Developing a quality improvement project to tackle the desflurane problem.

Anaesthesia is associated with the routine use of volatile anaesthetic agents, all of which are potent greenhouse gases in varying degrees. Desflurane, in particular, has a high global warming potential and in recent years, there has been a global movement to reduce or remove its usage entirely from operating theatres. We work in a large tertiary teaching hospital in Singapore with deeply entrenched practices of using desflurane to facilitate high turnover of operating theatre cases. We launched a quality improvement project to (1) reduce the median usage of desflurane by 50% (by volume), and (2) reduce the number of theatre cases administering desflurane by 50% over a period of 6 months.We collected baseline data to determine departmental monthly median usage of desflurane. We then deployed sequential quality improvement methods to educate staff and to eliminate misconceptions, as well as to promote a gradual cultural change.We successfully reduced monthly median desflurane usage from 31.5 L to 12.2 L per month (61.3% reduction) within our targeted time frame. We also achieved a reduction in the number of theatre cases using desflurane by approximately 80%. This translated to significant cost savings of US$195 000 per year and over 840 tonnes of carbon dioxide equivalents saved.Healthcare is a resource intensive industry. Anaesthetists are well placed to play an important role in reducing healthcare-related carbon emissions by choosing anaesthetic techniques and resources responsibly. Through multiple Plan-Do-Study-Act cycles and a persistent, multifaceted campaign, we achieved a sustained change in our institution.

SARS-CoV-2 in migrant worker dormitories: Geospatial epidemiology supporting outbreak management.

BACKGROUND: Migrant worker dormitories-residential complexes where 10-24 workers share living spaces-account for the majority of cases of SARS-CoV-2 infection in Singapore. To prevent overspill of transmission to the wider population, starting in early April 2020, residents were confined to their dormitories while measures were put in place to arrest the spread of infection. This descriptive study presents epidemiological data for a population of more than 60 000 migrant workers living in two barracks-style and four apartment-style dormitories located in western Singapore from April 3 to June 10, 2020. METHODS: Our report draws from data obtained over the first 50 days of outbreak management in order to describe SARS-CoV-2 transmission in high-density housing environments. Cumulative counts of SARS-CoV-2 cases and numbers of housing units affected were analyzed to report the harmonic means of harmonic means of doubling times and their 95% confidence intervals (CI). RESULTS: Multiple transmission peaks were identified involving at least 5467 cases of SARS-CoV-2 infection across six dormitories. Our geospatial heat maps gave an early indication of outbreak severity in affected buildings. We found that the number of cases of SARS-CoV-2 infection doubled every 1.56 days (95% CI 1.29-1.96) in barracks-style buildings. The corresponding doubling time for apartment-style buildings was 2.65 days (95% CI 2.01-3.87). CONCLUSIONS: Geospatial epidemiology was useful in shaping outbreak management strategies in dormitories. Our results indicate that building design plays an integral role in transmission and should be considered in the prevention of future outbreaks.

Inadvertent spinal injection of ondansetron.

Cesarean sections under spinal anesthesia are now a daily occurrence in most tertiary hospitals. We report the first published case of inadvertent spinal injection of ondansetron without any neurological sequelae in a patient undergoing elective Cesarean section under spinal anesthesia. She did not experience any permanent neurological sequelae, and also did not exhibit any central neuraxial opioid side effects-nausea, vomiting or pruritus. Vigilance is essential to reduce the risk of wrong route delivery of drugs, especially when presented in very similar-looking 2 mL ampules as in our institution.