Surgery

Labelling of Fluids in the Sterile Field During Orthopaedic Surgery: A Quality Improvement Initiative (2024)

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Type of publication:

Journal article

Author(s):

Sweetman, Benedict; *Younis, Zubair; Khan, Sarfraz; Amin, Jebran; Mohammed, Ghulam Dastagir Faisal; Jones, Ellen Ellysia; Lemaigre, Charlotte; Pydah, Satya.

Citation:

Cureus. 16(10):e72250, 2024 Oct.

Abstract:

Background Intraoperative safety protocols, including proper labelling of syringes, are critical to patient safety in surgical settings. While the Royal Pharmaceutical Society and the Royal College of Anaesthetists provide clear guidelines to prevent medication errors, ensuring consistent compliance with labelling protocols in the fast-paced and complex environment of orthopaedic surgery can still present practical challenges. The absence of proper labelling, combined with the use of multiple fluids such as normal saline, disinfectants, and local anaesthetics, increases the risk of adverse outcomes due to fluid misidentification. This quality improvement project aimed to assess current labelling practices in a district general hospital, identify barriers to compliance, and develop a cost-effective solution. Methodology The project was conducted in three orthopaedic theatres over two audit cycles. During the first audit cycle, 30 procedures were observed to assess compliance with labelling guidelines. Compliance was defined as the labelling of all syringes containing fluids present in the sterile field. Following this, an intervention was introduced, using surgical marker pens and sterile stickers for fluid labelling, along with a mandatory "tactical pause and check" and an awareness campaign. Two months later, a second audit of 34 procedures was conducted to evaluate the effectiveness of the intervention. Results In the first audit cycle, only three out of 30 procedures (10%) were compliant with labelling guidelines. Following the intervention, compliance increased dramatically to 32 out of 34 procedures (94%). The results were statistically significant (p < 0.05) as determined by Fisher's exact test. The use of sterile stickers and marker pens proved to be a simple and cost-effective solution that did not interfere with the sterile environment or increase costs. Conclusions This study demonstrates that a low-cost intervention using sterile stickers and surgical marker pens can significantly improve compliance with fluid labelling guidelines in orthopaedic surgery, thereby enhancing patient safety. While the intervention was successful, future research should explore more sustainable solutions, such as pre-printed sterile labels, and evaluate the long-term impact of such interventions across various surgical settings. Continuous education and regular audits will be essential in maintaining high compliance rates.

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An overview of cell salvage in orthopaedic hip and knee arthroplasty surgery (2024)

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Type of publication:

Journal article

Author(s):

*Patel, Ravi; Golding, Steven; Nandra, Rajpal; Banerjee, Robin.

Citation:

Journal of Perioperative Practice. 2024 Nov 12.[epub ahead of print]

Abstract:

Blood management is a critical aspect of patient care during surgical procedures. In the United Kingdom, there is a growing recognition of the need to integrate intraoperative cell salvage into blood management protocols, especially for invasive surgeries where significant blood loss is anticipated. While donated blood (allogeneic blood) is traditionally used in such cases, it carries risks and potential complications. Consequently, intraoperative cell salvage presents itself as an appealing alternative, particularly in hip and knee arthroplasty procedures. Intraoperative cell salvage involves the collection and reinfusion of a patient's own blood (autologous blood) lost during surgery. Studies have consistently shown that autologous blood collected via intraoperative cell salvage has fewer complications and greater benefits compared to donated blood. However, despite these advantages, the widespread adoption of intraoperative cell salvage in UK hospitals remains limited, primarily due to associated costs. While the integration of intraoperative cell salvage into blood management services may incur initial expenses, research suggests that it could ultimately prove to be cost-effective. This is because improved patient outcomes associated with intraoperative cell salvage may lead to reduced postoperative complications and shorter hospital stays. Thus, there is a growing imperative to overcome financial barriers and promote the implementation of intraopertive cell salvage as a standard practice in perioperative care across UK health care settings. The purpose of this scoping literature review is to consolidate the available information on the current use of intraoperative cell salvage and to identify intraoperative cell salvage techniques and devices described for use in an arthroplasty setting.

A systematic review of ultrasonography-guided transcutaneous fine needle aspiration cytology in the diagnosis of laryngeal malignancy (2024)

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Type of publication:

Journal article

Author(s):

Ahmed, A; *Yang, D; *Eastwood, M; *Saunders, T; *Ahsan, S F.

Citation:

Annals of the Royal College of Surgeons of England. 2024 Nov 15.

Abstract:

INTRODUCTION: Direct laryngoscopy and biopsy is the gold standard for obtaining a tissue diagnosis in patients with suspected laryngeal cancer. In patients with advanced disease or other medical comorbidities, this may come with significant anaesthetic risks, including tracheostomy. Ultrasonography-guided biopsy has been widely used in the diagnosis of malignancy involving cervical lymph nodes but it is not commonly employed in the diagnosis of laryngeal tumours. A systematic review was undertaken to assess the literature looking at whether ultrasonography-guided transcutaneous fine needle aspiration cytology (FNAC) is an adequate method in diagnosing laryngeal malignancy.

METHODS: Two independent researchers conducted a systematic review of the literature using the MEDLINE and Cochrane Library databases in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines.

RESULTS: A total of 568 studies were identified from the search, of which 3 met the inclusion criteria, resulting in 162 patient episodes. The pooled accuracy of transcutaneous FNAC in acquiring a sample adequate for histological diagnosis was 74.9%. Data on complications were limited, with a few cases of mild haemoptysis being recorded.

CONCLUSIONS: Transcutaneous FNAC can be considered a safe and quick method for establishing a histological diagnosis of laryngeal lesions, particularly in patients who may be severely comorbid, and it could therefore could reduce the risks of general anaesthesia and tracheostomy prior to commencing definitive treatment.

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A Standardised approach to Theatre training (2024)

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Type of publication:

Service improvement case study

Author(s):

*Nicola Bell, *Andrew Hutchinson

Citation:

SaTH Improvement Hub, June 2024

Abstract:

To ensure a consistent approach to training for all non-medical clinical staff, (including Nurses, Nursing Associates, Assistant practitioners and HCA’s ) that are new to Theatres, that results in them being competent & effectively developed to safely work as a non-supernumery member of the team, within six
months of starting their new role.

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Patient with Pneumomediastinum and Pneumoperitoneum-Importance of Human Factors (2024)

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Type of publication:

Conference abstract

Author(s):

*Lakshmipathy G.R.; *Ball W.

Citation:

British Journal of Surgery. Conference: Annual Congress of the Association of Surgeons of Great Britain and Ireland. Belfast United Kingdom. 111(Supplement 8) (pp viii119), 2024. Date of Publication: September 2024.

Abstract:

Clinical assessment: 70-year-old lady presents with one-day history of dyspnoea, chest and abdominal pain. She was recently discharged following a three-week hospital admission with fall related traumatic rib fractures and hospital acquired pneumonia. Her abdomen was soft and non-tender. CT scan with oral and IV contrast demonstrates pneumomediastinum and pneumoperitoneum with connection at diaphragmatic crura. Management: Patient was managed conservatively however two days after admission her CRP climbed to 150 and clinical suspicion remained high. Repeat CT scan over the weekend demonstrated increase in the pneumoperitoneum and decrease in the pneumomediastinum with a collection around sigmoid colon. Trainee raised concern to consultant and a laparotomy was done. Operative findings showed perforated sigmoid colon with faeculent peritonitis of unclear cause. Hartmann's procedure was done and patient continued post recovery in ITU. Discussion(s): This case demonstrates the complex varying presentations of our elderly co-morbid population. The presence of air in thoracic and abdominal cavities with unknown cause weeks after the fall was suspicious. Hence, the team communicated well from top-down and likewise from weekday to weekend. Low threshold for escalation and high index of suspicion enabled a re-scan which proved to be life-saving for this patient. Identifying complicated cases where errors can occur is a critical first step. Clear communication among staff, accurate documentation and addressing the patient concerns enabled the surgical team to navigate the complex disease process and ensure safe patient care.

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Does tranexamic acid really matter in reducing blood loss? A critical evaluation of its efficacy in orthognathic surgery through a comprehensive systematic review and meta-analysis (2024)

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Type of publication:

Systematic Review

Author(s):

Mortada H.; Hussain S.A.; Liyanage D.D.; Zou Y.; Subbiah P.; *George J.; Mansour H.R.K.; Khajuria A.

Citation:

British Journal of Oral and Maxillofacial Surgery. (no pagination), 2024. Date of Publication: 2024. [epub ahead of print]

Abstract:

Tranexamic acid (TXA) is acknowledged for reducing blood loss and transfusion requirements in various surgical specialties, yet its role in orthognathic procedures is less defined. Our study seeks to fill this knowledge gap by reviewing the available data and summarising the efficacy and clinical outcomes of TXA in orthognathic surgery. We performed a systematic review and meta-analysis, searching five databases for studies until 16 April, 2023. Our key outcome measures were intraoperative blood loss, postoperative bleeding, and transfusion rate. Previous weaknesses in systematic review and meta-analyses (SRMA) were identified using Assessing the Methodological Quality of Systematic Reviews-2 (AMSTAR-2). The risk of bias was evaluated with the RoB-2 tool. A total of 15 studies were included, involving a combined total of 1060 patients. Compared with the control, the TXA group demonstrated significant reductions in intraoperative blood loss (mean difference -135.60 mL; p < 0.00001; 95% CI, -177.51 to -93.70 mL), Hb level drop (mean difference: 2.67 [-0.63, 5.98]), and improved surgical field visibility [p < 0.00001. (MD -0.99) (CI -1.11 to -0.86)]. No significant differences were observed in postoperative haematocrit levels (mean difference: -0.42 [-2.19, 1.35]; p = 0.003; I<sup>2</sup> = 75%), operation duration (p = 0.21), or duration of hospital stay (p = 0.63) between TXA and control groups. In orthognathic surgery, TXA effectively minimises blood loss, demonstrating both safety and efficiency. Well-designed, larger studies and comparisons with other haemostatic agents could solidify TXA evidence.

Association of day-case rates with post COVID-19 recovery of elective laparoscopic cholecystectomy activity across England (2024)

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Type of publication:
Journal article

Author(s):
Ayyaz, F M; Joyner, J; *Cheetham, M; Briggs, Twr; Gray, W K.

Citation:
Annals of the Royal College of Surgeons of England. 2024 Apr 02.

Abstract:
INTRODUCTION: The aim of this study was to investigate the safety of day-case laparoscopic cholecystectomy, and the association between day-case rates and, post the COVID-19 pandemic, recovery of activity to prepandemic levels for integrated care boards (ICBs) in England. METHODS: This was a retrospective observational study of the Hospital Episodes Statistics (HES) data set. Elective laparoscopic
cholecystectomies for the period 1 January 2019 to 31 December 2022 were identified. Activity levels for 2022 were compared with those for the whole of 2019 (baseline). Day-case activity was identified where the length of stay recorded in the HES was zero days. RESULTS: Data were available for 184,252 patients across the 42 ICBs in England, of which 120,408 (65.3%) were day-case procedures. By December
2022, activity levels for the whole of England had returned to 88.2% of prepandemic levels. The South West region stood out as having recovered activity levels to the greatest extent, with activity at 97.3% of
prepandemic levels during 2022. The South West also had the highest postpandemic day-case rate at 74.9% of all patients seen as a day-case during 2022; this compares with an England average of 65.3%. At an ICB level, there was a significant correlation between day-case rates and postpandemic activity levels (r = 0.362, p = 0.019). There was no strong or consistent evidence that day-case surgery had poorer patient outcomes than inpatient surgery. CONCLUSIONS: Recovery of elective laparoscopic cholecystectomy activity has been better in South West England than in other regions. Increasing day-case rates may be important if ICBs in other regions are to increase activity levels up to and beyond prepandemic levels.

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Factors associated with conversion from day-case to in-patient elective inguinal hernia repair surgery across England: an observational study using administrative data (2024)

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Type of publication:
Journal article

Author(s):
Joyner, J; Ayyaz, F M; Cheetham, M; Briggs, T W R; Gray, W K.

Citation:
Hernia. 2024 Feb 12.

Abstract:
PURPOSE: Elective primary inguinal hernia repair surgery is increasingly being conducted as a day-case procedure. However, some patients planned for day-case surgery have to stay in hospital for at least one night. The aim of this study was to identify the factors associated with conversion from day-case to in-patient management for elective inguinal hernia repair surgery. METHODS: This was an exploratory retrospective analysis of observational data from the Hospital Episode Statistics dataset for England. All patients aged >= 17 years undergoing a first elective inguinal hernia repair between 1st April 2014 and 31st March 2022 that was planned as day-case surgery were identified. The exposure of interest was discharged on the day of admission (day-case) or requiring overnight stay. The primary outcome of interest was 30-day emergency readmission with an overnight stay. For reporting, providers were aggregated to an Integrated Care Board (ICB) level. RESULTS: A total of 351,528 planned day-case elective primary inguinal hernia repairs were identified over the eight-year study period. Of these, 45,305 (12.9%) stayed in hospital for at least one night and were classed as day-case to in-patient stay conversions. Patients who converted to in-patient stay were older, had more comorbidities, and were more likely to have bilateral surgery and be operated on by a low-annual volume surgeon. Post-procedural complications were strongly associated with conversion. Across the 42 ICBs in England, model-adjusted conversion rates varied from 3.3% to 21.3%. CONCLUSIONS: There was considerable variation in conversion to in-patient stay rates for inguinal hernia repair across ICBs in England. Our findings should help surgical teams to better identify patients suitable for day-case inguinal hernia repair and plan discharge services more effectively. This should help to reduce the variation in conversion rates.

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