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Obstructive Sleep Apnea (OSA) is the most common sleep-related breathing disorder in the United States. OSA affects 25 million adults nationally, with as many as 80% of patients potentially undiagnosed (Hines & Marschall, 2018). Early identification with a blue wristband will increase the anesthesia providers’ awareness of OSA-related concerns for potential airway manipulation, prolonged sedation from anesthetic agents, and increased sensitivity to opioids in the post-operative period. This is a Quality Improvement (QI) project using a descriptive design to identify patients with suspected OSA on the Day of Surgery (DOS) and examine the clinical practice of providers’ administration of benzodiazepines and opioids to this patient population. The PICOT question is: In patients who are greater than or equal to 18 years old scheduled for elective surgery at an ambulatory surgical center (P), how does the implementation of a blue wristband to identify patients with diagnosed or suspected OSA (STOP-Bang score >/=4) (I) compared to current practice (C) affect the perioperative management of OSA patients as defined as receiving benzodiazepines alone or in combination with opioids (O) within the intra-operative period (T)? The project’s setting occurred at the One Day Surgery (ODS) Outpatient Center at Atrium Health. The sample for this project consisted of a total of 73 patients who either underwent elective non-cardiac surgery at CMC Atrium Health ODS from June 2022 through August 2022 or who underwent elective non-cardiac surgery from October 2022 through November 2022. The author collected data via chart review.
Inclusion criteria for Atrium Health ODS pre and post-implementation group were female and male adults older than or equal to 18 years old, scheduled for elective non-cardiac surgery, and have a STOP-Bang score >/=4. Exclusion criteria include patients younger than 18 years old, emergency surgery, Intensive Care Unit (ICU) admission, or specialized surgeries, including trauma, cardiovascular, neurological, and obstetric surgeries. To maintain the confidentiality of data, all patient data collection was de-identified, and management was completed via Excel sheets under password protection. This QI project noted a decrease in the administration of benzodiazepines by 10% in patients identified with a blue wristband, although not statistically significant.
Obstructive Sleep Apnea (OSA) is the most common sleep-related breathing disorder in the United States. OSA affects 25 million adults nationally with as many as 80% of patients potentially undiagnosed (Hines & Marschall, 2018). Early identification with a blue wristband will increase the anesthesia providers’ awareness of OSA-related concerns for potential airway manipulation, prolonged sedation from anesthetic agents, and increased sensitivity to opioids in the post-operative period. This is a Quality Improvement (QI) project using a descriptive design to identify patients with suspected OSA on the day of surgery and examine the clinical practice of providers’ administration of benzodiazepines and opioids to this patient population. The PICOT question is: In patients who are greater than or equal to 18 years old scheduled for elective non-cardiac surgery at a level one trauma medical center (P) how does the implementation of a blue wristband to identify patients with diagnosed or suspected OSA (STOP-Bang score ≥ 4) (I) compared to current practice (C) affect the perioperative management of OSA patients as defined as receiving benzodiazepines alone or in combination with opioids (O) within the perioperative stay (pre-op, intra-op, PACU) (T)? The setting of the project is a surgery center in a major urban medical center. The sample for this project consisted of a total of 100 patients that have undergone elective non-cardiac surgery during the months of August 2022 (pre-implementation) and October through November 2022 (post-implementation). Data was collected via chart review.
Inclusion criteria for both pre- and post-implementation groups were female and male adults greater than or equal to 18 years old scheduled for elective non-cardiac surgery with a STOP-Bang score ≥ 4. Exclusion criteria includes patients younger than 18 years old, emergency surgery, Intensive Care Unit (ICU) admission, or specialized surgeries including trauma, cardiovascular, neurological, and obstetric surgeries. To maintain the confidentiality of data, all patient data collection was de-identified and management was completed via encrypted Excel sheets. This QI project demonstrated that patients with a STOP-Bang score ≥ 4 received nearly the same percentage of benzodiazepines and narcotics whether they were identified with a blue wristband or not.
Implicit biases are detrimental to patient care and health outcomes, yet they are prevalent among providers. Literature has shown implicit racial bias hinders rapport between patient and provider, leading to patients becoming resistant to medical advice and treatment protocols. The prevalence of implicit racial bias among healthcare providers must be recognized by healthcare systems, along with an understanding of the varying levels existing among varying levels of providers. This doctoral project aims to assess and establish baseline levels of existing racial bias among anesthesia providers working at specified Atrium Health facilities and bring awareness to this sensitive topic. Harvard’s Implicit Association Test was utilized to assess implicit racial bias via an online survey platform. Results were uploaded and demonstrated an average level of racial bias between slight and moderate ( D score 0.15-0.35) against black individuals compared to white individuals. Analysis of variance testing was used to determine a lack of statistical difference between the varying levels of anesthesia providers assessed for racial bias.
ABSTRACT
LLOREN MCKENZIE HILE. Effect of Stroke Volume Variation Monitoring on Acute Kidney Injury after Robotic Enhanced Recovery Protocol Surgery.
(Under the direction of DR. DAVID LANGFORD)
Acute kidney injury (AKI) is one of the most common complications after abdominal, colorectal, and gynecologic surgeries at a large urban trauma center in the southeast. This is exacerbated by the conditions of robotic enhanced recovery protocol (ERP) procedures. Robotic surgery and enhanced recovery protocols each have characteristics that lead to an increased risk of acute kidney injury. Stroke volume variation (SVV) is obtained from an invasive monitor that can measure the fluid balance of an individual under general anesthetic with mechanical ventilation. This measure is not used for every procedure in the operating room, and is typically reserved for high-risk individuals or specific procedures. This project used a retrospective correlational approach to examine the difference in AKI occurrence between a group with SVV monitoring and a group without SVV monitoring. The data was collected from the electronic medical record from May 2022 through August 2022. These groups had similar age and gender profiles. The non-SVV group had a higher average anesthesia time and American Society of Anesthesiologists (ASA) score. The non-SVV group had a 15% occurrence of AKI, while the SVV group had 0% AKI occurrence. This project shows a correlation between SVV monitoring and a decreased occurrence of AKI and suggests that SVV monitoring should be considered for patients at a high risk of developing an acute kidney injury.
Acute kidney injury (AKI) has been linked to intraoperative hypotension in previous studies. AKI may lead to prolonged recovery and hospital stays and complications such as chronic kidney disease. Factors associated with robotic surgery and enhanced recovery protocols (ERPs) may contribute to intraoperative hypotension. This quality improvement project aimed to explore the occurrence of AKI in robotic cases incorporating an ERP. The project design was a retrospective review of anesthesia records of robotic surgeries performed at Atrium Health (AH) Carolinas Medical Center (CMC) over a four-month period. Records were screened for the occurrence of hypotension. The charts of patients who experienced hypotension were then screened for a pre-operative and post-operative creatinine level. AKI was defined using the Kidney Disease Improving Guidelines (KDIGO). The sample size included 34 patients who experienced hypotension. The incidence of AKI was 5.88%. AKI did not differ by age, gender, ASA score, or procedure time.
Application of enhanced recovery protocols with robotic surgeries has gained favor across the country because of improved patient recovery times. Acute kidney injury has been found to be the number one postoperative complication for a large, urban trauma center. Use of non-steroidal anti-inflammatory drugs (NSAID) are favored in enhanced recovery protocols (ERP) due to their ability to decrease inflammatory responses associated with surgery and the absence of opioid side effects like respiratory depression, nausea and vomiting, and lack of cognitive effects. NSAIDs reduce the inflammatory response by inhibiting prostaglandin synthesis through inhibition of cyclooxygenase-1 (Cox-1) and cyclooxygenase-2 (Cox-2). Renal prostaglandins are vasodilators in the kidneys and generally do not contribute to regulating renal perfusion except in low perfusion states (Bell et al., 2020). This project is a retrospective, descriptive design looking at the incidence of acute kidney injury (AKI) within the 48-hour postoperative period following the administration of intraoperative non-steroidal anti-inflammatory drugs. The data collection period started in May 2022 and ended in August 2022. Patient and surgical characteristics like age, gender, surgical service, procedure duration, and NSAID dosage were all extracted from the medical record and evaluated. While the findings were not statistically significant across AKI and age, gender, procedure time, or dosage; findings are clinically significant suggesting there could be an increased incidence of AKI in patients greater than 55 years old receiving NSAIDs.
SHANITA DOMINIQUE GEORGE. ASSESSING THE VARIOUS LEVELS OF IMPLICIT WEIGHT BIAS TOWARD PATIENTS AMONG ANESTHESIA PROVIDERS. (Under the direction of DR. DAVID LANGFORD)
Social disparities and implicit bias have been identified as a potential issue that can be detrimental to patient care. Research has shown that implicit bias hinders rapport between patient and provider, leading to patients becoming resistant to medical advice and treatment protocols. Therefore, existing levels of implicit bias create a need for healthcare systems to recognize and understand the levels of implicit bias among providers and the ramifications that implicit bias could induce. This quality improvement doctoral project aimed to assess and establish a baseline level of existing weight bias among anesthesia providers in urban health system facilities. The author utilized the Harvard Implicit Association (IAT) Weight test as an assessment tool to garner a baseline level of implicit bias among anesthesia providers. There was a total of 46 individuals who participated in this project, the majority worked at a regional tertiary care hospital. The IAT results disclosed anesthesia providers to have a slight-moderate preference for thinner people compared to heavier people.
Keywords: Implicit bias in healthcare, Implicit Association Test, bias, obesity, obesity stigma, weight bias, overweight bias, effects of weight bias in healthcare.
To explain changes in users’ security behaviors and behavioral intentions, we investigated the different messaging approaches that followed the Protection Motivation Theory (PMT) design guidelines. These messaging approaches were used in different
security contexts in terms of authentication (e.g., using screen lock and Two Factor Authentication) and confidentiality (e.g., sharing sensitive information via secure email). As a part of our work, in the first approach, we investigated different risk appeal messaging designs based on PMT that were more suited for the Saudi population to adopt the screen lock. Our results showed that the Saudi-customized messaging
was extremely effective in changing our participants’ locking behavior. In the second approach, to encourage users to voluntarily adopt 2FA, we investigated whether video-based risk communication messages based on PMT would be received differently if they were delivered by a human speaker from the target population versus a cartoon speaker. Our evaluation showed that a video message from a human speaker
improved our participants’ behavior versus the animated speaker video message. Regarding the last approach, we first conducted a structured interview with Gmail users who had used Gmail’s Confidential Mode (GCM) to explore what motivated them
to use the confidential mode, what their perceptions were of confidential mode, and whether they understood the features of this mode for achieving confidentiality. We found that users used GCM to share their confidential or private documents with recipients and perceived GCM to be encrypted and confidential. Encouraged by these findings, we evaluated messaging approaches that followed the PMT and paired with
anticipated regret (PMT+AR) and planning techniques (PMT+AR+P) in persuading Gmail users to utilize an encrypted email (e.g., Virtru) for sharing their sensitive information. Our evaluation showed that both messaging approaches (PMT+AR and PMT+AR+P) increased the adoption rate of utilizing an encrypted email and motivated participants to use Virtru when they shared sensitive information via email. Therefore, our results offered further insights regarding how PMT video messaging incorporated with other elements can increase the likelihood that the actual behavior will be implemented.
While charismatic leadership tactics (CLTs) have been validated across a variety of settings and shown to improve leadership evaluations and predict follower behaviors, the role gender may play in charismatic leadership has been understudied. The present investigation assesses the influence of leader gender as well as a host of contextual variables on the efficacy of CLTs in influencing follower evaluations of leaders as well as follower prosocial behavior. Using signaling theory as an organizing framework, I examine critical moderators of the charismatic effect and integrate gender as a signal that may influence the efficacy of charismatic signaling. Through four independent experimental studies, which I conducted and then meta-analyzed, this paper identifies that the relationships between charismatic signaling, leader gender, and contextual moderators are nuanced and complex. I found a moderate main effect for charisma such that charismatic signaling did result in more positive follower evaluations (d = .185, k = 4, n = 1,002) and increased prosocial donation behavior (d = .1308, k = 4, n = 1,002), but the meta-analytic results revealed an interaction, such that these effects were often stronger for women than for men (e.g., attributed charisma d = .271 for women compared to d = .1342 for men). Furthermore, I found a main effect of gender for influence (d = .158, k = 4, n = 1,002) and donation behavior (d = .1142, k = 4, n = 1,002) favoring women, but this gender difference was reduced or disappeared entirely when the leader engaged in costly signaling behavior (influence d = .08, 95% CI = [-.0353 - .2147], k = 4, n = 1,002) or held only informal authority (influence d = .115, 95% CI = [-.0592 - .2886], k = 4, n = 1,002). Future directions and the need for a more nuanced theory of charismatic signaling are discussed.
The incidence of residual neuromuscular blockade (rNMB) following general anesthesia remains as high as 60%, placing patients at an increased risk of developing postoperative pulmonary complications (PPCs) (Saager et al., 2019). PPCs are associated with increased readmission rates, hospital length of stay, and overall morbidity and mortality (Kirmeier et al., 2019). A quality improvement project was conducted to examine anesthesia providers' current practice using sugammadex compared to evidenced base practice guidelines revealed throughout a comprehensive literature review. An anonymous survey was distributed among anesthesia providers throughout a level 1 trauma center to identify their current practice and knowledge regarding the use of sugammadex. Seventy-seven anesthesia providers completed the survey. Almost all providers correctly identified that sugammadex interferes with hormonal birth control, while only 58% were found to correctly dose sugammadex according to the patient's actual body weight. Thirty-seven percent of anesthesia providers revealed they avoid administering sugammadex in patients with kidney disease. A cognitive aid was developed and placed throughout the operating rooms, targeting knowledge gaps identified in the survey. This quality improvement project recommends continuing the analysis of current practice trends, as this will help inform and promote best practices consistent with contemporary literature.
