Surgical Unit Research Articles

Interprofessional Approach to Reducing Central Line–Associated Bloodstream Infections in a Cardiac Surgical Intensive Care Unit

Background Central line [catheter]–associated bloodstream infection (CLABSI) is associated with longer stays and increased cost, morbidity, and mortality. Local Problem An academic cardiothoracic intensive care unit had a high CLABSI incidence (standardized infection ratio of 2.3 at baseline). The hospital’s executive leadership team (chief nursing officer, chief medical officer, and chief of quality and performance improvement) directed intensive care unit leaders to reduce the standardized infection ratio. Methods Interprofessional CLABSI reduction efforts were formulated using A3 methods based on the plan-do-check-act cycle. Unit leaders (nurses, physicians, advanced practice providers, and allied health professionals) met every 2 weeks for 2 years to formulate CLABSI reduction efforts. Efficacy of CLABSI reduction was evaluated with the standardized infection ratio. Interventions Quality improvement activities included improved hand hygiene compliance, optimization of central venous catheter insertion, improved chlorhexidine dressing adherence, daily assessment of high-risk catheters for removal, use of an electronic intensive care unit bundle checklist to highlight central venous catheter duration for clinicians, and promotion of a blood culturing stewardship program with guidance on when to obtain blood samples for culture. Results Interprofessional CLABSI reduction efforts reduced the standardized infection ratio from 2.3 to 0.8 over 3 years. The standardized utilization ratio, reflecting observed to expected central venous catheter days, decreased from 1.0 to 0.89. Conclusion Interprofessional CLABSI reduction efforts can be effective in a cardiac surgical intensive care unit and improve patient safety. Keys to success include teamwork, accountability, acceptance from intensive care unit staff, and support from hospital executive leaders.

Enhancing Disaster surge capacity through reverse triage in Addis Ababa Ethiopia: A retrospective cross-sectional study.

Enhancing Disaster surge capacity through reverse triage in Addis Ababa Ethiopia: A retrospective cross-sectional study.

"First-in-human" totally robotic orthotopic heart transplant.

"First-in-human" totally robotic orthotopic heart transplant.

Short-term outcomes of chest wall resections

Abstract Introduction Chest wall resections (CWRs) pose a unique challenge for a thoracic surgeon by virtue of the complexities involved in maintaining anatomical integrity and functional dynamics of the region. We aimed at studying the outcomes of CWR from the thoracic surgery unit of a comprehensive cancer care centre located in a tier 2 city in India. Methods This is a retrospective study of all CWRs from our centre, between 15 January 2019 to 15 January 2025. Patients were identified from a prospectively maintained surgical database and electronic medical records. Results A total of 12 cases were identified who underwent CWR in the said duration, and the majority were for sarcoma (5/12, 41.6%). Rib resections were needed in 10/12 (83.3%) cases, with the 3rd rib (5/12, 41.6%) being the most commonly resected; and multiple rib resections were needed in 7/12 (58.3%) patients. Mesh repair was used in the majority of patients for reconstruction (10/12, 83.3%). No major perioperative morbidity was observed in any of the patients in the first 30 days of surgery. Conclusion This study provides preliminary evidence for safe CWR being feasible at a low-volume thoracic surgical unit in India.

Tracheostomy care knowledge and practice among nurses: insight from a tertiary hospital in Northern Tanzania

Background: Tracheostomy, a well-established life-saving procedure, is commonly performed worldwide on patients requiring prolonged mechanical ventilation. Adverse events following tracheostomy are not rare and significantly impact patients’ outcomes. Global estimates suggest that inadequate tracheostomy care leads to the death of between 10 and 60% of patients annually. The quality of nursing care after the procedure is crucial in determining patient outcome. From local settings, there is an observed increase in complications and mortality attributed to insufficient knowledge and suboptimal practice of tracheostomy care; however, the current gaps in knowledge and practice have not been systematically documented. This study aims to explore nurses’ level of knowledge and practice of tracheostomy care and its associated factors. Methods: An eight-month analytical cross-sectional study was conducted at Kilimanjaro Christian Medical Centre, where the ear, nose, and throat ward, medical, pediatric, and surgical intensive care units were the specified study units. Data collection tools were structured questionnaires and observation checklists. Descriptive and inferential statistics were utilized in data analysis. Results: Among 52 enrolled nurses, 75% had moderate knowledge, 13.5% had poor knowledge, and 11.5% had good knowledge. 75% of nurses had unsatisfactory practice, and 25% had satisfactory practice. Working units significantly influence nurses’ knowledge level and practice. Conclusions: Knowledge and practice regarding tracheostomy care among nurses is limited. The development of standardized tracheostomy care guidelines, in-service continuous education, and the implementation of a comprehensive tracheostomy care training program are highly recommended to improve proficiency.

ICA Window: A Reliable Landmark for Locating Parapharyngeal ICA via Endoscopic Transoral Medial Pterygomandibular Fold Approach.

One of the primary challenges in surgical procedures involving parapharyngeal space (PPS) lesions is accurately localizing the internal carotid artery (ICA) within the parapharyngeal space. This study aims to investigate the anatomical landmarks of the parapharyngeal internal carotid artery (ppICA) in endoscopic transoral approach surgery. A total of seven fresh frozen cadaveric heads (14 sides) were dissected using the endoscopic transoral medial pterygomandibular fold approach in the anatomical laboratory of the Surgical Treatment Technology Innovation Unit at Nasal Skull Base Tumor in Eye and ENT Hospital, Fudan University. Additionally, a comparative anatomical study was conducted on three cadaveric head specimens using the microscopic preauricular infratemporal approach. Photographic documentation and measurements were taken for adjacent structures of the ppICA, along with specific anatomical structures neighboring the ppICA. To illustrate the method for locating and protecting the ppICA, three cases involving the prestyloid, poststyloid, and retropharyngeal spaces were selected. The stylopharyngeal muscle was located anterolaterally to the ppICA, while the levator veli palatini and longus capitis muscles were situated anterosuperiorly and posteromedially to the ppICA, respectively. The area enclosed by these three muscles was named the "ICA window" in this study. The ppICA was posterior to this window, sealed by the stylopharyngeal fascia. This ICA window was considered a reliable landmark for identification of the ppICA via endoscopic transoral medial pterygomandibular fold approach for PPS surgery. The ICA window, delineated by the stylopharyngeal muscle, tensor veli palatini muscle, longus capitis muscle, vaginal process of the tympanic bone, and the intervening fascial structures, emerges as a reliable anatomical landmark for orienting the ppICA during endoscopic transoral surgery for parapharyngeal space procedures. N/A.

Implementation of High-Flow Oxygen Therapy in a Surgical High-Dependency Unit: A Cohort Study

Implementation of High-Flow Oxygen Therapy in a Surgical High-Dependency Unit: A Cohort Study

Effect of high-quality nursing care on postoperative complications and quality of life for patients undergoing common bile duct exploration

BackgroundComplications following common bile duct exploration for managing gallstones or choledocholithiasis negatively impact patients’ quality of life. Occasionally, high-quality nursing care is necessary to either improve the outcome or to avoid life-threatening consequences.AimThis study aimed to evaluate the effect of high-quality nursing care on postoperative complications and quality of life for patients who underwent common bile duct exploration.Patients and MethodA quasi-experimental research design was utilized. The study was conducted in the Hepatobiliary Surgical unit at Al-Rajhi Liver Hospital and the general surgery department at Assiut University Hospital. A purposive sample of sixty adult patients, whose ages ranged from 20 to 65 years, who underwent common bile duct exploration were included in the study. Patients were randomly divided into two equal groups (study and control) 30 patients for each. Tools: Tool (I): patient’s assessment form, Tool (II): Postoperative complications evaluation record, and Tool (III): Abdominal surgery impact scale.ResultsWound infection and T –Tube problems demonstrated a statistically significant difference between the two groups on follow-up as it occurred in (36.7%, and 26.7%) of the control group compared to (6.7%, and 3.3%) of the study group. Also, there was a significant improvement in total mean scores of QoL among the study group as it increased from 54.4 ± 22.11 on pre-intervention to 77.8 ± 6.15 post (P.value 0.001**).ConclusionHigh-quality nursing care proved to be effective in reducing the incidence of postoperative complications and improving quality of life among the study group compared to the control group. Recommendations: Nevertheless, high-quality nursing care is crucial and should serve as the basis for routine nursing care for patients undergoing common bile duct exploration.

Antimicrobial Stewardship Impact on the Treatment of Intra-abdominal Infections in the Surgical Intensive Care Unit.

Background: Broad-spectrum antibiotic agents are utilized for complicated intra-abdominal infection (cIAI); however, the need for empiric methicillin-resistant Staphylococcus aureus (MRSA) coverage is not clear as the incidence of MRSA cIAI is rare. Patients and Methods: A single-center, retrospective, pre- and post-cohort study of adults admitted to the surgical intensive care unit (SICU) with cIAI between March 1, 2021, to May 1, 2023, was conducted. Historically, the SICU utilized vancomycin for all cIAI; however, in April 2022, the preferred regimen was changed to either piperacillin-tazobactam with vancomycin added for patients with MRSA risk factors or for Enterococcus spp. coverage in cefepime- or levofloxacin-based regimens for penicillin-allergic patients. The primary outcome was number of vancomycin days of therapy (DOT) per 1,000 patient days. Categoric and continuous variables were analyzed with chi-square and Fisher exact tests. Results: A total of 142 SICU encounters were included, 64 in the pre-cohort and 78 in the post-cohort. There was no difference in median vancomycin DOT per 1,000 patient days (14 days [interquartile range or IQR 5-21]; 16 days [IQR 8-17] p = 0.522) between the pre- and post-cohort. There was a significant reduction in the number of patients given vancomycin after the protocol change (90.6%; 76.9%, p = 0.042). A significant increase in piperacillin-tazobactam exposure was also observed (48.4%; 82.1%, p < 0.001) in the post-cohort aligning with our institutional practice change. Conclusions: In critically ill surgical patients with cIAI, the implementation of an antimicrobial stewardship guideline did not reduce vancomycin DOT per 1,000 patient days, however, it did result in a significant reduction in vancomycin exposure.

Higher surgeon volume reduces early failure in first time revision of non-infected total knee arthroplasty: An analysis using data from the United Kingdom National Joint Registry.

Revision total knee replacement (RevKR) is an increasingly common procedure. It is hypothesised that higher surgical volume is linked to lower levels of adverse outcomes. The aim was to estimate the association of surgical volume on patient outcomes following first single-stage RevKR for non-infected indications. This population-based cohort study used data from the United Kingdom National Joint Registry, Hospital Episode Statistics and National Patient Reported Outcome Measures. Patients undergoing procedures between 1 January 2009 and 30 June 2019 were included. The primary outcome measure was re-revision within 2 years; chosen to reflect the quality of the surgical provision. Fixed effect multivariable regression models were used to examine the association between surgeon and surgical unit annual caseload and the risk of adverse outcomes. A total of 8695 patients underwent first time single stage revision for aseptic loosening, instability, or malalignment across 389 surgical units and 1204 surgeons. Following adjustment for age, gender, ASA grade, year of surgery and operation funder, higher surgeon volume was associated with a lower risk of re-revision at 2 years. The risk of re-revision decreased amongst surgeons performing ≥9 annual revisions (OR 0.77, 95% CI 0.62-0.95, p-value = 0.02) compared to those performing <9 annual revisions. Annual surgeon case volume of ≥9 first single-stage RevKR for non-infected indications is independently associated with reductions in early re-revision. This evidence supports the setting of minimum volume targets to improve outcomes for patients. Level III, retrospective cohort study of prospectively collected data.

A comparative analysis of logistic regression (LR) and artificial neural network (ANN) models for predicting antimicrobial resistance in surgical ICU patients: Insights from real-world evidence in India.

BackgroundMachine learning approaches for the prediction of antimicrobial resistance (AMR) are gaining attention but are yet to be commonly applied in practice.ObjectiveThis study aims to predict the AMR in surgical intensive care unit patients using logistic regression (LR) and artificial neural network (ANN) model.MethodsSurgical ICU patients with resistant infections, regardless of the microorganism, were considered cases. Those with susceptible or no infections were considered controls. A total of 104 variables for patient characteristics, disease-related and clinical parameters, and surgical, culture, and prescription details were tested for the prediction of AMR using two methods: LR and ANN. The dataset was divided into a training (n = 3179) and a test (n = 1363) set. The outcome was considered a binary outcome: resistant infection and sensitive infection. Model evaluation metrics were an area under the receiver operating characteristic curve (AUROC), sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Predictive analysis was performed by using R software.ResultsOut of 8010 ICU patients, 4542 patients underwent surgery. Out of these surgical ICU patients, 36.90% were cases and 63.09% were controls. Both models performed similarly concerning sensitivity (ANN 86.6%; LR 86%), while improvement was found with respect to accuracy (ANN 88.2%; LR 86%), specificity (ANN 91.2%; LR 86%), AUROC (ANN 94%; LR 93%), and NPV (ANN 82.8%; LR 91%).ConclusionsThe ANN model has more predicting performance than the LR model to predict AMR in surgical ICU patients. These prediction algorithms may assist clinical decisions to aid the prevention of AMR.

COMPARISON OF FISTULECTOMY VS LIFT PROCEDURE FOR ANAL FISTULA MANAGEMENT

Background: Although anal fistulae are benign, the condition can still negatively influence a patient’s quality of life. Despite its long history and prevalence, anal fistula management remains one of the most challenging and controversial topics in colorectal surgery today. This study aimed to compare the management of anal fistula with LIFT procedure and Fistulectomy. Methodology: A RCT was conducted in a single surgical unit of a tertiary teaching medical college hospital in Karachi from September 2010 through April 2016. A total of 1188 patients with anal fistula were included out of taken sample, Group A (LIFT): 610 patients (70.5% male, 29.5% female); Group B (Fistulectomy): 578 patients (64.9% male, 36.1% female). All patients were followed up for a total duration of twelve weeks during the postoperative period. Patients were followed up at weekly intervals for the initial 6 weeks and at 4-week intervals for another 6 months, and then 6 months for another 5 years. During each follow-up visit, the patient was assessed for postoperative pain, wound complication, and anal incontinence. Results: The mean age of the patients in group A was 41.11 ±7.49 while the mean age of the patients in group B was 45.03 ±7.07 (p-value 0.005). There were 70.5% males and 29.5% Females in group A, whereas 64.9% males and 36.1% female patients were in group B. Comparison of mean pain score showed statistically significant difference in group A and B (p-value &lt;0.05) with higher frequency of anal incontinence was in group B as compared to group A 1 (p-value 0.352). Conclusion: LIFT is an inexpensive and safe procedure that provided primary healing of anal fistula better than fistulectomy.

Thirty-day mortality risk prediction for geriatric patients undergoing non-cardiac surgery in the surgical intensive care unit

BackgroundThe prediction of mortality for elderly patients undergoing non-cardiac surgeries is a vital research area, as accurate risk assessment can help surgeons make better clinical decisions during the perioperative period. This study aims to build a mortality risk prediction model for surgical intensive care unit (ICU) patients aged 65 and older undergoing non-cardiac surgery.MethodsData was obtained from 1960 patients who underwent non-cardiac surgery from the medical information mart for intensive care IV (MIMIC-IV) database. The least absolute shrinkage selection operator (LASSO) regularization algorithm and the extreme gradient boosting (XGBoost) for feature importance evaluation were used to screen important predictors. Five predictive models were established: categorical boosting (CatBoost), logistic regression (LR), decision tree (DT), random forest (RF), and support vector machine (SVM). External validation was performed utilizing data from 153 patients in the MIMIC-III database. Finally, shapley additive explanations (SHAP) was utilized for a personalized analysis of the models.ResultsAmong the five predictive models developed in this study, the CatBoost model demonstrated superior overall performance in both the test data set (AUC = 0.96, F1 = 0.90) and the external validation data set (AUC = 0.98, F1 = 0.91). The decision curve analysis showed that the model offers a beneficial net benefit. The CatBoost model showed significant enhancements in classification accuracy when compared to the conventional revised cardiac risk index (RCRI) score. SHAP analysis revealed that anion gap, age, prothrombin time (PT), and weight were the four key variables influencing the predictive performance of the CatBoost model.ConclusionsThis study demonstrates the potential of machine learning methods for early prediction of outcomes in critically ill elderly patients undergoing non-cardiac surgery. A web-based application was developed, which could serve as an effective tool for clinicians in their risk assessment and clinical decision-making processes.Graphical abstract

Exploring nurses’ experiences and challenges in managing diabetic amputations: a qualitative study

BackgroundAmputation resulting from diabetes remains a significant public health challenge in Ghana, often culminating in morbidity and mortality. Nurses are the frontline health workers that often manage these patients.AimThis qualitative study explores nurses’ experiences and challenges in the care and management of patients undergone amputation due to diabetic complications at the Sunyani Teaching Hospital in Ghana.MethodsUsing a phenomenological approach, semistructured interviews were conducted with nurses working in diabetic and surgical units across the Sunyani Teaching Hospital (STH) between April 2024 and July 2024.ResultsThis study showed that nurses face emotional burdens, resource constraints, patient‒nurse relationships, and coping mechanisms in the bid to care for patient with diabetic related amputation.ConclusionThe findings provide invaluable insights into the challenges faced by nurses and suggest strategies for improving care delivery and outcomes for individuals with diabetic amputation.Clinical trial numberNot applicable.

Use of a Risk Assessment Model for Venous Thromboembolism Is Associated with Decreased Prophylaxis.

Venous thromboembolism (VTE) prophylaxis is often overprescribed to patients at low risk for VTE. Whether risk assessment models (RAMs) reduce prescribing to low-risk patients is unknown. We incorporated a validated RAM into admission order sets to help physicians determine risk of VTE. To quantify RAM use, determine its association with prophylaxis, and identify patient factors associated with concordance between calculated VTE risk and prophylaxis use. We hypothesized that use of the RAM would be associated with less prophylaxis. Cross-sectional study. We excluded surgical, COVID, and intensive care unit patients, and patients with contraindication to prophylaxis or already on anticoagulation. Medical inpatients aged ≥18 years admitted to 10 US hospitals from December 2020 to March 2023. Physician RAM use. Physician prophylaxis prescription and patient characteristics. Among 131,441 patient encounters, RAM use varied across hospitals from 54 to 99%. Overall, physician ordering was concordant with the RAM's recommendation for 68% of patients. Prophylaxis prescription was less common when the RAM was used than when it was not (44% vs. 73%, p < 0.001). When calculated risk was high (i.e., >0.75%), 96% of patients had prophylaxis prescribed versus 37% when risk was low. Across hospitals, prophylaxis prescription rates varied more for low-risk (21 to 77%) than for high-risk patients (87 to 98%). Among low-risk patients, prophylaxis was associated with male sex, older age, reduced mobility, and history of DVT, stroke, heart or respiratory failure, or active cancer. Use of the RAM was associated with reduced prophylaxis prescribing, but many low-risk patients still received prophylaxis, especially if they had a risk factor for VTE. Physicians appear to agree with high-risk assessments but are less comfortable not prescribing prophylaxis to patients at low risk.

Fostering eco-friendly excellence: exploring the relationship between green human resource practices and organizational environmental performance as perceived by nurses: a cross-sectional study

AimThis study investigates the association between green human resource practices and organizational environmental performance among nurses at Alexandria Main University Hospital.DesignA cross-sectional descriptive design following STROBE guidelines examined the relationship between green human resource practices and organizational environmental performance among nurses.Methods and toolsStaff nurses employed in all inpatient medical, surgical, and critical care units at Alexandria Main University Hospital (n = 745) comprised the participants, representing all target demographics. The nurses filled out the Organizational Environmental Performance Scale and the Green Human Resources Practices Questionnaire. Age, gender, education, and nursing experience were among the demographic details gathered. The data collection period was three months, from February 1st, 2023, to May 1st, 2023. Every query from the nurses was addressed, and justifications were provided. The data was analyzed using statistical techniques such as stepwise regression, ANOVA, t-tests, and Pearson correlation.Results60.7% of the studied nurses perceived low Green Human Resources Practices (63.27 ± 8.14). Furthermore, the majority of the nurses who participated in the study (90.1%) believe that environmental performance is at a moderate level, with a mean score of 73.86 ± 15.54. According to linear regression, the Green Human Resources Practices of the nurses under study can account for about 17.5% of the explained variance of their perceived environmental performance; this is a significant model (F = 157.939 & p < 0.001).ConclusionThe study highlights the importance of the perceived adoption of Green Human Resources Practices in supporting environmental performance. Addressing demographic factors and fostering a supportive work environment is crucial for optimizing organizational environmental performance.Nursing implicationsInsights from this study can enlighten battered interventions and policy pronouncements to augment nursing practice, organizational growth, and healthcare outcomes in Egypt. Green HR practices have consequences for nursing, such as enabling nurses to spearhead sustainability projects, encouraging environmentally friendly patient care techniques, and raising employee involvement through incentives and training. Nurses can make a substantial contribution to better environmental performance in healthcare settings by incorporating these practices. In the end, this promotes a sustainable culture that is advantageous to patients and the environment.Clinical trial numberNot applicable.

Hospital outbreak of NDM-producing Klebsiella pneumoniae in a surgical intensive care unit: Sink traps as the causing source of epidemic strain resurgence.

Hospital outbreak of NDM-producing Klebsiella pneumoniae in a surgical intensive care unit: Sink traps as the causing source of epidemic strain resurgence.

The impact of implementing a strategy on the rate reduction of catheter-associated urinary tract infections (CAUTI) in national health care facilities in Saudi Arabia.

The impact of implementing a strategy on the rate reduction of catheter-associated urinary tract infections (CAUTI) in national health care facilities in Saudi Arabia.

Evaluation of surgical nurses' knowledge and attitudes towards pressure ulcer prevention.

Evaluation of surgical nurses' knowledge and attitudes towards pressure ulcer prevention.

Chronic obstructive pulmonary disease is associated with a higher incidence of acute kidney injury in non-cardiac but not in cardiac surgery ICU-patients: a retrospective MIMIC-III database analysis.

Chronic obstructive pulmonary disease is associated with a higher incidence of acute kidney injury in non-cardiac but not in cardiac surgery ICU-patients: a retrospective MIMIC-III database analysis.