Benchmarking group surgical anesthesia productivity continues to be an important but challenging goal for anesthesiology groups. Benchmarking is important because it provides objective data to ...evaluate staffing needs and costs, identify potential operating room management decisions that could reduce costs or improve efficiency, and support ongoing negotiations and discussions with health system leadership. Unfortunately, good and meaningful benchmarking data are not readily available. Therefore, a survey of academic anesthesiology departments was done to provide current benchmarking data.
A survey of members of the Society of Academic Associations of Anesthesiology and Perioperative Medicine (SAAAPM) was performed. The survey collected data by facility and included type of facility, number and type of staff and anesthetizing sites each weekday, and the billed American Society of Anesthesiologists (ASA) units and number of cases over 12 months. The facility types included academic medical center (AMC), community hospital (Community), children's hospital (Children), and ambulatory surgical center (ASC). All anesthesia care billed using ASA units were included, except for obstetric anesthesia. Any care not billed or billed using relative value units (RVUs) were excluded. Percentage of nonoperating room anesthetizing sites, staffing ratio, and surgical anesthesia productivity measurements "per case" and "per site" were calculated.
Of the 135 society members, 63 submitted complete surveys for 140 facilities (69 AMC, 26 Community, 7 Children, and 38 ASC). In the survey, overall median productivity for AMC and Children was similar (12,592 and 12,364 total ASA units per anesthetizing site), while the ASC had the lowest median overall productivity (8911 total ASA units per anesthetizing site). By size of facility, in the survey, the smaller facilities (<10 sites, ASC or non-ASC) had lower median overall productivity as compared to larger facilities. For AMC and Children, >20% of anesthetizing sites were nonoperating room anesthetizing sites. Anesthesiology residents worked primarily in AMC and Children. In ASC and Community, residents worked only in 18% and 35% of facilities, respectively. More than half the AMCs reported at least 1 break certified nurse anesthetist (CRNA) each day.
To make data-driven decisions on clinical productivity, anesthesiology leaders need to be able to make meaningful comparisons at the facility level. For a group that provides care in multiple facilities, one can make internal comparisons among facilities and follow measurements over time. It is valuable for leaders to also be compare their facilities with industry-wide measurements, in other words, benchmark their facilities. These results provide benchmarking data for academic anesthesiology departments.
Endotracheal tubes (ETTs) are commonly secured with tape to prevent undesirable tube migration. Many methods of taping have been described, although little has been published comparing various ...methods of taping to one another. In this study, we evaluated several methods for securing ETTs with tape. We hypothesized a difference in mean peak forces between the methods studied during forced extubation.
Five methods of securing an ETT with tape were studied in a variety of contexts including cadaver and simulation lab settings. Testing included measurement of peak force (Newton N) during forced extubation, durability of taping following mechanical stress, effects of tape length-width variation, and characterization of failure mechanisms.
We found several significant differences in mean peak extubation forces between the 5 methods of taping, with mean peak forces during forced extubation ranging from 20 N to 156 N. In separate tests, we found an association between mean peak forces and total surface area as well as geometric configuration of tape on the face. Long thin strips of tape appeared to provide surprising durability against forced extubation, a phenomenon that was associated with minimization of the "peel angle" as tape was removed.
We found evidence of differential structural integrity between the 5 taping methods studied. More generally, we found that increased peak extubation forces were associated with increased total surface area of tape and that minimization of the "peel angle" by lateral application of tape is associated with surprisingly high relative peak extubation forces.
Despite the landmark study by Godina 30 years ago, opinions still vary within the literature about the management of complex traumatic wounds in the lower extremity. We present a large series of ...lower extremity reconstructions with vascularized free tissue and examine the perioperative factors that influenced the success of these cases.
We reviewed 88 patients with free flap reconstruction of traumatic lower extremity wounds over 8 years. Primary outcomes were flap infections, flap loss, total flap-specific complications, and total recipient site complications. Independent variables specific to perioperative care including time to flap coverage, injury classification, exposed or infected hardware, prior osteomyelitis, use of wound vacuum-assisted closure (VAC) therapy, and concurrent polytrauma were investigated to establish their influence on primary outcomes. Each independent variable was assessed using Chi-square or Fisher's exact test and was included in a logistic regression analysis to establish significance.
Of the 88 patients, 8 had flap loss, 8 had flap infections, and a total of 23 had primary adverse outcomes. Timing of the reconstruction, VAC use, injury classification, prior hardware or wound status, or presence of polytrauma had no statistically significant impact on the primary outcomes. Injury classification/severity on total recipient site complications (
= 0.051) and flap-specific complications (
= 0.073) trended toward significance; however, subgroup analysis did not achieve significance. Logistic regression of any recipient site complication including all independent variables similarly showed no significance.
Although the original study by Godina suggests early coverage is critical to optimize outcomes, in the modern era of advanced wound care, our study adds to a growing body of evidence that supports the de-emphasis of the 72-hour reconstruction interval. Our current management is focused on more effectively coordinating efficient peritraumatic and perioperative care on an individualized basis in the often very complicated polytrauma patient.
Anesthetic considerations for bariatric surgery Ogunnaike, Babatunde O; Jones, Stephanie B; Jones, Daniel B ...
Anesthesia and analgesia,
2002-December, Letnik:
95, Številka:
6
Journal Article
The amount of education debt incurred by medical school graduates in the United States has grown considerably over the last 30 years; it has outpaced inflation to reach a mean of $158,000. With this ...dramatic increase in education debt, there has been limited information on how medical school debt loads of anesthesiology physicians impact their decisions concerning moonlighting and future career choices. Our aim was to survey current anesthesiology interns, residents, and fellows to assess the correlation between the amount of medical school debt they had collected and (1) their outlook toward moonlighting activities, (2) future career plans, and (3) choice of employer with a debt repayment program.
We developed a web-based survey instrument and contacted residency training programs to obtain access to their anesthesiology interns, residents, and fellows (residents). We assessed each relationship of interest using a multivariable proportional odds model, adjusting for all available baseline potential confounding factors. Second, we compared participants with >$150,000 medical school debt versus participants with no debt on the same questions of interest, each using a multivariable proportional odds model with the same covariable adjustment.
We had access to 2386 residents through their training programs and 537 completed the survey. Those respondents with a 1-category-larger amount of medical school debt (i.e., $30,000) were associated with 7%(99.3% confidence interval: 0%, 13%) increased odds of having the desire to moonlight during residency/fellowship, and were associated with 7% (1%, 13%) decreased odds of saying they would choose a career as an academic faculty, respectively. Also, those with a larger amount of medical school debt were more likely to be swayed to be interested in an anesthesiology group with an education debt repayment program (odds ratio: 1.3 1.22, 1.39 for 1-category increase in the debt amount); furthermore, the corresponding odds ratio was increased to 4.6 (2.8, 7.5) comparing those with >$150,000 debt with those without debt.
In an effort to compete with private practice anesthesiology groups and to reduce the impact of debt on future career choices of residents/fellows, academic anesthesiology groups would do well to (1) promote moonlighting activities that are within the Accreditation Council for Graduate Medical Education and institutional guidelines, (2) develop financial curriculum for residents/fellows, and (3) offer debt repayment programs as an incentive for new faculty to join academic medicine.
Perioperative myocardial infarction (PMI) is a major cause of morbidity and mortality in patients undergoing noncardiac surgery. The incidence of PMI varies depending on the method used for diagnosis ...and is likely to increase as the population ages. Studies have examined different methods for prevention of myocardial infarction (MI), including the use of perioperative β-blockers, α2-agonists, and statin therapy. However, few studies have focused on the treatment of PMI. Current therapy for acute MI generally involves anticoagulation and antiplatelet therapy, raising the potential for surgical site hemorrhage in this population. This article reviews the possible mechanisms, diagnosis, and treatment options for MI in the surgical setting. We also suggest algorithms for treatment.
Potential benefits to reducing turnover times are both quantitative (e.g., complete more cases and reduce staffing costs) and qualitative (e.g., improve professional satisfaction). Analyses have ...shown the quantitative arguments to be unsound except for reducing staffing costs. We describe a methodology by which each surgical suite can use its own numbers to calculate its individual potential reduction in staffing costs from reducing its turnover times. Calculations estimate optimal allocated operating room (OR) time (based on maximizing OR efficiency) before and after reducing the maximum and average turnover times. At four academic tertiary hospitals, reductions in average turnover times of 3 to 9 min would result in 0.8% to 1.8% reductions in staffing cost. Reductions in average turnover times of 10 to 19 min would result in 2.5% to 4.0% reductions in staffing costs. These reductions in staffing cost are achieved predominantly by reducing allocated OR time, not by reducing the hours that staff work late. Heads of anesthesiology groups often serve on OR committees that are fixated on turnover times. Rather than having to argue based on scientific studies, this methodology provides the ability to show the specific quantitative effects (small decreases in staffing costs and allocated OR time) of reducing turnover time using a surgical suite's own data.
Many anesthesiologists work at hospitals where surgeons and/or operating room (OR) committees focus repeatedly on turnover time reduction. We developed a methodology by which the reductions in staffing cost as a result of turnover time reduction can be calculated for each facility using its own data. Staffing cost reductions are generally very small and would be achieved predominantly by reducing allocated OR time to the surgeons.
Perioperative myocardial infarction (PMI) is a major cause of morbidity and mortality in patients undergoing noncardiac surgery.
The incidence of PMI varies depending on the method used for diagnosis ...and is likely to increase as the population ages. Studies
have examined different methods for prevention of myocardial infarction (MI), including the use of perioperative β-blockers,
α 2 -agonists, and statin therapy. However, few studies have focused on the treatment of PMI. Current therapy for acute MI generally
involves anticoagulation and antiplatelet therapy, raising the potential for surgical site hemorrhage in this population.
This article reviews the possible mechanisms, diagnosis, and treatment options for MI in the surgical setting. We also suggest
algorithms for treatment.
Abstract Background Due to higher transthoracic impedance, obese patients may be less likely to be successfully defibrillated from ventricular tachycardia or ventricular fibrillation (VT/VF) arrest. ...However, the association between patient body mass index (BMI), defibrillation success, and survival outcomes of VT/VF arrest are poorly understood. Methods We evaluated 7110 patients with in-hospital VT/VF arrest at 286 hospitals within the Get With The Guidelines® -Resuscitation (GWTG-R) Multicenter Observational Registry between 2006 and 2012. Patients were categorized as underweight (BMI < 18.5 kg/m2 ), normal weight (BMI 18.5–24.9 kg/m2 ), over-weight (BMI 25.0–29.9 kg/m2 ), obese (BMI 30.0–34.9 kg/m2 ), and extremely obese (BMI ≥ 35.0 kg/m2 ). Using generalized linear mixed regression, we determined the risk-adjusted relationship between BMI and patient outcomes while accounting for clustering by hospitals. The primary outcome was successful first shock defibrillation (a post-shock rhythm other than VT/VF) with secondary outcomes of return of spontaneous circulation, survival to 24 h, and survival to discharge. Results Among adult patients suffering VT/VF arrest, 304 (4.3%) were underweight, 2061 (29.0%) were normal weight, 2139 (30.1%) were overweight, and 2606 (36.6%) were obese or extremely obese. In a risk-adjusted analysis, we observed no interaction between BMI and energy level for the successful termination of VT/VF with first shock. Furthermore, the risk-adjusted likelihood of successful first shock termination of VT/VF did not differ significantly across BMI categories. Finally, when compared to overweight patients, obese patients had similar risk-adjusted likelihood of survival to hospital discharge (odds ratio 0.786, 95% confidence interval 0.593–1.043). Conclusions There was no significant difference in the likelihood of successful defibrillation with the first shock attempt among different BMI categories.
Anesthesiology departments incur staffing costs that are not covered by revenue because the operating room (OR) time allocation and case scheduling are not done to maximize OR efficiency and because ...surgical durations are longer than average. The purpose of this article is to demonstrate a method to quantify net anesthesia staffing costs due to longer-than-average surgical durations and evaluate the factors that influence staffing costs.
Data collected from two anesthesiology departments in academic hospitals for 1 yr included date of surgery, time that patients entered the OR, time that patients exited the OR, surgical service, and the Current Procedural Terminology code for the primary surgical procedure. Anesthesia care performed outside the main surgical suite and services not billed with American Society of Anesthesiologists units were excluded. National average surgical durations were determined from the Current Procedural Terminology code from the Centers for Medicare and Medicaid Services' database. Actual surgical durations were then used to determine staffing solutions to maximize OR efficiency; national average surgical durations were then used to determine a second solution. The difference in staffing costs between these two staffing solutions represented the staffing costs attributable to longer surgical durations. Costs were converted to dollar amounts using compensation values reported in a national compensation survey. The differences in revenue were determined by applying conversion factors to the differences in surgical durations. The annual net cost attributable to longer surgical durations equaled the staffing costs minus the revenue produced by longer durations. Net staffing costs were estimated for two hospitals using median staffing compensation and median payer mix. Net staffing costs were then recalculated by varying the parameters (conversion factors, limits on differences between actual and average surgical duration, levels of compensation, surgical service size of OR allocation).
Using the median compensation of staff and an average conversion factor, the net annual staffing costs attributable to longer surgical durations were $672,100 for the first hospital. However, if staff members were highly compensated and the payer mix was unfavorable, the net staffing costs were $1,688,000. Reducing the difference between actual and average duration resulted in lower staffing costs. Net staffing costs were less in a second hospital studied that had many low-volume surgical services.
Longer-than-average surgical durations can increase net staffing costs for anesthesiology groups. The increase is dependent on factors such as staffing compensation and payer mix.
