Operating during the COVID-19 pandemic: How to reduce medical error
Identifieur interne : 000618 ( Pmc/Corpus ); précédent : 000617; suivant : 000619Operating during the COVID-19 pandemic: How to reduce medical error
Auteurs : R. Ellis ; A. G. C. Hay-David ; P. A. BrennanSource :
- The British Journal of Oral & Maxillofacial Surgery [ 0266-4356 ] ; 2020.
Abstract
Our professional and private lives changed on March 11 2020 when the coronavirus disease 2019 (COVID-19) was declared a pandemic by the WHO. By March 16, surgical training was suspended, MRCS and FRCS examinations cancelled and all courses postponed. In theory, essential cancer surgery, emergency and trauma operating will continue. All elective, non-essential cases are currently cancelled. While we adapt to our new ways of working, we remind ourselves that surgeons are flexible, resilient and, ultimately, we are doctors in the first instance. We present a short article on operating during the COVID-19 pandemic.
Url:
DOI: 10.1016/j.bjoms.2020.04.002
PubMed: 32312584
PubMed Central: 7152882
Links to Exploration step
PMC:7152882Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Operating during the COVID-19 pandemic: How to reduce medical error</title><author><name sortKey="Ellis, R" sort="Ellis, R" uniqKey="Ellis R" first="R." last="Ellis">R. Ellis</name><affiliation><nlm:aff id="aff0005">Urology Specialist Registrar, Royal Derby Hospital, Derby, DE22 3NE, UK</nlm:aff></affiliation></author><author><name sortKey="Hay David, A G C" sort="Hay David, A G C" uniqKey="Hay David A" first="A. G. C." last="Hay-David">A. G. C. Hay-David</name><affiliation><nlm:aff id="aff0010">Trauma & Orthopaedic Registrar, Queen Elizabeth University Hospital, Glasgow, G51 4TF, UK</nlm:aff></affiliation></author><author><name sortKey="Brennan, P A" sort="Brennan, P A" uniqKey="Brennan P" first="P. A." last="Brennan">P. A. Brennan</name><affiliation><nlm:aff id="aff0015">Maxillofacial Unit, Queen Alexandra Hospital, Portsmouth, PO6 3LY, UK</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">32312584</idno><idno type="pmc">7152882</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7152882</idno><idno type="RBID">PMC:7152882</idno><idno type="doi">10.1016/j.bjoms.2020.04.002</idno><date when="2020">2020</date><idno type="wicri:Area/Pmc/Corpus">000618</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000618</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Operating during the COVID-19 pandemic: How to reduce medical error</title><author><name sortKey="Ellis, R" sort="Ellis, R" uniqKey="Ellis R" first="R." last="Ellis">R. Ellis</name><affiliation><nlm:aff id="aff0005">Urology Specialist Registrar, Royal Derby Hospital, Derby, DE22 3NE, UK</nlm:aff></affiliation></author><author><name sortKey="Hay David, A G C" sort="Hay David, A G C" uniqKey="Hay David A" first="A. G. C." last="Hay-David">A. G. C. Hay-David</name><affiliation><nlm:aff id="aff0010">Trauma & Orthopaedic Registrar, Queen Elizabeth University Hospital, Glasgow, G51 4TF, UK</nlm:aff></affiliation></author><author><name sortKey="Brennan, P A" sort="Brennan, P A" uniqKey="Brennan P" first="P. A." last="Brennan">P. A. Brennan</name><affiliation><nlm:aff id="aff0015">Maxillofacial Unit, Queen Alexandra Hospital, Portsmouth, PO6 3LY, UK</nlm:aff></affiliation></author></analytic><series><title level="j">The British Journal of Oral & Maxillofacial Surgery</title><idno type="ISSN">0266-4356</idno><idno type="eISSN">1532-1940</idno><imprint><date when="2020">2020</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>Our professional and private lives changed on March 11 2020 when the coronavirus disease 2019 (COVID-19) was declared a pandemic by the WHO. By March 16, surgical training was suspended, MRCS and FRCS examinations cancelled and all courses postponed. In theory, essential cancer surgery, emergency and trauma operating will continue. All elective, non-essential cases are currently cancelled. While we adapt to our new ways of working, we remind ourselves that surgeons are flexible, resilient and, ultimately, we are doctors in the first instance. We present a short article on operating during the COVID-19 pandemic.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Brennan, P A" uniqKey="Brennan P">P.A. Brennan</name></author><author><name sortKey="Holden, C" uniqKey="Holden C">C. Holden</name></author><author><name sortKey="Shaw, G" uniqKey="Shaw G">G. Shaw</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Parry, D" uniqKey="Parry D">D. Parry</name></author><author><name sortKey="Oeppen, R S" uniqKey="Oeppen R">R.S. Oeppen</name></author><author><name sortKey="Gass, H" uniqKey="Gass H">H. Gass</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Parry, D A" uniqKey="Parry D">D.A. Parry</name></author><author><name sortKey="Oeppen, R S" uniqKey="Oeppen R">R.S. Oeppen</name></author><author><name sortKey="Amin, M S A" uniqKey="Amin M">M.S.A. Amin</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Murden, F" uniqKey="Murden F">F. Murden</name></author><author><name sortKey="Bailey, D" uniqKey="Bailey D">D. Bailey</name></author><author><name sortKey="Mackenzie, F" uniqKey="Mackenzie F">F. Mackenzie</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Green, B" uniqKey="Green B">B. Green</name></author><author><name sortKey="Oepen, R S" uniqKey="Oepen R">R.S. Oepen</name></author><author><name sortKey="Smith, D W" uniqKey="Smith D">D.W. Smith</name></author></analytic></biblStruct><biblStruct></biblStruct></listBibl></div1></back></TEI><pmc article-type="research-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">Br J Oral Maxillofac Surg</journal-id><journal-id journal-id-type="iso-abbrev">Br J Oral Maxillofac Surg</journal-id><journal-title-group><journal-title>The British Journal of Oral & Maxillofacial Surgery</journal-title></journal-title-group><issn pub-type="ppub">0266-4356</issn><issn pub-type="epub">1532-1940</issn><publisher><publisher-name>The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd.</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">32312584</article-id><article-id pub-id-type="pmc">7152882</article-id><article-id pub-id-type="publisher-id">S0266-4356(20)30146-7</article-id><article-id pub-id-type="doi">10.1016/j.bjoms.2020.04.002</article-id><article-categories><subj-group subj-group-type="heading"><subject>Article</subject></subj-group></article-categories><title-group><article-title>Operating during the COVID-19 pandemic: How to reduce medical error</article-title></title-group><contrib-group><contrib contrib-type="author" id="aut0005"><name><surname>Ellis</surname><given-names>R.</given-names></name><xref rid="aff0005" ref-type="aff">a</xref></contrib><contrib contrib-type="author" id="aut0010"><name><surname>Hay-David</surname><given-names>A.G.C.</given-names></name><email>hay-david@nhs.net</email><xref rid="aff0010" ref-type="aff">b</xref><xref rid="cor0005" ref-type="corresp">⁎</xref></contrib><contrib contrib-type="author" id="aut0015"><name><surname>Brennan</surname><given-names>P.A.</given-names></name><xref rid="aff0015" ref-type="aff">c</xref></contrib></contrib-group><aff id="aff0005"><label>a</label>Urology Specialist Registrar, Royal Derby Hospital, Derby, DE22 3NE, UK</aff><aff id="aff0010"><label>b</label>Trauma & Orthopaedic Registrar, Queen Elizabeth University Hospital, Glasgow, G51 4TF, UK</aff><aff id="aff0015"><label>c</label>Maxillofacial Unit, Queen Alexandra Hospital, Portsmouth, PO6 3LY, UK</aff><author-notes><corresp id="cor0005"><label>⁎</label>Corresponding author. <email>hay-david@nhs.net</email></corresp></author-notes><pub-date pub-type="pmc-release"><day>13</day><month>4</month><year>2020</year></pub-date><pmc-comment> PMC Release delay is 0 months and 0 days and was based on .</pmc-comment>
<pub-date pub-type="epub"><day>13</day><month>4</month><year>2020</year></pub-date><history><date date-type="accepted"><day>2</day><month>4</month><year>2020</year></date></history><permissions><copyright-statement>© 2020 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.</copyright-statement><copyright-year>2020</copyright-year><copyright-holder>The British Association of Oral and Maxillofacial Surgeons</copyright-holder><license><license-p>Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.</license-p></license></permissions><abstract id="abs0005"><p>Our professional and private lives changed on March 11 2020 when the coronavirus disease 2019 (COVID-19) was declared a pandemic by the WHO. By March 16, surgical training was suspended, MRCS and FRCS examinations cancelled and all courses postponed. In theory, essential cancer surgery, emergency and trauma operating will continue. All elective, non-essential cases are currently cancelled. While we adapt to our new ways of working, we remind ourselves that surgeons are flexible, resilient and, ultimately, we are doctors in the first instance. We present a short article on operating during the COVID-19 pandemic.</p></abstract><kwd-group id="kwd0005"><title>Keywords</title><kwd>COVID-19</kwd><kwd>Pandemic</kwd><kwd>Operating</kwd><kwd>Surgeons</kwd><kwd>Human Factors</kwd></kwd-group></article-meta></front><body><sec id="sec0005"><title>Introduction</title><p id="par0005">The COVID-19 pandemic is likely to be the biggest public health crisis that we will encounter in our lifetimes. The scale of viral spread worldwide, coupled with the subsequent burden on healthcare systems, makes tackling the virus a monumental task. Governments around the world are employing strategies to minimise loss of life while trying to maintain functioning economies. The changes in healthcare in the United Kingdom, seen over the last few weeks, are unprecedented. Intensive care capacity has been increased exponentially, resources including personal protection equipment (PPE) and ventilators are being manufactured at an impressive rate, and, the workforce is being mobilised or redeployed. It is estimated that 2, 660 doctors are among the 12,000 retired NHS staff returning to clinical practice.<xref rid="bib0005" ref-type="bibr"><sup>1</sup></xref> Medical and nursing students are volunteering their services. Final year medical students will have their graduation date brought forward in order to join the workforce. Since its launch on March 24 2020, 405,000 people applied to be a NHS volunteer responder within the first 24 hours. This number now stands at 700,000.<xref rid="bib0010" ref-type="bibr"><sup>2</sup></xref></p><p id="par0010">The response from the general public is mixed: one of fear and frustration. Initially manifested as panic-buying from supermarkets (soap, antibacterial hand gel, and toilet rolls), there is now a gradual acceptance that social distancing and self-isolation will stop the spread of covid-19 and thereby reduce the strain on the NHS. At time of writing 203 countries / areas are affected with 754,948 confirmed cases and 36,571 confirmed deaths.<xref rid="bib0015" ref-type="bibr"><sup>3</sup></xref> Conference centres are being converted into temporary hospitals to treat the less critical Covid-19 cases: Excel Centre, London (Nightingale Hospital) and with further plans for Manchester Central Conference Centre, Birmingham and Glasgow’s SEC Centre.</p></sec><sec id="sec0010"><title>Adapting to our new roles</title><p id="par0015">Updates from the four Royal Surgical Colleges have been delivered on a regular basis, providing support by keeping dialogue open (emails and webinars) and by providing educational material.</p><p id="par0020">It is unsurprising that some clinicians find this an unfamiliar and unnerving time with loss of routine and a rota that changes weekly (if not daily). A reminder by Dame Clare Marx, GMC Chair, that we must be flexible: to stick to basic principles; to adhere to GMC guidance; work intelligently; and, minimise risks to our own health.<xref rid="bib0020" ref-type="bibr"><sup>4</sup></xref></p><p id="par0025">With the cancellation of elective operating and clinics, clinicians are being redistributed throughout hospitals to assist colleagues in other specialties. These may include roles outside our comfort zones / normal remit. Many surgical colleagues are being trained in managing unwell patients suffering with coronavirus on the wards, others have been supporting emergency departments and intensive care units.</p><p id="par0030">Despite covering an increasing number of patients admitted with COVID-19, surgeons will still be dealing with emergency surgical admissions and will continue to operate on emergency cases. Many of these patients will be COVID-19 positive when tested and some may be acutely unwell as a result of the infection. Emergency operating during the COVID-19 crisis can be challenging for a wide variety of reasons. Additionally, we have started to see patients presenting late to hospital with advanced surgical pathology often due to a fear of hospital admission during this pandemic or due to a reduction in outpatient activity.</p></sec><sec id="sec0015"><title>What we can do now</title><p id="par0035">In light of these new and unfamiliar challenges, there are resources available to help surgeons revise their knowledge of acute medicine and receive updates on COVID-19 via webinars<xref rid="bib0025" ref-type="bibr">5</xref>, <xref rid="bib0030" ref-type="bibr">6</xref>; critical care websites with up to date guidelines and handbooks (such as the intensive care society: <ext-link ext-link-type="uri" xlink:href="http://www.ics.ac.uk/ICS/handbooks.aspx" id="intr0005">www.ics.ac.uk/ICS/handbooks.aspx</ext-link>); Systemic Training in Acute Illness Recognition and Treatment for Surgery (START) course, that includes a human factors presentation, on the RCS website; Non-Technical Skills for Surgeons course (NOTSS) presentations are available on the RCS Edinburgh website (<ext-link ext-link-type="uri" xlink:href="http://www.rcsed.ac.uk" id="intr0010">www.rcsed.ac.uk</ext-link>) to both members and non-members.</p></sec><sec id="sec0020"><title>Human factors and non-technical skills</title><p id="par0040">A greater understanding and appreciation for human factors (HF) can have a significant impact in the reduction of surgical error in such challenging circumstances.<xref rid="bib0035" ref-type="bibr"><sup>7</sup></xref></p><p id="par0045">Surgeons will find themselves operating in different theatres to normal and with unfamiliar (or different) equipment. Theatre teams may be unfamiliar with a particular specialty and we may find ourselves operating out of hours more frequently on acutely unwell patients. Never has there been a more important time to utilise our non-technical skills to reduce the risk of surgical error.</p><p id="par0050">We must take care to introduce ourselves and our role to all new team members during the briefing, to outline the proposed operation and its steps and to ensure all of the required equipment has been sourced before proceeding. Clarify any expected or potential concerns from a surgical and an anaesthetic perspective and ask the team if they have any questions. In some situations, surgical options may be limited by the patient’s general health or other factors, it is therefore important that these are considered before the planned procedure begins. The patient’s COVID-19 status must also be identified to ensure the appropriate PPE is used in line with the trust’s and Public Health England (PHE) advice.</p></sec><sec id="sec0025"><title>Personal protective equipment</title><p id="par0055">At time of writing, PHE advise full PPE (FFP3 mask, visor or safety glasses, gown and gloves) for aerosol generating procedures (AGPs) for patients with known or symptomatic COVID-19. There is currently variation in practise between trusts as to whether all patients should be treated as having COVID-19.</p><p id="par0060">Masks require training to ensure correct fit. Some trusts use the N95 mask that you must “pass” the test in order to use safely. If you are able to taste the aerosolised bitter solution sprayed you have “failed” the test and it is ineffective in providing protection. Training is also required in the donning and doffing process to ensure this is done correctly and minimises your own risk of exposure.</p><p id="par0065">Operating can be challenging: uncomfortable and unfamiliar. Full PPE can be distracting when first worn, therefore where possible operate with other senior team members to reduce the risk of error. Furthermore, as we have experienced, FFP3 masks can make some procedures such as operating down a microscope more challenging as it can affect the usual comfortable eye positions (<xref rid="fig0005" ref-type="fig">Fig. 1</xref>).<fig id="fig0005"><label>Fig. 1</label><caption><p>FFP3 mask and visor can impede certain procedures such as getting close to an operating microscope.<xref rid="bib0060" ref-type="bibr"><sup>12</sup></xref></p></caption><alt-text id="at0005">Fig. 1</alt-text><graphic xlink:href="gr1_lrg"></graphic></fig></p><p id="par0070">Wearing face masks and hoods can also significantly reduce the clarity of verbal communication between theatre staff. Additionally, it may be more difficult than usual to read non-verbal cues. Therefore, care must be taken to ensure open, focussed channels of communication are established between all team members throughout the entire procedure. We must use names to address individual team members and ask people to repeat our requests back to us to ensure a shared understanding.</p><p id="par0075">Situational awareness may be impaired given the circumstances; therefore care should be taken to ensure all team members are aware of our expectations for the procedure including volume of blood loss and duration. Consider allocating roles for various members of the team to raise the alarm if these exceed what is expected.</p><p id="par0080">Operating in full PPE can also be exhausting, when performing long procedures, breaks may be required to prevent fatigue. Dehydration and hunger are also linked to an increased risk of surgical error; therefore it is imperative that we look after ourselves at work.<xref rid="bib0040" ref-type="bibr"><sup>8</sup></xref> Lack of sleep has been attributed to slower cognitive processing and decision making, increasing the risk of error.<xref rid="bib0045" ref-type="bibr"><sup>9</sup></xref> Despite increasing workloads during this pandemic it is essential that clinicians take care of their own health to optimise their ability to care for others.</p><p id="par0085">Burn out amongst clinicians may become more common in such a demanding environment. It is important that we look out for this in ourselves and our colleagues, recognising and dealing with this early before it can lead to suboptimal performance.<xref rid="bib0050" ref-type="bibr"><sup>10</sup></xref> Many clinicians are away from families in order to avoid risk to loved ones. There are also more widespread concerns causing stress and anxiety: COVID-19 testing (patients and healthcare workers); distrust of governmental decisions; unnecessary “fake” news and scaremongering; concern over inconsistent policies by different trusts in the UK on PPE use (WHO standards versus PHE advice); concern for an overstretched health service that cannot deliver care; and, normal concerns for their own heath and that of their families. Trusts have access to support for healthcare workers suffering from burn out which should be utilised at the earliest opportunity.</p></sec><sec id="sec0030"><title>Conclusion</title><p id="par0090">We have entered a period of unease and uncertainty due to the COVID-19 pandemic and are seeing unprecedented changes in healthcare: junior members of staff training their seniors on how to complete ward jobs and other administrative tasks; intensive care nurses supervising non-intensive care unit doctors looking after patients in over-flow ICU spaces; surgeons working alongside physicians; and, senior team members taking bloods and cannulating patients.</p><p id="par0095">Overall, this public health crisis has united us in our pursuit of a common goal - flattening the work hierarchy and provoking a considerable change in the way we work in the UK.<xref rid="bib0055" ref-type="bibr"><sup>11</sup></xref> When we emerge from this crisis, we hope that we will continue to work together as valued team members.</p></sec><sec id="sec0035"><title>Conflict of interest</title><p id="par0100">We have no conflicts of interest.</p></sec><sec id="sec0040"><title>Ethics statement/confirmation of patients’ permission</title><p id="par0105">Not applicable.</p></sec></body><back><ref-list id="bibl0005"><title>References</title><ref id="bib0005"><label>1</label><mixed-citation publication-type="other" id="oref0005">Booth R., Campbell D. 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(2020). 1 April. Available here: <ext-link ext-link-type="uri" xlink:href="https://twitter.com/BrennanSurgeon?lang=en-gb" id="intr0045">https://twitter.com/BrennanSurgeon?lang=en-gb</ext-link> (Accessed April 1 2020).</mixed-citation></ref></ref-list></back></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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