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Vascular compromise and resulting ischaemic injury are known rare complications of cosmetic filler injections. Most hyaluronic acid vascular compromises present early and can be treated effectively by hyaluronidase. Here we present a case of ischaemic wound and mucosal necrosis after cosmetic facial hyaluronic acid injection that appeared within hours of injection but was not diagnosed and treated for 5 days. At day 5, the patient was treated with hyaluronidase injection immediately followed by 14 sessions of daily hyperbaric oxygen therapy (HBOT). Despite the delayed treatment, the patient had essentially complete recovery and the hyperbaric therapy was overall well-tolerated. Our case report suggests that hyaluronidase injection with concurrent daily HBOT sessions may be effective to allow recovery from late-presenting filler ischaemic complication. Furthermore, given the safety profile of HBOT, we suggest a more deliberate approach to this modality as a therapeutic adjunct by cosmetic practitioners when similar complications arise.

BackgroundDespite being implemented for over a decade, literature describing how the surgical safety checklist (SSC) is completed by operating room (OR) teams and how this relates to its effectiveness is scarce. This systematic review aimed to: (1) quantify how many studies reported SSC completion versus described how the SSC was completed; (2) evaluate the impact of the SSC on provider outcomes (Communication, case Understanding, Safety Culture, CUSC), patient outcomes (complications, mortality rates) and moderators of these relationships.MethodsA systematic literature search was conducted using Medline, CINAHL, Embase, PsycINFO, PubMed, Scopus and Web of Science on 10 January 2020. We included providers who treat human patients and completed any type of SSC in any OR or simulation centre. Statistical directional findings were extracted for provider and patient outcomes and key factors (eg, attentiveness) were used to determine moderating effects.Results300 studies were included in the analysis comprising over 7 302 674 operations and 2 480 748 providers and patients. Thirty-eight per cent of studies provided at least some description of how the SSC was completed. Of the studies that described SSC completion, a clearer positive relationship was observed concerning the SSC’s influence on provider outcomes (CUSC) compared with patient outcomes (complications and mortality), as well as related moderators.ConclusionThere is a scarcity of research that examines how the SSC is completed and how this influences safety outcomes. Examining how a checklist is completed is critical for understanding why the checklist is successful in some instances and not others.

Numerous guideline recommendations for airway and perioperative management during the COVID-19 pandemic have been published. We identified, synthesized, and compared guidelines intended for anesthesiologists.Member society websites of the World Federation of Societies of Anesthesiologists and the European Society of Anesthesiologists were searched. Recommendations that focused on perioperative airway management of patients with proven or potential COVID-19 were included. Accelerated screening was used; data were extracted by one reviewer and verified by a second. Data were organized into themes based on perioperative phase of care.Thirty unique sets of recommendations were identified. None reported methods for systematically searching or selecting evidence to be included. Four were updated following initial publication. For induction and airway management, most recommended minimizing personnel and having the most experienced anesthesiologist perform tracheal intubation. Significant congruence was observed among recommendations that discussed personal protective equipment. Of those that discussed tracheal intubation methods, most (96%) recommended videolaryngoscopy, while discordance existed regarding use of flexible bronchoscopy. Intraoperatively, 23% suggested specific anesthesia techniques and most (63%) recommended a specific operating room for patients with COVID-19. Postoperatively, a minority discussed extubation procedures (33%), or care in the recovery room (40%). Non-technical considerations were discussed in 27% and psychological support for healthcare providers in 10%.Recommendations for perioperative airway management of patients with COVID-19 overlap to a large extent but also show significant differences. Given the paucity of data early in the pandemic, it is not surprising that identified publications largely reflected expert opinion rather than empirical evidence. We suggest future efforts should promote coordinated responses and provide suggestions for studying and establishing best practices in perioperative patients.Open Science Framework ( https://osf.io/a2k4u/ ); date created, 26 March 2020.RéSUMé: OBJECTIF: De nombreuses recommandations ont été publiées pour la prise en charge des voies aériennes et périopératoires pendant la pandémie de COVID-19. Nous avons identifié, synthétisé et comparé les lignes directrices destinées aux anesthésiologistes.Les sites internet des sociétés membres de la Fédération mondiale des sociétés d’anesthésiologistes et de la Société européenne d’anesthésiologie ont été consultés. Les recommandations axées sur la prise en charge périopératoire des voies aériennes des patients atteints de COVID-19 prouvée ou potentielle ont été incluses. Une sélection accélérée a été utilisée; les données ont été extraites par un examinateur et vérifiées par un second. Les données ont été thématiquement organisées en fonction de la phase périopératoire des soins.Trente ensembles uniques de recommandations ont été identifiés. Aucun de ces ensemble n’a fait état de méthodes de recherche ou de sélection systématiques des données probantes à inclure. Quatre ont été mis à jour après leur publication initiale. Pour l’induction et la prise en charge des voies aériennes, la plupart ont recommandé de minimiser le personnel et de demander à l’anesthésiologiste le plus expérimenté de réaliser l’intubation trachéale. Une congruence significative a été observée parmi les recommandations qui portaient sur les équipements de protection individuelle. Parmi les lignes directrices évoquant les méthodes d’intubation trachéale, la plupart (96 %) ont recommandé la vidéolaryngoscopie, alors qu’il existait une discordance concernant l’utilisation de bronchoscopes flexibles. En peropératoire, 23 % ont suggéré des techniques d’anesthésie spécifiques et la plupart (63 %) ont recommandé une salle d’opération spécifique pour les patients atteints de COVID-19. En postopératoire, une minorité a abordé le sujet des procédures d’extubation (33 %) ou des soins en salle de réveil (40 %). Les considérations non techniques ont été traitées dans 27 % des cas et le soutien psychologique aux fournisseurs de soins de santé dans 10 %.Les recommandations pour la prise en charge périopératoire des voies aériennes des patients atteints de COVID-19 se chevauchent dans une large mesure, mais montrent également des différences significatives. Compte tenu de la rareté des données au début de la pandémie, il n’est pas surprenant que les publications identifiées reflètent en grande partie l’opinion d’experts plutôt que de se fonder sur des données probantes empiriques. Nous suggérons que les efforts futurs soient déployés de manière à promouvoir des réponses coordonnées et proposer des suggestions pour étudier et établir les meilleures pratiques chez les patients en période périopératoire. ENREGISTREMENT DE L’éTUDE: Open Science Framework ( https://osf.io/a2k4u/ ); date de création, 26 mars 2020.

Understanding which outcomes matter most and improving outcomes for the growing population of older surgical patients are top priorities for Canadian anesthesia research. Nevertheless, there is little understanding of which outcomes older surgical patients prioritize most highly. We evaluated how older people prioritized six outcomes after elective noncardiac surgery. These outcomes were recommended in core outcome sets for perioperative medicine.Following ethical approval, we conducted a prospective, nested, cross-sectional study of people one year after they had major elective noncardiac surgery. Participants were asked to rate the importance of six commonly measured outcomes (complications, length of stay, discharge disposition, days at home, disability score, and developing a new disability) on an 11-point Likert scale. Open-ended questions elicited other preferences. Pairwise comparisons were evaluated using Bayesian multivariate regression. K-means clustering identified subgroups of patients based on overall prioritization. Thematic analysis was applied to open-ended responses.One hundred and one consecutive participants responded. All outcomes scored at least 7.7/10 on average. Complications and discharge location were most highly rated, but only days at home and length of stay had substantial probability (99%) of being rated lower than the other four outcomes. Thematic analysis identified the need for greater procedure-specific information, support services, and physical recovery measures.Commonly recorded and recommended outcomes are reassuringly relevant to older people; however, system-related measures are less highly valued than those more directly related to health and function. Outcomes may need to be personalized to properly evaluate the success of perioperative care.RéSUMé: OBJECTIF: Pour la recherche canadienne en anesthésie, l’une des priorités absolues consiste à comprendre quelles issues comptent le plus et à améliorer les issues pour la population croissante de patients chirurgicaux plus âgés. Néanmoins, nous ne savons que peu de choses quant aux issues les plus importantes pour les patients chirurgicaux plus âgés. Nous avons évalué la façon dont les personnes âgées priorisaient six issues après une chirurgie non cardiaque non urgente. Ces issues étaient recommandées au sein d’ensembles de critères de base en médecine périopératoire. MéTHODE: Après avoir obtenu l’approbation du comité d’éthique, nous avons mené une étude prospective, imbriquée et transversale auprès de patients un an après une chirurgie majeure non cardiaque non urgente. Les participants devaient évaluer l’importance de six critères couramment mesurés (complications, durée de séjour, dispositions à la sortie, jours à la maison, score d’invalidité et développement d’une nouvelle incapacité) sur une échelle de Likert de 11 points. Les questions ouvertes ont suscité d’autres préférences. Les comparaisons par paires ont été évaluées par régression multivariée bayésienne. L’algorithme des K-moyennes a identifié des sous-groupes de patients en fonction de leur priorisation globale. L’analyse thématique a été appliquée aux réponses ouvertes. RéSULTATS: Cent un participants consécutifs ont répondu. Tous les critères ont obtenu une note d’au moins 7,7/10 en moyenne. Les complications et le lieu de sortie étaient les mieux notés, mais seuls les jours à la maison et la durée de séjour ont affiché une probabilité substantielle (99 %) d’être évalués moins haut que les quatre autres critères. L’analyse thématique a révélé la nécessité d’une plus grande information spécifique à l’intervention, de services de soutien et de mesures de rétablissement physique. CONCLUSION: De façon rassurante, les critères couramment enregistrés et recommandés sont pertinents pour les personnes âgées; toutefois, les mesures liées au système sont moins appréciées que celles qui sont plus directement liées à la santé et à la fonction. Il est possible que les critères dussent être personnalisés pour évaluer de façon adéquate le succès des soins périopératoires.

Introduction: Booster sessions can improve cardiopulmonary resuscitation (CPR) skill retention among healthcare providers; however, the optimal timing of these sessions is unknown. This study aimed to explore differences in skill retention based on booster session timing. Methods: After ethics approval, healthcare providers who completed an initial CPR training course were randomly assigned to either an early booster, late booster, or no booster group. Participants’ mean resuscitation scores, time to initiate compressions, and time to successfully provide defibrillation were assessed immediately post-course and four months later using linear mixed models. Results: Seventy-three healthcare professionals were included in the analysis. There were no significant differences by randomization in the immediate post-test (9.7, 9.2, 8.9) or retention test (10.2, 9.8, and 9.5) resuscitation scores. No significant effects were observed for time to compression. Post-test time to defibrillation (mean ± SE: 112.8 ± 3.0 sec) was significantly faster compared to retention (mean ± SE: 120.4 ± 2.7 sec) (p = 0.04); however, the effect did not vary by randomization. Conclusion: No difference was observed in resuscitation skill retention between the early, late, and no booster groups. More research is needed to determine the aspects of a booster session beyond timing that contribute to skill retention.

In light of the COVID-19 public health restrictions, the use of telemedicine has been on the rise. This care delivery model is valued for its potential to increase care access while providing safe care. However, it changes the way patients and providers interact. Communication during video consultations requires embodied engagement to compensate for the physical distance. This study aimed to identify patient-provider communication challenges during video consultations and assess the tools developed to support patient-provider communication according to the published literature from 2019 to 2022. Searches of eight databases (Medline (Ovid), PubMed, ProQuest Nursing and Allied Health, CINAHL, Web of Science, Scopus, PsychInfo, and Social Services Abstracts), and a Google search for grey literature were conducted. Nineteen articles met inclusion criteria. Findings show that patients and providers share the same concerns, such as a lack of trust relating to physical distance, the ability to establish a meaningful relationship, and a lack of confidence in clinical assessment. The available tools, however, are based on guidelines that are difficult to adapt to the diversity of interaction contexts. There is a need for tools that consider the complexity of patient-provider communication in order to address the challenges stemming from the lack of trust in the context of video consultations. These findings can inform strategies for effective patient-provider communication during video consultations to improve the quality of care and optimize outcomes in this context.

Abstract Background Despite substantial implications for healthcare provider practice and patient outcomes, gender has yet to be systematically explored with regard to interprofessional operating room (OR) teamwork. We aimed to explore and describe how gender and additional social identity factors shape experiences and perceptions of teamwork in the OR. Methods This study was a qualitative secondary analysis of semi-structured interviews with OR team members conducted between November 2018 and July 2019. Participants were recruited across hospitals in Ontario, Canada. We conducted both purposive and snowball sampling until data saturation was reached. Transcripts were analyzed thematically by two independent research team members, moving from open to axial coding. Results Sixty-six interviews of OR healthcare professionals were completed: anesthesia (n=17), nursing (n=19), perfusion (n=2), and surgery (n=26). Traditional gender roles, norms, and stereotypes were perceived and experienced by both women and men, but with different consequences. Both women and men participants described challenges that women face in the OR, such as being perceived negatively for displaying leadership behaviours. Participants also reported that interactions and behaviours vary depending on the team gender composition, and that other social identities, such as age and race, often interact with gender. Nevertheless, participants indicated a belief that the influence of gender in the OR may be modified. Conclusions The highly gendered reality of the OR creates an environment conducive to breakdowns in communuication and patient safety risks in addition to diminishing team morale, psychological safety, and provider well-being. Consequently, until teamwork interventions adequately account for gender, they are unlikely to be optimally effective or sustainable.

Background Healthcare curricula need summative assessments relevant to and representative of clinical situations to best select and train learners. Simulation provides multiple benefits with a growing literature base proving its utility for training in a formative context. Advancing to the next step, “the use of simulation for summative assessment” requires rigorous and evidence-based development because any summative assessment is high stakes for participants, trainers, and programs. The first step of this process is to identify the baseline from which we can start. Methods First, using a modified nominal group technique, a task force of 34 panelists defined topics to clarify the why, how, what, when, and who for using simulation-based summative assessment (SBSA). Second, each topic was explored by a group of panelists based on state-of-the-art literature reviews technique with a snowball method to identify further references. Our goal was to identify current knowledge and potential recommendations for future directions. Results were cross-checked among groups and reviewed by an independent expert committee. Results Seven topics were selected by the task force: “What can be assessed in simulation?”, “Assessment tools for SBSA”, “Consequences of undergoing the SBSA process”, “Scenarios for SBSA”, “Debriefing, video, and research for SBSA”, “Trainers for SBSA”, and “Implementation of SBSA in healthcare”. Together, these seven explorations provide an overview of what is known and can be done with relative certainty, and what is unknown and probably needs further investigation. Based on this work, we highlighted the trustworthiness of different summative assessment-related conclusions, the remaining important problems and questions, and their consequences for participants and institutions of how SBSA is conducted. Conclusion Our results identified among the seven topics one area with robust evidence in the literature (“What can be assessed in simulation?”), three areas with evidence that require guidance by expert opinion (“Assessment tools for SBSA”, “Scenarios for SBSA”, “Implementation of SBSA in healthcare”), and three areas with weak or emerging evidence (“Consequences of undergoing the SBSA process”, “Debriefing for SBSA”, “Trainers for SBSA”). Using SBSA holds much promise, with increasing demand for this application. Due to the important stakes involved, it must be rigorously conducted and supervised. Guidelines for good practice should be formalized to help with conduct and implementation. We believe this baseline can direct future investigation and the development of guidelines.

Le partage de commentaires formatifs est inhérent au processus de supervision et l'acceptation de la rétroaction par les apprenants est une étape essentielle à l'apprentissage. Cependant, recevoir des commentaires du superviseur suscite des émotions et les accepter n'est pas facile. Plusieurs recommandations guident les superviseurs sur la façon de partager leurs observations aux apprenants et toutes soulignent l’importance d’encourager l'apprenant à interagir de façon active au processus de rétroaction. Bien que des études dénotent l’effet positif d’informer et de former les apprenants sur la rétroaction, peu s’attardent à les outiller à mieux réagir à la rétroaction. Fondés sur les observations de superviseurs expérimentés, nous proposons un modèle cognitivo-comportemental qui vise à guider les apprenants à aborder la rétroaction avec un état d'esprit de croissance personnelle associé à la position d’apprentissage. Sous le registre de l’acquisition d’une compétence personnelle destinée à mieux accepter les commentaires, le modèle présente un ensemble interdépendant d’attitudes et de comportements destiné à faciliter la gestion des émotions, l’auto-réflexion et l’engagement dans le processus de rétroaction nécessaires à l’apprentissage et à l’acquisition de compétences. L’acronyme H.O.T.E. rappelle aux étudiants les quatre éléments essentiels du modèle : l'humilité, l'ouverture d'esprit, la ténacité et l'explicitation. S’inspirant du courant de la psychologie positive, chaque élément est défini et justifié par des concepts théoriques connus. Pour mieux assimiler les composantes du modèle, l’utilisation de dialogue intérieur est retenue pour faciliter l’entrainement et l’adoption des comportements. L’essence du modèle est discutée à la lumière de la littéracie en rétroaction dédiée aux apprenants.

Introduction: The need for intubation and mechanical ventilation among COVID-19 patients is associated with high mortality rates and places a substantial burden on the healthcare system. There is a strong pathophysiological rationale suggesting that hyperbaric oxygen treatment (HBOT), a low-risk and non-invasive treatment, may be beneficial for COVID-19 patients. This systematic review aimed to explore the potential effectiveness and safety of HBOT for treating patients with COVID-19. Methods: Medline, Embase, Scopus, and Google Scholar were searched from December 2019 to February 2021, without language restrictions. The grey literature was searched via an internet search engine and targeted website and database searches. Reference lists of included studies were searched. Independent reviewers assessed studies for eligibility and extracted data, with disagreements resolved by consensus or a third reviewer. Risk of bias was assessed using the Newcastle Ottawa Scale. Data were summarised descriptively. Results: Six publications (one cohort study, five case reports/series) met the inclusion criteria with a total of 37 hypoxaemic COVID-19 patients treated with HBOT. Of these 37 patients, the need for intubation and mechanical ventilation and in-hospital survival were assessed for 26 patients across three studies. Of these 26 patients, intubation and mechanical ventilation were not required for 24, and 23 patients survived. No serious adverse events of HBOT in COVID-19 patients were reported. No randomised trials have been published. Conclusions: Limited and weak evidence from non-randomised studies including one propensity-matched cohort study suggests HBOT is safe and may be a promising intervention to optimise treatment and outcomes in hypoxaemic COVID-19 patients. Randomised controlled studies are urgently needed.

Background Peripheral nerve blocks are being used with increasing frequency for management of hip fracture–related pain. Despite converging evidence that nerve blocks may be beneficial, safety data are lacking. This study hypothesized that peripheral nerve block receipt would not be associated with adverse events potentially attributable to nerve blocks, as well as overall patient safety incidents while in hospital. Methods This was a preregistered, retrospective population-based cohort study using linked administrative data. This study identified all hip fracture admissions in people 50 yr of age or older and identified all nerve blocks (although we were unable to ascertain the specific anatomic location or type of block), potentially attributable adverse events (composite of seizures, fall-related injuries, cardiac arrest, nerve injury), and any patient safety events using validated codes. The study also estimated the unadjusted and adjusted association of nerve blocks with adverse events; adjusted absolute risk differences were also calculated. Results In total, 91,563 hip fracture patients from 2009 to 2017 were identified; 15,631 (17.1%) received a nerve block, and 5,321 (5.8%; 95% CI, 5.7 to 6.0%) patients experienced a potentially nerve block–attributable adverse event: 866 (5.5%) in patients with a block and 4,455 (5.9%) without a block. Before and after adjustment, nerve blocks were not associated with potentially attributable adverse events (adjusted odds ratio, 1.05; 95% CI, 0.97 to 1.15; and adjusted risk difference, 0.3%, 95% CI, –0.1 to 0.8). Conclusions The data suggest that nerve blocks in hip fracture patients are not associated with higher rates of potentially nerve block–attributable adverse events, although these findings may be influenced by limitations in routinely collected administrative data. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Background Accumulating evidence suggests that hyperbaric oxygen therapy (HBOT) may be effective for inflammatory bowel disease (IBD). Our systematic review aimed to quantify the effectiveness and safety of HBOT in various IBD phenotypes. Methods We performed a proportional meta-analysis. Multiple databases were systematically searched from inception through November 2020 without language restriction. We included studies that reported effectiveness and/or safety of HBOT in IBD. Weighted summary estimates with 95% confidence intervals (Cis) were calculated for clinical outcomes for each IBD phenotype using random-effects models. Study quality was assessed using the Cochrane evaluation handbook and National Institute of Health criteria. Results Nineteen studies with 809 patients total were eligible: 3 randomized controlled trials and 16 case series. Rates of clinical remission included 87% (95% CI, 10–100) for ulcerative colitis (n = 42), 88% (95% CI, 46–98) for luminal Crohn’s disease (CD, n = 8), 60% (95% CI, 40–76) for perianal CD (n = 102), 31% (95% CI, 16–50) for pouch disorders (n = 60), 92% (95% CI, 38–100) for pyoderma gangrenosum (n = 5), and 65% (95% CI, 10–97) for perianal sinus/metastatic CD (n = 7). Of the 12 studies that reported on safety, 15% of patients (n = 30) had minor adverse events. Study quality was low in the majority of studies due to an absence of comparator arms, inadequate description of concomitant interventions, and/or lack of objective outcomes. Conclusions Limited high-quality evidence suggests that HBOT is safe and associated with substantial rates of clinical remission for multiple IBD phenotypes. Well-designed randomized controlled trials are warranted to confirm the benefit of HBOT in IBD.

While the operating room (OR) has significantly benefited from aviation strategies to improve safety, the rate of avoidable human errors remains relatively high. One key aviation strategy that has yet to be formally established in the OR is the “sterile cockpit” rule, which prohibits all non-essential behaviours during critical moments of a flight. Applying this rule to the OR may enhance patient safety, but the critical moments of surgery need to be defined first. This study used a modified Delphi methodology to determine critical moments during surgery according to OR team members across institutions, professions, and specialties. Analysis occurred after each round. The stopping criterion was consensus on 80% of survey items or no change in the mean score for any individual item between two consecutive rounds. The first round included 304 respondents. Of these, 115 completed the second-round survey, and 75 completed all three rounds (27 nurses, 29 anesthesiologists, 19 surgeons). Critical moments obtained by consensus were: induction of anesthesia; emergence from anesthesia; preoperative briefing; final counts at the end of the procedure; anesthesiologist- or surgeon-relevant intraoperative event; handovers; procedure-specific high-risk surgical moments; crisis resource management situations; medication and equipment preparation; and key medication administration. By defining the most critical moments of surgery, future research can determine the relative importance of behaviour and actions at each stage and target interventions to these stages.

Background A primary underlying cause of postoperative complications is related to the surgical stress response, which may be mitigated by hyperbaric oxygen therapy (HBOT), the intermittent administration of oxygen at a pressure higher than the atmospheric pressure at sea level. Promising clinical studies have emerged suggesting HBOT's efficacy for reducing some postoperative complications. Notwithstanding, the effectiveness (if any) of HBOT across a range of procedures and postoperative outcomes has yet to be clearly quantified. Objective This systematic review aimed to summarise the existing literature on peri-operative HBOT to investigate its potential to optimise surgical patient outcome. Design A systematic review of randomised controlled trials (RCTs) with narrative summary of results. Data sources MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials were searched without language restrictions through to 19 June 2018. Eligibility criteria Studies were included if they involved patients of any age undergoing any surgical procedure and provided with at least one HBOT session in the peri-operative period. Two independent reviewers screened the initial identified trials and determined those to be included. Risk of bias was assessed using the Cochrane Risk of Bias tool for RCTs. Results The search retrieved 775 references, of which 13 RCTs were included (627 patients). Ten RCTs (546 patients) reported treatment was effective for improving at least one of the patient outcomes assessed, while two studies (55 patients) did not find any benefit and one study (26 patients) found a negative effect. A wide range of patient outcomes were reported, and several other methodological limitations were observed among the included studies, such as limited use of sham comparator and lack of blinding. Conclusion Peri-operative preventive HBOT may be a promising intervention to improve surgical patient outcome. However, future work should consider addressing the methodological weaknesses identified in this review. Trial registration The protocol (CRD42018102737) was registered with the International ProspectiveRegister of Systematic Reviews (PROSPERO).

Skill retention after neonatal resuscitation training is poor. A distributed learning strategy – where learning is spread over multiple sessions – can improve retention of declarative memory (facts & knowledge). Session timings are critical – maximal retention occurs when a refresher session is scheduled at 10-30% of the time between initial training and test. We hypothesized this also holds true for neonatal resuscitation, a complex skill set requiring both declarative and procedural memory. We conducted a prospective, single-blinded randomized-controlled trial. University of Ottawa residents were recruited to training in neonatal resuscitation, with a high-fidelity simulated pre-test, immediate post-tests, and a retention test at 4 months. After training, they were randomized to either a refresher session at 3 weeks (18% of interval) or at 2 months (50%). Technical and non-technical skills were scored using validated checklists, knowledge with standardized questions. There was no difference between groups prior to the retention test. The early refresher group demonstrated significantly improved technical (mean ± 95% CI: 22.4 ± 1.3 v 18.2 ± 2.5, p = 0.02) and non-technical (31.0 ± 0.9 v 25.6 ± 3.1, p = 0.03) skill scores in the retention post-test compared to the late group. No difference was seen with knowledge scores. We conclude that both technical and non-technical aspects of neonatal resuscitation performance can benefit from an early refresher session. Session timings are critical and should be tailored to the desired length of skill retention. Findings may be generalizable to other interventions that depend on mixed types of memory.

Physician wellness is critical for patient safety and quality of care. Coaching has been successfully and widely applied across many industries to enhance well-being but has only recently been considered for physicians. This review aimed to summarize the existing evidence on the effect of coaching by trained coaches on physician well-being, distress and burnout. MEDLINE, Embase, ERIC, PsycINFO and Web of Science were searched without language restrictions to December 21, 2022. Studies of any design were included if they involved physicians of any specialty undergoing coaching by trained coaches and assessed at least one measure along the wellness continuum. Pairs of independent reviewers determined reference eligibility. Risk of bias was assessed using the Cochrane Risk of Bias Tools for Randomized Controlled Trials (RCTs) and for Non-randomized Studies of Interventions (ROBINS-I). Meta-analysis was not possible due to heterogeneity in study design and outcome measures as well as inconsistent reporting. The search retrieved 2531 references, of which 14 were included (5 RCTs, 2 non-randomized controlled studies, 4 before-and-after studies, 2 mixed-methods studies, 1 qualitative study). There were 1099 participants across all included studies. Risk of bias was moderate or serious for non-RCTs, while the 5 RCTs were of lower risk. All quantitative studies reported effectiveness of coaching for at least one outcome assessed. The included qualitative study reported a perceived positive impact of coaching by participants. Evidence from available RCTs suggests coaching for physicians can improve well-being and reduce distress/burnout. Non-randomized interventional studies have similar findings but face many limitations. Consistent reporting and standardized outcome measures are needed.

Background Evidence suggests that there are substantial inconsistencies in the practice of anesthesia. There has not yet been a comprehensive summary of the anesthesia literature that can guide future knowledge translation interventions to move evidence into practice. As the first step toward identifying the most promising interventions for systematic implementation in anesthesia practice, this scoping review of multicentre RCTs aimed to explore and map the existing literature investigating perioperative anesthesia-related interventions and clinical patient outcomes. Methods Multicenter randomized controlled trials were eligible for inclusion if they involved a tested anesthesia-related intervention administered to adult surgical patients (≥ 16 years old), with a control group receiving either another anesthesia intervention or no intervention at all. The electronic databases Embase (via OVID), MEDLINE, and MEDLINE in Process (via OVID), and Cochrane Central Register of Control Trials (CENTRAL) were searched from inception to February 26, 2021. Studies were screened and data were extracted by pairs of independent reviewers in duplicate with disagreements resolved through consensus or a third reviewer. Data were summarized narratively. Results We included 638 multicentre randomized controlled trials (n patients = 615,907) that met the eligibility criteria. The most commonly identified anesthesia-related intervention theme across all studies was pharmacotherapy (n studies = 361 [56.6%]; n patients = 244,610 [39.7%]), followed by anesthetic technique (n studies = 80 [12.5%], n patients = 48,455 [7.9%]). Interventions were most often implemented intraoperatively (n studies = 233 [36.5%]; n patients = 175,974 [28.6%]). Studies typically involved multiple types of surgeries (n studies = 187 [29.2%]; n patients = 206 667 [33.5%]), followed by general surgery only (n studies = 115 [18.1%]; n patients = 201,028 [32.6%]) and orthopedic surgery only (n studies = 94 [14.7%]; n patients = 34,575 [5.6%]). Functional status was the most commonly investigated outcome (n studies = 272), followed by patient experience (n studies = 168), and mortality (n studies = 153). Conclusions This scoping review provides a map of multicenter RCTs in anesthesia which can be used to optimize future research endeavors in the field. Specifically, we have identified key knowledge gaps in anesthesia that require further systematic assessment, as well as areas where additional research would likely not add value. These findings provide the foundation for streamlining knowledge translation in anesthesia in order to reduce practice variation and enhance patient outcomes.

Background Surgery is one of the most common patient experiences in the health care system. Yet, efforts to engage patients in surgical safety research have not matched those of other health care fields. This is a critical issue given the nature of surgery inhibits patients’ abilities to advocate for themselves as they are typically under anesthetic when the procedure is performed. We partnered with patients throughout our research program, which uses the Operating Room Black Box® to enhance surgical patient safety through transparent and proactive analysis of human factors to detect and prevent avoidable errors. Main body In this article, we outline the need for, and our approach to, patient engagement in surgical safety research. Our approach included a series of planned activities and skill development opportunities designed to build capacity and bring together patients, clinicians, and researchers to inform research and practice. We also conducted evaluation surveys during the first year of our program, which have indicated a positive experience by both patient partners and the research team. Conclusion We believe our approach can serve as an important first step toward building a model for patient engagement in the surgical safety field and could significantly contribute to improved quality of care and outcomes for surgical patients.

Retention of skills and knowledge has been shown to be poor after resuscitation training. The effect of a "booster" is controversial and may depend on its timing. We compared the effectiveness of an early versus late booster session after Basic Life Support (BLS) training for skill retention at 4 months.We performed a single-blind randomized controlled trial in a simulation environment. Eligible participants were adult laypeople with no BLS training or practice in the 6 months prior to the study. We provided participants with formal BLS training followed by an immediate BLS skills post-test. We then randomized participants to one of three groups: control, early booster, or late booster. Based on their group allocation, participants attended a brief BLS refresher at either 3 weeks after training (early booster), at 2 months after training (late booster), or not at all (control). All participants underwent a BLS skills retention test at 4 months. We measured BLS skill performance according to the Heart and Stroke Foundation's skills testing checklist for adult CPR and the use of an automated external defibrillator.A total of 80 laypeople were included in the analysis (control group, n = 28; early booster group, n = 23; late booster group, n = 29). The late booster group achieved better skill retention (mean difference in checklist score at retention compared to the immediate post-test = - 0.8 points out of 15, [95% CI - 1.7, 0.2], P = 0.10) compared to the early booster (- 1.3, [- 2.6, 0.0], P = 0.046) and control group (- 3.2, [- 4.7, - 1.8], P 0.001).A late booster session improves BLS skill retention at 4 months in laypeople.NCT02998723.RéSUMé: OBJECTIF: Il a été démontré que la rétention des compétences et des connaissances est faible après une formation en réanimation. L'effet d'un "booster" est controversé et peut dépendre de son moment. Nous avons comparé l'efficacité d'une session de rappel précoce ou tardive après la formation Basic Life Support (BLS) pour le maintien des compétences après quatre mois. MéTHODES: Nous avons réalisé un essai contrôlé randomisé en simple aveugle dans un environnement de simulation. Les participants éligibles étaient des laïcs adultes n'ayant pas suivi de formation ou pratiqué le BLS dans les 6 mois précédant l'étude. Nous avons fourni aux participants une formation BLS formelle suivie d'un post-test immédiat sur les compétences BLS. Nous avons ensuite randomisé les participants dans l'un des trois groupes suivants: groupe témoin, rappel précoce ou rappel tardif. En fonction de leur répartition dans le groupe, les participants ont assisté à un bref rappel de BLS soit 3 semaines après la formation (rappel précoce), soit 2 mois après la formation (rappel tardif), soit pas du tout (groupe témoin). Tous les participants ont été soumis à un test de maintien des compétences BLS après quatre mois. Nous avons mesuré la performance des compétences BLS selon la liste de contrôle des compétences de la Fondation des maladies du cœur pour la RCP chez l'adulte et l'utilisation d'un défibrillateur externe automatisé. RéSULTATS: Au total, 80 profanes ont été inclus dans l'analyse (groupe témoin, n = 28; groupe de rappel précoce, n = 23; groupe de rappel tardif, n = 29). Le groupe de rappel tardif a obtenu un meilleur maintien des compétences (différence moyenne du score de la liste de contrôle au moment du maintien par rapport au post-test immédiat = -0,8 points sur 15, [IC 95% -1,7, 0,2], P = 0,10) par rapport au groupe de rappel précoce (-1,3, [-2,6, 0,0], P = 0,046) et au groupe témoin (-3,2, [-4,7, -1,8], P 0,001). CONCLUSION: Une session de rappel tardive améliore la rétention des compétences BLS à 4 mois chez les profanes.

Background Bleeding is the leading cause of maternal mortality in the world. Tranexamic acid reduces bleeding in trauma and surgery. Several systematic reviews of randomized trials have investigated tranexamic acid in the prevention of bleeding in cesarean delivery. However, the conclusions from systematic reviews are conflicting. This overview aims to summarize the evidence and explore the reasons for conflicting conclusions across the systematic reviews. Methods A comprehensive literature search of Medline, Embase, and Cochrane Database of Systematic Reviews was conducted from inception to April 2021. Screening, data extraction, and quality assessments were performed by two independent reviewers. A Measurement Tool to Assess Reviews 2 and the Risk of Bias Assessment Tool for Systematic Reviews were used for study appraisal. A qualitative synthesis of evidence is presented. Results In all, 14 systematic reviews were included in our analysis. Across these reviews, there were 32 relevant randomized trials. A modest reduction in blood transfusions and bleeding outcomes was found by most systematic reviews. Overall confidence in results varied from low to critically low. All of the included systematic reviews were at high risk of bias. Quality of evidence from randomized trials was uncertain. Conclusions Systematic reviews investigating prophylactic tranexamic acid in cesarean delivery are heterogeneous in terms of methodological and reporting quality. Tranexamic acid may reduce blood transfusion and bleeding outcomes, but rigorous well-designed research is needed due to the limitations of the included studies. Data on safety and adverse effects are insufficient to draw conclusions.

BACKGROUND Artificial intelligence (AI) offers a promising solution to expedite various phases of the systematic review process such as screening. OBJECTIVE We aimed to assess the accuracy of an AI tool in identifying eligible references for a systematic review compared to identification by human assessors. METHODS For the case study (a systematic review of knowledge translation interventions), we used a diagnostic accuracy design and independently assessed for eligibility a set of articles (n = 300) using human raters and the AI system DistillerAI (Evidence Partners, Ottawa, Canada). We analysed a series of 64 possible confidence levels for the AI's decisions and calculated several standard parameters of diagnostic accuracy for each. RESULTS When set to a lower AI confidence threshold of 0.1 or greater and an upper threshold of 0.9 or lower, DistillerAI made article selection decisions very similarly to human assessors. Within this range, DistillerAI made a decision on the majority of articles (93-100%), with a sensitivity of 1.0 and specificity ranging from 0.9 to 1.0. CONCLUSION DistillerAI appears to be accurate in its assessment of articles in a case study of 300 articles. Further experimentation with DistillerAI will establish its performance among other subject areas.

PurposeNumerous guideline recommendations for airway and perioperative management during the COVID-19 pandemic have been published. We identified, synthesized, and compared guidelines intended for anesthesiologists.SourceMember society websites of the World Federation of Societies of Anesthesiologists and the European Society of Anesthesiologists were searched. Recommendations focused on perioperative airway management of patients with proven or potential COVID-19 disease were included. Accelerated screening was used; data extraction was performed by one reviewer and verified by a second. Data was organized into themes based on perioperative phase of care.Principal FindingsThirty unique sets of recommendations were identified. None reported methods for systematically searching or selecting evidence to be included. Four were updated following initial publication. For induction and airway management, most recommended minimizing personnel and having the most experienced anesthesiologist perform tracheal intubation. Significant congruence was observed amongst recommendations that discussed personal protective equipment. Of those that discussed tracheal intubation methods, most (96%) recommended video laryngoscopy, while discordance existed regarding use of flexible bronchoscopy. Intraoperatively, 23% suggested specific anesthesia techniques and most (63%) recommended a specific operating room for patients with COVID-19. Postoperatively, a minority discussed extubation procedures (33%), or care in the recovery room (40%). Non-technical considerations were discussed in 27% and psychological support for healthcare providers in 10%.ConclusionRecommendations for perioperative airway management of patients with COVID-19 overlap to a large extent. However, we also identified significant differences. This may reflect the absence of a coordinated response towards studying and establishing best-practices in perioperative patients with COVID-19.RegistrationOpen Science Framework (https://osf.io/a2k4u/)

Teamwork is fundamental to surgical patient safety but is inconsistently measured. While many tools have been developed for elective intraoperative situations, it is unclear which is the most robust. This systematic review aimed to identify tools to measure the teamwork of operating room teams. Studies were included if they examined the measurement properties of these tools. PsycINFO, Embase (via OVID), CINAHL, ERIC, Medline and Medline in Process (via OVID) were searched through to May 3, 2019, as were reference lists of included studies and previously published relevant reviews. Retrieved articles were screened and data extracted in duplicate by two independent reviewers. Quality was assessed using the COSMIN checklist. Of the 2121 references identified, 14 studies of six assessment tools were included. Tools were validated across various specialties, mostly in clinical rather than simulated settings. The Observational Teamwork Assessment for Surgery (OTAS) and Operating Theater Team Non-Technical Skills Assessment Tool (NOTECHS) were the most frequently investigated tools. Though acceptable for assessing teamwork, both NOTECHS and OTAS rely on the questionable assumption that the teamwork of a team is equivalent to the sum of individual performances. Future studies may investigate other assessment tools that assess the whole team as the unit of analysis along with the potential of these tools to provide healthcare providers with meaningful feedback in clinical practice.

Interprofessional simulation-based education is effective for learning non-technical critical care skills and strengthening interprofessional team collaboration to optimize quality of care and patient outcome. Implementation of interprofessional simulation sessions in initial and continuing education is facilitated by a team of "champions" from each discipline/profession to ensure educational quality and logistics. Interprofessional simulation training must be integrated into a broader interprofessional curriculum supported by managers, administrators and clinical colleagues from different professional programs. When conducting interprofessional simulation training, it is essential to account for sociological factors (hierarchy, power, authority, interprofessional conflicts, gender, access to information, professional identity) both in scenario design and debriefing. Teamwork assessment tools in interprofessional simulation training may be used to guide debriefing. The interprofessional simulation setting (in-situ or simulation centre) will be chosen according to the learning objectives and the logistics.

Personalized medicine aims to improve outcomes through application of therapy directed by individualized risk profiles. Whether personalized risk assessment is routinely applied in practice is unclear; the impact of personalized preoperative risk prediction and communication on outcomes has not been synthesized. Our objective was to perform a scoping review to examine the extent, range, and nature of studies where personalized risk was evaluated preoperatively and communicated to the patient and/or healthcare professional. A systematic search was developed, peer-reviewed, and applied to Embase, Medline, CINAHL, and Cochrane databases to identify studies of individuals having or considering surgery, where a process to assess personalized risk was applied and where these estimates were communicated to a patient and/or healthcare professional. All stages of the review were completed in duplicate. We narratively synthesized and described identified themes. We identified 796 studies; 24 underwent full-text review. Seven studies were included; one communicated personalized risk to patients, four to a healthcare professional, and two to both. Cardiac (n = 2) and orthopedic surgery (n = 2) were the most common surgical specialties. Four studies used electronic risk calculators, and three used paper-based tools. Personalized preoperative risk assessment and communication may improve accuracy of information provided to patients, improve consent processes, and influence length of stay. Methodologic weaknesses in study design were common. Personalized preoperative risk assessment and communication may improve patient and system outcomes. This evidence is limited, however, by weaknesses in study design. Appropriately powered, low risk of bias evaluation of personalized risk communication before surgery is needed.

Communication failures are often at the root of adverse events for surgical patients; however, evidence to inform best communication practice in the operating room is relatively limited. This narrative review outlines the importance of interprofessional communication for surgical patient safety, maps its barriers and facilitators, and highlights key strategies for enhancing communication quality in the operating room. Based on this review, a research agenda to inform best practices in interprofessional operating room communication is suggested.The non-systematic literature search included searches of relevant databases (Medline (via OVID), PubMed, Scopus, and EMBASE, PsycINFO, CINAHL), relevant grey literature sources (e.g., patient safety institute websites), and reference lists of selected articles.Effective interprofessional communication plays a critical role in the operating room, but faces many challenges at the individual, team, environmental, and organizational level. Factors that support effective communication are less documented than barriers, but include team integration, flattened hierarchies, and structure/standardization. Checklists, safety briefings, and teamwork/communication training are the most common techniques used to improve communication in the operating room. Of all communication techniques, closed-loop communication may be the most practical and inexpensive strategy.The perioperative community should be encouraged to implement existing effective solutions to improve communication and investigate creative solutions to identified barriers. Improved methods of data collection are needed to enhance evidence quality, increase understanding of communication barriers and facilitators, and identify the best strategy to advance practice.RéSUMé: OBJECTIF: Les problèmes de communication sont souvent à l’origine des événements indésirables pour les patients chirurgicaux, et les données probantes pour guider les meilleures pratiques de communication en salle d’opération sont encore relativement limitées. Ce compte rendu narratif souligne l’importance de la communication interprofessionnelle pour la sécurité des patients chirurgicaux, cartographie ses obstacles et les éléments la facilitant, et présente des stratégies clés pour améliorer la qualité de la communication en salle d’opération. Sur la base de ce compte rendu, un agenda de recherche visant à guider les meilleures pratiques en matière de communication interprofessionnelle en salle d’opération est proposé.Notre recherche de littérature non méthodique s’est intéressée aux bases de données pertinentes (Medline (via OVID), PubMed, Scopus, et EMBASE, PsycINFO, CINAHL), aux sources pertinentes de la littérature grise (par ex., sites Internet des instituts sur la sécurité des patients), et aux listes de références des articles sélectionnés.Une communication interprofessionnelle efficace joue un rôle crucial en salle d’opération, mais elle est souvent mise à l’épreuve tant aux niveaux de l’individu, de l’équipe, de l’environnement que de l’organisation. Les facteurs facilitant une communication efficace sont moins documentés que les obstacles; ils comprennent l’intégration de l’équipe, une structure organisationnelle horizontale et la structure/standardisation. Les listes de contrôle, les réunions sur la sécurité et la formation en travail d’équipe/communications sont les techniques les plus fréquemment utilisées pour améliorer la communication en salle d’opération. Parmi toutes les techniques de communication, la communication en circuit fermé pourrait constituer la stratégie la plus pratique et la moins onéreuse.La communauté périopératoire devrait être encouragée à appliquer les solutions existantes ayant prouvé leur efficacité afin d’améliorer la communication et explorer des solutions créatives pour pallier les obstacles identifiés. De meilleures méthodes de collecte de données sont nécessaires pour améliorer la qualité des données probantes, augmenter la compréhension des obstacles et des aides à la communication, et identifier les meilleures stratégies pour améliorer la pratique.

Objective To validate the Non-Technical Skills for Surgeons (NOTSS) system for assessment of the collective surgical teams' nontechnical skills after observing recordings of actual OR environment. Background The NOTSS system is a widely accepted tool to measure nontechnical skills of individual surgeons, and has mostly been used in the simulated setting. Surgical procedures are rarely performed by a single surgeon, but by a surgical team of attending surgeons, surgical assistants, and surgical trainees. Therefore, assessment of nontechnical skills may benefit from holistic assessment of the collective surgical teams. Methods Five trained participants assessed surgical team and attending surgeon using the NOTSS system after watching ten 20-minute long videos obtained from live OR. A set of reference ratings was provided by a multidisciplinary expert committee. We performed analyses to assess system sensitivity; examine inter-rater reliability of ratings; investigate concurrent construct validity; and assess feasibility and acceptability of using the NOTSS system to measure surgical team performance. Results There was adequate system sensitivity when comparing participants' and reference ratings. Inter-rater reliability among the participants' ratings was good except for decision-making category. The level of inter-rater reliability was similar when rating teams and attending surgeons. There was strong positive correlation between teams' and attending surgeons' NOTSS ratings at category [Pearson coefficient 0.86, 95% confidence interval (CI) 0.82-0.89] and element levels (0.83, 95% CI 0.80-0.85), demonstrating evidence of concurrent construct validity. The participants felt that the use of NOTSS system to measure teams' nontechnical skills was acceptable and feasible to a fair extent. Conclusion The NOTSS system, although developed for assessment of individual surgeons, is a useful tool for observing and rating surgical teams.

Purpose Direct observation is essential to assess and provide feedback to medical trainees. However, calls for its increased use in medical training persist as learners report that direct observation occurs infrequently. This study applied a theory-driven approach to systematically investigate barriers and enablers to direct observation in residency training. Method From September 2016 to July 2017, semistructured interviews of faculty and residents at The Ottawa Hospital were conducted and analyzed. An interview guide based on the theoretical domains framework (TDF) was used to capture 14 domains that may influence direct observation. Interview transcripts were independently coded using direct content analysis, and specific beliefs were generated by grouping similar responses. Relevant domains were identified based on the frequencies of beliefs reported, presence of conflicting beliefs, and perceived influence on direct observation practices. Results Twenty-five interviews (12 residents, 13 faculty) were conducted, representing 10 specialties. Ten TDF domains were identified as influencing direct observation: knowledge, skills, beliefs about consequences, social/professional role and identity, intention, goals, memory/attention/decision processes, environmental context and resources, social influences, and behavioral regulation. Discord between faculty and resident intentions, coupled with social expectations that residents should be responsible for ensuring that observations occur, was identified as a key barrier. Additionally, competing demands identified across multiple TDF domains emerged as a pervasive theme. Conclusions This study identified key barriers and enablers to direct observation. These influencing factors provide a basis for the development of potential strategies aimed at embedding direct observation as a routine pedagogical practice in residency training.

Introduction Frailty is a robust predictor of adverse outcomes in older people. Practice guidelines recommend routine screening for frailty; however, this does not occur regularly. The Clinical Frailty Scale (CFS) is a validated, feasible instrument that can be used in a variety of clinical settings and is associated with many adverse outcomes. Our objective was to develop and evaluate an online training module to guide frailty assessment using the CFS. Methods A multidisciplinary team of clinical experts developed an evidence-based, theory-grounded online training module for users who wished to perform frailty assessment using the CFS. The module was prospectively evaluated for user satisfaction, effectiveness and feasibility using a standardised questionnaire. Qualitative feedback was analysed with thematic analysis. Results Version 1 of the CFS module was used 627 times from 21 October 2019 to 24 March 2020. Satisfaction, effectiveness and feasibility of the module were positively rated (≥4/5 on a 5-point Likert scale n = 582 [93%], n = 507, [81%], n = 575, [91%], respectively). Qualitative feedback highlighted ease of use, likelihood of users to share the module with others and opportunities to increase multimedia content. Conclusion An online tutorial, designed using evidence and theory to guide frailty assessment using the CFS, was positively rated by users. The module’s content and structure was rated effective and feasible, and users were satisfied with, and likely to share, the module. Research evaluating the module’s impact on the accuracy of frailty assessment is required.

Background Hyperbaric oxygen therapy (HBOT) corrects tissue hypoxia, mobilizes stem cells and has immunomodulatory effects, all of which are key mechanisms for healing wounds. A number of studies have suggested that HBOT may be effective for healing inflammatory bowel disease (IBD). Aims Our systematic review aimed to quantify the effectiveness and safety of HBOT in IBD and its associated conditions. Methods We performed a proportional meta-analysis. MEDLINE, EMBASE, Web of Knowledge and The Cochrane Central Register of Controlled Trials were systematically searched from inception through November 2020 with no language restriction. We included randomized controlled studies, cohort studies and case series that contained a minimum of three patients and reported effectiveness and/or safety outcomes for HBOT in patients with IBD. Studies were stratified by IBD phenotype and weighted summary estimates with 95% confidence intervals (CI) were calculated for clinical response and remission using random-effects models. Study quality was assessed using the Cochrane risk-of-bias tool for randomized trials and a modified version of the National Institutes of Health (NIH) checklist for observational studies. Results Nineteen studies met our study criteria: 3 randomized controlled trials and 16 case series. The studies reported outcomes for luminal ulcerative colitis (UC) (n=373), luminal Crohn’s disease (CD) (n=250), enterocutaneous fistulae (ECF) (n=21), perianal CD (n=115), pouch disorders (n=60), pyoderma gangrenosum (PG) (n=5) and perianal sinus/metastatic CD (n=7). Rates of clinical response were 86% (95% CI, 66–95%) for luminal UC, 86% (95% CI, 81–90%) for luminal CD, 85% (95% CI, 61–95%) for ECF, 80% (95% CI, 70–87%) for perianal CD, 65% (95% CI, 52–76%) for pouch disorders, 92% (95% CI, 38–99%) for PG and 79% (95% CI, 36–96%) for perianal sinus/metastatic CD. Rates of clinical remission were 87% (95% CI, 10–100%) for luminal UC, 88% for luminal CD (95% CI, 46–98%), 50% for ECF (95% CI, 12–88%), 64% (95% CI, 52–75%) for perianal CD, 31% (95% CI, 16–50%) for pouch disorders, 92% (95% CI, 38–100%) for PG and 65% (95% CI, 10–97%) for perianal sinus/metastatic CD. Of the ten studies that reported on safety of HBOT, 19 patients (10.5%) had minor adverse events and no major event was reported. Study quality was low in the majority of studies due to an absence of comparator arms, inadequate description of interventions, and poorly defined outcomes. Conclusions Limited high-quality evidence suggest that HBOT is safe and associated with high rates of clinical response and remission for luminal IBD, perianal CD and pouch disorders. A well-designed large multicenter randomized controlled trial is warranted to confirm the benefit of HBOT in IBD. doi:10.17605/osf.io/gpz6d Funding Agencies None

Background A large proportion of surgical patient harm is preventable; yet, our ability to systematically learn from these incidents and improve clinical practice remains limited. The Operating Room Black Box was developed to address the need for comprehensive assessments of clinical performance in the operating room. It captures synchronized audio, video, patient, and environmental clinical data in real time, which are subsequently analyzed by a combination of expert raters and software-based algorithms. Despite its significant potential to facilitate research and practice improvement, there are many potential implementation challenges at the institutional, clinician, and patient level. This paper summarizes our approach to implementation of the Operating Room Black Box at a large academic Canadian center. Objective We aimed to contribute to the development of evidence-based best practices for implementing innovative technology in the operating room for direct observation of the clinical performance by using the case of the Operating Room Black Box. Specifically, we outline the systematic approach to the Operating Room Black Box implementation undertaken at our center. Methods Our implementation approach included seeking support from hospital leadership; building frontline support and a team of champions among patients, nurses, anesthesiologists, and surgeons; accounting for stakeholder perceptions using theory-informed qualitative interviews; engaging patients; and documenting the implementation process, including barriers and facilitators, using the consolidated framework for implementation research. Results During the 12-month implementation period, we conducted 23 stakeholder engagement activities with over 200 participants. We recruited 10 clinician champions representing nursing, anesthesia, and surgery. We formally interviewed 15 patients and 17 perioperative clinicians and identified key themes to include in an information campaign run as part of the implementation process. Two patient partners were engaged and advised on communications as well as grant and protocol development. Many anticipated and unanticipated challenges were encountered at all levels. Implementation was ultimately successful, with the Operating Room Black Box installed in August 2018, and data collection beginning shortly thereafter. Conclusions This paper represents the first step toward evidence-guided implementation of technologies for direct observation of performance for research and quality improvement in surgery. With technology increasingly being used in health care settings, the health care community should aim to optimize implementation processes in the best interest of health care professionals and patients.

Objective To investigate the effect of therapeutic suggestions played to patients through earphones during surgery on postoperative pain and opioid use. Design Blinded randomised controlled study. Setting Five tertiary care hospitals in Germany. Participants 385 of 400 patients consecutively recruited from January to December 2018 who were to undergo surgery for 1-3 hours under general anaesthesia. In the per protocol analysis 191 patients were included in the intervention group and 194 patients in the control group. Intervention The intervention comprised an audiotape of background music and positive suggestions based on hypnotherapeutic principles, which was played repeatedly for 20 minutes followed by 10 minutes of silence to patients through earphones during general anaesthesia. Patients in the control group were assigned to a blank tape. Main outcome measures The main outcome was dose of opioid administered by patient controlled analgesia or nurse controlled analgesia within the first postoperative 24 hours, based on regular evaluation of pain intensity on a numerical rating scale (range 0-10, with higher scores representing more severe pain). Results Compared with the control group, the intervention group required a significantly (P=0.002) lower opioid dose within 24 hours after surgery, with a median of 4.0 mg (interquartile range 0-8) morphine equivalents versus 5.3 (2-12), and an effect size (Cohen’s d) of 0.36 (95% confidence interval 0.16 to 0.56). The number of patients who needed opioids postoperatively was significantly (P=0.001) reduced in the intervention group: 121 of 191 (63%, 95% confidence interval 45% to 70%) patients in the intervention group versus 155 of 194 (80%, 74% to 85%) in the control group. The number needed to treat to avoid postoperative opioids was 6. Pain scores were consistently and significantly lower in the intervention group within 24 hours after surgery, with an average reduction of 25%. No adverse events were reported. Conclusions Therapeutic suggestions played through earphones during general anaesthesia could provide a safe, feasible, inexpensive, and non-drug technique to reduce postoperative pain and opioid use, with the potential for more general use. Based on the finding of intraoperative perception by a considerable number of patients, surgeons and anaesthetists should be careful about background noise and conversations during surgery. Trial registration German Clinical Trial Register DRKS00013800.

Background Effective teamwork is critical for safe, high-quality care in the operating room (OR); however, teamwork interventions have not consistently resulted in the expected gains for patient safety or surgical culture. In order to optimize OR teamwork in a targeted and evidence-based manner, it is first necessary to conduct a comprehensive, theory-informed assessment of barriers and enablers from an interprofessional perspective. Methods This qualitative study was informed by the Theoretical Domains Framework (TDF). Volunteer, purposive and snowball sampling were conducted primarily across four sites in Ontario, Canada and continued until saturation was reached. Interviews were recorded, transcribed, and de-identified. Directed content analysis was conducted in duplicate using the TDF as the initial coding framework. Codes were then refined whereby similar codes were grouped into larger categories of meaning within each TDF domain, resulting in a list of domain-specific barriers and enablers. Results A total of 66 OR healthcare professionals participated in the study (19 Registered Nurses, two Registered Practical Nurses, 17 anaesthesiologists, 26 surgeons, two perfusionists). The most frequently identified teamwork enablers included people management, shared definition of teamwork, communication strategies, positive emotions, familiarity with team members, and alignment of teamwork with professional role. The most frequently identified teamwork barriers included others’ personalities, gender, hierarchies, resource issues, lack of knowledge of best practices for teamwork, negative emotions, conflicting norms and perceptions across professions, being unfamiliar with team members, and on-call/night shifts. Conclusions We identified key factors influencing OR teamwork from an interprofessional perspective using a theoretically informed and systematic approach. Our findings reveal important targets for future interventions and may ultimately increase their effectiveness. Specifically, achieving optimal teamwork in the OR may require a multi-level intervention that addresses individual, team and systems-level factors with particular attention to complex social and professional hierarchies.

Skill retention after neonatal resuscitation training is poor. A distributed learning strategy – where learning is spread over multiple sessions – can improve retention of declarative memory (facts & knowledge). Session timings are critical – maximal retention occurs when a refresher session is scheduled at 10-30% of the time between initial training and test. We hypothesized this also holds true for neonatal resuscitation, a complex skill set requiring both declarative and procedural memory. We conducted a prospective, single-blinded randomized-controlled trial. University of Ottawa residents were recruited to training in neonatal resuscitation, with a high-fidelity simulated pre-test, immediate post-tests, and a retention test at 4 months. After training, they were randomized to either a refresher session at 3 weeks (18% of interval) or at 2 months (50%). Technical and non-technical skills were scored using validated checklists, knowledge with standardized questions. There was no difference between groups prior to the retention test. The early refresher group demonstrated significantly improved technical (mean ± 95% CI: 22.4 ± 1.3 v 18.2 ± 2.5, p = 0.02) and non-technical (31.0 ± 0.9 v 25.6 ± 3.1, p = 0.03) skill scores in the retention post-test compared to the late group. No difference was seen with knowledge scores. We conclude that both technical and non-technical aspects of neonatal resuscitation performance can benefit from an early refresher session. Session timings are critical and should be tailored to the desired length of skill retention. Findings may be generalizable to other interventions that depend on mixed types of memory.

BACKGROUND: Handover of anaesthesia patient care during surgery is common; however, its association with patient outcome is unclear. This systematic review aimed to assess the impact of anaesthesia handover during surgery on patient outcome. METHODS: All prospective and retrospective clinical studies specifically investigating the association of intraoperative transfer of anaesthesia care between anaesthesia providers in the operating room with patient morbidity and mortality were included. Searches were conducted from inception to April 24, 2019 in Medline, Medline in Process, CINAHL, and Embase. Reference lists of included studies were searched. Studies were assessed for eligibility and data were extracted by independent reviewers in duplicate with disagreements resolved by consensus or a third reviewer. Risk of bias was assessed in duplicate using the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Data were summarised narratively given substantial heterogeneity. An exploratory meta-analysis was conducted using a random-effects model for a subset of comparable studies. RESULTS: Eight studies met the inclusion criteria. Six studies focused on patients as the unit of analysis (n(patients)=605 678) and two focused on anaesthesia providers as the unit of analysis (n(providers)=307). Seven studies identified a relationship between anaesthesia handovers and adverse patient outcomes, whereas one suggested that handover may be beneficial to error detection or rectification. Included studies were of fair or good quality. Meta-analysis of four studies found a 40% increased risk of patients experiencing an adverse event when an anaesthesia handover occurs during the procedure (pooled risk ratio=1.40; 95% confidence interval, 1.19 to 1.65; P

BackgroundAt least 1 in 6 COVID-19 patients admitted to hospital and receiving supplemental oxygen will die of complications. More than 50% of patients with COVID-19 that receive invasive treatment such as mechanical ventilation will die in hospital. Such impacts overwhelm the limited intensive care unit resources and may lead to further deaths given inadequate access to care. Hyperbaric oxygen therapy (HBOT) is defined as breathing 100% oxygen at a pressure higher than 1.4 atmosphere absolute (ATA). HBOT is safe, including for lungs, when administered by experienced teams and is routinely administrated for a number of approved indications. Preliminary clinical evidence suggests clinical improvement when hypoxemic COVID-19 patients are treated with HBOT.ObjectiveWe aim to determine the effectiveness of HBOT for improving oxygenation, morbidity, and mortality among hypoxemic COVID-19 patients.Methods and analysisThis trial is a sequential Bayesian Parallel-group, individually Randomized, Open, Blinded Endpoint controlled trial. Admitted hypoxemic COVID-19 patients who require supplemental oxygen (without mechanical ventilation) to maintain a satisfying tissue oxygenation will be eligible to participate. The anticipated sample size of 234 patients is informed by data from a treatment trial of COVID patients recently published. The intervention group will receive one HBOT per day at 2.0 ATA for 75 minutes. Daily HBOT will be administered until the patient does not require any oxygen supplementation, requires any type of mechanical ventilation, or until day 10 of treatment. Patients in the control group will receive the current standard of care treatment (no HBOT). The primary outcome of this trial will be the 7-level COVID ordinal outcomes scale assessed on Day 7 post-randomization. Secondary outcomes will include: (a)clinicaloutcomes (length of hospital stay, days with oxygen supplementation, oxygen flow values to obtain a saturation by pulse oximetry ≥90%, intensive care admission and length of stay, days on invasive mechanical ventilation, sleep quality, fatigue, major thrombotic events, the 7-level COVID ordinal outcomes scale on Day 28; mortality, safety); (b)biologicaloutcomes (plasma inflammatory markers); and (c) healthsystemoutcomes (cost of care and cost-effectiveness). Predetermined inclusion/exclusion criteria have been specified. The analytical approach for the primary outcome will use a Bayesian proportional odds ordinal logistic semiparametric model. The primary analysis will be by intention-to-treat. Bayesian posterior probabilities will be calculated every 20 patients to assess accumulating evidence for benefit or harm. A planned subgroup analysis will be performed for pre-specified variables known to impact COVID-19 prognosis and/or HBOT (biologic sex and age).DiscussionBased on the mortality rate and substantial burden of COVID-19 on the healthcare system, it is imperative that solutions be found. HBOT is a non-invasive and low-risk intervention when contraindications are respected. The established safety and relatively low cost of providing HBOT along with its potential to improve the prognosis of severe COVID-19 patients make this intervention worth studying, despite the current limited number of HBOT centres. If this trial finds that HBOT significantly improves outcome and prevents further deterioration leading to critical care for severe COVID-19 patients, practice will change internationally. If no benefit is found from the intervention, then the current standard of care (no HBOT) will be supported by level I evidence.Trials RegistrationNCT04500626

Interprofessional simulation (IPS) training is an effective way to learn crisis resource management. The type of debriefing used in IPS training may affect participants' performance and their level of psychological safety. We aimed to assess and compare performance after standard collective debriefing versus a combination of individual and collective debriefing ("combined" approach).Randomized, controlled multicenter trial. IPS sessions were randomized to have either standard or combined debriefing. Each team's performance in the IPS session was assessed with the Team Emergency Assessment Measure. The participants assessed the debriefing quality with the Debriefing Assessment for Simulation in Healthcare.Forty IPS sessions were randomized, and 30 were analyzed, 15 using standard collective debriefing and 15 the combined individual-collective method. Teams' performance improved with both types of debriefing, based on pre-post testing (P.01), and there were no significant differences in overall performance scores between the 2 types of debriefing (P=.64). However, the combined approach was associated with higher scores for leadership skills (P.05) and psychological safety, and the participants' learning experience was better (P.05).During IPS courses on crisis resource management, debriefing improves participants' performance, but similar overall results can be obtained with both debriefing methods. Combined debriefing might be more effective for improving participants' leadership skills and psychological safety and also provide a better learning experience.La simulación interprofesional (SIP) es eficaz para aprender gestión de recursos de crisis. La modalidad de debriefing utilizada en la SIP puede influir en el rendimiento de los participantes y en su integridad psicológica. Se evalúa y compara el rendimiento de un debriefing estándar (DE) –colectivo– con un debriefing combinado (DC) –individual y colectivo– en cursos de SIP en escenarios que simulan pacientes con patología aguda y grave.Ensayo controlado, aleatorizado y multicéntrico. Se aleatorizó el tipo de debriefing realizado (DE o DC) en las sesiones de SIP. El rendimiento del debriefing se evaluó con la escala TEAM (Team Emergency Assessment Measure). La calidad de la SIP fue valorada por los participantes con la escala DASH (Debriefing Assessment for Simulation in Healthcare©).Se aleatorizaron 40 cursos de SIP de los que se analizaron 30. Quince realizaron DE y 15 DC. Ambos grupos mejoraron entre la pre y la posprueba (p0,01), pero no hubo diferencias en el rendimiento global entre ambas modalidades de debriefing (p = 0,64). El DC obtuvo mejores resultados que el DE en la capacidad de liderazgo (p0,05), en la percepción de seguridad psicológica y en la experiencia de aprendizaje eficaz (p0,05).Durante la SIP en situaciones de crisis, el debriefing mejora el rendimiento de los participantes, sin diferencias entre un DE y un DC. El DC podría ser más efectivo para mejorar la capacidad de liderazgo, la seguridad psicológica y la experiencia del aprendizaje.

Audit and feedback can improve physicians’ practice; however, the most effective type of feedback is unknown. Inadvertent perioperative hypothermia is associated with postoperative complications and remains common despite the use of effective and safe warming devices. This study aimed to measure the impact of targeted audit and feedback on anesthesiologists’ intraoperative temperature management and subsequent patient outcomes. This study was a three-arm cluster randomized-controlled trial. Anesthesiologists’ intraoperative temperature management performance was analyzed in two phases. The first was a baseline phase with audit but no feedback for eight months, followed by an intervention phase over the next seven-month period after participants had received interventions according to their randomized group allocation of no feedback (control), benchmarked feedback, or ranked feedback. Anesthesiologists’ percentage of hypothermic patients at the end of surgery (primary endpoint) and use of a warming device were compared among the groups. Forty-five attending anesthesiologists who took care of 7,846 patients over 15 months were included. The odds of hypothermia (temperature < 36°C at the end of surgery) increased significantly from pre- to post-intervention in the control and ranked groups (control odds ratio [OR], 1.27; 95% confidence interval [CI], 1.03 to 1.56; P = 0.02; ranked OR, 1.26; 95% CI, 1.01 to 1.56; P = 0.04) but not in the benchmarked group (OR, 1.05; 95% CI, 0.87 to 1.28; P = 0.58). Between-arm differences in pre- to post-intervention changes were not significant (benchmark vs control OR, 0.83; 95% CI, 0.62 to 1.10; P = 0.19; ranked vs control OR, 0.99; 95% CI, 0.73 to 1.33, P = 0.94). No significant overall effect on intraoperative warmer use change was detected. We found no evidence to suggest that audit and feedback, using benchmarked or ranked feedback, is more effective than no feedback at all to change anesthesiologists’ intraoperative temperature management performance. Feedback may need to be included in a bundle to produce its effect. www.clinicaltrials.gov (NCT02414191). Registered 19 March 2015.

Sex and gender, among other equity-related characteristics, influence the process of care and patients’ outcomes. Currently, the extent to which these characteristics are considered in the anesthesia literature remains unknown. This study assesses their incorporation in randomized controlled trials (RCTs) on anesthesia-related interventions, for both patients and healthcare providers. This is a cross-sectional analysis using an existing dataset derived from the anesthesia literature. The dataset originated from a scoping review searching MEDLINE, Embase, CINAHL, CENTRAL, and the Cochrane Database of Systematic reviews. RCTs investigating the effect of anesthesia-related interventions on mortality for adults undergoing surgery were included. Equity outcome measures were recorded for both patients and providers and assessed for inclusion in the study design, reporting of results, and analysis of intervention effects. Three-hundred sixty-one RCTs (n = 144,674) were included. Most RCTs (91%) reported patient sex/gender, with 58% of patients identified as male. There were 139 studies (39%), where 70% or more of the sample was male, compared to just 14 studies (4%), where 70% or more of the sample was female. Only 10 studies (3%) analyzed results by patient sex/gender, with one reporting a significant effect. There was substantial variation in how age was reported, although nearly all studies (98%) reported some measure of age. For healthcare providers, equity-related information was never available. Better consideration of sex/gender and additional health equity parameters for both patients and providers in RCTs is needed to improve evidence quality, and ultimately, patient care and outcome.

Introduction simulation can be a powerful tool to improve interprofessional teamwork and improve patient outcomes. This manuscript aims to describe a simulation intervention and explore its potential benefits and barriers to its successful implementation to inform future work. Methods this is a prospective observational study. We conducted 22 in situ simulation sessions in the operating room within a General Surgery division. Observations of surgical teams were conducted before the simulation, on the day of the simulation, and 3 to 4 months after the simulation. Team performance was measured using the NOTECHS scale, an instrument designed to assess the non-technical skills of interprofessional teams. Direct observation was used to assess teamwork, and variation in scores was assessed using ANOVA. Qualitative semi-structured interviews were conducted with participants to explore benefits and barriers of the intervention, and analyzed using content analysis. Results no change in team performance was observed using the NOTECHS scale. Participants described not being prepared enough to benefit from the sessions, voiced concerns regarding unequal role of participants in the simulation, and reported a fear of being judged by other team members during the sessions. Conclusion overall, we identified multiple potential barriers to implementation of in situ simulation as interprofessional teamwork training. The challenges identified here can inform the design and implementation of future teamwork training interventions.

BackgroundEffective teamwork between anaesthesiologists and surgeons is essential for optimising patient safety in the cardiac operating room. While many factors may influence the relationship between these two physicians, the role of sex and gender have yet to be investigated.ObjectivesWe sought to determine the association between cardiac physician team sex discordance and patient outcomes.DesignWe performed a population-based, retrospective cohort study.Participants and settingAdult patients who underwent coronary artery bypass grafting (CABG) and/or aortic, mitral or tricuspid valve surgery between 2008 and 2018 in Ontario, Canada.Primary and secondary outcome measuresThe primary outcome was all-cause 30-day mortality. Secondary outcomes included major adverse cardiovascular events at 30 days and hospital and intensive care unit lengths of stay (LOS). Mixed effects logistic regression was used for categorical outcomes and Poisson regression for continuous outcomes.Results79 862 patients underwent cardiac surgery by 98 surgeons (11.2% female) and 279 anaesthesiologists (23.3% female); 19 893 (24.9%) were treated by sex-discordant physician teams. Physician sex discordance was not associated with overall patient mortality or LOS; however, patients who underwent isolated CABG experienced longer hospital LOS when treated by an all-male physician team as compared with an all-female team (adjusted OR=1.07; p=0.049). When examining the impact of individual physician sex, the length of hospital stay was longer when isolated CABG procedures were attended by a male surgeon (OR=1.10; p=0.004) or anaesthesiologist (OR=1.02; p=0.01).ConclusionsPatient mortality and length of stay after cardiac surgery may vary by sex concordance of the attending surgeon–anaesthesiologist team. Further research is needed to examine the underlying mechanisms of these observed relationships.