Five-year follow-up to assess long-term sustainability of changing clinical practice regarding anesthesia and regional analgesia for lower extremity arthroplasty.

Background: Long-term and sustainable clinical practice changes in anesthesia procedures have not previously been reported. Therefore, we performed a 5-year audit following implementation of a clinical pathway change favoring spinal anesthesia for total knee arthroplasty (TKA). We similarly evaluated a parallel cohort of patients undergoing total hip arthroplasty (THA), who did not undergo a clinical pathway change, and studied utilization rates of continuous peripheral nerve block (CPNB). METHODS: We identified all primary unilateral TKA and THA cases completed from January 2013 through December 2018, thereby including clinical pathway change data from one-year pre-implementation to 5-years post-implementation. Our primary outcome was the overall application rate of spinal anesthesia. Secondary outcomes included CPNB utilization rate, 30-day postoperative complications, and resource utilization variables such as hospital readmission, emergency department visits, and blood transfusions. RESULTS: The sample included 1,859 cases, consisting of 1,250 TKAs and 609 THAs. During the initial year post-implementation, 174/221 (78.7%) TKAs received spinal anesthesia compared to 23/186 (12.4%) cases the year before implementation (P < 0.001). During the following 4-year period, 647/843 (77.2%) TKAs received spinal anesthesia (P = 0.532 vs. year 1). The number of THA cases receiving spinal anesthesia the year after implementation was 78/124 (62.9%), compared to 48/116 (41.4%) pre-implementation (P = 0.001); however, the rate decreased over the following 4-year period to 193/369 (52.3%) (P = 0.040 vs. year 1). CPNB use was high in both groups, and there were no differences in 30-day postoperative complications, hospital readmission, emergency department visits, or blood transfusions. CONCLUSIONS: A clinical pathway change promoting spinal anesthesia for TKA can be effectively implemented and sustained over a 5-year period.

What's in a Word? Qualitative and Quantitative Analysis of Leadership Language in Anesthesiology Resident Feedback.

BACKGROUND: Individuals who have agentic traits (eg, assertive, confident, competent) that are more commonly associated with men are often selected for leadership roles. For women, this poses a potential barrier to entry into the higher ranks of academic medicine. OBJECTIVE: We analyzed anesthesiology resident feedback for differences in the use of agentic descriptors using qualitative and quantitative methods based on resident gender and year of training. METHODS: This study uses textual analysis of 435 assessments of residents over a 1-year period within a single residency program. We performed a qualitative content analysis on the words used in resident feedback and performed negative binomial regression analyses to determine significant differences in the way residents were described based on gender and year of training. RESULTS: Female residents were less likely than male residents to be described as agentic after controlling for excerpt length, year of training, and evaluator variability (ß = -0.347; 95% confidence interval [CI] -0.666, -0.028; P = .033). Senior residents were more likely to be described as agentic (ß = 0.702; 95% CI 0.402-1.002; P < .001) compared to junior residents. The increased number of agentic codes among senior residents was driven by increased agentic description of female residents' ratings in the senior cohort (ß = 0.704; 95% CI 0.084-1.324; P = .026). CONCLUSIONS: Female residents were described as agentic less often than male residents in early years of training, but the gap was not present among senior residents.

Adherence to a Multimodal Analgesic Clinical Pathway: A Within-Group Comparison of Staged Bilateral Knee Arthroplasty Patients.

BACKGROUND AND OBJECTIVES: Multimodal analgesic clinical pathways for joint replacement patients often include perineural catheters, but long-term adherence to these pathways has not yet been investigated. Our primary aim was to determine adherence rate to a knee arthroplasty clinical pathway for patients undergoing staged bilateral procedures. METHODS: This study was performed at a hospital with a Perioperative Surgical Home program and knee arthroplasty clinical pathway using multimodal analgesia and adductor canal catheters. Data were examined for all orthopedic surgery patients over a 4-year period. We included patients who had staged bilateral knee arthroplasty electively scheduled on 2 separate dates. The primary outcome was rate of adductor canal catheter utilization as a measure of adherence to the clinical pathway. Other outcomes included rates of neuraxial anesthesia and minor and major perioperative complications. RESULTS: We analyzed data for 103 unique patients. The interval between surgeries was a median of 261 days (10th-90th percentile, 138-534 days). All 103 patients had adductor canal catheters for both the first and second surgeries (P > 0.999). Forty-one percent of patients had the same surgeon for both surgeries, but only 2% had the same anesthesiologist (P < 0.001). From the first to the second surgery, utilization of neuraxial anesthesia increased from 51% to 68%, respectively (P = 0.005). There were no differences in minor or major complications. CONCLUSIONS: For staged bilateral knee arthroplasty patients, 100% clinical pathway adherence including perineural catheters and multimodal analgesia is feasible despite multiple variables. We believe that patient-centered acute pain management requires consistent and reliable delivery of care.

The Perioperative Surgical Home model facilitates change implementation in anesthetic technique within a clinical pathway for total knee arthroplasty.

BACKGROUND: The challenge of knowledge translation in medical settings is well known, and implementing change in clinical practice can take years. For the increasing number total knee arthroplasty (TKA) patients annually, there is ample evidence to endorse neuraxial anesthesia over general anesthesia. The rate of adoption of this practice, however, is slow at the current time. We hypothesized that a Perioperative Surgical Home (PSH) model facilitates rapid change implementation in anesthesia. METHODS: The PSH clinical pathways workgroup at a tertiary care Veterans Affairs hospital embarked on a 5-month process of changing the preferred anesthetic technique for patients undergoing TKA. This process involved multiple sequential steps: literature review; development of a work document; training of staff; and prospective collection of data. To assess the impact of this change, we examined data 6 months before (PRE, n=90) and after (POST) change implementation (n=128), and our primary outcome was the overall proportion of spinal anesthesia usage for each 6 month period. Secondary outcomes included minor and major complications associated with anesthetic technique. RESULTS: Over a period of one year, there was an increase in the proportion of patients who received spinal anesthesia (13% vs. 63%, p<0.001). For the following year, 53-92% of TKA patients per month received spinal anesthesia. There were no differences in major complications. CONCLUSION: Rapid and sustained change implementation in clinical anesthesia practice based on emerging evidence is feasible. IMPLICATIONS: Perioperative Surgical Home model may facilitate rapid change implementation in surgical care. LEVEL OF EVIDENCE: Cohort study, Level 2.