Challenges for Nurse Anesthetists Reentering Practice Following Substance Use Disorder Treatment.

Substance use disorder (SUD) is a persistent, relapsing condition that is present in approximately 10% of anesthesia providers, who, compared with other healthcare providers, face a greater risk of developing an SUD by virtue of constant access to medications. The ability of certified registered nurse anesthesiologists (CRNAs) to obtain or maintain employment after treatment for SUD treatment is not well documented. The purpose of this qualitative study was to explore challenges encountered by CRNAs in recovery as they attempt to reenter practice following SUD treatment. The phenomenon was explored through multiple-case study, using qualitative semistructured interviews with participants in four cases: CRNAs in recovery, CRNA colleagues, CRNA employers, and professional health program employees. Thirty-six participants conveyed their perspectives about challenges that CRNAs in recovery face upon reentry into practice following SUD treatment. The Worker Well-Being conceptual model was used to guide this study. The study revealed that more SUD education is a key facilitator for reentry, risk of relapse was a major concern, and stigma was the most significant barrier for CRNAs in recovery. Stigma persists as a considerable barrier in many facets of SUD, contributing to an increase in shame associated with having the disease.

The Perception and Use of Dexmedetomidine Among Anesthesia Providers: A Quality Improvement Project.

PURPOSE: Intraoperative opioid use is associated with postoperative nausea and vomiting, respiratory depression, and persistent postoperative pain, all of which contribute to increased length of stay and health care costs. Although research shows adding dexmedetomidine as an adjunct leads to reduced opioid-related postoperative complications, many anesthesia providers are not using this medication. The purpose of this quality improvement project was to increase the use of dexmedetomidine among anesthesia providers to improve outcomes among spinal and orthopedic surgery patients. DESIGN: Quality improvement study. METHODS: The project consisted of a preimplementation retrospective chart review, a preimplementation staff survey, the implementation of an anesthesia training bundle, a postimplementation staff survey, and a postimplementation retrospective chart review. The team provided ongoing support for the use of dexmedetomidine with resource flyers, a recorded presentation, and provider support. FINDINGS: Preimplementation surveys indicated staff readiness for change and identified the lack of availability of dexmedetomidine within the operating rooms as the barrier to use. After receiving education, staff requested dexmedetomidine to be stocked within every operating room. Utilization increased by 67% after the implementation of the anesthesia training bundle. CONCLUSIONS: While there was no significant change in opioid-related complications as is found in the literature, the project education and support led to anesthesia provider interest in using dexmedetomidine, resulting in a significant increase in use. Similar projects should include education for postanesthesia care nurses.

Assessing and Improving Provider Knowledge for a Cardiothoracic Intensive Care Unit Electronic Dashboard Initiative.

BACKGROUND: Electronic dashboards measure intensive care unit (ICU) performance by tracking quality indicators, especially pinpointing sub-standard metrics. This helps ICUs scrutinize and change current practices in an effort to improve failing metrics. However, its technological value is lost if end users are unaware of its importance. This results in decreased staff participation, leading to unsuccessful initiation of the dashboard. Therefore, the purpose of this project was to improve cardiothoracic ICU providers' understanding of electronic dashboards by providing an educational training bundle in preparation for an electronic dashboard initiation. METHODS: A Likert survey assessing providers' knowledge, attitudes, skills, and application of electronic dashboards was conducted. Subsequently, an educational training bundle, consisting of a digital flier and laminated pamphlets, was made available to providers for four months. After bundle review, providers were assessed using the same pre-bundle Likert survey. RESULTS: A comparison of summated scores from pre-bundle (mean = 38.75) and post-bundle surveys (mean = 46.13) yielded an increased summated score overall (mean = 7.38, p ≤ 0.001). CONCLUSION: An educational bundle improved providers' understanding and increased their likelihood of using electronic dashboards upon its initiation. Further studies are needed to continue increasing staff participation such as providing specific education to navigate the interface for data retrieval and interpretation.

Patient and Provider Satisfaction With Telehealth Preanesthesia Examinations.

PURPOSE: Telehealth has become commonplace in many healthcare systems across the United States. Due to the COVID-19 pandemic, a large academic medical center in the southeast USA has increased the use of telehealth in the anesthesia department to complete preanesthetic assessments before the patient's surgery. This has allowed high-risk patient populations to limit potential exposure to COVID-19 and limit the financial burden of traveling from neighboring counties to complete their preanesthetic assessment in person. The purpose of this quality improvement project was to evaluate the effectiveness of a preanesthetic assessment via telehealth among patients undergoing anesthesia. DESIGN: A quality improvement project. METHODS: Two separate surveys assessing patient and provider satisfaction with telehealth preanesthesia assessments were developed. Patients undergoing anesthesia at the medical center completed a telehealth preanesthesia assessment and received a satisfaction survey via email post-procedure. Certified registered nurse anesthetists (CRNAs) who cared for patients that completed a telehealth preanesthesia assessment also received an emailed satisfaction survey. FINDINGS: Results demonstrate high satisfaction scores for both patients and providers. CONCLUSIONS: Current telehealth preanesthetic assessments prompt high satisfaction scores, supporting continued, and expanded use.

Improving Obstuctive Sleep Apnea Care in the Postanesthesia Care Unit.

PURPOSE: The purpose of this quality improvement project was to improve care of obstructive sleep apnea (OSA) patients through increased staff recognition of OSA in the postanesthesia care unit (PACU). DESIGN: Retrospective chart review with implementation of best practice guideline form to front of patient's chart. METHODS: Baseline data were collected during June 2020. Staff education was provided on current hospital policy of OSA patients. Implementation of a care guideline sheet was added to the front of patient charts for patients meeting inclusion criteria; it consisted of continuous pulse oximetry, 30-degree head of bed elevation, continuous positive airway pressure (CPAP) therapy, 1 hour minimum postoperative observation, nonopioid analgesics, and referral to polysomnography. A retrospective chart review was performed following the OSA guideline intervention. FINDINGS: Both pre- (N = 413) and postintervention (N = 420) groups had statistically similar demographics. CPAP use increased from 16 to 22 (t = 0.890; P = .336). The number of patients experiencing dyspnea decreased from 10 to 8 (t = 0.263; P = .608). The number of patients experiencing acute respiratory events (AREs) decreased from 24 to 18 (t = 1.012; P = .314). CONCLUSION: There were no significant statistical findings. However, increased recognition of OSA patients by PACU staff can lead to improved care alterations.

Concept analysis of longitudinal assessment for professional continued certification.

BACKGROUND: This concept analysis presents a scholarly epistemological approach to defining the attributes, empirical referents, antecedents, and consequences of a knowledge maintenance approach-known as longitudinal assessment-to professional certification. AIM: The analysis reports on the efforts of the National Board of Certification and Recertification for Nurse Anesthetists to explore this educational method as an approach to meet requirements for continued professional certification. METHOD: Using the classical approach to concept analysis, the authors explore the structure and function of longitudinal assessment and define the characteristics of the concept in a way that is meaningful to the continued certification of nursing and medical professionals. CONCLUSION: This analysis establishes a link between the goal and outcome of the continued certification process, including continuing education in nursing and medical practice, and the desirable characteristics of longitudinal assessment, which include proven principles of educational psychology. Through exploring model and borderline cases, the authors seek to demonstrate that longitudinal assessment is the best approach to foster lifelong learning of continuously evolving scientific, theoretical, and clinical knowledge in support of safe care for patients.

Longitudinal assessment: A strategy to improve continuing professional certification.

Healthcare certification organizations carefully balance a commitment to bring value to their membership through programs that support lifelong learning and professional growth, while protecting the public by ensuring competent certified practitioners. These certifying bodies are challenged with remaining current with their maintenance of certification programs while keeping pace with the growing breadth of knowledge, industry standards and guidelines, innovative advances, and rapid technological gains in testing and assessment. Within the context of process innovation, the National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA) evaluated the current landscape of Longitudinal Assessment (LA) as a potential strategy for the assessment of core knowledge as part of their Continued Professional Certification Program for Certified Registered Nurse Anesthetists. This manuscript details the evaluation of LA using a Logic Model as the tool to scaffold inquiry, a review of LA literature, an environmental scan of current LA programs with identification of LA program elements available, and the results of a LA feasibility study. The findings substantiate that continued professional certification which incorporates a LA strategy can augment lifelong learning, but is not an assessment strategy that can be implemented without thoughtful planning, customization and continuous maintenance.

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.

The Psychometric Analysis of the Certified Registered Nurse Anesthetist Workload Perception Scale (CWPS): Final Phase.

BACKGROUND AND PURPOSE: In two previous studies, the Certified Registered Nurse Anesthetist (CRNA) Workload Perception Scale (CWPS) was developed. The purpose of this paper is to report the final psychometric validation of the CWPS. METHODS: An 11-item CWPS was tested in a population of CRNAs. Classical psychometrics were performed on the 11-item instrument piloted in a sample of 393 CRNAs. RESULTS: Parametric and nonparametric analysis indicated 7 of 11 items were a good fit to measure perception of workload. CONCLUSIONS: A revised 7-item final CWPS was developed.

Development of the University Postoperative Obstructive Sleep Apnea Protocol (UPOP).

PURPOSE: The purpose of this project was to retrospectively analyze medical records to determine the relationship between surgical patients with obstructive sleep apnea (OSA) risk factors and the occurrence of a critical respiratory event (CRE) in the postanesthesia care unit (PACU), and to subsequently develop a protocol for postoperative care. Although OSA is prevalent among the surgical population, research has primarily focused on preoperative identification and tailored perioperative care with limited application of standardized postoperative OSA management. DESIGN: Surgical charts were retrospectively reviewed between April 1, 2019 and June 31, 2019. Medical records were reviewed to identify surgical patients who had a diagnosis of OSA or two or more OSA risk factors. For patients who met initial inclusion, PACU charts were reviewed for the occurrence of a CRE while in PACU. Data analysis involved use of both Microsoft Excel 2011 and IBM SPSS Statistics Base, version 26. METHODS: Medical records were reviewed to identify patients in PACU who had two or more documented OSA risk factors (body mass index >35, snoring, alcohol use, diabetes mellitus [DM], hypertension [HTN], or male) or a diagnosis of OSA (n = 1,361). This sample was further refined to determine the patients who had a CRE (oxygen saturation less than 92%; respiratory rate less than 10, Modified Aldrete Respiratory Score of 1 and/or lesser) while in the PACU (n = 200). FINDINGS: There was a statistically significant relationship between one CRE in the PACU and a pre-existing diagnosis of HTN, DM, snoring, alcohol use, and male gender (P < .001 for each variable). There was a statistically significant difference in body mass index between patients who experienced a CRE and those who did not (P = .004). HTN and DM (n = 16) were associated with the highest occurrence of a CRE. CONCLUSIONS: The University Postoperative Obstructive Sleep Apnea Protocol was designed based on results and current evidence-based practice. Development of a postoperative OSA protocol will positively impact patient outcomes and may reduce health care expenditures. Next steps include protocol implementation and analysis.

Doctor of Nursing Practice Team Project Synthesis Form.

ABSTRACT: The importance of teamwork in health care, the need for doctorally prepared advanced practice nurses, and the nationwide faculty shortage provided the impetus for an educational tool to synthesize the doctor of nursing practice (DNP) project. Clearly outlining the stages of the DNP project in a concise manner, the DNP project synthesis form aids learners and faculty in organization and documentation of planning, implementation, and evaluation of the project and serves as a one-stop resource when students are completing semesters. This article delineates why one school of nursing developed a project synthesis form for use across all DNP programs.

The Psychometric Analysis of an Instrument to Measure the Perceived Workload for Certified Registered Nurse Anesthetists.

BACKGROUND AND PURPOSE: In a previous study, the CRNA Workload Perception Scale (CWPS) was developed. The purpose of this study was to investigate the psychometrics of the CWPS. METHODS: The CWPS was tested in a population of CRNAs. This study was conducted in two phases. Phase I consisted of classical psychometrics; the 12-item instrument was piloted in a sample of 265 CRNAs. Phase II consisted of qualitative analysis to provide feedback on items that did not perform well. RESULTS: Phase I: Instrument demonstrated good reliability (r = .77). Parametric and nonparametric analysis indicated 6 of 12 items were good fit to measure perception of workload. PHASE II: Qualitative analysis resulted in refinement of four items, addition of one item, and elimination of two items. CONCLUSIONS: A revised 11-item CWPS was developed.

Introduction of evolving roles of Japanese perianesthesia nurses.

The aim of this special article is to introduce Perianesthesia Nurses (PANs) who play an essential role in assisting anesthesiologists to ensure the safety of patients undergoing anesthesia and to improve the quality of anesthetic care. In Japan, there is no national license for nurse anesthesia providers. Therefore, most of the tasks related to anesthesia are performed by the anesthesiologists. Due to the size and complexity of the aging population, higher quality perioperative care is needed. In search of a solution, PANs were introduced to improve anesthetic care in Japan, enabling anesthesiologists to delegate some of their tasks to PANs who work within the scope of registered nurse's policies. They are a new type of anesthesia care provider in Japan, and different from Certified Registered Nurse Anesthetists in the United States. Currently, six schools provide 2-year master's degree perianesthesia nursing programs, and graduates are now providing anesthetic care both inside and outside of the operating room under the direct supervision of anesthesiologists. PANs not only assist anesthesiologists and help to reduce anesthesiologists' workload, but also contribute to the expansion of anesthesia services. They ensure patient safety and improve the quality of patient care before, during, and after the patient undergoing anesthesia.

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.

Barriers to Reentry Into Nurse Anesthesia Practice Following Substance Use Disorder Treatment: A Concept Analysis.

Nursing knowledge surrounding anesthesia providers' maintaining or obtaining employment after treatment of substance use disorder (SUD) is notably absent in the literature. An alternative method, dimensional analysis, allows for exploration of this concept from many perspectives, with social context as the basis from which to determine what barriers exist and how to prevail over them. Anesthesia practice is a socially constructed profession. The concept, barriers to reentry into nurse anesthesia practice, was explored and defined for purposes of identifying their impact on the recovering certified registered nurse anesthetist (CRNA). Defining the barriers places the CRNA one step closer to successful reentry into anesthesia practice.

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.

Use of a Novel Memory Aid to Educate Perioperative Team Members on Proper Patient Positioning Technique.

Interdisciplinary collaboration is key to safe surgical positioning. Although the surgical procedure dictates the patient's position, surgeons, anesthesia care providers, intraoperative nurses, and ancillary staff members must work together to achieve the goal of safe positioning. Correct patient positioning includes the provision of adequate access to the surgical site for the surgeon and surgical assistants. Surgical positions may put the patient at risk of injury. Understanding human anatomy, including the nerves commonly affected by each surgical position, can help the surgical team prevent accidental and irreversible patient injury. A lack of knowledge of proper positioning practices can result in serious patient injury, such as permanent paralysis, blindness, tissue necrosis, burns, bone fracture, and even death. This article reviews surgical positioning and introduces a learning module that involves the use of mnemonics as memory aids for perioperative team members who are learning proper positioning techniques.

Certified Registered Nurse Anesthetist Perceptions of Factors Impacting Patient Safety.

Certified registered nurse anesthetists (CRNAs) provide more than 40 million anesthetics each year in the United States. This article describes a study that investigates relationships among CRNA organizational structures (CRNA practice models, work setting, workload, level of education, work experience), CRNA ratings of patient safety culture, and CRNA adverse anesthesia-related event (ARE) reporting. This is a cross-sectional survey study of 336 CRNAs randomly selected from American Association of Nurse Anesthetists database. Workload was measured using NASA Task-Load Index and the Revised Individual Workload Perception Scale. Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Overall Perceptions of Safety Scale and Hospital Survey on Patient Safety Patient Safety Grade Scale were utilized to measure safety culture. Dependent variables (ARE) included difficult intubation/extubation, inadequate ventilation/oxygenation, and pulmonary aspiration. The Revised Individual Workload Perception Scale workload was significantly associated with ARE. Years' experience and Patient Safety Grade Scale were inversely associated with ARE. Overall Perceptions of Safety Scale was significantly and inversely associated with ARE. Practice model, education, and work setting were not associated with ARE. Based on findings, CRNA workload, years' experience, and patient safety culture may be important markers for ARE. Administrative interventions designed to upgrade patient safety culture and ensure manageable CRNA workload may foster quality patient care.

Tablet-based Interactive Distraction (TBID) vs oral midazolam to minimize perioperative anxiety in pediatric patients: a noninferiority randomized trial.

INTRODUCTION: Perioperative anxiety is a common and undesirable outcome in pediatric surgical patients. The use of interactive tools to minimize perioperative anxiety is vastly understudied. The main objective of the current investigation was to compare the effects of a tablet-based interactive distraction (TBID) tool to oral midazolam on perioperative anxiety. We hypothesized that the TBID tool was not inferior to midazolam to reduce perioperative anxiety. METHODS: 108 children, ages 1-11 years, presenting for outpatient surgical procedures were prospectively randomized to oral midazolam (0.5 mg·kg(-1); 20 mg max) or TBID. The primary outcome was the change in anxiety level from baseline to parental separation and anesthetic induction. Other data collected included emergence delirium, parental satisfaction, time-to-PACU discharge, and posthospitalization behavior. RESULTS: The mean difference (95% CI) in the increase of anxiety at parental separation between the TBID and the midazolam group was -9 (-2.6 to -16.4), P = 0.006, demonstrating superiority to midazolam group (one-sided P = 0.003). For children 2-11 years, the mean difference (95% CI) in anxiety at induction was significant between the TBID and midazolam groups, -14.0 (-6.1 to -22.0), P < 0.001. The median (IQR) time-to-PACU discharge was 111 (75-197) min in the midazolam group and 87 (55-137) min in the TBID group, P = 0.03. Decreased emergence delirium and increased parental satisfaction were also observed in the TBID group. CONCLUSIONS: A TBID tool reduces perioperative anxiety, emergence delirium, and time-to-discharge and increases parental satisfaction when compared to midazolam in pediatric patients undergoing ambulatory surgery.