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Objectives In clinical practice, there are various methods that can be used for the rapid administration of fluid in infants and children. The current study prospectively evaluates gravity, pressure-assisted, and hand-pump methods for the rapid administration of fluid using an in vitro model. Methods Thirty participants were asked to deliver 500 mL of fluid using 1 of 6 setups: (1) standard blood tubing with gravity administration, (2) standard blood tubing with pressure bag maintained at 300 mm Hg, (3) standard blood tubing with pressure bag inflated to 300 mm Hg and left to flow, (4) blood tubing with in-line bulb pump, (5) blood tubing with in-line bulb pump and pressure bag, and (6) standard blood tubing with 20-mL syringe attached to the stopcock for a push-and-pull technique using a 20-mL syringe. Results The blood tubing with an in-line bulb pump to allow manual acceleration of the administration of fluid along with a pressure bag on the intravenous fluid bag achieved the fastest flow rate, requiring an average of 98 seconds to deliver 500 mL of fluid. Conclusions When considering factors that affect fluid administration, Poiseuille's law dictates that the most important variable is the radius of the intravenous cannula, whereas the length of the cannula and the viscosity of the fluid administered are of secondary importance. With these limitations in mind, other factors may be used to speed fluid administration. Our study demonstrates the advantage of using blood tubing with the in-line bulb pump combined with a pressure bag.

Study objective Evaluation of faculty anesthesiologists' clinical supervision is psychometrically reliable. Supervision scores often are used for ongoing professional practice and teaching evaluations. We evaluated whether anesthesiologists' clinical supervision rank could be determined reliably using 6- vs. 12-month data collection intervals and, for each, determined specificity (quartiles vs. halves). To serve as a comparator/control group, we analyzed anesthesiologists' evaluations of the work habits of nurse anesthetists. Design Residents evaluated 73 anesthesiologists and anesthesiologists evaluated 72 nurse anesthetists with whom they worked in operating rooms for ≥60 min, daily. Scores were adjusted for rater leniency. The reliability of ranking in halves and quartiles was determined and comparisons made. Measurements Clinical supervision and work habit scores, respectively. Main results Using 1 year of data, 5% of anesthesiologists had scores that were reliably in the lowest quartile and 21% had scores that were reliably in the lower half. No (0%) anesthesiologists were reliably in the highest quartile and 19% were reliably in the upper half. Corresponding percentages for nurse anesthetists' work habits scores were 3%, 10%, 0%, and 1%. The primary factor limiting the reliability of ranking in quartiles was the number of operating room days worked. Ranks based on raw (unadjusted) scores falsely misclassified 60% of anesthesiologists and 88% of nurse anesthetists. The percentages of anesthesiologists who could be ranked reliably was less when using a shorter evaluation period (6 months). Conclusions Using mixed effects regression to control for rater leniency, anesthesiologists' ranks based on supervision scores can be determined reliably for halves and quartiles, but fewer than half the anesthesiologists will be reliably ranked. The same ranking principles can be applied for evaluation of nurse anesthetists' work habits. Even when very high G-scores of 0.90 are obtained, ranking individuals into smaller groups (e.g., deciles) or using raw (observed) ranks is unreliable.

We consider the effect of the number of previous interactions between the anesthesia provider and a single neurosurgeon during neurosurgical procedures ("familiarity") and occurrence of an interval ≥15 min from the end of surgery (i.e., dressings applied) to tracheal extubation ("prolonged extubation") during subsequent glioma procedures by that neurosurgeon. The value of 15min is a threshold at which post-case activity by non-anesthesia personnel in the operating room ends.Historical observational study.Neurosurgical operating room suite in an academic teaching hospital.294 patients undergoing elective supratentorial glioma surgery between 2012 and 2017 by a single neurosurgeon.1) Time from end of surgery ("dressings applied") to extubation; 2) number of previous cases where the anesthesia provider had been present at the end of a neurosurgical procedure performed by the neurosurgeon; 3) case duration.Anesthesia providers (nurse anesthetists or anesthesia residents) were considered "unfamiliar" with the neurosurgeon if they had been present at the time of extubation for5 previous neurosurgical cases (including glioma and non-glioma surgery) performed by the neurosurgeon during the study interval. For approximately half the cases the anesthesia provider was unfamiliar with the neurosurgeon. There was an association between the provider's number of historical cases with the neurosurgeon and prolonged extubation (P = 0.0048); the adjusted odds ratio (by unadjusted logistic regression) for unfamiliarity was 2.10 (95% CI 1.28 to 3.44, P = 0.025). Consistent with previously shown associations between case duration and prolonged extubation, analyses were valid based on a near-linear relationship between the logit (prevalence of prolonged extubation) and the case duration quintile.Lack of familiarity between the anesthesia provider and neurosurgeon during previous anesthetics is associated with prolonged tracheal extubation following intracranial glioblastoma surgery.

The International Federation of Nurse Anesthetists is calling for international collaboration to develop advanced nursing practice in anesthesia settings globally. However, international collaboration is challenging. Limited information is available about what process and factors specifically lead to a successful international collaboration partnership. This article aimed to describe a theoretical and empirical base that can be used to build and maintain long-term international partnerships. The Theoretical Framework of Developing International Partnerships was developed, which comprises seven interrelated concepts including partnerships, collaborations, environment, structure, process for collaborating, outcomes, and sustainability. It was used to guide an equitable horizontal collaboration partnership to develop anesthesia nursing care in local culture and context. Five major challenges were identified during the collaboration process. Sixty-six strategies were developed to facilitate collaboration using the theoretical framework. This work can inform others in establishing an international collaboration and partnership in advancing nursing knowledge and culturally congruent health care delivery.

Problem Anesthesiologists are often expected to supervise residents, nurse anesthetists, and anesthesiologist assistants in their practice. Development of a supervisory skill set is important during anesthesiology training and has a potential impact on the quality of patient care. During anesthesiology residency training, residents develop different competencies through direct supervision by a staff anesthesiologist. However, there is significant variability among anesthesia residency programs in the United States in terms of the opportunity residents have to supervise other anesthesia providers. The supervisory competency is not routinely evaluated during residency training. Intervention This study aimed at evaluating an educational seminar to foster the competency of supervision in anesthesiology. The 90-minute seminar included a live lecture and a series of workshops. The lecture had a duration of 45 minutes followed by three workshops of 15 minutes each. The workshops consisted of different simulated case scenarios with the participation of actors and a manikin as a patient. A debriefing session took place after the scenarios. Every resident included in the study participated in the workshops. The workshops were aligned with the learning objectives of the educational strategy. Context The study included 12 junior anesthesiology residents supervised by 24 senior residents during simulated clinical encounters. Quality of supervision, using the nine-item Quality of Supervision Questionnaire validated by De Oliveira Filho, and self-perception were evaluated before and after the educational intervention consisting of a face-to-face seminar and individual workshops administered during each encounter. Impact There was a significant difference between the overall means among senior residents for the quality of supervision measured by a nine-item quality of supervision questionnaire before and after the educational intervention program (3.11 ± 0.29 vs 3.96 ± 0.17, p < 0.01). There was no significant difference between the overall means for the self-perception of the senior residents before and after the intervention program (3.51 ± 0.54 vs. 3.48 ± 0.20). Lessons learned A bimodal educational intervention combining face-to-face seminars and workshops is effective to improve the quality of supervision in senior residents; however, it does not change the self-perception of the supervisory process. Addition of this type of educational intervention to the anesthesiology residency curriculum would add to the development of the supervisory competency and warrants further research in clinical situations.

STUDY QUESTIONDo sperm-specific phospholipase C zeta (PLCZ1) mutations account for male infertility due to fertilization failure?SUMMARY ANSWERSix novel mutations and one reported mutation in PLCZ1 were identified in five of 14 independent families characterized by fertilization failure or poor fertilization, suggesting that these mutations may be responsible for fertilization failure in men exhibiting primary infertility.WHAT IS KNOWN ALREADYPLCZ1 is essential for the induction of intracellular calcium (Ca2+) oscillations and the initiation of oocyte activation during mammalian fertilization. However, genetic evidence linking PLCZ1 mutations with male infertility remains limited.STUDY DESIGN, SIZE, DURATIONFourteen unrelated primary infertility patients were recruited into this study from January 2016 to December 2018; the patients exhibited total fertilization failure or poor fertilization, as evidenced by ICSI and sperm-related oocyte activation deficiencies identified in mouse oocyte activation assays.PARTICIPANTS/MATERIALS, SETTING, METHODSGenomic DNA samples were extracted from the peripheral blood of patients. The whole exons of PLCZ1 were sequenced by Sanger sequencing. The PLCZ1 sequences were aligned by CodonCode software to identify rare variants. The ExAC database was used to search for the frequency of corresponding mutations. The pathogenicity of identified variants and their possible effects on the protein were assessed in silico. PLCZ1 protein levels in semen samples were evaluated by western blotting. Oocyte activation ability was assessed by the injection of wild-type and mutant PLCZ1 cRNAs into human mature metaphase II (MII) oocytes in vitro.MAIN RESULTS AND THE ROLE OF CHANCEWe identified six novel mutations and one reported mutation in PLCZ1 among five affected individuals. In addition to four novel missense mutations, two new types of genetic variants were identified, including one in-frame deletion and one splicing mutation. Western blot analysis revealed that PLCZ1 protein expression was not observed in the semen samples from the five affected patients. Microinjection with the PLCZ1 cRNA variants was performed, and a significant decrease in the percentage of pronuclei was observed for four novel missense mutations and one novel in-frame deletion mutation, suggesting that these mutations have a deleterious influence on protein function. By artificial oocyte activation treatment, the fertilization failure phenotypes of four affected patients were successfully rescued and three healthy babies were delivered.LARGE SCALE DATAN/ALIMITATIONS, REASONS FOR CAUTIONWe screened only the whole exons of PLCZ1. Additional possible mutations in the non-coding region of PLCZ1 should be further studied.WIDER IMPLICATIONS OF THE FINDINGSOur study not only further confirms the important role of PLCZ1 in human fertilization but also expands the mutational spectrum of PLCZ1 associated with male infertility, which provides a basis for assessing genetic variation in PLCZ1 as a potential diagnostic marker for infertile men suffering from fertilization failure.STUDY FUNDING/COMPETING INTEREST(S)This research was supported by the National Natural Foundation of China (81 571 486 and 81 771 649). All authors have no conflicts of interest to declare.

Sedation practices for pediatric burn patients during dressing changes vary between institutions and providers. To better understand the current trends in pediatric sedation practice, a survey was conducted among the members of the American Burn Association (ABA). Questions asked about nonoperating room sedation and analgesia practices for burn patients (ages 0-17) having dressing changes in the intensive care unit, inpatient unit, and outpatient clinics. ABA members providing sedation for pediatric patients undergoing burn dressing changes are diverse. Physician respondents included surgeons, critical care intensivists, and anesthesiologists. Others included physician assistants, nurse anesthetists, nurse practitioners, and sedation credentialed nurses. Opioids for pain control were prescribed by 100% of respondents, but use of adjuvant nonopioid analgesics was utilized

Objectives Quality improvement in geriatric trauma depends on timely identification of frailty, yet little is known about providers' knowledge and beliefs about frailty assessment. This study sought to understand trauma providers' understanding, beliefs, and practices for frailty assessment. Methods We developed a 20-question survey using the Health Belief Model of health behavior and surveyed physicians, advanced practice providers, and trainees on the trauma services at a single institution that does not use formal frailty screening of all injured seniors. Results were analyzed via mixed methods. Results One hundred fifty-one providers completed the survey (response rate 92%). Respondents commonly included calendar age as an integral factor in their determinations of frailty but also included a variety of other factors, highlighting limited definitional consensus. Respondents perceived frailty as important to older adult patient outcomes, but assessment techniques were varied because only 24/151 respondents (16%) were familiar with current formal frailty assessment tools. Perceived barriers to performing a formal frailty screening on all injured older adults included the burdensome nature of assessment tools, insufficient training, and lack of time. When prompted for solutions, 20% of respondents recommended automation of the screening process by trained, dedicated team members. Conclusions Providers seem to recognize the impact that a diagnosis of frailty has on outcomes, but most lack a working knowledge of how to assess for frailty syndrome. Some providers recommended screening by designated, formally trained personnel who could notify decision makers of a positive screen result.

Study objective Certified registered nurse anesthetists (CRNAs) can evaluate anesthesiologists with whom they work clinically using a psychometrically reliable and valid scale. Use of such a scale to evaluate performance depends on knowing thresholds for minimum and ideal anesthesiologist performance. Design Cohort study. Setting One large teaching hospital. Measurements 379 CRNA evaluations of anesthesiologists' performance, and associated thresholds for minimum and ideal scores, performed over 15 weeks. Main results The anesthesiologists' performance score was less than the CRNA's minimum score for the evaluation (i.e., too little anesthesiologist participation in patient care) for 25% (95) of the CRNA evaluations. The score was greater than the CRNA's ideal score for the evaluation (i.e., excessive participation in patient care) for 28% (106) of evaluations. Anesthesiologists' performance was assessed as not meeting expectations 53% of the time. Even if every anesthesiologist performed consistently at the same level, ≥50% of CRNAs would have been dissatisfied (187), not significantly different from observed (P = 0.34). Consistent results were found when the unit of analysis was individual CRNA. Among the 22 CRNAs who provided ≥10 evaluations, the median level of anesthesiologist performance was either less than the individual CRNA's mean minimum acceptable performance (8/22) or greater than their mean ideal performance (9/22), with overall dissatisfaction, 77%. Among the CRNA-anesthesiologist pairs working together, most did so less than once per month (76%, 1242/1635). Conclusions In this single-center study at a large teaching hospital, broad heterogeneity among CRNAs in their expectations for anesthesiologist collaborative practice was found. Anesthesiologists adjusting their behavior based on individual CRNA preferences was impractical because specific CRNA-anesthesiologist pairs work together infrequently. Future studies should examine consistency among organizations and whether changes in expectations, and perhaps less dissatisfaction, can be achieved by communication of results for CRNA preferences for anesthesiologists' participation in patient care and discussing shared expectations among the CRNAs and anesthesiologists.

Enhanced recovery pathways have quickly become part of the standard of care for patients undergoing elective surgery, especially in North America and Europe. One of the central tenets of this multidisciplinary approach is the use of multimodal analgesia with opioid-sparing and even opioid-free anesthesia and analgesia. However, the current state is a historically high use of opioids for both appropriate and inappropriate reasons, and patients with chronic opioid use before their surgery represent a common, often difficult-to-manage population for the enhanced recovery providers and health care team at large. Furthermore, limited evidence and few proven successful protocols exist to guide providers caring for these at-risk patients throughout their elective surgical experience. Therefore, the fourth Perioperative Quality Initiative brought together an international team of multidisciplinary experts, including anesthesiologists, nurse anesthetists, surgeons, pain specialists, neurologists, nurses, and other experts with the objective of providing consensus recommendations. Specifically, the goal of this consensus document is to minimize opioid-related complications by providing expert-based consensus recommendations that reflect the strength of the medical evidence regarding: (1) the definition, categorization, and risk stratification of patients receiving opioids before surgery; (2) optimal perioperative treatment strategies for patients receiving preoperative opioids; and (3) optimal discharge and continuity of care management practices for patients receiving opioids preoperatively. The overarching theme of this document is to provide health care providers with guidance to reduce potentially avoidable opioid-related complications including opioid dependence (both physical and behavioral), disability, and death. Enhanced recovery programs attempt to incorporate best practices into pathways of care. By presenting the available evidence for perioperative management of patients on opioids, this consensus panel hopes to encourage further development of pathways specific to this high-risk group to mitigate the often unintentional iatrogenic and untoward effects of opioids and to improve perioperative outcomes.

PICC-line, a peripherally inserted central venous catheter has been implemented by several Norwegian hospitals in recent years. Nurse Anesthetists play an important role in this process, and have been given new tasks as a result of PICC-line implementation. This study aimed to describe Nurse Anesthetists’ experiences with implementation of PICC-line in hospital. A qualitative design, the data are based on three focus groups interviews with fifteen nurse anesthetists. The interviews were analyzed using a hermeneutic approach. Being a PICC-line nurse led to a feeling of competence, independence, motivation and meaningfulness. The implementation required good structure and organization, as well as enthusiasm. Collaboration and support influenced the implementation process. Good organization and enough available personnel, as well as good collaboration and support from the Anesthesiologists and the management are essential for a successful implementation.

CONTEXT. Complex societal factors have been obstructing implementation of quality improvement education (QIE) and interprofessional learning (IPL) of perioperative teams. Mistrust between physician anesthesiologist and nurse anesthetist, and payment models that promote competition instead of teamwork, are two of the drivers that shape that picture. METHODOLOGY. In the first part of this critical-realist case study, thematic analysis and activity theory draw a complex picture of how perioperative clinicians perceive QIE, IPL, and technology-enhanced learning (TEL). Following that, critical realist abduction and retroduction logic define one mechanism shaping perceptions of QIE, IPL, and TEL in perioperative context. FINDINGS. Perceptions of QIE, IPL, and TEL of perioperative teams are intertwined, and perception of one phenomenon can have a transformative impact on perceptions of other phenomena in the context, creating a very dynamic picture. On the other hand, a learning healthcare system (LHS) is not part of the picture since technocentric and managerial visions of LHS promoted by the Institute of Medicine don’t support social complexity of QIE and IPL. THE MECHANISM shaping complexity of perceptions is: Our world acts as an agglomeration of nested learning systems. On each level, the mechanism is guiding ontological and epistemological transformation of the learning system, through four phases: egocentric >> technocentric >> ecocentric >> holocentric. Those transformations emerge on any level of agglomeration: from cells gathered to create the first multicellular organism to networks of individuals and groups creating professional societies or perioperative teams. The thesis contributes to knowledge by shedding additional light on how the complex world of perioperative healthcare is structured and how various systems involved in perioperative care interact. On a practical level, the map of QIE, IPL, and TEL perceptions, and insight into one mechanism that is shaping those perceptions, can help perioperative leaders better navigate the transformative changes affecting perioperative teams.

There are several unique considerations when preparing to sedate a patient for for endoscopic retrograde cholangiopancreatography (ERCP). Most endoscopists prefer to position the patient in the prone position. Because monitoring chest movement is particularly difficult in this circumstance, the use of capnography (end-tidal carbon dioxide (ETCO2) is recommended. The patient should be monitored by a health care provider who is not otherwise responsible for executing the procedure (e.g., an anesthesiologist, nurse anesthetist, or registered nurse). Sedation should be administered by a provider who is trained in the sedation continuum; patients undergoing ERCP require a depth of sedation ranging from moderate sedation to general anesthesia. In the US, if the targeted level of sedation is deep sedation or greater, a provider trained in the administration of anesthesia should be used. Consistent with other endoscopic procedures, there is an increasing trend to use an anesthesia provider for the administration of sedation during ERCP. Prior to ERCP, the team of providers should carefully assess the patient's risk for a sedation-related adverse event. This includes an understanding of the procedure's anticipated intensity and duration, which will inform the optimal approach to administering sedation (e.g., use of an endotracheal tube). Room setup and other considerations for patient and provider safety are essential, including the use of appropriate protective equipment for radiation safety. The provider whose sole responsibility is to monitor the patient during sedation should have visual and physical access to the patient's airway at all times.

Background Anesthesia departments start an agreed-upon number of locations each workday. For academic departments, variability in the number of anesthesiology residents available to start the first cases each day affects hiring and staff scheduling. These decisions depend on the median number of available residents and variability among days. We analyzed the number of residents starting first-cases of the day over a 13.5-year interval to provide quantitative data to guide long-term decision-making related to hiring other anesthesia providers (e.g., nurse anesthetists, anesthesia assistants). Methods We obtained electronic data from an academic hospital's anesthesia information management system to determine the number of cases started by anesthesiology residents and other anesthesia providers. We assessed variability among days using quartile regression with clustering by 6-month period. Results From 2006 through 2018, the annual number of anesthetics increased progressively from 31,559 to 44,981. The percentage of all cases started by residents decreased from 38.4% to 21.4%, as did the number of cases started during regular workdays (-9.7 [SE 2.9] cases per year, P = 0.008). The number of resident days starting a first-case was unchanged. On half the days (0.5 quartile), the percentage of full-time equivalent residents who started a first-case was 36.5% during July to December periods and 32.8% during January to June periods (difference = 3.7%, SE 0.7%, P Conclusions The fraction of anesthesiology residents starting first-cases on regular workdays remained stable over 13.5 years, but there was considerable day to day variability. For long-term staffing purposes, we suggest relying on the first quartile of residents starting first-cases (rounded down) as a strategy to calculate the number of anesthesia providers required each day to staff the first cases of the day.

Advanced practice providers (APPs) are qualified medically licensed health care providers, including nurse practitioners (NPs), physician assistants (PAs), nurse anesthetists, certified nurse-midwives, and clinical nurse specialists, who can function either independently or alongside a physician in population-centered care models, disease management integration, care coordination, or in the provision of direct patient care. They also can improve revenue and reduce physician burnout. The use of APPs in the practice of neurology is still in its infancy, and many neurologists are not sure how to integrate an APP in their practice. This article addresses some concerns related to integrating an APP in the inpatient and outpatient settings.

Introduction This article presents the results of the 2015 professional practice analysis (PPA) conducted by the National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA). The goal of the PPA was to establish and validate a content outline and test specifications for NBCRNA's examination for the continued professional certification (CPC) program. In professional certification test development, a PPA establishes the content validity of an examination and serves as the key evidentiary link between the test and clinical practice. Methods The PPA used survey and rating scale methodologies to collect data on the relative emphasis of various aspects of the nurse anesthesia knowledge domain and competencies. Overall, 726 survey responses were analyzed by a panel with expertise in clinical anesthesia and testing methodology, using conventional statistics and the Rasch rating scale model. Descriptions of how the survey results were used to develop test specifications are also provided. Results The results of the analysis provided strong validity evidence for the content outline and test specifications. Conclusion To a great extent, the responses of the PPA survey exhibited a high-degree endorsement for the knowledge statements included on the outline and thus serve as a basis of content validation for the CPC examination.

Clinical documentation is a critical tool in supporting care provided to patients. Sound documentation provides a picture of clinical events that can be used to improve patient care. However, many other uses for clinical documentation are equally important. Such documentation informs clinical decision support tools, creates a legal record of patient care, assists in financial reimbursement of services, and serves as a repository for secondary data analysis. Conversely, poor documentation can impair patient safety and increase malpractice risk exposure by reflecting poor or inaccurate information that ultimately may guide patient care decisions.Through an examination of anesthesia-related closed claims, a descriptive qualitative study emerged, which explored the antecedents and consequences of documentation quality in the claims reviewed. A secondary data analysis utilized a database generated by the American Association of Nurse Anesthetists Foundation closed claim review team. Four major themes emerged from the analysis. Themes 1, 2, and 4 primarily describe how poor documentation quality can have negative consequences for clinicians. The third theme primarily describes how poor documentation quality that can negatively affect patient safety.

The aim of this study was to prospectively evaluate effective dose (E) of operators performing transjugular intrahepatic portosystemic shunts (TIPS) in a single centre. Patients’ radiation exposure was also collected. Between 8/2015 and 6/2016, 45 consecutive TIPS were performed in adult patients using a flat-panel detector-based system (FPDS) and real-time ultrasound guidance (USG) for portal vein targeting. Electronic personal dosimeters were used to measure radiation doses to the primary and assistant operators, anaesthesia nurse and radiographer. Patients’ radiation exposure was measured with dose area product (DAP); fluoroscopy time (FT) was also collected. Mean E for the primary operator was 1.40 μSv (SD 2.68, median 0.42, range 0.12 – 12.18), for the assistant operator was 1.29 μSv (SD 1.79, median 0.40, range 0.10 – 4.89), for the anaesthesia nurse was 0.21 μSv (SD 0.67, median 0.10, range 0.03 – 3.99), for the radiographer was 0.42 μSv (SD 0.71, median 0.25, range 0.03 – 2.67). Mean patient DAP was 59.31 GyCm2 (SD 56.91, median 31.58, range 7.66 – 281.40); mean FT was 10.20 min (SD 7.40, median 10.40, range 3.8 – 31.8). The use of FPDS and USG for portal vein targeting allows a reasonably low E to operators performing TIPS. • The operators’ E vary according to the complexity of the procedure. • FPDS and USG allow a reasonably low E to TIPS operators. • FPDS and USG have an important role in reducing the occupational exposure.

The objective of this narrative review is to provide an overview of the problem of non-opioid anesthetic drug abuse among anesthesia care providers (ACPs) and to describe current approaches to screening, therapy, and rehabilitation of ACPs suffering from non-opioid anesthetic drug abuse. We first performed a search of all literature available on PubMed prior to April 11, 2016. The search was limited to articles published in Spanish and English, and the following key words were used: anesthesiology, anesthesia personnel, AND substance-related disorders. We also searched Ovid MEDLINE® databases from 1946-April 11, 2016 using the following search terms: anesthesiology OR anesthesia, OR nurse anesthetist OR anesthesia care provider OR perioperative nursing AND substance-related disorders. Despite an increased awareness of drug abuse among ACPs and improvements in preventive measures, the problem of non-opioid anesthetic drug abuse remains significant. While opioids are the most commonly abused anesthesia medications among ACPs, the abuse of non-opioid anesthetics is a significant cause of morbidity, mortality, and professional demise. Early detection, effective therapy, and long-term follow-up help ACPs cope more effectively with the problem and, when possible, resume their professional activities. There is insufficient evidence to determine the ability of ACPs to return safely to anesthesia practice after rehabilitation, though awareness of the issue and ongoing treatment are necessary to minimize patient risk from potentially related clinical errors.

Background Anesthesia in West Africa is associated with high mortality rates. Critical shortages of adequately trained personnel, unreliable electrical supply, and lack of basic monitoring equipment are a few of the unique challenges to surgical care in this region. This study aims to describe the anesthesia practice at 2 tertiary care hospitals in Sierra Leone. Methods We conducted an observational study of anesthesia care at Connaught Hospital and Princess Christian Maternity Hospital in Freetown, Sierra Leone. Twenty-five percent of the anesthesia workforce in Sierra Leone, resident at both hospitals, was observed from June 2012 to February 2013. Perioperative assessments, anesthetic techniques, and intraoperative clinical and environmental irregularities were noted and analyzed. The postoperative status of observed cases was ascertained for morbidity and mortality. Results Between the 2 hospitals, 754 anesthesia cases and 373 general anesthetics were observed. Ketamine was the predominant IV anesthetic used. Both hospitals experienced infrastructural and environmental constraints to the delivery of anesthesia care during the observation period. Vital sign monitoring was irregular and dependent on age and availability of monitors. Perioperative mortality during the course of the study was 11.9 deaths/1000 anesthetics. Conclusions We identified gaps in the application of internationally recommended anesthesia practices at both hospitals, likely caused by lack of available resources. Mortality rates were similar to those in other resource-limited countries.

In 2001, the Center for Medicare and Medicaid Services issued a rule permitting states to "opt-out" of federal regulations requiring physician supervision of nurse anesthetists. We examined the extent to which this rule increased access to anesthesia care for urgent cases.Using data from a national sample of inpatient discharges, we examined whether opt-out was associated with an increase in the percentage of patients receiving a therapeutic procedure among patients admitted for appendicitis, bowel obstruction, choledocholithiasis, or hip fracture. We chose these 4 diagnoses because they represent instances where urgent access to a procedure requiring anesthesia is often indicated. In addition, we examined whether opt-out was associated with a reduction in the number of appendicitis patients who presented with a ruptured appendix. In addition to controlling for patient morbidities and demographics, our analysis incorporated a difference-in-differences approach, with additional controls for state-year trends, to reduce confounding.Across all 4 diagnoses, opt-out was not associated with a statistically significant change in the percentage of patients who received a procedure (0.0315 percentage point increase, 95% confidence interval [CI] -0.843 to 0.906 percentage point increase). When broken down by diagnosis, opt-out was also not associated with statistically significant changes in the percentage of patients who received a procedure for bowel obstruction (0.511 percentage point decrease, 95% CI -2.28 to 1.26), choledocholithiasis (2.78 percentage point decrease, 95% CI -6.12 to 0.565), and hip fracture (0.291 percentage point increase, 95% CI -1.76 to 2.94). Opt-out was associated with a small but statistically significant increase in the percentage of appendicitis patients receiving an appendectomy (0.876 percentage point increase, 95% CI 0.194 to 1.56); however, there was no significant change in the percentage of patients presenting with a ruptured appendix (-0.914 percentage point decrease, 95% CI -2.41 to 0.582). Subanalyses showed that the effects of opt-out did not differ in rural versus urban areas.Based on 2 measures of access, opt-out does not appear to have significantly increased access to anesthesia for urgent inpatient conditions.

Summary Background The risk factors contributing to maternal mortality from anaesthesia in low-income and middle-income countries and the burden of the problem have not been comprehensively studied up to now. We aimed to obtain precise estimates of anaesthesia-attributed deaths in pregnant women exposed to anaesthesia and to identify the factors linked to adverse outcomes in pregnant women exposed to anaesthesia in low-income and middle-income countries. Methods In this systematic review and meta-analysis, we searched major electronic databases from inception until Oct 1, 2015, for studies reporting risks of maternal death from anaesthesia in low-income and middle-income countries. Studies were included if they assessed maternal and perinatal outcomes in pregnant women exposed to anaesthesia for an obstetric procedure in countries categorised as low-income or middle-income by the World Bank. We excluded studies in high-income countries, those involving non-pregnant women, case reports, and studies published before 1990 to ensure that the estimates reflect the current burden of the condition. Two independent reviewers undertook quality assessment and data extraction. We computed odds ratios for risk factors and anaesthesia-related complications, and pooled them using a random effects model. This study is registered with PROSPERO, number CRD42015015805. Findings 44 studies (632 556 pregnancies) reported risks of death from anaesthesia in women who had an obstetric surgical procedure; 95 (32 149 636 pregnancies and 36 144 deaths) provided rates of anaesthesia-attributed deaths as a proportion of maternal deaths. The risk of death from anaesthesia in women undergoing obstetric procedures was 1·2 per 1000 women undergoing obstetric procedures (95% CI 0·8–1·7, I 2 =83%). Anaesthesia accounted for 2·8% (2·4–3·4, I 2 =75%) of all maternal deaths, 3·5% (2·9–4·3, I 2 =79%) of direct maternal deaths (ie, those that resulted from obstetric complications), and 13·8% (9·0–20·7, I 2 =84%) of deaths after caesarean section. Exposure to general anaesthesia increased the odds of maternal (odds ratio [OR] 3·3, 95% CI 1·2–9·0, I 2 =58%), and perinatal deaths (2·3, 1·2–4·1, I 2 =73%) compared with neuraxial anaesthesia. The rate of any maternal death was 9·8 per 1000 anaesthetics (5·2–15·7, I 2 =92%) when managed by non-physician anaesthetists compared with 5·2 per 1000 (0·9–12·6, I 2 =95%) when managed by physician anaesthetists. Interpretation The current international priority on strengthening health systems should address the risk factors such as general anaesthesia and rural setting for improving anaesthetic care in pregnant women. Funding Ammalife Charity and ELLY Appeal, Bart's Charity.

In this prospective cohort study, 200 decontamination (cleaning and disinfection) procedures of the anesthesia workplace either by anesthesia nurses or by specially trained housekeeping staff were monitored. Time used by housekeeping staff was shorter (1.2 ± 0.1 vs 2.6 ± 0.2 minutes on average, data are mean ± SEM; P < 0.0001) with less visible marker spots (14.4 ± 0.68 [55%] vs 17.3 ± 0.75 [66.7%] on average, data are mean ± SEM; P = 0.0041), and the bacterial load showed a decrease (≅67%, P < 0.0001) compared with anesthesia nurses. Specially trained housekeeping staff outperformed anesthesia nurses in cleaning the anesthesia workplace. Specific training for anesthesia workplace cleaning is supported by these findings.

Summary Background Despite the expansion of capnography use, instruments for evaluating healthcare professionals' knowledge about capnography are missing from international literature. Objectives To develop and validate an instrument for evaluating nurses' knowledge about capnography, named the "Nurses' Knowledge about Capnography Test" (NKCT). Method A literature review was performed to formulate instrument items. Thirty-six items were initially developed, which covered principles of capnography function, conditions affecting end-tidal CO 2 pressure and capnography waveform, and indications for capnography use. Six items were deleted after content validity and intra-rater reliability evaluation. The final 30-item instrument was completed by 103 anesthesiology department nurses employed in six hospitals of Greece, to test its internal consistency, item difficulty and discrimination, and construct validity. Results Kuder–Richardson 20 coefficient was 0.79. Ten items were found to be of high difficulty, while item discrimination was low for two of them. Instrument scores were found significantly higher among participants with higher educational level and longer experience in capnography use. Conclusion NKCT is a psychometrically comprehensive instrument for evaluating nurses' knowledge about capnography, which is recommended to be re-validated beyond the anesthesiology department and be used for the assessment of educational programs on capnography.

Background/Aims: The efficacy of bispectral index (BIS) monitoring during colonoscopic sedation is debated. We aimed to determine whether BIS monitoring was useful for propofol dose titration, and to evaluate differences in sedative administration between expert and inexperienced medical personnel during colonoscopy procedures that required moderate sedation. Methods: Between February 2012 and August 2013, 280 consecutive patients scheduled to undergo a screening colonoscopy participated in this study and were randomly allocated to the expert or inexperienced endoscopist group. Each group was further divided into either a BIS or a modified Observer’s Assessment of Alertness/Sedation Scale (MOAA/S) subgroup. Trained nurses administered combined propofol sedation and monitored sedation using either the BIS or MOAA/S scale. Results: The mean BIS value throughout the procedure was 74.3 ± 6.7 for all 141 patients in the BIS group. The mean total propofol dose administered in the BIS group was higher than that in the MOAA/S group, independently of the endoscopists’ experience level (36.9 ± 29.6 and 11.3 ± 20.7, respectively; p < 0.001). The total dose of propofol administered was not significantly different between the inexperienced endoscopist group and the expert endoscopist group, both with and without the use of BIS (p = 0.430 and p = 0.640, respectively). Conclusions: Compared with monitoring using the MOAA/S score alone, BIS monitoring was not effective for titrating the dose of propofol during colonoscopy, irrespective of colonoscopist experience.

World-wide, nurse anesthetists provide anesthesia care in many countries. Because of different historical background responsibilities, tasks and roles vary widely around the world. Established in 1989, the International Federation of Nurse Anesthetists (IFNA) is a global organization representing nurse anesthetists. Each member country is represented in the Council of National Representatives who elect their Board of Officers who manage IFNA on a day-to-day basis. Together with several committees, the IFNA is dedicated to the advancement of educational standards and practices that will advance the art and science of nurse anesthesia and thereby support and enhance quality anesthesia worldwide. The IFNA has relationships with numerous institutions that share the professional interest in nurse anesthesia: International Council of Nurses, World Health Organization, World Federation of Societies of Anesthesiologists (WFSA) and European Society of Anesthesiology. The IFNA-Standards, the Anesthesia Program Approval Process and the IFNA-world congresses are important tools used in the globalization process. Currently, the focus is on a framework and guidelines for Continuous Professional Development, recertification, accreditation and legislation. This is not only important for further development of the profession and the constant improvement of quality anesthesia care but also to become known to the general public.

We appreciate the interest in our article advocating for a national strategy for anesthesia services in rural and remote regions of Canada.[1][1] Bland[2][2] and other commenters on the CMAJ website have proposed that the shortage of anesthesia care providers in rural Canada could be remedied

Background To make it efficient, health care waste (HCW) segregation has to be done at the source. It must be simple, safe, well explained and understood by the personnel. To maintain good practice, regular training systems for old and new staff members and continuous assessment are essential to assure a high quality of waste management. Our objective is to create a new practical tool to assess the practice of surgical team members at our university hospital regarding the segregation of HCW. Methods Surgical team members were divided into four groups and 9 subgroups. Nine different colors were assigned to each subgroup. Pictures of 30 surgical wastes were used instead of the items themselves. Each item was marked by one color from the population set of colors in a way that each subgroup of the sample has a complete set of the 13 wastes marked by the corresponding color. Five artificial empty waste containers were created using 5 colors. Sets were provided to the staff as they were entering the operating theater on the study days. Segregation of the items was done in an individual manner at the spot of the distribution. Data were collected into tables using Microsoft (MS) Excel 2016 and was checked twice. Descriptive statistic was used to analyze the data. Results 64 health care professionals participated and 832 items were segregated. The mean wrong segregation rate was 12.6%. The operating theatre technician, residents, visitors, anesthetists, non-specialized nurses, nurse anesthetists, and surgeons got respectively 92.3%, 85.6%, 84.6%, 84.6%, 81.7%, 79.8% and 78.1% correct segregations. Each visitor (medical students from other centers), operating theater technician, nurse anesthetist, non-specialized nurse, surgeon, anesthetist, and resident had a 7.7%, 7.7%, 2.5%, 2.3%, 1.7%, 1.9% and 0.6% risk of incorrect segregation. In total, each member had a 0.3% risk of wrong segregation. Conclusion To our knowledge, no similar study was done until now and no similar practice assessment method was used so far in the literature. We introduced a new experimental tool that permitted to conclude that the members of the team of our surgical theater have good knowledge reflected by the low rates of wrong segregations. The method was safe, fast, attracting and more comparable to the daily work rhythm at the department studied.

The coronavirus disease 2019 (COVID-19) pandemic created an unprecedented need for mechanical ventilation in critically ill patients. To meet this increased demand, some facilities were forced to use anesthesia gas machines (AGMs) as intensive care unit (ICU) ventilators. While an off-label use, AGM manufacturers, the Anesthesia Patient Safety Foundation, and the American Society of Anesthesiologists have guidelines for AGM use in the ICU, however, there is scant literature describing their use. This article describes our experiences at New York University Langone Medical Center using AGMs in the ICU for ventilating critically ill COVID-19 patients.

Purpose To study nurse anesthetists' experiences of key factors for successful airway management in general anesthesia of adult obese patients. Design The study was a qualitative observational study with a descriptive approach. Methods Eight semistructured interviews were conducted. Data were analyzed using the critical incident technique. Findings Five key factors for successful general anesthesia of adult obese patients were identified. These factors were preparing and planning the anesthesia, optimizing patient position, optimizing ventilation through proper preoxygenation and increasing positive end-expiratory pressure, quickly securing the airway, and working in teams. Conclusions Knowledge of key factors that facilitate and improve the anesthesia care of obese patients is important to provide safe and quality anesthesia to this patient group as obese patients often have small margins and urgent situations can quickly arise. This knowledge enables the nurse anesthetist to be one step ahead and to be ready to take action if complications occur.

Background Anesthesia providers in low- and middle-income countries face many challenges, including poor availability of functioning equipment designed to meet their environmental, organizational, and resource constraints. These are serious global health disparities which threaten access to care and patient safety for those who receive surgical care. In this study, we conducted a simulation-based human factors analysis of the Universal Anaesthesia Machine (UAM®), a device designed to support anesthesia providers in austere medical settings. Our team anticipated the introduction of the UAM® to the two major referral hospitals in Freetown, Sierra Leone. A prior observational study had identified these two hospitals as having environmental conditions consistent with an austere environment: an unstable electrical grid, as well as limited access to compressed oxygen, biomedical support, and consumables. Although the Baltimore simulation environment cannot reproduce all of the challenges present in a resource-constrained environment such as Sierra Leone, the major impediments to standard anesthesia machine functionality and human factors-associated use can be reproduced with the use of high-fidelity simulation. Using anesthesia care providers who have limited UAM® familiarity, this study allowed for the examination of machine-user issues in a controlled environment in preparation for further field studies concerning equipment introduction, training and device deployment in Sierra Leone. The goals of this study were: 1. to assess the usability of the UAM® (machine-user interface, simulated patient use, symbology, etc.) across different provider user groups during simulation of use in scenarios depicting routine use in healthy patients, use in clinically challenging patients and use in environmentally-challenging scenarios in a controlled setting devoid of patient risk, and 2. To gather feedback on available UAM manuals and cognitive aides and UAM usability issues in order to guide development of curricula for training providers on use of the UAM® in the intended austere clinical environments. Methods Residents, fellows, attending physician anesthesiologists, student nurse anesthetists, and nurse anesthetists participated in a variety of simulations involving the Universal Anaesthesia Machine® at the Johns Hopkins Medicine Simulation Center between September 2012 and July 2013. Data collected included participant demographics, performance during simulation scenarios captured with critical action checklists, workload ratings captured with the National Aeronautics and Space Administration Task Load Index (NASA TLX), and participant reactions to UAM® use captured through a post-session survey and semi-structured usability debriefing. The scenarios were: 1. normal use (machine check, induction, and maintenance of an uneventful case), 2. use in a challenging clinical condition (acute onset of bronchospasm) and 3.use in an adverse environmental event (power failure). Critical action checklists and workload ratings were analyzed by Analysis of Covariance (ANCOVA) to control for participant demographics. Usability debriefings were analyzed qualitatively. Results Thirty-five anesthesia providers participated in the study. Overall participant ratings, observations of performance in simulation scenarios, and usability debriefings indicated a high level of usability for the UAM®. Mean participant ratings were high for ease of use (5.4 ± 0.96) and clarity of instruction (6.2 ± 0.87) on a 7-point scale in which higher ratings indicate more positive perceptions. After adjusting for clinical experience, workload ratings were significantly higher in the bronchospasm scenario than in the normal/routine use (P = 0.046; 95% CI, 0.33–34.7) or power failure scenarios (P = 0.012; 95% CI, 5.24–37.9). Thirty-two specific usability issues were identified and grouped into five themes: device design and labeling, machine use during simulation scenarios, user-anticipated errors or hazards, curriculum issues, and overall impressions of the UAM®. Conclusions The UAM® design addresses many of the key challenges facing anesthesia providers in resource-constrained settings. The simulation-based human factors evaluation described here successfully identified opportunities for continued refinement of the initial device design as well as issues to be addressed in future curricula and cognitive aides.

How can one nurse change the world? This descriptive case study examines the remarkable career of Margaret Kollmer, a nurse and Mary-knoll Sister who developed Korea's first Certified Registered Nurse Anesthetist training program and organized the Korean Association of Nurse Anesthetists. Later, she joined a team serving displaced Korean families and helped establish the first hospice program in Korea, as well as a resident hospice program for homeless AIDS patients in New York. Her 59 years of service shows what faithful reliance on God can accomplish.

Background Anesthesia providers commonly cross-contaminate their workspace and subsequently put patients at risk for a health care–acquired infection. The primary objective of this project was to determine if education and implementation of standardized infection control guidelines that address evidence-based best practices would improve compliance with infection control procedures in the anesthesia workspace. Methods Patient care–related hand hygiene of nurse anesthetists was observed in 3 areas of anesthesia practice before and 3 weeks and 3 months after staff education, placement of visual reminders, and the implementation of infection control guidelines. After the observation periods, the percent compliance on the part of the providers was calculated for each of the 3 areas of anesthesia practice, and the results were compared using the Fisher exact test. Results There were a total of 95 observations performed during the 3 observation periods. When compared with preimplementation baseline data, there was a 26.2% increase in the number of providers compliant with hand hygiene practices after airway instrumentation (P = .029) and a 71.9% increase in the number of providers who separated clean from contaminated items in the workspace (P = .0001). Conclusions Education, visual reminders, and standardized infection control guidelines were shown to improve compliance with infection control best practices in a group of nurse anesthetists.

Purpose To compare perceived competence and self-efficacy (SE) among Swedish operating room (OR) nurses and registered nurse anesthetists (RNAs), and to evaluate the relationship between SE and competence, gender, age, and years of experience. Design Comparative cross-sectional survey. Methods Two validated questionnaires, Perceived Perioperative Competence Scale-Revised and General Self-Efficacy Scale, were sent to members of the Swedish Association of Health Professionals (n = 2,902). Findings The response rate was 39% (n = 1,033). OR nurses showed significantly higher scores on Perceived Perioperative Competence Scale-Revised subscale foundational knowledge and leadership as well as General Self-Efficacy Scale scores compared with RNAs. The RNA group showed significantly higher empathy scores compared with OR nurses. Among the OR nurses professional development made the strongest contribution to SE and proficiency among the RNAs. Conclusions These results suggest that there are differences in perceived competence and SE between OR nurses and RNAs. Gender may be an independent factor affecting SE.

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background In the United States, anesthesia care can be provided by an anesthesia care team consisting of nonphysician providers (nurse anesthetists and anesthesiologist assistants) working under the supervision of a physician anesthesiologist. Nurse anesthetists may practice nationwide, whereas anesthesiologist assistants are restricted to 16 states. To inform policies concerning the expanded use of anesthesiologist assistants, the authors examined whether the specific anesthesia care team composition (physician anesthesiologist plus nurse anesthetist or anesthesiologist assistant) was associated with differences in perioperative outcomes. Methods A retrospective analysis was performed of national claims data for 443,098 publicly insured elderly (ages 65 to 89 yr) patients who underwent inpatient surgery between January 1, 2004, and December 31, 2011. The differences in inpatient mortality, spending, and length of stay between cases where an anesthesiologist supervised an anesthesiologist assistant compared to cases where an anesthesiologist supervised a nurse anesthetist were estimated. The approach used a quasirandomization technique known as instrumental variables to reduce confounding. Results The adjusted mortality for care teams with anesthesiologist assistants was 1.6% (95% CI, 1.4 to 1.8) versus 1.7% for care teams with nurse anesthetists (95% CI, 1.7 to 1.7; difference −0.08; 95% CI, −0.3 to 0.1; P = 0.47). Compared to care teams with nurse anesthetists, care teams with anesthesiologist assistants were associated with non–statistically significant decreases in length of stay (−0.009 days; 95% CI, −0.1 to 0.1; P = 0.89) and medical spending (−$56; 95% CI, −334 to 223; P = 0.70). Conclusions The specific composition of the anesthesia care team was not associated with any significant differences in mortality, length of stay, or inpatient spending.

PURPOSE: To examine whether nurse anesthetists and postanesthesia nurses' administration of intravenous (IV) fluid therapy during surgery and in the postanesthesia care unit is based on evidence. Secondarily to investigate if providing indications for IV fluid administration changed nursing practice.DESIGN: Prospective, descriptive, single-center study in Scandinavia comparing two cohorts.METHODS: Descriptive, fluid volume, and type data were obtained in both cohorts. Cohort 1 (n = 126) was used as baseline data. In cohort 2 (n = 130), nurses recorded indications for type and volume of fluid therapy using a validated list. Analysis compared median volumes of crystalloid or colloid fluids of surgical types by cohort. Analysis compared frequency of given indication reasons for each IV fluid by surgical type.FINDINGS: Basic static variables were chosen most frequently for indications of IV fluid needed for all surgeries except high-risk abdominal surgery where dynamic variables were more frequent. Signs and symptoms of inadequate tissue perfusion were only sparsely indicated. The volume of intraoperative crystalloid fluids was statistically different for patients with hip fracture surgery in cohort 2. Volumes of both colloid and crystalloid fluids were significantly higher for high-risk abdominal surgery in cohort 2.CONCLUSIONS: Nurse anesthetists and nurses in the postanesthesia care unit rely more on basic static parameters than signs of inadequate tissue perfusion when they make decisions about fluid administration. The indications cited for fluid administered to high-risk abdominal surgery and hip fracture patients did not always fit guidelines. This indicates the need of a stronger intervention to change practice to follow evidence-based clinical guidelines.

BACKGROUND: Pre-hospital tracheal intubation success and complication rates vary considerably among provider categories. The purpose of this study was to estimate the success and complication rates of pre-hospital tracheal intubation performed by physician anaesthetist or nurse anaesthetist pre-hospital critical care teams.METHODS: Data were prospectively collected from critical care teams staffed with a physician anaesthetist or a nurse anaesthetist according to the Utstein template for pre-hospital advanced airway management. The patients served by six ambulance helicopters and six rapid response vehicles in Denmark, Finland, Norway, and Sweden from May 2015 to November 2016 were included.RESULTS: The critical care teams attended to 32 007 patients; 2028 (6.3%) required pre-hospital tracheal intubation. The overall success rate of pre-hospital tracheal intubation was 98.7% with a median intubation time of 25 s and an on-scene time of 25 min. The majority (67.0%) of the patients' tracheas were intubated by providers who had performed >2500 tracheal intubations. The success rate of tracheal intubation on the first attempt was 84.5%, and 95.9% of intubations were completed after two attempts. Complications related to pre-hospital tracheal intubation were recorded in 10.9% of the patients. Intubations after rapid sequence induction had a higher success rate compared with intubations without rapid sequence induction (99.4% vs 98.1%; P=0.02). Physicians had a higher tracheal intubation success rate than nurses (99.0% vs 97.6%; P=0.03).CONCLUSIONS: When performed by experienced physician anaesthetists and nurse anaesthetists, pre-hospital tracheal intubation was completed rapidly with high success rates and a low incidence of complications.CLINICAL TRIAL NUMBER: NCT 02450071.

Purpose To investigate why nurse anesthetists and operating room nurses choose to stay in the same workplace. Design Qualitative design. Methods Individual interviews were conducted with 15 nurse specialists from four hospitals in Sweden. Two men and 13 women aged between 43 and 63 participated. Data were analyzed with systematic text condensation according to Malterud. Findings Three themes were identified. (1) Organizational stability contributed to low staff turnover, with good spirits between colleagues, representing everyone's equal value and resulting in a feeling of homelikeness. (2) Sustained development in one's own profession. (3) A humane head nurse who was at hand, who was a facilitator, who knew staff members, and eliminated obstacles for them. Conclusions In a nonhierarchical and stable organization with a head nurse with caritative leadership skills, a welcoming working environment with opportunities for professional development is created. Thus, nurse specialists choose to stay, contributing to organizational development.

Currently, there are few evidence-based guidelines to inform optimal clinical data-entry template design that maximizes usability while reducing unintended consequences. This study explored the impact of data-entry template design and anesthesia provider workload on documentation accuracy, documentation efficiency, and user-satisfaction to identify the most beneficial data-entry methods for use in future documentation interface design.A study using observational data collection and psychometric instruments (for perceived workload and user-satisfaction) was conducted at three hospitals using different methods of data-entry for perioperative documentation (auto-filling with unstructured data, computer-assisted data selection with semi-structured documentation, and paper-based documentation). Nurse anesthetists at each hospital (N = 30) were observed completing documentation on routine abdominal surgical cases.Auto-filling (61.2%) had the lowest documentation accuracy scores compared to computer-assisted (81.3%) and paper-based documentation (76.2%). Computer-assisted data-entry had the best documentation efficiency scores and required the least percentage of the nurse anesthetists' time (9.65%) compared to auto-filling (11.43%) and paper-based documentation (15.23%). Paper-based documentation had the highest perceived workload scores (M = 288, SD = 88) compared to auto-filling (M = 160, SD = 93, U = 16.5, p 0.01) and computer assisted data-entry (M = 93, SD = 50, U = 4.0, P 0.001).Auto-filling with unstructured data needs to be used sparingly because of its low documentation accuracy. Computer-assisted data entry with semi-structured data needs to be further study because of its better documentation accuracy, documentation efficiency, and perceived workload.

Bakgrund: Vid svårt skadade patienter alternativt sviktande vitalparametrar dras ett traumalarm nivå ett på sjukhusen. Vid nivå ett larm samlas ett större antal interprofessionella specialister inom vården, bland andra specialistsjuksköterskor för att assistera vid luftvägen. Samma specialistsjuksköterskor deltar även vid hjärtstoppslarm inom sjukhuset. Syfte: Syftet med studien var att beskriva anestesi- och intensivvårdssjuksköterskors upplevelse av deltagande i larmverksamhet hospitalt. Metod: Studien har genomförts med en kvalitativ ansats med fokusgruppsintervjuer (n=2) och dyadiska intervjuer (n=2). Fyra intervjuer genomfördes med totalt 11 stycken specialistsjuksköterskor. Sex anestesisjuksköterskor och fem intensivvårdssjuksköterskor deltog i studien. Materialet från intervjuerna bearbetades genom en manifest innehållsanalys. Resultat: Tre kategorier framkom av innehållsanalysen. Att en god introduktion skapar ett tryggare omhändertagande, att rutiner och tydlig rollfördelning ger bättre omhändertagande och att vid larm tidigt vilja skapa en relation till patienten. Slutsats: Sjuksköterskorna upplever att introduktionen i dagsläget kan bli bättre då det inte känner sig tillräckligt förberedda inför att bära larmsökare. Det framkommer även önskan om mer utbildning kontinuerligt både för den egna tryggheten samt för att förbättra teamsamarbetet vid larmen.

PURPOSE The selection of applicants for the Master of Physician Assistant Studies program in the Netherlands is nationally regulated. The minimum criteria are 2 years of experience in health care and a bachelor's degree in nursing or allied health care. However, when students lack the requisite degree, entering a physician assistant (PA) program is possible through an additional assessment process that includes a test of cognitive ability and personality traits. Since 2004, a national registry has tracked all PA students into their employment setting. An evaluation of Master of Physician Assistant graduates who processed through both portals, traditional and alternative, was compared for validation of criteria. METHODS The success rate of PA students with a bachelor's degree was compared with the success of the cohort that completed the alternative assessment. Descriptive statistics and Pearson's chi square statistics were applied to ascertain differences between the 2 cohorts. RESULTS From 2004 to 2014, there were 1241 students enrolled in a PA program in the Netherlands; 184 nurses and nurse anesthetists were enrolled through the alternate pathway. Of the cohort with an assessment, 167 of 184 students (91%) graduated. Of the group with a prerequisite bachelor's degree, 944 students graduated (89%). Differences were considered negligible. CONCLUSIONS It seems that the nondegree alternative assessment of PA education is a reliable predictor of program completion. Because the nondegree alternative assessment is a national standard screening test, it was decided that there is no need to change the admission procedure for PA applicants.

Supportive care for pain relief and back discomfort during electrophysiology interventions is usually needed in the electrophysiology lab, especially in long-lasting procedures like atrial fibrillation ablation. Although this is usually achieved with conventional pharmacologic anesthesia, hypnosis has recently aroused interest as a reliable tool to complement and possibly enhance conscious sedation. We collected five case of percutaneous arrhythmia ablation in which, after informed consent, hypnosis was performed by nurse anesthetists in the cath lab. In each case at the end of the intervention, the patients described complete alterations of perception or memory of the pain or of the length of the study. No anesthetic drug was needed. While waiting for more robust data, we suggest hypnosis could be a reliable, inexpensive and well tolerated tool to obtain complete pain control and comfort during arrhythmia ablation.

This paper explores whether non-physician health professionals should be permitted to testify in medical negligence litigation regarding the medical standard of care applicable to physician-defendants. Can non-physician health professionals acquire the knowledge necessary to know and appreciate the standard of care despite the lack of classical medical education and medical degrees? Is it relevant that a significant amount of health care is provided by non-physicians, such as nurses, nurse practitioners, physician assistants and nurse anesthetists? Other non-physicians work with and may assist in the training of physicians. Are they able to know the medical standard of care? These timely topics will be discussed.

BACKGROUND Cesarean delivery is the most common surgical procedure in low- and middle-income countries, so provision of anesthesia services can be measured in relation to it. This study aimed to assess the type of anesthesia used for cesarean delivery, the level of training of anesthesia providers, and to document the availability of essential anesthetic drugs and equipment in provincial, district, and mission hospitals in Zimbabwe. METHODS In this cross-sectional survey of 8 provincial, 21 district, and 13 mission hospitals, anesthetic providers were interviewed on site using a structured questionnaire adapted from standard instruments developed by the World Federation of Societies of Anaesthesiologists and the World Health Organization. RESULTS The anesthetic workforce for the hospitals in this survey constituted 22% who were medical officers and 77% nurse anesthetists (NAs); 55% of NAs were recognized independent anesthetic providers, while 26% were qualified as assistants to anesthetic providers and 19% had no formal training in anesthesia. The only specialist physician anesthetist was part time in a provincial hospital. Spinal anesthesia was the most commonly used method for cesarean delivery (81%) in the 3 months before interview, with 19% general anesthesia of which 4% was ketamine without airway intubation. The mean institutional cesarean delivery rate was 13.6% of live births, although 5 district hospitals were