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Surgical Team Interventions

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Anesthesiologists and Certified Registered Nurse Anesthetists (CRNAs) are important contributors to success in the operating room (OR). However, novel changes in healthcare delivery in the United States are modifying the ways in which anesthesia professionals contribute to the operating room team. As a result of an increased emphasis on surgical outcomes, medical management experts recommend several team training intervention programs to increase efficiency and quality of care in the O.R. Across the literature, team training interventions in the OR are implemented via impactful changes in the practices of information technology systems and non-technical skills acquisition. The following article will describe recent developments in these arenas, while suggesting the path forward in reference to the role of anesthesia medical professionals.

Anesthesia Information Management Systems (AIMS) are a specialized form of technology that allow anesthesiologists and CRNAs to track, monitor, and gauge the administration of and effect from anesthesia throughout the perioperative cycle. The most typical form of AIMS is a software or hardware addition to the normal electronic medical records (EMR) system. AIMS can integrate information from multiple streams, led by the anesthesiologist, at multiple time points throughout the operative journey. Moreover, during surgery, most sophisticated AIMS can adapt to real-time changes in order to allow the anesthesiologist and surgeon to focus less on vital signs and more on the patient, allowing for greater capacity for decision-making. AIMS also formulate intensely accurate records of administered medications throughout the surgery, which is useful for post-operative billing, inventory, and reimbursement processes. In this way, AIMS increases the availability of historical records for surgeries, both fulfilling insurance reimbursement requirements and post-operative recovery. Changes with AIMS have sought to integrate the technologies as a team training intervention. A recently published study examined the impact of linking AIMS with the operating room data management system. The authors found that increasing access to AIMS data to non-anesthesia medical professions in the OR reference increased the utilization and accuracy of anesthesia data. In addition, the intersection of AIMS and operating room data management systems allow practitioners to refer back to focused data, aiding in the realms of retrospective and clinical research.

 

Team training interventions can also take the form of non-technical skills acquisition. In 2017, the Journal of Patient Safety published a paper which explored the effects of a brief team training intervention on the care teams’ observed NOTSS score, or nontechnical skills in surgery score. The researchers sought to find a potential solution to address the statistic that nearly 60% of adverse events that occur during surgery are the result of less than optimal teamwork and communication. So, the researchers devised an intervention. The study was designed as a pre-test, post-test interrupted time series design that had repeated measures analysis to evaluate presence and strength of longitudinal changes in surgical team members’ NOTSS score. The intervention was executed in a large tertiary hospital with over twenty operating rooms to attain a strong statistical power. The team training program involved a narrative training DVD with live follow-up. In the end, the researchers found a strong post-test rise in NOTSS score among intervention recipients, increasing confidence in the team training intervention program. Future studies will validate the use of this specific form of team training, while recognizing the context for different anesthesia and surgical professionals.

Anesthesiologists and CRNAs have a vital role to play in the evolution of surgical teams in the OR. As cornerstones of the surgical experience, anesthesia practitioners are valuable candidates for leadership in terms of patient advocacy alongside intra-practitioner communication and unity. As research into optimal ways to improve operational excellence in the OR continues, anesthesia management companies, anesthesiologists, and CRNAs can emerge as leaders in the journey for excellence and accurate patient care.

 

 

Sources

  1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3387486/
  2. https://www.ncbi.nlm.nih.gov/pubmed/29596094
  3. https://journals.lww.com/journalpatientsafety/Abstract/publishahead/Effects_of_a_Brief_Team_Training_Program_on.99504.aspx

Anesthesia Provider Shortage in the United States: A Case Study

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In June 2018, the Department of Veterans Affairs Office of Inspector General released a report detailing the VA Health Administration’s Occupational Staffing Shortages. The report describes the current state of VA Medical Centers across the United States, including self-reported disparities in staffing from the clinical and non-clinical perspectives. In addition, the report proposes to prioritize a standard medical center staffing model at the national level, with variance to compensate for diversity of individual centers at the local level. While staffing needs differed among centers, a central theme emerged throughout the report: there is a severe shortage of anesthesiologists across over 20% of the Veterans Health Administration facilities.

The importance of this statement cannot be further pronounced. As a preeminent model for providing healthcare for those who served for their country, the VA Health System is a critical healthcare institution in the United States. The VA provides not only primary care, but also ancillary healthcare services such as prescription refills, mental health treatment, and minor procedures. In addition, many VA facilities are licensed to perform operative procedures, ranging from basic outpatient procedures to advanced surgeries. In these facilities, which are often located in major urban areas with a high patient volume, anesthesiologists and Certified Registered Nurse Anesthetists (CRNAs) are essential.

Anesthesia  professional societies and Veterans Affairs advocacy groups alike agree that pushing for more anesthesia providers in VA hospitals is essential for providing comprehensive, specialist care. However, the policies surrounding anesthesiology are delineated and historic. In many hospitals and health centers across the United States, CRNAs are considered as highly skilled anesthesia professionals that can effectively manage the entire perioperative patient care episode. Despite the evolution of thought towards provider expertise, the VA has not yet aligned with this trend. In 2016, the VA released a policy change stating that advanced practice registered nurses would be granted full access — however, CRNAs were excluded from this ruling. The nurse subsets that were included in the full practice policy change were as follows: certified nurse practitioners (CNPs), certified nurse-midwives (CNMs), and clinical nurse specialists (CNSs). Upon inquiry as to why CRNAs were not included in the policy change, the VA responded that there was not an unmet need for anesthesiology providers in their hospitals – a discussion point that is in contradiction with the recent occupational staffing reports.

The shortage of anesthesia providers is not a problem isolated to the VA. In 2010, RAND Corporation released a study predicting that the U.S. would experience a shortage of anesthesiologists by 2020 in the magnitude of tens of thousands. National news outlets and the Xenon Health blog have reported previously on the shortage of anesthesia drugs nationwide. Logically, the question arises of a potential solution to such issues. CRNAs can pose as an answer to the question of burgeoning demands for anesthesia providers. As specialized nurses, CRNAs are highly trained to manage anesthesia needs throughout the perioperative cycle. Alongside anesthesiologists, CRNAs can serve as a valuable resource for patients and fellow clinical members of the operative team, guiding care to lead patients toward the best clinical outcomes. Whether in the VA, on a national scale, or hospital-by-hospital, the need for anesthesia providers, inclusive of both anesthesiologists and CRNAs, is evident in the U.S. healthcare system.

 

Sources:

  1. https://www.va.gov/oig/pubs/VAOIG-18-01693-196.pdf
  2. https://www.aana.com/news/news-detail/2018/06/15/aana-to-vha-now-is-the-time-to-grant-crnas-full-practice-authority
  3. https://patientengagementhit.com/news/nurses-call-for-expanded-scope-of-practice-to-fill-va-care-gaps

 

 

Anesthesia for the Parturient with Pre-eclampsia

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Expectant mothers can rejoice in knowing that healthcare advances have eradicated many preventable and rare diseases and improved their comfort and care. Last year, an estimated 4.5 million females in the United States conceived and gave birth. [1] Indeed, it has never been easier for a baby to reach the finish line of their term pregnancy, taking their first breath of our worldly air and completing a loving family. However, the bodily changes that accompany pregnancy are much the same regardless of the era in which we live.  The heart must pump blood for two, and the mother’s circulatory system must adjust to share blood and oxygen to the fetus. In turn, many changes in blood pressure can occur during pregnancy, and monitoring and follow-up for obvious blood pressure abnormalities is indicated over and above routine pre-natal care.

In 3-8% of pregnancies, some women may present with severe hypertension, or very high blood pressure (systolic blood pressure > 160 mmHg) along with significant amounts of protein in the urine. These findings are characteristics of pre-eclampsia, a disorder that typically presents in the third trimester and is due to compromised blood flow from the placenta to the developing baby. While some may report “frothy” urine after using the bathroom, it may also catch the obstetrician’s eye after providing a urine sample during routine prenatal visits. Headaches and edema, which is fluid accumulation in the legs and hands, are non-specific symptoms reported during pregnancy. However, they may be worse in patients with pre-eclampsia. In 10% of patients with poorly managed pre-eclampsia, seizures may occur around the time of labor, requiring continuous monitoring to prevent further harm to the baby. [2]

Anesthesia for pregnant womenAs an anesthesiologist, I am often asked by my pre-eclamptic patients approaching their due date about the available choices for pain control during labor. It is a valid question, considering that either an epidural approach for labor or spinal approach for cesarean section (“C-Section”) will itself affect (i.e. decrease) blood pressure. Other similar options are available for pre-eclamptic patients. If you are a patient with pre-eclampsia, please make sure to discuss the following items with your anesthesiologist ahead of time.

  1. Hydration – Your anesthesiologist will mention that you will need extra fluids prior to receiving an epidural or spinal. Hydration is decreased in pre-eclamptic patients, and you will need a “bolus” or continuous infusion of fluid through an IV ahead of time.
  2. Blood profile – A nurse will draw a sample of your blood to send off to the lab to check the levels of electrolytes, blood cells, and platelets (specialized cells that help to form a clot and stop bleeding). This level is low and can further decrease around the time of labor, thereby increasing the risk of bleeding with epidural procedures and complicating anesthetic management. Levels and function of our clotting system are also measured during this study. Your doctor may order for extra platelets or other related products if your levels are too low.
  3. Seizure prevention – Your obstetrician may administer magnesium around the time of labor to prevent seizures. This requires a planned hospitalization during the routine monitoring of magnesium levels.
  4. Blood pressure control – Pre-eclamptic patients are given medications to control their blood pressure while maintaining blood flow via the placenta. A beta-blocker (labetalol) and smooth muscle relaxant (hydralazine) have been thoroughly studied. However, your obstetrician and healthcare team monitoring your blood pressure can provide you with individualized treatment and monitoring plans after a diagnosis has been established.

Because of these considerations, many pre-eclamptic patients will receive their labor care, and even pre-natal care, at a hospital or center specializing in patients with similar hypertensive or other pregnancy-related disorders.

 

REFERENCES

  1. Curtin SC, Abma JC, Ventura SJ, Henshaw SK. Pregnancy rates for U.S. women continue to drop. NCHS data brief, no 136. Hyattsville, MD: National Center for Health Statistics. 2013.
  2. Ronsmans C, Graham WJ on behalf of the Lancet Maternal Survival Series steering group, “Maternal mortality; who, when, where and why.” The Lancet, Maternal Survival, September 2006.

 

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Machine Learning in Healthcare

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By Haroon Chaudhry MD

President and CEO, Xenon Health

The expansion of electronic health care records across hospitals and hospital systems, other healthcare institutions and physician offices has created a substantially large set of data that can be used to streamline healthcare delivery and improve patient outcomes. Machine learning involves computer pattern recognition of data sets and utilization of previous computations to produce dependable decisions. In other words, the computer learns without being programmed to perform specific tasks. Machine learning can be leveraged in a variety of settings in healthcare to assist or improve decision making.

Natural language processing, or NLP, is the manipulation of human language, including text, by software. Deep learning applications attempt to simulate neuronal activity of the human brain and recognize digital representations of images, sound and other information. Deep learning is being utilized to mine semantic interactions of radiologic images and reports from PACS, or picture archiving and communication systems. One study utilized natural language processing to mine 200,000 images and match them with their descriptions in automated fashion. Semantic diagnostic knowledge can be derived by mapping patterns between radiologists’ text reports and their related images. The objective would be to extract and associate radiologic images with clinically semantic labels via interleaved text/image data mining and deep learning on PACS databases. Due to the enormous collection of radio