The movement of syringes and medication during anesthesiology delivery: An observational study in laparoscopic surgeries.

The movements of syringes and medications during an anesthetic case have yet to be systematically documented. We examine how syringes and medication move through the anesthesia work area during a case. We conducted a video-based observational study of 14 laparoscopic surgeries. We defined 'syringe events' as when syringe was picked up and moved. Medications were administered to the patient in only 48 (23.6%) of the 203 medication or syringe events. On average, 14.5 syringe movements occurred in each case. We estimate approximately 4.2 syringe movements for each medication administration. When a medication was administered to the patient (either through the IV pump or the patient port), it was picked up from one of 8 locations in the work area. Our study suggests that the syringe storage locations vary and include irregular locations (e.g., patient bed or provider's pockets). Our study contributes to understanding the complexity in the anesthesia work practices.

The importance of discourse when discussing microplastic pollution with oyster stakeholders in Massachusetts, USA.

Oysters have socioeconomic and environmental importance globally and are currently threatened by microplastic pollution. Whether solutions (e.g., laws, policies, or best management practices) are needed to protect oysters from microplastic pollution is still in question given the complexity of the issue and the multitude of stakeholders involved. Minimal research has been done to examine the public's view of the microplastic problem and, separately, few economic studies have examined non-monetary values for oysters. Here, we employed a discourse-based method (deliberative multicriteria evaluation methodology) to engage with oyster-relevant stakeholders in Massachusetts, USA, to evaluate how the stakeholders discussed and interacted with each other on the topic of 'microplastics polluting oyster habitats' using hypothetical scenarios. Our qualitative analysis indicated that participants discussed human welfare and non-human welfare aspects of oysters when considering what is threatened by microplastic pollution in oyster habitats. In all the workshops, an important theme emerged which is the role of oysters in supporting services (e.g., the concept that microplastic filtration or ingestion by oysters might impact the oysters' role as eco-engineers). Decision-making is not a linear process, especially when complex pollutants (e.g., microplastics) are involved. Here, we learned that both environmental and social data are needed for the oyster stakeholders to make decisions, and discussion among stakeholders can highlight gaps in scientific knowledge. The results were then used to inform the development of a decision-making process for evaluating complex environmental issues, like microplastic pollution.

Systems safety in nonoperating room anesthesia locations.

PURPOSE OF REVIEW: Nonoperating room anesthesia (NORA) care is an area of rapid growth over the last decade. However, literature describing safety systems in NORA is limited. This review evaluates historical safety models described by Donabedian and Reason, assesses the NORA environment and safety concerns that may contribute to adverse events, and provides potential solutions via a human-centered systems safety design. RECENT FINDINGS: Systems Engineering Initiative for Patient Safety (SEIPS) 3.0 provides a framework for quality and patient safety improvement. Although the previous SEIPS 2.0 model has been used to evaluate NORA environments with focus on the case volume, high productivity pressure, and significant physical constraints common to NORA sites, literature describing SEIPS 3.0 in relation to NORA care is sparse. Given the rate of malpractice claims for death in NORA settings, solutions that address the multifactorial nature of adverse events are needed. SUMMARY: The SEIPS 3.0 model may be applied to NORA care. Changes should focus on staffing ratios, staff/patient education, checklist utilization, burnout prevention, scheduling efficiency, anesthesia workstation standardization, communication improvements, room layout, medication and supply availability and storage, and the global managerial approach. Team members must demonstrate flexibility and a willingness to adapt to successfully implement change.

Improving safety in the operating room: Medication icon labels increase visibility and discrimination.

Misreading labels, syringes, and ampoules is reported to make up a 54.4% of medication administration errors. The addition of icons to medication labels in an operating room setting could add additional visual cues to the label, allowing for improved discrimination, visibility, and easily processed information that might reduce medication administration errors. A multi-disciplinary team proposed a method of enhancing visual cues and visibility of medication labels applied to vasoactive medication infusions by adding icons to the labels. Participants were 1.12 times more likely to correctly identify medications from farther away (p < 0.001, AOR = 1.12, 95% CI: 1.02, 1.22) with icons. When icons were present, participants were 2.16 times more likely to be more confident in their identifications (p < 0.001, AOR = 2.16, 95%CI: 1.80, 2.57). Carefully designed icons may offer an additional method for identifying medications, and thus reducing medication administration errors.

Morbidity, mortality, and systems safety in non-operating room anaesthesia: a narrative review.

Non-operating room anaesthesia (NORA) describes anaesthesia delivered outside a traditional operating room (OR) setting. Non-operating room anaesthesia cases have increased significantly in the last 20 yr and are projected to account for half of all anaesthetics delivered in the next decade. In contrast to most other medication administration contexts, NORA is performed in high-volume fast-paced environments not optimised for anaesthesia care. These predisposing factors combined with increasing case volume, less provider experience, and higher-acuity patients increase the potential for preventable adverse events. Our narrative review examines morbidity and mortality in NORA settings compared with the OR and the systems factors impacting safety in NORA. A review of the literature from January 1, 1994 to March 5, 2021 was conducted using PubMed, CINAHL, Scopus, and ProQuest. After completing abstract screening and full-text review, 30 articles were selected for inclusion. These articles suggested higher rates of morbidity and mortality in NORA cases compared with OR cases. This included a higher proportion of death claims and complications attributable to inadequate oxygenation, and a higher likelihood that adverse events are preventable. Despite relatively few attempts to quantify safety concerns, it was possible to find a range of systems safety concerns repeated across multiple studies, including insufficient lighting, noise, cramped workspace, and restricted access to patients. Old and unfamiliar equipment, lack of team familiarity, and limited preoperative evaluation are also commonly noted challenges. Applying a systems view of safety, it is possible to suggest a range of methods to improve NORA safety and performance.

Train-the-trainer: Pilot trial for ebola virus disease simulation training.

Background: Highly infectious but rare diseases require rapid dissemination of safety critical skills to health-care workers (HCWs). Simulation is an effective method of education; however, it requires competent instructors. We evaluated the efficacy of an internet-delivered train-the-trainer course to prepare HCWs to care for patients with Ebola virus disease (EVD). Methods: Twenty-four individuals without prior EVD training were recruited and divided into two groups. Group A included nine trainees taught by three experienced trainers with previous EVD training. Group B included 15 trainees taught by five novice trainers without previous EVD training who completed the train-the-trainer course. We compared the efficacy of the train-the-trainer course by examining subject performance, measured by time to complete 13 tasks and the proportion of steps per task flagged for critical errors and risky and positive actions. Trainees' confidence in their ability to safely care for EVD patients was compared with a self-reported survey after training. Results: Overall trainees' confidence in ability to safely care for EVD patients did not differ by group. Participants trained by the novice trainers were statistically significantly faster at waste bagging (P = 0.002), lab specimen bagging (P = 0.004), spill clean-up (P = 0.01), and the body bagging (P = 0.008) scenarios compared to those trained by experienced trainers. There were no significant differences in the completion time in the remaining nine training tasks. Participants trained by novice and experienced trainers did not differ significantly with regard to the proportion of steps in a task flagged for critical errors, risky actions, or positive actions with the exception of the task "Man Down in Gown" (12.5% of steps graded by experienced trainers compared to 0 graded by novice trainers, P = 0.007). Discussion: The online train-the-trainer EVD course is effective at teaching novices to train HCWs in protective measures and can be accomplished swiftly.

Development of a Sterile Personal Protective Equipment Donning and Doffing Procedure to Protect Surgical Teams from SARS-CoV-2 Exposure during the COVID-19 Pandemic.

Background: The coronavirus disease 2019 (COVID-19) pandemic has become an increasingly challenging problem throughout the world. Because of the numerous potential modes of transmission, surgeons and all procedural staff represent a unique population that requires standardized procedures to protect themselves and their patients. Although several protocols have been implemented during other infectious disease outbreaks, such as Ebola virus, no standardized protocol has been published in regard to the COVID-19 pandemic. Methods: A multidisciplinary team of two surgeons, an anesthesiologist, and an infection preventionist was assembled to create a process with sterile attire adapted from the National Emerging Special Pathogen Training and Education Center (NETEC) donning and doffing process. After editing, a donning procedure and doffing procedure was created and made into checklists. The procedures were simulated in an empty operating room (OR) with simulation of all personnel roles. A "dofficer" role was established to ensure real-time adherence to the procedures. Results: The donning and doffing procedures were printed as one-page documents for easy posting in ORs and procedural areas. Pictures from the simulation were also obtained and made into flow chart-style diagrams that were also posted in the ORs. Conclusions: Coronavirus disease 2019 (COVID-19) is a quickly evolving pandemic that has spread all over the globe. With the rapid increase of infections and the increasing number of severely ill individuals, healthcare providers need easy-to-follow guidelines to keep themselves and patients as safe as possible. The processes for donning and doffing personal protective equipment (PPE) presented here provide an added measure of safety to surgeons and support staff to provide quality surgical care to positive and suspected COVID-19-positive patients.

A Pilot Study of Simulation Training in Difficult Bag Mask Ventilation Using a Computerized Patient Simulator.

OBJECTIVE: Bag mask ventilation (BMV) is fundamental to airway management. Simulation is effective in airway management training, but its effectiveness for difficult BMV training is less clear. We evaluated the difference between type of training (simulation vs on patients) and the pass rate on a post-test on patients. DESIGN: A single center pilot study was performed with 32 medical students randomized to participate in difficult BMV training on simulators or patients. Pre- and post-training tests on the simulator and on patients were recorded. Surveys of trainee confidence level were collected. The primary goal was to estimate the difference between type of training (simulation vs on patients) and the pass rate on the post-test on patients with an improvement of 10% or more in passing rate considered as a meaningful improvement. Secondary outcomes included whether or not participants passed the simulator post-test, post-test on patient confidence, and pre- and post-test confidence. MEASUREMENTS AND MAIN RESULTS: Participants trained on the simulator had 13% higher passing rate on the post-test on patients compared to participants trained on patients (88% vs 75%). In addition, subjects that passed the simulator post-test had 11 times the odds of passing a post-test on patients relative to subjects that did not pass the simulator post-test (P = 0.023, odds ratio = 11.0, 95% confidence interval [CI] = 1.48-81.6). Post-training confidence levels were higher among those who passed the simulator pre-test and post-test and received simulator training. CONCLUSIONS: Simulation training for difficult BMV led to a higher passing rate on a post-test on patients compared to those trained on patients. This finding will need to be confirmed in larger randomized controlled trials. Successfully completing difficult BMV training on a simulator with a passing grade correlated with passing a test on difficult BMV on patients.

Advantages of the New Tao Mask for Bag Mask Ventilation: a randomized crossover trial.

BACKGROUND AND AIMS: Manual bag mask ventilation is a life saving skill. An investigation was made to compare two different facemasks used in bag mask ventilation, the standard and the novel Tao face mask, and evaluate the ability of novices to achieve adequate tidal volume. METHODS: The study design was a crossover trial, which randomized forty medical students with no previous airway experience to learn bag mask ventilation with the standard mask and the Tao face mask. Primary outcome measures were mean and median tidal volume per mask, and secondary measures were hand area, age, gender, and order of mask usage. RESULTS: Medical students who used the Tao mask first achieved significantly more tidal volume than those who used the standard mask first (p = 0.002). However, when comparing face masks that were used second, the tidal volume did not differ significantly between the two masks (p = 1.000). Greater tidal volume was achieved on the second attempt relative to the first attempt with each mask. There was significantly more tidal volume achieved with greater hand size with the standard mask, whether it was used first or second (p < 0.001 and p = 0.012 respectively). Greater hand size was associated with greater tidal volume in the Tao mask also, but only when used first (p < 0.001). When first attempting bag mask ventilation, inexperienced students achieved greater tidal volume with the Tao Mask. The results also suggest that hand size matters less when using the Tao Mask. CONCLUSION: When first attempting bag mask ventilation inexperienced students achieved greater tidal volume with the Tao Mask. The results also suggest that hand size matters less when using the Tao mask.

Labor Epidural Analgesia and Postpartum Depression.

INTRODUCTION: Epidural labor analgesia may decrease the risk of postpartum depression (PPD). METHODS: In a secondary analysis of a prospective study, the association between epidural utilization and PPD was evaluated using a Fisher's exact test. PPD was defined as an Edinburgh Postnatal Depression score of ≥ 10 at 6-8 weeks postpartum. RESULTS: 20% (13/65) of women meet criteria for PDD. 24% (n=12/50) of women who received epidural labor analgesia developed PPD, compared to 6.7% (n=1/15) of women who did not receive epidural labor analgesia (P = 0.27). CONCLUSIONS: Labor epidural analgesia did not reduce the risk of postpartum depression.

An approach to moderate sedation simulation training.

INTRODUCTION: Each year millions of patients undergo procedures that require moderate sedation. These patients are at risk of complications from oversedation that can progress to respiratory depression or even death. This article describes the creation of a simulation-based medical education course for nonanesthesiologists who use sedation in their specialty practice and preliminary data from our precourse and postcourse assessments. METHODS: Our course combined online and lecture-based didactics with simulation education to teach moderate sedation and basic emergency airway management to nonanesthesiologists. After online precourse materials were reviewed, participants attended an 8-hour simulation-based training course focused on the recognition of different levels of sedation, medication titration, sedation reversal, and airway support and rescue. To evaluate the course, precourse, and postcourse educational impacts, cognitive and simulation tests were administered. Participants completed a postcourse survey. RESULTS: To date, 45 physicians have participated in the course. We have cognitive performance data on 19 participants and survey data for 45 participants. Postcourse simulation tests results were improved compared with precourse tests. Our course was rated "better" or "much better" in comparison to courses using lecture-only format by 100% of the participants. CONCLUSIONS: A course using a combination of didactic and simulation education to teach moderate sedation is described. Our initial data demonstrated a significant increase in knowledge, skills, and clinical judgment. Future research efforts should focus on examining the validity and reliability of scenario scoring and the impact of training on clinical practice.

Developing person-centred practice: nursing outcomes arising from changes to the care environment in residential settings for older people.

AIM: To present the nursing outcomes from the evaluation of developments in the care environment in residential settings for older people. DESIGN: The evaluation data reported here is derived from a larger national programme of work that focused on the development of person-centred practice in residential services for older people using an emancipatory practice development framework. A multi-method evaluation framework was utilised. Outcome data were collected at three time points between December 2007 and September 2009. The data reported here were collected using an instrument called the 'Person-Centred Nursing Index'. FINDINGS: Heavy workload was the main cause of stress among nurses. Personal and professional satisfaction with the job was scored highest by the total sample of nurses. Nineteen factors were examined using the Person-Centred Nursing Index. Statistically significant changes were observed in 12 of these. In addition, there were statistically significant changes in nurses' perceptions of caring, indicating a shift from a dominant focus on 'technical' aspects of care, to one where 'intimate' aspects of care were more highly valued. RELEVANCE TO CLINICAL PRACTICE: The findings highlight the importance of the development of effective teamwork, workload management, time management and staff relationships in order to create a culture where there is a more democratic and inclusive approach to practice and space for the formation of person-centred relationships.

Practice development: realising active learning for sustainable change.

This paper explores the concept of practice development in the context of professional development and strategies for facilitating learning in practice. In this paper we present the background to the methodology of emancipatory and transformational practice development. Key concepts underpinning a contemporary definition of practice development are unravelled and nine principles for effective practice development proposed. An example of a large-scale national practice development programme with older people residential settings in the Republic of Ireland is presented to illustrate the processes in action. The findings of the first year of the programme are offered and these findings demonstrate the ways in which practice development systematically uncovers the deeply embedded characteristics of practice cultures -- characteristics that often inhibit effective person-centred practice to be realised.