In the modern age of healthcare, one’s medical record isn’t merely a set of pages held together in a binder behind the office. Rather’s, a patient’s medical record is a complex set of electronic documents that is comprised of physician appointments, medical exams, testing results, scheduled operations, and operative reports. In the wake of the transition from paper to electronic, medical records have increased in complexity — including the levels of authority at which access is granted. It is important to remember that, ultimately, electronic medical records (EMRs) are centered on providing the highest level of patient care. Physicians, clinicians, researchers, and administrators are granted access to highly sensitive information in order to act in the best interests of the patient, in clinical and non-clinical capacities. However, as patients are navigating the world of patient portals, it is important to recognize which elements about an EMR are most critical for the patient to understand.

The first crucial entity to understand when discussing EMRs is HIPAA. HIPAA, or the Health Insurance Portability and Accountability Act of 1996, is a law that protects individual medical and health information throughout the United States. All healthcare providers and employees of healthcare providers, including clinical and non-clinical professionals, are required to comply with HIPAA. This essentially means that as a patient, one’s medical information must be protected to the highest degree, including encryption, password protection, and the use of anonymization. Patients should be cognizant that HIPAA does not only apply to their physician or nurse — it applies to all staff in the hospital, the third-party vendor that processes images or testing, health insurance companies, and any party that may be privy to a patient’s medical information at any point before, during, or after their clinical episode. HIPAA is built to protect patients from their confidential and sensitive medical information being shared with inappropriate parties. EMRs facilitate higher compliance with HIPAA requirements, and patient protection more broadly, because they can be secured with multiple methods of security. Undoubtedly, the healthcare provider or individual attempting to access a patient’s medical information will have to log-in through a secure server. Depending on the institution, the login may include additional security features, such as two-factor authentication, biometric identification, or VPN requirements. Such actions ensure that your EMR is highly protected and only accessible to the appropriate individuals or parties.

Alongside the security features, EMRs are more conducive to secure sharing amongst institutions. For example, if a patient decides to move healthcare providers or to seek a second opinion at a different institution, historically such a process would be laborious and require either direct mailing or faxing of health information — each of which are non-secure methods. However, with EMR, hospitals and healthcare providers can subscribe to Electronic Health Records, which are comprehensive software systems that allow for sharing amongst the licensed healthcare providers and institution that align. The inclusion of EHRs increases patient engagement in their own clinical journey, as well as the patient’s autonomy to move to the provider that they prefer for treatment.

In the coming years, healthcare technology will continue to improve and manifest itself in greater advantages for patients, providers, and institutions alike. Patients should take heed of such developments, understanding that their medical information is a critical resource in their diagnosis and treatment during clinical episodes, and throughout the rest of their lives.

References:

Agency for Healthcare Research and Quality. “Electronic Medical Record Systems”. US Department of Health and Human Services. Web. https://bit.ly/1MWVlUA

Garrett and Seidman. “EMR vs EHR – What is the Difference?”. The Office of the National Coordinator for Health Information Technology. Web. 2011. https://bit.ly/2aqf7PV

Kruse, Clemens Scott et al. “Security Techniques for the Electronic Health Records.” Journal of Medical Systems 41.8 (2017): 127. PMC. Web. 18 Sept. 2018.

Mitral regurgitation is a common valvular pathology that can lead to heart failure, so surgical correction is advised. However, some patients are unable to receive mitral valve surgical repair due to the increased perioperative risk. Percutaneous edge to edge mitral valve repair (PMVR) using the MitraClip system has been demonstrated to be a safe and effective alternative to treat severe mitral regurgitation in these patients. Unlike other percutaneous interventions, such as transcatheter aortic valve replacement (TAVR) that is getting more commonly performed under conscious or deep sedation, most PMVR procedures are currently being performed under general anesthesia. While general anesthesia provides advantages such as guaranteed immobility, ability to give breath holds for challenging anatomic conditions, and control of the airway, disadvantages include greater hemodynamic swings, greater incidence of perioperative hypotension, and increased duration of anesthesia. These disadvantages have been shown to be risk factors for prolonged hospital stay and increased morbidity.

Two European prospective studies were published last year comparing general anesthesia to deep sedation for PMVR. Each consisted of over 200 patients. Patients were not randomized in either study, but in the Patzelt study they were individually evaluated by the cardiology and anesthesia teams regarding suitability for deep sedation (patients selected for general anesthesia may have a more challenging anatomy, for example, which may have benefited from controlled ventilation). The Horn study used its scheduling system to assign patients to either group regardless of patient characteristics, though more patients ended up being in the deep sedation group. Both studies used midazolam and propofol as primary sedatives for the deep sedation group.

Despite significant differences between patient groups in the Patzelt study (general anesthesia patients were younger but tended to have more severe disease and comorbidities, though pulmonary hypertension was more prevalent in the deep sedation group), both studies nevertheless found similar outcomes. There was no difference found between the two groups in terms of procedure success, surgical complications, major cardiac and cerebrovascular events, or postoperative pneumonia. Both studies found advantages to deep sedation, including shorter preparation time in the cath lab and ICU stay duration. The Horn study found longer procedure time and fluoroscopy time for the general anesthesia group, however this may be confounded by baseline patient characteristic differences between the two groups.

These two single institution prospective studies provide encouraging data for the safety of deep sedation for percutaneous mitral valve repair procedures. For eligible patients, it may be worth discussing whether this anesthetic approach may be appropriate.

References:

Horn P, Hellhammer K, Minier M, Stenzel MA, Veulemans V, Rassaf T, Luedike P, Pohl J, Balzer J, Zeus T, Kelm M, Westenfeld R. Deep sedation Vs. general anesthesia in 232 patients undergoing percutaneous mitral valve repair using the MitraClip® system. Catheter Cardiovasc Interv. 2017 Dec 1;90(7):1212-1219.

Patzelt JI, Ulrich M, Magunia H, Sauter R, Droppa M, Jorbenadze R, Becker AS, Walker T, von Bardeleben RS, Grasshoff C, Rosenberger P, Gawaz M, Seizer P, Langer HF. Comparison of Deep Sedation With General Anesthesia in Patients Undergoing Percutaneous Mitral Valve Repair. J Am Heart Assoc. 2017 Dec 2;6(12)

Surgical site infections (SSIs) affect 1-3% of patients within 30 days after surgery.¹ While some infections are superficial and associated with mild irritation and discharge, deeper infections can impair wound healing, causing incisions to re-open and infection to spread. For most surgeries involving a significant skin incision, follow-up visits are typically scheduled within 2 weeks. However, sometimes compliance with follow-up is not perfect, and brewing infections can go unnoticed for a long period of time.

Prior to surgery, the anesthesiologist and surgeon evaluate for conditions that predispose a patient to SSI, including diabetes, cancer, kidney and liver disease, as well as habits including cigarette use, heavy alcohol or intravenous drug use. Longer procedures, especially near the intestines which normally harbor bacteria, can progressively increase the risk of bacterial infection and abscess formation. A risk calculator has been developed (and freely available) to assist surgeons, patients, and families in understanding the risks of major complications after surgical procedures.³

Such infections after surgery require a thorough evaluation (with an assessment for the need for re-operation) and several weeks of antibiotics, contributing significantly to healthcare costs that can exceed $20,000.⁴ For example, SSIs are a cost burden to the healthcare system; it adds more than $20,000 to the patient’s bill and contributes to almost $2 billion in additional healthcare expenditures nationally each year.^4,5 For this reason, anesthesia and perioperative care teams emphasize multiple evidence-based strategies during the pre-operative visit and enforce them during the day of surgery:

– Patient pre-operative instructions:

– Patients are instructed to shower the night before many surgeries using an antiseptic rinse, typically chlorhexidine gluconate.

– Hand-washing:

– Hand hygiene protocols in hospitals call for adequate hand washing and scrubbing in a sub-sterile environment immediately prior to entering the operating room.

– Hand sanitizers are recommended for intermittent use during and after procedures, especially when the anesthesia team goes between different equipment and medications.

– Sterile precautions:

– The anesthesia and operating room management have standardized the use of sterile gloves, autoclaved instruments, and large blue surgical barrier drapes.

– In addition, skin preparation with chlorhexidine (i.e. Chloraprep) or iodine (i.e. Betadine) is mandatory.

– Antibiotic prevention:

– Cefazolin (i.e. Ancef, Kefzol) is given by the anesthesiologist within 30-60 minutes of the anticipated start of surgery to prevent potential infections in the vast majority of procedures involving skin incision. Different antibiotics may be given as “prophylaxis” if the operative team anticipates exposure to specific types of bacteria.

– Wound irrigation and post-operative antibiotics:

– The surgeon will thoroughly explore for any potential debris and instill irrigation fluid prior to closing the surgical incision.

– Patients with a compromised immune system and those deemed to already have a severe infection will be continued on antibiotics after surgery, sometimes receiving multiple doses a day through an intravenous catheter for several weeks.

REFERENCES

1. Klevens, R.M., Edwards, J.R., Richards, C.L. Jr., Horan, T.C., Gaynes, R.P., Pollock, D.A. et al. Estimating health care-associated infections and deaths in US hospitals, 2002. Public Health Rep. 2007;122:160–166.
2. Razavi SM, Ibrahimpoor M, Sabouri Kashani A, Jafarian A. Abdominal surgical site infections: incidence and risk factors at an Iranian teaching hospital. BMC Surgery. 2005;5:2
3.  Walraven C, Musselman R (2013) The Surgical Site Infection Risk Score (SSIRS): A Model to Predict the Risk of Surgical Site Infections. PLOS ONE 8(6): e67167.
4. Reichman DE, Greenberg JA. Reducing Surgical Site Infections: A Review. Rev Obstet and Gynecol. 2009;2(4):212-221.
5.  Lissovoy G, Fraeman K, Hutchins V, Murphy D, Song D, Vaugn BB. Surgical site infection: incidence and impact on hospital utilization and treatment costs. Am J Infect Control. 2009 Jun;37(5):387-397.

In July 2018, the American Society of Regional Anesthesia and Pain Medicine (ASRA), American Academy of Pain Medicine (AAPM), and American Society of Anesthesiologists (ASA) released the groundbreaking consensus guidelines for the use of IV ketamine in acute pain cases. Ketamine is an NDMA receptor antagonist that has a strong anesthetic effect. In 1970, it was approved for use in humans in the United States. Since then, it has been utilized in operating rooms for both adult and children, as well as battlefields. It has gained prominence in medical literature over time as clinicians have explored its use for a variety of conditions such as treatment-resistant major depressive disorder (MDD), mood disorders, and post-traumatic stress disorder (PTSD). Evidence suggests that in small doses, ketamine can improve the symptoms of patients suffering from depressive disorders by affecting the glutamate neurotransmitter system.

Anesthesiologists, certified registered nurse anesthetists (CRNAs), and pain clinicians across the United States have increasingly started to administer ketamine to patients with acute and chronic pain. Given its safety, efficacy, and limited side effect profile, ketamine can serve as an effective drug for pain management.

Several major professional societies in the United States jointly developed guidelines for administering ketamine. In the guidelines published by the Regional Anesthesia and Pain Medicine journal, physician investigators outlined acceptable uses for IV ketamine. A group of patients undergoing invasive surgery might have an expected high level of pain post-operatively; according to the authors, they are good candidates for ketamine. In addition, the authors recommended that physicians consider patients who have tolerance or sensitivity/dependence to opioids as candidates for IV ketamine. The authors also identified several specific patient subgroups that could benefit from ketamine. These include patients with sickle cell disease, obstructive sleep apnea, and those with the potential for opioid-related respiratory depression. For each segment, the guidelines recommend specific dosing protocols.

Anesthesia providers should consider incorporating IV ketamine into their current practice based on the recommended indications.

As technological advances ensue in the medical field, medical specialists continue to improve upon historical processes for delivering healthcare. For anesthesiologists, issues around access and delivery of essential medications are critical to the discussion of innovation. In many medical centers across the nation, the vial-and-syringe technique is predominant in the operating room. In this method, anesthesiologists or clinically-trained Certified Registered Nurse Anesthetists (CRNAs) carefully transfer the assigned and coded medications from the vial, or a large quantity manufacturer container, to the syringe, a small unit of medication that is then administered directly to the patient. However, inherent in this process is a degree of waste. Along with medical waste, there is also an economic impact to the system. Underscoring each of these items is an effect on resource utilization at the hospital level, elucidating the argument for anesthesia professionals to transition from a vial to a pre-filled syringes system of care delivery.

To commence, the historical utilization of vials over syringes results in direct medical waste, impacting the patient, practitioner, and hospital. Upon transferring the medication from the vial to the syringe, often the entire quantity of medication in the vial does not divide evenly among the syringe. Thus, for each vial that is transferred to one or multiple syringes, a small amount of the medication is then left in the vial and disposed as biomedical waste. Medical waste impacts the patient because it requires a greater number of vials for the same net value of medication, resulting in a higher ratio of medical waste to patient. For the practitioner, the use of vials to syringes also has an effect on time. The anesthesiologist must include the conversion as an item on his or her roster of tasks, while the CRNA, nurses, or related operative staff must also ensure this is completed as a line item. Of course, the medical waste to the system is important to note because it reduces the level of efficacy and operative excellence. Rather than the vial-to-syringe method, pre-filled syringes would mitigate the level of waste by promoting a quantity-limited, separate amount of medication per patient and per procedure — allowing anesthesia management to streamline operative processes.

In addition to the operative benefits of reducing medical waste, there is also a strong cost consideration for adhering to pre-filled syringes. This cost impact may be viewed in terms of direct cost, or the dollars allocated to the drug itself, along with the indirect cost, or the number of allocated hours that clinicians devote to preparing medications. Numerous studies have indicated that pre-filled vials reduce the amount of preparation time per vial, while also minimizing the error impact during surgery.

Patient safety is also a strong concern, particularly in critical surgical cases that anesthesia providers may encounter. A study from the Journal of Patient Safety found that pre-filled syringes reduces patient risk, including that of dosage errors and contamination, and it also resulted in a reduction of healthcare practitioner errors, such as needle stick injury. Based on this seminal study, additional case reports, and institution cost-analyses, experts agree that pre-filled syringes are necessary to continue advancing patient care and safety from anesthesiologists and CRNAs perspective.

Moving forward, anesthesiologists, CRNAs, and other anesthesia care professionals should strongly consider pre-filled syringes as a technique to optimize care for all patients across institutions and centers of care.