Operating room disinfection: operator-driven ultraviolet 'C' vs. chemical treatment.

Background: In operating room (OR) surfaces, Nosocomial pathogens can persist on inanimate surfaces for long intervals and are highly resistant to traditional surface cleaning. Aim: This study compares traditional chemical operating room terminal disinfection to a unique operator-driven device that emits germicidal UV light at short distance onto vertical and horizontal surfaces. Methods: A randomized crossover analogous protocol assigned 40 end-of-day operating rooms into either group A (chemical then UVC treatments) or group B (UVC then chemical treatments). Initial Staphylococcal cultures were obtained prior to disinfection treatment, after the first treatment, and after the second treatment at 16 most commonly contaminated sites to represent overall room contamination. Success was defined as no growth and failure as 1 or more colony forming units. Thoroughness of chemical treatment vs UVC treatment was compared and used to determine if the second treatment was additive to the first treatment within each group. Findings: The operator driven UVC device outperformed chemical treatment in reducing the number of contaminated sites in the OR by more than half (P<0.001). Operator-driven UVC reduced contaminated sites after chemical treatment by nearly half (P<0.001). In contrast, chemical treatment after operator-driven UVC did not significantly reduce the number of contaminated sites. The mean employee time of disinfection for chemical treatment was 49 minutes and for the operator-driven UVC emitter 7.9 minutes (P<0.001). Conclusions: This study demonstrates that addition of an operator-driven UVC emitter to OR rooms between cases could be helpful in overall decreasing the number of contaminated sites.

Conversion Total Hip Arthroplasty in the Era of Bundled Care Payments: Impacts on Costs of Care.

BACKGROUND: Conversion hip arthroplasty is defined as a patient who has had prior open or arthroscopic hip surgery with or without retained hardware that is removed and replaced with arthroplasty components. Currently, it is classified under the same diagnosis-related group as primary total hip arthroplasty (THA); however, it frequently requires a higher cost of care. METHODS: A retrospective study of 228 conversion THA procedures in an orthopaedic specialty hospital was performed. Propensity score matching was used to compare the study group to a cohort of 510 primary THA patients by age, body mass index, sex, and American Society of Anesthesiologists score. These matched groups were compared based on total costs, implants used, operative times, length of stay (LOS), readmissions, and complications. RESULTS: Conversion THA incurred 25% more mean total costs compared to primary THA (P < .05), longer lengths of surgery (154 versus 122 minutes), and hospital LOS (2.1 versus 1.56 days). A subgroup analysis showed a 57% increased cost for cephalomedullary nail conversion, 34% increased cost for sliding hip screw, 33% for acetabular open reduction and internal fixation conversion, and 10% increased costs in closed reduction and percutaneous pinning conversions (all P < .05). There were 5 intraoperative complications in the conversion group versus none in the primary THA group (P < .01), with no statistically significant difference in readmissions. CONCLUSION: Conversion THA is significantly more costly than primary THA and has longer surgical times and greater LOS. Specifically, conversion THA with retained implants had the greatest impact on cost.

Web-based comparison of historical vs contemporary methods of fetal heart rate interpretation.

BACKGROUND: Contemporary interpretation of fetal heart rate patterns is based largely on the tenets of Drs Quilligan and Hon. This method differs from an older method that was championed by Dr Caldeyro-Barcia in recording speed and classification of decelerations. The latter uses a paper speed of 1 cm/min and classifies decelerations referent to uterine contractions as type I or II dips, compared with conventional classification as early, late, or variable with paper speed of 3 cm/min. We hypothesized that 3 cm/min speed may lead to over-analysis of fetal heart rate and that 1 cm/min may provide adequate information without compromising accuracy or efficiency. OBJECTIVE: The purpose of this study was to compare the Hon-Quilligan method of fetal heart rate interpretation with the Caldeyro-Barcia method among groups of obstetrics care providers with the use of an online interactive testing tool. STUDY DESIGN: We deidentified 40 fetal heart rate tracings from the terminal 30 minutes before delivery. A website was created to view these tracings with the use of the standard Hon-Quilligan method and adjusted the same tracings to the 1 cm/min monitoring speed for the Caldeyro-Barcia method. We invited 2-4 caregivers to participate: maternal-fetal medicine experts, practicing maternal-fetal medicine specialists, maternal-fetal medicine fellows, obstetrics nurses, and certified nurse midwives. After completing an introductory tutorial and quiz, they were asked to interpret the fetal heart rate tracings (the order was scrambled) to manage and predict maternal and neonatal outcomes using both methods. Their results were compared with those of our expert, Edward Quilligan, and were compared among groups. Analysis was performed with the use of 3 measures: percent classification, Kappa, and adjusted Gwet-Kappa (P < .05 was considered significant). RESULTS: Overall, our results show from moderate to almost perfect agreement with the expert and both between and within examiners (Gwet-Kappa 0.4-0.8). The agreement at each stratum of practitioner was generally highest for ascertainment of baseline and for management; the least agreement was for assessment of variability. CONCLUSION: We examined the agreement of fetal heart rate interpretation with a defined set of rules among a number of different obstetrics practitioners using 3 different statistical methods and found moderate-to-substantial agreement among the clinicians for matching the interpretation of the expert. This implies that the simpler Caldeyro-Barcia method may perform as well as the newer classification system.

Fellowship training: the ever-changing subspecialty of maternal-fetal medicine.

OBJECTIVE: To estimate the current scope of practice and evaluate the experience in training of maternal-fetal medicine specialists in the United States. METHODS: We administered an Internet-based, 16-question survey of 1,764 members of the Society for Maternal-Fetal Medicine, inquiring about aspects of fellowship training and scope of practice after completion of training. RESULTS: Approximately 36% (n=643) of surveys were returned. Most respondents were between 40 and 49 (230/640, 35.9%) and 50 and 59 (199/640, 31.1%) years old, and 411 were men (64.1%). Nearly all respondents (590/636, 92.8%) were certified in obstetrics and gynecology, and 80.1% (530/628) were certified in maternal-fetal medicine. The majority were in small-group practices of two to seven partners (359/634, 56.6%). Forty-nine percent (306/630) were in university-based practices, 26.8% (169/630) in university-affiliated practices, and 24.6% (155/630) in community-based or hospital-based practices. Most respondents work full time (40 hours per week or more), and the weekly practice profile consists primarily of ultrasonography (33.5%), consultation for high-risk patients (17.1%), and total obstetrical care for high-risk patients (15.4%).Training in most aspects of maternal-fetal medicine practice was felt to be adequate, with the exception of practice management. Time spent in training was spent primarily in high-risk pregnancy management (41%), ultrasonography (22%), and research (18%). CONCLUSION: The current scope of maternal-fetal medicine practice incorporates more ambulatory care than hospital-based care. Training programs rate highly in adequacy for high-risk pregnancy management and ultrasonography but lower in other aspects. LEVEL OF EVIDENCE: II.