SPA Spring Meeting Reviews

Saturday Session IV - Community/Private Practice Track: Our Community is Our Practice

By Behnoosh Shayegan, MD
Rush University Medical Center

How to Convince your CMO you Need Staff/Solutions

Melissa McLeroy, CFO (Medical City Dallas, Medical City Children’s Hospital, Medical City Heart and Spine, and Medical City Green Oaks) began by discussing how to connect requests for resources with their value, and then on presenting these to leadership in a way that emphasizes financial offset and outcomes.

As physicians, we are at the frontline of medicine and are too often faced with resource challenges.  These can vary from staffing issues, to equipment, supplies, and even financial deficits. We are left wondering what it is we actually need and how to ask for it successfully. Ms.  McLeroy outlined the process for doing just that.

She encouraged us to identify the resource needed (the “problem”), to then think about how to rectify it (the “solution”), and finally, to consider how solving that deficiency will add value to our system (the “result”). Would solving the problem increase patient safety or quality, increase staff or patient experience or satisfaction, or be financially lucrative?

The focus of the plan is to identify and describe these main aspects to leadership in order to share information in a way that will convey the need, the solution, and the anticipated outcome.

  1.  Define the problem
  2.  How would solving the problem add value (quantify its value if possible)
  3.  Create a solution
  4.  Effect of solution downstream

It is crucial to identify the financial benefit when it is not obvious through focusing on how the solution will potentially improve patient or employee safety or satisfaction as well. Often by improving employee satisfaction, productivity increases, which will result in increased overall revenue for the institution.

Finally, once the process has been mapped out, Melissa McLeroy encouraged us to make a
presentation for the Chief Suite (C-Suite).  She recommends that the presentation be brief and concise (no more than 6 slides), and include:

  1. What-The need or the ask
  2. How-The problem it will solve
  3. Why-Value it will bring (improvement potential)
  4. Benefit-The solution
  5. The Ask and the offset

Utilizing this method for outlining a need and potential solution, and connecting that to financial and satisfaction outcomes for an institution, can offer opportunities for growth and change when presented with this framework in mind.


Art Into Science: A Rational Approach to Extubation in Young Pediatric Patients

Thomas Templeton, MD (Wake Forest University) began his presentation by pointing out the lack of research and publications on extubations, specifically in the pediatric population, as compared to intubations. Most studies that he found were restrospective, acknowledged the higher risk of extubation, and outlined the risk factors for failure. The highest risk of failure was found to be in the NICU patient population, with one study reporting 9.1% post procedure respiratory events. The single most important risk factor for these adverse outcomes in the post anesthesia period were birth weight < 1.58 kg and post conception age at time of surgery < 41 weeks.  Another study, which evaluated 55,422 patients < 1 year of age, looked at a scoring system to evaluate the risk of reintubation.  They concluded that risk factors for reintubation (or failed extubation) included: supplemental oxygen prior to anesthetic, inpatient status, severe cardiac disease, need for nutritional support, premature birth, and operative time > 120 minutes.

This brought up the question of extubation criteria in the pediatric population. There is not a clear consensus on signs that tell us if the pediatric patient is ready for extubation. One option is the laryngeal stimulation test, or LST, which looks at return to spontaneous ventilation within five seconds of tracheal stimulation as a predictor of successful extubation. Rather than LST, Dr Templeton found these five factors to be the largest predictors of success (in order of early to late signs and prevalence):

  1. Tidal volumes >5 cc/kg
  2. Conjugate gaze
  3. Facial grimace
  4. Purposeful movement
  5. Eye opening

If 1-2 of these factors are present, positive predicted value (PPV) of successful extubation would be about 88%. However, if 4-5 of these factors are present, extubation will be successful > 97% of the time.

In conclusion, Dr. Templeton proposed a logical approach to extubation in the pediatric population. Without overlooking the importance of intuition and experience when it comes to patient care, he also recognized the critical role of science. He proposed that we look for at least 3 out of the 5 predictors of successful extubation, with eye opening being the latest sign, with a PPV of 98%. Be cautious when extubating if the end tidal CO2 is > 55 mmHg and strongly consider not extubating NICU patients that are < 41 weeks post conceptual age or if they had a birth weight < 1.58 kg.


Postoperative Apnea in Neonates: An Update

Faith J. Ross, MD (Seattle Children’s Hospital, University of Washington) started her presentation by defining a preterm infant as < 37 weeks gestational age and pointed out that descriptions of apnea vary based on the studies (clinical observation vs. monitoring and central vs. obstructive). Because of studies in the early 1980s, we know that preterm infants are prone to more complications after anesthesia than term infants. These studies demonstrated that apnea was more common in preterm infants than term infants, especially with a history of preexisting apnea. They showed that the incidence and duration of apnea is inversely proportional to post conceptual age and that this risk seems to start decreasing somewhere between 41 and 46 weeks gestational age.  Risk of apnea is ~ 60% if the post conceptual age is < 42 weeks and 10% if > 52 weeks. They also found that preoperative monitoring was not predictive of postoperative apnea and that most apnea occurred in the first two hours postoperatively.  The duration of apnea was directly proportional to prematurity, and more premature infants had apnea up to 48 hours after their procedure. IV caffeine was found to decrease and potentially prevent postoperative apnea.

In the 1990’s, studies emphasized that apnea was more prevalent after general anesthesia/sedation and was minimal following neuraxial or regional anesthesia techniques (without sedation). Anemia was identified as an independent risk factor and late apnea events shown to be more common than early ones.

In the 2000s, as more studies emerged, we learned that anemia potentially might not play a role in apnea. Regional anesthesia, without sedation, decreased the severity and frequency of early apnea but not necessarily late apnea.

So where does all this information leave us? At what age is it safe to discharge infants home after anesthesia?  Dr. Ross emphasized that discharge criteria for infants after anesthesia should be made on a case by case basis with consideration of the risk factors present. Children’s Surgical Verification recommends infants < 50 weeks post conceptual age be admitted for observation after procedures.  As pediatric anesthesiologists, we should be asking ourselves how much risk we are willing to accept and how we can mitigate these risks. Risk reduction should include the use of regional anesthesia without sedation whenever possible.


How to Develop an Educational Environment in Private Practice

Stephanie L. Davidson, DO and Judit M. Szolnoki, MD (US Anesthesia Partners, Nevada) presented their experience with opening an anesthesia residency program within their private practice model.

The initial phase of building a program should include discussions with the graduate medical education (GME) office and gaining the support of the Department of Surgery, surgeons and anesthesiologists within the group. They looked at other residency programs within their hospital system to gather information and ascertain examples of foundational content needed for a successful residency program.

Once these have been established, the foundation of the residency program should be developed. This includes looking at case volume and variety to support the number of residents, faculty needed to support the residency (program director, program coordinator, core and teaching faculty), hospital facilities, and experiential areas (simulation centers, lecture halls, etc).

Integration of the residency into current practice can be challenging. Practicing physicians must take on the role of supervising residents who provide anesthesia versus their current independent practice model, learn how to teach effectively, provide a sound learning environment, and create changes to daily workflow.

Once these basic parameters were in place and resident recruitment occured, Drs. Davidson and Szolnoki, looked at quality measures to help improve their residency. They initially focused on patient satisfaction as a way to confirm that the quality of patient care had remained the same. What they found was that their patient satisfaction was unaffected by their residency program. They also surveyed their residents, faculty, and surgeons on their impression of the program.

In conclusion, Drs. Davidson and Szolnoki demonstrated that although creating a residency program from scratch can bae cumbersome and challenging, it is also very rewarding and exciting. Their program is a work in progress, with learning and adjusting along the way, but they have found that their residents are performing well on exams and are satisfied with their program and education.

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