Education for Registered Nurses Completing Preoperative Anesthesia Interviews: A Quality Improvement Project.

PURPOSE: This quality improvement project implemented job-related education for registered nurses (RNs) completing preoperative anesthesia interviews (PAIs) to increase their knowledge and confidence, improve completeness of documented preoperative interviews, and decrease day of surgery (DOS) cancellations. DESIGN: Pre/post implementation design and retrospective chart review. METHODS: An educational module on PAIs was created and RNs working in the pre-admission testing (PAT) clinic were asked to complete the module. Pre and post implementation data was collected on RN knowledge and confidence, assessment completeness, and DOS cancellations. FINDINGS: Knowledge and confidence increases were not statistically significant, although several interview components within PAI documentation improved with statistical significance. Overall DOS cancellations, although not statistically significant, were found to decrease, 1.3% to 1.2%. CONCLUSIONS: Registered nurses' knowledge, confidence and PAI completeness improved after completing the educational module with anesthetic considerations. Patients seen at the PAT clinic for PAIs before the DOS allowed for patient optimization and education leading to decreased preventable DOS cancellations.

Preoperative Preparation and Guidelines for Cannabis-Using Patients Undergoing Elective Surgery.

PURPOSE: Appropriate preoperative screening techniques are needed to safely provide anesthesia to increasing numbers of cannabis using surgical patients. DESIGN: This was a quasi-experimental quality improvement project. METHODS: Preoperative identification of cannabis users by registered nurses (RNs) and certified registered nurse anesthetists (CRNAs) was compared to baseline identification rates. CRNAs' compliance with evidenced base guidelines was recorded. Perioperative medication requirements were recorded and compared between cannabis-users and noncannabis users. FINDINGS: Identification of cannabis users by CRNAs conducting preanesthetic assessments increased from 4.08% to 14.36% while RN identification improved from 11.22% to 13.81%. Compliance with identification guidelines was 69.2% among CRNAs. There were no differences in anesthetic requirements, complications, or postanesthesia care unit (PACU) length of stay between cannabis users and nonusers. CONCLUSIONS: Preoperative identification of cannabis users allows for safer, more effective perioperative care by CRNAs, registered nurses, and surgical staff.

Sustainability of an Operating Room to Pediatric Postanesthesia Care Unit Handoff Tool.

PURPOSE: The purpose of this quality improvement (QI) project was to reintroduce and assess the feasibility of a standardized, electronic health record (EHR) handoff tool and to evaluate the sustainability of a structured, team-based approach in a pediatric postanesthesia care unit (PACU). DESIGN: This QI project used an observational pre-post design using two separate convenience samples of handoffs and perianesthesia providers. METHODS: A standardized EHR handoff tool was reintroduced for operating room to pediatric PACU handoff communication. Handoffs between anesthesia providers, surgery team members, and PACU nurses were observed pre- and postreintroduction of the EHR handoff tool. Anesthesia providers and PACU RNs received training for giving and receiving handoffs and were provided directions on locating the EHR handoff tool. A bedside audit of items communicated for the six handoff phases (introductions, situation, background, assessment, recommendations, and questions), handoff duration, team member participation, and handoff tool utilization were performed for 149 handoffs pre- and 146 handoffs postimplementation. To evaluate sustainability, the audits were compared to postimplementation data from the 2014 pilot handoff project. FINDINGS: Following reintroduction, EHR handoff tool use increased from 4% to 19%. There was a statistically significant increase in items communicated for three of the six handoff phases when using the EHR tool (P < .05). There was no statistically significant increase in handoff duration (mean = 3.66 minutes, SD = 1.57 minutes) with the EHR handoff tool. Surgical team member presence for the team-based handoff increased from 90.7% pre to 95.9% post. Provider compliance with the team-based handoff approach, which includes a PACU RN, surgical team member, and anesthesia team member present for handoff, was sustained and increased 6 years postimplementation. Feedback from anesthesia providers and PACU RNs indicated mixed reports of satisfaction with the EHR tool, perceived handoff efficiency, and consistency in both giving and receiving handoff. Adherence to five of the six structured handoff phases, except introductions, was sustained and even improved 6 years following implementation. CONCLUSIONS: Evidence-based practice for handoff communication supports the use of a team approach and standardized EHR handoff tools. The reintroduction of a standardized EHR handoff tool improved the completeness of information transfer, yet did not lead to widespread adoption nor improved user satisfaction. There is an ongoing need to identify adoptable and sustainable perioperative handoff methods.

Improving Certified Registered Nurse Anesthetists' Adherence to a Standardized Intraoperative Lung Protective Ventilation Protocol.

PURPOSE: The use of lung protective ventilation (LPV) during general anesthesia is an effective strategy among certified registered nurse anesthetists (CRNAs) to reduce and prevent the incidence of postoperative pulmonary complications. The purpose of this project was to implement a LPV protocol, assess CRNA provider adherence, and investigate differences in ventilation parameters and postoperative oxygen requirements. DESIGN: This quality improvement project was conducted using a pre- and postimplementation design. METHODS: Sixty patients undergoing robotic laparoscopic abdominal surgery and 35 CRNAs at a community hospital participated. An evidence-based intraoperative LPV protocol was developed, CRNA education was provided, and the protocol was implemented. Pre- and postimplementation, CRNA knowledge, and confidence were assessed. Ventilation data were collected at 1-minute intervals intraoperatively and oxygen requirements were recorded in the postanesthesia care unit (PACU). FINDINGS: Use of intraoperative LPV strategies increased 2.4%. Overall CRNA knowledge (P = .588), confidence (P = .031), and practice (P < .001) improved from pre- to postimplementation. Driving pressures decreased from pre- to postimplementation (P < .001). Supplemental oxygen use on admission to the PACU decreased from 93.3% to 70.0%. CONCLUSIONS: Educational interventions and implementation of a standardized protocol can improve the use of intraoperative LPV strategies and patient outcomes.

How do we improve blood product administration audit rates.

BACKGROUND: Failure to comply with institutional and national standards for blood product administration poses patient safety risks. Monitoring adherence to blood product administration policy is important for maintaining patient safety and ensuring regulatory agency compliance. STUDY DESIGN AND METHODS: This post-implementation quality improvement project evaluated an electronic paging system that was developed to facilitate perioperative blood product administration audits. RESULTS: Of the 57 audits conducted, 55 (96.5%) audits were fully completed. Anesthesia providers verified the patient name and medical record number (MRN) on the patient's armband with the product ID tag in 36.5% (n = 20) of audits. Anesthesia providers ensured the name and MRN on the armband matched the compatibility label on the blood product in 23% (n = 23) of audits. DISCUSSION: Ongoing surveillance of blood product administration practices is needed to monitor adherence to blood product administration policy, promote patient safety, and avoid imminent financial consequences from noncompliance to national regulatory standards.

Creation and Implementation of a Preoperative Malignant Hyperthermia Screening Tool.

BACKGROUND: Malignant hyperthermia (MH) is a potentially lethal pharmacogenetic disorder triggered by certain anesthetic agents. There is currently no standardized preoperative screening tool utilized to identify MH-susceptible individuals. LOCAL PROBLEM: This quality improvement (QI) project aimed to enhance preoperative screening for MH susceptibility (MHS) by implementing an evidence-based screening tool for surgical patients at 2 sites. METHODS: This prospective descriptive QI project evaluated the success of implementing an MHS screening tool preoperatively and its impact on the anesthesia plan. INTERVENTIONS: Anesthesia professionals included the screening tool in their preoperative interview for surgical patients so that positively screened patients could receive MH prevention measures. RESULTS: A total of 95 patients at site A and 234 patients at site B were screened using the MH tool, a cumulative total of 21 patients were positively screened, and 1 anesthetic plan was altered. CONCLUSIONS: This MHS screening tool has the potential to prevent MH episodes when used consistently by staff.

Standardized Perioperative Note to Improve Perioperative Management of Patients With Cardiac Implantable Electronic Devices.

PURPOSE: Over 3 million people have a cardiac implantable electronic device (CIED) in the United States. Without an organization-wide, standardized approach to the perioperative management of patients with CIEDs, communication errors and subsequent periods of unintentional deactivation and management can leave patients vulnerable to untreated, life-threatening arrhythmias. The purpose of this quality improvement project was to refine the standardized approach for perioperative management of patients with CIEDs at a large academic medical center. DESIGN: A pre-post implementation design with two independent groups. METHODS: Patients with preexisting permanent CIEDs (n = 405) undergoing surgical and nonsurgical procedures with anesthesia were included. A preprocedure note was revised and implemented in the electronic health record for patients with CIEDs to include information about the device type, perioperative plan, and contact information for technical support. FINDINGS: When the preprocedure note was used, completion of the perioperative plan and contact information increased significantly (P < .001) and the number of undocumented interventions that occurred with CIEDs in the intraoperative period (magnet use, preoperative reprogramming, and postoperative reprogramming) was significantly reduced (P < .05). CONCLUSIONS: While documentation of the preprocedure note and intraoperative interventions increased, ongoing perioperative management improvements for patients with CIEDs are needed.

A 'novel' multi-component approach to promote physical activity among older cancer survivors: a pilot randomized controlled trial.

BACKGROUND: Physical activity (PA) provides many benefits for recovery from cancer treatments. Many older (65+ years) cancer survivors which comprise the majority of the cancer survivor population, do not meet recommended PA guidelines. This study explored the feasibility and acceptability of using audiobooks as part of a 12-week multi-component intervention to increase steps/day, light and moderate-to-vigorous intensity PA among older survivors. METHODS: Twenty older cancer survivors (95% female, mean age = 71.55 years, 90% White, 85% overweight/obese, 75% breast cancer survivors, mean 1.96 years since treatment completion) were randomized into one of the two study groups (Audiobook Group, n = 12, Comparison Group, n = 8). Both study groups were provided a tailored step goal program over the 12-week intervention; weekly step increases were based on a percent increase from baseline. Participant self-monitored their steps using a Fitbit Charge 2. In addition, the Audiobook group were encouraged to listen to audiobooks (downloaded onto a smartphone device via an app available at no cost from the local library) during PA to add enjoyment and increase PA. Regression analyses on steps/day, light and moderate-to-vigorous PA/week and sedentary time/week as assessed by the Actigraph were conducted, after adjusting for Actigraph wear time. Data from the post-intervention questionnaire were summarized. RESULTS: Overall, majority of participants (89%) stated they were very satisfied with their participation and 100% reported that they were able to maintain their activity upon study completion. Retention rates were high. At post-intervention, there were significant differences favoring the Audiobook group for steps/day and moderate-to-vigorous PA/week. No significant group differences were found for minutes of light intensity PA/week and sedentary time/week. CONCLUSION: Piloting the implementation of a sustainable, innovative intervention among older survivors to increase their PA has significance for this group of survivors.

Impact of the 21st Century Cures Act on Patients and the Healthcare Team.

The 21st Century Cures Act is designed to make healthcare information more accessible and transparent to patients and the healthcare team. The provisions to address information blocking dictate that health information such as.

Improving Waste Segregation in the Operating Room to Decrease Overhead Cost.

BACKGROUND AND OBJECTIVES: Operating rooms (ORs) disproportionally contribute 20% to 33% of hospital waste nationwide and therefore have a major impact on hospital waste management. Seventy percent of general OR waste is incorrectly eliminated as clinical waste, which compounds unnecessary financial burden and produces negative environmental impact. The primary purpose of this quality improvement (QI) project was to evaluate the effectiveness of waste segregation education for OR anesthesia staff on improving waste segregation compliance in the OR. METHODS: A waste segregation QI project was implemented at a 19-OR hospital. Sharps bins in each OR were monitored for weight in pounds and 6 ORs were monitored for percent compliance both pre- and post-institution of a waste segregation education. In addition, a waste segregation knowledge assessment, waste segregation barriers assessment, and a demographic survey were administered to anesthesia staff. Twenty-two certified registered nurse anesthetists (CRNAs), 13 anesthesiologists, and 4 anesthesia technicians responded to the initial surveys and assessments while 30 of these original 39 participants (77%) responded following the educational intervention. A cost analysis was calculated pre- and post-implementation by multiplying total weight of the sharps bins by the price per pound of sharps. RESULTS: Twenty-three percent of participants reported having formal waste segregation training. Survey responses revealed that the greatest barrier to waste segregation involved bin location (56.4%), followed by lack of time to segregate (25.6%), lack of knowledge of what content goes in the bin (25.6%), and lack of incentive (25.6%). A waste segregation knowledge assessment showed improvement from pre- ( M = 9.18, SD = 1.66) to post-implementation ( M = 9.90, SD = 1.64). Pre-implementation sharps bin compliance was 50.70% while post-implementation bin compliance improved to 58.44%. A 27.64% decrease in sharps disposal cost occurred following implementation, which is estimated to produce a $2964 cost savings per year. CONCLUSIONS: Waste segregation education for anesthesia staff increased their waste management knowledge, improved sharps waste bin compliance, and produced an overall cost savings.

The Development and Validation of an Objective Assessment Tool for Performing Ultrasound-Guided Transversus Abdominis Plane Blocks.

The transversus abdominis plane (TAP) block is a regional anesthesia technique used as part of a multimodal pain management plan in patients undergoing abdominal surgery. There are numerous approaches and techniques described in the literature, resulting in a lack of consistency in block performance. This potentially reduces efficacy while increasing risk to the patient. Competency assessment tools have been shown to lower patient risk and improve outcomes by improving provider skill. Checklists are used as formative and summative assessment tools throughout healthcare education, however, there is no validated tool for ultrasound-guided TAP blocks. The purpose of this evidence-based project was to develop a checklist using a modified Delphi method. The primary outcome measure was validation of the assessment tool, established by an expert panel consensus and guided by Messick's validity framework. A 43-item checklist was validated by six certified registered nurse anesthesiologists throughout the United States with expertise in regional anesthesia. Three rounds of feedback were required to exceed the threshold of consensus (0.8), establishing a method of evaluation that may allow future research in educational settings through improved skill assessment among providers performing TAP blocks.

A Mixed-Methods Exploration of Competencies and Professional Development Needs Among Chief Certified Registered Nurse Anesthetists.

This project sought to explore the experiences, self-perceived preparation, professional development needs, and preferred learning methods of certified registered nurse anesthetists (CRNAs) in a management role. A sample of 10 current chief CRNAs responded to a demographics survey and participated in one-on-one interviews using a 14-question, semi-structured interview framework modified from a previous study. Interview responses were deidentified and qualitatively analyzed for common themes by two content experts and one qualitative analysis expert. Results suggest that CRNAs entering the management field feel somewhat unprepared to perform the administrative tasks associated with their role. Qualitative analysis of interview responses elicited multiple key themes including interpersonal communication and handling crucial conversations, time and organizational management skills, team building and motivation, and financial management skills. Themes related to preferred learning methods of chief CRNAs included mentorship, peer networking, and experiential learning to obtain the required knowledge and skills for the role. The authors recommend incorporating each of the identified themes to guide development of CRNA management-specific educational programs. Establishing such a program will serve to better prepare aspiring CRNA managers and further develop the knowledge and skillset of current chief CRNAs.

Three-Dimensionally Printed Simulated Tracheas to Improve Cricothyrotomy Skills Among Anesthesia Providers.

Cricothyrotomy proficiency is imperative for anesthesia providers; however, opportunities to perform this skill are infrequent making skill maintenance essential. Increased accessibility of three-dimensional (3D) printing allows for production of low-cost simulation models. The models used for simulation-based teaching and deliberate practice facilitate skill development and refinement. A cost-effective, 3D printed airway model was designed and allowed 47 anesthesia providers to complete hands-on practice during a cricothyrotomy simulation-based training program. Assessment and comparison of pre- to post- intervention was completed for self-efficacy, knowledge, time to skill completion, compliance of required steps checklist, Global Rating Scale score, and successful ventilation. Statistically significant improvement from pre- to posttest was demonstrated in: 1) self-efficacy survey scores (P < .001); 2) knowledge test scores (P < .001); and 3) decreased time (minutes:seconds) to task completion (P < .001). Time from initial posttest to 3-month posttest (P = .046) significantly increased, however, the time at 3 months posttest remained significantly lower than pretest (P < .001). Providers' ability to ventilate, compliance with procedural steps, and technical skills significantly improved. 3D printing can produce anatomically similar simulation airway models that allow providers to practice and improve cricothyrotomy knowledge and skills. Developing an affordable and accessible simulation model provides a sustainable tool that allows providers multiple cricothyrotomy practice attempts.

Improved Technical Skill and Procedure Time With Central Venous Catheter Simulation.

Simulation manikins provide anesthetists a training modality to practice ultrasound-guided central venous catheter (CVC) insertion safely without the risk of patient harm. The goals of this quality improvement (QI) project were to increase technical skills and reduce procedure time among anesthesia providers during CVC placement by implementing an ultrasoundguided, simulated CVC insertion workshop. A primary benefit of simulation-based education is the provision of a safe learning environment-one in which learners and providers may practice and increase skillsets. This QI project utilized a pretest-posttest design for which anesthesia providers completed a CVC insertion educational session and three formally evaluated simulated CVC placements: preworkshop, immediate postworkshop, and 3 months postworkshop. CVC insertion skills were evaluated by two experienced raters who established interrater reliability using a validated checklist and recorded procedure time in minutes. When comparing preworkshop median checklist score (33.74/52 [65%]), significant improvement was found in the immediate postworkshop (46.32/52 [89%]) and 3-month follow-up (44.26/52 [85%]). Time for CVC insertion significantly improved immediately postworkshop (15.7 minutes) and 3-month follow-up (15.9 minutes) when compared with preworkshop (21.5 minutes). An ultrasound-guided CVC simulation workshop can appreciably advance anesthesia providers' technical skills and decrease procedure time when performing insertion of a simulated internal jugular CVC.

Design and Validation of a Simulation Scenario and Assessment Tool: A Pilot Project.

In 2016, the National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA) launched a Continued Professional Certification (CPC) Program to promote lifelong learning and to facilitate ongoing professional competency checks for practicing certified registered nurse anesthesiologists (CRNA). The use of simulation-based assessment is currently being studied by the NBCRNA for potential use in the CPC Program. The aim of the pilot project was to create and validate simulation scenarios and assessment tools for potential incorporation into the CPC Program. Using the modified Delphi method, an expert panel of eight CRNAs evaluated the validity of four simulation scenarios and the content validity and reliability of four scenario-specific assessment tools. Each of the eight individual surveys assessing simulation scenario validity and assessment tool validity reached ≥ 75% agreement among the expert panelists. Overall content validity index values for the four assessment tools ranged from 0.960 to 0.993. There was a direct relationship between panelists' scores and level of performance on all returned assessment tools. The expert panel validated four simulation scenarios and four accompanying assessment tools. All scenarios and assessment tools were determined to have high content validity and reliability. Using these scenarios and assessment tools would provide unique advantages over standardized assessment methods.

The association of urbanicity and travel time with lung cancer screening utilization.

BACKGROUND: To examine 1) the rate of lung cancer screening (LCS) utilization in a large healthcare system in South Carolina; 2) associations of urbanicity and travel time with LCS utilization. METHODS: LCS-eligible patients from 2019 were identified. The outcome was LCS utilization. The exposures were zip-code level urbanicity and travel time from the centroid of zip-code area to the nearest screening site (<10,10-<20, ≥20 min). Covariates included age, sex, race, marital status, insurance, body mass index, chronic obstructive pulmonary disease, Charlson Comorbidity Index (0, 1, 2, ≥3), and zip-code level median income. Chi-square tests and logistic regressions were employed. RESULTS: The analysis included 6930 patients, among whom 1432 (20.66%) received LCS. After adjusting for covariates, living in a non-metropolitan area (adjusted odds ratio: 0.32; 95% confidence interval: 0.26-0.40) and having longer travel time (0.80 [0.65-0.98] and 0.68 [0.54-0.86] for 10-<20 and ≥20 min travel time, respectively, compared to <10 min travel time) were significantly associated with lower odds of LCS utilization. CONCLUSIONS: The LCS utilization rate of a healthcare system was about 20% in 2019. Living in non-metropolitan areas or having longer travel time to LCS site were associated with lower LCS utilization.

The SunBEAm birth cohort: Protocol design.

Background: Food allergy (FA) and atopic dermatitis (AD) are common conditions that often present in the first year of life. Identification of underlying mechanisms and environmental determinants of FA and AD is essential to develop and implement effective prevention and treatment strategies. Objectives: We sought to describe the design of the Systems Biology of Early Atopy (SunBEAm) birth cohort. Methods: Funded by the National Institute of Allergy and Infectious Diseases (NIAID) and administered through the Consortium for Food Allergy Research (CoFAR), SunBEAm is a US population-based, multicenter birth cohort that enrolls pregnant mothers, fathers, and their newborns and follows them to 3 years. Questionnaire and biosampling strategies were developed to apply a systems biology approach to identify environmental, immunologic, and multiomic determinants of AD, FA, and other allergic outcomes. Results: Enrollment is currently underway. On the basis of an estimated FA prevalence of 6%, the enrollment goal is 2500 infants. AD is defined on the basis of questionnaire and assessment, and FA is defined by an algorithm combining history and testing. Although any FA will be recorded, we focus on the diagnosis of egg, milk, and peanut at 5 months, adding wheat, soy, cashew, hazelnut, walnut, codfish, shrimp, and sesame starting at 12 months. Sampling includes blood, hair, stool, dust, water, tape strips, skin swabs, nasal secretions, nasal swabs, saliva, urine, functional aspects of the skin, and maternal breast milk and vaginal swabs. Conclusions: The SunBEAm birth cohort will provide a rich repository of data and specimens to interrogate mechanisms and determinants of early allergic outcomes, with an emphasis on FA, AD, and systems biology.

The Genetic Management Clinic: Oncology Nurses and Management of Hereditary Cancer Risk.

Integrating clinics designed to manage hereditary cancer risk into oncology care models has the potential to improve navigation of individuals predisposed to increased cancer risk through risk-reducing education, as well as recommendations for cancer screening and surveillance. Oncology nurses have the unique opportunity and optimal position to navigate patients through the complex subject of genetics and hereditary cancer syndromes. Effectively and efficiently navigating patients with pathogenic variants to minimize and manage hereditary cancer risk has the potential to improve patient outcomes.

Mobile Cricothyrotomy Simulation Cart Improves Anesthesia Providers' Confidence, Technical Skills, and Procedure Time.

Cricothyrotomy is an invasive airway used in "cannot intubate, cannot ventilate" events and can be taught using simulation. A mobile cricothyrotomy simulation for 66 anesthesia providers included an initial cricothyrotomy attempt (pretest), education, practice and feedback, and a second cricothyrotomy attempt (posttest). Provider confidence, skills, and procedure time were measured. Comparison of the posttest to the pretest showed significant improvement in: (a) provider confidence scores (Z = 7.01, P < .001), (b) technical skills (Global Rating Scale for Cricothyrotomy: Z = 7.05, P <.001; Checklist for Cricothyrotomy Performance: Z = 7.07, P < .001), and (c) procedure time (Z = 2.68, P = .007). The mobile cricothyrotomy simulation significantly improved anesthesia providers' confidence, cricothyrotomy skills, and procedure time.