Improving teamwork and communication in the operating room by introducing the theatre cap challenge.

OBJECTIVE: One of the steps of the Surgical Safety Checklist is for the team members to introduce themselves. The objective of this study was to implement a tool to help remember and use each other's names and roles in the operating theatre. METHODS: This study was part of a pilot study in which a video and medical data recorder was implemented in one operating theatre and used as a tool for postoperative multidisciplinary debriefings. During these debriefings, name recall was evaluated. Following the implementation of the medical data recorder, this study was started by introducing the theatre cap challenge, meaning the use of name (including role) stickers on the surgical cap in the operating theatre. FINDINGS: In total, 41% (n = 40 out of 98) of the operating theatre members were able to recall all the names of their team at the team briefings. On average 44.8% (n = 103) was wearing the name sticker. CONCLUSIONS: The time-out stage of the Surgical Safety Checklist might be inadequate for correctly remembering and using your operating theatre team members' names. For this, the theatre cap challenge may help.

Management of Adults with Acute Oesophageal Soft Food Bolus and Foreign Body Obstructions at Two New Zealand District Health Boards.

AIM: 1. Investigate the characteristics of adult patients presenting with acute oesophageal soft food bolus obstruction (SFBO) and impacted foreign body (IFB) at two New Zealand district health boards (DHBs). 2. Review current management against international guidelines for SFBO and IFB. METHODS: A multicentre retrospective search of the Provation® endoscopy database identified patients presenting with acute oesophageal obstruction. Utilising electronic patient records, key data points including patient demographics, risk factors, pre-endoscopic medical therapies utilised, diagnostic radiological investigations performed and endoscopic complications were identified. Key timepoints and delays in the patient's hospital journey from oesophageal obstruction to therapeutic endoscopy were recorded. The probability of failing to undergo therapeutic endoscopy for SFBO within the timeframes advised in clinical guidelines as a result of a delay in referral to the endoscopy service was calculated. RESULTS: Over a cumulative 10.5-year period of data collection, 227 oesophago-gastro-duodenoscopies were performed: 195 SFBO, 16 IFB, 16 no obstruction identified. Median patient age was 57 (15-95) years. 143 male and 84 female patients. Radiographs were performed in 50.9% of uncomplicated SFBO. Pre-endoscopy medical therapies were administered in 41.4% of the cases. Median time delay from onset of obstruction to therapeutic endoscopy varied: SFBO 19h 0min, complete obstruction 17h 45min, impacted batteries 1h 15min, and presumed sharp objects 6h 0min. Three patients presenting with a soft food bolus obstruction failed to undergo therapeutic endoscopy due to a delay in referral to the endoscopy service, probability 0.034 (95% CI 0.012, 0.095). Two patients died of complications secondary to oesophageal obstruction. DISCUSSION: Oesophageal obstruction is a common gastroenterological presentation. At two large centres in New Zealand, patients waited considerably longer than the recommended timeframe from obstruction to therapeutic endoscopy. Contributing factors included patient-related delays to presentation, hospital system-related factors and delays in referral for endoscopy contributed to by unnecessary pre-endoscopic medical therapies and radiographic investigations. Education about oesophageal obstruction together with robust local guidelines have potential to reduce delays and length of hospital stay, as well as reduce patient discomfort and complications.

Emergency physician use of end-tidal oxygen monitoring for rapidsequence intubation.

BACKGROUND: End-tidal oxygen (ETO2) monitoring is used by anesthesiologists to quantify the efficacy of preoxygenation before intubation but is generally not used in emergency departments (EDs). We have previously published our findings describing preoxygenation practices in the ED during blinded use of ETO2. The purpose of this investigation is to determine whether the unblinded use of ETO2 monitoring led to improvements in preoxygenation during rapid sequence intubation in the ED and also the oxygen device or technique changes that were used to achieve higher ETO2 levels. METHODS: We conducted an interventional study at 2 academic EDs in Sydney, Australia and New York City, New York using ETO2 monitoring to investigate the preoxygenation process and effectiveness. We used data collected during a previous descriptive study for the control group, in which care teams in the same 2 EDs were blinded to the ETO2 value. In the study group, clinicians could utilize ETO2 to improve preoxygenation. Following an education process, clinicians were able to choose the method of preoxygenation and the techniques required to attempt to achieve an ETO2 level >85%. The primary outcome was the difference in ETO2 levels at the time of induction between the control and study group and the secondary outcome included the methods that were attempted to improve preoxygenation. RESULTS: A convenience sample of 100 patients was enrolled in each group. The median ETO2 level achieved at the time of induction was 80% (interquartile range 61 to 86, overall range 73) in the control group and 90% in the study group (interquartile range 83 to 92, overall range 41); the median difference was 12 (95% confidence interval: 8, 16, P = < 0.001). The majority of oxygen device changes were from non-rebreather mask to bag-valve-mask (BVM) (15%, n = 15) and changes in technique from improvements in mask seal (54%, n = 34). The final device used in the study group was BVM in 87% of cases. CONCLUSIONS: In 2 clinical studies of ETO2 in academic EDs, we have demonstrated that the use of ETO2 is feasible and associated with specific and potentially improved approaches to preoxygenation. A clinical trial is needed to further study the impact of ETO2 on the preoxygenation process and the rate of hypoxemia.

New Zealand National Audit of Outpatient Inflammatory Bowel Disease Standards of Care.

AIM: This study audits the delivery and standards of New Zealand (NZ) inflammatory bowel disease (IBD) care against international standards, with emphasis on the IBD nursing role. METHODS: Utilising international standards in IBD care, a 3 phase national multicentre survey study was performed between 2015 and 2019. We 1) evaluated the current role and practices of IBD nurses, 2) evaluated IBD service provision and identified areas for improvement, and 3) audited key aspects of IBD patient care, directly comparing nurse-led and doctor-led outpatient clinics. RESULTS: The median duration spent in an IBD nursing role was 21 months (range 2 to 120 months) with the majority (12/15) performing two or more nursing roles. The median IBD nurse full-time equivalent (FTE) was 0.8 (range 0.2 to 1.25). The average number of hours spent undertaking IBD nursing tasks was 22.2 - a 6.8-hour shortfall compared to rostered hours. No service had a per capita IBD multidisciplinary team (MDT) FTE which met international standards. Just under two-thirds (62.5%) of departments held a regular MDT meeting. All responding services could be contacted directly by IBD patients and respond within 48 hours of contact. During 492 doctor-led and 196 nurse-led scheduled outpatient clinic visits, nurses were significantly more likely to document weight, smoking status and organise appropriate colonoscopic surveillance than doctors. CONCLUSION: Multiple nursing job roles resulted in rostered hours being insufficient to complete IBD specific tasks. IBD FTE did not meet international standards. The IBD care was patient-centred, encouraging direct contact from patients with prompt response. IBD nurses in NZ provide high-quality outpatient care when measured against auditable standards. As the IBD nursing role continues to develop, following the implementation of an educational framework and education programme, an increase in numbers is required in order to achieve the recommended minimum FTE per 250 000 population.

Use of End Tidal Oxygen Monitoring to Assess Preoxygenation During Rapid Sequence Intubation in the Emergency Department.

STUDY OBJECTIVE: Preoxygenation is important to prevent oxygen desaturation during emergency airway management. The purpose of this study is to describe the use of end tidal oxygen (eto2) during rapid sequence intubation in the emergency department. METHODS: This study was carried out in 2 academic centers in Sydney, Australia, and New York City. We included patients undergoing rapid sequence intubation in the emergency department. A standard gas analyzer was used to measure eto2. Preoxygenation methods included nonrebreather mask and bag-valve-mask ventilation. We measured eto2 before preoxygenation and at administration of rapid sequence intubation medications. We also characterized peri-intubation SpO2, identifying instances of SpO2 less than 90%. RESULTS: We included 100 patients during a 6-month period. Median eto2 level before and after preoxygenation was 53% (interquartile range [IQR] 43% to 65%) and 78% (IQR 64% to 86%), respectively. One fourth of patients achieved an eto2 level greater than 85%. Median eto2 level achieved varied with preoxygenation method, ranging from 80% (IQR 60% to 87%) for the nonrebreather mask group to 77% (IQR 65% to 86%) for the bag-valve-mask group. The method with the highest median eto2 level was nonrebreather mask at flush rate (86%; IQR 80% to 90%) and the lowest median eto2 level was nonrebreather mask at 15 L/min (57%; IQR 53% to 60%). Eighteen patients (18%) experienced oxygen desaturation (SpO2 <90%); of these, 14 (78%) did not reach an eto2 level greater than 85% at induction. CONCLUSION: ETO2 varied with different preoxygenation techniques employed in the emergency department. Most patients undergoing rapid sequence intubation did not achieve maximal preoxygenation. Measuring ETO2 in the emergency department may be a valuable adjunct for optimizing preoxygenation during emergency airway management.

Severe tissue necrosis following intra-arterial injection of endodontic calcium hydroxide: a case series.

We present 2 cases of intra-arterial injection of endodontic calcium hydroxide via the root canal system of molar teeth. Nonsetting calcium hydroxide paste was used as a temporary dressing during endodontic treatment and in both cases delivered via an injectable syringe technique. Retrograde flow of the calcium hydroxide occurred along the artery until its origin where orthograde flow continued to the capillary bed. Case 1 demonstrates calcium hydroxide injected into the distal root canal of a lower second molar resulting in its distribution to the external carotid bed and case 2 demonstrates calcium hydroxide injected into the palatal root of an upper second molar with flow into the infraorbital artery. In both cases this resulted in severe clinical signs and symptoms ending in tissue necrosis. Long-term sequelae included scarring, deformity, and chronic pain. This case series illustrates the high toxicity of calcium hydroxide when displaced into vessels and soft tissues. Caution should be exercised when using injectable systems for endodontic calcium hydroxide.

Telling stories: news media, health literacy and public policy in Canada.

Mass media are very influential in shaping discourses about health but few studies have examined the extent to which newspaper coverage of such stories reflect issues embedded in health policy documents. We estimate the relative distribution of health stories using content analysis. Nine meta-topics are used to sort stories across a range of major influences shaping the health status of populations adapted from the document Toward a Healthy Future (Second Report on the Health of Canadians (1999)) (TAHF). A total of 4732 stories were analyzed from 13 Canadian daily newspapers (10 English, 3 French language) using a constructed week per quarter method. Stories were sampled from each chosen newspaper for the years 1993, 1995, 1997 and 2001. 72% (n=3405) of stories in this analysis were from English-language papers, 28% (n=1327) were from French-language papers. Topics related to health care (dealing either with issues of service provision and delivery or management and regulation) dominated newspaper stories, accounting for 65% of all stories. Physical environment topics accounted for about 13% of all stories, the socio-economic environment about 6% of stories, personal health practices about 5% of stories, and scientific advances in health research about 4% of stories. Other influences upon health identified in TAHF were rarely mentioned. The overall prominence of topics in newspapers is not consistent with the relative importance assigned to health influences in TAHF. Canadian newspapers rarely report on socio-economic influences frequently cited in the research literature (and reflected in TAHF) as being most influential in shaping population health outcomes.

Preclinical safety of anecortave acetate.

A number of preclinical safety pharmacology and toxicity studies have been performed on the angiostatic cortisene anecortave acetate in various species and using different routes of administration (oral, intravenous, subcutaneous, topical ocular, intraocular injection, posterior juxtascleral) and a wide range of doses (0-1,000 mg/kg). Anecortave acetate did not interact with a broad panel of pharmacological receptors and had no apparent pharmacological effects on major organ systems including the central nervous, gastrointestinal, renal, cardiovascular, and respiratory systems. Oral, topical ocular, and posterior juxtascleral administration of anecortave acetate had no significant ocular or systemic side effects or toxicity. In addition, there was no significant carcinogenic or reproductive/developmental toxicity associated with anecortave acetate in genotoxicity, carcinogenicity, and reproductive toxicity studies.