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Background: The Council of Faculty and Academic Societies (CFAS) comprises representatives from medical schools and professional societies who guide the Association of American Medical Colleges (AA...

Burnout amongst healthcare employees is considered an epidemic, prior research indicates a host of associated negative consequences, though more research is needed to understand the predictors of burnout across healthcare employees. All employees in a cancer-focused academic healthcare institution were invited to participate in a bi-annual online confidential employee survey. A 72% response rate yielded 9979 complete responses. Participants completed demographic items, a validated single-item measure of burnout, and items measuring eight employee job attitudes toward their jobs and organization (agility, development, alignment, leadership, trust, resources, safety, and teamwork). Department-level characteristics, turnover, and vacancy were calculated for group level analyses. A univariate F test revealed differences in burnout level by department type (F (3, 9827) = 54.35, p &lt, 0.05) and post hoc Scheffe&rsquo, s tests showed employees in clinical departments reported more burnout than other departments. Hierarchical multiple regression revealed that employee demographic and job-related variables (including department type) explained 8% of the variance of burnout (F (19, 7880) = 37.95, p &lt, 0.001), and employee job attitudes explained an additional 27% of the variance of burnout (F (8, 7872) = 393.18, p &lt, 0.001). Relative weights analysis at the group level showed that, of the constructs measured, alignment is the strongest predictor of burnout, followed by trust and leadership. The relationships are inverse in nature, such that more alignment is related to less burnout. Turnover and vacancy rates did not predict group level burnout. The results reported here provide evidence supporting a shift in the focus of research and practice from detection to prevention of employee burnout and from individual-focused interventions to organization-wide interventions to prevent burnout.

Study Objective Two of the most feared complications for patients undergoing thyroid surgery are pain and postoperative nausea and vomiting. Thyroidectomy is considered high risk for postoperative nausea and vomiting, and recent studies have looked at adjuncts to treat pain, limit narcotic use, "fast-track" the surgical process, and enhance recovery without compromising the patient's safety. One such perioperative medication of interest is dexmedetomidine (Dex), a centrally acting α-2 agonist that has been associated with reducing pain and postoperative opioid consumption. Our aim was to examine the effectiveness of Dex as an adjunctive intraoperative medication to reduce postoperative narcotic requirements in patients undergoing outpatient thyroid surgery. Design, Setting, Patients and Intervention After obtaining approval from the Institutional Review Board at The University of Texas MD Anderson Cancer Center, we searched the electronic medical record for the period October 2013 to March 2015 to identify patients who had undergone thyroid surgery in the ambulatory setting under general anesthesia. Measurements and Main Results A total of 71 patients underwent thyroidectomy or thyroid lobectomy in the outpatient setting. Of the patients receiving adjunctive Dex, a lower proportion (50%, n=9) received postoperative intravenous opioids when compared with control patients (79%, n=42) ( P =.017). One patient (5%) in the Dex group required rescue postoperative antiemetics as compared to 11 (21%) patients in the control group ( P =.273). Conclusions Our data suggest that intraoperative use of Dex reduced narcotic administration in the postoperative period among study population patients undergoing thyroidectomy.

PURPOSE: As health care costs rise, continuous quality improvement and increased efficiency are crucial to reduce costs while providing high-quality care. Time-driven activity-based costing (TDABC) can help identify inefficiencies in processes of cancer care delivery. This study measured the process performance of Port-a-Cath placement in an outpatient cancer surgery center by using TDABC to evaluate patient care process. METHODS: Data were collected from the Anesthesia Information Management System database and OneConnect electronic health record (EHR) for Port-a-Cath cases performed throughout four phases: preintervention (phase I), postintervention, stabilization, and pre–new EHR (phases II and III), and post–new EHR (phase IV). TDABC methods were used to map and calculate process times and costs. RESULTS: Comparing all phases, as measured with TDABC methodology, a decrease in post-anesthesia care unit (PACU) length of stay (LOS) was identified (83 minutes v 67 minutes; P < .05). The decrease in PACU LOS correlated with increased efficiency and decreasing process costs and PACU nurse resource use by fast tracking patients for Port-a-Cath placement. Port-a-Cath placement success and the functionality of ports remained the same as patient experience improved. CONCLUSION: TDABC can be used to evaluate processes of care delivery to patients with cancer and to quantify changes made to those processes. Patients’ PACU LOS decreased on the basis of the 2013 Port-a-Cath process improvement initiative and after implementation of a new EHR, over the course of 3 years, as quantified by TDABC. TDABC use can lead to improved efficiencies in patient care delivery that are quantifiable and measurable.

© 2016 SAGE Publications. Opening and charting in the incorrect patient electronic record presents a patient safety issue. The authors investigated the prevalence of reported errors and whether efforts utilizing the anesthesia time-out and barcoding have decreased the incidence of errors in opening and charting in the patient electronic medical record in the perioperative environment. The authors queried the database for all surgeries and procedures requiring anesthesia from January 2009 to September 2012. Of the 115,760 records of anesthesia procedures identified, there were 57 instances of incorrect record opening and charting during the study period. A decreasing trend was observed for all sites combined (p < 0.0001) and at the off-site locations (p = 0.0032). All locations and the off-site locations demonstrated a statistically significant decreasing pattern of errors over time. Barcoding and the anesthesia time-out may play an important role in decreasing errors in incorrect patient record opening in the perioperative environment.

Key Points Question What are the sex-based differences in Canadian residency applications and matching? Findings This cross-sectional analysis of aggregate data from the Canadian Residency Matching Services database revealed a total of 48 424 applicants between 1995 and 2019. Female applicants had the highest representation in obstetrics and gynecology and the lowest representation in neurosurgery. Meaning In this study, representation of residency applicants by sex varied among specialties., This cross-sectional analysis examines the representation of female medical school graduates in residency programs by specialty using aggregate data from the Canadian Residency Matching Service database., Importance Disparities in representation between sexes have been shown at multiple career stages in medicine despite increasing representation in the overall physician workforce. Objective To assess sex representation of applicants to the Canadian R-1 entry match for postgraduate training programs from 1995 to 2019, comparing distribution between different specialties as well as applied vs matched applicants. Design, Setting, and Participants This cross-sectional analysis of aggregate data provided by the Canadian Resident Matching Service between 1995 and 2019 analyzed aggregate data for the Canadian R-1 residency match from 1995 through 2019. Exposures Applicant sex as reported in the Canadian Resident Matching Service database. Main Outcomes and Measures The sex representation of applicants was compared and the longitudinal trends in sex representation were analyzed by specialty between 1995 and 2019. The sex representation of overall applicants to the Canadian R-1 entry match were compared with matched applicants, and both were stratified by specialty. Results A total of 48 424 applicants were identified (26 407 [54.5%] female applicants), of which 41 037 were matched applicants. Using specialty groupings, female applicants were most highly represented in obstetrics and gynecology (1776 of 2090 [85.0%]) and least represented in radiology (658 of 2055 [32.0%]). Within individual subspecialties, female applicants had the lowest representation in neurosurgery (90 of 394 [22.8%]). While female applicants represented an increasing proportion of the overall applicant population between 1995 and 2019 (z = 2.71; P = .007), significant increases were seen in some, but not all, individual specialties. Differences by sex were found among Canadian medical graduate match rates to their top-ranked specialty: female applicants had a lower likelihood of being rejected for family medicine (rejection of male applicants: OR, 0.46; 95% CI, 0.39-0.54; P

Takotsubo Cardiomyopathy (TC) is a reversible, stress-induced, non-ischemic cardiomyopathy associated with temporary weakness of the myocardium and midventricular or apical ballooning [11. Emanuele Cecchi, Guido Parodi, Cristina Giglioli, Silvia Passantino, Brunella Bandinelli, et al. (2013) Stress-Induced Hyperviscosity in the Pathophysiology of Takotsubo Cardiomyopathy. The Am J Cardiol: 1523–1529.,22. Sharkey SW, Lips DL, Pink VR, Maron BJ (2013) Daughter-Mother Tako-Tsubo Cardiomyopathy. The Am J Cardiol 137–138.]. Angina, ST abnormalities, elevated troponins, ventricular asynergy, CHF, and decreased EF are all components of TC. The unique finding is that they occur on the absence of CAD [33. Bielecka-Dabrowa A, Mikhailidis DP, Hannam S, Rysz J, Michalska M, et al. Takotsubo cardiomyopathy -The current state of knowledge. Int J Cardiol:120–125.]. In this case series with IRB approval we report three cases of post-operative cardiac symptoms that all resulted in a diagnosis of TC.

BACKGROUND Paravertebral blocks have gained popularity because of ease of implementation and a shift toward ambulatory breast surgery procedures. Previous retrospective studies have reported potential benefits of paravertebral blocks, including decreased narcotic and antiemetic use. METHODS The authors conducted a prospective controlled trial of patients undergoing breast reconstruction over a 3-year period. The patients were randomized to either a study group of paravertebral blocks with general anesthesia or a control group of general anesthesia alone. Demographic and procedural data, in addition to data regarding pain and nausea patient-reported numeric scores and consumption of opioid and antiemetic medications, were recorded. RESULTS A total of 74 patients were enrolled to either the paravertebral block (n = 35) or the control group (n = 39). There were no significant differences in age, body mass index, procedure type, or cancer diagnosis between the two groups. Patients who received a paravertebral block required less opioid intraoperatively and postoperatively combined compared with patients who did not receive paravertebral blocks (109 versus 246 fentanyl equivalent units; p < 0.001), and reported significantly lower pain scores at 0 to 1 (3.0 versus 4.6; p = 0.02), 1 to 3 (2.0 versus 3.2; p = 0.01), and 3 to 6 (1.9 versus 2.7; p = 0.04) hours postoperatively. The study group also consumed less antiemetic medication (0.7 versus 2.1; p = 0.05). CONCLUSIONS Incorporating paravertebral blocks carries considerable potential for improving pathways for breast cancer patients undergoing breast reconstruction--with minimal procedure-related morbidity. This is the first prospective study designed to assess paravertebral blocks in the setting of prosthetic breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, II.

Background. The STOP-BANG questionnaire has been used to identify surgical patients at risk for undiagnosed obstructive sleep apnea (OSA) by classifying patients as low risk (LR) if STOP-BANG score < 3 or high risk (HR) if STOP-BANG score ≥ 3. Few studies have examined whether postoperative complications are increased in HR patients and none have been described in oncologic patients.Objective. This retrospective study examined if HR patients experience increased complications evidenced by an increased length of stay (LOS) in the postanesthesia care unit (PACU).Methods. We retrospectively measured LOS and the frequency of oxygen desaturation (Results. The majority of patients in our study were men (77.7%), over the age of 50 (90.1%), and had BMI < 30 kg/m2(88.4%). STOP-BANG results were obtained on 404 patients. Cumulative incidence of the time to discharge between HR and the LR groups was plotted. By 8 hours, LR patients showed a higher cumulative probability of being discharged early (80% versus 74%,P=0.008).Conclusions. Urologic oncology patients at HR for OSA based on the STOP-BANG questionnaire were less likely to be discharged early from the PACU compared to LR patients.

Cancer treatment frequently requires a multimodality approach, involving surgical resection(s), radiotherapy, and chemotherapy. Advanced surgical approaches allow for the combination of two of these, offering patients intraoperative radiotherapy with surgical resection or intraoperative chemotherapy targeted and limited to a particular body region. The systemic toxic effect on nontargeted organs is always a concern in chemotherapy treatment. This potential limitation canminimize the dosage to that less than necessary for killing the intended malignancy. One option for overcoming this problem is administration of chemotherapy in a regionally limited method, which would expose the tumor to high drug concentrations yet reduce systemic exposure. In recent years, the practice of cytoreductive surgery combined with hyperthermic chemotherapy applied regionally has advanced as a treatment for cancermanagement. The incorporation of a hyperthermic variable improves the efficacy of numerous regionally administered chemotherapeutic agents. Malignant cells show a selective sensitivity to hyperthermia, and various causes have been hypothesized. On a cellular level, the tumor cells’ oxidative metabolism is inhibited, resulting in a lower pH and, in turn, an increase in lysosomal activity and cell death. In addition, membrane protein denaturation and an increase in vascular permeability may

Study objective To describe the adverse events associated with the intraoperative injection of isosulfan blue in a large group of patients having a wide range of surgical procedures, and to identify risk factors for these events. Design Retrospective chart review. Setting University-affiliated institution specializing in malignancies Patients 1835 patients representing a total of 1852 surgical procedures. Measurements Incidence, type, severity, onset time, duration, management, and the presence of potential risk factors for adverse events. Events were considered "major" if potentially life-threatening hypotension occurred. Main results Adverse events occurred in 28 procedures (1.5%) and 14 of these adverse events (0.75%) were classified as major. The types of events were: skin reactions in 21 patients, hypotension in 14 patients, edema in 1 patients, and unspecified in 1 patient. The time of onset for adverse events was 42.2 ± 53.9 minutes (median, 17.5; range, 1 to 180 min) after isosulfan blue injection, and was significantly longer for minor reactions compared with major events (p = 0.015). The longest adverse event lasted at least 21 hours. Treatment was successful with usual antiallergy/antianaphylaxis medications. Ten patients received diphenhydramine alone, and four patients received intravenous epinephrine infusions. Factors associated with a significantly increased incidence of adverse events were isosulfan blue injection in the vulvar area ( p = 0.000038), and the chronic preoperative use of angiotensin-converting enzyme inhibitors or angiotensin receptor-blocking agents ( p = 0.043). Trends toward an increased risk of an adverse event were noted with isosulfan blue injection in the breast area ( p = 0.19), and having more than one surgical procedure with isosulfan blue ( p = 0.14). Conclusions Although the most frequent adverse event associated with injection of isosulfan blue was a skin reaction, potentially life-threatening hypotension occurred in 0.75% of all procedures. Anesthesiologists must be aware of the variable onset time and potentially prolonged duration of the adverse events. They should recognize the need for extra vigilance in patients with potential risk factors, and have the usual antiallergy/antianaphylaxis medications available for administration if necessary.

Background The goal of the current study was to evaluate the effect of regional anesthesia using paravertebral block (PVB) on postoperative pain after breast surgery. Methods Patients undergoing unilateral breast surgery without reconstruction were randomized to general anesthesia (GA) only or PVB with GA and pain scores assessed. Results Eighty patients were randomized (41 to GA and 39 to PVB with GA). Operative times were not significantly different between groups. Pain scores were lower after PVB compared to GA at 1 hour (1 vs 3, P = .006) and 3 hours (0 vs 2, P = .001) but not at later time points. The overall worst pain experienced was lower with PVB (3 vs 5, P = .02). More patients were pain-free in the PVB group at 1 hour (44% vs 17%, P = .014) and 3 hours (54% vs 17%, P = .005) postoperatively. Conclusions PVB significantly decreases postoperative pain up to 3 hours after breast cancer surgery.

Background : This study assessed the efficacy of a continuous infusion pump system for postoperative pain control at muscle-sparing transverse rectus abdominis musculocutaneous (TRAM) flap donor sites. Methods : In this prospective, randomized, double-blind trial, a dual-catheter continuous infusion pump system was placed in the muscle-sparing TRAM flap donor-site area in all patients. Bupivacaine (0.375%; continuous infusion pump group) or isotonic saline (control group) was infused at 4 ml/hour. All patients also had a patient-controlled anesthesia system delivering intravenous narcotics on demand. Pain scores, patient satisfaction, narcotic use, milestones of surgical recovery, and side effects of narcotics were compared between the two groups. Results : Forty-eight patients were included in the study (23 continuous infusion pump patients and 25 control patients). The continuous infusion patients used less mean patient-controlled anesthesia narcotic during the first 2 postoperative days (78.0 mg versus 42.7 mg; p = 0.019) and transitioned earlier to oral narcotics than did control patients. Patients' overall pain satisfaction scores were significantly better in the continuous infusion group than in the control group. There were no significant differences between groups with regard to overall abdominal pain intensity scores, total narcotic use, length of hospitalization, incidence of narcotic side effects, or milestones of surgical recovery. Conclusions : The continuous infusion pump system appears to be a safe and effective method for postoperative donor-site pain management in TRAM flap breast reconstruction patients and should be considered for postoperative donor-site pain management. However, continuous infusion pump local anesthetic delivery to the muscle-sparing TRAM flap donor site did not eliminate narcotic use for pain control.

The authors report a case of intraoperative sinus arrest in an otherwise healthy patient undergoing craniotomy for aneurysm clipping after mild subarachnoid hemorrhage. The sinus arrest was precipitated by a rapid infusion of 1500 mg phenytoin and was successfully treated with standard resuscitative measures. The differential diagnosis of intra-operative cardiac arrest and the mechanisms of action of phenytoin are discussed. The authors emphasize the role of phenytoin in cerebral protection.