A Survey Evaluating Burnout, Health Status, Depression, Reported Alcohol and Substance Use, and Social Support of Anesthesiologists.

BACKGROUND: Burnout affects all medical specialists, and concern about it has become common in today's health care environment. The gold standard of burnout measurement in health care professionals is the Maslach Burnout Inventory-Human Services Survey (MBI-HSS), which measures emotional exhaustion, depersonalization (DP), and personal accomplishment. Besides affecting work quality, burnout is thought to affect health problems, mental health issues, and substance use negatively, although confirmatory data are lacking. This study evaluates some of these effects. METHODS: In 2011, the American Society of Anesthesiologists and the journal Anesthesiology cosponsored a webinar on burnout. As part of the webinar experience, we included access to a survey using MBI-HSS, 12-item Short Form Health Survey (SF-12), Social Support and Personal Coping (SSPC-14) survey, and substance use questions. Results were summarized using sample statistics, including mean, standard deviation, count, proportion, and 95% confidence intervals. Adjusted linear regression methods examined associations between burnout and substance use, SF-12, SSPC-14, and respondent demographics. RESULTS: Two hundred twenty-one respondents began the survey, and 170 (76.9%) completed all questions. There were 266 registrants total (31 registrants for the live webinar and 235 for the archive event), yielding an 83% response rate. Among respondents providing job titles, 206 (98.6%) were physicians and 2 (0.96%) were registered nurses. The frequency of high-risk responses ranged from 26% to 59% across the 3 MBI-HSS categories, but only about 15% had unfavorable scores in all 3. Mean mental composite score of the SF-12 was 1 standard deviation below normative values and was significantly associated with all MBI-HSS components. With SSPC-14, respondents scored better in work satisfaction and professional support than in personal support and workload. Males scored worse on DP and personal accomplishment and, relative to attending physicians, residents scored worse on DP. There was no significant association between MBI-HSS and substance use. CONCLUSIONS: Many anesthesiologists exhibit some high-risk burnout characteristics, and these are associated with lower mental health scores. Personal and professional support were associated with less emotional exhaustion, but overall burnout scores were associated with work satisfaction and professional support. Respondents were generally economically satisfied but also felt less in control at work and that their job kept them from friends and family. The association between burnout and substance use may not be as strong as previously believed. Additional work, perhaps with other survey instruments, is needed to confirm our results.

An Evaluation of Induced Failure Modes in the Belmont® Rapid Infuser.

BACKGROUND: Rapid infusers are vital tools during massive hemorrhage and resuscitation. Sporadic reports of overheating and shutdown of the Belmont® Rapid Infuser, a commonly used system, have been attributed to 1-sided clot blockage of the fluid path. We investigated multiple causes of failure of this device. METHODS: Packed red blood cells and thawed fresh frozen plasma with normal saline solution were used as base fluids for serial 10-minute trials using standard disposable sets in 2 Belmont devices. Possible contributors to device failure, including calcium-containing solutions and external leakage currents, were evaluated. Thermographic images of the heater and disposable cartridges were recorded. The effects of complete unilateral clotting were modeled by sealing half of the disposable cartridge with epoxy. RESULTS: Clotting on the surface of the heat exchanger coil increased with calcium concentration and was only observed at calcium concentrations >12.0 mmol/L (P < 0.0001) in a 1:1 plasma:red blood cell mixture, resulting in high-pressure downstream occlusion alarms and interruption of flow. CONCLUSIONS: Clot-based occlusion can be induced in the Belmont Rapid Infuser under unrealistic conditions. In the absence of complete unilateral flow blockage, we did not observe any significant overheating of the infuser under extreme operating conditions.

Anesthesia for liver transplantation in United States academic centers: intraoperative practice.

STUDY OBJECTIVE: To determine current practice patterns for patients receiving liver transplantation. DESIGN: International, web-based survey instrument. SETTING: Academic medical centers. MEASUREMENTS: Survey database responses to questions about liver transplant anesthesiology programs and current intraoperative anesthetic care and resource utilization were assessed. Descriptive statistics of intraoperative practices and resource utilization according to the size of the transplant program were recorded. MAIN RESULTS: Anesthetic management practices for liver transplantation varied across the academic centers. The use of cell salvage (Cell Saver®), transesophageal echocardiography, thrombelastography, and ultrasound guidance for catheter placement varies among institutions. CONCLUSION: Effective practices and more evidence-based intraoperative management have not yet been applied in many programs. Many facets of perioperative liver transplantation anesthesia care remain underexplored.

Early detection of a blood transfusion reaction utilizing a wireless remote monitoring device.

Continuously monitoring vital signs on general care units may provide earlier detection and intervention of instabilities in patients. These earlier interventions could prevent deaths and admission to critical care units, thereby increasing patient safety and improving patient outcomes.

The impact of peripheral nerve techniques on hospital stay following major orthopedic surgery.

OBJECTIVE: To determine the impact of regional anesthesia on hospital stay for selected orthopedic procedures compared with traditional pain control modalities. DESIGN: In an era of an increasing volume of orthopedic surgeries, pain modalities that can optimize patient care while minimizing hospital length of stay can have an impact on reducing hospital costs as well as increasing patient satisfaction and improving patient outcomes. Previous studies have shown the potential benefits of regional anesthesia over traditional intravenous (IV) narcotics in meeting these goals in selected orthopedic procedures. METHODS: We retrospectively analyzed the medical records of 494 patients who underwent major orthopedic procedures performed with traditional postoperative pain management alone (IV patient-controlled analgesia and oral narcotics), single injection peripheral nerve block (PNB), and continuous peripheral nerve block (CPNB) in order to determine the impact that different pain modalities might have on hospital length of stay. RESULTS: When compared with traditional pain control modalities, single PNB and CPNB were associated with decreased length of hospital stay, though results for specific surgeries varied. The hazard ratios for hospital discharge from a Current Procedural Terminology code-stratified, covariate (age, gender, and ASA status) adjusted Cox proportional hazards model for single PNB vs no PNB and for CPNB vs no PNB were 1.35 (95% confidence interval: 1.02-1.79) and 1.91 (95% confidence interval: 1.42-2.57), respectively, pointing toward earlier hospital discharge when PNBs were used. CONCLUSIONS Our retrospective case review showed that, overall, hospital lengths of stay tended to be shorter for orthopedic surgery patients receiving single PNB and CPNB than for those receiving no block and traditional pain management.

Anesthesia for liver transplantation in US academic centers: institutional structure and perioperative care.

Investigators at a single institution have shown that the organization of the anesthesia team influences patient outcomes after liver transplant surgery. Little is known about how liver transplant anesthesiologists are organized to deliver care throughout the United States. Therefore, we collected quantitative survey data from adult liver transplant programs in good standing with national governing agencies so that we could describe team structure and duties. Information was collected from 2 surveys in a series of quantitative surveys conducted by the Liver Transplant Anesthesia Consortium. All data related to duties, criteria for team membership, interactions/communication with the multidisciplinary team, and service availability were collected and summarized. Thirty-four of 119 registered transplant centers were excluded (21 pediatric centers and 13 centers not certified by national governing agencies). Private practice sites (26) were later excluded because of a poor response rate. There were minimal changes in the compositions of the programs between the 2 surveys. All academic programs had distinct liver transplant anesthesia teams. Most had set criteria for membership and protocols outlining the preoperative evaluation, attended selection committees, and were always available for transplant surgery. Fewer were involved in postoperative care or were available for patients needing subsequent surgery. Most trends were associated with the center volume. In conclusion, some of the variance in team structure and responsibilities is probably related to resources available at the site of practice. However, similarities in specific duties across all teams suggest some degree of self-initiated specialization.

Nurse adoption of continuous patient monitoring on acute post-surgical units: managing technology implementation.

AIM: To report an exploratory action-research process used during the implementation of continuous patient monitoring in acute post-surgical nursing units. BACKGROUND: Substantial US Federal funding has been committed to implementing new health care technology, but failure to manage implementation processes may limit successful adoption and the realisation of proposed benefits. Effective approaches for managing barriers to new technology implementation are needed. METHOD: Continuous patient monitoring was implemented in three of 13 medical/surgical units. An exploratory action-feedback approach, using time-series nurse surveys, was used to identify barriers and develop and evaluate responses. Post-hoc interviews and document analysis were used to describe the change implementation process. RESULTS: Significant differences were identified in night- and dayshift nurses' perceptions of technology benefits. Research nurses' facilitated the change process by evolving 'clinical nurse implementation specialist' expertise. CONCLUSIONS: Health information technology (HIT)-related patient outcomes are mediated through nurses' acting on new information but HIT designed for critical care may not transfer to acute care settings. Exploratory action-feedback approaches can assist nurse managers in assessing and mitigating the real-world effects of HIT implementations. IMPLICATIONS FOR NURSING MANAGEMENT: It is strongly recommended that nurse managers identify stakeholders and develop comprehensive plans for monitoring the effects of HIT in their units.

Technical communication: An initial evaluation of a novel anesthetic scavenging interface.

Waste anesthetic gas scavenging technology has not changed appreciably in the past 30 years. Open reservoir systems entrain high volumes of room air and dilute waste gases before emission into the atmosphere. This process requires a large vacuum pump, which is both costly to install and, although efficient, operates continuously and at near-full capacity. In an era of increasing energy costs and environmental awareness, carbon footprint reduction is a priority and a more efficient system of safely scavenging waste anesthetic gases is desirable. We tested a low-flow scavenger interface to evaluate the potential for cost and energy savings. The use of this interface in a suite of 4 operating rooms reduced scavenging flow from a constant 37 L/min to a value equal to the fresh gas flow (usually 2 L/min) for each anesthesia machine. Using the ventilator increased this flow by approximately 6 L/min because of the exhaust of ventilator drive gas into the scavenging circuit. Daytime workload of the central vacuum pump decreased from 92% to 12% (expressed as duty cycle). The new system produces energy savings and may increase vacuum pump lifespan.

Risk of burnout in perioperative clinicians: a survey study and literature review.

BACKGROUND: Burnout can lead to health and psychologic problems and is apparently increasing in physicians and nurses. Previous studies have not evaluated all healthcare workers within a single work unit. This study evaluates the risk of burnout in all medical personnel in one perioperative unit. METHODS: We developed an online survey that included demographics, a modified version of the Maslach Burnout Inventory-Human Services Survey, and the Social Support and Personal Coping Survey. Survey constructs (e.g., depersonalization and health) and a global score were calculated. Larger construct and global values were associated with higher risk of burnout. These were separately regressed on role, age, and sex. The global score was then regressed on each of the survey constructs. RESULTS: Of the 145 responses, 46.2% were physicians (22.8% residents), 43.4% were nurses or nurse anesthetists, and 10.3% were other personnel. After adjusting for sex and age, residents scored higher than other physicians on the following (expected change [95% confidence interval]): global score (1.12 [0.43-1.82]), emotional exhaustion (1.54 [0.44-2.60]), and depersonalization (1.09 [0.23-1.95]). Compared with nonphysicians, residents were 1 U or more higher on these items (P < 0.05 in all cases). Residents had higher health (1.49 [0.48-2.50]) and workload (1.23 [0.07-2.40]) values compared with physicians. Better health, personal support, and work satisfaction scores were related to decreased global scores (P < 0.05). CONCLUSIONS: Physicians (particularly residents) had the largest global burnout scores, implying increased risk of burnout. Improving overall health, increasing personal support, and improving work satisfaction may decrease burnout among perioperative team members.

Selective local anesthetic placement using ultrasound guidance and neurostimulation for infraclavicular brachial plexus block.

BACKGROUND: In this study, we performed the infraclavicular block with combined ultrasound guidance and neurostimulation to selectively target cords to compare the success rates of placing a single injection of local anesthetic either in a central or peripheral location. METHODS: Two hundred eighteen patients were enrolled in a consecutive, prospective study. Patients were randomized to injection of local anesthetic either centrally (posterior cord) or peripherally (medial or lateral cord) using ultrasound guidance and neurostimulation. Supervised senior anesthesiology residents or attending anesthesiologists performed the blocks. Both intent-to-treat and treatment-received analyses were used to compare central and peripheral placement efficacy. RESULTS: The overall success rate was significantly higher for the central placements than peripheral placements (96% vs 85%, P = 0.004). Individual cord success rates were as follows: posterior 99%, lateral 92%, and medial 84% (P = 0.001). The central group required attending physician intervention more frequently (27% vs 6%, P < 0.001). Postoperative pain scores of < or =3 were more likely with central placement (100% vs 94%, P = 0.012). CONCLUSION: Central placement of a single injection of local anesthetic targeted at the posterior cord resulted in a higher success rate for infraclavicular block.