Contributing Factors to Operating Room Delays Identified from an Electronic Health Record: A Retrospective Study.

The operating room (OR) is considered a major cost center and revenue generator for hospitals. Multiple factors contribute to OR delays and impact patient safety, patient satisfaction scores, and hospital financial performance. Reducing OR delays allows better utilization of OR resources and staffing and improves patient satisfaction while decreasing operating costs. Accurate scheduling can be the basis to achieve these goals. The objective of this initial study was to identify factors not normally documented in the electronic health record (EHR) that may contribute to or be indicators of OR delays. Materials and Methods. A retrospective data analysis was performed analyzing 67,812 OR cases from 12 surgical specialties at a small university medical center from 2010 through the first quarter of 2017. Data from the hospital's EHR were exported and subjected to statistical analysis using Statistical Analysis System (SAS) software (SAS Institute, Cary, NC). Results. Statistical analysis of the extracted EHR data revealed factors that were associated with OR delays including, surgical specialty, preoperative assessment testing, patient body mass index, American Society of Anesthesiologists (ASA) physical status classification, daily procedure count, and calendar year. Conclusions. Delays hurt OR efficiency on many levels. Identifying those factors may reduce delays and better accommodate the needs of surgeons, staff, and patients thereby leading to improved patient's outcomes and patient satisfaction. Reducing delays can decrease operating costs and improve the financial position of the operating theater as well as that of the hospital. Anesthesiology teams can play a key role in identifying factors that cause delays and implementing mitigating efficiencies.

Two Cardiac Arrests Because of Venous Air Embolism During Endoscopic Retrograde Cholangiopancreatography: A Case Report.

Venous air embolism is a rare but potentially catastrophic complication of endoscopic retrograde cholangiopancreatography. We report 2 cases of venous air embolism and subsequent cardiac arrests. During resuscitation efforts, a transesophageal echocardiogram was placed, which demonstrated significant air in the right heart. Although gastroenterologists seem to be more aware of this complication, it is underreported in the anesthesiology literature. As anesthesiologists continue to expand coverage to endoscopy suites, anesthesia providers must be aware of predisposing factors and maintain a high index of suspicion to recognize and treat in a timely manner to prevent serious adverse outcomes.

Superior vena cava syndrome with retropharyngeal edema as a complication of ventriculoatrial shunt.

Thirty-seven-year old female with hydrocephalus managed by a ventriculoatrial (VA) shunt presented with upper body edema, dysphagia, and headache. Imaging demonstrated thrombosis of the superior vena cava (SVC). Direct catheter thrombolysis led to resolution of thrombus burden. Superior vena cava thrombosis is a rare consequence of VA shunting and must be managed emergently.

The Effect of Previous Resident Interactions on the Assessment of Interpersonal and Communication Skills by Teaching Faculty: Are We the Best Evaluators?

BACKGROUND: Evaluating resident interpersonal and communication skills (ICS) presents a significant challenge. Unlike the In-Training-Exam, an objective measure of knowledge, the evaluation of ICS is subjective. Previous interactions could influence how teaching faculty evaluate this competency leading to inaccurate assessment of resident ICS. Faculty groups from other residencies and non-physicians were enlisted to compare assessments with those by teaching faculty. METHODS: A cross-sectional study was conducted comparing how different evaluator groups assessed the ICS of anesthesiology residents. Nine residents participated each in two Standardized Patient (SP) encounters that were video-recorded. The recordings were viewed by eleven evaluators representing four different evaluator groups, one non-blinded teaching faculty group, two blinded anesthesiology faculty groups from separate programs and one blinded non-physician group. They scored each encounter using a modified SEGUE framework evaluation form graded on a Likert scale. RESULTS: The mean score for each resident ICS encounter by evaluator group were as follows: non-blinded teaching faculty (57.89), non-physician group (57.42), and the blinded anesthesiology faculties (53.00) and (53.83) respectively. There was significant difference in how the evaluator groups scored the resident performances (p<0.001). Analysis of ranks showed excellent correlation comparing teaching faculty with the other anesthesiology faculty groups (r=0.764, p=0.017 and r=0.765, p=0.016, respectively). The highest ranked resident overall ranked high across all evaluator groups and the lowest ranked resident was ranked lowest across most evaluator groups. CONCLUSIONS: Though potential for biases from previous interactions exist, teaching faculty assessments of resident ICS are similar to the assessments of other anesthesiology faculty evaluator groups.

In vivo assessment of arterial stiffness in the isoflurane anesthetized spontaneously hypertensive rat.

BACKGROUND: Rodent models are increasingly used to study the development and progression of arterial stiffness. Both the non-invasive Doppler derived Pulse Wave Velocity (PWV) and the invasively determined arterial elastance index (EaI) have been used to assess arterial stiffness in rats and mice, but the need for anesthetic agents to make these in vivo estimates may limit their utility. Thus, we sought to determine: 1) if known differences in arterial stiffness in spontaneously hypertensive rats (SHR) are detectable by PWV and EaI measurements when made under isoflurane anesthesia, and 2) if these two uniquely acquired assessments of arterial elasticity correlate. METHODS: We obtained PWV and EaI measurements in isoflurane anesthetized young and old SHRs, which are known to have significant differences in arterial stiffness. Doppler pulse waves were recorded from carotid and iliac arteries and the distance (D) between probe applantation sites was recorded. Simultaneously, an EKG was obtained, and the time intervals between the R-wave of the EKG to the foot of the Doppler waveforms were measured and averaged over three cardiac cycles. Pulse-transit time (T) of the carotid to iliac artery was determined, and PWV was calculated as Distance (D)/Time (T), where D = the distance from the carotid to the iliac notch and T = (R to iliac foot) - (R to carotid foot). EaI was subsequently determined from pressure volumes loops obtained via left ventricle catheterization. RESULTS: PWV and EaI were found to be significantly faster in the older rats (13.2 ± 2.0 vs. 8.0 ± 0.8 m/sec, p < 0.001; 120 ± 20 vs. 97 ± 16 mmHg/µl/g, p <0.05). Bland-Altman analyses of intra- and inter-observer measures demonstrate a statistically significant relationship between readings (p < 0.0001). PWV and EaI measurements were found to be significantly and positively correlated with a correlation coefficient of 0.53 (p < 0.05). CONCLUSION: Our study suggests that isoflurane administration does not limit Doppler PWV or EaI measures in their ability to provide accurate, in vivo assessments of relative arterial stiffness in isoflurane anesthetised SHR rats. Furthermore, PWV data obtained in these rats correlate well with invasively determined EaI.

Cardiovascular monitoring: physiological and technical considerations.

The American Dental Association and several dental specialty organizations have published guidelines that detail requirements for monitoring patients during various levels of sedation and, in some cases, general anesthesia. In general, all of these are consistent with those guidelines suggested by the American Society of Anesthesiologists Task Force for Sedation and Analgesia by Non-Anesthesiologists. It is well-accepted that the principal negative impact of sedation and anesthesia pertains to the compromise of respiratory function, but attentive monitoring of cardiovascular function is also important. While monitoring per se is a technical issue, an appreciation of its purpose and the interpretation of the information provided require an understanding of basic cardiovascular anatomy and physiology. The focus of this continuing education article is to address essential physiological aspects of cardiovascular function and to understand the appropriate use of monitors, including the interpretation of the information they provide.

Respiratory monitoring: physiological and technical considerations.

The American Dental Association and several dental specialty organizations have published guidelines that detail requirements for monitoring patients during various levels of sedation and, in some cases, general anesthesia. In general, all these are consistent with those guidelines suggested by the American Society of Anesthesiologists for sedation and analgesia by nonanesthesiologists. It is well accepted that the principal negative impact of sedation and anesthesia is the compromise of respiratory function. While monitoring per se is a technical issue, an appreciation of its purpose and the interpretation of the information provided require an understanding of respiratory anatomy and physiology. The focus of this continuing education article is to address the physiological aspects of respiration and to understand the appropriate use of monitors, including the interpretation of the information they provide.

The Use of Standardized Patients to Evaluate Interpersonal and Communication Skills of Anesthesiology Residents: A Pilot Study.

OBJECTIVE: The study was conducted to explore the feasibility and validity of using standardized patients (SPs) in assessing the interpersonal and communication skills (ICS) of anesthesiology residents. METHODS: A cross-sectional study was conducted to assess the ICS of anesthesiology residents using SPs. Each resident participated in two staged encounters and was graded by the SPs using a modified SEGUE framework. Each encounter was videotaped and reviewed independently by two senior faculty members using the same checklist. RESULTS: The ICS scores improved with advancement of training. This was confirmed by both SP and faculty (CA-1, 47.8 ± 9.8 and CA-3, 64.8 ± 1.9, P=0.022) assessments. There was strong inter-faculty agreement for individual residents (r=0.95, P<0.001). In-training exam (ITE) scores appeared to correlate with the faculty ICS score (r=0.61, p<0.05). CONCLUSION: Standardized patient encounters using a modified SEGUE framework may be a useful tool to assess ICS among anesthesiology residents. Resident performance improves even in the absence of interventions to teach ICS. The improvement appears to correlate with increasing experience and knowledge.

Intraoperative identification of both a paradoxical embolism and its probable etiologic site.

We report a case of upper extremity arterial ischemia in a 41-year-old man. Intraoperative transesophageal echocardiography identified a paradoxical embolization that traversed a patent foramen ovale as the probable etiology. The diagnosis of paradoxical embolism with intraoperative identification of the etiologic site of the deep venous thrombosis is a rare event. This case presents the use of transesophageal echocardiography beyond its monitoring function in helping diagnose the cause of arterial ischemia.