Table 3

Summary of system issues and latent safety threats identified for management of patients with COVID-19 and subsequent system improvements, specifically related to operating theatre (OT), as well as common to OT and ICU39

DomainIssues identifiedSystem improvements
Equipment and drugsUnavailability of closed suction system and incompatibility with disposable masks and circuits (OT)Acquisition of compatible equipment and ensure availability (OT)
Unavailability of dedicated equipment for confirmed cases, including disposable video laryngoscopes, viral filters on expiratory limb of circuits (OT)Dedicated trolleys and equipment for confirmed cases, as well as development of equipment preparation checklists (OT)
Inability to rapidly provide key drugs or equipment for urgent use in the AIIR—particularly those requiring patient identification and/or special registration (ICU)Guideline amendment that additional gowned personnel, airway equipment and drugs should be immediately available in the anteroom (ICU)
High risk of contamination of extra equipment in AIIR, may result in cross-contamination or wastage (OT)Streamline equipment and limit unnecessary disposables in the AIIR (OT)
Stethoscopes have high risk of contamination (OT)Acquisition of electronic stethoscopes, as well as dedicated location for stethoscope in AIIR (OT)
Contamination of environment with used equipment such as laryngoscopes, intubating aids, suction devices (OT/ICU)Designated ‘dirty’ trolley for disposal of contaminated equipment (OT/ICU)
Some personal protective equipment (PPE), including certain models of N95 were not immediately available in the gown up room (OT)Ensure regular checks and availability of PPE in gown up room outside AIIR (OT)
Connections between the bag valve mask (BVM) resuscitator, PEEP valve, mainstream CO2 monitor, bacterial/viral filter and face mask were frequently incorrectly placed (ICU)Additional mainstream end-tidal CO2 sensor made available for use in ventilator circuit accompanied by guideline amendment (ICU)
TasksStaff were unfamiliar with donning and doffing procedures of PPE, and enter AIIR with inadequate self-protection (OT/ICU)Provision of visual aids in the gown up and gown down areas, and emphasis placed on buddy system to cross check. Also, established on-duty ‘patrol’ nurse to monitor donning and doffing procedures. (OT/ICU)
Personal belongings such as mobile phones were not taken out before donning of PPE, with risk of contamination, as well as inability to communicate with staff outside AIIR (OT/ICU)
  • Provision of visible signage in the gown up and anteroom to remind staff to put down personal belongings in the AIIR, as well as disposable plastic bags for hospital phones/pagers if needed to be brought into AIIR (OT).

  • Extra dedicated hospital mobile phone available inside and outside the AIIR, with use of speakerphone to allow easy communication and forwarded calls (ICU).

Inadequate airway and equipment planning, and allocation of tasks during intubation within the AIIR (OT/ICU)Establishment of equipment and drug checklists for intubation in AIIR, as well as visible cognitive aids for pre-intubation checks within the AIIR (OT/ICU)
Rapid cycle deliberate practice to enhance muscle memory and cognitive processes for circuit disconnection, as well as frequent cross-checking to maintain situation awareness as a team (OT)Failure to pause or standby ventilator before circuit disconnection, due to cognitive overload during stressful induction (OT)
Gas leakage around endotracheal tube due to inadequate cuff insufflation upon commencement of positive pressure ventilation, as well as leakage during cuff pressure checking (due to intrinsic problem of cuff pressure monitor (OT/ICU)Modification of guidelines to recommend confirmation of correct endotracheal tube position by the observation of end-tidal carbon dioxide and ensure cuff inflation prior to commencement of mechanical ventilation; as well as standby of ventilator during cuff pressure monitoring (OT/ICU)
EnvironmentStaff are unfamiliar with the location of the donning and doffing rooms for the AIIR in the OR, and often breach the interlocking doors between the ante room and the AIIR (OT)Provide signage that clearly points out the donning and doffing rooms, as well as physical barriers around the handles that can manually override the interlocking doors (OT)
Lack of clear signs to indicate the presence of a high-risk patient within the AIIR in the OT, which at other times may be used for non-infectious cases (OT)Clear signs that indicate high risk patient (COVID-19) within the AIIR in the operating theatre (OT)
It is unclear to staff which surfaces are clean and which surfaces are contaminated during management of patients with COVID-19—some surfaces are inevitably contaminated such as the ventilator on the anaesthetic machine as well as the control knobs (OT)Development of ‘contamination grid’ to identify clean versus contaminated surfaces, and provision of 1:49 chlorine wipes to readily clean contaminated surfaces (OT)
Confusion as to where doffing should take place, particularly in the operating theatre design of the AIIR is different from wards. (OT/ICU)Clear signs to indicate where to gown down, as well as education of staff of the design of the AIIR (OT/ICU)
Proximity of staff during doffing of PPE, resulting in possible cross contamination (OT/ICU)Clear signs to indicate that only one person should be in the gown down room at a time (OT/ICU)
PeopleThere were physical barriers to support and additional equipment during patient management, especially in operating theatre where the AIIR is far from other rooms. (OT/ICU)Dedicated standby backup/runner (with PPE protection) immediately outside AIIR to provide timely support and acquisition of equipment if needed (OT/ICU)
ProcessesUnclear workflow for transfer and handover of cases with COVID-19 to AIIR, including risk of cross-contamination of non-infected patients, and when doffing should occur when transferring a patient out of the AIIR for the operating theatre (OT)Revision of the guidelines to ensure clarity of the workflow of handover and transfer of patients with COVID-19 (OT)
OrganisationOnly 55% of staff working in the operating theatre had updated N95 leak test performed, with some staff up to 10 years outdated (OT)Plan for liaison with hospital infectioncontrol team for provision of timely N95 fit test for staff protection (OT)
Staff unclear as to criteria for utilisation of isolation theatre for suspected or confirmed cases (OT)Clarification in the guidelines and protocol for criteria for use of isolation theatre (OT)
  • ICU-specific system issues and improvements are published elsewhere.39

  • AIIR, airborne infection isolation rooms; ICU, intensive care unit; PEEP, positive end-expiatory pressure.