Continuity of Care in the Training Environment: Anesthesiology Residency in the Ambulatory Surgery Setting

摘要

What was known Anesthesiology residents acquire clinical skills from experience in anesthesia management, with continuity of cases allowing preparation and optimal learning.;What is new Slightly more than one-half of cases were started and finished by the originally scheduled resident and attending physician.;Limitations Single-site study limits generalizability, with potential underreporting of some transitions; outcomes are limited to instances of discontinuity, not their effect on patient care or learning.;Bottom line Transitions of care in anesthesia provision reduce continuity and fragment supervision, with both potentially reducing learning.;Introduction Providing anesthesia to patients undergoing procedural cases serves as the primary medium for learning in anesthesiology—each assignment requires patient assessment, formulation, and execution of an anesthetic plan, general medical management, response to the unexpected, returning the patient to homeostasis, and finally, handing off care. Residents move toward autonomy as they are assessed, and supervision is correspondingly reduced throughout these sequential steps. Preparatory study and discussion specific to assigned patients and their surgical procedures allows for application of new knowledge. However, changes to the surgical schedule on the day of surgery may result in the reassignment of cases. In addition, residents may provide anesthesia for patients and surgical procedures other than those anticipated. Finally, if the anesthesiology resident or attending physician is relieved midway through a case, the pairing and potential for discussion and longitudinal feedback is disrupted. With frequent movement of anesthesia providers, less study is followed by application, supervision is provided for shorter periods, and patient interactions during residency become more fragmented. Ambulatory surgery now dominates surgical volume, and the discipline of operating room (OR) management has emerged1–3 to inform optimal use of ORs by, for example, reassigning patients to different anesthesia teams as the day evolves to avoid delays or unused OR time. The OR management literature typically defines optimization in terms of use and bed occupancy, without measurement of, or regard for, provider movements or continuity.4–9 With rare exceptions, anesthesia providers are assumed to be interchangeable.10,11 In addition to schedule changes, the common practice of handoffs in the OR means that residents may induce anesthesia for a patient but not be present for their emergence from anesthesia. Within the anesthesia literature, fluid staffing is acknowledged, but quantitative descriptions are sparse.12–14 The effect of fluid staffing on resident learning and patient outcomes has received little study. Duty hour regulations have necessitated increased handoffs in general, but its extent is specific to a specialty and has not, to our knowledge, been studied for anesthesiology.15,16 In this study, we measured anesthesia provider movements at a single teaching institution. A further aim was to quantify the contribution of duty hour regulations toward resident movements specifically.;Methods This prospective, observational study compared originally scheduled anesthesiology patient assignments with actual patient assignments to identify changes before and after the initiation of care. The study included all procedural cases staffed by the Department of Anesthesiology for a 5-week period, Monday through Friday, in a 500-bed university medical center. The only excluded location was the obstetrics unit. For each day in the study, we recorded the surgical schedule as published from the day before, listing all originally scheduled “cases”: the originally scheduled patients, surgeons, and procedures, as well as the anesthesia providers and scheduled ORs. After the day of surgery, we obtained a list of the cases actually performed, from OR tracking software. Electronic anesthesia health records were