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Minehart RD, Foldy EG, Long JA, Weller JM. Challenging gender stereotypes and advancing inclusive leadership in the operating theatre. Br J Anaesth 2020; 124:e148-e154. [DOI: 10.1016/j.bja.2019.12.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 12/13/2019] [Accepted: 12/14/2019] [Indexed: 12/20/2022] Open
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52
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Frykholm P. Visual aids for pediatric airway management. Paediatr Anaesth 2020; 30:371-374. [PMID: 31841250 DOI: 10.1111/pan.13789] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 12/10/2019] [Indexed: 12/19/2022]
Abstract
Four basic types of visual aids are used for teaching airway management and decision-making in simulated as well as in real clinical situations: universal algorithms, sets of limited algorithms, concept-based cognitive aids, and checklists. The first three may represent an evolution in the understanding of the role of human error in both successful and failed airway management. Complex visual aids such as the American Society of Anesthesiology difficult airway algorithm may be more useful for teaching, while graphic cognitive aids like the Vortex may be more helpful for decision-making under stress. Not surprisingly, there is a lack of outcome studies, although some cognitive aids have been evaluated in simulation settings.
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Affiliation(s)
- Peter Frykholm
- Section of Anaesthesiology and Intensive Care Medicine, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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53
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Harman A, Tung A, Fox C, Lien CA. Heuristics, Overconfidence, and Experience: Impact on Monitoring Depth of Neuromuscular Blockade. Anesth Analg 2020; 128:1057-1059. [PMID: 31094765 DOI: 10.1213/ane.0000000000003965] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Ann Harman
- From the American Board of Anesthesiology, Raleigh, North Carolina
| | - Avery Tung
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
| | - Chris Fox
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Cynthia A Lien
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
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King CR, Abraham J, Kannampallil TG, Fritz BA, Ben Abdallah A, Chen Y, Henrichs B, Politi M, Torres BA, Mickle A, Budelier TP, McKinnon S, Gregory S, Kheterpal S, Wildes T, Avidan MS. Protocol for the Effectiveness of an Anesthesiology Control Tower System in Improving Perioperative Quality Metrics and Clinical Outcomes: the TECTONICS randomized, pragmatic trial. F1000Res 2019; 8:2032. [PMID: 32201572 PMCID: PMC7076336 DOI: 10.12688/f1000research.21016.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/12/2019] [Indexed: 01/25/2023] Open
Abstract
Introduction: Perioperative morbidity is a public health priority, and surgical volume is increasing rapidly. With advances in technology, there is an opportunity to research the utility of a telemedicine-based control center for anesthesia clinicians that assess risk, diagnoses negative patient trajectories, and implements evidence-based practices. Objectives: The primary objective of this trial is to determine whether an anesthesiology control tower (ACT) prevents clinically relevant adverse postoperative outcomes including 30-day mortality, delirium, respiratory failure, and acute kidney injury. Secondary objectives are to determine whether the ACT improves perioperative quality of care metrics including management of temperature, mean arterial pressure, mean airway pressure with mechanical ventilation, blood glucose, anesthetic concentration, antibiotic redosing, and efficient fresh gas flow. Methods and analysis: We are conducting a single center, randomized, controlled, phase 3 pragmatic clinical trial. A total of 58 operating rooms are randomized daily to receive support from the ACT or not. All adults (eighteen years and older) undergoing surgical procedures in these operating rooms are included and followed until 30 days after their surgery. Clinicians in operating rooms randomized to ACT support receive decision support from clinicians in the ACT. In operating rooms randomized to no intervention, the current standard of anesthesia care is delivered. The intention-to-treat principle will be followed for all analyses. Differences between groups will be presented with 99% confidence intervals; p-values <0.005 will be reported as providing compelling evidence, and p-values between 0.05 and 0.005 will be reported as providing suggestive evidence. Registration: TECTONICS is registered on ClinicalTrials.gov, NCT03923699; registered on 23 April 2019.
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Affiliation(s)
- Christopher R. King
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Joanna Abraham
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
- Institute for Informatics, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Thomas G. Kannampallil
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
- Institute for Informatics, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Bradley A. Fritz
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Yixin Chen
- Department of Computer Science and Engineering, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Bernadette Henrichs
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Mary Politi
- Department of Surgery, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Brian A. Torres
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Angela Mickle
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Thaddeus P. Budelier
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Sherry McKinnon
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Stephen Gregory
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Troy Wildes
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - TECTONICS Research Group
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
- Institute for Informatics, Washington University in St Louis, St Louis, MO, 63110, USA
- Department of Computer Science and Engineering, Washington University in St Louis, St Louis, MO, 63110, USA
- Department of Surgery, Washington University in St Louis, St Louis, MO, 63110, USA
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, 48109, USA
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Abstract
Cognitive bias is increasingly recognised as an important source of medical error, and is both ubiquitous across clinical practice yet incompletely understood. This increasing awareness of bias has resulted in a surge in clinical and psychological research in the area and development of various 'debiasing strategies'. This paper describes the potential origins of bias based on 'dual process thinking', discusses and illustrates a number of the important biases that occur in clinical practice, and considers potential strategies that might be used to mitigate their effect.
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Affiliation(s)
- E D O'Sullivan
- Department of Renal Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK,
| | - S J Schofield
- Centre for Medical Education, University of Dundee, UK
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56
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Addis DR, Moore BA, Garner CR, Fernando RJ, Kim SM, Russell GB. Case Start Time Affects Intraoperative Transfusion Rates in Adult Cardiac Surgery: A Single-Center Retrospective Analysis. J Cardiothorac Vasc Anesth 2019; 34:632-639. [PMID: 31882380 DOI: 10.1053/j.jvca.2019.10.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 10/09/2019] [Accepted: 10/26/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The goal of the study was to investigate the role time of day plays in perioperative outcomes. The authors examined intraoperative transfusion rates throughout the day in adult cardiac surgery patients. They hypothesized that the rate of transfusion changes with later case start times in scheduled cardiac surgery. DESIGN Retrospective observational study. SETTING Single academic medical center. PARTICIPANTS Adults undergoing cardiac surgery involving cardiopulmonary bypass. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was a composite variable of transfusion. The association between the time of day and the rate of transfusion was explored with a multivariate logistic regression to fit the effect of starting time as a cubic spline. There were 1,421 cases that met inclusion criteria. There were 1,220 cases that were matched for modeling. The estimated probability of a patient receiving a transfusion changed significantly with later case start times in the multivariable model after adjusting for initial hemoglobin, age, sex, height, ideal body weight, diabetes, peripheral vascular disease, stroke, chronic kidney disease, chronic obstructive pulmonary disease, duration of cardiopulmonary bypass, aortic cross clamp time, attending surgeon, and attending anesthesiologist (p = 0.032, C-statistic = 0.807, n = 1220). The estimated probability of receiving an intraoperative red blood cell transfusion increased with later case start times in the multivariable model (p = 0.027, C-statistic = 0.902, n = 1220). There was no difference in the probability of transfusion for plasma, cryoprecipitate, or platelets. CONCLUSIONS The observed rate of intraoperative blood product transfusion changed with later case start times in a multivariable model of scheduled cardiac surgery.
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Affiliation(s)
- Dylan R Addis
- Wake Forest School of Medicine, Department of Anesthesiology, Winston-Salem, NC; University of Alabama at Birmingham, Department of Anesthesiology and Perioperative Medicine, Division of Cardiothoracic Anesthesiology, Birmingham, AL.
| | - Blake A Moore
- Wake Forest School of Medicine, Department of Anesthesiology, Winston-Salem, NC; University of Tennessee Graduate School of Medicine, Department of Anesthesiology, Section on Cardiothoracic Anesthesiology, Knoxville, TN
| | - Chandrika R Garner
- Wake Forest School of Medicine, Department of Anesthesiology, Winston-Salem, NC
| | - Rohesh J Fernando
- Wake Forest School of Medicine, Department of Anesthesiology, Winston-Salem, NC
| | - Sung M Kim
- Wake Forest School of Medicine, Department of Anesthesiology, Winston-Salem, NC; Vanderbilt University Medical Center, Department of Anesthesiology, Nashville, TN
| | - Gregory B Russell
- Wake Forest School of Medicine, Department of Anesthesiology, Winston-Salem, NC
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57
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Fritz BA, Cui Z, Zhang M, He Y, Chen Y, Kronzer A, Ben Abdallah A, King CR, Avidan MS. Deep-learning model for predicting 30-day postoperative mortality. Br J Anaesth 2019; 123:688-695. [PMID: 31558311 DOI: 10.1016/j.bja.2019.07.025] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 06/21/2019] [Accepted: 07/22/2019] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Postoperative mortality occurs in 1-2% of patients undergoing major inpatient surgery. The currently available prediction tools using summaries of intraoperative data are limited by their inability to reflect shifting risk associated with intraoperative physiological perturbations. We sought to compare similar benchmarks to a deep-learning algorithm predicting postoperative 30-day mortality. METHODS We constructed a multipath convolutional neural network model using patient characteristics, co-morbid conditions, preoperative laboratory values, and intraoperative numerical data from patients undergoing surgery with tracheal intubation at a single medical centre. Data for 60 min prior to a randomly selected time point were utilised. Model performance was compared with a deep neural network, a random forest, a support vector machine, and a logistic regression using predetermined summary statistics of intraoperative data. RESULTS Of 95 907 patients, 941 (1%) died within 30 days. The multipath convolutional neural network predicted postoperative 30-day mortality with an area under the receiver operating characteristic curve of 0.867 (95% confidence interval [CI]: 0.835-0.899). This was higher than that for the deep neural network (0.825; 95% CI: 0.790-0.860), random forest (0.848; 95% CI: 0.815-0.882), support vector machine (0.836; 95% CI: 0.802-870), and logistic regression (0.837; 95% CI: 0.803-0.871). CONCLUSIONS A deep-learning time-series model improves prediction compared with models with simple summaries of intraoperative data. We have created a model that can be used in real time to detect dynamic changes in a patient's risk for postoperative mortality.
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Affiliation(s)
- Bradley A Fritz
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, USA.
| | - Zhicheng Cui
- Department of Computer Science and Engineering, Washington University in St Louis, St Louis, MO, USA
| | - Muhan Zhang
- Department of Computer Science and Engineering, Washington University in St Louis, St Louis, MO, USA
| | - Yujie He
- Department of Computer Science and Engineering, Washington University in St Louis, St Louis, MO, USA
| | - Yixin Chen
- Department of Computer Science and Engineering, Washington University in St Louis, St Louis, MO, USA
| | - Alex Kronzer
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, USA
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, USA
| | - Christopher R King
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, USA
| | - Michael S Avidan
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, USA
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Eisawi A, Aung M, Canelo R. A Novel Dual-Phase Activation-Dependent Foot-Switch Mechanism for Surgical Energy Devices as an Asset in Early Surgical Training: A Proof of Concept Study. Surg Innov 2019; 27:54-59. [DOI: 10.1177/1553350619870030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction. Many processes exist that limit or eliminate the incidence of adverse events in general surgery including the World Health Organization safety checklist. Technology and device advancement has a potentially expanding role in the context of surgical safety. Materials and Methods. A dual controlled accessory electrical diathermy footswitch ( Permissive diathermy foot switch device or PDf) device concept was developed in an effort to improve patient safety in theatre and enhance opportunities in training. Electrical diathermy is only activated if the senior supervising surgeon and the novice surgeon simultaneously activate their interconnected footswitches. The activation of the PDf accessory footswitch device allows a senior surgeon to exert control on “initiation” of activation of diathermy devices operated by a novice surgeon ( foot on pedal) as well as when desiring to deactivate the device ( foot off pedal). Results. A process of designing and prototyping was initiated to define the purpose and the functionality of the PDf device up till the stage of a fully functioning prototype. The PDf device was constructed as a final working and tested prototype in association with the local medical engineering department at the Cumberland Infirmary in Carlisle. The device was on a nonbiological model to determine efficacy and safety and passed its laboratory testing phase and was deemed ready for clinical use. Conclusion. We demonstrated the feasibility and functionality of the PDf device and propose a positive role in surgical training in the context of early surgical training and specific circumstances where more control is needed.
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Affiliation(s)
| | | | - Ruben Canelo
- Cumberland Infirmary, Carlisle, UK
- UCLan University, UK
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59
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Bryan YF, Morgan AG, Johnson KN, Harris HM, May J, Whelan DM, Tung A. Procedural Challenges During Intubation in Patients With Oropharyngeal Masses: A Prospective Observational Study. Anesth Analg 2019; 128:1256-1263. [PMID: 31094797 DOI: 10.1213/ane.0000000000004089] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND In patients who undergo surgery for oropharyngeal masses, intubation is almost always successful. However, technical aspects of airway management, including bag mask ventilation and oxygenation, may still be difficult. Although rates of airway difficulty and intubation success in these patients have been studied, these data may not reflect difficulty with individual components of the intubation process. We hypothesized that rates of complications with individual elements of the intubation process would not be reflected in the rate of eventual intubation success. To test our hypothesis, we observed the process of airway management and resulting complications with oxygenation and bag mask ventilation in patients with oropharyngeal masses undergoing otorhinolaryngology procedures under general anesthesia. METHODS Forty-four patients with oropharyngeal masses scheduled for surgery were observed during the process of airway management. Observers recorded the number of airway devices used, the overall number of intubation attempts, the number and type of manual maneuvers required during bag mask ventilation, and the incidence of oxygen desaturation. The eventual intubation success rate was also recorded. RESULTS All 44 patients (100%; 95% CI, 92%-100%) were successfully intubated. Thirty-six (81.8%) of 44 patients were intubated asleep and 8 (18.2%) of 44 were intubated awake using flexible fiberoptic bronchoscopy. Thirty-one (86.1%) of 36 patients who were intubated asleep received bag mask ventilation before intubation, while the other 5 patients underwent a rapid sequence induction. Twenty-seven (61.4%) of 44 patients (95% CI, 45%-75%) had ≥1 complication during airway management. Ten (23%) of 44 patients (95% CI, 11%-37%) required ≥3 attempts to intubate, 21 (68%) of 31 patients (95% CI, 49%-83%) had difficult mask ventilation, and 15 patients (34%; 95% CI, 20%-50%) experienced desaturation (oxygen saturation measured by pulse oximetry, <95%). CONCLUSIONS We found that, although all patients were successfully intubated, clinicians frequently encountered complications with both intubation and mask ventilation. These complications required frequent use of additional manual maneuvers during mask ventilation and a high incidence of oxygen desaturation. The difficulty of airway management in patients with oropharyngeal masses may not be effectively assessed by success rate alone.
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Affiliation(s)
- Yvon F Bryan
- From the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Amelia G Morgan
- From the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Kathleen N Johnson
- From the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Hannah M Harris
- From the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Joseph May
- From the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Deborah M Whelan
- From the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Avery Tung
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
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60
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Naguib M, Brull SJ, Hunter JM, Kopman AF, Fülesdi B, Johnson KB, Arkes HR. Anesthesiologists' Overconfidence in Their Perceived Knowledge of Neuromuscular Monitoring and Its Relevance to All Aspects of Medical Practice: An International Survey. Anesth Analg 2019; 128:1118-1126. [PMID: 31094776 DOI: 10.1213/ane.0000000000003714] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND In patients who receive a nondepolarizing neuromuscular blocking drug (NMBD) during anesthesia, undetected postoperative residual neuromuscular block is a common occurrence that carries a risk of potentially serious adverse events, particularly postoperative pulmonary complications. There is abundant evidence that residual block can be prevented when real-time (quantitative) neuromuscular monitoring with measurement of the train-of-four ratio is used to guide NMBD administration and reversal. Nevertheless, a significant percentage of anesthesiologists fail to use quantitative devices or even conventional peripheral nerve stimulators routinely. Our hypothesis was that a contributing factor to the nonutilization of neuromuscular monitoring was anesthesiologists' overconfidence in their knowledge and ability to manage the use of NMBDs without such guidance. METHODS We conducted an Internet-based multilingual survey among anesthesiologists worldwide. We asked respondents to answer 9 true/false questions related to the use of neuromuscular blocking drugs. Participants were also asked to rate their confidence in the accuracy of each of their answers on a scale of 50% (pure guess) to 100% (certain of answer). RESULTS Two thousand five hundred sixty persons accessed the website; of these, 1629 anesthesiologists from 80 countries completed the 9-question survey. The respondents correctly answered only 57% of the questions. In contrast, the mean confidence exhibited by the respondents was 84%, which was significantly greater than their accuracy. Of the 1629 respondents, 1496 (92%) were overconfident. CONCLUSIONS The anesthesiologists surveyed expressed overconfidence in their knowledge and ability to manage the use of NMBDs. This overconfidence may be partially responsible for the failure to adopt routine perioperative neuromuscular monitoring. When clinicians are highly confident in their knowledge about a procedure, they are less likely to modify their clinical practice or seek further guidance on its use.
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Affiliation(s)
- Mohamed Naguib
- From the Department of General Anesthesia, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio
| | - Sorin J Brull
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Jacksonville, Florida
| | - Jennifer M Hunter
- Department of Musculoskeletal Biology, University of Liverpool, Liverpool, United Kingdom
| | | | - Béla Fülesdi
- Department of Anesthesiology and Intensive Care, University of Debrecen Faculty of Medicine, Debrecen, Hungary
| | - Ken B Johnson
- Department of Anesthesiology, University of Utah, Salt Lake City, Utah
| | - Hal R Arkes
- Department of Psychology, The Ohio StateUniversity, Columbus, Ohio
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Murray-Torres T, Casarella A, Bollini M, Wallace F, Avidan MS, Politi MC. Anesthesiology Control Tower-Feasibility Assessment to Support Translation (ACTFAST): Mixed-Methods Study of a Novel Telemedicine-Based Support System for the Operating Room. JMIR Hum Factors 2019; 6:e12155. [PMID: 31012859 PMCID: PMC6658281 DOI: 10.2196/12155] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 02/21/2019] [Accepted: 03/13/2019] [Indexed: 01/26/2023] Open
Abstract
Background Despite efforts to improve patient outcomes, major morbidity and mortality remain common after surgery. Health information technologies that provide decision support for clinicians might improve perioperative and postoperative patient care. Evaluating the usability of these technologies and barriers to their implementation can facilitate their acceptance within health systems. Objective This manuscript describes usability testing and refinement of an innovative telemedicine-based clinical support system, the Anesthesiology Control Tower (ACT). It also reports stakeholders’ perceptions of the barriers and facilitators to implementation of the intervention. Methods Three phases of testing were conducted in an iterative manner. Phase 1 testing employed a think-aloud protocol analysis to identify surface-level usability problems with individual software components of the ACT and its structure. Phase 2 testing involved an extended qualitative and quantitative real-world usability analysis. Phase 3 sought to identify major barriers and facilitators to implementation of the ACT through semistructured interviews with key stakeholders. Results Phase 1 and phase 2 usability testing sessions identified numerous usability problems with the software components of the ACT. The ACT platform was revised in seven iterations in response to these usability concerns. Initial satisfaction with the ACT, as measured by standardized instruments, was below commonly accepted cutoffs for these measures. Satisfaction improved to acceptable levels over the course of revision and testing. A number of barriers to implementation were also identified and addressed during the refinement of the ACT intervention. Conclusions The ACT model can improve the standard of perioperative anesthesia care. Through our thorough and iterative usability testing process and stakeholder assessment of barriers and facilitators, we enhanced the acceptability of this novel technology and improved our ability to implement this innovation into routine practice. International Registered Report Identifier (IRRID) RR2-10.1186/s40814-018-0233-4
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Affiliation(s)
- Teresa Murray-Torres
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, Washington University in St. Louis, St. Louis, MO, United States
| | - Aparna Casarella
- Brown School of Social Work, Washington University in St. Louis, St. Louis, MO, United States
| | - Mara Bollini
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, Washington University in St. Louis, St. Louis, MO, United States
| | - Frances Wallace
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, Washington University in St. Louis, St. Louis, MO, United States
| | - Mary C Politi
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
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62
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Pumphrey O, Grenville J, Colquhoun M, Mullins B, Earls P, Eaton S, Cleeve S. Head, heart or checklist? How self-reported decision-making strategies change according to speciality and grade: a cross-sectional survey of doctors. Postgrad Med J 2019; 95:148-154. [PMID: 31004043 DOI: 10.1136/postgradmedj-2018-136184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 02/04/2019] [Accepted: 02/06/2019] [Indexed: 11/03/2022]
Abstract
PURPOSE To identify and analyse variations in self-reported decision-making strategies between medical professionals of different specialty and grade. STUDY DESIGN We conducted a cross-sectional survey of doctors of different specialities and grades at St. George's Hospital, London, UK. We administered 226 questionnaires asking participants to assign proportions of their clinical decision-making behaviour to four strategies: intuitive, analytical, rule-based and creative. RESULTS We found that physicians said they used rule-based decision-making significantly more than did surgeons and anaesthetists (p = 0.025) and analytical decision-making strategies significantly less (p = 0.003). In addition, we found that both intuitive (p = 0.0005) and analytical (p = 0.0005) decision-making had positive associations with increasing experience, whereas rule-based decision-making was negatively associated with greater experience (p = 0.0005). CONCLUSIONS Decision-making strategies may evolve with increasing clinical experience from a predominant use of rule-based approaches towards greater use of intuitive or analytical methods depending on the familiarity and acuity of the clinical situation. Rule-based strategies remain important for delivering evidence-based care, particularly for less experienced clinicians, and for physicians more than surgeons, possibly due to the greater availability and applicability of guidelines for medical problems. Anaesthetists and intensivists tend towards more analytical decision-making than physicians; an observation which might be attributable to the greater availability and use of objective data in the care environment. As part of broader training in non-technical skills and human factors, increasing awareness among trainees of medical decision-making models and their potential pitfalls might contribute to reducing the burden of medical error in terms of morbidity, mortality and litigation.
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Affiliation(s)
- Oliver Pumphrey
- Cardiothoracic Surgery, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Jack Grenville
- Emergency Medicine, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, UK
| | - Matthew Colquhoun
- Infectious Diseases, Northwick Park Hospital, London North West University Healthcare, London, UK
| | - Barry Mullins
- Orthopaedic Surgery, Poole Hospital NHS Foundation Trust, Poole, UK
| | - Patrick Earls
- Anaesthetics, Whipps Cross Hospital, Barts Health NHS Trust, London, UK
| | - Simon Eaton
- Great Ormond Street Institute of Child Health, University College London Medical School, London, UK
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63
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Severe patient injury associated with mechanical ventilators: a “never event”. Anaesth Crit Care Pain Med 2019; 38:109-110. [DOI: 10.1016/j.accpm.2019.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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64
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Stacey MR. How to be a resilient doctor: skills to maximize your antifragility. Br J Hosp Med (Lond) 2018; 79:704-707. [PMID: 30526108 DOI: 10.12968/hmed.2018.79.12.704] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Mark Rw Stacey
- Consultant Anaesthetist and Welsh Associate Dean, Department of Anaesthetics, University Hospital Wales, Cardiff and Vale University Health Board, Cardiff CF14 4XW
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Berger M, Terrando N, Smith SK, Browndyke JN, Newman MF, Mathew JP. Neurocognitive Function after Cardiac Surgery: From Phenotypes to Mechanisms. Anesthesiology 2018; 129:829-851. [PMID: 29621031 PMCID: PMC6148379 DOI: 10.1097/aln.0000000000002194] [Citation(s) in RCA: 146] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
For half a century, it has been known that some patients experience neurocognitive dysfunction after cardiac surgery; however, defining its incidence, course, and causes remains challenging and controversial. Various terms have been used to describe neurocognitive dysfunction at different times after cardiac surgery, ranging from "postoperative delirium" to "postoperative cognitive dysfunction or decline." Delirium is a clinical diagnosis included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Postoperative cognitive dysfunction is not included in the DSM-5 and has been heterogeneously defined, though a recent international nomenclature effort has proposed standardized definitions for it. Here, the authors discuss pathophysiologic mechanisms that may underlie these complications, review the literature on methods to prevent them, and discuss novel approaches to understand their etiology that may lead to novel treatment strategies. Future studies should measure both delirium and postoperative cognitive dysfunction to help clarify the relationship between these important postoperative complications.
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Affiliation(s)
- Miles Berger
- Assistant Professor, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Niccolò Terrando
- Assistant Professor, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - S. Kendall Smith
- Critical Care Fellow, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Jeffrey N. Browndyke
- Assistant Professor, Division of Geriatric Behavioral Health, Department of Psychiatry & Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Mark F. Newman
- Merel H. Harmel Professor of Anesthesiology, and President of the Private Diagnostic Clinic, Duke University Medical Center, Durham, NC
| | - Joseph P. Mathew
- Jerry Reves, MD Professor and Chair, Department of Anesthesiology, Duke University Medical Center, Durham, NC
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Gregory S, Murray-Torres TM, Fritz BA, Ben Abdallah A, Helsten DL, Wildes TS, Sharma A, Avidan MS. Study protocol for the Anesthesiology Control Tower-Feedback Alerts to Supplement Treatments (ACTFAST-3) trial: a pilot randomized controlled trial in intraoperative telemedicine. F1000Res 2018; 7:623. [PMID: 30026931 PMCID: PMC6039946 DOI: 10.12688/f1000research.14897.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/07/2018] [Indexed: 03/17/2024] Open
Abstract
Background: Each year, over 300 million people undergo surgical procedures worldwide. Despite efforts to improve outcomes, postoperative morbidity and mortality are common. Many patients experience complications as a result of either medical error or failure to adhere to established clinical practice guidelines. This protocol describes a clinical trial comparing a telemedicine-based decision support system, the Anesthesiology Control Tower (ACT), with enhanced standard intraoperative care. Methods: This study is a pragmatic, comparative effectiveness trial that will randomize approximately 12,000 adult surgical patients on an operating room (OR) level to a control or to an intervention group. All OR clinicians will have access to decision support software within the OR as a part of enhanced standard intraoperative care. The ACT will monitor patients in both groups and will provide additional support to the clinicians assigned to intervention ORs. Primary outcomes include blood glucose management and temperature management. Secondary outcomes will include surrogate, clinical, and economic outcomes, such as incidence of intraoperative hypotension, postoperative respiratory compromise, acute kidney injury, delirium, and volatile anesthetic utilization. Ethics and dissemination: The ACTFAST-3 study has been approved by the Human Resource Protection Office (HRPO) at Washington University in St. Louis and is registered at clinicaltrials.gov ( NCT02830126). Recruitment for this protocol began in April 2017 and will end in December 2018. Dissemination of the findings of this study will occur via presentations at academic conferences, journal publications, and educational materials.
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Affiliation(s)
- Stephen Gregory
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, 63110, USA
| | - Teresa M. Murray-Torres
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, 63110, USA
| | - Bradley A. Fritz
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, 63110, USA
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, 63110, USA
| | - Daniel L. Helsten
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, 63110, USA
| | - Troy S. Wildes
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, 63110, USA
| | - Anshuman Sharma
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, 63110, USA
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, 63110, USA
| | - ACTFAST Study Group
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, 63110, USA
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Gregory S, Murray-Torres TM, Fritz BA, Ben Abdallah A, Helsten DL, Wildes TS, Sharma A, Avidan MS. Study protocol for the Anesthesiology Control Tower-Feedback Alerts to Supplement Treatments (ACTFAST-3) trial: a pilot randomized controlled trial in intraoperative telemedicine. F1000Res 2018; 7:623. [PMID: 30026931 PMCID: PMC6039946 DOI: 10.12688/f1000research.14897.2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/07/2018] [Indexed: 01/15/2023] Open
Abstract
Background: Each year, over 300 million people undergo surgical procedures worldwide. Despite efforts to improve outcomes, postoperative morbidity and mortality are common. Many patients experience complications as a result of either medical error or failure to adhere to established clinical practice guidelines. This protocol describes a clinical trial comparing a telemedicine-based decision support system, the Anesthesiology Control Tower (ACT), with enhanced standard intraoperative care. Methods: This study is a pragmatic, comparative effectiveness trial that will randomize approximately 12,000 adult surgical patients on an operating room (OR) level to a control or to an intervention group. All OR clinicians will have access to decision support software within the OR as a part of enhanced standard intraoperative care. The ACT will monitor patients in both groups and will provide additional support to the clinicians assigned to intervention ORs. Primary outcomes include blood glucose management and temperature management. Secondary outcomes will include surrogate, clinical, and economic outcomes, such as incidence of intraoperative hypotension, postoperative respiratory compromise, acute kidney injury, delirium, and volatile anesthetic utilization. Ethics and dissemination: The ACTFAST-3 study has been approved by the Human Resource Protection Office (HRPO) at Washington University in St. Louis and is registered at clinicaltrials.gov ( NCT02830126). Recruitment for this protocol began in April 2017 and will end in December 2018. Dissemination of the findings of this study will occur via presentations at academic conferences, journal publications, and educational materials.
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Affiliation(s)
- Stephen Gregory
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, 63110, USA
| | - Teresa M Murray-Torres
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, 63110, USA
| | - Bradley A Fritz
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, 63110, USA
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, 63110, USA
| | - Daniel L Helsten
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, 63110, USA
| | - Troy S Wildes
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, 63110, USA
| | - Anshuman Sharma
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, 63110, USA
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, 63110, USA
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Cheval B, Cullati S, Pihl-Thingvad J, Mongin D, Von Arx M, Chopard P, Courvoisier DS. Impact of CAre-related Regret Upon Sleep (ICARUS) cohort study: protocol of a 3-year multicentre, international, prospective cohort study of novice healthcare professionals. BMJ Open 2018; 8:e022172. [PMID: 29588326 PMCID: PMC5875595 DOI: 10.1136/bmjopen-2018-022172] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 02/09/2018] [Accepted: 02/13/2018] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION Healthcare professionals are particularly at risk of developing numerous physical and psychological health problems. The experiences of emotional burden associated with providing healthcare, notably care-related regret, have been associated with these health problems, but only using cross-sectional data so far. Evidence of a causal impact of regret has not been assessed. The Impact of CAre-related Regret Upon Sleep (ICARUS) study is the first prospective and international cohort study established to examine how newly practising healthcare professionals adapt to their challenging job by assessing the impact of care-related regret on sleep and job quitting. METHOD AND ANALYSIS The ICARUS cohort study will include newly practising healthcare professionals working in acute care hospitals and clinics recruited between May 2017 and November 2019. Data collection, which will begin as soon as the participant starts working with patients, will consist of a 1-year weekly assessment using a secure web survey. Follow-up data will be collected at 6, 12, 18 and 24 months after the end of the first year. We will collect detailed information on the experience of care-related regret (ie, highest regret intensity, accumulation of regrets and coping strategies related to regrets), sleep problems and job quitting. Moreover, quality of life, health status and burnout will be assessed during the follow-up. Several confounders factors, including sociodemographic characteristics, personality, night shifts and work environment characteristics, will be assessed. ETHICS AND DISSEMINATION The study was approved by the Ethics Committee of Geneva Canton, Switzerland (CCER2016-02041), the Ethics Committee of London South Bank University (HSCSEP/17/06) and the University Research Ethics Committee of Bedfordshire (UREC106). Other study centres deemed local ethical approval unnecessary since the main ethics committee (Geneva) had already accepted the project. Results will be published in relevant scientific journals and be disseminated in international conferences. Fully anonymised data and questionnaires will be freely accessible to everyone (scientists and general public).
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Affiliation(s)
- Boris Cheval
- Quality of Care Service, University Hospital of Geneva, Geneva, Switzerland
- Department of General Internal Medicine, Rehabilitation and Geriatrics, University of Geneva, Geneva, Switzerland
| | - Stéphane Cullati
- Department of General Internal Medicine, Rehabilitation and Geriatrics, University of Geneva, Geneva, Switzerland
- Swiss NCCR “Lives: Overcoming Vulnerability: Life Course Perspectives”, University of Geneva, Geneva, Denmark
| | - Jesper Pihl-Thingvad
- Department of Occupational and Environmental Medicine, Odense University Hospital, Odense, Denmark
- National Center of Psychotraumatology, University of Southern Denmark, Odense, Denmark
| | - Denis Mongin
- Quality of Care Service, University Hospital of Geneva, Geneva, Switzerland
- Department of General Internal Medicine, Rehabilitation and Geriatrics, University of Geneva, Geneva, Switzerland
| | - Martina Von Arx
- Swiss NCCR “Lives: Overcoming Vulnerability: Life Course Perspectives”, University of Geneva, Geneva, Denmark
- Institute of Demography and Socioeconomics, University of Geneva, Geneva, Switzerland
| | - Pierre Chopard
- Quality of Care Service, University Hospital of Geneva, Geneva, Switzerland
- Department of General Internal Medicine, Rehabilitation and Geriatrics, University of Geneva, Geneva, Switzerland
| | - Delphine S Courvoisier
- Quality of Care Service, University Hospital of Geneva, Geneva, Switzerland
- Department of General Internal Medicine, Rehabilitation and Geriatrics, University of Geneva, Geneva, Switzerland
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Ward S, Guest C, Goodall I, Bantel C. Practice and bias in intraoperative pain management: results of a cross-sectional patient study and a survey of anesthesiologists. J Pain Res 2018; 11:561-570. [PMID: 29588614 PMCID: PMC5859906 DOI: 10.2147/jpr.s153857] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Perioperative pain carries a considerable risk of becoming persistent; hence aggressive preventive approaches are advocated. Persistently high prevalence of postoperative pain, however, suggests anesthesiologists underuse these strategies. A prospective cross-sectional study of patients in the postanesthetic care unit (PACU) and a survey of anesthesiologists were thus conducted to evaluate practice and uncover bias in intraoperative pain management. Methods Notes of PACU patients were reviewed and information regarding surgical context, comorbidities, and analgesic administration was retrieved. Variables were analyzed for their predictive properties on pain and intraoperative analgesic management. Furthermore, clinical dose–effect estimates for intraoperative morphine were determined. Finally, anesthesiologists completed a questionnaire comprising statements regarding pain relating to surgical context and morphine administration. Results Data of 200 patients and 55 anesthesiologists were analyzed. Prevalence of pain in PACU was 28% and was predicted by local anesthetic (LA) and low-dose morphine administration. Additionally, when LA was used, little coanalgesics were employed. These results suggest a restrained approach by anesthesiologists toward intraoperative pain management. It is supported by their reluctance to administer more than 10 mg morphine, despite these individuals regarding this practice as insufficient. The hesitancy toward morphine also transpired in the dose–effect estimates with the average applied dose operating on an ED63 instead of an ED95 level. Conclusion This study confirmed a high prevalence of pain in PACU. It also indicated conservative intraoperative analgesic administration by anesthesiologists. The modest morphine usage and overreliance on LA application, which are not supported by published evidence, additionally suggest bias in current intraoperative pain management.
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Affiliation(s)
- Stephen Ward
- Pain Service, Barts Health, St Bartholomew's Hospital, London, UK
| | - Charlotte Guest
- Pain Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Ian Goodall
- Pain Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Carsten Bantel
- Section of Anaesthetics, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Management, Universität Oldenburg, Oldenburg, Germany
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Wang JY, Feng Y, Fu YH, Liu GL. Effect of Sevoflurane Anesthesia on Brain Is Mediated by lncRNA HOTAIR. J Mol Neurosci 2018; 64:346-351. [PMID: 29352445 DOI: 10.1007/s12031-018-1029-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 01/10/2018] [Indexed: 01/19/2023]
Abstract
Postoperative cognitive dysfunction in elderly patients has been related to neurodegenerative disorders and mortality. Sevoflurane anesthesia has been implicated in both postoperative cognitive dysfunction and neurotoxicity. Given the advantages of using inhaled anesthetics like sevoflurane, it is important to understand how their usage results in neurotoxicity and subsequently devise ways to circumvent or attenuate the anesthetic-mediated induction in neurotoxicity. Long noncoding RNAs (LncRNAs) are a group of > 200 bp long RNAs and show specific spatiotemporal expression profiles. Several recent reports suggest that lncRNAs are involved in responses of the central nervous system (CNS) following acute injuries. However, their role in sevoflurane anesthesia-mediated cognitive dysfunction has not been studied. RNA immunoprecipitation (RIP) combined with qRT-PCR detection of six different lncRNAs showed that the HOTAIR lncRNAs were significantly more bound to both Sin3A and coREST, both corepressors of the RE-1 silencing transcription factor, within rat hippocampus following sevoflurane anesthesia compared with sham. Sevoflurane inhalation resulted in significant inhibition of brain-derived neurotrophic factor (BDNF) and cognitive impairment. Treatment with a combination of siRNAs targeting HOTAIR rescued BDNF expression and improved cognitive responses. Taken together, our results suggest that sevoflurane-mediated brain function impairment is at least in part mediated by the HOTAIR lncRNA.
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Affiliation(s)
- Jian-Yue Wang
- Department of Anesthesiology, Binzhou People's Hospital, No.515, Huangheqi Road, Binzhou, Shandong, 256610, China.
| | - Yong Feng
- Department of Anesthesiology, Binzhou People's Hospital, No.515, Huangheqi Road, Binzhou, Shandong, 256610, China
| | - Yan-Hong Fu
- Department of Anesthesiology, Binzhou People's Hospital, No.515, Huangheqi Road, Binzhou, Shandong, 256610, China
| | - Guang-Li Liu
- Department of Anesthesiology, Binzhou People's Hospital, No.515, Huangheqi Road, Binzhou, Shandong, 256610, China
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Honardar MR, Posner KL, Domino KB. Delayed Detection of Esophageal Intubation in Anesthesia Malpractice Claims: Brief Report of a Case Series. Anesth Analg 2017; 125:1948-1951. [PMID: 28207593 DOI: 10.1213/ane.0000000000001795] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This retrospective case series analyzed 45 malpractice claims for delayed detection of esophageal intubation from the Anesthesia Closed Claims Project. Inclusion criteria were cases from 1995 to 2013, after adoption of identification of CO2 in expired gas to verify correct endotracheal tube position as a monitoring standard by the American Society of Anesthesiologists. Forty-nine percent (95% confidence interval 34%-64%) occurred in the operating room or other anesthesia location where CO2 detection equipment should have been available. The most common factors contributing to delayed detection were not using, ignoring, or misinterpreting CO2 readings. Misdiagnosis, as with bronchospasm, occurred in 33% (95% confidence interval 20%).
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Affiliation(s)
- Marzieh R Honardar
- From the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
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Bryan YF, Johnson KN. Procedural difficulties during successful intubation in octogenarians: A prospective observational study. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2017; 64:499-505. [PMID: 28366293 DOI: 10.1016/j.redar.2017.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 01/27/2017] [Accepted: 01/31/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE Octogenarians undergo anatomic and physiopathologic degradation, making airway management problematic, specific to intubation, bag mask ventilation, leading to desaturation and aspiration. Our study's aim was to examine the process of airway management regarding the steps involved in intubation and any deviations or delays in the tasks. MATERIALS AND METHODS An institutional review board-approved difficult airway prospective observational study in older adults was conducted. Inclusion criteria included airway features indicative of difficult airway, history of failed intubation, the planned use of specialized airway devices, and/or expected airway complications due to comorbidities. Patients 80 years and older were analyzed. Demographic data collected were age, weight, BMI, gender, ASA classification, airway indices, diagnosis, and procedures. Problems with intubation (INT) (≥3 intubation attempts), laborious assisted ventilation (VEN) (2-person and/or application of CPAP>20cmH2O), and complications with oxygenation (OXY) (SpO2<95%) were analyzed. RESULTS Of the 41 patients enrolled in the study, 3 (7.3%) had all 3: problematic (INT), laborious (VEN), and desaturated (OXY); 8 (19.5%) patients experienced problematic (INT), 20 (48.8%) were described as laborious (VEN), and 14 (34.1%) experienced complications with (OXY). CONCLUSION In octogenarians, we found a low incidence of difficulty with INT-VEN-OXY together. However, bag mask ventilation was found to be laborious with a high incidence of desaturation. Success rate of INT as a sole metric may not accurately describe the process of the intubation. We recommend alternative airway devices and techniques and the establishment of protocols for airway management in the elderly.
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Affiliation(s)
- Y F Bryan
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, Estados Unidos.
| | - K N Johnson
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, Estados Unidos
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Jaatun EAA, Fallon M, Kofod-Petersen A, Halvorsen K, Haugen DF. Users' perceptions on digital visualization of neuropathic cancer-related pain. Health Informatics J 2017; 25:683-700. [PMID: 28747078 DOI: 10.1177/1460458217720392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Quality pain management implies a thorough pain assessment with structured communication between patients and healthcare providers. Pain distribution is an important dimension of cancer pain. Assessment of pain distribution is commonly performed on a pain body map. This study explores how a computerized pain body map may function as a communication tool and visualize pain in patients with advanced cancer. In previous studies, we have developed a tablet-based computerized pain body map for use in cancer patients. The aim of this study was to adapt the computerized pain body map program to patients with neuropathic cancer-related pain, and to develop a separate interface for healthcare providers. We also wanted to investigate the perceived usefulness of this system among patients and healthcare providers. Both patients and healthcare providers perceived that the visualization of pain in the computerized pain body map system had potential to be a positive contribution to clinical pain management, and to improve collaboration between healthcare providers.
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Affiliation(s)
- Ellen Anna Andreassen Jaatun
- Norwegian University of Science and Technology, Norway; St. Olavs Hospital, Trondheim University Hospital, Norway
| | | | - Anders Kofod-Petersen
- Norwegian University of Science and Technology, Norway; The Alexandra Institute, Denmark
| | | | - Dagny Faksvåg Haugen
- Norwegian University of Science and Technology, Norway; Haukeland University Hospital, Norway; University of Bergen, Norway
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Fresh-Frozen Plasma: Ordering Patterns and Utilization in the Operating Rooms of a Tertiary Referral Hospital. Anesth Analg 2017; 124:618-622. [PMID: 28067700 DOI: 10.1213/ane.0000000000001789] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Blood product transfusion is the most commonly performed hospital procedure. Intraoperative blood product utilization varies between institutions and anesthesiologists. In the United States in 2011, nearly 4 million plasma units were transfused. METHODS A retrospective analysis of intraoperative plasma ordering patterns and utilization (thawing and transfusing) was performed at a tertiary, academic hospital between January 2015 and March 2016. RESULTS Over 15 months, 46,002 operative procedures were performed. In 1540 of them, plasma was thawed or transfused: 8297 plasma units were thawed and 3306 of those units were transfused. These 3306 plasma units were transfused in 749 cases with a median of 2 plasma units (interquartile range, 2-4) transfused. The percentage of average monthly procedures with plasma thawed and none transfused was 51.3% (confidence interval, 49.0%-53.6%). The cardiac surgery service requested the greatest number of plasma units to be thawed (2143) but only transfused 712 (33.2%) of them. Of all plasma units not transfused, 45% were generated by procedures with 1 to 4 units of plasma thawed; 95.7% of these units were thawed as even integers (ie, 2, 4). CONCLUSIONS For operative procedures, far more plasma was thawed than was transfused and this practice occurred across surgical specialties and anesthesiologists. Considering the plasma that was not transfused, 45% occurred in procedures with 4 or fewer units of plasma requested suggesting these low-volume requests were a primary source of potential waste. Further studies are needed to examine associations between plasma utilization and clinical outcomes.
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Prakash S, Bihari S, Need P, Sprick C, Schuwirth L. Immersive high fidelity simulation of critically ill patients to study cognitive errors: a pilot study. BMC MEDICAL EDUCATION 2017; 17:36. [PMID: 28178963 PMCID: PMC5299766 DOI: 10.1186/s12909-017-0871-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 01/26/2017] [Indexed: 06/06/2023]
Abstract
BACKGROUND The majority of human errors in healthcare originate from cognitive errors or biases. There is dearth of evidence around relative prevalence and significance of various cognitive errors amongst doctors in their first post-graduate year. This study was conducted with the objective of using high fidelity clinical simulation as a tool to study the relative occurrence of selected cognitive errors amongst doctors in their first post-graduate year. METHODS Intern simulation sessions on acute clinical problems, conducted in year 2014, were reviewed by two independent assessors with expertise in critical care. The occurrence of cognitive errors was identified using Likert scale based questionnaire and think-aloud technique. Teamwork and leadership skills were assessed using Ottawa Global Rating Scale. RESULTS The most prevalent cognitive errors included search satisfying (90%), followed by premature closure (PC) (78.6%), and anchoring (75.7%). The odds of occurrence of various cognitive errors did not change with time during internship, in contrast to teamwork and leadership skills (x2 = 11.9, P = 0.01). Anchoring appeared to be significantly associated with delay in diagnoses (P = 0.007) and occurrence of PC (P = 0.005). There was a negative association between occurrence of confirmation bias and the ability to make correct diagnosis (P = 0.05). CONCLUSIONS Our study demonstrated a high prevalence of anchoring, premature closure, and search satisfying amongst doctors in their first post-graduate year, using high fidelity simulation as a tool. The occurrence of selected cognitive errors impaired clinical performance and their prevalence did not change with time.
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Affiliation(s)
- Shivesh Prakash
- Prideaux Centre for Research in Health Professions Education, Flinders University, Bedford Park, South Australia, 5042, Australia.
- Department of Intensive care, Flinders Medical Centre, 1 Flinders drive, Bedford Park, South Australia, 5042, Australia.
| | - Shailesh Bihari
- Department of Intensive care, Flinders Medical Centre, 1 Flinders drive, Bedford Park, South Australia, 5042, Australia
| | - Penelope Need
- Director of General Practice Training, Flinders Medical Centre, Flinders Drive, Bedford Park, SA, 5042, Australia
| | - Cyle Sprick
- Simulation Unit, School of Medicine - Flinders University, Bedford Park, South Australia, 5042, Australia
| | - Lambert Schuwirth
- Prideaux Centre for Research in Health Professions Education, Flinders University, Bedford Park, South Australia, 5042, Australia
- Health Professions Education, School of Medicine, Flinders University, Bedford Park, South Australia, 5042, Australia
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Hasske E, Beil M, Keller K. Competency-based Education and Training of medical staff. A Programm of the Medical Academy Waldbreitbach: Concept - Implementation - Materials. GMS JOURNAL FOR MEDICAL EDUCATION 2017; 34:Doc41. [PMID: 29085885 PMCID: PMC5654121 DOI: 10.3205/zma001118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 10/04/2016] [Accepted: 11/18/2016] [Indexed: 05/17/2023]
Abstract
Objective: The aim of the Medical Academy Waldbreitbach is to connect individual and organisational requirements in order to promote an appropriate and multi-locational development of medical competency in the face of the continuously evolving challenges of clinical practice. Integral processes in this are the reduction of organisational learning barriers and the successive integration of competency-oriented learning events in the structures of personnel and organisational development. The modular system for the further development of doctors' skills serves here as a supplementary and recommendation system for both existing curricula and those defined by regulatory organisations and professional associations. Methods: The Medical Academy's modular system has a two-dimensional structure. In addition to the axis of biography orientation, the model orients itself around issues relating to the needs of a doctor in any individual professional position, as well as with whom he comes into contact and where his primary challenges lie. In order to achieve better integration in day-to-day routine and a needs-specific orientation of content, the modular system provides a combination of "one, two or three day and two- three- or four-hour training units" depending upon the topic. The transfer of experiential knowledge with the aid of practical exercises is a central element of the didactic model. Results: Through the combined use of summative and formative assessment, the significance of a dialogue-orientated approach in both planning and in the organisational process was highlighted. In feedback discussions and quantitative evaluation sheets, participants identified in particular cross-generational knowledge sharing as a central element for the development of personal values alongside the interdisciplinary transfer of knowledge. The combination of specialist and interdisciplinary topics, for example on team processes or communication, is frequently emphasised, indicating that this had been taught insufficiently and impractically during medical school. Longitudinal evaluations of continuous course units support this, so that the reinforcement of informal learning processes through feedback and exchange of experience is established as an effective and integral learning pattern within the modular system. Conclusion: The of the modular system of the Medical Academy Waldbreitbach - as an institution of the Marienhaus Hospitals Ltd. - is to develop the knowledge, ability and motivation of doctors both individually and professionally. Here, an equally high demand is placed upon the advancement of individual dispositions, attitudes and values, as well as on specialised topics, in order to promote/develop solutions-based and overall medical activity.
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Affiliation(s)
- Eva Hasske
- Waldbreitbacher Ärzteakademie, Marienhaus Holding GmbH, Waldbreitbach, Germany
| | - Michael Beil
- Waldbreitbacher Ärzteakademie, Marienhaus Holding GmbH, Waldbreitbach, Germany
| | - Katrin Keller
- Waldbreitbacher Ärzteakademie, Stabsstelle Unternehmens- und Organisationsentwicklung, Marienhaus Holding GmbH, Waldbreitbach, Germany
- *To whom correspondence should be addressed: Katrin Keller, Waldbreitbacher Ärzteakademie, Stabsstelle Unternehmens- und Organisationsentwicklung, Marienhaus Holding GmbH, Margaretha-Flesch-Str. 5, D-56588 Waldbreitbach, Germany, E-mail:
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Aiming for excellence – A simulation-based study on adapting and testing an instrument for developing non-technical skills in Norwegian student nurse anaesthetists. Nurse Educ Pract 2017; 22:37-46. [DOI: 10.1016/j.nepr.2016.11.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 09/11/2016] [Accepted: 11/28/2016] [Indexed: 11/21/2022]
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79
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Coleman BG, Johnson TM, Erley KJ, Topolski R, Rethman M, Lancaster DD. Preparing Dental Students and Residents to Overcome Internal and External Barriers to Evidence-Based Practice. J Dent Educ 2016. [DOI: 10.1002/j.0022-0337.2016.80.10.tb06198.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Brandon G. Coleman
- U.S. Army Advanced Education Program in Periodontics; Fort Gordon Georgia
| | - Thomas M. Johnson
- U.S. Army Advanced Education Program in Periodontics; Fort Gordon Georgia
| | - Kenneth J. Erley
- U.S. Army Advanced Education Program in Periodontics; Fort Gordon Georgia
| | | | - Michael Rethman
- Baltimore College of Dental Surgery; University of Maryland; College of Dentistry; The Ohio State University
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80
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Gibbs N, Weightman W. A forcing strategy to improve the evaluation of clinical superiority in anaesthesia trials. Br J Anaesth 2016; 117:281-3. [DOI: 10.1093/bja/aew255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Maintaining Professional Excellence in Contemporary Anesthesia Practice. Int Anesthesiol Clin 2016; 54:170-87. [DOI: 10.1097/aia.0000000000000100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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82
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Suria S, Harkouk H, Eghiaian A, Weil G. How to rationalize preoperative tests? A method to implement local guidelines successfully. Anaesth Crit Care Pain Med 2015; 35:103-7. [PMID: 26711017 DOI: 10.1016/j.accpm.2015.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 06/19/2015] [Accepted: 10/06/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Preoperative screening includes clinical examination and tests. Systematic prescription leads to excessive tests. We conducted an observational retrospective study to assess the success of implementing a protocol-guided prescription procedure for preoperative tests (PTs). We compared the number of PTs prescribed for scheduled surgery before and after the implementation of local guidelines with a specific method. METHODS Local guidelines for prescribing PTs based on the French Society of Anaesthesia's recommendations were developed, validated by the anaesthesia team and actively implemented. The implementation procedure was complex and based on the application of sociologic concepts to facilitate PT prescriptions in accordance with the protocol. All PTs (except for children and emergency surgeries) prescribed over a one-week observation period were analysed before and after protocol implementation, respectively in 2011 and 2013. RESULTS Two hundred and ninety-two patient files were analysed: 157 in 2011 and 135 in 2013. Ninety-one percent of the prescriptions were in accordance with the recommendations in 2013. Excessive prescribing decreased significantly after the implementation of recommendations (7.1% versus 20.7%, P<0.0001), enabling us to reduce excess costs. CONCLUSION We observed excellent adherence to the prescription protocol for PTs. The method used to implement the protocol was successful. A future evaluation should be undertaken to confirm these results over the long-term.
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Affiliation(s)
- Stéphanie Suria
- Service d'anesthésie, Gustave-Roussy Cancer Campus, 94805 Villejuif, France.
| | - Hakim Harkouk
- Service d'anesthésie, Gustave-Roussy Cancer Campus, 94805 Villejuif, France.
| | - Alexandre Eghiaian
- Service d'anesthésie, Gustave-Roussy Cancer Campus, 94805 Villejuif, France.
| | - Grégoire Weil
- Service d'anesthésie, Gustave-Roussy Cancer Campus, 94805 Villejuif, France.
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83
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Review of crisis resource management (CRM) principles in the setting of intraoperative malignant hyperthermia. J Anesth 2015; 30:298-306. [DOI: 10.1007/s00540-015-2115-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Accepted: 11/23/2015] [Indexed: 12/21/2022]
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84
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Lighthall GK, Vazquez-Guillamet C. Understanding Decision Making in Critical Care. Clin Med Res 2015; 13:156-68. [PMID: 26387708 PMCID: PMC4720506 DOI: 10.3121/cmr.2015.1289] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 08/06/2015] [Indexed: 12/28/2022]
Abstract
BACKGROUND Human decision making involves the deliberate formulation of hypotheses and plans as well as the use of subconscious means of judging probability, likely outcome, and proper action. RATIONALE There is a growing recognition that intuitive strategies such as use of heuristics and pattern recognition described in other industries are applicable to high-acuity environments in medicine. Despite the applicability of theories of cognition to the intensive care unit, a discussion of decision-making strategies is currently absent in the critical care literature. CONTENT This article provides an overview of known cognitive strategies, as well as a synthesis of their use in critical care. By understanding the ways by which humans formulate diagnoses and make critical decisions, we may be able to minimize errors in our own judgments as well as build training activities around known strengths and limitations of cognition.
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Affiliation(s)
- Geoffrey K Lighthall
- Associate Professor, Department of Anesthesia, Stanford University School of Medicine, Stanford, California USA
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Abstract
PURPOSE OF REVIEW Cognitive aids and other methods of decision support are receiving increased interest by the anesthesia community. These tools have significant safety implications because of the possibility to decrease variability in human performance. RECENT FINDINGS Studies of the use of cognitive aids during realistic simulations supports use of cognitive aids and other decision support tools. SUMMARY The early work in this field of decision support is encouraging but there are many questions regarding the optimal design, presentation and use.
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Lane-Fall M, Gutsche JT, Augoustides JGT. Are intraoperative anesthesia handovers associated with harm? Getting to the heart of the matter in cardiac surgery: the search for the hat-trick of quality, safety, and continuous improvement. J Cardiothorac Vasc Anesth 2014; 29:8-10. [PMID: 25620138 DOI: 10.1053/j.jvca.2014.10.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Indexed: 12/19/2022]
Affiliation(s)
- Meghan Lane-Fall
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jacob T Gutsche
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G T Augoustides
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Spontaneous coronary artery dissection in a parturient with Nail-Patella syndrome. Int J Obstet Anesth 2014; 24:69-73. [PMID: 25433575 DOI: 10.1016/j.ijoa.2014.07.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Revised: 07/21/2014] [Accepted: 07/22/2014] [Indexed: 01/25/2023]
Abstract
Spontaneous coronary artery dissection is an uncommon cause of acute coronary syndrome, occurring predominantly in women during and immediately after pregnancy; it carries a mortality rate of greater than 50%. While the exact etiology is unknown, possible contributing factors include pregnancy-related hormonal, connective tissue and hemodynamic changes. We present a case of a 35-year-old multigravid woman with Nail-Patella syndrome who developed an acute myocardial infarction secondary to spontaneous coronary artery dissection during labor which was not diagnosed until after delivery. We hypothesize that abnormal collagen fiber formation found in Nail-Patella syndrome may have put her at an increased risk of coronary dissection and myocardial infarction. Regardless of etiology, a delay in diagnosis of myocardial ischemia can lead to significant morbidity and mortality. In light of the increasing burden of cardiac disease in the obstetric population, clinicians should remain vigilant for signs of myocardial infarction and prepare for definitive diagnosis and treatment.
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