A pilot study of recovery room bypass ("fast-track protocol") in a community hospital.

PURPOSE: To evaluate the effectiveness of short-acting anesthetic drugs and techniques to achieve recovery room bypass criteria after minor surgery in a community hospital environment. METHODS: After agreement by a multidisciplinary committee, a pilot project was undertaken to assess the usefulness of ultra- short acting anesthetic drugs and pre-emptive analgesia to facilitate rapid recovery from general anesthesia. A cohort of 100 ASA I-II patients aged 18-65 yr undergoing simple knee arthroscopy or minor peripheral orthopedic procedures was compared to a similar cohort treated in the three months prior to the study period. Outcomes of interest included patient morbidity, success in achieving post-anesthesia care unit (PACU) bypass criteria, impact upon nursing resources, duration of operating room (OR) and hospital stay, and pharmaceutical costs before and after implementation. RESULTS: No patient morbidity was demonstrated prior to discharge home, and successful PACU bypass occurred in 83% of cases. Achievement of PACU discharge criteria while in the OR did not prolong the OR time, and discharge from hospital occurred earlier in the patients who did not require PACU care (P=0.0006 all "fast-track cases" vs all "controls"). Nursing complaints were more numerous when the day surgery personnel did not normally participate in PACU care. The cost of anesthetic care was significantly more using ultra-short acting drugs (CDN $14.17 vs CDN $20.57), but closer adherence to protocol could reduce this differential (CDN $18.84). CONCLUSION: Not all patients who receive a general anesthetic require admission to a phase I recovery facility. However, the justification for use of more expensive pharmaceuticals to achieve PACU bypass requires extensive changes in operating systems and voluntary professional behaviours.

Does the method of payment affect anaesthetic practice? An evaluation of an alternate payment plan.

PURPOSE: To test the null hypothesis that the method of physician payment does not influence the practice of anaesthesia. METHODS: Retrospective cohort study of anaesthetists before (Jan-June, 1994) and after (Jan-June, 1995) departure from fee-for-service practice into an alternate funding arrangement (AFP). Another group of physicians was studied as a concurrent control. Case numbers, induction times, cancellation rates, and operating hours for the department, recorded by third parties, were compared before and after AFP implementation. Using index procedures, details of individual patient decisions made by anaesthetists were compared for the two study periods, and between subscribing and non-subscribing physicians. RESULTS: Implementation of AFP resulted in a modest reduction in case numbers (7.2%) offset by an increase (5.7%) in the average case duration. Net change in time dedicated to clinical service (2% per physician) is inconsequential to the academic mission of the department. There was no change in cancellation rate and the use of invasive monitors was unchanged. An increase in the use of regional anaesthesia occurred but, since a similar increase occurred in the practice of those still on fee-for-service, it cannot be ascribed to the AFP. With respect to hip arthroplasty, the case was prolonged (P = 0.001) if the surgeon was paid via the AFP. CONCLUSION: Payment of physicians by non-fee-for-service techniques did not have a constructive influence on measures of anaesthetic practice. The goal of alternate payment arrangements, to liberate time for academic pursuits, could not be achieved in this experimental model.

Soft tissue profile changes in late adolescent males.

The purpose of this study was to document soft tissue profile changes in late adolescent skeletal Class I males from 14 to 20 years of age and to compare these changes with those of the underlying hard tissues. Using serial lateral cephalograms from a sample of 33 untreated Class I adolescent males, 26 soft and hard tissue parameters were assessed at ages 14 to 16, 16 to 18, and 18 to 20 years. The concept that differential facial growth occurs from nasion to pogonion was substantiated by these data. The hard tissue chin moved forward more than A-point, which in turn moved forward more than nasion, resulting in the hard and soft tissue profile being flattened or reduced in convexity. Horizontal soft tissue thickening of 1.0 mm overlying the hard tissue surfaces from midface to chin was observed at 14-16 years. Continued change of the soft tissue profile from 16 to 20 was thus the result of underlying skeletal growth. Nasal tip increased significantly over all age periods, and underwent the largest growth change of all measurements assessed (approximately 8.0 mm). This growth increase declined by approximately one-half over each successive age period. Although variable, continued soft tissue movements throughout the 14- to 20-year age period affect treatment planning, maintenance of the posttreatment profile, and posttreatment occlusal retention requirements.

Assessing discomfort after anaesthesia: should you ask the patient or read the record?

OBJECTIVE: To assess the quality of anaesthesia care from the patients' viewpoint compared with the hospital record. DESIGN: Prospective study during 1988-9. SETTING: Four teaching hospitals (A-D) in Canada. PATIENTS: 15,960 inpatients receiving anaesthetic requiring at least an overnight stay, for whom an interview and review of hospital records within 72 hours of surgery were complete. MAIN MEASURES: Rates of postoperative symptoms of discomfort (nausea or vomiting, headache, back pain, sore throat, eye symptoms, and tingling) according to the hospital record versus interview and the relation between symptoms and patients' satisfaction with the anaesthetic experience. RESULTS: The preparation of completed interviews ranged from 31.0% to 72.7%, owing mainly to patients discharge (hospitals A and B) and severity of illness (C and D). Interviewed patients were similar to all inpatients in the hospitals but were younger and healthier and more had had effective operations and were general surgical than cardiovascular or neurosurgical patients. In all, 26% to 46% of patients at the four hospitals reported at least one symptom of discomfort. Agreement between interviews and hospital records was low, symptoms being more commonly reported by interview than in the record (for example, headache was reported for 5.8%-17% of patients compared with 0.3%-3.0% in hospital records). After controlling for case mix patients who reported at least one symptom were 2.91 times (95% confidence interval 1.89 to 4.50) more likely to be dissatisfied with their anaesthetic care than patients who did not. CONCLUSIONS: Anaesthesia services are typically neglected in studies of hospital quality, yet patients express considerable anxiety about anaesthetic care. Monitoring and recording patients' discomfort clearly need to be improved if the quality of anaesthesia is to be properly evaluated.

The postoperative interview: assessing risk factors for nausea and vomiting.

Most studies of postoperative nausea and vomiting have concentrated on single etiologic factors and have not detailed the method of assessing these symptoms. This study used postoperative interview data from patients at four teaching hospitals during 1988-89, to determine 1) risk factors for nausea/vomiting, 2) whether the type of surgery affected the rate of nausea/vomiting among female patients, 3) whether differences in rates across hospitals were due to differences in patient case-mix, and 4) whether there were differences in the rate of nausea/vomiting among the patients of individual anesthesiologists. Research nurses performed 16,000 interviews (59% of all inpatients) from a closed-question standardized format. With a multiple logistic regression that controlled simultaneously for all risk factors, factors associated with increased risk for nausea/vomiting for all patients included younger age, female, lower physical status score, no preoperative medical conditions, nonsmokers, elective procedures, longer duration of anesthesia, inhaled anesthetics, use of intraoperative opioids, and gynecologic or ophthalmologic operations. Among women, risk factors were similar, with minor gynecologic surgery associated with increased risk (relative odds = 2.30). We found marked variations in the rate of nausea/vomiting across hospitals (range, 39% to 73%), and these variations were not explained by the case-mix of patients. The rate of nausea/vomiting varied substantially across anesthesiologists in each hospital and the differences were not explained by differences in the patients they managed. Thus in the time period immediately preceding the introduction of newer antiemetic drugs, we found that the rates of this common problem were persistently high as perceived from the patients' point of view.

Differential post-irradiation caffeine response in normal diploid versus SV40-transformed human fibroblasts: potential role of nuclear organization and protein-composition.

To test the hypothesis that the enhancement of cell killing by post-irradiation treatment with caffeine (CAF) is mediated by alterations in chromatin structure, several nuclear parameters were examined in both caffeine-responsive and non-responsive cell lines. Cell killing, as determined by clonogenic assay, was not enhanced by post-irradiation treatment with 5 mM caffeine in a human diploid fibroblast line (AG1522) but an effect was seen in a SV40 T-antigen transformed derivative (1522-a). CAF caused a complete reversal of the radiation-induced G2 + S phase cell-cycle delays in the transformed cell line but only a partial reversal was noted for the parental cell line. The nuclear endpoints examined, which may be indicative of chromatin conformational changes, included enzymatic accessibility, DNA loop structure, and nuclear protein composition. In assays of the ability of DNA to undergo supercoiling changes, it was found that nucleoids isolated from CAF-treated cells had a significantly reduced propidium-iodide relaxable DNA loop size. The constraints to DNA unwinding produced by CAF were also maintained even in the presence of large numbers of single strand breaks produced by a test dose of radiation (10 Gy). This effect did not correlate well with the ability of CAF to enhance radiation-induced cell killing. The two other nuclear endpoints did detect differences between the normal and transformed cell lines. CAF had no effect on the DNase I digestion kinetics of the normal fibroblasts. However, in the transformed cell line, CAF appeared to render an additional 10-15% of the genome accessible to DNase I digestion. Several radiation and CAF-induced changes in the polypeptide pattern of isolated nucleoids were detected after metabolic labelling with 35S-methionine or 32P-orthophosphoric acid. While the identities of these proteins remain to be established, many had relative molecular weights similar to the other reported radiation-altered proteins and human cell cycle control gene products. The present cell lines should provide a convenient system in which to identify a nuclear protein change specifically associated with the ability of CAF to enhance radiation-induced cell killing.

The image of the anaesthetist.

Recent advances have reduced the risks of anaesthesia to a virtually immeasurable level. However, if the specialty wishes to continue to foster support, it will require active promotion of the benefits, not hazards, of our practice. The few published surveys of the image of the anaesthetist show that the public poorly understands either our background training or education, or the responsibility we bear in their care. Our medical and surgical colleagues, and even some practising anaesthetists, hold a view of our specialty that is subservient and less than flattering. It is certain that we cannot tolerate the sensationalized tragedies resulting from anaesthetic neglect in bygone years; we must effectively discipline ourselves if standards are not being met. We should lose no opportunity to become involved outside the operating room, whether in pre-admission clinics, pain management, obstetrics, critical care, or by becoming actively involved as full members of the medical staff. Doing so will further our professional image in the eyes of other physicians and, ultimately, the public we seek to influence.

A perspective on studies of anaesthesia morbidity and mortality.

Adverse outcomes arising from the delivery of healthcare have been the focus of extensive study in recent years. Overall, the incidence of anaesthesia complications has declined over several decades. However, the ability to interpret outcome data can be extremely difficult, as studies differ considerably with respect to the country of origin, the population examined, and the methodology employed. This review examines the importance of study design and country of origin in interpreting morbidity and mortality studies, and provides some guidelines for future studies to help overcome the problems of mortality and morbidity data comparison.

The Canadian four-centre study of anaesthetic outcomes: I. Description of methods and populations.

The objectives of this study were first to develop and institute a methodology for the study of anaesthetic outcome for parallel use in four teaching hospitals in Canada and second, to compare rates of morbidity and mortality associated with anaesthesia between the four centres. The basic design of the study was occurrence screening with anaesthetists entering data on patient demographics, anaesthetic and surgical factors. Research nurses reviewed anaesthetic records and hospital charts and interviewed patients postoperatively. Data on 37,665 anaesthetics were collected during 1988-89 in the four teaching centres. There were major differences found across the hospitals, particularly with regard to volume, patient case-mix, anaesthetic drugs and monitoring used. The use of parallel training, repeated consultations and use of rounds and inservices contributed to the reliability and validity of the data collection. We conclude that outcome surveillance can be instituted in different hospital Departments of Anaesthesia with sufficient confidence to form the basis of comparison of anaesthetic outcome.

The Canadian four-centre study of anaesthetic outcomes: III. Are anaesthetic complications predictable in day surgical practice?

To understand better the factors important to the safety of anaesthesia provided for day surgical procedures, we analyzed the intraoperative and immediate postoperative course of patients at four Canadian teaching hospitals' day treatment centres. After excluding those who received only monitored anaesthesia care, there were 6,914 adult (non-obstetrical) patients seen over a twelve-month period in 1988-89. The rate of adverse outcome consequent to their care was identified by a comprehensive surveillance system which included review of anaesthetic records (four hospitals) and follow-up telephone calls (two hospitals). The relationship between adverse events and preoperative factors was determined by using a multiple logistic regression analysis that included age, sex, duration of the procedure and the hospital care. There were no deaths during the study period and major morbid events were infrequent. Patient preoperative disease was predictive of some intraoperative events relating to the same organ system, but not to events in the PACU. Some unexpected relationships emerged including preoperative hypertension being related to a greater risk of difficult intubation, and neurological disease to perioperative cardiac abnormalities. Patients judged obese, or inadequately fasted, were found to experience a greater rate of recovery problems as well as discomfort. While the low response rate (36%) to the telephone interviews created a sampling bias, the high rate of patient dissatisfaction among those reached is disconcerting. We conclude that day surgical patients with preoperative medical conditions, even when optimally managed, are at higher risk for adverse events in the perioperative period.

The Canadian four-centre study of anaesthetic outcomes: II. Can outcomes be used to assess the quality of anaesthesia care?

Since anaesthesia, unlike medical or surgical specialties, does not constitute treatment, this study sought to determine if methods used to assess medical or surgical outcomes (that is the determination of adverse outcome) are applicable to anaesthesia. Anaesthetists collected information on patient, surgical and anaesthetic factors while data on recovery room and postoperative events were evaluated by research nurses. Data on 27,184 inpatients were collected and the analysis of outcomes determined for the intraoperative, post-anaesthetic care unit and postoperative time periods. Logistic regression was used to control for differences in patient populations across the four hospitals. In addition, a random selection of 115 major events was classified by a panel of anaesthetists into anaesthesia, surgical and patient-disease contributions. Across the three time periods, large variations in minor outcomes were found across the four hospitals; these variations ranged from two- to five-fold after case-mix adjustment (age, physical status, sex, emergency versus elective and length of anaesthesia). The rates of major events and deaths were similar across three hospitals; one hospital had a lower mortality rate (P less than 0.001) but had a higher rate of all major events (P less than 0.0001). Of major events assessed by physician panels, 18.3% had some anaesthetic involvement and no deaths were attributable partially or wholly to anaesthesia. Possible reasons to account for these variations in outcome include compliance in recording events, inadequate case-mix adjustment, differences in interpretation of the variables (despite guidelines) and institutional differences in monitoring, charting and observation protocols. The authors conclude that measuring quality of care in anaesthesia by comparing major outcomes is unsatisfactory since the contribution of anaesthesia to perioperative outcomes is uncertain and that variations may be explained by institutional differences which are beyond the control of the anaesthetist. It is suggested that minor adverse events, particularly those of concern to the patient, should be the next focus for quality improvement in anaesthesia.

Gastroesophageal reflux during anaesthesia.

While the number of patients at risk for vomiting and aspiration has been reported to be high, the incidence of clinically important pulmonary aspiration is low. We sought to define the incidence of gastroesophageal reflux (GER) and to correlate this with the clinical variables of obesity, history of oesophagitis, bucking and changes in body position. Continuous oesophageal pH measurement was used to determine the frequency of gastroesophageal reflux in 44 patients having general anaesthesia for elective surgical procedures. Acid reflux to a pH value of less than four occurred in seven patients (15.9%) during anaesthesia. This was associated temporally with straining on the endotracheal tube in six subjects (13.6%). We conclude that traditional risk factors are not always predictive of those patients at risk of regurgitation and aspiration.

Anesthesia in Canada's health care system.

Much has been written about Canada's health care system as all countries wrestle with rising health costs. Few, however, have attempted to describe the influence of a system of health care on a nonprimary care specialty such as anesthesia. The purpose of this review is to describe the Canadian system, contrast it with that of the United States, and outline the impact that Canadian Medicare has had on anesthetic practice. A centrally controlled health care system is potentially blessed with the stability (and rigidity) inherent in any program perceived by the public as being their right and privilege. Changes are slow to occur, be they changes of new technology or alterations in the form of physician reimbursement. However, such stability means that control of health care costs can be achieved without intrusion into physician-patient relationships and professional freedom is preserved. Similarly, the acquisition of technological support for the practice of anesthesia, necessary to ensure a high standard of public safety, has not been perceived as a problem in Canada. Anesthesia in Canada is a physician-only specialty, and nurse-administered anesthesia does not exist. It is highly dependent on the functioning of the hospitals, for widespread development of freestanding health care institutions has not occurred. Compensation is on a fee-for-service basis, although alternative compensation for certain aspects of practice exists in some jurisdictions. In general, fees are indexed to the surgical procedure at hand, with time (duration) modifiers, as well as modifiers for specific techniques. Overhead is minimal, so although fees for a given procedure are lower than in the United States, the disparity in earned income is reduced. Unfortunately, recent initiatives to control physician use have limited the ability of the profession to compensate completely for this North American discrepancy in fees. Since health care in Canada is a provincial responsibility, there are eleven separate plans linked only by the guiding principles of the National Health Act of 1971. Each provincial medical association is responsible for negotiating the fee schedules with the provinces on behalf of its members. Since these associations must respond to the majority of their members, it has been the perception of specialty groups such as anesthesia that the emphasis of allocations in recent years has been on primary care fields. Anesthetists have therefore found themselves increasingly involved with the collective negotiation process as an unwanted necessity of practice.(ABSTRACT TRUNCATED AT 400 WORDS)