Methods and evaluation metrics for reducing material waste in the operating room: a scoping review.

BACKGROUND: Operating rooms contribute up to 70% of total hospital waste. Although multiple studies have demonstrated reduced waste through targeted interventions, few examine processes. This scoping review highlights methods of study design, outcome assessment, and sustainability practices of operating room waste reduction strategies employed by surgeons. METHODS: Embase, PubMed, and Web of Science were screened for operating room-specific waste-reduction interventions. Waste was defined as hazardous and non-hazardous disposable material and energy consumption. Study-specific elements were tabulated by study design, evaluation metrics, strengths, limitations, and barriers to implementation in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. RESULTS: A total of 38 articles were analyzed. Among them, 74% of studies had pre- versus postintervention designs, and 21% used quality improvement instruments. No studies used an implementation framework. The vast majority (92%) of studies measured cost as an outcome, whereas others included disposable waste by weight, hospital energy consumption, and stakeholder perspectives. The most common intervention was instrument tray optimization. Common barriers to implementation included lack of stakeholder buy-in, knowledge gaps, data capture, additional staff time, need for hospital or federal policies, and funding. Intervention sustainability was discussed in few studies (23%) and included regular waste audits, hospital policy change, and educational initiatives. Common methodologic limitations included limited outcome evaluation, narrow scope of intervention, and inability to capture indirect costs. CONCLUSION: Appraisal of quality improvement and implementation methods are critical for developing sustainable interventions for reducing operating room waste. Universal evaluation metrics and methodologies may aid in both quantifying the impact of waste reduction initiatives and understanding their implementation in clinical practice.

The Technology of Video Laryngoscopy.

Tracheal intubation via laryngeal exposure has evolved over the past 150 years and has greatly expanded in the last decade with the introduction and development of newer, more sophisticated optical airway devices. The introduction of indirect and video-assisted laryngoscopes has significantly impacted airway management as evidenced by the presence of these devices in the majority of published difficult airway algorithms. However, it is quite possible that many airway managers do not have a thorough comprehension of how these devices actually function, an understanding that is vital not only for their use but also for assessing the devices' limitations. This article discusses the development of video laryngoscopy, how the video laryngoscope works, and the impact of video laryngoscopy on difficult airway management.

Anesthetic management and human factors in the intraoperative MRI environment.

PURPOSE OF REVIEW: The use of intraoperative MRI technology during neurosurgery has become increasingly more common over the past several years. These surgical procedures require a specialized operating room designed to accommodate an MRI machine, as well as MRI-compatible anesthesia equipment and monitors. The MRI environment also poses unique risks and challenges to both patients and medical staff. RECENT FINDINGS: General anesthesia in the MRI operating room suite poses several challenges not routinely experienced in a conventional operating room suite, and anesthesia providers delivering care in these suites must complete specialized training and screening. The presence of a magnetic field, as well as reduced access to the patient during the MRI scan, require high levels of vigilance. SUMMARY: The use of checklists and teamwork training can maximize both patient and provider safety in the intraoperative MRI environment.

Difficult airway response team: a novel quality improvement program for managing hospital-wide airway emergencies.

BACKGROUND: Difficult airway cases can quickly become emergencies, increasing the risk of life-threatening complications or death. Emergency airway management outside the operating room is particularly challenging. METHODS: We developed a quality improvement program-the Difficult Airway Response Team (DART)-to improve emergency airway management outside the operating room. DART was implemented by a team of anesthesiologists, otolaryngologists, trauma surgeons, emergency medicine physicians, and risk managers in 2005 at The Johns Hopkins Hospital in Baltimore, Maryland. The DART program had 3 core components: operations, safety, and education. The operations component focused on developing a multidisciplinary difficult airway response team, standardizing the emergency response process, and deploying difficult airway equipment carts throughout the hospital. The safety component focused on real-time monitoring of DART activations and learning from past DART events to continuously improve system-level performance. This objective entailed monitoring the paging system, reporting difficult airway events and DART activations to a Web-based registry, and using in situ simulations to identify and mitigate defects in the emergency airway management process. The educational component included development of a multispecialty difficult airway curriculum encompassing case-based lectures, simulation, and team building/communication to ensure consistency of care. Educational materials were also developed for non-DART staff and patients to inform them about the needs of patients with difficult airways and ensure continuity of care with other providers after discharge. RESULTS: Between July 2008 and June 2013, DART managed 360 adult difficult airway events comprising 8% of all code activations. Predisposing patient factors included body mass index >40, history of head and neck tumor, prior difficult intubation, cervical spine injury, airway edema, airway bleeding, and previous or current tracheostomy. Twenty-three patients (6%) required emergent surgical airways. Sixty-two patients (17%) were stabilized and transported to the operating room for definitive airway management. There were no airway management-related deaths, sentinel events, or malpractice claims in adult patients managed by DART. Five in situ simulations conducted in the first program year improved DART's teamwork, communication, and response times and increased the functionality of the difficult airway carts. Over the 5-year period, we conducted 18 airway courses, through which >200 providers were trained. CONCLUSIONS: DART is a comprehensive program for improving difficult airway management. Future studies will examine the comparative effectiveness of the DART program and evaluate how DART has impacted patient outcomes, operational efficiency, and costs of care.

A novel role for otolaryngologists in the multidisciplinary Difficult Airway Response Team.

OBJECTIVES/HYPOTHESIS: The Difficult Airway Response Team (DART) was implemented in July 2008 to address emergent difficult airway situations. The main objective of this study was to highlight the unique role and skill set that otolaryngologists bring and their impact on patient outcomes. STUDY DESIGN: Retrospective review of prospectively collected data from the hospital's airway registry. METHODS: We collected data on demographics, airway characteristics, airway management techniques used by each specialty, and clinical outcomes (such as cricothyrotomies) for patients for whom a code was activated between July 2006 and June 2010. We compared data between pre- and post-DART cohorts and between DART and non-DART patients using a matched case-control approach. RESULTS: Of the 2,826 codes, 90 patients required DART management between July 2008 and June 2010. Body mass index, cervical spine injury/fixation, history of difficult airway, head and neck mass, and oropharyngeal and/or supraglottic angioedema were identified as significant predictors for DART activation. Forty-nine (60%) patients' airways were secured by anesthesiologists, 30 (36%) by otolaryngologists, and three (4%) by trauma surgeons. Otolaryngologists were able to use specialized techniques such as Holinger and Dedo laryngoscopes to significantly decrease the number of cricothyrotomies from seven (0.73%) pre-DART implementation to four (0.21%) post-DART implementation. CONCLUSIONS: Otolaryngologists were able to decrease the need for cricothyrotomies using specialized techniques for patients with difficult airways. Otolaryngologists bring a special skill set to the DART that is beyond the scope of anesthesiologists and trauma surgeons and that can improve patient outcomes by preventing unnecessary emergency surgical airways.

Complications of airway management.

Although endotracheal intubation is commonly performed in the hospital setting, it is not without risk. In this article, we review the impact of endotracheal intubation on airway injury by describing the acute and long-term sequelae of each of the most commonly injured anatomic sites along the respiratory tract, including the nasal cavity, oral cavity, oropharynx, larynx, and trachea. Injuries covered include nasoseptal injury, tongue injury, dental injury, mucosal lacerations, vocal cord immobility, and laryngotracheal stenosis, as well as tracheomalacia, tracheoinnominate, and tracheoesophageal fistulas. We discuss the proposed mechanisms of tissue damage that relate to each and present their most common clinical manifestations, along with their respective diagnostic and management options. This article also includes a review of complications of airway management pertaining to video laryngoscopy and supraglottic airway devices. Finally, potential strategies to prevent intubation-associated injuries are outlined.

Mechanical airway obstruction due to dislodged spinal hardware.

A difficult airway caused by mechanical obstruction from dislodged spinal hardware in a patient undergoing revision surgery for a cervical chordoma is presented. Due to the logical, sequential multidisciplinary airway and patient management by the anesthesiology, neurosurgery, and otolaryngology teams working together in an environment of clear communication, a potential life-threatening crisis was averted with successful outcome for the patient.

A novel approach to implementation of quality and safety programmes in anaesthesiology.

Far too many patients suffer preventable harm from medical errors that add to needless suffering and cost of care. Underdeveloped residency training programmes in patient safety are a major contributor to preventable harm. Consequently, the Institute of Medicine has called for health professionals to reform their educational programmes to advance health-care safety and quality. Additionally, the Accreditation Council for Graduate Medical Education (ACGME) now requires education in 'systems-based practice' and 'practice-based learning and improvement' as core competencies of residency training programmes. The specific aim of this article is to describe the implementation of a novel programme designed to enhance residency education, meet ACGME core competencies and improve quality and safety education in one residency programme at an academic medical institution.

Use of the Laryngeal Mask Airway-Aintree Intubating Catheter-fiberoptic bronchoscope technique for difficult intubation.

STUDY OBJECTIVE: To determine whether intubation using an Aintree Intubation Catheter (AIC), fiberoptic intubation (FOB), and Laryngeal Mask Airway (LMA) is safe and effective for securing the airway in patients who are difficult to intubate after induction of general anesthesia. DESIGN: Retrospective review of departmental difficult airway database procedures completed between July 2006 and December 2009. SETTING: Academic medical center. MEASUREMENTS AND MAIN RESULTS: During the study period, 128 of 500 patients entered into the difficult airway database underwent the LMA-AIC-FOB technique for intubation. One hundred nineteen (93%) of the 128 patients were successfully intubated by the LMA-AIC-FOB technique, and 9 required an alternate technique. No patient who underwent the LMA-AIC-FOB technique experienced an airway-related mortality or required an emergency surgical airway procedure. CONCLUSION: The LMA-AIC-FOB technique is safe and effective for patients who are difficult to intubate after induction of anesthesia.

Blood wastage reduction using Lean Sigma methodology.

BACKGROUND: Red blood cell (RBC) product wastage in hospitals is reported to range from 0.1% to 6.7%. Wastage at our institution averaged 4.4% of 63,000 issued RBC products. Data indicated that approximately 87% of wasted RBC units were either individual units that were out of blood bank for more than 30 minutes (dispensed but not administered) or units packed in transport containers that had temperature indicators affixed to each unit. We hypothesized that Lean Sigma methodology could be used to reduce RBC wastage by 50%. STUDY DESIGN AND METHODS: An interdisciplinary hospital team (transfusion medicine, nursing, and anesthesiology) used Lean Sigma methodology as a tool to reduce RBC product wastage, with a focus on container wastage, which was determined to yield the largest impact. Using the five-part Lean Sigma process-define, measure, analyze, improve, and control-the team collected baseline wastage data, identified major factors affecting RBC product wastage, and implemented interventions to reduce amount of wastage. RESULTS: Factors identified as contributors to RBC wastage most amenable to improvement were lack of awareness and training of staff ordering and handling RBC products, management of temperature-validated containers, inconsistent interpretation of RBC temperature indicators, and need for accountability when ordering blood products. Overall RBC product wastage decreased from 4.4% to a sustained rate of less than 2%. This reduction decreased the number of RBC units wasted by approximately 4300 per year, savings approximately $800,000 over the 4-year period of the study. CONCLUSIONS: Lean Sigma methodology was an effective tool for reducing RBC wastage in a large academic hospital.

Need for emergency surgical airway reduced by a comprehensive difficult airway program.

BACKGROUND: Inability to intubate and ventilate patients with respiratory failure is associated with significant morbidity and mortality. A patient is considered to have a difficult airway if an anesthesiologist or other health care provider experienced in airway management is unable to ventilate the patient's lungs using bag-mask ventilation and/or is unable to intubate the trachea using direct laryngoscopy. METHODS: We performed a retrospective review of a departmental database to determine whether a comprehensive program to manage difficult airways was associated with a reduced need to secure the airway surgically via cricothyrotomy or tracheostomy. The annual number of unplanned, emergency surgical airway procedures for inability to intubate and ventilate reported for the 4 yr before the program (January 1992 through December 1995) was compared with the annual number reported for the 11 yr after the program was initiated (January 1996 through December 2006). RESULTS: The number of emergency surgical airways decreased from 6.5 +/- 0.5 per year for 4 yr before program initiation to 2.2 +/- 0.89 per year for the 11-yr period after program initiation (P < 0.0001). During the 4-yr period from January 1992 through December 1995, 26 surgical airways were reported, whereas only 24 surgical airways were performed in the subsequent 11-yr period (January 1996 through December 2006). CONCLUSIONS: A comprehensive difficult airway program was associated with a reduction in the number of emergency surgical airway procedures performed for the inability of an anesthesiologist to intubate and ventilate, a reduction that was sustained over an 11-yr period. This decrease occurred despite an increase in the number of patients reported to have a difficult airway and an overall increase in the total number of patients receiving anesthesia per year.

Prospective evaluation of pain and analgesic use following major elective intracranial surgery.

OBJECT: Opioid administration after major intracranial surgery is often limited by a presumed lack of need and a concern that opioids will adversely affect the postoperative neurological examination. The authors conducted a prospective study to evaluate the incidence, severity, and treatment of postoperative pain in patients who underwent major intracranial surgery. METHODS: One hundred eighty-seven patients (77 men and 110 women, mean age 52 +/- 15 years, mean weight 78.1 +/- 19.9 kg) underwent either supratentorial (129 patients) or infratentorial (58 patients) procedures. Sixty-nine percent of the patients reported experiencing moderate to severe pain (> or =4 on a 0-10 scale) during the 1st postoperative day. Pain scores greater than or equal to 4 persisted in 48% on the 2nd postoperative day. Approximately 80% of patients were treated with acetaminophen on the 1st postoperative day, whereas opioids (primarily intravenous fentanyl) were administered to 58%. Compared with patients who underwent supratentorial procedures, those who underwent infratentorial procedures reported more severe pain at rest (mean score 4.9 +/- 2.2 compared with 3.8 +/- 2.6; p = 0.015) and with movement (mean score 6.3 +/- 2.6 compared with 4.5 +/- 2.7; p < 0.001) on the 1st postoperative day. On both the 1st and 2nd postoperative days, patients who underwent infratentorial procedures received greater quantities of opioid (p < or = 0.019) and nonopioid (p < or = 0.013) analgesics than those who underwent supratentorial procedures. Patients' dissatisfaction with analgesic therapy was significantly associated with elevated pain levels on the first 2 postoperative days (p < 0.001). CONCLUSIONS: In contrast to prevailing assumptions, the study findings reveal that most patients undergoing elective major intracranial surgery will experience moderate to severe pain for the first 2 days after surgery and that this pain is often inadequately treated.

Strategies for airway management.

Airway management is a critical part of anaesthesia practice. Management includes mask ventilation, laryngoscopy, endotracheal intubation and extubation of the patient. Difficulty can be encountered at any of these stages, potentially resulting in significant complications. Thorough preoperative assessment, as well as careful planning and preparation, can reduce the potential for complications. The American Association of Anesthesiologists (ASA) developed and recently revised guidelines for the management of the difficult airway. These guidelines focus on strategies for intubation as well as alternative airway techniques that can be used when a patient with a difficult airway is encountered.