Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

Background End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001). Conclusion Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone

Visual Compatibility of Various Injectable Neuroleptic Agents with Benztropine and Lorazepam in Polypropylene Syringes

ABSTRACT Background: The nursing staff at the authors’ hospital are frequently called upon to administer medications by intramuscular injection during psychiatric emergencies. Many of these medications are considered incompatible when mixed together, and up to 3 separate injections may be required for a single patient. The need for multiple injections increases the risk of needle-stick injury in these situations.Objectives: The visual compatibility of various combinations of haloperidol, loxapine, chlorpromazine, benztropine, and lorazepam was studied, with the aim of reducing the number of injections required and hence reducing the risk to staff and increasing patient comfort.Methods: To emulate the setting of a nursing unit, single syringes of selected combinations of medications were prepared on a clean tabletop under fluorescent light at room temperature. The syringes were visually inspected for haze, immiscibility, precipitation, and colour change at 15, 30, and 45 min and at 1, 2, 3, and 4 h after mixing.Results: The haloperidol–benztropine mixtures and the haloperidol–benztropine–lorazepam mixtures were compatible on visual inspection throughout the observation period. The loxapine–benztropine and loxapine–lorazepam mixtures showed immediate incompatibility, as did the chlorpromazine–lorazepam and benztropine–lorazepam mixtures. A table of compatibilities was produced for quick reference on nursing units.Conclusions: Mixtures of haloperidol and benztropine and of haloperidol, benztropine, and lorazepam are compatible for periods of up to 4 h. The combinations of loxapine and benztropine, loxapine and lorazepam, chlorpromazine and lorazepam, and benztropine and lorazepam should not be mixed before administration.RÉSUMÉ Historique : Le personnel infirmier de l’hôpital où sont rattachés les auteurs est souvent sollicité à administrer des médicaments par voie intramusculaire au cours d’urgences psychiatriques. Beaucoup de ces médicaments sont jugés incompatibles lorsqu’on les mélange; par conséquent jusqu’à trois injections séparées pour un même patient peuvent être nécessaires pour les administrer. Or les nombreuses injections accroissent le risque de blessure avec aiguille dans ces situations.Objectifs : La compatibilité visuelle des diverses associations d’halopéridol, de loxapine, de chlorpromazine, de lorazépam et de benzatropine a été étudiée dans le but de réduire le nombre d’injections nécessaires et partant de diminuer le risque pour le personnel et d’améliorer le confort du patient.Méthodes : Afin de reproduire l’environnement d’une unité de soins, des seringues uniques d’associations médicamenteuses choisies ont été préparées sur un comptoir stérile sous éclairage fluorescent, à température ambiante. Les seringues ont été inspectées visuellement pour déceler toute turbidité, immiscibilité, précipitation ou altération de la couleur 15, 30 et 45 minutes, puis 1, 2, 3 et 4 heures après avoir mélangé les médicaments.Résultats : L’association halopéridol–benzatropine et halopéridol–benzatropine–lorazépam étaient compatibles à l’inspection visuelle pendant toute la durée de l’étude. L’association loxapine–benzatropine et loxapine–lorazépam ont immédiatement montré une incompatibilité, tout comme les associations chlorpromazine–lorazépam et benzatropine– lorazépam. Un tableau des compatibilités a été élaboré comme aide-mémoire sur les unités de soins.Conclusions : Les associations halopéridol-benzatropine et les associations halopéridol-benzatropine-lorazépam sont compatibles pendant un maximum de quatre heures. Les associations loxapine-benzatropine, loxapine-lorazépam, chlorpromazine-lorazépam, et benzatropine-lorazépam ne devraient pas être préparées avant leur administration