Search

Introduction: Hypothermia is common in emergency general surgical patients. It is known to be associated with major complications in multiple organ systems. It is also easily preventable with the use of safe and cost-effective equipment. However, by observation, it appears that this equipment is used too infrequently thus resulting in unnecessary harm to patients. Methods: This descriptive, observational, cross-sectional study was conducted in two arms to evaluate both emergency centres and operating theatres in the major state hospitals in Durban. It was conducted as an audit as well as a questionnaire-based study, to ascertain the availability of equipment used to prevent hypothermia and also how appropriately the equipment was being used. Results: There was good availability of equipment in both the operating theatres and the emergency centres. However it was being used very poorly, particularly in emergency centres (41% of responses deemed not beneficial to patients versus 29% from operating theatres; 39% of answers beneficial versus 54% from operating theatres). Institutions with hypothermia-prevention protocols scored significantly better than those without a protocol (59% versus 25% beneficial; p = 0.01). Conclusion: In the field of hypothermia prevention, there was sufficient equipment to result in optimal patient care. However there appears to be a lack of knowledge amongst health care providers, resulting in suboptimal use of this equipment. Protocolised management may provide a solution to this problem and improve patient outcomes. Keywords: Temperature control, Emergency centre, Trauma, Operation room, Questionnaire

Background The manner in which a critical intra-operative event is addressed can make the difference between life and death. Robust evidence shows that surgical teams do not adequately handle complications during surgery. The literature reports a rate of 145 critical events per 10,000 procedures, with medical errors being the leading cause of preventable injury and death in patients during surgery. Through a national initiative and an interdisciplinary team, we developed a software program in the form of an application (APP), for tablets and smartphones that allows to systematically deal with critical events in orthopaedic surgery. The tool was tested in high-fidelity simulation scenarios of operating theatres, with real clinical cases. To date, no similar tool has been reported in the literature.

Objective: Variation in practice in relation to indications and timing for both induction of labour (IOL) and planned caesarean section (CS) clearly exists. However, the extent of this variation, and how this variation is explained by clinicians remains unclear. The aim of this study was to map the variation in IOL and planned CS at eight Australian hospitals, and understand why variation occurs from the perspective of clinicians at these hospitals. Our ultimate aim was to identify opportunities for improvement as evidenced by hospital data, clinician experiences, and feedback. Design: A two-phased mixed method study using sequential explanatory study design. The first phase consisted of an analysis of routinely collected patient data to map variation between hospitals. The second phase consisted of focus groups with clinicians to gain their perspectives on the reasons for variation. Setting and Participants: Patient data consisted of routine data from 19,073 women giving birth at eight Sydney hospitals between November 2017 and October 2018. Focus groups were attended by a total of 61 medical staff and 121 midwives. Results: Hospital data analysis found substantial variation, before and after adjustment for case-mix, in rates of both IOL (adjusted rates 27.6%–42%) and planned CS (adjusted rate 15.4%–22.6%). Planned CS by gestation also showed variation, although after restricting analysis to term (≥37 weeks gestation) births, variation was reduced. At focus groups, five main themes explaining variation emerged: local guidelines, policies and procedures (inconsistency and ambiguity); uncertainty of the evidence/what is best practice (contradictory research and different interpretations of evidence); clinician preferences, beliefs and values; the culture of the unit; and organisational influences (access to specialised clinics, theatre time). Key conclusions: Considerable variation in IOL and planned CS, even after case-mix adjustment, was found in this sample of Australian hospitals. Engagement with hospital clinicians identified likely sources of this variation and enabled clinicians at each hospital to consider appropriate local responses to address variation, such as more detailed review of their planned birth cases. Implications for practice: At a macro level, measures to reduce unwarranted variation should initially focus on consistent national guidelines, while supporting equitable access to operating theatres for optimal CS timing, and shared decision-making training to reduce influence of clinician preference.

BACKGROUND The difficulty of supplying red blood cells within an adequate time to patients undergoing surgery is a known problem for transfusion services, particularly if the operating theater is located at some distance from the blood bank. The consequences frequently are that more blood is ordered than required; several units are allocated and issued; and unused units must be returned to the blood bank. Some sparse reports have demonstrated that remote blood issue systems can improve the efficiency of issuing blood. STUDY DESIGN AND METHODS This study describes a computer-controlled, self-service, remote blood-release system, combined with an automated refrigerator, installed in a hospital at which major surgery was performed, located 5 kilometers away from the transfusion service. With this system, red blood cell units were electronically allocated to patients immediately before release, when the units actually were needed. Two 2-year periods, before and after implementation of the system, were compared. RESULTS After implementation of the system, the ratio of red blood cell units returned to the transfusion service was reduced from 48.9% to 1.6% of the issued units (8852 of 18,090 vs. 182 of 11,152 units; p

Objectives To examine age and gender distribution for the most common types of surgery in Malawi and Zambia. Methods Data were collected from major operating theatres in eight district hospitals in Malawi and nine in Zambia. Raw data on surgical procedures were coded by specialist surgeons for frequency analyses. Results In Malawi female surgical patients had a mean age of 25 years, with 91% aged 16–40 years. Females accounted for 85%, and obstetric cases for 75%, of all surgical patients. In Zambia, female surgical patients had a mean age of 26, with 75% aged 16–40 years. They accounted for 55% of all cases, 34% being obstetric. Male surgical patients in Malawi were on average older (33 years) than in Zambia (23 years). General surgical cases in men and women, respectively, had a median age of 42 and 32 in Malawi and 26 and 30 in Zambia. The median age of trauma patients was 12 in males and 10 in females in both countries. Children aged 0–15 years accounted for 64–65% of all trauma cases in Malawi and 57–58% in Zambia, with peak incidences in 6- to 10-year-olds. Conclusions Women of reproductive (16–45 years) mainly undergoing Caesarean sections and children aged 0–15 years who accounted for two-thirds of trauma cases are the main patient populations undergoing surgery at district hospitals in Zambia and Malawi. Verification and analysis of routine hospital data, across 10–30% of districts countrywide, demonstrated the need to prioritise quality assurance in surgery and anaesthesia, and preventive interventions in children.

Volatile anaesthetic agents are a potential occupational health hazard to theatre and recovery staff. Operating theatres and anaesthetic rooms are required to be equipped with scavenging systems, but recovery units often are not. We compared exhaled, spectrophotometric sevoflurane and desflurane concentrations 15 cm from the mouth ('patient breathing zone') and 91 cm laterally to the patient ('nurse work zone') in 120 patients after tracheal extubation who were consecutively allocated to either ISO-Gard mask oxygen/scavenging or standard oxygen mask, 0 min, 10 min and 20 min after arrival in the theatre recovery unit. Median (IQR [range]) duration of anaesthesia was similar between groups (control 76 (44-119 [15-484]) min vs. study group 90 (64-130 [15-390]) min, p = 0.136). Using the ISO-Gard mask, the 20-min mean patient breathing zone and nurse work zone exhaled anaesthetic levels were ~ 90% and 78% lower than those recorded in the control group, respectively, and were within the recommended 2 ppm maximum environmental exposure limit in the patient breathing zone of 53 out of 60 (88%) and the nurse work zone of all 60 (100%) patients on first measurement in the recovery room (vs. 10 out of 60 (17%) and 40 out of 60 (67%) in the control group). Our study indicates that the ISO-Gard oxygen/scavenging mask reduces the level of exhaled sevoflurane and desflurane below recommended maximum exposure limits near > 85% of extubated patients within ~ 20 s of application in the recovery unit after surgery. We encourage the use of this mask to minimise the occupational exposure of recovery staff to exhaled volatile agents.

Background The efficient use of operating theatres is important to insure optimum cost-benefit for the hospital. We used the emergency Burns theatre as a model to assess theatre efficiency at our institution. Methods Data was collected retrospectively on every operation performed in the Burns theatre between 01/04/15 and 30/11/15. Each component of the operating theatre process was considered and integrated to calculate values for surgical/anaesthetic time, changeover time and ultimately theatre efficiency. Results A total of 426 operations were carried out over 887 h of allocated theatre time (ATT). Actual operating time represented 67.7%, anaesthetic time 8.8% and changeover time 14.2% of ATT. The average changeover time between patients was 30.1 min. Lists started on average 27.7 min late each day. There were a total of 5.8 h of overruns and 9.6 h of no useful activity. Operating theatre efficiency was 69.3% for the 8 month period. Conclusion Our study highlights areas where theatre efficiency can be improved. We suggest various strategies to improve this that may be applied universally.

Operating theatres and surgeons are among the most expensive resources in any hospital, so it is vital that they are used efficiently. Many European hospitals implement block scheduling, where each surgeon is assigned blocks of time in specific operating theatres on a cyclic basis. This paper proposes a model that assists hospitals in creating new master theatre timetables, which take account of reducing the maximum number of beds required, surgeons' availability, surgeons' preferences, variations in types of theatre and their suitability for different types of surgery, limited equipment availability, and the ability to vary the length of the cycle over which the timetable is repeated. The weightings given to each of these factors can be altered, thereby allowing exploration of a variety of possible timetables. Novel features of the model include consideration of surgeons' preferences for slots, smoothing of bed usage during the generation of master theatre timetables and the use of operating theatres with the potential for the same theatre to be belong to multiple non-nested types. These new features are considered in combination with a range of other factors that have been considered in previous studies on the development of master theatre timetables.

Understanding the general principles of homeostasis and its regulation in health and disease is key to managing patients in intensive care units and operating theatres. In these environments, it is crucial to realize that physiological control is a dynamic process aimed at achieving a balance between two opposing sets of factors. Whereas one set of factors (e.g. the sympathetic nervous system) attempt to increase a physiological variable of interest at any given time, opposing forces acting almost concurrently, (e.g. the parasympathetic nervous system) will result in the reduction in the value of this variable. The human body is a self-adapting system and as a result of its ability to adapt, new physiological ‘steady states' will be reached and maintained even in diseases. This review will explore some of the concepts and pathways involved in the regulation of homeostasis in the immediate, intermediate and delayed time scales following an initial perturbation, emphasizing the dynamic nature of this regulation.

This study targets 2D articulated human pose estimation (i.e. localisation of body limbs) in stereo videos. Although in recent years depth-based devices (e.g. Microsoft Kinect) have gained popularity, as they perform very well in controlled indoor environments (e.g. living rooms, operating theatres or gyms), they suffer clear problems in outdoor scenarios and, therefore, human pose estimation is still an interesting unsolved problem. The authors propose here a novel approach that is able to localise upper-body keypoints (i.e. shoulders, elbows, and wrists) in temporal sequences of stereo image pairs. The authors' method starts by locating and segmenting people in the image pairs by using disparity and appearance information. Then, a set of candidate body poses is computed for each view independently. Finally, temporal and stereo consistency is applied to estimate a final 2D pose. The authors' validate their model on three challenging datasets: `stereo human pose estimation dataset', `poses in the wild' and `INRIA 3DMovie'. The experimental results show that the authors' model not only establishes new state-of-the-art results on stereo sequences, but also brings improvements in monocular sequences.

Steelman (2014) stated that the concept of briefing and debriefing used in operating theatres derived from the airline industry in the 1970s. There had been a series of devastating air crashes and the airline industry had come under severe public scrutiny. Investigations identified that, while the crews operating these aircrafts were very skilled and knowledgeable, they lacked competence in their ability to perform as part of a team.

Surgical site infections are the most common cause of hospital acquired nosocomial infections. To evaluate the effects of applying and following the international standard guidelines for clean surgery on the final infection control in operation theatres, a comparative study was designed and carried out during the period from May 2014 to February 2015, at two operating theatres, the general surgical and the gynaecological theatre at Azadi teaching hospital – Duhok city – Kurdistan region. A total number of 492 samples (swabs and settles plate) were taken from different sites of intimate contact with the patients and were divided into two parts, pre (part I) and post (part II) samples. They were taken in a periodic day to day, and collected periodically three days of the week (Saturday -Monday- Wednesday) for a period of one month. Swabs were taken from different places were streaked on Blood and Mac-Conkey agar plates and incubated at 37°C under aerobic conditions for 24 hours. After incubation, the bacterial colonies were counted and diagnosed by Phoenix. The concentration of bacteria was expressed as colony forming units. The rates of bacterial contamination in places of close contact with patients of both theatres before the application of the WHO guidelines were as following: out of 348 samples collected from the surgical theatre in the first part; 105 (30.1%) showed significant growth in comparison to 32/144(22.2%) that showed significant growth from the gynaecological theatre, while all samples in part II from the surgical theatre showed no significant growth that 100%, in comparison to141/144(97.92%) in the gynaecological theatre in the second part after application of the WHO guidelines. As a conclusion there are 3 factors which have an effect on the result of surgical site infections namely patients, staff and environmental factors. The environmental factors have the greatest impact which are indirectly related to the degree of application of WHO standards of operation theaters.

INTRODUCTION This study aimed to determine the decision-to-delivery intervals (DDIs), total duration of surgery and factors influencing these for Caesarean sections (CSs). METHODS A retrospective study was conducted of all CSs performed from August 2013 to June 2014 at a single tertiary general hospital. Data collected included maternal demographics, indications for CS, category of urgency, DDI, total duration of surgery, grade of first surgeon and number of previous CSs. RESULTS In total, 488 CSs (Category 1: n = 28; Category 2: n = 137; Category 3: n = 184; Category 4: n = 139) were studied. Overall mean duration of surgery was 41.7 minutes. Mean DDI was 23.9 minutes and 64.5 minutes for Category 1 and Category 2 CSs, respectively. For Category 1 CSs, deliveries during office hours had a significantly shorter DDI than deliveries out of office hours (p < 0.05). For Category 2 CSs, deliveries during office hours had a significantly longer DDI (p < 0.05). Total duration of surgery for senior surgeons was significantly shorter than for trainee surgeons (p < 0.05). Women with no previous CSs had a significantly shorter duration of surgery than those who had one or more (p < 0.05). CONCLUSION The majority of the deliveries were within the recommended DDI corresponding to the degree of urgency of CS. The influence of time of day on DDI might be due to challenges of time taken to transfer patients to operating theatres. Total duration of surgery was influenced by surgical experience, history of previous CS and individual surgical styles and preferences.

Background There are increasing numbers of videolaryngoscopes marketed and increasing interest in the technology. The Difficult Airway Society's 2015 guidelines recommend that videolaryngoscopes should be immediately available at all times and that all anaesthetists should be trained and skilled in their use. Methods An electronic survey was sent to all UK National Health Service hospitals to examine availability, use, and attitudes to videolaryngoscopy, and closed in January 2014. Results The return rate was 67%. Videolaryngoscopy was available in 91% of operating theatres, ∼50% of intensive care units (ICUs) and obstetric theatres, with lower availability in emergency departments (EDs), paediatric anaesthesia, and independent sector hospitals. The most widely available devices were the Airtraq, the GlideScope, and C-MAC. Approximately one in seven respondents reported availability of videolaryngoscopy in all clinical areas. Most departments imposed restrictions on videolaryngoscopy use, especially the ICU and ED. Device selection was only infrequently based on published literature or formal trial. Structured introduction of videolaryngoscopy into practice was uncommon. Penetration of videolaryngoscopy was highly variable; fewer than a third reported widespread use or enthusiasm, although this increased where the C-MAC and GlideScope were widely available. Conclusions Videolaryngoscopy is available in most hospitals' main operating departments, but in fewer than half of other locations. There is marked variation in device, methods of introduction, usage, and clinical adoption. Most hospitals need to change practice to comply with current guidelines. Selection and implementation vary widely.

Objective The aim of this study was to determine the incidence of bacterial and fungal contamination in anaesthetic and vasopressor drugs before and after use in operating theatres. Methods A cross-sectional study was conducted in the operating theatres of a university hospital. We collected 945 samples of three different drugs, namely, propofol, vecuronium and ephedrine, from 20 operating rooms and refrigerators where the unused drugs were stored. Each drug was divided into two groups, the pre-use group and the post-use group. The pre-use drugs were cultured before the patient received the drug. The post-use drugs were cultured after the patient had received the drug or after the drugs had been transferred to other syringes. The culture results were reported as either positive or negative. Results Out of the 945 drug samples, 26 (2.8%, 95% confidence interval=1.8%-4.0%) gave a positive culture. Of the 317 propofol samples, 20 (6.3%) were found to have bacterial contamination, 11 in the pre-use group and 9 in the post-use group. Of the 318 ephedrine samples, 6 (1.9%) were found to be positive on culture, one in the pre-use group and five in the post-use group. Vecuronium gave no positive cultures. All organisms were non-pathogenic, and no fungal contamination was found. Conclusion The incidence of bacterial contamination in anaesthetic and vasopressor drugs was 2.8%. Anaesthetic teams must be aware of contamination issues in anaesthetic drugs that have been prepared for later use and, in order to reduce the risk of contamination, they must improve the methods of administering drugs to patients.

Noise in the operating theatre has an adverse impact on healthcare professionals, both physically and psychologically. It can be distracting, make communication difficult, and contribute to a perceived increase in stress. Staff in theatre must deliver high quality care, and overlook noise as a potentially damaging influence. The aim of this survey was to obtain further information about the perspective of healthcare professionals on how noise can affect their practice and whether it affects their work in theatre. We distributed six closed-ended questions in the form of a Survey Monkey® questionnaire to about 50 hospitals across the UK and target groups such as medical students, the Leeds Advanced Trauma Life Support faculty group, the Court of Examiners of the Royal College of Surgeons of England, and surgical trainees sitting the Member of the Royal College of Surgeons examination. We received 519 responses of which 415 respondents (83%) thought that noise contributed to human errors. A total of 282 participants (57%) thought that the theatre was the noisiest area within the theatre suite. Both communication among staff (n=400, 80%) and concentration (n=384, 77%) were thought to be adversely affected by noise. However, 385 (78%) did not feel that music adversely affected their performance. The results provide insights into the interplay of noise and its effect on people. Although the role of music remains contentious, our results suggest that it might have a calming influence.

This article discusses the development of the World Health Organisation (WHO) safety checklist and defines critical factors which impact on patient safety within operating theatres. Theatres are a high risk area and the ability of leaders and teams to communicate effectively plays a significant part in creating a safety culture. Whilst the WHO checklist has been in place for some time, surgical errors continue. This is in part due to communication and process failures which could be reduced with a greater understanding of the human factors involved. Empowering and valuing team members contributions creates an open dialogue where hierarchy within the theatre becomes a thing of the past.

Serious adverse incidents (SAIs) are events in healthcare that justify a heightened level of response as their impact on patients, staff or systems is so great.1 The National Health Service has a framework for reporting of SAIs, never events and near misses.2 Individual healthcare trusts are responsible for investigating these incidents and delivering recommendations to staff to avoid recurrence.1 These recommendations typically include education and training of staff. Immersive, in situ simulation is an effective interprofessional educational model3 that can lead to improvements in patient safety,4 and we believe it is the ideal tool to learn from SAI investigations. The aim of this project was to develop a more robust and educationally sound system to rapidly disseminate interprofessional learning, to minimise the risk of recurring errors. A multidisciplinary team including paediatric surgery, paediatric anaesthesia, theatre nursing, medical education and clinical governance managers was convened. Review was undertaken of SAIs reported over 5 years from the operating theatres at a tertiary referral children’s hospital. The team identified recurring themes and high-risk cases amenable to in situ simulation. Each simulation was based on an …

Advancements and increased availability of radiological services have revolutionised our approach to oncological and reconstructive surgical practice. With an increasing demand for accuracy in diagnosis and improved oncological outcome, the requirement for precise application of radiological tools and the exploration of novel software has developed. This has led to the evaluation of modern technologies such as computer-aided design to enhance reconstructive surgery. Mandibular reconstruction following oncological resection using an osteocutaneous fibular free flap is now considered to be the gold standard reconstructive surgical approach, as this approach provides more satisfactory outcomes for both patients and reconstructive surgeons. Recent years have seen Irish reconstructive surgeons introduce computer-aided design pre-operative planning to operating theatres as means of improving cosmetic, functional and oncological outcome, yet the detailed, complex planning required pre-operatively is not well described. Herein, the purpose of this article was to demonstrate the precision and accuracy of virtual surgical planning computer-aided design (VSP-CAD) as a modern surgical approach to craniofacial reconstruction following surgical resection of an American Joint Committee on Cancer stage 4 oral carcinoma.

Data-driven computational approaches have evolved to enable extraction of information from medical images with a reliability, accuracy and speed which is already transforming their interpretation and exploitation in clinical practice. While similar benefits are longed for in the field of interventional imaging, this ambition is challenged by a much higher heterogeneity. Clinical workflows within interventional suites and operating theatres are extremely complex and typically rely on poorly integrated intra-operative devices, sensors, and support infrastructures. Taking stock of some of the most exciting developments in machine learning and artificial intelligence for computer assisted interventions, we highlight the crucial need to take context and human factors into account in order to address these challenges. Contextual artificial intelligence for computer assisted intervention, or CAI4CAI, arises as an emerging opportunity feeding into the broader field of surgical data science. Central challenges being addressed in CAI4CAI include how to integrate the ensemble of prior knowledge and instantaneous sensory information from experts, sensors and actuators; how to create and communicate a faithful and actionable shared representation of the surgery among a mixed human-AI actor team; how to design interventional systems and associated cognitive shared control schemes for online uncertainty-aware collaborative decision making ultimately producing more precise and reliable interventions. ispartof: Proceedings Of The IEEE vol:108 issue:1 pages:198-214 ispartof: location:United States status: published

Colorectal cancer is the fourth-most prominent cause of cancer related fatalities across the globe. Conventional electrocautery techniques used in the resection of colon tissue cause a relatively high degree of collateral damage to the healthy tissues bordering the target sites. Ultrafast infrared lasers offer significantly improved localisation in the ablation of such biological tissues arising from a plasma-mediated ablation mechanism. This improved localisation is two-fold, with lateral confinement and precise depth control being advantageous in minimising thermal necrosis and avoiding bowel perforation respectively. Various laser scanning strategies and optical elements have been investigated, with the intent to exploit the inherent advantages offered from applying photonics to these procedures. Evaluation of the corresponding ablation characteristics was carried out using three-dimensional optical profilometry and histological analysis. If adopted in operating theatres, surgeons could benefit from more control when carrying out resection of neoplasia in the mucosal or submucosal layers of colon tissue, compared to previous electrocautery methods.

Correct intracuff pressure of endotracheal tubes and supraglottic airway devices is required to avoid complications such as sore throat, dysphagia and dysphonia, while maintaining an adequate airway seal. However, intracuff pressure monitoring of airway devices during general anaesthesia may not receive the attention it deserves. The aim of this survey was to investigate the current practice regarding intraoperative cuff pressure monitoring in hospitals across Australia and New Zealand. An online ten-question survey was disseminated by the Australian and New Zealand College of Anaesthetists Clinical Trials Network to a randomised selection of 1000 Australian and New Zealand College of Anaesthetists Fellows working in private and public hospitals of varying sizes. There were 305 respondents in total, but not all respondents answered all questions. In total, 67 of 304 respondents (22.0%) did not have access to a cuff pressure manometer at their main site of work, and of these, 30 (9.9%) expressed that they would like access to one in their daily practice. Of 288 respondents, 122 (40.0%) reported that they used cuff pressure monitoring as part of their routine practice, but 95 (33.0%) measured the cuff pressure at induction only. For supraglottic airway devices, only 44 of 250 respondents (17.6%) aimed for a cuff pressure of 40–60 cmH2O. Of 255 respondents, 101 (39.6%) aimed for a cuff pressure of 20–30 cmH2O for endotracheal tubes. These findings indicate that educational programmes are required to increase the availability and use of cuff pressure monitoring devices for both endotracheal tubes and supraglottic airway devices across Australia and New Zealand.

Purpose To understand factors contributing to disturbances during cardiac procedures, including frequency and nature of distractions, along with assessment of operator ‘work-load’ through NASA Task-load indices. Methods A single centre prospective observational study was conducted on 194 consecutive patients undergoing cardiac procedures in 3 adult cardiac CL’s over a period of 4 weeks. A distraction pro-forma was completed for each case by CL team members (predominantly physiologists), documenting procedural logistics and referring both to the level of risk of the procedure at that time (table 1) and frequency, nature and magnitude of each distraction/interruption (table 2). The primary operator completed a NASA Task-load questionnaire rating parameters to include mental and physical effort, level of frustration, time–urgency, and overall effort and performance on a scale of 1 – 21. Results 264 distractions occurred in 106 procedures (55% of total); 80% were not relevant to the case being undertaken; 13% were due to emergencies occurring in the ‘Hot- Lab’ predominantly to discuss potential ST-elevation myocardial infarction requiring emergency angioplasty. Frequency of distractions per case ranged from 1 to 16, with an average of 2.5; 16% (n=43) of these were documented to occur during high-risk stages (categories 3 or 4) of the procedure. Operator rating of NASA task-load parameters demonstrated higher levels of ‘mental’ and ‘physical’ workload and ‘effort’ when distractions occurred (figure 1). Conclusion In this first description of human factors in the adult cardiac CL we have shown that less than half of all procedures are completed without interruption/distraction. The vast majority of these are unnecessary and without relation to the case or list. We therefore propose the introduction of a ‘sterile cockpit’ environment in the CL, as has been adapted from the aviation industry within surgical operating theatres, to minimise non-emergent interruptions and disturbances, in an attempt to improve operator conditions and overall patient safety. Conflict of Interest Nil

The idea of the surgeon as puppeteer may be overly simplistic.1 The strings of Japanese Bunraku puppetry and surgical suturing are visible, whereas the strings of the puppetry that drives the safe and effective functioning of modern operating …

Surgical site infections are among the most frequent Health Care Associated Infections with severe impact on mortality and high economic costs; the role of air microbiological contamination in surgical site infections was amply discussed in the scientific literature, highlighting differences in air contamination rates between different ventilation systems, number of people present and door opening rates.The aim of our study was to monitor the presence of bacterial air contamination in operating theaters and its relationship with number of people and type of airflow over a period of nine years (January 2010-November 2018) at Messina's University Hospital. The Rho of Spearman test was used to evaluate differences in microbial contamination between empty and working theaters. The impact of the number of people on colony-forming unit values was assessed by performing a stepwise multiple regression analysis. The differences between the results recorded over the nine-year study period were evaluated using the variance analysis. Software R was used for the statistical assessment.Air samples were taken in each operating theater over nine years. A total of 1,425 samples were collected with a positivity rate of 37.3%. The median bacterial contamination rate was 30 cfu/m3 in empty theaters, while this rate was significantly higher (P0.001) in working theaters, where it reached 85 cfu/m3. A statistically significant difference was identified between laminar and turbulent airflow systems, with higher bacterial contamination rates with the latter (p0.001); in these cases, the value of bacterial contamination (microbial count) was higher in the presence of a higher number of individuals in the operating theater (p0.001).Our study demonstrates the complexity of the Operating Theatres environment, in which a good ventilation system is, indeed, only one prerequisite for clean air, but other factors, such as the behavior of healthcare professionals and environmental conditions, can influenced the bacterial count.

The World Health Organization published guidelines in 2016 for preventing surgical site infections. The guidelines contained a conditional recommendation that laminar airflow (LAF) ventilation systems should not be used to reduce the risk of infection after total joint arthroplasty (TJA). This recommendation was largely based on a systematic review and meta-analysis of information from hospital infection surveillance registries. The recommendation contradicts information published in earlier major studies carried out by Charnley and the UK Medical Research Council (MRC). The first aim of this article is to revisit and explain the MRC study, and reply to criticisms of it. The second aim is to suggest reasons why some recent studies have failed to demonstrate that ultraclean air (UCA) systems reduce deep joint infection after TJA. It demonstrates that if a UCA system establishes average airborne concentrations of microbe-carrying particles (MCPs)

Conventional microbial sampling of air in hospitals is usually carried out using settle plates or impaction air samples. This provides little information about intermittent contamination events and is unhelpful for source attribution. Direct continuous bioaerosol sampling is an established technology used to characterise ambient external air. Portable instruments such as the Wideband Integrated Bioaerosol Sensor (WIBS) combine laser particle size and shape detection with signals of biological origin (fluorescence from amino acids and NAD(P)H) characteristic of viable bioaerosols. Monitoring is continuous for weeks at a time and data collected remotely over the internet. We present evidence of the utility of WIBS analysis in characterising air in hospitals in three different environments: operating theatres (plenum ventilated and ultraclean), a respiratory ward, and a specialist cystic fibrosis outpatients. The airborne particle profile was quantitatively and qualitatively different in each environment. Plumes of biologically-relevant airborne particles were detected and source investigation of failing conventional counts in an operating theatre aided by the continuous record. Nebulised drugs contributed a detectable effect on airborne particles which lasted for several hours on the ward despite air changes. A significant effect of plasma air treatment on airborne particles in the ward was detected by WIBS and not conventional cultures. Continuous monitoring may in future allow objective standard setting for airborne particles in different hospital environments and facilitate rapid detection of airborne infection risks.

The potential of surgery lies in the technological advances that would complement it. The landscape of the field will differ depending on the time period being looked at and would no doubt include conjecture. Initial breakthroughs will need to pave the way for future medical technology and apply to the surgical sciences. Within the next 10 years we would expect to see the emergence of big data analysis, cuttingedge image processing techniques for surgical planning and better implementation of virtual and augmented reality in operating theatres for both patient care and teaching purposes. Over the next 50 to 100 years, the use of quantum computing should lead to increased automation in our healthcare systems. The inception of novel biomaterial invention and advanced genetic engineering will usher in the new age of regenerative medicine in the clinical setting. The future of surgery includes many predictions and promises, but it is apparent that the development will lead to bettering outcome and focus on patient care.