Changing Anesthesia Block Allocations Improves Endoscopy Suite Efficiency.

Non-operating room anesthesia (NORA) has grown and continues to expand as a proportion of all anesthesia practice in the United States [1, 2]. While many management processes have been adapted for NORA from the traditional operating room, it is still unclear what scheduling paradigm will maximize efficiency of resource utilization in this arena. In this study, we investigate the impact of tactical a shift from a shared group to individual, provider-specific block allocations for available anesthesia time in an endoscopy suite for adult patients undergoing elective endoscopy procedures at an academic hospital. Using a retrospective and prospective analysis, we measured elective time-in-block; elective time out-of-block; under-utilized (opportunity and non-opportunity unused) time; over-utilized time; and case tardiness to determine operational efficiency and clinical productivity. Over the study period, the monthly caseload remained constant. Elective time in block increased by 156% (p < 0.0001) and elective time out of block decreased by 38% (p < 0.0001). Opportunity unused time decreased by 28% (p < 0.0001) and productivity increased by 51% (p < 0.0001). Neither over-utilized time nor case tardiness showed a significant change after the intervention. Despite the evidence base supporting traditional approaches to anesthesia block allocation involving group block allocation and non-sequential case scheduling, we have demonstrated an advantage to individual block allocation in a GI endoscopy setting. This sequential case scheduling highlights how tactical decisions in NORA environments may require a rethinking of many practices that anesthesiologists have brought with them from the traditional OR. Using these efficiency and productivity metrics, further adjustments to scheduling practices should be investigated, and connecting these metrics to other systems outcomes, such as financial productivity, is an important next step as NORA services expand into the future.

Risk Factors for the Development of Stent-Associated Cholangitis Following Endoscopic Biliary Stent Placement.

BACKGROUND AND AIM: To elucidate the overall risk and risk factors for developing cholangitis following biliary stent placement by endoscopic retrograde cholangiopancreatography (ERCP) and to determine the clinical outcomes of these individuals. METHODS: We performed a retrospective review of 796 patients who had undergone 1127 ERCPs with biliary stent placement between 2007 and 2015 at a single tertiary care center. There were 91 episodes of stent-associated cholangitis (SAC) during the study period. Data obtained through the medical records included ERCP indication, patient factors (biliary anatomy, demographics, and comorbidities), stent characteristics (material, length, and design), change in serum bilirubin, stent indwelling time, rates and etiologies of bacteremia, and the mortality rate. RESULTS: Those with SAC were more likely to have an anatomic biliary stricture (13.1% vs. 2.3%, p < .0001), with hilar and multiple strictures having the highest risk (19.1% vs. 11.6%, p = .04). The ERCP indication of malignant biliary obstruction was associated with higher rates of SAC (15.6% vs. 3.4%, p = < .0001). Rates of SAC were higher in those who failed to normalize total bilirubin (16.9% vs. 7.8%, p = .0005), and these episodes occurred earlier compared to those who normalized total bilirubin (median 30.5 days vs. 140.5 days, p < .0001). CONCLUSIONS: Patients at increased risk of SAC include those with an anatomic stricture, malignant biliary obstruction, and those who fail to normalize total bilirubin after biliary stent placement. Future protocols should be designed to reduce the risk of cholangitis in these populations.

Prospective evaluation of bacteremia rates and infectious complications among patients undergoing single-operator choledochoscopy during ERCP.

BACKGROUND AND STUDY AIMS: Choledochoscopy is increasingly performed during endoscopic retrograde cholangiopancreatography (ERCP) for direct bile duct visualization. Choledochoscopy necessitates irrigation of the bile duct with water or saline, which may increase intrabiliary pressure and consequently the risks of bacteremia and cholangitis. The aim of this study was to prospectively evaluate the risk of bacteremia and infectious complications in patients undergoing single-operator choledochoscopy (SOC). PATIENTS AND METHODS: Patients requiring ERCP with SOC at two tertiary care centers were enrolled prospectively. Blood cultures were obtained immediately before the ERCP, after completion of the ERCP portion of the procedure (to determine ERCP-related bacteremia), and 15 minutes after completion of SOC. RESULTS: A total of 72 patients (mean age 64 years; 51.4 % male) underwent ERCP with SOC. True positive blood cultures were noted in 20 patients (27.8 %; 95 % confidence interval [CI] 17.86 % - 39.59 %), of whom 6 patients (8.3 %; 95 %CI 3.12 % - 17.26 %) had transient bacteremia following ERCP. Of 14 patients (19.4 %; 95 %CI 11.05 % - 30.46 %) with sustained bacteremia following ERCP or SOC, 10 patients (13.9 %; 95 %CI 6.86 % - 24.06 %) had sustained bacteremia related to SOC. Despite the use of post-procedure intravenous antibiotic administration, seven patients (9.7 %; 95 %CI 3.99 - 19.01 %) required further antibiotic treatment for infectious complications, three of whom (4.2 %; 95 %CI 0.86 % - 11.69 %) were hospitalized in order to receive intravenous antibiotic therapy. CONCLUSION: The bacteremia associated with ERCP with SOC and the subsequent risk of hospitalization for infectious complications suggest that preprocedure antibiotic prophylaxis should be considered for patients undergoing SOC, particularly in older patients and those with prior stent placement or undergoing intraductal stone lithotripsy. TRIAL REGISTRATION: clinical trials.gov (NCT01414400).