3 Questions on…
ASA Monitor Today
The go-to spot for busy clinicians to get the necessary answers on issues important to anesthesiologists.
2023 – November 28 | November 7 | September | August | July | June | May | April | March | February | January
3 Questions on… promoting a diverse anesthesiologist Workforce
ASA Monitor staff
November 28
The growing diversity within the U.S. population, as evidenced by 2021 census data, highlights a pressing need for a more representative health care workforce. In comparison to the U.S. Census, the 2021 Association of American Medical Colleges (AAMC) physician workforce data paints a less diverse picture for the medical profession: only 37.1% of physicians are female and 36.1% identify within minoritized groups. This inequity extends to medical subspecialties, notably in anesthesiology, where just 26.1% are female and 31.3% are from minoritized groups. The article “Equity: The Importance of Promoting a Diverse Anesthesiologist Workforce” highlights promising initiatives on the horizon.
1. What is an example of a successful initiative aimed at recruitment and purposeful inclusivity?
One efficacious strategy is the creation of pathway programs designed to elevate the number of well-qualified under-represented in medicine (URiM) candidates who are motivated to join health care professions. Research indicates that over 70% of URiM students who participated in these pathway programs either matriculated into MD/PhD/master’s health programs or were on course to do so, with nearly three-quarters of these pipeline participants hailing from minoritized backgrounds.
2. What outcomes improve when the health care workforce mirrors the diversity of the population it serves?
Studies indicate patients generally fare better when cared for by more diverse teams; patients received more accurate diagnoses, reported higher satisfaction, and exhibited greater compliance. Increasing the proportion of underrepresented minoritized groups in the health care workforce also increases the frequency of doctor-patient race- or gender-concordant care, which itself has been shown to be of benefit. Beyond enhancing health care outcomes, the diversification of the workforce offers economic advantages, as reducing health disparities among marginalized communities could save billions in indirect and direct medical costs annually.
3. What is the role of mentorship in developing and sustaining a diverse workforce?
Mentorship provides a sustained relationship in which mentees gain professional guidance, skill development, and expanded networking opportunities. Research has demonstrated the value mentees place on having mentors with demographic similarities, as this often implies a shared history and greater personal understanding. Additionally, the scarcity of diverse faculty presents an obstacle for residents in finding concordant mentors, thus highlighting the need for effective nonconcordant mentorship.
For more insight on these complex issues, read the full article.
3 Questions on… Impact of climate change in health care
ASA Monitor staff
November 7
November’s “In the Know” column focuses on one of 2023’s hottest topics: climate change. In this article, Editor-in-Chief Steve Shafer and his co-author Dibas K. Dash tackle an under-discussed aspect of this problem, namely, its impact on health systems and patients.
1. Excess temperatures result in more emergency department visits for heat-related conditions, but will it affect anesthesiology?
Anesthesiologists may encounter patients experiencing heat-induced complications before, during, or after surgical procedures, necessitating careful monitoring and management.
Further, anesthesiologists may encounter patients with heatstroke during surgical emergencies or because of heat-related complications following procedures. Anesthesiologists will likely be involved in the management of acute heatstroke, implementing aggressive cooling measures and maintaining cardiovascular stability until the core temperature decreases and homeostasis is restored.
2. How will climate change potentially influence the transmission patterns of infectious diseases?
As temperatures rise, disease vectors – such as mosquitoes and ticks – can expand their range, leading to an increased risk of vector-borne illnesses.
Diseases like dengue fever, chikungunya, and Zika virus pose a significant public health threat in the U.S. According to the CDC, mosquito-borne diseases doubled in the U.S. from 2004-2016, with cases reported in nearly every state. By 2050, global warming will result in nearly 50% of the world inhabiting areas where mosquito-borne diseases thrive.
Warmer temperatures and altered precipitation patterns will impact the distribution and prevalence of ticks, increasing the risk of tick-borne illnesses in specific geographic areas. Anesthesiologists must be aware of the potential for tick-borne diseases in their practice settings and consider appropriate prophylactic measures when necessary.
3. How might hospitals have to change their infrastructure?
Hospitals must plan and invest in reliable backup power sources to maintain uninterrupted health care services during extreme heat events.
Hospitals must prioritize sustainable cooling solutions, such as energy-efficient air conditioning systems, to maintain thermal comfort in patient care areas and ORs.
Hospitals situated in urban heat islands, where heat is trapped due to extensive urbanization and heat-absorbing materials, may face additional challenges. Anesthesiologists should advocate for hospital locations away from heat-intensive areas and building designs that incorporate heat-resistant materials.
September 2023
3 Questions on… country roads? Stay at home
ASA Monitor staff
September 5
By fostering both higher volume and higher-acuity care in rural affiliates, larger systems can reduce congestion evolving in urban ORs. There simply isn’t enough space for all of the work that needs to be done to have it all be done in urban facilities, when routine surgery could be done safely in rural affiliate hospitals.
1. While it’s financially beneficial for rural hospitals to increase the acuity of care delivered, what would the impact be on patient safety?
It is likely safer for older patients to receive the care they need closer to their homes.
2. Do rural facilities even have the bandwidth to accept new patients?
Rural facilities frequently have more available OR time than can be used by the available providers.
3. There’s a documented need for surgeons in rural areas. Which specialties have more openings for rural surgeons?
Pediatric general surgery is especially difficult to maintain in rural settings. Otolaryngology is another important service in rural settings. Children in need of myringotomy, adenoidal, and tonsillar surgeries face barriers to access.
Read more on this concept of rural OR utilization in the full article.
August 2023
3 Questions on… Two sides to the Ozempic story, if not more
ASA Monitor staff
August 24
In their latest column, ASA Monitor Editor-in-Chief Steve Shafer and Dibash K. Das, PhD, take on one of health care’s hottest topics: weight loss medications.
The full column was published Online First and here are the biggest takeaways.
1. Does Ozempic really work?
Semaglutide (Ozempic, Wegovy, and Rybelsus) is blowing up social media because it works. Patients on semaglutide typically lose 15% of their weight after a year of weekly injections. The weight loss is accompanied by reduced blood glucose and reduced HbA1c (uniformly demonstrated in all trials), improved cardiac function, improved renal function, improved liver function, reduced indicators of metabolic syndrome, and reduced all-cause mortality.
Secondary analyses of the published clinical trial data even suggest therapeutic efficacy in Parkinson’s disease and Alzheimer’s disease.
2. What are the side effects? The American public has heard recent news stories about patients on these new weight loss medications experiencing severe gastroparesis.
GLP-1 receptor agonists share common side effects. The most common are gastrointestinal symptoms, including nausea, diarrhea, vomiting, constipation, abdominal pain, dyspepsia, distention, burping, GERD, and flatulence. These are experienced by nearly half of the subjects in some trials. In several of the semaglutide trials, approximately 5% of the study subjects in the active arm discontinued therapy because the GI effects could not be tolerated. Fortunately (for everyone involved), these adverse events attenuated or completely disappeared within a month or two.
It should be mentioned that recent news stories have uncovered cases of severe gastroparesis that may have resulted from or been exacerbated by Ozempic, but no scientific conclusions have been reached as of this publication date.
3. Should patients take these medications with GLP-1 receptor agonists before surgery?
Good question! On June 29, the ASA Task Force on Preoperative Fasting released consensus-based guidance on the preoperative management of patients taking GLP-1 receptor agonists, which included recommendations to hold dosing up to a week before surgery.
3 Questions on… Palliative care principles and surgical oncology patients
ASA Monitor staff
August 10
Recent Medicare data indicates one in three patients requires a surgical procedure a year before death, which justifies applying a palliative care lens to high-risk surgical patients, as outlined in this month’s Anesthesia Incident Reporting System. This excerpt further negates the historical concept that palliative care is contradictory to the goals of surgical treatment aimed at cures.
1. How can palliative care be incorporated into Perioperative Surgical Home principles?
The recent concept of the Perioperative Surgical Home has similar principles in creating a multidisciplinary team, coordinating care, reducing complications, length of stay, and utilization of resources. These principles would include a multidisciplinary approach that incorporates risk mitigation, preoperative assessment, intraoperative considerations, and postoperative care planning.
2. How is it determined which patients are considered high risk?
Risk calculators such as ACS-NSQIP, Revised Cardiac Risk Index (RCRI), American Geriatrics Society (AGS) frailty index, or postoperative respiratory distress calculator are used to identify patients who are high risk (Anesth Analg 2018;127:284-8). Patients demonstrating a high probability of postoperative complications or mortality, increased length of stay, or likelihood of discharge to a skilled nursing facility would then be referred.
3. How can palliative care principles be included in the preoperative assessment and discussion?
A palliative care approach is not successful unless the patient's goals can be assessed, and prognostic outcomes can be communicated effectively to the patient and their family. Utilizing a communication tool may guide anesthesiologists in incorporating palliative care principles in their preoperative assessment and discussion. One potential approach is utilizing the following mnemonic, DIGNI-T (shown here).
July 2023
3 Questions on… Making nonclinical time worth one's while
ASA Monitor staff
July 6
A key barrier to anesthesiologists becoming involved in nonclinical administrative work is the discrepancy in financial reimbursement for the work performed. Clinical work is highly reimbursed, while administrative work at the entry level is often not. If compensation is being received, it is typically from a facility or department and is considered a cost center. As such, with the lower initial reimbursement for administrative work, many physicians take on nonclinical duties simply because they believe in the mission. Although these dedicated physicians should be lauded, this sets up a challenging precedent and perpetuates an unsustainable cycle of working more hours for less reimbursement. As such, it is important to support physicians engaged in administrative activities.
1. How does compensation for nonclinical duties differ in academic medical centers vs. private practice?
In an academic medical center, nonclinical time is often funded through an academic mission, allowing the clinician to position their work toward that defined goal. Often, this work is compensated by providing a carve out of clinical duties for that physician, effectively allowing them to maintain their base salary if they are not overscheduled beyond their clinical commitment. Unfortunately, given the current national shortage of clinical resources, this is often not the case. Anesthesiologists are frequently losing nonclinical days to cover staffing shortfalls, causing disruption in research and administrative work. It’s essential for the department to advocate for a fair compensation structure to address these scenarios to mitigate frustration and burnout.
In the private practice model, nonclinical compensation can be derived through two main sources: the practice itself or the health care facility in which the work is being done. In the case of the latter arrangement, funds can flow either directly to a practice for an individual’s work or can be sent directly to an individual physician. In both scenarios, there is underlying pressure to undervalue nonclinical time. For a practice, those performing clinical work may balk at paying someone to perform administrative duties. Also, with budgetary constraints, few administrators believe that an anesthesiologist, with little to no administrative experience, should be compensated at their baseline clinical rate. However, physicians involved in these administrative tasks are frequently working more for less compensation than their regular duties, placing additional stress on an already strained workforce.
2. What steps can physicians take to advocate for proper reimbursement?
Prepare to show what you have to offer as a strategic plan and provide evidence for your value. It may be challenging for a hospital system or a group to allot funding to an anesthesiologist they perceive as having minimal administrative background for nonclinical tasks. However, doing your research to show what you want to achieve and how to achieve it lends legitimacy to your experience. Focus the discussions not on what you have achieved, but rather what you intend to achieve. This also helps you think more strategically about the organization as a whole and helps ensure you are aligned with the organization's growth model.
3. What do physicians need to understand about management’s perspective when presented with such propositions?
Understand the financial constraints of an organization and try to work within those limitations. If your proposal reduces costs, consider contingency pricing to defer the initial cost of your project. This decreases risk to the institution and aligns both parties' incentives.
Consider timing and propose solutions when they can be implemented. You will want to make suggestions prior to the budget being set. It's much easier to approve funding prior to funds being allocated. Also, consider if your proposal matches the strategic mission, vision, and objectives of the organization. For more information, read the full article.
June 2023
3 Questions on… Owning the process: anesthesiologists and anesthesia technicians addressing supply chain disruption
ASA Monitor staff
June 20
Conversations about supply chain shortages got real in winter 2023 when one of only two domestic producers of liquid albuterol suddenly ceased its operations. The only remaining supplier reported that its albuterol formulation was on back order. In January 2023, it was reported that numerous shortages are also affecting local anesthetics, with Pfizer, Fresenius Kabi, Eugia, and Hikma Pharmaceuticals reporting bupivacaine shortages, and Amphastar Pharmaceuticals, Pfizer, and Fresenius Kabi reporting lidocaine backorders. Authors of this ASA Monitor article discuss the complexity behind the question, “Whose job is it to ensure that an anesthesiology department has the local anesthetic they need for regional anesthesia or neuraxial blockade, or a critical respiratory medication?
1. At some organizations, the onus of responsibility to order and stock emergency medications, paralytics, induction agents, and inhaled anesthetics may fall upon other personnel like anesthesia technicians. What is their official role as it relates to the supply chain?
Anesthesia technicians are integral members of the anesthesia team and often are responsible for essential components of the perioperative supply chain. According to their collective professional society, the American Society of Anesthesia Technologists and Technicians (ASATT), their main goal is to “assist licensed anesthesia providers in the acquisition, preparation and application of the equipment and supplies required for the administration of anesthesia.” In addition to assisting in the maintenance and preparation of OR equipment, anesthesia technicians are trained in supply chain and materials management. They may be directly responsible for equipment and medication acquisition, or they may work in tandem with a facility’s pharmacy, procurement, or materials managers to complete this crucial task.
2. What gaps exist in identifying the personnel involved in procurement and sourcing for perioperative supplies?
When this process involves anesthesia technicians, one should determine which supplies these care team members are responsible for. At the authors’ home institution, University Hospital in Newark, New Jersey, anesthesia technicians are responsible for ordering and stocking medications, with the exception of controlled substances, in all locations. This includes all emergency medications, such as cardiovascular agents, as well as local anesthetics, intravenous fluids, etc. They are responsible for determining the thresholds for reordering based on usage, sourcing of medications, and refilling medications in anesthesia workstations in the ORs, anesthesia carts for remote locations, and the perioperative central supply room. Controlled medications are refilled separately and tracked by the pharmacy. This kind of division causes confusion, especially late at night when an anesthesiologist is looking for a medication that has already run out. Calling the pharmacy to replace a vasopressor is futile; conversely, the anesthesia techs cannot refill controlled medications. The division of labor is often also confusing when it comes to durable and disposable anesthesia equipment.
Things get even more complicated when discussing shortages or items that are on backorder. While most items ordered have to be assessed by a value analysis committee (to ensure the financial and patient safety benefit of a medical device) and purchased through a group purchasing organization (GPO), anesthesia technicians at our home institution can circumvent the traditional procurement process in an emergent situation by seeking emergency authorization to purchase critical items directly from suppliers.
3. How can anesthesia leaders ensure accountability and clear lines of communication regarding equipment and medications?
It should be clearly delineated which health care workers monitor and reorder each medication or piece of equipment. Though it is preferable to have as much of that responsibility “in-house” with their departmental anesthesia technicians, a shortage in certified techs may cause out-sourcing to administrators, materials managers, etc. Without a centralized figure, such as the anesthesia technician who can coordinate procurement and monitor for shortages (for items ordered either within their own department or by another hospital or health care facility department), anesthesiology departments should identify an equipment “champion” or coordinator to ensure uninterrupted supply.
Anesthesiologists and anesthesia providers should be empowered to notify anesthesia technicians or the anesthesia “champion” regarding critical supply shortages or the need for additional supplies or medications. When formulations of medications change, and there is an increased risk posed by confusing vials due to similarities in their labelling, there should be a clear notification system in place to ensure safe medication handling by frontline clinicians. When backup equipment or medications are deployed due to shortages, anesthesiologists should also be informed to prevent frontline confusion at the patient’s bedside.
3 Questions on… Bye, bye noncompetes
ASA Monitor staff
June 7
It’s estimated that 45% of primary care physicians are bound to a noncompete. In this article, authors discuss the recent Federal Trade Commission (FTC)-proposed rule that would prohibit the use of noncompete clauses (also known as restrictive covenants) in employment contracts.
1. What is a noncompete clause?
Broadly, noncompete agreements specify a period of time and a location during and in which an anesthesiologist is restricted from practice after leaving the employ of a group. Often the restriction is for a one- to three-year period and may specify either a geographic radius or specific institutions at which an anesthesiologist is restricted from practice. They are frequently enacted to protect the business interests of an employment group and to protect the investment a group makes in their clinicians.
2. How would the ban on noncompete provisions affect the current shortage of anesthesiologists?
By removing one barrier to changing jobs, such a ban might exacerbate rapidly escalating salaries for anesthesiologists, leading to an “arms race” between practices and employers in geographies with more than one hospital. Removal of the ban might also encourage more anesthesiologists to engage in “gig work” as 1099 independent contractors rather than W-2 full-time employees. Such a change would have tax implications for both the individual and the practice; the Internal Revenue Service expects an employee working the equivalent of full-time at a single location to be W-2, with corresponding benefits. Having “full-time” 1099 workers could lead to penalties for both the group and the clinician. Furthermore, when the hospital’s anesthesiology department is composed of more part-time than full-time employees, it is harder to maintain consistent clinical policies and practices, academic teaching and research, or ongoing quality improvement.
3. Could the ban on noncompete clauses unleash medical entrepreneurship?
Hubs of innovation such as Silicon Valley are notorious for former employees starting new companies and rapidly achieving success, whereas mobility in medicine, especially for starting a new practice, is significantly more difficult due to the high barriers to entry and convoluted webs of regulation. It is doubtful that a ban on noncompete clauses will reverse a trend in physician practice consolidation and mergers motivated by economies of scale in practice management.
May 2023
3 Questions on… Don’t discard, reprocess!
ASA Monitor staff
May 30
Climate change derived solely from greenhouse gas emissions caused by hospitals results in Americans losing approximately 388,000 “daily adjusted life years,” or years of living in good health.
In this ASA Monitor article, authors discuss the role of health care workers in mitigating carbon emissions.
1. What is the “low hanging fruit,” or easy-to-implement changes, can health care workers implement to reduce emissions, particularly from the supply chain?
By turning over used medical devices labeled for single use but found by the U.S. Food and Drug Administration (FDA) to be reprocessable, health care providers are partnering with commercial reprocessing companies to extend the service lives of millions of devices. The practice slashes greenhouse gas emissions and saves tens of millions of dollars in the health care industry every year.
2. What are some barriers to more widespread use of reprocessing?
Recently published research from Yale University identified several barriers to more widespread adoption of reprocessing – chief among these being the anti-competitive, anti-consumer business practices of some medical device manufacturers (BMJ 2021;375:n2734; PLoS One 2022;17:e0279808). Another longstanding ailment in the health care sector under the spotlight: the concerted efforts of device manufacturers to sabotage the growth of reprocessing out of their own self-interest. Respondents described contracts with manufacturers that include language prohibiting reprocessing, even if the device is approved for such by the FDA. Moreover, they described instances of “forced obsolescence” wherein – both at the hardware and software levels – manufacturers design their products to make reprocessing impossible.
3. What can be done to promote reprocessing, despite these obstacles?
Hospital executives, surgical teams, nurses – and indeed all staff – have the ability to demand the shift from a “take-make-waste” linear approach to that of a circular economy that reduces emissions. If health care workers are fighting the good fight to reduce climate-changing emissions, their ability to choose FDA-regulated, reprocessed single-use devices is the front line of the battle.
3 Questions on… Lessons Learned from Mass Shootings
ASA Monitor staff
May 17
At the time of publication, there have been almost 200 mass shootings so far in 2023 (asamonitor.pub/3UGMBxG). This article covers excerpts from a first-of-its-kind collaboration on mass shooting incidents organized by the Uniformed Services University’s National Center for Disaster Medicine and Public Health. At this conference, 15 medical professionals representing three groups – emergency medical services (EMS) clinicians, emergency medicine (EM) physicians, and surgeons – shared common practices in responding to large-scale MSIs resulting in 15 or more victims.
Participants explored public health care responses to six U.S. MSIs: Orlando, FL (2016), Las Vegas, NV (2017), Sutherland Springs, TX (2017), Parkland, FL (2018), El Paso, TX (2019), and Dayton, OH (2019), and developed eight consensus recommendations.
1. Why is staged triaging important?
There were also significant concerns about bystanders who may transport patients to hospitals that are not trauma centers. This results in an uneven and inappropriate distribution of victims. New mapping technology or other programs could instruct the public on identifying local trauma centers, eliminating the need for injured patients to self-transport.
2. Which triaging protocols have proven most effective?
Dr. Gentz called SALT a good starting point. She noted, though, that health care professionals are not always surveying the entire body to look for the location of wounds (Disaster Med Public Health Prep 2008;2:245-6).
“Once the patient arrives in the hospital, ATLS protocol is activated and the entire body is surveyed to look for additional wounds,” said Dr. Gentz. “For example, a gunshot wound to the back of the head can be missed if the patient has a lot of hair. It’s especially important to remove all the clothing to assess the entire body for wounds."
3. What communication and transportation recommendations are available?
The group identified communication and transportation recommendations, including:
- Designating a mass gathering area, such as a convention center near the incident site, as a family assistance site.
- Establishing a help line with key phone numbers and a reunification center address.
- Widespread messaging through social and mass media.
3 Questions on… Should we add a question about “years of education” to preoperative screenings?
ASA Monitor staff
May 9
A recent article explored the possibility of including “years of education” as a health-associated variable worth reporting within patients' medical records. The full article is available here.
1. What is the argument for adding years of education to a patient’s preoperative screening?
Although not perfect, years of formal education is a good surrogate measure of premorbid intellect and cognitive reserve, based on a hypothesis that education may be protective against later cognitive decline, including protection from neurological insult and neurodegeneration (J Consult Clin Psych 1984;52:885-7;Neuropsychology 1996;7:273-95;Neuropsychology 2015;29:649-57;Clin Neuropsychol 2021;36:1291-5;Handb Clin Neurol 2019;167:181-90). Years of formal education is a predictor of postoperative cognitive decline, delirium, and postoperative emergency department visits (Anesthesiology 2008;108:18-30;Lancet 1998;351:857-61;Ann Thorac Surg 1995;59:1326-30;Anesth Analg 2021;132:846-55;J Laparoendosc Adv Surg Tech A 2018;28:1100-4). Years of education is associated with health literacy and comprehension of perioperative patient materials (Arthrosc Sports Med Rehabil 2022;4:e1575-9).
2. Are there any patient populations who would have greater benefit from adding years of education to their health record?
Acquiring years of education is particularly pertinent to providers serving older patients, those seeking to assess brain health with preoperative cognitive screening tools, and clinicians serving patients from disadvantaged neighborhoods, or individuals with limited education in the English language.
3. How would a physician attain a patient’s years of education?
Clinicians can rapidly add education to their considerations by asking, “How many years of school did you complete?” Skipped years count toward the total number of years. Repeated years do not add additional years. If the patient dropped out of high school, then record how many full years of school the patient completed. For example, a high school graduate counts as 12 years, a bachelor's degree counts as 16 years, a master's degree typically 18 years, and so forth. For clinicians acquiring education around the same time as a cognitive screener, we recommend providers ask for educational years before cognitive screening (Anesth Analg 2019;129:830-8).
3 Questions on… Are you down with Doulas?
ASA Monitor staff
May 3
“Who’s That in the Delivery Room?” highlights the role of the doula in obstetrics. Three key excerpts are highlighted here.
1. How long have doulas been practicing?
Dana Raphael, a medical anthropologist, coined the term doula in 1969. She described a doula as a nonmedical support woman who assisted mothers through childbirth and post-partum. In 1992, the first training and certification program, Doulas of North America (DONA), was established.
2. Doulas are often not covered by insurance. Are there any options for those who might find doula services cost-prohibitive?
Recently, hospital and community-based doula programs have emerged, with many of the participants originating from underserved populations. A 2021 study by Kett et al. found community-based doulas assisted their clients in navigating and mitigating discriminatory practices by establishing a strong doula-patient connection, facilitating culturally appropriate birth practices, and empowering mothers to advocate for themselves and their infant (Perspect on Sex Reprod Health 2022;54:99-108). According to Ogunwole et al., between 2015 to 2020, there was a nearly threefold increase in various state bills related to doula care. Most of the bills were Medicaid-related, with the hopes of decreasing health disparities while improving maternal and fetal outcomes (Womens Health Issues 2022;32:440-9).
3. What should anesthesiologists know about working with doulas?
As anesthesia professionals, we will undoubtedly run across a doula. We should be knowledgeable about their function, role, training, and limitations (Birth 2019;46:355-61). As the medical and nursing team is providing cutting-edge obstetric and anesthesia care, the doula is providing a special form of emotional support and patient advocacy.
April 2023
3 Questions on… USP’s Revision of Chapter <797> to Remove the “1-Hour Rule” for Pre-Spiking Intravenous Fluid Bags
ASA Monitor staff
April 26
After months of effort by ASA, United States Pharmacopeia (USP) revised Chapter <797> to exclude the preparation of I.V. solutions from the rules pertaining to compounding, thus eliminating all compounding restrictions, including the “1-hour rule.” Here are some key takeaways, and more information can be found in the Online First article.
1. Why was the 1-hour rule ever enacted?
The Joint Commission mandated that infusion of I.V. fluid bags must begin within one hour of spiking unless the bag is spiked in an ISO Class 5 cleanroom. This stemmed from a recommendation put forth by the Association for Professionals in Infection Control and Epidemiology (APIC), which apparently misinterpreted a United States Pharmacopeia (USP) rule that sets forth regulations concerning compounding of medications.
The rule in question is included in USP Chapter <797>, which sets the standards for compounding of sterile pharmaceuticals. This document was interpreted to be inclusive of the preparation of sterile I.V. solutions.
As part of this interpretation, The Joint Commission mandated that I.V. fluid bags be used within one hour of spiking because of perceived bacterial contamination risks, sparking clinical and economic concerns.
2. What are the new Joint Commission requirements regarding pre-spiking of I.V. bags?
As of this article, The Joint Commission has no specific requirement regarding pre-spiking of I.V. bags. They now recommend that each accredited organization have guidance within their policies on medication and I.V. fluid preparation and administration. Considerations should include:
- Product and device manufacturer’s instructions for use
- Evidence-based guidelines for safe administration practices
- Applicable law and regulations
3. What are some winning practices for successful review of an organization’s policy during surveys?
Organizations must educate department members on relevant medication preparation and administration protocols that are evidence-based and manufacturer-guided. These policies are best developed by partnering with hospital administrators and pharmacists and reviewing applicable federal and state regulations.
3 Questions on… Perioperative Handoffs
ASA Monitor staff
April 20
Every anesthesiologist has an opinion on the usefulness and proper protocols for interoperative handoffs. ASA Patient Safety Editorial Board authors: Alexander F. Arriaga, MD, MPH, ScD, Jonathan B. Cohen, MD, Jeffrey A. Green, MD, MSHA, FASA, Keith J. Ruskin, MD, Senthilkumar Sadhasivam, MD, MPH, MBA, FASA, Scott C. Watkins, MD, and Deborah Schwengel, MD, MEHP (Editor-in-Chief), review the current evidence.
1. What are the current requirements for perioperative handoffs from Anesthesia Patient Safety Foundation?
In a set of consensus recommendations on perioperative handoffs from a group convened by the Anesthesia Patient Safety Foundation (APSF), the authors recommended processes such as using setting-specific checklists or cognitive aids, having education and training, and documenting handoffs when they occur (Anesth Analg 2019;128:e71-8). This is all in addition to publications that have found positive outcomes from handoff interventions in other medical settings, such as multisite projects from the Illness severity, Patient summary, Action list, Situation awareness and contingency plans, and Synthesis by receiver (I-PASS) study groups (N Engl J Med 2014;371:1803-12; J Hosp Med 2023;18:5-14). The APSF group also highlighted the importance of factors such as leadership buy-in, involvement of all members of the team, team training, coaching, feedback, and didactic education (Anesth Analg 2019;128:e71-8).
2. What new developments are on the horizon with respect to perioperative handoffs?
There are important ongoing and future directions regarding perioperative handoffs. Checklists and cognitive aids can improve communication and add to locally customized handoff protocols (Curr Opin Anaesthesiol 2022;35:723-7). For OR to ICU handoffs, the Handoffs and Transitions in Critical Care – Understanding Scalability (HATRICC-US) project has already published their study protocol for a hybrid effectiveness implementation trial across adult and pediatric ICUs (Implement Sci 2021;16:63).
3. What is the role of the perioperative handoff in the patient safety landscape?
Handoffs may serve an important role within a continuum of perioperative interventions to improve patient safety, including routine safety checklists, crisis checklists, and critical event debriefing (Br J Anaesth 2021;127:830-3). As with similar work on cognitive aids, it will be critical to understand the means of use (e.g., paper vs. electronic) and methods of implementation (Clin Monit Comput 2016;30:275-83; ASA Monitor 2022;86:17). It will also be important for ongoing work to measure both the processes of care improved by the handoff as well as the impact of the handoff on patient outcomes (Crit Care Med 2018;46:1863-4).
3 Questions on… Cigna Policy Change on Modifier QZ Payment
ASA Monitor staff
April 14
Effective March 12, 2023, Cigna reduced payment on services reported with modifier QZ by 15%. Modifier QZ identifies services provided by CRNAs without medical direction of a physician. This move to align payment with other advanced practice providers (e.g., nurse practitioners) on its commercial lines of business is outlined in the article “Cigna Policy Change on Modifier QZ Payment.”
1. What impact will these payment reductions have on anesthesiology practices?
At this point, it is hard to determine the impact of this payment cut on business models that anesthesia practices are using. ASA will be monitoring the long-term implications of this policy change on anesthesia practices.
2. What do anesthesiologists need to qualify for medically directed service payments?
In order to qualify for medically directed service payment, the anesthesiologist who medically directs CRNAs or certified anesthesiologist assistants (CAAs) in two, three, or four concurrent cases must perform all of the following activities (asamonitor.pub/3lmOWAp):
- Perform a preanesthetic examination and evaluation
- Prescribe the anesthesia plan
- Personally participate in the most demanding procedures in the anesthesia plan, including, if applicable, induction and emergence
- Ensure that any procedures in the anesthesia plan they do not perform are performed by a qualified individual
- Monitor the course of anesthesia administration at frequent intervals
- Remain physically present and available for immediate diagnosis and treatment of emergencies
- Provide indicated postanesthesia care
3. Is it still considered medical direction if the anesthesiologist supervises more than four concurrent cases?
No! If the anesthesiologist happens to supervise more than four concurrent cases, it is no longer considered medical direction, but medical supervision, and it would be reported using modifier AD. Medicare only pays three value units per procedure for services reported with modifier AD to the anesthesiologist who supervised more than four concurrent cases. However, an additional time unit may be allowed if the anesthesiologist was present at induction and provides documentation. You might also want to note that Medicare does not allow the supervision of CAAs. CAAs always must work under the medical direction of physicians. Furthermore, private payers and your state's Medicaid policies might be different.
3 Questions on… Culturally Sensitive Communication
ASA Monitor staff
April 6
Engagement in global health can facilitate culturally sensitive communication and help anesthesiologists quickly establish rapport during the preoperative evaluation and consent process, especially since the approach to informed consent and medical decision-making varies greatly across cultures. Since communication and rapport-building skills are critical for anesthesiologists, having experience with global health outreach can guide interactions with patients from birth to end of life and enhance awareness of differences in language, culture, and belief systems that profoundly impact their medical care. In this ASA Monitor article, authors Fritz-Gerald Charles, MD, CNMT; Nada Ismaiel, MD, MSc, FRCPC and Cynthia Khoo, MD, PhD, draw attention to the nuances of communicating with patients and families in three critical life stages.
1. What is important to know about communicating with patients during childbirth?
The skills gained from global health engagement are readily applicable in obstetric care, where taking the time to understand a patient’s expectations and goals for delivery in the context of their cultural beliefs is paramount. For instance, many cultures embrace the strength of a woman and “heroism” through labor pain and may discourage any form of labor analgesia, especially invasive procedures like epidurals (Pain Manag Nurs 2003;4:145-54). The individual patient’s desires for labor analgesia may be overshadowed by family members in certain patriarchal or matriarchal societies, often due to a limited understanding of what treatment options entail or associated risks and benefits. To prepare patients to navigate these obstetric decisions, anesthesiologists can collaborate with obstetricians to develop inclusive and culturally sensitive pre-delivery educational programs. By investing in the time to understand family dynamics and educating obstetric patients and their families about anesthetic and analgesic options, anesthesiologists can establish rapport to improve health outcomes and the overall patient experience.
2. What communication principles are important for anesthesiologists communicating with diverse patients during major surgeries?
Medicine in the United States has transitioned from paternalistic to shared decision-making; however, globally there are different models of the physician-patient relationship. Emerging evidence has shown that the focus on autonomy might be overly narrow and that patients of certain cultures may prefer a broader rather than detailed approach to informed consent (JAMA 1995;274:820-5).
While physicians are encouraged to respect patient autonomy in all cultures, autonomy can extend to the patient’s right to refuse to know the details of a diagnosis or procedure directly and may prefer the information be discussed with their family instead.
3. End-of-life communication is a very sensitive topic. What should physicians keep in mind when discussing this stage with diverse patient populations?
Developing early rapport, encouraging patients to express their medical decision-making preferences in the context of their values, and understanding family relationships can lead to mutual respect between anesthesiologists and their diverse patients.
3 Questions on… International Institutional Collaborations
ASA Monitor staff
April 4
Strong relationships between institutions in India and the Department of Anesthesiology at the University of Minnesota facilitated collaboration between the Indian College of Anaesthesiologists (ICA), ASA, and the Society for Ambulatory Anesthesia (SAMBA). In the article “Global Health Initiatives: The University of Minnesota Experience in Karnataka, India,” authors outline what it takes for a successful partnership.
1. What do international collaborations need for accreditation purposes?
It is important to have well-executed agreements between institutions for accreditation purposes. The UOM IMER consummated affiliation agreements with St. John’s Medical College (SJMC) and Narayana Health, both in Bangalore, and Manipal Education and Medical Group (MEMG) in Manipal and Mangalore. Subsequently, two other institutions were added, a charitable facility, The Shanti Mangalick Hospital in Agra, and the Hospital for Orthopedics, Sports Medicine and Trauma (HOSMAT) in Bangalore. The agreements allowed significant educational and research interactions.
2. What are some of the opportunities these programs created for medical students both in the U.S. and India?
From SJMC, six students are selected annually for the abroad clerkship elective at the UOM by the dean and senior faculty who evaluate the many applicants interested in the UOM clerkship. Selection is based on their academic performance, sports, and extracurricular activities. Upon completion and return, the students are required to submit a report and a completion certificate from the UOM.
A similar process is used by MEMG for two students per year. These medical students rotate in different departments (including anesthesiology, surgery, medicine, and pediatrics) in the medical school and function like medical students at the UOM. Furthermore, several members of the departments of anesthesiology and surgery at the UOM have relevant experience in supporting global educational exchanges and expertise in educational training, and device development for bedside and operative procedures. They serve as mentors to these medical students.
Similarly, many UOM students and residents visited Karnataka for elective rotations. Several rotated in anesthesiology and were able to advance their knowledge and conduct research projects. All these rotators in Karnataka were successfully matched in leading residency programs in the U.S. Over the program period, the clinical volume at SJMC averaged 2,250 patients per day in their outpatient clinics, corresponding to approximately 52 patients per physician per day. Medical students and resident trainees from UOM recognized the value of exposure to the high clinical volume during their clerkships. Students from UOM also reported their participation in the SJMC rural outreach activities as highly valuable aspects of their international training experience, as was participating in outpatient clinics where nearly every decision is informed by the awareness of limited resources. A pediatric cardiac ECHO camp conducted in several rural villages by Narayana Health included 75 patients with congenital heart lesions. Anesthesia students rotating at HOSMAT were quickly able to grasp the value of regional anesthesia for orthopedic procedures in a resource-limited setting.
3. Do these international programs have any correlation with eventual physician matching?
Although not a goal of the program, medical students from SJMC demonstrated greater resident matching rates into U.S. residency training programs compared to average matching rates for international medical graduates (IMGs): the average matching rate for IMGs was 48% compared with a match rate of 88% for medical students participating in this exchange program (P=0.001) (J. Harmon. Unpublished data). Several medical students from SJMC and MEMG ended up being residents at the UOM, including achieving chief resident status.
March 2023
3 Questions on… Retirement, Leadership and Football
ASA Monitor staff
March 28
Outgoing ASA president Paul Pomerantz, FACHE, shares his thoughts on modern retirement planning “Tom Brady style” and on leadership, and accountability in this ASA Monitor article.
1. What are your plans after you retire from ASA in April 2024?
That plan is still in development, but I do plan to be engaged with what I am most passionate about – helping mission-driven organizations and their leaders perform at their best.
2. How has Tom Brady re-shaped the notion of retirement?
I was struck by an article published in Forbes on February 7 by Joseph Coughlin titled, “Tom Brady’s Decisions Tell Us A Lot About Retirement Planning.” Not that I see myself as a great quarterback, but… “Preparing for your retirement years means identifying the many different retirements you may have in what has been incorrectly defined as a single life stage and experience. Maybe it will be a traditional retirement, but maybe it won’t.” The article goes on to describe examples of post-retirement careers and journeys that many have taken and asserts that retirement planning could be more appropriately considered longevity planning. “You might just find you are more like Tom Brady than you ever imagined.… Your retirement might be on, off, and on again, too” (asamonitor.pub/417AeO6).
3. You’ve worked with a lot of leaders in your time at ASA. What have you learned about leadership?
Leaders are flawed human beings – we can excel in one moment and fail in the next. Leaders’ primary strengths are their ability to connect with others and their capacity for reflection and self-criticism. In the book “Think Again,” by Adam Grant, leaders are described as lifelong and relentless learners. Leaders must balance roles as politicians, preachers, and prosecutors, but the most effective are always seeking new feedback, criticism, and new information.
3 Questions on… Equity Issues During Economic Downturns
ASA Monitor staff
March 24
It’s well-known that patients in rural areas have worse health outcomes, especially in times of economic stress. In this ASA Monitor+ article, authors strategize about preserving equity during challenging times.
1. What effect do hospital mergers have on rural patients?
Historically, increases in mergers and affiliations of health systems have disproportionately affected rural patients. Mergers may delay elective and emergent care by increasing patient commutes to the nearest hospital. Consolidations and mergers may also impact insurance access and affordability at the patient level.
2. How does the “regionalization of health care” affect physicians in rural areas?
Rural clinicians face expanded patient loads, heavy call burdens, long commutes, and ever-broadening catchment areas. Health professional shortage areas (HPSAs) are regions with a shortage of primary care, dental, or mental health care providers. Access to other specialists is typically also reduced. While efforts have been made to increase rural access to specialists through multiple federal and state programs, including the CARES Act of 2020, these efforts have not provided adequate support to meet regional recruitment needs.
3. What can a single anesthesiologist or small group of anesthesiologists or physicians do to affect this pattern of consolidation and its impact on access to care?
The answer lies in getting more involved with advocacy efforts and being active in all aspects of care, including structural and organizational decisions.
3 Questions On… Anesthesia, Books, and Connection
ASA Monitor staff
March 15
ASA Monitor connected with Paul W. Horak, MD, Intern, Internal Medicine, Kaiser Foundation Hospital, on the unlikely relationship between literature, film, and medicine. This is an excerpt of his article “The ABCs: Anesthesia, Books and Connection” in the March 2023 issue of ASA Monitor.
1. How have your studies in humanities affected your career in anesthesiology?
Patients are vast webs of pathology, physiology, culture, and connection. Those precious minutes before the start of a case are an opportunity to explore patient values, both medical and humanistic. Before seeing a patient, I try to imagine what their home might look like and remind myself that it is my job to get them back there safely. It is one of the great joys and challenges in anesthesiology that our time with patients is short and impactful – the words we share can bring comfort to a person on one of the most important days of their life.
2. How has your medical training intersected with your passion for the humanities?
My love for Japanese culture and a desire to learn more about the frail elderly brought me to Japan for a summer in medical school. There I worked with home care doctors to look after centenarians and their families. When you walk into someone’s home, you see their whole life on display – family photographs, music records, ceramic collections – and you feel instantly more connected to them. I also had the opportunity to write short stories drawn from these encounters: reflecting and writing on these experiences has helped me to both process and sustain thoughtful, intentional medical practice.
3. How do you bring the humanities in patient encounters?
As an intern, it has been in the ICU where I have had to deliver the most bad news – and where I have also most called on my interest in the humanities. Among all the lines and pressors, I have been confronted with the fragility of the human condition. There have been times when I felt like Kurosawa’s Yasumoto, made to bear witness to suffering. But in talking with patients and their families about their interests, cultures, languages, and religions – essentially what makes them human – I have come to learn what most matters to them and how to best guide their care.
3 Questions On… Chief Experience Officers
ASA Monitor staff
March 8
Maintaining brand consistency is an important driver of perceived value. Hospitals that embrace this concept often seek to improve HCAHPS scores by designing systems where all consumer touchpoints achieve a standard level of service experience throughout the continuum of the patient’s journey. In this article, authors D. Matthew Sherrer, MD, MBA, FASA, FAACD; Andrew D. Franklin, MD, MBA, FASA, FAACD; Nirav V. Kamdar, MD, MPP, MBA; Mitchell H. Tsai, MD, MMM, FASA, FAACD; and Richard P. Dutton, MD, MBA, FASA, explore how anesthesiologists’ footprint across the entire health care system may organically translate into the chief experience officer role.
1. Why might anesthesiologists be well-suited for the chief experience officer role?
While the role of chief executive officer is certainly attainable, we suggest that the role of chief experience officer (CXO) is one that is also well suited to anesthesiologists. Anesthesiologists interact with nearly every medical specialty and have the unique opportunity to craft positive synergy across multiple service lines and multiple cross sections of health care providers. Through efforts in perioperative medicine, anesthesiologists even collaborate with primary care networks for surgical optimization and long-term follow-up. Anesthesiologists are the very physicians who COULD influence all aspects of the perioperative patient experience just as they have done with patient safety.
2. Why is the chief experience officer role so important in health care?
High-performing health care organizations recognize that patient experience is as vital as classic executive roles such as finance, operations, and marketing. Many CXO candidates come from outside the health care industry, frequently from customer service or technology positions. Some candidates come from within health care organizations, usually from operational or clinical backgrounds. Characteristics cited as vital to the CXO role include the ability to connect with multiple stakeholders, both on the front lines and in the C-suite, along with the ability to implement and navigate change by exerting influence across institutional silos (asamonitor.pub/3W0D3gc).
Data show that organizations who have formalized a CXO role are more likely to have higher HCAHPS scores relative to overall hospital rating. These organizations also have patients who are more likely to recommend the hospital to others.
3. What impact can anesthesiologists make in building brand equity for their organizations?
Building brand equity by crafting positive patient experiences throughout the continuum of perioperative care presents enormous financial opportunities for health care organizations and the intrinsic qualities of a high-performing CXO mirror those of a high-functioning anesthesiologist. Health care providers and hospital administrators alike stand to benefit from anesthesiology leadership in the role of CXO by creating brand equity at their institutions. We should move away from the dyadic model of viewing perioperative issues as unique to anesthesia, surgery, nursing, scheduling, etc. to one that is more focused on providing a harmonious and congruent experience across all touchpoints in the patient’s perioperative journey.
February 2023
3 Questions On… Corporate Partnerships
ASA Monitor staff
February 22
ASA Monitor published an article this month on the support the American Society of Anesthesiologists receives from corporate partnerships. The full article is available on our website and three key questions are outlined below.
1. What are some tangible results of what the corporate partnerships support?
Supporters advertise in our editorial products, exhibit at ASA meetings, fund unrestricted education grants, and sponsor year-round programs that target member needs and address shared priorities. In 2022, through our flagship Industry Supporter program, ASA brought in over $1.4 million. These unrestricted funds allow the society to create member resources for important initiatives, such as our Opioid Crisis and Perioperative Brain Health initiatives. In addition, revenue neared $4 million for Anesthesiology® 2022 and another $300,000 for ASA® Advance 2023: The Anesthesiology Business Event. Combined, our ASA corporate relations efforts added over $6 million of revenue – funding that helps ASA advance our mission.
2. What advantages does this additional revenue translate into for ASA members?
For members, this support means greater value in membership through reduced meeting registration fees, more innovative educational experiences, and enhanced opportunities for scientific discovery to support key patient care initiatives, not to mention a broad and diverse range of complimentary CME educational offerings at either reduced rates or for free.
3. How does ASA ensure quality in the programming corporate partners support?
ASA works hard to remove bias, perceived or actual, by developing programs based on literature reviews and identified needs and gaps. We follow ethics guidelines from numerous organizations, including the Accreditation Council for Continuing Medical Education (ACCME), American Medical Association, the Accreditation Council for Graduate Medical Education, the Council of Medical Specialty Societies, and others. Transparency is key to this effort. To learn more, please see our Guiding Principles for Corporate Support on the ASA website (asahq.org/about-asa/corporate-support-program/guiding-principles-for-corporate-support).
ASA has received the prestigious “Accreditation with Commendation” designation from the ACCME in recognition of ASA’s high-quality continuing medical education program. Accreditation in the ACCME system provides the medical community and the public the assurance that ASA delivers education that is relevant to clinicians’ needs, evidence-based, evaluated for its effectiveness, and independent of commercial influence.
3 Questions on… Anesthesiology® 2023
ASA Monitor staff
February 15
1. What’s the latest news in planning for ANESTHESIOLOGY 2023 in San Francisco?
The mayor of San Francisco, London Breed, made a special trip to Chicago to meet with ASA leadership. Acknowledging the bad press the city has earned in recent years, Mayor Breed gave the society’s leadership team her personal commitment that the city will be ready to host our event. The mayor added funding for more police officers near the convention center, where ASA activities will be centered. Our members will also benefit from San Francisco’s new Welcome Ambassador program, which features city employees strategically placed in key locations, sporting bright vests for easy identification. These ambassadors are trained to help visitors navigate the city. The visitor’s bureau is even supporting ASA with in-kind support.
2. What is ASA leadership doing to ensure the success of the 2023 annual meeting?
We’re making regular visits to the city to make sure preparations are advancing. The San Francisco visitor’s bureau is pitching in and has partially funded our January visit, where we shifted a meeting usually held in Chicago to give leadership a chance to see the progress. We’re busy planning the Monday night president’s reception and putting together the world-class educational and exhibits program, building on the work we’ve done since returning to in-person meetings a few years ago.
3. What is the ASA’s history of hosting meetings in San Francisco?
Some of ASA’s most well-attended meetings have been held in the Golden City. Perhaps it’s the ease of travel in and out of this hub city, or the rich cultural scene with its top-notch restaurants, iconic sights, and stirring attractions that draw such an engaged crowd. Whatever the magic, ASA and San Francisco have paired well in the past. The glowing reports ASA has received from other medical organizations that have held successful meetings in San Francisco in the past year give us confidence that ANESTHESIOLOGY 2023 will be yet another winning event.
January 2023
3 Questions on… RSV
Steve Shafer, ASA Monitor Editor-in-Chief and Richard Simoneaux
January 26
1. Who is most at risk for RSV?
RSV is one of the most prominent causes of lower respiratory tract infections, affecting nearly all children before the age of 2 (asamonitor.pub/3weGHbC). While RSV can cause infections among all age groups, the most severe infections typically occur in infants and young children. For most adults and older children, RSV infection does not pose a threat. However, severe infections are now increasing in the elderly and adults with comorbidities.
2. Can you elaborate on the role of “immunity debt”?
Some pediatricians have attributed the surge to “immunity debt.” Non-pharmaceutical interventions like masking and social distancing implemented in 2020 and 2021 to mitigate the transmission of Covid-19 prevented the typical exposure to pathogens. As a result, children did not develop immunity to the typical panoply of childhood infectious diseases. Instead, respiratory infections which typically would have occurred throughout 2020 and 2021 appeared as a destructive wave in 2022.
This concept of “immunity debt” was raised in a 2021 publication authored by a French Pediatric Infectious Disease Group, who observed that the “reduction of infectious contacts secondary to hygiene measures imposed by the pandemic may have led to a decreased immune training in children and possibly to a greater susceptibility to infections in children” (Infect Dis Now. 2021;51:418-23). Presciently they noted “low viral and bacterial exposures due to NPIs (non-pharmaceutical interventions) imposed by the Covid-19 pandemic raise concerns as we may witness strong pediatric epidemic rebounds once personal protection measures are lifted.”
The implementation of widespread masking and handwashing during the pandemic allowed for a comparison of the RSV disease activity during the pre-pandemic seasons to those during the pandemic. Typically, RSV disease activity peaks around December. During the pandemic, there was a dearth of RSV infection except for a surge during the summer of 2021 when non-pharmaceutical interventions were relaxed. As noted by Bardsley and colleagues, “the absence of RSV activity in England during the winter of 2020–21 and then atypical activity in summer 2021 was unprecedented in the modern epidemiological era, and was most likely due to the introduction and subsequent relaxation of public health non-pharmaceutical interventions to mitigate the spread of Covid-19” (Lancet Infect Dis. 2022:S1473-3099(22)00525-4). An accompanying commentary noted that “immunity debt” might be an unintended consequence of non-pharmaceutical interventions (Lancet Infect Dis. 2022:S1473-3099(22)00544-8).
This concept of immunity debt is controversial. A robust rebuttal was published by the McGill University (Canada) Office of Science and Society (asamonitor.pub/3iKMRNK). The author, Mr. Jarry, criticized the French Pediatric Infectious Disease Group for “boldly asserting the existence of an immunity debt in children” and “opening the floodgates.” As Mr. Jarry notes, following the publication by the French Pediatric Infectious Disease Group, immunity debt “was being quoted in other papers and in media reports, and now we are led to believe that our immune system is just like a muscle: stop working it out and it will atrophy.”
The primary criticism of immunity debt is that “…children during the pandemic were not kept in sterile bubbles. They were in contact with microorganisms from the food that they ate, the soil that they played with, and the adults in their lives.” Mr. Jarry attributes the rise in pediatric RSV and other infections to non-immune factors. “It’s not just RSV that is putting kids in the hospital but respiratory enteroviruses, influenza, and parainfluenza as well. These are viruses that many children were not exposed to {during the Covid lockdowns} … and there is now a lot of catching up to do.”
3. What does the future hold with regard to RSV?
As has happened with Covid-19 over the past 3 years, the surge in RSV is driving research into vaccines and novel therapeutics. We will be better prepared next time. The good news is that new variants of RSV do not appear to be emerging, based on genomic sequencing data (asamonitor.pub/3XAgksl). This is very different from SARS-CoV-2, which mutates faster than we can develop monoclonal antibodies. The low mutation rate for RSV suggests that the RSV surge seen over the past few months is not likely to recur for some time.
3 Questions on… Infectious Diseases
APSF Patient Safety Priorities Advisory Group - Infectious Diseases
January 12
ASA Monitor Today consults with APSF Patient Safety Priorities Advisory Group - Infectious Diseases. Read their answers to pertinent questions about infection prevention and control. The complete article can be found here.
1. Experts are saying that Covid will not be the world’s last pandemic. What is the goal for any emerging virus?
We should have learned from the Covid-19 pandemic that emerging viruses like monkeypox, Ebola, and polio join endemic viruses like respiratory syncytial virus and influenza as real threats to our patients and the health care team. Our interest in stopping the transmission of these viruses, along with pathogenic bacteria like Enterococcus, Staphylococcus aureus, Klebsiella, Acinetobacter, Pseudomonas, and Enterobacter spp., make this the perfect time for anesthesia professionals to refocus our attention on reducing patient harm through infection prevention. We can refocus the energy we have already learned to spend on Covid-19 mitigation into a holistic approach to pathogen reduction.
2. What does the literature say about basic infection control precautions in anesthesia?
There is no question that we, current and historical leaders in patient safety, can generate substantial reductions in bacterial transmission and, in turn, surgical site infections (SSIs). In fact, based on a recent randomized controlled trial and large postimplementation analysis, we can reduce surgical site infections by over 80% (JAMA Netw Open 2020;3:e201934; J Clin Anesth 2022;77:110632). This is of tremendous importance, as SSIs increase the risk of death for our patients by greater than two-fold and substantially increase health care costs (Surg Infect (Larchmt) 2012;13:307-11; Infect Control Hosp Epidemiol 1999;20:725-30). These same measures have also been shown to eliminate residual intraoperative environmental contamination with SARS-CoV-2.
3. Which infection control measures should be prioritized?
The committee recommends feedback optimization of:
- patient decolonization
- improvement in provider hand hygiene
- disinfection before each administration of an intravenous medication
- environmental cleaning done by the anesthesia provider to address the post-induction peak in environmental contamination.
Advertisement
Email alerts
Advertisement