Download Syllabus 2014

Department of Anesthesia
University of Ottawa
Annual Gary Johnson Anesthesiology Research Day
May 9th, 2014
POSTGRADUATE PROGRAM:
ANNUAL GARY JOHNSON
ANESTHESIOLOGY
RESEARCH DAY
Friday, May 9, 2014
0730 Hours – 1230 Hours
The Ottawa Hospital – General Campus
Royal Room
501 Smyth Road, Ottawa, Ontario
EVENING PROGRAM:
THE UNIVERSITY OF OTTAWA
DEPARTMENT OF ANESTHESIOLOGY
ANNUAL DINNER
&
AWARDS CEREMONY
Friday May 9, 2014
Reception – 1800 Hours
Dinner & Presentations – 1900 Hours
The Fairmont Chateau Laurier, Adam Room
2
University of Ottawa
Annual Gary Johnson Anesthesiology Research Day
May 9th, 2014
ACKNOWLEDGEMENTS:
Welcome to all of you! We are most grateful to the administrative and support staff for having so
carefully attended to the many details to make this day possible. A new venue adds to these
challenges. We appreciate the time and commitment of the research nurses and associates of
the University Department and the CHEO Research Institute, who provided invaluable
assistance towards the successful completion of many of the projects you will hear about today.
For the members of the Department of Anesthesiology who supervised individual students,
residents and fellows throughout the process, they are to be especially thanked. We very much
appreciate the willingness and cooperation of our colleagues who have implemented research
protocols on patients under their care. Finally, as I step down from this position after 5 years, I
can truthfully say that it has been an honour and privilege to chair this event. Many thanks to all
of you for your ongoing support of this venue to show case our Department’s research activity. I
leave it in good hands.
The IT Department of The Ottawa Hospital – General Campus has provided technical and
audiovisual support for the day.
MEETING CHAIR:
Dr. Kimmo Murto, Assistant Professor, Research Committee Member
Department of Anesthesiology, University of Ottawa
ADJUDICATORS:
Dr. Neal H. Badner
Visiting Professor
Clinical Professor of Anesthesia,
UBC – Okanagan Campus
Dr. Homer Yang
Professor,
Department of Anesthesiology, TOH
University of Ottawa
3
Dr. William Splinter
Associate Professor
Department of Anesthesiology, CHEO
University of Ottawa
University of Ottawa
Annual Gary Johnson Anesthesiology Research Day
May 9th, 2014
RESEARCH DAY OBJECTIVES:
A) Medical Student/Resident/Fellow Presentations
To provide an academic forum for medical students, residents and fellows in the Department of
Anesthesiology to present the results of clinical, bench and medical education research based
projects in which they have participated during the course of their training.
Following this activity, participants will be able to do the following:
Discuss results of anesthesia and perioperative medicine related clinical, education and
bench research that has been performed by medical students, residents and fellows
affiliated with the University of Ottawa, Department of Anesthesiology.
Evaluate and discuss the design and execution of randomized clinical trials, cohort
studies, systematic reviews, database analyses, quality improvement projects, and
retrospective chart reviews.
Review the merits of basic statistical tests as they apply to the areas of research
mentioned above.
B) Key Note Speaker – Dr. Neal Badner – “Evidence-Based Practice-Improved
Quality of Care or Decision Paralysis?”
Following this activity, participants will be able to do the following:
Question medical jargon
Self-reflect on one’s practice
Identify the benefits of new research
PLANNING COMMITTEE:
Dr. Kimmo Murto
Dr. Greg Bryson
Dr. Donald Miller
Dr. Jennifer Wilson
Ms. Lynne McHardy
Ms. Jennifer Borup
Ms. Laura Carr
PLANNED DISCUSSION PERIODS:
Each podium presentation will consist of a formal 10-minute talk, followed by a 5-minute
question and answer period. Each poster presentation will consist of a 5-minute summary,
followed by a 5-minute question and answer period. The address of the Visiting Professor will
be concluded by a 15-minute discussion period.
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University of Ottawa
Annual Gary Johnson Anesthesiology Research Day
May 9th, 2014
ACCREDITATION:
This event is an Accredited Group Learning Activity (Section 1) as defined by the Maintenance
of Certification program of the Royal College of Physicians and Surgeons of Canada.
This program has been reviewed and approved by the University of Ottawa, Office of Continuing
Medical Education for 3.50 CME Section 1 credits.
Please Note:
In order to receive your Certificate of Attendance, you will be required to fill in a Research Day
“Course Evaluation Form”. Your response will remain anonymous.
5
University of Ottawa
Annual Gary Johnson Anesthesiology Research Day
May 9th, 2014
ANNUAL GARY JOHNSON
ANESTHESIOLOGY RESEARCH DAY PROGRAM
0730 - 0800
Continental Breakfast, Exhibits
(Royal Room, General Campus)
0800 - 0815
Opening Remarks
Kimmo Murto, MD
Chair, Gary Johnson Research Day Planning Committee
SESSION ONE: PODIUM PRESENTATIONS:
0815 - 0830
Post-Operative Outcomes of Patients with Known OSA
Undergoing Inpatient Surgery
Eugene Choo, MD (PGY3)
0830 - 0845
Learning with our Peers: Peers versus Instructor Debriefing
For Simulated Crisis – A 3-arm Randomized Controlled Trial
Dan Dubois, MD (PGY5)
0845 - 0900
Perioperative Temperature Control – An Initial Review
Of Performance
Karim Mohamed, MD (PGY1)
0900 - 0915
Prediction Score Not Necessary for Patients with
Atrial Fibrillation before Cardiac Surgery
Jonathan Blankenstein (MS3)
0915 - 0930
Validation of Patient Self-Report Tool for Use in
Perioperative Triage
Jeremy Neufeld, MD (PGY3)
0930 - 0945
Chronic Pain in the Emergency Room
Jennifer Nelli, MD (PGY3)
0945 - 1000
Elective, Major Non-Cardiac Surgery on the Weekend:
A Population Base Cohort Study of 30-day Mortality
Daniel McIsaac, MD (PGY5)
1000 - 1030
COFFEE & POSTER VIEWING
(Royal Room)
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University of Ottawa
Annual Gary Johnson Anesthesiology Research Day
May 9th, 2014
SESSION TWO:
POSTER PRESENTATIONS:
1030 - 1040
Understanding the Burden of Chronic Pain at
The Ottawa Hospital Emergency Department
Steven Tremblay, MD (PGY4)
1040 - 1050
Out of Operating Room Endotracheal Intubation:
A Quality and Patient Safety Initiative
Brock Wilson, MD (PGY5)
1050 - 1100
A Retrospective Chart Analysis of 35 Matched Patients
Who underwent Minimally Invasive Esophagectomy
In our Institution
Mona Al Faraidy, MD (Fellow)
1100 - 1110
Mentorship during Anesthesia Residency:
A Qualitative Study
Alisic, Sarika, MD (PGY4)
1110 - 1120
Evaluation of the Cardiac Arrest Role Defined System
For Use in Intra-operative Cardiac Arrest: A Pilot Study
Alexandra Bunting (MS2)
SESSION THREE:
VISITING PROFESSOR’S PRESENTATION:
1120 - 1205
Evidence-Based Practice – Improved Quality of Care or
Decision Paralysis?
Neal H. Badner, MD, FRCPC
1205 - 1220
Questions
1220 - 1230
Wrap up
1230
Residents Photographs
(Outside the Royal Room, General Campus)
1800 - 2200
ANNUAL DINNER AND AWARDS CEREMONY
(Fairmont Château Laurier, Adam Room)
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University of Ottawa
Annual Gary Johnson Anesthesiology Research Day
May 9th, 2014
Title: Post-operative Outcomes of Patients with Known Obstructive Sleep Apnea Undergoing
Inpatient Surgery
Authors: Choo, E., Gomez, C., Taljard, M., Bryson, G.
Introduction: The ASA Clinical Practice guidelines on the perioperative management of patients with
obstructive sleep apnea (OSA) suggest that patients with OSA are at high risk of perioperative apneic
events. In June 2003, our institution introduced a protocol for the post-operative care of patients with
diagnosed OSA. The aim of this study was to document the outcomes of inpatients managed under this
protocol.
Methods: After institutional ethics approval, database analysts identified all patients who underwent
elective inpatient surgery between 2003.07.01 and 2012.03.31 who had previously undergone
polysomnogram (PSG) testing at our institution. Records for airway surgery and procedures involving the
surgical treatment for OSA were excluded. PSG reports were reviewed and OSA severity documented.
Inpatient records were reviewed manually to document patient, surgical and anesthetic characteristics.
The use of high-dependency units (HDU), calls to the ICU outreach (RACE) team, post-operative
complications, and compliance with CPAP was also recorded.
Multivariable logistic regression analysis was used to compare the rates of in-hospital mortality, planned
and unplanned HDU admission, and number of RACE calls between patients with PSG confirmed and
absent OSA.
Results: A total of 1586 subjects were included in the final analysis. 662 subjects (41.7%) did not have
OSA based on PSG testing; leaving 924 (58.3%) with PSG confirmed OSA.
Discussion: Patients with known sleep apnea undergoing inpatient surgery, managed under our
institutional OSA protocol, did not experience an increased rate of mortality, morbidity, or unanticipated
use of critical care resources.
Table 1 – Unadjusted and adjusted analysis of outcomes
No OSA
N =662
Any OSA
N=849
Odds Ratio
(95% CI)
Adjusted OR*
(95% CI)
p-value
In hospital mortality
1 (0.2%)
1 (0.1%)
0.78 (0.06 to 9.6)
-
-
Planned HDU admission
57 (8.7%)
128 (15.2%)
1.88 (1.35 to 2.6)
1.98 (1.39 to 2.8)
0.0002
Unplanned HDU admission
17 (2.6%)
23 (2.7%)
1.05 (0.56 to 1.99)
1.04 (0.53 to 2.0)
0.9009
RACE Team called
11 (1.7%)
17 (2.0%)
1.19 (0.57 to 2.6)
0.95 (0.41 to 2.2)
0.8947
Hazard Ratio
(95% CI)
Adjusted HR*
(95% CI)
0.98 (0.90 to
1.06)
Days admitted
3 (2-5)
3 (2-5)
1.06 (0.98 to 1.14)
(Median, Q1-Q3)
*Adjusted for age, BMI, Elixhauser Comorbidity Score, Type of Anesthesia
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0.5523
University of Ottawa
Annual Gary Johnson Anesthesiology Research Day
May 9th, 2014
Title: Learning With Our Peers: Peer vs. Instructor Debriefing for Simulated Crises. A Three-Arm
Randomised Controlled Trial.
Authors: Dubois, D., Jaffrelot, M., Boet, S., Floch, Y., Garg, N., Laparra, V., Touffett, L., Bould, D.
Introduction: In simulation-based education, debriefing has traditionally been led by an instructor, with
the limitation of cost and availability. Research on peer-assisted learning suggests that involving students
in peer-assessment could be effective and further develop their own competencies in learning. We
hypothesised that peer-debriefing alone would improve the performance of nontechnical skills (NTS) of
medical students in a simulated crisis.
Methods: After institutional ethics approval, volunteer undergraduate medical students (n=61), were
randomised to one of three groups: instructor debriefing (control), peer-debriefers, and peer-debriefees.
All students individually managed a simulated crisis (pre-test). All subjects then underwent two successive
simulation scenarios, each immediately followed by a debriefing. Subjects from the control group had an
instructor debriefing while the peer-debriefee group were debriefed by their peers (peer-debriefers). All
subjects then managed a further simulated scenario (immediate post-test) and a retention post-test two
months later. Two blinded and trained experts independently rated videos of all performances in a random
order, using the Ottawa Global Rating Scale (OGRS).
Results: For the three groups, performance significantly improved from pre-test to both immediate and
retention post-tests (p<.038). There was no significant difference between the immediate and retention
post-test. There was no significant difference in performance between-subjects for group allocation
ANOVA test (p=.147).
Conclusion: Peer-debriefing in simulated crisis situation effectively improved NTS performance in both
the peer-debriefers and peer-debriefees, and the degree of improvement was not different from instructor
debriefing. Learning with peers through simulation debriefing was a valuable alternative to traditional
instructor debriefing.
9
University of Ottawa
Annual Gary Johnson Anesthesiology Research Day
May 9th, 2014
Title: Perioperative Temperature Control – An Initial Review of Performance
Authors: Mohamed, K., Bryson, G., Boet, S.
Introduction: Perioperative hypothermia is known to affect up to 20% of patients and increases the
[1-4]
length of PACU stay, lethargy, infection rate, as well as respiratory and cardiac complications .
Methods: Research ethics approval was waived for this quality assurance project. Twenty-two
anesthesiologists agreed to contribute 20 records each for chart review. Consecutive cases were
identified from billing records. The Physician Quality Reporting System (PQRS) definition of temperature
management and hypothermia was used. Normothermia was defined as 36.0 degrees Celsius.
[5]
Esophageal and tympanic temperatures were compared using the Bland-Altman method .
Results: Of the 440 cases, 131 (TK%) reported intraopertive temperatures; 354 (TK%) reported
temperatures in PACU. Maximum temperature within 30 min of closure was 36.1 (SD 0.9). Maximum
temperature within 15 min of arrival in PACU was 35.8 (SD 0.7). 55 (42%) records noted temperature
<36C intraop as did 196 (55.4%) of measures in PACU. 299 of 440 (68%) records indicated the use of
intraoperative warming technologies; use varied between 20 and 94% among anesthesiologists. A BlandAltman plot revealed a correlation coefficient between the two methods of measurement of 0.2; p<0.05.
The Bland-Altman plot also revealed that the PACU tympanic probe temperature consistently gave
measurements below that of the esophageal probe.
Discussion: Hypothermia, as defined by PQRS was common both intra- and post-operatively.
Esophageal and tympanic measurements correlate poorly suggesting tympanic temperatures are
unreliable as a quality measure. Use of warming technologies is highly variable and represents an
opportunity for quality improvement.
Figure 1: Bland-Altman plot to determine the variance from the mean between the intraoperative
esophageal temperature probe and the postoperative tympanic temperature probe. Positive values
demonstrate that the esophageal probe value was higher than the tympanic value. Note that the yo
intercept is not visible in this figure but is equal to a value of -7.0 C and is representative of the fixed bias;
however this value is likely skewed given the range of measurements of the two methods. It is
interestingly noted however that the tympanic membrane readings were generally lower than the
esophageal readings. Additionally it should be noted that as the temperature mean increases, the
absolute variance from the mean also appears to increase indicating a proportional bias.
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University of Ottawa
Annual Gary Johnson Anesthesiology Research Day
May 9th, 2014
References:
1. Sessler DI: Complications and treatment of mild hypothermia. Anesthesiology 2001; 95: 531
2. Lenhardt R, Marker E, Goll V, et al: Mild intraoperative hypothermia prolongs postanesthetic recovery.
Anesthesiology 1997; 87: 1318
3. Sun LS, Adams DC, Delphin E, et al: Sympathetic response during cardiopulmonary bypass: Mild
versus moderate hypothermia. Crit Care Med 1997; 25: 1990
4. Frank SM, Fleisher LA, Breslow MJ, et al: Perioperative maintenance of normothermia reduces the
incidence of morbid cardiac events. A randomized clinical trial. JAMA 1997; 277: 1127
5. Altman DG, Bland JM (1983). "Measurement in medicine: the analysis of method comparison
studies". The Statistician 32: 307–317.doi:10.2307/2987937.
11
University of Ottawa
Annual Gary Johnson Anesthesiology Research Day
May 9th, 2014
Title: Prediction Score Not Necessary For Patients with Atrial Fibrillation before Cardiac Surgery
Authors: Blankenstein, J., Conrad, E., Tran, D.T.
Introduction: Atrial fibrillation is a common arrhythmia associated with increased morbidity and mortality
after cardiac surgery (1). We recently derived a clinical score to predict the probability of new onset
postoperative atrial fibrillation (POAF) (2). This project aims to test the predictive value of this atrial
fibrillation score in patients with known preoperative atrial fibrillation.
Methods: After research ethics approval, all patients with a history of atrial fibrillation who underwent nonemergent CABG/valve surgery between Jan 1st 2010 – Dec 31st 2011 at UOHI were assessed for the
development of POAF and clinical outcomes in-hospital. An atrial fibrillation score was calculated for each
patient. Prediction rule validation was performed using the Chi Squared goodness-of-fit test as well as
comparison of the area-under-the curve using the Hanley McNeil method.
Results: 293 (81%) of 362 patients developed POAF. All observed rates of POAF were significantly
higher than predicted at each level of the score (p<0.0034). The AUC under the ROC was 0.573 and was
significantly different from the derivation cohort (p=0.01). There was no significant difference in the
incidence of complications in POAF vs non-POAF patients, though POAF patients did experience
significantly longer length of hospital stay, 18.1 vs 11.5 days (p=0.001).
Discussion: The majority of patients who have any preoperative atrial fibrillation will also develop it after
cardiac surgery. The atrial fibrillation score is not applicable in this population; routine prophylaxis against
postoperative atrial fibrillation in this high risk subset is thus recommended. Prophylaxis may help reduce
costs associated with longer hospital stays.
References:
1. Int J Cardiol 2008; 129: 354-62
2. Cochrane Database Sys Rev 2004:003611
3. Anesth Analg 2013;116(SCA Suppl):SCA83
4. J Thor & Cardiovasc Surgery 2007;133: 182-9.
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University of Ottawa
Annual Gary Johnson Anesthesiology Research Day
May 9th, 2014
Title: Validation of Patient Self-Report Tool for use in Preoperative Triage
Authors: Neufeld, J., Wilson, J., Yang, H., Gagne, S., Taljaard, M., Crossan, M.
Introduction: Preoperative screening tools relying on patient self-reported comorbidities are being used
1, 2, 3, 4
in many institutions to help streamline pre-anesthetic care
. We performed a prospective
observational study analyzing the ability of our screening tool to appropriately triage patients into the
proper pre-op assessment stream.
Methods: After research ethics approval, 895 patients who were 18 years of age or older and could read
and write in one official language, coming for elective non-cardiac surgery in June-December 2013 were
selected as a convenience sample. Based on the completed tool the patients were triaged into nursing
telephone, nursing visit in person or anesthesiologist consult. This information was recorded on Form 1.
Form 2 was placed in the patient chart for the anesthesiologist performing the anesthetic to provide their
triage opinion and rationale prior to the induction of anesthesia (the gold standard). We calculated the
rates of upgraded and downgraded visits, the sensitivity and specificity of the questionnaire, and 95%
confidence intervals.
Results: 895 patients were screened. 17 did not meet inclusion criteria. 114 anesthesiologists
participated. Of the Form1-Form2 pairs, 385 (43.8%) were complete; 487 (55.4%) had a blank or missing
Form 2; 6 (0.68%) were missing Form 1. Results are recorded in Table 1.
Discussion: Our tool can be used to help triage patients coming for elective non-cardiac surgery into the
appropriate assessment stream. It identifies patients who require anesthesia consult with high probability
(90%) and rules out those who do not (nearly 80%). This information will help guide future improvement of
our tool and improve the efficiency of the PAU.
Table 1: Summary Of Statistical Comparison Between Tool Triage Type
and Anesthesiologist Recommended Visit Type
Sensitivity
%
(95% CI)
30.1
(+/- 9.9)
65.0
(+/- 9.2)
Specificity
%
(95% CI)
96.4
(+/- 2.1)
77.3
(+/- 4.9)
Anesthesia
89.9
(+/- 4.2)
79.0
(+/- 5.9)
Average
61.7
85.2
(weighted)
Visit Type
Telephone
Nursing
PPV
%
NPV
%
Kappa
%
Overall
Agreement %
69.4
83.4
33.3
82.0
51.1
85.8
39.0
74.0
82.1
88.0
69.2
84.7
References:
1. Can J Anaesth. 1998; 45:87–92
2. Journal of Arthroplasty. 2012; 27(10):1750-1756
3. Anaesthesia & Intensive Care. 2012; 40(2):297-304
4. Anaesthesia. 2003; 58 (9), pp. 874-877
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University of Ottawa
Annual Gary Johnson Anesthesiology Research Day
May 9th, 2014
Title: Understanding Chronic Pain as the Presenting Complaint in the Emergency Department (ED)
Authors: Nelli, J., Tremblay, S., Caluyong, M., Poulin, P., Carson, A., Small, R., Zambrana, A., Shergill,
Y., Nathan, H., Smyth, C.
1
Introduction: Chronic pain (CP) accounts for 10.4% of ED visits to The Ottawa Hospital, which is
2
comparable to other centres. Increased use of the ED for CP has come to the forefront as ED resources
3
are less accessible. The purpose of this study is to understand the patients and mitigating factors behind
these presentations.
Methods: This study was approved by the research ethics board. ED staff referred patients with CP to the
study during 30 randomly selected ED shifts in July and August 2013. Included participants had: 1) pain
as a primary concern; 2) pain greater than 3 months duration. Consenting participants completed a Pain
History Questionnaire administered by one of two medical residents, which included demographics and
4
several validated surveys as recommended in the IMMPACT guidelines.
Results: 59 patients met the inclusion criteria. The primary reason for ED visits was inability to cope with
pain (Table 1). Participants who presented to the ED because of inability to cope reported higher average
pain scores (p<0.05). Mental health problems were common: 61% had moderate-severe depression,
44.1% had moderate-severe anxiety and 44.1% had PTSD. Participants who scored high on the pain
catastrophizing scale (> 30) had greater rates of opioid misuse (p<0.001), anxiety (p <0.001), insomnia
(p<0.001) and PTSD (p<0.001).
Discussion: Poor coping and mental health co-morbidities may explain why CP patients seek help from
the ED. Understanding these factors will aid the development of an interdisciplinary pain program, leading
to a more rational use of resources in the treatment of CP.
Reason for ED visit
“I couldn’t cope with my pain”
Percentage
61%
“I was worried about what was causing my pain”
15.3%
“My doctor advised me to come”
10.2%
"My family or friends thought I should come”
5.1%
References:
1. Amanda Carson, Myka Calayung, Steven Tremblay, Jennifer Nelli, Yaad Shergill, Rebecca Small,
Aaron Zambrana, Howard Nathan, Patricia Poulin, and Catherine E Smyth (2013) Understanding the
th
burden of chronic pain at The Ottawa Hospital Emergency Department. Poster Abstract. 13 Annual
Ottawa Hospital Research Institute (OHRI) Research Day
2. McLeod, D., Nelson, K. (2013). The role of the emergency department in the acute management of
chronic or recurrent pain. Australasian Emergency Nurse J 2012.12.001.
3. Wilsey, B.L., Fishman, S., Crandall, M., Casamalhuapa, C., Bertakis, KD , (2008). A qualitative study
of the barriers to chronic pain management in the ED. American Journal of Emergency Medicine. 26,
255-263.
4. Dworkin RH et al. Core outcome measures for chronic pain clinical trials: IMMPACT
recommendations. Pain, 2005;113:9-19.
14
University of Ottawa
Annual Gary Johnson Anesthesiology Research Day
May 9th, 2014
Title: Elective, Major Non-Cardiac Surgery on the Weekend: A Population Based Cohort Study of
30-day Mortality
Authors: McIsaac, D., Bryson, G., van Walraven, C.
Introduction: The ‘weekend effect’ refers to worse outcomes among patients cared for on the weekend.
Following elective weekend surgery in the UK the odds of 30-day mortality was 1.82 times higher (95% CI
1.71-1.94) than weekday surgery (1). The generalizability of this association is unknown. The purpose of
this study was to evaluate this association in a population-based data registry.
Methods: Following research ethics approval, we undertook a retrospective cohort analysis of populationbased health administrative data. All elective, inpatient, intermediate to high risk non-cardiac surgery
patients from 2002-2012, in Ontario were identified. Propensity score matched and multivariable logistic
regression analyses were performed to test the association between elective weekend surgery and 30day mortality.
Results: 333 344 patients were identified. The overall 30-day mortality rate was 0.85%. 2 520 patients
had weekend elective surgery (0.76%). 2 518 weekend patients were propensity score matched (99.9%)
(key characteristics and derived balance Table 1). Within the propensity score matched cohort the odds of
30 day mortality was significantly higher in the weekend surgery group (OR 1.96, 95% CI 1.34-2.84). This
significant association was confirmed using logistic regression analysis (OR 1.51, 95% CI 1.19-1.92).
Conclusion: Hospitals eager to improve resource utilization may consider moving elective surgery to the
weekend (2) but must recognize the emerging association between weekend elective surgery and
increased risk of mortality. Population health data from Ontario supports the generalizability of the
‘weekend effect’ on elective surgical mortality, and confirms previously estimated effect sizes.
Mechanisms underlying this effect require further study.
Table 1: Key Population Characteristics and
Propensity Score Based Balancing of Confounders
Pre-match
Post-match
Weekend
2 520
Weekday
330 824
p-value
Weekend
2518
Weekday
2518
p-value
69.3
67.2
<0.0001
69
69
0.33
12
6.3
<0.0001
12
11.7
0.76
COPD (%)
23.4
19
<0.0001
23.4
23.7
0.79
DM (%)
25.3
22.5
<0.0001
25.2
25.3
0.92
Malignancy (%)
32.7
6.2
<0.0001
32.7
32
0.57
Renal disease
(%)
4.3
1
<0.0001
4.3
4.3
0.94
MRS (mean)
53.9
36.3
<0.0001
54
55
0.44
n
Age (mean)
Heart failure (%)
*DM: diabetes mellitus; COPD: chronic obstructive pulmonary disease; MRS: mortality risk
score
References:
1. (1) BMJ 2013 346: f2424
2. (2) Anes 2003 98(6): 1491-1496
15
University of Ottawa
Annual Gary Johnson Anesthesiology Research Day
May 9th, 2014
Title: Understanding the Burden of Chronic Pain at The Ottawa Hospital Emergency Department
Authors: Tremblay, S., Nelli, J., Smyth, C., Poulin, P., Shergill, Y., Small, R., Nathan, H.
Introduction: Pain represents a significant cause for visits to the emergency department (ED) (1,2,3).
The purpose of this study is to look at the proportion and characteristics of CP patients presenting to the
Ottawa Hospital ED.
Methods: Following REB approval, we performed two retrospective chart reviews of adult patients
presenting to The Ottawa Hospital (TOH) ED during the 2012-13 fiscal year. Group #1 included 1000
charts randomly selected by the TOH data warehouse, who had presented to TOH ED during the 2012-13
fiscal year. Group #2 included 255 charts of patients with 11 or more visits to TOH ED in 2012-13 fiscal
year (High frequency users (HFU)). All charts were evaluated looking at the proportion of patients who
had presented with CP as their primary complaint.
Results: In a random sample of 1000 ED visits 10.4% +/- 2.5% were related to CP. 36.5% of the HFUs
presented with CP as their primary complaint. In group #1 (random sample) 41.9% of the ED patients had
at least one mental health condition, 40.8% had a history of substance abuse and 64.5% had two or more
co-morbidities.
Discussion: A significant proportion of ED resources are consumed by CP patients. In addition, a
majority of CP patients presenting to the ED had 2 or more co-morbidities and a large proportion of them
had a history of mental health disorder and/or history of substance abuse.
References:
1. Wilsey, B.L., Fishman, S., Crandall, M., Casamalhuapa, C., Bertakis, KD , (2008). A qualitative study
of the barriers to chronic pain management in the ED. American Journal of Emergency Medicine. 26,
255-263.
2. Eder, S.C., Sloan, E.P., Todd, K. (2003). Documentation of ED patient pain by nurses and physicians.
Am J Emerg Med 21, 253-7.
3. Cordell, W.H., Keene, K.K., Giles, B.K., Jones, J.B., Jones, J.H., Brizendine, E.J. (2002). The high
prevalence of pain in emergency medical care. Am J Emerg Med 20,165-9.
16
University of Ottawa
Annual Gary Johnson Anesthesiology Research Day
May 9th, 2014
Title: Out of Operating Room Endotracheal Intubation: A Quality and Patient Safety Initiative
Authors: Wilson, B.
Background: Endotracheal intubation (ETI) is commonly done outside of the operating and is associated
with a higher complication rate than ETI done in the operating room. Higher complication rates are likely
multi-factorial as patients are commonly critically ill with poor physiologic reserve, non-optimized, nonfasted, and require urgent to emergent intervention in a setting that is frequently less controlled from an
operating room. Moreover, out of operating room ETI is frequently performed by non-airway experts and
trainees. We have therefore introduced a Quality and Patient Safety Initiative at The Ottawa Hospital, to
investigate our current out of operating room ETI practices and complication rates.
Methods: After REB approval, in order to assess our current practices we have introduced a standardized
out of operating room ETI procedure form to be completed post-ETI, which serves as the procedure note
as well as for data mining. This initiative has been introduced at present in two mixed medical/surgical
Intensive Care Units at a Canadian University teaching hospital.
Results: Data analysis is pending.
Future initiatives: Future initiatives include the introduction of a pre-ETI checklist, expanding beyond the
ICU to the entire hospital, and developing hospital wide guidelines on out of operating room ETI.
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University of Ottawa
Annual Gary Johnson Anesthesiology Research Day
May 9th, 2014
Title: Anesthesia Management and Outcome in MIS Esophagectomy: A Retrospective Analysis
Authors: Al-Faraidy, M., Thompson, C.
Introduction: Evidence suggests minimally invasive esophagectomy (MIE) is associated with a shorter
hospital stay, and a reduction in severity of complications. Ideal anesthetic management of MIE with
thoracic anastomosis is controversial. Thoracic epidural analgesia in combination with lung protective
strategies reduces the risk of respiratory complications. However thoracic epidural analgesia can increase
the risk of anastomotic leak when hypotension requires vasopressor therapy. We hypothesize that MIE
patients who receive epidurals, lung protective strategy, and goal directed fluid therapy have less severe
complications than patients who didn’t.
Methods: An REB approved retrospective analysis of 35 MIE patients between 2004-2012 with similar
thoracic anastomosis was conducted. Data was obtained through electronic charting. Severity of adverse
events was classified according to the TM&M (modified Clavien-Dindo classification).
Grade
Grade I
Grade II
Grade III
Grade III a
Grade III b
Grade IV
Grade IV a
Grade IV b
Grade V
Definition
No intervention required
Minor pharmacological treatment or minor intervention only
Requires surgical, radiological, endoscopic intervention or multitherapy
Intervention does not require general anesthesia
Intervention requires general anesthesia
Requiring intensive care unit management and life support
Single organ dysfunction
Multiorgan dysfunction
Any complication leading to death
Results: To be presented.
Discussion: To be presented.
References:
1. Smithers BM, Gotley DC, Martin I. Comparison of the outcomes between open and minimally invasive
esophagectomy. Ann Surg. 2007
2. Sgourakis G, Gockel I, Radtke A. Minimally invasive versus open esophagectomy: meta-analysis of
outcomes. Dig Dis Sci 2010
3. Noble F, Kelly JJ, Bailey IS. A prospective comparison of totally minimally invasive versus open ivor
lewis esophagectomy. Dis Esophagus 2013
4. Sebastien Gilbert, Andre B Martel, Gillian K Gresham, et al. Minimally invasive versus open
esophagectomy: propensity matched comparison of the severity of complications.
5. Seely AJE, Ivanovic J, Threader J, et al. Systemic classification of morbidity and mortality after
thoracic surgery. Ann Thorac Surg 2010
6. Urs Zingg, Alexander McQuinn, Dennis Divalentino, et al. Minimally invasive versus open
esophagectomy for patients with esophageal cancer. Ann Thor Surg 2009
7. Urs Zingg, Bernard M Smithers, David Gotley, et al. Factors associated with postoperative pulmonary
morbidity after esphagectomy for cancer. Ann of surg oncology 2011
8. Ju-Mei Ng, Update on anesthetic management for esphagectomy. Current Opinion in Anesth 2011
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University of Ottawa
Annual Gary Johnson Anesthesiology Research Day
May 9th, 2014
9. Omar Y Al Rawi, Stephen H Pennfather, Richard D Page,et al. The effect of thoracic epidural
bupivacaine and an intravenous adrenaline infusion on gastric tube blood flow during esophagectomy.
Anesth Anal 2008
10. Jasper Van Bommel, Jeroen De Jonge, Marc P Buise, et al. The effects of intravenous nitroglycerine
and norepinephrine on gastric microvascular perfusion in an experimental model of gastric tube
reconstruction. Surgery 2010
11. Tanya Zakrison, Bartolomeu A Nascimento Jr. Perioperative vasopressors are associated with an
increased risk of gastrointestinal anastomotic leakage. World J Surg 2007
19
University of Ottawa
Annual Gary Johnson Anesthesiology Research Day
May 9th, 2014
Title: Mentorship during Anesthesia Residency: A Qualitative Study
Authors: Alisic (Mann), S., Boet, S., Sutherland, S., Bould, D.
Introduction: Mentorship has been shown to improve career satisfaction, research productivity, and
1
retention of academic physicians. There are currently no qualitative studies that investigate mentorship
through both the faculty and resident perspectives, to explore factors that either promote or hinder
2
effective mentoring relationships.
Methods: Mentorship experiences were examined through semi-structured interviews, which were started
following research ethics board approval August 2013. Data was analyzed with a grounded theory
approach using open, axial, and selective coding to identify common themes effecting positive or negative
mentorship outcomes.
Results: A successful mentorship program was found to hinge on three key factors, as determined from
both the mentor and mentee perspectives: characteristics of the participants; the anticipated goals of a
mentorship relationship; and the structure the program.
Mentors and mentees independently identified compatible personalities and shared interests as key to
successful mentorship. A perceived lack of explicitly stated expectations and responsibilities of
mentorship led to confusion as to whether the relationship was fundamentally mentor or mentee driven.
This differentiation was integral to the development of the relationship and fulfillment of outcomes. When
themes were compared between mentors and mentees, differences in perception of the relationship
structure resulted in cases of participant disillusionment and negative mentorship outcomes.
The concept of a mentorship network, which has been well described in the business literature, emerged
as a possible solution to meeting the evolving needs of mentees as they progress through training.
Discussion: We were able to obtain multiple stakeholder perspectives through rich narratives including
proposed solutions on designing a mentorship program for postgraduate training programs.
References:
1. Stamm M, Buddeberg-Fisher B. The impact of mentoring during postgraduate training on doctors’
career success. Medical Education 2011; 45: 488-496.
2. Sambunjak D, Straus SE, Marusic A. A Systematic Review of Qualitative Research on the Meaning
and Characteristics of Mentoring in Academic Medicine. Journal of General Internal Medicine (JGIM)
2009; 25 (1): 72-78
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University of Ottawa
Annual Gary Johnson Anesthesiology Research Day
May 9th, 2014
Title: Evaluation of the Cardiac Arrest Roles Defined (C.A.R.D.) System for Use in Intraoperative
Cardiac Arrests: A Pilot Study
Authors: Bunting, A., Di Renna, T., Crooks, S., Fraser, A., Bould, D., Boet, S.
Introduction: Patient survival after intraoperative cardiac arrest highly depends upon rapid and
coordinated delivery of life-saving actions, reliant upon a multi-disciplinary team. Uncoordinated teamwork
1-3
due to overcrowding, lack of role definition and task overload is the most important barrier to the efficient
1, 4.
management of cardiac arrest.
This study assesses the value of CARD (Cognitive Aids with Roles
Defined), which is a cognitive aid delineating roles and tasks designed to facilitate crisis resource
management.
Methods: After REB approval, twelve multidisciplinary teams, each consisting of anesthesiologists,
surgeons, nurses, a respiratory therapist, and operating room attendants, underwent three successive
simulated intraoperative cardiac arrest scenarios each followed by a debriefing, and then a final focus
group. The first scenario ran as per current practice without CARD; the second scenario used CARD
without direct instruction; the third scenario used CARD after specific teaching. A retention test was
performed six months later on eight teams (4 with and 4 without CARD). Qualitative analysis was
performed on the results of focus groups discussing CARD for crisis management. Each scenario was
videotaped and rated by two blinded experts for technical and non-technical skills of teams (TEAM scale,
time to start CPR, hands-on time).
Results: Qualitative data revealed that CARD clarified roles and team coordination during crises but
requires initial instruction. Quantitative analysis did not show any change in team performance when using
CARD.
Discussion: CARD may facilitate crisis resource management for intraoperative cardiac arrest, but
requires some teaching. CARD would be easily exportable to other types of crises.
References:
1. Andersen PO, Jensen MK, Lippert A, √òstergaard D. Identifying non-technical skills and barriers for
improvement of teamwork in cardiac arrest teams. Resuscitation. 2010;81(6):695-702.
2. Marsch SC, Muller C, Marquardt K, Conrad G, Tschan F, Hunziker PR. Human factors affect the
quality of cardiopulmonary resuscitation in simulated cardiac arrests. Resuscitation. 2004;60(1):51-6.
Epub 2004/02/28.
3. Lerner S, Magrane D, Friedman E. Teaching teamwork in medical education. Mt Sinai J Med.
2009;76(4):318-29. Epub 2009/07/31.
4. DeAnda A, Gaba DM. Role of experience in the response to simulated critical incidents. Anesth Analg.
1991;72(3):308-15. Epub 1991/03/01.
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University of Ottawa
Annual Gary Johnson Anesthesiology Research Day
May 9th, 2014
Notes:
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University of Ottawa
Annual Gary Johnson Anesthesiology Research Day
May 9th, 2014
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