Multidisciplinary simulation training for endotracheal intubation during COVID-19 in one Hong Kong regional hospital: strengthening of existing procedures and preparedness.

Introduction: In early 2020, our hospital responded with high alertness when novel coronavirus SARS-CoV-2 appeared. A hospital-based training programme was rapidly arranged to prepare staff for the imminent threat. Objective: We developed a hospital-wide multidisciplinary infection control training programme on endotracheal intubation for healthcare workers to minimise nosocomial spread of COVID-19 during this high-stress and time-sensitive risky procedure. Methodology: Major stakeholders (Quality & Safety Department, Infection Control Team, Central Nursing Division, high-risk clinical departments and hospital training centre) formed a training programme task group. This group was tasked with developing high-fidelity scenario-based simulation training curriculum for COVID-19 endotracheal intubation with standard workflow and infection control practice. This group then implemented and evaluated the training programme for its effectiveness. Results: 101 training classes of 2-hour session were conducted from 5 February to 18 March 2020, involving 1415 hospital staff (~81% of target participants with training needs) either inside the hospital training centre or as in situ simulation training (intensive care unit or accident and emergency department). Learners' satisfaction was reflected by overall positive response percentage at 90%. Opinions of participating staff were incorporated into the standard airway management and infection control practice for endotracheal intubation of adult patients with COVID-19. Thirty-five patients with COVID-19 were intubated with the current workflow and guideline without any nosocomial transmission. Conclusion: An early planned and well-structured multidisciplinary hospital-wide simulation training programme was organised expeditiously to provide extensive staff coverage. The insight and experience gained from this project is valuable for future infectious disease challenges.

If not appendicitis, then what else can it be? A retrospective review of 1492 appendectomies.

OBJECTIVE: To audit the appendectomies at our institute, and summarise atypical pathological results with a discussion of appropriate management. DESIGN. Retrospective study. SETTING: Regional hospital, Hong Kong. PATIENTS: All patients who underwent appendectomy for presumed acute appendicitis from June 2003 to June 2008 were recruited. Incidental appendectomy was excluded. Patient demographics, pathological findings, and surgical outcomes were analysed. RESULTS. The overall negative appendectomy rate was 18.2%. Female patients of reproductive age (11-50 years) conferred an independent risk for a higher negative appendectomy rate than other females (28.7% vs 11.5%; P<0.001). The overall perforation rate was 22.5%; the extremes of age (<11 or >70 years) conferred an independent risk of perforated appendicitis (25.2% vs 16.3%; P=0.002). Preoperative imaging was not associated with a lower negative appendectomy rate or rate for perforated appendicitis (P=0.205 and 0.218, respectively). Multivariate analysis suggested that a preoperative white cell count of less than 13.5 x 10(9) /L was an independent predictor of negative appendectomy (P<0.001); the body temperature and pulse rate of the patients with perforated appendicitis were higher than in those without perforation (P=0.004 and 0.003, respectively). Only 4.0% of the appendectomy specimens contained other appendiceal pathologies. Appendiceal diverticulitis was the most common inflammatory pathology, contributing to 2.7% of all appendectomies, followed by granulomatous appendicitis. In this series there were eight carcinoid tumours, three adenocarcinomas, two mucinous cystadenomas; tubular adenoma, metastatic deposition, mucinous cystadenocarcinoma and pseudomyxoma peritonei each occurred in one patient only. CONCLUSIONS: A more focused utilisation of preoperative imaging in females of reproductive age and patients at the extremes of age is suggested. Long-term follow-up should be offered to patients with granulomatous appendicitis and neoplastic appendiceal diseases.

Surgical treatment of parastomal hernia complicating sigmoid colostomies.

PURPOSE: Parastomal hernia is a common late complication of colostomy. Surgical approach to the repair of parastomal hernia is controversial. Results of surgical treatment are disappointing. The aim of this study was to assess the outcome of surgical treatment of parastomal hernia. METHOD: This article reports a retrospective review of those patients who had undergone a surgical treatment of parastomal hernia complicating sigmoid colostomy. The indications, surgical procedures, complications, and outcome were carefully studied. RESULTS: There were 43 surgical treatments of parastomal hernia. Sixteen underwent simple local repair; 25 stomas were relocated, and 2 were locally repaired with mesh. Overall recurrence was 18 of 40 (45 percent). Recurrences for fascial repair and stoma relocation were 6 of 13 (46 percent) and 10 of 25 (40 percent), respectively. Stoma relocation could be accomplished without formal laparotomy in 19 of 25 cases. Incisional hernia occurred in only 2 of these 25 relocations. CONCLUSION: Fascial repair alone can be performed for symptomatic small hernias because of its advantage of minimal morbidity. Stoma relocation without formal laparotomy can be advocated for larger hernias. A combination of local resite together with mesh reinforcement may be the alternative for further improvement of results.

Audit of laparoscopic cholecystectomy in a single center.

A continuous audit is required to ensure laparoscopic cholecystectomy (LC) is performed safely in the surgical community in general. A retrospective review of all LC done in a single center was performed. A total of 1,244 LC were attempted. The conversion rate was 12.4%, the complication rate 3.5%, and the bile duct injury rate 0.4%. Forty percent of bile duct injury occurred after conversion. A decreasing trend of complication rate was seen in the early part of the series, then the rate steadied at about 2.5-3%. A higher threshold of conversion may not increase the bile duct injury rate. However, good laparoscopic technique and adequate experience are prerequisites to safe LC.

The investigation and management of thyroid nodules--a retrospective review of 183 cases.

The management of the patient with a thyroid nodule remains a clinical challenge because of its risk of malignancy. This is a retrospective audit of 183 patients undergoing thyroidectomy for thyroid nodules at the Queen Elizabeth Hospital, Hong Kong, in 1994. The history, physical examination and investigations done were charted and analysed against the final histopathology of the specimens. Age, sex, symptom duration and nodularity were not associated with malignancy statistically, whereas a nodule hard in consistency was shown to be associated with malignancy (P < 0.05). The sensitivity and specificity of ultrasonography, radionuclide scan and fine-needle aspiration cytology (FNAC) were 71% and 57%, 50% and 43%, and 93% and 60%, respectively. Hence, history and physical examination are unreliable for detecting malignant thyroid nodules and FNAC is mandatory. FNAC is superior to ultrasonography or radionuclide scan for evaluating thyroid nodules and should be used as the initial investigation.

Acute appendicitis---a recent audit of an old problem.

We conducted a retrospective review of all patients who had an appendicectomy performed at the Queen Elizabeth Hospital, Hong Kong, from January 1993 through December 1994. The diagnostic accuracy for true appendicitis was 74%. Nine per cent of patients had other pathologies, which also needed exploration. The diagnostic accuracy in female patients was 66%, compared with 82% for male patients (P<0.0001). Female patients aged between 15 to 40 years were diagnosed accurately 62% of the time, which has significantly lower than the rate for other female patients (P=0.016). the overall morbidity and mortality rates were 9.2% and 3%, respectively. Complicated appendicitis had a higher morbidity rate of 21%, compared with 9% for uncomplicated appendicitis (P<0.0001). Results for patients who were operated on the day of admission were compared with those who were operated on the day after admission. No significant difference in diagnostic accuracy (P=0.46), percentage of complicated appendicitis (P=0.7), and morbidity rate (P=0.8) was found.