Operating Room Research Articles

Pediatric Esophageal Button Battery Protocol Reduces Time From Presentation to Removal.

Evaluate implementation of an institutional protocol to reduce the time to removal of esophageal button battery (BB) and increase use of mitigation strategies. We developed a protocol for esophageal BB management [Zakai's Protocol (ZP)]. All cases of esophageal BB impaction managed at a tertiary care center before and after implementation from 2011 to 2023 were reviewed. Time to BB removal, adherence to critical steps, and use of mitigation strategies (honey/sucralfate, acetic acid) were evaluated. Fifty-one patients (38 pre-ZP, 13 post-ZP) were included. Median age was 2.3 years (IQR 1.3-3.4). After implementation, the time from arrival at the institution to arrival in the operating room (OR) reduced by 4.2 h [4.6 h (IQR 3.9-6.5) to 0.4 h (IQR 0.3-0.6), p < 0.001] and there was improvement in all management steps. The number of referrals direct to otolaryngology increased from 51% to 92%, arrival notification increased from 86% to 100%, avoidance of second x-ray increased from 63% to 100%, and direct transfer to OR increased from 92% to 100%. Adherence to mitigation strategies such as preoperative administration of honey or sucralfate increased from 0% to 38%, intraoperative use of acetic acid from 3% to 77%, and nasogastric tube insertion from 53% to 92%. Implementation of ZP substantially reduced the time to BB removal and the use of mitigation strategies in our tertiary care institution. Additional strategies focused on prevention of BB ingestion, and shortening the transfer time to the tertiary care hospital are required to prevent erosive complications. 3, Case-series Laryngoscope, 134:5170-5177, 2024.

Perceived work-related stress and associated factors among the surgical workforce in a Nigerian tertiary health facility: A cross-sectional study

Healthcare workers continue to experience high levels of work-related stress which continue to negatively affect their psychological, physical, and emotional well-being. This is even more prevalent among healthcare workers who work in surgical specialities, with the surgical operation room becoming a known stressor at hospitals. This study aims to assess work-related stress among surgical team members at Ahmadu Bello University Teaching Hospital in Zaria between January 2021–2022. Data analysis involved descriptive and inferential statistical approaches using the Statistical Package for Social Science (SPSS) version 23.0. The study found an overall high prevalence of work-related stress, with 65% of participants reporting moderate levels of stress. The majority of the participants have a mean age of 39.4 ± 7.8 years, most of them being physicians (66.3%), being males (59.9%), and identified with a Hausa ethnic tribe. Notably, the multiple regression analysis found that tribe (p = 0.008), professional cadres (p = 0.001) and age/years of experience (p = 0.0035) emerged as significant predictors of work-related stress. Key determinants of work-related stress among surgical team members include workload, complexity of work, and conflicting cognitive job demands that continue to subject professionals to increasing workloads and constant decision-making about their job. Organizational factors, such as job policy and procedure, communication problems, and the nature of facilities, were identified as the highest contributors to work-related stress in organizational, interpersonal, and physical/environmental dimensions. The findings lead to the conclusion that a considerable proportion of surgical team members experience a relatively high level of work-related stress, primarily attributed to workload and cognitive demands. In light of these results, urgent efforts are recommended to improve the working conditions and environment for surgical team members. Furthermore, the integration of stress management measures into the educational programs for the surgical team is emphasized to effectively address and mitigate the impact of work-related stress.

Risk Assessment and Recommended Approaches to Optimize Infection Control and Antibiotic Stewardship to Reduce External Ventricular Drain Infection: A Single-Center Study

Background: An external ventricular drain (EVD) is used to release elevated intracranial pressure by draining cerebrospinal fluid (CSF) from the brain’s ventricles. The establishment of an EVD is one of the most commonly performed neurosurgical procedures to treat intracranial pressure in patients. Nevertheless, infections are very frequent complications. Identifying the risk factors for EVD-related infections is a key to improving patient safety and outcomes. Methods: We conducted a retrospective, single-center study of patients who underwent EVD implantation between January 2022 and March 2024. Patients were classified into infected and non-infected groups based on their clinical symptoms, as well as laboratory and microbiological results. Patient characteristics and possible risk factors for infection were compared between the two groups. Results: In total, 123 patients treated with 156 EVDs were included in this study, with a mean age of 55.8 (range: 25–84) years. EVD-associated infections were observed in 37 patients (30%). We found no significant association between infection risk and patient characteristics, including gender, primary diagnosis, craniotomy, or immunosuppression. There was no significant difference in terms of EVD insertion, i.e., whether the insertion took place in the operating room (OR) with antibiotic prophylaxis or outside the OR with no periprocedural antibiotic treatment. However, within the intensive care unit (ICU), EVD infection was much lower (13%) if EVD insertion took place in a single-bed room compared to multiple-bed room insertions (34%). Furthermore, there were significant differences in terms of the duration of first EVD (both single and multiple catheterizations) (p &lt; 0.0001) and the total catheterization time (p = 0.0001). Additionally, there was a significant association with patient days in the ICU and EVD catheterization. Conclusions: Revisiting infection control measures is necessary, with special attention to the replacement of EVDs in single-bed ICU rooms, to introduce antibiotic prophylaxis in the ICU. Minimizing unnecessary EVD manipulation during catheterization is crucial in order to decrease the risk of EVD infection.

Utilization Fraction of Ambulatory Hand Procedures: Cost-Reduction Through Surgical Instrument Tray Optimization.

Our objective is to evaluate the utilization fraction (UF) of surgical instruments during a commonly performed ambulatory hand surgery case as an avenue for cost reduction, increased operating room efficiency, and systems quality improvement. The total number of instruments opened at the start of the case was recorded followed by instruments being divided into those used and not used during the procedure. Total sterile processing costs were estimated at $1.56 per instrument according to data from our institution's central sterilization processing (CSP) department. Nineteen hand procedures performed by 2 surgeons were included in this study. An average of 120.1 ± 10.9 instruments were opened at the start of each case, while an average of 12.6 ± 5.4 instruments were used per case (Figure 1). This yielded an UF of 10.7% ± 4.8%. Using our internal CSP estimate, we calculated an annual cost of $16 863 to reprocess the current hand tray (Figure 2). Using literature data, this cost ranged from $5 513 to $34 484 annually. The same cost calculations were performed for the theoretical optimized tray (incorporating instruments used at least 20% of the time when opened) containing 23.2 instruments. The annual reprocessing cost of this new tray according to CSP data was $3 260, demonstrating a cost-reduction of $13 603 or 80.7% (Figure 2). Evaluation of pre- and peri-operative processes is a valuable technique to mitigate increasing healthcare costs and reduce unnecessary healthcare spending, with broad applicability to multiple surgical subspecialties and procedures.

Early outcomes of treatment selections for infrarenal abdominal aortic aneurysms: The first five year experience of a single center

Aim: We examined the criteria governing patient selection in contemporary practice in cases of infrarenal abdominal aortic aneurysm (AAA) treated electively or urgently in our Cardiovascular Surgery Clinic (CVSC). Material and Methods: From January 2019 to January 2024, we retrospectively evaluated infrarenal AAA patients treated either electively or urgently with Open Surgical Repair (OSR) or standard Endovascular Aortic Repair (EVAR) at our CVSC. The primary endpoints are distribution of AAA patients by treatment modality, early morbidity and mortality. The secondary endpoints were intensive care unit (ICU) duration and length of hospital stay (LOS). Results: A total of 332 patients received EVAR (Group 1), including 296 elective cases, while 90 patients underwent OSR (Group 2), with 66 being elective. Early mortality rates were significantly lower in the EVAR group (1.3% for elective and 27.8% for emergent) compared to the OSR group (6.1% for elective and 54.2% for ruptured cases, p=0.001). Major postoperative complications occurred in 12.5% of elective EVAR patients and 39.4% of elective OSR patients (p=0.001), while in ruptured cases, the rates were 11.1% and 58.3%, respectively (p=0.001). Comparisons of ICU duration and LOS also favored EVAR (p=0.001). Conclusion: EVAR offers a survival benefit in the early period compared to OSR. The choice of treatment should be tailored to the patient's comorbidities, preferences, and the vascular surgeon's expertise. Advanced aortic centers with hybrid operating rooms (HOR) and specialized CVSCs should aim for optimized patient outcomes and cost-effectiveness in our country.

Point-of-Care Lung Ultrasound to Evaluate Lung Isolation During One-Lung Ventilation in Children: A Blinded Observational Feasibility Study.

Minimally invasive thoracic surgical techniques require effective lung isolation using one-lung ventilation (OLV). Verification of lung isolation may be confirmed by auscultation, visual confirmation using fiberoptic bronchoscopy (FOB), or more recently, point-of-care ultrasound (POCUS). The aim of this study was to prospectively compare lung ultrasound with clinical auscultation to confirm OLV before thoracic surgery in pediatric patients. This prospectively blinded feasibility study included 40 patients ranging in age from 0 to 20 years. After confirmation of lung separation by the primary anesthesia team using FOB, the sonographer and the auscultator, both blinded to the laterality of surgery and lung separation, entered the operating room. The sonographer evaluated for pleural lung sliding and the auscultator listened for breath sounds. Successful lung separation was definitively confirmed by direct visualization of lung collapse during the operation. In confirming effective single-lung ventilation, lung ultrasound had a diagnostic accuracy of 95% (95% confidence interval [CI], 82.7%-98.5%). In contrast, auscultation could only reliably confirm lung isolation with 68% accuracy (95% CI, 51.5%-80.4%). The McNemar test showed a statistically significant difference between the use of lung ultrasound and auscultation (P < .001). The median time to perform ultrasonography was 67 seconds (interquartile range [IQR], 46-142) and the median time to perform auscultation was 21 seconds (IQR, 10-32). Based on the initial results of our feasibility trial, lung ultrasound proved to be a fast and reliable method to verify single-lung ventilation in pediatric patients presenting for thoracic surgery with a high degree of diagnostic accuracy.

Involvement of anesthesiologists in pediatric sedation and analgesia outside the operating room in Japan: is it too late, or is there still time?

The global COVID-19 pandemic highlighted significant existing supply-demand imbalances in anesthesia workforce, particularly impacting non-operating room anesthesia. Despite documented risks and mortality rates associated with pediatric procedural sedation and analgesia (PPSA) outside the operating room (OR), there is a pressing need for improvements in safety infrastructure. Comparative analysis with international practices reveals that anesthesiologists' involvement is associated with fewer adverse events and improved outcomes. However, lower reimbursement rate for sedation and anesthesia workforce shortage, and decentralized health resources are contributing factors to limit their participation in PPSA outside the OR in Japan. Enhancing the involvement of anesthesiologists through the public health frameworks such as "high-risk approach" and "population approach" can contribute to improvement of the safety and quality of PPSA. By tackling these challenges and implementing effective solutions, anesthesiologists can play a key role in ensuring safer and more effective PPSA outside the OR. Future challenges include enhancing training, addressing reduced clinical exposure due to work style reform, and developing effective educational systems. Research on improved educational approaches and fundamental outcome indices is crucial for improving PPSA practices outside the OR.

The impact of Benson's relaxation technique on the quality of life of operating room nurses in hospitals southwest Iran: a randomized controlled trial.

In clinical settings, continuous changes lead to increased professional stress, affecting the quality of life of nurses. Some complementary interventions may influence the improvement of the quality of life. This study aimed to determine the effect of Benson's relaxation technique on the operating room nurses' quality of life. In this clinical trial, 180 operating room nurses were randomly allocated to two groups: intervention (Benson's relaxation technique) and control (routine activity). The study was conducted from December 2021 to March 2022 in hospitals affiliated with Shiraz University of Medical Sciences. Benson's relaxation technique was performed twice daily by the intervention group for 8 weeks. Quality of life was measured before and after the intervention using the SF-36 questionnaire. Data were analyzed using SPSS version 21 software, with a significance level set at a P < 0.05. After the intervention, the results showed that Benson's relaxation technique led to an increase in the quality of life in the intervention group (P < 0.0001). In terms of quality-of-life dimensions, significant improvements were observed in the intervention group in the domains of physical problems (P < 0.05), emotional problems (P < 0.05), general health (P < 0.05), pain (P < 0.0001), and social functioning (P < 0.05). However, no significant differences were found in the dimensions of physical functioning, energy, and emotional well-being. Benson's relaxation technique can serve as a complementary method to improve various dimensions of the operating room nurses' quality of life. IRCT20211002052650N1 with the Clinical Trial Registry (26.10.2022).

The Making of Confident Surgeons: Why and How?

Low self-confidence in surgical residents can be associated with poor self-efficacy and perceptions of sub-optimal preparedness for practice at graduation. The influence of social and biologic determinants of confidence deserves further study. Through a randomized controlled trial of procedure-specific didactic and low fidelity simulation training for vaginal surgery, we showed positive correlations between self-confidence and objective performance in the real operating room for three different surgical procedures and through validated scales. This demonstrates an accurate ability of novice surgeons to self-monitor in a high-stakes environment. Our trial results (described in full elsewhere), combined with our multiple one-on-one teaching interactions with surgical trainees through the trial, incentivized us to evaluate self-confidence in view of optimizing it through directed training and feedback. The current opinion piece summarizes our main findings for surgical educators and emphasizes their role engaging with trainees at extremes of confidence.

Abstract 4120270: Risk Factors for Catastrophic Complications Requiring Emergent Extracorporeal Life Support in Patients Undergoing Transcatheter Aortic Valve Replacement

Background: Transcatheter Aortic Valve Replacement (TAVR) is often performed in the cardiology catheterization suite. Although rare, instances of annular rupture, cardiac arrest, and coronary occlusion may occur requiring institution of emergent extracorporeal life support (ECLS). This study aims to examine the risk factors for complications requiring ECLS during TAVR procedures to identify patients who may benefit from having procedures performed in hybrid operating rooms. Methods: Data from the Transcatheter Valve Therapy registry for our institution was obtained on patients (n=4908) who underwent TAVR between November 2012 and July 2023. Univariable logistic regression was performed to compare relevant covariates in those requiring intraoperative ECLS (n=23) to the rest of the patient cohort (n=4885). All-cause mortality during the follow-up period was compared to assess the impact of emergent intraoperative ECLS. Results: The patients requiring ECLS experienced significantly higher all-cause mortality (69.6% versus 28.8%, p&lt;0.001) with median follow up of 2 years (Table 1) . Female sex (p=0.013) and smaller annulus size (p=0.007) were significant independent risk factors for complications requiring emergent intraoperative ECLS based on univariable logistic regression (Table 2). Patients requiring ECLS had significantly smaller annulus sizes (21.0-23.2 mm) compared to the uncomplicated cohort (22.0-25.8 mm). Of the patients requiring ECLS, 11 cases (47.8%) were due to annular/ventricular rupture while 4 cases (17.4%) resulted from valve embolization. Of note, valve type (self-expanding versus balloon expandable), annular calcification, and porcelain aorta were not found to be significant risk factors. Conclusions: In this large volume single-center retrospective cohort study, female sex and smaller aortic annular size significantly increased the risk of complications necessitating ECLS support during TAVR procedures. Our study represents the first to identify independent risk factors for catastrophic complications during TAVR procedures. Patients with these high-risk profiles should have their TAVR procedures performed in the hybrid operating room with cardiopulmonary bypass on immediate standby.

Integrated surgical intervention for intradural extramedullary hemangioblastoma of the cervical spine: a case report and literature review

IntroductionThe incidence of hemangioblastoma is low, constituting only 1-5% of all spinal cord tumors. Specifically, intradural extramedullary hemangioblastoma without Von Hippel-Lindau syndrome represents an exceedingly rare condition.MethodsWe report the first documented case of cervical intradural extramedullary hemangioblastoma in China. A 53-year-old male patient presented with a 3-year history of mild right hemiplegia, segmental muscle strength and sensation impairment, and a positive pyramidal tract sign. MRI showed an abnormal oval signal focus in the intradural and extramedullary region at the C6-C7 vertebral level. Before surgery, angiography was performed to identify the supplying arteries and draining veins. Subsequent interventional therapy achieved over 90% occlusion of blood vessels, creating optimal conditions for complete resection of the spinal tumor.ResultsThe patient demonstrated satisfactory postoperative recovery with significant restoration of sensory and motor functions. Pathological examination showed a significant upregulation of CD31 in tumor cells and a substantial presence of the neuro-specific marker S100 in the tumor stroma, consistent with the diagnostic criteria for spinal hemangioblastoma.ConclusionThe rarity of cervical intradural extramedullary hemangioblastoma without Von Hippel-Lindau syndrome was reaffirmed by a comprehensive review of the existing literature. Complete tumor resection remains the optimal approach for managing this uncommon condition, generally resulting in a favorable prognosis. Traditional open fenestration surgery is linked to elevated risks of bleeding and trauma. Meanwhile, endovascular injection of embolic agents may lead to residual lesions and an increased risk of recurrence. Therefore, we recommend a one-time combined treatment conducted in a hybrid operating room to achieve complete resection and effectively reduce intraoperative bleeding risk. Despite presenting challenges and requiring high proficiency, we still recommend this type of combined surgery as a suitable therapeutic option for such diseases.

Speech communication interference in the robotic operating room.

Miscommunication in the OR is a threat to patient safety and surgical efficiency. Our objective was to measure the frequency and causes of communication interference between robotic team members. We observed 78 robotic surgeries over 215h. 65.4% were General Surgery, most commonly cholecystectomy, identifying Speech Communication Interference (SCI) events, defined as "surgery-related group discourse that is disrupted according to the goals of the communication or the physical and situational context of the exchange". We noted the causes and strategies to correct the miscommunication, near misses, and case delays associated with each SCI event. Post-surgery interviews supported observations and were analyzed thematically. Overall, we observed 687 SCI events (mean 8.8 ± 6.5 per case, 3.2 per hour), ranging from one to 28 per case. 48 (7.0%) occurred during docking and 136 (19.8%) occurred during a critical moment. The most common causes were concurrent tasks (66.1%); loud noises (10.8%) from patient cart, lightbox fan, and suction machine; and overlapping conversations (4.2%). 94.8% resulted in a case delay. These events distracted from monitoring patient safety and resulted in near misses. Mitigating strategies included leaning out of the surgeon console to repeat the message and employing a messenger. These findings help characterize miscommunication in robotic surgery. Possible interventions include microphones and headsets, positioning the surgeon console closer to the bedside, moving loud equipment further away, and upgrading the patient cart speaker.

Operating room sterilization and disinfection methods

Operating room sterilization and disinfection methods

Effective blind bilateral superficial cervical plexus block for tracheostomy tube insertion in a geriatric patient with Ludwig angina with hypertension in resource constrained area: a case report

IntroductionLudwig angina is a rare, rapidly spreading submaxillary, submandibular, and sublingual necrotizing life-threatening widespread cellulitis of the soft tissue on the floor of the mouth that can cause fatal complications because of airway obstruction. Currently, there are few published studies assessing the efficacy of superficial cervical plexus block for airway surgery and there is no agreement in the literature about airway management. The published recommendations differ and are based on the authors’ own experiences and available resources. This report aimed to provide insight into critical patient management by performing regional anesthesia with fewer complications to the cardiovascular and respiratory systems.Case presentationWe report the case of a 70 year-old hypertensive Black Ethiopian woman with American Society of Anesthesiologist–Physical Status class III and hypertension, who was admitted to the hospital for treatment by her surgeon. The surgeon diagnosed her with Ludwig angina. After adequate physical examination and laboratory investigation, she arrived at the operation room for exploration and drainage of the abscess with a superficial cervical plexus block. She arrived safely at the adult intensive care unit for frequent suctioning. The block was effective until 6 h after the procedure with visual analogue scale (2/10), her vital signs remained stable throughout the postoperative period, and then the tracheostomy tube was removed by the surgeon after 10 days. The patient’s hemodynamic status and breathing effort were satisfactory, and she was discharged 15 days later.Clinical discussionProper airway management is critical for the survival of patients diagnosed with Ludwig angina. According to recent studies, an increasing number of patients with Ludwig angina require intensive care unit admission for tracheal intubation and mechanical breathing. However, it is uncertain whether intensive care reduces the death rate in patients with Ludwig angina. Finally, it is suggested that studies with large sample sizes and strong levels of evidence be conducted to conclude the effectiveness of superficial cervical plexus block for airway emergency surgeries.ConclusionManagement of the airway in patients with Ludwig angina is challenging. Clinicians must take precautions and make sharp decisions on the basis of a variety of circumstances, including the availability of equipment at medical facilities, such as fiberoptic intubation equipment; the anesthetist’s level of experience, such as performing superficial regional block and good mask ventilation; and the patient’s medical status at the time of presentation. As a result, intervention needs to be quick so as to avoid airway obstruction and further complications.

Postoperative pain management practice and associated factors among nurses working at public hospitals, in Oromia region, Ethiopia, 2021: an institution-based cross-sectional study

BackgroundManagement of postoperative pain leads to positive patient progress and shortens the duration of hospital stay. There is a lack of information on nurse’s postoperative pain management practice and its...

Paravertebral versus Pectoralis-II (Interpectoral and Pectoserratus) Nerve Blocks for Postoperative Analgesia after Nonmastectomy Breast Surgery: A Randomized, Controlled, Observer-masked Noninferiority Trial.

Pectoralis-II and paravertebral nerve blocks are both used to treat pain after breast surgery. Most previous studies involving mastectomy identified little difference of significance between the two approaches. Whether this is also accurate for nonmastectomy procedures remains unknown. Participants undergoing uni- or bilateral nonmastectomy breast surgery anticipated to have at least moderate postoperative pain were randomized to a pectoralis-II or paravertebral block (90 mg ropivacaine per side for both). Surgeons and recovery room staff were masked to treatment group assignment, and participants were not informed of their treatment group. Injectate for pectoralis-II blocks was ropivacaine 0.3% (30 ml) per side. Injectate for paravertebral blocks was ropivacaine 0.5% (9 ml in each of two levels) per side. This study hypothesized that pectoralis-II blocks would have noninferior analgesia (numeric rating scale) and noninferior cumulative opioid consumption within the operating and recovery rooms combined (dual primary outcomes). The study was adequately powered with n = 100, but the target enrollment was raised to n = 150 to account for higher-than-anticipated variability. The trial was ended prematurely with 119 (79%) of the original target of 150 participants enrolled due to (masked) surgeon preference. Within the recovery room, pain scores were higher in participants with pectoralis-II (n = 60) than paravertebral blocks (n = 59): median [interquartile range], 3.3 [2.3, 4.8] versus 1.3 [0, 3.6] (95% CI, 0.5 to 2.6; P < 0.001). Similarly, intravenous morphine equivalents were higher in the pectoralis-II group: 17.5 [12.5, 21.9] versus 10.0 mg [10, 20] (95% CI, 0.1 to 7.5; P = 0.004). No block-related adverse events were identified in either group. After nonmastectomy breast surgery, two-level paravertebral blocks provided superior analgesia and opioid sparing compared with pectoralis-II blocks. This is a contrary finding to the majority of studies in patients having mastectomy, in which little significant difference was identified between the two types of blocks.

Interdisciplinary Operating Room Ergonomics Needs and Priorities: A Survey of Operating Room Staff.

To examine perceived OR ergonomics facilitators and barriers, with a focus on the interdisciplinary team. Poor ergonomics causes musculoskeletal injuries affecting all operating room (OR) staff with repercussions on patient care, outcomes, and sustainability. Lack of ergonomic awareness and education are risk factors. We conducted a self-administered web-based survey of OR nurses, surgeons, and anesthesiologists at a single centre (n=238). We developed a questionnaire through items generation and reduction, followed by reliability and validity testing. Response rate was 53.8%. Respondents perceived that on average 80% of nurses, 70% of surgeons, and 40% anesthesiologists experienced MSK injuries, with no difference in professional groups' perceptions. Guideline ergonomics interventions were rarely used (<25%) except for specialized clothing (33%), equipment repositioning (59%), and seating (37%), though perceived beneficial by 80-90%. Reported barriers to optimal ergonomics were organizational/structural (lack of time, space, equipment, funding), whereas solutions were individual. Fear of unfavourable perception from others was a concern for 62%. Teams discussing, prioritizing, monitoring, or helping with ergonomics was indicated by <50%. Individual ergonomic adaptations were perceived as convenience by other staff. While structural/organizational issues are reported as barriers to ergonomics, solutions appeared as individual responsibilities. Team dynamics did not prioritize nor support ergonomics. Education tools leveraging the interdisciplinary team are warranted. This work will be supplemented by interviews and live observations to build tailored educational tools for OR teams.

Earthquake Preparedness for Operating Room Staff: Lessons Learned From Experiences and the Literature.

Earthquakes pose hazards to health care workers and patients in operating rooms. Proactive planning based on insights gained from past experiences is crucial for enhancing safety. Through a comprehensive literature review, we summarize challenges and lessons learned from real earthquake events to inform the development of effective safety measures in operating rooms. Additionally, we discuss the anesthesiologist's role in crisis management.

Impact of an Acute Care Surgery Clinical Pathway on Patient Outcomes in Acute Appendicitis.

Objectives: Acute care surgery (ACS) encompasses surgical critical care, emergency general surgery, and the surgical management of trauma. Following ACS implementation at our institution, we developed a perioperative clinical pathway for acute appendicitis (AA) to improve efficiency and standardize post-operative care. The purpose of our study is to assess patient outcomes utilizing our ACS clinical pathway for patients with AA. Methods: This is a retrospective cohort study involving patients admitted to our tertiary care facility with AA who underwent appendectomy. Patients were classified by pre-implementation (January 1, 2016-July 31, 2018) and post-implementation (August 1, 2018-December 31, 2020) of our ACS clinical pathway. The primary outcome was hospital length of stay (LOS). Statistical analysis was performed using SAS with a p-value <0.05 determined as significant. Results: Of the 492 patients included, 225 were in the pre- and 267 were in the post-implementation cohorts. Hospital LOS was substantially decreased in the post-implementation cohort (31.2 vs. 50.4 h, p < 0.001). The post-implementation group had a substantial decrease in computed tomography (CT) to operating room (OR) start time (6.81 vs. 11.4 h, p < 0.001), CT to antibiotic agents' administration (2.20 vs. 3.37 h, p < 0.001), inpatient opioid utilization (125 morphine equivalents [ME] vs. 172 ME, p < 0.001), and discharge antibiotic agents' prescription rates (23.6% vs. 30.7%, p = 0.077). Recovery unit discharges (20 vs. 9%, p < 0.001) were increased in the post-implementation cohort. Conclusion: Our ACS clinical pathway for AA resulted in earlier surgical intervention, enhanced opioid and antimicrobial stewardship, and gains in surgical care efficiencies.

Influence of Distraction Factors on Performance in Laparoscopic Surgery in Immersive Virtual Reality: Study Protocol of a Cross-Over Trial in Medical Students and Residents-DisLapVR.

Working in an operating room (OR) is physically and mentally challenging: the operation itself demands the surgeon's full attention, while time and cost efficiency constraints, daily planning, and emergency care interfere with the procedure. Thus, multitasking becomes an integral surgical competence. This study aims to examine the effect of disruptions during surgery in a highly immersive virtual reality (IVR) operation environment combined with a virtual reality (VR) laparoscopy simulator. This study aims to identify distractions in the OR and their importance in the clinical setting. An IVR environment was created using a high-resolution, stereoscopic 360° video of the OR. Different distractions were identified, classified as auditory, visual, or audio-visual, and recorded accordingly. The surrounding was combined with a VR laparoscopic simulator. Participants-medical students and surgical residents-received proficiency-based training in basic laparoscopic skills and were blinded to the aim of the experiment. Following a cross-over design, each participant received a unique order of virtual distraction factors while performing tasks on the laparoscopic simulator. During the experiment, subjective passing of time, stress, heart rate, and visually induced motion sickness are recorded. After the experiment, validated questionnaires for usability, immersion, and stress were completed, as well as subjective evaluation of the distractions. The questionnaires used included the system usability scale, Self-Assessment Manikin score, National Aeronautics and Space Administration Task Load Index, and the immersion rating scale as described by Nichols. Performance in the laparoscopic tasks in relation to distractions will be evaluated by the Wilcoxon test and ANOVA for continuous variables. Subgroup analyses in regard to age, gender, and expertise (medical students vs surgical residents) are planned. The described trial started in August 2022 and is ongoing. By July 2024, a total of 30 medical students and 9 surgeons have completed the study. We present a study protocol aiming to identify the impact of different disruptions in OR during laparoscopic training in IVR. Hence, it may lead to an improved awareness of distractions and facilitate accommodations toward an improved work environment. Prior research leads to the hypothesis that the performance of a more experienced surgeon is less impacted by distractions than the performance of inexperienced surgeons and medical students. Furthermore, we investigate which type of distraction has the largest impact on performance. With this knowledge, specific multitasking training can be devised, which may be particularly useful in medical education, for which VR might play a leading role. Additionally, workplace surroundings in the OR can be optimized with this knowledge. German Registry for Clinical Trials DRKS00030033; https://drks.de/search/en/trial/DRKS00030033. DERR1-10.2196/59014.