Maximizing Operational Efficiency Using an In-House Ambulatory Surgery Model at an Academic Medical Center.

EXECUTIVE SUMMARY: Given the rising costs of healthcare delivery and reimbursement constraints, large academic medical centers (AMCs) must improve efficiency while delivering high-quality care. With standardized cases and high volumes, ambulatory surgery is a high-value target for efficiency improvement. Mining a data set of more than 7,500 cases consisting of the three highest-volume ambulatory procedures in orthopedics, otolaryngology-head and neck surgery, and urology, we analyzed process times and wait times involved in patient flow. We examined differences among delayed versus early versus on-time cases, as well as differences in scheduled start times, day of the week, and each individual operating room. Our analysis found statistically and clinically significant differences in registration and setup wait times when comparing delayed versus early versus on-time cases. We then developed recommendations to increase value-added time. Using activity-based cost accounting, we created a model to quantify economic impact. Hospitals can adopt these methods to identify operational bottlenecks and employ our financial model to forecast changes in revenue. Application of this model can position AMCs for success in an increasingly competitive landscape.

Creation of Simulation-Based Curriculum of Perioperative Emergencies for Residents in Anesthesiology.

INTRODUCTION: Crisis management is difficult to practice and evaluate for resident learners and leadership given the rarity of these events in clinical practice. However, simulation provides a medium to bridge this gap. We identified a need for simulation in our anesthesiology residency program to help residents learn to treat perioperative emergencies. OBJECTIVE: To describe the process of curriculum development, content, and early outcomes of a simulation-based curriculum for the management of perioperative emergencies for all levels of anesthesiology learners. MATERIALS AND METHODS: Curriculum development began in the Spring of 2019 and simulations began in August 2019. All anesthesiology residents rotating at a single center through December 2020 were eligible. Each resident was given their own simulation scenario detailing a specific perioperative emergency and then debriefed as a group afterward. All residents participating in the scenario were given a post-simulation survey assessing the value of the educational experience, relevance to their level of training, and quality of learning environment. RESULTS: Out of 90 eligible residents, 79 participated in the study (87%). Overall, 100% of participants completed the post-simulation survey; 100% of residents reported that the curriculum was useful to their education; 98% of residents reported that the curriculum was relevant to their training level; 99% of residents reported that the simulation was an engaging learning experience. CONCLUSION: A simulation-based curriculum of perioperative emergencies for anesthesiology residents is feasible to implement, viewed as worthwhile by trainees, and can foster education in a different learning environment.

Chronic postthoracotomy pain in transapical transcatheter aortic valve replacement.

Objective: Chronic postthoracotomy pain (CPTP) is a persistent, occasionally debilitating pain lasting >2 months following thoracic surgery. This study investigates for the first time the prevalence and clinical impact of CPTP in patients who have undergone a transapical transcatheter aortic valve replacement (TA-TAVR). Design: This was a single-institution, prospective observational survey and a retrospective chart review. Setting: The study was conducted in the University Hospital. Participants: Patients. Materials and Methods: A survey of 131 participants with either a previous TA TAVR or transfemoral (TF) TAVR procedure was completed. A telephone interview was conducted at least 2 months following TAVR; participants were asked to describe their pain using the Short-Form McGill Pain Questionnaire. Measurements and Main Results: Odds ratio (OR) was calculated using the proportions of questionnaire responders reporting "sensory" descriptors in the TA-TAVR versus the TF-TAVR groups. Results were then compared to individual Kansas City Cardiomyopathy Questionnaire (KCCQ12) scores and 5-min walk test (5MWT) distances. A total of 119 participants were reviewed (63 TF, 56 TA). Among TA-TAVR questionnaire responders (n = 16), CPTP was found in 64.3% of participants for an average duration of 20.5-month postprocedure (OR = 10, [confidence interval (CI) 95% 1.91-52.5];P = 0.003). TA-TAVR patients identified with CPTP had significant reductions in 5MWT distances (-2.22 m vs. 0.92 m [P = 0.04]) as well as trend toward significance in negative change of KCCQ12 scores OR = 18.82 (CI 95% 0.85-414.99;P = 0.06) compared to those without CPTP. Conclusions: CPTP occurs in patients undergoing TA-TAVR and is possibly associated with a decline quality of life and overall function.

Comparison of forced-air and water-circulating warming for prevention of hypothermia during transcatheter aortic valve replacement.

INTRODUCTION: Transcatheter Aortic Valve Replacement (TAVR) procedures at our institution were complicated by perioperative hypothermia despite use of the standard of care forced-air convective warming device (the BairHugger, Augustine Medical Inc, Eden Prairie, MN, USA). To remedy this problem, we initiated a quality improvement process that investigated the use of a conductive warm water-circulating device (the Allon ThermoWrap, Menen Medical Corporation, Trevose, PA, USA), and hypothesized that it would decrease the incidence of perioperative hypothermia. METHODS: We compared two different intraoperative warming devices using a historic control. We retrospectively reviewed intraoperative records of 80 TAVRs between 6/2013 and 6/2015, 46 and 34 of which were done with the forced-air and water-circulating devices, respectively. Continuous temperature data obtained from pulmonary artery catheter, temperature upon arrival to cardiothoracic ICU (CTU), age, BSA, height, and BMI were compared. RESULTS: Patients warmed with both devices were similar in terms of demographic characteristics. First recorded intraoperative temperature (mean 36.26 ± SD 0.61 vs. 35.95 ± 0.46°C, p = 0.02), lowest intraoperative temperature (36.01 ± 0.58 vs. 34.89 ± 0.76°C, p<0.001), temperature at the end of the procedure (36.47 ± 0.51 vs. 35.17 ± 0.75°C, p<0.001), and temperature upon arrival to the CTU (36.35 ± 0.44 vs. 35.07 ± 0.78°C, p<0.001) were significantly higher in the water-circulating group as compared to the forced-air group. CONCLUSION: A quality improvement process led to selection of a new warming device that virtually eliminated perioperative hypothermia at our institution. Patients warmed with the new device were significantly less likely to experience intraoperative hypothermia and were significantly more likely to be normothermic upon arrival to the CTU.

To do or not to do a preinduction check-up of the anesthesia machine.

The anesthesia machine check is an integral part of the anesthesiologist's daily routine. It is standard operating procedure to check the high- and low-pressure systems of the machine as well as other integral parts that are accessible. Many new anesthesia machines offer a self-testing capability, but older ones with fewer electronics on board are still widely used. Whether the machines self test or not, each machine contains a CO2 absorber and a circuit that may be prone to problems. In our case we encountered an open CO2 absorber after a service of the machine had been performed between the cases without our knowledge. We were unable to ventilate the patient during induction. The presence of a backup self-filling manual ventilation bag was invaluable in preventing an otherwise inevitable emergency.