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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.
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.
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.
Residual neuromuscular blockade (rNMB) following general anesthesia can impair pulmonary mechanics and place patients at an increased risk to develop postoperative pulmonary complications (PPCs) (Saagar et al., 2019). PPCs are associated with increased readmission rate, hospital length of stay and overall morbidity and mortality (Kirmeier et al., 2019). Current literature suggests that clinicians play a pivotal role in the reduction of rNMB through the accurate assessment and interpretation of neuromuscular blockade with a peripheral nerve stimulator (PNS) (Thilen & Bhananker, 2016). For this project, a survey was distributed to anesthesia providers at a level-1 trauma center. Nine questions regarding neuromuscular blockade monitoring were included; two questions assessed current practice and seven questions assessed literature-based knowledge. The survey results revealed that while some content areas reflected up-to-date practice and knowledge by the practitioners, others did not align with current literature. For example, only 12.9% of survey participants correctly identified the most important and reliable use of the train-of-four count (TOFC), the most commonly used mode of the PNS. The identified areas of educational needs were identified via the survey and included on a cognitive aid to be used as an intra-operative reference tool. This quality improvement project recommends continuing the evaluation and analysis of current practice trends as new literature and management modalities evolve.
There are a variety of distractions that can occur in the operating room during the induction of anesthesia. A review of the literature revealed that common distractions include: noise, music, cell phones and pagers, production pressure, and unnecessary conversations. This project is part of a larger quality improvement project investigating anesthesia providers’ perceptions of the frequencies and types of distractions occurring during induction at three different sites: an ambulatory surgery center, a mid-sized, suburban hospital, and a level one trauma center. This project focuses on identifying distraction severity and frequency at an ambulatory surgery center. An anonymous, electronic survey was distributed to physician anesthesiologists, certified registered nurse anesthetists (CRNAs), and student registered nurse anesthetists (SRNAs), at these three different clinical locations within a large healthcare system. The survey asked providers to rate perceived frequency and severity of selected distractions on a modified Likert scale. A total of thirteen anesthesia providers working at the ambulatory surgery center responded to the survey. The results show that conversations were found to be the most severely distracting while music and equipment alarms were equally found to be the least distracting. Females found music, conversations, and personal cell phone use to be more distracting than males. Younger anesthesia providers found equipment alarms to be more distracting than older anesthesia providers. Across the three site locations, survey comparison found no difference between results. The aim of this project is to discover what is distracting to anesthesia providers during anesthetic induction so that future projects can begin to mitigate the occurrence of these distractors and promote increased patient safety during the induction of anesthesia.
ABBY CATHERINE SANDERS. Risk Factors and Nausea Prophylaxis in the Gynecological (GYN), Urological, and Ear, Nose and Throat (ENT) Surgical Population at an Urban Surgery Center
(Under the Direction of DR. STEPHANIE WOODS PHD)
This is a quality improvement (QI) project that examines post-op nausea and vomiting prophylaxis (PONV) and PONV in the Post Anesthesia Care Unit (PACU) in an Urban Hospital system. The clinical question for this QI project is: In the population of Gynecological (GYN), Urological, and Ear, Nose, and Throat (ENT) surgical patients 18 years and older, how does patient, anesthetic, and surgical risk factors for PONV and the delivery of antiemetics affect the incidence of PONV in the Urban setting?
The purpose of this project was to compare anesthetic, surgical, and patient risk factors with the number of antiemetics given, in order to determine anesthesia providers compliance with the Fourth Consensus Guidelines. Data related to patient, anesthetic, and surgical risk factors, and PONV in the PACU was collected via chart review. Data analyses were conducted to determine patient, anesthetic, and surgical risk factors, and PONV prophylaxis administration.
The Apfel score was not significantly associated with actual antiemetics. There was also no significant association between patient, anesthesia, and surgical risk factors and the risk for PONV. The percent of PONV at the Urban facility was 14.29%. Overall, 42.9% of patients did not receive the correct number of antiemetics. Education to improve the knowledge gap between understanding of the Fourth Consensus Guidelines and the application of its antiemetic interventions into practice is recommended to improve adherence to guidelines.
Keywords: PONV, gynecologic, ENT, Urologic, surgery, urban, anesthesia
