Transitional Pain Service: Optimizing Complex Surgical Patients.

PURPOSE OF REVIEW: The care of patients with complex postsurgical pain can be challenging and burdensome for the healthcare system. Transitional pain service (TPS) is a relatively new concept and has not been widely adopted in the USA. This article explores the benefits and barriers of transitional pain services and describes the development of a TPS at our institution. RECENT FINDINGS: Evidence from a few institutions that have adopted TPS has shown decreased postsurgical opioid consumption for patients on chronic opioids and decreased incidence of chronic postsurgical opioid use for opioid-naïve patients. The development of a transitional pain service may improve outcomes for these complex patients by providing longitudinal and multidisciplinary perioperative pain care. In this article, we describe the implementation of a TPS at a tertiary medical center. Our TPS model involves a multidisciplinary team of anesthesiologists, pain psychologists, surgeons, and advanced practice providers. We provide longitudinal care, including preoperative education and optimization; perioperative multimodal analgesic care; and longitudinal follow-up for 90 days post-procedure. With our TPS service, we aim to reduce long-term opioid use and improve functional outcomes for our patients.

Geospatial Variations and Neighborhood Deprivation in Drug-Related Admissions and Overdoses.

Drug overdoses are a national and global epidemic. However, while overdoses are inextricably linked to social, demographic, and geographical determinants, geospatial patterns of drug-related admissions and overdoses at the neighborhood level remain poorly studied. The objective of this paper is to investigate spatial distributions of patients admitted for drug-related admissions and overdoses from a large, urban, tertiary care center using electronic health record data. Additionally, these spatial distributions were adjusted for a validated socioeconomic index called the Area Deprivation Index (ADI). We showed spatial heterogeneity in patients admitted for opioid, amphetamine, and psychostimulant-related diagnoses and overdoses. While ADI was associated with drug-related admissions, it did not correct for spatial variations and could not account alone for this spatial heterogeneity.

Preoperative Disability in US Veterans.

Using the 12-item World Health Organization Disability Assessment Schedule (WHODAS-12), we measured the prevalence of disability in all eligible patients during a 4-month period who were presenting for preoperative evaluation at a US Veterans Affairs hospital. Overall disability was at least moderate in more than half of these patients (total n = 472 at Durham, NC). Two of the 6 WHODAS domains, "Getting Around" and "Participation in Society," contributed most to the overall scores-25% and 20%, respectively. Further studies are needed to determine the impact of domain-specific disabilities on postoperative outcomes and to identify potential interventions to address these vulnerabilities.

Delaying Elective Surgery in Geriatric Patients: An Opportunity for Preoperative Optimization.

Deciding whether to pursue elective surgery is a complex process for older adults. Comprehensive geriatric assessment (CGA) can help refine estimates of benefits and risks, at times leading to a delay of surgery to optimize surgical readiness. We describe a cohort of geriatric patients who were evaluated in anticipation of elective abdominal surgery and whose procedures were delayed for any reason. Themes behind the reasons for delay are described, and a holistic framework to guide preoperative discussion is suggested.

Differentiating between cold agglutinins and rouleaux: a case series of seven patients.

We present a case series of seven patients with suspected cold agglutinin antibodies, discovered after initiation of bypass. Laboratory analysis of blood samples intraoperatively determined the cause of the aggregation to be rouleaux formation in three of the patients and cold agglutinins in the other four.

Operating Room-to-ICU Patient Handovers: A Multidisciplinary Human-Centered Design Approach.

BACKGROUND: Patient handovers (handoffs) following surgery have often been characterized by poor teamwork, unclear procedures, unstructured processes, and distractions. A study was conducted to apply a human-centered approach to the redesign of operating room (OR)-to-ICU patient handovers in a broad surgical ICU (SICU) population. This approach entailed (1) the study of existing practices, (2) the redesign of the handover on the basis of the input of hand over participants and evidence in the medical literature, and (3) the study of the effects of this change on processes and communication. METHODS: The Durham [North Carolina] Veterans Affairs Medical Center SICU is an 11-bed mixed surgical specialty unit. To understand the existing process for receiving postoperative patients in the SICU, ethnographic methods-a series of observations, surveys, interviews, and focus groups-were used. The handover process was redesigned to better address providers' work flow, information needs, and expectations, as well as concerns identified in the literature. RESULTS: Technical and communication flaws were uncovered, and the handover was redesigned to address them. For the 49 preintervention and 49 postintervention handovers, the information transfer score and number of interruptions were not significantly different. However, staff workload and team behaviors scores improved significantly, while the hand over duration was not prolonged by the new process. Handover participants were also significantly more satisfied with the new handover method. CONCLUSIONS: An HCD approach led to improvements in the patient handover process from the OR to the ICU in a mixed adult surgical population. Although the specific handover process would unlikely be optimal in another clinical setting if replicated exactly, the HCD foundation behind the redesign process is widely applicable.

FOCUS: the Society of Cardiovascular Anesthesiologists' initiative to improve quality and safety in the cardiovascular operating room.

The Society of Cardiovascular Anesthesiologists (SCA) introduced the FOCUS initiative (Flawless Operative Cardiovascular Unified Systems) in 2005 in response to the need for a rigorous scientific approach to improve quality and safety in the cardiovascular operating room (CVOR). The goal of the project, which is supported by the SCA Foundation, is to identify hazards and develop evidence-based protocols to improve cardiac surgery safety. A hazard is anything that has the potential to cause a preventable adverse event. Specifically, the strategic plan of FOCUS includes 3 goals: (1) identifying hazards in the CVOR, (2) prioritizing hazards and developing risk-reduction interventions, and (3) disseminating these interventions. Collectively, the FOCUS initiative, through the work of several groups composed of members from different disciplines such as clinical medicine, human factors engineering, industrial psychology, and organizational sociology, has identified and documented significant hazards occurring daily in our CVORs. Some examples of frequent occurrences that contribute to reduce the safety and quality of care provided to cardiac surgery patients include deficiencies in teamwork, poor OR design, incompatible technologies, and failure to adhere to best practices. Several projects are currently under way that are aimed at better understanding these hazards and developing interventions to mitigate them. The SCA, through the FOCUS initiative, has begun this journey of science-driven improvement in quality and safety. There is a long and arduous road ahead, but one we need to continue to travel.

Blood or Fat? Differentiating Hemopericardium versus Epicardial Fat Using Focused Cardiac Ultrasound.

Basic point-of-care ultrasound of the heart-also known as Focused Cardiac Ultrasound (FoCUS)-has emerged as a powerful bedside tool to narrow the differential diagnosis of causes of hypotension. The list of causes of hypotension that a FoCUS provider is expected to be able to recognize includes a compressive pericardial effusion due to hemopericardium (blood in the pericardial sac). But hemopericardium can be difficult to distinguish from a more common condition that is not immediately life-threatening: epicardial fat. This paper reviews illustrative images of both epicardial fat and hemopericardium to provide practice guidance to the FoCUS user on how to differentiate these two phenomena.

Barriers to Implementation of Telehealth Pre-anesthesia Evaluation Visits in the Department of Veterans Affairs.

Background: Evaluations are conducted days or weeks before a scheduled surgical or invasive procedure involving anesthesia to assess patients' preprocedure condition and risk, optimize status, and prepare them for their procedure. The traditional pre-anesthesia evaluation is conducted in person, although telehealth modalities have been used for several years and have accelerated since the advent of the COVID-19 pandemic. Methods: We surveyed 109 anesthesiology services to understand the barriers and facilitators to the adoption of telephone- and video-based pre-anesthesia evaluation visits within the US Department of Veterans Affairs (VA). Results: The analysis included 55 responses from 50 facilities. Twenty-two facilities reported using both telephone and video, 11 telephone only, 5 video only, and 12 none of these modalities. For telehealth users, the ability to obtain a history of present illness, the ability to assess for comorbidities, and assess for health habits were rated highest while assessing nutritional status was lowest. Among nonusers of telehealth modalities, barriers to adoption included the inability to perform a physical examination and the inability to obtain vital signs. Respondents not using telephone cited concerns about safety, while respondents not using video also cited lack of information technology and staff support and patient-level barriers. Conclusions: We found no significant perceived advantages of video over telephone in the ability to conduct routine pre-anesthesia evaluations except for the perceived ability to assess nutritional status. Clinicians with no telehealth experience cited the inability to perform a physical examination and obtain vital signs as the most significant barriers to implementation. Future work should focus on delineating the most appropriate and valuable uses of telehealth for pre-anesthesia evaluation and/or optimization.

Can we make postoperative patient handovers safer? A systematic review of the literature.

Postoperative patient handovers are fraught with technical and communication errors and may negatively impact patient safety. We systematically reviewed the literature on handover of care from the operating room to postanesthesia or intensive care units and summarized process and communication recommendations based on these findings. From >500 papers, we identified 31 dealing with postoperative handovers. Twenty-four included recommendations for structuring the handover process or information transfer. Several recommendations were broadly supported, including (1) standardize processes (e.g., through the use of checklists and protocols); (2) complete urgent clinical tasks before the information transfer; (3) allow only patient-specific discussions during verbal handovers; (4) require that all relevant team members be present; and (5) provide training in team skills and communication. Only 4 of the studies developed an intervention and formally assessed its impact on different process measures. All 4 interventions improved metrics of effectiveness, efficiency, and perceived teamwork. Most of the papers were cross-sectional studies that identified barriers to safe, effective postoperative handovers including the incomplete transfer of information and other communication issues, inconsistent or incomplete teams, absent or inefficient execution of clinical tasks, and poor standardization. An association between poor-quality handovers and adverse events was also demonstrated. More innovative research is needed to define optimal patient handovers and to determine the effect of handover quality on patient outcomes.

The anesthesia team of the future.

PURPOSE OF REVIEW: This review is aimed at highlighting the recent developments and opportunities that are likely to impact the anesthesia team of the future. RECENT FINDINGS: The anesthesia team of the future aims to provide well tolerated, efficient, and cost-effective perioperative care. Certified and subspecialty trained anesthesiologists lead a diverse team of care providers in increasingly dissimilar environments. The spread of electronic health record systems has been the basis for the development of clinical decision support applications that promise to integrate quality control, enhanced efficiency, research opportunities, and improved patient care in the perioperative period. Perioperative epidemiology is a likely area of growth within the field of anesthesiology ultimately enabling the anesthesia team to translate precise real-time information into improved outcome. SUMMARY: The anesthesia team of the future will require the anesthesiologist to provide expertise across the entire domain of perioperative medicine. Meaningful decision support systems rely on accurate data analysis and incorporation of current clinical guidelines and recommendations.

Preoperative Care Assessment of Need Scores Are Associated With Postoperative Mortality and Length of Stay in Veterans Undergoing Knee Replacement.

BACKGROUND: Care Assessment of Need (CAN) scores predicting 90-day mortality and hospitalization are automatically computed each week for patients receiving care at Veterans Health Administration facilities. While currently used only by primary care teams for care coordination, we explored their value as a perioperative risk stratification tool before major elective surgery. METHODS: We collected relevant demographic and perioperative data along with perioperative CAN scores for veterans who underwent total knee replacement between July 2014 and December 2015. We examined score distribution, relationships of preoperative CAN 1-year mortality scores with 1-year postoperative mortality and index hospital length of stay (LOS), and patterns of mortality. RESULTS: Among 8206 patients, 1-year mortality was 1.4% (110 patients), and CAN scores exhibited near-normal distribution. Median scores among survivors were significantly higher than those of in nonsurvivors (45 vs 75; P < .001). The Kaplan-Meier curves showed an approximately 4-fold higher rate of death at 1 year in the highest tercile for 1-year mortality CAN scores compared with those with lower scores (2.0% vs 0.5% respectively; P < .001). Locally estimated scatterplot smoothing curves revealed a significant and nonlinear increase in hospital LOS across preoperative CAN scores. CONCLUSIONS: Although designed for ambulatory care use, CAN scores can identify patients at high risk for mortality and extended hospital LOS in an elective surgery population. The CAN scores may prove valuable in supporting informed decision making and preoperative planning in high-risk and vulnerable populations. Further study is needed to confirm the validity of CAN scores and compare them to other more widely used surgical risk calculators.

Development and usability testing of an audit and feedback tool for anesthesiologists.

BACKGROUND: We describe the creation and evaluation of a personal audit and feedback (A&F) tool for anesthesiologists. METHODS: A survey aimed at capturing barriers for personal improvement efforts and feedback preferences was administered to attending anesthesiologists. The results informed the design and implementation of 4 dashboards that display information on individual practice characteristics as well as comparative performance on several quality metrics. The dashboards' usability was then tested using the human-centered design framework. RESULTS: Anesthesiologists listed lack of information on current practice as the main barrier for improvement. Regarding usability, participants gave the dashboards an average score of 3.8 (scale 1-5) on consistency, learnability, and information organization, and performed the assigned tasks well, with an average score of 89% (range 79-100%). CONCLUSIONS: We describe the design, implementation, and usability testing of an innovative tool that utilizes data derived from the electronic health record (EHR) system to provide A&F to anesthesiology providers.