Measuring and Comparing Clinical Productivity of Individual Anesthesiologists.

Measuring and comparing clinical productivity of individual anesthesiologists is confounded by anesthesiologist-independent factors, including facility-specific factors (case duration, anesthetizing site utilization, type of surgical procedure, and non-operating room locations), staffing ratio, number of calls, and percentage of clinical time providing anesthesia. Further, because anesthesia care is billed with different units than relative value units, comparing work with other types of clinical care is difficult. Finally, anesthesia staffing needs are not based on productivity measurements but primarily the number and hours of operation of anesthetizing sites. The intent of this review is to help anesthesiologists, anesthesiology leaders, and facility leaders understand the limitations of anesthesia unit productivity as a comparative metric of work, how this metric often devalues actual work, and the impact of organizational differences, staffing models and coverage requirements, and effectiveness of surgical case load management on both individual and group productivity.

Characterizing the Structural Integrity of Endotracheal Tube Taping Techniques: A Simulation Study.

BACKGROUND: Endotracheal tubes (ETTs) are commonly secured with tape to prevent undesirable tube migration. Many methods of taping have been described, although little has been published comparing various methods of taping to one another. In this study, we evaluated several methods for securing ETTs with tape. We hypothesized a difference in mean peak forces between the methods studied during forced extubation. METHODS: Five methods of securing an ETT with tape were studied in a variety of contexts including cadaver and simulation lab settings. Testing included measurement of peak force (Newton [N]) during forced extubation, durability of taping following mechanical stress, effects of tape length-width variation, and characterization of failure mechanisms. RESULTS: We found several significant differences in mean peak extubation forces between the 5 methods of taping, with mean peak forces during forced extubation ranging from 20 N to 156 N. In separate tests, we found an association between mean peak forces and total surface area as well as geometric configuration of tape on the face. Long thin strips of tape appeared to provide surprising durability against forced extubation, a phenomenon that was associated with minimization of the "peel angle" as tape was removed. CONCLUSIONS: We found evidence of differential structural integrity between the 5 taping methods studied. More generally, we found that increased peak extubation forces were associated with increased total surface area of tape and that minimization of the "peel angle" by lateral application of tape is associated with surprisingly high relative peak extubation forces.

Industry-Wide Survey of Academic Anesthesiology Departments Provides Up-to-Date Benchmarking Data on Surgical Anesthesia Productivity.

BACKGROUND: Benchmarking group surgical anesthesia productivity continues to be an important but challenging goal for anesthesiology groups. Benchmarking is important because it provides objective data to evaluate staffing needs and costs, identify potential operating room management decisions that could reduce costs or improve efficiency, and support ongoing negotiations and discussions with health system leadership. Unfortunately, good and meaningful benchmarking data are not readily available. Therefore, a survey of academic anesthesiology departments was done to provide current benchmarking data. METHODS: A survey of members of the Society of Academic Associations of Anesthesiology and Perioperative Medicine (SAAAPM) was performed. The survey collected data by facility and included type of facility, number and type of staff and anesthetizing sites each weekday, and the billed American Society of Anesthesiologists (ASA) units and number of cases over 12 months. The facility types included academic medical center (AMC), community hospital (Community), children's hospital (Children), and ambulatory surgical center (ASC). All anesthesia care billed using ASA units were included, except for obstetric anesthesia. Any care not billed or billed using relative value units (RVUs) were excluded. Percentage of nonoperating room anesthetizing sites, staffing ratio, and surgical anesthesia productivity measurements "per case" and "per site" were calculated. RESULTS: Of the 135 society members, 63 submitted complete surveys for 140 facilities (69 AMC, 26 Community, 7 Children, and 38 ASC). In the survey, overall median productivity for AMC and Children was similar (12,592 and 12,364 total ASA units per anesthetizing site), while the ASC had the lowest median overall productivity (8911 total ASA units per anesthetizing site). By size of facility, in the survey, the smaller facilities (<10 sites, ASC or non-ASC) had lower median overall productivity as compared to larger facilities. For AMC and Children, >20% of anesthetizing sites were nonoperating room anesthetizing sites. Anesthesiology residents worked primarily in AMC and Children. In ASC and Community, residents worked only in 18% and 35% of facilities, respectively. More than half the AMCs reported at least 1 break certified nurse anesthetist (CRNA) each day. CONCLUSIONS: To make data-driven decisions on clinical productivity, anesthesiology leaders need to be able to make meaningful comparisons at the facility level. For a group that provides care in multiple facilities, one can make internal comparisons among facilities and follow measurements over time. It is valuable for leaders to also be compare their facilities with industry-wide measurements, in other words, benchmark their facilities. These results provide benchmarking data for academic anesthesiology departments.

Measuring Clinical Productivity of Anesthesiology Groups: Surgical Anesthesia at the Facility Level.

Benchmarking and comparing group productivity is an essential activity of data-driven management. For clinical anesthesiology, accomplishing this task is a daunting effort if meaningful conclusions are to be made. For anesthesiology groups, productivity must be done at the facility level in order to reduce some of the confounding factors. When industry or external comparisons are done, then the use of total ASA units per anesthetizing sites allows for overall productivity comparisons. Additional productivity components (total ASA units/h, h/case, h/operating room/d) allow for leaders to develop productivity dashboards. With the emergence of large groups that provide care in multiple facilities, these large groups can choose to invest more effort in collecting data and comparing facility productivity internally with group-defined measurements including total ASA units per full time equivalent.

Body mass index and outcomes of in-hospital ventricular tachycardia and ventricular fibrillation arrest.

BACKGROUND: Due to higher transthoracic impedance, obese patients may be less likely to be successfully defibrillated from ventricular tachycardia or ventricular fibrillation (VT/VF) arrest. However, the association between patient body mass index (BMI), defibrillation success, and survival outcomes of VT/VF arrest are poorly understood. METHODS: We evaluated 7110 patients with in-hospital VT/VF arrest at 286 hospitals within the Get With The Guidelines(®)-Resuscitation (GWTG-R) Multicenter Observational Registry between 2006 and 2012. Patients were categorized as underweight (BMI<18.5kg/m(2)), normal weight (BMI 18.5-24.9kg/m(2)), over-weight (BMI 25.0-29.9kg/m(2)), obese (BMI 30.0-34.9kg/m(2)), and extremely obese (BMI≥35.0kg/m(2)). Using generalized linear mixed regression, we determined the risk-adjusted relationship between BMI and patient outcomes while accounting for clustering by hospitals. The primary outcome was successful first shock defibrillation (a post-shock rhythm other than VT/VF) with secondary outcomes of return of spontaneous circulation, survival to 24h, and survival to discharge. RESULTS: Among adult patients suffering VT/VF arrest, 304 (4.3%) were underweight, 2061 (29.0%) were normal weight, 2139 (30.1%) were overweight, and 2606 (36.6%) were obese or extremely obese. In a risk-adjusted analysis, we observed no interaction between BMI and energy level for the successful termination of VT/VF with first shock. Furthermore, the risk-adjusted likelihood of successful first shock termination of VT/VF did not differ significantly across BMI categories. Finally, when compared to overweight patients, obese patients had similar risk-adjusted likelihood of survival to hospital discharge (odds ratio 0.786, 95% confidence interval 0.593-1.043). CONCLUSIONS: There was no significant difference in the likelihood of successful defibrillation with the first shock attempt among different BMI categories.

Anesthesiology residents' medical school debt influence on moonlighting activities, work environment choice, and debt repayment programs: a nationwide survey.

BACKGROUND: The amount of education debt incurred by medical school graduates in the United States has grown considerably over the last 30 years; it has outpaced inflation to reach a mean of $158,000. With this dramatic increase in education debt, there has been limited information on how medical school debt loads of anesthesiology physicians impact their decisions concerning moonlighting and future career choices. Our aim was to survey current anesthesiology interns, residents, and fellows to assess the correlation between the amount of medical school debt they had collected and (1) their outlook toward moonlighting activities, (2) future career plans, and (3) choice of employer with a debt repayment program. METHODS: We developed a web-based survey instrument and contacted residency training programs to obtain access to their anesthesiology interns, residents, and fellows (residents). We assessed each relationship of interest using a multivariable proportional odds model, adjusting for all available baseline potential confounding factors. Second, we compared participants with >$150,000 medical school debt versus participants with no debt on the same questions of interest, each using a multivariable proportional odds model with the same covariable adjustment. RESULTS: We had access to 2386 residents through their training programs and 537 completed the survey. Those respondents with a 1-category-larger amount of medical school debt (i.e., $30,000) were associated with 7%(99.3% confidence interval: 0%, 13%) increased odds of having the desire to moonlight during residency/fellowship, and were associated with 7% (1%, 13%) decreased odds of saying they would choose a career as an academic faculty, respectively. Also, those with a larger amount of medical school debt were more likely to be swayed to be interested in an anesthesiology group with an education debt repayment program (odds ratio: 1.3 [1.22, 1.39] for 1-category increase in the debt amount); furthermore, the corresponding odds ratio was increased to 4.6 (2.8, 7.5) comparing those with >$150,000 debt with those without debt. CONCLUSIONS: In an effort to compete with private practice anesthesiology groups and to reduce the impact of debt on future career choices of residents/fellows, academic anesthesiology groups would do well to (1) promote moonlighting activities that are within the Accreditation Council for Graduate Medical Education and institutional guidelines, (2) develop financial curriculum for residents/fellows, and (3) offer debt repayment programs as an incentive for new faculty to join academic medicine.

The effect of epsilon-aminocaproic acid and aprotinin on fibrinolysis and blood loss in patients undergoing primary, isolated coronary artery bypass surgery: a randomized, double-blind, placebo-controlled, noninferiority trial.

BACKGROUND: Until recently, aprotinin was the only antifibrinolytic drug with a licensed indication in cardiac surgery in the United States. The most popular alternative, epsilon-aminocaproic acid (EACA), has not been adequately compared with aprotinin. We undertook this study to test the hypothesis that EACA, when dosed appropriately, is not inferior to aprotinin at reducing fibrinolysis and blood loss. METHODS: Seventy-eight patients scheduled for primary, isolated coronary artery bypass graft surgery were randomly assigned to receive "full Hammersmith" dose aprotinin, high dose EACA (100 mg/kg initial loading dose, 5 g in the pump prime solution, 30 mg x kg(-1) x h(-1) maintenance infusion) or equal volumes of a saline-placebo in a double-blind trial. Reductions in peak D-dimer formation (a measure of fibrinolysis) and 24-h chest tube drainage (CTD) were the primary end points by which noninferiority of EACA was tested. The noninferiority limit was set at a 30% increase in peak D-dimer formation (a difference of 250 microg/mL) and 24-h CTD (a difference of 350 mL) relative to aprotinin. RESULTS: The between-group differences (EACA versus aprotinin) in peak D-dimer formation (-3.58 microg/L, 95% CI -203 to 195 microg/L) and 24-h CTD (67 mL, 95% CI -90 to 230 mL) were within the predetermined noninferiority margins (250 microg/mL and 350 mL, respectively) and satisfied the criteria for noninferiority. Compared with saline, significant between-group reductions in peak D-dimer formation were observed using EACA (589 microg/L, 95% CI 399-788 microg/L; P < 0.0001) and aprotinin (585 microg/L, 95% CI 393-778 microg/L; P < 0.0001). Similar reductions in 24 h CTD were also seen using EACA (239 mL, 95% CI 50-415 mL; P < 0.05) and aprotinin (323 mL, 95% CI 105-485 mL; P < 0.05) compared with saline. Plasma EACA levels were maintained well above a target of 260 microg/mL. CONCLUSIONS: When dosed in a pharmacologically guided manner, EACA is not inferior to aprotinin in reducing fibrinolysis and blood loss in patients undergoing primary, isolated coronary artery bypass surgery.

Monocyte activation in on-pump versus off-pump coronary artery bypass surgery.

OBJECTIVE: Monocyte activation plays a key role in amplifying both inflammatory and coagulopathic sequelae in patients undergoing on-pump coronary artery bypass graft (CABG) surgery. Off-pump CABG diminishes, but does not eliminate, the systemic inflammatory response and its influence on monocyte activation remains unclear. This study was performed to determine if off-pump CABG suppresses all features of monocyte activation. DESIGN: Prospective, controlled, clinical study. SETTING: University-affiliated veterans affairs hospital and laboratory. PARTICIPANTS: Twenty-two patients scheduled to undergo primary CABG surgery (11 on-pump and 11 off-pump). INTERVENTIONS: On-pump and off-pump CABG surgery was performed via median sternotomy. Anticoagulation and heparin reversal were identical. Moderate hypothermia (28 degrees-30 degrees C) was used for on-pump CABG surgery, whereas temperature was maintained above 35.5 degrees C for off-pump CABG. No antifibrinolytic agents were used. MEASUREMENTS AND MAIN RESULTS: Perioperative monocyte changes were assessed by using cellular (CD11b, monocyte-platelet conjugates) and secreted markers (plasma IL-6, IL-8, and IL-10) measured at 6 time points before, during, and after CABG surgery. Off-pump CABG surgery completely blocked the increases in monocyte CD11b expression (p < 0.001) and monocyte-platelet conjugate formation (p < 0.001) observed in the on-pump group. In contrast, plasma interleukin levels were significantly elevated in both groups, although off-pump CABG surgery resulted in lower levels (p < 0.001) and a delayed time course. CONCLUSIONS: Off-pump CABG surgery attenuates monocyte secreted cytokines and completely suppresses activation-dependent monocyte cell-surface changes (CD11b, monocyte-platelet conjugate formation). Whether these pathophysiologic differences in monocyte activation translate into a reduction in adverse events after CABG surgery warrants a larger, randomized, outcomes study.

Managing intergenerational differences in academic anesthesiology.

PURPOSE OF REVIEW: Common definitions for workplace generations are the silent generation (born 1925-1945), the baby boomer generation (1946-1962), generation X (1963-1981), and generation Y (1982-2000). Distinct motivational and value perceptions stereotype generations. This review defines the characteristics of workplace generations today and provides insight into how differences influence the workplace environment. RECENT FINDINGS: Senior faculty members are mostly boomers, whereas residents and junior faculty members tend to belong to generation X. Medical students and incoming interns are from generation Y. When compared with boomers, generation X is more savvy with technology, more independent, less loyal to the institution, and seeks balance between work and lifestyle. The 80-h resident working week restriction has reinforced differences between older and younger physicians. Generation Y exhibits traits that are similar to those of generation X. Their increased interest in anesthesiology may reflect, in part, their assumption that it affords better control of lifestyle. SUMMARY: Understanding, improved communication strategies, mentorship, and flexibility in methods employed to achieve common goals are most likely to capture the interest and cooperation of members of generation X and possibly Y. Future studies should test effects of particular interventions on outcome in terms of recruitment and performance milestones.

Independent study and performance on the anesthesiology in-training examination.

Intuitively, independent study by residents would be expected to improve performance on the in-training examination (ITE). So far, however, studies that have examined this issue have used historical controls and have not evaluated the amount of personal study and its impact on performance. We therefore examined the relationship between the amount of self-reported time devoted to personal study by 36 clinical anesthesia year 1 and 2 residents at the University of Texas Southwestern Medical Center, and their scores on the ITE administered in July 2003. The average time spent in self-study was 8 +/- 3.6 hours per week, and the average scaled score was 28.7 +/- 7.3. Linear regression analysis revealed a positive correlation between hours spent in self-study per week and scaled score performance on the ITE (correlation coefficient = 0.64, P < 0.0001), where the ITE scaled score = (1.3) (hours of self-study per week) + 18.4. Our findings emphasize the importance of personal study by residents. In conjunction with our diverse clinical and didactic experience, these findings indicate that anesthesiology residents who invest a minimum of 10.5 hours of personal study per week are well positioned to achieve a passing score on the ITE.

Management of perioperative myocardial infarction in noncardiac surgical patients.

Perioperative myocardial infarction (PMI) is a major cause of morbidity and mortality in patients undergoing noncardiac surgery. The incidence of PMI varies depending on the method used for diagnosis and is likely to increase as the population ages. Studies have examined different methods for prevention of myocardial infarction (MI), including the use of perioperative beta-blockers, alpha(2)-agonists, and statin therapy. However, few studies have focused on the treatment of PMI. Current therapy for acute MI generally involves anticoagulation and antiplatelet therapy, raising the potential for surgical site hemorrhage in this population. This article reviews the possible mechanisms, diagnosis, and treatment options for MI in the surgical setting. We also suggest algorithms for treatment.

The prevalence and characteristics of incentive plans for clinical productivity among academic anesthesiology programs.

Performance-based compensation is encouraged in medical schools to improve faculty productivity. Medical specialties other than anesthesiology have used financial incentives for clinical work. The goal of this study was to determine the prevalence and the types of clinical incentive plans among academic anesthesiology departments. We performed an electronic survey of the members of the Society of Academic Anesthesiology Chairs and the Association of Anesthesiology Program Directors in the spring of 2003. The survey included questions about departmental size, presence of a clinical incentive plan, characteristics of existing incentive plans, primary quantifiers of productivity, and factors used to modify productivity measurements. An incentive plan was considered to be present if the department measured clinical productivity and varied compensation according to the measurements. The plans were grouped by the primary measure used into the following categories: None, Charges, Time, Shift, Late/Call (only late rooms and call), and Other. Eighty-eight (64%) of 138 programs responded to the survey, and 5 were excluded for incomplete data. Of the responding programs, 29% had no system, 30% used a Late/Call system, 20% used a Shift system, 11% used a Charges system, 6% used a Time system, and 3% fit in the Other category. Larger groups (>40 faculty members) had a significantly more frequent prevalence of incentive plans compared with smaller groups (<20 faculty members). Incentives were paid monthly or quarterly in 85% of the groups. In 90% of groups, incentive payments accounted for <25% of total compensation. Adjustments for operating room schedule supervisors, personally performed cases, day surgery preoperative clinics, pain-management services, and critical care services were included in less than half of the programs that reported incentive plans. Call and late room compensation was based on varied formulas. Sixty-nine percent of academic anesthesiology departments did not vary compensation according to clinical activity during regular hours. Most did vary payments on the basis of call and/or late rooms worked. Larger departments were more likely to use clinical incentive plans.

Increasing the value of time reduces the lost economic opportunity of caring for surgeries of longer-than-average times.

UNLABELLED: Anesthesiology groups that provide care for surgical procedures of longer-than-average duration are economically disadvantaged by both increased staffing costs and reduced revenue. Under the current billing system, anesthesia time is valued the same regardless of the total case duration. In this study, we evaluated the effect on four academic anesthesiology departments of two hypothetical scenarios by changing the anesthesia care billing system to make more valuable either 1) all time units or 2) just second-hour and subsequent time units. From the four departments, case-specific data (anesthesia Current Procedural Terminology code and minutes of care) were collected for all anesthesia cases billed for 1 yr. Basic units were determined from the American Society of Anesthesiologists (ASA) relative value guide. The average time for each case was defined as the average anesthesia time for that specific Current Procedural Terminology code, as published by the Center for Medicare and Medicaid Services (CMS). The actual total ASA units per hour (tASA/h) was determined by adding all the basic units and time units and dividing by hours of anesthesia care (minutes of anesthesia care divided by 60). We then calculated a hypothetical CMS tASA/h for each group by substituting the CMS average time for each anesthesia procedure time for the actual time reported by each group and using 15-min time units. For each group, the Actual (Act) tASA/h and CMS tASA/h were calculated for both options-changing the interval for all time units or only for second and subsequent hours. Intervals were 15, 12, 10, 7, 6, or 5 min. When changing all time units, Act tASA/h and CMS tASA/h were never equal for all groups. The two productivity measures became approximately equal if only time units after the first hour were changed to 6- to 7-min intervals. When changes were applied only to the Act tASA/h (with CMS tASA/h remaining at 15-min intervals), at the 12-min interval either option resulted in a similar or higher Act tASA/h than CMS tASA/h. Both options increase the value of time and help compensate for the lost economic opportunity of longer-than-average surgical durations. IMPLICATIONS: Longer-than-average surgical durations result in less potential revenue per hour under current billing methodology. This study quantifies the increase in billing productivity when the value of time is increased, when evaluating the billing productivity of four academic anesthesiology groups.

Influence of crystalloid and colloid replacement solutions on hemodynamic variables during acute normovolemic hemodilution.

STUDY OBJECTIVE: To determine whether, in maintaining normovolemia during acute normovolemic hemodilution, replacement fluid choice influences intraoperative hemodynamic variables. DESIGN: Prospective, randomized, single-blinded study. SETTING: Operating room of a tertiary-care university hospital. PATIENTS: 40 adult, ASA physical status I, II, and III patients scheduled for acute normovolemic hemodilution during radical prostatectomy. INTERVENTIONS: Patients were randomly assigned to four replacement fluid groups to receive 1) Ringer's lactate, 2) 5% albumin, 3) 6% dextran 70, or 4) 6% hetastarch. A standardized general anesthetic was used, and patients underwent moderate hemodilution to a target hemoglobin of 9 gm/dL. MEASUREMENTS: Hemodynamic variables were recorded using standard monitors, 5-lead electrocardiography, radial arterial catheter, and pulmonary artery catheter. Red blood cell loss for the entire hospitalization was calculated. MAIN RESULTS: Demographic and clinical outcome data were similar among the groups. During acute normovolemic hemodilution, heart rate and pulmonary capillary wedge pressure were unchanged from baseline in all groups, but patients receiving Ringer's lactate or albumin had greater declines in mean arterial pressure at the end of acute normovolemic hemodilution. Cardiac and oxygen consumption indexes were stable during acute normovolemic hemodilution, but oxygen extraction increased. CONCLUSIONS: During hemodilution, anesthetized patients maintain whole body oxygenation by increasing oxygen extraction. The administration of hetastarch or dextran as the replacement fluid during acute normovolemic hemodilution is associated with a more stable mean arterial pressure, but overall acute normovolemic hemodilution is well tolerated irrespective of the replacement fluid used.

Quantifying net staffing costs due to longer-than-average surgical case durations.

BACKGROUND: Anesthesiology departments incur staffing costs that are not covered by revenue because the operating room (OR) time allocation and case scheduling are not done to maximize OR efficiency and because surgical durations are longer than average. The purpose of this article is to demonstrate a method to quantify net anesthesia staffing costs due to longer-than-average surgical durations and evaluate the factors that influence staffing costs. METHODS: Data collected from two anesthesiology departments in academic hospitals for 1 yr included date of surgery, time that patients entered the OR, time that patients exited the OR, surgical service, and the Current Procedural Terminology code for the primary surgical procedure. Anesthesia care performed outside the main surgical suite and services not billed with American Society of Anesthesiologists units were excluded. National average surgical durations were determined from the Current Procedural Terminology code from the Centers for Medicare and Medicaid Services' database. Actual surgical durations were then used to determine staffing solutions to maximize OR efficiency; national average surgical durations were then used to determine a second solution. The difference in staffing costs between these two staffing solutions represented the staffing costs attributable to longer surgical durations. Costs were converted to dollar amounts using compensation values reported in a national compensation survey. The differences in revenue were determined by applying conversion factors to the differences in surgical durations. The annual net cost attributable to longer surgical durations equaled the staffing costs minus the revenue produced by longer durations. Net staffing costs were estimated for two hospitals using median staffing compensation and median payer mix. Net staffing costs were then recalculated by varying the parameters (conversion factors, limits on differences between actual and average surgical duration, levels of compensation, surgical service size of OR allocation). RESULTS: Using the median compensation of staff and an average conversion factor, the net annual staffing costs attributable to longer surgical durations were $672,100 for the first hospital. However, if staff members were highly compensated and the payer mix was unfavorable, the net staffing costs were $1,688,000. Reducing the difference between actual and average duration resulted in lower staffing costs. Net staffing costs were less in a second hospital studied that had many low-volume surgical services. CONCLUSIONS: Longer-than-average surgical durations can increase net staffing costs for anesthesiology groups. The increase is dependent on factors such as staffing compensation and payer mix.

Antifibrinolytic therapy during cardiopulmonary bypass reduces proinflammatory cytokine levels: a randomized, double-blind, placebo-controlled study of epsilon-aminocaproic acid and aprotinin.

OBJECTIVES: Aprotinin is a broad-spectrum serine protease inhibitor that has been shown to attenuate the systemic inflammatory response in patients undergoing cardiac surgery with cardiopulmonary bypass. Although epsilon-aminocaproic acid is similar to aprotinin in its ability to inhibit excessive fibrinolysis (ie, plasmin activity and D-dimer formation), its ability to influence proinflammatory cytokine production remains unclear. This study was designed to compare the effects of epsilon-aminocaproic acid and aprotinin on plasma levels of interleukin-6 and interleukin-8 during and after cardiopulmonary bypass. METHODS: Sixty patients were randomized in a double-blind fashion to receive epsilon-aminocaproic acid, aprotinin, or saline (placebo) in similar dosing regimens (loading dose, pump prime, and infusion). Arterial blood samples were collected before, during, and after cardiopulmonary bypass, and plasma levels of D-dimer, interleukin-6, and interleukin-8 were measured. Data were analyzed using repeated measures analysis of variance. RESULTS: Both epsilon-aminocaproic acid and aprotinin administration resulted in significant (P <.05) reductions in D-dimer and interleukin-8 levels compared with saline. These reductions in D-dimer and interleukin-8 levels did not differ between the 2 drug-treated groups. The effect of these two antifibrinolytic agents on interleukin-6 was qualitatively similar to that noted with interleukin-8 but did not reach statistical significance. CONCLUSIONS: When dosed in a similar manner, epsilon-aminocaproic acid seems to be as effective as aprotinin at reducing interleukin-6 and interleukin-8 levels in patients undergoing primary coronary artery bypass graft surgery. These data indicate that suppression of excessive plasmin activity or D-dimer formation or both may play an important role in the generation of proinflammatory cytokines during and after cardiopulmonary bypass.

Use of operating room information system data to predict the impact of reducing turnover times on staffing costs.

UNLABELLED: Potential benefits to reducing turnover times are both quantitative (e.g., complete more cases and reduce staffing costs) and qualitative (e.g., improve professional satisfaction). Analyses have shown the quantitative arguments to be unsound except for reducing staffing costs. We describe a methodology by which each surgical suite can use its own numbers to calculate its individual potential reduction in staffing costs from reducing its turnover times. Calculations estimate optimal allocated operating room (OR) time (based on maximizing OR efficiency) before and after reducing the maximum and average turnover times. At four academic tertiary hospitals, reductions in average turnover times of 3 to 9 min would result in 0.8% to 1.8% reductions in staffing cost. Reductions in average turnover times of 10 to 19 min would result in 2.5% to 4.0% reductions in staffing costs. These reductions in staffing cost are achieved predominantly by reducing allocated OR time, not by reducing the hours that staff work late. Heads of anesthesiology groups often serve on OR committees that are fixated on turnover times. Rather than having to argue based on scientific studies, this methodology provides the ability to show the specific quantitative effects (small decreases in staffing costs and allocated OR time) of reducing turnover time using a surgical suite's own data. IMPLICATIONS: Many anesthesiologists work at hospitals where surgeons and/or operating room (OR) committees focus repeatedly on turnover time reduction. We developed a methodology by which the reductions in staffing cost as a result of turnover time reduction can be calculated for each facility using its own data. Staffing cost reductions are generally very small and would be achieved predominantly by reducing allocated OR time to the surgeons.

The effects of surgical case duration and type of surgery on hourly clinical productivity of anesthesiologists.

Surgical duration (hours per case; h/case) and type of surgery (ASA base units per case; base/case) determine the hourly clinical productivity (total ASA units per hour of anesthesia care; tASA/h) for anesthesiology groups. In previous studies, h/case negatively influenced tASA/h, but base/case did not differ significantly. However, when cases are grouped by surgical service, the mean base/case varies. In this study we evaluated the effect of h/case and base/case on tASA/h when these are grouped by surgical services. Data from one calendar year were collected from an academic anesthesiology department's billing database. All surgical cases for which the anesthesiology department provided care were included. Cases performed outside the main operating room, e.g., remote sites or obstetrics, were excluded. Any care not billed with ASA units was also excluded. Mean base/case and h/case were determined. For each service, tASA/h was calculated by dividing the sum of base/case and (4 x h/case) by h/case. A total of 12,769 cases were performed by 19 different surgical services. Mean base/case was 6.1 U, with a range of 4.0 U (orthopedics) to 16.0 U (cardiothoracic). Mean h/case was 2.9 h, with a range of 0.9 h (otolaryngology pediatric) to 5.4 h (orthopedic spine). Mean tASA/h was 6.35 U/h, with a range of 5.01 U/h (plastic surgery) to 9.71 U/h (otolaryngology pediatric). The services with high base/case did not necessarily have high tASA/h because of the longer h/case. The services with the shortest h/case had the highest tASA/h. The accurate prediction of both clinical and billing productivity requires inclusion of both base/case and surgical duration data. Anesthesiology groups should consider surgical duration when making strategic decisions.