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INTRODUCTION: The environmental impact of inhaled anesthetics is a subject of increasing research. However, little attention has been paid to optimizing high-concentration volatile anesthetics during the inhalational (mask) inductions that begin most pediatric anesthetics. METHODS: The performance of the GE Datex Ohmeda TEC 7 sevoflurane vaporizer was analyzed at different fresh gas flow (FGF) rates and two clinically relevant ambient temperatures. We found that an FGF rate of 5 liters per minute (LPM) is likely optimal for inhalational inductions, rapidly achieving dialed sevoflurane concentrations at the elbow of an unprimed pediatric breathing circuit while minimizing waste associated with higher FGF rates. We began educating our department regarding these findings, first with QR code labels on anesthetic workstations, then with targeted e-mails to pediatric anesthesia teams. We analyzed peak induction FGF in 100 consecutive mask inductions at our ambulatory surgery center at three different periods - baseline, post-labels, and post-emails - to assess the efficacy of these educational interventions. We also analyzed the time from induction to the start of myringotomy tube placement in a subset of these cases to determine if reducing mask induction FGF was associated with any change in the speed of induction. RESULTS: Our institution's median peak FGF during inhalational inductions decreased from 9.2 LPM at baseline to 8.0 LPM after labels were placed on anesthetic workstations to 4.9 LPM after targeted e-mails. There was no associated decrease in the speed of induction. CONCLUSION: Total fresh gas flow can be limited to 5 LPM during pediatric inhalational inductions, decreasing anesthetic waste and environmental impact without slowing the speed of induction. Educational labels on anesthetic workstations and direct e-mails to clinicians were effectively used in our department to enact change in this practice.
RESUMO
INTRODUCTION: Referral rates and patterns to specialists by family physicians have a significant impact on numerous aspects of medical care, including the quality and cost of care provided. The aim of this study was to examine the referral rate and pattern of family physician practices associated with a large academic health center. METHODS: We conducted a retrospective chart review of referrals for patients seen in the family medicine clinics associated with a large academic institution. Basic demographic information was collected. The primary outcome was the monthly referral rate, measured as the proportion of patient visits that resulted in a consult to a specialist outside of the referring family medicine clinic. Binomial and γ generalized linear mixed models were fit to determine the associations between high/medium/low referral rate clinics and patient demographics. RESULTS: The average monthly referral rate for all of the clinics was 20.3%, and the rate varied significantly between clinic groups. Patient gender, race, and being in a committed relationship were noted to be associated with lower referral rate. DISCUSSION: Referral rates among family physician practices differ widely and are associated with gender, race, and relationship status of patients. Referrals to several specific specialties are common among family physicians.