Process Optimization and Digital Quality Improvement to Enhance Timely Initiation of Epidural Infusions and Postoperative Pain Control

BACKGROUND

Although intraoperative epidural analgesia improves postoperative pain control, a recent quality improvement project demonstrated that only 59% of epidural infusions are started in the operating room before patient arrival in the postanesthesia care unit. We evaluated the combined effect of process and digital quality improvement efforts on provider compliance with starting continuous epidural infusions during surgery.

METHODS

In October 2014, we instituted 2 process improvement initiatives: (1) an electronic order queue to assist the operating room pharmacy with infusate preparation; and (2) a designated workspace for the storage of equipment related to epidural catheter placement and drug infusion delivery. In addition, we implemented a digital quality improvement initiative, an Anesthesia Information Management System-mediated clinical decision support, to prompt anesthesia providers to start and document epidural infusions in pertinent patients. We assessed anesthesia provider compliance with epidural infusion initiation in the operating room and postoperative pain-related outcomes before (PRE: October 1, 2012 to September 31, 2014) and after (POST: January 1, 2015 to December 31, 2016) implementation of the quality improvement initiatives.

RESULTS

Compliance with starting intraoperative epidural infusions was 59% in the PRE group and 85% in the POST group. After adjustment for confounders and preintervention time trends, segmented regression analysis demonstrated a statistically significant increase in compliance with the intervention in the POST phase (odds ratio, 2.78; 95% confidence interval, 1.73-4.49; P < .001). In the PRE and POST groups, cumulative postoperative intravenous opioid use (geometric mean) was 62 and 34 mg oral morphine equivalents, respectively. A segmented regression analysis did not demonstrate a statistically significant difference (P = .38) after adjustment for preintervention time trends.

CONCLUSIONS

Process workflow optimization along with Anesthesia Information Management System-mediated digital quality improvement efforts increased compliance to intraoperative epidural infusion initiation. Adjusted for preintervention time trends, these findings coincided with a statistically insignificant decrease in postoperative opioid use in the postanesthesia care unit during the POST phase.

Continuous intraoperative epidural infusions affect recovery room length of stay and analgesic requirements: a single-center observational study

PURPOSE

Continuous intraoperative epidural analgesia may improve post-operative pain control and decrease opioid requirements. We investigate the effect of epidural infusion initiation before or after arrival in the post-anesthesia care unit on recovery room duration and post-operative opioid use.

METHODS

We performed a retrospective chart review of abdominal, thoracic and orthopedic surgeries where an epidural catheter was placed prior to surgery at the University of Washington Medical Center during a 24 month period.

RESULTS

Patients whose epidural infusions were started prior to PACU arrival (Group 2: n = 540) exhibited a shorter PACU length of stay (p = .004) and were less likely to receive intravenous opioids in the recovery room (34 vs. 48%; p < .001) compared to patients whose infusions were started after surgery (Group 1: n = 374). Although the highest patient-reported pain scores were lower in Group 2 (5.3 vs. 6.0; p = .030), no differences in the pain scores prior to PACU discharge were observed.

CONCLUSION

Intraoperative continuous epidural infusions decrease PACU LOS as discharge criteria for patient-reported NRS pain scores are met earlier.

Ventilation by mask before and after the administration of neuromuscular blockade: a pragmatic non-inferiority trial

Background

Test ventilating prior to administration of neuromuscular blockade (NMB) in order to avoid a cannot intubate-cannot ventilate situation is a classic anesthesia teaching. The primary aim of our study was to show that facemask ventilation (FMV) after NMB was not inferior to FMV prior to NMB with respect to exhaled gas volumes before and after their administration.

Methods

This study was approved by the University of Washington Human Subjects Division (Seattle, Washington, USA). Written informed consent was obtained from all patients. Measurements of tidal volume (Vte) as well as other respiratory parameters during FMV were made for 60 s after induction of anesthesia and again after NMB. Difficult, impossible, inadequate, and dead-space only mask ventilation was graded using published definitions. Difficult intubation was defined as >2 attempts at intubation. The primary outcome was non-inferiority in Vte during both study periods defined as a mean difference of <50 mL. Multivariate analysis was performed to assess for interaction between operator experience, patient risk factors for difficult mask ventilation, exhaled volumes, and use of airway adjuncts.

Results

Two-hundred and ten patients were studied. Overall, FMV improved after NMBD. The mean (SD) V_te in mL/breath increased from 399 (169) to 428 (166) (mean dif. 30 mL, p = 0.001) and the minute ventilation in L/min from 5.6 (2.5) to 6.3 (2.5) (mean dif. 0.6, p < 0.001). No patient who was difficult to ventilate after induction became impossible after NMB.

Discussion

In patients at risk for or judged to be a difficult FMV by clinical grading scales, tidal volumes improved after administration of NMBDs. None of these patients exhibited a decline in ventilation or became impossible to ventilate after NMBDs. Several limitations are noted, including the use of hand-delivered breaths and inability to account for time-related changes in ventilation conditions independent of NMBDs.

Conclusion

We conclude that FMV is no worse after NMB than before and is likely to improve airway conditions.

Trial Registration

ClinicalTrials.gov Identifier: NCT02237443. Registered August 28, 2014

Electronic supplementary material

The online version of this article (doi:10.1186/s12871-015-0111-z) contains supplementary material, which is available to authorized users.

Modulation of P-glycoprotein at the Human Blood-Brain Barrier by Quinidine or Rifampin Treatment: A Positron Emission Tomography Imaging Study

Permeability-glycoprotein (P-glycoprotein, P-gp), an efflux transporter at the human blood-brain barrier (BBB), is a significant obstacle to central nervous system (CNS) delivery of P-gp substrate drugs. Using positron emission tomography imaging, we investigated P-gp modulation at the human BBB by an approved P-gp inhibitor, quinidine, or the P-gp inducer, rifampin. Cerebral blood flow (CBF) and BBB P-gp activity were respectively measured by administration of (15)O-water followed by (11)C-verapamil. In a crossover design, healthy volunteers received quinidine and 11-29 days of rifampin treatment during different study periods. CBF and P-gp activity was measured in the absence (control; prior to quinidine treatment) and presence of P-gp modulation. At clinically relevant quinidine plasma concentrations, P-gp inhibition resulted in a 60% increase in (11)C-radioactivity distribution across the human BBB as measured by the brain extraction ratio (ER) of (11)C-radioactivity. Furthermore, the magnitude of BBB P-gp inhibition by quinidine was successfully predicted by a combination of in vitro and macaque data, but not by rat data. Although our findings demonstrated that quinidine did not completely inhibit P-gp at the human BBB, it has the potential to produce clinically significant CNS drug interactions with P-gp substrate drugs that exhibit a narrow therapeutic window and are significantly excluded from the brain by P-gp. Rifampin treatment induced systemic CYP3A metabolism of (11)C-verapamil; however, it reduced the ER by 6%. Therefore, we conclude that rifampin, at its usual clinical dose, cannot be used to induce P-gp at the human BBB to a clinically meaningful extent and is unlikely to cause inadvertent BBB-inductive drug interactions.

Hypoglossal nerve palsy after airway management for general anesthesia: an analysis of 69 patients

Isolated hypoglossal nerve palsy (HNP), or neurapraxia, a rare postoperative complication after airway management, causes ipsilateral tongue deviation, dysarthria, and dysphagia. We reviewed the pathophysiological causes of hypoglossal nerve injury and discuss the associated clinical and procedural characteristics of affected patients. Furthermore, we identified procedural factors potentially affecting HNP recovery duration and propose several measures that may reduce the risk of HNP. While HNP can occur after a variety of surgeries, most cases in the literature were reported after orthopedic and otolaryngology operations, typically in males. The diagnosis is frequently missed by the anesthesia care team in the recovery room due to the delayed symptomatic onset and often requires neurology and otolaryngology evaluations to exclude serious etiologies. Signs and symptoms are self-limited, with resolution occurring within 2 months in 50% of patients, and 80% resolving within 4 months. Currently, there are no specific preventive or therapeutic recommendations. We found 69 cases of HNP after procedural airway management reported in the literature from 1926 to 2013.

Randomized clinical trial of interceptive and comprehensive orthodontics

Focusing public insurance programs on interceptive orthodontics (IO) may increase access for low-income children. This report presents outcomes from a randomized clinical trial (RCT) comparing IO with comprehensive orthodontics (CO) in Medicaid patients. One hundred seventy pre-adolescents with Medicaid-eligible malocclusions were randomized to IO (n = 86) followed by observation (OBS) or OBS followed by CO (n = 84). One hundred thirty-four completed the trial. Models at pre-treatment (baseline) and following ≤ 2 years of intervention and 2 years of OBS (48 mos) were scored by calibrated examiners using the Peer Assessment Rating (PAR) and Index of Complexity, Outcome and Need (ICON). Overall outcomes and clinically meaningful categorical ICON data on need/acceptability, complexity, and improvement were compared. At baseline, groups were balanced by age, gender, ethnicity, and PAR/ICON scores. Most were minorities. Most (77%) were rated as difficult-to-very difficult. Scores improved significantly for both groups, but CO more than IO (PAR, 18.6 [95%CI 15.1, 22.1] vs.10.1 [95%CI 6.7, 13.4]; ICON, 44.8 [95% CI 39.7, 49.9] vs. 35.2 [95%CI 29.7, 40.6], respectively). On average, IO is effective at reducing malocclusions in Medicaid patients, but less than CO. (ClinicalTrials.gov number CT00067379).

Circulating TNF alpha receptor levels identify older adults who fail to regain weight after acute weight loss

OBJECTIVE

Some healthy older adults have difficulty regaining weight after acute weight loss, and the reason for this failure to regain weight is unknown. The objective of this study was to determine if elevated leptin or pro-inflammatory cytokine levels are associated with failure to regain weight over two years after an acute weight loss intervention.

DESIGN

Two year prospective study after an acute weight loss intervention.

SETTING

University of Washington Medical Center from 2001-2006.

PARTICIPANTS

Nineteen older (≥ 70 years old) men and women.

MEASUREMENTS

Body weights, health status questionnaire, body composition data, serum leptin, glucose, insulin, C- reactive protein and pro-inflammatory cytokine levels were measured every six months for two years.

RESULTS

Five subjects out of 19 failed to regain weight after two years. The subjects who failed to regain weight after 2 years had higher circulating levels of tumor necrosis factor receptor particle 55 (TNFRp55) at baseline and at 6, 12, 18 and 24 months of follow up compared to subjects who regained weight after 2 years (P = 0.02 ).

CONCLUSION

Five out of 19 older subjects had difficulty regaining weight for up to 2 years following an acute weight loss intervention, and their TNFRp55 levels were persistently higher than in subjects who regained weight. Greater TNF α action, as reflected by higher circulating levels of TNFRp55, could be contributing towards inability of some older persons to regain weight after acute weight loss.

Effects of bronchoconstriction, minute ventilation, and deep inspiration on the composition of exhaled breath condensate

BACKGROUND

Exhaled breath condensate (EBC) is composed of droplets of airway surface liquid (ASL) diluted by water vapor. The goal of this study was to determine if the composition of EBC is affected by changes in airway caliber, minute ventilation, or forceful exhalation, factors that may differ among subjects with asthma in cross-sectional studies.

METHODS

In a group of subjects with asthma, we measured the effects of the following: (1) a series of three deep-inspiration and forceful-exhalation maneuvers; (2) a doubling of minute ventilation; and (3) acute bronchoconstriction induced by methacholine on EBC volume, dilution of ASL, and concentration of cysteinyl leukotrienes (CysLTs).

RESULTS

With the exception of an increase in EBC volume with increased minute ventilation, there were no significant changes in the volume, dilution, or levels of CysLTs in EBC introduced by each of these factors. The CIs surrounding the differences introduced by each factor showed that the maximum systematic errors due to these factors were modest.

CONCLUSIONS

These results indicate that changes in airway caliber, minute ventilation, or breathing pattern among subjects with asthma do not significantly alter the measurements of mediator concentrations in EBC.

Leptin levels recover normally in healthy older adults after acute diet-induced weight loss

OBJECTIVES

Involuntary weight loss affects 20% of community dwelling older adults. The underlying mechanism for this disorder is unknown. Objective is to determine if failure of older persons to regain weight is associated with elevated pro-inflammatory cytokine and leptin levels.

DESIGN

Prospective diet intervention study.

SETTING

University of Washington Medical Center from 2001-2005.

PARTICIPANTS

Twenty-one younger (18-35 years old) and nineteen older (>or= 70 years old) men and women.

INTERVENTION

Each subject was placed for two weeks on a weight-maintaining diet, followed in sequence by 2 weeks of 30% caloric restriction, then 4 weeks of ad libitum food intake.

MEASUREMENTS

Plasma leptin levels, fasting serum pro-inflammatory cytokine levels, and peripheral blood mononuclear cell cytokine levels were measured.

RESULTS

Leptin levels in the two cohorts decreased after caloric restriction and increased after ad-libitum food consumption resumed. Plasma TNF alpha levels were higher in older subjects compared to younger adults. However, there was no association between changes in TNF alpha levels and changes in AUC leptin.

CONCLUSION

Leptin levels in healthy older individuals responded appropriately in a compensatory manner to changes in body weight. These data do not support a cytokine dependent elevation in leptin levels as being responsible for the failure of older adults to regain weight.

Efficacy of a computerized shade selection system in matching the shade of anterior metal-ceramic crowns--a pilot study

OBJECTIVE

The purpose of this study was to determine whether anterior crowns fabricated using a computerized shade selection system (ShadeScan, Cynovad) (experimental procedure) match adjacent teeth better than anterior crowns fabricated using conventional shade prescription and clinical slides (control).

METHOD AND MATERIALS

Five subjects who required a crown to restore a maxillary central incisor were selected. Two metal-ceramic crowns were fabricated for each incisor, 1 using the experimental procedure and 1 using the control method. The shade selection method to be used for the first and second crowns was randomly assigned. The duration of each procedure was recorded. Each restoration was tried-in in a double-blind manner and evaluated for its level of match to adjacent teeth using modified Ryge criteria. Data were analyzed within each subject using descriptive statistics and paired t test (alpha = .05).

RESULTS

In 40% of the cases, both procedures did equally well. In the remaining 60% of the cases the control procedure (two-thirds of the cases) performed better than the experimental procedure (one-third of the cases). Duration of the control procedure was 14.4 +/- 5 minutes, and the experimental procedure was 5.2 +/- 3.3 minutes. A paired t test showed the difference was significant (P = .0045).

CONCLUSION

The level of matching of crowns fabricated with the ShadeScan system was not different from crowns fabricated using the control. However, it took significantly less time to record the shade with the ShadeScan system.

Effect of Aging on the Response of Ghrelin to Acute Weight Loss

OBJECTIVES

To determine whether the failure of the orexigenic hormone ghrelin to increase as it normally does with weight loss contributes to impaired weight recovery in older persons.

DESIGN

Prospective diet intervention study.

SETTING

University of Washington Medical Center from 2001 through 2005.

PARTICIPANTS

Twenty-one younger (18-35) and 18 older (> or =70) men and women.

INTERVENTION

Two weeks of a weight-maintaining diet were followed in sequence by 2 weeks of 30% calorie restriction, then 4 weeks of ad libitum food intake.

MEASUREMENTS

Twenty-four-hour plasma ghrelin levels, dual x-ray absorptiometry scan for body composition, resting energy expenditure, and calorie intakes were measured.

RESULTS

Both younger and older subjects lost weight with calorie restriction and failed to fully regain their baseline weight. The older adults trended toward increasing their calorie intake above their baseline level during the ad libitum period (111+/-66 kcal, P=.11), whereas the younger individuals did not (-236+/-95 kcal, P=.02). There was no statistically significant difference between the two cohorts in 24-hour ghrelin levels before or after calorie restriction. Ghrelin levels in the two cohorts increased equivalently after calorie restriction and decreased after ad libitum food consumption resumed.

CONCLUSION

Ghrelin levels in healthy older individuals respond appropriately in a compensatory manner to changes in body weight and calorie intake.

Bias induced by self-reported smoking on periodontitis-systemic disease associations

Non-causal associations between periodontitis and systemic diseases may be spuriously induced by smoking because of its strong relationship to both. The goal of this study was to evaluate whether adjustment for self-reported smoking removes tobacco-related confounding and eliminated such spurious confounding. Using NHANES III data, we evaluated associations between attachment loss and serum cotinine after adjustment by self-reported number of cigarettes smoked. Cotinine, a metabolite of nicotine, should not be related to attachment loss, if self-reported smoking captures the effect of tobacco on attachment levels. Adjustment for self-reported cigarette smoking did not completely remove the correlation between attachment loss and serum-cotinine level (r = 0.075, n= 1507, p = 0.003). Simulation studies indicated similar results for time-to-event data. These findings demonstrate the difficulty in distinguishing the effects of periodontitis from those of smoking with respect to a smoking-related outcome. Future studies should report results of analyses on separate subcohorts of never-smokers and smokers.

Prevalence of clinical and isolated subclinical cardiovascular disease in older adults with glucose disorders: the Cardiovascular Health Study

OBJECTIVE

Clinical cardiovascular disease (CVD) is highly prevalent among people with diabetes. However, there is little information regarding the prevalence of subclinical CVD and its relation to clinical CVD in diabetes and in the glucose disorders that precede diabetes.

RESEARCH DESIGN AND METHODS

Participants in the Cardiovascular Health Study, aged > or = 65 years (n = 5,888), underwent vascular and metabolic testing. Individuals with known disease in the coronary, cerebral, or peripheral circulations were considered to have clinical disease. Those without any clinical disease in whom CVD was detected by ultrasonography, electrocardiography, or ankle arm index in any of the three vascular beds were considered to have isolated subclinical disease.

RESULTS

Approximately 30% of the cohort had clinical disease, and approximately 60% of the remainder had isolated subclinical disease. In those with normal glucose status, isolated subclinical disease made up most of the total CVD. With increasing glucose severity, the proportion of total CVD that was clinical disease increased; 75% of men and 66% of women with normal fasting glucose status had either clinical or subclinical CVD. Among those with known diabetes, the prevalence was approximately 88% (odds ratio [OR] 2.46 for men and 4.22 for women, P < 0.0001). There were intermediate prevalences and ORs for those with impaired fasting glucose status and newly diagnosed diabetes.

CONCLUSIONS

Isolated subclinical CVD is common among older adults. Glucose disorders are associated with an increased prevalence of total CVD and an increased proportion of clinical disease relative to subclinical disease.

Daytime sleepiness predicts mortality and cardiovascular disease in older adults. The Cardiovascular Health Study Research Group

INTRODUCTION

As part of the baseline examination in the Cardiovascular Health Study, sleep disturbance symptoms including snoring and daytime sleepiness, were assessed as potential risk factors or precipitants of cardiovascular disease (CVD). Because of the association of sleep disturbance with poorer health and the possible associations of sleep apnea with CVD, we hypothesized that those with poorer sleep or daytime sleepiness may be at increased risk of mortality or incident CVD.

SETTING

Participants (n = 5888) were recruited in 1989, with an additional minority cohort recruited in 1993, in four US communities for a cohort study designed to evaluate risk factors for cardiovascular disease.

METHODS

An interview-administered questionnaire regarding health and sleep habits with ongoing ascertainment of total mortality and cardiovascular disease morbidity and mortality, including total CVD morbidity and mortality, incident myocardial infarction, and congestive heart failure.

RESULTS

Daytime sleepiness was the only sleep symptom that was significantly associated with mortality in both men and women. The unadjusted hazard ratio was 2.12 (1.66, 2.72) in women and 1.40 (1.12, 1.73) in men. Men who reported difficulty falling asleep also had an increased mortality rate (HR = 1.43 (1.14, 1.80)) which was not seen in women. The risks were attenuated with adjustment for age but remained significant for daytime sleepiness in women (HR = 1.82 (1.42, 2.34)) and for difficulty falling asleep in men. (HR = 1.29 (1.03, 1.63)). Frequent awakenings, early morning awakening, and snoring were not associated with a significantly increased risk of mortality in these older men and women. Crude event rates were evaluated for total incident cardiovascular morbidity and mortality, incident myocardial infarction, and incident congestive heart failure (CHF). Incident CVD rates were higher in both men and women with daytime sleepiness. The aged adjusted HR was 1.35 (95% CI = 1.03, 1.76) in men and was 1.66 (95% CI = 1.28, 2.16) in women. Incident CVD was not higher in those with any other sleep disturbance including snoring. The risk of CVD events associated with daytime sleepiness was attenuated but remained significant in women after adjustment for age. Incident myocardial infarction (MI) rates were also higher in women with daytime sleepiness but were not significantly higher in men. Incident CHF rates were increased in both men and women with daytime sleepiness. In men, the age adjusted HR was 1.49 (95% CI, 1.12- 1.98) and in women, was 2.21 (95% CI, 1.64-2.98). Women reporting both daytime sleepiness and frequent awakening had a hazard ratio of 2.34 (95% CI, 1.66-3.29) for incident CHF compared with those with daytime sleepiness but without frequent awakening. This interaction was not found in men.

CONCLUSIONS

In this study, daytime sleepiness was the only sleep disturbance symptom that was associated with mortality, incident CVD morbidity and mortality, MI, and CHF. These findings were stronger in women than men, i.e., the associations persisted for mortality, CVD, and CHF in women after adjustment for age and other factors. Thus, a report of daytime sleepiness identifies older adults at increased risk for total and cardiovascular mortality, and is an independent risk factor in women.

Cardiovascular disease in older adults with glucose disorders: comparison of American Diabetes Association criteria for diabetes mellitus with WHO criteria

BACKGROUND

The new fasting American Diabetes Association (ADA) criteria for the diagnosis of diabetes mellitus rely mainly on fasting blood glucose concentrations and use a lower cut-off value for diagnosis than the WHO criteria. We aimed to assess the sensitivity of these criteria for the detection of cardiovascular disease, the main complication of diabetes mellitus in the elderly.

METHODS

We did a cross-sectional and prospective analysis of 4515 participants of the Cardiovascular Health Study, an 8 year longitudinal study designed to identify factors related to the onset and course of cardiovascular disease in adults aged at least 65 years. We calculated the prevalence and incidence of cardiovascular disease for the ADA and WHO criteria.

FINDINGS

There was a higher prevalence of cardiovascular disease among individuals with impaired glucose or newly diagnosed diabetes by both criteria than among those with normal glucose concentrations. However, because fewer individuals had abnormal glucose states by the fasting ADA criteria (22.3%) than by the WHO criteria (46.8%), the number of cases of cardiovascular disease attributable to abnormal glucose states was a third of that attributable by the WHO criteria (53 vs 159 cases per 10,000). For the two sets of criteria, the relative risk for incident cardiovascular disease (mean follow-up 5.9 years) was higher in individuals with impaired glucose and newly diagnosed diabetes than in those with normal glucose. Individuals classified as normal by the fasting ADA criteria had a higher absolute number of incident events (455 of 581 events) than those classified as normal by the WHO criteria (269 of 581 events). Fasting ADA criteria were therefore less sensitive than the WHO criteria for predicting cardiovascular disease among individuals with abnormal glucose (sensitivity, 28% vs 54%).

INTERPRETATION

The new fasting ADA criteria seem to be less predictive than the WHO criteria for the burden of cardiovascular disease associated with abnormal glucose in the elderly.