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This study aimed to evaluate intraoperative interruptions by frequency, type, interference and source, and preventive measures. The interruptions in the operating theatre were evaluated for 52 surgical procedures based on real-time recordings and divided into routine operative procedures (ROP, n = 26, without intervention) and intervened operative procedures (IOP, n = 26, observed after team brief and placement of a warning sign for unnecessary door openings) groups. Intervened operative procedures vs. routine operative procedures was associated with a significantly lower number of interruptions (p = 0.014). Implementation of preventive measures was associated with a significantly lower number of entrances and exits (p = 0.001) and equipment issues (p = 0.003), interruptions that affected the circulating nurse or anaesthesia technician/associate (p = 0.003) and those caused by team members other than assisting surgeon and scrub nurse (p-value ranged from 0.015 to 0.009). Our findings revealed significantly reduced interruptions after a simple preventive measure including team brief and the placement of a warning sign for unnecessary door openings.

To assess the critical threshold to optimize operating room (OR) time for each surgical team member in robotically assisted sacrocolpopexy (RASCP) and to evaluate the most efficient team compositions. All women who underwent RASCP for pelvic organ prolapse (POP) were prospectively entered in a database. Patients having unrelated concomitant surgery were excluded. Our primary outcome measure was total OR time. We utilized factor analysis, regression analysis, and analysis of variance, OR time mapping, and stochastic optimization to identify ‘optimal’ surgical team configuration. The database included 359 consecutive RASCPs, all performed for stage III–IV POP: 156 (43%) were with total and 44 (12%) supracervical hysterectomies and 159 (44%) post-hysterectomy. Mean age was 58.6 ± 9.3 years. Mean parity was 2.8 ± 1.4, and mean body mass index was 28 ± 4.7 kg/m2. A total of 4 surgeons, 34 first assistants, 20 circulating nurses, 15 surgical technologists, and 59 anesthesiologist/nurse anesthetists were involved. Optimal experience levels for each team member were achieved at the following number of robotic procedures: surgeon 44; first assistant 13; surgical technologist 66; circulating nurse 56; anesthesia provider 46. Our analysis revealed that the surgical technologist and first assistant played the most significant roles within the team. The surgeon was ranked third followed by the circulating nurse and anesthesia provider, respectively. Operating time in robotic surgery is multifactorial. Experience of each member of a robotic surgery team is critical. An optimal team can be composed of a variety of combinations of experience levels among the robotic team members.

Successful spinal surgery demands high levels of concentration and cooperation from participating health care workers. The intraoperative stress levels and concentration levels of surgeons have been studied previously; however, those of nurses are rarely studied. Therefore, the purpose of this study is to understand the stresses affecting surgical nurses by their participating role during spinal surgery. A total of 160 surgical stress records were obtained during 40 surgeries, including electroencephalography (EEG) signals and heart rate variability (HRV) from three orthopedic spinal surgeons and six nurses; concentration, tension level and physical stress were analyzed. Levels of both concentration and tension were significantly higher in circulating nurses during all surgical stages (p < 0.05). Both beats per minute and low frequency/high frequency ratios, which reflect physical stress, were higher in scrub nurses (p < 0.05). As the surgical experience of scrub nurses increased, the key parameters related to stress tended to decrease (p < 0.01). These results will contribute to understanding the pattern of intraoperative stress of surgical nurses, and therefore help in enhancing the teamwork of the surgical team for optimal outcomes.

Introduction: The objective of this study was to determine if use of an automated irrigation pump (AIP) during ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL) affects circulating nurse l...

Surgical nursing roles include anaesthetist, surgical assistant and circulating nurse. Managing theatre is often the job of the veterinary nurse and successful management of these roles are vital f...

Operating rooms (ORs) contribute to at least 40 per cent of hospital costs. There is an existing cost waste in ORs for surgical devices that are opened without being used. There is a paucity of data evaluating the hospital cost of opened but unused OR supplies. The goal of this observational study is to examine the cost of opened but unused OR supplies for general surgery cases. We performed a quality improvement project of OR cost waste by observing 30 cases. Surgical cases of a senior surgeon who had been at the institution for more than five years were evaluated for items opened appropriately and whether the items are used. The cases evaluated ranged from open hernia repairs to robotic-assisted hernia repairs. We found that the cost of instruments opened but not used was $4528.18. Of the cases evaluated, we found that a range of 0 per cent to 27 per cent of total items were wasted, an average of 8.3 per cent. We found that for the open inguinal hernia case, there was minimal waste. The highest waste was among complex cases such as the robotic-assisted inguinal hernia with an average waste and cost of 15.8 per cent and $379. We found that on average for less complex cases such as open inguinal hernia repairs, $1.44 was potentially wasted per case, whereas for more complex cases up to $379 was wasted per case. We identified the outdated preference cards, lack of instrument knowledge, circulating nurse, and surgical technician distractions as reasons for contributing to waste.

Objective Equipment necessary to perform pediatric microlaryngoscopy/bronchoscopy (MLB) varies considerably depending on the selected interventions. In procedures with equipment variability, surgical case length may be increased due to the need to procure items intraoperatively. We hypothesized that use of standardized huddle tools listing necessary equipment would be associated with a shortened case duration in MLB. Methods As part of a quality improvement initiative at our academic, tertiary care pediatric hospital, a standardized huddle sheet was created that listed options of equipment for MLB. Listed items included telescope/bronchoscope size, laryngoscope selection, interventional equipment, suspension, microscopes, and topical medications. The tool was completed by otolaryngology and shared with the circulating nurse at the beginning of the day so equipment needs could be anticipated. The tool was introduced to staff in November 2017 and to trainees in February 2018. To assess intervention impact, monthly median surgical case duration and room turnover time were retrospectively tracked using control chart analysis from March, 2017 to June 2019. Results At baseline, the centerline case duration was 49 minutes. Two months following introduction of the huddle sheet to trainees, the centerline duration decreased to 43 minutes. This change was sustained throughout the period studied. No changes in room turnover time were observed during this period. Conclusions Standardized huddle tool use prior to MLB was associated with a median decrease of six minutes of operating room time without a change in operating room turnover time. Use of similar tools in procedures with significant equipment variability may be beneficial.

Iatrogenic contamination causes serious health threats to both patients and healthcare staff. Contact operation is an important transmission route for nosocomial infection. Reducing direct contact during medical treatment can reduce nosocomial infection quickly and effectively. Scientific and technological progress in the 5G era brings new solutions to the problem of iatrogenic contamination. We conducted experiments at 27 GHz and 37 GHz to achieve contactless gesture recognition through the bornprint of body centric channel. The original channel S-parameters can achieve 82% (27 GHz) and 89% (37 GHz) basic recognition accuracy through simple statistical analysis. Basic switch recognition and multi-gesture selection recognition can meet the common operation requirements of circulating nurses, greatly reducing contact operations and reducing the probability of cross-contamination. Fully physically isolated body centric channel gesture sensing provides a new entry point for reducing iatrogenic contamination.

Background: Circulating nurses are key members of the surgical team and play an essential role in ensuring patient safety in the operating room. They need to use non-technical skills to provide safe and efficient patient care. This study was conducted to identify the behaviors related to the circulating nurse´s nontechnical skills from the existing literature.Methods: A search of the literature between 1990 and 2020 was conducted using online sources, including Web of Science, MEDLINE, CINHAL, Scopus, OVID, and Cochran library. Furthermore, the publications of the Association of peri-operative registered nurses (AORN) and the National Association of Theater Nurses (NATH) were consulted. Then the skills were grouped into known categories of non-technical skills.Results: Behaviors related to circulating nurse´s non-technical skills were extracted from the existing literature. Then they were grouped into seven domains, including communication, leadership, coping, teamwork, situational awareness, task management, and decision-making and problem-solving. Furthermore, several improper behaviors were extracted.Conclusion: Circulating nurses need to use non-technical skills from the beginning until the end of surgery to perform efficiently. There is still a need for future work to identifying circulating nurses’ non-technical skills using other types of studies to develop an assessment tool.

OBJECT Surgery requires careful coordination of multiple team members, each playing a vital role in mitigating errors. Previous studies have focused on eliciting errors from only the attending surgeon, likely missing events observed by other team members. METHODS Surveys were administered to the attending surgeon, resident surgeon, anesthesiologist, and nursing staff immediately following each of 31 cerebrovascular surgeries; participants were instructed to record any deviation from optimal course (DOC). DOCs were categorized and sorted by reporter and perioperative timing, then correlated with delays and outcome measures. RESULTS Errors were recorded in 93.5% of the 31 cases surveyed. The number of errors recorded per case ranged from 0 to 8, with an average of 3.1 ± 2.1 errors (± SD). Overall, technical errors were most common (24.5%), followed by communication (22.4%), management/judgment (16.0%), and equipment (11.7%). The resident surgeon reported the most errors (52.1%), followed by the circulating nurse (31.9%), the attending surgeon (26.6%), and the anesthesiologist (14.9%). The attending and resident surgeons were most likely to report technical errors (52% and 30.6%, respectively), while anesthesiologists and circulating nurses mostly reported anesthesia errors (36%) and communication errors (50%), respectively. The overlap in reported errors was 20.3%. If this study had used only the surveys completed by the attending surgeon, as in prior studies, 72% of equipment errors, 90% of anesthesia and communication errors, and 100% of nursing errors would have been missed. In addition, it would have been concluded that errors occurred in only 45.2% of cases (rather than 93.5%) and that errors resulting in a delay occurred in 3.2% of cases instead of the 74.2% calculated using data from 4 team members. Compiled results from all team members yielded significant correlations between technical DOCs and prolonged hospital stays and reported and actual delays (p = 0.001 and p = 0.028, respectively). CONCLUSIONS This study is the only of its kind to elicit error reporting from multiple members of the operating team, and it demonstrates error is truly in the eye of the beholder—the types and timing of perioperative errors vary based on whom you ask. The authors estimate that previous studies surveying only the attending physician missed up to 75% of perioperative errors. By finding significant correlations between technical DOCs and prolonged hospital stays and reported and actual delays, this study shows that these surveys provide relevant and useful information for improving clinical practice. Overall, the results of this study emphasize that research on medical error must include input from all members of the operating team; it is only by understanding every perspective that surgical staff can begin to efficiently prevent errors, improve patient care and safety, and decrease delays.

Bacteria-carrying particles (BCPs) shed from surgical staff during surgery are one of the main causes of postoperative surgical site infections (SSIs), and the dynamic nature of personnel during surgery make indoor airflow and the distribution of BCPs complicated and difficult to characterize. To investigate the effect of a circulating nurse walking on the airflow and BCP concentration, the Realizable k-ϵ turbulence model and Lagrangian particle tracking model were adopted and validated using airflow velocity and normalized particle concentration obtained from data obtained in an operating room environment cabin. A walking circulating nurse was described by the dynamic mesh model. It was found that when the circulating nurse was not walking, the surgical lamps and thermal plume of surgical staff had a considerable influence on the airflow, resulting a high BCP concentration. This situation did not change when the circulating nurse walked. With increased walking speed, the disturbance of the airflow by the circulating nurse increased significantly, and the length of the wake behind the circulating nurse became longer. Although the walking of the circulating nurse made no difference to the airflow above the operating table, the BCP concentration above nearby instrument tables increased as the circulating nurse passed, resulting in an increased risk of SSI.

Background: Surgical site infections (SSIs) are a major cause of morbidity and mortality with an estimated cost of $3–10 billion annually in the United States. Laminar air flow in the operating room (OR) is 1 factor in reducing SSIs. Opening the OR door results in interruption of laminar air flow. As a part of annual infection prevention evaluation of our facility, we observed cases in the OR in which we identified excessive unnecessary door openings during surgical cases. We report an intervention in door openings in the OR and the effect on infection rate after surgery. Methods: We conducted an observational analytical study using prospective audit and feedback. Door-opening counters were placed on 4 OR doors. Each day, they were reset and the number was logged for each case by the circulating nurse. A baseline number of door openings was established between April 18, 2019, and May 2, 2019. Subsequently, daily feedback sheets were provided to all persons involved in the previous day’s procedures detailing the rationale to limit unnecessary door openings and the number of door openings that had occurred during the case(s) in which they were specifically involved from May 3, 2019, to June 4, 2019. Analyses of postoperative infection rates compared with historical controls were conducted. Using Stata version 15 statistical software, independent sample t tests were performed to see the difference between control and intervention groups. A CI 95% was set for significance. Results: There were no differences between control and intervention groups with the number of procedures (71 vs 80), OR, duration of procedure, or type of case. Outliers due to vibration of doors triggering the counters were removed, and door stabilizations were performed throughout the study. After removing outliers, there were no differences in control groups and interventions groups (39 vs 43). An independent sample t test showed a significant difference in the mean number of door openings between the control and intervention groups: 32.13 versus 24.84 (P < .05 and P = .0072). There have been no postoperative infections in any of the cases in the study to date compared to an overall annual rate of 1.5% in 2018 at our facility. Conclusions: Prospective audit and feedback to OR staff can reduce the number of unnecessary door openings during operating procedures. The baseline number of door openings from this study was 25 per case. No postoperative infections occurred in the patients receiving surgery in this study.Funding: NoneDisclosures: None

Medical equipment is implemented in highly complex hospital environments, such as operating rooms, in hospitals around the world. In operating rooms (ORs), technological equipment is used for surgical activities and activities in support of surgeries. The implementation of government policies in hospitals has resulted in varying implementation activities for (medical) equipment. These result in varying lead times and success rates. An integral and holistic protocol for implementation does not yet exist. In this study, we introduce a protocol for the implementation of (medical) equipment in ORs that consists of implementation factors and implementation activities. Factors and activities are based on data from a systematic literature review and an explorative survey among surgical support staff on factors for the successful implementation of technological and (medical) equipment in ORs. The protocol consists of five factors and related implementation activities: the establishment of a project plan, organisational preparation, technological preparation, maintenance, and training.

Verbal orders in the operating room between the surgeon and circulating nurse are prevalent at many institutions. We present a case in which a communication breakdown involving a verbal order resulted in the patient receiving an excessively high dose of epinephrine via subcuticular infiltration. The overdose was quickly identified by an increase in T-wave amplitude on electrocardiogram (ECG). The hemodynamic changes were treated, and the patient suffered no long-term sequelae. This report emphasizes the need to have strategies in place to prevent medication errors.

Objective Quantifying non-routine events (NREs) assists with identify underlying sociotechnical factors that could lead to adverse events. NREs are considered any event that is unusual or atypical during surgical procedures. This study aimed to use prospective observations to characterize the occurrence of non-routine events in gynecological surgeries. Methods Observational data were collected prospectively within one surgical gynecology department over a five month period. Researchers captured NREs in real time using a validated tablet PC-based tool according to the NRE type, impact, whom was affected, and duration. Researchers also noted what surgical approach (i.e. open, laparoscopic, robotic) was used. Results Across 45 surgical cases, 554 non-routine events (M = 12.31 NREs per case, SD = 9.81) were identified. The majority of non-routine events were external interruptions (40.3%), teamwork (26.7%), or equipment (21.3%). The circulating nurse was most frequently affected by NREs (43.2%) followed by the entire surgical team (13.7%). There was no statistically significant difference in non-routine events based on surgical approach. Conclusion Non-routine events are prevalent in the gynecological surgical setting. Identifying the sociotechnical factors that influence non-routine events are important in determining interventions that will combat the associated risks. Interventions focusing on teamwork, managing external interruptions, and coordinating equipment may have the greatest impact to reduce or eliminate NREs in gynecological surgeries.

Operating Rooms (OR’s) are complex, high tech environments with extensive use of medical equipment and information technology. The implementation of new medical equipment with the aim to increase safety, improve patient outcomes or to improve efficiency may initially cause disruptions in the OR, which influence its success. Between and within hospitals the implementation of medical equipment varies and a generic implementation model omits. The aim of this study is to identify factors for successful implementations according to surgical supportive staff. Results are compared with findings from other published studies. In total 90 out of 235 surveys were returned (38%). Respondents, scrub nurses and circulating nurses, indicate that implementation and integration of new medical equipment in current activities and ICT systems remain a challenge. In this study we identified the following factors: a coherent and holistic implementation approach; integration of medical equipment in processes, systems and organization; knowledge and skill development and effective communication during the implementation process.

Aseptic practices prevent exposure of a surgical wound to microbes, operating theatre environment and personnel. The circulating nurse assists the operating theatre personnel and supervises aseptic practices preventing surgical site infections. In the absence of analytical tools, few studies exist on intraoperative nursing-related aseptic practices. This study introduces recommendations to assess the role of the circulating nurse in aseptic practices. The authors used international recommendations and research findings to construct a 20-item self-report instrument with a demonstrated reliability across the scale. The authors structured the scale based on three phases: establishment; maintenance; and disestablishment of a sterile operating field. The tool was tested among operating theatre and day surgery nurses, and compared the differences in the mean acceptance rates of aseptic practice recommendations based on background characteristics. College-level nurses and nurses with 15 or more years’ work experience accepted the recommendations at higher levels than bachelor-level nurses and nurses with less work experience. Continual assessment of the evidence base and comprehensive evaluation represent important components in further developing the tool. A reasonable number of items covering clinical practice are necessary for assessing the effectiveness and cost-effectiveness of aseptic practices, and a larger response rate is needed to validate the tool in future.

Aim: To assess how the adjacencies of functionally different areas within operating rooms (ORs) can influence the circulating nurse’s (CN) workflow patterns and disruptions. Background: The CN plays a significant role in promoting patient safety during surgical procedures by observing, monitoring, and managing potential threats at and around the surgical field. Their work requires constant movement to different parts of the OR to support team members. The layout of the OR and crowded and cluttered environment might impact the CN’s workflow and cause disruptions during the surgery. Method: A convenience sample of 25 surgeries were video recorded and thematically coded for CN’s activities, locations, and flow disruptions. The OR layout was categorized into transitional zones and functional zones (workstations, supply zones, support zones, and sterile areas around the surgical table). CN’s activities were classified into patient-, equipment-, material-, and information-related activities. Flow disruptions included those related to environmental hazards and layout. Results: The CN traveled through multiple zones during 91% of the activities. The CN’s workstation acted as a main hub from which the CN made frequent trips to both sides of the surgical table, the foot of the OR table, supply zones, and support zones. Transitional zones accounted for 58.3% of all flow disruption that the CN was involved in whereas 28% occurred in areas surrounding the OR bed. Conclusion: The similarity of the movement and flow disruption patterns, despite variations in OR layout, highlighted the adjacencies required between major zones that CNs regularly visit. These optimum adjacencies should be considered while designing ORs such that they are more efficient and safer.

In the transition of a patient from the operating room (OR) to the postanesthesia care unit (PACU), it was hypothesized that (1) standardizing the members of sending and receiving teams and (2) requiring a structured handoff process would increase the overall amount of patient information transferred in the OR-to-PACU handoff process.A prospective cohort study was conducted at a 311-bed freestanding academic pediatric hospital in Northern California. The intervention, which was conducted in February-March 2013, consisted of (1) requiring the sending team to include a surgeon, an anesthesiologist, and a circulating nurse, and the receiving team to include the PACU nurse; (2) standardizing the content of the handoff on the basis of literature-guided recommendations; and (3) presenting the handoff verbally in the I-PASS format. Data included amount of patient information transferred, duration of handoff, provider presence, and nurse satisfaction.Forty-one audits during the preimplementation phase and 45 audits during the postimplementation phase were analyzed. Overall information transfer scores increased significantly from a mean score of 49% to 83% (p.0001). Twenty-two PACU nurse satisfaction surveys were completed after the preimplementation phase and 14 surveys were completed in the postimplementation phase. Paired mean total satisfaction scores increased from 36 to 44 (p =. 004). The duration of the handoffs trended downward from 4.1 min to 3.5 min (p = 0.10).A standardized, team-based approach to OR-to-PACU handoffs increased the quantity of patient information transferred, increased PACU nurse satisfaction, and did not increase the handoff duration.

The physical environment affects how work is done in operating rooms (OR). The circulating nurse (CN), in particular, requires access to and interacts with materials, equipment, and technology more than other OR team members. Naturalistic study of CN behavior is therefore valuable in assessing how OR space and physical configuration influences work patterns and disruptions. This study evaluated the CNs' work patterns and flow disruptions (FD) by analyzing 25 surgeries across three different ORs. The OR layouts were divided into transitional and functional zones, and the work of CNs was categorized into patient, equipment, material, and information tasks. The results reveal that information tasks involve less movement than other types of work, while across all ORs, CNs were more likely to be involved in layout and environmental hazard FDs when involved in patient, material, or equipment-related tasks compared to information tasks. Different CN work patterns and flow disruptions between ORs suggest a link between OR layout and a CN's work. Future studies should examine how specific layout elements influence outcomes.

This chapter provides a conservative estimate of the likely incidence of intraoperative failures in orthopaedic surgery across the UK. Surgery sits at the apex of the healthcare service, which makes it ideal for understanding both human error and the systemic properties that predispose error, since the sources of problems observed inside the operating theatre can often be attributed to deficient elements of the system. Total knee replacement (TKR) surgery is an elective and proceduralized operation usually involving two surgeons, an anaesthetist, a scrub nurse, a circulating nurse and an anaesthetic nurse. To prepare for the observations, ten similar cases were studied by both researchers before data collection began, and a task analysis and procedural-based error-capture checklists were produced for TKR operations. Observing small, recurrent problems in the operating theatre makes it possible to identify prospectively latent failures within the system which are regularly mitigated for, but occasionally cause harm.

Objective: We attempt to explore the effect of accurate angle of healthy side upper limb on body posture in radical mastectomy. Methods: We enrolled 150 patients who received radical mastectomy in our hospital and averagely randomized them into three groups: control group A, control group B and observation group. In control group A, the intraoperative abduction angle of healthy side upper limb was 90°, in control group B it was 0°, and observation group 75-80°. We scored the comfort level of the healthy side upper limb of patients in three groups prior to anesthesia induction and 24 hours after operation. At the end of operation, we scored the first assistant surgeon’s, anesthetist’s and circulating nurse’s satisfaction with standing space, the convenience of intravenous administration and convenience of observing transfusion during operation respectively. Results: There was significant difference in the comfort level between observation group and control group A, B (P 0.05). Anesthetist’s satisfaction with the convenience of intravenous administration during operation was 100% in observation group and control group A while it was 36% in control group B. There was a significant difference (P

Medical equipment is implemented in highly complex hospital environments, such as operating rooms, in hospitals around the world. In operating rooms (ORs), technological equipment is used for surgical activities and activities in support of surgeries. The implementation of government policies in hospitals has resulted in varying implementation activities for (medical) equipment. These result in varying lead times and success rates. An integral and holistic protocol for implementation does not yet exist. In this study, we introduce a protocol for the implementation of (medical) equipment in ORs that consists of implementation factors and implementation activities. Factors and activities are based on data from a systematic literature review and an explorative survey among surgical support staff on factors for the successful implementation of technological and (medical) equipment in ORs. The protocol consists of five factors and related implementation activities: the establishment of a project plan, organisational preparation, technological preparation, maintenance, and training.

Objetivo: Investigar a perspectiva do circulante de sala operatória sobre a contagem cirúrgica para a segurança dos pacientes. Método: Estudoexploratório, qualitativo, realizado em um centro cirúrgico de um hospital de grande porte do Nordeste do Brasil, entre janeiro e março de 2018. Foi realizadaAnálise de Conteúdo das entrevistas realizadas com 11 circulantes de sala operatória por saturação teórica. Resultados: As falas foram organizadasem duas categorias temáticas — “Contagem cirúrgica para a segurança do paciente” e “Falhas no protocolo de contagem cirúrgica” — , revelando quea mudança da prática deve ser investida, visto que a maioria entende ou reconhece a importância da contagem cirúrgica para os pacientes. Conclusão:Há o reconhecimento empírico da relevância da contagem cirúrgica, devendo ser reforçada por meio de ações que garantam a compreensão da dimensãoe a repercussão dessa prática na segurança dos pacientes.

Equipment and personnel contribute to the overall noise level in the operating room (OR). This study aims to determine intraoperative noise levels during percutaneous nephrostolithotomy (PCNL) and the effects of this noise upon intraoperative communication.A PCNL benchtop model was used to measure intraoperative noise and determine its effect upon communication in three progressively increasing sound environments (baseline ambient noise, ambient noise with PCNL equipment, and ambient noise with both PCNL equipment and music). Five trials with 20 different medical words/phrases were spoken by the surgeon and responses were recorded by the first assistant, anesthesiologist, and circulating nurse. In addition, noise levels during PCNL were compared to common environmental noise levels.In the bench top model, noise levels were 53.49 A-weighted decibels (dBA) with ambient noise, 78.79 dBA with equipment in use, and 81.78 dBA with equipment and music. At the ambient noise level, the first assistant, anesthesiologist, and circulator correctly recorded 100%, 100%, and 96% of the words, respectively. The correct response rate by the subjects decreased to 97% (p = 0.208), 81% (p = 0.012), and 56% (p 0.001) upon addition of PCNL equipment, and 90% (p = 0.022), 48% (p = 0.002), and 13% (p 0.001) upon addition of music and PCNL equipment in the first assistant, anesthesiologist, and circulator, respectively. In the simulated OR model, PCNL noise level (81.78 dBA) was comparable to a passing freight train at 30 feet (82.2 dBA, p = 0.44).Noise pollution decreases effective intraoperative communication during PCNL. It is important for surgeons to understand the effect noise can have on attempted communication to prevent errors due to miscommunication. In addition, methods to decrease intraoperative noise pollution and improve communication in the OR could improve patient safety and outcomes.

BACKGROUNDHealthcare provider hands are an important source of intraoperative bacterial transmission events associated with postoperative infection development.OBJECTIVETo explore the efficacy of a novel hand hygiene improvement system leveraging provider proximity and individual and group performance feedback in reducing 30-day postoperative healthcare-associated infections via increased provider hourly hand decontamination events.DESIGNRandomized, prospective study.SETTINGDartmouth-Hitchcock Medical Center in New Hampshire and UMass Memorial Medical Center in Massachusetts.PATIENTSPatients undergoing surgery.METHODSOperating room environments were randomly assigned to usual intraoperative hand hygiene or to a personalized, body-worn hand hygiene system. Anesthesia and circulating nurse provider hourly hand decontamination events were continuously monitored and reported. All patients were followed prospectively for the development of 30-day postoperative healthcare-associated infections.RESULTSA total of 3,256 operating room environments and patients (1,620 control and 1,636 treatment) were enrolled. The mean (SD) provider hand decontamination event rate achieved was 4.3 (2.9) events per hour, an approximate 8-fold increase in hand decontamination events above that of conventional wall-mounted devices (0.57 events/hour); PP=.626).CONCLUSIONSThe hand hygiene system evaluated in this study increased the frequency of hand decontamination events without reducing 30-day postoperative healthcare-associated infections. Future work is indicated to optimize the efficacy of this hand hygiene improvement strategy.Infect Control Hosp Epidemiol 2016;37:888–895

Background Preprocedural briefings have been adopted in many high consequence environments, but have not been widely accepted in medicine. We sought to develop, implement, and evaluate a preoperative briefing for cardiovascular surgery. Study Design The briefing was developed by using a combined questionnaire and semistructured focus group approach involving five subspecialties of surgical staff (n=55). The results were used to design and implement a preoperative briefing protocol. The briefing was evaluated by monitoring surgical flow disruptions, circulating nurse trips to the core, time spent in the core, and cost-waste reports before and after implementation of the briefing across 16 cardiac surgery cases. Results Focus group data indicated consensus among surgical staff concerning briefing benefits, duration, location, content, and potential barriers. Disagreement arose concerning timing of the brief and the roles of key participants. After implementation of the briefing, there was a reduction in total surgical flow disruptions per case (5.4 preimplementation versus 2.8 postimplementation, p=0.004) and reductions in per case average of procedural knowledge disruptions (4.1 versus 2.17, p=0.004) and miscommunication events (2.5 versus 1.17, p=0.03). There was no significant reduction in disruptions because of equipment preparation or disruptions from patient-related issues. On average, briefed teams experienced fewer trips to the core (10 versus 4.7, p=0.004) and spent less time in the core (397.4 seconds versus 172.3 seconds, p=0.006), and there was a trend toward decreased waste (30% versus 17%, p=0.15). Conclusions These findings demonstrate the feasibility of creating a specialty-specific preoperative briefing to decrease surgical flow disruptions and improve patient safety in the operating room.

Objective We discuss the importance of a “preanesthetic site verification” and highlight 2 significant modifications to a policy developed at our institution in 2003. Case Report The report describes 2 cases of wrong site peripheral nerve blocks that initiated protocol amendments to address shortcomings of the original policy. Two specific limitations were identified to improve upon. First, the practitioner must not overlook the site verification as it is essential prior to every block. Second, time delays between the verification and block performance should be minimized. Conclusions The “preanesthetic site verification” is an integral part of preventing wrong site block and surgery. To ensure that it is carried out before every peripheral nerve block, a unique multidisciplinary approach was adopted in which the block needles were removed from anesthesia carts and transferred to a separate container in the area of the circulating nurse. The anesthesiologist must now request a block needle from the circulating nurse immediately prior to block performance and confirm the site at that time. This safety process emulates the presurgical site verification that takes place before a scalpel is passed to a surgeon. Furthermore, the circulating nurse must remain at the bedside until block initiation to make sure that delays between site verification and block performance do not impinge on correct site placement.

The role of the operating room ‘‘team’’ before, during and after operative laparoscopy has expanded greatly over the past several decades. Minimally invasive surgical treatments for women have expanded to include a multitude of procedures. Although these treatment advances have expanded, so has the role of operating room personnel. As a result of phenomenal visualization, everyone in the operating room can anticipate, participate, and follow laparoscopic procedures from the simplest to the most intricate. The role of the team is more important than ever. Most would agree, the more efficient the team, the better the surgeon, which, in turn, may be directly correlated to the efficacy of the surgical treatment of the patient and ultimately the potential for improved patient outcomes. There is an important continuum with all types of surgery, and operative laparoscopy is no exception. The efficiency of the ‘‘team’’ is dependent on the continuum of care of the patient beginning with the preoperative period, through surgery, and culminating during the postoperative period. The ‘‘team’’ encompasses everyone involved with the care of the patient before, during, and after surgery. Specifically, in all 3 of these areas the team refers to perioperative nurses (to include preoperative nurses, the circulating nurse or nurses, laser nurse when a laser is used, and recovery room or postanesthesia care unit [PACU] nurses), anesthesiologist or anesthetist, surgeon, surgical assistant, surgical technician, and the person who cleans the instruments as well as anyone else involved in the surgery and care of the patient. The key ingredient for the team to be successful is that all these people who are involved in some manner with the care of the patient (either directly or indirectly) work together through effective communication to provide the patient with the best possible surgical experience. This includes a variety of people in the continuum of overall patient care [1–13].

Advances in computer enhancements for surgery, including a voice-activated control system for minimally invasive surgery, are being introduced into clinical practice. Few reports have objectively evaluated the utility of the voice-activated control system. The aim of this study was to evaluate the utility of a voice-activated control system for delivery of commands to specific operating room (OR) equipment.We evaluated a total of 30 laparoscopic procedures: 15 laparoscopic hernia repairs, 10 laparoscopic cholecystectomies, and 5 laparoscopic fundoplications performed with the HERMEStrade mark Operating Room Control Center (Computer Motion, Santa Barbara, California) voice-activated control system. When the voice command (VC) to the HERMES system was given, the circulating nurse was observed and her location was recorded. The 3 locations were A, the nurse was immediately available in the OR, not engaged in any other tasks; B, the nurse was in the OR but engaged in other tasks; or C, the nurse was outside the OR.The 30 cases were performed by the same surgeon and completed laparoscopically. For 170 VCs for gas insufflation, the location of the circulating nurse was: A=50, B=98, and C=22. For 135 light source adjustments, the locations were A=34, B=82, and C=19. In 76 white balance VCs: A=16, B=51, and C=9. In 128 VCs for camera adjustment: A=27, B=77, and C=24. Eight video capture VCs: A=1, B=3, and C=4. For 69 image capture VCs: A=5, B=41, and C=23. The total number of VCs was 586: A=133 (22.7%), B=352 (60%), and C=101(17.3%). All VCs were accurately interpreted by the HERMES system.Voice-activated control systems improve communication with and efficiency of OR staff. The surgeon is afforded the most timely equipment adjustment possible. Circulating nurses are allowed to concentrate on patient care instead of equipment adjustment during the course of the surgery.

ResumoA exposição ocupacional dos profissionais da área de saúde às doenças transmitidas pelo sangue tem sido preocupação crescente. Este estudo prospectivo foi realizado com o objetivo de avaliar a freqüência com que os profissionais que atuam na sala de operações neurocirúrgicas possam ser potencialmente contaminados através de contato direto com o sangue do doente. A ocorrência do contato dos profissionais com o sangue do doente, em 62 operações consecutivas, foi anotada em protocolo pré-estabelecido pela enfermeira da neurocirurgia do centro cirúrgico. O cirurgião foi o elemento da equipe cujo contato evidente com o sangue (através de ferimento perfurocortante ou através de contato cutâneo-mucoso sem ferimento) ocorreu com maior freqüência. Nesse profissional, contatos evidentes ocorreram, pelo menos uma vez, em 19,3% das operações realizadas, um terço deles por meio de ferimentos perfurocortantes. Seguiram-no, em ordem decrescente, a instrumentadora (9,7%) e a enfermeira (6,4%). Nenhum profissional que atua na sala de operações esteve livre do risco.Este estudo demonstrou que a incidência, no cirurgião e na instrumentadora, de pelo menos um episódio de contato direto com o sangue, ou com outro material orgânico contaminado pelo sangue do doente, é elevada. Há, portanto, a necessidade de se dispor de protocolos escritos para notificação imediata das exposições ocupacionais aos patógenos transmitidos pelo sangue do doente. A notificação é importante para que o Serviço de Controle da Infecção Hospitalar da instituição analise os riscos de contágio e, se necessário, institua a profilaxia recomendada. É importante, também, que se adotem medidas, naquele ambiente, visando à prevenção de novos acidentes.

Surgeons inherently favor performing procedures in the operating room. It is the obvious choice since it is a controlled, sterile environment, with the assistance of an anesthesiologist, surgical technician, and circulating nurse. However, through technological advances in the field of intensive care medicine, bringing the operating room to the bedside is becoming more feasible, cost-effective, efficient, and, most importantly, safe. Therefore, surgeons must adapt to this new operating venue if it will provide the best outcome for the patient. This chapter focuses on common procedures performed in the critically ill and the risks and benefits of performing these procedures at the bedside.

Family presence during resuscitation (FPDR) is a growing trend in many areas of health care facilities, and it may be time to consider allowing FPDR in the OR as well. Health care providers cite concerns against FPDR, however, including psychological trauma of family members, medical litigation, performance anxiety of staff members affecting performance quality, team member distractions, problems maintaining sterility, and questions regarding a patient's right to FPDR. The circulating nurse may be an appropriate person to advocate for the patient's wishes to allow family members access to the OR during resuscitation efforts. Two hospitals in Spokane, Washington, have implemented a hospital-wide FPDR policy, allowing family presence in the emergency department, trauma rooms, labor and delivery rooms, and on patient care floors. Committee members developed guidelines for FPDR in the OR, educated hospital staff members, and presented the concept of FPDR to surgery executive committee members.

Robotic-assisted surgery using the da Vinci® Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) has rapidly expanded in the field of urologic surgery. Although originally reported for use during radical prostatectomy, the last decade has witnessed expansion of its use in both the lower and upper urinary tract. With the rapid growth and expansion of urologic robotic surgery comes the need for proper training of both surgeon and surgical team. This includes a thorough understanding of the various currently available robotic platforms, instrumentation, operating room configuration, robot setup and breakdown processes. In addition, each member’s precise role must be clearly defined including the surgeon, surgical assistant(s), anesthesiologist, scrub technician, and circulating nurse.

As surgery needs have increased, the traditional surgical team has expanded to include personnel from radiology and perfusion services. A new surgical team member, the intraoperative monitoring technician, is needed to perform intraoperative monitoring during procedures that carry a higher risk of central and peripheral nerve injury. Including the intraoperative monitoring technician on the surgical team can create challenges, including surgical delays and anesthesia care considerations. When the surgical team members, including the surgeon, anesthesia care provider, and circulating nurse, understand and facilitate this new staff member's responsibilities, the technician is able to perform monitoring functions that promote the smooth flow of the surgical procedure and positive patient outcomes.

To determine the potential rate of intraoperative parenteral exposure of physicians and patients caused by glove perforation during ophthalmic surgery, gloves were analyzed after 125 procedures. Gloves were collected from all surgical team members (surgeon, assistants, scrub nurse, and circulating nurse). The rate of glove perforation was significantly lower for the surgeon, 0.3% (one of 303 gloves) than for the assistants, 5% (ten of 202 gloves [P = .001]), scrub nurses, 16% (52 of 326 gloves [P = .0001]), and circulating nurses, 15% (43 of 293 gloves [P = .0001]); similarly, assistants had a significantly lower rate than did scrub nurses (P = .0001) and circulating nurses (P = .001). There was no statistically significant difference in number of perforations on the basis of surgery duration or type of ophthalmic procedure. These findings suggest that the risk of parenteral exposure during ophthalmic surgery is low for the surgeon, and higher for other surgical personnel. We also analyzed additional safety precautions. Further study is warranted to determine the effectiveness of precautions and to guide policy formulation.

This study was undertaken to quantify the exposure of operating room staff to nitrous oxide during routine paediatric otolaryngeal surgery and to determine the influence of the method of induction of anaesthesia on this exposure. The nitrous oxide exposure of the anaesthetist, the surgeon and the circulating nurse were measured, using body-worn passive atmospheric samplers, during twelve routine paediatric otolaryngeal surgical lists. During six of the lists an inhalational technique, with nitrous oxide, oxygen and halothane, was used for the induction of anaesthesia. During the other six lists anaesthesia was induced using intravenous thiopentone. In all cases, anaesthesia was maintained using nitrous oxide, oxygen and halothane. Regardless of the induction technique used, the mean nitrous oxide exposures of the anaesthetist, the surgeon and the nurse all exceeded the maximum level of 25 ppm · hr−1 recommended by the United States National Institute for Occupational Safety and Health (NIOSH). The use of an intravenous technique for the induction of anaesthesia reduced the nitrous oxide exposure of the anaesthetist and the circulating nurse. This suggests that, although the use of an intravenous induction may reduce exposure to nitrous oxide, the NIOSH recommendations for maximum exposure of operating room personnel to nitrous oxide are currently unattainable in practice.

73-year-old man with a subdural hematoma was scheduled to receive bilateral parietal burr holes. As a result of the patient’s high risk for comorbidities, the procedure was performed with monitored anesthesia care. The anesthesia care provider placed an oxygen mask loosely on the patient’s face, with administration of oxygen at 6 L per minute. The circulating nurse shaved and prepped the patient’s head with a solution of iodoform in 74% isopropyl alcohol. After allowing the solution to dry for two minutes, the surgeon and scrub person draped the patient. The surgeon completed the burr hole procedure on the right side uneventfully. After removing the drapes and repositioning the patient’s head, the circulating nurse prepped and draped the left side in the usual manner. The surgeon then used an electrosurgical monopolar pencil after making the incision. Staff members heard a muffled “pop,” and immediately saw smoke coming from under the drapes. The surgeon quickly removed the drapes from the patient’s head, which was engulfed in flames. The anesthesia care provider turned off the oxygen flow. The fire was immediately controlled. The sequence of events lasted less than 15 seconds; however, the patient’s postoperative period was complicated with a lengthened intensive care unit (ICU) stay of two months before he was discharged to a rehabilitation center. 1

Background Recent publications have focused on increased operating room (OR) throughput without increasing total OR time. The authors hypothesized that a system of parallel processing for lower extremity joint arthroplasties sustainably reduces nonoperative time and increases throughput. Methods The high-throughput parallel processing strategy included neuraxial anesthesia performed in an "induction room" adjacent to the OR, patient selection, an additional circulating nurse, and end-of-case transfer of care to a recovery room nurse who transported the patient from the OR to recovery. Instruments and supplies were prepared in a dedicated sterile setup area. Data were extracted from administrative databases. Group comparisons used standard statistical methods; statistical process control was used to evaluate performance over time. Results There were 688 historic control cases from 299 days over 16 months, and 905 high-throughput cases from 304 days spanning 24 consecutive months starting September 1, 2004. Throughput increased from 2.6 +/- 0.7 (mean +/- SD) to 3.4 +/- 0.8 arthroplasties per day per room. Nonoperative time decreased by 36 min (or 50%) per case. Operative time also decreased by 14 min (12%) per case. The end time for the high-throughput OR day was only 16 min later than control. Nonoperative time, operative time, and throughput remained significantly improved after 2 yr of operation. Contribution margin increased 19.6%. Conclusion Reorganizing the perioperative work process for total joint replacements sustainably increased OR throughput. Because joint arthroplasties generated a positive margin greater than the incremental cost, the high-throughput system improved financial performance.

Occupational exposure to blood borne pathogens has led to HBV, HCV and HIV infections among surgeons, nurses and other operating room (OR) personnel and, to a lesser degree, patients (Ross et al 2000, The incident investigation teams and others 1997). Of seven OR studies in which an observer or circulating nurse recorded exposures, there was a percuataneous injury in 1.7–15% of all surgeries, and a mucocutaneous contamination in 6.2–50% of all surgeries. (Gerberding et al 1990, Panlilio et al 1991, Popejoy & Fry 1991, Quebbeman et al 1991, Tokars et al 1992, Lynch & White 1993, Stringer, Infante-Rivard & Hanley 2002). Surgeons and residents usually sustained the greatest number of percutaneous and other exposures during surgery.