RESUMO
BACKGROUND: Opioid use is common and associated with side effects and risks. Consequently, analgesic strategies to reduce opioid utilization have been developed. Regional anesthesia and multimodal strategies are central tenets of enhanced recovery pathways and facilitate reduced perioperative opioid use. Opioid-free anesthesia (OFA) protocols eliminate all intraoperative opioids, reserving opioids for postoperative rescue treatment. Systematic reviews show variable results for OFA. METHODS: In a series of Quality Improvement (QI) projects, multidisciplinary teams developed interventions to test and spread OFA first in our ambulatory surgery center (ASC) and then in our hospital. Outcome measures were tracked using statistical process control charts to increase the adoption of OFA. RESULTS: Between January 1, 2016, and September 30, 2022, 19 872 of 28 574 ASC patients received OFA, increasing from 30% to 98%. Post Anesthesia Care Unit (PACU) maximum pain score, opioid-rescue rate, and postoperative nausea and vomiting (PONV) treatment all decreased concomitantly. The use of OFA now represents our ambulatory standard practice. Over the same timeframe, the spread of this practice to our hospital led to 21 388 of 64 859 patients undergoing select procedures with OFA, increasing from 15% to 60%. Opioid rescue rate and PONV treatment in PACU decreased while hospital maximum pain scores and length of stay were stable. Two procedural examples with OFA benefits were identified. The use of OFA allowed relaxation of adenotonsillectomy admission criteria, resulting in 52 hospital patient days saved. Transition to OFA for laparoscopic appendectomy occurred concomitantly with a decrease in the mean hospital length of stay from 2.9 to 1.4 days, representing a savings of >500 hospital patient days/year. CONCLUSIONS: These QI projects demonstrated that most pediatric ambulatory and select inpatient surgeries are amenable to OFA techniques which may reduce PONV without worsening pain.
Assuntos
Anestesia por Condução , Transtornos Relacionados ao Uso de Opioides , Humanos , Criança , Analgésicos Opioides , Náusea e Vômito Pós-Operatórios/epidemiologia , Náusea e Vômito Pós-Operatórios/tratamento farmacológico , Dor Pós-Operatória/tratamento farmacológicoRESUMO
Measurement of quality and improvement in medicine has existed since Florence Nightingale's time. In modern times, medicine has sought to learn from other high-reliability industries such as aviation and nuclear power, where errors can result in catastrophic outcomes. Lean is a unique quality improvement strategy that seeks to improve both quality and safety by driving out waste and, where possible, standardizing work practices. It is a visual system with work aids and signals built into the workspace. An important tenet is that ideas come from the workers and that there is an iterative improvement. The improvement efforts are always viewed from the perspective of the customer, our patients, families, and coworkers. This paper describes the evolution of Lean in healthcare and highlights core principles of Lean. Examples are used to describe how various Lean tools can be applied by pediatric anesthesiologists to solve clinical problems.
Assuntos
Eficiência Organizacional , Melhoria de Qualidade , Criança , Humanos , Reprodutibilidade dos Testes , Gestão da Qualidade TotalRESUMO
BACKGROUND: Wake Up Safe, a Patient Safety Organization founded by the Society for Pediatric Anesthesia, collects data on serious adverse events along with demographic data from all pediatric patients receiving anesthesia care at participating institutions. This report reviews all events occurring between 2010 and 2015 and focuses on common adverse events that are anesthesia-related. AIMS: Determine which adverse events were most common from 2010 to 2015 among participating Wake Up Safe institutions. Determine how many anesthesia-related events were deemed to be preventable. METHODS: This is a descriptive report. The Wake Up Safe registry data were queried on September 29, 2017. Institutions were included if they had complete demographic data and at least 5 adverse events per year reported. At that time, 19 out of 29 institutions had complete demographic data for events from 2010 to 2015. This study describes demographic data and adverse events from these nineteen institutions. Descriptive data were extracted, and event rate was calculated for each adverse event category. In events that were assessed as primarily related to anesthesia, further detailed analysis was performed. RESULTS: Of all reported adverse events (2544 events), the most common were cardiac arrests (646, 31.6%), respiratory complications (598, 29.2%), and medication events (345, 16.9%). Of all anesthesia-related events (612 events), medication events were the most common (239, 31.9%), followed by respiratory complications (181, 24.1%), and cardiac arrests (139, 18.5%). Overall, 85% of anesthesia-related serious adverse events were deemed somewhat or almost certainly preventable. CONCLUSIONS: The majority of anesthesia-related serious adverse events reported to the Wake Up Safe database are preventable. Medication events are the most common anesthesia-related adverse events. Innovations aimed at decreasing medication events may be the most impactful.
Assuntos
Anestesia , Melhoria de Qualidade , Anestesia/efeitos adversos , Criança , Bases de Dados Factuais , Humanos , Segurança do Paciente , Sistema de RegistrosRESUMO
BACKGROUND: Sugammadex is a novel neuromuscular blockade reversal agent approved by the Food and Drug Administration in 2015, but little literature exists for patients less than 2 years of age. AIMS: The aims of this study were to: describe a cohort of patients 2 years old and younger who received sugammadex; describe any adverse effects of sugammadex in this age group; compare time from end of surgery to out of operating room for sugammadex versus neostigmine; compare time between last dose of neuromuscular blocking drug and reversal; and use train-of-four data to assess reversal. METHODS: Chart review of the medical record and the anesthesia information system captured all patients in this age cohort who received sugammadex or neostigmine over a two-year period. Adverse medication events were pulled from a mandatory quality improvement field in the electronic anesthesia record. T-tests were used for analyses. RESULTS: No adverse effects were reported with 331 doses of sugammadex. The average time in minutes between end of surgery and out of operating room was similar for neostigmine (19.6) versus sugammadex (19.4) (mean difference 0.2, 95% CI -1.5-1.8, P = 0.85). The average time in minutes between last dose of neuromuscular blocking drug and reversal agent was longer for neostigmine (103) than for sugammadex (84) (mean difference 19, 95% CI 13-26, P < 0.001). CONCLUSIONS: Sugammadex administration in this young population did not result in any adverse effects. It appears to be equally effective as neostigmine in patients under 2 years of age.
Assuntos
Neostigmina/uso terapêutico , Fármacos Neuromusculares não Despolarizantes/uso terapêutico , Sugammadex/uso terapêutico , Período de Recuperação da Anestesia , Humanos , Lactente , Recém-Nascido , Bloqueio NeuromuscularRESUMO
BACKGROUND: Medication errors continue to be a significant source of patient harm in the operating room with few concrete countermeasures. The organization and identification of medication syringes may have an impact on the commission of medication errors in anesthesia, so a team of physicians and designers at the University of Washington created the Anesthesia Medication Template (AMT) to define a formal way of organizing the anesthesia workspace. The purpose of this study is to assess the ability of the AMT to reduce perioperative medication errors by anesthesia providers. METHODS: This study evaluated the AMT in 2 phases: (1) 41 anesthesia providers administered medications in 2 prospective, randomized operating room simulations with or without the AMT, while medication errors were directly observed; and (2) around 200 providers prospectively self-reported medication errors from all anesthetizing locations during a 2-year period at Seattle Children's Hospital, an academic, pediatric medical center. RESULTS: In simulated emergencies, the odds of medication dosing errors using the AMT were 0.21 times the odds of medication dosing errors without AMT (95% confidence interval [CI], 0.07, 0.66), controlling for scenario, session, training level, and years at training level. During the year after implementation of the AMT, the mean monthly error rate for all reported medication errors that reached patients decreased from 1.24 (95% CI, 0.85-1.79) to 0.65 (95% CI, 0.39-1.09) errors per 1000 anesthetics. The mean monthly error rate of reported swap, preparation, miscalculation, and timing errors decreased from 0.97 (95% CI, 0.64-1.48) to 0.35 (95% CI, 0.17-0.70) errors per 1000 anesthetics. Medication errors that resulted in patient harm did not change after implementation of the AMT. CONCLUSIONS: Standardizing medication organization with the AMT is an intuitive, low-cost strategy with the potential to improve patient safety through reducing medication errors by anesthesia providers.
Assuntos
Anestesia/normas , Anestésicos , Erros de Medicação/estatística & dados numéricos , Anestesia/estatística & dados numéricos , Anestesiologia/educação , Anestésicos/administração & dosagem , Anestésicos/efeitos adversos , Simulação por Computador , Serviços Médicos de Emergência/estatística & dados numéricos , Humanos , Salas Cirúrgicas , Segurança do Paciente , Estudos Prospectivos , Seringas , WashingtonRESUMO
The Institute of Medicine has called for development of strategies to prevent medication errors, which are one important cause of preventable harm. Although the field of anesthesiology is considered a leader in patient safety, recent data suggest high medication error rates in anesthesia practice. Unfortunately, few error prevention strategies for anesthesia providers have been implemented. Using Toyota Production System quality improvement methodology, a multidisciplinary team observed 133 h of medication practice in the operating room at a tertiary care freestanding children's hospital. A failure mode and effects analysis was conducted to systematically deconstruct and evaluate each medication handling process step and score possible failure modes to quantify areas of risk. A bundle of five targeted countermeasures were identified and implemented over 12 months. Improvements in syringe labeling (73 to 96%), standardization of medication organization in the anesthesia workspace (0 to 100%), and two-provider infusion checks (23 to 59%) were observed. Medication error reporting improved during the project and was subsequently maintained. After intervention, the median medication error rate decreased from 1.56 to 0.95 per 1000 anesthetics. The frequency of medication error harm events reaching the patient also decreased. Systematic evaluation and standardization of medication handling processes by anesthesia providers in the operating room can decrease medication errors and improve patient safety.
Assuntos
Anestesia/normas , Análise do Modo e do Efeito de Falhas na Assistência à Saúde , Erros de Medicação/prevenção & controle , Anestesia/efeitos adversos , Criança , Rotulagem de Medicamentos/normas , Guias como Assunto , Hospitais Pediátricos , Humanos , Bombas de Infusão/normas , Salas Cirúrgicas/organização & administração , Segurança do Paciente , Pediatria , Melhoria de Qualidade , Resultado do TratamentoRESUMO
Wrong site surgery is a serious safety event that can result in temporary or even permanent harm. Various safety checklists and procedures have been added to our standard work in the operating room, but errors still get through our safety nets and patients are harmed. In this case report, we describe a wrong site frenulectomy in a child and discuss the root cause analysis of this error and also SMART (specific, measurable, achievable, realistic, timed) preventative actions that could be put into place to prevent a recurrence.
Assuntos
Freio Lingual/cirurgia , Erros Médicos , Feminino , Humanos , Lactente , Segurança do PacienteRESUMO
In 2006, the Quality and Safety Committee of the Society for Pediatric Anesthesia initiated a quality improvement project for the specialty of pediatric anesthesiology that ultimately resulted in the development of Wake Up Safe (WUS), a patient safety organization that maintains a registry of de-identified, serious adverse events. The ultimate goal of WUS is to implement change in processes of care that improve the quality and safety of anesthetic care provided to pediatric patients nationwide. Member institutions of WUS submit data regarding the types and numbers of anesthetics performed and information pertaining to serious adverse events. Before a member institution submits data for any serious adverse event, 3 anesthesiologists who were not involved in the event must analyze the event with a root cause analysis (RCA) to identify the causal factor(s). Because institutions across the country use many different RCA methods, WUS educated its members on RCA methods in an effort to standardize the analysis and evaluate each serious adverse event that is submitted. In this review, we summarize the background and development of this patient safety initiative, describe the standardized RCA method used by its members, demonstrate the use of this RCA method to analyze a serious event that was reported, and discuss the ways WUS plans to use the data to promote safer anesthetic practices for children.
Assuntos
Anestesia/efeitos adversos , Segurança do Paciente , Pediatria , Melhoria de Qualidade , Análise de Causa Fundamental , Criança , HumanosRESUMO
Health care quality and value are leading issues in medicine today for patients, health care professionals, and policy makers. Outcome, safety, and service-the components of quality-have been used to define value when placed in the context of cost. Health care organizations and professionals are faced with the challenge of improving quality while reducing health care related costs to improve value. Measurement of quality is essential for assessing what is effective and what is not when working toward improving quality and value. However, there are few tools currently for assessing quality of care, and clinicians often lack the resources and skills required to conduct quality improvement work. In this article, we provide a brief review of quality improvement as a discipline and describe these efforts within pediatric anesthesiology.
Assuntos
Anestesia/normas , Avaliação de Processos e Resultados em Cuidados de Saúde/normas , Segurança do Paciente/normas , Pediatria/normas , Qualidade da Assistência à Saúde/normas , Anestesia/efeitos adversos , Competência Clínica/normas , Humanos , Complicações Pós-Operatórias/prevenção & controle , Guias de Prática Clínica como Assunto , Melhoria de Qualidade , Indicadores de Qualidade em Assistência à Saúde/normas , Medição de Risco , Fatores de Risco , Resultado do TratamentoRESUMO
AIMS: Patients with central venous catheters who are transferred out of the Intensive Care Unit to the care of an anesthesiology team for an operation or interventional radiology procedure had excessive rates of catheter associated blood stream infection (CABSI). METHODS: We convened a multi-disciplinary team to audit anesthesia practice and to develop countermeasures for those aspects of practice that were thought to be contributing to CABSI's. It was noted that provider behavior changed in the presence of an auditor (Hawthorne effect) and so videorecordings were used, in the hope that this Hawthorne effect would be reduced. Clips were chosen from the hours of video (without audio) recordings that showed medication administration, airway management and touching the anesthesia cart of equipment/supplies. RESULTS: These clips were viewed by three observers and measurements were made to assess intra-rater and inter-rater reliability. The clips were then viewed to quantify differences in practice before and after our bundle of "best practices" was introduced. CONCLUSIONS: Although video recording has been used to evaluate adherence to resuscitation protocols in both trauma and in neonatal resuscitation, (Pediatric Emergency Care, 26, 2010, 803; Pediatrics, 117, 2006, 658; Pediatrics, 106, 2000, 654) we believe this is the first time that video has been used to record before and after behaviors for an anesthesia quality improvement initiative.
Assuntos
Anestesia/métodos , Melhoria de Qualidade/organização & administração , Gravação em Vídeo , Manuseio das Vias Aéreas , Anestesia/ética , Criança , Hospitais Pediátricos , Humanos , Higiene , Injeções Intravenosas , Variações Dependentes do Observador , Melhoria de Qualidade/ética , Software , Gravação em Vídeo/éticaRESUMO
BACKGROUND: A major strategic hospital goal is the prevention of catheter associated bloodstream infections (CABSI). In 2009, at our institution, the CABSI rate for patients who traveled out of the ICU to the operating room and other procedural areas under the care of an anesthesiologist was increased compared to patients who remained on the unit. AIMS: Our objective was to develop countermeasures to improve intraoperative cleanliness by anesthesia providers, minimize contamination of intravenous access points, and ultimately reduce CABSIs. MATERIALS & METHODS: A multidisciplinary team identified barriers to following best practices for reducing contamination of intravenous line entry-ports. Using Continuous Performance Improvement (CPI) or Lean techniques, staff directly impacted by the changes developed countermeasures to improve anesthesia practice. Compliance with the new "best practices" improved with coaching and feedback. RESULTS: Postimplementation, CABSI rates for patients traveling off the ICU with anesthesiology providers decreased from 14.1 per thousand trips off the ICU preintervention in 2009 to 9.7 per 1000 trips in 2010 and to 0 per 1000 trips in 2011 postintervention. Hospital-wide CABSI rates decreased from 3.5 per 1000 central line days preintervention to 2.2 per 1000 central line days after. CONCLUSION: Practice modification by anesthesiology providers in the operating room can decrease workspace contamination and is associated with decreased CABSI rates.
Assuntos
Anestesia/normas , Anestesiologia/normas , Infecções Relacionadas a Cateter/prevenção & controle , Manuseio das Vias Aéreas , Infecções Relacionadas a Cateter/sangue , Cateterismo Periférico , Catéteres , Criança , Clorexidina , Desinfetantes , Contaminação de Equipamentos/prevenção & controle , Desinfecção das Mãos , Humanos , Higiene , Controle de Infecções/métodos , Período Intraoperatório , Equipe de Assistência ao Paciente , Melhoria de Qualidade , Gestão da Qualidade Total , Dispositivos de Acesso Vascular/microbiologiaRESUMO
OBJECTIVES: The objective of this study was to determine whether the incidence of emergence agitation (EA) can be reduced by adding an additional, faster onset, non-IV analgesic, intranasal fentanyl or intramuscular (im) ketorolac to rectal acetaminophen. AIM: To compare the incidence of EA after analgesia with two agents vs acetaminophen alone in pediatric patients after bilateral myringotomy procedures (BM&T). BACKGROUND: Anesthesia for BM&T is usually performed with volatile anesthetics as a single agent without securing intravenous access. The anesthetic agent most commonly used is sevoflurane; however, EA has been reported in up to 67% of patients. Emergence agitation is distressing for parents, can impair the ability of nursing staff to adequately monitor the child, and can result in a child injuring him/herself if it is severe. METHODS/MATERIALS: A standardized anesthetic was used with oral midazolam premedication and sevoflurane for induction, and maintenance of anesthesia. All patients received 40 mg·kg(-1) rectal acetaminophen, group 1 received acetaminophen alone, group 2 received acetaminophen and 1 mcg·kg(-1) of intranasal fentanyl, and group 3 received acetaminophen and 1 mg·kg(-1) of intramuscular ketorolac. Incidence of EA was compared using chi-square test between the acetaminophen group alone vs the two-agent analgesia groups combined. RESULTS: There were no differences in demographic and clinical characteristics between the two groups. There were no statistically significant differences between the three groups for the incidence of EA at any time point during recovery from anesthesia nor were there any significant differences in pain scores or side effects. No significant side effects because of the administration of a second analgesic agent were reported. CONCLUSIONS: We conclude that two-agent analgesia is not superior to acetaminophen alone for decreasing the incidence of EA after inhalation anesthesia with sevoflurane for BM&T surgery. Our overall incidence of EA was low compared to previous studies, which could potentially have decreased our ability to detect differences between groups.
Assuntos
Acetaminofen/uso terapêutico , Analgésicos não Narcóticos/uso terapêutico , Analgésicos Opioides/uso terapêutico , Anti-Inflamatórios não Esteroides/uso terapêutico , Fentanila/uso terapêutico , Cetorolaco de Trometamina/uso terapêutico , Ventilação da Orelha Média/métodos , Dor Pós-Operatória/tratamento farmacológico , Agitação Psicomotora/prevenção & controle , Acetaminofen/administração & dosagem , Acetaminofen/efeitos adversos , Administração Intranasal , Administração Retal , Analgésicos não Narcóticos/administração & dosagem , Analgésicos não Narcóticos/efeitos adversos , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/efeitos adversos , Anestesia Geral , Anestésicos Inalatórios , Anti-Inflamatórios não Esteroides/administração & dosagem , Anti-Inflamatórios não Esteroides/efeitos adversos , Pré-Escolar , Método Duplo-Cego , Quimioterapia Combinada , Feminino , Fentanila/administração & dosagem , Fentanila/efeitos adversos , Humanos , Lactente , Injeções Intramusculares , Cetorolaco de Trometamina/administração & dosagem , Cetorolaco de Trometamina/efeitos adversos , Masculino , Éteres Metílicos , Medição da Dor/efeitos dos fármacos , Agitação Psicomotora/psicologia , SevofluranoRESUMO
BACKGROUND: Graft versus host disease (GVHD) of the gut is thought to delay gastric emptying and so may increase the risk of aspirating retained contents while under anesthesia. Knowing that gastric emptying is delayed in patients with GVHD might lead one to choose to intubate the trachea for all patients with suspected GVHD, who present for diagnostic esophagogastricduodenoscopy (EGD). We are not aware of published data that gives specific guidance as to the need for intubation in the pediatric bone marrow or stem cell transplantation (BMT) population. This review was intended to evaluate the gastric contents (pH and volume) in this group of patients, to provide anesthesiologists with data that would inform their decisions about airway management for these patients. METHODS: Retrospective chart review of patients Assuntos
Transplante de Medula Óssea
, Conteúdo Gastrointestinal
, Doença Enxerto-Hospedeiro
, Criança
, Feminino
, Esvaziamento Gástrico
, Humanos
, Concentração de Íons de Hidrogênio
, Intubação Intratraqueal
, Masculino
, Estudos Retrospectivos