Improving Emergency Cricothyroidotomies: Simulation-Based Training for Critical Care Providers.

This article discusses skill proficiency of providers related to emergency cricothyroidotomies. Various techniques to improve procedural skills were studied. Accurate identification of the cricothyroid membrane via palpation remained consistently inadequate. High-fidelity simulation including the use of human cadavers may be the preferred method of skill training for crisis management. The authors emphasize that additional research is needed regarding a method for rapid cricothyroid membrane identification as well as needle cricothyroidotomy versus surgical airway on cadavers. More consistent training will enable emergency care providers to perform this rare but lifesaving skill.

Use of Near-Infrared Spectroscopy to Measure Tissue Oxygen Saturation During Total Knee Arthroplasty With Use of a Tourniquet.

The primary purpose of this proof-of-concept quality improvement effort was to evaluate the practicality of using near-infrared spectroscopy (NIRS) to measure tissue oxygen saturation (Sto2) during total knee arthroplasty (TKA) with use of a tourniquet. NIRS sensors were applied to the biceps femoris (BF) and gastrocnemius (GS) muscles of both lower extremities of patients undergoing TKA procedures. For a convenience sample of 15 patients, measurement of Sto2 was attempted at baseline, following subarachnoid block administration, and after tourniquet inflation and deflation. Mean baseline Sto2 (SD) was 71% (6%) in the BF muscle and 66% (7%) in the GS muscle. Significant changes in Sto2 values were observed following subarachnoid block, tourniquet inflation, and tourniquet deflation. The Sto2 returned to or above baseline in the BF muscle but did not return to baseline in the GS muscle following tourniquet deflation. Changes in tissue oxygen saturation resulting from use of a tourniquet can be continuously monitored with the use of an NIRS device. Further evaluation of the use of NIRS should be undertaken to determine if it could be used to guide safe duration and pressure limits for tourniquet inflation.

A Quality Improvement Project to Increase Adherence to a Pain, Agitation, and Delirium Protocol in the Intensive Care Unit.

BACKGROUND: In recent years, the incidence of delirium has grown to epidemic proportions in the intensive care setting with up to 80% of mechanically ventilated patients being affected. This can lead to adverse patient outcomes such as increased lengths of hospital stay, increased mortality rates, and increased long-term cognitive impairment. OBJECTIVES: The objective of this project is to determine whether a quality improvement project can increase adherence to an existing pain, agitation, and delirium (PAD) protocol for enhanced patient outcomes. METHODS: Chart audits were conducted to determine baseline compliance, use of the PAD protocol was measured, and the type of medications administered to each mechanically ventilated patient was assessed. Using the Knowledge-to-Action framework, a multidisciplinary, multidimensional educational module was then developed and implemented that included an online tutorial, point-of-care reminders, written materials, and verbal coaching. A 3-month postimplementation chart audit was conducted to determine whether increased protocol competence was achieved. RESULTS: Protocol use unexpectedly decreased from 74% to 41% (P < .01);however, compliance with medication recommendations did increase despite the decrease in use. Intravenous opioid use increased from 12% to 40% (P ≤ .001), whereas sedative propofol infusions decreased from 82% to 35% (P ≤ .001). CONCLUSIONS: The implementation of a multidimensional, multidisciplinary project was successful in increasing compliance to the clinical practice guidelines for the management of PAD in adult intensive care unit patients, despite a decrease in protocol use. This unanticipated decrease in protocol use indicates the need for additional research in this area. Future recommendations also include a review of the existing PAD protocol to determine whether revisions could be made to better suit the needs of the staff while also improving patient outcomes in the arena of delirium experienced during critical care stays.

Virtual Orientation of Volunteer Short-Term International Health Teams to Increase Self-Confidence and Cultural and Global Health Competence.

International health team volunteers frequently arrive at service sites with considerable lack of confidence and knowledge gaps because of poor preparation. Preservice orientation has been shown to improve knowledge, confidence, and competence, but current practices fall short of meeting most needs. This health care improvement project was aimed to improve self-confidence and cultural and global health competence using a virtual preservice orientation format. The virtual innovation significantly narrowed the difference in confidence between new and experienced team members. Significant increases were observed in knowledge of global health and health equities for new and experienced team members. Following the orientation, a significant difference in global health skills for the entire team also was observed. Many Americans leave the United States annually attempting to help those in need. This effort is hindered by poor preparation and unreal expectations. Improving health team member confidence and competence is one way to address this concern. [J Contin Educ Nurs. 2019;50(1):35-40.].

Utilization of the STOP-Bang Questionnaire as a Standardized Screening Tool for Obstructive Sleep Apnea in Veteran Administration Surgical Patients.

PURPOSE: Obstructive sleep apnea (OSA) affects an estimated 20% of the adult surgical population. Veteran patients have many characteristics consistent with OSA, but lack of standardized screening results in decreased detection of patients at risk for OSA. DESIGN: Pre-post implementation design. METHODS: Preanesthesia clinic providers were educated about OSA and the STOP-Bang questionnaire. Chart reviews evaluating screening and patient demographics were conducted before and after intervention. FINDINGS: Thirty-one percent of patients had an established diagnosis of OSA. Compliance rates with preoperative STOP-Bang screening were 91.3%. Of patients screened preoperatively, 44% were at risk for OSA with a STOP-Bang score of 4 or greater. CONCLUSIONS: The prevalence of patients among the Veteran population with and at risk for OSA is higher than the general population. Utilization of the STOP-Bang questionnaire as a standardized preoperative screening tool in preanesthesia clinics can increase the identification of patients at risk for OSA.

Using the Electronic Medical Record to Improve Preoperative Identification of Patients at Risk for Obstructive Sleep Apnea.

PURPOSE: Obstructive sleep apnea (OSA) is a breathing disorder found in surgical patients and associated with complications in the postoperative period. The implementation of a preoperative universal screening process using the STOP-BANG questionnaire to identify patients at high risk for OSA provides opportunities for improved management. DESIGN: A pre-post design was used to evaluate screening compliance rates. METHODS: This initiative included staff education, which included the process for evaluating and documenting STOP-BANG scores. The data were collected via a chart review of the electronic medical record (EMR). FINDINGS: The rate of screening for OSA doubled after implementation of this initiative, and compliance with STOP-BANG questionnaire screening was 66.1%. High-risk designation in the EMR was 73.0%. Nearly half of the patients screened were found to be at high risk for OSA. CONCLUSIONS: Implementation of a universal screening initiative for patients and design for the EMR improves compliance with screening and identification of patients at high risk for OSA.