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      Impact of COVID-19 Pandemic on Trauma Theatre Efficiency

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      Cureus
      Cureus
      covid pandemic, theatre efficiency, trauma standardised operating procedures (sops)

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          Abstract

          Introduction

          A large transformation in the management of trauma has ensued following the COVID-19 (coronavirus disease 2019) pandemic. There has been an increase in reliance on guidance for decision-making and alterations in the working of the trauma theatre. This has largely been due to the safety measures implemented. Theatre efficiency has gained increasing importance over the years, and with the added pressure of the pandemic, it is essential that trauma theatres operate efficiently. There has been no data analysing the efficiency of trauma theatre during this pandemic.

          Methods and Results

          We retrospectively analyzed the data at our hospital and looked into the parameters to assess trauma theatre efficiency. It was noted that the operative time and anaesthetic time went up significantly in 2020 in comparison to 2019. Also, the change over time and the late start time was significantly high in 2020. A large proportion of cases did not start on time in 2020. This resulted in a decrease in the efficiency of theatre usage.

          Discussion

          Reduced productivity of the trauma theatre has been due to several reasons, many of which include implementation of safety measures, such as personal protective equipment (PPE), theatre cleaning, recovery of patients, using designated routes for transfer, and many others. The challenge lies in applying these new measures into our daily practice at the same time while providing efficient care.

          Conclusion

          Our study highlights the key areas of concern and improvement which need to be addressed in order to render effective trauma care.

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          Most cited references18

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          What we do when a COVID-19 patient needs an operation: operating room preparation and guidance

          To the Editor, We read with interest the recent review in the Journal by Wax and Christian1 on coronavirus disease 2019 (COVID-19). The first case of COVID-19 in Singapore was confirmed on 23 January 2020.2 In the week of February 13–19, the World Health Organization reported that Singapore had more cases of COVID-19 than any other country outside of mainland China.3 We wish to share the protocol that we use in our hospital in preparing an operating room (OR) for confirmed or suspected COVID-19 patients coming for surgery. An OR with a negative pressure environment located at a corner of the operating complex, and with a separate access, is designated for all confirmed (or suspected) COVID-19 cases. The OR actually consists of five interconnected rooms, of which only the ante room and anesthesia induction rooms have negative atmospheric pressures. The OR proper, preparation, and scrub rooms all have positive pressures (eFig. 1 in the Electronic Supplementary Material [ESM]). Understanding the airflow within the OR is crucial to minimizing the risk of infection. The same OR and the same anesthesia machine will only be used for COVID-19 cases for the duration of the epidemic. An additional heat and moisture exchanger (HME) filter is placed on the expiratory limb of the circuit. Both HME filters and the soda lime are changed after each case. The anesthetic drug trolley is kept in the induction room. Before the start of each operation, the anesthesiologist puts all the drugs and equipment required for the procedure onto a tray to avoid handling of the drug trolley during the case. Nevertheless, if there is a need for additional drugs, hand hygiene and glove changing are performed before entering the induction room and handling the drug trolley. A fully stocked airway trolley is also placed in the induction room. As far as possible, disposable airway equipment is used. The airway should be secured using the method with the highest chance of first-time success to avoid repeated instrumentation of the airway, including using a video-laryngoscope.4 Equipment in limited supply, such as bispectral index monitors or infusion pumps, may be requested but need to be thoroughly wiped down after use. The Figure  details the roles and responsibilities of each OR team member. Hospital security is responsible for clearing the route from the ward or intensive care unit (ICU) to the OR, including the elevators. The transfer from the ward to the OR will be done by the ward nurses in full personal protective equipment (PPE) including a well-fitting N95 mask, goggles or face shield, splash-resistant gown, and boot covers. For patients coming from the ICU, a dedicated transport ventilator is used. To avoid aerosolization, the gas flow is turned off and the endotracheal tube clamped with forceps during switching of ventilators. The ICU personnel wear full PPE with a powered air-purifying respirator (PAPR) for the transfer. Figure Complete operating room workflow for a coronavirus disease 2019 (COVID-19) case. CD = controlled drugs; ICU = intensive care unit; NM = nurse manager; OR = operating room; PAPR = powered air-purifying respirator; PC = personal computer; PPE = personal protection equipment; pre-op = preoperative In the induction room, a PAPR is worn during induction and reversal of anesthesia for all personnel within 2 m of the patient. For operative airway procedures such as tracheostomy, all staff keep their PAPR on throughout the procedure. For other procedures, regional anesthesia is preferable, but if general anesthesia is required, the principles of management are similar to those previously published.1,4 During the procedure, a runner is stationed outside the OR if additional drugs or equipment are needed. These are placed onto a trolley that will be left in the ante room for the OR team to retrieve. This same process in reverse is used to send out specimens such as arterial blood gas samples and frozen section specimens. The runner wears PPE when entering the ante room. Personnel exiting the OR discard their used gowns and gloves in the ante room and perform hand hygiene before leaving the ante room (ESM, eFig. 2). Any PAPR will be removed outside the ante room. Patients who do not require ICU care postoperatively are fully recovered in the OR itself. When the patient is ready for discharge, the route to the isolation ward or ICU is again cleared by security. A minimum of one hour is planned between cases to allow OR staff to send the patient back to the ward, conduct through decontamination of all surfaces, screens, keyboard, cables, monitors, and anesthesia machine. All unused items on the drug tray and airway trolley should be assumed to be contaminated and discarded. All staff have to shower before resuming their regular duties. As an added precaution, after confirmed COVID-19 cases, a hydrogen peroxide vaporizer will be used to decontaminate the OR. In summary, as healthcare workers are at increased risk of coronavirus infection, a comprehensive and robust infection control workflow has been put into place.5 Electronic supplementary material Below is the link to the electronic supplementary material. Supplementary material 1 (PDF 604 kb)
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            Covid-19: all non-urgent elective surgery is suspended for at least three months in England.

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              The cost of trauma operating theatre inefficiency

              The National Health Service (NHS) is currently facing a financial crisis with a projected deficit of £2billion by the end of financial year 2015/16. As operating rooms (OR) are one of the costliest components in secondary care, improving theatre efficiency should be at the forefront of efforts to improve health service efficiency. The objectives of this study were to characterize the causes of trauma OR delays and to estimate the cost of this inefficiency. A 1-month prospective single-centre study in St. Mary's Hospital. Turnaround time (TT) was used as the surrogate parameter to measure theatre efficiency. Factors including patient age, ASA score and presence of surgical and anaesthetic consultant were evaluated to identify positive or negative associations with theatre delays. Inefficiency cost was calculated by multiplying the time wasted with staff capacity costs and opportunity costs, found to be £24.77/minute. The commonest causes for increased TT were delays in sending for patients (50%) and problems with patient transport to the OR (31%). 461 min of delay was observed in 12 days, equivalent to loss of £951.58/theatre/day. Non-statistically significant trends were seen between length of delays and advancing patient age, ASA score and absence of either a senior clinician or an anaesthetic consultant. Interestingly, the trend was not as strong for absence of an anaesthetic consultant. This study found delays in operating TT to represent a sizable cost, with potential efficiency savings based on TT of £347,327/theatre/year. Further study of a larger sample is warranted to better evaluate the identified trends.
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                Author and article information

                Journal
                Cureus
                Cureus
                2168-8184
                Cureus
                Cureus (Palo Alto (CA) )
                2168-8184
                23 November 2020
                November 2020
                : 12
                : 11
                : e11637
                Affiliations
                [1 ] Trauma and Orthopaedics, Walsall Manor Hospital, Walsall, GBR
                Author notes
                Nikhil Aravind Khadabadi nik.khadabadi@ 123456gmail.com
                Article
                10.7759/cureus.11637
                7755676
                33376649
                35045e80-0b5e-42cd-bf79-fd5af1fed9e7
                Copyright © 2020, Khadabadi et al.

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 22 November 2020
                Categories
                Orthopedics
                Quality Improvement
                Trauma

                covid pandemic,theatre efficiency,trauma standardised operating procedures (sops)

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