Multi-Institutional Analysis of Outcomes in Supraglottic Jet Ventilation with a Team-Based Approach.

OBJECTIVES/HYPOTHESIS: To evaluate the safety and complications of endoscopic airway surgery using supraglottic jet ventilation with a team-based approach. STUDY DESIGN: Retrospective cohort study. METHODS: Subjects at two academic institutions diagnosed with laryngotracheal stenosis who underwent endoscopic airway surgery with jet ventilation between January 2008 and December 2018 were identified. Patient characteristics (age, gender, race, follow-up duration) and comorbidities were extracted from the electronic health record. Records were reviewed for treatment approach, intraoperative data, and complications (intraoperative, acute postoperative, and delayed postoperative). RESULTS: Eight hundred and ninety-four patient encounters from 371 patients were identified. Intraoperative complications (unplanned tracheotomy, profound or severe hypoxic events, barotrauma, laryngospasm) occurred in fewer than 1% of patient encounters. Acute postoperative complications (postoperative recovery unit [PACU] rapid response, PACU intubation, return to the emergency department [ED] within 24 hours of surgery) were rare, occurring in fewer than 3% of patient encounters. Delayed postoperative complications (return to the ED or admission for respiratory complaints within 30 days of surgery) occurred in fewer than 1% of patient encounters. Diabetes mellitus, active smoking, and history of previous tracheotomy were independently associated with intraoperative, acute, and delayed complications. CONCLUSIONS: Employing a team-based approach, jet ventilation during endoscopic airway surgery demonstrates a low rate of complications and provides for safe and successful surgery. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2292-2297, 2021.

Patient satisfaction survey scores are not an appropriate metric to differentiate performance among anesthesiologists.

STUDY OBJECTIVE: With the focus of patient-centered care in healthcare organizations, patient satisfaction plays an increasingly important role in healthcare quality measurement. We sought to determine whether an automated patient satisfaction survey could be effectively used to identify outlying anesthesiologists. DESIGN: Retrospective Observational Study. SETTING: Vanderbilt University Medical Center (VUMC). MEASUREMENTS: Patient satisfaction data were obtained between October 24, 2016 and November 1, 2017. A multivariable ordered probit regression was conducted to evaluate the relationship between the mean scores of responses to Likert-scale questions on SurveyVitals' Anesthesia Patient Satisfaction Questionnaire 2. Fixed effects included demographics, clinical variables, providers and surgeons. Hypothesis tests to compare each individual anesthesiologist with the median-performing anesthesiologist were conducted. MAIN RESULTS: We analyzed 10,528 surveys, with a 49.5% overall response rate. Younger patient (odds ratio (OR) 1.011 [per year of age]; 95% confidence interval (CI) 1.008 to 1.014; p < 0.001), regional anesthesia (versus general anesthesia) (OR 1.695; 95% CI 1.186 to 2.422; p = 0.004) and daytime surgery (versus nighttime surgery) (OR 1.795; 95% CI 1.091 to 2.959; p = 0.035) were associated with higher satisfaction scores. Compared with the median-ranked anesthesiologist, we found the adjusted odds ratio for an increase in satisfaction score ranged from 0.346 (95% CI 0.158 to 0.762) to 1.649 (95% CI 0.687 to 3.956) for the lowest and highest scoring providers, respectively. Only 10.10% of anesthesiologists at our institution had an odds ratio for satisfaction with a 95% CI not inclusive of 1. CONCLUSIONS: Patient satisfaction is impacted by multiple factors. There was very little information in patient satisfaction scores to discriminate the providers, after adjusting for confounding. While patient satisfaction scores may facilitate identification of extreme outliers among anesthesiologists, there is no evidence that this metric is useful for the routine evaluation of individual provider performance.

Comparison of a simplified nasal continuous positive airways pressure device with nasal cannula in obese patients undergoing colonoscopy during deep sedation: A randomised clinical trial.

BACKGROUND: Continuous positive airways pressure (CPAP) with a CPAP machine and mask has been shown to be more effective at minimising hypoxaemia than other devices under deep sedation. However, the efficacy of a new and simple CPAP device for spontaneously breathing obese patients during colonoscopy is unknown. OBJECTIVE: We hypothesised that oxygenation and ventilation in obese patients under deep sedation during colonoscopy using CPAP via a new nasal mask (SuperNO2VA) would be better than routine care with oxygen supplementation via a nasal cannula. DESIGN: Randomised study. SETTING: Single-centre, June 2017 to October 2017. PATIENTS: A total of 174 patients were enrolled and randomly assigned to Mask group or Control group. Thirty-eight patients were excluded and data from 136 patients underwent final analysis. INTERVENTION: Patients in the Mask group were provided with nasal CPAP (10 cmH2O) at an oxygen flow rate of 15 l min. In the Control group, patients were given oxygen via a nasal cannula at a flow rate of 5 l min. MAIN OUTCOME MEASURES: The primary outcome was elapsed time from anaesthesia induction to the first airway intervention. RESULTS: The elapsed time from anaesthesia induction to the first airway intervention was 19 ±â€Š10 min in the Mask group (n=63) vs. 10 ±â€Š12 min in the Control group (n=73, P < 0.001). In all, 87.5% (56/64) of patients achieved the target CPAP value. More patients in the Control group (63%) received airway intervention than in the Mask group (22%) (P < 0.001). Hypoxaemia (pulse oximeter oxygen saturation, SpO2 < 90%) occurred more frequently in the Control group (22%) than in the Mask group (5%) (P = 0.004). Minute ventilationPostinduction/minute ventilationBaseline and minute ventilationProcedure-end/minute ventilationBaseline was lower in the Control group than in the Mask group (P = 0.007 and 0.001, respectively). CONCLUSION: Application of a nasal mask at a target CPAP of 10 cmH2O improves ventilation and decreases the frequency and severity of hypoxaemia. TRIAL REGISTRATION: NCT03139448, registered at ClinicalTrials.gov.

Surgical Apgar score is associated with myocardial injury after noncardiac surgery.

STUDY OBJECTIVE: To assess the impact of intraoperative hemodynamics in the development of perioperative myocardial infarction (MI) and myocardial ischemia after noncardiac surgery. DESIGN: Single-center retrospective cohort study of surgical patients from 2007 to 2012. SETTING: Postanesthesia care unit, intensive care unit, and medical-surgical ward at an academic tertiary medical center. PATIENTS: A total of 46,799 adult noncardiac, nonthoracic surgery patients, for which 2290 peak cardiac troponin (cTn) levels were available. MEASUREMENTS: The 10-point Surgical Apgar Score (SAS) was calculated from intraoperative heart rate, blood pressure, and blood loss. Peak troponin (cTn) levels, hospital length of stay, 7- and 30-day postoperative mortality, patient demographics, and prior medical conditions were gathered. Troponin leak was defined as cTn-I 0.6 to 1.5 ng/mL or cTn-T 0.1 to 0.3 ng/mL; perioperative MI criteria were cTn-I greater than 1.5 ng/mL or cTn-T greater than 0.30 ng/mL. MAIN RESULTS: Of 46,799 noncardiac surgical cases, 209 (0.4%) and 192 (0.4%) suffered cTn leak and MI, respectively. Low SAS (0-4) was associated with increased risk of cTn leak and perioperative MI (univariate odds ratio, 2.76 and 2.06; 95% confidence interval, 2.20-3.45 and 1.57-2.70, respectively). In multivariable analysis, Surgical Apgar Score, age 65 years or older, American Society of Anesthesiologists physical status greater than or equal to III, emergency surgery, history of MI or hypertension, prolonged intraoperative tachycardia (heart rate >100 beats/min for >59 minutes), and prolonged hypotension (mean arterial pressure <40 mm Hg for >2 minutes) were independently associated with cTn leak and perioperative MI. CONCLUSIONS: Low SAS scores (0-4) may be associated with cTn elevation after noncardiac surgery. SAS-based risk stratification may guide perioperative cTn surveillance in lieu of routine postoperative screening.

Randomized controlled trial comparing the McGrath MAC video laryngoscope with the King Vision video laryngoscope in adult patients.

BACKGROUND: This study compares the performance of the McGrath MAC and King Vision laryngoscope systems for endotracheal intubation in adult patients with predicted normal airways when used by experienced laryngoscopists with limited prior video laryngoscopy experience. METHODS: The study is a randomized controlled trial in a general adult operating suite at an academic medical center in the South Eastern United States. Sixty-six adult surgical patients with predicted easy intubation were enrolled and randomized to undergo endotracheal intubation with either the McGrath MAC video laryngoscope or the King Vision video laryngoscope using the channeled blade attachment. The primary outcomes were success on first attempt and time of intubation. The laryngoscopic view, lowest observed oxygen saturation, number of attempts, assist maneuvers, and documented airway trauma events were also recorded. RESULTS: The median time for successful intubation was shorter in the McGrath MAC group compared to the King Vision group (17 vs. 38 seconds; P<0.001). There was a higher first attempt success rate in the McGrath MAC group compared to the King Vision group (100% vs. 89%, P<0.01). Also, more patients in the King Vision group had an oxygen desaturation below 90% compared to the McGrath MAC group (3 vs. 0; P<0.034). There were no significant differences between groups in laryngoscopic view, number of attempts, need for assist maneuvers, or airway trauma. CONCLUSION: The McGrath MAC video laryngoscope allowed for significantly shorter times to endotracheal intubation, higher success rates on first attempt, and fewer desaturations compared to the King Vision video laryngoscope when used by experienced laryngoscopists with limited prior video laryngoscopy experience.

Implementation of an enhanced safety-engineered sharp device oversight and bloodborne pathogen protection program at a large academic medical center.

OBJECTIVE: Exposure of healthcare personnel to bloodborne pathogens (BBPs) can be prevented in part by using safety-engineered sharp devices (SESDs) and other safe practices, such as double gloving. In some instances, however, safer devices and practices cannot be utilized because of procedural factors or the lack of a manufactured safety device for the specific clinical use. In these situations, a standardized system to examine requests for waiver from expected practices is necessary. DESIGN: Before-after program analysis. SETTING: Large academic medical center. INTERVENTIONS: Vanderbilt University Medical Center developed a formalized system for an improved waiver process, including an online submission and tracking site, and standards surrounding implementation of core safe practices. The program's impact on sharp device injuries and utilization of double gloving and blunt sutures was examined. RESULTS: Following implementation of the enhanced program, there was an increase in the amount of undergloves and blunt sutures purchased for surgical procedures, suggesting larger utilization of these practices. The rate of sharp device injuries of all at-risk employees decreased from 2.32% to 2.12%, but this decline was not statistically significant (P = .14). The proportion of reported injuries that were deemed preventable significantly decreased from 72.7% (386/531) before implementation to 63.9% (334/523; P = .002) after implementation of the enhanced program. CONCLUSIONS: An enhanced BBP protection program was successful at providing guidance to increase safe practices and at improving the management of SESD waiver requests and was associated with a reduction in preventable sharp device injuries.

Automated identification of drug and food allergies entered using non-standard terminology.

OBJECTIVE: An accurate computable representation of food and drug allergy is essential for safe healthcare. Our goal was to develop a high-performance, easily maintained algorithm to identify medication and food allergies and sensitivities from unstructured allergy entries in electronic health record (EHR) systems. MATERIALS AND METHODS: An algorithm was developed in Transact-SQL to identify ingredients to which patients had allergies in a perioperative information management system. The algorithm used RxNorm and natural language processing techniques developed on a training set of 24 599 entries from 9445 records. Accuracy, specificity, precision, recall, and F-measure were determined for the training dataset and repeated for the testing dataset (24 857 entries from 9430 records). RESULTS: Accuracy, precision, recall, and F-measure for medication allergy matches were all above 98% in the training dataset and above 97% in the testing dataset for all allergy entries. Corresponding values for food allergy matches were above 97% and above 93%, respectively. Specificities of the algorithm were 90.3% and 85.0% for drug matches and 100% and 88.9% for food matches in the training and testing datasets, respectively. DISCUSSION: The algorithm had high performance for identification of medication and food allergies. Maintenance is practical, as updates are managed through upload of new RxNorm versions and additions to companion database tables. However, direct entry of codified allergy information by providers (through autocompleters or drop lists) is still preferred to post-hoc encoding of the data. Data tables used in the algorithm are available for download. CONCLUSIONS: A high performing, easily maintained algorithm can successfully identify medication and food allergies from free text entries in EHR systems.

Early detection of a blood transfusion reaction utilizing a wireless remote monitoring device.

Continuously monitoring vital signs on general care units may provide earlier detection and intervention of instabilities in patients. These earlier interventions could prevent deaths and admission to critical care units, thereby increasing patient safety and improving patient outcomes.

Novel use of electronic whiteboard in the operating room increases surgical team compliance with pre-incision safety practices.

BACKGROUND: Despite evidence that use of a checklist during the pre-incision time out improves patient morbidity and mortality, compliance with performing the required elements of the checklist has been low. In an effort to improve compliance, a standardized time out interactive Electronic Checklist System [iECS] was implemented in all hospital operating room (OR) suites at 1 institution. The purpose of this 12-month prospective observational study was to assess whether an iECS in the OR improves and sustains improved surgical team compliance with the pre-incision time out. METHODS: Direct observational analyses of preprocedural time outs were performed on 80 cases 1 month before, and 1 and 9 months after implementation of the iECS, for a total of 240 observed cases. Three observers, who achieved high interrater reliability (kappa = 0.83), recorded a compliance score (yes, 1; no, 0) on each element of the time out. An element was scored as compliant if it was clearly verbalized by the surgical team. RESULTS: Pre-intervention observations indicated that surgical staff verbally communicated the core elements of the time out procedure 49.7 ± 12.9% of the time. After implementation of the iECS, direct observation of 80 surgical cases at 1 and 9 months indicated that surgical staff verbally communicated the core elements of the time out procedure 81.6 ± 11.4% and 85.8 ± 6.8% of the time, respectively, resulting in a statistically significant (P < .0001) increase in time out procedural compliance. CONCLUSION: Implementation of a standardized, iECS can dramatically increase compliance with preprocedural time outs in the OR, an important and necessary step in improving patient outcomes and reducing preventable complications and deaths.

Enhancing point of care vigilance using computers.

Information technology has the potential to provide a tremendous step forward in perioperative patient safety. Through automated delivery of information through fixed and portable computer resources, clinicians may achieve improved situational awareness of the overall operation of the operating room suite and the state of individual patients in various stages of surgical care. Coupling the raw, but integrated, information with decision support and alerting algorithms enables clinicians to achieve high reliability in documentation compliance and response to care protocols. Future studies and outcomes analysis are needed to quantify the degree of benefit of these new components of perioperative information systems.

Expansion of the surgical Apgar score across all surgical subspecialties as a means to predict postoperative mortality.

BACKGROUND: A surgical scoring system, akin to the obstetrician's Apgar score, has been developed to assess postoperative risk. To date, evaluation of this scoring system has been limited to general and vascular services. The authors attempt to externally validate and expand the Surgical Apgar Score across a wide breadth of surgical subspecialties. METHODS: Intraoperative data for 123,864 procedures including all surgical subspecialties were collected and associated with Surgical Apgar Scores (created by the summation of point values associated with the lowest mean arterial pressure, lowest heart rate, and estimated blood loss). Patients' death records were matched to the corresponding score, and logistic regression models were created in which mortality within 7, 30, and 90 days was regressed on the Apgar score. RESULTS: Lower Surgical Apgar Scores were associated with an increased risk of death. The magnitude of this association varied by subspecialty. Some subspecialties exhibited higher odds ratios, suggesting that the score is not as useful for them. For most of the subspecialties the association between the Apgar score and mortality decreased as the time since surgery increased, suggesting that predictive ability ceases to be helpful over time. After adjusting for the patient's American Society of Anesthesiologists classification, Apgar scores remained associated with death among most of the subspecialties. CONCLUSION: A previously published methodology for calculating risk among general and vascular surgical patients can be applied across many surgical services to provide an objective means of predicting and communicating patient outcomes in surgery as well as planning potential interventions.

Using information technology to improve quality in the OR.

This article summarizes the current state of technology as it pertains to quality in the operating room, ties the current state back to its evolutionary pathway to understand how the current capabilities and their limitations came to pass, and elucidates how the overlay of information technology (IT) as a wrapper around current monitoring and device technology provides a significant advance in the ability of anesthesiologists to use technology to improve quality along many axes. The authors posit that IT will enable all the information about patients, perioperative systems, system capacity, and readiness to follow a development trajectory of increasing usefulness.

Derivation and validation of Spo2/Fio2 ratio to impute for Pao2/Fio2 ratio in the respiratory component of the Sequential Organ Failure Assessment score.

OBJECTIVE: The Sequential Organ Failure Assessment (SOFA) score is validated to measure severity of organ dysfunction in critically ill patients. However, in some practice settings, daily arterial blood gas data required to calculate the respiratory component of the SOFA score are often unavailable. The objectives of this study were to derive Spo2/Fio2 (SF) ratio correlations with the Pao2/Fio2 (PF) ratio to calculate the respiratory parameter of the SOFA score, and to validate the respiratory SOFA obtained using SF ratios against clinical outcomes. PATIENTS AND MEASUREMENTS: We obtained matched measurements of Spo2 and Pao2 from two populations: group 1-patients undergoing general anesthesia and group 2-patients from the acute respiratory distress syndrome network-low-vs. high-tidal volume for the acute respiratory management of acute respiratory distress syndrome database. Using a linear regression model, we first determined SF ratios corresponding to PF ratios of 100, 200, 300, and 400. Second, we evaluated the contribution of positive end-expiratory pressure (PEEP) on the relationship between SF and PF, for patients on PEEP in centimeters of water (cm H2O) of <8, 8-12, and >12. Third, we calculated the SOFA scores in a separate cohort of intensive care unit patients using the derived SF ratios and validated them against clinical outcomes. RESULTS: The total SOFA scores calculated using SF ratios and PF ratios were highly correlated (Spearman's rho 0.85, p < 0.001) in all patients and in the three stratified PEEP categories (<8 cm H2O, Spearman's rho 0.87, p < 0.001; PEEP 8-12 cm H20, Spearman's rho 0.85, p < 0.001; PEEP >12 cm H2O, Spearman's rho 0.85, p < 0.001). The respiratory SOFA scores based on SF ratios and PF ratios correlated similarly with intensive care unit length of stay and ventilator-free days, when validated in a cohort of critically ill patients. CONCLUSION: The total and respiratory SOFA scores obtained with imputed SF values correlate with the corresponding SOFA score using PF ratios. Both the derived and original respiratory SOFA scores similarly predict outcomes.

Damage control hematology: the impact of a trauma exsanguination protocol on survival and blood product utilization.

BACKGROUND: The importance of early and aggressive management of trauma- related coagulopathy remains poorly understood. We hypothesized that a trauma exsanguination protocol (TEP) that systematically provides specified numbers and types of blood components immediately upon initiation of resuscitation would improve survival and reduce overall blood product consumption among the most severely injured patients. METHODS: We recently implemented a TEP, which involves the immediate and continued release of blood products from the blood bank in a predefined ratio of 10 units of packed red blood cells (PRBC) to 4 units of fresh frozen plasma to 2 units of platelets. All TEP activations from February 1, 2006 to July 31, 2007 were retrospectively evaluated. A comparison cohort (pre-TEP) was selected from all trauma admissions between August 1, 2004 and January 31, 2006 that (1) underwent immediate surgery by the trauma team and (2) received greater than 10 units of PRBC in the first 24 hours. Multivariable analysis was performed to compare mortality and overall blood product consumption between the two groups. RESULTS: Two hundred eleven patients met inclusion criteria (117 pre-TEP, 94 TEP). Age, sex, and Injury Severity Score were similar between the groups, whereas physiologic severity (by weighted Revised Trauma Score) and predicted survival (by trauma-related Injury Severity Score, TRISS) were worse in the TEP group (p values of 0.037 and 0.028, respectively). After controlling for age, sex, mechanism of injury, TRISS and 24-hour blood product usage, there was a 74% reduction in the odds of mortality among patients in the TEP group (p = 0.001). Overall blood product consumption adjusted for age, sex, mechanism of injury, and TRISS was also significantly reduced in the TEP group (p = 0.015). CONCLUSIONS: We have demonstrated that an exsanguination protocol, delivered in an aggressive and predefined manner, significantly reduces the odds of mortality as well as overall blood product consumption.

Improving timely surgical antibiotic prophylaxis redosing administration using computerized record prompts.

BACKGROUND: Timely prophylactic antibiotic administration aids in preventing postoperative superficial surgical site infections. However, during lengthy surgical procedures, redosing of prophylactic antibiotics may be unintentionally omitted. We assessed the utility of a computerized reminder as part of the anesthesia charting system to increase the rate of timely intraoperative prophylactic antibiotic redosing. METHODS: A retrospective observational analysis was performed on consecutive patients undergoing non-cardiac surgical procedures at a university-affiliated hospital prior to and after the institution of a computerized reminder system. The reminder system presented the clinician with a series of on-screen dialog boxes prior to the redose time for the specific prophylactic antibiotic administered preoperatively. Antibiotic redosing was defined as appropriate if it occurred within 30 min prior to or after the due time, calculated as twice the half-life of the specific antibiotic. Patients were excluded if the case duration was less than twice the half-life of the administered prophylactic antibiotic, or if no prophylactic antibiotic was given. RESULTS: A total of 287 cases were included in the study (148 pre-intervention, 139 post-intervention). Patient age, case length, and American Society of Anesthesiologists (ASA) score stratification did not differ between the groups. Use of the reminder system resulted in an increase in the appropriate redosing of antibiotics from 20% prior to institution of the reminder to 58% after institution (p < 0.001). CONCLUSIONS: A computerized reminder system is an effective tool to assist in appropriate intraoperative redosing of prophylactic antibiotics during lengthy surgical procedures.

Improving anesthesiologist performance through profiling and incentives.

STUDY OBJECTIVE: To determine the influence of profiling and incentives on anesthesiologist behavior in relation to several key indicators of performance. DESIGN: Prospective collection and analysis of operational data before and after implementation of a physician profiling, reporting, and incentive program. SETTING: University hospital. MEASUREMENTS: An intervention consisting of two components was studied with the intent of stimulating a high level of performance in relation to a peer group. The first component, a monthly report of physician performance via an individualized performance report, was provided to each physician for each of 6 months. The second component consisted of a financial incentive. For each month in the study, physicians were eligible to receive a variable financial incentive of between $0 and $500 per month depending on individual performance based scoring in relation to each other. Physician performance was tracked in five areas: 1) percentage of first cases of the day in the room at or before the scheduled in-room time, 2) percentage of cases with an anesthesia prep time less than a target, 3) percentage of cases delayed due to waiting for an anesthesiology patient evaluation, 4) percentage of cases delayed during the anesthesiology controlled time, and, 5) percentage of cases delayed due to waiting for the anesthesiology attending. Results were reported to each physician on a monthly basis, by e-mail distribution, of an individualized perioperative efficiency summary report. A monthly financial incentive was awarded to the top performing physicians in the form of a credit to the physician's personal CME/expense account. Also, all physicians received a rank order list of their performance on each indicator at the end of each month. MAIN RESULTS: 31 anesthesiologists, comprising the multispecialty division, and covering all services with the exception of obstetrics, pediatrics, and cardiothoracic anesthesia were tracked for 6 months. Compared to the first month, the percent of first cases of the day in the room at or before the scheduled start time and the percent of cases with an anesthesiology prep time less than target increased significantly (19 +/- 4.6%, vs. 61 +/- 6.5%, 95% CI, p <0.001; and 57 +/- 5.3%, vs. 73 +/- 5.1%, 95% CI, p <0 .001) during the sixth month. The mean number of cases per physician with a delay during anesthesiology controlled time decreased (14.9 +/- 2.9 vs. 3.3 +/- 1, p <0.001), no change occurred in the number of cases with a delay due to waiting for an anesthesiology patient evaluation or number of cases delayed due to waiting for the anesthesiology attending in the sixth month compared with the first month. CONCLUSION: Tracking and rewarding physician performance with monthly profiling and a financial incentive given to the best in a peer group improves anesthesiologist performance in several key areas.