A matrix model for valuing anesthesia service with the resource-based relative value system.

Background: The purpose of this study was to propose a new crosswalk using the resource-based relative value system (RBRVS) that preserves the time unit component of the anesthesia service and disaggregates anesthesia billing into component parts (preoperative evaluation, intraoperative management, and postoperative evaluation). The study was designed as an observational chart and billing data review of current and proposed payments, in the setting of a preoperative holing area, intraoperative suite, and post anesthesia care unit. In total, 1,195 charts of American Society of Anesthesiology (ASA) physical status 1 through 5 patients were reviewed.

Improving compliance with timely intraoperative redosing of antimicrobials in surgical prophylaxis.

Background: Appropriate use of antimicrobials for surgical prophylaxis is an important patient safety issue. Antimicrobial levels should be present during the duration of the surgical procedure until incision site closure. For prolonged surgical procedures in which the tissue concentration of the prophylactic antimicrobial may decrease to below the necessary minimum inhibitory concentration, intraoperative redosing of antimicrobials may be crucial.

Knowledge-assisted sequential pattern analysis with heuristic parameter tuning for labor contraction prediction.

The optimal dosing regimen of remifentanil for relieving labor pain should achieve maximal efficacy during contractions and little effect between contractions. Toward such a need, we propose a knowledge-assisted sequential pattern analysis with heuristic parameter tuning to predict the changes in intrauterine pressure,which indicates the occurrence of labor contractions. This enables giving the drug shortly before each contraction starts.

Transition to a novel advanced integrated vitrectomy platform: comparison of the surgical impact of moving from the Accurus vitrectomy platform to the Constellation Vision System for microincisional vitrectomy surgery.

Background: Microincisional vitrectomy surgery (MIVS) is the current standard surgical approach for pars plana vitrectomy. Historically, the most common surgical platform for vitrectomy surgery, since its introduction in 1997, has been the Accurus vitrectomy system. Recent introduction of the next generation of vitrectomy platforms has generated concerns associated with transitioning to new technology in the operating room environment.

Future of electronic health records: implications for decision support.

The potential benefits of the electronic health record over traditional paper are many, including cost containment, reductions in errors, and improved compliance by utilizing real-time data. The highest functional level of the electronic health record (EHR) is clinical decision support (CDS) and process automation, which are expected to enhance patient health and healthcare. The authors provide an overview of the progress in using patient data more efficiently and effectively through clinical decision support to improve health care delivery, how decision support impacts anesthesia practice, and how some are leading the way using these systems to solve need-specific issues.

Prediction of uterine contractions using knowledge-assisted sequential pattern analysis.

The usage of the systemic opioid remifentanil in relieving the labor pain has attracted much attention recently. An optimal dosing regimen for administration of remifentanil during labor relies on anticipating the timing of uterine contractions. These predictions should be made early enough to maximize analgesia efficacy during contractions and minimize the impact of the medication between contractions.

Retinoblastoma treatment burden and economic cost: impact of age at diagnosis and selection of primary therapy.

Purpose: To follow the treatment history of patients with retinoblastoma to identify the trends in the number of hospital visits over time and the direct cost of medical care as determined by age at diagnosis and selected primary treatment modality.

Design: An Institutional Review Board (IRB) approved consecutive retrospective case series.

Materials And Methods: Records from the Bascom Palmer Eye Institute were reviewed to identify 115 eligible patients (176 eyes) with retinoblastoma who underwent treatment at the Ocular Oncology Service between 1995 and 2010 and were available for extended follow-up evaluation.

Perioperative cardiac evaluation of simulated patients by practicing anesthesiologists is not consistent with 2007 ACC/AHA guidelines.

Study Objective: To determine if practicing anesthesiologists recommend preoperative evaluations consistent with the 2007 ACC/AHA guidelines on perioperative care.

Design: Survey instrument.

Setting: Academic medical center.

Shortcomings and challenges of information system adoption.

The number of institutions implementing AIMS is increasing. Shortcomings in the design and implementation of EMRs have been associated with unanticipated consequences, including changes in workflow. These have often resulted from the carryover of paper-based documentation practices into an electronic environment.

Can children undergoing ophthalmologic examinations under anesthesia be safely anesthetized without using an IV line?

Purpose: To document that with proper patient and procedure selection, children undergoing general inhalational anesthesia for ophthalmologic exams (with or without photos, ultrasound, laser treatment, peri-ocular injection of chemotherapy, suture removal, and/or replacement of ocular prosthesis) can be safely anesthetized without the use of an intravenous (IV) line. Children are rarely anesthetized without IV access placement. We performed a retrospective study to determine our incidence of IV access placement during examinations under anesthesia (EUA) and the incidence of adverse events that required intraoperative IV access placement.

2007 American College of Cardiology/American Heart Association (ACC/AHA) Guidelines on perioperative cardiac evaluation are usually incorrectly applied by anesthesiology residents evaluating simulated patients.

Background: The 2007 American College of Cardiology/American Heart Association (ACC/AHA) Guidelines on Perioperative Cardiac Evaluation and Care for Noncardiac Surgery is the accepted standard for perioperative cardiac evaluation. Anesthesiology training programs are required to teach these algorithms. We estimated the percentage of residents nationwide who correctly applied suggested testing algorithms from the ACC/AHA guidelines when they evaluated simulated patients in common clinical scenarios.

Intravitreal injection analysis at the Bascom Palmer Eye Institute: evaluation of clinical indications for the treatment and incidence rates of endophthalmitis.

Objective: To report the incidence of endophthalmitis, in addition to its clinical and microbiological aspects, after intravitreal injection of vascular-targeting agents.

Methods: A retrospective review of a consecutive series of 10,142 intravitreal injections of vascular targeting agents (bevacizumab, ranibizumab, triamcinolone acetonide, and preservative-free triamcinolone acetonide) between June 1, 2007 and January 31, 2010, performed by a single service (TGM) at the Bascom Palmer Eye Institute.

Results: One case of clinically-suspected endophthalmitis was identified out of a total of 10,142 injections (0.

Is the immediate reversal of diastolic dysfunction of cirrhotic cardiomyopathy after liver transplantation a sign of the metabolic etiology?

Cirrhotic cardiomyopathy currently is believed to be a multifactorial entity. This communication describes a case of immediate intraoperative recovery of diastolic function following liver transplantation. This suggests that an underlying metabolic inhibition of myocardial metabolism is an important factor in the development of cardiomyopathy in end-stage liver disease.

Anesthesia information management system implementation: a practical guide.

Anesthesia Information Management Systems (AIMS) display and archive perioperative physiological data and patient information. Although currently in limited use, the potential benefits of an AIMS with regard to enhancement of patient safety, clinical effectiveness and quality improvement, charge capture and professional fee billing, regulatory compliance, and anesthesia outcomes research are great. The processes and precautions appropriate for AIMS selection, installation, and implementation are complex, however, and have been learned at each site by trial and error.

Targeting operating room inefficiencies in the complex management of vision-threatening diseases in children.

Objective: To review the effect of interventions designed to decrease turnover time in infants and children (median age, 2.6 years; range, 1 month to 10 years) who required examinations under anesthesia.

Methods: Five efficiency interventions (3 anesthesia providers for 2 rooms, digital remote communication, change in patient scheduling, standardization of case order, and streamlining administration of preoperative medications) were implemented during a 4(1/2)-year period from January 2003 to July 2007.

The use of an anesthesia information system to identify and trend gender disparities in outpatient medical management of patients with coronary artery disease.

Background: Previous anesthesia information management systems-based studies have focused on intraoperative data analysis. Reviewing preoperative data could provide insight into the outpatient treatment of patients presenting for surgical procedures. As gender-based disparities have been demonstrated in the treatment of patients with cardiac disease, we hypothesized that there would be gender disparities in the outpatient pharmacologic management of patients with coronary artery disease (CAD) scheduled for elective noncardiac surgery.

Pacifier-induced bowel obstruction-not so soothing.

Pacifiers are nearly ubiquitous among children in the United States, and although safety regulations exist, the responsibility to choose and maintain a safe pacifier generally falls on the parents, many of whom are unaware of potential hazards. We report a case of a complete bowel obstruction because of an ingested pacifier nipple and recommend increased awareness among practitioners as well as education of parents.

Discrepancies in medication entries between anesthetic and pharmacy records using electronic databases.

Background: Accurate recording of disposition of controlled substances is required by regulatory agencies. Linking anesthesia information management systems (AIMS) with medication dispensing systems may facilitate automated reconciliation of medication discrepancies.

Methods: In this retrospective investigation at a large academic hospital, we reviewed 11,603 cases (spanning an 8-mo period) comparing records of medications (i.

Anesthesia information management systems: a survey of current implementation policies and practices.

Background: Anesthesia information management systems (AIMS) implementation is increasing, but there are no published recommendations from anesthesia professional societies to guide configuration and policy decisions that affect billing, security, medical-legal, and compliance issues.

Methods: A 45-question structured survey was developed by a committee of the Society for Technology in Anesthesia and was sent to the clinical administrator at 18 separate institutions, comprising six different installed AIMS systems. The primary goal of the survey was to establish a baseline of current policies and practices.

Evidence-based management assessment of return on investment from anesthesia information management systems.

A systematic and comprehensive review of the scientific literature revealed 4 evidence-based methods that contribute to a positive return on investment from anesthesia information management systems (AIMS): reducing anesthetic-related drug costs, improving staff scheduling and reducing staffing costs, increasing anesthesia billing and capture of anesthesia-related charges, and increased hospital reimbursement through improved hospital coding. There were common features to these interventions. Whereas an AIMS may be the ideal choice to achieve these cost reductions and revenue increases, alternative existing systems may be satisfactory for the studied applications (i.

Mean operating room times differ by 50% among hospitals in different countries for laparoscopic cholecystectomy and lung lobectomy.

We explored whether there were large differences in operating room (OR) times for two common procedures performed by multiple surgeons at each of several hospitals thousands of miles apart. Mean OR time, "wheels in" to "wheels out," for ten consecutive cases of each of laparoscopic cholecystectomy and lung lobectomy were obtained for each of ten hospitals in eight countries from their OR logs. After log transformation, the OR times were analyzed by analysis of variance.

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.

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.

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.