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... Senior Success: Transitions in Tumultuous Terrain Katherine Tucker MSN, RN, CPN, Kerri Irwin MSN, RN, Melissa Gaviola, M.Ed., & Diana Shenefield PhD, RN, CNE Leighton School of Nursing, Marian University, Indianapolis 3200 Cold Spring Rd, Indianapolis, IN 46222 Objective Senior Success Sessions Students Learning in Crisis Environment: Attendance: 12-18 of a cohort of 38 attended 4 success sessions Students maintained engagement/attendance The US Department of Labor cites that while the United States has over 4 million registered nurses, many of them are no longer practicing. This statistic existed pre-pandemic, yet, is augmented in this current pandemic climate. Student Comments: Down to earth, supportive, comfortable environment where you could be honest A personable environment where we could all come together and talk openly The pandemic also augmented nurse staffing concerns. Nurse preceptors continue to help with clinical and new hire orientation without pay, bonus, or other incentives. Nurse burnout, turnover, and compassion fatigue are at their highest levels. Senior nursing students have increasingly expressed concerns anecdotally about learning in the hospitals from burnt out professionals. Our question: what do we do as nursing faculty to help combat these concerns? Our group will share our interprofessional experience to engage students outside of the classroom through building relationships, sharing real life experiences, and improving self awareness and resilience. Alignment Inclusive: Learning activities engaged students outside the traditional classroom: Relationship building opportunities Small groups discussions and real life topics Safe space with hydration and nutrition Impactful: Learning activities relevant beyond college or course content: Managing Stress Confrontation/Crucial Conversations Personal & Professional Success Self Care & Work/Life Balance Integrated: Learning activities encouraged real life critical thinking: Developing spirit of lifelong learning Encouraged networks/relationships to approach real life problems Group debriefing and processing Outcomes Health care delivery systems are held together, glued together, enabled to function by the nurses. Adapted from Lewis Thomas Student Success Sessions Structure Monthly sessions 1 hour Student-driven content Student-drive faculty, leadership, & staff Student Confidence Scales: First round of raw data collected Desire to test validity and reliability of measures Student Engagement: Stayed engaged for the full hour Had questions pertaining to real life Immediate instructor feedback Franciscan Sponsorship Values Responsible Stewardship: Finding time to connect on days students were available and on campus Dignity of the Individual: Meeting students where they are Allowing students to be themselves Peace & Justice: Non-graded, safe environment Inclusive to all senior students Reconciliation: Sharing open, real life experiences Asking real-life questions Literature Cited American Association of Critical Care Nurses. (2022). AACN Leads Efforts to Prepare New Nurses with Stronger Skills in Leadership, Resilience, and Well-Being . Retrieved from https://www.aacnnursing.org/News-Information/Press-Releases/View/ArticleId/25176/competencybased-leadership-development-resilience-for-student-nurses Patterson, K., Grenny J., McMillan. R., & Switzler. (2005). Self Assessment Tool. Crucial confrontations McGraw-Hill: New York, NY. Wakefield, M.K., Williams, D.R., LeMenestrel S. & Flaubert, J.L. (2021). The Future of Nursing 20202030: Charting a Path to Achieve Health Equity. The National Academies of Sciences Engineering & Medicine. The National Academies Press. Washington, D.C. https://doi.org/10.17226/25982  ...

... I Want to Know Now: Using Student Assessments Throughout the Semester Matthew A. Walsh, PhD, MSW, LSW Marian University WHY? Waiting for Course Evaluations does not help the students currently in the class Using in-semester assessments allows instructors to make adjustments quickly and best serve their students Shows the students that the instructor values their opinion and learning Empowers students to be active participates in their education through self-reflection Exit Tickets Mid-Term Check-In Quiz Questions Quick check in at the end of class Can be Paper or Online (GoSoapBox) Can be Anonymous or not Halfway point check in Anonymous Survey (Canvas, Online, Paper) Check in questions embedded in quizzes (there is no wrong answer) Can be Paper or Online (Canvas) Questions to Ask Felt prepared for class Class was helpful Something I found helpful Something that still confuses me Questions to Ask How often do you read Thoughts on load and structure What should not change What should change Am I (student) achieving goals What does student need to do different and how can professor help Questions to Ask Confidence level with material Thoughts on using skill or resource Benefits Know what is working Know what to readdress if needed Forces students to reflect and evaluate themselves Response Rate Decreases as semester progresses 100% to 25% (example class) Benefits Get info with time to adjust Forces students to reflect and evaluate themselves Response Rate Can incentivize with extra credit 80% to 100% Benefits Increased participation (embedded an assignment) Quick feedback from student Know what to readdress if needed Forces students to reflect and evaluate themselves Response Rate Embedded in Quiz Close to 100%  ...

... What do I need to get there? How will I get there? What connections do I need? What do I want? Why?  ...

... IMPROVING UTLRASOUND SIMULATION EDUCATION Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 2022 Improving Ultrasound Simulation Education: Vascular Access Michael D. Sparks Marian University Leighton School of Nursing Chair: Dr. Christina Pepin ___________________________ Christina Pepin PhD RNCNE (Apr 24, 2022 19:42 EDT) Project Team Members: Dr. Marie Goez Dr. Marie Goez ___________________________ Dr. Marie Goez (Apr 24, 2022 18:54 CDT) Dr. Bradley Stelflug ___________________________ Date of Submission: July 19, 2021 1 IMPROVING UTLRASOUND SIMULATION EDUCATION 2 Table of Contents Abstract4 Introduction..6 Background...6 Problem Statement........7 Organizational Gap Analysis of Project Site.....8 Review of the Literature..8 Search Methodology.....8 Simulation.....9 Knowledge/Confidence...10 Prebriefing/Debriefing11 Conclusion..12 Theoretical Framework......13 Jeffries Simulation Framework...13 PEARLS Debriefing Framework13 Goals, Objectives, and Expected Outcomes..14 Project Design15 Project Site and Sample..15 Methods...16 Measurement Instruments...17 Student Satisfaction and Self-confidence Survey...17 Knowledge Survey..17 Data Collection Procedure..18 IMPROVING UTLRASOUND SIMULATION EDUCATION 3 Ethical Considerations18 Data Analysis..18 Results19 Demographics.19 Knowledge Test..19 Satisfaction Subscale..20 Self-confidence Subscale21 Discussion..21 Strengths and Limitations...22 Recommendations...23 Implications for Practice and Future Research...24 Conclusion.24 References..26 Appendix A31 Appendix B35 Appendix C36 Appendix D37 Appendix E38 Appendix F.39 IMPROVING UTLRASOUND SIMULATION EDUCATION 4 Abstract Background: Throughout the last decade simulation education has become an integral part of healthcare education. Designing simulation training for educational programs takes careful consideration and thought to plan an effective and efficient design. To design an effective simulation and learning experience for students a standardized framework must be used. The Jeffries simulation framework can help design an effective simulation experience. Within the framework the debriefing component is listed as an essential variable of simulation design. Its impact on simulation education outcomes is presented in literature. The current simulation education practice at Marian University lacks a formal debriefing period following simulation testing. Purpose: The purpose of this project was to add a debriefing component to the current practice of ultrasound simulation education, and determine if students knowledge, confidence, and satisfaction increased. Methods: This DNP project used a quality improvement design. Quantitative data was collected with post-test questionnaires and surveys. The data was used to assess for differences in satisfaction, confidence, and knowledge scores between the experimental and control group. Implementation Plan/Procedure: 24 students were randomly divided in two groups. The control group received the current practice, and the experimental group received the current practice with the addition of a debriefing period based on the PEARLS debriefing model. Following each simulation every student was asked to fill out a post-test survey including a knowledge test and the NLN satisfaction and self-confidence survey. Implications/Conclusion: A debriefing period enhanced student knowledge (p = 0.00) and increase student self-confidence (p = 0.01). Debriefing periods should be added as fundamental IMPROVING UTLRASOUND SIMULATION EDUCATION components of US simulation education. This project shows that students in nurse anesthesia programs would benefit with the addition of a formal debriefing period after simulation testing. Keywords: ultrasound, simulation, simulation-based, training, education, performance, confidence, confidence level, knowledge, knowledge level, impact, checklists, objectives, prebrief, prebriefing period, debrief, and debriefing period 5 IMPROVING UTLRASOUND SIMULATION EDUCATION 6 Improving Ultrasound Simulation Training: Vascular Access This project is submitted to the faculty of Marian University Leighton School of Nursing as partial fulfillment of degree requirements for the Doctor of Nursing Practice, Anesthesia track. In order to prepare for clinical rotations as a student registered nurse anesthetist (SRNA), it is imperative to gain experience with the tools used to develop anesthesia skills prior to entering the clinical setting. At Marian University, simulation training is currently used to help aid in the transition from didactic education to clinical reality. A portion of the simulation training involves learning how to operate the ultrasonography (US) machines and equipment. As the Marian University Anesthesia Program continues to develop, it seeks to improve the knowledge and confidence level of students prior to entering the clinical setting. This improvement will involve implementing US simulation training designed with the Jeffries simulation framework and the Promoting Excellence and Reflective Learning in Simulation debriefing framework. Background Receiving good US simulation education is important for any anesthesia provider. Anesthesia providers must be able to use the US to perform multiple procedures including establishing arterial or intravenous (IV) access. Establishing IV access is arguably the number one step in providing anesthesia safely for any procedure and sometimes this access needs to be acquired with the aid of US (Bortman et al., 2019). US is also used to deliver regional anesthetics and provides a structural view under the skin with simultaneous needle visualization as well as the visualization of local anesthetic spread (Hauglum et al., 2020). Thus, having the ability to be proficient at using US provides patients with a higher quality of safe care (Hauglum et al., 2020). Throughout the last decade, traditional educational methods of healthcare apprenticeship in medical training have shifted towards a simulation-based education model (Kalaniti & IMPROVING UTLRASOUND SIMULATION EDUCATION 7 Campbell, 2015). Simulation-based trainings worth and success in education has been proven throughout recent years. Shields & Gentry (2020) recently demonstrated that simulation training provides more significant improvement in knowledge than web-based learning alone. Eroglu & Coskun (2018) found that students can learn to use US with brief periods of training via simulation-based education. Chen et al. (2017) also displayed that US guided regional anesthesia comprehension and technical skills improve with simulation-based training. Simulation-based training is proficient at closing the gap between didactic education and real time clinical exposure. However, simulation-based training without a proper framework may hinder the participants ability to attain expected outcomes from this experiential learning method (INACSL Standards Committee, 2016). Jeffries (2005) created a simulation model that guides the development of an effective simulation educational experience. Within this model, debriefing is listed as an essential variable of a successful simulation design. The positive impact the debriefing component has had on the outcomes of simulation education have been presented in literature throughout the last two decades (Adamson, 2015; Issenberg et al., 2005; Jeffries, 2005; Levett-Jones & Lapkins, 2014; Paige et al., 2015). Problem Statement The current practice of US simulation training at Marian University does not follow a standardized framework for simulation development. Having a standardized framework to aid in the design and development of simulation will provide students with a better-quality experience (INACSL Standards Committee, 2016). Wiggins et al. (2018) showed that when a blended curriculum of deliberate practice, checklist, simulation, and debriefing are used for US simulation it results in increased knowledge and confidence gain for participants. This led to the IMPROVING UTLRASOUND SIMULATION EDUCATION 8 following PICO question: In student registered nurse anesthetists, how does ultrasound simulation training for vascular access with a debriefing period, compared with the current practice of ultrasound simulation training for vascular access, affect the satisfaction, confidence, and knowledge of students? Gap Analysis The current practice of US simulation education at Marian University lacks an important variable of simulation design. More specifically, US simulation training at Marian University lacks a debriefing period following the simulation experience. Currently students are given a checklist, online videos, and readings to prepare for the simulation experience. Upon entry into the simulation lab, students are tested on their ability to perform assigned techniques. The instructor may go over some of the aspects they did well or could improve upon after the skill has been performed. However, there is no formal debriefing period in which the instructor and student discuss the simulation experience. Thus, implementation of a debriefing period following US simulation training should help improve learning outcomes for students. Review of Literature Search Methodology PubMed, Google Scholar, and the AANA webpage were utilized for the search of applicable literature. Keywords used were: ultrasound, simulation, simulation-based, training, education, performance, confidence, confidence level, knowledge, knowledge level, impact, checklists, objectives, pre-brief, prebriefing period, debrief, and debriefing period. Articles that were not published within the last five years were excluded, with the exception of a comprehensive literature review written in 2005. In order to be included in this review, journal articles had to be published in the English language, and demonstrate measurement of IMPROVING UTLRASOUND SIMULATION EDUCATION 9 performance, confidence, or knowledge based on a simulation education experience. Articles also had to investigate the impact of having a debriefing period. All articles were screened by title and abstract. If the methods and results measured pertinent information the full article was screened. Following a thorough search, 20 journal articles, levels I-IV, were found and used to write this review of the literature (Appendix A). Simulation In recent years, simulation-based learning has become an integral part of education models (Kalaniti & Campbell, 2015). Simulation training allows participants to develop their technical skills and receive immediate feedback, which helps improve their comprehension and clinical performance (Kalaniti & Campbell, 2015; Wiggins et al., 2018). The ability to become proficient with skills in simulation before performing skills on patients provides participants with the knowledge and confidence to deliver a higher quality of patient care (Bortman et al., 2019; Griswold-Theodorson et al., 2015; Kalaniti & Campbell, 2015; Wiggins et al., 2018). US simulation has been shown to improve student registered nurse anesthetists (SRNAs) ability to perform regional anesthesia prior to entering the clinical arena. Hauglum et al. (2020) recently showed that novice SRNAs were able to improve their overall transverse abdominis plane block performance using simulation-based training with computer-guided US devices, (p = 0.010). In addition to improving performance during simulation sessions, it has been shown that improved performance carries over into the clinical setting. Ostergaard et al. (2019) displayed that radiology residents who receive simulation-based US training prior to clinical exposure performed better than the students who did not receive simulation training, (p < 0.001). Simulation-based US training is also beneficial for experienced practitioners. Kim et al. (2017) presented evidence that practicing anesthesiologists who participated in a simulation- IMPROVING UTLRASOUND SIMULATION EDUCATION 10 based ultrasound-guided regional anesthesia (UGRA) course went on to increase the number of blocks they performed in subsequent months. Overall, simulation-based training benefits any participant and is a great tool to prepare students for the clinical arena. Knowledge/Confidence There are several different uses for US in the clinical arena. Simulation-based training has been shown to improve the knowledge of participants on these uses. Shields & Gentry (2020) provided evidence that simulation training improved SRNAs knowledge of cardiac structures and recognition of those structures on US displays. Allowing students to develop this knowledge and learn what anatomic structures look like on US displays before entering clinical practice is beneficial to their transition into practice. A large portion of US usage for anesthesia is related to UGRA. A systematic review of 12 studies found that UGRA knowledge improved greatly with simulation-based training (Chen et al., 2017). The use of simulation training is also great for effectively improving knowledge in a short period of time. Bortman et al. (2019) provided evidence that certified registered nurse anesthetists gained a significant improvement of knowledge in a 2-day simulation-based training course, (p = 0.03). Eroglu et al. (2018) also showed that medical students had an improvement in knowledge through 20 hours of US simulation training (p < 0.0001). Jensen et al. (2018) went even further and provided evidence that US novice medical students can attain a mastery learning level with less than two hours of simulation-based training and practice. The majority of these studies show simulation training does not require a large amount of time to increase the knowledge of participants. US simulation-based training can be used to improve the confidence level of participants. Four articles were found that show both students and practicing providers can develop an IMPROVING UTLRASOUND SIMULATION EDUCATION 11 increased level of confidence after participating in simulation-based education (Roark et al., 2020; Schwid et al., 2019; Spencer & Spencer, 2019; Wiggins et al., 2018). Furthermore, all of these aforementioned studies provided evidence of improved confidence following some form of US simulation training (Roark et al., 2020; Schwid et al., 2019; Spencer & Spencer, 2019; Wiggins et al., 2018). Wiggins et al. (2018) emphasized that deliberate practice using a checklist before simulation and then follow-up with a debriefing period as important features to help improve the overall confidence level of participants. Prebriefing/Debriefing Ensuring that learning objectives are defined is a key component to developing a successful simulation training session (Adamson, 2015). Objectives can be provided in a checklist and the overall consensus in the literature is that checklist provide a standardized routine which is important for learning to perform anesthesia care in a consistent manner (Wiggins et al., 2018). Clear objectives enhance the development of thoughts which help participants plan ahead to form strategies for success (Paige-Cutrara & Turk, 2017). Objectives can be delivered to the participants in a pre-simulation briefing which allows participants to feel more inclined to actively engage in the simulation as well as the debriefing period (Kolbe et al., 2015). Using this design characteristic enables the instructor to clarify expectations and establish the goals of the simulation training experience (Kolbe et al., 2015). Paige-Cutrara & Turk (2017) provided evidence that prebriefing can positively impact simulation training by improving nursing student competency performance (p < 0.001). In addition to pre-simulation briefing, post-simulation debriefing has also been shown to improve learning outcomes. Issenberg et al. (2005) wrote a comprehensive literature review using 109 studies, 51 of which focused on the feedback portion of simulation-based education. IMPROVING UTLRASOUND SIMULATION EDUCATION 12 Issenberg et al. (2005) determined that educational feedback was the most important component of simulation-based learning. Educational feedback can easily take place during a debriefing period following the simulation training experience. Thus, having a debriefing session should be an important part of all simulation-based education curriculum. Bae et al. (2019) presented a new debriefing protocol developed for simulation-based education at the Nursing College of Yonsei University. Students who participated in the project noted that their clinical reasoning competency improved with a thorough debriefing process (Bae et al., 2019). Having a debriefing session also facilitates self-reflection and can improve both technical and non-technical skills learned throughout a simulation training experience (Ryoo & Ha, 2015). Overall, the use of debriefing after simulation training is good practice and aids in the learning process of participating students. Conclusion Simulation-based education improves the overall performance of participants (Kalaniti & Campbell, 2015; Wiggins et al., 2018). Gaining knowledge through simulation training before entering the clinical arena can aid in a smoother transition to clinical practice (Bortman et al., 2019; Griswold-Theodorson et al., 2015; Kalaniti & Campbell, 2015; Wiggins et al., 2018). Learning in a simulation environment increases the confidence level of participants which can lead to a better quality of patient care (Roark et al., 2020; Schwid et al., 2019; Spencer & Spencer, 2019; Wiggins et al., 2018). Having a pre-simulation briefing allows simulation objectives to be clearly understood and enables students to improve learning outcomes (Kolbe et al., 2015; Paige-Cutrara & Turk, 2017; Wiggins et al., 2018). Using a debriefing session ties everything together and provides valuable educational feedback that improves comprehension and clinical reasoning (Bae et al., 2019; Ryoo & Ha, 2015). IMPROVING UTLRASOUND SIMULATION EDUCATION 13 Theoretical Framework Jeffries Simulation Framework The Jeffries simulation framework is a middle-range theory that was created using theoretical literature and empirical evidence (Lafond & Van Hulle Vincent, 2012). It was created to aid educators in designing simulation experiences that provide relevant variables for successful learning (Jeffries, 2005). This framework was chosen to guide the process of designing, implementing, and evaluating an effective simulation experience that would positively impact learning outcomes for students participating in this DNP project. This simulation framework recognizes five major components that interact to bring about favored outcome variables from a simulation education experience. The five components are educator, student, educational practices, design characteristics of simulation, and outcomes (Jeffries, 2005). The first portion of the framework involves the teacher, student, and educational practices interaction (Jeffries, 2005). The interactions of these three components then go on to influence the design characteristics and outcomes that are desired (Jeffries, 2005). The focus of this DNP project is directed at improving the components designated as design characteristics and outcomes. More specifically, this project seeks to add a debriefing variable to the current practice. Using the Jeffries simulation model, depicted in Appendix B, a new simulation educational experience will be designed and implemented to view how these newly added variables will impact the knowledge and self-confidence of the participants. PEARLS Debriefing Framework Eppich and Cheng (2015) developed the Promoting Excellence and Reflective Learning in Simulation (PEARLS) framework (Appendix C). Eppich and Cheng developed this framework with the intention to help guide debriefing periods following simulation training, and IMPROVING UTLRASOUND SIMULATION EDUCATION 14 it is recommended for such use by the National League for Nursing (NLN). The framework divides debriefing into four phases: the reaction phase, the description phase, the analysis phase, and the summary phase (Eppich & Cheng, 2015). This framework was chosen to guide and give structure to implementing a debriefing period for this DNP project. In the PEARLS framework, the reaction phase is meant to allow the student to express how they are feeling following the simulation experience (Eppich & Cheng, 2015). During the description phase the student is encouraged summarize the simulation experience (Eppich & Cheng, 2015). The analysis phase is then used to transition into discussion, feedback and teaching (Eppich & Cheng, 2015). Questions can be directed to make this phase more of a learner self-assessment or it can be more of a directive feedback and teaching phase by the instructor (Eppich & Cheng, 2015). They summary phase is used to cover main learning points and can also be either instructor guided, or learner guided based on the questions that are used (Eppich & Cheng, 2015). Each phase is broken down in a debriefing script to help assist simulation instructors implement this debriefing model (Appendix D). This example will be used to help design a debriefing script for this DNP project. Goals, Objectives, and Expected Outcomes This project has three specific aims: 1) to evaluate the effect of a debriefing component on SRNAs satisfaction after US simulation for vascular access; 2) to evaluate the effect of a debriefing component on SRNAs confidence in performing US techniques for vascular access; 3) to evaluate the effect of a debriefing component on SRNAs knowledge regarding US use for vascular access. The desired effect was to have greater effects on satisfaction, confidence, and knowledge with the addition of a debriefing period compared to the control group which used the current practice with no debriefing period. IMPROVING UTLRASOUND SIMULATION EDUCATION 15 Project Design This DNP project used a quality improvement design. Quantitative data was collected with post-test questionnaires and surveys. The data was used to assess for differences in satisfaction, confidence, and knowledge scores between the experimental and control group. Project Site and Sample The project site was located on the main campus at Marian University of Indianapolis. The Marian University Certified Registered Nurse Anesthetist Program simulation lab located on campus was utilized to measure the proposed intervention. There is single simulation lab with one high-fidelity mannequin, four airway mannequins, and two vascular access mannequins on which student can practice prior to skill testing. Students practice in the same space in which testing of skills occurs. The debriefing period and post-test survey took place in a small office space located outside the simulation lab. The Marian University Certified Registered Nurse Anesthetist Program is a Bachelorette of Science in Nursing to DNP in Nurses Anesthesia Tract. Following completion of the program each student will be given the ability to obtain their Certified Registered Nurse Anesthetist certification by taking the national board exam. The program has one cohort matriculate per year. The number of students admitted to each cohort continues to increase every year. The cohort that was analyzed in this quality improvement project contained 24 SRNAs. Each student was given the option following US simulation to participate in the project. Participants were required to be SRNAs from the graduating class of 2023 who were in enrolled in the Anesthesia Principles Simulation I Course. IMPROVING UTLRASOUND SIMULATION EDUCATION 16 Methods Prior to conducting this project, IRB approval was obtained from Marian University. Following IRB approval, the debriefing script was developed utilizing questions and format from the PEARLS debriefing script (Appendix D), which was recommended by the NLN. After development of the debriefing script, the knowledge test was developed using information gathered from the Nurse Anesthesia textbook (Nagelhout & Sass, 2018). Content validity for the knowledge test was then received by anesthesia experts at Marian University. Prior to the test out day, students were given a reading assignment provided by the simulation instructor. Students also received a skills checklist developed by the program director and given the ability to practice the skills on their own in the simulation lab. The test out for this skill took place on two different days. The group of 24 students were randomly divided into two groups by the instructor in charge of the course. On test-out day each student received one-onone simulation testing with the instructor which lasted approximately 20 minutes. Following the training session each student met with the DNP student in the office outside the simulation lab. The group of students that had simulation test out on the first day was chosen to the be the control group and the group of students that had test out on the second day was chosen to be the experimental group. Each student in the control group were asked to complete the post-test surveys following simulation. Each student in the experimental group received a formal debriefing period with a structured guide based on the PEARLS debriefing model (Appendix D) and then completed the post-test surveys. Each debriefing session took approximately 10 minutes. IMPROVING UTLRASOUND SIMULATION EDUCATION 17 Measurement Instruments Student Satisfaction and Self-confidence Survey Student satisfaction and self-confidence were measured by utilizing the NLN student satisfaction and self-confidence survey (Appendix E). This tool is comprised of 13 questions. Each question is a five-point Likert scale question. The survey contains 2 subscales, student satisfaction and self-confidence. The student satisfaction subscale contains five questions which addresses the students satisfaction with the teaching methods and thus their ability to learn during simulation. The self-confidence subscale contains eight questions that addresses the students self-confidence in the knowledge and skills they acquired throughout the simulation experience. The data was evaluated for each subscale. The sum of the subscales were compared between groups, and higher scores were equivalent to better satisfaction and more selfconfidence. Franklin et al. (2014) provided evidence that the student satisfaction and selfconfidence survey is sufficiently reliable and valid for use in research. The reliability was determined with Cronbachs alpha and found to be 0.94 for satisfaction and 0.87 for selfconfidence. Knowledge Survey Knowledge gain was assessed using a post-test survey. The questions for the knowledge test were created using information provided by Nurse Anesthesia (Nagelhout & Sass, 2018). This tool was comprised of five questions. There was one select all that apply, two true or false, and two multiple choice questions (Appendix F). The questions focused mostly on US machine content and use (Appendix F). The test received content validity by three anesthesia experts at Marian University prior to use. The test contained questions regarding the US machine and its appropriate use which help students obtain vascular access (Appendix F). IMPROVING UTLRASOUND SIMULATION EDUCATION 18 Data Collection Data was collected by the DNP student project designer. Data collection took place following the simulation training exercise for the control group and after the debriefing session for the experimental group. Paper surveys were used to ensure that each student filled out the survey prior to leaving the building. After the student filled out the survey it was placed into a collection folder. Two separate folders were used, one for the control and once for the experimental. The surveys were resorted randomly upon removable from the folder to ensure anonymous collection of data. Ethical Considerations Participant consent was received prior to starting the debriefing period. There was minimal risk included in this project. Potential risk included an uncomfortable feeling when speaking about the simulation experience with DNP student project designer. Collection of survey responses was done anonymously. Only aggregate data was collected. The only person dealing with aggregate data was the DNP student project designer. Data Analysis Data and descriptive statistics were analyzed and computed using IBM SPSS Statistics (Version 27). Demographic data was the first to be analyzed and calculated using this statistical program. Measures of frequency were calculated for the demographic data (Table 1). A t test was used to compare the differences in mean knowledge test scores. A Wilcoxon Signed Rank test was used to determine the differences in satisfaction and self-confidence survey scores between the control and experimental group. Although the sample size of each group was small the t test is robust enough to handle violation of the assumptions of normal distribution (Cronk, 2016). IMPROVING UTLRASOUND SIMULATION EDUCATION 19 Results All SRNAs that participated in this project completed the post-test surveys. The post-test surveys included the knowledge test and student satisfaction and self-confidence survey which contained two subscales. Demographic data for the sample is listed in Table 1. Most participants were in the 25-35 age range (75%), identified as female (66.7%), and had 1-5 years of experience (46.0%). Table 1. Demographics of 24 SRNAs participants Characteristics n % Age Range 25-35 36-46 47-57 18 5 1 75.0 21.0 4.0 Sex Female Male 16 8 66.7 33.3 Years of Experience as Registered Nurse 1-5 6-11 12-17 18-23 11 8 4 1 46.0 33.0 17.0 4.0 Knowledge Test An independent t test was calculated using the mean knowledge test scores for the control and experimental group. There were five questions included on the knowledge test. The control groups most commonly missed questions included basic movements when using the US, knowing the frequency medical US machines operate, and understanding tissue echogenicity. In contrast, the experimental groups most commonly missed question only included understanding IMPROVING UTLRASOUND SIMULATION EDUCATION 20 the when to use high or low frequency US probes. The mean score for the control group was 33.3 (SD = 27.4), and the mean for the experimental group was 80.0 (SD = 19.1). A significant increase in score between the control and experimental group was found (p = 0.00). Data for the t test pertaining to knowledge scores is listed in Table 2. Table 2. Results of Knowledge Scores Control Experimental t p M SD M SD 33.3 27.4 80.0 19.1 4.84 0.00 Note: An independent t test was calculated to compare the control group mean knowledge test score and the experimental group mean knowledge test score. Statistically significant change at p < 0.05. Satisfaction Subscale Table 3 provides data for the Wilcoxon Signed Rank test comparing satisfaction scores between the control and experimental group. The mean scores for the control group ranged from 3.75 to 4.00 and the experimental group scores ranged from 4.17 to 4.33. The summed satisfaction score for the control group was 19.1 (SD = 0.11), and the summed score for the experimental group was 21.1 (SD = 0.07). Results were not statistically significant between the control and experimental group (p = 0.06). Table 3. Results of Satisfaction Subscale Item Satisfaction 1 Satisfaction 2 Satisfaction 3 Satisfaction 4 Satisfaction 5 Control M 3.83 3.75 3.75 4.00 3.75 SD 1.12 1.14 1.29 1.04 1.22 Experimental M SD 4.17 1.12 4.33 0.65 4.17 1.19 4.17 1.19 4.25 1.14 p 0.33 0.09 0.35 0.67 0.27 IMPROVING UTLRASOUND SIMULATION EDUCATION 21 Summed 19.1 0.11 21.1 0.07 0.06 Satisfaction Note: Wilcoxon Signed Rank test was used. Statistically significant change at p < 0.05. Self-Confidence Subscale The range of mean self-confidence scores for the control group was 3.67 to 4.25 and the range for the experimental group was 4.17 to 4.33. The summed score for the control group was 32.3 (SD = 0.22), and the summed score for the experimental group was 33.9 (SD = 0.20). The difference between summed scores that measured self-confidence were found to be statistically significant (p = 0.01). Data for the Wilcoxon Signed Rank test comparing the difference between self-confidence scores is displayed in Table 4. Table 4. Results of Self-Confidence Subscale Item Control M 3.67 4.00 3.75 4.08 4.17 4.25 4.08 4.25 32.3 SD 0.89 0.85 0.87 0.90 1.34 0.62 0.90 0.97 0.22 Experimental M SD 3.92 1.00 4.17 0.94 4.25 0.75 4.00 0.95 4.42 0.67 4.42 0.52 4.42 0.52 4.33 0.65 33.9 0.20 p Satisfaction 1 0.62 Satisfaction 2 0.66 Satisfaction 3 0.10 Satisfaction 4 0.86 Satisfaction 5 0.77 Satisfaction 6 0.42 Satisfaction 7 0.20 Satisfaction 8 0.82 Summed Self0.01 Confidence Note: Wilcoxon Signed Rank test was used. Statistically significant change at p < 0.05. Discussion Improvements in SRNAs knowledge scores were demonstrated between the control and experimental group in this project. The results from this project indicate that a formal debriefing period following an US simulation education can impact the knowledge obtained by SRNAs. These results were similar to the results presented by Bae et al. (2019). Past literature has also IMPROVING UTLRASOUND SIMULATION EDUCATION 22 shown that simulation-based training aids in improving the knowledge of its participants (Bortman et al., 2019; Chen et al., 2017; Eroglu et al., 2018; Jensen et al., 2018; Shields & Gentry, 2020). The results from this project indicate that a debriefing period can enhance the simulation knowledge gain following the simulation experience. Thus, with these results it can be inferred that a debriefing period should be considered a cornerstone for any simulation design. The results from the summed score comparison for the self-confidence subscale demonstrated that SRNAs from the experimental group were more confident than SRNAs from the control group following simulation (p = 0.01). Simulation-based education has been shown to increase the confidence level of participants in the past (Roark et al., 2020; Schwid et al., 2019; Spencer & Spencer, 2019; Wiggins et al., 2018). This project helps to provide more information on this subject and indicates that simulation with a debriefing period can be beneficial to the confidence gain of simulation participants. Although there was a difference between the summed scores for the satisfaction subscale it was not found to be statistically significant (p = 0.06). The experimental group may not have gained a significant increase in satisfaction because this survey took into consideration the entire simulation experience. It did not specifically measure the debriefing component itself. Students who may have been dissatisfied with the simulation component may not have been dissatisfied with the debriefing component. However, their dissatisfaction with the simulation component undoubtedly influenced their overall satisfaction scores. Strengths and Limitations A strength of this project is that it demonstrates simulation education has a potential benefit for SRNA knowledge and confidence gain. Moreover, simulation education with the IMPROVING UTLRASOUND SIMULATION EDUCATION 23 implementation of a debriefing period can enhance the simulation benefits. However, the project was limited by a number of different factors. First, this project used convenience sampling and had a limited sample size. There were only 12 participants for each group which limits the ability to determine statistical significance. A second noticeable limitation to this project was its proximity to final exams. Some students were noticeably distracted with finals week approaching the following week, as well as a large pharmacology exam they were required to take the following day. Finally, this project was the 7th simulation project they had participated in throughout the semester. Therefore, fatigue from participating in other simulation projects and filling out the NLN satisfaction and self-confidence survey for other projects may have affected their results. It is also possible that students may have been comparing this simulation experience to a previous one, and if they did not enjoy the format of the US simulation compared to a previous simulation their scores could be lower. Recommendations In future studies, it would be beneficial to measure a larger sample size. If this project was repeated with the entering class and combined with the data from this project, there would be approximately 29 samples for each group. Another option would be to use the two different US simulation exercises. The US vascular access simulation in the spring and the US regional anesthesia simulation in the summer could both be used. The vascular access simulation could serve as a control and the regional anesthesia simulation could serve as the experimental test. It would also be beneficial to conduct the project well in advance of final exam week and on a week that did not have an exam the following day. This would greatly reduce the amount of distraction students have and allow them to fully focus on the simulation experience. IMPROVING UTLRASOUND SIMULATION EDUCATION 24 Implications for Practice and Future Research This project shows that a formal debriefing period can enhance the students knowledge. This project also shows a formal debriefing period can help increase the student self-confidence. If students can gain more knowledge and increased self-confidence due to the addition of a debriefing period post simulation training, then it should be added as a fundamental component of US simulation education for nurse anesthesia programs. After analyzing the results, this project may have benefitted from a survey that measured the debriefing period impact on students satisfaction and self-confidence in addition to the overall simulation survey. In future studies it would be beneficial to develop a survey that specifically measures the debriefing components impact on students satisfaction and selfconfidence apart from the rest of the simulation experience. This may provide better evidence to support the benefit of the debriefing period and its addition to simulation education curriculum. Conclusion This project provides further insight on the benefit a formal debriefing period can add to student learning outcomes. More specifically, it shows that students knowledge and selfconfidence scores increase following a debriefing period post simulation training. Satisfaction scores increased slightly in the experimental group, but this was not a statistically significant result. Although satisfaction did not increase significantly, it is still evident that students benefitted from the debriefing period based on the increase in knowledge and self-confidence scores for the experimental group. Thus, with the results from this project, SRNAs in nurse anesthesia programs would benefit from a formal debriefing period following simulation training. Additional studies utilizing surveys created to measure students satisfaction and selfconfidence scores specific to the debriefing period itself could provide further evidence for its IMPROVING UTLRASOUND SIMULATION EDUCATION 25 benefit. The addition of more efficient methods to enhance student learning outcomes will improve the way our education system produces future healthcare providers. Efforts to improve simulation education must continue to be explored to help make learning a more efficient process in our ever-changing learning environments. IMPROVING UTLRASOUND SIMULATION EDUCATION 26 References Adamson, K. (2015). A systematic review of the literature related to the NLN/Jeffries simulation framework. Nursing Education Perspectives, 36(5), 281291. https://doi.org/10.5480/151655 Bae, J., Lee, J., Jang, Y., & Lee, Y. (2019). Development of simulation education debriefing protocol with faculty guide for enhancement clinical reasoning. BMC Medical Education, 19(197), 1-7. https://doi.org/10.1186/s12909-019-1633-8 Bortman, J., Mahmood, F., Mitchell, J., Feng, Baribeau, Y., Wong, V., Coolidge, B., Bose, R., Gao, Z., Jones, S., & Matyal, R. (2019). Ultrasound-guided intravenous line placement course for certified registered nurse anesthetists: A necessary next step. American Association of Nurse Anesthetist, 87(4), 269-275. https://www.aana.com/docs/defaultsource/aana-journal-web-documents-1/ultrasound-guided-intravenous-line-placementcourse-for-certified-registered-nurse-anesthetists-a-necessary-next-step-august2019.pdf?sfvrsn=3757d2bd_6 Chen, X. X., Trivedi, V., AlSafan, A. A., Todd, S. C., Tricco, A. C., McCartney, C. J. L., & Boet, S. (2017). Ultrasound-guided regional anesthesia simulation training. Regional Anesthesia and Pain Medicine, 42(6), 741-748. https://doi.org/10.1097/AAP.0000000000000639 Cheng, A., Eppich, W., Grant, V., Sherbino, J., Zendejas, B., & Cook, D. A. (2014). Debriefing for technology-enhanced simulation: a systematic review and meta-analysis. Medical Education, 48(7), 657666. https://doi.org/10.1111/medu.12432 Cronk, B. (2016). How to use SPSS: A step-by-by guide to analysis and interpretation. Pyrczak Publishing. IMPROVING UTLRASOUND SIMULATION EDUCATION 27 Eppich, W., & Cheng, A. (2015). Promoting Excellence and Reflective Learning in Simulation (PEARLS): development and rationale for a blended approach to health care simulation debriefing. Simulation in Healthcare: Journal of the Society for Simulation in Healthcare, 10(2), 106115. https://doi.org/10.1097/SIH.0000000000000072 Eroglu, O., & Coskun, F. (2018). Medical students knowledge of ultrasonography: Effects of a simulation-based ultrasound training program. Pan African Medical Journal, 30, 1-7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6201616/ Franklin, A. E., Burns, P., & Lee, C. S. (2014). Psychometric testing on the NLN student satisfaction and self-confidence in learning, simulation design scale, and educational practices questionnaire using a sample of pre-licensure novice nurses. Nurse Education Today, 34(10), 12981304. https://doi.org/10.1016/j.nedt.2014.06.011 Griswold-Theodorson, S., Ponnuru, S., Dong, C., Szyld, D., Reed, T., & McGaghie, W. C. (2015). Beyond the simulation laboratory: A realist synthesis review of clinical outcomes of simulation-based mastery learning. Academic Medicine: Journal of the Association of American Medical Colleges, 90(11), 15531560. https://doi.org/10.1097/ACM.0000000000000938 Hauglum, S., Vera, C., Alves, S. L., & Tran, C. (2020). Use of computer-assisted instrument guidance technology by student registered nurse anesthetists for simulated invasive procedures. American Association of Nurse Anesthetist, 88(4), 289-298. https://www.aana.com/docs/default-source/aana-journal-web-documents1/hauglum_r162af97fc17c4367ad00a9c264e04a34.pdf?sfvrsn=641e5a_4 INACSL Standards Committee. (2016). INACSL standards of best practice: Simulation design. Clinical Simulation in Nursing, 12, S5-S12. https://doi.org/10.1016/j.ecns.2016.09.005 IMPROVING UTLRASOUND SIMULATION EDUCATION 28 Issenberg, S. B., McGaghie, W. C., Petrusa, E. R., Lee Gordon, D., & Scalese, R. J. (2005). Features and uses of high-fidelity medical simulations that lead to effective learning: A BEME systematic review. Medical Teacher, 27(1), 1028. https://doi.org/10.1080/01421590500046924 Jeffries P. R. (2005). A framework for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nursing Education Perspectives, 26(2), 96103. https://journals.lww.com/neponline/pages/articleviewer.aspx?year=2005&issue=03000&arti cle=00009&type=abstract Jensen, J. K., Dyre, L., Jorgensen, M. E., Andreasen, L. A., & Tolsgaard, M. G. (2018). Simulation-based point-of-care ultrasound training: A matter of competency rather than volume. Acta Anaesthesiologica Scandinavica, 62, 811-819. https://doi.org/10.1111/aas.13083 Kalaniti, K., & Campbell, D. M. (2015). Simulation-based medical education: Time for a pedagogical shift. Indian Pediatrics. 52(1), 41-45. https://doi.org/10.1007/s13312-015-05656 Kim, T. E., Ganaway, T., Harrison, T. K., Howard, S. K., Shum, C., Kuo, A., & Mariano, E. R. (2017). Implementation of clinical practice changes by experience anesthesiologists after simulation-based ultrasound-guided regional anesthesia training. Korean Journal of Anesthesiology, 70(3), 318-326. https://doi.org/10.4097/kjae.2017.70.3.318 Kolbe, M., Grande, B., & Spahn, D. R. (2015). Briefing and debriefing during simulation-based training and beyond: Content, structure, attitude and setting. Best Practice & Research Clinical Anaesthesiology, 29(1), 8796. https://doi.org/10.1016/j.bpa.2015.01.002 IMPROVING UTLRASOUND SIMULATION EDUCATION 29 LaFond, C. M., & Van Hulle Vincent, C. (2013). A critique of the national league for nursing/Jeffries simulation framework. Journal of Advanced Nursing, 69(2), 465480. https://doi.org/10.1111/j.1365-2648.2012.06048.x Levett-Jones, T., Lapkin, S. (2014). A systematic review of the effectiveness of simulation debriefing in health professional education. Nurse Education. 34(6), e58-e63. https://doi.org/10.1016/j.nedt.2013.09.020 Nagelhout, J. J., & Elisha, S. (2018). Nurse anesthesia (6th ed.). Elsevier. Ostergaard, M. L., Nielsen, K. R., Albrecht-Beste, E., Ersboll, A. K., Konge, L., & Nielsen, M. B. (2019). Simulator training improves ultrasound scanning performance on patients: A randomized controlled trial. European Radiology, 29, 3210-3218. https://doi.org/10.1007/s00330-018-5923-z Page-Cutrara, K., & Turk, M. (2017). Impact of prebriefing on competency performance, clinical judgment and experience in simulation: An experimental study. Nurse Education Today, 48, 7883. https://doi.org/100.1016/j.nedt.2016.09.012 Paige, J. T., Arora, S., Fernandez, G., & Seymour, N. (2015). Debriefing 101: Training faculty to promote learning in simulation-based training. American Journal of Surgery, 209(1), 126 131. https://doi.org/10.1016/j.amjsurg.2014.05.034 Roark, A. A., Ebuoma, L. O., Ortiz-Perez, T., Sepulveda, K. A., Severs, F. J., Wang, T., Benveniste, A. P., & Sedgwick, E. L. (2018). Impact of simulation-based training on radiology trainee education in ultrasound-guided breast biopsies. Journal of the American College of Radiology, 15(10), 14581463. https://doi.org/10.1016/j.jacr.2017.09.016 IMPROVING UTLRASOUND SIMULATION EDUCATION 30 Ryoo, E. N., & Ha, E. (2015). The importance of debriefing in simulation-based learning: Comparison between debriefing and no debriefing. Computers, Informatics, Nursing, 33(12), 538-545. https://doi.org/10.1097/CIN.0000000000000194 Schwid, M., Harris, O., Landry, A., Eyre, A., Henwood, P., & Kimberly, H. (2019). Use of a refresher course increases confidence in point-of-care ultrasound skills in emergency medicine faculty. Cureus, 11(8), e5413. https://doi.org/10.7759/cureus.5413 Shields, J. A., & Gentry, R. (2020). Effect of simulation training on cognitive performance using transesophageal echocardiography. American Association of Nurse Anesthetist, 88(1), 59-65. https://www.aana.com/docs/default-source/aana-journal-web-documents-1/effect-ofsimulation-training-on-cognitive-performance-using-transesophageal-echocardiographyfebruary-2020.pdf?sfvrsn=af8dd107_6 Spencer, T. R., & Bardin-Spencer, A. J. (2020). Pre- and post-review of a standardized ultrasound-guided central venous catheterization curriculum evaluating procedural skills acquisition and clinician confidence. The Journal of Vascular Access, 21(4), 440448. https://doi.org/10.1177/1129729819882602 Wiggins, L. L., Morrison, S., Lutz, C., & ODonnell, J. (2018). Using evidence-based best practices of simulation, checklists, deliberate practices, and debriefing to develop and improve a regional anesthesia training course. American Association of Nurse Anesthetist. 86(2), 119-126. https://www.aana.com/docs/default-source/aana-journal-web-documents1/using-evidence-based-best-practices-of-simulation-checklists-deliberate-practice-anddebriefing-to-develop-and-improve-a-regional-anesthesia-training-course-april2018.pdf?sfvrsn=c2505fb1_8 IMPROVING UTLRASOUND SIMULATION EDUCATION Appendix A 31 IMPROVING UTLRASOUND SIMULATION EDUCATION 32 IMPROVING UTLRASOUND SIMULATION EDUCATION 33 IMPROVING UTLRASOUND SIMULATION EDUCATION 34 IMPROVING UTLRASOUND SIMULATION EDUCATION 35 Appendix B Jeffries Simulation Model, by P. R. Jeffries, 2005, Nursing Education Perspectives, 26(2), 96103(https://journals.lww.com/neponline/pages/articleviewer.aspx?year=2005&issue=03000&arti cle=00009&type=abstract). Copyright 2005 by National League for Nursing Inc. Reprinted with permission. IMPROVING UTLRASOUND SIMULATION EDUCATION Appendix C PEARLS Debriefing Framework, by Eppich & Cheng, 2015, Journal of the Society for Simulation in Healthcare, 10(2), 106115(https://doi.org/10.1097/SIH.0000000000000072). Copyright 2015 by Wolters Kluwer Health, Inc. Reprinted with permission. 36 IMPROVING UTLRASOUND SIMULATION EDUCATION Appendix D PEARLS Debriefing Script, by Eppich & Cheng, 2015, Journal of the Society for Simulation in Healthcare, 10(2), 106 115(https://doi.org/10.1097/SIH.0000000000000072). Copyright 2015 by Wolters Kluwer Health, Inc. Reprinted with permission. 37 IMPROVING UTLRASOUND SIMULATION EDUCATION 38 Appendix E Student Satisfaction and Self-Confidence in Learning Instructions: This questionnaire is a series of statements about your personal attitudes about the instruction you receive during your simulation activity. Each item represents a statement about your attitude toward your satisfaction with learning and self-confidence in obtaining the instruction you need. There are no right or wrong answers. You will probably agree with some of the statements and disagree with others. Please indicate your own personal feelings about each statement below by marking the numbers that best describe your attitude or beliefs. Please be truthful and describe your attitude as it really is, not what you would like for it to be. This is anonymous with the results being compiled as a group, not individually. Mark: 1 = STRONGLY DISAGREE with the statement 2 = DISAGREE with the statement 3 = UNDECIDED - you neither agree or disagree with the statement 4 = AGREE with the statement 5 = STRONGLY AGREE with the statement Satisfaction with Current Learning SD D UN A SA 1. The teaching methods used in this simulation were helpful and effective. 1 2 3 4 5 2. The simulation provided me with a variety of learning materials and activities to promote my learning the medical surgical curriculum. 1 2 3 4 5 3. I enjoyed how my instructor taught the simulation. 1 2 3 4 5 4. The teaching materials used in this simulation were motivating and helped me to learn. 1 2 3 4 5 5. The way my instructor(s) taught the simulation was suitable to the way I learn. 1 2 3 4 5 UN A SA Self-confidence in Learning SD D 6. I am confident that I am mastering the content of the simulation activity that my instructors presented to me. 1 2 3 4 5 7. I am confident that this simulation covered critical content necessary for the mastery of medical surgical curriculum. 1 2 3 4 5 8. I am confident that I am developing the skills and obtaining the required knowledge from this simulation to perform necessary tasks in a clinical setting 1 2 3 4 5 9. My instructors used helpful resources to teach the simulation. 1 2 3 4 5 10. It is my responsibility as the student to learn what I need to know from this simulation activity. 1 2 3 4 5 11. I know how to get help when I do not understand the concepts covered in the simulation. 1 2 3 4 5 12. I know how to use simulation activities to learn critical aspects of these skills. 1 2 3 4 5 13. It is the instructor's responsibility to tell me what I need to learn of the simulation activity content during class time.. 1 2 3 4 5 Copyright, National League for Nursing, 2005 Revised December 22, 2004 Student Satisfaction and Self-Confidence in Learning Questionnaire, by National League for Nursing, 2004 (http://www.nln.org/docs/default-source/default-document-library/instrument2_satisfaction-and-self-confidence-in-learning.pdf?sfvrsn=0). Copyright 2005 by National League for Nursing Inc. Reprinted with permission. IMPROVING UTLRASOUND SIMULATION EDUCATION Appendix F 1. True or False, the in-plane or axial/longitudinal approach allows the entire length of the needle (including the tip) to be visualized within the plane of the ultrasound image. a. True b. False 2. The basic movements when scanning with the ultrasound probe are? Select all that apply. a. b. c. d. e. Sliding Alignment Guiding Tilting Rotation 3. True or False, higher-frequency ultra-sound probes are best suited for visualizing deeper structures? a. True b. False 4. At what frequencies does a medical ultrasound machine operates between? a. b. c. d. 5-15 MHz 2-9 MHz 2-13 MHz 4-16 MHz 5. Anechoic areas do not reflect ultrasound waves and therefore appear what color on the screen? a. b. c. d. e. Gray White Blue Black Red Reference Nagelhout, J. J., & Elisha, S. (2018). Nurse anesthesia (6th ed.). Elsevier. 39  ...

... PRECEDEX AND PACU STAYS 1 Marian University Leighton School of Nursing Doctor of Nursing Practice Effects of Intraoperative Precedex in the Post-Anesthesia Care Unit Katelyn M. Stephens Submitted in partial fulfillment of degree requirements for the Doctor of Nursing Practice Nurse Anesthesia Marian University Leighton School of Nursing Chair: Dr. Sara Franco _________________________ (Signature) Date of Submission: (Date) PRECEDEX AND PACU STAYS 2 Abstract Precedex is a common sedative used for procedural sedation and as an adjunct in general anesthesia. This project uses a retrospective chart review to determine if intraoperative Precedex boluses increase the length of stay in the postoperative anesthesia care unit (PACU). This project focuses on pediatric patients, 2-12 years old, undergoing tonsillectomy and/or adenoidectomy surgery. Indiana University Arnett Hospital and its associated ambulatory surgery center (ASC) are the sole facilities of this project implementation. Neumans Systems Model Theory guides the framework for this project determining patient stressors and appropriate interventions. PRECEDEX AND PACU STAYS 3 Effects of Intraoperative Precedex in the Post-Anesthesia Care Unit This project is submitted to the faculty of Marian University Leighton School of Nursing as partial fulfillment of degree requirements for the Doctor of Nursing Practice, Certified Registered Nurse Anesthesia (CRNA) track. Adenoidectomy and tonsillectomy are common childhood procedures performed in outpatient surgery centers. These procedures are associated with increased incidence of postoperative emergence delirium (POED), hemorrhage, and postoperative nausea and vomiting (Bediril et al., 2017). Each of these complications are potential causes for prolonged post-anesthesia care unit (PACU) recovery times. Recently, Precedex is gaining popularity in prophylactic treatment of POED, especially in children. The significance of POED is the psychological and physical harm a patient may endure while going through the recovery phase from anesthesia. POED is more common among pediatric patients than adults. It is a transient, dissociated state of consciousness characterized by crying, inconsolability, restlessness, uncontrollable flailing of arms, and agitation in children that begins with emergence from anesthesia and continues through the early recovery period (Lerman, 2020). The complications associated with POED may increase the duration of a patients stay in the PACU. However, the side effects of Precedex may be the causative factor in prolonging PACU stays. The purpose of this project is to determine if intraoperative Precedex administration prolongs PACU recovery times. Background Reducing postoperative complications reduces length of PACU stay, reduces cost, and improves patient outcomes. Decreased PACU stays are associated with fewer postoperative complications and readmissions (Mann-Farr et al., 2019). The incidence of POED varies between 10% and 80% of pediatric patients undergoing surgery (Moore & Anghelescu, 2017). It PRECEDEX AND PACU STAYS 4 is one of the most common complications following pediatric surgery and may increase the risk of additional complications such as bleeding and self-harm. Risk factors for POED include the presence of preoperative anxiety, the childs temperament, and the presence of postoperative pain (FitzSimons et al., 2017). The exact cause of emergence delirium is unknown but considered multifactorial in origin. One of the greatest risk factors for emergence delirium is the use of anesthetic gases during surgery. The rapid onset and offset of these gases make them ideal for outpatient surgeries to decrease turn over time and time to discharge. The preferred inhalational and maintenance anesthetic for pediatric surgery is Sevoflurane. Sevoflurane causes less irritation to the airway compared to other inhalational anesthetics, induces anesthesia quickly, and results in a faster recovery (Bediril et al., 2017; Koceroglu et al., 2020). The rapid awakening from Sevoflurane places the patient at an increased risk for POED due to the interruption of the physiologic sleep cycle. Children frequently require medication for anxiolysis preoperatively. The drug of choice to reduce preoperative anxiety in children is oral midazolam. This medication has proven to be effective in assisting with inhalational induction and reducing preoperative anxiety and agitation. However, this drug has also shown to increase the incidence of POED. This drug works on the Gamma-aminobutyric acid (GABA) receptors and will create a hazy state of consciousness and anterograde amnesia (FitzSimons et al., 2017). When the patient arises from this state, they may be confused and become combative, agitated, or anxious. Despite this, it is still common practice to use oral midazolam as a first-choice anxiolytic preoperatively. Precedex works on the alpha-2 adrenergic receptors. Studies have suggested the use of an alpha-2 agonist may decrease the incidence of POED because it mimics a normal sleep cycle PRECEDEX AND PACU STAYS 5 (FitzSimons et al., 2017). Precedex works as a sedative, analgesic, and anxiolytic. Providers continue to use midazolam and Sevoflurane for preinduction treatment and maintenance of general anesthesia (GA), respectively. The use of these drugs should encourage the use of alpha2 agonists to decrease the incidence of POED. However, the use of Precedex to treat POED in pediatric patients is not yet approved by the Food and Drug Administration (FDA) (Taylor, 2016). Additionally, several studies have shown Precedex to prolonged emergence times and PACU stays (Bediril et al., 2017; Manning et al., 2020) Problem Statement POED is well documented in pediatric patients undergoing ear, nose, and throat surgeries. These patients are at increased risk for psychological stress and intentional self-harm in the postoperative period, thus prolonging their PACU stay. The question this project aims to answer is: in pediatric patients (ages 2-12 years old) undergoing a tonsillectomy and/or adenoidectomy, how do intraoperative Precedex boluses compared with no Precedex boluses affect PACU length of stay? This quality improvement project will entail a retrospective chart review. Patient age and weight are included in the data analysis. Pediatric patients undergoing tonsillectomy and/or adenoidectomy are the target population for this project. This project aims to prove the use of Precedex decreases the PACU length of stay in pediatric patients undergoing tonsillectomy and/or adenoidectomy. Organization Gap Analysis of Project Site The ambulatory surgery center (ASC) associated with Arnett Hospital in Lafayette, Indiana provides care for outpatient pediatric surgeries daily. This makes it an ideal facility to implement this quality improvement project. Indiana University Arnett Hospital and the PRECEDEX AND PACU STAYS 6 associated ASC began regularly using Precedex boluses intraoperatively within the past twelve months. Current practice at Arnett is to use intraoperative infusions for cases lasting longer than 60 minutes. There are no current practice guidelines for intraoperative Precedex boluses at these facilities. Recently, pharmacy began distributing 5 milliliter (mL) syringes containing 20 micrograms (mcg) of Precedex making it more readily available to anesthesia personnel at these facilities. This recent change has increased the use of intraoperative boluses, however there are barriers to its administration. Barriers to implement best practice are staff resistance to change, lack of staff knowledge regarding Precedex bolus administration, delayed emergence from anesthesia, and prolonged PACU recovery times. Search Methodology Research for supporting evidence for this review was provided through Cumulative Index Nursing & Allied Health Literature (CINAHL) and PubMed databases. The initial database search retrieved 5,215 articles and abstracts. However, only 206 articles were eligible for inclusion. Results were narrowed to include abstracts and full manuscripts published in English or translated to English within the last five years of this review (2015-2020). This review analyzes nine articles in total. For inclusion in analysis, study subjects were 2-12 years old, human, and receiving Precedex perioperatively. Exclusion criteria for this review were laboratory studies and adult patients. No exclusion criteria were included for gender, sample size, drug dose, drug route, or type of surgery. Keywords and search terms included Precedex, dexmedetomidine, emergence agitation, and emergence delirium. Boolean searches included pediatric emergence delirium and dexmedetomidine, pediatric emergence delirium and Precedex, prolonged PACU stays, and pediatric emergence delirium. PRECEDEX AND PACU STAYS 7 Review of the Literature Advantages of Precedex Precedex is gaining popularity as an anesthetic of choice due to its many advantageous properties. Advantages of Precedex include anxiolysis, experiencing a natural sleep pattern, analgesia, volatile agent-sparing properties, and minimal respiratory depressant effects (Fitzsimmons et al., 2017; Mahmoud & Mason, 2015). Precedex has shown potential organ protective effects. It creates a neuroprotective effect against hypoxemia and ischemic injury by decreasing cerebral blood flow in proportion to a decrease in cerebral metabolic rate (Mahmoud & Mason, 2015). A suggested nephroprotective mechanism of Precedex includes increased diuresis by reducing vasopressin secretion, enhanced renal blood flow, and improved glomerular filtration. (Mahmoud & Mason, 2015). Perhaps the greatest advantage to Precedex is its ability to create a cooperative and arousable sedative state rather than a cloudy, confused state of consciousness. This mimics a natural sleep pattern without significant respiratory depression (Cao et al., 2016; Mahmoud & Mason, 2015; Moore & Anghelescu, 2017). Some patients have been observed to be arousable and alert with stimulation and therefore require an adjunct anesthetic (Taylor, 2016). Most anesthetic plans in the operating room involve volatile agents. Precedex has been shown to decrease the requirement of volatile agents by 17% to 50%, depending on the dose (Fitzsimmons et al., 2017). Sevoflurane is the most used volatile agent for pediatric patients undergoing adenotonsillectomy. Faster recovery time is what makes Sevoflurane a desirable anesthetic. One of the main benefits to the use of Precedex is reduced POED (Hauber et al., 2015). Preschool-age children between the ages of two and six years old are at greatest risk for developing POED (Lerman, 2020). The incidence of POED diminishes with increased age. PRECEDEX AND PACU STAYS 8 In addition to diminishing volatile agent requirements, Precedex was found to lessen opioid consumption. Young children have decreased pain thresholds and exaggerated responses to pain (Fitzsimmons et al., 2017). Precedex significantly lowered opioid consumption when compared to control groups in pediatric patients (Cao et al., 2016; Hauber et al., 2015; Koceroglu et al., 2020; Mahmoud & Mason, 2015). Precedex works as an analgesic by supraspinal mechanisms and direct action on the spinal cord. This serves to augment the effects of exogenous opioids and thus reduce narcotic use by 30% to 50% (Fitzsimmons et al., 2017). Further advantages of Precedex are minimized oxygen desaturation and significantly reduced nausea and vomiting. Improved extubating conditions such as decreased apnea, coughing, and desaturation were found with Precedex administration (Koceroglu et al., 2020). There are no known active or toxic metabolites and no absolute contraindications to Precedex in the literature or package insert. However, Mahmoud and Mason (2015) recommend that the use of Precedex be avoided in children receiving digoxin, -adrenergic blockers, calcium channel blockers, or other agents that predispose the patient to bradycardia or hypotension. Disadvantages of Precedex The most significant adverse effects of Precedex are bradycardia, hypotension, and sinus arrest (Mahmoud & Mason, 2015). Bradycardia, or a decrease in resting heart rate (HR), is a predicted physiological response with the use of Precedex. Up to a 30% reduction in baseline HR is a normal finding (Mahmoud & Mason, 2015). In comparison, Hauber et al. (2015) found a rapid bolus of 0.5 mcg/kg of Precedex lowered HR by 22% compared with 10% in the control group. These moderations in HR are rarely significant enough to warrant an intervention. Moore and Anghelescu (2017) reported a dose-dependent reduction in HR and blood pressure (BP) believed to be caused by increased vagal activity. Two studies found intraoperative HR was PRECEDEX AND PACU STAYS 9 significantly lower in the Precedex group when compared to a control group receiving 0.9% normal saline (Coa et al., 2016; Hauber, 2015). However, Cao et al. (2016) found mean diastolic blood pressure (DBP) and systolic blood pressure (SBP) were not statistically different between groups. Some studies reported increased doses caused a transient hypertension intraoperatively (Hauber et al., 2015; Mahmoud & Mason, 2015; Taylor, 2016). Hauber et al. (2015) found a biphasic blood pressure response with a Precedex bolus of 0.5 mcg/kg over two to three seconds. A significant transient increase in SBP was seen at one minute followed by a significant decrease below baseline at three, four, and five minutes after a Precedex bolus. This change in BP was not enough to cause hemodynamic collapse or warrant pharmacological resuscitation (Hauber et al., 2015; Mahmoud & Mason, 2015). Recovery time was found to be significantly prolonged in patients receiving Precedex bolus or infusion near the end of surgery (Bediril et al., 2017; Cao et al., 2016). However, patients receiving Precedex boluses early perioperatively did not have prolonged recovery times (Cao et al., 2016). Hauber et al. (2015) found a discrepancy in post-anesthesia care unit (PACU) phase 1 recovery times. There was no significant prolonged recovery time in the Precedex group when compared to the control group in the main hospital. However, the surgical satellite campus saw prolonged PACU phase 1 recovery in the Precedex group. This is believed to be caused by other confounding variables such as different staff, fewer PACU resources, and patient populations. In addition to prolonged recovery times, prolonged extubation times were observed in two studies (Bediril et al., 2017; Koceroglu et al., 2020) Two pediatric deaths were filed between December 1999 through May 2015. 25 serious non-fatal adverse events (i.e. syncope, cardiac failure, Torsades de pointes, QT prolongation, and supraventricular tachycardia) with Precedex administration were reported in this same time PRECEDEX AND PACU STAYS 10 frame. It is noted these serious adverse events and deaths were confounded by serious patient comorbidities and may not be directly linked to the administration of Precedex (Taylor, 2016). Precedex versus alternative pharmacology The anesthetic choice is a contributing risk factor for POED. Multiple studies have shown increased incidence of POED among patients receiving volatile anesthetics (i.e. Sevoflurane, Isoflurane, Desflurane, and Halothane) (Bediril et al., 2017; Fitzsimmons et al., 2017; Lerman, 2020). The rapid emergence from anesthesia is considered the main risk factor in emergence delirium. Moore and Anghelescu (2017) conclude the most effective to least effective anesthetics for prevention of POED are Precedex, fentanyl, ketamine, clonidine, and a propofol bolus at the end of an anesthetic. Two studies reviewed the effects of Precedex versus the effects of tramadol on preventing POED. In a randomized control trial (RCT) of 60 pediatric patients undergoing adenotonsillectomy, the Precedex group had significantly lower HR and BP compared to the tramadol group (Koceroglu et al., 2020). Another RCT of 77 patients compared these drugs in patients undergoing adenotonsillectomy and found significant hypotension, bradycardia, prolonged sedation, and prolonged PACU stay with Precedex administration. Postoperatively, there was no difference in SBP, DBP, or HR between groups (Bediril et al., 2017). These studies found differing results on Precedex versus tramadol in preventing POED. Koceroglu et al. (2020) determined Precedex was more effective at reducing POED when compared to tramadol. However, Bediril et al. (2017) found no difference in POED between these two groups. When intranasal Precedex was compared to oral midazolam (a benzodiazepine class drug), patients were less likely to wake up with POED after receiving Precedex (Fitzsimmons et al., 2017). Fitzsimmons et al. (2017) predict the reason for this improvement in POED is the PRECEDEX AND PACU STAYS 11 ability of Precedex to mimic a natural sleep cycle. Midazolam works on GABA receptors and is unable to produce such a sleep-like state, thus interrupting the natural sleep cycle owing to its POED effects (Fitzsimmons et al., 2017). Literature suggests the use of Precedex is advantageous in preventing POED. Further advantages of Precedex are multifactorial and include minimal respiratory depressant effects, organ protective effects, decreased opiate consumption, decreased volatile agent use, decreased incidence of postoperative nausea and vomiting, improved extubating conditions, and a mimicked natural sleep cycle. Disadvantages of Precedex include hypotension, bradycardia, sinus arrest, and prolonged extubation and recovery times. The risks of Precedex should be weighed against the benefits on a per patient basis. patient basis. Theoretical Framework Neumans Systems Model nursing theory helps define the framework for this project. This model provides a comprehensive approach to nursing care for patients undergoing stressors. The focus of Neumans Systems Model is maintaining systemic stability which is created by forces and stressors from the person and the environment that surrounds them (See Appendix A). Stressors are separated into three categories under this nursing model: intrapersonal, interpersonal, and extrapersonal. Intrapersonal stressors are internal reactions to ones own appearance. Interpersonal stressors are the environmental events that occur around the individual. Extrapersonal stressors are uncontrollable events that occur on a societal level (Health Research Funding, 2020). Precedex administration perioperatively focuses on intrapersonal and interpersonal stressors. Patients enter a sedative, yet arousable state following Precedex administration (Moore & Anghelescu, 2017). This intervenes and prevents intrapersonal and interpersonal stressors from offsetting systemic balance. PRECEDEX AND PACU STAYS 12 Three prevention areas contribute to maintain systemic wellness (Petiprin, 2016). Primary prevention is initiated in patient assessment and intervention. Secondary prevention is applied after the patient shows signs and symptoms of stress. The third prevention is initiated following the stressor when the patient enters the maintenance phase back to primary prevention (Petiprin, 2016). Precedex administration focuses on primary prevention. The goal of Precedex perioperatively is to prevent POED and prolonged PACU stays. Proving successful, Precedex will prevent the patient from experiencing intrapersonal and interpersonal stressors and ultimately prevent the need for secondary prevention strategies lessening the PACU recovery period. Goals, Objectives, and Expected Outcomes The goal of this project is to determine if intraoperative Precedex boluses extend the length of stay in the PACU. The target population for this project is pediatric patients, 2-12 years old, undergoing tonsillectomy and/or adenoidectomy surgery. Charts from January 2018 to July 2021 were included in a retrospective chart review. It is expected that patients who received Precedex will have a longer PACU stay than patients who did not receive Precedex. Additionally, it is expected patients receiving greater than a 0.5mcg/kg dose of Precedex will have a prolonged PACU stay. Project Design This quality improvement project entails a practice intervention. This project will gather quantitative data using a retrospective chart review. The results of this project may encourage a practice change among practitioners at the Arnett facilities to incorporate Precedex boluses intraoperatively or administer Precedex preoperatively. Project site and Population: PRECEDEX AND PACU STAYS 13 This project will be completed at Indiana University Arnett Hospital and Ambulatory Surgery Center (ASC) in Lafayette, Indiana. The ASC provides same day, outpatient surgeries. This center includes six fully equipped operating rooms and two endoscopy suites (Indiana University Health, 2020). Various surgeries are offered at this site including general surgery, orthopedics, urology, pain management procedures, gastroenterology, otolaryngology, and podiatry. A variety of patient demographics are cared for in this facility, including pediatrics. The population of Lafayette is estimated to be 71,721 with persons under five years old accounting for 7.5% of the population and persons under 18 years old accounting for 22.2% of the population. 84.1% of the population is Caucasian, while 8.9% of the population is African American (United States Census Bureau, 2019). The stakeholders for this project include the ASC staff including PACU nurses, anesthesia providers, surgeons, and financial executives. PACU nurses may care for patients longer postoperatively following Precedex administration. Anesthesia personnel may experience fewer calls to PACU for POED and related symptoms following Precedex. Surgeons may have patients with improved emergence and thus greater satisfaction following surgery. Financial executives may see decreased cost with Precedex administration. Although this is an added medication cost, it may decrease cost of other concomitant medications (i.e. opioids, antiemetics, and volatile agents). However, PACU times may be prolonged with Precedex administration and therefore increase cost. Methods Senior clinical analysts from IU Health gathered data for this project electronically. Data gathered from 797 patient charts between January 2018 through July 2021 were obtained. Inclusion criteria for this project were patient ages 2-12 years old undergoing tonsillectomy, PRECEDEX AND PACU STAYS 14 adenoidectomy, or both. Data collected for each chart included: procedure type, Precedex dose administered, date of surgery, minutes spent in PACU, patient weight and birthdate, and start and stop time of surgery. Data Analysis Pediatric patients undergoing adenoidectomy and/or tonsillectomy are included in this project, regardless of Precedex administration intraoperatively. Children were not randomly assigned to either group. Determination of which child received Precedex was solely provider preference. Statistical Package for the Social Sciences (SPSS) software was used to interpret the data. Frequencies and distributions were calculated for patient demographics. Data are presented as mean and standard deviation, median and range when appropriate. Pearson Correlation Coefficients and independent samples t-test were used to analyze data on Precedex administration and other factors affecting PACU stays. The primary outcome analyzed was PACU length of stay. Confounding variables analyzed were total Precedex dose administered intraoperatively, Precedex dose per kg, and length of surgery. PRECEDEX AND PACU STAYS 15 Results Patient Demographics Patient weight was included for 782 participants, no weight measurement was provided for 15 patients. The mean weight was 27.5 kg (see fig.1). The 25th percentile for weight was 16.7 kg, 50th percentile was 22.8 kg, and 75th percentile was 33.7kg for this population. Ages ranged from 2 to 12 years old. 16.1% of the population were 3 Figure 1 years old at the time of surgery, while only 3.9% of patients were 12 years old. The median age was 5 years old at the time of surgery and the mean age was 5.8 years old (see fig.2). No information was provided on patient gender, American Society of Anesthesiologists (ASA) classification, or comorbidities. Figure 2 PRECEDEX AND PACU STAYS 16 Precedex Administration A total of 797 charts were reviewed for this project. Of these, 91 patients (11.4%) received Precedex intraoperatively. No patients received Precedex prior to September 2020. The mean dose of Precedex administered was 0.37 mcg/kg. The minimum and maximum doses of Precedex administered were 0.09 mcg/kg and 1.14 mcg/kg, respectively (see fig. 3). The only information provided on Precedex administration is the total dose Figure 3 given. It is unknown whether Precedex was given in multiple boluses throughout the procedure or in one single dose. Additionally, it unknown whether the doses were given early or late in the operative period. The mean PACU stay, regardless of Precedex administration, was 99.5 minutes. An independent-Samples t test comparing the mean PACU stays of the Precedex group versus the non-Precedex group found there was no significant difference (t(795)=0.761, p >.05). The mean duration of stay of the Precedex group (M= 102.07, sd=30.27) was not significantly different from the mean of the non-Precedex group (M=99.27, sd= 33.25) (See Table 1). Table 1 PRECEDEX AND PACU STAYS 17 Additionally, a Pearson Correlation Coefficient was calculated for the relationship between total Precedex dose administered and duration of PACU stay. A weak correlation that was not significant was found (r(2)=0.013, p >.05) (See Table 2). Precedex dose is not related to duration of PACU stay. Table 2 Type of Surgery Of the 797 charts reviewed, 541 procedures (67.9%) completed were tonsillectomy and adenoidectomy (T&A) combined. 45 procedures (5.6%) were tonsillectomy, and 211 procedures (26.5%) were adenoidectomy (see Fig. 4). A one-way ANOVA comparing the PACU length of stay of participants who underwent tonsillectomy, adenoidectomy, or T&A was completed. A significant Figure 4 difference was found among the procedures (F(2, 794)=27.32, p<0.05) (see Table 3). Tukeys HSD was used to determine the nature of the difference between the procedures. This analysis revealed patients who underwent T&A had longer PACU stays (M=104.89 minutes, sd=34.37) Table 3 PRECEDEX AND PACU STAYS 18 than tonsillectomy patients (M=100.69 minutes, sd=34.87). Patients undergoing adenoidectomy (M=85.77, sd=23.46) had the shortest PACU duration (See Tables 4&5). Table 4 Table 5 Duration of Surgery The mean duration of surgery was 14 minutes. Surgery times range from 1 minute to 47 minutes (See Figure 5). A Pearson Correlation Coefficient was calculated for the relationship between length of surgery and duration of PACU stay. A weak correlation that was not significant was found (r(2)=.079, p>.05) (see Table 5). Length of surgery is not related to PACU stay duration. A scatterplot with a linear regression model is show in figure 6. The coefficient of determination (R2=.006) indicates PACU stay cannot be explained by the length of surgery. PRECEDEX AND PACU STAYS Figure 5 Table 5 Figure 6 19 PRECEDEX AND PACU STAYS 20 Discussion This project found no significant impact of Precedex administration on duration of PACU stay. The average PACU time was 102 minutes for patients receiving Precedex and 99 minutes for those not receiving Precedex. This was not statistically significant. Total Precedex dose administered was then studied for its effect on PACU stay. Again, there was no statistically significant (p>.05) effect on PACU stay with higher doses of Precedex administered. The type of surgery was analyzed for its effects on duration of PACU stay. A Significant difference was found between T&A, adenoidectomy, and tonsillectomy PACU stays. T&A patients stayed in PACU the longest for a mean duration of 104 minutes, while adenoidectomy patients stayed an average of 85 minutes, and tonsillectomy patients stayed an average of 100 minutes. There is no clear understanding why T&A patients stay longer in the PACU. Next, length of surgery was compared with PACU stay. A weak correlation was made between longer duration of surgery and prolonged PACU stays. However, this was not statistically significant. Assumptions It is assumed all procedures were done under general anesthesia using Sevoflurane. It is also assumed all patients were endotracheally intubated for these procedures. Lastly, it is assumed these patients were not paralyzed. Thus, patients did not require reversal medications that could alter hemodynamics. From this it is also assumed these patients did not suffer from inadequate ventilation due to inadequate paralytic reversal. Strengths and Limitations This projects major strength is the large retrospective dataset obtained through electronic medical records. Additional strengths include data on patient weight, dosing of Precedex per PRECEDEX AND PACU STAYS 21 kilogram, and age of the patient. There are few strengths to this project and several confounding variables that are not accounted for. Any associations or correlations made in this project are weakly supported. One major limitation to this project is the last dose of Precedex is unknown. Studies have shown Precedex given within 60 minutes of the end of a procedure prolongs PACU stays (Koceroglu et al., 2020; Manning et al., 2020). Next, there is no information regarding patient status in the PACU. Prolonged PACU stays could be due nonclinical reasons such as lack of transportation, staff availability, and staff education or comfort level. Additionally, prolonged stays could be due to clinical reasons such as pain, postoperative nausea and vomiting, POED, uncontrolled bleeding, intraoperative complications, patient comorbidities, hemodynamic instability, or adjunct medications (i.e. opioids, benzodiazepines, volatile anesthetics, etc.). Another limitation to this project is the data was limited to one institution and its associated ASC. Precedex was never administered in the first year of data included in this project. This is in part due to the limited availability of Precedex at this institution prior to 2020. Staff education and comfort level could be a limiting factor to the reliability of this data. Additionally, staff turnover may be prominent at this institution. It is unknown whether the same perioperative staff members were caring for these patients throughout the 3 years included in this project. These are variables that are unaccounted for in this project. One large variation in this project is surgery time. Surgery time does not include total time under anesthesia. One procedure had a documented surgery time of 1 minute. The longest surgery time documented was 47 minutes. These two outliers may skew the data. Additionally, a 47-minute case could have unforeseen complications that are not included in this project. Surgery time does not account for time to extubation. Different anesthesia providers may have PRECEDEX AND PACU STAYS 22 their patients fully awake prior to PACU arrival, while others may take their patients the PACU heavily sedated and minimally arousable. This would alter the data as this would take away from charted PACU recovery time. This project does not account for extubation to PACU arrival time. Turnover time from OR to PACU could be prolonged and thus not account as PACU time although the patient was already recovering from anesthesia. Patient data is limited to weight and birthdate. Additional medical history for patients was not provided. This includes comorbidities, mental health concerns, and daily medications. It is unknown whether these patients received a tonsillectomy and/or adenoidectomy due to recurrent infections or obstructive sleep apnea (OSA). OSA is one of the most common indications for this surgery. OSA places patients at an increased risk postoperatively for respiratory complications (Cao et al., 2016). Additionally, if a patient is extremely anxious or fearful in the preoperative setting, they will likely experience these same feelings postoperatively (FitzSimmons et al., 2017). Daily medications can alter the patients metabolism of volatile anesthetics and other medications given. They may require higher dosing, potentially more narcotics, and thus achieve a deeper level of sedation in the PACU. Lastly, there is no intraoperative hemodynamic data provided. Intraoperative complications may lead to prolonged PACU stays. One study found the use of intraoperative Precedex prolonged PACU stays due to the hemodynamic instability (bradycardia and hypotension) the patient experienced intraoperatively (Haobo et al., 2021). Conclusion There are a vast number of confounding variables to make any significant conclusions from this project. Further research on the use of Precedex in pediatric patients is required. Longer, more complex cases may help determine the effect of early versus late dosing of PRECEDEX AND PACU STAYS 23 Precedex and its effect on PACU length of stay. Additionally, further studies on perioperative medications in addition to Precedex will help determine appropriate sedation levels to decrease length of PACU stays. Precedex may safely be used in pediatric patients undergoing tonsillectomy and/or adenoidectomy. Its side effects are not measured directly in this project however, it did not prolong PACU stays in this cohort. PRECEDEX AND PACU STAYS 24 References Bediril, N., Akcabay, M., & Emik, U. (2017). Tramadol vs dexmedetomidine for emergence agitation control in pediatric patients undergoing adenotonsillectomy with sevoflurane anesthesia: prospective randomized controlled clinical study. BMC Anesthesiology, 17(41), 1-7. https://doi:10.1186/s12871-017-0332-4 Cao, J., Pei, Y., Wei, J., & Zhang, Y. (2016). Effects of intraoperative dexmedetomidine with intravenous anesthesia on postoperative emergence agitation/delirium in pediatric patients undergoing tonsillectomy with or without adenoidectomy. Medicine, 95(49), 1-6. http://dx.doi.org/10.1097/MD.0000000000005566 FitzSimons, J., Bonanno, L. S., Pierce, S., & Badeaux, J. (2017). Effectiveness of preoperative intranasal dexmedetomidine, compared with oral midazolam, for the prevention of emergence delirium in the pediatric patient undergoing general anesthesia : a systematic review. The Joanna Briggs Institute, 14(8), 70-79. https://10.11124/JBISRIR-2016003059 Hauber, J. A., Davis, P. J., Bendenl, L. P., Martyn, S. V., McCarthy, D. L., Evans, M., Cladis, F. P., Cunningham, S., Lang, R. S., Campbell, N. F., Tuchman, J. B., & Young, M. C. (2015). Dexmedetomidine as a rapid bolus for treatment and prophylactic prevention of emergence agitation in anesthetized children. Anesthesia Analgesia, 121(5), 1308-1315. https://DOI:10.1213/ANE.0000000000000931 Health Research Funding. (2020). Betty Neumans nursing theory explained. Retrieved October 26, 2020, from https://healthresearchfunding.org/betty-neumans-nursing-theoryexplained/ PRECEDEX AND PACU STAYS 25 Indiana University Health. (2020). IU Health Arnette outpatient surgery center- Lafayette. Retrieved November 10, 2020, from https://iuhealth.org/find-locations/iu-health-arnettoutpatient-surgery-center-lafayette-iu-health-arnett-outpatient-surgery-center-1327veterans-memorial-pkwy-e Koceroglu, I., Devrim, S., Tanriverdi, T. B., & Celik, M. G. (2020). The effects of dexmedetomidine and tramadol on post-operative pain and agitation, and extubation quality in paediatric patients undergoing adenotonsillectomy surgery: A randomized trial. Journal of Clinical Pharmacy and Therapeutics, 45(2), 340-346. https://doi:10.1111/jcpt.13080 Lerman J. (2018). Emergence delirium and agitation in children. UpToDate. Retrieved September 11, 2020, from https://www.uptodate.com. Mahmoud, M. & Mason, K. P. (2015). Dexmedetomidine: review, update, and future considerations of paediatric perioperative and periprocedural applications and limitations. British Journal of Anaesthesia, 115(2), 171-182. https://doi:10.1093/bja/aev226 Mann-Farr, J., Egan E., Higgins, A., Wysocki, L., Vaux, A., Arndell, E., & Burmeister, E. A. (2019). Are postoperative clinical outcomes influenced by length of stay in the postanesthesia care unit?Journal of Perianesthesia Nursing, 34(2), 386-393. https://doi:10.1016/j.jopan.2018.07.004 Manning, A. N., Bezzo, L. K., Hobson, J. K., Zoeller, J. E., Brown, C. A., & Henderson, K. J. (2020). Dexmedetomidine dosing to prevent pediatric emergence delirium. The Journal of the American Association of Nurse Anesthetists, 88(5), 359-364. PRECEDEX AND PACU STAYS 26 Moore, A. D. & Anghelescu, D. L. (2017). Emergence delirium in pediatric anesthesia. Pediatric Drugs, 19, 11-20. https://doi.10.1007/s40272-016-0201-5. Petiprin, A. (2016). Neumans systems model. Retrieved from https://nursingtheory.org/theories-and-models/neuman-systems-model.php Taylor, A. M. (2016, April 12). Pediatric focused safety review Precedex (dexmedetomidine) pediatric advisory committee meeting. [PowerPoint slides]. U.S. Food and Drug Administration. https://www.fda.gov/media/96854/download United States Census Bureau. (2019). QuickFacts: Lafayette city, Indiana. Retrieved November 10, 2020, from https://www.census.gov/quickfacts/fact/table/lafayettecityindiana/PST045219 PRECEDEX AND PACU STAYS APPENDIX A: Neumans Systems Model 27 PRECEDEX AND PACU STAYS Reference in APA format 28 Level of Evidence Variables Sample Instruments Results References Bediril, N., Akcabay, M., & Emik, U. (2017). Tramadol vs dexmedetomidine for emergence agitation control in pediatric patients undergoing adenotonsillectomy with sevoflurane anesthesia: prospective randomized controlled clinical study. BMC Anesthesiology, 17(41), 1-7. https://doi:10.1186/s12871-017-0332-4 Cao, J., Pei, Y., Wei, J., & Zhang, Y. (2016). Effects of intraoperative dexmedetomidine with intravenous anesthesia on postoperative emergence agitation/delirium in pediatric patients undergoing tonsillectomy with or without adenoidectomy. Medicine, 95(49), 1-6. http://dx.doi.org/10.1097/MD.0000000000005566 Level II Level II tramadol administration intraoperatively, dexmedetomidine administration intraoperatively 1 mcg/kg dexmedetomidine infusion over 10 minutes vs. 0.9% normal saline infusion over 10 minutes (control group) 77 patients, aged 212yo undergoing adenotonsillectomy with sevoflurane anesthesia observational pain scale, Pediatric Anesthesia Emergence Delirium (PAED) scale, Aldrete scoring 68 patients aged 28yr of American Society of Anesthesiologist physical status I or II, scheduled for tonsillectomy with or without adenoidectomy under general anesthesia Pediatric Anesthesia Emergence Delirium (PAED) scale, objective pain score (OPS), summary statistics for HR, SBP, DBP, recovery time, and extubation time. dexmedetomidine caused intraoperative hypotension, bradycardia, prolonged extubation time, and residual sedation with prolonged PACU stay. Both dexmedetomidine and tramadol were effective in controlling postoperative pain and emergence agitation. intraoperative infusion of dexmedetomidine is sufficient anesthesia for patients undergoing tonsillectomy with or without adenoidectomy. Significant side effects (prolonged extubation time, bradycardia, and hypotension) and a lower incidence of OPS scores was observed with dexmedetomidine infusions. However, a significantly lower incidence of POED in the PRECEDEX AND PACU STAYS 29 dexmedetomidine group was not observed. FitzSimons, J., Bonanno, L. S., Pierce, S., & Badeaux, J. (2017). Effectiveness of preoperative intranasal dexmedetomidine, compared with oral midazolam, for the prevention of emergence delirium in the pediatric patient undergoing general anesthesia : a systematic review. JBI Database of Systematic Reviews and Implementation Reports, 15(7), 19341951. https://doi:10.11124/JBISRIR-2016-003096 Level I preoperative oral midazolam, preoperative intranasal dexmedetomidine 117 articles which reviewed pediatric patients aged 3-7yo with an American Society of Anesthesiologists (ASA) classification of I or II who underwent general anesthesia for elective/ambulatory surgery Pediatric Anesthesia Emergence Delirium (PAED) scale There is insufficient evidence to prove the use of intranasal dexmedetomidine, when compared to oral midazolam, is effective in preventing emergence delirium PRECEDEX AND PACU STAYS Hauber, J. A., Davis, P. J., Bendenl, L. P., Martyn, S. V., McCarthy, D. L., Evans, M., Cladis, F. P., Cunningham, S., Lang, R. S., Campbell, N. F., Tuchman, J. B., & Young, M. C. (2015). Dexmedetomidine as a rapid bolus for treatment and prophylactic prevention of emergence agitation in anesthetized children. Anesthesia Analgesia, 121(5), 1308-1315. https://DOI:10.1213/ANE.0000000000000931 Koceroglu, I., Devrim, S., Tanriverdi, T. B., & Celik, M. G. (2020). The effects of dexmedetomidine and tramadol on post-operative pain and agitation, and extubation quality in paediatric patients undergoing adenotonsillectomy surgery: A randomized trial. Journal of Clinical Pharmacy and Therapeutics, 45(2), 340-346. https://doi:10.1111/jcpt.13080 30 Level II dexmedetomidine bolus, heart rate, systolic blood pressure, diastolic blood pressure, respiratory rate, blood oxygen saturation, emergence delirium 400 pediatric patients, aged 410yo undergoing tonsillectomy with or without adenoidectomy, with or without myringotomy, and/or tympanostomy tube insertion Level II tramadol vs dexmedetomidine administration intraoperatively, hemodynamics (BP, HR), extubation time, postoperative pain, agitation, adverse events pain point system scale (PPSS), 60 patients, aged 2Riker Sedation9yo undergoing Agitation Scale adenotonsillectomies (SAS) Pediatric Anesthesia Emergence Delirium (PAED) scale Rapid IV bolus administration of dexmedetomidine in children improved their recovery by reducing the incidence of emergence delirium. A statistically significant change in hemodynamics wasobserved, but no patients required any intervention for hemodynamic changes.Dexmedetomidine reduced the incidence of postoperative opioid administration, and a trend of fewer adverseevents was observed. patients in dexmedetomidine group had significantly lower heart rates than the tramadol group. Dexmedetomidine group had improved extubating conditions (fewer periods of not breathing, no coughing, and less desaturation). Extubation time was significantly longer in the dexmedetomidine group. PRECEDEX AND PACU STAYS Mahmoud, M. & Mason, K. P. (2015). Dexmedetomidine: review, update, and future considerations of paediatric perioperative and periprocedural applications and limitations. British Journal of Anaesthesia, 115(2), 171-182. https://doi:10.1093/bja/aev226 Manning, A. N., Bezzo, L. K., Hobson, J. K., Zoeller, J. E., Brown, C. A., & Henderson, K. J. (2020). Dexmedetomidine dosing to prevent pediatric emergence delirium. The Journal of the American Association of Nurse Anesthetists, 88(5), 359-364. Moore, A. D. & Anghelescu, D. L. (2017). Emergence delirium in pediatric anesthesia. Pediatric Drugs, 19, 11-20. https://doi.10.1007/s40272-016-0201-5. 31 Level I pediatric perioperative use of dexmedetomidine (airway procedures, cardiac surgery, dental procedures, regional anesthesia, ambulatory surgery, painful procedures) and end-organ effects of dexmedetomidine (kidney and brain) POED, PONV, time to emergence (or awakening), PACU length of stay, analgesic requirements, incidence of bradycardia and HoTN Level I anesthesia techniques (propofol, benzodiazepines, opioids, gabapentin, ketamine and 99 published Dextromethorphan, scholarly articles Level I 127 published scholarly articles 7 published scholarly articles NA Dexmedetomidine provides sedation that parallels natural sleep, anxiolysis, analgesia, sympatholysis, and an anaesthetic-sparing effect with minimal respiratory depression. It has organ protective effects. High dose, rapid bolus will cause bradycardia and hypotension. Decreases postoperative pain scores. PAED, Watcha Scale, 5 point scale Faces Legs Activity Cry Consolability scale (FLACC), Pediatric Anesthesia Emergence Delirium (PAED) scale DEX immediately after induction of anesthesia is beneficial. DEX prevents POED in pediatric patients. DEX lessens need for opioids and decreases PONV. Interventional algorithm developed for preventing emergence delirium (ED). There are two options for reducing the risk of ED. The use of propofol as a single-agent anesthetic or add an adjuvant (e.g., dexmedetomidine, PRECEDEX AND PACU STAYS 32 alpha-2 agonists, regional blocks) fentanyl, ketamine, clonidine, propofol bolus at the end of anesthesia) to an inhalational anesthetic.  ...

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UTILIZATION OF ERAS PROTOCOLS Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 2022 Utilization of ERAS Protocols to Reduce Postoperative Opioid Consumption Nicholas Sparks Leighton School of Nursing, Marian University Chair: Dr. Marie Goez Dr. Marie Goez ___________________________ Dr. Marie Goez (Apr 24, 2022 18:53 CDT) Project Team Members: Dr. Christina Pepin ___________________________ Christina Pepin PhD RN CNE (Apr 24, 2022 19:54 EDT) 1 UTILIZATION OF ERAS PROTOCOLS 2 Table of Contents Abstract ........................................................................................................................................... 4 Utilization of ERAS Protocols to Reduce Postoperative Opioid Consumption ............................. 5 Background ................................................................................................................................. 5 Problem Statement ...................................................................................................................... 6 Gap Analysis ................................................................................................................................... 7 Review of Literature ....................................................................................................................... 8 Methods....................................................................................................................................... 8 Enhanced Recovery After Surgery ............................................................................................. 8 Postoperative Pain Management ................................................................................................. 9 Reduction in Opioid Consumption ........................................................................................... 10 Multimodal Therapies ............................................................................................................... 10 Theoretical Framework ................................................................................................................. 11 Proposition 1: Multimodal Therapy .......................................................................................... 12 Proposition 2: Attentive Care.................................................................................................... 12 Proposition 3: Patient Participation .......................................................................................... 13 Project Proposal Components ....................................................................................................... 13 Goals, Objectives, and Expected Outcomes ............................................................................. 13 Project Design ............................................................................................................................... 13 UTILIZATION OF ERAS PROTOCOLS 3 Sample........................................................................................................................................... 14 Methods......................................................................................................................................... 14 Measurement Instruments ......................................................................................................... 15 Data Collection ......................................................................................................................... 15 Data Analysis ............................................................................................................................ 16 Results ........................................................................................................................................... 17 Discussion ..................................................................................................................................... 18 Future Implications ................................................................................................................... 19 Ethical Considerations/Protection of Human Subjects ............................................................. 20 References ..................................................................................................................................... 21 Appendix A ................................................................................................................................... 25 Appendix B ................................................................................................................................... 36 UTILIZATION OF ERAS PROTOCOLS 4 Abstract The use of perioperative opioids for pain management can come with great consequences as the opioid crisis is more prevalent than ever. In the US, nearly 70% of all opioid tablets prescribed after surgery become problematic as they are diverted and not used for medical benefit (Soffin et al., 2019). Enhanced Recovery After Surgery (ERAS) guidelines were developed over two decades ago with over 17 tools to improve postoperative recovery as well as reduce the economic burdens of healthcare; including the burden of the opioid crisis (Beloeil et al., 2019). By retrospective chart review, analysis of potential benefits in reducing postoperative opioid consumption as well as pain scores led to developing suggestions for implementation of ERAS items into practice at the project site. With no current practice guidelines in effect, the study found that implementation of multimodal anesthesia through combinations of ERAS items can reduce overall fentanyl consumption (p<.001) as well as reduce pain for up to 4 hours after surgery (p=.022). By evaluating current practice at the project site, recommendations should be made to explore the benefits of implementing combinations of ERAS items to promote better postoperative recovery as well as reduce the burden of the prescription opioid crisis. UTILIZATION OF ERAS PROTOCOLS 5 Utilization of ERAS Protocols to Reduce Postoperative Opioid Consumption In the United States, it is estimated that over 2 million people struggle with the abuse of opioids with an estimation that an opioid overdose leads to one death every fifteen seconds (Soffin et al., 2019). Opioids are used in many areas of healthcare to treat moderate to severe pain, but a major contributor to opioid consumption is during the perioperative and postoperative period of anesthesia. Although opioids are known to effectively treat all types of pain, there is potential for serious adverse outcomes contributing to an annual healthcare cost of nearly $80 million (Soffin et al., 2019). To combat the opioid crisis, the implementation of new practice guidelines has and can continue to reduce the consumption of opioids during the postoperative period. Background Pain is a perception of sensory input received as result of a noxious or unpleasant stimulus (Brown et al., 2018). This unpleasant sensation results from a stimulus activating opioid receptors in sensory pathways throughout the spinal cord and brain (Tedesco et al., 2017). Opioids such as morphine, fentanyl, and hydromorphone are commonly used in anesthesia to block the transmission of pain signals at the opioid receptors caused by surgical stimulation, thus reducing the perception of pain (Brown et al., 2018). Since opioids are known to work on several sensory pathways, adverse effects can result from dose-dependent opioid administration such as respiratory depression, hyperalgesia, sedation, hemodynamic instability, nausea, and vomiting (Oseka & Pecka, 2018). These adverse effects have shown to increase hospital length of stay, morbidity and mortality, and healthcare cost (Wainwright et al., 2020). Over the last decade, implementation of ERAS protocols has helped reduce overall hospital stays for surgical patients from lengths of stay of 5-10 days to 1-3 UTILIZATION OF ERAS PROTOCOLS 6 days (Wainwright et al., 2020. To reduce the adverse effects of opioids, new protocols have been implemented to treat pain while reducing the overall consumption of opioids. To reduce the magnitude of the opioid crisis, anesthesia providers have developed Enhanced Recovery After Surgery (ERAS) protocols utilizing multimodal therapies to reduce postoperative pain, shorten hospital stays, and reduce opioid consumption (Oseka & Pecka, 2018). ERAS focuses on 17-20 areas that are centered around optimizing the patient preoperatively as well as choosing the best intraoperative plan to enhance recovery and promote patient satisfaction (Wainwright et al., 2020). Multimodal analgesia consists of many combinations of techniques ranging from neuraxial anesthesia and peripheral nerve blocks to non-steroidal anti-inflammatory drugs (NSAIDS) and gabapentinoids to alter pain perception resulting in less pain after surgery (Wainwright et al., 2020). Though the ERAS is not a universal practice guideline, it is a multifaceted tool that can be used to tailor the anesthetic plan to the specific situation or patient. For example, using alternative analgesics such as gabapentin can significantly reduce postoperative opioid consumption (p < .001) in patients undergoing surgical intervention for up to 48 hours (Clarke et al., 2014). By using alternative techniques outlined in ERAS guidelines, overall opioid consumption can be reduced by tailoring the plan to the individual patient. Problem Statement In many facilities, opioids continue to be a first-line treatment for pain, which adversely can increase the chance for lengthened hospital stays and adverse outcomes such as nausea, vomiting, delayed awakening, hypotension, bradycardia, or respiratory depression which can all delay recovery times and early transfer (Soffin et al., 2019). By evaluating and comparing the UTILIZATION OF ERAS PROTOCOLS 7 use of ERAS guided anesthesia, using a multimodal approach to reduce postoperative opioid consumption can provide major benefits during the first 24 hours of recovery after surgery. Gap Analysis Current practice implementation for the project site focuses heavily on the administration of opioid analgesics to reduce postoperative pain following surgery. As an acute care hospital, focus is on early recovery after surgery and quick discharge from the post-anesthesia care unit (PACU). Utilization of opioids can provide excellent analgesia but can also prolong recovery due to the adverse effects associated with administration. By implementing ERAS protocols with a multimodal approach, overall reduction of opioids can adequately lead to effective pain management as well as earlier recovery and less unwanted effects after surgery. The major barriers to implementation of this project include alteration of current practice as well as the development of a specific facility practice guideline designating ERAS items as a treatment protocol. In anesthesia, there is a vast variety of methods and techniques that can be used to delivery safe and effect anesthesia as if everyone has a certain recipe that they frequently use. Change and alteration of current practice will require strong evidence, administrative and partner support, and adequate data to support the need for change. This can be evaluated by beginning investigation into the potential improvements in recovery and pain management. Development of new protocols and guidelines is a multifaceted process involving a collection of specialties to ensure proper implementation. Not only will anesthesia providers require education and alteration in care delivery, auxiliary staff such as operating room nurses, recovery room nurses, physicians, and other healthcare personnel will need to be educated on ERAS recommendations as and the treatment guidelines that would change practice. Approval UTILIZATION OF ERAS PROTOCOLS 8 from administration to implement a new practice guideline could require ample time and resources to investigate its benefits through pilot studies and trials within the facility. With these barriers, the purpose of this study is to evaluate the potential benefits that could propose recommendations to improve clinical outcomes for surgical patients. Review of Literature Methods The search for evaluation of ERAS protocols and opioid consumption began through major database searching including PubMed, CINAHL, Google Scholar, and MEDLINE. The keywords and phrases that yielded the most significant results included ERAS protocols, reduced opioid consumption, ERAS AND multimodal analgesia and multimodal analgesia. The search was limited to peer-reviewed articles, systematic reviews, meta-analyses, and randomized control trials (RCTs) that have been published in the last 5 years. Even after narrowing the search with the above criteria, a collection of 1014 articles were discovered. In the current phase of research, seventeen articles currently have been discovered as relevant to the proposed topic of how ERAS protocols can reduce postoperative pain and opioid consumption. Enhanced Recovery After Surgery To improve overall patient outcomes for individuals undergoing surgery and anesthesia, collaborating healthcare professionals were driven to develop a set of guidelines to improve the overall patient surgical experience. The ERAS guidelines were developed to provide evidencebased recommendations that improve surgical outcomes (Oseka & Pecka, 2018). Such evidence has been proven to reduce postoperative complications, decrease length of stay, accelerate discharge, reduce opioid consumption, and reduce postoperative pain (American Association of Nurse Anesthetists, 2017). In a prospective control study evaluating the ERAS guidelines for UTILIZATION OF ERAS PROTOCOLS 9 patients undergoing TKA, 247 patients were evaluated for postoperative complications (Zhu et al., 2017). The results indicated that patients who received anesthesia guided by ERAS guidelines experienced 15% less complications than the control group as well as reduction in postoperative pain in the first 24 hours after surgery (Jiang et al., 2019). This information is further reiterated during a meta-analysis of 9936 orthopedic cases involving TKAs and total hip arthroplasties where significantly lower length of stays as well as postoperative complication rates were discovered in the 4205 cases receiving ERAS guidelines (p<.01) in comparison to those receiving control group modalities (Zhu et al., 2017). Postoperative Pain Management Though ERAS protocols are designed to deliver enhanced recovery over the entire continuum of care for an individual, the various strategies are best evaluated over the first 24 hours after surgery. Postoperative pain is one of the most common complications experienced after surgical intervention and often requires management to reduce nociception or sensory transmission (Brown et al., 2018). Nociception can occur without pain as pain is the conscious response to nociceptive stimulation (Kaye et al., 2020). This entails that physiological stress from nociception and pain can occur intraoperatively even with sedation, thus, requiring early intervention to reduce pain throughout the entire surgical continuum (Oseka & Pecka, 2018). Administration of powerful opioids is not the only way to manage pain after surgery. Wainwright et al. (2020), collectively produced 17 recommended guidelines driven by ERAS to manage patients undergoing surgery. Of these guidelines, they included alternative treatments to pain management that include choosing to provide neuraxial anesthesia and peripheral nerve blocks to reduce the overall general anesthesia requirements to enhance and quicken recovery as well as reduce opioid consumption (Oseka & Pecka, 2018). The American Association of Nurse UTILIZATION OF ERAS PROTOCOLS 10 Anesthetists published its own ERAS guidelines which include therapies like the use of steroids, NSAIDs, gabapentinoids, ketamine, local anesthetics, acetaminophen, dexmedetomidine, or different combinations of similarly classified medications to reduce the complications associated with excessive opioid consumption (American Association of Nurse Anesthetists, 2017). Reduction in Opioid Consumption The shocking statistics involving the consumption of opioids in the United States drives the need for alternative therapies. Opioid-related substance abuse disorder affects over 2 million Americans alone and results in an annual healthcare bill of $80 billion dollars to treat, contain, and control the damage it accrues (Soffin et al., 2019). To counter the opioid crisis, one major focus of ERAS protocols is to reduce opioid consumption during surgery by balancing anesthesia through the opioid-sparing effects of multiple therapies to provide better surgical outcomes with less complications (Wainwright et al., 2020). A double-blind RCT known as the OCTOPUS study utilized eight subject groups that received non-opioid analgesic treatments in comparison to a morphine control group (Beloeil et al., 2019). This study discovered that non-opioid analgesic treatments consumed significantly less morphine postoperatively (p<0.05) as well as had lower overall visual analog scores (p<0.01) for rating pain (Beloeil et al., 2019). Multimodal Therapies Though recommendations for ERAS guidelines include the use of opioids, alternative medications should be considered when individualizing pain management. By exploring all modalities, one can equip themselves with the necessary tools to individualize patient care. One heavily emerging therapy recommendation is the use of dexmedetomidine (Precedex), a potent alpha-2 agonist that greatly benefits anesthesia by providing hypnotic/sedation, anxiolytic, sympatholytic, and analgesic effects (Kaye et al., 2020). Few medications can provide all these UTILIZATION OF ERAS PROTOCOLS 11 benefits when used correctly, meaning less medications are used with less risk for adverse effects or synergistic outcomes. In a meta-analysis discussing the benefits of dexmedetomidine, over 1792 patients were evaluated after administration of dexmedetomidine and found that VAS ratings were lower than the control group and the dexmedetomidine group consumed 30% less opioids in the postoperative period (p<0.05) (Kaye et al., 2020). Another modality to combat opioid consumption as well as the negative side effects of various medication therapies is to use nonpharmacological treatment to reduce postoperative pain and opioid consumption. Patients can be very sensitive to medications or have previous histories of opioid dependence, therefore, exploring nonpharmacological methods can be beneficial to such patient populations. Alternative therapies such as continuous passive motion, preoperative exercise, cryotherapy, electrotherapy, and acupuncture have all been studied as effective therapies to counter postoperative pain (Tedesco et al., 2017). In a large systematic review, 3 large RCTs discovered electrotherapy to effectively reduce postoperative pain in the first 48 hours postoperative by stimulating with non-painful electrical stimulus to block pain transmission at pain fibers (Brown et al., 2018). Acupuncture has been studied and is shown to be beneficial in reducing postoperative pain by an average of 2 points on the VAS in the first 24 hours after operation (Tedesco et al., 2017). Alternatives may not be successful for all patients experiencing moderate to severe pain but can help reduce opioid consumption and related consequences if balanced with a multimodal approach. Theoretical Framework Some of the most important concepts of ERAS guidelines are promoting a quick recovery without adverse outcomes and adequate pain relief following surgery. The middle range theory known as a balance between analgesia and side effects was created by Marion Good in 1998, to UTILIZATION OF ERAS PROTOCOLS 12 promote recovery and reduce pain through multimodal therapy (Good, 1998). This coincides with the same goals as ERAS guidelines which align to reduce recovery room length of stay, minimize postoperative pain, and advocate for early ambulation (Oseka & Pecka, 2018). This theoretical framework is centered on a continuum of three propositions: 1) Multimodal Therapy; 2) Attentive Care; and, 3) Patient Participation (Good, 1998) (see Figure 1, Appendix B Framework). The framework connects the three propositions to the nursing process and how it could be utilized with ERAS guidelines. Proposition 1: Multimodal Therapy Postoperative pain management often starts with the use of opioids. One way to reduce opioid consumption is to incorporate the use of both pharmacological and non-pharmacological adjuvants in the treatment plan (Peterson & Bredow, 2013). The ERAS guidelines focus heavily on substituting non-steroidal anti-inflammatory drugs (NSAIDs), gabapentin, acetaminophen, and peripheral and regional nerve blocks for pain management (Oseka & Pecka, 2018). Proposition 2: Attentive Care Proper pain management requires frequent nursing assessment for analgesia as well as side effects. Using the nursing process to assess, diagnose, plan, implement, and evaluate in a cyclical pattern can be used to appropriately manage analgesia and side effects (Good, 1998). By utilizing assessment and evaluation of multimodal therapy, nurses can effectively balance analgesia and adverse outcomes while reducing opioid use in the postoperative period (Oseka & Pecka, 2018). UTILIZATION OF ERAS PROTOCOLS 13 Proposition 3: Patient Participation Educating the patient and setting realistic goals for pain can improve patient outcomes and reduce adverse events. Putting the patient at the center of his or her treatment plan can be the key to achieving postoperative goals and early recovery (Good, 1998). Project Proposal Components Goals, Objectives, and Expected Outcomes The purpose of this project is to determine the effectiveness of ERAS guidelines in reducing postoperative opioid consumption. The objective is to compare evidence-based practice guidelines and compare them to the current anesthesia delivery methods used at this project site, it is expected that utilizing ERAS guidelines will provide adequate postoperative pain relief with potential decrease in opioid consumption. This will be an assessment for this site and surgical population to determine if alteration or full implementation of ERAS guidelines can provide better outcomes for patients in the first 24 hours following surgery. Project Design A retrospective chart review was completed comparing the project sites traditional practice to ERAS guided anesthesia methods. The data was collected utilizing a quantitative descriptive approach utilizing cases that have been completed over a 9-month period. Reviewed case data completed during this period through electronic health records was manually entered into a Microsoft Excel spreadsheet and categorized and organized for analysis. Statistical analysis was completed through JASP data analysis software to determine correlations and relationships of patient variables and outcomes to the study design. UTILIZATION OF ERAS PROTOCOLS 14 Sample The collected sample consisted of 58 patients undergoing general or gynecological procedures. The subjects ranged in age from 18-85 years old and were randomly selected to meet the criteria for each group. The control group consisted of 30 patients selected at random from electronic medical record (EMR) data that were compared to 28 patients who received ERAS interventions. Inclusion criteria consists of patients undergoing surgery at the project site and receiving opioid analgesics throughout the perioperative period or ERAS recommendations as specified in the preoperative anesthetic evaluation. Exclusion criteria was used to eliminate procedures that resulted in severe postoperative complications such as surgical site infections (SSI), bowel dehiscence, or conversion to open laparotomy after laparoscopic designation. Methods The implementation of ERAS recommended interventions was compared to a control group with ample opioid administration in patients undergoing gynecological/obstetrical and general surgery procedures. With collaboration of a project mentor, an agreement was established to access data through chart audits of human subjects with the exemption granted from Marian Universitys Institutional Review Board (IRB) as well as approval from the sites research administration. A retrospective chart review was completed to evaluate the effects of implementation of ERAS guided anesthesia on reduction of opioid consumption and postoperative pain. Charts were reviewed investigating a 9-month period comparing opioid consumption and pain scores between an opioid control group and an ERAS guided anesthesia approach. Personal health information was avoided and de-identified from data collection. Demographic data such as age, gender, and ASA status was collected as well as anesthesia delivery techniques, medication UTILIZATION OF ERAS PROTOCOLS 15 reconciliation, pain scores, and opioid consumption. Data analysis was used to determine if ERAS recommendations can reduce opioid consumption and/or postoperative pain scores. Measurement Instruments Multiple variables were used during this project to determine the effectiveness of the ERAs interventions. The independent variables utilized include implemented ERAS recommendations as individual or combination techniques during the delivery of anesthesia. Such variables include perioperative use of acetaminophen, dexamethasone, ketorolac, dexmedetomidine, ketamine, magnesium, lidocaine, and regional or local anesthetic techniques. Combinations of the above were also evaluated per recommendation by ERAS guidelines. Dependent variables evaluated during this study include interval postoperative pain scores, total opioid consumption, and postoperative length of stay (LOS). Due to the format of EPIC electronic health records, a VAS score was unobtainable and replaced with a numerical pain scale ranging from 0-10 for time interval assessments. Data Collection Data was collected from July 2021 to October 2021 through retrospective chart review of surgical cases completed from January 2021 to September 2021. The data was compiled into Microsoft Excel as de-identified case numbers. The tool was self-created and organized based on the data collected from electronic health records (EHR) at the project site. The data selected for each case included demographics, perioperative interventions, postoperative outcomes, serial pain scores, and opioid consumption totals. Yes or no responses were used to detail if the patients received a specific perioperative intervention or a combination of ERAS interventions. Pain scores were recorded in time intervals of 30 minutes and 2, 4, 8, and 24 hours after surgery UTILIZATION OF ERAS PROTOCOLS 16 with a numerical scale ranging from 0-10. Opioid consumption was labeled and collected in terms of value by total amount consumed in milligrams and micrograms. Nominal variables including surgery type, gender, and ASA status were analyzed to distinguish relationships among variables. Age in years was entered as an integer variable. Other nominal variables include the proposed ERAS interventions and administrations of preoperative carbohydrates, acetaminophen, ketorolac, ketamine, dexmedetomidine, lidocaine, magnesium, and pregabalin as the data is entered in the form of a yes or no the patient did or did not receive the ERAS intervention. Pain scores were recorded as interval variables utilizing a numerical pain scale ranging from scores of 0-10, with 10 being the highest level of pain. Total opioid consumption values were provided as continuous data as dosing of each fentanyl, hydromorphone, and morphine are of different units and dosages. Data Analysis The focus of this project was to evaluate the benefit in implementing ERAS guidelines to reduce perioperative opioid consumption and evaluate postoperative pain management. By comparing an opioid control group to an ERAS group, descriptive statistics and independent T-tests were performed to evaluate if significant differences existed between the study groups and performed interventions. An alpha level of 5% was accepted for the data analysis and a p-value less than .05 was considered statistically significant and support that the outcome provided was likely a result of chance. Group descriptive statistics were analyzed to obtain mean values for age, gender, pain scores, and opioid consumption among comparison groups. Multiple independent sample t-tests were used to evaluate the difference in means between the opioid and ERAS groups. Student sample t-tests compared mean opioid consumption totals for both groups who received fentanyl, UTILIZATION OF ERAS PROTOCOLS 17 hydromorphone, and/or morphine. Other t-tests were used to determine differences in pain scores at 30 minutes, 2-, 4-, 8-, and 24-hour intervals among groups as well as for each individual ERAS intervention analgesic effects. Descriptive statistics compared mean pain scores at each interval between case types, gynecological or general surgery cases. By evaluating potential differences between groups and specific interventions, the focus was to suggest the implementation of significant findings in relation to the effects of ERAS interventions for this study sample. Results According to analysis of pain scores for both the ERAS and control groups, the mean postoperative pain scores were lower at 30 minutes in comparison to 2, 4, 8, and 24 hours after surgery. When comparing the control opioid group and ERAS group pains scores at 30 minutes, there was a significant difference in the mean scores of 4.033 and 2.893 respectively. On average, mean pain scores at 2, 4, and 8 hours into the postoperative period remained relatively similar with slightly lower scores in the ERAS group, whereas the 24-hour pain scores exhibited no difference across groups. These differences were not significant in independent t-tests at 2, 4, 8, 24 hours after surgery. Opioid consumption was compared between the two study groups. Independent T-tests were used to determine if there differences in the amount of opioid consumed in the postoperative period. Total values for fentanyl were recorded in micrograms (mcg) whereas hydromorphone and morphine were recorded in values of milligrams (mg). The ERAS group consumed significantly less fentanyl throughout the perioperative period in comparison to the opioid group (11.833, p < .001) with mean consumptions of 4.46 mcg and 117.5 mcg respectively. Similar results were found when evaluating the consumption of hydromorphone as UTILIZATION OF ERAS PROTOCOLS 18 the ERAS group consumption was lower than the control group (3.786, p < .001). There was not a significant reduction in morphine consumption between study groups. When evaluating the benefits of regional and/or local anesthesia in reducing pain scores, lower scores were recorded 30 minutes after surgery (p < .010) but not in any other time interval. ERAS protocols consist of a multimodal approach involving utilizing combination techniques to try to minimize pain. Individual interventions were evaluated as well to determine if each approach could yield better results. Dexmedetomidine was evaluated at each pain interval and found that there were not significantly different pain scores with this intervention alone. Similar results were found when evaluating individual interventions including ketamine, lidocaine, and magnesium infusions separately. When comparing pain scores of patients who received multimodal anesthesia involving infusions of magnesium, lidocaine, and dexmedetomidine, postoperative pain scores were lower in 14 patients who received this combination at 30 minutes, 2, and 4 hours after surgery (p < .001, p < .001, and p < .022 respectively). Average pain scores at these intervals for those who did not receive this combination of ERAS recommendations were 3.87, 4.12, and 3.957 compared to the multimodal groups scores of 1.82, 2.09, and 2.82 respectively. Aside from pain scores and opioid consumption, postoperative length of stay (LOS) was also included as a quality measurement but there were no differences in overall LOS for total hours between the two groups. When comparing case type to overall pain scores, there was no significant difference in pain scores between OB/GYN and general surgery cases. Discussion When compared to a traditional opioid-driven anesthetic, the ERAS protocols find their place as an alternative treatment plan that can yield many benefits to a faster and safer recovery UTILIZATION OF ERAS PROTOCOLS 19 after surgery. Patients in the ERAS group consumed significantly less fentanyl and hydromorphone than the control opioid group. By discharge, comparisons of morphine consumption were similar across groups, detailing that the perioperative period of 24 hours utilizing ERAS items can reduce overall opioid consumption. As for pain scores, there were no differences in mean values for the two groups at 2, 4, 8, and 24 hours after surgery for individual interventions of ketamine, magnesium, lidocaine, and acetaminophen administration. However, a multimodal analgesic approach combining magnesium, lidocaine, and dexmedetomidine yielded significant reduction in postoperative pain scores at 30 minutes, 2 and 4 hours into the postoperative period. For this study, patients experienced similar LOS as well as no significantly different pain scores between types of surgery. This study was designed to experiment various anesthetic plan opportunities that may or may not benefit the selected patient population. There is evidence that utilizing a combination of ERAS items can suggest improved outcomes for patients undergoing general and gynecological surgery. By utilizing a combination of ERAS items, opioid consumption was reduced as well as short-term postoperative pain goals. Though the 24-hour perioperative period did not see serial improvements in pain scores, the data shows that implementation of ERAS protocols can efficiently and comparably manage postoperative pain while erasing potential adverse effects of opioids. Anesthetic plans should be individualized to the patient and therefore the anesthesia provider should consider viable treatment options that better enhance the recovery of the surgical patient. Future Implications This study was an original investigation into ERAS recommendations for the project site. Though not all 17-20 recommendations were evaluated during this study, the goal was obtained UTILIZATION OF ERAS PROTOCOLS 20 to see if focused intervention could provide potential benefits for the subject population. If future studies or trials involved a full implementation and educational program utilizing ERAS recommendations, improvements in the above study could be made. The data collected was evaluated on specific surgical populations whereas other specialty surgeries could be investigated for the benefits of ERAS implementation such as orthopedics and/or obstetrical procedures. In order to increase the sample size, greater participation among surgeons and anesthesia providers could provide substantial support in determining the efficacy of ERAS implementations as the population of patients undergoing surgical procedures with ERAS protocols would increase. By obtaining a larger sample size and focusing on a narrower case selection could provide more efficient and specific implementation recommendations. Ethical Considerations/Protection of Human Subjects This study complies with standards discussed with both IRB approvals from both Marian University as well as the project site. No intervention or direct communication occurred with human subjects throughout this study. Personal health information was protected and deidentified. Completion of this project went without conflict of interest among facilities and without compensation for access to data collection. UTILIZATION OF ERAS PROTOCOLS 21 References American Association of Nurse Anesthetists. (2017). 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J., Thakur, P., Siddaiah, H., Kaye, R. J., Eng, L. K., Harbell, M. W., Lajaunie, J., & Cornett, E. M. (2020). Dexmedetomidine in enhanced recovery after surgery (ERAS) protocols for postoperative pain. Current Pain & Headache Reports, 24(5), 113. https://doi.org/10.1007/s11916-020-00853-z. Naik, B. I., Tsang, S., Knisely, A., Yerra, S., & Durieux, M. E. (2017). Retrospective casecontrol non-inferiority analysis of intravenous lidocaine in a colorectal surgery enhanced recovery program. BMC Anesthesiology, 17(1), 16. https://doi.org/10.1186/s12871-0170306-6 Oseka, L., & Pecka, S. (2018). Anesthetic management in early recovery after surgery protocols for total knee and total hip arthroplasty. AANA Journal, 86(1), 3239. Paduraru, M., Ponchietti, L., Casas, I. M., Svenningsen, P., & Zago, M. (2017). Enhanced recovery after emergency surgery: A systematic review. Bulletin of Emergency and Trauma, 5(2), 7078. Pdziwiatr, M., Mavrikis, J., Witowski, J., Adamos, A., Major, P., Nowakowski, M., & Budzyski, A. (2018). Current status of enhanced recovery after surgery (ERAS) protocol UTILIZATION OF ERAS PROTOCOLS 23 in gastrointestinal surgery. Medical Oncology, 35(6), 95. https://doi.org/10.1007/s12032018-1153-0 Peterson, S., & Bredow, T. (2013). Middle range theories: Application to nursing research (3rd ed.). Wolters Kluwer/Lippincott Williams & Wilkins Health. Samimi, S., Taheri, A., & Davari Tanha, F. (2015). Comparison between intraperitoneal and intravenous lidocaine for postoperative analgesia after elective abdominal hysterectomy, a double-blind placebo-controlled study. Journal of Family & Reproductive Health, 9(4), 193198. Shariffuddin, I. I., Teoh, W. H., Wahab, S., & Wang, C. Y. (2018). Effect of single dose dexmedetomidine on postoperative recovery after ambulatory ureteroscopy and ureteric stenting: A double blind randomized controlled study. BMC Anesthesiology, 18(1), 3. https://doi.org/10.1186/s12871-017-0464-6 Soffin, E. M., Lee, B. H., Kumar, K. K., & Wu, C. L. (2019). The prescription opioid crisis: Role of the anaesthesiologist in reducing opioid use and misuse. British Journal of Anaesthesia, 122(6), e198e208. https://doi.org/10.1016/j.bja.2018.11.019 Tedesco, D., Gori, D., Desai, K. R., Asch, S., Carroll, I. R., Curtin, C., McDonald, K. M., Fantini, M. P., & Hernandez-Boussard, T. (2017). Drug-free interventions to reduce pain or opioid consumption after total knee arthroplasty: A systematic review and metaanalysis. JAMA surgery, 152(10), e172872. https://doi.org/10.1001/jamasurg.2017.2872. Wainwright, T. W., Gill, M., McDonald, D. A., Middleton, R. G., Reed, M., Sahota, O., Yates, P., & Ljungqvist, O. (2020). Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery UTILIZATION OF ERAS PROTOCOLS 24 (ERAS) Society recommendations. Acta orthopaedica, 91(1), 319. https://doi.org/10.1080/17453674.2019.168379 Zhang, N., Wu, G., Zhou, Y., Liao, Z., Guo, J., Liu, Y., Huang, Q., & Li, X. (2020). Use of enhanced recovery after surgery (ERAS) in laparoscopic cholecystectomy (LC) combined with laparoscopic common bile duct exploration (LCBDE): A cohort study. Medical Science Monitor: International Medical Journal of Experimental and Clinical Research, 26, 924-946. https://doi.org/10.12659/MSM.924946 Zhu, S., Qian, W., Jiang, C., Ye, C., & Chen, X. (2017). Enhanced recovery after surgery for hip and knee arthroplasty: A systematic review and meta-analysis. Postgraduate Medical Journal, 93(1106), 736742. https://doi.org/10.1136/postgradmedj-2017-134991 UTILIZATION OF ERAS PROTOCOLS 25 Appendix A Literature Review Matrix Reference in APA format American Association of Nurse Anesthetists. (2017). Enhanced recovery after surgery considerations for pathway development and implementation. https://www.aana.com/docs/defaultsource/practice-aana-com-web-documents(all)/enhanced-recovery-aftersurgery.pdf?sfvrsn=6d184ab1_12 Brown, E. N., Pavone, K. J., & Naranjo, M. (2018). Multimodal general anesthesia: Theory and practice. Anesthesia and Analgesia, 127(5), 12461258. https://doi.org/10.1213/ANE.000000000000366 8 Level of Evidenc e Variables Level I There are no defined independent vs. dependent variables. These are the ERAS practice guidelines designed and implemented by the AANA. Level II The independent variable is the use of multimodal analgesics such as dexmedetomidin e and lidocaine to prevent adverse effects of opioid consumption (dependent variable) Sample Instruments Results There is also no designated sample as the guidelines provide multiple options for the delivery of care. There are over 92 citations included in this study with many of them meta-analyses, RCTs, and systematic reviews. ERAS guidelines, Apfel PONV risk scoring system, Recommendation s for optimal blood glucose levels during surgery, considerations for pre-, intra-, and postoperative opioid management. ERAS protocols have shown to significantly deliver positive patient outcomes, reduce postoperative length-of-stay, accelarate the recovery process, and lead to significantly early discharge times. ERAS guidelines for multimodal analgesia Opioid-free and multimodal analgesia can effectively provide balanced general anesthesia with adequate amnesia and muscle relaxation without sympathetic or 689 patients undergoing one of four surgeries: laminectomy, total knee replacement, cesarean delivery, or exploratory laparatomy. UTILIZATION OF ERAS PROTOCOLS 26 hemodynamic instability. Oseka, L., & Pecka, S. (2018). Anesthetic management in early recovery after surgery protocols for total knee and total hip arthroplasty. AANA Journal, 86(1), 3239. Level I IV: ERAS Protocols DV: postoperative pain, reduced opioid consumption Systematic review compiling 732,570 total knee arthroplasties in the United States between 2000 and 2010. ERAS guidelines, Apfel PONV risk scoring system, numeric pain scale 0-10 Integrating ERAS protocols for intraoperative and postoperative pain management can reduce overall pain and opioid consumption. Minimizing opioids and using ERAS guidelines can also contribute to earlier mobility and shorter hospital stays. UTILIZATION OF ERAS PROTOCOLS Soffin, E. M., Lee, B. H., Kumar, K. K., & Wu, C. L. (2019). The prescription opioid crisis: Role of the anaesthesiologist in reducing opioid use and misuse. British Journal of Anaesthesia, 122(6), e198e208. https://doi.org/10.1016/j.bja.2018.11.019 Level I IV: regional anesthetic techniques DV: decreased opioid use This metaanalysis did not list particular sample sizes but described multiple other RCTs and systematic reviews with significant data. 27 Supply & Demand Opioid prescription algorithm for anesthesiologists. Anesthetists can play an essential role in reducing the overall consumption of opioids by understanding both perioperative and post-discharge implications for opioids as well as alternative analgesic therapies. The importance of patient education on analgesia and opioids can also aid in improving patient outcomes during the recovery process. UTILIZATION OF ERAS PROTOCOLS Wainwright, T. W., Gill, M., McDonald, D. A., Middleton, R. G., Reed, M., Sahota, O., Yates, P., & Ljungqvist, O. (2020). Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations. Acta orthopaedica, 91(1), 3 19. https://doi.org/10.1080/17453674.2019.168379 Tedesco, D., Gori, D., Desai, K. R., Asch, S., Carroll, I. R., Curtin, C., McDonald, K. M., Fantini, M. P., & Hernandez-Boussard, T. (2017). Drugfree interventions to reduce pain or opioid consumption after total knee arthroplasty: A systematic review and meta-analysis. JAMA surgery, 152(10), e172872. https://doi.org/10.1001/jamasurg.2017.2872 28 Level 1 IV: Implementation of ERAS protocol recommendation s DV: reduction in opioid consumption This consensus statement contains multiple RCTs and systematic reviews with no specific sample sizes and only results from the mentioned studies. It targets 17 different areas with Level 1 and Level 2 evidence supporting the 17 different guideline areas. AANA ERAS Guidelines for TKA and THA Level 1 IV: Multimodal therapy for analgesia DV: reduced postoperative pain, reduced opioid consumption Meta-analysis of 2391 patients from 39 RCTs undergoing total knee arthroplasties. WOMAC Western Ontario and McMaster University Arthritis Index, VAS - visual analog scale for pain The use of nonopioid analgesics such as gabapentinoids, NSAIDs, and paracetamol are effective in reducing postoperative opioid consumption. Combined neuraxial anesthesia and/or peripheral nerve blocks provide effective analgesia and reduction of opioid use by 40% in the postoperative perioid. Electrotherapy and acupuncture were found to effectively reduce postoperative pain in the first 2 days of the postoperative period. UTILIZATION OF ERAS PROTOCOLS Beloeil, H., Albaladejo, P., Sion, A., Durand, M., Martinez, V., Lasocki, S., Futier, E., Verzili, D., Minville, V., Fessenmeyer, C., Belbachir, A., Aubrun, F., Renault, A., Bellissant, E., & OCTOPUS group (2019). Multicentre, prospective, double-blind, randomised controlled clinical trial comparing different nonopioid analgesic combinations with morphine for postoperative analgesia: The OCTOPUS study. British Journal of Anaesthesia, 122(6), e98e106. https://doi.org/10.1016/j.bja.2018.10.058 Zhu, S., Qian, W., Jiang, C., Ye, C., & Chen, X. (2017). Enhanced recovery after surgery for hip and knee arthroplasty: A systematic review and meta-analysis. Postgraduate Medical Journal, 93(1106), 736742. https://doi.org/10.1136/postgradmedj-2017134991 Jiang, H. H., Jian, X. F., Shangguan, Y. F., Qing, J., & Chen, L. B. (2019). Effects of enhanced recovery after surgery in total knee arthroplasty for patients older than 65 years. Orthopaedic Surgery, 11(2), 229235. https://doi.org/10.1111/os.12441 29 IV: Non-opioid analgesic combination DV: reduction in postoperative opioid consumption Double-blind RCT from 10 hospitals with 237 patients. visual analog scale (VAS) Level 1 IV: ERAS Protocols DV: Length of stay (LOS) and postoperative complications systematic review and meta-analysis of 9936 surgical cases with 4205 cases utilizing ERAS while 5731 cases used traditional treatments. visual analog scale (VAS) Level 2 IV: ERAS protocols DV: postoperation complications: pain, ROM, PONV RCT with 247 patients of 65 years of age or older, undergoing total-knee or total hip replacement. Level 2 VAS (visual analog scale) In a RCT with 10 hospitals and 237 surgical patients, patients receiving combined nonopioid analgesics had significantly less postoperative opioid consumption at 24 hours and 48 hours postoperative. ERAS significantly reduces postperative pain, length of stay, readmission rates, and reoperation rates in comparison to traditional treatments without guided protocols. ERAS protocol patients had significantly lower VAS scores in the first day postoperative. UTILIZATION OF ERAS PROTOCOLS Kaye, A. D., Chernobylsky, D. J., Thakur, P., Siddaiah, H., Kaye, R. J., Eng, L. K., Harbell, M. W., Lajaunie, J., & Cornett, E. M. (2020). Dexmedetomidine in enhanced recovery after surgery (ERAS) protocols for postoperative pain. Current Pain & Headache Reports, 24(5), 1 13. https://doi.org/10.1007/s11916-020-00853-z Zhang, N., Wu, G., Zhou, Y., Liao, Z., Guo, J., Liu, Y., Huang, Q., & Li, X. (2020). Use of enhanced recovery after surgery (ERAS) in laparoscopic cholecystectomy (LC) combined with laparoscopic common bile duct exploration (LCBDE): A cohort study. Medical Science Monitor: International Medical Journal of Experimental and Clinical Research, 26, e924946. https://doi.org/10.12659/MSM.924946 30 Level 2 IV: Use of dexmedetomidin e DV: reduced postoperative pain systematic review of 14 RCTs and meta-analyses containing a total of 6429 patients receiving dexmedetomidin e vs. control opioids VAS (visual analog scale) and WOMAC test Level 4 IV: ERAS protocols DV: postoperative analgesia, postoperative complications, hospital length of stay (LOS) A cohort study of 445 patients undergoing laparoscopic cholecystectomy; 148 received ERAS-guided care compared to a control group of 297 patients. Numerical pain scale (0-10) In comparison to other non-opioid analgesic methods, controlled studies revealed that VAS results were significantly lower at 24 hours, one month, and two months postoperatively in dexmedetomidin e group compared to control. Patients in the ELC (ERAS lap chole group) saw decreased incidences of nausea, incisional pain, and vomiting. It was also discovered that the patients in the E-LC group had shorter hospital LOS and improved quality of life. UTILIZATION OF ERAS PROTOCOLS Naik, B. I., Tsang, S., Knisely, A., Yerra, S., & Durieux, M. E. (2017). Retrospective case-control non-inferiority analysis of intravenous lidocaine in a colorectal surgery enhanced recovery program. BMC Anesthesiology, 17(1),7-16. https://doi.org/10.1186/s12871-017-0306-6 Mitra, S., Carlyle, D., Kodumudi, G., Kodumudi, V., & Vadivelu, N. (2018). New advances in acute postoperative pain management. Current Pain and Headache Reports, 22(5), 1-11. https://doi.org/10.1007/s11916-018-0690-8 Pdziwiatr, M., Mavrikis, J., Witowski, J., Adamos, A., Major, P., Nowakowski, M., & Budzyski, A. (2018). Current status of enhanced recovery after surgery (ERAS) protocol in gastrointestinal surgery. Medical oncology, 35(6), 95-103. https://doi.org/10.1007/s12032-018-1153-0 31 Level 4 IV: ERAS with lidocaine infusion DV: patientreported pain scores and opioid consumption A retrospective review of 104 patiends split into a LIDO group and an ERAS group. Mean morphine equivalents, numerical rating scale (0-10) for postoperative pain. Level 1 IV: ERAS guided multimodal analgesia DV: postoperative pain management Meta-analysis comparing level of evidence/support for multimodal analgesic techniques used in ERAS protocols VAS and numerical pain scores, morphine equivalent dosing (MED). IV: ERAS protocols in gastrointestinal surgery DV: Pain, N/V, and mobility A systematic review conducted compiling findings and suggested recommendation s of RCTs and current published guidelines for ERAS in multiple surgical disciplines including GI Level 1 No dedicated instrument/tool defined in study. Patients in the Lidocaine infusion group consumed less opioids in POD 1 and equal or slightly less in POD 2. POD 1 and 2 found no differnce in pain scores. ERAS pathways and guidelines are being implemented to set standards for reduced opioid consumption and improved postoperative pain management. ERAS guidelines in GI surgery not only decrease postoperative opioid consumption, pain scores, and hospital LOS, it also shows increasing 5-year survival rates after GI surgery. UTILIZATION OF ERAS PROTOCOLS 32 surgery, colorectal, and laparoscopy. Ren, Y., Sun, D., Pei, L., Liu, X., Liu, Y., & Liu, H. (2021). A full enhanced recovery after surgery program in gynecologic laparoscopic procedures: A randomized controlled trial. Journal of Minimally Invasive Gynecology, 15(21), 100-125. . https://doi.org/10.1016/j.jmig.2021.01.024 Level 2 IV: Full ERAS intervention, DV: postop LOS, hospital cost, postoperative pain 144 patients undergoing laparoscopic gynecologic procedures in a RCT split evenly into two groups: Full ERAS intervnetion vs control group of limited ERAS management. numerical rating scale for pain (010), quality of life -15 (QoR-15) questionnaire Postoperative LOS in the full ERAS intervention group was significantly shorter than the control group. Those assigned to the intervention group displayed decreased numerical pain scores after 2 hours postoperative up to 72 hours after surgery. UTILIZATION OF ERAS PROTOCOLS Wang, Y., Zhu, Z., Li, H., Sun, Y., Xie, G., Cheng, B., Ji, F., & Fang, X. (2019). Effects of preoperative oral carbohydrates on patients undergoing ESD surgery under general anesthesia: A randomized control study. Medicine, 98(20), 1-6. https://doi.org/10.1097/MD.0000000000015669 Simpson, J. C., Bao, X., & Agarwala, A. (2019). Pain Management in Enhanced Recovery after Surgery (ERAS) Protocols. Clinics in Colon and Rectal Surgery, 32(2), 121128. https://doi.org/10.1055/s-0038-1676477 Naik, B. I., Tsang, S., Knisely, A., Yerra, S., & Durieux, M. E. (2017). Retrospective case-control non-inferiority analysis of intravenous lidocaine in a colorectal surgery enhanced recovery program. BMC Anesthesiology, 17(1), 16. https://doi.org/10.1186/s12871-017-0306-6 73 patients undergoing endoscopic submucosal dissection (ESD) randomized into two groups; experimental carbohydrate drink group (36) and fasting control group (37). Level 2 IV: Oral carbohydrates 2 hours prior to surgery DV: 10 hours of fasting before surgery Level 1 Systematic review does not detail a specific Independent variable but N/A explains various pain management techniques Level 3 IV: administration of Lidocaine perioperative period DV: reduced postoperative opioid consumption 33 Visual analog scale (VAS) for 6 criteria including: thirst, hunger, mouth dryness, nausea, vomiting, and weakness). N/A 52 patients were given Lidocaine as MED scores, an additive numerical pain compared to an scale scores ERAS group Carbohydrates prior to ESD surgery resulted in shorter LOS, less postop complications, and less thirst and hunger. Detailed descriptions for each pain management technique are found within study backed by data collected from systematic review. The addition of a multi-component ERAS protocol to intravenous lidocaine incrementally reduces opioid consumption. This is most prominent in day one following UTILIZATION OF ERAS PROTOCOLS 34 surgery, but not as significant in day 2 or 3. Level 1 IV: Utlization of ERAS items in emergency surgery DV: conventional emergency surgery protocols 311 emergency patients were evaluated in 3 studies that were compared to 294 traditional treatment plans N/A Samimi, S., Taheri, A., & Davari Tanha, F. (2015). Comparison between intraperitoneal and intravenous lidocaine for postoperative Level 2 analgesia after elective abdominal hysterectomy, a double-blind placebo-controlled study. Journal of Family & Reproductive Health, 9(4), 193198. IV: administration of Lidocaine perioperative period DV: reduced postoperative VAS scores 109 patients undergoing elective abdominal hysterectomy controlled against a group receiving lidocaine infusion of 2mg/kg/hr VAS scores Paduraru, M., Ponchietti, L., Casas, I. M., Svenningsen, P., & Zago, M. (2017). Enhanced recovery after emergency surgery: A systematic review. Bulletin of Emergency and Trauma, 5(2), 7078. The implementation of 11-18 ERAS items resulted in fewer postoperative complications for patients undergoing emergency surgery. The pain intensity was significantly reduced in both IV and IP groups compared with control group until 12 hours postoperatively (p = 0.001) and there was no significant difference between IV and IP group in this regard (p > 0.05 UTILIZATION OF ERAS PROTOCOLS Shariffuddin, I. I., Teoh, W. H., Wahab, S., & Wang, C. Y. (2018). Effect of single dose dexmedetomidine on postoperative recovery after ambulatory ureteroscopy and ureteric stenting: A double blind randomized controlled study. BMC Anesthesiology, 18(1), 3. https://doi.org/10.1186/s12871-017-0464-6 Zhang, N., Wu, G., Zhou, Y., Liao, Z., Guo, J., Liu, Y., Huang, Q., & Li, X. (2020). Use of enhanced recovery after surgery (ERAS) in laparoscopic cholecystectomy (LC) combined with laparoscopic common bile duct exploration (LCBDE): A cohort study. Medical Science Monitor: International Medical Journal of Experimental and Clinical Research, 26, 924-946. https://doi.org/10.12659/MSM.924946 35 Level 2 IV: Administration of dexmedetomidin e DV: postoperative pain, MAC (minimal alveolar concentration) 60 patients undergoing uteroscopy received either dexmedetomidin e or saline to evaluate the benefits of pain relief and anesthesia agent requirements. Visual analog scale (VAS) Level 3 IV: ERAS regimen defined by study DV: flatus time, postoperative pain, N/V, length of stay 445 patients undergoing laparoscopic cholecystectomy that were divided evenly into a control group and an ERAS group. numerical pain scale scores Patients in the DEX group received less anesthestic agent, or decreased MAC, than the control group. They also saw decreased VAS scores after 1 hour during the postoperative period (p=.004) The incidence of nausea, incisional pain, and vomiting in the ELC group were lower than in the LC group, and the differences were statistically significant (p<0.05) UTILIZATION OF ERAS PROTOCOLS 36 Appendix B Figure 1: Pain: A Balance Between Analgesia and Side Effects Note. The middle range theory of a balance between analgesia and side effects. Adapted from Middle range theories: Application to nursing research (p. 55), by Good, M., 1998, Wolters Kluwer Health. Copyright 2013 by Lippincott Williams & Wilkins.  ...

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