Infection prevention in breast implant surgery - A review of the surgical evidence, guidelines and a checklist.

INTRODUCTION: As a result of increasing use of implant-based breast reconstruction, complications such as infection are being encountered more frequently. Surgical Site Infections (SSIs) cause morbidity for the patient, can lead to capsular contracture or implant loss and are costly to healthcare systems. National Guidelines suggesting methods to reduce SSI related complications have been produced, but are limited in the scope of interventions covered and underlying evidence presented. METHODS: We performed a literature review encompassing a wide variety of possible SSI prevention strategies. We aimed to present summaries of the available evidence and give pragmatic recommendations as to their validity to use as guidelines for infection prevention strategies for implant-based breast reconstruction. RESULTS: A lack of high quality data relating to the benefit of SSI prevention strategies in implant-based breast reconstruction exists. Many papers relate to orthopaedic implant surgery, or clean surgery in general. Following review of the evidence, sufficient data exists to support use of perioperative antibiotics at implant-based breast reconstruction, with continuation for an extended period in "high risk" patients. Alcohol containing skin preparations should be used over aqueous solutions. Laminar air flow use is suggested. Theatre traffic should be kept to a minimum, as should duration of operative procedure. The implant pocket should be washed prior to implantation. Double gloving and conductive warming are also endorsed. CONCLUSIONS: We have produced a perioperative "Theatre Implant Checklist" for SSI prevention in implant-based breast surgery, with a set of pragmatic up to date guidelines, which allows the reader to evaluate the evidence upon which our recommendations are based.

Portable treatment technologies for urgent care.

BACKGROUND: In recent years UK government policy has increased the provision of urgent care in the community. As part of this initiative the emergency ambulance service is gradually changing from an organisation designed to convey patients to hospital to a professional group capable of assessing urgency and delivering the appropriate treatment to the patient. METHODS: This paper explores the portable technology requirements needed to support the new professional roles and draws on examples from ambulance trusts (emergency care practitioner services), primary care (out-of-hours general practitioner services and minor injuries units), and acute trusts (emergency departments) to investigate the workplace layout and clinical activities, including the use of equipment and consumables. It describes the iterative process used to develop the design specification for portable technologies using a qualitative exploratory methodological framework with data collected at stakeholder workshops, responder bag audits, clinical treatment observations and design decision groups. RESULTS: The results are discussed as a three-level technology system for: personal kit; assessment packages (and storage for other clinical treatment packages), a clinical workspace. Future developments are predicted to improve diagnostic and decision-making services through both miniaturisation (eg, portable diagnostic imaging) and improved real-time support (communication systems). CONCLUSION: This study has provided empirical research for portable technology requirements in urgent care.

Ileostomy formation does not prolong hospital length of stay after open anterior resection when performed within an enhanced recovery programme.

AIM: Previous studies have implicated stoma formation as an independent factor prolonging length of stay (LOS) after colorectal surgery. We examined whether loop ileostomy (LI) formation during an open anterior resection affected LOS within a newly developed enhanced recovery programme (ERP). This involved reorganization of services, including stoma care, to optimize pre- and perioperative patient education, training and expectation, while applying the standard scientific principles of enhanced recovery. METHOD: Data were collected prospectively on 72 consecutive open anterior resections (33 with LI) to see whether LI affected LOS. Stomas were fashioned at the surgeon's discretion and patients were discharged according to agreed criteria. RESULTS: Thirty-three of the 72 patients had a covering LI performed. The overall age range was 32-85 years (median 68), with 40 patients being men. LOS for all 72 patients ranged from 3 to 34 days. The median and mean LOS were the same for both groups (median 6 days, mean 8 days). The complication rate was 44% (32/72) with a leak rate of 7% (5/72) and a mortality of 1.4% (1/72). Between the two groups (no ileostomy vs ileostomy), there was no statistically significant difference in complications (41%vs 48%), leakage (8%vs 6%) and readmission rates (12%vs 5%). CONCLUSION: A covering loop ileostomy need not prolong hospital stay after open anterior resection.

Psychometric properties of the Hospital Survey on Patient Safety Culture: findings from the UK.

BACKGROUND: Patient safety culture is measured using a range of survey tools. Many provide limited data on psychometric properties and few report findings outside of the US healthcare context. This study reports an assessment of the psychometric properties and suitability of the American Hospital Survey on Patient Safety Culture for use within the UK. METHODS: A questionnaire survey of three hospitals within a large UK Acute NHS Trust. 1437 questionnaires were completed (37% response rate). Exploratory factor analysis, confirmatory factor analysis and reliability analyses were carried out to assess the psychometric performance of this survey instrument and to explore potential improvements. RESULTS: Reliability analysis of the items within each proposed scale showed that more than half failed to achieve satisfactory internal consistency (Cronbach's α<0.7). Furthermore, a confirmatory factor analysis carried out on the UK data set achieved a poor fit when compared with the original American model. An optimal measurement model was then constructed via exploratory and confirmatory factor analyses with split-half sample validation and consisted of nine dimensions compared with the original 12 in the American model. CONCLUSION: This is one of the few studies to provide an evaluation of an American patient safety culture survey using data from the UK. The results indicate that there is need for caution in using the Hospital Survey on Patient Safety Culture survey in the UK and underline the importance of appropriate validation of safety culture surveys before extending their usage to populations outside of the specific geographical and healthcare contexts in which they were developed.

Designing emergency ambulances for the 21st century.

BACKGROUND: In 2005 the Department of Health set out a vision for the provision of future ambulance services with an increasing range of quality mobile healthcare services for patients with urgent and emergency care needs. This paper describes a scoping study funded by the National Patient Safety Agency and Ambulance Service Association to investigate the short and longer term requirements of future emergency ambulances. METHOD: Four stakeholder workshops were held to explore the wishes, concerns and preferences of the clinicians, operational staff and manufacturers about the future provision of ambulance services and problems and possible solutions relating to ambulance design and use. Incident reports relating to ambulance design and use were reviewed from three national and international databases. RESULTS: Nine design challenges were identified: access/egress; space and layout; securing people and equipment in transit; communication; security, violence and aggression; hygiene; equipment; vehicle engineering; patient experience. These were validated at the national UK ambulance conference (AMBEX 2006) with a rating questionnaire. CONCLUSION: The results are being used in the development of a national specification for future UK emergency ambulances.

Safe access/egress systems for emergency ambulances.

OBJECTIVE: To comparatively evaluate the three most widely used ambulance stretcher loading systems; easi-loader, ramp/winch and tail lift to identify a preferred system based on safety and usability evidence. METHODS: Three data types were collected in the field, the laboratory and from a national questionnaire. Field data were collected using the qualitative methods of observation (link analysis and hierarchical task analysis) and interview (critical incident technique) over 12 months during 2004-5. Laboratory data were collected for detailed postural analysis. A national ranking questionnaire was used to prioritise the resulting design issues. RESULTS: The field study data were analysed, triangulated and summarised in a taxonomy to identify the design and operational issues. A list of 14 criteria was used in a national ranking exercise with 134 ambulance staff and manufacturers. Patient and operator safety was ranked as the highest priority, followed by manual handling. The postural analysis found that the easi-loader system presented the highest postural risk. CONCLUSIONS: The tail lift was found to be the preferred and safest loading system from both the field and laboratory research and is the recommended option from the evaluated loading systems.

Spatial requirements in hospital shower and toilet rooms.

AIM: To determine the spatial requirements for hoist use in an assisted shower-toilet facility. METHOD: A simulation of two shower-toilet facilities (built since 2000) was constructed in a laboratory to compare a mobile hoist and a gantry (overhead) hoist for the task of transferring a patient from a wheelchair to the toilet. Twenty participants were recruited and trained in the use of both hoists. Data were recorded using video cameras and analysed for the space used to complete the task, time taken and postural risk scores. RESULTS: The mobile hoist needed significantly more space, took significantly longer and exposed the handlers to higher postural risks than the overhead hoist. CONCLUSION: Larger shower-toilet rooms should be planned and built as accessible facilities with sufficient space for independent and assisted wheelchair users. The findings will have an impact on the recommendation for increased numbers of single rooms with ensuite facilities in new hospitals. Healthcare planners and designers may need to consider building specific facilities for assisted wheelchair users rather than providing a 'one space fits all' solution.

A review of environmental hazards associated with in-patient falls.

Slips, trips and falls present the greatest risk to in-patients in terms of exposure (frequency of occurrence) but only present a low severity risk in terms of mortality. The risk factors have been categorized as intrinsic (individual to the patient, e.g. visual impairment, balance problems and medicine use) or extrinsic (environmental). Many recommendations have been made concerning the management of environmental hazards but, of these, only beds rails have supporting research evidence. Other recommendations include patient assessment, footwear, flooring, lighting, staffing levels and bed alarms. However, three systematic reviews and the current narrative review have all failed to find research evaluating the benefits of these recommendations. The most robust evidence relates to the use of bed rails. This research suggests that bed rails not only fail to reduce the frequency of falls, but may also exacerbate the severity of injury. As Maslow's Hierarchy of Needs model has been used as a framework for nursing models of care, it was chosen as the basis for the development of an environmental hazard assessment model. The environmental hazards are revisited using this model in order to take an ergonomic or patient-centred approach for risk assessment.

Do split-side rails present an increased risk to patient safety?

BACKGROUND: Concerns have been raised about the safety of split-side bed rails for patients in the UK. OBJECTIVES: To investigate whether split-side rails were more likely to be associated with entrapment and injury of patients than other bed rail types. To establish whether there was a difference in the site of injury caused by different bed rail types and whether the outcome of the injury (death versus survival) varied by bedrail type. METHODS: A search of the USA Food and Drug Administration MAUDE database was carried out. The reports were screened using rigorous inclusion/exclusion criteria and then coded for rail type, incident outcome, and area of body involved. RESULTS: Split-side rail incidents only accounted for 5% of the reports and were more likely to involve the chest or pelvis. Although the biggest overall risk by rail type cannot be determined from these data, the severity of the outcome changed with the equipment type. Incidents involving half rails were more likely to be associated with head, neck, or face entrapments and were also more likely than other bed rail types to result in death. DISCUSSION: Split-side rail entrapments were not a common occurrence. However, our findings suggest that bed rails are associated with some level of risk of entrapment that potentially could result in death. Healthcare providers should therefore ensure that they follow the guidelines for risk assessment and rail use from the MHRA and other professional bodies so that the cultural norm in the UK continues to be "opt in", where no bed rails are used unless indicated by a documented clinical assessment.

Intervention strategies to reduce musculoskeletal injuries associated with handling patients: a systematic review.

AIMS: To report, analyse, and discuss the results of a systematic review looking at intervention strategies to reduce the risk factors associated with patient handling activities. METHODS: A search strategy was devised to seek out research between 1960 and 2001. Inclusion/exclusion criteria limited the entry of papers into the review process. A checklist was selected and modified to include a wide range of study designs. Inter-rater reliability was established between six reviewers before the main review process commenced. Each paper was read by two reviewers and given a quality rating score, with any conflicts being resolved by a third reviewer. Papers were grouped by category: multifactor, single factor, and technique training based interventions. RESULTS: A total of 2796 papers were found, of which 880 were appraised. Sixty three papers relating to interventions are reported in this paper. The results are reported as summary statements with the associated evidence level (strong, moderate, limited, or poor). CONCLUSION: There is strong evidence that interventions predominantly based on technique training have no impact on working practices or injury rates. Multifactor interventions, based on a risk assessment programme, are most likely to be successful in reducing risk factors related to patient handling activities. The seven most commonly used strategies are identified and it is suggested that these could be used to form the basis of a generic intervention programme, with additional local priorities identified through the risk assessment process. Health care providers should review their policies and procedures in light of these findings.

Embedding ergonomics in hospital culture: top-down and bottom-up strategies.

In England there has been increasing emphasis on the use of ergonomics to tackle manual handling problems for the last seven years (MHO, 1992, 1998; HSAC, 1998). At Nottingham City Hospital NHS Trust, I have tried to incorporate an ergonomic approach throughout a wide range of activities since 1994. This paper does not seek to report a research project, simply to share the experience of trying to tackle hospital manual handling risks by taking an ergonomic approach. It will explain what this has involved, where it has been successful and where there have been difficulties. In the five years since the implementation of this strategy three measures have been used to monitor trends. These are (1) manual handling incidents: showing a 33% reduction; (2) days lost from musculoskeletal-related sickness absence: 36% reduction; and (3) completed risk actions: rising from 33% completion to over 75% completion.

Uniforms: a comparative evaluation of tunic tops.

AIM: The aim of this study was to produce a recommendation for selection of a tunic top for female nurses, based on previously established ergonomic criteria. METHOD: Four tunic top designs were evaluated using functional tests, including anthropometry, body-part discomfort charts, product feature questionnaires and comparative ranking. A convenience sample of nurses from one trust wore the tunics during the study tests. The trial draws heavily on previous research on nurses' uniforms and applies ergonomic criteria to tunic top design. RESULTS: The researchers were not able to identify on optimum design using the results of the trial. The tunics compared were relatively restrictive, with one tunic being identified as the least restrictive of the four. CONCLUSION: The researchers are now taking this initiative forward in a participatory ergonomics project with nursing staff to try to produce a uniform design that will meet functional ergonomic criteria. Prototypes will be evaluated using the protocol from this trial.

Rapid entire body assessment (REBA).

This technical note details the preliminary stage in the development of a postural analysis tool, Rapid Entire Body Assessment (REBA). REBA has been developed to fill a perceived need for a practitioner's field tool, specifically designed to be sensitive to the type of unpredictable working postures found in health care and other service industries. A team of ergonomists, physiotherapists, occupational therapists and nurses collected and individually coded over 600 postural examples to produce a new tool incorporating dynamic and static postural loading factors, human-load interface (coupling), and a new concept of a gravity-assisted upper limb position. Initial reliability for inter-observer coding shows promise but further work is needed to establish the validity of the tool.

Testing gloves used for common nursing tasks.

Nursing tasks often require high levels of dexterity. Gloves should not hinder hand function. Gloves bought for use by nurses need to be tested in ergonomic trials based on nursing tasks.

Postural analysis of nursing work.

Back pain in the nursing profession is an acknowledged wide spread occupational hazard. This study used OWAS (Ovako Working posture Analysis System) to measure the severity of the working postures adopted by nurses on Care of the Elderly wards when carrying out manual handling operations for animate and inanimate loads. Twenty-six nurses were observed on 31 occasions to obtain 4299 observations, these data were collected and processed using the OWASCO and OWASAN programs, and then analysed by grouping the results into defined patient (animate) handling and non-patient (inanimate) handling tasks. A statistical comparison was made between the two groups using the percentage of action categories two, three and four, to the total number of action categories. A significant difference (p < 0.05) was found, demonstrating that the percentage of harmful postures adopted during patient handling tasks was significantly higher than during non-patient handling tasks. This high level of postural stress and the poor track record of risk management within the Health Care Industry leads to the recommendation that an attitudinal change is needed to successfully address and reduce the manual handling burden which is currently being carried by the nursing staff.

Work-related back pain in nurses.

This summary draws together the findings form over 80 studies published over three decades. The studies reviewed are categorized into three groups: (a) epidemiological; (b) 'testing out'; and (c) exploratory. There has been agreement on a number of points, in particular that nursing is among the high risk occupations with respect to low back problems, with a point prevalence of approximately 17%, an annual (period) prevalence of 40-50% and a lifetime prevalence of 35-80%. When considering the contributory factors there is some divergence, but one of the popular notions is generally proven, that more frequent patient handling appears to correlate with increased incidence of low back pain. However, the traditional approach of training in lifting and handling techniques alone has been shown to be of little, or no, long-term benefit and the value of ergonomics remains to be seen. Much work has also been done by taking aspects of nursing work into the laboratory, using experimental studies which have mostly focused on specific sub-tasks (of the generic task of patient handling), looking at specific transfers and procedures (e.g. bed to chair) or transfer techniques ('stoop versus squat'). Although a level of quantification can be made about the different techniques, it is questionable whether this is of any practical use, especially when considering the wide variation of loads encountered during manual handling of patients. The limitations of using quantitative methodologies is revealed in the very small number of exploratory studies. All of the studies cited in this review used methodologies based in the positivist paradigm. There does not appear to be any published work using participative or interview methods to obtain qualitative data which might identify contributory factors in the onset of occupational low back pain in nursing staff.

Manual handling human loads in a hospital: an exploratory study to identify nurses' perceptions.

The high incident rate of musculoskeletal back problems in nursing work has long been recognized, and in many studies patient handling has been identified as a contributory factor. This paper seeks to question the application of the 'ergonomic model' for risk assessment of manual handling operations (MHO) as advocated in the MHO regulations. It describes an exploratory study, which uses a participatory approach and the qualitative analysis method of grounded theory to determine the factors perceived as important by the nurses for patient-handling tasks. The development of a model of these factors is discussed, together with the main outcome of questioning the practical benefits of dividing the generic task of patient handling into subtasks, eg bathing, for MHO risk assessment.