A Cross-Sectional Study of Anesthesia Safety in Wad Medani, Sudan: A Pre-war Status Indicating a Post-war Crisis

BACKGROUND

As the surgical burden grows, increasing patient safety during anesthesia and surgery becomes a major global public health priority. Anesthesia can be safely administered in higher-income countries, yet it is more challenging in third-world countries. This study focuses on Sudan, a third-world country, and its unmet anesthetic needs before the current war and how these needs might compromise the post-war status.

AIM

The aim of this study is to compare Sudan's outstanding anesthesia requirements to the World Health Organization's safe anesthesia practice standards in terms of workforce, medications, equipment, and anesthesia conduct.

METHODS

This study was carried out in four hospitals (Wad Medani Teaching Hospital, Wad Medani Maternity Hospital, Gezira Centre for Renal and Urological Surgeries, and the National Centre for Pediatric Surgeries) in Wad Medani, two of which were referral and two were state-run. Each hospital from every category was identified using a convenience sampling technique. The World Health Organization-World Federation of Societies of Anesthesiologists International Standard and earlier regional African publications were used to determine the minimum predicted safe anesthesia needs.

RESULTS

The results of our study demonstrate that overall, the hospitals surveyed fulfilled the minimum standards set by the World Health Organization and the World Federation of Societies of Anesthesiologists (WHO-WFSA) for safe anesthesia practice by 73% with no significant difference in the safety of anesthesia practice between state and referral hospitals.

CONCLUSIONS

The state of safe anesthesia care in Wad Medani hospitals surveyed fell well short of the expected minimal criteria due to important requirements such as patient monitoring indicators, the inaccessibility of life-saving facilities such as defibrillators, and difficult intubation instruments. More importantly, the conduct of anesthesia was far below the standard.

The use of checklists in the intensive care unit: a scoping review

BACKGROUND

Despite the extensive volume of research published on checklists in the intensive care unit (ICU), no review has been published on the broader role of checklists within the intensive care unit, their implementation and validation, and the recommended clinical context for their use. Accordingly, a scoping review was necessary to map the current literature and to guide future research on intensive care checklists. This review focuses on what checklists are currently used, how they are used, process of checklist development and implementation, and outcomes associated with checklist use.

METHODS

A systematic search of MEDLINE (Ovid), Embase, Scopus, and Google Scholar databases was conducted, followed by a grey literature search. The abstracts of the identified studies were screened. Full texts of relevant articles were reviewed, and the references of included studies were subsequently screened for additional relevant articles. Details of the study characteristics, study design, checklist intervention, and outcomes were extracted.

RESULTS

Our search yielded 2046 studies, of which 167 were selected for further analysis. Checklists identified in these studies were categorised into the following types: rounding checklists; delirium screening checklists; transfer and handover checklists; central line-associated bloodstream infection (CLABSI) prevention checklists; airway management checklists; and other. Of 72 significant clinical outcomes reported, 65 were positive, five were negative, and two were mixed. Of 122 significant process of care outcomes reported, 114 were positive and eight were negative.

CONCLUSIONS

Checklists are commonly used in the intensive care unit and appear in many clinical guidelines. Delirium screening checklists and rounding checklists are well implemented and validated in the literature. Clinical and process of care outcomes associated with checklist use are predominantly positive. Future research on checklists in the intensive care unit should focus on establishing clinical guidelines for checklist types and processes for ongoing modification and improvements using post-intervention data.

Frontofacial Surgery: Reducing Infection with the Development and 6-Year Outcome of a Frontofacial Protocol

BACKGROUND

Frontofacial surgery (FFS) creates a communication between the cranial and nasal cavities and is associated with significant infection risk. After a cluster of infections affecting patients undergoing FFS, a root cause analysis of index cases was undertaken, but no specifically remedial causes were identified. Basic principles incorporating known risk factors for the prevention of surgical-site infection were then applied to the creation of a perioperative management protocol. This study analyzes infection rates before and after its implementation.

METHODS

The protocol was designed around the needs of patients undergoing FFS and consists of three checklists covering their preoperative, intraoperative, and postoperative care. Compliance required the completion of each checklist. All patients undergoing FFS between 1999 and 2019 were studied retrospectively, and infections occurring before and after the implementation of the protocol were analyzed.

RESULTS

One hundred three patients underwent FFS (60 monobloc and 36 facial bipartition) before the implementation of the protocol in August of 2013, and 30 patients underwent FFS after its implementation. Compliance with the protocol was 95%. After implementation, there was a statistically significant reduction in infections from 41.7% to 13.3% ( P = 0.005).

CONCLUSIONS

Although no specific cause for a cluster of postoperative infection had been identified, the implementation of a bespoke protocol consisting of preoperative, perioperative, and postoperative checklists covering measures known to reduce infection risk was associated with a significant reduction in postoperative infections in patients undergoing FFS.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Development and implementation of an intraoperative documentation protocol for enhancing patient safety in the operating room: A mixed methods protocol study

BACKGROUND

Documentation is an important part of the patient care process; however, there is no regular program for documenting intraoperative care in Iran. This study was conducted to design an intraoperative documentation for enhancing patient safety in the operating room (OR).

MATERIALS AND METHODS

This exploratory, mixed-methods, qualitative-quantitative study (in 2021) consists of four phases. The first phase involves a conventional content analysis of healthcare providers in the OR to identify the needs, strategies, and content of a pertinent documentation. In this phase, purposeful sampling will be used to collect data through semi-structured interviews. In the second phase, a literature review will be carried out to extract the documentation procedures in the intraoperative period in many other countries. In the third phase, a panel of experts is recruited and the classic Delphi (RAND) technique is run to validate the initial draft of the designed program and, the protocol is then finalized. In the last phase, the designed protocol will be implemented through a quasi-experimental study in one group (before and after intervention), and the effectiveness of the intervention will be evaluated.

DISCUSSION

To design a protocol for intraoperative documentation, healthcare providers' experiences during surgery in the Iranian healthcare setting, where the lack of documentation might forensically harm both the healthcare providers and the patients, will be explored. This information alongside some universal standards developed in other countries should help improve patients' safety in ORs.

Decreasing the Rate of Surgical Site Infection in Patients Operated by Cesarean Section in a Tertiary Care Hospital in India: A Quality Improvement Initiative

Background Surgical site infections (SSIs) are a substantial cause of maternal morbidity and are associated with a significant increase in hospital stay and cost. The prevention of SSI is complex and requires the integration of a range of measures before, during, and after surgery. Jawaharlal Nehru Medical College (JNMC), Aligarh Muslim University (AMU) is one of the referral centers of India with a huge influx of patients. Methods The project was undertaken by the Department of Obstetrics and Gynaecology, JNMC, AMU, Aligarh. Our department was sensitized to the need for quality improvement (QI) through Laqshya, a Government of India initiative for labor rooms in 2018. We were facing problems like a high surgical site infection rate, poor documentation and records, no standard protocols, overcrowding, and no admission discharge policy. There was a high rate of surgical site infections, leading to maternal morbidity, increased days of hospitalization, more usage of antibiotics, and increased financial burden. A multidisciplinary quality improvement (QI) team was formed comprising obstetricians and gynecologists, the hospital infection control team, the head of the neonatology unit, staff nurses, and multitasking staff (MTS) workers. Results The baseline data were collected for a period of one month and it was found that the rate of SSI was around 30%. Our aim was to decrease the rate of SSI from 30% to less than 5% over a period of six months. The QI team worked meticulously, implemented evidence-based measures, regularly analyzed the results, and devised measures to overcome the obstacles. The point-of-care improvement (POCQI) model was adopted for the project. The rate of SSI decreased significantly in our patients and the rates are around 5% persistently. Conclusion The project not only helped in decreasing the infection rates but also led to vast improvements in the department with the formulation of an antibiotic policy, surgical safety checklist, and admission-discharge policy.

Coaching for Surgeons: A Scoping Review of the Quantitative Evidence

To characterize quantitative studies on coaching interventions for professional surgeons to understand how surgical coaching is defined; examine how different coaching programs are designed, implemented, and evaluated; and identify any relevant research gaps.

Mini Abstract: This scoping review revealed that very few studies have quantitatively assessed coaching programs for surgeons focus on technical and nontechnical skills. Studies demonstrate that coaching is well accepted by surgeons. However, effects on technical/nontechnical skills are inconsistent and no evidence confirms that coaching improves patient outcomes. Additional randomized control trials are needed to evaluate the effects of surgical coaching on surgeons’ performance, patient safety, and surgeons’ wellness.

Surgical safety checklist audits may be misleading! Improving the implementation and adherence of the surgical safety checklist: a quality improvement project

Despite good quality evidence for benefits with its use, challenges have been encountered in the correct and consistent implementation of the surgical safety checklist (SSC). Previous studies of the SSC have reported a discrepancy between what is documented and what is observed in real time. A baseline observational audit at our institution demonstrated compliance of only 3.5% despite a documented compliance of 100%. This project used quality improvement principles of identifying the problem and designing strategies to improve staff compliance with the SSC. These included changing the SSC from paper-based to a reusable laminated form, a broad multidisciplinary education and marketing campaign, targeted coaching and modifying the implementation in response to ongoing staff feedback. Five direct observational audits were undertaken over four Plan–Do–Study–Act cycles to capture real-time information on staff compliance. Two staff surveys were also undertaken. Compliance with the SSC improved from 3.5% to 63% during this study. Staff reported they felt the new process improved patient safety and that the new SSC was easily incorporated into their workflow. Improving compliance with the SSC requires deep engagement with and cooperation of surgical, anaesthesia and nursing teams and understanding of their work practices and culture. The prospective observational audit highlighted an initial 3.5% compliance rate compared with 100% based on an audit of the patient notes. Relying solely on a retrospective paper-based model can lead to hospitals being unaware of significant safety and quality issues. While in-person prospective observations are more time-consuming and resource-consuming than retrospective audits, this study highlights their potential utility to gain a clear picture of actual events. The significant variation between documented and observed data may have considerable implications for other retrospective studies which rely on human-entered data for their results.

Complexity and involvement as implementation challenges: results from a process analysis

Background

The study objective was to analyse the implementation challenges experienced in carrying out the IMPROVE programme. This programme was designed to implement checklist-related improvement initiatives based on the national perioperative guidelines using a stepped-wedge trial design. A process analysis was carried out to investigate the involvement in the implementation activities.

Methods

An involvement rating measure was developed to express the extent to which the implementation programme was carried out in the hospitals. This measure reflects the number of IMPROVE-implementation activities executed and the estimated participation in these activities in all nine participating hospitals. These data were compared with prospectively collected field notes.

Results

Considerable variation between the hospitals was found with involvement ratings ranging from 0 to 6 (mean per measurement = 1.83 on a scale of 0–11). Major implementation challenges were respectively the study design (fixed design, time planning, long duration, repeated measurements, and data availability); the selection process of hospitals, departments and key contact person(s) (inadequately covering the entire perioperative team and stand-alone surgeons); the implementation programme (programme size and scope, tailoring, multicentre, lack of mandate, co-interventions by the Inspectorate, local intervention initiatives, intervention fatigue); and competitive events such as hospital mergers or the introduction of new IT systems, all reducing involvement.

Conclusions

The process analysis approach helped to explain the limited and delayed execution of the IMPROVE-implementation programme. This turned out to be very heterogeneous between hospitals, with variation in the number and content of implementation activities carried out. The identified implementation challenges reflect a high complexity with regard to the implementation programme, study design and setting. The involvement of the target professionals was put under pressure by many factors. We mostly encountered challenges, but at the same time we provide solutions for addressing them. A less complex implementation programme, a less fixed study design, a better thought-out selection of contact persons, as well as more commitment of the hospital management and surgeons would likely have contributed to better implementation results.

Trial registration

Dutch Trial Registry: NTR3568, retrospectively registered on 2 August 2012.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07090-z.

Introduction of a rapid sequence induction checklist and its effect on compliance to guidelines and complications

BACKGROUND

Current evidence for the conduct of rapid sequence induction (RSI) is weak. This increases the risk of clinicians modifying the RSI procedure according to personal preferences. Checklists may help increase compliance to best practice guidelines and reduce complication rates. Their value during RSI, a critical procedure in anaesthesia, is unknown. The aim of this study was to investigate compliance to local guidelines and frequency of RSI-related complications before and after introduction of an RSI checklist.

METHODS

This was a prospective, observational, pre- and post-intervention study conducted at two hospitals. There were two interventions: the first was a standardized educational lecture to all staff at both hospitals, consisting of an educational instruction of the checklist and general information about RSI, and the second intervention was the introduction of a RSI checklist. The checklist consisted of 16 items. Compliance to guidelines was categorized as high, moderate and low, and was assessed pre- and post-intervention. The frequency of RSI-related complications was also measured.

RESULTS

We registered 811 RSI procedures of which 412 were pre-intervention. After intervention, the proportion of procedures with high compliance to RSI guidelines increased from 49% to 70% (P < .001). The proportion with partial and low compliance decreased from 37% to 26% (P < .001) and 13% to 3.3% (P < .001) respectively. No change in RSI-related complication rates was detectable post-intervention (16.6%-16.7% P = .56).

CONCLUSION

The introduction of a structured RSI checklist significantly increased compliance to RSI guidelines. A change in RSI-related complications could not be detected due to the size of the study. A checklist may be a useful tool to reduce variance during the RSI procedure.

A clinical perspective study on the compliance of surgical safety checklist in all surgical procedures done in operation theatres, in a teaching hospital, Ethiopia, 2021: A clinical perspective study

Background

Patient safety during surgery is an important component for good outcome of operated patients. To discuss an important details about each surgical case; surgical safety checklist is an important patient safety tool that is used by the team of operating room professionals. This study aimed to identify the compliance of surgical safety checklist.

Methods

This clinical perspective study was conducted from February 20 to March 20; 2021 at a teaching referral hospital. All surgical procedures done at a Comprehensive Specialized Teaching Hospital operation theatres were included. Data were collected through direct observation using World Health Organization standard checklist. Descriptive statistics were performed using SPSS version 20.

Results

A total of 100 operations were observed in the main operation theatres of their surgical safety before induction of anaesthesia, before surgical incision and before any team member leave the operation room. From those 100 surgical procedures; patients' identity, procedure and informed consent, anaesthesia machine checking and medication preparations were performed fully (100%) compliance with the standards.

Conclusions

some standards weren't compliant with the standards of WHO surgical safety checklists. We recommend preparing common discussion panel for the operation room team about the performance of the surgical safety checklists and act accordingly.

Perioperative pediatric mortality in Ethiopia: A prospective cohort study

Background

There was recording of excellent outcomes for pediatric surgery in developed countries of the world when it was carried out by an experienced pediatric surgeon and anesthetists with availabilities of equipment. However, this circumstance was not the ordinary for developing countries. The main objective of our study was to launch a pediatric perioperative mortality rate reference point and determination of associated factors under general or regional anesthesia in Ethiopia.

Materials and methods

the prospective electronic based data collection was done at Tibebe Ghion Specialized Teaching Hospital, Ethiopia with case specific of perioperative data for age less than 18 years old. We computed patients with mortality at 24 h, 48 h and 7 days in the form of percentages. Logistic regression was used for evaluation of mortality at different predictor variables.

Results

from 849 cases analyzed, there were mortality rate of 0.59%, 1.42%, and 2.58% within 24 h, 48 h and 7 days of surgery, respectively. The emergency surgeries (OR = 2.80 [95% CI, 1.78-3.82]; p < 0.03) were associated with an increased risk of mortality within 7 days of post-surgery.

Conclusion

Despite the progresses reached in the pediatric anesthesia and surgical safety in Tibebe Ghion Specialized Teaching Hospital, the pediatric perioperative mortality rates were still high or comparable to other low income African countries. Emergency surgeries were associated with an increased risk of perioperative mortality within 7 days of surgical intervention.Tibebe Ghion Specialized Teaching Hospital should emphasis on evaluation and monitoring of outcome for reduction of mortality with the emergency surgeries younger than 18 years old. We also suggested doing this research work at larger sample sizes for more actual information.

The current state of anesthesia safety in a third world country: a cross-sectional survey among anesthesia providers in Ethiopia

BACKGROUND

Improving patient safety during anesthesia and surgery becomes a major global public health issue due to the increasing in surgical burden. Anesthesia is delivered safely in developed countries, but its safety is hampered by complex problems in third world countries. This survey assesses the unmet anesthesia needs of one of a third world country, Ethiopia.

METHODS

A cross-sectional survey was conducted in Amhara region of Ethiopia from 15/12/2019 to 30/1/2020. All 81 hospitals of the region were stratified by their level as district, general, and referral hospital. The study was conducted in 66 hospitals. The number of hospitals from each strata were calculated by proportional sampling technique resulting; five referral, three general, and fifty eight primary hospitals. Each hospital from each strata was selected by convenience. Each anesthesia provider for the survey was selected randomly from each hospital and questionnaires were distributed. The minimum expected safe anesthesia requirements were taken from World Health Organization-World Federation of Societies of Anesthesiologists International Standard and Ethiopian Hospitals Standard. Anesthesia practice was expected safe if the minimum requirements were practiced always (100%) in each hospital. P < 0.05 with 95% confidence interval were used to compare the safety of anesthesia between higher and lower level hospitals.

RESULTS

Seventy eight (88.6%) anesthesia providers working in 62 hospitals responded to the survey. On aggregate, 36 (58%) hospitals from the total 62 hospitals have met the minimum expected safe anesthesia requirements. Among the different variables assessed; professional aspects 32 (52.45%), medication and intravenous fluid 33 (53.36%), equipment and facilities 33 (52.56%), patient monitoring 43(68.88%), and anesthesia conduct 38 (62.1%) of surveyed hospitals have met the minimum requirements. Anesthesia safety is relatively higher in higher level hospitals (general and referral) 6 (75%) when compared to district hospitals 30 (55.5%), P < 0.001.

CONCLUSION

Anesthesia safety in Ethiopia appears challenged by substandard continuous medical education and continuous professional development practice, and limited availability of some essential equipment and medications. Patient monitoring and anesthesia conduct are relatively good, but World Health Organization surgical safety checklist application and postoperative pain management are very low, affecting the delivery of safe anesthesia conduct.

Checklist feasibility and impact in gastrointestinal endoscopy: a systematic review and narrative synthesis

Background and study aim  Checklists prevent errors and have a positive impact on patient morbidity and mortality in surgical settings. Despite increasing use of checklists in gastrointestinal endoscopy units across many countries, a summary of cumulated experience is lacking. The aim of this study was to identify and evaluate the feasibility of successful checklist implementation in gastrointestinal endoscopy units and summarise the evidence of its impact on the commitment in safety culture. Methods  A comprehensive literature search was performed identifying the use of a checklist or time-out in endoscopy units from 1978 to January 2020 using OVID MEDLINE, EMBASE, and ISI Web of Knowledge databases, with search terms related to checklist and endoscopy. We summarised overall adherence to checklists from included studies through a narrative synthesis, characterizing barriers and facilitators according to nurse and physician perspectives, while also summarizing safety endpoints. Results  The seven studies selected from 673 screened citations were highly heterogeneous in terms of methodology, context, and outcomes. Across five of these, checklist adherence rates post-intervention varied for both nurses (84 % to 96 %) and physicians (66 % to 95 %). Various facilitators (education, continued reassessment) and barriers (lack of safety culture, checklist completion time) were identified. Most studies did not report associations between checklist implementation and clinical outcomes, except for better team communication. Conclusion  Implementation of a gastrointestinal endoscopy checklist is feasible, with an understanding of relevant barriers and facilitators. Apart from a significant increase in the perception of team communication, evidence for a measurable impact attributable to gastrointestinal checklist implementation on endoscopic processes and safety outcomes is limited and warrants further study.

The design and evaluation of a pre-procedure checklist specific to the cardiac catheterisation laboratory

BACKGROUND

With the increasing complexity of procedures being performed in the cardiac catheterisation laboratory, the multidisciplinary team has the challenge of providing safe care to patients who present with a multitude of healthcare needs. Although the use of a surgical safety checklist has become standard practice in operating theatres worldwide, the use of a pre-procedure checklist has not been routinely adopted into interventional cardiology.

OBJECTIVE

The aim of this study was to design and evaluate a pre-procedure checklist specific to the cardiac catheterisation laboratory.

METHOD

A descriptive, exploratory design was used to develop a specifically designed pre-procedure checklist for use in the cardiac catheterisation laboratory in a private hospital in Melbourne, Australia. The pre-procedure checklist was developed by exploring the multidisciplinary team's opinion regarding the organisation's previous surgical pre-procedure checklist through a pre-implementation survey and focus groups. Following an expert review, and implementation of the proposed pre-procedure checklist, a post-implementation survey was completed.

RESULTS

Thirty-five (70%) cardiac catheterisation laboratory healthcare professionals completed the pre-implementation survey, with 31 (62%) completing the post-implementation survey. Ninety-one per cent of participants agreed that important clinical information required for interventional procedures was not documented on the previous surgical checklist. A specific checklist was developed from the results of the survey and six focus groups (N = 25) and implemented in the cardiac catheterisation laboratory. In the post-implementation survey, participants identified that the cardiac catheterisation laboratory specific pre-procedure checklist included all relevant clinical information and improved documentation of patient information.

CONCLUSION

The development of a specific cardiac catheterisation laboratory pre-procedure checklist has led to an improved transfer of pertinent clinical information required prior to procedures being performed in the unit. The outcome of this study has implications for other cardiac catheterisation laboratories with the potential to standardise practice within interventional cardiology practice and improve patient safety outcomes.

Perioperative complications in a paediatric cardiac surgery program with limited systemic resources

BACKGROUND

The perioperative complications rate in paediatric cardiac surgery, as well as the failure-to-rescue impact, is less known in low- and middle-income countries.

AIM

To evaluate perioperative complications rate, mortality related to complications, different patients' demographics, and procedural risk factors for perioperative complication and post-operative death.

METHODS

Risk factors for perioperative complications and operative mortality were assessed in a retrospective single-centre study which included 296 consecutive children undergoing cardiac surgery.

RESULTS

Overall mortality was 5.7%. Seventy-three patients (24.7%) developed 145 perioperative complications and had 17 operative mortalities (23.3%). There was a strong association between the number of perioperative complications and mortality - 8.1% among patients with only 1 perioperative complication, 35.3% - with 2 perioperative complications, and 42.1% - with 3 or more perioperative complications (p = 0.007). Risk factors of perioperative complications were younger age (odds ratio 0.76; (95% confidence interval 0.61, 0.93), previous cardiac surgery (odds ratio 3.5; confidence interval 1.33, 9.20), extracardiac structural anomalies (odds ratio 3.03; confidence interval 1.27, 7.26), concomitant diseases (odds ratio 3.23; confidence interval 1.34, 7.72), and cardiopulmonary bypass (odds ratio 6.33; confidence interval 2.45, 16.4), whereas the total number of perioperative complications per patient was the only predictor of operative death (odds ratio 1.89; confidence interval 1.06, 3.37).

CONCLUSIONS

In a program with limited systemic resources, failure-to-rescue is a major contributor to operative mortality in paediatric cardiac surgery. Despite the comparable crude mortality, the operative mortality among patients with perioperative complications in our series was significantly higher than in the developed world. A number of initiatives are needed in order to improve failure-to-rescue rates in low- and middle-income countries.

Care of the surgical patient: part 1

This article provides clinical guidance on the care of a patient undergoing an elective surgical procedure. It discusses preoperative care and the preparation of the patient. It aims to provide an awareness of the complications associated with perioperative care. Through the use of a patient case study, the authors demonstrate the care required across the full perioperative journey from diagnosis to discharge.

What can surgery learn from other high-performance disciplines?

High-performance disciplines have always been concerned with safety and exceptional performance. They have established a culture of vigilance and accepted that human error is both inevitable and ubiquitous. These disciplines, therefore, have all implemented a 'systems approach' to error by focusing on predicting, preventing, rescuing and reporting errors that occur so that they can constantly adapt and improve. Given the complexity of surgery, and the error-prone environment within which it takes place, extracting positive behaviours from other high-performance disciplines will serve to improve performance and enhance patient safety. Surgery is being practiced in an ever-changing environment. Currently, there is less available operative experience for surgical trainees; multi-morbidity in patients is growing and rapidly evolving technology means that more high-tech equipment is being used in procedures. This article evaluates the effectiveness of current surgical protocol in reducing errors and possible modifications that can be made to fit the new environment that surgery is now being practiced in. It will then describe how three different high-performance disciplines: aviation, professional sport and Formula 1, have developed in their approaches to safety and excellence, which will serve as the basis for a discussion about what more can be learnt from these disciplines so that the surgical profession can continue to excel in the face of change.

Deep learning-based smart speaker to confirm surgical sites for cataract surgeries: A pilot study

Wrong-site surgeries can occur due to the absence of an appropriate surgical time-out. However, during a time-out, surgical participants are unable to review the patient's charts due to their aseptic hands. To improve the conditions in surgical time-outs, we introduce a deep learning-based smart speaker to confirm the surgical information prior to cataract surgeries. This pilot study utilized the publicly available audio vocabulary dataset and recorded audio data published by the authors. The audio clips of the target words, such as left, right, cataract, phacoemulsification, and intraocular lens, were selected to determine and confirm surgical information in the time-out speech. A deep convolutional neural network model was trained and implemented in the smart speaker that was developed using a mini development board and commercial speakerphone. To validate our model in the consecutive speeches during time-outs, we generated 200 time-out speeches for cataract surgeries by randomly selecting the surgical statuses of the surgical participants. After the training process, the deep learning model achieved an accuracy of 96.3% for the validation dataset of short-word audio clips. Our deep learning-based smart speaker achieved an accuracy of 93.5% for the 200 time-out speeches. The surgical and procedural accuracy was 100%. Additionally, on validating the deep learning model by using web-generated time-out speeches and video clips for general surgery, the model exhibited a robust and good performance. In this pilot study, the proposed deep learning-based smart speaker was able to successfully confirm the surgical information during the time-out speech. Future studies should focus on collecting real-world time-out data and automatically connecting the device to electronic health records. Adopting smart speaker-assisted time-out phases will improve the patients' safety during cataract surgeries, particularly in relation to wrong-site surgeries.

What is the effect of electronic clinical handovers on patient outcomes? A systematic review

Handover between physicians is a high-risk event for communication errors. Using electronic handover platforms has potential to improve the quality of informational transfer and therefore minimise this risk. This systematic review sought to compare the effectiveness of electronic handover methods on patient outcomes. Articles were identified by searching MEDLINE, EMbase, Scopus and CINAHL databases. Studies involving electronic handover between two healthcare personnel or teams, and which described patientspecific outcomes, were included. This search yielded 390 articles, with a total of nine publications included in the analysis. Outcomes reported in studies included length of stay, adverse event rates, time to procedure and handover completeness. This review suggests that e-handover may improve the handover completeness; however, it is unclear at this time if that translates to an improvement in patient care. The lack of reliable evidence highlights the need for further research exploring the effect of e-handovers on patient care.

Pediatric Perioperative Mortality in Kenya

Background

The global surgery access imbalance will have a dramatic impact on the growing population of the world’s children. In regions of the world with pediatric surgery and anesthesia manpower deficits and pediatric surgery–specific infrastructure and supply chain gaps, this expanding population will present new challenges. Perioperative mortality rate is an established indicator of the quality and safety of surgical care. To establish a baseline pediatric perioperative mortality rate and factors associated with mortality in Kenya, the authors designed a prospective cohort study and measured 24-h, 48-h, and 7-day perioperative mortality.

Methods

The authors trained anesthesia providers to electronically collect 132 data elements for pediatric surgical cases in 24 government and nongovernment facilities at primary, secondary, and tertiary hospitals from January 2014 to December 2016. Data assistants tracked all patients to 7 days postoperative, even if they had been discharged. Adjusted analyses were performed to compare mortality among different hospital levels after adjusting for prespecified risk factors.

Results

Of 6,005 cases analyzed, there were 46 (0.8%) 24-h, 62 (1.1%) 48-h, and 77 (1.7%) 7-day cumulative mortalities reported. In the adjusted analysis, factors associated with a statistically significant increase in 7-day mortality were American Society of Anesthesiologists Physical Status of III or more, night or weekend surgery, and not having the Safe Surgery Checklist performed. The 7-day perioperative mortality rate is less in the secondary (1.4%) and tertiary (2.4%) hospitals when compared with the primary (3.7%) hospitals.

Conclusions

The authors have established a baseline pediatric perioperative mortality rate that is greater than 100 times higher than in high-income countries. The authors have identified factors associated with an increased mortality, such as not using the Safe Surgery Checklist. This analysis may be helpful in establishing pediatric surgical care systems in low–middle income countries and develop research pathways addressing interventions that will assist in decreasing mortality rate.

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Impact of post-haemorrhoidectomy pain relief checklists on pain outcomes: a randomized controlled trial

BACKGROUND

Haemorrhoidectomy is associated with significant post-operative pain which is primarily managed pharmacologically. Whether a non-pharmacological adjunct such as a checklist can improve pain outcomes after an open haemorrhoidectomy has yet to be studied. The purpose of this study was to determine if a patient-completed checklist of prescribed post-haemorrhoidectomy pain medications would improve pain management after surgery.

METHODS

We conducted a dual-centre randomized controlled trial of patients undergoing a Milligan-Morgan haemorrhoidectomy for symptomatic third or fourth degree haemorrhoids. Thirty-five patients were randomized into either a control group which received post-operative pain medication plus a visual analogue scale (VAS) form, or an intervention group which received a post-operative medication checklist in addition to the items the control group received. Both groups recorded their pain levels on the VAS forms at 10.00, 14.00 and 20.00 hours each day for 14 days post-operatively.

RESULTS

Patients in the checklist group reported a significantly greater reduction in mean VAS pain score of 2.51 (95% confidence interval (CI) 1.34-3.68; P < 0.001) between day 1 post-op and day 14 post-op compared to 1.86 (95% CI 0.77-2.95; P = 0.001) for the control group. There was no significant difference between mean pain experienced by patients in either group over each of the 14 days individually or overall (P = 0.07).

CONCLUSION

The pain medication checklist lead to a greater reduction in pain between day 1 and 14 after an open haemorrhoidectomy compared to standard care but did not significantly reduce mean pain across any individual days or overall.

Near-Infrared Spectroscopy Monitoring in Cardiac and Noncardiac Surgery: Pairwise and Network Meta-Analyses

Goal-directed therapy based on brain-oxygen saturation (bSo2) is controversial and hotly debated. While meta-analyses of aggregated data have shown no clinical benefit for brain near-infrared spectroscopy (NIRS)-based interventions after cardiac surgery, no network meta-analyses involving both major cardiac and noncardiac procedures have yet been undertaken. Randomized controlled trials involving NIRS monitoring in both major cardiac and noncardiac surgery were included. Aggregate-level data summary estimates of critical outcomes (postoperative cognitive decline (POCD)/postoperative delirium (POD), acute kidney injury, cardiovascular events, bleeding/need for transfusion, and postoperative mortality) were obtained. NIRS was only associated with protection against POCD/POD in cardiac surgery patients (pooled odds ratio (OR)/95% confidence interval (CI)/I2/number of studies (n): 0.34/0.14-0.85/75%/7), although a favorable effect was observed in the analysis, including both cardiac and noncardiac procedures. However, the benefit of the use of NIRS monitoring was undetectable in Bayesian network meta-analysis, although maintaining bSo2 > 80% of the baseline appeared to have the most pronounced impact. Evidence was imprecise regarding acute kidney injury, cardiovascular events, bleeding/need for transfusion, and postoperative mortality. There is evidence that brain NIRS-based algorithms are effective in preventing POCD/POD in cardiac surgery, but not in major noncardiac surgery. However, the specific target bSo2 threshold has yet to be determined.

Developing an intervention around referral and admissions to intensive care: a mixed-methods study

Background

Intensive care treatment can be life-saving, but it is invasive and distressing for patients receiving it and it is not always successful. Deciding whether or not a patient will benefit from intensive care is a difficult clinical and ethical challenge.

Objectives

To explore the decision-making process for referral and admission to the intensive care unit and to develop and test an intervention to improve it.

Methods

A mixed-methods study comprising (1) two systematic reviews investigating the factors associated with decisions to admit patients to the intensive care unit and the experiences of clinicians, patients and families; (2) observation of decisions and interviews with intensive care unit doctors, referring doctors, and patients and families in six NHS trusts in the Midlands, UK; (3) a choice experiment survey distributed to UK intensive care unit consultants and critical care outreach nurses, eliciting their preferences for factors used in decision-making for intensive care unit admission; (4) development of a decision-support intervention informed by the previous work streams, including an ethical framework for decision-making and supporting referral and decision-support forms and patient and family information leaflets. Implementation feasibility was tested in three NHS trusts; (5) development and testing of a tool to evaluate the ethical quality of decision-making related to intensive care unit admission, based on the assessment of patient records. The tool was tested for inter-rater and intersite reliability in 120 patient records.

Results

Influences on decision-making identified in the systematic review and ethnographic study included age, presence of chronic illness, functional status, presence of a do not attempt cardiopulmonary resuscitation order, referring specialty, referrer seniority and intensive care unit bed availability. Intensive care unit doctors used a gestalt assessment of the patient when making decisions. The choice experiment showed that age was the most important factor in consultants’ and critical care outreach nurses’ preferences for admission. The ethnographic study illuminated the complexity of the decision-making process, and the importance of interprofessional relationships and good communication between teams and with patients and families. Doctors found it difficult to articulate and balance the benefits and burdens of intensive care unit treatment for a patient. There was low uptake of the decision-support intervention, although doctors who used it noted that it improved articulation of reasons for decisions and communication with patients.

Limitations

Limitations existed in each of the component studies; for example, we had difficulty recruiting patients and families in our qualitative work. However, the project benefited from a mixed-method approach that mitigated the potential limitations of the component studies.

Conclusions

Decision-making surrounding referral and admission to the intensive care unit is complex. This study has provided evidence and resources to help clinicians and organisations aiming to improve the decision-making for and, ultimately, the care of critically ill patients.

Future work

Further research is needed into decision-making practices, particularly in how best to engage with patients and families during the decision process. The development and evaluation of training for clinicians involved in these decisions should be a priority for future work.

Study registration

The systematic reviews of this study are registered as PROSPERO CRD42016039054, CRD42015019711 and CRD42015019714.

Funding

The National Institute for Health Research Health Services and Delivery Research programme. The University of Aberdeen and the Chief Scientist Office of the Scottish Government Health and Social Care Directorates fund the Health Economics Research Unit.

World Health Organization Surgical Safety Checklist: Compliance and Associated Surgical Outcomes in Uganda's Referral Hospitals

BACKGROUND

A pilot study on the World Health Organization (WHO) Surgical Safety Checklist (SSC) showed a reduction in both major complications and mortality of surgical patients. Compliance with this checklist varies around the world. We aimed to determine the extent of compliance with the WHO SSC and its association with surgical outcomes in 5 of Uganda's referral hospitals.

METHODS

A multicentre prospective cohort study was conducted in 5 referral hospitals in Uganda. Using a questionnaire based on the WHO SSC, patients undergoing surgical operations were systematically recruited into the study from April 2016 to July 2016. The patients were followed up daily for 30 days or until discharge for the purpose of documentation of complications. Logistic regression and linear regression were used to assess for association between compliance and perioperative surgical outcomes.

RESULTS

We recruited 859 patients into the study. Overall compliance with the WHO SSC was 41.7% (95% confidence interval [CI], 39.7-43.8) ranging from 11.9% to 89.8% across the different hospitals. Overall compliance with "sign in" was 44.7% (95% CI, 43-45.6), with "time out" was 42.0% (95% CI, 39.4-44.6), and with "sign out" was 33.3% (95% CI, 30.7-35.9). There was no association between compliance and perioperative surgical outcomes: length of hospital stay, adverse events, and mortality.

CONCLUSIONS

This study revealed low levels of compliance with the WHO SSC. There was a statistically significant association between this level of compliance and the incidence of pain and loss of consciousness postoperatively.

Establishing a sustainable anaesthetic education programme at Jimma University Medical Centre, Ethiopia

Lack of continuing education and physician anaesthetist support are commonly cited problems amongst Ethiopian anaesthetic providers. Whilst operating at Jimma University Medical Centre (JUMC), Operation Smile volunteers identified a clear need for improvement in anaesthetic care delivery at JUMC. JUMC is a 450-bed university teaching hospital 350 km southwest of Addis Ababa. At the start of this programme it had two physician anaesthetists, with the majority of anaesthesia historically having been provided by non-physician anaesthesia providers. A visiting lecturer programme was established at JUMC in 2012 following collaboration between two consultant anaesthetists, working for Operation Smile and JUMC respectively. UK trainee anaesthetists in their final years of anaesthetic training volunteered at JUMC for periods of two to six months, providing sustainable education and consistent physician anaesthetist presence to support service provision and training. Over its six-year history, nine visiting lecturers have volunteered at JUMC. They have helped establish a postgraduate training programme in anaesthesia, assisting in the provision of a future physician anaesthetist workforce. Four different training courses designed for low- and middle-income countries (LMICs) have been delivered and visiting lecturers have trained local anaesthetists in subsequent course delivery. Patient safety and quality improvement projects have included introducing the World Health Organization Surgical Safety Checklist, Lifebox pulse oximeters, obstetric spinal anaesthesia packs, improving critical care delivery and establishing two post-anaesthetic care units. Development of partnerships on local, national and global platforms were key to the effective delivery of relevant sustainable education and support. Instilling local ownership proved fundamental to implementing change in the local safety culture at JUMC. Sound mentorship from anaesthetic consultant supervisors both in the UK and in Jimma was crucial to support the UK trainee anaesthetists working in a challenging global setting. This model of sustainable capacity building in an LMIC with a significant deficit in its physician workforce could be replicated in a similar LMIC setting.

Does Attending Surgeon Presence at the Preinduction Briefing Improve Operating Room Efficiency?

OBJECTIVE

To examine if attending surgeon presence at the preinduction briefing is associated with a shorter time to incision.

STUDY DESIGN

Retrospective cohort study and survey.

SETTING

Tertiary academic medical center.

SUBJECTS AND METHODS

A retrospective cohort study was conducted of 22,857 operations by 141 attending surgeons across 12 specialties between August 3, 2016, and June 21, 2018. The independent variable was attending surgeon presence at the preinduction briefing. Linear regression models compared time from room entry to incision overall, by service line, and by surgeon. We hypothesized a shorter time to incision when the attending surgeon was present and a larger effect for cases with complex surgical equipment or positioning. A survey was administered to evaluate attending surgeons' perceptions of the briefing, with a response rate of 68% (64 of 94 attending surgeons).

RESULTS

Cases for which the attending surgeon was present at the preinduction briefing had a statistically significant yet operationally minor reduction in mean time to incision when compared with cases when the attending surgeon was absent. After covariate adjustment, the mean time to incision was associated with an efficiency gain of 1.8 ± 0.5 minutes (mean ± SD; P < .001). There were no statistically significant differences in the subgroups of complex surgical equipment and complex positioning or in secondary analysis comparing service lines. The surgeon was the strongest confounding variable. Survey results demonstrated mild support: 55% of attending surgeons highly prioritized attending the preinduction briefing.

CONCLUSION

Attending surgeon presence at the preinduction briefing has only a minor effect on efficiency as measured by time to incision.

Characteristics of team briefings in gynecological surgery

Preoperative briefings have been proven beneficial for improving team performance in the operating room. However, there has been minimal research regarding team briefings in specific surgical domains. As part of a larger project to develop a briefing structure for gynecological surgery, the study aimed to better understand the current state of pre-operative team briefings in one department of an academic hospital. Twenty-four team briefings were observed and video recorded. Communication was analyzed and social network metrics were created based on the team member verbal interactions. Introductions occurred in only 25% of the briefings. Network analysis revealed that average team briefings exhibited a hierarchical structure of communication, with the surgeon speaking the most frequently. The average network for resident-led briefings displayed a non-hierarchical structure with all team members communicating with the resident. Briefings conducted without a standardized protocol can produce variable communication between the role leading and the team members present.

Maternal and perinatal mortality and complications associated with caesarean section in low-income and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Universal and timely access to a caesarean section is a key requirement for safe childbirth. We identified the burden of maternal and perinatal mortality and morbidity, and the risk factors following caesarean sections in low-income and middle-income countries (LMICs).

METHODS

For this systematic review and meta-analysis, we searched electronic databases including MEDLINE and Embase (from Jan 1, 1990, to Nov 20, 2017), without language restrictions, for studies on maternal or perinatal outcomes following caesarean sections in LMICs. We excluded studies in high-income countries, those involving non-pregnant women, case reports, and studies published before 1990. Two reviewers undertook the study selection, quality assessment, and data extraction independently. The main outcome being assessed was prevalence of maternal mortality in women undergoing caesarean sections in LMICs. We used a random effects model to synthesise the rate data, and reported the association between risk factors and outcomes using odds ratios with 95% CIs. The study protocol has been registered with PROSPERO, number CRD42015029191.

FINDINGS

We included 196 studies from 67 LMICs. The risk of maternal death in women who had a caesarean section (116 studies, 2 933 457 caesarean sections) was 7·6 per 1000 procedures (95% CI 6·6-8·6, τ²=0·81); the highest burden was in sub-Saharan Africa (10·9 per 1000; 9·5-12·5, τ²=0·81). A quarter of all women who died in LMICs (72 studies, 27 651 deaths) had undergone a caesarean section (23·8%, 95% CI 21·0-26·7; τ²=0·62).

INTERPRETATION

Maternal deaths and perinatal deaths following caesarean sections are disproportionately high in LMICs. The timing and urgency of caesarean section pose major risks.

FUNDING

Ammalife Charity and ELLY Appeal, Barts Charity, and the UK National Institute for Health Research.

Neither magic bullet nor a mere tool: negotiating multiple logics of the checklist in healthcare quality improvement

Over two decades, the checklist has risen to prominence in healthcare improvement. This paper contributes to the debate between its proponents and critics, making the case for an Science and Technology Studies-informed understanding of the checklist that demonstrates the limitations of both the "checklist-as-panacea" and "checklist-as-socially-determined" positions. Attending to the checklist as a socio-material object endowed with affordances that call upon clinicians to act (Allen 2012, Hutchby 2001), the study revisits the efforts of a recent improvement initiative, the Enhanced Peri-Operative Care for High-risk patients trial. Rather than a singularised simple tool, this study discusses four different and relationally enacted logics of the checklist as a stop and check tool, a clinical prompt, an audit tool and a clinical record. Each logic is associated with specific temporality, beneficiaries, relationship with material forms, and interpellates (Law 2002) clinicians to initiate specific actions which can conflict. The paper seeks to make the case for intervention to improve such tools and consciously account for the consequences of their design and materiality and calls for supporting such settings and arrangements in which incoherences collected in tools can be locally negotiated.

Reducing surgical mortality in Scotland by use of the WHO Surgical Safety Checklist

Background

The WHO Surgical Safety Checklist has been implemented widely since its launch in 2008. It was introduced in Scotland as part of the Scottish Patient Safety Programme (SPSP) between 2008 and 2010, and is now integral to surgical practice. Its influence on outcomes, when analysed at a population level, remains unclear.

Methods

This was a population cohort study. All admissions to any acute hospital in Scotland between 2000 and 2014 were included. Standardized differences were used to estimate the balance of demographics over time, after which interrupted time-series (segmented regression) analyses were performed. Data were obtained from the Information Services Division, Scotland.

Results

There were 12 667 926 hospital admissions, of which 6 839 736 had a surgical procedure. Amongst the surgical cohort, the inpatient mortality rate in 2000 was 0·76 (95 per cent c.i. 0·68 to 0·84) per cent, and in 2014 it was 0·46 (0·42 to 0·50) per cent. The checklist was associated with a 36·6 (95 per cent c.i. –55·2 to –17·9) per cent relative reduction in mortality (P &lt; 0·001). Mortality rates before implementation were decreasing by 0·003 (95 per cent c.i. –0·017 to +0·012) per cent per year; annual decreases of 0·069 (–0·092 to –0·046) per cent were seen during, and 0·019 (–0·038 to +0·001) per cent after, implementation. No such improvement trends were seen in the non-surgical cohort over this time frame.

Conclusion

Since the implementation of the checklist, as part of an overall national safety strategy, there has been a reduction in perioperative mortality.

Laboratory Monitoring and Transfusion Guidelines to Influence Care in Patients Undergoing Multilevel Spinal Fusion Surgery

PURPOSE

The purpose of this project was to determine whether the use of the modified Northwestern high risk spine protocol in patients undergoing multilevel spinal fusion surgery would result in improved transfusion practices.

DESIGN

Preimplementation and postimplementation design.

METHODS

A laboratory monitoring and transfusion guideline protocol was implemented in patients undergoing multilevel spinal fusions. Data were collected via a manual retrospective chart review of the electronic medical record before and after implementation of the protocol.

FINDINGS

Laboratory values were monitored at guided intervals. There was a statistically significant (P = .004) decrease in the mean hemoglobin value at which a packed red blood cell transfusion was initiated.

CONCLUSIONS

Through the use of the protocol, laboratory value monitoring provided quantitative data to aid and improve clinical decision making for practitioners in the perioperative period.

Effective Surgical Teams: An Integrative Literature Review

It is imperative to understand the factors that contribute to effective surgical teams. The aim of this integrative review was to evaluate the aids and barriers for perioperative teams in functioning effectively, preventing adverse events, and fostering a culture of safety. The literature search was undertaken of 15 databases, which resulted in 70 articles being included. It was found perioperative teamwork was not widely understood. Findings indicated barriers to effective surgical teams comprised of confusion in tasks and responsibilities, existing hierarchies and prevailing misconceptions and understanding among team members. Although numerous quality initiatives exist, the introduction of protocols and checklists, team effectiveness in the perioperative setting is still insufficient and challenges in establishing effective surgical teams continue. Further research is recommended to obtain a comprehensive perception of environmental influences and barriers surgical teams encounter in the delivery of safe quality care.

Acute upper gastrointestinal bleeding: a guide for nurses

This article outlines latest evidence-based care for patients with acute upper gastrointestinal (GI) bleeding. It aims to help gastroenterology and general medical ward nurses plan nursing interventions and understand the diagnostic treatment options available. Acute upper GI bleeding can present as variceal or non-variceal bleeding and has a high death rate. Endoscopy is used for diagnosis and to provide therapy, prior to which the patient should be adequately resuscitated and assessed. Various therapies can be initiated at endoscopy, depending on the source of bleeding. If bleeding continues in spite of these therapies, further interventions such as the Sengstaken tube, oesophageal stents, radiological or surgical treatments may be required. After endoscopy, it is important to have a plan for ongoing treatment. Patients may require acid suppression treatment or eradication of Helicobacter pylori as part of their treatment plan. They may in additional require correction of their haemoglobin levels and follow-up endoscopy. It is essential that nurses caring for such patients are aware of the current UK guidance and help patients to adhere to agreed treatment plans.

Role of Perioperative Surgical Safety Checklist in Reducing Morbidity and Mortality among Patients: An Observational Study

Background:

Safe Surgery Saves Lives. Patient safety is a fundamental of good quality health care, and complications due to the health-care system are well-documented and constitute an important public health problem. Implementation of the checklist in medicine and surgery can help to decrease the risk of adverse events thus can improve patient safety.

Materials and Methods:

After the Institutional Ethical Committee clearance, a total of 500 patients were enrolled and divided into two equal groups. In Group 1 (n = 250), patients underwent surgery before regular implementation of the World Health Organization (WHO) surgical safety checklist (SSC), whereas in Group 2 (n = 250), patients underwent surgery after the WHO SSC was regularly implemented. All the patients were followed up after the surgery, and patients were looked for and compared for the postoperative complications.

Results:

We found that 27 patients (10.8%) in Group 1 and 13 patients (5.2%) in Group 2 developed major wound disruption (P < 0.05). There were 73 patients (29.2%) in Group 1 and 34 patients (13.6%) in the Group 2 who developed an infection of the surgical site (P < 0.05). There were five patients (2%) in Group 1 while none of the patients in Group 2 developed sepsis during the study (P < 0.05).

Conclusions:

We found that implementation of the WHO SSC significantly reduces surgical site infections, major disruptions of the wound, and sepsis.

Data Integrity-Based Methodology and Checklist for Identifying Implementation Risks of Physiological Sensing in Mobile Health Projects: Quantitative and Qualitative Analysis

Background

Mobile health (mHealth) technologies have the potential to bring health care closer to people with otherwise limited access to adequate health care. However, physiological monitoring using mobile medical sensors is not yet widely used as adding biomedical sensors to mHealth projects inherently introduces new challenges. Thus far, no methodology exists to systematically evaluate these implementation challenges and identify the related risks.

Objective

This study aimed to facilitate the implementation of mHealth initiatives with mobile physiological sensing in constrained health systems by developing a methodology to systematically evaluate potential challenges and implementation risks.

Methods

We performed a quantitative analysis of physiological data obtained from a randomized household intervention trial that implemented sensor-based mHealth tools (pulse oximetry combined with a respiratory rate assessment app) to monitor health outcomes of 317 children (aged 6-36 months) that were visited weekly by 1 of 9 field workers in a rural Peruvian setting. The analysis focused on data integrity such as data completeness and signal quality. In addition, we performed a qualitative analysis of pretrial usability and semistructured posttrial interviews with a subset of app users (7 field workers and 7 health care center staff members) focusing on data integrity and reasons for loss thereof. Common themes were identified using a content analysis approach. Risk factors of each theme were detailed and then generalized and expanded into a checklist by reviewing 8 mHealth projects from the literature. An expert panel evaluated the checklist during 2 iterations until agreement between the 5 experts was achieved.

Results

Pulse oximetry signals were recorded in 78.36% (12,098/15,439) of subject visits where tablets were used. Signal quality decreased for 1 and increased for 7 field workers over time (1 excluded). Usability issues were addressed and the workflow was improved. Users considered the app easy and logical to use. In the qualitative analysis, we constructed a thematic map with the causes of low data integrity. We sorted them into 5 main challenge categories: environment, technology, user skills, user motivation, and subject engagement. The obtained categories were translated into detailed risk factors and presented in the form of an actionable checklist to evaluate possible implementation risks. By visually inspecting the checklist, open issues and sources for potential risks can be easily identified.

Conclusions

We developed a data integrity–based methodology to assess the potential challenges and risks of sensor-based mHealth projects. Aiming at improving data integrity, implementers can focus on the evaluation of environment, technology, user skills, user motivation, and subject engagement challenges. We provide a checklist to assist mHealth implementers with a structured evaluation protocol when planning and preparing projects.

Health and sustainable development; strengthening peri-operative care in low income countries to improve maternal and neonatal outcomes

BACKGROUND

Uganda is far from meeting the sustainable development goals on maternal and neonatal mortality with a maternal mortality ratio of 383/100,000 live births, and 33% of the women gave birth by 18 years. The neonatal mortality ratio was 29/1000 live births and 96 stillbirths occur every day due to placental abruption, and/or eclampsia - preeclampsia and other unkown causes. These deaths could be reduced with access to timely safe surgery and safe anaesthesia if the Comprehensive Emergency Obstetric and Newborn Care services (CEmONC), and appropriate intensive care post operatively were implemented. A 2013 multi-national survey by Epiu et al. showed that, the Safe Surgical Checklist was not available for use at main referral hospitals in East Africa. We, therefore, set out to further assess 64 government and private hospitals in Uganda for the availability and usage of the WHO Checklists, and investigate the post-operative care of paturients; to advocate for CEmONC implementation in similarly burdened low income countries.

METHODS

The cross-sectional survey was conducted at 64 government and private hospitals in Uganda using preset questionnaires.

RESULTS

We surveyed 41% of all hospitals in Uganda: 100% of the government regional referral hospitals, 16% of government district hospitals and 33% of all private hospitals. Only 22/64 (34.38%: 95% CI = 23.56-47.09) used the WHO Safe Surgical Checklist. Additionally, only 6% of the government hospitals and 14% not-for profit hospitals had access to Intensive Care Unit (ICU) services for postoperative care compared to 57% of the private hospitals.

CONCLUSIONS

There is urgent need to make WHO checklists available and operationalized. Strengthening peri-operative care in obstetrics would decrease maternal and neonatal morbidity and move closer to the goal of safe motherhood working towards Universal Health Care.

Distractions and interruptions in a surgical room: perception of nursing staff

Abstract Objective: To understand the perception of nursing staff about intraoperative distractions and interruptions. Methods: An exploratory qualitative study was performed with 16 nursing professionals of a surgical center in Minas Gerais. The data were collected through a semi-structured interview and thematic content analysis was performed. Results: When reflecting on the occurrence of distractions and interruptions of intraoperative activities, nursing professionals define, identify and value events in a heterogeneous way, but believe that distractions and interruptions negatively affect both the quality of the work environment and the safety of care provided to the surgical patient. Factors contributing to the occurrence of distractions and interruptions are related to aspects inside the operating room such as equipment failure and use of cell phones and to external factors such as verbal messages given at the operating room door. Incidents have been reported due to distractions, but there are no established actions to minimize these events. Conclusion: This study indicates the importance of implementing strategies that minimize the occurrence of distractions and interruptions of intraoperative activities in order to plan surgical care better, and prevent and mitigate harm to patients.