clinical forum – ProCRNA

Patient Experience Affects Outcome

By Thomas Davis, CRNA, MAE Follow @procrnatom
Author, Leader Reader 1, Authentic Lessons in Leadership

Patient satisfaction, patient rights and the patient’s experience are factors that drive healthcare reimbursement across the United States. Those of us who have been healthcare providers for decades can remember the “good old days” when patients had few rights and little thought was given to patient experience. After all, we were trained professionals and knew what was best for our patients. The pendulum has now traveled to its opposite end of the arc and medical care is directed not only to curing disease but also creating a positive experience. The new model of healthcare delivery begs the question, “Does today’s patient-centered healthcare delivery system have any benefit beyond making the patient feel better about the experience?” The answer is a resounding YES. In the words of British physician Sir Sam Everington, “…it’s not about what is the matter with the patient, but what matters to the patient.”

In the present atmosphere of evidence based medicine, studies are ongoing and publications are appearing to support the concept that both safety and ultimate outcomes are tied to the patient’s overall experience which drives their satisfaction. The Agency for Healthcare Research and Quality (AHRQ) correlated patient satisfaction with outcome and made the following observations about the snowball effect that satisfaction has on outcome.
• Effective communication is essential for patients to have a positive experience.
• A good patient experience is related to a lower risk for malpractice claims.
• Patients who perceive the experience as positive are more likely to comply with treatment and achieve better results
• Efforts to improve the patient’s experience also result in a higher level of employee satisfaction and reduced staff turnover.
• The quality of the relationship between the patient and provider is a major predictor of loyalty to the provider and the treatment plan.

Articles related to improving the patient’s healthcare experience are weighted heavily toward improving communication between the physician and the patient. However, the overall experience of the patient depends on much more than the few minutes that they actually talk with the physician. In a system that is truly focused not only on quality care but also patient experience, every person in the organization is important. Patients don’t care how talented the doctors or nurses are if they must struggle to gain access to the system or sense a lack of respect. The Cleveland Clinic addressed the issue by implementing the tagline WE ARE ALL CAREGIVERS and applying it to ALL employees at all levels.

Regardless of your location or job description, when you interact with a patient, you are contributing to their experience. Along with the competence that you bring to the job, your attitude is important. When patients think back on their hospital experience, they often have a vivid memory of attitudes and the perception of being valued whereas the memory of the actual treatment received may be blurred.

Patients entering the hospital know that not all conditions and diseases have a happy outcome. A terminal condition will take its course, however, both the patient and family can feel valued and maintain their dignity based on their perception of respect and a sincere desire by the healthcare team to ease their pain. Here are some ways to create a positive experience even in the most difficult situations.
• Set the tone by showing up each day with a smile and positive attitude.
• Make eye contact and engage in conversation where appropriate.
• Always introduce yourself and let the patient and family know what you are doing before starting a treatment or giving a drug.
• Uncover the patient/family personal needs. Discover what is important to them beyond the medical care and make accommodations if possible.
• Take time to listen. Attentive listening validates the patient and their concerns.
• Resolve everything that you can immediately and on the spot. If there is something that you are qualified to address, don’t delay by seeking permission.
• Never settle for “OK.” Challenge yourself to make it perfect.

Patient-centered healthcare delivery has clear benefits beyond making the patient better. By extending the focus of patient-centered care to the family, we created the ultimate win-win scenario. Patients are more satisfied and have better outcomes. The work environment becomes more of a ‘happy place’ and staff engagement improves. Patient loyalty develops and patients walk away with the commitment that there is no other place where they would seek care.

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Flight Path to Patient Safety

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By Thomas Davis, CRNA

Flight Path to Patient Safety

With reimbursement and therefore job security tied to patient safety, it is incumbent on healthcare workers to become actively involved with the process of making healthcare safe for our patients. Since the publication of “To Err is Human” in 1999, much attention has been given to patient safety, however, statistics still show that your luggage is safer in the airline system than your grandmother is in your local hospital. What can we learn from the Airline industry?

The 1970s were a particularly tragic time for commercial aviation. In 1977 the collision of two 747 airliners on the runway in Tenerife killing 583 people followed by the famous airline crash in Portland in 1978, both due to poor communication, triggered a change in the way that the airlines conduct their business. Mandatory training and implementation of Crew Resource Management changed the way flight crew employees interact with one another and ushered the way to a 5 year period with zero adverse incidents. How did they do it?

Crew Resource Management is a set of training procedures for use in environments where human error can potentially have devastating effects. The focus of CRM is on interpersonal communication, leadership and decision making. Our patients deserve the same focus on healthcare safety that they would receive as passengers on an airline. Here are some recommendations for taking CRM from the cockpit to the hospital.

All humans are fallible and susceptible to error…period. The greatest disservice that we can do to our patients is to believe that because we have special knowledge or skills, we are infallible and cannot make mistakes. The airline crashes of the 1970s confirmed that the senior pilot did not have all the answers. Not only can we make mistakes but others around us can do the same. It is only when we acknowledge our fallibility, and engage with our team in vigilance, that patient safety can be ensured. Regardless of your position on the team, know that you can make a mistake, and also know that you can fend off the consequences of mistakes that others are about to make.

All potential problems must be openly communicated in a positive manner that supports our coworkers. In an environment focused on patient safety, sharing your concern with other team members should be welcomed and encouraged. In addition, you must welcome and solicit the concerns and observations of others. As healthcare professionals, we tend to get defensive when a co-worker points out a lapse in our delivery of a treatment. With a focus on collaboration, we set the stage for patient safety as we reply, “Thank you,” rather than feeling threatened. Your reply sets a tone for other team members to welcome feedback.

All team members must be respected and heard. Your knowledge and skills are respected. Your eyes and ears are open and your judgment is solid. Even so, remember that magicians make a living based on creating false perceptions. What you see and believe may not be true. The TV program “Who wants to be a Millionaire” offers the contestants lifelines when they do not know the answer. When statistics are reviewed “poll the audience” has the highest percentage of correct answers whereas “ask an expert” lags far behind in accuracy. When the goal is patient safety, the collective wisdom of the group is more likely to be correct than the opinion of the expert. Openly solicit and welcome the opinions of others regardless of their position on the team. Often, we can learn as much from people with lower status as we can from the recognized team leaders.

Problems must be anticipated and contingency plans must be in place. In his book Why Hospitals should fly: The Ultimate Flight Plan to Patient Safety and Quality, author John Nance recommends that healthcare workers view every patient as having a 50:50 chance of being harmed. With a team committed to anticipating, detecting and preventing harm, the patient is best protected. The team time out prior to a procedure is an opportunity for each member of the team to identify potential risk and offer a plan to prevent harm. All too often the time out is not given the respect that it deserves and potential risk is not adequately discussed among the team members. As a patient advocate, use the time out as an opportunity to focus the team on patient safety.

Reduce distractions at critical times. Regulating the airline industry, the FAA requires the observation of “sterile cockpit” during the critical times surrounding takeoff and landing. During this time, pilots must refrain from non-essential activities and conversation so that they can focus on the critical task at hand. Stories of lapses in communication among distracted healthcare workers abound. Distraction by idle conversation or use of social media during high risk times of patient care increases the risk of patient harm. In the hospital setting it is not unusual for side bar conversations to take place while checklists are being read or timeouts are being done. As patient advocates, we must all share responsibility for the focus of the team to be on the patient at all times.

Value every member of the team. On a recent flight, our boarding was delayed by an hour awaiting the arrival of a crew of flight attendants. Once we were on board, the pilot made an announcement. He apologized for the hour delay and said that we would be delayed a few more minutes…collective groan. He went on to say that the flight crew would be greater than 8 hours without food by the time we arrived at our destination. He announced that he had ordered dinner for the flight crew and that we would be under way once the food arrived…collective cheer from the passengers. By looking out for the crew, the pilots believed that the passengers would be better served. The lesson here is obvious. All too often we focus on our own needs and are not sensitive to the needs of others on our team.

As healthcare workers, our best opportunity for ensuring safety for our patients is to follow the example set by the airline industry and focus on communication and collaboration. Hospitals across the nation hire experts to provide training on patient safety and yet the statistics often do not improve. When training is an academic exercise, nothing changes. It is only by applying the knowledge that improvement is made. Use the lessons borrowed from the airline industry to ensure that your patients are safer your luggage.

Thomas Davis, CRNA is an experienced Chief CRNA, author, speaker and teambuilding coach.

The Importance of Patient Handoffs

At a time when patient safety is being linked to reimbursement, handoff of care from one provider/team to another has been identified as a time of vulnerability for the patient. The Joint Commission has stated that communication failure during this critical time may be the cause of up to 30% of sentinel events in the peri-operative period. To promote safety, The Joint Commission has identified patient handover as a top 5 initiative. Closed claims studies have identified a link between handover of care and negative outcomes based on the incomplete transfer of information.

A prospective study by Hudson et al published in the J Cardiothorac Vasc Anesth. (J Cardiothorac Vasc Anesth. 2015 Feb;29(1):11-6. doi: 10.1053/j.jvca.2014.05.018. Epub 2014 Nov 24.) explored the link between patient handover and outcome looking specifically at patients receiving cardiac surgery. They documented that errors/omissions in transferring patient information from one team to the next resulted in harm to the patient. In their study, the authors found that when was transferred from one team to another during cardiac surgery there was a 43% greater risk of in-hospital mortality and a 27% greater risk of morbidity.

Regardless of the type of case, transfer of information from one team to another both in the operating room and in the PACU is essential for patient safety. Intraoperative team changes should be kept to a minimum and anesthesia providers must resist production pressure and give a full and complete report when leaving patients in PACU or ICU.

Click here to review an abstract of the article.

Clinical Topic: Obstructive Sleep Apnea and Outpatient Surgery

The evolving changes in the delivery of Healthcare in general and anesthsia in particular has created an emphasis on patient safety. With the push for more cost effective delivery of healthcare, more procedures are being done on an outpatient basis on sicker patients. Combining the new economics with the obesity epidemic in America has created the scenario where an increasing number of patients with Obstructive Sleep Apnea are presenting for outpatient surgery. As anesthetists, we are tasked with providing safe care and answering the question of who is or is not a candidate for outpatient surgery.

In 2006 the ASA published guidelines for the perioperative management of patients with OSA. Although the guidelines were good at the time, the Society for Ambulatory Anesthesia felt that the ASA guidelines were due for review and updating, did a comprehenhive review, and published their findings.

An article by Joshi et al published in Anesth Analg 2012 (Society for Ambulatory Anesthesia Consensus Statement on Preoperative Selection of Adult Patients with Obstructive Sleep Apnea Scheduled for Ambulatory Surgery) reviewed the ASA guidelines. They went on to note that the Society for Ambulatory Anesthesia task force on practice guidelines developed a consensus statement for the selection of patients with OSA scheduled for ambulatory surgery. Some key points include:

Patients with a known diagnosis of OSA and optimized comorbid medical conditions can be considered for ambulatory surgery, if they are able to use a continuous positive airway pressure device in the postoperative period.
Patients with a presumed diagnosis of OSA, based on screening tools such as the STOP–Bang questionnaire, and with optimized comorbid conditions, can be considered for ambulatory surgery, if postoperative pain can be managed predominantly with nonopioid analgesic techniques.
On the other hand, OSA patients with nonoptimized comorbid medical conditions may not be good candidates for ambulatory surgery.

Click here for an abstract of the Joshi article.

As anesthetists, how do we assess patients and how do we determine who is at risk? The Society for Ambulatory Anesthesia recommends the use of the STOP-Bang assessment tool. The questionnaire asks 8 basic questions and gives the anesthtist valuable information about the OSA risk during the preoperative evaluation.

Click here for the STOP-Bang tool in a PDF format which can be downloaded and printed.

Combining a good physical evaluation with the STOP-Bang assessment will help identify those at risk and enable the anesthetist to make an informed decision regarding who should or should not receive outpatient care.

New Product: Handwashing Bracelet Improves Handwashing Compliance

According to the CDC, nearly 2 million people get infections while in US hospitals annually and around 100,000 of those people die. Hand washing is one of the most important and easy ways of reducing the transfer of pathogens from person to person.

An Article by By Ruth LeTexier, RN, BSN, PHN (Preventing Infection Through Handwashing) makes the following points:

In the healthcare setting, handwashing is often cited as the primary weapon in the infection control arsenal. The purpose of handwashing in the healthcare setting is microbial reduction in an effort to decrease the risk of nosocomial infections.
The CDC has identified handwashing as the single most important means of preventing the spread of infection.5 The premise of the handwashing CDC guideline is infection control. The CDC recommendations for handwashing are as follows:

Handwashing Indications
In the absence of a true emergency, personnel should always wash their hands:

1) Before performing invasive procedures (Category I).

2) Before taking care of particularly susceptible patients, such as those who are severely immunocompromised and newborns (Category I).

3) Before and after touching wounds, whether surgical, traumatic, or associated with an invasive device (Category I).

4) After situations during which microbial contamination of hands is likely to occur, especially those involving contact with mucous membranes, blood or body fluids, and secretions or excretions (Category I).

5) After touching inanimate sources that are likely to be contaminated with virulent or epidemiologically important microorganisms; these sources include urine-measuring devices or secretion collecting apparatuses (Category I).

6) After taking care of an infected patient or one who is likely to be colonized with microorganisms of special clinical or epidemiologic significance, for example multiple-resistant bacteria (Category I).

7) Between contacts with different patients in high-risk units (Category I).

An article by Cory Schultz (A new wristband measures hand washing compliance by healthcare providers) describes a new product which improves handwashing compliance:

The creators of IntelligentM have designed a bracelet/wristband that vibrates when the wearer has scrubbed their hands for a sufficient length of time.
An accelerometer can detect how long an employee spends washing their hands; the wristband buzzes once if the procedure is done correctly and three times if it’s not.

Click here to read about the new handwashing bracelet and how it can improve compliance with CMS and CDC standards.

Clinical topic: Do Drug Tests for Cocaine Improve Outcome?

Living and working in a society where substance abuse is not uncommon places the Anesthetist in a position where they may administer anesthesia to a patient who either is high or has recently used illegal drugs. Cocaine abuse has been associated with acute onset of hemodynamic changes and end organ dysfunction. This scenario begs the question as to whether or not we should routinely require a cocaine drug screen on preoperative patients.

In an original work by a CRNA and published in the AANA Journal (August 2012) Baxter et al explored the usefulness of Cocaine drug screens to predict safe delivery of general anesthesia. Three hundred subjects were included in the study with half testing cocaine positive. Baseline data were obtained and vital signs as well as complications were followed throughout the procedure.

From the Authors:

“Our study suports the argument that cocaine-related diseases as well as deaths are due less to overdose than they are the pathophysiology that develops from long-term use.”
“This suggests that the risk of anesthesia-related complications or death is unlikely to change based solely on drug screen findings.”
“Recent cocaine use alont may not necessarily be a contraindication to surgery if the patient is asymptomatic and has normal vital signs, ECG and review of systems.”

The authors found no benefit from routine Cocaine drug screening. Baseline vital signs and coexisting disease were more important factors than the presence of a positive Cocaine drug screen.

Click here to read the abstract published in Pubmed or click here to review the original article published in the AANA journal

The AANA foundation provides financial support for original CRNA research. Please support the AANA foundation with annual gift giving. Click here to visit the AANA foundation web site.

Clinical Topic: Effects of Cervical Collar on LMA seal

Supraglottic airway devices have proven to be an acceptable alternative to endotracheal intubation and easier to insert by the less experienced provider. As a result, paramedics and other first line responders are using the laryngeal mask airway more frequently to ensure an open airway while en route to definitive care. In addition to inserting the LMA, a cervical collar is commonly placed on the injured person. It is known that movement of the head and neck can affect the cuff pressure of the LMA, however, the effect of a cervical collar on the cuff pressure is unknown.

In a study by Mann, V et al published in Anaesthesia, 2012 (The effect of a cervical collar on the seal pressure of the LMA Supreme™: a prospective, crossover trial.) the authors examined the effect of a cervical collar on the cuff pressures within the LMA. Fifty patients were included in the study. After successful placement of the LMA was confirmed, cuff pressure measurements were made with the head neutral and extended both with and without the cervical collar.

The authors found that placing the cervical collar does not reduce the LMA cuff pressure during extension of the head and, in fact, found that the cervical collar improved the LMA seal. The authors concluded that the application of the cervical collar prevents the LMA from losing seal pressure if the head is extended and recommend the use of the cervical collar after placement of the LMA in all pre-hospital patients.

Click here to review an abstract of the original work.

Clinical Topic: Who is at risk for post-discharge PONV?

Those who read the anesthesia literature know that post-operative nausea and vomiting is a common topic. A colleague once said “if I have to read another puke article, I’m going to puke”. To the anesthetist, post op nausea is a concern. To the patient experiencing nausea along with post-op pain it is a terrible experience.

A recent article by Apfel et al (who is at risk for postdischarge nausea and vomiting after ambulatory surgery?) seeks to identify those most at risk for continued problems after discharge from a day surgery unit. “About one in four patients suffers from postoperative nausea and vomiting. Fortunately, risk scores have been developed to better manage this outcome in hospitalized patients, but there is currently no risk score for postdischarge nausea and vomiting (PDNV) in ambulatory surgical patients.”

The study by Apfel et al demonstrated a 37.1% incidence of post discharge nausea and vomiting (PDNV) with about 5% having severe vomiting. If extrapolated to the general outpatient population, about 4.3 million patients experience some form of PDNV. In this study, anti-emetic medications given in the recovery area did not have sufficient potency or duration to last into the post-discharge phase

The study went on to indentify risk factors for developing PDNV. They include:

female gender
age less than 50
history of PONV
PACU administered opiates
experience of nausea in the PACU

The presence of 0, 1, 2, 3, 4, or 5 of these factors was associated with 10%, 20%, 30%, 50%, 60%, and 80% respectively.

The author concludes “PDNV affects a substantial number of patients after ambulatory surgery. We developed and validated a simplified risk score to identify patients who would benefit from long-acting prophylactic antiemetics at discharge from the ambulatory care center.”

Click here to read an abstract of the original article

Clinical Topic: Systemic Lidocaine Improves Recovery

As anesthetists we face the challenge of providing a safe, comfortable and speedy recovery to our patients. Narcotics improve analgesia at the expense of nausea and speed of recovery. The use of non-opioid drugs to supplement and reduce the amout of narcotic administered should, in theory, provide a comfortable and speedy recovery. In this study, the use of systeminc lidocaine was evaluated.

A study published in Anesth Analg 2012, 115(2) 262-7 by De Oliveira GS Jr et al, (Systemic lidocaine to improve postoperative quality of recovery after ambulatory laparoscopic surgery.) examined the use of systemic lidocaine in 63 female patients undergoing laparoscopic surgery. Following induction, patients were given a loading dose of lidocaine 1.5 mg/kg followed by an infusion of 2mg/kg/hour for the duration of the case.

Assessment following surgery found that those receiving lidocaine had a decided improvement in the quality of postoperative recovery. Patients in the Lidocaine group had higher scores in physical independence and comfort with a 23% improvement in global recovery scores. There was significantly less opioid used in the lidocaine group. Also, those receiving lidocaine had a 26 min reduction in time to hospital discharge. Overall, in an outpatient setting, systemic lidocaine offered a definite advantage.

Click here to read an abstract of the original article.

A similar study by US Navy CRNAs (Grady et al, AANA Journal August 1012) followed a similar protocol. Although not statistically significant, the authors found that those receiving the intravenous lidocaine reported greater satisfaction and comfort than those in the control group. (P=0.08) Possibly with a larger N this study would also have reached statistical significance

Click here to read the article in the AANA Journal (page 282)

Clinical Topic: Predictors of Postoperative Sort Throat

As Anesthetists, we are known as airway experts. Both Surgeons and patients trust our skills at maintaining an open airway to ensure patient safety. At the end of the case, we wake our patients and take them to recovery with an open airway and then move on to the next patient. In the midst of production pressure we lose sight of the minor things that cause discomfort to our patients. Postoperative sore throat is an example.

Studies that assess patient concerns for surgery have found postoperative sore throat to be one of the top 10 concerns. The reported incidence varies but several studies find it to be around 40%. The problem is usually most severe in the first 6 hours after surgery and is common enough that many feel it is a natural consequence of general anesthesia.

In a study by Jaensson, Gupta, and Nilsson published in the August 2012 AANA Journal research edition, (Risk Factors for Development of Postoperative Sore Throat and Hoarsness After Endotracheal intubation in Women: A Secondary Analysis) the authors gathered data to determine risk factors for development of postoperative sore throat. Both patient demographic data and airway management techniques were reviewed.

The authors found that general anesthesia with endotracheal intubation can cause minor sore throat which is more common in the female population. In most cases, symptoms are minor and resolve spontaneously, however in some cases sever sore throat can cause prolonged discomfort to the patient. The authors found 3 risk factors for development of sore throat in women:

Age greater than 60
Use of a throat pack
Endotracheal tube size (#7 significantly more sore throats than #6)

The authors speculated that higher mallampati scores, therefore more difficult intubations, would increase the incidence of sore throat but that was not found to be true in this study. The authors were surprised to find that cuff pressures below 20 were associated with an increased incidence of hoarsness.

The authors noted that the reason for the higher incidence of sore throat in women is unclear and requires further study.

Click here to read the original article published in the AANA Journal

Clinical Topic: Effects of Anesthesia in Children

Anesthetists in locations ranging from community hospitals to large Children’s hospitals are frequently given the opportunity to anesthtize children of all ages. Three recent studies were recently reviewed by Karen Blum in Anesthesiology News (JANUARY 2013 | VOLUME: 39:1) looking at the effects of anesthesia on children.

Researchers presenting studies at the 2012 International Assembly for Pediatric Anesthesia found that children exposed to general anesthesia before age 1 were 4.5 times more likely to develop a learning disability. From Anesthesiology News:

“We have kids who are born otherwise healthy who come in for minor procedures, and we like to think they would wind up all right, But after accounting for variables including race, sex, maternal and paternal education, domestic living arrangements and afterschool activities, the only significant predictor of formally diagnosed learning disability was previous exposure to GA.”

The authors recommend looking at alternative methods of anesthesia such as propofol or regional anesthesia to reduce the exposure of small children to general anesthesia.

A second article in the series noted that children who have surgery tend to return for more surgery increasing the number of exposures to general anesthesia

The final article in the trilogy noted that children receiving Sevoflurane anesthesia had significantly higher lactate levels in the brain which increases brain activity and increases the likelyhood of anxiety or delirium upon emergence from anesthesia.

The review of the three articles was brief and well written in the posting by Karen Blum.

Click here to view the original article as published in Anesthesiology News

Clinical topic: Should Flu Shots Be Required?

As anesthetists we are on the front line of patient care. We are trusted with the responsibility to promote wellness and “first, do no harm”. Recently, we have been required to set aside our personal rights in order to enforce a greater good for our patient
population and the question has emerged “should healthcare workers be required to take a flu shot?”

What is driving the push for flu shots? The CDC estimates the number of yearly deaths from flu to be in the thousands; in a bad year like this one, it’s likely to be in the tens of thousands. Older and more debilitated patients are at increased risk of death related to the flu. Since hospitalized patients often encounter up to 50 different healthcare workers per day, it is important that all workers receive the shot.

In an effort to protect patients the Joint Commission and Medicare both require hospitals to have a program for flu vaccinations for their workers and require hospitals to report compliance data. The incentive for the hospital to require vaccination is obvious. The desire for increased compliance has pushed some hospitals to fire workers who refuse to get the vaccination.

In an excellent article by Bob Wachter, MD published in the blog Healthcare Finance News (Making clinicians get flu shots: More important than simply preventing
the flu) the author makes the case for requiring flu shots for ALL healthcare workers. In the blog, the author reviews reasons why workers object to receiving the shot and goes on to describe the advantage to both the patient population and the overall culture of the
institution.

The Wachter blog refers to the
Checklist Manifesto which lists common elements of professionalism to include:

Selflessness,
Patient’s expectation of skill
Patient’s expectation of trustworthiness.

The author suggests that discipline be added to the list. Discipline involves doing the
right thing for the patient regardless of our personal rights. Discipline within the organization transcends the “favored status” that some Doctors and Nurses claim for themselves. The recent push for hand washing is an example of how corporate culture can be changed when care is truly focused on what is best for the patient.

The bottom line is that in a patient centered institution, there are very few valid reasons for refusing the vaccination other than a documented allergy.

Click here to read the blog by Dr Wachter and use the comments box below to offer your opinions.

Clinical Topic: Cerebral O2 Saturation and Cognitive Dysfunction

Postoperative cognitive dysfunction (POCD) is a common complication after major surgery with general anaesthesia in the elderly. Due to the increase of average life expectancy, an increasing number of elderly patients undergo surgery. Following surgery, elderly patients may exhibit cognitive changes.

Anesthesia researchers have speculated that single lung ventilation places an elderly patient at increased risk for reduced cerebral oxygenation and also speculate that reduced cerebral oxygenation correlates with postoperative cognitive dysfunction. Two recent studies have addressed the issues described above.

In the first study by Tang L, et al (Br J Anaesth. 2012 Apr;108(4):623-9. doi: 10.1093/bja/aer501. Epub 2012 Feb 5.) titled “Reduced cerebral oxygen saturation during thoracic surgery predicts early postoperative cognitive dysfunction.” studied seventy-six patients undergoing thoracic surgery with single-lung ventilation (SLV) of an expected duration of >45 min were enrolled. Monitoring consisted of standard clinical parameters and absolute oximetry (S(ct)O(2)). The Mini-Mental State Exam (MMSE) test was used to assess cognitive function before operation and at 3 and 24 h after operation. In this study, the authors found that postoperative cognitive dysfunction correlated with reduced cerebral oxygenation during surgery

Click here to read the abstract of the original work.

A similar study by Suehiro K. et al found similar results. The study titled “Duration of cerebral desaturation time during single-lung ventilation correlates with mini mental state examination score.” published in J Anesth. 2011 Jun;25(3):345-9. doi: 10.1007/s00540-011-1136-1. Epub 2011 Apr 12. looked at “Sixty-nine patients , each of whom received combined thoracic epidural and general anesthesia. rSO(2) was measured using INVOS 5100 (Somanetics, Troy, MI, USA) before anesthesia (baseline value) and until SLV was completed. Patient cognitive function was assessed using the mini mental state examination (MMSE) on the day before surgery (baseline) and then repeated 4 days after surgery. The patients were classified into two groups: with (desaturation group, group D) and without (nondesaturation group, group N) cerebral desaturation during SLV. Cerebral desaturation was defined as a reduction of rSO(2) during SLV less than 80% of the baseline value.” They found that the duration of cerebral desaturation correlated with postoperative cognitive dysfunction.

Click here to read the abstract of the original work

Cerebral oxymetry is becoming increasingly available and should be considered for the elderly patient scheduled for one lung ventilaion.

Clinical topic: The Preanesthetic Set-up

Ensuring that the necessary equipment is present and in working condition is foundational in providing safe anesthetic care to each patient and is a standard of care to which we are held. Patients expect their anesthetist to be properly prepared for each and every case. The following comes from the Anesthesia Patient Safety Foundaton:

“While chatting with a patient about to undergo a laparoscopic cholecystectomy, you administer an induction dose of propofol and an intubating dose of vecuronium. The patient loses consciousness and spontaneous respiration ceases. You adjust the mask on the patient’s face to establish a secure fit and squeeze the reservoir bag, only to find that you are unable to deliver a positive pressure breath. A quick visual inspection of the breathing circuit does not reveal the cause of the problem. Can you reliably ventilate this patient before he becomes hypoxic? Is an alternative method of ventilation readily available and functioning? Is there a reliable source of oxygen? Furthermore, you are using a relatively new anesthesia machine that performs an automated checkout procedure. What functions of the anesthesia machine did the automated checkout actually evaluate? Did you perform a thorough check of the machine before use that could have detected the source of this problem?”

An article by Samuel Demaria, Jr., MD published in Anesthesia/Analgesia in 2011 titled Missed Steps in the Preanesthetic Set-Up discusses common steps that are omitted in the set-up process and offers a revised set-up procedure with the following steps being essential on every case:

Manual ventilation device
Full machine checkout done
Adequate suction
Emergency airway devices (endotracheal tube, laryngeal mask airway)
Emergency drugs
Working IV
ASA monitors

The study found that The most frequently omitted step was the availability of a manual resuscitation device. Another notable finding was that rooms with 5 or more cases scheduled had a higher incidence of missed steps when compared with rooms with less than 5 cases.

Click here to read the original article and review the guidelines.

The Anesthesia Patient Safety Foundation is committed to ensuring a safe anesthetic for every patient. In the APSF newsletter Spring 2008, Jeffrey M. Feldman, MD, MSE presented New Guidelines Available for Pre-Anesthesia Checkout.

Click here to read the article as published in the APSF newsletter.

“Do no harm” is one of the foundational tenets of healthcare and patients (and their lawyers) expect anesthesia providers to be prepared for each and every case. Review the articles and guidelines above and return to procrna.com to leave a comment.

Clinical Topic: Fluid optimization improves outcome

The clinical anesthetist is frequently challenged with the critically ill patient presenting for non-cardiac surgery. Often, they are in a weakened condition with very little physiologic reserve. It is essential that fluid administration is goal directed to optimize outcome. In this patient population, hypovolemia will lead to hypotension and related complications. However, excessive fluid administration will lead to heart failure. Therefore, fluid optimization is essential in the critically ill patient.

An essay published by the Edwards Company “Using Fluid Optimization to Improve Hemodynamics : FloTrac Sensor” makes the following statement:

Successful fluid optimization has been shown in numerous clinical studies to lead to improved patient outcomes, including reduced morbidity and shorter hospital stays
The studies are typically based on the physiological principles outlined by the Frank-Starling curve, which states that an increase in preload or volume will lead to cardiac flow-related improvement (e.g., better stroke volume) up to a certain point, after which the “law of diminishing returns” applies.

The essay goes on to state that there are 3 ways to assess fluid status:

Stroke Volume Variation (SVV): For control-ventilated patients, SVV has been proven to be a highlysensitive and specific indicator for preload responsiveness. As a dynamic parameter, SVV has the advantage of predicting whether a patient will benefit from volume before the fluid is given.
Passive Leg Raising (PLR): In situations where it is not possible to use SVV (i.e., during arrhythmias, when patients are not on control-mode of ventilation, or in patients at risk of complications from fluid loading), simply raising the legs has been proven clinically to act like a “self volume challenge” to indicate the patient’s status on the Frank-Starling curve. If the patient is fluid-responsive, SV will increase substantially.
SV Fluid Challenge: In the rare case when neither SVV nor PLR is feasible, the FloTrac system provides a highly efficient method for assessing fluid responsiveness via a standard fluid challenge. The administration of a small volume of fluid (e.g., 250-500 mL) and observance of the corresponding change in SV and/or CO can indicate whether further volume will improve cardiac performance.

Click here to read the essay

Maxime Cannesson MD, University of California, Irvine has published a full lecture complete with slides detailing the importance of goal directed fluid therapy during the intraoperative period. The lecture may be viewed on Youtube and will give the viewer a foundational understanding of optimizing fluid therapy. Click here to view the video.

To assist the anesthetist with goal directed fluid therapy, the Edwards Lifesciences Corporation has introduced the FloTrac Sensor and Vigileo monitor to clinical practice. These devices help the anesthetist to evaluate the patient’s fluid status with respect to the Frank Starling curve and make appropriate goal directed decisions with relation to fluid administration

Click here to go to the Edwards web site and learn about the FloTrac sensor and Vigileo monitor.

PROCRNA.COM would like to hear from anesthetists with experience using the Vigileo monitor. Please read the articles, view the video and return to share your comments with your colleagues.

Clinical Topic: Bis and Postoperative Cognitive Dysfunction

As anesthetists, we pride ourselves in our vigilance and our ability to maintain hemodynamic stability during difficult surgical situations. However, for the patient, the surgical experience is just one point in time in the continuum of life. They recover, leave the hospital and continue with life. The ability of an elderly patient to participate in the activities of daily living can be impaired by postoperative cognitive dysfunction.

The risk of postoperative cognitive dysfunction in the elderly was documented by JT Moller MD et al in an article published in The Lancet (Long-term postoperative cognitive dysfunction in the elderly: ISPOCD1 study, The Lancet, Volume 351, Issue 9106, Pages 857 – 861, 21 March 1998) The authors speculated that hypotension and hypoxemia might be correlated to cognitive dysfunction and state the following findings:

Postoperative cognitive dysfunction was present in 266 (25·8% [95% CI 23·1—28·5]) of patients 1 week after surgery and in 94 (9·9% [8·1—12·0]) 3 months after surgery, compared with 3·4% and 2·8%, respectively, of UK controls (p<0·0001 and p=0·0037, respectively). Increasing age and duration of anaesthesia, little education, a second operation, postoperative infections, and respiratory complications were risk factors for early postoperative cognitive dysfunction, but only age was a risk factor for late postoperative cognitive dysfunction. Hypoxaemia and hypotension were not significant risk factors at any time.

Click here for an abstract of the original article

A study by MT Chan et al (BIS-guided Anesthesia Decreases Postoperative Delirium and Cognitive Decline, PMID:23027226 [PubMed – as supplied by publisher]) utilized the BIS monitor to guide the amount of anesthesia administered and to correlate depth of anesthesia to postoperative cognitive dysfunction. In this study the BIS group had anesthesia adjusted to maintain a BIS level between 40-60. The control group had anesthesia administered based on clinical signs.

Based on their findings, the authors concluded:

BIS-guided anesthesia reduced anesthetic exposure and decreased the risk of POCD at 3 months after surgery. For every 1000 elderly patients undergoing major surgery, anesthetic delivery titrated to a range of BIS between 40 and 60 would prevent 23 patients from POCD and 83 patients from delirium.

Click here for an abstract of the original article

The debate remains….”to BIS or not to BIS” Many providers are comfortable that the depth of anesthesia is adequate without BIS guidance, however, the BIS may be useful in preventing excessive depth of anesthesia and, therefore, reducing the incidence of postoperative cognitive dysfunction in the elderly.

What say you? Please share your thoughts with your colleagues.

Clinical Topic: Intraoperative Hypotension and Stroke

As guardians of patient safety during the surgical procedure, anesthetists are tasked with the prevention of adverse intraoperative events. Of the many risks of surgery, death and stroke are two of the most devastating events that can occur. Ischemic stroke occurs in 0.1-3% of patients undergoing general anesthesia. Thus, maintenance of cerebral perfusion is essential during the perioperative period.

In an article by Bijker JB et al titled Intraoperative Hypotension and Perioperative Ischemic Stroke After General Anesthesia (Anesthesiology. 2009 Dec;111(6):1217-26) the relationship between intraoperative hypotension and stroke is evaluated. The purpose of the study was not only to validate a correlation between hypotension and stroke, but also to determine the degree of hypotension and the length of time associated with an adverse outcome.

The study found that the incidence of ischemic events was increased when the blood pressure dropped 30% below baseline. The longer the blood pressure was below the critical level, the greater the incidence of adverse outcome. In the words of the author:

“Our results suggest that intraoperative hypotension accounts for an increase in stroke risk of approximately 1.3% per minute hypotension (i.e., the risk is increased 1.013 times for every minute of hypotension), depending on the definition of IOH that is used (in this case a decrease in mean blood pressure more than 30% from baseline). For example, a cumulative duration of 10 min of hypotension will result in a 1.14 times increased stroke risk (1.01310). If applied to the POISE trial, this would mean an increase in absolute stroke risk from 0.5% (POISE trial control patients) to 0.57%.”

Again, in the words of the authors: “In conclusion, the most widely proposed mechanism of a postoperative stroke is arterial embolism. Nonetheless, the results of the current study support the hypothesis that hypotension can influence the evolution of a postoperative stroke by compromising (collateral) blood flow to ischemic areas. In this context, hypotension is best defined as a decrease in mean blood pressure relative to a preoperative baseline, rather than an absolute low blood pressure value.”

Since patients present with a wide variety of baseline blood pressures, there is no magic number for a mean blood pressure to be maintained during surgery. The anesthetist is advised to calculate each patients lowest acceptable blood pressure based on maintaining the blood pressure within 30% of baseline.

Click here to read the complete article

Clinical Topic: Prewarming, Does it really matter?

Peri-operative hypothermia is a common problem related to the practice of anesthesia. Numerous studies have documented the negative effects of hypothermia to the extent that SCIP has made patient temperature a marker of quality care. In an attempt to reduce hypothermia, many anesthesia providers recommend patient pre-warming in the holding area prior to surgery.

An article by Horn EP et al published in Anaesthesia (The effect of short time periods of pre-operative warming in the prevention of peri-operative hypothermia., Anaesthesia. 2012 Jun;67(6):612-7) evaluated the effects of 10, 20 and 30 minutes of forced air pre-warming on surgical patients. The study found that those who were not pre-warmed experienced a greater temperature drop during surgery regardless of the active measures used in the operating room to maintain body temperature. The Authors recommended a minimum of 10 minutes of pre-warming prior to surgery.

Click here for an abstract of the Horn et al study

In a separate study by Wagner, D published in AORN, the causes and problems related to hypothermia are listed. According to the author, the following factors place the patient at risk:

Cold ambient temperatures
Cold beds
Reduced Metabolism
Anesthesia / pharmacological agents
Evaporative heat loss

Patients who become hypothermic experience the following problems:

Negative nitrogen balance with reduced kidney perfusion
Respiratory distress
Reduced metabolism of medications
Delayed recovery from anesthesia
Impaired platelet function and clotting
Impaired wound healing
Increased wound infections.

To prevent intraoperative hypothermia, the author recommends forced air pre-warming

Click here to view the author’s article.

Clinical Topic: Predicting Sleep Apnea, the STOP-BANG scale

A foundational skill required of all anesthetists is airway management. With the obesity epidemic in our nation, obstructive sleep apnea (OSA) is becoming more common and presenting challenges to the anesthetist. Predicting which patients are at increased risk for OSA is an important part of the preoperative assessment. In a recent report published in the british J Anaesth, 2012; 108:5: 768-75, Chung F et all evaluated the correlation of the STOP-Bang scale to the occurrence of sleep apnea.

The STOP-BANG evaluation scale is simple to use. It consists of asking the patient yes or no questions regarding the following 8 items:

Snoring. Do you snore?
Tired. Are you frequently tired during the day?
Obstruction. Have you ever been told that you stop breathing when you are asleep?
Pressure. Do you have high blood pressure
BMI Is your BMI over 35?
Age. Are you over age 50?
Neck Circumference. Is your neck circumference over 40 cm?
Gender. Are you male? (should be obvious)

If the answer is yes to 3 or more of these questions, the patient is at increased risk for obstructive sleep apnea. The higher the number, the greater the risk. Of interest, a male over 50 starts with a score of 2 regardless of the other risk factors.

Click here to review the on line assessment tool published by thesleepmd.com

Click here to review the article by Chung et al. as presented by the Virginia Assn of Nurse Anesthetists.

Clinical Topic: JCAHO Sentinal Event Regarding Opioids

Patient safety is a foundational responsibility of all health care workers. The Joint Commission identifies “sentinel events” related to patient safety and distributes them to Hospitals. During accreditation visits, JCAHO evaluates the Hospital’s effectiveness in addressing, reporting, and eliminating sentinel events.

“A Sentinel Event is defined by The Joint Commission (TJC) as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient’s illness.” wikipedia

Examples of sentinel event are:

Infant abduction
Rape
Suicide
Transfusion reaction
Wrong surgery
Wrong radiation dose

Recently, the Joint Commission published a Sentinel Event related to the use of opioids in the Hospital. The following points are included in the Sentinel event report:

Implement effective practices, such as monitoring patients who are receiving opioids on an ongoing basis, use pain management specialists or pharmacists to review pain management plans, and track opioid incidents.
Use available technology to improve prescribing safety of opioids such as creating alerts for dosing limits, using tall man lettering in electronic ordering systems, using a conversion support system to calculate correct dosages and using patient-controlled analgesia (PCA).
Provide education and training for clinicians, staff and patients about the safe use of opioids.
Use standardized tools to screen patients for risk factors such as oversedation and respiratory depression.

By posting the Sentinel event, the Joint Commission has established guidelines for health care workers to follow, including anesthetists. Click here to read the advisory published by the Joint Commission.

Clinical Topic: What’s your favorite Anesthesia APP?

Controversy remains as to whether or not cell phones (hand held computers with audio capability) and iPads have a place in the operating room. It is true that they can be a distraction for healthcare workers but they also put a wealth of information at your finger tips. When used appropriately, they provide instant information to the anesthetist that could make a difference in patient safety.

Recently, I posed the question to several of my colleagues; What is your favorite Anesthesia APP? Below are a few of the favorites. I am asking porcrna.com readers the same question. What is your favorite APP? Look over the APPs listed below and use the comment box below to share your experience with these APPs or to add your own favorites.

Epocrates: This free drug reference is the #1 mobile drug reference for U.S. physicians. With it you can search brand, generic, and OTC medicines. Plus, you can customize your homepage for quick access to the features you use most frequently.

abeoCoder gives access to CPT®, ASA CROSSWALKS®, and ICD codes right from your iPhone or BlackBerry. abeoCoder app provides you with codes, base units, descriptions and more.
Coding Made Easy.

Pedi Safe is an advanced airway management and cardiac resuscitation app. In an emergency, healthcare providers can quickly identify a patient’s weight or Broselow color, and then Pedi Safe displays all appropriate weight based dosing, equipment sizes, and normal vital signs. An excellent reference for doctors, nurses and paramedics!

drawMD; Using the iPad, Anesthesiologists can create interactive visual guides as a way to explain complex issues and possible medical and surgical solutions for Anesthesia and Critical Care-specific conditions and procedures, such as a central line chest tube, intubation, spinal epidural, etc.

One more just for fun…….and this one works on your pet too!

Alivecor has developed the iPhone ECG—a case that transforms the iPhone into a wireless, clinical quality heart monitor. The case is able to monitor one’s heart rate almost immediately, and can even measure through a cotton shirt!

Browse, enjoy and leave a comment to share your favorite APP with your colleagues.

Clinical Topic: Learning Ultrasound Guided Regional Anesthesia

Ultrasound guided regional anesthesia has quickly established itself as the preferred technique for placing blocks. Several models of ultrasound devices are available and each vendor touts their product as the best. Time for placement, success of the block and patient satisfaction all reinforce ultrasound guided placement as the method of choice for regional anesthesia.

CME meetings across the country are offering hands on workshops to teach anesthesia providers how to properly use this new technology. Likewise, Nurse Anesthesia training programs have added ultrasound guided regional anesthesia to the curriculum. Educators agree that mastering ultrasound technology is important but to date teaching techniques have not been evaluated.

A study by John Gasko, CRNA et al funded by the AANA Foundation and recently published in AANA Journal — August 2012 Supplement (Effects of Using Simulation Versus CD-ROM in the Performance of Ultrasound-Guided Regional Anesthesia) compares two techniques for teaching ultrasound guided regional anesthesia to Student Nurse Anesthetists. Students were divided into groups and were taught either by the use of CD-ROM based teaching or by simulation with human subjects. A third group was taught using a combination of both approaches.

The authors found that there was no difference in learning between those using CD-ROM versus simulation. However, the study found that a combination of CD-ROM and simulation was clearly more effective than either technique separately.

Click here to read the original article published in the AANA Journal

Click here to learn about how you can support CRNA research through the AANA Foundation.

Return to procrna.com and share your comments with your colleagues.

Clinical Topic: Ipad APP for Anesthesia Patient Teaching

Are you still trying to justify whether or not to break down and buy and iPad? As the use of technology continues to grow and develop, devices such as the Ipad are becoming important tools for the anesthetist. Writing for the on-line Barton Blog, author Ben Amirault describes a newly developed APP for the iPad which enables the provider to better educate patients in the pre-op environment. According to Mr. Amiralut, “An informed patient is a happy patient. Providers who can effectively communicate with their patients can expect high patient satisfaction scores and improved outcomes.”

The drawMD APP has diagrams and descriptions of common anesthesia related procedures and enables the provider to better explain the planned anesthetic to the patient and the family. The APP is currently free and can be obtained through the iTunes store. As described by the vendor “drawMD Anesthesia & Critical Care enhances doctor-patient communication by offering a new paradigm for explaining the complex issues surrounding the intensive monitoring and care provided by anesthesiologists and critical care physicians. In order to improve patient understanding of medical problems, drawMD utilizes the iPad’s unique interface to allow anyone to sketch, stamp, or type directly on the detailed anatomic images included in the application.”

Click here to read the blog post by Mr Amirault

Click here to view the APP at the iTunes store

Download it, try it, and return to PROCRNA.COM and leave a comment.

Clinical Topic: CRNA liable for poor communication

Despite the requirement for all health care workers to have annual training related to fire safety, hospital fires continue to occur. Operating rooms have an ample supply of each of the elements required to ignite a fire and the anesthetist must be vigilant to the threat of fire at all times.

Ann Latner, JD, writing for the online blog clinicaladvisor.com describes an interesting scenario in which a fire occurred on a patient during a procedure. To summarize:

Routine case (facial area) with patient receiving Monitored Anesthesia Care
Patient’s Oxygen sat drops and CRNA applies supplemental oxygen
Oxygen buildup under the drapes
Surgeon uses cautery
prep solution ignites and patient receives a facial burn

In addition to the burns, the patient required psychiatric follow-up and filed a law suit against the CRNA, the surgeon and the Hospital. At trial, each of the defendants had separate lawyers and each gave testimony. The Hospital affirmed that they had provided the required fire safety training. The surgeon testified that had he known oxygen was in use, he never would have used cautery. The CRNA was the only one of the three found to be liable for damages.

In the words of Ann Latner, the author, “Good communication is one of the best ways to avoid being a party to a lawsuit. Whether it is talking with your patient or a colleague, when making referrals, or even in chart notes (an important form of medical communication), having clear, direct, and open lines of communication can prevent unfortunate results. Mrs. H would have never been injured had Mr. D simply notified the surgeon of the oxygen use. No amount of testimony could make up for those few missing words during the procedure. Communication is key to better patient outcomes and to protecting yourself.”

Click here to read the full article and return with your comments.

Clinical Topic: Intraoperative Hypothermia

Reducing or eliminating postoperative surgical site infection is an ongoing challenge to health care professionals. Infection following surgery constitutes up to 38% of nocosomial infections. Avoiding intraoperative hypothermia is thought to be an important to overall survival, especially in trauma patients. To improve the quality of care, SCIP protocol mandates the recording of intraoperative temperature and the use of forced air warming systems when patients are at risk for hypothermia.

A recent study by Seamon MJ, et al, (Ann Surg. 2012 Apr;255(4):789-95.) attempted to determine the impact of intraoperative temperatures on the incidence of surgical site infections in patients with abdominal trauma. Patients were supine on warm water blankets and forced air warmers were applied to upper and lower extremities. Antibiotics were administered per protocol. A total of 524 patients were included in the study, most were young males who had received either gunshot or stab wounds. Temperatures were closely monitored and patients were tracked for the development of postoperative infection.

The authors found that increased surgical site infection was correlated with hypothermia with a critical body temperature being 35 degrees C. The authors recommend that intraoperative normothermia should be strictly maintained in trauma patients.

Click here to read an abstract of the original work