Unintended consequences? Unanswered questions?
Explore the source record for details and available documents.
Academic Medical Centers↗
Biomedical subjects
David A Lubarsky
Publications and source records attributed to David A Lubarsky.
Failure to recognize loss of incoming data in an anesthesia record-keeping system may have increased medical liability.
Automated anesthesia record-keeping systems (AARKs) are increasingly being used. There is a perception that AARKs may limit medical liability. We report a case in which our AARK may have increased our medical liability exposure. Nine months after a patient suffered a serious intraoperative complication, the anesthesiologist was named (as one of several defendants) in a claim alleging failure to properly monitor anesthetic care. One reason why the anesthesiologist was named related to a gap of 93 min in which no vital signs were documented in the anesthesia record. Relying on the physiological monitors to assess the patient's condition, the anesthesiologist did not recognize the interruption of data transmission, because the "active" medication window obscured the graphical display of the vital sign window.
Anesthesiology↗
Changing medical group behaviors: increasing the rate of documentation of quality assurance events using an anesthesia information system.
In the United States, quality assurance (QA) documentation is required by numerous agencies for each anesthetic performed. The goal of this study was to determine the effect of several interventions on the voluntary completion rate of QA documentation. We hypothesized that optimizing workflow integration would increase both QA completion rates and complication capture rates and promote long-term successful changes in reporting behavior. Whereas electronic scanning of anesthetic records may automate some aspects of QA, there will continue to be a need for anesthesiologists to enter QA documentation that cannot be automated. Starting from a baseline completion rate of 48%, we instituted a series of interventions. We successively increased the completion rate to 55% (education), 68% (workflow integration), and 78% (individual feedback). Each intervention increased the completion rate from the previous intervention (P < 0.001). The increased completion rate suggests better overall data capture, because the percentage of "no complication" entries decreased. After the study period, the completion rate increased to 94%, principally because of the improved workflow integration. As implementation of anesthesia information systems increases, attention to user interface design may be a key component in the functionality and utility of these systems.
Anesthesia↗
The medicolegal importance of enhancing timeliness of documentation when using an anesthesia information system and the response to automated feedback in an academic practice.
Documentation should ideally occur in real time immediately after completion of a service. Although electronic records often do not print the time that documentation notes were entered on the medical record, automated anesthesia record keeping systems store an audit trail that time stamps events entered by all anesthesia providers. As more lawyers become aware of this fact and requisition audit trails, prospective charting of necessary documentation may undermine the integrity of an anesthesia care team accused of malpractice, with potentially significant medicolegal consequences. We changed existing documentation practices of a large academic practice via a three-step process. Educational sessions increased the percentage of cases with correct timing of emergence documentation from 25% to 60% over a 2-mo period. Automated email performance feedback further increased correct note timing to 70%. When combined with personal contact by a member of the billing office and email copy notification of the chair, the percentage increased to >99.5%. The behavioral change was seen in all individuals, as 95% of attendings had < or = 2 records/mo with untimely documentation at the end of the study period. Once the habits were ingrained, further input was rarely necessary over the next 9 mo. This suggests physician behavioral change related to work process flow, unlike that related to patient care, is easily sustained.
Academic Medical Centers↗
Effect of subspecialty organization of an academic department of anesthesiology on faculty perceptions of the workplace.
BACKGROUND: Many large academic practices have accepted the notion that subspecialization provides certain benefits-more consistent care, a higher degree of state-of-the-art knowledge, improved teaching, and better working relationships and communication among the subspecialty anesthesia faculty and their surgical and nursing colleagues. But a rigid subspecialty grouping is rarely done in the main body of an academic faculty. STUDY DESIGN: To evaluate if subspecialization provides greater satisfaction for an academic general services anesthesia faculty, a survey about work conditions and perceptions was undertaken before and after reorganization of a large academic practice. Scores for each question were on a scale of 1 to 5. RESULTS: Although there was a sense that excellent expert care was more often delivered after subspecialty reorganization, the overall faculty impression of their workplace was not markedly changed (prereorganization 3.52 +/- .56; postreorganization 3.60 +/- .34 [mean score +/- SD]; p = NS). CONCLUSIONS: The faculty did not perceive an overall benefit from a move to greater subspecialization in the organization of the anesthesia department, despite the leadership's opinion that the workplace had become much more functional and productive.
Academic Medical Centers↗
The impact of pharmacogenomics on postoperative nausea and vomiting: do CYP2D6 allele copy number and polymorphisms affect the success or failure of ondansetron prophylaxis?
BACKGROUND: Some patients treated with ondansetron for postoperative nausea and vomiting do not respond to therapy. One possible mechanism for this failure is ultrarapid drug metabolism via the cytochrome P-450 system, specifically the enzyme 2D6 (CYP2D6). Ultrarapid metabolism is seen in patients with multiple functional copies (>/= 3) of the CYP2D6 allele. This study was designed to determine whether patients who were given prophylactic ondansetron and had multiple CYP2D6 alleles had an increased rate of postoperative nausea and vomiting. METHODS: Two hundred fifty female patients undergoing standardized general anesthesia were given 4 mg ondansetron 30 min before extubation. Patients were observed for symptoms of nausea and vomiting. DNA was extracted from blood in all patients and was analyzed by using a gene-specific probe to determine the CYP2D6 gene copy number and genotyped by polymerase chain reaction amplification with a custom oligonucleotide microarray to determine the specific CYP2D6 genotypes. RESULTS: Eighty-eight patients experienced nausea, and 37 of those patients also had vomiting. In patients with one, two, or three CYP2D6 copies, the incidences of vomiting were 3 in 33 (27%), 27 in 198 (14%), and 7 in 23 (30%), respectively. The incidence of vomiting in subjects with three CYP2D6 copies was significantly different from those with two copies, but not from those with one copy. When analyzed by genotype, the incidences of vomiting in poor, intermediate, extensive, and ultrarapid metabolizers were 1 in 12 (8%), 5 in 30 (17%), 26 in 176 (15%), and 5 in 11 (45%), respectively (P < 0.01 vs. all other groups). There were no differences between groups in the incidence of nausea based on CYP2D6 copy number or genotype. CONCLUSIONS: Patients with three copies of the CYP2D6 gene, a genotype consistent with ultrarapid metabolism, or both have an increased incidence of ondansetron failure for the prevention of postoperative vomiting but not nausea.
Adolescent↗
Financial implications of a hospital's specialization in rare physiologically complex surgical procedures.
BACKGROUND: The authors previously identified a hospital that has a unique role in its region for surgical care. In children aged 0-2 yr, the hospital performed 64% of all physiologically complex procedures statewide (>or= 8 American Society of Anesthesiologists Relative Value Guide basic units). For all age groups combined, 48% of the physiologically complex procedures performed at that hospital were rare, defined as < 1/workday statewide. METHODS: The authors tested the hypothesis that financially important differences can result from performing relatively large numbers of such specialized procedures. Methods were developed to compare contribution margin (revenue from facility and professional fees minus variable costs) per operating room hour (CM/OR hour) between patient groups and different types of surgical procedures. RESULTS: CM/OR hour was significantly larger by a financially important amount (> 250 dollars/OR hour) for pediatric versus geriatric patients (P <or= 0.002), primarily because of higher professional reimbursements, with no difference in hospital reimbursements. Unexpectedly, CM/OR hour was also significantly greater by at least 250 dollars when a rare procedure was involved (P < 0.001 for all ages combined), primarily because of greater hospital reimbursements. For cases involving implant charges of 10,000 dollars or greater, overall CM/OR hour was negative because increased revenues did not compensate for the high variable costs. CONCLUSIONS: Other hospitals can use these methods to perform a similar analysis of the financial impact of those patient populations or surgical procedures that are unique to their own roles in their regional healthcare systems, and to identify the sources of financial losses and gains experienced by the hospital.
Child↗
Incentivize everything, incentivize nothing.
Explore the source record for details and available documents.
Academic Medical Centers↗
Using length of stay data from a hospital to evaluate whether limiting elective surgery at the hospital is an inappropriate decision.
STUDY OBJECTIVE: At hospitals without detailed managerial accounting data but with overall longer than average diagnosis-related groups (DRG)-adjusted lengths of stays (LOS), some administrators do not aggressively hire the nurses needed to maintain surgical hospital capacity. The consequence of this (long-term) decision is that day-of-surgery admit cases are delayed or cancelled from a lack of beds. The anesthesiologists suffer financially. In this paper, we show how publicly released national LOS data can be applied specifically to these cases. DESIGN: We applied the method to 1 year of data from two academic hospitals. Each case's LOS was compared to the United States national average LOS for cases with the same DRG. MEASUREMENTS AND MAIN RESULTS: A total of 8,050 and 10,099 hospitalizations, respectively. Among all surgical admissions, mean LOS was 2.5 days longer than the national average for Hospital #1 (95% confidence interval [CI], 2.1 to 2.8) and 3.1 days longer for Hospital #2 (95% CI, 2.8 to 3.4). Among patients undergoing elective, scheduled surgery with day of surgery admission, mean LOS was 0.7 days less than average for Hospital #1 (0.6 to 0.9) and 1.2 days less than average for Hospital #2 (1.1 to 1.4). CONCLUSIONS: This method can be used by anesthesiologists to show that LOS are not longer than average among patients whose surgeries may be cancelled or delayed for a lack of hospital ward staff.
Anesthesia Department, Hospital↗
Impact of reducing turnover times on staffing costs.
Explore the source record for details and available documents.
Appointments and Schedules↗
How much are patients willing to pay to avoid intraoperative awareness?
STUDY OBJECTIVE: To determine how much patients are willing to pay to avoid intraoperative awareness? DESIGN: Observational study SETTING: University-affiliated metropolitan hospital. PATIENTS: 60 patients who completed a questionnaire (39 F, 21 M). The mean age was 43 years and the median household income range of 45,000-60,000 US dollars. INTERVENTIONS: Patients completed an interactive computer-generated questionnaire on the value of preventing intraoperative awareness and their willingness to pay for a "depth of anesthesia" monitor. Their willingness to pay for the prevention of postoperative pain, nausea and vomiting, postoperative grogginess, and sleepiness was also determined as a means of comparison. MEASUREMENTS AND MAIN RESULTS: Patients were willing to pay (WTP) 34 US dollars, 10 US dollars to 42 US dollars (median, interquartile range) for a monitor that would assist an anesthesia care provider assess the depth of anesthesia in an effort to avoid awareness. This increased to 43 US dollars, 20 US dollars to 77 US dollars (p < 0.0,001) (median, interquartile range), if the insurance company was making the payment and the WTP value only decreased minimally to 33 US dollars if the incidence of awareness was reduced 10-fold. CONCLUSION: The incidence of intraoperative awareness and WTP value for monitoring awareness have a nonlinear relationship (a risk averse utility function), which suggests that patients assign an intrinsic base value for a rare or very rare possibility of an event. Other healthcare economic analyses (such as cost effectiveness) do not take this factor into account and assume a linear value relationship (i.e., if something occurs ten times less frequently, it has ten times less value). IMPLICATION: The median value for patients' WTP for a monitor that might prevent awareness under anesthesia was 34 US dollars given an incidence of 5/1,000 cases. The incidence of awareness and WTP value have a nonlinear relationship suggesting that patients assign an intrinsic base value for the possibility of awareness.
Adult↗
A study of anesthetic drug utilization in different age groups.
STUDY OBJECTIVE: To determine anesthetic drug utilization in different age groups. DESIGN: Retrospective, automated, intraoperative database study. SETTING: Tertiary care medical center. MEASUREMENTS: 30,842 noncardiac general anesthesia case records between January 1991 and July 1997 were studied. We investigated the effect of age on anesthetic requirements for fentanyl (F), midazolam (M), thiopental sodium (T), propofol (P), isoflurane (I), and nitrous oxide (N). Because drugs are not given in isolation we looked at the most common drug combinations, IFNTM, IFNPM, INFT, and PFNM. Regression analyses on log-transformed drug dosages were used to test the significance of age on individual requirements. RESULTS: In each of the above anesthetic drug combinations, reduced doses of fentanyl, propofol, midazolam, thiopental, and isoflurane were used with increasing age. Fentanyl, propofol, thiopental, and isoflurane showed a 10%, 8%, 6%, and 4% reduction in dose per decade of age, respectively, from age of maximum dose to age 80 years. CONCLUSIONS: In clinical practice, increasing age results in decreased anesthetic drug administration. The mechanism of this observation needs to be determined.
Adult↗
Operating room utilization alone is not an accurate metric for the allocation of operating room block time to individual surgeons with low caseloads.
INTRODUCTION: Many surgical suites allocate operating room (OR) block time to individual surgeons. If block time is allocated to services/groups and yet the same surgeon invariably operates on the same weekday, for all practical purposes block time is being allocated to individual surgeons. Organizational conflict occurs when a surgeon with a relatively low OR utilization has his or her allocated block time reduced. The authors studied potential limitations affecting whether a facility can accurately estimate the average block time utilizations of individual surgeons performing low volumes of cases. METHODS: Discrete-event computer simulation. RESULTS: Neither 3 months nor 1 yr of historical data were enough to be able to identify surgeons who had persistently low average OR utilizations. For example, with 3 months of data, the widths of the 95% CIs for average OR utilization exceeded 10% for surgeons who had average raw utilizations of 83% or less. If during a 3-month period a surgeon's measured adjusted utilization is 65%, there is a 95% chance that the surgeon's average adjusted utilization is as low as 38% or as high as 83%. If two surgeons have measured adjusted utilizations of 65% and 80%, respectively, there is a 16% chance that they have the same average adjusted utilization. Average OR utilization can be estimated more precisely for surgeons performing more cases each week. CONCLUSIONS: Average OR utilization probably cannot be estimated precisely for low-volume surgeons based on 3 months or 1 yr of historical OR utilization data. The authors recommend that at surgical suites trying to allocate OR time to individual low-volume surgeons, OR allocations be based on criteria other than only OR utilization (e.g., based on OR efficiency).
Computer Simulation↗
Labor costs incurred by anesthesiology groups because of operating rooms not being allocated and cases not being scheduled to maximize operating room efficiency.
UNLABELLED: Determination of operating room (OR) block allocation and case scheduling is often not based on maximizing OR efficiency, but rather on tradition and surgeon convenience. As a result, anesthesiology groups often incur additional labor costs. When negotiating financial support, heads of anesthesiology departments are often challenged to justify the subsidy necessary to offset these additional labor costs. In this study, we describe a method for calculating a statistically sound estimate of the excess labor costs incurred by an anesthesiology group because of inefficient OR allocation and case scheduling. OR information system and anesthesia staffing data for 1 yr were obtained from two university hospitals. Optimal OR allocation for each surgical service was determined by maximizing the efficiency of use of the OR staff. Hourly costs were converted to dollar amounts by using the nationwide median compensation for academic and private-practice anesthesia providers. Differences between actual costs and the optimal OR allocation were determined. For Hospital A, estimated annual excess labor costs were $1.6 million (95% confidence interval, $1.5-$1.7 million) and $2.0 million ($1.89-$2.05 million) when academic and private-practice compensation, respectively, was calculated. For Hospital B, excess labor costs were $1.0 million ($1.08-$1.17 million) and $1.4 million ($1.32-1.43 million) for academic and private-practice compensation, respectively. This study demonstrates a methodology for an anesthesiology group to estimate its excess labor costs. The group can then use these estimates when negotiating for subsidies with its hospital, medical school, or multispecialty medical group. IMPLICATIONS: We describe a new application for a previously reported statistical method to calculate operating room (OR) allocations to maximize OR efficiency. When optimal OR allocations and case scheduling are not implemented, the resulting increase in labor costs can be used in negotiations as a statistically sound estimate for the increased labor cost to the anesthesiology department.
Anesthesiology↗
Use of operating room information system data to predict the impact of reducing turnover times on staffing costs.
UNLABELLED: Potential benefits to reducing turnover times are both quantitative (e.g., complete more cases and reduce staffing costs) and qualitative (e.g., improve professional satisfaction). Analyses have shown the quantitative arguments to be unsound except for reducing staffing costs. We describe a methodology by which each surgical suite can use its own numbers to calculate its individual potential reduction in staffing costs from reducing its turnover times. Calculations estimate optimal allocated operating room (OR) time (based on maximizing OR efficiency) before and after reducing the maximum and average turnover times. At four academic tertiary hospitals, reductions in average turnover times of 3 to 9 min would result in 0.8% to 1.8% reductions in staffing cost. Reductions in average turnover times of 10 to 19 min would result in 2.5% to 4.0% reductions in staffing costs. These reductions in staffing cost are achieved predominantly by reducing allocated OR time, not by reducing the hours that staff work late. Heads of anesthesiology groups often serve on OR committees that are fixated on turnover times. Rather than having to argue based on scientific studies, this methodology provides the ability to show the specific quantitative effects (small decreases in staffing costs and allocated OR time) of reducing turnover time using a surgical suite's own data. IMPLICATIONS: Many anesthesiologists work at hospitals where surgeons and/or operating room (OR) committees focus repeatedly on turnover time reduction. We developed a methodology by which the reductions in staffing cost as a result of turnover time reduction can be calculated for each facility using its own data. Staffing cost reductions are generally very small and would be achieved predominantly by reducing allocated OR time to the surgeons.
Algorithms↗
Calculating a potential increase in hospital margin for elective surgery by changing operating room time allocations or increasing nursing staffing to permit completion of more cases: a case study.
UNLABELLED: Administrators routinely seek to increase contribution margin (revenue minus variable costs) to better cover fixed costs, provide indigent care, and meet other community service responsibilities. Hospitals with high operating room (OR) utilizations can allocate OR time for elective surgery to surgeons based partly on their contribution margins per hour of OR time. This applies particularly when OR caseload is limited by nursing recruitment. From a hospital's annual accounting data for elective cases, we calculated the following for each surgeon's patients: variable costs for the entire hospitalization or outpatient visit, revenues, hours of OR time, hours of regular ward time, and hours of intensive care unit (ICU) time. The contribution margin per hour of OR time varied more than 1000% among surgeons. Linear programming showed that reallocating OR time among surgeons could increase the overall hospital contribution margin for elective surgery by 7.1%. This was not achieved simply by taking OR time from surgeons with the smallest contribution margins per OR hour and giving it to the surgeons with the largest contribution margins per OR hour because different surgeons used differing amounts of hospital ward and ICU time. We conclude that to achieve substantive improvement in a hospital's perioperative financial performance despite restrictions on available OR, hospital ward, or ICU time, contribution margin per OR hour should be considered (perhaps along with OR utilization) when OR time is allocated. IMPLICATIONS: For hospitals where elective surgery caseload is limited by nursing recruitment, to increase one surgeon's operating room time either another surgeon's time must be decreased, nurses need to be paid a premium for working longer hours, or higher-priced "traveling" nurses can be contracted. Linear programming was performed using Microsoft Excel to estimate the effect of each of these interventions on hospital contribution margin.
Elective Surgical Procedures↗
Can succinylcholine be used safely in hyperkalemic patients?
UNLABELLED: The use of succinylcholine in hyperkalemic patients (serum potassium >5.5 mEq/L) is often viewed as relatively contraindicated, although there are no systematic data to define what preoperative potassium level is safe. We retrospectively reviewed more than 40,000 general anesthetics administered over 70 mo in which succinylcholine was given at the induction. This search yielded 38 patients with a preoperative potassium of 5.6 mEq/L or greater. Survival of the anesthetic was 100%, and no dysrhythmias or other major morbidity were documented upon manual review of the intraoperative automated record keeper charts or the patient medical records. These data allow a 95% confidence interval assessment of maximal risk for an event of 7.9%, which is not negligible, but which almost certainly grossly overestimates the risk for patients with moderately increased potassium levels. A prospective trial to definitively assess the safety margin for succinylcholine use in hyperkalemic patients would be difficult. Therefore, these data, taken in the context of a compelling case for rapid intubating conditions without long-term paralysis, suggest safety in succinylcholine use in patients with modest hyperkalemia. IMPLICATIONS: In a review of more than 40,000 general anesthetics in which succinylcholine was given at induction, 38 patients had a preoperative potassium of 5.6 mEq/L or greater. All patients survived the anesthetic with no dysrhythmias or other major morbidity documented. Succinylcholine may be appropriate and safe for use in certain patients with moderate hyperkalemia.
Adolescent↗
Sampling error can significantly affect measured hospital financial performance of surgeons and resulting operating room time allocations.
UNLABELLED: Hospitals with limited operating room (OR) hours, those with intensive care unit or ward beds that are always full, or those that have no incremental revenue for many patients need to choose which surgeons get the resources. Although such decisions are based on internal financial reports, whether the reports are statistically valid is not known. Random error may affect surgeons' measured financial performance and, thus, what cases the anesthesiologists get to do and which patients get to receive care. We tested whether one fiscal year of surgeon-specific financial data is sufficient for accurate financial accounting. We obtained accounting data for all outpatient or same-day-admit surgery cases during one fiscal year at an academic medical center. Linear programming was used to find the mix of surgeons' OR time allocations that would maximize the contribution margin or minimize variable costs. Confidence intervals were calculated on these end points by using Fieller's theorem and Monte-Carlo simulation. The 95% confidence intervals for increases in contribution margins or reductions in variable costs were 4.3% to 10.8% and 6.0% to 8.9%, respectively. As many as 22% of surgeons would have had OR time reduced because of sampling error. We recommend that physicians ask for and OR managers get confidence intervals of end points of financial analyses when making decisions based on them. IMPLICATIONS: The common approach of using one fiscal year of perioperative accounting data can be insufficient to prevent random error from influencing important management decisions. When accounting data are used for hospital and operating room management decision making, confidence intervals should be calculated for the key financial variables (e.g., variable cost per hour of operating room time).
Costs and Cost Analysis↗