Imagining in Time: The Legacy of Olive Berger (1898-1981).

Olive Berger was a true nurse anesthesia pioneer for our profession. She dedicated her life to the advancement of nurse anesthesia through her leadership, advocacy, scholarly writing, clinical achievements and innovation. She blazed the trail by forming and establishing education requirements for nurse anesthesia programs, established a state nurse anesthesia organization, and led the American Association of Nurse Anesthetists as its 14th president in 1958. She was the Chief Certified Registered Nurse Anesthetist and Program Director at the Johns Hopkins Hospital and is best known for her collaboration with surgeons Dr. Alfred Blalock and Dr. Helen Taussig, providing anesthesia care during the groundbreaking repair of tetralogy of Fallot on infants.

Estimating conductive sapwood area in diffuse and ring porous trees with electronic resistance tomography.

Accurately estimating sapwood area is essential for modelling whole-tree or stand-scale transpiration from point-flow sap-flux observations. In this study, we tested the validity of electrical resistance tomography (ERT) to locate the sapwood-heartwood (SW/HW) interface for two ring porous (Quercus nigra L. and Quercus virginiana Mill.) and one diffuse porous (Acer rubrum L.) species. Estimates derived from the ERT analyses were compared with the SW/HW interface measured following dye perfusion testing. The ERT results revealed spatial variation in electrical resistance, with higher resistivity in the inner part of the cross sections. Regression analyses showed that ERT was able to accurately account for 97% and 80% of the variation in sapwood area (calculated as R2) for Q. virginiana (n = 19) and Q. nigra (n = 7), respectively, and 56% of the variation in the diffuse porous species (n = 8). Root mean square error (RMSE) values for sapwood areas of the ring porous species were 11.12 cm2 (19%) and 25.98 cm2 (33%) for Q. virginiana and Q. nigra, respectively. Sapwood area estimates for diffuse wood carried greater error (RMSE = 33.52 cm2 (131%)). Model bias for all sapwood area estimates was negative, suggesting that ERT had a tendency to overestimate sapwood areas. Electrical resistance tomography proved to be a significant predictor of sapwood area in the three investigated species, although it was more reliable for ring porous wood. In addition to the results, a comprehensive code sequence for use with R statistical software is provided, so that other investigators may follow the same method.

Initiating an Enhanced Recovery Pathway Program: An Anesthesiology Department's Perspective.

BACKGROUND: Enhanced recovery pathways (ERPs) for surgical patients may reduce variation in care and improve perioperative outcomes. Mainstays of ERPs are standardized perioperative pathways. At The Johns Hopkins Hospital (Baltimore), an integrated ERP was proposed to further reduce the surgical site infection rate and the longer-than-expected hospital length of stay in colorectal surgery patients. METHODS: To develop the technical components of the anesthesia pathway, evidence on enhanced recovery was reviewed and the limitations of the hospital infrastructure and policies were considered. The goals of the perioperative anesthesiology pathway were achieving superior analgesia, minimizing postoperative nausea and vomiting, facilitating patient recovery, and preserving perioperative immune function. ERP was implemented in phases during a 30-day period, starting with the anesthesiology elements and followed by the pre- and postoperative surgical team processes. The perioperative anesthetic regimen was tailored to meet the goal of preservation of perioperative immune function (in an attempt to decrease surgical site infection and cancer recurrence), in part by minimizing perioperative opioid use. RESULTS: After six months of exposure to all ERP elements, a 45% reduction in length of stay was observed among colorectal surgery patients. In addition, patient satisfaction scores for this cohort of patients improved from the 37th percentile preimplementation to >97th percentile postimplementation. CONCLUSIONS: Development of an ERP requires collaboration among surgeons, anesthesiologists, and nurses. Thoughtful, collaborative pathway development and implementation, with recognition of the strengths and weakness of the existing surgical health care delivery system, should lead to realization of early improvement in outcomes.

Organizational Culture Changes Result in Improvement in Patient-Centered Outcomes: Implementation of an Integrated Recovery Pathway for Surgical Patients.

BACKGROUND: The goals of quality improvement are to partner with patients and loved ones to end preventable harm, continuously improve patient outcomes and experience, and eliminate waste, yet few programs have successfully worked on of all these in concert. STUDY DESIGN: We evaluated implementation of a pathway designed to improve patient outcomes, value, and experience in colorectal surgery. The pathway expanded on pre-existing comprehensive unit-based safety program infrastructure and used trust-based accountability models at each level, from senior leaders (chief financial officer and senior vice president for patient safety and quality) to frontline staff. It included preoperative education, mechanical bowel preparation with oral antibiotics, chlorhexidine bathing, multimodal analgesia with thoracic epidurals or transversus abdominus plane blocks, a restricted intravenous fluids protocol, early mobilization, and resumption of oral intake. Eleven months of pre- and post-pathway outcomes, including length of stay (LOS), National Surgical Quality Improvement Program surgical site infection (SSI), venous thromboembolism, and urinary tract infection rates, patient experience, and variable direct costs were compared. RESULTS: Three hundred ten patients underwent surgery in the baseline period, the mean LOS was 7 days, and the mean SSI rate was 18.8%. There were 330 patients who underwent surgery on the pathway, the LOS was 5 days, and the rate of SSI was 7.3%. Patient experience improved and variable direct costs decreased. CONCLUSIONS: Our trust-based accountability model, which included both senior hospital leadership and frontline providers, provided an enabling structure to rapidly implement an integrated recovery pathway and quickly improve outcomes, value, and experience of patients undergoing colorectal surgery. The study findings have significant implications for spreading surgical quality improvement work.