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Peer reviewed Research Published: 04.08.2021
Safe surgery – set-up and organisation of instrument tables for surgery: a scoping review
This is a scientific research article. It has been reviewed and approved by the editor in chief of the Norwegian Journal of Nursing Research and independent peer reviewers. It has been translated from Norwegian. The original Norwegian version can be accessed by clicking 'Norsk' in the upper right corner.
Background: Setting up and organising instrument tables is a complex work process that requires a broad evidence base. Adopting evidence-based recommendations improves safety in the operating room.
Objective: The objective of the study was to strengthen the practitioners' basis for decision-making. This is done through the collection, structuring, summarising and presentation of evidence-based recommendations.
Method: We conducted a scoping review based on Arksey and O'Malley's methodological framework and Aveyard's thematic analysis.
Results: The literature is presented under two main topics: 1) Set-up of instruments, equipment and medications on instrument tables, and 2) Reorganisation of instruments, equipment and medications on instrument tables. The recommendations cover prevention of deviations from sterile technique, sharps injuries, retained surgical items in the patient, handling medication and fire safety. One of the guidelines describes a practical, specific and systematic procedure for setting up instrument tables.
Conclusion: The results present a wide range of evidence-based recommendations that can support decision-making in the set-up and organisation of instrument tables. The results of the study can be used in development and improvement work and can form the basis for a standardised set-up of instrument tables for various surgical procedures and for improvements to the 'Safe Surgery' checklist. Only one guideline specifies a practical and systematic procedure for setting up instrument tables. We recommend that evidence-based guidelines, standards and clinical procedures be drawn up in Norwegian. We also recommend that operating room nurses' experiences with setting up and organising instrument tables be examined, and that literature reviews include guidelines from countries that are not covered in this study.
Set-up and organisation
Safe surgery
Human error often occurs as a result of deviations from routine practice (1). The World Health Organization (WHO) points out that the knowledge and experience of the surgical team is the most critical resource. WHO also emphasises that implementing standardised safety procedures, such as the 'Safe Surgery' checklist, can prevent errors when many people and advanced techniques are involved, thereby improving patient safety (2).
However, WHO also acknowledges that the autonomy of the professions means that there is no standardisation culture in surgical departments (2).
Setting up and organising instrument tables for surgical procedures is a complex work process in which instruments, equipment and medications must be controlled, correctly placed and always available. Organisation helps provide an overview of the instruments and equipment on the instrument tables, and their placement ensures the safety of the patient, surgical team and equipment (3).
In a study conducted at 16 hospitals in Norway, only four surgical departments used written procedures for the set-up of instrument tables (4). This is due to the lack of national and evidence-based guidelines and clinical procedures.
Surgery exposes patients to critical phases where mistakes can be made, leading to injuries and complications (2). Most mistakes are a result of communication failures between members of the surgical team (2, 5, 6). Combined with the lack of guidelines and standards, this can have a negative impact on patient safety.
Reported complications and injuries from surgical procedures include postoperative infections (7), retained surgical items in the patient (5), medication errors (8), injuries from electrical equipment (9), surgical fires (10), transmission of blood-borne pathogens by sharps injuries (11) and infection or disease transmitted by exposure to surgical plume (12).
In any form of surgery, there is a requirement for evidence-based practice (EBP), which encompasses knowledge based on research, practitioners' experience and the patient's wishes and needs in the given situation (13). In the study conducted by Hjelen and Sagbakken at three hospitals in Norway, the operating room nurses reported that their work was not evidence-based (14). This highlights the need for literature reviews that simplify access to research-based knowledge for practitioners and help them make informed decisions.
The purpose of this literature study was to generate knowledge that can strengthen practitioners' basis for decision-making in the set-up and organisation of instrument tables for surgical procedures. We also wanted to improve training and stimulate further research.
The target group is operating room nurses, technicians and nursing students who set up and organise instrument tables, those responsible for drawing up procedures for clinical settings as well as individuals and authorities that develop evidence-based or national guidelines, standards and evidence-based clinical procedures. The study is also aimed at researchers in the field.
We investigated the following research question:
What evidence-based recommendations are available to support clinical decision-making in the set-up and organisation of instrument tables in the sterile field that contribute to safe surgery?
This article collates, structures, summarises and presents the results of evidence-based recommendations and peer-reviewed studies. The article also highlights research gaps and the need for further research.
The research question was addressed using a five-stage approach in the methodological framework devised by Arksey and O'Malley, which required an accurate and transparent approach without the need for method validation (15).
In addition to the framework, we clarified the research question and the objective of the study, established an effective search strategy and carried out a repeated search and selection process, as recommended by Levac et al. (16).
Furthermore, we have reported the results that are relevant to the research question and discussed implications for future research, practice and policy, as recommended by Levac et al. (16). We started by defining and documenting key concepts, frameworks, objectives and search criteria, and planned the sample as recommended by Peters et al. We then identified research gaps (17).
Supplemented by Kahlil et al., the research question helped with the development of specific inclusion and exclusion criteria (18), which in this study provided information on phenomena of interest, population, context, outcome and literature choices (Table 1).
The set-up and organisation of instrument tables is a complex process. This makes a precise, delimited and systematic understanding and assessment difficult, and we therefore chose to carry out a scoping review (18). Earlier literature reviews had not covered this scope.
Identifying the research question (stage 1)
We performed and completed searches in three rounds (in 2017, 2018 and 2019), which generated knowledge about earlier research and helped define the research question and search strategy. The research question focuses on the work process for 'the set-up and organisation of instrument tables', which was defined, and keywords selected.
The population was sterile tables with instruments, equipment and medications used in connection with surgical procedures. In the study, 'instrument table' is a generic term, and specific terms are 'Mayo stand' and 'back table'.
In addition, instrument trays, instruments, equipment (technical medical equipment, supplementary equipment and disposable equipment such as compresses, surgical covers and swabs) and medications are included. The desired outcome was also specified in the inclusion criteria (Table 1).
Identifying relevant literature (stage 2)
The first and second authors, with input from the third author, planned and developed the literature search using a PICOT form as described by Aveyard (19). Several searches with different terms helped to clarify the inclusion and exclusion criteria as well as the final choice of search terms. The search consisted of text words and subject headings that we discussed thoroughly and adapted to the various databases.
Sources for guidelines and knowledge summaries were reviewed both by searching for overarching search terms or for topics (e.g. operating rooms, safe surgery, patient safety, surgical instruments/equipment, sterile field), and by reviewing content indexes.
This was performed for Norwegian clinical procedures via the Norwegian Electronic Health Library, national guidelines from the Directorate of Health, the Norwegian Electronic Health Library's guideline database; UpToDate, the pyramid search in the Norwegian Electronic Health Library, Evidence-Based Medicine, Evidence-Based Nursing, NICE, GIN, Socialstyrelsen.se, the Danish Health Authority, the Danish Centre for Clinical Guidelines and the New Zealand Guideline Group: Guideline Central. We also searched the Cochrane Library and Epistemonikos.
The second author performed the final systematic database searches in June and July 2019. The searches were performed in Medline and then in Cinahl, Svemed+ and Embase. The search strategy consisted of text words and controlled search terms that were adapted to the thesaurus of the individual database.
The key search terms we used included the following: operating rooms/theatre/suite/sterile field, surgical instruments/equipment, instrument table, patient safety, safe surgery, guideline/standards/recommendations/checklists. The search terms were combined with the Boolean operators AND and OR. The search strategy from Medline is detailed in an appendix (Appendix 1).
The complexity and scope of the topic resulted in searching for numerous text words and also a recognition that the topic was mainly described in the full text or tables of the articles. It was therefore also necessary to search for general concepts in the individual study databases in addition to resources with more summarised content.
We also carried out repeated manual searches in central organisations' guidelines: AORN Guidelines for Perioperative Practice: 2018 edition (20), AST Standard of Practice (21), the guidelines from Sweden's national association for surgical health care (22), WHO Guidelines (23) and EORNA Recommendations (24). In addition to this, we reviewed the references in the individual studies included.
Literature selection (stage 3)
We excluded documents by reading titles, summaries or full text, and selected documents based on the inclusion and exclusion criteria in order to balance feasibility with breadth and scope, as recommended by Peters et al. (17).
Criteria that were included describe phenomena of interest, context, population, outcome, type of literature, time period and language. The search strategy and inclusion of studies were largely governed by their relevance to practice. We included guidelines that we found in manual searches, following discretionary assessments of their relevance to the research question.
In order to quality assure clinicians' basis for decision-making, as recommended by Peters et al. (17), we deviated from Arksey and O'Malley's framework by placing an emphasis on the documents' position in the 5S model (the knowledge pyramid).
Available literature at the top of the pyramid encompassed reference material and guidelines, and at the bottom we find quality-assessed individual studies with original results (25). We selected literature at the top of the pyramid if the recommendations overlapped, and any new knowledge identified lower in the pyramid was also included.
We chose to limit ourselves to 'open surgery' as this often requires more equipment and more detailed organisation. In addition, instruments and equipment are mainly set up and organised on the instrument tables, in contrast to invasive endoscopic procedures, where instruments or equipment are also placed in the wound or in special bags in the 'field'.
In total, we identified 2191 documents (Figure 1). After removing duplicates in Endnote, the first and third authors individually checked the relevance of the literature in relation to the research question based on the title (first) and summary.
We then compared each other's selection of documents. Documents that we had both selected were automatically included, and we discussed and assessed the remainder together. The review resulted in a sample of 68 full-text documents. We then individually reviewed all the documents in full text, this time based on the inclusion and exclusion criteria.
After a joint review, both authors agreed that 43 documents met the inclusion criteria. Furthermore, we jointly excluded 16 documents with identical recommendations found in documents higher up the knowledge pyramid.
The final sample consisted of 27 documents based on consensus decisions and agreement through discussion, as recommended by Levac et al. (16) (Figure 1).
Charting the data (stage 4)
The first and third authors presented the selected documents in the form of charts mapping, as recommended by Arksey and O'Malley (15).
Inspired by the categories suggested by Arksey and O'Malley (15), we categorised the documents under author(s), year of publication, document title, journal, country, purpose, type of document/methodology, assessment system and important results. See Appendix 2 [in Norwegian] for details.
Collating, summarising and reporting the results (stage 5)
Based on the charts mapping, the first and third authors sorted, summarised, and presented the data in a numerical analysis, as recommended by Arksey and O'Malley (15) (Table 2).
The numerical analysis showed how the documents were distributed between the following categories: year of publication, country, purpose, type of document and assessment system. The WHO Guidelines for Safe Surgery published in 2009 (2) were included because they are still relevant to practice.
The first and third authors performed a thematic analysis as recommended by Aveyard for literature reviews (19), and as recommended by Arksey and O'Malley (15). Our development of themes was based on recommendations that we identified in the selected documents. We then did a broad comparison of the results and ended up with eight preliminary main topics.
Next, we assessed the topics against the research question. The categorisation and content of the topics were re-systematised and adjusted, and the review resulted in two main topics, each with four sub-topics. We carried out a final review of the results in the charts mapping in order to prevent relevant results in the literature being omitted. The final result is presented in Table 3 and in a narrative presentation.
In summary, the numerical analysis showed that 22 of the 27 documents in the final sample had been published within the last five years. The bulk of them - 16 - were published in the United States, and 9 were from Europe, including 2 from Scandinavia.
The purpose of all the documents was to prevent injury and complications during surgery, mainly aimed at the patient. Two areas; fire safety and transmission of blood-borne pathogens, focused on both patients and staff.
The majority of the documents - 19 - were guidelines or reference material, and 16 documents used an assessment system to grade results or recommendations. See Table 2 for more details.
The thematic analysis resulted in the following:
Theme 1 focused on the initial preparations – set-up of instruments, equipment and medications on instrument tables. The recommendations are limited in time from establishment of the sterile field and the opening of sterile equipment, up until surgery starts subsequent to a time-out phase in line with the 'Safe Surgery' checklist.
Theme 2 related to the phase from 'incision of the skin' up until the patient is moved out of the operating room, including the final phase in the 'Safe Surgery' checklist. The spotlight was on the reorganisation of instruments, equipment and medications on the instrument table based on changes vis-à-vis the patient, surgery and situation.
Set-up of instruments, equipment and medications on instrument tables (H1)
It is recommended that a risk assessment is performed during the preparations for surgery in order to prevent complications and injuries. The surgical team and the scrub nurse in particular should be focussed on preventing non-compliance with sterile techniques, identifying non-compliance and implementing corrective measures.
Other specific recommendations relate to the risk of transferring and administering medications, assessing the risk (score) associated with the fire triad and the use of monopolar diathermy (Electro Surgery Unit (ESU)), as well as exposure to surgical plume.
The guidelines recommend preventing surgical items being retained in the patient by assessing the risk to the patient (overweight/size, state of health), surgery (trauma, bleeding), the situation (time for preparation and counting) and equipment (quantity, size, detectable). Verbal confirmation is recommended where there is a high risk of blood-borne pathogens. See Table 3, H1:a for details.
Communication and teamwork
Preoperative team briefing and two-person cross-checking are recommended for confirming and controlling that the correct equipment and medications are available. This includes sterility, function, the correct number, as well as checking the surgeon's preference card and documenting the control routines.
The team must assess and verbally confirm whether there is a fire risk. Furthermore, the team must have a plan to reduce the risk and delegate tasks to prevent and deal with any fire. Observed risk of fire or potential fire must be verbalised loudly and immediately. See Table 3, H1:b for details.
Standardised set-up of instrument tables
The set-up of sterile instruments is described with varying degrees of detail in the documents. The literature recommends using standardised trays with an instrument list, and establishing a logical, sequential and efficient pattern when setting up, which is the same for back tables and Mayo stands.
During dirty surgery, instrument tables are positioned in the room so as to prevent contamination of equipment and instruments. According to recommendations, instrument tables for abdominal and perineal areas must be kept separate, and instruments or equipment that have not been used must remain in specific zones on the back table, separate from those used.
The set-up of sterile instruments is described with varying degrees of detail in the documents.
Instrument tables are established as close to the start of surgery as possible, with sterile equipment only. A standardised transfer process, storage and placing of instruments, equipment and medications is recommended. It is further recommended that information about medication is standardised, doses are pharmaceutically prepared, medication is labelled immediately and that the time factor is heeded in relation to opening and transfer.
The scrub nurse must know where the instruments and equipment are throughout the surgical procedure. Consistent counting is enabled through standardised procedures, and through equipment being assembled and arranged to give an overview and ensure accurate and efficient counting where sharp objects are placed in a specified area on the Mayo stand and back table. See Table 3, H1:c for details.
Safe work practices
The recommendations cover the prevention of non-compliance with sterile techniques and medication errors when opening, handing over and setting up sterile instruments, equipment and medications.
Trays and instruments are controlled against the table of contents and indicators. Their function is also checked and they are examined for dirt. The trays and instruments are replaced if necessary and prepared for use. Only one medication at a time should be handed over, and use of a blunt cannula is recommended.
Sharp instruments and sutures are arranged in sequences designed for efficient and accurate counting as well as safe storage and disposal. Safety measures to break the fire triad are recommended in the form of inspecting the isolation of the ignition source cable (energy-generating equipment) and storing the diathermy pen in an isolated safety sleeve. Consideration should be given to using monopolar diathermy.
Assessments, measures and deviations must be documented. Accounts must also be kept for all items, including supplementary equipment and instrument parts, which are counted separately. Documentation can be produced in an electronic format, on a separate form or as part of the nursing documentation. See Table 3, H1:d for details.
Reorganisation of instruments, equipment and medications on instrument tables (H2)
It is important to note that the team has a joint responsibility for indicating when mistakes are made and when non-compliance with sterile techniques is discovered. In order to prevent interruptions and communication failures, it is recommended that counting and transfer processes are carried out in a distraction-free zone.
A standardised counting procedure is recommended with a fixed order, verbal confirmation and written documentation, as well as a standardised administration and transfer process for medications and solutions. The position of the neutral zone must be clarified in the team, and a verbal message must be given when sharp objects are in use. In order to break the fire triad, the anaesthetist must be notified before monopolar diathermy is used over the sternum. See Table 3, H2:a for details.
It is recommended that instrument tables are monitored and covered according to a standardised procedure and at set times. In cases of varying wound classifications, separate instruments and instrument tables are recommended, as well as isolation techniques for intestinal surgery or cancer surgery.
Contaminated items are removed from the sterile field, and sterile instruments are used to close wounds. It is recommended that medication is handed over immediately prior to use and administered as quickly as possible. Unlabelled medications are to be discarded. Equipment and waste remain in the operating room until the end of surgery, and documentation is completed in accordance with standardised information.
Two people carry out a standardised counting procedure visually and verbally in a fixed order at a set time. The scrub nurse decides when the counting will be carried out, and all the equipment in the sterile field is included in the final count and documented.
To prevent sharps injuries, controlled work processes are recommended, such as non-touch technique, use of a neutral zone and zones for storage and placement of sharp instruments on the sterile tables. In addition, it is recommended that the tempo is reduced when sharp instruments are in use.
In order to break the fire triad, it is recommended that alcohol is kept away from the wound when energy-generating equipment (diathermy) is in use, that wet compresses and sterile water or saline are available, and that the oxygen concentration is reduced. Nitric oxide should also be avoided when using energy-generating equipment over the sternum. See Table 3, H2:b for details.
Technology and safety equipment
Various technologies are recommended for supporting the manual and systematic counting of items. A combination of manual counting using a whiteboard and plastic folders as well as scanning with a barcode or radio-frequency identification is recommended.
Only X-ray-proof items and compresses, surgical covers and swabs with X-ray detectable thread are used in surgical wounds. Safety equipment such as safety syringes, self-sheathing needles, blunt cannula and suture needles are recommended for preventing sharps injuries. Use of safe scalpel blades is also described.
Scalpel blade removal tools, equipment for alternative incision and closing methods, storage boxes for needles and scalpel blades and puncture-proof waste containers with a functionality for safe closing and disposal are also recommended. See Table 3, H2:c for details.
Non-conformance and non-conformance management
When a breach in sterility is identified, corrective action is recommended immediately where this is compatible with patient safety. Before a surgical procedure is completed, instruments and supplementary equipment need to be counted. If an item is missing, a search must be made of the entire room and in the wound, and a re-count must then be undertaken. If the item is not found, and the patient's condition permits, an intraoperative X-ray is performed before closing the incision. The result is reported to the surgeon in charge and the team, and assessments, measures and accounts are documented.
If an item is missing, a search must be made of the entire room and in the wound, and a re-count must then be undertaken.
In the event of a fire in or on the patient, all gas to the respiratory tract is stopped. Combustible material is removed, sterile water or saline is applied to fire sites, and the RACE fire procedure is followed (Rescue: save the patient from the fire, Alarm: activate the fire alarm, Confine: close the operating room door after evacuation, Extinguish: use a fire extinguisher during evacuation). See Table 3, H2:d for details.
Summary of main findings
In combination, the recommendations relate to teamwork and communication, risk assessment and non-conformance management, standardised set-up, technology and safety equipment as well as safe work practices.
Only one guideline drawn up by operating room technicians sets out recommendations that specify a standardised, systematic and practical set-up of instrument tables. See Table 3 for details.
Status in Norway and potential improvements
The 'Safe Surgery' checklist (2) and the EU directive on the prevention of sharps injuries (47), which was introduced to reduce the risk of injuries and complications, are international measures that are important for the set-up and organisation of instrument tables. In addition, evidence-based recommendations help to improve the safety of the operating room and protect patients and staff (6).
Several recommendations found in this literature review are not included in the WHO 'Safe Surgery' checklist and should be implemented. The recommendations in this literature review can clarify risk factors that the surgical team should focus on during the time-out phase (H1:1a).
In addition, the team must plan and prepare measures and distribute tasks to prevent and deal with errors and injuries (H1: 1a, 1b and 1d, H2: 2a and 2b), and assess the need to have the necessary safety equipment available (H2:2c).
Several recommendations found in this literature review are not included in the WHO 'Safe Surgery' checklist and should be implemented.
An emphasis is placed on the team members' responsibility to voice any breach of sterility and observed errors, as well as to avoid distractions and interruptions during counting and transfer processes (H2:2a and 2d).
In relation to the closing phase of the 'Safe Surgery' checklist, the recommendations provide guidelines for non-conformance management and documentation (H1:1d, H2:2b and 2d). Overall, the recommendations identified can improve the 'Safe Surgery' checklist.
There is a lack of Norwegian guidelines and standards for setting up and organising instrument tables. Only one relevant evidence-based clinical procedure for surgical counting is complete and available on the Norwegian Electronic Health Library's website (41). Prevention of sharps injuries is discussed in the Infection Control Guide (48) and in statutory requirements for the working environment (49).
Written procedures for the set-up and organisation of instrument tables are seldom used in Norway (4). According to the National Health and Hospital Plan 2020–2023, there is considerable variation in many areas of the health service, and the government wants to see more cooperation and sharing of knowledge as well as clinical coordinating committees that will develop procedures (50).
Are evidence-based guidelines and standardised procedures necessary?
The health service is required to apply an evidence-based approach to practice (50). In addition, research shows that using evidence-based recommendations and standardised procedures and techniques improves the safety of processes (2, 6).
Time is critical for patient outcome in all surgical procedures, and according to Høyland et al., planning and preparation save time (51). Accuracy, efficiency and continuity in the surgical team are achieved by following the same pattern and process in line with standardised procedures (52).
One guideline describes a thoroughly considered standardised transfer, storage and placement of instruments, equipment and medications that can contribute to the efficient and safe set-up and organisation of instrument tables (Table 3, H1: 1d).
In Norway, instruments in the sterile field are set up on the basis of a written procedure or picture of the set-up (4), or a 'separate system for setting up instrument tables' (53). When an experienced scrub nurse sets up and organises instruments based on a system he or she has developed over time, the work can be performed quickly using the technique he/she has established.
Experienced scrub nurses know that the set-up and organisation of instrument tables must be adapted to different patients and situations, and the work is affected by predictable and unpredictable changes along the way that require continuous reorganisation of equipment and instrument tables. Introducing a standardised set-up that may differ from an established routine can be a daunting prospect for experienced staff.
If the individual scrub nurse has to develop a 'best practice' himself/herself, this entails a great deal of responsibility that requires advanced skills. It may also lead to different 'individual systems', thereby creating an undesirable variation in patient care and quality. In addition, 'individual systems' can lead to challenges when team members are replaced during breaks or in connection with changes to the staff on duty.
If the individual scrub nurse has to develop a 'best practice' himself/herself, this entails a great deal of responsibility that requires advanced skills.
When an operating room nurse takes over someone else's instruments table, it takes time to reorganise it to 'their own system'. The time and effort required for this work compete with the sterile assistance associated with surgery. Two demanding processes distract each other, and errors often occur in the transitions.
In addition, it is agreed that distractions are one of the main causes of failures and errors, and can result in complications and injuries that must be avoided (5, 6, 39, 45, 46).
Another challenge concerns the training of operating room nurses. Supervisors need to maintain an overview and control in case they have to take over from the student nurse. Students are therefore asked to set up instrument tables using the supervisor's 'system' (53).
If the supervisors have different systems for setting up and organising the instrument tables, it can prevent students from receiving sufficient training and mastering the task. Students are looking for a 'recipe' they can learn, and that facilitates better learning (53).
Best practice and effective adaptation to the patient and the situation require evidence-based assessments and skills which in turn require reflective practitioners to have experience and competence. Common procedures based on sustainable knowledge in accordance with evidence-based practice enable operating room nurses to ensure quality in practice to a greater extent and to dispense with unwanted variation.
For students or inexperienced operating room nurses, available guidelines, standards or clinical procedures will provide important support for decision-making.
A common procedure or standard can help ensure that the entire team contributes to patient safety.
Recommendations set out the surgical team's joint responsibility to notify other team members when errors are observed (2, 5, 6, 33). In order to identify errors, particularly in complex situations like surgery, a common system is required that everyone knows and can monitor, as well as react to when it is not correct. A common procedure or standard can help ensure that the entire team contributes to patient safety.
In addition, the standard or procedure can serve as a quality assurance measure and form a good starting point for adjustments to the patient or the situation. The standard can also remove unwanted variation in the statutory documentation. The documentation plays an important role in quality assuring patient care and students' learning, and can be used actively in the improvement work in practice.
Assessment of method
The research question in this literature review covers a complex topic that includes literature from many different areas. This may have resulted in errors during the literature search. The results from the search process show that a variation of search terms is required depending on which level in the 5S model the search is aimed at.
In addition, there is also the choice of controlled subject headings and text words, combinations of these and other search engine techniques. This process is complex and time-consuming, and requires researchers to work closely with the librarian. Guidelines that are unavailable in full text, and/or costly to access in full text are further challenges in the process.
In this literature review, it was crucial that the literature was relevant to practice, which resulted in us including various documents. We did not evaluate the methods used in the research literature or rate the quality of the recommendations in the documents, which is in line with Arksey and O'Malley's framework (15).
However, we also note that 19 documents are at the top of the 5S model, and 16 of these used an assessment system to grade the recommendations.
Inclusion criteria for context (open surgery) and language (English and Scandinavian languages) may have excluded literature that could have contributed new, relevant knowledge. In addition, financial constraints have limited the access to relevant guidelines of surgical nursing organisations in English-speaking countries such as Australia and Canada.
In order to ensure the safety of the patient and staff in connection with surgical procedures, careful planning and preparation of instrument tables is crucial. It is also important to set aside and prioritise time for planning and preparation.
In the literature review, we identified recommendations from a comprehensive and broad area that impact on and are part of choices that are made in the set-up and organisation of instrument tables. The recommendations must be adapted to the patient, the surgery and the surgeon's preferences for equipment, as well as the team and the situation in general.
The results of the literature review may indicate that there are areas covered by the recommendations that are not included in the 'Safe Surgery' checklist, and which are important for patient and staff safety. Only one guideline specified a practical and systematic set-up of instrument tables, drawn up by and aimed at operating room technicians.
We did not identify any evidence-based or national guidelines or standards in Norwegian for the set-up and organisation of instrument tables, and only one relevant clinical procedure for surgical counting in Norwegian is accessible in the Norwegian Electronic Health Library.
Implications for clinical practice, training and research
Evidence-based recommendations can help staff to adopt an evidence-based approach to practice as they serve as a support for decision-making among operating room nurses, technicians and nursing students who set up and organise instrument tables, and are important for the development of clinical procedures in hospitals.
The lack of guidelines and standards should be considered problematic and the medical profession in Norway should be encouraged to develop evidence-based or national guidelines and standards for the set-up and organisation of instrument tables. In addition, we encourage those responsible for developing and improving clinical procedures and checklists at hospitals to implement the relevant recommendations we have identified in the literature review.
We also recommend that master's students in operating room nursing should draw up clinical procedures on the set-up and organisation of instrument tables for various surgical procedures, for inclusion in their thesis.
We further recommend that guidelines drawn up in other countries, which are not included in this literature review, be examined. Research on experiences and practices in connection with the set-up and organisation of instrument tables should be prioritised by operating room nurses in educational institutions and clinical settings.
Resistance to the use of standards in surgical departments may seem incomprehensible when the research community agrees that standardisation improves safety in the operating room. We call for a professional discussion with the spotlight on the use of standards in surgical departments.
The first author has participated in a programme for qualification as an associate professor and wishes to acknowledge and thank Emeritus Professor Ole Petter Rekvig for his professional guidance in connection with the work on this article.
The first author would also like to thank Inga Segtnan, Tove J. Berntsen, Ulla M. Svensson, Anna K. Roer and Anita Eilertsen for their useful input. Between them they have 170 years of experience as operating room nurses.
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OVERVIEW: The set-up and organisation of instrument tables is a complex work process. Instruments, equipment and medications must be controlled, correctly placed and always available. Illustrasjonsfoto: Nazile Keskin / Mostphotos
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Unni Igesund
Operasjonssykepleier og universitetslektor UiT – Norges arktiske universitet
Grete Overvåg
Hovedbibliotekar UiT – Norges arktiske universitet
Guri Rasmussen
Operasjonssykepleier og førstelektor Norges teknisk-naturvitenskapelige universitet, Trondheim
DOI number
10.4220/Sykepleienf.2021.84445en
Sykepleien Forskning 2021;16(84445):e-84445
Download the article (pdf, 3.41 MB)
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Administrative Separation Board
Misuse of Insurance Proceeds
NJP: Nonjudicial Punishment
Officer Misconduct Military Lawyer
Computer Sex Crimes
Fraternization & Adultery
Sexual Assault Under Article 120 UCMJ
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AWOL -- Failure to Report for Duty
Drug Use In The Military
Fraud & Larceny
Pay & Allowance Fraud
Government Property Theft
Appellate and Review Boards
Physical Evaluation Board Appeals
Security Clearance
Court Martial Appeals
IRR Mobilization
Advice for Military Members Facing Court Martial
Criminal Defense Attorney Dallas Texas
Discusses History in Military As JAG Lawyer
Ignite SBOT Patrick McLain
Patrick J. McLain Judge Advocate
Tough Criminal Defense
Texas Bar TV
Naval Base Coronado
Naval Air Station North Island
Naval Base San Diego
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There really is so much to write about on a weekly basis. At the beginning of each week I have so many things I'm sure I want to say so I think, OH, I'll just post a little now, but then I think, No! Keep it simple... once a week!...or something..like...that...The thing is, by the end of the week, I forgot all the things I wanted to say, even though I am constantly "writing" in my brain. Since I was little (oh, you know, four or so) I felt like I was narrating my life, sort of like that Will Ferrell movie that no one probably remembers the name of because it was pretty depressing (hint, see my post title), where the lady tells the story of his life while he's doing it. Yeah, that's how I live my life. It's no wonder I always enjoyed writing.
India is full of things stranger than fiction. And as many of our friends and family from the US have discovered, many of our best stories come from those closest to us. So really, for this post, I'm not making any of my own stuff up at all. I'm just stealing from the things people tell me (Kind of like the picture up there from the movie... um, that picture, minus what I added to it, because when one is in India, one should always brush with filtered water. Yeah, but that picture totally belongs to the movie people. Does that cover me?? Eek...). Because the things people here tell us make some pretty darn good stories. I'll limit myself to just three for the time being because really I could go on and on, but then who'd want to read me do that? I'll count 'em down backwards for you.
I'll bet half, if not all, Americans have no idea that cold water gives you an actual cold. Seriously. It makes you sick. I am proof of this, you know. One sweltering summer day here I was totally fine, minding my own business, completely healthy- but very thirsty- so I went to the water cooler. Our driver happened to be in the kitchen at the time making tea and he said to me, "Cold water bad, Madam. Make very sick." Um, okay. So I said, "Um, okay. That's okay... I like cold water..." and I drank it. Well, you will never guess what. The next day I got a sinus infection. Granted, the doctor said it probably had never gone away from the sinus infection like, weeks before, but still. My driver was smug the whole way to the hospital. He even mentioned it on the way, like "Cold water, Madam. Bad." So there you have it. If you want to die, or you want to get sick, or you're just begging for a sinus infection that you had weeks ago to present itself again, go ahead, I dare you. Drink that icy cold beverage.
Which brings me to my next story. In what was not my finest moment in smartness, I punched my hand accidentally through a hard plastic planter. The result was none other than profuse bleeding. As I walked as calmly to the kitchen as I possibly could to stick my bloody hand under the water as quickly as I could, Maria, our maid (I prefer to refer to her as our "housekeeper")...and yes, we have one, just like everyone else here- don't get so excited!, comes to see how I'm doing. When she sees the what-I'm-doing, she says "No! No madam! That won't stop the bleeding. Only drinking water will stop the bleeding." Of course, I don't think putting my hand under disgustingly filthy water will actually stop the bleeding, but it's good to see what I'm working with, and somehow I hardly believe drinking water will stop the bleeding either. Maria did not offer to get me any water. It is a good thing too, because I would have wanted it served cold.
1) Here's to you, Mrs. Reddy.
Maria always gives me some pretty great stories. She's Christian, as opposed to being Hindu or Muslim, the other main religions here. For whatever reason, she likes to recount all her churchly escapades of the week/month/whatever it happens to be at the time to me. This time there was no telling me about her bus trip to the 11 different "churches" all in one day, which really turned out to be an amusement park-like setting for the stations of the cross. Instead the story was better than I could have ever hoped for. As I sat in my "office/craft" room working on a quilt and listening to music, she came in and began cleaning. Sometimes I think she likes to be in the room I'm in simply because she is nosy, but that's beside the point. When Simon and Garfunkel came on, I knew she would start up a conversation. "Hm, very nice," she said. "Is this a Jesus song??" Hmm....not exactly.
So folks, it all comes back to stories. And how we have so many of them to tell. And how I am always narrating my life and how it becomes increasingly more interesting while living in another country. So I think, if it's alright with you all, I might just post whenever I have something to say, that way I don't get into this habit of forgetting what I wanted to write and not going back to it when I do remember just because I can be lazy like that. I really will try to limit it though... you know, only 10 times a week. Haha, just kidding. Maybe 2 times. If I'm so so so lucky. And I doubt anything will be this involved. But I'm sure all our posts will be so much stranger than fiction.


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What's special about Valgard?
Home/Publications/What's special about Valgard?
Valgard is a top-down shoot 'em up, but with some very peculiar characteristics:
In almost every top-down shoot 'em up the main character don't collide with the environment, even because in the majority of the games the main character is flying. In Valgard you are a person, and you walk in the environment, you can fall, you can get stuck and even fall in traps. Obviously, some enemies are subject to this too.
You can shoot forward and backward, while you walk in any direction. This feature provides a much more circular combat and opens a lot of awesome enemy behavior.You can shoot forward and backward, while you walk in any direction. This feature provides a much more circular combat and opens a lot of awesome enemy behavior.
There are traps, as was said before, but the curious thing about is that you can use the traps against your enemies. You have only to find the switch before them.
Every stage has a boss fight tailored for the environment. All these fights are planned to be very challenging and tricky. Our main reference for this, besides Knightmare and Elemental Master, is Dark Souls.
By Revolver|2017-12-12T11:24:12+00:00December 30th, 2015|


Tully Mill Cottages face the park land connected to the 18th-century Florence Court House providing easy access to a range of outdoor pursuits. The world famous Marble Arch Caves Geopark is only minutes away and the well-known Tully Mill Restaurant is located just next door.
Ideally located on the outskirts of Florence Court Park with the magnificent backdrop of the Benaughlin and Cuilcagh Mountains, Tully Mill Cottage guests can explore the best of The Fermanagh Lakelands from their doorstep.


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Province of British Columbia
21st Annual Privacy and Security Conference
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4th Annual Canadian Videogame Awards Apr 20, 2013, Vancouver, BC
Canada will gather on the West Coast this spring to celebrate its world-class video game developers at the fourth annual Canadian Videogame Awards ceremony in Vancouver, British Columbia on April 20, 2013.
The Canadian Videogame Awards are presented by Future Shop and will be held in conjunction with Fan Expo Vancouver™ at the beautiful Vancouver Convention Centre. As the third largest developer of video games in the world, the show celebrates Canada's spot on the world stage as a leader in interactive entertainment.
Click here to visit the Canadian Videogame Awards website.
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21st Annual Privacy and Security Conference Feb.5-7, 2020, Victoria, BC
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Feeling like you keep putting on the same event, over and over again?
Have the urge to create something bigger and better?
Want to keep up with the latest marketing movements?
Leveraging the community aspect of events is your answer!
There's a growing desire of consumers to feel a part of something beyond one or two-day events. It's human nature to love being part of a movement, connecting with others, and getting involved.
Why not serve your audience and your brand better by leveraging your event and expanding it out into a true community?
Event planners are beginning to see how events extend beyond the actual event, starting before the event begins and continuing long after the event has passed.
The event lifecycle has extended as social media, new marketing strategies, and more conscious consumers have flooded the marketplace and encouraged companies to step up their game.
The new marketing landscape is all about storytelling, connection, and relationship building! "Events as communities" is a great way to put these ideas into practice and increase the impact of your event.
You have the ability to capture audience attention on a much deeper level than ever before, encouraging consumer engagement outside of the limited time you have available to host an event.
Who will manage the community? This strategy requires other marketing experts past the event planner in charge of the event. It takes brand ambassadors to truly nurture a community and ensure the community stays focused. Be prepared to invest the personnel to make this strategy effective.
What is truly the point of the community? What is the bigger movement that your audience relates to and can get behind? It could be environmental issues, conscious consumerism, buying local, or other big vision causes that your brand supports and believes in. Ensure the vision is aligned with your brand and is related to your event.
What is really the goal with creating the community outside of the event? Perhaps it's increasing attendance at the event, fostering connections between attendees, building customers for life, continuing the community yearly, or changing perceptions. There are a lot of reasons communities exist, but if you aren't clear on the purpose of your community, then your lack of true connection will show and it will be confusing why it exists in the first place.
Consumers are intelligent and picky about how they spend their time and where they spend their money. If you want your event to truly stand out, link it to a larger community that serves a true purpose for your audience and your brand.
Connection is currency and your event community can prove to be well worth the effort.
Let's talk safety at events.
Check out our tips on considering safety at events.
PLANNING EVENTS IS FUN AND ADVENTUREOUS.
YOU GET TO CREATE SOMETHING FROM NOTHING AND WATCH IT COME TO LIFE!
In all of the fun planning around things like ambiance, it can feel burdensome to worry about something like safety. But it's important to properly plan for such measures when you're in charge of an event and the people attending.
When people attend events, they don't think about things like safety – they expect that the organisers already have. So that if they do find themselves in an emergency situation, you will take care of them.
It's an important part of your responsibility in hosting an event. We've put together this starting guide to the basics of safety at events, in case you don't know where to start.
IDENTIFY POSSIBLE RISKS at your event so that you can then control those risks in an appropriate manner. In order to do this you must think about what might cause harm to the attendees at your event and determine if you are taking reasonable steps to prevent that harm. The goal with risk management is not to entirely remove risks, but to identify sensible measures to control the risks and ensure measures are in place that are reasonable if a situation arises.
STEP INTO THEIR SHOES....stepping into the shoes of a worker or attendee and seeing the day from their vantage point. What will they see, where will they be, how will they get from place to place. A good place to start is to think about the safety of structures above their heads and what's at their feet.
Identify the hazards at your event, the potential of harm, what can be done to lessen the risk, and what will be done if something happens.
These findings will create your risk management and safety plans.
IDENTIFY EVENT NEEDS - identify the products you're using at your event and the potential for harm. Have you chosen products that help alleviate safety concerns? Do your structures meet safety standards and have they got engineering certificates? What wind load and ballasts are required to keep structures steady and in place in high winds/ rain? For instance, Stretch Structures use the best material designed to meet most global fire, structural, and safety standards. The strong fabric contains built in fire retardant, adding an additional level of prevention to your risk management plans. They also come with engineering certificates and wind guidelines.
AREAS OUT OF BOUNDS - Similar prevention methods should also include considering the best people to install electrical equipment and highlighting areas attendees should stay away from throughout your event.
Choose products that will protect those at your event. Its always good to prepare an emergency plan just in case something does go wrong. It's worth the extra level of protection and peace of mind.
SAFETY FOR WORKERS AND ATTENDEES -The people at your event will fall into two categories – those working and those attending. You'll want to ensure that those working your event have safe working conditions for themselves, plus the ability to help attendees in emergency situations.
HELPING HAND -Structures and equipment can sometimes be very heavy so the more hands to help, the lighter the workload and the safer of workers. If you need installation staff, its worth investing in the cost to ensure that you look after your workers and ensure the installation is done correctly.
OLD, YOUNG AND FRAIL- It's also important to note the wide range of people you could have both working and attending your event and the individual needs they could have. People who could need more attention include those who are very young or old, those with severe allergies, expectant mothers, and people with disabilities. Responsible planning for your event will include taking these populations into consideration.
Additionally, those working the event will be expected to be leaders in the case of an emergency. Go over safety protocol so workers are well prepared to help patrons with anything that arises, from sending someone to first aid to a full-scale evacuation.
4. TAKE CONTROL OF SAFETY AT YOUR EVENTS!
It's imperative that you consider safety at your event and understand you are responsible for ensuring measures are in place in the case of emergency.
This guide just covers the basics of event planning safety and just touches on these important topics. It is by all means not an extensive list but a starting point to consider safety at your events. Check your local environmental and health safety laws to ensure you are considering all the safety elements at your events and to receive additional guidance to make your event a success.
Nothing can ruin the fun and an exciting event like someone getting harmed. Add this very important component to your event planning process and make sure to take steps to alleviate possibilities of issues at your events.
If you are using Stretch Structures and are concerned about safety at your event, contact us to discuss how we can help ensure the safety of our structures and your patrons. We take safety very seriously and have our own safety practices to ensure we are helping you plan for the best event possible.
7 reasons to choose inflatables at your next event.
There are a lot of decisions to be made when planning your event. Luckily we take the guesswork out of one big decision that can make or break your event. This one thing can set the tone for your entire function and create just the right environment for your needs. The structures! And not just any structure, but one that draws attention to your event, is inviting to our customers and creates an ambiance that is remembered!
The venue, setting, and environment are the biggest decision to be made and it all starts here. The decision you make here sets the tone for everything else. Inflatable structures made my StretchStructures make it easy to plan your event and create just the right setting. The decision is easy with these top seven reasons for using inflatable structures.
As we like to say, your imagination is your only limitation. Inflatable structures give you more choices and control over the look and feel of your space than any other options available. From size to color to branding to shape – our design team are sure to create the perfect customized creation for you.
They're portable and easy to assemble, which means you can save time and manpower. Some structures only require one person and 10 minutes to set up. The inflatable nature of the structure is meant to provide fast and easy set up that allows you to set the stage for your entire event faster. And get home at the end of the day.
Accommodate up to 500 people in our variety of structures. Shells, domes, arches, or cubes – the choice is yours. The variety of sizes and shapes ensures you find the perfect one to set the tone for your event and take care of all your guests.
The ability to print on these structures means you can save on other brand recognition efforts. No need for buying extra signage or figuring out how to attach banners to your structure to ensure they stay put and don't blow away. With inflatable structures, your logo and brand is represented right on the structure. You design your own logo placement with mockups and a graphic designer to assist.
Inflatable structures are engineered tough to withstand the outdoor temperament, but can also be used to make indoor spaces pop. The modular nature of the structures, along with the variety of shapes and sizes, means you can use them anywhere you need that special extra something. Protecting guests from the weather or creating a pop of color indoors, these structures are fun to play with and are useable anywhere you need to go.
Because the safety of your guests and the life of your products are important, inflatable structures are made with standard or fire retardant fabric, plus are built to withstand strong winds and other elements. Mother Nature shouldn't crash your event and with a sturdy inflatable structure, your guests stay safe while your product does all the work and lives to see many more events.
All of the above provide excellent reasons for choosing an inflatable structure for your next event, but we also believe you should play with your imagination and create products that allow you to stand out from the crowd. These structures are fun and unique because they give you the opportunity to let your imagination run wild. Where will it take you today?
Distinct and practical, inflatable structures give you choices and peace of mind like no other product available on the market.
Contact us today to begin your journey to your imagination and the perfect event.
From a bride whose passion is the environment to throwing an Earth Day festival, there are many reasons and opportunities to create an environmentally friendly event. Now more than ever, consumers are calling for better awareness around environmental impact and companies are being held to higher standards.
You can hop on this smart train by approaching your events with the environment in mind. And these days, environmentally friendly doesn't just apply to the picnics or events with a rustic feel. You can take any event and create a fun, stylish affair with the environment in mind.
Every event evokes a particular emotion. Events are an experience that brings the guests along for a ride. And you are the train conductor. You determine what kind of ride your guests will have and where you want them to go. You get to decide how you want your guests to feel.
A classic country wedding that invokes romance and simplicity, the feelings of days gone by. The big annual meeting that has employees excited about their jobs, the future, and increases feelings of loyalty. The family festival in the park that swells with laughter and encourages community, where parents leave grateful for a safe and fun place to take their kids.
To that wedding guest, that loyal employee, and that grateful parent, that event wasn't just a way to spend a few hours of their day. It was an experience to remember that lingers with positive emotions. And when they think of this event in the future, they'll once again recall those emotions and think of it fondly.
And that is exactly the point!
So how do you create an experience that will have your guests evoking positive associations for months and possibly years to come?
Using StretchStructures at your next event isn't just about finding a tent to protect your guests from the weather. It's creating an entire experience. And the easiest way to create this experience is through high-quality and well thought out event architecture.
There are a wide variety of stretch fabric architecture, exhibition, and event products available to provide dramatic visual impact and to highlight the feeling of your event.
Signage or company branding at festivals, conferences, events, and trade shows – make sure guests remember who sponsored their favorite event or who they interacted with.
You can transform your space and demand attention with any of these exciting pieces.
And with StretchStructures you know you are getting the same high-quality you've come to expect. The high performance stretch Lycra used in all of our architecture pieces is flame retardant, printable, and long lasting. We also make it convenient to use these products by keeping them lightweight, cost effective, easy to install, and a snap to pack down for shipping and moving.
Stretch event architecture is a fun way to create your perfect setting, enthrall your guests, and ensure that feeling remains long after your event is over.
Contact us today to create the experience you're looking for.
Let's paint for you a picture……So people are still raving on about your last event you planned. They've commented on the fabulous food and entertainment. They've gushed about the stunning atmosphere. And they've thanked you for creating true ambience and an experience they'll remember.


People 19 years old and younger in Hawaii are under assault by Type 2 diabetes. In that age group, 3,700 individuals develop Type 2 in the state each year, the Akaka Falls Lions Club reports. For context, that number is about triple the entire population of Kurtistown.
Diabetes in young people was a trigger for the Lions Club to organize the 2017 Hawaii Island Diabetes Conference from 8 a.m.-2 p.m. today in the Hilo High School cafeteria. The conference is open to the public; admission is $5 per person.
Type 1 diabetes happens when the body's pancreas stops producing insulin, a hormone that's supposed to help regulate the body's intake of nutrients. Type 2 develops when a person becomes resistant to insulin.
Nurse practitioner Michelle Soga, conference co-chairwoman, said eating habits that start early in a person's life can affect the risk of Type 2. High school students might not know much about what carbohydrates are, what a healthy meal is or how fast calories add up when consuming soda, she said.
"I think everybody has something to learn from this conference," Soga said.
Blayne Hanagami, district governor for the District 50 Hawaii Lions, said similar to soft drinks, the carb-rich "plate lunch" covered with gravy, macaroni salad, meat and a couple of scoops of rice as a daily happening can have bad effects. He said if he eats about 21 meals a week, he tries to make 14 of them healthier ones.
"We're not saying don't eat a typical plate lunch," he said. Instead, try to mix in some healthier meals with fruits and veggies.
Big Island residents overall might find the conference important because 12 of every 100 adults now have Type 1 or Type 2 diabetes, according to the 2017 National Diabetes Statistics Report from the Centers for Disease Control and Prevention.
"As the number of people living with diabetes increases, so does the number of people with impaired vision," the CDC report says, noting diabetes is the leading cause of adult blindness.
The Lions Club has worked many years to prevent blindness, Hanagami said.
"Virtually everyone is touched by a family member with diabetes," he said.
Hanagami hopes for a diversity of ages and other demographic characteristics among attendees. Native Hawaiians have the highest diabetes death rate of any ethnic group in the state, according to conference planners — 47 diabetes-related deaths per 100,000 annually.
The majority of Pacific Islanders and Asian-Americans with diabetes have Type 2, the Lions Club reports.
People who exercise and focus on diet can improve Type 2 and, in some cases, reverse it, research has revealed.
Soga said the Lions Club Vision Van will offer vision screenings at the conference and the University of Hawaii at Hilo School of Pharmacy will offer health screenings, including blood pressure and blood-glucose checks. If someone is worried about the possibility of diabetes, checking blood glucose is a quick way to tell if a visit to the doctor is needed.
Conference presenters include endocrinologist Dr. Wilfred Fujimoto, optometrist Dr. Giezel Rivera, certified diabetes educator and registered dietitian Stacy Haumea, Blue Zones Project lead coordinator Jana Ortiz-Misiaszek and Audrey Wilson, Hawaii Tribune-Herald food columnist, who will do a cooking demonstration.
By JEFF HANSEL Hawaii Tribune-Herald | Saturday, October 14, 2017, 10:05 a.m.


Avoid contamination – Avoid bringing in contaminated dirt from other places, don't plant things around your lawn which are unhealthy or sick looking, and be careful when it comes to walking on your lawn after you have been in contact with grassed areas in public.
Aerating the soil, which reduces compaction and makes it easier for your lawn to fight off the disease on its own. There are plenty of basic aerating tools out there, and there is no reason to buy an expensive one.
Spraying with a fungicide. If you can identify the problem, you may be able to use a fungicide to get rid of it. Speak to your local nursery or garden center.
Keep your grass watered and fertilised. Doing so will reduce environmental stresses on your lawns, making it easier for them to get rid of funguses and diseases on their own.
Lawn disease can be a big problem, but it isn't one which can't be solved. Do some research, put a bit of work in, and your lawn will be looking healthy again before you know it!


Share the post "Loch Leven Bird Hide"
A new bird hide on the west bank of Loch Leven south of Kinross for The Rural Access Committee of Kinross-shire (TRACKS) and Scottish Natural Heritage, designed and installed as part of a phase of works extending the perimeter path around the loch shore.
The design is part hide, part bridge and part screening, all constructed from Scottish Douglas Fir and Larch. Viewing apertures are lined in oak, which was also used to form shelves and benches. Completed October 2011.


Top 50 Indie MRH has signed an agreement with the Co-op to pilot a new franchise convenience store at seven MRH sites across the UK.
The first of the 1,000-1,500sq ft stores will open next week in Eastcote in north-west London, with the pilot running throughout the year.
The pilot is part of MRH's wider strategy to invest in its service stations and to develop partnerships which increase the choice for customers visiting its sites. Currently, MRH has a range of nationwide partnerships in retail and food-to-go with Spar, Costa Coffee, Subway and Greggs.
MRH chief executive Karen Dickens said: "This pilot is an exciting development for MRH, and part of a wider move to increase the retail offering for customers at our sites.
Jo Whitfield, retail chief executive, Co-op, said: "This is an exciting opportunity for the Co-op to expand its presence further in the convenience sector, which is one of the fastest-growing areas in UK grocery.
MRH is number one in Forecourt Trader's Top 50 Indies with a total of 480 sites across the UK.


If you don't ride a motorcycle, walking into a Harley-Davidson® dealership around Christmas time to shop for a loved one can feel overwhelming. Don't worry, you don't need a secret password to get into the store. And finding the perfect gift for that avid rider isn't that hard when you have a variety of items to choose from in a wide range of prices.
Friendly people are also there to help—like Katie Smith, MotorClothes® collection manager at Buffalo Harley-Davidson® in New York. She says gift-givers have many choices, like Christmas ornaments, baseball hats, gloves, tin signs (for the man cave), jackets, and bike accessories to add some style and flair to your loved one's motorcycle. "You can even put that dream bike under the tree for him or her," says Katie.
Women's Miss Enthusiast 3-n-1 Leather Jacket: Starting at $495, this jacket is practical all year-round. It has a removable hoodie with thumbholes that can be worn separately, along with a venting system that includes two shoulder vents and two vertical exit vents. It also has 3M ScotchliteTM reflective material to increase low light visibility.
The Men's Killian Riding Jacket: This jacket starts at $295 and is highly functional. It includes reinforced shoulders, fixed body armor, and air vents. A dual-liner system adds greater versatility, including a zip-out waterproof liner with its very own warmth liner, which is removable.
Rain Gear: This is a great gift for H-DTM riders. Starting at $125, unisex rain gear is a smart item to keep with the bike. When it starts raining out of the blue, your loved one will be thanking you. It's a versatile item and can be worn on more than just rainy days.
Ride Bell (also known as Gremlin Bells): This is the perfect stocking stuffer. Starting at $12.95, it's the least expensive gift on our list. Legend has it that evil road gremlins bring bad luck to your ride by creating mechanical problems and scattering road debris into your path. Ride bells are purported to keep the Evil Road Spirits away—and their lucky power is more potent when given as a gift.
Motorcycle covers: These are a common gift and are relatively affordable at $99.95. Riders will undoubtedly get a lot of use from it. Whether the bike spends its time in a heated garage or on the driveway, riders need to protect their bike if they want it to stand the test of time. So, if they don't already have one, and it's in your budget, a motorcycle cover is a reliable buy.
Harley Bike Wash Kit: Everyone needs a clean ride—even the rider who isn't picky about how their bike looks. That's because cleaning it, protects it. At $49.95, this is the perfect gift for that biker who has everything, because everyone needs the proper tools to clean their ride.
Battery Tender: This is another practical gift idea. Many riders don't think about this item until it's too late. Starting at $39.95, it's the gift that keeps on giving. Using a battery tender in the off-season—and even between rides—ensures you don't have to shell out for a new battery because someone left an accessory on or went out of town and couldn't get the bike started for a while.
"Chances are, if you can tell us the make and model of that special someone's bike and a little about what they like, we can help you find the right fit for the rider in your life," says Travis Spade, parts department manager at Buffalo Harley-Davidson®.
According to Spade, you don't need to know how to ride to make a great buy. When you head into a Harley-Davidson® dealership, you'll find friendly and knowledgeable staff there to help.
This dealership provides an extensive retail clothing and collectible department. The separation from the parts and service department creates a comfortable specialty store setting for an enjoyable shopping experience. In addition to all this, Buffalo Harley-Davidson® also has an antique motorcycle museum with more than 90 bikes and many rare collectible antique photos and memorabilia. It's open to the public and there's no admission charge.


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About Autism Centre
How is ASD Diagnosed?
When diagnosing Autism Spectrum Disorder (ASD), clinicians and diagnosticians use a number of measures to determine whether or not an individual meets the criteria for a diagnosis. They may conduct observations, take a developmental history, and assess the individual's communication skills, social and play skills, adaptive behaviour and cognitive skills. Usually a number of professionals are involved in the diagnosis, including a paediatrician, psychiatrist or psychologist.
The Cooperative Research Centre for Living with Autism (Autism CRC) has now released Australia's first National Guideline for the Assessment and Diagnosis of Autism Spectrum Disorders. The recommendations of the guideline are based on the best available scientific evidence and have been approved by the National Health and Medical Research Council (NHMRC) and had financial support from the National Disability Insurance Scheme (NDIS).
Register to download the guidelines and supporting documents from the Autism CRC's website.
The DSM
One of the items in a diagnostician tool kit is the Diagnostic and Statistical Manual of Mental Disorders (DSM, A publication of the American Psychiatric Association which includes the diagnostic criteria for many different conditions including ASD). The DSM is revised periodically to bring it in line with current research and practice. As new evidence about a condition is discovered, the manual changes to more closely reflect the new understanding of the condition.
The fourth edition of the DSM (DSM-IV) was published in 1994, and since this time there have been many studies conducted and thousands of articles published to give us a greater understanding of autism.
In May 2013, the DSM-5 was released and in it there have been some changes to the diagnostic criteria for ASD. These were based on expert advice from clinicians and researchers in the field of ASD. The proposed criteria were open for public discussion and underwent a number of revisions before the final criteria were settled. The criteria as they appear in the new edition are through to capture how we currently conceptualise ASD.
EMAIL autism@marymead.org.au


South Adelaide midfielder Tonia Fielke will miss the remainder of the SANFL Statewide Super Women's League season after tearing her ACL.
Fielke suffered the injury to her right knee in the opening minutes of the Panthers Round 2 clash with Sturt at Hickinbotham Oval.
"Tonia came off the field early in the piece against Sturt and scans on Monday revealed a full tear of her ACL," said Women's Football Operations Manager, Jonathon Parker.
"It is a devastating blow for Fielkes, who has shown rapid improvement during the preseason and was one of our better performers in Round 1.
"We know Tonia will attack her rehab with the same dedication and determination that put her in a position to represent the Panthers.
"The club wish Tonia the best in her recovery and look forward to her continuing to provide strong leadership to our girls even from the sidelines."


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What to expect from this year's Met Gala theme: 'Camp: Notes on Fashion'
Every year on the first Monday in May, celebrities, models and designers descend on the steps of the Metropolitan Museum in New York for fashion's most high-octane night of the year- the Met Gala.
With Elton John, Serena Williams and Lady Gaga among the major names expected on the red carpet for this year's camp-themed night, the event is set to bring us as many dazzling looks as ever. Check The Telegraph's fashion page for live coverage of the best red carpet looks on the night.
The annual extravaganza hails the opening of the annual exhibition which takes place at the museum's Costume Institute. Previous themes have included fashion's relationship with Catholicism, the intersection of fashion and technology, China's influence on Western fashion and retrospectives on designers who have left lasting impressions. This year, inspired by Susan Sontag's seminal 1964 essay 'Notes on Camp', the exhibition will explore how camp themes have influenced fashion.
The exhibition consists of around 200 pieces of fashion and art, and is open from May 9th to September 8th. Highlights are set to include Gucci's eccentric runway looks, the exaggerated ruffles, shoulders and corsets of the early 1900s, archive pieces from Moschino and John Paul Gaultier and trompe l'oeil designs, seen here in Thom Browne's SS17 collection.
Click through for everything you need to know about this year's event and theme...
By Madaleine Lee
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