Perceptions of Use of Names, Recognition of Roles, and Teamwork After Labeling Surgical Caps.

Importance: Communication failures in perioperative areas are common and have negative outcomes for both patients and clinicians. Names and roles of teammates are difficult to remember or discern contributing to suboptimal communication, yet the utility of labeled surgical caps with names and roles for enhancing perceived teamwork and connection is not well studied. Objective: To evaluate the use of labeled surgical caps in name use and role recognition, as well as teamwork and connection, among interprofessional perioperative teammates. Design, Setting, and Participants: In this quality improvement study, caps labeled with names and roles were distributed to 967 interprofessional perioperative clinicians, along with preimplementation and 6-month postimplementation surveys. Conducted between July 8, 2021, and June 25, 2022, at a single large, academic, quaternary health care center in the US, the study comprised surgeons, anesthesiologists, trainees, and all interprofessional hospital staff who work in adult general surgery perioperative areas. Intervention: Labeled surgical caps were offered cost-free, although not mandatory, to each interested clinician. Main Outcome and Measure: Quantitative survey of self-reported frequency for name use and role recognition as well as postimplementation sense of teamwork and connection. The surveys also elicited free response comments. Results: Of the 1483 eligible perioperative clinicians, 967 (65%; 387 physicians and 580 nonphysician staff; 58% female) completed preimplementation surveys and received labeled caps, and 243 of these individuals (51% of physicians and 8% of staff) completed postimplementation surveys. Pre-post results were limited to physicians, due to the low postsurvey staff response rate. The odds of participants reporting that they were often called by their name increased after receiving a labeled cap (adjusted odds ratio [AOR], 13.37; 95% CI, 8.18-21.86). On postsurveys, participants reported that caps with names and roles substantially improved teamwork (80%) and connection (79%) with teammates. Participants who reported an increased frequency of being called by their name had higher odds for reporting improved teamwork (AOR, 3.46; 95% CI, 1.91-6.26) and connection with teammates (AOR, 3.21; 95% CI, 1.76-5.84). Free response comments supported the quantitative data that labeled caps facilitated knowing teammates' names and roles and fostered a climate of wellness, teamwork, inclusion, and patient safety. Conclusions and Relevance: The findings of this quality improvement study performed with interprofessional teammates suggest that organizationally sponsored labeled surgical caps was associated with improved teamwork, indicated by increased name use and role recognition in perioperative areas.

Improving Operating Room Efficiency Through Reducing First Start Delays in an Academic Center.

BACKGROUND: Delays in operating room (OR) first-case start times can cause additional costs for hospitals, healthcare team frustration and delay in patient care. Here, a novel process improvement strategy to improving first-case start times is presented. METHODS: First case in room start times were recorded for ORs at an academic medical center. Three interventions-automatic preoperative orders, dot phrases to permit re-creation of unavailable consent forms, and improved H&P linking to the surgical encounter-were implemented to target documentation-related delays. Monthly percentages of first-case on-time starts (FCOTS) and time saved were compared with the "preintervention" time period, and total cost savings were estimated. RESULTS: During the first 3-months after implementation of the interventions, the percentage of FCOTS improved from an average of 36.7%-52.7%. Total time savings across all ORs over the same time period was found to be 55.63 hours, which is estimated to have saved a total of $121,834.52 over the 3-month interventional period. CONCLUSIONS: By implementing multiple quality improvement interventions, delays to first start in room OR cases can be meaningfully reduced. Quality improvement protocols targeted toward root causes of OR delays can be a significant driver to reduce healthcare costs.

Framework for prioritizing head and neck surgery during the COVID-19 pandemic.

The COVID-19 pandemic has placed an extraordinary demand on the United States health care system. Many institutions have canceled elective and non-urgent procedures to conserve resources and limit exposure. While operational definitions of elective and urgent categories exist, there is a degree of surgeon judgment in designation. In the present commentary, we provide a framework for prioritizing head and neck surgery during the pandemic. Unique considerations for the head and neck patient are examined including risk to the oncology patient, outcomes following delay in head and neck cancer therapy, and risk of transmission during otolaryngologic surgery. Our case prioritization criteria consist of four categories: urgent-proceed with surgery, less urgent-consider postpone > 30 days, less urgent-consider postpone 30 to 90 days, and case-by-case basis. Finally, we discuss our preoperative clinical pathway for transmission mitigation including defining low-risk and high-risk surgery for transmission and role of preoperative COVID-19 testing.

Overlapping Surgery: A Case Study in Operating Room Throughput and Efficiency.

A keystone of operating room (OR) management is proper OR allocation to optimize access, safety, efficiency, and throughput. Access is important to surgeons, and overlapping surgery may increase patient access to surgeons with specialized skill sets and facilitate the training of medical students, residents, and fellows. Overlapping surgery is commonly performed in academic medical centers, although recent public scrutiny has raised debate about its safety, necessitating monitoring. This article introduces a system to monitor overlapping surgery, providing a surgeon-specific Key Performance Indicator, and discusses overlapping surgery as an approach toward OR management goals of efficiency and throughput.

Changing healthcare providers' behavior during pediatric inductions with an empirically based intervention.

BACKGROUND: Each year more than 4 million children experience significant levels of preoperative anxiety, which has been linked to poor recovery outcomes. Healthcare providers (HCPs) and parents represent key resources for children to help them manage their preoperative anxiety. The current study reports on the development and preliminary feasibility testing of a new intervention designed to change HCP and parent perioperative behaviors that have been reported previously to be associated with children's coping and stress behaviors before surgery. METHODS: An empirically derived intervention, Provider-Tailored Intervention for Perioperative Stress, was developed to train HCPs to increase behaviors that promote children's coping and decrease behaviors that may exacerbate children's distress. Rates of HCP behaviors were coded and compared between preintervention and postintervention. In addition, rates of parents' behaviors were compared between those that interacted with HCPs before training to those interacting with HCPs after the intervention. RESULTS: Effect sizes indicated that HCPs who underwent training demonstrated increases in rates of desired behaviors (range: 0.22-1.49) and decreases in rates of undesired behaviors (range: 0.15-2.15). In addition, parents, who were indirectly trained, also demonstrated changes to their rates of desired (range: 0.30-0.60) and undesired behaviors (range: 0.16-0.61). CONCLUSIONS: The intervention successfully modified HCP and parent behaviors. It represents a potentially new clinical way to decrease anxiety in children. A multisite randomized control trial funded by the National Institute of Child Health and Development will examine the efficacy of this intervention in reducing children's preoperative anxiety and improving children's postoperative recovery.

Economic advantages to a distraction decision tree model for management of neonatal upper airway obstruction.

BACKGROUND: Neonatal upper airway obstruction demands urgent attention. Tracheostomy can prove to be lifesaving but has morbidities. Recently, the authors found reduced morbidity/mortality when using a distraction decision tree model compared with conventional "case-by-case" management. In this current study, the authors assess the long-term costs of (1) a decision tree model versus conventional treatment and (2) tracheostomy versus distraction osteogenesis. METHODS: An inpatient cost-matrix analysis study on neonates with upper airway obstruction and micrognathia was performed (n=149). In Part I, conventionally treated neonates managed on a case-by-case basis received home monitoring or a tracheostomy. Decision tree model-managed newborns had specialist consultations and diagnostic testing to determine whether home monitoring, tracheostomy, or distraction osteogenesis would be implemented. In Part II, tracheostomy treatment was compared directly to distraction osteogenesis. RESULTS: In Part I (conventional versus decision tree model), taking into account the costs of the distraction, tracheostomy, hospital stay, diagnostic studies, physician fees, and emergency department visits, the total per patient treatment cost was 1.5 greater in the conventional treatment group ($332,673) compared with the decision tree model ($225,998) (p<0.05). In Part II (tracheostomy versus distraction osteogenesis), the total per-patient treatment cost in the tracheostomy group was two times greater than in the distraction group ($382,246 versus $193,128) (p<0.05). CONCLUSIONS: In treating newborns with micrognathia and upper airway obstruction, a decision tree model with mandibular distraction decreases long-term health care costs compared with conventional treatment. Furthermore, when comparing distraction to tracheostomy, similar decreases in long-term health care costs occurred.

Dexmedetomidine and ketamine for fiberoptic intubation in a child with severe mandibular hypoplasia.

A 6-year-old girl with Treacher Collins syndrome presented for implantation of a hearing device. The patient was developmentally delayed and had severe micrognathia. After induction of anesthesia with dexmedetomidine and ketamine, the patient tolerated the introduction of a flexible fiberoptic bronchoscope without any change in respiration, and intubation was achieved easily.

Continuous monitoring of dynamic pulmonary compliance enables detection of endobronchial intubation in infants and children.

BACKGROUND: Auscultation of breath sounds is used routinely to confirm tracheal placement of endotracheal tubes (ETT). In infants and children, this method is limited by the conduction of breath sounds bilaterally, despite endobronchial intubation. Although several methods of detecting endobronchial intubation have been described, none is both simple and reliable. In this investigation, we determined whether changes in pulmonary compliance and airway pressures, measured using continuous side stream spirometry, can reliably detect endobronchial intubation in pediatric patients. METHODS: Forty patients aged 1 month to 6 years were included. After endotracheal intubation the ETT was incrementally advanced as two observers monitored breath sounds and spirometry (Pressure-Volume Loops). Changes in pulmonary compliance, peak inspiratory pressure, or auscultation were reported, at which point ETT position was confirmed by fiberoptic bronchoscopy. RESULTS: Endobronchial intubation decreased measured pulmonary compliance by 45 +/- 11% (mean +/- sd; P < 0.001, Range 26%-66%) and increased peak airway pressures by 26 +/- 17% (mean +/- sd; P < 0.001, Range 0-87). Changes in peak airway pressures were smaller and more variable when compared to changes in compliance. Breath-sound auscultation failed to detect endobronchial intubation in 7.5% of cases. CONCLUSIONS: Pulmonary compliance changes are a sensitive and an accurate indicator of endobronchial intubation in infants and children. Both increased peak airway pressures and changes in breath sounds are less sensitive indicators of endobronchial intubation.