1
|
Mulumba KY, Mariano ER, Leng JC, Kou A, Hunter OO, Tamboli M, Memtsoudis SG, Mudumbai SC. Changing a clinical pathway to increase spinal anesthesia use for elective hip arthroplasty: a single-centre historical cohort study. Can J Anaesth 2023; 70:211-218. [PMID: 36482246 DOI: 10.1007/s12630-022-02371-5] [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: 01/05/2022] [Revised: 08/24/2022] [Accepted: 08/24/2022] [Indexed: 12/13/2022] Open
Abstract
PURPOSE International consensus recommendations support neuraxial anesthesia as the preferred anesthetic technique for total hip arthroplasty. We hypothesized that an institutional initiative to promote spinal anesthesia within a clinical pathway would result in increased use of this technique. METHODS We reviewed primary unilateral total hip arthroplasty data between June 2017 and June 2019-one year before vs one year after implementation. The primary outcome was rate of spinal anesthesia use. Secondary outcomes included postoperative pain scores and opioid use, rates of postoperative complications, and unplanned resource use. We built a run chart-tracking rates of spinal anesthesia; compared postoperative outcomes based on anesthetic technique; and developed a mixed model, multivariable logistic regression with margins analysis evaluating the use of spinal anesthesia. RESULTS The final sample included 172 patients (87 before and 85 after implementation) with no significant differences in baseline characteristics. For the primary outcome, 42/87 (48%) patients received spinal anesthesia before implementation compared with 48/85 (56%) postimplementation (unadjusted difference, 8%; 95% confidence interval, -7 to 23; P = 0.28). There were no differences in secondary outcomes. Factors associated with receipt of spinal anesthesia included American Society of Anesthesiologists Physical Status II (vs III), lower body mass index, and shorter case duration. Using a reduced mixed model, the average marginal effect was 10.7%, with an upper 95% confidence limit of 25.7%. CONCLUSION Implementation of a clinical pathway change to promote spinal anesthesia for total hip arthroplasty may not have been associated with increased use of spinal anesthesia, but utilization rates can vary widely. Baseline spinal anesthesia usage at our institution was higher than the USA national average, and many factors may influence choice of anesthesia technique. Patients who receive spinal anesthesia have decreased opioid requirements and pain scores postoperatively.
Collapse
Affiliation(s)
- Kabungo Y Mulumba
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Edward R Mariano
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue (112A), Palo Alto, CA, 94304, USA.
| | - J C Leng
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue (112A), Palo Alto, CA, 94304, USA
| | - Alex Kou
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue (112A), Palo Alto, CA, 94304, USA
| | - Oluwatobi O Hunter
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue (112A), Palo Alto, CA, 94304, USA
| | - Mallika Tamboli
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Stavros G Memtsoudis
- Departments of Anesthesiology and Public Health, Weill Cornell Medical College, New York, NY, USA
- Department of Anesthesiology, Hospital for Special Surgery, New York, NY, USA
| | - Seshadri C Mudumbai
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue (112A), Palo Alto, CA, 94304, USA
| |
Collapse
|
2
|
Kwong JZ, Mudumbai SC, Hernandez-Boussard T, Popat RA, Mariano ER. Practice Patterns in Perioperative Nonopioid Analgesic Administration by Anesthesiologists in a Veterans Affairs Hospital. PAIN MEDICINE 2021; 21:e208-e214. [PMID: 31559430 DOI: 10.1093/pm/pnz226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Although multimodal analgesia (MMA) is recommended for perioperative pain management, previous studies have found substantial variability in its utilization. To better understand the factors that influence anesthesiologists' choices, we assessed the associations between patient or surgical characteristics and number of nonopioid analgesic modes received intraoperatively across a variety of surgeries in a university-affiliated Veteran Affairs hospital. METHODS We included elective inpatient surgeries (orthopedic, thoracic, spine, abdominal, and pelvic procedures) that used at least one nonopioid analgesic within a one-year period. Multivariable multinomial logistic regression models were used to estimate adjusted odds ratios and 95% confidence intervals (CIs). We also described the combinations of analgesia used in each surgical subtype and conducted exploratory analyses to test the associations between the number of modes used and postoperative outcomes. RESULTS Of the 1,087 procedures identified, 33%, 53%, and 14% were managed with one, two, and three or more modes, respectively. Older patients had lower odds of receiving three or more modes (adjusted odds ratio [aOR] = 0.28, 95% confidence interval [CI] = 0.15-0.52), as were patients with more comorbidities (two modes: aOR = 0.87, 95% CI = 0.79-0.96; three or more modes: aOR = 0.81, 95% CI = 0.71-0.94). Utilization varied across surgical subtypes P < 0.0001). Increasing the number of modes, particularly use of regional anesthesia, was associated with shorter length of stay. CONCLUSIONS Our study suggests that age, comorbidities, and surgical type contribute to variability in MMA utilization. Risks and benefits of multiple modes should be carefully considered for older and sicker patients. Future directions include developing patient- and procedure-specific perioperative MMA recommendations.
Collapse
Affiliation(s)
- Jereen Z Kwong
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Seshadri C Mudumbai
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California.,Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | | | - Rita A Popat
- Health Research and Policy (Epidemiology), Stanford University, Stanford, California, USA
| | - Edward R Mariano
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California.,Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| |
Collapse
|
3
|
Spielberger J, Heid F, Schmidtmann I, Drees P, Betz U, Schwaderlapp W, Pestel G. [Patient-centered perioperative vigilance: perioperative process quality, effectiveness of pain treatment and mobilization progress after implementation of a treatment bundle for total knee endoprosthesis]. Anaesthesist 2020; 70:213-222. [PMID: 33103209 PMCID: PMC7921075 DOI: 10.1007/s00101-020-00874-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 07/21/2020] [Accepted: 07/25/2020] [Indexed: 12/03/2022]
Abstract
Hintergrund In den USA wurde das Konzept des „perioperative surgical home“ initialisiert, in dem ein teamorientiertes Vorgehen einen umfassenderen und zügigeren Heilverlauf erzielen soll. Fragestellung Evaluation des Effekts eines interdisziplinären Maßnahmenbündels (patient*innenzentrierte perioperative Versorgung, PPV) auf Aspekte der Prozessqualität unter deutschen Rahmenbedingungen. Material und Methoden Nach Einführung des PPV-Maßnahmenbündels (1. Patient*innenseminar, 2. spezifische Chirurgietechnik, 3. spezifische Anästhesietechnik, 4. Physiotherapiebeginn am Operationstag) wurden 34 Patient*innen mit elektiver Knietotalendoprothese prospektiv untersucht und mit „matched-pair“-Kontrollen verglichen. Endpunkte sind Dauer der Einleitungszeit (primär) und Krankenhausverweildauer, Ruhe- und Belastungsschmerz am 1. postoperativen Tag (numerische Analogskala), und Mobilisationsfortschritt (MBF) an den postoperativen Tagen 1, 3 und 6 (sekundär). Gruppenvergleiche wurden mit Wilcoxon-Mann-Whitney-Tests auf Nichtunterlegenheit durchgeführt. Im Fall von Nichtunterlegenheit wurde anschließend auf Überlegenheit getestet. Ergebnisse Die Einleitungszeit in der PPV-Gruppe betrug im Median 13,5 min (Kontrollgruppe: 60 min, p < 0,0001), die Krankenhausverweildauer betrug in der PPV-Gruppe 8 Tage (Kontrollgruppe: 12 Tage, p < 0,0001). Am ersten postoperativen Tag betrug die mediane Ruheschmerzstärke in der PPV-Gruppe 30 (Kontrollgruppe: 20); die Belastungsschmerzstärke war in beiden Gruppen gleich (Median 40). Die Mobilisation der Patienten*innen der PPV-Gruppe gelang an den postoperativen Tagen 1, 3 und 6 besser (jeweils p < 0,0001). Schlussfolgerung Das Konzept der patient*innenzentrierten perioperativen Versorgung (PPV) erscheint vielversprechend genug, um weitere klinische Studien zu rechtfertigen.
Collapse
Affiliation(s)
- J Spielberger
- Klinik für Anästhesiologie, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - F Heid
- Klinik für Anästhesiologie, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - I Schmidtmann
- Institut für Medizinische Biometrie, Epidemiologie und Informatik, Universitätsmedizin Mainz, Mainz, Deutschland
| | - P Drees
- Zentrum für Orthopädie und Unfallchirurgie, Universitätsmedizin Mainz, Mainz, Deutschland
| | - U Betz
- Institut für Physikalische Therapie, Prävention und Rehabilitation, Universitätsmedizin Mainz, Mainz, Deutschland
| | - W Schwaderlapp
- Klinik für Anästhesiologie, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - G Pestel
- Klinik für Anästhesiologie, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland.
| |
Collapse
|
4
|
Yuan D, Zhang QS, Zhang K, Cao YW, Chen GH, Ling ZZ, Xu H. Total Knee Arthroplasty Using a Medial Pivot or Posterior Cruciate-Stabilizing Prosthesis in Chinese Patients. J Knee Surg 2020; 33:892-898. [PMID: 31064021 DOI: 10.1055/s-0039-1688784] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
There is an unmet need for a prosthesis designed according to the anatomical parameters of the Chinese population. This study aims to compare the use of a medial pivot (MP) implant or posterior cruciate ligament (PCL) substitution (posterior-stabilized [PS]) prosthesis for unilateral total knee arthroplasty (TKA) in a Chinese population. The medical records of patients undergoing unilateral TKA with an MP implant (Group A) or a PS prosthesis (Group B) at our institution between January 2010 and December 2011 were retrospectively reviewed. Patients were followed up for 5 years. Preoperatively and at the December 2016 postoperative follow-up, the Hospital for Special Surgery scoring system (HSS knee score) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score were measured to evaluate TKA outcomes. This study included 49 patients in Group A and 51 in Group B. As of December 2016, there were no significant differences in the preoperative/postoperative changes in any category of the HSS knee score or WOMAC score between the groups. There were no postoperative complications in either group during the 5-year follow-up. There were no periprosthetic infections or need for revision surgery. One patient in Group A experienced aching and a small amount of effusion in the articular cavity that was attributed to overexertion. In conclusion, there were no significant differences in midterm outcomes in Chinese patients receiving an MP implant or a PS prosthesis for unilateral TKA. These data suggest that the MP and PCL substitution design are safe and effective for unilateral TKA in China.
Collapse
Affiliation(s)
- Ding Yuan
- Department of Emergency Medicine, Qingdao Municipal Hospital Group, Qingdao, Shandong, China
| | - Quan-San Zhang
- Department of Emergency Medicine, Qingdao Municipal Hospital Group, Qingdao, Shandong, China
| | - Kun Zhang
- Department of Urology, Qingdao Eighth People's Hospital, Qingdao, Shandong, China
| | - Yan-Wei Cao
- Department of Urology, Affiliated Hospital of Medical College, Qingdao University, Qingdao, Shandong, China
| | - Guan-Hong Chen
- Department of Orthopedics, Shanxian Central Hospital, Shanxian, Shandong, China
| | - Zong-Zhun Ling
- Department of Emergency Medicine, Qingdao Municipal Hospital Group, Qingdao, Shandong, China
| | - Hui Xu
- Department of Anesthesiology, Affiliated Hospital of Medical College, Qingdao University, Qingdao, China
| |
Collapse
|
5
|
Improving the cost, quality, and safety of perioperative care: A systematic review of the literature on implementation of the perioperative surgical home. J Clin Anesth 2020; 63:109760. [DOI: 10.1016/j.jclinane.2020.109760] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/17/2020] [Accepted: 02/28/2020] [Indexed: 12/14/2022]
|
6
|
The impact of individualized care after artificial knee replacement surgery for patients with valgus deformity of the knee†. FRONTIERS OF NURSING 2020. [DOI: 10.2478/fon-2020-0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Objective
To evaluate the perioperative nursing of total knee arthroplasty for patients with valgus deformity of the knee.
Methods
Seventy-six patients who underwent surgical treatment were enrolled in the study from March 2014 to March 2018. The patients in the control group were treated with routine nursing. The experimental group was treated not only with routine nursing but also with health education, psychological care, family social support, and other nursing intervention. Hospital for special surgery and Pittsburgh sleep quality index were used to evaluate the effect of nursing intervention on patients after operation.
Results
All the index scores of the experimental group were lower than those of the control group (P < 0.05), indicating that the function of the diseased limb and the patient's sleep status improved significantly after the intervention.
Conclusions
Individualized nursing can improve the recovery of limb function and improve the patients’ quality of life. It is very effective for nurses to implement individualized nursing measures for patients after surgery.
Collapse
|
7
|
Joo SS, Hunter OO, Tamboli M, Leng JC, Harrison TK, Kassab K, Keeton JD, Skirboll S, Tharin S, Saleh E, Mudumbai SC, Wang RR, Kou A, Mariano ER. Implementation of a patient-specific tapering protocol at discharge decreases total opioid dose prescribed for 6 weeks after elective primary spine surgery. Reg Anesth Pain Med 2020; 45:474-478. [DOI: 10.1136/rapm-2020-101324] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 03/05/2020] [Accepted: 03/07/2020] [Indexed: 01/30/2023]
Abstract
Background and objectivesAt our institution, we developed an individualized discharge opioid prescribing and tapering protocol for joint replacement patients and implemented the same protocol for neurosurgical spine patients. We then tested the hypothesis that this protocol will decrease the oral morphine milligram equivalent (MME) dose of opioid prescribed postdischarge after elective primary spine surgery.MethodsIn this retrospective cohort study, we identified all consecutive elective primary spine surgery cases 1 year before and after introduction of the protocol. This protocol used the patient’s prior 24-hour inpatient opioid consumption to determine discharge opioid pill count and tapering schedule. The primary outcome was total opioid dose prescribed in oral MME from discharge through 6 weeks. Secondary outcomes included in-hospital opioid consumption in MME, hospital length of stay, MME prescribed at discharge, opioid refills, and rates of minor and major adverse events.ResultsEighty-three cases comprised the final sample (45 preintervention and 38 postintervention). There were no differences in baseline characteristics. The total oral MME (median (IQR)) from discharge through 6 weeks postoperatively was 900 (420–1440) preintervention compared with 300 (112–806) postintervention (p<0.01, Mann-Whitney U test), and opioid refill rates were not different between groups. There were no differences in other outcomes.ConclusionsThis patient-specific prescribing and tapering protocol effectively decreases the total opioid dose prescribed for 6 weeks postdischarge after elective primary spine surgery. Our experience also demonstrates the potential generalizability of this protocol, which was originally designed for joint replacement patients, to other surgical populations.
Collapse
|
8
|
Leng JC, Mariano ER. A little better is still better: using marginal gains to enhance ‘enhanced recovery’ after surgery. Reg Anesth Pain Med 2020; 45:173-175. [DOI: 10.1136/rapm-2019-101239] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 12/21/2019] [Indexed: 12/11/2022]
|
9
|
Mariano ER, Schatman ME. A Commonsense Patient-Centered Approach to Multimodal Analgesia Within Surgical Enhanced Recovery Protocols. J Pain Res 2019; 12:3461-3466. [PMID: 31920369 PMCID: PMC6935269 DOI: 10.2147/jpr.s238772] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 12/14/2019] [Indexed: 12/18/2022] Open
Affiliation(s)
- Edward R Mariano
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Michael E Schatman
- Department of Public Health & Community Medicine, Tufts University School of Medicine, Boston, MA, USA.,Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, MA, USA
| |
Collapse
|
10
|
Tamboli M, Leng JC, Hunter OO, Kou A, Mudumbai SC, Memtsoudis SG, Walters TL, Lochbaum GM, Mariano ER. Five-year follow-up to assess long-term sustainability of changing clinical practice regarding anesthesia and regional analgesia for lower extremity arthroplasty. Korean J Anesthesiol 2019; 73:401-407. [PMID: 31865661 PMCID: PMC7533175 DOI: 10.4097/kja.19400] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 12/19/2019] [Indexed: 11/10/2022] Open
Abstract
Background Long-term and sustainable clinical practice changes in anesthesia procedures have not previously been reported. Therefore, we performed a 5-year audit following implementation of a clinical pathway change favoring spinal anesthesia for total knee arthroplasty (TKA). We similarly evaluated a parallel cohort of patients undergoing total hip arthroplasty (THA), who did not undergo a clinical pathway change, and studied utilization rates of continuous peripheral nerve block (CPNB). Methods We identified all primary unilateral TKA and THA cases completed from January 2013 through December 2018, thereby including clinical pathway change data from one-year pre-implementation to 5-years post-implementation. Our primary outcome was the overall application rate of spinal anesthesia. Secondary outcomes included CPNB utilization rate, 30-day postoperative complications, and resource utilization variables such as hospital readmission, emergency department visits, and blood transfusions. Results The sample included 1,859 cases, consisting of 1,250 TKAs and 609 THAs. During the initial year post-implementation, 174/221 (78.7%) TKAs received spinal anesthesia compared to 23/186 (12.4%) cases the year before implementation (P < 0.001). During the following 4-year period, 647/843 (77.2%) TKAs received spinal anesthesia (P = 0.532 vs. year 1). The number of THA cases receiving spinal anesthesia the year after implementation was 78/124 (62.9%), compared to 48/116 (41.4%) pre-implementation (P = 0.001); however, the rate decreased over the following 4-year period to 193/369 (52.3%) (P = 0.040 vs. year 1). CPNB use was high in both TKA and THA patient groups, and there were no differences in 30-day postoperative complications, hospital readmission, emergency department visits, or blood transfusions between patients who underwent spinal and general anesthesia in both TKA and THA groups. Conclusions A clinical pathway change promoting spinal anesthesia for TKA can be effectively implemented and sustained over a 5-year period.
Collapse
Affiliation(s)
- Mallika Tamboli
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Jody C Leng
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Oluwatobi O Hunter
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Alex Kou
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Seshadri C Mudumbai
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Stavros G Memtsoudis
- Departments of Anesthesiology and Public Health, Weill Cornell Medical College, New York, NY, USA.,Department of Anesthesiology, Hospital for Special Surgery, New York, NY, USA
| | - Tessa L Walters
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Gregory Milo Lochbaum
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Edward R Mariano
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| |
Collapse
|
11
|
Sun L, Tamboli M, Wang RR, Kandarian BS, Wong A, Lochbaum GM, Mariano ER. How anesthesiologists adapted to a nationwide spinal bupivacaine drug shortage. J Clin Anesth 2019; 61:109668. [PMID: 31761415 DOI: 10.1016/j.jclinane.2019.109668] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 10/11/2019] [Accepted: 11/16/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Lisa Sun
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA; Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA.
| | - Mallika Tamboli
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA; Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA.
| | - Rachel R Wang
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA; Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA.
| | - Brandon S Kandarian
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA; Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA.
| | - Audrey Wong
- Pharmacy Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA.
| | - Gregory Milo Lochbaum
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA; Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA.
| | - Edward R Mariano
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA; Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA.
| |
Collapse
|
12
|
Chi D, Mariano ER, Memtsoudis SG, Baker LC, Sun EC. Regional Anesthesia and Readmission Rates After Total Knee Arthroplasty. Anesth Analg 2019; 128:1319-1327. [PMID: 31094807 PMCID: PMC6605076 DOI: 10.1213/ane.0000000000003830] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Total knee arthroplasty is a commonly performed procedure and an important contributor to national health care spending. Reducing the incidence of readmission could have important consequences for patient well-being and relevant financial implications. Whether regional anesthesia techniques are associated with decreased readmission rates and costs among privately insured patients remains unknown. METHODS Using administrative claims data, we identified 138,362 privately insured patients 18-64 years of age who underwent total knee arthroplasty between 2002 and 2013. We then examined whether the use of a nerve block was associated with decreases in readmission rates and related costs during the 90 days after discharge. Our analyses were adjusted for potential confounding variables including medical comorbidities and previous use of opioids and other medications. RESULTS After adjusting for patient demographics, comorbidities, and preoperative medication use, the adjusted 90-day readmission rate was 1.8% (95% confidence interval [CI], 1.1-2.4) among patients who did not receive a block compared to 1.7% (95% CI, 1.1-2.4) among patients who did (odds ratio, 0.99; 95% CI, 0.91-1.09; P = .85). The adjusted readmission-related postoperative cost for patients who did not receive a block was $561 (95% CI, 502-619) and $574 (95% CI, 508-639) for patients who did (difference, $13; 95% CI, -75 to 102; P = .74). This lack of statistically significant differences held for subgroup and sensitivity analyses. CONCLUSIONS Nerve blocks were not associated with improved measures of long-term postoperative resource use in this younger, privately insured study population.
Collapse
Affiliation(s)
- Debbie Chi
- From the Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford University, Stanford, California
| | - Edward R Mariano
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford University, Stanford, California
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York
| | - Laurence C Baker
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
- National Bureau of Economic Research, Cambridge, Massachusetts
| | - Eric C Sun
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford University, Stanford, California
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
| |
Collapse
|
13
|
Kandarian B, Indelli PF, Sinha S, Hunter OO, Wang RR, Kim TE, Kou A, Mariano ER. Implementation of the IPACK (Infiltration between the Popliteal Artery and Capsule of the Knee) block into a multimodal analgesic pathway for total knee replacement. Korean J Anesthesiol 2019; 72:238-244. [PMID: 30776878 PMCID: PMC6547229 DOI: 10.4097/kja.d.18.00346] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 02/14/2019] [Indexed: 01/17/2023] Open
Abstract
Background The Infiltration between the Popliteal Artery and Capsule of the Knee (IPACK) block is a new anesthesiologist- administered analgesic technique for controlling posterior knee pain that has not yet been well studied in total knee arthroplasty (TKA) patients. We compared pain outcomes in TKA patients before and after implementation of the IPACK with the hypothesis that patients receiving IPACK blocks will report lower pain scores on postoperative day (POD) 0 than non-IPACK patients. Methods With Institutional Review Board approval, we retrospectively reviewed data for consecutive TKA patients by a single surgeon 4 months before (PRE) and after (POST) IPACK implementation. All TKA patients received adductor canal catheters and peri-operative multimodal analgesia. The primary outcome was pain on POD 0. Other outcomes were daily pain scores, opioid consumption, ambulation distance, length of stay, and adverse events within 30 days. Results Post-implementation, 48/50 (96%) of TKA patients received an IPACK block, and they were compared with 32 patients in the PRE group. On POD 0, the lowest pain score (median [10th–90th percentiles]) was significantly lower for the POST group compared to the PRE group (0 [0–4.3] vs. 2.5 [0–7]; P = 0.003). The highest patient-reported pain scores on any POD were similar between groups with no differences in other outcomes. Conclusions Within a multimodal analgesic protocol, addition of IPACK blocks decreased the lowest pain scores on POD 0. Although other outcomes were unchanged, there may be a role for new opioid-sparing analgesic techniques, and changing clinical practice change can occur rapidly.
Collapse
Affiliation(s)
- Brandon Kandarian
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Pier F Indelli
- Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, CA, USA.,Orthopedic Surgery Section, Surgical Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Sanjay Sinha
- Department of Anesthesiology, St. Francis Hospital and Medical Center, Hartford, CT, USA
| | - Oluwatobi O Hunter
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Rachel R Wang
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - T Edward Kim
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Alex Kou
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Edward R Mariano
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| |
Collapse
|
14
|
Mudumbai SC, Auyong DB, Memtsoudis SG, Mariano ER. A pragmatic approach to evaluating new techniques in regional anesthesia and acute pain medicine. Pain Manag 2018; 8:475-485. [DOI: 10.2217/pmt-2018-0017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Anesthesiologists set up regional anesthesia and acute pain medicine programs in order to improve the patient outcomes and experience. Given the increasing frequency and volume of newly described techniques, applying a pragmatic framework can guide clinicians on how to critically review and consider implementing the new techniques into clinical practice. A proposed framework should consider how a technique: increases access; enhances efficiency; decreases disparities and improves outcomes. Quantifying the relative contribution of these four factors using a point system, which will be specific to each practice, can generate an overall scorecard to help clinicians make decisions on whether or not to incorporate a new technique into clinical practice or replace an incumbent technique within a clinical pathway.
Collapse
Affiliation(s)
- Seshadri C Mudumbai
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - David B Auyong
- Department of Anesthesiology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY, USA
- Departments of Anesthesiology and Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, USA
| | - Edward R Mariano
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| |
Collapse
|
15
|
Elkassabany NM, Memtsoudis SG, Mariano ER. What Can Regional Anesthesiology and Acute Pain Medicine Learn from "Big Data"? Anesthesiol Clin 2018; 36:467-478. [PMID: 30092941 DOI: 10.1016/j.anclin.2018.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Demonstrating value added to patients' experience through regional anesthesiology and acute pain medicine is critical. Evidence supporting improved outcomes can be derived from prospective studies or retrospective cohort studies. Population-based studies relying on existing clinical and administrative databases are helpful when an outcome is rare and detecting a change would require studying large numbers of patients. This article discusses the effect of regional anesthesiology and acute pain medicine interventions on mortality and morbidity, infection rate, cancer recurrence, inpatient falls, local anesthetic systemic toxicity, persistent postsurgical pain, and health care costs.
Collapse
Affiliation(s)
- Nabil M Elkassabany
- Sections of Orthopedic and Regional Anesthesiology, Department of Anesthesiology and Critical Care, University of Pennsylvania, 3400 Spruce Street, Dulles 6, Philadelphia, PA 19104, USA.
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Weill Cornell Medical College, Hospital for Special Surgery, 535 East 70th street, New York, NY 10021, USA
| | - Edward R Mariano
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Stanford University School of Medicine, 3801 Miranda Avenue, Palo Alto, CA 94304, USA
| |
Collapse
|
16
|
Walters TL, Kim TE, Mariano ER, Lighthall GK. Perioperative Surgical Home Reduces Rapid Response Calls to a Postoperative Surgical Ward: How Anesthesiologists Are Improving the Inpatient Safety Net. Semin Cardiothorac Vasc Anesth 2018. [PMID: 29514558 DOI: 10.1177/1089253218761813] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Perioperative Surgical Home (PSH) is an anesthesiologist-led, coordinated care model that may improve patient experience and safety. We hypothesized that PSH will decrease activation of the rapid response system for surgical inpatients. METHODS This retrospective study was performed at an academic Veterans Affairs hospital with a PSH. Data from both medical and surgical cohorts admitted to a single ward were analyzed for the Pre-PSH (July 2006 to October 2010) and Post-PSH (November 2011 to May 2015) epochs. The primary outcome was incidence of rapid response team (RRT) activations per 1000 bed-days. RESULTS Surgical patients had 5.8 RRT activations per 1000 bed-days Pre-PSH versus 3.7/1000 bed-days Post-PSH ( P = .006). There was no difference in RRT activations per 1000 bed-days for medical patients before and after PSH implementation. Pre-PSH was an independent predictor of mortality in the multivariable model (odds ratio = 1.7; P = .010). CONCLUSION PSH is associated with decreased RRT activations among surgical inpatients only.
Collapse
Affiliation(s)
- Tessa L Walters
- 1 VA Palo Alto Health Care System, Palo Alto, CA, USA.,2 Stanford University School of Medicine, Stanford, CA, USA
| | - T Edward Kim
- 1 VA Palo Alto Health Care System, Palo Alto, CA, USA.,2 Stanford University School of Medicine, Stanford, CA, USA
| | - Edward R Mariano
- 1 VA Palo Alto Health Care System, Palo Alto, CA, USA.,2 Stanford University School of Medicine, Stanford, CA, USA
| | - Geoffrey Kenton Lighthall
- 1 VA Palo Alto Health Care System, Palo Alto, CA, USA.,2 Stanford University School of Medicine, Stanford, CA, USA
| |
Collapse
|
17
|
Rangachari P. Innovation Implementation in the Context of Hospital QI: Lessons Learned and Strategies for Success. ACTA ACUST UNITED AC 2018; 5:1-14. [PMID: 29546884 DOI: 10.2147/ieh.s151040] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In 1999, the Institute of Medicine reported that 98,000 people die each year due to medical errors. In the following years, the focus on hospital quality was intensified nationally, with policymakers providing evidence-based practice guidelines for improving health care quality. However, these innovations (evidence-based guidelines) that were being produced at policy levels were not translating to clinical practice at the hospital organizational level easily, and stark variations continued to persist, in the quality of health care. Circa 2009, nearly a decade after the release of the IOM report, the health care organizational literature began referring to this challenge as "innovation implementation failure" in health care organizations (HCOs), ie, failure to implement an evidence-based practice that is new to a HCO. This stream of literature drew upon management research to explain why innovation implementation failure occurs in HCOs and what could be done to prevent it. This paper conducts an integrative review of the literature on "innovation implementation" in hospitals and health systems over the last decade, since the spotlight was cast on "innovation implementation failure" in HCOs. The review reveals that while some studies have retrospectively sought to identify the key drivers of innovation implementation, through surveys and interviews of practitioners (the "what"), other studies have prospectively sought to understand how innovation implementation occurs in hospitals and health systems (the "how"). Both make distinctive contributions to identifying strategies for success in innovation implementation. While retrospective studies have helped identify the key drivers of innovation implementation, prospective studies have shed light on how these drivers could be attained, thereby helping to develop context-sensitive management strategies for success. The literature has called for more prospective research on the implementation and sustainability of health care innovations. This paper summarizes the lessons learned from the literature, discusses the relevance of management research on innovation implementation in HCOs, and identifies future research avenues.
Collapse
Affiliation(s)
- Pavani Rangachari
- College of Allied Health Sciences, Augusta University, Augusta, Georgia, United States
| |
Collapse
|
18
|
Mariano ER, Vetter TR, Kain ZN. The Perioperative Surgical Home Is Not Just a Name. Anesth Analg 2017; 125:1443-1445. [DOI: 10.1213/ane.0000000000002470] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
|
19
|
A matched case-control comparison of hospital costs and outcomes for knee replacement patients admitted postoperatively to acute care versus rehabilitation. J Anesth 2017; 31:785-788. [PMID: 28477230 DOI: 10.1007/s00540-017-2372-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Accepted: 04/27/2017] [Indexed: 12/22/2022]
Abstract
For select total knee arthroplasty (TKA) patients, we have established an alternative pathway to bypass the acute care surgical ward and directly admit patients from the post-anesthesia care unit to on-campus rehabilitation. We retrospectively examined whether this 'fast track' pathway decreased costs and improved patient outcomes. After reviewing records of consecutive primary unilateral TKA patients over a 15-month period, each patient admitted to rehabilitation was matched with a control admitted to the acute care ward. The primary outcome was estimated total hospitalization cost (length of stay in days multiplied by the average cost per day). Secondary outcomes were length of stay, in-hospital pain scores, opioid use, maximum ambulatory distance and 30-day readmission, morbidity, and mortality. Of the 262 TKA patients during the study period, 14 were admitted to rehabilitation and were matched to 14 patients admitted to acute care. Estimated total hospitalization cost [median (10th-90th percentiles)] was US$30,755 (US$23,066-38,444) for ward patients compared to US$17,620 (US$13,215-33,918) for rehabilitation patients (P = 0.006). This difference [mean (95% CI)] was US$10,143 (US$2174-18,112). There were no other differences. For facilities similar to ours, direct postoperative admission of select TKA patients to subacute rehabilitation may be less costly than acute care and may not negatively affect outcomes.
Collapse
|
20
|
|