We Asked the Experts: The WHO Surgical Safety Checklist and the COVID-19 Pandemic: Recommendations for Content and Implementation Adaptations.

BACKGROUND: As surgical systems are forced to adapt and respond to new challenges, so should the patient safety tools within those systems. We sought to determine how the WHO SSC might best be adapted during the COVID-19 pandemic. METHODS: 18 Panelists from five continents and multiple clinical specialties participated in a three-round modified Delphi technique to identify potential recommendations, assess agreement with proposed recommendations and address items not meeting consensus. RESULTS: From an initial 29 recommendations identified in the first round, 12 were identified for inclusion in the second round. After discussion of recommendations without consensus for inclusion or exclusion, four additional recommendations were added for an eventual 16 recommendations. Nine of these recommendations were related to checklist content, while seven recommendations were related to implementation. CONCLUSIONS: This multinational panel has identified 16 recommendations for sites looking to use the surgical safety checklist during the COVID-19 pandemic. These recommendations provide an example of how the SSC can adapt to meet urgent and emerging needs of surgical systems by targeting important processes and encouraging critical discussions.

Treatment of pancreatic cancer with intravenous vitamin C: a case report.

Pancreatic ductal adenocarcinoma (PDA) has a dismal prognosis and is often discovered at an advanced stage with few therapeutic options. Current conventional regimens for PDA are associated with significant morbidity, decreased quality of life, and a considerable financial burden. As a result, some patients turn to integrative medicine therapies as an alternate option after a diagnosis of PDA. Intravenous pharmacologic ascorbic acid (PAA) is one such treatment. The use of PAA has been passionately debated for many years, but more recent rigorous scientific research has shown that there are significant blood concentration differences when ascorbic acid is given parenterally when compared to oral dosing. This pharmacologic difference appears to be critical for its role in oncology. Here, we report the use of PAA in a patient with poorly differentiated stage IV PDA as an exclusive chemotherapeutic regimen. The patient survived nearly 4 years after diagnosis, with PAA as his sole treatment, and he achieved objective regression of his disease. He died from sepsis and organ failure from a bowel perforation event. This case illustrates the possibility of PAA to effectively control tumor progression and serve as an adjunct to standard of care PDA chemotherapy regimens. Our patient's experience with PAA should be taken into consideration, along with previous research in cell, animal, and clinical experiments to design future treatment trials.

Adapting the World Health Organization's Surgical Safety Checklist to High-Income Settings: A Hybrid Effectiveness-Implementation Trial Protocol.

Objectives: The proposed study aims to assess users' perceptions of a surgical safety checklist (SSC) reimplementation toolkit and its impact on SSC attitudes and operating room (OR) culture, meaningful checklist use, measures of surgical safety, and OR efficiency at 3 different hospital sites. Background: The High-Performance Checklist toolkit (toolkit) assists surgical teams in modifying and implementing or reimplementing the World Health Organization's SSC. Through the explore, prepare, implement, and sustain implementation framework, the toolkit provides a process and set of tools to facilitate surgical teams' modification, implementation, training on, and evaluation of the SSC. Methods: A pre-post intervention design will be used to assess the impact of the modified SSC on surgical processes, team culture, patient experience, and safety. This mixed-methods study includes quantitative and qualitative data derived from surveys, semi-structured interviews, patient focus groups, and SSC performance observations. Additionally, patient outcome and OR efficiency data will be collected from the study sites' health surveillance systems. Data analysis: Statistical data will be analyzed using Statistical Product and Service Solutions, while qualitative data will be analyzed thematically using NVivo. Furthermore, interview data will be analyzed using the Consolidated Framework for Implementation Research and reach, effectiveness, adoption, implementation, maintenance implementation frameworks. Setting: The toolkit will be introduced at 3 diverse surgical sites in Alberta, Canada: an urban hospital, university hospital, and small regional hospital. Anticipated impact: We anticipate the results of this study will optimize SSC usage at the participating surgical sites, help shape and refine the toolkit, and improve its usability and application at future sites.

Does the Type of Surgical Headwear Worn in the OR Matter? A Review of Evidence and Opinions.

Proper surgical attire is essential in decreasing surgical site infections; however, the effectiveness of the different types of headwear is a controversial topic. We conducted a narrative review based on studies identified through a focused literature search to summarize and critically assess evidence and opinions on the most appropriate type of headwear for OR personnel. We included 48 articles: 17 original research studies and 31 non-peer-reviewed articles of various types. Research published before 2014 mostly supports the complete coverage of all hair, which aligns with the 2015 AORN guidelines. However, more recent literature rebuts these guidelines and emphasizes the importance of clean headwear. Although earlier studies (published before 2017) lacked scientific rigor, later studies (published after 2017) have other various limitations, including missing data on compliance, surgery-related techniques, and surgical attire other than headwear. The findings from this review highlight the importance of solid evidence-based guidelines and expert collaboration.

Health Disparities Experienced by Surgical Patients of Color: What is Known and Key Actions to Take.

In July of 2020, AORN created a comprehensive Diversity, Equity, and Inclusion plan that includes a patient-focused committee whose goal is to improve the care, experience, and outcomes of each patient by providing relevant information, education, and resources about diversity, equity, and inclusion to the perioperative team. To gain insight into racial disparities in the surgical setting, the committee conducted a literature search and identified relevant evidence. As in health care in general, disparities in surgical care and outcomes exist between patients of color and their white counterparts. The reasons are multifactorial and interconnected, with contributing factors related to the patient, health care providers, the health care system, and surgical and postoperative care. Disparities can occur at any point along the perioperative continuum. Research conducted during the past 10 years supports the existence of disparities in the surgical setting and across surgical specialties, but few researchers have recommended strategies that perioperative teams can implement for improvement. The white paper identifies disparities in the surgical setting, actions that facilities and perioperative teams can take to mitigate disparities, and information gaps that should be the focus of future research. Perioperative team members and health care organizations are ethically responsible to lead the development and implementation of changes in health care settings and in public and health policies that address disparities in surgical care and outcomes.

Back to Basics: Medication Safety.

Perioperative nurses administer some medications but are primarily responsible for obtaining, preparing, and documenting medications. Unlike personnel in many other patient care areas, perioperative personnel may not have immediate access to a pharmacist; this lack of pharmacy support can complicate medication administration processes. A variety of medication errors occur in the perioperative setting and can negatively affect patients and personnel. Perioperative nurses should review regulatory information and professional organization guidance documents when they work with other health care team members to address medication safety issues. Some recommendations include submitting clear medication orders, using aseptic technique when transferring medications to the sterile field, and using standardized labeling. In addition, perioperative nurses should obtain only one patient's medications from a dispensing unit at a time and prepare one medication at a time. After reviewing this article and the supporting literature, perioperative nurses should have increased knowledge about medication safety.

Back to Basics: Preventing Workplace Bullying.

Inappropriate workplace behavior such as bullying can negatively affect patient safety and staff member satisfaction. Bullying can be directed at individuals, groups of team members, or leaders and can include a variety of behaviors. Disrespectful behaviors are learned, tolerated, and reinforced; a certain degree of disrespect is accepted in some settings. Perioperative team members should use direct and meaningful communication to encourage and contribute to healthy work environments that address conflict and promote patient safety. They should follow applicable zero-tolerance policies on bullying and report disrespectful behaviors to leaders who, in turn, should address the behavior in a fair manner according to disciplinary guidelines. When disrespectful behaviors are reported and managed appropriately, bullying in the workplace can be minimized or even eliminated, which improves the overall workplace culture.

Back to Basics: Laser Safety.

Surgeons use lasers for a variety of inpatient and outpatient procedures. Perioperative nurses should have a basic understanding of the physics involved in producing the beam of energy and the risks associated with laser use. Although perioperative laser safety is the responsibility of all personnel involved in a laser procedure, health care facility leaders can implement certain strategies (eg, creating a laser safety committee with a laser safety officer) to help team members mitigate risk. This Back to Basics article reviews the history of lasers and identifies safety issues that perioperative nurses may encounter during laser procedures. It also discusses ways to prevent adverse outcomes associated with laser use and provides resources for additional information. By reviewing this article, perioperative nurses and leaders should be able to identify gaps related to laser safety that may be present in their organizations.

Back to Basics: Minimally Invasive Surgery.

In the past 20 to 30 years, minimally invasive surgery (MIS) has become commonplace in almost all surgical specialties. The needs of the perioperative team and patients are different during MIS than during traditional open surgery. The equipment and instrumentation required to perform MIS are extensive and continue to evolve as new techniques are developed. As advances in MIS occur and more procedures are completed using this method, some surgeons are conducting research studies related to the efficacy of certain longstanding MIS protocols. Perioperative nurses are challenged to stay current on the available technology and results of research studies so that they can provide safe patient care. This Back to Basics article will provide basic strategies for perioperative nurses to ensure successful MIS outcomes for patients.

Back to Basics: Mass Casualty Incidents.

Terrorist attacks, mass shootings, violent crimes, and other disasters may leave those affected feeling afraid and overwhelmed with emotion. It has been more than 17 years since the attacks on the World Trade Center in New York City killed almost 3,000 people. Since that time, the world has experienced a profuse number of mass casualty events; they are becoming commonplace and a risk that everyone recognizes as part of daily life. When disasters occur, health care providers may be required to mobilize and should be prepared for anything. Regardless of the size of the facility or the trauma level designation, perioperative nurses need to be aware of how they may be affected by traumatic events. This Back to Basics article reviews some significant mass casualty incidents and explores strategies for perioperative staff members to execute a successful response.

Back to Basics: Social Determinants of Health.

Social determinants of health (SDOH) are the conditions that people are born into and live under that affect their health. Nurses are responsible for addressing these determinants when possible. Perioperative nurses encounter the effects of SDOH when patients express concern about surgery scheduling times, transportation, child care, and other support-related issues during the perioperative period. Some SDOH are related to social identity (eg, race, ethnicity, sexual orientation) as a result of the oppression and discrimination that some groups experience. Perioperative nurses can establish trust with their patients by identifying their needs and partnering with community-based organizations to address some of those needs (eg, transportation, legal assistance), which may help relieve stress for their patients and promote better postsurgical outcomes. Although health care workers can assist individual patients to address the effects of SDOH on their health and life, policy change is needed to ensure long-term benefits.

Back to Basics: Unplanned Patient Hypothermia: 1.3 www.aornjournal.org/content/cme.

Unplanned perioperative hypothermia is a common occurrence and can negatively affect a patient's postoperative course. Perioperative nurses are responsible for identifying patients at risk for hypothermia and working with the entire surgical team to prevent this complication from occurring. Multiple interventions can be implemented to address hypothermia, including active or passive warming and warm IV and irrigation fluids. This Back to Basics article addresses patient assessment concerns, identifies a variety of evidence-based interventions that can prevent or mitigate perioperative patient temperature changes, and provides basic steps for perioperative RNs to follow to help prevent perioperative hypothermia in their patients.

Back to Basics: Protection From Surgical Smoke: 1.2 www.aornjournal.org/content/cme.

Surgical smoke is formed when energy-generating devices (ie, electrosurgery units, lasers, powered instruments) raise the intracellular temperature of tissue to at least 100º C (212º F), causing tissue vaporization in the form of surgical smoke. Surgical smoke contains components that are known health hazards, such as benzene, toluene, hydrogen cyanide, formaldehyde, volatile organic compounds, viruses, and bacteria. There have been case reports of human disease tied to the inhalation of surgical smoke; therefore, it is important for perioperative team members to minimize their exposure and patient exposure. In spite of the health risks, many perioperative departments do not consistently and effectively evacuate surgical smoke. This Back to Basics article provides basic steps that perioperative team members can take to protect themselves and their patients from the harm caused by surgical smoke exposure.

Back to Basics: Autologous Tissue: 1.5 www.aornjournal.org/content/cme.

Perioperative personnel manage autologous tissue when they care for patients undergoing procedures requiring the use of bone, soft tissue, or other autologous tissue to repair or replace defects. Use of autologous tissue can minimize the risk of rejection, disease transfer, and infection compared with the use of artificial materials. There are important steps to follow when handling autologous tissue to ensure it is safe for replantation and does not become contaminated. This Back to Basics article provides strategies for managing some types of autologous tissue, including bone flaps, parathyroid tissue, skin grafts, and veins. Tissue management strategies include creating strict documentation policies, standardizing processes and communication, and implementing routine audits to assess compliance.

Back to Basics: Pneumatic Tourniquet Use.

Pneumatic tourniquets are commonly used in surgeries involving the limbs to achieve a nearly bloodless surgery and an optimal operating field or when administering regional anesthesia during surgery on a limb. Complications can arise from the use of tourniquets, including nerve injuries, pain, compartment syndrome, pressure injuries, chemical burns, and tissue necrosis. More serious injuries-including deep vein thrombosis, thermal damage to tissues, severe ischemic injuries, and rhabdomyolysis-also can occur. Therefore, it is important for perioperative team members to understand how to use pneumatic tourniquets effectively and safely to provide the best possible care to patients. This article addresses the safety risks to patients when using pneumatic tourniquets and optimal safe use of these devices.

Back to Basics: Instrument Cleaning.

Adequately cleaning and processing surgical instruments may be challenging for perioperative team members; however, the cleaning and processing of instruments are critical steps in making instruments safe to use on patients and achieving an appropriately safe OR environment. Instruments that are cleaned properly have had organic debris and soil removed, rendering them ready for sterilization or disinfection. This Back to Basics article covers the basic steps and considerations for cleaning and processing instruments before sterilization.

Back to Basics: Environmental Cleaning Hazards.

Perioperative personnel must clean and disinfect the perioperative environment numerous times throughout the day to help prevent the risk of exposing patients to pathogenic microorganisms. However, this practice exposes perioperative team members to chemicals that could be harmful to their health. Exposure to cleaning and disinfecting products has been associated with potential health problems such as skin irritation, burns, rashes, and difficulty breathing. This Back to Basics article offers strategies for perioperative team members to implement to decrease their risk of harmful exposure to these products.