Inefficiency in the Post Anesthesia Care Unit: A Quality Improvement Initiative

Background: The post anesthesia care unit (PACU) is a busy environment in which nurses communicate with patients, family members, and a large team of perioperative professionals. PACU nurses were experiencing an unmanageable number of work interruptions due to a higher patient census which increased the daily surgical caseload. Aim: The purpose of this project was to improve efficiency and nurses’ job satisfaction by making work interruptions manageable in the PACU. Methods: Based on Kotter’s Change Theory, a quality improvement initiative was implemented using a change in the communication process. Qualitative and quantitative data was gathered in the PACU and on other units with the intervention roll-out. A pre and post-intervention survey was used to evaluate work interruptions and their effects experienced by nurses in the PACU environment. Results: The use of communication technology impacted work interruptions, but not significantly enough to improve nursing efficiency and nurse satisfaction in the PACU. Conclusion and Implications for CNL® Practice: The next step is to recommend adding a CNL® as a surgical nurse liaison (SNL) to the perioperative team. Ideally, a CNL® with excellent communication and quality improvement skills will exemplify the roles of lateral integrator and patient advocate to improve efficiency. This physical solution, coupled with the communicative technology tool being widely integrated to all members of the perioperative team is expected to influence work interruptions and improve nurse satisfaction more dramatically

Improve Intra-Operative Nurse-to-Nurse Communication Using a Safety Checklist

Poor and inadequate handoff, or transfer of care of the surgical patient care from the primary to the relief operating room registered nurse circulators, can result in irreversible patient harm, or sentinel events, such as retained foreign items. In this study, Rogers\u27 diffusion of innovation theory was the framework for implementing the handoff safety checklist. Also, Donabedian\u27s structure process and outcome was the model to investigate the feasibility, acceptability, and improvement in the quality of patient handoff communication and improvement of nurse satisfaction over time. Nineteen-statement surveys, conducted at multiple timeframes, were completed by volunteer operating room nurse participants. In comparison, outcomes of the pre-intervention and post-intervention surveys illustrated significance in the quality of nurse communication and satisfaction of the handoff safety checklist. The value of standardized handoff safety checklists is evident in the study. However, further research of handoff safety checklists in the intraoperative arena is warranted

Local anaesthetic bupivacaine induced ovarian and prostate cancer apoptotic cell death and underlying mechanisms in vitro

Retrospective studies indicate that the use of regional anesthesia can reduce cancer recurrence after surgery which could be due to ranging from immune function preservation to direct molecular mechanisms. This study was to investigate the effects of bupivacaine on ovarian and prostate cancer cell biology and the underlying molecular mechanisms. Cell viability, proliferation and migration of ovarian carcinoma (SKOV-3) and prostate carcinoma (PC-3) were examined following treatment with bupivacaine. Cleaved caspase 3, 8 and 9, and GSK-3β, pGSK-3β(tyr216) and pGSK-3β(ser9) expression were assessed by immunofluorescence. FAS ligand neutralization, caspase and GSK-3 inhibitors and GSK-3β siRNA were applied to further explore underlying mechanisms. Clinically relevant concentrations of bupivacaine reduced cell viability and inhibited cellular proliferation and migration in both cell lines. Caspase 8 and 9 inhibition generated partial cell death reversal in SKOV-3, whilst only caspase 9 was effective in PC-3. Bupivacaine increased the phosphorylation of GSK-3β(Tyr216) in SKOV-3 but without measurable effect in PC3. GSK-3β inhibition and siRNA gene knockdown decreased bupivacaine induced cell death in SKOV-3 but not in PC3. Our data suggests that bupivacaine has direct ‘anti-cancer’ properties through the activation of intrinsic and extrinsic apoptotic pathways in ovarian cancer but only the intrinsic pathway in prostate cancer

MOBILE and the provision of total joint replacement

Modern joint replacements have been available for 45 years, but we still do not have clear indications for these interventions, and we do not know how to optimize the outcome for patients who agree to have them done. The MOBILE programme has been investigating these issues in relation to primary total hip and knee joint replacements, using mixed methods research

Targeted Strategic Alignment via Real-time Perioperative Performance Dashboards

This study examines business process management practices of business analytics via balanced scorecards and performance dashboards within hospital processes to target and achieve improvement aligned to strategy. The study maps specific perioperative metrics in the hospital environment to clinical results and demonstrates how business process management is applicable for aligning perioperative clinical outcomes to hospital strategy. Identification of existing limitations, potential capabilities, and the subsequent contextual understanding are contributing factors that yield measured improvement within the hospital’s perioperative process. Based on a 150-month longitudinal study of a large 1,046 registered-bed academic medical center, this case study investigates the impact of integrated systems to qualify and quantify business analytics to improve hospital efficiency and effectiveness across patient quality of care, patient satisfaction, operational efficiency, and financial cost effectiveness. The theoretical and practical implications and/or limitations of this study’s results are also discussed

Alveolar macrophages and Toll-like receptor 4 mediate ventilated lung ischemia reperfusion injury in mice.

BackgroundIschemia-reperfusion (I-R) injury is a sterile inflammatory process that is commonly associated with diverse clinical situations such as hemorrhage followed by resuscitation, transient embolic events, and organ transplantation. I-R injury can induce lung dysfunction whether the I-R occurs in the lung or in a remote organ. Recently, evidence has emerged that receptors and pathways of the innate immune system are involved in recognizing sterile inflammation and overlap considerably with those involved in the recognition of and response to pathogens.MethodsThe authors used a mouse surgical model of transient unilateral left pulmonary artery occlusion without bronchial involvement to create ventilated lung I-R injury. In addition, they mimicked nutritional I-R injury in vitro by transiently depriving cells of all nutrients.ResultsCompared with sham-operated mice, mice subjected to ventilated lung I-R injury had up-regulated lung expression of inflammatory mediator messenger RNA for interleukin-1β, interleukin-6, and chemokine (C-X-C motif) ligand-1 and -2, paralleled by histologic evidence of lung neutrophil recruitment and increased plasma concentrations of interleukin-1β, interleukin-6, and high-mobility group protein B1 proteins. This inflammatory response to I-R required toll-like receptor-4 (TLR4). In addition, the authors demonstrated in vitro cooperativity and cross-talk between human macrophages and endothelial cells, resulting in augmented inflammatory responses to I-R. Remarkably, the authors found that selective depletion of alveolar macrophages rendered mice resistant to ventilated lung I-R injury.ConclusionsThe data reveal that alveolar macrophages and the pattern recognition receptor toll-like receptor-4 are involved in the generation of the early inflammatory response to lung I-R injury

American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on measurement to maintain and improve quality of enhanced recovery pathways for elective colorectal surgery.

BACKGROUND: This article sets out a framework for measurement of quality of care relevant to enhanced recovery pathways (ERPs) in elective colorectal surgery. The proposed framework is based on established measurement systems and/or theories, and provides an overview of the different approaches for improving clinical monitoring, and enhancing quality improvement or research in varied settings with different levels of available resources. METHODS: Using a structure-process-outcome framework, we make recommendations for three hierarchical tiers of data collection. DISCUSSION: Core, Quality Improvement, and Best Practice datasets are proposed. The suggested datasets incorporate patient data to describe case-mix, process measures to describe delivery of enhanced recovery and clinical outcomes. The fundamental importance of routine collection of data for the initiation, maintenance, and enhancement of enhanced recovery pathways is emphasized