Best Practice & Research-Clinical Anaesthesiology最新文献

Leadership is an infinite and tremendously complex journey along with paradoxes that cannot be captured comprehensively. Over the past decades, key dimensions of leadership have caught the attention of practitioners in the field of management sciences. Yet, leadership education in healthcare is still limited. This personal perspective aims to summarize key aspects of leadership, ranging from managing people to managing systems and oneself.

To create a successful ambulatory care center, healthcare systems need management that can understand and improve key ambulatory success factors such as quality of clinical care, clinical competence, regulatory compliance, financial management, and customer service. Effective leadership is a vital skill that can improve all these factors. This manuscript discusses successful perioperative leadership styles in the ambulatory setting and provides a framework for proven strategies that have improved patient care.

Today's effective leaders create opportunities for their teams to develop both technical and non-technical skills. In the perioperative arena, the focus until now mainly has been on improving non-technical skills, with only few studies analyzing the relationship between technical skills and patient outcomes. Technical competence requires assessment of one's own strengths and weaknesses, inclusion of deliberate goal-oriented practice, objective structured feedback assessment, and a focus on best practice and improved patient outcomes. In this article, we address the prerequisites, assessment, and implications of technical skills for perioperative leadership, and provide key metrics impacting patient outcomes and leadership development.

Perioperative medicine is now a well-recognized albeit still evolving, interdisciplinary subspecialty, which encompasses a wide array of equally invested stakeholders and equally important contributors. The practice of perioperative medicine is fundamentally and optimally a collaborative effort, which aims to provide a comprehensive framework encompassing all aspects of the patient's surgical journey. Moving from a conceptual model of perioperative medicine to an operational perioperative medicine program and clinic requires a methodical management approach. This comprehensive management approach considers a variety of factors, such as defining the mission of a perioperative medicine program, expanding the role of the anesthesiologist and internal medicine hospitalist, recognizing the role of the advanced practice provider, stratifying perioperative management of surgical patients, developing and implementing a program, undertaking a clinical proof-of-concept pilot of a program, scaling up and building out a program, maximizing the electronic health record, leveraging telemedicine and virtual health, and providing adjunctive services.

Bottlenecks limit the maximum output of a system and indicate operational congestion points in process management. Bottlenecks also affect perioperative care and include dimensions such as infrastructure, architectural design and limitations, inefficient equipment and material supply chains, communication-related limitations on the flow of information, and patient- or staff-related factors. Improvement of workflow is, therefore, becoming a priority in most healthcare settings. We provide an overview of bottleneck management in the perioperative setting and introduce dimensions, including aligned strategic decision-making, tactical planning, and operational adjustments.

Without the appropriate administrative structure, even well-thought-out strategic plans or detailed process improvement initiatives will fail. Developing a strong foundation for governance and leadership is a critical element of any high-functioning organization, and it applies just as well in the perioperative setting.

Yet, perioperative patient care teams and operating room (OR) management structures can be very complex, due to relationships both within the OR and between the OR and other departments. Frequently, reliable management of the perioperative process is lacking.

We aim to provide an overview of the structural and elemental components and roles of perioperative management teams, as well as the administrative structure that guides them, since effective perioperative care teams and OR leaders are of paramount importance for any successful hospital.

Healthcare institutions are currently under enormous financial, political and social pressure. Especially in the perioperative setting, various professional groups with differing agendas, dynamic teams, high-stress levels and diverging stakeholder interests are contributing to tension on a variety of levels. These players ask for guidance that goes beyond defined goals, clear structures or rules for process optimization. The impact of culture, which is influenced by core values, unspoken behaviours and practices, a shared purpose and implicit norms, has been often neglected. However, culture is a key factor in the search for optimal patient outcomes, quality of care, protection and long-time retention of staff, as well as economic success. In this review, we discuss important aspects to consider in building a great perioperative workplace, discuss indispensable adaptations in times of crisis and touch on urgently needed further investigations to optimize the art of developing, protecting, and cultivating a well-balanced culture.

Uterotonics play an important role in the management of postpartum haemorrhage (PPH), often caused by uterine atony. The World Health Organization (WHO) recommends the application of uterotonics for all births. Oxytocin, considered the first-line uterotonic, binds to a G protein-coupled receptor which is subject to down sensitization upon repeated or prolonged administration of oxytocin. Consequently, a uterotonic with a different mechanism of action should be chosen early when oxytocin does not restore uterine tone. Choice of the second-line uterotonic is determined by institutional preferences as well as by maternal co-morbidities since most uterotonics have cardiovascular side effects. Slow injection of all uterotonics is strongly recommended to blunt these reactions. Methylergometrine and carboprost should, therefore, be avoided in many cardiovascular pathologies. Carbetocin is a chemical modification of oxytocin with a longer half-time, and therefore one bolus of carbetocin is usually sufficient. Its heat stability makes it an ideal candidate in resource-restricted settings.

Leading causes of intensive care unit (ICU) admission include hemorrhage, hypertensive disorders of pregnancy, and sepsis. Although the incidence of ICU admission in pregnancy may be low, this does not account for critical illness in labor and delivery or maternity unit suites, which is as high as 1–3%. Most admissions, for example, to an ICU unit occur in the postpartum period, where studies have shown a range from 62 to 92% of admissions occurring during this period. A total of 60% of maternal deaths have been reported as preventable, with a delay in diagnosis and prompt medical treatment cited as primary factors, prompting for early recognition of high-risk obstetric patients. Recently, comorbidity-based screening tools, which quantify a patient's medical comorbidity burden, have been developed and validated in predicting ICU admission and death. Noninvasive ultrasonography such as point-of-care ultrasonography becomes essential in determining hemodynamic status, guides resuscitation, and manages cardiovascular dysfunction.