In this article, we address whether emergency manuals are an effective means of helping anesthesiologists and perioperative teams apply known best practices for critical events. We review the ...relevant history of such cognitive aids in health care, as well as examples from other high stakes industries, and describe why emergency manuals have a role in improving patient care during certain events. We propose 4 vital elements: create, familiarize, use, and integrate, necessary for the widespread, successful development, and implementation of medical emergency manuals, using the specific example of the perioperative setting. The details of each element are presented, drawing from the medical literature as well as from our combined experience of more than 30 years of observing teams of anesthesiologists managing simulated and real critical events. We emphasize the importance of training clinicians in the use of emergency manuals for education on content, format, and location. Finally, we discuss cultural readiness for change, present a system example of successful integration, and highlight the importance of further research on the implementation of emergency manuals.
Energy transition scenarios are characterized by increasing electrification and improving efficiency of energy end uses, rapid decarbonization of the electric power sector, and deployment of carbon ...dioxide removal (CDR) technologies to offset remaining emissions. Although hydrocarbon fuels typically decline in such scenarios, significant volumes remain in many scenarios even at the time of net-zero emissions. While scenarios rely on different approaches for decarbonizing remaining fuels, the underlying drivers for these differences are unclear. Here we develop several illustrative net-zero systems in a simple structural energy model and show that, for a given set of final energy demands, assumptions about the use of biomass and CO
sequestration drive key differences in how emissions from remaining fuels are mitigated. Limiting one resource may increase reliance on another, implying that decisions about using or restricting resources in pursuit of net-zero objectives could have significant tradeoffs that will need to be evaluated and managed.
Overexpression of prostate-specific membrane antigen (PSMA) in tumor tissue and serum has been linked to increased risk of biochemical recurrence in surgically treated prostate cancer patients, but ...none of the studies have assessed its association with disease-specific mortality.
We examined whether high PSMA protein expression in prostate tumor tissue was associated with lethal disease, and with tumor biomarkers of progression, among participants of two U.S.-based cohorts (n = 902, diagnosed 1983-2004). We used Cox proportional hazards regression to calculate multivariable HRs and 95% confidence intervals (CI) of lethal prostate cancer, defined as disease-specific death or development of distant metastases (n = 95). Partial Spearman rank correlation coefficients were used to correlate PSMA with tumor biomarkers.
During an average 13 years of follow-up, higher PSMA expression at prostatectomy was significantly associated with lethal prostate cancer (age-adjusted HRQuartile(Q)4vs.Q1 = 2.42; Ptrend < 0.01). This association was attenuated and nonsignificant (multivariable-adjusted HRQ4vs.Q1 = 1.01; Ptrend = 0.52) after further adjusting for Gleason score and prostate-specific antigen (PSA) at diagnosis. High PSMA expression was significantly (P < 0.05) correlated with higher Gleason score and PSA at diagnosis, increased tumor angiogenesis, lower vitamin D receptor and androgen receptor expression, and absence of ets-related gene (ERG) expression.
High tumor PSMA expression was not an independent predictor of lethal prostate cancer in the current study. PSMA expression likely captures, in part, malignant features of Gleason grade and tumor angiogenesis.
PSMA is not a strong candidate biomarker for predicting prostate cancer-specific mortality in surgically treated patients.
Geomagnetic indices are convenient quantities that distill the complicated physics of some region or aspect of near‐Earth space into a single parameter. Most of the best‐known indices are calculated ...from ground‐based magnetometer data sets, such as Dst, SYM‐H, Kp, AE, AL, and PC. Many models have been created that predict the values of these indices, often using solar wind measurements upstream from Earth as the input variables to the calculation. This document reviews the current state of models that predict geomagnetic indices and the methods used to assess their ability to reproduce the target index time series. These existing methods are synthesized into a baseline collection of metrics for benchmarking a new or updated geomagnetic index prediction model. These methods fall into two categories: (1) fit performance metrics such as root‐mean‐square error and mean absolute error that are applied to a time series comparison of model output and observations and (2) event detection performance metrics such as Heidke Skill Score and probability of detection that are derived from a contingency table that compares model and observation values exceeding (or not) a threshold value. A few examples of codes being used with this set of metrics are presented, and other aspects of metrics assessment best practices, limitations, and uncertainties are discussed, including several caveats to consider when using geomagnetic indices.
Plain Language Summary
One aspect of space weather is a magnetic signature across the surface of the Earth. The creation of this signal involves nonlinear interactions of electromagnetic forces on charged particles and can therefore be difficult to predict. The perturbations that space storms and other activity causes in some observation sets, however, are fairly regular in their pattern. Some of these measurements have been compiled together into a single value, a geomagnetic index. Several such indices exist, providing a global estimate of the activity in different parts of geospace. Models have been developed to predict the time series of these indices, and various statistical methods are used to assess their performance at reproducing the original index. Existing studies of geomagnetic indices, however, use different approaches to quantify the performance of the model. This document defines a standardized set of statistical analyses as a baseline set of comparison tools that are recommended to assess geomagnetic index prediction models. It also discusses best practices, limitations, uncertainties, and caveats to consider when conducting a model assessment.
Key Points
We review existing practices for assessing geomagnetic index prediction models and recommend a “standard set” of metrics
Along with fit performance metrics that use all data‐model pairs in their formulas, event detection performance metrics are recommended
Other aspects of metrics assessment best practices, limitations, uncertainties, and geomagnetic index caveats are also discussed
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•Current guidelines suggest personalized pain education for patients.•We designed a simple pain management education tool for knee arthroplasty patients.•The education project was ...implemented using plan-do-study-act methodology.•Use of the education tool decreased median opioid use by nearly half.
Effects of patient education on perioperative analgesic utilization are not well defined. We designed a simple pain management educational card for total knee arthroplasty (TKA) patients and retrospectively reviewed clinical data before and after implementation to test the hypothesis that more informed patients will use less opioid.
With IRB approval, we analyzed clinical data collected perioperatively on all TKA patients one month before (PRE) and one month after (POST) card implementation. The card was designed using a modified Delphi method; the front explained all analgesic medications and the Defense and Veterans Pain Rating Scale was on the back. The primary outcome was total opioid dosage in morphine milligram equivalents (MME) for the first two postoperative days. Secondary outcomes included daily opioid usage, pain scores, ambulation distance, hospital length of stay and use of antiemetics.
There were 20 patients in each group with no differences in baseline characteristics. Total two-day MME median (10th–90th percentiles) was 71 (32–285) for PRE and 38 (1–117) for POST (p = 0.001). There were no other differences.
Educating TKA patients in multimodal pain management using a simple tool decreases opioid usage.
Empowering TKA patients with education can reduce opioid use perioperatively.
Emergency manuals (EMs), context-relevant sets of cognitive aids or crisis checklists, have been used in high-hazard industries for decades, although this is a nascent field in health care. In the ...fall of 2012, Stanford clinically implemented EMs, including hanging physical copies in all Stanford operating rooms (ORs) and training OR clinicians on the use of, and rationale for, EMs. Although simulation studies have shown the effectiveness of EMs and similar tools when used by OR teams during crises, there are little data on clinical implementations and uses. In a subset of clinical users (ie, anesthesia residents), the objectives of this pilot study were to (1) assess perspectives on local OR safety culture regarding cognitive aid use before and after a systematic clinical implementation of EMs, although in the context of long-standing resident simulation trainings; and (2) to describe early clinical uses of EMs during critical events.
Surveys collecting both quantitative and qualitative data were used to assess clinical adoption of EMs in the OR. A pre-implementation survey was e-mailed to Stanford anesthesia residents in mid-2011, followed by a post-implementation survey to a new cohort of residents in early 2014. The post-implementation survey included pre-implementation survey questions for exploratory comparison and additional questions for mixed-methods descriptive analyses regarding EM implementation, training, and clinical use during critical events since implementation.
Response rates were similar for the pre- and post-implementation surveys, 52% and 57%, respectively. Comparing post- versus pre-implementation surveys in this pilot study, more residents: agreed or strongly agreed "the culture in the ORs where I work supports consulting a cognitive aid when appropriate" (73.8%, n = 31 vs 52.9%, n = 18, P = .0017) and chose more types of anesthesia professionals that "should use cognitive aids in some way," including fully trained anesthesiologists (z = -2.151, P = .0315). Fifteen months after clinical implementation of EMs, 19 respondents (45%) had used an EM during an actual critical event and 15 (78.9% of these) agreed or strongly agreed "the EM helped the team deliver better care to the patient" during that event, with the rest neutral. We present qualitative data for 16 of the 19 EM clinical use reports from free-text responses within the following domains: (1) triggering EM use, (2) reader role, (3) diagnosis and treatment, (4) patient care impact, and (5) barriers to EM use.
Since Stanford's clinical implementation of EMs in 2012, many residents' self-report successful use of EMs during clinical critical events. Although these reports all come from a pilot study at a single institution, they serve as an early proof of concept for feasibility of clinical EM implementation and use. Larger, mixed-methods studies will be needed to better understand emerging facilitators and barriers and to determine generalizability.
Objectives
Objective measures are needed to guide the novice's pathway to expertise. Within and outside medicine, eye tracking has been used for both training and assessment. We designed this study ...to test the hypothesis that eye tracking may differentiate novices from experts in static image interpretation for ultrasound (US)‐guided regional anesthesia.
Methods
We recruited novice anesthesiology residents and regional anesthesiology experts. Participants wore eye‐tracking glasses, were shown 5 sonograms of US‐guided regional anesthesia, and were asked a series of anatomy‐based questions related to each image while their eye movements were recorded. The answer to each question was a location on the sonogram, defined as the area of interest (AOI). The primary outcome was the total gaze time in the AOI (seconds). Secondary outcomes were the total gaze time outside the AOI (seconds), total time to answer (seconds), and time to first fixation on the AOI (seconds).
Results
Five novices and 5 experts completed the study. Although the gaze time (mean ± SD) in the AOI was not different between groups (7 ± 4 seconds for novices and 7 ± 3 seconds for experts; P = .150), the gaze time outside the AOI was greater for novices (75 ± 18 versus 44 ± 4 seconds for experts; P = .005). The total time to answer and total time to first fixation in the AOI were both shorter for experts.
Conclusions
Experts in US‐guided regional anesthesia take less time to identify sonoanatomy and spend less unfocused time away from a target compared to novices. Eye tracking is a potentially useful tool to differentiate novices from experts in the domain of US image interpretation.
Performing key actions efficiently during crises can determine clinical outcomes, yet even expert clinicians omit key actions. Simulation-based studies of crises show that correct performance of key ...actions dramatically increases when emergency manuals (EMs) are used. Despite widespread dissemination of EMs, there is a need to understand in clinical contexts, when, how, and how often EMs are used and not used, along with perceived impacts.
We conducted interviews with the anesthesia professionals involved in perioperative crises, identified with criterion-based sampling, occurring between October 2014 and May 2016 at 2 large academic medical centers with a history of EM training and implementation. Our convergent, mixed-methods study of the interview data extracted quantitative counts and qualitative themes of EM use and nonuse during clinical crises.
Interviews with 53 anesthesia professionals yielded 80 descriptions of applicable clinical crises, with varying durations and event types. Of 69 unique patients whose cases involved crises, the EM was used during 37 (54%; 95% confidence interval CI, 41-66). Impacts on clinician team members included decreased stress for individual anesthesia professionals (95%), enabled teamwork (73%), and calmed atmosphere (46%). Impacts on delivery of patient care included specific action improvements, including catching errors of omission, for example, turning off anesthetic during cardiac arrest, only after EM use (59%); process improvements, for example, double-checking all actions were completed (41%); and impediments (0%). In 8% of crises, EM use was associated with potential distractions, although none were perceived to harm delivery of patient care. For 32 EM nonuses (46%; 95% CI, 34-59), participants self-identified errors of omission or delays in key actions (56%), all key actions performed (13%), and crisis too brief for EM to be used (31%).
This study provides evidence that EMs in operating rooms are being used during many applicable crises and that clinicians perceive EM use to add value. The reported negative effects were minimal and potentially offset by positive effects.
Background
Femoral continuous peripheral nerve blocks (CPNBs) provide effective analgesia after TKA but have been associated with quadriceps weakness and delayed ambulation. A promising alternative ...is adductor canal CPNB that delivers a primarily sensory blockade; however, the differential effects of these two techniques on functional outcomes after TKA are not well established.
Questions/purposes
We determined whether, after TKA, patients with adductor canal CPNB versus patients with femoral CPNB demonstrated (1) greater total ambulation distance on Postoperative Day (POD) 1 and 2 and (2) decreased daily opioid consumption, pain scores, and hospital length of stay.
Methods
Between October 2011 and October 2012, 180 patients underwent primary TKA at our practice site, of whom 93% (n = 168) had CPNBs. In this sequential series, the first 102 patients had femoral CPNBs, and the next 66 had adductor canal CPNBs. The change resulted from a modification to our clinical pathway, which involved only a change to the block. An evaluator not involved in the patients’ care reviewed their medical records to record the parameters noted above.
Results
Ambulation distances were higher in the adductor canal group than in the femoral group on POD 1 (median 10
th
–90
th
percentiles: 37 m 0–90 m versus 6 m 0–51 m; p < 0.001) and POD 2 (60 m 0–120 m versus 21 m 0–78 m; p = 0.003). Adjusted linear regression confirmed the association between adductor canal catheter use and ambulation distance on POD 1 (
B
= 23; 95% CI = 14–33; p < 0.001) and POD 2 (
B
= 19; 95% CI = 5–33; p = 0.008). Pain scores, daily opioid consumption, and hospital length of stay were similar between groups.
Conclusions
Adductor canal CPNB may promote greater early postoperative ambulation compared to femoral CPNB after TKA without a reduction in analgesia. Future randomized studies are needed to validate our major findings.
Level of Evidence
Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
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