Surgeons' and anesthesiologists' perceptions of turnover times.

BACKGROUND: Perception of turnovers may be influenced less by actual turnover times per se than by a mental model of factors influencing turnover times. METHODS: A survey was performed at a U.S. academic hospital in 2010. Each of the 78 subjects estimated characteristics of his/her turnover times in 2009. Responses were compared with the actual times. RESULTS: Numbers of comments were not proportional to actual total waiting times experienced. Surgeons with 2 or more comments (n = 10) averaged the same numbers of turnovers as did surgeons who made 1 or no comments (n = 13) (P = 0.62). Four of the 10 surgeons with 2 or more comments averaged <2 turnovers per month ("very few turnovers"). Perceptions of turnover times were influenced by opinion about team activity during shift change. Most (>79%) subjects thought that the time of the day with the subject's largest number of prolonged (>45 minutes) turnovers was at least 2 hours later than actual (P < 0.0001). Although most prolonged turnovers occurred around noon, 8 surgeons mentioned shift change qualitatively, and most (68%, P = 0.002) subjects estimated a time overlapping with shift change. Surgeons overall overestimated their observed percentage of prolonged turnovers (P = 0.020), and anesthesiologists' estimates were overall unbiased. Surgeons' bias cannot be explained by knowing times of a longer interval such as "skin to skin," because the other surgeons, with very few turnovers, had responses that were essentially identical (P ≥ 0.87). When we corrected for each subject's actual mean turnover time, surgeons' estimates for their averages were longer than were anesthesiologists' estimates (P = 0.002). Responses were again essentially indistinguishable from those of subjects with very few turnovers (P ≥ 0.23). CONCLUSIONS: Managers should not rely on surgeons or anesthesiologists for their expert judgment on turnover times. Managers should also not interpret comments about turnover times as literally referring to the time, but instead as factors perceived as contributing to the time (e.g., attitude about the facility and the activity of its personnel).

Clinical comparison of two stylet angles for orotracheal intubation with the GlideScope video laryngoscope.

STUDY OBJECTIVE: To compare the success of orotracheal intubation in 62 seconds or less using the GlideScope video laryngoscope (GVL) and a 60 degrees or 90 degrees angled stylet with reverse loading of the endotracheal tube (ETT). DESIGN: Prospective, randomized study. SETTING: Operating room of a university hospital. PATIENTS: 120 ASA physical status I, II, and III adult patients undergoing elective surgery requiring general anesthesia with orotracheal intubation. INTERVENTIONS: Patients were randomly allocated to two groups (n = 60 each); both groups received general anesthesia and neuromuscular relaxation. A conventional ETT was styleted and then bent from its straight configuration just above the cuff, either at 60 degrees or 90 degrees against its concave natural curve (reverse loading). Four attending anesthesiologists, who were blinded as to stylet assignment (the 60 degrees or 90 degrees group), intubated the tracheas of all patients with the GVL using either the primary or secondary stylet. MEASUREMENTS: The primary outcome was success of orotracheal intubation in 62 seconds or less. The secondary outcome was actual time to intubation (TTI). MAIN RESULTS: The odds ratio (OR) for intubation success was higher in the 90 degrees group than the 60 degrees group (OR = 10.41; P < 0.03), as evidenced by 59 of 60 patients whose tracheas were intubated successfully within 62 seconds, compared with 51 of 60 patients in the 60 degrees group. Seven of the 9 failures were due to inability of the 60 degrees stylet to reach the glottic opening. The three remaining failures were associated with TTI of more than 62 seconds. CONCLUSIONS: The 90 degrees angled malleable stylet with reverse loading of the ETT provided more reliable ETT delivery to the glottic opening and had a higher success rate than the 60 degrees stylet.

Predicting orthopedic surgeons' preferences for peripheral nerve blocks for their patients.

BACKGROUND: A 2002 survey of 468 Canadian orthopedic surgeons found that the "two principal reasons regional anesthesia is not favored" are "delays in operating rooms" and "unpredictable success." We reanalyzed the data from the study to evaluate whether these concerns were the best predictors of an individual surgeon's willingness to use peripheral nerve blocks for their patients. METHODS: Of the five procedures included in the survey, three had relevant questions for our reanalysis of the results: arthroscopic shoulder surgery, arthroscopic anterior cruciate ligament reconstruction, and total knee replacement. RESULTS: A surgeon's preference for peripheral nerve block for him or herself strongly predicted his or her anesthetic preference for patients (all P < 0.001). Concordance rates were 89% for arthroscopic shoulder surgery, 87% for anterior cruciate ligament reconstruction, and 93% for total knee replacement. There was almost no incremental predictive value for the surgeon's preference for patients from the surgeon's perception of the times to perform a block (P > or = 0.27) or perception of block success rate (P > or = 0.30). There was also almost no direct predictive value for the surgeon's preference for patients from the surgeon's perception of the times to perform a block (Kendall's tau < or = 0.04, P > or = 0.28) or perception of block success rate (Kendall's tau < or = 0.02, P > or = 0.24). An economically important percentage of surgeons (37%, 95% confidence interval: 32%-41%) would choose a peripheral nerve block for their own surgery for some, but not all, of the procedures (i.e., for 1 or 2 versus 0 or 3). CONCLUSIONS: A surgeon's preference for peripheral nerve blocks for his or her own surgery predicted a surgeon's preference for his or her patients. Perceptions of delays and success rate did not add sufficient incremental information to the surgeon's preferences to be of economic importance. These results are important to better forecast the net economic impact on an anesthesia group of a regional block team.