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Decreasing Same-Day Cancellations in an Interventional Pain Management Practice Improves Patient Care and Productivity

In an interventional pain management practice, scheduling errors can increase the risk of procedural complications and often necessitate provider-initiated same-day procedure cancellations. To reduce the number of scheduling errors in the interventional pain management division of an orthopedic practice while simultaneously increasing the sites of service, a quality improvement project was initiated. The quality improvement plan consisted of instituting PDSA cycles of error data collection and workflow interventions. A quasi-experimental observational study, utilizing an interrupted time series design to assess the effects of interventions was implemented to reduce scheduling errors and same-day cancellations. For the time periods observed, total errors decreased by 57% between Q1 2019 and Q1 2020 (190 to 81) with the error rate decreasing 59% from 6.4% to 2.6% of patients scheduled (p-value = 8.8×10E -13). Total Q1 procedure cancellations decreased by 38% (100 to 62) with the cancellation rate decreasing 41% from 3.4% to 2.0% of patients scheduled (p-value = 9.24×10E -4). These decreases were found to be statistically significant. Though the overall rate of errors and cancellations decreased, some error categories increased between the two time periods observed. Cancellations due to active infections increased from 0 to 8 incidents, anticoagulants and NSAIDs not being held increased by11.9% and 18.9% respectively, and lack of necessary imaging increased by10.2%. This study demonstrated that though the interventions were successful at decreasing the overall scheduling errors and cancellation rates, more investigation should be conducted to identify additional factors contributing to scheduling errors and same-day cancellations along with effective interventions to address these factors

Tracheal intubation in critically ill adults with a physiologically difficult airway. An international Delphi study.

PURPOSE Our study aimed to provide consensus and expert clinical practice statements related to airway management in critically ill adults with a physiologically difficult airway (PDA). METHODS An international Steering Committee involving seven intensivists and one Delphi methodology expert was convened by the Society of Critical Care Anaesthesiologists (SOCCA) Physiologically Difficult Airway Task Force. The committee selected an international panel of 35 expert clinician-researchers with expertise in airway management in critically ill adults. A Delphi process based on an iterative approach was used to obtain the final consensus statements. RESULTS The Delphi process included seven survey rounds. A stable consensus was achieved for 53 (87%) out of 61 statements. The experts agreed that in addition to pathophysiological conditions, physiological alterations associated with pregnancy and obesity also constitute a physiologically difficult airway. They suggested having an intubation team consisting of at least three healthcare providers including two airway operators, implementing an appropriately designed checklist, and optimizing hemodynamics prior to tracheal intubation. Similarly, the experts agreed on the head elevated laryngoscopic position, routine use of videolaryngoscopy during the first attempt, preoxygenation with non-invasive ventilation, careful mask ventilation during the apneic phase, and attention to cardiorespiratory status for post-intubation care. CONCLUSION Using a Delphi method, agreement among a panel of international experts was reached for 53 statements providing guidance to clinicians worldwide on safe tracheal intubation practices in patients with a physiologically difficult airway to help improve patient outcomes. Well-designed studies are needed to assess the effects of these practice statements and address the remaining uncertainties