Anesthesia Coverage Research Articles

A Nurse-Directed Model for Nitrous Oxide Use During Labor.

Nitrous oxide has a long history of use and has been well documented in the literature as a safe, effective, and inexpensive option for pain management in labor in other countries, but it is underused in the United States. Pain relief options for laboring women in rural community hospitals with a small perinatal service are limited due to lack of availability of in-house anesthesia coverage. This quality improvement project involved development and implementation of a nurse-driven, self-administered, demand-flow nitrous oxide program as an option for pain relief for laboring women in a rural community hospital. Women's Services registered nurses developed the project using an interdisciplinary team approach based on an extensive literature review and consultation with experts across the country. The hospital is part of a large healthcare system; approval was sought and obtained by the system as part of the project. Cost analysis and patient satisfaction data were evaluated. Outcomes were monitored. Approximately one half of the patients who have given birth at the hospital since initiation of the project have used nitrous oxide during labor. The majority of women who participated in a survey after birth found it helpful during mild-to-moderate labor pain. No adverse effects have noted in either the mother or the baby following nitrous oxide use. Initiation and management of nitrous oxide by registered nurses is a safe and cost-effective option for labor pain. It may be especially beneficial in hospitals that do not have 24/7 in-house anesthesia coverage.

Development of a tail vein transection bleeding model in fully anaesthetized haemophilia A mice - characterization of two novel FVIII molecules.

The tail tip bleeding model and the tail vein transection survival model in mice are important tools for assessment of in vivo effect in haemostasis research. While the tail vein transection model exhibits the best sensitivity to pharmacological intervention it uses death or near-death as endpoint which is fully avoided in the tail tip bleeding model. The aim of this study was to develop a new tail bleeding model maintaining the sensitivity of the previous survival model but avoiding death/near-death as endpoint. Combining the two existing tail bleeding models we developed an optimized version of the survival model with full anaesthetic coverage and short duration of experiments. Using this model, we characterized the effect of turoctocog alfa, a B-domain truncated FVIII molecule (NovoEight(®) ), as well as the prolonged half-life version of the same molecule (turoctocog alfa pegol, N8-GP). Data showed that the model was sensitive to clinically relevant doses of both turoctocog alfa as well as N8-GP when dosed for 'on demand' treatment. The model also correctly identified a longer duration of effect for N8-GP compared with turoctocog alfa. Moreover, the model allowed the use of mice of both genders and was reproducible over time. The optimized tail vein transection bleeding model is sensitive to standard as well as half-life prolonged FVIII molecules and should be a valuable alternative to both the tail tip bleeding model, enhancing sensitivity to pharmacological intervention, as well as to the previously used tail vein transection survival model, avoiding death or near-death as endpoint.

Vascularized Partial Free Toe Tissue Transfer Under Local Anesthesia

This study was designed to introduce free toe soft tissue transfer using local infiltration anesthesia in patients not suitable for general anesthesia and local tissue coverage. From January 2006 to August 2012, a total of 11 traumatic fingertip defects were reconstructed by toe soft tissue transfer. All procedures except 1 were done as primary reconstructions, with either the lateral side of the great toe (5 cases) or the medial side of the second toe (6 cases) used as a donor. Postoperative follow-up periods were between 8 months to 2 years and 6 months. Flap sizes varied from 1.0 × 2.0 to 2.0 × 3.5 cm. The mean operative times were 4 hours 29 minutes for cases done by a single team and 3 hours 21 minutes for cases done by a 2-team approach. Approximately 5.8 mL of local anesthetic agent was used in each finger and 5.9 mL was used in the toes for a total of 11.7 mL. All flaps survived and were fully taken without complications, except 1 case that presented partial necrosis. Fingertip soft tissue reconstruction by free toe tissue transfer under local anesthesia uses a more limited operative field, with a shorter operative time, enabling reconstruction in patients not suitable for general anesthesia. This is even more so with a microsurgical 2-team approach, which reduces the volume of anesthetic agent needed, making this method a sufficiently realistic option for fingertip soft tissue reconstruction.

Besoins, intégration, conditions de travail des anesthésistes-réanimateurs remplaçants dans les centres hospitaliers généraux en région Rhône-Alpes

ObjectivesTo evaluate the need for locum anaesthetic coverage and the practical consequences (integration, working conditions, quality and safety) arising during the first 5 days of work, when a temporary position is accepted. Measured parameters1) Telephone enquiry of administrative services of community hospitals (CH) in one French administrative area (Rhône-Alpes) about their need for locum anaesthetists; 2) if a position was offered, it was accepted when the participation to on-call duties was delayed after the first 5 days of work; 3) during the working period, the following characteristics were assessed: integration of the locum anesthesiologist among team members, comparison of practice patterns to national guidelines; 4) data from the Platines-website of the French Ministry of Health were used to quantify indicators of activity and size of the hospitals and search for correlations between these parameters and working conditions of the locum anaesthetist. ResultsOf the 32 CH questioned, 28 were looking for temporary anaesthetic work force but only 11 (35%) accepted a 5-day period before participation to on-call duties and 17 refused this integration period. Four CH declared not to be looking for temporary work force. Characteristics of integration of the locum anaesthetist and standards of work were very different among centers. No hospital administration had a strategy for evaluation of recruited locums. ConclusionTemporary work force in anaesthesia is widely required in CH of the Rhône-Alpes area but this practice had not been formalised. No recruitment strategy was observable. This questions about the institutions’ requirements for anaesthetic services in French public hospitals.

A survey of access to trial of labor in California hospitals in 2012.

BackgroundIn 2010, the NIH and ACOG recommended increasing women’s access to trial of labor after cesarean (TOLAC). This study explored access to TOLAC in California, change in access since 2007 and 2010, and characteristics of TOLAC and non-TOLAC hospitals.MethodsBetween November 2011 and June 2012, charge nurses at all civilian California birth hospitals were surveyed about hospitals’ TOLAC availability and requirements for providers. VBAC rates were obtained from the California Office of Statewide Health Planning and Development (OSHPD). Distance between hospitals was calculated using OSHPD geocoding.ResultsAll 243 birth hospitals that were contacted participated. In 2010, among the 56% TOLAC hospitals, the median VBAC rate among TOLAC hospitals was 10.8% (range 0-37.3%). The most cited reason for low VBAC rates was physician unwillingness to perform them, especially due to the requirement to be continually present during labor. TOLAC hospitals were more likely to be larger hospitals in urban communities with obstetrical residency training. However, there were six (11.3%) residency programs in non-TOLAC hospitals and 5 (13.5%) rural hospitals offering TOLAC. The majority of TOLAC hospitals had 24/7 anesthesia coverage and required the obstetrician to be continually present if a TOLAC patient was admitted; 17 (12.2%) allowed personnel to be 15-30 minutes away. TOLAC eligibility criteria included one prior cesarean (32.4%), spontaneous labor (52.5%), continuous fetal monitoring and intravenous access (99.3%), and epidural analgesia (19.4%). The mean distance from a non-TOLAC to a TOLAC hospital was 37 mi. with 25% of non-TOLAC hospitals more than 51 mi. from the closest TOLAC hospital.In 2012, 139 hospitals (57.2%) offered TOLAC, 16.6% fewer than in 2007. Since 2010, five hospitals started and four stopped offering TOLAC, a net gain of one hospital offering TOLAC with three more considering it. Only two hospitals cited change in ACOG guidelines as a reason for the change.ConclusionsDespite the 2010 NIH and ACOG recommendations encouraging greater access to TOLAC, 44% of California hospitals do not allow TOLAC. Of the 56% allowing TOLAC, 10.8% report fewer than 3% VBAC births. Thus, national recommendations encouraging greater access to TOLAC had a minor effect in California.

A Survey of Access to Trial of Labor in California Hospitals in 2012

In 2010, the NIH and ACOG recommended increasing women’s access to trial of labor after cesarean (TOLAC). This study explored access to TOLAC in California, change in access since 2007 and 2010, and characteristics of TOLAC and non-TOLAC hospitals. Between November 2011 and June 2012, charge nurses at all civilian California birth hospitals were surveyed about hospitals’ TOLAC availability and requirements for providers. VBAC rates were obtained from the California Office of Statewide Health Planning and Development (OSHPD). Distance between hospitals was calculated using OSHPD geocoding. All 243 birth hospitals that were contacted participated. In 2010, among the 56% TOLAC hospitals, the median VBAC rate among TOLAC hospitals was 10.8% (range 0-37.3%). The most cited reason for low VBAC rates was physician unwillingness to perform them, especially due to the requirement to be continually present during labor. TOLAC hospitals were more likely to be larger hospitals in urban communities with obstetrical residency training. However, there were six (11.3%) residency programs in non-TOLAC hospitals and 5 (13.5%) rural hospitals offering TOLAC. The majority of TOLAC hospitals had 24/7 anesthesia coverage and required the obstetrician to be continually present if a TOLAC patient was admitted; 17 (12.2%) allowed personnel to be 15-30 minutes away. TOLAC eligibility criteria included one prior cesarean (32.4%), spontaneous labor (52.5%), continuous fetal monitoring and intravenous access (99.3%), and epidural analgesia (19.4%). The mean distance from a non-TOLAC to a TOLAC hospital was 37 mi. with 25% of non-TOLAC hospitals more than 51 mi. from the closest TOLAC hospital. In 2012, 139 hospitals (57.2%) offered TOLAC, 16.6% fewer than in 2007. Since 2010, five hospitals started and four stopped offering TOLAC, a net gain of one hospital offering TOLAC with three more considering it. Only two hospitals cited change in ACOG guidelines as a reason for the change. Despite the 2010 NIH and ACOG recommendations encouraging greater access to TOLAC, 44% of California hospitals do not allow TOLAC. Of the 56% allowing TOLAC, 10.8% report fewer than 3% VBAC births. Thus, national recommendations encouraging greater access to TOLAC had a minor effect in California.

Con: A General Anesthesiologist With a Certain Skill Set Is Qualified to Provide Services in the Interventional Cardiology and Electrophysiology Laboratory

IN THE PAST DECADE, expansion of the anesthesia services provided in remote locations has been exponential. Interventional cardiology and electrophysiology (EP) laboratories have been in the forefront of the offsite locations where these services are provided. 1 Shook D.C. Gross W. Offsite anesthesiology in the cardiac catheterization lab. Curr Opin Anaesthesiol. 2007; 20: 352-358 Crossref PubMed Scopus (26) Google Scholar This expansion happened at the same time as a decrease in the volume of cases done in the operating rooms in some institutions was seen. Although increasingly there are examples of facilities in which cardiac surgery and cardiology occupy contiguous space with an integrated intensive care unit, the cardiology unit is typically remote from the operating room. Different models of anesthetic practice have been adopted by different hospitals. These models range from direct attending providers to staff anesthesiologists supervising certified registered nurse anesthetists (CRNA) or residents. The variability in practice models is dependent on the volume and complexity of procedures performed in each institution and the availability of the anesthesia providers. Anesthesia coverage has typically been based on the notion of paying for availability; a single anesthesiologist or CRNA is paid to sit around and wait for a request to provide anesthesia for a cardioversion or defibrillator testing. In the cardiac catheterization laboratory, minimal sedation with fentanyl and midazolam is typically all that is provided. For those who work in institutions in which this is the reality, the notion that subspecialty anesthesia coverage is required may seem as odd as to suggest that neuroanesthesiologists are required for cataract surgery because of the proximity of the eye to the brain. The EP unit at the authors' institution is one of the busiest in the United States, with 5 suites in use daily. It is not uncommon to see 4 pulmonary vein isolations (PVI) or ventricular tachycardia (VT) ablations, 3 automatic implantable cardioverter-defibrillator (AICD) implants, and 5 outpatient cardioversions on a typical day. The Department of Anesthesiology has played a key role in the growth in volume of the facility through several new anesthetic paradigms.

Ropivacaina 0.5% vs Levobupivacaina 0.5 Endoscopic Urological Surgery

Subarachnoid anaesthesia has been demonstrated to be safe and effective in elderly patients. Isobaric Ropivacaine 0.5% has been recently introduced for subarachnoid anaesthesia: aim of our trial is to compare this drug with 0.5 Levobupivacaine in elderly patients scheduled for endoscopic urological surgery. Premedication: Atropine 0.5 mg + Fenotiazine 50 mg im. Lumbar intrathecal anaesthesia, Group L (n=25) receiving Levobupivacaine 15 mg, Group R (n=25) receiving Ropivacaine 18.05 mg (relative motor blocking potency ratio Ropivacaine / Levobupivacaine = 0.83). Statistical analisys: Bonferroni test and variance analisys. No statistically relevant differences between the 2 groups in terms of antropometric characteristics, onset time and duration of sensitive and motor block, perioperative complications, postoperative analgesic consumption and customer satisfaction. Large presence of comorbidities in the studied population. The presence of cases of subtotal anaesthetic coverage (with necessity to recur to general anaesthesia), and others with good anaesthetic coverage, but difficultly treatable hypotensions show that the best dosage of these local anaesthetics is to be found yet. The indications to use a standard dosage for every patient have to be re-evalutated. As positive point, very important the postoperative fast recovery from under limb motor block. A longer recovery time (typical with hyperbaric local anaesthetics) was frequently cause of cognitive alterations in a population of elderly patients.

Response to Commentary: What Conclusions Can We Draw from Recent Analyses of Anesthesia Provider Model and Patient Outcomes?

In our study “Anesthesia provider model, hospital resources, and maternal outcomes” (Needleman and Minnick 2009), we examined the relationship between models for delivery of anesthesia services in obstetrics and maternal outcomes, notably maternal death, anesthesia-related complications, and other complications. The relationship of anesthesia provider type and adverse outcomes has been the focus of several studies. Debates about reimbursement rules and, at the state level, debates about certified registered nurse-anesthetist (CRNA) scope of practice and supervision have been ongoing. We return to the discussion of our findings within this policy context at the end of this paper. Our study used data from 365 hospitals in six states that responded to a survey on the organization and staffing of obstetrical and obstetrical anesthesia services and 1.14 million obstetrical discharges from those hospitals over a 3-year period. Using logistic regression and a variety of propensity models to control for selection, we found no evidence that maternal mortality or anesthesia and other complication rates were higher in hospitals that relied on CRNAs only or both anesthesiologists and CRNAs for obstetrical anesthesia, compared with hospitals using only anesthesiologists for these services. All comparisons of mortality or anesthesia-related complications and provider models found either small, nonsignificant differences or small statistically significant lower rates of complications in hospitals using CRNAs. We then suggested that our findings may have potential importance for policy in that, at least in the area of obstetrical services, there may be no gain in anesthesia safety from restricting which licensed providers can provide these services. Use of CRNAs makes it possible to provide obstetrical anesthesia coverage where anesthesiologists are not available. We suggested other paths for improving safety beyond restrictions based on training. In their commentary on our study, Neuman, Schwartz, and Fleisher (2010), while recognizing that we controlled for a range of potential confounders, argued that our study may have been limited by unobserved differences in patient risk. They offered examples of potential sources of bias not measured and, based on their speculation of how these could impact the results, urged caution in using our findings to guide specific health policy decisions. Expanding beyond our study's results and implications, Neuman and his colleagues raise issues as to how policy makers, physicians, and patients should use findings from any observational study in their decision making. In this response, we first address the general approach to dealing with the limitations to observational studies. Then we discuss the comments as they apply to our work and offer some new analyses to address some of Neuman and colleagues' sources of bias. We conclude with our perspective on the broader issues about when and whether to draw inferences for action from observational studies.

Vaginal Twin Delivery: A Survey and Review of Location, Anesthesia Coverage and Interventions

Obstetric Anesthesia Digest: June 2009 - Volume 29 - Issue 2 - p 66 doi: 10.1097/01.aoa.0000350600.66958.14

Vaginal twin delivery: a survey and review of location, anesthesia coverage and interventions

Vaginal twin delivery: a survey and review of location, anesthesia coverage and interventions

Labor and Cesarean Delivery Patterns

Lucile Packard Children’s Hospital, Stanford University School of Medicine, Stanford, California. bcarvalho@stanford.eduThe unpredictability and variations in obstetric patient load make staffing anesthesiologists on the labor floor very difficult. If we were more aware of the actual workload patterns, then we could improve obstetric anesthetic service. Some studies1–3suggest that patients’ circadian rhythms influence delivery times; others4–7suggest that institutional factors exert a greater influence.To help us determine delivery patterns, we recently reviewed data we collected during a 3-month period from our labor and delivery unit at Lucile Packard Children’s Hospital, Stanford, California. Our institution, a tertiary referral center with dedicated day and night obstetric anesthesia coverage, performs more than 5,000 deliveries per year. Of these deliveries, 25–30% are cesarean, and the labor epidural rate is > 80%. Up to four cesarean deliveries are scheduled daily (Monday to Friday), but only one is scheduled per day on the weekends. We admit patients to the labor and delivery suite at 7 am for induction of labor.Figure 1compares the scheduled number of cesarean deliveries with the actual number of cesarean deliveries (scheduled plus nonscheduled) that occur during a week. Although the majority of scheduled cesarean deliveries were performed on Tuesday, Wednesday, and Thursday, the actual cesarean deliveries peaked on Thursday and Friday. Figure 2shows a similar peak (Thursday and Friday) in the weekly pattern of total (vaginal and cesarean) number of deliveries. The mean ± SD number of total deliveries per day during the week was 14.2 ± 4.5 compared with the 12.7 ± 4.2 during the weekend (P = 0.13). The mean ± SD of actual cesarean deliveries per day during the week was 3.6 ± 1.9 compared with 3.0 ± 1.6 during the weekend (P = 0.15).A number of studies have found that institutional factors are more influential than natural factors on the delivery workload.4–7Despite the fact that scheduled cesarean deliveries at our institution account for 53% of our total cesarean deliveries, the scheduled ones did not appear to impact the overall cesarean workload pattern. Our results show that despite a bias toward more scheduled cesarean deliveries earlier in the week, the peak workload occurs in the latter part of the week. We are not sure why this workload bias exists. Clinicians may increase cesarean deliveries on Thursday and Friday in anticipation of the weekend. Induction policies may influence overall cesarean delivery times more than do scheduled deliveries. We did not find that cesarean and total deliveries were significantly reduced over the weekend. Reduced weekend and night coverage may give clinicians the impression of an increased workload.We recommend that institutions review their obstetric workload to help plan their anesthetic coverage and staffing requirements. Obstetricians’ practices and organizations vary greatly among institutions. Our findings suggest that increasing the number of scheduled cesarean deliveries earlier in the week may compensate for the increased deliveries in the latter part of the work week, evening out the workload throughout the week. Our obstetricians and nursing management are aware of these workload biases and plan to use this data to organize future staffing and scheduling changes. However, constraints related to physicians, nurses, patients, and families may make altering weekly patterns in cesarean delivery workload very difficult. In addition, the benefits derived from institutional and/or patient factors that have cause these observed biases may outweigh the increased costs related to this nonuniform, less-efficient workload pattern.Lucile Packard Children’s Hospital, Stanford University School of Medicine, Stanford, California. bcarvalho@stanford.edu

Time of delivery and neonatal morbidity and mortality

The objective of the study was to examine the association between time of delivery and neonatal outcomes in term deliveries. We conducted a retrospective cohort study of all term pregnancies delivered at an academic institution with 24-hour in-house obstetric and anesthesia coverage. Time of delivery was categorized as day (7 am to 6 pm), evening (6 pm to 12 midnight), and late night (12 midnight to 7 am). Outcomes included 5-minute Apgar less than 7, umbilical artery pH less than 7.0, base excess less than -12, admission to the neonatal intensive care unit (NICU), and neonatal death. We excluded patients delivered via cesarean delivery not in labor. We had greater than 80% power to detect a 25% difference in Apgar score, base excess, and admission to the NICU and 80% power to detect a 50% difference in umbilical artery pH less than 7.0. Among the 34,424 deliveries meeting inclusion criteria, 15,664 were during the day, 8495 were during the evening, and 10,265 were during the night. In univariate comparisons, there were no statistically significant differences in neonatal outcomes. For example, the rate of pH less than 7.0 was 0.7% during the day, 1.0% in the evening, and 0.6% at night (P = .12). Admissions to the NICU were 3.6% during the day, 3.7% in the evening, and 3.5% at night (P = .81). When we controlled for obstetric history, demographic factors, and labor characteristics, there were still no differences in rates of either neonatal morbidity or mortality by time of delivery. At our institution, we could not demonstrate any significant differences in neonatal morbidity or mortality by time of day among neonates delivered at term. These data can be used to counsel patients and families concerned about differences in time of delivery and potential impact on their infant's health. Future research should include time of delivery in relation to maternal and neonatal outcomes in various types of inpatient settings.

Vaginal twin delivery: a survey and review of location, anesthesia coverage and interventions

Background Twin pregnancies are associated with increased perinatal morbidity and mortality. No consensus exists whether vaginal twin delivery should take place in the labor room or operating room, or whether anesthesiologists should be present. We surveyed members of the California Society of Anesthesiologists (CSA) to review management of vaginal twin delivery, and examined anesthetic intervention retrospectively at our institution. Methods 230 CSA members were asked to complete an online survey on location of vaginal twin delivery in their institution and whether they were required to be present throughout. We then retrospectively reviewed charts of vaginal twin deliveries at our institution over a 36-month period to analyze frequency and type of anesthetic intervention. Results The online survey response rate was 58%; 64% of responders reported that vaginal twin deliveries were performed in the operating room and 55% that an anesthesiologist was present. There was a strong association between anesthesiologist’s presence and delivery in the operating room (OR 7; 95% CI 3-20). We reviewed 81 charts of women who underwent vaginal twin delivery. The median (range) time that the anesthesiologist was present for each delivery was 60 (20-380) min. Of women undergoing vaginal twin delivery, 27% required anesthetic intervention during the second stage of labor with 6% having emergency cesarean delivery. Conclusion There is a lack of consensus regarding the appropriate location for vaginal twin delivery and the role of anesthesiologists. A significant percentage of women undergoing vaginal twin delivery in our institution received anesthetic intervention in the immediate delivery period.

A survey of labor patient-controlled epidural anesthesia practice in California hospitals

Background Patient-controlled epidural analgesia (PCEA) offers many advantages over continuous epidural infusions for labor analgesia including fewer physician interventions, improved analgesia and satisfaction, and reduced local anesthetic doses. However, anesthesiologists have been slow to adopt this technique, first described in 1988. No previous studies have evaluated specific labor patient-controlled epidural analgesia practices in the United States. The aim of this study was to determine labor epidural and patient-controlled epidural analgesia practices among California hospitals. Methods Following institutional review board exemption approval, an online survey was created using freeonlinesurveys.com®. An anonymous survey was sent via e-mail to 230 California Society of Anesthesiologists’ members chosen at random to represent their hospitals’ labor analgesia practices. Results We received 133 replies from the 230 survey requests sent, a 58% response rate. The median labor epidural rate among the hospitals involved was 65% (range 0-95%). Overall, only 25% of California hospitals use patient-controlled epidural analgesia for analgesia in labor, with greater use among hospitals with dedicated obstetric anesthesia coverage and larger numbers of deliveries. Reasons given for not using patient-controlled epidural analgesia include cost, clinician preference, safety concerns and the inconvenience of change. Conclusions Despite the potential advantages of patient-controlled epidural analgesia over continuous epidural infusions for labor analgesia, patient-controlled epidural analgesia has not been widely adopted in California hospitals. Education regarding this technique is needed to encourage its increased use.

Anestesia obstétrica en Cataluña

The aim of this arm of the ANESCAT 2003 study was to describe obstetric anesthesia and analgesia practice in Catalonia, Spain. Using information obtained from a survey of anesthesia performed in Catalonia in 2003, data was identified on anesthesia for obstetric procedures: labor, cesarean section, and others unrelated to childbirth. Patient characteristics were analyzed along with anesthetic techniques and the rates at which they are used in the population. Obstetric procedures were performed in 71 hospitals (54% of the hospitals surveyed). Obstetric anesthesia represented 11.3% of total anesthesia practice, corresponding to an estimated 67,864 anesthetic procedures per year. Of those procedures, 87.7% were associated with labor and childbirth. An estimated 82% of the 71,851 births in Catalonia were assisted by an anesthesiologist. Cesarean sections accounted for 25.1% of births and the rate increased with age. Regional anesthesia for labor and cesarean section was used in 98.7% and 96.2% of cases, respectively. Epidural anesthesia was used in 96.9% of vaginal births. In elective and emergency cesarean sections, spinal block was used in 75.5% and 44.8% of cases, respectively, while epidural anesthesia was used in 23.3% and 53.3%, respectively. The anesthesia coverage for labor in Catalonia is the highest published. The use of regional anesthetic techniques in Catalonia is also the highest recorded. Although continuous epidural anesthesia is the most widely used technique, spinal block is also increasingly employed.

Medical directorship of anesthesia services: are you a player… or are you just being played?

Hospital CEOs often propose that a particular anesthesiologist, often the chairperson of the anesthesia department, serve as the “medical director” of anesthesia services with the duty of coordinating, and assuring, anesthesia coverage in the absence of an exclusive contract. This article discusses the differences between a simple medical directorship and an exclusive contract and exposes the risks that must be considered by a prospective medical director before accepting the position.

Enhancing our practice and providing a pediatric friendly environment in an ambulatory surgery unit

Background: Over the past year we have strived to improve care of pediatric patients undergoing surgical and interventional procedures. Our practice setting was m need of systems and environmental improvements. Objectives: Presently we are expanding our ambulatory pediatnc PACU to recover Same Day Admission (SDA) patients, in-house patients, and pediatnc patients having procedures in other departments. The goal of this process is to create a pediatnc friendly environment and respond to the current capacity management issues in the main PACUs. Implementation: The process included training and educational preparation in the care of acutely ill pediatric patients; adjustment of staffing patterns to provide later evening coverage; expand anesthesia coverage. In-services were provided to meet educational needs and staff were encouraged to attend PALS classes. A task force was formed to discuss systems issues and create a triage system for accepting the non-same day surgery PACU patients. Successful practice: The post anesthesia care of pediatnc patients is now smoother and more efficient. The staff has found their practice more challenging and rewarding Implications for penanesthesia nursing. The competing demands of bed capacity and patient care needs were the catalyst to improve our patient care and enhancement of our pediatnc ambulatory practice setting.

VBAC: Safety for the Patient and the Nurse

During the 1970s and 1980s, some women fought for the opportunity to deliver vaginally after a cesarean birth (VBAC). The American College of Obstetricians and Gynecologists initially supported VBAC for many low-risk women. Interventions increased and complications of VBAC were reported, however, and recommendations changed. VBAC should be performed in hospitals equipped to care for women at high risk. Nurses caring for patients undergoing VBAC should be able to recognize and respond to the signs and symptoms of uterine rupture, including the most common symptom, which is a nonreassuring fetal monitor tracing. Nurses also should be aware of the necessity for 24-hour blood banking, electronic fetal monitoring, on-site anesthesia coverage, and continuous presence of a surgeon.

Ethics: an essential dimension of clinical obstetric anesthesia.

Ethics: an essential dimension of clinical obstetric anesthesia.