Theatre Facilities Research Articles

Orthopaedic surgical treatment delays at a tertiary hospital in sub Saharan Africa: Communication gaps and implications for clinical outcomes

Background:Delay in surgical treatment is a source of distress to patients and an important reason for poor outcome. We studied the delay before carrying out scheduled operative orthopaedic procedures and the factors responsible for it.Materials and Methods:This prospective study was carried out between March 2011 and December 2012. Temporal details of the surgical procedures at our hospital were recorded in a proforma including the patients’ perception of the causes of the delay to surgery. Based on the urgency of the need for surgery, patients were classified into three groups using a modification of the method employed by Lankester et al. Data was analyzed using the Statistical Package for the Social Sciences, version 17.0. Predictors of surgical delay beyond 3 days were identified by logistic regression analysis.Results:Two hundred and forty-nine patients with a mean age 36.2 ± 19.2 years and M:F ratio 1.3 were recruited. 34.1% were modified Lankester group A, 45.4% group B and 20.5% group C. 47 patients (18.9%) had comorbidities, hypertension being the commonest (22 patients; 8.8%). Median delay to surgery was 4 days (mean = 17.6 days). Fifty percent of emergency room admissions were operated on within 3 days, the figure was 13% for other admissions. Lack of theatre slot was the commonest cause of delay. There was full concordance between doctors and patients in only 70.7% regarding the causes of the delay. In 15.7%, there was complete discordance. Logistic regression analysis confirmed modified Lankester groups B and C (P = 0.003) and weekend admission (P = 0.016) as significant predictors of delay to surgery of >3 days.Conclusion:Promptness to operative surgical care falls short of the ideal. Theatre inefficiency is a major cause of delay in treating surgical patients in our environment. Theatre facilities should be expanded and made more efficient. There is a need for better communication between surgeons and patients about delays in surgical treatment.

Causes of Surgical Delay and Demographic Characteristics in Patients with Hip Fracture

Background: Several studies analyze how surgical delay affects patients with hip fracture. The aim of this study was to identify the causes of surgical delay and demographic characteristics in patients with hip fracture who had delays longer than 24 hours from admission to hospital. Methods: Quantitative retrospective register study of 484 patients was consecutively included during the period November 1, 2010 and October 31, 2011 in the University Hospital in Lund (Sweden). Results: A frequency of 29.4% had a surgical delay longer than 24 hours. The main reasons for delays to surgery were lack of theatre facilities (54%), medical unstable patient (16%) and anticoagulant treatment (10%). Of all patients, 69% (n = 332) were women and 31% (n = 151) were men. The mean age for women were 83.6 (CI 83-85) vs. 79 (CI 77-81) for men, respectively. The most common type of hip fracture was displaced cervical hip fracture (39%, n = 188) with a majority of fractures in male patients. In total, women suffered hip fractures to a greater extent than men (69% vs. 31%, p = 0.016), but no relationship was found with respect to the fracture type and age (p = 0.358). Conclusion: The main result demonstrated that delays longer than 24 hours were due to lack of theatre facilities. Further researches have to be done in order to investigate whether lack of theatre facilities depends on improper operation planning and/or on lack of medical staff.

Orthopaedic surgical treatment delays: communication gaps between the surgical team and patients

BackgroundDelay in surgical treatment is often a reason for poor outcome in patients. An understanding of the causes of treatment delays is important in improving services.ObjectivesWe reviewed factors responsible for...

Staging Raja Tangkai Hati at Istana Budaya: Modernizing Malaysian Mak Yong

Staging Raja Tangkai Hati at Istana Budaya: Modernizing Malaysian Mak Yong Kathy Foley (bio) and Sabzali Musa Kahn (bio) This report will consider scenic issues of staging contemporary mak yong by looking at the 2003 production of Raja Tangkai Hati (King of the Heart; literally, “liver stem”) presented at Istana Budaya, Malaysia’s National Theatre in Kuala Lumpur during the artistic director-ship (2001–2005) of Hatta Azad Khan. The genre is the dance-drama of the Kelantan-Patani area that was supported in palace and/or village environments prior to the 1940s. The guru leading this offering was National Artist and mak yong prima donna Khadijah Awang (1941–2009), who used a combination of professional artists from her group (Kumpulan Seri Temengggung KST) and students she trained in mak yong at the national arts school, ASK.1 The design head for scenery, lighting, property, and stage elements was coauthor Sabzali Musa Kahn, and this report, as a result, will often focus on scenic issues in the translation [End Page 419] of a regional, traditional art of eastern Malaysia into the context of the urban “world-class” theatre facility in the national capital. The discussion will touch on issues of traditional versus contemporary, on the one hand, and the contrast of regional, national, and global, on the other. While we deal with only a single production, the decisions highlight larger strategies of modernizing heritage arts. After introducing the narrative and discussing traditional staging, the personnel and the theatrical space of this performance will be detailed. Finally, specific design choices will be discussed. For mak yong to continue into the twenty-first century, adaptation is necessary. Cultural heritage that remains too “true” to the past makes for an endangered form. By using alternative spaces and new technologies, designers perpetuate older forms like mak yong into the future. Narrative Raja Tangkai Hati is one of the twelve major narratives of traditional mak yong. Plays like Dewa Muda and Dewa Pechil are felt by some practitioners to be more central to the tradition, probably because those stories were heavily used in main puteri (literally, “playing the princess”), a healing genre intertwined with mak yong in the Kelantan-Patani area, where Malaysia meets Thailand. Narratively Raja Tangkai Hati is interesting in that, as with other mak yong stories, it reflects the melodrama of love and loss. It also shows the old seagoing tradition of the east coast of Malaysia. An explanation of the traditional plot (drawn from Ghulam-Sawar [1976: 316–319], but with names of people and sites spelled as in the 2003 program) will clarify some changes in focus for this production. Raja Tangkai Hati is the ruler of Sekota Batu. He sails to neighboring kingdoms for diplomacy and trade, but he stops temporarily at the Pulau Mati Anak (Island of Dead Children), home of an ogre princess, Puteri Bota. She transforms herself into a beautiful woman and enchants the king, who pledges his love. But, sailing to the next port, he marries Puteri Cempaka Emas and has two sons, Malim Bisnun and Malim Bongsu. As the king returns with this new family to his capital, the ogress waylays the ship. She disguises herself as a flower (Figure 1), which Puteri Cempaka Emas picks. The ogress immediately transforms Puteri Cempaka Emas into a half human, half monkey and assumes the princess’s form. When the sons reject this false Puteri Cempaka Emas, their father throws them into the sea. Betara Guru (literally, “God Teacher,” Shiva) transforms them into sea creatures, limpets, which attach to the bottom of the vessel. Arriving in Sekota Batu, the ship mysteriously cannot enter the harbor: a bomoh (shaman), who is actually Betara Guru in disguise, is called. He returns the limpets to human [End Page 420] form and tasks them with saving their monkey mother. The father now claims he is childless, but his memory is jogged when his sons turn up at the palace, and one challenges and kills the false Puteri Cempaka Emas. The sons collect the demoness’s blood, which, poured on their true mother, restores her to her original form. The family is reunited. The story has patterns that are common to other...

Amputations of limbs during the 2005 earthquake in Pakistan: a firsthand experience of the author

On 8 October 2005 a massive earthquake hit the northern mountainous areas of Pakistan and Kashmir causing 73,338 deaths and leaving over 125,000 severely injured. In a region which was less prepared for such an enormous disaster, mobilising rescue, relief and rehabilitation posed great challenges. The lead author (SMA) established two level 1 orthopaedic trauma and rehabilitation units in existing public hospitals through private philanthropy in the earthquake struck cities of Muzaffarabad in Kashmir and Mansehra in Khyber Pakhtun Khuwa (KPK) Province. The purpose was to combat the major catastrophe and later study the pattern of injuries especially amputations so as to improve the future strategies in similar scenarios. This is a retrospective descriptive study of patients suffering from injuries of the limbs due to the earthquake who were managed in these centres with special emphasis on the patients with amputated limbs. The patients were received, worked up, investigated and prepared for definitive surgical procedures, in this case amputations. All patients were provided assistance for the fitting of a prosthesis and rehabilitation by referring them to specialised centres. Of 128,304 patients, 19,700 were managed in the centres established by the lead author over a period of seven months. Of these, 112 patients underwent amputations of upper and lower limbs. In a massive calamity over a wide geographic area away from big university hospitals, such as the 2005 Pakistan earthquake, the level 1 operating theatre facilities must be established within the area to meet the needs of the patients nearest to their homes and families, and run forever so that patients can have excellent follow-up and can use the same facilities regularly. For example, in this study we managed 112 amputees and placed them in a rehabilitation programme, and transferred these centres to the hospital authorities after five years.

Approach to Trauma Care in the Armed Forces

Approach to Trauma Care in the Armed Forces

Surgical site infection following primary joint replacement at the National Orthopaedic Hospital, Enugu

Background: Total joint replacement is increasingly in use for treatment of orthopaedic ailments. Infection following joint replacement surgery can be devastating. Infection rates of 1-2.3% are reported in developed countries. In Nigeria proper theatre facilities, like controlled airflow systems and the use of body exhaust suits, for joint replacement surgeries are not commonplace. Aim: To determine the surgical site infection rates for total joint replacements done in the National Orthopaedic Hospital Enugu and to compare this to what is obtainable in developed countries where proper laminar airflow theatre facilities exist. Materials and Methods: At the National Orthopaedic Hospital Enugu, 33 total joint replacement surgeries were done in 5 years giving an average of 6.6 surgeries per year and the number is increasing. One patient had revision hip arthroplasty and was excluded from the study. Thirty two patients met the inclusion criteria and were recruited into the study. Results: Twenty-three patients had total hip replacement while nine patients had total knee replacement. There were 19 males and 13 females enrolled in the study with a ratio of 1.5:1. The mean age was 57.4years. One patient had superficial incisional surgical site infection giving a surgical site infection rate of 3.1% reported in this study with pseudomonas as the causative organism. Conclusion: It is concluded that these surgeries can be done in the conventional theatres available in Nigeria as the infection rate reported in this study is comparable to what is obtainable in developed countries.

Using emergency theatre facilities

National guidelines exist for optimal provision of emergency theatre services. Through publicised audits, the Freeman Hospital, Newcastle—a tertiary referral centre—has significantly reduced median waiting times for surgery and the incidence of ‘unnecessary’ delays, increasing daytime operating and consultant anaesthetic input into patient care. A subsequent ‘unpublicised’ audit demonstrated maintenance of such standards despite a significantly increased workload, suggesting long-term changes in theatre management.

A prospective study of the factors affecting access to equitable surgical care in the Southern Province of Rwanda

Background: Access to equitable surgical care significantly reduces morbidity and mortality from traumatic injuries, abdominal, extra-abdominal, acquired and congenital conditions. In Rwanda, like many other developing countries, there are is a wide range of factors affecting access to surgical care across the different levels of health care delivery. The main objective of this study was to document the factors affecting access to surgical care in the Southern Province of Rwanda. Methods: This prospective observational study randomly selected 5 of the 11 district hospitals in the province. The other health unit included was the regional referral hospital for the province, Butare (CHUB). The variables tested included surgical capacity, timeliness, safety, and affordability, for all the included health units in the province. The lists of elective surgical patients, compared with the lists of operated patients over a period of six months, were used to indicate the performance and outputs to surgical access for the various health units in this study. In addition, 5 patient interviews were conducted at each health unit, from patients who were randomly selected, from both the surgical outpatients and the surgical wards. They were questioned regarding their views to surgical care access. Percentages were used to indicate the extent of the challenges to surgical access. Results: The lack of adequate surgical staff was the commonest challenge to surgical access (75% for the district hospitals, and10% for the regional referral hospital) identified. At the regional referral hospital (CHUB), limited operating theatre space was a challenge in 50% of the cases. This was followed by the limited number of specialists and sub-specialties rated at 10%, and limited anesthetic plus ICU facilities rated at 10%. The other challenge was the issue of affordability for the consumables required, rated at 10% The average surgical output and the pending (representing unmet need), calculated from the elective waiting lists for a period of 6 months, indicated that the number of operated patients were rated at 75 %, and an unmet need of surgical access of 25% for CHUB; while for the district hospitals it was 63% with an unmet need of 37%. The patients’ views also pointed at challenges of limited surgical services at the district hospital (70%), and affordability (30%). Conclusions: Access to surgical care in the Southern Province of Rwanda was affected by the limited number of specialists and doctors with the minimum skills to carry out non-specialized operations at the district hospitals, the limited operating theatre facilities, limited sub-specialist services, and specialized investigations. Keywords: surgical care; access; challenges; capacity; safety; affordability; timing

The Impact of Multi-Skilled Staff Availability on Day Surgery Cancellations

This paper outlines a study undertaken by Helen Lloyd to assess the impact of multi-skilled theatre practitioners on reducing cancellations in stand alone day surgery units in England and Wales. The author provides the background to the study together with an overview of the results. The literature review undertaken before the study is published in full. It identifies what factors influence the efficiency of day surgery and operating theatre facilities, traditional staffing of operating theatres and day surgery facilities, together with other influencing factors for theatre utilisation. The author recieved partial funding from ERFF to complete her MBA in Health Service Management at Greenwich School of Management (accredited to University of Hull) in 2007.

Tonsillectomy à chaud for quinsy: revisited

In a prospective study involving 16 patients over a 12 month period, we determined whether tonsillectomy à chaud is an acceptable alternative to interval tonsillectomy for patients with quinsy. Guidelines for the acute surgical management of quinsy (or peritonsillar abscess) were established following a departmental audit. Sixteen patients were admitted with a quinsy plus an indication for tonsillectomy; 12 were evaluated prospectively. Each was treated either by incision and drainage or needle aspiration, rehydration, analgesia and intravenous antibiotic therapy, followed by a tonsillectomy à chaud (immediate tonsillectomy) within 30 h of the acute admission. Despite initial drainage, a high incidence of pus was detected intra-operatively. A much larger group of patients had peritonsillitis rather than peritonsillar abscess. Of the 16 patients admitted with a quinsy and indication for tonsillectomy over a 12 month period, 12 consented to tonsillectomy à chaud. Aspiration was used to confirm the presence of a quinsy in seven patients (58%), and incision and drainage in the remaining five. There were no complications, and further hospitalisations were avoided thus reducing patient morbidity and costs. We propose that tonsillectomy à chaud remains a justifiable alternative to interval tonsillectomy for such patients when personnel and theatre facilities permit.

GS12P MANAGEMENT OF UPPER GASTROINTESTINAL HAEMORRHAGE IN A DISTRICT HOSPITAL

Background This study was conducted to assess the management of acute upper gastrointestinal bleeding in a district hospital and to compare these results with national guidelines and the published literature.Materials And Methods This prospective and retrospective study included 112 patients, mean age 66 years, who presented with acute upper gastrointestinal bleeding between July 2004 and February 2005. All patients were assigned a Rockall risk assessment score.Results The surgical on‐call teams managed all the patients according to an agreed protocol. 49 patients had a Rockall score > or = 4. Endoscopy was performed in all patients, with 60% accomplished within the first 24 hours. The most common cause found was peptic ulcer (30%). Therapeutic endoscopy was undertaken in 10 patients (9%) with a success rate of 70%. Open surgery was performed in 3 patients. One patient died after having surgery and the Rockall score was >5. Of the patients admitted with acute upper gastrointestinal bleeding, 90.2% were discharged without complication. 11 patients died (9.8%) and all of them from the high risk group with Rockall scores >5. Their mean hospital stay was 17.8 days (range, 2–43 days).Conclusion High‐standard results in acute upper gastrointestinal bleeding can be achieved in a district hospital. The management, including the use of the operating theatre facilities with operative and anaesthetic support, was safe and efficient. A 24‐hour‐a‐day endoscopy service is important to achieve early diagnosis and to plan management. A protocol and early endoscopy improve clinical outcome and reduce mortality, which occurred mostly among elderly patients with high risk scores. It is advisable to introduce the Rockall scoring system in practice.

Management of Acute Upper Gastrointestinal Bleeding in a District Hospital

This study was conducted to assess the management of acute upper gastrointestinal bleeding in a district hospital and to compare these results with national guidelines and the published literature. This prospective and retrospective study included 112 patients, mean age 66 years, who presented with acute upper gastrointestinal bleeding between July 2004 and February 2005. All patients were assigned a Rockall risk assessment score. The surgical on-call teams managed all the patients according to an agreed protocol. Forty-nine patients had a Rockall score > or =4. Endoscopy was performed in all patients, with 60% accomplished within the first 24 hours. The most common cause found was peptic ulcer (30%). Therapeutic endoscopy was undertaken in 10 patients (9%) with a success rate of 70%. Open surgery was performed in 3 patients. One patient died after having surgery and the Rockall score was >5. Of the patients admitted with acute upper gastrointestinal bleeding, 90.2% were discharged without complication. Eleven patients died (9.8%) and all of them from the high risk group with Rockall scores > or =5. Their mean hospital stay was 17.8 days (range, 2-43 days). High-standard results in acute upper gastrointestinal bleeding can be achieved in a district hospital. The management, including the use of the operating theater facilities with operative and anesthetic support, was safe and efficient. A 24-hour-a-day endoscopy service is important to achieve early diagnosis and to plan management. A protocol and early endoscopy improve clinical outcome and reduce mortality, which occurred mostly among elderly patients with high risk scores. It is advisable to introduce the Rockall scoring system in practice.

Advantages of a nurse-led central venous vascular access service

Inserting central venous catheters for patients requiring parenteral nutrition (PN) is expensive and time consuming, particularly if operating theatre facilities are used. Expanding the role of a clinical nurse specialist, with previous experience in critical care, enabled this procedure to be performed percutaneously at the bedside, cutting costs, freeing medical staff time and improving patient care.

Implications for Burns Unit design following outbreak of multi-resistant Acinetobacter infection in ICU and Burns Unit

We reviewed the emergence of 13 cases of multi-resistant Acinetobacter infection in burns patients over a 12-month period. The outbreak was started in a non-burn patient in the intensive care unit (ICU) that spread to burns patients in ICU and then the Burns Unit. The importance of opportunistic infection, potential risk factors, treatment and clinical outcome of Acinetobacter infection in burns patients from this cluster of cases is described. This paper implicates the movement of burns patients and medical equipment between ICU and the Burns Unit in the spread of this infection. Future design of Burn Units should aim to incorporate features to allow the management of all burns cases in one location with all intensive care, burns and theatre facilities built in close proximity.

Theatre Audience Surveys: towards a Semiotic Approach

Surveys are used to define an audience in a quantifiable way. Awareness of the typical gender, age, and income of their patrons, along with their rating of a theatre's facilities, help theatre producers to address an audience's needs. However, producers seldom explore the audience response to a specific performance – something that is difficult to quantify. Thus, the audience's interaction with the performance – whether with particular actors, the space configuration, or with fellow spectators – is neglected in favour of such demographics as age, income, and occupation. Christopher Olsen suggests that surveys handed out to audience members might benefit from a more qualitative approach based on semiotic analysis. He asked sixty professional theatres in the USA – ranging from major repertory institutions to small theatres targeting specific audiences – to send examples of recent audience surveys they have conducted. Using the surveys (of which the most extensive is reproduced in full), as a guide, he tabulates the most common questions asked, and offers examples of further survey questions guided by semiotic principles. Chris Olsen is currently an adjunct professor at Montgomery College and Shenandoah University in the Washington, DC, area. Having written his dissertation on the Arts Lab phenomenon in Britain during the late 1960s and early 1970s, he is now working on a book about the second wave of the Off-Off-Broadway movement in New York.

The provision of general surgical services in rural South Australia: a new model for rural surgery.

Rural South Australia (SA), like other rural areas in Australia, faces a crisis in the medical workforce. It is also generally assumed that the same applies to rural surgical services but finding evidence to support this is scarce. All hospitals situated outside the outer metropolitan area of SA were surveyed about surgical services (n = 57). Questions were asked about the frequency of emergency and elective theatre usage and which surgeons provided surgical services. Operating theatre facilities were in active use in 39 of the 57 hospitals studied. At the time of the study there were seven specialist general surgeons resident in rural SA. General practitioners continued to have a major input in the provision of surgical services, either by providing the general anaesthetic (34/39) or by performing the surgical procedures (26/39). The Department of Surgery at the University of Adelaide is instituting various measures to counter the rural surgical workforce problem and is developing a model that serves either the individual or the two-person surgical practice. Metropolitan teaching hospitals can play an important role in supporting current rural surgeons and can foster an increased commitment to the future of rural general surgery.

Modelling resource availability in general hospitals design and implementation of a decision support model

Admission planning in general hospitals means selecting elective patients from a waiting list in order to obtain optimal utilisation of the available beds, nursing staff and operating theatre facilities while taking into account emergency admissions. Also, a wide variety of other factors, often situational and not explicitly stated, play a part in this decision process. As such, it is a complex problem which is difficult to handle for any decision maker. In this paper a statistical model for the prediction of resource availability is presented. The model is first tested on empirical data. On the basis of the model a DSS was designed which is now in daily use in several hospitals. Problems encountered in that implementation process will be stated. The results obtained with the model show that such an approach based on statistical data provides sufficiently accurate results to be useful.

GIFT, ZIFT, and related techniques

This review focuses on the theoretical backgrounds for tubal gamete and zygote/embryo transfer, as well as the clinical results of gamete intrafallopian transfer (GIFT), which are compared with other non-fertilization procedures in infertile women with patent fallopian tubes. While GIFT and zygote intrafallopian transfer (ZIFT) probably result in a more synchronized entry of embryos into the uterine cavity, prospective, randomized studies have not shown these methods to be preferable to conventional in-vitro fertilization and embryo transfer. Nevertheless, co-culture with various cell types seems to yield more viable embryos with a high rate of implantation. The promising results with co-culture do not seem to be a cell- or species-specific phenomenon. This non-specific positive or negative conditioning effect of co-culture on embryo quality indicates that more optimal culture media for in-vitro fertilization can probably be devised. The requirements of laparoscopy and general anesthesia with GIFT have prompted the development of simpler methods based on fertilization in vivo. Various methods of artificial insemination combined with controlled ovarian hyperstimulation yield comparable results with GIFT in unexplained infertility. In endometriosis, GIFT seems to give better results compared with insemination techniques. Less invasive transcervical gamete and embryo transfer techniques have now been established, obviating the need for operating theater facilities.

Directing in Educational Theatre

When I began to think about “directing across boundaries”, and making decisions from “particular political or social vantage points or within particular performance theory”,1 I became distinctly grumpy. I was immersed in the final (hellish) week of rehearsals for a large-cast musical revue / extravaganza at the Scarborough campus of the University of Toronto, where I teach acting and theatre history and direct a variety of shows. Our only “theatre facility” at the College was built as a television studio in the mid-1960s when videotaping lectures and feeding them out to several classrooms at once was thought to make sound pedagogical sense. The folly of this notion was soon discovered, and, in the early 1970s, the studio became the sole teaching-and-performance space for the new Division of Drama, without, however, any particular conversion to the somewhat different requirements of a theatre having been made. For twenty years, consequently, dozens of productions have been presented in, and the drama program has been run out of, a cramped, ugly, woefully inadequate space. And yet interesting and valuable theatre has sometimes been made in what is still referred to as the TV Studio. Fortunately, plans to renovate are (finally) going through, but when I began to think about directorial decisions, I was rehearsing my show in the only space on campus large enough to hold it, the cavernous concrete nightmare known as the Meeting Place; the thought of writing about any director who has the luxury (as I saw it in my sullen state) to be truly creative, to make artistic decisions that are not based on any limitations whatsoever of facilities, funds, or talent, made my eyes cross with antipathy. Directing across boundaries indeed, I thought, what about those of us who direct, if one can even call it that, almost exclusively within boundaries, limits, confines?