Reducing perioperative red blood cell unit issue orders, returns, and waste using failure modes and effects analysis.

BACKGROUND: Surgical transfusion has an outsized impact on hospital-based transfusion services, leading to blood product waste and unnecessary costs. The objective of this study was to design and implement a streamlined, reliable process for perioperative blood issue ordering and delivery to reduce waste. STUDY DESIGN AND METHODS: To address the high rates of surgical blood issue requests and red blood cell (RBC) unit waste at a large academic medical center, a failure modes and effects analysis was used to systematically examine perioperative blood management practices. Based on identified failure modes (e.g., miscommunication, knowledge gaps), a multi-component action plan was devised involving process changes, education, electronic clinical decision support, audit, and feedback. Changes in RBC unit issue requests, returns, waste, labor, and cost were measured pre- and post-intervention. RESULTS: The number of perioperative RBC unit issue requests decreased from 358 per month (SD 24) pre-intervention to 282 per month (SD 16) post-intervention (p < .001), resulting in an estimated savings of 8.9 h per month in blood bank staff labor. The issue-to-transfusion ratio decreased from 2.7 to 2.1 (p < .001). Perioperative RBC unit waste decreased from 4.5% of units issued pre-intervention to 0.8% of units issued post-intervention (p < .001), saving an estimated $148,543 in RBC unit acquisition costs and $546,093 in overhead costs per year. DISCUSSION: Our intervention, designed based on a structured failure modes analysis, achieved sustained reductions in perioperative RBC unit issue orders, returns, and waste, with associated benefits for blood conservation and transfusion program costs.

Protocol for a proof-of-concept observational study evaluating the potential utility and acceptability of a telemedicine solution for the post-anesthesia care unit.

Introduction: The post-anesthesia care unit (PACU) is a clinical area designated for patients recovering from invasive procedures. There are typically several geographically dispersed PACUs within hospitals. Patients in the PACU can be unstable and at risk for complications. However, clinician coverage and patient monitoring in PACUs is not well regulated and might be sub-optimal. We hypothesize that a telemedicine center for the PACU can improve key PACU functions. Objectives: The objective of this study is to demonstrate the potential utility and acceptability of a telemedicine center to complement the key functions of the PACU. These include participation in hand-off activities to and from the PACU, detection of physiological derangements, identification of symptoms requiring treatment, recognition of situations requiring emergency medical intervention, and determination of patient readiness for PACU discharge. Methods and analysis: This will be a single center prospective before-and-after proof-of-concept study. Adults (18 years and older) undergoing elective surgery and recovering in two selected PACU bays will be enrolled. During the initial three-month observation phase, clinicians in the telemedicine center will not communicate with clinicians in the PACU, unless there is a specific patient safety concern. During the subsequent three-month interaction phase, clinicians in the telemedicine center will provide structured decision support to PACU clinicians. The primary outcome will be time to PACU discharge readiness determination in the two study phases. The attitudes of key stakeholders towards the telemedicine center will be assessed. Other outcomes will include detection of physiological derangements, complications, adverse symptoms requiring treatments, and emergencies requiring medical intervention. Registration: This trial is registered on clinicaltrials.gov, NCT04020887 (16 th July 2019).

Time Is Money: Can Punctuality Decrease Operating Room Cost?

BACKGROUND: Inefficient operating room (OR) use wastes resources. Studies have suggested "first case on-time starts" (FCOTS) reduce OR "idle time," yet no direct association between FCOTS and markers of OR efficiency, like "last case on-time end" (LCOTE) or overtime costs, have been reported. We performed this study to evaluate factors associated with FCOTS, LCOTE, and OR overtime costs. STUDY DESIGN: In April 2017, our medical center launched an FCOTS improvement initiative. Prospectively collected data concerning cases performed in the 6-month pre- (October 2016 to March 2017) and post-intervention (October 2017 to March 2018) periods were retrospectively analyzed. Elective, nontraumatic cases performed by orthopaedics, gynecology, urology, minimally invasive surgery, or colorectal surgery were eligible. Univariate and multivariable analyses were used to evaluate 3 outcomes of interest: the association between FCOTS and LCOTE (primary), the change in FCOTS rates after intervention implementation (secondary), and estimated overtime cost savings associated with FCOTS (secondary). RESULTS: We analyzed 12,073 cases (6,095 pre- vs 5,978 post-intervention) performed over 2,631 OR days (1,401 pre vs 1,230 post). The FCOTS rate increased after intervention (76.1% vs 86.6%, p < 0.001), with post-intervention cases twice as likely to start on time (adjusted odds ratio [aOR] 2.07; 95% CI 1.73 to 2.46, p < 0.001). Additionally, starting on time was associated with a higher likelihood of LCOTE (aOR 1.76; 95% CI 1.38 to 2.24, p < 0.001) and 21.8 fewer overtime minutes (95% CI 13.7 to 29.8, p < 0.001) per OR day. Post-intervention estimated savings of $87,954 in direct OR costs over 6 months were associated with the FCOTS initiative. CONCLUSIONS: The FCOTS initiative was associated with higher frequency of FCOTS, which was independently associated with LCOTE. This achieved an estimated 6-month cost savings of more than $80,000 in direct OR expenditures.

A quantitative model to predict blood use in adult orthotopic liver transplantation.

To identify preoperative predictors for the use of any blood component during and after orthotopic liver transplantation (OLT), we performed a retrospective analysis on 602 OLT patients who were randomly split into a training set (n = 482) and a validation set (n = 120). Hemoglobin and calculated MELD score were identified as independent predictors for blood use using bootstrap aggregation. A logistic regression model constructed using both variables showed comparable performance in the training and validation sets. Predictive scores can be obtained from a nomogram, and a score above -2.328 predicted transfusion of any blood component with a positive predictive value of 97% and 96% in the training and validation sets, respectively.

Postreperfusion cardiac arrest and resuscitation during orthotopic liver transplantation: dynamic visualization and analysis of physiologic recordings.

We recently reported on the Multi Wave Animator (MWA), a novel open-source tool with capability of recreating continuous physiologic signals from archived numerical data and presenting them as they appeared on the patient monitor. In this report, we demonstrate for the first time the power of this technology in a real clinical case, an intraoperative cardiopulmonary arrest following reperfusion of a liver transplant graft. Using the MWA, we animated hemodynamic and ventilator data acquired before, during, and after cardiac arrest and resuscitation. This report is accompanied by an online video that shows the most critical phases of the cardiac arrest and resuscitation and provides a basis for analysis and discussion. This video is extracted from a 33-min, uninterrupted video of cardiac arrest and resuscitation, which is available online. The unique strength of MWA, its capability to accurately present discrete and continuous data in a format familiar to clinicians, allowed us this rare glimpse into events leading to an intraoperative cardiac arrest. Because of the ability to recreate and replay clinical events, this tool should be of great interest to medical educators, researchers, and clinicians involved in quality assurance and patient safety.

Toward optimal display of physiologic status in critical care: I. Recreating bedside displays from archived physiologic data.

BACKGROUND: Physiologic data display is essential to decision making in critical care. Current displays echo first-generation hemodynamic monitors dating to the 1970s and have not kept pace with new insights into physiology or the needs of clinicians who must make progressively more complex decisions about their patients. The effectiveness of any redesign must be tested before deployment. Tools that compare current displays with novel presentations of processed physiologic data are required. Regenerating conventional physiologic displays from archived physiologic data is an essential first step. OBJECTIVES: The purposes of the study were to (1) describe the SSSI (single sensor single indicator) paradigm that is currently used for physiologic signal displays, (2) identify and discuss possible extensions and enhancements of the SSSI paradigm, and (3) develop a general approach and a software prototype to construct such "extended SSSI displays" from raw data. RESULTS: We present Multi Wave Animator (MWA) framework--a set of open source MATLAB (MathWorks, Inc., Natick, MA, USA) scripts aimed to create dynamic visualizations (eg, video files in AVI format) of patient vital signs recorded from bedside (intensive care unit or operating room) monitors. Multi Wave Animator creates animations in which vital signs are displayed to mimic their appearance on current bedside monitors. The source code of MWA is freely available online together with a detailed tutorial and sample data sets.

Comparison of calibrated and uncalibrated arterial pressure-based cardiac output monitors during orthotopic liver transplantation.

Arterial pressure-based cardiac output monitors (APCOs) are increasingly used as alternatives to thermodilution. Validation of these evolving technologies in high-risk surgery is still ongoing. In liver transplantation, FloTrac-Vigileo (Edwards Lifesciences) has limited correlation with thermodilution, whereas LiDCO Plus (LiDCO Ltd.) has not been tested intraoperatively. Our goal was to directly compare the 2 proprietary APCO algorithms as alternatives to pulmonary artery catheter thermodilution in orthotopic liver transplantation (OLT). The cardiac index (CI) was measured simultaneously in 20 OLT patients at prospectively defined surgical landmarks with the LiDCO Plus monitor (CI(L)) and the FloTrac-Vigileo monitor (CI(V)). LiDCO Plus was calibrated according to the manufacturer's instructions. FloTrac-Vigileo did not require calibration. The reference CI was derived from pulmonary artery catheter intermittent thermodilution (CI(TD)). CI(V)-CI(TD) bias ranged from -1.38 (95% confidence interval = -2.02 to -0.75 L/minute/m(2), P = 0.02) to -2.51 L/minute/m(2) (95% confidence interval = -3.36 to -1.65 L/minute/m(2), P < 0.001), and CI(L)-CI(TD) bias ranged from -0.65 (95% confidence interval = -1.29 to -0.01 L/minute/m(2), P = 0.047) to -1.48 L/minute/m(2) (95% confidence interval = -2.37 to -0.60 L/minute/m(2), P < 0.01). For both APCOs, bias to CI(TD) was correlated with the systemic vascular resistance index, with a stronger dependence for FloTrac-Vigileo. The capability of the APCOs for tracking changes in CI(TD) was assessed with a 4-quadrant plot for directional changes and with receiver operating characteristic curves for specificity and sensitivity. The performance of both APCOs was poor in detecting increases and fair in detecting decreases in CI(TD). In conclusion, the calibrated and uncalibrated APCOs perform differently during OLT. Although the calibrated APCO is less influenced by changes in the systemic vascular resistance, neither device can be used interchangeably with thermodilution to monitor cardiac output during liver transplantation.

Outpatient minimally invasive parathyroidectomy using local/regional anesthesia: a safe and effective operative approach for selected patients.

BACKGROUND: Minimally invasive parathyroidectomy (MIP) using local/regional anesthesia has become an accepted treatment for selected patients with primary hyperparathyroidism (HPT) and can be performed in the ambulatory setting. METHODS: From 1999 to 2004, 139 consecutive patients at our institution with HPT caused by a single localized parathyroid adenoma underwent MIP through a 2.5- to 3-cm incision. Anesthesia included preoperative local/regional blocks with moderate intravenous sedation. Patient follow-up data were reviewed retrospectively. RESULTS: All 139 MIP patients had biochemical HPT and a single adenoma localized by sestamibi scan alone (n = 119; 86%) or combined with other imaging (n = 20; 14%). The mean adenoma size was 1,184 +/- 1,091 mg. Total calcium and parathyroid hormone levels were 11.3 +/- 0.8 mg/dL and 451 pg/mL preoperatively, respectively, decreasing to 9.4 +/- 0.6 mg/dL and 34 pg/mL postoperatively, respectively. Of MIP cases, 117 (84%) were completed with local/regional anesthesia, and 22 (16%) used general anesthesia (4 local/regional conversions). The mean operative time when reported was 56 +/- 21 minutes (n = 28). Same-day discharges occurred for 120 (86%) patients, whereas 16 patients were observed overnight and 3 patients were observed for 48 hours. Operative cure was achieved in 137 (98.6%) patients (follow-up period, 15.2 +/- 12.4 mo) with 1 morbidity (0.7%). CONCLUSIONS: Outpatient MIP is safe and effective in selected patients. A low morbidity (0.7% in this series), rapid recovery, and high biochemical cure rate (98.6%) parallels 4-gland exploration under general anesthesia.