Perioperative quality indicators specific to the practice of anesthesia in noncardiac surgery: an umbrella review.

PURPOSE: Improvement in delivery of perioperative care depends on the ability to measure outcomes that can direct meaningful changes in practice. We sought to identify and provide an overview of perioperative quality indicators specific to the practice of anesthesia in noncardiac surgery. SOURCE: We conducted an umbrella review (a systematic review of systematic reviews) according to Joanna Briggs Institute methodology. We included systematic reviews examining perioperative indicators in patients ≥ 18 yr of age undergoing noncardiac surgery. Our primary outcome was any quality indicator specific to anesthesia. Indicators were classified by the Donabedian system and perioperative phase of care. The quality of systematic reviews was assessed using AMSTAR 2 criteria. Level of evidence of quality indicators was stratified by the Oxford Centre for Evidence-Based Medicine Classification. PRINCIPAL FINDINGS: Our search returned 1,475 studies. After removing duplicates and screening of abstracts and full texts, 23 systematic reviews encompassing 3,164 primary studies met our inclusion criteria. There were 330 unique quality indicators. Process indicators were most common (n = 169), followed by outcome (n = 114) and structure indicators (n = 47). Few identified indicators were supported by high-level evidence (45/330, 14%). Level 1 evidence supported indicators of antibiotic prophylaxis (1a), venous thromboembolism prophylaxis (1a), postoperative nausea/vomiting prophylaxis (1b), maintenance of normothermia (1a), and goal-directed fluid therapy (1b). CONCLUSION: This umbrella review highlights the scarcity of perioperative quality indicators that are supported by high quality evidence. Future development of quality indicators and recommendations for outcome measurement should focus on metrics that are supported by level 1 evidence. Potential targets for evidence-based quality-improvement programs in anesthesia are identified herein. STUDY REGISTRATION: PROSPERO (CRD42020164691); first registered 28 April 2020.

RéSUMé: OBJECTIF: L'amélioration de la prestation des soins périopératoires dépend de la capacité de mesurer les résultats qui peuvent orienter des changements significatifs dans la pratique. Nous avons cherché à identifier et à fournir une vue d'ensemble des indicateurs périopératoires de qualité spécifiques à la pratique de l'anesthésie en chirurgie non cardiaque. SOURCES: Nous avons mené une revue d'ensemble (une revue systématique des revues systématiques) selon la méthodologie de l'Institut Joanna Briggs. Nous avons inclus des revues systématiques examinant les indicateurs périopératoires chez les patient·es âgé·es de 18 ans ou plus bénéficiant d'une chirurgie non cardiaque. Notre critère d'évaluation principal était tout indicateur de qualité spécifique à l'anesthésie. Les indicateurs ont été classés en fonction du système de Donabedian et de la phase périopératoire des soins. La qualité des revues systématiques a été évaluée à l'aide des critères AMSTAR 2. Le niveau de donnée probante des indicateurs de qualité a été stratifié selon l'Oxford Centre for Evidence-Based Medicine Classification. CONSTATATIONS PRINCIPALES: Notre recherche a permis de trouver 1475 études. Après avoir éliminé les doublons et examiné les résumés et les textes intégraux, 23 revues systématiques englobant 3164 études primaires ont répondu à nos critères d'inclusion. Il y avait 330 indicateurs de qualité uniques. Les indicateurs de processus étaient les plus courants (n = 169), suivi des indicateurs de résultats (n = 114) et des indicateurs de structure (n = 47). Peu d'indicateurs identifiés étaient étayés par des données probantes de haut niveau (45/330, 14 %). Les données probantes de niveau 1 ont confirmé les indicateurs de l'antibioprophylaxie (1a), de la prophylaxie pour la thromboembolie veineuse (1a), de la prophylaxie postopératoire pour les nausées/vomissements (1b), du maintien de la normothermie (1a) et de la fluidothérapie ciblée (1b). CONCLUSION: Cet examen d'ensemble met en évidence la rareté des indicateurs périopératoires de qualité qui sont étayés par des données probantes de haute qualité. L'élaboration future d'indicateurs de qualité et de recommandations pour la mesure des résultats devrait être axée sur des paramètres étayés par des données probantes de niveau 1. Les cibles potentielles des programmes d'amélioration de la qualité de l'anesthésie fondés sur des données probantes sont identifiées dans le présent manuscrit. ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42020164691); premier enregistrement le 28 avril 2020.

Impact of Anesthetic Choice on Time to Discharge for Same-Day Discharge Joints.

BACKGROUND: As total joint arthroplasty programs continue to move towards same-day discharge (SDD), time to discharge is an increasingly important performance indicator. The primary objective of this study was to determine the impact of the choice of anesthetic on the time to discharge after SDD primary hip and knee arthroplasty. METHODS: A retrospective chart review was conducted within our SDD arthroplasty program, with 261 patients identified for analysis. Baseline characteristics, length of surgery, anesthetic drug, dose, and perioperative complications were extracted and recorded. The time from the patient leaving the operating room to physiotherapy assessment and from the operating room to discharge were recorded. These were referred to as ambulation time and discharge time, respectively. RESULTS: The ambulation time was significantly reduced when hypobaric lidocaine was used in a spinal block compared to isobaric or hyperbaric bupivacaine-135 minutes (range, 39 to 286), 305 minutes (range, 46 to 591), and 227 minutes (range, 77 to 387), respectively-(P < .0001). Similarly, the discharge time was also significantly lower with hypobaric lidocaine compared to isobaric bupivacaine, hyperbaric bupivacaine, and general anesthesia-276 minutes (range, 179 to 461), 426 minutes (range, 267 to 623), 375 minutes (range, 221 to 511), and 371 minutes (range, 217 to 570), respectively-(P < .0001). No cases of transient neurologic symptoms were reported. CONCLUSION: Patients receiving a hypobaric lidocaine spinal block experienced significantly reduced ambulation time and time to discharge compared to other anesthetics. Surgical teams should feel confident in using hypobaric lidocaine during spinal anesthesia as it is rapid and efficacious.

Identifying positive and negative use of non-technical skills by anesthesiologists in the clinical operating room: An exploratory descriptive study.

Background: Teamwork is a critical competency in high-risk settings like the operating room (OR). While conventional approaches focus on describing and learning from negative performance, there may be value in learning from high-performing behaviour, particularly in specialties where serious safety events are relatively rare. This study aimed to explore both the positive and negative use of non-technical skills by anesthesia practitioners in the OR and situate them within the clinical OR context. Methods: This study employed a prospective observational design. Following research ethics approval, a sample of surgical cases in a tertiary hospital were recorded using the OR Black Box®. Data related to surgical phase timing, non-technical skills, team factors, and environmental factors were identified by analysts according to a modified Systems Engineering Initiative for Patient Safety model. We performed descriptive statistics and qualitative description of these observations. Results: We observed 25 surgical cases capturing 242 instances of positive non-technical skills among anesthesiologists in the operating room and 9 instances of negative demonstrations. Situational awareness was most frequently (n = 160) observed, followed by communication and teamwork skills (n = 82), and were most often demonstrated in the context of potential environmental distractions (e.g., doors opening, unnecessary interruptions). The least common category of positive non-technical skills observed was leadership (n = 3). Conclusions: Our findings show anesthesiologists are doing a lot "right" and there may be many opportunities for learning from positive practice in the clinical setting. These findings can inform future work to better understand and standardize best practices for non-technical performance in anesthesia.

Accidental administration of tranexamic acid into the epidural space: a case report.

PURPOSE: Tranexamic acid administration into the epidural space has not been previously reported. We describe our experience managing and investigating a drug error involving incorrect route of tranexamic acid administration through an epidural catheter. CLINICAL FEATURES: A syringe containing tranexamic acid, intended for intravenous bolus and infusion intraoperatively using microbore tubing, was inadvertently attached to an epidural catheter via the Luer-type connector on the microbore tubing and epidural adapter. CONCLUSIONS: Saline lavage of the epidural space may be considered if tranexamic acid has been administered into the epidural space. Early multidisciplinary team involvement combined with repeated postevent neurologic monitoring is recommended to guide therapy. Adoption of neuraxial route-specific connectors, when available, may be warranted to reduce Luer-type misconnections.

RéSUMé: OBJECTIF: L'administration d'acide tranexamique dans l'espace péridural n'a pas été rapportée auparavant. Nous décrivons notre expérience de prise en charge et d'investigation d'une erreur médicamenteuse due à une erreur dans la voie d'administration d'acide tranexamique via un cathéter péridural. CARACTéRISTIQUES CLINIQUES: Une seringue contenant de l'acide tranexamique, destinée à l'administration peropératoire intraveineuse de bolus et de perfusion via des tubulures de microcalibre, a été fixée par inadvertance à un cathéter péridural via un connecteur de type Luer sur la tubulure de microcalibre et l'adaptateur péridural. CONCLUSION: Un lavage salin de l'espace péridural peut être envisagé si de l'acide tranexamique a été administré dans l'espace péridural. La participation rapide d'une équipe multidisciplinaire combinée à un monitorage neurologique répété après l'événement sont recommandés pour guider le traitement. L'adoption de connecteurs spécifiques à la voie neuraxiale, lorsqu'ils sont disponibles, pourrait être utile pour réduire les erreurs de connexion de type Luer.

Quality and patient safety committee structure and activities in an academic department of anesthesiology: a narrative description.

Quality and patient safety (QPS) activities continue to attract more attention and are deemed an essential component of care provision by all departments of anesthesiology, but examples of the structure and processes to manage QPS matters at the department level in Canada are not well described in the literature. This narrative article highlights the creation, structure, evolution, and experiences of a QPS committee in a Canadian department of anesthesiology and pain medicine. Specific focus and case examples of the QPS committee's use of a hospital-wide incident reporting system to monitor and respond to perioperative QPS matters are provided.

Change in staff anesthesiologists' opinions of an Anesthesia Information Management System (AIMS).

Following introduction of an Anesthesia Information Management System (AIMS) at a tertiary care, academic health sciences centre, a quality assurance initiative was conducted to assess staff opinions of the AIMS using a previously published, anonymous survey tool at 1 and 5 years following AIMS introduction. At 5 years compared to 1 year after implementation of AIMS, the majority (18 of 24, 75%) of responses to the survey questions had a statistically significant change (P < 0.05) in the proportion of respondents favoring AIMS compared to the 1 year survey. Domains noted to be more favorable 5 years compared to 1 year after AIMS introduction included patient safety in the Operating Rooms and Post-Anesthesia Care Unit, quality of handover and overall documentation, and communication amongst healthcare workers. The ideal time period at which to assess AIMS after introduction is not clear.