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Purpose: This quality improvement (QI) project aims to familiarize peri-anesthesia healthcareprofessionals with non-pharmacological, evidence-based methods for managing preoperative pediatric anxiety. Background: Preoperative anxiety affects millions of children undergoing surgery annually and can have immediate and long-term effects. Thus, peri-anesthesia healthcare professionals must be aware of all non-pharmacological methods to help reduce preoperative anxiety to provide a safe, quality anesthetic course. Method: At Akron Children’s Hospital, certified registered nurse anesthesiologists (CRNAs), physician anesthesiologists, and preoperative, intraoperative, and post-anesthesia care unit (PACU) nurses received an educational PowerPoint presentation along with a post-pre-Qualtrics survey to assess for increased knowledge and understanding of non-pharmacological techniques for reducing pediatric patients’ anxiety before surgery. The willingness of healthcare providers to modify their practices in response to the project's education was also examined. Results: Eleven peri-anesthesia healthcare professionals answered the post-pre survey after the educational presentation. A Wilcoxon signed rank t-test revealed a statistically significant increase in knowledge, understanding, and willingness to modify practice, as evidenced by a p-value of <0.05 in all categories. Conclusion: The results of this QI project support the implementation of an educational session among peri-anesthesia healthcare professionals outlining current evidence-based practices on the best non-pharmacological approaches to reduce pediatric preoperative anxiety.

Purpose. This process improvement project aimed to promote systematic perioperative eye protection for patients who undergo general anesthesia for nonocular surgery.Background. Perioperative eye injuries can cause distress from severe pain, vision loss, and even blindness. Anesthesia practice pattern is associated with perioperative eye protection outcomes. Eye protection beyond taping the eyes with general anesthesia is institution and practitioner dependent. Clinical evidence indicated that consistent anesthesia department-wide eye protection practice changes improve outcomes. Presenting current practice-based evidence could promote local process improvement toward a sustained result. Methods. The Ottawa Model of Research Use Theory guided this education and survey-based project design. All eligible anesthesia providers (n=12) were invited to review a PowerPoint presentation of an innovative four-step eye protection Bundle and its associated theory and clinical evidence. Their current practice and future practice change were surveyed for each component of the Bundle. Two data points—the participation rate and the Bundle acceptance rate in the post-survey—have to reach a predetermined threshold to consider implementing any component of the Bundle. In addition, the post-survey must receive a higher approval rate than the corresponding pre-survey question. Results. The first data point is the participation rate which is 67% (8/12), over the threshold of 50%. The second data point is that Five Bundle components reached the threshold of 60% in the post-presentation survey with three of the five components showing significant differences from pre-presentation survey. The three components are Individualized eye protection- “Need-based product choice,” “implementing an anesthesia department-wide perioperative eye complication treatment protocol, and collecting data on eye-protection outcomes. Conclusions. This project identified three priority areas of practice change for

Purpose: The purpose of this project was to increase healthcare provider knowledge of evidence-based culturally competent practices specific to transgender individuals in the acute care setting.Background: Transgender individuals often face harassment, discrimination, and violence when seeking healthcare (James et al., 2016). They also encounter providers who lack essential knowledge in care of the transgender individual (Samuels et al., 2017). These issues discourage transgender individuals from seeking care, creating a disparity in health (Samuels et al., 2017). Providers report witnessing discrimination against transgender individuals and lacking knowledge required to provide care for this minority population (Carabez et al., 2016). Methods: An online interactive educational module was created using EdApp for providers to access at their convenience. The material was tailored specifically to acute care providers and was restricted to evidence-based culturally competent practices. The module was paired with a pre- and post-survey powered by Qualtrics to obtain de-identified participant data. Results: Twenty-five participants accessed the pre-survey, five participants participated in the educational module, and three participants completed the post-survey. A majority of participants identified as female, registered nurses, and between the ages of 25-44. The high level of dropout between pre- and post-survey confounded statistical analysis using either a paired t-test or Wilcoxon signed-rank test. Post-survey participants rated themselves as very likely to implement a change to their practice after the training module. Conclusions: While significant limitations were identified in the implementation of this project, it served as an important proof of concept in educating providers on culturally competent practices specific to transgender individuals. Recommendations are made for future researchers.

Purpose: The purpose of this project was to increase awareness and airway provider confidence levels with use of a COVID-19 adult intubation checklist at a rural medical facility in northern Arizona. Background: Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), the virus responsible for COVID-19, has infected over 1.9 million people within the state of Arizona. Some of these COVID-19 patients will develop acute respiratory failure with profound hypoxemia, multi-organ failure, and often may require intubation with invasive mechanical ventilation needs. Airway management of COVID-19 patients may be improved through use of a facility-specific COVID-19 adult intubation checklist. New strategies are needed to decrease the transmission of COVID-19, thus educating airway providers on current recommended checklist use may be critical for providers, healthcare workers, medical organizations, and the surrounding communities. Methods: Through an educational presentation, the recommendations, benefits, and potential for quality improvements with utilization of a COVID-19 adult intubation checklist was presented to project participants. Surveys were conducted before and after the presentation. The survey information was used to identify increases in checklist awareness, airway provider confidence levels, and future intent to use a specialized COVID-19 intubation checklist. Results: Four certified registered nurse anesthetists participated in this project representing a 57% response rate during recruitment. All four participants completed the PowerPoint presentation and both surveys. Survey data displayed reported increases in airway provider confidence levels and likelihood to use a site-specific COVID-19 intubation checklist. 100% (n=4) of participants agreed on improved communication and team performance benefits with use of a properly implemented checklist. Conclusions: Through creating awareness of the current recommendations for intubation of COVID-19 patients

Purpose: The primary purpose of this project was to assess and improve anesthesia providers’ acceptance and intent to use emergency manuals in their practice. A secondary purpose was to determine how emergency manual usage would change anesthesia providers’ confidence in their performance during the management of crisis scenarios in the operating room. Background: Emergency manuals provide medical providers with vital information to manage various critical life-threatening situations. The use of emergency manuals during a crisis improves provider performance and patient outcomes, however, many anesthesia providers do not currently utilize these manuals during such situations. Training sessions have been shown to improve provider usage of such manuals. Methods: The project utilized pre-training and post-training electronic surveys created by Qualtrics to assess anesthesia providers’ attitudes towards emergency manuals and their willingness to utilize them. The pre-training survey was taken by participants before viewing a Panopto presentation training that presented the importance and benefits of emergency manual usage. The participants then completed the post-training survey that contained similar questions to assess changes in the providers’ attitudes towards the manuals, and how they perceived the manual would change their performance. Results: The number of participants who stated they were “extremely likely” to utilize the emergency manuals in their practice increased from four (30.7%) to eight (66.7%) after participation in the training session. The training session also showed an improvement in attitudes, as those rating emergency manuals as “extremely useful” in managing crisis situations in the OR increased from three (23.1%) to seven (58.3%). Additionally, those stating they “strongly agree” that emergency manual usage improves anesthesia provider performance in managing crises increased from three (23.1%) to seven (58.3%). Provider’s reporting, they were “

Purpose: The purpose of this quality improvement (QI) project is to increase anesthesia providers' MMA knowledge and willingness to use MMA through a live presentation educational event at Arrowhead Regional Medical Center (ARMC). Background: Prescription opioid misuse causes about 17,000 deaths annually, with over 10 million individuals misusing prescription opioids (CDC, 2019; SAMHSA, 2019). The opioid epidemic forces all healthcare providers to examine their role in this crisis. Anesthesia providers play a significant role in the crisis by introducing their patients to opioids and managing postoperative pain. Poorly managed postoperative pain may lead to acute and chronic pain syndromes (Mills et al., 2019). The introduction of Multimodal Analgesia (MMA) utilizes multiple non-opioid medications targeting various receptors to reduce acute and chronic pain (Brown et al., 2018). MMA effectively manages postoperative pain and reduces opioid requirements (Li & Chen, 2019; Xu et al., 2018). Methods: The design is a pre- and post-survey educational program to assess ARMC anesthesia providers’ MMA knowledge and willingness to use MMA techniques. The PI created an MMA training after a review of the literature. The PI provided anesthesia providers with live MMA training via a PowerPoint presentation, collected demographic data, assessed current MMA knowledge and utilization, and assessed post-training MMA knowledge and willingness to use MMA techniques. Results: Eighteen anesthesia providers attended the MMA presentation, including six certified registered nurse anesthetists (CRNAs) and 12 resident registered nurse anesthetists (RRNAs). There was a statistically significant increase in anesthesia providers’ MMA knowledge, as demonstrated by the increase in post-survey scores following the MMA training. The anesthesia providers also reported being more confident in utilizing MMA and more likely to use MMA in future practice. Conclusions: This project successfully demonstrat

Purpose. The purpose of this quality improvement project was to develop and present an educational video presentation to anesthesia providers regarding anesthetic considerations for patients who use electronic cigarettes, and to assess whether the educational presentation causes a change in the anesthesia providers’ attitudes, knowledge, confidence, and intent to change clinical practice. Background. The prevalence of electronic cigarette use has been increasing, especially among adolescents and young adults. Research findings have associated electronic cigarette use with multiple adverse health effects that should be considered when providing anesthetic care to these patients. Anesthesia providers may not be fully informed about these effects and may not be adequately screening patients for electronic cigarette use prior to surgery. Methods. Participants were instructed to take a pretest survey, view a pre-recorded educational presentation, and then complete a posttest survey. The surveys were intended to assess for changes in anesthesia providers’ self-reported attitudes, knowledge, confidence, and intent to change clinical practice before and after viewing the presentation. Results. Three out of 25 anesthesia providers participated in the project. All participants reported improved attitudes towards the importance of anesthetic considerations for electronic cigarette users, increased knowledge, increased confidence in caring for patients who use electronic cigarettes, and a positive intent to include questions about electronic cigarette use when interviewing patients preoperatively as well as to incorporate the anesthetic considerations described in the educational presentation in their clinical practices. Conclusions. Although the survey results showed changes had occurred in the outcome measures, due to the limited sample size no conclusions could be drawn.

Purpose: The purpose of this project was to increase anesthesia care provider awareness and knowledge of the ‘hemafuse device’ through an educational presentation at a community hospital in Casa Grande, Arizona. Background: The SARS-CoV-2 virus has led to a steep decline in blood available for allogeneic transfusion throughout the United States (US). Autologous transfusion technology can decrease the reliance on allogenic blood for surgical procedures. The hemafuse device was developed as a low-cost technology for autologous intraoperative transfusion. The hemafuse has been used in Ghana and Kenya for intraoperative autologous transfusion due to the chronic blood shortage experienced in those countries. The US is currently in an acute blood shortage in which use of the hemafuse device could be beneficial at a community hospital. Methods: The anesthesia care providers at Banner Casa Grande Medical Center were the participants in the project. An educational presentation was emailed to all current providers with a post-then-pre survey to complete after watching the video. The video included an explanation of the hemafuse device, the setup, demonstration of the use, and indication and contraindications for use in clinical practice. Results: Two anesthesia care providers participated in the educational presentation. Both providers reported an increase in awareness of the device and increased knowledge of the indications and contraindications for use. Other measures, such as awareness of the current blood shortage, current autologous technology, desire for hands-on hemafuse training, and utility of the device at BCGMC remained unchanged by the educational presentation. Conclusions: The hemafuse device could decrease the reliance on allogeneic blood for surgical patients. An educational video can be used to increase awareness and knowledge of the device if it were to become available for clinical use at Banner Casa Grande Medical Center. The hemafuse device could be used t

Background: Anesthesia provider burnout levels are rising across the United States. Evidence shows mindfulness-based interventions reduce stress among healthcare providers, which can aid in decreasing burnout levels. A burnout survey was distributed among anesthesia providers (anesthesiologists and certified registered nurse anesthetists) to determine level of burnout prior and following an evidence-based mindfulness intervention.Objective: The purpose of this project is to determine how the use of an online, self-administered mindfulness-based intervention affects anesthesia provider burnout. Design: This is a quality improvement that evaluated the efficacy of a mindfulness based intervention. The project assessed anesthesia provider burnout using the Maslach Burnout Inventory (MBI) survey and then evaluated effects of an intervention consisting of an educational Microsoft PowerPoint and supplemental handout provided to participants. A follow up MBI survey performed one month after intervention was used to assess impact on provider burnout. Participants: The recruitment pool consisted of 78 anesthesiologists and CRNAs from a two-site local health care facility in Tucson, Arizona. Measurements: The MBI survey was administered anonymously to assess three dimensions of burnout: emotional exhaustion, depersonalization, and personal accomplishment. An online, asynchronous, evidenced-based educational mindfulness Microsoft PowerPoint and supplemental handout was disseminated through email for anesthesia providers to administer at their convenience. After a four-week period, the same follow-up MBI survey was administered. Results of surveys were automatically transferred to Qualtrics, maintained anonymity and linked pre- and post-surveys. All data was anonymous, and no demographic data was collected to ensure anonymity. Results: Four providers completed the pre-intervention burnout survey. The results demonstrate composite MBI emotional exhaustion score of 13.8 +/- 10.4

Purpose: Informal surveys have indicated that anesthesia providers are often unaware of latest evidence-based care regarding the provision of anesthesia to children with Down syndrome.Background: Children with Down syndrome can present a wide array of abnormalities that are significant to anesthesia providers. Thus, it is vital that anesthesia providers be aware of these abnormalities in order to provide a safe, quality anesthetic course. Methods: Certified registered nurse anesthetists at Banner University Medical Center-Tucson received a pre-recorded video presentation with associated pretest and posttest surveys to assess for increases in confidence in and knowledge of providing quality anesthesia to children with Down syndrome. Results: Out of the 27 certified registered nurse anesthetists who received the video presentation, only four participated and filled out the surveys. While all the items of the surveys generally indicated an increase of confidence and knowledge levels, only two items showed a significant increase from the pretest to the posttest. Conclusions: This video presentation was effective in increasing confidence and knowledge levels for providing anesthesia to children with Down syndrome. This project also shows that certified registered nurses anesthetists may benefit from receiving education regarding latest evidence-based practices for providing anesthesia to children with Down syndrome.

Purpose: This project aimed to evaluate anesthesia provider attitudes surrounding the clinical topic of perioperative peripheral nerve injury. Additionally, the project sought to introduce anesthesia providers to a novel risk assessment device that may help identify patients at high risk for perioperative peripheral nerve injury while assessing its potential utility in anesthesia practice.Background: Perioperative peripheral nerve injury is a significant cause of patient morbidity and medical litigation. Anesthesia-related lawsuits involving perioperative nerve injury are the second most common type of intraoperative malpractice lawsuit, consistently representing 15-18% of claims (Grant et al., 2019). Research shows that nerve injury is more common in patients with specific comorbidities, predisposing them to nerve damage (Welch et al., 2009). These patients have physiologic characteristics that may be easily identifiable during a preoperative assessment (ASA, 2018). Methods: The project utilized a descriptive design with quantitative evaluation by an electronic survey created by Qualtrics. The survey was distributed to participants following a medicolegal analysis presentation about perioperative peripheral nerve injury and the introduction of a peripheral nerve injury risk assessment tool created by the author. The study's survey gathered data in two main areas, the providers’ opinions and attitudes towards the problem of a perioperative peripheral nerve injury and their view of the presented screening tool’s usefulness. Results: The strongest metrics resulting from the survey showed that anesthesia providers have an increased interest in improving documentation, improving patient assessment efforts, improving patient communication, and perioperative team communication, with the highest metric showing interest in reducing legal risk. When asked if the anesthesia providers could see themselves using the presented screening tool in their clinical practice, 69% of an

Purpose. The purpose of this quality improvement (QI) project was to develop an algorithm based on evidence-based practice to manage perioperative pain in chronic pain patients. The goal was to educate and improve anesthesia provider’s baseline knowledge on managing perioperative pain in the chronic pain population.Background. It can be difficult to manage acute perioperative pain in chronic pain patients due to physiologic changes that occur with chronic exposure to opioids such as opioid tolerance, opioid-induced hyperalgesia, and physical dependence (Coluzzi et al., 2017). A study by Gan, Habib, Miller, White, and Apfelbaum (2014) found that more than 70% of patients who underwent surgery reported post-surgical pain as moderate to extreme. The necessity to control perioperative pain in chronic pain patients is of upmost importance due to increased risk of postoperative complication, prolong hospital stay, increased risk of infection, and increased healthcare cost related to uncontrolled postoperative pain. Methods. Lewin’s change theory (LCT) served as theoretical framework as it was used as a guide to influence provider knowledge with education on management of perioperative pain in chronic pain patients. Participants (n=13) included certified registered nurse anesthetists (CRNAs) at a level one trauma facility. A pretest and posttest survey was submitted to participants before and after an educational PowerPoint (PPT) presentation that included principal investigator’s (PI) developed perioperative acute pain management algorithm for chronic pain patients. Results. A Wilcoxon signed-rank test was utilized to compare overall pretest and posttest scores and there was statistically significant improvement (Z = -3.06, p = 0.002). Most participant’s test scores improved 92% (n=12) with the exception of one participant who scored 100% in pretest therefore could not improve. Conclusion. There was a knowledge gap among CRNAs at this Level 1 trauma facility in managing a

Purpose: The purpose of this evidenced-based quality improvement (QI) project is to implement a continuing education program designed to arm anesthesia providers with the current information to deliver anesthetics to patients who chronically use marijuana. The goal is to decrease perioperative complications and improve patient outcomes by equipping anesthesia providers with the tools they need to anticipate the potential complications associated with marijuana use.Background: With the rising medicinal and recreational legalization of marijuana across the United States (U.S.), more and more surgical patients are participating in regular use. Chronic marijuana use increases the risk of respiratory, cardiac, neurological, and hemodynamic complications during anesthesia, even among young, otherwise healthy patients. Methods: A QI project designed to assess confidence levels when caring for patients who chronically use marijuana among anesthesia providers employed by an anesthesia group in Phoenix, AZ. The initial confidence levels were then compared to confidence levels obtained after viewing an educational presentation addressing current literature findings surrounding marijuana use and its associated anesthetic complications. This was done by participant completion of a pre-survey before the presentation, followed by a post-survey of the same Grundy confidence scale after viewing. Average scores for both surveys were calculated and compared. Results: Comparison of the 14 participants’ averaged confidence scale scores revealed a 19.5% increase from pre- to post-survey. Participant feedback also brought to light the participants’ perception of the relevance of the information presented and the existing gaps in knowledge surrounding this unique patient population. Conclusions: Anesthesia provider education is beneficial for increasing confidence levels when providing anesthesia to chronic marijuana users. The relevance of this topic continues to grow, especially in Arizo

Many anesthesia providers rely on traditional theories and methods for the management of perioperative fluid resuscitation in colorectal surgery (Bamboat & Bordeianou, 2009). Historically, prior training favored liberal intraoperative fluid replacement, particularly after bowel or emergent colorectal surgeries. In the 2000s, data supported the use of restrictive approaches to perioperative fluid administration, especially with goal-directed fluid therapy (GDFT). Within the past two years, current evidence shows that GDFT is appropriate in some populations and colorectal procedures but not beneficial for others. This Doctor of Nursing Practice (DNP) project provides evidence-based recommendations on suggested intraoperative fluid replacement therapy in colorectal surgery in the form of an algorithm that is based on a modified clinical practice guideline. The algorithm was developed for anesthesia providers at a Level 3 hospital in Mesa, Arizona. The Iowa Model was the conceptual framework, which guided this project by making recommendations to change current practice. An algorithm guided by the “2018 ERAS CPG for Colorectal Surgery Recommendation 13” was developed by the principal investigator (PI). Prior to developing the algorithm, participants (n=3) included DNP-Certified Registered Nurse Anesthetists (CRNAs) who used the “Appraisal of Guidelines for Research and Evaluation II” (AGREE II) tool to determine the quality of the guideline. Results determined that these guidelines were of good quality. The GDFT algorithm was presented to anesthesia providers during a monthly staff meeting. Ultimately, the anesthesia providers (N=4) filled out the Stakeholder Feedback Form and confirmed it was a quality algorithm, and that they would adopt it into their own practice. Anesthesia providers must change practice as evidence-based research provides current evidence to guide practice in improving patient outcomes.