Modelling the economic constraints and consequences of anaesthesia associate expansion in the UK National Health Service: a narrative review.

Shortages in the physician anaesthesia workforce have led to proposals to introduce new staff groups, notably in the UK National Health Service (NHS) Anaesthesia Associates (AAs) who have shorter training periods than doctors and could potentially contribute to workflow efficiencies in several ways. We analysed the economic viability of the most efficient staffing model, previously endorsed by both the UK Royal College of Anaesthetists and the Association of Anaesthetists, wherein one physician supervises two AAs across two operating lists (1:2 model). For this model to be economically rational (something which neither national organisation considered), the employment cost of the two AAs should be equal to or less than that of a single supervisor physician (i.e. AAs should be paid <50% of the supervisor's salary). As the supervisor can be an autonomous specialty and specialist (SAS) doctor, this sets the economically viable AA salary envelope at less than £40,000 per year. However, we report that actual advertised AA salaries greatly exceed this, with even student AAs paid up to £48,472. Economically, one way to justify such salaries is for AAs to become autonomous such that they eventually replace SAS doctors at a lower cost. We discuss some other options that might increase AA productivity to justify these salaries (e.g. ≥1:3 staffing ratios), but the medico-political consequences of each of them are also profound. Alternatively, the AA programme should be terminated as economically nonviable. These results have implications for any country seeking to introduce new models of working in anaesthesia.

Analysis of the airflow features and ventilation efficiency of an Ultra-Clean-Air operating theatre by qDNS simulations and experimental validation.

Ultra-Clean-Air (UCA) operating theatres aim to minimise surgical instrument contamination and wound infection through high flow rates of ultra-clean air, reducing the presence of Microbe Carrying Particles (MCPs). This study investigates the airflow patterns and ventilation characteristics of a UCA operating theatre (OT) under standard ventilation system operating conditions, considering both empty and partially occupied scenarios. Utilising a precise computational model, quasi-Direct Numerical Simulations (qDNS) were conducted to delineate flow velocity profiles, energy spectra, distributions of turbulent kinetic energy, energy dissipation rate, local Kolmogorov scales, and pressure-based coherent structures. These results were also complemented by a tracer gas decay analysis following ASHRAE standard guidelines. Simulations showed that contrary to the intended laminar regime, the OT's geometry inherently fosters a predominantly turbulent airflow, sustained until evacuation through the exhaust vents, and facilitating recirculation zones irrespective of occupancy level. Notably, the occupied scenario demonstrated superior ventilation efficiency, a phenomenon attributed to enhanced kinetic energy induced by the additional obstructions. The findings underscore the critical role of UCA-OT design in mitigating MCP dissemination, highlighting the potential to augment the design to optimise airflow across a broader theatre spectrum, thereby diminishing recirculation zones and consequently reducing the propensity for Surgical Site Infections (SSIs). The study advocates for design refinements to harness the turbulent dynamics beneficially, steering towards a safer surgical environment.

Innovations towards achieving environmentally sustainable operating theatres: A systematic review.

INTRODUCTION: The NHS accounts for 5.4% of the UK's total carbon footprint, with the perioperative environment being the most resource hungry aspect of the hospital. The aim of this systematic review was to assimilate the published studies concerning the sustainability of the perioperative environment, focussing on the impact of implemented interventions. METHODS: A systematic review was performed using Pubmed, OVID, Embase, Cochrane database of systematic reviews and Medline. Original manuscripts describing interventions aimed at improving operating theatre environmental sustainability were included. RESULTS: 675 abstracts were screened with 34 manuscripts included. Studies were divided into broad themes; recycling and waste management, waste reduction, reuse, reprocessing or life cycle analysis, energy and resource reduction and anaesthetic gases. This review summarises the interventions identified and their resulting effects on theatre sustainability. DISCUSSION: This systematic review has identified simple, yet highly effective interventions across a variety of themes that can lead to improved environmental sustainability of surgical operating theatres. Combining these interventions will likely result in a synergistic improvement to the environmental impact of surgery.

Nine years of microbiological air monitoring in the operating theatres of a university hospital in Southern Italy.

INTRODUCTION: Surgical site infections are among the most frequent Health Care Associated Infections with severe impact on mortality and high economic costs; the role of air microbiological contamination in surgical site infections was amply discussed in the scientific literature, highlighting differences in air contamination rates between different ventilation systems, number of people present and door opening rates. MATERIAL AND METHODS: The aim of our study was to monitor the presence of bacterial air contamination in operating theaters and its relationship with number of people and type of airflow over a period of nine years (January 2010-November 2018) at Messina's University Hospital. The Rho of Spearman test was used to evaluate differences in microbial contamination between empty and working theaters. The impact of the number of people on colony-forming unit values was assessed by performing a stepwise multiple regression analysis. The differences between the results recorded over the nine-year study period were evaluated using the variance analysis. Software R was used for the statistical assessment. RESULTS: Air samples were taken in each operating theater over nine years. A total of 1,425 samples were collected with a positivity rate of 37.3%. The median bacterial contamination rate was 30 cfu/m3 in empty theaters, while this rate was significantly higher (P < 0.001) in working theaters, where it reached 85 cfu/m3. A statistically significant difference was identified between laminar and turbulent airflow systems, with higher bacterial contamination rates with the latter (p<0.001); in these cases, the value of bacterial contamination (microbial count) was higher in the presence of a higher number of individuals in the operating theater (p<0.001). CONCLUSION: Our study demonstrates the complexity of the Operating Theatres environment, in which a good ventilation system is, indeed, only one prerequisite for clean air, but other factors, such as the behavior of healthcare professionals and environmental conditions, can influenced the bacterial count.

ATP bioluminescence assay for evaluating cleaning practices in operating theatres: applicability and limitations.

BACKGROUND: Environmental cleaning practice plays an important role in reducing microbial contamination in hospital surfaces and contributes to prevent Healthcare Associated Infections. Adenosine Triphosphate (ATP) bioluminescence assay is a commonly used method for assessing environmental cleanliness on healthcare surfaces. This study tested the feasibility of using ATP-bioluminescence assay for evaluating the efficiency of cleaning procedures in the operating theatre settings, comparing the ATP-bioluminescence test with the traditional culture method. METHODS: The surfaces of 10 operating rooms of two public hospitals (140 samples in total) were examined "at rest", in two moments of the same daily session: before the first scheduled operation (Pre), and before the second, after a clean environment was re-established (Post). Surface contamination was assessed using the cultural method to detect Total Viable Counts (TVC36°C) and ATP-bioluminescence assay (RLU). RESULTS: The examined surfaces presented very low TVCs (geometric means: 1.8 CFU/plate; IC95%: 1.6-2.0), always compliant with the relative reference standards. No statistical correlation was found between ATP values and TVCs. However, considering the results in terms of general evaluation of hygienic quality of surfaces, the two methods were consistent in identifying the most contaminated areas (Hospital A > Hospital B; Pre > Post; most contaminated surfaces: scialytic lamp). Furthermore, the ATP mean values showed a progressive increase from surfaces with TVC = 0 to surfaces with TVC > 15 CFU/plate. CONCLUSIONS: Although not an alternative to cultural methods, the ATP-bioluminescence-assay can be a useful tool to measure the efficiency of cleaning procedures also in environments with very low microbial counts. Each health facility should identify appropriate reference values, depending on the devices used and on the basis of the analysis of the data collected through spatial and temporal sampling series. By providing a rapid feedback, the ATP-assay helps to increase the awareness of operators and allows immediate action to be taken in critical situations.

A study to assess the influence of interprofessional point of care simulation training on safety culture in the operating theatre environment of a university teaching hospital.

Interprofessional point of care or in situ simulation is used as a training tool in our operating theatre directorate with the aim of improving crisis behaviours. This study aimed to assess the impact of interprofessional point of care simulation on the safety culture of operating theatres. A validated Safety Attitude Questionnaire was administered to staff members before each simulation scenario and then re-administered to the same staff members after 6-12 months. Pre- and post-training Safety Attitude Questionnaire-Operating Room (SAQ-OR) scores were compared using paired sample t-tests. Analysis revealed a statistically significant perceived improvement in both safety (p < 0.001) and teamwork (p = 0.013) climate scores (components of safety culture) 6-12 months after interprofessional simulation training. A growing body of literature suggests that a positive safety culture is associated with improved patient outcomes. Our study supports the implementation of point of care simulation as a useful intervention to improve safety culture in theatres.

'Herding cats': A mixed methods investigation into the educational value of debriefing in operating theatres.

AIM: The aim of the study was to explore the value of debriefing to enhance learning within operating theatres. METHODS: A sequential mixed method study was undertaken at a local District General Hospital Trust in 2020. A total of 106 surveys were distributed to all multidisciplinary team members based in the trauma and orthopaedic theatres. Following the survey stage, 11 in-depth semi-structured qualitative interviews were undertaken with volunteers from the survey stage which included a range of health care professionals. FINDINGS: Participants identified debriefing as a valuable tool for learning and reflection. However, significant barriers were identified, including lack of time and conflicting priorities. Some interviewees referred to the current debriefing process as a 'tick box' and a 'herding cats' exercise, attributing it to a lack of structure, leadership and organisational buy-in. CONCLUSIONS: Debriefing in the operating theatre is a valuable tool for individual and team learning. However, formalising the structure of the debriefing, along with joint team and organisational commitment, was deemed vital in optimising the value of debriefings in the future.

Enhancing Surgical Safety: Microbiological Air Control in Operating Theatres at University Medical Centre Maribor.

BACKGROUND: the aim of the study was to assess microbiological air quality in operating theatres by determining the level of microbiological contamination of the air and critical surfaces using the passive air sampling method and compliance of the operating theatre staff with infection control measures. MATERIALS AND METHODS: The prospective study was conducted in the surgical block of the University Medical Centre Maribor. For two months continuously, ten operating theatres were assessed for microbial contamination of air and surfaces during quiet and active times of the day. A passive air sampling method with Petri dishes on an agar specially adapted for this purpose (plate count agar) was used. In addition, ten surgical procedures were observed to assess staff compliance with recommended practises. RESULTS: Air samples met microbiological standards in all operating theatres. In both sampling sessions of the day (quiet and active periods), microbial contamination of the air was always within the limit of 10 CFU/m3. The average number of bacterial colonies was zero to two during quiet phases and one to four during active phases. Approximately 60% of the isolates from the operating theatres belonged mainly to the genus Staphylococcus: S. epidermidis (36% of the isolates), S. hominis (17.5%) and S. haemolyticus (5.5%). The rest were identified as Streptococcus anginosus (23%) and Bacillus sp. (18%). Pathogenic bacteria and moulds were not present. In regard to staff compliance with good surgical practise, the former varied by behaviour and function, with non-compliance in pre-operative skin preparation and operating theatre congestion being notable. The cleanliness of the environment was satisfactory. CONCLUSIONS: Microbiological air control is extremely important for the safety and success of both surgical and postoperative practises. In spite of good results obtained in the study, further improvements in surgical staff compliance with good surgical practise are essential to reduce surgical site infections.

Distractions and the anaesthetist: a qualitative study of context and direction of distraction.

BACKGROUND: Distractions are cited as contributory to healthcare-associated errors in a large proportion of incidents including those involving anaesthetists. The anaesthetist is relatively understudied, despite the closer coupling between action and outcome than in surgery. METHODS: After formal regulatory approval, we undertook an observational study using a validated rating scale for the observed effect of distractions. We also recorded the parties involved, the relative urgency of the distraction and the likely benefit or harm to the initiator and recipient. RESULTS: Thirty-two separate surgical operations were observed. Median case duration was 103 min (range 22-227 min). 3557 potentially distracting events were observed, of which 1173 (33%) were deemed to score ≥ 2 on the distraction scale (i.e. caused distraction). Of these 3557 events, 1227 involved the anaesthetist either as an initiator of a potential/actual distraction, or the recipient of an actual distraction. The commonest initiators of distraction were the circulating nurse (832/3557) and the anaesthetist (816/3557). Sixty distracting events were observed while the anaesthetist was preparing or administering drugs (~2 per case). Of the 60 drug-related distracting events, 26 were initiated by the anaesthetist, and 3 of 7 airway events. CONCLUSIONS: Distracting events involving the anaesthetist are common, but approximately two-thirds of these events have no externally visible effect. Another anaesthetist was the most common recipient of a distracting event initiated by the anaesthetist. Anaesthetists need to address themselves as causes of distractions and the potential impact on patient safety.

Pregnant theatre staff in orthopaedic operating rooms: An observational study.

PURPOSE: Trauma & Orthopaedic (T&O) surgery presents several occupational hazards to pregnant women and the unborn child. National bodies have produced guidelines to mitigate these risks as far as possible but individual trusts must be aware of them and implement them in their local policies. Our study aims to re-assess whether national guidelines for the protection of pregnant women are better adhered to nationally by providing a comparison to a previous study in 2018. METHODS: A national observational study of 146 NHS trusts in the UK was conducted. Each trust was asked to complete a freedom of information request regarding all orthopaedic guidelines relating to pregnant theatre staff, which specifically related to the protection of the mother and foetus from exposure to harmful activity in theatre. Compliance was ascertained by cross-checking local policies with national guidelines. RESULTS: 82/146 (52.0%) of NHS trusts responded to the Freedom of Information  request. 31/75 (41.3%) respondents followed Health and Safety Executive (HSE) guidance for New and Expectant Mothers with 17/75 (22.7%) following multiple national guidelines. 16/75 (21.3%) NHS trusts do not follow any national guidelines in protecting new and expectant mothers from occupational hazards in the orthopaedic theatre setting. CONCLUSIONS: Although an improvement has been made since 2018 in complying with national guidelines protecting new and expectant mothers from orthopaedic-related hazards, a sizeable proportion of NHS trusts do not comply with any national guidelines, putting employees at undue risk. There is a continued need for pregnant surgeons to be aware of and seek occupational health advice from dedicated professional bodies if the NHS trust does not provide specific guidance. Simultaneously, a sustained effort must be present to continue to inform NHS employers of their duty to protect new and expectant mothers and signpost them to relevant guidance.

Risk Influence of Some Environmental and Behavioral Factors on Air Contamination in the Operating Room: An Experimental Study.

Air contamination in operating rooms (ORs) depends on the conditions of the room and on activities therein performed. Methodologies of air quality assessment in ORs are often inadequately described in the scientific literature, and the time required for a change in status in air quality is never taken into account. The purpose of this study was to determine the influence of the state and the presence of human operators on air quality by implementing a precise measurement protocol that also took into account the time required for changes in the room to affect air pollution. As the main indicators of air pollution, bacterial load and concentration of airborne dust were measured. The results showed that: the use of surgical masks by operators in the OR did not significantly affect bacterial load within a distance of 2 m; keeping OR doors open did not induce a significant increase in bacterial load and of 5 µm particles while 10 µm particles concentration was positively affected; and air pollution measured with open doors was not significantly different from that due to the presence of two staff members, whether or not they were wearing masks. The results clarified the role of some factors on air pollution in ORs.

Theatre practitioners and organisational adaptive capacity in disaster response.

Disasters are increasing globally, requiring flexible strategic approaches from healthcare organisations to manage the resultant influx of patients requiring care while also maintaining normal operational services. Theatre practitioners play a key role in disaster response and recovery; however, a lack of appropriate skill utilisation may be reducing overall organisational adaptive capacity and leading to poorer outcomes for organisations, staff and patients. Understanding what skills individual practitioners have, and how they can be deployed to the greatest effect, is a concern for managers to ensure optimal use of resources and to reduce negative impacts of disaster response upon healthcare personnel. This is especially pertinent in the post-COVID healthcare climate where a paucity of operating theatre practitioners and poor workforce planning has led to a lack of surgical capacity at a time when it is most needed.

UCL MotionInput: Touchless computing interactions in clinical training, radiology and operating theatres.

Coupled with advances to federated on-device computer vision, the convenience of use and ease of access of cameras integrated into existing computers and tablets will increase touchless computing uptake in the form of gesture recognition software in healthcare for both clinicians and patients.

Measuring patient safety climate in operating rooms: Validation of the Spanish version of the hospital survey on patient safety.

OBJECTIVE: The measurement of patient safety climate within hospitals, and specifically in operating rooms is a basic tool for the development of the patient's safety policy. There are no validated Spanish versions of instruments to measure safety climate. The objective of this research was to validate the Spanish version of the Hospital Survey on Patient Safety (HSOPS®), with the addition of a module for surgical units, to evaluate the patient safety climate in operating rooms. METHODS: Survey validation study. The Hospital Survey on Patient Safety (HSOPS®) was applied to health workers from 6 acute general hospitals, from Medellín (Colombia), with surgical procedures greater than 300 per month, 18 items were added considered specific for Operating Rooms. For construct validation, an exploratory factor analysis (EFA) was used, utilizing principal components as the extraction method. Reliability was evaluated with Cronbach's α. RESULTS: A 10 dimensions model was obtained with EFA, most of the dimensions of the original questionnaire were conserved, although the factorial structure was not reproduced. Two new dimensions emerged from the added items. The Cronbach's α ranged between 0.66 and 0.87. Conclusions: We found the HSOPS questionnaire is valid and reliable for measuring patient safety climate in Spanish speaking Latin American countries. Two additional dimensions are proposed for Operating Rooms.

Clearing the air on surgical plume.

BACKGROUND: Surgical smoke or plume is produced by a variety of surgical coagulators and dissectors. A number of jurisdictions have recently introduced policies to reduce the associated occupational health risks including WorkSafe Victoria and New South Wales Health. METHOD: This paper is a narrative review of potential risks, including any associated with COVID-19, and options for mitigation. RESULTS: Surgical smoke or plume contains potentially toxic chemicals, some of which are carcinogens. Plume may also contain live virus, notably Human Papilloma and Hepatitis B, though any possible viral transmission is limited to a few case reports. Despite identifying COVID-19 ribonucleic acid fragments in various body tissues and fluids there are no current reports of COVID-19 transmission. Although plume is rapidly removed from the atmosphere in modern operating rooms, it is still inhaled by the operative team. Mitigation should include ensuring diathermy devices have evacuators while plume extraction should be standard for laparoscopic procedures. Consideration needs to be given to the potential to compromise the operating field of view, or the noise of the extractor impairing communication. There is an increasing range of suitable products on the market. The future includes pendant systems built into the operating room. CONCLUSION: The potential risks associated with surgical plume cannot be ignored. Health services should invest in plume extraction devices with a view to protecting their staff. The conduct of the operation should not be compromised by the devices chosen. Future operating theatres need to be designed to minimize exposure to plume.

Building a critical incident peer response team: A full theatre team welfare intervention.

The psychological impact (second victim effect) of in-theatre critical incidents is increasingly recognised. Different styles of psychological support programme have recently been published, including some utilising 'near in time' peer support. Most of these programmes either target their support to individuals, or focus on one vocational group rather than the multidisciplinary team. However, the in-theatre team consists of different craft groups who nonetheless function as a single team and are therefore 'peers'. This paper sets out the design and implementation of a critical incident peer response programme at Waikato Hospital, New Zealand, which provides peer-led group psychological first aid to full theatre teams. The programme is administered by trained representatives from multiple in-theatre craft groups including nurses, midwives, anaesthetic technicians, recovery room nurses, surgeons and anaesthetists. It emphasises team education and peer support, and has a wholly welfare focus. The programme has voluntary participation but mandatory activation triggers so that individuals do not need to seek support actively at a time when they may not recognise the need to do so. The programme is becoming embedded in the Waikato Hospital theatre culture so that participating in psychological support is normalised following a critical event. This framework is shared in the hope that it will assist other hospitals to develop welfare interventions to support full theatre teams.

Study of Bacterial Contamination in Operating Theatres at Al-Hussein Teaching Hospital in Al-Samawah, Iraq.

The continuing bacterial contamination in hospitals operating units and theaters has an important role in the spread of hospital infections. The current study evaluated the level of bacterial contamination in the operating theatres at Al-Hussein Teaching Hospital in Al-Samawah, Iraq. For the purpose of sample collection from surgical equipment surfaces, the swab plate method conducted by nurses and laboratory workers was used to collect the samples in the operating theater. The samples were then transferred to the laboratory unit for diagnosis by standard methods. The present study found different rates among operating theatres. According to bacterial contamination rate, especially for the operating theatre in emergency wings with 334 contaminated isolates, the highest rates of contaminated bacterial isolates were Staphylococcus epidermidis (n=171; 26.1%), Bacillus species (spp.) (n=118; 18%), S. aureus (n=111; 16.9%), Klebsiella spp. (n=92; 14%), Enterobacter spp. (n=82; 12.5%), P.aurogenosa (n=24; 3.7%), and Escherichia coli (n=23; 3.7%). Despite the use of all methods of sterilization among the hospital wards, especially the surgical halls in the hospital wards, bacterial contamination is still widespread among these units. It was noted that the bacteria isolated in this study posed a risk as pathogenic bacteria.

Access to surgical care as an efficiency issue: using lean management in French and Australian operating theatres.

PURPOSE: Millions around the world still cannot access safe, timely and affordable surgery. Considering access as a function of efficiency, this paper examines how the latter can be improved within the context of operating theatres. Carried out in France and Australia, this study reveals different types of waste in operating theatres and a series of successful tactics used to increase efficiency and eliminate wastefulness. DESIGN/METHODOLOGY/APPROACH: Data for this qualitative study were collected through 48 semi-structured interviews with operating theatre staff in France (n = 20) and Australia (n = 28). Transcripts were coded using a theory-driven thematic analysis to characterise sources of waste in operating theatres and the tactics used to address them. FINDINGS: The study confirmed the prominence of seven types of waste in operating theatres commonly found in industry and originally identified by Ohno, the initiator of lean: (1) underutilised operating rooms; (2) premature or delayed arrival of patients, staff or equipment; (3) need for large onsite storage areas and inventory costs; (4) unnecessary transportation of equipment; (5) needless staff movements; (6) over-processing and (7) quality defects. The tactics used to address each of these types of waste included multiskilling staff, levelling production and implementing just-in-time principles. ORIGINALITY/VALUE: The tactics identified in this study have the potential of addressing the chronic and structurally embedded problem of waste plaguing health systems' operating theatres, and thus potentially improve access to surgical care. In a global context of resource scarcity, it is increasingly necessary for hospitals to optimise the ways in which surgery is delivered.

Microbial Air Monitoring in Turbulent Airflow Operating Theatres: Is It Possible to Calculate and Hypothesize New Benchmarks for Microbial Air Load?

Multiple studies have demonstrated the presence of microorganisms commonly associated with surgical site infections (SSIs), in the air within the operating theatre (OT). In some countries such Italy, the limit of microbial concentration in the air for OT with turbulent airflows is 35 CFU/m3 for an empty OT and 180 CFU/m3 during activity. This study aims to hypothesize new benchmarks for the airborne microbial load in turbulent airflow operating theatres in operational and at rest conditions using the percentile distribution of data through a 17-year environmental monitoring campaign in various Italian hospitals that implemented a continuous quality improvement policy. The quartile distribution analysis has shown how in operational and at rest conditions, 75% of the values were below 110 CFU/m3 and 18 CFU/m3, respectively, which can be considered a new benchmark for the monitored OTs. During the initial stages of the monitoring campaign, 28.14% of the concentration values in operational conditions and 29.29% of the values in at rest conditions did not conform to the Italian guidelines' reference values. In contrast, during the last 5 years, all values in both conditions conformed to the reference values and 98.94% of these values were below the new benchmarks. Continuous improvement has allowed contamination to be reduced to levels well below the current reference values.