Operating room black box: GIMMICK or a patient safety tool?

The Operating Room Black Box (ORBB) is a relatively recent technology that provides a comprehensive solution for assessing technical and non-technical skills of the operating team. Originating from aviation, the ORBB enables real-time observation and continuous recording of intraoperative events allowing for an in-depth analysis of efficiency, safety, and adverse events. Its dual role as a teaching tool enhances transparency and patient safety in surgical training. In comparison to traditional methods, like checklists that have limitations, the ORBB offers a holistic understanding of clinical and non-clinical performances that are responsible for intraoperative patient outcomes. It facilitates systematic observation without additional personnel, allowing for review of numerous surgical cases. This review highlights the potential benefits of the ORBB in enhancing patient safety, its role as a surgical training tool, and addresses barriers especially in resource-constrained settings. It signifies a transformative step towards global surgical practices, emphasizing transparency and improved surgical outcomes.

SAFE USE OF INTRA-OPERATIVE TOURNIQUETS IN A DISTRICT HOSPITAL IN THE UK-AN AUDIT STUDY IN ORTHOPAEDIC THEATRES AND REVIEW OF CURRENT LITERATURE.

The use of tourniquet is common in orthopaedic surgeries as it reduces blood loss, enhances visualization of the operating field, and leads to quicker procedures. However, the use of tourniquet has certain risks which can be avoided by following guidelines like British Orthopaedic Association Standards for Trauma (BOAST) guidelines for safe use of tourniquet. This audit study was done in a District general hospital to check the compliance of two trauma theatres with BOAST guidelines. The audit found that there was poor documentation of tourniquet details in the operation notes (10%). Regarding tourniquet time and pressure, the compliance in the two theatres was 95 % & 97.5 %. The recommendations of this audit were to use a template to improve documentation of tourniquet details in the operation notes and training of theatre staff on BOAST guidelines for safe use of tourniquet.

Comparison of the effects of apprenticeship training by sandwich feedback and traditional methods on final-semester operating room technology students' perioperative competence and performance: a randomized, controlled trial.

BACKGROUND: Effective feedback is fundamental in clinical education, as it allows trainers to constantly diagnose the trainees' condition, determine their weaknesses, and intervene at proper times. Recently, different feedback-based approaches have been introduced in clinical training; however, the effectiveness of such interventions still needs to be studied extensively, especially in the perioperative field. Therefore, this study sought to compare the effects of apprenticeship training using sandwich feedback and traditional methods on the perioperative competence and performance of Operating Room (OR) technology students. METHODS: Thirty final-semester undergraduate OR technology students taking the apprenticeship courses were randomly allocated into experimental (n = 15) and control (n = 15) groups through the stratified randomization approach. The students in the experimental group experienced Feedback-Based Learning (FBL) using a sandwich model, and the students in the control group participated in Traditional-Based Training (TBT) in six five-hour sessions weekly for three consecutive weeks. All students completed the Persian version of the Perceived Perioperative Competence Scale-Revised (PPCS-R) on the first and last days of interventions. Also, a blinded rater completed a checklist to evaluate all students' performance via Direct Observation of Procedural Skills (DOPS) on the last intervention day. Besides, the students in the FBL filled out a questionnaire regarding their attitude toward the implemented program. RESULTS: The mean total score of the PPCS-R was significantly higher in the FBL than in the TBT on the last intervention day (P < 0.001). Additionally, the increase in mean change of PPCS-R total score from the first to last days was significantly more in the FBL (P < 0.001). Likewise, the FBL students had higher DOPS scores than the TBT ones (P < 0.001). Most FBL students also had a good attitude toward the implemented program (n = 8; 53.3%). CONCLUSION: Apprenticeship training using a sandwich feedback-based approach was superior to the traditional method for enhancing perioperative competence and performance of final-semester OR technology students. Additional studies are required to identify the sustainability of the findings.

Improving Team Members' Attention During the OR Briefing or Time Out.

Effective coordination among health care professionals is crucial to achieving optimal outcomes. In the OR, even minor errors can have catastrophic consequences. To mitigate the risk of error, health care professionals have adopted a briefing culture like that used in the aviation industry. Briefings are essential to ensure that everyone involved in a procedure knows the plan and potential risks and is prepared to perform their duties safely and effectively. The fundamental human sense involved in briefings is auditory perception; although important, hearing alone does not equate to focused attention. To enhance the efficacy of briefings, engaging the use of a second sense by adding a visual checklist may increase attentiveness and the chances of early error detection and prevention. Using a projection device may enhance all team members' engagement and participation during the briefing or time-out process and can be an effective tool for improving communication and reducing errors.

Cell Phones in the OR: A Cross-Sectional Study of Norwegian Perioperative Nurses' Knowledge, Practice, and Attitudes.

Few studies have focused on the use of cell phones in the OR. In Norway, researchers sought to assess perioperative nurses' knowledge, practice, and attitudes associated with cell phone use in the OR and distributed a nationwide questionnaire via a social media platform. More than 80% of the 332 respondents thought that cell phones were contaminated and that pathogens could contaminate hands. Almost all respondents brought their phone to work; approximately 61% of respondents carried it in their pocket in the OR. Responses to questions about phone cleaning showed that 39 (11.7%) of the respondents routinely cleaned their phone before entering the OR and 33 (9.9%) of the respondents cleaned it when leaving the OR. Less than 20% of respondents indicated their facility had guidelines for cleaning personal cell phones. Opportunities for improvement in cell phone cleaning in ORs exist and additional research involving all perioperative team members is needed.

Application Value of High-Quality Nursing in Operating Room in Rectal Cancer Operation and its Influence on Postoperative Rehabilitation.

OBJECTIVE: To study the value of high-quality care in operating room during operation of patients with rectal cancer and the effect of this nursing model on postoperative rehabilitation. METHODS: This study recruited 72 patients with rectal cancer, including 36 in the control group and 36 in the observation group. Patients in the control group received routine care, and those in the observation group received high-quality care in operating room. RESULTS: The anxiety score (5.50 ± .77 vs 10. 08 ± 1.13), stress score (6.97 ± .60 vs 8.61 ± .99), and depression score (4.02 ± .65 vs 5.50 ± .91) in the observation group were less than the control group after treatment (P < .05). The measured values of diastolic blood pressure (73.19 ± 1.96 vs 86.13 ± 2.0), systolic blood pressure (121.08 ± 1.62 vs 130.63 ± 2.84), heart rate (73.05 ± 1.63 vs 87.11 ± 2.91) and adrenaline E(E) (58.40 ± 3.02 vs 61.42 ± 3.86) in the observation group were less than the control group after treatment (P < .05). The cooperation degree (94.44 vs 75.00) in the observation group was greater than the control group, but the operation time (308.47 ± 9.92 vs 339.47 ± 12.70), postoperative intestinal function recovery time (16.30 ± 1.14 vs 30.94 ± 2.10) and length of stay (10.47 ± 1.85 vs 13.33 ± 1.95) were all shorter than the control group (P < .05). The nasopharyngeal temperature in the observation group was greater than the control group at 30 minutes during operation (36.16 ± .50 vs 35.19 ± .40) and after operation, and fear score (2.22 ± .42 vs 3.63 ± .72) was less than the control group (P < .05). CONCLUSION: The application of high-quality care in the operating room during rectal cancer surgery has a significantly good clinical outcome.

Challenging Dogma by Skipping the Emergency Department Thoracotomy: A Propensity Score Matched Analysis of the Trauma Quality Improvement Database.

INTRODUCTION: Survival following emergency department thoracotomy (EDT) for patients in extremis is poor. Whether intervention in the operating room instead of EDT in select patients could lead to improved outcomes is unknown. We hypothesized that patients who underwent intervention in the operating room would have improved outcomes compared to those who underwent EDT. METHODS: We conducted a retrospective review of the Trauma Quality Improvement Program database from 2017 to 2021. All adult patients who underwent EDT, operating room thoracotomy (ORT), or sternotomy as the first form of surgical intervention within 1 h of arrival were included. Of patients without prehospital cardiac arrest, propensity score matching was utilized to create three comparable groups. The primary outcome was survival. Secondary outcomes included time to procedure. RESULTS: There were 1865 EDT patients, 835 ORT patients, and 456 sternotomy patients who met the inclusion criteria. There were 349 EDT, 344 ORT, and 408 sternotomy patients in the matched analysis. On Cox multivariate regression, there was an increased risk of mortality with EDT versus sternotomy (HR 4.64, P < 0.0001), EDT versus ORT (HR 1.65, P < 0.0001), and ORT versus sternotomy (HR 2.81, P < 0.0001). Time to procedure was shorter with EDT versus sternotomy (22 min versus 34 min, P < 0.0001) and versus ORT (22 min versus 37 min, P < 0.0001). CONCLUSIONS: There was an association between sternotomy and ORT versus EDT and improved mortality. In select patients, operative approaches rather than the traditional EDT could be considered.

Eliminating Hands-Off Handoffs: Improvement in Perioperative Handoff Communication With a Multidisciplinary Tool Initiative.

INTRODUCTION: Handoffs between the operating room (OR) and post-anesthesia care unit (PACU) require a high volume and quality of information to be transferred. This study aimed to improve perioperative communication with a handoff tool. METHODS: Perioperative staff at a quaternary care center was surveyed regarding perception of handoff quality, and OR to PACU handoffs were observed for structured criteria. A 25-item tool was implemented, and handoffs were similarly observed. Staff was then again surveyed. A multidisciplinary team led this initiative as a collaboration. RESULTS: After implementation, nursing reported improved perception of time spent (2.63-3.68, p = .02) and amount of information discussed (2.85-3.73, p = .05). Anesthesia also reported improved personal communication (3.69-4.43, p = .004), effectiveness of handoffs (3.43-3.82, p = .02), and amount of information discussed (4.26-4.76, p = .05). After implementation, observed patient information discussed during handoffs increased for both surgical and anesthesia team members. The frequency of complete and near-complete handoffs increased (40%-74%, p < .001). CONCLUSIONS: A structured handoff tool increased the amount of essential information reported during handoffs between the OR and PACU and increased team members' perception of handoffs.

The Economic Impact of Standardization and Digitalization in the Operating Room: A Systematic Literature Review.

Hospital face increased resource constraints and competition. This escalates the need for efficiency optimization especially in resource-intense areas, such as the Operating Room (OR). Efficiency cannot happen at expenses of patient outcomes. Innovative digital support systems (DSS) have been introduced into the market to support established standardization methods of intraoperative workflows further. This review aimed to analyze whether applied standardization methods and implemented DSS of intraoperative surgical workflows lead to increasing efficiency and demonstrate economic improvements. A systematic review of intraoperative surgical workflows standardization and digitalization was performed. Journal articles and reviews from 2000 to 2023 were retrieved from EBSCO, PubMed, and Scopus databases, as well as the internal database of Johnson & Johnson. 17 articles showed a significant increase in efficiency through standardization, which led to cost reductions between $70.20 to $3,516 per case without negatively impacting quality. Five additional articles on DSS demonstrated a significant positive impact on efficiency and quality. Reduction in OR-time between 6 to 22% per case was one main contributor. No literature on DSS revealed any correlated economic impact. Selected standardization methods and introduced DSS for intraoperative surgical workflows effectively increase efficiency while maintaining or even improving quality. Demonstrated cost-effectiveness of non-digital standardization methods across surgical areas requires more research on complex and resource-intensive procedures and the economic value of DSS to support hospital management's strategic decisions to overcome the increasing economic burden.

Hand Hygiene among Anesthesiologists and Microorganisms Contamination in Anesthesia Environments: A Single-Center Observational Study.

Objective: To investigate the baseline levels of microorganisms' growth on the hands of anesthesiologists and in the anesthesia environment at a cancer hospital. Methods: This study performed in nine operating rooms and among 25 anesthesiologists at a cancer hospital. Sampling of the hands of anesthesiologists and the anesthesia environment was performed at a ready-to-use operating room before patient contact began and after decontamination. Results: Microorganisms' growth results showed that 20% (5/25) of anesthesiologists' hands carried microorganisms (> 10 CFU/cm 2) before patient contact began. Female anesthesiologists performed hand hygiene better than did their male counterparts, with fewer CFUs ( P = 0.0069) and fewer species ( P = 0.0202). Our study also found that 55.6% (5/9) of ready-to-use operating rooms carried microorganisms (> 5 CFU/cm 2). Microorganisms regrowth began quickly (1 hour) after disinfection, and increased gradually over time, reaching the threshold at 4 hours after disinfection. Staphylococcus aureus was isolated from the hands of 20% (5/25) of anesthesiologists and 33.3% (3/9) of operating rooms. Conclusion: Our study indicates that male anesthesiologists need to pay more attention to the standard operating procedures and effect evaluation of hand hygiene, daily cleaning rate of the operating room may be insufficient, and we would suggest that there should be a repeat cleaning every four hours.

The Supervisor's Toolkit: Strategies of Supervisors to Entrust and Regulate Autonomy of Residents in the Operating Room.

OBJECTIVE: To identify what strategies supervisors use to entrust autonomy during surgical procedures and to clarify the consequences of each strategy for a resident's level of autonomy. BACKGROUND: Entrusting autonomy is at the core of teaching and learning surgical procedures. The better the level of autonomy matches the learning needs of residents, the steeper their learning curves. However, entrusting too much autonomy endangers patient outcome, while entrusting too little autonomy results in expertise gaps at the end of training. Understanding how supervisors regulate autonomy during surgical procedures is essential to improve intraoperative learning without compromising patient outcome. METHODS: In an observational study, all the verbal and nonverbal interactions of 6 different supervisors and residents were captured by cameras. Using the iterative inductive process of conversational analysis, each supervisor initiative to guide the resident was identified, categorized, and analyzed to determine how supervisors affect autonomy of residents. RESULTS: In the end, all the 475 behaviors of supervisors to regulate autonomy in this study could be classified into 4 categories and nine strategies: I) Evaluate the progress of the procedure: inspection (1), request for information (2), and expressing their expert opinion (3); II) Influence decision-making: explore (4), suggest (5), or declare the next decision (6); III) Influence the manual ongoing action: adjust (7), or stop the resident's manual activity (8); IV) take over (9). CONCLUSIONS: This study provides new insights into how supervisors regulate autonomy in the operating room. This insight is useful toward analyzing whether supervisors meet learning needs of residents as effectively as possible.

Utilization of lean project management principles and health informatics to reduce operating room delays in a vascular surgery practice.

OBJECTIVES: Perioperative inefficiency can increase cost. We describe a process improvement initiative that addressed preoperative delays on an academic vascular surgery service. METHODS: First case vascular surgeries from July 2019-January 2020 were retrospectively reviewed for delays, defined as late arrival to the operating room (OR). A stakeholder group spearheaded by a surgeon-informaticist analyzed this process and implemented a novel electronic medical records (EMR) preoperative tool with improved preoperative workflow and role delegation; results were reviewed for 3 months after implementation. RESULTS: 57% of cases had first case on-time starts with average delay of 19 min. Inappropriate preoperative orders were identified as a dominant delay source (average delay = 38 min). Three months post-implementation, 53% of first cases had on-time starts with average delay of 11 min (P < 0.05). No delays were due to missing orders. CONCLUSIONS: Inconsistent preoperative workflows led to inappropriate orders and delays, increasing cost and decreasing quality. A novel EMR tool subsequently reduced delays with projected savings of $1,200/case. Workflow standardization utilizing informatics can increase efficiency, raising the value of surgical care.

The surgical debrief: Just another checklist or an instrument to drive cultural change?

INTRODUCTION: Post-procedural debrief is recommended to improve patient safety. We examined operating room (OR) clinicians' perceptions of the impact of a multi-disciplinary debrief on OR culture. METHODS: A survey was administered to 182 OR clinicians at a major academic medical center. Attitudes toward the surgical debrief and its effect on patient safety and OR culture were evaluated. RESULTS: Majority of clinicians (58.2%) believed creating a culture of safety in the OR was a shared care team responsibility, however, surgical attendings and trainees were more likely to assign this responsibility to the surgical attending. Few circulating nurses and trainees felt comfortable initiating a surgical debrief. Overall clinicians agreed that a debrief would impact both patient safety outcomes and OR culture. CONCLUSIONS: Clinicians felt implementation of a surgical debrief would positively affect the OR culture of safety by improving interdisciplinary communication and influencing the power hierarchy that exists in many ORs.

Improving Formative Feedback in the Operating Room Setting: Developing and Implementing an Initiative to Improve Feedback Quality and Culture.

PROBLEM: Formative feedback, given in an ongoing fashion during the learning process, is fundamental to clinical education. However, dissatisfaction with formative feedback among residents is common. Difficulties with formative feedback are intensified in the operating room (OR) setting due to fast pace, space limitations, and frequent rotation of residents and attendings. APPROACH: In the anesthesiology and critical care department at the University of Pennsylvania Perelman School of Medicine, the authors launched the Feedback Moment initiative from January 2018 to May 2018 in which 24 first-year residents and attendings were given a short series of prompts designed to facilitate regular, high-quality formative feedback. The authors conducted semistructured interviews with residents before and after the initiative to evaluate its impact. OUTCOMES: In baseline interviews, 18 participating residents stressed the importance of formative feedback but described feeling unsure of their performance due to lack of ongoing constructive input from attendings. They felt hesitant to approach attendings for feedback due to a desire not to interrupt OR workflow or appear incompetent. In follow-up interviews, residents described the initiative as helping to normalize constructive formative feedback but difficult to execute regularly due to OR workflow issues and frequent rotation of attendings with varying approaches. NEXT STEPS: Challenges faced by participants in this initiative highlight several considerations for effective OR-based formative feedback. Alternative timings for initiating feedback must be considered in light of the hectic nature of the OR workflow. Residents should be equipped with the skills necessary to adapt to varying practice patterns and frequent rotation between attendings, while attendings should be trained to provide a clear rationale for constructive feedback that allows residents to quickly adapt to practice variation. Finally, establishing clear goals among resident-attending pairs is critical to ensuring that formative feedback given in necessarily brief sessions is focused and productive.

Six Sigma in surgery: how to create a safer culture in the operating theatre using innovative technology.

Safe delivery of patient care in the operating theatre is complex and co-dependent of many individual, organisational, and environmental factors, including patient, task and technology, individual, and human factors. The Six Sigma approach aims to implement a data-driven strategy to reduce variability and consequently improve safety. Analytical data platforms such as a Black Box ought to be embraced to support process optimisation and ultimately create a higher level of Six Sigma safety performance of the operating theatre team.

Impact of the WHO Surgical Safety Checklist Relative to Its Design and Intended Use: A Systematic Review and Meta-Meta-Analysis.

BACKGROUND: The aim of this study was to identify what parts of the World Health Organization Surgical Safety Checklist (WHO SSC) are working, what can be done to make it more effective, and to determine if it achieved its intended effect relative to its design and intended use. STUDY DESIGN: We conducted a qualitative thematic analysis and meta-meta-analyses of findings in WHO SSC systematic reviews following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. RESULTS: Twenty systematic reviews were included for qualitative thematic analysis. Narrative information was coded in 4 primary areas with a focus on impact of the WHO SSC. Four themes-Clinical Outcomes, Process Measures, Team Dynamics and Communication, and Safety Culture-pertained directly to the aims or purposes behind the development of the SSC. The other 2 themes-Efficiency and Workload involved in using the checklist and Checklist Impact on Institutional Practices-are associated with SSC use, but were not focal areas considered during its development. Included in the 20 systematic reviews were 24 unique observational cohort studies that reported pre-post data on a total of 18 clinical outcomes. Mortality, morbidity, surgical site infection, pneumonia, unplanned return to the operating room, urinary tract infection, blood loss requiring transfusion, unplanned intubation, and sepsis favored the use of the WHO SSC. Deep vein thrombosis was the only postoperative outcome assessed that did not favor use of the WHO SSC. CONCLUSIONS: The WHO SSC positively impacts the things it was explicitly designed to address and does not positively impact things it was not explicitly designed for.

Sales Representatives in the Operating Room: Conflict of Interest or Clinical Support?

BACKGROUND: The Physician Payment Sunshine Act, which became federal law in January 2012, mandated that medical device manufacturers must disclose any financial support provided to individual physicians on a publicly available Web site. The law reflects increasing concern about physician-industry relationships. METHODS: The connection between surgeon and sales representative creates possibilities for both financial and non-financial conflicts of interest (COIs). Indeed, COIs may be inherent when a sales representative is motivated by profit while also serving a critical role in many surgeries. RESULTS: The potential benefits and risks for patients, who may not even be aware of the sales representative's presence in the operating room, must be considered. CONCLUSIONS: This paper adds to the national discussion about neurosurgical physician-industry conflicts of interests and the issues relative to sales representatives in the operating room.

A quantitative evaluation of aerosol generation during supraglottic airway insertion and removal.

Many guidelines consider supraglottic airway use to be an aerosol-generating procedure. This status requires increased levels of personal protective equipment, fallow time between cases and results in reduced operating theatre efficiency. Aerosol generation has never been quantitated during supraglottic airway use. To address this evidence gap, we conducted real-time aerosol monitoring (0.3-10-µm diameter) in ultraclean operating theatres during supraglottic airway insertion and removal. This showed very low background particle concentrations (median (IQR [range]) 1.6 (0-3.1 [0-4.0]) particles.l-1 ) against which the patient's tidal breathing produced a higher concentration of aerosol (4.0 (1.3-11.0 [0-44]) particles.l-1 , p = 0.048). The average aerosol concentration detected during supraglottic airway insertion (1.3 (1.0-4.2 [0-6.2]) particles.l-1 , n = 11), and removal (2.1 (0-17.5 [0-26.2]) particles.l-1 , n = 12) was no different to tidal breathing (p = 0.31 and p = 0.84, respectively). Comparison of supraglottic airway insertion and removal with a volitional cough (104 (66-169 [33-326]), n = 27), demonstrated that supraglottic airway insertion/removal sequences produced <4% of the aerosol compared with a single cough (p < 0.001). A transient aerosol increase was recorded during one complicated supraglottic airway insertion (which initially failed to provide a patent airway). Detailed analysis of this event showed an atypical particle size distribution and we subsequently identified multiple sources of non-respiratory aerosols that may be produced during airway management and can be considered as artefacts. These findings demonstrate supraglottic airway insertion/removal generates no more bio-aerosol than breathing and far less than a cough. This should inform the design of infection prevention strategies for anaesthetists and operating theatre staff caring for patients managed with supraglottic airways.