RESUMEN
BACKGROUND: Perioperative care has been identified as an area of wide variability in quality, with conflicting models, and involving multiple specialties. In 2014, the Loma Linda University Departments of Anesthesiology and Urology implemented a perioperative hospitalist service (PHS), consisting of anesthesiology-trained physicians, to co-manage patients for the entirety of their perioperative period. We hypothesized that implementation of this PHS model would result in an improvement in patient recovery. METHODS: As a quality improvement (QI) initiative, the PHS service was formed of selected anesthesiologists who received training on the core competencies for hospitalist medicine. The service was implemented following a co-management agreement to medically manage patients undergoing major urologic procedures (prostatectomy, cystectomy, and nephrectomy). Impact was assessed by comparisons to data from the year prior to PHS service implementation. Data was compared with and without propensity matching. Primary outcome marker was a reduction in length of stay. Secondary outcome markers included complication rate, return of bowel function, number of consultations, reduction in total direct patient costs, and bed days saved. RESULTS: Significant reductions in length of stay (p < 0.05) were demonstrated for all surgical procedures with propensity matching and were demonstrated for cystectomy and nephrectomy cases without. Significant reductions in complication rates and ileus were also observed for all surgical procedures post-PHS implementation. Additionally, reductions in total direct patient costs and frequency of consultations were also observed. CONCLUSIONS: Anesthesiologists can safely function as perioperative hospitalists, providing appropriate medical management, and significantly improving both patient recovery and throughput.
RESUMEN
BACKGROUND: Gaining proficiency with various airway management tools is an important goal for anesthesiology training. Indirect video laryngoscopes facilitate tracheal intubation in adults, but it is not clear whether these findings translate to children. This study evaluates the total time to successful intubation when performed by anesthesiology trainees using GlideScope Cobalt® video laryngoscopy (GlideScope), Storz DCI® video laryngoscopy (Storz), or direct laryngoscopy (Direct) in children <2 years old with normal airway anatomy. METHODS: Sixty-five children presenting for elective surgery were randomly assigned to undergo tracheal intubation using GlideScope, Storz, or Direct. Laryngoscopists were anesthesiology trainees in clinical anesthesia year ≥2 who had proven basic proficiency with each laryngoscope on an infant airway manikin. Total time to successful intubation (TTSI, seconds), rate of successful intubation on first laryngoscopy attempt, and the change in intubation time from manikin to clinical settings were recorded. An intubation time difference >10 seconds was defined as clinically significant. RESULTS: TTSI was longer for Storz (42.1; 34.0 to 59.0) than for Direct (21.5; 17.0 to 34.3; p=0.002). We were not able to demonstrate a difference >10 seconds between the GlideScope and the other laryngoscopes. Median manikin intubation time was <10 seconds and increased significantly in the clinical setting for all laryngoscopes (all p <0.0001). CONCLUSIONS: Anesthesiology trainees completed manikin tracheal intubation rapidly with all laryngoscopes studied, but required a clinically significant longer time to tracheally intubate children <2 years. Our findings suggest in vivo training should be included to facilitate proficiency with device-specific intubation techniques.