Room Entry Research Articles

WP5.3 - Rejuvenating the golden patient protocol in a tertiary centre general surgical emergency theatre

Abstract Aims Poor patient flow and complex sub-specialty decision making discussions lengthened time to operation of lower priority operations e.g. appendicectomy/abscesses. By prioritising start times and registrar patient selection for low complexity cases/day case discharge, we rejuvenated the golden patient protocol (GPP) and assessed the implementation and impact of a novel GPP in a tertiary centre emergency list on surgical wait times and overall theatre flow. Methods The GPP was agreed between surgical/anaesthetic night registrars and theatre staff which took into consideration the urgency of the surgery, fitness of patient and anaesthetic/technical difficulties. Eligible patients were identified prior to 08:00 and scheduled as the first case of the day to be huddled and sent for by 08:30. Two cycles were conducted, one month before and after GPP introduction, using the trust theatre management system (TMIS). Results Time series analysis was conducted for patient sent-for, anaesthetic room entry, and procedure start times during both cycles. Results indicated a median decrease of 11-minutes in patient sent-for time (Cycle 1: 08:56, Cycle 2: 08:45) and a 12-minute reduction in median procedure start time (Cycle 1: 09:42, Cycle 2: 09:30). The proportion of low complexity cases performed first-on-list also increased by 22.5% (Cycle 1: 35.5%, Cycle 2: 58.0%). Conclusions This analysis demonstrates a positive change by starting theatre faster with lower complexity cases, developing surgical registrar independence, improving time to treatment without complex discussions delaying first send.

Factors associated with correction of personal protective equipment nonadherence in a multidisciplinary emergency department setting: A retrospective video review

Despite local and national recommendations, health care provider adherence to personal protective equipment (PPE) varied during the COVID-19 pandemic. Previous studies have identified factors influencing initial PPE adherence but did not address factors influencing behaviors leading to correction after initial nonadherence. We conducted a retrospective video review of 18 pediatric resuscitations involving aerosol-generating procedures from March 2020 to December 2022 to identify factors associated with nonadherence correction. We quantified adherent and nonadherent providers, instances of PPE nonadherence, and time to correction. We also analyzed correction behaviors, including provider actions and correction locations. Among 434 providers, 362 (83%) were nonadherent with at least 1 PPE. Only 186 of 1,832 instances of nonadherence were corrected, primarily upon room entry and during patient care. Correction time varied by PPE type and nonadherence level (incomplete vs absent). Most corrections were self-initiated, with few reminders from other providers. Potential barriers to correction include a lack of social pressure and external reminders. Solutions include optimizing PPE availability, providing real-time feedback, and educating on double gloving. Most providers were nonadherent to PPE requirements during high-risk infection transmission events. The low correction rate suggests challenges in promoting collective responsibility and maintaining protective behaviors during medical emergencies.

Appendicectomy pathway: Insights from electronic medical records of a local health district in Australia

BackgroundThis study aims to identify the common pathways of appendicectomy, the most common emergency surgery in Australia’s public hospitals and any variations within a regional public health district in New South Wales, Australia. MethodsWe analyzed the electronic medical records of 3,943 patients who underwent appendicectomy between January 2014 and July 2020 at 2 hospitals in the Illawarra Shoalhaven Local Health District, New South Wales, Australia, using the PM2 approach for surgical pathway identification and subsequent statistical analyses. ResultsAmong 3,943 patients, 3,606 (91.5%) followed an 11-step main pathway: (1) emergency department admission, (2) surgery booking, (3) anesthesia start, (4) operating room entry, (5) surgery start, (6) surgery end, (7) anesthesia end, (8) operating room discharge, (9) postanesthesia care unit admission, (10) postanesthesia care unit discharge, and (11) hospital discharge. The median length of stay was 48.13 hours (interquartile range 32.74). The main pathway differed from either variation 1 (n = 246, 6.2%) or variation 2 (n = 30, 0.8%) only in the timing and location of anesthesia administration or conclusion. Variation 3 (n = 26, 0.7%) included patients who underwent appendicectomy twice, whereas variation 4 (n = 25, 0.6%) included patients booked for surgery before emergency department admission through community doctor referrals. Thirteen exceptional cases experienced combinations of the aforementioned pathways. The length of stay and phase durations varied between the main pathway and these variations. ConclusionThe appendicectomy pathway was largely standardized across the studied hospitals, with the location of anesthesia administration or conclusion affecting specific stages but not the overall length of stay. Only a complex 2-surgery pathway increased length of stay.

KardiaMobile 6L versus 12-lead ECG: Effects on clinic utilization time.

We aimed to study whether KardiaMobile 6L 30-second capture technology could shorten ECG collection time compared to standard 12L ECG without compromising data usability. A single-center, non-randomized trial was performed on patients presenting for follow-up visits to the electrophysiology (EP)clinic. Providers in the KardiaMobile 6L group were allowed to request a standard 12L if the 6L was deemed insufficient for clinical care. Room utilization times, defined as the time from medical assistant room entry to exit, were compared for each group. There were 100 patients in the study, with 50 in each arm. Average room utilization time for the 12L group and 6L groups were 10.33 ± 2.2and 7.27 ± 1.93 min, respectively (p < .001). In 8 (16%) visits for the 6L group, an additional 12L was requested. For EP follow-up visits, clinic utilization time was significantly reduced with the KardiaMobile 6L compared to the 12L ECG with infrequent need for an additional 12L.

Optimizing environmental enrichment for Sprague Dawley rats: Exemplary insights into the liver proteome.

Considering the expected increase in the elderly population and the growing emphasis on aging-related biomedical research, the demand for aged laboratory animals has surged, challenging established husbandry practices. Our objective was to establish a cost-effective method for environmental enrichment, utilizing the liver as a representative organ to assess potential metabolic changes in response to differing enrichment levels. We conducted a six-month study involving 24 male Sprague Dawley rats, randomly assigned to four environmental enrichment groups. Two groups were housed in standard cages, while the others were placed in modified rabbit cages. Half of the groups received weekly playtime in an activity focused rat housing unit. We evaluated hormone levels, playtime behavior, and subjective handling experience. Additionally, liver tissue proteomic analysis was performed. Initial corticosterone levels and those after 3 and 6 months showed no significant differences. Yet, testosterone levels were lower in the control group by the end of the study (p = 0.007). We observed 1871 distinct proteins in liver tissue, with 77% being common across groups. In gene ontology analysis, no specific pathways were overexpressed. In semiquantitative analysis, we observed differences in proteins associated in lipid metabolism such as Apolipoprotein A-I and Acyl-CoA 6-desaturase, which were lower in the control group (p = 0.024 and p = 0.009). Rats in the intervention groups with weekly playtime displayed the least amount of reported distress during inspection or upon room entry and were less prone to accepting treats. Removing animals from their enclosure was most effortless for those in the large cage group. Over time, there was a decrease in conflicts among rats that interacted only twice weekly during playpen time. In summary, refining husbandry practices for aging rats is both simple and budget-friendly, with no apparent adverse effects on stress levels, animal development, or relevant metabolic changes in the liver.

Cardiopulmonary resuscitation at operating room entry in acute aortic dissection type A patients: is surgery contraindicated?

This study aimed to compare the short-term outcomes of surgical treatment for acute type A aortic dissection between patients undergoing cardiopulmonary arrest at the time of entry into the operating room and patients who received successful preoperative cardiopulmonary resuscitation before entering the operating room or patients who had cardiopulmonary arrest on the operating room table after entering the operating room without cardiopulmonary arrest. In the present study, we focused on the circulatory status at the time of entering the operating room because it is economically and emotionally difficult to cease intervention once the patient has entered the operating room, where surgeons, anesthesiologists, nurses, and perfusionists are already present, all necessary materials are packed off and cardiopulmonary bypass have already been primed. Twenty (5.5%) of 362 patients who underwent surgical treatment for acute type A aortic dissection between January 2016 and March 2022 had preoperative cardiopulmonary arrest. To compare the early operative outcomes, the patients were divided into the spontaneous circulation group (n = 14, 70.0%) and the non-spontaneous circulation group (n = 6, 30.0%) based on the presence or absence of spontaneous circulation upon entering the operating room. The primary endpoint was postoperative 30-day mortality. The secondary endpoints included in-hospital complications and persistent neurological disorders. Thirty-day mortality was 65% (n = 13/20) in the entire cohort; 50% (n = 7/14) in the spontaneous circulation group and 100% (n = 6/6) in the non-spontaneous circulation group. The major cardiopulmonary arrest causes were aortic rupture and cardiac tamponade (n = 16; 80.0%), followed by coronary malperfusion (n = 4; 20.0%). Seven patients (50.0%) survived in the spontaneous circulation group, and none survived in the non-spontaneous circulation group (P = .044). Five survivors walked unaided and were discharged home; the remaining two were comatose and paraplegic. The outcomes were extremely poor in patients with acute type A aortic dissection who had preoperative cardiopulmonary arrest and received ongoing cardiopulmonary resuscitation at entry into the operating room. Therefore, surgical treatment might be contraindicated in such patients.

Using a novel ambulatory monitoring system to support patient safety on an acute infectious disease ward during an unfolding pandemic.

To gain staff feedback on the implementation and impact of a novel ambulatory monitoring system to support coronavirus patient management on an isolation ward. Qualitative service evaluation. Semi-structured interviews were conducted with 15 multidisciplinary isolation ward staff in the United Kingdom between July 2020 and May 2021. Interviews were audio-recorded, transcribed and analysed using thematic analysis. Adopting Innovation to Assist Patient Safety was identified as the overriding theme. Three interlinked sub-themes represent facets of how the system supported patient safety. Patient Selection was developed throughout the pandemic, as clinical staff became more confident in choosing which patients would benefit most. Trust In the System described how nurses coped with discrepancies between the ambulatory system and ward observation machines. Finally, Resource Management examined how, once trust was built, staff perceived the ambulatory system assisted with caseload management. This supported efficient personal protective equipment resource use by reducing the number of isolation room entries. Despite these reported benefits, face-to-face contact was still highly valued, despite the risk of coronavirus exposure. Hospital wards should consider using ambulatory monitoring systems to support caseload management and patient safety. Patients in isolation rooms or at high risk of deterioration may particularly benefit from this additional monitoring. However, these systems should be seen as an adjunct to nursing care, not a replacement. Nurses valued ambulatory monitoring as a means of ensuring the safety of patients at risk of deterioration and prioritizing their workload. The findings of this research will be useful to all those developing or considering implementation of ambulatory monitoring systems in hospital wards. This manuscript follows the Consolidated criteria for Reporting Qualitative Research (COREQ) guidelines with inclusion of relevant SQUIRE guidelines for reporting quality improvement. No Patient or Public Contribution.

Promoting a Sleep-friendly Environment by Minimizing Overnight Room Entries

Introduction: Despite its importance in illness recovery, the sleep of hospitalized children is frequently interrupted. This quality improvement intervention aimed to reduce overnight room entries by minimizing unnecessary interventions. Methods: This study occurred at a university-affiliated children’s hospital on the hospital medicine services from March 26, 2021, to April 14, 2022. The intervention included order set changes and the implementation of a rounding checklist designed to address factors most closely associated with sleep disruption and overnight room entries. The outcome measure was overnight (10 pm to 6 am) room entries, counted using room entry sensors. Process measures reflected the intervention targets (overnight vital sign orders, medication administration, and intravenous fluid use). The method of analysis was statistical process control charting. Results: After identifying special cause variation, the average number of overnight room entries decreased from 8.1 to 6.8, a 16% decrease. This decrease corresponded with the implementation of a rounding checklist. However, there continued to be variability in average room entries, suggesting a process lacking ongoing stability. During this period, avoidance of overnight medications and intravenous fluid increased by 28% and 17%, respectively. Conclusions: Implementing a rounding checklist to a broad patient population decreased overnight room entries. However, future work is needed to better understand the factors associated with sustaining such an improvement.

Direct Gloving vs Hand Hygiene Before Donning Gloves in Adherence to Hospital Infection Control Practices

Current guidelines require hand hygiene before donning nonsterile gloves, but evidence to support this requirement is lacking. To evaluate the effectiveness of a direct-gloving policy on adherence to infection prevention practices in a hospital setting. This mixed-method, multicenter, cluster randomized clinical trial was conducted at 4 academic centers in Baltimore, Maryland, or Iowa City, Iowa, from January 1, 2016, to November 30, 2017. Data analysis was completed April 25, 2019. Participants were 3790 health care personnel (HCP) across 13 hospital units. Hospital units were randomly assigned to direct gloving, with hand hygiene not required before donning gloves (intervention), or to usual care (hand hygiene before donning nonsterile gloves). The primary outcome was adherence to the expected practice at room entry and exit. A random sample of HCPs' gloved hands were imprinted on agar plates at entry to contact precautions rooms. The intention-to-treat approach was followed, and all analyses were conducted at the level of the participating unit. Primary and secondary outcomes between treatment groups were assessed using generalized estimating equations with an unstructured working correlation matrix to adjust for clustering; multivariate analysis using generalized estimating equations was conducted to adjust for covariates, including baseline adherence. In total, 13 hospital units participated in the trial, and 3790 HCP were observed. Adherence to expected practice was greater in the 6 units with the direct-gloving intervention than in the 7 usual care units (1297 of 1491 [87%] vs 954 of 2299 [41%]; P < .001) even when controlling for baseline hand hygiene rates, unit type, and universal gloving policies (risk ratio [RR], 1.76; 95% CI, 1.58-1.97). Glove use on entry to contact precautions rooms was also higher in the direct-gloving units (1297 of 1491 [87%] vs 1530 of 2299 [67%]; P = .008. The intervention had no effect on hand hygiene adherence measured at entry to non-contact precautions rooms (951 of 1315 [72%] for usual care vs 1111 of 1688 [66%] for direct gloving; RR, 1.00 [95% CI, 0.91-1.10]) or at room exit (1587 of 1897 [84%] for usual care vs 1525 of 1785 [85%] for direct gloving; RR, 0.98 [95% CI, 0.91-1.07]). The intervention was associated with increased total bacteria colony counts (adjusted incidence RR, 7.13; 95% CI, 3.95-12.85) and greater detection of pathogenic bacteria (adjusted incidence RR, 10.18; 95% CI, 2.13-44.94) on gloves in the emergency department and reduced colony counts in pediatrics units (adjusted incidence RR, 0.34; 95% CI, 0.19-0.63), with no change in either total colony count (RR, 0.87 [95% CI, 0.60 to 1.25] for adult intensive care unit; RR, 0.59 [95% CI, 0.31-1.10] for hemodialysis unit) or presence of pathogenic bacteria (RR, 0.93 [95% CI, 0.40-2.14] for adult intensive care unit; RR, 0.55 [95% CI, 0.15-2.04] for hemodialysis unit) in the other units. Current guidelines require hand hygiene before donning nonsterile gloves, but evidence to support this requirement is lacking. The findings from this cluster randomized clinical trial indicate that a direct-gloving strategy without prior hand hygiene should be considered by health care facilities. ClinicalTrials.gov Identifier: NCT03119389.

Sleep quantity and quality of critically ill children perceived by caregivers and bedside nursing staff: a pilot study.

Sleep is crucial for healing but often impaired in the pediatric intensive care unit due to environmental disruptions. Caregivers and bedside nursing staff are often most aware of these factors and the impact on patient sleep, but studies have not yet compared their perceptions. Caregivers and bedside nursing staff of pediatric patients staying a second night in the pediatric intensive care unit were asked to complete a survey regarding environmental factors (ie, temperature, light, sound, nursing staff room entries), sleep quality, and sleep quantity (ie, sleep duration, number of naps) of the pediatric patient. Caregivers were asked similar questions about their child's sleep at home. The caregivers and nursing staff of 31 pediatric patients participated in this pilot study. There was no significant difference between caregiver and nursing staff ratings of sleep quality, sleep duration, number of naps, room temperature, sound, or light (P > .05 for all). Nursing staff did report significantly more room entries than caregivers (P = .01). Compared to sleep at home, caregivers reported sleep in the hospital to be of lower quality (P = .009) with more frequent room entries (P = .01). Caregivers rate their child's sleep in the pediatric intensive care unit as lower quality than sleep at home. Caregivers and bedside nursing staff largely agree about pediatric patient sleep quality and quantity as well as environmental factors. This agreement may facilitate further research and interventions at improving sleep in the pediatric intensive care unit. Witte MA, Lloyd RM, McGree M, Kawai Y. Sleep quantity and quality of critically ill children perceived by caregivers and bedside nursing staff: a pilot study. J Clin Sleep Med. 2023;19(12):2027-2033.

Assessment of Temporary Radioactivation for Tissue Expanders in Breast Radiation Therapy: Preliminary Study

Background: As breast tissue expanders consist of metallic materials in the needle guard and ferromagnetic injection port, irradiation can produce radioactivation.Materials and Methods: A CPX4 (Mentor Worldwide LLD) breast tissue expander was exposed using the Versa HD (Elekta) linear accelerator. Two photon energies of 6 and 10 MV-flattening filter free (FFF) beams with 5,000 monitor units (MU) were irradiated to identify the types of radiation. Furthermore, 300 MU with 10 MV-FFF beam was exposed to the CPX4 breast tissue expander by varying the machine dose rates (MDRs) 600, 1,200, and 2,200 MU/ min. To assess the instantaneous dose rates (IDRs) solely from the CPX4, a tissue expander was placed outside the treatment room after beam irradiation, and a portable radioisotope identification device was used to identify the types of radiation and measure IDR.Results and Discussion: After 5,000 MU delivery to the CPX4 breast tissue expander, the energy spectrum whose peak energy of 511 keV was found with 10 MV-FFF, while there was no resultant one with 6 MV-FFF. The time of each measurement was 1 minute, and the mean IDRs from the 10 MV-FFF were 0.407, 0.231, and 0.180 μSv/hr for the three successive measurements. Following 10 MV-FFF beam irradiation with 300 MU indicated around the background level from the first measurement regardless of MDRs.Conclusion: As each institute room entry time protocol varies according to the working hours and occupational doses, we suggest an addition of 1 minute from the institutes’ own room entry time protocol in patients with CPX4 tissue expander and the case of radiotherapy vaults equipped with a maximum energy of 10 MV photon beams.

BMI Had a Negative Effect on Decision-to-Incision Times for Urgent Cesarean Deliveries [ID: 1377147

INTRODUCTION: Greater maternal body mass index (BMI) is associated with worse maternal and fetal outcomes. Intrapartum care of patients may be more difficult with higher BMIs. We studied the effect of BMI on decision-to-incision times less than 30 minutes for urgent cesarean sections. METHODS: After IRB approval, a retrospective chart review of 186 consecutive urgent cesarean deliveries during 2020 at an academic medical center were examined. Data were abstracted from patient and neonate charts. Statistical analysis was performed using χ2, t test, and Pearson’s r test. RESULTS: Seventy-one percent of patients with BMI greater than 30 had decision-to-incision times of more than 30 minutes, compared to 46% with BMI less than 30 (P=.03). The mean time from decision-to-incision with BMI greater than 30 was 44 minutes, and 36 minutes with BMI less than 30 (P=.005). When BMI was greater than 40, the mean time was 50 minutes (P=.03). 16% of patients with BMI greater than 30 had decision-to-incision times of more than 60 minutes, compared to 2% with BMI less than 30 (P=.007). BMIs greater than 30 had longer decision-to-operating room (OR) entry (22 versus 17 minutes, P=.02) and OR entry-to-incision times (22 versus 19 minutes, P=.053). Body mass indexes of greater than 40 had both longer decision-to-OR entry (24 versus 19 minutes) and OR entry-to-incision times (25 versus 19 minutes, P=.005). Mothers with BMI greater than 50 had the longest times from OR entry-to-incision and had babies most likely to go to the neonatal intensive care unit (NICU) (50% versus 16%). CONCLUSION: Greater maternal BMIs had longer times for urgent cesarean sections for decision to incision, decision to OR entry, and OR entry to incision. There was a lengthening of decision-to-incision times with increasing BMI. The highest maternal BMIs were most likely to result in NICU admissions. Decision-to-incision time of greater than 30 minutes did not affect umbilical cord arterial pH or NICU admission.

A Quantitative Analysis of Smartphone-Based Endoscopy and Video Tower Endoscopy.

Examine the differences between traditional tower-based endoscopy (TBE) and smartphone-based endoscopy (SBE) using objective measures of cost, setup time, and image quality. Cost analysis study and randomized single-blinded prospective trial was performed at a tertiary academic health center. Twenty-three healthcare providers, 2 PA-C, 9 residents, 2 fellows, 10 attendings varying in practice from 1 to 27 years were a part of the study. Actual cost analysis was used for purchase of the Karl Storz video tower system and the Save My Scope smartphone-based endoscopy system for cost analysis. For setup time, providers entered a room and were randomized to set up either an SBE or TBE system and timed from room entry to a visible on-screen image. A crossover was then performed so all providers performed both setups. For image discernment, standardized photos of a modified Snellen's test were sent via text message to providers who were blinded as to which photo represented which system. Practitioners were randomized as to which photo to receive first. Cost savings was 95.8% ($39,917 USD) per system. Setup time for the smartphone system was 46.7 seconds less than video tower system on average (61.5 vs 23.5 seconds; P < .001, 95% CI: 30.3-63.1 seconds). Level of visual discernment was slightly better for SBE over TBE, with reviewers able to identify Snellen test letters at a size of 4.2 mm with SBE versus 5.9 mm with TBE (P < .001). Smartphone-based endoscopy was found to be cheaper, quicker to set up, and to have marginally better image quality when transmitted via messaging than tower-based endoscopy, although the clinical significance of these visual differences are unknown. If appropriate for their needs, clinicians should consider smartphone-based endoscopy as a viable option for viewing and collaborating on endoscopic images from a fiberoptic endoscope.

Interventions Associated With Increased Nighttime Room Entries in General Medical Patients

Sleep is vital to recovery from illness, yet it is frequently interrupted in the hospital setting. Existing literature relying on survey data identifies vitals, medications, and pulse oximetry as major disruptors to sleep. This study was designed to assess the degree to which these candidate sleep disruptors are associated with objective room entries. Room entry sensors were placed on doors to 18 rooms on acute medical-surgical units at a tertiary academic center. The number of entries into rooms between 10 Pm and 6 Am were logged on patients admitted to hospital medicine services from March 2021 through February 2022. Medical records were reviewed to extract orders for vital sign frequency, medication timing, continuous pulse oximetry, and intravenous fluid use overnight. Negative binomial regression was used to evaluate associations. Room entry data were collected for 112 admissions and 192 patient-nights. There was an average of 7.8 room entries per patient-night. After adjustments for the other variables and for patients represented in multiple nights, vitals ordered every 4 hours were associated with a 1.3-fold increase in room entries (95% confidence interval 1.0-1.5; P = .013), as were medications scheduled during overnight hours (1.3; 95% confidence interval 1.0-1.5; P = .016). There was no association between room entries and continuous pulse oximetry use. After adjustment, there was also no association with administration of intravenous fluids. Vitals ordered every 4 hours and medications scheduled during sleep hours are independently associated with increased room entries and may be reasonable initial targets for quality improvement interventions designed to minimize nighttime disruptions.

1213. The Effect of a Prospective Intervention Program with Automated Monitoring on Hand Hygiene Performance in Long-term and Acute Care Units at a Veteran Affairs Medical Center

Abstract Background There is emerging evidence that implementation of an automated hand hygiene monitoring system (AHHMS) must be part of a multimodal hand hygiene (HH) program that includes complementary strategies. There are few published studies describing in detail the intervention strategies used with an AHHMS. Methods An AHHMS that provides group HH performance rates (100 x HH product dispenses divided by the number of room entries plus exits) was implemented on two Acute Care (AC) units and six long-term care (LTC) units at a Veterans Affairs Medical Center from March 2021 through April 2022. After a 4-week baseline period and 2.5-week washout period, the 52-week intervention period included many components, such as weekly huddles, unit nurse manager engagement, vendor provided clinician-based training and feedback, leadership support, unit recognition, signage and development of a new slogan to remind colleagues to perform HH. Statistical analysis was performed with a Poisson general additive mixed model. Results During the 4-week baseline period, the median HH performance rate was 18.6 (95% CI: [16.5, 21.0]) for all 8 units. During the intervention period, the median HH rate increased to 21.6 [19.1, 24.4], and during the last 4 weeks of the intervention period (exactly 1 year after baseline), the 8 units exhibited a median HH rate of 25.1 [22.2, 28.4], (p &amp;lt; 0.0001) [Figure 1]. The median HH rate increased from 17.5 to 20.0 (p &amp;lt; 0.0001) in LTC units and from 22.9 to 27.2 (p &amp;lt; 0.0001) in AC units. The intervention increased the use of hand sanitizer from 57.5% during baseline to 65.1% (p &amp;lt; 0.0001). The increase in HH rates was due to HH events increasing from 88,758 dispenses during the baseline to 123,722 dispenses during the last 4 weeks of the intervention. Direct observation results during the same periods showed HH compliance ranging from 61-86%. Figure 1- Monthly Hand Hygiene Performance Rates for all Units The green curve shows the change in the median HH rate during the intervention period compared to the baseline and washout periods, with vertical bars showing 95% confidence intervals for the monthly HH rate. Conclusion The intervention increased hand sanitizer usage and HH performance rates for all units. AC units were consistently better than LTC units, which have more visitors and more mobile veterans. Further HH improvement will rely on continued implementation of complementary strategies and long-term monitoring. Disclosures James W. Arbogast, PhD, GOJO Industries, Inc.: employee Pamela Wagner, RN MSN CPPS, GOJO Industries, Inc: Employee of GOJO Gregory A. Robbins, BS, GOJO Industries, Inc.: Current employee of GOJO Industries, Inc. Albert E. Parker, PhD, GOJO Industries: Advisor/Consultant John M. Boyce, MD, Diversey: Advisor/Consultant|Diversey: Expert Testimony|Diversey: Travel support|GOJO Industries: Advisor/Consultant|GOJO Industries: Expert Testimony|GOJO Industries: Travel support|Sodexo Healthcare: Advisor/Consultant.

8 Hybrid intracavitary and interstitial brachytherapy for cervical cancer in the outpatient setting

Image-guided hybrid intracavitary and interstitial brachytherapy (HBT) for the treatment of locally advanced cervical cancer may improve outcomes compared to intracavitary brachytherapy alone. Pain control is usually achieved with general anesthesia (GA), which increases both treatment duration and the risk of complications with each treatment. Here we detail the results of our institution's protocol with CT-guided interstitial needle placement, utilizing minimal sedation. A single-institutional database of patients who underwent HBT for cervical cancer from June 2018 to May 2020 was queried. Patterns of anesthesia usage, step-by-step procedural times, medication usage, and treatment-related complications were reviewed. All patients had a Smit sleeve placed in the OR under GA days before their first HBT treatment. Prior to HBT, patients received minimal sedation, composed of oral lorazepam and hydrocodone/acetaminophen. Tandem and ovoids were inserted and interstitial needles were placed under CT guidance. The patients were moved from the CT table to a surgical bed, and then to the radiation vault for treatment delivery. The applicator was then removed and vaginal packing was inserted if any bleeding occurred. A total of 244 implants were placed in 63 patients under minimal sedation. 61 patients (96.8%) tolerated the procedure, 2 (3.2%) required epidural anesthesia, and 0 required transition to GA. The median time for the entire procedure (CT room entry to exit of the HDR room) was 70.0 mins (mean 70.3 mins, range 54–100 mins). The median time for the interstitial needle insertion portion was 9.0 mins (mean 9.8 mins, range 4–24 mins). Bleeding occurred in 54 (22.1%) implants, which resolved after 3 minutes of vaginal packing (mean 3.33 mins, range 1–8 mins). Our outpatient HBT protocol was efficient and well-tolerated, with reasonable bleeding rates which were minimal and quickly resolved. HBT with minimal sedation was achievable at a high percentage (96.8%). The performance of HBT without GA may reduce treatment time, costs, and anesthesia-related adverse effects. Treatment with minimal sedation has the potential to enable more universal use of HBT, improve brachytherapy dosimetry, and enhance patient outcomes. Further investigation is warranted.

Variability of the times remaining in surgical cases and the importance of knowing when closure has started

BackgroundWhen a patient enters the operating room, the projected time to room exit is the time of room entry plus the estimated case duration. Subsequent estimates are provided based on a probability distribution for time remaining in the case, conditional on the interval from room entry. There have been several recent studies investigating and showing good accuracy of different suitable methods. However, it is unknown whether and why these methods are useful compared with the historical data and original surgeon/ scheduler estimate known before the case started. We hypothesized that knowing when closure has started, patient has been extubated, etc., gives substantive incremental information. MethodsOur retrospective cohort study included all 23,343 surgical cases at a large hospital over 4.2 years wherein each case's surgeon scheduled the procedure ≥29 times. The sample size was n = 244 combinations of scheduled Current Procedural Terminology code and surgeon. ResultsVariability in the logarithmic scale (i.e., proportional variability in the time scale) increased progressively as cases advanced. Specifically, the 90th percentiles of times to operating room exit were ≈40% longer than 50th percentiles (medians) at the start of cases versus 142% longer at the time of the start of closure. These ratios were less at starts of cases than at closures for 99.2% of n = 244 combinations (P <0.0001). The 5th percentiles were ≈32% briefer than 50th percentiles at the start of cases versus 85% briefer at the time of the start of closure. These ratios were less at starts of cases than at closures for 100% of combinations (P <0.0001). ConclusionsThere is considerable information value in knowing when key milestones have occurred near the end of cases that managers can use for quality decision-making (e.g., when closure has started). Organizations should document these milestones in real-time.

Reconsidering the Nil per Os Guidelines for Cardiac Surgery

Introduction: With wider acceptance of enhanced recovery after surgery protocols and preoperative glucose-rich supplements for patients undergoing cardiac surgery, the current nil per os (NPO) guidelines should be re-evaluated. We investigated postoperative outcomes after coronary artery bypass grafting operation by fasting time. METHODS: All coronary artery bypass grafting cases performed at our institution from January 2015 to August 2020 were reviewed. Patients with diabetes mellitus, ejection fraction less than 40, or urgent/emergent operation were excluded. The final population was grouped according to NPO times (less than 8 hours or 8 hours and greater), derived from the operating room entry time and the institutional guideline of NPO after midnight. The primary outcome was postoperative length of stay (LOS); secondary outcomes included ICU LOS and incidence of delayed extubation. Continuous and categorical variables were compared using the Mann-Whitney and Fisher’s exact statistical tests, respectively. RESULTS: Among 2681 coronary artery bypass grafting patients, we excluded 1,410 with diabetes, 217 with ejection fraction less than 40, and 296 urgent/emergent cases. In our study population of 763 patients, 192 (25.2%) were NPO less than 8 hours, and 571 (74.8%) were NPO 8 hours and greater. Postoperative LOS did not differ between patients with NPO less than 8 hours (5 [4 to 6] days) vs NPO 8 hours and greater (5 [4 to 7] days; p = 0.196). However, patients with NPO less than 8 hours experienced longer ICU LOS (21.9 [18.7 to 28.6] vs 18.8 [14.5 to 25.8] hours; p < 0.001) despite less frequent delayed extubation (2 [1.04%] vs 24 [4.20%]; p = 0.023). CONCLUSION: Given comparable postoperative recovery and rarer delayed extubation in patients with shorter NPO times—coupled with the known benefits on patient comfort, nutrition, and mental status—NPO after midnight should be reconsidered before cardiac surgery. Future studies should compare the rate of pulmonary aspiration for safe recommendation of such a guideline change.

Redistributional Hypothermia Prevention by Prewarming with Forced-Air: Exploratory, Open, Randomized, Clinical Trial of Efficacy.

Avoiding redistributional hypothermia that decreases core temperature by 0.5-1.5°C within the 1st hour of surgery is difficult. The efficacy of prewarming using a forced-air warming (FAW) device with a lower-body blanket on redistribution hypothermia during epidural procedures have not been investigated. After ethics approval, 113 patients undergoing laparoscopic surgery under general anesthesia combined with epidural anesthesia were enrolled. Intervention (prewarming) group patients who were warmed from operating room entry, including during epidural anesthesia, was compared with the control group that was warmed from just before surgery started. In total, 104 patients (52, control; 52, prewarming) were analyzed. In the prewarming group, compared to the control group, the core temperature 20 minutes after anesthesia induction (36.9 ± 0.4 vs. 37.1 ± 0.4°C, p < 0.02) was significantly higher. The core temperature was higher in the prewarming group than in the control group until 3 hours after the surgery. In the prewarming group, compared to the control group, the core temperature-time integral below baseline till 180 minutes after surgery start (65.1 ± 64.0 vs. 8.1 ± 18.6°C/min, p < 0.0001) or 30 minutes after anesthesia induction (5.3 ± 6.2 vs. 2.0 ± 4.7°C/min, p < 0.0001) were significantly smaller. Postoperative shivering was comparable between the groups. Prewarming during epidural catheter insertion with a FAW device could safely prevent a core temperature decrease induced by redistribution or heat loss without additional preparation, effort, space, or time requirements.

Bacterial Contamination of Floors in a Hematology/Oncology Unit in a Children's Hospital

Background Healthcare associated infections (HAIs) continue to be prevalent in hospitals, including pediatric Hematology/Oncology (HO) Units. Contamination of floors in HO units may pose a unique problem for the immunocompromised patients treated there. The objective of this study was to determine whether Clostridium difficile (Cdiff) or Methicillin Resistant Staphylococcus aureus (MRSA) were present on floors in a Hematology/Oncology unit of a Children's Hospital, potentially serving as a reservoir for these pathogens. Methods Two locations in four rooms (floor at room entry and room bathroom floor), and two floor locations (main sink and the adjoining hallway) were swabbed weekly for seven weeks with sterile transport swabs. Swabs were used to inoculate Hardy CHROM MRSA agar plates (to detect MRSA), and to inoculate Hardy Cdiff Banana Broth tubes (to detect Cdiff). Incubation was at 37°C for 48 hours. Data was analyzed with SPSS 26 and used descriptive statistics and odds-ratios to compare contamination by site. Results Results of the cultures indicated the following: the percent positive swabs for the room sites for Cdiff were 29.2% and 25.0% (floor by door, and bathroom), and for the hallways were 19.0% and 33.3% (by the main sink, and main door). For MRSA presence the percent positive for the room sites were 42.3% and 26.9% (floor by door, and bathroom), and for the hallways 42.9% and 33.3% (by the main sink, and main door). Odds-ratios were highest (1.99) for room entry doors. Conclusions The data presented suggests that Cdiff is fairly uniformly distributed throughout the floors of the rooms, possibly serving as the source of this contamination in the hallway. MRSA in the rooms appears to represent a possible reservoir for this pathogen, leading to contamination of the hallway floors. Our data suggests that the floors in HemOnc patient rooms present a potential hazard for HAIs in these patients. Healthcare associated infections (HAIs) continue to be prevalent in hospitals, including pediatric Hematology/Oncology (HO) Units. Contamination of floors in HO units may pose a unique problem for the immunocompromised patients treated there. The objective of this study was to determine whether Clostridium difficile (Cdiff) or Methicillin Resistant Staphylococcus aureus (MRSA) were present on floors in a Hematology/Oncology unit of a Children's Hospital, potentially serving as a reservoir for these pathogens. Two locations in four rooms (floor at room entry and room bathroom floor), and two floor locations (main sink and the adjoining hallway) were swabbed weekly for seven weeks with sterile transport swabs. Swabs were used to inoculate Hardy CHROM MRSA agar plates (to detect MRSA), and to inoculate Hardy Cdiff Banana Broth tubes (to detect Cdiff). Incubation was at 37°C for 48 hours. Data was analyzed with SPSS 26 and used descriptive statistics and odds-ratios to compare contamination by site. Results of the cultures indicated the following: the percent positive swabs for the room sites for Cdiff were 29.2% and 25.0% (floor by door, and bathroom), and for the hallways were 19.0% and 33.3% (by the main sink, and main door). For MRSA presence the percent positive for the room sites were 42.3% and 26.9% (floor by door, and bathroom), and for the hallways 42.9% and 33.3% (by the main sink, and main door). Odds-ratios were highest (1.99) for room entry doors. The data presented suggests that Cdiff is fairly uniformly distributed throughout the floors of the rooms, possibly serving as the source of this contamination in the hallway. MRSA in the rooms appears to represent a possible reservoir for this pathogen, leading to contamination of the hallway floors. Our data suggests that the floors in HemOnc patient rooms present a potential hazard for HAIs in these patients.