Our results indicated that the necessity of pain control was higher on POD1 for VATS lobectomy. Both EPCA and IVPCA can provide an adequate, continuous and effective means for postoperative pain management and a lower VAS-M was found in EPCA on POD2.
BACKGROUND: We implemented a previously described barcode-based drug safety system in all of our anesthetizing locations. Providers were instructed to scan the barcode on syringes using our Anesthesia Information Management System before drug administration, but the rate of provider adherence was low. We studied an implementation intervention intended to increase the rate of scanning. METHODS: Using our Anesthesia Information Management System and Smart Anesthesia Manager software, we quantified syringe drug administrations by anesthesia providers with and without barcode scanning. We use an anesthesia team model in which an attending anesthesiologist is paired with a certified registered nurse anesthetist (CRNA) or a resident. Our system identified the pair of providers associated with a particular drug administration, but did not distinguish which providers actually administered the drug. Therefore, the rate of barcode scanning for a particular case was assigned to both providers equally. A baseline rate of scanning was established over a period of 17 months. An audit and feedback intervention was then performed that consisted of monthly performance reports sent by email to individual providers along with coffee gift card awards for top performers. The coffee gift cards were awarded in only the first 2 months of the intervention, while the email performance reports continued on a monthly basis. The coffee card awards were made public. The monthly emails reported the individual provider’s rank order of performance relative to other providers, but was otherwise anonymous. The baseline rate of scanning was compared to the rate of scanning after the intervention for a period of 7 months. RESULTS: From November 2014 to March 2017, we accumulated 60,197 cases performed by 88 attending anesthesiologists, 65 CRNAs, and 148 residents. The total number of syringe drug administrations was 653,355. Average scanning performance improved from 8.7% of syringe barcodes scanned during the baseline period from November 2014 to February 2016 to 64.4% scanned during the period September 2016 to March 2017 (P < .001). Variation in performance among individuals was marked, ranging from 0% to 100% of syringes scanned. The performance of some individuals showed marked oscillation over time. There was greater variation in performance attributable to residents than in performance attributable to CRNAs. CONCLUSIONS: Feedback of individual provider performance data from the anesthesia information system to providers can be used in conjunction with other measures to improve performance. Despite improved average performance, there was marked variation in performance between individuals, and some individuals had marked oscillation of their performance over time.
Background There are no tested in-hospital traumatic brain injury (TBI) care programs. We examined the implementation and effectiveness of the Pediatric Guideline Adherence and Outcomes (PEGASUS) program in severe pediatric TBI. Methods In this prospective hybrid implementation-effectiveness study, we examined service provision, achieving key performance indicator (KPI) adherence, and discharge outcomes in children (age < 18 years) with severe (GCS ≤ 8) TBI (trauma mechanism and imaging findings) associated with the PEGASUS program. Implementation outcomes and achieving KPI adherence are described. Poisson regression with robust standard errors estimate the association between achieving KPI adherence and discharge outcomes. Findings Among the 199 participants 11·9 (12·7) years who received the PEGASUS program between 2011-2017, 193 (97%) program recipients had severe TBI. Adherence to at least one KPI was achieved in 101 (96·2%), and 44 (41·9%) achieved adherence to all three KPIs. Program participants achieved KPI adherence to hypocarbia KPI (72·4%), nutrition KPI (81 ·4%), and cerebral perfusion pressure KPI (64·3%). Adherence to KPI-nutrition was associated with 2·70-fold (95% CI 1·54-4·73) higher discharge survival and 3 05-fold (95% CI 1·52-6·11) more favorable discharge disposition. Adherence to KPI-CPP was also associated with higher discharge survival (RR 1 ·33; 95% CI 1 · 12-1·59) and favorable disposition (RR 1 ·53; 95% CI 1 · 19·1-96). Adherence to each additional KPI was significantly associated with 1·27 (95% CI, 1 · 12-1·44) times higher survival rate and 1·46 (95% CI, 1 ·23-1·72) times higher favorable discharge disposition in a dose-response fashion. Interpretation The new multilevel hospital-wide high fidelity and comprehensive PEGASUS program achieved favorable levels of service provision, KPI adherence and was associated with favorable discharge outcomes across the full spectrum of pediatric patients with severe TBI. Adherence to CPP, nutrition and hypocarbia KPI targets are essential program components and associated with favorable discharge outcomes. The PEGASUS program may benefit children and adolescents hospitalized with severe TBI.
Key Points Question Is end-tidal carbon dioxide (EtCO 2 ) a reliable surrogate for partial pressure of carbon dioxide, arterial (Pa co 2 ) in children admitted to the intensive care unit with traumatic brain injury? Findings In this secondary analysis of a prospective cohort study that included 445 paired Pa co 2 -EtCO 2 values from 137 patients, only 42.0% of Pa co 2 values were within 0 to 5 mm Hg of paired EtCO 2 values. Development of pediatric acute respiratory distress syndrome within 24 hours after admission was associated with significantly lower likelihood of Pa co 2 -EtCO 2 agreement than was no development of pediatric acute respiratory distress syndrome. Meaning This study suggests that EtCO 2 values are not a reliable substitute for Pa co 2 values during the first 24 hours after pediatric traumatic brain injury, especially in the presence of pediatric acute respiratory distress syndrome.
The overall incidence of intraoperative seizures was 2.3%. Independent risk factors for intraoperative seizures were seizure history, diagnosis of intracranial tumor, and temporal craniotomy. Intraoperative prophylactic anticonvulsant use was protective.
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Background: Understanding quality improvement (QI) reporting patterns is important for practice-based improvement and for prioritizing QI initiatives. The aim of this project was to identify major domains of neuroanesthesiology QI reports at a single academic institution with 2 hospital-based practice sites.Methods: We retrospectively reviewed institutional QI databases to identify reports from neuroanesthesia cases between 2013 and 2021. Each report was categorized into one of the 16 primary predefined QI domains; the QI report domains were ranked by frequency. Descriptive statistics are used to present the analysis.Results: Seven hundred three QI reports (3.2% of all cases) were submitted for the 22,248 neurosurgical and neuroradiology procedures during the study period. Most of the QI reports across the institution were in the domain of communication/ documentation (28.4%). Both hospitals shared the same 6 top QI report domains, although the relative frequency of each domain differed between the 2 hospitals. Drug error was the top QI report domain at one hospital, representing 19.3% of that site's neuroanesthesia QI reports. Communication/documentation was the top domain at the other hospital, representing 34.7% of that site's reports. The other 4 shared top domains were equipment/ device failure, oropharyngeal injury, skin injury, and vascular catheter dislodgement. Conclusions:The majority of neuroanesthesiology QI reports fell into 6 domains: drug error, communication/documentation, equipment/device failure, oropharyngeal injury, skin injury, and vascular catheter dislodgement. Similar analyses from other centers can guide generalizability and potential utility of using QI reporting domains to inform the development of neuroanesthesiology quality measures and reporting frameworks.
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