Category Archives: Patient Safety

Beyond COVID-19: Stand Up for Veterans Having Surgery

Our Veterans have made tremendous sacrifices to defend our freedoms. Now it is our time to defend them.

Many people, even those who work in the operating room every day, take safe anesthesia care for granted. There has been growing pressure during this pandemic to remove physician supervision of nurse anesthetists with the latest threat coming from within Veterans Affairs (VA) healthcare. For our Veterans, our heroes and arguably some of the most medically complex patients, having a physician in charge of anesthesia care at hospitals where anesthesiologists and nurse anesthetists work together as a team makes the most sense.

Having a team with members who train differently and have different perspectives can only benefit the patient; anesthesiologists are physicians who draw on their medical training while nurse anesthetists bring valuable nursing experience. If you were a patient having surgery, wouldn’t you want an anesthesiologist directly involved in your care? If the answer is yes, please sign the Safe VA Care petition and let your elected officials know by filling out this contact form.

Continue reading Beyond COVID-19: Stand Up for Veterans Having Surgery

Providing anesthesia is often compared to flying a passenger airplane, and the anesthesia care team model is like having both a pilot and a co-pilot. Who thinks flying has become so safe that we no longer need the pilot? Seconds count in flight, and they count just as much in the operating room when a patient’s life is on the line. 

In 2016, the VA rejected independent practice for nurse anesthetists after careful consideration, but this decision was recently overturned by a memo citing the COVID-19 pandemic. This memo abolishes the anesthesia care team model without giving Veterans a choice. Veterans having surgery may now only get a nurse anesthetist without the option of having an anesthesiologist involved. If they were given the choice, however, I think our Veterans would choose an anesthesiologist or an anesthesia care team instead of a nurse anesthetist alone. We all should. With the COVID-19 pandemic, elective surgeries at the VA have been stopped so there is no shortage of anesthesiologists. Anesthesiologists all over the world have been fighting COVID-19 and have shown what they can do with their specialized medical training in a crisis. Although commonly referred to as “going to sleep,” general anesthesia is more like a complex drug-induced coma that can carry serious risk. If or when a crisis happens during surgery, every patient should have access to an anesthesiologist.

Modern anesthesiologists are physicians but also scientists, educators, and patient safety advocates. Anesthesiologists specialize in relieving anxiety, preventing and treating pain, preventing and managing complications related to surgery, critical care, and improving patient outcomes. The average anesthesiologist spends nearly a decade in postgraduate education after college including medical school and logs 16,000 hours of clinical training to learn to apply the best available evidence in clinical practice. Academic physicians and scientists focused on anesthesiology are responsible for the discovery of newer and safer anesthetics, pain therapies, and technologies that are advancing healthcare throughout the world.

Anesthesia administration by non-physicians such as nurse anesthetists and certified anesthesiologist assistants is supported by the American Society of Anesthesiologists within the physician-led anesthesia care team model. To uphold safe, high-quality physician-led anesthesia care for our nation’s Veterans, please speak up by signing the petition and reaching out to legislators using this contact form. It only takes a minute to stand up for safety, but the consequences of not saying something may be serious and long-lasting.

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My Trip to Washington: Speaking Out Against Drug Shortages

From left to right: Daniel Teich (Fairview Pharmacy Services), Dr. Peter Adamson (Children’s Hospital of Philadelphia), Senator Susan Collins, me, and Brian Marden (MaineHealth Pharmacy)

On November 5, 2019, I had the opportunity to participate in a Congressional briefing related to drug shortages at the Capitol in Washington, DC. Senator Susan Collins (R-ME) opened the session and co-sponsored the MEDS Act with Senator Tina Smith (D-MN). I was one of only two physicians on the panel and tried to represent the voice of clinicians involved in perioperative care and the patients we care for (video). Below are the notes from my presentation.

As a physician specializing in anesthesiology, this ongoing crisis of drug shortages in the United States is frankly terrifying.

Continue reading My Trip to Washington: Speaking Out Against Drug Shortages

Anesthesiology is a unique specialty within medicine. Our patients are the most vulnerable in the hospital. Patients under general anesthesia cannot advocate for themselves and trust us with their lives.

We do not know what the next drug shortage will be or how long it will last. This week it is prefilled syringes of lidocaine, a life-saving emergency medication we give in case of a dangerous heart rhythm. Two weeks ago it was phenylephrine, a routine medication we use to increase blood pressure when it goes down after inducing anesthesia.

Last year, we had complete shortages of common injectable opioids and local anesthetics used for numbing injections. This directly affected surgical patients in terms of anesthesia and pain management. For 3 months in 2018, we did not have the local anesthetic indicated for spinal anesthesia. We know this is the safest anesthetic for patients having certain surgeries. During this shortage, we used an alternative anesthetic in order to continue providing spinal anesthesia, but our patients experienced more side effects. The reasons for this shortage were complex and involved a limited number of manufacturers and quality issues.

Thankfully, the shortage of spinal local anesthetic ended. We do not know when or if the rest of our current drug shortages will end. All we know for sure is that there will be another one.

The predictably unpredictable cycle of drug shortages puts physicians in an impossible position. Medicine is a calling, and we physicians have sworn an oath to support the well-being of our community and humanity in general.

Not having access to the right drugs at the right time for every patient and being forced to use less acceptable alternatives, if any exist at all, represents a form of moral injury. Moral injury “is being unable to provide high-quality care and healing in the context of health care” and is now recognized as a contributor to the epidemic of physician burnout.

Listen to my interview with Paul Costello on SoundCloud.

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More Reasons for Doctors to Tweet

This press release came out during the annual scientific meeting of the New Zealand Society of Anaesthetists based on my talk, “The Role of Social Media in Modern Medicine.” While in New Zealand, I was interviewed on Newstalk ZB by host Andrew Dickens and Afternoons with Jesse Mulligan.

Doctors need to be active on social media and other communication platforms to offset the noise of the anti-science movement according to a visiting professor of anaesthesiology, Dr. Ed Mariano from Stanford University in the US.

Continue reading More Reasons for Doctors to Tweet

Dr. Mariano is speaking at the New Zealand Anaesthesia Annual Scientific Meeting in Queenstown this week on the role of social media and medicine. He says, there has been a growing anti-science movement and physicians have a moral imperative to stand up for science and evidence-based treatments.

“Surveys show that physicians are one of the most trusted professions in the eyes of the public. Yet most people in the world today get their information, including health information, from the internet. We have to be there to offset the noise,” he says. “We can’t ignore where our patients get their information, and we can join the conversation.”

Dr. Mariano, who is one of the top 10 anaesthetists on Twitter, says social media also offers a way for doctors to keep up-to-date with the latest research and new treatments. For example he cites the exponential growth of regional anaesthesia. Regional anaesthesia allows procedures to be done without the patient being unconscious and can provide targeted pain relief.

“We have more tools at our disposal. New blocks are being performed and described every month and it’s hard to keep up with the literature. Social media allows you to be part of a learning community made up of people who have similar interests and it can curate information for you,” he says.

Dr. Mariano says it works the other way too. He says he’s created great collaborations through social media. “As well as learning things, I’ve had interesting conversations on Twitter that have developed into projects. As an academic physician, I’ve found the use of social media has been invaluable. Engaging in social media gives physicians a worldwide community of colleagues who can help curate the vast and ever-growing amount of information available today.”

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My Top Ten Articles for #RAUK20

I have the honor of being the next Bruce Scott Lecturer for the 2020 Regional Anaesthesia United Kingdom (RA-UK) meeting in Sheffield on May 18 and 19, 2020.

As part of the preparation for what will be a fantastic conference filled with the latest education in regional anesthesia, point-of-care ultrasound, acute pain management, and social media for medical education, Dr. Amit Pawa has started a thread on Twitter featuring my “Top Ten” published articles.

I hope to see you at #RAUK20! You can access the thread and check out the list of articles by clicking the tweet below:

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My Reasons to Visit San Francisco for #ANES18

This year’s American Society of Anesthesiologists meeting (#ANES18) happens to be in my “neck of the woods”—one of the greatest cities in the world—San Francisco, California. Here are a few things you may or may not have known about San Francisco.

San Francisco is the biggest little city. At just under 47 square miles and with more than 800,000 inhabitants, San Francisco is second only to New York City in terms of population density. Despite its relatively small size, “the City” (as we suburbanites refer to it) consists of many small neighborhoods, each with its own charm and character: Union Square, the Financial District, Pacific Heights, the Marina, Haight-Ashbury, Chinatown, Little Italy, Nob Hill, Russian Hill, SoMa (South of Market), the Fillmore, Japantown, Mission District, Noe Valley, Twin Peaks, Castro, Sunset, Tenderloin, and others. This is probably why die-hard New Yorkers love it so much.

In the summer especially, San Francisco weather is somewhat unpredictable even when going from one side of the city to the other (part of the unique experience of visiting the city). “The coldest winter I ever spent was a summer in San Francisco,” a quote often mistakenly attributed to Mark Twain (no one really knows who actually said it), is nevertheless often true. Here in the San Francisco Bay Area, our local meteorologists provide daily forecasts for each of the region’s microclimates. The western side of the City along California’s coast is regularly plagued with fog while the eastern side of the City tends to be sunny most days of the year. It’s always a good idea to check the microclimate forecast before heading over to see the Golden Gate Bridge just in case it happens to be shrouded in fog. Average July temperatures in the City range in the 50s-60s Fahrenheit (no different than average November temperatures), so summer tourists often contribute to the local economy by buying “SF” logo sweatshirts for their walk across the City’s most famous bridge. Fortunately, #ANES18 is in the fall, and the weather near Moscone Center and the popular shopping area Union Square tends to stay reliably nice most of the year.

San Francisco is very family-friendly. If you’re debating whether or not to make a family trip out of #ANES18, my advice is to do it. Right around the convention center there are a number of attractions and events worth checking out. I highly recommend visiting the farmers market at the Ferry Building. While there, you can also take a ferry ride to a number of other destinations in the Bay Area (try Sausalito, a short trip that takes you past Alcatraz). For kids, there are parks within walking distance as well as the Children’s Creativity Museum, the San Francisco Railway Museum, Exploratorium, and the cable car turnabout at Powell and Market Street. Trips to Fisherman’s Wharf, Ghiradelli Square, or the aquarium are a short taxi or cable car ride away. In addition, runners will love running up and down the Embarcadero which gives you a view of the Bay Bridge and takes you past the City’s many piers. Shoppers will be in heaven, and foodies will have to make the impossible decision of choosing where to eat for every meal.

But don’t take my word for it—come to #ANES18 and see for yourself!

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Why We Should Worry about Drug Shortages in Regional Anesthesia

The crisis of prescription opioid overuse and abuse has affected countries around the world, and anesthesiologists are well-positioned to make positive changes (1).  Even minor outpatient surgical procedures, and their associated anesthesia and analgesia techniques, can lead to long-term opioid use (2,3).  Patients who present for surgery with an active opioid prescription are very likely to still be on opioids after a year (4).

Anesthesiologists have been working to set up regional anesthesiology and acute pain medicine programs with careful coordination of inpatient and outpatient pain management to improve patient outcomes.  Regional anesthesia, especially with continuous peripheral nerve block (CPNB) techniques, has been shown repeatedly to reduce patients’ need for opioid analgesia (5).

Today, the crisis of drug shortages threatens to reverse the many advances in perioperative pain control that have been achieved.  Local anesthetics or “numbing medications” represent a class of drugs that is our strongest weapon against opioids.  These drugs (e.g., bupivacaine, lidocaine, ropivacaine) are currently in shortage.  Targeted injections of local anesthetic in the form of regional anesthesia eliminate sensation at the site of surgery and can obviate the need for injectable opioids (e.g., fentanyl, hydromorphone, morphine) which also happen to be in short supply.  Local anesthetics are also the critical ingredient in providing epidural pain relief and spinal anesthesia for childbirth.  Without them, new moms will miss the first moments of their babies’ lives.

The following are potential ramifications of the current drug shortages affecting anesthesia and pain management on patient care:

Decreased Quality of Acute Pain Management

Regional anesthesia techniques, which include spinal, epidural, and peripheral nerve blocks, offer patients many potential advantages in the perioperative and peripartum period.  Human studies have demonstrated the following benefits: decreased pain, nausea and vomiting, and time spent in the recovery room (6,7).  Long-acting local anesthetics (e.g., bupivacaine, levobupivacaine, and ropivacaine) generally provide analgesia of similar duration for 24 hours or less (8-11).  These clinical effects of nerve blocks typically last long enough for patients to meet discharge eligibility from recovery and avoid unnecessary hospitalization for pain control (12).  CPNB techniques (also known as perineural catheters) permit delivery of local anesthetic solutions to the site of a peripheral nerve on an ongoing basis (13).  Portable infusion devices can deliver a solution of plain local anesthetic for days after surgery, often with the ability to titrate the dose up and down or even stop the infusion temporarily when patients feel too numb (14,15).  In a meta-analysis comparing CPNB to single-injection peripheral nerve blocks in humans, CPNB results in lower patient-reported worst pain scores and pain scores at rest on postoperative day (POD) 0, 1, and 2 (16).  Patients who receive CPNB also experience less nausea, consume less opioids, sleep better, and are more satisfied with pain management (16).  By using local anesthetic medication to interrupt nerve transmission along peripheral nerves, patients continue to experience decreased sensation as long as the infusion is running.  A shortage of local anesthetic medications makes it impossible for anesthesiologists to provide this potent form of opioid-sparing pain control for all surgical patients.  This also means that local anesthetics cannot be administered by surgeons as wound infiltration to help patients with incisional pain, and epidural analgesia for laboring women may not be universally available.

Increased Incidence of Postoperative Complications

Based on the study by Memtsoudis and colleagues, overall 30-day mortality for total knee arthroplasty patients is lower for patients who receive regional anesthesia, either neuraxial and combined neuraxial-general anesthesia, compared to general anesthesia alone (17).  In most categories, the rates of occurrence of in-hospital complications (e.g. all-cause infections, pulmonary, cardiovascular, acute renal failure) are also lower for the neuraxial and combined neuraxial-general anesthesia groups vs. the general anesthesia only group, and transfusion requirements are lowest for neuraxial anesthesia patients compared to all other groups (17).  The inability to offer regional anesthesia (e.g., spinal or epidural) to all patients due to lack of local anesthetics therefore represents a threat to patient safety.

Increased Risk of Persistent Postsurgical Pain

Chronic pain may develop after many common operations including breast surgery, cesarean delivery, hernia repair, thoracic surgery, and amputation and is associated with severe acute pain in the postoperative period (18).  A Cochrane systematic review and meta-analysis reviewed published studies on this subject, and the results favor epidural analgesia for prevention of persistent postsurgical pain (PPSP) after thoracotomy and favor paravertebral block for prevention of PPSP after breast cancer surgery at 6 months (19).  Only regional blockade with local anesthetics can block patients’ sensation during and after surgery.  Without local anesthetics for nerve blocks, spinals, and epidurals, patients will experience greater than expected acute pain, require additional opioid treatment, and potentially be at higher risk of developing chronic pain.

Increased Health Care Costs

Approximately 31% of costs related to inpatient perioperative care is attributable to the ward admission (20).  Anesthesiologists as perioperative physicians have an opportunity to influence the cost of surgical care by decreasing hospital length of stay through effective pain management and by developing coordinated multi-disciplinary clinical pathways (21,22).  Regional anesthesia and analgesia can improve outcomes through integration into clinical pathways that involve a multipronged approach to streamlining surgical care (23,24).  Inadequate pain control can delay rehabilitation, prolong hospital admissions, increase the rate of readmissions (25), and increase the costs of hospitalization for surgical patients.

In summary, regional anesthesia and analgesia has been shown in multiple studies to improve outcomes for obstetric and surgical patients.  The current shortage of local anesthetics and other analgesic medications negatively affects quality of care and pain management and is a threat to patient safety.

References

  1. Alam A, Juurlink DN. The prescription opioid epidemic: an overview for anesthesiologists. Can J Anaesth 2016;63:61-8.
  2. Sun EC, Darnall BD, Baker LC, Mackey S. Incidence of and Risk Factors for Chronic Opioid Use Among Opioid-Naive Patients in the Postoperative Period. JAMA internal medicine 2016;176:1286-93.
  3. Rozet I, Nishio I, Robbertze R, Rotter D, Chansky H, Hernandez AV. Prolonged opioid use after knee arthroscopy in military veterans. Anesth Analg 2014;119:454-9.
  4. Mudumbai SC, Oliva EM, Lewis ET, Trafton J, Posner D, Mariano ER, Stafford RS, Wagner T, Clark JD. Time-to-Cessation of Postoperative Opioids: A Population-Level Analysis of the Veterans Affairs Health Care System. Pain Med 2016;17:1732-43.
  5. Richman JM, Liu SS, Courpas G, Wong R, Rowlingson AJ, McGready J, Cohen SR, Wu CL. Does continuous peripheral nerve block provide superior pain control to opioids? A meta-analysis. Anesth Analg 2006;102:248-57.
  6. Liu SS, Strodtbeck WM, Richman JM, Wu CL. A comparison of regional versus general anesthesia for ambulatory anesthesia: a meta-analysis of randomized controlled trials. Anesth Analg 2005;101:1634-42.
  7. McCartney CJ, Brull R, Chan VW, Katz J, Abbas S, Graham B, Nova H, Rawson R, Anastakis DJ, von Schroeder H. Early but no long-term benefit of regional compared with general anesthesia for ambulatory hand surgery. Anesthesiology 2004;101:461-7.
  8. Casati A, Borghi B, Fanelli G, Cerchierini E, Santorsola R, Sassoli V, Grispigni C, Torri G. A double-blinded, randomized comparison of either 0.5% levobupivacaine or 0.5% ropivacaine for sciatic nerve block. Anesth Analg 2002;94:987-90, table of contents.
  9. Hickey R, Hoffman J, Ramamurthy S. A comparison of ropivacaine 0.5% and bupivacaine 0.5% for brachial plexus block. Anesthesiology 1991;74:639-42.
  10. Klein SM, Greengrass RA, Steele SM, D’Ercole FJ, Speer KP, Gleason DH, DeLong ER, Warner DS. A comparison of 0.5% bupivacaine, 0.5% ropivacaine, and 0.75% ropivacaine for interscalene brachial plexus block. Anesth Analg 1998;87:1316-9.
  11. Fanelli G, Casati A, Beccaria P, Aldegheri G, Berti M, Tarantino F, Torri G. A double-blind comparison of ropivacaine, bupivacaine, and mepivacaine during sciatic and femoral nerve blockade. Anesth Analg 1998;87:597-600.
  12. Williams BA, Kentor ML, Vogt MT, Williams JP, Chelly JE, Valalik S, Harner CD, Fu FH. Femoral-sciatic nerve blocks for complex outpatient knee surgery are associated with less postoperative pain before same-day discharge: a review of 1,200 consecutive cases from the period 1996-1999. Anesthesiology 2003;98:1206-13.
  13. Ilfeld BM. Continuous peripheral nerve blocks: a review of the published evidence. Anesth Analg 2011;113:904-25.
  14. Ilfeld BM. Continuous peripheral nerve blocks in the hospital and at home. Anesthesiol Clin 2011;29:193-211.
  15. Ilfeld BM, Enneking FK. Continuous peripheral nerve blocks at home: a review. Anesth Analg 2005;100:1822-33.
  16. Bingham AE, Fu R, Horn JL, Abrahams MS. Continuous peripheral nerve block compared with single-injection peripheral nerve block: a systematic review and meta-analysis of randomized controlled trials. Reg Anesth Pain Med 2012;37:583-94.
  17. Memtsoudis SG, Sun X, Chiu YL, Stundner O, Liu SS, Banerjee S, Mazumdar M, Sharrock NE. Perioperative comparative effectiveness of anesthetic technique in orthopedic patients. Anesthesiology 2013;118:1046-58.
  18. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet 2006;367:1618-25.
  19. Andreae MH, Andreae DA. Regional anaesthesia to prevent chronic pain after surgery: a Cochrane systematic review and meta-analysis. Br J Anaesth 2013;111:711-20.
  20. Macario A, Vitez TS, Dunn B, McDonald T. Where are the costs in perioperative care? Analysis of hospital costs and charges for inpatient surgical care. Anesthesiology 1995;83:1138-44.
  21. Ilfeld BM, Mariano ER, Williams BA, Woodard JN, Macario A. Hospitalization costs of total knee arthroplasty with a continuous femoral nerve block provided only in the hospital versus on an ambulatory basis: a retrospective, case-control, cost-minimization analysis. Reg Anesth Pain Med 2007;32:46-54.
  22. Jakobsen DH, Sonne E, Andreasen J, Kehlet H. Convalescence after colonic surgery with fast-track vs conventional care. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland 2006;8:683-7.
  23. Macario A, Horne M, Goodman S, Vitez T, Dexter F, Heinen R, Brown B. The effect of a perioperative clinical pathway for knee replacement surgery on hospital costs. Anesth Analg 1998;86:978-84.
  24. Hebl JR, Kopp SL, Ali MH, Horlocker TT, Dilger JA, Lennon RL, Williams BA, Hanssen AD, Pagnano MW. A comprehensive anesthesia protocol that emphasizes peripheral nerve blockade for total knee and total hip arthroplasty. J Bone Joint Surg Am 2005;87 Suppl 2:63-70.
  25. Hernandez-Boussard T, Graham LA, Desai K, Wahl TS, Aucoin E, Richman JS, Morris MS, Itani KM, Telford GL, Hawn MT. The Fifth Vital Sign: Postoperative Pain Predicts 30-day Readmissions and Subsequent Emergency Department Visits. Ann Surg 2017;266:516-24.

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Why I Still Love Being an Anesthesiologist

When I first wrote “What I Love about Being an Anesthesiologist” for KevinMD in 2014, it was shared over 14,000 times!

Nearly 4 years later, I still love what I do – in fact, I think I love it even more now! My wife and I were at a party recently attended by healthcare and non-healthcare people. Of course, I was asked the inevitable questions, “What do you do?” and “What is it like?”

Here is how I answered:

Being a physician anesthesiologist is the honor of a lifetime, and it comes with a tremendous amount of responsibility. My patients rely on me to be their personal physician during surgery.  Under general anesthesia, they need me to be their voice because they can’t speak. They need me to act because they cannot protect themselves.

  • I have to understand my patients’ medical conditions.
  • I adapt my anesthetic plans to their needs.
  • I anticipate challenges that may take place during an operation.
  • I recognize problems early and prevent them when possible.
  • I react quickly and appropriately to make sure my patients make it through surgery safely with the best possible outcomes.

In the operating room, I cannot write an order and expect someone else to carry it out. I have to know how everything in my environment works, from top to bottom, so I can take the best care of my patients. I set up my own anesthetic equipment and supplies in preparation for surgery. I prepare all of the medications that I will personally administer to my patients.

I will admit that a big reason I chose this specialty was the people in it. Now my fellow physician anesthesiologists are my colleagues and mentors who continually challenge and inspire me.

I have the best job in the world:  helping patients through the stressful experience of surgery, relieving pain, and making new discoveries through research that will hopefully benefit future patients.

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Partnering with Patients for Patients

As an anesthesiologist, I am a physician who cares for patients when they are most vulnerable.  Under anesthesia, no one is able to call for help.  Every day patients have surgery in operating rooms all over the world, and it is the job of the physician anesthesiologist to watch over them, monitor their bodies’ responses to stress, breathe for them, provide them with pain relief, and fight for them when unexpected crises occur.  It is my job to calm the fears of my patients and families, listen to their requests, manage their expectations, and develop a plan that will provide them with the best outcome after surgery.

My belief in this connection between physicians, patients, and families as an anesthesiologist stretches into my administrative roles as well.  As Chief of the Anesthesiology and Perioperative Care Service and Associate Chief of Staff for Inpatient Surgical Services at the VA Palo Alto Health Care System (VAPAHCS), I am grateful for the opportunity to work with an incredible team of physicians, respiratory therapists, surgeons, advanced practice providers, technicians, and administrative staff members who are focused on our mission to provide the highest quality Veteran-centered care by leading, educating, and innovating in anesthesiology and perioperative medicine.

In order to accomplish this mission, we need the best information available to guide our decisions and a diversity of perspectives to enhance our ability to train new clinicians and explore relevant research questions.  We have been fortunate to partner with our friends and colleagues in the Veteran and Family Advisory Council (VFAC) on a number of exciting projects.  First, our Service manages the simulation center at VAPAHCS and is responsible for coordinating simulation-based training for all clinicians.  Members of VFAC have been directly involved in simulation activities, even taking on active roles as the patient or family member in standardized training scenarios, to help us educate clinicians from various disciplines and all training levels.  Debriefing after these simulation exercises gives our clinical trainees and practicing clinicians the unique perspective of real patients and family members which is essential to their professional development as modern medicine continues to progress towards a model of patient-centered care.

Once a year, our Service organizes a faculty development retreat during which we reassess our mission, vision, strategic priorities, and tactics and work on one or two big ideas.  Two years ago in 2015, we invited our VFAC partners to join us at our annual retreat to brainstorm improvement ideas related to patient-centered care in the perioperative environment, intensive care unit, and pain management.  The general theme of the retreat addressed public perception and professional reputation of anesthesiologists and the specialty of anesthesiology.  Having members of VFAC present at the retreat to share their knowledge, opinions, and questions has inspired a few subsequent improvement activities and other projects to enhance the range of services that we provide to our patients and their families.

Finally, working together with VFAC, and knowing members personally, has allowed our clinical Service to solicit feedback on a regular basis.  Not all hospitals enjoy the level of access to a community of engaged patients and families like we do at VAPAHCS.  When we revised our preoperative education materials for patients, we went to VFAC for input.  When we were critically reviewing our website to update our online patient educational materials on anesthesia and perioperative care, we presented at the VFAC meeting to get the members’ feedback and suggestions.  With their help, we have been able to improve the accessibility and readability of our online content and provide our patients and their families with useful information that can help prepare them for surgery.

We are very grateful to VFAC for its priceless contributions to our healthcare system, our patients, and our Service.  We look forward to continued collaboration on future projects!

This blog has also appeared as a featured story on the VA Palo Alto Health Care System website.

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Physician-Led Anesthesia is Safe Anesthesia

Anesthesia1Many people, even those who work in the operating room every day, take safe anesthesia care for granted.  There has been growing pressure recently to abandon the team model and remove physician anesthesiologists’ supervision of nurse anesthetists with the latest threat coming from within Veterans Affairs (VA) healthcare.  For our Veterans, our heroes and arguably some of the most medically complex patients, having both physician anesthesiologists and nurse anesthetists working together as a team makes sense.

Having a team with members who train differently and have different perspectives can only benefit the patient; physician anesthesiologists draw on their medical training while nurse anesthetists bring valuable nursing experience.  Providing anesthesia is often compared to flying a passenger airplane, and the care team model is like having both a pilot and a co-pilot.  Has flying become so safe that we no longer need the pilot?  Seconds count in flight, and they count in the operating room when a patient’s life is on the line.  If approved, the proposed change in the VA nursing handbook will abolish this team model without giving Veterans a choice and will require VA hospitals to assign Veterans having surgery either a nurse anesthetist OR a physician anesthesiologist but not offer both.  If they were given the choice, however, I think our Veterans would choose “AND” instead of “OR.”  We all should.  In case a crisis happens during surgery, every patient should have access to a physician anesthesiologist.

Not too long ago operating room personnel had to worry about explosive anesthetic gases, and patients faced the risk of developing organ failure after every time they had anesthesia in addition to the usual perils of having surgery.  This changed when anesthesiology became a medical specialty and profession for physicians.

How is anesthesiology different than anesthesiaAnesthesia, a word with Greek origin, means “without sensation.”  Often referred to as “going to sleep,” general anesthesia is more like a complex drug-induced coma that can still carry serious risk, and a person’s physical and emotional reactions to anesthetic agents are not always predictable.

Anesthesiology is a science like biology or physiology and a specialty field of medicine like cardiology or radiology.  Modern anesthesiologists are physicians, scientists, educators, and patient safety advocates.  The heart of anesthesiology continues to be the patient experience.  As physician anesthesiologists, we specialize in relieving anxiety, preventing and treating pain, preventing and managing complications related to surgery, and improving the outcomes for patients who undergo invasive procedures.  The average physician anesthesiologist spends nearly a decade in postgraduate education after college and logs 16,000 hours of clinical training to learn to apply the best available evidence in clinical practice.  Academic physicians and scientists focused on anesthesiology are responsible for the discovery of the newer and safer anesthetic and analgesic agents we use every day.

Anesthesia administration by non-physicians such as nurse anesthetists and certified anesthesiologist assistants is supported by the American Society of Anesthesiologists within the physician-led anesthesia care team model.  A similar model is used in the intensive care unit with physician intensivists supervising teams that include acute care nurse practitioners.  To preserve safe, high-quality physician-led anesthesia care for our nation’s Veterans, please support the team model and #SafeVACare by speaking up on http://www.safevacare.org by July 25th.  It only takes a minute to post a comment, but the consequences of not saying something may be serious and long-lasting.

This post has also been featured on KevinMD.com.

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Pain Medicine, Perioperative Surgical Home, and the Patient Experience

VAPAHealthcare around the world is changing. In the United States, healthcare reform has been focused on achieving the “triple aim” as described by Berwick (1). This triple aim encompasses 3 goals: improving the patient experience, reducing costs of care, and improving population health. The Perioperative Surgical Home (PSH) is a conceptual model introduced by the American Society of Anesthesiologists (ASA) in the past 5 years that may serve as an integrator to help hospitals achieve the triple aim (2). PSH is defined as “a patient-centered, physician anesthesiologist-led, multidisciplinary team-based practice model that coordinates surgical patient care throughout the continuum from the decision to pursue surgery through convalescence” (3). In reality, a PSH can take many forms, and the concept is analogous to the “Perioperative Medicine: the Pathway to Better Surgical Care” initiative by the Royal College of Anaesthetists in the United Kingdom. To date, there have been few published descriptions of actual PSH programs.

Role of Pain Medicine in the PSH

Pain medicine is woven throughout the three main elements of the PSH: preoperative preparation, intraoperative care, and postoperative recovery and rehabilitation (4). Preoperatively, anesthesiologists and pain medicine specialists have an opportunity to influence patient care by identifying patients who are considered high risk for surgery and tailor an individualized preoperative preparation plan for them. For example, the patient with chronic pain treated with long-acting opioids may benefit from optimizing the preoperative analgesic medication regimen, even tapering the opioid dose, or prescribing cognitive, behavioral, or physical therapy prior to elective major surgery like lower extremity joint replacement. During the intraoperative period, anesthetic protocols provide consistent care for surgical patients, and implementing clinical pathways that include regional anesthesia techniques have been shown to decrease perioperative opioid use and improve outcomes. For patients who have surgery, pain has a profound influence on the hospital experience. In the United States, the patient experience of care is one of three domains that influence hospital incentive payment amounts from the Center for Medicare and Medicaid Services. Patient experience is assessed using a survey, and 7 of 32 questions directly or indirectly relate to pain management (5). After the immediate postoperative period, integrated pain management can help patients achieve physical therapy goals and facilitate the transition to after-hospital rehabilitation. For challenging patients with chronic pain, this process may require careful coordination between the in-hospital anesthesiologist, outpatient pain clinic physician, and primary care physician (4).

Thinking Beyond Pain

The practice of anesthesiology in the United States is evolving, and there is a greater emphasis on demonstrating value. Anesthesiologists have historically been successful in establishing perioperative clinical pathways that improve acute pain management especially in orthopedic surgery, and setting up regional anesthesia and acute pain medicine programs has played a key role (6). However, competing priorities require revision of clinical pathways from time to time. For example, concerns regarding quadriceps muscle weakness with femoral nerve blocks (7) and the potential for falls (8) have led to innovations in selective nerve block techniques for knee replacement patients (9) and greater achievements in functional rehabilitation (10). By establishing a PSH model, anesthesiologists have greater opportunity but also greater responsibility for reducing perioperative complications that may or may not typically be considered within the realm of anesthesiology (11).

Future Directions

physical_med_rehab_indexTo date, anesthetic interventions focused on targeting acute pain have not demonstrated long-term functional benefits (12,13). Perhaps implementation of a PSH with better care coordination that includes individualized preoperative preparation and follow-up after surgery during rehabilitation will have greater potential for positive long-term outcomes. In addition to improvements in functional outcomes, a PSH may be able to provide patients a smoother transition from hospital to home in terms of pain management and decrease the incidence of chronic pain after common elective procedures like joint replacement (14). Finally, more health economic research is needed to prove the financial benefits of a PSH in terms of cost savings for hospitals.

In summary, the PSH is a model that can be applied many ways to provide coordinated care of the surgical patient from the decision to proceed with surgery through convalescence. Pain medicine plays an integral role in any PSH implementation. However, to be effective, anesthesiologists as leaders of the PSH need to target improvement strategies beyond pain outcomes and the immediate postoperative period.

References

  1. Berwick DM, Nolan TW, Whittington J: The triple aim: care, health, and cost. Health Aff (Millwood) 2008; 27: 759-69
  2. Vetter TR, Boudreaux AM, Jones KA, Hunter JM, Jr., Pittet JF: The perioperative surgical home: how anesthesiology can collaboratively achieve and leverage the triple aim in health care. Anesth Analg 2014; 118: 1131-6
  3. Mariano ER, Walters TL, Kim TE, Kain ZN: Why the perioperative surgical home makes sense for veterans affairs health care. Anesth Analg 2015; 120: 1163-6
  4. Walters TL, Mariano ER, Clark JD: Perioperative Surgical Home and the Integral Role of Pain Medicine. Pain Med 2015; 16: 1666-72
  5. Mariano ER, Miller B, Salinas FV: The expanding role of multimodal analgesia in acute perioperative pain management. Adv Anesth 2013; 31: 119-136
  6. Mariano ER: Making it work: setting up a regional anesthesia program that provides value. Anesthesiol Clin 2008; 26: 681-92, vi
  7. Charous MT, Madison SJ, Suresh PJ, Sandhu NS, Loland VJ, Mariano ER, Donohue MC, Dutton PH, Ferguson EJ, Ilfeld BM: Continuous femoral nerve blocks: varying local anesthetic delivery method (bolus versus basal) to minimize quadriceps motor block while maintaining sensory block. Anesthesiology 2011; 115: 774-81
  8. Feibel RJ, Dervin GF, Kim PR, Beaule PE: Major complications associated with femoral nerve catheters for knee arthroplasty: a word of caution. J Arthroplasty 2009; 24: 132-7
  9. Lund J, Jenstrup MT, Jaeger P, Sorensen AM, Dahl JB: Continuous adductor-canal-blockade for adjuvant post-operative analgesia after major knee surgery: preliminary results. Acta Anaesthesiol Scand 2011; 55: 14-9
  10. Mudumbai SC, Kim TE, Howard SK, Workman JJ, Giori N, Woolson S, Ganaway T, King R, Mariano ER: Continuous adductor canal blocks are superior to continuous femoral nerve blocks in promoting early ambulation after TKA. Clin Orthop Relat Res 2014; 472: 1377-83
  11. Kim TE, Mariano ER: Developing a Multidisciplinary Fall Reduction Program for Lower-Extremity Joint Arthroplasty Patients. Anesthesiol Clin 2014; 32: 853-864
  12. Ilfeld BM, Ball ST, Gearen PF, Mariano ER, Le LT, Vandenborne K, Duncan PW, Sessler DI, Enneking FK, Shuster JJ, Maldonado RC, Meyer RS: Health-related quality of life after hip arthroplasty with and without an extended-duration continuous posterior lumbar plexus nerve block: a prospective, 1-year follow-up of a randomized, triple-masked, placebo-controlled study. Anesth Analg 2009; 109: 586-91
  13. Ilfeld BM, Shuster JJ, Theriaque DW, Mariano ER, Girard PJ, Loland VJ, Meyer S, Donovan JF, Pugh GA, Le LT, Sessler DI, Ball ST: Long-term pain, stiffness, and functional disability after total knee arthroplasty with and without an extended ambulatory continuous femoral nerve block: a prospective, 1-year follow-up of a multicenter, randomized, triple-masked, placebo-controlled trial. Reg Anesth Pain Med 2011; 36: 116-20
  14. Lavand’homme PM, Grosu I, France MN, Thienpont E: Pain trajectories identify patients at risk of persistent pain after knee arthroplasty: an observational study. Clin Orthop Relat Res 2014; 472: 1409-15

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