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Introduction The Veterans Health Administration (VHA) is the largest healthcare network in the USA and has been a national leader in opioid safety for acute pain management. However, detailed information on the availability and characteristics of acute pain services within its facilities is lacking. We designed this project to assess the current state of acute pain services within the VHA. Methods A 50-question electronic survey developed by the VHA national acute pain medicine committee was emailed to anesthesiology service chiefs at 140 VHA surgical facilities within the USA. Data collected were analyzed by facility complexity level and service characteristics. Results Of the 140 VHA surgical facilities contacted, 84 (60%) completed the survey. Thirty-nine (46%) responding facilities had an acute pain service. The presence of an acute pain service was associated with higher facility complexity level designation. The most common staffing model was 2.0 full-time equivalents, which typically included at least one physician. Services performed most by formal acute pain programs included peripheral nerve catheters, inpatient consult services, and ward ketamine infusions. Conclusions Despite widespread efforts to promote opioid safety and improve pain management, the availability of dedicated acute pain services within the VHA is not universal. Higher complexity programs are more likely to have acute pain services, which may reflect differential resource distribution, but the barriers to implementation have not yet been fully explored. [ABSTRACT FROM AUTHOR]

Introduction: Continuous interscalene nerve block techniques are an effective form of targeted non-opioid postoperative analgesia for shoulder arthroplasty patients. One of the limiting risks, however, is potential phrenic nerve blockade with resulting hemidiaphragmatic paresis and respiratory compromise. While studies have focused on block-related technical aspects to limit the incidence of phrenic nerve palsy, little is known about other factors associated with increased risk of clinical respiratory complications in this population. Methods: A single-institution retrospective cohort study was conducted using electronic health records from adult patients who underwent elective shoulder arthroplasty with continuous interscalene brachial plexus blocks (CISB). Data collected included patient, nerve block, and surgery characteristics. Respiratory complications were categorized into four groups (none, mild, moderate, and severe). Univariate and multivariable analyses were conducted. Results: Among 1025 adult shoulder arthroplasty cases, 351 (34%) experienced any respiratory complication. These 351 were subdivided into 279 (27%) mild, 61 (6%) moderate, and 11 (1%) severe respiratory complications. In an adjusted analysis, patient-related factors were associated with an increased likelihood of respiratory complication: ASA Physical Status III (OR 1.69, 95% CI 1.21 to 2.36); asthma (OR 1.59, 95% CI 1.07 to 2.37); congestive heart failure (OR 1.99, 95% CI 1.19 to 3.33); body mass index (OR 1.06, 95% CI 1.03 to 1.09); age (OR 1.02, 95% CI 1.00 to 1.04); and preoperative oxygen saturation (SpO2). For every 1% decrease in preoperative SpO2, there was an associated 32% higher likelihood of a respiratory complication (OR 1.32, 95% CI 1.20 to 1.46, p<0.001). Conclusions: Patient-related factors that can be measured preoperatively are associated with increased likelihood of respiratory complications after elective shoulder arthroplasty with CISB. [ABSTRACT FROM AUTHOR]

For select total knee arthroplasty (TKA) patients, we have established an alternative pathway to bypass the acute care surgical ward and directly admit patients from the post-anesthesia care unit to on-campus rehabilitation. We retrospectively examined whether this 'fast track' pathway decreased costs and improved patient outcomes. After reviewing records of consecutive primary unilateral TKA patients over a 15-month period, each patient admitted to rehabilitation was matched with a control admitted to the acute care ward. The primary outcome was estimated total hospitalization cost (length of stay in days multiplied by the average cost per day). Secondary outcomes were length of stay, in-hospital pain scores, opioid use, maximum ambulatory distance and 30-day readmission, morbidity, and mortality. Of the 262 TKA patients during the study period, 14 were admitted to rehabilitation and were matched to 14 patients admitted to acute care. Estimated total hospitalization cost [median (10th-90th percentiles)] was US$30,755 (US$23,066-38,444) for ward patients compared to US$17,620 (US$13,215-33,918) for rehabilitation patients (P = 0.006). This difference [mean (95% CI)] was US$10,143 (US$2174-18,112). There were no other differences. For facilities similar to ours, direct postoperative admission of select TKA patients to subacute rehabilitation may be less costly than acute care and may not negatively affect outcomes., Author(s): Brian K. Tse [sup.1] , Tessa L. Walters [sup.1] [sup.2] , Steven K. Howard [sup.1] [sup.2] , T. Edward Kim [sup.1] [sup.2] , Stavros G. Memtsoudis [sup.3] [sup.4] , [...]

Ultrasound-guided regional anesthesia (UGRA) requires an advanced procedural skill set that incorporates both sonographic knowledge of relevant anatomy as well as technical proficiency in needle manipulation in order to achieve a successful outcome. Understanding how to differentiate a novice from an expert in UGRA using a quantifiable tool may be useful for comparing educational interventions that could improve the rate at which one develops expertise. Exploring the gaze pattern of individuals performing a task has been used to evaluate expertise in many different disciplines, including medicine. However, the use of eye-tracking technology has not been previously applied to UGRA. The purpose of this preliminary study is to establish the feasibility of applying such technology as a measurement tool for comparing procedural expertise in UGRA. eye-tracking data were collected from one expert and one novice utilizing Tobii Glasses 2 while performing a simulated ultrasound-guided thoracic paravertebral block in a gel phantom model. Area of interest fixations were recorded and heat maps of gaze fixations were created. Results suggest a potential application of eye-tracking technology in the assessment of UGRA learning and performance., Author(s): T. Kyle Harrison[sup.1] [sup.2] , T. Edward Kim[sup.1] [sup.2] , Alex Kou[sup.1] [sup.2] , Cynthia Shum[sup.1] , Edward R. Mariano[sup.1] [sup.2] , Steven K. Howard[sup.1] [sup.2] , The ADAPT [...]

Background: Routine follow-up of patients who receive a nerve block for ambulatory surgery typically consists of a phone call from a regional anesthesia clinician. This process can be burdensome for both patients and clinicians but is necessary to assess the efficacy and complication rate of nerve blocks.Methods: We present our experience developing an automated system for completing follow-up via short message service text messaging and our preliminary results using it at three clinical sites. The system is built on REDCap, a secure online research data capture platform developed by Vanderbilt University and currently available worldwide.Results: Our automated system queried patients who received a variety of nerve block techniques, assessed patient-reported nerve block duration, and surveyed patients for potential complications. Patient response rate to text messaging averaged 91% (higher than our rates of daily phone contact reported previously) for patients aged 18 to 90 years.Conclusions: Given the wide availability of REDCap, we believe this automated text messaging system can be implemented in a variety of health systems at low cost with minimal technical expertise and will improve both the consistency of patient follow-up and the service efficiency of regional anesthesia practices. [ABSTRACT FROM AUTHOR]

Background: Long-term and sustainable clinical practice changes in anesthesia procedures have not previously been reported. Therefore, we performed a 5-year audit following implementation of a clinical pathway change favoring spinal anesthesia for total knee arthroplasty (TKA). We similarly evaluated a parallel cohort of patients undergoing total hip arthroplasty (THA), who did not undergo a clinical pathway change, and studied utilization rates of continuous peripheral nerve block (CPNB). Methods: We identified all primary unilateral TKA and THA cases completed from January 2013 through December 2018, thereby including clinical pathway change data from one-year pre-implementation to 5-years post-implementation. Our primary outcome was the overall application rate of spinal anesthesia. Secondary outcomes included CPNB utilization rate, 30-day postoperative complications, and resource utilization variables such as hospital readmission, emergency department visits, and blood transfusions. Results: The sample included 1,859 cases, consisting of 1,250 TKAs and 609 THAs. During the initial year post-implementation, 174/221 (78.7%) TKAs received spinal anesthesia compared to 23/186 (12.4%) cases the year before implementation (P < 0.001). During the following 4-year period, 647/843 (77.2%) TKAs received spinal anesthesia (P = 0.532 vs. year 1). The number of THA cases receiving spinal anesthesia the year after implementation was 78/124 (62.9%), compared to 48/116 (41.4%) pre-implementation (P = 0.001); however, the rate decreased over the following 4-year period to 193/369 (52.3%) (P = 0.040 vs. year 1). CPNB use was high in both TKA and THA patient groups, and there were no differences in 30-day postoperative complications, hospital readmission, emergency department visits, or blood transfusions between patients who underwent spinal and general anesthesia in both TKA and THA groups. Conclusions: A clinical pathway change promoting spinal anesthesia for TKA can be effectively implemented and sustained over a 5-year period. [ABSTRACT FROM AUTHOR]

Objective. This retrospective cohort study tested the hypothesis that implementing a multidisciplinary patient-specific discharge protocol for prescribing and tapering opioids after total hip arthroplasty (THA) will decrease the morphine milligram equivalent (MME) dose of opioids prescribed. Methods. With institutional review board approval, we analyzed a Perioperative Surgical Home database and prescription data for all primary THA patients three months before (PRE) and three months after (POST) implementation of this new discharge opioid protocol based on patients’ prior 24-hour inpatient opioid consumption. The primary outcome was total opioid dosage in MME prescribed and opioid refills for six weeks after surgery. Secondary outcomes included the number of tablets and MME prescribed at discharge, in-hospital opioid consumption, length of stay, and postoperative complications. Results. Forty-nine cases (25 PRE and 24 POST) were included. Total median (10th–90th percentiles) MME for six weeks post-operatively was 900 (57–2082) MME PRE vs 295 (69–741) MME POST (mean difference = 721, 95% confidence interval [CI] = 127–1316, P = 0.007, Mann-Whitney U test). Refill rates did not differ. The median (10th–90th percentiles) initial discharge prescription in MME was 675 (57–1035) PRE vs 180 (18–534) POST (mean difference = 387, 95% CI = 156–618, P = 0.003, Mann-Whitney U test) MME. There were no differences in other outcomes. Conclusions. Implementation of a patient-specific prescribing and tapering protocol decreases the mean six-week dosage of opioid prescribed by 63% after THA without increasing the refill rate. [ABSTRACT FROM AUTHOR]

Objective Guidelines on postoperative pain management recommend inclusion of patient and caregiver education on opioid safety. Patient education materials (PEMs) should be written at or below a sixth grade reading level. We designed this study to compare the readability of online PEMs related to postoperative opioid management produced by institutions with and without a regional anesthesiology and acute pain medicine (RAAPM) fellowship. Methods With institutional review board exemption, we constructed our cohort of PEMs by searching RAAPM fellowship websites from North American academic medical centers and identified additional websites using structured Internet searches. Readability metrics were calculated from PEMs using the TextStat 0.4.1 textual analysis package for Python 2.7. The primary outcome was the Flesch-Kincaid Grade Level (FKGL), a score based on words per sentence and syllables per word. We also compared fellowship-based and nonfellowship PEMs on the presence or absence of specific content-related items. Results PEMs from 15 fellowship and 23 nonfellowship institutions were included. The mean (SD) FKGL for PEMs was grade 7.84 (1.98) compared with the recommended sixth grade level (P  < 0.001) and was not different between groups. Less than half of online PEMs contained explicit discussion of opioid tapering or cessation. Disposal and overdose risk were addressed more often by nonfellowship PEMs. Conclusions Available online PEMs related to opioid management are beyond the recommended reading level, but readability metrics for online PEMs do not differ between fellowship and nonfellowship groups. More than two-thirds of RAAPM fellowship programs in North America are lacking readable online PEMs on safe postoperative opioid management. [ABSTRACT FROM AUTHOR]

Background: Malignant hyperthermia is a rare but potentially fatal complication of anesthesia, and several different cognitive aids designed to facilitate a timely and accurate response to this crisis currently exist. Eye tracking technology can measure voluntary and involuntary eye movements, gaze fixation within an area of interest, and speed of visual response and has been used to a limited extent in anesthesiology. Methods: With eye tracking technology, we compared the accessibility of five malignant hyperthermia cognitive aids by collecting gaze data from twelve volunteer participants. Recordings were reviewed and annotated to measure the time required for participants to locate objects on the cognitive aid to provide an answer; cumulative time to answer was the primary outcome. Results: For the primary outcome, there were differences detected between cumulative time to answer survival curves (P < 0.001). Participants demonstrated the shortest cumulative time to answer when viewing the Society for Pediatric Anesthesia (SPA) cognitive aid compared to four other publicly available cognitive aids for malignant hyperthermia, and this outcome was not influenced by the anesthesiologists' years of experience. Conclusions: This is the first study to utilize eye tracking technology in a comparative evaluation of cognitive aid design, and our experience suggests that there may be additional applications of eye tracking technology in healthcare and medical education. Potentially advantageous design features of the SPA cognitive aid include a single page, linear layout, and simple typescript with minimal use of single color blocking. [ABSTRACT FROM AUTHOR]