A Mixed-Methods Exploration of Competencies and Professional Development Needs Among Chief Certified Registered Nurse Anesthetists.

This project sought to explore the experiences, self-perceived preparation, professional development needs, and preferred learning methods of certified registered nurse anesthetists (CRNAs) in a management role. A sample of 10 current chief CRNAs responded to a demographics survey and participated in one-on-one interviews using a 14-question, semi-structured interview framework modified from a previous study. Interview responses were deidentified and qualitatively analyzed for common themes by two content experts and one qualitative analysis expert. Results suggest that CRNAs entering the management field feel somewhat unprepared to perform the administrative tasks associated with their role. Qualitative analysis of interview responses elicited multiple key themes including interpersonal communication and handling crucial conversations, time and organizational management skills, team building and motivation, and financial management skills. Themes related to preferred learning methods of chief CRNAs included mentorship, peer networking, and experiential learning to obtain the required knowledge and skills for the role. The authors recommend incorporating each of the identified themes to guide development of CRNA management-specific educational programs. Establishing such a program will serve to better prepare aspiring CRNA managers and further develop the knowledge and skillset of current chief CRNAs.

Improving Waste Segregation in the Operating Room to Decrease Overhead Cost.

BACKGROUND AND OBJECTIVES: Operating rooms (ORs) disproportionally contribute 20% to 33% of hospital waste nationwide and therefore have a major impact on hospital waste management. Seventy percent of general OR waste is incorrectly eliminated as clinical waste, which compounds unnecessary financial burden and produces negative environmental impact. The primary purpose of this quality improvement (QI) project was to evaluate the effectiveness of waste segregation education for OR anesthesia staff on improving waste segregation compliance in the OR. METHODS: A waste segregation QI project was implemented at a 19-OR hospital. Sharps bins in each OR were monitored for weight in pounds and 6 ORs were monitored for percent compliance both pre- and post-institution of a waste segregation education. In addition, a waste segregation knowledge assessment, waste segregation barriers assessment, and a demographic survey were administered to anesthesia staff. Twenty-two certified registered nurse anesthetists (CRNAs), 13 anesthesiologists, and 4 anesthesia technicians responded to the initial surveys and assessments while 30 of these original 39 participants (77%) responded following the educational intervention. A cost analysis was calculated pre- and post-implementation by multiplying total weight of the sharps bins by the price per pound of sharps. RESULTS: Twenty-three percent of participants reported having formal waste segregation training. Survey responses revealed that the greatest barrier to waste segregation involved bin location (56.4%), followed by lack of time to segregate (25.6%), lack of knowledge of what content goes in the bin (25.6%), and lack of incentive (25.6%). A waste segregation knowledge assessment showed improvement from pre- ( M = 9.18, SD = 1.66) to post-implementation ( M = 9.90, SD = 1.64). Pre-implementation sharps bin compliance was 50.70% while post-implementation bin compliance improved to 58.44%. A 27.64% decrease in sharps disposal cost occurred following implementation, which is estimated to produce a $2964 cost savings per year. CONCLUSIONS: Waste segregation education for anesthesia staff increased their waste management knowledge, improved sharps waste bin compliance, and produced an overall cost savings.

Improving Certified Registered Nurse Anesthetists' Adherence to a Standardized Intraoperative Lung Protective Ventilation Protocol.

PURPOSE: The use of lung protective ventilation (LPV) during general anesthesia is an effective strategy among certified registered nurse anesthetists (CRNAs) to reduce and prevent the incidence of postoperative pulmonary complications. The purpose of this project was to implement a LPV protocol, assess CRNA provider adherence, and investigate differences in ventilation parameters and postoperative oxygen requirements. DESIGN: This quality improvement project was conducted using a pre- and postimplementation design. METHODS: Sixty patients undergoing robotic laparoscopic abdominal surgery and 35 CRNAs at a community hospital participated. An evidence-based intraoperative LPV protocol was developed, CRNA education was provided, and the protocol was implemented. Pre- and postimplementation, CRNA knowledge, and confidence were assessed. Ventilation data were collected at 1-minute intervals intraoperatively and oxygen requirements were recorded in the postanesthesia care unit (PACU). FINDINGS: Use of intraoperative LPV strategies increased 2.4%. Overall CRNA knowledge (P = .588), confidence (P = .031), and practice (P < .001) improved from pre- to postimplementation. Driving pressures decreased from pre- to postimplementation (P < .001). Supplemental oxygen use on admission to the PACU decreased from 93.3% to 70.0%. CONCLUSIONS: Educational interventions and implementation of a standardized protocol can improve the use of intraoperative LPV strategies and patient outcomes.

Sustainability of an Operating Room to Pediatric Postanesthesia Care Unit Handoff Tool.

PURPOSE: The purpose of this quality improvement (QI) project was to reintroduce and assess the feasibility of a standardized, electronic health record (EHR) handoff tool and to evaluate the sustainability of a structured, team-based approach in a pediatric postanesthesia care unit (PACU). DESIGN: This QI project used an observational pre-post design using two separate convenience samples of handoffs and perianesthesia providers. METHODS: A standardized EHR handoff tool was reintroduced for operating room to pediatric PACU handoff communication. Handoffs between anesthesia providers, surgery team members, and PACU nurses were observed pre- and postreintroduction of the EHR handoff tool. Anesthesia providers and PACU RNs received training for giving and receiving handoffs and were provided directions on locating the EHR handoff tool. A bedside audit of items communicated for the six handoff phases (introductions, situation, background, assessment, recommendations, and questions), handoff duration, team member participation, and handoff tool utilization were performed for 149 handoffs pre- and 146 handoffs postimplementation. To evaluate sustainability, the audits were compared to postimplementation data from the 2014 pilot handoff project. FINDINGS: Following reintroduction, EHR handoff tool use increased from 4% to 19%. There was a statistically significant increase in items communicated for three of the six handoff phases when using the EHR tool (P < .05). There was no statistically significant increase in handoff duration (mean = 3.66 minutes, SD = 1.57 minutes) with the EHR handoff tool. Surgical team member presence for the team-based handoff increased from 90.7% pre to 95.9% post. Provider compliance with the team-based handoff approach, which includes a PACU RN, surgical team member, and anesthesia team member present for handoff, was sustained and increased 6 years postimplementation. Feedback from anesthesia providers and PACU RNs indicated mixed reports of satisfaction with the EHR tool, perceived handoff efficiency, and consistency in both giving and receiving handoff. Adherence to five of the six structured handoff phases, except introductions, was sustained and even improved 6 years following implementation. CONCLUSIONS: Evidence-based practice for handoff communication supports the use of a team approach and standardized EHR handoff tools. The reintroduction of a standardized EHR handoff tool improved the completeness of information transfer, yet did not lead to widespread adoption nor improved user satisfaction. There is an ongoing need to identify adoptable and sustainable perioperative handoff methods.

Three-Dimensionally Printed Simulated Tracheas to Improve Cricothyrotomy Skills Among Anesthesia Providers.

Cricothyrotomy proficiency is imperative for anesthesia providers; however, opportunities to perform this skill are infrequent making skill maintenance essential. Increased accessibility of three-dimensional (3D) printing allows for production of low-cost simulation models. The models used for simulation-based teaching and deliberate practice facilitate skill development and refinement. A cost-effective, 3D printed airway model was designed and allowed 47 anesthesia providers to complete hands-on practice during a cricothyrotomy simulation-based training program. Assessment and comparison of pre- to post- intervention was completed for self-efficacy, knowledge, time to skill completion, compliance of required steps checklist, Global Rating Scale score, and successful ventilation. Statistically significant improvement from pre- to posttest was demonstrated in: 1) self-efficacy survey scores (P < .001); 2) knowledge test scores (P < .001); and 3) decreased time (minutes:seconds) to task completion (P < .001). Time from initial posttest to 3-month posttest (P = .046) significantly increased, however, the time at 3 months posttest remained significantly lower than pretest (P < .001). Providers' ability to ventilate, compliance with procedural steps, and technical skills significantly improved. 3D printing can produce anatomically similar simulation airway models that allow providers to practice and improve cricothyrotomy knowledge and skills. Developing an affordable and accessible simulation model provides a sustainable tool that allows providers multiple cricothyrotomy practice attempts.

Improved Technical Skill and Procedure Time With Central Venous Catheter Simulation.

Simulation manikins provide anesthetists a training modality to practice ultrasound-guided central venous catheter (CVC) insertion safely without the risk of patient harm. The goals of this quality improvement (QI) project were to increase technical skills and reduce procedure time among anesthesia providers during CVC placement by implementing an ultrasoundguided, simulated CVC insertion workshop. A primary benefit of simulation-based education is the provision of a safe learning environment-one in which learners and providers may practice and increase skillsets. This QI project utilized a pretest-posttest design for which anesthesia providers completed a CVC insertion educational session and three formally evaluated simulated CVC placements: preworkshop, immediate postworkshop, and 3 months postworkshop. CVC insertion skills were evaluated by two experienced raters who established interrater reliability using a validated checklist and recorded procedure time in minutes. When comparing preworkshop median checklist score (33.74/52 [65%]), significant improvement was found in the immediate postworkshop (46.32/52 [89%]) and 3-month follow-up (44.26/52 [85%]). Time for CVC insertion significantly improved immediately postworkshop (15.7 minutes) and 3-month follow-up (15.9 minutes) when compared with preworkshop (21.5 minutes). An ultrasound-guided CVC simulation workshop can appreciably advance anesthesia providers' technical skills and decrease procedure time when performing insertion of a simulated internal jugular CVC.

Design and Validation of a Simulation Scenario and Assessment Tool: A Pilot Project.

In 2016, the National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA) launched a Continued Professional Certification (CPC) Program to promote lifelong learning and to facilitate ongoing professional competency checks for practicing certified registered nurse anesthesiologists (CRNA). The use of simulation-based assessment is currently being studied by the NBCRNA for potential use in the CPC Program. The aim of the pilot project was to create and validate simulation scenarios and assessment tools for potential incorporation into the CPC Program. Using the modified Delphi method, an expert panel of eight CRNAs evaluated the validity of four simulation scenarios and the content validity and reliability of four scenario-specific assessment tools. Each of the eight individual surveys assessing simulation scenario validity and assessment tool validity reached ≥ 75% agreement among the expert panelists. Overall content validity index values for the four assessment tools ranged from 0.960 to 0.993. There was a direct relationship between panelists' scores and level of performance on all returned assessment tools. The expert panel validated four simulation scenarios and four accompanying assessment tools. All scenarios and assessment tools were determined to have high content validity and reliability. Using these scenarios and assessment tools would provide unique advantages over standardized assessment methods.

Education for Registered Nurses Completing Preoperative Anesthesia Interviews: A Quality Improvement Project.

PURPOSE: This quality improvement project implemented job-related education for registered nurses (RNs) completing preoperative anesthesia interviews (PAIs) to increase their knowledge and confidence, improve completeness of documented preoperative interviews, and decrease day of surgery (DOS) cancellations. DESIGN: Pre/post implementation design and retrospective chart review. METHODS: An educational module on PAIs was created and RNs working in the pre-admission testing (PAT) clinic were asked to complete the module. Pre and post implementation data was collected on RN knowledge and confidence, assessment completeness, and DOS cancellations. FINDINGS: Knowledge and confidence increases were not statistically significant, although several interview components within PAI documentation improved with statistical significance. Overall DOS cancellations, although not statistically significant, were found to decrease, 1.3% to 1.2%. CONCLUSIONS: Registered nurses' knowledge, confidence and PAI completeness improved after completing the educational module with anesthetic considerations. Patients seen at the PAT clinic for PAIs before the DOS allowed for patient optimization and education leading to decreased preventable DOS cancellations.

Preoperative Preparation and Guidelines for Cannabis-Using Patients Undergoing Elective Surgery.

PURPOSE: Appropriate preoperative screening techniques are needed to safely provide anesthesia to increasing numbers of cannabis using surgical patients. DESIGN: This was a quasi-experimental quality improvement project. METHODS: Preoperative identification of cannabis users by registered nurses (RNs) and certified registered nurse anesthetists (CRNAs) was compared to baseline identification rates. CRNAs' compliance with evidenced base guidelines was recorded. Perioperative medication requirements were recorded and compared between cannabis-users and noncannabis users. FINDINGS: Identification of cannabis users by CRNAs conducting preanesthetic assessments increased from 4.08% to 14.36% while RN identification improved from 11.22% to 13.81%. Compliance with identification guidelines was 69.2% among CRNAs. There were no differences in anesthetic requirements, complications, or postanesthesia care unit (PACU) length of stay between cannabis users and nonusers. CONCLUSIONS: Preoperative identification of cannabis users allows for safer, more effective perioperative care by CRNAs, registered nurses, and surgical staff.

How do we improve blood product administration audit rates.

BACKGROUND: Failure to comply with institutional and national standards for blood product administration poses patient safety risks. Monitoring adherence to blood product administration policy is important for maintaining patient safety and ensuring regulatory agency compliance. STUDY DESIGN AND METHODS: This post-implementation quality improvement project evaluated an electronic paging system that was developed to facilitate perioperative blood product administration audits. RESULTS: Of the 57 audits conducted, 55 (96.5%) audits were fully completed. Anesthesia providers verified the patient name and medical record number (MRN) on the patient's armband with the product ID tag in 36.5% (n = 20) of audits. Anesthesia providers ensured the name and MRN on the armband matched the compatibility label on the blood product in 23% (n = 23) of audits. DISCUSSION: Ongoing surveillance of blood product administration practices is needed to monitor adherence to blood product administration policy, promote patient safety, and avoid imminent financial consequences from noncompliance to national regulatory standards.

Mobile Cricothyrotomy Simulation Cart Improves Anesthesia Providers' Confidence, Technical Skills, and Procedure Time.

Cricothyrotomy is an invasive airway used in "cannot intubate, cannot ventilate" events and can be taught using simulation. A mobile cricothyrotomy simulation for 66 anesthesia providers included an initial cricothyrotomy attempt (pretest), education, practice and feedback, and a second cricothyrotomy attempt (posttest). Provider confidence, skills, and procedure time were measured. Comparison of the posttest to the pretest showed significant improvement in: (a) provider confidence scores (Z = 7.01, P < .001), (b) technical skills (Global Rating Scale for Cricothyrotomy: Z = 7.05, P <.001; Checklist for Cricothyrotomy Performance: Z = 7.07, P < .001), and (c) procedure time (Z = 2.68, P = .007). The mobile cricothyrotomy simulation significantly improved anesthesia providers' confidence, cricothyrotomy skills, and procedure time.

Standardized Perioperative Note to Improve Perioperative Management of Patients With Cardiac Implantable Electronic Devices.

PURPOSE: Over 3 million people have a cardiac implantable electronic device (CIED) in the United States. Without an organization-wide, standardized approach to the perioperative management of patients with CIEDs, communication errors and subsequent periods of unintentional deactivation and management can leave patients vulnerable to untreated, life-threatening arrhythmias. The purpose of this quality improvement project was to refine the standardized approach for perioperative management of patients with CIEDs at a large academic medical center. DESIGN: A pre-post implementation design with two independent groups. METHODS: Patients with preexisting permanent CIEDs (n = 405) undergoing surgical and nonsurgical procedures with anesthesia were included. A preprocedure note was revised and implemented in the electronic health record for patients with CIEDs to include information about the device type, perioperative plan, and contact information for technical support. FINDINGS: When the preprocedure note was used, completion of the perioperative plan and contact information increased significantly (P < .001) and the number of undocumented interventions that occurred with CIEDs in the intraoperative period (magnet use, preoperative reprogramming, and postoperative reprogramming) was significantly reduced (P < .05). CONCLUSIONS: While documentation of the preprocedure note and intraoperative interventions increased, ongoing perioperative management improvements for patients with CIEDs are needed.

Creation and Implementation of a Preoperative Malignant Hyperthermia Screening Tool.

BACKGROUND: Malignant hyperthermia (MH) is a potentially lethal pharmacogenetic disorder triggered by certain anesthetic agents. There is currently no standardized preoperative screening tool utilized to identify MH-susceptible individuals. LOCAL PROBLEM: This quality improvement (QI) project aimed to enhance preoperative screening for MH susceptibility (MHS) by implementing an evidence-based screening tool for surgical patients at 2 sites. METHODS: This prospective descriptive QI project evaluated the success of implementing an MHS screening tool preoperatively and its impact on the anesthesia plan. INTERVENTIONS: Anesthesia professionals included the screening tool in their preoperative interview for surgical patients so that positively screened patients could receive MH prevention measures. RESULTS: A total of 95 patients at site A and 234 patients at site B were screened using the MH tool, a cumulative total of 21 patients were positively screened, and 1 anesthetic plan was altered. CONCLUSIONS: This MHS screening tool has the potential to prevent MH episodes when used consistently by staff.

Certified Registered Nurse Anesthetists' Adherence to an Intraoperative Lung Protective Ventilation Protocol.

The clinical application of intraoperative mechanical ventilation is highly variable and often determined by providers' attitudes and preferences, rather than evidence. Ventilation strategies using high tidal volumes (VT) with little to no positive end-expiratory pressure (PEEP) are associated with lung injury, increasing the risk of postoperative pulmonary complications. Literature demonstrates that applying lung protective ventilation (LPV) strategies intraoperatively, including low VT, individualized PEEP, and alveolar recruitment maneuvers, can reduce the risk of postoperative pulmonary complications. This multicenter quality improvement project aimed to develop and implement an LPV protocol to increase nurse anesthetists' knowledge and adherence to LPV strategies in adults undergoing laparoscopic cholecystectomy. The anesthesia providers were educated about LPV strategies and their intraoperative application to individualize ventilation settings based on patient comorbidities and body habitus. Adherence was determined by collecting ventilator data and evaluating the data using logistic regression. The overall protocol adherence significantly increased (P=.01). Additionally, there was a significant improvement in adherence to each individual component of the protocol (all P<.05) except for VT. Decreasing the oxygen concentration administered during maintenance and emergence was the most commonly adopted practice (P<.0001). This project demonstrates that education and a standardized protocol can increase the use of intraoperative LPV strategies.