The impact of a medically directed student registered nurse anesthesia staffing model on Postprocedural patient outcomes.

STUDY OBJECTIVE: In 2018, the American Society of Anesthesiologists stated that student registered nurse anesthetists (SRNAs) "are not yet fully qualified anesthesia personnel." It remains unclear, however, whether postprocedural outcomes are affected by SRNAs providing anesthesia care under the medical direction of anesthesiologists, as compared with medically directed anesthesiology fellows or residents, or certified registered nurse anesthetists (CRNAs). We therefore aimed to examine whether medically directed SRNAs serving as in-room anesthesia providers impact surgical outcomes. DESIGN: Retrospective, matched-cohort analysis. SETTING: Adult patients (≥18 years old) undergoing inpatient surgery between 2000 and 2017 at a tertiary academic medical center. PATIENTS: 15,365 patients exclusively cared for by medically directed SRNAs were matched to 15,365 cared for by medically directed CRNAs, anesthesiology residents, and/or fellows. INTERVENTIONS: None. MEASUREMENTS: The primary composite outcome was postoperative occurrence of in-hospital mortality and six categories of major morbidities (infectious, bleeding, serious cardiac, gastrointestinal, respiratory, and urinary complications). In-hospital mortality was analyzed as the secondary outcome. MAIN RESULTS: In all, 30,730 cases were matched using propensity score matching to control for potential confounding. The primary outcome was identified in 2295 (7.5%) cases (7.5% with exclusive medically directed SRNAs vs 7.4% with medically directed CRNAs, residents and/or fellows; relative risk, 1.02; 95% CI, 0.94-1.11). Thus, our effort to determine noninferiority (10% difference in relative risk) with other providers was inconclusive (P = .07). However, the medically directed SRNA group (0.8% [118]) was found to be noninferior (P < .001) to the matched group (1.0% [156]) on in-hospital mortality (relative risk, 0.75; 95% CI, 0.59-0.96). CONCLUSIONS: Among 30,730 patients undergoing inpatient surgery at a single hospital, findings were inconclusive regarding whether exclusive medically directed SRNAs as in-room providers were noninferior to other providers. The use of medically directed SRNAs under this staffing model should be subject to further review. Clinical Trial and Registry URL: Not applicable.

Respiratory parameters as a surrogate marker for duration of intubation: potential application of automated vital sign collection.

Prolonged time during endotracheal tube placement has been associated with poor outcomes, including cardiac arrest and death. For this reason, the accurate measurement of the duration of intubation time is an important metric in studies that evaluate interventions to improve airway outcomes. In the current study we correlated the gaps in routinely measured ventilatory parameters with duration of the intubation procedure to determine if these intervals could be used to accurately calculate the intubation time. Fifty-six random airway management encounters were video recorded along with a continuous video feed of the patient monitor. Intubation event times were measured and correlated with "gap" times of end-tidal carbon dioxide, airway pressure, airway flow, tidal volume, and respiratory rate defined as the disappearance of the parameter at the end of mask ventilation to the reappearance after intubation. Scatter plots were generated for intubation times versus each parameter time gap and correlation coefficients were calculated. Of the 56 recordings 50 of were suitable for analysis. The correlation of the gaps in airway pressure and airway flow correlated best with the duration of intubation (R(2) = 0.88) and were available on all cases. The gap in measured tidal volume of 39 ± 53 s most closely approximated the actual duration of intubation of 38 ± 28 s, (R(2) = 0.85, y = x - 0.87). During intubation, the disappearance gaps in tidal volume, and the airway pressure and flow waveforms highly correlate with the duration of the intubation procedure and may be useful in the evaluation of airway management interventions. However, just as there are limitations to a labor-intensive method of recording airway management timing, there are limitations to using an automated method.

Inflammatory myofibroblastic tumor of the mesentery with a SQSTM1::ALK fusion responding to alectinib.

BACKGROUND: Inflammatory myofibroblastic tumor (IMT) is an ultra-rare soft tissue neoplasm associated with fusion proteins encompassing the anaplastic lymphoma kinase (ALK) protein fused to a variety of partner proteins. Data regarding response to ALK-targeting agents based on fusion partner is limited. CASE: A 30-year-old female sought emergency care after onset of abdominal and lower back pain in 2019. Computed tomography (CT) demonstrated a cystic, mesenteric mass within the pelvis measuring up to 8.9 cm. Complete laparoscopic excision of the mass from the mesentery of the right colon and terminal ileum was performed. Pathologic assessment revealed IMT with a fusion between sequestosome 1 and ALK (SQSTM1::ALK), described in only two other cases of IMT. Four months after surgery, CT revealed multi-focal, unresectable disease recurrence. She was referred to the University of Washington/Fred Hutchinson Cancer Center and placed on therapy with alectinib, after which she experienced a partial response. Three years after IMT recurrence, disease remains under control. CONCLUSION: This is the third reported case of IMT associated with the novel SQSTM1::ALK fusion protein, and the second treated with alectinib. Treatment with the ALK inhibitor alectinib appears to be active in this setting.

Nurse adoption of continuous patient monitoring on acute post-surgical units: managing technology implementation.

AIM: To report an exploratory action-research process used during the implementation of continuous patient monitoring in acute post-surgical nursing units. BACKGROUND: Substantial US Federal funding has been committed to implementing new health care technology, but failure to manage implementation processes may limit successful adoption and the realisation of proposed benefits. Effective approaches for managing barriers to new technology implementation are needed. METHOD: Continuous patient monitoring was implemented in three of 13 medical/surgical units. An exploratory action-feedback approach, using time-series nurse surveys, was used to identify barriers and develop and evaluate responses. Post-hoc interviews and document analysis were used to describe the change implementation process. RESULTS: Significant differences were identified in night- and dayshift nurses' perceptions of technology benefits. Research nurses' facilitated the change process by evolving 'clinical nurse implementation specialist' expertise. CONCLUSIONS: Health information technology (HIT)-related patient outcomes are mediated through nurses' acting on new information but HIT designed for critical care may not transfer to acute care settings. Exploratory action-feedback approaches can assist nurse managers in assessing and mitigating the real-world effects of HIT implementations. IMPLICATIONS FOR NURSING MANAGEMENT: It is strongly recommended that nurse managers identify stakeholders and develop comprehensive plans for monitoring the effects of HIT in their units.

Multi-Institutional Analysis of Outcomes in Supraglottic Jet Ventilation with a Team-Based Approach.

OBJECTIVES/HYPOTHESIS: To evaluate the safety and complications of endoscopic airway surgery using supraglottic jet ventilation with a team-based approach. STUDY DESIGN: Retrospective cohort study. METHODS: Subjects at two academic institutions diagnosed with laryngotracheal stenosis who underwent endoscopic airway surgery with jet ventilation between January 2008 and December 2018 were identified. Patient characteristics (age, gender, race, follow-up duration) and comorbidities were extracted from the electronic health record. Records were reviewed for treatment approach, intraoperative data, and complications (intraoperative, acute postoperative, and delayed postoperative). RESULTS: Eight hundred and ninety-four patient encounters from 371 patients were identified. Intraoperative complications (unplanned tracheotomy, profound or severe hypoxic events, barotrauma, laryngospasm) occurred in fewer than 1% of patient encounters. Acute postoperative complications (postoperative recovery unit [PACU] rapid response, PACU intubation, return to the emergency department [ED] within 24 hours of surgery) were rare, occurring in fewer than 3% of patient encounters. Delayed postoperative complications (return to the ED or admission for respiratory complaints within 30 days of surgery) occurred in fewer than 1% of patient encounters. Diabetes mellitus, active smoking, and history of previous tracheotomy were independently associated with intraoperative, acute, and delayed complications. CONCLUSIONS: Employing a team-based approach, jet ventilation during endoscopic airway surgery demonstrates a low rate of complications and provides for safe and successful surgery. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2292-2297, 2021.

Factor V Leiden protects against blood loss and transfusion after cardiac surgery.

BACKGROUND: The outcome of cardiac surgery is influenced by several factors, but the impact of specific genetic variants has not been systematically explored. Because blood conservation is a pressing issue in cardiac surgery, we tested the hypothesis that factor V Leiden (FVL), a common coagulation factor polymorphism, may protect against blood loss and transfusion in patients undergoing cardiac surgery. METHODS AND RESULTS: We enrolled 517 patients undergoing cardiac surgery, including 26 heterozygous FVL carriers, and evaluated the impact of FVL on chest tube output and transfusion by using univariate and multivariate techniques. For patients with FVL, blood loss at 6 (238+/-131 mL) and 24 hours (522+/-302 mL) was significantly lower than that for noncarriers (358+/-259 mL and 730+/-452 mL; P<0.001 and P=0.001, respectively). In a multivariate regression analysis, controlling for ethnicity and factors known to affect blood loss, FVL was a significant independent contributor at both time points. Using a similar regression approach, FVL did not have a significant effect on the number of units transfused. However, logistic regression of the risk of receiving any transfusion during hospitalization demonstrated a significant independent protective effect of FVL on overall transfusion risk. CONCLUSIONS: FVL represents a common genetic trait that may protect against blood loss and transfusion in this population. This study demonstrates that genetic variability can affect the outcome of cardiac surgery.

Improving anesthesiologist performance through profiling and incentives.

STUDY OBJECTIVE: To determine the influence of profiling and incentives on anesthesiologist behavior in relation to several key indicators of performance. DESIGN: Prospective collection and analysis of operational data before and after implementation of a physician profiling, reporting, and incentive program. SETTING: University hospital. MEASUREMENTS: An intervention consisting of two components was studied with the intent of stimulating a high level of performance in relation to a peer group. The first component, a monthly report of physician performance via an individualized performance report, was provided to each physician for each of 6 months. The second component consisted of a financial incentive. For each month in the study, physicians were eligible to receive a variable financial incentive of between $0 and $500 per month depending on individual performance based scoring in relation to each other. Physician performance was tracked in five areas: 1) percentage of first cases of the day in the room at or before the scheduled in-room time, 2) percentage of cases with an anesthesia prep time less than a target, 3) percentage of cases delayed due to waiting for an anesthesiology patient evaluation, 4) percentage of cases delayed during the anesthesiology controlled time, and, 5) percentage of cases delayed due to waiting for the anesthesiology attending. Results were reported to each physician on a monthly basis, by e-mail distribution, of an individualized perioperative efficiency summary report. A monthly financial incentive was awarded to the top performing physicians in the form of a credit to the physician's personal CME/expense account. Also, all physicians received a rank order list of their performance on each indicator at the end of each month. MAIN RESULTS: 31 anesthesiologists, comprising the multispecialty division, and covering all services with the exception of obstetrics, pediatrics, and cardiothoracic anesthesia were tracked for 6 months. Compared to the first month, the percent of first cases of the day in the room at or before the scheduled start time and the percent of cases with an anesthesiology prep time less than target increased significantly (19 +/- 4.6%, vs. 61 +/- 6.5%, 95% CI, p <0.001; and 57 +/- 5.3%, vs. 73 +/- 5.1%, 95% CI, p <0 .001) during the sixth month. The mean number of cases per physician with a delay during anesthesiology controlled time decreased (14.9 +/- 2.9 vs. 3.3 +/- 1, p <0.001), no change occurred in the number of cases with a delay due to waiting for an anesthesiology patient evaluation or number of cases delayed due to waiting for the anesthesiology attending in the sixth month compared with the first month. CONCLUSION: Tracking and rewarding physician performance with monthly profiling and a financial incentive given to the best in a peer group improves anesthesiologist performance in several key areas.

An observational analysis of surgical team compliance with perioperative safety practices after crew resource management training.

BACKGROUND: Acknowledging the need to improve team communication and coordination among health care providers, health care administrators and improvement officers have been quick to endorse and invest in aviation crew resource management (CRM). Despite the increased interest in CRM there exists limited data on the effectiveness of CRM to change team behavior and performance in clinical settings. METHODS: Direct observational analyses were performed on 30 surgical teams (15 neurosurgery cases and 15 cardiac cases) to evaluate surgical team compliance with integrated safety and CRM practices after extensive CRM training. RESULTS: Observed surgical teams were compliant with only 60% of the CRM and perioperative safety practices emphasized in the training program. CONCLUSIONS: The results highlight many of the challenges the health care industry faces in its efforts to adapt CRM from aviation to medicine. Additional research is needed to develop and test new team training methods and performance feedback mechanisms for clinical teams.

Evaluation of a hands-free wireless communication device in the perioperative environment.

The objective of this study was to evaluate the efficiency and reliability of a hands-free voice over Internet protocol (VOIP) communication system in the perioperative environment. Two surveys were administered to anesthesiologists and operating room (OR) nurses working at an academic medical center. Providers were queried by alphanumeric pages or VOIP queries during OR work shifts to measure communication response times. Providers, responding to the query, were asked to verbally complete a system performance survey to capture information regarding their workload and work environment at the time of the query. A user feedback survey was independently administered in writing to a convenience sample of OR providers to obtain information regarding provider communication preferences, concerns, and recommendations. OR providers responded to communication queries four times faster when using VOIP compared to alphanumeric pagers. Providers found VOIP to be much less reliable than conventional pager-telephone systems. Dead spots in the 802.11b network and errors in speaker recognition were frequently cited as sources of system failures. Providers also expressed concern in maintaining confidentiality of patient data or other clinical data communicated using this system. The results of this study suggest that VOIP is still a developing technology but one that is currently viable in the clinical setting. The technology can be used efficiently and securely in health care if users are given the proper training its functions and capabilities.

A preliminary study of 24-hour post-cesarean patient controlled analgesia: postoperative pain reports and morphine requests/utilization are greater in abstaining smokers than non-smokers.

BACKGROUND: Previous clinical studies have not examined the relationship between nicotine abstinence and opioid use for postoperative analgesia. This may be important because tobacco smokers are routinely required to abstain from smoking just before and during acute post-surgical recovery. This study investigated IV morphine self-administration [patient controlled analgesia (PCA)], subjective pain/drug effects and other measures during post-operative (elective Cesarean section) recovery. MATERIAL/METHODS: Seven females, selected to vary in nicotine use [4 non-using controls (CON), 3 users (NIC)], completed the protocol. Gender, time and type of surgery, and pre- and intra-operative medications were controlled. Subject assessments included the McGill Pain Questionnaire and the Profile of Mood States; drug effects were measured using the Addiction Research Center Inventory. RESULTS: Mean (M +/-SD) 24-hr morphine responding (button-pressing requests) was significantly higher for NIC (M=183+/-50) than CON (M=38+/-10). Weight-adjusted morphine use (mg/kg/24 hr) was significantly higher for NIC (M=1.80+/-0.23) than CON (M=0.64+/-0.14). Although the groups reported similar pain severity following morphine loading, NIC patients reported significantly greater pain severity than CON patients after 24 hr PCA. CONCLUSIONS: These preliminary data suggest that a history of nicotine use and/or short-term nicotine abstinence can modulate morphine use and analgesia during post-operative recovery. These procedures provide a model for studying patterns and determinants of analgesic self-administration in medical settings.

Food restriction modulates amphetamine-conditioned place preference and nucleus accumbens dopamine release in the rat.

Food restriction has been shown to increase self-administration of psychostimulants, including cocaine and amphetamine (AMPH). Consistent with this, food-restricted rats are more sensitized to the rewarding effects of cocaine as measured by conditioned place preference (CPP). This study investigated whether moderate food restriction in rats (15 g/day) results in an increased CPP, relative to ad libitum-fed controls, to a second psychostimulant, AMPH. Conditioning trials consisted of six alternating injections of i.p. AMPH (0.425-6.8 mg/kg) and i.p. saline, paired with distinct environments. On Day 7, a drug-free 20-min choice test for environment was carried out to assess CPP. 0.85 mg/kg AMPH significantly increased CPP in food-restricted vs. ad libitum-fed rats. At 1.7 and 3.4 mg/kg AMPH, food-restricted rats showed decreased CPP, but increased locomotor activity, relative to ad libitum fed controls. To evaluate whether an alteration in extracellular fluid DA levels in the nucleus accumbens (NAc) core could account for these behavioral alterations, DA release was measured by microdialysis. DA release to a single acute i.p. injection of either 0.85 or 1.7 mg/kg AMPH was comparable in food-restricted and ad libitum fed rats. However, ad libitum fed rats demonstrated conditioned DA release after an AMPH conditioning paradigm analogous to the CPP paradigm, whereas food-restricted rats demonstrated no conditioned DA release. In conclusion, altered DA release in the nucleus accumbens core is not a primary effect of moderate food restriction and cannot completely account for either the altered CPP behavior or enhanced locomotor activity observed in this study.