Influence on the incidence of prolonged times to tracheal extubation from the anesthesia practitioner having completed few prior cases with the surgeon

Abstract

BackgroundProlonged extubations are defined as an interval ≥15 min between the end of surgery and extubation after general anesthesia when both intubation and extubation occur in the operating room. Earlier studies showed that prolonged extubations are rated poorly by anesthesiologists, and are associated with reintubations, respiratory interventions, longer operating room times, delayed starts of to-follow cases and surgeons, and longer duration workdays. Furthermore, they often are preventable. We test the hypothesis that, at a large teaching hospital with several hundred surgeons, when the anesthesia practitioner who finished a case had finished fewer than five cases previously with the surgeon, there was significantly greater probability of prolonged tracheal extubation. MethodsThis retrospective cohort study included all anesthetics from October 2011 through December 2022 not involving prone positing and where tracheal intubation and extubation occurred in the operating room. The first three years were used for counting earlier cases that the anesthesia practitioner (e.g., nurse anesthetist or resident) had finished with the surgeon to establish their baseline experience. We used the final 53 eight-week periods’ extubations (N = 133,527 cases) in mixed effects logistic regressions with the surgeons treated as random effects. ResultsProlonged extubations occurred in 23% of cases and were associated with a mean of 14.7 min longer time from the end of surgery to operating room exit than cases without prolonged extubations (99% confidence interval 14.7 to 14.8 min, P < 0.0001). The anesthesia practitioner not having finished at least five cases previously with the surgeon over the past 36 months was associated with 16% greater odds of prolonged extubation (99% confidence interval 1.11 to 1.21, P < 0.0001). There was a larger effect on prolonged extubation when the case was finished by a trainee (odds ratio 1.70, 99% confidence interval 1.64–1.76, P < 0.0001). The odds of prolonged extubation was reliably greater for the criterion that the anesthesia practitioner had not finished at least five cases with the surgeon within the previous 36 months versus alternative intervals of within 24 or within 12 months. Pediatric surgeons’ cases had significantly greater odds of prolonged extubations (2.02, 99% confidence interval 1.67–2.44, P < 0.0001). There was negligible effect on the incidences of prolonged extubation from the surgeon having principally an adult ambulatory surgery practice. ConclusionsMultispecialty teaching hospitals can validly monitor their incidence of prolonged extubations as a measure of anesthesia department performance. Consider revising anesthesia assignments and anesthesiologist supervision when frequent.