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Effective communication is essential between health professionals during surgical procedures for delivery of safe patient care. The influence of noise on communication during critical moments of surgery and on communication failures is unclear.
To examine communication events among health professionals in the operating room and investigate the influence of noise on communication.
Non-participatory observations were undertaken of communication between health professionals during surgical procedures while simultaneously measuring sound pressure levels. Audio visual recording was used to document communication events, ensuring data accuracy. A generalised linear mixed model was used to examine relationships between various explanatory variables and the presence of at least one communication failure. The STROBE checklist guided the reporting of this paper.
A representative range of procedures was observed from diverse surgical specialties (N = 80). Observations comprised 2274 communication events; communication failures were observed in 24% and repeated communication was observed in 25% of all communication events. The mean maximum sound pressure levels were 64.9 dB[A] for communication events, 64.5 dB[A] for communication failures and 65.5 dB[A] for repeats. The type of surgical procedure, the emergence from anaesthesia compared to other phases of surgery, communication related to the surgical safety checklist, communication related to the surgical count, the presence of multitasking, and the use of surgical facemasks, were associated with the presence of at least one communication failure.
This research identified the inherent risks and occurrence of communication failure in noisy operating room environments where health professionals are undertaking complex cognitive tasks and where effective communication is essential to ensure patient safety.
This study did not include patient or public involvement in its design, conduct, or reporting.
To test the agreement and usability of a novel quality appraisal tool: A MeaSurement Tool to Assess systematic Reviews of Prognostic Factor studies (AMSTAR-PF).
Observational study.
14 appraisers of varied experience levels and backgrounds, including undergraduate, master’s and PhD students, postgraduate researchers, research fellows and clinicians.
Eight systematic reviews were rated by all reviewers using AMSTAR-PF.
Planned measures included intrapair and inter-pair agreement using Cohen’s and Fleiss’ kappa, time of use and time to reach consensus. Interrater agreement was an added measure, and Gwet’s agreement coefficient was calculated and presented due to its greater stability across agreement levels. The percentage of intrapair agreements identical or one category apart was also presented.
Interrater agreement averaged 0.59 (range 0.21–0.90), inter-pair agreement 0.61 (range 0.24–0.91) and intrapair agreement 0.75 (range 0.45–0.95) across the domains, with agreement for the overall rating 0.46 (95% CI 0.30 to 0.62) for interrater agreement, 0.46 (95% CI 0.17 to 0.74) for inter-pair agreement and 0.68 (range of averages 0.22–1.00) for intrapair agreement. The majority (60.7%) of intrapair ratings were identical, with 94.6% of final ratings either identical or only one category different for the overall appraisal. The time taken to appraise a study with AMSTAR-PF improved with use and averaged around 34 min after the first two appraisals.
Despite some variance in agreement for different domains and between different appraisers, the testing results suggest that AMSTAR-PF has clear utility for appraising the quality of systematic reviews of prognostic factor studies.
Poor cardiopulmonary fitness is an important risk factor for postoperative complications, yet a feasible, objective and prognostically accurate method to assess preoperative fitness has not been established. The 6 min walk test (6MWT) is a simple, inexpensive and widely applicable measure that shows promise for predicting postoperative risk. However, robust data are lacking on whether the 6MWT accurately predicts complications, provides incremental prognostic value beyond routinely collected clinical factors or outperforms simpler alternatives such as questionnaires, cardiac biomarkers or grip strength testing. The Functional Assessment for Surgery by a Timed Walk (FAST Walk) study is designed to address these knowledge gaps by evaluating whether the 6MWT improves prediction of key postoperative outcomes compared with clinical factors and simpler measures of fitness.
The FAST Walk study is an international multicentre prospective cohort study of 1672 adults (≥40 years) undergoing major elective non-cardiac surgery at centres in Canada, Hong Kong, Australia, Spain and the Netherlands. Participants complete a preoperative 6MWT and baseline assessments of comorbidities, self-reported cardiopulmonary fitness (MET: Re-evaluation for Perioperative Cardiac Risk questionnaire), biomarkers (N-terminal pro-B-type natriuretic peptide) and grip strength. The primary outcome is 30-day death or major postoperative complication, defined as Clavien-Dindo grade II or higher. Secondary outcomes are (1) death or new significant disability at 90 days after surgery and (2) days alive and out of hospital at 30 days after surgery. Disability is measured using the short-form WHO Disability Assessment Schedule 2.0 instrument. Multivariable regression models and complementary metrics of prediction performance will be used to determine whether 6MWT distance adds prognostic value beyond routinely collected clinical factors and simpler measures of fitness.
The FAST Walk study has received research ethics board approval at all participating sites. Recruitment commenced in June 2024, with completion of participant follow-up expected in 2026. Findings will be disseminated through peer-reviewed publications and conference presentations, with the primary results anticipated in 2027.
The 2013–2016 Western African outbreak of the Ebola virus disease (EVD), the largest recorded outbreak since the discovery of Ebola virus (EBOV) in 1976, destabilised local health systems and left thousands of survivors at risk for postacute sequelae, including vision-threatening uveitis. In an EVD survivor with severe panuveitis, the detection of persistent EBOV in the aqueous humour, long after clearance of acute viremia, focused clinical and research attention on the host-EBOV interaction in the unique terrain of ocular immune privilege. Despite the recognition that uveitis is common and consequential in EVD survivors, our understanding of pathogenesis is extremely limited, including the contributions of viral persistence and ocular-specific and systemic immune responses to disease expression. In this study protocol, we outline a multifaceted approach to characterise EVD-associated intraocular inflammation, including the clinical phenotype and complications; the presence of EBOV (or EBOV RNA/antigen) in ocular fluids and tissues; and associated local ocular-specific and peripheral immune responses.
We use an observational cohort design, which includes EVD survivors and close contacts of EVD survivors (ie, no documented history of EVD), and we propose disease (clinical examination and imaging), as well as molecular, virologic and immunologic characterisation, to meet research objectives.
This study has received Institutional Review Board approval from University of Nebraska Medical Centre, Emory University and Sierra Leone Ministry of Health. Findings will be disseminated through peer-reviewed publications.
To develop survey items for a national patient registry on Long COVID using a modified Delphi process.
This study was based on a modified Delphi process involving three rounds of anonymous, online surveys to develop consensus on and prioritise survey elements to be included in a minimum dataset for use in a national patient registry in Canada. Initial Long COVID items were identified through an environmental scan of the literature.
This study focused on healthcare systems in Canada and was conducted online.
A panel of 52 experts (patients, caregivers, clinicians and researchers) participated in all three rounds of the online survey. These participants were recruited through the Long COVID Web network and word of mouth.
In total, 243 survey elements related to care, quality of life and symptoms were included in round 1 of the survey. 200 reached consensus and moved to round 2 with two additional elements being developed based on open-ended responses. In round 2, participants ranked these survey elements and 34 advanced. In round 3, 33 survey elements met the threshold of consensus with one added a priori. The 33 survey elements were then used to develop a Long COVID minimum dataset, which consists of 48 items.
The findings affirm broad consensus for collecting data related to fatigue, post-exertional malaise, cardiovascular issues, respiratory problems and cognitive issues. This highlighted the desire for quality-of-life indicators and information related to care utilisation, quality and access.
Acute hypoxaemic respiratory failure is a common reason for intensive care unit (ICU) admission. Non-invasive respiratory support strategies such as high-flow nasal oxygen (HFNO) and helmet non-invasive ventilation may reduce the need for invasive mechanical ventilation and death. The High-flow nasal Oxygen with or without alternating helmet Non-invasive ventilation for Oxygenation sUpport in acute Respiratory failure pilot trial is designed to compare helmet non-invasive ventilation combined with HFNO vs HFNO alone in patients with acute hypoxaemic respiratory failure and to determine the feasibility of a larger randomised controlled trial.
This is a pragmatic, open-label, multicentre randomised controlled pilot trial enrolling 200 critically ill adults with acute hypoxaemic respiratory failure across 12 Canadian ICUs. Participants are randomised 1 to 1 to receive either helmet non-invasive ventilation plus HFNO or HFNO alone for at least 48 hours. The primary aim is to assess feasibility metrics including recruitment rate, protocol adherence and fidelity to pre-specified intubation criteria. Secondary outcomes include rates of intubation, all-cause mortality, ventilator-free days, ICU length of stay and quality of life at 6 months. Primary and secondary outcomes will be analysed using Bayesian methods.
Ethics approval has been obtained at all participating centres. Findings will inform the feasibility and design of a future full-scale trial and be disseminated through peer review publications and conference presentations.
ClinicalTrials.gov Identifier: NCT05078034.
Preventable intraoperative adverse events (iAEs) are common despite widespread implementation of surgical quality improvement initiatives. These events often result from the interaction of multiple system-based factors (safety threats, STs) that coalesce to compromise safety. Existing research does not fully capture how STs vary across institutions, and how surgical teams either recover from or anticipate challenges (resilience supports, RSs). Consequently, efforts to design and align interventions are hindered by an incomplete understanding of the system-level contributors to patient safety risks. This study uses a human factors approach to gain a comprehensive understanding of STs and RSs across four hospitals by analysing operating room (OR) video recordings and conducting interviews with clinical teams to contextualise STs and RSs.
This mixed-method study will analyse 120 surgical video recordings from four hospitals, using a comprehensive multimodal data capture platform, called OR Black Box (ORBB, Surgical Safety Technologies New York City, USA). All ORBB videos will be coded for case information, surgical phase, iAE type and severity. Human factor researchers will then retrospectively identify and code STs and RSs, applying a combined deductive (Systems Engineering Initiative for Patient Safety components: person, tasks, tools/technology, environment, organisation) and inductive approach. Detailed qualitative observations of STs and RSs will be transcribed, with the roles of the involved individuals noted. Quantitative and qualitative cross-institutional comparisons will highlight potential effective interventions (eg, radiofrequency sponge detection wands used during surgical counts) at specific sites, offering insights that could inform potential improvements at other institutions. Additionally, interviews with clinicians at each site will provide contextual insights into the prevalent STs and RSs.
Ethics approval was obtained from the research ethics boards of: North York General Hospital (REB #2024-0174-993), a large Canadian community academic hospital; Sunnybrook Health Sciences Centre (REB #5779; REB #6688) and Unity Health Toronto (REB #16243), large Canadian academic hospitals and the Panel on Human Subjects Medical Research of Stanford University (IRB #6208), for its large American academic hospital. Results will be published in peer-reviewed journals, presented at conferences and to stakeholders.
Self-harm and suicide are common among prison inmates, but less is known about these phenomena in those with psychosis.
The aim of this study was to examine self-harm behaviour in New South Wales (NSW) prisons in Australia among inmates diagnosed with psychosis. This study also examined self-harm-related alerts applied by Corrective Services to assist staff with the management of the security and well-being of inmates.
A retrospective case-control data-linkage study was conducted using administrative data collections in NSW, Australia.
The study included all individuals diagnosed with psychosis and incarcerated between 2001 and 2020 in NSW as cases and an age and sex matched control group with no such diagnosis with a record of incarceration in the same time period.
The primary outcome measure was self-harm among the cases and controls. The secondary outcome measure was the application of alerts by Corrective Services in relation to self-harm incidents.
Multivariate regression analysis was used to examine predictors of self-harm in prison. Prisoners with psychosis (n=14 900) were more likely to self-harm than controls (n=2713), with 15.0% versus 3.6% engaging in self-harm (highest odds of self-harm observed in those with schizophrenia and related psychoses, aOR=4.84, 95% CI: 3.93 to 5.98). Those of Aboriginal heritage had an increased risk of self-harm (aOR=1.58, 95% CI: 1.43 to 1.75). Factors associated with a lower risk of self-harm were male sex and older age (≥25 years) at the time of their first incarceration. 35.6% of those released from prison with a prior psychosis diagnosis had at least one alert applied during incarceration compared with 10.1% of prisoners without a diagnosis of psychosis. Overall, 35 individuals with psychosis and 1 individual from the control group died while in prison between 2001 and 2020. 17 prison suicides were recorded from the study population; all occurred in the psychosis group.
Given the heightened risk of self-harm in those with histories of psychosis, consideration should be given to sharing mental health information between agencies to improve the care and management of this group during incarceration. Prison alerts may be a useful tool to help staff manage inmates’ well-being if used appropriately.
Progressive supranuclear palsy (PSP) is a devastating neurodegenerative disease characterised by cognitive, behavioural and motor problems. Motor symptoms are highly disabling, while cognitive and behavioural changes have a major impact on carer burden, quality of life and prognosis. Apathy and impulsivity are very common, often coexistent in PSP, and negatively predict survival. In preclinical models and other diseases, apathy and impulsivity are associated with noradrenergic deficits, which can be severe in PSP.
Noradrenaline for Progressive Supranuclear Palsy Syndromes trial is a randomised, double-blind, placebo-controlled, crossover design, Phase IIb clinical trial to evaluate the efficacy and safety of oral atomoxetine for the treatment of cognitive and behavioural changes in PSP. Participants receive atomoxetine 40 mg (10 mg/mL oral solution) once daily or a matched placebo solution, in random order, each for 8 weeks. An ‘informant’, who knows the patient with PSP well, is co-recruited to complete some of the trial outcome measures. Participants remain in the trial for 22 weeks after randomisation. The primary objectives are to assess (1) safety and tolerability and (2) efficacy versus placebo on challenging behaviours as reported in a subscale of the Cambridge Behavioural Inventory. Secondary and exploratory measures relate to cognition, the PSP Rating Scale, mood and potential baseline predictors of individual response to atomoxetine computed from imaging, genetic and cognitive measures at baseline.
The trial was approved by the South Central-Oxford B Research Ethics Committee (REC) and the Medicines and Healthcare products Regulatory Agency (REC reference: 20/SC/0416). Dissemination will include publication in peer-reviewed journals, presentations at academic and public conferences and engagement with patients, the public, policymakers and practitioners.
ISRCTN99462035; DOI:
Background
Older adults from specific racial and ethnic minoritized groups experience disproportionately higher asthma prevalence, morbidity, and mortality. They also often use emergency departments (EDs) to manage their asthma. High-quality primary care can improve asthma control and prevent ED use. Nurse practitioners (NPs) provide an increasing proportion of primary care to minoritized patients, yet often, they work in poor work environments that strain NP care.
Objectives
We examined whether racial and ethnic health disparities in ED visits among older adults with asthma are moderated by the NP work environment in primary care practices.
Methods
In 2018–2019, we used a cross-sectional design to collect survey data on NP work environments from 1,244 NPs in six geographically diverse states (i.e., Arizona, California, New Jersey, Pennsylvania, Texas, and Washington). We merged the survey data with 2018 Medicare claims data from 46,658 patients with asthma to assess the associations of all-cause and ambulatory care-sensitive conditions, ED visits with NPs’ work environment, and race and ethnicity using logistic regression.
Results
More than one third of patients with asthma visited the ED in 1 year, and a quarter of them had an ambulatory care-sensitive condition ED visit. Black and Hispanic patients were more likely than White patients to have all-cause and ambulatory care-sensitive condition ED visits. NP work environment moderated the association of race with all-cause and ambulatory care-sensitive condition ED visits among patients with asthma. Greater standardized NP work environment scores were associated with lower odds of all-cause and ambulatory care-sensitive condition ED visits between Black and White patients.
Discussion
Disparities in ED visits between Black and White patients with asthma decrease when these patients receive care in care clinics with more favorable NP work environments. Preventing unnecessary ED visits among older adults with asthma is a likely benefit of favorable NP work environments. As the NP workforce grows, creating favorable work environments for NPs in primary care is vital for narrowing the health disparity gap. Background
Patients with multiple chronic conditions often have many care plans, polypharmacy, and unrelieved symptoms that contribute to high emergency department and hospital use. High-quality primary care delivered in practices that employ nurse practitioners can help prevent the need for such acute care services. However, such practices located in primary care health professional shortage areas face challenges caring for these patients because of higher workloads and fewer resources.
Objective
We examined differences in hospitalization and emergency department use among patients with multiple chronic conditions who receive care from practices that employ nurse practitioners in health professional shortage areas compared to practices that employ nurse practitioners in non-health professional shortage areas.
Methods
We performed an analysis of Medicare claims, merged with Health Resources and Services Administration data on health professional shortage area status in five states. Our sample included 394,424 community-dwelling Medicare beneficiaries aged ≥65 years, with at least two of 15 common chronic conditions who received care in 779 practices that employ nurse practitioners. We used logistic regression to assess the relationship between health professional shortage area status and emergency department visits or hospitalizations.
Results
We found a higher likelihood of emergency department visits among patients in health professional shortage areas compared to those in non-health professional shortage areas and no difference in the likelihood of hospitalization.
Discussion
Emergency department use differences exist among older adults with multiple chronic conditions receiving care in practices that employ nurse practitioners in health professional shortage areas, compared to those in non-health professional shortage areas. To address this disparity, the health professional shortage area program should invest in recruiting and retaining nurse practitioners to health professional shortage areas to ease workforce shortages. 
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