Continuous Quality Improvement Measured With Time-Driven Activity-Based Costing in an Outpatient Cancer Surgery Center.

PURPOSE: As health care costs rise, continuous quality improvement and increased efficiency are crucial to reduce costs while providing high-quality care. Time-driven activity-based costing (TDABC) can help identify inefficiencies in processes of cancer care delivery. This study measured the process performance of Port-a-Cath placement in an outpatient cancer surgery center by using TDABC to evaluate patient care process. METHODS: Data were collected from the Anesthesia Information Management System database and OneConnect electronic health record (EHR) for Port-a-Cath cases performed throughout four phases: preintervention (phase I), postintervention, stabilization, and pre-new EHR (phases II and III), and post-new EHR (phase IV). TDABC methods were used to map and calculate process times and costs. RESULTS: Comparing all phases, as measured with TDABC methodology, a decrease in post-anesthesia care unit (PACU) length of stay (LOS) was identified (83 minutes v 67 minutes; P < .05). The decrease in PACU LOS correlated with increased efficiency and decreasing process costs and PACU nurse resource use by fast tracking patients for Port-a-Cath placement. Port-a-Cath placement success and the functionality of ports remained the same as patient experience improved. CONCLUSION: TDABC can be used to evaluate processes of care delivery to patients with cancer and to quantify changes made to those processes. Patients' PACU LOS decreased on the basis of the 2013 Port-a-Cath process improvement initiative and after implementation of a new EHR, over the course of 3 years, as quantified by TDABC. TDABC use can lead to improved efficiencies in patient care delivery that are quantifiable and measurable.

Effect of adjunctive dexmedetomidine on postoperative intravenous opioid administration in patients undergoing thyroidectomy in an ambulatory setting.

STUDY OBJECTIVE: Two of the most feared complications for patients undergoing thyroid surgery are pain and postoperative nausea and vomiting. Thyroidectomy is considered high risk for postoperative nausea and vomiting, and recent studies have looked at adjuncts to treat pain, limit narcotic use, "fast-track" the surgical process, and enhance recovery without compromising the patient's safety. One such perioperative medication of interest is dexmedetomidine (Dex), a centrally acting α-2 agonist that has been associated with reducing pain and postoperative opioid consumption. Our aim was to examine the effectiveness of Dex as an adjunctive intraoperative medication to reduce postoperative narcotic requirements in patients undergoing outpatient thyroid surgery. DESIGN, SETTING, PATIENTS AND INTERVENTION: After obtaining approval from the Institutional Review Board at The University of Texas MD Anderson Cancer Center, we searched the electronic medical record for the period October 2013 to March 2015 to identify patients who had undergone thyroid surgery in the ambulatory setting under general anesthesia. MEASUREMENTS AND MAIN RESULTS: A total of 71 patients underwent thyroidectomy or thyroid lobectomy in the outpatient setting. Of the patients receiving adjunctive Dex, a lower proportion (50%, n=9) received postoperative intravenous opioids when compared with control patients (79%, n=42) (P=.017). One patient (5%) in the Dex group required rescue postoperative antiemetics as compared to 11 (21%) patients in the control group (P=.273). CONCLUSIONS: Our data suggest that intraoperative use of Dex reduced narcotic administration in the postoperative period among study population patients undergoing thyroidectomy.

The Impact of Paravertebral Block Analgesia on Breast Cancer Survival After Surgery.

BACKGROUND AND OBJECTIVES: The impact of regional anesthesia on breast cancer recurrence is controversial. We tested the hypothesis that the use of paravertebral block (PVB) analgesia during breast cancer surgery prolongs the recurrence-free survival (RFS) and overall survival (OS) of women with breast cancer. METHODS: Seven hundred ninety-two women with nonmetastatic breast cancer were included in this retrospective study. Patients were divided based on the administration of PVB analgesia for mastectomy surgeries. One hundred ninety-eight (25%) were given a PVB, the remainder were treated with opioid-based analgesia. Propensity score matching was developed using several variables. Univariate and multivariate analyses were used to assess the impact of PVB analgesia on RFS and OS. RESULTS: The median follow-up times for RFS and OS were 5.8 and 6 years, respectively. In the propensity score matching model, a total of 396 women were included in each group of treatment (non-PVB group, n = 198 vs PVB group, n = 198). As expected, the fentanyl consumption was significantly lower in PVB (122.8 ± 77.85 µg) patients than non-PVB subjects (402.23 ± 343.8 µg). Other variables were not statistically significant. After adjusting for several important covariates, the analysis indicated that the use of PVB is not associated with a significant change in RFS [1.60 (0.81-3.16), P = 0.172] or OS [1.28 (0.55-3.01)] survival. DISCUSSION: This retrospective study does not support the hypothesis that the use of regional analgesia is associated with longer survival after surgery for breast cancer.

Length of Stay in Ambulatory Surgical Oncology Patients at High Risk for Sleep Apnea as Predicted by STOP-BANG Questionnaire.

Background. The STOP-BANG questionnaire has been used to identify surgical patients at risk for undiagnosed obstructive sleep apnea (OSA) by classifying patients as low risk (LR) if STOP-BANG score < 3 or high risk (HR) if STOP-BANG score ≥ 3. Few studies have examined whether postoperative complications are increased in HR patients and none have been described in oncologic patients. Objective. This retrospective study examined if HR patients experience increased complications evidenced by an increased length of stay (LOS) in the postanesthesia care unit (PACU). Methods. We retrospectively measured LOS and the frequency of oxygen desaturation (<93%) in cancer patients who were given the STOP-BANG questionnaire prior to cystoscopy for urologic disease in an ambulatory surgery center. Results. The majority of patients in our study were men (77.7%), over the age of 50 (90.1%), and had BMI < 30 kg/m(2) (88.4%). STOP-BANG results were obtained on 404 patients. Cumulative incidence of the time to discharge between HR and the LR groups was plotted. By 8 hours, LR patients showed a higher cumulative probability of being discharged early (80% versus 74%, P = 0.008). Conclusions. Urologic oncology patients at HR for OSA based on the STOP-BANG questionnaire were less likely to be discharged early from the PACU compared to LR patients.

A Prospective, Randomized, Controlled Trial of Paravertebral Block versus General Anesthesia Alone for Prosthetic Breast Reconstruction.

BACKGROUND: Paravertebral blocks have gained popularity because of ease of implementation and a shift toward ambulatory breast surgery procedures. Previous retrospective studies have reported potential benefits of paravertebral blocks, including decreased narcotic and antiemetic use. METHODS: The authors conducted a prospective controlled trial of patients undergoing breast reconstruction over a 3-year period. The patients were randomized to either a study group of paravertebral blocks with general anesthesia or a control group of general anesthesia alone. Demographic and procedural data, in addition to data regarding pain and nausea patient-reported numeric scores and consumption of opioid and antiemetic medications, were recorded. RESULTS: A total of 74 patients were enrolled to either the paravertebral block (n = 35) or the control group (n = 39). There were no significant differences in age, body mass index, procedure type, or cancer diagnosis between the two groups. Patients who received a paravertebral block required less opioid intraoperatively and postoperatively combined compared with patients who did not receive paravertebral blocks (109 versus 246 fentanyl equivalent units; p < 0.001), and reported significantly lower pain scores at 0 to 1 (3.0 versus 4.6; p = 0.02), 1 to 3 (2.0 versus 3.2; p = 0.01), and 3 to 6 (1.9 versus 2.7; p = 0.04) hours postoperatively. The study group also consumed less antiemetic medication (0.7 versus 2.1; p = 0.05). CONCLUSIONS: Incorporating paravertebral blocks carries considerable potential for improving pathways for breast cancer patients undergoing breast reconstruction--with minimal procedure-related morbidity. This is the first prospective study designed to assess paravertebral blocks in the setting of prosthetic breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Reduction of incorrect record accessing and charting patient electronic medical records in the perioperative environment.

Opening and charting in the incorrect patient electronic record presents a patient safety issue. The authors investigated the prevalence of reported errors and whether efforts utilizing the anesthesia time-out and barcoding have decreased the incidence of errors in opening and charting in the patient electronic medical record in the perioperative environment. The authors queried the database for all surgeries and procedures requiring anesthesia from January 2009 to September 2012. Of the 115,760 records of anesthesia procedures identified, there were 57 instances of incorrect record opening and charting during the study period. A decreasing trend was observed for all sites combined (p < 0.0001) and at the off-site locations (p = 0.0032). All locations and the off-site locations demonstrated a statistically significant decreasing pattern of errors over time. Barcoding and the anesthesia time-out may play an important role in decreasing errors in incorrect patient record opening in the perioperative environment.

Anesthetic choices and breast cancer recurrence: a retrospective pilot study of patient, disease, and treatment factors.

The purpose of this work was to investigate differences in patient, disease, and treatment factors between women who received outpatient surgical treatment of breast cancer with paravertebral and general anesthesia compared with women who received general anesthesia alone. A total of 358 patients with stage 0-III disease received a partial or total mastectomy without axillary node dissection at a large academic cancer center. Study median follow-up time was 28.8 months. Patient demographic characteristics were equally represented across anesthesia groups. Mean body mass index (kg/m) was greater in those who received general anesthesia alone (mean = 29, SD = 6.8) than in those who received paravertebral regional block with general anesthesia (mean = 28, SD = 5.1) (P = .001). The paravertebral regional block with general anesthesia group contained advanced stages of disease (P = .01) and had longer surgical procedures (P = .01) than the general anesthesia alone group. Breast cancer recurrence was detected in 1.7% of the study population (paravertebral regional block with general anesthesia: n = 4; and general anesthesia alone: n = 2). Overall, no association between anesthesia type and recurrence was detected (P = .53), with an unadjusted estimated hazard ratio of 1.84 (95% confidence interval, 0.34-10.08). The overall rate of recurrence was very small in this population. A larger study is needed to detect significant differences in rates of recurrence attributable to type of anesthesia.

A case series of thoracic paravertebral blocks using a combination of ropivacaine, clonidine, epinephrine, and dexamethasone.

Five patients who underwent surgery for breast cancer were followed for 6 days after placement of a multiple-injection, one-time paravertebral block. Data were collected on patient satisfaction, analgesic consumption, side effects, and complications. Ropivacaine as a sole agent in paravertebral blocks has a clinical duration of up to 6 hours. The addition of epinephrine, clonidine, and dexamethasone prolonged the clinical duration considerably.

Improved postoperative pain control using thoracic paravertebral block for breast operations.

Thoracic paravertebral block (PVB) in breast surgery can provide regional anesthesia during and after surgery with the potential advantage of decreasing postoperative pain. We report our institutional experience with PVB over the initial 8 months of use. All patients undergoing breast operations at the ambulatory care building from September 09, 2005 to June 28, 2005 were reviewed. Comparison was performed between patients receiving PVB and those who did not. Pain scores were assessed immediately, 4 hours, 8 hours and the morning after surgery. 178 patients received PVB and 135 patients did not. Patients were subdivided into three groups: Group A-segmental mastectomy only (n = 89), Group B-segmental mastectomy and sentinel node surgery (n = 111) and Group C-more extensive breast surgery (n = 113). Immediately after surgery there was a statistically significant difference in the number of patients reporting pain between PVB patients and those without PVB. At all time points up until the morning after surgery PVB patients were significantly less likely to report pain than controls. Patients in Group C who received PVB were significantly less likely to require overnight stay. The average immediate pain scores were significantly lower in PVB patients than controls in both Group B and Group C and approached significance in Group A. PVB in breast surgical patients provided improved postoperative pain control. Pain relief was improved immediately postoperatively and this effect continued to the next day after surgery. PVB significantly decreased the proportion of patients that required overnight hospitalization after major breast operations and therefore may decrease cost associated with breast surgery.

Prospective randomized trial of paravertebral block for patients undergoing breast cancer surgery.

BACKGROUND: The goal of the current study was to evaluate the effect of regional anesthesia using paravertebral block (PVB) on postoperative pain after breast surgery. METHODS: Patients undergoing unilateral breast surgery without reconstruction were randomized to general anesthesia (GA) only or PVB with GA and pain scores assessed. RESULTS: Eighty patients were randomized (41 to GA and 39 to PVB with GA). Operative times were not significantly different between groups. Pain scores were lower after PVB compared to GA at 1 hour (1 vs 3, P = .006) and 3 hours (0 vs 2, P = .001) but not at later time points. The overall worst pain experienced was lower with PVB (3 vs 5, P = .02). More patients were pain-free in the PVB group at 1 hour (44% vs 17%, P = .014) and 3 hours (54% vs 17%, P = .005) postoperatively. CONCLUSIONS: PVB significantly decreases postoperative pain up to 3 hours after breast cancer surgery.