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Background: During coronavirus disease 2019 (COVID‐19)–related operating room closures, some multidisciplinary thoracic oncology teams adopted a paradigm of stereotactic ablative radiotherapy (SABR) as a bridge to surgery, an approach called SABR‐BRIDGE. This study presents the preliminary surgical and pathological results. Methods: Eligible participants from four institutions (three in Canada and one in the United States) had early‐stage presumed or biopsy‐proven lung malignancy that would normally be surgically resected. SABR was delivered using standard institutional guidelines, with surgery >3 months following SABR with standardized pathologic assessment. Pathological complete response (pCR) was defined as absence of viable cancer. Major pathologic response (MPR) was defined as ≤10% viable tissue. Results: Seventy‐two patients underwent SABR. Most common SABR regimens were 34 Gy/1 (29%, n = 21), 48 Gy/3–4 (26%, n = 19), and 50/55 Gy/5 (22%, n = 16). SABR was well‐tolerated, with one grade 5 toxicity (death 10 days after SABR with COVID‐19) and five grade 2–3 toxicities. Following SABR, 26 patients underwent resection thus far (13 pending surgery). Median time‐to‐surgery was 4.5 months post‐SABR (range, 2–17.5 months). Surgery was reported as being more difficult because of SABR in 38% (n = 10) of cases. Thirteen patients (50%) had pCR and 19 (73%) had MPR. Rates of pCR trended higher in patients operated on at earlier time points (75% if within 3 months, 50% if 3–6 months, and 33% if ≥6 months; p =.069). In the exploratory best‐case scenario analysis, pCR rate does not exceed 82%. Conclusions: The SABR‐BRIDGE approach allowed for delivery of treatment during a period of operating room closure and was well‐tolerated. Even in the best‐case scenario, pCR rate does not exceed 82%. During COVID‐19–related operating room closures, a paradigm of stereotactic ablative radiotherapy as a bridge to surgery >3 months later was well‐tolerated and allowed for curative treatment of early‐stage lung malignancy with delay. Pathological complete response (pCR) was 50%, with best‐case scenario sensitivity analysis demonstrating that maximal possibly achievable pCR rate is 82%. [ABSTRACT FROM AUTHOR]

Intraoperative teamwork is vital for patient safety. Conventional tools for studying intraoperative teamwork typically rely on behaviorally anchored rating scales applied at the individual or team level, while others capture narrative information across several units of analysis. This prospective observational study characterizes teamwork using two conventional tools (Operating Theatre Team Non-Technical Skills Assessment Tool [NOTECHS]; Team Emergency Assessment Measure [TEAM]), and one alternative approach (modified-Systems Engineering Initiative for Patient Safety [SEIPS] model). We aimed to explore the advantages and disadvantages of each for providing feedback to improve teamwork practice. Fifty consecutive surgical cases at a Canadian academic hospital were recorded with the OR Black Box®, analyzed by trained raters, and summarized descriptively. Teamwork performance was consistently high within and across cases rated with NOTECHS and TEAMS. For cases analyzed with the modified-SEIPS tool, both optimal and suboptimal teamwork behaviors were identified, and team resilience was frequently observed. NOTECHS and TEAM provided summative assessments and overall pattern descriptions, while SEIPS facilitated a deeper understanding of teamwork processes. As healthcare organizations continue to prioritize teamwork improvement, SEIPS may provide valuable insights regarding teamwork behavior and the broader context influencing performance. This may ultimately enhance the development and effectiveness of multi-level teamwork interventions. [ABSTRACT FROM AUTHOR]

Background: There has been considerable research into burnout but much less into how surgeons thrive and find joy. This study, conducted by the SAGES Reimagining the Practice of Surgery Task Force, explored factors influencing surgeon well-being, the eventual goal being translating findings into tangible changes to help restore the joy in surgery. Methods: This was a qualitative, descriptive study. Purposive sampling ensured representation across ages, genders, ethnicities, practice types, and geographies. Semi-structured interviews were recorded and transcribed. We coded inductively, finalized the codebook by consensus, and then constructed a thematic network. Global themes formed our conclusions; organizing themes gave additional detail. Analysis was facilitated by NVivo. Results: We interviewed 17 surgeons from the US and Canada. Total interview time was 15 hours. Our global and organizing themes were: Stressors (Work–life Integration, Administration-related Concerns, Time and Productivity Pressures, Operating Room Factors, and Lack of Respect). Satisfaction (Service, Challenge, Autonomy, Leadership, and Respect and Recognition). Support (Team, Personal Life, Leaders, and Institutions). Values (Professional and Personal). Suggestions (Individual, Practice, and System level). Values, stressors, and satisfaction influenced perspectives on support. Experiences of support shaped suggestions. All participants reported stressors and satisfiers. Surgeons at all stages enjoyed operating and being of service. Supports and suggestions included compensation and infrastructure, but human resources were most critical. To experience joy, surgeons needed high-functioning clinical teams, good leaders/mentors, and supportive family/social networks. Conclusions: Our results indicated organizations could (1) better understand surgeons' values, like autonomy; (2) provide more time for satisfiers, like patient relationship building; (3) minimize stressors, like time and financial pressures; and (4) at all levels focus on (4a) building teams and leaders and (4b) giving surgeons time and space for healthy family/social lives. Next steps include developing an assessment tool for individual institutions to build "joy improvement plans" and to inform surgical associations' advocacy efforts. [ABSTRACT FROM AUTHOR]

The distributed operating room (OR) scheduling problem aims to find an assignment of surgeries to ORs across collaborating hospitals that share their waiting lists and ORs. We propose a stochastic extension of this problem where surgery durations are considered to be uncertain. In order to obtain solutions for the challenging stochastic model, we use sample average approximation and develop two enhanced decomposition frameworks that use logic-based Benders (LBBD) optimality cuts and binary decision diagram based Benders cuts. Specifically, to the best of our knowledge, deriving LBBD optimality cuts in a stochastic programming context is new to the literature. Our computational experiments on a hospital data set illustrate that the stochastic formulation generates robust schedules and that our algorithms improve the computational efficiency. Summary of Contribution: We propose a new model for an important problem in healthcare scheduling, namely, stochastic distributed operating room scheduling, which is inspired by a current practice in Toronto, Ontario, Canada. We develop two decomposition methods that are computationally faster than solving the model directly via a state-of-the-art solver. We present both some theoretical results for our algorithms and numerical results for the evaluation of the model and algorithms. Compared with its deterministic counterpart in the literature, our model shows improvement in relevant evaluation metrics for the underlying scheduling problem. In addition, our algorithms exploit the structure of the model and improve its solvability. Those algorithms also have the potential to be used to tackle other planning and scheduling problems with a similar structure. [ABSTRACT FROM AUTHOR]

Objectives: Mass Casualty Incidents (MCIs) are rare but devastating events that require extensive planning in order to minimize morbidity and mortality. There are two broad categories limiting a hospital's response: physical assets (e.g., critical care beds, operating rooms, food, communication devices) as well as operating procedures (e.g., MCI committees, regional coordination, provider training). The purpose of this study is to provide an examination of MCI preparedness according to these categories in Level 1 Trauma Centre across Canada.Methods: This study surveyed all Level 1 Trauma Centres across Canada in order to assess the physical assets and operating procedures they had in place in the event of a hypothetical MCI on one of the busiest days of the year for trauma care.Results: Of the 28 Trauma Centres contacted, 13 completed surveys (46%). Most hospitals had sufficient food (9/13) water (9/13), fuel (7/13), and communication assets (8/13) for a hypothetical MCI. A median of 38 mechanical ventilators could be mobilized. No hospitals mandated physician training for MCIs, and 6/13 centres were certain that they had a Strategic Emergency Management Plan (SEMP). Only 6/13 hospitals had dedicated MCI committees, Overall, 4/13 hospitals had explicit plans developed with community hospitals.Conclusion: This study demonstrated that physical assets are generally less limiting than operating procedures. Four key areas of potential improvement have been identified: 1) provider training (especially physicians), 2) coordination with small hospitals, 3) mechanical ventilator availability, and 4) MCI committees with explicit Strategic Emergency Management Plans. [ABSTRACT FROM AUTHOR]

Background: The role of physician assistants (PAs) in surgical care in Canada is expanding. Similarly, the acute care surgery (ACS) model continues to evolve, and PAs are increasingly being considered as members of ACS teams. However, their exact impact and contribution has not been well studied. Our study describes the contribution of a PA who worked full time on weekdays on an ACS team in a Canadian academic tertiary hospital.Methods: To quantify the PA's contributions, an ACS database was created in September 2016. Data on the number of ACS patient encounters, the number of ACS surgical consults, the number of ACS admissions, the PA's involvement in the operating room, the number of PA patient encounters and the number of multidisciplinary meetings were prospectively collected. We report data for 365 consecutive days from Dec. 30, 2016, to Dec. 29, 2017.Results: The ACS team had 11 651 patient encounters during the year, with a mean of 31.92 per day. The mean number of surgical consults per day was 5.89, and a mean of 2.08 surgical procedures were performed per day. The PA was involved in 53.5% of all patient encounters, despite working only during daytime hours on weekdays. Multidisciplinary meetings were conducted by the PA 94.9% of the time. Alternate level of care patients were seen by the PA 96.2% of the time. The PA was directly involved in 2.0% of the operating room procedures during the study period.Conclusion: Integrating a PA on an ACS team adds value to patient care by providing consistency and efficient management of ward issues and patient care plans, including multidisciplinary discharge planning, timely emergency department consultations and effective organization of the ACS team members. [ABSTRACT FROM AUTHOR]

Introduction: Abdominal sacrocolpopexy provides effective longterm outcomes for apical pelvic organ prolapse. The introduction of robotic-assisted laparoscopic sacrocolpopexy (RALS) has mitigated the risks of abdominal surgery. This study aims to evaluate the preoperative patient characteristics, intraoperative surgical parameters, and postoperative outcomes of RALS, which has not been previously performed in Canada. Methods: A retrospective chart review of 47 patients who have undergone RALS from 2016-2018 by a single surgeon at a tertiary care hospital in Canada was completed. Results: This case series had a mean age of 60.2 years, body mass index (BMI) of 28.3 kg/m2, and Charlson comorbidity index of 2.0. Preoperatively, 13 (28%), 23 (49%), and 11 (23%) patients had Baden-Walker grade 2, 3, and 4 apical prolapse, respectively. Intraoperatively, 45 (96%) patients underwent concomitant procedures, including 36 (77%) with adnexal surgery, 32 (68%) with anti-incontinence surgery, and 25 (53%) with hysterectomy. Intraoperative complications included one ureteric injury, two bladder injuries, and three vaginotomies. The mean robotic console time, surgery time, and total operating room times were 125.6, 148.6, and 190.6 minutes, respectively. Postoperatively, data was analyzed for 32 (68%) patients with greater than 12 weeks' followup. There was no recurrence of apical prolapse on exam after a mean followup of 60.1 weeks. Seven (22%) patients experienced symptomatic prolapse in the posterior compartment. There were two grade 3 Clavien- Dindo complications, including osteomyelitis and mesh exposure. Conclusions: RALS can be safely and effectively performed with other pelvic procedures with good outcomes. Concurrent posterior repairs may be considered in select patients. [ABSTRACT FROM AUTHOR]

Definitive treatment for patients diagnosed with locally advanced cervical cancer includes chemoradiation and image-based brachytherapy. This requires significant multidisciplinary and intradepartmental coordination. Our goal was to assess and share gynecologic brachytherapy best practices from high volume brachytherapy centers within the United States and Canada. A brachytherapy best practices survey was developed using our institution's Qualtrics software. The survey was sent to 42 centers that perform a high volume of complex gynecologic brachytherapy procedures. Complex brachytherapy was defined as non-vaginal cylinder intracavitary and interstitial brachytherapy. Data was analyzed and descriptive statistics were performed using Excel. Responses were collected from 32/42 (76%) institutions. 41% of responding institutions perform >100 complex brachytherapy procedures per year, 26% perform 51-100, 29% perform 11-50 and 3% perform 1-10. 97% of surveyed centers receive 25-75% of their complex brachytherapy patients as referrals from an in-network satellite or out of network facility. External beam plan acquisition from referring institutions was viewed as important but difficult to consistently coordinate. Most departments have >1 brachytherapist performing procedures. 85% of respondents complete 1-2 complex brachytherapy procedures per day, 59% complete all their own cases and 59% perform complex brachytherapy procedures 2 days per week. The majority have specified days of the week that are devoted to brachytherapy (65%), though most respondents see patients in clinic on their procedure days (74%). 91% of departments have dedicated nurses, physicists, and other staff devoted to brachytherapy, which is pivotal for a successful program. Scheduling includes a combination of brachytherapy coordinators (33%), nursing staff (20%), department schedulers (20%), physicians (16%), and advanced practice practitioners (7%), and requires physicians to enter orders for each procedure. Respondents spend a median of 30 minutes on scheduling per week. 56% of tandem-based intracavitary procedures and 52% of interstitial hybrid procedures take place in a brachytherapy suite within a department while 50% of interstitial template procedures take place in an operating room. Surveyed institutions use MRI (35%), CT (24%) or a combination (24%) for treatment planning. 88% of respondents use sedation for tandem based procedures which include general (28%), MAC (23%), epidural/spinal (15%), oral medication (11%) and paracervical block (5%). Coordination with Anesthesiology and Gyn Onc is variably approached but an essential component of a successful program. Respondents cite high complexity of care, insufficient reimbursement, untimely referrals from external beam radiation oncologists, shared operative and clinical duties, expensive applicator acquisition and complex scheduling as the most challenging aspects of providing brachytherapy services. Conversely, respondents cite a dedicated team, a departmental brachytherapy suite, well organized coordination of procedures and personnel, anesthesia support, a full range of applicators, image-based planning near the department and supportive administration as integral components in providing high volume complex brachytherapy. Most institutions performing a high volume of complex gynecologic brachytherapy have >1 brachytherapist who perform 1-2 procedures per day and a dedicated brachytherapy space and team that assists with coordination and scheduling efforts. A well supported multidisciplinary team is vital to ensure state of the art brachytherapy which is essential in curing these challenging malignancies. [ABSTRACT FROM AUTHOR]

Context: In postgraduate medical programmes, the progressive development of autonomy places residents in situations in which they must cope with uncertainty. We explored the phenomenon of hesitation, triggered by uncertainty, in the context of the operating room in order to understand the social behaviours surrounding supervision and progressive autonomy. Methods: Nine surgical residents and their supervising surgeons at a Canadian medical school were selected. Each resident–supervisor pair was observed during a surgical procedure and subsequently participated in separate post‐observation, semi‐structured interviews. Constructivist grounded theory was used to guide the collection and analysis of data. Results: Three hesitation‐related themes were identified: the principle of progress; the meaning of hesitation, and the judgement of competence. Supervisors and residents understood hesitation in the context of a core surgical principle we termed the ‘principle of progress’. This principle reflects the supervisors’ and residents’ shared norm that maintaining progress throughout a surgical procedure is of utmost importance. Resident hesitation was perceived as the first indication of a disruption to this principle and was therefore interpreted by supervisors and residents alike as a sign of incompetence. This interpretation influenced the teaching–learning process during these moments when residents were working at the edge of their abilities. Conclusions: The principle of progress influences the meaning of hesitation which, in turn, shapes judgements of competence. This has important implications for teaching and learning in direct supervision settings such as surgery. Without efforts to change the perception that hesitation represents incompetence, these potential teaching–learning moments will not fully support progressive autonomy. [ABSTRACT FROM AUTHOR]

In the decade since its inception, the World Health Organization's surgical safety checklist has fundamentally changed the conduct of surgery the world over. A critical component of the checklist -- the "pause" or "time-out" -- requires all operating room staff to stop other activities and together review critical information about the case to ensure that nothing is missed. Surgical trainees in Canada are transitioning to a competency-based medical education model; a core aspect of this model requires trainees to advocate for their own learning goals. We propose the use of a detailed and formalized preoperative pause as a means to enable superior and more targeted intraoperative learning for surgical trainees. [ABSTRACT FROM AUTHOR]

Background: The objective of this analysis is to explore potential impact on operating room (OR) efficiency and incidence of residual neuromuscular blockade (RNMB) with use of sugammadex (Bridion™, Merck & Co., Inc., Kenilworth, NJ USA) versus neostigmine for neuromuscular block reversal in Canada. Methods: A discrete event simulation (DES) model was developed to compare ORs using either neostigmine or sugammadex for NMB reversal over one month. Selected inputs included OR procedure and turnover times, hospital policies for paid staff overtime and procedural cancellations due to OR time over-run, and reductions in RNMB and associated complications with sugammadex use. Trials show sugammadex's impact on OR time and RNMB varies by whether full neuromuscular recovery (train-of-four ratio ≥0.9) is verified prior to extubation in the OR. Scenarios were therefore evaluated reflecting varied assumptions for neuromuscular reversal practices. Results: With use of moderate neuromuscular block, when full neuromuscular recovery is verified prior to extubation (93 procedures performed with sugammadex, 91 with neostigmine), use of sugammadex versus neostigmine avoided 2.4 procedural cancellations due to OR time over-run and 33.5 h of paid staff overtime, while saving an average of 62 min per OR day. No difference was observed between comparators for these endpoints in the scenario when full neuromuscular recovery was not verified prior to extubation, however, per procedure risk of RNMB at extubation was reduced from 60% to 4% (reflecting 51 cases prevented), with associated reductions in risks of hypoxemia (12 cases avoided) and upper airway obstruction (23 cases avoided). Sugammadex impact in reversing deep neuromuscular block was evaluated in an exploratory analysis. When it was hypothetically assumed that 30 min of OR time were saved per procedure, the number of paid hours of staff over-time dropped from 84.1 to 32.0, with a 93% reduction in the per patient risk of residual blockade. Conclusions: In clinical practice within Canada, for the majority of patients currently managed with moderate neuromuscular block, the principal impact of substituting sugammadex for neostigmine is likely to be a reduction in the risk of residual blockade and associated complications. For patients maintained at a deep level of block to the end of the procedure, sugammadex is likely to both enhance OR efficiency and reduce residual block complications. [ABSTRACT FROM AUTHOR]

The article discusses a study designed to provide continued validation of the Ottawa Surgical Competency Operating Room Evaluation (O-SCORE) for the assessment of technical skills (TS) and operative competence of surgical trainees. Among the findings include the relationship of the O-SCORE with other surgical skill assessment tools and the Objective Structured Assessment of TS global rating scale, and the contribution of raters to the reliability of O-SCORE.

Objective: Day-of-surgery cancel lations have a negative effect on operating room (OR) resources, as weil as on patient satisfaction and perception of quality of care. Given increas ing wait times in a universal healthcare system and the nature of urological surgery in our aging population, it should be a priority to identify modifiable risks of OR cancellations to assure timely and efficient delivery of care. We explore the rate and reasons for elective surgery cancellations in a Canadian urological practice. Methods: We eva luated the rate and reason of urological surgery ca ncell ation at a single academie institution, prospectively co llected in our centre's Operating Room Scheduling Office System (ORSOS) database. Documented reasons for cancellations were divided into 3 components: (1) structural factors (e.g., no hospital bed); (2) patient factors (e.g., patient unwell); and (3) process factors (e.g ., schedu ling error). Rates and reasons for cancell ations were compared to those of General Surgery and Gynecology. The documented reasons for cancellation in the ORSOS database were confirmed or extended by chart review and interviews with a subset of cancel led patients. Results: Between 2005 and 2009, 1544 out of 19 141 (8.07 %) elective surgica l cases were ca ncel led w ithin the three surgica l specialties (general surgery, gynecology and urology); urology had the highest average rate of 9.53%. Non-oncological cases represented a higher percentage of cancel led cases (15%, p < 0.001) and overal l rates varied significantly over ti me in urology compared to the other surgica l spec ialt ies. Potentially modifiable, processrelated causes were by far the most common reason for ca ncellation (58.5%) and "standby" cases were a common cause of overall cancel lation rates. Patient interviews confirmed the emotional and financial impact of cancellation; there was no overwhelming concern that clin ica! outcomes were negatively affected. Conclusions: This contemporary exploration of cancel led urologieal cases is consistent with previous reports, although variable over time and dependent on definitions used. Potentially modifiable, process-related factors appear to be most frequent! y associated with cancellation, although more thorough and detailed documentation is required to further mitigate inefficient OR use. We suggest that ali OR cancel lations shou ld be considered to be adverse incidents to be monitored by institutions in a systematic fashion. [ABSTRACT FROM AUTHOR]

Background: In Canadian hospitals, which are typically financed by global annual budgets, overuse of operating rooms is a financial risk that is frequently managed by cancelling elective surgical procedures. It is uncertain how different scheduling rules affect the rate of elective surgery cancellations. Methods: We used discrete event simulation modelling to represent perioperative processes at a hospital in Toronto, Canada. We tested the effects of the following 3 scenarios on the number of surgical cancellations: scheduling surgeons' operating days based on their patients' average length of stay in hospital, sequencing surgical procedures by average duration and variance, and increasing the number of post - surgic al ward beds. Results: The number of elective cancellations was reduced by scheduling surgeons whose patients had shorter average lengths of stay in hospital earlier in the week, sequencing shorter surgeries and those with less variance in duration earlier in the day, and by adding up to 2 additional beds to the postsurgical ward. Conclusion: Discrete event simulation modelling can be used to develop strategies for improving efficiency in operating rooms. [ABSTRACT FROM AUTHOR]

The article presents a study which examined the efficacy of a patient-controlled active warming gown in optimizing patients' perioperative body temperature and in reducing postoperative pain after total knee arthroplasty (TKA). It explains that half of the patients received a hospital gown and prewarmed standard cotton blanket and the other half received a single-use, forced-air warming gown connected to a portable warming unit. It also discusses the impact of hypothermia on the patients.

HIGGINS B.L. & MACINTOSH J. (2010) Operating room nurses' perceptions of the effects of physician-perpetrated abuse. International Nursing Review 57, 321–327 Background: Operating room (OR) nurses experience abuse perpetrated by physicians; however, little research has been conducted to examine nurses' perceptions of the effects of such abuse. Aims: The aim of this research was to understand participants' perceptions of physician-perpetrated abuse on their health and ability to provide patient care. Materials/Methods: In this qualitative descriptive study, ten operating room nurses working in Eastern Canada participated in open-ended, individual audiotaped interviews that were transcribed for analysis using Boyatzis' method for code development. Results: Three categories of factors contributing to abuse were developed. The first, culture of the OR, included environment and hierarchy. The second, catalysts of abuse, included nurses' positions and experience as well as non-nurse factors such as resources and interpersonal relationships among physicians. The third category, perceived effects, included psychological, physical and social health consequences for nurses. Effects on patient care consisted of safety and potential challenges to access. Discussion: Nursing practice implications included mentoring, support and accountability for action. Educational implications related to interdisciplinary education and increased education on communication, assertiveness, and awareness of abuse. Implications for research included studying perceptions of other health-care providers including physicians, studying recruitment and retention in relation to abuse, and studying other abuse in health care such as horizontal violence. Conclusion: We suggest a proactive approach for empowering OR nurses to address abuse and an increased focus on interdisciplinary roles. [ABSTRACT FROM AUTHOR]

The author calls for delivery of timely surgery in Canadian hospitals. He reports results of a study on reasons of delays in emergency surgery including pre-emption by more urgent procedures and unavailability of a surgeon or open operating room. He discusses a paradox that bedevils managers of surgical services and suggests interventions to reduce surgical care costs such as configuring financial centers in hospitals and transformation of perioperative services departments into profit centers.

The author reflects on the barriers to surgical innovation and also reveals that innovation is not seen in operating rooms. Topics discussed include investment of business enterprises in Canada more than the investment of the federal government, technology investment and expansion to a product line, and administration not interested in new technology.

The article focuses on the testing of a surgical black box designed to address malpractice in hospitals in Canada. The technology was the product of the research of Dr. Teodor Grantcharov of the University of Toronto and it involves several cameras and microphones. The purpose of the technology which is to enhance health team performance and pinpoint errors in the operating room is offered.

The article presents information on reforms related to the creation of new positions called "instrumentalist" in the operating rooms of hospitals in Canada. According to Gaétan Barrette, president of the Federation of Medical Specialists of Quebec, the health care system must look into new staffing and procedural solutions to move more patients through operating rooms to reduce the waiting times of surgery. He suggested that nurses should not be doing this work as they should be with the patients who need them more. He also said that instrumentalists do not require any medical training. However, the Canadian Nurses Association is concerned about accountability as such instrumentalists will not be covered under any professional laws or regulations.