Put PEP in your step with a Podiatric Enhanced Recovery After Surgery Protocol in the outpatient adult population: a best practice implementation project.

OBJECTIVE: The goal of this implementation project was to improve postoperative outcomes in the Day Surgery Podiatric patient population with the implementation of an enhanced recovery after surgery (ERAS) protocol at a large urban health system in the northeastern United States. We aimed to improve postoperative patient pain scores and reduce patient length of stay (LOS) with the implementation of the podiatric ERAS protocol (PEP). INTRODUCTION: ERAS provides an evidence-based interdisciplinary approach to the preparation and care of surgical patients. The core goals of ERAS promote accelerated patient recovery after surgery by incorporating broad patient education with strategies to reduce the physiologic stress associated with surgery and anesthesia. This strategy has been applied to many major surgical specialties but has not been established in podiatric patients. METHODS: The PEP evidence implementation initiative integrates two Joanna Briggs Institute tools: the Getting Research into Practice audit and feedback tool, and Practical Application of Clinical Evidence System, by incorporating proactive planning and data analyses. Baseline electronic health record data were collected in July 2019, followed by interdisciplinary PEP review, revision, implementation, and three data collection cycles. Strategic education was provided to stakeholders throughout data collection cycles. RESULTS: This use of ERAS in the outpatient podiatric surgery population demonstrated excellence in compliance with best practice recommendations. The proactive multimodal approach of PEP revealed improvement in four measures of patient pain, with improvement from 83 to 100% of patients having a pain goal higher than their admission postoperative pain score. Patient pain goal greater than discharge pain score was also found but not sustained. Baseline data collection established that 29% of podiatric patients had a LOS less than 90 min, which improved to 42% with PEP. This finding was also not sustained in the third cycle of audit data. Missing data may have influenced these results, reinforcing the need for further study. CONCLUSION: The use of ERAS in orthopedic patients has an established empirical basis for use, demonstrating a reduction in both postoperative pain and LOS. This novel use of ERAS in a podiatric surgery outpatient population has similar findings but was not sustained in all audit criteria. PEP demonstrated promising reductions in postoperative pain and LOS; however, further implementation replication is needed to confirm this expansion of ERAS and the promising results.

Perianesthesia Nurses' Survey of Their Knowledge and Practice With Obstructive Sleep Apnea.

PURPOSE: Anesthesia, sedation, and analgesia can negatively impact adult patients with obstructive sleep apnea (OSA). Despite known risks, current evidence, and practice guidelines, insufficient evidence exists that standardization and clinical application of OSA screening tools, problem identification, and perioperative nursing intervention and management strategies are consistently implemented for OSA patients across perianesthesia settings. The purpose of this study was to conduct a knowledge and practice assessment of perianesthesia nurses who care for adult patients with diagnosed or undiagnosed OSA. DESIGN: An anonymous descriptive study was used to survey perianesthesia nurses who care for adult patients with OSA who present for elective surgical procedures. METHODS: A total of 1,222 participants completed an expert-developed 27-question online survey. FINDINGS: The findings indicate the need for more education and research across all perianesthesia settings. CONCLUSIONS: Next steps also include policy development and an interprofessional collaborative infrastructure nurses need to translate evidence-based screening and management strategies into their clinical practice.

Role of comprehension on performance at higher levels of Bloom's taxonomy: Findings from assessments of healthcare professional students.

The first four levels of Bloom's taxonomy were used to create quiz questions designed to assess student learning of the gross anatomy, histology, and physiology of the gastrointestinal (GI) system. Information on GI histology and physiology was presented to separate samples of medical, dental, and podiatry students in computer based tutorials where the information from the two disciplines was presented either separately or in an integrated fashion. All students were taught GI gross anatomy prior to this study by course faculty as part of the required curriculum of their respective program. Student responses to the quiz questions were analyzed to assess both the validity of Bloom's cumulative hierarchy and the effectiveness of an integrated curriculum. No statistically significant differences were found between quiz scores from students who received the integrated tutorial and from those who received the separate tutorials. Multiple regression analyses provided partial support for a cumulative hierarchy where scores on the lower levels of Bloom's taxonomy predicted scores on higher levels. Notably, in the majority of regression analyses, the comprehension score was the key foundational predictor for application and analysis scores. This study supports the suggestion that educators increase the number of comprehension level questions, even at the expense of knowledge level questions, in course assessments both to evaluate lower order cognitive skills and also as a predictor of success on questions requiring application and analysis levels of the higher order cognitive skills of Bloom's taxonomy. Anat Sci Educ 11: 433-444. © 2018 American Association of Anatomists.

Local Anesthesia Toxicity and Lipid Rescue.

Regional anesthesia as a treatment modality for the control of surgical pain has been in practice since the late 1880s with the introduction of cocaine. The use of lipid emulsion therapy as an emerging treatment for the rare but life-threatening development of local anesthesia systemic toxicity (LAST) has been in the animal literature for approximately 20 years, and case reports have documented successful results with this treatment in humans. The perianesthesia nurse has a significant role in the assessment, communication with the anesthesia care provider, and the emergent management of the patient experiencing LAST. Using a fictitious case study of a patient with LAST, the conduction of sensory information will be reviewed. The pharmacologic characteristics of local anesthetics will be presented, and the evidence-based practice recommendations for the prevention, monitoring, and treatment will be provided.

Traumatic brain injury and increased intracranial pressure.

Traumatic brain injury (TBI) affects approximately 1.4 million individuals and has a mortality rate greater than 30% in the first 72 hours after injury. The patient with TBI can present a significant challenge for the perianesthesia nurse in the acute care setting. Increased intracranial pressure is a common consequence of TBI and the rapid assessment and management can affect the long term outcome of the patient with TBI. New monitoring modalities have been developed to monitor cerebral blood flow and nutritional supply to neurologic tissues. A case scenario will be used to identify priorities for the perianesthesia nurse caring for this challenging patient.

Simulation as a means to foster collaborative interdisciplinary education.

The purpose of this study was multifaceted: to initiate an interdisciplinary collaborative relationship between nursing and medical students; to determine the usefulness of an interdisciplinary approach using simulations as an educational strategy; and to analyze students' perceptions of collaboration. A pre/posttest design was used to assess students' perceptions of interdisciplinary collaboration with a mock code experience using a high-fidelity simulator. Open-ended questions provided another perspective of interdisciplinary collaboration. A convenience sample of fourth-year nursing students and third-year medical students from a large urban university participated in the study. Statistically significant differences (p < 0.05) were seen in medical students' posttest scores for two factors, collaboration and nursing autonomy. The narrative responses revealed that nursing students' perceptions of the nurse-physician relationship became more collaborative after the simulation experience. Both medical and nursing students described the experience as one that should be continued.