Alcohol skin preparation causes surgical fires.

INTRODUCTION: Surgical fires are a rare but serious preventable safety risk in modern hospitals. Data from the US show that up to 650 surgical fires occur each year, with up to 5% causing death or serious harm. This study used the National Reporting and Learning Service (NRLS) database at the National Patient Safety Agency to explore whether spirit-based surgical skin preparation fluid contributes to the cause of surgical fires. METHODS: The NRLS database was interrogated for all incidents of surgical fires reported between 1 March 2004 and 1 March 2011. Each report was scrutinised manually to discover the cause of the fire. RESULTS: Thirteen surgical fires were reported during the study period. Of these, 11 were found to be directly related to spirit-based surgical skin preparation or preparation soaked swabs and drapes. CONCLUSIONS: Despite manufacturer's instructions and warnings, surgical fires continue to occur. Guidance published in the UK and US states that spirit-based skin preparation solutions should continue to be used but sets out some precautions. It may be that fire risk should be included in pre-surgical World Health Organization checklists or in the surgical training curriculum. Surgical staff should be aware of the risk that spirit-based skin preparation fluids pose and should take action to minimise the chance of fire occurring

The minor chicken class I gene BF1 is deleted between short imperfect direct repeats in the B14 and typical B15 major histocompatibility complex (MHC) haplotypes

The chicken major histocompatibility complex (MHC, also known as the BF-BL region of theB locus) is notably small and simple with few genes, most of which are involved in antigenprocessing and presentation. There are two classical class I genes, of which only BF2 is wellandsystemically-expressed as the major ligand for cytotoxic T lymphocytes (CTLs). The otherclass I gene, BF1, is believed to be primarily a natural killer (NK) cell ligand. Among moststandard chicken MHC haplotypes examined in detail, BF1 is expressed ten-fold less thanBF2 at the RNA level due to defects in the promoter or in a splice site. However, in the B14and typical B15 haplotypes, BF1 RNA was not detected and here we show that a deletionbetween imperfect 32 nucleotide direct repeats has removed the BF1 gene entirely. Thephenotypic effects of not having a BF1 gene (particularly on resistance to infectiouspathogens) have not been systematically explored, but such deletions between short directrepeats are also found in some BF1 promoters and in the 5’ untranslated region (5’UTR) ofsome BG genes found in the BG region of the B locus. Despite the opposite transcriptionalorientation of homologous genes in the chicken MHC, which might prevent the loss of keygenes from a minimal essential MHC, it appears that small direct repeats can still lead todeletion

Patient Safety Incidents Caused by Poor Quality Surgical Instruments

Objectives: Surgeons require high-quality surgical instruments to carry out successful procedures. Poor quality instruments may break intraoperatively leading to a failed procedure or causing harm to the patient. By examining the National Reporting and Learning Service (NRLS) database, the study aims to define the scale of the problem and provide evidence for the formation of surgical instrument quality control.Methods: The NRLS was searched from August 2004 - December 2010. The search revealed 2036 incidents, 250 of which were randomly selected and analyzed by a clinical reviewer.Results: One hundred and sixty-one incidents were identified causing five reoperations, one incident of severe harm, six incidents of moderate harm, 35 of low harm, and 119 no harm incidents. No patient deaths were discovered. Drillbits were the most commonly broken instrument.Conclusions: This report is likely to only be the tip of the iceberg. Poor reporting of patient safety incidents means that there may be as many as 1500 incidents a year of poor quality surgical instruments causing harm. We suggest that forming a Surgical Instrument Quality Service at Trusts within the National Health Service (NHS) could prevent harm coming to patients, reduce cost, and improve the outcomes of surgical procedures. <br/

Utility of bedside leucocyte esterase testing to rule out septic arthritis

IntroductionSuspected septic arthritis is a common presentation to EDs. The underlying diagnosis is often non-infective pathology. Differentiating between aetiologies is difficult. A bedside test with high negative predictive value (NPV) may allow safe discharge of patients, reduce the time in the ED, hospital admission and associated costs. This study aims to evaluate the NPV of bedside leucocyte esterase (LE) in the assessment of these patients.MethodsA prospective multicentre observational study of ED adult patients referred to orthopaedics with suspected native joint septic arthritis between October 2015 and April 2016. At three hospital sites in the Bristol region, the results of the LE test exposed to aspirated synovial fluid were recorded along with Gram stain, culture, haematinics and length of stay. A positive LE test was considered 2+ or 3+ leucocytes based on the test strip colour. Data were analysed to establish sensitivity, specificity, NPV and positive predictive value (PPV) against the gold standard 48-hour culture. We determined the potential number of inpatient bed-days that might be avoided using this bedside test.ResultsEighty patients underwent joint aspiration. Five cases had positive 48-hour culture. All (5/5) infected cases showed ≥2+ LE, sensitivity of 100% (95% CI 47.8% to 100%) while the Gram stain was positive in only one case (sensitivity 20%, 95% CI 0.51% to 71.6%). Twenty-three LE were read negative or 1+, all with negative 48-hour culture results, resulting in an NPV of 100% (95% CI 82.1% to 1.00%) for a negative LE test. Specificity of a positive LE test was 30.7% (95% CI 20.5% to 42.45%) with PPV of 8.77% (95% CI 7.64% to 10.1%). It was calculated that 57 orthopaedic bed-days could have potentially been saved by immediately discharging those with a negative LE test.ConclusionsLE point-of-care testing for suspected septic arthritis of native joints has a high NPV. Implementation of LE may facilitate more rapid discharge of patients with negative results. This test has the potential to reduce diagnostic uncertainty and costs to the healthcare system

Opioid Use Prior to Adult Spine Deformity Correction Surgery is Associated With Worse Pre- and Postoperative Back Pain and Prolonged Opioid Demands

Opioid use; Pain management; Spine surgeryConsum d'opioides; Gestió del dolor; Cirurgia de la columna vertebralConsumo de opioides; Gestión del dolor; Cirugía de la columna vertebralStudy Design Prospective multicenter database post-hoc analysis. Objectives Opioids are frequently prescribed for painful spinal conditions to provide pain relief and to allow for functional improvement, both before and after spine surgery. Amidst a current opioid epidemic, it is important for providers to understand the impact of opioid use and its relationship with patient-reported outcomes. The purpose of this study was to evaluate pre-/postoperative opioid consumption surrounding ASD and assess patient-reported pain outcomes in older patients undergoing surgery for spinal deformity. Methods Patients ≥60 years of age from 12 international centers undergoing spinal fusion of at least 5 levels and a minimum 2-year follow-up were included. Patient-reported outcome scores were collected using the Numeric Rating Scale for back and leg pain (NRS-B; NRS-L) at baseline and at 2 years following surgery. Opioid use, defined based on a specific question on case report forms and question 11 from the SRS-22r questionnaire, was assessed at baseline and at 2-year follow-up. Result Of the 219 patients who met inclusion criteria, 179 (81.7%) had 2-year data on opioid use. The percentages of patients reporting opioid use at baseline (n = 75, 34.2%) and 2 years after surgery (n = 55, 30.7%) were similar (P = .23). However, at last follow-up 39% of baseline opioid users (Opi) were no longer taking opioids, while 14% of initial non-users (No-Opi) reported opioid use. Regional pre- and postoperative opioid use was 5.8% and 7.7% in the Asian population, 58.3% and 53.1% in the European, and 50.5% and 40.2% in North American patients, respectively. Baseline opioid users reported more preoperative back pain than the No-Opi group (7.0 vs 5.7, P = .001), while NRS-Leg pain scores were comparable (4.8 vs 4, P = .159). Similarly, at last follow-up, patients in the Opi group had greater NRS-B scores than Non-Opi patients (3.2 vs 2.3, P = .012), but no differences in NRS-Leg pain scores (2.2 vs 2.4, P = .632) were observed. Conclusions In this study, almost one-third of surgical ASD patients were consuming opioids both pre- and postoperatively world-wide. There were marked international variations, with patients from Asia having a much lower usage rate, suggesting a cultural influence. Despite both opioid users and nonusers benefitting from surgery, preoperative opioid use was strongly associated with significantly more back pain at baseline that persisted at 2-year follow up, as well as persistent postoperative opioid needs

Effect of a Digital Health Exercise Program on the Intention for Spinal Surgery in Adult Spinal Deformity: Exploratory Cross-Sectional Survey

BACKGROUND: Adult spinal deformity (ASD) is a prevalent condition estimated at 38%. Symptomatic ASD is associated with substantial health care costs. The role of nonoperative interventions in the management of ASD remains elusive. The National Scoliosis Clinic\u27s (NSC) scoliosis realignment therapy (SRT) is a personalized digital health exercise program for the nonoperative management of ASD. OBJECTIVE: This exploratory study had two objectives: (1) to evaluate the effect of the SRT program on users\u27 intention of having spinal fusion; and (2) from a US payer perspective, to estimate the annual cost savings per 100,000 beneficiaries by averting spinal surgery. METHODS: Individuals were enrolled in the SRT study from October 1, 2023 to September 1, 2024. Participants completed a web-based, cross-sectional survey about their history of prior scoliosis surgery and intent of having surgery before and after use of SRT (on a 4-point Likert scale, where 1 = No Intent for Surgery and 4 = High Intent for Surgery ). Intent for surgery before and after participation in SRT was compared using a nonparametric Wilcoxon signed-rank test for paired data. Annual cost savings per 100,000 beneficiaries by averting spinal fusions were estimated separately for commercial payers and Medicare using published literature and public data sources. Payer expenditures were inflation-adjusted to 2024 US dollars using the Hospital Services component of the Consumer Price Index. RESULTS: A total of 62 NSC members (38.8%) responded to the survey and were enrolled in the SRT program for an average (SD) of 17 (12) weeks. The mean (SD) age was 65.3 (13.5) years, and the majority were female (47/48, 98%) and White (45/46, 98%). Among the SRT users who did not have prior scoliosis surgery (n=56), 14% (8/56) reported a decrease in intent for surgery (that is, a lower Likert score) with the use of SRT. The mean (SD) intent for surgery scores before compared to after SRT were 1.29 (0.53) and 1.14 (0.35), respectively (mean difference 0.15 [P=.006]). Participants with No Intent for Surgery pre- versus postuse of SRT (42/56 versus 48/56, respectively) corresponded to an absolute risk reduction of 11% and a number needed to treat of 9 to avert one spinal fusion. Among the 6 participants who transitioned to No Intent for spinal surgery with the use of SRT, 3 were aged \u3c 65 years and 3 were ≥65 years of age. The annual cost savings from averted spinal surgeries were estimated at US $415,000 per 100,000 commercially-insured beneficiaries and US$617,000 per 100,000 Medicare beneficiaries. CONCLUSIONS: SRT is a personalized, scoliosis-specific digital health exercise program with the potential for averting 1 spinal surgery for every 9 participants, resulting in a substantial reduction in payer expenditures while improving the quality of care for commercial payers and Medicare beneficiaries

A realist analysis of hospital patient safety in Wales:Applied learning for alternative contexts from a multisite case study

Background: Hospital patient safety is a major social problem. In the UK, policy responses focus on the introduction of improvement programmes that seek to implement evidence-based clinical practices using the Model for Improvement, Plan-Do-Study-Act cycle. Empirical evidence that the outcomes of such programmes vary across hospitals demonstrates that the context of their implementation matters. However, the relationships between features of context and the implementation of safety programmes are both undertheorised and poorly understood in empirical terms. Objectives: This study is designed to address gaps in conceptual, methodological and empirical knowledge about the influence of context on the local implementation of patient safety programmes. Design: We used concepts from critical realism and institutional analysis to conduct a qualitative comparative-intensive case study involving 21 hospitals across all seven Welsh health boards. We focused on the local implementation of three focal interventions from the 1000 Lives+ patient safety programme: Improving Leadership for Quality Improvement, Reducing Surgical Complications and Reducing Health-care Associated Infection. Our main sources of data were 160 semistructured interviews, observation and 1700 health policy and organisational documents. These data were analysed using the realist approaches of abstraction, abduction and retroduction. Setting: Welsh Government and NHS Wales. Participants: Interviews were conducted with 160 participants including government policy leads, health managers and professionals, partner agencies with strategic oversight of patient safety, advocacy groups and academics with expertise in patient safety. Main outcome measures: Identification of the contextual factors pertinent to the local implementation of the 1000 Lives+ patient safety programme in Welsh NHS hospitals. Results: An innovative conceptual framework harnessing realist social theory and institutional theory was produced to address challenges identified within previous applications of realist inquiry in patient safety research. This involved the development and use of an explanatory intervention–context–mechanism–agency–outcome (I-CMAO) configuration to illustrate the processes behind implementation of a change programme. Our findings, illustrated by multiple nested I-CMAO configurations, show how local implementation of patient safety interventions are impacted and modified by particular aspects of context: specifically, isomorphism, by which an intervention becomes adapted to the environment in which it is implemented; institutional logics, the beliefs and values underpinning the intervention and its source, and their perceived legitimacy among different groups of health-care professionals; and the relational structure and power dynamics of the functional group, that is, those tasked with implementing the initiative. This dynamic interplay shapes and guides actions leading to the normalisation or the rejection of the patient safety programme. Conclusions: Heightened awareness of the influence of context on the local implementation of patient safety programmes is required to inform the design of such interventions and to ensure their effective implementation and operationalisation in the day-to-day practice of health-care teams. Future work is required to elaborate our conceptual model and findings in similar settings where different interventions are introduced, and in different settings where similar innovations are implemented. Funding: The National Institute for Health Research Health Services and Delivery Research programme