The use of relational databases in the transition from quality assurance to continuous quality improvement: a clinical practice model.

The use of both clinical medical and administrative databases is discussed in the context of an academic anesthesiology's transition from the tenets of quality assurance to those of continuous quality improvements. A historical framework is presented. The basic and aggregate models are introduced, and examples are used to illustrate the composite system.

Transesophageal echocardiography and the perioperative management of valvular heart disease.

Transesophageal echocardiography (TEE) is an integral part of decision-making and monitoring in the perioperative period for patients undergoing valvular heart surgery. Multiplanar probes with improved pre- and intraoperative evaluation, eg, improved accuracy of estimation of mitral regurgitation jet size, have led to a more precise surgical approach. In the intensive care unit, TEE is proving invaluable in diagnosing occult causes of clinical instability that are usually surgically correctable. Advances in imaging technology with three- and four-dimensional TEE will facilitate preoperative decision-making, determine intraoperative approaches to valvular surgery, and provide earlier recognition of complications in the intensive care unit.

Anesthesiology.

In suitable candidates undergoing cardiac surgery, inhalation agents and new protocols for postoperative care have facilitated early extubation and reduced levels of intensive care. Volunteers with no prior experience in resuscitation were more successful in maintaining patent airways with the laryngeal mask airway than with the standard face mask and oral airway.

Cocaine abuse in the parturient and effects on the fetus and neonate.

The growing use of cocaine among pregnant women and women of childbearing age has become an issue of great concern to physicians. Cocaine abuse among parturients is associated with multi-target organ involvement, including the cardiovascular, respiratory, neurologic, and hematologic systems. Cocaine use during pregnancy is also an independent contributor to the risk of placental abruption, preterm labor, precipitate delivery, stillbirth, and others. Although a history of premature rupture of membranes, smoking, alcohol use, syphilis serology, and use of other illicit drugs suggests cocaine abuse, the single most important predictor is the absence of prenatal care. The intraoperative anesthetic management should take into consideration the different effects of cocaine on the mother, the fetus, and the neonate.

Preoperative evaluation of the cardiac patient for noncardiac surgery.

Perioperative cardiac events continue to represent a significant cause of morbidity in patients undergoing noncardiac surgery. The evaluation of the high risk patient should begin with an assessment of the probability of coronary artery disease and exercise tolerance. Decisions to undergo further evaluation, including noninvasive testing, should be based upon the perioperative morbidity and mortality rate for the planned surgical procedure. In patients with significant coronary artery stenoses and a high probability of perioperative cardiac morbidity, coronary artery bypass grafting, percutaneous transluminal coronary angioplasty, and preoperative optimization of hemodynamics in an intensive care unit have all been advocated as means of reducing risk.

The patient care evaluation system: patients' perception of anesthetic care.

Our department's Patient Care Evaluation Survey was developed to measure the patients' perception of the care they received by our anesthesia caregivers (attending physicians, residents, and certified registered nurse anesthetists [CRNAs]), and identify those areas of patient contact which might require improvement in the delivery of anesthesia. The survey instrument (a personal letter sent by the chairman), is mailed to randomly selected patients two weeks following discharge from the hospital or ambulatory surgery center. Patients rated the anesthesia care they received from one (poor) to 10 (excellent) in three areas: the preoperative visit, the postoperative visit, and overall satisfaction. From October 1986 to October 1991, a total of 2,374 (n = 2,374) questionnaires representing a random sample of 99,964 anesthetics, were sent to patients. Fifty-four percent or 1,291/2,374 patients returned the survey. A high degree of patient satisfaction is seen for all categories: the preoperative visit, (mean score of 9.17 +/- 1.6); the postoperative visit (8.33 +/- 2.7); and overall satisfaction (9.15 +/- 1.7). Of the responses returned, 0.9% of the patients surveyed rated their interaction with the department as unsatisfactory in all three areas; 2.6% in two areas; 10.8% in at least one area. The Patient Care Evaluation system has served as an important means of feedback for medical, educational, and administrative goals of the department.