Implementation of a SAFE OB Handover for CRNAs.

Unstructured, verbal, obstetrical anesthesia handovers have led to omission of critical information, which can harm patients or delay care. The SAFE Handover Tool is a standardized mnemonic: Sick patients, At-risk patients, Follow-ups, and Epidurals. Use of the tool during handover significantly increases the percentage of relevant parturients that are discussed and improves provider communication. This study implemented the SAFE Handover Tool for Certified Registered Nurse Anesthetists (CRNAs) in a Level III (Subspecialty) Maternal Care unit. A mixed methodology was used to operationalize handover quality. Descriptive, statistical, and content analyses showed significant improvements between PRE- and POST-implementation assessments of handover quality after using the SAFE Handover Tool. The SAFE Handover Tool improved the quality of CRNA communication and enabled situational awareness. A modified SAFE Handover Tool was subsequently integrated into the obstetrical anesthesia electronic charting system. The SAFE Handover Tool is a novel, low-cost, sustainable method to improve CRNA handovers and patient safety.

Development of a Common Clinical Assessment Tool for Evaluation in Nurse Anesthesia Education.

There is a lack of standardization among evaluations completed by clinical educators of student registered nurse anesthetists (SRNAs) during their clinical education as reported by nurse anesthesia program administrators and students. To address this issue, the Council on Accreditation of Nurse Anesthesia Educational Programs (COA) Board created the Common Clinical Assessment Tool (CCAT) Special Interest Group to develop a standardized clinical evaluation instrument. The goal was to improve the consistency of clinical evaluation across nurse anesthesia programs while assisting program administrators to make programmatic changes to ensure compliance with COA standards. In May 2016, the CCAT Special Interest Group began to create an evaluation instrument that was competency based and reflective of the COA's Practice Doctorate Standards. After a review of literature, input from the communities of interest, results from the American Association of Nurse Anesthetists professional practice survey, and analysis of the National Certification Examination for Nurse Anesthetists content outline and information from other sources, a draft CCAT was completed. A Delphi study was conducted, and expert opinions from program administrators, academic and clinical faculty, and students were collected to ascertain consensus on competencies, competency descriptors, and progression indicators.

Patient Satisfaction With Anesthesia Care: What Do We Know?

This evidence review aimed to conceptualize patient satisfaction with anesthesia care (PSAC), which has been linked to reimbursement, competency evaluations, and litigation; to describe factors affecting PSAC; and to develop provider recommendations to enhance PSAC. The search for systematic reviews, survey reports, qualitative studies, and consumer satisfaction reports within the last 20 years excluded pediatric and obstetric articles. The search yielded 27 quantitative, 7 qualitative, and 9 consumer satisfaction articles. High levels of PSAC are reported using a variety of methods. Studies evaluating patient perioperative experiences document that fear and anxiety with prior patient experiences have an impact on anticipatory anxiety. Patients reported desiring positive experiences and emotional connections with anesthesia providers. Modifiable dissatisfiers included anxiety, inadequate explanation of anesthesia, postoperative pain and nausea or vomiting, long surgeries or wait times, and anesthesia complications. Besides providing preoperative information with reasonable expectations (eg, for nausea and vomiting) and treating discomfort, anesthetists must engage emotionally with patients. Measures of PSAC should include the emotional component of PSAC. Future research addressing patient experiences with differing anesthesia methods would be helpful for providers trying to understand and facilitate patient coping.

Venous Thromboembolism: New Concepts in Perioperative Management.

Venous thromboembolism (VTE) is a serious pathophysiologic condition that is a major cause of morbidity and mortality, especially during the perioperative period. A collective term, VTE is used to describe a blood clot that develops inside the vasculature and results in a deep vein thrombosis (DVT) and/or a pulmonary embolism (PE). Deep vein thrombosis and PE are the third leading cause of cardiovascular mortality, superseded only by myocardial infarction and stroke. Patients who receive treatment for acute PE are 4 times more likely to die of a recurrent VTE within the next year. In hospitalized patients who have had surgery, the incidence of VTE and PE is estimated to be 100 times more prevalent than in the general population. The Joint Commission has established Surgical Care Improvement Project measures to address prophylactic interventions to minimize the incidence of VTE. This journal course will review the current approaches to pharmacologic and nonpharmacologic prevention and management of VTE during the perioperative period. Identification and treatment of deep vein thrombosis and acute PE are also described.

Anesthesia case management for endovascular aortic aneurysm repair.

The incidence of angiopathology involving the aorta and microvasculature is expected to become more prevalent because of increased life expectancy and incidence of obesity. With the advent of endovascular aortic repair (EVAR), patients who were not considered surgical candidates for abdominal aortic aneurysmectomy because of their tenuous physical status can undergo corrective treatment and return to their activities of daily living. Because of the limited invasiveness of the procedure, it is unnecessary to cross-clamp the aorta, which minimizes hemodynamic variability and release of inflammatory mediators. As a result, the rate of myocardial ischemia, acute kidney injury, mesenteric ischemia, and blood loss is decreased. However, there are serious complications that can occur with EVAR, which include cerebral and myocardial ischemia, rapid massive hemorrhage, damage to access vessels, and endoleak. Presently, the most common anesthetic technique provided to patients undergoing EVAR is local anesthesia and monitored anesthetic care. A thorough understanding of the surgical procedure, perioperative process, and anesthetic considerations is vital to provide comprehensive care.

Anesthesia case management for video-assisted thoracoscopic surgery.

As the population ages, the number of patients in whom lung disease develops and who require surgical intervention will continue to rise. When compared with open thoracotomy, video-assisted thoracoscopic surgery (VATS) offers patients significant advantages. Decreased invasiveness results in less blood loss, a lower rate of infection, and less postoperative pain and allows for quicker recovery. A description of the significant physiologic changes related to pulmonary blood flow, ventilation, and perfusion when patients are placed in the lateral decubitus position is included. A common method of providing one-lung ventilation during VATS is via a double-lumen endotracheal tube. Proper use, placement, ventilation strategies, and methods to minimize the incidence and treat hypoxia for a double-lumen tube are reviewed. One-lung ventilation poses significant challenges for anesthetists. As a result, adequate preparation during the preoperative, intraoperative, and postoperative phases is essential.

Anesthesia case management for bariatric surgery.

An increasing number of bariatric surgeries are performed every year. A thorough understanding of the pathophysiologic changes, surgical procedure, and anesthesia case management for morbidly obese patients and of the pharmacology of weight-reduction and anesthetic drugs is essential to provide high-quality anesthetic care. The various comorbidities associated with obesity may complicate anesthetic management. Anesthetists must perform a thorough preoperative assessment to identify potential risk factors related to anesthesia and adequately prepare for intraoperative management. Intubation, maintenance of oxygenation, and pain management may be particularly challenging, and various strategies are presented. In addition, an obese patient is at higher risk for postoperative complications. Signs and symptoms of surgical complications may mimic medical complications, making diagnosis difficult.

Clinical education experiences: perceptions of student registered nurse anesthetists.

The purpose of this study was to describe the experiences and attitudes of student registered nurse anesthetists (SRNAs) related to clinical instruction. This descriptive study used a cross-sectional survey method with a regionally stratified randomly selected sample of SRNA members from the American Association of Nurse Anesthetists data bank. A total of 2,673 SRNAs were invited by email to respond to an online, 54-item questionnaire; 696 SRNAs participated. Verbal abuse was reported by almost 70% of SRNA participants, but fewer experienced sexual harassment (13%), physical abuse (14%), or racial discrimination (72%). However, SRNAs reported that their Certified Registered Nurse Anesthetist (CRNA) preceptors most often served as positive role models. These SRNAs found CRNA preceptors, unique cases, reading, and clinical lectures more helpful to their clinical learning compared with grand rounds, surgeons, and anesthesiology residents. The SRNAs' perceptions of the ideal behavioral characteristics for CRNA preceptors included calmness during stressful events, use of nonthreatening communication, clear communication, and encouraging independent decision making. The educational process for nurse anesthetists is continually evolving and improving. Study findings offer insights that may assist in improvements in the clinical component of SRNA education.

Anesthesia case management for thyroidectomy.

An intimate knowledge of the anatomy, physiology, pathophysiology, pharmacology, and specific issues related to anesthesia case management for thyroidectomy is essential to provide high-quality care. Airway management may be difficult despite a normal airway examination due to impingement of a thyroid mass on the laryngeal and tracheal structures. Anesthetists must be prepared to use emergency airway adjuncts in case a patient cannot be ventilated or intubated. Because sympathetic nervous system hyperactivity is associated with increased amounts of thyroid hormone, it is essential that all patients having an elective thyroidectomy be in a euthyroid state before surgery. There are multiple preoperative antithyroid medication regimens that effectively treat thyroid hormone hypersecretion. However, although a rare event, thyroid storm can still occur during the perioperative period. Anesthetic considerations and surgical complications are presented.

Should I continue or discontinue that medication?

Patients are admitted for surgery while taking a wide array of medications, and nurse anesthetists must evaluate their effectiveness and compatibility with anesthesia. Anesthetists must be familiar with the basic pharmacology of each drug and the potential adverse effects and possible drug interactions that may occur when anesthetic drugs are administered. If a medication requires discontinuation, we must ensure that the patient's disease remains controlled throughout the perioperative period. It is estimated that up to 50% of patients admitted for surgery will be taking some of type of medication preoperatively. The most common types are the drugs used to treat cardiovascular, central nervous system, and gastrointestinal disorders. There are few clinical or evidence-based guidelines regarding the preoperative management of many of these drugs. Most medications taken for minor disorders that do not have systemic effects can be safely continued without incident. Some medications may require discontinuation or temporary alteration of the dosing schedule to avoid problems in the perioperative period. This course reviews the current literature regarding the anesthetic management of several commonly encountered drug classes.

A successful partnership to help reduce health disparities: the Institute for Culturally Competent Care and the Kaiser Permanente School of Anesthesia/California State University Fullerton.

An innovative partnership with Kaiser Permanente's Institute for Culturally Competent Care (ICCC) enabled the Kaiser Permanente School of Anesthesia/California State University Fullerton (KPSA) to present a formal, 4-module cultural competency certification program within the nurse anesthesia curriculum. The goals of developing the cultural competency curriculum were to increase students' awareness of cultural differences and to enhance students' communication skills with an increasingly diverse patient population. The cultural competency courses are integrated throughout the nurse anesthesia curriculum. During their clinical education, nurse anesthesia students travel to numerous urban and rural areas to serve diverse patient populations. The collaboration between the ICCC and KPSA represents a unique opportunity for the organization and for KPSA to have an impact on patient care. This article describes the genesis and evolution of the collaboration as well as the impact of this ongoing educational effort.

An educational curriculum used to improve the knowledge and the perceptions of certified registered nurse anesthetist clinical educators.

An educational curriculum using adult learning principles in an active learning format was developed for Certified Registered Nurse Anesthetist clinical educators (CRNACEs) to help improve the quality of the clinical learning experiences for student nurse anesthetists (SNAs). This exploratory study sought to determine the extent to which an 8-hour educational course modified the behavioral perceptions and the knowledge of CRNACEs. The effects of the CRNACE course were measured using a questionnaire that consisted of 22 Likert scale items and 8 open-ended questions. The study population included 33 CRNACEs. Their responses were assessed before the course, after the course, and during a 2-month follow-up. It was determined that the CRNACE course positively modified participants' perceived behaviors and knowledge after instruction and at the 2-month followup. Additional findings included that information provided during the CRNACE course did not change the perceptions of CRNACEs related to their ability to communicate with students or their willingness to modify their teaching practices. Providing instruction incorporating principles of adult learning using an active learning format for CRNACEs may improve the clinical learning experiences for SNAs. As a result, SNAs would be better prepared to make the transition to clinical expert.