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)

The Use of Ultrasound to Measure the Depth of Thoracic Epidural Space

Introduction: The use of ultrasound to aid in regional blocks has increased in recent years as a result of improvement in ultrasound technology. There have been many studies to evaluate the use of ultrasound to measure the depth of the epidural space in the lumbar region1-9,10,11,12. Studies have shown a strong correlation between the depth of the lumbar epidural space measured by ultrasound and the distance of the needle from the skin after establishing the loss of resistance in the epidural space3,6,7. This study looked at the epidural space in the thoracic space to evaluate the possibility to visualize the thoracic spine anatomy and the possibility to measure the depth of the epidural space and it\u27s correlation with the actual depth by the loss of resistance technique. This study was also designed to assess the ability of the ultrasound to define the best needle insertion point and limit the number of needle skin puncture attempts. Methods: After approval of the IRB at the UMass Medical School and written consent was obtained, 29 patients were enrolled in the study. Exclusion criteria included pregnancy, prisoners, and patients with an absolute contra-indication to thoracic epidural. Ultrasound scan technique: We used a curvilinear 2-5 MHz probe. Both longitudinal para-median and transverse scan were done before the placement of the epidural catheter. The transducer was stabilized at the the best image of intra-laminal space and a mark was placed at the midpoints of the transducer. The puncture point was determined by the intersection of those two lines. The depth of the epidural space was measured using the built-in calipers. The ultrasound depth (UD) was also measured in the transverse view. The epidural catheter was placed using the standard technique at the UMass Memorial Medical Center. Assessment of the catheter function was based on the technique, response to test dose and pain control on post operative day number one. Statistical analysis included the distributional characteristics of the measures, Pearson’s correlation analysis and general linear model. Difference by gender groups were evaluated using Student’s t-test. Results: Mean ultrasound distance (UD) values were 4.22cm ± 0.82 and actual distance (AD) values were 5.59 cm ± 1.29 with Pearson’s correlation coefficient between AD and ultrasound longitudinal (USL) and ultrasound short axis (USS) values were 0.637 and 0.566 respectively, The mean number of attempts were 1.96 ± 1. The number of attempts were defined as the number of skin puncture points by a single provider or the number of providers attempting in the same insertion point. The use of ultrasound was able to identify the depth of the thoracic epidural space in 24/29 cases (83 %) of the cases. The catheter was considered at least partially functioning in 26/29 patients (20 functioning, 6 partially functioning (89.65 %)). Conclusion: Ultrasound scanning can be used to measure the depth of the thoracic epidural space with good correlation

A system of relational syllogistic incorporating full Boolean reasoning

We present a system of relational syllogistic, based on classical propositional logic, having primitives of the following form: Some A are R-related to some B; Some A are R-related to all B; All A are R-related to some B; All A are R-related to all B. Such primitives formalize sentences from natural language like `All students read some textbooks'. Here A and B denote arbitrary sets (of objects), and R denotes an arbitrary binary relation between objects. The language of the logic contains only variables denoting sets, determining the class of set terms, and variables denoting binary relations between objects, determining the class of relational terms. Both classes of terms are closed under the standard Boolean operations. The set of relational terms is also closed under taking the converse of a relation. The results of the paper are the completeness theorem with respect to the intended semantics and the computational complexity of the satisfiability problem.Comment: Available at http://link.springer.com/article/10.1007/s10849-012-9165-

Psychological distress as predictor of quality of life in men experiencing infertility: a cross-sectional survey

<p>Abstract</p> <p>Background</p> <p>Infertility is associated with impairment in human life. The quality of life (QOL) construct allows measuring the impact of health conditions in a broader way. The study aimed to explore the impact of the psychological distress on QOL's dimensions in men experiencing infertility.</p> <p>Methods</p> <p>162 men were completed a socio-demographic form, SF-36, WHOQOL-BREF, Beck Anxiety Inventory and Beck Depression Inventory. Hierarchical regressions included demographic and clinic variables, and subsequently depression and anxiety were added.</p> <p>Results and Discussion</p> <p>Model 1 was not accurate in predicting QOL. R²values ranged from 0.029 (Social Functioning) to 0.149 (Mental Health). Eight domains were not associated with any of the predictors. In the second model, a R²increase was observed in all domains. R²of QOL scores ranged from .209 (Role Physical) to .406 (Social Functioning). The intensity of the depression was a significant predictor for all outcomes. The load of depression was higher than the ones of the socio-demographic and clinical variables. Anxiety levels have also presented the same effect, but with less intensity.</p> <p>Conclusion</p> <p>Subthreshold depression and anxiety were major predictors of QOL in men experiencing infertility. Health professionals need to include assessment of psychological symptomatology to plan more efficient interventions to infertile patients.</p

Multilevel home energy management integrated with renewable energies and storage technologies considering contingency operation

This paper presents a multilevel energy management system between homes and the electrical grid. The proposed model includes three levels: the first level is made of the utility grid, and it can send or receive energy from the second level. The second level is formed as a common level that is equipped with a wind turbine, battery energy storage, and a diesel generator. The second level can exchange energy with both the first and third levels. The third level is formed with a set of buildings with different loading patterns, and some of them are also equipped with solar panels. The third level can send or receive energy from the second level. The second level is a common level between two other levels. The proposed planning minimizes the cost of consumed energy by houses in the third level through optimal utilization and management of all levels. The problem optimizes the power between levels 1 and 2, the power between levels 2 and 3, the charging-discharging pattern of the battery in level 2, and the operation pattern of the diesel generator in level 2. The plan optimally utilizes both wind and solar resources (in levels 2 and 3) to minimize the energy cost and deals with their intermittency nature by means of stochastic programming. The plan is also designed to operate under contingency conditions when the utility grid (first level) is out of access. In such a situation, the problem utilizes the available technologies in levels 2 and 3 (i.e., wind, solar, battery, and diesel) to supply the houses in the third level. The diesel generator plays a major role under contingency and emergency conditions to maintain the resiliency of the system.Scopu

Telladoy, Ellen Khayata, and John M.

We simulate the performance of an equalized Gaussian Minimum Shift Keying (GMSK) signal in an indoor radio environment with fading, noise, cochannel interference and Inter Symbol Interference (ISI). We show that data rates of 20 Mbps at Bit Error Rates (BER) 10 \Gamma4 are possible with rms delay spreads up to 25 ns using a simple limiter-discriminator-integrator receiver and a (6,4) Decision Feedback Equalizer (DFE). In environments with larger rms delay spreads, coherent detection is required for the same performance. We introduce a DFE structure which compensates for both modulator and channel ISI, and yet requires no power-intensive multiplication operations in the feedback section. An (8,8) DFE with 2-level switched (selection) diversity is shown to allow 20 Mbps data transfer at BER 10 \Gamma4 for rms delay spreads under 150 ns, with cochannel interference. Adding a (26,31) BCH code allows error-free reception of over 90% of packets with rms delay spreads under 150 ns, and ..

Ultrasound-guided epidural blood patch

Presents a case where an epidural injection was performed under real-time ultrasound guidance

Adaptive Dfe For Gmsk In Indoor Radio Channels

We simulate the performance of an equalized Gaussian Minimum Shift Keying (GMSK) signal in an indoor radio environment with fading, noise, imperfect carrier recovery, Co-Channel interference (CCI) and Inter Symbol Interference (ISI). We show that data rates of 20 Mbps at Bit Error Rates (BER) 10 \Gamma4 are possible with rms delay spreads up to 25 ns using a simple Limiter-Discriminator-Integrator (LDI) receiver and a (6,4) Decision Feedback Equalizer (DFE). In environments with larger rms delay spreads, coherent detection is required for the same performance. We show that using a decision-directed secondorder digital carrier synchronizer with time varying loop filters, frequency offsets up to 200 kHz can be corrected with negligible performance degradation. We introduce a DFE structure which compensates for both modulator and channel ISI, and yet requires no power-intensive multiplication operations in the feedback section. An (8,8) DFE with 2-level switched (selection) diversity i..

Relationships Between Atrial Flutter and Fibrillation: The Border Zone

: Atrial flutter and fibrillation have been inextricably linked in the study of electrophysiology. With astute clinical observation, advanced diagnostic equipment in the Electrophysiology Laboratory, and thoughtful study of animal models, the mechanism and inter-relationship between the 2 conditions have been elucidated and will be reviewed in this article. Though diagnosis and management of these conditions have many similarities, the mechanisms by which they develop and persist are quite unique