The Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) would like to dismiss the misleading information shared by Mr Jack Bloom regarding cancelled operations.
CMJAH would like to put it on record that there were no “more than 50 elective cases cancelled due to the cold weather conditions”. The statement by Mr Bloom creates the impression that all elective cases were cancelled, which is not true.
There were 53 operations scheduled for Monday, 10 July 2023, and 26 cases were done, while only 15 were cancelled due to low temperatures at theatres and 12 were cancelled for reasons not related to low temperatures.
Out of the 15 cancelled cases, 3 were for Thoracic, 6 were for Trauma Orthopaedic, 2 were for Paeds Orthopaedic, 1 was for Paeds plastics, and 3 were for Ear, Nose, & Throat.
The problem of temperature control has been a challenge for the facility for years, but it became worse in the last two years due to the copper theft which took place during the period when the facility was evacuated for months after the fire incident. This affected the central heating system of the facility, which regulates the level of acceptable temperatures in the entire hospital, but mostly in the theatres.
To remedy the situation, the process of installing Schedule 40 pipes, which are less susceptible to theft as they do not have an attractive market value as copper does, has started. During the installation process, the theatres and intensive care units (ICU) were prioritised. From the date of appointment, 28 June 2023, to date, the contractor has completed the installation of schedule 40 pipes for Blocks 2, 3 and 4. The installation process at Block 5 has already started and the work is progressing well, ahead of schedule.
The water system is currently running, with close monitoring, at all three blocks where the schedule 40 pipes were installed to check for any possible leaks as the system has not been running for the past two years.
The facility would like to apologise to the public for any inconvenience this might have caused. The installation of the schedule 40 pipes is a necessary project that would address the issue of copper theft and the central heating system.
The facility would further like to assure the public that this matter is getting the urgency it deserves, and cancelled cases are being attended to.
A plastic surgeon in the US has had her medical licence permanently revoked for livestreaming parts of her surgeries and causing harm to her patients while doing so, according to the Washington Post.
Dr Katherine Grawe, who was also fined US$4500, streamed her operations with between 100 000 and 500 000 viewers at a time, speaking to the camera and on occasion answering viewers’ questions.
Three of her patients whose surgeries she had streamed experienced complications – infections, a perforated intestine and a loss of brain function – that required further medical care. She told the Washington Post that she did not believe that her livestreaming her surgeries had resulted in harm to her patients.
“Nobody wants a complication, and we never want things to go poorly, but any complications that happened with me were not because I was not paying attention,” Grawe said. “My whole goal in life is to give these people confidence and make them more beautiful. And, unfortunately, they suffered these complications, and I feel very sad for them. I would never want anything bad to happen to them.”
She specialised in cosmetic surgery for women’s breasts, as well as tummy tucks and other procedures, Grawe said. She is also being sued by the three patients who had complications. Since she started practising in 2010 with her Dr Roxy practice, she built up a social media following and eventually began livestreaming on TikTok in an effort to break down “this scary wall” between patients and doctors. Her patients all signed consent forms for their procedures to be livestreamed.
Grawe’s licence was suspended in November, and she pleaded with the board, saying that she would never livestream her surgeries again. The board was not moved by her appeal. “Dr Grawe’s social media was more important to her than the lives of the patients she treated,” the board stated.
The board had warned her in 2018 over patient confidentiality concerns in her livestreaming, and again in 2021.
Surgeries conducted in front of an audience are nothing new in medicine; medical students and clinicians alike observe procedures to learn and share knowledge. Some operating theatres are specially designed to host audiences behind windows overlooking the operating table. In the 21st century, it has become commonplace for educational livestreaming of surgeries, with considerable benefits for surgeons and increased anatomy knowledge scores.
There is also some evidence of risks to patients: one review found no increased risk of harm in urology, but this was not true for other surgical fields. Thirteen
Unlike in-person viewing of surgeries, data protection considerations must be employed as operating on a patient often may reveal identifiable information even if not livestreaming to a wide audience. Certain video conferencing platforms may not be secure, and recordings of the procedure may inadvertently be accessible to others, eg being stored on network drives, on the cloud without password protection and so on. There are secure communication apps that can be used to confidentially view and share patient data, such as TigerConnect, Medic Bleep, Forward Health and Siilo.
In a review of patient treatment data, researchers have found that surgical stabilisation of odontoid fractures was associated with better outcomes than nonsurgical approaches. The article will appear in the September issue of Neurosurgery.
Michael B. Cloney, MD, MPH, of the Department of Neurological Surgery at Northwestern University in Chicago, and colleagues have published evidence that surgery should be considered as the initial approach for many patients. Compared with nonoperative approaches to treatment, surgical stabilisation of the fracture was associated with less myelopathy (mobility impairment due to spinal cord damage), and lower rates of fracture nonunion, 30-day mortality, and one year mortality.
“Given the increasing incidence of odontoid fractures with the aging population, we believe our findings could assist with neurosurgical decision-making for an increasingly common and complex problem,” the researchers say.
Accounting for nonrandomised patient groups
Dr Cloney and his colleagues reviewed initial treatment data on 296 patients who were cared for at Northwestern Memorial Hospital between January 1, 2010, and December 31, 2020, because of an odontoid fracture. Their average age was 73. During the hospitalisation, 22% had surgery and 78% had nonoperative treatment (5% were immobilised in a halo-vest and 73% received a cervical collar).
Since the patients weren’t randomised to these treatments, the research team used a type of analysis called propensity score adjustment. They calculated “propensity scores” for each individual – the probability that the patient would have been assigned to receive one of the two treatment approaches based on certain characteristics.
For example, to study the effect of surgery on mortality rates, patients were matched on age, sex, Injury Severity Score, Nurick score (a measure of myelopathy), their number of chronic diseases and chronic conditions such as smoking, and whether they had to be admitted to the intensive care unit.
Surgical stabilisation leads to better results
Follow up with patients lasted an average of 45 weeks. On the propensity score–matched analyses, the group that underwent surgery showed significantly better outcomes than the nonoperative group:
Lower rate of fracture nonunion – 39.7% vs 57.3%; treatment effect, 15% less risk of nonunion
Lower 30-day mortality rate – 1.7% vs 13.8%; treatment effect, 10% less risk of death
Lower one year mortality rate – 7.0% vs 23.7%; treatment effect, 10% less risk of death
Other analyses showed patients in the surgery group were 52% less likely than those in the nonoperative group to have poor Nurick scores at the 26-week postoperative follow-up visit and were 41% less likely to die during the overall follow-up period. Both differences were statistically significant.
“The mortality benefit calculated in the existing literature typically represents an unadjusted mortality rate between two potentially different populations, which leaves it liable to confounding,” the authors note. “Our study represents a relatively large institutional series that suggests a benefit from surgical stabilisation in this population while controlling for confounding factors more thoroughly than existing literature.”
Most ischaemic stroke patients taking the anticoagulant warfarin were no more likely than those not on the medication to experience a brain bleed when undergoing endovascular thrombectomy (EVT), UT Southwestern Medical Center researchers report in a new study. The findings, published in JAMA, could help doctors better gauge the risk of EVT, widening the pool of patients for this intervention.
“Although not very common, patients taking warfarin may still experience a stroke. In clinical practice, it’s very possible that some physicians may withhold an endovascular thrombectomy because patients have been treated with warfarin before their strokes. Our study could increase the number of patients for whom this lifesaving and function-saving surgery would be appropriate,” said study leader Ying Xian, MD, PhD, Associate Professor of Neurology at UT Southwestern.
EVT – a surgery that removes the clot by threading instruments through the blood vessels – is the most common treatment for acute ischaemic stroke. EVTs can sometimes cause potentially fatal symptomatic intracranial haemorrhage (sICH), Dr Xian explained. Although warfarin is a known risk factor for bleeding, it’s been unknown whether the risk of sICH following EVT is higher for stroke patients who have been on the blood thinner.
To help answer this question, Dr Xian worked with Eric Peterson, MD, MPH, Professor of Internal Medicine at UTSW, along with colleagues from other medical institutions across the country. Together, they gathered data on 32 715 stroke patients who underwent EVT within six hours of stroke symptom onset between 2015 and 2020. Data came from the American Heart Association’s Get with the Guidelines-Stroke registry – the world’s largest registry of stroke patients.
The researchers compared a variety of outcomes for the 3087 patients who took warfarin prior to stroke and the 29 628 patients who did not take any blood thinner. They evaluated whether patients experienced sICH within 36 hours of their EVT procedure, whether they had a serious systemic haemorrhage, or whether they had other complications that required additional medical intervention or an extended hospital stay. Researchers also tracked complications from additional therapies that reintroduced blood flow in the brain, in-hospital deaths, and discharges to hospice care.
After adjusting for differences inherent to patients taking or not taking warfarin, the researchers found no difference in overall risk of sICH or other adverse outcomes in patients in these two groups. However, patients with an international normalised ratio (INR) greater than 1.7 – a measure of clotting tendency of blood in patients taking warfarin – the risk of experiencing sICH increased by about 4%.
Whether this effect translates into worse outcomes for patients is unclear, Dr Peterson said. Except for higher risk of bleeding, these patients with INRs greater than 1.7 were no more likely than those not taking warfarin to die or have worse functional outcomes at discharge.
“Physicians must evaluate stroke patients on a case-by-case basis to determine whether EVT is appropriate, but our study suggests that taking warfarin alone should not necessarily be a limiting factor,” he added.
Drs Xian and Peterson said they are planning to study whether other anticoagulants frequently taken by patients at risk of stroke might increase the risk of sICH or other serious complications following EVT for ischaemic stroke.
Surgical knot tied on a rigid support. Credit: Alain Herzog / EPFL
Surgeons knot sutures intuitively. While simple square and granny sliding knots are often used in surgery, it takes years to master them so that they stay in place without loosening or breaking. Much mathematical research has been done on knot topology and geometry, but little is known about the physics of knot mechanics, like the material properties of knotted filaments. Now, in Science Advances, researchers have published the first physics-based study on the mechanics of surgical knots, and exactly what properties influence their strength.
“It’s astonishing to think how much we rely on knots, when we don’t really understand how they work,” says Pedro Reis, head of the Flexible Structures Lab in the School of Engineering (Institute of Mechanical Engineering). Reis and PhD student Paul Johanns teamed up with Lausanne-based plastic surgeon Samia Guerid to lead the study.
“Understanding surgical knot mechanics can raise awareness among experienced surgeons, be incorporated into training programs, and advance robotic surgery by enabling more effective knot-tying capabilities,” says Guerid. “Such knowledge could also influence the development of suture materials that enhance slippage resistance in sliding knots.”
The power of plasticity
Reis, an avid climber, has a personal interest in secure knots and has conducted several previous studies on knot mechanics. He explains that many knots can be described as free-ended structures that provide a holding force, with their functionality dictated by the variables of topology, geometry, elasticity, contact, and friction. But for the study of surgical knots, Reis and his colleagues considered a key sixth factor: polymer plasticity of the suturing filament.
The strength of sutures made from polypropylene filaments used in surgery depends on the tension applied during the tying of the knot (pretension). This pretension permanently deforms, or stretches the filament, creating a holding force. Too little pretension causes the knot to come undone; too much snaps the filament.
The team analyzed 50-100 knots tied by Guerid, and found that the surgeon was able, thanks to her years of experience, to intuitively target the pretension ‘sweet spot’. Using precision experiments, X-ray micro-computed tomography, and computer simulations, the scientists defined a threshold between ‘loose’ and ‘tight’ knots, and uncovered relationships between knot strength and pretension, friction, and number of throws.
“Surprisingly, despite the complex interplay between all six factors, we observed a simple, robust emergent behavior vis-à-vis knot strength. But we still don’t have a predictive model to fully explain the relationship between knot pretension and strength, which seems to be consistent, even outside surgical knots. We’re already looking into this question.”
A training tool for surgeons…and robots
The team’s findings could be a valuable tool for training surgeons, as they could allow the parameters of a secure knot to be translated into practical guidelines. While experience would remain important, the idea is that safe knot-tying could be taught using predictive models, rather than intuition gained only through years of practice.
“Our data gives us a recipe for determining the ideal pretension and number of throws, for example, depending on the type of filament used,” Reis says
“The lack of physics-based analysis has been a limitation,” Guerid adds. “Quantifiable data on knot mechanics could be integrated into training programs to assess the tensile strength of each knot, ensuring trainees acquire necessary skills for successful surgeries. The data could also facilitate development of robotic surgery via the programming of robotic systems.”
Despite significant advances over the last 30 years, surgical research is still limited to comparing the benefit of one technique over another. It can be founded on assumptions that a new device or approach is always better – leading to poorly evaluated devices and procedures having negative effects on patients.
Writing in The Lancet, experts from the NIHR Global Health Research Unit for Global Surgery GlobalSurg Collaborative – a programme backed by funding from the NIHR (National Institute for Health and Care Research) – propose three priority areas for surgery:
Access, equity, and public health must be recognised as crucial issues for surgery.
In 2015, five billion people did not have access to safe and affordable surgical care. Of those who did, 33 million individuals faced catastrophic health expenditure in payment for surgery and anaesthesia. During the COVID-19 pandemic, over 28 million cases of elective surgery are likely to have been cancelled. Surgery has a key role in addressing the most important and growing global health challenges, such as trauma, congenital anomalies, safe childbirth, and non-communicable diseases.
Inclusion and diversity must improve in both surgical research and the profession.
Women, minoritised groups, and patients from low-income and middle-income countries remain under-represented in clinical practice and major research work. Advancing inclusion and diversity will ensure a research agenda that delivers pragmatic, simple, and context-specific research that reflects the needs of all patients.
Climate change is the greatest global health threat facing the world.
Surgical theatres are some of the most energy and resource intense areas of a hospital. Surgical practice relies on many single-use, non-biodegradable products as well as anaesthetic gases that have a large environmental footprint. Moving towards net-zero operating practices could reduce health-sector carbon emissions and allow surgeons and policy makers to reassess how surgery fits into a wider health system.
Comment co-author Dmitri Nepogodiev, from the University of Birmingham, said: “Richard Horton, Editor-in-Chief of The Lancet, once described surgical research as ‘a comic opera performance’. That was in 1996 and things have changed significantly since then.
“However, truly improving lives requires surgical researchers to use the next quarter of a century to tackle the most pressing questions on equity and access, the role of surgery in public health, and sustainability.
“Despite the problems of large waiting lists and an economic squeeze on health systems, surgeons must focus on these priority areas — placing surgery as a leader in medical specialties and demonstrating its value as a fundamental element of universal health care.”
The experts note that large, randomised controlled trials with well-defined endpoints are now more usual in surgical research, whilst exploration into the placebo effect, has led to a fundamental re-examination of the benefits of some surgical procedures and whether they benefit patients at all.
Surgeons and anaesthetists have developed successful international collaborative research efforts that have enabled rapid recruitment of participants and globally relevant studies and trials, while following internationally set standards of clinical trial practice. Surgeons can now provide reliable answers to crucial questions in operative surgery, and their research has improved patient care and resource use in health systems.
Pre-surgery exercise and education, or ‘prehabilitation’, can significantly improve outcomes for patients undergoing orthopaedic surgery, according to new research published in JAMA Network Open.
An ageing population plus the COVID pandemic has put great strains on healthcare systems, creating a longer waiting time for patients due to undergo routine elective surgical procedures. This can cause mental and physical deconditioning in patients, potentially impacting their surgical outcomes.
The study found prehabilitation may mitigate these negative factors and assist in improving strength and function prior to a surgical intervention. This may include exercise, patient education, pain management and psychological support.
Researchers from Anglia Ruskin University (ARU), Addenbrooke’s – Cambridge University Hospitals NHS Foundation Trust (CUH) and Western University in Ontario, Canada, examined the results of 48 unique clinical trials involving prehabilitation techniques such as exercise, pain management and acupuncture among patients about to undergo orthopaedic surgery.
Outcomes were measured prior to surgery as well as at intervals post-operation. Results were graded for certainty, or confidence that results were true.
Prior to surgery, the study found strong evidence that prehabilitation led to a reduction in back pain for people waiting for lower back surgery and evidence of moderate certainty for improvement in their health-related quality of life.
For patients waiting for total knee replacement, evidence of moderate certainty showed prehabilitation improved function and muscle strength. For patients waiting for a total hip replacement, evidence of moderate certainty showed prehabilitation improved health-related quality of life and hip muscle strength.
Following an operation, the study found that prehabilitation improved function in the short to medium term compared with no prehabilitation. In particular, evidence of moderate certainty suggested prehabilitation had favourable outcomes on function in those who had undergone knee replacement surgery at six weeks post-operatively. Evidence of moderate certainty also suggests prehabilitation improved function six months after lower back surgery.
Lead author Anuj Punnoose, ARU PhD candidate and Clinical Specialist Physiotherapist at CUH, said: “This study stemmed out of a need to find the best ways to prepare orthopaedic patients prior to surgery and prevent them from further deconditioning. Furthermore, any prehabilitation programme should ideally be delivered for at least four to six weeks prior to the surgical intervention and twice a week for optimum results. Health services looking at developing such programmes could utilise recommendations from this study.”
Much of South Africa’s public health sector is plagued by long waiting times for surgery, a situation that was made much worse by the COVID-19 pandemic. Now, an inspiring project at Groote Schuur Hospital in Cape Town has reached the target of slashing its backlog by 1 500 elective surgeries – two months ahead of target.
At the end of March, a small team of healthcare workers completed the project called ‘Surgical Recovery’. The project ran from May 2022 and was originally planned to conclude 12 months later.
While this hasn’t cleared the entire backlog of people waiting for surgery at Groote Schuur, it has helped the hospital return to about the same waiting list level as it had before the COVID-19 pandemic, according to Professor Lydia Cairncross, the head of general surgery at Groote Schuur. (Spotlight previously reported on the human cost of surgical waiting lists and on what could be done about it.)
The surgeries took place mainly in the E4 Surgical Day Ward at Groote Schuur. Cairncross explains that ward E4 was built as a Day Ward – meaning it handles surgeries where patients don’t require an overnight stay pre- or post-surgery – with the aim of increasing daycare surgery capacity for the hospital. And for the last 12 months, it has been the host of the Surgical Recovery Project.
E4 has 16 patient beds, four recovery beds, and two theatres, which were completed just as the COVID-19 pandemic hit the country. During the third wave of the pandemic, it was used as a COVID High Care Unit.
According to Dr Shrikant Peters, a public health specialist and the medical manager of theatre and ICU services at Groote Schuur, the hospital’s CEO Dr Bhavna Patel “had the foresight to request provincial use of COVID funding to develop the space as COVID High Care, and eventually to be used long-term as an Operating Suite and High Care Ward in line with prior hospital plans”.
The Surgical Recovery Project
By the end of the third wave of the COVID-19 pandemic, according to Cairncross, there were discussions about how to catch up on the surgeries that had to be postponed because of COVID-19.
“The backlog in surgery comes on top of a pre-existing backlog. So, it’s not that the backlog was created by COVID, but it made it much, much, much worse,” she says, “In November 2021, we did an audit of how many patients were just physically waiting for surgery at the hospital. It was around 6 000 plus. We don’t actually have a baseline for pre-COVID, but we knew that we lost about 50% of our operating capacity,” Cairncross says.
“So, the idea was really to find a way to utilise this theatre space so that we could catch up with some of that backlog.”
From here, the Surgical Recovery Project for Groote Schuur was born with the ambitious target of performing 1 500 surgeries in 12 months.
Funds from the project came from three sources. Kristy Evans, head of the Groote Schuur Hospital Trust, tells Spotlight that fundraising for the project was kick-started by a R5 million donation from Gift of the Givers. The recently established Groote Schuur Hospital Trust focused on Surgical Recovery as their first project to fundraise for. An additional R1 million was raised by the Trust from over 500 corporate and private donors.
“People are always willing… [they] give what they can. We had donations from people who would transfer R10 into the account, sometimes people transfer R180 000,” Evans says.
She adds that the Project will continue into its second year, but the details regarding targets had not yet been finalised by the time of publication.
The Western Cape Provincial Department of Health also donated around R6.5 million to the project from their budget for surgical recovery post-COVID-19. According to Mark van der Heever, the provincial health spokesperson, this money was part of the R20 million that the department allocated to various surgical backlog recovery initiatives.
“[The] COVID-19 pandemic meant that elective surgical services had to be significantly de-escalated, as staff were deployed to COVID services, and this resulted in an increase in the backlog of operations. Hence, a specific practi[cal] plan to address this backlog in the short and long term has been developed,” says van der Heever. “Similar projects and initiatives across hospitals have already taken shape and also yielded success, such as at Karl Bremer Hospital, which also received a portion of the R20 million from the department. The hospital was able to perform an extra 328 procedures since August last year.”
Working around difficulties
At Groote Schuur, the project had to find a way to work around the difficulties of surgical catch-up. According to Cairncross, with any surgical catch-up, the challenges don’t just come from needing a physical space to operate in but also from having the appropriately trained staff. Not having enough trained staff in the public health sector, like theatre and surgery nurses, makes it hard to implement a surgical catch-up programme, even if there is money to do so.
To work around these difficulties, they came up with a centralised model for surgical recovery, where one theatre team of nurses could be employed on a contract rate for the 12 months. This team, led by Sister Melinda Davids, the nursing operations manager for the E4 theatre, would work Monday to Thursday in one of the E4 theatres and occasionally other theatres in the hospital for each of the 1 500 surgeries.
According to Cairncross, many surgeons, herself included, would come and operate on patients in addition to their normal surgeries and other duties. The funds, a total of about R 12.5 million, were used to pay the staff involved in the surgeries. The day-to-day operations were run by Davids and Peters.
According to Peters, the 1 500 operations occurred across all surgical specialities, ranging from cataract to cardiothoracic.
Success factors
Cairncross attributes the success of the project to the existing systems at Groote Schuur, supportive management, and the dedication of the surgical team and surgeons that gave their time to the project.
She says that because the hospital has a relatively functional system to start off with and a supportive management team, it allowed for “enough of a regulatory environment to keep things safe and above board but not to the extent where you can’t move”.
It was also about having the right person in charge of the team, she adds, gesturing to Davids.
Davids, who started her nursing career in 1989 and qualified as a theatre nurse in 2009, started working at Groote Schuur six years ago. She explains that the surgical team at E4 consisted of about 18 people. This includes herself, five scrub nurses, three anaesthetic nurses, three floor nurses, a registered nurse who assists in recovery, and a clerk. Peters adds that there are also two surgical medical officers and two anaesthetic registrars.
According to Davids, when the project started, several of the nurses had not worked in a theatre before so had to be trained and upskilled by her and some of the specialist nurses who make up the scrub nurse team. She also had to get creative about having the right equipment for each surgery, which sometimes meant she had to borrow equipment from other theatres.
“It’s been a challenge, but it’s a good challenge that’s kept me going,” she says. “We’re a good team.”
“Trust [in staff] has been fundamental to this,” says Peters, “I mean, the ability to trust junior staff to upskill themselves to become scrub nurses, to hand surgeons the right instrument when they asked for it. That’s been really heart-warming.”
‘Behind every number on the list is a patient’
When asked why it was so important to do this kind of catch-up, Cairncross says the surgeries that were postponed during the COVID-19 pandemic were ones that weren’t urgent or emergent, but those patients who were bumped still struggled physically because of the delays.
“Behind every number on the list is a patient with a story of either progressive blindness, invasive skull tumours, or tumours around the auditory canal that result in hearing loss, chronic pain from joint problems and urinary retention with recurrent infections and admissions or having a stoma bag [a colostomy bag] with them for months longer than needed,” Cairncross says. “Heart-breaking stories and often these were the patients who kept getting cancelled [on]. They would come in and if something urgent would come up, they would be cancelled or the COVID wave would come.”
She adds that at the time when the idea for Surgical Recovery came about, the morale amongst the surgical teams was at a real low. Patients would be coming to the outpatient clinics and asking, for the umpteenth time, “when am I going to have my operation?” to which the healthcare workers had to keep responding that they don’t know.
“It’s just a terrible thing and so people [staff] started to feel disempowered and disillusioned and I really think that the project helped them to at least see some progress. That there were some changes or some shift in what they were dealing with,” Cairncross says. “It hasn’t cleared our entire backlog, and a once-off project will not do that, but it has reset us pretty close to where we were pre-COVID-19.”
Peters adds that while the backlogs haven’t been fully cleared, “for every case that we’ve done in the project, it’s someone off of a waiting list”.
Health system at a ‘precipice’
While the COVID-19 pandemic caused many surgeries to be postponed and added tremendously to surgical waiting lists, it isn’t the only factor contributing to backlogs. According to Peters, the issue of a shrinking health budget for tertiary services is and will continue to add to the existing backlogs across the country.
“There’s this building backlog coming up against the shrinking budget. And that’s going to be with us for multiple years going into the future and if the clinicians aren’t protecting the budget for these patients that get missed, we’re going to focus on as we have been the emergency patients that come through the door,” he says. “But it’s always difficult for tertiary academic services because to keep up the skills of surgeons to maintain the quality of care, they do need to be managing waiting lists of booked patients. And so, I think across the country we’re going to be struggling with that across all tertiary services.”
Cairncross tells Spotlight that the project is just a temporary measure. In the long term, healthcare systems need to be fixed in order to address issues like surgical backlogs.
“The lesson, I suppose, is that these are temporising measures. We can do them, but fundamentally we need to fix the health system at a core, structural level. And we can’t work in isolation from the rest of the country because we are one health system and tertiary hospitals are only a part of that ecosystem,” she says. “The services at Groote Schuur Hospital, for example, cannot be sustained if the health systems from primary care to district health facilities, in urban and rural facilities, and across provinces are not supported and strengthened.”
The health system is at a precipice, according to Cairncross, and big academic hospitals need to be anchoring elective surgical services together with emergency services, as the problem with emergency services will only get bigger down the line if electives aren’t dealt with now.
“We know that postponed elective surgery just becomes emergency surgery over time, making cancelling elective surgery a false economy. We need to plan robust systems that ensure all types of surgical services are maintained,” she says.
“The strongest voice [in defence of the health system] is a conscious and motivated health workforce. So, where the nurses and doctors and managers are standing and defending patient services, they are supporting the health system,” she says. “I think this is an example of health workers standing up and saying, we can’t allow this deterioration in services. We’ve got to do more. We really want to tell the story, so that people can see it can be done.”
Antibiotics administered before and during surgery should be discontinued immediately after a patient’s incision is closed, according to updated recommendations for preventing surgical site infections.
Experts found no evidence that continuing antibiotics after a patient’s incision has been closed, even if it has drains, prevents surgical site infections. Continuing antibiotics does increase the patient’s risk of C. difficile infection, which causes severe diarrhoea, and antimicrobial resistance.
Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2022 Update, published in the journal Infection Control and Healthcare Epidemiology, provides evidence-based strategies for preventing infections for all types of surgeries from top experts from five medical organisations led by the Society for Healthcare Epidemiology of America.
“Many surgical site infections are preventable,” said Michael S. Calderwood, MD, MPH, lead author on the updated guidelines. “Ensuring that healthcare personnel know, utilise, and educate others on evidence-based prevention practices is essential to keeping patients safe during and after their surgeries.”
Surgical site infections are among the most common and costly healthcare-associated infections, occurring in approximately 1% to 3% of patients undergoing inpatient surgery. Patients with surgical site infections are up to 11 times more likely to die compared to patients without such infections.
Other recommendations:
Obtain a full allergy history from patients who self-report penicillin allergy. Many patients with a self-reported penicillin allergy can safely receive cefazolin, a cousin to penicillin, rather than alternate antibiotics that are less effective against surgical infections.
For high-risk procedures, especially orthopaedic and cardiothoracic surgeries, decolonise patients with an anti-staphylococcal agent in the pre-operative setting. Decolonization, which was elevated to an essential practice in this guidance, can reduce post-operative S. aureus infections.
For patients with an elevated blood glucose level, monitor and maintain post-operative blood glucose levels between 110 and 150mg/dL regardless of diabetes status. Higher glucose levels in the post-operative setting are associated with higher infection rates. However, more intensive post-operative blood glucose control targeting levels below 110mg/dL has been associated with a risk of significantly lowering the blood glucose level and increasing the risk of stroke or death.
Use antimicrobial prophylaxis before elective colorectal surgery. Mechanical bowel preparation without use of oral antimicrobial agents has been associated with significantly higher rates of surgical site infection and anastomotic leakage. The use of parenteral and oral antibiotics prior to elective colorectal surgery is now considered an essential practice.
Consider negative-pressure dressings, especially for abdominal surgery or joint arthroplasty patients. Placing negative-pressure dressings over closed incisions was identified as a new option because evidence has shown these dressings reduce surgical site infections in certain patients. Negative pressure dressings are thought to work by reducing fluid accumulation around the wound.
Additional topics covered in the update include specific risk factors for surgical site infections, surveillance methods, infrastructure requirements, use of antiseptic wound lavage, and sterile reprocessing in the operating room, among other guidance.
Hospitals may consider these additional approaches when seeking to further improve outcomes after they have fully implemented the list of essential practices. The document classifies tissue oxygenation, antimicrobial powder, and gentamicin-collagen sponges as unresolved issues according to current evidence.
Researchers in Sweden have performed a nation-wide study of patients who underwent bioprosthetic aortic valve replacement between 2003 and 2018. The study, published in the Journal of the American College of Cardiology, shows that it is less dangerous than previously believed to receive a small bioprosthetic aortic valve in relation to the patients size.
During surgical aortic valve replacement, the patient receives a valve prosthesis that matches the size of the aortic root. Sometimes, that size is too small in relation to the patient’s body size. This puts strain on the heart to pump enough blood that the body needs through a narrow valve. The level of “narrowness” is measured as Prosthesis Patient Mismatch, PPM.
“Prior studies have shown that both moderate and severe PPM decreases survival and increases the risk for heart failure. In our study, we can confirm that severe PPM decreases survival and increases the risk for heart failure, while moderate PPM has a very limited effect on survival and no effect on the risk for heart failure”, says Michael Dismorr, postdoctoral researcher at the Department of Molecular Medicine and Surgery and first author of the study.
The study
The study included all patients who underwent bioprosthetic aortic valve replacement in Sweden between 2003 and 2018. Patients were identified from the Swedish cardiac surgery register, part of the SWEDEHEART register. The database was enriched with data from other national health data registers. By using the statistical method regression standardization we were able to estimate the risk for the outcomes death, heart failure and reintervention in absolute terms between the groups no, moderate and severe PPM.
The study shows that the estimated risk difference between no and moderate PPM for death after 10 years of follow-up was -1.7% (-3.3% to -0.1%) compared to -4.6% (-8.5% to -0.7%) for severe PPM.
The risk difference for heart failure after 10 years of follow-up was -1.1% (-2.5% to 0.2%) between patients with no and moderate PPM.
“A risk difference of a single percent after 10 years of follow-up cannot be said to be of clinical significance, even if it is statistically so. However, it is important to note that these are hard clinical outcomes. We did not have access to “soft” outcomes such as quality of life, which might be decreased in patients with moderate PPM, and in that case of course of great importance to those patients”, says Michael Dismorr.
Next steps
“Now we want to study the effect of PPM in patients who underwent transcatheter aortic valve replacement, a so called TAVR procedure. This is important knowledge when deciding which patients will benefit the most from a surgical replacement, and which patients will benefit the most from a transcatheter replacement”, says Michael Dismorr.
