Duration of CPR: How Long is Too Long? A Positive Outcome After 90 Minutes of CPR

INTRODUCTION: Survival and neurologic function following prolonged cardiopulmonary resuscitation (CPR) are often poor and currently there lacks a formal recommendation for the maximum duration of resuscitative efforts. However, there have been multiple case reports of positive neurological outcomes following prolonged CPR. This case presentation helps to support and encourage the continuation of CPR in the appropriate setting and with available resources including intra-arrest percutaneous intervention (PCI) and extracorporeal membrane oxygenation (ECMO). CONCLUSION: Prolonged CPR can result in favorable patient outcomes if done promptly and effectively, utilizing all available resources including intra-arrest PCI and ECMO

Identifying a site for maximum delivery of oxygen to transplanted cells

For in vivo cell implantation techniques to be successful, the energy and metabolic substrate requirement of the cells being grown must be met. Certain cells with high-energy requirements (e.g., hepatocytes, pancreatic island cells) experience a high degree of cell death after implantation due to a limited supply of oxygen. We proposed that the pleural cavity might be an oxygen-rich environment and hence an excellent site for cell implantation. To test the hypothesis that the delivery of oxygen to the pleural cavity is directly proportional to the inspired oxygen concentration we measured the pO(2) of saline instilled in the pleural cavity as compared to that of the peritoneal cavity. We postulated that the physiologic basis for any difference was the result of direct diffusion of oxygen into the pleural space across the alveoli. The study was conducted on sheep (n = 6), after induction of general anesthesia, in two phases, control and experimental. Saline was instilled into the peritoneal and pleural cavities via catheters, after equilibration at given FiO(2), the pO(2) of the paline aspirated from the two cavities was compared. In the experimental group, animals were sacrificed (no circulation) and ventilated. The same sequence of steps as in the control phase were repeated. In the control group, the pO(2) of saline aspirated from the pleural cavity approached the arterial pO(2) at all FiO(2) levels. The pO(2) of the peritoneal saline aspirate fell over time. In the experimental phase (no circulation), the pO(2) of the pleural cavity saline rose to \u3e400 mm Hg. We conclude that this is a result of direct diffusion and is a potential source of unlimited oxygen supply not dependent on vascular supply

The Perioperative Surgical Home: A New Paradigm in a Surgical Episode of Care

An overview and review of a Perioperative Surgical Home (PSH) pilot developed using hte guiding principles of the patient-centered medical home. The PSH coordinates care and decisions from the decision to operate through return to primary care. The pilot demonstrated that a PSH improves efficiencies, decreases waste, improves patient and physician satisfaction and decreases care costs

Post-Anesthesia Evaluation: Using a Systems Based Team Approach to Achieve Compliance with CMS Interpretive Guidelines

Introduction: In December of 2009 the Center for Medicare and Medicaid Services (CMS) issued Revised Anesthesia Services Interpretive Guidelines. The revised post-anesthesia evaluation rules require assessment and documentation within 48 hours from the time the patient is moved into the recovery area for patients (includes outpatients prior to discharge as well as all inpatients). It applies to all patients who have had monitored anesthesia services, regional or general anesthesia. It must be performed and documented by a practitioner who is qualified to administer anesthesia and can be completed at any time and location as long as the patient has recovered sufficiently from anesthesia to answer the key questions related to the evaluation. Required key elements include assessment of mental status, pain, nausea and vomiting, temperature, hydration, respiratory and cardiovascular status. We describe the systems based team approach we used to achieve compliance with the 93% or higher post-anesthesia evaluation set by CMS and The Joint Commission. Background: UMass Memorial is a multi-campus medical center (A: Ambulatory Surgery Center (ASC), C: Tertiary University site, B: Memorial).Annually we provide anesthesia coverage for approximately 37,000 patients at 43 anesthetizing locations (44% inpatients and 56% outpatient procedures). The spread of Anesthesiology resources over three sites and the resident work hour restrictions posed a challenge to ensure compliance with CMS requirements for post-anesthesia evaluation and documentation. Methods: With input from the Anesthesiologists at all three sites we designed a template form that captured the required elements of the post-anesthesia evaluation and became part of the patient medical record (figure 1). We also modified the discharge process from the Post Anesthesia Care Unit (PACU). Previously our patients were discharged when the Alderete criteria were met using a standardized post-anesthesia order set. We modified this post-anesthesia order set to add post-anesthesia evaluation and documentation to the discharge criteria (figure 2). The Peri-anesthesia staff (PACU and Surgical Admission unit) was educated about these changes. We implemented a visual clue by the patient stretcher in the PACU when the patient was discharge ready. A member of the Anesthesia team completed the evaluation and documentation prior to patient discharge from the PACU. Patients who were admitted directly to the ICU or were not seen in the PACU were seen the following day by a member of the group. We used a systems based team approach with the help of the Anesthesiology staff and Peri-anesthesia nursing to implement this process across all three campuses. Random monthly chart audits were performed by our Quality department to assess our compliance with these CMS revised guidelines (20 charts at each site per month). Conclusion: We were able to achieve an average compliance rate of 82 to 93% across the medical center (figure 3)

Primary Care and the Perioperative Surgical Home

Our team partnered with UMass Memorial Medical Center’s Urology and Anesthesiology departments on a pilot patient-centered, physician-led, multidisciplinary team-based system of coordinated care for the surgical patient. The goals were to improve the patient experience, improve health care and reduce costs. Primary care physicians were surveyed to understand how surgical teams can better coordinate care with primary care. The results of the survey show that concise, useful communication about mutual patients is important to primary care physicians; there is no need for immediate follow-up appointments with primary care physicians unless necessary – appointments are recommended for two to four weeks after discharge; and defining the roles of primary care physicians and the surgeon is important

Patient Flow in Peri-Operative Services: Analysis of Factors that Impact OR Turn Over Time

Introduction: The University Campus of UMass Memorial Medical Center has 16 operating rooms. The average Turn Over Time (TOT), defined as patient out of OR to next patient in, is 43 minutes. This is a source of dissatisfaction for the surgeons and has an impact on the patient experience. We did an observational study to map and time patient flow from the Surgical Admission Unit (SACU) to the Operating Room and the process for OR turn over and arrival of the next patient. The goal was to assess how the process could be modified to enhance the patient experience and improve surgeon satisfaction. Methods: Observation and hand recording of three rooms in the University OR was performed from 6/13/2011 – 8/5/2011 (Orthopedic and Neurosurgery cases). Time points for all processes directly involving the patient were collected. Data collection was done by three undergraduate students. Support for the students was provided by Orthopedics, Anesthesiology and Peri-Operative Services. Results: See Figure 1 for patient flow and turn over process map. Subsequent figures show time intervals from SACU to OR case completion, call for cleaning, completion of cleaning and arrival of next patient. Cleaning was complete in 18 minutes but TOT was 43 minutes because nondependent tasks were being performed in series (Figure 5). Summary: Nondependent tasks are being performed in series in the SACU and during OR turn over. There is an opportunity to decrease patient length of stay in the SACU. By doing parallel practice OR TOT can be decreased from 43 to 19 minutes if the anesthesia team is allowed to bring the patient in the room once the room is clean. This process can enhance the patient experience and improve surgeon satisfaction

Intraoperative echocardiographic images of right ventricular outflow tract sarcoma

A rare case of right ventricular outflow tract (RVOT) primary spindle cell sarcoma with intraoperative TEE images is reported below

Diffusion of nitrous oxide into the pleural cavity

We postulated that nitrous oxide transfer into the pleural cavity can occur by diffusion from the alveoli, independent of vascular transport. Under general anaesthesia, six sheep were studied in two phases, a control and an experimental phase. The sheep were anaesthetized, intubated, and received positive pressure mechanical ventilation. A catheter was placed in the right pleural cavity and 150 ml air injected. The animals were ventilated with 100% oxygen. The inspired gas was changed to a mixture of 50% nitrous oxide and 50% oxygen, and the rate of increase of nitrous oxide concentration in the pleural space was measured. The animals were then ventilated with 100% oxygen and then killed by exsanguination while ventilation was continued. The inspired mixture was changed to 50% nitrous oxide and 50% oxygen and the rate of increase in nitrous oxide concentration was measured in the pleural space again. During venitilation with nitrous oxide in the living animals, the concentration of nitrous oxide in the pleural cavity increased rapidly and decreased to zero during ventilation with 100% oxygen. During ventilation without circulation, the rate of increase in the concentration of nitrous oxide in the pleural cavity was the same as in the control phase. This suggests that nitrous oxide enters the pleural space by diffusion, rather than by vascular delivery. This mechanism may explain the rapid increase in the volume of pneumothorax if nitrous oxide is given in the inspired gas

Elimination of waste: creation of a successful Lean colonoscopy program at an academic medical center

OBJECTIVE: Lean processes involve streamlining methods and maximizing efficiency. Well established in the manufacturing industry, they are increasingly being applied to health care. The objective of this study was to determine feasibility and effectiveness of applying Lean principles to an academic medical center colonoscopy unit. METHODS: Lean process improvement involved training endoscopy personnel, observing patients, mapping the value stream, analyzing patient flow, designing and implementing new processes, and finally re-observing the process. Our primary endpoint was total colonoscopy time (minutes from check-in to discharge) with secondary endpoints of individual segment times and unit colonoscopy capacity. RESULTS: A total of 217 patients were included (November 2013-May 2014), with 107 pre-Lean and 110 post-Lean intervention. Pre-Lean total colonoscopy time was 134 min. After implementation of the Lean process, mean colonoscopy time decreased by 10 % to 121 min (p = 0.01). The three steps of the process affected by the Lean intervention (time to achieve adequate sedation, time to recovery, and time to discharge) decreased from 3.7 to 2.4 min (p \u3c 0.01), 4.0 to 3.4 min (p = 0.09), and 41.2 to 35.4 min (p = 0.05), respectively. Overall, unit capacity of colonoscopies increased from 39.6 per day to 43.6. Post-Lean patient satisfaction surveys demonstrated an average score of 4.5/5.0 (n = 73) regarding waiting time, 4.9/5.0 (n = 60) regarding how favorably this experienced compared to prior colonoscopy experiences, and 4.9/5.0 (n = 74) regarding professionalism of staff. One hundred percentage of respondents (n = 69) stated they would recommend our institution to a friend for colonoscopy. DISCUSSION: With no additional utilization of resources, a single Lean process improvement cycle increased productivity and capacity of our colonoscopy unit. We expect this to result in increased patient access and revenue while maintaining patient satisfaction. We believe these results are widely generalizable to other colonoscopy units as well as other process-based interventions in health care