Reader response
Myron Yaster MD
From Dave Moore, MD Pediatric Cardiac Anesthesiologist, Vanderbilt Children’s Hospital
I have been following the discourse on gun violence and preparedness over the last few weeks and just have a few comments. I spent 29 years in the Navy, the first few enlisted, and the last few as an anesthesiologist. With multiple combat deployments, I feel comfortable saying that I have more experience than most at managing tourniquets as well as managing wounds from both 5.56 (NATO M-16/M-4) and 7.62 (AK-47) caliber rifles. Tourniquets have saved more lives and limbs than any other medical device in combat. If you have any inclination to provide first aid in an emergency, you should carry one and know how to use it. My kids have been able to operate a military tourniquet from the time they could tie their shoes. Gun violence aside, it’s an integral part of any modern first aid kit. It’s amazing to me that some commercial first aid kits still have the venom vacuum thing for snake bites (useless) but no tourniquets. If SPA puts on workshops on how to use these devices count me in as an instructor!
From Lynn Martin MD MBA Seattle Children’s Hospital
As always, I very much enjoyed the anecdotes and assessments shared by Drs. Yaster and Deshpande in their review of the excellent article authored by Olbrecht et al.1 I completely agree that survival is now an expected outcome and not a viable marker of quality in modern pediatric anesthesia practice. I commend Olbrecht et al for their willingness to use the IOM domains of quality (safety, effectiveness, efficacy, equity, timeliness, and patient-centeredness). Both the American College of Surgeons’ NSQIP-P and CVP as well as the SPA’s Wake Up Safe QI initiative were worthy first steps to define standard national quality measures. As an (now former) anesthesia leader at an institution participating in all of these efforts, we struggled with many of the issues highlighted in the article by Olbrecht. I spent many long days (and nights) thinking about the challenges associated with defining quality measures. Once we had our quality list, we submitted our requests for the data and waited months or years to get the data extracted from our electronic records by our institution’s ‘knowledge management’ teams. Needless-to-say, a very frustrating process.
I was complaining yet again to one of my colleagues about my inability to improve the quality of our care without access to the data to show our outcomes. Much to my surprise (and subsequent delight) he came back to me 1 month later with a proposal to solve this problem. His solution: build a clinician-facing (self-service) solution that pulls from our institutional data warehouse that also organizes the data into statistical process control (SPC) charts and uses artificial intelligence to identify special cause variation (so we could discern if changes made to our system actually result in improvement). I told him it sounds like a dream come true and sent him off with my endorsement not expecting anything to come of it. One year later he came back to me with his new venture capital backed company and a prototype which greatly exceeded my wildest expectations in his demo. Eight years later you can see some of the fruits our labors (both anesthesia and surgical) with this unique capability we have embraced in Seattle.2-9
At the risk of sounding too much like a commercial, but only a very satisfied user/customer, the answer to Myron and Jay’s last question (‘how can all of the data be collected in a cost-effective fashion that all institutions can provide?’) is that it already exists! For any area of the hospital (OR, IR, Cath Lab, ICU, ED, Urgent Care, etc.), clinicians can pull measures that quantify the processes of care as well as the outcomes of that care. In perioperative care that includes most of Olbrecht’s list. You can look at the results daily, weekly, monthly, or whatever interval you choose. We are no longer passive recipients of reports that are pushed to us without the ability to ‘ask the next question’. We can see group, service, and individual performance on these measures – we can quantify the variation in clinical practice and outcomes. We can identify and learn from top performers to improve care and coach others where needed. More importantly, the SPC charts tell us if the changes are simply random noise versus true statistical signal (indicating improvement or degradation). This ability to access data in minutes vs months has catapulted Seattle Children’s evolution to a true Learning Health System. The software solution gives you immediate access to the data from your expensive EMRs and stored in your institutional data warehouses, thereby maximizing the value of that data.
I close by issuing a challenge. Show me your outcomes from last week’s cases. Few centers will be able to meet this request. Before sending data to some central depository to sit and gather dust, first consider how you can better access and use your own center’s data today to improve your outcomes tomorrow rather than years from now. I invite readers to send questions to my email (lynn.martin@seattlechilren’s.org) and check out this 90 second overview www.adaptx.com/intro
References
1. Olbrecht VA, Uffman JC, Morse RB, Engelhardt T, Tobias JD. Setting a universal standard: Should we benchmark quality outcomes for pediatric anesthesia care? Paediatr Anaesth. 2022 Aug;32(8):892-898. PMID: 35476807
2. Franz AM, Dahl JP, Huang H, Verma ST, Martin LD, Martin LD, Low DKW: The Development of an Opioid Sparing Anesthesia Protocol for Pediatric Ambulatory Tonsillectomy and Adenotonsillectomy Surgery - A Quality Improvement Project. Pediatr Anesth 2019; 29: 682-9. PMID: 31077491
3. Chinonyerem, O., Shannon, C., Daniel, L., Thomas, L. (2020). MP66-18 The Pudendal Nerve Block for Ambulatory Urology: The Old is New Again J Urol 2020; 203(S4): e990. doi.org/10.1097/ju.0000000000000941.018
4. Franz A, Martin LD, Liston D, Latham G, Richards M, Low DKW: In pursuit of an Opioid-Free Pediatric Ambulatory Surgery Center – A Quality Improvement Initiative. Anesth Analg 2021; 132:788-97. PMID: 32282383
5. Loy KA, Lam AS, Franz AM, Martin LD, Manning SC, Ou HC, Perkins JA, Parikh SR, Low DK, Dahl JP: Impact of Eliminating Local Anesthesia on Immediate Postoperative Analgesia in Pediatric Ambulatory Adenotonsillectomy. Pediatr Qual Saf 2021; 6: e405; doi:1097/pq9.0000000000000405. PMID 33977193
6. Chiem JL, Donohue LD, Martin LD, Low DK: An Opioid Free Anesthesia Protocol for Pediatric Strabismus Surgery: A Quality Improvement Project. Pediatr Qual Saf: 2021; 6: e462 doi: 10.1097/pq9.0000000000000462. PMID 34476314
7. Chiem JL; Franz A, Bishop N; Liston D, Low DK. An Opioid Sparing Anesthesia Protocol for Pediatric Open Inguinal Hernia Repair: A Quality Improvement Project. Pediatr Qual Saf: 2022;7: e548 doi: 10.1097/pq9.0000000000000548
8. Feldman RM, Low DK, Gorbounova I, Ambartsumyan L, Martin LD: Leveraging Real-World Data to Increase Procedural Room Capacity: A Multidisciplinary Quality Improvement Project. Pediatr Qual Saf, 2022 (in press).
9. Fernandez N, Low D, Cain M, Martin L, Merguerian P: Recovering from COVID – Improving Operating Room Capacity. J Pediatr Urol 2022 (in press).