Awareness of healthcare providers on environment-friendly practices in operating rooms in selected hospitals in Riyadh, Saudi Arabia

Abstract

Climate change will have a great impact on humanity in upcoming years and will affect the health of all living creatures. Hospitals play a significant role in climate change due to their substantial waste production and they are considered a profound pollution source, with the Operating Theater as a main contributor. This study was aimed to examine the level of knowledge among healthcare professionals in Saudi Arabia concerning the proper implementation of operating room (OR) environmental procedures and efficient management of hospital waste. This is a cross sectional study performed across 3 hospitals in Riyadh, Saudi Arabia. The hospitals included are Prince Sultan military hospital, National guard hospital and King Salman hospital. The study included all the staff and health workers in OR (operating room), excluding all staff and health workers not in OR. The study took place between September 1 and November 1, 2022. None of the study participants mentioned that their institute or hospital fully engaged in Greenhealth Greening the OR initiative. Almost 1 to 3rd of the study participants (38.1%) mentioned that endorsement and participation in the practice of Greenhealth Greening the OR initiative was not implemented at all, and 45% of the participants were completely unaware of such an initiative. The study’s findings suggest that healthcare providers in Saudi Arabia are not fully aware of environmentally friendly practices. Further, the current initiatives undertaken by the hospital administration fall short in attaining environmentally sustainable benchmarks.

1. Introduction

Climate change will influence humanity in the upcoming years and affect the health of all living creatures. Hospitals play significant roles in climate change because of their substantial waste production and hospitals and operating theaters are considered to be profound pollution sources. Furthermore, the amount of medical waste has surged in recent years, and several medical products can lead to pollution and food contamination. For instance, medical waste is one of the listed sources of mercury and dioxin emissions in the United States.^[1] Hospitals have undergone radical modifications in the types of products they use in the last 5 decades. For example, hospitals rapidly approved single-use products. With the growing understanding of communicable diseases, such as human immunodeficiency virus and hepatitis, more rules have been established concerning the secure waste disposal of materials contaminated by bodily fluids. The introduction of universal precaution standards led to the treatment of most medical waste as infectious items in an attempt to protect the community. Annually, more than 4 million tons of hospital waste is produced, and operating theaters produce approximately 1 to 3rd of the total hospital waste.^[2] Further, labor and delivery waste accounts for approximately 70% of hospital waste.

Currently, hospitals commonly eliminate waste by using cost-effective processes such as microwave sterilization systems, autoclaves, and chemical disinfection. In addition, numerous hospitals incinerate and dump waste into junkyards. These disposal techniques are linked to various public health and environmental concerns.^[3] Biohazard waste management, including tissues, body fluids, and whatever they touch (such as sponges, gowns, and gloves), will require incineration, autoclaving, and other energy-intensive processes. However, up to 90% of the waste sent to biohazard containers is not hazardous. Anesthetic gases, such as isoflurane and other halogenated ethers, are up to 3760 times more powerful in trapping heat than carbon dioxide and up to 95% of anesthetics are released into the environment. As an estimate, the annual anesthetic gas emissions from a hospital are similar to the carbon dioxide emissions from 1200 automobiles.^[4]

Some US hospitals have shown leadership in creating environmentally friendly, sustainable strategies which include increasing energy efficiency, recycling, eliminating mercury products, serving sustainable foods, reprocessing devices, controlling pharmaceutical waste, and creating green buildings. When utilized properly, environment-friendly approaches can lead to significant cost savings.^[3]

The question in healthcare is how to innovatively support sustainability while handling a substantial quantity of hazardous waste and ensuring patient safety. Healthcare providers are required to engage in this process by altering their professional and personal behaviors without affecting their quality of care. The change towards greening healthcare to create a better environment at hospitals has been initiated to reduce medical waste, and operating theaters have a special chance to be more environmentally friendly, leading to waste and pollution reduction.^[3] The key to the transformation lies in the development of economical, reusable items for everyday use in operating theaters. Additionally, there are nontechnical green approaches, such as the careful sorting of waste generated in the operating theater. This research aimed to comprehensively examine the level of knowledge among healthcare professionals in Saudi Arabia concerning the proper implementation of operating room (OR) environmental procedures and efficient management of hospital waste.

Surgeons serve as guardians of the medical profession, assuming leadership roles not only within the operating room but also within their communities. Consequently, it is incumbent upon surgeons to proactively address multifaceted concerns encompassing quality, cost, and environmental sustainability. These encompass challenges such as global warming, excessive landfill accumulation, responsible disposal of toxic waste, and the scarcity of valuable resources, which necessitate urgent attention. Fortunately, surgeons can derive substantial benefits by adopting environmentally conscious surgical practices, including cost savings, time efficiency, and waste reduction. Even modest modifications implemented within the operating room can yield significant outcomes by curbing expenses and mitigating the detrimental environmental impact associated with surgical procedures. Numerous surgeons have already emerged as pioneers in this field, continually advocating for innovative and impactful environmentally conscious measures within their respective institutions.^[5,6]

2. Methods

2.1. Study design

This cross sectional study included 3 hospitals: Prince Sultan Military Hospital (center of Riyadh), National Guard Hospital (Eastern region of Riyadh), and King Salman Hospital (Southern region of Riyadh). The selection of these hospitals offers a strategic approach to studying healthcare within different areas of the city. The inclusion criteria encompassed the selection of all healthcare professionals present in the operating room (including OR nurses, surgeons, and anesthetists), while excluding any staff or healthcare workers not assigned to the OR. The study was conducted between September 1 and November 1, 2022. The Research Ethics Committee in Health and Science Disciplines at the College of Medicine, Prince Sattam Bin Abdulaziz University, with the institutional review board approved the current study with approval number (SCBR-001-2023). Verbal consent was obtained from each participant who was included in the research. To maintain ethical standards, the identities of the participants were kept confidential throughout the study.

2.2. Data collection methods

Data were collected using the Greening OR Checklist designed by Practice Greenhealth (2011)^[7] (Fig. 1). The Greening the OR Checklist contains 46 items that are categorized under 4 topics, including organizational development (3 items), waste reduction and prevention in the OR (9 items), environmentally preferable purchasing in the OR (19 items), and built environment (15 items).

Figure 1.

Greening OR checklist designed by practice greenhealth (2011). OR = operating room.

The staff participated in interviews, which collected information on operating theater characteristics and environmental practices through an electronic survey. Each section of the Greening OR Checklist was assessed based on the following responses: fully established, implementation in progress, not implemented, and unaware of the program.

Frequencies and proportions were used to describe the characteristics of the study population. More specifically, we reported frequencies and proportions to describe the characteristics of the study population for categorical variables such as job title, surgeon’s specialty, and type of hospital. The frequencies and proportions for major domains and subdomains were computed for “Organizational Development,” “Waste Reduction and Prevention in the OR,” “Environmentally Preferable Purchasing in the OR,” and “Built Environment.” Data analysis was performed using SPSS 23.0 (IBM SPSS Statistics, USA)

3. Results

3.1. Sociodemographic characteristics of the study participants

Table 1 presents the sociodemographic characteristics of the study participants. About 40.2% of the study participants were from King Salman Hospital (followed by the National Guard Hospital (29.1%) and Prince Sultan Military Hospital (30.7%). About 33% of the study participants were nurses in the OR, and 44% were surgeons. Most of the study participants were residents (41.3%), followed by nurses (18%), and consultants (11.6%). Approximately 1-quarter of the surgeons were general surgeons, followed by obstetricians and gynecologists, as shown in Table 1.

Table 1.

Sociodemographic characteristics of the participants (n = 189).

Characteristics	n	%
Type of hospital
King Salman hospital	76	40.2
National Guard hospital	55	29.1
Prince Sultan military hospital	58	30.7
Job title
Anesthesia	32	16.9
Operating room nurse	66	34.9
Others	8	4.2
Surgeon	83	43.9
Level
Consultant	22	11.6
Nurse	34	18
Resident	78	41.3
Specialist	51	27
Student	2	1.1
Technician	2	1.1
Specialty of surgeon
Ear, nose, and throat	2	1.06
General surgery	39	20.63
Neurosurgery	1	0.53
Obstetrics and gynecology	19	10.05
Orthopedics	10	5.29
Pediatric surgery	1	0.53
Plastic surgery	2	1.06
Urology	9	4.76

3.2. Distribution of environment-friendly practices in the OR

The distribution of environment-friendly practices in the OR is illustrated in Tables 2, 3, and 4. Under the main domain of organizational development, we found that none of the study participants mentioned that their institute or hospital fully engaged in Greenhealth “Greening the OR” initiative. Over 1 to 3rd of the study participants (38.1%) mentioned that endorsement and participation in the practice of Greenhealth “Greening the OR” initiative was not implemented, and 45% of the participants were completely unaware of such an initiative. More than half of the study participants were unaware if their institution had educated them on the advantages of greening and hoped for cost, waste reduction, and safety benefits.

Table 2.

Distribution of environment-friendly practices in the operating room (OR) (n = 189).

	Fully established (>1 Year)		Implementation in progress		Not implemented		Unaware of the program/process		Not applicable (N/A)
Organizational development	n	%	n	%	n	%	n	%	n	%
Endorse and participate in practice greenhealth greening the OR initiative	0	0	20	10.6	72	38.1	86	45.5	11	5.8
Build a green team specific to surgical services/OR	0	0	28	14.8	77	40.7	68	36	16	8.5
Educate OR staff on the benefits of greening and opportunities for cost and waste reduction and safety benefits	0	0	21	11.1	61	32.3	100	52.9	7	3.7
Waste reduction and prevention in the OR	n	%	n	%	n	%	n	%	n	%
Conduct a waste audit in surgical services/OR	43	22.8	35	18.5	37	19.6	67	35.4	7	3.7
Implement a process to divert pre-incision, non-pharmaceutical waste from the regulated medical waste stream into a clear bag for noninfectious waste disposal	14	7.4	22	11.6	57	30.2	88	46.6	8	4.2
Implement a process to segregate noninfectious solid waste from the regulated medical waste stream during and after the procedure.	117	61.9	28	14.8	12	6.3	23	12.2	9	4.8
Recycle medical plastics from the OR, including:
Clean, rigid plastics of any shape (e.g., trays, containers, and packaging)	0	0	13	6.9	77	40.7	94	49.7	5	2.6
Clean, empty bottles (e.g., saline and alcohol)	9	4.8	81	42.9	67	35.4	27	14.3	5	2.6
Clean blue wrap (polypropylene sterile wrap)	0	0	37	19.6	62	32.8	80	42.3	10	5.3
Clean, soft plastics (e.g., overwraps)	1	0.5	48	25.4	49	25.9	83	43.9	8	4.2
Clean Tyvek	1	0.5	45	23.8	70	37	62	32.8	11	5.8
Utilize a fluid management system for capturing liquid waste from surgery in reusable containers that empty liquid directly to the sanitary sewer	0	0	22	11.6	38	20.1	118	62.4	11	5.8
Recycle batteries generated in the OR	1	0.5	23	12.2	82	43.4	64	33.9	19	10.1
Utilize a reusable sharps container system	9	4.8	21	11.1	114	60.3	27	14.3	18	9
Collect FDA-approved medical devices for reprocessing with an FDA-approved third-party re-processor	11	5.8	27	14.3	43	22.8	96	50.8	12	6.3
Segregate pharmaceutical waste into specially labeled containers for appropriate disposal	8	4.2	24	12.7	42	22.2	96	50.8	19	10.1

OR = operating room.

Table 3.

Distribution of environmentally preferable purchasing in the operating room (OR) (n = 189).

	Fully established (>1 yr)		Implementation in progress		Not implemented		Unaware of the program/ process		Not applicable (N/A)
Environmentally preferable purchasing in the OR	n	%	n	%	n	%	n	%	n	%
Reformulate OR kits to reduce excess supplies and overage	35	18.5	32	16.9	41	21.7	65	34.4	16	8.5
Purchase reprocessed medical devices from an FDA-approved third-party re-processor	0	0	23	12.2	53	28	95	50.3	18	9.5
Replace disposable items with reusable items in OR kits where demonstrated safe and economically viable	0	0	34	18	105	55.6	36	19	14	7.4
Utilize reusable hard cases for surgical instrumentation	19	10.1	36	19	72	38.1	49	25.9	13	6.9
Use PVC and DEHP-free IV bags and tubing	25	13.2	27	14.3	54	28.6	70	37	13	6.9
Purchase PVC-free (non-vinyl) surgical gloves	8	4.2	24	12.7	73	38.6	72	38.1	12	6.3
Purchase reusable gowns for surgical staff	26	13.8	18	9.5	69	36.5	53	28	23	12.2
Purchase reusable covers for mayo stands	0	0	21	11.1	100	52.9	49	25.9	19	10.1
Purchase reusable covers for the back table	9	4.8	32	16.9	72	38.1	58	30.7	18	9.5
Purchase reusable surgical (huck) towels	1	0.5	28	14.8	88	46.6	55	29.1	17	9
Purchase energy-efficient or energy star-rated monitors for equipment	4	2.1	32	16.9	77	40.7	63	33.3	13	6.4
Purchase EPEAT-registered* computers and monitors for use in the OR	2	1.1	28	14.8	84	44.4	64	33.9	11	5.8
Utilize mercury-free blood pressure devices	86	45.5	24	12.7	21	11.1	35	18.5	23	12.2
Use reusable pulse oximeter sensors/probes	95	50.3	26	13.8	31	16.4	27	14.3	10	5.3
Purchase other reusable devices or products; please describe:
Utilize reusable grounding pad	0	0	9	4.8	154	81.5	19	10.1	7	3.7
Utilize rubber corners for surgical trays wrapped in a blue wrap to prevent breakage requiring re-sterilization	0	0	9	4.8	103	54.5	72	38.1	5	2.6
Utilize environmentally preferable cleaners or disinfectants for hard surfaces in the OR	115	60.8	35	18.5	12	6.3	21	11.1	6	3.2
Utilize reusable totes for delivering surgical supplies to the OR	59	31.2	44	23.3	64	33.9	18	9.5	4	2.1

OR = operating room.

Table 4.

Participants responses regarding the built environment (n = 189).

	Fully established (>1 Year)			Implementation in progress			Not implemented			Unaware of the program/process			Not applicable (N/A)
Built Environment	n	%	n		%	n		%	n		%	n		%
Utilize occupancy sensors for lighting to reduce energy use in unoccupied ORs	0	0	14		7.4	135		71.4	34		18	6		3.2
Program HVAC system to reduce air changes when ORs are unoccupied in order to reduce energy use	0	0	43		22.8	26		13.8	106		56.1	14		7.4
Utilize LED surgical lighting to reduce energy use and increase thermal comfort	58	30.7	40		21.2	26		13.8	51		27	14		7.4
Use an anesthetic gas capture system to capture waste anesthetic gases (WAGs) and prevent venting to the outside air	35	18.5	31		16.4	27		14.3	81		42.9	15		7.9
Install a power boom with a laser smoke capture system	5	2.6	28		14.8	31		16.4	103		54.5	22		11.6
Utilize modular casework that does not contain urea formaldehyde	3	1.6	32		16.9	18		9.5	118		62.4	18		9.5
Utilize PVC-free edge details in casework	7	3.7	29		15.3	21		11.1	117		61.9	15		7.9
Utilize durable countertops such as solid surfacing in the OR	11	5.8	30		15.9	19		10.1	111		58.7	18		9.5
Utilize PVC-free wall and door protection	0	0	29		15.3	28		14.8	120		63.5	12		6.3
Utilize PVC-free flooring (such as rubber flooring) in the OR	0	0	35		18.5	25		13.2	111		58.7	18		9.5
Utilize epoxy-free and bisphenol A (BPA)-free coatings for walls	0	0	20		10.6	26		13.8	131		69.3	12		6.3
Implement ASHRAE 170 guidance for air changes as a mechanism to reduce energy use in the OR	0	0	16		8.5	26		13.8	139		735	8		4.2
Implement ASHRAE 170 guidance for humidity control as a mechanism to reduce energy use in the OR	1	0.5	20		10.6	21		11.1	133		70.4	14		7.4
Follow ASHRAE 170 guidance for air distribution as a means to reduce energy use, enhance infection prevention and reduce air changes in the OR	3	1.6	20		10.6	40		21.2	111		58.7	15		7.9
Use paperless documentation systems to prevent errors, speed information exchange, conserve resources, and reduce space.	86	45.5	20		10.6	30		15.9	32		16.9	21		11.1

OR = operating room.

Regarding waste reduction, the data revealed that only 22.8% of the study participants mentioned that a waste audit in the surgical services/OR was fully established. Moreover, more than 1 to 3rd of the study participants (35.4%) were unaware of the program. However, more than half of the participants (61.9%) mentioned that the process of separating noncontagious solid waste from the regulated medical waste stream during and after the procedure was fully established. Unfortunately, almost half of the study participants (40.7%) mentioned that the process of recycling material, such as cleansing hard plastics of any form (e.g., trays, containers, and packaging), was not implemented at all, and 49.7% were not aware of the recycling process. Similarly, approximately half of the study participants (50.8%) were unaware of whether their institution was engaged in separating pharmaceutical waste into specifically tagged containers for proper disposal, and 60.3% mentioned that utilizing a reusable sharps container system was not fully implemented in their hospitals, as shown in Table 2.

Table 3 presents the distribution of environmentally preferable purchases in the OR. The data revealed that almost 1 to 3rd of the study participants were unaware of reformulating operating theater kits to reduce excess supplies. Moreover, 18.5% mentioned that it was fully established in their hospitals, and 28% of the study participants mentioned that it was not fully implemented. None of the participants mentioned that replacing 1-use items with reusable items in operating theater kits was fully established, and 55.6% stated that it was not fully implemented. Only 10.1% of the participants reported that utilizing reusable hard cases for surgical instrumentation was fully established; more than 1 to 3rd (38.1%) mentioned that it was not implemented, and the same proportion (38.1%) of the participants was unaware of this. Only 2.1% of the participants mentioned that their hospitals bought energy-efficient equipment monitors; 40.7% mentioned that it was not implemented, and 33.3% were unaware. One-third of the study participants (31.2%) reported that utilizing environmentally recommended cleaners for hard surfaces in operating theaters was fully established, and 33.9% stated that it was not implemented. None of the participants reported that utilizing a reusable grounding pad was fully established, and 81.5% mentioned that it was not implemented, as illustrated in Table 3.

Table 4 shows participants’ responses regarding the built environment. Utilizing occupancy detectors for lighting to decrease energy in empty operating theaters was established in none of the hospitals, and 71.4% of the study participants mentioned that it was not implemented. However, almost 1 to 3rd of the study participants mentioned that using LED light to decrease energy use and increase thermal comfort was fully established, and 21.2% mentioned that it was in progress. About 43% of the study participants stated they were unaware of using an anesthetic gas capture system to catch waste anesthetic gases and avoid venting to the environment. More than half of the study participants (54.5%) mentioned that their hospitals installed a power boom with a laser smoke capture system. The data illustrates that more than 50% of the study participants were unaware of the different subdomains of the built environment, such as using modular casework that does not consist of urea formaldehyde, utilizing epoxy-free and bisphenol A-free coatings for surfaces, and using a paperless documentation program to speed up data exchange, avoid errors, and preserve resources as shown in Table 4.

4. Discussion

This cross sectional study was undertaken to assess the awareness among healthcare providers about environment-friendly practices in the OR and the management of hospital waste. Overall, the study findings were not appealing, as most participants were unaware of the various domains and subdomains regarding environment-friendly practices in the OR and the management of hospital waste. For example, under organizational development, about half of the healthcare providers were unaware of endorsing and participating in Greenhealth Greening the OR Initiative. The other half was unaware of educating employees on the advantages of greening and chances for cost and waste reduction, along with safety advantages. Similarly, approximately half of the healthcare providers were unaware of recycling plastics from the operating theater, such as cleaning hard plastics of any form, cleaning blue wrap, and collecting FDA-approved devices for recycling with FDA-approved third-party recyclers. Healthcare providers seemed aware of environmentally recommended purchases in operating theaters. However, environmentally recommended purchases have not been implemented in all hospitals. Surprisingly, more than half of the healthcare professionals were unaware of the built environment subdomains.

Our findings contradict those of a cross sectional study conducted in Turkey.^[8] Although the authors in Turkey used the same checklist as used in Saudi Arabia, there was a huge difference in the findings between the 2 settings. For example, Dönmez et al^[8] found that more than half of healthcare providers mentioned that subdomains under organizational development are fully established in their hospitals, in contrast to our study, where none of the hospitals had fully established the subdomains of organizational development. Similarly, Dönmez et al found that more than 80% of healthcare providers mentioned that their hospitals use a waste audit in surgical services, as opposed to 22.8% in our study. Further, about 90% of the healthcare providers in the study by Dönmez et al reported that recycled battery generation was fully established in their hospitals, as opposed to 0.5% in our study. Moreover, a significant proportion of healthcare providers were unaware of the environment-friendly protocol in the operating room and the management of hospital waste, mainly in the subdomains of the built environment. This reveals the degree of the lack of awareness among healthcare providers of environmentally friendly practices in the operating room and hospital waste management.

Despite using the same checklist, Greening the OR Checklist, the differences between the 2 studies contradicted each other greatly. These differences can be explained by differences in the settings and priorities. For example, Turkey is a developed country that focuses on healthcare services and aims to increase healthcare providers’ knowledge and awareness of waste management and environmentally friendly practices. Another reason could be the importance given by health administrators on maintaining the environment of the hospitals. Managing hospital waste is important but challenging, and having a separate metal recycling unit is crucial for recycling metal parts.^[9] Waste reduction approaches should aim to mitigate the environmental impact of hospitals without affecting patient health.^[10,11] Unfortunately, the data from the current study illustrate that hospitals in Saudi Arabia may not prioritize these practices. The findings regarding the use of recycled medical plastics from the OR are also not encouraging in the current study, as recycling is not fully established or implemented in the study hospitals, even though recycling is proven to be cost-effective. For example, 1 study revealed that using disposable and reusable surgical gowns is more cost-effective than discarding these items away.^[12]

In addition, the rate of utilization of reusable grounding pads was not established in our study, and more than half of the study participants mentioned that it was not fully implemented in their hospitals. These findings are similar to those of Dönmez et al However, the evidence suggests that utilizing reusable grounding pads is an efficient and safe approach, especially when the devices are fully examined, calibrated, and used by trained personnel.^[13] Furthermore, our study demonstrated that Saudi hospitals do not meet the current environment-friendly standards, as reflected by their built environment. For example, LED surgical lighting is still not fully established in all hospitals in Saudi Arabia, despite evidence that LED bulbs decrease energy use by almost half compared to regular bulbs. Saving energy using alternative and efficient methods is a cost-effective approach and should be considered by hospital administrations. Additionally, the literature highlights the importance of using smart cooling and heating systems to adjust the temperature in operating rooms, mainly those that are not occupied.^[14,15]

4.1. Strengths and limitations

One of the strengths of the current study is that it provides useful insights into Saudi healthcare providers awareness of waste management and environmentally friendly practices. These findings can provide a framework for revisiting current standards and developing strategies to raise awareness among healthcare providers and improve environmentally friendly standards in Saudi Arabia. In addition, we used a standard checklist to collect data on waste management and environment-friendly practices. which has been used in previous studies as well.

However, the findings of this study should be interpreted considering some limitations. For example, our study was a cross sectional study conducted in 3 Saudi Arabia hospitals with limited sample size. This limitation prevented us from generalizing the study findings to other parts of Saudi Arabia. Having a convenience rather than a random sample of study participants may not represent the true waste management practices in Saudi Arabia. In addition, we did not explore the reasons for the lack of awareness regarding waste management and environmentally friendly practices, hindering our ability to dive deeper into the causes of poor-quality environmental standards in hospitals in Saudi Arabia.

5. Conclusion

The findings of this study suggest that healthcare providers in Saudi Arabia are not fully aware of environmentally friendly practices. Furthermore, the existing efforts by the hospital administration to achieve environmentally friendly standards are inadequate. Waste separation and supervision practices, as well as battery recycling practices, are unsatisfactory in hospitals in Saudi Arabia. These findings suggest that strategies should be developed to raise healthcare providers awareness of waste management and environmentally friendly practices. In addition, hospital administrations need to revisit their standards to ensure that hospitals comply with environmentally friendly practices and objectives in order to raise the standards of the hospitals.

Acknowledgements

We would like to thank Editage (www.editage.com) for English language editing.

Author contributions

Conceptualization: Emad Aljohani.

Data curation: Mohammed Almaslouk, Fahad Alqahtani, Mishari Alshammari, Mohammed Alanazi, Sultan Alqahtani.

Formal analysis: Abdullah Albarak.

Investigation: Abdullah Albarak, Hatim Akkasi, Nasser Aljasir.

Methodology: Emad Aljohani, Nasser Aljasir.

Supervision: Emad Aljohani.

Writing – original draft: Hatim Akkasi, Nasser Aljasir, Mohammed Almaslouk, Fahad Alqahtani, Mishari Alshammari, Mohammed Alanazi, Sultan Alqahtani.

Writing – review & editing: Emad Aljohani.