Medical education continues to advance to further domains, and anesthesia training is aligned with this trend. In the traditional method of clinical education to become a specialist, aspiring anesthesiologists would complete two years of a standard pre-clinical academic curriculum, followed by two years of rotations, and a residency and optional fellowship. Physician skills were taught under the direction of a more senior physician in the surgical suite, and students typically learned with the increasing complexity of more clinical responsibilities.

However, questions have emerged in the didactic literature on the benefits of effective preparation prior to even entering the operating room. This has begun to shift at the medical school level. For example, in anatomy, a critical knowledge base for anesthesiologists and surgeons to acquire, many medical schools have now integrated advanced technology into the curriculum, which allows students to explore the human body and perform virtual dissections before they attend the actual laboratory class. Such technologies are improving with each year, to qualitatively positive results from students. Given such successes, virtual reality is increasingly used as a tool for education throughout training, including anesthesiology residency.

A 2018 study from the University of Toronto investigated the efficacy of virtual reality education compared to standard education with respect to resident acquisition of fiberoptic intubation skills. Anesthesia residents were divided into a control group, which learned and practiced intubation on a standard medical training mannequin, and the experimental group, which learned the same skills on a virtual reality program. The virtual reality program was developed by a third-party manufacturer, specific for anesthesiologists. Following this training regimen, anesthesia residents from both groups were required to perform intubations on live patients, and were scored rigorously. Scores were acquired on the basis of time, a global rating scale, and a checklist of numerical completion. The raters were blinded to the order and group origin of each resident. Following analysis, the research team found that the residents who learned under the virtual reality condition reached their optimal performance more quickly, that is after fewer practice sessions, than the control group. In addition, the global rating scales were higher, and time improved slightly, in the virtual reality group. Based on the results, the researchers have advocated for teaching hospitals to integrate virtual reality into the anesthesiology residency curriculum where possible. Furthermore, it is advised that future studies will explore the long-term retention of skills acquired with virtual reality, as well as increase the breadth of procedures taught through this method.

In addition to the tactical and surgical skills required of an anesthesiologist, patient care metrics are also critical. Virtual reality is thus entering the anesthesia clinical services domain, as exhibited by recent developments, specifically with regards to managing patient pain. A recently concluded program from Stanford University explored the efficacy of a virtual reality application that allows clinicians to engage with patients, with real-time results, with the objective of increasing patient satisfaction. Physicians were able to understand the ways in which specific actions can alter the relationship between patient and provider. Furthermore, this technology has been used by anesthesiologists and other anesthesia providers to learn more about how anxiety affects pain, which aids in planning post-operative recovery. When used successfully, these strategies are documented to lead to decreased anxiety, as well as a decreased perception of pain from the patient perspective.

Future studies will continue to explore the efficacy of virtual reality as a tool for training, education, and skills acquisition in the anesthesia space. Anesthesiologists, in engaging with such technological advancements, will continue to hold leadership positions and move forward with improved patient outcomes.

In the last ten years there have been significant efforts made toward building a healthcare information technology (IT) infrastructure in the United States that allows for secure and reliable exchange of patient information between healthcare providers, medical professionals, individual patients, and their families. The success of these systems has tremendous implications for the overall health and well-being of the entire population—allowing providers and patients to have a more complete understanding of their particular needs. While individual patients are the centerpiece of these efforts, it is important to also acknowledge the impact that effective electronic health record (EHR) interoperability would have on healthcare policy by providing population-level data for national decision making. Despite the seemingly obvious benefits associated with health IT interoperability, numerous barriers still stand in the way of its successful implementation. The complexity of standardization, cultural challenges, physician burdens and burnout, privacy and security concerns, and high costs associated with EHR and HIE adoption are all challenges that remain to be addressed.

In 2009, President Obama signed the American Recovery and Reinvestment Act, which sought to improve the national health care delivery system by digitizing all patient records. The Health Information Technology for Economic and Clinical Health (HITECH) Act was a part of this initiative that invested $35 billion in an effort to incentivize the adoption of EHRs by hospitals and providers, and to achieve interoperability through all levels of the health system. HITECH evaluates “Meaningful Use” of EHR information based on: 1. Data Capture and Sharing, 2. Advance Clinical Processes, and 3. Improved Outcomes. Though HITECH has succeeded in its mission to increase utilization of EHRs, with 96% of hospitals and 80% of office-based physicians in the US having adopted a certified EHR program, the overall effectiveness of these systems is less conclusive. Only 12% of physicians were able to meet stage 2 of the Meaningful Use criteria and only 6% were able to share patient data with other EHR systems in 2015.¹ In a survey of 5,000 anesthesiologists, 49% reported unanticipated need for ongoing IT support and 61% reported difficult integration of Anesthesia Information Management Systems (AIMS)

with an existing EMR as major problems associated with adopting such a system.²

Experts examining the Health IT ecosystem identify challenges that include lack of cooperation among stakeholders, bureaucratic red tape and regulations, along with a misplaced focus on incentivizing EHR adoption without considering health information exchange (HIE) between EHR systems that would allow EHR platforms to interface. In fact, the Office of the National Coordinator for Health and Information Technology (ONC) found evidence of information blocking between EHR and HIE leaders, which led to the passing of bipartisan legislation instituting penalties of up to $1 million to tech developers, networks, and providers who participate in information blocking.^1,3

Increased adoption of EHRs also place additional strain on physicians in their daily practices along with financial burdens for small-practice physicians. Researchers found that physicians spent two hours on clerical or EHR-related duties for every hour of clinical work they performed.^1,4 Certification demands by the federal government as well as documentation requirements for demonstrating “meaningful use” of EHR systems can unintentionally penalize physicians for technology failures. Eligible practices that failed to implement EHR or demonstrate its meaningful use could be penalized between 1-5% of Medicare Part B reimbursements each year. In 2017, over 170,000 providers have faced meaningful use penalties.^1,5 Additional financial strains that place disproportionate burden on smaller practices include the high yearly EHR implementation costs that are estimated to range from $15,000-$70,000 per provider. Many have opted out of the meaningful use program, choosing to lose Medicare reimbursements rather than comply with requirements that divert time and resources away from patient care.^1,6 Despite these caveats, some argue that EHR systems could save smaller anesthesiology practices by keeping them relevant as anesthesia procedures require more data-driven justification by insurance companies for MACRA and MIPS reporting.⁷

Since the passing of HITECH, the ONC has outlined a 10-year vision for achieving an interoperable health IT infrastructure by 2024. Among their list of guiding principles are customization, ease of use and access, value of care, and security of patient information.⁸ They plan to establish core technical standards and functions for terminology, vocabulary, content and format, transport, and security while utilizing the ONC Health IT Certification Program to test health IT products and services. “Building Block #5” in their plan also addresses their responsibility to help establish a governance mechanism for a national health information network. Additionally, the document describes continued monitoring of digital health information exchange systems to identify and address weaknesses and gaps in security.

As a health care professional in your own practice, you may already have encountered the challenges and benefits associated with EHR adoption and compliance. Moving forward, it will be important for you to continue to weigh the short and long term costs and benefits associated with investing in EHR interoperability, considering what is necessary and meaningful for your practice’s bottom-line while also considering the bigger picture in terms of contributing to a national vision for improved patient care through improved information access and exchange. As a health care provider and leader in your field, it is important to advocate for and empower your patients to utilize the EHR information that is available to them.

References:

1. Reisman M. (2017). EHRs: The Challenge of Making Electronic Data Usable and Interoperable. P & T : a peer-reviewed journal for formulary management, 42(9), 572–575.
2. Trentman, T.L., Mueller, J.T., Ruskin, K.J. et al. J Clin Monit Comput (2011) 25: 129. https://doi.org/10.1007/s10877-011-9289-x
3. Upton F. H.R.6—21st Century Cures Act. 114th Congress (2015–2016); July 13, 2015; [Accessed June 4, 2017]. Available at:www.congress.gov/bill/114th-congress/house-bill/6?r=9. 
4. Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: a time and motion study in four specialties. Ann Intern Med. 2016;165(11):753–760.
5. Centers for Medicare and Medicaid Services. Medicare electronic health record (EHR) incentive program payment adjustment fact sheet for eligible professionals. [Accessed June 25, 2017]. p. 2017. Available at: www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/PaymentAdj_EPTipsheet.pdf.
6. Creswell J. Doctors find barriers to sharing digital medical records. The New York Times. Sep 30, 2014. [Accessed June 30, 2017]. Available at:www.nytimes.com/2014/10/01/business/digital-medical-records-become-common-but-sharing-remains-challenging.html.
7. Health IT News. (2017). Anesthesiologists find EHRs free up face-time for patients. Retrieved from https://www.healthcareitnews.com/news/anesthesiologists-find-ehrs-free-face-time-patients.
8. The Office of the National Coordinator for Health Information Technology (ONC). (April 30, 2018). Interoperability. Retrieved from https://www.healthit.gov/topic/interoperability

Operations Management for hospitals, healthcare providers, and outpatient units that provide surgical services encounter several challenges with respect to managing census and providing services in a timely, cost-effective operation. One central challenge that has gained traction in the press is that on the instances of double-booked surgeries. As the name suggests, double-booked surgeries refers to the practice in which a lead surgeon, and potentially a lead anesthesiologist, is assigned to more than one surgery scheduled in the same time-slot. In this manner, the lead physician will typically execute the major or most complex parts of the surgery, leaving the simpler elements to physicians-in-training, e.g. residents and/or fellows. In many ways, the process of double-booking surgeries is treated as an educational training tool. Junior physicians are able to observe experts in the field, while also taking on significant surgical tasks that will mirror their clinical responsibilities as full-time, attending physicians. However, there are also potential downsides to the practice as detailed in the literature, namely that double-booked surgeries may pose a risk to the patient, and can be logistically difficult to execute from the management perspective. This article will detail the challenges associated with double-booking surgeries for anesthesiologists and practice managers, while also considering the impact to patient population.

The practice of double-booking surgeries, while mainstream at many healthcare institutions, can pose a serious administrative challenge to practice managers. Double-booking surgeries requires a level of coordination at the individual level. Surgeons must identify which segments of the surgery are most difficult to perform, and effectively communicate these recommendations to operating room (OR) managers, who then schedule surgeries in specific OR rooms and with associated staff, including anesthesiologists. For lead anesthesiologists and other anesthesia staff, the process of a surgeon moving from room to room can be a distraction. Specifically, one viable side effect of double-booking surgeries is the potential for tardiness. Tardiness can contribute to OR delays, result in anesthesiologists and anesthesia staff working over-time, and cause an unnecessary cost burden to the institution. Allen et al measured the impact of tardiness on surgical healthcare institutions in the Journal of Healthcare Management¹. The research team concluded that each lost minute in the OR was valued at approximately $9.56 in associated costs. In an intervention that targeted delayed surgical start times, part of which were attributed to the presence of double-booked surgeries, cost savings resulted in over $700,000 to the facility. Therefore, if not executed smoothly, double-booked surgeries may represent a significant economic impact to the hospital.

In addition to the economic impact of double-booked surgeries, patient safety represents a viable cause for concern. Given that double booking surgeries requires multiple transitions during the operation, combined with junior surgeons performing a majority of the surgery, several thought leadership pieces have questioned whether there is a significant patient safety issue associated with double-booked surgeries. The literature in fact, suggests the opposite. In a recent publication in JAMA, Sun et al conducted a large-scale retrospective study to determine post-operative outcomes of patients who underwent surgery under double-booked conditions². The cohort included over 60,000 adult patients, and data points were analyzed for in-hospital mortality, post-operative complications, and surgical characteristics. It was found that patients who were in the
double-booked situation did not experience any increase in mortality or complication rates.

However, the mean length of time in surgery was increased for double-booked surgeries, which aligns with previously stated concerns. This research was impactful for providing data to counter any patient safety concerns around double-booked surgeries, while acknowledging that the surgery itself may be impacted in ways including time.

surgical characteristics. It was found that patients who were in the double-booked situation did not experience any increase in mortality or complication rates.

However, the mean length of time in surgery was increased for double-booked surgeries, which aligns with previously stated concerns. This research was impactful for providing data to counter any patient safety concerns around double-booked surgeries, while acknowledging that the surgery itself may be impacted in ways including time.

To sum, the process of double-booking surgeries provides benefits, as well as costs, for individual physicians as well as healthcare institutions at-large. Anesthesiologists and anesthesia staff, who are deeply involved in surgical coordination initiatives, will find value in understanding the policies, research, and practice connected with this initiative.

1. Allen, Robert W., et al. “First Case On-Time Starts Measured by Incision On-Time and No Grace Period.” Journal of Healthcare Management, vol. 64, no. 2, 2019, pp. 111–121., doi: 10.1097/jhm-d-17-00203.

2. Sun, Eric, et al. “Association of Overlapping Surgery with Perioperative Outcomes.” Jama, vol. 321, no. 8, 2019, p. 762. doi:10.1001/jama.2019.0711.

In February 2019, the New York Times published an article entitled, “Having Anesthesia Once as a Baby Does Not Cause Learning Disabilities, New Research Shows”¹. The article unveiled the results of a randomly controlled trial that compared neural development between infants that were exposed to anesthesia, and the control cohort of infants who had no such exposure. This study conclusively found that there were no significant neurodevelopment differences among the cohort. In producing such results, the New York Times contributed to a larger debate in the surgical and anesthesia services community on the use of pediatric anesthesia. Over the past decade, multiple conflicting reports have emerged regarding the effects of administering anesthesia to pediatric patients on neurological development. The topic is oft-debated in the academic literature. A brief summary of important research to-date is useful for evaluating this question and deciding treatment plans for the pediatric population.

The theory suggesting that pediatric anesthesia administration could potentially impart negative effects on patients was early introduced on by results from animal studies. In 2003, Dr. Jevtovic-Todorovic and her research team discovered that exposure to nitrous oxide, isoflurane, and midazolam led to significant neurodevelopmental effects in neonatal rats². In this study, the exposure to anesthesia agents was designed to mimic that of percentages utilized in surgery. Furthermore, the length of exposure similarly matched an average surgery, approximately 6 hours, in order to include time as a relevant factor. The results revealed that the neonatal rats exposed to anesthesia suffered apoptotic neurodegeneration, impaired memory and learning, and a decrease in hippocampal function. These specific and impactful results served as a cause for concern, as animal models often preempt human subjects’ trials. The result of this animal study therefore spurred debate among the anesthesiology and surgical academic fields as to the relevance of the results, as well as the possible mechanisms by which these effects occur.

Of note, Block et al revealed in a 2012 study that early exposure to anesthesia, defined in this study as before one year of age, results in a significant decrease of white matter in the brain³. The longitudinal study followed two cohorts, the anesthesia exposure cohort and the control, recording intellectual capability as measured by academic achievement over a decade. The study subjects also underwent significant neuro-imaging, including MRI. In this study, subjects who had anesthesia as infants reported a 4% decrease in white matter content compared to the control. For reference, white matter is linked with neural communications, as well as learning and neuronal function⁴.

In the same wave that academic research commenced a focus on these topics, national healthcare policy similarly followed suit. The U.S. Food and Drug Administration (FDA) has released multiple bulletins detailing that the agency warned against administering anesthesia to patients less than three years of age⁵. If anesthesia is necessary, the FDA recommended that the procedure be less than three hours in totality. These guidelines were readily adopted in multiple healthcare institutions across the States, according to FDA data.

However, in recent years, human subject studies have provided results in contrast with earlier research on this topic, thus suggesting that previous results may have been based on confounding factors. The Mayo Anesthesia Safety in Kids study, results published in 2018, compared three cohorts of pediatric patients and followed the subjects for up to 20 years post-exposure⁶. The cohorts included control of unexposed patients, patients who were exposed to anesthesia once, and patients who were exposed to anesthesia multiple times. The results showed that exposure of anesthesia before 3 years of age was not associated with negative impacts with regards to IQ and neuropsychological assessment. These results were supported by a recent large-scale study, which examined the effect of anesthesia exposure for more than 10,000 study subjects over time and found that exposure to anesthesia was not associated with any neurocognitive deficits⁷. Therefore, current studies clearly suggest that the previous links to neurological defects are not indicative of causality and are likely due to confounding or external biological and environmental factors.

Researchers in the anesthesia and surgical space will continue to study pediatric anesthesia and its specific effects until the advent of a clinically accepted definition. However, the recent press attributed to this topic underscores the importance of focusing clinical care on pediatric and other vulnerable populations, for anesthesia providers, researchers, and policy-makers alike.

1 Klass, Perri. “Having Anesthesia Once as a Baby Does Not Cause Learning Disabilities, New Research Shows.” The New York Times, The New York Times, 18 Feb. 2019, www.nytimes.com/2019/02/18/well/family/one-exposure-to-anesthesia-in-children-does-not-cause-learning-disabilities-new-research-shows.html.

2 Jevtovic-Todorovic, V, et al. “Early Exposure to Common Anesthetic Agents Causes Widespread Neurodegeneration in the Developing Rat Brain and Persistent Learning Deficits.” Journal of Neurosurgical Anesthesiology, vol. 15, no. 3, 1 Feb. 2003, pp. 295–296., doi:10.1097/00008506-200307000-00029.

3 Block, Robert I., et al. “Are Anesthesia and Surgery During Infancy Associated With Altered Academic Performance During Childhood?” Survey of Anesthesiology, vol. 57, no. 2, 2013, p. 80., doi:10.1097/sa.0b013e318287d938.

4 U.S. National Library of Medicine. “White Matter of the Brain: MedlinePlus Medical Encyclopedia.” MedlinePlus, U.S. National Library of Medicine, medlineplus.gov/ency/article/002344.htm.

5 Center for Drug Evaluation and Research. “Drug Safety and Availability – FDA Drug Safety Communication: FDA Review Results in New Warnings about Using General Anesthetics and Sedation Drugs in Young Children and Pregnant Women.” U S Food and Drug Administration Home Page, Center for Drug Evaluation and Research, www.fda.gov/drugs/drugsafety/ucm532356.htm.

6 Warner, David O, et al. “Neuropsychological and Behavioral Outcomes after Exposure of Young Children to Procedures Requiring General Anesthesia: The Mayo Anesthesia Safety in Kids (MASK) Study.” Anesthesiology, U.S. National Library of Medicine, July 2018, www.ncbi.nlm.nih.gov/pubmed/29672337.

7 O’Leary, James D., et al. “Influence of Surgical Procedures and General Anesthesia on Child Development Before Primary School Entry Among Matched Sibling Pairs.” JAMA Pediatrics, vol. 173, no. 1, 2019, p. 29., doi:10.1001/jamapediatrics.2018.3662.

In October 2017, the Department of Health and Human Services officially declared that the opioid crisis constituted a nationwide public health emergency¹. The recent recognition of ubiquitous over-prescription of opioids from physicians and policy-makers concurs with this statement. Opioid monotherapy may be considered the standard of care at multiple healthcare institutions given its high magnitude analgesic qualities. However, as noted in the public health emergency declaration, opioid monotherapy is associated with several adverse effects, from respiratory depression to delirium, that may impede post-operative recovery. In response to this scenario, it is introduced that multi-modal pain regimens may affect post-operative pain control for patients, serving as an alternative solution.

Multi-modal pain regimens, also known as multi-modal analgesia, are comprised of two or more pain relief treatments administered simultaneously. The treatments may be pharmacologic agents, such as opioids, anticonvulsants, and benzodiazepines, or non-pharmacologic treatments such as applied heat or ice, massage, or electroanalgesia². In a broad sense, the appropriate multi-modal pain regimen is decided by anesthesiologists, surgeons and other perioperative physicians. It may vary depending on the patient’s health history and the specific surgical operation’s outcomes. Furthermore, a multi-modal approach is endorsed by leaders in anesthesia and pain management. The American Pain Society published a set of guidelines for post-surgical pain management, including dedicated algorithms for a multi-modal approach³. The Society specifically determined that acetaminophen and/or non-steroidal anti-inflammatory drugs should be included as part of a multi-modal approach. This set of guidelines was further endorsed by the American Society for Regional Anesthesia, a professional society for clinicians and researchers. Multi-modal treatments will range in terms of the combinations of treatments, and effective algorithms continue to be studied.

Recently, research has suggested that a multi-modal analgesia approach delivered to women undergoing Cesarean section (C-section) has a significant effect on patient post-operative opioid use, as well as length of stay. Maternal and pregnant populations are oft understudied in academic medical research, particularly in cases of sensitive anesthesia and pain management services. To respond to this gap in the literature, researchers from the University of Illinois Hospital and Health Sciences System developed a multi-modal approach for C-section mothers⁴. In the intervention cohort, mothers were administered a combination of ketorolac, gabapentin, and/or acetaminophen medications depending on the patient’s pain designation score. A small subset of patients who reported significantly higher pain scores were treated with an opioid in combination with other drugs. The control was conventional care opioid prescriptions. In the study, the intervention cohort reported a greater than 50% decrease in number of opioid tablets prescribed at discharge. For reference, 89% of control patients were prescribed opioids at discharge, compared to 32.5% of intervention cohort patients. In addition, the intervention cohort reported a decrease in length of stay, which implies positive connotations towards the patient’s recovery. Long-term effects of the patients in this study will continue to be studied, yet the current results point to a promising future of non-opioid or minimized opioid multi-modal regimens for post-C-section patients.

Developing research-supported, modern regimens to treat patients remains a high priority for clinicians and scientists in anesthesia and pain management. Multi-modal analgesia represents a significant opportunity to improve post-operative acute care in sensitive populations, further contributing to clinical efficacy as well as public health.

1. U.S. Department of Health and Human Services. “HHS Acting Secretary Declares Public Health Emergency to Address National Opioid Crisis.” HHS.gov, US Department of Health and Human Services, 23 May 2018, www.hhs.gov/about/news/2017/10/26/hhs-acting-secretary-declares-public-health-emergency-address-national-opioid-crisis.html.

2. Helander, Erik M., et al. “Multi-modal Analgesia, Current Concepts, and Acute Pain Considerations.” Current Pain and Headache Reports, vol. 21, no. 1, 2017, doi:10.1007/s11916-017-0607-y.

3. Chou R, Gordon DB, de Leon-Casasola, et al. Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016;17:131-157.

4. Khudeira, Zahra. “Use of Multi-modal Analgesia in Women Post-Cesarean Section: From Innovation to Bedside.” ICHP: Journal of the Illinois Council of Health-System , vol. 44, no. 08, 2018.