Anna M. Varughese

Real-Time Assessment of Perioperative Behaviors and Prediction of Perioperative Outcomes

Background and Aims: New onset maladaptive behaviors, such as temper tantrums, nightmares, bed-wetting, attention-seeking, and fear of being alone are common in children after outpatient surgery. Preoperative anxiety, fear and distress behaviors of children predict postoperative maladaptive behaviors as well as emergence delirium. Parental anxiety has also been found to influence children’s preoperative anxiety. Currently, there is no real-time and feasible tool to effectively measure perioperative behaviors of children and parents. We developed a simple and real-time scale, the Perioperative Adult Child Behavioral Interaction Scale (PACBIS) to assess perioperative child and parent behaviors that might predict postoperative problematic behavior and emergence excitement. METHODS: We used the PACBIS to evaluate perioperative behaviors during anesthetic induction and recovery in a sample of 89 children undergoing tonsillectomies and adenoidectomies, and their parents. Preoperative anxiety with the modified Yale Preoperative Anxiety Scale, compliance with induction of anesthesia with Induction Compliance Checklist, and incidence of emergence excitement were also recorded. RESULTS: The PACBIS demonstrated good concurrent validity with modified Yale Preoperative Anxiety Scale and Induction Compliance Checklist and predicted postanesthetic emergence excitement. DISCUSSION: The PACBIS is the first real-time scoring instrument that evaluates children’s and parents’ perioperative behavior. The specific behaviors identified by the PACBIS might provide targets for interventions to improve perioperative experiences and postoperative outcomes.

Impact of a nurse practitioner-assisted preoperative assessment program on quality

Background : The anesthesia manpower shortage in the last few years in the US has limited many hospital pediatric surgical services. We sought to meet an increasing surgical caseload, while providing safe, timely and patient‐centered care by instituting a nurse practitioner‐assisted preoperative evaluation (NPAPE) program. The strategic goal of this program was to shift anesthesiologists from the preanesthesia clinic to the operating room (OR), while maintaining the quality of preoperative care. Our study sought to evaluate the quality of the NPAPE program.

Factors predictive of poor behavioral compliance during inhaled induction in children.

BACKGROUND: Preoperative identification of children at risk of emotional distress and poor behavioral compliance during inhaled induction of anesthesia allows targeted interventions to reduce distress, thereby enhancing the quality of the anesthetic experience. We sought to identify patient, procedural, and health care system factors predictive of poor behavioral compliance during induction. METHODS: We studied 861 developmentally appropriate children ages 1–13 yr, The American Society of Anesthesiologists physical status I to III, presenting for inhaled induction of anesthesia. All inductions were performed in an induction room with parent(s) present. Behavioral compliance was assessed using the Induction Compliance Checklist (ICC), an observational scale consisting of 10 behaviors scored as the number of behaviors observed during induction; ICC ≥4 was considered poor behavioral compliance. A multivariable ordinal logistic regression model for behavioral compliance was generated and the performance of the multivariable model was evaluated by the c statistic. RESULTS: Twenty-one percent of children exhibited poor behavioral compliance on induction. Factors increasing the odds of poor behavioral compliance were younger age (<4 yr, P < 0.0001), shorter preoperative preparation time (P = 0.004), and high anxiety levels in the preoperative clinic (modified-Yale preoperative anxiety scale >40; P = 0.016). Previous anesthesia experience increased the odds in school-age children (P = 0.046); this effect was ameliorated in children attending the preoperative tour (P = 0.018). The model using these factors demonstrated moderate discrimination between children with poor compliance and those with perfect compliance (ICC = 0) (c statistic = 0.75). CONCLUSIONS: Factors predictive of poor behavioral compliance were age, previous anesthesia, preoperative tour attendance, preoperative preparation time and anxiety levels in the preoperative clinic. These factors, bundled into a predictive algorithm, may help identify children who could benefit from behavioral or pharmacological interventions and avoid use of interventions to those at low risk.

Quality of recovery from two types of general anesthesia for ambulatory dental surgery in children: a double-blind, randomized trial

Background:  Pediatric dental procedures are increasingly performed under general anesthesia because of the inability to cooperate, situational anxiety, or other behavioral problems. Volatile anesthetics have been associated with emergence delirium in children, whereas the use of propofol for anesthetic maintenance has been shown to reduce the incidence of emergence delirium after other types of surgeries. The aim of this study is to compare a sevoflurane‐based anesthetic with a propofol‐based technique as it relates to the incidence of emergence delirium and the quality of recovery after pediatric dental surgery, in patients who present with risk factors for perioperative behavioral issues.

Quality in pediatric anesthesia

In 2001, the Institute of Medicine (IOM) issued recommendations for the American health care delivery system to improve the quality of health care. The IOM reported that our health care system does not consistently provide high-quality care to all Americans, frequently falls short in translation from knowledge into practice, often does not apply new technology safely and appropriately, and does not make the best use of its resources. The IOM defined quality along six dimensions to improve health care delivery (1). Health care should be as follows: Safe – avoiding injuries to patients from the care intended to help them. Effective – providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse). Patient centered – providing care that is respectful of and responsive to individual patients’ preferences, needs, and values, and ensuring that parental expectations and values guide all clinical decisions. Timely – reducing waits and sometimes harmful delays for both those who receive and those who provide care. Efficient – avoiding waste, including waste of equipment, supplies, ideas, and energy. Equitable – providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, or socioeconomic status. This review describes the journey of the Department of Anesthesiology at Cincinnati Children’s Hospital Medical Center (CCHMC) to imbed the IOM principles of quality into its health care delivery. The Department contains three divisions: Anesthesia, Pain Management, and Neurobiology. In this review, we will address four key areas of the quality system in the Division of Anesthesia. First, we will discuss definitions of quality specific to pediatric anesthesia. Second, we will describe our methodologies to measure quality. Third, we will address how to assess and communicate quality through the use of dashboards, benchmarks, and run charts. Finally, we will provide examples of quality improvement projects through the use of tests of change. In 1998, Cincinnati Children’s Hospital started this journey, driven by the CEO and the Board of Trustees, shortly after articulating a vision of ‘being the leader in improving child health’. Many companies use quality systems, among which Toyota’s Production System and General Electric’s Six Sigma are renowned. Cincinnati Children’s leadership began to visit these companies and Intermountain Healthcare with guidance from the Institute for Healthcare Improvement. The Cincinnati Children’s Quality System (CCQS) as we know it today blended these systems with our own experience. The CCQS contains definitions of quality along the IOM six dimensions, a variety of methodologies to measure quality, classes in quality improvement for employees, multidisciplinary quality improvement teams, and performance-based privileging to link improvement with clinical practice. In late 2002, the Department of Anesthesiology began to implement CCQS in a series of steps (Figure 1). At that time, because CCQS was a work in progress, our Department soon became a ‘test bed’ for the medical center and our learnings contributed to the shaping of the CCQS as it is today. In the Division of Anesthesia, we began to define quality in 2002, started to measure quality Correspondence to: Anna Varughese, MD, MPH, Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, ML 2001, Cincinnati, OH 45229, USA (email: anna.varughese@cchmc.org). Pediatric Anesthesia 2010 20: 684–696 doi:10.1111/j.1460-9592.2010.03329.x

Cost‐effectiveness of intravenous acetaminophen for pediatric tonsillectomy

The primary outcome of this study was to examine the cost‐effectiveness of the intraoperative combination of intravenous (IV) acetaminophen and IV opioids, versus IV opioids alone, as a part of an inhalational anesthetic technique for tonsillectomy in children.

Real-Time Assessment of Perioperative Behaviors in Children and Parents: Development and Validation of the Perioperative Adult Child Behavioral Interaction Scale

BACKGROUND:Behavior in response to distressful events during outpatient pediatric surgery can contribute to postoperative maladaptive behaviors, such as temper tantrums, nightmares, bed-wetting, and attention seeking. Currently available perioperative behavioral assessment tools have limited utility in guiding interventions to ameliorate maladaptive behaviors because they cannot be used in real time, are only intended to be used during 1 phase of the experience (e.g., perioperative), or provide only a static assessment of the child (e.g., level of anxiety). A simple, reliable, real-time tool is needed to appropriately identify children and parents whose behaviors in response to distressful events at any point in the perioperative continuum could benefit from timely behavioral intervention. Our specific aims were to (1) refine the Perioperative Adult Child Behavioral Interaction Scale (PACBIS) to improve its reliability in identifying perioperative behaviors and (2) validate the refined PACBIS against several established instruments. METHODS:The PACBIS was used to assess the perioperative behaviors of 89 children aged 3 to 12 years presenting for adenotonsillectomy and their parents. Assessments using the PACBIS were made during perioperative events likely to prove distressing to children and/or parents (perioperative measurement of blood pressure, induction of anesthesia, and removal of the IV catheter before discharge). Static measurements of perioperative anxiety and behavioral compliance during anesthetic induction were made using the modified Yale Preoperative Anxiety Scale and the Induction Compliance Checklist (ICC). Each event was videotaped for later scoring using the Child-Adult Medical Procedure Interaction Scale-Short Form (CAMPIS-SF) and Observational Scale of Behavioral Distress (OSBD). Interrater reliability using linear weighted kappa (&kgr;w) and multiple validations using Spearman correlation coefficients were analyzed. RESULTS:The PACBIS demonstrated good to excellent interrater reliability, with &kgr;w ranging from 0.62 to 0.94. The Child Coping and Child Distress subscores of the PACBIS demonstrated strong concurrent correlations with the modified Yale Preoperative Anxiety Scale, ICC, CAMPIS-SF, and OSBD. The Parent Positive subscore of the PACBIS correlated strongly with the CAMPIS-SF and OSBD, whereas the Parent Negative subscore showed significant correlation with the ICC. The PACBIS has strong construct and predictive validities. CONCLUSIONS:The PACBIS is a simple, easy to use, real-time instrument to evaluate perioperative behaviors of both children and parents. It has good to excellent interrater reliability and strong concurrent validity against currently accepted scales. The PACBIS offers a means to identify maladaptive child or parental behaviors in real time, making it possible to intervene to modify such behaviors in a timely fashion.

Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia.

In 2006, the Quality and Safety Committee of the Society for Pediatric Anesthesia initiated a quality improvement project for the specialty of pediatric anesthesiology that ultimately resulted in the development of Wake Up Safe (WUS), a patient safety organization that maintains a registry of de-identified, serious adverse events. The ultimate goal of WUS is to implement change in processes of care that improve the quality and safety of anesthetic care provided to pediatric patients nationwide. Member institutions of WUS submit data regarding the types and numbers of anesthetics performed and information pertaining to serious adverse events. Before a member institution submits data for any serious adverse event, 3 anesthesiologists who were not involved in the event must analyze the event with a root cause analysis (RCA) to identify the causal factor(s). Because institutions across the country use many different RCA methods, WUS educated its members on RCA methods in an effort to standardize the analysis and evaluate each serious adverse event that is submitted. In this review, we summarize the background and development of this patient safety initiative, describe the standardized RCA method used by its members, demonstrate the use of this RCA method to analyze a serious event that was reported, and discuss the ways WUS plans to use the data to promote safer anesthetic practices for children.

Systematic review of risk factors for surgical site infection in pediatric scoliosis surgery

BACKGROUND CONTEXT Risk factors for surgical site infection (SSI) in children derived from the studies in the adult population are potentially misleading because of differences in pathophysiology and management. PURPOSE This systematic review addresses the key question: What are the risk factors for SSI in pediatric patients undergoing scoliosis surgery? STUDY DESIGN This is a qualitative systematic literature review. PATIENT SAMPLE Retrospective and observational trials of children undergoing scoliosis surgery reported on the occurrence of risk factors for SSI and the occurrence of SSI. METHODS Pubmed (Medline), Ovid Evidence-Based Medicine Reviews (EBMR), Scopus, and Cumulative Index to Nursing and Allied Health (CINAHL) were searched electronically for relevant articles in all the languages between January 1, 1991 and August 27, 2012, and cross-references were checked. Two independent reviewers identified articles and appraised quality with the Agency for Healthcare Research and Quality (AHRQ) criteria based on a weighted scoring of 0 to 100. RESULTS Our search identified 135 abstracts and 14 studies meeting the inclusion criteria. The AHRQ grading showed that five articles were high quality with a score of greater than 67, and five articles were moderate quality with a score between 50 and 67. The percent agreement between the two independent reviewers was 84%, and kappa agreement score was 0.91 (95% confidence interval [CI]: 0.78-1.03). There were 76 risk factors identified, of which 22 factors were reported in more than one study. Odds ratios and 95% CIs were reported inconsistently. Pooled p analysis of high- and moderate-quality articles identified five risk factors predictive of SSI: inappropriate antibiotic use (p=.001), neuromuscular scoliosis (p=.014), instrumentation (p=.023), increased hospital stay days (p=.003), and residual postoperative curve (p=.003). CONCLUSIONS The systematic review identified inappropriate antibiotic use, neuromuscular scoliosis, instrumentation, increased hospital stay days, and residual postoperative curve as risk factors for SSI after pediatric scoliosis surgery.

Using quality improvement methods to optimize resources and maximize productivity in an anesthesia screening and consultation clinic

The anesthesia preoperative screening and evaluation of a patient prior to surgery is a critical element in the safe and effective delivery of anesthesia care. In this era of increased focus on cost containment, many anesthesia practices are looking for ways to maximize productivity while maintaining the quality of the preoperative evaluation process by harnessing and optimizing all available resources. We sought to develop a Nurse Practitioner‐assisted Preoperative Anesthesia Screening process using quality improvement methods with the goal of maintaining the quality of the screening process, while at the same time redirecting anesthesiologists time for the provision of nonoperating room (OR) anesthesia. The Nurse practitioner (NP) time (approximately 10 h per week) directed to this project was gained as a result of an earlier resource utilization improvement project within the Department of Anesthesia. The goal of this improvement project was to increase the proportion of patient anesthesia screens conducted by NPs to 50% within 6 months.