Lack of Validity of Absolute Percentage Errors in Estimated Operating Room Case Durations as a Measure of Operating Room Performance: A Focused Narrative Review.

Commonly reported end points for operating room (OR) and surgical scheduling performance are the percentages of estimated OR times whose absolute values differ from the actual OR times by ≥15%, or by various intervals from ≥5 to ≥60 minutes. We show that these metrics are invalid assessments of OR performance. Specifically, from 19 relevant articles, multiple OR management decisions that would increase OR efficiency or productivity would also increase the absolute percentage error of the estimated case durations. Instead, OR managers should check the mean bias of estimated OR times (ie, systematic underestimation or overestimation), a valid and reliable metric.

Bibliometric Analysis of Contributions of Anesthesiology Journals and Anesthesiologists to Operating Room Management Science.

BACKGROUND: Anesthesiology journals appear to have been progressively publishing a smaller percentage of operating room (OR) management studies. Similarly, non-anesthesiologists have increasingly been authors of these publications. Five hypotheses were formulated to evaluate these impressions based on 2 of the authors' curation of an online, comprehensive bibliography of OR management articles and corresponding referenced course materials. METHODS: We studied all 2938 publications having Scopus' SciVal topic T.6319 (OR management) more than 28 years from 1996 through May 2023, including 8608 distinct authors. RESULTS: Half (50%) of the publications were absent from PubMed, and the percentage absent has been increasing progressively (Kendall's τ = 0.71; P < .0001). Fewer than half were published in journals including anesthesiology as the sole classification (20%) or as one of the classifications (27%). The anesthesiology journals have been publishing a progressively decreasing fraction (τ = -0.61; P < .0001). Among the 11 authors each contributing at least 1% of the OR management science publications, 9 were anesthesiologists and the other 2 had anesthesiologists as coauthors on all these publications. Only 3% of authors had at least 10 OR management publications from earlier years. There were 75% of authors with no such earlier publications and 85% with 0 or 1. There was a progressive increase in the number of authors publishing OR management annually and with at most 1 such earlier publication (τ = 0.90; P < .0001). Only 20% of publications had any author with at least 10 earlier OR management publications, 48% had every author with no such earlier publications, and 60% had all authors with 0 or 1. CONCLUSIONS: Although most of the authors with the greatest production of OR management science were anesthesiologists, the percentage of publications in anesthesiology journals has been decreasing progressively. Anesthesiologists cannot rely solely on anesthesiology journals to keep up with the field. For most publications, every author had few or no earlier publications on the topic. Clinicians and managers relying on OR management science will continue to need to apply more information when judging whether published results can reliably be applied to their facilities.

Predictive Validity of Anesthesiologists' Quality of Clinical Supervision and Nurse Anesthetists' Work Habits Assessed by Their Associations With Operating Room Times.

BACKGROUND: At all Joint Commission-accredited hospitals, the anesthesia department chair must report quantitative assessments of anesthesiologists' and nurse anesthetists' (CRNAs') clinical performance at least annually. Most metrics lack evidence of usefulness, cost-effectiveness, reliability, or validity. Earlier studies showed that anesthesiologists' clinical supervision quality and CRNAs' work habits have content, convergent, discriminant, and construct validity. We evaluated predictive validity by testing for (expected) small but statistically significant associations between higher quality of supervision (work habits) and reduced probabilities of cases taking longer than estimated. METHODS: Supervision quality of each anesthesiologist was evaluated daily by assigned trainees using the 9-item de Oliveira Filho scale. The work habits of each CRNA were evaluated daily by assigned anesthesiologists using a 6-item scale. Both are scored binary, 1 if all items are rated the maximum, 0 otherwise. From 40,718 supervision evaluations and 53,722 work habit evaluations over 8 fiscal years, 16 mixed-effects logistic regression models were estimated, with raters as fixed effects and ratees (anesthesiologists or CRNAs) as random effects. Empirical Bayes means in the logit scale were obtained for 561 anesthesiologist-years and 605 CRNA-years. The binary-dependent variable was whether the case took longer than estimated from the historical mean time for combinations of scheduled procedures and surgeons. From 264,060 cases, 8 mixed-effects logistic regression models were fitted, 1 per fiscal year, using ratees as random effects. Predictive validity was tested by pairing the 8 one-year analyses of clinical supervision, and the 8 one-year analyses of work habits, by ratee, with the 8 one-year analyses of whether OR time was longer than estimated. Bivariate errors in variable linear least squares linear regressions minimized total variances. RESULTS: Among anesthesiologists, 8.2% (46/561) had below-average supervision quality, and 17.7% (99/561), above-average. Among CRNAs, 6.3% (38/605) had below-average work habits, and 10.9% (66/605) above-average. Increases in the logits of the quality of clinical supervision were associated with decreases in the logits of the probabilities of cases taking longer than estimated, unitless slope = -0.0361 (SE, 0.0053), P < .00001. Increases in the logits of CRNAs' work habits were associated with decreases in the logits of probabilities of cases taking longer than estimated, slope = -0.0238 (SE, 0.0054), P < .00001. CONCLUSIONS: Predictive validity was confirmed, providing further evidence for using supervision and work habits scales for ongoing professional practice evaluations. Specifically, OR times were briefer when anesthesiologists supervised residents more closely, and when CRNAs had better work habits.

Pediatric Intraoperative Electromyographic Responses at the Adductor Pollicis and Flexor Hallucis Brevis Muscles: A Prospective, Comparative Analysis.

BACKGROUND: Peripheral nerve stimulation with a train-of-four (TOF) pattern can be used intraoperatively to evaluate the depth of neuromuscular block and confirm recovery from neuromuscular blocking agents (NMBAs). Quantitative monitoring can be challenging in infants and children due to patient size, equipment technology, and limited access to monitoring sites. Although the adductor pollicis muscle is the preferred site of monitoring, the foot is an alternative when the hands are unavailable. However, there is little information on comparative evoked neuromuscular responses at those 2 sites. METHODS: Pediatric patients undergoing inpatient surgery requiring NMBA administration were studied after informed consent. Electromyographic (EMG) monitoring was performed simultaneously in each participant at the hand (ulnar nerve, adductor pollicis muscle) and the foot (posterior tibial nerve, flexor hallucis brevis muscle). RESULTS: Fifty patients with a mean age of 3.0 ± standard deviation (SD) 2.9 years were studied. The baseline first twitch amplitude (T1) of TOF at the foot (12.46 mV) was 4.47 mV higher than at the hand (P <.0001). The baseline TOF ratio (TOFR) before NMBA administration and the maximum TOFR after antagonism with sugammadex were not different at the 2 sites. The onset time until the T1 decreased to 10% or 5% of the baseline value (T1) was delayed by approximately 90 seconds (both P =.014) at the foot compared with the hand. The TOFR at the foot recovered (TOFR ≥0.9) 191 seconds later than when this threshold was achieved at the hand (P =.017). After antagonism, T1 did not return to its baseline value, a typical finding with EMG monitoring, but the fractional recovery (maximum T1 at recovery divided by the baseline T1) at the hand and foot was not different, 0.81 and 0.77, respectively (P =.68). The final TOFR achieved at recovery was approximately 100% and was not different between the 2 sites. CONCLUSIONS: Although this study in young children demonstrated the feasibility of TOF monitoring, interpretation of the depth of neuromuscular block needs to consider the delayed onset and the delayed recovery of TOFR at the foot compared to the hand. The delay in achieving these end points when monitoring the foot may impact the timing of tracheal intubation and assessment of adequate recovery of neuromuscular block to allow tracheal extubation (ie, TOFR ≥0.9).

Associations Between Fresh Gas Flow and Duration of Anesthetic on the Maximum Potential Benefit of Anesthetic Gas Capture in Operating Rooms and in Postanesthesia Care Units to Capture Waste Anesthetic Gas.

BACKGROUND: Sevoflurane and desflurane are halogenated hydrocarbons with global warming potential. We examined the maximum potential benefit assuming 100% efficiency of waste gas capture technology used in operating rooms and recovery locations. METHODS: We performed computer simulations of adult patients using the default settings of the Gas Man software program, including the desflurane vaporizer setting of 9% and the sevoflurane vaporizer setting of 3.7%. We performed 21 simulations with desflurane and 21 simulations with sevoflurane, the count of 21 = 1 simulation with 0-hour maintenance + (1, 2, 3, 4, or 5 hours of maintenance) × (0.5, 1, 2, or 4 L per minute fresh gas flow during maintenance). RESULTS: (1) A completely efficient gas capture system could recover a substantive amount of agent even when the case is managed with low flows. All simulations had at least 22 mL agent recovered per case, considerably greater than the 12 mL that we considered the minimum volume of economic and environmental importance. (2) All 42 simulations had at least 73% recovery of the total agent administered, considerably greater than the median 52% recovery measured during an experimental study with one gas capture technology and desflurane. (3) The maximum percentage desflurane (or sevoflurane) that could be captured decreased substantively with progressively longer duration anesthetics for low-flow anesthetics but not for higher-flow anesthetics. However, for all 8 combinations of drug and liters per minute simulated, there was a substantively greater recovery in milliliters of agent for longer duration anesthetics. In other words, if gas capture could be near perfectly efficient, it would have greater utility per case for longer duration anesthetics. (4) Even using a 100% efficient gas capture process, at most 6 mL liquid desflurane or 3 mL sevoflurane per case would be exhaled during the patient's stay in the postanesthesia care unit. Therefore, the volume of agent exhaled during the first 1 hour postoperatively is not a substantial amount from an environmental and economic perspective to warrant consideration of agent capture by having all these patients in the postanesthesia care unit, or equivalent locations, using the specialized anesthetic gas scavenging masks with access to the hospital scavenging system at each bed. CONCLUSIONS: Simulations with Gas Man show a strong rationale based on agent uptake and distribution for using volatile anesthetic agent capture in operating rooms if the technology can be highly efficient at volatile agent recovery.

Patients Undergoing Elective Inpatient Major Therapeutic Procedures in Florida Had No Significant Change in Hospital Mortality or Mortality-Related Comorbidities Between 2007 and 2019.

BACKGROUND: In a recent study, rapid response team implementation at 1 hospital was associated with only a 0.1% reduction in inpatient mortality from 2005 to 2018, characterized in the accompanying editorial as a "tepid" improvement. The editorialist postulated that an increase in the degree of illness of hospitalized patients might have masked a larger reduction that otherwise might have occurred. Impressions of greater patient acuity during the studied period might have been an artifact of efforts to document more comorbidities and complications, possibly facilitated by the change in diagnosis coding from the International Classification of Diseases , Ninth Revision ( ICD-9 ) to the Tenth Revision ( ICD-10 ). METHODS: We used inpatient data from every nonfederal hospital in Florida from the last quarter of 2007 through 2019. We studied hospitalizations for major therapeutic surgical procedures with lengths of stay ≥2 days. Using logistic regression with clustering by the Clinical Classification Software (CCS) code of the primary surgical procedure, we evaluated the trends for decreased mortality, changes in the prevalence of Medicare Severity Diagnosis Related Groups (MS-DRG) with complications or comorbidities (CC) or major complications or major comorbidities (MCC), and changes in the van Walraven index (vWI), a measure of patient comorbidities associated with increased inpatient mortality. Also incorporated in the modeling was the change from ICD-9 to ICD-10 . RESULTS: There were 3,151,107 hospitalizations comprising 130 distinct CCS codes and 453 MS-DRG groups among 213 hospitals. Despite a progressive increase of 4.1% per year in the odds of a CC or MCC ( P = .001), there were no significant changes in the marginal estimates of in-house mortality over time (net estimated decrease, 0.036%; 99% confidence interval [CI], -0.168% to 0.097%; P = .49). There was also absence of a significantly greater fraction of discharges with vWI >0 attributable to the year of the study (odds ratio, 1.017 per year; 99% CI, 0.995-1.041). The changes in MS-DRG to those with CC or MCC were not increased significantly from either the ICD-10 coding change or the number of years after the change. CONCLUSIONS: Consistent with the previous study, there was at most a small decrease in the mortality rate over a 12-year period. We found no reliable evidence that patients undergoing elective inpatient surgical procedures were any sicker in 2019 than in 2007. There were substantively more comorbidities and complications documented over time, but this was unrelated to the change to ICD-10 coding.

Most hospital patients at risk for bacterial infection undergo an anesthetic: implications for infection control practices related to the anesthesia workspace.

PURPOSE: Even with nearly 100% compliance with prophylactic antibiotic protocols, many surgical patients (> 5%) develop surgical site infections, some caused by pathogens transmitted from the anesthesia workspace (e.g., anesthesia machine), including multidrug-resistant Staphylococcus aureus. Reducing contamination of the anesthesia workspace substantively reduces the risk of surgical site infections. We estimated the percentage of hospital patients at risk for health care-associated infections who may benefit from the application of basic preventive measures under the control of anesthesia practitioners (e.g., their hand hygiene). METHODS: We conducted a retrospective cohort study which included every patient admitted to the University of Miami Health System from April 2021 through March 2022 for hospitalization, surgery, emergency department visits, or outpatient visits. Lists were created for the start date and times of every parenteral antibiotic administered and every anesthetic. RESULTS: Among 28,213 patient encounters including parenteral antibiotic(s), more than half (64.3%) also included an anesthetic (99% confidence interval, 62.2 to 66.6). The hypothesis that most antibiotics were administered during encounters when a patient underwent an anesthetic was accepted (P < 0.001). This observation may seem counterintuitive because parenteral antibiotics were administered for fewer than half of the 53,235 anesthetics (34.2%). The result was a consequence of most anesthetics (63.5%) at the health system being conducted in nonoperating room locations, and only 7.2% of such patients received a parenteral antibiotic. CONCLUSIONS: Because approximately two-thirds of patients who receive an intravenous antibiotic also undergo an anesthetic, greater use of effective infection control measures in the anesthesia operating room workspace has the potential to substantively reduce overall rates of hospital infections.

RéSUMé: OBJECTIF: Même avec un respect de près de 100 % des protocoles antibiotiques prophylactiques, bon nombre de patients et patientes en chirurgie (> 5 %) développent des infections du site opératoire, dont certaines sont causées par des agents pathogènes transmis par l'espace de travail anesthésique (p. ex. appareil d'anesthésie), y compris un staphylocoque doré multirésistant. La réduction de la contamination de l'espace de travail anesthésique réduit considérablement le risque d'infections du site opératoire. Nous avons estimé le pourcentage de patientes et patients hospitalisé·es à risque d'infections associées aux soins de santé qui pourraient bénéficier de l'application de mesures préventives de base sous le contrôle de praticiens et praticiennes d'anesthésie (par exemple, leur hygiène des mains). MéTHODE: Nous avons mené une étude de cohorte rétrospective qui comprenait toutes les personnes admises au Système de santé de l'Université de Miami d'avril 2021 à mars 2022 pour une hospitalisation, une intervention chirurgicale, des visites aux urgences ou des consultations externes. Des listes ont été créées pour la date et l'heure de début de chaque antibiotique parentéral administré et de chaque anesthésique. RéSULTATS: Parmi les 28 213 consultations avec les patient·es comprenant des antibiotiques parentéraux, plus de la moitié (64,3 %) comportaient également un anesthésique (intervalle de confiance à 99 %, 62,2 à 66,6). L'hypothèse selon laquelle la plupart des antibiotiques étaient administrés lors de rencontres lorsqu'une personne bénéficiait d'une anesthésie a été acceptée (P < 0,001). Cette observation peut sembler contre-intuitive, car des antibiotiques parentéraux ont été administrés pour moins de la moitié des 53 235 anesthésiques (34,2 %). En effet, la plupart des anesthésies (63,5 %) ont été administrées en dehors de la salle d'opération, et seulement 7,2 % de cette patientèle a reçu un antibiotique parentéral. CONCLUSION: Étant donné qu'environ les deux tiers des patientes et patients qui reçoivent un antibiotique par voie intraveineuse bénéficient également d'une anesthésie, une plus grande utilisation de mesures efficaces de contrôle des infections dans l'espace de travail anesthésique de la salle d'opération pourrait réduire considérablement les taux globaux d'infections hospitalières.

Evaluation of Activated Clotting Times With a Heparin Reversal Protocol Designed to Conserve Protamine During Drug Shortages: A Retrospective, Cohort Study.

OBJECTIVE: To retrospectively evaluate a protamine conservation approach to heparin reversal implemented during times of critical shortages. This approach was aimed at maintaining access to cardiac surgical services. SETTING: In-patient hospital setting. PARTICIPANTS: Eight hundred-one cardiac surgical patients>18 years old. INTERVENTIONS: Patients undergoing cardiac surgery who received >30,000 U of heparin were given a single fixed vial protamine dose of 250 mg or a standard 1 mg of protamine to 100 U of heparin ratio-based dose to reverse heparin. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was differences in post-reversal activated clotting times between the 2 groups. The secondary endpoint was differences in the number of protamine vials used between the 2 reversal strategies. The first activated clotting times values measured after initial protamine administration were not different between the Low Dose and Conventional Dose groups (122.3 s v 120.6 s, 1.47 s, 99% CI -1.47 to 4.94, p = 0.16). The total amount of protamine administered in the Low Dose group was less than that in the Conventional Dose group (-100.5 mg, 99% CI -110.0 to -91.0, p < 0.0001), as were the number of 250 mg vials used per case (-0.69, 99% CI -0.75 to -0.63, p < 0.0001). The mean initial protamine doses between groups were 250 mg and 352 mg, p < 0.0001. The mean protamine vials used were 1.33 v 2.02, p < 0.0001. When the calculations were based on 50 mg vials, the number of vials used per case in the Low Dose group was even less (-2.16, 99% CI -2.36 to -1.97, p < 0.0001).) CONCLUSIONS: Conservation measures regarding critical medications and supplies during times of shortages can maintain access to important services within a community.

Optical refrigeration of payloads to T < 125†K.

A modified all-solid-state optical cryocooler prototype based on anti-Stokes fluorescence in a 10%-doped Yb:YLF crystal cooled a payload to temperatures below 125 K starting from room temperature. To achieve this record performance, the optical refrigerator employed a novel, to the best of our knowledge, textured-MgF2 thermal link to improve the thermal transport and fluorescence escape. Additionally, it used spectrally selective, high-reflection coatings in the pump circulator cavity to suppress parasitic lasing and amplified spontaneous emission.

Managing capacity for urgent surgery: staffing, staff scheduling in-house or on-call from home, and work assignments.

Parmar and colleagues developed and validated a graphical method for choosing the number of operating theatres to set aside for urgent surgical cases. We address appropriate usage of their new method for calculating anaesthesia staffing, including comparison with previously published techniques. Parmar and colleagues' method is based on all staff scheduled in-house, rather than some on-call from home. We review that this is not nearly as large a limitation as it may seem because of behavioural factors of staff assignment.

Case duration prediction and estimating time remaining in ongoing cases.

In this issue of the British Journal of Anaesthesia, Jiao and colleagues applied a neural network model for surgical case durations to predict the operating room times remaining for ongoing anaesthetics. We review estimation of case durations before each case starts, showing why their scientific focus is useful. We also describe managerial epidemiology studies of historical data by the scheduled procedure or distinct combinations of scheduled procedures included in each surgical case. Most cases have few or no historical data for the scheduled procedures. Generalizability of observational results such as theirs, and automatic computer assisted clinical and managerial decision-making, are both facilitated by using structured vocabularies when analysing surgical procedures.

More surgery in December among US patients with commercial insurance is offset by unrelated but lesser surgery among patients with Medicare insurance.

STUDY OBJECTIVE: Evaluate whether there is more surgery (in the US State of Florida) at the end of the year, specifically among patients with commercial insurance. DESIGN: Observational cohort study. SETTING: The 712 facilities in Florida that performed inpatient or outpatient elective surgery from January 2010 through December 2019. RESULTS: Among patients with commercial insurance, December had more cases than November (1.108 [1.092-1.125]) or January (1.257 [1.229-1.286]). In contrast, among patients with Medicare insurance (traditional or managed care), December had fewer cases than November (ratio 0.917 [99% confidence interval 0.904-0.930]) or January (0.823 [0.807-0.839]) of the same year. Summing among all cases, December did not have more cases than November (ratio 1.003 [0.992-1.014]) or January (0.998 [0.984-1.013]). Comparing December versus November (January) ratios for cases among patients with commercial insurance to the corresponding ratios for cases among patients with Medicare, years with more commercial insurance cases had more Medicare cases (Spearman rank correlation +0.36 [+0.25], both p < 0.0001). CONCLUSIONS: In the US State of Florida, although some surgeons' procedural workloads may have seasonal variation if they care mostly for patients with one category of insurance, surgical facilities with patients undergoing many procedures will have less variability. Importantly, more commercial insurance cases were not causing Medicare cases to be postponed or vice-versa, providing mechanistic explanation for why forecasts of surgical demand can reasonably be treated as the sum of the independent workloads among many surgeons.

Scheduling staff for ambulatory anaesthesia.

PURPOSE OF REVIEW: In this study, we summarize six articles published from January 2020 through June 2022 covering anaesthesia staff scheduling and consider their relevance to ambulatory surgery. Staff scheduling refers to the planned shift length of each person working on specific dates. RECENT FINDINGS: Increasing shift lengths compensates for COVID-19 pandemic staffing issues by reducing patient queues and mitigating the impact of staff absence from SAR-CoV-2 infection. Reduced labour costs can often be achieved by regularly scheduling more practitioners than expected from intuition. Probabilities of unscheduled absences, estimated using historical data, should be incorporated into staff scheduling calculations. Anesthetizing locations, wherein anaesthesiologists are scheduled, may need to be revised if the practitioner is lactating to facilitate uninterrupted breast milk pumping sessions. If room assignments are based on the educational value for residents, then schedule other practitioners based on residents' expected work hours, not their planned shift lengths. Mixed integer programming can be used effectively to reduce variability among resident physicians in workloads during their rotations. SUMMARY: Readers can reasonably select among these studies and benefit from the one or two applicable to their facilities' characteristics and work hours.

The secret identities of TMPRSS2: Fertility factor, virus trafficker, inflammation moderator, prostate protector and tumor suppressor.

The human TMPRSS2 gene is pathogenetically implicated in both coronaviral lung infection and prostate cancer, suggesting its potential as a drug target in both contexts. SARS-COV-2 spike polypeptides are primed by the host transmembrane TMPRSS2 protease, triggering virus fusion with epithelial cell membranes followed by an endocytotic internalisation process that bypasses normal endosomal activation of cathepsin-mediated innate immunity; viral co-opting of TMPRSS2 thus favors microbial survivability by attenuating host inflammatory responses. In contrast, most early hormone-dependent prostate cancers express TMPRSS2:ERG fusion genes arising from deletions that eliminate the TMPRSS2 coding region while juxtaposing its androgen-inducible promoter and the open reading frame of ERG, upregulating pro-inflammatory ERG while functionally disabling TMPRSS2. Moreover, inflammatory oxidative DNA damage selects for TMPRSS2:ERG-fused cancers, whereas patients treated with antiinflammatory drugs develop fewer of these fusion-dependent tumors. These findings imply that TMPRSS2 protects the prostate by enabling endosomal bypass of pathogens which could otherwise trigger inflammation-induced DNA damage that predisposes to TMPRSS2:ERG fusions. Hence, the high oncogenic selectability of TMPRSS2:ERG fusions may reflect a unique pro-inflammatory synergy between androgenic ERG gain-of-function and fusogenic TMPRSS2 loss-of-function, cautioning against the use of TMPRSS2-inhibitory drugs to prevent or treat early prostate cancer.

Open-aperture Z-scan study for absorption saturation: accurate measurement of saturation intensity in YLF:Yb for optical refrigeration.

Knowledge of saturation intensity of gain or absorption plays a fundamental role in a variety of applications ranging from lasers to many nonlinear optical processes. Here, we present an analytical expression for open-aperture Z-scan transmission for accurately measuring the saturation intensity in the low absorbance samples but at arbitrary pump intensities. We exploit this formalism to investigate the absorption saturation of LiYF4:Yb3+ (YLF:Yb) in the anti-Stokes excitation region for optical refrigeration at high pump intensities. An absorption saturation intensity of 14.5±1kW/cm2 was measured in YLF:Yb at 1020 nm (E||c) at room temperature.

Successful Implementation of a Perioperative Data Warehouse Using Another Hospital's Published Specification From Epic's Electronic Health Record System.

BACKGROUND: Many hospitals have replaced their legacy anesthesia information management system with an enterprise-wide electronic health record system. Integrating the anesthesia data within the context of the global hospital information infrastructure has created substantive challenges for many organizations. A process to build a perioperative data warehouse from Epic was recently published from the University of California Los Angeles (UCLA), but the generalizability of that process is unknown. We describe the implementation of their process at the University of Miami (UM). METHODS: The UCLA process was tested at UM, and performance was evaluated following the configuration of a reporting server and transfer of the required Clarity tables to that server. Modifications required for the code to execute correctly in the UM environment were identified and implemented, including the addition of locally specified elements in the database. RESULTS: The UCLA code to build the base tables in the perioperative data warehouse executed correctly after minor modifications to match the local server and database architecture at UM. The 26 stored procedures in the UCLA process all ran correctly using the default settings provided and populated the base tables. After modification of the item lists to reflect the UM implementation of Epic (eg, medications, laboratory tests, physiologic monitors, and anesthesia machine parameters), the UCLA code ran correctly and populated the base tables. The data from those tables were used successfully to populate the existing perioperative data warehouse at UM, which housed data from the legacy anesthesia information management system of the institution. The time to pull data from Epic and populate the perioperative data warehouse was 197 ± 47 minutes (standard deviation [SD]) on weekdays and 260 ± 56 minutes (SD) on weekend days, measured over 100 consecutive days. The longer times on weekends reflect the simultaneous execution of database maintenance tasks on the reporting server. The UCLA extract process has been in production at UM for the past 18 months and has been invaluable for quality assurance, business process, and research activities. CONCLUSIONS: The data schema developed at UCLA proved to be a practical and scalable method to extract information from the Epic electronic health system database into the perioperative data warehouse in use at UM. Implementing the process developed at UCLA to build a comprehensive perioperative data warehouse from Epic is an extensible process that other hospitals seeking more efficient access to their electronic health record data should consider.

Effects of State Law Limiting Postoperative Opioid Prescription in Patients After Cesarean Delivery.

BACKGROUND: The impact of the Florida State law House Bill 21 (HB 21) restricting the duration of opioid prescriptions for acute pain in patients after cesarean delivery is unknown. Our objective was to assess the association of the passage of Florida State law HB 21 with trends in discharge opioid prescription practices following cesarean delivery, necessity for additional opioid prescriptions, and emergency department visits at a large tertiary care center. METHODS: This was a retrospective cohort study conducted at a large, public hospital. The 2 cohorts represented the period before and after implementation of the law. Using a confounder-adjusted segmented regression analysis of an interrupted time series, we evaluated the association between HB 21 and trends in the proportions of patients receiving opioids on discharge, duration of opioid prescriptions, total opioid dose prescribed, and daily opioid dose prescribed. We also compared the need for additional opioid prescriptions within 30 days of discharge and the prevalence of emergency department visits within 7 days after discharge. RESULTS: Eight months after implementation of HB 21, the mean duration of opioid prescriptions decreased by 2.9 days (95% confidence interval [CI], 5.2-0.5) and the mean total opioid dose decreased by 20.1 morphine milligram equivalents (MME; 95% CI, 4-36.3). However, there was no change in the proportion of patients receiving discharge opioids (95% CI of difference, -0.1 to 0.16) or in the mean daily opioid dose (mean difference, 5.3 MME; 95% CI, -13 to 2.4). After implementation of the law, there were no changes in the proportion of patients who required additional opioid prescriptions (2.1% vs 2.3%; 95% CI of difference, -1.2 to 1.5) or in the prevalence of emergency department visits (2.4% vs 2.2%; 95% CI of difference, -1.6 to 1.1). CONCLUSIONS: Implementation of Florida Law HB 21 was associated with a lower total prescribed opioid dose and a shorter duration of therapy at the time of hospital discharge following cesarean delivery. These reductions were not associated with the need for additional opioid prescriptions or emergency department visits.

Intraoperative Focused Cardiac Ultrasound for Assessment of Hypotension: A Systematic Review.

Focused cardiac ultrasound (FoCUS) has become a valuable tool to assess unexplained hypotension in critically ill patients. Due to increasing availability of transthoracic echocardiography (TTE) equipment in the operating room, there is a widespread interest in its usefulness for intraoperative diagnosis of hypotension as an alternative to transesophageal echocardiography (TEE). The objective of this systematic review is to evaluate the utility of intraoperative FoCUS to assess patients experiencing unexplained hypotension while undergoing noncardiac surgery. We performed a systematic literature search of multiple publication databases for studies that evaluated the utility of intraoperative FoCUS for assessment and management of unexplained hypotension in patients undergoing noncardiac surgery, including retro- and prospective clinical studies. A summary of the study findings, study quality, and assessment of level of evidence is presented. We identified 2227 unique articles from the literature search, of which 27 were potentially relevant, and 9 were included in this review. The number of patients pooled from these studies was 255, of whom 228 had intraoperative diagnoses with the aid of intraoperative FoCUS. The level of evidence of all studies included was very low according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) guidelines. This systematic review has demonstrated that FoCUS may be a useful, noninvasive method to differentiate causes of intraoperative hypotension and guide correcting interventions, although the quality of evidence is very low. Further prospective high-quality studies are needed to investigate whether intraoperative FoCUS has a diagnostic utility that is associated with improved outcomes.

Quantifying and interpreting inequality of surgical site infections among operating rooms.

PURPOSE: The incidence of surgical site infection differs among operating rooms (ORs). However, cost effectiveness of interventions targeting ORs depends on infection counts. The purpose of this study was to quantify the inequality of infection counts among ORs. METHODS: We performed a single-centre historical cohort study of elective surgical cases spanning a 160-week period from May 2017 to May 2020, identifying cases of infection within 90 days using International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes. We used the Gini index to measure inequality of infections among ORs. As a reference, the Gini index for inequality of household disposable income in the US in 2017 was 0.39, and 0.31 for Canada. RESULTS: There were 3,148 (3.67%) infections among the 85,744 cases studied. The 20% of 57 ORs with the most and least infections accounted for 44% (99% confidence interval [CI], 36 to 52) and 5% (99% CI, 2 to 8), respectively. The Gini index was 0.40 (99% CI, 0.31 to 0.50), which is comparable to income inequality in the US. There were more infections in ORs with more minutes of cases (Spearman correlation ρ = 0.68; P < 0.001), but generally not in ORs with more total cases (ρ = 0.11; P = 0.43). Moderately long (3.3 to 4.8 hr) cases had a large effect, having greater incidences of infection, while not being so long as to have just one case per day per OR. There was substantially greater inequality in infection counts among the 557 observed combinations of OR specialty (Gini index 0.85; 99% CI, 0.81 to 0.88). CONCLUSIONS: Inequality of infections among ORs is substantial and caused by both inequality in the incidence of infections and inequality in the total minutes of cases. Inequality in infections among OR and specialty combinations is due principally to inequality in total minutes of cases.

RéSUMé: OBJECTIF: L'incidence d'infections opératoires diffère d'une salle d'opération (SOP) à une autre. Toutefois, le rapport coût-efficacité des interventions ciblant les SOP dépend de l'incidence des infections. Le but de cette étude était de quantifier l'inégalité du nombre d'infections entre les SOP. MéTHODE: Nous avons effectué une étude de cohorte historique et monocentrique des cas chirurgicaux non urgents couvrant une période de 160 semaines allant de mai 2017 à mai 2020. Nous avons identifié les cas d'infection dans les 90 jours suivant l'opération à l'aide des codes de diagnostic de la Classification internationale des maladies, dixième révision, modification clinique. Nous avons utilisé l'indice de Gini pour mesurer l'inégalité des infections entre les SOP. À titre de référence, en 2017, l'indice de Gini pour l'inégalité du revenu disponible des ménages était de 0,39 aux États-Unis et de 0,31 pour le Canada. RéSULTATS: Il y a eu 3148 (3,67 %) infections parmi les 85 744 cas étudiés. Les quintiles des 57 SOP ayant le plus et le moins d'infections représentaient 44 % (intervalle de confiance [IC] 99 %, 36 à 52) et 5 % (IC 99 %, 2 à 8) des infections, respectivement. L'indice de Gini était de 0,40 (IC 99 %, 0,31 à 0,50), ce qui est comparable à l'inégalité des revenus aux États-Unis. Il y avait plus d'infections dans les SOP comptant plus de minutes de cas (corrélation de Spearman ρ = 0,68; P < 0,001), mais généralement pas dans les SOP avec un nombre plus élevé de cas totaux (ρ = 0,11; P = 0,43). Les cas modérément longs (3,3 à 4,8 heures) ont eu un effet important, ayant des incidences plus importantes d'infection, tout en n'étant pas suffisamment longs pour n'avoir qu'un seul cas par jour et par SOP. Une inégalité sensiblement plus prononcée a été remarquée dans le nombre d'infections parmi les 557 combinaisons observées de spécialité de SOP (indice de Gini 0,85; IC 99 %, 0,81 à 0,88). CONCLUSION: L'inégalité des infections entre les SOP est importante et causée à la fois par l'inégalité dans l'incidence des infections et par l'inégalité dans la durée totale (en minutes) des cas. L'inégalité dans les infections entre les SOP et les combinaisons de spécialités est principalement due à l'inégalité dans le nombre total de minutes des cas.

Annual Number of Spinal Cord Stimulation Procedures Performed in the State of Florida During 2018: Implications for Establishing Neuromodulation Centers of Excellence.

OBJECTIVE: To assess the volume of spinal cord stimulation procedures performed by physicians in the state of Florida in 2018. MATERIALS AND METHODS: We obtained information from publicly available state databases for all patients undergoing procedures in 2018 at Florida hospitals, hospital-owned facilities, and independent ambulatory surgery centers. Cases in which a spinal cord stimulation procedure was performed were identified. We estimated for each physician office-based spinal cord stimulation trials (not subject to state reporting) based on the published Florida conversion factor of 25.6% of the total number of such procedures. The medical specialty of the listed performing physician was determined based on the national provider identifier. Counts of neurostimulation procedures performed by physician and within specialties were determined. The numbers of physicians and specialties performing various thresholds between 1 and ≥100 per year were determined, and the percentages of patients whose care was delivered by physicians below each threshold were determined. RESULTS: The data analyzed included 10,762 spinal cord stimulation cases. Among the 606 physicians who performed at least one spinal cord stimulation procedure, only nine performed at least 100 cases in 2018. During 2018, 78.4% of physicians performed, on average, <2 spinal cord stimulation procedures per month; there were 29.4% of spinal cord stimulation patients cared for by such physicians. Physicians performing less than four cases per month provided care for 56.9% of all cases. CONCLUSIONS: Few physicians performing spinal cord stimulation procedures in the state of Florida in 2018 would have been considered as "high volume." Although volume is only one among many criteria used to designate centers of excellence for other procedures, the potential impact on physician practice and patient access to care should be considered if a specific minimum number of annual cases by physician is to be established.