Sustained Implementation of an Evidence-Based Extubation Checklist Reduced Extubation Failure in Trauma Patients.

Extubation failure remains a challenge in the perioperative setting. The aim of this intervention was to decrease the rate of perioperative extubation failure through the utilization of an extubation checklist. A five-item evidence-based extubation readiness checklist was implemented at a level I trauma center on all patients who were electively extubated in the operating room (OR). Extubation failure rates before and after implementation of the checklist were compared. Of 26,867 trauma patients extubated in the OR after the intervention, 84 cases (0.31%) failed extubation in the immediate postoperative period. A significant and sustained decrease in extubation failure rate per case performed was observed between the pre- and post-checklist period (OR, 0.33; 95% CI, 0.19, 0.56; P < 0.001). Partial (vs full) checklist completion, higher ASA physical status score, advanced age, and longer case length were independently associated with increased odds of extubation failure in the postintervention period.

Anesthesia-Related Malpractice Claims in Maryland 1994-2017.

This article presents data on anesthesia cases filed with the Maryland Health Claims Alternative Dispute Office between 1994 and 2017, a publicly available resource that includes all anesthesia-related claims filed in Maryland, regardless of whether they were reported to any national claims repository. Analysis of anesthesia malpractice claims offers critical information that can both decrease legal liability and improve patient outcomes for those receiving anesthesia. A total of 276 claims were filed. Variables under investigation included venue, types of surgery, legal cause of action, trends, and outcomes. Types of anesthesia-related claims included the administration of general anesthesia (59.8%), monitored anesthesia care (14.9%), pain management (10.9%), epidural/spinal anesthesia (9%), nerve blocks (2.9%), and local anesthesia infiltration (2.6%). Most cases (39.5%) involved failure to adequately monitor the patient. Inadequate perioperative care was alleged as the cause of action in 68.8% of cases. Major adverse patient outcomes were death (38.8%), brain damage (21%), and permanent nerve damage (14.9%). Understanding the events that lead to legal action can assist anesthesia providers to focus on ways to improve their practice.

Advanced Prehospital Trauma Resuscitation With a Physician and Certified Registered Nurse Anesthetist: The Shock Trauma "Go-Team".

OBJECTIVE: The R Adams Cowley Shock Trauma Center (STC) is Maryland's primary adult resource center for trauma care. The Shock Trauma "Go-Team" is a specialized component of Maryland's emergency medical system and is composed of a physician and certified registered nurse anesthetist. They are dispatched when advanced prehospital resuscitation is required. The purpose of this study is to describe the capabilities and historic epidemiology outcomes of the Go-Team. METHODS: A retrospective case series review of recoverable Go-Team records was performed from 2011 to 2018. Go-Team call logs/records were identified from multiple sources. Medical records were reviewed for patient demographics, mechanisms of injury, and treatments in the field. There was a total of 61 activations, with 22 deployments to the scene of injury. RESULTS: The majority of deployments were via helicopter (73%) and lasted 2 hours. The most common indications for deployment were motor vehicle entrapment (41%), trench collapse (14%), and building collapse (9%). Of the 22 patients treated by the Go-Team, 50% received at least 1 blood transfusion in the field, and 23% required an advanced airway. No field amputations were required. CONCLUSION: The STC Go-Team is a unique multidisciplinary specialized component of a statewide emergency medical system.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as an Option for Uncontrolled Hemorrhagic Shock: Current Best Practices and Anesthetic Implications.

Noncompressible torso hemorrhage is reported to be a leading cause of potentially preventable mortality in both civilian trauma victims and military combat casualties. This hemorrhage may come from venous, arterial, or additional combined sources in the chest, abdomen, pelvis, axilla, or groin regions. Aortic occlusion as an adjunct to strategies for trauma damage control can decrease the amount of bleeding distal to the occluded site and provide a time-sensitive opportunity for resuscitation and definitive hemorrhage control. Recently, resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as a temporary hemorrhage control and resuscitation technique that has the advantage of being minimally invasive and may offer improved patient morbidity and mortality compared with the traditional emergency department thoracotomy. An overview of the history of REBOA and indications and contraindications for its use is provided. A placement strategy for this technology, which includes basic suggested insertion techniques and anatomical placement sites, is also provided. Additionally, device-related morbidity and mortality are addressed. Anesthetic implications in the perioperative period are reviewed in light of current best practices. Recommendations are given for future research aimed at refining and improving the care of seriously injured patients who may require this type of lifesaving treatment.

Positive behaviour support training for staff for treating challenging behaviour in people with intellectual disabilities: a cluster RCT.

BACKGROUND: Preliminary studies have indicated that training staff in Positive Behaviour Support (PBS) may help to reduce challenging behaviour among people with intellectual disability (ID). OBJECTIVE: To evaluate whether or not such training is clinically effective in reducing challenging behaviour in routine care. The study also included longer-term follow-up (approximately 36 months). DESIGN: A multicentre, single-blind, two-arm, parallel-cluster randomised controlled trial. The unit of randomisation was the community ID service using an independent web-based randomisation system and random permuted blocks on a 1 : 1 allocation stratified by a staff-to-patient ratio for each cluster. SETTING: Community ID services in England. PARTICIPANTS: Adults (aged > 18 years) across the range of ID with challenging behaviour [≥ 15 Aberrant Behaviour Checklist - Community total score (ABC-CT)]. INTERVENTIONS: Manual-assisted face-to-face PBS training to therapists and treatment as usual (TAU) compared with TAU only in the control arm. MAIN OUTCOME MEASURES: Carer-reported changes in challenging behaviour as measured by the ABC-CT over 12 months. Secondary outcomes included psychopathology, community participation, family and paid carer burden, family carer psychopathology, costs of care and quality-adjusted life-years (QALYs). Data on main outcome, service use and health-related quality of life were collected for the 36-month follow-up. RESULTS: A total of 246 participants were recruited from 23 teams, of whom 109 were in the intervention arm (11 teams) and 137 were in the control arm (12 teams). The difference in ABC-CT between the intervention and control arms [mean difference -2.14, 95% confidence interval (CI) -8.79 to 4.51; p = 0.528] was not statistically significant. No treatment effects were found for any of the secondary outcomes. The mean cost per participant in the intervention arm was £1201. Over 12 months, there was a difference in QALYs of 0.076 in favour of the intervention (95% CI 0.011 to 0.140 QALYs) and a 60% chance that the intervention is cost-effective compared with TAU from a health and social care cost perspective at the threshold of £20,000 per QALY gained. Twenty-nine participants experienced 45 serious adverse events (intervention arm, n = 19; control arm, n = 26). PBS plans were available for 33 participants. An independent assessment of the quality of these plans found that all were less than optimal. Forty-six qualitative interviews were conducted with service users, family carers, paid carers and service managers as part of the process evaluation. Service users reported that they had learned to manage difficult situations and had gained new skills, and carers reported a positive relationship with therapists. At 36 months' follow-up (n = 184), the mean ABC-CT difference between arms was not significant (-3.70, 95% CI -9.25 to 1.85; p = 0.191). The initial cost-effectiveness of the intervention dissipated over time. LIMITATIONS: The main limitations were low treatment fidelity and reach of the intervention. CONCLUSIONS: Findings from the main study and the naturalistic follow-up suggest that staff training in PBS as delivered in this study is insufficient to achieve significant clinical gains beyond TAU in community ID services. Although there is an indication that training in PBS is potentially cost-effective, this is not maintained in the longer term. There is increased scope to develop new approaches to challenging behaviour as well as optimising the delivery of PBS in routine clinical practice. TRIAL REGISTRATION: This study is registered as NCT01680276. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 15. See the NIHR Journals Library website for further project information.

Clinical outcomes of staff training in positive behaviour support to reduce challenging behaviour in adults with intellectual disability: cluster randomised controlled trial.

BACKGROUND: Staff training in positive behaviour support (PBS) is a widespread treatment approach for challenging behaviour in adults with intellectual disability. Aims To evaluate whether such training is clinically effective in reducing challenging behaviour during routine care (trial registration: NCT01680276). METHOD: We carried out a multicentre, cluster randomised controlled trial involving 23 community intellectual disability services in England, randomly allocated to manual-assisted staff training in PBS (n = 11) or treatment as usual (TAU, n = 12). Data were collected from 246 adult participants. RESULTS: No treatment effects were found for the primary outcome (challenging behaviour over 12 months, adjusted mean difference = -2.14, 95% CI: -8.79, 4.51) or secondary outcomes. CONCLUSIONS: Staff training in PBS, as applied in this study, did not reduce challenging behaviour. Further research should tackle implementation issues and endeavour to identify other interventions that can reduce challenging behaviour. Declaration of interest None.

Clinical and cost effectiveness of staff training in Positive Behaviour Support (PBS) for treating challenging behaviour in adults with intellectual disability: a cluster randomised controlled trial.

BACKGROUND: Many people with intellectual disability present with challenging behaviour which often has serious consequences such as the prescription of long term medication, in-patient admissions and disruption of normal daily activities. Small scale studies of Positive Behaviour Support (PBS) delivered by paid carers suggest that it reduces challenging behaviour and costs of care and improves quality of life. This study aims to investigate whether professionals training in the delivery of PBS as part of routine practice is clinically and cost effective compared to treatment as usual in community intellectual disability services. METHOD: The study is a multi-centre cluster randomised controlled trial involving community intellectual disability services in England and service users with mild to severe intellectual disability and challenging behaviour. The teams will be randomly allocated into one of two conditions, either training and support to deliver PBS or treatment as usual. We will carry out assessments of challenging behaviour, use of services, quality of life, mental health, and family and paid carer burden at six and 12 months. We will monitor treatment fidelity and we will interview a sample of paid and family carers, service users, staff and managers about what they think of the treatment and how best we can deliver it in routine care. The main outcome is reduction in challenging behaviour at one year after randomisation. We will also carry out a health economic evaluation to examine the costs and consequences of staff training in PBS. DISCUSSION: The study findings will have significant implications for the delivery of PBS in community based services with the potential for reducing inpatient admissions and out-of-area placements for adults with intellectual disability and challenging behaviour. TRIAL REGISTRATION: This trial is registered with Clinical Trials.gov (Ref NCT01680276 ). Clinical Trials Unit: PRIMENT https://www.ucl.ac.uk/priment/ .

Implementation of an evidence-based extubation checklist to reduce extubation failure in patients with trauma: a pilot study.

This prospective, case-controlled observational study assessed whether an evidence-based extubation checklist would increase anesthesia providers' documentation of standardized extubation criteria and reduce the occurrence of preventable extubation failures in the early postoperative period. The sample consisted of 622 ASA Physical Status I to IV patients, aged 10 to 100 years but primarily adults, who underwent elective and emergency surgeries at a university-based adult trauma teaching hospital. Before the study, all anesthesia and postanesthesia care unit staff received an in-service on adherence to an evidence-based extubation checklist, followed by implementation of the checklist for 12 weeks. Demographic data, anesthesia flow sheets, provider notes, and quality assurance records were reviewed to determine utilization of the checklist before extubation and to ascertain those patients who required reintubation. Following use of the extubation checklist, documentation of patient readiness for extubation increased from 54% to 92.5%, and extubation failures decreased from 2.5 per month to 7.2 per month. This study confirmed that extubation failure occurred less frequently when the extubation checklist was used (P = .001, Fisher exact test). Study results indicate that an extubation checklist may positively influence provider documentation of evidence-based criteria for extubation and can reduce the occurrence of preventable extubation failures.

Severe occupational injuries among older workers: demographic factors, time of injury, place and mechanism of injury, length of stay, and cost data.

Between 2002 and 2012, the number of individuals > 55 years of age in the workforce is projected to climb by approximately 50%. Few studies have substantiated that severe occupational injury to older workers is a significant problem. To identify the variables related to traumatic injuries of older workers, data were abstracted retrospectively from a regional trauma center database, including demographic and injury characteristics, length of hospital and intensive care unit (ICU) stay, and cost. The results showed that older workers had higher fatality rates than younger workers. As age increased, the Injury Severity Score also increased. Most injuries were the result of falls, with orthopedic injuries being the most common type of injury. Patients spent an average of 6 days in the ICU at a cost of > 4920 US dollars/day. By identifying the characteristics associated with older workers' severe occupational injuries, further research and better industry programs targeting this group can be implemented.

Breastfeeding problems following anesthetic administration.

Research literature supports the notion that maternal comfort should be considered a priority and that mothers should receive adequate information regarding any drug prior to receiving that drug. Some studies indicate that difficulties with breastfeeding may be related to the amount of the anesthetic or analgesic that is administered to the mother. Thus, it seems wise to administer the lowest possible dose to the mother in order to minimize the amount of drug (or metabolite) exposure to the nursing infant. Infant exposure can be further reduced if breastfeeding is avoided during the times when the mother receives high doses of anesthetics and analgesics. However, because relatively small amounts of the drug are excreted into the breast milk, some mothers may opt to continue nursing after weighing the benefits of breastfeeding against the potential risk to the infant. Others may choose to "pump and dump" breast milk while they receive anesthetic or analgesic agents. Any concerns in this regard should be discussed with the anesthesia provider, preferably prior to labor or to any surgeries while breastfeeding.

Anesthetic implications of necrotizing fasciitis.

Necrotizing fasciitis, also known as necrotizing acute soft tissue injury (NASTI), commonly occurs as a consequence of group A streptococcal disease. An estimated 9,400 cases of invasive group A streptococcal disease occur annually in the United States, with 600 cases classified as NASTI. Mortality associated with NASTI is estimated at 20% to 50%. Research indicates that early diagnosis and surgical excision of necrotic tissue is the key to minimalization of morbidity and mortality associated with NASTI. Repeated surgeries typically are required in patients with NASTI, posing unusual anesthetic challenges. This article provides an overview of NASTI and includes preoperative, intraoperative, and postoperative anesthetic considerations.