How many parents should we let into the operating room?

Objective:  This study compared anxiety of children with one and two parents present at anesthesia induction.
Methodology:  Baseline measures of parent and child anxiety were obtained; parents were randomly assigned to the two study groups. Validated and reliable tools were used to assess the outcomes of interest.
Results:  We found that observed anxiety of children as well as compliance of children with the induction process was not different between the two study groups. Parent's anxiety was also evaluated using two-way anova with repeated measures. A group by time interaction was demonstrated and parents in the one-parent group reported significantly higher anxiety than parents in the two-parents group ( M  = 48.6, sd  = 13.1 vs M  = 39.7, sd  = 11.5, P  < 0.02).
Conclusions:  We conclude that while allowing two parents into the operating rooms does not affect observed child anxiety, it does reduce parent self-reported anxiety. As the presence of multiple parents during invasive medical procedures is in congruence with family centered-care we recommend that institutions examine this modality.     

How often do patients return to the operating room after colorectal resections?

Aim We sought to identify the rate of re‐operation after an index colorectal surgical procedure and potential contributing risk factors. Method This is a retrospective cohort study from the American College of Surgeons National Surgical Quality Improvement Program. We identified all patients who either returned or did not return to the operating room after any colorectal resection from January 2005 to December 2008. Results From a total cohort of 635 265 patients included in the National Surgical Quality Improvement Program over the 4‐year study period, we identified 54 237 patients who underwent colorectal operations. A return to the operating room was coded in 5.4 ± 0.1% of non colorectal resection patients and 7.6 ± 0.2% of colorectal resection patients (P < 0.001). The multivariate model identified patients with postoperative diagnostic codes for abdominal cavity hernia or colostomy complication as having the highest odds of return to the operating room within 30 days. Patients returning to the operating room had longer length of stay and higher overall mortality compared with those patients who did not return to the operating room. Conclusion Return to the operating room is a relatively common occurrence after colorectal resections, with an associated high rate of mortality. Given the association between return to the operating room and adverse patient outcomes, emphasis should be placed on determining strategies to reduce the need for return to the operating room.     

Repairing interatrial septal defects from the operating room to the cardiac catheterization laboratory: 2D or not 2D?

Uncorrected congenital interatrial septal defect can be found in nearly a third of all adults and are associated with significant morbidity, including pulmonary hypertension, right-heart failure, atrial arrhythmias, and paradoxical embolic stroke. With advancing technology, percutaneous closure of atrial septal defects has become a viable alternative to open surgical repair. In this review, the authors provide 3 examples in which 3-dimensional interventional transesophageal echocardiogram effectively provided more precise visualization of the dynamic surface and geometry of the atrial septum and related structures than 2-dimensional TEE, permitting accurate sizing and repair of the defects.     

Are basic robotic surgical skills transferable from the simulator to the operating room? A randomized,prospective, educational study

IntroductionWe aimed to assess the transferability of basic robotic skills from the simulator to the operating room (OR) while performing robotic-assisted radical prostatectomy (RARP).MethodsFourteen urology residents were randomized into two groups: group A was required to practice three sessions (nine tasks each) on the simulator, whereas group B was required to practice (same nine tasks) until they reached competency. Both groups were recorded while practicing on the da Vinci Surgical Skills Simulator. Both groups were then recorded while performing bladder mobilization during RARP. Senior residents from both groups were also recorded while performing urethro-vesical anastomosis during RARP. Recordings were assessed blindly using the validated Global Evaluative Assessment of Robotic Skills (GEARS) tool by C-SATS. Spearman’s correlation coefficient (rho) was used to assess correlation between GEARS scores from practice sessions on the da Vinci Simulator and the GEARS scores from bladder mobilization and urethro-vesical anastomosis during RARP.ResultsThere was no difference in total GEARS scores between the two groups in the OR. Total GEARS scores for “ring and rail 2” and “suture sponge” tasks correlated with the total GEARS scores during urethro-vesical anastomosis (rho=0.86, p=0.007; rho=0.90, p=0.002, respectively). GEARS’ efficiency component during “energy and dissection” task on the da Vinci Simulator correlated with GEARS’ efficiency component during bladder mobilization (rho=0.62, p=0.03). GEARS’ force sensitivity component during “ring and rail 2” and “dots and needles” tasks on the da Vinci Simulator correlated with GEARS’ force sensitivity component during bladder mobilization (rho=0.58, p=0.047; rho =0.65, p=0.02, respectively).ConclusionsObjective assessments of urology residents on the da Vinci Surgical Skills Simulator tasks ring and rail 2 and suture sponge correlated with their objective assessments of bladder mobilization and urethro-vesical anastomosis. Therefore, basic robotic skills could be transferred from the simulator to the OR.     

Can we make airway management (even) safer?--lessons from national audit

The Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society (NAP4) has published an extensive report examining both current practices in the United Kingdom regarding airway management during anaesthesia and the complications of airway management during anaesthesia and in intensive care units and emergency departments. The report makes more than 160 recommendations designed to improve care of patients. These recommendations have implications for individuals, departments, organisations and potentially for national policy in terms of training, standards of practice and the need for guidelines. The report also indicates several specific areas where future research might be directed. This article focuses on the implementation phase of NAP4, emphasising the importance of taking the lessons derived from NAP4 and turning them into actions to improve the safety of airway care delivered to patients, wherever in hospital this takes place.     

Is unplanned return to the operating room a useful quality indicator in general surgery?

HYPOTHESIS: To test our hypothesis that unplanned return to the operating room (OR) is a useful quality indicator, we examined how often and for what reasons patients go back to the OR in a broad-based general surgery practice. DESIGN AND SETTING: Prospective cohort study at a rural tertiary care center. PATIENTS: Consecutive series of 3044 patients undergoing general surgery procedures in the OR between September 1, 1998, and March 31, 2000. Information about all postoperative adverse events occurring before discharge or within 30 days (whichever was longer) was collected prospectively. Unplanned return to the OR was defined as any secondary procedure required for a complication resulting directly or indirectly from the index operation. MAIN OUTCOME MEASURES: Unplanned return to the OR, mortality, and hospital charges. RESULTS: Overall, 107 (3.5%) had an unplanned return to the OR. A relatively small number of inpatient procedures accounted for a disproportionate share of unplanned reoperations, including colon resection (18% of total reoperations), renal transplant (9%), gastric bypass (6%), and pancreatic resection (6%). As expected, hospital charges were markedly higher for patients with unplanned returns to the OR. Reoperation was also associated with higher mortality rates; statistically significant increases were noted for pancreatic resection (33% vs 3.7%; P =.04), esophagogastrectomy (100% vs 4.2%; P =.002), and laparoscopic Nissen fundoplication (50% vs 0%; P =.01). Overall, 91 reoperations (85%) were for complications occurring at the original surgical site, including those related to an anastomosis (n = 16), surgical wound (n = 21), infection (n = 16), bleeding (n = 12), and other (n = 26). CONCLUSIONS: Unplanned returns to the OR occur across a broad spectrum of general surgical procedures and carry significant implications. Because they most often reflect problems related to the procedure itself, reoperation rates may be useful for monitoring quality across hospitals and for identifying opportunities for quality improvement locally.     

Can we make postoperative patient handovers safer? A systematic review of the literature

Postoperative patient handovers are fraught with technical and communication errors and may negatively impact patient safety. We systematically reviewed the literature on handover of care from the operating room to postanesthesia or intensive care units and summarized process and communication recommendations based on these findings. From >500 papers, we identified 31 dealing with postoperative handovers. Twenty-four included recommendations for structuring the handover process or information transfer. Several recommendations were broadly supported, including (1) standardize processes (e.g., through the use of checklists and protocols); (2) complete urgent clinical tasks before the information transfer; (3) allow only patient-specific discussions during verbal handovers; (4) require that all relevant team members be present; and (5) provide training in team skills and communication. Only 4 of the studies developed an intervention and formally assessed its impact on different process measures. All 4 interventions improved metrics of effectiveness, efficiency, and perceived teamwork. Most of the papers were cross-sectional studies that identified barriers to safe, effective postoperative handovers including the incomplete transfer of information and other communication issues, inconsistent or incomplete teams, absent or inefficient execution of clinical tasks, and poor standardization. An association between poor-quality handovers and adverse events was also demonstrated. More innovative research is needed to define optimal patient handovers and to determine the effect of handover quality on patient outcomes.