The Adult Cardiac Anesthesiology Section of STS Adult Cardiac Surgery Database: 2020 Update on Quality and Outcomes.

The Society of Cardiovascular Anesthesiologists, in partnership with The Society of Thoracic Surgeons, has developed the Adult Cardiac Anesthesiology Section of the Adult Cardiac Surgery Database. The goal of this landmark collaboration is to advance clinical care, quality, and knowledge, and to demonstrate the value of cardiac anesthesiology in the perioperative care of cardiac surgical patients. Participation in the Adult Cardiac Anesthesiology Section has been optional since its inception in 2014 but has progressively increased. Opportunities for further growth and improvement remain. In this first update report on quality and outcomes of the Adult Cardiac Anesthesiology Section, we present an overview of the clinically significant anesthesia and surgical variables submitted between 2015 and 2018. Our review provides a summary of quality measures and outcomes related to the current practice of cardiothoracic anesthesiology. We also emphasize the potential for addressing high-impact research questions as data accumulate, with the overall goal of elucidating the influence of cardiac anesthesiology contributions to patient outcomes within the framework of the cardiac surgical team.

Clevidipine compared with nitroglycerin for blood pressure control in coronary artery bypass grafting: a randomized double-blind study.

PURPOSE: We tested the hypothesis that clevidipine, a rapidly acting dihydropyridine calcium channel blocker, is not inferior to nitroglycerin (NTG) in controlling blood pressure before cardiopulmonary bypass (CPB) during coronary artery bypass grafting (CABG). METHODS: In this double-blind study from October 4, 2003 to April 26, 2004, 100 patients undergoing CABG with CPB were randomized at four centres to receive intravenous infusions of clevidipine (0.2-8 µg·kg(-1)·min(-1)) or NTG (0.4 µg·kg(-1)·min(-1) to a clinician-determined maximum dose rate) from induction of anesthesia through 12 hr postoperatively. The study drug was titrated in the pre-CPB period with the aim of maintaining mean arterial pressure (MAP) within ± 5 mmHg of a clinician-predetermined target. The primary endpoint was the area under the curve (AUC) for the total time each patient's MAP was outside the target range from drug initiation to the start of CPB, normalized per hour (AUCMAP-D). The predefined non-inferiority criterion for the primary endpoint was a 95% confidence interval (CI) upper limit no greater than 1.50 for the geometric means ratio between clevidipine and NTG. RESULTS: Total mean [standard deviation (SD)] dose pre-bypass was 4.5 (4.7) mg for clevidipine and 6.9 (5.4) mg for NTG (P < 0.05). The geometric mean AUCMAP-D for clevidipine was 283 mmHg·min·hr(-1) (n = 45) and for NTG was 292 mmHg·min·hr(-1) (n = 48); the geometric means ratio was 0.97 (95% CI 0.74 to 1.27). The geometric mean AUCMAP-D during aortic cannulation was 357.7 mmHg·min·hr(-1) for clevidipine compared with 190.5 mmHg·min·hr(-1) for NTG. Mean (SD) heart rate with clevidipine was 76.0 (13.8) beats·min(-1) compared with 81.5 (14.4) beats·min(-1) for NTG. There were no clinically important differences between groups in adverse events. CONCLUSION: During CABG, clevidipine was not inferior to NTG for blood pressure control pre-bypass.

Cerebral oximetry during cardiac surgery: the association between cerebral oxygen saturation and perioperative patient variables.

OBJECTIVE: This "real-world" study was designed to assess the patterns of regional cerebral oxygen saturation (rSO(2)) change during adult cardiac surgery. A secondary objective was to determine any relation between perioperative rSO(2) (baseline and during surgery) and patient characteristics or intraoperative variables. DESIGN: Prospective, observational, multicenter, nonrandomized clinical study. SETTING: Cardiac operating rooms at 3 academic medical centers. PARTICIPANTS: Ninety consecutive adult patients presenting for cardiac surgery with or without cardiopulmonary bypass. INTERVENTIONS: Patients received standard care at each institution plus bilateral forehead recordings of cerebral oxygen saturation with the 7600 Regional Oximeter System (Nonin Medical, Plymouth, MN). MEASUREMENTS AND MAIN RESULTS: The average baseline (before induction) rSO(2) was 63.9 ± 8.8% (range 41%-95%); preoperative hematocrit correlated with baseline rSO(2) (0.48% increase for each 1% increase in hematocrit, p = 0.008). The average nadir (lowest recorded rSO(2) for any given patient) was 54.9 ± 6.6% and was correlated with on-pump surgery, baseline rSO(2), and height. Baseline rSO(2) was found to be an independent predictor of length of stay (hazard ratio 1.044, confidence interval 1.02-1.07, for each percentage of baseline rSO(2)). CONCLUSIONS: In cardiac surgical patients, lower baseline rSO(2) value, on-pump surgery, and height were significant predictors of nadir rSO(2), whereas only baseline rSO(2) was a predictor of postoperative length of stay. These findings support previous research on the predictive value of baseline rSO(2) on length of stay and emphasize the need for further research regarding the clinical relevance of baseline rSO(2) and intraoperative changes.

Effect of adenosine-regulating agent acadesine on morbidity and mortality associated with coronary artery bypass grafting: the RED-CABG randomized controlled trial.

CONTEXT: Ischemia/reperfusion injury remains an important cause of morbidity and mortality after coronary artery bypass graft (CABG) surgery. In a meta-analysis of randomized controlled trials, perioperative and postoperative infusion of acadesine, a first-in-class adenosine-regulating agent, was associated with a reduction in early cardiac death, myocardial infarction, and combined adverse cardiac outcomes in participants undergoing on-pump CABG surgery. OBJECTIVE: To assess the efficacy and safety of acadesine administered in the perioperative period in reducing all-cause mortality, nonfatal stroke, and severe left ventricular dysfunction (SLVD) through 28 days. DESIGN, SETTING, AND PARTICIPANTS: The Reduction in Cardiovascular Events by Acadesine in Patients Undergoing CABG (RED-CABG) trial, a randomized, double-blind, placebo-controlled, parallel-group evaluation of intermediate- to high-risk patients (median age, 66 years) undergoing nonemergency, on-pump CABG surgery at 300 sites in 7 countries. Enrollment occurred from May 6, 2009, to July 30, 2010. INTERVENTIONS: Eligible participants were randomized 1:1 to receive acadesine (0.1 mg/kg per minute for 7 hours) or placebo (both also added to cardioplegic solutions) beginning just before anesthesia induction. MAIN OUTCOME MEASURE: Composite of all-cause mortality, nonfatal stroke, or need for mechanical support for SLVD during and following CABG surgery through postoperative day 28. RESULTS: Because results of a prespecified futility analysis indicated a very low likelihood of a statistically significant efficacious outcome, the trial was stopped after 3080 of the originally projected 7500 study participants were randomized. The primary outcome occurred in 75 of 1493 participants (5.0%) in the placebo group and 76 of 1493 (5.1%) in the acadesine group (odds ratio, 1.01 [95% CI, 0.73-1.41]). There were no differences in key secondary end points measured. CONCLUSION: In this population of intermediate- to high-risk patients undergoing CABG surgery, acadesine did not reduce the composite of all-cause mortality, nonfatal stroke, or SLVD. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00872001.

The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2021 Update on Echocardiography.

The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) is the world's premier clinical outcomes registry for adult cardiac surgery and a driving force for quality improvement in cardiac surgery. Echocardiographic data provide a wealth of hemodynamic, structural, and functional data and have been part of STS ACSD data collection since its inception. An increasing body of evidence suggests that the use of echocardiography in patients undergoing cardiac surgery has a positive impact on postoperative outcomes. In this report, we describe and summarize the type and rate of reporting of echocardiography-related variables in the STS ACSD, including the Adult Cardiac Anesthesiology Module, from July 2017 to December 2019 for the most frequently performed cardiac surgical procedures. With this review, we aim to increase awareness of the importance of collecting accurate and consistent echocardiography data in the STS ACSD and to highlight opportunities for growth and improvement.

A multinational study of the influence of health-related quality of life on in-hospital outcome after coronary artery bypass graft surgery.

BACKGROUND: The effect of health-related quality of life on in-hospital outcomes after coronary artery bypass grafting surgery has not been investigated in international multicenter studies. We hypothesized that poor preoperative health status is associated with mortality and length of hospital stay. METHODS: In the Multicenter Study of Perioperative Ischemia Epidemiology II, preoperative Short-Form 12, Mental Component Summary (MCS), and Physical Component Summary (PCS) scores were obtained prospectively from 4,811 patients (3,834 men, 977 women) undergoing coronary artery bypass grafting surgery at 72 centers in 17 countries. Primary outcome measures were in-hospital mortality and prolonged (>14 days) length of hospital stay. RESULTS: One hundred fifty-one patients (3.1%) died. After adjustment for regional differences, a 10-point reduction in MCS score was associated with higher mortality risk (odds ratio [OR] 1.17, 95% CI 1.004-1.37, P = .04) and prolonged hospital stay (OR 1.11, 95% CI 1.01-1.21, P = .03). The preoperative PCS score was not associated with mortality risk but significantly predicted prolonged length of hospital stay (OR 1.20, 95% CI 1.09-1.33, P < .001). There was no significant interaction between gender and either the MCS or the PCS score. DISCUSSION: The preoperative PCS predicted prolonged postoperative hospital stay, whereas the preoperative MCS score was an independent predictor of both prolonged length of hospital stay and mortality. Preoperative assessment of health-related quality of life factors with the Short-Form 12 might be a useful tool for risk stratification and planning for hospital discharge and rehabilitation.

Surgeons' and anesthesiologists' perceptions of turnover times.

BACKGROUND: Perception of turnovers may be influenced less by actual turnover times per se than by a mental model of factors influencing turnover times. METHODS: A survey was performed at a U.S. academic hospital in 2010. Each of the 78 subjects estimated characteristics of his/her turnover times in 2009. Responses were compared with the actual times. RESULTS: Numbers of comments were not proportional to actual total waiting times experienced. Surgeons with 2 or more comments (n = 10) averaged the same numbers of turnovers as did surgeons who made 1 or no comments (n = 13) (P = 0.62). Four of the 10 surgeons with 2 or more comments averaged <2 turnovers per month ("very few turnovers"). Perceptions of turnover times were influenced by opinion about team activity during shift change. Most (>79%) subjects thought that the time of the day with the subject's largest number of prolonged (>45 minutes) turnovers was at least 2 hours later than actual (P < 0.0001). Although most prolonged turnovers occurred around noon, 8 surgeons mentioned shift change qualitatively, and most (68%, P = 0.002) subjects estimated a time overlapping with shift change. Surgeons overall overestimated their observed percentage of prolonged turnovers (P = 0.020), and anesthesiologists' estimates were overall unbiased. Surgeons' bias cannot be explained by knowing times of a longer interval such as "skin to skin," because the other surgeons, with very few turnovers, had responses that were essentially identical (P ≥ 0.87). When we corrected for each subject's actual mean turnover time, surgeons' estimates for their averages were longer than were anesthesiologists' estimates (P = 0.002). Responses were again essentially indistinguishable from those of subjects with very few turnovers (P ≥ 0.23). CONCLUSIONS: Managers should not rely on surgeons or anesthesiologists for their expert judgment on turnover times. Managers should also not interpret comments about turnover times as literally referring to the time, but instead as factors perceived as contributing to the time (e.g., attitude about the facility and the activity of its personnel).

The Adult Cardiac Anesthesiology Section of STS Adult Cardiac Surgery Database: 2020 Update on Quality and Outcomes.

The Society of Cardiovascular Anesthesiologists, in partnership with The Society of Thoracic Surgeons, has developed the Adult Cardiac Anesthesiology Section of the Adult Cardiac Surgery Database. The goal of this landmark collaboration is to advance clinical care, quality, and knowledge, and to demonstrate the value of cardiac anesthesiology in the perioperative care of cardiac surgical patients. Participation in the Adult Cardiac Anesthesiology Section has been optional since its inception in 2014 but has progressively increased. Opportunities for further growth and improvement remain. In this first update report on quality and outcomes of the Adult Cardiac Anesthesiology Section, we present an overview of the clinically significant anesthesia and surgical variables submitted between 2015 and 2018. Our review provides a summary of quality measures and outcomes related to the current practice of cardiothoracic anesthesiology. We also emphasize the potential for addressing high-impact research questions as data accumulate, with the overall goal of elucidating the influence of cardiac anesthesiology contributions to patient outcomes within the framework of the cardiac surgical team.

Repletion of factor XIII following cardiopulmonary bypass using a recombinant A-subunit homodimer. A preliminary report.

Bleeding following cardiac surgery involving cardiopulmonary bypass (CPB) remains a major concern. Coagulation factor XIII (FXIII) functions as a clot-stabilising factor by cross-linking fibrin. Low post-operative levels of FXIII correlate with increased post-operative blood loss. To evaluate preliminary safety and pharmacokinetics of recombinant FXIII (rFXIII-A(2)) in cardiac surgery, patients scheduled for coronary artery bypass grafting were randomised to receive a single dose of either rFXIII-A(2) (11.9, 25, 35 or 50 IU/kg) or placebo in a 4:1 ratio. Study drug was given post-CPB within 10 to 20 minutes after first protamine dose. Patients were evaluated until day 7 or discharge, with a follow-up visit at weeks 5-7. The primary end-point was incidence and severity of adverse events. Thirty-five patients were randomised to rFXIII-A(2) and eight to placebo. Eighteen serious adverse events were reported. These were all complications well recognised during cardiac surgery. Although one patient required an implantable defibrillator, all recovered without sequelae. One myocardial infarction in a patient receiving 35 IU/kg rFXIII-A(2) was identified by the Data Monitoring Committee after reviewing ECGs and cardiac enzymes. No other thromboembolic events were seen. Dosing with 25-50 IU/kg rFXIII-A(2) restored levels of FXIII to pre-operative levels, with a tendency towards an overshoot in receiving 50 IU/kg. rFXIII-A(2), in doses from 11.9 IU/kg up to 50 IU/kg, was well tolerated. For post-operative FXIII replenishment, 35 IU/kg of rFXIII-A(2) may be the most appropriate dose.

Incentive payments to academic anesthesiologists for late afternoon work did not influence turnover times.

BACKGROUND: Anesthesiologists are often paid extra for hours worked in the late afternoon and evening. Although anesthesiologists have little influence on their operating room (OR) assignments and workloads late in the afternoon, they can influence turnover times. METHODS: OR turnover times on workdays were reviewed for n = 30 mo before there was incremental pay, for n = 15 mo with incremental pay for work past 3:30 pm, and for n = 8 mo with pay for work past 4:00 pm. The end point was the percentage of turnovers that were prolonged, defined as longer than 1 h. Turnovers straddling 3:30 pm (n = 3945), 4:00 pm (n = 3602), and 5:00 pm (n = 2834) were studied, as were those straddling 2:00 pm (n = 4407) as a control. In addition, qualitative (survey) assessment of n = 30 anesthesiologists was performed the last month to learn about their opinions on working late on weekdays. RESULTS: Most respondents considered an OR to run late if it finished after a specific time of day (87%, P < 0.001), unrelated to the room's type of procedures (90%, P < 0.001) or to the payment for working after 4:00 pm (100%, P < 0.001). There was no significant effect of implementation or changes to the incentive program on the incidences of prolonged turnover times at each of the studied times in the afternoon (all P > 0.14). CONCLUSION: Our results suggest that hospital administrators, deans, and other executives need not be especially concerned about disincentives produced by methods of internal compensation of anesthesiologists on highly visible OR turnover times late in afternoons.

Both bias and lack of knowledge influence organizational focus on first case of the day starts.

BACKGROUND: The economic costs of reducing first case delays are often high, because efforts need to be applied to multiple operating rooms (ORs) simultaneously. Nevertheless, delays in starting first cases of the day are a common topic in OR committee meetings. METHODS: We added three scientific questions to a 24 question online, anonymous survey performed before the implementation of a new OR information system. The 57 respondents cared sufficiently about OR management at the United States teaching hospital to complete all questions. RESULTS: The survey revealed reasons why personnel may focus on the small reductions in nonoperative time achievable by reducing tardiness in first cases of the day. (A) Respondents lacked knowledge about principles in reducing over-utilized OR time to increase OR efficiency, based on their answering the relevant question correctly at a rate no different from guessing at random. Those results differed from prior findings of responses at a rate worse than random, resulting from a bias on the day of surgery of making decisions that increase clinical work per unit time. (B) Most respondents falsely believed that a 10 min delay at the start of the day causes subsequent cases to start at least 10 min late (P < 0.0001 versus random chance). (C) Most respondents did not know that cases often take less time than scheduled (P = 0.008 versus chance). No one who demonstrated knowledge (C) about cases sometimes taking less time than scheduled applied that information to their response to (B) regarding cases starting late (P = 0.0002). CONCLUSIONS: Knowledge of OR efficiency was low among the respondents working in ORs. Nevertheless, the apparent absence of bias shows that education may influence behavior. In contrast, presence of bias on matters of tardiness of start times shows that education may be of no benefit. As the latter results match findings of previous studies of scheduling decisions, interventions to reduce patient and surgeon waiting from start times may depend principally on the application of automation to guide decision-making.

Jugular venous oxygenation during hypothermic cardiopulmonary bypass in patients at risk for abnormal cerebral autoregulation: influence of alpha-Stat versus pH-stat blood gas management.

In a prospective, randomized study of cardiac surgical patients at risk for impaired cerebral blood flow autoregulation, we compared alpha-stat and pH-stat blood gas management. The 40 patients enrolled had age >70 yr, diabetes, prior stroke, or uncontrolled hypertension. During hypothermia and early rewarming, jugular oxygen tensions were significantly lower in alpha-stat patients (n = 12) than pH-stat patients (n = 19; P < 0.05). During rewarming, jugular venous desaturation (i.e., SjvO(2) <50%) occurred in 6 of 12 alpha-stat patients, but no pH-stat patients (P = 0.0006). Patients at risk for poor cerebral autoregulation have higher oxygen tensions and saturations if pH-stat blood gas management is used during cardiopulmonary bypass.

Nosocomial contamination of laryngoscope handles: challenging current guidelines.

BACKGROUND: Laryngoscope blades are often cleaned between cases according to well-defined protocols. However, despite evidence that laryngoscope handles could be a source of nosocomial infection, neither our institution nor the American Society of Anesthesiologists has any specific guidelines for handle disinfection. We hypothesized that laryngoscope handles may be sufficiently contaminated with bacteria and viruses to justify the implementation of new handle-cleaning protocols. METHODS: Sixty laryngoscope handles from the adult operating rooms were sampled with premoistened sterile swabs. Collection was performed between cases, in operating rooms hosting a broad variety of subspecialty procedures, after the room and equipment had been thoroughly cleaned for the subsequent case. Samples from 40 handles were sent for aerobic bacterial culture, and antimicrobial susceptibility testing was performed for significant isolates. Samples from 20 handles were examined for viral contamination using a polymerase chain reaction assay that detects 17 respiratory viruses. RESULTS: Of the 40 samples sent for culture, 30 (75%) were positive for bacterial contamination. Of these positive cultures, 25 (62.5%) yielded coagulase-negative staphylococci, seven (17.5%) Bacillusspp. not anthracis, three (7.5%) alpha-hemolytic Streptococcusspp., and one each (2.5%) of Enterococcusspp., Staphylococcus aureus(S. aureus), and Corynebacteriumspp. No vancomycin-resistant enterococci, methicillin-resistant S. aureus, or Gram-negative rods were detected. All viral tests were negative. CONCLUSION: We found a high incidence of bacterial contamination of laryngoscope handles despite low-level disinfection. However, no vancomycin-resistant enterococci, methicillin-resistant S. aureus, Gram-negative rods, or respiratory viruses were detected. Our results support adoption of guidelines that include, at a minimum, mandatory low-level disinfection of laryngoscope handles after each patient use.

Complications of the COX-2 inhibitors parecoxib and valdecoxib after cardiac surgery.

BACKGROUND: Valdecoxib and its intravenous prodrug parecoxib are used to treat postoperative pain but may involve risk after coronary-artery bypass grafting (CABG). We conducted a randomized trial to assess the safety of these drugs after CABG. METHODS: In this randomized, double-blind study involving 10 days of treatment and 30 days of follow-up, 1671 patients were randomly assigned to receive intravenous parecoxib for at least 3 days, followed by oral valdecoxib through day 10; intravenous placebo followed by oral valdecoxib; or placebo for 10 days. All patients had access to standard opioid medications. The primary end point was the frequency of predefined adverse events, including cardiovascular events, renal failure or dysfunction, gastroduodenal ulceration, and wound-healing complications. RESULTS: As compared with the group given placebo alone, both the group given parecoxib and valdecoxib and the group given placebo and valdecoxib had a higher proportion of patients with at least one confirmed adverse event (7.4 percent in each of these two groups vs. 4.0 percent in the placebo group; risk ratio for each comparison, 1.9; 95 percent confidence interval, 1.1 to 3.2; P=0.02 for each comparison with the placebo group). In particular, cardiovascular events (including myocardial infarction, cardiac arrest, stroke, and pulmonary embolism) were more frequent among the patients given parecoxib and valdecoxib than among those given placebo (2.0 percent vs. 0.5 percent; risk ratio, 3.7; 95 percent confidence interval, 1.0 to 13.5; P=0.03). CONCLUSIONS: The use of parecoxib and valdecoxib after CABG was associated with an increased incidence of cardiovascular events, arousing serious concern about the use of these drugs in such circumstances.

Operating room nursing directors' influence on anesthesia group operating room productivity.

BACKGROUND: Implementation of initiatives to increase anesthesia group productivity depends not just on anesthesia groups, but on operating room (OR) nursing administration. OR nursing directors may encourage organizational change based on the needs of their hospitals and nurses. These changes may differ from those that would increase the anesthesia group's productivity. We assessed reward structures using (A) letters of nomination for the "OR Manager of the Year" award offered annually by the publication OR Manager, and (B) data from a salary/career survey of OR directors by the same publication. METHODS: (A) There were 164 nomination letters submitted from 2004 through 2007 for 45 nominees. The letters contained n = 2659 full sentences and n = 50,821 words. We systematically created a list of 36 terms related to finance, profit, and productivity. We also analyzed the frequency of use of these terms relative to the use of the 15 most common relationship-oriented terms (e.g., compassion, encourage, mentor, and respect). (B) The salary/career survey's questions relevant to anesthesia group productivity had responses from 303 US OR directors, 97% of whom were nurses. We tested the strength of the relationship between the budget responsibility of the OR nursing director and his or her annual salary. RESULTS: (A) 2.6% of sentences in the nomination letters included at least one term related to profit and productivity (95% confidence interval 2.0%-3.2%). Relationship-oriented terms were 9.0 times more prevalent (95% confidence interval 7.1-11.4). (B) There was statistically significant positive proportionality between the OR nursing director's operational budget (including personnel) and his or her salary (Pearson r = 0.64, P < 0.001). The 10th percentile of the operational budget was $1 million and the 90th percentile was $36 million. The budget of $1 million was associated with a salary 22% less than the median and the budget of $36 million was associated with a salary 22% larger than the median. CONCLUSION: Through (A) organizational constituencies, and (B) compensation, many US OR nursing directors likely are encouraged to enhance relations with nursing staff, not to champion organizational initiatives that would reduce under-utilized OR time and OR nursing labor costs. Resulting decisions can differ from those that would increase the productivity (profit) of the anesthesia group. Anesthesia groups need to champion initiatives to increase anesthesia productivity, while being sensitive to institutional expectations of nursing directors.

Long-term forecasting of anesthesia workload in operating rooms from changes in a hospital's local population can be inaccurate.

BACKGROUND: Anesthesia department planning depends on forecasting future demand for perioperative services. Little is known about long-range forecasting of anesthesia workload. METHODS: We studied operating room (OR) times at Hospital A over 16 yr (1991-2006), anesthesia times at Hospital B over 26 yr (1981-2006), and cases at Hospital C over 13 yr (1994-2006). Each hospital is >100 yr old and is located in a US city with other hospitals that are >50 yr old. Hospitals A and B are the sole University hospitals in their metropolitan statistical areas (and many counties beyond). Hospital C is the sole tertiary hospital for >375 km. RESULTS: Each hospital's choice of a measure of anesthesia work to be analyzed was likely unimportant, as the annual hours of anesthesia correlated highly both with annual numbers of cases (r = 0.98) and with American Society of Anesthesiologist's Relative Value Guide units of work (r = 0.99). Despite a 2% decline in the local population, the hours of OR time at Hospital A increased overall (Pearson r = -0.87, P < 0.001) and for children (r = -0.84). At Hospital B, there was a strong positive correlation between population and hours of anesthesia (r = 0.97, P < 0.001), but not between annual increases in population and workload (r = -0.18). At Hospital C, despite a linear increase in population, the annual numbers of cases increased, declined with opening of two outpatient surgery facilities, and then stabilized. The predictive value of local personal income was low. In contrast, the annual increases in the hours of OR time and anesthesia could be modeled using simple time series methods. CONCLUSIONS: Although growth of the elderly population is a simple justification for building more ORs, managers should be cautious in arguing for strategic changes in capacity at individual hospitals based on future changes in the national age-adjusted population. Local population can provide little value in forecasting future anesthesia workloads at individual hospitals. In addition, anesthesia groups and hospital administrators should not focus on quarterly changes in workload, because workload can vary widely, despite consistent patterns over decades. To facilitate long-range planning, anesthesia groups and hospitals should save their billing and OR time data, display it graphically over years, and supplement with corresponding forecasting methods (e.g., staff an additional OR when an upper prediction bound of workload per OR exceeds a threshold).