London M J, Shroyer A L, Grover F L, Sethi G K, Moritz T E, Henderson W G, VillaNueva C B, Tobler H G, McCarthy M J, Hammermeister K E
Department of Anesthesia, Denver Veterans Affairs Medical Center, Colorado, USA.
Med Care. 1995 Oct;33(10 Suppl):OS66-75. doi: 10.1097/00005650-199510001-00008.
Anesthesia care is an integral component of cardiac surgery. Emphasis on cost-effectiveness and decreased hospital stay has prompted reevaluation of anesthesia practice. However, the role of anesthesia process and structure variables in relation to patient outcomes is largely unknown. Processes, Structures and Outcomes of Care in Cardiac Surgery is the first epidemiologic study to collect data on anesthesia processes, such as the pharmacologic components of anesthesia and types of cardiovascular monitors used. Structures of care, such as resident staffing, supervision, completeness of documentation, and training and experience of care providers, are also being assessed. Pilot data collected from September 1992 to September 1993 demonstrate substantial variation between the six study sites in selected processes and structures. Despite the near-universal use of narcotic anesthesia as the primary anesthetic technique, variation in the type of opioid and adjuvant benzodiazepine used was observed. Regarding invasive hemodynamic monitoring, most centers used only one type of catheter. Intraoperative transesophageal echocardiography was used commonly at several centers for valve surgery, whereas other centers did not use it at all. Its use during coronary artery bypass grafting was less common. Assessment of the preoperative anesthesia note revealed that coronary anatomy and ventricular function were noted in nearly all instances. However, a clear notation that risks and benefits of anesthesia were discussed was less frequent. Structures related to anesthesia attending staffing, board certification, and experience revealed variation. Some sites had smaller and/or more experienced attending staffs, whereas others had larger and/or less experienced staffs. These pilot findings appear to validate the authors' hypotheses that variations in anesthesia practice are present within the Veterans Affairs system. They suggest that the variable set is robust enough to relate processes and structures of anesthesia care to patient outcome.
麻醉护理是心脏手术不可或缺的组成部分。对成本效益和缩短住院时间的重视促使人们重新评估麻醉实践。然而，麻醉过程和结构变量与患者预后之间的关系在很大程度上尚不清楚。《心脏手术中的护理过程、结构与结果》是第一项收集麻醉过程数据的流行病学研究，这些数据包括麻醉的药理学成分以及所使用的心血管监测类型。护理结构，如住院医师配备、监督、文件记录的完整性以及护理人员的培训和经验，也在评估范围内。1992年9月至1993年9月收集的试点数据表明，六个研究地点在选定的过程和结构方面存在很大差异。尽管几乎普遍使用麻醉性麻醉作为主要麻醉技术，但观察到所使用的阿片类药物和辅助性苯二氮䓬类药物类型存在差异。关于有创血流动力学监测，大多数中心仅使用一种类型的导管。术中经食管超声心动图在几个中心常用于瓣膜手术，而其他中心根本不使用。其在冠状动脉旁路移植术中的使用不太常见。对术前麻醉记录的评估显示，几乎所有病例都记录了冠状动脉解剖结构和心室功能。然而，明确记录讨论麻醉风险和益处的情况则较少见。与麻醉主治人员配备、委员会认证和经验相关的结构存在差异。一些地点的主治人员较少和/或经验更丰富，而其他地点的主治人员较多和/或经验较少。这些试点结果似乎证实了作者的假设，即退伍军人事务系统内存在麻醉实践差异。它们表明，该变量集足够强大，足以将麻醉护理的过程和结构与患者预后联系起来。
