Theatre Staff Research Articles

HPB SO53 - Implementation of High Volume-Low Complexity 'GIRFT' lists for laparoscopic cholecystectomy

Abstract Background Waiting times for elective surgery have risen steadily since 2010, with particularly sharp increases after the Covid pandemic. There have been several initiatives to improve theatre productivity and increase operative numbers and these are broadly encompassed within GIRFT standards and the development of the concept of a High Volume-Low Complexity list. Current GIRFT standards recommend six laparoscopic cholecystectomies on an all-day operating list. This study aimed to describe the development and implementation of these lists within out district general hospital setting and outline the key barriers and solutions for other units to learn from. Method All patients on the waiting list for laparoscopic cholecystectomy were assessed and screened by a panel of consultant surgeons to assess suitability for a HVLC list. Theatre staff, anaesthetists and surgeons were widely consulted within local focus groups and a novel method of remuneration for additional work was developed: a 'cost-per-case (CPC)' remuneration structure was introduced (in contrast to standard remuneration by session time) to ensure productivity and high quality surgery. Operations were carried out on weekend lists in a dedicated accredited Elective Surgical Hub and staff were able to finish the day when all operations were completed. Results CPC lists took place from August 2023 to May 2024. All lists had six laparoscopic cholecystectomies or eight hernia repairs (or a combination) in line with GIRFT standards. Overall 124 cholecystectomies were performed and 119 were completed on a day case basis. The remaining 5 patients had a single night stay. There were no returns-to-theatre or major morbidity. All lists had started by 830AM and the latest finish time throughout the study period was 1525PM. The utilisation of CPC lists contributed to waiting times falling dramatically from over 52 weeks to 28 weeks by the end of the study period. Conclusion By utilising a novel form of remuneration, based on volume of work completed rather than time, we were able to maximise productivity without compromising safety whilst developing employment conditions that encouraged colleagues to perform additional work. Key facets to successful implementation include appropriate screening of cases, allowing staff to leave when the work is completed (rather than have to wait till the end of the day) and standardising equipment and kit to reduce wastage and turnaround time between cases. These lessons can be implemented in any surgical unit to improve productivity and increase volume of cases performed.

EDI&S SO03 Replacing Single-use Chloraprep with Low Carbon Cost-effective Surgical Skin Preparation: A QI Project for Sustainability in Surgery

Abstract Background Operating theatre waste accounts for approximately 50% of all hospital waste produced in the NHS [1] and two-thirds of carbon contributions come from single-use items [2]. With a major goal of the NHS being net-zero, surgeons have a collective responsibility for reducing the carbon footprint through eliminating single-use equipment and plastic waste such as Chloraprep wands. The aim of this quality improvement project was to introduce the use of chlorhexidine solution poured into reusable gallipots and applied using reusable sponge-holders into local practice, which is more environmentally friendly, significantly cheaper and is the first-line skin preparation recommended by NICE [3]. Method Chloraprep use in consecutive operations performed by the trust in a month before and after the intervention was retrospectively collected and categorised based on specialties. The intervention was a series of local oral presentations, leaflets and posters to highlight the benefits of chlorhexidine solution over Chloraprep. The change in percentage of Chloraprep use in all cases completed in 1 month pre- and post-intervention was retrospectively collected and analysed. Further qualitative data was obtained through pre- and post-intervention surveys. Results There was a reduction in use of Chloraprep across all specialties targeted by the intervention, with 27% of cases pre-intervention and 24% of cases post-intervention using Chloraprep. The highest percentage reduction was seen by the local upper gastrointestinal surgery team (37%). The percentage reductions in the cases using Chloraprep 10 days post intervention were general surgery 9%, upper GI 3%, colorectal 1% and vascular 6%. The pre- and post-intervention surveys also showed a decrease in Chloraprep use from 94.1% to 80% and corresponding increased use of swabs and antiseptic solution. 100% of the responders agreed with using the sustainable option. Conclusion The educational intervention has proven to be effective in achieving the aims of this project. Critical analysis of the literature has shown no difference in surgical site infection rates between the two options [2]. However, there is a need for high quality trials that directly compare the clinical effectiveness of both methods of application. We hope to encourage surgeons and theatre staff to opt out of using Chloraprep and consider the use of swabs dipped in chlorhexidine alcohol solution. Thus, we recommend the re-usable low carbon low-cost alternative method and encourage efforts to promote sustainability in surgery.

EDI&S SO08 A novel approach to environmentally sustainable surgical theatre by rationalising surgical instrument set – a qualitative analysis

Abstract Background The surgical theatres are a major source of hospital waste generation. The NHS has set a net zero supply chain target by 2045. This aim is supported by the RCS intercollegiate green theatre checklist to reduce the environmental impact of operating theatres. One key area identified in this process, that will support the net-zero target is surgical instrument tray rationalisation. Laparoscopic cholecystectomy was identified as one of the most common surgical procedures performed in England. The purpose of this study was to demonstrate the impact of rationalising the number of surgical instruments, enabling surgeons to drive towards net zero surgery. Method Our Trust participated in this study, in collaboration with NHS England sustainable procurement team and the innovation agency. Total 58 cholecystectomies performed across two sites, Pinderfields and Dewsbury were included in this prospective audit undertaken from January – March 2023. The surgical tray checklists were used to record the actual instrument usage and noted the redundant and supplementary instruments. This data presented to a surgical advisory group, who agreed on routine instruments and proposed removal of redundant. A green pilot tray was approved and used for cholecystectomy. Qualitative questionnaire feedback was collected from surgeons and operation theatre staff from both sites. Results The instrument use matrix revealed almost 50% instruments from the previously used major tray were never used in any of the 58 cholecystectomy surgeries performed. Subsequently, based on the use matrix data, we switched from using major tray containing 84 instruments, to a reduced size tray containing 46 instruments including re-usable metal ports. Survey results revealed tray rationalisation led to easier and faster surgery preparation, improved efficiency and a reduction in waste, thereby reducing the cost to the Trust. It was also noted that having a smaller tray means less time to count instruments during the surgical pause. Conclusion The results of tray rationalisation are very positive and have demonstrated cost savings, carbon reduction and time saved preparing for surgery and the post-operative instrument count. This pilot study has shown that by making the surgical set smaller, savings have been achieved from a reduction of slots required per machine cycle for decontamination. Tray rationalisation goes some way towards the net goal of zero carbon surgery and delivering a sustainable future.

HAS THE INITIATION OF A FORMAL PATHWAY FOR TUMOUR TISSUE COLLECTION IN NEURO ONCOLOGY PATIENTS LED TO AN INCREASE IN PATIENT’S HAVING WHOLE GENOME SEQUENCING (WGS), AND HOW WILL THIS IMPACT ONCOLOGY MANAGEMENT IN THE FUTURE?

Abstract AIMS To change the standard of care for collection of glial tumour tissue at a London teaching hospital. This would enable WGS on the tumour tissue, and give patients access to further clinical trials. METHOD The previous standard of care was for brain tumour pathology samples to be stored in paraffin. This was not suitable for WGS or for many clinical trials; the tumour samples needed to be sent to the lab as fresh tissue. The introduction of a genomics clinical nurse specialist meant that relationships were built between the surgical team, pathology teams and ward teams. There was a teaching by one of the neurosurgical team to the theatre staff. Genomics CNS led training for the nursing team. Adults started having WGS in May 2023 but many patient’s still had tissue incorrectly stored and could not have the sequencing performed. There was an introduction of a formal pathway in theatre created by one of the neurosurgeons in Dec 2023. RESULTS From May 2023 - November 2023, 58% adult glioma patients had WGS. Since December 2023 - current (March 2023) and the introduction of the formal pathways, 71% had WGS. CONCLUSION A formal pathway has now changed the standard of care for collecting tissue. There is still not 100% compliance, and this remains multifactorial. However the introduction of a formal pathway has now increased the percentage of eligible patients receiving WGS. This positive outcome has now led to discussions about freezing the fresh glioma tissue to allow glioma patient’s wider access to clinical trials which they would previously not have had access to.

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.

EP335 - Audit of the Use of WHO Surgical Safety Checklist and its Awareness, Perception and Acceptability Amongst Theatre Personnel in a Tertiary Hospital in Sub-Saharan Africa

Abstract Aims The World Health Organization Surgical Safety Checklist (SSC) was developed to prevent perioperative adverse events. This study aimed to assess the utilization of the SSC and evaluate awareness and acceptability among theatre staff at a tertiary centre in sub-Saharan Africa. Methods We conducted a prospective audit of the SSC utilization during elective and emergency surgery, and a survey of awareness, perception and acceptability amongst theatre personnel (nurses, surgeons and anaesthetists) using a 15-item self-administered questionnaire between May 2022 and January 2023. Results 117 surgeries were observed for compliance with SSC and 81 theatre personnel took part in the survey. The checklist was used in 52.1% of all surgeries, 80% and 5.4% of major and minor surgeries respectively. In Time Out phase, activities were stopped in 23% of cases, and scrub nurses were asked relevant questions 31-47% of the time. Sign Out was the least completed phase. Three of five questions were asked 23-48% of the time. 28% of respondents who previously witnessed adverse events agreed that they could have been prevented by proper implementation of the SSC. 65.4% of members of the surgical team had not had any formal training on the SSC. There was no difference in its awareness, perception and acceptability based on profession of the respondents. Conclusion SSC was not fully utilized during the audit period. Lack of formal training may be contributory. There is broad awareness of SSC and its ability to prevent advert events. Key words: WHO, Surgical Safety Checklist, Awareness

FP8.11 - Surgical Site Infection Post-operation (gowning vs not gowning): A District General Hospital Experience

Abstract Aims Increasing evidence shows that surgical site infection (SSI) does not differ significantly between main operation theatre and field sterility for many surgical procedures. This audit aimed to assess the rate of surgical site infection (comparing the operating surgeon using a disposable gown vs not using one) for emergency/elective skin procedures like uncomplicated incision and drainage of abscess, excision of lipoma, sebaceous cyst, and pilonidal sinus. Methods The electronic database was used to collect data (September-October 2023) on the type of surgery performed, number of theatre staff scrubbed in. Poster displays and informal education were used to raise awareness of theatre wastage (November 2023). All were advised to wear an apron, mask, sterile gloves, and field sterility only for uncomplicated cases. Data was recollected (December 2023-January 2024). Results 54 cases were performed in September and October 2023. All theatre staff scrubbed in and 160 gowns were used. 5/54 (9.3%) returned with wound infection and managed with antibiotics. The median of the number of days in which the patients returned post-operatively is 7 days. 24 cases were performed from December 2023-January 2024. Theatre staff in 5/24 cases did not scrub in and none of these patients returned with wound infection. Out of the other 17/24 cases, 5/17 (29.4%) returned with wound infection. Conclusions With the limitation of small sample size and multi-factorial aetiology of wound infection, surgeons who did not gown up had no increased risk of wound infection. The higher monetary and environmental costs of complete gowning without improvement of patients’ care are unjustifiable.

EP474 - Recycling Theatre Waste: A Quality Improvement Project

Abstract Background Theatre waste recycling is a crucial aspect of sustainable theatre production. Staff are usually under time pressure to empty and clean the theatre. This quality improvement project (QIP) aims to assess and reduce waste-related cost and carbon footprint by improving the proportion of waste recycled. Methods A retrospective review of the waste data and related cost for main theatres in Nottingham City Hospital (NCH) in 2022 was audited. A quick guide for waste disposal and recycling was made with the help of environmental department and was disseminated to the theatre staff electronically and physically. Data was reaudited for February to March 2023 post intervention. Results 86.6 tons of waste was generated from the main theatres in NCH in 2022 and 18.4% of the waste was recycled. Monthly proportion of waste recycled ranged from 9.3% (January 2022) to 35.0% (December 2022). The proportion of waste recycled for February and March was 36.7% and 26.4% respectively. Conclusion The findings of this QIP demonstrate the potential for significant improvements in theatre waste recycling rates, which can lead to reduced cost and carbon footprint. The use of a quick guide for waste disposal and recycling proved to be an effective intervention in improving recycling rates among theatre staff. This QIP highlights the importance of promoting sustainable practices in the theatre industry, and the necessity to sustain the effort to maintain the impact.

WP6.5 - Setting Up For Success: Supporting New General Surgical Registrars' Non-Operative Technical Skills Development

Abstract Aim Entry into Higher Surgical Training is associated with new challenges to trainees’ clinical, technical, professional and inter-personal skills. A three-day modular “bootcamp” course was designed for new General Surgery ST3s transitioning from Core Surgical Training to bridge the gap and support areas of developmental need. Methods Four varied modules were undertaken by candidates; one focussed on non-operative technical skills in surgery (NOTSS). Following pre-interviews with all stakeholders, immersive scenarios were developed. The programme encompassed operating in a stressful environment with a focus on crisis resource management principles, ward round leadership, theatre prioritisation, difficult communication, and a further workshop on managing bullying and sexual harassment. A multi-professional faculty included anaesthetists, theatre staff, psychiatrists and geriatricians alongside surgeons. Results All 26 trainees were invited to self-rate confidence using a 5-point Likert scale, as well as free text annotation. 13 (50%) completed both pre- and post-course confidence questionnaires. Data showed significant improvement in self-rated confidence across all NOTSS domains, particularly for operating in a stressful environment ("Confident"/ "Strongly Confident" = 69% pre-course to 100% post-course). Free text responses included highly positive feedback for high faculty to trainee ratio allowing detailed personalised feedback, exposure to multi-professional perspectives and opportunities to reflect on difficult professional scenarios. Conclusion Following the success of this course, it has now become part of ST3 Induction in Yorkshire - an opportunity to promote a positive working culture and strengthen professional relationships. A multi-specialty faculty allows for sharing of transferable inter-specialty skills. We recommend all transitional training stages would benefit from embedded induction courses.

Noise in operating theatres, is it safe?

Noise-Induced Hearing Loss (NIHL) is a condition caused by repeated exposure to loud noise, with operating theatre personnel potentially at risk. The aims of this study were to establish the typical noise levels in orthopaedic theatres and to compare these to The Control of Noise at Work Regulations 2005. We measured the average noise levels in 40 trauma and orthopaedic surgeries in a single centre. We used the Decibel X app to take measurements, then performed corrections to ascertain noise levels at the surgeon's ear (Leq). The daily noise exposure level for theatre staff for each procedure (LEP, d) and the LEP, d over an average 8-hour working day when performing different groups of procedures were calculated. Data were analysed using descriptive statistics, ANOVA, t-test and the Pearson coefficient of correlation. The LEP, d lower action value (80 dBA) as set by the Health and Safety Executive (HSE) was met by performing a single revision total knee replacement or a right open ankle debridement. Assuming three procedures are conducted per list, lists consisting of joint replacements (82 dBA) or medium elective procedures (81 dBA) exceed this lower limit. Additionally, lists comprising large and medium bone fractures would be within 1 dB of the limit (79 dBA and 79 dBA, respectively). Soft tissue (74 dBA), arthroscopic (73 dBA), and small bone fracture (71 dBA) procedures had the lowest LEP, d. The greatest contributors to noise levels were surgical instruments. The number of people in the room made a significant difference to noise levels (p = 0.032). We have established the baseline noise levels in various orthopaedic procedures. Measures should be taken to meet UK regulations. Further research should determine suitable measures for protection from hearing damage for theatre staff and evaluate the risks high noise levels pose to patients.

578 Optimising Emergency Theatre Efficiency with the Use of a Pre-Anaesthetic Holding Bay, a Quality Improvement Project

Abstract Aim An efficient emergency theatre depends on the coordination of multiple surgical specialties, anaesthetists, and theatre staff. The serial nature of an operating list leads to downtime between cases. We sought to reduce delays between emergency cases by implementing a pre-anaesthetic holding bay. Method Anonymised data was collected from a prospectively maintained mandatory database of theatre activity. Exclusion criteria were non-surgical procedures, first case, out-of-hours procedures, and critical care admissions. Suitability was determined from a period pre-implementation and a pre-defined trial period to ensure safe rollout. Pre-, trial, and post-implementation were compared. Results 349 emergency procedures were performed in three months post-implementation. After exclusion criteria 110 were suitable for pre-anaesthetic holding bay use, and in 35 (31.8%) it was utilised. Most cases were general surgery (61%), vascular surgery (15%), and gynaecology (12%). Holding bay use decreased time without a patient in the anaesthetic room from 50 to 5 minutes (p<.001) and the time between procedures from 86 to 43 minutes (p<.001). There was no difference in anaesthetic time between the groups (36 vs 38 minutes, p=.40). Over the three months 40 more in-hours cases were completed in 48 days with no difference in procedures across the periods. Conclusions Pre-anaesthetic holding bay use reduced theatre downtime by 90%, allowing more procedures to be performed in-hours. All specialties engaged with the holding bay but to varying extent, and ensuring investment from surgeons, anaesthetists, and theatre staff is essential. This intervention, implemented with no extra resources, has increased efficiency and improved safety in the emergency theatre list.

910 MIND THE BUMP - a Multi-Site Initiative Promoting Allyship for Pregnant Colleagues in Theatres

Abstract Aim Awareness of considerations to keep pregnant colleagues safe in theatres is crucial for equity and diversity. National orthopaedic guidance exists for radiation, cement exposure, gas induction, scrub, and managing symptoms. Lack of knowledge of guidance can cause anxiety for pregnant staff and friction between colleagues. This multi-centre initiative assessed and improved awareness of pregnancy considerations amongst theatre staff, promoting allyship and a supportive environment, Method A questionnaire assessing knowledge of published guidance on pregnancy considerations was completed by orthopaedic theatre staff (surgeons, anaesthetists, nurses, allied health professionals and students) at eight trusts. Educational posters were displayed in theatres and changing areas. The questionnaire was then repeated. Results 290 pre-poster (49.1%:50.2%:0.7% Male:Female:Non-Binary) and 220 post-poster (37.8%:62.2%:0.0% M:F:NB) questionnaires were completed. Pre-poster, the average percentage of correct questionnaire answers was 22.4%, with a significant 47.3% increase post-poster to 69.8% (95%CI 43.8%-50.8%, p=0.0000). Knowledge varied widely across domains, increasing across all topics (radiation 9.0% to 61.4%, scrub 17.2% to 74.5%, cement 30.3% to 72.3%, gas induction 10.7% to 57.7% and symptom management 45.2% to 82.7%). There was a significant post-poster difference of 21.9% (95% CI 16.3%-27.5%, p=0.0000) between female and male scores (females scoring higher), compared to a non-significant pre-poster difference of 4.2% (95%CI -0.4% to +8.8%, p=0.0783). Conclusions This study revealed a low pre-existing knowledge of important pregnancy considerations amongst theatre staff. A simple poster campaign transformed awareness in all staff groups and should be expanded across specialties and nationwide to promote allyship and support for our pregnant colleagues.

1276 Creating Safer Theatres. Tackling Religious Headwear Discrimination Nationally

Abstract Aim To identify and challenge discriminatory EDI practices. To improve adoption of national policies on surgical headwear in theatre. Method Freedom of information requests were sent to 124 hospitals with emergency general surgery theatres. Data requested included total staff number, BAME staff percentage, theatre staff percentage, Muslim theatre staff (including ODPs, porters, medical, nursing staff, surgeons, junior doctors), female Muslim staff number, and copies of uniform policies, especially on religious headwear. Two senior trainees reviewed policies. Results 100 of 124 trusts responded to the FOI request. Percentage of BAME staff ranged from 5% to 47%. 12 trusts had no BAME members of staff working in theatres or could not release this data for risk of their few personal being identified. 97 policies were reviewed. 80% of the policies reviewed adhered or replicated the national guidance. Potentially discriminatory practices included necessitating disposable head wear be always worn, lack of specific guidance on the wearing of hijabs, and one policy which appeared to request they would not be worn. Conclusions This project highlights significant disparities in EDI policies within hospital theatre teams, especially regarding religious headwear. The lack of specific accommodations for religious garments creates an exclusionary environment. This can lead to increased stress and lower sense of belonging amongst minority staff. The findings emphasise the need for hospitals to re-evaluate and reform their policies, those with poor practices have been contacted. We aim to foster a more inclusive, equitable workplace.

728 Laparoscopic Fundoplication as a Day Case Procedure - Patient Comprehension for a Successful Model

Abstract Aim The British Association of Day Surgery states that elective laparoscopic Nissen’s fundoplication procedures should be performed as a day case in 40% of patients. The purpose of the study was to design a model for laparoscopic fundoplication to increase the numbers done as a day case procedure. Method This was a retrospective study of all patients who underwent laparoscopic fundoplication from 2014 - 2019. We introduced patient information leaflets and awareness amongst the patients regarding the procedure following our initial audit in 2014. Further intervention in terms of the surgical team and theatre staff awareness to reach our goal by distributing surgery-oriented pamphlets and information. We re-audited to see if there were any improvements in 2016 and 2019 when compared to our previous cohort. A total of 104 patients were audited through the years. Results In 2019, 34.4 % patients regardless of hiatus hernia size were discharged on the same day; 48.2 % patients were discharged on the next day; 24.1% patients had a large hiatus hernia or gastric volvulus; 40.9% patients excluding large and complicated hiatus hernia were discharged on the same day; 75.8 % patients had intraoperative local anaesthetic inject at the operative field. Conclusions The main two factors which contributed to improvement of our results were Intraoperative injection of local anaesthetic medications to operative field and Patient information pamphlets. Also, when a patient is made aware of the procedure being a day case in advance, they are more prepared to return home the same day following the procedure.

Creating Novel Standards for Datapoints on an Elective Orthopaedic Theatre List Document.

Orthopaedic theatre lists are an important tool which must convey essential information to all staff to run an effective and safe theatre list. However, there are no set standards or guidelines on the components of an Orthopaedic theatre list. The objective of this study is to formulate guidelines for elective Orthopaedic theatre lists which improve efficiency and reduce errors. We looked at 326 elective Orthopaedic theatre lists from October to November 2018. Various factors such as: theatre and patient demographics, surgical team, type of anaesthesia, Surgery, acronyms and finally extra information such as allergies. Additionally, a survey was distributed to a variety of theatre staff to understand their requirements from a theatre list. Thereafter, we created a proforma for waiting list coordinators. Subsequently, we re-audited six more weeks of theatre lists (255) from November to December 2019. The orthopaedic consultant in charge was noted for 100% of patients compared to 85% previously. There was an improvement in documenting the required anaesthesia such as noting 14.5% required spinal compared to 0.3% previously. Prosthesis/equipment was mentioned for 34% of patients compared to 23%. Fluoroscopy was noted as being required for 25% of patients compared to 11%. We believe standards should be in place in order for us to follow to ensure we carry out safe and efficient Orthopaedic theatre lists, and these standards should entail the parameters we have audited. The 'William Harvey theatre list standard' should be used as a gold standard for all elective Orthopaedic theatre lists.

Nursing Leadership in a Post-Pandemic Elective Orthopaedic Theatre Department: A Detailed Thematic Analysis of an Open-Ended Qualitative Survey.

The COVID-19 pandemic has impacted nursing theatre staff, departmental activity, and delivery of services to patients. This work-based project aimed to investigate the challenges of nursing leadership in an elective orthopaedic department at current times. The study collected qualitative data exploring theatre staff's expectations from leadership, offering insight on how the pandemic has influenced the way of working and exploring how the future in this unit may look. The answers from 20 practitioners to an anonymised open-ended survey were examined using thematic analysis. The participants described a leader as a good communicator who focuses on empowering others and supporting the team, identified by the majority as a senior team member. From the findings, three topics were identified: immediate changes, delayed changes, and pre-existing conditions. The answers painted a reality that is complex and multifaceted, where numerous variables play a part in the physical and mental health of each candidate, impacting their performance as well as their work/life balance. Overall, the strongest subjects recurring in the findings were the need for nursing leadership to focus on supporting staff with training opportunities, to actively plan for a reduction in staffing shortages, and to be constantly mindful of staff well-being. This study pointed out that the need for constant communication with their staff, building honest relationships, and being a reliable leader, focused on empowering others and supporting the team were important factors for the nursing management during the COVID-19 pandemic and post-COVID-19 era.

Preconceived Impressions Regarding Holmium:YAG Laser Safety in the Urology Operating Theatre.

Since its introduction over two decades ago, the surgical laser has served in the lithotripsy of urinary calculi, resection of bladder tumours, bladder neck incisions, and prostate enucleation. Concerns regarding the safe use of holmium lasers have resulted in potentially excessive and overly precautious theatre regulations. We aimed to evaluate the preconceived impressions and practice patterns at a single site surrounding laser use in endourology. We designed a three-part online questionnaire that could be accessed using a smart device or computer. This survey was distributed to all theatre staff involved in laser surgery at our single site, including surgical, nursing, and anaesthetic staff of varying seniority. It asked questions regarding holmium laser safety, provided an up-to-date summary of published literature surrounding the safe use of lasers, and finally gave participants further option to alter the answers to several previously encountered questions. A total of 54 theatre staff completed the survey, including 17 theatre nurses (31.5%), 10 urology consultants (18.5%), 8 urology registrars (14.8%), 7 anaesthetic registrars (13%), 4 anaesthetic consultants (7.4%). About 51.9% of participants believed that current laser safety protocols were adequate, with 38.9% finding them excessive. After reading recently published information on laser safety, 22.2% thought current laser safety measures were adequate (57% decrease) and 77.8% found them to be excessive (100% increase). About 74.1% of participants found that laser safety goggles impair their vision and that 79.6% would choose not to wear them if they were optional. Strict laser safety guidelines reflect an overestimated risk associated with using holmium laser in operating theatres. Laser safety regulations should be re-evaluated to align with current research and potential hazards inherent to the device. In doing so, a more effective distribution of staff could enable greater access to laser surgery, thereby reducing patient morbidity and hospital wait times.

European Robotic Surgery Consensus (ERSC): Protocol for the development of a consensus in robotic training for gastrointestinal surgery trainees.

The rapid adoption of robotic surgical systems across Europe has led to a critical gap in training and credentialing for gastrointestinal (GI) surgeons. Currently, there is no existing standardised curriculum to guide robotic training, assessment and certification for GI trainees. This manuscript describes the protocol to achieve a pan-European consensus on the essential components of a comprehensive training programme for GI robotic surgery through a five-stage process. In Stage 1, a Steering Committee, consisting of international experts, trainees and educationalists, has been established to lead and coordinate the consensus development process. In Stage 2, a systematic review of existing multi-specialty robotic training curricula will be performed to inform the formulation of key position statements. In Stage 3, a comprehensive survey will be disseminated across Europe to capture the current state of robotic training and identify potential challenges and opportunities for improvement. In Stage 4, an international panel of GI surgeons, trainees, and robotic theatre staff will participate in a three-round Delphi process, seeking ≥ 70% agreement on crucial aspects of the training curriculum. Industry and patient representatives will be involved as external advisors throughout this process. In Stage 5, the robotic training curriculum for GI trainees will be finalised in a dedicated consensus meeting, culminating in the production of an Explanation and Elaboration (E&E) document. The study protocol has been registered on the Open Science Framework (https://osf.io/br87d/).

Toward Environmentally sustainable surgery: Waste recycling in general surgery operating room. Preliminary cognitive audit.

It is common practice to classify waste from the operating theater as "clinical". The development of sustainable policies could have a significant impact. In the first phase, our study aims to measure general surgery waste and to assess the potential financial and carbon savings of appropriate recycling. Based on this information, we will plan for a second phase in which educational interventions will be put in place to promote waste segregation in surgical environments. We conducted a preliminary cognitive audit of the most common general surgery procedures to examine the types and quantity of waste produced. We calculated the economic and environmental impacts of disposing of waste treated as clinical or general, and we measured how much of it could actually be recycled. Then, we attempted a projection of the savings we could expect if recycling policies were implemented. We found that more than 30% of total waste was actually recyclable. Considering a projection based on annual procedures performed in our hospital, we estimated that for each kind of surgical procedure, we could expect a reduction of the carbon footprint by approximately 6%, and an average 3% reduction in costs every year, only by improving waste segregation in the general surgery operating rooms. There could be a great potential for reducing environmental and economic footprint of the operating rooms by promoting waste recycling protocols. Surgeons are in a unique position to implement for these protocols. Interventions should be codesigned with theater staff to create a "green culture".

Nuclear medicine procedure guideline for sentinel lymph node localization

The authors present a procedure guideline for scintigraphic detection of sentinel lymph nodes in malignant melanoma, in breast cancer, in penile and vulva tumors, in head and neck cancer, and in prostate carcinoma. Important goals of sentinel lymph node scintigraphy comprise reduction of the extent of surgery, lower postoperative morbidity and optimization of histopathological examination focussing on relevant lymph nodes. Sentinel lymph node scintigraphy itself does notdiagnose tumorous lymph node involvement and is not indicated when lymph node or distant metastases have been definitely diagnosed before sentinel lymph node scintigraphy. Procedures are compiled with the aim to reliably localise sentinel lymph nodes with a high detection rate typically in early tumour stages. New aspects in this guideline are new radiopharmaceuticals such as tilmanocept and Tc-99m-PSMA and SPECT/CT allowing an easier anatomical orientation. Initial dynamic lymphoscintigraphy in breast cancer is of little significance nowadays. Radiation exposure is low so that pregnancy is not a contraindication for sentinel lymph node scintigraphy. A one-day protocol should preferentially be used. Even with high volumes of scintigraphic sentinel lymph node procedures surgeons, theatre staff and pathologists receive a radiation exposure < 1 mSv/year so that they do not require occupational radiation surveillance. Aspects of quality control were included (scintigraphy, quality control of gamma probe, 6 h SLN course for surgeons, certified breast centers, medical surveillance center).