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Dexter F, Epstein RH, Titler SS. Larger anesthesia practitioner per operating room ratios are needed to prevent unnecessary non-operative time than to mitigate patient risk: A narrative review. J Clin Anesth 2024; 96:111498. [PMID: 38759610 DOI: 10.1016/j.jclinane.2024.111498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 05/04/2024] [Accepted: 05/06/2024] [Indexed: 05/19/2024]
Abstract
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.
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Wachtendorf LJ, Tsay ML, Witt AS, Ferrazza DM, Hess PE, Schaefer MS, Eikermann M, Fassbender P. Impact of changes in anaesthesia staff assignments on billing compliance, financial margins, and costs of anaesthesia services: development and application of a margin-cost estimation tool. Br J Anaesth 2024:S0007-0912(24)00348-9. [PMID: 38987036 DOI: 10.1016/j.bja.2024.05.032] [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: 03/01/2024] [Revised: 05/01/2024] [Accepted: 05/07/2024] [Indexed: 07/12/2024] Open
Abstract
BACKGROUND The US Centers for Medicare and Medicaid Services provide guidelines for the coverage of anaesthesia residents and certified registered nurse anaesthetists (CRNAs) by anaesthesiologists. We tested the hypothesis that changes in the anaesthesia staffing model increase billing compliance. METHODS We analysed 13 926 anaesthesia cases performed between September 2019 and November 2019 (baseline), and between September 2020 and November 2020 (after change in staff model) at a US academic medical centre using an estimation tool. The intervention was assignment of additional 12-h weekday CRNAs plus an additional anaesthesiologist who covered weekdays after 17:00, weekends, and holidays. The proportion of cases with billing compliant coverage (covered either by solo anaesthesiologist or anaesthesiologist covering two or fewer residents or four or fewer CRNAs) was analysed using logistic and segmented regression analyses. RESULTS The change in staff model was associated with a decrease in non-optimal anaesthesia staff assignments from 4.2% to 1.2% of anaesthesia cases (adjusted odds ratio 0.25; 95% confidence interval [CI] 0.20-0.32; P<0.001) and an increase in billable anaesthesia units of 0.6 per anaesthesia case (95% CI 0.4-0.8; P<0.001). An increased revenue margin associated with optimal staffing levels would only be achieved with salary levels at the 25th percentile of relevant benchmark compensation levels. Total staff overtime for all anaesthesia providers decreased (adjusted absolute difference -4.1 total overtime hours per day; 95% CI -7.0 to -1.3; P=0.004). CONCLUSIONS Implementation of a change in anaesthesia staffing model was associated with improved billing compliance, higher billable anaesthesia units, and reduced overtime. The effects of the anaesthesia staff model on revenue and financial margin can be determined using our web-based margin-cost estimation tool.
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Affiliation(s)
- Luca J Wachtendorf
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Minghan L Tsay
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Annika S Witt
- Department of Anesthesiology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Dawn M Ferrazza
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Phil E Hess
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Maximilian S Schaefer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Anesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany
| | - Matthias Eikermann
- Department of Anesthesiology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA; Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, Essen, Germany.
| | - Philipp Fassbender
- Department of Anesthesiology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA; Klinik für Anästhesiologie, Operative Intensivmedizin, Schmerz- und Palliativmedizin, Marien Hospital Herne, Universitätsklinikum der Ruhr-Universität Bochum, Herne, Germany
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Dyer MW, Kor BT, Kor NT, Hanson AC, Kor JJ, Kor TM, Stewart TM, Sviggum HP. Improvement in Accuracy and Concordance of American Society of Anesthesiologist's Physical Status (ASA-PS) Scoring Assignment over a 11 Year Time Period Using Patient BMI as a Comorbidity Finding. Anesthesiol Res Pract 2024; 2024:6989174. [PMID: 38813264 PMCID: PMC11136541 DOI: 10.1155/2024/6989174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 05/03/2024] [Accepted: 05/04/2024] [Indexed: 05/31/2024] Open
Abstract
Background Anesthesia providers categorize patients utilizing the American Society of Anesthesiologists Physical Status (ASA-PS) classification originally created by the ASA in 1941. There is published variability and discordance among providers when assigning patient ASA scores in part due to the subjectivity of scoring utilizing patient medical conditions, but variability is also found using objective findings like BMI. To date, there are few studies evaluating the accuracy of anesthesia providers' ASA assignment based on objective body mass index (BMI) alone. The aim of this retrospective chart review is to determine improvement in accuracy of anesthesia providers to correctly assign patient ASA scores, based on BMI criteria added to the ASA-PS in October of 2014, utilizing a multifaceted strategy including creation of an active finance committee in the fall of 2015, multiple e-mail communications about the updated definitions and recommendations for ASA-PS scoring in the fall of 2015 and spring of 2016, a department grand rounds presentation in February 2016, placement of laminated copies of the ASA definitions and recommendations in the anesthesia chartrooms, and the development of a tool embedded into our EMR providing a recommendation of ASA-PS based on patient comorbidity findings. Methods After attaining IRB approval, all eligible patients over the age of 18 who had surgical procedures under general anesthesia at Mayo Clinic in Rochester, MN, between January 1, 2010, and December 31, 2020, were retrospectively analyzed. A segmented logistic regression model was used to estimate the trends (per-year change in odds) of ASA under classification according to severity of obesity during 3 epochs: preimplementation (2010-2014), implementation (2015), and postimplementation (2016-2020). Results A total of 16,467 patients of the 200,423 (8.2%) patients with obesity (class 1, 2, and 3) were underscored based on BMI alone. Accuracy of ASA-PS classification, as it pertains to BMI alone, was found to show meaningful improvement year-to-year following the updated ASA-PS guidelines with examples released in October of 2014 (P < 0.001). Most of the improvement occurred in 2015-2017 with relatively little between-year variability in the rate of underscoring from 2017-2020. Conclusion Despite updated ASA-PS published guidelines, providers may still be unaware of the updated guidelines and inclusion of examples used within the ASA-PS classification system. Accuracy of scoring did improve annually following the release of the updated guidelines with examples as well as department-wide educational activities on the topic. Additional education and awareness should be offered to those responsible for preanesthesia evaluation and assignment of ASA-PS in patients to improve accuracy as it pertains to BMI.
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Affiliation(s)
- Matthew W. Dyer
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Benjamin T. Kor
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nathan T. Kor
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Andrew C. Hanson
- Department of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Jennifer J. Kor
- Kentucky College of Osteopathic Medicine, University of Pikeville, Pikeville, KY, USA
| | - Todd M. Kor
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Thomas M. Stewart
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Hans P. Sviggum
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
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Yu A, Birkemeier KL, Mills JR, Kuo T, Tachikawa N, Dai F, Thakkar K, Cable C, Brenner A, Godley PJ. Implementing a Quality Intervention to Improve Confidence in Outpatient Venous Thromboembolism Management. Cardiol Ther 2024:10.1007/s40119-024-00370-9. [PMID: 38773006 DOI: 10.1007/s40119-024-00370-9] [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: 02/16/2024] [Accepted: 04/24/2024] [Indexed: 05/23/2024] Open
Abstract
INTRODUCTION Guidelines recommend that patients with acute venous thromboembolism (VTE) represented by low-risk deep vein thrombosis (DVT) and pulmonary embolism (PE) receive initial treatment at home versus at the hospital, but a large percentage of these patients are not managed at home. This study assessed the effectiveness of a quality intervention on provider knowledge and confidence in evaluating outpatient treatment for patients with VTE in the emergency department (ED). METHODS A pilot program to overcome obstacles to outpatient VTE treatment in appropriate patients was initiated at Baylor Scott & White Health Temple ED. Subsequently, a formalized quality intervention with a targeted educational program was developed and delivered to ED providers. Provider surveys were administered pre- and post-quality intervention in order to assess clinical knowledge, confidence levels, and perceived barriers. Patient discharge information was extracted from electronic health records. RESULTS Twenty-five ED providers completed the pre- and post-surveys; 690 and 356 patients with VTE were included in the pre- and post-pilot and pre- and post-quality intervention periods, respectively. Many ED providers reported that a major barrier to discharging patients to outpatient care was the lack of available and adequate patient follow-up appointments. Notably, after the quality intervention, an increase in provider clinical knowledge and confidence scores was observed. Discharge rates for patients with VTE increased from 25.6% to 27.5% after the pilot intervention and increased from 28.5% to 29.9% after the quality intervention, but these differences were not statistically significant. Despite instantaneous uptick in discharge rates after the interventions, there was not a long-lasting effect. CONCLUSION Although the quality intervention led to improvements in provider clinical knowledge and confidence and identified barriers to discharging patients with VTE, discharge rates remained stable, underscoring the need for additional endeavors.
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Affiliation(s)
- Anthony Yu
- Baylor Scott & White Health, 2401 S 31st St, Temple, TX, 76508, USA
| | | | - J Rebecca Mills
- Pfizer Inc, 66 Hudson Boulevard East, New York, NY, 10001-2192, USA
| | - Tiffany Kuo
- Baylor Scott & White Health, 2401 S 31st St, Temple, TX, 76508, USA
| | - Nina Tachikawa
- Pfizer Inc, 66 Hudson Boulevard East, New York, NY, 10001-2192, USA
| | - Feng Dai
- Pfizer Inc, 66 Hudson Boulevard East, New York, NY, 10001-2192, USA
| | - Karishma Thakkar
- Baylor Scott & White Health, 2401 S 31st St, Temple, TX, 76508, USA
| | - Christian Cable
- Baylor Scott & White Health, 2401 S 31st St, Temple, TX, 76508, USA
| | - Allison Brenner
- Pfizer Inc, 66 Hudson Boulevard East, New York, NY, 10001-2192, USA
| | - Paul J Godley
- Baylor Scott & White Health, 2401 S 31st St, Temple, TX, 76508, USA.
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Kim DD, Chiang E, Volio A, Skolaris A, Nutcharoen A, Vogan E, Krivanek K, Ayad SS. Reducing inpatient opioid consumption after caesarean delivery: effects of an opioid stewardship programme and racial impact in a community hospital. BMJ Open Qual 2024; 13:e002265. [PMID: 38684344 PMCID: PMC11086205 DOI: 10.1136/bmjoq-2023-002265] [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: 01/17/2023] [Accepted: 04/08/2024] [Indexed: 05/02/2024] Open
Abstract
Caesarean section is the most common inpatient surgery in the USA, with more than 1.1 million procedures in 2020. Similar to other surgical procedures, healthcare providers rely on opioids for postoperative pain management. However, current evidence shows that postpartum patients usually experience less pain due to pregnancy-related physiological changes. Owing to the current opioid crisis, public health agencies urge providers to provide rational opioid prescriptions. In addition, a personalised postoperative opioid prescription may benefit racial minorities since research shows that this population receives fewer opioids despite greater pain levels. Our project aimed to reduce inpatient opioid consumption after caesarean delivery within 6 months of the implementation of an opioid stewardship programme.A retrospective analysis of inpatient opioid consumption after caesarean delivery was conducted to determine the baseline, design the opioid stewardship programme and set goals. The plan-do-study-act method was used to implement the programme, and the results were analysed using a controlled interrupted time-series method.After implementing the opioid stewardship programme, we observed an average of 80% reduction (ratio of geometric means 0.2; 95% CI 0.2 to 0.3; p<0.001) in inpatient opioid consumption. The institution designated as control did not experience relevant changes in inpatient opioid prescriptions during the study period. In addition, the hospital where the programme was implemented was unable to reduce the difference in inpatient opioid demand between African Americans and Caucasians.Our project showed that an opioid stewardship programme for patients undergoing caesarean delivery can effectively reduce inpatient opioid use. PDSA, as a quality improvement method, is essential to address the problem, measure the results and adjust the programme to achieve goals.
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Affiliation(s)
- Daniel Dongiu Kim
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eric Chiang
- Anesthesiology Institute, Fairview Hospital, Cleveland, Ohio, USA
| | - Andrew Volio
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alexis Skolaris
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Eric Vogan
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kevin Krivanek
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sabry Salama Ayad
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
- Anesthesiology Institute, Fairview Hospital, Cleveland, Ohio, USA
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Krishnamoorthy V, Harris R, Chowdhury AM, Bedoya A, Bartz R, Raghunathan K. Building Learning Healthcare Systems for Critical Care Medicine. Anesthesiology 2024; 140:817-823. [PMID: 38345893 DOI: 10.1097/aln.0000000000004847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
Learning healthcare systems are an evolving way of integrating informatics, analytics, and continuous improvement into daily practice in healthcare. This article discusses strategies to build learning healthcare systems for critical care medicine.
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Affiliation(s)
- Vijay Krishnamoorthy
- Department of Anesthesiology, Division of Critical Care Medicine; Critical Care and Perioperative Population Health Research Program, Department of Anesthesiology; and Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Ronald Harris
- Duke University School of Medicine, Durham, North Carolina
| | - Ananda M Chowdhury
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Armando Bedoya
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Raquel Bartz
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Karthik Raghunathan
- Department of Anesthesiology, Division of Critical Care Medicine; Critical Care and Perioperative Population Health Research Program, Department of Anesthesiology; and Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
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7
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Dada RS, McGuire JA, Hayanga JWA, Thibault D, Schwartzman D, Ellison M, Hayanga HK. Anesthetic Management for Ventricular Tachycardia Ablation: A National Anesthesia Clinical Outcomes Registry Analysis. J Cardiothorac Vasc Anesth 2024; 38:675-682. [PMID: 38233244 DOI: 10.1053/j.jvca.2023.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 12/11/2023] [Accepted: 12/13/2023] [Indexed: 01/19/2024]
Abstract
OBJECTIVES The authors analyzed anesthetic management trends during ventricular tachycardia (VT) ablation, hypothesizing that (1) monitored anesthesia care (MAC) is more commonly used than general anesthesia (GA); (2) MAC uses significantly increased after release of the 2019 Expert Consensus Statement on Catheter Ablation of Ventricular Arrhythmias; and (3) anesthetic approach varies based on patient and hospital characteristics. DESIGN Retrospective study. SETTING National Anesthesia Clinical Outcomes Registry data. PARTICIPANTS Patients 18 years or older who underwent elective VT ablation between 2013 and 2021. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Covariates were selected a priori within multivariate models, and interrupted time-series analysis was performed. Of the 15,505 patients who underwent VT ablation between 2013 and 2021, 9,790 (63.1%) received GA. After the 2019 Expert Consensus Statement on Catheter Ablation of Ventricular Arrhythmias supported avoidance of GA in idiopathic VT, no statistically significant increase in MAC was evident (immediate change in intercept post-consensus statement release adjusted odds ratio 1.41, p = 0.1629; change in slope post-consensus statement release adjusted odds ratio 1.06 per quarter, p = 0.1591). Multivariate analysis demonstrated that sex, American Society of Anesthesiologists physical status, age, and geographic location were statistically significantly associated with the anesthetic approach. CONCLUSIONS GA has remained the primary anesthetic type for VT ablation despite the 2019 Expert Consensus Statement on Catheter Ablation of Ventricular Arrhythmias suggested its avoidance in idiopathic VT. Achieving widespread clinical practice change is an ongoing challenge in medicine, emphasizing the importance of developing effective implementation strategies to facilitate awareness of guideline release and subsequent adherence to and adoption of recommendations.
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Affiliation(s)
- Rachel S Dada
- Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Joseph A McGuire
- Department of Anesthesiology, West Virginia University, Morgantown, WV
| | - J W Awori Hayanga
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV
| | - Dylan Thibault
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV
| | - David Schwartzman
- Division of Cardiology, Department of Medicine, West Virginia University, Morgantown, WV
| | - Matthew Ellison
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology, West Virginia University, Morgantown, WV
| | - Heather K Hayanga
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology, West Virginia University, Morgantown, WV.
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Bartels K, Conroy JM, Gan TJ. Perioperative Quality Improvement: Opportunities and Challenges for Pragmatic Trial Designs. Anesth Analg 2024; 138:514-516. [PMID: 38364242 PMCID: PMC10919161 DOI: 10.1213/ane.0000000000006838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Affiliation(s)
- Karsten Bartels
- University of Nebraska Medical Center, Department of Anesthesiology, Omaha, NE, USA
| | - Joanne M Conroy
- Dartmouth Health and Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | - Tong J Gan
- University of Texas MD Anderson Cancer Center, Division of Anesthesiology, Critical Care and Pain Medicine, Houston, TX, USA
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Carr SG, Clifton JC, Freundlich RE, Fowler LC, Sherwood ER, McEvoy MD, Robertson A, Dunworth B, McCarthy KY, Shotwell MS, Kertai MD. Improving Neuromuscular Monitoring Through Education-Based Interventions and Studying Its Association With Adverse Postoperative Outcomes: A Retrospective Observational Study. Anesth Analg 2024; 138:517-529. [PMID: 38364243 PMCID: PMC10878712 DOI: 10.1213/ane.0000000000006722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
BACKGROUND We assessed the association between education-based interventions, the frequency of train-of-four (TOF) monitoring, and postoperative outcomes. METHODS We studied adults undergoing noncardiac surgery from February 1, 2020 through October 31, 2021. Our education-based interventions consisted of 3 phases. An interrupted time-series analysis, adjusting for patient- and procedure-related characteristics and secular trends over time, was used to assess the associations between education-based interventions and the frequency of TOF monitoring, postoperative pulmonary complications (PPCs), 90-day mortality, and sugammadex dosage. For each outcome and intervention phase, we tested whether the intervention at that phase was associated with an immediate change in the outcome or its trend (weekly rate of change) over time. In a sensitivity analysis, the association between education-based interventions and postoperative outcomes was adjusted for TOF monitoring. RESULTS Of 19,422 cases, 11,636 (59.9%) had documented TOF monitoring. Monitoring frequency increased from 44.2% in the first week of preintervention stage to 83.4% in the final week of the postintervention phase. During the preintervention phase, the odds of TOF monitoring trended upward by 0.5% per week (odds ratio [OR], 1.005; 95% confidence interval [CI], 1.002-1.007). Phase 1 saw an immediate 54% increase (OR, 1.54; 95% CI, 1.33-1.79) in the odds, and the trend OR increased by 3% (OR, 1.03; 95% CI, 1.01-1.05) to 1.035, or 3.5% per week (joint Wald test, P < .001). Phase 2 was associated with a further immediate 29% increase (OR, 1.29; 95% CI, 1.02-1.64) but no significant association with trend (OR, 0.96; 95% CI, 0.93-1.01) of TOF monitoring (joint test, P = .04). Phase 3 and postintervention phase were not significantly associated with the frequency of TOF monitoring (joint test, P = .16 and P = .61). The study phases were not significantly associated with PPCs or sugammadex administration. The trend OR for 90-day mortality was larger by 24% (OR, 1.24; 95% CI, 1.06-1.45; joint test, P = .03) in phase 2 versus phase 1, from a weekly decrease of 8% to a weekly increase of 14%. However, this trend reversed again at the transition from phase 3 to the postintervention phase (OR, 0.82; 95% CI, 0.68-0.99; joint test, P = .05), from a 14% weekly increase to a 6.2% weekly decrease in the odds of 90-day mortality. In sensitivity analyses, adjusting for TOF monitoring, we found similar associations between study initiatives and postoperative outcomes. TOF monitoring was associated with lower odds of PPCs (OR, 0.69; 95% CI, 0.55-0.86) and 90-day mortality (OR, 0.79; 95% CI, 0.63-0.98), but not sugammadex dosing (mean difference, -0.02; 95% CI, -0.04 to 0.01). CONCLUSIONS Our education-based interventions were associated with both TOF utilization and 90-day mortality but were not associated with either the odds of PPCs or sugammadex dosing. TOF monitoring was associated with reduced odds of PPCs and 90-day mortality.
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Affiliation(s)
- Shane G. Carr
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Jacob C. Clifton
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert E. Freundlich
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Leslie C. Fowler
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Edward R. Sherwood
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew D. McEvoy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amy Robertson
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Brent Dunworth
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Karen Y. McCarthy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew S. Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Miklos D. Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
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Lasocki S, Belbachir A, Mertes PM, Le Pelley E, Bosch L, Bezault C, Belarbia S, Capdevila X. Changes in Practices After Implementation of a Patient Blood Management Program in French Surgical Departments: The National Multicenter Observational PERIOPES Study. Anesth Analg 2024:00000539-990000000-00769. [PMID: 38412110 DOI: 10.1213/ane.0000000000006917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
BACKGROUND Patient blood management (PBM) is an evidence-based approach recommended to improve patient outcomes. Change in practices is often challenging. We report here data from French surgical departments before and after a standardized implementation of a PBM program. METHODS This was a national, multicenter, observational study in surgical centers ("expert" centers with an already established protocol for preoperative anemia or "pilot" centers). Data from consecutive surgical patients of different specialties were retrieved before and after the implementation of a PBM program. Primary outcome variables (preoperative anemia treatment rates, transfusion rates, and length of hospital stay) before and after the implementation of a PBM program were analyzed with segmented regression adjusted on confounders (American Society of Anesthesiologists [ASA] scores and centers). RESULTS A total of 1618 patients (ASA physical status III and IV, 38% in the first period and 45% in the second period) were included in expert (N = 454) or pilot (N = 1164) centers during the first period (January 2017-August 2022) and 1542 (N = 440 and N = 1102, respectively) during the second period (January 2020-February 2023). After implementation of the PBM program, the rate of preoperative anemia treatment increased (odds ratio, 2.37; 95% confidence interval [CI], 1.20-4.74; P = .0136) and length of hospital stay in days decreased (estimate, -0.11; 95% CI, -0.21 to -0.02; P = .0186). Transfusion rate significantly decreased only in expert centers (odds ratio, 0.17; 95% CI, 0.03-0.88; P = .0354). CONCLUSIONS PBM practices in various surgical specialties improved significantly after the implementation of a PBM program. However, too many patients with preoperative anemia remained untreated.
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Affiliation(s)
- Sigismond Lasocki
- From the Département Anesthésie Réanimation, CHU Angers, Angers, France
| | - Anissa Belbachir
- Department of Anesthesia and Critical Care Medicine, Cochin University Paris-Descartes Hospital, Paris, France
| | - Paul-Michel Mertes
- Department of Anesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, INSERM U1255, FMTS de Strasbourg, Strasbourg, France
| | | | | | | | | | - Xavier Capdevila
- Department of Anesthesia and Critical Care Medicine, Lapeyronie University Hospital and Montpellier University, Montpellier, France
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Attal H, Huang Z, Kuan WS, Weng Y, Tan HY, Seow E, Peng LL, Lim HC, Chow A. N-of-1 Trials of Antimicrobial Stewardship Interventions to Optimize Antibiotic Prescribing for Upper Respiratory Tract Infection in Emergency Departments: Protocol for a Quasi-Experimental Study. JMIR Res Protoc 2024; 13:e50417. [PMID: 38381495 PMCID: PMC10918537 DOI: 10.2196/50417] [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: 06/30/2023] [Revised: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND Antimicrobial stewardship programs attempting to optimize antibiotic therapy and clinical outcomes mainly focus on inpatient and outpatient settings. The lack of antimicrobial stewardship program studies in the emergency department (ED) represents a gap in tackling the problem of antimicrobial resistance as EDs treat a substantial number of upper respiratory tract infection cases throughout the year. OBJECTIVE We intend to implement two evidence-based interventions: (1) patient education and (2) providing physician feedback on their prescribing rates. We will incorporate evidence from a literature review and contextualizing the interventions based on findings from a local qualitative study. METHODS Our study uses a quasi-experimental design to evaluate the effects of interventions over time in the EDs of 4 public hospitals in Singapore. We will include an initial control period of 18 months. In the next 6 months, we will randomize 2 EDs to receive 1 intervention (ie, patient education) and the other 2 EDs to receive the alternative intervention (ie, physician feedback). All EDs will receive the second intervention in the subsequent 6 months on top of the ongoing intervention. Data will be collected for another 6 months to assess the persistence of the intervention effects. The information leaflets will be handed to patients at the EDs before they consult with the physician, while feedback to individual physicians by senior doctors is in the form of electronic text messages. The feedback will contain the physicians' antibiotic prescribing rate compared with the departments' overall antibiotic prescribing rate and a bite-size message on good antibiotic prescribing practices. RESULTS We will analyze the data using segmented regression with difference-in-difference estimation to account for concurrent cluster comparisons. CONCLUSIONS Our proposed study assesses the effectiveness of evidence-based, context-specific interventions to optimize antibiotic prescribing in EDs. These interventions are aligned with Singapore's national effort to tackle antimicrobial resistance and can be scaled up if successful. TRIAL REGISTRATION ClinicalTrials.gov NCT05451863; https://clinicaltrials.gov/study/NCT05451836. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/50417.
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Affiliation(s)
- Hersh Attal
- Accident & Emergency Department, Changi General Hospital, Singapore, Singapore
| | - Zhilian Huang
- Department of Preventive and Population Medicine, Office of Clinical Epidemiology, Analytics, and Knowledge, Tan Tock Seng Hospital, Singapore, Singapore
| | - Win Sen Kuan
- Department of Emergency Medicine, National University Hospital, Singapore, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yanyi Weng
- Department of Emergency Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Hann Yee Tan
- Acute and Emergency Care Department, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Eillyne Seow
- Acute and Emergency Care Department, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Li Lee Peng
- Department of Emergency Medicine, National University Hospital, Singapore, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Hoon Chin Lim
- Accident & Emergency Department, Changi General Hospital, Singapore, Singapore
| | - Angela Chow
- Department of Preventive and Population Medicine, Office of Clinical Epidemiology, Analytics, and Knowledge, Tan Tock Seng Hospital, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
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Okoro T, Wan M, Mukabeta TD, Malev E, Gross M, Williams C, Manjra M, Kuiper JH, Murnaghan J. Assessment of the effectiveness of weight-adjusted antibiotic administration, for reduced duration, in surgical prophylaxis of primary hip and knee arthroplasty. World J Orthop 2024; 15:170-179. [PMID: 38464351 PMCID: PMC10921182 DOI: 10.5312/wjo.v15.i2.170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/08/2023] [Accepted: 01/05/2024] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Prophylactic antibiotics have significantly led to a reduction in the risk of post-operative surgical site infections (SSI) in orthopaedic surgery. The aim of using antibiotics for this purpose is to achieve serum and tissue drug levels that exceed, for the duration of the operation, the minimum inhibitory concentration of the likely organisms that are encountered. Prophylactic antibiotics reduce the rate of SSIs in lower limb arthroplasty from between 4% and 8% to between 1% and 3%. Controversy, however, still surrounds the optimal frequency and dosing of antibiotic administration. AIM To evaluate the impact of introduction of a weight-adjusted antibiotic prophylaxis regime, combined with a reduction in the duration of administration of post-operative antibiotics on SSI incidence during the 2 years following primary elective total hip and knee arthroplasty. METHODS Following ethical approval, patients undergoing primary total hip arthroplasty (THA)/total knee arthroplasty (TKA) with the old regime (OR) of a preoperative dose [cefazolin 2 g intravenously (IV)], and two subsequent doses (2 h and 8 h), were compared to those after a change to a new regime (NR) of a weight-adjusted preoperative dose (cefazolin 2 g IV for patients < 120 kg; cefazolin 3g IV for patients > 120 kg) and a post-operative dose at 2 h. The primary outcome in both groups was SSI rates during the 2 years post-operatively. RESULTS A total of n = 1273 operations (THA n = 534, TKA n = 739) were performed in n = 1264 patients. There was no statistically significant difference in the rate of deep (OR 0.74% (5/675) vs NR 0.50% (3/598); fishers exact test P = 0.72), nor superficial SSIs (OR 2.07% (14/675) vs NR 1.50% (9/598); chi-squared test P = 0.44) at 2 years post-operatively. With propensity score weighting and an interrupted time series analysis, there was also no difference in SSI rates between both groups [RR 0.88 (95%CI 0.61 to 1.30) P = 0.46]. CONCLUSION A weight-adjusted regime, with a reduction in number of post-operative doses had no adverse impact on SSI incidence in this population.
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Affiliation(s)
- Tosan Okoro
- Department of Arthroplasty, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry SY10 7AG, United Kingdom
- School of Medicine, Keele University, Staffordshire ST5 5BG, United Kingdom
| | - Michael Wan
- St Joseph’s Health Centre, Unity Health Toronto, Toronto M6R 1B5, Canada
| | - Takura Darlington Mukabeta
- Department of Arthroplasty, The Royal London Hospital, Barts Health NHS Trust, London E1 1BB, United Kingdom
| | - Ella Malev
- Department of Arthroplasty, Sunnybrook Holland Orthopaedic and Arthritis Centre, Toronto M4Y 1H1, Canada
| | - Marketa Gross
- Department of Arthroplasty, Sunnybrook Holland Orthopaedic and Arthritis Centre, Toronto M4Y 1H1, Canada
| | - Claudia Williams
- Department of Arthroplasty, Sunnybrook Holland Orthopaedic and Arthritis Centre, Toronto M4Y 1H1, Canada
| | - Muhammad Manjra
- Department of Arthroplasty, Sunnybrook Holland Orthopaedic and Arthritis Centre, Toronto M4Y 1H1, Canada
| | - Jan Herman Kuiper
- Institute for Science and Technology in Medicine, Keele University, Staffordshire ST5 1BG, United Kingdom
| | - John Murnaghan
- Department of Arthroplasty, Sunnybrook Holland Orthopaedic and Arthritis Centre, Toronto M4Y 1H1, Canada
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Dunt DR, Jiang H, Room R. Early closing of hotels: Impacts on alcohol consumption, drunkenness, liver disease and injury mortality. Drug Alcohol Rev 2024; 43:491-500. [PMID: 38048172 DOI: 10.1111/dar.13780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/20/2023] [Accepted: 10/23/2023] [Indexed: 12/06/2023]
Abstract
INTRODUCTION Early (six o'clock) closing of hotels was introduced in 1916 in Australia to curb heavy drinking. It lasted between 21 and 51 years in four Australian states. The aim of this study is to assess the impact of early closing on alcohol consumption, liver disease mortality rates, drunkenness and various forms of injury. METHODS Time series analysis was undertaken using an Autoregressive Integrated Moving Averages modelling technique. Relevant data were derived from annual publications of the Australian Bureau of Statistics and its predecessor organisations. RESULTS Early closing had a substantial downward effect on alcohol consumption across 1901-2006. It had a substantial and beneficial effect on liver disease mortality. Drunkenness rates declined pre-World War II (WWII), though they increased post-WWII. Rates for homicide decreased substantially, and close to substantially for suicide and female homicide. Early closing impacts were more beneficial pre-WWII than post-WWII. DISCUSSION AND CONCLUSIONS Early closing has not been favourably remembered in Australia in recent years. However, all pre-WWII impacts of early closing were beneficial including public drunkenness rates. Post-WWII, beneficial effects were less clear-cut and drunkenness increased. Resistance to early closing may also have arisen in the 1950s as families had more disposable income and ability to consume alcohol. While universal six o'clock closing is no longer feasible or desirable, opening hours and days for hotels are still part of the policy discussion in Australia. The experience of early closing pre-WWII gives confidence that the impacts of these can be beneficial.
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Affiliation(s)
- David R Dunt
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Heng Jiang
- Centre for Alcohol Policy Research, La Trobe University, Melbourne, Australia
| | - Robin Room
- Centre for Alcohol Policy Research, La Trobe University, Melbourne, Australia
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Rubin DS, Lin AZ, Ward RP, Nagele P. Trends and In-Hospital Mortality for Perioperative Myocardial Infarction After the Introduction of a Diagnostic Code for Type 2 Myocardial Infarction in the United States Between 2016 and 2018. Anesth Analg 2024; 138:420-429. [PMID: 36795598 PMCID: PMC10427730 DOI: 10.1213/ane.0000000000006404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
BACKGROUND The frequency of perioperative myocardial infarction has been declining; however, previous studies have only described type 1 myocardial infarctions. Here, we evaluate the overall frequency of myocardial infarction with the addition of an International Classification of Diseases 10th revision (ICD-10-CM) code for type 2 myocardial infarction and the independent association with in-hospital mortality. METHODS A longitudinal cohort study spanning the introduction of the ICD-10-CM diagnostic code for type 2 myocardial infarction using the National Inpatient Sample (NIS) from 2016 to 2018. Hospital discharges that included a primary surgical procedure code for intrathoracic, intraabdominal, or suprainguinal vascular surgery were included. Type 1 and type 2 myocardial infarctions were identified using ICD-10-CM codes. We used segmented logistic regression to estimate change in frequency of myocardial infarctions and multivariable logistic regression to determine the association with in-hospital mortality. RESULTS A total of 360,264 unweighted discharges were included, representing 1,801,239 weighted discharges, with median age 59 and 56% female. The overall incidence of myocardial infarction was 0.76% (13,605/1,801,239). Before the introduction of type 2 myocardial infarction code, there was a small baseline decrease in the monthly frequency of perioperative myocardial infarctions (odds ratio [OR], 0.992; 95% confidence interval [CI], 0.984-1.000; P = .042), but no change in the trend after the introduction of the diagnostic code (OR, 0.998; 95% CI, 0.991-1.005; P = .50). In 2018, where there was an entire year where type 2 myocardial infarction was officially a diagnosis, the distribution of myocardial infarction type 1 was 8.8% (405/4580) ST elevation myocardial infarction (STEMI), 45.6% (2090/4580) non-ST elevation myocardial infarction (NSTEMI), and 45.5% (2085/4580) type 2 myocardial infarction. STEMI and NSTEMI were associated with increased in-hospital mortality (OR, 8.96; 95% CI, 6.20-12.96; P < .001 and OR, 1.59; 95% CI, 1.34-1.89; P < .001). A diagnosis of type 2 myocardial infarction was not associated with increased odds of in-hospital mortality (OR, 1.11; 95% CI, 0.81-1.53; P = .50) when accounting for surgical procedure, medical comorbidities, patient demographics, and hospital characteristics. CONCLUSIONS The frequency of perioperative myocardial infarctions did not increase after the introduction of a new diagnostic code for type 2 myocardial infarctions. A diagnosis of type 2 myocardial infarction was not associated with increased in-patient mortality; however, few patients received invasive management that may have confirmed the diagnosis. Further research is needed to identify what type of intervention, if any, may improve outcomes in this patient population.
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Affiliation(s)
- Daniel S Rubin
- From the Department of Anesthesia and Critical Care, The University of Chicago Medical Center, Chicago, Illinois
| | - Antonia Z Lin
- Department of Anesthesiology, Rush Medical Center, Chicago, Illinois
| | - R Parker Ward
- Department of Medicine, Section of Cardiology, University of Chicago, Chicago, Illinois
| | - Peter Nagele
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
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Koning NJ, Lokin JLC, Roovers L, Kallewaard JW, van Harten WH, Kalkman CJ, Preckel B. Introduction of a Post-Anaesthesia Care Unit in a Teaching Hospital Is Associated with a Reduced Length of Hospital Stay in Noncardiac Surgery: A Single-Centre Interrupted Time Series Analysis. J Clin Med 2024; 13:534. [PMID: 38256668 PMCID: PMC10816897 DOI: 10.3390/jcm13020534] [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: 12/18/2023] [Revised: 01/10/2024] [Accepted: 01/16/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND A post-anaesthesia care unit (PACU) may improve postoperative care compared with intermediate care units (IMCU) due to its dedication to operative care and an individualized duration of postoperative stay. The effects of transition from IMCU to PACU for postoperative care following intermediate to high-risk noncardiac surgery on length of hospital stay, intensive care unit (ICU) utilization, and postoperative complications were investigated. METHODS This single-centre interrupted time series analysis included patients undergoing eleven different noncardiac surgical procedures associated with frequent postoperative admissions to an IMCU or PACU between January 2018 and March 2019 (IMCU episode) and between October 2019 and December 2020 (PACU episode). Primary outcome was hospital length of stay, secondary outcomes included postoperative complications and ICU admissions. RESULTS In total, 3300 patients were included. The hospital length of stay was lower following PACU admission compared to IMCU admission (IMCU 7.2 days [4.2-12.0] vs. PACU 6.0 days [3.6-9.1]; p < 0.001). Segmented regression analysis demonstrated that the introduction of the PACU was associated with a decrease in hospital length of stay (GMR 0.77 [95% CI 0.66-0.91]; p = 0.002). No differences between episodes were detected in the number of postoperative complications or postoperative ICU admissions. CONCLUSIONS The introduction of a PACU for postoperative care of patients undergoing intermediate to high-risk noncardiac surgery was associated with a reduction in the length of stay at the hospital, without increasing postoperative complications.
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Affiliation(s)
- Nick J. Koning
- Department of Anesthesiology and Pain Medicine, Rijnstate Hospital, Wagnerlaan 55, 6815 AD Arnhem, The Netherlands
| | - Joost L. C. Lokin
- Department of Anesthesiology and Pain Medicine, Rijnstate Hospital, Wagnerlaan 55, 6815 AD Arnhem, The Netherlands
- Department of Anesthesiology, Radboud University Medical Centre, 6525 GA Nijmegen, The Netherlands
| | - Lian Roovers
- Clinical Research Center, Rijnstate Hospital, 6815 AD Arnhem, The Netherlands (W.H.v.H.)
| | - Jan Willem Kallewaard
- Department of Anesthesiology and Pain Medicine, Rijnstate Hospital, Wagnerlaan 55, 6815 AD Arnhem, The Netherlands
- Department of Anesthesiology, Amsterdam University Medical Centre, 1105 AZ Amsterdam, The Netherlands
| | - Wim H. van Harten
- Clinical Research Center, Rijnstate Hospital, 6815 AD Arnhem, The Netherlands (W.H.v.H.)
- Health Services & Technology Research, University of Twente, 7522 NB Enschede, The Netherlands
| | - Cor J. Kalkman
- Department of Anesthesiology, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands
| | - Benedikt Preckel
- Department of Anesthesiology, Amsterdam University Medical Centre, 1105 AZ Amsterdam, The Netherlands
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Bako AT, Potter T, Pan AP, Borei KA, Prince T, Britz GW, Vahidy FS. Poor haemorrhagic stroke outcomes during the COVID-19 pandemic are driven by socioeconomic disparities: analysis of nationally representative data. BMJ Neurol Open 2024; 6:e000511. [PMID: 38268748 PMCID: PMC10806835 DOI: 10.1136/bmjno-2023-000511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 12/22/2023] [Indexed: 01/26/2024] Open
Abstract
Background Nationally representative studies evaluating the impact of the COVID-19 pandemic on haemorrhagic stroke outcomes are lacking. Methods In this pooled cross-sectional analysis, we identified adults (≥18 years) with primary intracerebral haemorrhage (ICH) or subarachnoid haemorrhage (SAH) from the National Inpatient Sample (2016-2020). We evaluated differences in rates of in-hospital outcomes between the prepandemic (January 2016-February 2020) and pandemic (March-December 2020) periods using segmented logistic regression models. We used multivariable logistic regression to evaluate differences in mortality between patients admitted from April to December 2020, with and without COVID-19, and those admitted from April to December 2019. Stratified analyses were conducted among patients residing in low-income and high-income zip codes, as well as among patients with extreme loss of function (E-LoF) and those with minor to major loss of function (MM-LoF). Results Overall, 309 965 patients with ICH (47% female, 56% low income) and 112 210 patients with SAH (62% female, 55% low income) were analysed. Prepandemic, ICH mortality decreased by ~1% per month (adjusted OR, 95% CI: 0.99 (0.99 to 1.00); p<0.001). However, during the pandemic, the overall ICH mortality rate increased, relative to prepandemic, by ~2% per month (1.02 (1.00 to 1.04), p<0.05) and ~4% per month (1.04 (1.01 to 1.07), p<0.001) among low-income patients. There was no significant change in trend among high-income patients with ICH (1.00 (0.97 to 1.03)). Patients with comorbid COVID-19 in 2020 had higher odds of mortality (versus 2019 cohort) only among patients with MM-LoF (ICH, 2.15 (1.12 to 4.16), and SAH, 5.77 (1.57 to 21.17)), but not among patients with E-LoF. Conclusion Sustained efforts are needed to address socioeconomic disparities in healthcare access, quality and outcomes during public health emergencies.
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Affiliation(s)
- Abdulaziz T Bako
- Department of Neurosurgery, Houston Methodist, Houston, Texas, USA
| | - Thomas Potter
- Department of Neurosurgery, Houston Methodist, Houston, Texas, USA
| | - Alan P Pan
- Center for Health Data Science and Analytics, Houston Methodist Research Institute, Houston, Texas, USA
| | - Karim A Borei
- Department of Neurosurgery, Houston Methodist, Houston, Texas, USA
| | - Taya Prince
- Department of Neurosurgery, Houston Methodist, Houston, Texas, USA
| | - Gavin W Britz
- Department of Neurosurgery, Houston Methodist, Houston, Texas, USA
| | - Farhaan S Vahidy
- Department of Neurosurgery, Houston Methodist, Houston, Texas, USA
- TIRR Memorial Hermann, Houston, Texas, USA
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Janda AM, Vaughn MT, Colquhoun D, Mentz G, Buehler MS RN CPPS K, Nathan H, Regenbogen SE, Syrjamaki J, Kheterpal S, Shah N. Does Anesthesia Quality Improvement Participation Lead to Incremental Savings in a Surgical Quality Collaborative Population? A Retrospective Observational Study. Anesth Analg 2023; 137:1093-1103. [PMID: 37678254 PMCID: PMC10592579 DOI: 10.1213/ane.0000000000006565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
BACKGROUND The Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) Collaborative Quality Initiative (CQI) was launched as a partnership among hospitals to measure quality, review evidence-based practices, and improve anesthesia-related outcomes. Cost savings and improved patient outcomes have been associated with surgical CQI participation, but the impact of an anesthesia CQI on health care cost has not been thoroughly assessed. In this study, we evaluated whether participation in an anesthesia CQI led to health care savings. We hypothesized that ASPIRE participation is associated with reduced total episode payments for payers and major, high-volume procedures included in the Michigan Value Collaborative (MVC) registry. METHODS In this retrospective observational study, we compared MVC episode payment data from Group 1 ASPIRE hospitals, the first cluster of 8 Michigan hospitals to join ASPIRE in January 2015, to non-ASPIRE matched control hospitals. MVC computes price-standardized, risk-adjusted payments for patients insured by Blue Cross Blue Shield of Michigan Preferred Provider Organization, Blue Care Network Health Maintenance Organization, and Medicare Fee-for-Service plans. Episodes from 2014 comprised the pre-ASPIRE time period, and episodes from June 2016 to July 2017 constituted the post-ASPIRE time period. We performed a difference-in-differences analysis to evaluate whether ASPIRE implementation was associated with greater reduction in total episode payments compared to the change in the control hospitals during the same time periods. RESULTS We found a statistically significant reduction in total episode (-$719; 95% CI [-$1340 to -$97]; P = .023) payments at the 8 ASPIRE hospitals (N = 17,852 cases) compared to the change observed in 8 matched non-ASPIRE hospitals (N = 12,987 cases) for major, high-volume surgeries, including colectomy, colorectal cancer resection, gastrectomy, esophagectomy, pancreatectomy, hysterectomy, joint replacement (knee and hip), and hip fracture repair. In secondary analyses, 30-day postdischarge (-$354; 95% CI [-$582 to -$126]; P = .002) payments were also significantly reduced in ASPIRE hospitals compared to non-ASPIRE controls. Subgroup analyses revealed a significant reduction in total episode payments for joint replacements (-$860; 95% CI [-$1222 to -$499]; P < .001) at ASPIRE-participating hospitals. Sensitivity analyses including patient-level covariates also showed consistent results. CONCLUSIONS Participation in an anesthesiology CQI, ASPIRE, is associated with lower total episode payments for selected major, high-volume procedures. This analysis supports that participation in an anesthesia CQI can lead to reduced health care payments.
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Affiliation(s)
- Allison M. Janda
- Department of Anesthesiology, Michigan Medicine, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Michelle T. Vaughn
- Department of Anesthesiology, Michigan Medicine, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Douglas Colquhoun
- Department of Anesthesiology, Michigan Medicine, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Graciela Mentz
- Department of Anesthesiology, Michigan Medicine, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Kathryn Buehler MS RN CPPS
- Department of Anesthesiology, Michigan Medicine, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Hari Nathan
- Department of Surgery, Michigan Medicine, Ann Arbor, MI 48109, USA
| | | | - John Syrjamaki
- Michigan Value Collaborative (MVC), Department of Surgery, Michigan Medicine, Ann Arbor, MI 48109, USA
| | - Sachin Kheterpal
- Department of Anesthesiology, Michigan Medicine, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Nirav Shah
- Department of Anesthesiology, Michigan Medicine, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
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Gosling AF, Wright MC, Cherry A, Milano CA, Patel CB, Schroder JN, DeVore A, McCartney S, Kerr D, Bryner B, Podgoreanu M, Nicoara A. The Role of Recipient Thyroid Hormone Supplementation in Primary Graft Dysfunction After Heart Transplantation: A Propensity-Adjusted Analysis. J Cardiothorac Vasc Anesth 2023; 37:2236-2243. [PMID: 37586950 DOI: 10.1053/j.jvca.2023.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/14/2023] [Accepted: 07/19/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVES To investigate whether recipient administration of thyroid hormone (liothyronine [T3]) is associated with reduced rates of primary graft dysfunction (PGD) after orthotopic heart transplantation. DESIGN Retrospective cohort study. SETTING Single-center, university hospital. PARTICIPANTS Adult patients undergoing orthotopic heart transplantation. INTERVENTIONS A total of 609 adult heart transplant recipients were divided into 2 cohorts: patients who did not receive T3 (no T3 group, from 2009 to 2014), and patients who received T3 (T3 group, from 2015 to 2019). Propensity-adjusted logistic regression was performed to assess the association between T3 supplementation and PGD. MEASUREMENTS AND MAIN RESULTS After applying exclusion criteria and propensity-score analysis, the final cohort included 461 patients. The incidence of PGD was not significantly different between the groups (33.9% no T3 group v 40.8% T3 group; p = 0.32). Mortality at 30 days (3% no T3 group v 2% T3 group; p = 0.53) and 1 year (10% no T3 group v 12% T3 group; p = 0.26) were also not significantly different. When assessing the severity of PGD, there were no differences in the groups' rates of moderate PGD (not requiring mechanical circulatory support other than an intra-aortic balloon pump) or severe PGD (requiring mechanical circulatory support other than an intra-aortic balloon pump). However, segmented time regression analysis revealed that patients in the T3 group were less likely to develop severe PGD. CONCLUSIONS These findings indicated that recipient single-dose thyroid hormone administration may not protect against the development of PGD, but may attenuate the severity of PGD.
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Affiliation(s)
- Andre F Gosling
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC.
| | - Mary C Wright
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Anne Cherry
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Carmelo A Milano
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Chetan B Patel
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Jacob N Schroder
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Adam DeVore
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Sharon McCartney
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Daryl Kerr
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Benjamin Bryner
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Mihai Podgoreanu
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Alina Nicoara
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
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Muinga N, Tuti T, Mwaniki P, Gicheha E, Paton C, Beňová L, English M. Evaluating the documentation of vital signs following implementation of a new comprehensive newborn monitoring chart in 19 hospitals in Kenya: A time series analysis. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002440. [PMID: 37910489 PMCID: PMC10619831 DOI: 10.1371/journal.pgph.0002440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 10/04/2023] [Indexed: 11/03/2023]
Abstract
Multi-professional teams care for sick newborns, but nurses are the primary caregivers, making nursing care documentation essential for delivering high-quality care, fostering teamwork, and improving patient outcomes. We report on an evaluation of vital signs documentation following implementation of the comprehensive newborn monitoring chart using interrupted time series analysis and a review of filled charts. We collected post-admission vital signs (Temperature (T), Pulse (P), Respiratory Rate (R) and Oxygen Saturation (S)) documentation frequencies of 43,719 newborns with a length of stay > 48 hours from 19 public hospitals in Kenya between September 2019 and October 2021. The primary outcome was an ordinal categorical variable (no monitoring, monitoring 1 to 3 times, 4 to 7 times and 8 or more times) based on the number of complete sets of TPRS. Descriptive analyses explored documentation of at least one T, P, R and S. The percentage of patients in the no-monitoring category decreased from 68.5% to 43.5% in the post-intervention period for TPRS monitoring. The intervention increased the odds of being in a higher TPRS monitoring category by 4.8 times (p<0.001) and increased the odds of higher monitoring frequency for each vital sign, with S recording the highest odds. Sicker babies were likely to have vital signs documented in a higher monitoring category and being in the NEST360 program increased the odds of frequent vital signs documentation. However, by the end of the intervention period, nearly half of the newborns did not have a single full set of TPRS documented and there was heterogenous hospital performance. A review of 84 charts showed variable documentation, with only one chart being completed as designed. Vital signs documentation fell below standards despite increased documentation odds. More sustained interventions are required to realise the benefits of the chart and hospital-specific performance data may help customise interventions.
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Affiliation(s)
- Naomi Muinga
- Athena Institute, VU University Amsterdam, Amsterdam, Netherlands
- KEMRI/Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Public Health, Institute of Tropical Medicine, Sexual and Reproductive Health Group, Antwerp, Belgium
| | - Timothy Tuti
- Athena Institute, VU University Amsterdam, Amsterdam, Netherlands
| | - Paul Mwaniki
- Athena Institute, VU University Amsterdam, Amsterdam, Netherlands
| | - Edith Gicheha
- Rice360 Global Health Institute, Rice University, Texas, United States of America
| | - Chris Paton
- Nuffield Department of Medicine, Health systems Collaborative, University of Oxford, Oxford, England
- Department of Information Science, University of Otago, Dunedin, New Zealand
| | - Lenka Beňová
- Department of Public Health, Institute of Tropical Medicine, Sexual and Reproductive Health Group, Antwerp, Belgium
| | - Mike English
- Athena Institute, VU University Amsterdam, Amsterdam, Netherlands
- Nuffield Department of Medicine, Health systems Collaborative, University of Oxford, Oxford, England
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20
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Tooba R, Rose S, Modlin C, Liang C, Mascha EJ, Perez-Protto S. Using Preanesthesia Clinic Visits to Improve Advance Directives Completion: An Interrupted Time Series Analysis. Anesth Analg 2023; 137:906-916. [PMID: 37450641 DOI: 10.1213/ane.0000000000006533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND Advance directives documentation can increase the likelihood that patient's wishes are respected if they become incapacitated. Unfortunately, completion rates are suboptimal overall, and disparities may exist, especially for vulnerable groups. We assessed whether implementing an initiative to standardize advance directives discussions during preanesthesia visits was associated with changes in rates of advance directives completion over time, and whether the association depends on race, insurance type, or income. METHODS We conducted a before-after interrupted time series evaluation between January 1, 2015 and June 30, 2019 in a single-center, outpatient preanesthesia clinic. Participants were adults who visited the preanesthesia clinic at Cleveland Clinic and had >1 comorbidity before a noncardiac surgery of either medium or high risk. The intervention in March of 2017 consisted of training staff to help patients complete and witness advance directives documents during visits. We measured advance directives completion, by race, payor, and income (using the 2019 Federal Poverty Line). We assessed the confounder-adjusted association between intervention (pre versus post) and proportion of patients completing advanced directives over time using segmented regression to compare slopes between periods and assess changes at start of the intervention. We used similar models to assess whether changes depended on race, insurance type, or income level. RESULTS We included 26,368 visits from 22,430 patients. We analyzed financial status for 16,788 visits from 14,274 patients who had address data. There were 11,242 (43%) visits preintervention and 15,126 (57%) visits postintervention. Crude completion rates for advance directives increased from 29% to 78%, with odds of completion an estimated 18 times higher than preintervention (odds ratio [95% CI] of 18 [16-21]; P < 0.001). Regarding race, Black patients had lower completion rates preintervention than White patients, although the gap steadily closed after the intervention ( P = .001). Postintervention, both race groups immediately increased, with no difference in amount of increase ( P = .17) or postintervention change in slope difference ( P = .17). Regarding insurance, patients with Medicaid had lower preintervention completion rates than those with private. Intervention was associated with increases in both groups, but the difference in slopes ( P = .43) or proportions ( P = .23) between the groups did not change after intervention. Regarding the Federal Poverty Line, the completion rate gap between those below (<100%) and above (139%-400%) narrowed by approximately half (0.51: 95% CI, 0.27-0.98; P = .04). CONCLUSIONS Standardizing advance directives discussions during preanesthesia visits was associated with more patients completing advance directives, particularly in vulnerable patient groups.
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Affiliation(s)
- Rubabin Tooba
- From the Department of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, Texas
| | - Susannah Rose
- Center for Bioethics and Safety, Quality and Patient Experience, Clinical Transformation, Cleveland Clinic, Cleveland, Ohio
| | | | - Chen Liang
- Departments of Quantitative Health and Sciences
- Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward J Mascha
- Departments of Quantitative Health Sciences
- Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Silvia Perez-Protto
- Departments of Intensive Care & Resuscitation
- Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
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21
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Shustak RJ, Huang J, Tam V, Stagg A, Giglia TM, Ravishankar C, Mercer‐Rosa L, Guevara JP, Gardner MM. Neighborhood Social Vulnerability and Interstage Weight Gain: Evaluating the Role of a Home Monitoring Program. J Am Heart Assoc 2023; 12:e030029. [PMID: 37702068 PMCID: PMC10547291 DOI: 10.1161/jaha.123.030029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 08/08/2023] [Indexed: 09/14/2023]
Abstract
Background Poor interstage weight gain is a risk factor for adverse outcomes in infants with hypoplastic left heart syndrome. We sought to examine the association of neighborhood social vulnerability and interstage weight gain and determine if this association is modified by enrollment in our institution's Infant Single Ventricle Management and Monitoring Program (ISVMP). Methods and Results We performed a retrospective single-center study of infants with hypoplastic left heart syndrome before (2007-2010) and after (2011-2020) introduction of the ISVMP. The primary outcome was interstage weight gain, and the secondary outcome was interstage growth failure. Multivariable linear and logistic regression models were used to examine the association between the Social Vulnerability Index and the outcomes. We introduced an interaction term into the models to test for effect modification by the ISVMP. We evaluated 217 ISVMP infants and 111 pre-ISVMP historical controls. The Social Vulnerability Index was associated with interstage growth failure (P=0.001); however, enrollment in the ISVMP strongly attenuated this association (P=0.04). Pre-ISVMP, as well as high- and middle-vulnerability infants gained 4 g/d less and were significantly more likely to experience growth failure than low-vulnerability infants (high versus low: adjusted odds ratio [aOR], 12.5 [95% CI, 2.5-62.2]; middle versus low: aOR, 7.8 [95% CI, 2.0-31.2]). After the introduction of the ISVMP, outcomes did not differ by Social Vulnerability Index tertile. Infants with middle and high Social Vulnerability Index scores who were enrolled in the ISVMP gained 4 g/d and 2 g/d more, respectively, than pre-ISVMP controls. Conclusions In infants with hypoplastic left heart syndrome, high social vulnerability is a risk factor for poor interstage weight gain. However, enrollment in the ISVMP significantly reduces growth disparities.
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Affiliation(s)
- Rachel J. Shustak
- Division of Cardiology, Department of Pediatrics, The Children’s Hospital of Philadelphia and Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Jing Huang
- Department of Biomedical and Health Informatics, Data Science and Biostatistics UnitThe Children’s Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - Vicky Tam
- Cartographic Modeling LabUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Alyson Stagg
- Division of Cardiology, Department of Pediatrics, The Children’s Hospital of Philadelphia and Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Therese M. Giglia
- Division of Cardiology, Department of Pediatrics, The Children’s Hospital of Philadelphia and Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Chitra Ravishankar
- Division of Cardiology, Department of Pediatrics, The Children’s Hospital of Philadelphia and Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Laura Mercer‐Rosa
- Division of Cardiology, Department of Pediatrics, The Children’s Hospital of Philadelphia and Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - James P. Guevara
- Division of General Pediatrics, Department of Pediatrics, The Children’s Hospital of PhiladelphiaPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPAUSA
| | - Monique M. Gardner
- Division of Cardiac Critical Care Medicine, The Children’s Hospital of Philadelphia and Department of Anesthesiology and Critical CarePerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPAUSA
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22
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Martin LD, Franz AM, Rampersad SE, Ojo B, Low DK, Martin LD, Hunyady AI, Flack SH, Geiduschek JM. Outcomes for 41 260 pediatric surgical patients with opioid-free anesthesia: One center's experience. Paediatr Anaesth 2023; 33:699-709. [PMID: 37300350 DOI: 10.1111/pan.14705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 04/21/2023] [Accepted: 05/25/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Opioid use is common and associated with side effects and risks. Consequently, analgesic strategies to reduce opioid utilization have been developed. Regional anesthesia and multimodal strategies are central tenets of enhanced recovery pathways and facilitate reduced perioperative opioid use. Opioid-free anesthesia (OFA) protocols eliminate all intraoperative opioids, reserving opioids for postoperative rescue treatment. Systematic reviews show variable results for OFA. METHODS In a series of Quality Improvement (QI) projects, multidisciplinary teams developed interventions to test and spread OFA first in our ambulatory surgery center (ASC) and then in our hospital. Outcome measures were tracked using statistical process control charts to increase the adoption of OFA. RESULTS Between January 1, 2016, and September 30, 2022, 19 872 of 28 574 ASC patients received OFA, increasing from 30% to 98%. Post Anesthesia Care Unit (PACU) maximum pain score, opioid-rescue rate, and postoperative nausea and vomiting (PONV) treatment all decreased concomitantly. The use of OFA now represents our ambulatory standard practice. Over the same timeframe, the spread of this practice to our hospital led to 21 388 of 64 859 patients undergoing select procedures with OFA, increasing from 15% to 60%. Opioid rescue rate and PONV treatment in PACU decreased while hospital maximum pain scores and length of stay were stable. Two procedural examples with OFA benefits were identified. The use of OFA allowed relaxation of adenotonsillectomy admission criteria, resulting in 52 hospital patient days saved. Transition to OFA for laparoscopic appendectomy occurred concomitantly with a decrease in the mean hospital length of stay from 2.9 to 1.4 days, representing a savings of >500 hospital patient days/year. CONCLUSIONS These QI projects demonstrated that most pediatric ambulatory and select inpatient surgeries are amenable to OFA techniques which may reduce PONV without worsening pain.
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Affiliation(s)
- Lynn D Martin
- Department of Anesthesiology & Pain Medicine and Pediatrics, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
| | - Amber M Franz
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
| | - Sally E Rampersad
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
| | - Bukola Ojo
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
| | - Daniel K Low
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
| | - Lizabeth D Martin
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
| | - Agnes I Hunyady
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
| | - Sean H Flack
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
| | - Jeremy M Geiduschek
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
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23
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Momesso T, Gokpinar B, Ibrahim R, Boyle AA. Effect of removing the 4-hour access standard in the ED: a retrospective observational study. Emerg Med J 2023; 40:630-635. [PMID: 37369563 DOI: 10.1136/emermed-2023-213142] [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: 02/06/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Time-based targets are used to improve patient flow and quality of care within EDs. While previous research often highlighted the benefits of these targets, some studies found negative consequences of their implementation. We study the consequences of removing the 4-hour access standard. METHODS We conducted a before and after, retrospective, observational study using anonymised, routinely collected, patient-level data from a single English NHS ED between April 2018 and December 2019. The primary outcomes of interest were the proportion of admitted patients, that is, the admission rate, the length of stay in the ED and ambulance handover times. We used interrupted time series models to study and estimate the impact of removing the 4-hour access standard. RESULTS A total of 169 916 attendances were included in the analysis. The interrupted time series models for the average daily admission rate indicate a drop from an estimated 35% to an estimated 31% (95% CI -4.1 to -3.9). This drop is only statistically significant for Majors (Ambulant) patients (from an estimated 38.3% to an estimated 31.4%) and, particularly, for short-stay admissions (from an estimated 18.1% to an estimated 12.8%). The models also show an increase in the average daily length of stay for admitted patients from an estimated 316 min to an estimated 387 min (95% CI 33.5 to 108.9), and an increase in the average daily length of stay for discharged patients from an estimated 222 min to an estimated 262 min (95% CI 6.9 to 40.4). CONCLUSION Lifting the 4-hour access standard reporting was associated with a drop in short-stay admissions to the hospital. However, it was also associated with an increase in the average length of stay in the ED. Our study also suggests that the removal of the 4-hour standard does not impact all patients equally. While certain patient groups such as those Majors (Ambulant) patients with less severe issues might have benefited from the removal of the 4-hour access standard by avoiding short-stay hospital admissions, the average length of stay in the ED seemed to have increased across all groups, particularly for older and admitted patients.
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Affiliation(s)
- Tomas Momesso
- UCL School of Management, University College London, London, UK
| | - Bilal Gokpinar
- UCL School of Management, University College London, London, UK
| | - Rouba Ibrahim
- UCL School of Management, University College London, London, UK
| | - Adrian A Boyle
- Emergency Department, Addenbrooke's Hospital Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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24
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Ramadan M. Temporal patterns of the burden of Alzheimer's disease and their association with Sociodemographic Index in countries with varying rates of aging 1990-2019. Aging Med (Milton) 2023; 6:281-289. [PMID: 37711254 PMCID: PMC10498825 DOI: 10.1002/agm2.12260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/15/2023] [Accepted: 06/18/2023] [Indexed: 09/16/2023] Open
Abstract
Objective To we examine the temporal patterns of the burden of Alzheimer's disease and their association with Sociodemographic Index in countries with varying rates of aging. Method Data were obtained from Global Burden of Diseases studies (GBD) 2019 and were used to compare countries with different rates of change in aging population from 1990 to 2019. We collected the data of the age-standardized rates per 100,000 of disability-adjusted life years (DALYs), incidence, prevalence of Alzheimer's disease and other dementias, and the age-specific population rates per 100,000. Results Countries with high rates of change in their aging populations had an increase in DALYs, incidence, and prevalence of Alzheimer's disease and other dementias over the last 30 years. Countries with a high rate of change in aging population had a significantly positive association among DALYs, incidence, and prevalence of Alzheimer's disease and other dementias. In contrast, countries with a medium and low rate of change in aging population had negative associations between DALYs and incidence of Alzheimer's disease and other dementias. Conclusion This study highlights the significant impact of demographic changes on the burden, prevalence, and incidence of Alzheimer's disease and other dementia. The study also found that robust health care and social systems, as reflected by a higher Sociodemographic Index, can contribute to reducing the burden of Alzheimer's disease and other dementias in medium to low rates of aging populations. The findings underscore the importance of investing in health care and social systems to address the growing burden of these conditions, especially in countries with a high rate of change in the aging population.
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Affiliation(s)
- Majed Ramadan
- King Abdullah International Medical Research Center (KAIMRC), Population Health Research SectionKing Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard – Health AffairsJeddahSaudi Arabia
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25
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Epstein RH, Dexter F, Fahy BG. Patients Undergoing Elective Inpatient Major Therapeutic Procedures in Florida Had No Significant Change in Hospital Mortality or Mortality-Related Comorbidities Between 2007 and 2019. Anesth Analg 2023; 137:306-312. [PMID: 37058427 DOI: 10.1213/ane.0000000000006494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
BACKGROUND In a recent study, rapid response team implementation at 1 hospital was associated with only a 0.1% reduction in inpatient mortality from 2005 to 2018, characterized in the accompanying editorial as a "tepid" improvement. The editorialist postulated that an increase in the degree of illness of hospitalized patients might have masked a larger reduction that otherwise might have occurred. Impressions of greater patient acuity during the studied period might have been an artifact of efforts to document more comorbidities and complications, possibly facilitated by the change in diagnosis coding from the International Classification of Diseases , Ninth Revision ( ICD-9 ) to the Tenth Revision ( ICD-10 ). METHODS We used inpatient data from every nonfederal hospital in Florida from the last quarter of 2007 through 2019. We studied hospitalizations for major therapeutic surgical procedures with lengths of stay ≥2 days. Using logistic regression with clustering by the Clinical Classification Software (CCS) code of the primary surgical procedure, we evaluated the trends for decreased mortality, changes in the prevalence of Medicare Severity Diagnosis Related Groups (MS-DRG) with complications or comorbidities (CC) or major complications or major comorbidities (MCC), and changes in the van Walraven index (vWI), a measure of patient comorbidities associated with increased inpatient mortality. Also incorporated in the modeling was the change from ICD-9 to ICD-10 . RESULTS There were 3,151,107 hospitalizations comprising 130 distinct CCS codes and 453 MS-DRG groups among 213 hospitals. Despite a progressive increase of 4.1% per year in the odds of a CC or MCC ( P = .001), there were no significant changes in the marginal estimates of in-house mortality over time (net estimated decrease, 0.036%; 99% confidence interval [CI], -0.168% to 0.097%; P = .49). There was also absence of a significantly greater fraction of discharges with vWI >0 attributable to the year of the study (odds ratio, 1.017 per year; 99% CI, 0.995-1.041). The changes in MS-DRG to those with CC or MCC were not increased significantly from either the ICD-10 coding change or the number of years after the change. CONCLUSIONS Consistent with the previous study, there was at most a small decrease in the mortality rate over a 12-year period. We found no reliable evidence that patients undergoing elective inpatient surgical procedures were any sicker in 2019 than in 2007. There were substantively more comorbidities and complications documented over time, but this was unrelated to the change to ICD-10 coding.
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Affiliation(s)
- Richard H Epstein
- From the Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami, Miller School of Medicine, Miami, Florida
| | - Franklin Dexter
- Division of Management Consulting, Department of Anesthesia, University of Iowa, Iowa City, Iowa
| | - Brenda G Fahy
- Department of Anesthesiology, University of Florida, Gainesville, Florida
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26
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Guglielminotti J, Daw JR, Friedman AM, Landau R, Li G. Medicaid expansion and risk of eclampsia. Am J Obstet Gynecol MFM 2023; 5:101054. [PMID: 37330007 PMCID: PMC10527027 DOI: 10.1016/j.ajogmf.2023.101054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/23/2023] [Accepted: 06/11/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND Eclampsia is an indicator of severe maternal morbidity and can be prevented through increased prenatal care access and early prenatal care utilization. The 2014 Medicaid expansion under the Patient Protection and Affordable Care Act allowed states to expand Medicaid coverage to nonelderly adults with incomes up to 138% of the federal poverty level. Its implementation has led to a significant increase in prenatal care access and utilization. OBJECTIVE This study aimed to assess the association of Medicaid expansion under the Affordable Care Act with eclampsia incidence. STUDY DESIGN This natural experiment study was based on US birth certificate data from January 2010 to December 2018 in 16 states that expanded Medicaid in January 2014 and in 13 states that did not expand Medicaid during the study period. The outcome was eclampsia incidence, the intervention was the implementation of the Medicaid expansion, and the exposure was state expansion status. Using the interrupted time series method, we compared temporal trends in the incidence of eclampsia before and after the intervention in expansion vs non-expansion states with adjustments for patient and hospital county characteristics. RESULTS Of the 21,570,021 birth certificates analyzed, 11,433,862 (53.0%) were in expansion states and 12,035,159 (55.8%) were in the postintervention period. The diagnosis of eclampsia was recorded in 42,677 birth certificates or 19.8 per 10,000 (95% confidence interval, 19.6-20.0). The incidence of eclampsia was higher for Black people (29.1 per 10,000) than for White (20.7 per 10,000), Hispanic (15.3 per 10,000), and birthing people of other race and ethnicity (15.4 per 10,000). In the expansion states, the incidence of eclampsia increased during the preintervention period and decreased during the postintervention period; in the nonexpansion states, a reverse pattern was observed. A statistically significant difference was observed between expansion and nonexpansion states in temporal trends between the pre- and postintervention periods, with an overall 1.6% decrease (95% confidence interval, 1.3-1.9) in the incidence of eclampsia in expansion states compared with nonexpansion states. The results were consistent in subgroup analyses according to maternal race and ethnicity, education level (less than high school or high school and higher), parity (nulliparous or parous), delivery mode (vaginal or cesarean delivery), and poverty in the residence county (high or low). CONCLUSION Implementation of the Affordable Care Act Medicaid expansion was associated with a small statistically significant reduction in the incidence of eclampsia. Its clinical significance and cost-effectiveness remain to be determined.
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Affiliation(s)
- Jean Guglielminotti
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY (Drs Guglielminotti, Landau, and Li).
| | - Jamie R Daw
- Departments of Health Policy and Management (Dr Daw)
| | - Alexander M Friedman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY (Dr Friedman)
| | - Ruth Landau
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY (Drs Guglielminotti, Landau, and Li)
| | - Guohua Li
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY (Drs Guglielminotti, Landau, and Li); Epidemiology (Dr Li), Columbia University Mailman School of Public Health, New York, NY
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27
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Hansen EE, Chiem JL, Righter-Foss K, Zha Y, Cockrell HC, Greenberg SLM, Low DK, Martin LD. Project SPRUCE: Saving Our Planet by Reducing Carbon Emissions, a Pediatric Anesthesia Sustainability Quality Improvement Initiative. Anesth Analg 2023; 137:98-107. [PMID: 37145976 DOI: 10.1213/ane.0000000000006421] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
BACKGROUND Children are particularly vulnerable to adverse health outcomes related to climate change. Inhalational anesthetics are potent greenhouse gasses (GHGs) and contribute significantly to health care-generated emissions. Desflurane and nitrous oxide have very high global warming potentials. Eliminating their use, as well as lowering fresh gas flows (FGFs), will lead to reduced emissions. METHODS Using published calculations for converting volatile anesthetic concentrations to carbon dioxide equivalents (CO 2 e), we derived the average kilograms (kg) CO 2 e/min for every anesthetic administered in the operating rooms at our pediatric hospital and ambulatory surgical center between October 2017 and October 2022. We leveraged real-world data captured from our electronic medical record systems and used AdaptX to extract and present those data as statistical process control (SPC) charts. We implemented recommended strategies aimed at reducing emissions from inhalational anesthetics, including removing desflurane vaporizers, unplugging nitrous oxide hoses, decreasing the default anesthesia machine FGF, clinical decision support tools, and educational initiatives. Our primary outcome measure was average kg CO 2 e/min. RESULTS A combination of educational initiatives, practice constraints, protocol changes, and access to real-world data were associated with an 87% reduction in measured GHG emissions from inhaled anesthesia agents used in the operating rooms over a 5-year period. Shorter cases (<30 minutes duration) had 3 times higher average CO 2 e, likely due to higher FGF and nitrous oxide use associated with inhalational inductions, and higher proportion of mask-only anesthetics. Removing desflurane vaporizers corresponded with a >50% reduction of CO 2 e. A subsequent decrease in anesthesia machine default FGF was associated with a similarly robust emissions reduction. Another significant decrease in emissions was noted with educational efforts, clinical decision support alerts, and feedback from real-time data. CONCLUSIONS Providing environmentally responsible anesthesia in a pediatric setting is a challenging but achievable goal, and it is imperative to help mitigate the impact of climate change. Large systems changes, such as eliminating desflurane, limiting access to nitrous oxide, and changing default anesthesia machine FGF rates, were associated with rapid and lasting emissions reduction. Measuring and reporting GHG emissions from volatile anesthetics allows practitioners to explore and implement methods of decreasing the environmental impact of their individual anesthesia delivery practices.
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Affiliation(s)
- Elizabeth E Hansen
- From the Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, Washington
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Jennifer L Chiem
- From the Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, Washington
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Kimberly Righter-Foss
- From the Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, Washington
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Yuanting Zha
- From the Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, Washington
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Hannah C Cockrell
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, Washington
- Department of Surgery, University of Washington, Seattle, Washington
| | - Sarah L M Greenberg
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, Washington
- Department of Surgery, University of Washington, Seattle, Washington
| | - Daniel K Low
- From the Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, Washington
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Lynn D Martin
- From the Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, Washington
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
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Tuyishime JDDH, Niyitegeka J, Olufolabi AJ, Powers S, Naik BI, Tsang S, Durieux ME, Twagirumugabe T. Investigating the Association Between a Risk-Directed Prophylaxis Protocol and Postoperative Nausea and Vomiting: Validation in a Low-Income Setting. Anesth Analg 2023; 136:588-596. [PMID: 36223370 DOI: 10.1213/ane.0000000000006251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The efficacy of postoperative nausea and vomiting (PONV) prevention protocols in low-income countries is not well known. Different surgical procedures, available medications, and co-occurring diseases imply that existing protocols may need validation in these settings. We assessed the association of a risk-directed PONV prevention protocol on the incidence of PONV and short-term surgical outcomes in a teaching hospital in Rwanda. METHODS We compared the incidence of PONV during the first 48 hours postoperatively before (April 1, 2019-June 30, 2019; preintervention) and immediately after (July 1, 2019-September 30, 2019; postintervention) implementing an Apfel score-based PONV prevention strategy in 116 adult patients undergoing elective open abdominal surgery at Kigali University Teaching Hospital in Rwanda. Secondary outcomes included time to first oral intake, hospital length of stay, and rate of wound dehiscence. Interrupted time series analyses were performed to assess the associated temporal slopes of the outcome before and immediately after implementation of the risk-directed PONV prevention protocol. RESULTS Compared to just before the intervention, there was no change in the odds of PONV at the beginning of the postintervention period (odds ratio [OR], 0.23; 95% confidence interval [CI], 0.05-1.01). There was a decreasing trend in the odds of nausea (OR, 0.60; 95% CI, 0.36-0.97) per month. However, there was no difference in the incidence of nausea immediately after implementation of the protocol (OR, 0.96; 95% CI, 0.25-3.72) or in the slope between preintervention and postintervention periods (OR, 1.48; 95% CI, 0.60-3.65). In contrast, there was no change in the odds of vomiting during the preintervention period (OR, 1.01; 95% CI, 0.61-1.67) per month. The odds of vomiting decreased at the beginning of the postintervention period compared to just before (OR, 0.10; 95% CI, 0.02-0.47; P = .004). Finally, there was a significant decrease in the average time to first oral intake (estimated 14 hours less; 95% CI, -25 to -3) when the protocol was first implemented, after adjusting for confounders; however, there was no difference in the slope of the average time to first oral intake between the 2 periods ( P = .44). CONCLUSIONS A risk-directed PONV prophylaxis protocol was associated with reduced vomiting and time to first oral intake after implementation. There was no substantial difference in the slopes of vomiting incidence and time to first oral intake before and after implementation.
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Affiliation(s)
- Jean de Dieu H Tuyishime
- From the Department of Anesthesiology, Critical Care and Emergency Medicine, University of Rwanda, Kigali, Rwanda
| | - Joseph Niyitegeka
- From the Department of Anesthesiology, Critical Care and Emergency Medicine, University of Rwanda, Kigali, Rwanda
| | | | | | - Bhiken I Naik
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Siny Tsang
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Marcel E Durieux
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Theogene Twagirumugabe
- From the Department of Anesthesiology, Critical Care and Emergency Medicine, University of Rwanda, Kigali, Rwanda
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Peel JK, Keshavjee S, Naimark D, Liu M, Del Sorbo L, Cypel M, Barrett K, Pullenayegum EM, Sander B. Determining the impact of ex-vivo lung perfusion on hospital costs for lung transplantation: A retrospective cohort study. J Heart Lung Transplant 2023; 42:356-367. [PMID: 36411188 DOI: 10.1016/j.healun.2022.10.016] [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: 06/03/2022] [Revised: 10/04/2022] [Accepted: 10/20/2022] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Ex-vivo lung perfusion (EVLP) has improved organ utilization for lung transplantation, but it is not yet known whether the benefits of this technology offset its additional costs. We compared the institutional costs of lung transplantation before vs after EVLP was available to identify predictors of costs and determine the health-economic impact of EVLP. METHODS We performed a retrospective, before-after, propensity-score weighted cohort study of patients wait-listed for lung transplant at University Health Network (UHN) in Ontario, Canada, between January 2005 and December 2019 using institutional administrative data. We compared costs, in 2019 Canadian Dollars ($), between patients referred for transplant before EVLP was available (Pre-EVLP) to after (Modern EVLP). Cumulative costs were estimated using a novel application of multistate survival models. Predictors of costs were identified using weighted log-gamma generalized linear regression. RESULTS A total of 1,199 patients met inclusion criteria (352 Pre-EVLP; 847 Modern EVLP). Mean total costs for the transplant hospitalization were $111,878 ($94,123-$130,767) in the Pre-EVLP era and $110,969 ($87,714-$136,000) in the Modern EVLP era. Cumulative five-year costs since referral were $278,777 ($82,575-$298,135) in the Pre-EVLP era and $293,680 ($252,832-$317,599) in the Modern EVLP era. We observed faster progression to transplantation when EVLP was available. EVLP availability was not a predictor of waitlist (cost ratio [CR] 1.04 [0.81-1.37]; p = 0.354) or transplant costs (CR 1.02 [0.80-1.29]; p = 0.425) but was associated with lower costs during posttransplant years 1&2 (CR 0.75 [0.58-1.06]; p = 0.05) and posttransplant years 3+ (CR 0.43 [0.26-0.74]; p = 0.001). CONCLUSIONS At our center, EVLP availability was associated with faster progression to transplantation at no significant marginal cost.
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Affiliation(s)
- John Kenneth Peel
- Department of Anesthesiology, University Health Network, Toronto, Ontario, Canada; Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School for Public Health, University of Toronto, Toronto, Ontario, Canada.
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - David Naimark
- Institute of Health Policy, Management and Evaluation, Dalla Lana School for Public Health, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Mingyao Liu
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Lorenzo Del Sorbo
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Kali Barrett
- Institute of Health Policy, Management and Evaluation, Dalla Lana School for Public Health, University of Toronto, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Eleanor M Pullenayegum
- Institute of Health Policy, Management and Evaluation, Dalla Lana School for Public Health, University of Toronto, Toronto, Ontario, Canada; The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Beate Sander
- Institute of Health Policy, Management and Evaluation, Dalla Lana School for Public Health, University of Toronto, Toronto, Ontario, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; ICES, Ontario, Canada; Public Health Ontario, Ontario, Canada.
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Olmos AV, Robinowitz D, Feiner JR, Chen CL, Gandhi S. Reducing Volatile Anesthetic Waste Using a Commercial Electronic Health Record Clinical Decision Support Tool to Lower Fresh Gas Flows. Anesth Analg 2023; 136:327-337. [PMID: 36638512 PMCID: PMC9846579 DOI: 10.1213/ane.0000000000006242] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Volatile anesthetic consumption can be reduced by minimizing excessive fresh gas flows (FGFs). Currently, it is unknown whether decision support tools embedded within commercial electronic health record systems can be successfully adopted to achieve long-term reductions in FGF rates. The authors describe the implementation of an electronic health record-based clinical decision support tool aimed at reducing FGF and evaluate the effectiveness of this intervention in achieving sustained reductions in FGF rates and volatile anesthetic consumption. METHODS On August 29, 2018, we implemented a decision support tool within the Epic Anesthesia Information Management System (AIMS) to alert providers of high FGF (>0.7 L/min for desflurane and >1 L/min for sevoflurane) during maintenance of anesthesia. July 22, 2015, to July 10, 2018, served as our baseline period before the intervention. The intervention period spanned from August 29, 2018, to December 31, 2019. Our primary outcomes were mean FGF (L/min) and volatile agent consumption (mL/MAC-h). Because a simple comparison of 2 time periods may result in false conclusions due to underlying trends independent of the intervention, we performed segmented regression of the interrupted time series to assess the change in level at the start of the intervention and the differences in slopes before and after the intervention. The analysis was also adjusted for potential confounding variables. Data included 44,899 cases using sevoflurane preintervention with 26,911 cases postintervention, and 17,472 cases using desflurane with 1185 cases postintervention. RESULTS Segmented regression of the interrupted times series demonstrated a decrease in mean FGF by 0.6 L/min (95% CI, 0.6-0.6 L/min; P < .0001) for sevoflurane and 0.2 L/min (95% CI, 0.2-0.3 L/min; P < .0001) for desflurane immediately after implementation of the intervention. For sevoflurane, mL/MAC-h decreased by 3.8 mL/MAC-h (95% CI, 3.6-4.1 mL/MAC-h; P < .0001) after implementation of the intervention and decreased by 4.1 mL/MAC-h (95% CI, 2.6-5.6 mL/MAC-h; P < .0001) for desflurane. Slopes for both FGF and mL/MAC-h in the postintervention period were statistically less negative than the preintervention slopes (P < .0001 for sevoflurane and P < .01 for desflurane). CONCLUSIONS A commercial AIMS-based decision support tool can be adopted to change provider FGF management patterns and reduce volatile anesthetic consumption in a sustainable fashion.
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Affiliation(s)
- Andrea V. Olmos
- Department of Anesthesia and Perioperative Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, CA
| | - David Robinowitz
- Department of Anesthesia and Perioperative Care, University of California, San Francisco Benioff Children’s Hospital, San Francisco, CA
| | - John R. Feiner
- Department of Anesthesia and Perioperative Care, University of California, San Francisco (UCSF) Medical Center, San Francisco, CA
| | - Catherine L. Chen
- Department of Anesthesia and Perioperative Care, University of California, San Francisco (UCSF) Medical Center, San Francisco, CA
- Philip R. Lee Institute for Health Policy Studies at UCSF
- UCSF Center for Healthcare Value
| | - Seema Gandhi
- Department of Anesthesia and Perioperative Care, University of California, San Francisco (UCSF) Medical Center, San Francisco, CA
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Chambrin C, de Souza S, Gariel C, Chassard D, Bouvet L. Association Between Anesthesia Provider Education and Carbon Footprint Related to the Use of Inhaled Halogenated Anesthetics. Anesth Analg 2023; 136:101-110. [PMID: 35986678 DOI: 10.1213/ane.0000000000006172] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Inhaled halogenated anesthetics are responsible for half of operating room total greenhouse gas emissions. Sustainable anesthesia groups were set up in 4 Lyon, France, university hospitals (Hospices Civils de Lyon) in January 2018 and have supported a specific information campaign about the carbon footprint related to the use of inhaled halogenated anesthetics in June 2019. We aimed to assess whether implementing such information campaigns was associated with a decrease in the carbon footprint related to inhaled halogenated anesthetics. METHODS This retrospective cohort study was conducted from January 1, 2015, to February 29, 2020, in 4 hospitals of the Hospices Civils de Lyon in France. Information meetings on sustainable anesthesia practices were organized by sustainable anesthesia groups that were set up in January 2018. In addition, a specific information campaign about the carbon footprint related to inhaled halogenated anesthetics was conducted in June 2019; it was followed by a questionnaire to be completed online. The monthly purchase of sevoflurane, desflurane, and propofol was recorded, and the estimated monthly carbon footprint from desflurane- and sevoflurane-related perioperative emissions was calculated. The interrupted time-series data from January 2015 to February 2020 were analyzed by segmented regression, considering both interventions (setting up of the sustainable anesthesia groups and specific information campaign) in the analysis and adjusting for 2 confounding factors (seasonality of the data and number of general anesthesia uses). RESULTS Among the 641 anesthesia providers from the study hospitals, 121 (19%) attended the information meetings about the carbon footprint of inhaled halogenated anesthetics, and 180 (28%) completed the questionnaire. The anesthetic activity from all 641 providers was considered in the analysis. After the sustainable anesthesia groups were set up, the carbon footprint of sevoflurane and desflurane started decreasing: the slope significantly changed ( P < .01) and became significantly negative, from -0.27 (95% confidence interval [CI], -1.08 to 0.54) tons.month -1 to -14.16 (95% CI, -16.67 to -11.65) tons.month -1 . After the specific information campaign, the carbon footprint kept decreasing, with a slope of -7.58 (95% CI, -13.74 to -1.41) tons.month -1 ( P = .02), which was not significantly different from the previous period ( P = .07). CONCLUSIONS The setup of the sustainable anesthesia groups was associated with a dramatic reduction in the carbon footprint related to halogenated anesthetics. These results should encourage health care institutions to undertake information campaigns toward anesthesia providers so that they also take into account the environmental impact in the choice of anesthetic drugs, in addition to the benefits for the patient and economic concerns.
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Affiliation(s)
- Coralie Chambrin
- From the Department of Anesthesia and Critical Care, Femme Mère Enfant Hospital, Hospices Civils de Lyon, Lyon, France
| | - Sander de Souza
- Department of Medical Public Health, Hospices Civils de Lyon, Lyon, France
| | - Claire Gariel
- From the Department of Anesthesia and Critical Care, Femme Mère Enfant Hospital, Hospices Civils de Lyon, Lyon, France
| | - Dominique Chassard
- From the Department of Anesthesia and Critical Care, Femme Mère Enfant Hospital, Hospices Civils de Lyon, Lyon, France
| | - Lionel Bouvet
- From the Department of Anesthesia and Critical Care, Femme Mère Enfant Hospital, Hospices Civils de Lyon, Lyon, France
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Takata ET, Eschert J, Mather J, McLaughlin T, Hammond J, Hashim SW, McKay RG, Sutton TS. Enhanced Recovery After Surgery Is Associated With Reduced Hospital Length of Stay after Urgent or Emergency Isolated Coronary Artery Bypass Surgery at an Urban, Tertiary Care Teaching Hospital: An Interrupted Time Series Analysis With Propensity Score Matching. J Cardiothorac Vasc Anesth 2023; 37:31-41. [PMID: 36379833 DOI: 10.1053/j.jvca.2022.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 10/04/2022] [Accepted: 10/06/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To evaluate whether enhanced recovery after surgery (ERAS) was associated with reduced length of stay (LOS) after urgent or emergency coronary artery bypass graft surgery (CABG). DESIGN A retrospective analysis of an institutional database for urgent or emergency isolated CABG before versus after ERAS. Propensity matching identified comparable subpopulations pre- versus post-ERAS. Interrupted time series analysis was used to evaluate LOS. SETTING At a tertiary care teaching hospital. PARTICIPANTS A total of 1,012 patients undergoing urgent or emergent CABG-346 from 2016 to 2017 (pre-ERAS), and 666 from 2018 to 2020 (post-ERAS). Emergent CABG was performed within 24 hours, and urgent CABG was performed during the same hospitalization to reduce clinical risk. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Propensity-matched post-ERAS (n = 565) versus pre-ERAS patients (n = 330) demonstrated reduced LOS (9 [8-13] v (10 [8-14] days p = 0.015), increased likelihood of extubation within 6 hours (46.0% v 35.8%, p = 0.003), shorter ventilation time (6.3 [5.1-10.2] v (7.2 [5.4-12.2] hours, p = 0.003), reduced morphine milligram equivalent use on postoperative days 1 and 2 (69.6 ± 62.2 v 99.0 ± 61.6, p < 0.001), and increased intraoperative ketamine use (58.8% v 35.2%, p < 0.001). There were no differences regarding reintubation, intensive care unit readmission, or 30-day morbidity. Adjusted segmental regression (n = 1,012) for LOS demonstrated reduced mean LOS of approximately 2 days after ERAS (β2 coefficient -1.943 [-3.766 to -0.121], p = 0.037), with stable trends for mean LOS and no change in slope throughout the pre-ERAS and post-ERAS time periods. CONCLUSIONS Enhanced recovery after surgery was associated with reduced LOS after urgent or emergency CABG without adverse effects on prolonged ventilation, reintubation, intensive care unit readmission, or 30-day outcomes.
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Affiliation(s)
- Edmund T Takata
- Integrated Anesthesia Associates, Hartford Hospital, Hartford, CT
| | - John Eschert
- Integrated Anesthesia Associates, Hartford Hospital, Hartford, CT
| | - Jeff Mather
- Research Administration, Hartford Hospital, Hartford, CT
| | | | - Jonathan Hammond
- Department of Cardiac Surgery and Heart and Vascular Institute, Hartford Hospital, Hartford, CT
| | - Sabet W Hashim
- Department of Cardiac Surgery and Heart and Vascular Institute, Hartford Hospital, Hartford, CT
| | - Raymond G McKay
- Heart and Vascular Research Institute, Hartford Hospital, Hartford, CT
| | - Trevor S Sutton
- Integrated Anesthesia Associates, Hartford Hospital, Hartford, CT.
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Martin LD, Chiem JL, Hansen EE, Low DK, Reece K, Casey C, Wingate CS, Bezzo LK, Merguerian PA, Parikh SR, Susarla SM, O'Reilly-Shah VN. Completion of an Enhanced Recovery Program in a Pediatric Ambulatory Surgery Center: A Quality Improvement Initiative. Anesth Analg 2022; 135:1271-1281. [PMID: 36384014 DOI: 10.1213/ane.0000000000006256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) was first established in 2001 focusing on recovery from complex surgical procedures in adults and recently expanded to ambulatory surgery. The evidence for ERAS in children is limited. In 2018, recognized experts began developing needed pediatric evidence. Center-wide efforts involving all ambulatory surgical patients and procedures have not previously been described. METHODS A comprehensive assessment and gap analysis of ERAS elements in our ambulatory center identified 11 of 19 existing elements. The leadership committed to implementing an Enhanced Recovery Program (ERP) to improve existing elements and close as many remaining gaps as possible. A quality improvement (QI) team was launched to improve 5 existing ERP elements and to introduce 6 new elements (target 17/19 ERP elements). The project plan was broken into 1 preparation phase to collect baseline data and 3 implementation phases to enhance existing and implement new elements. Statistical process control methodology was used. Team countermeasures were based on available evidence. A consensus process was used to resolve disagreement. Monthly meetings were held to share real-time data, gather new feedback, and modify countermeasure plans as needed. The primary outcome measure selected was mean postanesthesia care unit (PACU) length of stay (LOS). Secondary outcomes measures were mean maximum pain score in PACU and patient/family satisfaction scores. RESULTS The team had expanded the pool of active ERP elements from 11 to 16 of 19. The mean PACU LOS demonstrated significant reduction (early in phase 1 and again in phase 3). No change was seen for the mean maximum pain score in PACU or surgical complication rates. Patient/family satisfaction scores were high and sustained throughout the period of study (91.1% ± 5.7%). Patient/family and provider engagement/compliance were high. CONCLUSIONS This QI project demonstrated the feasibility of pediatric ERP in an ambulatory surgical setting. Furthermore, a center-wide approach was shown to be possible. Additional studies are needed to determine the relevance of this project to other institutions.
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Affiliation(s)
- Lynn D Martin
- From the Departments of Anesthesiology & Pain Medicine and Pediatrics
| | - Jennifer L Chiem
- Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington
| | - Elizabeth E Hansen
- Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington
| | - Daniel K Low
- Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington
| | - Kayla Reece
- Department of Perioperative Services, Seattle Children's Hospital, Seattle, Washington; and Departments of
| | - Corrie Casey
- Department of Perioperative Services, Seattle Children's Hospital, Seattle, Washington; and Departments of
| | - Christina S Wingate
- Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington
| | - Leah K Bezzo
- Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington
| | | | - Sanjay R Parikh
- Plastic Surgery, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington
| | - Srinivas M Susarla
- Plastic Surgery, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington
| | - Vikas N O'Reilly-Shah
- Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington
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Hammond G, Orav EJ, Zheng J, Epstein AM, Joynt Maddox KE. Changes in Racial Equity Associated With Participation in the Bundled Payments for Care Improvement Advanced Program. JAMA Netw Open 2022; 5:e2244959. [PMID: 36469318 PMCID: PMC9855294 DOI: 10.1001/jamanetworkopen.2022.44959] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE The Medicare alternative payment models are designed to incentivize cost reduction and quality improvement, but there are no requirements established for evaluating the outcomes of the Medicare populations. OBJECTIVE To examine whether participation in the Medicare Bundled Payments for Care Improvement Advanced (BPCI-A) program was associated with narrowing or widening of Black and White racial inequities in outcomes and access. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort alternative payment models on equity and quality for disadvantaged populations were studied between April 6, 2021, and August 28, 2022, in US hospitals. Black and White Medicare beneficiaries admitted for any of the 29 inpatient conditions in the BPCI-A program between January 1, 2017, and September 31, 2019, were included. EXPOSURES BPCI-A participation implemented in 2018. MAIN OUTCOMES AND MEASURES Ninety-day readmission and mortality, healthy days at home, and proportion of Black patients hospitalized. Segmented regression models were used to examine quarterly changes in slopes for each outcome. RESULTS The sample included 6 690 336 episodes (6 019 359 White patients, 670 977 Black patients). The population comprised approximately 43% men, 57% women, 17% individuals younger than 65 years, 47% between ages 65 and 80 years, and 36% older than 80 years. Prior to implementation of the BPCI-A program, compared with episodes for White patients, Black patients had higher 90-day readmissions (36.3% vs 29.6%), similar 90-day mortality (12.3% vs 13.3%), and fewer healthy days at home (mean, 68.5 vs 69.5 days). BPCI-A participation was not associated with significant changes in the racial gap in readmissions but was associated with a greater gain in heathy days at home (differences by race, -0.07 days per quarter; 95% CI, -0.12 to -0.01 days per quarter). Among Black patients admitted to BPCI-A hospitals vs controls, healthy days at home increased by 0.09 more days/episode per quarter (95% CI, 0.02-0.17 days/episode per quarter). The proportion of Black patients decreased similarly at BPCI-A and control hospitals. CONCLUSIONS AND RELEVANCE In this cohort study, BPCI-A participation was not associated with improvements in racial inequities in clinical outcomes. Black patients in BPCI-A had a slight gain in healthy days at home; there were no changes in access. The findings of this study suggest that more needs to be done if payment policy reform is going to be part of the efforts to address glaring racial inequities in health care quality and outcomes. These findings support a need for payment policy reform specifically targeting equity-enhancing programs.
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Affiliation(s)
- Gmerice Hammond
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - E. John Orav
- Division of General Internal Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston Massachusetts
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston Massachusetts
| | - Jie Zheng
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Arnold M. Epstein
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Karen E. Joynt Maddox
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
- Institute for Public Health at Washington University, St. Louis, Missouri
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Prophylactic Enoxaparin Against Catheter-Associated Thrombosis in Postoperative Cardiac Children: An Interrupted Time Series Analysis. Pediatr Crit Care Med 2022; 23:774-783. [PMID: 35699766 DOI: 10.1097/pcc.0000000000003010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The effectiveness of pharmacologic prophylaxis against catheter-associated thrombosis in children is unclear. We evaluated the compliance and outcomes associated with a prophylactic enoxaparin protocol in postoperative cardiac children. DESIGN The protocol was implemented as a quality improvement initiative and then analyzed using interrupted time series method. Data collected from November 2014 to December 2018 were divided into preprotocol (period 1), protocol implementation (period 2), and protocol revision (period 3). SETTING A 12-bed academic pediatric cardiac ICU. PATIENTS Children less than or equal to 18 years old with congenital heart disease admitted postoperatively with central venous catheter in situ for greater than or equal to 1 day. INTERVENTIONS Before 2016, prophylactic enoxaparin was administered according to physician preference. In January 2016, an enoxaparin protocol was implemented with a goal anti-Xa range of 0.25-0.49 international units/mL. Protocol was revised in February 2017 to increase the starting dose by 25% for infants less than 1 year old. MEASUREMENTS AND MAIN RESULTS We analyzed 780 hospitalizations from 636 children. Median percentage of catheter-days on prophylactic enoxaparin was 33% (interquartile range [IQR], 23-47%), 42% (IQR, 30-51%), and 38% (IQR, 35-52%) in periods 1-3, respectively. Percentage of catheter-days on enoxaparin showed immediate increase of 90% (95% CI, 17-210%) between periods 1 and 2 and sustained increase of 2% (95% CI, 0.3-4%) between periods 2 and 3. Median rates of thrombosis per 1,000 catheter-days were 5.8 (IQR, 0-9.3), 3.8 (IQR, 0-12), and 0 (IQR, 0-5.3) in periods 1-3, respectively. Rate of thrombosis showed immediate decrease of 67% (95% CI, 12-87%) between periods 1 and 2 and sustained decrease of 11% (95% CI, 2-18%) between periods 1 and 3. CONCLUSIONS The temporal association between increase in percentage of catheter-days on enoxaparin and decrease in rate of thrombosis suggests the effectiveness of prophylactic enoxaparin.
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Negriff S, Huang BZ, Sharp AL, DiGangi M. The impact of stay-at-home orders on the rate of emergency department child maltreatment diagnoses. CHILD ABUSE & NEGLECT 2022; 132:105821. [PMID: 35939889 PMCID: PMC9355635 DOI: 10.1016/j.chiabu.2022.105821] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 07/18/2022] [Accepted: 07/26/2022] [Indexed: 05/22/2023]
Abstract
BACKGROUND There is limited data regarding the rates and severity of child maltreatment in medical settings during the COVID-19 pandemic, and the reports are somewhat contradictory. OBJECTIVE To examine the rates of emergency department (ED) child maltreatment (CM) diagnosis before and after the California statewide stay-at-home order, as well as potential disparities by age, gender, race/ethnicity, and Medicaid status. METHODS A retrospective pre-post interrupted time series was conducted using data from the electronic health records of children (<18 years) with at least one emergency department visit between January 1, 2019 and September 30, 2021. Enactment of the stay-at-home order in California, March 2020 was used to determine a change in trend of rates of diagnosis of CM in the ED. RESULTS Overall the study included 407,228 pediatric ED visits. There was a significant change in the percentage of CM visits immediately after the stay-at-home order, followed by small month to month decreases returning to near pre-stay-at-home order levels. This significant increase was driven by higher risk for children <4 years old. The increased rate of CM in the first month after the stay-at-home order was also elevated for female, Black, and Hispanic children. CONCLUSIONS Our results indicated the rates of CM diagnoses in the ED doubled after the March 2020 stay-at-home order in California. Additionally, our findings suggest that some children may be at higher risk than others, which supports the importance of social safety nets for children in times of national emergency.
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Affiliation(s)
- Sonya Negriff
- Kaiser Permanente Southern California, Department of Research & Evaluation, Pasadena, CA, United States of America; Kaiser Permanente Bernard J Tyson School of Medicine, Pasadena, CA, United States of America.
| | - Brian Z Huang
- Kaiser Permanente Southern California, Department of Research & Evaluation, Pasadena, CA, United States of America
| | - Adam L Sharp
- Kaiser Permanente Southern California, Department of Research & Evaluation, Pasadena, CA, United States of America; Kaiser Permanente Bernard J Tyson School of Medicine, Pasadena, CA, United States of America
| | - Mercie DiGangi
- Kaiser Permanente Southern California, Department of Pediatrics, Bellflower, CA, United States of America; Kaiser Permanente Bernard J Tyson School of Medicine, Pasadena, CA, United States of America
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Wachnik AA, Welch-Coltrane JL, Adams MCB, Blumstein HA, Pariyadath M, Robinson SG, Saha A, Summers EC, Hurley RW. A Standardized Emergency Department Order Set Decreases Admission Rates and In-Patient Length of Stay for Adults Patients with Sickle Cell Disease. PAIN MEDICINE 2022; 23:2050-2060. [PMID: 35708651 PMCID: PMC9714532 DOI: 10.1093/pm/pnac096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/20/2022] [Accepted: 06/10/2022] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Pain associated with sickle cell disease (SCD) causes severe complications and frequent presentation to the emergency department (ED). Patients with SCD frequently report inadequate pain treatment in the ED, resulting in hospital admission. A retrospective analysis was conducted to assess a quality improvement project to standardize ED care for patients presenting with pain associated with SCD. METHODS A 3-year prospective quality improvement initiative was performed. Our multidisciplinary team of providers implemented an ED order set in 2019 to improve care and provide adequate analgesia management. Our primary outcome was the overall hospital admission rate for patients after the intervention. Secondary outcome measures included ED disposition, rate of return to the ED within 72 hours, ED pain scores at admission and discharge, ED treatment time, in-patient length of stay, non-opioid medication use, and opioid medication use. RESULTS There was an overall 67% reduction in the hospital admission rate after implementation of the order set (P = 0.005) and a significant decrease in the percentage admission rate month over month (P = 0.047). Time to the first non-opioid analgesic decreased by 71 minutes (P > 0.001), and there was no change in time to the first opioid medication. The rate of return to the ED within 72 hours remained unchanged (7.0% vs 7.1%) (P = 0.93), and the ED elopement rate remained unchanged (1.3% vs 1.85%) (P = 0.93). After the implementation, there were significant increases in the prescribing of orally administered acetaminophen (7%), celecoxib (1.2%), and tizanidine (12.5%) and intravenous ketamine (30.5%) and ketorolac (27%). ED pain scores at discharge were unchanged for both hospital-admitted (7.12 vs 7.08) (P = 0.93) and non-admitted (5.51 vs 6.11) (P = 0.27) patients. The resulting potential cost reduction was determined to be $193,440 during the 12-month observation period, with the mean cost per visit decreasing by $792. CONCLUSIONS Use of a standardized and multimodal ED order set reduced hospital admission rates and the timeliness of analgesia without negatively impacting patients' pain.
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Affiliation(s)
| | | | | | | | | | | | - Amit Saha
- Department of Anesthesiology and Pain Service Line
| | - Erik C Summers
- Department of Internal Medicine Section of Hospital Medicine
| | - Robert W Hurley
- Correspondence to: Robert W. Hurley, MD, PhD, FASA, Department of Anesthesiology, Neurobiology and Anatomy, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27051, USA. Tel: 336-716-2266; Fax: 336-716-8773; E-mail:
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Tuti T, Aluvaala J, Malla L, Irimu G, Mbevi G, Wainaina J, Mumelo L, Wairoto K, Mochache D, Hagel C, Maina M, English M. Evaluation of an audit and feedback intervention to reduce gentamicin prescription errors in newborn treatment (ReGENT) in neonatal inpatient care in Kenya: a controlled interrupted time series study protocol. Implement Sci 2022; 17:32. [PMID: 35578243 PMCID: PMC9109356 DOI: 10.1186/s13012-022-01203-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 04/10/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Medication errors are likely common in low- and middle-income countries (LMICs). In neonatal hospital care where the population with severe illness has a high mortality rate, around 14.9% of drug prescriptions have errors in LMICs settings. However, there is scant research on interventions to improve medication safety to mitigate such errors. Our objective is to improve routine neonatal care particularly focusing on effective prescribing practices with the aim of achieving reduced gentamicin medication errors. METHODS We propose to conduct an audit and feedback (A&F) study over 12 months in 20 hospitals with 12 months of baseline data. The medical and nursing leaders on their newborn units had been organised into a network that facilitates evaluating intervention approaches for improving quality of neonatal care in these hospitals and are receiving basic feedback generated from the baseline data. In this study, the network will (1) be expanded to include all hospital pharmacists, (2) include a pharmacist-only professional WhatsApp discussion group for discussing prescription practices, and (3) support all hospitals to facilitate pharmacist-led continuous medical education seminars on prescription practices at hospital level, i.e. default intervention package. A subset of these hospitals (n = 10) will additionally (1) have an additional hospital-specific WhatsApp group for the pharmacists to discuss local performance with their local clinical team, (2) receive detailed A&F prescription error reports delivered through mobile-based dashboard, and (3) receive a PDF infographic summarising prescribing performance circulated to the clinicians through the hospital-specific WhatsApp group, i.e. an extended package. Using interrupted time series analysis modelling changes in prescribing errors over time, coupled with process fidelity evaluation, and WhatsApp sentiment analysis, we will evaluate the success with which the A&F interventions are delivered, received, and acted upon to reduce prescribing error while exploring the extended package's success/failure relative to the default intervention package. DISCUSSION If effective, these theory-informed A&F strategies that carefully consider the challenges of LMICs settings will support the improvement of medication prescribing practices with the insights gained adapted for other clinical behavioural targets of a similar nature. TRIAL REGISTRATION PACTR, PACTR202203869312307 . Registered 17th March 2022.
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Affiliation(s)
- Timothy Tuti
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.
| | - Jalemba Aluvaala
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Lucas Malla
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- London School of Hygiene and Tropical Medicine, London, UK
| | - Grace Irimu
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - George Mbevi
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - John Wainaina
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - Kefa Wairoto
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - Christiane Hagel
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Michuki Maina
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Mike English
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Symum H, Zayas-Castro J. Impact of Statewide Mandatory Medicaid Managed Care (SMMC) Programs on Hospital Obstetric Outcomes. Healthcare (Basel) 2022; 10:healthcare10050874. [PMID: 35628011 PMCID: PMC9141169 DOI: 10.3390/healthcare10050874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 04/24/2022] [Accepted: 05/01/2022] [Indexed: 11/16/2022] Open
Abstract
The state of Florida implemented mandatory managed care for Medicaid enrollees via the Statewide Medicaid Managed Care (SMMC) program in April of 2014. The objective of this study was to examine the impact of the implementation of the SMMC program on the access to care and quality of maternal care for Medicaid enrollees, as measured by several hospital obstetric outcomes. The primary data source for this retrospective observational study was the Hospital Cost and Utilization Project (HCUP) all-payer State ED (SED) visit and State Inpatient Databases (SIDs) from 2010 to 2017. The primary health outcomes for obstetric care were primary cesarean, preterm birth, postpartum preventable ED visits, postpartum preventable readmissions, and vaginal delivery after cesarean (VBAC) rates. Using difference-in-differences (DID) estimation, selected health outcomes were examined for Florida residents with Medicaid beneficiaries (treatment) and the commercially insured population (comparison), before and after the implementation of SMMC. Improvement in disparities for racial/ethnic minority Medicaid enrollees was estimated relative to whites, compared to the relative change among commercially insured patients. From the DID estimation, the findings showed that SMMC is statistically significantly associated with a higher reduction in primary cesarean rates, preterm births, preventable postpartum ED visits, and readmissions among Medicaid beneficiaries relative to their commercially insured counterparts. However, this study did not find any significant reduction in racial/ethnic disparities in obstetric outcomes. In general, this study highlights the impact of SMMC implementation on obstetric outcomes in Florida and provides important insights and potential scope for improvement in obstetric care quality and associated racial/ethnic disparities.
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Yuan J, Li M, Liu Y, Xiong X, Zhu Z, Liu F, Wang Y, Hu W, Lu ZK, Liu R, Zhao J. Analysis of Time to the Hospital and Ambulance Use Following a Stroke Community Education Intervention in China. JAMA Netw Open 2022; 5:e2212674. [PMID: 35579896 PMCID: PMC9115614 DOI: 10.1001/jamanetworkopen.2022.12674] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 03/29/2022] [Indexed: 12/03/2022] Open
Abstract
Importance Prehospital delay (time from symptom onset of stroke to the door of a hospital) in patients with stroke is long in China. With the goal of improving public awareness and knowledge of stroke recognition, Stroke 1-2-0 was developed in China as an education program to prompt rapid response to the onset of stroke based on clinical practice in China, and examination of its outcomes is needed. Objective To investigate the association of the Stroke 1-2-0 educational campaign with prehospital delay for patients with ischemic stroke. Design, Setting, and Participants In a population-based cross-sectional study, all patients with ischemic stroke events were admitted to the Minhang Hospital, which is the only tertiary care hospital with a stroke center that provides acute stroke care in Xinzhuang county, Shanghai, China. The study period was from January 1, 2016, to December 31, 2019, and data analysis was performed from January 1 to July 31, 2021. Exposures A multifaceted Stroke 1-2-0 educational campaign comprising slides, videos, brochures, and posters distributed in the community. Main Outcomes and Measures Proportion of patients with hospital arrival within 3 hours and use of an ambulance to seek medical care, as well as the odds of seeking medical attention within 3 hours after the stroke before vs after initiation of the multifaceted educational campaign. Results A total of 2857 patients (1774 men [62.1%]; mean [SD] age, 69.83 [12.66] years) with stroke were identified, including 503 in the precampaign period and 2354 in the postcampaign period. Following the multifaceted campaign, the median (IQR) prehospital delay time decreased from 18.72 (7.44-27.84) hours to 6.00 (2.00-16.35) hours (P < .001). After the implementation of the Stroke 1-2-0 campaign, the proportion of patients with hospital arrival time within 3 hours increased from 5.8% to 33.4% (P < .001) and use of an ambulance increased from 3.2% to 30.6% (P < .001). In an interrupted time series analysis, the initiation of the Stroke 1-2-0 campaign was associated with significantly increased odds of arriving at the hospital within 3 hours (odds ratio, 8.01; 95% CI, 7.17-8.95; P < .001) and use of an ambulance (odds ratio, 9.41; 95% CI, 8.24-10.74; P < .001). Conclusions and Relevance The persistent multifaceted campaign using the Stroke 1-2-0 program was associated with reduced prehospital delay and improved timely arrival rate and ambulance arrival rate for patients with stroke. These findings suggest that Stroke 1-2-0 can be adopted in other regions of China to possibly improve health outcomes and reduce clinical burdens for all patients with stroke.
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Affiliation(s)
- Jing Yuan
- Department of Clinical Pharmacy, School of Pharmacy, Fudan University, Shanghai, China
| | - Minghui Li
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis
| | - Yang Liu
- Department of Neurology, Minhang Hospital, Fudan University, Minhang District, Shanghai, China
| | - Xiaomo Xiong
- Clinical Pharmacy and Outcomes Sciences Department, University of South Carolina, Columbia
| | - Zhengbao Zhu
- Department of Epidemiology, School of Public Health, Medical College of Soochow University, Suzhou, China
| | - Fangyu Liu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yong Wang
- Department of Neurology, Minhang Hospital, Fudan University, Minhang District, Shanghai, China
| | - Wei Hu
- Department of Cardiology, Minhang Hospital, Fudan University, Minhang District, Shanghai, China
| | - Z. Kevin Lu
- Clinical Pharmacy and Outcomes Sciences Department, University of South Carolina, Columbia
| | - Renyu Liu
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Jing Zhao
- Department of Neurology, Minhang Hospital, Fudan University, Minhang District, Shanghai, China
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Factora F, Maheshwari K, Khanna S, Chahar P, Ritchey M, O’Hara J, Mascha EJ, Mi J, Halvorson S, Turan A, Ruetzler K. Effect of a Rapid Response Team on the Incidence of In-Hospital Mortality. Anesth Analg 2022; 135:595-604. [DOI: 10.1213/ane.0000000000006005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Illescas A, Zhong H, Cozowicz C, Gonzalez Della Valle A, Liu J, Memtsoudis SG, Poeran J. Health Services Research in Anesthesia: A Brief Overview of Common Methodologies. Anesth Analg 2022; 134:540-547. [PMID: 35180171 DOI: 10.1213/ane.0000000000005884] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The use of large data sources such as registries and claims-based data sets to perform health services research in anesthesia has increased considerably, ultimately informing clinical decisions, supporting evaluation of policy or intervention changes, and guiding further research. These observational data sources come with limitations that must be addressed to effectively examine all aspects of health care services and generate new individual- and population-level knowledge. Several statistical methods are growing in popularity to address these limitations, with the goal of mitigating confounding and other biases. In this article, we provide a brief overview of common statistical methods used in health services research when using observational data sources, guidance on their interpretation, and examples of how they have been applied to anesthesia-related health services research. Methods described involve regression, propensity scoring, instrumental variables, difference-in-differences, interrupted time series, and machine learning.
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Affiliation(s)
- Alex Illescas
- From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York
| | - Haoyan Zhong
- From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York
| | - Crispiana Cozowicz
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | | | - Jiabin Liu
- From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York.,Department of Anesthesiology, Weill Cornell Medical College, New York, New York
| | - Stavros G Memtsoudis
- From the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York.,Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria.,Department of Anesthesiology, Weill Cornell Medical College, New York, New York.,Department of Health Policy and Research, Weill Cornell Medical College, New York, New York
| | - Jashvant Poeran
- Department of Population Health Science & Policy/Department of Orthopedics, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York
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Vogt KM, Citro AT, Adams PS, Metro DG, Sakai T. Early immersion in a dedicated one-month Anesthesiology Professional Practice rotation for Post-Graduate Year-1 interns is associated with an increase in scholarly activity during residency. J Clin Anesth 2022; 76:110566. [PMID: 34695751 PMCID: PMC8904148 DOI: 10.1016/j.jclinane.2021.110566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 09/23/2021] [Accepted: 10/17/2021] [Indexed: 02/03/2023]
Abstract
STUDY OBJECTIVE Despite the Accreditation Council for Graduate Medical Education scholarly activity requirement, incorporating education on scholarly fundamentals into residency is challenging. We designed and implemented an academic non-clinical rotation for Post Graduate Year-1 (PGY-1) interns and its association with subsequent resident scholarly productivity was determined. We hypothesized that early immersion in such a rotation would be associated with increased scholarly activity during residency. DESIGN Retrospective educational comparative study, of two cohorts of anesthesiology residents in the graduating classes of 2015-2020. SETTING Large anesthesiology residency program at a U.S. academic medical center. INTERVENTION A one-month academic rotation titled Anesthesia Professional Practice for PGY-1 interns has been implemented since 2014. The rotation curriculum broadly covers important topics for scholarly projects and provides introductions to academic faculty and institutional resources. MEASUREMENTS The scholarly products (abstracts, publications, book chapters, research protocols, and grant applications) were quantified using Scholarly Activity Points, a previously described metric that accounts for significance and the resident's contribution. Total Scholarly Activity Points for each resident and number of publications prior to residency were determined for both cohorts. Segmented regression was employed with Scholarly Activity Points as the outcome; participation in the early immersion rotation and prior publications were used as input variables. MAIN RESULTS Resident participation in the early immersion rotation was significantly associated with higher Scholarly Activity Points. The confounding variable of pre-residency publication count was not significantly correlated to this increase. CONCLUSIONS Immersion in a one-month academic program during PGY-1 internship may contribute to increased scholarly productivity during residency.
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Affiliation(s)
- Keith M. Vogt
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine,Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh,Center for the Neural Basis of Cognition
| | - Ally T. Citro
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine
| | - Philip S. Adams
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine
| | - David G. Metro
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine
| | - Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine,Clinical and Translational Science Institute, University of Pittsburgh,McGowan Institute of Regenerative Medicine, University of Pittsburgh,Corresponding author: Tetsuro Sakai, Address: 3459 Fifth Avenue, UPMC Montefiore - Suite 469.4, Pittsburgh, PA 15213, Phone: (412)-648-6943,
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O’Carroll J, Carvalho B, Sultan P. Enhancing recovery after cesarean delivery – A narrative review. Best Pract Res Clin Anaesthesiol 2022; 36:89-105. [DOI: 10.1016/j.bpa.2022.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 01/17/2022] [Indexed: 11/25/2022]
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Chen YYK, Lekowski RW, Beutler SS, Lasic M, Walls JD, Clapp JT, Fields K, Nichols AS, Correll DJ, Bader AM, Arriaga AF. Education based on publicly-available keyword data is associated with decreased stress and improved trajectory of in-training exam performance. J Clin Anesth 2021; 77:110615. [PMID: 34923227 DOI: 10.1016/j.jclinane.2021.110615] [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: 05/15/2021] [Revised: 10/31/2021] [Accepted: 11/20/2021] [Indexed: 11/28/2022]
Abstract
STUDY OBJECTIVE This study aimed to assess the impact of data-driven didactic sessions on metrics including fund of knowledge, resident confidence in clinical topics, and stress in addition to American Board of Anesthesiology In-Training Examination (ITE) percentiles. DESIGN Observational mixed-methods study. SETTING Classroom, video-recorded e-learning. SUBJECTS Anesthesiology residents from two academic medical centers. INTERVENTIONS Residents were offered a data-driven didactic session, focused on lifelong learning regarding frequently asked/missed topics based on publicly-available data. MEASUREMENTS Residents were surveyed regarding their confidence on exam topics, organization of study plan, willingness to educate others, and stress levels. Residents at one institution were interviewed post-ITE. The level and trend in ITE percentiles were compared before and after the start of this initiative using segmented regression analysis. RESULTS Ninety-four residents participated in the survey. A comparison of pre-post responses showed an increased mean level of confidence (4.5 ± 1.6 vs. 6.2 ± 1.4; difference in means 95% CI:1.7[1.5,1.9]), sense of study organization (3.8 ± 1.6 vs. 6.7 ± 1.3;95% CI:2.8[2.5,3.1]), willingness to educate colleagues (4.0 ± 1.7 vs. 5.7 ± 1.9;95% CI:1.7[1.4,2.0]), and reduced stress levels (5.9 ± 1.9 vs. 5.2 ± 1.7;95% CI:-0.7[-1.0,-0.4]) (all p < 0.001). Thirty-one residents from one institution participated in the interviews. Interviews exhibited qualitative themes associated with increased fund of knowledge, accessibility of high-yield resources, and domains from the Kirkpatrick Classification of an educational intervention. In an assessment of 292 residents from 2012 to 2020 at one institution, there was a positive change in mean ITE percentile (adjusted intercept shift [95% CI] 11.0[3.6,18.5];p = 0.004) and trajectory over time after the introduction of data-driven didactics. CONCLUSION Data-driven didactics was associated with improved resident confidence, stress, and factors related to wellness. It was also associated with a change from a negative to positive trend in ITE percentiles over time. Future assessment of data-driven didactics and impact on resident outcomes are needed.
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Affiliation(s)
- Yun-Yun K Chen
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, CWN-L1, Boston, MA 02115, USA.
| | - Robert W Lekowski
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, CWN-L1, Boston, MA 02115, USA.
| | - Sascha S Beutler
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, CWN-L1, Boston, MA 02115, USA.
| | - Morana Lasic
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, CWN-L1, Boston, MA 02115, USA.
| | - Jason D Walls
- Department of Anesthesiology and Critical Care, University of Pennsylvania Health System, Philadelphia, Perelman School of Medicine - University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| | - Justin T Clapp
- Department of Anesthesiology and Critical Care, University of Pennsylvania Health System, Philadelphia, Perelman School of Medicine - University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| | - Kara Fields
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, CWN-L1, Boston, MA 02115, USA.
| | - Angela S Nichols
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, CWN-L1, Boston, MA 02115, USA.
| | - Darin J Correll
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, CWN-L1, Boston, MA 02115, USA
| | - Angela M Bader
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, CWN-L1, Boston, MA 02115, USA; Center for Surgery and Public Health, One Brigham Circle, 1620 Tremont Street, Boston, MA 02120, USA.
| | - Alexander F Arriaga
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, CWN-L1, Boston, MA 02115, USA; Center for Surgery and Public Health, One Brigham Circle, 1620 Tremont Street, Boston, MA 02120, USA; Ariadne Labs, 401 Park Drive, Boston, MA 02215, USA.
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Vetter TR, Joshi GP. Enhanced Recovery in an Ambulatory Surgical Oncology Center: The Tip of the Scalpel. Anesth Analg 2021; 133:1387-1390. [PMID: 34784325 DOI: 10.1213/ane.0000000000005746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Thomas R Vetter
- From the Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, Texas
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
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Warner MA, Schulte PJ, Hanson AC, Madde NR, Burt JM, Higgins AA, Andrijasevic NM, Kreuter JD, Jacob EK, Stubbs JR, Kor DJ. Implementation of a Comprehensive Patient Blood Management Program for Hospitalized Patients at a Large United States Medical Center. Mayo Clin Proc 2021; 96:2980-2990. [PMID: 34736775 PMCID: PMC8649051 DOI: 10.1016/j.mayocp.2021.07.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 07/08/2021] [Accepted: 07/27/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To assess changes in inpatient transfusion utilization and patient outcomes with implementation of a comprehensive patient blood management (PBM) program at a large US medical center. PATIENTS AND METHODS This is an observational study of graduated PBM implementation for hospitalized adults (age ≥18 years) from January 1, 2010, through December 31, 2017, at two integrated hospital campuses at a major academic US medical center. Allogeneic transfusion utilization and clinical outcomes were assessed over time through segmented regression with multivariable adjustment comparing observed outcomes against projected outcomes in the absence of PBM activities. RESULTS In total, 400,998 admissions were included. Total allogeneic transfusions per 1000 admissions decreased from 607 to 405 over the study time frame, corresponding to an absolute risk reduction for transfusion of 6.0% (95% confidence interval [CI]: 3.6%, 8.3%; P<.001) and a 22% (95% CI: 6%, 37%; P=.006) decrease in the rate of transfusions over projected. The risk of transfusion decreased for all blood components except cryoprecipitate. Transfusion reductions were experienced for all major surgery types except liver transplantation, which remained stable over time. Hospital length of stay (multiplicative increase in geometric mean 0.85 [95% CI: 0.81, 0.89]; P<.001) and incident in-hospital adverse events (absolute risk reduction: 1.5% [95% CI: 0.1%, 3.0%]; P=.04) were lower than projected at the end of the study time frame. CONCLUSION Patient blood management implementation for hospitalized patients in a large academic center was associated with substantial reductions in transfusion utilization and improved clinical outcomes. Broad-scale implementation of PBM in US hospitals is feasible without signal for patient harm.
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Affiliation(s)
- Matthew A Warner
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN; Patient Blood Management Program, Mayo Clinic, Rochester, MN.
| | - Phillip J Schulte
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Andrew C Hanson
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | | | - Jennifer M Burt
- Patient Blood Management Program, Mayo Clinic, Rochester, MN
| | | | - Nicole M Andrijasevic
- Anesthesia Clinical Research Unit, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Justin D Kreuter
- Division of Transfusion Medicine, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Eapen K Jacob
- Division of Transfusion Medicine, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - James R Stubbs
- Division of Transfusion Medicine, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Daryl J Kor
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN; Patient Blood Management Program, Mayo Clinic, Rochester, MN
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The PATH to patient safety. Br J Anaesth 2021; 127:830-833. [PMID: 34635288 DOI: 10.1016/j.bja.2021.09.006] [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: 07/31/2021] [Revised: 09/10/2021] [Accepted: 09/12/2021] [Indexed: 11/22/2022] Open
Abstract
Communication is critical to safe patient care. In this issue of the British Journal of Anaesthesia, Jaulin and colleagues show that use of a Post-Anaesthesia Team Handover (PATH) checklist is associated with fewer hypoxaemia events in the PACU, reduced handover interruptions, and other important metrics related to improved communication. The PATH checklist provides a link within a broader chain of safety checklists and other interventions that comprise a perioperative chain of survival.
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Drzymalski DM, Seth S, Johnson JR, Trzcinka A. Improving accuracy of American Society of Anesthesiologists Physical Status using audit and feedback and artificial intelligence: a time-series analysis. Int J Qual Health Care 2021; 33:6328624. [PMID: 34310685 DOI: 10.1093/intqhc/mzab113] [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: 05/18/2021] [Revised: 07/01/2021] [Accepted: 07/26/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND While the American Society of Anesthesiologists (ASA) Physical Status (PS) is used to adjust for greater mortality risk with higher ASA PS classification, inaccurate classification can lead to an inaccurate comparison of institutions. OBJECTIVE The purpose of this study was to assess the effect of audit and feedback with a rule-based artificial intelligence algorithm on the accuracy of ASA PS classification. METHODS We reviewed 78 121 anesthetic records from 1 January 2017 to 19 February 2020. The first intervention entailed audit and feedback emphasizing accurately documenting ASA PS classification using body mass index (BMI), while the second intervention consisted of implementing a rule-based artificial intelligence algorithm. If a patient with a BMI ≥40 kg/m2 had a documented ASA PS classification of 1 or 2, the provider was alerted to change the ASA PS classification to 3 or above. The primary outcome was the overall proportion of patients with inaccurate ASA PS classification based on BMI per month. Secondary outcomes included the proportion of patients with a BMI ≥40 or a BMI 30-39.9 who had inaccurate ASA PS classification and the proportion of patients documented as having ASA 3-5. Data were analyzed using interrupted time-series analysis. RESULTS For the primary outcome, the slope for ASA PS classification inaccurately incorporating BMI was unchanging before the first intervention (parameter coefficient 0.002, 95% CI -0.034 to 0.038; P = 0.911). Following the first intervention, there was an immediate level change (parameter coefficient -0.821, 95% CI -1.236 to -0.0406; P < 0.001) without significant change in slope (parameter coefficient -0.048, 95% CI -0.100 to 0.004; P = 0.067). The post-intervention slope was negative (parameter coefficient -0.046, 95% CI -0.083 to -0.009; P = 0.017). Following the second intervention, there was no level change (parameter coefficient 0.203, 95% CI -0.380 to 0.463; P = 0.839) and no significant change in slope (parameter coefficient 0.013, 95% CI -0.043 to 0.043; P = 0.641). The post-intervention slope was not significant (parameter coefficient -0.034, 95% CI -0.078 to 0.010; P = 0.121). The proportion of patients whose ASA PS classification inaccurately incorporated BMI at the first and final timepoint of the study was 2.6% and 0.8%, respectively. CONCLUSIONS Our quality improvement efforts successfully modified clinician behavior to accurately incorporate BMI into the ASA PS classification. By combining audit and feedback methodology with a rule-based artificial intelligence algorithm, we created a process that resulted in immediate and sustained effects. Improving ASA PS classification accuracy is important because it affects quality metrics, research design, resource allocation and workflow processes.
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Affiliation(s)
- Dan M Drzymalski
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA
| | - Sonika Seth
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA
| | - Jeffrey R Johnson
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA
| | - Agnieszka Trzcinka
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA
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Amon CC, Paley AR, Forbes JA, Guzman LV, Rajwani AA, Trzcinka A, Comenzo RL, Drzymalski DM. Implementing structured handoffs to verify operating room blood delivery using a quality academy training program: an interrupted time-series analysis. Int J Qual Health Care 2021; 33:6213818. [PMID: 33825860 DOI: 10.1093/intqhc/mzab061] [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: 01/11/2021] [Revised: 03/02/2021] [Accepted: 04/06/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Blood transfusion is a complex process at risk for error. OBJECTIVE To implement a structured handoff during the blood transfusion process to improve delivery verification. METHODS A multidisciplinary team participated in the quality academy training program at an academic medical center and implemented a structured handoff of blood delivery to the operating room (OR) using Plan-Do-Study-Act cycles between 28 October 2019 and 1 December 2019. An interrupted time-series analysis was performed to investigate the proportions of verified deliveries (primary outcome) and of verified deliveries among those without a handoff (secondary outcome). Delivery duration was also assessed. RESULTS A total of 2606 deliveries occurred from 1 July 2019 to 19 April 2020. The baseline trend for verified deliveries was unchanging [parameter coefficient -0.0004; 95% confidence interval (CI) -0.002 to 0.001; P = 0.623]. Following intervention, there was an immediate level change (parameter coefficient 0.115; 95% CI 0.053 to 0.176; P = 0.001) without slope change (parameter coefficient 0.002; 95% CI -0.004 to 0.007; P = 0.559). For the secondary outcome, there was no immediate level change (parameter coefficient -0.039; 95% CI -0.159 to 0.081; P = 0.503) or slope change (parameter coefficient 0.002; 95% CI -0.022 to 0.025; P = 0.866). The mean (SD) delivery duration during the intervention was 12.4 (2.8) min and during the post-intervention period was 9.6 (1.6) min (mean difference 2.8; 95% CI 0.9 to 4.8; P = 0.008). CONCLUSION Using the quality academy framework supported the implementation of a structured handoff during blood delivery to the OR, resulting in a significant increase in verified deliveries.
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Affiliation(s)
- Carly C Amon
- Tufts University School of Medicine, 145 Harrison Ave, Boston, MA 02111, USA
| | - Adina R Paley
- Tufts University School of Medicine, 145 Harrison Ave, Boston, MA 02111, USA
| | - Judith A Forbes
- Department of Pathology and Laboratory Medicine, Tufts Medical Center, 800 Washington St, Boston, MA 02111, USA
| | - Leidy V Guzman
- Department of Quality and Patient Safety, Tufts Medical Center, 800 Washington St, Boston, MA 02111, USA
| | - Aliysa A Rajwani
- Department of Quality and Patient Safety, Tufts Medical Center, 800 Washington St, Boston, MA 02111, USA
| | - Agnieszka Trzcinka
- Tufts University School of Medicine, 145 Harrison Ave, Boston, MA 02111, USA.,Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, 800 Washington St #298 Ziskind Building, 6th Floor, Boston, MA 02111, USA
| | - Raymond L Comenzo
- Tufts University School of Medicine, 145 Harrison Ave, Boston, MA 02111, USA.,Department of Pathology and Laboratory Medicine, Tufts Medical Center, 800 Washington St, Boston, MA 02111, USA
| | - Dan M Drzymalski
- Tufts University School of Medicine, 145 Harrison Ave, Boston, MA 02111, USA.,Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, 800 Washington St #298 Ziskind Building, 6th Floor, Boston, MA 02111, USA
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