Development of a Preoperative Patient Clearance and Consultation Screening Questionnaire.

The optimal timing of the preanesthesia evaluation varies with the patient's comorbidities. As anesthesiologists assume a broader role in perioperative care, there may be opportunities to provide additional patient management beyond historical routine anesthesia services. This study was thus undertaken to survey our institutional perioperative clinicians regarding their perceptions of patient medical conditions that (a) need additional time for preoperative clearance by anesthesiology before actually scheduling the date of surgery and (b) warrant additional preoperative evaluation and management services by an anesthesiologist. These data were used to create a pilot version of a Preoperative Patient Clearance and Consultation Screening Questionnaire.

A Primer on Population Health Management and Its Perioperative Application.

The movement toward value-based payment models, driven by governmental policies, federal statutes, and market forces, is propelling the importance of effectively managing the health of populations to the forefront in the United States and other developed countries. However, for many anesthesiologists, population health management is a new or even foreign concept. A primer on population health management and its potential perioperative application is thus presented here. Although it certainly continues to evolve, population health management can be broadly defined as the specific policies, programs, and interventions directed at optimizing population health. The Population Health Alliance has created a particularly cogent conceptual framework and interconnected and very useful population health process model, which together identify the key components of population health and its management. Population health management provides a useful rationale for patients, providers, payers, and policymakers to move collectively away from the traditional system of individual, siloed providers to a more integrated, coordinated, team-based approach, thus creating a holistic view of the patient population. The goal of population health management is to keep the targeted patient population as healthy as possible, thus minimizing the need for costly interventions such as emergency department visits, acute hospitalizations, laboratory testing and imaging, and diagnostic and therapeutic procedures. Population health management strategies are increasingly more important to leaders of health care systems as the health of populations for which they care, especially in a strong cost risk-sharing environment, must be optimized. Most population health management efforts rely on a patient-centric team approach, coordination of care, effective communication, robust outcomes data analysis, and continuous quality improvement. Anesthesiologists have an opportunity to help lead these efforts in concert with their surgical and nursing colleagues. The Triple Aim of Healthcare includes (1) improving the patient experience of care (including quality and satisfaction); (2) improving the health of populations; and (3) reducing per-capita costs of care. The Perioperative Surgical Home essentially seeks to transform perioperative care by achieving the Triple Aim, including improving the health of the surgical population. Many health care delivery systems and many clinicians (including anesthesiologists) are just beginning their population health management journeys. However, by doing so, they are preparing to navigate a much greater risk-sharing landscape, where these efforts can create greater financial stability by preventing major financial loss. Anesthesiologists can and should be leaders in this effort to add value by improving the comprehensive continuum of care of our patients.

Perceptions about the relative importance of patient care-related topics: a single institutional survey of its anesthesiologists, nurse anesthetists, and surgeons.

BACKGROUND: Persistently variable success has been experienced in locally translating even well-grounded national clinical practice guidelines, including in the perioperative setting. We have sought greater applicability and acceptance of clinical practice guidelines and protocols with our novel Perioperative Risk Optimization and Management Planning Tool (PROMPT™). This study was undertaken to survey our institutional perioperative clinicians regarding (a) their qualitative recommendations for (b) their quantitative perceptions of the relative importance of a series of clinical issues and patient medical conditions as potential topics for creating a PROMPT™. METHODS: We applied a mixed methods research design that involved collecting, analyzing, and "mixing" both qualitative and quantitative methods and data in a single study to answer a research question. Survey One was qualitative in nature and asked the study participants to list as free text up to 12 patient medical conditions or clinical issues that they perceived to be high priority topics for development of a PROMPT™. Survey Two was quantitative in nature and asked the study participants to rate each of these 57 specific, pre-selected clinical issues and patient medical conditions on an 11-point Likert scale of perceived importance as a potential topic for a PROMPT™. The two electronic, online surveys were completed by participants who were recruited from the faculty in our Department of Anesthesiology and Perioperative Medicine and Department of Surgery, and the cohort of hospital-employed certified registered nurse anesthetists. RESULTS: A total of 57 possible topics for a PROMPT™ was created and prioritized by our stakeholders. A strong correlation (r = 0.82, 95% CI: 0.71, 0.89, P < 0.001) was observed between the quantitative clinician survey rating scores reported by the anesthesiologists/certified registered nurse anesthetists versus the surgeons. The quantitative survey displayed strong inter-rater reliability (ICC = 0.92, P < 0.001). CONCLUSIONS: Our qualitative clinician stakeholder survey generated a comprehensive roster of clinical issues and patient medical conditions. Our subsequent quantitative clinician stakeholder survey indicated that there is generally strong agreement among anesthesiologists/certified registered nurse anesthetists and surgeons about the relative importance of these clinical issues and patient medical conditions as potential topics for perioperative optimization and risk management.

Preoperative management of antiplatelet drugs for a coronary artery stent: how can we hit a moving target?

BACKGROUND: With the advent of percutaneous coronary intervention, specifically the bare metal stent and subsequently, the drug-eluting stent, the scope of interventional cardiology has greatly increased. Aspirin, in combination with a thienopyridine is the present-day cornerstone of oral antiplatelet therapy after coronary artery stent placement. Continuing this chronic antiplatelet therapy, to mitigate a perioperative major adverse cardiac event, can be challenging and remains controversial in patients with a coronary artery stent undergoing non-cardiac surgery. We describe here the rationale for and successful use of an alternate approach to formulating local institutional management protocols for patients with a coronary artery stent, undergoing an elective surgical procedure. DISCUSSION: A recent systematic review identified 11 clinical practice guidelines for the perioperative management of antiplatelet therapy in patients with a coronary stent who need non-cardiac surgery. However, there is significant variance and inadequacy with these current applicable professional society guidelines. Moreover, persistently variable success has been experienced in translating even well-grounded national clinical guidelines into local practice, including in the perioperative setting. Under the auspices of a broadly multidisciplinary institutional task force and applying the Consensus-Oriented Decision-Making model, we created two evidence-informed and local expert opinion-supported standardized clinical assessment and management plans for the preoperative management of antiplatelet therapy in patients with a coronary artery stent. SUMMARY: Patient care can be optimized via evidence-based, yet locally developed and reiterative standardized clinical assessment and management plans for patients with coronary artery stents undergoing surgical procedures. Such standardized clinical assessment and management plans can result in greater consistency in care, providing a positive feedback loop in which the care plan itself can be continuously reevaluated, improved, and brought up to date with the most recent available data and knowledge.

Predictors of patient medication compliance on the day of surgery and the effects of providing patients with standardized yet simplified medication instructions.

BACKGROUND: Anesthesiologists are responsible for optimizing patients' preoperative medications, including maximizing their compliance with preoperative medication instructions. The authors hypothesized that a standardized, simplified instruction sheet presented and verbally reinforced during the preanesthesia clinic visit would improve patient medication compliance on the day of surgery. METHODS: An unmatched case-control design was applied, with nonrandomized, preintervention (controls) and postintervention (cases) data collected. In the preintervention group, patient education/instruction regarding taking medications on the day of surgery continued in the existing, unstandardized manner. In the postintervention group, patients were given a simplified, multicolored Preoperative Patient Medication Instruction Sheet, which was consistently verbally reviewed with patients. Group differences and independent variable associations were analyzed with conventional inferential biostatistics. RESULTS: A total of 521 and 531 patients were enrolled in the preintervention group and postintervention group, respectively. Of this, 309 patients (60%) of preintervention group versus 391 patients (74%) of postintervention group (P < 0.001) were compliant with their preoperative medication instructions on the day of surgery. Use of the Preoperative Medication Instruction Sheet (adjusted odds ratio [aOR] = 1.83; P < 0.001), Caucasian race (aOR = 1.74; P = 0.007), and recalling receiving both verbal/written preoperative medication instructions (aOR = 1.51; P = 0.006) were associated with greater patient medication compliance. Older age (aOR = 0.67; P = 0.014) and higher American Society of Anesthesiologists status (aOR = 0.60; P = 0.004) were associated with lesser patient medication compliance. CONCLUSIONS: A standardized, multicolored, pictorial Preoperative Patient Medication Instruction Sheet, with patient communication in both verbal/written forms, seems to improve patient medication compliance on the day of surgery. African-Americans, older patients, and those with greater comorbidities may require a more concerted effort to achieve an adequate preoperative medication compliance.

The Perioperative Surgical Home: how can it make the case so everyone wins?

BACKGROUND: Varied and fragmented care plans undertaken by different practitioners currently expose surgical patients to lapses in expected care, increase the chance for operational mistakes and accidents, and often result in unnecessary care. The Perioperative Surgical Home has thus been proposed by the American Society of Anesthesiologists and other stakeholders as an innovative, patient-centered, surgical continuity of care model that incorporates shared decision making. Topics central to the debate about an anesthesiology-based Perioperative Surgical Home include: holding the gains made in anesthesia-related patient safety; impacting surgical morbidity and mortality, including failure-to-rescue; achieving healthcare outcome metrics; assimilating comparative effectiveness research into the model; establishing necessary audit and data collection; a comparison with the hospitalist model of perioperative care; the perspective of the surgeon; the benefits of the Perioperative Surgical Home to the specialty of anesthesiology; and its associated healthcare economic advantages. DISCUSSION: Improving surgical morbidity and mortality mandates a more comprehensive and integrated approach to the management of surgical patients. In their expanded capacity as the surgical patient's "perioperativist," anesthesiologists can play a key role in compliance with broader set of process measures, thus becoming a more vital and valuable provider from the patient, administrator, and payer perspective. The robust perioperative databases created within the Perioperative Surgical Home present new opportunities for health services and population-level research. The Perioperative Surgical Home is not intended to replace the surgeon's patient care responsibility, but rather leverage the abilities of the entire perioperative care team in the service of the patient. To achieve this goal, it will be necessary to expand the core knowledge, skills, and experience of anesthesiologists. Anesthesiologists will need to view becoming perioperative physicians as an expansion of the specialty, rather than an abdication of their traditional intraoperative role. The Perioperative Surgical Home will need to create strategic added value for a health system and payers. This added value will strengthen the position of anesthesiologists as they navigate and negotiate in the face of finite, if not decreasing fiscal resources. SUMMARY: Broadening the anesthesiologist's scope of practice via the Perioperative Surgical Home may promote standardization and improve clinical outcomes and decrease resource utilization by providing greater patient-centered continuity of care throughout the preoperative, intraoperative, and postoperative periods.

The creation and impact of a dedicated section on quality and patient safety in a clinical academic department.

Optimizing the effectiveness, efficiency, integration, and satisfaction associated with delivered health care is not only highly principled but also good business practice in an extremely competitive environment. Programs that foster quality improvement and patient safety efforts while also promoting a scholarly focus can generate the incentives and organizational recognition needed to make patient safety and quality improvement bona fide components of the academic mission. The authors describe the development, implementation, and results of a dedicated Section on Quality and Patient Safety (SQPS) within an academic anesthesiology department. Spearheaded by a physician champion and vigorously supported by the departmental chair, this SQPS engaged core leaders from the Department of Anesthesiology. This departmental quality and patient safety management team adopted quality improvement and performance improvement techniques that have been successfully used in other industries. The SQPS has gained support through data-driven results and reiterative promotion. Transparency and accountability have also been powerful motivators for achieving clinician buy-in and changing behavior. Since its inception in 2007, the SQPS has initiated or managed through to completion more than 25 quality and performance improvement projects, including an intraoperative corneal injury reduction program, a wrong-sided regional anesthesia procedure, a drug-eluting coronary stent protocol, and a practice-improvement initiative for resident physicians. The SQPS has not only robustly promoted a departmental culture of quality patient care and safety but also set the standard for other departments and stakeholders within the authors' health system.

A case-control study of an intraoperative corneal abrasion prevention program: holding the gains made with a continuous quality improvement effort.

BACKGROUND: Corneal injury is the most frequent ocular complication during general anesthesia. Although prevention has appeared feasible, inconsistent use and timing of conventional eye ointment and eyelid tape had failed to adequately prevent intraoperative corneal injuries at a department of anesthesiology in an academic medical center. A continuous quality improvement (CQI) program was thus undertaken to prevent intraoperative corneal injury. PLAN-DO-CHECK-ACT: A departmentwide Plan-Do-Check-Act cycle, and specifically the Seven-Step Problem-Solving Model, were applied. The new standardized eye- protection method involved eye lubrication with aqueous-based gel and application of clear, square occlusive dressings that were large enough to cover the eyelids and surrounding skin. Standardized documentation of patient eye protection in the electronic anesthesia record was also implemented. A systematic approach maximized departmental awareness about this new eye-protection method and its documentation. Subsequent individual practitioner counseling and reinforcement was undertaken. RESULTS: A total of 50,151 sequential general anesthetics before and 113,044 sequential general anesthetics after implementation of the new corneal injury prevention program were analyzed. The corneal injury rate was 1.20/1,000 general anesthetics before versus 0.09/1,000 general anesthetics after implementing our prevention program (p < .001). This pattern of a marked reduction in intraoperative corneal injuries was sustained for the entire 45-month follow-up period. DISCUSSION: A simple and cost-effective method for preventing intraoperative corneal injuries was successfully identified, implemented, and sustained. The systematic approach involved a rigorous reiterative approach and resulted in a fundamental change in local practice pattern.

The perioperative management of patients with coronary artery stents: surveying the clinical stakeholders and arriving at a consensus regarding optimal care.

BACKGROUND: The perioperative management of patients with a coronary artery stent is a major patient safety issue currently confronting clinicians. Surgery on a patient on antiplatelet therapy creates the following dilemma: is it better to withdraw the drugs and reduce the hemorrhagic risk or to maintain them and reduce the risk of a myocardial ischemic event? METHODS: An electronic survey was used to sample a cross-section of local clinicians regarding the perioperative management of patients with an indwelling coronary artery stent. The reiterative Consensus-Oriented Decision-Making model was applied by an institutional task force with representation from anesthesiology, cardiology, primary care medicine, and surgery. RESULTS: Significant disagreement existed among the multidisciplinary survey respondents regarding various aspects of the perioperative management of patients with indwelling coronary artery stents. CONCLUSIONS: We clarified the perioperative risk factors for coronary stent thrombosis and an alternate process for immediate access to a cardiac catheterization laboratory at our institution.

Outcomes of intubation in difficult airways due to head and neck pathology.

The purpose of this study was to examine the impact of surgical pathology, anesthesiologist experience, and airway technique on surgically relevant outcomes in patients identified by preoperative laryngoscopy to have a difficult airway due to head and neck pathology. We prospectively recorded a series of 152 difficult airway cases due to head and neck pathology out of 2,145 direct laryngoscopies undertaken between November 2005 and June 2008. One of two senior anesthesiologists specializing in head and neck procedures intubated 101 (66.4%) of the 152 patients and did so 3.3 minutes faster (p = 0.51), with better oxygenation (87.3 vs. 81.8%; p = 0.02) and fewer airway plan changes (p = 0.001) than did other, nonspecialist anesthesiologists. Predictors of failure of the first intubation plan included: cancer diagnosis (p = 0.02), previous radiotherapy (p = 0.03), and supraglottic lesions (p = 0.03). Glottic/subglottic lesions required the most intubation attempts (p = 0.02). Awake fiberoptic intubation was the most common method used (44.7%) but resulted in a change in the airway plan in 6 cases (8.8%). Gas induction maintained the best oxygenation (p = 0.01). Awake tracheostomy was infrequent (1.3%) and took the longest (p = 0.006). We concluded that difficult airways due to head and neck pathology require teamwork and a backup plan. An anesthesiologist specializing in head and neck procedures may help to avoid adverse outcomes associated with cancer, especially previously irradiated supraglottic/glottic lesions, leading to a less frequent need for awake tracheostomy.

Durable improvements in efficiency, safety, and satisfaction in the operating room.

BACKGROUND: Enhanced productivity and efficiency in the operating room must be balanced with patient safety and staff satisfaction. In December 2004, transition to an expanded replacement hospital resulted in mandatory overtime, unpredictable work hours, and poor morale among operating room (OR) staff. A staff-retention crisis resulted, which threatened the viability of the OR and the institution. We report the changes implemented to efficiently deliver safe patient care in a supportive environment for surgeons and OR staff. STUDY DESIGN: University of Alabama at Birmingham University Hospital OR data were evaluated for fiscal year 2004 and compared with fiscal years 2005 and 2006. Case volumes, number of operational ORs, and on-time case starts were evaluated. OR adverse events were tabulated. Percentage of registered nurse hires and staff departures served as a proxy for staff satisfaction. RESULTS: Short, intermediate, and longterm strategies were implemented by an engaged OR management committee with the guidance of surgical, anesthesia, and hospital leadership. These included new block time release policies; use of traveling nurses until new staff could be hired and trained; and incentive-based, voluntary, employee-scheduled overtime. Mandatory nursing education time was blocked weekly. Enforcement of the National Patient Safety Goals were implemented and adjudicated with a "surgeon-of-the-day" system providing backup for nurse management. We demonstrated an increase in operations per year, on-time starts, and registered nurse hires in fiscal years 2005 and 2006. During this same time, we were able to markedly decrease the number of adverse events, admitting delays, and staff departures. CONCLUSIONS: Change is difficult to accept but essential when vital clinical activities are impaired and at risk. To maintain important clinical environments like the OR in an academic center, we developed and implemented effective, data-driven changes. This allowed us to retain critical human resources and restore a supportive environment for the patients, the doctors, and the staff.

Preemptive vessel dilator cricothyrotomy aids in the management of upper airway obstruction.

PURPOSE: Our objective was to demonstrate that preemptive vessel dilator cricothyrotomy may be useful when managing the patient with airway obstruction. METHODS: An Institutional Review Board approved retrospective study was undertaken in 88 patients for whom this technique was selected. The anesthesiologists and surgeons identified as authors were directly involved in the care of these patients. All vessel dilator cricothyrotomies were performed in the operating rooms of University Hospital, UAB, Medical Center. The patients selected for this airway management technique were afflicted with some type of supraglottic lesion, usually squamous cell carcinoma, which was obstructing their airways to an extent that complete airway obstruction during induction of anesthesia was a significant possibility. Prior to induction of anesthesia, the vessel dilator was inserted into the tracheal lumen through the cricothyroid membrane as described. Oxygenation was maintained with jet ventilation from a Sanders jetting device. Age, sex, weight, initial and lowest O(2) saturation, first recorded ETCO(2), blood pressure and duration of jet ventilation were recorded. RESULTS: The airways were successfully managed in all 88 patients with this technique. There were no deaths, and no postoperative hypoxic sequelae; also complications were minor. CONCLUSION: Vessel dilator cricothyrotomy as a preemptive procedure in the management of patients with significant supraglottic airway obstruction may be a useful addition to the anesthesiologists' armamentarium of airway management devices.

Ethical dilemmas for pediatric surgical patients.

Anesthesiologists are confronted with interesting and sometimes difficult ethical situations in pediatric surgery. They are forced to deal with everything from "do not resuscitate" issues, heroic last-chance surgical efforts, religious and cultural conflicts, disputes among colleagues, and situations that are, at worst, uncomfortable and, at best, miscarriages of duty. It is incumbent on anesthesiologists to learn how to logically and appropriately handle these issues. The pediatric surgical patient requires special consideration in bioethics. This article discusses the principle of autonomy and its ascension in importance in bioethics. The concepts of informed parental permission, assent, and dissent are presented. The authors provide a framework for ethical problem-solving, as well as a discussion of judicial decision-making. In addition, several examples of clinical-ethical situations and the processes used for resolutions are discussed. By using a well-reasoned ethical decision-making process, any situation, from the simple conflict to the most serious resuscitation and withdrawal of care issues, may be appropriately resolved.