Improving compliance with personal protective equipment among anaesthetists through behaviour-changing interventions during the coronavirus disease 2019(COVID-19) pandemic.

Since 2020, the coronavirus disease 2019 (COVID-19) pandemic has seen many changes in our daily infection prevention behaviours so as to reduce healthcare-associated transmission of COVID-19 in patients and healthcare workers. In the early phases of the COVID-19 pandemic of 2020, there was much emphasis on compliant personal protective equipment utilization in the operating theatres (OTs) for COVID-19-positive patients. However, during this period, there was a lack of international validated protocols on the appropriate handling and subsequent storage of personal protective equipment in the context of aerosol-generating procedures in OTs for asymptomatic antigen rapid test (ART)-negative patients. Given the potential for transmission even with a negative ART due to the incubation period, our team developed a checklist of eye protection (e.g. goggles/face shield) and N95 mask handling and storage in non-isolation OTs for these patients. We sought to improve the compliance of best practices from 20% to 80% amongst junior anaesthetists in Singapore General Hospital so as to prevent infection transmission and cross-contamination in the OT through education and behaviour-changing interventions. This quality improvement project took place over 19 weeks from June to October 2020 by our team of anaesthetists and nurse clinicians in the non-isolation OT setting. To analyse the problem, we performed a root cause analysis to understand attitudes and beliefs driving their behaviour. The top 80% of cited root causes for non-compliance then guided prioritization of resources for subsequent behaviour-changing interventions. Using the comprehensive infection control checklist, we conducted several plan-do-study-act cycles while implementing this new checklist amongst junior anaesthetists. A total of 227 assessments of junior anaesthetists were made in the care of asymptomatic ART-negative patients. Compliance with correctly handling goggles post-intubation started out as 33.3% in Week 1, which improved to 78.5% by Week 19. Compliance with goggle storage and face shield disposal started out at 13.6% in Week 1 and increased to 78.6% by Week 19. We attributed this improvement to education and behaviour-changing interventions. This quality improvement project focusing on improving compliance with personal protective equipment utilization during the COVID-19 pandemic in the management of asymptomatic ART-negative patients in non-isolation OTs demonstrated the importance of interventions of education, persuasion, modelling, and training in effecting and sustaining organizational behaviour change in physicians and other healthcare personnel.

Case Report: Anesthesia for a Neonate With Cutis Aplasia.

Cutis aplasia is a rare condition characterized by skin and subcutaneous tissue defects. Researchers have previously described both conservative and surgical management methods. We report herein the case of a neonate with extensive cutis aplasia involving 37% of the total body surface area. Due to the risk of meningitis and catastrophic hemorrhage associated with scalp defects, she underwent staged surgical procedures with skin harvesting and synthetic skin application, followed by the application of cultured epithelial autografts. This report highlights the challenges in temperature and fluid management as well as intraoperative positioning in a neonate with cutis aplasia.

Process-Oriented In Situ Simulation Is a Valuable Tool to Rapidly Ensure Operating Room Preparedness for COVID-19 Outbreak.

STATEMENT: Process-oriented in situ simulation has been gaining widespread acceptance in the evaluation of the safety of new healthcare teams and facilities. In this article, we highlight learning points from our proactive use of in situ simulation as part of plan-do-study-act cycles to ensure operating room facility preparedness for COVID-19 outbreak. We found in situ simulation to be a valuable tool in disease outbreak preparedness, allowing us to ensure proper use of personal protective equipment and protocol adherence, and to identify latent safety threats and novel problems that were not apparent in the initial planning stage. Through this, we could refine our workflow and operating room setup to provide timely surgical interventions for potential COVID-19 patients in our hospital while keeping our staff and patients safe. Running a simulation may be time and resource intensive, but it is a small price to pay if it can help prevent disease spread in an outbreak.

Practical considerations for performing regional anesthesia: lessons learned from the COVID-19 pandemic.

Coronavirus disease (COVID-19) was declared a pandemic by the World Health Organization on 11 March 2020 because of its rapid worldwide spread. In the operating room, as part of hospital outbreak response measures, anesthesiologists are required to have heightened precautions and tailor anesthetic practices to individual patients. In particular, by minimizing the many aerosol-generating procedures performed during general anesthesia, anesthesiologists can reduce exposure to patients' respiratory secretions and the risk of perioperative viral transmission to healthcare workers and other patients. To avoid any airway manipulation, regional anesthesia should be considered whenever surgery is planned for a suspect or confirmed COVID-19 patient or any patient who poses an infection risk. Regional anesthesia has benefits of preservation of respiratory function, avoidance of aerosolization and hence viral transmission. This article explores the practical considerations and recommended measures for performing regional anesthesia in this group of patients, focusing on control measures geared towards ensuring patient and staff safety, equipment protection, and infection prevention. By doing so, we hope to address an issue that may have downstream implications in the way we practice infection control in anesthesia, with particular relevance to this new era of emerging infectious diseases and novel pathogens. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is not the first, and certainly will not be the last novel virus that will lead to worldwide outbreaks. Having a well thought out regional anesthesia plan to manage these patients in this new normal will ensure the best possible outcome for both the patient and the perioperative management team.

RéSUMé: Le 11 mars 2020, l'Organisation mondiale de la Santé déclarait que la nouvelle maladie du coronavirus 2019 (COVID-19) était une pandémie en raison de sa propagation mondiale rapide. En salle d'opération, dans le cadre des mesures de réponse aux épidémies, les anesthésiologistes doivent prendre des précautions supplémentaires et adapter les pratiques anesthésiques au cas par cas selon chaque patient. Plus particulièrement, en minimisant les nombreuses interventions générant des aérosols pendant la réalisation de l'anesthésie générale, les anesthésiologistes peuvent réduire l'exposition aux sécrétions respiratoires des patients et le risque de transmission virale périopératoire aux travailleurs de la santé et aux autres patients. Afin d'éviter toute manipulation des voies aériennes, il convient d'envisager la réalisation d'une anesthésie régionale si une chirurgie est prévue chez un patient sous enquête de COVID-19 ou confirmé, ou chez tout patient posant un risque infectieux. L'anesthésie régionale comporte des avantages en matière de maintien de la fonction respiratoire et ce, tout en évitant la production d'aérosols et par conséquent la transmission virale. Cet article explore les considérations pratiques et les mesures recommandées pour réaliser une anesthésie régionale dans ce groupe de patients, en se concentrant sur les mesures de surveillance visant à garantir la sécurité des patients et du personnel soignant, la protection des équipements et la prévention des infections. Ce faisant, nous espérons répondre à des interrogations qui pourraient avoir des implications à plus long terme dans la manière dont nous pratiquerons la prévention de la contagion en anesthésie, avec une pertinence toute particulière pour cette nouvelle ère de maladies infectieuses émergentes et de nouveaux pathogènes. Le coronavirus du syndrome respiratoire aigu sévère 2 (SARS-CoV-2) n'est pas le premier et ne sera certainement pas le dernier nouveau virus qui entraînera des épidémies mondiales. En disposant d'un plan bien conçu d'anesthésie régionale pour prendre en charge ces patients dans cette nouvelle ère, les meilleures issues possibles seront assurées tant pour le patient que pour l'équipe de prise en charge périopératoire.

Healthcare workers' beliefs, attitudes and compliance with mobile phone hygiene in a main operating theatre complex.

BACKGROUND: Phone hygiene is increasingly recognized in infection prevention. We aimed to explore the beliefs, attitudes and performance of phone hygiene amongst healthcare workers (HCWs) in the major operation theatre (MOT) complex of a Singapore tertiary acute care hospital. We also monitored the impact of phone hygiene stations, introduced to improve phone hygiene. METHODS: We sent two online anonymous surveys to the Departments of Anaesthesia and MOT Nurses one month before and after we set up phone hygiene stations. Four phone hygiene stations displaying visual phone hygiene reminders and Mikrozid® sensitive wipes were set up at MOT entrances. RESULTS: A total of 205 and 91 HCWs responded to the first and second surveys respectively. In the first survey, 11.5% cleaned their phones daily while 9.4% never cleaned their phones. These changed to 16.9% and 3.8% respectively after the introduction of phone hygiene stations. 80.0% in the first survey said they would clean their phones more often if there were a readily accessible disinfection method in the MOT. A majority believed phones are a source of healthcare associated infection. Common reasons for not cleaning phones were 'lack of available resources' and 'I don't think about it.' Senior doctors were the least compliant to phone hygiene. CONCLUSION: Phone hygiene is easily overlooked during our busy workday. Besides increasing awareness of phone hygiene, having a readily available disinfection method in the MOT complex is important to improve phone hygiene. We suggest HCWs clean their phones before entering and/or after leaving the MOT daily.

Production pressures among anaesthesiologists in Singapore.

INTRODUCTION: Production pressure is the pressure on personnel to prioritise production ahead of safety. We assessed the prevalence of production pressures among anaesthesiologists in Singapore. METHODS: A random online survey was conducted among local anaesthesiologists. Questions were asked about attitudes to production pressures in the work environment, occurrence of situations involving unsafe actions, and rating of the intensity of external and internal sources of pressure. RESULTS: Demographically, our respondents were largely similar to all anaesthesiologists in Singapore and were fairly distributed across various tertiary hospitals. Nearly half (44.5%) had witnessed production pressures, with a colleague pressured to conduct anaesthesia in an unsafe manner. Such events included pressure from surgeons to proceed for elective surgery in patients without adequate optimisation, pressure to employ anaesthetic techniques that surgeons wanted, having to source for operating rooms to finish the surgeon's list, and being misled regarding surgical time. Over half (52.3%) made errors in clinical judgement due to excess workload. A heavy elective list workload was significantly associated with proceeding with patients despite lack of appropriate support, making changes to practices to avoid delaying the start of surgery and sourcing for operating rooms to finish the surgeon's list (p < 0.05), and being pressured to proceed with patients that the anaesthesiologist would otherwise have cancelled (p < 0.01). The need to avoid delaying the start of surgery and reduce turnover time between patients were the top-ranked internal and external pressures, respectively. CONCLUSION: Production pressure is prevalent among anaesthesiologists in Singapore and is correlated with a heavy workload.

Comparison of Medical Adhesive Tapes in Patients at Risk of Facial Skin Trauma under Anesthesia.

Introduction. Adhesive tapes are used for taping eyelids closed and securing endotracheal tubes during general anesthesia. These tapes can cause facial skin injury. We compared the incidence of facial skin injury and patient satisfaction with different tapes used. Methods. A total of 60 adult patients at risk of skin trauma were randomized to use 3M™ Kind Removal Silicone Tape or standard acrylate tapes: 3M Durapore (endotracheal tube) and Medipore (eyelids). Patients were blinded to tape used. Postoperatively, a blinded recovery nurse assessed erythema, edema, and denudation of skin. Anesthesiologist in charge also assessed skin injury. On postoperative day 1, patients rated satisfaction with the condition of their skin over the eyelids and face on a 5-point Likert scale. Results. More patients had denudation of skin with standard tapes, 4 (13.3%) versus 0 with silicone tape (p = 0.026) and in anesthesiologist-evaluated skin injury 11 (37%) with standard versus 1 (3%) with silicone (p = 0.002). No significant differences were found in erythema and edema. Patient satisfaction score was higher with silicone tape: over eyelids: mean 3.83 (standard) versus 4.53 (silicone), Mann-Whitney U test, p < 0.001; over face: mean 3.87 (standard) versus 4.57 (silicone) (p < 0.001). Conclusion. Silicone tape use had less skin injury and greater patient satisfaction than standard acrylate tapes.

The effects of intravenous lidocaine on pain during injection of medium- and long-chain triglyceride propofol emulsions.

Propofol formulated in medium- and long-chain triglycerides (MCT/LCT) is thought to cause less pain on injection. In this study we sought to determine if adding lidocaine to propofol-MCT/LCT is more effective in decreasing pain compared with propofol-MCT/LCT alone or conventional propofol-lidocaine mixtures. Seventy-five patients were randomized into three groups. Group A received conventional propofol-lidocaine mixtures with 20 mg lidocaine, group B received propofol-MCT/LCT with saline, and group C received propofol-MCT/LCT with 20 mg lidocaine. The incidence of pain was 24% in groups A and B and 4% in group C. The number needed to treat to prevent pain was 5. We conclude that propofol-MCT/LCT-lidocaine mixtures significantly reduce pain.