Suggested Work Guidelines, Based on Operating Room Data, for Departments with a Breast Milk Pumping Supervising Anesthesiologist

Larger anesthesia practitioner per operating room ratios are needed to prevent unnecessary non-operative time than to mitigate patient risk: A narrative review

When choosing the anesthesia practitioner to operating room (OR) ratio for a hospital, objectives are applied to mitigate patient risk: 1) ensuring sufficient anesthesiologists to meet requirements for presence during critical intraoperative events (e.g., anesthesia induction) and 2) ensuring sufficient numbers to cover emergencies outside the ORs (e.g., emergent reintubation in the post-anesthesia care unit). At a 24-OR suite with each anesthesiologist supervising residents in 2 ORs, because critical events overlapped among ORs, ≥14 anesthesiologists were needed to be present for all critical events on >90% of days. The suitable anesthesia practitioner to OR ratio would be 1.58, where 1.58 = (24 + 14)/24. Our narrative review of 22 studies from 17 distinct hospitals shows that the practitioner to OR ratio needed to reduce non-operative time is reliably even larger. Activities to reduce non-operative times include performing preoperative evaluations, making prompt evidence-based decisions at the OR control desk, giving breaks during cases (e.g., lunch or lactation sessions), and using induction and block rooms in parallel to OR cases. The reviewed articles counted the frequency of these activities, finding them much more common than urgent patient-care events. Our review shows, also, that 1 anesthesiologist per OR, working without assistants, is often more expensive, from a societal perspective, than having a few more anesthesia practitioners (i.e., ratio > 1.00). These results are generalizable among hundreds of hospitals, based on managerial epidemiology studies. The implication of our narrative review is that existing studies have already shown, functionally, that artificial intelligence and monitoring technologies based on increasing the safety of intraoperative care have little to no potential to influence anesthesia or OR productivity. There are, in contrast, opportunities to use sensor data and decision-support to facilitate communication among anesthesiologists outside of ORs to choose optimal task sequences that reduce non-operative times, thereby increasing production and OR efficiency.

Occupational Factors Associated With Time to Breastfeeding Discontinuation After Return to Work Among Female Anesthesiologists in China: A Nationwide Survey

BACKGROUND

Breast milk is of great benefit to both infants and mothers. Due to occupational barriers, female physicians are at high risk of unintentionally discontinuing breastfeeding. However, evidence among anesthesiologists was limited. The purpose of this study was to investigate occupational factors associated with time to breastfeeding discontinuation among female anesthesiologists following maternity leave in China.

METHODS

We conducted a nationwide survey of female anesthesiologists who had given birth since January 1, 2015. A 60-item anonymous questionnaire was developed to collect information regarding breastfeeding practices and related factors. The questionnaire was revised based on the recommendations of 15 experts and feedback from the pilot survey. The survey was distributed by the Chinese Society of Anesthesiology.

RESULTS

The completion rate was 57.9%. In total, 1364 responders were analyzed from all 31 provinces of Mainland China. In total, 1311 (96.1%) responders reported a reduction in breast milk supply on returning to work. Among the 1161 responders who discontinued breastfeeding, 836 (72.0%) did not achieve desired goals due to occupational factors. The median [interquartile range] of maternity leave length and breastfeeding duration were 5 [4-6] months and 10 [7-12] months, respectively. The following occupational factors were associated with longer time to breastfeeding discontinuation after adjusting for confounding effects of personal factors: length of maternity leave (hazard ratio [HR] per month 0.44; 95% confidence interval [CI], 0.36-0.54; P < .001), pumping breast milk during work time (HR, 0.04; 95% CI, 0.02-0.08; P < .001), support from colleagues (HR, 0.92; 95% CI, 0.86-0.99; P = .032), and additional nonclinical activities (HR, 0.87; 95% CI, 0.77-0.98; P = .022). Trainees under supervision (HR, 1.20; 95% CI, 1.06-1.43; P = .005) and the need to remain in the operating room during cases (HR, 2.59; 95% CI, 1.09-6.12; P = .031) were associated with shorter time to breastfeeding discontinuation. Approximately 899 (65.9%) responders pumped breast milk during work time. Among them, reduction in pumping frequency (HR, 1.17; 95% CI, 1.00-1.36; P = .049) and difficulty in finding opportunities for pumping (HR, 2.34; 95% CI, 1.36-4.03; P = .002) were associated with shorter time to breastfeeding discontinuation.

CONCLUSIONS

We identified modifiable occupational factors associated with time to breastfeeding discontinuation. These findings underscored the necessity of facilitating breastfeeding in the workplace, including encouraging longer maternity leave and breastfeeding breaks, considering the feasibility of pumping in daily case assignments, establishing supportive culture, providing lactation rooms, and offering nonclinical activities.

Preventing Prolonged Times to Awakening While Mitigating the Risk of Patient Awareness: Gas Man Computer Simulations of Sevoflurane Consumption From Brief, High Fresh Gas Flow Before the End of Surgery

Prolonged times to tracheal extubation are associated with adverse patient and economic outcomes. We simulated awakening patients from sevoflurane after long-duration surgery at 2% end-tidal concentration, 1.0 minimum alveolar concentration (MAC) in a 40-year-old. Our end-of-surgery target was 0.5 MAC, the Michigan Awareness Control Study's threshold for intraoperative alerts. Consider an anesthetist who uses a 1 liter/minute gas flow until surgery ends. During surgical closure, the inspired sevoflurane concentration is reduced from 2.05% to 0.62% (i.e., MAC-awake). The estimated time to reach 0.5 MAC is 28 minutes. From a previous study, 28 minutes exceeded ≥95% of surgical closure times for all 244 distinct surgical procedures (N=23,343 cases). Alternatively, the anesthetist uses 8 liters/minute gas flow with the vaporizer at MAC-awake for 1.8 minutes, which reduces the end-tidal concentration to 0.5 MAC. The anesthetist then increases the vaporizer to keep end-tidal 0.5 MAC until the surgery ends. An additional simulation shows that, compared with simulated end-tidal agent feedback control, this approach consumed 0.45 mL extra agent. Simulation results are the same for an 80-year-old patient. The extra 0.45 mL has a global warming potential comparable to driving 26 seconds at 40 kilometers (25 miles) per hour, comparable to route modification to avoid potential roadway hazards.

Survey of Lactating Anesthesiologists Using Wearable Breast Milk Pumps While Working in Operating Rooms and Other Clinical Settings

We performed a prospective Internet survey study of anesthesiologists lactating in 2022 or 2023. Approximately half (48%, 75 of 156) lacked convenient dedicated lactation space and approximately half (55%, 86 of 155) used a wearable breast pump. The vast majority using a wearable pump did so in clinical settings, including operating rooms (88%, 76 of 86). When using during cases, approximately half reported that milk production was sufficient to substitute for lactation pumping sessions (52%, 39 of 75). Based on probability distributions of surgical times, future research can evaluate the usefulness of wearable pumps based on the objective of reducing anesthesiologists' durations of lactation sessions to <15 minutes.

Lactation in Anesthesiology

There are several work-related barriers to breastfeeding among physician mothers including: lack of appropriate place for breastmilk expression, unpredictable and inflexible schedules, and lack of time to breastfeed or express milk. In a survey of physician mothers, those who were in surgical and procedural subspecialties, including anesthesiology, reported a lack of lactation facilities in close proximity to the operating room as a barrier to breastfeeding. Unlike other physicians and clinicians in different health care environments, anesthesiology is unique in that there is often no built-in time for breaks or a predictable end time to the operating room schedule. A break system is typically established, within an institution, for meal break relief for trainees, Certified Registered Nurse Anesthetist, and Anesthesia Assistants. This system for breaks may not be sufficient to accommodate the frequency or length required for lactation sessions. In addition, these break systems do not typically provide relief for supervising anesthesiologists for meals or lactation sessions. A study of physician mothers across specialties identified anesthesiologists as significantly more likely than women of other medical specialties to self-report maternal discrimination. The study defined maternal discrimination as discrimination based on pregnancy, maternity leave, or breastfeeding. As a workforce and specialty, we must support our breastfeeding anesthesiologists and facilitate lactation needs on return to the workplace.

Feasibility of Anesthesiologists Giving Nurse Anesthetists 30-Minute Lunch Breaks and 15-Minute Morning Breaks at a University’s Facilities

Background

Managers of an anesthesia department sought an estimation of how often each anesthesiologist can give lunch breaks and morning breaks to nurse anesthetists to plan staff scheduling. When an anesthesiologist supervising the nurse anesthetists can give a break, it would be preferred because fewer extra nurse anesthetists would be scheduled to facilitate breaks.

Methodology

Our methodological development used retrospective cohort data from the three surgical suites of a single anesthesia department. Surgical times were estimated using three years of data from October 2016 through September 2019, with 95,146 cases. Comparison was made with the next year from October 2019 through September 2020, with 30,987 cases. The 5% lower prediction bounds for surgical time were estimated based on two-parameter, log-normal distributions. The times when two and three sequential rooms had overlapping lower prediction limits were calculated. Sequential rooms were used because that was how anesthesiologists’ assignments were made at the studied department, when feasible given constraints. Percentages of cases were reported with 15 minutes available starting sometime between 9:00 and 10:30 and 30 minutes starting sometime between 11:15 and 12:45, times characteristic for the studied department. At the studied university’s facilities, the nurse anesthetists were independent practitioners (e.g., an anesthesiologist supervising two nurse anesthetists each with a long case could give a break to one of the two rooms).

Results

The percentage of days for which an anesthesiologist could give a lunch break (11:15-12:45) was close to the percentage of cases when an anesthesiologist could give the same-length break anytime throughout the workday. In other words, the length of the break was important, not the time of the day of the break. The absolute percentages also depended on how many rooms the anesthesiologist supervised, the duration of cases, and facility. For example, among anesthesiologists at the adult surgical suite supervising three nurse anesthetists, a lunch break could be given by the anesthesiologist on at most one-third of the days without affecting workflow.

Conclusions

Our results show that the feasibility of an anesthesiologist clinically supervising one, two, or three rooms to give lunch breaks to the nurse anesthetists in the rooms depends principally on how many rooms are supervised, the duration of the break, and the facility’s percentage of cases with surgical times longer than that duration. The specific numerical results will differ among departments. Our methodology would be useful to other departments where anesthesiologists are clinically supervising independent practitioners, sometimes during cases long enough for a break, and there is anesthesiologist backup help. Such departments can use our methodology to plan their staff scheduling for additional nurse anesthetists to give the remaining breaks.

Low Prevalence of Designated Lactation Spaces at Hospitals and Ambulatory Surgery Centers in Iowa: An Educational Tool for Graduates' Job Selection

Many anesthesiologists and nurse anesthetists want to continue breastfeeding their babies when returning to work from maternity leave. The cornerstone of breast milk supply maintenance is breast milk pumping sessions at regular intervals. These breast milk pumping sessions require time and private space for lactation. We surveyed Iowa hospitals and ambulatory surgery centers and created an educational spreadsheet to guide inquiry and postgraduate job selection of our anesthesiology residents and nurse anesthetist students (eg, when considering future family planning). The survey and spreadsheet showed a low prevalence of dedicated lactation space for anesthesia practitioners near the surgical suites.