Tag: procrna.com

NWAS Arlington VA

Reviewed by:  MD,  West Virginia

Meeting Date:   06/23-26/2016washington-dc-fireworks

Meeting location:  Arlington Virginia, Westin Arlington Gateway Hotel

Meeting presented by:   NWAS

Meeting strengths / interesting topics & speakers:    This meeting lived up to the high standard set by NWAS.   The variety of speakers (both CRNA and MD) as well as the broad spectrum of topics held my interest for the entire 4 days.    This meeting offered more credits than most meetings and was done around noon every day.

I found both the hotel and the DC area to be friendly.  I had my family with me and there was no shortage of things to see and do.  My teen aged kids especially enjoyed the Smithsonian museums.   Getting around town was easy.  If we return to DC we will rent bikes  and enjoy the bike path to Mt Vernon along the river.

All in all, it was a good meeting and a great location.

Suggested improvements:   None

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

The Value of Vision

By Thomas Davis, CRNA

“You’ve got to be very careful if you don’t know where you are going because you might not get there” – Yogi Berra

moon picOn May 25th, 1961 John F. Kennedy had a vision and shared it with the American public. “By the end of the decade we will send a man to the moon and safely return him to earth.” The race to space was launched. NASA quickly became one of the most important Government Agencies, spurring math and science to dominate higher education.   Clearly, Kennedy had inspired the nation and when Neil Armstrong took the first step on the Moon in 1969 the vision was fulfilled. Creating, sharing and gaining commitment to a vision produced amazing results.

Creating a vision is the first step toward success and is all too often overlooked by emerging leaders. In his book The7 habits of highly effective people, author Stephen Covey recommends that we start with the end in mind.  As a leader, having and sharing a greater goal is essential for producing collaborative teamwork and achieving the desired goal.   Writing in the Harvard Business Review, Kouzes and Posner state that when workers are asked to describe the characteristics of a great boss, creating and sharing a vision are rated as very important. Across the board, leadership trainers and coaches agree on the importance of a vision when attempting to develop a highly effective team.   Having a vision and implementing it is the difference between leading and managing.

What is a vision statement? A vision statement is a short sentence or tagline that defines where you want to go and describes your future state. Sharing the vision and encouraging collaboration helps to define how you will get there.  The vision statement should be easy to remember and it should align with the needs and goals of your workgroup as well as the mission of the larger organization. Individuals in a workgroup may disagree on technical issues, however, everyone should be in agreement with the greater vision. The vision statement must be well known to the group, be achievable, and function as a point of reference when administrative decisions are made. Always ask, “Does this decision/policy support our vision?”

Corporations often condense their vision into a catchphrase easily remembered by both their workforce and the public.

  • “Where imagination meets nature” – Seaworld
  • “To provide access to the world’s information in one click” – Google
  • “People working together as a lean, global enterprise for automotive leadership” – Ford

When both employees and customers know the vision, there is common ground for aligning expectations not only about what is to be done but also how business is to be conducted.

Vision statements are equally important in healthcare to provide focus to all members of the organization, both professional and support staff.   In my tenure at Baylor Scott & White Medical Center in Texas, any employee could be asked the vision of the organization – To be the most trusted and valued name in Healthcare in America – and it rolled off their lips.   Every employee knew and embraced the vision.  The Cleveland Clinic boasts that they have no employees, only caregivers. The tagline well known to every Cleveland Clinic employee is, “We are all caregivers.” Coincidentally, after adopting the tagline, employee engagement scores have improved throughout the organization.

Status quo is a powerful force. Vision and courage are needed to make meaningful changes. A new healthcare manager, James, was hired to be the Chief Nurse Anesthetist in a department known for low morale and recruiting problems. Clearly an opportunity for improvement existed and focus was needed to transform a dysfunctional workgroup into a collaborative team. As a new leader, James shared his vision “to be the Nurse Anesthesia employer of choice in America” and went to work communicating the vision with the group. In a subsequent meeting, each member of the group was asked to describe what would be required to achieve the vision. Discussion identified things that could be changed immediately and things that would need to change over time.   The group walked away enthused and engaged with a commitment to become an employer of choice. Over the following year, results were amazing and now the group has more applicants than openings and employee satisfaction scores have improved.   The success achieved by a group of Nurse Anesthetists with a shared vision is typical of what can happen in any group with a common focus.

All too often we laugh at comments like the Yogi Berra quote above and then continue to go through our daily tasks without a unifying vision or goal.   Just as GE is a place where “we bring good things to life,” a leader, must have a vision and then engage the group to bring life to the stated vision.

Watch for the follow-up article for tips on how to write and implement a vision.

Thomas Davis is an experienced clinical anesthetist, leader, author, speaker and teambuilding coach.

Employee Wellness is No Joke

Employee Wellness is No Joke
liz fitness

By Liz Sanner Davis.  Liz is a Certified personal trainer and frequent author for procrna.com

 

It’s one of the biggest jokes in the lay community. Q. Where can you find the sickest people? A. In a hospital!   You probably don’t think that’s funny because every day you look at people with broken arms or legs, or repeat patients who have brutally aggressive melanomas or who live with the consequences of diabetes. Their pain is not amusing. But the joke, the cynically funny part, is that the joke is really referring to the hospital employees, your physician or physician’s assistant, the chief surgeon or anesthetist, the head of HR or the department secretary, YOU. The overweight and out of shape hospital employee appears as a huge disappointment to patients who are sick and seek your help.

Two-hundred-plus years ago, extra body fat was considered to be a sign of wealth. Abbigail Adams, after all, was short and fat. In spite of her years of physical labor on the farm and having to endure significant revolutionary war shortages, Abby still “enjoyed” a majority of her years ingesting quantities of comfort food. She and others of wealth and repute often made huge contributions to society whilst making ample time, following the years of economic travails of the war, for sitting, eating and being served often, if not well.

Is that you? Are you, in spite of 40-50 hours per week on your feet, in spite of regular paychecks and good benefits, in spite of wellness issues smacking you with direct hits daily, are you fat and flabby with chronic pain that plagues you all the way to the peanut butter cups and chocolate bars in the break room? Well, then, the joke’s on you, ‘though the patient isn’t laughing.

Don’t get me wrong. Being laughed at is ok on occasion, but laughing with is a whole lot more fun, and being the laughingstock? Not fun at all. In a new society that likes to outsource responsibility for their health to the healthcare industry, what part of your health problem is theirs, and what part of the problem is yours to fix or to prevent?

One can follow the history of workplace wellness in a timeline that begins with centuries-old Asian cultures, where employers dictated the wellness rules to employees. Throughout central Europe taxpayers supported and still support mandatory month-long employee holidays, thermal baths included. In the 1800’s, westward across the pond the wealthy elite offered workplace exercise activities to other wealthy elite. George Pullman, of rail fame, was one of the first to provide for general employee onsite wellness. (http://www.marketwatch.com/story/companies-meddling-in-employee-health-since-1880-2013-04-11)

The1970’s until the present have brought gradual changes to wellness in America. We have tried to approach wellness the same way we approach politics – by keeping The Nutrition Party and the Exercise Party separate. But over the last 45+ years, we have learned that exercise coupled with nutrition equals wellness. Along the way during those 45 years, the cost of living, the cost of healthcare and, therefore, the cost of taxes has risen exponentially. Fewer people carry the large economic burden and as medical know-how improves and the need for healthcare increases, the health of over-worked, over-stressed and over-tired employees has created a greater need than ever for wellness in the workplace. Employers are stepping up.

 

  • Broward, in Ft. Lauderdale, Fla, advertises, “We are a hospital-based fitness center with professionals certified by the American College of Sports Medicine and the National Strength and Conditioning Association. Our staff includes nutritionists and personal trainers who are educated in exercise physiology and nutrition, helping you create a healthier body, inside and out.”
  • Employees at The Johns Hopkins, Baltimore, MD provide a wealth of options presented on a monthly calendar that guides employees to the right location whether to enjoy a walking program or a smoking cessation appointment. Incentives are offered to encourage participation and commitment, and who doesn’t love praise and free stuff?
  • Grant Health and Fitness Center in Columbus, Ohio promotes “…health enhancement and disease prevention.” It is associated with a vast network of area hospitals and all locations have employee-friendly hours, a no-excuses kind of offer to help you maintain your status as an employee rather than as a patient.
  • The Cooper Institute, Dallas, TX has associated itself with healthcare entities for decades and offers certification for employees to return to the workplace and develop wellness/fitness programs. The Cooper’s credible certification program attracts healthcare, corporate and government clients worldwide. 

 

Providing employee wellness programs like these benefits the employer as well as the participant. Company insurance rates go down based on number of participants and proven results. Employee absenteeism is significantly reduced. People who work out together, work better together. They’re happier and, usually, just nicer to be around. And the quality of work provided by the healthy employee improves the entire company culture. Good health should reduce healthcare costs and reduced health care costs should lower our taxes!

But, be ready to pay if you want to play. Everyone wants something for free. If one thing has a fee and the other is free, we all know we will try very hard to make the freebie work, even if it really doesn’t. And if something costs nothing, the likelihood that we will follow through with the acquisition diminishes along with the return.

If wellness and fitness programs are not available at your place of work, get on it. the gym manager to your department chair. Head to Dallas to get certified at the Cooper Institute. After a rigorous week or two of classes and examinations, you could be qualified to blaze some trails to a clinic back home in Mississippi or Wyoming.

If wellness and fitness programs are available at your place of work, get to it. Join a program or help design a new one. Arrange to work with a qualified trainer. Get a work-out buddy and give and get the support that a partner provides, even and especially if you get to make a new friend doing it. For quality results, be certain to follow an integrated program that includes nutrition along with fitness. Be prepared and willing to pay the fee if it isn’t free.

So, what card will you be at work – the joke or the joker? Peanut butter and banana sandwiches may be how many of us got through college, but not through life. Take advantage of the whole-meal-deal offered by the employer at your place of work, and remember: The changes you make, the integrated health that you display to the patient, increases their trust and respect in the entire healthcare industry. Together, the patient’s trust and your good health will leave a permanent impression on history.

 

More:

http://www.corporatewellnessmagazine.com/worksite-wellness/the-evolution-of/http://www.bethesdaweb.com/employee-wellness-programshttp://www.beckershospitalreview.com/hospital-management-administration/18-most-popular-wellness-programs-for-hospital-employees.html

http://www.fiercehealthcare.com/story/what-hospitals-are-doing-employee-wellness/2012-03-15

http://www.amnhealthcare.com/the-roi-of-hospital-employee-wellness-programs/

http://www.cooperinstitute.org/pub/class_list.cfm?course_id=303

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)

Clinical Topic: Predictors of Postoperative Sort Throat

As Anesthetists, we are known as airway experts.  Both Surgeons and patients trust our skills at maintaining an open airway to ensure patient safety.   At the end of the case, we wake our patients and take them to recovery with an open airway and then move on to the next patient.  In the midst of production pressure we lose sight of the minor things that cause discomfort to our patients.  Postoperative sore throat is an example.

Studies that assess patient concerns for surgery have found postoperative sore throat to be one of the top 10 concerns.  The reported incidence varies but several studies find it to be around 40%.  The problem is usually most severe in the first 6 hours after surgery and is common enough that many feel it is a natural consequence of general anesthesia.

In a study by Jaensson, Gupta, and Nilsson published in the August 2012 AANA Journal research edition, (Risk Factors for Development of Postoperative Sore Throat and Hoarsness After Endotracheal intubation in Women: A Secondary Analysis)  the authors gathered data to determine risk factors for development of postoperative sore throat.  Both patient demographic data and airway management techniques were reviewed.

The authors found that general anesthesia with endotracheal intubation can cause minor sore throat which is more common in the female population.  In most cases, symptoms are minor and resolve spontaneously, however in some cases sever sore throat can cause prolonged discomfort to the patient.  The authors found 3 risk factors for development of sore throat in women:

  • Age greater than 60
  • Use of a throat pack
  • Endotracheal tube size (#7 significantly more sore throats than #6)

The authors speculated that higher mallampati scores, therefore more difficult intubations, would increase the incidence of sore throat but that was not found to be true in this study.  The authors were surprised to find that cuff pressures below 20 were associated with an increased incidence of hoarsness.

The authors noted that the reason for the higher incidence of sore throat in women is unclear and requires further study.

Click here to read the original article published in the AANA Journal

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

 

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: New HIPAA rules released

On January 17th, HHS Office for Civil Rights Director Leon Rodriguez issued a press release announcing the new HIPAA rules being published by the HHS Office of Civil Rights.  The 563 page document strengthen the requirements placed on providers and institutions to protect the privacy and health care information of the patient.  According to Rodriguez “These changes not only greatly enhance a patient’s privacy rights and protections, but also strengthen the ability of my office to vigorously enforce the HIPAA privacy and security protections, regardless of whether the information is being held by a health plan, a health care provider, or one of their business associates.”

Some of the items in the new rule:

  • Increase the protection and control of health information.
  • Especially effects health information associates, contractors and subcontractors who help healthcare workers gather and store information.  Some of the largest breaches have been by associates.
  • Maximum penalty for violation has been increased to 1.5 million per violation
  • New rules also strengthen the requirement to report breaches to HHS and to notify the patient.
  • New rules make it easier for a patient to share their information for research purposes
  • Patients can ask for a copy of medical records in an electronic form
  • New rules regarding how information can be used for marketing and fundraising

The new rules add new regulations and stiff penalties related to gathering and storing protected information.  The actual implementation and enforcement of new rules will become apparent over the upcoming months but as anesthesia providers, we can expect questions about our health information security during future CMS visits.

For those with insomnia, click here to review the entire 563 page document

 

Chief CRNA: “Never Events” in Anesthesia

Never events are inexcusable actions in a health care setting, the things we talk about in the lounge and just can’t believe actually happened.   We wonder how somebody could have possibly made such a terrible mistake.  The National Quality Forum has formulated a list of 28 never events in the hospital setting.   In the Operating room, never events include things such as wrong patient, wrong operation, wrong body part, use of contaminated drugs and many other issues.  Click here for a list of never events.

A recent press release from Johns Hopkins University School of Medicine states that across the country, never events occur at lease 4000 times per year.  The press release refers to research done over a 10 year period to quantify the occurence rate of never events.  Among other things, the study found:  Of the 80,000 patients who were affected by never events, 6.6% died, 32.9 % suffered permanent injury, and 59.2% suffered temporary injury as a result of the mistake. The events also led to 9,744 paid malpractice claims over the same period with payments totaling $1.3 billion.

The press report mentions policies hospitals and healthcare centers can implement to prevent never events, including mandatory “timeouts” in the operating room before operations begin to make sure medical records and surgical plans match the patient on the table. Other steps include surgical checklists as well as surgical instruments with electronic bar codes that allow for precise counts of materials and limit human error.

Click here to read the press release from Johns Hopkins.

As  CRNAs, we are instrumental in developing a corporate culture of safety.  As leaders in the perioperative area, CRNAs can make a difference.

 

 

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: The Preanesthetic Set-up

Ensuring that the necessary equipment is present and in working condition is foundational in providing safe anesthetic care to each patient and is a standard of care to which we are held.  Patients expect their anesthetist to be properly prepared for each and every case.  The following comes from the Anesthesia Patient Safety Foundaton:

“While chatting with a patient about to undergo a laparoscopic cholecystectomy, you administer an induction dose of propofol and an intubating dose of vecuronium. The patient loses consciousness and spontaneous respiration ceases. You adjust the mask on the patient’s face to establish a secure fit and squeeze the reservoir bag, only to find that you are unable to deliver a positive pressure breath. A quick visual inspection of the breathing circuit does not reveal the cause of the problem. Can you reliably ventilate this patient before he becomes hypoxic? Is an alternative method of ventilation readily available and functioning? Is there a reliable source of oxygen? Furthermore, you are using a relatively new anesthesia machine that performs an automated checkout procedure. What functions of the anesthesia machine did the automated checkout actually evaluate? Did you perform a thorough check of the machine before use that could have detected the source of this problem?”

An article by Samuel Demaria, Jr., MD published in Anesthesia/Analgesia in 2011 titled Missed Steps in the Preanesthetic Set-Up  discusses common steps that are omitted in the set-up process and offers a revised set-up procedure with the following steps being essential on every case:

  • Manual ventilation device
  • Full machine checkout done
  • Adequate suction
  • Emergency airway devices (endotracheal tube, laryngeal mask airway)
  • Emergency drugs
  • Working IV
  • ASA monitors

The study found that The most frequently omitted step was the availability of a manual resuscitation device.  Another notable finding was that rooms with 5 or more cases scheduled had a higher incidence of missed steps when compared with rooms with less than 5 cases.

Click here to read the original article and review the guidelines.

The Anesthesia Patient Safety Foundation is committed to ensuring a safe anesthetic for every patient.  In the APSF newsletter Spring 2008, Jeffrey M. Feldman, MD, MSE  presented New Guidelines Available for Pre-Anesthesia Checkout.

Click here to read the article as published in the APSF newsletter.

“Do no harm” is one of the foundational tenets of healthcare and patients (and their lawyers) expect anesthesia providers to be prepared for each and every case.  Review the articles and guidelines above and return to procrna.com to leave a comment.

CRNA Topic: Volunteer Your Time and Talent.

Hello everyone.  I want to tell all of you about another exciting opportunity for us to pay it forward.  Earlier in the year, I wrote an article about volunteerism.  My first opportunity to teach other nurses anesthesia education outside of the United States was in Eritrea (Eastern Africa).  Now I am honored to have another opportunity to again be the Nurse Anesthesia program director for a joint venture between Health Volunteers Overseas and Johns Hopkins University.  I worked with Dr. John Sampson of Johns Hopkins for many years in the advancement of anesthesia education.  We first met and worked together as colleagues at Walter Reed Army Medical Center when I was on active duty in the early 2000’s.  Since then, Dr. Sampson and I have collaborated on anesthesia education overseas with great success.  Our next site is Sierra Leone in Western Africa.
The primary lecture site in country will be the Prince Christian Maternity Hospital.  Johns Hopkins already has a presence in Sierra Leone, so no one needs to worry that we are going to the site as the first educators from the U.S.  Currently one of the goals of the Hopkins program is to implement a distance-learning program for anesthetists in Sierra Leone.  Instructors in the program would be from Johns Hopkins, but also interested volunteers from HVO may be invited to participate.  Another CRNA colleague of mine, Terry English and I would screen and mentor HVO nurse anesthesia volunteers for involvement in Sierra Leone.  Length of engagement would be a minimum of 2 weeks.  Pending funding for the next iteration of nurse anesthesia students from the health ministry, the goal is to begin sending volunteers in March 2013.

The following list is the desired structure of the HVO / JHH program developed by Dr. Sampson and his colleagues at Hopkins.

•    There shall be an anesthesiology program director and a nurse anesthetist program director.
•    The two program directors will need to continuously communicate with each other about the activities and problems encountered in their respective areas.
•    Volunteers will come from a nation-wide pool of applicants and all volunteers will have to pass through the usual HVO process for registering and serving as a volunteer.
•    A Johns Hopkins based meeting will take place monthly where nurse anesthetists and anesthesiology physicians will discuss methods of enhancing the impact of educational efforts and methods of assessing this impact.
•    An effort will be made to teleconference and video-teleconference interested individuals who are remote to Johns Hopkins Hospital so that they may participate in the development of nurse anesthesia education in Sierra Leone.
•    Every effort will be made to accommodate the time of year choices made by the volunteer applicants.
•    Every effort will be made to coordinate the trips so that experienced travelers make trips in pairs with novice travelers.
•    All volunteers are asked to keep a record of both the intellectual and material contributions that they make toward improving nurse anesthesia education in Sierra Leone.
•    A discussion group web site will be established whereby Sierra Leone nurse anesthetists are able to discuss clinical and academic questions with past and future volunteers to the program.

According to Dr. Sampson, the latest information is as follows.  Current airfare ticket prices are approximately $1300.  Of course this will vary and the individual volunteer will need to research this accordingly.  The hotel rate negotiated is currently $80 per day (breakfast included) other meals are $7 per day.  Transportation from the hotel to hospital via taxi is about $5 each way.  Regarding cabs, we will generate a list of cab drivers with cell phones and encourage visitors to use the same drivers daily because in the morning the cab drivers are so busy picking up groups of people that finding a dedicated cab to the hospital can be a challenge.
The hotel is the Kona Lodge (http://thekonalodgesl.com).  The distance to the hospital is about 7 miles.  But due to traffic congestion, the trip can take up to 45 minutes.  The best time to travel to the hospital in the shortest amount of time would be in the early morning hours.
Our goal is 12 volunteers per year.  A standard classroom is available and is dedicated to nurse anesthesia education. An LCD projector can be arranged for presentations.  Johns Hopkins will assist with education program development.
Even though the country made headlines in the 90’s because of hostilities in the nation, since the peace of 2002 Sierra Leone has become a vibrant city attracting investors and holiday travelers alike.  Reconstruction is evident in many parts of the country.  However, Freetown has the usual Western comforts.  Plus the beaches are beautiful and not yet crowded by commercial ventures.  Leisure activities are centered around the Aberdeen Beach area.  Regarding attire for the volunteers, shorts pants  (shorts, mini skirts) are not recommended. Casual to business casual dress is appropriate attire.  Scrubs are to be worn in the hospital only.  Standard urban precautions against petty theft are prudent and plenty of Christian churches from a variety of denominations are present.
I urge any of you who read this to strongly consider volunteering.  Visit the HVOusa.org website and learn about what we do on a large scale.

If you have any questions please contact me at lexterrae1230@gmail.com.

Pamela Chambers, CRNA

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?