Emergence delirium following sevoflurane anesthesia in adults: prospective observational study / Delirium do despertar após anestesia com sevoflurano em adultos: estudo observacional prospectivo

Abstract Background and objectives: Emergence delirium after general anesthesia with sevoflurane has not been frequently reported in adults compared to children. This study aimed to determine the incidence of emergence delirium in adult patients who had anesthesia with sevoflurane as the volatile agent and the probable risk factors associated with its occurrence. Design & methods: A prospective observational study was conducted in adult patients who had non-neurological procedures and no existing neurological or psychiatric conditions, under general anesthesia. Demographic data such as age, gender, ethnicity and clinical data including ASA physical status, surgical status, intubation attempts, duration of surgery, intraoperative hypotension, drugs used, postoperative pain, rescue analgesia and presence of catheters were recorded. Emergence delirium intensity was measured using the Nursing Delirium Scale (NuDESC). Results: The incidence of emergence delirium was 11.8%. The factors significantly associated with emergence delirium included elderly age (>65) (p = 0.04), emergency surgery (p = 0.04), African ethnicity (p = 0.01), longer duration of surgery (p = 0.007) and number of intubation attempts (p = 0.001). Factors such as gender, alcohol and illicit drug use, and surgical specialty did not influence the occurrence of emergence delirium. Conclusions: The incidence of emergence delirium in adults after general anesthesia using sevoflurane is significant and has not been adequately reported. Modifiable risk factors need to be addressed to further reduce its incidence.

Resumo Justificativa e objetivos: O delirium do despertar após a anestesia geral com sevoflurano não tem sido relatado com frequência em adultos como nas crianças. Este estudo teve como objetivo determinar a incidência de delirium do despertar em pacientes adultos submetidos à anestesia com sevoflurano como agente volátil e os prováveis fatores de risco associados à sua ocorrência. Desenho e métodos: Um estudo observacional prospectivo foi conduzido com pacientes adultos sem distúrbios neurológicos ou psiquiátricos submetidos à anestesia geral para procedimentos não neurológicos. Dados demográficos como idade, sexo, etnia e dados clínicos, inclusive estado físico ASA, estado cirúrgico, tentativas de intubação, tempo de cirurgia, hipotensão intraoperatória, drogas usadas, dor pós-operatória, analgesia de resgate e presença de cateteres, foram registrados. A intensidade do delirium do despertar foi medida com a Escala de Triagem de Delirium em Enfermagem (Nursing Delirium Scale - NuDESC). Resultados: A incidência de delirium do despertar foi de 11,8%. Os fatores significativamente associados ao delirium do despertar incluíram idade avançada (> 65) (p = 0,04), cirurgia de emergência (p = 0,04), descendência africana (p = 0,01), tempo maior de cirurgia (p = 0,007) e número de tentativas de intubação (p = 0,001). Fatores como sexo, uso de álcool e drogas ilícitas e especialidade cirúrgica não influenciaram a ocorrência de delirium do despertar. Conclusões: A incidência de delirium do despertar em adultos após a anestesia geral com sevoflurano é significativa e não tem sido relatada adequadamente. Fatores de risco modificáveis precisam ser abordados para reduzir ainda mais sua incidência.

[Emergence delirium following sevoflurane anesthesia in adults: prospective observational study]. / Delirium do despertar após anestesia com sevoflurano em adultos: estudo observacional prospectivo.

BACKGROUND AND OBJECTIVES: Emergence delirium after general anesthesia with sevoflurane has not been frequently reported in adults compared to children. This study aimed to determine the incidence of emergence delirium in adult patients who had anesthesia with sevoflurane as the volatile agent and the probable risk factors associated with its occurrence. DESIGN AND METHODS: A prospective observational study was conducted in adult patients who had non-neurological procedures and no existing neurological or psychiatric conditions, under general anesthesia. Demographic data such as age, gender, ethnicity and clinical data including ASA physical status, surgical status, intubation attempts, duration of surgery, intraoperative hypotension, drugs used, postoperative pain, rescue analgesia and presence of catheters were recorded. Emergence delirium intensity was measured using the Nursing Delirium Scale (NuDESC). RESULTS: The incidence of emergence delirium was 11.8%. The factors significantly associated with emergence delirium included elderly age (>65) (p=0.04), emergency surgery (p=0.04), African ethnicity (p=0.01), longer duration of surgery (p=0.007) and number of intubation attempts (p=0.001). Factors such as gender, alcohol and illicit drug use, and surgical specialty did not influence the occurrence of emergence delirium. CONCLUSIONS: The incidence of emergence delirium in adults after general anesthesia using sevoflurane is significant and has not been adequately reported. Modifiable risk factors need to be addressed to further reduce its incidence.

Postoperative Shivering Among Cannabis Users at a Public Hospital in Trinidad, West Indies.

PURPOSE: Postoperative shivering has been anecdotally observed to be frequent and severe in Cannabis smokers following general anesthesia in the Caribbean. The aim of this study was to compare the frequency and intensity of postoperative shivering in Cannabis users versus non-users. DESIGN: A prospective, cross-sectional, observational design was used. METHODS: Demographic data were obtained. Patients were grouped into Cannabis users and non-users. All patients received standardized general anesthesia and were administered warmed fluids intraoperatively. Ambient room temperatures and clinical data were recorded. Patients' core body temperature was recorded at 10-minute intervals both in the operating room and the post-anesthesia care unit (PACU). Postoperatively an independent observer assessed the patients who had shivering using a scoring system ranging from 0 to 3. Treatment for shivering and post-treatment shivering scores were also recorded. FINDINGS: Fifty-five patients were studied, of which 71% were male. There were 25 (45%) Cannabis users, of which 50% smoked < 5 joints per week, and 35% smoked >10 joints per week; 30 (55%) patients were non-users. The overall incidence of postoperative shivering was 36%; 16% had a shivering score of '3', 13% had '2' and 7% had a score of '1'. The incidence of postoperative shivering among Cannabis users was 40% while it was 33.3% in non-users. Also, 90% of Cannabis users had shivering scores of 2 and 3, compared to 70% of non-users. CONCLUSIONS: There was a higher incidence and intensity of shivering in Cannabis smokers, although the study could not establish a statistically significant difference in the frequency and severity of shivering between Cannabis users and non-users.

Does preoperative psychological status of patients affect postoperative pain? A prospective study from the Caribbean.

OBJECTIVES: Patients with high anxiety states in the preoperative period often have more intense postoperative pain, despite adequate pain control during the intraoperative period. This study aimed to determine the relationship between the preoperative psychological status and the pain experienced postoperatively in a sample of Caribbean patients. DESIGN AND METHODS: A prospective study was conducted in elective surgical adult patients at a teaching hospital in the Caribbean. Patients' preoperative psychological status was assessed using Hospital Anxiety and Depression Scale (HADS), and a preoperative 'expected' pain score was recorded. Postoperatively, 'observed' pain scores at 4 and 24 hours and the maximum pain score during 24 hours were recorded. Demographic data and clinical details including data regarding postoperative analgesia were collected. Expected and observed pain scores were compared between patients with and without anxiety and depression. RESULTS: A total of 304 patients were enrolled. The overall prevalence of anxiety and depression was 43% and 27%, respectively, based on the HADS scores. There were significant associations between the postoperative pain scores and factors such as preoperative anxiety and depression (HADS) scores, preoperative expected pain scores, patient educational level, presence of preoperative pain and surgical duration. Age, gender, ethnicity and type of anaesthesia did not impact postoperative pain scores. CONCLUSION: The presence of preoperative anxiety and depression as indicated by HADS score may significantly influence postoperative pain. Other factors such as educational level, presence of preoperative pain and surgical duration may also impact postoperative pain. Some of these factors may be modifiable and must be addressed in the preoperative period.

Costs and Utilization of Operating Rooms in a Public Hospital in Trinidad, West Indies.

CONTEXT: A top-down evaluation of the costs of operating rooms (ORs) is not commonly done because it is relevant mostly in a publicly funded system. OBJECTIVE: This study was conducted to determine the costs and utilization of ORs in a public hospital in Trinidad, West Indies, for two one-year periods using a top-down model. DESIGN: Quantitative observational study.Main Outcome Measures: A "cost-block" model suggested for evaluation of intensive care unit costs was adapted to suit ORs. Data were obtained from personal interviews, records, and surveys from the appropriate hospital departments. Adjusted OR utilization times also were recorded for both years. RESULTS: The total annual costs of 4 ORs for the years 2006 and 2009 were approximately US $2.2 and $3.2 million, respectively. Capital expenditure contributed to 70% of the costs, followed by consumables (15%) and medical staff salary (8%). The daily cost of running the ORs was US $6242 in 2006, which rose to $8873 in 2009. The cost of unutilized OR time was approximately US $298,342 in 2006 and was reduced to $198,315 during 2009. CONCLUSION: The adapted cost-block model was useful to evaluate the costs of ORs in a public hospital in Trinidad and can be used from the government's expenditure perspective. Because the cost of running the ORs was high, efficiency must be improved to minimize waste.

Perioperative outcome of colorectal cancer and validation of CR-POSSUM in a Caribbean country.

OBJECTIVE: To evaluate the risk-adjusted perioperative outcome of colorectal cancer surgery, applying the Colorectal Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (CR-POSSUM). METHODS: A retrospective chart review of patients who underwent colorectal cancer surgery from 2004 to 2007 was done. Data including demographics and physiological data for CR-POSSUM were recorded. Predicted mortality was calculated; validation of CR-POSSUM was done using Hosmer-Lemeshow goodness-of-fit and Receiver Operating Characteristic (ROC) Curve analyses. RESULTS: 232 patients were studied. The overall mean CR-POSSUM score was 18.3+/-3.8 (SD). Predicted mortality was 7.7%, observed mortality was 6.9% and the standardized mortality ratio was 0.9. 34.4% of patients presented with Duke's Stage C or D and had a higher risk of mortality (Odds Ratio (OR) 3.1, 95% Confidence Intervals (CI) 1.1, 9.1). Emergency surgery was associated with a higher risk of mortality (OR 4.7, 95% CI 1.5, 14.1). CR-POSSUM calibrated well (Hosmer-Lemeshow Chi-square value 4.3; df: 8; p=0.82) and fairly discriminated outcome as shown by the area under the ROC Curve 0.69, (Standard Error: 0.07). CONCLUSIONS: Perioperative outcome of colorectal surgery in Trinidad and Tobago is comparable to the developed countries as evaluated by the CR-POSSUM. Patients presenting for emergency surgery and those with advanced stages of cancer had higher perioperative mortality.

Perioperative outcome of colorectal cancer and validation of CR-POSSUM in a Caribbean country

OBJECTIVE: To evaluate the risk-adjusted perioperative outcome of colorectal cancer surgery, applying the Colorectal Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (CR-POSSUM). METHODS: A retrospective chart review of patients who underwent colorectal cancer surgery from 2004 to 2007 was done. Data including demographics and physiological data for CR-POSSUM were recorded. Predicted mortality was calculated; validation of CR-POSSUM was done using Hosmer-Lemeshow goodness-of-fit and Receiver Operating Characteristic (ROC) Curve analyses. RESULTS: 232 patients were studied. The overall mean CR-POSSUM score was 18.3+/-3.8 (SD). Predicted mortality was 7.7%, observed mortality was 6.9% and the standardized mortality ratio was 0.9. 34.4% of patients presented with Duke's Stage C or D and had a higher risk of mortality (Odds Ratio (OR) 3.1, 95% Confidence Intervals (CI) 1.1, 9.1). Emergency surgery was associated with a higher risk of mortality (OR 4.7, 95% CI 1.5, 14.1). CR-POSSUM calibrated well (Hosmer-Lemeshow Chi-square value 4.3; df: 8; p=0.82) and fairly discriminated outcome as shown by the area under the ROC Curve 0.69, (Standard Error: 0.07). CONCLUSIONS: Perioperative outcome of colorectal surgery in Trinidad and Tobago is comparable to the developed countries as evaluated by the CR-POSSUM. Patients presenting for emergency surgery and those with advanced stages of cancer had higher perioperative mortality.

Patient perception of the utility of the Preanesthetic Clinics in a Caribbean developing country.

BACKGROUND AND OBJECTIVES: Perception of the patients regarding the utility of the Preanesthetic Clinics and flow time in clinics has not been widely studied in the developing world. The present study aims to study this aspect. METHODS: A self-administered 15-item questionnaire survey was conducted among patients attending the Preanesthetic Clinics at a tertiary care teaching hospital in Trinidad. The questionnaire was also distributed to the patients attending the General Surgical Clinic for comparison. Another questionnaire was distributed among the staff of the Preanesthetic Clinic. Patient demographics including age, gender, and educational status and American Society of Anesthesiologists physical status were noted. Other data recorded were patient flow time and details of attending staff. RESULTS: Of the 220 patients who attended the Preanesthetic Clinics, 92.7% participated in the study. The reliability of the questionnaire was supported by Cronbach's alpha coefficient (0.67). The median time for referral from the surgical clinic to Preanesthetic Clinic was 50 days, median waiting time in the clinic was 2.7 hours, and the median waiting time for surgery after acceptance in the clinic was 13 days. The patients' opinions regarding the benefits of the clinic, length of the waiting time was independent of their age and educational status. Patients felt that attending the Preanesthetic Clinic was beneficial and not costly to them, although the waiting times were found to be longer. CONCLUSIONS: Patients perceive that attending the Preanesthetic Clinic has been useful before the surgical procedure and the care they received in the clinic was satisfactory.

Percepção dos pacientes a respeito da utilidade do Ambulatório de Avaliação Pré-anestésica em um país caribenho em desenvolvimento / Patient perception of the utility of the Preanesthetic Clinics in a caribbean developing country / Percepción de los pacientes respecto de la utilidad del Ambulatorio de Evaluación Preanestésica en un país caribeño en desarrollo

JUSTIFICATIVA E OBJETIVOS: A percepção dos pacientes a respeito da utilidade do Ambulatório de Avaliação Pré-anestésica e o fluxo de pacientes não foram extensamente estudados no mundo em desenvolvimento. O objetivo deste estudo foi analisar esse aspecto. MÉTODO: Foi realizada pesquisa aplicando-se questionário entre pacientes atendidos no Ambulatório de Avaliação Pré-anestésica de um hospital terciário de ensino em Trinidad. A título de comparação, esse questionário também foi distribuído aos pacientes atendidos no Ambulatório de Cirurgia Geral. Os parâmetros demográficos, incluindo idade, sexo, nível escolar e estado físico ASA foram anotados. Outros dados registrados incluíam o fluxo de pacientes e detalhes a respeito da equipe médica. RESULTADOS: Dos 220 pacientes atendidos no Ambulatório de Avaliação Pré-anestésica, 92,7% participaram do estudo. A validade do questionário foi apoiada pelo coeficiente alfa de Cronbach (0,67). O tempo médio para o encaminhamento do Ambulatório de Cirurgia para a Clínica Pré-anestésica foi de 50 dias; a espera média na clínica foi de 2,7 horas e da espera pela intervenção cirúrgica após a aceitação pelo ambulatório foi de 13 dias. As opiniões dos pacientes a respeito dos benefícios da clínica e tempo de espera não foram influenciadas pela idade nem pelo nível educacional. Na opinião dos pacientes, o atendimento no Ambulatório de Avaliação Pré-anestésica foi satisfatório, mas os tempos de espera foram considerados longos. CONCLUSÕES: Na opinião dos pacientes, a consulta no Ambulatório de Avaliação Pré-anestésica antes do procedimento cirúrgico foi útil e o atendimento foi considerado satisfatório.

BACKGROUND AND OBJECTIVES: Perception of the patients regarding the utility of the Preanesthetic Clinics and flow time in clinics has not been widely studied in the developing world. The present study aims to study this aspect. METHODS: A self-administered 15-item questionnaire survey was conducted among patients attending the Preanesthetic Clinics at a tertiary care teaching hospital in Trinidad. The questionnaire was also distributed to the patients attending the General Surgical Clinic for comparison. Another questionnaire was distributed among the staff of the Preanesthetic Clinic. Patient demographics including age, gender, and educational status and American Society of Anesthesiologists physical status were noted. Other data recorded were patient flow time and details of attending staff. RESULTS: Of the 220 patients who attended the Preanesthetic Clinics, 92.7% participated in the study. The reliability of the questionnaire was supported by Cronbach's alpha coefficient (0.67). The median time for referral from the surgical clinic to Preanesthetic Clinic was 50 days, median waiting time in the clinic was 2.7 hours, and the median waiting time for surgery after acceptance in the clinic was 13 days. The patients' opinions regarding the benefits of the clinic, length of the waiting time was independent of their age and educational status. Patients felt that attending the Preanesthetic Clinic was beneficial and not costly to them, although the waiting times were found to be longer. CONCLUSIONS: Patients perceive that attending the Preanesthetic Clinic has been useful before the surgical procedure and the care they received in the clinic was satisfactory.

JUSTIFICATIVA Y OBJETIVOS: La percepción de los pacientes respecto de la utilidad del Ambulatorio de Evaluación Preanestésica como también el flujo de pacientes, no fueron extensamente estudiados en el mundo en desarrollo. El objetivo de este estudio fue analizar ese aspecto. MÉTODOS: Se realizó una investigación aplicando un cuestionario entre los pacientes atendidos en el Ambulatorio de Evaluación Preanestésica de un hospital subcontratado de enseñanza en Trinidad. Como comparación, ese cuestionario también se distribuyó a los pacientes atendidos en el Ambulatorio de Cirugía General. Los parámetros demográficos, incluyendo edad, sexo, nivel escolar y estado físico ASA se registraron. Otros datos registrados incluían el flujo de pacientes y los detalles respecto del equipo médico. RESULTADOS: De los 220 pacientes atendidos en el Ambulatorio de Evaluación Pré-anestésica, un 92,7% participaron del estudio. La validez del cuestionario fue apoyada por el coeficiente alfa de Cronbach (0,67). El tiempo promedio para la derivación al ambulatorio de cirugía para la Clínica Preanestésica fue de 50 días; el tiempo promedio de espera en la clínica fue de 2,7 horas y el de espera por la cirugía después de la aceptación por parte del ambulatorio fue de 12 días. Las opiniones de los pacientes respecto de los beneficios de la clínica y tiempo de espera no tuvieron ningún influjo por la edad ni por el nivel cultural. Según los pacientes, la atención en el Ambulatorio de Evaluación Preanestésica fue benéfica, pero los tiempos de espera fueron considerados extensos. CONCLUSIONES: Según los pacientes, la consulta en el Ambulatorio de Evaluación Preanestésica antes del procedimiento quirúrgico fue útil y la atención fue considerada satisfactoria.

Patient perception of the utility of the preanesthetic clinics in a Caribbean developing country.

BACKGROUND AND OBJECTIVES: Perception of the patients regarding the utility of the Preanesthetic Clinics and flow time in clinics has not been widely studied in the developing world. The present study aims to study this aspect. METHODS: A self-administered 15-item questionnaire survey was conducted among patients attending the Preanesthetic Clinics at a tertiary care teaching hospital in Trinidad. The questionnaire was also distributed to the patients attending the General Surgical Clinic for comparison. Another questionnaire was distributed among the staff of the Preanesthetic Clinic. Patient demographics including age, gender, and educational status and American Society of Anesthesiologists physical status were noted. Other data recorded were patient flow time and details of attending staff. RESULTS: Of the 220 patients who attended the Preanesthetic Clinics, 92.7 percent participated in the study. The reliability of the questionnaire was supported by Cronbach's alpha coefficient (0.67). The median time for referral from the surgical clinic to Preanesthetic Clinic was 50 days, median waiting time in the clinic was 2.7 hours, and the median waiting time for surgery after acceptance in the clinic was 13 days. The patients' opinions regarding the benefits of the clinic, length of the waiting time was independent of their age and educational status. Patients felt that attending the Preanesthetic Clinic was beneficial and not costly to them, although the waiting times were found to be longer. CONCLUSIONS: Patients perceive that attending the Preanesthetic Clinic has been useful before the surgical procedure and the care they received in the clinic was satisfactory.

Evaluation of trauma care applying TRISS methodology in a Caribbean developing country.

There have been conflicting reports regarding the applicability of Trauma Injury Severity Score (TRISS) methodology to evaluate trauma care in a developing country setting. The objective of this study was to apply TRISS methodology to evaluate trauma care in the public hospitals of a Caribbean developing country. A prospective, observational study was conducted in the three major general hospitals in Trinidad. Major trauma patients were included. Demographic data, waiting time in the Emergency Department, and nature of injury (blunt or penetrating) were noted. Revised Trauma Score, Injury Severity Score, and Glasgow Coma Scale were applied to all patients on admission. Hospital outcomes were noted. Predicted outcomes were calculated for adult patients using TRISS methodology. M, Z statistics and receiver operating characteristic (ROC) curve analysis were done. There were 326 trauma patients studied, of whom 279 adults were evaluated by the TRISS methodology. Men were more frequently involved in trauma than women; there was more blunt trauma than penetrating trauma. The M statistic was 0.98 and the overall Z statistic was 5.81. The ROC curve analysis showed TRISS to be a fair discriminator in the study case-mix with an area under the curve of 0.82 (95% confidence interval 0.69-0.96). There is a considerable disparity between predicted and observed outcomes when trauma patients are evaluated by the TRISS methodology in a developing country setting.

The utilities of the therapeutic intervention scoring system (TISS-28)

BACKGROUND AND AIMS: The study evaluates the utility of therapeutic intervention scoring system (TISS-28) in quantifying the resource utilization, costs and predicting outcome of critically ill patients. MATERIALS AND METHODS: TISS-28 was prospectively applied to patients consecutively admitted to the intensive care units (ICU) of three public teaching hospitals and two private hospitals in Trinidad on a daily basis for a period of eight weeks. Demographic data, diagnoses on admission, nurse-patient ratio, ICU length of stay and hospital outcomes were recorded. Simplified acute physiology score (SAPS)-II was applied for all adult patients. Costs were calculated from data collected from the public hospitals in relation to TISS-28 score. RESULTS : TISS-28 scores of five hundred and ninety-five patient-days were analyzed. The median daily TISS-28 per patient was 27 [24.5, 30.6 quartiles (IQR)]; the median day-1 TISS-28 score was 29 (25, 33 IQR) and the median last day TISS-28 score was 25 (21, 30 IQR). The overall average TISS per nurse was 26.2 per day. The mean cost per patient per day was 414 US dollars. The discriminatory function of day-1 TISS-28 as a prognostic scoring system was less compared to SAPS II as shown by the area under the receiver operating characteristic curve (0.65 compared to 0.71). CONCLUSIONS: TISS-28 is useful for evaluating the resource utilization and costs and may not be useful as a prognostic scoring system.

A study of the efficacy of diclofenac iontophoresis for providing effective topical analgesia.

Background & Objectives: Iontophoresis has evolved as one of the attractive methods for enhanced drug delivery The purpose of the study was to determine the efficacy of iontophoresis of diclofenac gel in providing topical analgesia Methods : Healthy volunteers were tested using the Iontophor meter. To the right dorsum of the hand of each volunteer, an electrode containing diclofenac gel was applied. No gel was applied to the left dorsum as a control. A current of 0.4 milliamps was applied for ten minutes to the right dorsum. The dorsal surfaces of both hands were tested with an eighteen gauge needle at 0, 5 and 10 minute intervals. The volunteer's response to the pinprick was recorded using the Visual Analogue Scale (VAS). Results: 48 volunteers were tested. The control group had no significant variation from the overall mean pain score during the time of study. However, the mean pain score of the iontophoresis group decreased with time. Multivariate analysis of repeated measures to determine the effect of iontophoresis on the perception of pain showed statistical significance with respect to decrease in pain scores over time (p<0.001). Conclusions: Iontophoresis with diclofenac gel significantly reduces pain for pinprick and may be used as an alternative technique to provide topical analgesia.

Evaluation of the utilization of the preanaesthetic clinics in a university teaching hospital.

BACKGROUND: Dedicated out-patient preanaesthetic clinics are relatively recent phenomenon and information is sparse from developing world. This study attempted to evaluate the utilization of adult and paediatric preanaesthetic clinics and its impact on the cancellations of surgery in Trinidad. METHODS: All patients scheduled to have elective surgery during the period of twelve weeks were enrolled for prospective collection of data including demographics, the admitting diagnoses, surgical procedure, category of surgery and specialty, and the patients' attendance to preanaesthetic clinics. Cancellations on the day of surgery along with reasons were recorded. The difference between patients who attended and did not attend the clinic was analysed. RESULTS: Of 424 patients scheduled for procedures during the study period, 213 were adults and 211 were children. Overall 39% of adults and 46% of the children scheduled for surgery had previously attended the preanaesthetic clinic. Among adults, general surgery patients were the largest majority to attend the preanaesthetic clinic. The paediatric preanaesthetic clinic was mostly utilized by paediatric general surgery. Overall 30% of procedures in adults and 26% of those in children were cancelled. There was a statistically significant difference in cancellations between patients who attended and did not attend the preanaesthetic clinic (p = 0.004). There was a 52% more chance of the procedure getting cancelled if the patient did not attend the clinic. CONCLUSION: The study highlights the inadequate use of the preanaesthetic clinics and the impact of the clinics on last-minute cancellations.

Evaluation of the utilization of the preanaesthetic clinics in a University teaching hospital

BACKGROUND: Dedicated out-patient preanaesthetic clinics are relatively recent phenomenon and information is sparse from developing world. This study attempted to evaluate the utilization of adult and paediatric preanaesthetic clinics and its impact on the cancellations of surgery in Trinidad. METHODS: All patients scheduled to have elective surgery during the period of twelve weeks were enrolled for prospective collection of data including demographics, the admitting diagnoses, surgical procedure, category of surgery and specialty, and the patients' attendance to preanaesthetic clinics. Cancellations on the day of surgery along with reasons were recorded. The difference between patients who attended and did not attend the clinic was analysed. RESULTS: Of 424 patients scheduled for procedures during the study period, 213 were adults and 211 were children. Overall 39 percent of adults and 46 percent of the children scheduled for surgery had previously attended the preanaesthetic clinic. Among adults, general surgery patients were the largest majority to attend the preanaesthetic clinic. The paediatric preanaesthetic clinic was mostly utilized by paediatric general surgery. Overall 30 percent of procedures in adults and 26 percent of those in children were cancelled. There was a statistically significant difference in cancellations between patients who attended and did not attend the preanaesthetic clinic (p = 0.004). There was a 52 percent more chance of the procedure getting cancelled if the patient did not attend the clinic. CONCLUSION: The study highlights the inadequate use of the preanaesthetic clinics and the impactof the clinics on last-minute cancellations.

Performance of a pediatric ambulatory anesthesia program--a developing country experience.

BACKGROUND: The aim of this study was to evaluate the performance of a pediatric ambulatory anesthesia program in a tertiary care teaching hospital in a developing country. METHODS: Data on all pediatric patients (<16 years of age) scheduled to have elective day-care surgery during a 1 year period from January 1999 to December 1999 were collected retrospectively. An audit form was used to determine the specialty of the procedures, anesthesia techniques, postoperative analgesia, perioperative complications, unplanned admissions and outcomes with respect to morbidity and mortality. RESULTS: A total of 763 pediatric ambulatory surgical procedures were performed during the year of 1999. The procedures included general surgery, ENT, orthopedic and plastic surgery. The most common procedure was inguinal hernia repair followed by umbilical hernia repair, adenotonsillectomy and circumcision and 96% of the patients had general anesthesia. There were only three unplanned admissions (0.4%); one for a surgical reason and two for anesthetic reasons. There was no serious morbidity or mortality in any patient. CONCLUSIONS: Performance of pediatric day-care anesthesia has been good in our day-care unit and we have a successful ambulatory surgery program, despite the limitations of a developing country.

Innovation management using logical framework in hospital-based healthcare units

Innovation is part and parcel of any service in today's environment, so as to remain competitive. Quality improvement in healthcare services is a complex, multi-dimensional task. This study proposes innovation management in healthcare services using a logical framework. A problem tree and an objective tree are developed to identify and mitigate issues and concerns. A logical framework is formulated to develop a plan for implementation and monitoring strategies, potentially creating an environment for continuous quality improvement in a specific unit. We recommend logical framework as a valuable model for innovation management in healthcare services.

Performance of a pediatric ambulatory anesthesia program – a developing country experience

BACKGROUND:  The aim of this study was to evaluate the performance of a pediatric ambulatory anesthesia program in a tertiary care teaching hospital in a developing country. METHODS:  Data on all pediatric patients (<16 years of age) scheduled to have elective day-care surgery during a 1 year period from January 1999 to December 1999 were collected retrospectively. An audit form was used to determine the specialty of the procedures, anesthesia techniques, postoperative analgesia, perioperative complications, unplanned admissions and outcomes with respect to morbidity and mortality. RESULTS:  A total of 763 pediatric ambulatory surgical procedures were performed during the year of 1999. The procedures included general surgery, ENT, orthopedic and plastic surgery. The most common procedure was inguinal hernia repair followed by umbilical hernia repair, adenotonsillectomy and circumcision and 96% of the patients had general anesthesia. There were only three unplanned admissions (0.4%); one for a surgical reason and two for anesthetic reasons. There was no serious morbidity or mortality in any patient. CONCLUSIONS:  Performance of pediatric day-care anesthesia has been good in our day-care unit and we have a successful ambulatory surgery program, despite the limitations of a developing country.

Application of analytic hierarchy process for measuring and comparing the global performance of intensive care units.

PURPOSE: To develop a model for the global performance measurement of intensive care units (ICUs) and to apply that model to compare the services for quality improvement. MATERIALS AND METHODS: Analytic hierarchy process, a multiple-attribute decision-making technique, is used in this study to evolve such a model. The steps consisted of identifying the critical success factors for the best performance of an ICU, identifying subfactors that influence the critical factors, comparing them pairwise, deriving their relative importance and ratings, and calculating the cumulative performance according to the attributes of a given ICU. Every step in the model was derived by group discussions, brainstorming, and consensus among intensivists. RESULTS: The model was applied to 3 ICUs, 1 each in Barbados, Trinidad, and India in tertiary care teaching hospitals of similar setting. The cumulative performance rating of the Barbados ICU was 1.17 when compared with that of Trinidad and Indian ICU, which were 0.82 and 0.75, respectively, showing that the Trinidad and Indian ICUs performed 70% and 64% with respect to Barbados ICU. The model also enabled identifying specific areas where the ICUs did not perform well, which helped to improvise those areas. CONCLUSIONS: Analytic hierarchy process is a very useful model to measure the global performance of an ICU.

Application of analytic hierarchy process for measuring and comparing the global performance of intensive care units

Purpose: To develop a model for the global performance measurement of intensive care units (ICUs) and to apply that model to compare the services for quality improvement. Materials and Methods: Analytic hierarchy process, a multiple-attribute decision-making technique, is used in this study to evolve such a model. The steps consisted of identifying the critical success factors for the best performance of an ICU, identifying subfactors that influence the critical factors, comparing them pairwise, deriving their relative importance and ratings, and calculating the cumulative performance according to the attributes of a given ICU. Every step in the model was derived by group discussions, brainstorming, and consensus among intensivists. Results: The model was applied to 3 ICUs, 1 each in Barbados, Trinidad, and India in tertiary care teaching hospitals of similar setting. The cumulative performance rating of the Barbados ICU was 1.17 when compared with that of Trinidad and Indian ICU, which were 0.82 and 0.75, respectively, showing that the Trinidad and Indian ICUs performed 70 per cent and 64 per cent with respect to Barbados ICU. The model also enabled identifying specific areas where the ICUs did not perform well, which helped to improvise those areas. Conclusions: Analytic hierarchy process is a very useful model to measure the global performance of an ICU.