Practical Considerations of Perioperative Assessment and Optimization in Major Colorectal Surgery.

Successful outcomes after colorectal surgery result not only from technique in the operating room, but also from optimization of the patient prior to surgery. This article will discuss the role of preoperative assessment and optimization in the colorectal surgery patient. Through discussion of the various clinical models, readers will understand the range of options available for optimization. This study will also present information on how to design a preoperative clinic and the barriers to success.

American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Postoperative Delirium Prevention.

Postoperative delirium is a geriatric syndrome that manifests as changes in cognition, attention, and levels of consciousness after surgery. It occurs in up to 50% of patients after major surgery and is associated with adverse outcomes, including increased hospital length of stay, higher cost of care, higher rates of institutionalization after discharge, and higher rates of readmission. Furthermore, it is associated with functional decline and cognitive impairments after surgery. As the age and medical complexity of our surgical population increases, practitioners need the skills to identify and prevent delirium in this high-risk population. Because delirium is a common and consequential postoperative complication, there has been an abundance of recent research focused on delirium, conducted by clinicians from a variety of specialties. There have also been several reviews and recommendation statements; however, these have not been based on robust evidence. The Sixth Perioperative Quality Initiative (POQI-6) consensus conference brought together a team of multidisciplinary experts to formally survey and evaluate the literature on postoperative delirium prevention and provide evidence-based recommendations using an iterative Delphi process and Grading of Recommendations Assessment, Development and Evaluation (GRADE) Criteria for evaluating biomedical literature.

Safe Anesthesia Care in Western Kenya: A Preliminary Assessment of the Impact of Nurse Anesthetists at Multiple Levels of Government Hospitals.

BACKGROUND: Only 20% of the surgical burden in eastern sub-Saharan Africa is currently met, leaving >17 million surgical cases annually in need of safe surgery and anesthesia. Similarly, there is an extreme shortage of anesthesia providers in East Africa, with just 0.44 anesthesiologists per 100,000 people in Kenya compared to 20.82 per 100,000 in the United States. Additionally, surgical access is not equally distributed within countries, with rural settings often having the greatest unmet need. We developed and tested a set of tools to assess if graduates of the Kenya registered nurse anesthetist (KRNA) training program, who were placed in rural hospitals in Kenya, would have any impact on surgical numbers, referral patterns, and economics of these hospitals. METHODS: Cross-sectional data were collected from facility assessments in 9 referral hospitals to evaluate the possible impact of the KRNAs on anesthesia care. The hospitals were grouped based on both the number of beds and the assigned national hospital level. At each level, a hospital that had KRNA graduates (intervention) was matched with comparison hospitals in the same category with no KRNA graduates (control). The facility assessment survey included questions capturing data on personnel, infrastructure, supplies, medications, procedures, and outcomes. At the intervention sites, the medical directors of the hospitals and the KRNAs were interviewed. Descriptive statistics were used to present the findings. RESULTS: Intervention sites had a density of anesthesia providers that was 43% higher compared to the control sites. Intervention sites performed at least twice as many surgical cases compared to the control sites. Most KRNAs stated that the anesthesia training program had given them sufficient training and leadership skills to perform safe anesthesia in their clinical practice setting. Medical directors at the intervention sites reported increased surgical volumes and fewer referrals to larger hospitals due to the anesthesia gaps that had been addressed. CONCLUSIONS: Our findings from this study suggest that KRNAs may be associated with an increased volume of surgical cases completed in these rural Kenyan hospitals and may therefore be filling a known anesthetic void. The presence of skilled anesthesia providers is a first step toward providing safe surgery and anesthesia care for all; however, significant gaps still remain. Future analysis will focus on surgical outcomes, the appropriate anesthesia delivery model for a rural population, and how the availability of anesthesia infrastructure impacts referral patterns and safe surgery capacity.

Decision Support Tool Improves Real and Perceived Anesthesiology Resident Relief Equity.

BACKGROUND: The Accreditation Council of Graduate Medical Education requires monitoring of resident clinical and educational hours but does not require tracking daily work patterns or duty hour equity. Lack of such monitoring may allow for inequity that affects resident morale. No defined system for resident relief of weekday operating room (OR) clinical duties existed at our institution, leaving on-call residents to independently decide daily relief order. We developed an automated decision support tool (DST) to improve equitable decision making for clinical relief and assessed its impact on real and perceived relief equity. METHODS: The DST sent a daily e-mail to the senior resident responsible for relief decisions. It contained a prioritized relief list of noncall residents who worked in the OR beyond 5 PM the prior clinical day. We assessed actual relief equity using the number of times a resident worked in the OR past 5:30 PM on 2 consecutive weekdays as our outcome, adjusting for the mean number of open ORs each day between 5:00 PM and 6:59 PM in our main OR areas. We analyzed 14 months of data before implementation and 16 months of data after implementation. We assessed perceived relief equity before and after implementation using a questionnaire. RESULTS: After implementing the DST, the percentage of residents held 2 consecutive weekdays over the total of resident days worked decreased from 1.33% to 0.43%. The percentage of residents held beyond 5:30 PM on any given day decreased from 18.09% to 12.64%. Segmented regression analysis indicated that implementation of the DST was associated with a reduction in biweekly time series of residents kept late 2 days in a row, independent of the mean number of ORs in use. Surveyed residents reported the DST aided their ability to make equitable relief decisions (pre 60% versus post 94%; P = .0003). Eighty-five percent of residents strongly agreed that a prioritized relief list based on prior day work hours after 5 PM aided their decision making. After implementation, residents reported fewer instances of working past 5 PM within the past month (P < .005). CONCLUSIONS: A DST systematizing the relief process for anesthesiology residents was associated with a lower frequency of residents working beyond 5:30 PM in the OR on 2 consecutive days. The DST improved the perceived ability to make equitable relief decisions by on-call senior residents and residents being relieved. Success with this tool allows for broader applications in resident education, enabling enhanced monitoring of resident experiences and support for OR assignment decisions.

Assessment Tools for Use During Anesthesia-Centric Pediatric Advanced Life Support Training and Evaluation.

BACKGROUND: Pediatric perioperative cardiac arrests are rare events that require rapid, skilled and coordinated efforts to optimize outcomes. We developed an assessment tool for assessing clinician performance during perioperative critical events termed Anesthesia-centric Pediatric Advanced Life Support (A-PALS). Here, we describe the development and evaluation of the A-PALS scoring instrument. METHODS: A group of raters scored videos of a perioperative team managing simulated events representing a range of scenarios and competency. We assessed agreement with the reference standard grading, as well as interrater and intrarater reliability. RESULTS: Overall, raters agreed with the reference standard 86.2% of the time. Rater scores concerning scenarios that depicted highly competent performance correlated better with the reference standard than scores from scenarios that depicted low clinical competence (P < 0.0001). Agreement with the reference standard was significantly (P < 0.0001) associated with scenario type, item category, level of competency displayed in the scenario, correct versus incorrect actions and whether the action was performed versus not performed. Kappa values were significantly (P < 0.0001) higher for highly competent performances as compared to lesser competent performances (good: mean = 0.83 [standard deviation = 0.07] versus poor: mean = 0.61 [standard deviation = 0.14]). The intraclass correlation coefficient (interrater reliability) was 0.97 for the raters' composite scores on correct actions and 0.98 for their composite scores on incorrect actions. CONCLUSIONS: This study provides evidence for the validity of the A-PALS scoring instrument and demonstrates that the scoring instrument can provide reliable scores, although clinician performance affects reliability.

A perioperative consult service results in reduction in cost and length of stay for colorectal surgical patients: evidence from a healthcare redesign project.

BACKGROUND: A major restructuring of perioperative care delivery is required to reduce cost while improving patient outcomes. In a test implementation of this notion, we developed and implemented a perioperative consult service (PCS) for colorectal surgery patients. METHODS: A 6-month planning process was undertaken to engage key stakeholders from surgery, nursing, and anesthesia in a healthcare redesign project that resulted in the creation of a PCS to implement a coordinated clinical pathway. After Institutional Review Board (IRB) approval, data were collected for all elective colorectal procedures for three phases: phase 0 (pre-implementation; 1/2014-6/2014), phase 1 (7/2014-10/2014), and phase 2 (11/2014-10/2015). Length of stay (primary endpoint; LOS), total hospital cost, use of clinical pathway components, markers of functional recovery, and readmission and reoperation rates were analyzed. Outcomes and patient characteristics among phases were compared by two-tailed t tests and Wilcoxon rank-sum tests. Categorical variables were analyzed by chi-square and Fisher's exact tests. RESULTS: We studied 544 patients (phase 0 = 179; phase 1 = 124; phase 2 = 241), with 365 consecutive patients being cared for in the redesigned care structure. Median LOS was reduced and sustained after implementation (phase 0, 4.24 days; phase 1, 3.32 days; phase 2, 3.32 days, P < 0.01 phase 0 v. phases 1 and 2), and mean LOS was reduced in phase 2 (phase 0, 5.26 days; phase 1, 4.93 days; phase 2, 4.36 days, P < 0.01 phase 0 v. phase 2). Total hospital cost was reduced by 17 % (P = 0.05, median). Application of clinical pathway components was higher in phases 1 and 2 compared to phase 0 (P < 0.01 for all components except anti-emetics); measures of functional recovery improved with successive phases. Reoperation and 30-day readmission rates were no different in phase 1 or phase 2 compared to phase 0 (P > 0.15). CONCLUSIONS: Restructuring of perioperative care delivery through the launch of a PCS-reduced LOS and total cost in a significant and sustainable fashion for colorectal surgery patients. Based on the success of this care redesign project, hospital administration is funding expansion to additional services.

Validity and reliability assessment of detailed scoring checklists for use during perioperative emergency simulation training.

INTRODUCTION: Few valid and reliable grading checklists have been published for the evaluation of performance during simulated high-stakes perioperative event management. As such, the purposes of this study were to construct valid scoring checklists for a variety of perioperative emergencies and to determine the reliability of scores produced by these checklists during continuous video review. METHODS: A group of anesthesiologists, intensivists, and educators created a set of simulation grading checklists for the assessment of the following scenarios: severe anaphylaxis, cerebrovascular accident, hyperkalemic arrest, malignant hyperthermia, and acute coronary syndrome. Checklist items were coded as critical or noncritical. Nonexpert raters evaluated 10 simulation videos in a random order, with each video being graded 4 times. A group of faculty experts also graded the videos to create a reference standard to which nonexpert ratings were compared. P < 0.05 was considered significant. RESULTS: Team leaders in the simulation videos were scored by the expert panel as having performed 56.5% of all items on the checklist (range, 43.8%-84.0%), and 67.2% of the critical items (range, 30.0%-100%). Nonexpert raters agreed with the expert assessment 89.6% of the time (95% confidence interval, 87.2%-91.6%). No learning curve development was found with repetitive video assessment or checklist use. The κ values comparing nonexpert rater assessments to the reference standard averaged 0.76 (95% confidence interval, 0.71-0.81). CONCLUSIONS: The findings indicate that the grading checklists described are valid, are reliable, and could be used in perioperative crisis management assessment.

Effect of a cognitive aid on adherence to perioperative assessment and management guidelines for the cardiac evaluation of noncardiac surgical patients.

BACKGROUND: The 2007 American College of Cardiologists/American Heart Association Guidelines on Perioperative Cardiac Evaluation and Care for Noncardiac Surgery is the standard for perioperative cardiac evaluation. Recent work has shown that residents and anesthesiologists do not apply these guidelines when tested. This research hypothesized that a decision support tool would improve adherence to this consensus guideline. METHODS: Anesthesiology residents at four training programs participated in an unblinded, prospective, randomized, cross-over trial in which they completed two tests covering clinical scenarios. One quiz was completed from memory and one with the aid of an electronic decision support tool. Performance was evaluated by overall score (% correct), number of incorrect answers with possibly increased cost or risk of care, and the amount of time required to complete the quizzes both with and without the cognitive aid. The primary outcome was the proportion of correct responses attributable to the use of the decision support tool. RESULTS: All anesthesiology residents at four institutions were recruited and 111 residents participated. Use of the decision support tool resulted in a 25% improvement in adherence to guidelines compared with memory alone (P < 0.0001), and participants made 77% fewer incorrect responses that would have resulted in increased costs. Use of the tool was associated with a 3.4-min increase in time to complete the test (P < 0.001). CONCLUSIONS: Use of an electronic decision support tool significantly improved adherence to the guidelines as compared with memory alone. The decision support tool also prevented inappropriate management steps possibly associated with increased healthcare costs.

Simulation curriculum can improve medical student assessment and management of acute coronary syndrome during a clinical practice exam.

BACKGROUND: It has been noted that increased focus on learning acute care skills is needed in undergraduate medical curricula. This study investigated whether a simulation-based curriculum improved a senior medical student's ability to manage acute coronary syndrome as measured during a clinical performance examination (CPX). The authors hypothesized that simulation training would improve overall performance when compared with targeted didactics or historical controls. METHODS: All 4th-year medical students (n = 291) over 2 years at the authors' institution were included in this study. In the 3rd year of medical school, the "control" group received no intervention, the "didactic" group received a targeted didactic curriculum, and the "simulation" group participated in small group simulation training and the didactic curriculum. For intergroup comparison on the CPX, the authors calculated the percentage of correct actions completed by the student. Data are presented as mean ± standard deviation with significance defined as P < 0.05. RESULTS: There was a significant improvement in overall performance with simulation versus both didactics and control (P < 0.001). Performance on the physical examination component was significantly better in simulation versus both didactics and control, as was for diagnosis: simulation versus both didactics and control (P < 0.02 for all comparisons). CONCLUSIONS: Simulation training had a modest impact on overall CPX performance in the management of a simulated acute coronary syndrome. Additional studies are needed to evaluate how to further improve curricula regarding unstable patients.