Because the latter study included multiple anesthesiology groups, data were also from patients receiving care at outpatient surgery centers 2. ...individual performance evaluation is appropriate and ...necessary 8. The challenge of evaluating anesthesiologists is nicely summarized by Freundlich et al.: “Anesthesiology is practiced in a complex environment, in which patients may be meeting multiple physicians, nurse anesthetists, nurses, and care partners.
We describe an evidence-based approach for optimization of infection control and operating room management during the coronavirus disease 2019 (COVID-19) pandemic. Confirmed modes of viral ...transmission are primarily, but not exclusively, contact with contaminated environmental surfaces and aerosolization. Evidence-based improvement strategies for attenuation of residual environmental contamination involve a combination of deep cleaning with surface disinfectants and ultraviolet light (UV-C). (1) Place alcohol-based hand rubs on the intravenous (IV) pole to the left of the provider. Double glove during induction. (2) Place a wire basket lined with a zip closure plastic bag on the IV pole to the right of the provider. Place all contaminated instruments in the bag (eg, laryngoscope blades and handles) and close. Designate and maintain clean and dirty areas. After induction of anesthesia, wipe down all equipment and surfaces with disinfection wipes that contain a quaternary ammonium compound and alcohol. Use a top-down cleaning sequence adequate to reduce bioburden. Treat operating rooms using UV-C. (3) Decolonize patients using preprocedural chlorhexidine wipes, 2 doses of nasal povidone-iodine within 1 hour of incision, and chlorhexidine mouth rinse. (4) Create a closed lumen IV system and use hub disinfection. (5) Provide data feedback by surveillance of Enterococcus, Staphylococcus aureus, Klebsiella, Acinetobacter, Pseudomonas, and Enterobacter spp. (ESKAPE) transmission. (6) To reduce the use of surgical masks and to reduce potential COVID-19 exposure, use relatively long (eg, 12 hours) staff shifts. If there are 8 essential cases to be done (each lasting 1–2 hours), the ideal solution is to have 2 teams complete the 8 cases, not 8 first case starts. (7) Do 1 case in each operating room daily, with terminal cleaning after each case including UV-C or equivalent. (8) Do not have patients go into a large, pooled phase I postanesthesia care unit because of the risk of contaminating facility at large along with many staff. Instead, have most patients recover in the room where they had surgery as is done routinely in Japan. These 8 programmatic recommendations stand on a substantial body of empirical evidence characterizing the epidemiology of perioperative transmission and infection development made possible by support from the Anesthesia Patient Safety Foundation (APSF).
Furthermore, several examples of vignettes from Chen et al.'s Table 1 describe anesthesia trainees' work habits, previously characterized 4 but not among Chen et al.'s listed themes 1. ...our ...impression is that when Chen et al. developed the list of themes using “an inductive qualitative content analysis,” the methods were precisely as described (i.e., without systematic consideration of earlier work, including supervision and work habits 2–5). ...themes were not assigned hierarchically, first to dimensions characterized previously 2–5, and then with additional themes created inductively from the remaining vignettes. ...the process 1 for developing themes may have resulted in counts sensitive to definitions that were, at least in part, inconsistent with earlier studies 2–5.
Earlier studies showed net cost saving from anesthesia practitioners' use of a bundle of infection prevention products, with feedback on monitored Staphylococcus aureus intraoperative transmission. ...ESKAPE pathogens also include Enterococcus and gram-negative pathogens: Klebsiella, Acinetobacter, Pseudomonas, and Enterobacter. We evaluated whether bacterial contamination of patient nose, patient groin and axilla, anesthesia practitioners' hands, anesthesia machine, and intravenous lumen all contribute meaningfully to ESKAPE pathogen transmission within anesthesia work areas.
The retrospective cohort study used bacterial count data from nine hospitals, 43 months, and 448 ESKAPE pathogen transmission events within anesthesia areas of 86 operating rooms. Transmission was measured within and between pairs of successive surgical cases performed in the same operating room on the same day.
There were 203 transmission events with S. aureus, 72 with Enterococcus, and 173 with gram negatives. ESKAPE pathogens in the nose contributed to transmission for 50% (99% confidence limit ≥45%) of case pairs, on the groin or axilla for 54% (≥49%), on the hands for 53% (≥47%), on the anesthesia machine for 21% (≥17%), and in the intravenous lumen for 24% (≥20%). ESKAPE pathogens in the nose started a transmission pathway for 27% (≥22%) of case pairs, on the groin or axilla for 24% (≥19%), on the hands for 38% (≥33%), on the anesthesia machine for 11% (≥7.6%), and in the intravenous lumen for 8.0% (≥5.3%). All P ≤ 0.0022 compared with 5%.
To prevent intraoperative ESKAPE pathogen transmission, anesthesia practitioners would need to address all five categories of infection control approaches: nasal antisepsis (e.g., povidone-iodine applied the morning of surgery), skin antisepsis (e.g., chlorhexidine wipes), hand antisepsis with dispensers next to the patient, decontamination of the anesthesia machine before and during anesthetics, and disinfecting caps for needleless connectors, disinfecting port protectors, and disinfecting caps for open female Luer type connectors.
•Prevention of intraoperative bacterial pathogen transmission needs all five bundle items?•Retrospective cohort study of ESKAPE pathogen transmission within anesthesia work areas.•>5% transmission pathways included patient, practitioner hands, and environment.•>5% transmission pathway starts for patient, practitioner hands, and environment.•Anesthesia practitioners need to use all five categories of infection control approaches.
A deficiency of the postanesthesia care unit (PACU) beds or nurses may cause delays in the operating rooms (ORs) and increase the number of cancellations. Some disruptions like the COVID-19 pandemic ...may cause this deficiency. This paper investigates two integrated OR and PACU scheduling problems; one with few PACU beds, and the other with few PACU nurses. For each problem, a mathematical model and a matheuristic are proposed for minimising the number of cancellations. To the best of our knowledge, it is the first study that investigates the implications of a severe lack of the PACU beds or nurses on the number of cancellations. The matheuristics hybridise the decomposition of each instance into some small-sized sub-instances with a variable neighbourhood search algorithm. The main advantages of these methods are their flexibility to incorporate many problem details (such as a step-wise demand for the PACU nurses) and to solve any large-scale problem. Numerical results for a data set with 22 ORs show that with an increasingly severe lack of PACU capacity there is progressively greater benefit of the matheuristics than their initial solutions. Moreover, these results show the influence of the overtime and the recovery in ORs on improving the situation.
The objective of this systematic review was to estimate the relative risk of prolonged times to tracheal extubation with desflurane versus sevoflurane or isoflurane. Prolonged times are defined as ...≥15 min from end of surgery (or anesthetic discontinuation) to extubation in the operating room. They are associated with reintubations, naloxone and flumazenil administration, longer times from procedure end to operating room exit, greater differences between actual and scheduled operating room times, longer times from operating room exit to next case start, longer durations of the workday, and more operating room personnel idle while waiting for extubation. Published randomized clinical trials of humans were included. Generalized pivotal methods were used to estimate the relative risk of prolonged extubation for each study from reported means and standard deviations of extubation times. The relative risks were combined using DerSimonian-Laird random effects meta-analysis with Knapp-Hartung adjustment. From 67 papers, there were 78 two-drug comparisons, including 5167 patients. Studies were of high quality (23/78) or moderate quality (55/78), the latter due to lack of blinding of observers to group assignment and/or patient attrition because patients were extubated after operating room exit. Desflurane resulted in a 65% relative reduction in the incidence of prolonged extubation compared with sevoflurane (95% confidence interval 49% to 76%, P < .0001) and in a 78% relative reduction compared with isoflurane (58% to 89%, P = .0001). There were no significant associations between studies' relative risks and quality, industry funding, or year of publication (all six meta-regressions P ≥ .35). In conclusion, when emergence from general anesthesia with different drugs are compared with sevoflurane or isoflurane, suitable benchmarks quantifying rapidity of emergence are reductions in the incidence of prolonged extubation achieved by desflurane, approximately 65% and 78%, respectively. These estimates give realistic context for interpretation of results of future studies that compare new anesthetic agents to current anesthetics.
•Prolonged times to tracheal extubation are ≥15 min end of surgery to extubation.•Prolonged extubations are expensive and costly clinically, they need to be prevented.•Desflurane reduces by 65% versus sevoflurane and 78% versus isoflurane.•Estimates give realistic context for future studies as to how fast drugs than be relative to others.
A recent publication reported that at three hospitals within one academic health system, female surgeons received less surgical block time than male surgeons, suggesting potential gender-based bias ...in operating room scheduling. We examined this observation's generalizability.
Our cross-sectional retrospective cohort study of State of Florida administrative data included all 4,176,551 ambulatory procedural encounters and inpatient elective surgical cases performed January 2017 through December 2019 by 8875 surgeons (1830 female) at all 609 non-federal hospitals and ambulatory surgery centers. There were 1,509,190 lists of cases (i.e., combinations of the same surgeon, facility, and date). Logistic regression adjusted for covariables of decile of surgeon's quarterly cases, surgeon's specialty, quarter, and facility.
Selecting randomly a male and a female surgeons' quarter, for 66% of selections, the male surgeon performed more cases (P < .0001). Without adjustment for quarterly caseloads, lists comprised one case for 44.2% of male and 54.6% of female surgeons (difference 10.4%, P < .0001). A similar result held for lists with one or two cases (difference 9.1%, P < .0001). However, incorporating quarterly operative caseloads, the direction of the observed difference between male and female surgeons was reversed both for case lists with one (-2.1%, P = .03) or one or two cases (-1.8%, P = .05).
Our results confirm the aforementioned single university health system results but show that the differences between male and female surgeons in their lists were not due to systematic bias in operating room scheduling (e.g., completing three brief elective cases in a week on three different workdays) but in their total case numbers. The finding that surgeons performing lists comprising a single case were more often female than male provides a previously unrecognized reason why operating room managers should help facilitate the workload of surgeons performing only one case on operative (anesthesia) workdays.
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Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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