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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. 4 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) 6 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) 7 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 8 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. 10 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. 12 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 13 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. 17 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 18 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 20 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. 21 University of Ottawa Annual Gary Johnson Anesthesiology Research Day May 9th, 2014 Notes: 22 University of Ottawa Annual Gary Johnson Anesthesiology Research Day May 9th, 2014 23