Awake Craniotomy Program Implementation.

Importance: Implementing multidisciplinary teams for treatment of complex brain tumors needing awake craniotomies is associated with significant costs. To date, there is a paucity of analysis on the cost utility of introducing advanced multidisciplinary standardized teams to enable awake craniotomies. Objective: To assess the cost utility of introducing a standardized program of awake craniotomies. Design, Setting, and Participants: A retrospective economic evaluation was conducted at Mayo Clinic Florida. All patients with single, unilateral lesions who underwent elective awake craniotomies between January 2016 and December 2021 were considered eligible for inclusion. The economic perspective of the health care institution and a time horizon of 1 year were considered. Data were analyzed from October 2022 to May 2023. Exposure: Treatment with an awake craniotomy before standardization (2016-2018) compared with treatment with awake craniotomy after standardization (2018-2021). Main Outcomes and Measures: Patient demographics, perioperative, and postoperative outcomes, including length of stay, intensive care (ICU) admission, extent of resection, readmission rates, and 1-year mortality were compared between patients undergoing surgery before and after standardization. Direct medical costs were estimated from Medicare reimbursement rates for all billed procedures. A cost-utility analysis was performed considering differences in direct medical costs and in 1-year mortality within the periods before and after standardization of procedures. Uncertainty was explored in probability sensitivity analysis. Results: A total of 164 patients (mean [SD] age, 49.9 [15.7] years; 98 [60%] male patients) were included in the study. Of those, 56 underwent surgery before and 108 after implementation of procedure standardization. Procedure standardization was associated with reductions in length of stay from a mean (SD) of 3.34 (1.79) to 2.46 (1.61) days (difference, 0.88 days; 95% CI, 0.33-1.42 days; P = .002), length of stay in ICU from a mean (SD) of 1.32 (0.69) to 0.99 (0.90) nights (difference, 0.33 nights; 95% CI, 0.06-0.60 nights; P = .02), 30-day readmission rate from 14% (8 patients) in the prestandardization cohort to 5% (5 patients) (difference, 9%; 95% CI, 19.6%-0.3%; P = .03), while extent of resection and intraoperative complication rates were similar between both cohorts. The standardized protocol was associated with mean (SD) savings of $7088.80 ($12 389.50) and decreases in 1-year mortality (dominant intervention). This protocol was found to be cost saving in 75.5% of all simulations in probability sensitivity analysis. Conclusions and Relevance: In this economic evaluation of standardization of awake craniotomy, there was a generalized reduction in length of stay, ICU admission time, and direct medical costs with implementation of an optimized protocol. This was achieved without compromising patient outcomes and with similar extent of resection, complication rates, and reduced readmission rates.

What Is the Learning Curve for Lumbar Spine Surgery Under Spinal Anesthesia?

BACKGROUND: Spinal anesthesia (SA) is routinely used in obstetrics and orthopedic surgery but has not been widely adopted in lumbar spine surgery (LSS). One perceived barrier is the learning curve for the neurosurgical and anesthesia team associated with managing a patient in the prone position under SA. METHODS: A retrospective cohort of 34 LSS cases under SA at our institution was examined. Operative time, corrected operative time per level, and complications were analyzed. The learning curve was assessed using a curve-fit regression analysis. RESULTS: Of patients, 62% were female, with mean (SD) age and body mass index of 60.7 (10.8) years and 29.9 (4.6) kg/m2, respectively. The mean (SD) for each time segment was operating room arrival to incision 35.7 (8.1) minutes, total surgical time 100.4 (35.8) minutes, and procedure finish to operating room exit 3.4 (2.5) minutes. When the times were normalized to procedure type and analyzed sequentially, the mean (SD) slope of all trendlines was 0.003 (0.005) with correlation coefficients of R2 = 0.0002-0.01, indicating no appreciable learning curve. Normalized postanesthesia care unit time was significantly shorter for overnight stay versus same-day discharge (0.64 vs. 1.36, P = 0.0005). CONCLUSIONS: Our data demonstrate the lack of a learning curve when SA is implemented in LSS cases by an anesthetic team already familiar with SA techniques for other procedures. Importantly, the surgical team was already familiar with the minimally invasive surgery approaches used in conjunction with SA. This study highlights that the barriers to transitioning to SA for LSS may be fewer than perceived.

Self-efficacy measurement instrument for neonatal resuscitation training: An integrative review.

Neonatal resuscitation is recognized by the World Health Organization as one of the priority interventions to reduce neonatal mortality rate. Measuring self-efficacy regarding neonatal resuscitation is one important criterion for evaluating the effectiveness of related training programs. This integrative review aims to critique evidence from high and low-to-middle-income countries. Additionally, guides appraisals of the instruments that measure self-efficacy in resuscitation training programs and adapt for low-to-middle-income countries. The databases searched for studies from 1980 to 2017 include: PubMed, CINAHL, SCOPUS, PyschINFO, and ERIC. and revealed 212 publications. Data extracted from eight instruments included theoretical framework, study location, instrument description and scoring, reliability and validity, and self-efficacy measurement outcomes. Six of eight self-efficacy instruments reported utilizing Bandura's Social Cognitive Theory while two of the eight instruments implied the use of self-efficacy. Most of the instruments reported acceptable internal consistency as Cronbach's alpha values ranged from 0.74 to 0.98 for reliability. Five of eight instruments were used in low-to-middle-income countries. A valid and reliable self-efficacy instrument is a necessary antecedent to evaluating the effectiveness of a neonatal resuscitation training program. Future studies may consider self-efficacy instruments with Visual Analog Scales in low-to-middle-income countries due to the ease of implementing the simple visual instrument.

Review of educational interventions to increase traditional birth attendants' neonatal resuscitation self-efficacy.

BACKGROUND: Annually, up to 2.7 million neonatal deaths occur worldwide, and 25% of these deaths are caused by birth asphyxia. Infants born in rural areas of low-and-middle-income countries are often delivered by traditional birth attendants and have a greater risk of birth asphyxia-related mortality. AIM: This review will evaluate the effectiveness of neonatal resuscitation educational interventions in improving traditional birth attendants' knowledge, perceived self-efficacy, and infant mortality outcomes in low-and-middle-income countries. METHODS: An integrative review was conducted to identify studies pertaining to neonatal resuscitation training of traditional birth attendants and midwives for home-based births in low-and-middle-income countries. Ten studies met inclusion criteria. FINDINGS: Most interventions were based on the American Association of Pediatrics Neonatal Resuscitation Program, World Health Organization Safe Motherhood Guidelines and American College of Nurse-Midwives Life Saving Skills protocols. Three studies exclusively for traditional birth attendants reported decreases in neonatal mortality rates ranging from 22% to 65%. These studies utilized pictorial and oral forms of teaching, consistent in addressing the social cognitive theory. Studies employing skill demonstration, role-play, and pictorial charts showed increased pre- to post-knowledge scores and high self-efficacy scores. In two studies, a team approach, where traditional birth attendants were assisted, was reported to decrease neonatal mortality rate from 49-43/1000 births to 10.5-3.7/1000 births. CONCLUSION: Culturally appropriate methods, such as role-play, demonstration, and pictorial charts, can contribute to increased knowledge and self-efficacy related to neonatal resuscitation. A team approach to training traditional birth attendants, assisted by village health workers during home-based childbirths may reduce neonatal mortality rates.

Evaluation of Simulated Ventilation Techniques With the Upright and Conventional Self-Inflating Neonatal Resuscitators.

BACKGROUND: The study assessed the impact of simulated ventilation techniques using upright and conventional self-inflating neonatal resuscitators on delivered tidal volume (VT) and pressure. METHODS: We analyzed videos of participants ventilating a manikin using an upright (upright, n = 33) and a conventional resuscitator (conventional, n = 32) under normal and low lung compliance. Mask hold, number of fingers squeezing the bag, and degree of bag squeeze were compared with VT and peak inspiratory pressure (PIP). RESULTS: VT and PIP values were higher when using the upright resuscitator than when using the conventional resuscitator. With low compliance, differences in VT were insignificant except with the use of the OK/C hold, (upright, 29.6 ± 4.0 mL, vs conventional, 24.8 ± 6.0 mL, P = .02). PIP was significantly higher when using the upright resuscitator with the OK hold (upright, 36.3 ± 4.4 mL, vs conventional, 30.3 ± 6.6 mL, P = .009) and when the bag was squeezed by more than half (upright, 33.8 ± 16.3 mL, vs conventional, 29.3 ± 9.5 mL, P = .046). With normal compliance, VT was high with both resuscitators, being significantly higher when using the upright resuscitator with the OK hold (upright, 64.3 ± 9.5 mL, vs conventional, 45.8 ± 9.4 mL; P < .001), and when the bag was squeezed using more than 2 fingers (upright, 58.0 ± 17.2 mL, vs conventional, 45.7 ± 12.6 mL, P = .01) and by more than half (upright, 58.7 ± 16.6 mL, vs conventional, 45.8 ± 12.2 mL, P = .004). PIP, too, was significantly higher when using the upright resuscitator with the OK hold (upright, 29.3 ± 3.5 mL, vs conventional, 21.5 ± 4.0 mL, P = <.001) and when the bag was squeezed using more than 2 fingers (upright, 27.2 ± 7.0 mL, vs conventional, 21.6 ± 5.7 mL, P = .005), and by more than half (upright, 27.6 ± 6.6 mL, vs conventional, 21.7 ± 5.4 mL, P = .001). CONCLUSIONS: Improved mask design, larger bag volume, and upright orientation of the upright resuscitator likely contributed to higher VT and PIP. However, high VT was observed with both resuscitators, possibly due to excessive squeezing of the bag, especially during low compliance. Thus, the design of the resuscitator and manner in which the device is utilized can both significantly influence the VT and PIP attained.