Research – ProCRNA

Robert Greenleaf; The first serving leader

By Thomas Davis, CRNA, MAE, DNAP candidate

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“Where there is not community; trust, respect, and ethical behavior are difficult for the young to learn and for the old to maintain.”
― Robert K. Greenleaf,

Health care delivery in the United States and around the world is in a state of transition as traditional physician-driven hierarchies are being replaced with collaborative teamwork. At the root of this drive is a hope for improving employee engagement, productivity and loyalty to the organization. More than at any point in history, empowering leadership at all levels is being viewed as the key to building powerful teams and the serving leadership style is being promoted as the panacea for workplace woes.

Robert Greenleaf was born in Terre Haute, IN, in 1904, the son of a machinist and community steward. Robert attended Rose Polytechtic and Carlton College earning a degree in engineering. He took a position with AT&T where he worked as a loyal employee for 38 years and became known for his theories about empowering leadership. During that time, Robert headed a division for management training and created the first center for corporate assessment in America. One of the first to promote women and blacks into non-menial positions within the AT&T organization, Greenleaf became well known as a pioneer in leadership by seeking ways to utilize each person to his/her fullest capability.

Following retirement from AT&T at age 60, Robert worked as a consultant to businesses that had an interest in leadership development and taught them to implement his core belief that effective leadership is a partnership wherein “the organization exists as much for the person as the person exists for the organization.” In 1970, Greenleaf published his essay, The Servant Leader which coined the term and introduced the notion that the best leaders are servants first. The style of leadership that he espoused proved to be effective and requests for his leadership coaching grew into creation of the Greenleaf Center for Servant Leadership. The center states as its mission: “to advance the awareness, understanding and practice of servant leadership by individuals and organizations.” Long after the death of Robert Greenleaf, the center remains a strong advocate for servant leadership and continues to offer training through the Greenleaf academy.

Writing in EmergingRNLeader, nurse and author Rose Sherman identifies the leadership style described in The Servant Leader as an essential component of a highly effective healthcare workplace. Crediting the work of Robert Greenleaf, the following were described by Sherman as essential characteristics of the Greenleaf serving leadership style.

Listening
Empathy
Healing
Awareness
Persuasion
Conceptualization
Foresight
Stewardship
Commitment to professional development of staff
Building community

Click here for an explanation of the 10 principles listed above.

Robert Greenleaf had an unshakable belief that through collaboration and the creation of a work environment that empowers people to work at their highest capability, people will be happy, engaged and highly productive. History records that Robert was never driven by a quest for fame or fortune, but by a belief that the potential within each person that could be released, can be released, through servant leadership. Etched in his grave stone are the following words, “Potentially a good plumber; Ruined by sophisticated education.”

In the decades following the publication of his famous essay, Robert’s principles of servant leadership have become the foundation for many versions of leadership development in America and worldwide. Books, videos, and workshops may put a new spin on Greenleaf’s original work; however, when all is said and done, the beliefs of Robert Greenleaf are still alive and evident in leadership development worldwide.

“A better society, one that is more just and more loving, one that provides greater creative opportunity for its people.”

~Robert Greenleaf

Tom is a noted author and popular speaker at State Association meetings.

Research: Steep Trundelenburg and Postoperative Visual Loss

Postoperative visual loss is a rare but catastrophic event that has an increased in frequency with robotic surgery in the steep head-down position. Studies have been conducted and reported in the literature relating intraocular pressure to postoperative visual loss. One study conducted in the steep head-down position with laparoscopic surgery demonstrated increased intraocular pressure as time progressed. Normally, cerebral and ophthalmic circulatory autoregulation prevent increased intraocular pressure, however, this may not be the case during general anesthesia in the steep head-down position.

Research conducted by Bonnie Molloy, CRNA, PhD (A Preventive Intervention for Rising Intraocular Pressure: Development of the Molloy/Bridgeport Anesthesia Associates Observation Scale) and published in the AANA Journal (AANA Journal, June 2012, Vol. 80, No. 3) is a “must read” for any anesthesia provider administering anesthesia to patients in the steep head-down position. This comprehensive review of postoperative visual impairment following head-down surgery details the pathophysiology and describes observable, physical changes that will alert the observant provider that intraocular pressures are increasing.

Data obtained by the author revealed that increasing intraocular pressure in the patient in the steep head-down position correlates to increasing eyelid and conjunctival edema. These physical signs can be used to determine when it is advisable to level the patient and allow the intraocular pressures to decrease.

The result of this excellent, well documented study was the development of the Molloy/Bridgeport Anesthesia Associates Observation Scale. Using the signs of eyelid and conjunctival edema, the anesthetist can predict when intraocular pressures are increasing. The original work is complete with illustrations to guide the anesthetist in the use of the observation scale.

This original work was funded in part by a grant from the AANA Foundation and is essential knowledge for anybody routinely doing cases in the steep trundelenburg position lasting greater than 2-3 hours. Click here to view the original publication.

Research: What is the best handwashing technique?

Postoperative infections are a major concern throughout the healthcare industry to the extent that infection rates have become a marker of “quality care”. Patients expect health care workers to protect them from exposure to harmful organisms and, as we know, handwashing is foundational for any infection control program. As anesthesia care providers, we are called upon for insertion of invasive lines where a sterile field is as essential as the sterile field required by the surgeon. Therefore, handwashing among anesthesia providers is essential for patient safety.

Since the advent of the germ theory, handwashing has been the first line of defense against pathogenic organisms. In the operating room, handwashing has evolved into a full 5 minute scrub using a bacteriocidal soap or solution. Recently waterless antiseptic solutions have emerged on the market and have been touted as being equally effective as the full 5 minute hand scrub. The efficacy of the antiseptic solutions is still being studied.

A study by Burch et al, Anesth Analg. 2012 Mar;114(3):622-5 (Is alcohol-based hand disinfection equivalent to surgical scrub before placing a central venous catheter?) Looks specifically at anesthesia providers using various techniques for hand cleaning prior to insertion of a Central Venous Catheter. Five different hand cleaning techniques were used and hands were cultured after cleaning. The techniques were as follows

Traditional 5 minute hand scrub
Traditional 5 minute hand scrub, 15 minute break, then alcohol only cleanser
Alcohol only cleanser
Alcohol only cleanser, 15 minute break, then traditional 5 minute scrub
Waterless surgical scrub alone

The authors found that method 3, the alcohol only cleanser was significantly less effective than the traditional hand scrub. This study supports the theory that hands are best decontaminated by using the full 5 minute scrub at the beginning of each day.

Click here to read an abstract of the original work.

Research: Partner’s Presence During Epidural Placement

The constant pursuit of patient safety and satisfaction is foundational to excellence in patient care. Involvement of the patient’s family has been shown to increase satisfaction and enhance the overall medical experience. Many hospitals allow parents into the operating room for induction of anesthesia in their children. In the area of labor and delivery, epidural anesthesia has been shown to not only reduce the pain of labor but also relieve anxiety of both the patient and the partner. A question yet to be answered is whether or not the presence of the partner during placement of the epidural reduces anxiety and increases satisfaction.

A study by Orbach-Zinger et al published in Anesth Analg 2012 (Partner’s presence during initiation of epidural labor analgesia does not decrease maternal stress: a prospective randomized controlled trial.) seeks to assess whether the partner’s presence during labor epidural chtheter placement reduces mother and partner anxiety level. The study included 84 couples who were divided into two groups; partner present or partner absent during catheter placement. Anxiety levels, pain and time to placement were measured.

At baseline, there was no difference in anxiety or pain between the groups. During catheter placement, anxiety levels and pain during insertion were significantly higher in the group with the partner present. The authors concluded that partner presence during epidural catheter insertion did not decrease anxiety levels. The anxiety and pain of catheter placement were greater with the partner present.

Click here to read the original abstract of this study.

Research: Optical Fibers for Nerve Block placement

The application of technology to practice has enabled the CRNA to deliver patient care that is safer and more reliable than at any other time in history. The placement of nerve blocks has always been challenging. Thirty years ago, soliciting paresthesia or trans arterial needle placement were common methods for administering an axillary block. The Ultra sound guided nerve block has increased not only the success rate but also safety to the patient. What can be done to improve on Ultra Sound?

Desjardins AE et al recognized that the success of a nerve block depends upon the proper placement of the needle. They developed a stylet with optical fibers that could collect light for analysis of optical reflectance spectrometry. The theory was that different tissues reflect a different wavelength of light and the stylet could be used to differentiate between nerve and vascular tissues. Click here to read an abstract of their work.

Taking the concept one step further, Balthasar A, et al used the technique on human subjects. They reported that the stylet with optical fibers was able to differentiate between nerve and vascular tissue an on 2 cases detected actual vascular penetration by the needle. Click here to read an abstract of their study.

Will the optical stylet replace ultra sound for nerve block placement? Probably not. However, the addition of the optical stylet which detects penetration of the needle into either vascular or nerve structures could add another element of safety to nerve block placement.

Research: ECG as source of infection

Hospital acquired infections are a major concern to the American Health Care Industry. Each year infections cost an estimated 30-50 Billion dollars and cause 100,00 deaths to patients who trust their health to all levels of providers across the Nation. Research to identify common sources of infection has implicated ECG wires as a reservoir for bacteria.

A study by Gilske, D et al at Advocate Lutheral General Hospital, Park Ridge, IL examined ECG wires as a source of Hospital Acquired infection. In this study, 35 sets of ECG wires from ICU were disinfected using the standard Hospital protocol for cleaning rooms after discharge of a patient. Both wires and snaps were cultured. These researchers found:

From the 35 cultures, 57 organisms were detected

65% positive for coagulase negative stahp
11% positive for methacillin resistant staph aureus
14% positive for vancomycin sensitive enterococcus
3% positive for vancomycin resistant enterococcus

They concluded that standard decontamination methods applied to reusable ECG wires and snaps are not effective.

Click here to review a poster session presenting the original work.

The Lifesync Corporation has introduced a wireless ECG to the marketplace. The disposable leads are placed on the patient and connected to a wireless device which sends signals to a receiver connected to the standard monitor. The immediate and obvious advantage is the reduced risk of infection offered by the disposable ECG leads. The secondary gain for the Anesthetist is removal of wires from the work area. The ability to position the patient lateral or prone without the mess of ECG wires is a definite plus of this system. Click here to go to the Lifesync web site. If you have used this product, please write a review in the comments section of this post.

Disclaimer: PROCRNA.COM has NO financial tie to Lifesync Corporation or it’s products. All questions should be directed to Lifesync.

Research: Anesthesia causes jet-lag

A press release from the University of Aickland dated April 17th, 2012 described a recent study done there that linked anesthesia to a feeling of jet-lag following surgery.

The researcher, Dr. Guy Warman, noted, “Our work shows that general anesthesia effectivly shifts you to a different time zone, producing chemically-induced jet-lag. It provides scientific explanation for why people wake up from surgery feel as though very little time has passed.”

Dr. Warman goes on to state, “It’s been known for sometime that after anesthesia, people’s biological clocks are disrupted and this can compromise their sleep pattern and mood as well as wound healing and immune function.”

This interesting work was done on honey bees which are known to have a keen sense of time.

Click here to read the original press release

Clinical Topic: Ethanol intoxication, Brain injury and outcome

All CRNAs who take call in a medical center have had the challenge of caring for the intoxicated driver who arrives at the Hospital with a head injury. Imagine that both drivers sustained a traumatic head injury. One driver was intoxicated and the other was completely sober. Which driver is more likely to have a better outcome?

A study by Lustenberger, T, et al published in the Journal of Neurotrauma looked at outcomes of patients with traumatic brain injury. The aim of this study was to determine the impact of ethanol (ETOH) on the incidence of severe traumatic brain injury associated coagulopathy and to examine the effect of ETOH on in-hospital outcomes in patients sustaining sTBI. The incidence of admission coagulopathy, in-hospital complications, and mortality were compared between patients who were ETOH positive and ETOH negative.

The authors found that coagulopathy was significantly less frequent in the ETOH (+) patients compared to their ETOH (-) counterparts

For brain-injured patients arriving alive to the hospital, ETOH intoxication is associated with a significantly lower incidence of early coagulopathy and in-hospital mortality.

Click here to read an abstract and link to the original article by Thomas Lustenberger.

Anesthesia Awareness and the Bispectral Index

To BIS or not to BIS. That is a common topic for discussion in the anesthesia community. Unanticipated intraoperative awareness is a traumatic event for the patient with many developing post traumatic stress disorder. Anesthetists are challenged with providing safe anesthesia which includes the absence of recall by the patient.

The Bispectral Index was developed from technology related to the processed electroencephalogram. Claims are made that when the BIS value remains below 60 the risk of awareness under anesthesia is greatly reduced.

A study by Avidan et al published in the New Engl J Med studied the effectiveness of the BIS monitor compared to strict monitoring of the end tidal anesthetic gas concentration. Target values of 40-60 were used for the BIS group and 0.7-1.3 MAC for the end tidal anesthetic group. Alarms were set to warn the anesthetist when patient values were outside the prescribed limits.

The authors concluded that use of the BIS monitor did not reduce awareness as compared to strict monitoring of the end tidal anesthetic gas concentration. The study suggests that using the end tidal gas concentration protocol in patients at high risk for awareness could be of benefit. Setting alarms for monitoring end tidal gas concentration is essential.

Click here to read the full article. Please use the “comments” prompt at the top of this page to share your thoughts and experiences.

The Influence of Perioperative Care and Treatment on the 4-Month Outcome in Elderly Patients With Hip Fracture

With the baby boomers coming of age, the demographics of those seeking health care is changing. The percentage of those considered “elderly” in the surgical population has had a steady increase over the past few decades. In a study published in the February 2011 edition of the AANA Journal, Bjorkelund et al discuss risk factors of anesthesia related to the elderly population.

In this study of elderly patients with hip fracture, premedication, prolonged fasting and fracture type were related to postoperative confusion and mortality at 4 month. The authors found that decreased SpO2, prolonged fasting and increased number of units transfused all impaired recovery and were correlated to a higher mortality rate. Patients with the longest fasting times tended to receive a larger volume of fluid which may have stressed physiologic reserve.

The effects of preoperative medication on outcome produced an unexpected finding. In this study, those who received no premedication had a higher rate of confusion and mortality at 4 months. The authors speculate that either the premedication reduced the stress of surgery and improved outcome or that those who were not premedicated were in a higher risk group and possibly not a candidate for sedation.

Click here to view the study published in the AANA Journal.

Promote your Profession

Nurse Anesthesia has a long and proud history dating back to the late 1800’s. Watchful Care by Marianne Bankert documents our history and the contributions made by the early pioneers of the profession. Nurses were selected as the ideal anesthetists because of our attention to detail, vigilance, and commitment to patient safety. Day in and day out, Nurse Anesthetists delivered quality care to patients and service to surgeons.

In the century that followed, many changes in Health care have taken place but one factor remains constant; the safety and quality of patient care delivered by Nurse Anesthetists. To support the quality of care we deliver, we must actively promote our profession and contribute to the body of knowledge If we are to remain trusted and respected in the of delivery of anesthesia services. We must all contribute to promoting our profession. Some will participate in research or Public Relations projects. Others who can not actively work to promote the profession must help by supporting the work of others.

The AANA foundation has the mission of advancing the science of anesthesia through education and research. The Foundation provides an excellent opportunity for each individual CRNA to support our profession by supporting the research done by our colleagues. Original studies to promote safe practice and to validate the safety and cost effectiveness of Nurse Anesthesia have been funded and published by the AANA Foundation.

Did you know that last year the AANA Foundation:

Funded $73,045 in research initiatives

Awarded $129,000 in student scholarships

Awarded $250,000 in Post-Doctoral and Doctoral fellowships

Presented 95 research posters

Please take the opportunity to support your profession through support of the AANA Foundation. Regardless of the size of your contribution, add your name to the list of those who support CRNA research and education through the AANA Foundation. Click here to go to the Foundation web site. After reviewing the site, please contribute.

Medication vial label study

The United States Pharmacopeia is sponsoring a research study concerning the usage and disposal terms on injectable medication vial labels. The objective of the study is to acquire input from professional healthcare providers on possible changes to the terms on the label describing the use and disposal of the drug product.

The AANA and other professional organizations respectfully request your participation in this research study, as your input may help improve the clarity of terms used on labels and improve the safe use of injectable drug products in the future.

This brief survey should take no more than 10 minutes of your time.

Please click here to participate in the study

Cost Effectiveness Evaluation of Anesthesia Providers

Anesthesiologists and certified
registered nurse anesthetists
provide high-quality, efficacious
anesthesia care to the U.S.
population.

This research and analyses
indicate that CRNAs are less
costly to train than anesthesiologists
and have the potential for
providing anesthesia care efficiently.

Anesthesiologists and CRNAs
can perform the same set of
anesthesia services, including
relatively rare and difficult procedures
such as open heart
surgeries and organ transplantations,
pediatric procedures,
and others.

CRNAs are generally salaried,
their compensation lags behind
anesthesiologists, and they
generally receive no overtime
pay.

As the demand for health care
continues to grow, increasing
the number of CRNAs, and permitting
them to practice in the
most efficient delivery models,
will be a key to containing costs
while maintaining quality care.

Read the Full article in Nursing Economic$, 2010;28(3):159-169.