Moving toward point-of-care surgery in Ukraine: testing an ultra-portable operating room in an active war zone

PURPOSE

In conflict zones, providers may have to decide between delaying time-sensitive surgeries or performing operative interventions in the field, potentially subjecting patients to significant infection risks. We conducted a single-arm crossover study to assess the feasibility of using an ultraportable operating room (U-OR) for surgical procedures on a porcine cadaver abdominal traumatic injury model in an active war zone.

METHODS

We enrolled participants from an ASSET-type course designed to train Ukrainian surgeons before deployment to active conflict zones. They performed three standardized consecutive abdominal surgical procedures (liver, kidney, and small bowel injury repair) with and without the U-OR. Primary outcomes included surgical procedure completion rate, procedure time, and airborne particle count at the start of surgery. Secondary survey-based outcomes assessed surgery task load index (SURG-TLX) and perceived operative factors.

RESULTS

Fourteen surgeons performed 76 surgical procedures (38 with the U-OR, 38 without the U-OR). The completion rate for each surgical procedure was 100% in both groups. While the procedure time for the liver injury repair did not differ significantly between the two groups, the use of the U-OR was associated with a longer time for kidney (155 vs. 56 s, p = 0.002), and small bowel (220 vs. 103 s, p = 0.004) injury repair. The average airborne particle count within the U-OR was substantially lower compared to outside the U-OR (6,753,852 vs. 232,282 n/m3, p < 0.001). There was no statistically significant difference in SURG-TLX for procedures performed with and without the U-OR.

CONCLUSION

The use of the U-OR did not affect the procedure completion rate or SURG-TLX. However, there was a marked difference in airborne particle counts between inside and outside the U-OR during surgery. These preliminary findings indicate the potential feasibility of using a U-OR to perform abdominal damage-control surgical procedures in austere settings.

A survey of bloodborne occupational exposure protection behavior among qualified Chinese midwives: A cross-sectional study

Background

Bloodborne occupational exposure is a major public health concern of the China Health Commission, especially among midwives who are at high risk among healthcare workers. Knowledge of occupational exposure and appropriate protective behaviors play important roles in reducing occupational exposure. The purpose of this study was to understand the knowledge and level of protection against bloodborne occupational exposure among midwives in China.

Methods

This was a multi-center, cross-sectional study. Midwives from hospitals that are members of Infectious Disease Nursing Committee of Chinese Nursing Association were selected as survey participants from February 2019 to February 2022 using a judged sampling method. Data were collected by using a self-developed questionnaire for Chinese midwives to report their current knowledge and behavior related to bloodborne occupational exposure protection.

Results

A total of 2850 questionnaires were distributed and 2742 valid questionnaires were obtained, resulting in an effective rate of 96.21 %. Midwives scored 2742 (6.495 ± 1.529) points for their knowledge about bloodborne occupational exposure protection, with the level and type of hospital being independent factors affecting the midwives' knowledge of bloodborne occupational exposure protection (χ2 = 27.284, P = 0.038; χ2 = 28.374, P = 0.000). Of the midwives, 1460 were qualified for bloodborne occupational exposure protection behavior, with a qualified rate of 53.25 %. Working years (χ2 = 9.372, P = 0.002) and working hours (χ2 = 13.933, P = 0.000) were also the independent factors for bloodborne occupational exposure protective behavior in midwives.

Conclusion

Chinese midwives possess relatively good knowledge of bloodborne exposure protection against bloodborne infectious diseases, but their behavioral level is not optimistic. Improvements to both knowledge and behavioral level of bloodborne occupational exposure protection are necessary.

A Paradigm Shift in Critical Care Infrastructure in Complex Settings: Evaluating an Ultraportable Operating Room to Improve Field Surgical Safety

INTRODUCTION

Scarcity of operating rooms and personal protective equipment in far-forward field settings make surgical infections a potential concern for combat mortality and morbidity. Surgical and transport personnel also face infectious risks from bodily fluid exposures. Our study aimed to describe the serial, proof-of-concept testing of the SurgiBox technology: an inflatable sterile environment that addresses the aforementioned problems, fits on gurneys and backpacks, and drapes over incisions.

MATERIALS AND METHODS

The SurgiBox environmental control unit and inflatable enclosure were optimized over five generations based on iterative feedback from stakeholders experienced in surgery in austere settings. The airflow system was developed by analytic modeling, verified through in silico modeling in SOLIDWORKS, and confirmed with prototype smoke-trail checking. Particulate counts evaluated the enclosure's ability to control and mitigate users' exposures to potentially infectious contaminants from the surgical field in various settings. SurgiBox enclosures were setup over a mannequin's torso, in a configuration and position for either thoracic or abdominal surgery. A particle counter was serially positioned in sternotomy and laparotomy positions, as well as bilateral flank positions. This setup was repeated with open ports exposing the enclosure to the external environment. To simulate stress scenarios, sampling was repeated with enclosure measurements during an increase in external particulate concentration.

RESULTS

The airflow technology effectively kept contaminants away from the incision and maintained a pressure differential to reduce particle entry. Benchtop testing demonstrated that even when ports were opened or the external environment had high contaminant burden, the enclosed surgical field consistently registered 0 particle count in all positions. Time from kit opening to incision averaged 54.5 seconds, with the rate-limiting step being connecting the environmental control unit to the enclosure. The portable kit weighted 5.9 lbs.

CONCLUSIONS

Analytic, in silico, and mechanical airflow modeling and benchtop testing have helped to quantify the SurgiBox system's reliability in creating and maintaining an operating room-quality surgical field within the enclosure as well as protecting the surgical team outside the enclosure. More recent and ongoing work has focused on specifying optimal use settings in the casualty chain of care, expanding support for circumferential procedures, automating airflow control, and accelerating system setup. SurgiBox's ultimate goal is to take timely, safe surgery to patients in even the most austere of settings.