Background: Preparedness efforts for a COVID-19 outbreak required redesign and implementation of a perioperative workflow for the management of obstetric patients. In this report we describe factors which influenced rapid cycle implementation a novel comprehensive perioperative checklist for care of the COVID-19 parturient.Methods: Implementation of a novel workflow for the COVID-19 parturient requiring perioperative care was accomplished through rapid cycling, debriefing and on-site walkthroughs. Post-implementation, consistent use of the workflow was reported for all obstetric COVID-19 perioperative cases (100% workflow checklist utilization). Retrospective analysis of the factors influencing implementation was performed using a group deliberation approach, mapped against the Consolidated Framework for Implementation Research (CFIR). Results: Analysis of factors influencing implementation using CFIR revealed domains of process implementation and innovation characteristics as overwhelming facilitators for success. Constructs within the outer setting, inner setting, and characteristic of individuals (external pressures, baseline culture, and personal attributes) were perceived to act as early barriers. Constructs such as communication culture and learning climate, shifted in influence over time.Conclusion: We describe the influential factors of implementing a novel comprehensive obstetric workflow for care of the COVID-19 perioperative parturient during the first surge of the pandemic using the CFIR framework. Early workflow adoption was facilitated primarily by two domains, namely thoughtful innovation design and careful implementation planning in the setting of a long-standing culture of improvement. Factors initially assessed as barriers such as communication, culture and learning climate, transitioned into facilitators once a perceived benefit was experienced by healthcare teams. These results provide important information for the implementation of rapid change during a time of crisis.

Background Advancements in virtual reality (VR) technology have resulted in its expansion into healthcare. Preliminary studies have found VR to be effective as an adjunct to anesthesia to reduce pain and anxiety for patients during upper gastrointestinal endoscopies, dental procedures and joint arthroplasties. Current standard care practice for upper extremity surgery includes a combination of regional anesthesia and intraoperative propofol sedation. Commonly, patients receive deep propofol sedation during these cases, leading to potentially avoidable risks of over-sedation, hypotension, upper airway obstruction, and apnea. The objective of this study is to evaluate the effectiveness of VR technology to promote relaxation for patients undergoing upper extremity surgery, thereby reducing intraoperative anesthetic requirements and improving the perioperative patient experience.Methods In this single-center randomized controlled trial, 40 adult patients undergoing upper extremity orthopedic surgery will be randomly allocated to either intraoperative VR immersion or usual care. VR immersion is designed to provide patients a relaxing virtual environment to alleviate intraoperative anxiety. All patients receive a peripheral nerve block prior to surgery. Patients in the intervention group will select videos or immersive environments that will be played in the VR headset during surgery. An anesthesia provider will perform their usual clinical responsibilities intraoperatively and can administer anesthetic medications if/when clinically necessary. Patients in the control arm will undergo perioperative anesthesia according to standard care practice. The primary outcome is the difference in intraoperative propofol dose between groups. Secondary outcomes include postoperative analgesia requirements and pain scores, length of stay in the post-anesthesia care unit, overall patient satisfaction and postoperative functional outcomes.Discussion It is unknown whether the use of VR during upper extremity surgery can reduce intraoperative anesthetic requirements, reduce perioperative complications, or improve the postoperative patient experience. A positive result of this clinical trial would add to the growing body of evidence that demonstrates the effectiveness of VR as an adjunct to anesthesia in reducing intraoperative pain and anxiety for multiple procedure types. This could lead to a change in practice, with the introduction of a non-pharmacologic intervention potentially reducing the burden of over-sedation while still providing a satisfactory perioperative experience.

Background Advancements in virtual reality (VR) technology have resulted in its expansion into healthcare. Preliminary studies have found VR to be effective as an adjunct to anesthesia to reduce pain and anxiety for patients during upper gastrointestinal endoscopies, dental procedures and joint arthroplasties. Current standard care practice for upper extremity surgery includes a combination of regional anesthesia and intraoperative propofol sedation. Commonly, patients receive deep propofol sedation during these cases, leading to potentially avoidable risks of over-sedation, hypotension, upper airway obstruction, and apnea. The objective of this study is to evaluate the effectiveness of VR technology to promote relaxation for patients undergoing upper extremity surgery, thereby reducing intraoperative anesthetic requirements and improving the perioperative patient experience. Methods In this single-center randomized controlled trial, 40 adult patients undergoing upper extremity orthopedic surgery will be randomly allocated to either intraoperative VR immersion or usual care. VR immersion is designed to provide patients a relaxing virtual environment to alleviate intraoperative anxiety. All patients receive a peripheral nerve block prior to surgery. Patients in the intervention group will select videos or immersive environments that will be played in the VR headset during surgery. An anesthesia provider will perform their usual clinical responsibilities intraoperatively and can administer anesthetic medications if/when clinically necessary. Patients in the control arm will undergo perioperative anesthesia according to standard care practice. The primary outcome is the difference in intraoperative propofol dose between groups. Secondary outcomes include postoperative analgesia requirements and pain scores, length of stay in the post-anesthesia care unit, overall patient satisfaction and postoperative functional outcomes. Discussion It is unknown whether the use of VR during upper extremity surgery can reduce intraoperative anesthetic requirements, reduce perioperative complications, or improve the postoperative patient experience. A positive result of this clinical trial would add to the growing body of evidence that demonstrates the effectiveness of VR as an adjunct to anesthesia in reducing intraoperative pain and anxiety for multiple procedure types. This could lead to a change in practice, with the introduction of a non-pharmacologic intervention potentially reducing the burden of over-sedation while still providing a satisfactory perioperative experience.

Background: Preparedness efforts for a COVID-19 outbreak required redesign and implementation of a perioperative workflow for the management of obstetric patients. In this report we describe the rapid cycle implementation of a comprehensive perioperative checklist for care of the COVID-19 parturient and a retrospective analysis of the factors which influenced implementation success.Methods: A newly designed workflow for COVID-19 parturients requiring perioperative care was produced as a checklist, intended for use as a cognitive aid. Implementation and refinement of the workflow was accomplished through rapid-cycling, debriefing and on-site walkthroughs. Retrospective evaluation of the implementation experience was performed using a group deliberation approach, mapped against the Consolidated Framework for Implementation Research (CFIR). Results: Post-implementation, consistent use of the workflow was reported for all obstetric COVID-19 perioperative cases (100% compliance). Evaluation of our implementation using CFIR revealed domains of process implementation and innovation characteristics as overwhelming facilitators for success. Constructs within the outer setting, inner setting and characteristic of individuals (external pressures, baseline culture, and personal attributes) were felt to act as barriers. Constructs such as communication, shifted in influence over time.Conclusion: We describe the implementation of a comprehensive obstetric workflow checklist for care of the COVID-19 perioperative patient. A retrospective evaluation of our implementation experience was possible using CFIR, which enabled identification of barriers and facilitators for change within our unit. Furthermore, we observed that implementation success was possible, despite facilitation being perceived within only two domains at baseline. Emerging themes from this study highlight the importance of thoughtful innovation design, careful implementation planning and the establishment of a long-standing culture of improvement, in order to facilitate implementation of change during a time of crisis.

Abstract Background Preparedness efforts for a COVID-19 outbreak required redesign and implementation of a perioperative workflow for the management of obstetric patients. In this report we describe the rapid cycle implementation of a comprehensive perioperative checklist for care of the COVID-19 parturient and a retrospective analysis of the factors which influenced implementation success. Methods A newly designed workflow for COVID-19 parturients requiring perioperative care was produced as a checklist, intended for use as a cognitive aid. Implementation and refinement of the workflow was accomplished through rapid-cycling, debriefing and on-site walkthroughs. Retrospective evaluation of the implementation experience was performed using a group deliberation approach, mapped against the Consolidated Framework for Implementation Research (CFIR). Results Post-implementation, consistent use of the workflow was reported for all obstetric COVID-19 perioperative cases (100% compliance). Evaluation of our implementation using CFIR revealed domains of process implementation and innovation characteristics as overwhelming facilitators for success. Constructs within the outer setting, inner setting and characteristic of individuals (external pressures, baseline culture, and personal attributes) were felt to act as barriers. Constructs such as communication, shifted in influence over time. Conclusion We describe the implementation of a comprehensive obstetric workflow checklist for care of the COVID-19 perioperative patient. A retrospective evaluation of our implementation experience was possible using CFIR, which enabled identification of barriers and facilitators for change within our unit. Furthermore, we observed that implementation success was possible, despite facilitation being perceived within only two domains at baseline. Emerging themes from this study highlight the importance of thoughtful innovation design, careful implementation planning and the establishment of a long-standing culture of improvement, in order to facilitate implementation of change during a time of crisis.