Sustainability in surgical practice: a collaborative call toward environmental sustainability in operating rooms.

BACKGROUND: The healthcare system plays a pivotal role in environmental sustainability, and the operating room (OR) significantly contributes to its overall carbon footprint. In response to this critical challenge, leading medical societies, government bodies, regulatory agencies, and industry stakeholders are taking measures to address healthcare sustainability and its impact on climate change. Healthcare now represents almost 20% of the US national economy and 8.5% of US carbon emissions. Internationally, healthcare represents 5% of global carbon emissions. US Healthcare is an outlier in both per capita cost, and per capita greenhouse gas emission, with almost twice per capita emissions compared to every other country in the world. METHODS: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the European Association for Endoscopic Surgery (EAES) established the Sustainability in Surgical Practice joint task force in 2023. This collaborative effort aims to actively promote education, mitigation, and innovation, steering surgical practices toward a more sustainable future. RESULTS: Several key initiatives have included a survey of members' knowledge and awareness, a scoping review of terminology, metrics, and initiatives, and deep engagement of key stakeholders. DISCUSSION: This position paper serves as a Call to Action, proposing a series of actions to catalyze and accelerate the surgical sustainability leadership needed to respond effectively to climate change, and to lead the societal transformation towards health that our times demand.

Frontline nursing staff's perceptions of intravenous medication administration: the first step toward safer infusion processes-a qualitative study.

OBJECTIVES: Intravenous medication errors continue to significantly impact patient safety and outcomes. This study sought to clarify the complexity and risks of the intravenous administration process. DESIGN: A qualitative focus group interview study. SETTING: Focused interviews were conducted using process mapping with frontline nurses responsible for medication administration in September 2020. PARTICIPANTS: Front line experiened nurses from a Japanese tertiary teaching hospital. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measure was to identify the mental models frontline nurses used during intravenous medication administration, which influence their interactions with patients, and secondarily, to examine the medication process gaps between the mental models nurses perceive and the actual defined medication administration process. RESULTS: We found gaps between the perceived clinical administration process and the real process challenges with an emphasis on the importance of verifying to see if the drug was ordered for the patient immediately before its administration. CONCLUSIONS: This novel and applied improvement approach can help nurses and managers better understand the process vulnerability of the infusion process and develop a deeper understanding of the administration steps useful for reliably improving the safety of intravenous medications.

The growing burden of workplace violence against healthcare workers: trends in prevalence, risk factors, consequences, and prevention - a narrative review.

Workplace violence (WPV) against healthcare workers (HCW) is a globally growing problem in healthcare systems. Despite decades of research and interventions violent incidents are rising in their severity and frequency. A structured review of PubMed and Scopus databases and supplementary internet searches, resulted in a synthesis of evidence covering multiple countries and healthcare worker populations. High rates of WPV are increasingly common due to unmet patient expectations, poor communication, long wait times and organizational factors such as resourcing and infrastructure. We highlight links between WPV and poor worker health outcomes, staff turnover, reduced patient safety and medical errors. Few prevention and mitigation activities have shown sustained effects, highlighting the challenges in understanding and addressing the complex interplay of factors that drive violence against HCWs. The rapidly rising incidence of WPV requires special consideration and action from multiple stakeholders including patients and visitors, healthcare providers, law enforcement, media and policy makers.

Validation of a natural language processing algorithm using national reporting data to improve identification of anesthesia-related ADVerse evENTs: The "ADVENTURE" study.

BACKGROUND: Reporting and analysis of adverse events (AE) is associated with improved health system learning, quality outcomes, and patient safety. Manual text analysis is time-consuming, costly, and prone to human errors. We aimed to demonstrate the feasibility of novel machine learning and natural language processing (NLP) approaches for early predictions of adverse events and provide input to direct quality improvement and patient safety initiatives. METHODS: We used machine learning to analyze 9559 continuously reported AE by clinicians and healthcare systems to the French National Health accreditor (HAS) between January 1, 2009, and December 31, 2020 . We validated the labeling of 135,000 unique de-identified AE reports and determined the associations between different system's root causes and patient consequences. The model was validated by independent expert anesthesiologists. RESULTS: The machine learning (ML) and Artificial Intelligence (AI) model trained on 9559 AE datasets accurately categorized 8800 (88%) of reported AE. The three most frequent AE types were "difficult orotracheal intubation" (16.9% of AE reports), "medication error" (10.5%), and "post-induction hypotension" (6.9%). The accuracy of the AI model reached 70.9% sensitivity, 96.6% specificity for "difficult intubation", 43.2% sensitivity, and 98.9% specificity for "medication error." CONCLUSIONS: This unsupervised ML method provides an accurate, automated, AI-supported search algorithm that ranks and helps to understand complex risk patterns and has greater speed, precision, and clarity when compared to manual human data extraction. Machine learning and Natural language processing (NLP) models can effectively be used to process natural language AE reports and augment expert clinician input. This model can support clinical applications and methodological standards and used to better inform and enhance decision-making for improved risk management and patient safety. TRIAL REGISTRATION: The study was approved by the ethics committee of the French Society of Anesthesiology (IRB 00010254-2020-20) and the CNIL (CNIL: 118 58 95) and the study was registered with ClinicalTrials.gov (NCT: NCT05185479).

Teaching Medical Procedural Skills for Performance.

Procedures are a core element of medical professional practice. Today's training approach was formulated in the mid-twentieth century based on a computer analogue of the brain. Despite minor modifications, the system has remained relatively unchanged for the past 70 years. It delivers competence. However, competence is not reliable performance. The inability to adapt to the variety of patients and variations in the performance environments, such as the operating room, results in patient morbidity and mortality. There is a need for changes in the development and training of medical procedural skills based on current theories of skill acquisition, movement theory, and motor control. Achieving optimal performance necessitates the ability to adapt through training in diverse patient and performance environments rather than merely imitating prescribed movements. We propose a novel model of training, the Constraints-Led Approach, which allows for robust training by altering the factors affecting skill acquisition and lifelong learning.

Quality improvement in public-private partnerships in low- and middle-income countries: a systematic review.

BACKGROUND: Public-private partnerships (PPP) are often how health improvement programs are implemented in low-and-middle-income countries (LMICs). We therefore aimed to systematically review the literature about the aim and impacts of quality improvement (QI) approaches in PPP in LMICs. METHODS: We searched SCOPUS and grey literature for studies published before March 2022. One reviewer screened abstracts and full-text studies for inclusion. The study characteristics, setting, design, outcomes, and lessons learned were abstracted using a standard tool and reviewed in detail by a second author. RESULTS: We identified 9,457 citations, of which 144 met the inclusion criteria and underwent full-text abstraction. We identified five key themes for successful QI projects in LMICs: 1) leadership support and alignment with overarching priorities, 2) local ownership and engagement of frontline teams, 3) shared authentic learning across teams, 4) resilience in managing external challenges, and 5) robust data and data visualization to track progress. We found great heterogeneity in QI tools, study designs, participants, and outcome measures. Most studies had diffuse aims and poor descriptions of the intervention components and their follow-up. Few papers formally reported on actual deployment of private-sector capital, and either provided insufficient information or did not follow the formal PPP model, which involves capital investment for a explicit return on investment. Few studies discussed the response to their findings and the organizational willingness to change. CONCLUSIONS: Many of the same factors that impact the success of QI in healthcare in high-income countries are relevant for PPP in LMICs. Vague descriptions of the structure and financial arrangements of the PPPs, and the roles of public and private entities made it difficult to draw meaningful conclusions about the impacts of the organizational governance on the outcomes of QI programs in LMICs. While we found many articles in the published literature on PPP-funded QI partnerships in LMICs, there is a dire need for research that more clearly describes the intervention details, implementation challenges, contextual factors, leadership and organizational structures. These details are needed to better align incentives to support the kinds of collaboration needed for guiding accountability in advancing global health. More ownership and power needs to be shifted to local leaders and researchers to improve research equity and sustainability.

Indonesian COVID-19 lesson: A mixed-methods study on adolescent health status and health services during pandemic.

TOPIC: The COVID-19 pandemic affected adolescents' physical and psychological health. There must be specific services to cater to the needs of adolescents during COVID-19 in Indonesia. Lessons learned from previous pandemics will be beneficial for nurses and other health professionals to prepare services for future pandemics. PURPOSE: This mixed-method study aimed to examine 459 Indonesian adolescents' health, literacy, preventive measures, and preferred health services during the COVID-19 pandemic. This study also examines sociodemographics, respondent characteristics, health information sources, and media choices. RESULTS: A total of 47.5% of adolescents knew about COVID-19, 26.8% experienced physical health changes, and 61.7% considered wearing masks. Adolescent health information came from teachers (26.6%) and the Internet (32.9%). Psychological changes showed 67.8% irritation. Indonesians preferred online counseling (53.8%) and WhatsApp (45.8%) for pandemic health services. COVID-19 literacy did not affect physical or mental health (p > 0.05). CONCLUSIONS: Most adolescents reported mental and physical health changes during COVID-19. Our data suggest that adolescents' strong COVID-19 knowledge did not prevent anxiety and other psychological difficulties. The longitudinal studies could be utilized if pandemic demands social and physical distance. The government, as well as nurses, might utilize WhatsApp-based remote online treatment for health services.

Martha's rule: applying a behaviour change framework to understand the potential of complementary roles of clinicians and patients in improving safety of patients deteriorating in hospital.

AIMS/BACKGROUND: Martha's rule stipulates the right of patients and their families to escalate care as a way to improve safety while in hospital. This article analyses the possible impact of the proposed policy through the lens of a behaviour change framework and explores new opportunities presented by the implementation of Martha's rule.. METHODS: A descriptive analysis was undertaken of interactions between patients, family, friends and clinicians during clinical deterioration in hospital. The capability-opportunity-motivation behaviour change framework was applied to understand reasons for failure to respond to deterioration. RESULTS: Care of deteriorating patients requires recording of vital signs, recognition of abnormalities, reporting through escalation and response by a competent clinician. Regarding the care of patients who deteriorate in hospital, healthcare professionals have capability and motivation to provide safe, high-quality care, but often lack the physical and social opportunity to report or respond through lack of time and peer pressure. Patients and family members have motivation and might have time to support safety systems. Martha's rule or similar arrangements allow healthcare organisations to create opportunities for patients and families to report and escalate care to experts in critical care when they recognise deterioration. CONCLUSIONS: The capability-opportunity-motivation behaviour change framework provides insights into the causes of failure to rescue in deteriorating patients and an argument for opportunities through escalation by patients and families through Martha's rule. This might reduce the number of system failures and enable safer care.

Front-Line Health Care Workers' COVID-19 Infection Contamination Risks: A Human Factors and Risk Analysis Study of Personal Protective Equipment.

Infectious risks escalate with complex donning and doffing personal protective equipment (PPE) protocols. Recent studies suggest that PPE donning and doffing behaviors that deviate from protocol during PPE reuse compounded the risks of health care worker (HCW) self-contamination. This study quantified the occurrence of behaviors associated with known risks in PPE use and reuse. We conducted a prospective study of emergency department HCWs and video-recorded PPE donning and doffing 5 times in simulated patient encounters. Trained coders recorded HCW behaviors according to an evidence-based guide. All 28 participants deviated from the Centers for Disease Control and Prevention (CDC) sanctioned donning and doffing protocol order, and most were documented to have (92.85%) self-contaminated at least once during each simulated clinical encounter. Behaviors that compounded self-contamination due to PPE reuse were also observed. Wide variation in PPE donning and doffing behaviors was found among front-line, experienced HCWs. Future work is needed to determine which deviations put HCWs at increased risk for accidental self-contamination and what changes are needed to the CDC protocol for protecting HCW from infections.

Facility-Based Audit System With Integrated Community Engagement to Improve Maternal and Perinatal Health Outcomes in Rural Pakistan: Protocol for a Mixed Methods Implementation Study.

BACKGROUND: Maternal and newborn mortality in Pakistan remains as a major public health challenge. Pakistan faces significant infrastructure challenges and inadequate access to quality health care, exacerbated by sociocultural factors. Facility-based audit systems coupled with community engagement are key elements in achieving improved health system performance. We describe an implementation approach adapted from the World Health Organization audit cycle in real-world settings, with a plan to scale-up through mixed methods evaluation plan. OBJECTIVE: This study aims to implement a locally acceptable and relevant audit system and evaluate its feasibility within the rural health system of Pakistan for scale-up. METHODS: The implementation of the audit system comprises six phases: (1) identify facility and community leadership through consultative meetings with government district health offices, (2) establish the audit committee under the supervision of district health officer, (3) initiate audit with ongoing community engagement, (4) train the audit committee members, (5) launch the World Health Organization audit cycle (monthly meetings), and (6) quarterly review and refresher training. Data from all deliveries, live births, maternal deaths, maternal near misses, stillbirths, and neonatal deaths will be identified and recorded from four sources: (1) secondary-level care rural health facilities, (2) lady health workers' registers, (3) community representatives, and (4) project routine survey team. Concurrent quantitative and qualitative data will be drawn from case assessments, process analysis, and recommendations as components of iterative improvement cycles during the project. Outcomes will be the geographic distribution of mortality to measure the reach, proportion of facilities initiated to implement an audit system for measuring the adoption, proportion of audit committees with community representation, and proportion of audit committee members' sharing feedback regularly to measure acceptability and feasibility. In addition, outcomes of effectiveness will be measured based on data recording and reporting trends, identified modifiable factors for mortality and morbidity as underpinned by the Three Delays framework. Qualitative data will be analyzed based on perceived facilitators, barriers, and lessons learned for policy implications. Results will be summarized in frequencies and percentages and triangulated by the project team. Data will be analyzed using Stata (version 16; StataCorp) and NVivo (Lumivero) software. RESULTS: The study will be implemented for 20 months, followed by an additional 4-month period for follow-up. Initial results will be presented to the district health office and the District Health Program Management Team Meeting in the districts. CONCLUSIONS: This study will generate evidence about the feasibility and potential scale-up of a facility-based mortality audit system with integrated community engagement in rural Pakistan. Audit committees will complete the feedback loop linking health care providers, community representatives, and district health officials (policy makers). This implementation approach will serve decision makers in improving maternal and perinatal health outcomes. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/49578.

Evaluating the Efficacy of ChatGPT in Navigating the Spanish Medical Residency Entrance Examination (MIR): Promising Horizons for AI in Clinical Medicine.

The rapid progress in artificial intelligence, machine learning, and natural language processing has led to increasingly sophisticated large language models (LLMs) for use in healthcare. This study assesses the performance of two LLMs, the GPT-3.5 and GPT-4 models, in passing the MIR medical examination for access to medical specialist training in Spain. Our objectives included gauging the model's overall performance, analyzing discrepancies across different medical specialties, discerning between theoretical and practical questions, estimating error proportions, and assessing the hypothetical severity of errors committed by a physician. MATERIAL AND METHODS: We studied the 2022 Spanish MIR examination results after excluding those questions requiring image evaluations or having acknowledged errors. The remaining 182 questions were presented to the LLM GPT-4 and GPT-3.5 in Spanish and English. Logistic regression models analyzed the relationships between question length, sequence, and performance. We also analyzed the 23 questions with images, using GPT-4's new image analysis capability. RESULTS: GPT-4 outperformed GPT-3.5, scoring 86.81% in Spanish (p < 0.001). English translations had a slightly enhanced performance. GPT-4 scored 26.1% of the questions with images in English. The results were worse when the questions were in Spanish, 13.0%, although the differences were not statistically significant (p = 0.250). Among medical specialties, GPT-4 achieved a 100% correct response rate in several areas, and the Pharmacology, Critical Care, and Infectious Diseases specialties showed lower performance. The error analysis revealed that while a 13.2% error rate existed, the gravest categories, such as "error requiring intervention to sustain life" and "error resulting in death", had a 0% rate. CONCLUSIONS: GPT-4 performs robustly on the Spanish MIR examination, with varying capabilities to discriminate knowledge across specialties. While the model's high success rate is commendable, understanding the error severity is critical, especially when considering AI's potential role in real-world medical practice and its implications for patient safety.

The Wolfson Prize: designing the hospital of the future.

Background: The 2021 Wolfson Economics Prize asked how new hospitals should be designed to radically improve patient experiences, clinical outcomes, staff wellbeing and integration with wider health and social care. With a major programme to rebuild and renew hospitals in England underway, the Prize offered an opportunity to understand current thinking about hospitals and their future place. Methods: The 41 submissions that were identified as 'most promising' were reviewed and subjected to framework analysis. Emerging themes were identified and discussed iteratively. Results: Five dominant themes were identified: a calming environment; systems of care; distribution of services; use of technology; and going green. Several tensions and trade-offs were evident across the submissions and a number of gaps were identified in the knowledge base that need to be remedied to ensure that new hospitals are safe and efficient. Conclusion: The previous approach to building new hospitals, with its over-riding drive to reduce costs, has not served the UK well. New ways of thinking about hospital building and design are urgently needed, especially the funding of research and the creation of a national repository devoted to design solutions and post-build evaluations of new hospitals.

Strategies for Strengthening the Resilience of Public Health Systems for Pandemics, Disasters, and Other Emergencies.

OBJECTIVE: The aim of this study was to identify and prioritize strategies for strengthening public health system resilience for pandemics, disasters, and other emergencies using a scorecard approach. METHODS: The United Nations Public Health System Resilience Scorecard (Scorecard) was applied across 5 workshops in Slovenia, Turkey, and the United States of America. The workshops focused on participants reviewing and discussing 23 questions/indicators. A Likert type scale was used for scoring with zero being the lowest and 5 the highest. The workshop scores were analyzed and discussed by participants to prioritize areas of need and develop resilience strategies. Data from all workshops were aggregated, analyzed, and interpreted to develop priorities representative of participating locations. RESULTS: Eight themes emerged representing the need for better integration of public health and disaster management systems. These include: assessing community disease burden; embedding long-term recovery groups in emergency systems; exploring mental health care needs; examining ecosystem risks; evaluating reserve funds; identifying what crisis communication strategies worked well; providing non-medical services; and reviewing resilience of existing facilities, alternate care sites, and institutions. CONCLUSIONS: The Scorecard is an effective tool for establishing baseline resilience and prioritizing actions. The strategies identified reflect areas in most need for investment to improve public health system resilience.

Validation of Bayesian design for broadband microslit panel absorbers using causal inference.

This paper discusses experimental validations of multilayer microslit panels (MSPs) designed via Bayesian inference to obtain both high sound absorption and wide bandwidth simultaneously. Microslit perforation in thin panels is similar to microperforated panels [Xiang, Fackler, Hou, and Schmitt (2022). J. Acoust. Soc. Am. 151(5), 3094-3103]. MSP absorbers in single-layer configurations are functioning in a limited frequency range. By stacking the MSPs in multiple layered structures, absorbing performance may be widened in frequency ranges while retaining high absorption coefficients. Besides design challenges of multiple MSPs in layered structures to fulfill a practical requirement and minimize fabrication complexity, this paper further discusses challenges in experimental validations when experimental results undesirably deviate from the initial Bayesian design. Causation analysis is applied to the validation efforts where a causal model-based inference effectively provides causal reasoning of fabrication inaccuracies. Along with the causal inference, a causal reasoning conducted in this work can guide corrections due to fabrication inaccuracies during the iterative validation process.

"I Believe More in the Ability of the Small Person to Make Big Changes": Innovation and Social Entrepreneurship to Promote Public Health in Israel.

Social entrepreneurship has grown worldwide in recent decades as it attempts to create and implement innovative solutions to social and environmental issues through business strategies. The aim of this study was to explore what motivates public health social entrepreneurs to act, the challenges and barriers they face, achievements, and competencies required for success. As such, we interviewed 15 social entrepreneurs in Israel. Budget issues, regulatory barriers, and struggles against powerful companies were the frequent barriers to success. The interviewees indicated several achievements at the health policy level by positioning and becoming an authority in the field, positively influencing other people's lives. They highlighted the importance of creativity, determination and courage, leadership, and the ability to persevere in the face of overwhelming adverse odds as essential for the social entrepreneur's success. Social entrepreneurship in public health is essential when struggling with health disparities. Nevertheless, recognizing that social entrepreneurship is not a substitute for methodological government planning and accountability is crucial.

Simulation as a key training method for inculcating public health leadership skills: a mixed methods study.

Background: Successful management of public health challenges requires developing and nurturing leadership competencies. We aimed to evaluate the effectiveness of training simulations to assess public health leadership and decision-making competencies during emergencies as an effective learning and training method. Methods: We examined the effects of two simulation scenarios on public health school students in terms of their experience (compared to face-to-face learning) and new skills acquired for dealing with similar emergent situations in the future. A mixed-methods design included developing a validated and pre-tested questionnaire with open-and closed-ended questions that examined the simulation impact and the degree of student satisfaction with the conditions in which it was conducted. Semi-structured in-depth interviews were conducted with the students after going through the simulations. The questionnaire results were evaluated using descriptive analytics. The interviews were analyzed using thematic analyses. All data were collected during June 2022. Results: The questionnaire results indicate that students strengthened their interpersonal communication skills and learned about the importance of listening to the opinions of others before formulating their positions. Four themes emerged from 16 in-depth interviews, according to Kolb's experimental learning cycle. Students emphasized the effectiveness of experiential learning versus traditional classroom learning. The simulation scenarios were felt to realistically convey critical issues regarding leadership, decision-making, and teamwork challenges. They effectively conveyed the importance of building a culture of conducting substantive and respectful discussions. Conclusion: Simulation is a powerful pedagogical training tool for public health leadership competencies. Simulations were seen to be advantageous over face-to-face learning in imparting a range of leadership skills and hands-on practice. We recommend integrating simulations in all public health leadership training programs.