Comparing Anesthesia and Surgery Controlled Time for Primary Total Knee and Hip Arthroplasty Between an Academic Medical Center and a Community Hospital: Retrospective Cohort Study.

BACKGROUND: Osteoarthritis is a significant cause of disability, resulting in increased joint replacement surgeries and health care costs. Establishing benchmarks that more accurately predict surgical duration could help to decrease costs, maximize efficiency, and improve patient experience. We compared the anesthesia-controlled time (ACT) and surgery-controlled time (SCT) of primary total knee (TKA) and total hip arthroplasties (THA) between an academic medical center (AMC) and a community hospital (CH) for 2 orthopedic surgeons. OBJECTIVE: This study aims to validate and compare benchmarking times for ACT and SCT in a single patient population at both an AMC and a CH. METHODS: This retrospective 2-center observational cohort study was conducted at the University of Colorado Hospital (AMC) and UCHealth Broomfield Hospital (CH). Cases with current procedural terminology codes for THA and TKA between January 1, 2019, and December 31, 2020, were assessed. Cases with missing data were excluded. The primary outcomes were ACT and SCT. Primary outcomes were tested for association with covariates of interest. The primary covariate of interest was the location of the procedure (CH vs AMC); secondary covariates of interest included the American Society of Anesthesiologists (ASA) classification and anesthetic type. Linear regression models were used to assess the relationships. RESULTS: Two surgeons performed 1256 cases at the AMC and CH. A total of 10 THA cases and 12 TKA cases were excluded due to missing data. After controlling for surgeon, the ACT was greater at the AMC for THA by 3.77 minutes and for TKA by 3.58 minutes (P<.001). SCT was greater at the AMC for THA by 11.14 minutes and for TKA by 14.04 minutes (P<.001). ASA III/IV classification increased ACT for THA by 3.76 minutes (P<.001) and increased SCT for THA by 6.33 minutes after controlling for surgeon and location (P=.008). General anesthesia use was higher at the AMC for both THA (29.2% vs 7.3%) and TKA (23.8% vs 4.2%). No statistically significant association was observed between either ACT or SCT and anesthetic type (neuraxial or general) after adjusting for surgeon and location (all P>.05). CONCLUSIONS: We observed lower ACT and SCT at the CH for both TKA and THA after controlling for the surgeon of record and ASA classification. These findings underscore the efficiency advantages of performing primary joint replacements at the CH, showcasing an average reduction of 16 minutes in SCT and 4 minutes in ACT per case. Overall, establishing more accurate benchmarks to improve the prediction of surgical duration for THA and TKA in different perioperative environments can increase the reliability of surgical duration predictions and optimize scheduling. Future studies with study populations at multiple community hospitals and academic medical centers are needed before extrapolating these findings.

Benchmarking of Anesthesia and Surgical Control Times by Current Procedural Terminology (CPT®) Codes.

Over half of hospital revenue results from perioperative patient care, thus emphasizing the importance of efficient resource utilization within a hospital's suite of operating rooms (ORs). Predicting surgical case duration, including Anesthesia-controlled time (ACT) and Surgical-controlled time (SCT) has been significantly detailed throughout the literature as a means to help manage and predict OR scheduling. However, this information has previously been divided by surgical specialty, and only limited benchmarking data regarding ACT and SCT exists. We hypothesized that advancing the granularity of the ACT and SCT from surgical specialty to specific Current Procedural Terminology (CPT®) codes will produce data that is more accurate, less variable, and therefore more useful for OR schedule modeling and management. This single center study was conducted using times from surgeries performed at the University of Colorado Hospital (UCH) between September 2018 - September 2019. Individual cases were categorized by surgical specialty based on the specialty of the primary attending surgeon and CPT codes were compiled from billing data. Times were calculated as defined by the American Association of Clinical Directors. I2 values were calculated to assess heterogeneity of mean ACT and SCT times while Levene's test was utilized to assess heterogeneity of ACT and SCT variances. Statistical analyses for both ACT and SCT were calculated using JMP Statistical Discovery Software from SAS (Cary, NC) and R v3.6.3 (Vienna, Austria). All surgical cases (n = 87,537) performed at UCH from September 2018 to September 2019 were evaluated and 30,091 cases were included in the final analysis. All surgical subspecialties, with the exception of Podiatry, showed significant variability in ACT and SCT values between CPT codes within each surgical specialty. Furthermore, the variances of ACT and SCT values were also highly variable between CPT codes within each surgical specialty. Finally, benchmarking values of mean ACT and SCT with corresponding standard deviations are provided. Because each mean ACT and SCT value varies significantly between different CPT codes within a surgical specialty, using this granularity of data will likely enable improved accuracy in surgical schedule modeling compared to using mean ACT and SCT values for each surgical specialty as a whole. Furthermore, because there was significant variability of ACT and SCT variances between CPT codes, incorporating variance into surgical schedule modeling may also improve accuracy. Future investigations should include real-time simulations, logistical modeling, and labor utilization analyses as well as validation of benchmarking times in private practice settings.

Preoperatively Screened Obstructive Sleep Apnea Is Associated With Worse Postoperative Outcomes Than Previously Diagnosed Obstructive Sleep Apnea.

BACKGROUND: Obstructive sleep apnea (OSA) affects up to 26% of US adults, is often undiagnosed, and increases perioperative morbidity. We hypothesized that patients screened on the day of surgery as moderate/high risk for OSA (S-OSA) present similar perioperative respiratory complications, hospital use, and mortality than patients with previously diagnosed OSA (D-OSA). Second, we hypothesized that both OSA groups have more respiratory complications than No-OSA patients. METHODS: The electronic medical database from 1 academic and 2 community hospitals was retrospectively queried to identify adults undergoing nonemergent inpatient surgery (January 1, 2012, to December 31, 2014). Based on the day-of-surgery preoperative assessment and STOP-BANG (Snoring, Tiredness, Observed apnea during sleep, high blood Pressure, Body mass index >35, Age >50 years, thick Neck, Gender male) score, they were classified as D-OSA, S-OSA, or No-OSA. Perioperative respiratory events and interventions, hospital use, and mortality were measured. The primary outcome composite (adverse respiratory events [AREs]) included perioperative hypoxemic events and difficult airway management. Hypoxemic event was defined as peripheral saturation of oxygen (SpO2) <90% by continuous pulse oximetry for ≥3 minutes, or if validated and/or manually entered into the medical chart. Hypoxemia was classified as mild (lowest SpO2 86%-89%) or moderate/severe (lowest SpO2 ≤85%). Secondary outcomes included postoperative respiratory interventions, intensive care unit admission, hospital length of stay, and 30-day and 1-year all-cause mortality. Outcomes were compared using linear and logistic regression analyses. RESULTS: A total of 28,912 patients were assessed: 3432 (11.9%) D-OSA; 1546 (5.3%) S-OSA; and 23,934 (82.8%) No-OSA patients. At least 1 ARE was present in 68.0% of S-OSA; 71.0% of D-OSA; and 52.1% of No-OSA patients (unadjusted P < .001), primarily ≥1 moderate/severe hypoxemic event after discharge from the postanesthesia care unit (PACU; 39.9% in S-OSA; 39.5% in D-OSA; and 27.1% in No-OSA patients). S-OSA patients compared to D-OSA patients presented lower rates of moderate/severe hypoxemia in the PACU but similar intraoperatively and postoperatively, higher difficult mask ventilation rates, and similar difficult intubation reports. After adjusting for demographic, health, and surgical differences and hospital type, the likelihood of ≥1 ARE was not different in S-OSA and D-OSA patients (adjusted odds ratio 0.90 [99% confidence interval, 0.75-1.09]; P = .15). S-OSA patients compared to D-OSA patients had significantly increased postoperative reintubation, mechanical ventilation, direct intensive care unit admission after surgery, hospital length of stay, and 30-day all-cause mortality. CONCLUSIONS: Patients classified as S-OSA have similar rates of AREs to D-OSA patients, but increased postoperative respiratory interventions, hospital use, and 30-day all-cause mortality. These worse postoperative outcomes in S-OSA patients than D-OSA patients could reflect the lack of awareness and appropriate management of this bedside S-OSA diagnosis after PACU discharge. Multidisciplinary interventions are needed for these high-risk patients.

Safety interventions on the labor and delivery unit.

PURPOSE OF REVIEW: The present review highlights recent advances in efforts to improve patient safety on labor and delivery units and well tolerated care for pregnant patients in general. RECENT FINDINGS: Recent studies in obstetric patient safety have a broad focus but repetitive themes for interdisciplinary training include: simulating critical events, having open multidisciplinary communication, frequent reviews of cases of maternal morbidity, and implementing maternal early warning systems. The National Partnership for Maternal Safety is also active in promoting care bundles across many topics on maternal safety. SUMMARY: A culture of safety is the goal for all obstetric units. Achieving that ideal requires multidisciplinary collaboration, frequent reassessment for areas of improvement, and a culture of openness to change when improvement opportunities arise.

Peripartum Care of the Jehovah's Witness Patient.

Postpartum hemorrhage is a leading cause of maternal mortality. Jehovah's Witnesses (JWs) refuse allogeneic blood transfusion, and thus treatment of hemorrhagic complications in this patient population is complex. Recognition and respect for religious beliefs are essential when caring for the JW parturient and several ethical and legal considerations must be taken into account. Interdisciplinary teamwork and communication as well as active patient participation are critical in the decision-making process for JW patients. Various techniques and technologies are available to optimize red blood cell mass, minimize bleeding, increase tolerance to anemia and support multiorgan derangements derived from antepartum and postpartum hemorrhage.

Using an at-risk salary model to improve throughput in academic medical center operating rooms.

STUDY OBJECTIVE: The objective was to analyze if an at-risk salary model for faculty anesthesiologists could improve on-time first case starts (FCSs) and case turnovers (TOs) in an academic hospital inpatient operating room (IOR) and ambulatory surgery center (ASC). Organizational goals were 65% and 70% on-time FCS and case TO times for IOR and ASC, respectively. DESIGN: This was a retrospective study. SETTING: Surgical cases performed at both the IORs and the ASCs at a large academic medical center were included. INTERVENTIONS: We converted 5% to 7% (academic rank dependent) of anesthesiologist salary from guaranteed to an at-risk salary model. Salary was earned back on a case-by-case basis by starting cases on time or by documenting a valid reason for case delay in the anesthesia record. On-time first case and goal TO times were determined using American Association of Clinical Directors standard definitions. MEASUREMENTS: Data were reviewed for 1 year prior to implementation of the at-risk salary model and for 1 year after the implementation. Monthly average on-time FCS and TO times were compared between the preimplementation and postimplementation time frames. Data were analyzed using analysis of variance for repeated measures. MAIN RESULTS: After the implementation of the at-risk salary model, the organization experienced a 33% and 86% improvement in on-time FCSs (P< .01) in the inpatient and ambulatory operating rooms, respectively. A 41% (IOR) and 44% (ASC) improvement in timely case TOs (P< .01) was also seen. CONCLUSIONS: Anesthesiologists can drive efficiency in an operating room setting. By incentivizing on-time FCS and timely case TO with an at-risk salary model for faculty anesthesiologists, we were able to demonstrate a sustained significant improvement for these metrics. In both an inpatient and an ambulatory setting, operating room efficiency may be best served by aligning provider financial incentives with desired outcome metrics.

Basal transethmoidal encephalocele and malignant hypertension in a parturient with a seizure disorder. A case report.

BACKGROUND: Nasal encephaloceles are uncommon in North America and may be diagnosed only as incidental findings. The presence of an encephalocele and malignant hypertension in the parturient requires complex coordination of care. CASE: We present a case of severe chronic hypertension in a pregnant patient with a seizure disorder and new finding of a basal transethmoidal encephalocele. She required 5 antihypertensive agents and cesarean delivery at 34 weeks' gestation under general anesthesia. The obstetric and anesthetic management of encephalocele are reviewed. CONCLUSION: Nasal encephaloceles are rarely reported in pregnancy and present additional peripartum obstetric and anesthetic considerations that require multidisciplinary planning for optimization of maternal and fetal outcomes.

The use of postpartum hemorrhage protocols in United States academic obstetric anesthesia units.

BACKGROUND: Postpartum hemorrhage (PPH) is the leading cause of severe maternal morbidity, cardiac arrest, and death during the hospitalization for childbirth. Protocol-driven care has been associated with improved outcomes in many settings; the National Partnership for Maternal Safety now recommends that PPH protocols be implemented in every labor and delivery unit in the United States. In this study, we sought to identify the level of PPH protocol availability in academic United States obstetric units. We hypothesized that the majority (>80%) of academic obstetric anesthesia units would have a PPH protocol in place. METHODS: A survey was developed by an expert panel. Domains included hospital characteristics, availability of PPH protocol or plans to develop such a protocol, and protocol components included in the upcoming National Partnership for Maternal Safety obstetric hemorrhage safety bundle initiative. The electronic survey was emailed to the 104 directors of United States academic obstetric anesthesia units. Responses were stratified by PPH protocol availability as appropriate. Univariate statistics were used to characterize survey responses and the probability distribution for PPH protocol availability was estimated using the binomial distribution. RESULTS: The survey response rate was 58%. The percentage of responding units with a PPH protocol was lower than hypothesized (P = 0.03); there was a PPH protocol in 67% of responding units (N = 40, 95% confidence interval [CI]: 53%-78%). The median annual delivery volume for responding units with PPH protocol was 3900 vs 2300 for units without PPH protocol (P = 0.002), with no difference in cesarean delivery rate (P = 0.73) or observed PPH rate (P = 0.69). There was no difference in annual delivery volume between responding and nonresponding hospitals (P = 0.06), suggesting that academic centers with delivery volume >3200 births per year are more likely than smaller volume hospitals to have a PPH protocol in place (odds ratio 3.16 (95% CI: 1.01-9.90). Adjusting for delivery volume among nonresponding hospitals, we estimate that 67% (95% CI: 55%-77%) of all academic obstetric anesthesia units had a PPH protocol in place at the time of this survey. Institutional processes for escalation do not correlate with the presence of a PPH protocol. There was a massive transfusion protocol in 95% of units with a PPH protocol and in 90% of units without (95% CI of difference: -7% to 7%). A PPH code team or rapid response team was available in 57% of responding institutions, with no difference between units with or without a PPH protocol [mean difference 4%, 95% CI (-24% to 32%)]. CONCLUSIONS: Despite increasing emphasis on national quality improvement in patient safety, there are no PPH protocols in at least 20% of U.S. academic obstetric anesthesia units. Delivery volume is the most important variable predicting the presence of a PPH protocol. National efforts to ensure universal presence of a PPH protocol in all academic centers will achieve the greatest impact by focusing on small-volume facilities. Future work is needed to evaluate and facilitate PPH implementation in nonacademic obstetric units.