Litigation in Anesthesia and Intensive Care Units: An Italian Retrospective Study

Maladaptive personality traits are associated with burnout risk in Italian anesthesiologists and intensivists: a secondary analysis from a cross-sectional study

BACKGROUND

Burnout is a maladaptive response to chronic stress, particularly prevalent among clinicians. Anesthesiologists are at risk of burnout, but the role of maladaptive traits in their vulnerability to burnout remains understudied.

METHODS

A secondary analysis was performed on data from the Italian Association of Hospital Anesthesiologists, Pain Medicine Specialists, Critical Care, and Emergency (AAROI-EMAC) physicians. The survey included demographic data, burnout assessment using the Maslach Burnout Inventory (MBI) and subscales (emotional exhaustion, MBI-EE; depersonalization, MBI-DP; personal accomplishment, MBI-PA), and evaluation of personality disorders (PDs) based on DSM-IV (Diagnostic and Statistical Manual of Mental Disorders Fourth Edition) criteria using the assessment of DSM-IV PDs (ADP-IV). We investigated the aggregated scores of maladaptive personality traits as predictor variables of burnout. Subsequently, the components of personality traits were individually assessed.

RESULTS

Out of 310 respondents, 300 (96.77%) provided complete information. The maladaptive personality traits global score was associated with the MBI-EE and MBI-DP components. There was a significant negative correlation with the MBI-PA component. Significant positive correlations were found between the MBI-EE subscale and the paranoid (r = 0.42), borderline (r = 0.39), and dependent (r = 0.39) maladaptive personality traits. MBI-DP was significantly associated with the passive-aggressive (r = 0.35), borderline (r = 0.33), and avoidant (r = 0.32) traits. Moreover, MBI-PA was negatively associated with dependent (r =  - 0.26) and avoidant (r =  - 0.25) maladaptive personality features.

CONCLUSIONS

There is a significant association between different maladaptive personality traits and the risk of experiencing burnout among anesthesiologists. This underscores the importance of understanding and addressing personality traits in healthcare professionals to promote their well-being and prevent this serious emotional, mental, and physical exhaustion state.

Beyond the self: a novel framework to enhance non-technical team skills for anesthesiologists

Human factors and non-technical skills (NTS) have been identified as essential contributors to both the propagation and prevention of medical errors in the operating room. Despite extensive study and interventions to nurture and enhance NTS in anesthesiologists, gaps to effective team practice and patient safety remain. Furthermore, the link between added NTS training and clinically significant improved outcomes has not yet been demonstrated. We performed a narrative review to summarize the literature on existing systems and initiatives used to measure and nurture NTS in the clinical operating room setting. Controlled interventions performed to nurture NTS (N.=13) were identified and compared. We comment on the body of current evidence and highlight the achievements and limitations of interventions published thus far. We then propose a novel education and training framework to further develop and enhance non-technical skills in both individual anesthesiologists and operating room teams. We use the cardiac anesthesiology environment as a starting point to illustrate its use, with clinical examples. NTS is a key component of enhancing patient safety. Effective framing of its concepts is central to apply individual characteristics and skills in team environments in the OR and achieve tangible, beneficial patient outcomes.

The Intra-Hospital Medical Dispute Burden and Capacities: A Nationwide Survey in Taiwan

(1) Background: Medical disputes have long been resolved via lawsuits. Alternative dispute resolutions have been promoted for their benefits and win-win results. This study aims to investigate Taiwanese hospital medical dispute capacities and burdens. (2) Methods: This study used 2015 nationwide questionnaire data. The number and value of medical disputes that occurred in 2014 was examined to evaluate hospitals' capabilities. Poisson regressions were used to determine the impact of coping abilities on the incidence of disputes and the associated compensation. (3) Results: The response rate of the questionnaire was 90%. Hospital features associated with higher medical disputes incidence included those of a scale ≤ 100 or 200-499 and having a dispute-inform process of over 4 h. In contrast, hospitals whose compensation fund was solely based on medical liability insurance reported less medical dispute incidence. The features associated with higher compensation were lack of continuing training and having a dispute-inform process over 4 h. In contrast, hospitals with standard operating procedures for in-hospital mediation and solicitude paid lower compensation. (4) Conclusions: Hospitals with quicker response times experienced fewer medical disputes and paid lower compensation. Dispute coping skills, other than reaction time, were more visible in compensation bargaining, but were not significantly correlated with incidence.

The Clinical Researcher Journey in the Artificial Intelligence Era: The PAC-MAN’s Challenge

Artificial intelligence (AI) is a powerful tool that can assist researchers and clinicians in various settings. However, like any technology, it must be used with caution and awareness as there are numerous potential pitfalls. To provide a creative analogy, we have likened research to the PAC-MAN classic arcade video game. Just as the protagonist of the game is constantly seeking data, researchers are constantly seeking information that must be acquired and managed within the constraints of the research rules. In our analogy, the obstacles that researchers face are represented by “ghosts”, which symbolize major ethical concerns, low-quality data, legal issues, and educational challenges. In short, clinical researchers need to meticulously collect and analyze data from various sources, often navigating through intricate and nuanced challenges to ensure that the data they obtain are both precise and pertinent to their research inquiry. Reflecting on this analogy can foster a deeper comprehension of the significance of employing AI and other powerful technologies with heightened awareness and attentiveness.

Development and implementation of databases to track patient and safety outcomes

PURPOSE OF REVIEW

Recent advancements in big data analytical tools and large patient databases have expanded tremendously the opportunities to track patient and safety outcomes.We discuss the strengths and limitations of large databases and implementation in practice with a focus on the current opportunities to use technological advancements to improve patient safety.

RECENT FINDINGS

The most used sources of data for large patient safety observational studies are administrative databases, clinical registries, and electronic health records. These data sources have enabled research on patient safety topics ranging from rare adverse outcomes to large cohort studies of the modalities for pain control and safety of medications. Implementing the insights from big perioperative data research is augmented by automating data collection and tracking the safety outcomes on a provider, institutional, national, and global level. In the near future, big data from wearable devices, physiological waveforms, and genomics may lead to the development of personalized outcome measures.

SUMMARY

Patient safety research using large databases can provide actionable insights to improve outcomes in the perioperative setting. As datasets and methods to gain insights from those continue to grow, adopting novel technologies to implement personalized quality assurance initiatives can significantly improve patient care.

Neurostimulation for Chronic Low Back Pain during Pregnancy: Implications for Child and Mother Safety

Pain therapy for low back pain in pregnancy is a very topical issue. In fact, it is necessary to balance the patient's needs to control pain with the need to manage a pregnancy without negative effects on the fetus. We report a case of a 37-year-old woman with low back pain treated with neurostimulation before pregnancy. She described severe chronic low back pain unresponsive to pharmacologic treatments. We first implanted a subcutaneous stimulator into the patient, and then a definitive stimulator resulting in excellent pain control. The improvement in her quality of life allowed the woman to become pregnant. We decided to stop neurostimulation with the patient during pregnancy. The patient completed her pregnancy without complications and the baby was born healthy. During the pregnancy, the woman took only paracetamol when needed. However, this painful symptomatology, completely anecdotal, is not attributable solely to the previous spine problem but probably also to the changes occurring during pregnancy. At the end of pregnancy, the neurostimulator was reactivated without any discomfort for the patient, who is now pain free. This case report provides a first line of evidence of a possible treatment of low back pain in women intending to become pregnant, with risk-free management for both the patient and the child.

Medical Dispute Cases Caused by Errors in Clinical Reasoning: An Investigation and Analysis

Studies that examine medical dispute cases (MDC) due to clinical reasoning (CR) are scarce in Taiwan. A retrospective analysis was undertaken to review MDC filed at four hospitals in Taiwan between 2011 and 2015. Cases were examined for the healthcare professionals involved, their relevance to CR errors, clinical specialties, and seniority. Seventy-eight MDC were identified and 57.7% of which were determined to be related to CR errors (n = 45). Among the 45 cases associated with CR errors, 82.2% (37) and 22.2% (10) were knowledge- and skill-related errors, respectively. The healthcare professionals with the most MDC were obstetrician-gynecologists (10/90, 11.1%), surgeons (8/90, 8.9%), and emergency physicians (7/90, 7.8%). The seniority of less than 5 years or lower had the highest number of attending physicians to be associated with MDC. In contrast, the highest seniority (>25 years) in the physician group and year 6 in the resident group are both shown with zero MDC. In our study, the larger hospitals had a significantly higher incidence of MDC compared to the smaller hospitals (Pearson Correlation Coefficient = 0.984, p = 0.016). An examination of MDC reveals the frequency and nature of medical errors in Taiwanese hospitals. Having identified that CR errors contributed a substantial fraction to the overall MDC, strategies to promote reasoning skills and hence reduce medico-legal issues help safeguard both patients and healthcare professionals.

Hypopharynx, oropharynx morphology and histology in severe Coronavirus 2 patients treated by noninvasive ventilation: comparison between full-face mask and helmet strategies

BACKGROUND

Non-invasive ventilation may alter the morphology and histology of the upper airway mucosa. This study aimed to investigate the alterations of hypopharynx and oropharynx mucosa, identified during oro-tracheal intubation procedure via video-assisted laryngoscopy, in severe acute respiratory syndrome Coronavirus 2 related, treated by non-invasive ventilation via full-face mask or helmet.

METHODS

Data of patients affected by Coronavirus 2 admitted to COVID Hospital of L'Aquila (Italy), presenting hypopharynx and oropharynx morphology alterations, requiring oro-tracheal intubation for invasive ventilation and initially treated with non-invasive ventilation were included in the study. The study aimed to investigate the upper airway mucosa alterations using oropharyngeal and hypopharyngeal images and biopsies taken during video-assisted-laryngoscopy. Data from the hypopharynx and oropharynx morphology and histology alterations between non-invasive ventilation via a full-face mask or helmet used during hospitalization were compared.

RESULTS

From 220 data recorded, 60 patients were included in the study and classified into non-invasive ventilation full-face mask group (30/60) and via helmet group. Comparing data between groups, significant differences were found with respect to hyperemia (77% vs. 20%), laryngeal bleeding ulcerations (87% vs. 13%), and vocal cord edema with >50% narrowing of the tracheal lumen (73% vs. 7%), respectively. The histology examination revealed fibrin-necrotic exudate with extensive necrotic degenerative changes in the sample tissue of the groups. There were not any differences in the duration time of non-invasive ventilation, time from hospitalization and the start of ventilation between groups.

CONCLUSIONS

The data from this research suggested that there were differences in airway mucosa damages among patients treated with a full-face mask or helmet. Further studies should be planned to understand which non-invasive ventilation support may mitigate upper airway mucosa damages when oro-tracheal intubation is requested for invasive respiratory support.

Analysis on Burnout, Job Conditions, Alexithymia, and Other Psychological Symptoms in a Sample of Italian Anesthesiologists and Intensivists, Assessed Just before the COVID-19 Pandemic: An AAROI-EMAC Study

Background. It was previously reported that health care professionals working in the fields of anesthesiology and emergency are at higher risk of burnout. However, the correlations between burnout, alexithymia, and other psychological symptoms are poorly investigated. Furthermore, there is a lack of evidence on which risk factors, specific to the work of anesthetists and intensivists, can increase the risk of burnout, and which are useful for developing remedial health policies. Methods. This cross-sectional study was conducted in 2020 on a sample of 300 professionals recruited from AAROI-EMAC subscribers in Italy. Data collection instruments were a questionnaire on demographic, education, job characteristics and well-being, the Maslach Burnout Inventory Tool, the Toronto Alexithymia Scale, the Symptom Checklist-90-R, and the Rosenberg Self-Esteem Scale administered during refresher courses in anesthesiology. Correlations between burnout and physical and psychological symptoms were searched. Results. With respect to burnout, 29% of individuals scored at high risk on emotional exhaustion, followed by 36% at moderate–high risk. Depersonalization high and moderate–high risk were scored by 18.7% and 34.3% of individuals, respectively. Burnout personal accomplishment was scored by 34.7% of respondents. The highest mean scores of burnout dimensions were related to dissatisfaction with one’s career, conflicting relationships with surgeons, and, finally, difficulty in explaining one’s work to patients. Conclusions. Burnout rates in Italian anesthesiologists and intensivists have been worrying since before the COVID-19 pandemic. Anesthesiologists with higher levels of alexithymia are more at risk for burnout. It is therefore necessary to take urgent health policy measures.

Medical Malpractice Lawsuits Involving Trainees in Obstetrics and Gynecology in the USA

Background: While the liability risks for obstetrics and gynecology (ob/gyn) physicians are widely recognized, little is known about how trainees have been involved in ob/gyn lawsuits. Objectives: To characterize involvement of trainees in malpractice lawsuits related to ob/gyn. Methods: The legal database Westlaw was utilized to collect ob/gyn-related malpractice lawsuits involving trainees reported from 1986 to 2020 in the USA. Outcome: Forty-six malpractice cases involving ob/gyn trainees were identified, including 34 cases related to obstetrics and 12 to gynecology. There were 11 cases alleging lack of informed consent, including 7 cases alleging lack of consent for trainee involvement. Of the 34 obstetrics cases, 27 related to procedural complications, 17 to treatment, 13 to diagnosis, and 4 to informed consent. Of these, 17 were decided in favor of the physician, 6 resulted in findings of negligence, 9 had unknown outcomes, and 3 ended in settlement. For the 6 cases ending in a finding of negligence, the mean award was $2,174,472 compared to $685,000 for those that were settled. Of the 12 gynecology cases, 8 related to procedural complications, 7 to informed consent, 3 to diagnosis, and 2 to treatment. Of these, 6 were decided in favor of the physician, 3 resulted in findings of negligence, and 3 had unknown outcomes. For the cases ending in a finding of negligence, the mean award was $465,000. Conclusions and Outlook: This review of malpractice cases highlights types of situations in which trainees are sued and reveals the importance of designing curriculum around faculty training and supervision regarding trainee involvement in patient care.

"White cord syndrome after cervical or thoracic spinal cord decompression. Haemodynamic complication or mechanical damage? An understimated nosographic entity"

The ischemia-reperfusion mechanism is believed to be responsible for parenchymal damage caused by temporary hypoperfusion and worsened by the subsequent attempt of reperfusion. This represents a true challenge for physicians of several fields, including neurosurgeons. A limited number of papers have shed the light on a rare pathological condition that affects patients experiencing an unexplained neurological deficit after spine surgery, the so-called "white cord syndrome". This entity is believed to be caused by an "ischemia-reperfusion" injury on the spinal cord, documented by a post-operative intramedullary hyperintensity on T2 weighted MRI sequences. To date, the cases of white cord syndrome reported in literature mostly refer to cervical spine surgery. However, the analysis of several reviews focusing on spine surgery outcome suggest that post-operative neurological deficits of new onset could be charged to a mechanism of ischemia-reperfusion, even if the physiopathology of this event is seldom explored or at least discussed. The same neuroradiological finding can suggest a mechanical damage due to surgical inappropriate manipulation. On this purpose, we performed a systematic revision of literature with the aim to identify and analyze all the factors potentially contributing to ischemic-reperfusion damage of the spinal cord that may potentially complicate any spinal surgery, without distinction between cervical or thoracic segment. Finally, we believe that post-operative neurological deficit after spinal surgery constituting the "white cord syndrome", could be underreported, while both neurosurgeons and patients should be fully aware of this rare but potentially devasting complication burdening cervical and thoracic spine surgery.

A Modified Approach for Ultrasound-Guided Thoracic Paravertebral Block via Thoracic Intervertebral Foramen in an Adolescent Patient: A Case Report

This case report describes a modified approach for a thoracic paravertebral block by performing a bilateral ultrasound-assisted injection of 12 mL of 0.5% levobupivacaine near the thoracic intervertebral foramen, combined with general anesthesia, in a patient who underwent emergent laparotomy for small intestinal volvulus. Two continuous catheter sets were used for a bilateral continuous block with levobupivacaine 0.25% at a rate of 5–8 mL/h. No complications during the execution of the block were recorded. No supplemental opioids were administered and the patient was hemodynamically stable, requiring no pharmacological cardiovascular support during surgery. At the end of the surgical procedure, the patient received a continuous flow of 0.2% levobupivacaine as postoperative analgesia, at a basal flow of 4 mL/h per each side, a bolus of 4 mL, and a lockout time of 60 min was used. The postoperative pain on the Numeric Rating Scale was 2 at rest and it was 4 in motion, without neurological or respiratory sequelae due to block in the first 72 h after surgery.

Dose-Related Analysis in Percutaneous Central Venous Catheters Insertion: Experience of a Pediatric Interventional Radiology Center

Background: There are many techniques for long-term central venous catheter (CVC) placement, but none of them are specific for pediatric patients or focused on the delivered dose of ionizing radiation. Materials and Methods: This retrospective study examined a sample of pediatric patients who received percutaneous long-term CVC positioning in a tertiary care pediatric hospital. Effective dose, dose-area product (DAP) and length of time of exposition during the procedure were determined, using an appropriate technical procedure, exam and program set of the angiograph, and compared with an unpaired t-test analysis. Results: The study included 1410 enrolled patients, with a median age of 10 years (range 0.2–18 years), between 2016 and 2019. In 2016 (318 pts), the mean effective dose was 0.13 mSv and the mean DAP dose was 18.95 µGy/m² In 2017 (353 pts), the mean effective dose was 0.11 mSv and the mean DAP dose was 17.26 µGy/m². In 2018 (351 pts), the mean effective dose was 0.05 mSv and the mean DAP dose was 7.23 µGy/m². In 2019 (388 pts), the mean effective dose was 0.02 mSv and the mean DAP dose was 3.10 µGy/m². Conclusions: Medical and technical expertise led to a remarkable reduction in the radiation dose. Therefore, the authors’ hypothesis is that US- and fluoroscopy-guided percutaneous long-term CVC insertion technique is safer, more cost-effective and lower in terms of radiation exposure if correctly applied, compared to surgical or percutaneous by direct puncture techniques.

Strengths and Weaknesses of Cancer Pain Management in Italy: Findings from a Nationwide SIAARTI Survey

Objectives: Despite guidelines, a large percentage of cancer patients continue to suffer from ineffectively treated pain. The authors undertook this survey to assess the strengths and weaknesses of cancer pain management in Italy. Design: This was a prospectively administered survey. Participants: The participants were anesthesiologists of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI). Intervention: A 58-item questionnaire covered the demographics and features of cancer pain management in the Italian context. Results: The authors received responses from 611 pain therapists of 279 centers. Only 22% of physicians are exclusively pain therapists. Seventy-five percent are specialists in anesthesiology, intensive care, and pain medicine. Most pain centers are hospital or university facilities (78%). The strengths of cancer pain management in Italy are the careful opioid prescriptions, the use of strategies for the treatment of neuropathic pain, patient/healthcare provider partnerships, and breakthrough cancer pain management. Weaknesses to be addressed include poor adherence to guidelines, inadequate attention toward the patient’s quality of life, insufficient use of minimally invasive techniques, lack of teamwork approaches, inappropriate timing of pain specialist engagement, and poor telemedicine use. Conclusions: Despite several strengths, further efforts are needed to improve the care of patients suffering from cancer pain in Italy.

Open Issues and Practical Suggestions for Telemedicine in Chronic Pain

Telemedicine represents a major opportunity to facilitate continued assistance for patients with chronic pain and improve their access to care. Preliminary data show that an improvement can be expected of the monitoring, treatment adherence, assessment of treatment effect including the emotional distress associated with pain. Moreover, this approach seems to be convenient and cost-effective, and particularly suitable for personalized treatment. Nevertheless, several open issues must be highlighted such as identification of assessment tools, implementation of monitoring instruments, and ability to evaluate personal needs and expectations. Open questions exist, such as how to evaluate the need for medical intervention and interventional procedures, and how to define when a clinical examination is required for certain conditions. In this context, it is necessary to establish dynamic protocols that provide the right balance between face-to-face visits and telemedicine. Useful tips are provided to start an efficient experience. More data are needed to develop precise operating procedures. In the meantime, the first experiences from such settings can pave the way to initiate effective care pathways in chronic pain.

Pursuing the Recovery of Severe Chronic Musculoskeletal Pain in Italy: Clinical and Organizational Perspectives from a SIAARTI Survey

Background

Increased attention to the functional impact of chronic pain (CP), as highlighted by the 11th revision of the International Classification of Diseases (ICD-11) and advocated by the International Classification of Functioning, Disability and Health (ICF), is an important step forward for optimizing its management. Evidence about perspectives of Italian physicians on the relevance of musculoskeletal (MSK) pain care to improve patients’ functioning and Quality of Life is scant. The study aimed to investigate the physicians’ perception of the value of functional recovery in severe MSK pain patients, their attitude towards its assessment and achievement in Italy.

Methods

A survey was conducted in Italy between October 2020 and January 2021. Specialist centers members of the SIAARTI (n = 395) were sent an online questionnaire encompassing the Italian pain therapy network. Participants rated their agreement to questionnaire items according to a 5-point Likert-type scale.

Results

A total of 305 centers (77%) completed the survey. Most physicians rated the recovery of functioning as very relevant in MSK pain treatment and, when they assessed it, devoted great attention to the ability to perform daily activities, pain, ability to ambulate and sleep quality. Multidimensional questionnaires were less employed in favor of physical examination and pain intensity scales. Pharmacological therapy, rehabilitation and lifestyle changes and/or physical exercise were all rated optimal strategies to pursue the recovery of patients’ functioning. When considering pharmacological therapy, weak and strong opioids, either alone or combined with paracetamol, were the most frequently employed analgesics.

Conclusion

Clinicians seem to recognize the recovery of functioning as equally important as pain intensity reduction, but there is a need of streamlining available tools to effectively assess both across different MSK pain patients.