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Objective: Electronic medical records (EMR) may increase the safety and efficiency of healthcare. Anesthesia care is a significant component of the perioperative period, yet little is known about the adoption of anesthesia information management systems (AIMS) by US anesthesiologists, particularly in non-academic settings. Herein, we report the results of a survey of US anesthesiologists regarding adoption of AIMS and anesthesiologist-perceived advantages and barriers to AIMS adoption.Methods: Using the e-mail database of the American Society of Anesthesiologists, we solicited randomly selected US anesthesiologists to participate in a survey of their AIMS adoption, perceived advantages and barriers to AIMS. Two and then 3 weeks after the initial mailing, a follow-up e-mail was sent to each anesthesiologist. The study was closed 4 weeks after the initial mailing.Results: Five thousand anesthesiologists were solicited; 615 (12.3%) responses were received. Twenty-four percent of respondents had installed an AIMS, while 13% were either installing a system now or had selected one, and an additional 13% were actively searching. Larger anesthesiology groups with large case loads, urban settings, and government affiliated or academic institutions were more likely to have adopted AIMS. Initial cost was the most frequently cited AIMS barrier. The most commonly cited benefit was more accurate clinical documentation (79%), while unanticipated need for ongoing information technology support (49%) and difficult integration of AIMS with an existing EMR (61%) were the most commonly cited problems. There were no barriers cited significantly more often by non-adopters than adopters.Conclusions: At least 50% of our survey respondents were currently using, installing, planning to install, or searching for an AIMS. However, the strength of any conclusion is undermined by a low survey response rate and potential bias as respondents using or searching for an AIMS may be more likely to participate. Nonetheless, challenges exist for anesthesiologists considering AIMS adoption including cost. Furthermore, important questions remain regarding payment for anesthesia services and the relationship of AIMS and "meaningful use" as defined by the Centers for Medicare & Medicaid Services. [ABSTRACT FROM AUTHOR]

Significant knowledge gaps exist in the perioperative pain management of patients with a history of chronic pain, substance use disorder, and/or opioid tolerance as highlighted in the US Health and Human Services Pain Management Best Practices Inter-Agency Task Force 2019 report. The report emphasized the challenges of caring for these populations and the need for multidisciplinary care and a comprehensive approach. Such care requires stakeholder alignment across multiple specialties and care settings. With the intention of codifying this alignment into a reliable and efficient processes, a consortium of 15 professional healthcare societies was convened in a year-long modified Delphi consensus process and summit. This process produced seven guiding principles for the perioperative care of patients with chronic pain, substance use disorder, and/or preoperative opioid tolerance. These principles provide a framework and direction for future improvement in the optimization and care of 'complex' patients as they undergo surgical procedures., Competing Interests: Competing interests: DMD receives research support from Abbott and SPR therapeutics; speaker and/or consulting fees from Abbott, SPR Therapeutics, Vertos, Pfizer, Myovant, Nalu, and Biotronik; NME receives consulting fees for legal case review and from Pacira; SS receives consulting fees from SPR Therapeutics, Masimo Corp, and Allergan. GS receives consulting fees from Pacira and holds minor stake equity (stock options) in Dorsal Health; MS receives consulting fees and research support from Saluda Medical, consulting fees from Patch technologies, Witness, etc and iVitalie, and holds stock and/or receives consulting fees from Cellarian, Spark Biomedical, Nanomedical Systems, Full Spectrum Healthcare Management, MedAnswers, Reveliance solutions, and Assurance Med Management, (© American Society of Regional Anesthesia & Pain Medicine 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To determine the differential impact of Medicaid expansion on all-cause mortality between Black, Latino/a, and White populations in rural and urban areas, and assess how expansion impacted mortality disparities between these groups., Methods: We employ a county-level time-varying heterogenous treatment effects difference-in-difference analysis of Medicaid expansion on all-cause age-adjusted mortality for those 64 years of age or younger from 2009 to 2019. For all counties within the 50 US States and the District of Columbia, we use restricted-access vital statistics data to estimate Average Treatment Effect on the Treated (ATET) for all combinations of racial and ethnic group (Black, Latino/a, White), rurality (rural, urban), and sex. We then assess aggregate ATET, as well as how the ATET changed as time from expansion increased., Findings: Medicaid expansion led to a reduction in all-cause age-adjusted mortality for urban Black populations, but not rural Black populations. Urban White populations experienced mixed effects dependent on years after expansion. Latino/a populations saw no appreciable impact. While no effect was observed for rural Black and Latino/a populations, rural White all-cause age-adjusted mortality unexpectedly increased due to Medicaid expansion. These effects reduced rural- and urban-specific Black-White mortality disparities but did not shrink the rural-urban mortality gap., Conclusions: The mortality-reducing impact of Medicaid expansion has been uneven across racial and ethnic groups and rural-urban status; suggesting that many populations-particularly rural individuals-are not seeing the same benefits as others. It is imperative that states work to ensure Medicaid expansion is being appropriately implemented in rural areas., (© 2024 The Author(s). The Journal of Rural Health published by Wiley Periodicals LLC on behalf of National Rural Health Association.)

During the first year of the COVID-19 pandemic, federal spending to government safety net programs in the U.S. increased dramatically. Despite this unparalleled spending, government safety nets were widely critiqued for failing to fully meet many households' needs. Disaster research suggests that informal modes of social support often emerge during times of disruption, such as the first year of the pandemic. However, use of formal government programs and informal support are rarely examined relative to each other, resulting in an incomplete picture of how households navigate disaster impacts and financial shocks. This study compares estimates of informal social support to formal government program use in the rural U.S. West, drawing on data from a rapid-response survey fielded during the summer of 2020 and the 2021 Annual Social and Economic Supplement of the Current Population Survey (CPS-ASEC). We find that informal social support systems were, on aggregate, used almost as extensively as long-standing government programs. Our findings highlight the critical role of person-to-person assistance, such as sharing financial resources, among rural households during a disruptive disaster period. Routine and standardized data collection on these informal support behaviors could improve future disaster research and policy responses, especially among rural populations.

We have demonstrated the effect of covering an N95 filtering facepiece respirator (FFR) with an overlying face mask. In total, 100 participants successfully completed quantitative fit testing wearing a 3M 1870+ FFR. Among them, 13 (13%; 95% CI, 7%-22%) failed subsequent fit testing when simultaneously wearing a Halyard 47117 procedural mask over the FFR.

The continued citation of retracted publications from the medical literature is a well-known and persistent problem. We describe the contexts of ongoing citations to manuscripts that have been retracted from a selection of anesthesiology journals. We also examine how bibliographic databases and publisher websites document the retracted status of these manuscripts. The authors performed an analysis of retracted publications from anesthesiology journals using the Retraction Watch database. We then examined how the retraction information was displayed on bibliographic databases, search engines, and publisher websites. The primary outcome was the context of continued citation after retraction of flawed publications within the specialty of anesthesiology. Secondary outcomes included comparison of the documentation, bibliographic databases, search engines, and publisher websites used in identifying the retracted status of these publications and provision of access to the respective retraction notices. A total of 245 original publications were retracted over a 28-year period from 9 anesthesiology journals. PubMed, compared to the other databases and search engines, was the most consistent (98.8%) in documenting the retracted status of the publications examined, as well as providing a direct link to the retraction notice. From the 211 publications retracted before January 2020, there were 1307 postretraction citations accessed from Scopus. The median number of postretraction citations was 3.5 (range, 0-88, with at least 1 citation in 164 publications) in Scopus. Of the postretraction citations, 80% affirmed the validity of the retracted publications, while only 5.2% of citations acknowledged the retraction or misconduct. In 10.2% of the citations from original research studies, retracted manuscripts appeared to influence the decision to pursue or the methods used in subsequent original research studies. The frequency of citation of the 15 most cited retracted publications declined in a similar pattern during the 10 years after retraction. Citation of manuscripts retracted from anesthesiology journals remains a common occurrence. Technological innovations and application of standards for handling retracted publications, as suggested by coalitions of researchers across the spectrum of scientific investigation, may serve to reduce the persistence of this error., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 International Anesthesia Research Society.)

Background: Universal classroom-based interventions are a useful method to increase the mental health and resilience in children. Resilience describes the process that leads to a positive development despite adversities. It comprises the seven resources access to material resources, relationships, identity, power and control, cultural adherence, social justice and cohesion. Yet there is a paucity of studies evaluating interventions that enhance resilience in children exposed to adverse childhood experiences., Method: This systematic review investigates whether universal classroom-based interventions can increase the seven resilience-related resources in children that live in adverse environments. Search strings were formulated based on an adapted version of the PICO criteria. The risk of bias of the individual studies was assessed using the ROBINS-I tool., Results: Seventeen studies were included in the review, of which 15 found an increase in resilience. The resource power and control was targeted in every intervention. Not one intervention included all seven resources. Intervention outcomes related mostly to just two of the resources (power and control and identity) and were rarely linked to what was being trained in the intervention., Conclusion: The results of this review show that classroom-based interventions are suitable for promoting resilience in children living in adverse environments. Yet more high-quality studies are needed that evaluate the effectiveness of universal interventions on children living in adverse environments and specifically the effectiveness of training each of the seven resources. Future developments of school-based interventions should be careful to target and assess all resilience-related resources., (© 2021 The Authors. Child and Adolescent Mental Health published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.)

The recently finalized changes to the disclosure avoidance policies of the U.S. Census Bureau for the 2020 census, grounded in differential privacy, have faced increasing criticism from demographers and other social scientists. Scholars have found that estimates generated via Census-released test data are accurate for aggregate total population statistics of larger spatial units (e.g. counties), but introduce considerable discrepancies for estimates of subgroups. At present, the ramifications of this new approach remain unclear for rural populations. In this brief, we focus on rural populations and evaluate the ability of the finalized differential privacy algorithm to provide accurate population counts and growth rates from 2000 to 2010 across the rural-urban continuum for the total, non-Hispanic white, non-Hispanic Black, Hispanic or Latino/a, and non-Hispanic American Indian population. We find the method introduces significant discrepancies relative to the prior approach into counts and growth rate estimates at the county level for all groups except the total and non-Hispanic white population. Further, discrepancies increase dramatically as we move from urban to rural. Thus, the differential privacy method likely introduced significant discrepancies for rural and non-white populations into 2020 census tabulations., Competing Interests: Conflict of Interest/Competing Interests: The authors have no conflict to disclose.

Study Objective: The Merit-Based Incentive Payment System (MIPS) program was intended to align CMS quality and incentive programs. To date, no reports have described anesthesia clinician performance in the first two years of the program., Design: Observational retrospective cohort study., Setting: Centers for Medicare and Medicaid Services public datasets for their Quality Payment Program., Patients: Anesthesia clinicians who participated in MIPS for 2017 and 2018 performance years., Interventions: Descriptive statistics compared anesthesia clinician characteristics, practice setting, and MIPS performance between the two years to determine associations with MIPS-based payment adjustments., Measurements: Logistic regression identified independent predictors of bonus payments for exceptional performance., Main Results: Compared with participants in 2017 (n = 25,604), participants in 2018 (n = 54,381) had a higher proportion of reporting through groups and alternative payment models (APMs) than as individuals (p < 0.001). The proportion of clinicians earning performance bonuses increased from 2017 to 2018 except for those MIPS participants reporting as individuals. Median total MIPS scores were higher in 2018 than 2017 (84.6 vs. 82.4, p < 0.001), although median total scores fell for participants reporting as individuals (40.9 vs 75.5, p < 0.001). Among clinicians with scores in both years (n = 20,490), 10,559 (51.3%) improved their total score between 2017 and 2018, and 347 (1.7%) changed reporting from individual to APM. Reporting as an individual compared with group reporting (OR: 0.75; 95% CI: 0.71 to 0.80; p < 0.001) was associated with lower rates of bonus payments, as was having a greater proportion of patients dual-eligible for Medicaid and Medicare. Reporting through an APM (OR: 149.6; 95% CI: 110 to 203.4; p < 0.001) and increasing practice group size were associated with higher likelihood of bonus payments., Conclusions: Anesthesia clinician MIPS participation and performance were strong during 2017 and 2018 performance years. Providers who reported through groups or APMs have a higher likelihood of receiving bonus payments., (Copyright © 2021 Elsevier Inc. All rights reserved.)

The US Health and Human Services Pain Management Best Practices Inter-Agency Task Force initiated a public-private partnership which led to the publication of its report in 2019. The report emphasized the need for individualized, multimodal, and multidisciplinary approaches to pain management that decrease the over-reliance on opioids, increase access to care, and promote widespread education on pain and substance use disorders. The Task Force specifically called on specialty organizations to work together to develop evidence-based guidelines. In response to this report's recommendations, a consortium of 14 professional healthcare societies committed to a 2-year project to advance pain management for the surgical patient and improve opioid safety. The modified Delphi process included two rounds of electronic voting and culminated in a live virtual event in February 2021, during which seven common guiding principles were established for acute perioperative pain management. These principles should help to inform local action and future development of clinical practice recommendations., Competing Interests: Competing interests: JMS declares salary support from Blue Cross Blue Shield of Michigan; research funding from Neuros Medical (Willoughby, OH, USA), Setpoint Medical (Valencia, CA, USA), and Medtronic (Dublin, Ireland; legal consulting for Yates, McLamb and Weyher, LLP (Raleigh, NC, USA). KKKH is a consultant for True Digital Surgery (Goleta, CA, USA). GS is an advisory board member for Dorsal Health (New York, NY, USA) and consultant for Pacira Biosciences (Parsippany-Troy Hills, NJ, USA). SS is a consultant for Masimo (Irvine, CA, USA), Allergan (Dublin, Ireland), and SPR Therapeutics (Cleveland, OH, USA). These companies had absolutely no input into any aspect of the project design, Pain Summit, or manuscript preparation. None of the other authors has any financial interests to declare., (© American Society of Regional Anesthesia & Pain Medicine 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

In this study we examined the psychological distress, self-rated health, COVID-19 exposure, and economic disruption of a sample of the nonmetropolitan western U.S. population and labor force one year after the start of the COVID-19 pandemic. Using novel primary survey data from non-metropolitan counties in the eleven contiguous western United States collected from February 28 until April 3, 2021 (n = 1203), we descriptively analyzed variables and estimated binomial and multinomial logit models of the association between economic disruption, COVID-19 exposure, self-rated health, and psychological distress. Results showed there was widespread presence of psychological distress, COVID-19 exposure, and economic disruption among the overall sample and members of the labor force. There was extremely high incidence of serious psychological distress (14.8% CI [12.1,17.8] of the weighted sample), which was heightened among the labor force (16.6%, CI [13.0,20.9] of those in the labor force). We found economic disruption was associated with severe psychological distress, but exposure to infection was not. Comparatively, overall self-rated health was at similar levels as prior research and was not significantly associated with economic disruption or COVID-19 exposure. COVID-19, particularly its associated economic effects, had a significant relationship with serious psychological distress in this sample of adults in the nonmetropolitan western United States., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Poverty scholarship in the United States is increasingly reliant upon the Supplemental Poverty Measure (SPM) as opposed to the Official Poverty Measure of the United States for research and policy analysis. However, the SPM still faces several critiques from scholars focused on poverty in nonmetropolitan areas. Key among these critiques is the geographic adjustment for cost of living employed in the SPM, which is based solely upon median rental costs and pools together all nonmetropolitan counties within each state. Here, we evaluate the current geographic adjustment of the SPM using both microdata and aggregate data from the American Community Survey for 2014-2018. By comparing housing costs, tenure, and commuting, we determine that median rent is likely an appropriate basis for geographic adjustment. However, by demonstrating the wide variability between median rents of nonmetropolitan counties within the same state, we show that the current operationalization of this geographic adjustment could be improved through the use of more-specific categories such as metropolitan adjacency or Rural Urban Continuum Codes., Competing Interests: Conflict of interestNone to disclose., (© The Author(s), under exclusive licence to Springer Nature B.V. 2022.)

The accurate measurement of poverty is essential for the development of effective poverty policy. Unfortunately, approaches that use poverty rates to assess the causes and consequences of poverty do not fully capture the components of change in the poverty population because changes in the conventional poverty rate can occur owing to processes of natural increase, migration, or transitions in and out of poverty. This article presents an accounting framework for changes in poverty within and between places. The framework, termed the poverty balancing equation, generates a series of summary statistics that can be used in place of the conventional poverty rate in future research. The approach is demonstrated using the 2014 panel of the Survey of Income and Program Participation to generate state-level estimates of the poverty components of change for three states in the American South between January and December of 2013. Results show that even when poverty rates remain constant, there is significant dynamism within poor and nonpoor populations. By applying this approach, either completely or in part, researchers can provide more specific and actionable evidence for poverty alleviation policy., (Copyright © 2021 The Author.)

Many households in the United States face issues of incomplete plumbing and poor water quality. Prior scholarship on this issue has focused on one dimension of water hardship at a time, leaving the full picture incomplete. Here we complete this picture by documenting the full scope of water hardship in the United States and find evidence of a regionally-clustered, socially unequal nationwide household water crisis. Using data from the American Community Survey and the Environmental Protection Agency, we show there are 489,836 households lacking complete plumbing, 1,165 community water systems in Safe Drinking Water Act Serious Violation, and 21,035 Clean Water Act permittees in Significant Noncompliance. Further, we demonstrate this crisis is regionally clustered, with the specific spatial pattern varying by the specific form of water hardship. Elevated levels of water hardship are associated with the social dimensions of rurality, poverty, indigeneity, education, and age-representing a nationwide environmental injustice.

Objective : Occupations in agriculture and natural resources persistently have some of the highest rates of injury and illness. Additionally, these fields are dominated by segments of the population known to demonstrate poorer health, such as those with less education, lower family income, and more irregular labor force participation. Thus, it is unclear if health disparities between those in these sectors and the rest of the labor force are unique to these occupations, or a reflection of their demographic composition. The objective of this study was to determine how much of the difference in self-rated health between those who work agriculture and natural resource occupations - meaning farming, forestry, fishing, hunting, and resource extraction - and the rest of the labor force was due to demographic characteristics versus unexplained factors unique to the occupations. Methods : Using the National Health Interview Survey from 2008 to 2017, a two-way Oaxaca-Blinder decomposition of linear probability models predicting poor self-rated health between those reporting agriculture and natural resource occupations and other working adults with sociodemographic characteristics was performed. Results : Results show more than the total difference in the probability of poor self-rated health between the two groups (0.0173) can be explained by demographic composition (0.0303). If the agriculture and natural resource workforce had the average demographic composition between them and the rest of the labor force, they would have lower rates of poor self-rated health than the broader labor force. Conclusion : While agriculture and natural resource occupations are hazardous, the prevalence of poor self-rated health in the labor force is not unique to these occupations, but appears common among all occupations dominated by those with low income and education.

Despite considerable social scientific attention to the impacts of the COVID-19 pandemic on urbanized areas, very little research has examined its impact on rural populations. Yet rural communities-which make up tens of millions of people from diverse backgrounds in the United States-are among the nation's most vulnerable populations and may be less resilient to the effects of such a large-scale exogenous shock. We address this critical knowledge gap with data from a new survey designed to assess the impacts of the pandemic on health-related and economic dimensions of rural well-being in the North American West. Notably, we find that the effects of the COVID-19 pandemic on rural populations have been severe, with significant negative impacts on unemployment, overall life satisfaction, mental health, and economic outlook. Further, we find that these impacts have been generally consistent across age, ethnicity, education, and sex. We discuss how these findings constitute the beginning of a much larger interdisciplinary COVID-19 research effort that integrates rural areas and pushes beyond the predominant focus on cities and nation-states., Competing Interests: The authors declare no competing interest.

COVID-19 has had dramatic impacts on economic outcomes across the United States, yet most research on the pandemic's labor-market impacts has had a national or urban focus. We overcome this limitation using data from the U.S. Current Population Survey's COVID-19 supplement to study pandemic-related labor-force outcomes in rural and urban areas from May 2020 through February 2021. We find the pandemic has generally had more severe labor-force impacts on urban adults than their rural counterparts. Urban adults were more often unable to work, go unpaid for missed hours, and be unable to look for work due to COVID-19. However, rural workers were less likely to work remotely than urban workers. These differences persist even when adjusting for adults' socioeconomic characteristics and state-level factors. Our results suggest rural-urban differences in the nature of work during the pandemic cannot be explained by well-known demographic and political differences between rural and urban America.

Objectives. To demonstrate how inferences about rural-urban disparities in age-adjusted mortality are affected by the reclassification of rural and urban counties in the United States from 1970 to 2018. Methods. We compared estimates of rural-urban mortality disparities over time, produced through a time-varying classification of rural and urban counties, with counterfactual estimates of rural-urban disparities, assuming no changes in rural-urban classification since 1970. We evaluated mortality rates by decade of reclassification to assess selectivity in reclassification. Results. We found that reclassification amplified rural-urban mortality disparities and accounted for more than 25% of the rural disadvantage observed from 1970 to 2018. Mortality rates were lower in counties that reclassified from rural to urban than in counties that remained rural. Conclusions. Estimates of changing rural-urban mortality differentials are significantly influenced by rural-urban reclassification. On average, counties that have remained classified as rural over time have elevated mortality. Longitudinal research on rural-urban health disparities must consider the methodological and substantive implications of reclassification. Public Health Implications. Attention to rural-urban reclassification is necessary when evaluating or justifying policy interventions focusing on geographic health disparities.

Executive Summary: Quality improvement, regulatory, and payer organizations use various definitions of hospital mortality as clinical outcome measures. In this prospective study, the authors evaluated a multicomponent intervention aimed at reducing inpatient mortality in a multistate healthcare delivery system. The project was initiated because of a statistically nonsignificant upward trend in mortality suggested by a six-quarter rise in the observed/expected mortality ratio generated by the Vizient Clinical Data Base and Resource Manager. The design of the mortality reduction plan was influenced by the known limitations of using hospital-wide mortality as a quality improvement measure. The primary objective was to reduce mortality through focused care redesign. The project leadership team attempted to implement standardized system-wide improvements while allowing individual hospitals to simultaneously pursue site-specific practice redesign opportunities. Between Q3, 2015, and Q4, 2017, system-wide mortality reduced from 1.78 to 1.53 (per 100 admissions; p = .01). The actual plan implemented in Mayo Clinic's hospitals is included as Appendix A to this article, published online as Supplemental Digital Content. The authors included it to allow comparison with similar efforts at other healthcare systems, as well as to stimulate criticism and discussion by readers.

Evidence concerning the link between park access, use, programming and health has continued to grow. However, government funding for parks and recreation is highly susceptible to the ebbs and flows of the national economy. Given this, the purpose of this study was to test the relationship between county area spending on parks and recreation operations and all-cause mortality in the United States from the years 1980-2010. Using data from 1980 to 2010 collected from the U.S. Census Bureau and the Institute for Health Metrics and Evaluation, we analyzed the relationship between per capita county area spending on parks and recreation and county-level all-cause age-standardized female, male, and overall mortality using county and year fixed effects as well as relevant time-variant controls. The study was conducted during 2017 and 2018. County area spending on parks and recreation was negatively associated with overall and female-specific mortality from 1980 to 2010. According to our models for female and overall all-cause age-standardized mortality, when holding all else equal, a hundred-dollar increase in 2010 dollars in per capita parks and recreation operational expenditures was associated with an average decrease in morality of 3.9 and 3.4 deaths per 100,000, respectively. Although not commonly viewed as a form of healthcare spending, increased government funding for parks and recreation services had a significant association with decreased county level mortality. Our results suggest higher levels of per capita spending on parks and recreation may lead to lower levels of mortality.

In augmented reality, video games and the physical world converge as individuals participate in digital leisure overlaid on physical spaces. In Pokémon Go, game play in the physical world is impacted by constraints that limit access and play of marginalized groups. Global popularity of Pokémon Go created an opportunity to explore experiences of marginalized groups participating in augmented reality game play. Grey literature surrounding Pokémon Go is rich with accounts of constraints experienced by marginalized groups, particularly individuals self-identifying as White women, Black women, or Black men. Their experiences with Pokémon Go illustrate the need for social justice in digital leisure. Because the lifespan of mobile applications is limited, the gradual process from research to social change may be insufficient in addressing ever evolving digital platforms. Researchers need to strategically work with industry partners to identify needs for social justice during the planning and designing stages.

A comprehensive central venous catheter (CVC) safety program reduces mechanical and infectious complications and requires an integrated multidisciplinary effort. A multistate health care system implemented a discovery and diffusion project addressing CVC insertion, maintenance, and removal. Process and outcome measures were collected before and after the intervention. The project was completed in 12 months. It was associated with statistically significant improvement in 6 process measures and reduction in the rate of ICU central line-associated bloodstream infection (from 1.16 to 0.80 infections/1000 catheter days; incidence rate ratio = 0.69; 95% confidence interval = 0.51, 0.93). A comprehensive CVC standardization project increased compliance with several established best practices, was associated with improved outcomes, produced a refined definition of discovery and diffusion project components, and identified several discrete leadership principles that can be applied to future clinical improvement initiatives.

Objective: To investigate sedation and anesthesia trends and practice patterns for procedures in the cardiac electrophysiology laboratory (EPL)., Design: A survey distributed by e-mail., Setting: US teaching hospitals with a training program in cardiac electrophysiology., Participants: Cardiologists involved in procedures in the electrophysiology laboratory of academic electrophysiology programs., Interventions: A survey was e-mailed to the selected programs. The survey questions included the use of anesthesia professional (MD/CRNA) and nonanesthesia professional (RN) services, medications administered, commonly performed airway interventions, satisfaction with anesthesia services, and reasons that anesthesia professionals are not used when RNs administer sedation., Measurements and Main Results: Of the 95 academic electrophysiology programs surveyed, there were 38 responses (40%). The majority (71%) of respondents used a combined model of care with both anesthesia professional care and nonanesthesia professional (RN) sedation, although there were EPLs that had exclusively anesthesia professional (n = 6) and exclusively nonanesthesia professional coverage (n = 5); 26.3% of respondents answered that care by an anesthesia professional was warranted most (>50%) of the time regardless of their current care model. The main reasons cited for having RN-administered sedation were the lack of availability of anesthesia professionals, difficulty with scheduling, and increased operating room suite turnover times. Programs using exclusively RN sedation (13%) reported all levels of anesthesia including general anesthesia (patient unarousable to repeated deep stimulation)., Conclusions: This survey suggested that sedation for EPL procedures was sometimes allowed to progress to deep sedation and general anesthesia and that selection of anesthesia provider frequently was made based on availability, operating room efficiency, and economic reasons before patient safety issues. The implications of the survey must be explored further in a larger-scale sample population before more definitive statements can be made, but results suggested that sedation in the EPL is an area that would benefit from updated guidelines specific to the current practice as well as attention from the anesthesia community to address the deficiency in provision of anesthesia care., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: In 2005, the authors' ambulatory surgery center (ASC) was closed, and the breast operations performed there were integrated into the hospital. This change allowed a comparison of perioperative time intervals for patients undergoing these procedures at an outpatient facility versus a hospital., Methods: The records of 92 patients who underwent breast operations at the ASC between January 2004 and December 2005 were compared with those of 92 patients who underwent outpatient breast operations at the hospital starting January 2006. Anesthetic techniques, recovery room events, and perioperative time intervals were analyzed., Results: Age and recovery room times were similar. Complications were negligible at both facilities. The preoperative, operating room entry to incision, and total facility time intervals significantly increased when breast cases were moved back to the hospital setting., Conclusions: These data demonstrate significantly shorter perioperative time intervals at the ASC. Incorporating time-saving practices from the outpatient setting could contribute to greater hospital productivity., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Background: Occipital nerve stimulation is a modality reserved for refractory headache disorders. Leads (wires) are inserted subcutaneously in the occipital region to stimulate the distal C1-3 nerves; lead migration may result from repeated mechanical forces on the lead associated with patient movement. The primary aim of this study was to determine implantation pathways associated with the least pathway length change secondary to body movement in an in vitro model of an occipital stimulator system., Methods: After institutional review board approval, 10 volunteers were recruited. The expected pathway of an occipital stimulator system was identified and measured externally, and then changes in pathway length were measured during various volunteer movements, including neck and low back flexion, extension, rotation, and lateral flexion. The pathways studied included those that connect internal pulse generators in the gluteal, low abdominal, and infraclavicular regions to occipital leads inserted via a cervical or retromastoid approach., Results: The flexion/extension pathway length changes associated with midline occipital and retromastoid sites to the infraclavicular site were significantly less than those pathways to the periscapular site. Also, the abdominal site was associated with less pathway length change during flexion/extension than the gluteal site., Conclusions: Internal pulse generators in sites other than the buttock, including infraclavicular or low abdomen, may be associated with lower lead migration risk. There are many considerations when selecting insertion sites and lead pathways for occipital nerve stimulation. Implanters and patients may consider these results when contemplating surgical approaches to this challenging form of peripheral nerve stimulation.

Objective: To quantify the incidence of airway interventions during cardiac electrophysiology laboratory procedures., Design: A retrospective chart review., Setting: A tertiary care teaching hospital., Participants: Two-hundred eight adult patients undergoing cardiac electrophysiology laboratory procedures during a 2-year period, March 2006 to March 2008. The patients underwent the following procedures: supraventricular tachycardia ablation, atrial tachycardia ablation, atrial flutter ablation, premature ventricular contraction ablation, and ventricular tachycardia ablation. Patients who were intubated (in the intensive care unit or emergency department) before the ablation began, patients with ventricular assist devices or intra-aortic balloon pumps, and patients receiving inotropic support before the procedure were excluded., Interventions: None., Measurements and Main Results: The data were summarized by using the mean and standard deviation. Of the 208 patients, 186 were planned monitored anesthesia care, and 22 were planned general anesthetics. Of the monitored anesthesia care cases, 20 were converted to general anesthesia, and 54 received some type of airway intervention including oral-pharyngeal airway or nasal airway insertion. Therefore, 40% (74/186) of the non-general anesthesia cases required an airway intervention., Conclusions: These results suggest that a significant proportion of the authors' patients undergoing cardiac electrophysiology laboratory procedures required deep sedation if not general anesthesia, although a non-general anesthetic was planned. The issue of depth of sedation has implications for patient safety, privileging, and regulatory compliance. Based on the present results, the authors believe sedation for these procedures is best given by anesthesia providers; furthermore, caregivers should be aware that these procedures are likely to require deep sedation if not general anesthesia.

Numerous studies have found no clinically significant benefit to the perioperative use of pulmonary artery catheters (PACs), and peripherally inserted central venous catheters (PICCs) have been reported to measure central venous pressure (CVP) accurately. The objective of this study was to determine whether the dynamic shifts in preload associated with elective reconstruction of abdominal aortic aneurysms (AAAs) are accurately reflected by CVP measurements from open-ended PICCs compared to CVP measurements from concomitant indwelling PACs. This is a retrospective review of prospectively collected data. PICCs and PACs were placed preoperatively in five patients undergoing elective AAA reconstruction. CVP measurements were recorded every 15 min during the operation. Bland-Altman statistical analysis was used to determine the degree of agreement in data collected by the two measurement devices. Seventy-three paired measurements of CVP from concomitant indwelling PICCs and PACs obtained from five patients undergoing elective AAA reconstruction revealed PICC measurements to be higher than PAC measurements by 0.6 mm Hg (overall correlation coefficient 0.92). The difference between the two measurement devices was expected to be <3.4 mm Hg at least 95% of the time. The findings of this pilot study indicate that PICCs are an effective method for CVP monitoring in situations of dynamic systemic compliance and preload, such as those observed during elective AAA reconstruction.