Mental illness comorbidity significantly impacts surgical outcomes for emergency surgical patients.

BACKGROUND: Whilst both mental illness comorbidity and the delivery of emergency surgery are commonplace in Australia, there is little evidence investigating any link between them. As such, this study examines the emergency surgical outcomes for patients with mental illness compared to other surgical patients within the Australian public surgical system. METHODS: Retrospective cohort study involving adult emergency and elective surgical patients treated at three public hospitals in Sydney, Australia between 2018 and 2019. Patients were identified using ICD-10 diagnosis codes, and grouped by those with decompensated mental illness, chronic depression, or those without mental illness. Outcome measures included those within the emergency department (ED), along with in-hospital mortality and surgical outcomes. RESULTS: Of 48 338 total patients, 31 890 (66.0%) had elective and 16 448 (34.0%) had emergency surgery. For patients with decompensated mental illness, only 228 (0.7%) had elective whilst 425 (2.6%) had emergency surgery. Their outcomes for this surgery type included being triaged significantly higher (Cat 1 or 2, 34% vs. 15%) and longer ED stays (8.3 vs. 6.6 h). They also had significantly more post-operative complications (26% vs. 8%) and total days in hospital (33.8 vs. 8.5 days). There was no significant difference for in-hospital mortality. CONCLUSION: Patients with mental illness are significantly more likely to have emergency surgery including presenting to the ED with more acute physical illness and to experience worse surgical outcomes compared to other surgical patients for every measure analyzed except mortality. There is considerable opportunity to further investigate how these differences might be improved.

Optimizing theatre utilization for abscess drainage: going beyond priority categories.

BACKGROUND: Day-only emergency surgery for abscess drainage is poorly implemented in Australia. This study assessed the feasibility, outcomes, cost, and impact of an acute day-only surgery (ADOS) program. METHOD: A retrospective pre-post implementation study of patients requiring abscess drainage in theatre was performed. Following implementation of an ADOS program for abscess management, eligible patients were discharged from the emergency department and prioritized first on the following day's emergency list. Outcomes from the first 12 months of the ADOS era were compared with those of the preceding 6 months (pre-ADOS). Primary outcome was length of hospital stay (LOS). Secondary outcomes included 30-day complications, admission costs, and impact on overall emergency theatre workflow (measured by emergency appendicectomy metrics). RESULTS: Overall, 266 patients during the ADOS era (including 95 eligible for the ADOS pathway) were compared with 115 patients during the pre-ADOS era. Baseline characteristics were comparable. Median LOS was shorter during the ADOS era (21.9 h (IQR 11.8-43.3) vs. 30.1 h (IQR 24.7-48.8), P < 0.001). Median LOS was 10.2 h (IQR 8.9-13.1) for patients on the ADOS pathway. There were no significant differences in 30-day complications (9.3% vs. 9.5%), emergency department re-presentations (7.4% vs. 5.1%), or abscess recurrence (5.6% vs. 5.7%). Average cost per patient was lower during the ADOS era ($4155 vs. $4916, p = 0.005). ADOS did not appear to materially impact other emergency procedures. CONCLUSION: ADOS for abscess drainage is feasible, safe, and produces cost savings, while being implemented without significant additional resources.

Prospective cohort study investigating quality of life outcomes following multi-speciality robotic-assisted surgery.

INTRODUCTION: Despite recent evidence on the surgical outcomes of robotic-assisted surgery (RAS), other patient centre outcomes, including quality of life (QOL), are lacking. This study aims to examine changes in QoL trajectories following RAS across different surgical specialities. PATIENTS AND METHODS: A prospective cohort study was conducted for patients undergoing urologic, cardiothoracic, colorectal or benign gynaecological RAS, between June 2016 and January 2020 at a tertiary referral hospital in Australia. QoL was measured using the 36-item Short-Form Health Survey at pre-operative, 6 weeks and 6 months postoperatively. Physical and mental summary scores and utility index were primary outcomes, and sub-domains were secondary outcomes. STATISTICAL ANALYSIS USED: Mixed-effects linear regressions were used to determine changes in QoL trajectories. RESULTS: Of the 254 patients undergoing RAS, 154 underwent urologic, 36 cardiothoracic, 24 colorectal and 40 benign gynaecological surgery. Overall, the average age was 58.8 years and most patients were male (75.1%). Physical summary scores significantly decreased from pre-operative to 6 weeks' post-operative in urologic and colorectal RAS; with all surgical specialities at least returning to pre-operative levels within 6 months postoperatively. Mental summary scores consistently increased from pre-operative to 6 months postoperatively for colorectal and gynaecological RAS. CONCLUSIONS: RAS contributed to positive changes in QoL, with physical health returning to the pre-operative level and mental health improvements across specialities, in the short term. While degrees of post-operative changes varied amongst specialities, significant improvements demonstrate benefits in RAS.

Delivering complex surgical services: lessons learned from the evolution of a specialised pelvic exenteration centre.

Pelvic exenteration (PE) is a potentially curative, ultra-radical surgical procedure for the treatment of advanced pelvic tumours, which involves surgical resection of multiple pelvic organs. Delivering such a complex low-volume, high-cost surgical program presents a number of unique health management challenges, and requires an organisation-wide approach involving both clinical and administrative teams. In contrast to the United Kingdom and France, where PE services have been historically decentralised, a centralised approach was developed early on in Australia and New Zealand (ANZ) with referral of these complex patients to a small number of quaternary centres. The PE program at the authors' institution was established in 1994 and has since evolved into the highest volume PE centre in the ANZ region and the largest single institution experience globally. These achievements have required navigation of specific funding and management issues, supported from inception by a proactive and collaborative relationship with hospital administration and management. The comprehensive state-wide quaternary referral model that has been developed has subsequently been successfully applied to other complex surgical services at the authors' institution, as well as by more recently established PE centres in Australia. This article aims to summarise the authors' experience with establishing and expanding this service and the lessons learned from a health management perspective.

Impact of Preoperative Mental Health on Surgical Outcomes Following Robotic-assisted Radical Prostatectomy.

OBJECTIVES: To explore the association between preoperative mental health status and surgical outcomes following robotic-assisted radical prostatectomy (RARP). METHODS: This cohort study included consecutive patients undergoing RARP surgery for prostate cancer between October 2016 and May 2022 at a major public hospital in Sydney, Australia. The primary outcome was preoperative self-reported mental health status measured using the mental component score from the Short Form 36 survey. Other variables included patients' characteristics, surgical outcomes, postoperative quality of life, pain and decision regret. Data were analysed using linear regression analysis. RESULTS: A total of 266 men underwent RARP during the studied period. Of these, 242 patients (91%) completed the preoperative survey and were analyzed. Poorer preoperative mental health had significant univariate associations with younger age (P = .025), reduced access to economic resources (P = .043), diagnosis of a mental illness (P = .033), poorer mental health at 6 weeks and 6 months postoperatively (both P <.001), greater pain (P = .001), and higher decision regret (P = .001) 6 weeks following surgery. In the multivariate analysis, poorer preoperative mental health status was associated with younger age (P = .028) and poorer mental health at 6 weeks (P <.001) and 6 months (P = .025) postoperatively. CONCLUSION: For patients undergoing RARP, poor preoperative mental health status was associated with younger age and poorer postoperative mental health. Future studies should investigate if targeted preoperative psychological interventions would improve postoperative mental health outcomes, specifically in younger men undergoing RARP.

Surgical outcomes and cost analysis of a multi-specialty robotic-assisted surgery caseload in the Australian public health system.

This study aims to compare surgical outcomes and in-hospital cost between robotic-assisted surgery (RAS), laparoscopic and open approaches for benign gynaecology, colorectal and urological patients and to explore the association between cost and surgical complexity. This retrospective cohort study included consecutive patients undergoing RAS, laparoscopic or open surgery for benign gynaecology, colorectal or urological conditions between July 2018 and June 2021 at a major public hospital in Sydney. Patients' characteristics, surgical outcomes and in-hospital cost variables were extracted from the hospital medical records using routinely collected diagnosis-related groups (DRG) codes. Comparison of the outcomes within each surgical discipline and according to surgical complexity were performed using non-parametric statistics. Of the 1,271 patients included, 756 underwent benign gynaecology (54 robotic, 652 laparoscopic, 50 open), 233 colorectal (49 robotic, 123 laparoscopic, 61 open) and 282 urological surgeries (184 robotic, 12 laparoscopic, 86 open). Patients undergoing minimally invasive surgery (robotic or laparoscopic) presented with a significantly shorter length of hospital stay when compared to open surgical approach (P < 0.001). Rates of postoperative morbidity were significantly lower in robotic colorectal and urological procedures when compared to laparoscopic and open approaches. The total in-hospital cost of robotic benign gynaecology, colorectal and urological surgeries were significantly higher than other surgical approaches, independent of the surgical complexity. RAS resulted in better surgical outcomes, especially when compared to open surgery in patients presenting with benign gynaecology, colorectal and urological diseases. However, the total cost of RAS was higher than laparoscopic and open surgical approaches.

Acceptability and face validity of two mental health screening tools for use in the routine surgical setting.

BACKGROUND: Preoperative assessment of mental health rarely occurs within routine surgery. Any screening tool selected to form part of this process must be deemed practical, acceptable and valid by clinicians and consumers alike. This study aims to assess the acceptability and face validity of two existing mental health screening tools to select one for further development and use in the routine surgical setting. METHODS: A survey of clinicians and consumers was conducted from October 2020 to March 2021 at a tertiary hospital in Sydney, Australia. Using a Likert scale (1-5, lowest to highest rating), the clinicians evaluated four domains for acceptability and two for validity (six overall) and the consumers four domains for acceptability and one for validity (five overall) on the preoperative use of the amended Kessler Psychological Distress Scale (K10) and the Somatic and Psychological Health Report-12 (SPHERE-12). Consensus was achieved through a rating of 4 or 5 being given by 70% or more of participants with domains able to remain unchanged. Free text responses were analysed into themes. RESULTS: A total of 73 participants (51 clinicians; 22 consumers) were included. The K10 received consensus scores (≥ 70%) in four out of six domains for clinicians (4/4 acceptability; 0/2 validity), and all five domains for consumers (4/4 acceptability; 1/1 validity). The SPHERE-12 received consensus scores (≥ 70%) in three domains for clinicians (3/4 acceptability; 0/2 validity), and three domains for consumers (3/4 acceptability; 0/1 validity). Six qualitative themes were described including (1) amendments to tool structure and language; (2) scale response options; (3) difficulty with somatic questions; (4) practicality and familiarity with K10; (5) challenges for specific patient cohorts and (6) timing considerations for patients. CONCLUSION: Adequate acceptability was established for the K10. However further development is required to strengthen its validity for this specific surgical cohort and purpose. Future research to determine the feasibility and acceptability of implementing and using the K10 in the routine surgical setting is now needed.

From the sidelines: The indirect repercussions of COVID-19 on the delivery of hospital surgical services.

BACKGROUND: Despite relatively few COVID-19 cases within New South Wales, the uncertainty surrounding the pandemic has prevented a return to business as usual for the delivery of surgical services. This study aims to describe the evolving impact of COVID-19 on surgical activity and patient outcomes at a major public tertiary referral hospital. METHODS: A retrospective cohort study involving adult surgical patients treated at a large public tertiary referral hospital in Sydney, Australia. Surgical activity, surgical outcomes and patient demographics were compared across two time periods, including the 'first wave' (February-May 2020 vs. February-May 2019) and the 'perseverance phase' (June-September 2020 vs. June-September 2019). Variables across both groups were compared using an independent t test or chi-squared test. RESULTS: A -32% reduction in surgical separations was observed in the 'first wave', including -20% emergency and -37% elective. In the 'perseverance phase', there was a -19% reduction in surgical activity, including 0% emergency and -27% elective. The average length of stay, intensive care admissions, postoperative complications and in-hospital costs significantly increased in the 'first wave'. The proportion of public patients increased marginally (3%) in the 'first wave'. CONCLUSION: The impact of COVID-19 was most severely experienced in the initial months of the pandemic and observed in the number of patients treated. Although there was an initial effect on surgical outcomes, overall, the standard of care remained safe. The delivery of elective surgery remains a challenge and reflects the ongoing system-wide changes that are required to manage the COVID-19 pandemic.

Surgical outcomes for people with serious mental illness are poorer than for other patients: a systematic review and meta-analysis.

OBJECTIVE: To assess the association between having a serious mental illness and surgical outcomes for adults, including in-hospital and 30-day mortality, post-operative complications, and hospital length of stay. STUDY DESIGN: Systematic review and meta-analysis of publications in English to 30 July 2018 of studies that examined associations between having a serious mental illness and surgical outcomes for adults who underwent elective surgery. Primary outcomes were in-hospital and 30-day mortality, post-operative complications, and length of hospital stay. Risk of bias was assessed with the Quality in Prognosis Studies (QUIPS) tool. Studies were grouped by serious mental illness diagnosis and outcome measures. Odds ratios (ORs) or mean differences (MDs), with 95% confidence intervals (CIs), were calculated in random effects models to provide pooled effect estimates. DATA SOURCES: MEDLINE, EMBASE, PsychINFO, and the Cochrane Library. DATA SYNTHESIS: Of the 3824 publications identified by our search, 26 (including 6 129 806 unique patients) were included in our analysis. The associations between having any serious mental illness diagnosis and having any post-operative complication (ten studies, 125 624 patients; pooled effect: OR, 1.44; 95% CI, 1.15-1.79) and a longer stay in hospital (ten studies, 5 385 970 patients; MD, 2.6 days; 95% CI, 0.8-4.4 days) were statistically significant, but not those for in-hospital mortality (three studies, 42 926 patients; OR, 1.21; 95% CI, 0.69-2.12) or 30-day mortality (six studies, 83 013 patients; OR, 1.85; 95% CI, 0.86-3.99). CONCLUSIONS: Having a serious mental illness is associated with higher rates of post-operative complications and longer stays in hospital, but not with higher in-hospital or 30-day mortality. Targeted pre-operative interventions may improve surgical outcomes for these vulnerable patients. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42018080114 (prospective).

Validated specialty-specific models for multi-disciplinary microsurgery training laboratories: a systematic review.

BACKGROUND: Laboratory simulation is increasingly important for teaching microsurgical skills. Training microsurgeons of different specialties within the same simulation laboratory increases efficiency of resource use. For maximal benefit, simulations should be available for trainees to practice specialty-specific, higher-order skills. Selection of appropriate simulations requires knowledge of the efficacy and validity of the numerous described laboratory models. Here we present a systematic review of validated training models that may serve as useful adjuncts to achieving competency in specialty elements of microsurgery, and appraise the evidence behind them. METHODS: In setting up a multi-disciplinary microsurgery training course, we performed a systematic review according to preferred reporting items for systematic reviews and meta-analyses guidelines. EMBASE, MEDLINE, Cochrane and PubMed databases were searched for studies describing validated, microscope-based, specialty-specific simulations, and awarded a level of evidence and level of recommendation based on a modified Oxford Centre for Evidence-Based Medicine classification. RESULTS: A total of 141 papers describing specialty-specific microsimulation models were identified, 49 of which included evidence of validation. Eleven were in the field of neurosurgery, 21 in otolaryngology/head and neck surgery, two in urology/gynaecology and 15 plastic and reconstructive surgery. These papers described synthetic models in 19 cases, cadaveric animals in 10 cases, live animals in 12 cases and human cadaveric material in 10 cases. CONCLUSION: Numerous specialty-specific models for use in the microscope laboratory are available, but the quality of evidence for them is poor. Provision of models that span numerous specialties may encourage use of a microscope lab whilst still enabling more specific skills training over a 'one-size-fits-all' approach.

Surgical experience for patients with serious mental illness: a qualitative study.

BACKGROUND: People with serious mental illness (SMI) have significantly worse surgical outcomes compared to the general population. There are many contributing factors to this complex issue, however consideration of the surgical experience from the patient's own perspective has never been undertaken. This lack of understanding prevents the provision of truly patient centred care and may limit the impact of potential improvement initiatives. Therefore this study aims to describe and better understand the surgical experience from the perspective of patients with SMI. METHODS: Within this qualitative study, semi-structured, audio-recorded interviews were conducted between August 2019 - June 2020, with 10 consenting participants with SMI who had surgery in the previous 2 years. A thematic analysis approach was used to explore both the positive and negative aspects of the participant's surgical experience commencing from pre-operative consultation to hospital discharge and follow-up. RESULTS: Four main themes and related subthemes emerged including i) the perceived lack of mental ill health recognition, ii) highly variable patient and clinician interactions, iii) the impact of healthcare services, and iv) strategies for improvement. CONCLUSION: Surgical patients with SMI want to be treated like everyone else whilst still having their mental ill health acknowledged and proactively managed despite this rarely occurring, which is valuable information for all surgical teams to consider and learn from. Participants were able to describe several readily implementable strategies to potentially improve their care and overall surgical experience, and as such highlight considerable opportunities for these to be tested and evaluated for this underserved patient group.

Cost-analysis of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with peritoneal malignancy: An Australian perspective with global application.

BACKGROUND: Cost-effective cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for treatment of patients with peritoneal malignancy remains an ongoing financial challenge for healthcare systems, hospitals and patients. This study aims to describe the detailed in-hospital costs of CRS and HIPEC compared with an Australian Activity Based Funding (ABF) system, and to evaluate how the learning curve, disease entities and surgical outcomes influence in-hospital costs. METHODS: A retrospective descriptive costing review of all CRS and HIPEC cases undertaken at a large public tertiary referral hospital in Sydney, Australia from April 2017 to June 2019. In-hospital cost variables included staff, critical care, diagnosis, operating theatre, and other costs. Univariate and multivariate analyses were conducted to investigate the differences between actual cost and the provision of funding, and potential factors associated with these costs. RESULTS: Of the 118 CRS and HIPEC procedures included in the analyses, the median total cost was AU$130,804 (IQR: 105,744 to 153,972). Provision of funding via the ABF system was approximately one-third of the total CRS and HIPEC costs (p < 0.001). Surgical staff proficiency seems to reduce the total CRS and HIPEC costs. Surgical time, length of intensive care unit and hospital stay are the main predictors of total CRS and HIPEC costs. CONCLUSION: Delivery of CRS and HIPEC is expensive with high variability. A standard ABF system grossly underestimates the specific CRS and HIPEC funding required with supplementation essential to sustaining this complex highly specialised service.

Evolving experience of operating theatre staff with the implementation of robotic-assisted surgery in the public sector.

Objectives The use of robotic-assisted surgery (RAS) remains predominantly in the private sector. In the public sector, the effect of the implementation of RAS on theatre staff is unknown. The aim of this study was to examine the knowledge and attitudes of theatre staff before and after implementation of RAS in the public sector. Methods In all, 250 theatre staff, including nursing, medical and support staff, were invited to participate in the study. A survey investigating the benefits of RAS for patients and staff, concerns towards the workplace environment and facilitators towards the implementation of new technology was administered before (June 2016) and after (February 2019) the implementation of a comprehensive RAS program. Results The survey was completed by 164 (65.6%) staff before and 200 (80.0%) staff after the implementation of RAS. With time, most nursing (P=0.002) and medical staff (P=0.003) indicated that RAS may benefit patients by reducing intraoperative complications, whereas support staff remained uncertain about this benefit (P=0.594). Before the implementation, most medical staff indicated that RAS would benefit staff, although after they were unsure about this benefit. Overall, before RAS implementation, theatre staff were mostly concerned about workplace safety, but this concern was significantly reduced after RAS implementation (P<0.010). Conclusions With time, operating theatre staff considered their RAS program to be associated with enhanced benefits to patients, and their concerns regarding workplace safety were significantly reduced. Conversely, theatre staff were unsure about the benefits of RAS to themselves. It is important for organisations to consider the evolving impact of new technology on their staff and to refine ongoing education and training programs in line with these changes. What is known about the topic? The implementation of RAS is rapidly evolving in major hospitals. Therefore, it is important to investigate the knowledge, attitudes and experiences of operating theatre staff before and after the implementation of RAS, especially in the public sector. What does this paper add? This study found that with time theatre staff considered RAS to be beneficial to patients, and their initial concerns about the effect on workplace safety were significantly reduced. What are the implications for practitioners? It is important for organisations to consider the evolving impact of the implementation of new technology on operating theatre staff and to refine ongoing education and training programs as required.

Research as the gatekeeper: introduction ofrobotic-assisted surgery into the public sector.

Objective Within Australia, robotic-assisted surgery (RAS) has largely been undertaken within the private sector, and predominately based within urology. This is rapidly developing, with RAS becoming increasingly prevalent across surgical specialties and within public hospitals. At this point in time there is a need to consider how this generation of the technology can be appropriately and safely introduced into the public health system given its prohibitive costs and lack of high-level long-term evidence. Methods This paper describes a unique approach used to govern the establishment of a new RAS program within a large public tertiary referral hospital in Australia. This included the creation of a comprehensive governance framework that covered research, training and operational components, with research being the ultimate gatekeeper to accessing the technology. Results Taking this novel approach, both benefits and challenges were encountered. Although initially there was a trade-off of activity to enable time for the research program to be developed, it was found the model strengthened patient safety in introducing the technology, fostered a breadth of surgical speciality involvement, ensured uniformity of data collection and, in the longer term, will enable a significant contribution to be made to the evidence regarding the appropriateness of RAS being used across several surgical specialties. Conclusions There is potential for this comprehensive governance framework to be transferred to other public hospitals commencing or with existing RAS programs and to be applied to the introduction of other new and expensive surgical technology. What is known about the topic? RAS is rapidly evolving and becoming increasingly prevalent across surgical specialities in major public hospitals. Consequently, it is important that this new technology is safely and appropriately implemented into the public health system. What does this paper add? This article describes the benefits and implementation challenges of a novel RAS approach, including a comprehensive governance framework that covered research, training and operational components, with research being the ultimate gatekeeper to accessing the technology. What are the implications for practitioners? This comprehensive governance framework can be transferred to other public hospitals introducing, or already using, new and expensive surgical technology.

Accelerating the learning curve in cytoreductive surgery and hyperthermic intraperitoneal chemotherapy using an external mentor model.

BACKGROUND: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is an accepted therapeutic approach in selected patients with peritoneal malignancy. The aim of this study was to describe early outcomes in the first 50 patients managed with CRS and HIPEC in a newly established peritoneal malignancy centre in Sydney, Australia, under the guidance of an experienced peritoneal malignancy mentor. METHODS: This is a retrospective review of a prospective maintained database of early outcomes in the first 50 patients who underwent CRS and HIPEC between April 2017 and April 2018 at a newly established peritoneal malignancy centre. Type of primary, surgery time, length of hospital stay, blood loss, peritoneal carcinomatosis index, completeness of surgery, complications, recurrence rate and 30-day mortality were reviewed. RESULTS: A total of 135 patients were referred and reviewed at the multidisciplinary team meeting with 50 (26 male) patients undergoing CRS and HIPEC. Of these 50 patients, 47 (94%) underwent complete cytoreduction while three (6%) had maximal tumour debulking surgery. Tumour pathology was of appendix origin (44%) and colorectal peritoneal metastases (44%). Median surgical time was 7.4 h (interquartile range 5.7-10.0). Median length of hospital stay was 13 days (interquartile range 9.7-19.0). Six (12%) patients experienced a grade III or IV Clavien-Dindo complication. There was no 30-day mortality. CONCLUSION: This study reports the successful establishment of a peritoneal malignancy centre under the guidance of an experienced peritoneal malignancy mentor. The short-term surgical outcomes observed in the first 50 cases are promising and comparable to other more experienced centres.

Knowledge and attitudes of theatre staff prior to the implementation of robotic-assisted surgery in the public sector.

BACKGROUND: The use of robotic-assisted surgery (RAS) is becoming increasingly prevalent across a range of surgical specialties within public hospitals around Australia. As a result, it is critical that organisations consider workplace factors such as staff knowledge, attitudes and behaviours prior to the implementation of such new technology. This study aimed to describe the knowledge and attitudes of operating theatre staff from a large public tertiary referral hospital prior to the commencement of an RAS program. METHODS: A cross-sectional survey of nursing, medical and support staff working in the operating theatre complex of a large public tertiary referral hospital was completed over a one-week period in June 2016. A 23-item questionnaire was utilised for data collection. RESULTS: 164 (66%) theatre staff returned the surveys and were included in this study. The majority of medical staff reported being knowledgeable about RAS, whilst the majority of nursing and support staff did not. Overall the theatre staff were neutral about the potential benefits of RAS to patients. The majority of medical staff believed the implementation of RAS will increase the value of staff roles and job satisfaction, while nursing and support staff were uncertain about these benefits. All three staff groups were concerned about the impact of an RAS program on Workplace Health and Safety, and care and handling. CONCLUSION: Operating theatre staff presented different knowledge and attitudes prior to the introduction of RAS. Whilst theatre staff were more favourable towards RAS than negative, they largely reserved their judgement about the new system prior to their own experiences. Collectively, these findings should be taken into consideration for training and support strategies prior to the implementation of a RAS program.