Change Proposal Monitored Anesthesia Care

CAPSTONE PROJECT CHANGE PROPOSAL

Benchmark – Capstone Project Change Proposal

Background

Monitored anesthesia care (MAC) has become more widely used to avoid the complications of general anesthesia (GA) (Sammour et al., 2021). Monitored anesthesia care (MAC) is a safer alternative to general anesthesia (GA) in some surgical procedures. Indeed, as Sammour et al., (2021) observe, utilizing MAC seems to be more efficient without compromising safety. Complications of MAC include airway obstruction, de-saturation, cardiovascular collapse, and aspiration (Sohn et al, 2016). Though the complications of MAC are comparable to GA, inpatients who have undergone MAC are kept unmonitored outside of the PACU for prolonged periods of time negating optimal patient care. This practice is deleterious to patient care and can cause substantial professional and institutional liability resulting in malpractice claims (Kellner et al, 2018). A gap in care, among inpatients who have undergone monitored anesthesia care (MAC) and are not admitted to the post anesthesia care unit (PACU) but are transferred to the surgical floors by non-clinical personnel, was identified.

Clinical Problem Statement

The clinical challenge at the heart of this study centers on the increased vulnerability of surgical patients who have undergone MAC to postoperative complications. The risks associated with insufficient postoperative nursing management extend beyond the immediate recovery, potentially leading to prolonged recuperation periods, heightened healthcare expenditures, and decreased patient satisfaction. Addressing this issue is imperative as it impacts the well-being of individual patients and carries broader implications for the healthcare system. The proposed solution, effective postoperative nursing management, is poised to yield a positive patient outcome by notably reducing postoperative complications during the critical 24 to 48-hour period post-surgery. This anticipated outcome carries multifaceted benefits, including enhanced patient recovery, shortened hospital stays, and an overall elevation in the caliber of healthcare delivery, aligning with the fundamental goals of patient-centered and cost-effective care.

Purpose of the Change Proposal

The omission of providing immediate postsurgical monitoring and management significantly amplifies the patients’ risk for these complications. By highlighting the incidence of these complications in patients who have received MAC, the implementation of this quality improvement initiative prioritizes postoperative patient safety through attempt to persuade policy change by admitting these patients to the PACU.

The following measurable outcomes were identified as being relevant in this particular context.

1. Staff will be knowledgeable about the complications associated with monitored anesthesia care (MAC) especially within the immediate postoperative period as exhibited by competence in acknowledging such complications.

Rationale: Staff having knowledge about complications associated with MAC will facilitate early detection of clinical decline and initiation of early treatment/ resuscitation. Staff members who are knowledgeable about MAC complications can also effectively communicate with other team members, fostering a collaborative and coordinated approach to patient care.

2. A post anesthesia care unit (PACU) admission protocol for postoperative inpatients who have undergone MAC will be developed.

Rationale: Development of an admission protocol for postoperative inpatients will ensure optimal, quality, culturally appropriate health care delivery which will improve health outcomes through utilization of the code of ethics that guide professional decisions and practices. The implementation of a defined protocol simplifies the admission procedure for MAC patients, allowing for more effective use of resources in the PACU. This involves improving personnel numbers, equipment, and monitoring capabilities to meet these patients\' specific demands.

3. Organizational barriers that may interfere with implementation of an admission protocol for the admission of postoperative inpatients who have undergone monitored anesthesia care will be identified and perioperative staff will be compliant with the admission protocol.

Rationale: Strategies to address organizational barriers will be addressed resulting in staff compliance and implementation of the admission protocol into practice. Recognizing and overcoming organizational impediments can help perioperative personnel implement the admission routine more smoothly. Understanding possible issues enables for targeted interventions and campaigns to assist employees in adopting the new protocol into their workflow.

PICOT Question

PICOT Question: “In surgical patients, how does effective postoperative nursing management of inpatients who have undergone monitored anesthesia care (MAC) compared to usual practice influence the risk for developing postoperative complications within a 24 to 48-hour period?”

Patient Population: Surgical patients

Intervention: Effective postoperative nursing management

Comparison: Usual postoperative care practices

Outcome: Risk for developing postoperative complications

Time: Within a 24 to 48-hour period

The PICOT question delves into the realm of surgical patient care by examining the impact of postoperative nursing management on the risk of developing complications within a specific timeframe. The question focuses on inpatients who have undergone MAC and emphasizes the importance of effective postoperative nursing practices. The patient population under consideration is those who have undergone surgical procedures, making it relevant to many healthcare scenarios. The intervention, effective postoperative nursing management, is a potential catalyst for positive change. By comparing this intervention to the standard of usual postoperative care practices, the study aims to discern the efficacy of heightened nursing involvement in mitigating the risk of postoperative complications. The specified outcome, the risk for developing complications, underscores the project\'s clinical relevance and the designated time frame of 24 to 48 hours sharpens the focus on the critical postoperative period, aiming for timely and targeted improvements in patient care.

Literature Search Strategy

From the onset, the relevant search terms were identified. Some of the search terms utilized on this front were inclusive of, but they were not limited to: monitored anesthesia care (MAC), MAC patient care, MAC postoperative nursing management, surgical patients MAC, and MAC postoperative complications. In addition to the above search terms, synonyms of such words were also taken into consideration. This was followed by the identification of the relevant resources – with deliberate measures being taken to ensure that the resources identified in this case were reliable and credible. Google Scholar and Emerald were two of the main bibliographic databases used. The identified resources were filtered in line with their relevance to the subject matter and research area. The currency of the resources in question was also taken into consideration.

Evaluation of the Literature

The purpose of the literature review was to develop the findings needed to articulate a comprehensive PICOT question that can serve as the foundation for a capstone project change proposal, addressing the clinical problem associated with postoperative complications in patients who have received MAC.

The research questions in the first two studies (numbers correspond to evaluation table numbering) reviewed examined optimal sedation dosing during MAC for varicose vein stripping surgery to avoid respiratory depression and compare surgical outcomes for sialendoscopy with MAC versus general anesthesia. The third and fourth questions investigated whether MAC has comparable rates of postoperative complications and mortality to general anesthesia for transcatheter aortic valve replacement surgery, and whether adding a supraglottic airway to MAC can achieve similar procedural efficiency and adverse events as standard MAC without an airway device. Additional research questions introduced other aspects of MAC.

The fifth study’s research question focused on using a respiratory volume monitor to improve safety for patients getting gastrointestinal endoscopies with MAC. By contrast, the sixth study’s research question compared deep sedation MAC to general anesthesia for atrial septal defect closure surgery in terms of outcomes and complications. The penultimate study’s research question investigated whether administering dexmedetomidine during MAC or general anesthesia affects post-anesthesia care unit length of stay for ambulatory surgery patients. Finally, the eighth focuses on when providers should convert MAC to general anesthesia when sedation causes airway instability.

While the specifics of these studies varied, all of the research questions ultimately aim to clarify the optimal approach for airway/breathing management, sedation dosing, monitoring, and conversion to general anesthesia in order to maximize the safety and efficacy of MAC across different procedures. The research questions also sought to determine how MAC compares to general anesthesia for many surgeries regarding complications, mortality, recovery times, procedural efficiency, and other important outcomes.

A comparison of sample populations

The sample populations come from academic hospitals, medical centers, and surgical databases across the United States. The first study utilized hospital data on transcatheter aortic valve replacement (TAVR) procedures from the American College of Surgeons National Surgical Quality Improvement Program registry. The second study was conducted at an academic hospital among 51 patients getting varicose vein stripping surgery with MAC. The third study took place at Thomas Jefferson University including 172 patients who had sialendoscopic surgery with either MAC or general anesthesia.

The fourth study, performed at a tertiary academic medical center, matched 148 patients who got transcatheter femoral-transapical valve replacement surgery with a supraglottic airway to 148 who had the surgery with standard MAC. The fifth study enrolled 65 patients at the University of Texas Medical Branch undergoing upper and lower gastrointestinal endoscopies using total intravenous anesthesia for MAC. The sixth study retrospectively analyzed records from the Asan Medical Center in Korea for 311 patients who had atrial septal defect closure surgery with either deep sedation MAC or general anesthesia. Notably, the seventh study leveraged data on over 130,000 adult ambulatory surgery patients at Beth Israel Deaconess Medical Center to investigate associations between dexmedetomidine and recovery times. Finally, the eighth study examined over 219,000 cases at Mount Sinai Hospital in New York City when providers had to rescue patients’ airways by converting from initial MAC to general anesthesia due to sedation-related instability.

All of these studies focused exclusively on adult patient populations undergoing surgical or invasive medical procedures ranging from minimally invasive endoscopies to more complex surgeries like transcatheter valve replacement and atrial septal defect closure. Many studies emphasize ambulatory surgery populations or procedures commonly performed with MAC, highlighting the relevance of MAC for shorter outpatient surgeries. While sample sizes range considerably, many studies incorporate hundreds or even over a hundred thousand patients to generate sufficient statistical power for their analyses of relatively uncommon outcomes like postoperative complications. Together, the population samples reflect substantial data-driven efforts to clarify best clinical practices for optimizing patient safety and clinical outcomes with MAC.

The analyses in the selected studies rely heavily on retrospective data, which can introduce biases and confounders that prospective randomized controlled trials would minimize. Appropriate statistical techniques were used to control variables between comparison groups, but residual confounding is still possible. Likewise, most of the findings lacked long-term follow-up, with outcomes limited to the perioperative period and 30 days postoperatively. Consequently, longer follow-up could help identify the respective advantages of one anesthesia approach over another that short-term data misses.

In some cases, comparatively small sample sizes may limit the generalizability of results and predispose some analyses to type II errors failing to detect true differences between groups when effects are subtle. Larger multi-center trials could improve statistical power and external validity. In addition, and perhaps most importantly, the criterion for converting MAC to general anesthesia was not standardized and left to clinical judgment, introducing subjectivity and variability. Therefore, more objective, protocolized criteria could facilitate comparisons between groups. It is also important to note that self-reported measures like patient satisfaction and some complications (nausea, pain) have inherent subjectivity vulnerable to placebo effects. Blinded outcome assessors would optimize objectivity. Finally, the single-center nature for most studies means findings may not apply to other settings with variable provider experience, monitoring capabilities, and patient factors; multi-center designs enhance result reproducibility and improve the trustworthiness of the findings that emerge from these types of studies.

Applicable Change Theory

Rogers’ theory was utilized as this provides a framework based on the writer’s influence as a change agent to stimulate change, utilize persons who are essential to the implementation of the change and manage factors that may obstruct or delay the change. Roger’s change theory, an expounded and modified form of Lewin’s three-stage model, describes five stages: stage1 (impart knowledge regarding the reason for change, the occurrence of the change and the individuals involved in this change), stage 2 (persuade employees to accept the change by informing them of important information while being cognizant of their attitudes and responses regarding the proposed change), stage 3 (make a decision regarding adopting the change by forming a data analysis and implementing a pilot study or trial of the new process for such change), stage 4 (change will be implemented or established permanently as the organization evolves to accommodate the change), and stage 5 which describes the adoption of the change is confirmed by the employees who are responsible for and affected by the change (Udod & Wagner, n.d).

Proposed Implementation Plan

Strategic planning is essential to prepare for potential organizational challenges that may interfere with the implementation of the capstone change proposal. Assessment of the organization’s culture revealed that the perioperative nursing staff’s hindrance to readily accept new changes was a potential challenge to incorporate the nursing practice intervention. The intended nursing intervention is for monitoring in the post anesthesia care unit of surgical inpatients who have undergone monitored anesthesia care. Through educational activities by the change agent, perioperative nursing staff be sensitized about postoperative complications that can result from monitored anesthesia care and the necessity of these patients to be monitored by nurses in the post anesthesia care unit. These educational activities will communicate the roles, expectations of the perioperative team (director of surgical services, surgeons, operating room nurses, anesthesiologists, certified registered nurse anesthetists, and post anesthesia care registered nurses), and coordination of workflow in ensuring safe, optimal postoperative care delivery.