Safe preoperative regional nerve blocks.

BACKGROUND: Procedural time-outs and checklists are proven to be an effective means of improving teamwork and preventing wrong-sided procedures. The main objective of this study was to ensure that all regional nerve blocks being performed in the preoperative area at our hospital were executed with a proper time-out. The goal of this project was to increase integration of a safe preoperative block process including a time-out checklist to ensure; complete consents, correct patient and laterality were marked prior to each procedure. We focused on recognising events that took place before, during and after the nerve block including non-compliance with the checklist and deviations from protocol. METHODS: A safe preoperative block process current and future state flowchart, revised time-out checklist and action/implementation plan as part of our Plan-Do-Study-Act model was constructed using a multidisciplinary approach. Pre-implementation and post- implementation data were collected by medical students acting anonymously via direct observation noting the presence of an anaesthesiologist, resident, nurse, time-out for procedure, checklist completed and procedure start and sedation time representing a complete time-out. RESULTS: The direct observations in the pre-implementation group showed a 20% (3/15) compliance with a correct time-out. The direct observations in the post implementation group showed 85% (12/14) compliance. This revealed a 65% increase in all portions of the time-out checklist completed. Comparative analysis confirmed decrease in non-compliance and deviations from protocol as displayed by 65% increase in all portions of time-out checklist completed. CONCLUSION: We aimed to improve safety, communication and compliance for preoperative nerve blocks through development and implementation of a safe preoperative block process using a multidisciplinary model. We conclude that creation of a safe nerve block was achieved by integration of a preoperative nerve block process which included increased compliance to the time-out checklist, verifying patients and laterality with marking of patient prior to each procedure, identifying proper consents were completed and ensuring each regional nerve block was executed with a proper time-out.

The role of the built environment and private rooms for reducing central line-associated bloodstream infections.

Private hospital rooms are believed to offer some protective effect against hospital-acquired infections, including central line-associated bloodstream infections. Yet a recent meta-analysis found the evidence-base to be lacking from a policy perspective. We sought to determine whether private rooms were associated with a lower risk of central-line infections. We examined the discharge records of more than one million inpatients from 335 Texas hospitals to determine patients that stayed in private rooms. Patients who stayed in bay rooms had 64 percent more central line infections than patients who stayed in private rooms. Even after adjusting for relevant covariates, patients assigned to bay rooms had a 21 percent greater relative risk of a central line infection (p = 0.005), compared with patients assigned to private rooms. At the hospital level, a 10% increase in private rooms was associated with an 8.6% decrease in central line infections (p<0.001), regardless of individual patients' room assignment. This study demonstrates and validates the use of private rooms as a structural measure and independent predictor of hospital quality.

Quality and the Health System: Becoming a High Reliability Organization.

Since the publication of "To Err is Human" in 1999, substantial efforts have been made within the health care industry to improve quality and patient safety. Although improvements have been made, recent estimates continue to indicate the need for a marked change in approach. In this article, the authors discuss the concepts and characteristics of high reliability organizations, safety culture, and clinical microsystems. The health care delivery system must move beyond current quality and patient safety approaches and fully engage in these new concepts to transform health care system performance.

Risks predicting prolonged hospital discharge boarding in a regional acute care hospital.

BACKGROUND: Prolonged hospital discharge boarding can impact patient flow resulting in upstream Emergency Department crowding. We aim to determine the risks predicting prolonged hospital discharge boarding and their direct and indirect effects on patient flow. METHODS: Retrospective review of a single hospital discharge database was conducted. Variables including type of disposition, disposition boarding time, case management consultation, discharge medications prescriptions, severity of illness, and patient homeless status were analyzed in a multivariate logistic regression model. Hospital charges, potential savings of hospital bed hours, and whether detailed discharge instructions provided adequate explanations to patients were also analyzed. RESULTS: A total of 11,527 admissions was entered into final analysis. The median discharge boarding time was approximately 2 h. Adjusted Odds Ratio (AOR) of patients transferring to other hospitals was 7.45 (95% CI 5.35-10.37), to court or law enforcement custody was 2.51 (95% CI 1.84-3.42), and to a skilled nursing facility was 2.48 (95% CI 2.10-2.93). AOR was 0.57 (95% CI 0.47-0.71) if the disposition order was placed during normal office hours (0800-1700). AOR of early case management consultation was 1.52 (95% CI 1.37-1.68) versus 1.73 (95% CI 1.03-2.89) for late consultation. Eighty-eight percent of patients experiencing discharge boarding times within 2 h of disposition expressed positive responses when questioned about the quality of explanations of discharge instructions and follow-up plans based on satisfaction surveys. Similar results (86% positive response) were noted among patients whose discharge boarding times were prolonged (> 2 h, p = 0.44). An average charge of $6/bed/h was noted in all hospital discharges. Maximizing early discharge boarding (≤ 2 h) would have resulted in 16,376 hospital bed hours saved thereby averting $98,256.00 in unnecessary dwell time charges in this study population alone. CONCLUSION: Type of disposition, case management timely consultation, and disposition to discharge dwell time affect boarding and patient flow in a tertiary acute care hospital. Efficiency of the discharge process did not affect patient satisfaction relative to the perceived quality of discharge instruction and follow-up plan explanations. Prolonged disposition to discharge intervals result in unnecessary hospital bed occupancy thereby negatively impacting hospital finances while delivering no direct benefit to patients.

The effects of gastroretentive gabapentin (Gralise®) on spinal stenosis patients with radicular pain.

BACKGROUND: The health and efficacy profiles of Gralise® in the treatment of pain from spinal stenosis and radicular symptomatology have not been measured. A review of the current literature indicates that no studies exist that evaluate the safety and efficacy profiles of Gralise® in the treatment of pain from spinal stenosis and radicular symptomatology. OBJECTIVE: Our study is aimed at determining whether Gralise is a safe and effective pharmacotherapy for the pain from spinal stenosis and radicular symptomatology. STUDY DESIGN: A 4-week prospective open label single arm and single center study of patients with MRI diagnosis of spinal stenosis with radicular pain. METHODS: The primary measure of efficacy was a change in average daily pain (ADP) score from baseline to completion of Gralise therapy for 4 weeks. The secondary efficacy endpoints were the patients' Patients Global Impression of Change Scale (PGIC), the clinician's Clinical Global Impression of Change Scale (CGI) reports, and the Medical Outcomes Study (MOS) sleep scale of improvement from baseline to completing 4 weeks of Gralise therapy. The safety and tolerability were evaluated by the incidence of adverse events reported while on Gralise therapy. SETTING: The study was performed at the Clinical Research Facilities at Tulane Medical Center, New Orleans, Louisiana, in the period from December 1, 2012, to August 30, 2013. RESULTS: Thirty-five patients achieved an efficacy point of one-week Gralise medication treatment. Twenty-seven of 35 (77.2%) patients completed all 5 visits. The PGIC noted a significant positive change in: (1) activity limitations; (2) symptoms; (3) emotions and overall quality of life when related to their condition from first visit as well as improved degree of change when related to their condition from first to last visit. The MOS sleep scale and sleep diaries noted a significant increase of hours slept on average (an increase in over one hour per night--5.8 hours versus 6.86 hours) from the beginning of the study to the end. The CGI noted a majority of 10 out of 27 with marked significant therapeutic effect with no side effects. The ADP rating from pain intensity scale and pain diaries noted significant improvement of lesser levels of pain experienced (P =.5907 and P =.8547 respectively). No significant adverse effects were noted in the study. LIMITATIONS: Variation in degree of spinal stenosis, small sample size. CONCLUSIONS: Gralise demonstrated moderate efficacy with reduced pain intensity and increased sleep and was well tolerated in spinal stenosis patients with radicular symptoms.

Low concentration lidocaine (0.5%) bolus epidurally can initiate fast-onset, effective and safe analgesia for early stage labor.

There is no consensus on the optimal local anesthetic agent to initiate labor analgesia for patients in active labor. Currently used local anesthetic agents for initiating labor analgesia include 0.25% bupivacaine, 0.5% bupivacaine, 0.2% ropivacaine without or with various types and doses of opioids. All these agents are administered in incremental doses and are relatively "slow onset" in initiation of labor analgesia. We used 0.5% lidocaine 10 ml as the loading dose given as an epidural bolus to initiate epidural analgesia for patients in early stages of labor. We included 32 cases (16 in Lidocaine group and 16 in Bupivacaine group). We found that 0.5% lidocaine is fast-onset, very effective and safe in initiating epidural analgesia for early stage labor.

A multisite validity study of self-reported anesthesia outcomes.

The purpose of this study was to assess the validity of a multisite anesthesia voluntary adverse event reporting process. A data validation methodology was used through medical chart review on live records at 3 facilities (N = 600). The per-item aggregated error rate among all 42 data items was 0.3%: 0.1% for quality indicators, 1.3% for demographic/status variables, and 1.7% for administrative items. The per-patient error rate among all 42 data items was 6.3%: 3.0% for quality indicators, 1.7% for demographic/status variables, and 3.0% for administrative items. Trends such as better accuracy for more serious events continue, but observed error rates were lower than those found in previous surveys-an indication that, while further study is needed, nonpunitive voluntary reporting may reduce errors in anesthesia care.