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The primary objective of this study was to develop hospital-level metrics of major complications associated with mortality that allows for the identification of opportunities for improvement. The secondary objective is to improve upon current metrics for failure to rescue (i.e., death from serious but treatable complications.).Agency for Healthcare Research and Quality metrics served as the basis for identifying specific complications related to major organ system morbidity associated with death. Complication-specific occurrence rates, observed mortality, and risk-adjusted mortality indices were calculated for the study institution and 182 peer organizations using component International Classification of Disease, Tenth Revision codes. Data were included for adults over a 4-year period, with exclusion of hospice patients and complications present on admission. Temporal visualizations of each metric were used to compare past and recent performance at the study hospital and in comparison to peers.The complication-specific method showed statistically significant differences in the study hospital occurrence rates and associated mortality rates compared with peer institutions. The monthly control-chart presentation of these metrics provides assessment of hospital-level interventions to prevent complications and/or reduce failure to rescue deaths.The method described supplements existing metrics of serious complications that occur during the course of acute hospitalization allowing for enhanced visualization of opportunities to improve care delivery systems. This method leverages existing measure components to minimize reporting burden. Monthly time-series data allow interventions to prevent and/or rescue patients to be rapidly assessed for impact.

Objectives The primary study objective was to investigate the impact of surveillance monitoring (i.e., continuous monitoring optimized for deterioration detection) on mortality and severe morbidity associated with administration of sedative/analgesic medications in the general care setting. A second objective was consideration of the results in the context of previous investigations to establish practice recommendations for this approach to patient safety. Methods Retrospective review of available rescue event and patient safety data from a tertiary care hospital in a rural setting was performed for a 10-year period. Systematic analysis of all adult general care inpatient data followed by chart review for individual patients was used to identify patient death or permanent harm (i.e., ventilator dependency, hypoxic encephalopathy) related to administration of sedative/analgesics. Results Of 111,488 patients in units with surveillance monitoring available, none died or were harmed by opioid-induced respiratory depression when surveillance monitoring was in use. One patient died from opioid-induced respiratory depression in a unit where surveillance monitoring was available; however, the patient was not monitored at the time of the adverse event. In unmonitored units (15,209 patients during 29 months of incremental implementation), three patients died from opioid overdose (19.73 deaths per 100,000 at risk patients). The reduced death rate when surveillance monitoring was available (0.0009%) versus not available (0.02%) was significant (P = 0.03). Conclusions For a 10-year period, the rescue system with continuous surveillance monitoring had a profound effect on death from sedative/analgesic administration in the general care setting. This approach to patient safety can help address the risk of sedative/analgesic-related respiratory arrests in hospitals.

Background Allocation of limited resources to improve quality, patient safety, and outcomes is a decision-making challenge health care leaders face every day. While much valuable health care management research has concentrated on administrative data analysis, this approach often falls short of providing actionable information essential for effective management of specific system implementations and complex systems. This comprehensive performance analysis of a hospital-wide system illustrates application of various analysis approaches to support understanding specific system behaviors and identify leverage points for improvement. The study focuses on performance of a hospital rescue system supporting early recognition and response to patient deterioration, which is essential to reduce preventable inpatient deaths. Methods Retrospective analysis of tertiary care hospital inpatient and rescue data was conducted using a systems analysis approach to characterize: patient demographics; rescue activation types and locations; temporal patterns of activation; and associations of patient factors, including complications, with post-rescue care disposition and outcomes. Results Increases in bedside consultations (20% per year) were found with increased rescue activations during periods of resource limitations and changes (e.g., shift changes, weekends). Cardiac arrest, respiratory failure, and sepsis complications present the highest risk for rescue and death. Distributions of incidence of rescue and death by day of patient stay may suggest opportunities for earlier recognition. Conclusions Specific findings highlight the potential of using rescue-related risk and targeted resource deployment strategies to improve early detection of deterioration. The approach and methods applied can be used by other institutions to understand performance and allow rational incremental improvements to complex care delivery systems.

PURPOSE: The study objective was to understand if features derived from continuous pulse oximetry data can provide advanced warning of pulseless electrical activity arrest in the general care inpatient setting. METHODS: Retrospective analysis of SpO2 and pulse rate data derived from continuous pulse oximetry was performed for pulseless electrical activity (n=38) and control (n=42) patient cohorts. Measures of central tendency and variation over time intervals ranging from 1 minute to 1 hour were used for inter- and intra-group comparisons. Logistic regression was applied to understand ability of features to predict pulseless electrical activity in future time intervals. RESULTS: Overall, the pulseless electrical activity arrest group tended to have lower mean SpO2 and higher mean pulse rate values than the control group. SpO2 and pulse rate variability was higher in the pulseless electrical activity arrest cohort. Changes in variability were observed beginning several hours prior to the rescue event. Up to 20 minutes before rescue events, pulse rate features were significantly different from feature values for the preceding 30-minute interval (>10% difference in mean, >46% difference in range). Similar results were found for SpO2 features 10 minutes before the event (>4% difference in mean, >60% difference in range). CONCLUSIONS: There is a significant difference in SpO2 and pulse rate features derived from continuous pulse oximetry between pulseless electrical activity and control groups. Integration of automated feature calculation and clinician notification into clinical monitoring and information systems may increase patient safety by supporting early detection of such events.

Although it is widely acknowledged that health care delivery systems are complex adaptive systems, there are gaps in understanding the application of systems engineering approaches to systems analysis and redesign in the health care domain. Commonly employed methods, such as statistical analysis of risk factors and outcomes, are simply not adequate to robustly characterize all system requirements and facilitate reliable design of complex care delivery systems. This is especially apparent in institutional-level systems, such as patient safety programs that must mitigate the risk of infections and other complications that can occur in virtually any setting providing direct and indirect patient care. The case example presented here illustrates the application of various system engineering methods to identify requirements and intervention candidates for a critical patient safety problem known as failure to rescue. Detailed descriptions of the analysis methods and their application are presented along with specific analysis artifacts related to the failure to rescue case study. Given the prevalence of complex systems in health care, this practical and effective approach provides an important example of how systems engineering methods can effectively address the shortcomings in current health care analysis and design, where complex systems are increasingly prevalent.

Failure to rescue events, or events involving preventable deaths from complications, are a significant contributor to inpatient mortality. While many interventions have been designed and implemented over several decades, this patient safety issue remains at the forefront of concern for most hospitals. In the first part of this study, the development and implementation of one type of highly studied and widely adopted rescue intervention, algorithm-based patient assessment tools, is examined. The analysis summarizes how a lack of systems-oriented approaches in the design and implementation of these tools has resulted in suboptimal understanding of patient risk of mortality and complications and the early recognition of patient deterioration. The gaps identified impact several critical aspects of excellent patient care, including information-sharing across care settings, support for the development of shared mental models within care teams, and access to timely and accurate patient information. This chapter describes the use of several system-oriented design and implementation activities to establish design objectives, model clinical processes and workflows, and create an extensible information system model to maximize the benefits of patient state and risk assessment tools in the inpatient setting. A prototype based on the product of the design activities is discussed along with system-level considerations for implementation. This study also demonstrates the effectiveness and impact of applying systems design principles and practices to real-world clinical applications.

Background The growing number of monitoring devices, combined with suboptimal patient monitoring and alarm management strategies, has increased "alarm fatigue," which have led to serious consequences. Most reported alarm man- agement approaches have focused on the critical care setting. Since 2007 Dartmouth-Hitchcock (Lebanon, New Hamp- shire) has developed a generalizable and effective design, implementation, and performance evaluation approach to alarm systems for continuous monitoring in general care settings (that is, patient surveillance monitoring). Methods In late 2007, a patient surveillance monitoring system was piloted on the basis of a structured design and implementation approach in a 36-bed orthopedics unit. Beginning in early 2009, it was expanded to cover more than 200 inpatient beds in all medicine and surgical units, except for psychiatry and labor and delivery. Results Improvements in clinical outcomes (reduction of unplanned transfers by 50% and reduction of rescue events by more than 60% in 2008) and approximately two alarms per patient per 12-hour nursing shift in the original pilot unit have been sustained across most D-H general care units in spite of increasing patient acuity and unit occupancy. Sample analysis of pager notifications indicates that more than 85% of all alarm conditions are resolved within 30 seconds and that more than 99% are resolved before escalation is triggered. Conclusion The D-H surveillance monitoring system employs several important, generalizable features to manage alarms in a general care setting: alarm delays, static thresholds set appropriately for the prevalence of events in this setting, directed alarm annunciation, and policy-driven customization of thresholds to allow clinicians to respond to needs of individual patients. The systematic approach to design, implementation, and performance management has been key to the success of the system.

Background Some preventable deaths in hospitalized patients are due to unrecognized deterioration. There are no publications of studies that have instituted routine patient monitoring postoperatively and analyzed impact on patient outcomes. Methods The authors implemented a patient surveillance system based on pulse oximetry with nursing notification of violation of alarm limits via wireless pager. Data were collected for 11 months before and 10 months after implementation of the system. Concurrently, matching outcome data were collected on two other postoperative units. The primary outcomes were rescue events and transfers to the intensive care unit compared before and after monitoring change. Results Rescue events decreased from 3.4 (1.89-4.85) to 1.2 (0.53-1.88) per 1,000 patient discharges and intensive care unit transfers from 5.6 (3.7-7.4) to 2.9 (1.4-4.3) per 1,000 patient days, whereas the comparison units had no change. Conclusions Patient surveillance monitoring results in a reduced need for rescues and intensive care unit transfers.

Aim: To compare the quality between 2 commonly used sedation practices for upper endoscopic ultrasound (EUS) by using expert observational analysis of the sedation practice. Methods: After institutional review board approval, 50 adults undergoing EUS had videotape observation of the procedural sedation: 25 received benzodiazepine/opiate administered by the endoscopy team as per the standard protocol at our institution, and 25 received propofol administered by a dedicated anesthesiologist. Quantitative analysis of the video was performed using the Dartmouth Operative Conditions Scale (DOCS). The DOCS is a tool previously developed to quantify the adequacy of procedural sedation through an objective measurement of the patient state during the sedation process. In this study, the DOCS was used in a novel way to compare the quality of sedation provided by different sedation protocols. Data were collected on patient demographics, patient and provider satisfaction, efficiency, side effects, and safety measures. Results: Videotape analysis using the DOCS revealed that 52% (13/25) of the standard group exhibited an uncontrolled patient state (significant undersedation and/or oversedation) on 1 or more occasion during their EUS procedure compared with 28% (7/25) of the propofol group. Patients in the standard group spent 7.1% of the procedure in an uncontrolled patient state, whereas patients in the propofol group experienced an uncontrolled state approximately 1.0% of the procedure time. Overall efficiency as measured by time in both the procedure room and in recovery was superior in the propofol group. These patients spent 12 less minutes on average in the procedure room and were ready for discharge in about half the time (56 minutes versus 109 minutes). The propofol group experienced significantly less in-hospital and at-home nausea and vomiting and felt back to baseline status more quickly. Finally, patient satisfaction was improved in the propofol group: 60% felt the procedure was better than anticipated versus 21% in the standard group. Conclusions: Expert videotape analysis of the patient state during procedural sedation allows direct comparison of sedation methodologies using small numbers of patients. In our institution, endoscopist-directed sedation using a midazolam/narcotic combination for EUS proved inferior to sedation using propofol given by an anesthesiologist. Specifically, a midazolam/narcotic combination provided less effective intraprocedural conditions, was less efficient both before and after the procedure, and was less satisfactory to patients as compared with propofol. Results of this type of analysis can be used to drive appropriate system redesign and improve patient care.

A nesthesiologists have long been involved in the process of making sedation safer for all patients. The specialty has played a critical role in the development of guidelines for sedation practice from the American Society of Anesthesiologists (ASA) and the American Academy of Pediatrics [1,2]. The stalwart defense of appropriate patient assessment, good monitoring, and the establishment of appropriate backup systems have doubtless saved lives and improved the practice for all specialties that have been involved sedation over the past 20 years. Anesthesiologists have also played leading roles in individual hospitals worldwide, where they have been asked to help develop appropriate training for sedation providers and participate in the ongoing quality assurance in the various sedation venues each institution uses. The specialty now faces a new challenge: defining its role in training and educating the next generation of sedation providers who are much more aggressive in their application of potent sedatives. At no time has the issue of sedation training and education been more topical or difficult to define. A veritable explosion had occurred in the procedures and tests accomplished outside the operating room that require deep sedation for the comfort and safety of the patient and the operating needs of the proceduralist. Furthermore, the public demands the best possible pain/anxiety control for uncomfortable or distressing experiences in the hospital. Compared with previous generations, this patient base is much less likely to accept pain and distress associated with medical care as ‘‘unavoidable’’ for themselves (or their children).

While HF is enjoying a growing profile within the medical community, the role of HF with respect to clinical training and education in particular has not been clearly defined. The purpose of this panel is to explore the intersection of HF and clinical training, and to delineate some of the opportunities and challenges that exist. The panel will discuss a number of current examples of how HF techniques are being applied to develop and implement clinical education initiatives.

Background and Objectives Ultrasound-guided regional anesthesia is a rapidly growing field. There exists little information regarding the competencies involved with such a practice. The objective of this exploratory study was to characterize the behavior of novices as they undertook the challenges of learning a new technique. In addition to assessing for both committed errors and accuracy, we aimed to identify previously unrecognized quality-compromising behaviors that could help structure effective training interventions. Methods By using detailed video analyses, the performances of 6 anesthesia residents were evaluated while on a dedicated 1-month rotation in ultrasound-guided regional anesthesia. From these video reviews, we assessed accuracy, errors committed, performance times, and searched for previously unrecognized quality-compromising behaviors. Results A total of 520 nerve blocks were videotaped and reviewed. All residents performed at least 66 nerve blocks, with an overall success rate of 93.6% and 4 complications. Both speed and accuracy improved throughout the rotation. There were a total of 398 errors committed, with the 2 most common errors consisting of the failure to visualize the needle before advancement and unintentional probe movement. Five quality-compromising patterns of behavior were identified: (1) failure to recognize the maldistribution of local anesthesia, (2) failure to recognize an intramuscular location of the needle tip before injection, (3) fatigue, (4) failure to correctly correlate the sidedness of the patient with the sidedness of the ultrasound image, and (5) poor choice of needle-insertion site and angle with respect to the probe preventing accurate needle visualization. Conclusions Based on the analysis of the committed errors and the identification of quality-compromising behaviors, we are able to recommend important targets for learning in future training and simulation programs.

Societal awareness of medical errors has rapidly increased following the 1999 publication of the IOM report, To Err is Human (e.g., Kohn, Corrigan & Donaldson, 1999). This report encouraged hospitals to focus on patient safety as a central focus of quality improvement work and to develop proactive approaches to protect patients from medical error. Large hospitals often lack robust mechanisms for reliably identifying patient safety threats, developing effective countermeasures and broadly implementing those measures across the entire healthcare organization. The result is that patient safety activity is heterogeneous across a healthcare organization. Best practices regarding patient safety do not automatically spread horizontally in a hospital, but rather tend to remain isolated. Dartmouth-Hitchcock Medical Center (DHMC) is a large tertiary care facility and academic teaching hospital that self-identified this variation in patient safety processes as an organizational threat to patient safety. Internal reviews identified multiple examples of safety threats countered in one clinical unit, only to have an accident due to the same threat in a clinical unit physically proximate to the first. An Active Error Management (AEM) process utilized in the Department of Anesthesiology that was effective in supporting local learning was identified as a potential vehicle for organizational learning and horizontal spread of patient safety countermeasures. In this report we describe: a) the organizational intervention that was implemented - the Patient Safety Collaborative Forum (PSCF); b) the active error management process that was taught, modeled and coached via this vehicle for organizational learning; c) one example of organizational spread resulting from the PSCF; and finally d) a naturalistic experiment that compares best practice implementation among units that participated in the PSCF to those units that did not.

The practice of sedating patients in the hospital for diagnostic and therapeutic procedures may be associated with life-threatening respiratory depression. We describe a method that uses a simulated event to identify latent system failures. A simulated scenario was developed that was reproducible with realistic physiology that degraded over time if no interventions occurred and improved when treated appropriately. Management of the scenario was observed in an ideal setting, a radiology department, and an emergency department. Event management was videotaped. The simulator's physiological data were saved automatically at 5-s intervals. Deviations from "best practice" were measured by using a set of video markers for event detection, diagnosis, and treatment. The simulator data files were used to calculate time out of range for critical variables. Hypoxia and hypotension lasted 4.5 and 5.5 min in the radiology and emergency departments, respectively, compared with 0 min in the gold standard setting. Many latent failures were identified by reviewing the video. This study supports the feasibility of using available human simulation as a crash-test dummy to more objectively quantify rescue system performance in actual sedation care settings. This method revealed vulnerabilities in personnel and in care systems even though sedation care regulatory requirements were met.

Studies of pediatric sedation practice have suffered from the lack of an objective scale that would allow for a comparison of the effectiveness and safety of sedation provided by various providers and techniques. We present the Dartmouth Operative Conditions Scale (DOCS), which is designed as a research tool to codify the appropriateness of the procedural conditions provided by various sedation interventions. To begin, human factors methodology was used to develop a model of the pediatric sedation process and to define the criteria for measuring a patient's condition during a procedure (DOCS). To accomplish validation, 70 video clips (30-s duration) were then selected from more than 300 h of procedural video tape for testing/grading purposes. Inter-rater reliability was tested by comparing the score for each video clip among 10 different raters. Intra-rater reliability was evaluated by retesting all of the raters 1 yr after their initial rating. Construct validity was confirmed by analyzing the change in DOCS score relative to the time that sedation intervention was undertaken. Criterion validity was tested by comparing the DOCS to a modified COMFORT score. The DOCS was completed with excellent inter-rater (kappa = 0.84) and intra-rater (kappa = 0.91) agreement by 10 health care providers with various backgrounds during the 1-yr study period. Criterion validity was supported by the close correlation between the DOCS and the modified COMFORT scores for 20 distinct video clips (Spearman correlation coefficient = 0.98; P

Background and objective Ultrasound has become an increasingly popular modality in facilitating the performance of peripheral nerve blocks. There exists no literature that examines the learning curve of the ultrasound novice. In this prospective series, we evaluated the learning curve of inexperienced anesthesia residents in performing a simulated ultrasound-guided interventional procedure. In doing so, we hoped to identify reproducible patterns of human errors, which could potentially aid in the prevention of real-life iatrogenic injuries. Methods Ten subjects were prospectively enrolled. After a brief introduction to the ultrasound system, the subjects were asked to perform 6 sequential trials of a simulated breast cyst aspiration. For the first 3 trials, each subject attempted to place a 22-gauge b-bevel needle into any aspect of an olive buried inside the turkey breast. After completion of these 3 trials, the subjects were asked to place the needle into the exact midpoint of the olive wall closest to the transducer. Trials were videotaped and analyzed for task performance in terms of speed and accuracy. Results All subjects successfully completed the 6 interventional trials. The mean time to perform the task was reduced by 38% and 48%, respectively, for the second and third trials. A composite score of accuracy showed an improvement of 36% and 59%, respectively, for the second and third trials. The most common committed error, which occurred in 7 of 10 subjects, was the failure to accurately image the needle while advancing. This resulted in excessive depth of penetration and inadvertent transfixation of the olive in 5 of these subjects. Conclusions Anesthesiology residents, with little or no ultrasound experience, can rapidly learn and improve their speed and accuracy in performing a simulated interventional ultrasound procedure. A concerning novice pattern was identified where the subjects advanced the needle even though it was not appropriately visualized in the ultrasound beam. This resulted in needle placement error, which could cause iatrogenic injury in the clinical setting.

Anaesthetic information displays have been shown to influence anaesthesiologists’ situation awareness. In study 1 an object display was compared with the traditional display currently used. Twelve anaesthesiologists (residents and faculty members) participated in a simulator evaluation of the displays. Reaction times for detection of critical events and situation awareness were measured. The object display improved situation awareness for one of four test scenarios. Low-level situation awareness was higher with the traditional display, and medium-level situation awareness was higher with the new display. In study 2, an integrated 3D display was compared to the traditional display. Twelve students participated in the evaluation. The new 3D display helped the observers to see changes more rapidly. In one scenario, situation awareness was higher with the new display than with the traditional display. In summary, during 63% of the simulated scenarios, reliable differences were found in favour of the new displays. Thus, by introducing integrated graphical displays in the operating room, anaesthesiologists’ performance may be improved.

Typical low-level telemetry displays provide little support for understanding how a monitored system is changing over time. Similarly, advanced display techniques have not explicitly addressed the representation of change and events. This paper describes a study which seeks to work towards a foundation for displays which highlight coherent units of behavior in system properties (“events”). In the study, 17 medical professionals viewed simulated telemetry from a surgical procedure. A technique adapted from social perception research was used to trace participants' flow of attention to new information as they viewed the case. The results demonstrate that observers dynamically construct higher-level descriptions of system behavior from instantaneous data values, and that these descriptions implicate various types of contextual information.

The practice of sedating pediatric patients undergoing diagnostic and therapeutic procedures represents an ideal model for evaluating systems of health care delivery. We present detailed evidence of how different systems acting on the same patient under similar conditions result in very different outcomes. In contrast to epidemiological methods, our research follows a Human Factors approach of observing a small number of representative cases in great detail to characterize the critical components and processes of ideal sedation care. In this descriptive article we present a framework by which this work domain can be codified and evaluated. We conclude with a demonstration of how a patient simulator can be used to quantify responses to sedation emergencies. These data constitute the basis for innovating novel sedation care systems and strategies that will optimize safety and efficacy.

The anesthesiologist is expected to monitor multiple data streams from the anesthetized patient, recognize problem states, identify the etiology or cause of problem states (i.e., perform diagnosis) and take corrective action to return a patient to the desired goal state. This study represents efforts to further investigate features of a multi-dimensional Object display of hemodynamic data. Clinicians using this Object display recognized problem states and determined etiology, faster and more accurately than when they used a Single Sensor Single Indicator (SSSI) Numeric display. This study hypothesized that shapes designed into the Object display accounted for the diagnostic performance gain observed. To test this hypothesis, variant of the Object display, with the emergent shape features removed ( Object Minus Shapes display) was used as a probe to assess the impact of the shape-encoded information on diagnostic performance. Both the Object and Object Minus Shapes displays improved problem state recognition when compared to the Numeric SSSI display. The former displays graphically represent current data values and boundary information using a pointer, a reference scale, and solid bars to depict normal and abnormal value ranges. The emergent shape features in the Object display were the essential graphical elements that conferred improved etiology determination by anesthesiologists. This study partially validates the design goal used to construct the Object display under investigation—to map multi-dimensional physiologic relationships of hemodynamic data using graphical representations with emergent features that are clinically meaningful.

Objective.We tested the hypothesis that a monitoring display proposed by Blike et al. improves the performance of anesthesiologists. We measured the performance of anesthesiologists using the new display and compared it to their performance with at raditional display. We studied three different displays on how they affected recognition and differentiation of five etiologies ofshock–anaphylaxis, bradycardia, hypovolemia, ischemia and pulmonary embolus. Methods.The participants monitored heartrate, systemic arterial and pulmonary blood pressure, central venous pressure, and cardiac output during five shock states and five non-shock states. The resulting 10 data sets made up ten decision screens, which we presented randomly on a computer monitor to the subjects in one of three different formats (a Single Sensor Single Indicator (SSSI)Numericdisplay; anObjectdisplay; and an Object Minus Shapesdisplay). Subjects used soft-buttons on a computer touch-screen monitor to: a) advance to the next display; b) differentiate a non-shock state from a shock state; and, c) select the etiology of shock state represented by the display (Figure 4). The internal clock and memory of the computer made the collection of data automatic. Results.The subjects recognized a problem more rapidly with the help of a graphical “pointer on a referencescale” in both Objectdisplays, but their accuracy had not improved in comparison to the SSSI Numericdisplay. The shape of the Objectdisplay improved performance of etiology determination compared to the Object Minus Shapesdisplay andSSSI Numericdisplay. Testing (10 trials) was completed in less than 45 minutes. Conclusions.The new display with“emergent features” can improve the diagnostic performance of clinicians.

Objective. This study tests the hypothesis that a graphical object display (a data display consisting of meaningful shapes) will affect the ability of anesthesiologists to perform a diagnostic task rapidly and correctly. The diagnostic tasks studied were recognition and differentiation of five etiologies of shock – anaphylaxis, bradycardia, myocardial ischemia, hypovolemia, pulmonary embolus. Methods. Data sets consisting of HR, Systemic Arterial BP, Pulmonary Arterial BP, CVP, and Cardiac Output were generated for five shock states and five non-shock states. The resulting 10 data sets were presented on a computer monitor to study subjects twice (first in an alpha-numeric format and then in the object format) for a total of twenty decision screens. Subjects used soft-buttons on a computer touch-screen monitor to: a) advance to the next display; b) differentiate a non-shock state from a shock state; and, c) select the etiology of shock state represented by the display (Figure 2). Data collection was automatic, using the internal clock and memory of the computer. Results.Eleven anesthesiologists participated in this study. They completed a total of 3060 diagnostic decisions, half with each display format. Performance measures were time to decision and diagnostic accuracy. The object display improved no-shock recognition by 1.0 second and shock etiology determination by 1.4 seconds (p < 0.05). The object display also significantly improved accuracy for shock recognition by 1.4% and etiology determination by 4.1% (p < 0.05). Testing was completed in a time interval of

Over the past decade, ambulatory care in the United States has been subject to dramatic pressures to cut costs, meet regulations, and transition to electronic health records. Many physicians expres...

Implications Visual strokes can occur after prolonged hypotension or as a complication of preeclampsia-eclampsia. This case describes the diagnostic dilemma posed by a patient who developed transient blindness after a hypotensive episode during cesarean delivery for severe preeclampsia-eclampsia.

The interpretation and use of standard triage protocols differ widely among first responders. We believe that experience among first responders is a major cause of these differences. The intent of this study is twofold; to present a novel design for an experimental architecture to observe first responders perform triage, and to use the experimental architecture in a pilot study to explore the hypotheses that expert first responders deviate from standard triage protocols, and experience makes expert first responders deviate from standard triage protocols and leads to more accurate triage assessments because experts consider physiological variables not looked at in standard triage protocols and recognize subtle physiological trends indicative of injury. Results from the pilot study demonstrated that particular physiological information given to expert subjects consistently caused the expert subjects to assign a higher triage assessment category than the START protocol dictated. This key physiological information included drops in the oxygen saturation level, prolonged airway obstruction, and signs of a serious internal injury.

Objective. Central and obstructive apneas are sources of morbidity and mortality associated with primary patient conditions as well as secondary to medical care such as sedation/analgesia in post-operative patients. This research investigates the predictive value of the respirophasic variation in the noninvasive photoplethysmography (PPG) waveform signal in detecting airway obstruction. Methods. PPG data from 20 consenting healthy adults (12 male, 8 female) undergoing anesthesia were collected directly after surgery and before transfer to the Post Anesthesia Care Unit (PACU). Features of the PPG waveform were calculated and used in a neural network to classify normal and obstructive events. Results. During the postoperative period studied, the neural network classifier yielded an average (±standard deviation) 75.4 (±3.7)% sensitivity, 91.6 (±2.3)% specificity, 84.7 (±3.5)% positive predictive value, 85.9 (±1.8)% negative predictive value, and an overall accuracy of 85.4 (±2.0)%. Conclusions. The accuracy of this method shows promise for use in real-time monitoring situations.

The extreme conditions of combat and multi-casualty rescue often make field triage difficult and put the medic or first responder at risk. In an effort to improve field triage, we have developed an automated remote triage system called ARTEMIS (automated remote triage and emergency management information system) for use in the battlefield or disaster zone. Common to field injuries is a sudden change in arterial pressure resulting from massive blood loss or shock. In effort to stabilize the arterial pressure, the sympathetic system is strongly activated and sympathetic tone is increased. This preliminary research seeks to empirically demonstrate that a forehead reflectance pulse oximeter is a viable sensor for detecting sudden changes in sympathetic tone. We performed the classic supine-standing experiment and collected the raw waveform, the photoplethysmogram (PPG), continuously using a forehead reflectance pulse oximeter. The resulting waveform was processed in Matlab using various spectral analysis techniques (FFT and AR). Our preliminary results show that a relative ratio analysis (low frequency power/high frequency power) for both the raw PPG signal and its derived pulse statistics (height, beat-to-beat interval) is a useful technique for detecting change in sympathetic tone resulting from positional change.

Article-at-a-Glance Background A performance improvement competency development program, known as the Value Institute (VI), was established at Dartmouth-Hitchcock (D-H; Lebanon, New Hampshire) in 2011 to develop a performance improvement–focused workforce and systems capable of meeting the challenges of creating a sustainable health system. Methods A tiered competency development program that provides patient safety, health care quality, and improvement science education, and an execution support infrastructure that enables access to performance improvement tools for all employees, comprise the core of the VI. Results At 20 months after the launch of the first VI classes, more than 10% of all employees were trained to the Yellow Belt level, and approximately 1.5% of all employees became advanced practitioners (Green Belts or Black Belts). Improvement projects have focused on both clinical and business process optimization, as well as regulatory and accreditation compliance and patient safety. Project savings during the two years of operation have exceeded the investment of resources to establish this long-term performance improvement capability by 2.5 times. Conclusions The D-H VI model promotes multidisciplinary team-based learning, incremental skill development, and access to a common continuous improvement vocabulary and method for all employees—all key to building the teams and momentum needed for successful execution of improvement work and to maintain outcomes. Initial outcomes, represented by organizational spread, project execution status, participants' feedback scores, and return on investment estimates, suggest that robust team-based learning combined with coaching provides sufficient depth and breadth of learning and effective opportunities to gain practical experience in continuous improvement.

Pediatric sedation continues to evolve. It is an area of practice that involves a variety of pediatric subspecialties, the practitioners of many of which are not fully aware of what is being done by others involved in this care. The purpose of this review is to consider the current status of pediatric sedation in general and to discuss the most recent literature concerning this practice. Specifically we will discuss the use of new medications for pediatric sedation, issues concerning fasting status, issues surrounding the effectiveness of sedation, and discharge criteria after sedation.Propofol sedation is growing rapidly outside of the operating room environment. Emergency-medicine and intensive-care providers are regularly employing propofol for procedural sedation and reporting its effective use in their hands. Also in the emergency-medicine field, evidence is emerging that fasting status is not a particularly important factor in the genesis of critical events during sedation. Anesthesiologists are evaluating the use of dexmedetomidine for sedation of children and new reports describe the advantages of deep sedation and anesthesia over moderate sedation for painful procedures. Finally an important study shows that a patient's condition on discharge after sedation can be improved through the implementation of specific criteria using objective scoring techniques.Anesthesiologists and those outside of anesthesiology are employing new potent sedative hypnotic agents to accomplish effective pediatric sedation. At the same time, the consensus-generated sedation guidelines--particularly with respect to fasting guidelines--are being questioned. All of this is occurring in the face of mounting evidence that sedation depth needs to be adequate to provide optimal operating conditions and patient satisfaction. Regardless of sedation method used, recovery criteria need to be carefully considered in order to optimize patient safety.

Purpose of review The paper will review the few studies that have been published recently on nonoperating room pediatric anesthesia/sedation. These studies target gaps in our understanding of critical factors associated with the provision of nonoperating room anesthesia safety and reliability in children. Recent findings More objective data regarding the safety and reliability of this practice have become available. Video can accurately capture a child's state and allow comparison of different sedation techniques more objectively than is possible with available literature. The use of standard simulated events allows rescue performance in actual care systems to be tested for their ability to manage a rare, but critical respiratory depression episode. Preliminary findings from a large multicenter study from the Pediatric Procedural Sedation Research Consortium suggests critical adverse events are rare (one cardiac arrest in over 30,000 sedation encounters), but that potentially critical events occur commonly (one in 400 procedures was associated with stridor, laryngospasm, wheezing or apnea). Summary Research into the critical factors that impact safety and reliability in the performance of nonoperating room anesthesia for children is providing objective observational techniques along with large outcomes databases that should enable targeted improvements in the safety and reliability of this growing practice.

Sedating children for diagnostic and therapeutic procedures remains an area of rapid change and considerable controversy. Exploration of this topic is made difficult by the fact that the reports of techniques and outcomes for pediatric sedation appear in a wide range of subspecialty publications and rarely undergo comprehensive examination. In this review article, we will touch on many aspects of the topic of pediatric sedation from the perspective of the anesthesiologist. We begin with a review of the historical role of anesthesiologists in the development of the current standards for pediatric sedation. We also examine the current status of pediatric sedation as reflected in published studies and reports. A specific review of the issues surrounding safety of sedation services is included. Current trends in sedation practice, including the expanding role of potent sedative hypnotic drugs outside the field of anesthesiology, are noted. Finally, we suggest future areas for research and clinical improvement for sedation providers.

The extreme conditions of combat and multi-casualty rescue often make field triage difficult and put the medic or first responder at risk. In an effort to improve Reid triage, we have developed an automated remote triage system called ARTEMIS for use in the battlefield or disaster zone. This preliminary research seeks to empirically demonstrate that the Nonin forehead reflectance pulse oximeter is a viable sensor for measuring essential physiological parameters used in automated field triage systems such as ARTEMIS.

Ascertaining the medical status of soldiers deployed in the battlefield is essential for medical and strategic decision-making. The diagnostic and treatment methods used in the battlefield are currently suboptimal due to limited field resources and communication mechanisms. The system described herein is designed to remotely assess the medical status of deployed soldiers to augment resources of the medic, promoting more efficient and timely treatment of battlefield injuries. Key components of this combat casualty care system are an intelligent mobile agent information management network, a sensor capable of collecting pertinent physiological data, an assessment and alert algorithm, an ad hoc wireless routing system, and a user interface. The focus of this paper is on the development and preliminary evaluation of our medical model and assessment algorithms, which were implemented using hard-coded rules and a fuzzy logic approach. We discuss results of our initial simulations, the limitations of our medical model, and present a strategy for testing and improving different implementations of our model.

Article-at-a-Glance Background This article explores patient safety from a microsystems perspective and from an injury epidemiological perspective and shows how to embed safety into a microsystem's operations. Microsystems patient safety scenario Allison, a 5-year-old preschooler with a history of "wheezy colds," and her mother interacted with several microsystems as they navigated the health care system. At various points, the system failed to address Allison's needs. The Haddon matrix provides a useful framework for analyzing medical failures in patient safety, setting the stage for developing countermeasures. Case study The case study shows the types of failures that can occur in complex medical care settings such as those associated with pediatric procedural sedation. Six patient safety principles, such as "design systems to identify, prevent, absorb, and mitigate errors," can be applied in a clinical setting. In response to this particular case, its subsequent analysis, and the application of microsystems thinking, the anesthesiology department of the Children's Hospital at Dartmouth developed the PainFree Program to provide optimal safety for sedated patients. Conclusion Safety is a property of a microsystem and it can be achieved only through thoughtful and systematic application of a broad array of process, equipment, organization, supervision, training, simulation, and teamwork changes.

Summary We present a case report of two infants given a bupivacaine caudal anaesthetic as a means of achieving sedation for a diagnostic brain magnetic resonance imaging (MRI). Patient 1 was born at 27 weeks of gestation and presented to our hospital at 39 weeks postconception with a history of bronchopulmonary dysplasia and apnoea/bradycardia spells. He was undergoing a brain MRI for the work up of persistent apnoea and craniofacial abnormalities. Patient 2 was a term infant at 42 weeks postconception undergoing a MRI for the work up of a seizure disorder. Both infants fell asleep shortly after placement of the caudal blocks and the studies were completed successfully without complications. Utilizing this technique, we avoided dealing with a potentially difficult airway (patient 1), exacerbating postoperative apnoea and the negative implications of intravenous sedation during a study where there is limited access to the patient's airway.