Outcomes for 41 260 pediatric surgical patients with opioid-free anesthesia: One center's experience.

BACKGROUND: Opioid use is common and associated with side effects and risks. Consequently, analgesic strategies to reduce opioid utilization have been developed. Regional anesthesia and multimodal strategies are central tenets of enhanced recovery pathways and facilitate reduced perioperative opioid use. Opioid-free anesthesia (OFA) protocols eliminate all intraoperative opioids, reserving opioids for postoperative rescue treatment. Systematic reviews show variable results for OFA. METHODS: In a series of Quality Improvement (QI) projects, multidisciplinary teams developed interventions to test and spread OFA first in our ambulatory surgery center (ASC) and then in our hospital. Outcome measures were tracked using statistical process control charts to increase the adoption of OFA. RESULTS: Between January 1, 2016, and September 30, 2022, 19 872 of 28 574 ASC patients received OFA, increasing from 30% to 98%. Post Anesthesia Care Unit (PACU) maximum pain score, opioid-rescue rate, and postoperative nausea and vomiting (PONV) treatment all decreased concomitantly. The use of OFA now represents our ambulatory standard practice. Over the same timeframe, the spread of this practice to our hospital led to 21 388 of 64 859 patients undergoing select procedures with OFA, increasing from 15% to 60%. Opioid rescue rate and PONV treatment in PACU decreased while hospital maximum pain scores and length of stay were stable. Two procedural examples with OFA benefits were identified. The use of OFA allowed relaxation of adenotonsillectomy admission criteria, resulting in 52 hospital patient days saved. Transition to OFA for laparoscopic appendectomy occurred concomitantly with a decrease in the mean hospital length of stay from 2.9 to 1.4 days, representing a savings of >500 hospital patient days/year. CONCLUSIONS: These QI projects demonstrated that most pediatric ambulatory and select inpatient surgeries are amenable to OFA techniques which may reduce PONV without worsening pain.

Outcomes of a Failure Mode and Effects Analysis for medication errors in pediatric anesthesia.

The Institute of Medicine has called for development of strategies to prevent medication errors, which are one important cause of preventable harm. Although the field of anesthesiology is considered a leader in patient safety, recent data suggest high medication error rates in anesthesia practice. Unfortunately, few error prevention strategies for anesthesia providers have been implemented. Using Toyota Production System quality improvement methodology, a multidisciplinary team observed 133 h of medication practice in the operating room at a tertiary care freestanding children's hospital. A failure mode and effects analysis was conducted to systematically deconstruct and evaluate each medication handling process step and score possible failure modes to quantify areas of risk. A bundle of five targeted countermeasures were identified and implemented over 12 months. Improvements in syringe labeling (73 to 96%), standardization of medication organization in the anesthesia workspace (0 to 100%), and two-provider infusion checks (23 to 59%) were observed. Medication error reporting improved during the project and was subsequently maintained. After intervention, the median medication error rate decreased from 1.56 to 0.95 per 1000 anesthetics. The frequency of medication error harm events reaching the patient also decreased. Systematic evaluation and standardization of medication handling processes by anesthesia providers in the operating room can decrease medication errors and improve patient safety.

Assessing the Impact of the Anesthesia Medication Template on Medication Errors During Anesthesia: A Prospective Study.

BACKGROUND: Medication errors continue to be a significant source of patient harm in the operating room with few concrete countermeasures. The organization and identification of medication syringes may have an impact on the commission of medication errors in anesthesia, so a team of physicians and designers at the University of Washington created the Anesthesia Medication Template (AMT) to define a formal way of organizing the anesthesia workspace. The purpose of this study is to assess the ability of the AMT to reduce perioperative medication errors by anesthesia providers. METHODS: This study evaluated the AMT in 2 phases: (1) 41 anesthesia providers administered medications in 2 prospective, randomized operating room simulations with or without the AMT, while medication errors were directly observed; and (2) around 200 providers prospectively self-reported medication errors from all anesthetizing locations during a 2-year period at Seattle Children's Hospital, an academic, pediatric medical center. RESULTS: In simulated emergencies, the odds of medication dosing errors using the AMT were 0.21 times the odds of medication dosing errors without AMT (95% confidence interval [CI], 0.07, 0.66), controlling for scenario, session, training level, and years at training level. During the year after implementation of the AMT, the mean monthly error rate for all reported medication errors that reached patients decreased from 1.24 (95% CI, 0.85-1.79) to 0.65 (95% CI, 0.39-1.09) errors per 1000 anesthetics. The mean monthly error rate of reported swap, preparation, miscalculation, and timing errors decreased from 0.97 (95% CI, 0.64-1.48) to 0.35 (95% CI, 0.17-0.70) errors per 1000 anesthetics. Medication errors that resulted in patient harm did not change after implementation of the AMT. CONCLUSIONS: Standardizing medication organization with the AMT is an intuitive, low-cost strategy with the potential to improve patient safety through reducing medication errors by anesthesia providers.

Quality and safety in pediatric anesthesia.

Health care quality and value are leading issues in medicine today for patients, health care professionals, and policy makers. Outcome, safety, and service-the components of quality-have been used to define value when placed in the context of cost. Health care organizations and professionals are faced with the challenge of improving quality while reducing health care related costs to improve value. Measurement of quality is essential for assessing what is effective and what is not when working toward improving quality and value. However, there are few tools currently for assessing quality of care, and clinicians often lack the resources and skills required to conduct quality improvement work. In this article, we provide a brief review of quality improvement as a discipline and describe these efforts within pediatric anesthesiology.

Video observation of anesthesia practice: a useful and reliable tool for quality improvement initiatives.

AIMS: Patients with central venous catheters who are transferred out of the Intensive Care Unit to the care of an anesthesiology team for an operation or interventional radiology procedure had excessive rates of catheter associated blood stream infection (CABSI). METHODS: We convened a multi-disciplinary team to audit anesthesia practice and to develop countermeasures for those aspects of practice that were thought to be contributing to CABSI's. It was noted that provider behavior changed in the presence of an auditor (Hawthorne effect) and so videorecordings were used, in the hope that this Hawthorne effect would be reduced. Clips were chosen from the hours of video (without audio) recordings that showed medication administration, airway management and touching the anesthesia cart of equipment/supplies. RESULTS: These clips were viewed by three observers and measurements were made to assess intra-rater and inter-rater reliability. The clips were then viewed to quantify differences in practice before and after our bundle of "best practices" was introduced. CONCLUSIONS: Although video recording has been used to evaluate adherence to resuscitation protocols in both trauma and in neonatal resuscitation, (Pediatric Emergency Care, 26, 2010, 803; Pediatrics, 117, 2006, 658; Pediatrics, 106, 2000, 654) we believe this is the first time that video has been used to record before and after behaviors for an anesthesia quality improvement initiative.

Modification of anesthesia practice reduces catheter-associated bloodstream infections: a quality improvement initiative.

BACKGROUND: A major strategic hospital goal is the prevention of catheter associated bloodstream infections (CABSI). In 2009, at our institution, the CABSI rate for patients who traveled out of the ICU to the operating room and other procedural areas under the care of an anesthesiologist was increased compared to patients who remained on the unit. AIMS: Our objective was to develop countermeasures to improve intraoperative cleanliness by anesthesia providers, minimize contamination of intravenous access points, and ultimately reduce CABSIs. MATERIALS & METHODS: A multidisciplinary team identified barriers to following best practices for reducing contamination of intravenous line entry-ports. Using Continuous Performance Improvement (CPI) or Lean techniques, staff directly impacted by the changes developed countermeasures to improve anesthesia practice. Compliance with the new "best practices" improved with coaching and feedback. RESULTS: Postimplementation, CABSI rates for patients traveling off the ICU with anesthesiology providers decreased from 14.1 per thousand trips off the ICU preintervention in 2009 to 9.7 per 1000 trips in 2010 and to 0 per 1000 trips in 2011 postintervention. Hospital-wide CABSI rates decreased from 3.5 per 1000 central line days preintervention to 2.2 per 1000 central line days after. CONCLUSION: Practice modification by anesthesiology providers in the operating room can decrease workspace contamination and is associated with decreased CABSI rates.

Gastric contents in pediatric patients following bone marrow transplantation.

BACKGROUND: Graft versus host disease (GVHD) of the gut is thought to delay gastric emptying and so may increase the risk of aspirating retained contents while under anesthesia. Knowing that gastric emptying is delayed in patients with GVHD might lead one to choose to intubate the trachea for all patients with suspected GVHD, who present for diagnostic esophagogastricduodenoscopy (EGD). We are not aware of published data that gives specific guidance as to the need for intubation in the pediatric bone marrow or stem cell transplantation (BMT) population. This review was intended to evaluate the gastric contents (pH and volume) in this group of patients, to provide anesthesiologists with data that would inform their decisions about airway management for these patients. METHODS: Retrospective chart review of patients

A case of awareness despite an "adequate depth of anesthesia" as indicated by a Bispectral Index monitor.

We report a case of awareness that occurred despite the presence of an "adequate" depth of anesthesia as measured by Bispectral Index. Our patient was at high risk for this complication. Hypotension limited the use of sevoflurane, and neuromuscular, sympathetic, and beta-adrenergic blockade prevented the patient from responding to his awareness. Preoperative use of opioids and gabapentin for chronic pain may have modified his response to anesthesia or affected his Bispectral Index reading. Our attempt to measure depth of anesthesia may have resulted in false reassurance concerning adequacy of anesthesia and contributed to awareness.