standard deviation 0.76], P = .023).

CONCLUSION

The use of a shortened teamwork assessment instrument as a debriefing guide for student teams in student operating room team training was more effective in analysis of actions than the original, longer tool. Next steps include determining the efficacy of the quick teamwork assessment scale in an actual clinical setting.

Unmasking bias and perception of lead surgeons in the operating room: A simulation based study

BACKGROUND

Perception of a surgeon based on physical attributes in the operating room (OR) environment has not been assessed, which was our primary goal.

METHODS

A common OR scenario was simulated using 8 different actors as a lead surgeon with combinations of age (<40 vs. >55), race (white vs. black), and gender (male vs. female). One video scenario with a survey was electronically distributed to surgeons, residents, and OR nurses/staff. The overall rating, assessment, and perception of the lead surgeon were assessed.

RESULTS

Of 974 respondents, 64.5% were females. There were significant differences in the rating and assessment based upon surgeon's age (p = .01) favoring older surgeons. There were significant differences in the assessments of surgeons by the study group (p = .03). The positive assessments as well as perceptions trended highest towards male, older, and white surgeons, especially in the stressful situation.

CONCLUSION

While perception of gender bias may be widespread, age and race biases may also play a role in the OR. Inter-professional education training for OR teams could be developed to help alleviate such biases.

Using performance frontiers to differentiate elective and capacity-based surgical services

BACKGROUND

Acute care surgery (ACS) model of care delivery has many benefits. However, since the ACS surgeon has limited control over the volume, timing, and complexity of cases, traditional metrics of operating room (OR) efficiency almost always measure ACS service as "inefficient." The current study examines an alternative method-performance fronts-of evaluating changes in efficiency and tests the following hypotheses: (1) in an institution with a robust ACS service, performance front methodology is superior to traditional metrics in evaluating OR throughput/efficiency, and (2) introduction of an ACS service with block time allocation will improve OR throughput/efficiency.

METHODS

Operating room metrics 1-year pre-ACS implementation and post-ACS implementation were collected. Overall OR efficiency was calculated by mean case volumes for the entire OR and ACS and general surgery (GS) services individually. Detailed analysis of these two specific services was performed by gathering median monthly minutes-in block, out of block, after hours, and opportunity unused. The two services were examined using a traditional measure of efficiency and the "fronts" method. Services were compared with each other and also pre-ACS implementation and post-ACS implementation.

RESULTS

Overall OR case volumes increased by 5% (999 ± 50 to 1,043 ± 46: p < 0.05) with almost all of the increase coming through ACS (27 ± 4 to 68 ± 16: p < 0.05). By traditional metrics, ACS had significantly worse median efficiency versus GS in both periods: pre (0.67 [0.66-0.71] vs. 0.80 [0.78-0.81]) and post (0.75 [0.53-0.77] vs. 0.83 [0.84-0.85]) (p < 0.05). As compared with the pre, GS efficiency improved significantly in post (p < 0.05), but ACS efficiency remained unchanged (p > 0.05). The alternative fronts chart demonstrated the more accurate picture with improved efficiency observed for GS, ACS, and combined.

CONCLUSION

In an institution with a busy ACS service, the alternative fronts methodology offers a more accurate evaluation of OR efficiency. The provision of an OR for the ACS service improves overall throughput/efficiency.

The Vanguard Study: Human Performance Evaluation of UK National Organ Retrieval Service Teams Utilizing a Single Scrub Practitioner in Multiorgan Retrieval

BACKGROUND

The National Organ Retrieval Service (NORS) 2015 review recommended a single scrub practitioner provide support simultaneously to abdominal and cardiothoracic teams in UK multiorgan retrieval. Previously, this model had been used only by the combined abdominal and cardiac team in Scotland. This study reports the impact on performance as part of the Vanguard project, which utilized the single scrub practitioner role with 5 NORS teams, to determine applicability United Kingdom wide.

METHODS

Participants comprised members of abdominal (n = 56) and cardiothoracic (n = 54) teams attending UK thoraco-abdominal retrievals. Data were collected by validated psychometric scales to assess individual workload, anxiety, confidence, demands/coping resources, and teamwork. Additional data were collected through open comments and quantitative data describing context and outcome of retrieval.

RESULTS

Abdominal and cardiothoracic teams showed different responses when using single (Vanguard) or dual scrub practitioners (Standard). Vanguard configuration was associated with significantly higher anxiety for abdominal but not cardiothoracic teams. Perceived workload increased for abdominal teams during Vanguard but decreased for cardiothoracic teams. Scrub practitioners reported elevated anxiety and decreased confidence in retrievals using Vanguard configuration.

CONCLUSIONS

This is the first large study examining human performance during organ retrieval in the United Kingdom. Despite previous regional success, this study showed a significant negative impact of the single scrub practitioner when extrapolated widely to UK teams. As a result of this study, NORS declined to implement the single scrub model. These data support the use of human performance analysis as an essential part of successful development in organ retrieval practice.

Examining the Development of Operative Autonomy in Vascular Surgery Training and When Trainees and Program Directors Agree and Disagree

BACKGROUND

Lack of autonomy in the operating room (OR) during general surgery residency is a major contributing factor to low confidence operating independently after graduation. Although attempts to address decreased autonomy and development of entrustment in the OR are being made in general surgery programs, this issue has not been examined thoroughly in vascular surgery. We sought to determine barriers and opportunities for developing operative autonomy during vascular surgery training by surveying program directors (PDs) and trainees (integrated residents and fellows) in U.S. vascular surgery training programs.

METHODS

An anonymous electronic survey was sent via email to all PDs (n = 155) and trainees (n = 516) in United States vascular surgery training programs. Demographics, academic characteristics, and responses regarding factors impacting the development of entrustment were collected.

RESULTS

Thirty-five PDs and 100 trainees completed the survey (22.5% and 19.4% response rate, respectively). Sixty percent of trainees were integrated residents and 40% were fellows. Twenty percent of PDs and 33% of trainees were female, and 5% of all PDs and trainees were from underrepresented minorities. The single most positive factor affecting the development of autonomy according to trainees and PDs is familiarity of the faculty with the trainee. Both PDs and trainees thought the trainee's preparation for the case positively affected development of autonomy; however, more PDs believed that involvement with preoperative preparation in particular (marking the patient, consenting the patient, filling out a history and physical, prepping and draping the patient) was important (P < 0.05). PDs believed that duty-hour limitations negatively affected the trainee's ability to develop autonomy in the OR, whereas more trainees believed that hospital or OR efficiency policies played a negative role (P < 0.05). Finally, compared with trainees, PDs believed that the appropriate amount of time for safe struggle before the attending should take over the case was when OR efficiency was compromised or at any moment the trainee is unsure of themselves (P < 0.05); trainees believed that the attending should take over the case after the limit of their skill set or troubleshooting ability was reached (P < 0.05).

CONCLUSIONS

Familiarity of the attending physician with the trainee is an important positive factor for development of entrustment and autonomy in vascular surgery trainees. Duty-hour limitations and belief of the need for hospital efficiency may negatively impact operative independence of trainees. An open discussion about balancing OR efficiency and trainees' safe struggle is essential to address the growth of independent operative skills in vascular surgery trainees.

Sizing of airborne particles in an operating room

Medical procedures that produce aerosolized particles are under great scrutiny due to the recent concerns surrounding the COVID-19 virus and increased risk for nosocomial infections. For example, thoracostomies, tracheotomies and intubations/extubations produce aerosols that can linger in the air. The lingering time is dependent on particle size where, e.g., 500 μm (0.5 mm) particles may quickly fall to the floor, while 1 μm particles may float for extended lengths of time. Here, a method is presented to characterize the size of <40 μm to >600 μm particles resulting from surgery in an operating room (OR). The particles are measured in-situ (next to a patient on an operating table) through a 75mm aperture in a ∼400 mm rectangular enclosure with minimal flow restriction. The particles and gasses exiting a patient are vented through an enclosed laser sheet while a camera captures images of the side-scattered light from the entrained particles. A similar optical configuration was described by Anfinrud et al.; however, we present here an extended method which provides a calibration method for determining particle size. The use of a laser sheet with side-scattered light provides a large FOV and bright image of the particles; however, the particle image dilation caused by scattering does not allow direct measurement of particle size. The calibration routine presented here is accomplished by measuring fixed particle distribution ranges with a calibrated shadow imaging system and mapping these measurements to the in-situ imaging system. The technique used for generating and measuring these particles is described. The result is a three-part process where 1) particles of varying sizes are produced and measured using a calibrated, high-resolution shadow imaging method, 2) the same particle generators are measured with the in-situ imaging system, and 3) a correlation mapping is made between the (dilated) laser image size and the measured particle size. Additionally, experimental and operational details of the imaging system are described such as requirements for the enclosure volume, light management, air filtration and control of various laser reflections. Details related to the OR environment and requirements for achieving close proximity to a patient are discussed as well.

Association of In-Ear Device Use With Communication Quality Among Individuals Wearing Personal Protective Equipment in a Simulated Operating Room

IMPORTANCE

The COVID-19 pandemic has brought forth new challenges for health care workers, such as the daily use of personal protective equipment, including reusable facial respirators. Poor communication while wearing respirators may have fatal complications for patients, and no solution has been proposed to date.

OBJECTIVE

To examine whether use of an in-ear communication device is associated with improved communication while wearing different personal protective equipment (N95 mask, half-face elastomeric respirator, and powered air-purifying respirator [PAPR]) in the operating room.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study was conducted in June 2020. Surgical residents from the Department of Otolaryngology-Head and Neck Surgery at McGill University in Montreal, Quebec, Canada, were recruited. All participants had normal hearing, were fluent in English, and had access to the operating rooms at the Royal Victoria Hospital.

EXPOSURES

All participants performed the speech intelligibility tasks with and without an in-ear communication device.

MAIN OUTCOMES AND MEASURES

Speech intelligibility was measured using a word recognition task (Modified Rhyme Test) and a sentence recognition task (AzBio Sentence Test). A percentage correct score (0% to 100%) was obtained for each speech intelligibility test. Listening effort was assessed using the NASA Task Load Index. An overall workload score, ranging from 0 points (low workload) to 100 points (high workload), was obtained.

RESULTS

A total of 12 participants were included (mean [SD] age, 31.2 [1.9] years; 8 women [66.7%]). AzBio Sentence Test results revealed that, while wearing the N95 mask, the mean (SD) speech intelligibility was 98.8% (1.8%) without the in-ear device vs 94.3% (7.4%) with the device. While wearing the half-face elastomeric respirator, the mean speech intelligibility was 58.5% (12.4%) without the in-ear device vs 90.8% (8.9%) with the device. While wearing the PAPR, the mean speech intelligibility was 84.6% (9.8%) without the in-ear device vs 94.5% (5.5%) with the device. Use of the in-ear device was associated with a significant improvement in speech intelligibility while wearing the half-face elastomeric respirator (32.3%; 95% CI, 23.8%-40.7%; P < .001) and the PAPR (9.9%; 95% CI, 1.4%-18.3%; P = .01). Furthermore, use of the device was associated with decreased listening effort. The NASA Task Load Index results reveal that, while wearing the N95 mask, the mean (SD) overall workload score was 12.6 (10.6) points without the in-ear device vs 17.6 (9.2) points with the device. While wearing the half-face elastomeric respirator, the mean overall workload score was 67.7 (21.6) points without the in-ear device vs 29.3 (14.4) points with the in-ear device. While wearing the PAPR, the mean overall workload score was 42.2 (18.2) points without the in-ear device vs 23.8 (12.8) points with the in-ear device. Use of the in-ear device was associated with a significant decrease in overall workload score while wearing the half-face elastomeric respirator (38.4; 95% CI, 23.5-53.3; P < .001) and the PAPR (18.4; 95% CI, 0.4-36.4; P = .04).

CONCLUSIONS AND RELEVANCE

This study found that among participants using facial respirators that impaired communication, a novel in-ear device was associated with improved communication and decreased listening effort. Such a device may be a feasible solution for protecting health care workers in the operating room while allowing them to communicate safely, especially during the COVID-19 pandemic.

Emergency surgical management of cervical spine fracture-dislocation with acute paraplegia in COVID-19 (Coronavirus disease 2019)-suspected patient: first experience from a German spine centre

PURPOSE

We present an organized hospital plan for the management of Coronavirus disease (COVID-19) patients requiring emergency surgical interventions. To introduce a multidisciplinary approach for the management of COVID-19-infected patients and to report the first operated patient in the Corona unit.

METHODS

A detailed presentation of the hospital plan for a separate Corona unit with its intensive care unit and operating rooms. Description of the management of the first spine surgery case treated in this unit.

RESULTS

The Corona unit showed a practical approach for the management of an emergency cervical spine fracture-dislocation with acute paralysis. The patient is 92-year-old female. The mechanism of injury was a simple fall during the stay in the internal medicine department where the patient was treated in the referring hospital. The patient had no other injuries and was awake and oriented. The patient did not have the clinical symptom of COVID-19, and the test result of COVID-19 done in the referring hospital was not available on admission in our emergency room. Education of the medical staff and organization of the operating theatre facilitated the management of the patient without an increased risk of spreading the infection.

CONCLUSIONS

The current COVID-19 pandemic requires an extra-ordinary organization of the medical and surgical care of the patients. It is possible to manage an infected or a potentially infected patient surgically, but a multidisciplinary plan is necessary to protect other patients and the medical staff.

[Cancellations of Elective Surgeries on the Day of the Operation in a Portuguese Hospital: One Year Overview]

INTRODUCTION

Cancellations of elective operations on the day of the surgery reflect the efficiency and quality within organisations, and have a significant clinical, social and economic impact, not only for the patient and their families, but also for healthcare institutions. This study assesses the extent of these cancellations in one public Portuguese hospital, through case quantification and identification of the causes, origin, as well as its predictability according to the sociodemographic variables of the patient and interventions used to decrease it.

MATERIAL AND METHODS

Non-experimental descriptive quantitative methodology - longitudinal and retrospective - of operation cancellation cases on the day of the surgery, from the 1st of January to the 31st of December 2018.

RESULTS

The rate of cancellations of elective surgeries on the same day of the operation was 2.9% with variations among different surgical specialties; cancelled operations are more frequent in female patients, in patients aged between 50 and 80 years old, physical status classified as II or III according to the American Society of Anesthesiology, and without anaesthetic pre assessment or preoperative consultations; the three most relevant causes for cancellations are: lack of operative time, scarcity of beds and/or medical equipment, and changes in health status; most of which can be avoided and are the responsibility of the institution.

DISCUSSION

Different reasons for cancellation of elective operations reflect a variety of upstream and downstream processes causing cancellation of surgeries and whose origin/imputability is related to both the institution and patients.

CONCLUSION

The rate of cancellations of elective surgeries on the same day of the operation is relatively low, but the causes are often preventable, thus justifying the generalization of cancellation reduction strategies.

Using Simulation-Based Education to Improve Team Communication During a Massive Transfusion Protocol in the OR

Hemorrhaging during operative and other invasive procedures can result in devastating outcomes for surgical patients. An effective plan of action in the form of a massive transfusion protocol (MTP), along with teamwork and clear communication among OR personnel, is critical during a hemorrhagic crisis to improve patient outcomes. However, perioperative personnel may be unprepared to manage a hemorrhagic crisis because they lack experiential knowledge of these uncommon, high-risk scenarios. Perioperative leaders at a 500-bed acute-care hospital in the Midwest developed an educational activity involving a video-recorded simulated MTP scenario, learning modules, and debriefing sessions to educate more than 150 employees. Perioperative personnel received pre-education and watched the video-recorded MTP simulation together, and then participated in team debriefings after watching the video. Based on team debriefings and evaluation feedback, most staff members believed that the activity improved team communication.

Changes in Neuroanesthesia Practice During the Early Stages of the COVID-19 Pandemic: Experiences From a Single Center in China

BACKGROUND

Coronavirus disease 2019 (COVID-19), caused by a novel coronavirus, is highly contagious. Global medical systems have been heavily impacted by the COVID-19 pandemic. Although the majority of patients with intracranial disease require time-sensitive surgery, how to conduct neurosurgery and prevent and control nosocomial infection during a pandemic is challenging.

MATERIALS AND METHODS

We retrospectively reviewed the clinical data of patients undergoing neurosurgical and neurointerventional procedures at Beijing Tiantan Hospital, China during the early stages of the COVID-19 pandemic between January 21 and July 31, 2020. A 3-level system of COVID-19 risk was established based on medical conditions, epidemiologic, and symptom inquiry and the results of triage. A transitional unit was established for patients in whom COVID-19 had not been ruled out on admission to hospital.

RESULTS

A total of 4025 patients underwent neurosurgery during the study period, including 768 emergent and 3257 nonemergent procedures. Of these patients, 3722 were low-risk for COVID-19, 303 were moderate-risk, and none were high-risk. In addition, 1419 patients underwent neurointerventional procedures, including 114 emergent and 1305 nonemergent interventions, of which 1339 were low-risk patients, 80 were moderate-risk and none were high-risk. A total of 895 patients (neurosurgical and neurointerventional) were admitted to the transitional unit. Forty-five patients were diagnosed with COVID-19 and transferred to the COVID-19 designated hospital. There were no cases of COVID-19 nosocomial infections among surgical patients or health care workers.

CONCLUSION

On the basis of our single-center experience, developing a full screening protocol for COVID-19, establishing a risk level, and using a transitional unit for those with unknown COVID-19 status are effective measures to provide a safe environment for patients and health care workers.

Probabilistic forecasting of surgical case duration using machine learning: model development and validation

OBJECTIVE

Accurate estimations of surgical case durations can lead to the cost-effective utilization of operating rooms. We developed a novel machine learning approach, using both structured and unstructured features as input, to predict a continuous probability distribution of surgical case durations.

MATERIALS AND METHODS

The data set consisted of 53 783 surgical cases performed over 4 years at a tertiary-care pediatric hospital. Features extracted included categorical (American Society of Anesthesiologists [ASA] Physical Status, inpatient status, day of week), continuous (scheduled surgery duration, patient age), and unstructured text (procedure name, surgical diagnosis) variables. A mixture density network (MDN) was trained and compared to multiple tree-based methods and a Bayesian statistical method. A continuous ranked probability score (CRPS), a generalized extension of mean absolute error, was the primary performance measure. Pinball loss (PL) was calculated to assess accuracy at specific quantiles. Performance measures were additionally evaluated on common and rare surgical procedures. Permutation feature importance was measured for the best performing model.

RESULTS

MDN had the best performance, with a CRPS of 18.1 minutes, compared to tree-based methods (19.5-22.1 minutes) and the Bayesian method (21.2 minutes). MDN had the best PL at all quantiles, and the best CRPS and PL for both common and rare procedures. Scheduled duration and procedure name were the most important features in the MDN.

CONCLUSIONS

Using natural language processing of surgical descriptors, we demonstrated the use of ML approaches to predict the continuous probability distribution of surgical case durations. The more discerning forecast of the ML-based MDN approach affords opportunities for guiding intelligent schedule design and day-of-surgery operational decisions.

Our experiences of resuming services in ENT departments in Wuhan, once a COVID-19 epicenter

The pandemic of coronavirus disease 2019 (COVID-19) showed a significant impact on routine daily services in departments of otorhinolaryngology head and neck surgery. The city of Wuhan, as the first reported epicenter in the world, resumed medical service since April 8, 2020. As the biggest ENT services provider in Wuhan, we share out institution's triage and screening system in the resuming period.

Use of a Modified Rep Model in Primary Joint Arthroplasty: Lessons Learned

Orthopedic implant device sales representatives ("reps") can provide intraoperative guidance based on their product knowledge, as part of their many responsibilities. However, for experienced high-volume arthroplasty surgeons, a representative may not be required in the room for most primary total knee arthroplasty (TKA) procedures. The goal of this study was to describe the authors' experience with a modified rep model for primary TKA. Between January and December 2017, a total of 100 unilateral primary TKAs were performed with a modified rep model and compared with 100 primary TKAs that were performed before this protocol. The authors adopted 2 additional initiatives to institute this protocol safely: (1) improved education of operating room staff and allocation of responsibilities; and (2) reengineering of the existing surgical trays. No perioperative complications, including readmission, periprosthetic fracture, or infection, occurred in either group. In addition, no difference was found in mean length of stay between the modified rep and conventional cohorts (2.2 and 2.4 days, respectively; P=.49). Mean operating room time was less with the modified rep cohort (102.1 vs 117.8 minutes; P<.001), as was total instrument turnover time in the operating room (13.9 vs 29.7 minutes; P<.0001) and in central sterilization (59.4 vs 126.8 minutes; P<.001). No errors occurred with implant accuracy or trays, and there was no need to change the type of implant with the modified rep model, compared with 6% of trays requiring additional sterilization with the conventional model. The negotiated implant cost with the modified rep model was approximately $2000 less than that for the conventional group. This study found that the modified rep model for primary TKA is safe and has the potential for substantial cost savings. [Orthopedics. 2020;43(6):e538-e542.].

The rapid transformation of cardiac surgery practice in the coronavirus disease 2019 (COVID-19) pandemic: insights and clinical strategies from a centre at the epicentre

OBJECTIVES

The onset of the coronavirus disease 2019 (COVID-19) pandemic has forced our cardiac surgery programme and hospital to enact drastic measures that has forced us to change how we care for cardiac surgery patients, assist with COVID-19 care and enable support for the hospital in terms of physical resources, providers and resident training.

METHODS

In this review, we review the cardiovascular manifestations of COVID-19 and describe our system-wide adaptations to the pandemic, including the use of telemedicine, how a severe reduction in operative volume affected our programme, the process of redeployment of staff, repurposing of residents into specific task teams, the creation of operation room intensive care units, and the challenges that we faced in this process.

RESULTS

We offer a revised set of definitions of surgical priority during this pandemic and how this was applied to our system, followed by specific considerations in coronary/valve, aortic, heart failure and transplant surgery. Finally, we outline a path forward for cardiac surgery for the near future.

CONCLUSIONS

We recognize that individual programmes around the world will eventually face COVID-19 with varying levels of infection burden and different resources, and we hope this document can assist programmes to plan for the future.

Improving Transfusion Safety in the Operating Room With a Barcode Scanning System Designed Specifically for the Surgical Environment and Existing Electronic Medical Record Systems: An Interrupted Time Series Analysis

BACKGROUND

Manual processes for verifying patient identification before blood transfusion and documenting this pretransfusion safety check are prone to errors, and compliance with manual systems is especially poor in urgent operating room settings. An automated, electronic barcode scanner system would be expected to improve pretransfusion verification and documentation.

METHODS

Audits were conducted of blood transfusion documentation under a manual paper system from January to October 2014. An electronic barcode scanning system was developed to streamline transfusion safety checking and automate documentation. This system was implemented in 58 operating rooms between October and December 2014, with follow-up compliance audits through December 2015. The association of barcode scanner implementation with transfusion documentation compliance was assessed using an interrupted time series analysis. Anesthesia providers were surveyed regarding their opinions on the electronic system. In mid-2016, the scanning system was modified to transfer from the Metavision medical record system to Epic OpTime. Follow-up analysis assessed performance of this system within Epic during 2017.

RESULTS

In an interrupted time series analysis, the proportion of units with compliant documentation was estimated to be 19.6% (95% confidence interval [CI], 10.7-25.6) the week before scanner implementation, and 74.4% (95% CI, 59.4-87.4) the week after implementation. There was a significant postintervention level change (odds ratio 10.80, 95% CI, 6.31-18.70; P < .001) and increase in slope (odds ratio 1.14 per 1-week increase, 95% CI, 1.11-1.17; P < .001). After implementation, providers chose to use the new electronic system for 98% of transfusions. Across the 2 years analyzed (15,997 transfusions), the electronic system detected 45 potential transfusion errors in 27 unique patients, and averted transfusion of 36 mismatched blood products into 20 unique patients. A total of 69%, 86%, and 88% of providers reported the electronic system improved patient safety, blood transfusion workflow, and transfusion documentation, respectively. When providers used the barcode scanner, no transfusion errors or reactions were reported. The scanner system was successfully transferred from Metavision to Epic without retraining staff or changing workflows.

CONCLUSIONS

A barcode-based system designed for easy integration to different commonly used anesthesia information management systems was implemented in a large urban academic hospital. The system allows a single user with the assistance of a software system to perform and document pretransfusion safety verification. The system improved transfusion documentation compliance, averted potential transfusion errors, and became the preferred method of blood transfusion safety checking.

Resuming elective hip and knee arthroplasty after the first phase of the SARS-CoV-2 pandemic: the European Hip Society and European Knee Associates recommendations

PURPOSE

The Covid-19 pandemic has disrupted health care systems all over the world. Elective surgical procedures have been postponed and/or cancelled. Consensus is, therefore, required related to the factors that need to be in place before elective surgery, including hip and knee replacement surgery, which is restarted. Entirely new pathways and protocols need to be worked out.

METHODS

A panel of experts from the European Hip Society and European Knee Association have agreed to a consensus statement on how to reintroduce elective arthroplasty surgery safely. The recommendations are based on the best available evidence and have been validated in a separate survey.

RESULTS

The guidelines are based on five themes: modification and/or reorganisation of hospital wards. Restrictions on orthopaedic wards and in operation suite(s). Additional disinfection of the environment. The role of ultra-clean operation theatres. Personal protective equipment enhancement.

CONCLUSION

Apart from the following national and local guidance, protocols need to be put in place in the patient pathway for primary arthroplasty to allow for a safe return.

Caseload is increased by resequencing cases before and on the day of surgery at ambulatory surgery centers where initial patient recovery is in operating rooms and cleanup times are longer than typical

Study objective

The coronavirus disease 2019 (COVID-19) pandemic impacts operating room (OR) management in regions with high prevalence (e.g., >1.0% of asymptomatic patients testing positive). Cases with aerosol producing procedures are isolated to a few ORs, initial phase I recovery of those patients is in the ORs, and multimodal environmental decontamination applied. We quantified the potential increase in productivity from also resequencing these cases among those 2 or 3 ORs.

Design

Computer simulation provided sample sizes requiring >100 years experimentally. Resequencing was limited to changes in the start times of surgeons' lists of cases.

Setting

Ambulatory surgery center or hospital outpatient department.

Main results

With case resequencing applied before and on the day of surgery, there were 5.6% and 5.5% more cases per OR per day for the 2 ORs and 3 ORs, respectively, both standard errors (SE) < 0.1%. Resequencing cases among ORs to start cases earlier permitted increases in the hours into which cases could be scheduled from 10.5 to 11.0 h, while assuring >90% probability of each OR finishing within the prespecified 12-h shift. Thus, the additional cases were all scheduled before the day of surgery. The greater allocated time also resulted in less overutilized time, a mean of 4.2 min per OR per day for 2 ORs (SE 0.5) and 6.3 min per OR per day for 3 ORs (SE 0.4). The benefit could be achieved while limiting application of resequencing to days when the OR with the fewest estimated hours of cases has ≤8 h.

Conclusions

Some ambulatory surgery ORs have unusually long OR times and/or room cleanup times (e.g., infection control efforts because of the pandemic). Resequencing cases before and on the day of surgery should be considered, because moving 1 or 2 cases occasionally has little to no cost with substantive benefit.

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COVID-19 influences management for aerosol producing procedures.

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Simulation studied case resequencing applied before and on the day of surgery.

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>5% more queued cases can be done per OR per day with practical heuristic.

Adult Cardiac Surgery and the COVID-19 Pandemic: Aggressive Infection Mitigation Strategies Are Necessary in the Operating Room and Surgical Recovery

The COVID-19 pandemic necessitates aggressive infection mitigation strategies to reduce the risk to patients and healthcare providers. This document is intended to provide a framework for the adult cardiac surgeon to consider in this rapidly changing environment. Preoperative, intraoperative, and postoperative detailed protective measures are outlined. These are guidance recommendations during a pandemic surge to be used for all patients while local COVID-19 disease burden remains elevated.

Eco-responsibility in the operating theater: An urgent need for organizational transformation

Factors associating environmental degradation with human health have shown that air pollution is a source of morbi-mortality throughout the world. Unfortunately, hospitals are themselves "silent polluters". As healthcare professionals, we are the guarantors not only of quality of patient care, but also of proper hospital conduct. The aim of this attempt at clarification is to outline what can be done in the operating theater to reduce the environmental impact of the treatments we administer. Our recommendations will go above and beyond regulatory frameworks and draw upon daily practice concerning waste management, energy consumption, utilization of anesthetic agents and multiple forms of waste. A number of French and international pilot experimentations have been carried out and could strongly contribute to the modification of clinical practices with a societal impact, at a time when ecology has become one of the main preoccupations of our fellow citizens.

Surgery scheduling heuristic considering OR downstream and upstream facilities and resources

BACKGROUND

Surgical theater (ST) operations planning is a key subject in the healthcare management literature, particularly the scheduling of procedures in operating rooms (ORs). The OR scheduling problem is usually approached using mathematical modeling and made available to ST managers through dedicated software. Regardless of the large body of knowledge on the subject, OR scheduling models rarely consider the integration of OR downstream and upstream facilities and resources or validate their propositions in real life, rather using simulated scenarios. We propose a heuristic to sequence surgeries that considers both upstream and downstream resources required to perform them, such as surgical kits, post anesthesia care unit (PACU) beds, and surgical teams (surgeons, nurses and anesthetists).

METHODS

Using hybrid flow shop (HFS) techniques and the break-in-moment (BIM) concept, the goal is to find a sequence that maximizes the number of procedures assigned to the ORs while minimizing the variance of intervals between surgeries' completions, smoothing the demand for downstream resources such as PACU beds and OR sanitizing teams. There are five steps to the proposed heuristic: listing of priorities, local scheduling, global scheduling, feasibility check and identification of best scheduling.

RESULTS

Our propositions were validated in a high complexity tertiary University hospital in two ways: first, applying the heuristic to historical data from five typical ST days and comparing the performance of our proposed sequences to the ones actually implemented; second, pilot testing the heuristic during ten days in the ORs, allowing a full rotation of surgical specialties. Results displayed an average increase of 37.2% in OR occupancy, allowing an average increase of 4.5 in the number of surgeries performed daily, and reducing the variance of intervals between surgeries' completions by 55.5%. A more uniform distribution of patients' arrivals at the PACU was also observed.

CONCLUSIONS

Our proposed heuristic is particularly useful to plan the operation of STs in which resources are constrained, a situation that is common in hospital from developing countries. Our propositions were validated through a pilot implementation in a large hospital, contributing to the scarce literature on actual OR scheduling implementation.

Organization of the operating room and specific instruments for the implant of penile prosthesis

After more than 1600 penile implant surgeries, we can affirm the need for a procedure protocol of the steps prior to this type of surgery, and the importance of carefully control the preparation for the surgical act. The instruments that must be available for surgery include elements that have been specifically designed for this type of intervention, such as the Cavernotomo dilators (Rossello®) or the Furlow. These are essential for penile implant surgeries in the usual practice, especially in complex cases or when complications arise. We should avoid complications as much as we can, or at least we should be able to minimize, address and resolve them with effective organization and adequate instruments. Undoubtedly, the surgeon's skills and experience are one of the key components for success, but the great importance of an adequately performed and rigorously applied protocol by all team members should not be underestimated. The objective of this article is to explain the basis of the details of this procedure in a clear and realistic way.

Operating Room Guide for Confirmed or Suspected COVID-19 Pregnant Patients Requiring Cesarean Delivery

We sought to provide a clinical practice protocol for our labor and delivery (L&D) unit, to care for confirmed or suspected COVID-19 patients requiring cesarean delivery. A multidisciplinary team approach guidance was designed to simplify and streamline the flow and care of patient with confirmed or suspected COVID-19 requiring cesarean delivery. A protocol was designed to improve staff readiness, minimize risks, and streamline care processes. This is a suggested protocol which may not be applicable to all health care settings but can be adapted to local resources and limitations of individual L&D units. Guidance and information are changing rapidly; therefore, we recommend continuing to update the protocol as needed. KEY POINTS: · Cesarean delivery for confirmed or suspected novel coronavirus disease 2019 (COVID-19) patients. · Team-based approach for streamline care. · Labor and delivery protocols for COVID-19 positive patients.

Precautions for Operating Room Team Members During the COVID-19 Pandemic

BACKGROUND

The novel coronavirus SARS-CoV-2 (COVID-19) can infect healthcare workers. We developed an institutional algorithm to protect operating room team members during the COVID-19 pandemic and rationally conserve personal protective equipment (PPE).

STUDY DESIGN

An interventional platform (operating room, interventional suite, and endoscopy) PPE taskforce was convened by the hospital and medical school leadership and tasked with developing a common algorithm for PPE use, to be used throughout the interventional platform. In conjunction with our infectious disease experts, we developed our guidelines based on potential patterns of spread, risk of exposure, and conservation of PPE.

RESULTS

A decision tree algorithm describing our institutional guidelines for precautions for operating room team members was created. This algorithm is based on urgency of operation, anticipated viral burden at the surgical site, opportunity for a procedure to aerosolize virus, and likelihood a patient could be infected based on symptoms and testing.

CONCLUSIONS

Despite COVID-19 being a new threat, we have shown that by developing an easy-to-follow decision tree algorithm for the interventional platform teams, we can ensure optimal health care worker safety.

Emergency surgery during the COVID-19 pandemic: what you need to know for practice

INTRODUCTION

Several articles have been published about the reorganisation of surgical activity during the COVID-19 pandemic but few, if any, have focused on the impact that this has had on emergency and trauma surgery. Our aim was to review the most current data on COVID-19 to provide essential suggestions on how to manage the acute abdomen during the pandemic.

METHODS

A systematic review was conducted of the most relevant English language articles on COVID-19 and surgery published between 15 December 2019 and 30 March 2020.

FINDINGS

Access to the operating theatre is almost exclusively restricted to emergencies and oncological procedures. The use of laparoscopy in COVID-19 positive patients should be cautiously considered. The main risk lies in the presence of the virus in the pneumoperitoneum: the aerosol released in the operating theatre could contaminate both staff and the environment.

CONCLUSIONS

During the COVID-19 pandemic, all efforts should be deployed in order to evaluate the feasibility of postponing surgery until the patient is no longer considered potentially infectious or at risk of perioperative complications. If surgery is deemed necessary, the emergency surgeon must minimise the risk of exposure to the virus by involving a minimal number of healthcare staff and shortening the occupation of the operating theatre. In case of a lack of security measures to enable safe laparoscopy, open surgery should be considered.

Importance of operating room case scheduling on analyses of observed reductions in surgical site infections from the purchase and installation of capital equipment in operating rooms

BACKGROUND

We review the impact of the consequences of operating room (OR) management decision making on power analyses for observational studies of surgical site infections (SSIs) among patients receiving care in ORs with interventions versus without interventions involving physical changes to ORs. Examples include ventilation systems, bactericidal lighting, and physical alterations to ORs.

METHODS

We performed a narrative review of operating room management and surgical site infection articles. We used 10-years of operating room data to estimate parameters for use in statistical power analyses.

RESULTS

Creating pivot tables or monthly control charts of SSI per case by OR and comparing among ORs with or without intervention is not recommended. This approach has low power to detect a difference in SSI rates among the ORs with or without the intervention. The reason is that appropriate OR case scheduling decision making causes risk factors for SSI to differ among ORs, even when stratifying by surgical specialty. Such risk factors include case duration, urgency, and American Society of Anesthesiologists' Physical Status. Instead, analyze SSI controlling for the OR, where the patient had surgery, and matching patients using these variables is preferable. With α = 0.05, 600 cases per OR, 5 intervention ORs, and 5 or 1 control patients for each intervention patient, reasonable power (≅94% or 78%, respectively) can be achieved to detect reductions (3.6% to 2.4%) in the incidence of SSI between ORs with or without the intervention.

CONCLUSIONS

By using this matched cohort design, the effect of the purchase and installation of capital equipment in ORs on SSI can be evaluated meaningfully.

Relocating to a New OR Suite: Practical Observations

Operating room renovation projects usually involve updated technology and processes that can create challenges for administrative leaders (eg, maintaining a surgery schedule during a move) and require staff member adjustments. The perioperative team of a large tertiary care and trauma center relocated from a 35-year-old suite to a new suite, which required years of planning, months of training, and weeks of organizing. This article discusses the processes and observations that helped ensure a smooth transition to the new space. Early planning allowed time for leaders to make equipment decisions, develop and test new processes, and train staff members. The actual move required detailed planning, thorough execution, patience, and flexibility to ensure a safe transition. Perioperative leaders balanced operational needs with relocation plans to maintain patient and staff member safety. Open, multidisciplinary communication combined with staff member participation and buy-in contributed to an efficient, safe move at this facility.

Team performance during postsurgical patient handovers in paediatric care

Postsurgical handover of paediatric patients from operating rooms to intensive care units is a critical moment. This process is susceptible to errors and inefficiencies particularly if poor teamwork in this multidisciplinary and ad hoc collaboration occurs. Through combining provider- and observer-rated team performance, we aimed to determine agreement levels on team performance and associations with mental demands, disruptions, and stress. An observational and multisource study of provider and concomitant expert-observer ratings was established. In an Academic Paediatric Hospital, we conducted standardized observations of postsurgical handovers to PICU. We applied established observational and self-reported teamwork tools. Nested fixed and mixed models were established to estimate agreement within teams, between providers' and observer's ratings, as well as for estimations between team performance and mental demands, disruptions, and stress outcomes. Thirty-one postsurgical patient handovers were included with overall 109 ratings of involved providers. Provider-perceived team performance was rated high. Within the receiving sub-team, situation awareness was perceived lower compared to the handoff sub-team [F(df = 1) = 4.41, p = .04]. Inter-provider agreement on handover team performance was low for the overall team yet higher within handover sub-teams. We observed that high level of distractions during the handover was associated with inferior team performance rated by observers (B = - 0.72, 95% CI = - 1.44, - 0.01).Conclusion: We observed substantial disagreements on how involved professionals as well as observers rated teamwork during patient transfers. Investigations into paediatric teamwork and particular team-based handovers should carefully consider if concurrent provider and observer assessments are a valid and reliable way to evaluate teamwork in paediatric care. Common handover language should be established and mandatory before jointly evaluating this process. Our findings advocate also that handovers should be performed under low levels of distractions.What is Known:• Efficient teamwork during transfers of critically ill children is fundamental to quality and safety of handover practice.• Postoperative handovers are often performed by ad hoc teams of caregivers with multiple backgrounds and are prone to suboptimal team performance, communication, and information transfer.What is New:• Our provider and expert evaluations of team performance during OR-PICU handovers showed poor agreement for team performance. Our findings challenge previous results drawing upon single source assessments and inform future studies to carefully consider what approach of team performance assessments is required.• We further demonstrate that high levels of disruptions are associated with poor team performance during patient handovers and that efforts to ensure undisrupted handover practices in clinical care are necessary.

Surgical Practice in the Current COVID-19 Pandemic: A Rapid Systematic Review

The coronavirus disease (COVID-19) outbreak </mac_aq>started in Wuhan, China, in December 2019, and evolved into a global problem in a short period. The pandemic has led to many social and health-care challenges. In this context, surgery is an area that is facing the need for many adaptations. In this systematic literature review, we analyzed different perspectives concerning this situation, aiming to provide recommendations that could guide surgeons and </mac_aq>entities toward screening, elective and emergency surgeries, decision making, and operating room management. A computerized search in PubMed, Scopus, and Scientific Electronic Library Online (SciELO) for relevant literature up to April 4, 2020, was performed. Articles were included if they were related to surgery dynamics in the context of the COVID-19 pandemic. Of the 281 articles found in our initial search and 15 articles from alternative sources, 39 were included in our review after a systematic evaluation. Concerning preoperative testing </mac_aq>for severe acute respiratory syndrome coronavirus 2 infection, 29 (74.4%) articles recommended some kind of </mac_aq>screening. Another major suggestion was postponing all (or at least selected) elective operations (29 articles, </mac_aq>74.4%). Several additional recommendations with respect to surgical practice or surgical staff were also assessed and discussed, such as performing laparoscopic surgeries and avoiding the use of electrocauterization. On the basis of the current literature, we concluded that any surgery that can be delayed should be postponed. COVID-19 screening is strongly recommended for all surgical cases. Moreover, surgical staff should be reduced to the essential members and provided with institutional psychological support.

Applying Systems Engineering to Increase Operating Room Efficiency

Systems engineering is an interdisciplinary approach to creating, evaluating, and managing a complex process in order to increase reliability, cost-effectiveness, and quality. The operating room is a complex environment that requires human-human interaction, human-device interaction, planning, and coordination of scarce resources for the purpose of providing surgery to patients in a safe and efficient manner. The operating room is an important revenue generator, but it can also be responsible for unsustainable costs if not managed effectively. Reducing costs and increasing the efficiency of surgical cases is important for generating health care value. Efficiency efforts that aim for standardization of surgical protocols must be balanced by flexibility in the unpredictable operating room environment. This paper reviews systems engineering efforts to improve efficiency in the operating room including operating room scheduling, personnel factors, resource management, orthopedicspecific initiatives, and future innovations.

"Disruptive behavior" in the operating room: A prospective observational study of triggers and effects of tense communication episodes in surgical teams

BACKGROUND

Tense communication and disruptive behaviors during surgery have often been attributed to surgeons' personality or hierarchies, while situational triggers for tense communication were neglected. Goals of this study were to assess situational triggers of tense communication in the operating room and to assess its impact on collaboration quality within the surgical team.

METHODS AND FINDINGS

The prospective observational study was performed in two university hospitals in Europe. Trained external observers assessed communication in 137 elective abdominal operations led by 30 different main surgeons. Objective observations were related to perceived collaboration quality by all members of the surgical team. A total of 340 tense communication episodes were observed (= 0.57 per hour); mean tensions in surgeries with tensions was 1.21 per hour. Individual surgeons accounted for 24% of the variation in tensions, while situational aspects accounted for 76% of variation. A total of 72% of tensions were triggered by coordination problems; 21.2% by task-related problems and 9.1% by other issues. More tensions were related to lower perceived teamwork quality for all team members except main surgeons. Coordination-triggered tensions significantly lowered teamwork quality for second surgeons, scrub technicians and circulators.

CONCLUSIONS

Although individual surgeons differ in their tense communication, situational aspects during the operation had a much more important influence on the occurrence of tensions, mostly triggered by coordination problems. Because tensions negatively impact team collaboration, surgical teams may profit from improving collaboration, for instance through training, or through reflexivity.

The effect of gender on operative autonomy in general surgery residents

BACKGROUND

Despite an increasing number of women in the field of surgery, bias regarding cognitive or technical ability may continue to affect the experience of female trainees differently than their male counterparts. This study examines the differences in the degree of operative autonomy given to female compared with male general surgery trainees.

METHODS

A smartphone app was used to collect evaluations of operative autonomy measured using the 4-point Zwisch scale, which describes defined steps in the progression from novice ("show and tell") to autonomous surgeon ("supervision only"). Differences in autonomy between male and female residents were compared using hierarchical logistic regression analysis.

RESULTS

A total of 412 residents and 524 faculty from 14 general surgery training programs evaluated 8,900 cases over a 9-month period. Female residents received less autonomy from faculty than did male residents overall (P < .001). Resident level of training and case complexity were the strongest predictors of autonomy. Even after controlling for potential confounding factors, including level of training, intrinsic procedural difficulty, patient-related case complexity, faculty sex, and training program environment, female residents still received less operative autonomy than their male counterparts. The greatest discrepancy was in the fourth year of training.

CONCLUSION

There is a sex-based difference in the autonomy granted to general surgery trainees. This gender gap may affect female residents' experience in training and possibly their preparation for practice. Strategies need to be developed to help faculty and residents work together to overcome this gender gap.

Effectiveness of a multicomponent safe surgery intervention on improving surgical quality in Tanzania's Lake Zone: protocol for a quasi-experimental study

INTRODUCTION

Effective, scalable strategies for improving surgical quality are urgently needed in low-income and middle-income countries; however, there is a dearth of evidence about what strategies are most effective. This study aims to evaluate the effectiveness of Safe Surgery 2020, a multicomponent intervention focused on strengthening five areas: leadership and teamwork, safe surgical and anaesthesia practices, sterilisation, data quality and infrastructure to improve surgical quality in Tanzania. We hypothesise that Safe Surgery 2020 will (1) increase adherence to surgical quality processes around safety, teamwork and communication and data quality in the short term and (2) reduce complications from surgical site infections, postoperative sepsis and maternal sepsis in the medium term.

METHODS AND ANALYSIS

Our design is a prospective, longitudinal, quasi-experimental study with 10 intervention and 10 control facilities in Tanzania's Lake Zone. Participants will be surgical providers, surgical patients and postnatal inpatients at study facilities. Trained Tanzanian medical data collectors will collect data over a 3-month preintervention and postintervention period. Adherence to safety as well as teamwork and communication processes will be measured through direct observation in the operating room. Surgical site infections, postoperative sepsis and maternal sepsis will be identified prospectively through daily surveillance and completeness of their patient files, retrospectively, through the chart review. We will use difference-in-differences to analyse the impact of the Safe Surgery 2020 intervention on surgical quality processes and complications. We will use interviews with leadership and surgical team members in intervention facilities to illuminate the factors that facilitate higher performance.

ETHICS AND DISSEMINATION

The study has received ethical approval from Harvard Medical School and Tanzania's National Institute for Medical Research. We will report results in peer-reviewed publications and conference presentations. If effective, the Safe Surgery 2020 intervention could be a promising approach to improve surgical quality in Tanzania's Lake Zone region and other similar contexts.