Survey of anesthesia department chairs about the environmental sustainability initiatives of their programs.

BACKGROUND: Anesthesia departments can reduce their environmental impact. Barriers exist to the promotion of individual anesthesiologists' roles in environmentally sustainable practices. We hypothesized that accountability of departmental leadership is associated with reports of practices that can encourage and sustain environmentally favorable practices. METHODS: Invitations to complete a six-question survey were sent to academic anesthesia department chairs in the United States and Canada. Questions were presented in random sequence. We assessed the association between the sum of the answers to five questions about department- and hospital-related sustainability activities (e.g., more than one "educational session dedicated to environmental sustainability … for anesthesiology residents or other trainees?") and the sixth question ("In the past 12 months, did review of the anesthesia department chair or review of your department include" more than one "item related to promotion of environmental sustainability?"). RESULTS: Of the 138 departments receiving invitation and reminder emails, 63 departments (46%) responded to our requests. The median (interquartile range) was 1 (0,3) sustainability activity for "No" items evaluating the department chair or department (N = 43) versus 4 (2, 4.5) activities for "Yes" evaluation of department chair or department (N = 20) (Wilcoxon-Mann-Whitney test, P = 0.0021; median regression, P = 0.0002). Results were similar for sensitivity analyses (excluding one question about hospital leadership, excluding the four responding Canadian departments, controlling for time to complete the survey, and controlling for the date of completion of the survey). CONCLUSIONS: Anesthesia department chairs and departments with annual performance evaluations that included items related to environmental sustainability reported more activities to promote sustainability. The result suggests that leadership-sponsored initiatives directed toward environmental sustainability are associated with environmental sustainability activities in anesthesia departments.

Association between an anesthesia department development program for junior faculty and long-term production of publications: A longitudinal cohort study.

BACKGROUND: An important mission of academic medical departments is to further the scholarship and education of its junior faculty. In 2013, Hindman et al. described the design and initial outcomes of a faculty development program for junior faculty at the University of Iowa Department of Anesthesia. In the current study, we reassessed whether the program increased the production of publications long-term. We included all department faculty, years before joining the department, and years after leaving the department, to control for the effects of simply being current faculty in the department, benefiting from its resources, and having had progressively more experience working. METHODS: The population studied was the faculty for any period between January 2006 and December 2022. The dependent variable was the count of publications in Scopus each year with the faculty member's Scopus identifier, 1996 through 2022. The two-year faculty development program included non-clinical time, two mentors, defined mentorship plan, didactic program, and financial support for clinical and/or laboratory studies. Statistical analyses were with logistic and Poisson random effect models for panel data, with standard errors estimated using jackknife resampling. RESULTS: Among the 128 distinct faculty in the department from 2006 through 2022, the 10% with the most publications per year accounted for 54% of the total annual publications. The two-year program was completed by 41% (53/128). Completion of the faculty development program was associated with a 17% absolute increase in the predicted marginal probability of one or more publications per year, from 25% to 41%. The 95% confidence interval for the 17% absolute increase was 9% to 24% (P < .0001). The predictive marginal effect of completing the program was 1.7 more publications per year per faculty (95% confidence interval 1.1 to 2.4, P < .0001). The estimate was also 1.7 more publications per year while limiting consideration to the 108 faculty who joined the department after 1996 and including as an independent variable the count of publications the year before joining the department. CONCLUSIONS: A faculty development program for junior faculty can reliably increase the production of publications in an anesthesiology department by at least one per year. However, there is considerable heterogeneity in publication production among faculty.

Implementation and evaluation of an event reporting system in an academic anaesthesia department.

BACKGROUND: Reporting adverse clinical events is essential to a culture of safety in healthcare. However, self-reporting such events is generally not widely prevalent in a typical academic anaesthesia department. METHODS: We set out to create a self-reporting tool to securely accept data from multiple anaesthesia service locations, including data linked to our electronic anaesthesia record, and combine them into an accessible database.We created a web-based database module for incident reporting integrated into the department's intranet. The system was also designed to actively prompt anaesthesia providers for reports following each day of clinical work. RESULTS: 478 events were recorded in the database in the first year of implementation. There were 33 347 anaesthesia encounters in that period, translating to a reporting rate of 1.43% (95% CI 1.31% to 1.57%). In the second year, which coincided with the second phase of implementation, 608 events were reported out of 45 985 anaesthesia encounters, for a reporting rate of 1.32% (95% CI 1.22% to 1.43%). Approximately 40% of events entered into the database occurred in a non-operating room location. The annual reporting rates for 2014, 2015, 2016, 2017, 2018 and 2019 were 1.26% (95% CI 1.16% to 1.37%), 1.15% (95% CI 1.05% to 1.25%), 1% (95% CI 0.9% to 1.1%), 0.6% (95% CI 0.53% to 0.68%), 0.5% (95% CI 0.44% to 0.57%), 0.4% (95% CI 0.3% to 0.5%), respectively. CONCLUSIONS: Our incident reporting system facilitated reporting of events within and outside the operating room. The system captured event data valid for quality improvement within the anaesthesia department.

Overall anesthesia department quality of clinical supervision of trainees over a year evaluated using mixed effects models.

BACKGROUND: Earlier studies of supervision in anesthesiology focused on how to evaluate the quality of individual anesthesiologist's clinical supervision of trainees. What is unknown is how to evaluate clinical supervision collectively, as provided by the department's faculty anesthesiologists. This information can be a metric that departments report annually or use to evaluate the effect of programs on the quality of clinical supervision over time. METHODS: This retrospective cohort study used all 48,788 evaluations of the 115 faculty anesthesiologists using the De Oliveira Filho supervision scale completed by 202 residents and fellows over nine academic years at one department. RESULTS: The distributions of mean scores among raters had marked negative skewness and were inconsistent with normal distributions. Consequently, accurate confidence intervals were impracticably wide, and their interpretation suggested lack of validity. In contrast, the logits of the proportions of scores equaling the maximum possible value, calculated for each rater, followed distributions sufficiently close to normal for statistically reliable use in random effects modeling. Parameters and confidence intervals were estimated using the intercept only random effects models, and then inverses computed to convert results from the logit scale to proportions. That approach is analogous to random effect meta-analysis of proportional incidence (or prevalence). Departments that chose to use semi-annual or annual surveys of trainees regarding supervision quality, and report those raw counts, will have far lower estimates of supervision quality versus when calculated accurately using daily evaluations of individual anesthesiologists. CONCLUSIONS: Random effects meta-analysis of percentage incidences of maximum scores is a suitable statistical approach to analyze the daily supervision scores of individual anesthesiologists to evaluate the overall quality of clinical supervision provided to the trainees by the department over a year.

Sepsis et choc septique en réanimation à Brazzaville (Congo) / Sepsis and septic shock in polyvalent intensive care at Brazzaville (Congo)

Objectifs. Décrire les aspects cliniques, bactériologiques et évolutifs du sepsis et du choc septique dans le service de réanimation polyvalente du CHUB. Patients et méthodes. Il s'agit d'une étude transversale, monocentrique et descriptive, durant 12 mois, incluant les patients âgés d'au moins 18 ans admis en réanimation polyvalente pour un sepsis ou choc septique. Les variables épidémiologiques, cliniques, bactériologiques et évolutives ont été analysées avec Excel 2019. Résultats. 56 patients ont été retenus (20,7%). Leur âge moyen était de 43,1 ± 17,9 ans (extrêmes de 18 et 84 ans), avec 66,1% des hommes. Le foyer infectieux initial était péritonéal (64,3 %). À l'admission, le nombre médian de défaillances d'organes par patient était de trois (maximum 5). Les défaillances rénale (71,4%), hépatique (69,6%) et hémodynamique (62,5%) étaient les plus représentées. Le taux de réalisation du bilan bactériologique était de 35,7% : hémoculture (10,7%), uroculture (14,3%), porte d'entrée infectieuse (7,1%). La durée d'hospitalisation des patients sortis vivants était de 8,1 ± 6,3 jours (extrêmes de 2 et 31 jours). Le taux de mortalité était de 57,1%. Les décès survenaient au-delà de 24 h d'hospitalisation (75%), chez des patients avec comorbidités (65,6%), porte d'entrée péritonéale (59,4%), et défaillances hémodynamique (81,2%) et rénale (75%). Conclusion. Les prévalences du sepsis et du choc septique dans notre série sont superposables à celles de la littérature. Le taux de réalisation des bilans bactériologiques reste faible. La mortalité du sepsis demeure très élevée.

Introduction. No accurate data on sepsis and septic shock in intensive care unit (ICU) in the Republic of Congo are available. The aim of the study was to describe the course of patients with sepsis and/or septic shock in the polyvalent ICU of the University Teaching Hospital of Brazzaville. Patients and methods. This was a cross-sectional, monocentric and descriptive study, lasting 12 months, including patients aged at least 18 years admitted to ICU for sepsis or septic shock. The clinical presentation, the bacteriological findings and the outcome were analyzed with Excel 2019. Results. 56 patients were selected (20.7%). The average age was 43.1 ± 17.9 years (extremes 18 and 84 years), with 66.1% of men. The initial infection was peritoneal (64.3%). At admission, the median number of organ failures per patient was three (maximum 5). Renal (71.4%), hepatic (69.6%) and hemodynamic (62.5%) failures were the most common. Bacteriological assessment rate was 35.7%: blood culture (10.7%), urine culture (14.3%). The duration of hospitalization of alive patients was 8.1 ± 6.3 days (extremes 2 and 31 days). The mortality rate was 57.1%. Deaths occurred beyond 24 hours of hospitalization (75%), in patients with comorbidities (65.6%), peritonitis (59.4%), hemodynamic (81.2%) and renal (75%) failures. Conclusion. The prevalence of sepsis and septic shock in our study is comparable to other published series. The bacteriological assessments rate is still low. The mortality is very high.

Assessment of Cost-awareness and Likelihood to Consider Costs for Postoperative Nausea and Vomiting Medications in a Military Anesthesia Department.

PURPOSE: To evaluate the impact of an informational presentation on acquisition cost-awareness and likelihood to consider acquisition costs for post-operative nausea and vomiting (PONV) medications among military anesthesia providers. DESIGN: A descriptive, longitudinal survey was conducted between March 9, 2020, and April 3, 2020. METHODS: Military anesthesia providers (n = 12) estimated the institutional acquisition costs of 9 PONV-related medications and rated their likelihood to consider costs before and after an informational presentation. FINDINGS: Nine paired surveys were completed and returned. After an informational presentation, providers significantly improved estimation accuracy for 4 medications and significantly increased the likelihood to consider costs. CONCLUSIONS: A survey evaluation highlighted deficiencies in acquisition cost-awareness and likelihood to consider acquisition costs for PONV medications among military anesthesia providers that improved after an informational presentation.

The Impact of a 22-Month Multistep Implementation Program on Speaking-Up Behavior in an Academic Anesthesia Department.

BACKGROUND: Speaking-up is a method of assertive communication that increases patient safety but often encounters barriers. Numerous studies describe programs introducing speaking-up with varying success; the common denominator seems to be the need for a multimodal and sustained approach to achieve the required change in behavior and culture for safer health care. METHODS: Before implementing a 22-month multistep program for establishing and strengthening speaking-up at our institution, we assessed perceived safety culture using the "Safety Attitudes Questionnaire." After program completion, participants completed parts of the same Safety Attitudes Questionnaire relevant to speaking-up, and preresult and postresult were compared. In addition, levels of speaking-up and assertive communication were compared with a Swiss benchmark using results from the "Speaking-up About Patient Safety Questionnaire." RESULTS: Safety Attitudes Questionnaire scores were significantly higher after program completion in 2 of 3 answered questions (median [first quartile, third quartile), 5.0 [4.0, 5.0] versus 4.0 [4.0, 5.0], P = 0.0002, and 5.0 [4.0, 5.0] versus 4.0 [4.0, 4.0] P = 0.002; n = 34). Our composite score on the Speaking-up About Patient Safety Questionnaire was significantly higher (mean ± SD, 5.9 ± 0.7 versus 5.2 ± 1.0; P < 0.001) than the benchmark (n = 65). CONCLUSIONS: A long-term multimodal program for speaking-up was successfully implemented. Attitude and climate toward safety generally improved, and postprogram perceived levels of assertive communication and speaking-up were higher than the benchmark. These results support current opinion that multimodal programs and continued effort are required, but that speaking-up can indeed be strengthened.

Understanding the Economic Impact of an Essential Service: Applying Time-Driven Activity-Based Costing to the Hospital Airway Response Team.

BACKGROUND: As the United States moves toward value-based care metrics, it will become essential for anesthesia groups nationwide to understand the costs of their services. Time-driven activity-based costing (TDABC) estimates the amount of time it takes to perform a clinical activity by dividing complex tasks into process steps and mapping each step and has historically been used to estimate the costs of various health care services. TDABC is a tool that can be adapted for variable staffing models and the volume of service provided. Anesthesia departments often provide staffing for airway response teams (ART). The economic implications of staffing ART have not been well described. We present a TDABC model for ART activation in a tertiary-care center to estimate the cost incurred by an anesthesiology department to staff an ART. METHODS: Pages received by the Brigham and Women's Hospital ART over a 24-month time period (January 2019 to December 2020) were analyzed and categorized. The local administrative database was queried for the Current Procedural Terminology (CPT) code used to bill for emergency airway placements. Sessions were held by multiple members of the ART to create process maps for the different types of ART activations. We estimated the staffing costs using the estimated time it took for each type of ART activation as well as the data collected for local ART activations. RESULTS: From the paging records, we analyzed 3368 activations of the ART. During the study period, 1044 airways were billed for with emergency airway CPT code. The average revenue collected per airway was $198.45 (95% CI, $190-$207). For STAT/Emergency airway team activations, process maps and non-STAT airway team activations were created, and third subprocess map was created for performing endotracheal intubation. Using the TDABC, the total staffing costs are estimated to be $218,601 for the 2-year study period. The ART generated $207,181 in revenue during the study period. CONCLUSIONS: Our analysis of ART-activation pages suggests that while the revenue generated may cover the cost of staffing the team during ART activations, it does not cover consumable equipment costs. Additionally, the current fee-for-service model relies on the team being able to perform other clinical duties in addition to covering the airway pager and would be impossible to capture using traditional top-down costing methods. By using TDABC, anesthesia groups can demonstrate how certain services, such as ART, are not fully covered by current reimbursement models and how to negotiate for subsidy agreements.As the transition from traditional fee-for-service payments to value-based care models continues in the United States, improving the understanding and communication of medical care costs will be essential. In the United States, it is common for anesthesia groups to receive direct revenue from hospitals to preserve financial viability, and therefore, knowledge of true cost is essential regardless of payer model.1 With traditional payment models, what is billable and nonbillable may not reflect either the need for or the cost of providing the service. As anesthesia departments navigate the transition of care from volume to value, actual costs will be essential to understand for negotiations with hospitals for support when services are nonbillable, when revenue from payers does not cover anesthesia costs, and when calculating the appropriate share for anesthesia departments when bundled payments are distributed.

Evaluation of the Duration of Preanesthesia Consultation: Prospective and Multicenter Study.

BACKGROUND: The time allocated to the preanesthesia consultation (PAC) of a patient undergoing an elective surgical procedure is an important factor to optimize consultation sessions. The main objective of this study was to build a model predictive of the duration of the PAC. METHODS: We prospectively studied 1007 patients undergoing a PAC from January 2016 to June 2018 in 4 different hospitals. A general linear model was fitted to predict the overall duration of the PAC. Secondary models predicted the time spent on clinical evaluation and the time assigned to delivering information. RESULTS: After exclusion of 40 patients with major data inconsistencies, the mean (standard deviation [SD]) overall duration of the PAC was 11.2 (5.8) minutes, split into 6.8 (4.1) minutes of information and 4.4 (2.7) minutes of clinical evaluation. It was, respectively, 11.4 (5.9), 6.9 (4.2), and 4.4 (2.7) in the 924 patients ≥16 years of age and, respectively, 8.3 (2.3), 4.3 (1.8), and 4.1 (1.8) in 43 children. The American Society of Anesthesiologists (ASA) score, the number of comorbidities or treatment, surgery discipline, and context (ambulatory, conventional hospitalization, and intensive care unit) were significantly correlated to PAC time. In the 924 adult patients, the models had an R2 adjusted for overfitting at 0.47 for the total duration of PAC, 0.45 for the clinical examination time, and 0.24 for the information time. The estimated residual standard deviations were, respectively, 4.3, 3.1, and 2.7 minutes. CONCLUSIONS: The predictive performances of the model explaining the overall duration of PAC were average (R2 = 0.47) and should be confirmed by further studies to use it for optimizing the organization of the consultation by individualizing the time dedicated to each consultation.

Anesthesia Management at Fuwai Hospital:Practice, Evidence and Outcomes.

Fuwai Hospital was established in 1956 and the Anesthesia Department of Fuwai Hospital was one of the earliest anesthesia departments then in China. Under the leadership of several department directors and with the concerted efforts of all generations of colleagues, the Anesthesia Department of Fuwai Hospital has dramatically transformed, upgraded and modernized. For more than six decades, the Anesthesia Department has been providing high-quality peri-operative anesthesia care for cardiovascular surgeries, conducting innovative experimental and clinical researches, and offering comprehensive training on cardiovascular anesthesiology for professionals across China. Currently, Fuwai Hospital is the National Center for Cardiovascular Diseases of China and one of the largest cardiovascular centers in the world. The present review introduces the Anesthesia Department of Fuwai Hospital, summarizes its current practice of anesthesia management, the outcomes of cardiovascular surgeries at Fuwai Hospital, accumulates relevant evidence, and provides prospects for future development of cardiovascular anesthesiology.

Impaired psychological well-being of healthcare workers in a German department of anesthesiology is independent of immediate SARS-CoV-2 exposure - a longitudinal observational study.

Background: The study aimed to assess the mental well-being of healthcare professionals at a German department of anesthesiology and critical care with a specialized ICU for treatment of COVID-19 patients during the first two peaks of the 2020 pandemic, and identifying risk and protective factors. Methods: A single-center longitudinal, online-based survey was conducted in healthcare workers from a department of anesthesiology and critical care in Bavaria, the most affected federal state in Germany at the time of assessment. Validated scores for depression, anxiety, somatic disorders, burnout, resilience, and self-management were used and complemented by questions about perceived COVID-19-related stressors. In parallel, patient characteristics in the ICU were collected. Results: 24 and 23 critically ill COVID-19 patients were treated during both observation periods in April/May and November/December 2020, respectively. 87.5% and 78.2% of patients had moderate to severe acute respiratory distress syndrome. From March 6, 2020 onwards, the hospital had switched to a command and control-based hospital incident command system (HICS) and increased work forces. Point prevalence of depression-like symptoms (13.6% and 12.8%) and burnout (21.6% and 17.4%) in the department's healthcare professionals was high. Exposure to SARS-CoV-2 did not increase psychological burden. Consequences of the lockdown were rated as highly distressing by a majority of all ICU personnel. High self-reported trait resilience was protective against signs of depression, generalized anxiety, and burnout. Conclusions: During the pandemic, healthcare professionals have been suffering from increased psychological distress compared to reference data for both the general population and ICU personnel. General effects of the lockdown appear more relevant than actual COVID-19 patient contact. High trait resilience has a protective effect, yet vulnerable individuals may require specific support. Prevention against potential after effects of the lockdown, and in particular measures allowing to avoid another lockdown, appear warranted.

Increasing the use of multimodal analgesia during adult surgery in a tertiary academic anaesthesia department.

OBJECTIVE: Multimodal analgesia pathways have been shown to reduce opioid use and side effects in surgical patients. A quality improvement initiative was implemented to increase the use of multimodal analgesia in adult patients presenting for general anaesthesia at an academic tertiary care centre. The aim of this study was to increase adoption of a perioperative multimodal analgesia protocol across a broad population of surgical patients. The use of multimodal analgesia was tracked as a process metric. Our primary outcome was opioid use normalised to oral morphine equivalents (OME) intraoperatively, in the postanaesthesia care unit (PACU), and 48 hours postoperatively. Pain scores and use of antiemetics were measured as balancing metrics. METHODS: We conducted a quality improvement study of a multimodal analgesia protocol implemented for adult (≥18 and≤70) non-transplant patients undergoing general anaesthesia (≥180 min). Components of multimodal analgesia were defined as (1) preoperative analgesic medication (acetaminophen, celecoxib, diclofenac, gabapentin), (2) regional anaesthesia (peripheral nerve block or catheter, epidural catheter or spinal) or (3) intraoperative analgesic medication (ketamine, ketorolac, lidocaine infusion, magnesium, acetaminophen, dexamethasone ≥8 mg, dexmedetomidine). We compared opioid use, pain scores and antiemetic use for patients 1 year before (baseline group-1 July 2018 to 30 June 2019) and 1 year after (implementation group-1 July 2019 to 30 June 2020) project implementation. RESULTS: Use of multimodal analgesia improved from 53.9% in the baseline group to 67.5% in the implementation group (p<0.001). There was no significant difference in intraoperative OME use before and after implementation (ß0=44.0, ß2=0.52, p=0.875). OME decreased after the project implementation in the PACU (ß0=34.4, ß2=-3.88, p<0.001) and 48 hours postoperatively (ß0=184.9, ß2=-22.59, p<0.001), while pain scores during those time points were similar. CONCLUSION: A perioperative pragmatic multimodal analgesic intervention was associated with reduced OME use in the PACU and 48 hours postoperatively.

Implementation of a Second Victim Peer Support Program in a Large Anesthesia Department.

The second victim phenomenon occurs when healthcare providers experience emotional or physical distress as a result of traumatic clinical events. Few hospitals have formalized peer support programs for second victims to navigate the postevent experience and offload associated emotional labor. This article describes the implementation of a second victim peer support program in a large academic anesthesiology practice, with the goal of augmenting emotional support for anesthesia providers. Program activations were tracked in a shared mailbox. Following peer support, second victims completed an evaluation assessing support received; trained peer supporters completed 2 evaluations assessing their comfort level and peer support encounters. From July 2018 to June 2020, ninety-one program activations (179 affected individuals) were made. A total of 130 peer support encounters were documented. Trained peer supporters were able to provide helpful support to affected colleagues nearly all (98.8%) of the time. Nearly 97% of second victims (25 of 31 evaluation respondents) reported the support as extremely or very beneficial, and 96.8% would recommend the program to colleagues. A second victim peer support program was successfully deployed in a large anesthesia department. This program was effective at a departmental level, fostering providers' well-being.

The anesthetizing sites supervised to anesthesiologist ratio is an invalid surrogate for group productivity in academic anesthesia departments when used without consideration of the corresponding managerial decisions.

When the anesthesiologist does not individually perform the anesthesia care, then to make valid comparisons among US anesthesia departments, one must consider the staffing ratio (i.e., how many cases each anesthesiologist supervises when working with Certified Registered Nurse Anesthetists [CRNAs] or Certified Anesthesiologist Assistants [CAA]). The staffing ratio also must be considered when accurately measuring group productivity. In this narrative review, we consider anesthesia departments with non-physician anesthesia providers and anesthesiology residents. We investigate the validity of such departments assessing the overall ratio of anesthetizing sites supervised per anesthesiologist as a surrogate for group clinical productivity. The sites/anesthesiologist ratio can be estimated accurately using the arithmetic mean calculated by anesthesiologist, the harmonic mean calculated by case, or the harmonic mean calculated by CRNA or CAA, but not by the arithmetic mean ratio by case. However, there is lack of validity to benchmarking the percentage time that anesthesiologists are supervising the maximum possible number of CRNAs or CAAs when some of the anesthesiologists also are supervising resident physicians. Assignments can differ in the total number anesthesiologists needed while every anesthesiologist is supervising as many sites as possible. Similarly, there is lack of validity to limiting assessment to the anesthesiologists supervising only CRNAs or CAAs. There also is lack of validity to limiting assessment only to cases performed by supervised CRNAs or CAAs. When cases can be assigned to anesthesiology residents or CRNAs or CAAs, increasing sites/anesthesiologist while limiting consideration to the CRNAs or CAAs creates incentive for the CRNAs or CAAs to be assigned cases, even when lesser productivity is the outcome. Decisions also can increase sites/anesthesiologist without increasing productivity (e.g., when one anesthesiologist relieves another before the end of the regular workday). A suitable alternative approach to fallaciously treating the sites/anesthesiologist ratio as a surrogate for productivity is that, when a teaching hospital supplies financial support, a responsibility of the anesthesia department is to explain annually the principal factors affecting productivity at each facility it manages and to show annually that decisions were made that maximized productivity, subject to the facilities' constraints.

Organizational aspects of pediatric anesthesia and surgery between two waves of Covid-19.

BACKGROUND: The initial wave of the Covid-19 pandemic has hit Italy, and Lombardy in particular, with violence, forcing to reshape all hospitals' activities; this happened even in pediatric hospitals, although the young population seemed initially spared from the disease. "Vittore Buzzi" Children's Hospital, which is a pediatric/maternal hospital located in Milan (Lombardy Region), had to stop elective procedures-with the exception of urgent/emergent ones-between February and May 2020 to leave space and resources to adults' care. We describe the challenges of reshaping the hospital's identity and structure, and restarting pediatric surgery and anesthesia, from May on, in the most hit area of the world, with the purpose to avoid and contain infections. Both patients and caregivers admitted to hospital have been tested for Sars-CoV-2 in every case. METHODS: Observational cohort study via review of clinical charts of patients undergoing surgery between 16th May and 30th September 2020, together with SARS-CoV -2 RT-PCR testing outcomes, and comparison to same period surgeries in 2019. RESULTS: An increase of approximately 70% in pediatric surgeries (OR 1.68 [1.33-2.13], P < .001) and a higher increase in the number of surgeries were reported (OR 1.75 (1.43-2.15), P < .001). Considering only urgent procedures, a significant difference in the distribution of the type of surgery was observed (Chi-squared P-value < .001). Sars-CoV-2-positive patients have been 0.8% of total number; 14% of these was discovered through caregiver's positivity. CONCLUSION: We describe our pathway for safe pediatric surgery and anesthesia and the importance of testing both patient and caregiver.

Implementing ERAS: how we achieved success within an anesthesia department.

BACKGROUND: The Massachusetts General Hospital is a large, quaternary care institution with 58 operating rooms, 164 anesthesiologists, 76 certified nurse anesthetists (CRNAs), an anesthesiology residency program that admits 25 residents annually, and 35 surgeons who perform laparoscopic, vaginal, and open hysterectomies. In March of 2018, our institution launched an Enhanced Recovery After Surgery (ERAS) pathway for patients undergoing hysterectomy. To implement the anesthesia bundle of this pathway, an intensive 14-month educational endeavor was created and put into effect. There were no subsequent additional educational interventions. METHODS: We retrospectively reviewed records of 2570 patients who underwent hysterectomy between October 2016 and March 2020 to determine adherence to the anesthesia bundle of the ERAS Hysterectomy pathway. RESULTS: Increased adherence to the four elements of the anesthesia bundle (p < 0.001) was achieved during the intervention period. Compliance with the pathway was sustained in the post-intervention period despite no additional actions. CONCLUSIONS: Implementing the anesthesia bundle of an ERAS pathway in a large anesthesia group with diverse providers successfully occurred using implementation science-based approach of intense interventions, and these results were maintained after the intervention ceased.