Infusion Pump Education: A Quality Improvement Project.

PURPOSE: This quality improvement project was designed to increase the number of registered nurses who have been educated and are proficient in working with the infusion medical pumps used for patients receiving continuous peripheral nerve block or epidural infusions. Our aim was to increase by 10% the percentage of nurses who are proficient with infusion pumps and increase by 25% the ability of nursing staff on 4 West at Brooke Army Medical Center to hang a new infusion bag and subsequently program the pump. DESIGN: Our outcome measured pre and post intervention surveys and timing exercises assessing the ability and efficiency of the nurses hanging new infusion bags and programming the pumps. METHODS: We gathered baseline data via surveys and a timing exercise. We then implemented a visual aid with simple instructions affixed to the pump and formally educated the nursing staff. Finally, we measured the results via surveys and repeated the timing exercise. FINDINGS: We achieved both of our objectives. We increased the number of registered nurses who were educated and who were proficient in working with the infusion medical pumps. Prior to the project, 80% of the nurses felt proficient with infusion pumps and 45% of nurses were able to hang a new infusion bag. After the visual aid was affixed to the pumps and the nurses were educated, 95% of nurses felt proficient with infusion pumps and 91% were able to hang a new infusion bag. Nurses also showed an increase in efficiency in hanging a new infusion bag with an average decreased time to successful programing of 41 seconds. CONCLUSION: This project demonstrated that affixing visual aids and formalizing hands-on education can lead to significantly increased proficiency with infusion medical pumps and efficiency in hanging a new infusion bag. Ultimately, we hope this may lead to significant reductions in hospital cost by limiting time spent by physicians and nurses changing infusion bags and increase the quality of patient care by decreasing the amount of time patient analgesia is delayed.

Pediatric Fellowship-Trained Anesthesiologists Improve Anesthesia-Controlled Time in a Pediatric Endoscopy Suite.

OBJECTIVES: The objective of this study was to determine the difference in anesthesia-controlled time (ACT) between subspecialty-trained pediatric anesthesiologists and general anesthesiologists during esophagogastroduodenoscopy (EGD) and colonoscopy. We hypothesized pediatric anesthesiologists would demonstrate a shorter ACT compared to general anesthesiologists. METHODS: We conducted a retrospective analysis of pediatric endoscopy cases requiring general endotracheal anesthesia within our pediatric sedation unit from 2017 to 2020. Demographic and procedural variables were collected and assessed for potential confounding. The imbalance in baseline variables was controlled for utilizing a generalized linear model (GLM). The GLM had a model fit of adjusted R2 = 0.146 and was statistically significant with P < 0.001. A priori power analysis was performed for a 2-tailed independent means t test with alpha = 0.05, and Power = 0.80, which revealed a minimum sample size of 64 patients per group to detect a mean difference of 3 minutes of ACT. RESULTS: A total of 269 cases met inclusion criteria. Adjusted results demonstrated fellowship-trained pediatric anesthesiologists were associated with a 3.7-minute (95% CI: 2.005-5.478; P < 0.001) reduction in ACT when compared to general practice anesthesiologists. Patient age was associated with a 0.4-minute (95% CI: -0.558 to -0.243; P < 0.001) decrease in ACT for each advancing year in age. CONCLUSIONS: We observed an association between the subspecialty training of the anesthesiology provider and ACT for EGDs and colonoscopies. When EGDs and colonoscopies are performed under the supervision of pediatric anesthesiologists, ACT reduction potentially reduces cost and improves efficiency.

A Multidisciplinary Approach to Improvements in Perioperative Antibiotic Prophylaxis at a Military Treatment Facility.

INTRODUCTION: Surgical site infections complicate 2%-5% of surgeries. According to the Centers for Disease Control and Prevention, half of all surgical site infections are preventable. Adherence to published recommendations regarding perioperative antibiotic administration decreases the incidence of surgical site infections. Members of the Department of Anesthesia noticed casual observations of inaccurate prescribing of antibiotics at our institution, Brooke Army Medical Center, and approached the Antimicrobial Stewardship Program to collaborate on this issue. MATERIALS AND METHODS: A team of anesthesiologists, clinical pharmacists, and infectious disease specialists collaborated with the Department of Surgery to improve this effort as part of a multiyear project from 2018 to 2021. We first assessed adherence to recommended perioperative antibiotic use to establish a baseline and next, noticing gaps, created a project with the goal to improve compliance to >90% across surveyed measures. Our key interventions included educational initiatives, creation of facility-specific guidelines, peer benchmarking, updating order sets, interdisciplinary collaboration, creation of intraoperative reminders and visual aids, and tailored presentations to selected services. RESULTS: Of 292 charts (2.3% of cases from January to October 2018) reviewed pre-intervention, compliance rates were 84% for antibiotic choice, 92% for dose, 65% for redosing, and 71% for postoperative administration. Of doses, 100% were timed correctly, and thus, this variable was not targeted. Post-intervention, our review of 387 charts (10% of cases from May to November 2020) showed no change in correct antibiotic choice (84%) and statistical improvement to 96% for correct dose, 95% for correct redosing, and 85% for correct postoperative administration (P < .05 for all). CONCLUSIONS: Our multidisciplinary approach of collaboration with multiple departments, creating guidelines and providing feedback, improved compliance with perioperative antibiotic administration recommendations.

Competency-Based Assessments: Leveraging Artificial Intelligence to Predict Subcompetency Content.

PURPOSE: Faculty feedback on trainees is critical to guiding trainee progress in a competency-based medical education framework. The authors aimed to develop and evaluate a Natural Language Processing (NLP) algorithm that automatically categorizes narrative feedback into corresponding Accreditation Council for Graduate Medical Education Milestone 2.0 subcompetencies. METHOD: Ten academic anesthesiologists analyzed 5,935 narrative evaluations on anesthesiology trainees at 4 graduate medical education (GME) programs between July 1, 2019, and June 30, 2021. Each sentence (n = 25,714) was labeled with the Milestone 2.0 subcompetency that best captured its content or was labeled as demographic or not useful. Inter-rater agreement was assessed by Fleiss' Kappa. The authors trained an NLP model to predict feedback subcompetencies using data from 3 sites and evaluated its performance at a fourth site. Performance metrics included area under the receiver operating characteristic curve (AUC), positive predictive value, sensitivity, F1, and calibration curves. The model was implemented at 1 site in a self-assessment exercise. RESULTS: Fleiss' Kappa for subcompetency agreement was moderate (0.44). Model performance was good for professionalism, interpersonal and communication skills, and practice-based learning and improvement (AUC 0.79, 0.79, and 0.75, respectively). Subcompetencies within medical knowledge and patient care ranged from fair to excellent (AUC 0.66-0.84 and 0.63-0.88, respectively). Performance for systems-based practice was poor (AUC 0.59). Performances for demographic and not useful categories were excellent (AUC 0.87 for both). In approximately 1 minute, the model interpreted several hundred evaluations and produced individual trainee reports with organized feedback to guide a self-assessment exercise. The model was built into a web-based application. CONCLUSIONS: The authors developed an NLP model that recognized the feedback language of anesthesiologists across multiple GME programs. The model was operationalized in a self-assessment exercise. It is a powerful tool which rapidly organizes large amounts of narrative feedback.

Implementation of an Un-Pairing Passport to Improve the Transition From Intern to Resident During a Critical Period of Anesthesiology Residency Training.

Background: The transition from intern year to the first year of clinical anesthesiology residency (CA-1) is a challenging period for residents and their supervisors. Orientation methods and instructional material targeting this transition vary across U.S. residency programs. An un-pairing passport was implemented during the 2021-2022 transition to guide and provide expectations for interns, senior residents, and staff. The objective of this quality improvement project was to assess the effectiveness of the passport in improving the transition period and overall preparedness of the new CA-1s. Methods: We surveyed 3 groups (CA-1s, CA-2s/CA-3s, and staff anesthesiologists) 6 months after the completion of passport implementation to retrospectively assess the 2021-2022 CA-1 class's preparedness across 7 domains compared with those who transitioned before passport implementation. Mann-Whitney U statistics and median effect sizes were used to compare pre- and postintervention. Results: Self-reflected preparedness scores of the CA-1s were higher across all domains compared with the senior resident group (r = 0.328-0.548). Overall level of comfort and preparedness for the start of the CA-1 year was higher in the postintervention group (r = 0.162- 0.514). Staff anesthesiologists' perceived preparedness of the residents was also higher across all domains for the postintervention group (r = 0.197-0.387). Conclusion: The un-pairing passport improved residents' and staff anesthesiologists' subjective assessments of the readiness of new CA-1 residents after a critical transition in their training. Similar tools can be more broadly applied to other anesthesiology residency and possibly fellowship programs as well as subspecialty rotations within those programs.