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June 15, 2017

BehindTheMedspeak: Why you should insist your surgery be the first scheduled case of the day

Predicted prob AE

Seems like a no-brainer to me.

But then, so do a lot of things.

When you have no brain that's pretty much your baseline.

But I digress.

Coverage

From the Duke University Department of Anesthesiology came this juicy study, confirming what's been been pretty obvious to me since I entered my third year of med school (September 1972, U.C.L.A.) and my clinical rotations and really clear once I began my anesthesia residency (September 1977, once again U.C.L.A.) and ever since: as the day wears on, problems multiply.

By the time the bumped cases and add-ons get going in the late afternoon, you're not getting maximum capability and attention from your doctors — yes, even anesthesiologists like moi.

For cryin' out loud, we're tired!

It's been a long day, we've been up since before 6 a.m., and you expect first-class treatment, our very best?

Wake up and smell the isoflurane, baby.

Feel the propofol burn.

It ain't happening.

Not in your O.R.

So make sure you're the first scheduled case and things will have a better chance of going the way they should.

Thankfully for you, anesthesiology's a very forgiving specialty: trust me, me and my departments have graduated some very, shall we say, shaky... residents out into the great world.

But I digress.

Start time

Wrote James Hamblin in The Atlantic, "In a study of surgeries at Duke, the likelihood of problems related to anesthesia increased from a low of 1% during surgeries starting at 9 a.m. to a high of 4.2% for those starting at 4 p.m., possibly because practitioners grew tired over the course of the day."

Here's the abstract of the 2006 paper.

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Time of day effects on the incidence of anesthetic adverse events

Background: We hypothesized that time of day of surgery would influence the incidence of anesthetic adverse events (AEs).

Methods: Clinical observations reported in a quality improvement database were categorized into different AEs that reflected (1) error, (2) harm, and (3) other AEs (error or harm could not be determined) and were analyzed for effects related to start hour of care.

Results: As expected, there were differences in the rate of AEs depending on start hour of care. Compared with a reference start hour of 7 am, other AEs were more frequent for cases starting during the 3 pm and 4 pm hours (p < 0.0001). Post hoc inspection of data revealed that the predicted probability increased from a low of 1.0% at 9 am to a high of 4.2% at 4 pm. The two most common event types (pain management and postoperative nausea and vomiting) may be primary determinants of these effects.

Conclusions: Our results indicate that clinical outcomes may be different for patients anesthetized at the end of the work day compared with the beginning of the day. Although this may result from patient related factors, medical care delivery factors such as case load, fatigue, and care transitions may also be influencing the rate of anesthetic AEs for cases that start in the late afternoon.

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Related: On March 30, 2013 I explained here why surgery on weekends is not in your best interest.

[via a reader in New Mexico who emailed me last week asking for advice about anesthesia for his upcoming orthopedic procedure. You inspired me to offer the same advice today to all my readers that I gave you then. Free, the way we like it. And worth every penny you paid for it. Wait a sec....]

June 15, 2017 at 12:01 PM | Permalink | Comments (0)

Rolex Chronometer Wall Clock

Screen Shot 2017-05-29 at 12.38.42 PM

20.5"Ø.

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$7,000.

June 15, 2017 at 08:01 AM | Permalink | Comments (0)

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