Airway management in the emergency department.
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Airway management in the emergency department and the role of anaesthetists and emergency physicians is reviewed. The training for emergency physicians in the advanced airway skills of rapid sequence induction and tracheal intubation is discussed. (+info)
Emergency analgesia in the paediatric population. Part I: current practice and perspectives.
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Children frequently present to the accident and emergency (A&E) department in pain. Most presentations are acute, but children with pain of longer duration also present. Children also often undergo painful procedures in A&E in the process of diagnosis or treatment. These papers review recent literature to examine factors involved in the provision of emergency analgesia in the paediatric population. This will include a discussion of current practice and make recommendations for future management of children's pain and anxiety in the A&E department. Part I: Current practice and perspectives. Part II: Pharmacological methods of paediatric analgesia. Part III: Non-pharmacological methods of pain control and anxiolysis. Part IV: Paediatric sedation in accident and emergency. (+info)
A comparison of operative times in arthroscopic ACL reconstruction between orthopaedic faculty and residents: the financial impact of orthopaedic surgical training in the operating room.
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There is no published data regarding the financial impact of training orthopaedic residents in the operating room. No comparisons between orthopaedic faculty and residents in regard to operative time and costs are known. One hundred eleven cases of anterior cruciate ligament reconstruction with or without partial meniscectomy were evaluated from 1996 to 1997. Fifty-three cases met the selection criteria of times, documentation and identification of the surgeon. Twenty-one cases were performed by the orthopaedic attending (RCS) while 32 cases were performed by the senior orthopaedic resident. All procedures had the same faculty member present in the operating room either as the primary surgeon or as an assistant providing supervision and instruction as needed. In a two year period, comparisons were made between the attending and residents for the total anesthesia time and actual operative case time. Attending case time and anesthesia times averaged 94.62 minutes (range 60-125 min) and 128.1 minutes (range 84-185 min) respectively. Resident case and anesthesia times averaged 137.09 minutes (range 95-210 min) and 190.48 minutes (range 145-255 min) respectively. The anesthesia time was significantly less for the attending (p<.0001) as was the case time (p<.0001). The true costs of training orthopaedic surgery residents in the operating room is not known. The operative time and subsequent cost difference between experienced faculty and orthopaedic residents in certain arthroscopic procedures is not inconsequential. On average, the difference is equivalent to $228.73 per case for anesthesia costs. Based on increased operative times, operating room costs, on average, were increased by $661.85. The significant differences demonstrated between residents and faculty suggest the need to develop strategies and technical training facilities in order to improve orthopaedic residents' surgical skills and efficiency outside of the cost-central operating room. (+info)
Improvement of information gained from the pre-anaesthetic visit through a quality-assurance programme.
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BACKGROUND: Pre-anaesthetic evaluation is a fundamental component of anaesthetic practice. The aims of the present study were to assess the quality of the preoperative anaesthetic information gathered and to observe the quality profile after the introduction of a standardized form. This occurred through a four-step quality assurance programme over a 4-yr period. METHODS: The proportion of cases in which a complete recording of data was collected at the preoperative assessment was evaluated by searching in each patient's medical record for what was considered to be the minimum information required to provide satisfactory perioperative care. Fifteen criteria were selected. The recovery profile for each indicator and a global quality index (GQI expressed in %) for each patient's record were collected. In phase 1, the existing situation was assessed. Next, a standardized pre-anaesthetic form (PAF 1) was designed and its implementation evaluated (Phase 2). Phase 3 was performed 16 months after implementation of PAF 1 to assess the long-term value. The form was revised (PAF 2) and its use evaluated again 6 months later (Phase 4). For each evaluation, the records of a 1-month period were examined. Overall 1129 medical records were audited. RESULTS: The GQI increased significantly from 62 to 88% with similar changes for both elective and emergency cases. The recovery profile was improved for most indicators. CONCLUSIONS: We conclude that the quality of information recorded from the pre-anaesthetic visit is improved by using a standardized form. This will hopefully help to improve patient outcome and facilitate computerization of the anaesthetic record. (+info)
Acute pain services in Hong Kong: facilities, volume, and quality.
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Acute pain services in public hospitals in Hong Kong were studied. Audit data on the volume and quality of acute pain services were collected prospectively from 1997 to 1999, and data on related facilities were collected in 2000. About 20% of patients undergoing a major operation received an acute pain service; of these, 78.6% were satisfied with the treatment provided. In 2000, 86% (18/21) of hospitals providing anaesthetic services were running an acute pain service. Staffing was better in hospitals providing a high volume of acute pain services, ranging from a full-time specialist anaesthesiologist assisted by a half-time trainee to a half-time specialist assisted by a full- or half-time trainee. However, only four hospitals were staffed with pain nurses. In total, 57% of patients received intravenous patient-controlled analgesia and 32% epidural analgesia. The mean duration of acute pain service treatment was 3.1 days. Currently anaesthesiologist-based acute pain services take care of a limited number of patients. To expand the coverage, there should be a move towards an anaesthesiologist-led, pain nurse-based, acute pain service. The present shortage of pain nurses should be addressed. (+info)
Unexpected cardiac arrest among children during surgery, a North American registry to elucidate the incidence and causes of anesthesia related cardiac arrest.
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Relatively rare adverse events, such as unexpected cardiac arrest, are difficult to study in the clinical setting. These events are often unpredictable in their occurrence (prompting interest in their investigation) and do not occur with sufficient frequency in any single institution to provide an adequate sample for analysis. A disease-specific registry is an epidemiological technique that can be used to collect data on a set of relatively rare unpredictable events. This approach was adopted for investigation of cardiac arrest in children when it became apparent from analysis of malpractice claims that a significant clinical problem existed. This report provides a brief historical account of the development of the Pediatric Peri-Operative Cardiac Arrest (POCA) Registry and elaborates on the methodology including strengths, weaknesses, and practical implementation issues. (+info)
Controlled substance dispensing and accountability in United States anesthesiology residency programs.
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Controlled substance dependence (CSD) among anesthesiology personnel, particularly residents, has become a matter of increasing concern. Opinions vary as to the effectiveness of controlled substances (CS) accountability in deterring, identifying, or confirming CSD. A survey of program directors of American anesthesiology training programs was conducted in the summer of 1990 to determine the level of CS dispensing and accountability within their programs. The survey demonstrated that CS dispensing and accountability varied considerably among programs, among hospitals associated with individual programs, and within geographically distinct anesthesia delivery areas within the separate hospitals. Nevertheless, most institutions were moving toward improved methods of CS dispensing and providing more and better CS accountability. The presence of significant CSD, particularly among anesthesiology residents, was reconfirmed. We were unable to correlate the level of accountability of CS with the incidence of CSD. It remains to be seen to what extent CS accountability will continue to develop and whether CSD prevalence will then be changed. (+info)
Quantifying net staffing costs due to longer-than-average surgical case durations.
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BACKGROUND: Anesthesiology departments incur staffing costs that are not covered by revenue because the operating room (OR) time allocation and case scheduling are not done to maximize OR efficiency and because surgical durations are longer than average. The purpose of this article is to demonstrate a method to quantify net anesthesia staffing costs due to longer-than-average surgical durations and evaluate the factors that influence staffing costs. METHODS: Data collected from two anesthesiology departments in academic hospitals for 1 yr included date of surgery, time that patients entered the OR, time that patients exited the OR, surgical service, and the Current Procedural Terminology code for the primary surgical procedure. Anesthesia care performed outside the main surgical suite and services not billed with American Society of Anesthesiologists units were excluded. National average surgical durations were determined from the Current Procedural Terminology code from the Centers for Medicare and Medicaid Services' database. Actual surgical durations were then used to determine staffing solutions to maximize OR efficiency; national average surgical durations were then used to determine a second solution. The difference in staffing costs between these two staffing solutions represented the staffing costs attributable to longer surgical durations. Costs were converted to dollar amounts using compensation values reported in a national compensation survey. The differences in revenue were determined by applying conversion factors to the differences in surgical durations. The annual net cost attributable to longer surgical durations equaled the staffing costs minus the revenue produced by longer durations. Net staffing costs were estimated for two hospitals using median staffing compensation and median payer mix. Net staffing costs were then recalculated by varying the parameters (conversion factors, limits on differences between actual and average surgical duration, levels of compensation, surgical service size of OR allocation). RESULTS: Using the median compensation of staff and an average conversion factor, the net annual staffing costs attributable to longer surgical durations were $672,100 for the first hospital. However, if staff members were highly compensated and the payer mix was unfavorable, the net staffing costs were $1,688,000. Reducing the difference between actual and average duration resulted in lower staffing costs. Net staffing costs were less in a second hospital studied that had many low-volume surgical services. CONCLUSIONS: Longer-than-average surgical durations can increase net staffing costs for anesthesiology groups. The increase is dependent on factors such as staffing compensation and payer mix. (+info)