Above the GRADE: Evaluation of Guidelines in Critical Care Medicine.

OBJECTIVES: We examined recommendations within critical care guidelines to describe the pairing patterns for strength of recommendation and quality of evidence. We further identified recommendations where the reported strength of recommendation was strong while the reported quality of evidence was not high/moderate and then assessed whether such pairings were within five paradigmatic situations offered by Grading of Recommendations Assessment, Development and Evaluation methodology to justify such pairings. DATA SOURCES AND EXTRACTION: We identified all clinical critical care guidelines published online from 2011 to 2017 by the Society of Critical Care Medicine along with individual guidelines published by Surviving Sepsis Campaign, Kidney Disease Improving Global Outcomes, American Society for Parenteral and Enteral Nutrition, and the Infectious Disease Society of America/American Thoracic Society. DATA SYNTHESIS: In all, 15 documents specifying 681 eligible recommendations demonstrated variation in strength of recommendation (strong n = 215 [31.6%], weak n = 345 [50.7%], none n = 121 [17.8%]) and in quality of evidence (high n = 41 [6.0%], moderate n = 151 [22.2%], low/very low n = 298 [43.8%], and Expert Consensus/none n = 191 [28.1%]). Strength of recommendation and quality of evidence were positively correlated (ρ = 0.66; p < 0.0001). Of 215 strong recommendations, 69 (32.1%) were discordantly paired with evidence other than high/moderate. Twenty-two of 69 (31.9%) involved Strong/Expert Consensus recommendations, a category discouraged by Grading of Recommendations Assessment, Development and Evaluation methodology. Forty-seven of 69 recommendations (68.1%) were comprised of Strong/Low or Strong/Very Low variation requiring justification within five paradigmatic scenarios. Among distribution in the five paradigmatic scenarios of Strong/Low and Strong/Very Low recommendations, the most common paradigmatic scenario was life threatening situation (n = 20/47; 42.6%). Four Strong/Low or Strong/Very Low recommendations (4/47; 8.5%) were outside Grading of Recommendations Assessment, Development and Evaluation methodology. CONCLUSIONS: Among a large, diverse assembly of critical care guideline recommendations using Grading of Recommendations Assessment, Development and Evaluation methodology, the strength of evidence of a recommendation was generally associated with the quality of evidence. However, strong recommendations were not infrequently made in the absence of high/moderate quality of evidence. To improve clarity and uptake, future guideline statements may specify why such pairings were made, avoid such pairings when outside of Grading of Recommendations Assessment, Development and Evaluation criteria, and consider separate language for Expert Consensus recommendations (good practice statements).

Speaker Gender Representation at the American Society of Anesthesiology Annual Meeting: 2011-2016.

The American Society of Anesthesiologists (ASA) Annual Meeting is the primary venue for anesthesiologists to present research, share innovations, and build networks. Herein, we describe gender representation for physician speakers at the Annual Meeting relative to the specialty overall. Details of ASA Annual Meeting presentations for individuals and panels were abstracted from the ASA archives for 2011-2016. Observed speaker gender composition was compared to expected composition based on the gender distribution of members of the ASA. There were 5167 speaker slots across 2025 presentations and panels. Of the speaker slots, 3874 were assigned to men and 1293 to women. Speaker slot gender composition was relatively consistent between 2011 and 2016 (annual percentage 22.3%-27.7% women, trend test P = .062). ASA membership composition of women increased slightly over the study period (24%-28%). The overall observed number of women in speaker slots over the study period did not differ significantly from what would be expected based on the ASA membership composition (25.0% observed versus 25.9% expected; P = .153). However, the percentage of single speakers who were women was significantly less than would be expected based on the ASA gender distribution (20.2% observed versus 25.9% expected; P < .001). Interestingly, for panels that included 2-5 anesthesiologists, single-gender panels were more common than would be expected by chance, with all-male panels predominating (all P < .01). The gender composition of speakers at the ASA Annual Meeting largely reflected gender composition within the specialty, although women were not overrepresented at any meeting. The predominance of single-gender panels and underrepresentation of women as single speakers is a potential target to improve gender representation.

Whole-lung Lavage and Pulmonary Alveolar Proteinosis: Review of Clinical and Patient-centered Outcomes.

OBJECTIVE: The objective of this retrospective review was to evaluate the perioperative and procedural management of patients with pulmonary alveolar proteinosis (PAP) who presented for whole-lung lavage (WLL). DESIGN: The records of all adult patients with PAP who underwent WLL between January 1, 1988 and August 20, 2017 were reviewed and pertinent demographic, preoperative, anesthetic, procedural, and postoperative data were recorded. SETTING: Large academic tertiary referral center. PARTICIPANTS: Forty patients with PAP underwent 79 WLL procedures. INTERVENTIONS: Patients with PAP undergoing WLL. MEASUREMENTS: Successful WLL, defined by visual clearing of lavage fluid, was completed in 91% of cases. Whole-lung lavage was terminated prematurely in 9% of cases (refractory hypoxia most common), while 8% of cases were found to have 30-day complications. There were no cases of intraoperative death, hemodynamic collapse, pneumothorax or hydrothorax, or need for emergent reintubation. Postoperative clinical follow-up at the authors' institution within 6 months of WLL showed 68% of patients reported improvement in symptoms and/or functional status. CONCLUSION: The authors here present a retrospective study describing the perioperative and procedural management of PAP patients undergoing WLL to help familiarize providers with the management of this population (Fig 1). The findings of this study outline a successful and consistent approach to WLL using a multidisciplinary team experienced in this procedure. Even in experienced hands, procedural complications and 30-day postoperative complications emphasize the risk in this complex patient population.

Characterizing the spectrum of body mass index associated with severe postoperative pulmonary complications in children.

PURPOSE: While high body mass index (BMI) is a recognized risk factor for pulmonary complications in adults, its importance as a risk factor for complications following pediatric surgery is poorly described. We evaluated the association between BMI and severe pediatric perioperative pulmonary complications (PPCs). METHODS: In this retrospective cohort study, we evaluated pediatric patients (aged 2-17 years) undergoing elective procedures in the 2015 Pediatric National Surgical Quality Improvement Program (NSQIP-P). Severe PPCs were defined as either pneumonia/reintubation within 3 days of surgery, or pneumonia/reintubation as an index complication within 7 days. Univariate and multivariable logistic regression analyses adjusting for patient factors and surgical case-mix tested associations between BMI class-using the Centers for Disease Control age- and sex-dependent BMI percentiles-and severe PPCs. RESULTS: Among 40,949 patients, BMI class was distributed as follows: 2740 (6.7%) were underweight, 23,630 (57.7%) normal weight, 6161 (15.0%) overweight, and 8418 (20.6%) obese. Overweight BMI class was not associated with PPCs in univariate analyses, but became statistically significant after adjustment [OR 1.84 (95% CI 1.07-3.15), p = 0.03], and persisted across multiple adjustment approaches. Neither underweight [OR 1.01 (95% CI 0.53-1.94), p = 0.97] nor obesity [OR 1.10 (95% CI 0.63-1.94), p = 0.73] were associated with PPCs after adjustment. CONCLUSION: Overweight pediatric patients have an elevated, previously underappreciated risk of severe PPCs. Contrary to prior studies, the present study found no greater risk in obese children, perhaps due to bias, confounding, or practice migration from "availability bias". Findings from the present study, taken with prior work describing pulmonary risks of obesity, suggest that both obese and overweight children may be evaluated for tailored perioperative care to improve outcomes.

Assessing the Safety of Overlapping Surgery at a Children's Hospital.

IMPORTANCE: Media reports have questioned the safety of overlapping surgical procedures, and national scrutiny has underscored the necessity of single-center evaluations of its safety; however, sample sizes are likely small. We compared the safety profiles of overlapping and nonoverlapping pediatric procedures at a single children's hospital and discussed methodological considerations of the evaluation. DATA AND DESIGN: Retrospective analysis of inpatient pediatric surgical procedures (January 2013 to September 2015) at a single pediatric referral center. Overlapping and nonoverlapping procedures were matched in an unbalanced manner (m:n) by procedure. Mixed models adjusting for Vizient-predicted risk, case-mix, and surgeon compared inpatient mortality and length of stay (LOS). RESULTS: Among 315 overlapping procedures, 256 (81.3%) were matched to 645 nonoverlapping procedures. There were 6 deaths in all. The adjusted odds ratio for mortality did not differ significantly between nonoverlapping and overlapping procedures (adjusted odds ratio = 0.94 vs overlapping; 95% CI, 0.02-48.5; P = 0.98). Wide confidence intervals were minimally improved with Bayesian methods (95% CI, 0.07-12.5). Adjusted LOS estimates were not clinically different by overlapping status (0.6% longer for nonoverlapping; 95% CI, 9.7% shorter to 12.2% longer; P = 0.91). Among the 87 overlapping procedures with the greatest overlap (≥60 min or ≥50% of operative duration), there were no deaths. CONCLUSIONS: The safety of overlapping and nonoverlapping surgical procedures did not differ at this children's center. These findings may not extrapolate to other centers. LOS or intraoperative measures may be more appropriate than mortality for safety evaluations due to low event rates for mortality.

Hospital Rating Systems and Implications For Patient Travel to Better-rated Hospitals.

Publicly reported hospital ratings aim to encourage transparency, spur quality improvement, and empower patient choice. Travel burdens may limit patient choice, particularly for older adults (aged 65 years and more) who receive most medical care. For 3 major hospital ratings systems, we estimated travel burden as the additional 1-way travel distance to receive care at a better-rated hospital.Distances were estimated from publicly available data from the US Census, US News Top Hospitals, Society of Thoracic Surgeons composite rating for coronary artery bypass grafting (STS-CABG), and Centers for Medicare and Medicaid Services Hospital Consumer Assessment of Healthcare Providers and Services (HCAHPS).Hospitals were rated for HCAHPS (n = 4656), STS-CABG (n = 470), and US News Top Hospitals (n = 15). Older adults were commonly located within 25 miles of their closest HCAHPS hospital (89.6%), but less commonly for STS-CABG (62.9%). To receive care at a better-rated hospital, travel distances commonly exceeded 25 miles: HCAHPS (39.2%), STS-CABG (62.7%), and US News Top Hospital (85.2%). Additional 1-way travel distances exceeded 25 miles commonly: HCAHPS (23.7%), STS-CABG (36.7%), US News Top Hospitals (81.8%).Significant travel burden is common for older adults seeking "better" care and is an important limitation of current hospital ratings for empowering patient choice.

Safety of Overlapping Surgery at a High-volume Referral Center.

OBJECTIVE: To compare safety profiles of overlapping and nonoverlapping surgical procedures at a large tertiary-referral center where overlapping surgery is performed. BACKGROUND: Surgical procedures are frequently performed as overlapping, wherein one surgeon is responsible for 2 procedures occurring at the same time, but critical portions are not coincident. The safety of this practice has not been characterized. METHODS: Primary analyses included elective, adult, inpatient surgical procedures from January 2013 to September 2015 available through University HealthSystem Consortium. Overlapping and nonoverlapping procedures were matched in an unbalanced manner (m:n) by procedure type. Confirmatory analyses from the American College of Surgeons-National Surgical Quality Improvement Program investigated elective surgical procedures from January 2011 to December 2014. We compared outcomes mortality and length of stay after adjustment for registry-predicted risk, case-mix, and surgeon using mixed models. RESULTS: The University HealthSystem Consortium sample included 10,765 overlapping cases, of which 10,614 (98.6%) were matched to 16,111 nonoverlapping procedures. Adjusted odds ratio for inpatient mortality was greater for nonoverlapping procedures (adjusted odds ratio, OR = 2.14 vs overlapping procedures; 95% confidence interval, CI 1.23-3.73; P = 0.007) and length of stay was no different (+1% for nonoverlapping cases; 95% CI, -1% to +2%; P = 0.50). In confirmatory analyses, 93.7% (3712/3961) of overlapping procedures matched to 5,637 nonoverlapping procedures. The 30-day mortality (adjusted OR = 0.69 nonoverlapping vs overlapping procedures; 95% CI, 0.13-3.57; P = 0.65), morbidity (adjusted OR = 1.11; 95% CI, 0.92-1.35; P = 0.27) and length of stay (-4% for nonoverlapping; 95% CI, -4% to -3%; P < 0.001) were not clinically different. CONCLUSIONS: These findings from administrative and clinical registries support the safety of overlapping surgical procedures at this center but may not extrapolate to other centers.

Risk Prediction Accuracy Differs for Emergency Versus Elective Cases in the ACS-NSQIP.

BACKGROUND: Accurate risk estimation is essential when benchmarking surgical outcomes for reimbursement and engaging in shared decision-making. The greater complexity of emergency surgery patients may bias outcome comparisons between elective and emergency cases. OBJECTIVE: To test whether an established risk modelling tool, the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) predicts mortality comparably for emergency and elective cases. METHODS: From the ACS-NSQIP 2011-2012 patient user files, we selected core emergency surgical cases also common to elective scenarios (gastrointestinal, vascular, and hepato-biliary-pancreatic). After matching strategy for Common Procedure Terminology (CPT) and year, we compared the accuracy of ACS-NSQIP predicted mortality probabilities using the observed-to-expected ratio (O:E), c-statistic, and Brier score. RESULTS: In all, 56,942 emergency and 136,311 elective patients were identified as having a common CPT and year. Using a 1:1 matched sample of 37,154 emergency and elective patients, the O:E ratios generated by ACS-NSQIP models differ significantly between the emergency [O:E = 1.031; 95% confidence interval (CI) = 1.028-1.033] and elective populations (O:E = 0.79; 95% CI = 0.77-0.80, P < 0.0001) and the c-statistics differed significantly (emergency c-statistic = 0.927; 95% CI = 0.921-0.932 and elective c-statistic = 0.887; 95% CI = 0.861-0.912, P = 0.003). The Brier score, tested across a range of mortality rates, did not differ significantly for samples with mortality rates of 6.5% and 9% (eg, emergency Brier score = 0.058; 95% CI = 0.048-0.069 versus elective Brier score = 0.057; 95% CI = 0.044-0.07, P = 0.87, among 2217 patients with 6.5% mortality). When the mortality rate was low (1.7%), Brier scores differed significantly (emergency 0.034; 95% CI = 0.027-0.041 versus elective 0.016; 95% CI = 0.009-0.023, P value for difference 0.0005). CONCLUSION: ACS-NSQIP risk estimates used for benchmarking and shared decision-making appear to differ between emergency and elective populations.

Hospital-level Variation in Secondary Complications After Surgery.

OBJECTIVES: To assess whether hospital rates of secondary complications could serve as a performance benchmark and examine associations with mortality. BACKGROUND: Failure to rescue (death after postoperative complication) is a challenging target for quality improvement. Secondary complications (complications after a first or "index" complication) are intermediate outcomes in the rescue process that may provide specific improvement targets and give us insight into how rescue fails. METHODS: We used American College of Surgeons' National Surgical Quality Improvement Program data (2008-2012) to define hospital rates of secondary complications after 5 common index complications: pneumonia, surgical site infection (SSI), urinary tract infection, transfusion/bleed events, and acute myocardial infarction (MI). Hospitals were divided into quintiles on the basis of risk- and reliability-adjusted rates of secondary complications, and these rates were compared along with mortality. RESULTS: A total of 524,860 patients were identified undergoing one of the 62 elective, inpatient operations. After index pneumonia, secondary complication rates varied from 57.99% in the highest quintile to 22.93% in the lowest [adjusted odds ratio (OR), 4.64; confidence interval (CI), 3.95-5.45). Wide variation was seen after index SSI (58.98% vs 14.81%; OR, 8.53; CI, 7.41-9.83), urinary tract infection (38.41% vs 8.60%; OR, 7.81; CI, 6.48-9.40), transfusion/bleeding events (27.14% vs 12.88%; OR, 2.54; CI, 2.31-2.81), and acute MI (64.45% vs 23.86%, OR, 6.87; CI, 5.20-9.07). Hospitals in the highest quintile had significantly greater mortality after index pneumonia (10.41% vs 6.20%; OR, 2.17; CI, 1.6-2.94), index MI (18.25% vs 9.65%; OR, 2.67; CI, 1.80-3.94), and index SSI (2.75% vs 0.82%; OR, 3.93; CI, 2.26-6.81). CONCLUSIONS: Hospital-level rates of secondary complications (failure to arrest complications) vary widely, are associated with mortality, and may be useful for quality improvement and benchmarking.

Anesthesia Care Transitions and Risk of Postoperative Complications.

BACKGROUND: A patient undergoing surgery may receive anesthesia care from several anesthesia providers. The safety of anesthesia care transitions has not been evaluated. Using unconditional and conditional multivariable logistic regression models, we tested whether the number of attending anesthesiologists involved in an operation was associated with postoperative complications. METHODS: In a cohort of patients undergoing elective colorectal surgical in an academic tertiary care center with a stable anesthesia care team model participating in the American College of Surgeons National Surgical Quality Improvement Program, using unconditional and conditional multivariable logistic regression models, we tested adjusted associations between numbers of attending anesthesiologists and occurrence of death or a major complication (acute renal failure, bleeding that required a transfusion of 4 units or more of red blood cells within 72 hours after surgery, cardiac arrest requiring cardiopulmonary resuscitation, coma of 24 hours or longer, myocardial infarction, unplanned intubation, ventilator use for 48 hours or more, pneumonia, stroke, wound disruption, deep or organ-space surgical-site infection, superficial surgical-site infection, sepsis, septic shock, systemic inflammatory response syndrome). RESULTS: We identified 927 patients who underwent elective colectomy of comparable surgical intensity. In all, 71 (7.7%) patients had major nonfatal complications or death. One anesthesiologist provided care for 530 (57%) patients, 2 anesthesiologists for 287 (31%), and 3 or more for 110 (12%). The number of attending anesthesiologists was associated with increased odds of postoperative complication (unadjusted odds ratio [OR] = 1.52, 95% confidence interval [CI] 1.18-1.96, P = 0.0013; adjusted OR = 1.44, 95% CI 1.09-1.91, P = 0.0106). In sensitivity analyses, occurrence of a complication was significantly associated with the number of in-room providers, defined as anesthesia residents and nurse anesthetists (adjusted OR = 1.39, 95% CI 1.01-1.92, P = 0.0446) and for all anesthesia providers (adjusted OR = 1.58, 95%CI 1.20-2.08, P = 0.0012). Findings persisted across multiple, alternative adjustments, sensitivity analyses, and conditional logistic regression with matching on operative duration. CONCLUSIONS: In our study, care by additional attending anesthesiologists and in-room providers was independently associated with an increased odds of postoperative complications. These findings challenge the assumption that anesthesia transitions are care neutral and not contributory to surgical outcomes.

Safety of Noncardiac Surgery in Patients With Hypertrophic Obstructive Cardiomyopathy at a Tertiary Care Center.

OBJECTIVES: This study's purpose was to review non-cardiac surgery (NCS) in patients with hypertrophic obstructive cardiomyopathy (HOCM) to examine perioperative management and quantify postoperative mortality and worsening heart failure. DESIGN: Retrospective review. SETTING: A single tertiary care center. PARTICIPANTS: The study included 57 adult patients with HOCM who underwent NCS from January 1, 1996, through January 31, 2014. INTERVENTIONS: Noncardiac surgery. MEASUREMENTS AND MAIN RESULTS: The authors identified 57 HOCM patients who underwent 96 NCS procedures. Vasoactive medications were administered to the majority of NCS patients. Three patients (3%) died within 30 days of NCS, but causes of death did not appear to be cardiac in nature. Death after NCS was not significantly associated with preoperative left ventricular ejection fraction (p = 0.2727) or peak instantaneous systolic resting gradient (0.8828), but was associated with emergency surgery (p = 0.0002). Three patients experienced worsening heart failure postoperatively, and this was significantly associated with preoperative New York Heart Association Class III-IV symptoms compared with I-II symptoms (p = 0.0008). CONCLUSIONS: HOCM patients safely can undergo NCS at multidisciplinary centers experienced in caring for these patients. The mortality rate in this study was less than that reported in the majority of other studies. Postoperative complications, including increasing heart failure, may occur, especially in patients with more severe preoperative cardiac symptoms.

Anesthetic considerations for patients with Bardet-Biedl syndrome: a case series and review of the literature.

BACKGROUND: Bardet-Biedl syndrome (BBS) is a rare genetic condition with manifestations that can impact anesthetic and perioperative care. There is a void of literature describing the perioperative anesthetic management in this complex patient population. OBJECTIVES: The purpose of this retrospective series was to describe the perioperative care of patients diagnosed with BBS at a large academic tertiary referral center with experience in caring for these patients. METHODS: All patients receiving anesthesia during the time between July 10, 1997 and Jan 1, 2015 were identified. Anesthetic and perioperative records were reviewed in detail for demographic, echocardiographic, preoperative, intraoperative, and postoperative data. RESULTS: We identified 12 patients with BBS undergoing 40 anesthetics at our institution. The study identified a high risk for difficult airway with need for advanced airway techniques (67% of patient's ≥ 18 years of age required either awake fiberoptic or video laryngoscopy techniques), cardiac abnormalities, renal impairment, morbid obesity, and intellectual disability as the main syndrome manifestations of interest to the anesthesiologist. No patient had perioperative complications directly related to BBS; however, each underwent thorough perioperative evaluation with emphasis on the systemic comorbidities associated with the syndrome. This report illustrates that patients with BBS can safely undergo anesthesia, but a detailed and often multidisciplinary preoperative evaluation is prudent.

Complication timing and association with mortality in the American College of Surgeons' National Surgical Quality Improvement Program database.

BACKGROUND: The relationship between timing of postoperative complications on mortality is unknown. We investigated the time-variable mortality risks of common surgical complications. METHODS: We identified patients undergoing nonemergent, in-patient surgery in the National Surgical Quality Improvement Program (NSQIP) database during 2005-2011 who experienced any of 13 complications within 2 wk of surgery. "Expected timing" was defined as the median postoperative day of occurrence. Hazard ratios (HRs) for complications earlier or later than expected were calculated using Cox proportional hazards, adjusted for age, procedure, American Society of Anesthesiology (ASA), and functional status. A secondary analysis evaluated the effect of preceding complication burden on the relationship between complication timing and mortality. RESULTS: Among 77,443 patients experiencing complications, significantly higher mortality was observed with early wound infections (superficial HR 1.30, confidence interval [CI] 1.01-1.70; deep HR 1.52, CI 1.07-2.16; and organ space HR 1.38, CI 1.11-1.70) despite adjustment for patient and operative factors and complication burden. Early cardiac arrest and unplanned intubation were associated with lower mortality, which persisted after adjustment (HR 0.59, CI 0.51-0.68; HR 0.38, CI 0.33-0.43, respectively). By contrast, late occurrence of acute myocardial infarction, pneumonia, and cerebrovascular accident was associated with significantly greater mortality risk (HR 1.41, CI 1.18-1.69; HR 1.37, CI 1.24-1.52; and HR 1.61, CI 1.31-1.98, respectively), but these associations became nonsignificant after adjustment for complication burden. CONCLUSIONS: Timing of complications plays an important role in mortality. Surgeons and trainees should be aware of these patterns and tailor their clinical care and monitoring practices to account for the implications of complication timing on mortality.

A meta-analysis of the predictive accuracy of postoperative mortality using the American Society of Anesthesiologists' physical status classification system.

BACKGROUND: The American Society of Anesthesiologists' physical status (ASA) tool has been applied to determine compensation, risk adjustment and risk prediction, but little is known about the accuracy and generalizability of this tool for prediction of postoperative mortality. METHODS: We systematically investigated prior published reports of associations between ASA physical status and mortality to test the hypothesis that ASA physical status will have varying accuracy in prediction of postoperative mortality across surgical populations with varying surgical risk of mortality. We used random effects models and metaregression to account for heterogeneity. RESULTS: Combining 77 studies with 165,705 patients, the ASA physical status tool demonstrated the following pooled performance (95 % confidence intervals)--sensitivity 0.74 (0.73, 0.74), specificity 0.67 (0.67, 0.67), and area under summary receiver operating curve 0.736 (0.725, 0.747). Metaregression revealed that study death rates and surgical specialty were significant factors. CONCLUSION: ASA physical status is a better predictor of postoperative mortality in settings with lower rather than higher death rates.

The Impact of a Shortage of Pharmacy-Prepared Ephedrine Syringes on Intraoperative Medication Use.

BACKGROUND: Anesthesia-related medication shortages have become increasingly common in the United States. We tested whether a local shortage of pharmacy-prepared ephedrine syringes, replaced by provider-prepared ephedrine, was associated with provider-level changes in ephedrine and phenylephrine use and patient-level changes in intraoperative hemodynamics. METHODS: Consecutive patients undergoing general and orthopedic surgery at a tertiary care center were included 1 month before and 1 month after the start of the pharmacy-prepared ephedrine syringe shortage. Lowest mean arterial blood pressure and slowest heart rate were obtained as measures of hemodynamics. Adjusted associations were tested using mixed-effects regression with repeated measures. RESULTS: Three hundred four patients before the shortage and 298 patients after the shortage began were included. The administration of at least 1 bolus of ephedrine was significantly more common before versus during the shortage (148/304 [48.7]% vs 117/298 [39.3]%; P = 0.0199). After adjusting for age, sex, ASA physical status, surgery type, anesthesia provider, and operative duration, patients were significantly less likely to receive ephedrine during the shortage (relative risk [RR] = 0.78 [95% confidence interval {CI}, 0.61-0.96]; P = 0.0198) and more likely to receive a phenylephrine bolus (RR = 1.27 [95% CI, 1.02-1.51]; P = 0.0357). Patient hemodynamics assessed by slowest heart rate or lowest mean arterial blood pressure did not differ significantly during the shortage. CONCLUSIONS: There was an alteration in medication administration patterns during a shortage of pharmacy-prepared syringes. Changes in ephedrine and phenylephrine use were noted; however, patient hemodynamics remained comparable. Provider use patterns were sensitive even to a relative and not absolute medication shortage as observed in this study.

What can the national quality forum tell us about performance measurement in anesthesiology?

BACKGROUND: Anesthesiologists face increasing pressure to demonstrate the value of the care they provide, whether locally or nationally through public reporting and payor requirements. In this article, we describe the current state of performance measurement in anesthesia care at the national level and highlight gaps and opportunities in performance measurement for anesthesiologists. METHODS: We evaluated all endorsed performance measures in the National Quality Forum (NQF), the clearinghouse for all federal performance measures, and classified all measures as follows: (1) anesthesia-specific; (2) surgery-specific; (3) jointly attributable; or (4) other. We used NQF-provided descriptors to characterize measures in terms of (1) structure, process, outcome, or efficiency; (2) patients, disease, and events targeted; (3) procedural specialty; (4) reporting eligibility; (5) measures stewards; and (6) timing in the care stream. RESULTS: Of the 637 endorsed performance measures, few (6, 1.0%) were anesthesia-specific. An additional 39 measures (6.1%) were surgery-specific, and 67 others (10.5%) were jointly attributable. "Anesthesia-specific" measures addressed preoperative antibiotic timing (n = 4), normothermia (n = 1), and protocol use for the placement of central venous catheter (n = 1). Jointly attributable measures included outcome measures (n = 49/67, 73.1%), which were weighted toward mortality alone (n = 24) and cardiac surgery (n = 14). Other jointly attributable measures addressed orthopedic surgery (n = 4), general surgical oncologic resections (n = 12), or nonspecified surgeries (n = 15), but none specifically addressed anesthesia care outside the operating room such as for endoscopy. Only 4 measures were eligible for value-based purchasing. No named anesthesiology professional groups were among measure stewards, but surgical professional groups (n = 33/67, 47%) were frequent measure stewards. CONCLUSIONS: Few NQF performance measures are specific to anesthesia practice, and none of these appears to demonstrate the value of anesthesia care or differentiate high-quality providers. To demonstrate their role in patient-centered, outcome-driven care, anesthesiologists may consider actively partnering in jointly attributable or team-based reporting. Future measures may incorporate surgical procedures not proportionally represented, as well as procedural and sedation care provided in nonoperating room settings.

Protein intake and lumbar bone density: the Multi-Ethnic Study of Atherosclerosis (MESA).

Dietary protein has been shown to increase urinary Ca excretion in randomised controlled trials, and diets high in protein may have detrimental effects on bone health; however, studies examining the relationship between dietary protein and bone health have conflicting results. In the present study, we examined the relationship between dietary protein (total, animal and vegetable protein) and lumbar spine trabecular volumetric bone mineral density (vBMD) among participants enrolled in the Multi-Ethnic Study of Atherosclerosis (n 1658). Protein intake was assessed using a FFQ obtained at baseline examination (2000-2). Lumbar spine vBMD was measured using quantitative computed tomography (2002-5), on average 3 years later. Multivariable linear and robust regression techniques were used to examine the associations between dietary protein and vBMD. Sex and race/ethnicity jointly modified the association of dietary protein with vBMD (P for interaction = 0·03). Among white women, higher vegetable protein intake was associated with higher vBMD (P for trend = 0·03), after adjustment for age, BMI, physical activity, alcohol consumption, current smoking, educational level, hormone therapy use, menopause and additional dietary factors. There were no consistently significant associations for total and animal protein intakes among white women or other sex and racial/ethnic groups. In conclusion, data from the present large, multi-ethnic, population-based study suggest that a higher level of protein intake, when substituted for fat, is not associated with poor bone health. Differences in the relationship between protein source and race/ethnicity of study populations may in part explain the inconsistent findings reported previously.

Barriers and Strategies for Effective Patient Rescue: A Qualitative Study of Outliers.

BACKGROUND: Organizational factors influencing failure-to-rescue (FTR)-or death after postoperative complications-are poorly understood. Case studies were conducted to generate hypotheses that could inform future FTR research and improvement strategies. METHODS: Publicly reported 2009-2011 data were used to identify 144 outlier hospitals with statistically better or worse FTR performance than the national average. Of these 144 hospitals, 7 were selected for case studies in a purposive sample. Outliers enabled a focus on the organizational factors and processes at the extremes of performance. Semi-structured interviews were conducted in 2013 with key informants at each hospital, and transcripts were analyzed using the constant comparative method to identify emergent organizational behavioral themes. RESULTS: The 7 hospitals-4 high- and 3 low-performing-yielded 106 interviews. Critical barriers to effective rescue were ineffective communication, lack of psychological safety, staffing discontinuity, imbalance of shared ownership and individual responsibility, lack of appropriate training and education, and difficulty using current metrics. Participants also identified strategies to overcome these barriers-rapid response teams, flattening the hierarchy, escalation strategies, health information technology, structured communication tools, constant team structures, standardized care pathways, and organizational learning. CONCLUSION: FTR is a complex process that is viewed, defined, and acted on differently across and within organizations. Early recognition of patients deviating from normal recovery was enhanced in high-performing hospitals through the use of standardized postoperative recovery pathways and automated escalation protocols. Current FTR measures may be less actionable for the purposes of quality improvement.