The application value of operating room ventilation with laminar airflow for surgical site infection: A protocol for a systematic review and meta-analysis.

BACKGROUND: The presence of biological particles in the air inside operating theatres has the potential to cause severe surgical site infections. Recently, laminar airflow systems have been regarded as a means to reducing surgical site infections using airborne microbes. Still, other publications have argued the benefits of laminar airflow systems, stating the likelihood of adverse effects. Therefore, we will conduct this systematic study to evaluate the applicational value of adopting laminar airflow systems in operating theatres to minimize surgical site infections. METHODS: Reporting of this study adheres to the guidelines of Preferred Reporting Items for Systematic Review and Meta-analysis Protocols. The authors will perform a systematic search on MEDLINE, Web of Science, EMBASE, the China national knowledge infrastructure, and the Cochrane Library from their commencement until June 2021. The search will identify relevant randomized and non-randomized controlled trials that evaluates the applicational value of using laminar airflow ventilation in surgical theatres to minimize surgical site infections. There are no restrictions on language. Two authors will independently screen the identified studies, perform data extraction, and use an appropriate method to evaluate the bias risk in the included studies. RESULTS: The work done in the present study will enhance the existing literature on the applicational value of laminar airflow ventilation in surgical theatre to reduce surgical site infections. CONCLUSION: The outcomes are a reference for healthcare practitioners and patients when making informed decisions regarding care during surgeries.

Radiofrequency Identification Track for Tray Optimization: An Instrument Utilization Pilot Study in Surgical Oncology.

BACKGROUND: Surgical instrument tray reduction attempts to minimize intraoperative inefficiency and processing costs. Previous reduction methods relied on trained observers manually recording instrument use (i.e. human ethnography), and surgeon and/or staff recall, which are imprecise and inherently limited. We aimed to determine the feasibility of radiofrequency identification (RFID)-based intraoperative instrument tracking as an effective means of instrument reduction. METHODS: Instrument trays were tagged with unique RFID tags. A RFID reader tracked instruments passing near RFID antennas during 15 breast operations performed by a single surgeon; ethnography was performed concurrently. Instruments without recorded use were eliminated, and 10 additional cases were performed utilizing the reduced tray. Logistic regression was used to estimate odds of instrument use across cases. Cohen's Kappa estimated agreement between RFID and ethnography. RESULTS: Over 15 cases, 37 unique instruments were used (median 23 instruments/case). A mean 0.64 (median = 0, range = 0-3) new instruments were added per case; odds of instrument use did not change between cases (OR = 1.02, 95%CI 1.00-1.05). Over 15 cases, all instruments marked as used by ethnography were recorded by RFID tracking; 7 RFID-tracked instruments were never recorded by ethnography. Tray size was reduced 40%. None of the 25 eliminated instruments were required in 10 subsequent cases. Cohen's Kappa comparing RFID data and ethnography over all cases was 0.82 (95%CI 0.79-0.86), indicating near perfect agreement between methodologies. CONCLUSIONS: Intraoperative RFID instrument tracking is a feasible, data-driven method for surgical tray reduction. Overall, RFID tracking represents a scalable, systematic, and efficient method of optimizing instrument supply across procedures.

Impact of surgical clothing and footwear on operating room contamination during standstill and intraoperative stepping motion.

BACKGROUND: In view of preventing surgical site infection (SSI) in the orthopedic operating room (OR), evidence concerning types of footwear and clothing is limited. This study aimed to investigate how different footwear and clothing affect the cleanliness of the OR environment. METHODS: The airborne dust concentration in a bioclean room (NASA class 100) was measured around an operator by using a handheld particle counter under the following conditions: (I) wearing a sterilized full-type space suit with OR dedicated clean sandals; (II) wearing a sterilized full-type space suit with non-dedicated (outside) shoes or severely contaminated outside shoes with surgical glove powder (2 µm mean particle size); and (III) wearing an unsterilized medical scrub uniform with OR dedicated sandals. The participant was standing still or stepping in place at 1 Hz during the testing. RESULTS: The concentrations of airborne dusts in the operative field were independent of footwear and clothing types under the stand-still condition. However, these values significantly increased 1.96- to 16.23-fold after simple stepping motion in all the test conditions, and often became dissatisfaction level with the NASA100 requirement for the OR cleanliness. The worst contamination occurred when an operator wore the powder-contaminated shoes and also the unsterilized scrub uniform. CONCLUSION: The present study showed that the stepping motion triggered a considerable contamination in the operative field (beyond the level of NASA100 threshold) particularly when an operator used the outside shoes or unsterilized scrub uniform. Therefore, these results tell us that the one-footwear system (i.e., no use of OR dedicated clean shoes) and unsterilized scrub are likely to be a potential risk factor for SSI. Nevertheless, further studies are necessary to conclude the real efficacy of OR dedicated shoes and sterilized clothes on the SSI prevention.

Clearing the surgical backlog caused by COVID-19 in Ontario: a time series modelling study.

BACKGROUND: To mitigate the effects of coronavirus disease 2019 (COVID-19), jurisdictions worldwide ramped down nonemergent surgeries, creating a global surgical backlog. We sought to estimate the size of the nonemergent surgical backlog during COVID-19 in Ontario, Canada, and the time and resources required to clear the backlog. METHODS: We used 6 Ontario or Canadian population administrative sources to obtain data covering part or all of the period between Jan. 1, 2017, and June 13, 2020, on historical volumes and operating room throughput distributions by surgery type and region, and lengths of stay in ward and intensive care unit (ICU) beds. We used time series forecasting, queuing models and probabilistic sensitivity analysis to estimate the size of the backlog and clearance time for a +10% (+1 day per week at 50% capacity) surge scenario. RESULTS: Between Mar. 15 and June 13, 2020, the estimated backlog in Ontario was 148 364 surgeries (95% prediction interval 124 508-174 589), an average weekly increase of 11 413 surgeries. Estimated backlog clearance time is 84 weeks (95% confidence interval [CI] 46-145), with an estimated weekly throughput of 717 patients (95% CI 326-1367) requiring 719 operating room hours (95% CI 431-1038), 265 ward beds (95% CI 87-678) and 9 ICU beds (95% CI 4-20) per week. INTERPRETATION: The magnitude of the surgical backlog from COVID-19 raises serious implications for the recovery phase in Ontario. Our framework for modelling surgical backlog recovery can be adapted to other jurisdictions, using local data to assist with planning.

Surgical Smoke Evacuators Reduce the Risk of Fires From Alcohol-Based Skin Preparations.

Surgical smoke evacuators may reduce the concentration of alcohol vapors from skin preparations at the site of electrosurgical device activation, decreasing operating room fire risk. Our aim was to compare the incidence of flames with and without smoke evacuation in a porcine ex vivo model. A monopolar device was activated after application of either 70% isopropyl alcohol/2% chlorhexidine gluconate (CHG-IPA) or 74% isopropyl alcohol/0.7% iodine povacrylex (iodine-IPA) skin preparations. No suction was compared with standard wall suction and 2 monopolar devices with built-in smoke evacuators. Flames were generated in 60% of CHG-IPA and 47% of iodine-IPA tests without suction. Wall suction did not significantly reduce fires (CHG-IPA 43% vs. 60%, P=0.30; iodine-IPA 57% vs. 47%, P=0.61). Use of both smoke evacuation devices reduced fires for CHG-IPA (17% vs. 60%, P=0.001 and 20% vs. 60%, P=0.004) but not for iodine-IPA. Smoke evacuation devices reduce fire risk when used with a chlorhexidine-alcohol skin preparation.

Microbiological assessment of cleanliness of surfaces and equipment in a children's operating theatre on the example of a selected hospital.

INTRODUCTION: The operating theatre is one of the most important places in a hospital. Due to the presence of numerous reservoirs of microorganisms and the invasiveness of surgical procedures it is necessary to ensure high hygiene standards in these locations. OBJECTIVE: The aim of the study was to carry out a qualitative assessment of the microbiological cleanliness of the surfaces and equipment in an operating theatre. MATERIAL AND METHODS: The results of microbiological tests of the surfaces and equipment of the Children's Operating Theatre in Clinical Provincial Hospital No. 2 in Rzeszów, southeast Poland, during 2007-2012 were reviewed retrospectively. RESULTS AND CONCLUSIONS: For the analysis, a total of 1,819 swabs were collected, of which 1.05% were positive. Positive results were obtained mainly from samples taken from moist places (57.9%). Among the microorganisms isolated, Gram-negative bacteria constituted the majority (57.9%), Pseudomonas bacteria were found most frequently (31,6%). Isolated microbes can be the etiological agent of nosocomial infections.

Cataract Surgery Quality and Capacity.

Cataract surgery is the most common operation performed in most developed countries, including Canada. Nuanced, evidence-driven policies are needed to ensure appropriate access to this sight-saving operation while maintaining the highest standards in quality of care. The Vision Health Services Research Program at Queen's University, in partnership with members of the Ontario Provincial Vision Task Force, has developed evidence to inform policies aimed at optimizing both access and quality across the eye care spectrum.

'Golden Patient': A quality improvement project aiming to improve trauma theatre efficiency in the Royal Gwent Hospital.

The efficiency of trauma lists when compared with elective orthopaedic lists is a frustration of many orthopaedic departments. At the Royal Gwent Hospital, late start times affecting total operating capacity of the trauma list were recognised as a problem within the department. The design team aimed to improve the start time of the list with the introduction of the 'golden patient' initiative. A protocol was agreed between the orthopaedic, anaesthetic and theatre staff where a 'golden patient' was selected for preoperative anaesthetic assessment by 14:00 the day before surgery and sent for at 08:15 as the first case on the trauma list. Baseline data was collected over a month. Two Plan-Do-Study-Act (PDSA) cycles were completed, one on the month the 'golden patient' initiative was implemented and one 4 months after the change. All data was collected from the Operating Room Management Information Service theatre system for the trauma theatre at the Royal Gwent Hospital. Results demonstrated significant improvement in patient arrival time in the theatre suite; PDSA1 by 33 min (p≤0.001) and PDSA2 by 29 min (p≤0.001) and an earlier start of the first procedure; PDSA1 by 19 min (p=0.018) and PDSA2 by 26 min (p≤0.001). There was also increased mean operating time per list (PDSA1 +16 min and PDSA2 +33 min), increased total case number (PDSA1 +20 cases and PDSA2 +36 cases) and reduced cancellations (PDSA1 -2 cases and PDSA -5 cases) compared with our baseline data. We demonstrated that the introduction of a 'golden patient' to the trauma theatre list improved the start time and overall operating capacity for the trauma list. Continuing this project, we plan to introduce assessment of all patients with fractured neck of femur in a similar way to the 'golden patient' to continue improving trauma theatre efficiency and reduce case cancellations.

Innovation in surgery/operating room driven by Internet of Things on medical devices.

BACKGROUND: With the improvement of sensor technology, the trend of Internet of Things (IoT) is affecting the medical devices. The aim of this study is to verify whether it is possible to "visualize instrument usage in specific procedures" by automatically accumulating the digital data related to the behavior of surgical instruments/forceps in laparoscopic surgery. METHODS: Five board-certified surgeons (PGY 9-24 years) performed laparoscopic cholecystectomy on 35-kg porcine (n = 5). Radio frequency identifier (RFID) was attached to each forceps with RFID readers installed on the left/right of the operating table. We automatically recorded the behavior by tracking the operator's right/left hands' forceps with RFID. The output sensor was installed in the electrocautery circuit for automatic recordings of the ON/OFF times and the activation time. All data were collected in dedicated software and used for analysis. RESULTS: In all cases, the behaviors of forceps and electrocautery were successfully recorded. The median operation time was 1828 s (range 1159-2962 s), of which the electrocautery probe was the longest held on the right hand (1179 s, 75%), followed by Maryland dissectors (149 s, 10%), then clip appliers (91 s, 2%). In contrast, grasping forceps were mainly used in the left hand (1780 s, 93%). The activation time of electrocautery was only 8% of the total use and the remaining was mainly used for dissection. These situations were seen in common by all operators, but as a mentor surgeon, there was a tendency to change the right hand's instruments more frequently. The median activation time of electrocautery was 0.41 s, and these were confirmed to be 0.14-0.57 s among the operators. CONCLUSION: By utilization of IoT for surgery, surgical procedure could be "visualized." This will improve the safety on surgery such as optimal usage of surgical devices, proper use of electrocautery, and standardization of the surgical procedures.

Training of Tunisian future urologists: how to improve it ?

BACKGROUND: The lack of continuous evaluation of training tools in medicine, especially in developing countries, represents a brake to the development of the latter. AIM: To establish an inventory of the training facilities available to residents in urology in Tunisia, to assess their satisfaction and their expectations, and to propose solutions to improve residents training. METHODS: An anonymous questionnaire was sent by E-mail in 2015 to all residents in urology in Tunisia. The questionnaire addressed demographic characteristics, educational resources used and desired, the current medical and university curriculum and evaluation of the training. RESULTS: Among 33 residents, 66.6% responded to the survey. Medical staff, courses organized by the national college of urology, reading french-language articles and daily activity in operating room were the most used pedagogic resources. Training was judged unsatisfactory by 59.1% of respondents because of a lack of theoretical training in 18.1% of cases, a lack of practical training in 13.6% of cases and both of them in 27.2% of cases. Training on animals and simulator, creation of an educational booklet, use of online course materials, and the institution of a mentoring process during residency were rated favorable by the majority of respondents. CONCLUSION: The majority of residents in urology in Tunisia believe their training is unsatisfactory. The E-learning, improved access to surgical training in animals and simulator, better information on existing resources and strengthening of companionship through tutoring should enhance satisfaction.

First establishment of a new table-rotated-type hybrid emergency room system.

The hybrid emergency room (hybrid ER) system was first established in 2011 in Japan. It is defined as an integrated system including an ER, emergency computed tomography (CT) and interventional radiology (IVR) rooms, and operating rooms. Severe trauma patients can undergo emergency CT examinations and therapies (surgeries) without being transferred. The hybrid ER system is attracting attention because trauma resuscitation using this system has been reported to potentially improve the mortality rate in severe trauma patients. In August 2017, we established a new table-rotated-type hybrid ER to facilitate surgical functions. Herein, we introduce a new table-rotated-type hybrid ER consisting of an IVR-CT-operating room system and discuss its efficiency and feasibility for trauma resuscitation, including surgery and IVR. This system includes four new concepts: (1) to secure a wide working space during trauma resuscitation by reconsidering the arrangement of the C-arm, (2) ensure an air-conditioned operating room in the hybrid ER, (3) adopt an operating table but not interventional radiology table, and (4) prepare a trauma bay with three additional beds for multiple victims. This hybrid ER system also adopted the rotated-type table to secure a wide working space during the resuscitation phase. The C-arm was located away from the patients and placed on the wall opposite to the CT gantry, in contrast to that in previous systems. If patients needed an emergency IVR, the table was just rotated, and the IVR could be conducted immediately. This improvement can secure a wide working space in the hybrid ER. Moreover, the patient table was also a surgical operating table, and the hybrid ER system had an air-conditioned operating room (class 10,000). In the anticipation of many trauma patients being transported to the ER, a new trauma bay with three additional beds next to the hybrid ER was established, which also had an air-conditioned operating room. This new rotated-type hybrid ER system facilitates efficient surgical functions during trauma resuscitation and can secure a wide working space for the medical team to immediately perform resuscitative procedures and IVRs without delay.

Scratch to state-of-the-art: setting up a new robotic facility in a developing country.

The potential challenges encountered for setting up a robotic assisted surgical facility in developing country like India are many. We describe the initial hurdles and troubleshooting in establishing a facility of such kind. This experience might help to decrease initial hiccups in setting up such an innovative technology at other institutes.

Hybrid operating room Dyna-computed tomography combined image-guided electromagnetic navigation bronchoscopy dye marking and hookwire localization video-assisted thoracic surgery metastasectomy.

Hybrid operating room Dyna-computed tomography imaging is increasingly recognized as an important adjunct for management of small pulmonary lesions, either for biopsy or for localization to guide surgical resection. We describe for the first time the combined hybrid operating room Dyna-computed tomography image-guided electromagnetic navigation bronchoscopy dye marking and hookwire localization approach to localize multiple sub-centimetre nodules for video-assisted thoracic surgery metastasectomy. Furthermore, such complex set of procedures can be safely and effectively performed within one operating environment, maximizing work efficiency and minimizing the potential for complications.

Evaluating quality indicators of tertiary care hospitals for trauma care in Japan.

OBJECTIVE: This study examined the associations between trauma mortality and quality of care indicators currently used in Japan. DESIGN: This is a retrospective two-level discrete-time survival analysis. Quality indicators were derived from the 2012-2013 annual hospital survey conducted by the Ministry of Health, Labour and Welfare. Trauma mortality data were derived from the Japan Trauma Data Bank for the period of April 2012 to March 2013. SETTING: Tertiary care centers designated as emergency and critical care centers (ECCCs) in Japan. PARTICIPANTS: The analysis included 12 378 patients aged ≥15 years with blunt trauma and an Injury Severity Score ≥9, registered to the data bank from 91 ECCCs. INTERVENTION: Quality of care indicators examined in the annual hospital survey. MAIN OUTCOME MEASURES: Deaths within 30 days. RESULTS: Of the 12 378 patients, 660 (5%) died within 30 days. Higher indicator score was significantly associated with lower mortality risk (hazard ratio [HR] for the second, third and fourth quartiles vs. lowest quartile 0.61, 0.55 and 0.52, respectively). Factors significantly associated with lower mortality risk were, higher patient volume (HR for the highest vs. lowest quartile, 0.74), director's qualification as specialist (HR 0.57) or consultant (HR 0.58), review of patient arrival process (HR 0.68), triage functions (HR 0.69), availability of psychiatrists (HR 0.75) and operating room being ready 24-h (HR 0.81). CONCLUSIONS: The study identified certain indicators associated with trauma patient mortality. Further refinement of indicators is required to specifically identify what needs changing.

Pilot Use of a Novel Tool to Assess Neurosurgical Capacity in Uganda.

INTRODUCTION: There is a significant burden of unmet surgical need in many low- and middle-income countries (>80% in parts of Africa). This need is even larger for specialties such as neurosurgery. Surgical capacity tools have been developed and used to assess needs and plan for resource allocation. This study piloted a new tool to assess neurosurgical capacity and describes its use. METHODS: A surgical capacity tool was adapted to assess neurosurgical capacity. An expert panel of neurosurgeons and researchers reviewed the Surgeons OverSeas PIPES (personnel, infrastructure, procedures, equipment, and supplies) assessment and added additional items essential to perform common neurosurgery procedures. This tool was then piloted at 3 public hospitals in Uganda and each hospital was given a score of neurosurgical capacity. At 1 hospital, 3 respondents were asked to answer the survey to assess reliability. RESULTS: The hospital with the largest neurosurgery caseload and 5 neurosurgeons scored the highest on our survey, followed by a regional hospital with 1 practicing neurosurgeon. The third hospital, without a neurosurgeon, scored the lowest on the scale. At the hospital that completed the reliability assessment, scores were varied between respondents. CONCLUSIONS: NeuroPIPES survey scores were in keeping with the number of neurosurgeons and respective caseloads of each hospital. However, the variation in scores between respondents at the same hospital suggests that adaptations could be made to the tool that may improve reliability and validity. The methodology used to create NeuroPIPES may be successfully applied to a variety of other surgical subspecialties for similar assessments.

Improving time to surgery for hip fracture patients. Impact of the introduction of an emergency theatre.

Hip fractures are a major cause of morbidity and mortality1. Surgery performed on the day of or after admission is associated with improved outcome2,3. An audit cycle was performed examining time to surgery for hip fracture patients. Our initial audit identified lack of theatre space as one factor delaying surgery. A dedicated daytime emergency theatre was subsequently opened and a re-audit was performed to assess its impact on time to surgery. Following the opening of the theatre, the proportion of patients with a delay to hip fracture surgery greater than 36 hours was reduced from 49% to 26% with lack of theatre space accounting for 23% (3 of 13) of delayed cases versus 28.6% (9 of 32) previously. 44% of hip fracture surgeries were performed in the emergency theatre during daytime hours, whilst in-hospital mortality rose from 4.6% to 6%. We conclude that access to an emergency theatre during daytime hours reduced inappropriate delays to hip fracture surgery.