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Publication Intravenous Magnesium Sulfate Use in Hip Arthroscopy Patients and Anesthesia Provider Satisfaction with Patient Care at an Ambulatory Surgery Center(2021-06-28) Song, Naomi; Yi, Erica; Bagley, JulianneHip arthroscopy patients experience high levels of postoperative pain. Intravenous (IV) magnesium sulfate is widely used in anesthesia practice as a multimodal analgesic but is infrequently utilized at Penn Presbyterian Medical Center (PPMC). Does the option of adding intravenous magnesium sulfate to the current pain pathway increase provider satisfaction with patient care and magnesium use? The purpose was to add IV magnesium sulfate to the multimodal analgesic pathway for hip arthroscopy patients to evaluate anesthesia provider satisfaction and use of IV magnesium sulfate. The Middle Range Theory of Acute Pain was used to provide a theoretical framework. The conceptual framework utilized was the Plan-Do-Study-Act cycle. Anesthesia providers were refamiliarized with IV magnesium sulfate's analgesic properties to encourage its administration in hip arthroscopy procedures yielding high levels of postoperative pain. A survey was distributed to assess provider satisfaction using the Accessibility of Intervention Measure (AIM) and magnesium use. Frequency counts were used to determine provider satisfaction with patient care and a run-chart was created to analyze changes in IV magnesium sulfate usage before and after implementation. Compared to the pre-implementation phase, there was an 85.7% increase in IV magnesium use among anesthesia providers. Over 12 weeks, ten CRNAs participated in a total of fourteen hip arthroscopy cases. Nine out of ten providers would consider using magnesium in future practice. The project served to re-introduce IV magnesium sulfate as an analgesic adjunct for many surgical procedures and hoped to promote a culture that utilizes IV magnesium sulfate readily.Publication World Health Organizations Surgical Safety Checklist Project(2018-12-02) Lyons, AmberMedical error, especially in the operating room, claims the lives of patients and contributes to complications. A project was conducted to investigate the effectiveness of the World Health Organizations Surgical Safety Checklist. Communication, teamwork, and the readiness of use by the operating room team was measured. The project design was descriptive utilizing the Surgical Safety Checklist and a modified version of the Safety Attitudes Questionnaire Operating Room. Post-implementation responses to the Safety Attitudes Questionnaire Operating Room survey revealed a significant improvement in the surgical teams’ perception of teamwork and communication. Results show the World Health Organizations Surgical Safety Checklist improves teamwork and communication, and improves awareness of patient safety factors when consistently implemented before each operation.Publication Propofol Waste Reduction in the Operating Room(2019-12-21) Lincul, David A; Chambers, Elizabeth R; Fitzhenry, John JPropofol is the most wasted intravenous medication used in anesthesia in the operating room (OR) (More, Dabhade, & Ghongane, 2015). Propofol, a sedative anxiolytic, is utilized as a continuous infusion in sedation procedures, or monitored anesthesia care (Nagelhout & Elisha, 2014). Inherent to these infusions is unpredictability in determining the amount of medication needed for the duration of a procedure. This project implemented customized propofol preparation charts consistent with the literature to aid the administering professional in determining the approximate milliliter requirement for the duration of a procedure. The pre-intervention steps consisted of voluntary data collection among anonymous anesthesia professionals in the OR regarding infusion characteristics. Patient weight, a commonly used infusion rate, and the duration of procedure were used in the calculation within customized charts. Post-intervention data collection was conducted in the same manner to capture the impact of the charts. This data was measured simultaneously at a local healthcare system’s main hospital and separate surgery center site, and waste reduction from baseline data was found to be 49% and 60%, respectively. This project was conducted over a four-month period and translates to a potential yearly savings of greater than $15,000 for the healthcare system. A culture of waste reduction leads to savings for anesthesia departments and healthcare organizations as a whole.Publication An Electronic Alert to Reduce Postoperative Delirium in the Older Adult(2019-12-23) Warner, Vanessa; Fontanilla, Linda; Prendergast, CassieOlder adults frequently experience delirium after surgery, contributing to a decline in quality of life, increasing morbidity and mortality rates, and adding significant costs to the healthcare system. The Beers Criteria was developed by the American Geriatrics Society and lists medications correlated with a decline in cognition among older adults. These medications are commonly administered in the perioperative period by anesthesia practitioners. At a large university hospital, an educational video was distributed, followed by the launch of an electronic health record alert advising over 300 anesthesia practitioners to reduce dosing or omit Beers Criteria medications in patients aged 70 or older. The total administration and total mean dosage of Beers Criteria medications administered were measured across four study periods: pre-educational video/pre-alert, post-education/pre-alert, and at two post-education/post-alert time points in select surgeries. This quality improvement project demonstrated significant reduction in Beers Criteria medications administered to patients 70 years or older to reduce rates of cognitive decline.Publication Pressure Injury Prevention in Cardiac Surgery Using Risk Factor Assessment and Standardization(2021-08-05) Madeira, Timothy HCardiac surgical patients are more susceptible to pressure injury (PI) than other surgical specialties, and little is known about PI prevention (PIP) in this population. How do PIP strategies, compared to standard care, affect the incidence of PI during the post-operative recovery among adult cardiac surgery patients? The aim was to reduce the incidence of UAPI in an adult CVSICU by 5% in six weeks. The conceptual framework chosen was The Iowa Model Revised, and the theoretical framework employed was the Theoretical Model for Lesion Development. Quality improvement, single-group pretest-posttest design. Sample consisted of 69 cardiac surgery, LVAD, ECMO patients at Johns Hopkins CVSICU. The intervention was a standardized PIP bundle provided to “highest risk” patients screened before surgery. Outcome measures were UAPI count and incidence rates. Process measures were percentage of patients screened, prophylactic sacral dressing, rental bed cost. Balancing measures were PI severity, anatomic location, and time between wounds. Baseline data consisted of historic data and intervention data consisted of weekly survey observations. Implementation consisted of staff education, daily preoperative screening, weekly wound rounds. 33% of patients screened as “highest risk” and received the PIP bundle. PI count decreased from 25 to 13 during implementation and wound stages improved. Chi Square test of 2-proportions showed a reduced PI incidence of 8.56% (Z=1.66, p= .048) and 2-sample Poisson rate showed significance in count (Z=1.95, p=.036). Location changed to nose, buttocks, and occipital locations. There was an overall cost savings of $78,660. Reducing PI lead to reduced morbidity and cost.Publication Minimizing Obstetric Hemorrhage(2019-12-30) DeLuca, Dena M.; Kelly, Ashley D.; McGuire, Helen M.; Bent, Dawn E.; DiDonato, AngelaPatients undergoing cesarean deliveries are at risk for hemorrhage. In fact, hemorrhage is the leading cause of preventable maternal mortality and accounts for more than 140,000 deaths each year worldwide (O’Brien & Ulh, 2016). Hemorrhage has been associated with a number of well-established risk factors which could be recognized prior to delivery. Women who do not have these risk factors could still experience postpartum hemorrhage, but using a risk assessment tool has been shown to identify 60-85% of women who will experience hemorrhage (Shields, Goffman, & Caughey, 2017). The postpartum hemorrhage (PPH) risk assessment tool, developed by the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), identifies women with PPH risk factors. The tool allows clinicians to prepare for possible interventions and close monitoring of women at increased risk of bleeding, to ultimately prevent mortality. At a metropolitan hospital PPH risk assessments were not being discussed during standard pre-procedure huddles. This quality improvement project added the PPH risk assessment tool to the pre procedure huddle sheet. This facilitated interdisciplinary team discussion of PPH risk factors for patients undergoing cesarean deliveries. There were a total of 575 mothers in the study with 297 in the pre intervention period and 278 in the post. There was a statistically significant increase in estimated blood loss (EBL) between the pre and post intervention groups. While the study tool did not result in a decrease in EBL, it increased awareness among the interdisciplinary care team by facilitating discussion about PPH.Publication Airway Fire Prevention in the Operating Room(2020-12-07) Patel, Dipika; Smith, Kendall; Woodmansee, ScottAirway fires during surgical procedures are preventable events that result in devastating outcomes for patients, healthcare providers, and healthcare facilities. Minimization of the risk of fires is a subsection of Standard 6 of the American Association of Nurse Anesthetists’ Standards for Nurse Anesthesia Practice. A central priority of operating room fire mitigation is the minimized use of oxidizing agents. Oxygen is one component of the fire triad responsible for increasing the likelihood of these events, which is controlled by anesthesia providers in the operating room. The primary aim of this quality improvement project was to increase anesthesia provider knowledge pertaining to airway fire risk mitigation strategies through the implementation of an evidenced-based educational intervention. The secondary aim of this quality improvement project was to demonstrate a quantitative reduction of airway fire risk through a comparison of pre-intervention and post-intervention supplemental oxygen administration levels during surgical procedures. The overall goal of this project was to highlight the value of optimized provider knowledge regarding airway fire risk mitigation techniques, especially among high-risk airway fire procedures.Publication The Utilization of the STOP-Bang Questionnaire for Identification of Surgical Patients at Risk for Obstructive Sleep Apnea(2020-12-01) Borden, Weatherall J; DiVincenzo, Leslie; Masi, Natalie RObstructive sleep apnea (OSA) is a breathing disorder that if left untreated during the perioperative period can lead to deleterious complications. Considering there remains a significant amount of Americans undiagnosed, it is of utmost importance that adult surgical patients undergoing elective procedures be appropriately screened to detect OSA risk in order to decrease adverse events through individualized interventions during the surgical phases. Polysomnography testing is the diagnostic standard, but its complexity in the perioperative setting renders it impractical. The STOP-Bang questionnaire is a validated screening tool that can be utilized as an alternative in this population to accurately identify at risk patients. At a local urban hospital in Pennsylvania, a data analytics team determined that a 1.6% annual compliance rate exists with this risk stratification tool amongst anesthesia providers. The aim of this quality improvement (QI) project is to increase overall compliance of the STOP-Bang questionnaire via incorporation into the preoperative nursing assessment and ultimately, increase detection of OSA risk in the undiagnosed surgical population at this healthcare institution. Post implementation data was analyzed and it was revealed that STOP-Bang compliance increased at an upwards of 62.2% over a 4–week period. It was also shown that 14.8% of the surgical population was identified as intermediate to high-risk for OSA development. The STOP-Bang questionnaire is well documented for its reliability, precision, and ability to aid in provider identification of surgical patients at risk for OSA. Considering the specialized, individualized, and careful management OSA patients require to prevent perioperative complications, screening with the STOP-Bang questionnaire is recommended.Publication Implementing an Enhanced Recovery After Breast Surgery Protocol to Reduce Opioid Use(2020-12-22) MacDonald, Kendall S; Reynolds, Kelsey DPatients undergoing breast surgery are at risk of developing persistent post-operative pain and prolonged opioid use. Most patients who receive breast surgery do not have chronic pain pre-operatively, but up to 60 percent will experience chronic pain post-operatively. AtlantiCare Medical Center made opioid minimization a top priority in the institution and has openly adopted Enhanced Recovery After Surgery (ERAS) protocols for other surgical specialties. After performing a systematic literature review, an ERAS protocol for breast surgery patients was developed for use in a quality improvement project. Patients selected included those undergoing unilateral or bilateral mastectomy and/or, staged reconstruction surgery. The protocol was implemented via an electronic application utilized by the Anesthesia Department for ERAS anesthesia techniques. Key aspects of the protocol were broken down into pre-operative, intra-operative and post-operative aspects. Preoperatively, Acetaminophen and Gabapentin were administered. Intraoperatively, pectoralis blocks were performed by anesthesia, administration of long-acting opioids were minimized, and adequate prevention of post-operative nausea and vomiting (PONV) were utilized. Post-operatively, patients were encouraged early oral intake and reduced use of opioid for pain control. Total morphine milliequivalents (MMEs) during anesthesia care were analyzed pre- and post-protocol implementation via deidentified medication administration reports. Patients of similar American Society of Anesthesiologists (ASA) status, weight and surgical procedure were compared to provide consistent analysis between pre-intervention and post-intervention groups.