Effect of a Cognitive Aid on Reducing Sugammadex Use and Associated Costs: A Time Series Analysis.

BACKGROUND: The authors observed increased pharmaceutical costs after the introduction of sugammadex in our institution. After a request to decrease sugammadex use, the authors implemented a cognitive aid to help choose between reversal agents. The purpose of this study was to determine if sugammadex use changed after cognitive aid implementation. The authors' hypothesis was that sugammadex use and associated costs would decrease. METHODS: A cognitive aid suggesting reversal agent doses based on train-of-four count was developed. It was included with each dispensed reversal agent set and in medication dispensing cabinet bins containing reversal agents. An interrupted time series analysis was performed using pharmaceutical invoices and anesthesia records. The primary outcome was the number of sugammadex administrations. Secondary outcomes included total pharmaceutical acquisition costs of neuromuscular blocking drugs and reversal agents, adverse respiratory events, emergence duration, and number of neuromuscular blocking drug administrations. RESULTS: Before cognitive aid implementation, the number of sugammadex administrations was increasing at a monthly rate of 20 per 1,000 general anesthetics (P < 0.001). Afterward, the monthly rate was 4 per 1,000 general anesthetics (P = 0.361). One month after cognitive aid implementation, the number of sugammadex administrations decreased by 281 per 1,000 general anesthetics (95% CI, 228 to 333, P < 0.001). In the final study month, there were 509 fewer sugammadex administrations than predicted per 1,000 general anesthetics (95% CI, 366 to 653; P < 0.0001), and total pharmaceutical acquisition costs per 1,000 general anesthetics were $11,947 less than predicted (95% CI, $4,043 to $19,851; P = 0.003). There was no significant change in adverse respiratory events, emergence duration, or administrations of rocuronium, vecuronium, or atracurium. In the final month, there were 75 more suxamethonium administrations than predicted per 1,000 general anesthetics (95% CI, 32 to 119; P = 0.0008). CONCLUSIONS: Cognitive aid implementation to choose between reversal agents was associated with a decrease in sugammadex use and acquisition costs.

[Digital technology in clinical surgery and rehabilitation]. / Tsifrovye tekhnologii v klinicheskoi khirurgii i reabilitatsii.

This article is devoted to a very actual and insufficiently imagine in the literature theme - innovation and digital technologies in clinical surgery and rehabilitation. AIM: To schow posibilities of modern digital and information technologies in clinical practice based on the experience of the Pirogov Center. MATERIAL AND METHODS: Analysis of experience in the application of innovative technologies, robotic surgery, intraoperative navigation computer, robotic systems in medical rehabilitation, integrated operating room, surgical video communication systems in service of those doing the Pirogov Center for the past 10 years. RESULTS: Shows the feasibility of the considered technologies in modern clinical practice clinics. CONCLUSION: The experience of the Pirogov Center indicates that the extensive use in clinical practice of modern health care facilities of the latest high-tech equipment in conjunction with the introduction of process automation and digital integrated technology management and medical-diagnostic activity is an essential reserve to increase the activity of providing specialized, including high-tech medical care, carrying out a variety of scientific and educational activities.

Descriptive study of case scheduling and cancellations within 1 week of the day of surgery.

BACKGROUND: We performed a descriptive study of operating room (OR) case scheduling within 1 week of the day of surgery. METHODS: The data used were from the case scheduling and transaction audit tables of a hospital's anesthesia and OR information management systems. Each change to a scheduled case in the OR information system was captured in an audit table, including the date and time when the change was made. The timestamps allowed reconstruction of the elective OR schedule for each date of surgery at preceding dates (e.g., 2 workdays ahead). The sample size was n = 17 consecutive 4-week periods. The allocated OR time, for each combination of service and day of the week, was the number of hours that minimized the inefficiency of use of OR time, a weighted combination of the hours of underutilized OR time and the more expensive hours of overutilized OR time. Data are reported as mean ±SE. RESULTS: (1) The percentage of OR date combinations with at least 1 add-on case was 24.1% ± 0.3%. The most recent addition of a case to an OR occurred 1 working day before surgery for 22.3% ± 0.4% of OR date combinations. At least half (51.5% ± 0.5%) of ORs had its last case scheduled or changed within 2 working days of surgery. In addition, when allocated OR time was filled and the service scheduled additional case(s), the median time ahead when each such case was scheduled was 2.2 ± 0.2 workdays. Thus, managers can productively focus on the day of surgery starting 2 working days before surgery. (2) Once allocated time was full, the ratio of the net additional cases scheduled to the total number performed was 1.2% ± 0.6%. However, 11.1% ± 1.7% of the total were additional cases. Thus, schedulers should rely on the allocated time to be predictive of the actual (net) workload that will occur in the future, on the day of surgery. (3) For service and day combinations for which 2 working days ahead the scheduled hours exceeded the allocated hours, there was no significant net increase in minutes of cases scheduled (P = 0.79), unlike when the scheduled hours were less than allocated (P < 0.0001). Thus, additional hours of cases scheduled within the same number of workdays are heterogeneous both within and among services based on the prior hours of cases scheduled. CONCLUSIONS: Planning anesthesia assignments, ORs to target, etc., can be done productively starting 2 working days ahead of surgery. There are so many changes to the OR schedule those last 2 workdays that anesthesia groups should be engaged with the scheduling office during that period. The primary predictor of additional net hours of cases to be scheduled is the difference between the allocated (i.e., forecasted) OR time and the hours scheduled so far.

Seguridad del paciente en el quirófano. Implantación del checklist en cirugía general / Patient safety in the operating room. Checklist implementation of general surgery

Objetivos: planificar, implementar y evaluar estrategias de implantación de Checklist en unos quirófanos de cirugía general y evaluación preliminar de la experiencia en opinión de los profesionales de enfermería. Metodología: implementación tecnológica y evaluación de la aplicación de un Checklist de formato similar al publicado por la OMS. El proceso se realizó en tres fases mediante estrategias de planificación, implementación y evaluación. Tras formar a los profesionales, diseñar la lista de comprobaciones en cada una de las fases, asignar a los responsables del chequeo y determinar la forma de registro, se aplicó durante 10 meses en un 68% de las intervenciones programadas y un 30% de las urgentes. Evaluación preliminar mediante técnicas cualitativas: análisis de los discursos de las enfermeras de quirófano que participaron en su aplicación y observación durante la misma. Conclusiones: la evaluación cualitativa es útil para conocer las actitudes, opiniones y dificultades de las enfermeras para la implantación de innovaciones que requieren la colaboración interdisciplinaria. La aplicación incrementa cargas de trabajo pero hace visibles algunas actividades. La amplia participación de las enfermeras revela su implicación para favorecer la seguridad del paciente, pero también las necesidades en su formación. Resulta imprescindible la concienciación de todos los profesionales para llevar a cabo el Checklist, que solo se podrá imponer si existe una cultura del cambio, innovación y seguridad y trabajo en equipo. Para que la comprobación no caiga en la rutina, sería recomendable efectuar una evaluación periódica. La lista debe ser clara, concisa y fiable(AU)

Objectives: To plan, implement and evaluate strategies for implementation of Checklist in a general surgery operating rooms and preliminary evaluation of the experience in view of the nurses. Methodology: Implementation and evaluation of technological application of a checklist format similar to that published by WHO. The process was conducted in three phases using strategies for planning, implementation and evaluation. After training the professionals, design the checklist at each stage, assign the responsibility of screening and determine how registration was applied for 10 months in 68% of planned interventions and 30% urgent. Preliminary evaluation using qualitative methods, discourse analysis of operating room nurses who participated in its implementation and monitoring during implementation. Conclusions: The qualitative assessment is useful to know the attitudes, opinions and problems of nurses for the implementation of innovations that require interdisciplinary collaboration The application workload increases, but makes visible some activities. The broad participation of nurses reveal their involvement to promote patient safety, but also their training needs. It is essential to the awareness of all professionals to carry out the checklist, which can only be imposed if there is a culture change, innovation and safety and teamwork. For the test does not fall into the routine, it would be wise to do a periodic evaluation. The list should be clear, concise and reliable(AU)

Manual editing of automatically recorded data in an anesthesia information management system.

BACKGROUND: Anesthesia information management systems allow automatic recording of physiologic and anesthetic data. The authors investigated the prevalence of such data modification in an academic medical center. METHODS: The authors queried their anesthesia information management system database of anesthetics performed in 2006 and tabulated the counts of data points for automatically recorded physiologic and anesthetic parameters as well as the subset of those data that were manually invalidated by clinicians (both with and without alternate values manually appended). Patient, practitioner, data source, and timing characteristics of recorded values were also extracted to determine their associations with editing of various parameters in the anesthesia information management system record. RESULTS: A total of 29,491 cases were analyzed, 19% of which had one or more data points manually invalidated. Among 58 attending anesthesiologists, each invalidated data in a median of 7% of their cases when working as a sole practitioner. A minority of invalidated values were manually appended with alternate values. Pulse rate, blood pressure, and pulse oximetry were the most commonly invalidated parameters. Data invalidation usually resulted in a decrease in parameter variance. Factors independently associated with invalidation included extreme physiologic values, American Society of Anesthesiologists physical status classification, emergency status, timing (phase of the procedure/anesthetic), presence of an intraarterial catheter, resident or certified registered nurse anesthetist involvement, and procedure duration. CONCLUSIONS: Editing of physiologic data automatically recorded in an anesthesia information management system is a common practice and results in decreased variability of intraoperative data. Further investigation may clarify the reasons for and consequences of this behavior.

Tactical increases in operating room block time based on financial data and market growth estimates from data envelopment analysis.

BACKGROUND: Data envelopment analysis (DEA) is an established technique that hospitals and anesthesia groups can use to understand their potential to grow different specialties of inpatient surgery. Often related decisions such as recruitment of new physicians are made promptly. A practical challenge in using DEA in practice for this application has been the time to obtain access to and preprocess discharge data from states. METHODS: A case study is presented to show how results of DEA are linked to financial analysis for purposes of deciding which surgical specialties should be provided more resources and institutional support, including the allocation of additional operating room (OR) block time on a tactical (1 yr) time course. State discharge abstract databases were used to study how to perform and present the DEA using data from websites of the United States' (US) Healthcare Cost and Utilization Project (HCUPNet) and Census Bureau (American FactFinder). RESULTS: DEA was performed without state discharge data by using census data with federal surgical rates adjusted for age and gender. Validity was assessed based on multiple criteria, including: satisfaction of statistical assumptions, face validity of results for hospitals, differentiation between efficient and inefficient hospitals on other measures of how much surgery is done, and correlation of estimates of each hospital's potential to grow the workload of each of eight specialties with estimates obtained using unrelated statistical methods. CONCLUSIONS: A hospital can choose specialties to target for expanded OR capacity based on its financial data, its caseloads for specific specialties, the caseloads from hospitals previously examined, and surgical rates from federal census data.

Disruptive visions.

A number of concepts have been advocated for the next generation operating room based on some inadequacies of the current systems. Most have focused on removing excess tubes and wiring, others on information systems or robotics. An analysis of other industries, a projected direction of current technologies, a focus on the importance of integrated information systems, and a serious consideration of emerging basic technologies suggest a significantly different approach.

Gestión clínica de la lista de espera en un servicio de cirugía general / Management of the hospital waiting list in a general surgery department

Introducción. Presentamos nuestra experiencia en la gestión clínica de la lista de espera del Servicio de Cirugía General del Hospital de Viladecans (hospital público del Institut Català de la Salut).Objetivos. Diseño de una base de datos para la gestión clínica de la lista de espera del servicio de cirugía general, y evaluación de los resultados tras su diseño y aplicación.Material y método. Base de datos creada a tal fin, y que recoge todos los pacientes incluidos en lista de espera para intervención quirúrgica electiva durante un período de 5 años (desde el 1 de enero de 1996 al 31 de diciembre de 2000).Resultados. El número de intervenciones quirúrgicas electivas año tras año se ha mantenido por debajo de la demanda, creando un déficit que equivaldría a incrementar nuestra actividad en un 23,8 por ciento para adecuarla a la demanda. La lista de espera para la cirugía electiva ha estado condicionada a la presión de urgencias, que ha ido progresivamente en aumento. El criterio establecido de prioridad se ha demostrado útil, habiendo operado el 60,8 por ciento de los pacientes preferentes antes de 3 meses, y el 65,2 por ciento de los pacientes no preferentes entre 3 y 9 meses.Conclusiones. 1) Existe un progresivo incremento de la demanda de servicios quirúrgicos en nuestra área de influencia. 2) Se ha logrado una mejor gestión clínica, con un progresivo descenso en el número de anulaciones y un incremento en la actividad quirúrgica. 3) Se ha reducido el número de reprogramaciones de un 32 a un 14,3 por ciento. 4). Calculamos un déficit de recursos (horas de quirófano) que equivaldría a un 23,8 por ciento de nuestra actividad quirúrgica actual para poder adecuarnos a la demanda. 5) La base de datos diseñada por nosotros ha demostrado ser un instrumento útil de gestión de nuestra lista de espera (AU)

Robotics and systems technology for advanced endoscopic procedures: experiences in general surgery.

The advent of endoscopic techniques changed surgery in many regards. This paper intends to describe an overview about technologies to facilitate endoscopic surgery. The systems described have been developed for the use in general surgery, but an easy application also in the field of cardiac surgery seems realistic. The introduction of system technology and robotic technology enables today to design a highly ergonomic solo-surgery platform. To relief the surgeon from fatigue we developed a new chair dedicated to the functional needs of endoscopic surgery. The foot pedals for high frequency, suction and irrigation are integrated into the basis of the chair. The chair is driven by electric motors controlled with an additional foot pedal joystick to achieve the desired position in the OR. A major enhancement for endoscopic technology is the introduction of robotic technology to design assisting devices for solo-surgery and manipulators for microsurgical instrumentation. A further step in the employment of robotic technology is the design of 'master-slave manipulators' to provide the surgeon with additional degrees of freedom of instrumentation. In 1996 a first prototype of an endoscopic manipulator system. named ARTEMIS, could be used in experimental applications. The system consists of a user station (master) and an instrument station (slave). The surgeon sits at a console which integrates endoscopic monitors, communication facilities and two master devices to control the two slave arms which are mounted to the operating table. Clinical use of the system, however, will require further development in the area of slave mechanics and the control system. Finally the implementation of telecommunication technology in combination with robotic instruments will open new frontiers, such as teleconsulting, teleassistance and telemanipulation.

Is there a future for minimally invasive cardiac surgery?

Although cardiac surgery has made significant contributions to the cardiac health of millions of patients over the past 40 years, it has evolved from an 'emerging growth' to a 'mature' industry. Along with this maturation has come an 'inertia of success' and lack of innovation. Minimally invasive cardiac surgery is an attempt to develop more patient friendly cardiac procedures yet maintain the superior long term results of conventional cardiac surgery. A broad spectrum of new surgical techniques and technical innovations has been fostered. The impact has been not only that of 'discontinuous innovation' of a new type of cardiac surgery but also a significant 'coat-tail' effect of 'upgrading' conventional cardiac surgery. It is difficult to adapt to change. But if we maintain an open-mindedness toward evolution with a firm foundation in proven standards, our patients will be the beneficiaries.

Operating room: 2010.

Using expert systems, virtual reality, and commercial and futuristic technology, visionary operating room (OR) nurses will have the opportunity in the 21st century to dramatically improve the way the OR functions. Eliminating counting, decreasing occurrences of patient injuries, and improving staff and patient education are just some of the possibilities!

Architecture and functional design of advanced neurosurgical operating environments.

Although modern operative neurosurgery is a complex technical undertaking requiring an amalgam of technologies and instrumentations, few reported efforts have dealt with the definition and development of suitable and optimal dedicated operating environments. This report presents the first detailed description of a dedicated, self-contained neurosurgical operating suite incorporating major surgical instrumentation and visualization technologies to provide an "idealized" environment for stereotactic, microscopic, and microstereotactic procedures. Advanced computer technology for visualization to augment, simulate, document, and facilitate all aspects of neurosurgery is described. The architectural and functional design of the operating suite is itself an integral surgical instrument as well as a laboratory for development of new dimensions of neurosurgery.

Advanced technology in the operating room.

Today's operating room is a high-tech environment. Minimally invasive procedures are fast becoming a standard for certain conditions. Lasers have taken their place as routine surgical tools in many specialties. On the horizon are new imaging technologies. If you are planning for new ORs, you'll want to consider the role of advanced technology in your new suite.