A Life Cycle Assessment of Reusable and Disposable Surgical Caps.

INTRODUCTION: Surgical cap attire plays an important role in creating a safe and sterile environment in procedural suites, thus the choice of reusable versus disposable caps has become an issue of much debate. Given the lack of evidence for differences in surgical site infection (SSI) risk between the two, selecting the cap option with a lower carbon footprint may reduce the environmental impact of surgical procedures. However, many institutions continue to recommend the use of disposable bouffant caps. METHODS: ISO-14044 guidelines were used to complete a process-based life cycle assessment to compare the environmental impact of disposable bouffant caps and reusable cotton caps, specifically focusing on CO2 equivalent (CO2e) emissions, water use and health impacts. RESULTS: Reusable cotton caps reduced CO2e emissions by 79% when compared to disposable bouffant caps (10 kg versus 49 kg CO2e) under the base model scenario with a similar reduction seen in disability-adjusted life years. However, cotton caps were found to be more water intensive than bouffant caps (67.56 L versus 12.66 L) with the majority of water use secondary to production or manufacturing. CONCLUSIONS: Reusable cotton caps have lower total lifetime CO2e emissions compared to disposable bouffant caps across multiple use scenarios. Given the lack of evidence suggesting a superior choice for surgical site infection prevention, guidelines should recommend reusable cotton caps to reduce the environmental impact of surgical procedures.

Psychological Safety and Hierarchy in Operating Room Debriefing: Reflexive Thematic Analysis.

INTRODUCTION: Debriefing is a team discussion in a constructive, supportive environment. Barriers exist to consistent, effective team debriefing in the clinical setting, especially in operating theaters. The purpose of this study was to gain insights from frontline workers on how to set up an effective debriefing policy for our operating room. METHODS: This was a qualitative study in which we interviewed operating room workers in a tertiary children's hospital. Interviews were audio-recorded, transcribed, and coded. Data were analysed using the reflexive thematic analysis technique within a critical realism paradigm. RESULTS: Interviews were analysed from 40 operating room staff: 14 nurses, seven anesthetic technicians, seven anaesthetists, and 12 surgeons; 25 (65%) were female. The three key themes were (1) "commitment to learning"-healthcare workers are committed to teamwork and quality improvement; (2) "it is a safe space"-psychological safety is a prerequisite for, and is enhanced by, debriefing; and (3) "natural leader"-the value of leadership, but also constructs around leadership that maintain hierarchies. CONCLUSIONS: Psychological safety is both a prerequisite for and a product of debriefing. Leadership, if viewed as a collective responsibility, could help break down power structures. Given the results of this study and evidence in the literature, it is likely that routine debriefing, if well done, will improve psychological safety, facilitate team learning, reduce errors, and improve patient safety.

The Retained Surgical Items Risk Assessment Scale: Development and Psychometric Characteristics.

INTRODUCTION: Retained surgical items in operating rooms (ORs) continue to contribute significantly to medical errors. The first step in addressing the problem of retained surgical items is to identify the main risk factors. Identification of risk factors can impact OR standards and reduce such errors. METHODS: The research included 270 participants. The data of the study were collected with the Sociodemographic and Clinical Characteristics Form, Operating Room Count Control Form and the Retained Surgical Items Risk Assessment Scale developed. In the analysis of the data, Content Validity Index, Cronbach α, item-total score correlation, Kuder-Richardson, Kappa, exploratory and confirmatory factor analysis, and Receiver Operating Characteristic (ROC) curve analysis were performed. RESULTS: The Content Validity Index of the scale was 0.92. Kappa value was 0.993. The explained variance in the exploratory factor analysis of the scale was 50.03%. After confirmatory factor analysis, two factors were obtained for the final version of the 15 items. Factors had been determined as "Count and Surgery" and "Equipment". Among the subdimensions of the scale, Cronbach's α values were between 0.742 and 0.760, and 0.722 for the entire scale. When the ROC analysis results were examined, the cut-off point was ≥8, the specificity was 93.13%, and the sensitivity was 87.50%. The area under the ROC curve was calculated as 0.938. CONCLUSIONS: The scale was presented as a valid and reliable measurement tool developed to assess the Retained Surgical Items Risk in ORs. If high-risk patients are checked and necessary precautions are taken before leaving the ORs, the incidence of retained surgical items can be significantly reduced.

Surgeon-Dependent Variability in Cost of Gastrointestinal Operations in a Single Cancer Center.

INTRODUCTION: Cancer operations are increasingly utilizing specialized equipment and technology. Related costs are often not known to the responsible surgeon. We seek to evaluate cost aspects of care episodes attributable to the surgeon's management decisions. METHODS: Financial cost data in a tertiary academic cancer center were queried over 3 y. Consecutive patients undergoing gastrointestinal operations followed by inpatient admission of two or more days were included, excluding patients with 40+ d admissions. Analysis of variance, Kruskal-Wallis, and multiple regression statistics were utilized. RESULTS: The study population included 1540 patients: 54% men and 46% women, with a median age of 64 y (range 15-95). Eight surgeons conducted major (82%) and minor (18%) operations, with a minimally invasive surgical approach in 60.4%. Procedures included colorectal (37%), pancreatic (19%), esophagogastric (18%), hepatobiliary (18%), and small bowel resections (8%). Total direct costs differed between surgeons with an analysis of variance coefficient range between -$3265 and +$6163 (P < 0.001). Surgeons' cost differences were observed for central medical supply, operating room (OR) supply, total OR, inpatient room, laboratory, pharmacy, supportive care (P < 0.001), and radiology costs (P < 0.02). OR supply cost was the dominant consistent domain with significant differences between surgeons in all case subcategories. When controlled for case category and minimally invasive surgical approach, multiple regression showed the most significant variations between surgeons in ORs, medical supply, and nutrition costs (P < 0.001), followed by laboratory costs (P < 0.01). Top OR supply costs were staplers and energy devices. CONCLUSIONS: Even in a highly subspecialized surgical environment, surgeons' variable utilization of ORs and medical supplies is strongly linked to variations in care-related costs. Specific queries into supply items should reduce costs and optimize value generated.

User experience of wearing comfort of reusable versus disposable surgical gowns and environmental perspectives: A cross-sectional survey.

OBJECTIVE: To determine the user experience of wearing comfort of reusable sterile surgical gowns and compare these gowns with conventional disposable surgical gowns. DESIGN: Cross-sectional survey. SETTING: An academic hospital in the Netherlands. POPULATION: Gynaecologists, surgeons, residents and operating room assistants (n=80). METHODS: Quantitative and qualitative data were obtained via a written questionnaire. Participants provided subjective comments and scored the reusable gown on each individual topic with a score from 1 to 5 (1 = unsatisfactory, 2 = moderate, 3 = good, 4 = very good, 5 = excellent) and compared the reusable gown with the conventional disposable alternative (better, equal or worse). MAIN OUTCOME MEASURES: Wearing comfort: ventilation and temperature regulation, fit and length, functionality, barrier function and ease of use. RESULTS: The results of the overall scores of the reusable gown are scored as 'very good' (mean 4.3, SD ± 0.5) by its users. Regarding comparison of the gowns, more than 79% (lowest score 79%, highest score 95%) of the participants scored the reusable gown equal or higher on six of seven topics. The topic 'ease of use' was scored equal or higher by 59% of the participants. Subjective comments provided information on possible improvements. CONCLUSIONS: The findings of this study demonstrate that there is professional acceptance regarding the utilisation of reusable surgical gowns. To facilitate broader adoption, it is imperative to foster collaboration among suppliers and healthcare institutions. The reusable surgical gown is an environmentally sustainable, safe and comfortable alternative in the operating room.

The carbon footprint of different modes of birth in the UK and the Netherlands: An exploratory study using life cycle assessment.

OBJECTIVE: To compare the carbon footprint of caesarean and vaginal birth. DESIGN: Life cycle assessment (LCA). SETTING: Tertiary maternity units and home births in the UK and the Netherlands. POPULATION: Birthing women. METHODS: A cradle-to-grave LCA using openLCA software to model the carbon footprint of different modes of delivery in the UK and the Netherlands. MAIN OUTCOME MEASURES: 'Carbon footprint' (in kgCO2 equivalents [kgCO2 e]). RESULTS: Excluding analgesia, the carbon footprint of a caesarean birth in the UK was 31.21 kgCO2 e, compared with 12.47 kgCO2 e for vaginal birth in hospital and 7.63 kgCO2 e at home. In the Netherlands the carbon footprint of a caesarean was higher (32.96 kgCO2 e), but lower for vaginal birth in hospital and home (10.74 and 6.27 kgCO2 e, respectively). Emissions associated with analgesia for vaginal birth ranged from 0.08 kgCO2 e (with opioid analgesia) to 237.33 kgCO2 e (nitrous oxide with oxygen). Differences in analgesia use resulted in a lower average carbon footprint for vaginal birth in the Netherlands than the UK (11.64 versus 193.26 kgCO2 e). CONCLUSION: The carbon footprint of a caesarean is higher than for a vaginal birth if analgesia is excluded, but this is very sensitive to the analgesia used; use of nitrous oxide with oxygen multiplies the carbon footprint of vaginal birth 25-fold. Alternative methods of pain relief or nitrous oxide destruction systems would lead to a substantial improvement in carbon footprint. Although clinical need and maternal choice are paramount, protocols should consider the environmental impact of different choices.

Too loud to hear myself think: deleterious effects of noise in the operating room.

Noise is part of daily life in the operating room, and too often is viewed as a necessary evil. However, much of the noise in operating rooms (ORs) is unnecessary, such as extraneous conversations and music, and could be reduced. At the least, noise is known to increase staff stress and to hamper effective communication; at the worst, it adversely affects patient outcomes. Every member of the OR team should be cognisant of this and work to reduce unnecessary noise.

Reducing the time to activation of the emergency call system in operating theatres: effect of installing vertical red line indicators.

BACKGROUND: The 7th National Audit Project of the Royal College of Anaesthetists (NAP7) recommended that an emergency call system be immediately accessible in all anaesthesia locations. It is essential that all theatre team members can rapidly call for help to reduce the risk of patient harm. However, the ability of staff to activate this system in a timely manner can be affected by cluttered or unfamiliar environments and cognitive overload. One proposed strategy to enable rapid identification and activation of emergency call systems is to install a red vertical painted stripe on the wall from the ceiling to the activation button. We investigated the effect of introducing this vertical red line on activation times in operating theatres in the UK and Australia. METHODS: Operating theatre team members, including anaesthetists, surgeons, anaesthetic nurses, surgical and theatre nurses, operating theatre practitioners, and technicians, were approached without prior warning and asked to simulate activation of an emergency call. Vertical red lines were installed, and data collection repeated in the same operating theatres 4-12 months later. RESULTS: After installation of vertical red lines, the proportion of activations taking >10 s decreased from 31.9% (30/94) to 13.6% (17/125, P=0.001), and >20 s decreased from 19.1% (18/94) to 4.8% (6/125, P<0.001). The longest duration pre-installation was 120 s, and post-installation 35 s. CONCLUSIONS: This simple, safe, and inexpensive design intervention should be considered as a design standard in all operating theatres to minimise delays in calling for help.

Effects of multiple protection model in the operating room on physiological stress and risk events in patients undergoing coronary artery stent implantation.

OBJECTIVE: To analyze the impact of multiple protection model in the operating room on patients' physiological stress and risk events after coronary artery stent implantation (CASI). METHODS: During October 2021 to October 2022, 150 patients with coronary heart disease (CHD) were picked as the research subjects, all of whom underwent CASI. The clinical data were retrospectively analyzed, and the patients were divided into two groups according to different nursing methods, with 75 cases in each group. Patients in the intervention group received multiple protection model intervention in the operating room, and the patients in the control group adopted conventional care model. The patient satisfaction with nursing, postoperative recovery, psychological stress scores, physiological stress indicators, and adverse cardiac risk events were recorded. RESULTS: Patients in the intervention group had much higher percentage of the patient satisfaction with nursing than those in the control group (P < 0.05). The time to get out of bed and hospital stay was significantly shorter and the 6-min walking distance was markedly longer in the intervention group than the control (P < 0.05). The Hamilton Anxiety (HAMA) scale and Hamilton Depression (HAMD) scale score of patients in two groups were sharply decreased after the intervention (P < 0.05), which were strongly lower in the intervention group than the control (P < 0.001). After the intervention, the heart rate, cortisol and epinephrine of patients were all sensibly elevated in two groups (P < 0.05), which were all memorably lower in the intervention group than the control (P < 0.001). The incidence of adverse cardiac risk events in the intervention group was 5.33%, which was dramatically lower than 16.00% in the control group (P < 0.05). CONCLUSION: The application of multiple protection model in the operating room on patients undergoing coronary stent implantation promoted postoperative recovery, reduced patients' psychological and physiological stress, maintained blood pressure and other vital signs, reduced the incidence of adverse cardiac risk events, and improved the patient satisfaction with nursing.

Reintubation Rate and Mortality After Emergent Airway Management Outside the Operating Room.

BACKGROUND: Little is known about reintubations outside of the operating room. The objective of this study was to evaluate the reintubation rate and mortality after emergent airway management outside operating room (OR), including intensive care unit (ICU) and nonICU settings. METHODS: A retrospective cohort study. The primary outcome measures were reintubation rate and mortality. Secondary outcome measures were location and indication for intubation, time until reintubation, total intubated days, ICU-stay, hospital-stay, 30-day in-hospital mortality, and overall in-hospital mortality. RESULTS: A total of 336 outside-OR intubations were performed in 275 patients. Of those 275 patients, 51 (18.5%) were reintubated during the same hospital admission. (41%) of the reintubations occurred in a non-ICU setting. Reintubations occurred after up to 30-days after extubation. Most frequently between 7 and 30 days (32.8%, n = 20). Most of the reintubated patients were reintubated just once (56.9%; n = 29), but some were reintubated 2 times (29.4%; n = 15) or over 3 times (13.7%; n = 7). Reintubated patients had significant longer total ICU-stay (24 ± 3 days vs 12 ± 1 day, p < .001), hospital stay (37 ± 3 vs18 ± 1, p < .001), and total intubation days (8 ± 1 vs 7 ± 0.6, P < .02). The 30-day in-hospital mortality in reintubated patients was 13.7% (n = 7) compared to nonreintubated patients 35.9% (n = 80; P = .002). CONCLUSION: Reintubation was associated with a significant increase in hospital and ICU stay. The higher mortality rate among nonreintubated patients may indicate survival bias, in that severely sick patients did not survive long enough to attempt extubation.

Training and education of operating room nurses in robot-assisted surgery: a systematic review.

BACKGROUND: With the introduction of robot-assisted surgery, the role and responsibility of the operating room nurses have been expanded. The surgical team for robotic-assisted surgery depends on the ability of the operating room nurses to operate and handle the robotic system before, during, and after procedures. However, operating room nurses must acquire the necessary competencies for robotic-assisted surgery. METHOD: We performed a systematic review using the databases MEDLINE and EMBASE to review the evidence on educating and training operating room nurses in robot-assisted surgery. Studies describing operating room nurses' training and team-training with operating room nurses for robot-assisted surgery were included. The Medical Education Research Study Quality Instrument (MERSQI) and the Newcastle-Ottawa Scale-Education (NOS-E) were used to evaluate the quality of the included studies. RESULTS: We identified 3351 potential studies and included 16 in the final synthesis. Nine studies focused on team-training in robot-assisted surgery: four focused solely on training for operating room nurses, and only three on operating room nurses as first assistants in robot-assisted surgery. Most studies examined team-training in RAS, including OR nurses, focused on emergency situations and conversion to an open procedure. Only a few studies addressed other competencies relevant to OR nurses in RAS. No randomized controlled trials were identified. Only a few studies used pre- and post-testing, and only one examined clinical outcomes. The quality assessment of the included studies was moderate to low, with a median MERSQI score of 10.3 and a median NOS-E score of 2. CONCLUSION: There is sparse research on the education of operating room nurses in robot-assisted surgery, and the literature emphasizes the training of surgeons. More research is needed to develop evidence-based training for operating room nurses in robot-assisted surgery.

Characterisation and mitigation of gas leaks at laparoscopy: an international prospective, multi-center cohort clinical trial.

INTRODUCTION: Gas leaks polluting the operating room are common in laparoscopy. Studies defining methods for sensitive leak characterisation and mechanical mitigation in real world settings are, however, lacking. METHODS: Mobile optical gas imagers (both a miniaturised Schlieren system and sensitive tripod-mounted near-infrared carbon dioxide camera (GF343, FLIR)) prospectively defined trocar-related gas leaks occurring either spontaneously or with instrumentation during planned laparoscopic surgery at three hospitals. A boutique Matlab-based analyser using sequential frame subtraction categorised leaks (class 0-no observable leak; class 1-marginally detectable leak; class 2-short-lived plume; class 3-energetic, turbulent jet). Concurrently, the usefulness of a novel vacuum-ring device (LeakTrap™, Palliare, Ireland) designed as a universal adjunct for existing standard laparoscopic ports at both abdominal wall and port valve level was determined similarly in a phase I/11 clinical trial along with the device's useability through procedural observation and surgeon questionnaire. RESULTS: With ethical and regulatory approval, 40 typical patients (mean age 58.6 years, 20 males) undergoing planned laparoscopic cholecystectomy (n = 36) and hernia repair (n = 4) were studied comprising both control (n = 20) and intervention (n = 20) cohorts. Dual optical gas imaging was successfully performed across all procedures with minimal impact on procedural flow. In total, 1643 trocar instrumentations were examined, 819 in the control group (mean 41 trocar instrumentations/procedure) and 824 in the intervention group (mean 41.2 trocar instrumentations/procedure). Gas leaks were detected during 948(62.6%) visualised trocar instrumentations (in 129-7.8%-the imaging was obscured). 14.8% (110/742) and 60% (445/742) of leaks in control patients were class 0 and 3, respectively, versus 59.1% (456/770) and 8.7% (67/772) in the interventional group (class 3 v non-class 3, p < 0.0001, χ2). The Leaktrap proved surgically acceptable without significant workflow disruption. CONCLUSION: Laparoscopic gas leaks can be sensitively detected and consistently, effectively mitigated using straightforward available-now technology with most impact on the commonest, highest energy instrument exchange leaks.

Perspectives on sustainability among surgeons: findings from the SAGES-EAES sustainability in surgical practice task force survey.

BACKGROUND: Surgical care significantly contributes to healthcare-associated greenhouse gas emissions (GHG). Surgeon attitudes about mitigation of the impact of surgical practice on environmental sustainability remains poorly understood. To better understand surgeon perspectives globally, the Society of American Gastrointestinal and Endoscopic Surgeons and the European Association for Endoscopic Surgery established a joint Sustainability in Surgical Practice (SSP) Task Force and distributed a survey on sustainability. METHODS: Our survey asked about (1) surgeon attitudes toward sustainability, (2) ability to estimate the carbon footprint of surgical procedures and supplies, (3) concerns about the negative impacts of sustainable interventions, (4) willingness to change specific practices, and (5) preferred educational topics and modalities. Questions were primarily written in Likert-scale format. A clustering analysis was performed to determine whether survey respondents could be grouped into distinct subsets to inform future outreach and education efforts. RESULTS: We received 1024 responses, predominantly from North America and Europe. The study revealed that while 63% of respondents were motivated to enhance the sustainability of their practice, less than 10% could accurately estimate the carbon footprint of surgical activities. Most were not concerned that sustainability efforts would negatively impact their practice and showed readiness to adopt proposed sustainable practices. Online webinars and modules were the preferred educational methods. A clustering analysis identified a group particularly concerned yet willing to adopt sustainable changes. CONCLUSION: Surgeons believe that operating room waste is a critical issue and are willing to change practice to improve it. However, there exists a gap in understanding the environmental impact of surgical procedures and supplies, and a sizable minority have some degree of concern about potential adverse consequences of implementing sustainable policies. This study uniquely provides an international, multidisciplinary snapshot of surgeons' attitudes, knowledge, concerns, willingness, and preferred educational modalities related to mitigating the environmental impact of surgical practice.

A discrete-event simulation model for assessing operating room efficiency of thoracic, gastrointestinal, and orthopedic surgeries.

BACKGROUND: In hospital management, pinpointing steps that most enhance operating room (OR) throughput is challenging. While prior literature has utilized discrete event simulation (DES) to study specific strategies such as scheduling and resource allocation, our study examines an earlier planning phase, assessing all workflow stages to determine the most impactful steps for subsequent strategy development. METHODS: DES models real-world systems by simulating sequential events. We constructed a DES model for thoracic, gastrointestinal, and orthopedic surgeries summarized from a tertiary Chinese hospital. The model covers preoperative preparations, OR occupation, and OR preparation. Parameters were sourced from patient data and staff experience. Model outcome is OR throughput. Post-validation, scenario analyses were conducted for each department, including: (1) improving preoperative patient preparation time; (2) increasing PACU beds; (3) improving OR preparation time; (4) use of new equipment to reduce the operative time of a selected surgery type; three levels of improvement (slight, moderate, large) were investigated. RESULTS: The first three improvement scenarios resulted in a 1%-5% increase in OR throughput across the three departments. Large reductions in operative time of the selected surgery types led to approximately 12%, 33%, and 38% increases in gastrointestinal, thoracic, and orthopedic surgery throughput, respectively. Moderate reductions resulted in 6%-17% increases in throughput and slight reductions of 1%-7%. CONCLUSIONS: The model could reliably reflect OR workflows of the three departments. Among the options investigated, model simulations suggest that improving OR preparation time and operative time are the most effective.

Surgeon perspectives on preference cards and environmental stewardship.

BACKGROUND: Refinement of surgical preference cards may reduce waste from surgery. This study aimed to characterize surgeon perceptions and practices regarding preference card maintenance, identify barriers to updating preference cards, and explore whether opinions on environmental stewardship relate to preference card maintenance. METHODS: This was a mixed methods survey performed at a single tertiary academic medical center. Surgeons completed questions on accuracy, frequency of updates, and perceived environmental impact of their preference cards. Responses were compared between early career and mid-to late-career surgeons using Kruskal-Wallis, chi-squared, and Fisher's exact tests. RESULTS: The response rate was 46.4% (n = 89/192). Among respondents, 46.1% (n = 41/89) rarely or never updated preference cards. Nearly all (98.9%, n = 87/88) said some of their cases had unused items on their cards. Most (87.6%, n = 78/89) made updates via verbal requests. Unfamiliar processes (83.7%, n = 72/86) and effort required (64.0%, n = 55/86) were viewed as barriers to card maintenance. Most agreed that more frequent updates would reduce waste (80.5%, n = 70/87), but respondents did not feel knowledgeable about the environmental impact of items on their cards (62.1%, n = 54/87). Mid-to late-career surgeons were less likely to update their cards annually or more often compared to early career surgeons (18.9%, n = 7/37 vs. 57.1%, n = 24/42, p < 0.001). No other responses varied significantly between early career and mid-to late-career surgeons. CONCLUSIONS: Surgeons acknowledged the utility of preference card maintenance in environmental stewardship, but unfamiliar systems and perceived effort hindered preference card review. Greater attention to preference card maintenance would promote environmentally sustainable practices in surgery.

Why can't we improve turnover time? A systematic review.

BACKGROUND: Despite substantial efforts to reduce operating room (OR) turnover time (TOT), delays remain a frustration to physicians, staff, and hospital leadership. These efforts have employed many systems and human factor-based approaches with variable results. A deeper dive into methodologies and their applicability could lead to successful and sustained change. The aim of this study was to conduct a systematic review to evaluate relevant research focused on improving OR TOT and clearly defining measures of successful intervention. MATERIAL AND METHODS: A systematic review of OR TOT interventions implemented between 1980 through October 2022 was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. Research databases included: 1) PubMed; 2) Web of Science; and 3) OVID Medline. RESULTS: A total of 38 articles were appropriate for analysis. Most employed a pre/post intervention approach (29, 76.3%), the remaining utilized a control/intervention approach. Nine intervention methods were identified: the majority included a process redesign bundle (24, 63%), followed by overlapping induction, dedicated unit/team/space feedback, financial incentives, team training, education, practice guidelines, and redefinition of roles/responsibilities. Studies were further categorized into one of two groups: (1) those that utilized predetermined interventions based on anecdotal experience or prior literature (18, 47.4%) and (2) those that conducted a prospective analysis on baseline data to inform intervention development (20, 52.6%). DISCUSSION: There are significant variability in the methodologies utilized to improve OR TOT; however, the most effective solutions involved process redesign bundles developed from a prospective investigation of the clinical work-system.

Factors associated with 30- and 90-day mortality in intubations among critically ill patients.

BACKGROUND: Emergency intubations are commonly associated with adverse events when performed in critically ill patients. A detailed look at intubation factors and their association with procedural success and mortality has yet to be fully conducted. METHODS: A total of 299 successive intubations at a tertiary Veteran Affair hospital were analyzed. Situational factors, personnel involved, intubation indications, induction agents, and airway management techniques were prospectively collected and entered into univariable and multivariable analyses to identify factors associated with procedural difficulty and mortality. RESULTS: The use of paralytics was associated with easier intubations (OR: 0.31, 95% CI: 0.11-0.87, p = .03). The use of direct laryngoscopy or video laryngoscopy had no significant association with difficult intubation. Factors associated with increased 30-day mortality were cardiac arrest (OR: 7.90, 95% CI: 2.77-22.50, p < .001), hypoxia as indication for intubation (OR: 2.31, 95% CI: 1.23-4.35, p = .009), and nadir SpO2 < 90% (OR: 2.70, 95% CI: 1.01-7.21, p = .048). Presence of an attending anesthesiologist during intubation was associated with a lower 30-day mortality (OR: 0.11, 95% CI: 0.04-0.29, p < .001). Factors associated with increased 90-day mortality were cardiac arrest (OR: 6.57, 95% CI: 2.23-19.34, p = .001), hypoxia as indication for intubation (OR: 1.97, 95% CI: 1.10-3.55, p = .023), and older age (OR: 1.38, 95% CI: 1.07-1.78, p = .013). Similarly, presence of an attending anesthesiologist was found to be associated with a lower 90-day mortality (OR: 0.19, 95% CI: 0.07-0.50, p = .001). CONCLUSION: Cardiovascular and respiratory instability were associated with increased 30- and 90-day mortality. Presence of an attending anesthesiologist was associated with a better survival following intubation outside operating room.

Leveraging the potential of the German operating room benchmarking initiative for planning: A ready-to-use surgical process data set.

We present a freely available data set of surgical case mixes and surgery process duration distributions based on processed data from the German Operating Room Benchmarking initiative. This initiative collects surgical process data from over 320 German, Austrian, and Swiss hospitals. The data exhibits high levels of quantity, quality, standardization, and multi-dimensionality, making it especially valuable for operating room planning in Operations Research. We consider detailed steps of the perioperative process and group the data with respect to the hospital's level of care, the surgery specialty, and the type of surgery patient. We compare case mixes for different subgroups and conclude that they differ significantly, demonstrating that it is necessary to test operating room planning methods in different settings, e.g., using data sets like ours. Further, we discuss limitations and future research directions. Finally, we encourage the extension and foundation of new operating room benchmarking initiatives and their usage for operating room planning.

The impact of spinal versus general anesthesia on the variability of surgical times: a systematic review and meta-analysis.

BACKGROUND: With spinal anesthesia, when cases are taking longer than usual, there may be behavioural tendencies for surgical teams to work more quickly. We conducted a systematic review with meta-analysis to examine standard deviations of surgical times for single-dose spinal anesthetics versus general anesthesia. We compared ratios of mean surgical times as a secondary endpoint. METHODS: We included randomized trials of humans where general or spinal anesthesia was used for one category of surgical procedure (e.g., hip arthroplasty) and the article reported the means and standard deviations of operative durations. We used statistical methods suitable for surgical times following log-normal distributions. We used generalized confidence intervals to calculate point estimates of ratios and standard errors for each study, followed by pooling among studies using DerSimonian and Laird random-effects meta-analysis with Knapp-Hartung adjustment. RESULTS: Among the 77 included studies, 96% were of high quality for our endpoint (i.e., had a low risk of bias), as no (0%) study focused on comparing variability of surgical times and none had surgical time as the primary endpoint. Spinal anesthesia was associated with 6.6% smaller standard deviations than general anesthesia (95% confidence interval, 15.8% smaller to 1.9% larger, P = 0.13). By meta-regression, there was no significant association of the ratios of standard deviations with study quality (P = 0.39), year of publication (P = 0.76), or categories of procedures (all five P ≥ 0.28). Spinal anesthesia was associated with 1.1% smaller means than general anesthesia (95% confidence interval, 3.7% smaller to 1.5% larger, P = 0.42). There were no significant associations between the ratios of means and study quality (P = 0.47), year of publication (P = 0.95), or categories of procedures (all five, P ≥ 0.63). CONCLUSIONS: The results of this systematic review and meta-analysis show with high confidence that the effect of choosing spinal anesthesia on variability in surgical time, if present, is sufficiently small to have no substantive direct economic effect. The same conclusion applies to mean surgical time. Therefore, although anesthetic choice has a clinical (biological) impact and affects anesthesia times, the direct effects on surgical times and workflow are minimal at most. Anesthetic choice does not influence operating theatre productivity via changes to surgical times. The impact of spinal anesthetic effects is limited to nonoperative times (e.g., reducing anesthesia-controlled times by using a block room before the patient enters the operating room). STUDY REGISTRATION: PROSPERO ( CRD42023461952 ); first submitted 8 September 2023.

RéSUMé: CONTEXTE: Lors de l'utilisation de rachianesthésie, si les cas prennent plus de temps que d'habitude, les équipes chirurgicales pourraient avoir tendance à travailler plus rapidement. Nous avons réalisé une revue systématique avec méta-analyse pour examiner les écarts types des temps chirurgicaux pour les rachianesthésies en dose unique par rapport à l'anesthésie générale. Nous avons comparé les rapports des durées chirurgicales moyennes comme critère d'évaluation secondaire. MéTHODE: Nous avons inclus des études randomisées chez l'humain dans lesquelles l'anesthésie générale ou rachidienne avait été utilisée pour une catégorie d'intervention chirurgicale (par exemple, l'arthroplastie de la hanche) et pour lesquelles les moyennes et les écarts types des durées opératoires étaient rapportés. Nous avons utilisé des méthodes statistiques adaptées aux temps chirurgicaux suivant des distributions log-normales. Nous avons utilisé des intervalles de confiance généralisés pour calculer des estimations ponctuelles des ratios et des erreurs-types pour chaque étude, suivis d'un regroupement entre les études à l'aide d'une méta-analyse à effets aléatoires de DerSimonian et Laird avec ajustement de Knapp-Hartung. RéSULTATS: Parmi les 77 études incluses, 96 % étaient de haute qualité pour notre critère d'évaluation (c'est-à-dire qu'elles présentaient un faible risque de biais), car aucune étude (0 %) ne s'est concentrée sur la comparaison de la variabilité des temps chirurgicaux et aucune n'avait le temps chirurgical comme critère d'évaluation principal. La rachianesthésie était associée à des écarts types inférieurs de 6,6 % à ceux de l'anesthésie générale (intervalle de confiance à 95 %, 15,8 % plus petit à 1,9 % plus grand, P = 0,13). Par métarégression, il n'y avait pas d'association significative entre les ratios des écarts types et la qualité de l'étude (P = 0,39), l'année de publication (P = 0,76), ou des catégories de procédures (les cinq P ≥ 0,28). La rachianesthésie était associée à des moyennes inférieures de 1,1 % à celles de l'anesthésie générale (intervalle de confiance à 95 %, 3,7 % plus petit à 1,5 % plus grand, P = 0,42). Il n'y a pas eu d'association significative entre les ratios des moyennes et la qualité des études (P = 0,47), l'année de publication (P = 0,95), ou les catégories de procédures (toutes les cinq, P ≥ 0,63). CONCLUSION: Les résultats de cette revue systématique et de cette méta-analyse montrent avec un degré de confiance élevé que l'effet du choix de la rachianesthésie sur la variabilité du temps chirurgical, le cas échéant, est suffisamment faible pour n'avoir aucun effet économique direct substantiel. La même conclusion s'applique au temps chirurgical moyen. Par conséquent, bien que le choix de l'anesthésie ait un impact clinique (biologique) et affecte les temps d'anesthésie, les effets directs sur les temps chirurgicaux et le flux de travail sont tout au plus minimes. Le choix du type d'anesthésie n'influence pas la productivité de la salle d'opération en modifiant les temps chirurgicaux. L'impact des effets de la rachianesthésie est limité aux périodes non opératoires (p. ex., réduire les temps de contrôle de l'anesthésie en utilisant une salle de bloc avant que le patient ou la patiente n'entre en salle d'opération). ENREGISTREMENT DE L'éTUDE: PROSPERO ( CRD42023461952 ); première soumission le 8 septembre 2023.

Safe Landing: Feasibility and Safety of Operating Room Extubation in Minimally Invasive Cardiac Valve Surgery.

OBJECTIVE: This study was designed to explore key safety outcomes after operating room (OR) extubation in minimally invasive cardiac valve surgery. DESIGN: Single-center retrospective chart review. SETTING: Academic medical center in the United States. PARTICIPANTS: Patients undergoing valvular surgery via thoracotomy (November 2017-October 2022) at a single institution. INTERVENTIONS: The OR extubation protocol was implemented on August 20, 2020. MEASUREMENTS AND MAIN RESULTS: Delirium rates, reintubation rates, and intubation duration were compared before and after OR extubation protocol implementation. Logistic regression identified patient perioperative characteristics associated with unsuccessful OR extubation. Among 312 patients, 254 were extubated in the intensive care unit (ICU) and 58 in the OR. Preoperative demographics were comparable except for the Charlson Comorbidity Index (median: 2.0 ICU extubation v 1.5 OR extubation). Interrupted time series analysis showed no change in postoperative delirium post-OR extubation implementation, with a trend toward decreasing delirium (risk ratio = 0.37, CI: 0.13-1.10, p = 0.07). The postimplementation era also had a lower median intubation duration (8 hours v 13 hours, p < 0.001) without increasing reintubation rates (1.7% v 7.9%, p = 0.159). Increased bypass length (odds ratio = 0.99, CI: 0.98-0.99, p < 0.001), intraoperative morphine milligram equivalents (odds ratio = 0.99, CI: 0.99-1.0, p = 0.009), and preoperative Charlson Comorbidity Index above 3 (odds ratio = 0.42, CI: 0.19-0.95, p = 0.037) were associated with decreased odds of OR extubation. CONCLUSIONS: OR extubation was not associated with increased postoperative delirium or reintubation rates but did decrease intubation duration. Successful OR extubation relies upon the consideration of various patient perioperative characteristics.