•Drug shortages in anesthesia and analgesia have become commonplace.•For 3 months in 2018, hyperbaric spinal bupivacaine was in shortage nationwide.•At one institution, collaboration with pharmacy ...maintained spinal anesthesia access.•Isobaric bupivacaine replaced hyperbaric with increased use of adjuvants.
Multimodal analgesic clinical pathways for joint replacement patients often include perineural catheters, but long-term adherence to these pathways has not yet been investigated. Our primary aim was ...to determine adherence rate to a knee arthroplasty clinical pathway for patients undergoing staged bilateral procedures.
This study was performed at a hospital with a Perioperative Surgical Home program and knee arthroplasty clinical pathway using multimodal analgesia and adductor canal catheters. Data were examined for all orthopedic surgery patients over a 4-year period. We included patients who had staged bilateral knee arthroplasty electively scheduled on 2 separate dates. The primary outcome was rate of adductor canal catheter utilization as a measure of adherence to the clinical pathway. Other outcomes included rates of neuraxial anesthesia and minor and major perioperative complications.
We analyzed data for 103 unique patients. The interval between surgeries was a median of 261 days (10th-90th percentile, 138-534 days). All 103 patients had adductor canal catheters for both the first and second surgeries (P > 0.999). Forty-one percent of patients had the same surgeon for both surgeries, but only 2% had the same anesthesiologist (P < 0.001). From the first to the second surgery, utilization of neuraxial anesthesia increased from 51% to 68%, respectively (P = 0.005). There were no differences in minor or major complications.
For staged bilateral knee arthroplasty patients, 100% clinical pathway adherence including perineural catheters and multimodal analgesia is feasible despite multiple variables. We believe that patient-centered acute pain management requires consistent and reliable delivery of care.
Long-term sustainability of clinical practice changes in anesthesia has not been previously reported. Therefore, we performed a 5-year audit following implementation of a clinical pathway change to ...favor spinal anesthesia for total knee arthroplasty (TKA). We similarly evaluated a parallel cohort of patients undergoing total hip arthroplasty (THA) which did not undergo clinical pathway change as well as the utilization of regional analgesia.
We identified all primary unilateral TKA and THA cases performed from January 2013 through December 2018 to include data from one-year pre-implementation and 5-years post-implementation of the clinical pathway change. Our primary outcome was the overall rate of spinal anesthesia usage. Secondary outcomes included rate of nerve block utilization, 30-day postoperative complications, and resource utilization variables such as hospital readmission, emergency department visits, and blood transfusions.
The sample consisted of 1859 cases (1250 TKAs, 609 THAs). In the first year post-implementation, 174/221 (78.7%) TKAs received spinal anesthesia compared to 23/186 (12.4%) in the year before implementation (p<0.001). In the subsequent 4-year period, 647/843 (77.2%) TKAs received spinal anesthesia (p=0.532 vs. year 1). For THA, 78/124 (62.9%) received spinal anesthesia in the year after implementation compared to 48/116 (41.4%) pre-implementation (p=0.001), but this rate decreased in the subsequent 4-year period to 193/369 (52.3%) (p=0.040 vs. year 1). Utilization of regional analgesia was high in both groups, and there were no differences in other outcomes.
A clinical pathway change promoting spinal anesthesia for TKA can be effectively implemented and sustained over a 5-year period.
Individuals who have agentic traits (eg, assertive, confident, competent) that are more commonly associated with men are often selected for leadership roles. For women, this poses a potential barrier ...to entry into the higher ranks of academic medicine.
We analyzed anesthesiology resident feedback for differences in the use of agentic descriptors using qualitative and quantitative methods based on resident gender and year of training.
This study uses textual analysis of 435 assessments of residents over a 1-year period within a single residency program. We performed a qualitative content analysis on the words used in resident feedback and performed negative binomial regression analyses to determine significant differences in the way residents were described based on gender and year of training.
Female residents were less likely than male residents to be described as agentic after controlling for excerpt length, year of training, and evaluator variability (β = -0.347; 95% confidence interval CI -0.666, -0.028;
= .033). Senior residents were more likely to be described as agentic (β = 0.702; 95% CI 0.402-1.002;
< .001) compared to junior residents. The increased number of agentic codes among senior residents was driven by increased agentic description of female residents' ratings in the senior cohort (β = 0.704; 95% CI 0.084-1.324;
= .026).
Female residents were described as agentic less often than male residents in early years of training, but the gap was not present among senior residents.
Abstract Background The challenge of knowledge translation in medical settings is well known, and implementing change in clinical practice can take years. For the increasing number total knee ...arthroplasty (TKA) patients annually, there is ample evidence to endorse neuraxial anesthesia over general anesthesia. The rate of adoption of this practice, however, is slow at the current time. We hypothesized that a Perioperative Surgical Home (PSH) model facilitates rapid change implementation in anesthesia. Methods The PSH clinical pathways workgroup at a tertiary care Veterans Affairs hospital embarked on a 5-month process of changing the preferred anesthetic technique for patients undergoing TKA. This process involved multiple sequential steps: literature review; development of a work document; training of staff; and prospective collection of data. To assess the impact of this change, we examined data 6 months before (PRE, n=90) and after (POST) change implementation (n=128), and our primary outcome was the overall proportion of spinal anesthesia usage for each 6 month period. Secondary outcomes included minor and major complications associated with anesthetic technique. Results Over a period of one year, there was an increase in the proportion of patients who received spinal anesthesia (13% vs. 63%, p<0.001). For the following year, 53-92% of TKA patients per month received spinal anesthesia. There were no differences in major complications. Conclusion Rapid and sustained change implementation in clinical anesthesia practice based on emerging evidence is feasible. Implications Perioperative Surgical Home model may facilitate rapid change implementation in surgical care. Level of evidence Cohort study, Level 2
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