A survey of surgical team members' awareness and perceptions toward the implementation of the surgical safety checklist in gynecological and obstetrical operations.

ABSTRACT: The World Health Organization Surgical Safety Checklist was developed to improve communication in perioperative care, reduce mortality and complications of patients, and ensure the consistent use of procedures for safe surgery. Despite the increased awareness of the checklist, the implementation compliance is reported as low and the degree of completeness varies. This study aimed to explore the possible supportive factors for the effective implementation and to identify potential awareness and barriers to its implementation in gynecological and obstetrical operation.A survey using a cross-sectional design that included surgeons, anesthetists, and operating room nurses was performed. We used an online link to distribute the survey to all eligible surgical team members in our hospital. The survey contained various aspects of perceptions on the Surgical Safety Checklist and an open-ended question that allowed respondents to offer their opinions on the topic.The overall self-reported awareness of the checklist within each professional group was high. The awareness of surgeons was lower than that of operating room nurses, particularly in the Time-out section. Most participants believed that operating room nurses ranked the highest compliance to the protocols, while surgeons stayed the lowest. Active leadership with experienced operating room nurses, good training for surgical team members, and simplification of the checklist would be the positive factors for the effective implementation.Although there is a high acceptance and adequate self-reported awareness of the Surgical Safety Checklist, it is not always possible to implement it successfully. Our findings suggest that with experienced and effective leadership, barriers to implementation can be overcome. With positive perception and commitment, the Surgical Safety Checklist is easy to implement and it can make a profound improvement on the safety of surgical care. Moreover, a strategy of repetitive training and assessment on the part of the involved health care professionals may be necessary to further improve patients' safety during surgery.

Global surgery, obstetric, and anaesthesia indicator definitions and reporting: An Utstein consensus report.

BACKGROUND: Indicators to evaluate progress towards timely access to safe surgical, anaesthesia, and obstetric (SAO) care were proposed in 2015 by the Lancet Commission on Global Surgery. These aimed to capture access to surgery, surgical workforce, surgical volume, perioperative mortality rate, and catastrophic and impoverishing financial consequences of surgery. Despite being rapidly taken up by practitioners, data points from which to derive the indicators were not defined, limiting comparability across time or settings. We convened global experts to evaluate and explicitly define-for the first time-the indicators to improve comparability and support achievement of 2030 goals to improve access to safe affordable surgical and anaesthesia care globally. METHODS AND FINDINGS: The Utstein process for developing and reporting guidelines through a consensus building process was followed. In-person discussions at a 2-day meeting were followed by an iterative process conducted by email and virtual group meetings until consensus was reached. The meeting was held between June 16 to 18, 2019; discussions continued until August 2020. Participants consisted of experts in surgery, anaesthesia, and obstetric care, data science, and health indicators from high-, middle-, and low-income countries. Considering each of the 6 indicators in turn, we refined overarching descriptions and agreed upon data points needed for construction of each indicator at current time (basic data points), and as each evolves over 2 to 5 (intermediate) and >5 year (full) time frames. We removed one of the original 6 indicators (one of 2 financial risk protection indicators was eliminated) and refined descriptions and defined data points required to construct the 5 remaining indicators: geospatial access, workforce, surgical volume, perioperative mortality, and catastrophic expenditure. A strength of the process was the number of people from global institutes and multilateral agencies involved in the collection and reporting of global health metrics; a limitation was the limited number of participants from low- or middle-income countries-who only made up 21% of the total attendees. CONCLUSIONS: To track global progress towards timely access to quality SAO care, these indicators-at the basic level-should be implemented universally as soon as possible. Intermediate and full indicator sets should be achieved by all countries over time. Meanwhile, these evolutions can assist in the short term in developing national surgical plans and collecting more detailed data for research studies.

Criteria for placenta accreta spectrum in the International Federation of Gynaecology and Obstetrics classification, and topographic invasion area are associated with massive hemorrhage in patients with placenta previa.

INTRODUCTION: Placenta previa with placenta accreta spectrum (PAS) is a life-threatening disease that results in massive hemorrhage. The clinical and histologic criteria of PAS were adopted according to the International Federation of Gynaecology and Obstetrics (FIGO) classification. We aimed to investigate whether FIGO criteria and topography were associated with maternal complications in patients with placenta previa. MATERIAL AND METHODS: Patients with placenta previa who underwent cesarean section at our institution between January 2003 and December 2019 were identified. First, they were divided based on FIGO classification, as follows: Group A, with clinical criteria; Group B, with histologic criteria; and Group C: without clinical or histologic criteria. Next, cases with PAS were classified according to the topographic invasion area, as follows: type 1, upper posterior bladder; type 2, lower posterior bladder; type 3, parametrium; type 4, posterior lower uterine segment. Predictive factors for massive hemorrhage were retrospectively analyzed. RESULTS: Among the 350 patients, 24 (6.9%) were classified as Group A, 16 (4.6%) as Group B and 310 (88.5%) as Group C. Regarding maternal history and hemostatic procedures, there were no significant factors other than hysterectomy (p < .01) in Groups A and B. The volume of blood loss in both Groups A and B was greater than in Group C (p < .01). The rates of uterine artery embolization and blood transfusion were higher in Groups A and B than in Group C (p < .01). In addition, there were no significant factors other than hysterectomy between Groups A and B. In the multivariate analysis for massive hemorrhage, Group A (odds ratio: 2.73, p = .04) and Group B (odds ratio: 12.69, p < .01) were identified as independent predictive factors. In addition, massive hemorrhage was closely related to the lower posterior bladder and parametrial invasion in both Groups A and B. CONCLUSIONS: Both clinical and histologic criteria for PAS in the FIGO classification were associated with massive hemorrhage. Diagnosing clinical PAS using the FIGO classification, additional hemostatic procedures might be necessary according to the topographic invasion area.

Hand hygiene in surgery in Benin: opportunities and challenges.

BACKGROUND: Hand Hygiene (HH) has been described as the cornerstone and starting point in all infection control. Compliance to HH is a fundamental quality indicator. The aim of this study was to investigate the HH compliance among Health-care Workers (HCWs) in Benin surgical care units. METHODS: A multicenter prospective observational study was conducted for two months. The World Health Organization (WHO) Hand Hygiene Observation Tool was used in obstetric and gastrointestinal surgery through six public hospitals in Benin. HH compliance was calculated by dividing the number of times HH was performed by the total number of opportunities. HH technique and duration were also observed. RESULTS: A total of 1315 HH opportunities were identified during observation period. Overall, the compliance rate was 33.3% (438/1315), without significant difference between professional categories (nurses =34.2%; auxiliaries =32.7%; and physicians =32.4%; p = 0.705). However, compliance rates differed (p < 0.001) between obstetric (49.4%) and gastrointestinal surgery (24.3%). Generally, HCWs were more compliant after body fluid exposure (54.5%) and after touching patient (37.5%), but less before patient contact (25.9%) and after touching patient surroundings (29.1%). HCWs were more likely to use soap and water (72.1%) compared to the alcohol based hand rub solution (27.9%). For all of the WHO five moments, hand washing was the most preferred action. For instance, hand rub only was observed 3.9% after body fluid exposure and 16.3% before aseptic action compared to hand washing at 50.6 and 16.7% respectively. Duration of HH performance was not correctly adhered to 94% of alcohol hand rub cases (mean duration 9 ± 6 s instead of 20 to 30 s) and 99.5% of hand washing cases (10 ± 7 s instead of the recommended 40 to 60 s). Of the 432 HCWs observed, 77.3% followed HH prerequisites (i.e. no artificial fingernails, no jewellery). We also noted a lack of permanent hand hygiene infrastructures such as sink, soap, towels and clean water. CONCLUSION: Compliance in surgery was found to be low in Benin hospitals. They missed two opportunities out of three to apply HH and when HH was applied, technique and duration were not appropriate. HH practices should be a priority to improve patient safety in Benin.

Development of a surgical assessment tool for national policy monitoring & evaluation in Ethiopia: A quality improvement study.

BACKGROUND: A baseline assessment of surgical capacity is recommended as a first-step to surgical system strengthening in order to inform national policy. In Ethiopia, the World Health Organization's Tool for Situational Analysis (WHO SAT) was adapted to assess surgical, obstetric, and anesthesia capacity as part of a national initiative: Saving Lives Through Safe Surgery (SaLTS). This study describes the process of adapting this tool and initial results. MATERIALS AND METHODS: The new tool was used to evaluate fourteen hospitals in the Southern Nations, Nationalities, and People's Region of Ethiopia between February and March 2017. Two analytic methods were employed. To compare this data to international metrics, the WHO Service Availability and Readiness Assessment (SARA) framework was used. To assess congruence with national policy, data was evaluated against Ethiopian SaLTS targets. RESULTS: Facilities had on average 62% of SARA items necessary for both basic surgery and comprehensive surgery. Primary, general, and specialized facilities offered on average 84%, 100%, and 100% of SARA basic surgeries, and 58%, 73% and 90% of SARA comprehensive surgeries, respectively. An average of 68% of SaLTS primary surgeries were available at primary facilities, 83% at general facilities, and 100% at specialized facilities. General and specialized hospitals offered an average of 80% of SaLTS general surgeries, while one specialized hospital offered 38% of SaLTS specialized surgeries. CONCLUSION: While the modified SaLTS Tool provided evaluation against Ethiopian national benchmarks, the resultant assessment was much lengthier than standard international tools. Analysis of results using the SARA framework allowed for comparison to global standards and provided insight into essential parts of the tool. An assessment tool for national surgical policy should maintain internationally comparable metrics and incorporation into existing surveys when possible, while including country-specific targets.

Effectiveness of a multicomponent safe surgery intervention on improving surgical quality in Tanzania's Lake Zone: protocol for a quasi-experimental study.

INTRODUCTION: Effective, scalable strategies for improving surgical quality are urgently needed in low-income and middle-income countries; however, there is a dearth of evidence about what strategies are most effective. This study aims to evaluate the effectiveness of Safe Surgery 2020, a multicomponent intervention focused on strengthening five areas: leadership and teamwork, safe surgical and anaesthesia practices, sterilisation, data quality and infrastructure to improve surgical quality in Tanzania. We hypothesise that Safe Surgery 2020 will (1) increase adherence to surgical quality processes around safety, teamwork and communication and data quality in the short term and (2) reduce complications from surgical site infections, postoperative sepsis and maternal sepsis in the medium term. METHODS AND ANALYSIS: Our design is a prospective, longitudinal, quasi-experimental study with 10 intervention and 10 control facilities in Tanzania's Lake Zone. Participants will be surgical providers, surgical patients and postnatal inpatients at study facilities. Trained Tanzanian medical data collectors will collect data over a 3-month preintervention and postintervention period. Adherence to safety as well as teamwork and communication processes will be measured through direct observation in the operating room. Surgical site infections, postoperative sepsis and maternal sepsis will be identified prospectively through daily surveillance and completeness of their patient files, retrospectively, through the chart review. We will use difference-in-differences to analyse the impact of the Safe Surgery 2020 intervention on surgical quality processes and complications. We will use interviews with leadership and surgical team members in intervention facilities to illuminate the factors that facilitate higher performance. ETHICS AND DISSEMINATION: The study has received ethical approval from Harvard Medical School and Tanzania's National Institute for Medical Research. We will report results in peer-reviewed publications and conference presentations. If effective, the Safe Surgery 2020 intervention could be a promising approach to improve surgical quality in Tanzania's Lake Zone region and other similar contexts.

Safety Culture and Perioperative Quality at the Volta River Authority Hospital in Akosombo, Ghana.

BACKGROUND: The Volta River Authority Hospital (VRAH) is a district hospital associated with a large public works project in Akosombo, Ghana, that has developed a reputation for high-quality care. We hypothesized that this stems from a culture of safety and standardized processes typical of high-risk engineering environments. To investigate this, we evaluated staff and patient perceptions of safety and quality, as well as perioperative process variability. MATERIALS AND METHODS: The Safety Attitudes Questionnaire (SAQ) and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys were used to evaluate staff and patient perceptions of safety. Perioperative general surgery and obstetrical procedure observations generated process maps, which were analyzed for variability and waste. RESULTS: Thirty-one SAQs were administered. 83% of workers held a positive perception of teamwork, and 77.4% held a positive perception of safety culture. Fifteen HCAHPS surveys of surgical inpatients showed a median hospital rating of 10 [IQR 8.5-10] on a ten-point scale. 90% gave maximal scores for pain management and 84.4% for nurse communication. Ten general surgery and obstetrical procedures were observed for which process map analysis was notable for no consistent waste steps and 100% adherence to the World Health Organization Safe Surgery Checklist. CONCLUSIONS: Surveys suggest an institutional commitment to safety with strong teamwork culture and patient communication. Perioperative process mapping supports this culture, with low levels of variability and waste, and is useful for evaluating standardization of care. VRAH demonstrates the feasibility of delivering high standards of perioperative care in a low-resource setting.

Committee Opinion No. 720 Summary: Maternal-Fetal Surgery for Myelomeningocele.

Myelomeningocele, a severe form of spina bifida, occurs in approximately 1 in 3,000 live births in the United States. The extent of disability is generally related to the level of the myelomeningocele defect, with a higher upper level of lesion generally corresponding to greater deficits. Open maternal-fetal surgery for myelomeningocele repair is a major procedure for the woman and her affected fetus. Although there is demonstrated potential for fetal and pediatric benefit, there are significant maternal implications and complications that may occur acutely, postoperatively, for the duration of the pregnancy, and in subsequent pregnancies. Women with pregnancies complicated by fetal myelomeningocele who meet established criteria for in utero repair should be counseled in a nondirective fashion regarding all management options, including the possibility of open maternal-fetal surgery. Maternal-fetal surgery for myelomeningocele repair should be offered only to carefully selected patients at facilities with an appropriate level of personnel and resources.

Committee Opinion No. 720: Maternal-Fetal Surgery for Myelomeningocele.

Myelomeningocele, a severe form of spina bifida, occurs in approximately 1 in 3,000 live births in the United States. The extent of disability is generally related to the level of the myelomeningocele defect, with a higher upper level of lesion generally corresponding to greater deficits. Open maternal-fetal surgery for myelomeningocele repair is a major procedure for the woman and her affected fetus. Although there is demonstrated potential for fetal and pediatric benefit, there are significant maternal implications and complications that may occur acutely, postoperatively, for the duration of the pregnancy, and in subsequent pregnancies. Women with pregnancies complicated by fetal myelomeningocele who meet established criteria for in utero repair should be counseled in a nondirective fashion regarding all management options, including the possibility of open maternal-fetal surgery. Maternal-fetal surgery for myelomeningocele repair should be offered only to carefully selected patients at facilities with an appropriate level of personnel and resources.

Multidisciplinary Delphi Development of a Scale to Evaluate Team Function in Obstetric Emergencies: The PETRA Scale.

OBJECTIVE: The objective of this study was to develop a new interdisciplinary teamwork scale, the Perinatal Emergency: Team Response Assessment (PETRA), for the management of obstetric crises, through consensus agreement of obstetric caregivers. METHODS: This prospective study was performed using expert consensus, based on a Delphi method. The study investigators developed a new PETRA tool, specifically related to obstetric crisis management, based on the existing literature and discussions among themselves. The scale was distributed to a selected panel of experts in the field for the Delphi process. After each round of Delphi, every component of the scale was analyzed quantitatively by the percentage of agreement ratings and each comment reviewed by the blinded investigators. The assessment scale was then modified, with components of less than 80% agreement removed from the scale. The process was repeated on three occasions to reach a consensus and final PETRA scale. RESULTS: Fourteen of 24 invited experts participated in the Delphi process. The original PETRA scale included six categories and 48 items, one global scale item, and a 3-point rubric for rating. The overall percentage agreement by experts in the first, second, and third rounds was 95.0%, 93.2%, and 98.5%, respectively. The final scale after the third round of Delphi consisted of the following seven categories: shared mental model, communication, situational awareness, leadership, followership, workload management, and positive/effective behaviours and attitudes. There were 34 individual items within these categories, each with a 5-point rating rubric (1 = unacceptable to 5 = perfect). CONCLUSION: Using a structured Delphi method, we established the face and content validity of this assessment scale that focuses on important aspects of interdisciplinary teamwork in the management of obstetric crises.

A Practice Improvement Project to Reduce Cesarean Surgical Site Infection Rates.

We implemented an evidence-based practice improvement project at a health care facility in the Midwestern United States to address the increasing rate of cesarean surgical site infections. Women who experienced cesarean birth were cared for using a standardized evidence-based protocol including preoperative and postoperative care and education. In addition, a team-created educational video was used by both women and their families during the postoperative period and at home after discharge. This new protocol resulted in a decrease in the rate of cesarean surgical site infections from 1.35% in 2013 to 0.7% in 2014 and 0.36% in 2015. Our interdisciplinary approach to integrate best-practice strategies resulted in decreased infection rates and improved patient satisfaction scores.

Clinical Performance of Emergency Surgical Officers in Southern Ethiopia.

BACKGROUND: Serious shortage of gynecologists and surgeons for several decades leading to a three-year masters level training was initiated in 2009. However, systematic analysis was not done to assess the graduates' performance. The purpose of this study was to assess improvement in access to emergency surgical and obstetrical care services. METHODS: Both quantitative and qualitative methods were employed to assess the competence of emergency surgical officers (ESOs) in their decision making and surgical skills in eight hospitals between 2012 and 2014. Anesthesia time, post-operative hospital stay and change in hemoglobin level were, among others, used as proxy indicators of their surgical skills. RESULTS: A total of 4075 obstetric and surgical operations was performed in the study hospitals. Of which, 93% were done on emergency base. Of the total emergency procedures, 3570(94%) were done by ESOs. Nearly two-thirds (63%) of all the emergency operations were cesarean sections, which were done by ESOs. Out of 239 uterine ruptures, hysterectomy was done for 58%. The proportion of cesarean and instrumental deliveries over the total deliveries were 13% and 0.7%, respectively. Explorative laparotomies and appendectomies were the majority of the non-obstetric emergency operations. Interviewed staff in the respective hospitals stated that ESOs' clinical decision making, surgical skill and commitment to discharge their responsibilities were in the best possible. CONCLUSIONS: The study showed that deployment of ESOs made the emergency surgery services accessible to the majority, and their clinical decision making and surgical skills were remarkable.

[Surgical treatment of postpartum hemorrhage]. / Prise en charge chirurgicale d'une hémorragie du post-partum.

OBJECTIVE: Systematic revue of different conservative and non-conservative surgical treatment of postpartum hemorrhage (PPH). Elaboration of surgical strategy after failed medical treatment of PPH. METHODS: French and English publications were identified through PubMed and Cochrane databases. RESULTS: Each obstetrical unit has to rewrite a full protocol of management of PPH depending on local environment quickly available in theatre (professional consensus). Conservative surgical treatment of PPH: efficacy of vascular ligature (bilateral uterine artery ligation (BUAL) or bilateral hypogastric artery ligation (BHAL)) as a first line of surgical treatment of PPH is about 60 % to 70 % (EL4). Bilateral uterine artery ligation (BUAL) is easy to perform with low rate of immediate severe complication (professional consensus). BUAL as BHAL seems not to affected fertility and obstetrical outcomes of next pregnancies (EL4). Efficacy of haemostatics brace suturing in case of failed medical treatment of PPH is about 75 % (EL3), without risk of major obstetrical complications at the next pregnancy (EL4). Radical surgical treatment of PPH: total hysterectomy is not significantly associated with more urinary tract injury in comparison with subtotal hysterectomy (EL3). Choice of surgical procedure of hysterectomy (total or subtotal) will depend on local consideration and clinicians habits (professional consensus). Surgical strategy: conservative surgical treatment are efficient and associated with low morbidity, they have to be primarily performed in women with further fertility desire. Specific medical consideration as massive PPH or cardiovascular instability has to consider performing haemostatic hysterectomy as the first line surgical treatment of PPH. PPH during caesarean delivery: in case of PPH during caesarean section, embolisation is not recommended, surgical treatment using vascular devascularisation or compression brace suturing should be performed (professional consensus). Surgical conservative technique will depend on local considerations and clinicians habits (professional consensus). PPH diagnosed after caesarean section should indicate relaparotomy. Arterial embolisation, if quickly vacant in the same hospital, may be performed in case of cardiovascular stability without surgical complication diagnoses on intraperitoneal hemorrhage (professional consensus). PPH during vaginal delivery: cardiovascular instability centre indicate the interhospital transfer and must lead to achieve haemostatic surgery on site (professional consensus). In the presence of a unit of embolisation in the maternity delivery, it is preferable to move towards embolisation, if maternal hemodynamic status permits (professional consensus). In case of cardiovascular stability associated with absence of heavy bleeding, the interhospital transfer may be considered for arterial embolisation (professional consensus). CONCLUSION: When medical treatment of PPH failed, conservative surgical treatment has a 70 % efficacy to stop hemorrhage whatever treatment used (vascular ligature or haemostatics brace suturing). In absence of rapid response to conservative medical and surgical treatment, hysterectomy should be performed without delay (professional consensus).

Interstitial pregnancy: a 'road map' of surgical treatment based on a systematic review of the literature.

An electronic search concerning the surgical approach in cases of interstitial pregnancy from January 2000 to May 2013 has been carried out. Fifty three studies have been retrieved and included for statistical analysis. Conservative and radical surgical treatments in 354 cases of interstitial pregnancy are extensively described. Hemostatic techniques have been reported as well as clinical criteria for the medical approach. Surgical outcome in conservative versus radical treatment were similar. When hemostatic techniques were used, lower blood losses and lower operative times were recorded. Conversion to laparotomy involved difficulties in hemostasis and the presence of persistent or multiple adhesions. Laparoscopic injection of vasopressin into the myometrium below the cornual mass was the preferred approach.

Patient safety in the obstetric and gynecologic office setting.

The modern patient safety movement began around 2000, when attention was drawn to error-related hospital mortality by the Institute of Medicine. Several years later the American College of Obstetricians and Gynecologists addressed safety issues in office practice, in recognition of the migration of increasingly complex surgical procedures to the office setting. Efforts begun in 2008 resulted in development of a program for safety certification of ob/gyn offices. Elements of the program are described, with recommendations on how they can be incorporated into standard office practice to reduce the chances of patient harm caused by errors or other adverse events.

Pain relief for obstetric and gynecologic ambulatory procedures.

As minor gynecologic procedures move from the operating room to the office, providers need to ensure that patients are comfortable and that procedures are performed safely. Although local anesthesia is commonly used for gynecologic procedures, a multimodal approach may be more effective. If necessary, sedation can be safely provided in an office setting with the correct tools and training. This article reviews evidence-based approaches to pain management for gynecologic procedures in the ambulatory setting.