Amr E. Abouleish

Quantifying net staffing costs due to longer-than-average surgical case durations.

BackgroundAnesthesiology departments incur staffing costs that are not covered by revenue because the operating room (OR) time allocation and case scheduling are not done to maximize OR efficiency and because surgical durations are longer than average. The purpose of this article is to demonstrate a method to quantify net anesthesia staffing costs due to longer-than-average surgical durations and evaluate the factors that influence staffing costs. MethodsData collected from two anesthesiology departments in academic hospitals for 1 yr included date of surgery, time that patients entered the OR, time that patients exited the OR, surgical service, and the Current Procedural Terminology code for the primary surgical procedure. Anesthesia care performed outside the main surgical suite and services not billed with American Society of Anesthesiologists units were excluded. National average surgical durations were determined from the Current Procedural Terminology code from the Centers for Medicare and Medicaid Services’ database. Actual surgical durations were then used to determine staffing solutions to maximize OR efficiency; national average surgical durations were then used to determine a second solution. The difference in staffing costs between these two staffing solutions represented the staffing costs attributable to longer surgical durations. Costs were converted to dollar amounts using compensation values reported in a national compensation survey. The differences in revenue were determined by applying conversion factors to the differences in surgical durations. The annual net cost attributable to longer surgical durations equaled the staffing costs minus the revenue produced by longer durations. Net staffing costs were estimated for two hospitals using median staffing compensation and median payer mix. Net staffing costs were then recalculated by varying the parameters (conversion factors, limits on differences between actual and average surgical duration, levels of compensation, surgical service size of OR allocation). ResultsUsing the median compensation of staff and an average conversion factor, the net annual staffing costs attributable to longer surgical durations were

Combined spinal-epidural analgesia in advanced labour

672,100 for the first hospital. However, if staff members were highly compensated and the payer mix was unfavorable, the net staffing costs were

Sub-tenon’s injection for local anesthesia in posterior segment surgery

1,688,000. Reducing the difference between actual and average duration resulted in lower staffing costs. Net staffing costs were less in a second hospital studied that had many low-volume surgical services. ConclusionsLonger-than-average surgical durations can increase net staffing costs for anesthesiology groups. The increase is dependent on factors such as staffing compensation and payer mix.

Intrathecal sufentanil and epidural bupivacaine for labor analgesia: Dose-response of individual agents and in combination

The combined spinal-epidural technique is a modification of epidural analgesia which combines the rapid onset of spinal analgesia with the flexibility of an epidural catheter. We sought to evaluate the effectiveness of an intrathecal opioid — low-dose local anaesthetic combination for parturients in advanced labour, a setting where satisfactory epidural analgesia is often difficult to achieve. The technique was evaluated in an open-label, non-randomized trial using parturients in advanced, active labour for the provision of pain relief during the late first stage and second stage of labour. Thirty-eight term parturients in active, advanced labour received a spinal injection of bu-pivacaine 2.5 mg and sufentanil, 10 μg, via a 25- or 27-gauge Whitacre needle placed into the subarachnoid space through a 17- or 18- gauge Weiss epidural needle which had been placed into the epidural space. This was followed by placement of an epidural catheter for supplemental analgesia if required. Onset of analgesia was noted by asking patients if their contractions were comfortable. Motor blockade was assessed using the Bromage criteria. Patients were asked if they experienced either pruritus or nausea on a four-point scale (none, mild, moderate, severe). The mean cervical dilatation at placement of the spinal medication was 6.1 ± 2.2 cm. Thirty-two patients had spontaneous vaginal delivery, two were delivered by outlet forceps, and four by Caesarean section. Onset of analgesia was rapid (< five minutes) in all cases. Twenty-three patients (60%) delivered vaginally with no additional anaesthetic. The remaining 15 had supplemental local anaesthetic given via the epidural catheter, a mean of 123 ± 33 min after the original spinal dose. Side effects were limited to pruritus in eight (21%) patients, and mild lower extremity motor weakness in one patient. One patient experienced transient hypotension. No patient developed postdural puncture headache. This technique allows for profound analgesia with a rapid onset and few bothersome side effects. In particular, the absence of motor blockade may facilitate maternal expulsive efforts or positioning during the second stage of labour.RésuméLa technique combinée rachi-épidurale est une modification de l’analgésie épidurale qui associe le court délai d’une analgésie rachidienne avec la maniabilité d’un cathéter épidural. Nous évaluons l’efficacité de la combinaison d’un opiacé intrathécal et d’une faible dose d’anesthésique local chez des parturientes en travail avancé, moment où une analgésie épidurale satisfaisante est souvent difficile à obtenir. Cette technique est évaluée au cours d’une étude ouverte, non aléatoire chez des parturientes en travail avancé et actif, afin d’avoir une disparition des douleurs pour la fin de la première étape et à la deuxième étape du travail. Trente huit patientes à terme en travail actif et avancé reçoivent une injection rachidienne de 2,5 mg de bupivacaïne et de 10 μg de sufentanyl par une aiguille Whitacre de calibre 25 ou 27 gauge placée dans l’espace sous-archnoïdien à travers une aiguille épidurale Weiss de calibre 17 ou 18 qui est placée dans l’espace épidural. Ensuite, on place le cathéter épidural pour une analgésie supplémentaire si nécessaire. Le début de l’analgésic est appréciée en interrogeant les patientes sur leur confort pendant les contractions. Le bloc moteur est évalué selon les critères de Bromage. On demande aux patientes si elles éprouvent du prurit ou des nausées dont l’intensité est graduée en quatre niveaux (aucun, léger, modéré, sévère). La dilatation moyenne du col au moment de l’installation de l’analgésie rachidienne est de 6,1 ±2,2 cm. Trente-deux patientes ont accouché spontanément par voie vaginale, deux ont été accouchées au moyen d’un forceps de sortie, et quatre par césarienne. Le début de l’analgésie est rapide (< 5 min) dans tous les cas. Vingt-trois patientes (60%) ont accouché par voie vaginale sans adjonction d’anesthésique. Les 15 restantes ont reçu un supplément d’anesthésique local par le cathéter épidural, à environ 123 ±33 min après la dose rachidienne de départ. Les effets secondaires se sont limités au prurit chez huit patientes (21%), et à une faiblesse légère des extrémités inférieures chez une patiente. Une patiente a eu une hypotension transitoire. Aucune patiente n’a eu de céphalée postponction dure-mérienne. Cette technique procure une analgésie intense avec un début rapide et peu d’effets secondaires ennuyeux. En particulier, l’absence de bloc moteur peut faciliter les efforts maternels d’expulsion ou de positionnement pendant la deuxième étape du travail.

The prevalence and characteristics of incentive plans for clinical productivity among academic anesthesiology programs

OBJECTIVE To determine whether the sub-Tenons parabulbar approach for local anesthesia is a safe and effective choice for posterior segment surgery. DESIGN Prospective, noncomparative case series. PARTICIPANTS Two hundred seventy-six consecutive patients underwent posterior segment surgery at the University of Texas Medical Branch. INTERVENTION Two hundred patients received sub-Tenons parabulbar anesthesia containing an 11 -ml mixture of 5-ml 2% lidocaine (Xylocaine), 5-ml 0.5% bupivacaine (Marcaine), and 1 ml of 150 hyaluronidase (Wydase) units as primary anesthesia. The method did not involve a separate transcutaneous lid nerve or subconjunctival injection. MAIN OUTCOME MEASURES The proportion of cases receiving supplementation (significant intravenous anesthesia, intraoperative local anesthesia, or both) was estimated. Its relationship to duration of surgery and surgical procedures deemed painful was assessed. Surgery lasting 3 hours or more was considered a long duration. Both scleral buckle and cryotherapy were considered painful procedures. The proportion of cases receiving additional local anesthesia preoperatively was also evaluated. Complications associated with sub-Tenons parabulbar injection were monitored. RESULTS There were 101 instances of patients receiving additional anesthesia. Nineteen received additional preoperative sub-Tenons anesthesia, 12 received intraoperative local anesthesia supplementation, and 70 received intravenous medication. Of these 70, 19 required what the authors defined as a significant amount of intravenous medication, three of whom also received intraoperative local anesthesia supplementation. Consequently, 28 of 200 patients (14%; 95% confidence interval: 9.5, 19.6) received supplementation (significant intravenous anesthesia, intraoperative local anesthesia, or both). The proportion of cases receiving supplementation was directly related to duration of surgery. Patients involved in longer cases (51.7% vs. 7.6%; P < 0.001) and those involved in more painful procedures (48.2% vs. 8.7%; P < 0.001) were more likely to receive supplementation. Adjusting for surgery duration, a greater proportion of patients undergoing painful procedures required supplementation (31.3% vs. 0.5% for surgery < 3 hours, P = 0.003; 72.7% vs. 38.9% for surgery > or = 3 hours, P = 0.13). No associated ocular or systemic complications were observed. CONCLUSIONS The results of this large study demonstrate that a single injection of sub-Tenons anesthesia is relatively safe and effective for achieving local anesthesia during vitrectomies, with or without other intraocular procedures, lasting less than 3 hours. Other types of posterior segment surgery may require supplementation if they are more painful procedures, such as scleral buckle or cryotherapy, or last longer than 3 hours.

Intravenous nitroglycerin for intrapartum external version of the second twin

Backgrounds and Objectives. Combinations of local anesthetics and opioids are frequently used during spinal and epidural analgesia for the relief of labor pain. This combination allows for a dose‐sparing effect which may reduce potential side effects or toxicity. The precise nature of the interaction between opioids and local anesthetics in the clinical setting, i.e., additivity versus synergism, has not been established. This trial was designed to utilize a validated technique of analysis of drug interactions, isobolography, to investigate this interaction. Methods. One hundred healthy laboring patients at term receiving a combined spinal and epidural technique were divided into nine groups as follows: intrathecal sufentanil 2, 5, or 10 μg (2 mL volume) and epidural saline (10 mL); epidural bupivacaine 5, 12.5, or 25 mg and intrathecal saline (2 mL volume); or combination of 1, 2.5, and 5 μg intrathecal sufentanil plus 2.5, 6.25, or 12.5 mg epidural bupivacaine, using similar volumes, respectively. All drugs were administered in a randomized, double‐blind fashion. Pain relief scores were assessed 20 minutes after drug injection, and isobolographic analysis was utilized to determine the nature of the interaction. Results. The ED50 of intrathecal sufentanil alone was 2.3 μg (95% CI 1.7‐3.2), and the ED50 for epidural bupivacaine was 24 mg (95% CI 12‐50). The combined sufentanil and bupivacaine fractional dose ED50 (in fractions of the single‐dose ED50 values) was found to be approximately one‐third and one‐tenth of the single drug fractional dose, respectively; sufentanil 0.85 μg (0.36) and bupivacaine 2.2 mg (0.09). The duration of analgesia was nearly equivalent in all sufentanil‐alone groups (83, 102, and 99 minutes); a dose‐response effect was more apparent in the bupivacaine group (35, 42, and 74 minutes; P = .006) and the combination group (60, 79, 101 minutes; P = .028). Isobolography showed the combination dose to lie well within the area of synergism; however, the 95% confidence limits cross the line of additivity thus a pure additive interaction cannot be excluded. Conclusions. Markedly reduced doses of these drugs in combination can be used to provide adequate analgesia during labor compared with either single drug alone.

Organizational Factors Affect Comparisons of the Clinical Productivity of Academic Anesthesiology Departments

Performance-based compensation is encouraged in medical schools to improve faculty productivity. Medical specialties other than anesthesiology have used financial incentives for clinical work. The goal of this study was to determine the prevalence and the types of clinical incentive plans among academic anesthesiology departments. We performed an electronic survey of the members of the Society of Academic Anesthesiology Chairs and the Association of Anesthesiology Program Directors in the spring of 2003. The survey included questions about departmental size, presence of a clinical incentive plan, characteristics of existing incentive plans, primary quantifiers of productivity, and factors used to modify productivity measurements. An incentive plan was considered to be present if the department measured clinical productivity and varied compensation according to the measurements. The plans were grouped by the primary measure used into the following categories: None, Charges, Time, Shift, Late/Call (only late rooms and call), and Other. Eighty-eight (64%) of 138 programs responded to the survey, and 5 were excluded for incomplete data. Of the responding programs, 29% had no system, 30% used a Late/Call system, 20% used a Shift system, 11% used a Charges system, 6% used a Time system, and 3% fit in the Other category. Larger groups (>40 faculty members) had a significantly more frequent prevalence of incentive plans compared with smaller groups (<20 faculty members). Incentives were paid monthly or quarterly in 85% of the groups. In 90% of groups, incentive payments accounted for <25% of total compensation. Adjustments for operating room schedule supervisors, personally performed cases, day surgery preoperative clinics, pain-management services, and critical care services were included in less than half of the programs that reported incentive plans. Call and late room compensation was based on varied formulas. Sixty-nine percent of academic anesthesiology departments did not vary compensation according to clinical activity during regular hours. Most did vary payments on the basis of call and/or late rooms worked. Larger departments were more likely to use clinical incentive plans.

Measurement of individual clinical productivity in an academic anesthesiology department.

A lthough the use of tocolytics for external version in the antepartum period is controversial (1,2), intrapartum external version can be accomplished only when the uterus is not contracting (3-5). Tocolysis with /3 agonists, such as ritodrine or terbutaline, has been used for external version of a singleton fetus or a second twin. These agents were infused over at least 15 min to minimize side effects such as tachycardia, palpitations, arrhythmias, chest pain, and hypotension (6,7). To achieve uterine relaxation for intrapartum external version of the second twin, in the case that follows we chose intravenous nitroglycerin (NTG) because of its rapid onset, short half-life, and minimal side effects.

The impact of longer-than-average anesthesia times on the billing of academic anesthesiology departments.

Productivity measurements based on “per operating room (OR) site” and “per case” are not influenced by staffing ratios and have permitted meaningful comparisons among small samples of both academic and private-practice anesthesiology groups. These comparisons have suggested that a larger sample would allow for clinical groups to be compared using a number of different variables (including type of hospital, number of OR sites, type of surgical staff, or other organizational characteristics), which may permit more focused benchmarking. In this study, we used such grouping variables to compare clinical productivity in a broad survey of academic anesthesiology programs. Descriptive, billing, and staffing data were collected for 1 fiscal or calendar year from 37 academic anesthesiology departments representing 58 hospitals. Descriptive data included types of surgical staff (e.g., academic versus private practice) and hospital centers (e.g., academic medical centers and ambulatory surgical centers [ASCs]). Billing and staffing data included total number of cases performed, total American Society of Anesthesiologists units (tASA) billed, total time units billed (15-min units), and daily number of anesthetizing sites staffed (OR sites). Measurements of total productivity (tASA/OR site), billed hours per OR site per day (h/OR/d), surgical duration (h/case), hourly billing productivity (tASA/h), and base units/case were compared. These comparisons were made according to type of hospital, number of OR sites, and type of surgical staff. The ASCs had significantly less tASA/OR site, fewer h/OR/d, and less h/case than non-ASC hospitals. Community hospitals had significantly less h/OR/d and h/case than academic medical centers and indigent hospitals and a larger percentage of private-practice or mixed surgical staff. Academic staffs had significantly less tASA/h and significantly more h/case. tASA/h correlated highly with h/case (r = −0.68). This study showed that the hospitals at which academic anesthesiology groups provide care are not all the same from a clinical productivity perspective. By grouping based on type of hospital, number of OR sites, and type of surgical staff, academic anesthesiology departments (and hospitals) can be better compared by using clinical productivity measurements based on “per OR site” and “per case” measurements (tASA/OR, billed h/OR/d, h/case, tASA/h, and base/case).

Adding Examples to the Asa-physical Status Classification Improves Correct Assignment to Patients

BackgroundThe ability to measure productivity, work performed, or contributions toward the clinical mission has become an important issue facing anesthesiology departments in private practice and academic settings. Unfortunately, the practice and billing of anesthesia services makes it difficult to quantify individual productivity. This study examines the following methods of measuring individual productivity: normalized clinical days per year (nCD/yr); time units per operating-room day worked (TU/OR day); normalized time units per year (nTU/yr); total American Society of Anesthesiologists (ASA) units per OR day (tASA/OR day); and normalized total ASA units per year (ntASA/yr). MethodsBilling and scheduling data for clinical activities of faculty members of an anesthesiology department at a university medical center were collected and analyzed for the 1998 fiscal year. All clinical sites and all clinical faculty anesthesiologists were included unless they spent less than 20% of their time during the fiscal year providing clinical care, i.e., less than 0.2 clinical full-time equivalent. Outliers, defined as faculty who had productivity greater or less than 1 SD from the mean, were examined in detail. ResultsMean and median values were reported for each measurement, and different groups of outliers were identified. nCD/yr identified faculty who worked more than their clinical full-time equivalent would have predicted. TU/OR day and tASA/OR day identified apparently low-productivity faculty as those who worked a large portion of their time in obstetric anesthesia or an ambulatory surgicenter. tASA/OR day identified specialty anesthesiologists as apparently high-productivity faculty. nTU/yr and ntASA/yr were products of the per-OR day measurement and nCD/yr. ConclusionEach of the measurements studied values certain types of productivity more than others. By defining what type of service is most important to reward, the most appropriate measure or combination of measures of productivity can be chosen. In the authors’ department, nCD/yr is the most useful measure of individual productivity because it measures an individual anesthesiologist’s contribution to daily staffing, includes all clinical sites, is independent of nonanesthesia factors, and is easy to collect and determine.