anesthesia clinical topic – Page 3

Chief CRNA: CRNAs as OR Leaders

Across the Nation, Chief CRNAs are probably among the most under utilized group of talented health care providers. In addition to developing the work schedule and assuring that providers are present to support the posted schedule, Chief CRNAs know the strengths and weaknesses of the staff members and are in a unique position to guide the work flow to optimize patient care.

An original article Written by Sabrina Rodak details why Anesthesia providers are well positioned to guide the work flow in the operating room. Click here to read the original article.

Three experts on anesthesia services explain why anesthesia providers are best positioned to lead the operating room of a hospital.

1. “The perioperative leader should be an excellent communicator with a deep knowledge of OR management in order to successfully make the necessary changes required in carrying out the hospital’s overall goals. As anesthesiologists are present in the OR every single day, it is important that the anesthesia chair takes on this role to promote consistency across the board through this time of change,” says Leo Penzi, MD, executive vice chair of the department of anesthesia at North Shore University Hospital in Manhasset, N.Y., a member of the board of directors of North American Partners in Anesthesia and assistant professor in the department of anesthesiology at Hofstra North Shore-Long Island Jewish School of Medicine.

2. In a case study presented by Surgical Directions, a hospital recruited anesthesia providers to drive perioperative performance by granting them leadership positions and aligning incentives. The anesthesiologists received financial rewards for increasing patient volume and a stipend for fulfilling certain service standards, including increasing the availability of regional blocks, accommodating add-ons and participating in the OR’s daily huddle, a process in which the OR team discusses issues from recent cases and prepares for the next day’s schedule. Anesthesia leadership was an important element of the hospital’s success in perioperative services.

3. Proper anesthesia leadership in the OR is a key element of integrated delivery of care. Robert Stiefel, MD, a principal with Enhance Healthcare, defines this as “healthcare professionals and supporting facilities working towards one goal: optimized patient care that is more efficient and cost effective.” Integrated care in the OR depends on the coordination of hospital administration, OR staff, surgeons and anesthesiologists. Anesthesia providers’ involvement in all aspects of the OR makes them prime candidates to oversee this coordination. “Anesthesia providers are the most consistent component of the entire perioperative experience,” Dr. Stiefel says.

Legal Topic: Documentation

Same Song Different Verse – If It Wasn’t Documented…..

Consider for a moment, that you or a colleague is facing legal action that, on the face of things, appears absurd. How absurd? Well, think for a moment about the first time that you learned how to place an intravenous (IV) line. The first thing that you were taught to do (after determining the correct patient, catheter size, and limb selection) was – clean the site. Traditionally we used alcohol either provided in an IV start kit or provided by our facility. How many of us thought about, or consulted the relevant science, regarding which preparation solution was actually better for patient care?

Now lets take it up notch. Consider what you do as an anesthesia provider when you are preparing to place an epidural catheter or a subarachnoid block. Most of the kits that we used in school and current practice have supplied within them a skin cleansing preparation. According to one manufacturer, B. Braun (bbraunusa.com/images/bbraun_usa/bbrauncatalog.pdf; F3), the supplied cleaning preparation in standard single dose epidural trays is povidone iodine. Again, how many of us question the skin preparation solution provided in a kit by a manufacturer that our facility has chosen to select for us? Relevant science indicates that a better skin preparation solution for neuraxial blocks is chlorhexidine. Furthermore, this solution is optimal when used from a single use package, instead of poured from a multi-use container.

What is the importance of such minutiae? Well, suppose a post-partum patient presented to the ER 4 days after discharge from the mother-baby unit of Smallville Community Hospital with the following symptoms: low grade fever, back ache, intermittent weakness of the right lower extremity. During her ER workup, the on call anesthesiologist, Dr. Nurves, is consulted since the patient had an epidural for labor analgesia. After his physical exam, Dr. Nurves suspects the patient has an epidural abscess. He orders an MRI that confirms his suspicions. Now fast forward 18 months. The patient decides to file a claim against her anesthesia providers for causing the pain and disability from which she now suffers. She suspects her current problems are from the epidural abscess…….

When an attorney is tasked to evaluate this type of claim, the attorney will seek a healthcare professional who is familiar with the standards of care surrounding the activities related the client’s labor epidural for analgesia. Imagine the professional conundrum provided by the following clause on the anesthesia record “Sterile prep and drape” without further elaboration. Would it make any difference if we added another detail: the epidural was placed by a trainee (either physician or nurse) and the use of the trainee was NOT noted on the anesthesia record. Additionally, the patient, and her spouse, recalls multiple attempts at placing the epidural; this is also not noted on the chart. So how does one determine if standards of customary practice were met in such a situation? The use of the trainee, and the multiple attempts at placing the epidural catheter are not documented in the records. These items are not facts in evidence. It is a fact however, that if cultures are obtained from an epidural abscess with bacterium that are not normally found in the epidural space, AND the patient’s physical exam prior to the placement of the epidural does not specifically indicate a bacterial infection in the area where the epidural catheter was to be placed AND (perhaps most importantly to us) the modality for transmission of bacterium into the epidural space is under the exclusive control of the anesthesia provider, then supporting data can be introduced to create a scenario whereby the anesthesia providers who placed the epidural catheter caused the epidural abscess AND the related sequela. What type of supporting data? Standards of care regarding neuraxial blockade; sterile skin preparation; and care documentation. Documents of professional standards, along with several peer- reviewed clinical reports regarding sterile skin preparation are readily available in any medical library (electronic or traditional) or via the world wide web.

A well researched review providing the who, what, when, where, and why of how we are supposed to practice our craft can speak volumes to a trier of fact (a judge or a jury) as to whether or not a patient’s claim has merit. So what is the take home message: Know and adhere to your professional standards of care (review them if necessary) and keep up with the state of your science.

Pamela Chambers, MSN, CRNA, EJD
www.lexterraeconsulting.com

References
Barash, P.G., Cullen, B.F., & Stoelting, R.K. Clinical Anesthesia 3rd Ed. Ch 26 Epidual and Spinal Anesthesia p 651 Lippincott Raven, New York 1997

Birnbach D.J. et al, Povidone Iodine and skin disinfection before initiation of epidural anesthesia. Anesthesiology. 1998; 88:668-672

Nagelhout, J. J., Zaglaniczny, K.L. Nurse Anesthesia 3rd Ed. Ch 44 Obstetric Anesthesia p 1066 Elsevier Saunders, St. Louis 2005

Stoelting, R. K., Miller, R.D. Basics of Anesthesia 3rd Ed., Ch. 12 Spinal and Epidural Anesthesia p 173, Churchill Livingstone, New York. 1994

Pamela Chambers, MSN, CRNA, EJD
www.lexterraeconsulting.com

CRNA Fitness: Decompress the stress

PROCRNA asked me to mount the March podium on the issue of stress-reduction which would be nearly laughable…except for the fact that I have so much personal experience. So here it is, the Body Firm method to decompress the stress.

Where do most of my clients turn for comfort during or after a tough day with the head, hands or heart? Why, food, of course. The number one method of coping with pretty much anything these days is comfort food or drink. Some of you will turn to the box of goodies in the lounge, some of you will opt to ingest a 16-ounce cola, and some (more of you than would like to admit it) will eat two or three doughnuts pretending it’s breakfast. But be careful of calorie-dense stress relievers. Sugar elevates your mood very briefly before acting as the downer it really is, dropping you as fast as a plumb line, and leaving unwanted calories and irritation behind. And in the long run, useless food raises your stress. Instead, munch on an orange, or snack on a handful of almonds, or both. An orange will administer quick sugar, it’s true, but it’s loaded with vitamin C and will provide nutrients along with energy. Nuts are a great source of protein that can hold you over until a real meal or simply sustain you through another case. Try walnuts or pecans, too, and limit your serving to a clean, even dozen. The crunch of the munch is very satisfying and brings fast relief.

You may be tempted to just flop on the decrepit sofa in the lounge when someone relieves you in the OR, not always a bad idea. But even better: Walk the hallway, stop to do squats every 12 strides, stretch your calves and quads and stretch your arms above your head, jog down the stairs to 2nd floor and jog up the stairs to 4th. Pause to do a couple of Yoga positions and bring your heart rate back to normal, then re-enter your case room with mental peace restored.

Dr. Coyote howled, Dr. Hound bit, Dr. Wolf snarled throughout the last heart case and, quite possibly, the patient’s heart is now doing better than yours. Instead of chatting it up with staff and cohorts when you exit the room, pull out a good read. Weird Sisters is a current hoot for chicks, and author, Olen Steinauer can capture either gender’s attention in short order. Try reading the daily “funnies” for comic and cardiac relief, or read anything cheerful that will take your mind off the present and help restore your equilibrium and your gift for humor. LOL.

You may not be in charge of selecting music for the gall bladder room. Pink Floyd or
George Strait may be the surgeon’s consistent choice of genre, but when you get to choose, or when you go on a break, listen to music that relieves tension. Relax with alternative sounds like waterfalls or crashing waves from a Narada collection. Classical melody from Smetana’s “The Moldau” or Debussy’s “Daphnis and Chloe,” and even big Wagnerian themes from “Tannheuser” or “Lohengrin” can fill your soul and remove the excess tension. Schubert piano solos or symphonies, unrestrained strains from LAGQ, Chis Botti love tunes on the trumpet or any of the music you simply know and love can take off the edge, and pull you back from it. Massage your hands and feet while you listen to music and get maximum de-fusing.

Finally, here’s one of the best stress-busters known to Venus or Mars – Meditation. You’ll need a quiet corner for this activity unless you’re an excellent self-hynotic. Close your eyes and preferably a door, get seated and settled with good core support, then start with slow, deep breaths in through the nose, out over the lips, switching to all nose breathing when you’re fully “centered.” Tune out any and all distractions and focus on the breath (Toothpaste trumps garlic!); in…and out….in ….and out…”…he loves me….he loves me not….one for you…one for me…” Relaxation is in the focus and in the rhythm.

K, I hate to wake you up, but there you have it – Body Firm’s favorite decompression session. An anesthetist has almost no time to relax during the workday. Morning break is not a given. Lunch can be 11:00 or 2:00 or not at all. The comfort and outcome of the patient will always be your ultimate concern. But put your own health next in line and treat your stress with safe, un-medicated relief. Your patient will benefit, and it may keep you from becoming one.

Visit Liz online at www.bdyfrm.com Read daily Lizlines and leave a stress-free comment!

Chief CRNA: OR Efficiency

The following information was provided by Jay Horowitz, candidate for AANA Region 7 director. With the current budget restraints and emphasis on efficiency, Jay has documented the inherent inefficiency of staffing ratios and the cost to the system. Read Jay’s comments, link to the supporting articles and return to procrna.com and offer your comments.

From Jay: This week an article appears in “Anesthesiology, The Journal of the American Society of Anesthesiologists, Inc.” (!!): Supervision Ratios that gets to the heart of the inefficiencies, waste and fraud inherent in “supervision” and “medical direction” models of anesthesia delivery. With an average 22 minute delay in multiple operating rooms several times a day, and an average Medicare reimbursement rate of $1.43/minute X 250 working days a year X 1000’s of US operating rooms, the money adds up awfully fast! So do the savings with greater CRNA utilization models validated in the recent Health Affairs and Nursing Economics articles with NO compromise in quality of care. Click here to read the ASA article.

I’ve been writing about these inefficiencies for some time now: Streamlining Anesthesia Care and how we might rationally fix the problem. We need to make sure that this kind of information is available to every state and national decision maker and other stakeholders. Click here to read an article from the Herald Tribune.

Read, enjoy, and return to make a comment

Topic: Continuous Capnography Linked to Lower Monitoring Costs

In the age of Health Care Reform where we are all being tasked with providing more care for less money, simple ways to save are gaining popularity. In an article published in Anesthesiology News, Dana Hawkins-Simons discusses the use of capnography in the Intensive Care Unit to save money. In the article, she refers to an study by Courtney Rowan, MD who compared to total number of blood gas measurements done before and after the ICU began using continuous capnography on all patients.

The study showed that after beginning the policy of capnography measurement on all patients, the number of blood gas tests dropped from an average of 21.6 per patient to only 13.8. This reduction in testing resulted in a savings of $985,130. It was speculated that there could have also been savings due to a reduced requirement to transfuse blood in the smallest of patients where frequent drawing of blood for samples resulted in a lowered Hemoglobin level.

Click here to read the article in Anesthesiology News and return to PROCRNA.COM to make a comment and share your opinion.

Clinical topic: Lower Central line infections

In the midst of the pressure to lower infection rates and meet CMS standards, is it possible to reduce the rate of central line infection to zero? That question was addressed in an article by Kate O’Rourke published in Anesthesiology news. The author states that new research has found that multidisciplinary team approaches are making great strides in dramatically reducing rates. She describes a study done at the University of Massachusetts finding that involving caregivers at all levels and providing frequent, regular feedback on infection rates to hospital staff are two key elements that have made these programs a success, experts said.

The article continues by quoting Matthias Walz, MD, chief of vascular anesthesiology at UMASS Medical Center, who said the guidelines at his facility were developed by a small task force and then approved by the institution’s Critical Care Operations Committee prior to implementation. “From the ICU physicians to the ICU nurses, respiratory therapists, pharmacy team, occupational therapists—everybody is at the table.” Because all disciplines were involved in creating the guidelines, all caregivers feel they have a stake in the process, he said.

A good infection control program will show positive results, however, for the success to be continued, participants must continue to be updated and motivated. Ongoing education is essential. Reducing infection rates is a total team effort by all caregivers. Communication and coordination is mandatory.

Click here to read the article as published. Return to www.procrna.com and leave a comment.

Clinical Topic: Propofol allergy in Children

Propofol is currently the hypnotic drug of choice for anesthetic induction. With the increase in TIVA anesthesia, Propofol is also being used as a maintenance drug. Propofol is a lipid preparation which incorporates egg lecitin, phosphatide and soy oil in the preparation. Egg and Soy allergies are listed as contraindication to the use of propofol. Due to the presence of egg products in the formula, the question emerges as to whether or not propoful should be used in the patient with egg allergy.

In a retrospective chart review study by Murphy A, et al published in Anasth Analg the topic of propofol use in the egg allergic patient is explored. The authors report that egg lecithin used in the propofol formulation has not been found to have residual egg proteins. The literature revealed only one case where an egg allergic patient reacted to the lecithin used in propofol. Since egg lecithin comes from the egg yolk, the authors speculate that up to 75% of pediatric patients with egg allergy could tolerate Propofol without incident. Nevertheless, the authors recommend skin testing of patients with egg allergy prior to propofol use.

Click here to read an abstract of the original work and return to procrna.com to leave a comment.

Clinical Topic: Defenses to Negligence

In earlier articles, I discussed some basics about medical malpractice. Now I want to briefly review some defenses to negligence. Keep in mind that all negligence claims are not credible; and even if a credible claim exists, there are many avenues to resolution. If the required elements of negligence are present and cannot be contested, defenses to negligence may be considered.

One method for mounting a defense to medical malpractice is to assert that the plaintiff caused their own injury, and because of the plaintiff’s action the defendant should not be held liable for the injury. A jurisdiction that recognizes contributory negligence would bar recovery by the plaintiff if the plaintiff is found to have contributed to the cause of his injury. A jurisdiction that recognizes comparative negligence (of the plaintiff) would decrease any award for a plaintiff’s claim based on the amount of fault the court determines the plaintiff contributed to the injury. Additionally, if the defense can establish the plaintiff knew the risks involved in an activity and voluntarily performed the activity, then assumption of the risk might be the appropriate defense to relive the defendant of liability. Adherence to these theories is ascertained by reviewing relevant case law in the applicable jurisdiction, and review of relevant statutes in the applicable jurisdiction.

Consider this example: Priscilla Patient arrives at Sunshine Valley Ambulatory Surgical Center (ASC) for a laproscopic appendectomy. After completing and signing all of the required forms in the admitting office, Priscilla is led to the dressing room to disrobe and to change into her gown for surgery. Priscilla disrobes leaving only her underwear remaining under the gown. As Priscilla gathers her belonging and opens the door to exit the changing room, Priscilla’s right great toe makes contact with the door of the dressing room. The contact doesn’t initially bother her so she doesn’t tell anyone about it. The next day, during the follow-up post-operative call, when asked if she has any questions or concerns about her procedure the prior day, Priscilla states, “My surgery went fine, but my right big toe is really hurting where the door hit it. Now it’s swollen and really hot.”

This example is hypothetical. However, at this point many options can occur. If Priscilla decides to sue the ASC for her injured toe, all of the required steps (such as fact gathering and determining if the claim is credible) will begin to be pursued by her legal team. In a claim of negligence against the Sunshine Valley ASC, if a defense to negligence for a claim like this were considered, it is reasonable to suggest that Priscilla had something to do with the injury that she now has because she didn’t tell anyone about it when it occurred. If a court believed that proposition, any award to which Priscilla may have been entitled to would be either barred in a contributory negligence jurisdiction, or reduced in a comparative negligence jurisdiction. If the defense can establish that Priscilla chose to exit the dressing room without foot coverings, knew she was injured before she had surgery, and before she left the facility, and she chose not to inform medical personnel who were readily able to assess and treat any injury if any were present, then assumption of the risk might be the choice to rebut Priscilla’s claim of injury to her toe. The legal team will evaluate the facts of the case and apply the law as indicated.

Pamela Chambers, MSN, CRNA, EJD

About the author: Pamela Chambers is a staff CRNA a Central Texas regional trauma center and the affiliated Children’s hospital. Ms Chambers received her MSN in 2000 while on active duty in the U.S. Army; then received her Executive Juris Doctor (EJD) in Health Law in 2008 from Concord Law School. Ms. Chambers owns Lex Terrae Consulting a health law research and consulting firm and also teaches Legal Nurse Consulting for Kaplan University. Ms. Chambers is not an attorney. The information provided is legal research and should not replace consultation with an attorney or physician when warranted. Click here to learn more about Lex Terrae Legal consulting services.

Clinical Topic: Propofol Related Infusion Syndrome (PRIS)

Propofol Related Infusion Syndrome (PRIS) is typically associated with metabolic acidosis followed by cardiovascular failure. The condition is most commonly reported in ICU patients who require long term sedation. As the incidence of PRIS increase, so do the number of case reports and studies published in the literature.

An excellent review by Fudickar and Bein published in Minerva Anesthesiol offers a historical perspective and details pathophysiologic changes that occur when propofol in infused over a prolonged period of time. The authors describe cytolysis of cardiac and skeletal muscle as being central to the problem. Mitochondrial fatty acid metabolism impairment was implicated. Patients with a low carbohydrate supply, such as children, are at increased risk for developing PRIS. The authors state that their protocol limits propofol to no more than 4mg/kg/hour for long term sedation.

The question arises as to whether or not we place our patients at risk by using TIVA for general anesthesia. Children receive up to 9 mg/kg/hour for up to 4 hour procedures and infusion rates of up to 30mg/kg/hr have been reported when TIVA is used in adults. Are we placing our patients at risk?

An article by Guitton et al published in Neurocritical Care describes the development of PRIS in an adolescent with status epilepticus who received propofol sedation for seizure control. The patient developed a metabolic syndrome with rhabdomylitis after 58 horus of propofol at 8.8mg/kg/hr. Cardiac arrest followed and extracorporal membrane oxygenation was required.

Various articles agree that PRIS is related to dose and length of time that propofol is administered. In the ICU, long term dosage should be kept below 4-5 mg/kg/hour. In the operating room when higher doses are required, the anesthetist should consider stopping the TIVA as soon as it is no longer absolutely required for the procedure. During the procedure, be aware of the dosage you are giving and try to limit it to the lowest effective dose.

Review the articles that this posting links to and then come back and tell us about your experience and recommendations for TIVA

Distracted Health Care Providers

Hospitals across the nation have encouraged the use of computers, ipads, smart phones and other devices to improve the access of health care workers to information essential for safe patient care. Information about lab interpretation, drugs, and diagnosis are all readily available on line. In some institutions, the Anesthetist is encouraged to call or text the Recovery area prior to delivering a fresh post-op patient. It now appears that the use of technology can be a two edged sword.

In addition to the intended use of electronic devices to enhance patient care, there is increasing evidence that health care providers are becoming distracted from patient care. A front page article by Matt Richtel in the New York times titled “As Doctors Use More Devices, Potential for Distraction Grows?” tells of a Neurosurgeon taking 10 personal calls during a case in which the patient was harmed. An article in Perfusion magazine reported that nearly half of the perfusionists in a survey admitted to texting or making a personal call while the patient was on cardiopulmonary bypass. Other stories include Circulating nurses making airline reservations during a case as well as texting facebook friends.

Patient advocate Suzanne Gordon writes of the problem of distracted drivers using cell phones and notes that 15 states still do not have laws against texting while driving. When discussing the case of the Neurosurgeon making numerous calls during surgery, she asks “where were the other OR staff when this was going on?” She notes that the same people who are texting in their cars are now texting while doing patient care. Suzanne recommends that one person in the operating room be designated as the only person to have access to cell phones during the case.

The challenge for health care workers is to fix the problem themselves before congress or Joint Commission imposes new rules. We must remember that the welfare of the patient comes first and resist the urge to text, call, or surf the net while providing patient care.