The Perception and Use of Dexmedetomidine Among Anesthesia Providers: A Quality Improvement Project.

PURPOSE: Intraoperative opioid use is associated with postoperative nausea and vomiting, respiratory depression, and persistent postoperative pain, all of which contribute to increased length of stay and health care costs. Although research shows adding dexmedetomidine as an adjunct leads to reduced opioid-related postoperative complications, many anesthesia providers are not using this medication. The purpose of this quality improvement project was to increase the use of dexmedetomidine among anesthesia providers to improve outcomes among spinal and orthopedic surgery patients. DESIGN: Quality improvement study. METHODS: The project consisted of a preimplementation retrospective chart review, a preimplementation staff survey, the implementation of an anesthesia training bundle, a postimplementation staff survey, and a postimplementation retrospective chart review. The team provided ongoing support for the use of dexmedetomidine with resource flyers, a recorded presentation, and provider support. FINDINGS: Preimplementation surveys indicated staff readiness for change and identified the lack of availability of dexmedetomidine within the operating rooms as the barrier to use. After receiving education, staff requested dexmedetomidine to be stocked within every operating room. Utilization increased by 67% after the implementation of the anesthesia training bundle. CONCLUSIONS: While there was no significant change in opioid-related complications as is found in the literature, the project education and support led to anesthesia provider interest in using dexmedetomidine, resulting in a significant increase in use. Similar projects should include education for postanesthesia care nurses.

A Systematic Review of Race, Sex, and Socioeconomic Status Differences in Postoperative Pain and Pain Management.

PURPOSE: Optimal postoperative pain management remains a significant problem despite the availability of multiple preoperative, intraoperative, and postoperative pain management interventions. Recent studies suggest that racialized minorities, female sex, and individuals of lower socioeconomic status (SES) are more likely to experience more severe pain and inadequate pain management postoperatively. Our systematic review aimed to determine race, sex, and SES differences in postoperative pain and postoperative pain management. DESIGN: This study is a systematic review of literature. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology, we systematically searched 5 databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, Embase, Scopus, and Cochrane. We included primary source peer-reviewed articles published after 1990 that measured postoperative pain and race/ethnicity, sex/gender, or SES, which were published in English. Two pairs of reviewers independently screened each title, abstract, and article for inclusion. In cases of disagreement, a third reviewer broke the tie. FINDINGS: A total of 464 articles were screened, of which 32 were included in this study. In most studies, Blacks/African American experience more severe postoperative pain than Whites/Caucasians. Whites were more likely to be prescribed opioids for pain management than Blacks, Hispanics, and Asians. Also, individuals of lower SES and females reported more postoperative pain. One study found no race/ethnic group differences in pain scores and opioid use after the implementation of the enhanced recovery after surgery (ERAS) protocol. CONCLUSIONS: Optimal postoperative pain relief continues to be a challenge for individuals who self-identify as racialized minorities, females, and those of lower SES. Standardization of care may help reduce disparities in postoperative pain management.

Mentoring Team Projects for the Doctor of Nursing Practice: Considerations for Nurse Anesthesia Faculty.

The American Association of Colleges of Nursing and the Council on Accreditation of Nurse Anesthesia Educational Programs have specified that Doctor of Nursing Practice (DNP) and Doctor of Nursing Anesthesia Practice students complete a doctorate project as part of the education toward becoming Certified Registered Nurse Anesthetists. As nurse anesthesia programs (NAPs) transition to DNP entry into practice, management of DNP projects has been identified as a major challenge facing nursing faculty. Also, adequate mentorship has been identified as a crucial part of doctorate education. Despite the absence of literature on team mentorship in nursing, many NAPs are opting for DNP team projects and group mentoring. In team DNP projects, the mentors foster professionalism, establish the ground rules for communication, resolve conflict, and provide expert knowledge. Effective implementation of projects can enhance relational learning and teamwork, which are essential for a successful career in healthcare. Additionally, mentoring teams can simultaneously improve the professional growth of junior faculty, reduce the faculty workload, and improve the quality of DNP projects. This article brings attention to best practices for mentoring DNP team projects and also provides an exemplar of successful implementation of DNP team projects in a NAP.

Using Eye Tracking for Measuring Cognitive Workload During Clinical Simulations: Literature Review and Synthesis.

High-fidelity clinical simulations can be used by clinicians to acquire technical (physical ability and knowledge) and non-technical (cognitive and social processes) skills. Excessive cognitive workload contributes to medical errors because of the impact on both technical and non-technical skills. Many studies measure cognitive workload with psychometric instruments that limit the assessment of cognitive workload to a single time period and may involve response bias. Using eye tracking to measure task-evoked pupillary responses allows the measurement of changes in pupil diameter related to the cognitive workload associated with a specific activity. Incorporating eye tracking with high-fidelity clinical simulations provides a reliable and continuous assessment of cognitive workload. The purpose of this literature review is to summarize the use of eye-tracking technology to measure cognitive workload of healthcare providers to generate evidence-based guidelines for measuring cognitive workload during high-fidelity clinical simulations. What this manuscript adds to the body of literature is a summary of best practices related to the different methods of measuring cognitive workload, benefits and limitations of using eye tracking, and high-fidelity clinical simulation design considerations for successful integration of eye tracking.

Impact of Data Entry Interface Design on Cognitive Workload, Documentation Correctness, and Documentation Efficiency.

Clinical documentation serves as the legal record of patient care and used to guide clinical decision making. Inadequately designed data entry user-interfaces may result in unintended consequences that negatively impact patient safety and outcomes because inaccurate information is used to guide clinical decision making. This study utilized an electronic simulated documentation interface (i.e., artificial electronic health record) combined with eye-tracking hardware to analyze documentation correctness, documentation efficiency, and cognitive workload of anesthesia providers (N = 20) generating documentation using different computer-assisted data entry types (drop-down box, radio button, check-box, and free text with autocomplete suggestions). Our study methodology incorporating eye-tracking with electronic health record user interfaces to assess documentation correctness, efficiency, and cognitive workload can be translated to other health care provider types.

From the Operating Room to the Front Lines: Shared Experiences of Nurse Anesthetists During the Coronavirus Pandemic.

Coronavirus disease 2019 (COVID-19) has resulted in severe health, economic, social, political, and cultural consequences while thrusting Certified Registered Nurse Anesthetists (CRNAs) at the forefront of battling an often invisible enemy. A mixed-methods study was conducted to assess the impact of the COVID-19 pandemic on CRNA practice. The purpose of the qualitative component of the study, a focused ethnography, was to use personal and group interviews to determine the shared experiences of CRNAs who worked during the COVID-19 pandemic. Six themes were identified: (1) CRNAs are part of the solution, (2) doing whatever it takes, (3) CRNAs are valued contributors, (4) removal of barriers promotes positive change, (5) trying times, and (6) expertise revealed. The quantitative component of the study will be discussed in a separate article.

Development of the University Postoperative Obstructive Sleep Apnea Protocol (UPOP).

PURPOSE: The purpose of this project was to retrospectively analyze medical records to determine the relationship between surgical patients with obstructive sleep apnea (OSA) risk factors and the occurrence of a critical respiratory event (CRE) in the postanesthesia care unit (PACU), and to subsequently develop a protocol for postoperative care. Although OSA is prevalent among the surgical population, research has primarily focused on preoperative identification and tailored perioperative care with limited application of standardized postoperative OSA management. DESIGN: Surgical charts were retrospectively reviewed between April 1, 2019 and June 31, 2019. Medical records were reviewed to identify surgical patients who had a diagnosis of OSA or two or more OSA risk factors. For patients who met initial inclusion, PACU charts were reviewed for the occurrence of a CRE while in PACU. Data analysis involved use of both Microsoft Excel 2011 and IBM SPSS Statistics Base, version 26. METHODS: Medical records were reviewed to identify patients in PACU who had two or more documented OSA risk factors (body mass index >35, snoring, alcohol use, diabetes mellitus [DM], hypertension [HTN], or male) or a diagnosis of OSA (n = 1,361). This sample was further refined to determine the patients who had a CRE (oxygen saturation less than 92%; respiratory rate less than 10, Modified Aldrete Respiratory Score of 1 and/or lesser) while in the PACU (n = 200). FINDINGS: There was a statistically significant relationship between one CRE in the PACU and a pre-existing diagnosis of HTN, DM, snoring, alcohol use, and male gender (P < .001 for each variable). There was a statistically significant difference in body mass index between patients who experienced a CRE and those who did not (P = .004). HTN and DM (n = 16) were associated with the highest occurrence of a CRE. CONCLUSIONS: The University Postoperative Obstructive Sleep Apnea Protocol was designed based on results and current evidence-based practice. Development of a postoperative OSA protocol will positively impact patient outcomes and may reduce health care expenditures. Next steps include protocol implementation and analysis.

Exploring Production Pressure and Normalization of Deviance and Their Relationship to Poor Patient Outcomes.

Production pressure and/or normalization of deviance contribute to poor patient outcomes. The purpose of this study was to explore the relationship between production pressure and normalization of deviance to poor patient outcomes. A team of experienced qualitative researchers conducted a metasynthesis of all qualitative closed claims studies that used the American Association of Nurse Anesthetists (AANA) Foundation Closed Claims database and were accepted for publication at the time of the study. Three central concepts emerged from the analysis: (1) impaired culture of safety, (2) violations of standards of care, and (3) impaired patient safety and outcomes. It is imperative that anesthesia providers support a culture of safety and follow AANA Standards for Nurse Anesthesia Practice.

A Practical Approach to Acute Postoperative Pain Management in Chronic Pain Patients.

In the United States, more than 100 million people suffer from chronic pain. Among patients presenting for surgery, about one in four have chronic pain. Acute perioperative pain management in this population is challenging because many patients with chronic pain require long-term opioids for the management of this pain, which may result in tolerance, physical dependence, addiction, and opioid-induced hyperalgesia. These challenges are compounded by the ongoing opioid epidemic that has resulted in calls for a reduction in opioid use, with a concurrent increase in the number of patients with chronic opioid exposure presenting for surgery. This article aims to summarize practical considerations for acute postoperative pain management in patients with chronic pain conditions. A patient-centered acute pain management plan, including nonopioid analgesics, regional anesthesia, and careful selection of opioid medications, can lead to adequate analgesia and satisfaction with care. Also, a meticulous rotation from one opioid to another may decrease opioid requirement, increase analgesic effectiveness, and improve satisfaction with care.

Using Clinical Simulations to Train Healthcare Professionals to Use Electronic Health Records: A Literature Review.

Unintended consequences are adverse events directly related to information technology and may result from inappropriate use of electronic health records by healthcare professionals. Electronic health record competency training has historically used didactic lectures with hands-on experience in a live classroom, and this method fails to teach learners proficiency because the sociotechnical factors that are present in real-world settings are excluded. Additionally, on-the-job training to gain competency can impair patient safety because it distracts clinicians from patient care activities. Clinical simulation-based electronic health record training allows learners to acquire technical and nontechnical skills in a safe environment that will not compromise patient safety. The purpose of this literature review was to summarize the current state-of-the-science on the use of clinical simulations to train healthcare professionals to use electronic health records. The benefits of using simulation-based training that incorporates an organization's contextual factors include improvement of interdisciplinary team communication, clinical performance, clinician-patient-technology communication skills, and recognition of patient safety issues. Design considerations for electronic health record training using clinical simulations involve establishing course objectives, identifying outcome measures, establishing content requirements of both the clinical simulation and electronic health record, and providing adequate debriefing.

Perioperative Considerations for Patients With Major Depressive Disorder Undergoing Surgery.

In the United States, approximately 15% of adults suffer from major depressive disorder (MDD), which results in an annual cost of over $200 billion per year. In the perioperative setting, MDD is associated with increased morbidity and mortality. The exact causes of the increase in adverse outcomes are unknown. Major depression affects virtually all major systems in the human body, and most antidepressants affect dopamine, norepinephrine, and serotonin levels or alter their target receptors. Unfortunately, anesthesia and medications used in the perioperative period affect the same neurotransmitters. As a result, patients with MDD are at an increased risk for cardiovascular effects, altered thermoregulation, and postoperative cognitive dysfunction. To determine when to continue or hold antidepressants preoperatively and avoid potential drug interactions, perioperative providers must understand the pharmacological action of antidepressants. This article reviews the pathophysiology of MDD, mechanism of action of antidepressants, and perioperative considerations for patients on antidepressant medications.

Evaluation of Methods to Measure Production Pressure: A Literature Review.

BACKGROUND: Production pressure is a major contributor to the occurrence of medical errors. Production pressure is the demand on health care professionals to increase the quantity of work at the expense of quality. PURPOSE: The purpose was to summarize the state of the science on measuring production pressure in health care settings so that evidence-based strategies could be identified that minimize medical errors. METHODS: This was a literature review. The electronic databases PubMed, Embase, and Scopus were queried using the keywords "work pressure" or "production pressure." RESULTS: Production pressure is often measured with quantitative approaches that measure efficiency, staff workload, capacity utilization (number of hospital beds occupied), or psychometric instruments. Ethnography is a qualitative method that is also used to assess production pressure. CONCLUSIONS: There were several strategies identified to minimize the impact of production pressure on the occurrence of medical errors. These strategies can be categorized as administrator, educational, or workflow related.

It's Never Just a Block: An Analysis of Regional Anesthesia Closed Claims.

Anesthesia care increasingly includes use of regional anesthesia techniques, either as a primary anesthetic or to reduce the patient's postoperative pain. Both neuraxial anesthesia and peripheral nerve blockade have several noteworthy functions. These functions include diminishing sensory sensation to pain and potentially producing a motor blockade, both of which may facilitate the surgical procedure. The desire to reduce reliance on opioid medications, protocols to enhance and accelerate patient recovery from surgery, and patient expectations all contribute to the likelihood that use of regional anesthesia will continue to gain popularity. As such, it is essential to understand whether an association exists between regional anesthesia and adverse outcomes of care. The American Association of Nurse Anesthetists Foundation Closed Claim Research Team searched the most current database of closed claims that involved adverse outcomes when either a peripheral nerve block or a neuraxial block was a component of care in the claims. Although there were only 32 claims in the dataset, a thematic analysis resulted in the identification of 3 themes: errors in cognitive decision making, ineffective communication patterns, and production pressure.

Preventable Closed Claims in the AANA Foundation Closed Malpractice Claims Database.

Medical errors are among the top 3 causes of patient deaths in the United States, with up to 400,000 preventable deaths occurring in hospitalized patients each year. Although improvements have been made in anesthesia patient safety, adverse outcomes continue to occur. This study used thematic analysis to examine anesthesia closed claims that were associated with preventable morbidity and mortality. Investigators determined that 123 closed malpractice claims files from the American Association of Nurse Anesthetists (AANA) Foundation closed claims database involved events that the involved Certified Registered Nurse Anesthetist could have prevented. Factors that were associated with preventable closed claims included communication failures, violations of the AANA Standards for Nurse Anesthesia Practice, and errors in judgment.

A Review of Measuring the Cognitive Workload of Electronic Health Records.

The To Err Is Human report stated that 98 000 patients die yearly because of medical errors, and that medication errors kill more people than workplace injuries. The inadequate design and utilization of the electronic health record have been identified as major contributing factors to medical errors. Increased cognitive workload of clinicians has consistently been linked to the occurrence of medical errors. The purpose of this article was to synthesize the current state of the science on measuring clinicians' cognitive workload associated with using electronic health records in order to inform evidence-based guidelines. The major considerations identified in the literature involve the use of psychometric instruments, using efficiency as a proxy for cognitive workload, and eye tracking. The National Aeronautics and Space Administration Task Load Index was the most used psychometric instrument, but reliability measures were not reported. It is important to evaluate reliability of psychometric instruments because the consistency of the instrument can change when administered to different populations. Efficiency is an observable measure defined by the total time to complete a task and the total number of physical interactions with the user interface. Efficiency can allow the use of statistical modeling, but it does not directly evaluate the mental activity associated with using an electronic health record interface. Eye tracking has been used extensively in the literature to measure cognitive workload via changes in pupil size related to mental activity, but it is not often used to measure the cognitive workload associated with using the electronic health record. Eye tracking is very useful for continuous monitoring of cognitive workload.

The effect of data-entry template design and anesthesia provider workload on documentation accuracy, documentation efficiency, and user-satisfaction.

INTRODUCTION: Currently, there are few evidence-based guidelines to inform optimal clinical data-entry template design that maximizes usability while reducing unintended consequences. This study explored the impact of data-entry template design and anesthesia provider workload on documentation accuracy, documentation efficiency, and user-satisfaction to identify the most beneficial data-entry methods for use in future documentation interface design. METHODOLOGY: A study using observational data collection and psychometric instruments (for perceived workload and user-satisfaction) was conducted at three hospitals using different methods of data-entry for perioperative documentation (auto-filling with unstructured data, computer-assisted data selection with semi-structured documentation, and paper-based documentation). Nurse anesthetists at each hospital (N = 30) were observed completing documentation on routine abdominal surgical cases. RESULTS: Auto-filling (61.2%) had the lowest documentation accuracy scores compared to computer-assisted (81.3%) and paper-based documentation (76.2%). Computer-assisted data-entry had the best documentation efficiency scores and required the least percentage of the nurse anesthetists' time (9.65%) compared to auto-filling (11.43%) and paper-based documentation (15.23%). Paper-based documentation had the highest perceived workload scores (M = 288, SD = 88) compared to auto-filling (M = 160, SD = 93, U = 16.5, p < 0.01) and computer assisted data-entry (M = 93, SD = 50, U = 4.0, P < 0.001). CONCLUSIONS: Auto-filling with unstructured data needs to be used sparingly because of its low documentation accuracy. Computer-assisted data entry with semi-structured data needs to be further study because of its better documentation accuracy, documentation efficiency, and perceived workload.

Electronic Health Records in Simulation Education: Literature Review and Synthesis.

STATEMENT: During the last decade, the use of electronic health records (EHRs) in clinical settings has risen sharply. Many clinical education programs have not incorporated the use of electronic documentation into their curriculum. It is important to incorporate technologies that will be used in real-world settings into educational clinical simulations to better prepare students for clinical practice and promote patient safety. Electronic documentation can be harder to teach to students because it requires a more in-depth orientation on how to use the electronic documentation system and because health care organizations often give students limited or no access to the documentation system. This review will include a discussion on the benefits and disadvantages of using educational EHRs, barriers and facilitators to implementing educational EHRs, and best practices for incorporating educational EHRs into current educational curriculums.

Evidence-Based Guidelines for Interface Design for Data Entry in Electronic Health Records.

Electronic health records use a variety of data entry methods that are often customized to clinician needs. Data entry interfaces must be appropriately designed to maximize benefits and minimize unintended consequences. There was relatively little evidence in the literature to guide the selection of specific data entry methods according to the type of data documented. This literature review summarizes existing data entry design recommendations to guide data entry interface design. Structured data entry uses predefined charting elements to limit acceptable data entry to standard coded data and improve completeness and data reuse at the expense of correctness. Unstructured data entry methods use natural language and improve correctness, at the expense of completeness and data reusability. Semistructured data entry uses a combination of these data entry methods to complement the strengths and minimize the weaknesses of each method. Documentation quality is influenced by the method of data entry. It is important to choose data entry methods based on the type of data to be documented. This literature review summarizes data entry design guidelines to inform clinical practice and future research.

Transfer of Care in Perioperative Settings: A Descriptive Qualitative Study.

Transfer of care is defined as the exchange of information and professional accountability for patient care between individuals. This article describes a qualitative content analysis (N = 19) using a closed-claims database generated by the American Association of Nurse Anesthetists (AANA) Foundation. The purpose of this study was to explore perioperative transfer-of-care events that contributed to professional malpractice claims to identify general themes, antecedents, and consequences to improve clinical practices and guide future research. A brief summary of the 6 themes that emerged in this study is as follows. (1) Patients should be transferred to an appropriate level of care based on their needs. (2) Production pressure leads to normalization of deviance. (3) Clinicians need to conduct their own patient assessments and health record reviews without relying solely on another clinician's report. (4) Interdisciplinary team communication failure is a leading cause of adverse outcomes. (5) Inadequate patient monitoring and physical assessment after the transfer of care is completed is a leading cause of adverse outcomes. (6) Transfer of care should not occur during high-risk patient care events or during periods of patient hemodynamic or respiratory instability.

Thematic Analysis of Obstetric Anesthesia Cases From the AANA Foundation Closed Claims Database.

Maternal morbidity and mortality in the United States continues to be high. Understanding parturient complications and causes of death is critical to determine corrective actions. Analysis of closed malpractice claims evaluates patient care, identifies preventable morbidity and mortality, and offers recommendations for improvement. A review of obstetric anesthesia malpractice claims filed against nurse anesthetists (N = 21), extracted from the American Association of Nurse Anesthetists Foundation Closed Claims database, was completed. The malpractice claims included 18 maternal claims and 3 neonatal claims. The most common adverse maternal outcomes were maternal death (8/18) and nerve injury (4/18). Hemorrhage accounted for the greatest number of maternal deaths (3/8) followed by cardiovascular failure, emboli, and neuraxial opioid overdose. All neonatal claims (3/3) involved hypoxic encephalopathy resulting in 1 neonatal death and 2 cases of neonatal permanent brain injury. The majority of maternal cases were identified as nonemergent (15/18) and involved relatively healthy patients (15 identified as ASA physical status 2). Qualitative analysis of closed claims provides the opportunity to identify patterns of injuries, precipitating events, and interventions to improve care. Themes related to poor outcomes in this study include care delays, failed communication, incomplete documentation, maternal hemorrhage, and lack of provider vigilance.