Innovations towards achieving environmentally sustainable operating theatres: A systematic review.

INTRODUCTION: The NHS accounts for 5.4% of the UK's total carbon footprint, with the perioperative environment being the most resource hungry aspect of the hospital. The aim of this systematic review was to assimilate the published studies concerning the sustainability of the perioperative environment, focussing on the impact of implemented interventions. METHODS: A systematic review was performed using Pubmed, OVID, Embase, Cochrane database of systematic reviews and Medline. Original manuscripts describing interventions aimed at improving operating theatre environmental sustainability were included. RESULTS: 675 abstracts were screened with 34 manuscripts included. Studies were divided into broad themes; recycling and waste management, waste reduction, reuse, reprocessing or life cycle analysis, energy and resource reduction and anaesthetic gases. This review summarises the interventions identified and their resulting effects on theatre sustainability. DISCUSSION: This systematic review has identified simple, yet highly effective interventions across a variety of themes that can lead to improved environmental sustainability of surgical operating theatres. Combining these interventions will likely result in a synergistic improvement to the environmental impact of surgery.

The Association Between Timing of Elective Surgery Scheduling and Operating Theater Utilization: A Cross-Sectional Retrospective Study.

BACKGROUND: Overutilization of operating theaters (OTs) occurs when actual surgery duration exceeds scheduled duration, which could potentially result in delays or cancelations in subsequent surgeries. We investigate the association between the timing of elective surgery scheduling and OT overutilization. METHODS: A cross-sectional retrospective study was conducted using electronic health record data of 27,423 elective surgeries from July 1, 2016, to July 31, 2018, at a mid-Atlantic academic medical center with 56 OTs. The scheduling precision of each surgery is measured using the ratio of the actual (A) over the scheduled or forecast (F) length of surgery to derive the predictor variable of A/F (actual-to-forecast ratio [AF]). Student t test and χ2 tests analyzed differences between OTs reserved within and over 7 days of surgery for continuous and dichotomous variables, respectively. Hierarchical regression models, controlling for potential confounds from the hospital environment, clinicians' work experience and workloads, patient factors, scheduled OT length, and operational and team factors isolated the association between OTs reserved within 7 days of the elective surgery with AF. RESULTS: The Student t test indicates that OTs reserved within 7 days of surgery had significantly higher AF (1.13 ± 0.53 vs 1.08 ± 0.41; P < .001). In-depth Student t test analyses for 4 patient groups, namely, outpatient, extended recovery, admission after surgery, and inpatient, indicate that AF was only significantly different for OTs reserved within 7 days for the admission after surgery group (1.15 ± 0.47 vs 1.09 ± 0.35; P < .001) but did not reach statistical significance among the outpatient, extended recovery, and inpatient groups. After controlling for potential confounds, hierarchical regression for the admission after surgery group reveals that OTs reserved within 7 days took 2.7% longer than the scheduled length of surgery (AFbeta, 0.027; 95% CI, 0.003-0.051; P = .027). CONCLUSIONS: Elective surgeries scheduled within 7 days of surgery were associated with significantly higher likelihood of OT overutilization for surgical patients who will be admitted after surgery. Further studies at other hospitals and a longer period of time are needed to ascertain a potential "squeeze-in" effect.

The surgical debrief: Just another checklist or an instrument to drive cultural change?

INTRODUCTION: Post-procedural debrief is recommended to improve patient safety. We examined operating room (OR) clinicians' perceptions of the impact of a multi-disciplinary debrief on OR culture. METHODS: A survey was administered to 182 OR clinicians at a major academic medical center. Attitudes toward the surgical debrief and its effect on patient safety and OR culture were evaluated. RESULTS: Majority of clinicians (58.2%) believed creating a culture of safety in the OR was a shared care team responsibility, however, surgical attendings and trainees were more likely to assign this responsibility to the surgical attending. Few circulating nurses and trainees felt comfortable initiating a surgical debrief. Overall clinicians agreed that a debrief would impact both patient safety outcomes and OR culture. CONCLUSIONS: Clinicians felt implementation of a surgical debrief would positively affect the OR culture of safety by improving interdisciplinary communication and influencing the power hierarchy that exists in many ORs.

Unmasking bias and perception of lead surgeons in the operating room: A simulation based study.

BACKGROUND: Perception of a surgeon based on physical attributes in the operating room (OR) environment has not been assessed, which was our primary goal. METHODS: A common OR scenario was simulated using 8 different actors as a lead surgeon with combinations of age (<40 vs. >55), race (white vs. black), and gender (male vs. female). One video scenario with a survey was electronically distributed to surgeons, residents, and OR nurses/staff. The overall rating, assessment, and perception of the lead surgeon were assessed. RESULTS: Of 974 respondents, 64.5% were females. There were significant differences in the rating and assessment based upon surgeon's age (p = .01) favoring older surgeons. There were significant differences in the assessments of surgeons by the study group (p = .03). The positive assessments as well as perceptions trended highest towards male, older, and white surgeons, especially in the stressful situation. CONCLUSION: While perception of gender bias may be widespread, age and race biases may also play a role in the OR. Inter-professional education training for OR teams could be developed to help alleviate such biases.

Utilization of lean project management principles and health informatics to reduce operating room delays in a vascular surgery practice.

OBJECTIVES: Perioperative inefficiency can increase cost. We describe a process improvement initiative that addressed preoperative delays on an academic vascular surgery service. METHODS: First case vascular surgeries from July 2019-January 2020 were retrospectively reviewed for delays, defined as late arrival to the operating room (OR). A stakeholder group spearheaded by a surgeon-informaticist analyzed this process and implemented a novel electronic medical records (EMR) preoperative tool with improved preoperative workflow and role delegation; results were reviewed for 3 months after implementation. RESULTS: 57% of cases had first case on-time starts with average delay of 19 min. Inappropriate preoperative orders were identified as a dominant delay source (average delay = 38 min). Three months post-implementation, 53% of first cases had on-time starts with average delay of 11 min (P < 0.05). No delays were due to missing orders. CONCLUSIONS: Inconsistent preoperative workflows led to inappropriate orders and delays, increasing cost and decreasing quality. A novel EMR tool subsequently reduced delays with projected savings of $1,200/case. Workflow standardization utilizing informatics can increase efficiency, raising the value of surgical care.

Application of Deep Neural Network Factor Analysis Model in Operating Room Management Nursing Analysis of Postoperative Infection Nursing after Thoracic Surgery.

Thoracic surgery is the main surgical method for the treatment of respiratory diseases and lung diseases, but infections caused by improper care are prone to occur during the operation, which can induce pulmonary edema and lung injury and affect the effect of the operation and the subsequent recovery. Therefore, it is necessary to control the disease in time and adopt more scientific and comprehensive nursing measures. Based on the neural network algorithm, this paper constructs a neural network-based factor analysis model and applies the operating room management nursing to postoperative infection nursing after thoracic surgery and verifies the effect through the neural network model. The statistical parameters in this article mainly include the postoperative infection rate of thoracic surgery, patient satisfaction, postoperative rehabilitation effect, and complications. Through statistical analysis, it can be known that operating room management and nursing can play an important role in postoperative infection nursing after thoracic surgery, effectively reducing postoperative infection nursing after thoracic surgery, and improving the recovery effect of patients after infection.

Recommendations for Orthopedic Surgeons during the COVID-19 Pandemic.

BACKGROUND: Toward the end of 2019, the coronavirus disease-2019 (COVID-19) pandemic began to create turmoil for global health organizations. The illness, caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), spreads by droplets and fomites and can rapidly lead to life-threatening lung disease, especially for the old and those with health co-morbidities. Treating orthopedic patients, who presented with COVID-19 while avoiding nosocomial transmission, became of paramount importance. OBJECTIVES: To present relevant methods for pandemic control and hospital accommodation with emphasis on orthopedic surgery. METHODS: We searched search PubMed and Google Scholar electronic databases using the following keywords: COVID-19, SARS-CoV-2, screening tools, personal protective equipment, and surgery triage. RESULTS: We included 25 records in our analysis. The recommendations from these records were divided into the following categories: COVID-19 disease, managing orthopedic surgery in the COVID-19 era, general institution precautions, triage of orthopedic surgeries, preoperative assessment, surgical room setting, personal protection equipment, anesthesia, orthopedic surgery technical precautions, and department stay and rehabilitation. CONCLUSIONS: Special accommodations tailored for each medical facility, based on disease burden and available resources can improve patient and staff safety and reduce elective surgery cancellations. This article will assist orthopedic surgeons during the COVID-19 medical crisis, and possibly for future pandemics.

The Effect of Educational Intervention on the Improvement of Nontechnical Skills in Circulating Nurses.

BACKGROUND: Nontechnical skills are necessary for clinicians' safe performance and prevention of errors in the operating room. Educational intervention is a useful way to improve these skills, which are a vital area for improvement. Circulating nurses are surgical team members whose work depends heavily on using nontechnical skills. This study is aimed at assessing the effect of an educational intervention on the improvement of circulating nurses' nontechnical skills. METHODS: This semiexperimental study was conducted on 300 circulating nurses divided into the intervention and no intervention groups each containing 150 participants. The nontechnical skills were assessed using the circulating practitioners' list of nontechnical skills. Then, the intervention group received training regarding these skills, and the two groups were evaluated again. After all, the data were entered into the SPSS 24 software and were analyzed using descriptive statistics and Wilcoxon and Mann-Whitney tests. Furthermore, Kendall's tau, independent sample t-test, and one-way ANOVA were used for assessment of relationship between median scores and demographics. RESULTS: The results revealed a significant improvement in the scores of all domains of nontechnical skills in the intervention group (p < 0.05). The highest and lowest improvements were observed in teamwork (42%) and situational awareness (16.7%), respectively. After the intervention, the scores of some of the behaviors were still below the average level or were not improved significantly. CONCLUSIONS: Circulating nurses' nontechnical skills can be improved by educational interventions. However, regarding the low scores or no improvements in the scores of some behaviors, other intervention types such as policymaking and correcting the existing hierarchies in the operating room can be useful to complete the educational interventions.

Prevalence and factors associated with cancellation and deferment of elective surgical cases at a rural private tertiary hospital in Western Uganda: a cross-sectional study.

INTRODUCTION: the cancellation of elective surgery is still a worldwide challenge and this is associated with emotional and economical trauma for the patients and their families as well as a decrease in the efficiency of the operating theatre. This study aimed at determining the prevalence and factors associated with cancellation and deferment of elective surgery in a rural private tertiary teaching hospital in Western Uganda. METHODS: a cross-sectional study design was conducted. Data was collected from 1st July 2019 to 31st December 2019. Patients scheduled for elective surgery and either cancelled or deferred on the actual day of surgery were included in the study. Statistical analysis was done using STATA version 15. RESULTS: four hundred patients were scheduled for elective surgery during the study period, among which 90 (22.5%) were cancelled and 310 (78.5%) had their surgeries as scheduled. The highest cancellation of elective surgical operations was observed in general surgery department with 81% elective cases cancelled or deferred, followed by orthopedic department 10% and gynecology department 9%. The most common reasons for cancellation were patient-related (39%) and health worker-related (35%) factors. Other factors included administrative (17%) and anesthesia related factors (9%). Cancellation was mainly due to lack of finances which accounted for 23.3% of the patients, inadequate patient preparation (16.6%) and unavailability of surgeons (15.5%). Major elective surgeries were cancelled 1.7 times more than minor electives surgeries [adjusted prevalence ratio 1.7 (95%CI: 1.07-2.73) and p-value: 0.024]. CONCLUSION: cancellation and deferment of elective surgeries is still of a major concern in this private rural tertiary hospital with most of the reasons easily preventable through proper scheduling of patients, improved communication between surgical teams and with patients; and effective utilization of available resources and man power.

Systematic review of the efficacy of a hybrid operating theatre in the management of severe trauma.

BACKGROUND: Hybrid operating theatres (OT) allow for simultaneous interventional radiology and operative procedures, serving as a one-stop facility for the treatment of severely injured patients. Several countries have adopted the use of the hybrid OT however their clinical impact in improving efficiency and quality of care remains unclear. This study systematically reviews the clinical impact of the hybrid OT for treatment of the severely injured. METHODS: A literature review of the PubMed, Embase and Cochrane databases was performed to identify all published articles in English, from 1st January 2000 to 31st December 2020, reporting on the impact of a hybrid OT for severe trauma. Articles were also reviewed for references of interest. RESULTS: Five studies reporting the clinical impact of the hybrid OT, in a total of 951 patients, were shortlisted. All were cohort studies that compared patient outcomes in the hybrid OT versus a conventional group. Out of 3 studies that assessed timeliness to intervention, one reported shorter time associated with the hybrid OT, while the other two reported no difference. Mortality outcomes were reported in 4 studies and showed no significant difference associated with treatment in the hybrid OT. Two studies revealed shorter total procedure times associated with the hybrid OT. Two out of 3 studies that evaluated blood transfusion requirements reported decreased transfusion rates in the hybrid OT group. Only 1 study examined complication rates and demonstrated morbidity benefits associated with the hybrid OT. CONCLUSION: Establishment of a hybrid OT requires a significant capital investment as well as a highly functioning multi-disciplinary team. The cost-benefit ratio remains unclear. Future studies, preferably in the form of clinical trials, are required to evaluate its usefulness in improving timeliness to definitive haemorrhage control and outcomes in severe trauma.

Design of a novel multifunction decision support/alerting system for in-patient acute care, ICU and floor (AlertWatch AC).

BACKGROUND: Multifunction surveillance alerting systems have been found to be beneficial for the operating room and labor and delivery. This paper describes a similar system developed for in-hospital acute care environments, AlertWatch Acute Care (AWAC). RESULTS: A decision support surveillance system has been developed which extracts comprehensive electronic health record (EHR) data including live data from physiologic monitors and ventilators and incorporates them into an integrated organ icon-based patient display. Live data retrieved from the hospitals network are processed by presenting scrolling median values to reduce artifacts. A total of 48 possible alerts are generated covering a broad range of critical patient care concerns. Notification is achieved by paging or texting the appropriated member of the critical care team. Alerts range from simple out of range values to more complex programing of impending Ventilator Associated Events, SOFA, qSOFA, SIRS scores and process of care reminders for the management of glucose and sepsis. As with similar systems developed for the operating room and labor and delivery, there are green, yellow, and red configurable ranges for all parameters. A census view allows surveillance of an entire unit with flashing or text to voice alerting and enables detailed information by windowing into an individual patient view including live physiologic waveforms. The system runs via web interface on desktop as well as mobile devices, with iOS native app available, for ease of communication from any location. The goal is to improve safety and adherence to standard management protocols. CONCLUSIONS: AWAC is designed to provide a high level surveillance view for multi-bed hospital units with varying acuity from standard floor patients to complex ICU care. Alerts are generated by algorithms running in the background and automatically notify the selected member of the patients care team. Its value has been demonstrated for low acuity patients, further study is required to determine its effectiveness in high acuity patients.

Team training and surgical crisis management.

Team training and crisis management derive their roots from fundamental learning theory and the culture of safety that burgeoned forth from the industrial revolution through the rise of nuclear energy and aviation. The integral nature of telemedicine to many simulation-based activities, whether to bridge distances out of convenience or necessity, continues to be a common theme moving into the next era of surgical safety as newer, more robust technologies become available.

Society for Maternal-Fetal Medicine Special Statement: Surgical safety checklists for cesarean delivery.

The routine use of surgical safety checklists can reduce perioperative complications. Generic surgical safety checklists are insufficient for cesarean delivery because each cesarean delivery involves 2 patients (the mother and the fetus or newborn), each with separate care teams and health and safety considerations. To address the added complexity of care coordination and communication inherent in cesarean delivery, the Society for Maternal-Fetal Medicine presents sample standard surgical safety checklists for cesarean delivery that include elements of care for both the mother and newborn. In addition, we present an alternative checklist for time-critical emergency cesarean deliveries in which there is no time to safely perform the standard checklist and a sample preoperative checklist for use before moving the patient to the operating room. We also recommend steps for implementation of the checklists at individual facilities.

Improvement in student-led debriefing analysis after simulation-based team training using a revised teamwork assessment tool.

BACKGROUND: Team debriefing is an important teamwork development intervention for improving team outputs in healthcare. Debriefing is a key component of experiential team training teamwork development interventions such as simulation-based training. Improving the quality of debriefing of healthcare teams, therefore, has multiple benefits. We investigated whether the quality of student-led debriefing improved using a shortened guide. METHODS: Senior medical students, nurse anesthesia students, and senior undergraduate nursing students participated in student operating room team training at a health sciences center in the southeastern United States. Student teams participated in a dual-scenario simulation-based training session with immediate after-action debriefings after each scenario. In 2018, student teams conducted the second debriefing using as a guide the teamwork assessment scale, an 11-item, 3-subscale, 6-point Likert-type instrument. In 2019, they used a shortened, revised, 5-item version of the teamwork assessment scale, the quick teamwork assessment scale. Trained observers rated the quality of the student-led debriefings using the Objective Structured Assessment of Debriefing, an 8-item, 5-point instrument. The Wilcoxon-Mann-Whitney test was used to compare the teamwork assessment scale-guided and the quick teamwork assessment scale-guided mean item debriefing scores. RESULTS: Two observers rated 3 student-led team debriefings using the teamwork assessment scales as a guide in 2018, and 6 such debriefings happened using the quick teamwork assessment scale as a guide in 2019. For each debriefing, observer scores were averaged for each Objective Structured Assessment of Debriefing item; these mean scores were then averaged with other mean scores for each year. The use of the quick teamwork assessment scale resulted in a statistically significant higher mean score for the Analysis Objective Structured Assessment of Debriefing item compared with the use of the teamwork assessment scale (4.92 [standard deviation 0.20] versus 3.83 [standard deviation 0.76], P = .023). CONCLUSION: The use of a shortened teamwork assessment instrument as a debriefing guide for student teams in student operating room team training was more effective in analysis of actions than the original, longer tool. Next steps include determining the efficacy of the quick teamwork assessment scale in an actual clinical setting.

COVID-19 and plastic surgery: lessons from a national speciality review in the United Kingdom.

BACKGROUND: Ramifications of coronavirus disease 2019 (COVID-19) on the re-structuring of healthcare are widespread, including delivery of surgical services across all specialties, including plastic surgery. Re-deployment of personnel and cessation of elective services are commonplace. However, there is a continued need for both emergency and oncological surgery. A national review of practice was conducted during the COVID-19 pandemic, to assess impact on services, staffing and training. METHODS: Key aspects of current plastic surgery practice in the United Kingdom were examined in this cross-sectional study; operating capacity, location of theatre lists (national health service or outsourced private institutions (PIs)), differences across sub-specialties, change in anaesthesia practices, staffing, re-deployment, on-call provision and impact on training. RESULTS: Three-hundred and forty-four plastic surgeons in the United Kingdom provided practice data across 51 units. Theatre capacity and outpatient services were markedly reduced. Outsourcing of operating lists to PIs was widely utilised. Increased use of local anaesthetic hand procedures, the prioritisation of shorter operations with reduced microsurgery in both head and neck/lower limb and almost complete cessation of breast reconstruction were noted, together with marked regional variations. Re-deployment occurred at all staffing levels, whilst telemedicine played a critical role in both patient management and training. CONCLUSIONS: COVID-19 has enforced unprecedented changes to surgical care delivery and training, as identified by examination of plastic surgery nationally in the United Kingdom. Novel means to support continued elective and emergency services, including oncology have been identified. Lessons learned will allow phased return of services and improved preparation for the future.