Using Simulation to Enhance Education Regarding Epidural Analgesia for Registered Nurses.

BACKGROUND: Registered nurses (RNs) receive didactic training regarding caring for patients receiving epidural analgesia. Although RNs are tested on their knowledge after this training, their ability to critically think through adverse events has not been assessed at our institution. AIM: The aim of this study was to examine the feasibility and effectiveness of simulation education for RNs regarding the assessment and management of patients receiving epidural analgesia. METHOD: The study included an education intervention, which consisted of a 4-hour workshop. After obtaining informed consent, RNs completed a preworkshop evaluation of skill performance where they completed an Objective Structured Clinical Examination (OSCE) in which they demonstrated an epidural assessment of a standardized patient. RNs then completed a demographic and knowledge questionnaire followed by a lecture regarding care, management, and assessment of patients who are receiving epidural analgesia. After the lecture, RNs practiced epidural assessments within small groups. A postworkshop OSCE, questionnaire, and debriefing were completed before the end of the workshop. RESULTS: Thirty-seven RNs completed the workshop. The mean age of participants was 43 years. For the pre- and postworkshop knowledge questionnaire, there was significant improvement in answers related to epidural pharmacology and assessment of blockade questions. For the pre- and postworkshop OSCE, there was a significant increase in the number of correct procedures performed in all categories, with the exception of assessment of equipment. There was also a significant change in the proportion of RNs who stated that they felt confident in their assessment of a patient receiving epidural analgesia.

Pain After Unilateral Total Knee Arthroplasty: A Prospective Randomized Controlled Trial Examining the Analgesic Effectiveness of a Combined Adductor Canal Peripheral Nerve Block with Periarticular Infiltration Versus Adductor Canal Nerve Block Alone Versus Periarticular Infiltration Alone.

BACKGROUND: Total knee arthroplasty is a painful surgery that requires early mobilization for successful joint function. Multimodal analgesia, including spinal analgesia, nerve blocks, periarticular infiltration (PI), opioids, and coanalgesics, has been shown to effectively manage postoperative pain. Both adductor canal (AC) and PI have been shown to manage pain without significantly impairing motor function. However, it is unclear which technique is most effective. This 3-arm trial examined the effect of AC block with PI (AC + PI) versus AC block only (AC) versus PI only (PI). The primary outcome was pain on walking at postoperative day (POD) 1. METHODS: One hundred fifty-one patients undergoing unilateral total knee arthroplasty were included. Patients received either AC block with 30 mL of 0.5% ropivacaine or sham block. PI was performed intraoperatively with a 110-mL normal saline solution containing 300 mg ropivacaine, 10 mg morphine, and 30 mg ketorolac. Those patients randomly assigned to AC only received normal saline knee infiltration. RESULTS: On POD 1, participants who received AC + PI reported significantly lower pain numeric rating scale scores on walking (3.3) compared with those who received AC (6.2) or PI (4.9) (P < 0.0001). Participants who received AC reported significantly higher pain scores at rest and knee bend compared with those who received AC + PI or PI (P < 0.0001). The difference in pain scores between participants who received AC + PI and those who received AC was 2.83 (95% confidence interval, 1.58-4.09) and the difference between those who received AC + PI and those who received PI was 1.61 (95% confidence interval, 0.37-2.86). On POD 2, participants who received AC + PI reported significantly less pain on walking (4.4) compared with those who received AC (5.6) or PI (5.6) (P = 0.006). On POD 2, there was no difference between the groups for pain at rest or knee bending. Participants who received AC used more IV patient-controlled analgesia on POD 0. There was no difference between the groups regarding distance walked. CONCLUSIONS: Participants who received AC + PI reported significantly less pain on walking on PODs 1 and 2 compared with those who received AC only or PI only.

Prediction of the time to complete a series of surgical cases to avoid cardiac operating room overutilization.

PURPOSE: Operating room (OR) efficiency could be improved by reducing overutilization. In this article we suggest a methodology to accurately determine the time to complete a series of surgical cases in a single cardiac OR to avoid overutilization. Our methodology includes the basic assumptions that the first case starts on time, there are no add-on cases, and there is a predetermined OR time allocation. METHODS: We studied 6,090 cases performed by the department of cardiovascular surgery service at St. Michael's Hospital. Lognormal distributions were fitted to surgical times and turnover times. The distribution of the duration of the schedule was estimated using the Fenton-Wilkinson approximation. A simple model utilizing these distributions was then applied to three months of data to determine if overutilization could be predicted using the model. RESULTS: The mean difference between the actual schedule duration and the average duration was 0.19 hr (11.64 min). The difference with the second tertile cut-off point was 0.59 hr (35.40 min). Schedules that overran were correctly predicted by the average duration in 86.49% of the cases (with 12 false predictions), and they were correctly predicted by the second tertile cut-off point in 94.59% of the cases (with 26 false predictions). CONCLUSIONS: These results suggest that the sum of the average duration of surgeries and turnover times is indeed a good estimator of the duration of the series of surgical cases. Neither the estimated averages nor the second tertile cut-off points were useful to predict overrun when used alone. The use of the estimated average duration of the schedule, validated by use of the second tertile cut-off point, could reduce overtime when allocating surgeries in a single cardiac OR.

Speckle tracking for the intraoperative assessment of right ventricular function: a feasibility study.

OBJECTIVES: Speckle tracking is an ultrasound method that assesses B-mode features to measure tissue displacement and derive deformation parameters. The objective of this study was to assess the feasibility of using speckle tracking in the measurement of right ventricular (RV) longitudinal strain during cardiac surgery using transesophageal echocardiography (TEE). DESIGN: This was a prospective, observational cohort study. SETTING: A single university hospital setting. PARTICIPANTS: Twenty-one patients without valvular disease referred for coronary artery bypass graft surgery were studied. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: After the induction of anesthesia and mechanical ventilation, transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) were used to obtain tricuspid annular plane systolic excursion (TAPSE), RV fractional area of change (FAC), and 2-dimensional strain analysis (speckle tracking) on 3 consecutive heart beats. There was a larger percentage of measurable segments achieved when using TEE. All segments could be analyzed per cardiac cycle in 73% of loops when using TEE and 38% when using TTE. The global strain value was similar using both methods (TEE: -20.4%, TTE: -20.1%). The TAPSE could be measured in only 52% of the segments using TTE and 100% using TEE. The FAC could be measured in 90.5% of the loops using TEE and in only 33.3% of the loops using TTE. CONCLUSIONS: Perioperative measurements of RV strain using TEE in ventilated patients is feasible. The success rate was higher using TEE in ventilated patients under anesthesia. Differences between the 2 methods were likely the result of differences in 2-dimensional image quality.

From a project to transformation: how "going against the flow" led to improved access and patient flow in an academic hospital.

A results-driven approach to optimizing patient flow, grounded on quality improvement, change management and organizational learning principles, is described. Tactics included collaborative governance, performance management, rapid process improvements and implementation toolkits. Results included an 83.1% decrease in emergent volumes waiting for greater than 24 hours and a 49.1% improvement in emergency department length of stay for admitted patients. There were no adverse outcomes on other key indicators. Sustainability remains the challenge but early results are encouraging.

Induction of anesthesia does not alter tricuspid annular velocities: a tissue Doppler assessment.

PURPOSE: In this prospective observational cohort study, we investigated whether tricuspid annular velocities (TAV) are altered after induction of anesthesia in patients undergoing coronary artery bypass graft (CABG) surgery. METHODS: Twenty-four elective CABG patients were assessed before and after induction of anesthesia, and a convenience sample of nine healthy volunteers was used for comparison of TAV only. Measurements included mean arterial pressure (MAP), heart rate (HR), pulmonary artery pressure (PAP), and cardiac index (CI) as assessed post-induction. Tricuspid annular plane systolic excursion (TAPSE) was measured in anatomical M-mode. The S (systolic) wave velocity and isovolemic acceleration (IVA) were measured from colour tissue Doppler (TD). Paired and unpaired Student's t tests were used to compare all variables pre-and post-induction. RESULTS: In response to anesthetic induction, MAP decreased from 105 +/- 14 to 79 +/- 9 mmHg, but HR was unchanged (67 +/- 13 beats x min(-1) pre-induction compared with 67 +/- 9 beats x min(-1) post-induction). The mean PAP and CI post-induction were 20 +/- 6 mmHg and 2.3 +/- 0.4 L x min(-1) x m(-2), respectively. While there was no change post-induction in either S velocity (8.80 +/- 1.23 vs 9.0 +/- 1.92 cm x sec(-1)) or IVA (1.63 +/- 0.61 vs 1.84 +/- 0.83 m x sec(-2)), TAPSE decreased from 23 +/- 4 to 21 +/- 4 mm (P = 0.039). All pre-induction echocardiographic variables were lower in the CABG group compared with the normal group (IVA: 2.34 +/- 0.34 m x sec(-2), S wave: 11.14 +/- 2.78 cm x sec(-1), TAPSE 2D: 26 +/- 4 mm), respectively. CONCLUSIONS: Induction of anesthesia for CABG surgery does not alter velocity-based parameters of RV function. There was a small decrease in TAPSE. The TD parameters were lower in CABG patients compared with the normal group.

The effect of heart rate on tricuspid annular velocities in cardiac surgical patients with atrial fibrillation.

OBJECTIVES: Tricuspid annular isovolumic acceleration is a load-independent measure of contractility, but its relationship to heart rate is unknown in humans. The authors investigated the effect of heart rate on measurements of isovolumic acceleration and systolic wave velocities in postoperative cardiac surgical patients with atrial fibrillation. DESIGN: This was a prospective observational study. SETTING: Single-university hospital setting. PARTICIPANTS: Postoperative cardiac surgical patients with atrial fibrillation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Lateral tricuspid isovolumic acceleration and peak systolic wave velocity were measured using color-tissue Doppler. The corresponding heart rate was calculated from the preceding R-R interval. Regression analysis was used to assess the relationship between heart rate and tricuspid annular velocity. A heart rate threshold value was determined at which the tissue Doppler variables were significantly altered by heart rate. Seven hundred fifteen beats in 15 patients were analyzed. There was a positive linear correlation between isovolumic acceleration and heart rate and a negative polynomial correlation between the systolic wave and heart rate. A significant reduction in systolic wave velocity occurred at heart rates greater than 110 beats/min. CONCLUSIONS: In this patient population, isovolumic acceleration significantly increased with increasing heart rate. Tachycardia-induced preload alterations and impaired force-frequency responses may have been responsible for the decrease in systolic wave velocities.

Regional differences in color tissue Doppler-derived measures of longitudinal right ventricular function using transesophageal and transthoracic echocardiography.

OBJECTIVE: This study was designed to compare the right ventricular (RV) Doppler tissue imaging parameters of tricuspid annular isovolumic acceleration (IVA), systolic velocity (S), and basilar myocardial strain and strain rate (SR) by using both transesophageal echocardiography (TEE) (inferior wall) and transthoracic echocardiography (TTE) (free wall) in a cardiac surgical population under general anesthesia. DESIGN: Prospective observational study. SETTING: University hospital. PARTICIPANTS: Twenty-four elective patients undergoing coronary artery bypass surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Under general anesthesia, simultaneous Doppler tissue-imaging measurements of tricuspid annular velocities and basilar myocardial deformation were performed by using both TEE and TTE approaches. Interclass correlation coefficients were used to compare the measurements using both methods. When TEE and TTE methods were compared, there was good correlation for the IVA (r = 0.70) but no correlation for S-wave velocities, strain, and SR. The S-wave velocities were lower using the TEE approach. The basilar strain and SR were higher using the TEE approach. CONCLUSIONS: In cardiac surgical patients under anesthesia, the IVA appears to be the most consistent variable in the evaluation of RV function measured by either the TTE (lateral wall) or TEE (inferior wall). Technical difficulties may preclude the use of the deformation parameters in the assessment of RV function.

Right ventricular tissue Doppler parameters in a patient with massive pulmonary embolus.

We present right ventricular tissue Doppler findings in a 41-year-old man with pelvic fracture who had a near-fatal pulmonary embolus. We found small early systolic lengthening and reduced delayed systolic shortening using strain and strain rate imaging. There were also delayed and fused diastolic waves. Normal systolic tricuspid annular velocities were absent and there was only one late tricuspid annular ascent velocity. Strain, strain rate, and tricuspid annular velocities were normalized early after surgical embolectomy.

Tricuspid annular velocity in patients undergoing cardiac operation using transesophageal echocardiography.

BACKGROUND: The complex geometry of the right ventricle (RV) and poor endocardial definition make quantitative assessment of RV function difficult. Doppler tissue imaging may be helpful in quantifying RV function through measurement of tricuspid annular velocity (TAV). This prospective study assessed the feasibility of using color Doppler tissue imaging to measure TAV using a novel transgastric RV inflow view in patients undergoing cardiac surgery. METHODS: We used the transgastric RV inflow view and measured the TAV using Doppler tissue imaging and quantitative analysis software. We also measured left ventricular fractional area of contraction and hemodynamic variables. We compared values before and after cardiopulmonary bypass in patients undergoing coronary artery bypass graft. RESULTS: TAV could be measured in 19 of 23 patients (83%) undergoing coronary artery bypass graft. There was a significant decrease postbypass in TAV: isovolumic acceleration was 1.71 +/- 0.59 versus 1.32 +/- 0.66 m/s2, isovolumic velocity was 4.34 +/- 1.19 versus 3.13 +/- 1.35 cm/s, and systolic annular descent velocity was 5.15 +/- 1.15 versus 3.77 +/- 1.18 cm/s. There was a significant change in heart rate and cardiac index without any change in stroke volume index. There was no change in left ventricular function (fractional area of contraction: 54 +/- 10 vs 52 +/- 10%). CONCLUSION: Determination of TAV using the transgastric RV inflow view is feasible and may provide quantitative information on systolic RV function in patients undergoing coronary artery bypass graft. We found a decrease in systolic TAV after cardiopulmonary bypass without a significant change in stroke volume index.