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

Letter to the editor: It is not acceptance, it is sowing the seed to better understand an educational tension. Replica

En respuesta a la carta de los académicos John Vergel, Martha Ortiz, Diana Laverde y Gustavo Quintero del artículo «Autenticidad y calidad en la investigación educativa cualitativa: multivocalidad», recientemente publicado, en primer lugar queremos agradecer los comentarios, y el interés por intercambiar experiencias y puntualizar conceptos de investigación cualitativa en educación en ciencias de la salud. Coincidimos que en las prácticas educativas ocurren tensiones que es necesario hacer visibles para reflexionar en ellas y alcanzar una mejor comprensión de su complejidad. Somos conscientes que, para un gran número de profesionales formados en el marco del positivismo, será muy difícil que admitan a la investigación cualitativa como un método más para investigar. En nuestra conclusión aludimos a incrementar la aceptación del enfoque cualitativo a través de la reflexividad de sus elementos esenciales, no como una manera de someterla al paradigma positivista, sino para fundamentarla y mostrar cómo se conjugan sus particularidades para darle credibilidad. (Tomado del texto

Letter to the editor: It is not acceptance, it is sowing the seed to better understand an educational tension. Replica

En respuesta a la carta de los académicos John Vergel, Martha Ortiz, Diana Laverde y Gustavo Quintero del artículo «Autenticidad y calidad en la investigación educativa cualitativa: multivocalidad», recientemente publicado, en primer lugar queremos agradecer los comentarios, y el interés por intercambiar experiencias y puntualizar conceptos de investigación cualitativa en educación en ciencias de la salud. Coincidimos que en las prácticas educativas ocurren tensiones que es necesario hacer visibles para reflexionar en ellas y alcanzar una mejor comprensión de su complejidad. Somos conscientes que, para un gran número de profesionales formados en el marco del positivismo, será muy difícil que admitan a la investigación cualitativa como un método más para investigar. En nuestra conclusión aludimos a incrementar la aceptación del enfoque cualitativo a través de la reflexividad de sus elementos esenciales, no como una manera de someterla al paradigma positivista, sino para fundamentarla y mostrar cómo se conjugan sus particularidades para darle credibilidad. (Tomado del texto

Additional file 1: of A typology of uncertainty derived from an analysis of critical incidents in medical residents: A mixed methods study

“Examples of Critical Incidents sort by different type of uncertainty”. The file includes five examples of the critical incidents written by the residents to illustrate different types of uncertainty (technical, conceptual, communicational, systemic and ethical). (PDF 225 kb

Avances del Modelo Educativo para Desarrollar Actividades Profesionales Confiables (MEDAPROC)☆

Resumen: El Modelo Educativo para Desarrollar Actividades Profesionales Confiables (MEDAPROC) surge como respuesta a la implementación de la educación basada en competencias. Es un proyecto multidisciplinario fundamentado en la epistemología interpretativa, el paradigma constructivista, las transformaciones del Sistema Nacional de Salud y el contexto del ejercicio actual de la medicina. Su meta es favorecer la adquisición de conocimientos, habilidades y actitudes indispensables por parte del estudiante de medicina. Integra la tendencia internacional de las Entrustable Professional Activities y las naturaliza como las Actividades Profesionales Confiables (APROC). MEDAPROC propone que el desarrollo de las APROC se promueva de manera inversa, desde el perfil de egreso hasta el inicio de los estudios de pregrado, por lo tanto, se involucra en diversas fases y procesos de aprendizaje y enseñanza (planeación, didáctica, evaluación y realimentación) por medio de proyectos para implementar estrategias didácticas y recursos de evaluación, con el apoyo de la formación docente, la investigación educativa y la tecnología. Su objetivo es lograr la mejora de la educación médica y de las ciencias de la salud, con el firme propósito de generar un cambio positivo en la calidad de la atención desde el entorno educativo. Abstract: The Educational Model to Develop Entrustable Professional Activities (MEDAPROC) arises as a response to the implementation of competency-based education. It is a multidisciplinary project based on interpretative epistemology, the constructivist paradigm, the transformations of the national health system, and the context of the current practice of medicine. Its purpose is to encourage the acquisition of essential knowledge, skills, and attitudes by the medical student. It integrates the international trend of the entrustable professional activities and converts them into entrustable professional activities (APROC). MEDAPROC proposes that the development of the APROC be promoted in an inverse manner, from the profile of the graduate to the beginning of the undergraduate studies. Therefore, it is involved in several phases of the learning and teaching process (planning, didactics, assessment, and feedback) through projects to implement didactic strategies and assessment resources, with the support of teacher training, educational research, and technology. Its aim is to improve medical and health sciences education, with the firm purpose of making a positive change in the health care quality from the educational environment. Palabras clave: Modelo educativo, Educación médica, Educación de pregrado en medicina, Ciencias de la salud, Actividades profesionales confiables, Keywords: Educational model, Medical education, Undergraduate medical education, Health sciences, Entrustable professional activitie

Adittional file 2:

“Questionnaire applied to family medicine residents”. The file content refers to: (1) instructions to answer the instrument; (2) socio demographic and academic information; (3) 45 uncertainty situations that the residents may have experienced with 12 multiple choise options for each one. (PDF 269 kb

Percepción de la Utilidad del Expediente Clínico Electrónico en un Instituto Nacional de Salud

INTRODUCTION: The electronic clinical record is one of the most representative development examples of the biomedical informatics in Mexico. However the idea that prevails on the advantages it entails the implementation of this strategy in health facilities, after conducting a thorough review of the Ibero-American medical literature, not found evidence sufficient to recommend it as a good practice. MATERIAL AND METHODS: 890 electronic clinical record users were invited to participate in a public opinion survey Likert-type with a range of responses ranging from anything useful to very useful, they agreed to answer it 577 users among physicians, residents, nurses, administrative staff, social workers, therapists, psychologists and nutritionists/dietitians. The 23 version of the SPSS program was used for statistical analysis. RESULTS: Frequency, internal consistency (Cronbach´s alpha) and interobserver concordance (W Kendall) was calculated for each subset of users previous identification of reagents which shared the questionnaires of different disciplines and were subsequently grouped for each item, analyzing responses through non-parametric tests in order to find differences in the distribution of scores (Kruskal Wallis test), found that the questionnaires for physicians and nutrition staff had greater reliability for internal consistency (Cronbach = α. 943). Greater interobserver agreement took place between physicians (W Kendall =. 530). The questionnaire for nursing was the least consistent and concordant. CONCLUSION: Responses in general, provide evidence to recommend as good practice the use of the electronic clinical record during patients care since health professionals prefer this mode above the traditional clinical record; they believe that it contributes to improving the safety of patients to be more available information and approve its use is widespread in other national institutes of health.INTRODUCCIÓN: El Expediente Clínico Electrónico es uno de los ejemplos más representativos del desarrollo de la Informática Biomédica en México. No obstante la idea que prevalece sobre las ventajas que conlleva la implementación de esta estrategia en los establecimientos de salud, tras realizar una revisión exhaustiva de la literatura médica iberoamericana, no se encontró evidencia suficiente para recomendarla como punto de buena práctica. METODOLOGÍA: Se invitó a 890 usuarios del expediente clínico electrónico a participar en una encuesta de opinión tipo Likert con una gama de respuestas que va desde nada útil a muy útil, accedieron a responderla 577 usuarios entre los cuales se encontraban médicos adscritos y residentes, enfermeras, personal técnico administrativo, trabajadores sociales, terapeutas, psicólogos y nutriólogos/ dietistas. Para el análisis estadístico se utilizó la versión 23 del programa SPSS. RESULTADOS: La frecuencia, consistencia interna (alpha de Cronbach) y concordancia interobservador (W de Kendall) se calculó para cada subgrupo de usuarios previa identificación de los reactivos que compartían los cuestionarios de las diferentes disciplinas y posteriormente se agruparon para cada ítem, analizando las respuestas a través de pruebas no paramétricas con el fin de encontrar diferencias en la distribución de las puntuaciones (Prueba de Kruskal Wallis o de la mediana), se encontró que los cuestionarios para médicos adscritos y para el personal de nutrición tuvieron la mayor confiabilidad por consistencia interna (α de Cronbach= .943). La mayor concordancia interobservador sucedió entre los médicos adscritos (W de Kendall= .530). El cuestionario para enfermería fue el menos consistente y concordante. CONCLUSIÓN: Las respuestas en lo general, aportan evidencia para recomendar como punto de buena práctica el uso del expediente clínico electrónico durante el proceso de atención médica de los pacientes ya que los profesionales de la salud prefieren esta modalidad que el expediente clínico tradicional; consideran que contribuye a mejorar la seguridad de los pacientes al estar más disponible y consultable la información y aprueban que su uso se generalice en otros Institutos Nacionales de Salud

Intraoperative transfusion practices in Europe

Transfusion of allogeneic blood influences outcome after surgery. Despite widespread availability of transfusion guidelines, transfusion practices might vary among physicians, departments, hospitals and countries. Our aim was to determine the amount of packed red blood cells (pRBC) and blood products transfused intraoperatively, and to describe factors determining transfusion throughout Europe. We did a prospective observational cohort study enrolling 5803 patients in 126 European centres that received at least one pRBC unit intraoperatively, during a continuous three month period in 2013. The overall intraoperative transfusion rate was 1.8%; 59% of transfusions were at least partially initiated as a result of a physiological transfusion trigger- mostly because of hypotension (55.4%) and/or tachycardia (30.7%). Haemoglobin (Hb)- based transfusion trigger alone initiated only 8.5% of transfusions. The Hb concentration [mean (sd)] just before transfusion was 8.1 (1.7) g dl and increased to 9.8 (1.8) g dl after transfusion. The mean number of intraoperatively transfused pRBC units was 2.5 (2.7) units (median 2). Although European Society of Anaesthesiology transfusion guidelines are moderately implemented in Europe with respect to Hb threshold for transfusion (7-9 g dl), there is still an urgent need for further educational efforts that focus on the number of pRBC units to be transfused at this threshold

Intraoperative transfusion practices in Europe

BACKGROUND: Transfusion of allogeneic blood influences outcome after surgery. Despite widespread availability of transfusion guidelines, transfusion practices might vary among physicians, departments, hospitals and countries. Our aim was to determine the amount of packed red blood cells (pRBC) and blood products transfused intraoperatively, and to describe factors determining transfusion throughout Europe. METHODS: We did a prospective observational cohort study enrolling 5803 patients in 126 European centres that received at least one pRBC unit intraoperatively, during a continuous three month period in 2013. RESULTS: The overall intraoperative transfusion rate was 1.8%; 59% of transfusions were at least partially initiated as a result of a physiological transfusion trigger- mostly because of hypotension (55.4%) and/or tachycardia (30.7%). Haemoglobin (Hb)- based transfusion trigger alone initiated only 8.5% of transfusions. The Hb concentration [mean (sd)] just before transfusion was 8.1 (1.7) g dl(-1) and increased to 9.8 (1.8) g dl(-1) after transfusion. The mean number of intraoperatively transfused pRBC units was 2.5 (2.7) units (median 2). CONCLUSION: Although European Society of Anaesthesiology transfusion guidelines are moderately implemented in Europe with respect to Hb threshold for transfusion (7-9 g dl(-1)), there is still an urgent need for further educational efforts that focus on the number of pRBC units to be transfused at this threshold. CLINICAL TRIAL REGISTRATION: NCT 01604083