Improving Formative Feedback in the Operating Room Setting: Developing and Implementing an Initiative to Improve Feedback Quality and Culture.

PROBLEM: Formative feedback, given in an ongoing fashion during the learning process, is fundamental to clinical education. However, dissatisfaction with formative feedback among residents is common. Difficulties with formative feedback are intensified in the operating room (OR) setting due to fast pace, space limitations, and frequent rotation of residents and attendings. APPROACH: In the anesthesiology and critical care department at the University of Pennsylvania Perelman School of Medicine, the authors launched the Feedback Moment initiative from January 2018 to May 2018 in which 24 first-year residents and attendings were given a short series of prompts designed to facilitate regular, high-quality formative feedback. The authors conducted semistructured interviews with residents before and after the initiative to evaluate its impact. OUTCOMES: In baseline interviews, 18 participating residents stressed the importance of formative feedback but described feeling unsure of their performance due to lack of ongoing constructive input from attendings. They felt hesitant to approach attendings for feedback due to a desire not to interrupt OR workflow or appear incompetent. In follow-up interviews, residents described the initiative as helping to normalize constructive formative feedback but difficult to execute regularly due to OR workflow issues and frequent rotation of attendings with varying approaches. NEXT STEPS: Challenges faced by participants in this initiative highlight several considerations for effective OR-based formative feedback. Alternative timings for initiating feedback must be considered in light of the hectic nature of the OR workflow. Residents should be equipped with the skills necessary to adapt to varying practice patterns and frequent rotation between attendings, while attendings should be trained to provide a clear rationale for constructive feedback that allows residents to quickly adapt to practice variation. Finally, establishing clear goals among resident-attending pairs is critical to ensuring that formative feedback given in necessarily brief sessions is focused and productive.

Anesthesiologist Specialization and Use of General Anesthesia for Cesarean Delivery.

BACKGROUND: Guidelines for obstetric anesthesia recommend neuraxial anesthesia (i.e., spinal or epidural block) for cesarean delivery in most patients. Little is known about the association of anesthesiologist specialization in obstetric anesthesia with a patient's likelihood of receiving general anesthesia. The authors conducted a retrospective cohort study to compare utilization of general anesthesia for cesarean delivery among patients treated by generalist versus obstetric-specialized anesthesiologists. METHODS: The authors studied patients undergoing cesarean delivery for live singleton pregnancies from 2013 through 2017 at one academic medical center. Data were extracted from the electronic medical record. The authors estimated the association of anesthesiologist specialization in obstetric anesthesia with the odds of receiving general anesthesia for cesarean delivery. RESULTS: Of the cesarean deliveries in our sample, 2,649 of 4,052 (65.4%) were performed by obstetric-specialized anesthesiologists, and 1,403 of 4,052 (34.6%) by generalists. Use of general anesthesia differed for patients treated by specialists and generalists (7.3% vs. 12.1%; P < 0.001). After adjustment, the odds of receiving general anesthesia were lower among patients treated by obstetric-specialized anesthesiologists among all patients (adjusted odds ratio, 0.71; 95% CI, 0.55 to 0.92; P = 0.011), and in a subgroup analysis restricted to urgent or emergent cesarean deliveries (adjusted odds ratio, 0.75; 95% CI, 0.56 to 0.99; P = 0.049). There was no association between provider specialization and the odds of receiving general anesthesia in a subgroup analysis restricted to evening or weekend deliveries (adjusted odds ratio, 0.76; 95% CI, 0.56 to 1.03; P = 0.085). CONCLUSIONS: Treatment by an obstetric anesthesiologist was associated with lower odds of receiving general anesthesia for cesarean delivery; however, this finding did not persist in a subgroup analysis restricted to evening and weekend deliveries.

Epidural Analgesia for Labor: Continuous Infusion Versus Programmed Intermittent Bolus.

Despite the traditional practice to maintain labor analgesia with a combination of continuous epidural infusion and patient-controlled epidural analgesia using an automated epidural pump; compelling data now shows that bolus injection through the epidural catheter may result in better distribution of anesthetic solution in the epidural space. The programmed intermittent epidural bolus technique is proposed as a better maintenance mode and may represent a more effective mode of maintaining epidural analgesia for labor, especially prolonged labor. Additional prospective and adequately powered studies are needed to confirm findings and determine the optimal combination of volume, rate, time, and drug concentration.

The incidence of un-indicated preoperative testing in a tertiary academic ambulatory center: a retrospective cohort study.

BACKGROUND: Despite existing evidence and guidelines advocating for appropriate risk stratification, ambulatory surgery in low-risk patients continues to be accompanied by a battery of routine tests prior to surgery. Using a single-center retrospective cohort study, we aimed to quantify the incidence of un-indicated preoperative testing in an academic ambulatory center by utilizing recommendations by the recently developed American Society of Anesthesiology (ASA) "Choosing Wisely" Top-5 list. METHODS: We utilized data from the EPIC medical records of 3111 patients who had ambulatory surgery at the Hospital of the University of Pennsylvania during a 6-month period. Data were abstracted from laboratory studies- complete blood count, electrolyte panel, coagulation studies, and cardiac studies-stress test, and echocardiogram obtained within 30 days prior to surgery. Preoperative tests obtained from each patient were categorized into "indicated" (ASA ≥ 3) and "un-indicated" (ASA 1 and 2) tests, and percentages were reported. RESULTS: During the study period, 52.9 % (95 % confidence interval (CI) 37.6-66.4) of all patients had at least one un-indicated laboratory test performed preoperatively. Further analysis revealed variation in the incidence of preoperative ordering between tests; 73 % of all complete blood counts (CBCs), 70 % of all metabolic panels, and 49 % of all coagulation studies were considered un-indicated by "Top-5 List" criteria. Stated differently, of the patients included in the sample, 51 % of patients received an un-indicated CBC, 41 % an un-indicated metabolic panel, and 16 % un-indicated coagulation studies. Twelve percent of "any un-indicated preoperative test" were obtained from ASA 1 healthy patients. Of the 587 patients less than 36 years old, 331 (56 %) had at least one test that was deemed un-indicated. Forty-one patients had either an echocardiogram or stress test ordered and performed within 30 days of surgery. Of these, eight (19.5 %) studies were un-indicated as determined by chart review. CONCLUSIONS: The incidence of ordering "at least one un-indicated preoperative test" in low-risk patients undergoing low-risk surgery remains high even in academic tertiary institutions. In the emerging era of optimizing patient safety and financial accountability, further studies are needed to better understand the problem of overuse while identifying modifiable attitudes and institutional influences on perioperative practices among all stakeholders involved. Such information would drive the development of feasible interventions.

Breastfeeding after Anesthesia: A Review for Anesthesia Providers Regarding the Transfer of Medications into Breast Milk.

Doctors, nurses, and midwives often inform mothers to "pump and dump" their breast milk for 24 hours after receiving anesthesia to avoid passing medications to the infant. This advice, though cautious, is probably outdated. This review highlights the more recent literature regarding common anesthesia medications, their passage into breast milk, and medication effects observed in breastfed infants. We suggest continuing breastfeeding after anesthesia when the mother is awake, alert, and able to hold her infant. We recommend multiple types of medications for pain relief while minimizing sedating medications. Few medications can have sedating effects to the infant, but those medications are specifically outlined. For additional safety, anesthesia providers and patients may screen medications using the National Institute of Health' LactMed database.

The effects of resource improvement on decision-to-delivery times for cesarean deliveries in a Ghanaian regional hospital.

OBJECTIVE: To evaluate the effects of having a dedicated obstetric operating room (OR) on the decision-to-delivery interval (DDI) in a large referral hospital in Ghana. METHODS: An observational study was undertaken of all patients undergoing cesarean delivery at Ridge Regional Hospital, Accra, before (pre-OR; August-September 2011) and after (post-OR; August-September 2012) introduction of an obstetric OR. The primary outcome was the DDI. RESULTS: In total, 581 cesareans were performed in the pre-OR period and 574 in the post-OR period. Overall, the median DDI decreased from 259 min (interquartile range [IQR] 161-432) in the pre-OR period to 195 min (IQR 138-319) in the post-OR period (P<0.001). DDI was lower in the post-OR period than in the pre-OR period for both emergency (175 min [IQR 126-241] vs 220 min [IQR 146-315]; P<0.001) and elective (1828 min [IQR 1432-2985] vs 4291 min [IQR 2992-5862]; P<0.001) cesarean deliveries. Only one emergency cesarean-in the post-OR period-was conducted within the recommended 30-minute timeframe. CONCLUSION: An obstetric OR lowered the DDI for cesarean delivery; however, a realistic timeframe for emergency cesareans in low-income countries remains to be determined.

Choosing wisely in anesthesiology: the gap between evidence and practice.

To develop a "top-five" list of unnecessary medical services in anesthesiology, we undertook a multistep survey of anesthesiologists, most of whom were in academic practice, and a consequent iterative process with the committees of the American Society of Anesthesiologists. We generated a list of 18 low-value perioperative activities from American Society of Anesthesiologists practice parameters and the literature. Starting with this list and proceeding with a 2-step survey using a 5-point Likert scale questionnaire, we eventually identified 5 common activities that are of low quality or benefit and high cost and have poor evidence supporting their use. The 2 preoperative practices in the top-five list addressed the avoidance of unindicated baseline laboratory studies or diagnostic cardiac stress testing. The 3 intraoperative practices involved the avoidance of the routine use of the pulmonary artery for cardiac surgery and the use of packed red blood cells or colloid when not indicated.