Using a Retrospective Secondary Data Analysis to Identify Risk Factors for Pulmonary Complications in Trauma Patients in Pietermaritzburg, South Africa.

BACKGROUND: The trauma burden in South Africa is significant. The objective of this project was to investigate the incidence of posttrauma pulmonary complications (PPCs) and to identify patient, health risks, and hospital factors, which predispose trauma patients to develop PPCs hospital in Pietermaritzburg, South Africa. METHODS: The design was a retrospective secondary data analysis of patients who presented as a trauma admission via the health systems' Hybrid Electronic Medical Registry. The final data set included 6382 trauma admissions. RESULTS: The PPC rate was 9.4% for patients with a surgical intervention versus 1.9% for those without a surgical intervention. Of the total 289 PPCs reported, the most common included pneumonia or atelectasis (46.4%) and prolonged ventilation (36.0%). The risk of developing a PPC was statistically significantly (P < 0.0001) associated with surgical intervention and the number of surgeries. CONCLUSIONS: The trauma burden in South Africa requires complex medical and surgical interventions. The incidence of PPCs is significantly associated with surgical intervention. With the increasing demand to harness data and improve patient care, the Hybrid Electronic Medical Registry proves to be a driver for quality improvement.

Improving Emergency Cricothyroidotomies: Simulation-Based Training for Critical Care Providers.

This article discusses skill proficiency of providers related to emergency cricothyroidotomies. Various techniques to improve procedural skills were studied. Accurate identification of the cricothyroid membrane via palpation remained consistently inadequate. High-fidelity simulation including the use of human cadavers may be the preferred method of skill training for crisis management. The authors emphasize that additional research is needed regarding a method for rapid cricothyroid membrane identification as well as needle cricothyroidotomy versus surgical airway on cadavers. More consistent training will enable emergency care providers to perform this rare but lifesaving skill.

Considerations for an aging nurse anesthetists workforce.

The Certified Registered Nurse Anesthetists (CRNA) workforce is aging. It is estimated that nearly half (49.7%) of the CRNA workforce is age 50 or greater, with those practicing in management positions and as educators having the oldest mean ages. Older CRNAs face workplace challenges that can lead to decreased productivity and overall job satisfaction. Common injuries to older practitioners result from repetitive motion, slips and falls, needle sticks, fatigue, and emotional or mental health related illness. Because of the high acuity environment in which CRNAs practice they are at an elevated risk for these injuries. Creating a healthy and supportive work environment has been shown to improve the retention of aging healthcare workers, and succession planning is essential in preparing for their retirement.

A historical look at men's involvement in nursing and leadership in GAPNA.

The role of men in nursing is not always evident. Men have been care takers in early societies, military health care, and the religious sector. The perception of men in nursing, however, took a shift from one of honor to one of deviance and failure from medical school. As the contributions of historical men in nursing, such as Walt Whitman, are brought to light, so are the contributions of select men within the Gerontological Advanced Practice Nurses Association (GAPNA). Dr. George Peraza-Smith provides an exclusive interview, shares his dedication and contributions to the care of the aging adult, and provides words of wisdom to those wanting to impact the care of geriatric nursing.

Increasing Medication Access by Promoting Appropriate Use of Multi-dose Vials.

Medication shortage is a problem that affects patients, providers, and institutions of all sizes and scope across the United States. The objective of this quality improvement project was to promote the appropriate use of multi-dose vials (MDVs) by anesthesia providers at an independent plastic surgery office. Multi-dose vials can be used to decrease waste and potentially cost, thus increasing access to necessary medications for the patients at this practice. A focus group was used to obtain an understanding of barriers to the use of MDVs at this practice. A focused E-learning module on safe use based on established guidelines was then created, and a simplified flow sheet was implemented and placed in medication preparation areas as a cognitive aid. The education and flow sheet focused on identification and preparation of the medication area, proper identification of MDVs versus single-use vials, hand hygiene, proper beyond-use labeling, septum cleaning, use of a new sterile syringe and needle, and administration time frames. Provider feedback included high levels of satisfaction with the E-learning module. Our comparison of the use of ketamine from MDVs during the pre- and postimplementation phases showed a 14% increase in the number of doses used per vial. This finding suggests that were similar practices implemented at a larger site with MDVs of medications other than ketamine, resources could be impacted to manage shortages and increase access to medications.

The importance of the STOP- BANG questionnaire as a preoperative assessment tool for the elderly population.

Undiagnosed obstructive sleep apnea (OSA) may adversely impact surgical patients and can lead to increased morbidity and mortality during the perioperative period, especially among the geriatric patient population (Chung et al. 2008, 2012, 2014; McDonald et al., 2018; Zietlow et al., 2018; Singh et al., 2012). The setting of this quality improvement project was a preoperative anesthesia and geriatric evaluation clinic housed within a 957-bed tertiary academic affiliated hospital. The sample included 45 patients who met the criteria established for surgery and OSA screening preoperatively. Nine patients (20.0%) were assessed as low risk (Stop-bang [SB] score /= 3 indicative of high-risk for OSA. The retrospective utilization of a modified SB screening on charts that did not receive a clinical OSA evaluation (n = 52) detected 23 (44.2%) patients who were considered high-risk for OSA but were not identified prior to surgery. The SB questionnaire is underutilized, and patients' OSA is often unidentified prior to surgery.

Improving Emergency Airway Knowledge and Self-Efficacy Levels of Outpatient Gastroenterology Staff via Implementation of Online Education and In Situ Simulation.

Twenty percent of all ambulatory surgery cases utilizing monitored anesthesia care and sedation report at least one perioperative respiratory complication such as bronchospasm, hypoxia, laryngospasm, or aspiration (). However, the national Standards of Practice for both surgical technicians and ambulatory care nurses do not mandate emergency airway education beyond cardiopulmonary resuscitation and Basic Life Support training. A local outpatient gastroenterology clinic noticed the gap in education, and the anesthesia team decided to implement an evidence-based dual-factorial quality improvement project utilizing online education and in situ simulation. First, registered nurses and procedural technologists completed a test to assess their baseline knowledge and airway emergency performance self-efficacy levels. Then an online module was distributed that included information on the 3 most common anesthesia airway emergencies in the outpatient setting: laryngospasm, aspiration, and obstruction with resultant hypoxemia. Next, participants completed an in situ simulation of the 3 airway emergencies using low-fidelity mannequins. A post-education assessment was distributed after completion of the simulation training and again at 6 weeks and 3 months post-implementation. The data collected showed a statistically significant increase in both knowledge scores and levels of self-efficacy at 6 weeks and 3 months posteducation (p < .001).

Utilization of the STOP-Bang Questionnaire as a Standardized Screening Tool for Obstructive Sleep Apnea in Veteran Administration Surgical Patients.

PURPOSE: Obstructive sleep apnea (OSA) affects an estimated 20% of the adult surgical population. Veteran patients have many characteristics consistent with OSA, but lack of standardized screening results in decreased detection of patients at risk for OSA. DESIGN: Pre-post implementation design. METHODS: Preanesthesia clinic providers were educated about OSA and the STOP-Bang questionnaire. Chart reviews evaluating screening and patient demographics were conducted before and after intervention. FINDINGS: Thirty-one percent of patients had an established diagnosis of OSA. Compliance rates with preoperative STOP-Bang screening were 91.3%. Of patients screened preoperatively, 44% were at risk for OSA with a STOP-Bang score of 4 or greater. CONCLUSIONS: The prevalence of patients among the Veteran population with and at risk for OSA is higher than the general population. Utilization of the STOP-Bang questionnaire as a standardized preoperative screening tool in preanesthesia clinics can increase the identification of patients at risk for OSA.

Administration of Oral Acetaminophen to Reduce Costs for the Hysterectomy Patient at a Community Hospital.

PURPOSE: This quality improvement project aimed to change the practice of administration route of acetaminophen from intravenous (IV) to oral to patients having a hysterectomy at a community hospital, reduce costs, and maintain postanesthesia care unit pain scores for patients who receive oral acetaminophen comparable to those who receive IV acetaminophen. DESIGN: There were 46 participants: 23 in the preintervention group and 23 in the postintervention group. METHODS: Data retrieved from the electronic medical record included the route of acetaminophen administered, cost, and pain scores. FINDINGS: Implementation of this quality improvement project resulted in no difference in the pain scores between the preintervention and postintervention groups (P = .637). In addition, the hospital cost for acetaminophen decreased 95.25% and patients saved $6,683 during the 3-month implementation period. CONCLUSIONS: The administration of oral acetaminophen provided equivalent postoperative analgesia compared with IV acetaminophen and reduced costs for both the hospital and patients.

Using the Electronic Medical Record to Improve Preoperative Identification of Patients at Risk for Obstructive Sleep Apnea.

PURPOSE: Obstructive sleep apnea (OSA) is a breathing disorder found in surgical patients and associated with complications in the postoperative period. The implementation of a preoperative universal screening process using the STOP-BANG questionnaire to identify patients at high risk for OSA provides opportunities for improved management. DESIGN: A pre-post design was used to evaluate screening compliance rates. METHODS: This initiative included staff education, which included the process for evaluating and documenting STOP-BANG scores. The data were collected via a chart review of the electronic medical record (EMR). FINDINGS: The rate of screening for OSA doubled after implementation of this initiative, and compliance with STOP-BANG questionnaire screening was 66.1%. High-risk designation in the EMR was 73.0%. Nearly half of the patients screened were found to be at high risk for OSA. CONCLUSIONS: Implementation of a universal screening initiative for patients and design for the EMR improves compliance with screening and identification of patients at high risk for OSA.

Treating Chronic Nonmalignant Pain: Evidence and Faith-Based Approaches.

A significant portion of the world's population is impacted by chronic pain; in the United States, chronic pain costs billions annually in treatment and lost productivity. A needs assessment was conducted to evaluate the prevalence of chronic nonmalignant pain (CNMP) at a university occupational therapy clinic over a 3-month period; recommendations were made to improve pain management at the clinic and referring hospital system. Graded Chronic Pain Scale 2.0 results indicated the prevalence of CNMP was a significant problem. Three evidence-based interventions based on the biblically based CREATION Health Model were developed.

The Role of Pharmacogenomics in Anesthesia Pharmacology.

The field of pharmacogenomics seeks to identify the impact of genetic variants on drug dosing, response, metabolism, and safety outcomes. The narrow therapeutic indices for anesthesia drugs, variability of patient responses to anesthesia, and the risks associated with surgery make anesthetics and the perioperative period prime targets for pharmacogenetic research. Anesthesia providers strive to optimize anesthesia delivery and patient outcomes and to specifically reduce anesthesia-related risks and negative outcomes. Despite pharmacogenomics emerging from the field of anesthesia, the most significant advances to date in the understanding and application of genetics to pharmacology have occurred outside of anesthesiology. This chapter provides an overview of genetic concepts fundamental to understanding the pharmacogenetics of anesthesia practice and presents the current state of the science with respect to the genetic influence on the response to volatile and intravenous anesthetic agents and opioid receptor agonists commonly used in anesthesia practice. In addition, the chapter delineates U.S. Food and Drug Administration labeling tenets for pharmacogenetics, discusses clinical implications of pharmacogenomics for family members, and highlights the potential for future paradigm shifts in pharmacogenomics of anesthesia practice.

Evaluating the Implementation of a Preemptive, Multimodal Analgesia Protocol in a Plastic Surgery Office.

Many patients undergoing plastic surgery experience significant pain postoperatively. The use of preemptive, multimodal analgesia techniques to reduce postoperative pain has been widely described in the literature. This quality improvement project evaluated the implementation of a preemptive, multimodal analgesia protocol in an office-based plastic surgery facility to decrease postoperative pain, decrease postoperative opioid consumption, decrease postanesthesia care time, and increase patient satisfaction. The project included adult patients undergoing surgical procedures at an outpatient plastic and cosmetic surgery office, and the protocol consisted of oral acetaminophen 1,000 mg and gabapentin 1,200 mg. Using a pre-/postintervention design, data were collected from patient medical records and telephone interviews of patients receiving the standard preoperative analgesia regimen (preintervention group: n = 24) and the evidence-based preemptive, multimodal analgesia protocol (postintervention group: n = 23). Results indicated no significant differences between the pre- and postintervention groups for any of the outcomes measured. However, results showed that patients in both groups experienced moderate to severe pain postoperatively. In addition, adverse side effects such as dizziness and drowsiness were higher in the postintervention group than in the preintervention group. Although this quality improvement project did not meet the goals it set out to achieve for patients undergoing plastic surgery, it did illustrate the substantial presence of pain after surgical procedures. Thus, clinicians need to continue to focus on identifying targeted treatment plans that use multimodal, non-opioid-based strategies to manage and prevent postoperative pain.

Structured Handover in the Pediatric Postanesthesia Care Unit.

PURPOSE: To establish a structured handover in the pediatric postanesthesia care unit. DESIGN: An observational prequality and postquality improvement design was used. METHODS: Convenience samples of 52 preimplementation and 51 postimplementation handover interactions (N = 103) were observed and compared to a 42-item Introductions, Situation, Background, Assessment, Recommendations, & Questions checklist. Patient care team members' satisfaction was assessed using voluntary electronic surveys. Data were analyzed for descriptive measures and differences in the pre- and postchecklist, and satisfaction total scores were compared using a two-sample t test. FINDING: The implementation of the handover checklist resulted in a statistically significant increase in the percentage of items discussed during five of six handover phases (P < .001). Overall, a significant increase in provider satisfaction was demonstrated from preimplementation to postimplementation (P < .01). The average duration of handover (in minutes) was not significantly different from pre (mean = 5.80 ± 3.80) to post (mean = 6.80 ± 2.30), P = .15. CONCLUSIONS: A structured handover checklist is associated with increased communication of handover content information and improved provider satisfaction. No statistically significant effect on handover duration time was found.

Survival outcomes following norwood procedure for hypoplastic left heart.

Prior studies evaluating the association of HLHS anatomic variants and mortality report conflicting results. Our objective was to determine if antegrade flow across the mitral within variants of HLHS with aortic atresia is associated with increased mortality compared to ventricular hypoplasia variants without antegrade mitral flow. All patients with HLHS born between 2002 and 2011 year who underwent stage I Norwood palliation with complete history and echocardiograms for patency of the mitral and aortic valves were studied. The cohort was divided into three groups: aortic atresia-mitral atresia (AA-MA), aortic stenosis-mitral stenosis (AS-MS), and aortic atresia-mitral stenosis (AA-MS). Demographic, comorbidities, and operative variables were analyzed. Analysis of variance techniques was applied for continuous variables and categorical variables. Survival analysis was performed using the Kaplan-Meier method with log-rank testing. A total of 70 consecutive patients who underwent Norwood Procedure were analyzed. There were no statistical differences in gender, birth weight, and age at time of Norwood procedure. Thirty patients had AA-MA variant, 23 had AA-MS, and 17 had AS-MS. Long-term Norwood survival was 60% for AA-MA, 65% for AS-MS, and 26% for AA-MS (p = 0.043). Use of extracorporeal membrane oxygenation as well as shunt revisions was more frequent for the AA-MS compared to other variants (p < 0.05). Patient weight at time of Norwood and length of regional perfusion were the highest predictors for hospital death following Norwood procedure. The Norwood procedure for mitral stenosis and aortic atresia is more often associated with use of extracorporeal membrane oxygenation and shunt revision compared to other variants. This HLHS variant has lowest long-term survival.

Utilization of a Preemptive, Multimodal Analgesic Regimen in Adult Ambulatory Septoplasty Patients: A Quality Improvement Project.

This paper describes a quality improvement project designed to decrease postoperative pain, decrease post-operative nausea and vomiting (PONV), decrease time in the recovery room, and increase patient satisfaction in adult ambulatory septoplasty patients using a multimodal, preemptive analgesic regimen. The project was conducted in a community hospital setting with nine operating rooms, and a twenty one bed recovery room. Project participants included certified registered nurse anesthetists, anesthesiologists, operating room nurses, recovery room nurses, and otolaryngology surgeons. Following a period of departmental education, adult patients scheduled for outpatient septoplasty surgery received a preoperative regimen of medications that included gabapentin, celecoxib, and acetaminophen. Using a pre-post test design, (intervention group n = 17, non-intervention group n = 17) data was collected from patient and analyzed using SPSS version 18.0. The change in practice resulted in a significant decrease in pain scores in the recovery room and on discharge from the recovery room. In addition, patients who received the preemptive regimen also required significantly fewer opioid medications and were ready to be discharged from the recovery room in less time.

The Utility of BIS™ Monitoring in Anesthesia for Elderly Patients.

Aging leads to anatomic and physiologic changes in the brain, making it more sensitive to the depressant effects of anesthetic medications and increasing the risk of postoperative neurocognitive complications such as postoperative delirium and postoperative cognitive dysfunction. This article explores the implications of anesthesia on elderly patients' brain health, emphasizing the heightened risk of postoperative neurocognitive disorders, and describes the BIS™ Monitoring System as a neuromonitoring tool for anesthesia professionals to assess the depth of anesthesia. The integration of the BIS Monitoring System into clinical practice can contribute to a more tailored and patient-centered approach to anesthesia management, ultimately improving perioperative outcomes and safety.

Supporting CRNA Clinical Practice: A Review of New and Updated Professional Practice Documents.

The American Association of Nurse Anesthesiology (AANA) Practice Committee, in collaboration with AANA Professional Practice staff, advisory panels, and subject matter experts, annually applies a standardized evidence-based process to review, evaluate, and revise clinical resource documents found in the Professional Practice Manual for the CRNA (Certified Registered Nurse Anesthetist) and on the AANA website. This article highlights several revised and newly developed documents, which include topics such as diversity, equity, and inclusion, anesthesia and analgesia for obstetric patients, and safe injection guidelines.

The genomes of Hercules beetles reveal putative adaptive loci and distinct demographic histories in pristine North American forests.

Beetles, despite their remarkable biodiversity and a long history of research, remain lacking in reference genomes annotated with structural variations in loci of adaptive significance. We sequenced and assembled high-quality chromosome-level genomes of four Hercules beetles which exhibit divergence in male horn size and shape and body colouration. The four Hercules beetle genomes were assembled to 11 pseudo-chromosomes, where the three genomes assembled using Nanopore data (Dynastes grantii, D. hyllus and D. tityus) were mapped to the genome assembled using PacBio + Hi-C data (D. maya). We demonstrated a striking similarity in genome structure among the four species. This conservative genome structure may be attributed to our use of the D. maya assembly as the reference; however, it is worth noting that such a conservative genome structure is a recurring phenomenon among scarab beetles. We further identified homologues of nine and three candidate-gene families that may be associated with the evolution of horn structure and body colouration respectively. Structural variations in Scr and Ebony2 were detected and discussed for their putative impacts on generating morphological diversity in beetles. We also reconstructed the demographic histories of the four Hercules beetles using heterozygosity information from the diploid genomes. We found that the demographic histories of the beetles closely recapitulated historical changes in suitable forest habitats driven by climate shifts.

Analysis of a Needs Assessment Survey to Develop an Online Resource Repository Supporting Nurse Anesthesia Educators.

BACKGROUND: Without highly qualified nurse anesthesia educators and administrators, the health care system will be threatened by the inadequate supply of certified registered nurse anesthetists (CRNAs). PURPOSE: American Association of Nurse Anesthesiologists' Faculty Stabilization Task Force (FSTF) analyzed reasons for high faculty turnover and developed recommendations to support nurse anesthesia faculty and administrators. METHODS: A survey evaluated participants' current role, leadership development opportunities, mentorship experiences, and resource needs. RESULTS: Of 109 respondents, 87 (80%) were program administrators or assistant administrators with less than 5 years of experience in their role. Despite academic experience, 51% felt adequately prepared for their role. CONCLUSIONS: The FSTF provided 2 recommendations: to create a robust faculty development program for all faculty at all levels of CRNA education and a repository of information needed for program administrators and faculty to oversee and educate students in a high-quality CRNA program.