Improving Postanesthesia Care Unit (PACU) Delays: A Quality Improvement Project.

PURPOSE: Delays within the postanesthesia care unit (PACU) are a major cause of complications and inefficiency. In this project, we investigated the factors associated with delays in the PACU and implemented policies to mitigate these factors. DESIGN: A quality improvement project. METHODS: Data were collected for 10 months and included 1,134 surgical patients in a tertiary Obstetrics and Gynecology hospital in Kuwait. Several meetings were held with stakeholders to identify and overcome the reasons contributing to delays within the PACU. FINDINGS: Among the top reasons for PACU delay were manpower shortage and lack of bed availability in the surgical wards due to improper admission and discharge policies. Policies were implemented to improve admission policy, hasten patient discharge, and improve patient flow through the operating theater (OT). These policies lead to a significant reduction (25 minutes) in the average time patients spend in the OT, mainly by reducing the stay in the PACU by 19 minutes. CONCLUSIONS: PACU delays were mostly due to reasons outside the OT. Further, follow-up is needed to assess the sustainability of these improvements and identify any new challenges that may arise.

The Scheduling Mode of Anesthesia Nurses Affects Postanesthesia Care Unit Efficiency: A Single-Center Retrospective Study From China.

PURPOSE: Anesthesia nurses play an important postsurgical role during the anesthesia recovery period, which is characterized by a high incidence of complications related to anesthesia and surgery. Strengthening staff allocation and skill management in the postanesthesia care unit (PACU) is therefore particularly important in managing length of stay. We aimed to investigate the effect of two schedule modes for anesthesia nurses on PACU efficiency. DESIGN: A retrospective observational cohort study. METHODS: We conducted a retrospective study in a large tertiary academic medical center. In 2018, the PACU operated with traditional scheduling and the nurse-to-patient ratio was 1.2:1. The PACU implemented intensive scheduling and this ratio was adjusted to 1:1 in 2019 by adjusting the anesthesia nurse allocation scheme. We compared the number of admitted patients, length of PACU stay, the incidence of anesthesia-related complications, and nurse satisfaction with the two modes. FINDINGS: The total number of admitted patients was 10,531 in 2018 and 10,914 in 2019. PACU admitted 401 more patients in 2019 than in 2018, even with two fewer nurses per day. Nevertheless, the median length of PACU stay in 2019 was statistically significantly shorter than in 2018 (29 [22-40] vs 28 [21-39], P < .001], while the incidence of anesthesia-related complications including postoperative pain, nausea and vomiting, hypertension, and shivering were comparable in the 2 years (P > .091). The intensive scheduling implemented in 2019 received more satisfaction from nurses than the traditional scheduling applied in 2018 (P < .01). CONCLUSIONS: The scheduling of anesthesia nurses affects PACU efficiency. The intensive scheduling mode implemented in 2019 resulted in a comparable number of admitted patients, a better quality of care, and higher nurse satisfaction than those under the traditional scheduling mode.

Pain Predictors in Patients in the Postanesthesia Care Unit.

PURPOSE: To analyze the effects of pain-predicting factors on patients in the postanesthesia care unit (PACU). DESIGN: This is an observational and prospective study. METHODS: This study was conducted at a University Hospital in the state of Minas Gerais (Brazil). To collect data on demographic, clinical, and surgical factors, a collection instrument was devised. The verbal numerical scale was employed to measure pain levels before and after surgery in the PACU. A path analysis was used to assess a predictive model. FINDINGS: A total of 226 patients were included in this study. The incidence of pain in the PACU was 31.9%. A model with demographic, clinical, and surgical variables was tested. The final model, after including modification indices, obtained results that indicated an acceptable data fit (comparative fit index = 0.996; root mean square error of approximation = 0.08). Age (being young), sex (being a woman), oncological diagnosis as an indication for the surgical procedure, type of surgery (surgery of the digestive system), duration of surgery (longer surgeries), and high intraoperative doses of opioids were predictive variables for pain in the PACU. CONCLUSIONS: This study's findings provide support for pain management in the PACU. Furthermore, the results of this research can be used to anticipate the occurrence of acute postoperative pain and personalized perioperative analgesia needs.

Effect of Interpectoral-Pectoserratus Plane (PECS II) Block on Recovery Room Discharge Time in Breast Cancer Surgery.

Background and Objectives: The increase in the incidence and diagnosis rate of breast cancer demands the optimization of resources. The aim of this study was to assess whether the supplementation of the interpectoral-pectoserratus plane block (PECS II) reduces surgery and post-anesthesia care unit (PACU) time in patients undergoing breast cancer surgery. Materials and methods: This was a retrospective data-analysis study. In 2016, PECS II block was introduced as a supplement to general anesthesia for all mastectomies with or without axillary resections in South Jutland regional hospital, Denmark. The perioperative data of patients operated 3 years before and 3 years after 2016 was retrieved through the Danish anesthesia database and patient journals and systematically analyzed. Female patients aged over 18 years, with no use of muscle relaxant, intubation, and inhalation agents, were included. The eligible data was organized into two groups, i.e., Block and Control, where the Block group received PECS II Block, while the Control group received only general anesthesia. Parameters such as surgery time, anesthesia time, PACU time, opioid consumption, and the incidence of postoperative nausea and vomiting (PONV) in PACU were retrieved and statistically analyzed. Results: A total of 172 patients out of 358 patients met eligibility criteria. After applying exclusion criteria, 65 patients were filtered out. A total of 107 patients, 51 from the Block and 56 from the Control group, were eligible for the final analysis. The patients were comparable in demographic parameters. The median surgery time was significantly less in the Block group (78 min (60-99)) in comparison to the Control group (98.5 min (77.5-139.5) p < 0.0045). Consequently, the median anesthesia time was also shorter in the Block group (140 min (115-166)) vs. the Control group (160 min (131.5 to 188), p < 0.0026). Patients from the Block group had significantly lower intraoperative fentanyl consumption (60 µg (30-100)) as compared with the Control group (132.5 µg (80-232.5), p < 0.0001). The total opioid consumption during the entire procedure (converted to morphine) was significantly lower in the Block group (16.37 mg (8-23.6)) as compared with the Control group (31.17 mg (16-46.5), p < 0.0001). No statistically significant difference was found in the PACU time, incidences of PONV, and postoperative pain. Conclusions: The interpectoral-pectoserratus plane (PECS II) block supplementation reduces surgery time, anesthesia time, and opioid consumption but not PACU time during breast cancer surgery.

Machine Learning-Based Models Predicting Outpatient Surgery End Time and Recovery Room Discharge at an Ambulatory Surgery Center.

BACKGROUND: Days before surgery, add-ons may be scheduled to fill unused surgical block time at an outpatient surgery center. At times, outpatient surgery centers have time limitations for end of block time and discharge from the postanesthesia care unit (PACU). The objective of our study was to develop machine learning models that predicted the following composite outcome: (1) surgery finished by end of operating room block time and (2) patient was discharged by end of recovery room nursing shift. We compared various machine learning models to logistic regression. By evaluating various performance metrics, including F1 scores, we hypothesized that models using ensemble learning will be superior to logistic regression. METHODS: Data were collected from patients at an ambulatory surgery center. The primary outcome measurement was determined to have a value of 1 (versus 0) if they met both criteria: (1) surgery ends by 5 pm and (2) patient is discharged from the recovery room by 7 pm. We developed models to determine if a procedure would meet both criteria if it were scheduled at 1 pm, 2 pm, 3 pm, or 4 pm. We implemented regression, random forest, balanced random forest, balanced bagging, neural network, and support vector classifier, and included the following features: surgery, surgeon, service line, American Society of Anesthesiologists score, age, sex, weight, and scheduled case duration. We evaluated model performance with Synthetic Minority Oversampling Technique (SMOTE). We compared the following performance metrics: F1 score, area under the receiver operating characteristic curve (AUC), specificity, sensitivity, precision, recall, and Matthews correlation coefficient. RESULTS: Among 13,447 surgical procedures, the median total perioperative time (actual case duration and PACU length stay) was 165 minutes. When SMOTE was not used, when predicting whether surgery will end by 5 pm and patient will be discharged by 7 pm, the average F1 scores were best with random forest, balanced bagging, and balanced random forest classifiers. When SMOTE was used, these models had improved F1 scores compared to no SMOTE. The balanced bagging classifier performed best with F1 score of 0.78, 0.80, 0.82, and 0.82 when predicting our outcome if cases were to start at 1 pm, 2 pm, 3 pm, or 4 pm, respectively. CONCLUSIONS: We demonstrated improvement in predicting the outcome at a range of start times when using ensemble learning versus regression techniques. Machine learning may be adapted by operating room management to allow for a better determination whether an add-on case at an outpatient surgery center could be appropriately booked.

Cell Phone Use in the Post Anesthesia Care Unit Best Practice Project.

PURPOSE: Each year cell phones have evolved in capability and sophistication enticing society to become more dependent on them. Presently, our hospital policy states there is no cell phone use allowed in the postanesthesia care unit (PACU) for patients or family members. However, given the almost addictive use of the mobile phone today, a patient connecting with family and friends during a very anxious and personally vulnerable time triggered us to re-evaluate this policy. DESIGN: This was a quality improvement project. METHODS: A literature review of published research on cell phone use in the recovery room in five databases was conducted. Two hundred seventy six articles were screened for eligibility, and seven articles were critically appraised and synthesized. FINDINGS: Evidence supported that cell phone electromagnetic radiation interference with the mechanics of the medical equipment at bedside is negated by distance. CONCLUSION: The sustainability of cell phone use in the PACU will be determined by quality indicators of patient compliance with respectfulness to the atmosphere of the quiet zone of surgery recovery bays, and satisfaction indicators of patient care not being negatively impacted.

Higher Surgery and Recovery Room Air Pressures Associated with Reduced Surgical Site Infection Risk.

BACKGROUND: Incisional surgical site infections (SSIs) following coronary artery bypass grafting (CABG) prolong hospital stays, elevate healthcare costs and increase likelihood of further complications. High air pressure deactivates bacteria and is utilized for commercial food preservation, assuring microbiologically safe pharmaceuticals and sanitizing instruments. However, research on utilizing air pressure deactivation thresholds in surgical and postoperative rooms to reduce rates of SSIs is lacking. METHODS: A case-control study of 801 CABG patients, 128 SSI cases and 673 controls was conducted from January 1, 2006 through March 31, 2009 in Yerevan, Armenia. Patient and surgery characteristics, air pressure measurements and seasons were selected as independent variables with SSI rates as the outcome. The novel threshold regression analysis was used to determine potential air pressure bacterial deactivation thresholds. A final multivariate logistic regression model adjusted for confounders. RESULTS: Overall, bacterial deactivation air pressure threshold was 694.2 mmHg, with the presence of infection for higher air pressure values not statistically significant from zero. Individual deactivation thresholds for Staphylococcus epidermidis (threshold = 694.2 mmHg) and Escherichia coli (threshold = 689.2) showed similar patterns. Multivariate logistic regression showed air pressure above the deactivation threshold was highly protective against SSIs with adjOR = 0.27 (p-value = 0.009, 95%CI: 0.10-0.72). Other SSI risk factors included female sex, adjOR = 2.12 (p-value = 0.006, 95%CI: 1.24-3.62), diabetes, adjOR = 2.61 (p-value < 0.001, 95%CI: 1.72-3.96) and longer time on ventilator, adjOdds = 1.01 (p-value = 0.012, 95%CI: 1.00-1.02). CONCLUSION: Maintaining air pressures in operating and postoperative rooms exceeding bacterial-deactivation thresholds might substantially reduce SSI rates following surgery. Further research should identify specific bacterial-deactivation air pressure thresholds in surgical and postoperative rooms to reduce SSI rates, especially for drug-resistant bacteria.

The effect of advanced recovery room care on postoperative outcomes in moderate-risk surgical patients: a multicentre feasibility study.

Postoperative complications are common and may be under-recognised. It has been suggested that enhanced postoperative care in the recovery room may reduce in-hospital complications in moderate- and high-risk surgical patients. We investigated the feasibility of providing advanced recovery room care for 12-18 h postoperatively in the post-anaesthesia care unit. The primary hypothesis was that a clinical trial of advanced recovery room care was feasible. The secondary hypothesis was that this model may have a sustained impact on postoperative in-hospital and post-discharge events. This was a multicentre, prospective, feasibility before-and-after trial of moderate-risk patients (predicted 30-day mortality of 1-4%) undergoing non-cardiac surgery and who were scheduled for postoperative ward care. Patients were managed using defined assessment checklists and goals of care in an advanced recovery room care setting in the immediate postoperative period. This utilised existing post-anaesthesia care unit infrastructure and staffing, but extended care until the morning of the first postoperative day. The advanced recovery room care trial was deemed feasible, as defined by the recruitment and per protocol management of > 120 patients. However, in a specialised cancer centre, recruitment was slow due to low rates of eligibility according to narrow inclusion criteria. At a rural site, advanced recovery room care could not be commenced due to logistical issues in establishing a new model of care. A definitive randomised controlled trial of advanced recovery room care appears feasible and, based on the indicative data on outcomes, we believe this is warranted.

Association of dexmedetomidine with recovery room and hospital discharge times: A retrospective cohort analysis.

BACKGROUND: Dexmedetomidine is a useful anesthetic adjunct, increasingly popular during pediatric surgery and procedural sedation. Its half-life of 2-3 hours might prolong recovery and discharge times when compared with an un-supplemented propofol anesthetic. This may create an additional burden in a busy post-anesthetic care unit (PACU). AIM: To investigate whether intraoperative adjuvant dexmedetomidine delays PACU discharge in patients undergoing propofol anesthesia for day surgery or procedural investigations with minimal anticipated post-procedural pain. METHODS: We conducted a retrospective review of outpatient procedures performed during a six-month period including pediatric patients, ASA physical status I-III, who underwent intravenous anesthesia with propofol and remifentanil for magnetic resonance imaging (MRI), strabismus repair, upper gastrointestinal endoscopy, or combined upper/lower gastrointestinal endoscopy. Patients receiving a sedative premedication, long-acting opioids, or volatile anesthetics for maintenance of anesthesia, were excluded. Duration of PACU stay was compared for patients who did or did not receive intraoperative dexmedetomidine in the four procedure groups. RESULTS: Charts were reviewed for 359 patients; 130 (36%) received dexmedetomidine. Median differences in duration of PACU stay for dexmedetomidine versus non-dexmedetomidine cases were: 5 minutes (95%CI 0 to 10, p=0.037) for MRI; 5 minutes (95%CI -3 to 15, p=0.258) for strabismus surgery; 7 minutes (95%CI 3 to 10, p<0.001) for upper endoscopy; and 5 minutes (95%CI 1 to 12, p=0.021) for combined upper/lower endoscopy. Linear regression (F=61.1, adjusted R2 =0.40) indicated a significant relationship between dexmedetomidine dose (estimate 14.6 minutes per µg/kg, 95%CI 8.2 to 21.1, p<0.001) and duration of PACU stay. CONCLUSION: We found evidence for a small association of intraoperative dexmedetomidine with duration of recovery from propofol anesthesia for a set of common outpatient procedures, with a potential dose relationship equivalent to approximately 15 minutes delay per µg/kg dexmedetomidine administered. Future research into the benefits of dexmedetomidine in pediatric anesthesia should further evaluate this relationship.

Sugammadex Reduces PACU Recovery Time after Abdominal Surgery Compared with Neostigmine.

OBJECTIVE: This study blindly evaluated sugammadex compared with neostigmine on length of stay in the postanesthesia care unit (PACU). METHODS: Fifty patients undergoing elective laparoscopic cholecystectomy or abdominal wall hernia repair consented to receive either sugammadex (2 mg/kg) or neostigmine (0.07 mg/kg) for the reversal of rocuronium neuromuscular blockade. Reversal agents were administered during surgical closing, and the train of four was measured until a twitch ratio of T4:T1 ≥ 0.9 was obtained to signify a robust reversal. Postreversal outcomes also were measured during PACU stay. Aldrete scores, pain visual analog scale score, and nausea were measured during the PACU stay. RESULTS: Patients receiving sugammadex experienced a shorter PACU stay at the time of discharge than patients receiving neostigmine, by an average of 12 minutes (P < 0.05). CONCLUSIONS: Sugammadex patients had a significantly shorter PACU stay.

[Complications and emergencies in the recovery room]. / Komplikationen und Notfälle im Aufwachraum.

The recovery room as a central monitoring unit plays a crucial role in the perioperative care of patients. Here, the patient is monitored until the subsequent transfer to a further care ward; however, due to the previous anesthesia and surgery the recovery room also provides a high risk for (the development of) complications. The present article provides an overview of the most frequent complications to be expected in the recovery room (in adults), the diagnostics and the acute treatment.

Fast-Tracking Patients in an Academic Hospital to Increase Efficiency and Decrease Discharge Delays: A Process Improvement Plan.

PURPOSE: The purpose of this quality improvement project was to determine if implementing a Phase II postanesthesia care unit (PACU II) to fast-track patients following surgery in an academic hospital would decrease OR hold times and increase patient flow efficiency. DESIGN: An observational pre-post design was used to compare PACU bypass rates and recovery times for ambulatory surgery (AS) patients before and after implementation of a patient fast-tracking program. METHODS: A PACU II was instituted and a fast-tracking program using the White Fast-Track Scoring tool was adopted. Nursing staff as well as anesthesia providers were educated to assess patients using the tool as well as the appropriate patient population to be transferred to the new PACU II. FINDINGS: Following implementation of the new unit and the fast-tracking program, a PACU bypass rate of 30% was achieved and there was a significant decrease in PACU length of stay for AS patients. CONCLUSIONS: The results suggest that fast-tracking is a suitable intervention to decrease inefficiencies in an academic setting despite higher acuity patient populations.

Balancing Workload in the PACU by Using an Integrated OR Planning Methodology.

PURPOSE: The individual scheduling of the operating rooms (ORs) has a significant influence on postoperative care at hospital facilities. We studied the effect of incorporating postoperative departments in the decision process with regard to scheduling ORs and developed an integrated OR planning methodology that determines an optimal surgery sequence and postanesthesia care unit (PACU) nursing staff level, with the objective to level the variability in inflow of patients in the PACU. DESIGN: We developed an integrated OR planning methodology that investigates the sequencing of a surgical suite process with multiple ORs and postoperative hospital facilities. METHODS: This research was performed by representing a discrete-time two-stage flow shop problem. A retrospective study was performed in which the derived model was validated using discrete-event simulation. FINDINGS: Simulation results show that applying the integrated planning methodology decreased the variability in bed demand and smoothed the workload for the nursing staff in the PACU. Moreover, applying the algorithm led to a decrease in PACU completion time and a reduced amount of overtime hours for the surgical suite. Based on our results, we derived simple scheduling guidelines. CONCLUSIONS: Our simulation results confirmed the hypothesis that prospectively sequencing ORs' cases can effectively decrease the variability in bed demand and smoothen the workload for the staff personnel. Moreover, applying the algorithm leads to a decrease in PACU completion time and less overtime hours for the surgical suite. As such, an integrated OR planning methodology facilitates hospitals in improving OR efficiency.

Increased Patient Satisfaction in the Postanesthesia Care Unit with the Implementation of a Controlled Noise Reduction Program.

PURPOSE: Noise in the postanesthesia care unit (PACU) is a significant source of postoperative patient discomfort and can affect patient sleep and recovery. Interventions involving structural alterations in the environment reduce noise and improve patient satisfaction; however, there are no studies focusing on staff education as a method to reduce PACU noise. DESIGN: We designed and implemented a prospective PACU noise reduction program using education and training to minimize staff contributions to noise. METHODS: Noise levels, measured hourly with a decibel meter, patient satisfaction, and patient rest were assessed before and after implementation. FINDINGS: We found statistically significant decreases in noise levels and increases in patient satisfaction scores after the implementation of our noise reduction project. CONCLUSIONS: These findings demonstrate that an inexpensive and easily implemented noise reduction program can effectively reduce environmental noise, increase patient satisfaction, and potentially improve recovery.

[Contribution of a hospital pharmacy team to critical care of patients infected with SARS-CoV-2]. / Contribution d'une équipe de pharmacie hospitalière à la prise en charge en réanimation des patients infectés par le SARS-CoV-2.

With regard to the hospital drug supply chain, the safest system is the individual automated drug dispensing one provided by the pharmacy. For several years we have been trying to convince hospital decision-makers to set it up. In the meantime, to mitigate the risks of medication errors incurred by patients and caregivers, we have set up several work teams within the care units. These teams, made up of one pharmacist and one or two hospital pharmacy technicians, who notably manage the medicine cabinets in care units. The close collaboration with doctors and nurses developed over the years was a determining factor when it became necessary to provide the newly created additional intensive care units with drugs and medical devices (MDs) in order to cope with the crisis triggered by the SARS-CoV-2 epidemic. Daily monitoring of the drugs consumed by each patient, particularly neuromuscular blocking agents and MDs was a key element in managing stocks and anticipating changes of drugs, packaging and/or devices references. These facts give weight to the Claris report published in France which recognizes that the interactions of pharmacy technicians and pharmacists in the care units have positive effects in terms of quality and safety of patient care. They highlight the dangers to which patients and caregivers are exposed on Saturdays, Sundays and holidays when the pharmacy is closed. They legitimize the question of extending the opening of the pharmacy with a full team 365 days a year.

Risks associated with pathogenic fungi isolated from surgical centers, intensive care units, and materials sterilization center in hospitals. Risks associated with pathogenic fungi isolated from critical hospital areas.

The hospital environment requires special attention to air quality, since it needs to be healthy for the protection of patients and health professionals in order to prevent them against hospital infections. The objective of this study was to isolate, identify and evaluate the susceptibility profile of isolated fungi from two hospitals. For air sampling the impaction (Spin Air, IUL®) and passive sedimentation methods were used. For the isolation of fungi from surfaces, contact plates (RODAC®) were used. The identification of the fungi was performed by observing the macroscopic and microscopic aspects of the colonies, whereas for better visualization of fruiting structures, the microculture technique was performed on slides. To evaluate the susceptibility profile, the broth microdilution test recommended by CLSI was performed. Thirty-five isolates were identified: Aspergillus flavus (12), Aspergillus fumigatus (11), Aspergillus niger (1), Aspergillus terreus (2), Penicillium spp. (7), and Fusarium spp. (2) in the hospitals evaluated. All isolates had a minimum inhibitory concentration (MIC) more than 128 µg/ml for fluconazole; 0.5 to 4.0 µg/ml for amphotericin B (hospital 1), and all isolates from haospital 2 had MIC ≥2.0 µg/ml. In hospital 1, MIC for posaconazole ranged from 0.25 µg/ml to ≥32 µg/ml, and hospital 2 ranged from 0.5 to 1.0 µg/ml. The monitoring and evaluation of air quality and surfaces are essential measures for prevention and control of hospital infections, as these microorganisms are becoming increasingly resistant to antimicrobial agents, thus making treatment difficult, especially in immunocompromised individuals.

Efficiency and efficacy of planning and care on a post-anesthesia care unit: a retrospective cohort study.

BACKGROUND: In the post-anesthesia care unit in our hospital, selected postoperative patients receive care from anesthesiologists and nursing staff if these patients require intensive hemodynamic monitoring or treatment to stabilize vital functions (e.g., vasopressor use and mechanical ventilation support) during a one-night admission. We investigated the agreement between elective preoperative planning for post-anesthesia care unit admission and the postoperative reality, along with the consequences of planning failures. METHODS: Data from records for 479 consecutive patients from June 1 to November 30, 2014, in a tertiary referral hospital were reviewed and analyzed. All patients admitted to PACU were included, along with patients scheduled to be referred to PACU but ultimately transferred to another ward. The primary outcome was the efficiency of planning PACU admission for elective patients. Secondary outcomes included secondary admissions to PACU or the intensive care unit (ICU) and 30-day morbidity and mortality. RESULTS: Of the 479 included patients, 342 (71%) were admitted per preoperative planning. Five patients (1%) needed cardiopulmonary resuscitation, and six (1%) did not survive the follow-up period. Patients admitted to PACU because of a shortage of beds in the ICU had the highest readmission (20%) and mortality rates (20%) (P = 0.01). CONCLUSIONS: Preoperative planning for PACU admission was off-target for 29%. However, efficient care always takes precedence over efficient planning. In particular, downgrading patients to PACU because of a shortage of beds in the ICU was associated with a mortality increase.

Computerized 4-choice reaction time test for the measurement of psychomotor recovery after general anesthesia.

The recovery of patients after general anesthesia is usually estimated by using clinical scores. Since there is a lack of objective methods for assessing psychomotor recovery, the aim of this study was to evaluate three psychological tests for this purpose. Patients, scheduled for ambulatory gynecological surgery, underwent 3 standard psychological tests before (T1), 15 min after the surgery (T2) and on discharge from the recovery room (T3). The tests used were Wechsler memory scale (test 1, working memory capacity), d2-test (test 2, concentration endurance) and computer-based 4-choice-reaction time (4CRT, test 3, reaction time) as well as Postanesthesia Discharge Scoring System (PADSS). The same test battery was used in healthy female volunteers, all test results were compared at the different time points. In 109 patients, working memory capacity and concentration (tests 1 and 2) decreased, the reaction time (test 3) was prolonged at T2 in comparison with T1 and T3 (P < 0.01). PADSS increased from 8 (T2) to 10 (T3) (medians, P < 0.001). Fifty-seven healthy volunteers demonstrated a practice effect in all 3 tests through the course of the study (P <0.01). 4CRT test had shortest duration and enabled computerized data processing. All three tests objectively assess the recovery of psychomotor function in patients after general anesthesia, the computer-based 4CRT seems to be the most convenient for the clinical routine.

Continuous hemoglobin and plethysmography variability index monitoring can modify blood transfusion practice and is associated with lower mortality.

To determine the effect of implementing an algorithm of fluid and blood administration based on continuous monitoring of hemoglobin (SpHb) and PVI (plethysmography variability index) on mortality and transfusion on a whole hospital scale. This single-center quality program compared transfusion at 48 h and mortality at 30 days and 90 days after surgery between two 11-month periods in 2013 and 2014 during which all the operating and recovery rooms and intensive care units were equipped with SpHb/PVI monitors. The entire team was trained to use monitors and the algorithm. Team members were free to decide whether or not to use devices. Each device was connected to an electronic wireless acquired database to anonymously acquire parameters on-line and identify patients who received the monitoring. All data were available from electronic files. Patients were divided in three groups; 2013 (G1, n = 9285), 2014 without (G2, n = 5856) and with (G3, n = 3575) goal-directed therapy. The influence of age, ASA class, severity and urgency of surgery and use of algorithm on mortality and blood use were analyzed with cox-proportional hazard models. Because in 2015, SpHb/PVI monitors were no longer available, we assessed post-study mortality observed in 2015 to measure the impact of team training to adjust vascular filling on a patient to patient basis. During non-cardiac surgery, blood was more often transfused during surgery in G3 patients as compared to G2 (66.6% vs. 50.7%, p < 0.001) but with fewer blood units per patient. After adjustment, survival analysis showed a lower risk of transfusion at 48 h in G3 [OR 0.79 (0.68-0.93), p = 0.004] but not in G2 [OR 0.90 (0.78-1.04) p = 0.17] as compared to G1. When adjusting to the severity of surgery as covariable, there was 0.5 and 0.7% differences of mortality at day 30 and 90 whether patients had goal directed therapy (GDT). After high risk surgery, the mortality at day 30 is reduced by 4% when using GDT, and 1% after intermediate risk surgery. There was no difference for low risk surgery. G3 Patients had a lower risk of death at 30 days post-surgery [OR 0.67 (0.49-0.92) p = 0.01] but not G2 patients [OR 1.01, (0.78-1.29), p = 0.96]. In 2015, mortality at 30 days and 90 days increased again to similar levels as those of 2013, respectively 2.18 and 3.09%. Monitoring SpHb and PVI integrated in a vascular filling algorithm is associated with earlier transfusion and reduced 30 and 90-day mortality on a whole hospital scale.

Effect of postoperative partial bladder filling after minimally invasive hysterectomy on postanesthesia care unit discharge and cost: a single-blinded, randomized controlled trial.

BACKGROUND: Hysterectomy is one of the most common surgical procedures performed each year with substantial related health care costs. This trial studied the effect of postoperative bladder backfilling to submicturition level in the operating room and its effect on early postoperative patient care and related cost. OBJECTIVE: The objective of the study was to compare the effect of bladder backfilling on early postoperative patient care and related cost. STUDY DESIGN: This was a randomized, single-blinded, controlled trial conducted between April 2016 and February 2017 at a single urban university hospital providing tertiary care for minimally invasive gynecologic surgery. Ninety-one patients undergoing straight-stick laparoscopic and robot-assisted hysterectomy by minimally invasive gynecologic surgeons for benign indications were recruited. The bladder was partially backfilled with 150 mL of normal saline postoperatively in the intervention group and drained in the control group, as per standard of care. Main outcomes studied were time needed to void, time spent in the postanesthesia care unit, and postanesthesia care unit cost after minimally invasive hysterectomy. Our secondary outcomes were postoperative complications. RESULTS: Forty-six patients (50.5%) were randomized to the intervention group, and 45 patients (49.5%) to the control group. Baseline comparative analysis of demographics and preoperative patient-specific variables, surgical history, intraoperative characteristics, and administered medications found the 2 groups to be largely homogenous. After regression analyses for adjustment, we found a significant reduction in the time needed to void, time spent in the postanesthesia care unit, and postanesthesia care unit-associated cost in the intervention group. Patients voided 64.9 minutes earlier than the control group (P = .015) ans spent 64 fewer minutes in the postanesthesia care unit (P = .006), resulting in $401.5 (USD) saving per patient (P = .006). None of the patients encountered any postoperative complications. CONCLUSION: Based on the findings of this randomized clinical trial, postoperative bladder backfilling to submicturition level shortens the time needed for patients to void in the postanesthesia care unit, resulting in shorter postanesthesia care unit stay and resultant cost savings. Conservatively projecting our findings on minimally invasive hysterectomy procedure is estimated to result in $69 million to $139 million (USD) per year in savings. Initiating similar investigations in other ambulatory surgical fields will likely result in a more substantial impact.