A Systematic Review of Race, Sex, and Socioeconomic Status Differences in Postoperative Pain and Pain Management.

PURPOSE: Optimal postoperative pain management remains a significant problem despite the availability of multiple preoperative, intraoperative, and postoperative pain management interventions. Recent studies suggest that racialized minorities, female sex, and individuals of lower socioeconomic status (SES) are more likely to experience more severe pain and inadequate pain management postoperatively. Our systematic review aimed to determine race, sex, and SES differences in postoperative pain and postoperative pain management. DESIGN: This study is a systematic review of literature. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology, we systematically searched 5 databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, Embase, Scopus, and Cochrane. We included primary source peer-reviewed articles published after 1990 that measured postoperative pain and race/ethnicity, sex/gender, or SES, which were published in English. Two pairs of reviewers independently screened each title, abstract, and article for inclusion. In cases of disagreement, a third reviewer broke the tie. FINDINGS: A total of 464 articles were screened, of which 32 were included in this study. In most studies, Blacks/African American experience more severe postoperative pain than Whites/Caucasians. Whites were more likely to be prescribed opioids for pain management than Blacks, Hispanics, and Asians. Also, individuals of lower SES and females reported more postoperative pain. One study found no race/ethnic group differences in pain scores and opioid use after the implementation of the enhanced recovery after surgery (ERAS) protocol. CONCLUSIONS: Optimal postoperative pain relief continues to be a challenge for individuals who self-identify as racialized minorities, females, and those of lower SES. Standardization of care may help reduce disparities in postoperative pain management.

Using Eye Tracking for Measuring Cognitive Workload During Clinical Simulations: Literature Review and Synthesis.

High-fidelity clinical simulations can be used by clinicians to acquire technical (physical ability and knowledge) and non-technical (cognitive and social processes) skills. Excessive cognitive workload contributes to medical errors because of the impact on both technical and non-technical skills. Many studies measure cognitive workload with psychometric instruments that limit the assessment of cognitive workload to a single time period and may involve response bias. Using eye tracking to measure task-evoked pupillary responses allows the measurement of changes in pupil diameter related to the cognitive workload associated with a specific activity. Incorporating eye tracking with high-fidelity clinical simulations provides a reliable and continuous assessment of cognitive workload. The purpose of this literature review is to summarize the use of eye-tracking technology to measure cognitive workload of healthcare providers to generate evidence-based guidelines for measuring cognitive workload during high-fidelity clinical simulations. What this manuscript adds to the body of literature is a summary of best practices related to the different methods of measuring cognitive workload, benefits and limitations of using eye tracking, and high-fidelity clinical simulation design considerations for successful integration of eye tracking.

Mentoring Team Projects for the Doctor of Nursing Practice: Considerations for Nurse Anesthesia Faculty.

The American Association of Colleges of Nursing and the Council on Accreditation of Nurse Anesthesia Educational Programs have specified that Doctor of Nursing Practice (DNP) and Doctor of Nursing Anesthesia Practice students complete a doctorate project as part of the education toward becoming Certified Registered Nurse Anesthetists. As nurse anesthesia programs (NAPs) transition to DNP entry into practice, management of DNP projects has been identified as a major challenge facing nursing faculty. Also, adequate mentorship has been identified as a crucial part of doctorate education. Despite the absence of literature on team mentorship in nursing, many NAPs are opting for DNP team projects and group mentoring. In team DNP projects, the mentors foster professionalism, establish the ground rules for communication, resolve conflict, and provide expert knowledge. Effective implementation of projects can enhance relational learning and teamwork, which are essential for a successful career in healthcare. Additionally, mentoring teams can simultaneously improve the professional growth of junior faculty, reduce the faculty workload, and improve the quality of DNP projects. This article brings attention to best practices for mentoring DNP team projects and also provides an exemplar of successful implementation of DNP team projects in a NAP.

Impact of Data Entry Interface Design on Cognitive Workload, Documentation Correctness, and Documentation Efficiency.

Clinical documentation serves as the legal record of patient care and used to guide clinical decision making. Inadequately designed data entry user-interfaces may result in unintended consequences that negatively impact patient safety and outcomes because inaccurate information is used to guide clinical decision making. This study utilized an electronic simulated documentation interface (i.e., artificial electronic health record) combined with eye-tracking hardware to analyze documentation correctness, documentation efficiency, and cognitive workload of anesthesia providers (N = 20) generating documentation using different computer-assisted data entry types (drop-down box, radio button, check-box, and free text with autocomplete suggestions). Our study methodology incorporating eye-tracking with electronic health record user interfaces to assess documentation correctness, efficiency, and cognitive workload can be translated to other health care provider types.

From the Operating Room to the Front Lines: Shared Experiences of Nurse Anesthetists During the Coronavirus Pandemic.

Coronavirus disease 2019 (COVID-19) has resulted in severe health, economic, social, political, and cultural consequences while thrusting Certified Registered Nurse Anesthetists (CRNAs) at the forefront of battling an often invisible enemy. A mixed-methods study was conducted to assess the impact of the COVID-19 pandemic on CRNA practice. The purpose of the qualitative component of the study, a focused ethnography, was to use personal and group interviews to determine the shared experiences of CRNAs who worked during the COVID-19 pandemic. Six themes were identified: (1) CRNAs are part of the solution, (2) doing whatever it takes, (3) CRNAs are valued contributors, (4) removal of barriers promotes positive change, (5) trying times, and (6) expertise revealed. The quantitative component of the study will be discussed in a separate article.

Exploring Production Pressure and Normalization of Deviance and Their Relationship to Poor Patient Outcomes.

Production pressure and/or normalization of deviance contribute to poor patient outcomes. The purpose of this study was to explore the relationship between production pressure and normalization of deviance to poor patient outcomes. A team of experienced qualitative researchers conducted a metasynthesis of all qualitative closed claims studies that used the American Association of Nurse Anesthetists (AANA) Foundation Closed Claims database and were accepted for publication at the time of the study. Three central concepts emerged from the analysis: (1) impaired culture of safety, (2) violations of standards of care, and (3) impaired patient safety and outcomes. It is imperative that anesthesia providers support a culture of safety and follow AANA Standards for Nurse Anesthesia Practice.

A Practical Approach to Acute Postoperative Pain Management in Chronic Pain Patients.

In the United States, more than 100 million people suffer from chronic pain. Among patients presenting for surgery, about one in four have chronic pain. Acute perioperative pain management in this population is challenging because many patients with chronic pain require long-term opioids for the management of this pain, which may result in tolerance, physical dependence, addiction, and opioid-induced hyperalgesia. These challenges are compounded by the ongoing opioid epidemic that has resulted in calls for a reduction in opioid use, with a concurrent increase in the number of patients with chronic opioid exposure presenting for surgery. This article aims to summarize practical considerations for acute postoperative pain management in patients with chronic pain conditions. A patient-centered acute pain management plan, including nonopioid analgesics, regional anesthesia, and careful selection of opioid medications, can lead to adequate analgesia and satisfaction with care. Also, a meticulous rotation from one opioid to another may decrease opioid requirement, increase analgesic effectiveness, and improve satisfaction with care.

Using Clinical Simulations to Train Healthcare Professionals to Use Electronic Health Records: A Literature Review.

Unintended consequences are adverse events directly related to information technology and may result from inappropriate use of electronic health records by healthcare professionals. Electronic health record competency training has historically used didactic lectures with hands-on experience in a live classroom, and this method fails to teach learners proficiency because the sociotechnical factors that are present in real-world settings are excluded. Additionally, on-the-job training to gain competency can impair patient safety because it distracts clinicians from patient care activities. Clinical simulation-based electronic health record training allows learners to acquire technical and nontechnical skills in a safe environment that will not compromise patient safety. The purpose of this literature review was to summarize the current state-of-the-science on the use of clinical simulations to train healthcare professionals to use electronic health records. The benefits of using simulation-based training that incorporates an organization's contextual factors include improvement of interdisciplinary team communication, clinical performance, clinician-patient-technology communication skills, and recognition of patient safety issues. Design considerations for electronic health record training using clinical simulations involve establishing course objectives, identifying outcome measures, establishing content requirements of both the clinical simulation and electronic health record, and providing adequate debriefing.

Perioperative Considerations for Patients With Major Depressive Disorder Undergoing Surgery.

In the United States, approximately 15% of adults suffer from major depressive disorder (MDD), which results in an annual cost of over $200 billion per year. In the perioperative setting, MDD is associated with increased morbidity and mortality. The exact causes of the increase in adverse outcomes are unknown. Major depression affects virtually all major systems in the human body, and most antidepressants affect dopamine, norepinephrine, and serotonin levels or alter their target receptors. Unfortunately, anesthesia and medications used in the perioperative period affect the same neurotransmitters. As a result, patients with MDD are at an increased risk for cardiovascular effects, altered thermoregulation, and postoperative cognitive dysfunction. To determine when to continue or hold antidepressants preoperatively and avoid potential drug interactions, perioperative providers must understand the pharmacological action of antidepressants. This article reviews the pathophysiology of MDD, mechanism of action of antidepressants, and perioperative considerations for patients on antidepressant medications.

Evaluation of Methods to Measure Production Pressure: A Literature Review.

BACKGROUND: Production pressure is a major contributor to the occurrence of medical errors. Production pressure is the demand on health care professionals to increase the quantity of work at the expense of quality. PURPOSE: The purpose was to summarize the state of the science on measuring production pressure in health care settings so that evidence-based strategies could be identified that minimize medical errors. METHODS: This was a literature review. The electronic databases PubMed, Embase, and Scopus were queried using the keywords "work pressure" or "production pressure." RESULTS: Production pressure is often measured with quantitative approaches that measure efficiency, staff workload, capacity utilization (number of hospital beds occupied), or psychometric instruments. Ethnography is a qualitative method that is also used to assess production pressure. CONCLUSIONS: There were several strategies identified to minimize the impact of production pressure on the occurrence of medical errors. These strategies can be categorized as administrator, educational, or workflow related.

Preventable Closed Claims in the AANA Foundation Closed Malpractice Claims Database.

Medical errors are among the top 3 causes of patient deaths in the United States, with up to 400,000 preventable deaths occurring in hospitalized patients each year. Although improvements have been made in anesthesia patient safety, adverse outcomes continue to occur. This study used thematic analysis to examine anesthesia closed claims that were associated with preventable morbidity and mortality. Investigators determined that 123 closed malpractice claims files from the American Association of Nurse Anesthetists (AANA) Foundation closed claims database involved events that the involved Certified Registered Nurse Anesthetist could have prevented. Factors that were associated with preventable closed claims included communication failures, violations of the AANA Standards for Nurse Anesthesia Practice, and errors in judgment.

The effect of data-entry template design and anesthesia provider workload on documentation accuracy, documentation efficiency, and user-satisfaction.

INTRODUCTION: Currently, there are few evidence-based guidelines to inform optimal clinical data-entry template design that maximizes usability while reducing unintended consequences. This study explored the impact of data-entry template design and anesthesia provider workload on documentation accuracy, documentation efficiency, and user-satisfaction to identify the most beneficial data-entry methods for use in future documentation interface design. METHODOLOGY: A study using observational data collection and psychometric instruments (for perceived workload and user-satisfaction) was conducted at three hospitals using different methods of data-entry for perioperative documentation (auto-filling with unstructured data, computer-assisted data selection with semi-structured documentation, and paper-based documentation). Nurse anesthetists at each hospital (N = 30) were observed completing documentation on routine abdominal surgical cases. RESULTS: Auto-filling (61.2%) had the lowest documentation accuracy scores compared to computer-assisted (81.3%) and paper-based documentation (76.2%). Computer-assisted data-entry had the best documentation efficiency scores and required the least percentage of the nurse anesthetists' time (9.65%) compared to auto-filling (11.43%) and paper-based documentation (15.23%). Paper-based documentation had the highest perceived workload scores (M = 288, SD = 88) compared to auto-filling (M = 160, SD = 93, U = 16.5, p < 0.01) and computer assisted data-entry (M = 93, SD = 50, U = 4.0, P < 0.001). CONCLUSIONS: Auto-filling with unstructured data needs to be used sparingly because of its low documentation accuracy. Computer-assisted data entry with semi-structured data needs to be further study because of its better documentation accuracy, documentation efficiency, and perceived workload.

A Review of Measuring the Cognitive Workload of Electronic Health Records.

The To Err Is Human report stated that 98 000 patients die yearly because of medical errors, and that medication errors kill more people than workplace injuries. The inadequate design and utilization of the electronic health record have been identified as major contributing factors to medical errors. Increased cognitive workload of clinicians has consistently been linked to the occurrence of medical errors. The purpose of this article was to synthesize the current state of the science on measuring clinicians' cognitive workload associated with using electronic health records in order to inform evidence-based guidelines. The major considerations identified in the literature involve the use of psychometric instruments, using efficiency as a proxy for cognitive workload, and eye tracking. The National Aeronautics and Space Administration Task Load Index was the most used psychometric instrument, but reliability measures were not reported. It is important to evaluate reliability of psychometric instruments because the consistency of the instrument can change when administered to different populations. Efficiency is an observable measure defined by the total time to complete a task and the total number of physical interactions with the user interface. Efficiency can allow the use of statistical modeling, but it does not directly evaluate the mental activity associated with using an electronic health record interface. Eye tracking has been used extensively in the literature to measure cognitive workload via changes in pupil size related to mental activity, but it is not often used to measure the cognitive workload associated with using the electronic health record. Eye tracking is very useful for continuous monitoring of cognitive workload.

Electronic Health Records in Simulation Education: Literature Review and Synthesis.

STATEMENT: During the last decade, the use of electronic health records (EHRs) in clinical settings has risen sharply. Many clinical education programs have not incorporated the use of electronic documentation into their curriculum. It is important to incorporate technologies that will be used in real-world settings into educational clinical simulations to better prepare students for clinical practice and promote patient safety. Electronic documentation can be harder to teach to students because it requires a more in-depth orientation on how to use the electronic documentation system and because health care organizations often give students limited or no access to the documentation system. This review will include a discussion on the benefits and disadvantages of using educational EHRs, barriers and facilitators to implementing educational EHRs, and best practices for incorporating educational EHRs into current educational curriculums.

Transfer of Care in Perioperative Settings: A Descriptive Qualitative Study.

Transfer of care is defined as the exchange of information and professional accountability for patient care between individuals. This article describes a qualitative content analysis (N = 19) using a closed-claims database generated by the American Association of Nurse Anesthetists (AANA) Foundation. The purpose of this study was to explore perioperative transfer-of-care events that contributed to professional malpractice claims to identify general themes, antecedents, and consequences to improve clinical practices and guide future research. A brief summary of the 6 themes that emerged in this study is as follows. (1) Patients should be transferred to an appropriate level of care based on their needs. (2) Production pressure leads to normalization of deviance. (3) Clinicians need to conduct their own patient assessments and health record reviews without relying solely on another clinician's report. (4) Interdisciplinary team communication failure is a leading cause of adverse outcomes. (5) Inadequate patient monitoring and physical assessment after the transfer of care is completed is a leading cause of adverse outcomes. (6) Transfer of care should not occur during high-risk patient care events or during periods of patient hemodynamic or respiratory instability.

Evidence-Based Guidelines for Interface Design for Data Entry in Electronic Health Records.

Electronic health records use a variety of data entry methods that are often customized to clinician needs. Data entry interfaces must be appropriately designed to maximize benefits and minimize unintended consequences. There was relatively little evidence in the literature to guide the selection of specific data entry methods according to the type of data documented. This literature review summarizes existing data entry design recommendations to guide data entry interface design. Structured data entry uses predefined charting elements to limit acceptable data entry to standard coded data and improve completeness and data reuse at the expense of correctness. Unstructured data entry methods use natural language and improve correctness, at the expense of completeness and data reusability. Semistructured data entry uses a combination of these data entry methods to complement the strengths and minimize the weaknesses of each method. Documentation quality is influenced by the method of data entry. It is important to choose data entry methods based on the type of data to be documented. This literature review summarizes data entry design guidelines to inform clinical practice and future research.

The Role of Documentation Quality in Anesthesia-Related Closed Claims: A Descriptive Qualitative Study.

Clinical documentation is a critical tool in supporting care provided to patients. Sound documentation provides a picture of clinical events that can be used to improve patient care. However, many other uses for clinical documentation are equally important. Such documentation informs clinical decision support tools, creates a legal record of patient care, assists in financial reimbursement of services, and serves as a repository for secondary data analysis. Conversely, poor documentation can impair patient safety and increase malpractice risk exposure by reflecting poor or inaccurate information that ultimately may guide patient care decisions.Through an examination of anesthesia-related closed claims, a descriptive qualitative study emerged, which explored the antecedents and consequences of documentation quality in the claims reviewed. A secondary data analysis utilized a database generated by the American Association of Nurse Anesthetists Foundation closed claim review team. Four major themes emerged from the analysis. Themes 1, 2, and 4 primarily describe how poor documentation quality can have negative consequences for clinicians. The third theme primarily describes how poor documentation quality that can negatively affect patient safety.

A review of dashboards for data analytics in nursing.

Dashboards are data-driven clinical decision support tools used to analyze data from multiple databases using easy-to-read, color-coded graphical displays, much like the dashboards of automobiles. Dashboards can be used to promote data-driven decision making and improve adherence to evidence-based practice guidelines. The purpose of this article was to provide a review of dashboards used to query electronic health records for the purpose of guiding clinical practice and research. An inductive content analysis approach was used to identify emerging themes directly from the literature. Five basic dashboard properties identified include the type of database integration, visual properties, purpose, time focus (ie, retrospective, real time, or predictive), and type of process monitored. These dashboard properties are determined by the characteristics of the specific organization, user, and purpose of data analysis. Using dashboards to perform automated analytical reviews of clinical data will prove more efficient when data elements stored in electronic health records become standardized. Other limitations of dashboard use include user anxiety, information overload, and technology overload. The increased use of electronic documentation in healthcare settings will provide a wealth of data, and dashboards will play a pivotal role in converting these data into actionable knowledge.

An integrative literature review on accuracy in anesthesia information management systems.

An anesthesia information management system is a dynamic electronic documentation system that generates the legal records of patient care while the patient is receiving anesthesia. The generated documentation can be used to guide patient care, facilitate billing for services, and be used for clinical research. The purpose of this article was to synthesize the previous empirical and theoretical literature pertaining to the concept of accuracy in documentation in a wide range of disciplines in order to refine the concept and more effectively guide future research, clinical practice, and policy development in anesthesia informatics. The basic definition of accuracy is generally agreed upon, but the exact method of measuring accuracy is very different across disciplines. The concept of accuracy is defined in the published literature using the terms completeness, comprehensiveness, correctness, precision, legibility, readability, quantity of data, redundancy of data, clearness of data, concordance of data, and legitimacy. In nursing, accuracy can be defined as the presence of correct data that provide a complete, comprehensive, and precise representation of patient care. In anesthesia, accuracy is often defined in terms of correctness and completeness of data. Correctness, completeness, comprehensiveness, and precision are the primary constituents of accuracy with each discipline emphasizing different aspects.

An integrative literature review of contextual factors in perioperative information management systems.

Perioperative information management systems are used to generate the official documentation of patient care throughout the surgical experience. Successful implementation of perioperative information management systems requires a careful assessment of the contextual factors (ie, the social, cultural, and physical environment) that are present at the site. Failure to sufficiently assess these contextual factors is one of the leading causes of unsuccessful system implementation and can result in decreased patient safety, poor documentation quality, inefficient work processes, and wasted financial resources. Clearly defining and identifying the contextual factors are necessary to improve the performance and utilization of information management systems. The purpose of this article was to provide an integrative review of the empirical and theoretical literature on the contextual factors present in the perioperative environment to help guide future research and clinical practice. Specifically, this review addresses a gap in the literature regarding the descriptions of the contextual factors and how these factors affect implementation practices and system use. By clearly identifying these contextual factors and determining their relationship to successful system implementations, informatics specialists can tailor implementation and assessment tools to both patients and perioperative settings.