Exploring Production Pressure and Normalization of Deviance and Their Relationship to Poor Patient Outcomes.

Production pressure and/or normalization of deviance contribute to poor patient outcomes. The purpose of this study was to explore the relationship between production pressure and normalization of deviance to poor patient outcomes. A team of experienced qualitative researchers conducted a metasynthesis of all qualitative closed claims studies that used the American Association of Nurse Anesthetists (AANA) Foundation Closed Claims database and were accepted for publication at the time of the study. Three central concepts emerged from the analysis: (1) impaired culture of safety, (2) violations of standards of care, and (3) impaired patient safety and outcomes. It is imperative that anesthesia providers support a culture of safety and follow AANA Standards for Nurse Anesthesia Practice.

The common meanings and shared practices of sedation assessment in the context of managing patients with an opioid: A phenomenological study.

AIMS AND OBJECTIVES: To examine the common meanings of opioid-induced sedation and shared practices in the context of post-operative pain management in expert Post-Anesthesia Care Unit nurses during patient's pain management with opioids. BACKGROUND: Within the clinical setting, linear pain and sedation scales are not enough to support clinical judgement with acute pain management. Because sedation measurement rests along a fluctuating continuum, it is possible for a patient to be sedated and then shift to increasing alertness, and then to drift back to a sedated state. This potential for acute clinical transition can be challenging to nurses of all levels, even for expert nurses. DESIGN: Interpretive phenomenology. METHODS: Twenty expert Post-Anesthetic Care Unit nurses, with more than 7 years of nursing experience, participated in qualitative interviews regarding their lived experiences. Interviews were analysed using a modified seven-stage process for interpretation by Diekelmann, Allen and Tanner. The manuscript was developed utilising the COREQ guidelines for reporting qualitative studies. RESULTS: Four themes identified through the participant's stories were recognising every patient is different, engaging in iterative knowing, walking a fine line, and looking beyond and anticipating. This study identified a constitutive pattern of interpreting sedation by integrating practical understanding and anticipating beyond. CONCLUSIONS: This study indicates a deeper complexity in the way opioid-induced sedation is assessed and balanced with pain management by nurses in the Post-Anesthetic Care Unit. RELEVANCE TO PRACTICE: Nurses in the study adapted their practices around pain management with opioids, in response to their patient's level of sedation; incorporating practices such as giving small, incremental doses and changing the drug. Nurses valued the importance of having "eyeballs on everybody" and being ready to meet the needs of their patient. They appreciate the time to watch and wait for their patient to respond, to better judge the result of their interventions.

The Role of Documentation Quality in Anesthesia-Related Closed Claims: A Descriptive Qualitative Study.

Clinical documentation is a critical tool in supporting care provided to patients. Sound documentation provides a picture of clinical events that can be used to improve patient care. However, many other uses for clinical documentation are equally important. Such documentation informs clinical decision support tools, creates a legal record of patient care, assists in financial reimbursement of services, and serves as a repository for secondary data analysis. Conversely, poor documentation can impair patient safety and increase malpractice risk exposure by reflecting poor or inaccurate information that ultimately may guide patient care decisions.Through an examination of anesthesia-related closed claims, a descriptive qualitative study emerged, which explored the antecedents and consequences of documentation quality in the claims reviewed. A secondary data analysis utilized a database generated by the American Association of Nurse Anesthetists Foundation closed claim review team. Four major themes emerged from the analysis. Themes 1, 2, and 4 primarily describe how poor documentation quality can have negative consequences for clinicians. The third theme primarily describes how poor documentation quality that can negatively affect patient safety.

Cooperation and conflict between very similar occupations: the case of anesthesia.

This article examines the features of a labor market in which there are two professional groups that both cooperate and directly compete with each other: certified registered nurse anesthetists (CRNAs) and anesthesiologists (MDAs). We examine how the relative numbers of these two types of anesthesia providers, and differences in regulation, affect the earnings of CRNAs, and the extent of supervision of CRNAs by MDAs. We find that both the earnings, and the likelihood of medical supervision of CRNAs, are closely determined by their market share. As the market share of CRNAs increases from 0% to 50%, the gains to MDAs from restricting competition increase; over this range the likelihood that CRNAs are supervised increases and their expected earnings decline. However, as the CRNAs' market share increases beyond 50%, the costs to MDAs of anticompetitive measures become too large, therefore, the probability of supervision declines, and the earnings of CRNAs increase.

[Ambulatory anaesthesia, beneficial for children]. / L'anesthésie ambulatoire, un bénéfice pour l'enfant.

The advantages of ambulatory surgery and anaesthesia are widely recognised. Apart from their interest in terms of reducing hospital costs, they are overwhelmingly preferred by patients. Of all patients, it is children who can benefit the most.

Telephone pre-anaesthesia assessment for ambulatory breast surgery.

OBJECTIVE: To review the efficacy of telephone preoperative anaesthesia assessment in patients undergoing ambulatory breast surgery. DESIGN: Retrospective study. SETTING: Day Surgery Centre, Tung Wah Hospital, Hong Kong. PATIENTS: Patients with breast lumps to be excised were seen by dedicated breast surgeons and informed of day procedures and preoperative anaesthesia assessment. Those who fulfilled the selection criteria of age (18-45 years) and American Society of Anesthesiologists grade I were recruited for telephone anaesthesia assessment preoperatively. The patients were contacted by senior day surgery nurses via telephone before the scheduled operation date, and information was retrieved using a standard assessment form. Prospective data from January 2002 to December 2007 were analysed. MAIN OUTCOME MEASURES: Proportion of patients who successfully underwent day surgery after telephone preoperative anaesthesia assessment. RESULTS: Of 482 patients receiving ambulatory surgery for breast lumps during the study period, 283 patients were selected for preoperative telephone anaesthesia assessment. Five (2%) patients with problems identified by this method underwent further assessment at the Day Surgery Centre; the remaining 278 (98%) required no further assessment and proceeded to have a successful day surgery procedure. CONCLUSION: Preoperative anaesthesia assessment by telephone is an effective means of preoperative assessment in selected patients undergoing ambulatory breast surgery.

Quality Review in Anesthesia: then, now, and the future.

The Quality Review in Anesthesia (QRIA) newsletter is a significant, evolving resource to the Certified Registered Nurse Anesthetist (CRNA) in clinical practice. Since its inception in 1997, the newsletter has been modified to meet the changing needs of anesthesia practice. The goal of the newsletter is improvement in patient care and risk avoidance by keeping CRNAs abreast of the latest changes in risk management, quality assurance, and malpractice concerns. By incorporating reports of patient safety adverse events, it is anticipated CRNAs will better understand the need for compliance and adherence to the standards of care. A chronological history of the development of the QRIA newsletter is provided. The methodology of how an article is conceived, reviewed, and published is presented so the CRNA can appreciate the mechanisms involved in putting together each publication. The QRIA newsletter now has a chronological and alphabetical index on the AANA website. This electronic format allows the CRNA to access articles that might be of special interest to a certain aspects of practice. Each issue of QRIA is planned carefully to meet the needs of the CRNA and is offered as a valuable membership service.

The AANA Foundation Closed Malpractice Claims Study on nerve injuries during anesthesia care.

Anesthesia-associated nerve injury is a common cause of patient morbidity and litigation. To identify factors associated with perioperative nerve injuries and rationalize preventive strategies, 44 cases from the American Association of Nurse Anesthetists (AANA) Foundation Closed Malpractice Claims Database pertaining to nerve injuries in which nurse anesthetists provided care were analyzed. Emerging patterns and themes related to the development of injury were identified. The database is a collection of medical liability claims filed against CRNAs insured by the St Paul Fire and Marine Insurance Company; 44 claims of anesthesia-related nerve injury were analyzed. The most common injury was to the brachial plexus (15 [34%]), followed by ulnar nerve injury (7 [16%]), radial nerve injury (5 [11%]), peroneal nerve injury (4 [9%]), paraplegia (4 [9%]), lumbosacral injury (3[7%]), and a variety of "other" injuries (8[18%]). These numbers and percentages total more than 44 (100%) as some patients incurred multiple injuries. Documentation on the anesthesia record of the use of intraoperative protective padding and patient position was lacking or inadequate in a majority of the claims. Effective strategies for the prevention of nerve injury during anesthesia are reviewed. Abnormal body habitus, several disease states, anesthesia technique, improper positioning, lack of adequate padding, and tourniquet use have been implicated as risk factors.

Preventable adverse patient outcomes: a closed claims analysis of respiratory incidents.

Closed claims analysis of adverse anesthesia outcomes was initiated through the AANA Foundation in 1995 to examine adverse outcomes of anesthesia care provided by Certified Registered Nurse Anesthetists (CRNAs). A research team of 8 CRNAs using an instrument incorporating more than 150 variables undertook document analyses of closed claim files. All files reviewed involved incidents in which the CRNA named in the policy was potentially involved in the adverse patient outcome. Thirty-eight percent (58/151) of CRNA-related claims involved a respiratory incident as the primary cause of the negative patient outcome. Patient outcomes involving respiratory incidents were more likely to result in death or permanent injury compared with nonrespiratory incidents (P < .01). Reviewers found that respiratory claims were more likely to have involved inappropriate anesthesia management (P < .01), more likely to have involved a lack of vigilance (P < .01), and more likely to have been judged by the reviewer as preventable (P < .01). A higher percentage of respiratory incidents occurred in emergency cases (75% vs 34%, P < .01) and in cases involving general anesthesia (44% vs 17%, P < .01). Adverse respiratory incidents are largely preventable and frequently result in serious patient morbidity and mortality.

Anesthesiologist direction and patient outcomes.

The relationship between physicians and nurses in the delivery of anesthesia care is politically and financially charged, and hotly debated. Against this backdrop, federal regulators have proposed dropping a Medicare requirement that nurse anesthetists be supervised by a physician. Proponents note that the new regulations would resolve inconsistencies between Medicare supervisory requirements and state law, while opponents voice concerns for patient safety. This Issue Brief describes the current controversy, and summarizes a newly published study that suggests differences in patient outcomes depending on the nature and level of anesthesiologist involvement in surgical care.

Conditions of anesthesia practice on the Ivory Coast.

The Ivory Coast is one of the most developed countries in Africa, but conditions of practice of anesthesia are difficult. From anesthesia equipment to medications that are available, all resources are limited, and nurse anesthetists as well as sole anesthesia providers, have to manage with isolation and lack of information in uncomfortable situations.

Streamlining the perioperative process.

Health-care reform and capitated reimbursements have and will continue to influence decreased lengths of hospital stay and continued efficiency in perioperative nursing practice. Collaborative efforts by perioperative nurses, anesthesia care providers, and surgical staff should continue to emphasize concise documentation processes as well as comprehensive assessment and evaluation phases to prepare patients and families for earlier discharge and recovery at home. The objective of new documentation practices and streamlining perioperative preparation processes is to eliminate the duplication of information, meet standards set by professional organizations, and provide quality, efficient care along with patient and family satisfaction.

The price of anesthesia care.

The focus on the cost of health care presents a paradox. Although society demands lower cost healthcare, few want to cut health services or the quality of the care received. There continues to be strong consumer pressure to improve the quality of health care and to increase the scope of services, while keeping cost increases to a minimum. Obviously, there is no single answer to the complex issues facing the health care industry. The nurse anesthetist, must however, begin answering these demands with an analysis of our own practice. Our role in the health care system of the future will be determined, not just on our clinical competency, but also on how we respond to the system as a whole. "Cost effectiveness" will need to be redefined as CRNAs provide a "value added" service.