Annette Erichsen Andersson

Traffic flow in the operating room: An explorative and descriptive study on air quality during orthopedic trauma implant surgery

BACKGROUND Understanding the protective potential of operating room (OR) ventilation under different conditions is crucial to optimizing the surgical environment. This study investigated the air quality, expressed as colony-forming units (CFU)/m(3), during orthopedic trauma surgery in a displacement-ventilated OR; explored how traffic flow and the number of persons present in the OR affects the air contamination rate in the vicinity of surgical wounds; and identified reasons for door openings in the OR. METHODS Data collection, consisting of active air sampling and observations, was performed during 30 orthopedic procedures. RESULTS In 52 of the 91 air samples collected (57%), the CFU/m(3) values exceeded the recommended level of <10 CFU/m(3). In addition, the data showed a strongly positive correlation between the total CFU/m(3) per operation and total traffic flow per operation (r = 0.74; P = .001; n = 24), after controlling for duration of surgery. A weaker, yet still positive correlation between CFU/m(3) and the number of persons present in the OR (r = 0.22; P = .04; n = 82) was also found. Traffic flow, number of persons present, and duration of surgery explained 68% of the variance in total CFU/m(3) (P = .001). CONCLUSIONS Traffic flow has a strong negative impact on the OR environment. The results of this study support interventions aimed at preventing surgical site infections by reducing traffic flow in the OR.

The application of evidence-based measures to reduce surgical site infections during orthopedic surgery - report of a single-center experience in Sweden

BackgroundCurrent knowledge suggests that, by applying evidence-based measures relating to the correct use of prophylactic antibiotics, perioperative normothermia, urinary tract catheterization and hand hygiene, important contributions can be made to reducing the risk of postoperative infections and device-related infections. The aim of this study was to explore and describe the application of intraoperative evidence-based measures, designed to reduce the risk of infection. In addition, we aimed to investigate whether the type of surgery, i.e. total joint arthroplasty compared with tibia and femur/hip fracture surgery, affected the use of protective measures.MethodData on the clinical application of evidence-based measures were collected structurally on site during 69 consecutively included operations involving fracture surgery (n = 35) and total joint arthroplasties (n = 34) using a pre-tested observation form. For observations in relation to hand disinfection, a modified version of the World Health Organization hand hygiene observation method was used.ResultsIn all, only 29 patients (49%) of 59 received prophylaxis within the recommended time span. The differences in the timing of prophylactic antibiotics between total joint arthroplasty and fracture surgery were significant, i.e. a more accurate timing was implemented in patients undergoing total joint arthroplasty (p = 0.02). Eighteen (53%) of the patients undergoing total joint arthroplasty were actively treated with a forced-air warming system. The corresponding number for fracture surgery was 12 (34%) (p = 0.04).Observations of 254 opportunities for hand hygiene revealed an overall adherence rate of 10.3% to hand disinfection guidelines.ConclusionsThe results showed that the utilization of evidence-based measures to reduce infections in clinical practice is not sufficient and there are unjustifiable differences in care depending on the type of surgery. The poor adherence to hand hygiene precautions in the operating room is a serious problem for patient safety and further studies should focus on resolving this problem. The WHO Safe Surgery checklist “time out” worked as an important reminder, but is not per se a guarantee of safety; it is the way we act in response to mistakes or lapses that finally matters.

Comparison between mixed and laminar airflow systems in operating rooms and the influence of human factors: Experiences from a Swedish orthopedic center

BACKGROUND The importance of laminar airflow systems in operating rooms as protection from surgical site infections has been questioned. The aim of our study was to explore the differences in air contamination rates between displacement ventilation and laminar airflow systems during planned and acute orthopedic implant surgery. A second aim was to compare the influence of the number of people present, the reasons for traffic flow, and the door-opening rates between the 2 systems. METHODS Active air sampling and observations were made during 63 orthopedic implant operations. RESULTS The laminar airflow system resulted in a reduction of 89% in colony forming units in comparison with the displacement system (P < .001). The air samples taken in the preparation rooms showed high levels of bacterial growth (≈ 40 CFU/m(3)). CONCLUSIONS Our study shows that laminar airflow-ventilated operating rooms offer high-quality air during surgery, with very low levels of colony forming units close to the surgical wound. The continuous maintenance of laminar air flow and other technical systems are crucial, because minor failures in complex systems like those in operating rooms can result in a detrimental effect on air quality and jeopardize the safety of patients. The technical ventilation solutions are important, but they do not guarantee clean air, because many other factors, such as the organization of the work and staff behavior, influence air cleanliness.

Hand hygiene and aseptic techniques during routine anesthetic care - observations in the operating room

BackgroundMore knowledge is needed about task intensity in relation to hand hygiene in the operating room during anesthetic care in order to choose effective improvement strategies. The aim of this study was to explore the indications and occurrence of hand hygiene opportunities and the adherence to hand hygiene guidelines during routine anesthetic care in the operating room.MethodsStructured observational data on hand hygiene during anesthetic care during 94 surgical procedures was collected using the World Health Organization’s observational tool in a surgical department consisting of 16 operating rooms serving different surgical specialties such as orthopedic, gynecological, urological and general surgery.ResultsA total of 2,393 opportunities for hand hygiene was recorded. The number of hand hygiene opportunities when measured during full-length surgeries was mean = 10.9/hour, SD 6.1 with an overall adherence of 8.1%. The corresponding numbers for the induction phase were, mean =77.5/h, SD 27.4 with an associated 3.1% adherence to hand hygiene guidelines. Lowest adherence was observed during the induction phase before an aseptic task (2.2%) and highest during full-length surgeries after body fluid exposure (15.9%).ConclusionsThere is compelling evidence for low adherence to hand hygiene guidelines in the operating room and thus an urgent need for effective improvement strategies. The conclusion of this study is that any such strategy should include education and practical training in terms of how to carry out hand hygiene and aseptic techniques and how to use gloves correctly. Moreover it appears to be essential to optimize the work processes in order to reduce the number of avoidable hand hygiene opportunities thereby enhancing the possibilities for adequate use of HH during anesthetic care.

Changes in safety climate and teamwork in the operating room after implementation of a revised WHO checklist: a prospective interventional study

BackgroundInter-professional teamwork in the operating room is important for patient safety. The World Health Organization (WHO) checklist was introduced to improve intraoperative teamwork. The aim of this study was to evaluate the safety climate in a Swedish operating room setting before and after an intervention, using a revised version of the WHO checklist to improve teamwork.MethodsThis study is a single center prospective interventional study. Participants were personnel working in operating room teams including surgeons, anesthesiologists, scrub nurses, nurse anaesthetists and nurse assistants. The study started with pre-interventional observations of the WHO checklist use followed by education on safety climate, the WHO checklist, and non-technical skills in the operating room. Thereafter a revised version of the WHO checklist was introduced. Post-interventional observations regarding the performance of the WHO checklist were carried out. The Safety Attitude Questionnaire was used to assess safety climate at baseline and post-intervention.ResultsAt baseline we discovered a need for improved teamwork and communication. The participants considered teamwork to be important for patient safety, but had different perceptions of good teamwork between professions. The intervention, a revised version of the WHO checklist, did not affect teamwork climate. Adherence to the revision of the checklist was insufficient, dominated by a lack of structure.ConclusionsThere was no significant change in teamwork climate by use of the revised WHO checklist, which may be due to insufficient implementation, as a lack of adherence to the WHO checklist was detected. We found deficiencies in teamwork and communication. Further studies exploring how to improve safety climate are needed.Trial registrationNCT02329691.

Images of suffering depicted in diaries of family caregivers in the acute stage of necrotising soft tissue infection: A content analysis

OBJECTIVES Severe necrotising soft tissue infections (NSTI) are rare life threatening rapidly progressing bacterial infections requiring immediate diagnosis and treatment. The aim of the study was to explore the experience of family caregivers of patients with necrotising soft tissue infection during the acute stage of disease. METHODS Our study had a qualitative descriptive binational design using qualitative content analysis to explore diaries written by close family members (n=15). Participants were recruited from university hospitals in Denmark and Sweden. FINDINGS Three main categories emerged: Trajectory, Treatment, and Patient & Family. The first helped us construct an overview of the NSTI trajectory showing issues of importance to patient and family caregivers. The following categories were analysed further to describe four themes central to the family caregiver experience: craving information, needing to be near, suffering separation and network taking over. CONCLUSIONS Necrotising soft tissue infections are uncommon causing shock and concern. Centralised treatment might involve physical separation of patient and family during the acute stage of illness. Family accommodations near the patient and accessibility to adequate communication devices at the bedside are recommended. Health professionals need to keep in mind the importance of information and reassurance on the wellbeing of the family and ultimately of the patient.

Experiences of family caregivers the first six months after patient diagnosis of necrotising soft tissue infection: A thematic analysis

BACKGROUND Necrotising soft tissue infection, or necrotising fasciitis, is a rapidly progressing disease requiring immediate diagnosis and treatment consisting of antimicrobial therapy, hyperbaric oxygen, debridement surgery and treatment in the intensive care unit. The harrowing illness trajectory affects the family caregivers potentially producing long-term psychological issues. OBJECTIVES We aimed to explore the experiences and coping strategies of family caregivers during the first six months after patient diagnosis of necrotising soft tissue infection. METHODS Our study had a prospective, explorative, qualitative design using semi-structured interviews and thematic analysis to understand necrotising soft tissue infection as an intrinsic and instrumental case. Family caregivers (n = 25) were recruited at three university hospitals in Denmark and Sweden. FINDINGS We identified three chronological themes describing issues of importance to the family caregivers. In the intensive care unit: Coping with illness and intensive care; In the ward: Coping with injury and post-intensive care and At home: Coping with recovery and new home life. CONCLUSION Challenges facing family caregivers of necrotising soft tissue infections survivors are still under-recognised. Healthcare professionals need to ensure that families and stakeholders throughout the patient trajectory have access to and co-create timely information and care plans to bridge the knowledge gap across care environments and to relieve family responsibility.

Signs, symptoms and diagnosis of necrotizing fasciitis experienced by survivors and family: a qualitative Nordic multi-center study

BackgroundNecrotizing soft tissue infection is the most serious of all soft tissue infections. The patient’s life is dependent on prompt diagnosis and aggressive treatment. Diagnostic delays are related to increased morbidity and mortality, and the risk of under- or missed diagnosis is high due to the rarity of the condition. There is a paucity of knowledge regarding early indications of disease. The aim of the study has thus been to explore patients’ and families’ experiences of early signs and symptoms and to describe their initial contact with the healthcare system.MethodsA qualitative explorative design was used to gain more knowledge about the experience of early signs and symptoms. Fifty-three participants from three study sites were interviewed. The framework method was used for data analysis.ResultsMost of the participants experienced treatment delay and contacted healthcare several times before receiving correct treatment. The experience of illness varied among the participants depending on the duration of antecedent signs and symptoms. Other important findings included the description of three stages of early disease progression with increase in symptom intensity. Pain experienced in necrotizing soft tissue infections is particularly excruciating and unresponsive to pain medication. Other common symptoms were dyspnea, shivering, muscle weakness, gastrointestinal problems, anxiety, and fear.ConclusionOur study adds to the understanding of the lived experience of NSTI by providing in-depth description of antecedent signs and symptoms precipitating NSTI-diagnosis. We have described diagnostic delay as patient-related, primary care related, or hospital related and recommend that patient and family narratives should be considered when diagnosing NSTI to decrease diagnostic delay.

Iterative co-creation for improved hand hygiene and aseptic techniques in the operating room : experiences from the safe hands study

BackgroundHand hygiene and aseptic techniques are essential preventives in combating hospital-acquired infections. However, implementation of these strategies in the operating room remains suboptimal. There is a paucity of intervention studies providing detailed information on effective methods for change. This study aimed to evaluate the process of implementing a theory-driven knowledge translation program for improved use of hand hygiene and aseptic techniques in the operating room.MethodsThe study was set in an operating department of a university hospital. The intervention was underpinned by theories on organizational learning, culture and person centeredness. Qualitative process data were collected via participant observations and analyzed using a thematic approach.ResultsDoubts that hand-hygiene practices are effective in preventing hospital acquired infections, strong boundaries and distrust between professional groups and a lack of psychological safety were identified as barriers towards change. Facilitated interprofessional dialogue and learning in “safe spaces” worked as mechanisms for motivation and engagement. Allowing for the free expression of different opinions, doubts and viewing resistance as a natural part of any change was effective in engaging all professional categories in co-creation of clinical relevant solutions to improve hand hygiene.ConclusionEnabling nurses and physicians to think and talk differently about hospital acquired infections and hand hygiene requires a shift from the concept of one-way directed compliance towards change and learning as the result of a participatory and meaning-making process. The present study is a part of the Safe Hands project, and is registered with ClinicalTrials.gov (ID: NCT02983136). Date of registration 2016/11/28, retrospectively registered.