BACKGROUND: Nonoperating room anesthesia (NORA) poses unique challenges to the anesthesia clinician, yet existing evidence on patient safety in NORA is limited. The aim of this study was to characterize NORA quality assu...BACKGROUND: Nonoperating room anesthesia (NORA) poses unique challenges to the anesthesia clinician, yet existing evidence on patient safety in NORA is limited. The aim of this study was to characterize NORA quality assurance (QA) events at a large academic health system based on a validated qualitative framework to provide insights and suggest potential safety interventions. METHODS: This two-center qualitative retrospective cohort study included all adult NORA cases performed between August 1, 2018, and December 31, 2022. QA event reporting was mandatory for every anesthetic during the study. The analyzed dataset included anesthesia clinician QA event reports associated with an optional free response comment, and each comment was coded using both deductive and inductive approaches in parallel. Each QA event was categorized in an inductive fashion, and the System Engineering Initiative for Patient Safety (SEIPS) framework was used to categorize event descriptions deductively. Emerging categories and representative scenarios were summarized. RESULTS: A total of 497,175 cases were performed during the study period, of which 106,476 (21.4%) were performed in NORA locations. After applying exclusion criteria, 984 QA report free-response comments were analyzed. Diverse subcategories emerged among the QA event categories (eg, employee safety concerns, patient positioning issues, unclear protocols). Some of the commonly identified SEIPS categories were "Organization" and "Tools and technology." From deductive and inductive analyses, challenges with teamwork, communication, care processes, variability in access to equipment, and equipment malfunctions were identified in the NORA setting. In addition to patient outcomes, negative organizational and employee outcomes were described on account of NORA-specific complexities. CONCLUSIONS: This large qualitative study characterized NORA QA events across multiple dimensions. Our findings highlight that QA events in NORA are complex and often due to a combination of factors, underscoring both clinical and systems-level vulnerabilities. These findings may provide a framework for targeted quality improvement interventions.
BACKGROUND: Exploring participants' experiences in comparative effectiveness anesthesia clinical trials offers valuable insights for improving trial design, conduct, and outcome measures while identifying factors that ma...BACKGROUND: Exploring participants' experiences in comparative effectiveness anesthesia clinical trials offers valuable insights for improving trial design, conduct, and outcome measures while identifying factors that may hinder trial success. The challenges and opportunities of conducting comparative effectiveness trials are distinct from classic explanatory trials. To optimize and conduct a full-scale comparative effectiveness trial, we interviewed patients to identify barriers and facilitators to study participation and offer strategies to improve the recruitment and retention of participants in anesthesia comparative effectiveness clinical trials. METHODS: We conducted qualitative semi-structured interviews using constructs from the Consolidated Framework for Implementation Research. Interviews assessed barriers and facilitators to study participation in an anesthesia clinical trial comparing outcomes after receiving either total intravenous anesthesia (TIVA) or inhaled volatile anesthesia (INVA). Interview guides were co-developed with a multidisciplinary team, including patient partners, and addressed study participation, acceptability of the study procedures, and prior experiences with anesthesia. Participants were recruited at two large academic medical centers. Two coders used a standardized codebook to code each interview, achieving > 95% agreement. Interview transcripts were analyzed using thematic analysis. RESULTS: Ninety-one patients were approached, 43 agreed to participate, and 35 interviews were conducted until we reached thematic saturation. Patients found participation in the anesthesia research study to be positive, straightforward, and non-intrusive. Study-related barriers to enrollment and participation included survey language, blinding, randomization, and concerns for breach of confidentiality. Patient-related barriers included fear and mistrust of research and discomfort with technology. Study-related facilitators included the safety and non-experimental nature of both general anesthesia techniques, use of digital technology, minimal time burden, trust and clear communication by the study staff, and compensation. Patients were motivated to participate by altruistic values. Adaptable barriers were addressed, and solutions were implemented to improve study procedures and staff responsibilities, aimed at enhancing participation and ensuring positive experiences for patients in future anesthesia comparative effectiveness clinical trials. CONCLUSIONS: Key elements to consider when designing and conducting a comparative effectiveness anesthesia trial include promoting participant comfort and trust, ensuring clear communication, highlighting the safety and clinical equipoise of the trial comparators, supportive behaviors from the clinical team, minimizing time burden, and using simple-to-learn digital technology. Findings of this study were used to refine the full-scale pragmatic, comparative effectiveness, randomized controlled trial evaluating patient experiences with TIVA and INVA.
BACKGROUND: Maternal fever during labor analgesia may arise from infectious causes (such as chorioamnionitis) or noninfectious causes (such as epidural-related maternal fever [ERMF]). While chorioamnionitis is associated...BACKGROUND: Maternal fever during labor analgesia may arise from infectious causes (such as chorioamnionitis) or noninfectious causes (such as epidural-related maternal fever [ERMF]). While chorioamnionitis is associated with neonatal outcomes, the impact of isolated ERMF remains controversial. This is due, in part, to the potential for occult intrauterine infection, which may not be clinically apparent during labor. Consequently, inadequate consideration of histological chorioamnionitis has limited the scope and validity of previous studies. This study aimed to evaluate the effects of ERMF on neonatal outcomes by excluding confirmed histological chorioamnionitis and minimizing suspected infection using predefined clinical criteria. METHODS: This retrospective study included women with singleton term deliveries under labor analgesia between January 2017 and July 2023. Cases with fetal anomalies or growth restriction were excluded. Placental pathological examination was performed when any of the predefined risk-based criteria were met, irrespective of maternal fever: clinical suspicion of chorioamnionitis, prolonged rupture of membranes, and neonatal asphyxia. Among febrile cases, short-term neonatal outcomes were first compared between those with and without histological chorioamnionitis. Subsequently, outcomes were compared between mothers with intrapartum fever (≥38 °C) and those without fever using propensity score matching. Long-term infant development was assessed using a Maternal and Child Health Handbook-based questionnaire. RESULTS: Overall, 186 matched pairs were included. All matched covariate standardized mean differences were <0.1, confirming acceptable balance. Compared with the nonfever group, the fever group had longer mean ± standard deviation durations from rupture of membranes to delivery (12.9 ± 9.4 vs 8.7 ± 10.9 hours; difference 4.2 hours; 95% confidence interval [CI], 2.17-6.33), first stage of labor (13.2 ± 6.7 vs 9.6 ± 6.3 hours; difference 3.6 hours; 95% CI, 2.32-4.99), and duration of labor analgesia (14.9 ± 9.6 vs 8.6 ± 6.7 hours; difference 6.3 hours; 95% CI, 4.62-8.01), along with a higher incidence of fetal tachycardia (36.0 vs 10.7%; absolute risk difference 25.3%; 95% CI, 12.3-37.2). In contrast, maternal fever was not associated with adverse neonatal outcomes, including umbilical artery pH <7.2, Apgar score <7 at 1 and 5 minutes, or neonatal intensive care unit admission. Growth and developmental milestones assessed at long-term follow-up using the Maternal and Child Health Handbook questionnaire were within the normal range in both groups. CONCLUSIONS: Following exclusion of histological chorioamnionitis, ERMF was associated with prolonged labor and fetal tachycardia but was not associated with adverse short-term neonatal outcomes or impaired long-term development.
BACKGROUND: Cardiovascular comorbidities increase perioperative risk in patients undergoing noncardiac surgery. Optimizing medication adherence in this population is critical; yet adherence remains low in many low- and m...BACKGROUND: Cardiovascular comorbidities increase perioperative risk in patients undergoing noncardiac surgery. Optimizing medication adherence in this population is critical; yet adherence remains low in many low- and middle-income countries (LMICs), where health beliefs, systemic barriers, and healthcare communication bring significant challenges. This study aimed to explore the acceptability of validated patient-reported questionnaires and to investigate the beliefs and experiences influencing adherence to cardiovascular medication before surgery in a South African tertiary hospital. METHODS: A mixed-methods study was conducted using semistructured interviews with 21 patients taking cardiovascular medication before vascular surgery. Participants completed four validated self-report questionnaires: Brief Illness Perception Questionnaire (BIPQ), Beliefs about Medicines Questionnaire (BMQ), SHARED decision-making questionnaire, and SURE decisional conflict scale. Questionnaire responses were summarized with descriptive statistics. Thematic analysis of interview data was conducted using Braun and Clarke's six-step framework. RESULTS: Most participants perceived their illness as chronic (15/20, 75%) and their treatment as effective (18/21, 86%), yet 15 of 21 (71%) reported high concern and 9 of 21 (43%) reported emotional distress. Belief in the need for medication was strong (21/21, 100%), but 14 of 21 (67%) worried about long-term side effects and 10 of 21 (47%) described their medication as a "mystery." Shared decision-making appeared limited: only 7 of 21 (33%) recalled being asked for their views. Thematic analysis revealed seven major themes: understanding illness and treatment, health professional interactions, service access, social support, individual factors, routines, and habits. CONCLUSIONS: Patient-reported tools were acceptable and highlighted complex, interrelated factors associated with adherence. Integrating these tools into preoperative care may help identify at-risk patients and support person-centered perioperative planning in LMICs.
BACKGROUND: Without strategic intervention to support medical education research in anesthesiology, the training of future anesthesiologists may be compromised. Currently no comprehensive strategy exists for developing e...BACKGROUND: Without strategic intervention to support medical education research in anesthesiology, the training of future anesthesiologists may be compromised. Currently no comprehensive strategy exists for developing education research into a robust and self-sustaining discipline within anesthesiology. Few anesthesiologists are qualified to mentor the next generation of rigorous researchers in education who will advance both the theory and practice of medical education in our specialty and throughout medicine. METHODS: The Anesthesia Research Council convened a working group of education leaders and charged them with mapping the future of education research in anesthesiology. This working group sought to understand the current state of anesthesiology education research funding and to identify key initiatives to consider in generating research excellence in this field. This article explores three key aspects of developing a path forward for medical education research: understanding the current state of anesthesiology education research funding and publications as markers of impact; integrating educational frameworks that support diversity, equity, and inclusion to ensure that anesthesiology training reflects the diverse needs of learners and patients; and making recommendations for improving medical education research in anesthesiology to help democratize the resources necessary for research, cultivate collaboration, and advance faculty development. A qualitative thematic analysis of relevant literature was completed. RESULTS: Recommendations for expanding the current education frameworks, measures, and methods include addressing (1) diversification of the physician workforce, (2) teaching styles and learning environments, (3) quality and accountability of graduate medical education, (4) cultural competency and intersectionality, and (5) advocacy. Identifying high-priority immediate and future actions that key stakeholders should undertake to generate centers of excellence and establish early career development programs in medical education research will likely have a national impact in anesthesiology and in medicine. CONCLUSIONS: This article provides a specialty-specific analysis of anesthesiology education research grant funding, publication efficiency, and the integration of diversity, equity, and inclusion frameworks. It sets forth a road map for building robust education research capacity through strategic recommendations, including fostering collaborations, incorporating artificial intelligence competencies, democratizing resources, and transforming funding and review processes.