Tag: CRNA topics

Clinical Topic: Ipad APP for Anesthesia Patient Teaching

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

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

Click here to read the blog post by Mr Amirault

Click here to view the APP at the iTunes store

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

Clinical Topic: CRNA liable for poor communication

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

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

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

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

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

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

Clinical Topic: Intraoperative Hypothermia

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

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

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

Click here to read an abstract of the original work

Clinical Topic: Ultrasound Guidance in Anesthesia

For nearly 60 years ultrasonography has been in use in clinical medicine.  Over the past few decades the use of ultrasonography in anesthesia has increased.  As imaging machines improve in technology and the use of ultrasonography becomes everyday practice, patients are benefiting in terms of safety, comfort and cost.  The number of hands on workshops to teach anesthesia providers the proper use of ultrasonography is an indication of the importance and popularity of the technique.

An excellent article by Jonathan P. Kline, CRNA, MSNA titled “Ultrasound Guidance in Anesthesia” and published in the AANA Journal (AANA Journal, June 2011, Vol. 79, No. 3) gives a comprehensive overview of ultrasonography in Anesthesia.  The author describes the history of imaging, scanning techniques and use of the Doppler mode.  Most important, the author describes the use of the technique for the following specific procedures:

  • Central line placement
  • Spinal and epidural placement
  • Regional blocks
  • Perivascular injections

This comprehensive review reinforces the knowledge of those already experienced in the use of the ultrasound and tweaks the interest of those who have yet to learn the technique.  As ultrasonography becomes main stream in anesthesia practice, patient expect their provider to be skilled with the technique.

 Click here to read the original articles and view the pictures.

Research: Steep Trundelenburg and Postoperative Visual Loss

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

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

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

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

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

Product Review: enFlow fluid warming system

PROCRNA.COM presents new products of interest to the anesthesia community.   Inclusion on this web site does not constitute an endorsement of the product.  Please review this information, visit the enFlow web site and obtain a demonstration from your local representative. 

Keeping surgical patients at a normal body temperature is a daily struggle for those in the medical field. Among the 45 million inpatient1 and 34.7 million ambulatory2 surgeries occurring annually in the United States, it is estimated that 50-90% suffer from hypothermia (defined as a core temperature below 36 degrees Celsius).3 Hypothermia in the perioperative environment is caused by a variety of factors including low operating room temperatures, large surgical incisions, a core-to-peripheral redistribution of body heat as a result of anesthetics, chilled IV solutions, surgical procedure length, and more.4 Hypothermia has a significant impact on postoperative outcomes, which are almost exclusively undesirable.

Hypothermia is one of the most preventable complications resulting from an operative procedure, and prevention is most effective when warming begins preoperatively5 and continues across the surgical workflow. Vital Signs Inc., a GE Healthcare Company, has introduced an IV fluid/blood warmer that helps hospitals start the warming process early and continue warming across the patient’s care journey to reduce the occurrence of hypothermia.

The enFlow* IV Fluid/Blood Warming System is helping hospitals warm their patients with mobility, speed, and accuracy. The patient-dedicated cartridge attaches in-line to standard IV fluid/blood delivery sets at the start of procedures and moves with the patient, allowing care givers an easy, efficient, and cost effective way to warm across each stage of the surgical process. When it is time to move from one area of the surgical workflow to another, the user simply removes the cartridge from the enFlow warming unit, allowing the IV set in its’ entirety to be moved with the patient when transported. Once the patient arrives at the next area, the cartridge is easily inserted into an enFlow warming unit stationed in that area and is back to heating within seconds. In addition to mobility and speed, the system also enables accurate temperature control with a differentiated warmer that sits close to the patient (reducing the opportunity for fluids to cool in the IV line) and has eight temperature sensors ensuring fluids are the right temperature for patients.

To learn more about the enFlow IV Fluid/Blood Warming System and the impact it can have on your Anesthesia Department.  Click here to visit the enflow web site.

*enFlow is a trademark of General Electric Company

1 Center for Disease Control and Prevention, FastStats. Inpatient Surgery, Data are for the U.S. Accessed November 29, 2011. http://www.cdc.gov/nchs/fastats/insurg.htm.
2 Center for Disease Control and Prevention. U.S. Outpatient Surgeries on the Rise. Accessed November 29, 2011. http://www.cdc.gov/media/pressrel/2009/r090128.htm.
3 Young, V. Watson, M. Prevention of Perioperative Hypothermia in Plastic Surgery. Aesthetic Surgery Journal. 2006; 551-571.
4 Kurz A, Sessler DI, Lenkhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. N Engl J Med 1996;334:1209-15.
5 Paulikas, CA. Prevention of Unplanned Perioperative Hypothermia. AORN J. 2008; 88(3): 358-365. DOC1194144

Clinical Topic: Does Anesthetic Technique Make a Difference?

The belief that the choice of anesthetic technique has little effect on long term outcome is being challenged.  New evidence is being presented in the literature suggesting that anesthetic technique, in fact, may make a difference in long term outcome.

A recent study by Kavanagh T, and Buggy DJ. (Curr Opin Anaesthesiol. 2012 Apr;25(2):185-98.) titled Can anaesthetic technique effect postoperative outcome? examines aspects of anesthetic management that may effect postoperative outcomes.  According to the authors, a review of the literature has revealed the following:

  • Administration of supplemental oxygen and the avoidance of perioperative hypothermia, allogeneic blood transfusion, hyperglycaemia or large swings in blood glucose levels reduces postoperative infection rates.
  • The use of regional anaesthesia techniques reduces chronic postsurgical pain.
  • The avoidance of nitrous oxide reduces the long-term risk of myocardial infarction.

The authors point out that the findings of many studies can be debated and recommend large scale studies with long term followup to gather better data.  Such studies could better identify correlations between anesthetic technique and cancer recurrence, neurotoxicity, and the development of postoperative cognitive dysfunction.

Click here to read an abstract of the original work and return to procrna.com and share your thoughts.

 

 

 

 

 

Clinical Topic: Control Infection with disposable ECG wires

Hospital acquired infection effects nearly 2 million patients annually and has become a marker for quality care.  The SCIP guidelines have specific requirements for antibiotic administration in the peri-operative period, however, antibiotics are only one piece of the infection control puzzle.  Sterile instruments and hand washing with every patient contact are also essential elements.  One area that is often overlooked is the use of contaminated ECG wires from patient to patient and the risk of introducing organisms to an otherwise clean/sterile area.

A study by Laura Boegli, Elinor Pulcini, Ph.D. and Garth James, Ph.D,  (Bacterial Migration on Reuseable Electrocardiography (ECG) Lead Wires)   The study cultured 100 randomly selected ECG telemetry leads and found that 77% were contaminated with at least one antibiotic resistant pathogen.  The authors make the following comments regarding the difficulty in cleaning ECG wires and cables:

“Reusable ECG cables and lead wires also have specific cleaning challenges that may cause cleaning to be inconsistent and ineffective such as (1) numerous “nooks and crannies” that patient’s blood and body fluids can seep into thereby providing an environment for bacterial growth (2) inability to submerge for cleaning and cleaning agents potentially degrading the product efficacy and functionality over time and (3) multiple surfaces on ECG lead wires and cables which may make it difficult for cleaning agents to reach all surfaces when cleaning in between patients.”

Click here to read the study.  It is a PDF download and starts with the conclusion.  The reader must forward to the start of the article.

Covidian has introduced disposable ECG wires to the marketplace enabling each patient to have clean ECG wires starting in the OR and then going with the patient to PACU and on to ICU or the patient room if necessary.  This product eliminates the risk of patient to patient transfer of antibiotic resistant organisms in the operating room.  Click here to view the manufacturer’s information and return to procrna.com with your comments.

Make the Most of the AANA Meeting in San Francisco

Boston, Seattle, San Francisco, Honolulu, Jackson Hole, San Antonio…there are some amazing destinations for anesthesia meetings right here in the USA. Most of the venues are places where there is a long list of thing s to see and do. And all of the destinations provide plenty of opportunities for you to stay active.

 

Run For Fun

AANA’s annual meeting has been offering a 5-K fun run for just under a decade. It’s an easy 3.1 mile course along the city’s most scenic route with shuttle service provided start and finish. Runners, walkers, strollers (those are the people who stayed up late the night before) are all welcome and you’re the celebrity. Beautiful surroundings, beautiful celebs, and a free t-shirt as beautiful as t-shirts get, make all that exercise a beautiful bonus. Sometimes the local ANA offers early morning fitness classes at the host hotel with leadership provided by CRNA’s who apparently enjoy waking people up as much as putting them to sleep. Click here for the AANA wellness run in San Francisco

Take Your Bands

Exercise bands are almost as easy to use as they are to pack. You can do a complete work-out in your hotel room, in the hotel gym, in a park, at the beach or looking out over the harbor in Seattle or Boston. All you need is two or three bands, a doorjamb, railing or a pole to anchor them, a little backpack to carry them, or a waist small enough to tie them around your middle. With access to cool water and a hotel-sized washcloth, aka sweat rag, you’re good to go. Bands weigh less than an I-pad and they pack flatter than a ten-dollar bill.

Rent A Bike

One of the best ways to see your city and get some great exercise at the same time is to rent a bike. Google “bicycle tours in Vancouver” or “rent a bicycle in Austin” and refine the search from there. Be sure to use the word bicycle because otherwise you’ll end up with Harley Suzuki as your travel companion, which might be a blast, but you won’t get much exercise unless you fall off and have to walk back. You may be able to get a private, guided bicycle tour – more money, of course, but if you like to be at the head of the class asking questions, money talks and the expense will pay off. Click here to learn about bike rental in San Francisco.

Many cities have initiated bike-share programs. This service goes by a variety of names – like Q-bikes in Portland, B-cycle in San Antonio, or simply Bike-share in Boston – and features a fleet of bicycles that anyone can use. Just swipe your credit card at the vertical terminal, release one of many bikes from its locked stall, then ride it on marked cycling routes throughout the city, or directly to a destination. Parking stalls and routes are indicated on maps at each bike installation so you won’t get lost. Each time you stop to sight-see near a bike-share stall, just slide the bike into a rack, it locks automatically, and very shortly it will become someone else’s exercise partner. The beauty of the service is that it generally doesn’t require a helmet. One of the drawbacks of the service is that it generally doesn’t require a helmet… AND if you have to wait for a bike to become available when you’re in Brooklyn, you could be late for cocktails in the Bronx. Click here to learn about community bike share in San Francisco.

Walk

If you didn’t download a city map and a printable walking tour before leaving town for your meeting, you can ask your hotel concierge to highlight the best walking destinations on a brochure and outline some routes for you. Check things off on your brochure as you go so you don’t miss the major attractions, and don’t be afraid to get off the beaten path. Make note of noteworthy and eccentric establishments as your cabbie whisks you through the city from the airport, then go back and find them on your feet. You’ll run into the best coffee art cafes, the most interesting old houses, and charming little corner stores that you won’t find on Tourist Avenue. You may burn enough calories to almost justify the mouth-watering apple fritter you found at Dave’s Sugar Shack not to mention the energy you’ll have the rest of the day just from staying on your toes. If Rick Steves or Lonely Planet has published a travel guide for the city you’re visiting, it’ll be a quality purchase, and when it rains, you can walk the halls, climb stairs between 2nd and 12th, or go to the hotel fitness club. Remember to pack your Nike’s and your fitness duds so you can avoid blisters and excuses. Click here to learn about walking tours in San Francisco.

Go to The Fitness Club

One of the criteria for selecting a hotel is the quality of the fitness club. Every large hotel in a large city has a fitness center and some of them have glitz galore. The Omni in San Diego, the Sheraton in Seattle, the Sheraton in Boston, even the Holiday Inn in Columbia, MO all have exceptional facilities for working out. Check online or talk to the actual hotel desk staff before you reserve your room and ask about these items: Cardio equipment(treadmills, elliptical trainers, lifecycles, walking tracks); strength-training equipment(training circuit, free weights, vertical bands stations); abs room or abs corner (mats, fitballs, body bars, medicine balls); and towel service as well as a decent-sized pool. Gym-rats are going to get to the facility early, so go really early or go a bit late, but get going.

Your anesthesia meeting is a place to learn more about your ever-changing industry but it’s also a place to have fun with old friends and to make news ones, a place to experience a new city in a new way. Hike Aspen Mountain, jog the stairs next to the San Diego Convention Center, power walk the promenade while cruising between glaciers in Alaska, cycle from Fenway Park to The Old South Church. You won’t be putting anyone to sleep or trying to stay awake for one whole week. Go make the most of it!

You can visit Liz at www.bdyfrm.com and learn more about her Traveling Bands comprehensive work-out indoors or out, and how to gain access to the Bands In the Park mobile browser. Read motivational, entertaining Lizlines every weekday including the weekly original Lizlimerick.

 

Chief CRNA: CRNA supervision requirement reviewed by CMS

Physician supervision of CRNAs has been an ongoing topic of debate within the Anesthesia community for decades.  Under current law, CRNAs are required to be supervised by a physician unless the individual State “opts out” of the requirement.   To date, 17 States (Kentucky the most recent) have opted out of the requirement.

In a post on The Anesthesia Insider, blogger Neda Mirafzali, Esq  (Anesthesiologists Targeted in CMS’ Review of Existing Rules)  states that Health and Human Services (HHS) has been directed to review all existing rules related to health care and make them more effective, efficient, flexible and streamlined.   As a part of the review, CMS is looking at the issue of CRNA supervision as a condition of participation in the care of Medicare and Medicaid patients with the possibility that the supervision requirement be removed on a Federal level.

The blog post includes a brief but excellent review of who may supervise a CRNA and what constitutes supervision.  Changing the regulations would have no effect on the states that have already opted out of the requirement for supervision.  The remaining 33 States would, in essence, be automatically opted out by virtue of the rule change

Click here to read the original blog post and return to procrna.com to make a comment.

Clinical Topic: SSEP Not required for Cervical Spine surgery

As anesthetists, we are frequently called upon to administer safe and effective anesthesia to patients with cervical spine disease.  Patients with symptomatic spondylosis or stenosis have symptoms of myelopathy and/or radiculopathy.  The goal for the surgeon and the anesthetist is for the patient to be free of neurologic symptoms postoperatively.

Somatosensory evoked potential  (SSEP) monitoring has been used to detect adverse surgical effects on nerve roots during scoliosis surgery.  In recent years, SSEP monitoring has been used increasingly for other types of spine surgery, including decompression.  This study was done to evaluate the value of the use of SSEP for Cervical Decompression surgery.

Dr. VINCENT C. TRAYNELIS, MD a Neurosurgeon from Rush University did a comprehensive record review of cases involving decompression of the Cervical Spine between 2000 and 2009. The results were published in J Neurosurg Spine. (2012 Feb;16(2):107-13. Epub 2011 Nov 11.)  The records of 720 patients who had a total of 1,534 levels decompressed without the use of SSEP were reviewed.  Specifically, the authors were seeking new neurological symptoms related to the surgery.  They found 3 patients with new neurologic symptoms after surgery,  1 had a preoperative diagnosis of radiculopathy, while the other 2 were treated for myelopathy.   The new postoperative deficits completely resolved in all 3 patients and did not require additional treatment.

The authors concluded that decompression of the cervical spine without intraoperative monitors is not only safe but offers a significant savings.  In this case, the authors speculated that the cost of monitoring the patients who were reviewed would have been 1,024,754.

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

Chief CRNA: Corporate takeover of your Department?

As Healthcare workers, we watch the reports on the evening news about corporate takeovers in the business community and are relieved that we don’t have to worry about things like that in our profession, but are we really safe?   An post on Anesthesia Reviews Blog by William Hass, MD, MBA explains why investors with venture capital investing in and profiting from the Healthcare industry. He lists the following reasons for their new interest in making profit from Healthcare:

  • The stock market as a whole has barely risen in the past decade,
  • Bond yields are unusually low
  • With the global savings glut there is just so much capital chasing too few worthwhile investments.

Among the options are anesthesia management companies who undercut your contract to provide services.  Once they have secured the contract to provide services at your hospital (your job), all staffing and equipment decisions are made based on generating a profit for investors.  Sadly, the group of people who are not actively managing the business of anesthesia and maintaining contracts are the anesthesia professionals.  Dr Hass lists the following as things that we could and should be doing to protect our jobs and the quality of care offered to our patients;

  • Be politically active at the facility, community, state, or national level
  • Spend money and time for business education
  • Develop and utilize an effective human resource program
  • Understand anesthesia service and OR management
  • Give group leaders time to lead
  • Educate and develop the next generation of leaders

This warning by Dr Hass reinforces the experience that small anesthesia departments are having across the nation.  Now is the time for CRNA leaders to be proactive and solidify the relationship between the Hospital and the anesthesia group.  Failure to maintain vigilance in the front office may cost you your job.

Click here to read the original blog post by Dr Hass and return to procrna.com to make a comment.

Clinical Topic: Fluid management in Major Surgery

Fluid management during major surgery has been a topic of discussion for decades.  The goal of evidence based practice has produces many studies related to fluid management.  Despite the number of studies that have been published, to date there is no universal protocol recommending optimal fluid management guidelines

A review by Corcoran,T et al published in Anes Analg  (2012 Mar;114(3):640-51. Epub 2012 Jan 16) titled Perioperative fluid management strategies in major surgery: a stratified meta-analysis looked at major works that have been published in an attempt to clarify whether goal directed fluid therapy had an advantage over liberal fluid replacement during major surgery.  Those in the goal directed group had fluids administered based on hemodynamic targets.

The study reviewed databases from 1950 to 2009.  Postoperative complication such as pneumonia, pulmonary edema, time to first bowel movement and length of hospitalization were all greater in the liberal fluid group.  They found no difference in wound infection/dehiscence, myocardial infarction, renal complications or mortality.

The goal directed patients received more colloid fluids during surgery and had shorter hospitalization with fewer renal complications.  The authors concluded that the goal directed group had better outcomes than the liberal fluid group.  However, they could not state that goal directed therapy is superior to liberal fluid use.

Click here to read an abstract of the original article.

Research: Partner’s Presence During Epidural Placement

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

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

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

Click here to read the original abstract of this study.

Research: ECG as source of infection

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

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

From the 35 cultures, 57 organisms were detected

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

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

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

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

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

 

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.

 

Clinical Topic: Handwashing Standards

New patient safety guidelines require increased vigilance in handwashing by healthcare providers.  Previous guidelines established by OSHA required soap and water handwashing between every patient contact.  Over the past few years, alcohol based handwashing agents have been introduced to the hospital setting raising the question about their efficacy and risk.

An article By Gina Pugliese, RN, MS; Judene Bartley, MS, MPH, CIC; Tammy Lundstrom, MD, reviews the topic of the use of alcohol based handwashing solutions.  They state:

“The evidence is clear; HCW compliance with hand hygiene can reduce the 2 million healthcare-associated infections that occur in patients annually, as well as reduce the risk of infections transmitted to workers. But the use of these waterless alcohol-based hand antiseptics, the centerpiece of the new CDC guideline, has been perceived to be in conflict with existing healthcare safety regulations. These include, for example, handwashing requirements from the Occupational Safety and Health Administration (OSHA), flammability issues from the National Fire Protection Agency (NFPA), and corridor obstruction issues from Centers for Medicare and Medicaid Services (CMS).”

The article goes on to discuss the fire risk related to the use of alcohol based handwashing solutions.  As CMS tightens enforcement of handwashing in the healthcare workplace, this information is essential for CRNAs.  Click here to read the article and return to PROCRNA.COM to share your comments.  ( If the link takes you to an ad, wait about 5 seconds and it will go on to the article)

Chief CRNA: HHS to Audit for HIPAA Violations

Is Big Brother watching?  You bet!   The Office of Civil Rights from the Department of Health and Human Services has initiated a pilot program to audit Hospitals and assure that HIPPA standards are being met.   Fines of up to $50,000 per occurence are in place and the auditors are ready to search for violations.

As reported by Drinker Biddle,  ” The U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) has begun auditing covered entities for compliance with the Health Insurance Portability and Accountability Act (HIPAA) under the HIPAA Audit Program (Audit Program). The Audit Program is funded by the Health Information Technology for Economic Clinical Health (HITECH) Act and requires HHS to conduct periodic audits to ensure both covered entities and business associates are complying with the HIPAA Privacy and Security Rules, as well as all Breach Notification standards.”

The department of HHS has released information regarding the audit plan.  The information provided by HHS includes information about who will be audited, how the program works and the timeline for auditing.  Click here to review the information provided by HHS.

Share this information with your Chief CRNA colleagues and return to this page to make a comment and share your opinions.

 

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 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.

 

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

Clarus Video System

Having trouble with insertion of the ET tube into the trachea? Would you rather see than feel tracheal rings to insure intubation?  There are a number of video laryngoscopes on the market, now Clarus has introduced the video intubating stylet.

The Clarus Video System allows visualization at the end of the distal point of the stylet (ie the end of the tracheal tube).  The HD screen of the CVS gives the intubater maximum visualization, making it simple to maneuver the tracheal tube into the airway for both regular and difficult intubations.  Also with a click of a  button, a red LED light will illuminate the airway and transluminate through the cricothyroid membrane providing additional insurance that the intubation was successful.

We would like to hear from CRNAs who have used this product.   How does it compare to the standard video laryngoscope?

Click here to go to the manufacturer’s web site and review the product.  Return to PROCRNA.COM and use the comments box to share your thoughts with your colleagues.

Clinical topic: Lower Central line infections

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

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

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

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

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.