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Abouleish AE, Pomerantz P, Peterson MD, Cannesson M, Akeju O, Miller TR, Rathmell JP, Cole DJ. Closing the Chasm: Understanding and Addressing the Anesthesia Workforce Supply and Demand Imbalance. Anesthesiology 2024; 141:238-249. [PMID: 38884582 DOI: 10.1097/aln.0000000000005052] [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: 06/18/2024]
Abstract
The imbalance in anesthesia workforce supply and demand has been exacerbated post-COVID due to a surge in demand for anesthesia care, especially in non-operating room anesthetizing sites, at a faster rate than the increase in anesthesia clinicians. The consequences of this imbalance or labor shortage compromise healthcare facilities, adversely affect the cost of care, worsen anesthesia workforce burnout, disrupt procedural and surgical schedules, and threaten academic missions and the ability to educate future anesthesiologists. In developing possible solutions, one must examine emerging trends that are affecting the anesthesia workforce, new technologies that will transform anesthesia care and the workforce, and financial considerations, including governmental payment policies. Possible practice solutions to this imbalance will require both short- and long-term multifactorial approaches that include increasing training positions and retention policies, improving capacity through innovations, leveraging technology, and addressing financial constraints.
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Affiliation(s)
- Amr E Abouleish
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas
| | - Paul Pomerantz
- American Society of Anesthesiologists, Chicago, Illinois
| | | | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Oluwaseun Akeju
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Thomas R Miller
- Center for Anesthesia Workforce Studies, American Society of Anesthesiologists, Schaumburg, Illinois
| | - James P Rathmell
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts
| | - Daniel J Cole
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
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2
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Routman JS, Tran BK, Vining BR, Salei A, Gunn AJ, Raja J, Huang J. Non-operating room anesthesia workflow (NORA) implementation to improve start times in interventional radiology. Curr Probl Diagn Radiol 2024; 53:477-480. [PMID: 38553349 DOI: 10.1067/j.cpradiol.2024.03.009] [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: 02/28/2024] [Accepted: 03/07/2024] [Indexed: 06/17/2024]
Abstract
BACKGROUND Non-OR Anesthesia (NORA) is rapidly becoming standard in many high-volume institutions and efficiency in these spaces has yet to be optimized. On-time first start percentage has been suggested to correlate with more efficient flow, and this correlation is established within the surgical space. PURPOSE To investigate the effects of timetable targets on first case on-time first start percentage within a NORA setting. MATERIALS AND METHODS A retrospective study of anesthesia-supported first start cases from October 2022 to April 2023 was performed to analyze the effect of timetable targets on on-time first-case starts for planned cases. Statistical analysis was calculated using Student's t-tests with statistical significance defined as p < 0.05. Additionally, analysis of variance was used to compare three or more groups, and Tukey Kramer was used to evaluate groups pairwise. RESULTS One hundred twenty-four first start cases were included in the evaluation. After intervention with timetable targets, average patient arrival to the room time improved from 7:49 AM to 7:40 AM (p < 0.05) and procedure start time improved from 8:31 AM to 8:20 AM (p < 0.01). The percentage of procedure start times occurring prior to the goal time increased from 35 % to 58 % after the implementation (p < 0.05). With exception of Tuesdays (Anesthesia Late Start Day), on-time starts improved from 17 % to 48 % (p < 0.01) and sustained this improvement throughout the post-implementation period. CONCLUSION Implementation of novel timetable targets yielded statistically significant improvement in first case start times. This improvement in efficiency and throughput results in increased room utilization, improved case throughput, and decreased block overrun times, all of which contribute toward increased revenues, decreased costs, and thus improved return on investment.
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Affiliation(s)
- Justin S Routman
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Benjamin K Tran
- University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, United States.
| | - Brooke R Vining
- Associate Vice President Perioperative Services, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Aliaksei Salei
- Department of Interventional Radiology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Andrew J Gunn
- Department of Interventional Radiology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Junaid Raja
- Department of Interventional Radiology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Junjian Huang
- Department of Interventional Radiology, University of Alabama at Birmingham, Birmingham, AL, United States
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3
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Jarraya A, Kammoun M, Khcharem J, Cherif O, Feki W, Mnif Z. Incidence of complications after nonoperating room anesthesia in children in a low- and middle-income country: A prospective and observational study. Paediatr Anaesth 2024. [PMID: 38923209 DOI: 10.1111/pan.14955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 05/24/2024] [Accepted: 06/11/2024] [Indexed: 06/28/2024]
Abstract
INTRODUCTION Nonoperating room anesthesia is a growing field of medicine that can have an increased risk of complications, particularly in low- and middle-income countries. AIMS The aim of this study was to describe the incidence of complications after pediatric nonoperating room anesthesia and investigate its risk factors. METHODS In this prospective observational study, we included all children aged less than 5 years who were sedated or anesthetized in the radiology setting of a university hospital in a low- and middle-income country. Patients were divided into two groups: complications or no-complications groups. Then, we compared both groups, and univariable and multivariable logistic regression models were used to investigate the main risk factors for complications. RESULTS We included 256 children, and the incidence of complications was 8.6%. The main predictors of nonoperating room anesthesia-related morbidity were: critically-ill children (aOR = 2.490; 95% CI: 1.55-11.21), predicted difficult airway (aOR = 5.704; 95% CI: 1.017-31.98), and organization insufficiencies (aOR = 52.6; 95% CI:4.55-613). The preanesthetic consultation few days before NORA protected against complications (aOR = 0.263; 95%CI: 0.080-0.867). CONCLUSIONS The incidence of complications during NORA among children in our radiology setting remains high. Investigating predictors for morbidity allowed high-risk patient selection, which allowed taking precautions. Several improvement measures were taken to address the organization's insufficiencies.
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Affiliation(s)
- Anouar Jarraya
- Pediatric Anesthesia Department, Hedi Chaker University Hospital, University of Sfax, Sfax, Tunisia
| | - Manel Kammoun
- Pediatric Anesthesia Department, Hedi Chaker University Hospital, University of Sfax, Sfax, Tunisia
| | - Jaouhar Khcharem
- Pediatric Anesthesia Department, Hedi Chaker University Hospital, University of Sfax, Sfax, Tunisia
| | - Olfa Cherif
- Pediatric Anesthesia Department, Hedi Chaker University Hospital, University of Sfax, Sfax, Tunisia
| | - Wiem Feki
- Radiology Department, Hedi Chaker University Hospital, University of Sfax, Sfax, Tunisia
| | - Zeinab Mnif
- Radiology Department, Hedi Chaker University Hospital, University of Sfax, Sfax, Tunisia
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Bilgin S, Dost B, Turunc E, Koksal E, Ustun YB, Tulgar S. Ultrasound-Guided Sacral Erector Spinae Plane Block: A Feasible Option for Pain Management During Magnetic Resonance Imaging: A Case Report. A A Pract 2024; 18:e01788. [PMID: 38727139 DOI: 10.1213/xaa.0000000000001788] [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: 07/03/2024]
Abstract
Inability to remain motionless owing to pain during magnetic resonance imaging (MRI) may increase the need for sedation and analgesia. Here, we present a case where ultrasound-guided sacral erector spinae plane block (ESPB) was used successfully for pain management during an MRI in a patient suffering from severe sacral pain. Sacral ESPB was performed with a total of 30 mL of 0.25% bupivacaine at the level of the intermediate sacral crest. The patient achieved sensory block in the L5-S4 dermatomes without motor block, resulting in complete pain relief. This case report highlights the feasibility of ultrasound-guided sacral ESPB as a potential pain management technique.
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Affiliation(s)
- Sezgin Bilgin
- From the Department of Anesthesiology and Reanimation, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey
| | - Burhan Dost
- From the Department of Anesthesiology and Reanimation, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey
| | - Esra Turunc
- From the Department of Anesthesiology and Reanimation, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey
| | - Ersin Koksal
- From the Department of Anesthesiology and Reanimation, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey
| | - Yasemin Burcu Ustun
- From the Department of Anesthesiology and Reanimation, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey
| | - Serkan Tulgar
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Samsun Training and Research Hospital, Samsun University, Samsun, Turkey
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Fabbri C, Scalvini D, Paolo G, Binda C, Mauro A, Coluccio C, Mazza S, Trebbi M, Torello Viera F, Anderloni A. Complications and management of interventional endoscopic ultrasound: A critical review. Best Pract Res Clin Gastroenterol 2024; 69:101888. [PMID: 38749575 DOI: 10.1016/j.bpg.2024.101888] [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: 01/13/2024] [Accepted: 01/30/2024] [Indexed: 07/13/2024]
Abstract
In the last decades, Endoscopic ultrasound (EUS) has rapidly grown and evolved from being mainly a diagnostic procedure, to being an interventional and therapeutic tool in several pathological clinical scenarios. With the progressive growth in technical expertise and dedicated devices, interventional endoscopic ultrasound procedures (IEUSP) have shown high rates of technical and clinical success, together with a relatively safe profile. However, the description and the standardization of different and specific types of adverse events (AEs) are still scarce in literature, and, consequently, even less the management of AEs. The aim of this study is to critical review and to describe AEs related to each of the main IEUSP, and to provide an overview on the possible management strategies of endoscopic complications. Future studies and guidelines are surely required to reach a better standardization of different AEs and their best management.
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Affiliation(s)
- Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì, Italy
| | - Davide Scalvini
- Gastroenterology and Digestive Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Giuffrida Paolo
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì, Italy.
| | - Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì, Italy
| | - Aurelio Mauro
- Gastroenterology and Digestive Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Chiara Coluccio
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì, Italy
| | - Stefano Mazza
- Gastroenterology and Digestive Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Margherita Trebbi
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì, Italy
| | - Francesca Torello Viera
- Gastroenterology and Digestive Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Andrea Anderloni
- Gastroenterology and Digestive Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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Durai Samy NK, Taksande K. Revolutionizing Cardiac Anesthesia: A Comprehensive Review of Contemporary Approaches Outside the Operating Room. Cureus 2024; 16:e55611. [PMID: 38586747 PMCID: PMC10995652 DOI: 10.7759/cureus.55611] [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: 01/04/2024] [Accepted: 03/05/2024] [Indexed: 04/09/2024] Open
Abstract
This review article provides a comprehensive examination of the evolution of cardiac anesthesia, emphasizing contemporary approaches beyond the traditional operating room (OR) setting. Tracing the historical roots of cardiac anesthesia from its inception in the mid-20th century, the narrative explores the significant paradigm shift driven by technological advancements and changing procedural approaches. The review highlights the emergence of non-OR environments, such as hybrid operating rooms, catheterization laboratories, and electrophysiology labs, as integral spaces for cardiac interventions. Key findings underscore the importance of patient selection, preoperative assessment, and specialized anesthetic management in optimizing outcomes. Implications for the future of cardiac anesthesia include the potential for enhanced patient-centered care, reduced complications, and improved resource utilization through the integration of advanced technologies. The call to action involves encouraging ongoing research and fostering collaboration among healthcare professionals to refine protocols further, address challenges, and propel the field toward continued innovation in contemporary cardiac interventions.
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Affiliation(s)
| | - Karuna Taksande
- Anaesthesiology, Jawaharlal Nehru Medical College, Wardha, IND
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7
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Oung C, Tesoro R, Marti V, Mavromati M, Lahoud MJ. Hypnosis in High-Intensity Focused Ultrasound for Thyroid Nodule Ablation. AMERICAN JOURNAL OF CASE REPORTS 2023; 24:e941524. [PMID: 37980542 PMCID: PMC10670948 DOI: 10.12659/ajcr.941524] [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: 06/10/2023] [Revised: 10/16/2023] [Accepted: 10/05/2023] [Indexed: 11/20/2023]
Abstract
BACKGROUND Current medical technologies enable physicians to treat patients outside operating rooms using minimally invasive techniques. Non-operating room anesthesia (NORA) represents a growing field of medicine, with an increasing number of cases performed over the last decade. As a result, anesthesia providers will need to enhance their understanding of the resources, medical and paramedical staff, and environment outside the operating room. Patients undergoing such procedures under light conscious sedation still experience discomfort such as pain and anxiety, thus requiring the use of pain control medication or sedative drugs. At the same time, the use of hypnosis is spreading in medical practice, particularly with minimally invasive procedures. Many studies have investigated the use of hypnosis in cases of minimally invasive procedures, showing an effective reduction of patients' discomfort and consumption of pain control medication, thus improving patient safety. CASE REPORT We describe the case of a woman in her 70s who underwent a thyroid nodule thermal ablation through high-intensity focused ultrasound (HIFU) performed under hypnosis in a NORA setting. The procedure was well endured; the patient experienced comfort and was satisfied with having avoided general anesthesia. Post-HIFU follow-up showed a 30% decrease of thyroid nodule volume. The patient was completely satisfied with the esthetic result. The operator did not encounter any difficulties with the awoken patient or movements during the procedure. CONCLUSIONS Our case confirms the effective role of hypnosis in relaxation and coping with painful procedures and highlights patient satisfaction without the use of sedative drugs in the context of NORA procedures.
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Affiliation(s)
- Caroline Oung
- Division of Anesthesiology, Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Rosa Tesoro
- Department of Psychiatry, Geneva University Hospitals, Geneva, Switzerland
| | - Valentin Marti
- Unit of Forensic Pathology, University Center of Legal Medicine Lausanne-Geneva, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Maria Mavromati
- Division of Endocrinology, Geneva University Hospitals, Geneva, Switzerland
| | - Marie-José Lahoud
- Division of Anesthesiology, Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
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8
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Huang Y, Sun L, Guo J, Zhang C, Xu J. Exploration and Application of the Peri-anesthesia Nursing Management Mode of the Five-Sphere Integrated Plan. Am J Health Behav 2023; 47:489-497. [PMID: 37596745 DOI: 10.5993/ajhb.47.3.6] [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: 08/20/2023]
Abstract
Objectives: The objective of this research was to test the application of peri-anesthesia nursing management (anesthesia preparation room, operating room, recovery room, post anesthesia visit, and anesthesia general management) on hospital services. Methods: We used a quantitative research design to collect data from 311 nurses, with structural equation modeling used for data analysis. Results: The application of the peri- anesthesia nursing management mode of the five-sphere integrated plan impacted hospital services for patients. Conclusion: The practice of the five-sphere integrated mode not only highlighted the professional characteristics of anesthesia nursing, but also ensured the quality of medical treatment of patients during peri-anesthesia, and provided new ideas and references for nursing management of other specialties.
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Affiliation(s)
- Yian Huang
- Department of Anesthesiology, School of Medicine, The Fourth Affiliated Hospital, Zhejiang University, Yiwu, China
| | - Linmin Sun
- Department of Anesthesiology, School of Medicine, The Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Jian Guo
- Department of Anesthesiology, School of Medicine, The Fourth Affiliated Hospital, Zhejiang University, Yiwu, China
| | - Cao Zhang
- Department of Anesthesiology, School of Medicine, The Fourth Affiliated Hospital, Zhejiang University, Yiwu, China
| | - Jianhong Xu
- Department of Anesthesiology, School of Medicine, The Fourth Affiliated Hospital, Zhejiang University, Yiwu, China
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9
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Wang X, Liu X, Mi J. Perioperative management and drug selection for sedated/anesthetized patients undergoing MRI examination: A review. Medicine (Baltimore) 2023; 102:e33592. [PMID: 37083779 PMCID: PMC10118336 DOI: 10.1097/md.0000000000033592] [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: 03/01/2023] [Accepted: 03/31/2023] [Indexed: 04/22/2023] Open
Abstract
In recent years, magnetic resonance imaging (MRI) technology has become an indispensable imaging tool owing to significant improvements in MRI that have opened up new diagnostic perspectives. Due to the closed environment, long imaging time, and need to remain still during the examination process, the examiner may cannot cooperate with the completion of the examination of the procedure, which increases the need for deep sedation or anesthesia. Achieving this can sometimes be challenging, especially in the special nontraditional environment of MRI equipment (unfamiliar and narrow spaces, away from patients, strong magnetic fields) and in special populations requiring sedation/anesthesia during examinations, which pose certain challenges for the perioperative anesthesia management of MRI. A simple "checklist" is necessary because it allows the anesthesiologist to become familiar with the particular environment and human and material resources as quickly as possible. For the choice of sedative/anesthetic, the traditional drugs, such as midazolam and ketamine, are still used due to the ease of administration despite their low sedation success rate, prolonged recovery, and significant adverse events. Currently, dexmedetomidine, with respiratory drive preservation, propofol, with high effectiveness and rapid recovery, and sevoflurane, which is mild and nonirritating, are preferred for sedation/anesthesia in children and adults undergoing MRI. Therefore, familiarity with the perioperative management of patient sedation and general anesthesia and drug selection in the MRI environment is critical for successful surgical completion and for the safe and rapid discharge of MRI patients receiving sedation/anesthesia.
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Affiliation(s)
- Xiaoyu Wang
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - XueQuan Liu
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Junqiao Mi
- Julius-Maximilians-Universität of Würzburg, Würzburg, Germany
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10
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Wang J, Dai Z, Chang J, Shi J(J, Liu H. Robust surgical scheduling for nonoperating room anesthesia (NORA) under surgical duration uncertainty. DECISION SCIENCES 2022. [DOI: 10.1111/deci.12584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Jian‐Jun Wang
- School of Economics and Management Dalian University of Technology Dalian China
| | - Zongli Dai
- School of Economics and Management Dalian University of Technology Dalian China
| | - Jasmine Chang
- Tuchman School of Management New Jersey Institute of Technology Newark New Jersey
| | - Jim (Junmin) Shi
- Tuchman School of Management New Jersey Institute of Technology Newark New Jersey
| | - Haiguan Liu
- School of Economics and Management Dalian University of Technology Dalian China
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11
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Urdaneta F, Wardhan R, Wells G, White JD. Prevention of pulmonary complications in sedated patients undergoing interventional procedures in the nonoperating room anesthesia setting. Curr Opin Anaesthesiol 2022; 35:493-501. [PMID: 35787534 DOI: 10.1097/aco.0000000000001158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Nonoperating room anesthesia (NORA) procedures have expanded in number, variety, and complexity. NORA involves all age groups, including frail older adults and patients often considered too sick to tolerate traditional surgical interventions. Postoperative pulmonary complications are a significant source of adverse events in the perioperative setting. We present a review focused on preventing pulmonary complications in the interventional NORA setting. RECENT FINDINGS NORA locations should function as independent, autonomous ambulatory units. We discuss a strategic plan involving a thorough preoperative evaluation of patients, including recognizing high-risk patients and their anesthetic management. Finally, we offer guidance on the challenges of conducting sedation and anesthesia in patients with coronavirus disease 2019 (COVID-19) or a history of COVID-19. SUMMARY The demands on the interventional NORA anesthesia team are increasing. Strategic planning, checklists, consistent staffing assignments, and scheduled safety drills are valuable tools to improve patient safety. In addition, through quality improvement initiatives and reporting, NORA anesthetists can achieve reductions in periprocedural pulmonary complications.
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Affiliation(s)
- Felipe Urdaneta
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
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12
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Frameworks for value-based care in the nonoperating room setting. Curr Opin Anaesthesiol 2022; 35:508-513. [PMID: 35861474 DOI: 10.1097/aco.0000000000001164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Nonoperating room anesthesia (NORA) presents a unique opportunity for the application of value-based care (VBC) principles to procedures performed in the office-based and nonoperating room inpatient settings. The purpose of this article is to review how value is defined in NORA and enabling principles by which anesthesiologists can maximize value in NORA. RECENT FINDINGS In order to drive value, NORA providers can target improvements in clinical outcomes where NORA lags behind operating room-based anesthesia (death, over-sedation, nerve injury), implement protocols focusing on intermediate outcomes/quality (postoperative nausea and vomiting, pain control, hypothermia, delirium), incorporate patient-reported outcomes (PROs) to assess the trajectory of a patient's perioperative care, and reduce costs (direct and indirect) through operational and supply-based efficiencies. Establishing a culture of patient and provider safety first, appropriate patient selection with targeted, perioperative optimization of comorbidities, and efficient deployment of staff, space, and resources are critical enablers for success. SUMMARY Value in NORA can be defined as clinical outcomes, quality, patient-reported outcomes, and efficiency divided by the direct and indirect costs for achieving those outcomes. We present a novel framework adapting current VBC practices in operating room anesthesia to the NORA environment.
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13
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Herman AD, Jaruzel CB, Lawton S, Tobin CD, Reves JG, Catchpole KR, Alfred MC. Morbidity, mortality, and systems safety in non-operating room anaesthesia: a narrative review. Br J Anaesth 2021; 127:729-744. [PMID: 34452733 DOI: 10.1016/j.bja.2021.07.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 07/01/2021] [Accepted: 07/09/2021] [Indexed: 11/18/2022] Open
Abstract
Non-operating room anaesthesia (NORA) describes anaesthesia delivered outside a traditional operating room (OR) setting. Non-operating room anaesthesia cases have increased significantly in the last 20 yr and are projected to account for half of all anaesthetics delivered in the next decade. In contrast to most other medication administration contexts, NORA is performed in high-volume fast-paced environments not optimised for anaesthesia care. These predisposing factors combined with increasing case volume, less provider experience, and higher-acuity patients increase the potential for preventable adverse events. Our narrative review examines morbidity and mortality in NORA settings compared with the OR and the systems factors impacting safety in NORA. A review of the literature from January 1, 1994 to March 5, 2021 was conducted using PubMed, CINAHL, Scopus, and ProQuest. After completing abstract screening and full-text review, 30 articles were selected for inclusion. These articles suggested higher rates of morbidity and mortality in NORA cases compared with OR cases. This included a higher proportion of death claims and complications attributable to inadequate oxygenation, and a higher likelihood that adverse events are preventable. Despite relatively few attempts to quantify safety concerns, it was possible to find a range of systems safety concerns repeated across multiple studies, including insufficient lighting, noise, cramped workspace, and restricted access to patients. Old and unfamiliar equipment, lack of team familiarity, and limited preoperative evaluation are also commonly noted challenges. Applying a systems view of safety, it is possible to suggest a range of methods to improve NORA safety and performance.
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Affiliation(s)
- Abigail D Herman
- College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Candace B Jaruzel
- College of Health Professions, Medical University of South Carolina, Charleston, SC, USA
| | - Sam Lawton
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Catherine D Tobin
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Joseph G Reves
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Kenneth R Catchpole
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Myrtede C Alfred
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA.
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14
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Nonoperating room anesthesia: strategies to improve performance. Int Anesthesiol Clin 2021; 59:27-36. [PMID: 34456276 DOI: 10.1097/aia.0000000000000339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Beg T, Daoud BE, Richman DC. Preoperative optimization of patients undergoing interventional procedures: infrastructure, logistics, and evidence-based medicine. Curr Opin Anaesthesiol 2021; 34:482-489. [PMID: 34184642 DOI: 10.1097/aco.0000000000001013] [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: 11/25/2022]
Abstract
PURPOSE OF REVIEW Patients presenting for non-operating room procedures are often 'too sick' for surgery and require specific anesthesia care in remote areas with logistical and scheduling challenges. RECENT FINDINGS Increased complexity and scope of minimally invasive procedures have expanded this practice. In addition, the concept of therapeutic options other than conventional surgery is gaining traction. SUMMARY Our review of recent literature confirms the complexity and supports the safety of providing care in non-operating room anesthesia locations. Standard preanesthesia assessments and principles apply to these areas.
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Affiliation(s)
- Tazeen Beg
- Department of Anesthesia, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York, USA
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Beal B, Du AL, Urman RD, Gabriel RA. Frameworks for trainee education in the nonoperating room setting. Curr Opin Anaesthesiol 2021; 34:470-475. [PMID: 34052824 DOI: 10.1097/aco.0000000000001023] [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: 11/25/2022]
Abstract
PURPOSE OF REVIEW As the volume and types of procedures requiring anesthesiologist involvement in the nonoperating room anesthesia (NORA) setting continue to grow, it is important to create a formal curriculum and clearly define educational goals. RECENT FINDINGS A NORA rotation should be accompanied by a dedicated curriculum that should include topics such as education objectives, information about different interventional procedures, anesthesia techniques and equipment, and safety principles. NORA environment may be unfamiliar to anesthesia residents. The trainees must also learn the principles of efficiency, rapid recovery from anesthesia, and timely room turnover. Resident education in NORA should be an essential component of their training. The goals and objectives of the NORA educational experience should include not only developing the clinical knowledge necessary to implement the specific type of anesthetic desired for each procedure, but also the practical knowledge of care coordination needed to safely and efficiently work in the NORA setting. SUMMARY As educators, we must foster and grow a resident's resilience by continually challenging them with new clinical scenarios and giving them appropriate autonomy to take risks and move outside of their comfort zone. Residents should understand that exposure to such unique and demanding environment can be transformative.
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Affiliation(s)
| | - Austin L Du
- School of Medicine, University of California, San Diego, La Jolla, California
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Rodney A Gabriel
- Department of Anesthesiology
- Division of Biomedical Informatics, University of California, San Diego, La Jolla, California, USA
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Schroeck H, Taenzer AH, Schifferdecker KE. Team factors influence emotions and stress in a non-operating room anaesthetising location. Br J Anaesth 2021; 127:e95-e98. [PMID: 34253321 DOI: 10.1016/j.bja.2021.06.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/25/2021] [Accepted: 06/10/2021] [Indexed: 11/18/2022] Open
Affiliation(s)
- Hedwig Schroeck
- Geisel School of Medicine at Dartmouth College, Hanover, NH, USA; Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
| | - Andreas H Taenzer
- Geisel School of Medicine at Dartmouth College, Hanover, NH, USA; Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA; The Dartmouth Institute, Lebanon, NH, USA
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18
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Obara S, Kuratani N. Training in pediatric anesthesia in Japan: how should we come along? J Anesth 2020; 35:471-474. [PMID: 33009926 DOI: 10.1007/s00540-020-02859-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 09/19/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Soichiro Obara
- Department of Anesthesia, Tokyo Metropolitan Ohtsuka Hospital, 2-8-1, Minami-ohtsuka, Toshima-ku, Tokyo, 170-8476, Japan.
- Teikyo University Graduate School of Public Health, Tokyo, Japan.
| | - Norifumi Kuratani
- Teikyo University Graduate School of Public Health, Tokyo, Japan
- Department of Anesthesia, Saitama Children's Medical Center, Saitama, Japan
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