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STUDY OBJECTIVE: Physician-led multidisciplinary care coordination decreases hospital-associated care needs. We aimed to determine whether such care coordination can show benefits through the posthospital discharge period for elective hip surgery. DESIGN: Time Series of prospectively recorded and historical data. SETTING: Academic tertiary care medical center and health system. PATIENTS: 449 patients undergoing elective primary hip surgery. INTERVENTIONS: For the intervention group we redesigned care with a comprehensive 14-16 week multidisciplinary standardized clinical pathway, the Ochsner hip arthroplasty perioperative surgical home (PSH). Essential pathway components were preoperative medical risk assessment, frailty scoring, home assessment, education and expectation setting. Collaborative team-based care, rigorous application of perioperative milestones, and proactive postoperative care coordination were key elements. MEASUREMENTS: The intervention group was compared to historical controls with regard to demographics, risk factors, quality metrics, resource utilization and discharge disposition, the primary outcomes were hospital length of stay and postacute facility utilization. MAIN RESULTS: Compared to historical controls, the intervention group had similar risk factors and the same or better quality outcomes. It had less combined skilled nursing facility (SNF) and inpatient rehabilitation facility (IRF) utilization compared to controls (16.5% vs. 27.5%). More intervention patients were discharged with home self-care compared to historical controls (10.7% vs 5.3%). During the intervention period combined SNF/IRF utilization decreased substantially from 19.8% early on, to 13.2% during a later phase. Intervention patients had fewer hospital days compared to historical controls (1.86 vs 3.34 days, respectively; P < 0.0001). CONCLUSIONS: A perioperative population management oriented care model redesign was effective in decreasing hospital days and postacute facility-based care utilization, while quality metrics were maintained or improved.
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Artroplastia de Reemplazo de Cadera , Atención Subaguda , Hospitales , Humanos , Tiempo de Internación , Alta del Paciente , Mejoramiento de la Calidad , Instituciones de Cuidados Especializados de EnfermeríaAsunto(s)
COVID-19 , Defensa Civil , Continuidad de la Atención al Paciente/normas , Insuficiencia Cardíaca , Capacidad de Camas en Hospitales , Manejo de Atención al Paciente , COVID-19/epidemiología , COVID-19/prevención & control , Defensa Civil/métodos , Defensa Civil/organización & administración , Insuficiencia Cardíaca/epidemiología , Insuficiencia Cardíaca/terapia , Trasplante de Corazón , Corazón Auxiliar , Humanos , Colaboración Intersectorial , Manejo de Atención al Paciente/métodos , Manejo de Atención al Paciente/organización & administración , Guías de Práctica Clínica como Asunto , SARS-CoV-2 , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: The Foundation for Anesthesia Education and Research Medical Student Anesthesia Research Fellowship (MSARF) program is an 8-week program that pairs medical students with anesthesiologists performing anesthesia-related research. This study evaluated the proportion of students who published an article from their work, as well as the percentage of students who entered anesthesiology residency programs. METHODS: A list of previous MSARF participants (2005 to 2012), site, and project information was obtained. Searches for publications were performed using PubMed. The primary outcome was the publication rate for MSARF projects. The MSARF abstract-to-publication ratio was compared with the percentage of abstracts presented at biomedical meetings that resulted in publication as estimated by a Cochrane review (44%). For students who had graduated from medical school, match lists from the students' medical schools were reviewed for specialty choice. RESULTS: Forty-two percent of the 346 MSARF projects were subsequently published. There was no difference between the MSARF abstract-to-publication ratio and the publication rate of articles from abstracts presented at scientific meetings (P = 0.57). Thirty percent (n = 105; 95% CI, 25 to 35%) of all the MSARF students were authors on a publication. Fifty-eight percent of the students for whom residency match data (n = 255) were available matched into anesthesiology residencies (95% CI, 52 to 64%). CONCLUSIONS: The MSARF program resulted in many students being included as a co-author on a published article; the majority of these students entered anesthesiology residency programs. Future research should determine whether the program has a long-term impact on the development of academic anesthesiologists.
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Anestesiología/educación , Investigación Biomédica , Selección de Profesión , Becas , Fundaciones , Estudiantes de Medicina , Adulto , Femenino , Humanos , Internado y Residencia , Masculino , Edición , Adulto JovenRESUMEN
BACKGROUND: Anesthesiology is among the medical specialties expected to have physician shortage. With little known about older anesthesiologists' work effort and retirement decision making, the American Society of Anesthesiologists participated in a 2006 national survey of physicians aged 50-79 yr. METHODS: Samples of anesthesiologists and other specialists completed a survey of work activities, professional satisfaction, self-defined health and financial status, retirement plans and perspectives, and demographics. A complex survey design enabled adjustments for sampling and response-rate biases so that respondents' characteristics resembled those in the American Medical Association Physician Masterfile. Retirement decision making was modeled with multivariable ordinal logistic regression. Life-table analysis provided a forecast of likely clinical workforce trends over an ensuing 30 yr. RESULTS: Anesthesiologists (N = 3,222; response rate = 37%) reported a mean work week of 49.4 h and a mean retirement age of 62.7 yr, both values similar to those of other older physicians. Work week decreased with age, and part-time work increased. Women worked a shorter work week (mean, 47.9 vs. 49.7 h, P = 0.024), partly due to greater part-time work (20.2 vs. 13.1%, P value less than 0.001). Relative importance of factors reported among those leaving patient care differed by age cohort, subspecialty, and work status. Poor health was cited by 64% of anesthesiologists retiring in their 50s as compared with 43% of those retiring later (P = 0.039). CONCLUSIONS: This survey lends support for greater attention to potentially modifiable factors, such as workplace wellness and professional satisfaction, to prevent premature retirement. The growing trend in part-time work deserves further study.
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Anestesiología/tendencias , Toma de Decisiones , Fuerza Laboral en Salud/tendencias , Médicos/tendencias , Jubilación/tendencias , Factores de Edad , Anciano , Estudios de Cohortes , Estudios Transversales , Recolección de Datos/métodos , Femenino , Humanos , Satisfacción en el Trabajo , Masculino , Persona de Mediana Edad , Estados UnidosRESUMEN
An array of clinical events may lead to perioperative neurological injury. We first review the general cellular mechanisms leading to brain tissue injury and death. The genesis and mechanisms of injury after cerebral aneurysm surgery, traumatic brain injury, postoperative vascular insult in patients with severe cerebrovascular disease are discussed, as are strategies for prevention and treatment. More has become known about the epidemiology, risk factors and potential preventive strategies in postoperative delirium, and, to a lesser extent, postoperative cognitive dysfunction. Finally, emerging concepts in clinical brain protection are discussed, including preconditioning, gene therapy and stem cells.
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Lesiones Encefálicas/patología , Encéfalo/patología , Trastornos Cerebrovasculares/patología , Procedimientos Neuroquirúrgicos/efectos adversos , Complicaciones Posoperatorias/patología , Animales , Lesiones Encefálicas/etiología , Lesiones Encefálicas/genética , Lesiones Encefálicas/mortalidad , Lesiones Encefálicas/prevención & control , Lesiones Encefálicas/psicología , Muerte Celular , Trastornos Cerebrovasculares/etiología , Trastornos Cerebrovasculares/genética , Trastornos Cerebrovasculares/mortalidad , Trastornos Cerebrovasculares/prevención & control , Trastornos Cerebrovasculares/psicología , Trastornos del Conocimiento/etiología , Trastornos del Conocimiento/patología , Trastornos del Conocimiento/psicología , Delirio/etiología , Delirio/patología , Delirio/psicología , Terapia Genética , Humanos , Hipoxia-Isquemia Encefálica/etiología , Hipoxia-Isquemia Encefálica/patología , Fármacos Neuroprotectores/uso terapéutico , Periodo Perioperatorio , Complicaciones Posoperatorias/genética , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/prevención & control , Trasplante de Células MadreRESUMEN
The purpose of this review is to present a comprehensive assessment of the anesthesia workforce during the past decade and attempt forecasting the future based on present knowledge. The supply of anesthesiologists has gradually recovered from a deficit in the mid to late 1990 s. Current entry rates into our specialty are the highest in more than a decade, but are still below the level they were in 1993. These factors along with slower surgical growth and less capital available for expanding anesthetizing locations have resulted in greater availability of anesthesiologists in the labor market. Despite these recent events, the intermediate-term outlook of a rapidly aging population and greater access of previously uninsured patients portends the need to accommodate increasing medical and surgical procedures requiring anesthesia, barring disruptive industry innovations. Late in the decade, nationwide surveys found shortages of anesthesiologists and certified registered nurse anesthetists to persist. In response to increasing training program output with stagnant surgical growth, compensation increases for these allied health professionals have moderated in the present. Future projections anticipate increased personnel availability and, possibly, less compensation for this group. It is important to understand that many of the factors constraining current demand for anesthesia personnel are temporary. Anesthesiologist supply constrained by small graduation growth combined with generation- and gender-based decrements in workforce contribution is unlikely to keep pace with the substantial population and public policy-generated growth in demand for service, even in the face of productivity improvements and innovation.
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Anestesiología , Personal de Salud , Necesidades y Demandas de Servicios de Salud , Fuerza Laboral en Salud , Anestesiología/historia , Anestesiología/tendencias , Selección de Profesión , Predicción , Personal de Salud/historia , Personal de Salud/tendencias , Accesibilidad a los Servicios de Salud/historia , Accesibilidad a los Servicios de Salud/tendencias , Necesidades y Demandas de Servicios de Salud/historia , Necesidades y Demandas de Servicios de Salud/tendencias , Fuerza Laboral en Salud/historia , Fuerza Laboral en Salud/tendencias , Historia del Siglo XXI , Humanos , Enfermeras Anestesistas/historia , Enfermeras Anestesistas/provisión & distribución , Enfermeras Anestesistas/tendencias , Asistentes Médicos/historia , Asistentes Médicos/provisión & distribución , Asistentes Médicos/tendencias , Estados UnidosRESUMEN
BACKGROUND: The bare metal self-expanding Wingspan stent (Boston Scientific, Natick, MA) was approved by the Food and Drug Administration under the Humanitarian Device Exemption in August 2005 for patients with intracranial atherosclerotic disease (ICAD) who are refractory to medical therapy. Relatively low rates of periprocedural morbidity and mortality have been reported. METHODS: After receiving institutional review board approval, we conducted a retrospective chart review to examine the anesthetic management and perioperative mortality and morbidity for all Wingspan stent insertions performed at our institution from 2005 to 2007. RESULTS: A total of 72 patients with a history of intracranial stenosis had angioplasty and Wingspan stent insertion: 34 male and 38 female, with an average age of 64 ± 11.6 years. Preoperative systolic blood pressure was 200 ± 45 mmHg, and diastolic blood pressure was 100 ± 23 mmHg. All patients received general anesthesia for stent insertion. Five patients died (6.9%), 4 had perioperative stroke (5.5%), and 9 had recurrent stenosis (12.5%). CONCLUSIONS: Anesthetic management for Wingspan stent insertion for ICAD is challenging. Maintenance of hemodynamic stability with optimum brain perfusion during the stent deployment is crucial to patient safety. A prospective study is warranted to assess the optimal anesthetic choice during Wingspan stent insertion.
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BACKGROUND: Opioid-based anesthetic techniques are commonly used during neurosurgical procedures. In the present randomized prospective study, we studied emergence after 4 anesthetic regimens combining intermediate duration opioids with isoflurane and nitrous oxide (N(2)O), in patients undergoing craniotomy for large (> 30 mm diameter with intracranial mass effect) intracranial tumors. METHODS: One hundred seven patients were randomized into 4 groups: Group A: fentanyl (≤ 5 µg/kg) + isoflurane (≤ 1 minimum alveolar concentration [MAC]), Group B: sufentanil (1-2 µg/kg plus infusion) + isoflurane (≤ 0.5 MAC), Group C: sufentanil (2 µg/kg bolus only) + isoflurane (≤ 1 MAC), and Group D: alfentanil (100 µg/kg plus infusion) + isoflurane (≤ 0.5 MAC). Boluses were administered as divided doses during induction, laryngoscopy, head pinning, and incision. Blood pressure was controlled at ±25% of baseline levels. All infusions were discontinued at the start of dural closure. Emergence was assessed using a mini-neurologic examination consisting of 7 questions. Groups were compared on time to emergence using survival analysis methods. RESULTS: The groups did not differ regarding extubation time, which occurred at a median of 4 to 6 minutes across groups after discontinuing N(2)O. The median emergence time ranged from 15 to 22.5 minutes and did not differ among groups. However, across all groups more women had emerged by 30 minutes compared with men (83% vs 57%, P â=â .002). The median emergence time in women was found to be significantly shorter (0-15 minutes) than in men (15-30 minutes) (P â=â .012). CONCLUSIONS: No between-group differences in emergence time were observed; the study was stopped early because of evidence that no differences were likely to be found if the study were continued. However, in a post hoc analysis, female gender was associated with faster emergence.
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INTRODUCTION: Hurricanes Katrina and Rita impacted a large portion of the medical community in Louisiana. We attempt to determine their impact on the anesthesiology workforce in Louisiana. METHODS: In May 2006, a survey was mailed to 368 Louisiana anesthesiologists, collecting demographic data, retirement plans, impact of Hurricanes Katrina and Rita, position vacancies, practice conditions, and the general state of healthcare in their area. All 3 anesthesiology residency programs in the state were contacted regarding their recent graduates. The 2010 RAND survey of the anesthesiology workforce was reviewed with respect to findings relevant to the state and region. RESULTS: One hundred seventy surveys were returned, yielding a 46.2% response rate. Among the respondents, 13.9% intended to retire within 5 years and another 24% in 5 to 10 years. Since 2005, 63.9% had seen an increase in their daily caseload, 46.9% saw an increase in work hours, and 36.8% stated that their practices were trying to hire new anesthesiologists and were having difficulty filling these positions. Since 2005, the number of anesthesiology residents in Louisiana had declined by almost 50%, and the number of graduates remaining to practice in Louisiana had decreased by 43% from 7 to 4 annually. CONCLUSIONS: Our 2006 survey provided qualitative evidence for a shortage of anesthesiologists in the state of Louisiana after the natural disasters in 2005 that was likely to worsen as residency output plummeted, fewer residents stayed in the state, and projected retirement increased. The regional data from the RAND survey a year later confirmed the impressions from our survey, with an estimate of an anesthesiologist shortage as high as 39% of the workforce. State membership surveys may serve as accurate barometers in the wake of major environmental upheavals affecting regional anesthesiology workforce conditions.
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α(2)-Agonists are a novel class of drugs with mechanisms of action that differ from other commonly used anesthetic drugs. They have neuroprotective, cardioprotective, and sedative effects. These unique characteristics make them potentially useful during neuroanesthesia and intensive care. We review the effects of dexmedetomidine on cerebral blood flow and cerebral metabolism, along with recent advances in using α(2)-agonists in neuroanesthesia and neurointensive care.
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BACKGROUND: Hospitals are increasingly required to publicly report outcomes, yet performance is best interpreted in the context of population and procedural risk. We sought to develop a risk-adjustment method using administrative claims data to assess both national-level and hospital-specific performance. METHODS: A total of 35,179,507 patient stay records from 2001-2006 Medicare Provider Analysis and Review (MEDPAR) files were randomly divided into development and validation sets. Risk stratification indices (RSIs) for length of stay and mortality endpoints were derived from aggregate risk associated with individual diagnostic and procedure codes. Performance of RSIs were tested prospectively on the validation database, as well as a single institution registry of 103,324 adult surgical patients, and compared with the Charlson comorbidity index, which was designed to predict 1-yr mortality. The primary outcome was the C statistic indicating the discriminatory power of alternative risk-adjustment methods for prediction of outcome measures. RESULTS: A single risk-stratification model predicted 30-day and 1-yr postdischarge mortality; separate risk-stratification models predicted length of stay and in-hospital mortality. The RSIs performed well on the national dataset (C statistics for median length of stay and 30-day mortality were 0.86 and 0.84). They performed significantly better than the Charlson comorbidity index on the Cleveland Clinic registry for all outcomes. The C statistics for the RSIs and Charlson comorbidity index were 0.89 versus 0.60 for median length of stay, 0.98 versus 0.65 for in-hospital mortality, 0.85 versus 0.76 for 30-day mortality, and 0.83 versus 0.77 for 1-yr mortality. Addition of demographic information only slightly improved performance of the RSI. CONCLUSION: RSI is a broadly applicable and robust system for assessing hospital length of stay and mortality for groups of surgical patients based solely on administrative data.
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Mortalidad Hospitalaria , Tiempo de Internación , Ajuste de Riesgo/métodos , Anciano , Anciano de 80 o más Años , Bases de Datos Factuales/normas , Femenino , Predicción , Hospitalización , Humanos , Masculino , Medicare/normas , Persona de Mediana Edad , Estudios Prospectivos , Distribución Aleatoria , Reproducibilidad de los Resultados , Ajuste de Riesgo/normas , Estados UnidosRESUMEN
Dexmedetomidine, which is a relatively selective alpha2-adrenoceptor agonist, is used for sedation and analgesia in intensive care unit patients, during awake craniotomies in pediatric and adult patients, and during magnetic resonance imaging, with minimal depression of respiratory function. The successful use of dexmedetomidine in a pediatric patient undergoing bilateral deep brain stimulator placement for the treatment of generalized dystonia, is presented.
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Estimulación Encefálica Profunda/métodos , Dexmedetomidina/uso terapéutico , Hipnóticos y Sedantes/uso terapéutico , Niño , Trastornos Distónicos/terapia , Humanos , MasculinoRESUMEN
In North America and Europe, a spectrum of anesthesia personnel exists to deliver anesthesia care. The common transatlantic features, however, are increasing demand for and shortage of anesthesia caregivers. Mechanisms counteracting this shortage include increased entry into practice from higher numbers of anesthesia residents and changes in the delivery of anesthesia care by extension of the role of nonphysician anesthesia providers. The training, professional and technical roles, and workforce contribution of anesthesiologists, anesthetists, and various support personnel in Europe and the United States are described. Current and future factors influencing the relationship between provider availability, use, and demand differ across the Atlantic and within Europe.
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Servicio de Anestesia en Hospital , Anestesiología , Quirófanos , Admisión y Programación de Personal , Factores de Edad , Servicio de Anestesia en Hospital/organización & administración , Anestesiología/educación , Anestesiología/tendencias , Canadá , Europa (Continente) , Humanos , Internado y Residencia , Enfermeras Anestesistas/educación , Enfermeras Anestesistas/provisión & distribución , Asistentes Médicos/provisión & distribución , Rol Profesional , Salarios y Beneficios , Factores Sexuales , Estados Unidos , Recursos Humanos , Carga de TrabajoRESUMEN
BACKGROUND: In neuroanesthesia practice, muscle relaxants may at times need to be avoided to facilitate intraoperative motor pathway monitoring. Our study's objective was to determine the optimal dose of remifentanil required to prevent movement after neurosurgical stimulation. METHODS: After Institutional Review Board approval and written informed consent, 132 patients undergoing elective craniotomy randomly received one of 12 remifentanil dose regimens (0.10 to 0.21 microg/kg/min). Remifentanil was started before induction with propofol and succinylcholine. Anesthesia was maintained with isoflurane (0.6% end-tidal) in air/oxygen. During the study, movement was assessed on predetermined criteria by the anesthesiology, nursing, and neurosurgical teams. Heart rate and blood pressure were recorded every 5 minutes. We assessed the relationship between movement, hypotension, bradycardia, and dose using probit analysis and logistic regression. RESULTS: Sixty-five percent of the patients moved in response to surgical stimuli [95% confidence interval (CI): 49%-79%] at a remifentanil infusion rate of 0.10 microg/kg/min, and movement decreased to 21% (95% CI: 11-35) at 0.21 microg/kg/min. The probability of movement was 50% at an infusion rate (95% CI) of 0.13 (0.10 to 0.15) microg/kg/min remifentanil and decreased to 25% at an infusion rate of 0.19 (0.17 to 0.29) microg/kg/min. The probability of hypotension and bradycardia was 50% at 0.13 (0.10 to 0.15) microg/kg/min and 0.17 (0.15 to 0.21) microg/kg/min, respectively. CONCLUSIONS: Higher doses of remifentanil lessen the risk of movement in the absence of muscle relaxants with surgical stimulation for elective craniotomy. Hypotension and bradycardia were common at higher doses. Even at the maximum dose (0.21 mcg/kg/min) there was a 20% chance of movement. Adjunctive therapy is needed to ablate movement reliably, and to counteract the hypotensive effect of remifentanil. These findings may be helpful for clinicians administering remifentanil and isoflurane during procedures, where muscle relaxants may not be desirable.