The subject of noise in the operating theatre was recognized as early as 1972 and has been compared to noise levels on a busy highway. While noise-induced hearing loss in orthopaedic surgery specifically has been recognized as early as the 1990s, it remains poorly studied. As a result, there has been renewed focus in this occupational hazard. Noise level is typically measured in decibels (dB), whereas noise adjusted for human perception uses A-weighted sound levels and is expressed in dBA. Mean operating theatre noise levels range between 51 and 75 dBA, with peak levels between 80 and 119 dBA. The greatest sources of noise emanate from powered surgical instruments, which can exceed levels as high as 140 dBA. Newer technology, such as robotic-assisted systems, contribute a potential new source of noise. This article is a narrative review of the deleterious effects of prolonged noise exposure, including noise-induced hearing loss in the operating theatre team and the patient, intraoperative miscommunication, and increased cognitive load and stress, all of which impact the surgical team’s overall performance. Interventions to mitigate the effects of noise exposure include the use of quieter surgical equipment, the implementation of sound-absorbing personal protective equipment, or changes in communication protocols. Future research endeavours should use advanced research methods and embrace technological innovations to proactively mitigate the effects of operating theatre noise. Cite this article:
The burden of revision total hip arthroplasty (rTHA) continues to grow. The surgery is complex and associated with significant costs. Regional rTHA networks have been proposed to improve outcomes and to reduce re-revisions, and therefore costs. The aim of this study was to accurately quantify the cost and reimbursement for a rTHA service, and to assess the financial impact of case complexity at a tertiary referral centre within the NHS. A retrospective analysis of all revision hip procedures was performed at this centre over two consecutive financial years (2018 to 2020). Cases were classified according to the Revision Hip Complexity Classification (RHCC) and whether they were infected or non-infected. Patients with an American Society of Anesthesiologists (ASA) grade ≥ III or BMI ≥ 40 kg/m2 are considered “high risk” by the RHCC. Costs were calculated using the Patient Level Information and Costing System (PLICS), and remuneration based on Healthcare Resource Groups (HRG) data. The primary outcome was the financial difference between tariff and cost per patient episode.Aims
Methods
The National Health Service produces over 500,000 tonnes of waste and 25 mega tonnes of CO2 annually.
Knee arthroscopy with meniscectomy is the third most common Orthopaedic surgery performed after TKA and THA, comprising up to 16.6% of all procedures. The efficiency of Orthopaedic care delivery with respect to waiting times and systemic costs is extremely concerning. Canadian Orthopaedic patients experience the longest wait times of any G7 country, yet perioperative surgical care constitutes a significant portion of a hospital's budget. In-Office Needle Arthroscopy (IONA) is an emerging technology that has been primarily studied as a diagnostic tool. Recent evidence shows that it is a cost-effective alternative to hospital- and community-based MRI with comparable accuracy. Recent procedure guides detailing IONA medial meniscectomy suggest a potential node for OR diversion. Given the high case volume of knee arthroscopy as well as the potential amenability to be diverted away from the OR to the office setting, IONA has the potential to generate considerable improvements in healthcare system efficiency with respect to throughput and cost savings. As such, the purpose of this study is to investigate the cost savings and impact on waiting times on a mid-sized Canadian community hospital if IONA is offered as an alternative to traditional operating room (OR) arthroscopy for medial meniscal tears. In order to develop a comprehensive understanding and accurate representation of the quantifiable operations involved in the current state for medial meniscus tear care, process mapping was performed that describes the journey of a patient from when they present with knee pain to their general practitioner until case resolution. This technique was then repeated to create a second process map describing the hypothetical proposed state whereby OR diversion may be conducted utilizing IONA. Once the respective process maps for each state were determined, each process map was translated into a Dupont decision tree. In order to accurately determine the total number of patients which would be eligible for this care pathway at our institution, the OR booking scheduling for arthroscopy and meniscectomy/repair over a four year time period (2016-2020) were reviewed. A sensitivity analysis was performed to examine the effect of the number of patients who select IONA over meniscectomy and the number of revision meniscectomies after IONA on 1) the profit and profit margin determined by the MCS-Dupont financial model and 2) the throughput (percentage and number) determined by the MCS-throughput model. Based on historic data at our institution, an average of 198 patients (SD 31) underwent either a meniscectomy or repair from years 2016-2020. Revenue for both states was similar (p = .22), with the current state revenue being $ 248,555.99 (standard deviation $ 39,005.43) and proposed state of $ 249,223.86 (SD $ 39,188.73). However, the reduction in expenses was significant (p < .0001) at 5.15%, with expenses in the current state being $ 281,415.23 (SD $ 44,157.80) and proposed state of $ 266,912.68 (SD $ 42,093.19), representing $14,502.95 in savings. Accordingly, profit improvement was also significant (p < .0001) at 46.2%, with current state profit being $ (32,859.24) (SD $ 5,153.49) and proposed state being $ (17,678.82) (SD $ 2,921.28). The addition of IONA into the care pathway of the proposed state produced an average improvement in throughput of 42 patients (SD 7), representing a 21.2% reduction in the number of patients that require an OR procedure. Financial sensitivity analysis revealed that the proposed state profit was higher than the current state profit if as few as 10% of patients select IONA, with the maximum revision rate needing to remain below 40% to achieve improved profits. The most important finding from this study is that IONA is a cost-effective alternative to traditional surgical arthroscopy for medial meniscus meniscectomy. Importantly, IONA can also be used as a diagnostic procedure. It is shown to be a cost-effective alternative to MRI with similar diagnostic accuracy. The role of IONA as a joint diagnostic-therapeutic tool could positively impact MRI waiting times and MRI/MRA costs, and further reduce indirect costs to society. Given the well-established benefit of early meniscus treatment, accelerating both diagnosis and therapy is bound to result in positive effects.
Tissue adhesives (TAs) are a commonly used adjunct to traditional surgical wound closures. However, TAs must be allowed to dry before application of a surgical dressing, increasing operating time and reducing intraoperative efficiency. The goal of this study is to identify a practical method for decreasing the curing time for TAs. Six techniques were tested to determine which one resulted in the quickest drying time for 2-octyle cyanoacrylate (Dermabond) skin adhesive. These were nothing (control), fanning with a hand (Fanning), covering with a hand (Covering), bringing operating room lights close (OR Lights), ultraviolet lights (UV Light), or prewarming the TA applicator in a hot water bath (Hot Water Bath). Equal amounts of TA were applied to a reproducible plexiglass surface and allowed to dry while undergoing one of the six techniques. The time to complete dryness was recorded for ten specimens for each of the six techniques.Aims
Methods
The primary aim of this study was to assess the independent association of the coronavirus disease 2019 (COVID-19) on postoperative mortality for patients undergoing orthopaedic and trauma surgery. The secondary aim was to identify factors that were associated with developing COVID-19 during the postoperative period. A multicentre retrospective study was conducted of all patients presenting to nine centres over a 50-day period during the COVID-19 pandemic (1 March 2020 to 19 April 2020) with a minimum of 50 days follow-up. Patient demographics, American Society of Anesthesiologists (ASA) grade, priority (urgent or elective), procedure type, COVID-19 status, and postoperative mortality were recorded.Aims
Methods
Introduction. While additional resources associated with direct anterior (DA) approach total hip arthroplasty (THA) such as fluoroscopy, staff, and special tables are well recognized, time consumption is not well studied. The purpose of this study was to analyze anesthesia and surgical time in DA and posterior approach THA in a large healthcare system across multiple facilities and surgeons. Methods. 3,155 unilateral primary THAs performed via DA or posterior approaches between 1/1/2017 and 06/30/2019 at nine hospitals and ambulatory surgery centers (ASC) in a large metropolitan healthcare system were retrospectively reviewed. All surgeons were experienced and beyond learning curves. 247 cases were excluded to eliminate confounds.
The COVID-19 pandemic creates unique challenges in the practice of spinal surgery. We aim to show how the use of a high-definition 3D digital exoscope can help streamline workflows, and protect both patients and healthcare staff.
Elective operating was halted during the COVID-19 pandemic to increase the capacity to provide care to an unprecedented volume of critically unwell patients. During the pandemic, the orthopaedic department at the Aneurin Bevan University Health Board restructured the trauma service, relocating semi-urgent ambulatory trauma operating to the isolated clean elective centre (St. Woolos’ Hospital) from the main hospital receiving COVID-19 patients (Royal Gwent Hospital). This study presents our experience of providing semi-urgent trauma care in a COVID-19-free surgical unit as a safe way to treat trauma patients during the pandemic and a potential model for restarting an elective orthopaedic service. All patients undergoing surgery during the COVID-19 pandemic at the orthopaedic surgical unit (OSU) in St. Woolos’ Hospital from 23 March 2020 to 24 April 2020 were included. All patients that were operated on had a telephone follow-up two weeks after surgery to assess if they had experienced COVID-19 symptoms or had been tested for COVID-19. The nature of admission, operative details, and patient demographics were obtained from the health board’s electronic record. Staff were assessed for sickness, self-isolation, and COVID-19 status.Aims
Methods
Despite few good-quality studies on the subject, total hip arthroplasty (THA) is increasingly being performed for displaced intracapsular fractures of the neck of femur. We compared outcomes of all patients with displacement of these fractures treated surgically over a ten-year period in one institution. A total of 2,721 patients with intracapsular fractures of the femoral neck treated with either a cemented hemiarthroplasty or a THA at a single centre were retrospectively reviewed. The primary outcomes analyzed were readmission for any reason and revision surgery. We secondarily looked at mortality rates.Aims
Methods
During the pandemic of COVID-19, some patients with COVID-19 may need emergency surgeries. As spine surgeons, it is our responsibility to ensure appropriate treatment to the patients with COVID-19 and spinal diseases. A protocol for spinal surgery and related management on patients with COVID-19 has been reviewed. Patient preparation for emergency surgeries, indications, and contraindications of emergency surgeries, operating room preparation, infection control precautions and personal protective equipments (PPE), anesthesia management, intraoperative procedures, postoperative management, medical waste disposal, and surveillance of healthcare workers were reviewed. It should be safe for surgeons with PPE of protection level 2 to perform spinal surgeries on patients with COVID-19. Standardized and careful surgical procedures should be necessary to reduce the exposure to COVID-19.
The aim of this study was to assess the influence of the true operating room (OR) ventilation on the risk of revision due to infection after primary total hip arthroplasty (THA) reported to the Norwegian Arthroplasty Register (NAR). 40 orthopedic units were included during the period 2005 – 2015. The Unidirectional airflow (UDAF) systems were subdivided into small-area, low-volume, vertical UDAF (lvUDAF) (volume flow rate (VFR) (m3/hour) <=10,000 and diffuser array size (DAS) (m2) <=10); large-area, high-volume, vertical UDAF (hvUDAF) (VFR >=10,000 and DAS >=10) and Horizontal UDAF (H-UDAF). The systems were compared to conventional, turbulent ventilation (CV) systems. The association between revision due to infection and OR ventilation was assessed using Cox regression models, with adjustments for sex, age, indication for surgery, ASA-classification, method of fixation, modularity of the components, duration of surgery, in addition to year of primary THA. All included THAs received systemic, antibiotic prophylaxis.Aim
Method
Introduction. The practice of overlapping surgery has been increasing in the delivery of orthopaedic care, aiming to provide efficient, high-quality care. However, there have been concerns about the safety of this practice. The purpose of this study is to examine safety and efficacy of a model of partially overlapping surgery that we termed “the swing room” in practice in primary hip and knee arthroplasty. Methods. A retrospective review of prospectively collected data using an administrative database was carried out on patients who underwent primary unilateral total hip and total knee arthroplasty from 2006 to 2017 at two sites of one academic center staffed by four arthroplasty surgeons. All revisions and bilateral primary procedures were excluded. Cases were stratified as overlapping or non-overlapping. Overlapping was defined when a surgeon had access to two operating rooms with two teams, and non-overlapping was defined as when a surgeon only had access to a single operating room on a particular day. Patient demographic characteristics, operating room time, procedure time, length of stay, Postoperative complications within 30 days of the procedure, unplanned hospital readmissions, unplanned reoperations, and emergency department visits were collected. The Fisher's exact Wilcoxon rank-sum test and logistic regression analysis were used for statistical analysis. Results. Of 12,225 cases were performed at our institution, 10600 cases (86.7%) were overlapping, and 1625 cases (13.3%) were non-overlapping. There was no difference in the mean age, sex, BMI, side and length of stay between patients who underwent overlapping surgery and those who underwent non- overlapping surgery.
According to Webster's Dictionary, efficiency is defined as the capacity to produce desired results with a minimal expenditure of energy, money, time, and materials. For a surgeon performing an operative procedure this would mean “skillfulness in avoiding wasted time and effort.” (. www.webster-dictionary.org. ) The essential ingredient to becoming efficient is to promote a culture of efficiency. There are 10 elements: 1) proactive surgeon perspective; 2) effective utilization of preoperative holding area; 3) preoperative planning / templating; 4) development of preference cards; 5) operating room set-up protocols; 6) operating room team concept; 7) streamlined instrument sets; 8) consistent operative workflow; 9) standardised closure / dressings; and 10) prompt and meticulous room turnover. Efficient performance of an operative procedure requires skillfulness in avoiding wasted time and effort. Perioperative efficiencies are optimised by development of “swing,” “flip,” or “double occupancy” criteria, understanding of timing of when to initiate the anesthetic block for the next case, skin closure routine by physician assistant/nurse practitioner/private scrub, and marking the operative site of your first two patients upon arrival to the hospital or surgery center. Utilise a pro-active approach to prepare case carts the day before surgery. The operating room team turns over their own rooms, with a “clean as you go” mentality. Develop a formalised communication process for patient flow issues, such as real-time push-to-talk group calling phones. Determine in advance the number of instrument sets required for the day's caseload to mitigate flash sterilization and decrease room turnover time. The goal of the surgeon is to be out of the operating room for 5 minutes in between cases before the next incision, utilizing that time to enter orders, communicate with the family, dictate, and mark the operative site of the patient who will follow the one in the case about to start. Implant selection can help if consistent. Everyone must know the instrument trays including surgeon, scrubs, and nurses. Minimise both the number of trays and the redundancy of instrumentation. Templating should be done in advance of the day of surgery. Keep your surgery consistent and always deliver your best product. The workflow for inpatient and outpatient surgeries should be the same: same implant, same approach, and same closure. The culture of efficiency requires buy-in by all involved in the operative procedure. Every one entering the operating theatre should have proper body coverage – no hair visible, no nose visible. There should be a strict limit to needless activity: minimum opening of doors, no changing of personnel during an operation, and use of intercom/telephone to request equipment. As the surgeon and the team begin to embrace efficiency, surgical times will decrease. Multiple studies have demonstrated that increased surgical time is associated with a higher incidence of infection. This is secondary to time-dependent contamination of the surgical wound and field. The take home message is to develop and embrace efficiency.
Introduction. Total knee arthroplasty is a highly effective procedure to improve the quality of life in patients with advanced osteoarthritis. The number of these procedures are expected to grow 174% by 2030. This growth rate is expected to economically strain the health care system. A potential solution to alleviate this problem is the utilization of single use instruments (SUI). Potential advantages of SUI include: improved operating room efficiencies, decreased costs associated with traditional instrument management (sterile processing, shipping), and decreased infection risk. The present study examines the clinical results of SUI compared to standard instrumentation. Furthermore, economic modeling is performed to examine the cost savings that is potentially realized with their use. Materials and Methods. 51 patients receiving a TKA with use of SUI were prospectively compared to 49 patients utilizing standard instrumentation. Knee Society Scores and Radiographic alignment will be evaluated. Adverse events will be recorded. Economic modeling of SUI will be performed in 4 different areas: 1. Decreased infection burden; 2.
Prosthetic joint infection (PJI) remains a serious complication that is associated with high morbidity and costs. The aim of this study was to prepare a systematic review to examine patient-related and perioperative risk factors that can be modified in an attempt to reduce the rate of PJI. A search of PubMed and MEDLINE was conducted for articles published between January 1990 and February 2018 with a combination of search terms to identify studies that dealt with modifiable risk factors for reducing the rate of PJI. An evidence-based review was performed on 12 specific risk factors: glycaemic control, obesity, malnutrition, smoking, vitamin D levels, preoperative Aims
Materials and Methods
Trainees experience significant stress in the operating room, with potentially adverse effects on performance and learning. Psychological resilience explains why some individuals excel despite significant stress, meeting challenges with optimism and flexibility. The purpose of this study was to explore the relationships between trainee resilience, intraoperative stress, and desire to leave residency training. Qualitative focus groups and a literature review were used to develop a new instrument to assess Surgical TRainee Experiences of StresS in the
One method of surgical site infection prevention is lowering intraoperative environmental contamination. We sought to evaluate our hospitals operating room (OR) contamination rates and compare it to the remainder of the hospital. We tested environmental contamination in preoperative, intraoperative and postoperative settings of a total joint arthroplasty patient. 190 air settle plates composed of trypsin soy agar (TSA) were placed in 19 settings within our hospital. Locations included the OR with light and heavy traffic, with and without masks, jackets, and shoe covers, sub-sterile rooms, OR hallways, sterile equipment processing center, preoperative areas, post-anesthesia care units, orthopaedic floors, emergency department, OR locker rooms and restrooms, a standard house in the local community, and controls. The plates were incubated in 36 degrees celsius for 48 hours and colony counts were recorded. Numbers were averaged over each individual area.Introduction
Materials & Methods
Nowadays, foot switches are used in almost every operating theatre to support the interaction with medical devices. Foot switches are especially used to release risk-sensitive functions of e.g. the drilling device, the high-frequency device or the X-ray C-arm. In general, the use of foot switches facilitates the work, since they enable the surgeon to use both hands exclusively for the manipulation within the operation procedures. Due to the increasing number of (complex) devices controlled by foot switches, the surgeons face a variety of challenges regarding usability and safety of these human-machine-interfaces. In the future, the approach of integrated medical devices in the OR on the basis of the open communication standard IEEE 11073 gives the opportunity to provide a central surgical cockpit with a universal foot switch for the surgeon, enabling the interaction with various devices different manufacturers. In the framework of the ongoing OR.NET initiative founded on the basis of the OR.NET research project (2012–2016) a novel concept for a universal foot switch (within the framework of a surgical workstation) has been developed in order to optimise the intraoperative workflow for the OR-personnel. Here, we developed three wireless functional models of a universal foot switch together with a standardised modular interface for visual feedback via a central surgical cockpit display. Within the development of our latest foot switch, the requirements have been inter alia to provide adequate functionalities to cover the needs for the interventions in the medical disciplines orthopaedic surgery, neurosurgery and ENT. The evaluation has been conducted within an interaction-centered usability analysis with surgeons from orthopaedics, neurosurgery and ENT. By using the Thinking Aloud technique in a Wizard-of-Oz experiment the usability criteria effectiveness, learnability and user satisfaction have been analysed. Regarding learnability 83.25% of the subjects stated that the usage of the universal foot switch is easy to learn. An average of 77,2% of users rated the usability of the universal foot switch between good and excellent on the SUS scale. The intuitiveness of the graphical user interface has been approved with 91.75% and the controllability with 83.25%. Finally, 86% of the subjects stated a high user satisfaction.
The World Health Organization (WHO) and the Centre
for Disease Control and Prevention (CDC) recently published guidelines
for the prevention of surgical site infection. The WHO guidelines,
if implemented worldwide, could have an immense impact on our practices
and those of the CDC have implications for healthcare policy in
the United States. Our aim was to review the strategies for prevention of periprosthetic
joint infection in light of these and other recent guidelines. Cite this article:
