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1.
Curr Opin Anaesthesiol ; 32(4): 504-510, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31157626

RESUMO

PURPOSE OF REVIEW: To review the findings of National Transportation Safety Board-related aviation near misses and catastrophes and apply these principles to the nonoperating room anesthesia (NORA) suite. RECENT FINDINGS: NORA is a specialty that has seen tremendous growth. In 2019, NORA contributes to a larger proportion of anesthesia practice than ever before. With this growth, the NORA anesthesiologist and team are challenged to provide safe, high-quality care for more patients, often with complex comorbidities, and are forced to utilize deeper levels of sedation and anesthesia than ever before. These added pressures create new avenues for human error and adverse outcomes. SUMMARY: Safety in modern anesthesia practice often draws comparison to the aviation industry. From distinct preoperational checklists, defined courses of action, safety monitoring and the process of guiding individuals through a journey, there are many similarities between the practice of anesthesia and flying an airplane. Consistent human performance is paramount to creating safe outcomes. Although human errors are inevitable in any complex process, the goal for both the pilot and physician is to ensure the safety of their passengers and patients, respectively. As the aviation industry has had proven success at managing human error with a dramatic improvement in safety, a deeper look at several key examples will allow for comparisons of how to implement these strategies to improve NORA safety.


Assuntos
Anestesia/efeitos adversos , Anestesiologia/organização & administração , Aviação/organização & administração , Segurança do Paciente , Qualidade da Assistência à Saúde , Acidentes Aeronáuticos/prevenção & controle , Acidentes Aeronáuticos/estatística & dados numéricos , Anestesiologistas/organização & administração , Lista de Checagem , Humanos , Colaboração Intersetorial , Erros Médicos/prevenção & controle , Equipe de Assistência ao Paciente/organização & administração , Estados Unidos
2.
Curr Opin Anaesthesiol ; 32(2): 136-143, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30817385

RESUMO

PURPOSE OF REVIEW: Teaching in the stressful, high-acuity environment of the ICU is challenging. The intensivist-educator must use teaching strategies that are both effective and time-efficient, as well as evidence-based approaches to the ICU curriculum. This review provides an overview of pertinent educational theories and their implications on educational practices, a selection of effective teaching techniques, and a review on feedback. RECENT FINDINGS: Evidence supports the role of conceptual frameworks in providing the educator with a key perspective to obtain a deeper understanding of the factors contributing to an effective and goal-directed education in the ICU. The role of simulation training for technical and nontechnical skills acquisition is growing. Feedback is difficult to provide, but critical to facilitate learner success; frameworks, and approaches are becoming more standardized. SUMMARY: Direct teaching should be goal-oriented, sequential, and adjusted to the level of the learner. The ICU curriculum should optimize cognitive load, reduce stress that is unrelated to the activity, include resilience training, and help trainees deal with stressful clinical situations better. Simulation is a powerful tool to promote technical and nontechnical skills. Providing feedback is essential and a skill that can be taught and enhanced with structure, prompts, and tools.


Assuntos
Anestesiologia/educação , Medicina Baseada em Evidências/educação , Unidades de Terapia Intensiva/organização & administração , Internato e Residência/organização & administração , Ensino , Anestesiologistas/organização & administração , Anestesiologistas/psicologia , Competência Clínica , Currículo , Eficiência Organizacional , Metas , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Estresse Ocupacional/prevenção & controle , Estresse Ocupacional/psicologia , Resiliência Psicológica , Treinamento por Simulação/organização & administração , Treinamento por Simulação/tendências
3.
Anesth Analg ; 129(1): 294-300, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30855341

RESUMO

Inadequate access to anesthesia and surgical services is often considered to be a problem of low- and middle-income countries. However, affluent nations, including Canada, Australia, and the United States, also face shortages of anesthesia and surgical care in rural and remote communities. Inadequate services often disproportionately affect indigenous populations. A lack of anesthesia care providers has been identified as a major contributing factor to the shortfall of surgical and obstetrical care in rural and remote areas of these countries. This report summarizes the challenges facing the provision of anesthesia services in rural and remote regions. The current landscape of anesthesia providers and their training is described. We also explore innovative strategies and emerging technologies that could better support physician-led anesthesia care teams working in rural and remote areas. Ultimately, we believe that it is the responsibility of specialist anesthesiologists and academic health sciences centers to facilitate access to high-quality care through partnership with other stakeholders. Professional medical organizations also play an important role in ensuring the quality of care and continuing professional development. Enhanced collaboration between academic anesthesiologists and other stakeholders is required to meet the challenge issued by the World Health Organization to ensure access to essential anesthesia and surgical services for all.


Assuntos
Anestesia , Prestação Integrada de Cuidados de Saúde/organização & administração , Países Desenvolvidos , Acesso aos Serviços de Saúde/organização & administração , Disparidades em Assistência à Saúde/organização & administração , Segurança do Paciente , Serviços de Saúde Rural/organização & administração , Anestesia/efeitos adversos , Anestesia/economia , Anestesiologistas/organização & administração , Prestação Integrada de Cuidados de Saúde/economia , Países Desenvolvidos/economia , Acesso aos Serviços de Saúde/economia , Disparidades em Assistência à Saúde/economia , Humanos , Liderança , Equipe de Assistência ao Paciente/organização & administração , Segurança do Paciente/economia , Papel do Médico , Fatores de Risco , Serviços de Saúde Rural/economia
4.
BMC Anesthesiol ; 19(1): 19, 2019 01 31.
Artigo em Inglês | MEDLINE | ID: mdl-30704395

RESUMO

BACKGROUND: Extra Corporeal Membrane Oxygenation (ECMO) has become an accepted treatment option for severely ill patients. Due to a limited availability of ECMO support therapy, patients must often be transported to a specialised centre before or after cannulation. According to the ELSO guidelines, an ECMO specialist should be present for such interventions. Here we describe the safety and efficacy of a reduced team approach involving one anaesthesiologist, experienced in specialised intensive care medicine, and a specialised critical care nurse. METHODS: This study is a 10 years retrospective, single institution analysis of all data collected between January 2007 and December 2016 from the medical records at the University Hospital Bonn, Germany. RESULTS: The Bonner mobile ECMO team was deployed in 170 cases for on-site evaluation for ECMO support therapy. 4 (2.4%) patients died prior to arrival or during the implementation of ECMO support. Of the remaining 166 patients, 126 were cannulated at the referring site, 40 were transported without ECMO. Of those, 21 were subsequently cannulated out our centre. 19 patients never received ECMO treatment. The primary indication for ECMO treatment was ARDS (159/166 patients). Veno-venous ECMO was initiated in 137, whilst 10 patients received veno-arterial ECMO treatment. Mean transportation time was 75 ± 36 min, and mean transport distance was 56 ± 57 km. In total, 26 complications were observed, three being directly transport-related. The overall survival was 55%. CONCLUSIONS: Initiation of extracorporeal membrane oxygenation and subsequent transport can be safely and efficiently performed by a two-man team with good outcome.


Assuntos
Oxigenação por Membrana Extracorpórea/métodos , Equipe de Assistência ao Paciente/organização & administração , Transferência de Pacientes/organização & administração , Síndrome do Desconforto Respiratório do Adulto/terapia , Adolescente , Adulto , Idoso , Anestesiologistas/organização & administração , Estudos de Coortes , Feminino , Alemanha , Hospitais Universitários , Humanos , Masculino , Pessoa de Meia-Idade , Recursos Humanos de Enfermagem no Hospital/organização & administração , Estudos Retrospectivos , Adulto Jovem
5.
J Clin Anesth ; 53: 20-26, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30290278

RESUMO

STUDY OBJECTIVE: Switching from one specialty to another increases mean turnover times (i.e., interval between the exit and entrance of consecutive patients in an operating room [OR]). We estimate the effect on the mean tardiness of to-follow surgeons from following another surgeon of a different versus same specialty. Tardiness of a case's start time refers to the number of minutes the patient enters the OR later than scheduled; tardiness is 0 min if the patient enters early. Tardiness cause surgeon waiting. There are multiple causes of tardiness, but, most often, the preceding case(s) took longer than estimated. DESIGN: 10-year historical cohort study with all surgical cases performed during regular workdays. SETTING: Large teaching hospital. MEASUREMENTS: Estimated OR end times were calculated using a Bayesian method. Because tardiness is influenced by the estimated case start time (i.e., later starting cases have greater tardiness), tardiness values were adjusted to a 12 noon start time for the 2nd surgeon. MAIN RESULTS: The cases of to-follow surgeons in ORs had mean tardiness of 45.1 (SE 0.6) min. When the to-follow surgeon in the OR was of a different versus the same specialty from the first surgeon, the mean turnover time was 7.3 (0.4) min longer (P < 0.00001). However, the mean tardiness was not significantly affected (0.1 min, 95% confidence interval [CI] -2.7 to 3.0 min; P = 0.93). In comparison, if one or more of the preceding cases in an OR was an add-on case, the increase in mean tardiness was 35 min (95% CI 28 to 43 min; P < 0.00001). CONCLUSIONS: OR managers can assure surgeons with afternoon starts that following a surgeon of a different specialty generally will not increase their waiting time. Case scheduling should focus on reducing over-utilized OR time and thus the hours that anesthesiologists and nurses work late.


Assuntos
Salas Cirúrgicas/organização & administração , Admissão e Escalonamento de Pessoal , Cirurgiões/organização & administração , Recursos Humanos/organização & administração , Anestesiologistas/organização & administração , Estudos de Coortes , Hospitais de Ensino/organização & administração , Hospitais de Ensino/estatística & dados numéricos , Humanos , Enfermeiras e Enfermeiros/organização & administração , Salas Cirúrgicas/estatística & dados numéricos , Fatores de Tempo
6.
Int J Med Inform ; 121: 58-63, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30545490

RESUMO

INTRODUCTION: The pharmaceutical record system (PRS) is a French nationwide centralized electronic database shared among all community pharmacists listing all drugs dispensed by community pharmacists in the last four months. The objective of this study, the Medication Assessment Through Real time Information eXchange - Distributed Pharmaceutical Record System (MATRIX - DPRS) study, was to assess the clinical impact of the PRS upon granting access to physicians in three hospital specialties: anesthesiology, emergency medicine and geriatrics. MATERIAL AND METHODS: A multicenter prospective study was conducted in six hospital departments, two per specialty. Participating physicians noted medication information found exclusively in the pharmaceutical record (PR) of each patient unavailable elsewhere and any diagnostic or therapeutic management changes resulting from the PR information. The primary objective was to assess the proportion of diagnostic or therapeutic management changes attributable to the PR among patients who had an accessible PR. RESULTS: The inclusion level ranged from 1.1 to 30% in the six departments. The rate of diagnostic or therapeutic management changes was highest in geriatrics (n = 31/67; 46.3% 95% Confidence IntervaI (CI): 34.0-58.9%) and lowest in anesthesiology (n = 36/227; 15.9% 95% CI: 11.4-21.3%). Emergency medicine was intermediate (n = 5/22; 22.7% 95% CI: 7.8-45.4%). CONCLUSION: Although the inclusion rate and statistical precision were low, these findings suggest that the information contained in the PRS is useful and may result in modifying patient management in a sizeable proportion of patients. This opens the prospect of evaluating other hospital specialties, as well as primary and secondary care settings.


Assuntos
Acesso à Informação , Anestesiologistas/organização & administração , Registros Eletrônicos de Saúde/estatística & dados numéricos , Serviço Hospitalar de Emergência/organização & administração , Geriatras/organização & administração , Conduta do Tratamento Medicamentoso , Farmacêuticos/organização & administração , Padrões de Prática Médica/normas , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Adulto Jovem
7.
A A Pract ; 12(6): 193-195, 2019 Mar 15.
Artigo em Inglês | MEDLINE | ID: mdl-30169388

RESUMO

Urgent airway management is challenging because time constraints limit thorough evaluation and planning before endotracheal intubation. In this report, we describe a case in which an airway history review revealed extraordinarily complex airway anatomy that led to a decision not to attempt intubation in a man with end-stage chronic obstructive pulmonary disease. We emphasize the utility of reviewing history and imaging before attempted urgent intubation. We discuss the importance of a multidisciplinary approach that includes the patient, their family, and consultants when high-risk intubation is contemplated. The ethical role of the anesthesiologist is also discussed.


Assuntos
Manuseio das Vias Aéreas/métodos , Anestesiologistas/ética , Intubação Intratraqueal/métodos , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Manuseio das Vias Aéreas/ética , Anestesiologistas/organização & administração , Tomada de Decisão Clínica/ética , Humanos , Intubação Intratraqueal/ética , Masculino , Pessoa de Meia-Idade
10.
Semin Cardiothorac Vasc Anesth ; 22(4): 383-394, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30095030

RESUMO

The term "coronary artery anomalies" encompasses a large and heterogeneous group of disorders that may affect origin, intrinsic anatomy, course, location, and termination of the coronary arteries. With these different anatomies, presentation, symptoms, and outcomes are heterogeneous as well. While significant efforts are directed toward improving diagnosis and risk-stratification, best evidence-guided practices remain in evolution. Data about anesthetic management of patients with coronary anomalies are lacking as well. This review aims to provide the anesthesiologist with a better understanding of an important subgroup of coronary artery anomalies: anomalous aortic origin of a coronary artery. We will discuss classification, pathophysiology, incidence, evaluation, management, and anesthetic implications of this potentially fatal disease group.


Assuntos
Anestesia/métodos , Anestésicos/administração & dosagem , Anomalias dos Vasos Coronários/complicações , Anestesiologistas/organização & administração , Anestesiologia/métodos , Aorta/anormalidades , Anomalias dos Vasos Coronários/fisiopatologia , Humanos
11.
Can J Anaesth ; 65(11): 1196-1209, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30159716

RESUMO

PURPOSE: Audit and feedback can improve physicians' practice; however, the most effective type of feedback is unknown. Inadvertent perioperative hypothermia is associated with postoperative complications and remains common despite the use of effective and safe warming devices. This study aimed to measure the impact of targeted audit and feedback on anesthesiologists' intraoperative temperature management and subsequent patient outcomes. METHODS: This study was a three-arm cluster randomized-controlled trial. Anesthesiologists' intraoperative temperature management performance was analyzed in two phases. The first was a baseline phase with audit but no feedback for eight months, followed by an intervention phase over the next seven-month period after participants had received interventions according to their randomized group allocation of no feedback (control), benchmarked feedback, or ranked feedback. Anesthesiologists' percentage of hypothermic patients at the end of surgery (primary endpoint) and use of a warming device were compared among the groups. RESULTS: Forty-five attending anesthesiologists who took care of 7,846 patients over 15 months were included. The odds of hypothermia (temperature < 36°C at the end of surgery) increased significantly from pre- to post-intervention in the control and ranked groups (control odds ratio [OR], 1.27; 95% confidence interval [CI], 1.03 to 1.56; P = 0.02; ranked OR, 1.26; 95% CI, 1.01 to 1.56; P = 0.04) but not in the benchmarked group (OR, 1.05; 95% CI, 0.87 to 1.28; P = 0.58). Between-arm differences in pre- to post-intervention changes were not significant (benchmark vs control OR, 0.83; 95% CI, 0.62 to 1.10; P = 0.19; ranked vs control OR, 0.99; 95% CI, 0.73 to 1.33, P = 0.94). No significant overall effect on intraoperative warmer use change was detected. CONCLUSION: We found no evidence to suggest that audit and feedback, using benchmarked or ranked feedback, is more effective than no feedback at all to change anesthesiologists' intraoperative temperature management performance. Feedback may need to be included in a bundle to produce its effect. TRIALS REGISTRATION: www.clinicaltrials.gov (NCT02414191). Registered 19 March 2015.


Assuntos
Anestesiologistas/organização & administração , Retroalimentação , Hipotermia/prevenção & controle , Cuidados Intraoperatórios/métodos , Adulto , Idoso , Benchmarking , Temperatura Corporal/fisiologia , Análise por Conglomerados , Feminino , Humanos , Hipotermia/epidemiologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Padrões de Prática Médica/normas , Reaquecimento/métodos
12.
J Surg Res ; 228: 281-289, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29907223

RESUMO

BACKGROUND: Emergency general surgery (EGS) is characterized by high rates of morbidity and mortality. Though checklists and associated communication-based huddle strategies have improved outcomes, these tools have never been specifically examined in EGS. We hypothesized that use of an evidence-based communication tool aimed to trigger intraoperative discussion could improve communication in the EGS operating room (OR). MATERIALS AND METHODS: We designed a set of discussion prompts based on modifiable factors identified from previously published studies aimed to encourage all team members to speak up and to centralize awareness of patient disposition and intraoperative transfusion practices. This tool was pilot-tested using OR human patient simulators and was then rolled out to EGS ORs at an academic medical center. The perceived effect of our tool's implementation was evaluated through mixed-methodologic presurvey and postsurvey analysis. RESULTS: Preimplementation and postimplementation survey-based data revealed that providers reported the EGS-focused discussion prompts as improving team communication in EGS. A trend toward shared awareness of intraoperative events was observed; however, nurses described cultural impedance of discussion initiation. Providers described a need for further reinforcement of the tool and its indications during implementation. CONCLUSIONS: Use of a discussion-based communication tool is perceived as supporting team communication in the EGS OR and led to a trend toward improving a shared understanding of intraoperative events. Analyses suggest the need for enhanced reinforcement of use during implementation and improvement of team-based education regarding EGS. Furthermore work is needed to understand the full impact of this evidence-based tool on OR team dynamics and EGS patient outcomes.


Assuntos
Comunicação , Medicina Baseada em Evidências/métodos , Cuidados Intraoperatórios/métodos , Salas Cirúrgicas/organização & administração , Equipe de Assistência ao Paciente/organização & administração , Anestesiologistas/organização & administração , Anestesiologistas/psicologia , Conscientização , Tratamento de Emergência/métodos , Humanos , Enfermeiras e Enfermeiros/organização & administração , Enfermeiras e Enfermeiros/psicologia , Projetos Piloto , Cirurgiões/organização & administração , Cirurgiões/psicologia
15.
Curr Opin Anaesthesiol ; 31(4): 439-445, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29794854

RESUMO

PURPOSE OF REVIEW: After decades without substantial advances, multiple novel antidepressants show promise against treatment-resistant depression. Interestingly, many of these are anesthetics. The purpose of this review is to discuss the evidence for the antidepressant effects of ketamine, nitrous oxide, isoflurane and propofol and to consider potential clinical, administrative and research implications for anesthesiologists. RECENT FINDINGS: Ketamine has acute, transient antidepressant and antisuicidal effects. Nitrous oxide has also shown antidepressant efficacy. There are converging preclinical and clinical data that isoflurane (and perhaps propofol), dosed to burst suppression, has relatively rapid, robust and durable antidepressant effects and lacks the adverse effects associated with electroconvulsive therapy (ECT). SUMMARY: Several anesthetics show promise as novel antidepressants. Ketamine is the most well studied. Anesthetic-induced burst-suppression may provide an alternative to ECT that lacks adverse cognitive effects. Further study is necessary to better understand how these drugs work and how they might be used as effective antidepressant therapy.


Assuntos
Anestésicos/uso terapêutico , Antidepressivos/uso terapêutico , Córtex Cerebral/efeitos dos fármacos , Transtorno Depressivo Resistente a Tratamento/terapia , Anestesiologistas/organização & administração , Anestésicos/farmacologia , Antidepressivos/farmacologia , Córtex Cerebral/fisiopatologia , Transtorno Depressivo Resistente a Tratamento/epidemiologia , Transtorno Depressivo Resistente a Tratamento/fisiopatologia , Eletroconvulsoterapia/efeitos adversos , Eletroconvulsoterapia/estatística & dados numéricos , Humanos , Isoflurano/farmacologia , Isoflurano/uso terapêutico , Ketamina/farmacologia , Ketamina/uso terapêutico , Óxido Nitroso/farmacologia , Óxido Nitroso/uso terapêutico , Seleção de Pacientes , Prevalência , Papel Profissional , Propofol/farmacologia , Propofol/uso terapêutico , Resultado do Tratamento
16.
Curr Opin Anaesthesiol ; 31(4): 492-497, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29771695

RESUMO

PURPOSE OF REVIEW: Nonoperating room anesthesia (NORA) and procedural services often are associated with dispersed geographic settings and small volumes of cases. These lead to scheduling challenges that, if not managed well, result in decreased patient and healthcare team satisfaction and reduced efficiency. This review describes recent studies and provides examples on how NORA scheduling issues have been addressed. RECENT FINDINGS: Increased use of blocked time for consolidated NORA services can lead to sufficiently large volumes of cases that allow improved scheduling and maintain patient and healthcare team satisfaction and better efficiency of care. In general, patients and proceduralists find that service blocks offered at least once every 2 weeks are acceptable. With the ability to perform the full scope of perioperative practices such as preoperative assessment and postoperative management, anesthesiologists are well positioned to lead NORA services. There is a rising expectation for both graduate medical education experiences and continuing education in quality improvement for NORA services. SUMMARY: Many factors play a role in successful scheduling of NORA services. Increasing consolidation of services, the use of block scheduling, and leadership by anesthesiologists can help improve patient and healthcare team satisfaction and practice efficiencies.


Assuntos
Anestesia/métodos , Anestesiologistas/organização & administração , Anestesiologia/organização & administração , Agendamento de Consultas , Melhoria de Qualidade , Anestesia/economia , Análise Custo-Benefício , Humanos , Liderança , Equipe de Assistência ao Paciente/organização & administração
17.
Semin Cardiothorac Vasc Anesth ; 22(4): 345-352, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29514558

RESUMO

BACKGROUND: The Perioperative Surgical Home (PSH) is an anesthesiologist-led, coordinated care model that may improve patient experience and safety. We hypothesized that PSH will decrease activation of the rapid response system for surgical inpatients. METHODS: This retrospective study was performed at an academic Veterans Affairs hospital with a PSH. Data from both medical and surgical cohorts admitted to a single ward were analyzed for the Pre-PSH (July 2006 to October 2010) and Post-PSH (November 2011 to May 2015) epochs. The primary outcome was incidence of rapid response team (RRT) activations per 1000 bed-days. RESULTS: Surgical patients had 5.8 RRT activations per 1000 bed-days Pre-PSH versus 3.7/1000 bed-days Post-PSH ( P = .006). There was no difference in RRT activations per 1000 bed-days for medical patients before and after PSH implementation. Pre-PSH was an independent predictor of mortality in the multivariable model (odds ratio = 1.7; P = .010). CONCLUSION: PSH is associated with decreased RRT activations among surgical inpatients only.


Assuntos
Anestesiologistas/organização & administração , Assistência Centrada no Paciente/organização & administração , Assistência Perioperatória/métodos , Cuidados Pós-Operatórios/métodos , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Mortalidade Hospitalar , Hospitalização , Hospitais de Veteranos , Humanos , Pacientes Internados , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Ressuscitação/estatística & dados numéricos , Estudos Retrospectivos , Provedores de Redes de Segurança/organização & administração
18.
Int J Health Care Qual Assur ; 31(2): 150-161, 2018 Mar 12.
Artigo em Inglês | MEDLINE | ID: mdl-29504875

RESUMO

Purpose The purpose of this paper is to increase efficiency in ORs without affecting quality of care by improving the workflow processes. Administrative processes independent of the surgical act can be challenging and may lead to clinical impacts such as increasing delays. The authors hypothesized that a Lean project could improve efficiency of surgical processes by reducing the length of stays in the recovery ward. Design/methodology/approach Two similar Lean projects were performed in the surgery departments of two hospitals of the Centre Hospitalier Universitaire de Québec: Hôtel Dieu de Quebec (HDQ) and Hôpital de l'Enfant Jesus (HEJ). The HDQ project designed around a Define, Measure, Analyse, Improve and Control process revision and a Kaizen workshop focused on patients who were hospitalized in a specific care unit after surgery and the HEJ project targeted patients in a post-operative ambulatory context. The recovery ward output delay was measured retrospectively before and after project. Findings For the HDQ Lean project, wasted time in the recovery ward was reduced by 62 minutes (68 percent reduction) between the two groups. The authors also observed an increase of about 25 percent of all admissions made in the daytime after the project compared to the time period before the project. For the HEJ Lean project, time passed in the recovery ward was reduced by 6 min (29 percent reduction). Originality/value These projects produced an improvement in the flow of the OR without targeting clinical practices in the OR itself. They demonstrated that change in administrative processes can have a great impact on the flow of clinical pathways and highlight the need for comprehensive and precise monitoring of every step of the elective surgery patient trajectory.


Assuntos
Eficiência Organizacional , Salas Cirúrgicas/organização & administração , Melhoria de Qualidade/organização & administração , Sala de Recuperação/organização & administração , Fluxo de Trabalho , Idoso , Anestesiologistas/organização & administração , Comunicação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recursos Humanos de Enfermagem no Hospital/organização & administração , Admissão do Paciente , Quebeque , Estudos Retrospectivos , Fatores de Tempo
19.
Can J Anaesth ; 65(1): 60-75, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-29086358

RESUMO

There is increased interest in the perioperative management of patients with sleep-disordered breathing (SDB). Anesthesiologists must distill information from clinical reports to make key decisions for optimizing perioperative care. A patient with SDB may present with a sleep study report at the time of surgery. Knowledge of the essential components of such a report can help the anesthesiologist evaluate the patient and optimize the perioperative management. In this narrative review, we describe how level I (i.e., laboratory-based) polysomnography (PSG) data are collected and scored using the recommended scoring guidelines, as well as the basic information and salient features of a typical PSG report relevant to the anesthesiologist. In addition, we briefly review the indications for sleep studies, including the types of laboratory-based studies, as well as the role and limitations of portable monitors (level II-IV studies) and examples of PSG reports in the clinical context.


Assuntos
Anestesiologia/métodos , Assistência Perioperatória/métodos , Síndromes da Apneia do Sono/fisiopatologia , Anestesiologistas/organização & administração , Humanos , Polissonografia/métodos , Síndromes da Apneia do Sono/diagnóstico
20.
Eur J Cardiothorac Surg ; 53(5): 973-979, 2018 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-29228138

RESUMO

OBJECTIVES: Accurate risk assessments are particularly important for elderly patients being considered for lobectomy. Considering the positive effects of the thoracoscopic approach on postoperative outcomes, we sought to review the reliability of the established risk factors for elderly patients undergoing thoracoscopic lobectomy. METHODS: From January 2009 to March 2016, 441 patients in our institution underwent thoracoscopic lobectomy for early-stage lung cancer. Clinical outcomes were compared between elderly (>70 years, n = 176) and younger patients (n = 265). RESULTS: There was no significant difference in postoperative mortality and morbidity between elderly and younger patients. In the regression analyses restricted to elderly patients, American Society of Anesthesiologists physical status (ASA-PS) was the single strong predictor of postoperative morbidity. The odds of pulmonary and cardiopulmonary complications increased nearly 6- and 3-fold, respectively, in those with ASA-PS Grade 3 compared with patients with ASA-PS Grade <3. Additionally, male gender was found to have a possible causal effect of pulmonary complication in elderly patients. After confounder adjustment using propensity score matching, the generalized linear mixed model revealed more than an 8-fold increase in the odds of pulmonary complications in elderly men compared with elderly women. To check the robustness of the above-mentioned finding, inverse probability of treatment weighting was used as an alternative analysis indicating a weaker but still substantively significant effect of male gender, with an odds ratio >3. CONCLUSIONS: Our results suggest that ASA-PS is a strong predictor of morbidity among elderly patients considered for thoracoscopic lobectomy. Compared with elderly women, elderly men are particularly prone to postoperative pulmonary complications.


Assuntos
Neoplasias Pulmonares , Pneumonectomia , Complicações Pós-Operatórias/epidemiologia , Medição de Risco/métodos , Toracoscopia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Anestesiologistas/organização & administração , Feminino , Humanos , Pulmão/cirurgia , Neoplasias Pulmonares/epidemiologia , Neoplasias Pulmonares/fisiopatologia , Neoplasias Pulmonares/cirurgia , Masculino , Pessoa de Meia-Idade , Pneumonectomia/efeitos adversos , Pneumonectomia/mortalidade , Guias de Prática Clínica como Assunto , Estudos Retrospectivos , Fatores de Risco , Toracoscopia/efeitos adversos , Toracoscopia/mortalidade
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