Home Telemonitoring Improved Pain Registration in Patients With Cancer.

INTRODUCTION: For adequate pain treatment in patients with cancer, it is important to monitor and evaluate pain regularly. Although the numeric rating scale (NRS) is implemented in hospitals in the Netherlands, pain is still not systematically registered during outpatient consultations. The aim of this study was to assess whether home telemonitoring increases pain registration in medical records of outpatients with cancer. METHODS: Patients with cancer were included in the intervention group (IG) when they visited the outpatient clinic. They received a short message service and an interactive voice response on their mobile phones 3 times a week, asking them to provide their pain score (NRS). When the reported NRS pain score was ≥5, a specialized oncology nurse adapted the pain treatment when necessary. Outcomes were compared to a control group (CG) without home telemonitoring. In both groups, medical records were analyzed and data on pain and analgesics were collected. RESULTS: In each group, the medical records of 54 patients were analyzed on 3 consecutive outpatient visits. In the CG, pain registration or its absence was described in 60 visits (37.0%). In the IG, pain registration or its absence was reported in 83 visits (51.2%). Patients in the IG received a prescription for analgesics significantly more often (36/54 patients [66.6%]) than did patients in the CG (18/54 patients [33.3%]), P < 0.01). CONCLUSION: Home telemonitoring for patients with cancer significantly increases registration of pain and prescriptions of analgesics in outpatient medical records. Home telemonitoring helps to increase the awareness of pain and its management.

Where are my instruments? Hazards in delivery of surgical instruments.

BACKGROUND: Unavailability of instruments is recognised to cause delays and stress in the operating room, which can lead to additional risks for the patients. The aim was to provide an overview of the hazards in the entire delivery process of surgical instruments and to provide insight into how Information Technology (IT) could support this process in terms of information availability and exchange. METHODS: The process of delivery was described according to the Healthcare Failure Mode and Effects Analysis methodology for two hospitals. The different means of information exchange and availability were listed. Then, hazards were identified and further analysed for each step of the process. RESULTS: For the first hospital, 172 hazards were identified, and 23 of hazards were classified as high risk. Only one hazard was considered as 'controlled' (when actions were taken to remove the hazard later in the process). Twenty-two hazards were 'tolerated' (when no actions were taken, and it was therefore accepted that adverse events may occur). For the second hospital, 158 hazards were identified, and 49 of hazards were classified as high risk. Eight hazards were 'controlled' and 41 were 'tolerated'. The means for information exchange and information systems were numerous for both cases, while there was not one system that provided an overview of all relevant information. CONCLUSIONS: The majority of the high-risk hazards are expected to be controlled by the use of IT support. Centralised information and information availability for different parties reduce risks related to unavailability of instruments in the operating room.

Multibody dynamic modeling of the behavior of flexible instruments used in cervical cancer brachytherapy.

BACKGROUND: The steep radiation dose gradients in cervical cancer brachytherapy (BT) necessitate a thorough understanding of the behavior of afterloader source cables or needles in the curved channels of (patient-tailored) applicators. PURPOSE: The purpose of this study is to develop and validate computer models to simulate: (1) BT source positions, and (2) insertion forces of needles in curved applicator channels. The methodology presented can be used to improve the knowledge of instrument behavior in current applicators and aid the development of novel (3D-printed) BT applicators. METHODS: For the computer models, BT instruments were discretized in finite elements. Simulations were performed in SPACAR by formulating nodal contact force and motion input models and specifying the instruments' kinematic and dynamic properties. To evaluate the source cable model, simulated source paths in ring applicators were compared with manufacturer-measured source paths. The impact of discrepancies on the dosimetry was estimated for standard plans. To validate needle models, simulated needle insertion forces in curved channels with varying curvature, torsion, and clearance, were compared with force measurements in dedicated 3D-printed templates. RESULTS: Comparison of simulated with manufacturer-measured source positions showed 0.5-1.2 mm median and <2.0 mm maximum differences, in all but one applicator geometry. The resulting maximum relative dose differences at the lateral surface and at 5 mm depth were 5.5% and 4.7%, respectively. Simulated insertion forces for BT needles in curved channels accurately resembled the forces experimentally obtained by including experimental uncertainties in the simulation. CONCLUSION: The models developed can accurately predict source positions and insertion forces in BT applicators. Insights from these models can aid novel applicator design with improved motion and force transmission of BT instruments, and contribute to the estimation of overall treatment precision. The methodology presented can be extended to study other applicator geometries, flexible instruments, and afterloading systems.

Time-action and patient experience analyses of locally advanced cervical cancer brachytherapy.

BACKGROUND AND PURPOSE: Although MRI-based image guided adaptive brachytherapy (IGABT) for locally advanced cervical cancer (LACC) has resulted in favorable outcomes, it can be logistically complex and time consuming compared to 2D image-based brachytherapy, and both physically and emotionally intensive for patients. This prospective study aims to perform time-action and patient experience analyses during IGABT to guide further improvements. MATERIALS AND METHODS: LACC patients treated with IGABT were included for the time-action (56 patients) and patient experience (29 patients) analyses. Times per treatment step were reported on a standardized form. For the patient experience analysis, a baseline health status was established with the EQ-5D-5L questionnaire and the perceived pain, anxiety and duration for each treatment step were assessed with the NRS-11. RESULTS: The median total procedure time from arrival until discharge was 530 (IQR: 480-565) minutes. Treatment planning (delineation, reconstruction, optimization) required the most time and took 175 (IQR: 145-195) minutes. Highest perceived pain was reported during applicator removal and treatment planning, anxiety during applicator removal, and duration during image acquisition and treatment planning. Perceived pain, anxiety and duration were correlated. Higher pre-treatment pain and anxiety scores were associated with higher perceived pain, anxiety and duration. CONCLUSION: This study highlights the complexity, duration and impact on patient experience of the current IGABT workflow. Patient reported pre-treatment pain and anxiety can help identify patients that may benefit from additional support. Research and implementation of measures aiming at shortening the overall procedure duration, which may include logistical, staffing and technological aspects, should be prioritized.

Differences between attendings' and residents' operative notes for laparoscopic cholecystectomy.

BACKGROUND: Operative notes are the gold standard for detecting adverse events and near misses and form the basis for scientific research. In order to guarantee safe patient care, operative notes must be objective, complete, and accurate. This study explores the current routine of note writing for laparoscopic cholecystectomy (LC) and the differences between the notes of attendings and residents. METHODS: Attendings and residents were sent a DVD with footage of three LCs and were asked to "write" the corresponding notes and to complete a questionnaire. Dictation tapes were transcribed and items in the notes were analyzed for each procedure ("item described" or "item not described"). Fisher's exact tests were performed using SPSS 16.0 for Mac. RESULTS: Thirteen sets of typewritten notes and 10 dictation tapes were returned. The results of the questionnaire showed that 16 of the 23 sets of notes were dictated. Eight participants found the current system for generating notes inadequate. 14 items (31 %) were included more often in the attendings' notes and 25 items (56 %) were included more often in the residents' notes. Overall, residents significantly more often described the location of the epigastric trocar (P = 0.018), the size of both working trocars (P = 0.019), the opening of the peritoneal envelope (P = 0.002), Critical View of Safety reached (P = 0.002), and the location for removing the gallbladder (P = 0.019). With the exception of "gallbladder perforation" (20 of 21 notes), complications were underreported. CONCLUSIONS: In this study residents described more items than attendings. All notes lacked information concerning complications in the procedure, which makes the notes subjective and incomplete. A procedure-specific template or black-box-based operative notes based on established guidelines could improve the quality of the notes of both attendings and residents.

Body size measuring techniques enabling stress-free growth monitoring of extreme preterm infants inside incubators: A systematic review.

INTRODUCTION: Growth monitoring of preterm infants is essential for assessing the nutritional effects on their growth. The current growth monitoring techniques are too stressful, however, for the smallest preterm infants. We performed a systematic review to summarize studies on stress-free techniques for measuring the body size of preterm infants inside incubators other than the traditional calliper and tape measure-based instruments. METHODS: We searched four online literature databases: Embase, Medline, Web of Science Core Collection, and Cochrane, using search terms related to patients (neonates, infants, children) and body size measuring techniques. By means of expert judgement we assessed the techniques' suitability for stress-free body size measurement of an infant lying in an incubator. As a criterion for suitability, we used an imaginary ideal technique. RESULTS: Twenty-six studies were included in this review. In 24 studies, the technique for body size measurement was related to 3D technology, and the majority of these studies acknowledged clinical superiority of 3D over 2D data. Two 3D techniques were assessed as suitable for stress-free measurement of preterm infants inside incubators. The first technique used a commercially available 3D handheld scanner which needed 3D postprocessing to derive measurement data. The second technique used a self-developed stereoscopic vision system. CONCLUSIONS: 3D volumetric parameters have higher clinical value for growth monitoring than 2D. In addition, contactless 3D measurements enable stress-free growth monitoring of even the smallest preterm infants. However, the time-consuming 3D postprocessing challenges the usability of 3D techniques. Regrettably, none of the identified suitable 3D techniques met all our requirements of an ideal all-in-one body size measuring technique for extreme preterm infants. Handheld 3D scanning might have the best properties for developing this ideal technique.

Evaluation of operative notes concerning laparoscopic cholecystectomy: are standards being met?

BACKGROUND: Laparoscopic cholecystectomy (LC) is the most performed minimal invasive surgical procedure and has a relatively high complication rate. As complications are often revealed postoperatively, clear, accurate, and timely written operative notes are important in order to recall the procedure and start follow-up treatment as soon as possible. In addition, the surgeon's operative notes are important to assure surgical quality and communication with other healthcare providers. The aim of the present study was to assess compliance with the Dutch guidelines for writing operative notes for LC. METHODS: Nine hospitals were asked to send 20 successive LC operative notes. All notes were compared to the Dutch guideline by two reviewers and double-checked by a third reviewer. Statistical analyses on the "not described" items were performed. RESULTS: All hospitals participated. Most notes complied with the Dutch guideline (52-69%); 19-30% of items did not comply. Negative scores for all hospitals were found, mainly for lacking a description of the patient's posture (average 69%), bandage (94%), blood loss (98%), name of the scrub nurse (87%), postoperative conclusion (65%), and postoperative instructions (78%). Furthermore, notes from one community hospital and two teaching hospitals complied significantly less with the guidelines. CONCLUSIONS: Operative notes do not always fully comply with the standards set forth in the guidelines published in the Netherlands. This could influence adjuvant treatment and future patient treatment, and it may make operative notes less suitable background for other purposes. Therefore operative note writing should be taught as part of surgical training, definitions should be provided, and procedure-specific guidelines should be established to improve the quality of the operative notes and their use to improve patient safety.

The Effect of Chemical Cleaning on Mechanical Properties of Three-Dimensional Printed Polylactic Acid.

Three-dimensional (3D) printing may be a solution to shortages of equipment and spare parts in the healthcare sector of low- and middle-income countries (LMICs). Polylactic acid (PLA) for 3D printing is widely available and biocompatible, but there is a gap in knowledge concerning its compatibility with chemical disinfectants. In this study, 3D-printed PLA tensile samples were created with six different printer settings. Each of these six batches consisted of five sets with five or six samples. The first set remained untreated, the others were soaked in Cidex OPA or in a chlorine solution. These were applied for seven consecutive days or in 25 short cycles. All samples were weighed before and after treatment and subjected to a tensile test. Results showed that a third of the treatments led to an increase of the median weight with a maximum of 8.3%, however, the samples with the best surface quality did not change. The median strength increase was 12.5% and the largest decrease was 8.8%. The median stiffness decreased 3.6% in one set and increased in three others up to 13.6%. When 3D printing PLA medical tools, surface porosity must be minimized to prevent transfer of disinfectants to people. The wide variability of mechanical properties due to 3D printing itself and as a consequence of disinfection must be considered when designing medical tools by selecting appropriate printer settings. If these conditions are met, reusing 3D-printed PLA medical tools seems safe from a mechanical point of view.

Safety status system for operating room devices.

BACKGROUND: Since the increase of the number of technological aids in the operating room (OR), equipment-related incidents have come to be a common kind of adverse events. This underlines the importance of adequate equipment management to improve the safety in the OR. OBJECTIVE: A system was developed to monitor the safety status (periodic maintenance and registered malfunctions) of OR devices and to facilitate the notification of malfunctions. The objective was to assess whether the system is suitable for use in an busy OR setting and to analyse its effect on the notification of malfunctions. METHODS: The system checks automatically the safety status of OR devices through constant communication with the technical facility management system, informs the OR staff real-time and facilitates notification of malfunctions. The system was tested for a pilot period of six months in four ORs of a Dutch teaching hospital and 17 users were interviewed on the usability of the system. RESULTS: The users provided positive feedback on the usability. For 86.6% of total time, the localisation of OR devices was accurate. 62 malfunctions of OR devices were reported, an increase of 12 notifications compared to the previous year. CONCLUSIONS: The safety status system was suitable for an OR complex, both from a usability and technical point of view, and an increase of reported malfunctions was observed. The system eases monitoring the safety status of equipment and is a promising tool to improve the safety related to OR devices.

Safety by design: effects of operating room floor marking on the position of surgical devices to promote clean air flow compliance and minimise infection risks.

OBJECTIVE: To evaluate the use of floor marking on the positioning of surgical devices within the clean air flow in an operating room (OR) to minimise infection risk. Laminar flow clean air systems are important in preventing infection in ORs but, for optimal results, surgical devices must be correctly positioned. METHODS: The authors evaluated floor marking in four ORs at an eye hospital using time series analysis. Through observations during 829 surgeries over a 20-month period, the positions of surgical devices were determined. Eight semistructured interviews with surgical staff were conducted to assess user experiences and team dynamics. RESULTS: Before marking, the instrument table was positioned completely within the laminar flow in only 6.1% of the cases. This increased to 36.1% and finally 53.8%. Mayo stands were increasingly positioned within the laminar flow: from 74.2% to 84.7%. The surgical lamp decreasingly obstructed flow: from 41.8% to 28.7%. At T3 (20 months), however, in 48.6% of the applicable cases the lamp was positioned in the flow again. Discussions and site visits between airside operators and surgical staff resulted in increasing awareness of specific risk areas in the OR. CONCLUSIONS: OR floor markings facilitated and stimulated safety awareness and resulted in significantly increased compliance with the positioning of surgical devices in the clean air flow. Safety and quality approaches in hospital care, therefore, should include a human factors approach that focuses on system design in addition to teaching clinical and non-technical skills.

Evaluation of protocol uniformity concerning laparoscopic cholecystectomy in the Netherlands.

BACKGROUND: Iatrogenic bile duct injury remains a current complication of laparoscopic cholecystectomy. One uniform and standardized protocol, based on the "critical view of safety" concept of Strasberg, should reduce the incidence of this complication. Furthermore, owing to the rapid development of minimally invasive surgery, technicians are becoming more frequently involved. To improve communication between the operating team and technicians, standardized actions should also be defined. The aim of this study was to compare existing protocols for laparoscopic cholecystectomy from various Dutch hospitals. METHODS: Fifteen Dutch hospitals were contacted for evaluation of their protocols for laparoscopic cholecystectomy. All evaluated protocols were divided into six steps and were compared accordingly. RESULTS: In total, 13 hospitals responded--5 academic hospitals, 5 teaching hospitals, 3 community hospitals--of which 10 protocols were usable for comparison. Concerning the trocar positions, only minor differences were found. The concept of "critical view of safety" was represented in just one protocol. Furthermore, the order of clipping and cutting the cystic artery and duct differed. Descriptions of instruments and apparatus were also inconsistent. CONCLUSIONS: Present protocols differ too much to define a universal procedure among surgeons in The Netherlands. The authors propose one (inter)national standardized protocol, including standardized actions. This uniform standardized protocol has to be officially released and recommended by national scientific associations (e.g., the Dutch Society of Surgery) or international societies (e.g., European Association for Endoscopic Surgery and Society of American Gastrointestinal and Endoscopic Surgeons). The aim is to improve patient safety and professional communication, which are necessary for new developments.