Evidence-based guidelines on infection prevention and control in operation theatres for anesthetists in a resource-limited setting: systematic review/meta-analysis

Surgical site infections and nosocomial infections are the most frequent source of prolonged hospital stay and cross-contamination of infection in the operating room. Despite the perception, the operating rooms are not sterile environments as it has sterile and nonsterile areas, as well as sterile and nonsterile personnel. The contaminated environment, like the anesthesia environment, is the most potent transmission vehicle for pathogens.

Objective

The objective of this review is to develop evidence-based guidelines on infection prevention and control in operation theaters for anesthesia care providers in a resource-limited setting.

Methodology

This review is reported based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Articles published in the English language were searched from different sources to identify studies for the review using the keywords. Database search was done by using Boolean operators like AND, OR, NOT, or AND NOT from Cochrane review, Hinari, PubMed, Google Scholar, and Medline databases, and filtering was made based on the intervention, outcome, data on population, and methodological quality. The conclusion was made based on the level of evidence that was referred to by the Oxford Center for Evidence-Based Medicine.

Results

Generally, 1672 articles were identified through database searching strategies. Articles were searched by filtering systems such as publication year, level of evidence, and duplicates that were unrelated to the topics. Finally, 20 articles (9 randomized controlled trials, 4 meta-analyses and systematic reviews, 4 reviews, and 3 observational studies) were identified by using keywords from different databases by different search strategies from 10 July to 14 August 2022.

Conclusion

As primary patient patrols anesthetists face significant infection risk and also contaminate the operating room environment. Precautions that are practical, affordable, and efficient in the anesthesia setting are needed considering the limited availability of personal protective equipment.

Environmentally Sustainable Practices in the Operating Room: A French Nationwide Cross-Sectional Survey of Anaesthesiologists and Nurse Anaesthesiologists

OBJECTIVE

In France, healthcare facilities account for 7% of greenhouse gas emissions and 3.5% of total waste generation. Operating rooms generate 30% of hospital waste and hence should be a primary focus of environmental sustainability initiatives. The aim of this study was to evaluate environmentally sustainable anaesthesiology practices in France in 2020 and understand the barriers to their adoption.

METHODS

An anonymous survey of 28 questions was published online. The website did not record participants' IP addresses. The survey's link was sent by email to anaesthesiologist and anaesthesia nurse members of the French Society of Anesthesia and Intensive Care Medecine (SFAR), in February and June 2020. The survey was closed in August 2020.

RESULTS

Of the 10 877 recipients, 1092 (10%) responded to the questionnaire. Waste sorting was organized in 69% of respondents' workplaces (691/1007), and 90% (793/879) of respondents stated that they most often followed the instructions. Sixty-five percent (659/1007) of respondents avoided using the most polluting anaesthetic gases. Thirty-nine percent of respondents (417/1064) had already received environmental sustainability training and 73% (705/972) stated that they wanted more training. The main barriers to the adoption of recycling identified by respondents were staff training (by 70% of respondents, 691/993), budget constraints (66%, 652/993), and a lack of administrative support (60%, 602/993).

CONCLUSION

French anaesthesiologists and anaesthesia nurses who responded to the survey are environmentally aware and want to improve sustainable practices in the operating room. More widespread adoption could be achieved by offering training to all healthcare professionals and administrative staff and by creating local environmental focus groups to coordinate actions.

Risk factors for unplanned return to the operating room within 24 hours: A 9-year single-center observational study

The purpose of the retrospective case-control study was to identify the causes of and risk factors for unplanned return to the operating room (uROR) within 24 hours in surgical patients.We examined 275 cases of 24-hour uROR in our hospital from January 2010 to December 2018. The reasons for 24-hour uROR were classified into several categories. Controls were randomly matched to cases in a 1:1 ratio with the selection criteria set for the same surgeon and operation code in the same corresponding year.The mortality rate was significantly higher in patients with 24-hour uROR (11.63% vs 5.23%). Bleeding was the most common etiology (172/275; 62.55%) and technical error (14.5%) also contributed to 24-hour uROR. The clinical factors that led to bleeding included a history of liver disease (P = .032), smoking (P = .002), low platelet count in preoperative screening (P = .012), and preoperative administration of antiplatelet or anticoagulant agents (P = .014).Clinicians should recognize the risk factors for bleeding and minimize errors to avoid the increase in patient morbidity and mortality that is associated with 24-hour uROR.Level of Evidence: Level IV.

Pressure Injury Prevention for Complex Cardiovascular Patients in the Operating Room and Intensive Care Unit: A Quality Improvement Project

PURPOSE

The purpose of our project was to examine the effect of an alternating pressure (AP) overlay on hospital-acquired pressure injury (HAPI) in high-risk cardiovascular surgical patients.

PARTICIPANTS AND SETTING

This quality improvement (QI) initiative was conducted in a core group of 8 cardiovascular operating room (OR) suites and 1 cardiovascular surgical critical intensive care unit (ICU) in a large Indiana-based academic hospital. The sample comprised adult patients who underwent complex cardiovascular surgical procedures and those in the cardiovascular surgical ICU with extracorporeal membrane oxygenation (ECMO), ventricular assistive device (VAD), and undergoing heart and/or lung transplant, or open chest procedures.

APPROACH

The AP overlay was placed on OR cardiovascular foam surfaces and on selected ICU support surfaces for patients who met inclusion criteria. We used a pre/postcomparative QI design to assess outcomes including OR-related HAPI rates, ICU aggregate unit HAPI data, related costs, and staff satisfaction during the 3-month project period.

OUTCOMES

Operating room-related HAPIs were reduced from 8/71 (11%) preintervention to 0/147 (0%) postintervention (P = .008), resulting in a cost avoidance of $323,048 and positive staff satisfaction (mean = 3.85; 1- to 4-point Likert scale). No adverse outcomes occurred. Although not significant, ICU HAPI rates decreased from 10 to 7 pre/postintervention (P = .29), demonstrating a 14% HAPI reduction with a cost avoidance of $121,143. The ICU incidence density decreased from 3.57 to 3.24; however, there was no decrease in ICU monthly unit prevalence. Critical care staff satisfaction was positive (mean = 2.95; 1- to 4-point Likert scale) with most staff members preferring the AP overlay to a fluid immersion surface. A cost savings of 48% (AP overlay vs fluid immersion rental) was identified in the ICU.

IMPLICATIONS FOR PRACTICE

We achieved fewer HAPIs and reduced costs and observed positive staff satisfaction, along with no adverse events with the use of the AP overlay. Further research is needed to determine the safety and efficacy of this device for this pressure injury prevention option for immobile patients in both the OR and the ICU.

Quality improvement in the surgery-related processes: Managerial challenges and solutions from hospitals of Iran

BACKGROUND

There is a growing global movement toward quality and safety in healthcare and quality improvement (QI) in general surgery. The first step in any QI initiative is identifying the challenges and barriers to achieve such goals and then to define appropriate actions. This study aims to provide an overview of the QI challenges in Iranian hospitals' surgery-related processes and suggest applied solutions accordingly.

METHODS

This is a sequential (qual-quant) mixed-method study from November 2019 to January 2020, involving 21 face-to-face interviews with hospital managers, quality officers, and surgery-related clinicians and staff, followed by a Delphi consensus-seeking stage to finalize solutions. MAXQDA software was applied for organizing the concepts, and thematic content analysis was used for analyzing the data as an inductive approach to extract the emerging themes and sub-themes.

RESULTS

The managerial problems were classified into four groups of (I) defects and delays in completing patient medical records, (II) irregularity and the lack of transparency in the direction of processes in the hospital, (III) inappropriate and unrealistic operating scheduling, and (IV) poor safety considerations. The proposed solutions included imposing stricter regulations for competing for medical records, such as reduction of payments, development of guiding brochures or protocols for patients on their arrival, assigning a certain number of experienced nurses and surgeons for schedule management, rewarding the report of medical and surgical error cases, and developing a regular monitoring program for the proper implementation of surgical safety guidelines.

CONCLUSION

There are various managerial barriers that hamper QI in hospitals' surgery-related processes. Implementing simple but agreed solutions can lead to saving patients' lives, reduction of the unnecessary use of resources, and enhance of patient and staff satisfaction.

Emergency Surgery during COVID-19: Lessons Learned

Introduction  The ongoing coronavirus disease-2019 (COVID-19) pandemic has disrupted health services throughout the world. It has brought in several new challenges to deal with surgical emergencies. Herein, we report two suspected cases of COVID-19 that were operated during this "lockdown" period and highlight the protocols we followed and lessons we learned from this situation. Result  Two patients from "red zones" for COVID-19 pandemic presented with acute abdomen, one a 64-year male, who presented with perforation peritonitis and another, a 57-year male with acute intestinal obstruction due to sigmoid volvulus. They also had associated COVID-19 symptoms. COVID-19 test could not be done at the time of their presentation to the hospital. Patients underwent emergency exploratory laparotomy assuming them to be positive for the infection. Surgical team was donned with full coverall personal protective equipment. Sudden and uncontrolled egression intraperitoneal free gas was avoided, Echelon flex 60 staplers were used to resect the volvulus without allowing the gas from the volvulus to escape; mesocolon was divided using vascular reload of the stapler, no electrosurgical devices were used to avoid the aerosolization of viral particles. Colostomy was done in both the patients. Both the patients turned out to be negative for COVID-19 subsequently and discharged from hospital in stable condition. Conclusion  Surgeons need to adapt to safely execute emergency surgical procedures during this period of COVID-19 pandemic. Preparedness is of paramount importance. Full precautionary measures should be taken when dealing with any suspected case.

All India difficult airway association (AIDAA) consensus guidelines for airway management in the operating room during the COVID-19 pandemic

Severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) which causes coronavirus disease (COVID-19) is a highly contagious virus. The closed environment of the operation room (OR) with aerosol generating airway management procedures increases the risk of transmission of infection among the anaesthesiologists and other OR personnel. Wearing complete, fluid impermeable personal protective equipment (PPE) for airway related procedures is recommended. Team preparation, clear methods of communication and appropriate donning and doffing of PPEs are essential to prevent spread of the infection. Optimal pre oxygenation, rapid sequence induction and video laryngoscope aided tracheal intubation (TI) are recommended. Supraglottic airways (SGA) and surgical cricothyroidotomy should be preferred for airway rescue. High flow nasal oxygen, face mask ventilation, nebulisation, small bore cannula cricothyroidotomy with jet ventilation should be avoided. Tracheal extubation should be conducted with the same levels of precaution as TI. The All India Difficult Airway Association (AIDAA) aims to provide consensus guidelines for safe airway management in the OR, while attempting to prevent transmission of infection to the OR personnel during the COVID-19 pandemic.

Educational concern of surgical technology students in the operating room: A grounded theory study

INTRODUCTION

Bachelor's program in surgical technology is a major of medical science, in Iran. Learning and adapting to different skills and roles in the operation room environment is a daunting work. The complexity of this environment needs to bring together researchers in this field to work on different aspects. The aim of this qualitative study was comprehensively understanding of clinical teaching process in surgical technology.

MATERIALS AND METHODS

The present study was conducted based on the qualitative research design of the grounded theory approach (Corbin and Strauss, 2008). This study was conducted at schools of nursing and paramedical in five academic settings. Study participants in the present study include 14 students, seven educational instructors, six staff of operation room, one dean of faculty, three surgeon assistants, one instructor, and four head nurses of operation room. A semi-structured interview method and a memo were conducted using theoretical and purposive sampling. Constant comparative analysis was used for data analysis.

RESULTS

Findings showed that the nonacceptance of student by surgical team was identified as the main concern of the students. The "gaining clinical competence and approval" was found the central process (strategy) in response to main concern of clinical education, and the "interactive and dynamic nature of the operation room environment" was defined as the context for this major concern. Strategies that students used to address this concern included individual efforts to overcome distrust, learning in the shadow of surgical team members, and seeking help and support of the instructor.

CONCLUSION

Accepting the students of surgical technology as a member of surgical team creates opportunities for students to learn, gain experience, and enhance their professional qualifications and abilities.

Non-technical skills training to enhance performance of obstetrics and gynaecology residents in the operating room

The importance of incorporating non-technical skills in surgical training cannot be understated, however, these remain non-core components of training. The aim of our study was to evaluate the effectiveness of a training course in improving residents' non-technical skills performance in the operating room. Twenty-eight eligible Obstetrics and Gynaecology residents were divided into conventional and experimental groups by using blocked randomisation. The experimental group received a training course comprising of 20 h over 5 weeks as an educational intervention. A blinded assessor assessed non-technical skill performance by using non-technical skill for surgeons rating system while performing two procedures evacuation and curettage and elective caesarean section in pretest and post-test phase. The post-test results of experimental training group improved significantly in all four categories: situational awareness, decision-making, communication and leadership than the conventional training group demonstrating the effectiveness of a training course. Participants found the course useful and relevant to their practices and strongly recommended the incorporation of similar courses in early years of training. Impact Statement What is already known on this subject? Operating room is the mainstay of surgeons and the majority of the studies done in the operating room relate to structured courses to teach residents about non-technical skills, with training and evaluation done on the same day. These either explores the perception of trainees, expansion of the cognitive component and/or feasibility of training for non-technical skills. To date, there is a lack of evidence in the literature to address questions regarding the appropriate time to incorporate non-technical skills in the curriculum, due to study designs. This highlights the need for more randomised control trials with different curricular designs to evaluate effectiveness. What do the results of this study add? The results of our study enable a comparative analysis between learning curves of conventional training, with the experimental group demonstrating the effectiveness of a training course. This strongly supports implementation of non-technical training in postgraduate competency-based curricula. What are the implications of these findings for clinical practice and/or further research? This study shall be used as an evidence-based source to design curricula for teaching non-technical skills to residents.

Response to a Fire Incident in the Operation Room: A Cautionary Tale

Health care facilities are always seen as places of haven and protection for managing external incidents, but situations become difficult and challenging when such facilities themselves are affected by internal hazards. Such incidents are arguably more disruptive than external incidents, because patients are dependent on supportive measures and are neither in position to respond to such crisis situation nor do they know how to respond. Operating room fires are rare but potentially catastrophic, involving loss of costly resources and possibly lives. This case report details a true operating room fire incident in an emergency operating room and details the real-life challenges encountered by operating room staff in preserving both life and property. As a result of this work, precautionary measures may be implemented to mitigate such incidents. Careful coordination, continuous training, and fire drill exercises can improve the overall outcomes and minimize the possibility of these potentially fatal problems, thereby making a safer health care environment for every worker and patient.

Balanced versus isotonic saline resuscitation-a systematic review and meta-analysis of randomized controlled trials in operation rooms and intensive care units

BACKGROUND

Fluid resuscitation is the cornerstone in treatment of shock, and intravenous fluid administration is the most frequent intervention in operation rooms and intensive care units (ICUs). The composition of fluids used for fluid resuscitation gained interest over the past decade, with recent focus on whether balanced solutions should be preferred over isotonic saline.

METHODS

Systematic review and meta-analysis of randomized controlled trials (RCTs) comparing fluid resuscitation with a balanced solution versus isotonic saline in adult patients in operation room or ICUs. Primary outcome was in-hospital mortality, secondary outcomes included occurrence of acute kidney injury (AKI) and need for renal replacement therapy (RRT).

RESULTS

The search identified 11 RCTs involving 2,703 patients; 8 trials were conducted in operation room and 3 in ICU. In-hospital mortality, as well as the occurrence of AKI and need for RRT was not different between resuscitation with balanced solutions versus isotonic saline, neither in operation room nor in ICU patients. Serum chloride levels, but not arterial pH, were significantly lower in patients resuscitated with balanced solutions.

CONCLUSIONS

Currently evidence insufficiently supports the use of balanced over isotonic saline for fluid resuscitation to improve outcome of operation room and ICU patients.

Application of mathematical models in combination with Monte Carlo simulation for prediction of isoflurane concentration in an operation room theater

Applicability of two mathematical models in inhalation exposure prediction (well mixed room and near field-far field model) were validated against standard sampling method in one operation room for isoflurane. Ninety six air samples were collected from near and far field of the room and quantified by gas chromatography-flame ionization detector. Isoflurane concentration was also predicted by the models. Monte Carlo simulation was used to incorporate the role of parameters variability. The models relatively gave more conservative results than the measurements. There was no significant difference between the models and direct measurements results. There was no difference between the concentration prediction of well mixed room model and near field far field model. It suggests that the dispersion regime in room was close to well mixed situation. Direct sampling showed that the exposure in the same room for same type of operation could be up to 17 times variable which can be incorporated by Monte Carlo simulation. Mathematical models are valuable option for prediction of exposure in operation rooms. Our results also suggest that incorporating the role of parameters variability by conducting Monte Carlo simulation can enhance the strength of prediction in occupational hygiene decision making.

Anesthetic drug wastage in the operation room: A cause for concern

CONTEXT

The cost of anesthetic technique has three main components, i.e., disposable supplies, equipments, and anesthetic drugs. Drug budgets are an easily identifiable area for short-term savings.

AIM

To assess and estimate the amount of anesthetic drug wastage in the general surgical operation room. Also, to analyze the financial implications to the hospital due to drug wastage and suggest appropriate steps to prevent or minimize this wastage.

SETTINGS AND DESIGN

A prospective observational study conducted in the general surgical operation room of a tertiary care hospital.

MATERIALS AND METHODS

Drug wastage was considered as the amount of drug left unutilized in the syringes/vials after completion of a case and any ampoule or vial broken while loading. An estimation of the cost of wasted drug was made.

RESULTS

Maximal wastage was associated with adrenaline and lignocaine (100% and 93.63%, respectively). The drugs which accounted for maximum wastage due to not being used after loading into a syringe were adrenaline (95.24%), succinylcholine (92.63%), lignocaine (92.51%), mephentermine (83.80%), and atropine (81.82%). The cost of wasted drugs for the study duration was 46.57% (Rs. 16,044.01) of the total cost of drugs issued/loaded (Rs. 34,449.44). Of this, the cost of wastage of propofol was maximum being 56.27% (Rs. 9028.16) of the total wastage cost, followed by rocuronium 17.80% (Rs. 2856), vecuronium 5.23% (Rs. 840), and neostigmine 4.12% (Rs. 661.50).

CONCLUSIONS

Drug wastage and the ensuing financial loss can be significant during the anesthetic management of surgical cases. Propofol, rocuronium, vecuronium, and neostigmine are the drugs which contribute maximally to the total wastage cost. Judicious use of these and other drugs and appropriate prudent measures as suggested can effectively decrease this cost.