Implications of anesthesiology resident availability on first-case staffing

Effect of a non-reactive absorbent with or without environmentally oriented electronic feedback on anesthesia provider's fresh gas flow rates: A greening initiative

STUDY OBJECTIVE

To examine the effects of a non-reactive carbon dioxide absorbent (AMSORB® Plus) versus a traditional carbon dioxide absorbent (Medisorb™) on the FGF used by anesthesia providers and an electronic educational feedback intervention using Carestation™ Insights (GE HealthCare) on provider-specific change in FGF.

DESIGN

Prospective, single-center cohort study set in a greening initiative.

SETTING

Operating room.

PARTICIPANTS

157 anesthesia providers (i.e., anesthesiology trainees, certified registered nurse anesthetists, and solo anesthesiologists).

INTERVENTIONS

Intervention #1 was the introduction of AMSORB® Plus into 8 Aisys CS2, Carestation™ Insights-enabled anesthesia machines (GE HealthCare) at the study site. At the end of week 6, anesthesia providers were educated and given an environmentally oriented electronic feedback strategy for the next 12 weeks of the study (Intervention #2) using Carestation™ Insights data.

MEASUREMENTS

The dual primary outcomes were the difference in average daily FGF during maintenance anesthesia between machines assigned to AMSORB® Plus versus Medisorb™ and the provider-specific change in average fresh gas flows after 12 weeks of feedback and education compared to the historical data.

MAIN RESULTS

Over the 18-week period, there were 1577 inhaled anesthetics performed in the 8 operating rooms (528 for intervention 1, 1049 for intervention 2). There were 1001 provider days using Aisys CS2 machines and 7452 provider days of historical data from the preceding year. Overall, AMSORB® Plus was not associated with significantly less FGF (mean - 80 ml/min, 97.5% confidence interval - 206 to 46, P = .15). The environmentally oriented electronic feedback intervention was not associated with a significant decrease in provider-specific mean FGF (-112 ml/min, 97.5% confidence interval - 244 to 21, P = .059).

CONCLUSIONS

This study showed that introducing a non-reactive absorbent did not significantly alter FGF. Using environmentally oriented electronic feedback relying on data analytics did not result in significantly reduced provider-specific FGF.

Long-term capacity planning for obstetric surgical suites using quantile linear regression

Obstetric surgical suites differ from most inpatient surgical suites, serving one specialty, and often small. We evaluated long-term capacity planning for these operating rooms. The retrospective cohort study included all caesarean births in three operating rooms over 28 years, 1994 through 2021, plus all other obstetric procedures over the latter 19 years. We calculated the obstetric anaesthesia activity index, 0.5 × neuraxial labour analgesia placement + 1.0 × caesarean births. Annual caesarean births from one year to the next had a Pearson linear correlation coefficient of 0.993. Therefore, linear regression can be used for long-term capacity planning. However, the difference between 0.9 and 0.1 quantiles in weekly caseloads was greater than tenfold larger than the annual rate of growth in births per week. Therefore, clinicians likely would be unable to distinguish, by experience, between growth versus being busy due to variability, suggesting value of the modelling. Over 19 years, the fraction of the obstetric workload from caesarean births was unchanging, Pearson correlation coefficient of 0.04. Therefore, use of the obstetric anaesthesia activity index to judge changes in workload was appropriate. The annual total for the index increased linearly, Pearson correlation coefficient of 0.98, supporting validity of the finding that long-term capacity can be planned with linear regression. The difference between 0.9 and 0.1 quantiles in weekly totals of the index exceeded annual rate of growth, supporting validity of the finding that variability week to week is very large relative to growth. These results help decision-makers ensure that operating rooms and staff meet referring hospitals' needs.

The anesthetizing sites supervised to anesthesiologist ratio is an invalid surrogate for group productivity in academic anesthesia departments when used without consideration of the corresponding managerial decisions

When the anesthesiologist does not individually perform the anesthesia care, then to make valid comparisons among US anesthesia departments, one must consider the staffing ratio (i.e., how many cases each anesthesiologist supervises when working with Certified Registered Nurse Anesthetists [CRNAs] or Certified Anesthesiologist Assistants [CAA]). The staffing ratio also must be considered when accurately measuring group productivity. In this narrative review, we consider anesthesia departments with non-physician anesthesia providers and anesthesiology residents. We investigate the validity of such departments assessing the overall ratio of anesthetizing sites supervised per anesthesiologist as a surrogate for group clinical productivity. The sites/anesthesiologist ratio can be estimated accurately using the arithmetic mean calculated by anesthesiologist, the harmonic mean calculated by case, or the harmonic mean calculated by CRNA or CAA, but not by the arithmetic mean ratio by case. However, there is lack of validity to benchmarking the percentage time that anesthesiologists are supervising the maximum possible number of CRNAs or CAAs when some of the anesthesiologists also are supervising resident physicians. Assignments can differ in the total number anesthesiologists needed while every anesthesiologist is supervising as many sites as possible. Similarly, there is lack of validity to limiting assessment to the anesthesiologists supervising only CRNAs or CAAs. There also is lack of validity to limiting assessment only to cases performed by supervised CRNAs or CAAs. When cases can be assigned to anesthesiology residents or CRNAs or CAAs, increasing sites/anesthesiologist while limiting consideration to the CRNAs or CAAs creates incentive for the CRNAs or CAAs to be assigned cases, even when lesser productivity is the outcome. Decisions also can increase sites/anesthesiologist without increasing productivity (e.g., when one anesthesiologist relieves another before the end of the regular workday). A suitable alternative approach to fallaciously treating the sites/anesthesiologist ratio as a surrogate for productivity is that, when a teaching hospital supplies financial support, a responsibility of the anesthesia department is to explain annually the principal factors affecting productivity at each facility it manages and to show annually that decisions were made that maximized productivity, subject to the facilities' constraints.