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PubMed1993

The Australian Incident Monitoring Study. Recovery room incidents in the first 2000 incident reports.

Of the first 2000 incidents reported to the Australian Incident Monitoring Study 120 (6%) occurred in the recovery room after general, regional or local anaesthesia. Over two thirds (69%) of these involved the respiratory system, 19% were cardiovascular, 3% involved the central nervous system and 9% were miscellaneous in nature. These recovery room incidents were associated with significantly more adverse outcomes (56%) than incidents in the operating theatre (24%). The types and relative frequencies of these recovery room incidents were similar to those of serious recovery complications in a recent analysis of closed malpractice claims; this suggests that incident monitoring may be useful in the study and prevention of recovery room complications. Over three quarters (77%) of all recovery incidents (and 88% of respiratory incidents) were detected clinically; the remainder were first detected by a monitor. A theoretical analysis showed that over 95% of respiratory events, had they been allowed to evolve, would have been detected by pulse oximetry before organ damage occurred, emphasising the potential importance of pulse oximetry in reducing adverse outcome from any complication in the recovery ward which might be "missed" by clinical observation. The findings of this study underline the importance of having an adequate number of trained recovery nursing staff supported by the availability of a pulse oximeter for each patient at least until the return of protective reflexes and the ability to maintain adequate arterial saturation has been established.

Accidents↗

PubMed1989

Thioethers, mutagens, and D-glucaric acid in urine of operating room personnel exposed to anesthetics.

Mutagenic hazards related to occupational exposure to nitrous oxide and enflurane was studied in the personnel of five operating rooms using a coupled environmental and biological monitoring approach. The environmental monitoring revealed air concentrations of the two anesthetics exceedings the TLVs by 10-15-fold. These values were correlated individually with the concentrations of the two anesthetics in the expired air of the exposed subjects. The biological monitoring was carried out by determining two parameters associated with mutagen exposure (urinary mutagenicity and thioethers) and a parameter associated with the enzymatic induction (D-glucaric acid) in the urine of exposed and unexposed subjects (N = 64 and N = 37, respectively). The results showed no difference in the two groups for urine mutagenicity and D-glucaric acid, but urine thioethers were significantly increased among highly exposed subjects.

Adult↗

PubMed2000

Factors influencing the reporting of adverse perioperative outcomes to a quality management program.

UNLABELLED: Quality management programs have used several data reporting sources to identify adverse perioperative outcomes. We compared reporting sources and identified factors that might improve data capture. Adverse perioperative outcomes between January 1, 1992, and December 31, 1994, were reported to the Department of Anesthesiology Quality Management program by anesthesiologists, hospital chart reviewers, and other hospital personnel using incident reports. The reports were compared for preoperative health status, severity of outcome, and associated human error. Subsequently, personnel representing the various sources were surveyed regarding factors that might affect their reporting of adverse outcomes. Of 37,924 anesthetics, 734 (1. 9%) adverse outcomes were reported, 519 (71%) of which were identified by anesthesiologists, 282 (38%) by chart reviewers, and 67 (9.1%) by incident report. There was no statistically significant difference in reporting rates by anesthesiologists according to preexisting disease, severity of outcome, or presence of human error. Thirteen cases involving human error, however, resulted in disabling patient injury, with a higher rate of self-reporting for these cases (92%, P < 0.05). Rates of reporting by chart reviewers varied (P < 0.05) according to severity of patient illness and severity of outcome. Incident reports identified only 67 adverse outcomes (9.1%), but included a significantly higher percentage of the adverse outcomes involving human error (23.3%, P < 0.05). Twenty attending anesthesiologists, 15 resident anesthesiologists, 29 operating room nurses, 19 postanesthesia care unit nurses, and 6 hospital chart reviewers responded to the survey. Only the potential to improve quality of patient care influenced or strongly influenced a decision by all groups to report an adverse outcome to a peer review process. Physician self-reporting is a more reliable method of identifying adverse outcomes than either medical chart review or incident reporting. IMPLICATIONS: Physician self-reporting is a more reliable method of identifying adverse outcomes than either medical chart review or incident reporting. Reporting by chart reviewers is biased both by the severity of outcome and severity of patient illness, whereas incident reports tend to focus on human error. All groups feel compelled to report adverse outcomes when the data may result in improved patient care.

Adverse Drug Reaction Reporting Systems↗

PubMed1999

Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee.

EXECUTIVE SUMMARY The "Guideline for Prevention of Surgical Site Infection, 1999" presents the Centers for Disease Control and Prevention (CDC)'s recommendations for the prevention of surgical site infections (SSIs), formerly called surgical wound infections. This two-part guideline updates and replaces previous guidelines.1,2 Part I, "Surgical Site Infection: An Overview," describes the epidemiology, definitions, microbiology, pathogenesis, and surveillance of SSIs. Included is a detailed discussion of the pre-, intra-, and postoperative issues relevant to SSI genesis. Part II, "Recommendations for Prevention of Surgical Site Infection," represents the consensus of the Hospital Infection Control Practices Advisory Committee (HICPAC) regarding strategies for the prevention of SSIs.3 Whenever possible, the recommendations in Part II are based on data from well-designed scientific studies. However, there are a limited number of studies that clearly validate risk factors and prevention measures for SSI. By necessity, available studies have often been conducted in narrowly defined patient populations or for specific kinds of operations, making generalization of their findings to all specialties and types of operations potentially problematic. This is especially true regarding the implementation of SSI prevention measures. Finally, some of the infection control practices routinely used by surgical teams cannot be rigorously studied for ethical or logistical reasons (e.g., wearing vs not wearing gloves). Thus, some of the recommendations in Part II are based on a strong theoretical rationale and suggestive evidence in the absence of confirmatory scientific knowledge.It has been estimated that approximately 75% of all operations in the United States will be performed in "ambulatory," "same-day," or "outpatient" operating rooms by the turn of the century.4 In recommending various SSI prevention methods, this document makes no distinction between surgical care delivered in such settings and that provided in conventional inpatient operating rooms. This document is primarily intended for use by surgeons, operating room nurses, postoperative inpatient and clinic nurses, infection control professionals, anesthesiologists, healthcare epidemiologists, and other personnel directly responsible for the prevention of nosocomial infections. This document does not: Specifically address issues unique to burns, trauma, transplant procedures, or transmission of bloodborne pathogens from healthcare worker to patient, nor does it specifically address details of SSI prevention in pediatric surgical practice. It has been recently shown in a multicenter study of pediatric surgical patients that characteristics related to the operations are more important than those related to the physiologic status of the patients.5 In general, all SSI prevention measures effective in adult surgical care are indicated in pediatric surgical care. Specifically address procedures performed outside of the operating room (e.g., endoscopic procedures), nor does it provide guidance for infection prevention for invasive procedures such as cardiac catheterization or interventional radiology. Nonetheless, it is likely that many SSI prevention strategies also could be applied or adapted to reduce infectious complications associated with these procedures. Specifically recommend SSI prevention methods unique to minimally invasive operations (i.e., laparoscopic surgery). Available SSI surveillance data indicate that laparoscopic operations generally have a lower or comparable SSI risk when contrasted to open operations.6-11 SSI prevention measures applicable in open operations (e.g., open cholecystectomy) are indicated for their laparoscopic counterparts (e.g., laparoscopic cholecystectomy). Recommend specific antiseptic agents for patient preoperative skin preparations or for healthcare worker hand/forearm antisepsis. Hospitals should choose from products recommended for these activitie

Humans↗

PubMed1998

An examination of the variables associated with the adoption of a computerized innovation (an operating room simulation model).

The purpose of this study was to describe the variables that influenced senior staff to decide to adopt (or reject) a computerized innovation (Operating Room Simulation Model) and to describe the decision process at four hospitals. Rogers' Innovation-Decision Process Model (1983) and Model of the Innovation Process in Organizations (1983) formed the conceptual framework for this study. Five specific variables (relevant advantage, compatibility, complexity, trialability, observability), that were shown in the literature to increase the probability of an innovation to be adopted, were investigated. The results of this study indicated that there was a match between relevant advantage and adoption and no match between compatibility and adoption. There were insufficient data to determine if a match existed between complexity, trialability and observability with adoption of the Model. The links between the organizational variables (agenda setting, matching, decision) and adoption of the OR Simulation Model were not conclusive.

Attitude to Computers↗

PubMed1994

Healthcare and the environment.

There are many reasons why you should be concerned about the environment, particularly if you are a healthcare professional. Every environmental pollutant is also associated with a human health risk. So improving the environment will mean better healthcare. In addition we should make sure all our actions are such as not to impair the development of future generations. National governments and, in particular, the European Commission have recognised this public concern and have generated a large amount of environmental legislation in order to change the way we behave. A summary of this legislation is provided along with more detailed discussions on waste legislation.

Environmental Health↗

PubMed1996

PEG--percutaneous endoscopic gastrostomy.

Percutaneous Endoscopic Gastrostomy is simply a plastic tube, placed in the stomach and passed through both the wall of the stomach and abdomen with the aid of a gastroscope, therefore avoiding the need for a laparotomy to form a gastrostomy. Egeberg proposed surgical gastrostomy in 1837. This was not carried out successfully until 1876 by Verneuil. The procedure, however, requires laparotomy and anaesthesia with its associated risks. The first gastrostomy without the need for a laparotomy is reported to have been performed in 1979 by Gauderer and Ponsky at Case Western Reserve University School of Medicine, Cleveland, USA. In 1980 they described the technique. Since then a variety of kits with which to perform the procedure have become available. PEG can be used for long term enteral nutrition or as an intermediate stage between Total Parentral Nutrition (TPN) and normal feeding. An important requirement is a successfully accomplished gastroscopy.

Enteral Nutrition↗

PubMed1993

Ectopic pregnancy and occupational exposure to antineoplastic drugs.

The incidence of ectopic pregnancy has risen substantially during the past two decades, but the aetiology of a third of cases remains unknown. We have used data from a survey of nurses in Paris, France, to examine the relation between ectopic pregnancy and various occupational exposures. We studied two groups of women--operating-theatre staff and nurses from other departments. The women were asked about outcomes of all pregnancies and occupational exposure to anaesthetic gases, formol, ionising radiation, and antineoplastic drugs during the first trimester of pregnancy. Of 734 pregnancies reported, 15 (2%) had been ectopic. In chi-square analysis, there were significant associations (p < 0.02) between ectopic pregnancy and exposure to antineoplastic drugs, the woman's age, and the number of previous pregnancies. Other occupational exposures and working in an operating theatre did not show significant associations. In logistic regression analysis with adjustment for gravidity, the odds ratio (by the exact method) for ectopic pregnancy associated with occupational exposure to antineoplastic drugs was 10.0 (95% CI 2.1-56.2). Because we had only small numbers of ectopic pregnancies, the odds ratios we estimated have wide confidence intervals. Our findings should be confirmed by a larger study specifically designed to investigate the relation between antineoplastic exposure and ectopic pregnancy.

Adult↗

PubMed1978

Cigarette smoking during pregnancy and the occurrence of spontaneous abortion and congenital abnormality.

A multiple logistic regression analysis of 12,914 pregnancies and 10,523 live births, based on a mail survey of professional women in medicine, was carried out to determine the relationship between maternal cigarette smoking, and spontaneous abortion and congenital abnormality. After controlling for interfering variables (age, exposure to trace anesthetic gases, pregnancy history, and mailing response), a statistically significant increase in risk associated with maternal cigarette smoking was found for spontaneous abortions and congenital abnormalities. The risk of spontaneous abortion for the heavy smoker is estimated to be as much as 1.7 times that of the nonsmoker in certain risk groups. The risk for congenital abnormality for babies born of smoking mothers is estimated to be as much as 2.3 times that of the nonsmoker, depending on age, pregnancy history, and other factors.

Abortion, Spontaneous↗

PubMed1996

Isoflurane waste gas exposure during general anaesthesia: the laryngeal mask compared with tracheal intubation.

We have compared exposure to isoflurane while using the laryngeal mask airway (LMA) during anaesthesia under positive pressure ventilation with exposure while using tracheal intubation. Trace concentrations of isoflurane were measured directly using a highly sensitive photoacoustic infrared spectrometer (Bruel and Kjaer 1302, Denmark) during general anaesthesia in 20 eye surgery procedures. Measurements were made at six locations (three personnel-related, three leakage-related) in the operating theatre. Despite some high isoflurane values (greater than 2000 ppm at one leakage-related measurement point) all measured values at the personnel-related points were low (the majority were less than isoflurane 2 ppm). In the LMA group, mean trace concentrations were slightly higher than in the tracheal tube (ET) group. Mean exposure to isoflurane, expressed as median (range) related to anaesthetic administration, was highest for the auxiliary nurse (0.64 (0.22-26.89) ppm for the LMA compared with 0.31 (0.02-1.07) ppm for the tracheal tube), followed by the anaesthetist (0.50 (0.28-2.28) ppm for the LMA compared with 0.35 (0.02-0.73) ppm for the tracheal tube) and the surgeon (0.36 (0.20-3.93) ppm for the LMA compared with 0.29 (0.01-0.50) ppm for the tracheal tube). We conclude that the use of the LMA in patients undergoing ventilation is not associated necessarily with high concentrations of isoflurane in a modern working environment.

Anesthesia, Inhalation↗

PubMedDate not supplied

Prevalence of immunoglobulin G to Helicobacter pylori among endoscopy nurses/technicians.

The purpose of this study was to compare the prevalence of Helicobacter pylori (HP) seropositivity among gastroenterology nurses and technicians with that of the general population. Nurses attending the 1996 Indiana Society of Gastroenterology Nurses and Associates Spring and Fall Education Courses were asked to complete a checklist regarding employment, current symptoms, and use of universal precautions, and to have 3 ml blood drawn. These 138 blood specimens as well as 112 serum samples from generally age- and sex-matched blood donors (representing the general population) underwent qualitative HP antibody testing. Results showed that the prevalence of seropositivity for immunoglobulin G (IgG) antibody for HP among the gastroenterology nurses and technicians was 19 of 138 (13.8%), which was less than that of the blood donor control group, whose seropositivity was 20 of 112 (17.9%). However, this difference failed to reach statistical significance. Seropositivity tended to increase with age, but there was no association between clinical symptomatology and seropositivity. Likewise, there was no difference in seropositivity between nurses assisting with endoscopic procedures for more than 10 years and those assisting for less than 10 years. Although the differences were not significant, these findings refute those of an earlier study in which the researchers found 122 gastroendoscopists and endoscopy nurses significantly more likely to be positive for HP antibodies. Therefore, the findings reported here provide important information.

Adult↗

PubMed2004

Anticipating events of in-hospital cardiac arrest.

STUDY OBJECTIVES: To determine whether in-hospital cardiac arrests occurring in regular wards are preceded by some event(s), and the diagnostic and therapeutic measures adopted. METHODS: From 1 May 1999 to 31 December 2001, events occurring in the 6 h preceding cardiac arrest were reviewed by checking the medical and nurse records and interviewing the attending staff. Exclusion criteria were (a) location in the Coronary Care Unit, the Intensive Care Unit, the Emergency Department and the operating rooms; (b) the presence of rapidly fatal disease; (c) the lack of adequate documentation. RESULTS: Overall, 263 cardiac arrests occurred in the period under consideration. A total of 148 patients (61 women, 87 men, aged 74.3+/-1.2 years) fulfilled the entry criteria. Anticipating events were reported in 128 patients (86.4%). These included alterations in consciousness, cardiac arrhythmias, dyspnoea and chest pain. The restoration of cardiac rhythm was obtained in 23 patients (15.5%). Eight (5.4%) survived without major neurological sequelae. Survivors were significantly younger than non-survivors (survivors 44.3+/-6.8 years; non-survivors 76.7+/-2.1 years; P<0.005). In a substantial number of cases, ranging from 23 to 81%, according to the anticipating event, no diagnostic investigations were performed. CONCLUSION: Most in-hospital cardiac arrests are preceded by events that often go overlooked and whose correct interpretation could be associated with a reduced mortality rate.

Adult↗

PubMed1993

Hospital saves with bedside point-of-care system.

Do bedside and point-of-care systems actually deliver on their promise of reducing operating expenses while helping improve the overall quality of healthcare? And how does a healthcare facility quantify associated "productivity" improvements to prove cost savings? These are two critical issues that healthcare providers face in implementing a bedside or point-of-care (POC) system. Barnes Hospital, St. Louis, is a 1,000 bed member facility of the Barnes-Jewish Inc./Christian Health Services integrated health system. Barnes Hospital has indeed seen significant cost savings as a result of a POC project.

Cost Savings↗

PubMed1998

Transfusion-free surgery is a treatment plan for all patients.

Due to the increased risks associated with allogenic blood transfusion, blood management in surgical procedures, especially in orthopedic settings, should include reduction of perioperative blood loss. Preoperative nursing assessment will help define patients at increased risk for transfusion. Both nonpharmacologic and pharmacologic techniques can help minimize allogenic transfusion by reducing blood loss. One such method of managing anemia and reducing patient exposure to allogenic transfusion is the perioperative use of recombinant human erythropoietin--erythropoietin alfa--an innovative surgical blood management tool. Increased awareness by perioperative nurses of the use of erythropoietin alfa and patient implications can contribute to the overall blood conservation goal.

Anemia↗

PubMed1993

A comparison of patient-controlled and intramuscular morphine in patients after abdominal surgery.

This prospective, randomized study compared the effects of two methods of morphine administration after abdominal surgery in 62 adults. All patients were offered intravenous morphine in the Postanesthesia Care Unit. On the ward, one group (PCA-CI) received a continuous infusion of morphine that could be supplemented by a patient-controlled bolus every 10 minutes. The other group (IM) received intramuscular morphine (0.08-0.12 mg/kg) as often as every 3 hours when requested. During three postoperative interviews, patients were questioned about pain relief (visual analogue scale), adverse opioid effects, and satisfaction with the method of analgesia. Total dose of morphine (mg, mg/kg body weight), time to first oral analgesic medication, length of hospital stay, and cost were calculated following discharge. There was a wide interindividual variation in reported pain intensity and morphine usage in both groups. Comparison of both groups demonstrated no significant differences in analgesia, incidence of adverse opioid effects, 24 and 36 hour morphine dose, time to first oral analgesic medication, operating cost, and length of hospital stay. Patients in the PCA-CI group received a slightly greater dose of morphine in relation to body weight (24 hr, P = 0.03; 36 hr, P = 0.05) and reported a greater degree of satisfaction at each assessment (P = 0.005, P = 0.02, P = 0.01). These data support the greater patient satisfaction associated with patient-controlled analgesia but suggest that the wide range of reported pain scores and morphine requirements makes it difficult to demonstrate, in a small population, superior pain relief from patient-controlled analgesia when nurses are encouraged to administer intramuscular pain medication more effectively.

Abdomen↗

PubMed1988

Fetal death and work in pregnancy.

The relation between spontaneous abortion (n = 5010), stillbirth without congenital defect (n = 210), and working conditions was analysed in 22,613 previous pregnancies of 56,067 women interviewed, 1982-4, immediately after termination of their most recent (current) pregnancy. The 22,613 previous pregnancies were those in which at time of conception the women were employed 30 or more hours a week. Ratios of observed (O) to expected (E) fetal deaths after allowance by logistic regression for seven non-occupational confounding variables were calculated at four stages of pregnancy in 60 occupational groups and six main sectors for women whose work entailed various physical demands, environmental conditions, and exposure to chemicals. The O/E ratios for abortion were raised in the sales sector (1.13, p less than 0.05) and services sector (1.11, p less than 0.01) and for stillbirth in the sales sector (1.50, p less than 0.1). Substantially increased O/E ratios for late but not early abortion were found in operating room nurses (2.92, p less than 0.05), radiology technicians (3.82, p less than 0.01), and employees in agriculture and horticulture (2.40, p less than 0.05); in all categories the O/E ratio for stillbirth were also raised but only significantly (5.55, p less than 0.01) in the latter group. The O/E ratio for stillbirth was also raised in leather manufacture (3.09, p less than 0.01). In both individual and grouped analysis (the latter undertaken to minimise the possible effect of recall bias) significantly increased O/E ratios for abortion were found in women exposed to various high levels of physical stress, particularly weight lifting, other physical effort, and standing (p less than 0.01). Increased ratios for stillbirth at this level of significance (p less than 0.01) were found for other physical effort and vibration. Noteworthy chemical exposure was identified only in the health, services, and manufacturing sectors; the O/E ratio for stillbirth approached two in women exposed to solvents, almost all in manufacturing (p less than 0.01). In the latter sector exposed to solvents was also associated with an approximately 20% increase in abortion ratio at similar probability level.

Abortion, Spontaneous↗

PubMed2001

Update for nurse anesthetists. Patr 1. The hazards of surgical smoke.

Inhaling surgical smoke is an ever-growing concern since the majority of all surgeries generate laser or electrosurgical smoke. Anesthesia providers must understand the dangers of surgical smoke and how to control or minimize exposure. This Journal course explores the hazards of surgical smoke (including plume odor, particulate matter size, viability of the smoke contents, and laparoscopic concerns) by citing significant research studies that support the threats and potential threats associated with surgical smoke. Effective methods to evacuate this plume are described to protect not only the healthcare professional but also the patient. Surgical smoke will continue to cause problems and concerns unless the surgical team is committed to providing a safe environment through appropriate and diligent smoke evacuation methods.

Electrosurgery↗

PubMed1998

Exposure of postoperative nurses to exhaled anesthetic gases.

UNLABELLED: The National Institute of Occupational Safety and Health (NIOSH) has established recommended exposure limits of 25 parts per million (ppm) as a time-weighted average for nitrous oxide and a ceiling of 2 ppm for volatile anesthetics. We quantified exposure of postanesthetic nurses to exhaled anesthetic gases. This study was conducted in the postanesthesia care unit (PACU) of a medium-sized hospital. PACU air exchanges averaged 8 vol/h; however, much of this air was recirculated. We evaluated 50 adults anesthetized with either isoflurane (n = 19) or desflurane (n = 31). Roughly half the patients were tracheally extubated in the operating room, whereas the others were extubated just after admission to the PACU. Exhaled anesthetic gases were sampled through a 20-m hose attached to the participating nurses' shoulders (breathing zone). We also evaluated nursing exposure to exhaled anesthetic gases during recovery of 15 patients who had been anesthetized with nitrous oxide. Exposure was quantified with lapel dosimeters. Anesthetic and recovery durations were each approximately 1 h, with most patients being tracheally extubated in the PACU. Breathing-zone anesthetic concentrations in the patients given isoflurane exceeded NIOSH recommendations in 37% of the patients, representing 12% of recovery time. Breathing-zone anesthetic concentrations in the patients given desflurane, however, exceeded NIOSH limits in 87% of the patients, representing 49% of recovery time. Altogether, noncompliant episodes were detected in 68% of these patients, representing 35% of the entire recovery duration. Breathing-zone anesthetic concentrations in the patients given nitrous oxide exceeded NIOSH limits in 53% of the patients. Our data suggest that postoperative nurses' exposure to exhaled anesthetic gases exceeds NIOSH limits under some circumstances. IMPLICATIONS: Some epidemiological evidence suggests that exposure to waste anesthetic gases may be associated with reproductive toxicity. Accordingly, the National Institute of Occupational Safety and Health has established recommended exposure limits for nitrous oxide and volatile anesthetics. Our data suggest that exposure of healthcare personnel may exceed recommended levels in poorly ventilated postanesthesia care units.

Air Pollutants, Occupational↗