Accuracy of drawing up liquid medications by veterinary anaesthetists and nurses.

OBJECTIVE: To evaluate the accuracy with which veterinary anaesthetists and nurses of different experience draw up small volumes of liquid. STUDY DESIGN: Prospective blinded randomized study. METHODS: A group of seven European College of Veterinary Anaesthesia and Analgesia (ECVAA) diplomates, six ECVAA residents and six anaesthesia nurses participated in the study. For each participant, five target volumes between 0.01 and 1.0 mL were randomly allocated. They were drawn up 20 times in random order using a 1 mL syringe attached to a 23 gauge needle. A total of 1900 measurements were analysed. An investigator filled the syringe and needle dead space with water for injection before each experiment. The change in mass of the syringe once filled to the target volume was used to calculate the actual volume of liquid drawn up. RESULTS: Large errors were made with measurements < 0.04 mL, so they were excluded from the statistical analysis. There was a significant effect of the target volume (p < 0.001) and of the order (p < 0.01). For each mL increase in the target volume, the absolute error decreased by 4% and from the first to the hundredth withdrawal each participant's absolute error decreased by 1%. The target volume was underestimated in 52.3% of measurements, 42% were overestimated and 5.7% were on target. None of the between-subject predictor variables approached significance. CONCLUSIONS AND CLINICAL RELEVANCE: Accuracy of veterinary anaesthetists and nurses in drawing up medications decreases as the target volume becomes smaller. Small veterinary patients receive small volumes of anaesthetic drugs with higher risks of overdosing compared with larger dogs. Years of experience and staff grade are not associated with greater accuracy. Large percentage errors may be seen with target volumes less than 0.04 mL. Dilutions are recommended for volumes > 0.19 mL in 1 mL syringe.

Relationship Between Population Density and Scope of Practice for Certified Registered Nurse Anesthetists in Arizona.

Certified Registered Nurse Anesthetists (CRNAs) work in practice models ranging from full scope (independent) to limited scope (dependent). Little is known about the influence of population density on CRNAs' scope of practice (SOP) and job satisfaction in Arizona, an independent practice state. The objectives were to examine relationships between (1) SOP and population density and (2) job satisfaction and SOP. In this descriptive study, an 11-question survey was sent to CRNAs practicing in Arizona. A total of 515 surveys were distributed; 261 responses (50%) were received, and 230 respondents (46%) met inclusion criteria. Spearman rank-order correlation was used to analyze the relationship between SOP and population density and between SOP and job satisfaction. Rank biserial correlation was used to examine association between CRNAs' SOP and geographic location. More than half the participants were male (54%), and 46% were female (age range, 27-75 years; years' experience, 1-50 years). Population density had no association with SOP (P=.074). However, SOP and job satisfaction showed a positive correlation (P<.001). These findings suggest that removal of regulatory barriers to CRNAs' SOP could decrease costs and increase access to care. Autonomy plays a clear role in job satisfaction, which may have implications for recruitment and retention.

From the Operating Room to the Front Lines: Shared Experiences of Nurse Anesthetists During the Coronavirus Pandemic.

Coronavirus disease 2019 (COVID-19) has resulted in severe health, economic, social, political, and cultural consequences while thrusting Certified Registered Nurse Anesthetists (CRNAs) at the forefront of battling an often invisible enemy. A mixed-methods study was conducted to assess the impact of the COVID-19 pandemic on CRNA practice. The purpose of the qualitative component of the study, a focused ethnography, was to use personal and group interviews to determine the shared experiences of CRNAs who worked during the COVID-19 pandemic. Six themes were identified: (1) CRNAs are part of the solution, (2) doing whatever it takes, (3) CRNAs are valued contributors, (4) removal of barriers promotes positive change, (5) trying times, and (6) expertise revealed. The quantitative component of the study will be discussed in a separate article.

Redeployment of Certified Registered Nurse Anesthetists During the Coronavirus Disease 2019 Pandemic.

Certified Registered Nurse Anesthetists (CRNAs) are uniquely skilled anesthesia providers with substantial experience managing critically ill patients. During the coronavirus disease 2019 (COVID) pandemic, CRNAs at a large academic medical center in the Mid-Atlantic United States experienced a shift in their daily responsibilities. As the hospital transitioned to the management of patients who tested positive for the virus that causes COVID, the severe acute respiratory syndrome-coronavirus type 2 (SARS-CoV-2), CRNAs were redeployed into the roles of respiratory therapists and intensive care unit registered nurses. Although facing the stress of the global pandemic, this facility's CRNAs proved to be flexible, capable, and necessary members of the care team for patients with COVID-19.

Psychometric Testing of a Structured Assessment Instrument for Non-technical Skills (NANTS-no) for Use in Clinical Supervision of Student Nurse Anesthetists.

BACKGROUND: This study evaluated psychometric properties of a structured behavioral assessment instrument, Nurse Anaesthetists' Non-Technical Skills-Norway (NANTS-no). It estimated whether reliable assessments of nontechnical skills (NTS) could be made after taking part in a workshop. An additional objective was to evaluate the instrument's acceptability and usability. METHODS: An explorative design was used. Nurse anesthetists (n = 46) involved in clinical supervision attended a 6-hour workshop on NTS, then rated NTS in video-recorded simulated scenarios and completed a questionnaire. RESULTS: High reliability and dependability were estimated in this setting. Participants regarded the instrument as useful for clinical supervision of student nurse anesthetists (SNAs). CONCLUSIONS: Findings suggest that NANTS-no may be reliable for performing clinical assessments of SNAs and encouraging critical reflection. However, further research is needed to explore its use in clinical settings.

Anaesthesia care providers employed in humanitarian settings by Médecins Sans Frontières: a retrospective observational study of 173 084 surgical cases over 10 years.

OBJECTIVE: To describe the extent to which different categories of anaesthesia provider are used in humanitarian surgical projects and to explore the volume and nature of their surgical workload. DESIGN: Descriptive analysis using 10 years (2008-2017) of routine case-level data linked with routine programme-level data from surgical projects run exclusively by Médecins Sans Frontières-Operational Centre Brussels (MSF-OCB). SETTING: Projects were in contexts of natural disaster (ND, entire expatriate team deployed by MSF-OCB), active conflict (AC) and stable healthcare gaps (HG). In AC and HG settings, MSF-OCB support pre-existing local facilities. Hospital facilities ranged from basic health centres with surgical capabilities to tertiary referral centres. PARTICIPANTS: The full dataset included 178 814 surgical cases. These were categorised by most senior anaesthetic provider for the project, according to qualification: specialist physician anaesthesiologists, qualified nurse anaesthetists and uncertified anaesthesia providers. PRIMARY OUTCOME MEASURE: Volume and nature of surgical workload of different anaesthesia providers. RESULTS: Full routine data were available for 173 084 cases (96.8%): 2518 in ND, 42 225 in AC, 126 936 in HG. Anaesthesia was predominantly led by physician anaesthesiologists (100% in ND, 66% in AC and HG), then nurse anaesthetists (19% in AC and HG) or uncertified anaesthesia providers (15% in AC and HG). Across all settings and provider groups, patients were mostly healthy young adults (median age range 24-27 years), with predominantly females in HG contexts, and males in AC contexts. Overall intra-operative mortality was 0.2%. CONCLUSION: Our findings contribute to existing knowledge of the nature of anaesthetic provision in humanitarian settings, while demonstrating the value of high-quality, routine data collection at scale in this sector. Further evaluation of perioperative outcomes associated with different models of humanitarian anaesthetic provision is required.

Advanced Prehospital Trauma Resuscitation With a Physician and Certified Registered Nurse Anesthetist: The Shock Trauma "Go-Team".

OBJECTIVE: The R Adams Cowley Shock Trauma Center (STC) is Maryland's primary adult resource center for trauma care. The Shock Trauma "Go-Team" is a specialized component of Maryland's emergency medical system and is composed of a physician and certified registered nurse anesthetist. They are dispatched when advanced prehospital resuscitation is required. The purpose of this study is to describe the capabilities and historic epidemiology outcomes of the Go-Team. METHODS: A retrospective case series review of recoverable Go-Team records was performed from 2011 to 2018. Go-Team call logs/records were identified from multiple sources. Medical records were reviewed for patient demographics, mechanisms of injury, and treatments in the field. There was a total of 61 activations, with 22 deployments to the scene of injury. RESULTS: The majority of deployments were via helicopter (73%) and lasted 2 hours. The most common indications for deployment were motor vehicle entrapment (41%), trench collapse (14%), and building collapse (9%). Of the 22 patients treated by the Go-Team, 50% received at least 1 blood transfusion in the field, and 23% required an advanced airway. No field amputations were required. CONCLUSION: The STC Go-Team is a unique multidisciplinary specialized component of a statewide emergency medical system.

Late first-case of the day starts do not cause greater minutes of over-utilized time at an endoscopy suite with 8-hour workdays and late running rooms. A historical cohort study.

STUDY OBJECTIVE: We consider the influence of the tardiness of first-case of the day start times on the minutes that rooms finish late for procedural suites with relatively interchangeable rooms and mean workloads ≅ 7 h per room, thus regularly filling 8-hour of allocated time. DESIGN: Historical cohort of N = 331 workdays of data. SETTING: Gastrointestinal endoscopy suite. MAIN RESULTS: By unadjusted analyses, reductions in the number of first-cases of the day starting ≥5 min late were associated with less minutes that the day's cases ended beyond the allocated 8 h. However, there were no significant relationships in adjusted analyses, controlling for the daily total hours of cases and turnovers ("workload") or the daily caseload of elective cases. There also were no significant relationships in adjusted analyses between the minutes of cases ending beyond the allocated 8 h and either the count of cases starting ≥15 min late or the mean minutes of case tardiness. The differences between unadjusted and adjusted results were explained by slight positive associations between the count of first-cases starting ≥5 min late and both the daily workload and caseload. Days with less hours of cases had significantly fewer cases starting near simultaneously at the beginning of the day; the same was true for days with fewer total cases. CONCLUSIONS: For procedural suites with relatively interchangeable rooms and mean workloads ≅ 7 h per room, reducing tardiness of first-case of the day start times does not result in beneficial reductions in over-utilized time. The focus of improving on-time starts for the first-cases of the day should be on services with mean workloads that exceed the minimum scheduled duration of the workday.

The use of a pedometer to measure the physical activity during 12-hour shift of ICU and nurse anaesthetists in Poland.

BACKGROUND: Nurses are the largest group of employees in hospitals yet their working environment and conditions are not always optimal. Moreover, nurses may be convinced that the physical activity they perform during working hours is sufficient to maintain a healthy lifestyle. OBJECTIVES: The study aimed to measure the number of steps, the distance and the energy expenditure during a 12-hour shift in the intensive care unit and for nurse anaesthetists in selected hospitals in Poland. METHODS: Data were collected via a pedometer and a socio-demographic interview. The project was multicentre, data were collected from 11.11.2013 to 04.05.2014. RESULTS: The median number of steps taken by nurse anaesthetists within the operating room was 7404 (IQR 4461-9443) while in the ICU it was 7358 (IQR 4705-9101). During the day in the operating and recovery room, both nurse anaesthetists (IQR 3.90-6.26) and ICU nurses (IQR 3.54-6.39) reached the median distance of five kilometres. There were significant differences in the distance covered during day and night between ICU (p = 0.0003) and anaesthetic staff (p = 0.0001) as well as the number of steps (ICU p = 0.0002; ANEST p = 0.0001) and energy expenditure (ICU p = 0.0004; ANEST p = 0.0001). CONCLUSION: The professional activity of nurses alone is insufficient to meet the recommendation of taking 10,000 steps daily, which would contribute to improved quality of life.

Nurse Anesthetists' Communication in Brief Preoperative Meeting With Orthopaedic Patients-An Interview Study.

PURPOSE: To explore the experience of preoperative communication of nurse anesthetists (NAs) in brief meetings with patients in an orthopaedic setting. DESIGN: Qualitative research. METHODS: Three group interviews based on experiences of 18 NAs were conducted. Content data analysis was used. FINDINGS: The brief communication was characterized by both difficulties and opportunities. Protecting the patient's integrity, informing worried patients, lack of routines, language difficulties, being present at the meeting, protecting the patient from disturbance, and encouraging the patient to participate were stated as the main challenges in the brief meeting with patients. The NAs also gave some suggestions for improvement. CONCLUSIONS: The Preoperative meetings need to be developed and structured to improve communication. A way to assess the results of this conversation should be developed. Other recommendations include finding a way to improve patient involvement in this dialogue and development of skills of NAs to enhance the meeting for patients.

Nurse anesthetists' preferences for anesthesiologists' participation in patient care at a large teaching hospital.

STUDY OBJECTIVE: Certified registered nurse anesthetists (CRNAs) can evaluate anesthesiologists with whom they work clinically using a psychometrically reliable and valid scale. Use of such a scale to evaluate performance depends on knowing thresholds for minimum and ideal anesthesiologist performance. DESIGN: Cohort study. SETTING: One large teaching hospital. MEASUREMENTS: 379 CRNA evaluations of anesthesiologists' performance, and associated thresholds for minimum and ideal scores, performed over 15 weeks. MAIN RESULTS: The anesthesiologists' performance score was less than the CRNA's minimum score for the evaluation (i.e., too little anesthesiologist participation in patient care) for 25% (95) of the CRNA evaluations. The score was greater than the CRNA's ideal score for the evaluation (i.e., excessive participation in patient care) for 28% (106) of evaluations. Anesthesiologists' performance was assessed as not meeting expectations 53% of the time. Even if every anesthesiologist performed consistently at the same level, ≥50% of CRNAs would have been dissatisfied (187), not significantly different from observed (P = 0.34). Consistent results were found when the unit of analysis was individual CRNA. Among the 22 CRNAs who provided ≥10 evaluations, the median level of anesthesiologist performance was either less than the individual CRNA's mean minimum acceptable performance (8/22) or greater than their mean ideal performance (9/22), with overall dissatisfaction, 77%. Among the CRNA-anesthesiologist pairs working together, most did so less than once per month (76%, 1242/1635). CONCLUSIONS: In this single-center study at a large teaching hospital, broad heterogeneity among CRNAs in their expectations for anesthesiologist collaborative practice was found. Anesthesiologists adjusting their behavior based on individual CRNA preferences was impractical because specific CRNA-anesthesiologist pairs work together infrequently. Future studies should examine consistency among organizations and whether changes in expectations, and perhaps less dissatisfaction, can be achieved by communication of results for CRNA preferences for anesthesiologists' participation in patient care and discussing shared expectations among the CRNAs and anesthesiologists.

How Anesthesiologists and Nurse Anesthetists Assess and Handle Patients' Perioperative Worries Without a Validated Instrument.

PURPOSE: To study how nurse anesthetists and anesthesiologists assess and handle patients' perioperative anxiety without using a validated instrument. DESIGN: Qualitative study. METHODS: Individual in-depth face-to-face interviews were conducted with nurse anesthetists (n = 9) and anesthesiologists (n = 5) from a university hospital in Sweden. Data were analyzed with thematic analysis according to Braun and Clark. FINDINGS: Two themes were identified: (1) I ask about anxiety, look for visual signs, and observe communication and (2) I handle patients' anxieties individually. In addition to subthemes describing assessment and handling of adults, it appeared that parents played an important role in children's perioperative anxiety. CONCLUSIONS: When not using a validated instrument, assessing perioperative anxiety is commonly based on the anesthesiologist's and nurse anesthetist's experience, knowledge, views, and attitudes. The evaluator's capability of using different strategies in the assessment and handling of perioperative anxiety is important.

The Art Is to Extubate, Not to Intubate-Swedish Registered Nurse Anesthetists' Experiences of the Process of Extubation After General Anesthesia.

PURPOSE: To describe Registered Nurse Anesthetists' (RNA's) experiences of the process of extubation of the endotracheal tube in patients undergoing general anesthesia. DESIGN: A descriptive qualitative design. METHODS: This study was conducted in two hospitals with 20 RNAs in total. Data were generated from focus group interviews. Content analysis was used to analyze data. FINDINGS: The RNAs' experiences were described within four categories and eight subcategories. The category To be a step ahead includes assessment and preparation, and To be on my toes, their ability to recognize patterns and build a connection. To use situation awareness relates to their use of experience and feelings, and To be alone in a critical moment, to feeling alone in the team and protecting the patient. CONCLUSIONS: The RNAs make decisions when to extubate by combining theoretical knowledge, clinical experience, and intuition with the uniqueness of each patient.

Unscheduled absences in a cohort of nurse anesthetists during a 3-year period: Statistical implications for the identification of outlier personnel.

STUDY OBJECTIVE: To estimate the prevalence of unscheduled absences in a cohort of certified registered nurse anesthetists (CRNAs) over a 3-year period, for purposes of critiquing statistical review of individual providers relative to potential identification of patterns of such absences. DESIGN: Retrospective, observational study. SETTING: University hospital. SUBJECTS: 99 CRNAs performing clinical assignments in the operating rooms. INTERVENTIONS: None. MEASUREMENTS: CRNA daily clinical assignments and unscheduled absences were retrieved from the department's staff assignment software package. Data were extracted and analyzed to estimate the prevalence of unscheduled absences by CRNAs by day of the week, and whether each absence occurred on the workday before or after either a holiday or a personal vacation. A statistical power analysis was performed to determine the number of workdays of data required to identify outlier personnel above the 95th percentile among all CRNAs while controlling for a family-wise error rate of 5%. MAIN RESULTS: The overall incidence of unscheduled absences pooled by days was 1.7%, with small differences among days of the week, and before or after vacations. A year of data would be required to detect outliers for unscheduled absences exceeding the 95% upper confidence limit among all CRNAs. Attempting to identify patterns of absences being on specific days of the week or as related to holidays and vacations would require multiple years of data. CONCLUSIONS: OR managers can detect CRNAs with excessive numbers of unscheduled absences, but at least a year of data is required. Detecting apparent "patterns" of absences would require multiple years of data and is thus impractical.

Local Anesthetic Systemic Toxicity (LAST): Designing an Educational Effort for Nurses That Will Last.

PURPOSE: To improve knowledge and raise awareness of nurses who assist certified registered nurse anesthetists or anesthesiologists with peripheral nerve block or spinal block procedures about a potential life-threatening local anesthetic systemic toxicity (LAST) event. DESIGN: An evidence-based practice project design. METHODS: Nurses in units where nerve block procedures were performed (ie, postanesthesia care unit, preoperative, operating room, outpatient services, labor and delivery unit) received a pretest about their knowledge of LAST events, participated in a 30-minute educational session, and then completed a post-test. The data were analyzed for differences and statistical significance. Included in the test was a question about the nurse's comfort level with managing a LAST event. FINDINGS: The findings demonstrated a knowledge deficit related to LAST events. The average of all three units combined pretest scores was 60% and post-test scores increased to 95%. The average comfort level of all three units was 3.5/10 (35%) before the educational in-service program and increased to 7.9/10 (79%) after education. CONCLUSIONS: Nurses working in units where nerve blocks are performed are lacking in knowledge of the signs and symptoms and the correct course of treatment for a LAST event. This could lead to poor outcomes of a very high-risk low-volume event.

Difficult Airways: Key Factors for Successful Management.

PURPOSE: To describe anesthetic nurses' experiences of key factors for the successful management of difficult airways in adult patients. DESIGN: This study had a qualitative observational and descriptive design following the critical incident technique. METHODS: Twelve experienced anesthetic nurses were interviewed. FINDINGS: We identified five key factors for the successful management of difficult airways: identification of the difficult airway, creating a plan of action, remaining calm and focusing on the task, technical skills, and using the equipment. Identification of the difficult airway implies preassessment with standardized methods and actively observing for signs indicative of a difficult airway. Having all equipment available at bedside during induction and creating a backup plan increases the action force in unexpected situations. A calm and methodical work procedure facilitates the management of the difficult airway as well as selecting techniques and equipment according to the patient and situation. CONCLUSIONS: Reflective practice can aid the anesthetic nurse in drawing on experience and remaining calm in acute situations.