The influence of the type and design of the anesthesia record on ASA physical status scores in surgical patients: paper records vs. electronic anesthesia records.

BACKGROUND: The American Society of Anesthesiologists Physical Status classification (ASA PS) of surgical patients is a standard element of the preoperative assessment. In early 2013, the Department of Anesthesia was notified that the distribution of ASA PS scores for sampled patients at the University of Iowa had recently begun to deviate from national comparison data. This change appeared to coincide with the transition from paper records to a new electronic Anesthesia Information Management System (AIMS). We hypothesized that the design of the AIMS was unintentionally influencing how providers assigned ASA PS values. METHODS: Primary analyses were based on 12-month blocks of data from paper records and AIMS. For the purpose of analysis, ASA PS was dichotomized to ASA PS 1 and 2 vs. ASA PS >2. To ensure that changes in ASA PS were not due to "real" changes in our patient mix, we examined other relevant covariates (e.g. age, weight, case distribution across surgical services, emergency vs. elective surgeries etc.). RESULTS: There was a 6.1 % (95 % CI: 5.1-7.1 %) absolute increase in the fraction of ASA PS 1&2 classifications after the transition from paper (54.9 %) to AIMS (61.0 %); p < 0.001. The AIMS was then modified to make ASA PS entry clearer (e.g. clearly highlighting ASA PS on the main anesthesia record). Following the modifications, the AS PS 1&2 fraction decreased by 7.7 % (95 % CI: 6.78-8.76 %) compared to the initial AIMS records (from 61.0 to 53.3 %); p < 0.001. There were no significant or meaningful differences in basic patient characteristics and case distribution during this time. CONCLUSION: The transition from paper to electronic AIMS resulted in an unintended but significant shift in recorded ASA PS scores. Subsequent design changes within the AIMS resulted in resetting of the ASA PS distributions to previous values. These observations highlight the importance of how user interface and cognitive demands introduced by a computational system can impact the recording of important clinical data in the medical record.

Molecular characterisation and epidemiology of transmission of intraoperative Staphylococcus aureus isolates stratified by vancomycin minimum inhibitory concentration (MIC).

Background: Reduced vancomycin susceptibility in Staphylococcus aureus (S. aureus) is considered a more pathogenic strain characteristic and is associated with treatment failure. We aimed to characterise the epidemiology of intraoperative transmission of S. aureus isolates with reduced vancomycin susceptibility. Methods: S. aureus isolates (N=173) collected from 274 randomly selected operating room environments at three major academic medical centres in 2009-2010 were characterised by vancomycin minimum inhibitory concentration (MIC). We aimed to characterise the transmission dynamics for VISA and isolates with relatively reduced vancomycin (MIC= 2µg/mL) susceptibility at the range of therapeutic differentiation. Results: Intraoperative S. aureus MIC was 1.38 ± 0.34 µg/mL. No VISA isolates were identified (95% upper confidence limit 2.1%) and those with an MIC of 2 µg/mL accounted for 12.72% (22/173) of all isolates. MIC=2 µg/mL isolates were more frequently cultured from the hands of healthcare providers [19.3% (16/83)] versus otherwise [6.7% (6/90)], with unadjusted risk ratio 2.89, P=0.021, and from patients with >2 major comorbidities [25.0% (8/32)] versus otherwise [9.9% (14/141)], with unadjusted risk ratio 2.52, P=0.035. Both were significant when tested simultaneously. The adjusted relative risk for provider hands was 2.77 (95% CI 1.15 to 6.69, P=0.024). The adjusted relative risk for patients with >2 major comorbidities was 2.37 (95% CI 1.11 to 5.05, P=0.026). MIC=2µg/mL was not associated with greater risk of clonal transmission (unadjusted P=0.34, adjusted P=0.18). Conclusion: Intraoperative VISA is a rare event. S. aureus isolates MIC=2µg/mL isolates were not associated with increased risk of intraoperative transmission. The epidemiology of detected intraoperative transmission is consistent with Centers for Disease Control guidelines.

Assessment of anesthesia machine redesign on cleaning of the anesthesia machine using surface disinfection wipes.

BACKGROUND: The use of surface disinfection wipes after induction of anesthesia improves anesthesia machine cleaning. We assessed whether anesthesia machine surface redesign improves disinfection wipe cleaning by anesthesia residents. METHODS: Sixteen anesthesia residents were assigned to 2 cases in series. The first case was randomly assigned to regional knee or hip surgery, a brief or detailed checklist, and the Perseus A500 (redesigned) or GE Aespire 7900 (conventional) machine. The second case was assigned to the opposite for each condition. Setup checklists included cleaning instructions. Eight machine sites representing redesign were contaminated with fluorescent gel prior to setup and reassessed after setup to assess cleaning efficacy. Cleaning was compared by fluorescence quantification of before and after setup images. Our primary hypothesis was that, overall, more sites would be cleaned on the Perseus machine. Our secondary hypothesis was that redesign would affect some sites. RESULTS: Overall, the number of sites cleaned did not differ between machines (median 0.74 more sites out of 8 for the Perseus A500; 25th and 75th percentiles, -0.34 and 1.04; P = .093). However, greater cleaning was observed for the work surface and manual bag arm/hose of the Perseus machine (0.58 more sites out of 2; 25th and 75th percentiles, 0.35 and 1.05; P = .0004). CONCLUSIONS: The number of sites cleaned overall did not differ between the conventional and redesigned Perseus A500 machines. However, the redesigned work surface and smooth manual bag arm features improved resident cleaning with surface disinfection wipes.

The Effect of Improving Basic Preventive Measures in the Perioperative Arena on Staphylococcus aureus Transmission and Surgical Site Infections: A Randomized Clinical Trial.

Importance: Surgical site infections increase patient morbidity and health care costs. The Centers for Disease Control and Prevention emphasize improved basic preventive measures to reduce bacterial transmission and infections among patients undergoing surgery. Objective: To assess whether improved basic preventive measures can reduce perioperative Staphylococcus aureus transmission and surgical site infections. Design, Setting, and Participants: This randomized clinical trial was conducted from September 20, 2018, to September 20, 2019, among 19 surgeons and their 236 associated patients at a major academic medical center with a 60-day follow-up period. Participants were a random sample of adult patients undergoing orthopedic total joint, orthopedic spine, oncologic gynecological, thoracic, general, colorectal, open vascular, plastic, or open urological surgery requiring general or regional anesthesia. Surgeons and their associated patients were randomized 1:1 via a random number generator to treatment group or to usual care. Observers were masked to patient groupings during assessment of outcome measures. Interventions: Sustained improvements in perioperative hand hygiene, vascular care, environmental cleaning, and patient decolonization efforts. Main Outcomes and Measures: Perioperative S aureus transmission assessed by the number of isolates transmitted and the incidence of transmission among patient care units (primary) and the incidence of surgical site infections (secondary). Results: Of 236 patients (156 [66.1%] women; mean [SD] age, 57 [15] years), 106 (44.9%) and 130 (55.1%) were allocated to the treatment and control groups, respectively, received the intended treatment, and were analyzed for the primary outcome. Compared with the control group, the treatment group had a reduced mean (SD) number of transmitted perioperative S aureus isolates (1.25 [2.11] vs 0.47 [1.13]; P = .002). Treatment reduced the incidence of S aureus transmission (incidence risk ratio; 0.56; 95% CI, 0.37-0.86; P = .008; with robust variance clustering by surgeon: 95% CI, 0.42-0.76; P < .001). Overall, 11 patients (4.7%) experienced surgical site infections, 10 (7.7%) in the control group and 1 (0.9%) in the treatment group. Transmission was associated with an increased risk of surgical site infection (8 of 73 patients [11.0%] with transmission vs 3 of 163 [1.8%] without; risk ratio, 5.95; 95% CI, 1.62-21.86; P = .007). Treatment reduced the risk of surgical site infection (hazard ratio, 0.12; 95% CI, 0.02-0.92; P = .04; with clustering by surgeon: 95% CI, 0.03-0.51; P = .004). Conclusions and Relevance: Improved basic preventive measures in the perioperative arena can reduce S aureus transmission and surgical site infections. Trial Registration: ClinicalTrials.gov Identifier: NCT03638947.

Dynamics of intraoperative Klebsiella, Acinetobacter, Pseudomonas, and Enterobacter transmission.

BACKGROUND: Our primary objective was to examine anesthesia work area reservoir isolation of Klebsiella, Acinetobacter, Pseudomonas, and Enterobacter spp (KAPE) pathogens. This is a retrospective analysis of a randomized, prospective, and observational study involving 3 academic medical centers. METHODS: Patients included adults undergoing general anesthesia. Gram-negative isolates (N = 2,682) were collected from anesthesia work area reservoirs in 274 randomly selected operating room case pairs. Nine hundred and forty-five isolates were included in this study. Chi square tests were used to examine the association of anesthesia work area reservoirs with KAPE genera isolation. RESULTS: Acinetobacter pathogens were more likely to be isolated from anesthesia provider hands (risk ratio [RR], 1.07; 95% confidence interval [CI], 1.04-1.10; corrected P = .004) and less likely to be isolated from patients (RR, 0.2; 95% CI, 0.08-0.50; corrected P < .0001). Enterobacter pathogens were more likely to be isolated from patients (RR, 3.34; 95% CI, 1.92-5.81; corrected P = 0.001) and less likely to be isolated from provider hands (RR, 0.89; 95% CI, 0.83-0.97; corrected P = .007). CONCLUSIONS: Anesthesia provider hands are important reservoirs for Acinetobacter spp, whereas patient skin surfaces are key reservoirs for Enterobacter spp. Future work should examine the impact of a multimodal program in controlling the intraoperative spread of Acinetobacter and Enterobacter pathogens.

Validation and Extension of the Prolonged Mechanical Ventilation Prognostic Model (ProVent) Score for Predicting 1-Year Mortality after Prolonged Mechanical Ventilation.

RATIONALE: Prognostic models can inform management decisions for patients requiring prolonged mechanical ventilation. The Prolonged Mechanical Ventilation Prognostic model (ProVent) score was developed to predict 1-year mortality in these patients. External evaluation of such models is needed before they are adopted for routine use. OBJECTIVES: The goal was to perform an independent external validation of the modified ProVent score and assess for spectrum extension at 14 days of mechanical ventilation. METHODS: This was a retrospective cohort analysis of patients who received prolonged mechanical ventilation at the University of Iowa Hospitals. Patients who received 14 or more days of mechanical ventilation were identified from a database. Manual review of their medical records was performed to abstract relevant data including the four model variables at Days 14 and 21 of mechanical ventilation. Vital status at 1 year was checked in the medical records or the social security death index. Logistic regressions examined the associations between the different variables and mortality. Model performance at 14 to 20 days and 21+ days was assessed for discrimination by calculating the area under the receiver operating characteristic curve, and calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test. MEASUREMENTS AND MAIN RESULTS: A total of 180 patients (21+ d) and 218 patients (14-20 d) were included. Overall, 75% were surgical patients. One-year mortality was 51% for 21+ days and 32% for 14 to 20 days of mechanical ventilation. Age greater than 65 years was the strongest predictor of mortality at 1 year in all cohorts. There was no significant difference between predicted and observed mortality rates for patients stratified by ProVent score. There was near-perfect specificity for mortality in the groups with higher ProVent scores. Areas under the curve were 0.69 and 0.75 for the 21+ days and the 14 to 20 days cohorts respectively. P values for the Hosmer-Lemeshow statistics were 0.24 for 21+ days and 0.22 for 14 to 20 days. CONCLUSIONS: The modified ProVent model was accurate in our cohort. This supports its geographic and temporal generalizability. It can also accurately identify patients at risk of 1-year mortality at Day 14 of mechanical ventilation, but additional confirmation is required. Further studies should explore the implications of adopting the model into routine use.