Tag: CRNA topics

Meeting Review: Pennsylvania ANA State Meeting

Meeting Date:   05/03/2013

Meeting location:  Hershey PA

Meeting presented by:   PANA

Meeting strengths / interesting topics & speakers:

This meeting was an exceptional offering and probably one of the best State meetings in the country. The meeting was held at the Hershey Hotel in Hershey PA. (the sweetest city in America). The hotel was historic located on a hillside and having great gardens. The Pennsylvania Assn of Nurse Anesthetist selected top notch CRNA speakers and also had concurrent sessions with ACLS, PALS and an Ultrasound workshop. Offering 20 CEUs during a weekend State meeting exceeds expectations.

Suggested improvements:

None. You guys have it together

Overall value for the money:

Exceptional value. This was as good or better than most of the commercial meetings. If the word gets out, this could rival the AANA National meeting as the premier meeting of the year.

New Product: Handwashing Bracelet Improves Handwashing Compliance

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

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

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

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

1) Before performing invasive procedures (Category I).

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

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

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

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

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

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

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

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

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

 

Chief CRNA: Are Smartphones safe in the Operating Room?

We live in the age of instant access to information literally in the palm of your hand.  As more and more information becomes available on smartphones, notebooks and pads, their ligitimate use by healthcare workers has increased.   However, the device that delivers information can also create distractions.

Lawyers know that distracted healthcare workers are more likely to make errors and frequently examine phone records when investigating an injury to a patient.  The following come from the leagal blog “FindLaw KnowledgeBase”

  • Medical errors and other adverse events in hospitals claim nearly 180,000 lives every year. This is an astonishing number, and it implicates all types of medical professionals providing care in a hospital setting.
  • More comprehensively, anesthesiologists are responsible for monitoring the condition of the patient throughout the surgical procedure. This includes paying close attention to oxygen levels and temperature.

 

An article published in Anaesth Intensive Care. 2012 Jan;40(1):71-8 By Jorm CM, O’Sullivan G. made the following points

  • Experienced anaesthetists are skilled at multi-tasking while maintaining situational awareness, but there are limits. Noise, interruptions and emotional arousal are detrimental to the cognitive performance of anaesthetists.
  • While limited reading during periods of low task load may not reduce vigilance, computer use introduces text-based activities that are more interactive and potentially more distracting

 

When preparing for legal action, lawyers commonly apply the standards set forth by the professional organization.  Non compliance with established guidelines strengthens the case against the anesthetist.  The AANA does not have a formal policy statement, however they have a position statement 2.18 regarding the use of mobile devices.  The following is from the AANA position statement 2.18

Mobile Devices may:

Aid communication
Cause a contamination risk
May distract anesthetists / reduce vigilance
Should never be used for reading, gaming or texting
Camera use violates HIPAA regulations
Use should follow institutional policy

 

The risks of Anesthetists distracted by mobile devices is well documented.  CRNAs are advised to avoid using devices for personal entertainment and to always base decisions on patient safety.

 

Meeting Review: Frank Moya, Orlando

Reviewed by MB, Texas

The conference provided a sound foundation of anesthetic knowledge related to obstetric anesthesia. It served both as a review of principles and a presentation of new ideas. The faculty was well versed and knowledgeable.

Suggestions for Improvement:   None

Overall value for the money:   Great value for the money.

Clinical Topic: Effects of Cervical Collar on LMA seal

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

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

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

Click here to review an abstract of the original work.

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

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

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

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

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

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

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

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

Click here to read an abstract of the original article

 

 

Chief CRNA: Should You Use Social Media?

We live in a turned-on, linked-in world where instant access to information is the norm.  Long gone are the days of reference books and extensive library searches.  The generation who grew up using web based technology is now entering the workplace and bringing their mobile devices with them.  As Chief CRNAs, it is to our advantage to use social media to enhance the flow of information within our work groups.  However, the use of personal devices in the workplace is not without risk to the patient and administration must establish policies that balance the flow of information with patient privacy and safety.

In a blog by his own name, Phil Baumann makes the case that there is a place for twitter among healthcare workers.  His article lists 140 uses of twitter to enhance communication and efficiency among workers.  A few items on the list include:

  • —  Disaster alerting and response
  • —  Emergency response team management
  • —  Alarming silent codes (psychiatric emergencies, security incidents)
  • —  Biomedical device data capture and reporting
  • —  Triage management in emergency rooms
  • —  Publishing health-related news
  • —  Reporting hospital staff injuries
  • —  Reporting medical device malfunctions
  • —  Discussing HIPAA reform in the age of micro-sharing
  • —  Recruitment of health care staff

 

The blog goes to warn of dangers of using social media in the operating room:

  • Patient dignity and privacy
  • Professional oaths to do no harm (distracted workers and Infection risk)
  • Litigation concerns
  • HIPAA

Click here to read the Baumann Blog

An article by Barker, A et al published in the Journal of Clinical Anesthesia discussed the use of social media by Residency programs.  The Barker group found that only 30% of residency programs have social media policies in place.  They also found that 12% of the programs use a social media search as a part of the initial applicant screening.

The article concluded: “residency programs should have a written policy related to social media use. Residency program directors should be encouraged to become familiar with the professionalism issues related to social media use in order to serve as adequate resident mentors within this new and problematic aspect of medical ethics and professionalism.”

Click here to read an abstract of the Barker article.

Here is the question for PROCRNA.COM readers: Does your department have a social media policy and, if so, is it known by front line workers and enforced by administration?  Please leave your comments below.

 

Chief CRNA: How to Motivate your Staff

Being an effective Chief CRNA involves multitasking to meet the needs of the patient, the institution, the regulatory agencies and the needs of your staff.  Staff engagement is a buzz word in corporate America.  According to Wikipedia, An “engaged employee” is one who is fully involved in, and enthusiastic about their work, and thus will act in a way that furthers their organization’s interests.   As Chief CRNAs, it is easy to become so focused on the daily grind that we often ignore things that will promote engagement within our staff.

An interesting article by Martin Dewhurst et al and published in the McKinsey Quarterly addresses the issue of staff engagement.  All too often, administration relies on financial recognition for motivation of employees.  Dewhurst et al point out that there are more effective non-financial motivators of your staff.  According to the report, the top 3 non-financial motivators are:

  • Praise, commendation and interaction with the supervisor
  • Attention from leaders
  • Opportunities to lead projects or task forces

“The survey’s top three nonfinancial motivators play critical roles in making employees feel that their companies value them, take their well-being seriously, and strive to create opportunities for career growth. These themes recur constantly in most studies on ways to motivate and engage employees.”

“One-on-one meetings between staff and leaders are hugely motivational,” explained an HR director from a mining and basic-materials company—“they make people feel valued during these difficult times.” By contrast, our survey’s respondents rated large-scale communications events, such as the town hall meetings common during the economic crisis, as one of the least effective nonfinancial motivators”

“A chance to lead projects is a motivator that only half of the companies in our survey use frequently, although this is a particularly powerful way of inspiring employees to make a strong contribution at a challenging time. Such opportunities also develop their leadership capabilities, with long-term benefits for the organization.”

Click here to read the original article posted in the McKinsey Quarterly

As Chief CRNAs we need to not only ensure that patients receive the highest quality of care but also that they receive the care from a motivated and engaged staff.  Finding ways to involve and value individual staff members will pay high dividends in the long run.

Clinical Topic: Systemic Lidocaine Improves Recovery

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

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

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

Click here to read an abstract of the original article.

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

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

Chief CRNA: Patient Safety and the Aging CRNA

We have all heard the stories of the super star who played one season too many leaving the sport at the bottom of his game rather than at the top.  The physical effects of aging are well documented in the literature and we are reminded of those changes every time we pre-op a geriatric patient.  As the baby boomers reach retirement age, many super star CRNAs who carried our professional torch for the past several decades are experiencing many of the physical changes that they see in their aging patient.  The question arises, does the aging healthcare provider pose a safety risk to the patient?  How can the skills of the aging CRNA be fairly assessed to ensure patient safety?  Is aging really a problem anyway?

Canadian researcher Michael J. Tessler M.D. writing in Anesthesiology and published in the on line blog Community Health Network (Older Anesthesiologists have Higher Litigation Rates) notes:

“We found a higher frequency of litigation and a greater severity of injury in patients treated by anesthesiologists in the 65+ group. The reasons for these findings should become an active field of research.”

Click here to read the blog

An editorial published by the ASA addressed the issue of the aging Anesthesiologist.   The editorial reminds the reader that the older provider brings years of experience to the job and has valuable insight to be shared with the younger providers.  From the editorial:

“Older physicians, including anesthesiologists, have developed a wealth of experiences during their years in practice that regularly benefit patients,” said Dr. Warner. “The study’s findings remind all physicians that they need to understand their practices, the changes that they personally will experience as they age and the value of working with colleagues to gain continuous feedback about their personal performance in patient care.”

Dr. Warner added, “All physicians should know their personal limits and adjust their practices as they get older to best serve patients. For example, older physicians may choose to reduce the number of hours they work during the nighttime to ensure that they are well rested and alert when caring for patients.”

Click here to read the editorial

CRNAs tend to be at the front line of patient care and are found at the head of the table providing hands on care.  We need to respect the knowledge and skills of our “experienced” CRNAs while, at the same time, protecting the safety of the patient.

Here is the question for procrna.com readers:  How do we assess the continued competency of the aging CRNA?  Use the comments box below.

 

 

Clinical Topic: Effects of Anesthesia in Children

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

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

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

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

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

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

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

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

 

Meeting Review: NAFA Disney World

Have you been to an Anesthesia CME Meeting lately?  Share your experiences with your colleagues.

Meeting Date:  11/25/2012

Meeting location:  Disney World

Meeting presented by:   NAFA

Meeting strengths / interesting topics & speakers:

Overall, the meeting was very good. It was a great value for the money. The location was fantastic as well as the time of year as WDW wasn’t too busy right after Thanksgiving. The meeting facilities were nice and the breakfast was hot. Most of the topics were taught by CRNA’s and had a great diversity to include- politics, pedi, OB, etc. They also started earlier in the morning to allow extra CE’s and went till 1 pm to allow time for family.

Suggested improvements:  None.

Overall value for the money:

They had two early bird sessions for an extra 2 CEU and also it is affiliated with students so they allowed students to put up their posters and we can get an extra CE for commenting on posters. Overall- 23 CE’s for $550. By far the best value as far as CE for money. Plus the meeting rate for the resort was about a 1/3 of what somebody would have to pay regularly. The resort was very nice.

Reviewed by David P, (Texas)

Click here to visit the NAFA web site.

Clinical topic: Should Flu Shots Be Required?

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

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

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

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

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

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

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

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

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

Chief CRNA: The anesthesia team of the future

In the era of Healthcare reform, the practice of anesthesia is being redefined by both the advancement of technology and the impact of regulations.  As the scope of anesthesia care emerges from the head of the table to include care across the entire perioperative course, the anesthesia team must evolve to meet the new demands.

An article by Bartels K, et al published in Curr Opin Anaesthesiol. 2011 Dec;24(6):687-92, speculates on the anesthesia team of the future.

According to Bartels, the anesthesia team of the future must provide well tolerated, efficient, and cost-effective perioperative care.  Some of the points made are:

  • The team of the future must develop standards for simulation assuming that simulation will improve healthcare delivery
  • The team of the future will draw large volumes of information and generate data that is more accurate and complete related to the patient’s physiologic parameters.  The providers will use smart phones and other devices to add portability to the data they compile.
  • Electronic resources will provide real time updates along with physilologic data and pictures to help the provider determine interventions for optimal patient care.
  • Merging of databases will streamline operating room utilization, hospital bed utilization and supply ordering and storage

The anesthesia team of the future will utilize all available emerging technology to provide expertise across the perioperative continuum.

Click here to review an abstract of the original work

 

Clinical Topic: Cerebral O2 Saturation and Cognitive Dysfunction

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

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

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

Click here to read the abstract of the original work.

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

Click here to read the abstract of the original work

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

Clinical Topic: Fluid optimization improves outcome

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

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

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

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

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

Click here to read the essay

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

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

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

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

Chief CRNA: Billing audits, Are You At Risk?

Every year the Department of Health and Human Services Office of the Inspector General conducts audits and on-site inspections of Health Care Facilities to ensure that billing and payment policies are being followed.   Recovery audit contractors are utilized to make the inspections and are reimbursed by collecting a percentage of the money saved due to the inspection.   In other words, the more billing discrepancies they uncover, the more they make.   The office of the Inspector General has over 600 auditors, the largest number of auditors of any Federal Agency.

Writing for the on-line blog MiraMed, Tony Mira discusses the 2013 OIG work plan and the implication for hospitals.    According to Mira,

“While the Work Plan sets forth the OIG’s attention for the upcoming year, it also provides insight into the attention other agencies and contractors (e.g., the Centers for Medicare and Medicaid Services (CMS), Recovery Audit Contractors (RACs), etc.) will pay, as well.  When the OIG cracks down on one body (e.g., CMS), that body cracks down on bodies beneath it (e.g., Medicare Administrative Contractors (MACs)), sending a ripple downstream all the way to the provider.  As such, it is important for providers to be aware of the OIG’s focal points in the upcoming year as they, too, will feel the impact.”

Click here to review the OIG 2013 work plan

According to the plan, several ongoing areas of review remain from previous work plans:

  • Hospitals—Same-Day Readmissions
  • Program Integrity—Medical Review of Part A and Part B Claims Submitted by Top Error-Prone Providers
  • Program Integrity—High Cumulative Part B Payments
  • Physicians—Error Rate for Incident-To Services Performed by Nonphysicians
  • Physicians—Place-of-Service Coding Errors
  • Evaluation and Management (E/M) Services—Potentially Inappropriate Payments in 2010

New areas of interest for review in 2013 include:

  • Hospitals—Inpatient Billing for Medicare Beneficiaries
  • Hospitals—The DRG Window
  • Hospitals—Non-Hospital-Owned Physician Practices Using Provider-Based Status
  • Hospitals—Compliance with Medicare’s Transfer Policy

 The OIG has published a video discussing the priorities of the 2013 work plan.  Click here to view the video.

As anesthetists, it is essential that our records and the billing for our services are accurate.   Inspectors have a plan to uncover billing fraud and recover excess payment.  As providers, we must be aware of the issues being audited.

Clinical Topic: Bis and Postoperative Cognitive Dysfunction

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

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

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

Click here for an abstract of the original article

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

Based on their findings, the authors concluded:

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

Click here for an abstract of the original article

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

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

Clinical Topic: Intraoperative Hypotension and Stroke

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

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

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

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

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

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

Click here to read the complete article

 

Clinical Topic: Prewarming, Does it really matter?

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

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

Click here for an abstract of the Horn et al study

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

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

Patients who become hypothermic experience the following problems:

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

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

Click here to view the author’s article.

 

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

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

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

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

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

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

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

Clinical Topic: JCAHO Sentinal Event Regarding Opioids

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

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

Examples of sentinel event are:

  • Infant abduction
  • Rape
  • Suicide
  • Transfusion reaction
  • Wrong surgery
  • Wrong radiation dose

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

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

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

 

 

 

Chief CRNA: Are your Electronic Records Secure?

Patient privacy and the security of protected health information is a hot issue throughout healthcare from the primary physician’s office through diagnostic testing and including  records of hospitalization.  The Federal Government is urging health care workers to move to total electronic records and have initiated bonus money to encourage compliance.  However, the move to electronic records presents the challenge of security.

Writing for the on line blog The Anesthesiology Insider, Tony Mira states:

“Collecting, analyzing, reporting and storing electronic patient information present perhaps even greater HIPAA challenges than does the use of paper records, however.  Data entered on a computer can be copied more easily, more cheaply, more prolifically and even passively.  Once unsecured data are moved from the computer on which they are created to other media, manually or wirelessly, controlling the information becomes nearly impossible. “

A recent case settled with the Phoenix Cardiac Surgery Center demonstrates the cost of not securing protected patient information.  In this case, the center was fined $100,000 for their breach of security related to protected health information.

The Department of Health and Human Services Office of Civil Rights is actively investigating breaches of security related to protected health information.   A recent post on procrna.com discussed the HHS/OCR pilot program to investigate 20 health care institutions looking specifically for breaches in security.   Patients are being made aware of their rights to security of their records and the Office of Civil Rights has a web page with instructions for patients to file a complaint related to unsecured records.

As Chief CRNAs working in departments that either have automated record keeping or are moving in that direction, we must ask “where are the records stored and how are they secured?”  Any breach of security can be costly.

Clinical Topic: What’s your favorite Anesthesia APP?

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

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

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

 

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

 

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

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

 

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

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

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

Chief CRNA: “Sterile Cockpit” and distracted workers.

Despite what the name suggests, a sterile cockpit is not an excessively clean area of an airplane. Rather it is a distraction-free cockpit–a time when the captain and crew engage only in flight-related conversation.

“The Sterile Cockpit Rule is an FAA regulation requiring pilots to refrain from non-essential activities during critical phases of flight, normally below 10,000 feet. The FAA imposed the rule in 1981 after reviewing a series of accidents that were caused by flight crews who were distracted from their flying duties by engaging in non-essential conversations and activities during critical parts of the flight. One such notable accident was Eastern Air Lines Flight 212, which crashed just short of the runway at Charlotte/Douglas International Airport in 1974 while conducting an instrument approach in dense fog. The National Transportation Safety Board (NTSB) concluded that a probable cause of the accident was distraction due to idle chatter among the flight crew during the approach phase of the flight.”    Wikipedia.

The Sterile cockpit philosophy has been applied to conversation in the operating room by several specialties. David J. Rosinski, MPS, LCP writes in J Thorac Cardiovasc Surg about the importance of protocol-driven communication between cardiothoracic surgeons and perfusionists noting that eliminating idle chatter improves safety.

Anesthetists, like pilots, are the busiest and need the most focus during take-off (induction) and landing (emergence).  Unfortunately, those are times when the room is full of commotion and idle chatter.  Gillian Campbell writing in Anaesthesia reported a study where video surveillance was assessed for distractions during critical times and found that distractions during emergence were common.

The following statement comes from the Oregon Patient Safety Commission; “While the sterile cockpit concept is associated with specific times in the flight process, in healthcare the concept is not only applied to specific times in a process (e.g., patient emergence from anesthesia), but also to specific activities (e.g., critical events in cardiovascular surgery) and specific places (e.g., a “no interruption” zone during medication preparation in an intensive care unit). According to Wadhera et al. (2010), “…effective communication can be structured around critical events rather than defined intervals analogous to the sterile cockpit, with reduction in communication breakdowns.”

As Health care professionals and anesthesia providers, we have an obligation to patient safety.  There is a clear need for us to take the lead in eliminating distractions in the operating room during critical times related to anesthesia.

What are your thoughts and experiences?