Meeting Review: NWAS, Turks and Caicos

Meeting Date: 4/22/2012

Location: Turks and Caicos

Strengths of meeting: Interesting topics and speakers. Beautiful location, great beaches, great for scuba and snorkeling

Suggestions: No suggestions for improving the meeting. The hotel was all inclusive with several dining options. The food was not good and the service was not up to par for the price.

Overall value for the money: Overpriced resort

From PROCRNA.COM: If you have attended a meeting lately and want to share your experience with your colleagues, click on “meeting review” on the navigation tab and submit your review.

From the meeting sponsor: “Northwest Anesthesia Seminars was founded in 1976 with the primary objective of offering high quality continuing education seminars for the anesthesia provider. This remains our principal objective today and our programs are designed to keep you current in the practice of anesthesiology while at the same time providing a forum for professional exchange with your colleagues from around the world. We know that your time is valuable and combining continuing education with a vacation is not only practical, but rewarding as well!

Be sure to browse our full course schedule to explore our locations with something for every traveler’s taste, budget and desire. Visit our website at www.nwas.com or call 1-800-222-6927 to learn more. There are many great reasons to attend a Northwest Anesthesia Seminar and we hope to see you soon.” Click here to visit the NWAS web site.

Clinical Topic: Glucose Control in the OR

The intra-operative management of the Diabetic patient poses many challenges to the anesthetist. Theories abound related to the advantages of “tight control” using an insulin infusion versus a less strict approach using bolus dosing. Regardless of your beliefs regarding blood sugar control, being informed and having a plan is essential for the safety of your patient.

An excellent review article by Joseph F. Answine, M.D. titled Peri-operative Diabetes Management for Dummies: Just Check the Sugar! and published by the Pennsylvania Society of Anesthesiologists discusses the foundational points to be considered when administering anesthesia to the diabetic patient.

From Dr Answine: “What do we know about peri-operative glucose control? We know that infection rate, length of hospital stay, overall cost for the hospitalization, and morbidity and mortality are directly proportional to peri-operative blood glucose levels. We also know that there are numerous studies demonstrating improved overall outcomes with improved glucose control.”

The article goes on to advise the anesthetist to know the patient’s normal and work to keep the intraoperative blood sugar as close to the patient’s normal as possible. The use of the glucometer intraoperatively is essential as is documentation. When the patient comes with an insulin pump it is best to leave it on and check glucose levels frequently.

Other basics of managing the diabetic patient:

Do diabetics first case of the day
If outpatient, discuss post op glucosecontrol both pre op and again before discharge
Test glucose pre-op
Know when patient last took diabetic medications
Know your patient’s history for self-control of diabetes
Intraop….infusions are better than a bolus
If the patient tells you how to manage their diabetes…..listen carefully

The bottom line is to know your patient’s history and glucose level. With that knowledge, treat the patient appropriately.

The Full article continues with a chart showing the types of insulin, peak, and duration of action. Click here to read the full article and return to www.procrna.com with your comments.

Chief CRNA: Coordinated care; Reduce Cost and Improve Care

Managing health care dollars in more important now than ever in the era of healthcare reform. Limiting the use of extra supplies and running low gas flows is helpful but a coordinated approach involving the entire peri-operative team is needed to achieve maximum results.

Tony Mira of MiraMed Global Services posted a web based article detailing the contribution that anesthesiology makes to coordinated case management in the patient receiving total knee replacement. Tony states “Coordinated care” is one of the key concepts in health system reform. It is central to the cost savings and quality improvements expected from Accountable Care Organizations, value-based purchasing and the medical home.”

He goes on to identify three areas where the anesthetist can add value and reduce cost to the patient receiving a total knee replacement. According to Tony:

Coordinated management of patients. “First, we found that the health system with the lowest in-hospital complication rate had successfully developed and implemented an outpatient preoperative approach that emphasized multi-specialty evaluation of potential arthroplasty candidates, followed by an inpatient co-management approach involving anesthesia, internal medicine, and orthopedic surgery.”
Dedicated operating room team. “The benefit of a dedicated operating room team seems logical, given that total knee replacement is a procedure that requires staff to be familiar with multiple pans of instruments, machinery, and other technologies that are used to implant the knee prostheses. The total knee replacement surgeons agreed that working with an experienced arthroplasty team led to a smoother and faster workday.” The article does not mention anesthesiologists or nurse anesthetists as part of the dedicated OR team, but it seems reasonable that familiarity across both sides of the ether screen would be beneficial.
Management of patients’ expectations. “After having examined its data, one member health care system implemented a patient expectations management process, whereby patients were activated and engaged in the process of discharge planning before admission. The result was an initial reduction in length-of-stay, without a change in complication rates.”

By becoming active participants in the patient’s overall surgical experience we not only reduce the overall cost, but we improve patient satisfaction. CRNAs have a long history of excellence at the head of the table. It is time for us to become more actively involved in the entire process.

Click here to read the original article posted by Tony Mira and return to leave a comment.

Chief CRNA: Automated Recordkeeping

Automated Anesthesia Recordkeeping (AARK) has been available for over 20 years and is being used in more and more operating rooms across America and around the world. Despite becoming mainstream technology, AARK continues to generate controversy. Is the advantage of automatic physiologic data capture offset by a loss of vigilence by the anesthesia provider? Several studies have investigated the loss of vigilence related to AARK.

J. Allard, R, D. Zwoncaky et al published the results of a study in the British Journal of Anaesthesia addressing the issue of the effects of AARK on provider vigilence.

As stated by the Authors: “Proponents of this technology profess that automated record keepers reduce record keeping time thereby leaving more time for data interpretation and patient care . Moreover, others suggest that computer-generated records are more accurate and complete than those charted manually . On the other hand, critics argue that allowing the AARK to chart the vital signs removes the anesthetist from the information feedback loop and thereby has an adverse effect on vigilance . The main intent of this study was to determine the effect of an AARK on intraoperative record keeping time and vigilance.”

“Thirty-seven cases were charted manually and the remaining 29 were charted with a commercially available AARK. In order to evaluate vigilance, a physician examiner entered the operating room unannounced once during 33 of the manually charted cases and during 22 of the automatically charted cases and asked the anesthetist to turn away from the monitors and recall the current value of eight patient physiological variables. The examiner recorded the recalled values and also the actual current monitor values of these variables. The videotapes were reviewed and the anesthetist’s intraoperative time was categorized into 15 predefined activities, including intraoperative anesthesia record keeping time. We compared recalled and actual variable values to determine if the recalled values were within clinically relevant error limits.”

The authors conclude the use of the AARK did not significantly affect vigilance. They go on to state that it appears that in using an AARK, the provider reallocates intraoperative record keeping time from manual charting to dealing with problems.

Click here to read the complete study and return to procrna.com with your comments.

Clinical Topic: Propofol – Remifentanil Sedation

Epidural Anesthesia is becoming increasingly popular for Orthopedic procedures of the lower extremities. Anesthetists are tasked with keeping the patient comfortably sedated while the Epidural provides adequate anesthesia during the procedure. The goal is to keep the patient oxygenated and comfortable with hemodynamic stability and a rapid wake up at the end of the case. An increasing number of anesthetists are finding that the combination of propofol – remifentanil is the answer.

A.A. Samaan and V. Srinivasan published an observational study done in the Department of Anaesthesia, Diana Princess of Wales Hospital, Grimsby, England.

As reported by the authors: “Regional anaesthesia offers many advantages for major joint replacement surgery of the lower limb. These operations are usually lengthy and carried out on elderly patients. There is a need for effective and controllable sedation with fast recovery profile. This obviates the need to administer general anaesthesia in addition to the regional anaesthesia. We undertook to evaluate the efficacy and side effects of combined infusions of Propofol and Remifentanil in this clinical set up.”

“This is an observational study of 123 consecutive patients who required joint replacement surgery; primary hip, primary knee, revision hip, revision knee and bilateral hip replacement. Epidural anaesthesia was performed in 111 patients. The Epidural site was either high lumbar or low thoracic. The Local Anaesthetic used was Bupivacaine 0.5%, warmed to body temperature, with Adrenaline added to achieve the strength of 1:200,000. The motor and the sensory functions were checked to ensure adequate blockade.”

Patients were sedated during the surgery with a manually controlled Remifentanil infusion (20 mg per ml solution) and a Target Controlled Infusion of Propofol.

The authors conclude “Sedation with Propofol and Remifentanil complemented successful Epidural regional anaesthesia for major joint replacement surgery. It was especially valuable in prolonged surgery such as in the case of revision hip replacements. This avoided the need for general anaesthesia. Sedation with Propofol and Remifentanil is associated with minimal side effects, even in prolonged operations of durations up to 260 minutes, provided there is adherence to a carefully titrated dosage. In our experience the average infusion rate for Propofol was 2.5 mg.kg.hr and 0.02 mg.kg .min for Remifentanil.”

Click here to read the study and return to procrna.com to share your comments with your colleagues.

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: Patient Safety, The Helsinki Declaration

The European Board of and Society of Anesthesiology have adopted the Helsinki Declaration for Patient Safety in Anesthesia and have made recommendations for standards that further improve patient safety.

The authors state that patient safety has 3 components; a set of guiding principles, a body of knowledge and a collection of tools. The basic principles are the tendency for things to go wrong is both natural and normal, rather than an opportunity to find someone to blame; safety can be improved by analyzing errors and critical incidents, rather than pretending they have not happened; and humans, machines and equipment are all part of a system, the component parts of which interact to make the system safe or unsafe.

The following Abstract was printed in the European Journal of Anesthesiology:

Anaesthesiology, which includes anaesthesia, perioperative care, intensive care medicine, pain therapy and emergency medicine, has always participated in systematic attempts to improve patient safety. Anaesthesiologists have a unique, cross-specialty opportunity to influence the safety and quality of patient care. Past achievements have allowed our specialty a perception that it has become safe, but there should be no room for complacency when there is more to be done. Increasingly older and sicker patients, more complex surgical interventions, more pressure on throughput, new drugs and devices and simple chance all pose hazards in the work of anaesthesiologists. In response to this increasingly difficult and complex working environment, the European Board of Anaesthesiology (EBA), in cooperation with the European Society of Anaesthesiology (ESA), has produced a blueprint for patient safety in anaesthesiology. This document, to be known as the Helsinki Declaration on Patient Safety in Anaesthesiology, was endorsed by these two bodies together with the World Health Organization (WHO), the World Federation of Societies of Anaesthesiologists (WFSA), and the European Patients’ Federation (EPF) at the Euroanaesthesia meeting in Helsinki in June 2010. The Declaration represents a shared European view of that which is worthy, achievable, and needed to improve patient safety in anaesthesiology in 2010. The Declaration recommends practical steps that all anaesthesiologists who are not already using them can successfully include in their own clinical practice. In parallel, EBA and ESA have launched a joint patient safety task-force in order to put these recommendations into practice. It is planned to review this Declaration document regularly.

The original article by Staender et al is a “must read” for all providers who sincerely seek to improve patient safety. Click here to read the original article.

Return to procrna.com to share your thoughts with your colleagues.

Clinical Forum: Sevoflurane with RSI in Obese Patient

With the growing Obesity epidemic in America, anesthetists are continually facing the risk of induction and intubation with a potentially difficult airway. Many theories are in the literature about the “best” technique for safe induction of the morbidly obese patient. Pre-oxygenation is essential and proper positioning increases the odds of successful airway management.

A recent article by Toso et al. published in the European Journal of Anesthesiology (Eur J Anaesthesiol. 2011 Nov;28(11):781-7. described adding a component of inhalation anesthesia to the rapid sequence induction technique for morbidly obese patients. In this study, the authors positioned and pre-oxygenated patients. When ready for induction, the researchers turned on Sevoflurane and after 30 seconds of breathing the agent, they followed with a rapid sequence induction using propofol, alfentanil and Succinylcholine. All patients were easily intubated on the first attempt and there were not occasions of desaturation.

The authors demonstrated that adding Sevoflurane to the RSI sequence provided conditions for a safe and controlled induction of anesthesia.

Click here to read an abstract of the original article. Return to Procrna.com and share your opinion with your colleagues.

CRNA Wellness: Nutrition

Gary, Gary, quite contrary
How does your garden grow?
With onions, tomatoes,
Vine-ripe sweet potatoes,
And lima beans all in a row.

April is the time to plan ‘n’ plant the garden. The delightful thing about your garden is that it will provide a solitary escape after a 50-hour work week. Or it will serve as a dual retreat for you and your partner. And, it’s sure to be a family affair in which everyone can select some favorite veggies to coax and encourage to fruition. When you grow things, you grow, and when you grow, your body heals.

Sweet potatoes are an amazing garden food, big on nutrients and huge on color. There are lots of varieties but pick one that grows well in your soil. Beta carotene has enjoyed solid mag’ rap in the last ten years having been praised and criticized nearly equally. The truth about sweet potatoes is that in addition to the starch and sugar, the abundance of A, C and beta carotene make every sweet sensation worthwhile. I recommend that my clients consume at least one serving of a variety of sweet potato each week. Prepare it clean – bake without butter, boil and peel, microwave in a potato bag and slice, cut into strips and bake as fries. You don’t need salt, fats, or seasonings of any kind to enhance the flavor of this already sweet, generous source of nutrients. Click here to learn about Sweet Potato nutrients.

Green beans provide a rich supply of vitamins A and C that do not stick to your ribs or add unwanted calories to your spring plate. You can plant pole beans or traditional snap beans in a raised garden. But if you have room for rows and rows of snaps, haricot verts or favas, go ahead and plant the seeds, fertilize, water, watch for worms, harvest and enjoy. Eat them fresh-steamed next to your grilled tuna, or stir fry them with onions and mushrooms. Cut and drop raw into veggie soup or snip, steam and eat them with your fingers in front of HGTV. If you get at this early in the season, you may have time to plant a second crop. Click here to learn about Green Bean nutrients.

Yellow zucchini is becoming more and more expensive to purchase, so you may as well grow your own and eat the best. Like sweet potatoes, the vines take up some space but vertical gardening is always a space-saving option. Packed with vitamin A and plenty of C, this vegan delight is so low in calories that you can eat a bowlful of sunshine several times a week. Stir fry it, steam it, slice it and grill it with olive oil or flavored Pam, and use the leftover slices on a fresh veggie sandwich. Watery and lightweight, zucchini begs to be undercooked. Your lean machine will love both yellow and green. Click here to learn about Zucchini nutrients.

Tomatoes are a thing of beauty in your diet and on your table. By now most guys know the health benefits of lypocene to the prostate, and both genders are continually reminded through research studies of the cancer preventative capacity in a snappy tomato. There is some proof that cooked tomatoes are a better option than raw but all kinds, sizes and methods of prep are tasty and healthful. Think A (B) C then go ahead, prepare a big old ground white turkey burger, slap on a thick slice of Beefsteak tomato, put on a layer of avocado and support it all with an unbuttered whole wheat bun and some leafy lettuce…serve steamed broccoli florets as a healthy side, and indulge. You’re a Garden Gourmet! Click here to learn about tomato nutrients.

Mary, Mary, quite contrary,
How does your garden grow?
With orange, green, yellow, red,
A rainbow in the bed,
With rich vitamins all in a row.

Gardening is an art form that delivers pleasure to every sense. Feel the cool rich earth slipping between your fingers, see the tiny sprouts and watch them flourish, hear the sweet songbirds nearby, then smell and taste the results of your labor. There is no place on earth like a garden for feeding both mind and body. This, you understand, because you’re a healer.

Read Liz’s daily column lizlines at www.bdyfrm.com

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.

Chief CRNA: Delivering value

As Anesthetists, delivering quality anesthesia care is foudational to our work. As Chief CRNAs, we must ensure that developing and delivering value also includes delivering value to our Hospitals / organizations as well as our patients. The following information was Posted by William Hass, MD, MBA in Anesthesiareviews. Read the work below or click here to go to the original posting by Dr. Hass.

Developing and delivering value is part of business strategy. This concept can be used for an entire organization or any of its parts or functions. Usually the focus of the value proposition is externally toward customers, but a locally owned and operated anesthesia service cannot provide external value unless its support functions are providing internal value to the group.

Support services for a community anesthesia services can be incestuous. In-laws, family friends, and childhood acquaintances may be providing some or all of its support services including billing, benefits, accounting, and legal services. These inbred services are quite variable in cost and quality ranging from well-priced high quality services to high priced poorly functioning pseudo-payoffs. The value proposition of a group’s support service becomes important when there is subsidy request.

Why should a facility pay for your poor management?
Can you produce superior clinical services without adequate support?

This is where anesthesia management companies (“AMCs”) and physician practice management companies (“PPMCs”) have an advantage because they’re supposed to have a well-oiled administrative “engine.” Some do and some do not.

Their management may be centralized, but can provide excellent on-site management?
Can they get the “little things” and the not so “little things” right at a distant site?
Do they understand the culture of the facility from somewhere over the horizon?

Some PPMCs never really get anesthesia billing right because their experience is in other specialties. (Believe it or not, PPMC anesthesia billing can be significantly better than the billing services provided by the lowest bidder to a facility or multi-facility corporation.) Diligent review is required when selecting an AMC or PPMC.

There is an important problem. The progress and development of management service organizations (“MSOs”) are being slowed by nepotism. While an MSO’s advantages of lowering the overhead costs and expanding services are easy to understand, ending a combined friendship/business relationship with an in-law, family friend, and childhood buddy can be difficult, if not traumatic. If attention is not paid to the business aspects of its practice, the choices for an anesthesia group may be between amputation (of nepotism) to join an MSO or execution/extinction by an AMC or PPMC.

Survival and success in business requires difficult decisions. Anesthesia group leaders may need to make hard and unpopular decisions unless they want someone else to be making hard and unpopular decisions for them.

Take Home Points:

Nepotism can slow the development of MSOs
MSOs can lower costs and improve group management
Survival and success in business requires hard decisions
Anesthesia group leaders need to hard and unpopular decisions unless they want someone else to be making hard and unpopular decisions for them

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

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.

Chief CRNA: How to balance your life

Life has many demands at home and at work. As CRNAs, we are expected to provide first time value to patients with each encounter and we are expected to be available 24/7. As Chief CRNAs, we add the responsibility of department management to the clinical responsibilities. After a long day at the Hospital, we often go home to a long list of “must do” items leaving little time for rest and relaxation. Over time it takes a toll. As professionals, we must balance our lives if we are to avoid burn out.

In a blog posted on Rock the post, the author presents 7 key tips for bringing your life back into balance. The author concludes, “If you don’t have a sense of harmony between your personal and professional life, things can take a toll on you mentally and physically.” Taking simple approaches, like those listed in the blog, can help you get your life back in balance so that you can be productive at work and have fun with your family and friends.

Click here to go to the blog and read the 7 tips. Return to www.procrna.com and leave your comments.

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 Forum: Evidence Based Management

“Show me the money” “Where’s the beef?” Health care delivery has evolved over the past few decades to evidence based practice. With the emergence of new drugs, techniques, and regulations health care providers are demanding “where’s the evidence”. In our quest for evidence to guide our medical resource management, we often overlook the fact that our personnel are the most important resource that we manage.

An excellent article by Vicki Hess, RN published in Hospital and Health News (Jan 19, 2012) encourages evidence based management as a tool for increasing employee satisfaction and productivity.

In the article, Vicki states that in recent years, scholars have studied and written about evidence-based leadership and evidence-based management. A logical progression in this thinking is evidence-based employee engagement. Employees are engaged when they are satisfied (they like what they do), energized (they put effort behind it) and productive (their work contributes to organizational goals). Leaders who are effective in engaging others are facilitators of the engagement process. Because no one external source can motivate an employee, providing an environment that encourages intrinsic motivators is critical.

The article continues with the concept that employee preferences are an important but often overlooked factor in department management. Engaged managers are in touch with employee preferences and make personal contact with employees on a daily basis.

She concludes that by adopting an evidence-based employee engagement approach that combines current engagement research, leadership insights and employee preferences, leaders can positively impact important business results without subtracting from the bottom line.

Click here to read the excellent article by Vicki Hess, RN

Clinical Topic: Post-op Fluids for Children

The literature is full of studies related to postoperative nausea and vomiting. I once heard an Anesthesia instructor say “if I have one more student do a vomiting study, I’m going to puke”. Even so, PONV continues to be a problem and creative investigators continue to find new aspects to study.

A recent study by Mercan et al published in Paediatric Anaesthesia looked at the timing and temperature of the first liquid given after recovery from anesthesia. Different groups of Children were given a first liquid at different time intervals and different temperatures following recovery. Liquids were either at room temperature or at body temperature. The researchers found that children receiving liquids at body temperature had significantly less post-operative vomiting than children receiving liquids at room temperature.

Click here to read more about this study and their findings.

CRNA Fitness: Procrna Fit-tips

Integrating healthy concepts into your life is like riding a tandem bike. It takes two participants and a bicycle that works. To meet the challenge of getting in shape this month, be sure to integrate both sound nutrition (see January posting) and efficient exercise into a quality plan. Once you have tweaked or completely revamped your daily diet and selected a venue for structured exercise, start supplementing your coffee break with some gentle stretches like slow, easy toe-touches to loosen hamstrings and relieve stress on the lower back. When the lunch-break-boy finally makes it into your room, take a few minutes in the lounge to do seated leg raises and neck rotations. And if some kind soul mercifully shows up to give you a potty break, take an extra minute to carefully lunge back down the hall on your way to relieve the reliever. As your 8-hour day stretches into 12, remember, careful stretching provides relief, while too much coffee requires it.

To read Lizlines and to view seated leg raises, click on www.bdyfrm.com.

Liz Sanner Davis is the owner of Body Firm Integrated Fitness Solutions. She is the author of Lizlines, posted each weekday on her web site.

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.

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.

Opioid-Induced Respiratory Depression

The Anesthesia Patient Safety Foundation is committed to the safe and reliable administration of every anesthetic. An area of concern has been respiratory depression in the immediate postoperative period secondary to narcotic administration. The following information comes directly from the foundation;

The APSF believes that clinically significant, drug-induced respiratory depression in the postoperative period remains a serious patient safety risk that continues to be associated with significant morbidity and mortality since it was first addressed by the APSF in 2006.1 The APSF envisions that “no patient shall be harmed by opioid-induced respiratory depression in the postoperative period,” and convened the second multidisciplinary conference on this serious patient safety issue in June of this year in Phoenix, AZ, with 136 stakeholders in attendance. The conference addressed “Essential Monitoring Strategies to Detect Clinically Significant Drug-Induced Respiratory Depression in the Postoperative Period.”

Click here to read the full report by the APSF regarding drug-induced depression in the postoperative period. After reading the report, click the back arrow to return to this site and leave a comment for your colleagues.

Ketamine Supplement for Anesthesia

Ketamine is an old drug which has come in and out of favor many times over the past decades. Currently, articles are emerging touting the advantages of Ketamine as a supplement for both general anesthesia and monitored anesthesia care. Below is a description by Pamela Chambers, CRNA regarding her clinical experience using Ketamine as a supplement. Read her excellent review, scan the articles and leave a comment to share your experiences with your colleagues.

Submitted by Pamela Chambers, CRNA

Lexterrae legal consulting service

For the EP case that lasted 6+ hours, GETA with .5 mac Desflurane and Propofol infusion at 30 ug/kg/min, the Propofol Ketamine mixture performed very well. I mixed 50mg Ketamine in each 50ml bottle of propofol. I used less than 3 bottles for the case and never used more than .5 mac Des. I used a total of 25 ug Fent, just after intubation, for the case. The patient was 83 yo male, approx 90 kg, EF 20%.

Upon emergence the patient denied any pain or discomfort. He was appropriately responsive to verbal and did not cough on extubation. VS were stable and he was A&O x3 on arrival to the EP room for phase 2 recovery.

A few days later, I used Ketamine as an analgesic adjunct for another long case (10 hr bilateral mastectomy and tram flap). I used a total of 195 mg Ketamine. The patient was an ASA 1. After 100 ug Fent (and 3mg Versed) prior to induction, I used 30 mg Ketamine approximately 3 mins prior to incision. Then I administered 30 mg Ketamine at hr number 2, and hr #3. Around hr #4, I decreased the Ketamine to 15mg for each hrs successive dose with a plan to halt Ketamine admin when I believed the case was 2 hrs from completion. My last Ketamine dose was at 1430 during the last phases of the case. The patient began spontaneous ventilations after reversal of NDMR at approximately 1640. The case ended at approximately 1730. The patient

received a total of 2200 ug Fent dosed approximately 100 ug every 30-45 mins.

Intermittent rescue doses for SNS spike were not required. Pressor agents were not used. Hemodynamics were extremely stable, almost like the proverbial railroad track!

Total fluid administered was 2 liters NS and 1 liter 5% Albumin, UO was 150 ml, EBL 300ml. I also adminstered 2 mg Versed at 1600 to facilitate decreasing the inhaled agent level and to ameliorate any emergence delirium associated with the Ketamine. The patient was appropriately responsive to verbal prior to extubation, and did not cough during extubation. She also denied any c/o pain immediately post-operatively. No emergence delirium was appreciated.

Click here to read a review article by Laskowshi et. al regarding Ketamine use

Click here to read an article by McCartney et al regarding the role of the NMDA receptor

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Clinical Forum

The PROCRNA clinical forum is your area to present and discuss topics related to clinical anesthesia that interest you. Have you had a case management dilemma that you would like to share? Read more…

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Have you been to a meeting lately? Was it a great experience or a waste of your valuable time and money? This is your opportunity to rate the meetings that you attend and review the ratings of others… Read more..

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If we are to give the best possible care to our patients, we must keep ourselves both mentally and physically fit. Become an active promoter of wellness among health care providers…. Read more..

Healthcare Leadership coaching

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PROCRNA Consulting Services

PROCRNA.COM is a web site designed by and for CRNAs. In addition to the professional topics shared on this web site, PROCRNA.COM offers a wide range of consulting services to… read more

Research

Any unpublished research completed by a CRNA or SRNA may be submitted here for a review. Read More…

Equipment/Product review

So many new drugs and devices on the market. Tell us what works and what doesn’t. Submit a product review or read the comments of others. Let the Anesthesia community know what works and what doesn’t. read more

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