Preoperative Checklist Research Articles

A call to action: Standardisation of intravaginal hygiene product reporting in preoperative evaluation.

Preoperative checklists have demonstrated efficacy in improving patient care in the surgical setting. While the assessment of perioperative risks through patient inquiry is extensive, the menstrual status of the patient is one question that is not frequently discussed. If a patient is menstruating during their surgical procedure, unknown use of an intravaginal menstrual hygiene product, such as a tampon or menstrual cup, places the patient at risk of infection. This review seeks to bring attention to these risks by exploring Boyer v. Morimoto, a case where a patient developed toxic shock syndrome after a tampon was left in after surgery. We conclude with recommendations for standardised documentation of intravaginal menstrual hygiene products, with the aim to minimise perioperative risks.

Implementation of an Optimized Preoperative Checklist for Endoscopic Sinus Surgery Within a Multiinstitutional Resident Education Curriculum.

Preoperative review of computed tomography (CT) imaging assists with endoscopic sinus surgery (ESS) planning, where trainees may benefit from a systematic approach. We have previously developed an optimized preoperative checklist for sinus CT imaging using an iterative modified Delphi method. In this study, we assess the utility of an optimized preoperative checklist for residents performing ESS. Resident sinus CT scan education consisted of a preintervention questionnaire, an 18-min video outlining the optimized preoperative checklist, and a delayed postintervention questionnaire; these were distributed via Qualtrics to otolaryngology residents across 5 training programs in the NY metro area. The preintervention questionnaire contained 25 survey questions and a 225-point quiz on sinus CT anatomy; the delayed postintervention questionnaire contained the same 25 survey questions and a second, distinct 225-point quiz. In total, 74 residents completed the preintervention questionnaire, 47 completed the postintervention questionnaire, and 36 completed both. Among residents completing both questionnaires, the average preintervention quiz score was 136.8 ± 24.0 and the average postintervention quiz score was 156.0 ± 23.5 (P < .001). Resident habitual utilization of a systematic preoperative CT imaging checklist increased significantly from 21.6% to 72.9% as a result of the curriculum intervention. We find that an educational program centered on an iteratively optimized preoperative checklist for ESS improves the ability of trainees to identify critical sinus CT structures. Further integration of checklists and educational curricula may enhance rhinology education efforts and improve surgical anatomy competency.

Improving communication during damage control surgery: a survey of adult major trauma centres in England.

Deficiencies in non-technical skills can severely impede the functioning of teams in high-intensity scenarios, such as in damage control surgery for the critically injured trauma patient. Truncated preoperative checklists, modified from the standard World Health Organization preoperative checklist, and situational reporting at intervals during surgery are long-established practices in the military, and are recommended in the National Health Service guidelines on major incidents. These tools allow the multiprofessional team to create a shared mental model of the anaesthetic and operative plan, thereby improving team efficiency. Our aim was to establish whether adult major trauma centres in England are using truncated preoperative checklists and situational reporting for damage control surgery. An online survey was devised and distributed via the national programme of care for trauma in November 2020. Responses were received from all 23 adult major trauma centres in England. Nine centres (39.1%) reported using a truncated preoperative checklist for damage control surgery albeit in a variety of formats. Common components were blood products received and/or available, presence of allergies, tranexamic acid and antibiotic administration, availability of viscoelastic tests, equipment required, availability of cell saver, role allocation and reference to other personnel needed, and discussion of the plan. Twelve centres (52.2%) have formal policies in place for situational reporting. Again, these were in multiple formats but all focused on patient physiology to direct surgical planning. We have identified key components to advanced communication aids for damage control surgery, providing a foundation on which other major trauma centres can build their own versions of these potentially lifesaving tools.

A 10-point preoperative checklist: selecting patients for outpatient joint replacement surgery

BackgroundWith advancements in perioperative care, joint replacement (JR) surgery is undergoing a transition from opacified in-patient institutions to nimble out-patient Ambulatory Surgical Centers (ASC). The goal of JR in ASC setting is safe patient discharge with subsequent rehabilitation without readmission. Multi-modal preoperative rehabilitation (MMPR) is a novel field of perioperative care, encompassing comprehensive parameters to ensure smooth transition from fitness for surgery to JR in outpatient setting. At present, there are no open-access schemes for selecting patients qualified for JR in the ASC setting. In this article, we propose an evidence-based, 10-point systematic evaluation of patients with target endpoints for MMPR to qualify patients for JR as an outpatient procedure. This checklist is a non-proprietary scheme serving as an initial framework for surgeons exploring surgery in the ASC setting.BodyWe introduce factors for a prehabilitation scheme, called Checklist Outpatient-Joint Replacement (CO-JR) to qualify patients for outpatient JR surgery. These factors have been developed based on an extensive literature review and the significant experience of authors to incorporate variables that drive a successful outpatient JR procedure. The factors include patient education, psychiatric & cognitive ability, medical fitness, musculoskeletal capability, financial ability, transportation access, patient motivation, information technology (IT) capabilities, along with ability to recover independently at home postoperatively. The CO-JR scheme is under the process of validation at multiple institutions. We introduce this as a starting point for collaborative development of an open-access scheme for all surgeons to learn and adapt as needed for their respective global region.ConclusionWe established a non-proprietary 10-point CO-JR scheme, serving as a framework for surgeons to successfully select patients for JR surgery in the ASC setting. We encourage concomitant validation of this scheme globally. Our goal is to reach an international consensus on an open-access scheme, available for all surgeons to enrol patients for JR in the ASC setting, but modifiable to accommodate regional needs.

A Knowledge Assessment of the Surgical Safety Checklist among Operating Room Nurses in Malaysia

Surgical complications present a significant challenge worldwide. To address this issue, the World Health Organisation (WHO) introduced the Surgical Safety Checklist (SSC) as a means to decrease complications and fatalities during surgery. Nurses play a critical role in ensuring patient safety throughout the operation. A clear understanding of the checklist promotes effective communication within the surgical team, fosters a safety culture, and reduces complications. However, limited research has been conducted in accessing knowledge of operating room (OR) nurses regarding SSC, especially in the context of Malaysian healthcare. Therefore, this study was conducted to evaluate the level of knowledge of SSC among OR nurses in Malaysia. A quantitative approach with a descriptive design was used, involving ninety (90) OR nurses from Sultan Ahmad Shah Medical Centre (SASMEC@IIUM). The nurses completed a self-administered questionnaire and the results revealed good knowledge of the preoperative phase checklist (68.9%), intraoperative phase checklist (73.3%), and postoperative phase checklist (77.8%). However, a minority of nurses (around 20–30% across three different phases) needed improvement. This study suggests that the SSC has been effectively implemented at SASMEC@IIUM. However, it also emphasises the importance of ongoing education to ensure that all nurses have a thorough understanding of the checklist.

Just in Time: Improving Preoperative Checklist Compliance in the Cardiac Cath Lab

Just in Time: Improving Preoperative Checklist Compliance in the Cardiac Cath Lab

Relationship between preoperative psychological stress and short-term prognosis in elderly patients with femoral neck fracture

BACKGROUND Older adults are at high risk of femoral neck fractures (FNFs). Elderly patients face and adapt to significant psychological burdens, resulting in different degrees of psychological stress response. Total hip replacement is the preferred treatment for FNF in elderly patients; however, some patients have poor postoperative prognoses, and the underlying mechanism is unknown. We speculated that the postoperative prognosis of elderly patients with FNF may be related to preoperative psychological stress. AIM To explore the relationship between preoperative psychological stress and the short-term prognosis of elderly patients with FNF. METHODS In this retrospective analysis, the baseline data, preoperative 90-item Symptom Checklist score, and Harris score within 6 months of surgery of 120 elderly patients with FNF who underwent total hip arthroplasty were collected. We analyzed the indicators of poor short-term postoperative prognosis and the ability of the indicators to predict poor prognosis and compared the correlation between the indicators and the Harris score. RESULTS Anxiety, depression, garden classification of FNF, cause of fracture, FNF reduction quality, and length of hospital stay were independent influencing factors for poor short-term postoperative prognoses in elderly patients with FNF (P &lt; 0.05). The areas under the curve for anxiety, depression, and length of hospital stay were 0.742, 0.854, and 0.749, respectively. The sensitivities of anxiety, depression, garden classification of FNF, and prediction of the cause of fracture were 0.857, 0.786, 0.821, and 0.821, respectively. The specificities of depression, FNF quality reduction, and length of hospital stay were the highest at 0.880, 0.783, and 0.761, respectively. Anxiety, depression, and somatization scores correlated moderately with Harris scores (r = -0.523, -0.625, and -0.554; all P &lt; 0.001). CONCLUSION Preoperative anxiety, depression, and somatization are correlated with poor short-term prognosis in elderly patients with FNF and warrant consideration.

Successful Pediatric Cochlear Implantation In Persistent Stapedial Artery: First Reported Case In India WithLiterature Review AndRelevance of Preoperative Imaging Checklist.

We report the first successful pediatric cochlear implantation in bilateral persistent stapedial artery (pSA) in India. Another child with unilateral pSA, the contralateral side was initially implanted. Both children were preoperatively diagnosed. Preoperative imaging checklist for pSA, facilitates counselling for bilateral and decision-making for the contralateral side in unilateral abnormality.

A Clinical Practice Guideline for Prevention, Diagnosis and Management of Intraoperative Spinal Cord Injury: Recommendations for Use of Intraoperative Neuromonitoring and for the Use of Preoperative and Intraoperative Protocols for Patients Undergoing Spine Surgery.

Development of a clinical practice guideline following the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) process. The objectives of this study were to develop guidelines that outline the utility of intraoperative neuromonitoring (IONM) to detect intraoperative spinal cord injury (ISCI) among patients undergoing spine surgery, to define a subset of patients undergoing spine surgery at higher risk for ISCI and to develop protocols to prevent, diagnose, and manage ISCI. All systematic reviews were performed according to PRISMA standards and registered on PROSPERO. A multidisciplinary, international Guidelines Development Group (GDG) reviewed and discussed the evidence using GRADE protocols. Consensus was defined by 80% agreement among GDG members. A systematic review and diagnostic test accuracy (DTA) meta-analysis was performed to synthesize pooled evidence on the diagnostic accuracy of IONM to detect ISCI among patients undergoing spinal surgery. The IONM modalities evaluated included somatosensory evoked potentials (SSEPs), motor evoked potentials (MEPs), electromyography (EMG), and multimodal neuromonitoring. Utilizing this knowledge and their clinical experience, the multidisciplinary GDG created recommendations for the use of IONM to identify ISCI in patients undergoing spine surgery. The evidence related to existing care pathways to manage ISCI was summarized and based on this a novel AO Spine-PRAXIS care pathway was created. Our recommendations are as follows: (1) We recommend that intraoperative neurophysiological monitoring be employed for high risk patients undergoing spine surgery, and (2) We suggest that patients at "high risk" for ISCI during spine surgery be proactively identified, that after identification of such patients, multi-disciplinary team discussions be undertaken to manage patients, and that an intraoperative protocol including the use of IONM be implemented. A care pathway for the prevention, diagnosis, and management of ISCI has been developed by the GDG. We anticipate that these guidelines will promote the use of IONM to detect and manage ISCI, and promote the use of preoperative and intraoperative checklists by surgeons and other team members for high risk patients undergoing spine surgery. We welcome teams to implement and evaluate the care pathway created by our GDG.

Enhanced Recovery After Surgery (ERAS) Spine Pathways and the Role of Perioperative Checklists.

Enhanced recovery after surgery (ERAS) proposes a multimodal, evidence-based approach to perioperative care. ERAS pathways have been shown to help reduce complications, hospital length of stay (LOS), 30-day readmission rates, pain scores, and ultimately surgical costs, while improving patient satisfaction scores and outcomes in multiple surgical subspecialties [1-6]. Numerous specialties have implemented ERAS programs across the globe, providing a foundation for spine surgeons to begin the process themselves. Over the last few years, a significant number of papers have been addressing ERAS pathways for spinal surgery [7-19]. The majority have addressed the lumbar spine [9, 20-26]. The number of cervical ERAS pathways has been limited [27-29]. Many spine programs have begun the implementation of ERAS pathways, incorporating principles and interventions to various spine surgical procedures. Although differences in implementation across programs exist, there are a few common elements that promote a successful enhanced recovery approach [11, 16, 23, 25, 30-33]. All spinal ERAS pathways have three major elements, which are preoperative, perioperative, and postoperative phases. Within these phases some common elements include preoperative and intraoperative surgical checklists. Intraoperative checklist in addition to the "surgical time out" has been integrated into the workflow of most hospitals doing surgeries and have become a standard of care. The surgical checklist is designed to help reduce surgical errors and prevent wrong site/patient surgeries. Several surgical checklists have been developed throughout the years. Despite these safety protocols wrong site/level and other surgical errors continue to occur. Many cases of wrong level spine surgery (WLSS) still occur even when intraoperative imaging is performed [34, 35]. One survey reported that about 50% of spine surgeons have performed at least one WLSS during their career [36, 37]. Another survey reported that 36% of spine surgeons had performed at least one WLSS that was not recognized intraoperatively [38]. On a similar account, about 30% of spine surgery fellows have experienced wrong-site surgery [39]. From raw incidence rates, WLSS may seem rare, but these surveys show that the experience of WLSS is rather common among spine surgeons. WLSS is not yet a "never event." This may be due to poor quality of the intraoperative images, hindering subsequent level identification [34, 35, 38, 40]. Errors in interpretation of the imaging may also occur, including inconsistency in numbering vertebrae, inconsistency in landmark usage for level counting, and problems with numbering vertebrae due to lumbosacral transitional vertebrae (LSTV) and other anatomical variants [34, 38, 41-43]. This chapter will describe a framework for the development and implementation of ERAS pathway for patients undergoing spine surgery. In addition, we will propose preoperative imaging guidelines and a comprehensive spine surgical checklist to incorporate into the perioperative phase to help reduce further surgical errors and WLSS.

Creation of an institutional preoperative checklist to support clinical risk assessment in patients with ulcerative colitis (UC) considering ileoanal pouch surgery

BackgroundTotal proctocolectomy with ileal pouch–anal anastomosis (IPAA) is the most established restorative operative approach for patients with ulcerative colitis. It has associated morbidity and the potential for major repercussions on...

Reducing Operating Room (OR) Cancellations: Results from a Quality Improvement Study from a Tertiary Care Children's Cancer Center

Introduction: Operating Room (OR) is a critical resource that may be used inefficiently in pediatric hematology oncology services and surgical cancellations is a major cause of OR underutilization with major implications on cost-savings, patient satisfaction, quality-of-care and hospital metrics. The purpose of this performance improvement (PI) study was to reduce the surgical cancellation rate by 10% (Pre-PI cancellation rate,22%) at pediatric hematology oncology services at a large tertiary care children's cancer center in Riyadh, Saudi Arabia. Methods: Plan, Do, Study, Act (PDSA) cycle was adapted as project methodology on this performance improvement study. Preoperative checklist was created using REDCap electronic data capture tool hosted at our institution, also served as project database. Daily OR -Huddle was conducted to identify key points of intervention that included customized medical plans involving provision of pre-anesthesia evaluation clinic, sub-specialized inpatient and outpatient consultations, blood product support, while intervention required for improved communication included patient and nursing education. Patients were re-evaluated and preoperative checklist rechecked for provision of 24-hour notice of cancellation to the OR-scheduling team. All elective procedures scheduled between November 2021 and December 2022 were included, cancelled procedures were examined to identify potential reasons. Results: During the PI period, a total of 1063 elective surgical procedures were scheduled, majority 77% (816) were line-related, followed by bone marrow harvest in stem cell transplant donors, 11% (118) ; dental extraction and restoration, 6% (63) ; bone marrow aspiration or biopsy,4% (47) and other (lumbar puncture, Intrathecal chemotherapy etc.) procedures ,2% (19). Majority 58% (621), of the procedures scheduled for malignant diagnoses; followed by stem cell harvests or patients requiring line-insertion for stem cell infusion in 29% (308) and non-malignant diagnoses in 13% (134). Post-intervention, surgical cancellation observed in 54 cases, with majority 93% (50) being line-related cancellation. When compared to the pre-intervention period (12 months prior to PI-project initiation) rate of surgical cancellation dropped from 22% to 5% resulting in 17% improvement. Root cause analysis reports a significant decrease in cancellation related to inappropriate preoperative workup, 40%; followed by co-morbid conditions related to patients disease requiring sub-specialized consultation in 29% ; insufficient routine blood tests in 19% and inappropriate patient education in 8%. The preoperative checklist was approved and adapted as standard of care - clinical pathway to be integrated with the institutional Electronic medical records. Conclusion: In our experience, the observed high rate of elective OR cancellations were associated with ineffective preoperative workflow, team communication, patient coordination and education. Post-intervention measures enabled a visual system to harmonize patients' preoperative progress and the multi-disciplinary, daily OR-Huddle allowed lean-decision minimizing “last minute” cancellations. These interventions are easy to replicate against available resources by other tertiary care centers to improve inefficient OR utilization. Cost-effectiveness analysis resulting from the improvement is warranted.

Health care professionals most relevant phrases used in a digital medical translation tool in 24-7 communication with minority speaking heart surgery patients during hospitalization

Abstract Background/Introduction Health care professionals’ communications with hospitalized minority speaking heart patients are even in 2023 still frequently limited to non-verbal language, notes from informal caregivers and "google translate" in situations where interpreters are not available. Health care based digital solutions aiding translation may help improve health care professionals’ assessment, information about and treatment of minority speaking patients, and there is an urgent need for innovative research into this area. Purpose To describe the most relevant phrases used by health care professionals’ in a digital, medical translation tool for 24-7 communication with minority speaking heart surgery patients during hospitalization. Methods A digital medical translation tool was customized using the internationally recognized ABCDE (Airway, Breathing, Circulation, Disability, Exposure) systematic approach to assess and treat, in addition with the pre-operative surgical safety checklist employed as a framework. Health care professionals’ use of phrases in the digital tool when communicating with the minority speaking heart surgery patient’s during their clinical hospital pathway (Figure 1) were then counted, categorized, and finally linked to health care professionals’ actions. Results Fifty-five health care professionals (i.e. registered nurses, intensive care nurses, operating room nurses, anaesthesia nurses and physiotherapists) were during 60 shifts with 24-7 follow-up of five minority speaking heart surgery patients using a total of 410 phrases from the digital medical translation tool. The phrases were categorized and counted into the ten most common categories (Figure 2): 1. Pain (e. g. are you in pain?), 2. Nutrition (e. g. are you hungry?), 3. Respiration (e.g. breathe in), 4. Mobilisation (e.g. you have to get up and stand), 5. Psychological support (e.g. the surgery went well), 6. Safe surgery (e.g. do you have any teeth that are loose?), 7. Medications (e.g. pain relievers), 8. Communication (e.g. just answer "yes" or "no"), 9. Examination (e.g. you are going to have an x-ray examination), 10. Circulation (e.g. do you feel dizzy?). Health care professionals’ actions (i.e. assessment, information and reassurance, and instructions) were categorized and related to these phrases. Conclusions A health care based digital medical translation tool can aid in communication with minority speaking patients in situations when interpreters are not available. This study shows how health care professionals’ use of such a translation tool when communicating with minority speaking heart surgery patients during hospitalization can employ phrases and categories 24-7 to improve patients’ healthcare.Fig.1 Clinical pathwayFig.2 HCP communication

Early Integrated Palliative Care Within a Surgical Oncology Clinic

Advance directive (AD) designation is an important component of advance care planning (ACP) that helps align care with patient goals. However, it is underutilized in high-risk surgical patients with cancer, and multiple barriers contribute to the low AD designation rates in this population. To assess the association of early palliative care integration with changes in AD designation among patients with cancer who underwent surgery. This cohort study was a retrospective analysis of a prospectively maintained registry of adult patients who underwent elective surgery for advanced abdominal and soft tissue malignant tumors at a surgical oncology clinic in a comprehensive cancer center with expertise in regional therapeutics between June 2016 and May 2022, with a median (IQR) postoperative follow-up duration of 27 (15-43) months. Data analysis was conducted from December 2022 to April 2023. Integration of ACP recommendations and early palliative care consultations into the surgical workflow in 2020 using electronic health records (EHR), preoperative checklists, and resident education. The primary outcomes were AD designation and documentation. Multivariable logistic regression was performed to assess factors associated with AD designation and documentation. Among the 326 patients (median [IQR] age 59 [51-67] years; 189 female patients [58.0%]; 243 non-Hispanic White patients [77.9%]) who underwent surgery, 254 patients (77.9%) designated ADs. The designation rate increased from 72.0% (131 of 182 patients) before workflow integration to 85.4% (123 of 144 patients) after workflow integration in 2020 (P = .004). The AD documentation rate did not increase significantly after workflow integration in 2020 (48.9% [89 of 182] ADs documented vs 56.3% [81 of 144] ADs documented; P = .19). AD designation was associated with palliative care consultation (odds ratio [OR], 41.48; 95% CI, 9.59-179.43; P < .001), palliative-intent treatment (OR, 5.12; 95% CI, 1.32-19.89; P = .02), highest age quartile (OR, 3.79; 95% CI, 1.32-10.89; P = .01), and workflow integration (OR, 2.05; 95% CI, 1.01-4.18; P = .048). Patients who self-identified as a race or ethnicity other than non-Hispanic White were less likely to have designated ADs (OR, 0.36; 95% CI, 0.17-0.76; P = .008). AD documentation was associated with palliative care consulation (OR, 4.17; 95% CI, 2.57- 6.77; P < .001) and the highest age quartile (OR, 2.41; 95% CI, 1.21-4.79; P = .01). An integrated ACP initiative was associated with increased AD designation rates among patients with advanced cancer who underwent surgery. These findings demonstrate the feasibility and importance of modifying clinical pathways, integrating EHR-based interventions, and cohabiting palliative care physicians in the surgical workflow for patients with advanced care.

ThTP3.8 Promoting Awareness and optimizing perioperative management for Jehovah's Witnesses (JW) patients: A Quality Improvement Project (QIP)

Abstract Aims The restriction in using blood products poses a unique challenge to healthcare providers during treatment of JW patients. Current trust guidelines cover the peri-operative aspects of the management. We carried out a QIP to review the awareness amongst clinicians of appropriate guidelines and protocols in managing this cohort of patients. Methods An online survey was sent out to clinicians of all grades within the Trust, asking specific questions related to the use of blood products and alternative options; awareness of protocols including who to contact for advice. Results Our results of 102 responses revealed, 76% clinicians were not familiar with the trust guidelines. There was a wide variation in the knowledge about blood products which could be used and 42% were not aware of acceptable alternative options. 68% were not sure whom to contact for advice in and out of hours. 20% knew how to update an alert on the online medical records to identify patents’ wish of refusal for use of blood products. 94% were unaware of any preoperative and consent checklist for blood products. 50% were aware of checking Advance Directive for Refusal of Treatment (ADRT). Conclusion This QIP highlighted the lacunae in the awareness of trust protocols amongst clinicians of all grades. We aim to provide support and alerts on our Trust Intranet for managing this cohort of patients. Our ultimate goal is to produce a uniform national protocol available to all hospitals in the UK.

Implementation of Electronic Postoperative Nausea and Vomiting Assessment and Best Practice Advisory Tools to Improve Patient Care.

Postoperative nausea and vomiting (PONV) affects 30% of surgical patients undergoing anesthesia. PONV is a substantial cause of increased length of stay, cost of care, and unanticipated patient admission and readmission. Seventy percent of patients received PONV prophylaxis; PONV assessment was performed in only 63% of patients in this hospital system. A standardized PONV preoperative assessment checklist and a best practice advisory (BPA) were implemented in our electronic medical record (EMR) and charting system. Anesthesia providers and postanesthesia care unit (PACU) nurses completed training on patient management for PONV, including preoperative assessment and BPA use. The PONV preoperative assessment achieved high adoption, and providers followed its recommendations in more than 90% of cases. During the 6-month implementation phase, PONV rates decreased from 56% to 43.6%. Implementing a standardized, electronic PONV preoperative risk assessment checklist and a BPA effectively reduced PONV rates in this hospital system.

Documentation of Assessments and Interventions Using a Pediatric Preoperative Risk Assessment Checklist in the Postanesthesia Care Unit: A Quality Improvement Initiative

PurposeDescribe the impact of the implementation of an evidence-based pediatric preoperative risk assessment (PPRA) checklist on the frequency of postanesthesia care unit (PACU) nursing assessments and interventions in children at risk for respiratory complications during emergence from anesthesia. DesignProspective pre-/postdesign. MethodsPediatric perianesthesia nurses assessed 100 children preintervention according to current standard. After nurses received pediatric preoperative risk factor (PPRF) education, another 100 children were assessed postintervention using the PPRA checklist. Pre-/postpatients were unmatched for statistical purposes due to two different groups. Frequency of PACU nursing respiratory assessments/interventions was evaluated. FindingsDemographic variables, risk factors, frequency of nursing assessments/interventions were summarized in pre-/postinterventions. Significant differences (P < .001) were noted between pre-/postintervention groups with increased frequency of postnursing assessments/interventions that correlated with increased risk factors and weighted risk factors. ConclusionsBy identifying total PPRFs, PACU nurses used their plan of care to frequently assess and pre-emptively intervene with children who had increased risk factors to prevent or mitigate respiratory complications on emergence from anesthesia.

Tips and Tricks to Safely Perform an Endoscopic Endonasal Trans-Sphenoidal Pituitary Surgery: A Surgeon's Checklist.

The authors aimed to develop an extensive preoperative checklist of CT scan findings during endoscopic access to the ventral skull base and implement it in clinical practice. A comprehensive literature review was conducted to identify the radiological landmarks crucial to endoscopic skull base surgery. Four electronic databases were searched: PubMed, MEDLINE, EMBASE, and Google Scholar using search terms/keywords such as "radiological landmarks," "endoscopic skull base surgery," "CT scan," "pituitary surgery," "anatomical variations," "internal carotid," "optic nerve," "sphenoid sinus," "pneumatization," "dehiscence," and "protrusion". Inclusion criteria were limited to original articles and systematic reviews published in English, between the years 2000 and 2021, which pertained to the radiological landmarks to be identified during endoscopic skull base surgery. Full-text articles were retrieved and collated into a narrative review focused on a 12-item checklist the authors agreed upon. The mnemonic "O ROAD TO SELLA" was used to represent the checklist and include the following landmarks: Sphenoid Ostium, Sphenoid Rostrum, Onodi cells, Anatomic variations of the sphenoid sinus, Distance between the carotids, Tumor characteristics, Optic nerve dehiscence/protrusion, Septation/insertion of the sphenoid sinus, Entrance to the sellar floor, Lateral recess of the sphenoid sinus, cLinoid process pneumatization, and internal carotid Artery dehiscence/protrusion. The checklist is designed to be used by attending physicians, fellows, and residents and the authors intend to implement it into electronic medical records at the institution's medical center to monitor the outcomes of EEPS after implementation.

INTERVENTIONS TO IMPROVE ACCURACY OF UK NATIONAL HIP FRACTURE DATABASE INTRAOPERATIVE DATA: A CLOSED LOOP AUDIT WITH POSITIVE RESULTS

The National Hip Fracture Database (NHFD) is a clinically led web based audit used to inform national policy guidelines. The aim of this audit was to establish the accuracy of completion of NHFD v13.0 theatre collection sheets, identify common pitfalls and areas of good practice, whilst raising awareness of the importance of accuracy of this data and the manner in which it reflects performance of CAH Trauma &amp; Orthopaedic unit in relation to national guidelines. Our aim was to improve completion up to &gt;80% by the operating surgeon and improve overall accuracy.The methodology within both cycles of the audit were identical. It involved reviewing the NHFD V13.0 completed by the operating surgeon and cross-checking their accuracy against clinical notes, operation notes, imaging, anaesthetic charts and A&amp;E admission assessment.Following completion of cycle 1 these results were presented, and education surrounding V13.0 was provided, at the monthly trust audit meeting. At this point we introduced a sticker onto the pre-operative checklist for Hip fractures. This included time of admission and reason for delay. We then completed a re-audit.Cycle-1 included 25 operations, 56% (n=14) had a completed V13.0 form. Of these 21% (n=3) were deemed to be 100% accurate. Cycle-2 included 31 operations (between April – June 21) 81% (n=25) had a completed intra-operative from and showed an increase in accuracy to 56% (n=14)Through raising awareness, education and our interventions we have seen a significant improvement in the completion and accuracy of v13.0. Although 100% accuracy was not achieved its clear that education and intervention will improve compliance over time.Through the interventions that we have implemented we have shown that it is possible to improve completion and accuracy of the NHFD V13.0 theatre collection sheet locally and feel this could be implemented nationally.

Frontofacial Surgery: Reducing Infection with the Development and 6-Year Outcome of a Frontofacial Protocol.

Frontofacial surgery (FFS) creates a communication between the cranial and nasal cavities and is associated with significant infection risk. After a cluster of infections affecting patients undergoing FFS, a root cause analysis of index cases was undertaken, but no specifically remedial causes were identified. Basic principles incorporating known risk factors for the prevention of surgical-site infection were then applied to the creation of a perioperative management protocol. This study analyzes infection rates before and after its implementation. The protocol was designed around the needs of patients undergoing FFS and consists of three checklists covering their preoperative, intraoperative, and postoperative care. Compliance required the completion of each checklist. All patients undergoing FFS between 1999 and 2019 were studied retrospectively, and infections occurring before and after the implementation of the protocol were analyzed. One hundred three patients underwent FFS (60 monobloc and 36 facial bipartition) before the implementation of the protocol in August of 2013, and 30 patients underwent FFS after its implementation. Compliance with the protocol was 95%. After implementation, there was a statistically significant reduction in infections from 41.7% to 13.3% ( P = 0.005). Although no specific cause for a cluster of postoperative infection had been identified, the implementation of a bespoke protocol consisting of preoperative, perioperative, and postoperative checklists covering measures known to reduce infection risk was associated with a significant reduction in postoperative infections in patients undergoing FFS. Therapeutic, III.