Implementation of a Postoperative Electronic Health Record Alert for Cardiac Implantable Electronic Device Patients.

PURPOSE: Approximately 2% of surgical patients have an existing cardiac implantable electronic device (CIED). Perioperative device reprogramming requires postoperative care to ensure that device settings are restored. Electronic health record (EHR) alerts have been shown to improve communication between providers and decrease time to necessary interventions in other areas of medicine. The aim of this quality improvement project was to create an EHR alert for postoperative CIED patients who require device reprogramming to help clinicians track, remember, and document the timely and safe restoration of device settings. DESIGN: This project used a pre-post observational design. METHODS: This project was conducted at a major academic medical center using a pre-post observational design. To prevent anesthesia providers from closing an encounter in the EHR before postoperative restoration of device settings, an alert was developed and embedded within the intraoperative EHR to track preoperative device reprogramming, and alert anesthesia providers to perform and document postoperative restoration of safe settings. FINDINGS: The postimplementation group (n = 272) had fewer unknown or undocumented preoperative CIED interventions (12.9% vs 30.9%), a 7.3% shorter device suspension time (median = 165 minutes vs 178 minutes), 6.8% improvement in documentation of postoperative re-enabling of device therapies (78.8% vs 72.0%), and a 72.48% decrease in length of stay (median = 625 hours vs 172 hours) when compared with the preimplementation group (n = 132). CONCLUSION: Electronic prompts effectively captured patients who received preoperative CIED reprogramming and provided a process for reprogramming devices to safe settings, both significant steps in preventing negative patient outcomes associated with undocumented CIED interventions. Perioperative CIED documentation improved, and length of stay decreased after project implementation.

Implementation of a Multimodal Analgesia Protocol Among Outpatient Neurosurgical Patients Undergoing Spine Surgery to Improve Patient Outcomes.

PURPOSE: This quality improvement project implemented an evidence-based multimodal analgesia protocol among patients undergoing outpatient spine surgery in an attempt to decrease postoperative opioid requirements, postoperative pain scores, and facility and postanesthesia care unit length of stay (LOS). DESIGN: Two independent samples were compared with a preimplementation and postimplementation design. There were 37 patients in the preimplementation group and 36 patients in the postimplementation group. METHODS: Data were collected by a retrospective chart review of neurosurgical patients undergoing spine surgery and included postoperative opioid requirements, postoperative pain scores, facility and postanesthesia care unit LOS, and the number of protocol components implemented on each patient. FINDINGS: Intraoperative and postoperative by mouth opioid requirements were significantly decreased postimplementation. Postoperative opioid requirements decreased, and postimplementation pain scores were reduced across all time points. LOS did not significantly change. CONCLUSIONS: This multimodal analgesia protocol significantly decreased opioid consumption among neurosurgical patients at this surgery center.

Fast-Tracking Patients in an Academic Hospital to Increase Efficiency and Decrease Discharge Delays: A Process Improvement Plan.

PURPOSE: The purpose of this quality improvement project was to determine if implementing a Phase II postanesthesia care unit (PACU II) to fast-track patients following surgery in an academic hospital would decrease OR hold times and increase patient flow efficiency. DESIGN: An observational pre-post design was used to compare PACU bypass rates and recovery times for ambulatory surgery (AS) patients before and after implementation of a patient fast-tracking program. METHODS: A PACU II was instituted and a fast-tracking program using the White Fast-Track Scoring tool was adopted. Nursing staff as well as anesthesia providers were educated to assess patients using the tool as well as the appropriate patient population to be transferred to the new PACU II. FINDINGS: Following implementation of the new unit and the fast-tracking program, a PACU bypass rate of 30% was achieved and there was a significant decrease in PACU length of stay for AS patients. CONCLUSIONS: The results suggest that fast-tracking is a suitable intervention to decrease inefficiencies in an academic setting despite higher acuity patient populations.

A deep learning approach to student registered nurse anesthetist (SRNA) education.

OBJECTIVES: This manuscript describes the application of deep learning to physiology education of Student Registered Nurse Anesthetists (SRNA) and the benefits thereof. A strong foundation in physiology and the ability to apply this knowledge to challenging clinical situations is crucial to the successful SRNA. Deep learning, a well-studied pedagogical technique, facilitates development and long-term retention of a mental knowledge framework that can be applied to complex problems. Deep learning requires the educator to facilitate the development of critical thinking and students to actively learn and take responsibility for gaining knowledge and skills. METHODS: We applied the deep learning approach, including flipped classroom and problem-based learning, and surveyed SRNA students (n=127) about their learning experience. RESULTS: Survey responses showed that the majority of students favored the deep learning approach and thought it advanced their critical thinking skills. CONCLUSIONS: SRNAs reported that their physiology knowledge base and critical thinking benefited from the use of the deep learning strategy.

Using Simulation With Deliberate Practice to Improve Pediatric ICU Nurses' Knowledge, Clinical Teamwork, and Confidence.

PURPOSE: The purpose of this quality improvement project was to implement an educational intervention involving High-Fidelity Simulation (HFS) with deliberate practice for low-frequency, high-impact events in a Pediatric Intensive Care Unit (PICU), with the goal of improving nurses' crisis management skills. DESIGN AND METHODS: Four interprofessional simulation education sessions with scenarios were created for this project. A list of knowledge and skills points was used to guide debriefings. All scenarios were based on low-frequency, high-impact events that required the use of Pediatric Advanced Life Support algorithms. Participants included 24 PICU nurses with less than two years of nursing experience. Knowledge and confidence were measured at three timepoints: pre-simulation, one-week post-simulation, and one-month post-simulation series. Clinical teamwork performance was measured twice, during the first and second scenario of each simulation session. RESULTS: Scores for knowledge, confidence, and clinical teamwork performance improved from pre- to post-simulation, with confidence scores showing the largest increase. CONCLUSIONS: Regular simulation training with deliberate practice can improve PICU nurses' knowledge, clinical teamwork skills, and confidence when managing low-frequency, high-impact events. PRACTICE IMPLICATIONS: Regular in-situ simulation training with deliberate practice can improve nursing comfort with managing high-impact, low-frequency events in the PICU. This could lead to improved management of actual events, especially for novice nurses with less than one year of PICU experience.

Usability Assessment of an Electronic Handoff Tool to Facilitate and Improve Postoperative Communication Between Anesthesia and Intensive Care Unit Staff.

The handoff or handover is the exchange of pertinent medical information from one provider to another. Inadequate handoff communication between healthcare providers can negatively impact patient outcomes. In an effort to improve handoff communication, many studies have developed and evaluated the use of a handoff tool such as a handoff checklist or handoff form to facilitate handoff communication. Recently, the use of the IPASS handoff form, based on the mnemonic for the process, has been associated with a reduction in the rate of adverse events and improvement in information transfer and nurse satisfaction. This quality improvement project adapted the IPASS handoff form for postoperative use in an iterative approach over a series of four phases: (1) requirements/information gathering, (2) adaptation/development, (3) evaluation and modification, and (4) usability testing. Results of this project show that participants viewed the postoperative IPASS handoff form to be easy to use (87.5%), satisfactory (75.0%), and user-friendly (75.0%), which can facilitate its widespread adoption. The key feature identified in making the handoff form user-friendly was its customization feature, which allowed the handoff report to be shortened or expanded to meet the provider- or unit-specific needs.

Integrating the STOP-Bang Questionnaire Into the Preanesthetic Assessment at a Military Hospital.

PURPOSE: This quality improvement project integrated the STOP-Bang (Snoring, Tiredness, Observed apnea, Blood Pressure, Body Mass Index, Age, Neck circumference, male Gender) questionnaire into the preanesthetic assessment to identify patients at risk for obstructive sleep apnea (OSA), decrease postanesthesia care unit (PACU) length of stay (LOS), and decrease unanticipated admissions. DESIGN: This is an observational pre/post design and retrospective chart review. METHODS: Registered nurses assessed STOP-Bang scores among patients seen in the preanesthesia clinic and documented scores in the electronic health record. After PACU discharge, the electronic health record was reviewed for OSA risk stratification, PACU LOS, and unanticipated admissions. FINDINGS: Forty-eight percent of patients screened were identified as intermediate or high risk. No difference existed between preimplementation and postimplementation PACU times (P = .767). No unanticipated admissions were identified during either period. CONCLUSIONS: The STOP-Bang questionnaire increased identification of surgical patients at risk for OSA but did not affect PACU LOS or unanticipated admissions.

Pulmonary Artery Catheters: Impact of e-Learning on Hemodynamic Assessments.

Pulmonary artery catheters (PACs) are invasive devices placed in critically ill patients to monitor hemodynamic data. They are a high-risk, and in some settings a low-volume, medical device due to the complex insertion procedure and potentially lethal complications. Smaller intensive care units (ICUs) have large variances in exposure to PACs, therefore strengthening ICU nurses' belief in their ability to manage these hemodynamic monitoring devices is of utmost importance. The design is a single-group, pre/posttest study conducted on a 15-bed ICU to survey nurses' self-efficacy, knowledge, and satisfaction of an e-learning educational module. Both PAC and noninvasive cardiac output monitor patient application data were collected prior to and following the intervention. Fifteen ICU nurses completed all components of the module. Confidence in ability to accurately interpret hemodynamic data increased from pre- to postintervention (P < .001), and knowledge also increased from pre- to postintervention, albeit not statistically significantly (P = .088). Overall, nurses reported satisfaction with the educational module. With increased self-efficacy, nurses can feel empowered and motivated to further improve patient care management. Thus, workplaces should continue to advocate for additional educational tools for high-risk, low-volume devices.

Improving Emergency Airway Knowledge and Self-Efficacy Levels of Outpatient Gastroenterology Staff via Implementation of Online Education and In Situ Simulation.

Twenty percent of all ambulatory surgery cases utilizing monitored anesthesia care and sedation report at least one perioperative respiratory complication such as bronchospasm, hypoxia, laryngospasm, or aspiration (). However, the national Standards of Practice for both surgical technicians and ambulatory care nurses do not mandate emergency airway education beyond cardiopulmonary resuscitation and Basic Life Support training. A local outpatient gastroenterology clinic noticed the gap in education, and the anesthesia team decided to implement an evidence-based dual-factorial quality improvement project utilizing online education and in situ simulation. First, registered nurses and procedural technologists completed a test to assess their baseline knowledge and airway emergency performance self-efficacy levels. Then an online module was distributed that included information on the 3 most common anesthesia airway emergencies in the outpatient setting: laryngospasm, aspiration, and obstruction with resultant hypoxemia. Next, participants completed an in situ simulation of the 3 airway emergencies using low-fidelity mannequins. A post-education assessment was distributed after completion of the simulation training and again at 6 weeks and 3 months post-implementation. The data collected showed a statistically significant increase in both knowledge scores and levels of self-efficacy at 6 weeks and 3 months posteducation (p < .001).

Reducing Preventable Surgical Cancellations: Improving the Preoperative Anesthesia Interview Process.

PURPOSE: Thorough and accurate preoperative anesthesia interviews may help improve perioperative efficiency by reducing unnecessary preoperative testing and preventable surgical cancellations, both of which create financial burdens. Standardized anesthesia preoperative interview guidelines and online educational modules for registered nurses (RNs) conducting preoperative interviews may improve this process. DESIGN: Predesign and postdesign, retrospective chart review. METHODS: Online educational modules and standardized preoperative anesthesia interview guidelines were developed for RNs conducting preoperative interviews. A retrospective chart review compared preoperative anesthesia interview record completion rates, compliance with laboratory testing, and the total number of preventable surgical cancellations. FINDINGS: Documentation of preoperative anesthesia interview records increased, whereas unnecessary preoperative testing decreased, neither with statistical significance. Preventable cancellation rates decreased significantly from 34.3% to 20% (P < .5) contributing to a 3-month postimplementation cost savings of approximately $30,000. CONCLUSIONS: A standardized preoperative anesthesia interview guideline and online anesthesia educational modules for RNs conducting preoperative anesthesia interviews improved preoperative record completion rates, reduced unnecessary laboratory testing, and averted surgical cancellations.

Administration of Oral Acetaminophen to Reduce Costs for the Hysterectomy Patient at a Community Hospital.

PURPOSE: This quality improvement project aimed to change the practice of administration route of acetaminophen from intravenous (IV) to oral to patients having a hysterectomy at a community hospital, reduce costs, and maintain postanesthesia care unit pain scores for patients who receive oral acetaminophen comparable to those who receive IV acetaminophen. DESIGN: There were 46 participants: 23 in the preintervention group and 23 in the postintervention group. METHODS: Data retrieved from the electronic medical record included the route of acetaminophen administered, cost, and pain scores. FINDINGS: Implementation of this quality improvement project resulted in no difference in the pain scores between the preintervention and postintervention groups (P = .637). In addition, the hospital cost for acetaminophen decreased 95.25% and patients saved $6,683 during the 3-month implementation period. CONCLUSIONS: The administration of oral acetaminophen provided equivalent postoperative analgesia compared with IV acetaminophen and reduced costs for both the hospital and patients.

Preoperative Risk Assessment to Guide Prophylaxis and Reduce the Incidence of Postoperative Nausea and Vomiting.

PURPOSE: This article describes the implementation of a postoperative nausea and vomiting (PONV) risk prediction and prophylaxis protocol. DESIGN: This is a retrospective pre/post implementation quality improvement project. METHODS: This project used chart reviews to assess the impact of the implemented PONV assessment and prophylaxis in a sample population of adult females undergoing gynecologic surgical procedures. FINDINGS: The mean number of prophylactic antiemetics administered significantly increased during the postimplementation period from 3.64 (SD, 0.878) in the preimplementation period to 4.07 (SD, 1.021) in the postimplementation period (P < .001). The greatest increase in antiemetic administration occurred in the moderate-risk (risk score, 4) and the high-risk (risk score, 5 to 6) groups. The incidence of PONV decreased from 32.3% in the preimplementation period to 28.9% in the postimplementation period; however, this reduction did not meet statistical significance. Antiemetic administration compliance increased from 37% in the preimplementation group to 61% in the postimplementation group (P < .001). CONCLUSIONS: The results of this project suggest that a risk-tailored approach to PONV prophylaxis using a risk assessment tool along with treatment recommendations is effective at reducing the incidence of PONV. The effectiveness of this approach is limited by the involvement of the anesthesia providers responsible for completing the assessments and administering PONV prophylaxis.

Implementation of Vulnerable Elders Survey-13 Frailty Tool to Identify At-Risk Geriatric Surgical Patients.

PURPOSE: The primary purpose of this project was to preoperatively identify frail and vulnerable geriatric patients aged 65 or older using the Vulnerable Elders Survey (VES-13) tool, and to use those scores to assist with perioperative decision-making. DESIGN: This feasibility study was implemented as a quality improvement initiative with a postimplementation group only. METHODS: The VES-13 was introduced to the perioperative nursing staff and anesthesia providers and then added to the traditional preoperative assessment. The VES-13 scores were correlated to hospital length of stay, postanesthesia care unit stay, altered mental status, and morbidity. FINDINGS: Increased identification of older adult surgical patients at risk for increased length of stay, altered mental status, and morbidity in the preoperative setting was not evident, although the VES-13 was effective in identifying functional deficits in the older adult surgical patient. CONCLUSIONS: A detailed and comprehensive preoperative assessment remains the most efficient way to identify frail geriatric surgical patients.

Implementation of Physiological Scoring to Determine Discharge Readiness for Patients Undergoing Otolaryngology Head and Neck Procedures.

PURPOSE: This quality improvement project examined whether the use of a validated physiological scoring protocol to determine discharge readiness for surgical procedures proximal to the airway would decrease the time at which discharge criteria were met and postanesthesia care unit (PACU) length of stay. DESIGN: An observational pre-post design compared preimplementation recovery times to postimplementation recovery times. METHODS: PACU nurses were trained to use two physiological scoring protocols to determine when patients met discharge criteria and to document when discharge criteria were met. FINDINGS: During the postimplementation period, there was a significant decrease in the time it took patients to meet PACU discharge criteria when using the physiological scoring protocols compared with the preimplementation group (P < .001). CONCLUSIONS: These results suggest that physiological scoring protocols are safe and appropriate to determine discharge readiness for patients who have surgery proximal to the airway.

Perianesthetic Implications and Considerations for Myasthenia Gravis.

Myasthenia gravis (MG) is a chronic autoimmune neuromuscular disease in which antibodies against the post-nicotinic acetylcholine receptor at the neuromuscular junction develop. Although the exact cause of MG remains unknown, the thymus is a common factor in many cases. Patients with underlying junctional disease, such as MG, have greater anesthesia-related risks because of their known predisposition toward prolonged muscle weakness. Medications given in the perioperative period, such as anesthetic agents, antibiotics, cardiovascular drugs, and corticosteroids, affect neuromuscular transmission that contributes to muscle weakness. Judicious use of neuromuscular blocking agents for patients with MG must be considered. This patient population is at high risk for respiratory failure, and therefore must be carefully assessed throughout the perioperative period to ensure that a regular spontaneous respiratory pattern is sufficient to provide adequate oxygenation. Perianesthesia providers must consider anesthetic, ventilatory, and pharmacologic implications when proposing, providing, and recovering anesthesia for the patient with MG.

Low-Dose Ketamine Infusion to Decrease Postoperative Delirium for Spinal Fusion Patients.

PURPOSE: The primary aim of this project was to decrease the incidence of postoperative delirium after spine surgery. DESIGN: A prospective preimplementation and postimplementation design was used. METHODS: A reduced dose ketamine protocol was implemented for adult patients undergoing elective spinal fusion surgery. Thirty patients were assessed at five time points for the presence of postoperative delirium in the postanesthesia care unit (PACU) using the 3-Minute Diagnostic Interview for Confusion Assessment Method Defined Delirium tool and opioid requirements were compared. FINDINGS: A statistical difference was noted between two groups in the incidence of delirium at three of five time points: on arrival to the PACU, and at 60 and 90 minutes after arrival to the PACU. CONCLUSIONS: This pilot study establishes groundwork for further studies to investigate if the ketamine dose can decrease the incidence of postoperative delirium in the initial 90 minutes after surgery without decreasing its analgesic effect.

Pediatric Review and Perioperative Considerations.

Perioperative management of pediatric patients demands knowledge of the relevant ways in which pediatric physiology and physiological regulation differs from the adult. This article will outline some of these most pertinent differences, and also present current recommendations for perioperative management.

Multimodal Perioperative Analgesia Regimen to Improve Patient Outcomes After Total Knee Arthroplasty: A Multidisciplinary Quality Improvement Project.

PURPOSE: The primary aim of this quality improvement project was to improve mobilization for patients after total knee arthroscopy by developing and implementing a standardized, evidence-based, multimodal analgesia regimen and patient-educational video. Secondary outcomes included opioid consumption, pain, and length of stay. DESIGN: A pre-post implementation design was used to compare two independent samples. METHODS: Patients were screened based on inclusion and exclusion criteria 1-2 weeks before surgery. The anesthesia provider made the final determination for inclusion. Data were collected by retrospective chart review. FINDINGS: Following implementation, patients displayed significantly improved mobilization, reduced opioid consumption, and reduced length of stay. Patient-reported pain scores were similar or significantly lower in the postimplementation group. CONCLUSIONS: Variability of patient outcomes was reduced, and quality of care was improved by standardizing care and incorporating the best available evidence, consistent with organization's resources in the nonacademic-affiliated, community hospital setting.

Evaluating the Implementation of a Preemptive, Multimodal Analgesia Protocol in a Plastic Surgery Office.

Many patients undergoing plastic surgery experience significant pain postoperatively. The use of preemptive, multimodal analgesia techniques to reduce postoperative pain has been widely described in the literature. This quality improvement project evaluated the implementation of a preemptive, multimodal analgesia protocol in an office-based plastic surgery facility to decrease postoperative pain, decrease postoperative opioid consumption, decrease postanesthesia care time, and increase patient satisfaction. The project included adult patients undergoing surgical procedures at an outpatient plastic and cosmetic surgery office, and the protocol consisted of oral acetaminophen 1,000 mg and gabapentin 1,200 mg. Using a pre-/postintervention design, data were collected from patient medical records and telephone interviews of patients receiving the standard preoperative analgesia regimen (preintervention group: n = 24) and the evidence-based preemptive, multimodal analgesia protocol (postintervention group: n = 23). Results indicated no significant differences between the pre- and postintervention groups for any of the outcomes measured. However, results showed that patients in both groups experienced moderate to severe pain postoperatively. In addition, adverse side effects such as dizziness and drowsiness were higher in the postintervention group than in the preintervention group. Although this quality improvement project did not meet the goals it set out to achieve for patients undergoing plastic surgery, it did illustrate the substantial presence of pain after surgical procedures. Thus, clinicians need to continue to focus on identifying targeted treatment plans that use multimodal, non-opioid-based strategies to manage and prevent postoperative pain.

Fast-tracking ambulatory surgery patients following anesthesia.

PURPOSE: The purpose of this process improvement project was to introduce and evaluate the efficacy of fast-tracking ambulatory surgical patients in a community hospital. DESIGN: An observational pre-post design was used, in which patient data from a reference period (pre-fast-tracking) was compared with patient data collected during an implementation period (post-fast-tracking). METHODS: Anesthesia providers were trained to use a tool to assess patients for eligibility to bypass the postanesthesia care unit (PACU). Fifty-nine patients met the fast-track criteria during the implementation period and were transferred directly to the ambulatory care unit from the operating room. FINDING: During the fast-track implementation period, a PACU-bypass rate of 79% was achieved, and a significant decrease in the total number of patients held in the operating room and in total length of stay was noted. CONCLUSIONS: Results suggest that fast-tracking is a suitable intervention to increase work flow efficiency and decrease both patient and hospital costs while promoting a more rapid discharge from the facility.