Anesthesiology

Sheridan Healthcare has been supplying anesthesia services to hospitals and ambulatory surgery centers for nearly 60 years. We are more experienced than any other anesthesia provider in the country, and we’ve retained our first clients since 1953.

We work toward increasing the use of operating rooms and reducing overall hospital expenses. Access to an operating room is facilitated through better capacity management, efficient turnover, availability of coverage and improved on-time starts. Often, increased OR volumes, coupled with the collaborative working relationships our teams foster, result in the highest approval ratings from surgeons and hospital administrators.

Our locally based teams are comprised of full-time, board-certified or board-eligible anesthesiologists, CRNAs and AAs (anesthesiologist assistants). Learn more about our anesthsia management services.

Read our anesthesiology-related posts:

3 November2016

Sheridan CRNA Jobina Ruiz Featured on AANA Journal’s October Cover

Sheridan is proud that the cover of the AANA Journal’s October issue features a photo of Sheridan Certified Registered Nurse Anesthetist (CRNA) Jobina Ruiz setting up for an obstetric fistula repair surgery in Rwanda. Ruiz participated in a global anesthesia immersion experience in Rwanda with the International Organization for Women and Development (IOWD) at the beginning of this year, when she was a student registered nurse anesthetist at Northeastern University. The IOWD is a non-profit organization that, among other things, provides free treatment and care to Rwandan patients suffering from obstetric fistulae, gynecologic and pelvic floor disorders. Ruiz, who was invited to participate in the mission at the invitation of her instructor, made the trip at her own expense.

Her 16 days in Rwanda with the IOWD was a valuable and eye-opening experience. For the first few days, she worked with the gynecological surgical team on general anesthesia cases and had the opportunity to watch those patients over an extended period of time. For the rest of her stay, she worked primarily on less invasive fistula repair cases and cystoscopies under epidural and spinal anesthesia. 

Working with the IOWD volunteers and local clinicians in Rwanda was both challenging and exciting. It provided Ruiz with many new learning opportunities, for example, administering anesthesia drugs such as halothane and sodium thiopental that are no longer used in the United States. Language barriers sometimes made communication challenging, and learning about the cultural differences between Africa and the U.S. was fascinating but also could be frustrating, such as the local cultural bias against using extreme measures to save the lives of critically ill neonates. But Ruiz fell in love with Africa and the people she met there – especially the women whose pain she helped manage during obstetric fistula repair surgeries. 

 

Jobina Ruiz draws blood from a Rwandan woman’s anti cubical vein as an anesthesiologist places an epidural to administer a blood patch

Fistula, a hole in the wall between a woman’s bladder and vagina, is a terrible condition found in women who have experienced a prolonged and obstructed labor without medical assistance, or sometimes as a result of injury to the bladder during a difficult surgery. This hole causes constant urine leakage. If the rectal wall is also affected, the woman also has no control over her feces. Ruiz learned that Rwandan women with untreated obstetric fistula are ostracized by their husbands and shamed by society, becoming social outcasts.

These women were incredibly grateful for the help of the surgical team volunteers, looking at them with eyes filled with hope and saying in their native language, “You’re going to fix me!” Ruiz said she’s equally thankful for having had the opportunity to meet and help them. “I helped these women,” she explained, “but in return they taught and helped me so much more! I am a better person because of them and this experience, and I am extremely grateful I was able to go.” She also appreciates the experience of having to make do with very limited supplies, equipment and drugs: “It taught me what I’m capable of.” Ruiz, who is well traveled, said she is anxious to return to Rwanda, next time with her husband.

She joined Sheridan in early September, immediately after passing her CRNA exam, and works at Memorial Regional Hospital in Hollywood, Florida. Prior to returning to school to earn her graduate degree and CRNA certification, she worked as a critical care registered nurse at the Mayo Clinic in Scottsdale, Arizona and NYU Langone Medical Center, Beth Israel Medical Center, New York-Presbyterian Hospital and Midtown Surgery Center in Manhattan, New York.

She hit the ground running at Memorial Regional, becoming a preceptor for nursing students after just two weeks. Her favorite thing about being a Sheridan CRNA is the strong sense of community. “It’s like being welcomed into a family.”

24 October2016

Using CRM and Time-Outs to Focus Hurried OR Teams on Patient Safety

The shift to value-based care and the imminent implementation of MACRA have made efficiency healthcare’s new mantra, and U.S. hospitals and healthcare systems have made operating rooms a high-priority target for optimization. ORs in U.S. hospitals generate about 70% of a hospital’s revenues and operate at a staffed-capacity utilization of 60-70% and OR time costs roughly $80 an hour, so it’s not surprising that metrics like on-time starts, turnover times, same-day cancellations and OR under- and overutilization are under scrutiny. But speed is not the same thing as efficiency, and the faster OR teams work, the greater the risk of something going wrong. 

Dr. Adam Blomberg, National Education Director for Sheridan’s Anesthesiology Division, has long been an advocate of improving efficiency in the OR, calling it a win for “the anesthesiologists, surgeons, nurses, administrators, and most of all, the patients.” But he also worries that the enormous pressure on healthcare providers nationwide to speed up care delivery could eventually result in rushing at the expense of patient safety. An April 2016 analysis commissioned by The Leapfrog Group conservatively estimated that more than 206,000 avoidable deaths in U.S. hospitals each year are caused by medical errors, and those numbers could increase if hospitals’ drive for greater efficiency isn’t paired with an equally strong push to improve patient safety.

In a recent interview with Becker’s ASC Review, Dr. Blomberg urged surgical teams to slow down while speeding up – to work quickly and efficiently but also to remember to “slow down, take a deep breath and still think of the patient first.” He is a strong proponent of crew resource management (CRM) for OR teams. CRM training brings all team members together to learn how to communicate, make decisions and work together as a team both efficiently and effectively. It also standardizes the routine use of checklists and protocols, such as empowering any team member who identifies potential harm to the patient to call a “time-out,” immediately causing the entire team to pause and discuss that member’s safety concern. 

Dr. Blomberg is also Chief of Anesthesiology at Memorial Regional Hospital (MRH) in Hollywood, FL, which is part of the Memorial Healthcare System (MHS) that has experienced significant quality and safety improvements, fewer untoward outcomes and sentinel events, and improved patient experience and satisfaction after implementing CRM.

Dr. Blomberg stresses to his teams the importance of time-outs and has standardized the use of an anesthesia time-out at MRH to make sure the patient and the OR team are on the same page prior to induction of anesthesia. Sheridan’s standard anesthesia time-out is a brief conversation between the anesthesia care team and the circulating nurse to verify that the team has the correct patient, correct side and correct equipment in the OR, and that any necessary vendor or representative for surgical equipment is available prior to induction. The anesthesia time-out can take place after the patient has had pre-op sedation but before he or she is under general anesthesia. Sheridan anesthesiologists also do a surgical time-out with the surgeon as a final double-check prior to incision.

Twelve years after The Joint Commission’s Universal Protocol was introduced, creating widespread adoption of pre-procedure verification, site marking and time-outs, embedding patient safety into surgical teams’ SOP is more important than ever. It’s time we made National Time Out Day redundant.

19 October2016

Sheridan’s 2016 Leadership Conference Recognizes Eight Outstanding Clinical Leaders

The annual three-day Sheridan Leadership Conference is Sheridan Leadership Academy’s flagship event. This year’s conference took place Sept. 30-Oct. 2 in Orlando, Florida and was attended by nearly 600 physician and allied health leaders. 

 

Strengthening the Core

President of Physician Services Robert Coward and CEO Chris Holden provided opening remarks and introduced this year’s conference theme, “Strengthening the Core,” which focused on the key attributes required to succeed as a Sheridan clinical leader. Throughout the conference, each service line held multiple breakout sessions to promote discussion and knowledge sharing of topics related to the conference theme.

New Leadership Academy Programs

This year’s conference also marked the expansion of the Leadership Academy’s programs, whose participants are nominated by their leaders. In addition to the Emerging Leaders Program that began in 2014, the Academy added two new programs this year, the Physician Chiefs Program and the Allied Health Chiefs Program. Each of the three leadership programs kicked off its first course at the conference.

The 2016 Sheridan Leadership Award Winners

One of the highlights of the conference was the awards dinner, which took place on Oct. 1. Eight outstanding Sheridan physicians were honored with 2016 Leadership Awards:

Dr. Mike Adkins, Anesthesia Services Chief of the Year

Michael Adkins has been with Valley Anesthesiology since 1994 – providing cardiac anesthesia services for 13 years, serving as medical director at an outpatient plastic surgery center, and currently is chairman of anesthesia at Banner University Medical Center-Phoenix.

He also has filled important administrative roles during his tenure, including scheduling coordinator, division manager, board member, and principal in the formation and launch of Valley’s Mobile Services Division.

He is a former board member of the Arizona Medical Association and is president-elect of the Arizona Society of Anesthesiologists. He earned his medical degree from the University of Minnesota-Minneapolis, did a surgical internship at the University of Illinois in Chicago and received training in cardiothoracic and neuroanesthesia at Stanford University.

 

Dr. Joseph Toscano, Emergency Medicine Chief of the Year

Dr. Toscano has been an attending emergency physician at San Ramon Regional Medical Center since 1999 and chief of the department since 2013.

He has extensive experience and expertise in the field. In the early 2000s, he was a partner and corporate medical director for Pinnacle Medical Group, which operated five urgent care clinics in California and Arizona. He lectures frequently at urgent care conferences and is on the board of directors of the Urgent Care Association of America. He has been medical director of San Ramon Regional’s occupational medicine clinic since 1999.

He graduated from Dartmouth College and earned his medical degree from the Duke University School of Medicine. He trained in internal medicine at the naval hospital in San Diego and began practicing emergency medicine during an operational tour of duty with the U.S. Navy in the early 1990s. He moved to California in 1994 and has been an EM physician there ever since.

Dr. Frank Seidelmann, Radiology Chief of the Year

Dr. Frank Seidelmann is co-founder, chairman, and visionary force driving the success of Radisphere. Dr. Seidelmann brings a wealth of experience in radiology with subspecialty expertise in MRI and neuroradiology. He has more than 25 years’ experience in interpreting MRI cases and functions as a consultant on difficult cases for radiologists and clinicians around the country. He has lectured on MRI, both nationally and internationally.

Before venturing into subspecialty teleradiology in 1996, Dr. Seidelmann co-founded a highly successful hospital and outpatient imaging center based radiology group with 20 contracts in the Midwest and central states, at one time employing more than 50 physicians, which was acquired by Med Partners and later became Team Health. He also has owned several diagnostic imaging centers in Ohio and co-founded RIS Logic, a leading radiology software company that targeted diagnostic imaging centers. RIS Logic was later acquired by Merge Healthcare in 2003. Additionally, he has held staff positions at the Cleveland Clinic Foundation and Case Western Reserve University, and has expertise in small joint imaging.

Dr. Mitchell Stern, Women’s and Children’s Chief of the Year

Mitchell Stern, MD joined what was then known as Neonatology Certified in 1987, immediately after completing his Neonatal Fellowship at Babies Hospital (Columbia Presbyterian Medical Center) in New York City. He did his residency, including a chief residency, at Brookdale Hospital Medical Center in Brooklyn, New York. He attended medical school at St. George’s University School of Medicine in Grenada, WI and attended college at Cornell University in Ithaca, New York. 

Dr. Stern joined the staff of Plantation General Hospital in 1987 and became a Director of the unit shortly after Neonatology Certified became a part of Sheridan Healthcare in 1996. Besides being the clinical and administrative leader of the PGH Level III NICU, Dr. Stern has also been the Principal Investigator in several multicentered research projects and has been involved with several committees at both the hospital and HCA Corporate Levels.

Dr. Adam Blomberg, Diamond Award Winner

Adam L. Blomberg, M.D. is the Chief of Anesthesiology for Memorial Regional Hospital in Hollywood, Florida., as well as the National Education Director for Sheridan Healthcare’s Anesthesia Division. He serves on the Anesthesia Quality Committee at Sheridan as the co-chair of the Clinical Education & Best Practice Subcommittee. He has held positions at Memorial on the Physician's Satisfaction Committee and the Multidisciplinary Peer Review Committee as well as the Co-Chair of the Surgical Services Executive Committee.

Dr. Blomberg has had numerous articles published on anesthesia trends and best practices in leading industry publications, such as the Wall Street Journal, CNN Health, ASA Newsletter, Anesthesia Patient Safety Foundation Newsletter, HealthLeaders, Managed Care Outlook and Becker’s Hospital Review. In addition, he has spent more than 15 years as the national speaker for the “Driving Responsibly” campaign.

Dr. Blomberg completed his training at Brigham & Women's Hospital, a teaching affiliate of Harvard Medical School in Boston in the Department of Anesthesiology, Perioperative and Pain Medicine. During his final year of residency, he served as Chief Resident. He is a graduate of the University of Miami School of Medicine in Miami, Florida.

Cindy Houck, CRNA, Platinum Award Winner

Cynthia Houck, CRNA joined Sheridan Healthcare in 1984 after graduating from George Washington University’s Nurse Anesthesiology Program. She has witnessed the growth of Sheridan from a small private anesthesia group to the nation’s largest anesthesia outsourcing provider.

Cynthia has served as the Chief of Allied Health at Memorial Regional Hospital, a 700-bed tertiary care level-one trauma center, since 1993. She has also been the Regional Director of Allied Health, South Florida Region since 2009. Her responsibilities include oversight of all Allied Health in Dade and Broward Counties, 14 hospitals and 6 ambulatory facilities. She was the Clinical Coordinator for SRNAs from FIU from 2006 until 2012.

In addition to her clinical duties, Ms. Houck is also co-chair of the Policy & Procedure Subcommittee for Quality Improvement

 

Dr. Gary Gomez, Innovation Award Winner

Dr. Gary Gomez has served as chief of anesthesiology at Memorial Hospital Miramar since 2013 and has led several clinical improvement projects. These include enhanced recovery after surgery protocols, PONV prophylaxis tools and i

ntrathecal catheter management protocols. He also was one of three lead physicians to develop the ClearPATh anesthesia patient readiness program and is currently collaborating to develop further clinical pathways as part of Sheridan/AMSURG’s nationwide initiatives.

Dr. Gomez received his medical degree from the University of Florida and is currently enrolled at UF’s executive MBA program. He lives in South Florida with his wife and three children.

Dr. Jonathan Katz, Innovation Award Winner

Dr. Jonathan Katz started with Sheridan eight years ago as a member of the cardiac team at a 227-bed hospital. He was promoted to vice chief a year later and has been a regional medical director for 1.5 years.

Dr. Katz graduated from the University of Pennsylvania School of Dental Medicine and got his medical degree from the University of Connecticut in oral and maxillofacial surgery. He completed his anesthesia residency at the University of Miami, where he served as chief resident and did his cardiothoracic anesthesia fellowship. He also worked as an attending in UM’s cardiac anesthesia subdivision and was assistant program director for the anesthesia residency.

 

 

Please join us in congratulating this year’s Sheridan Leadership Award winners.

19 September2016

How Physicians, Hospitals and Health Systems Are Dealing With the U.S. Drug Shortage Crisis

The ongoing drug shortage crisis in the U.S. is sending prices for some medications skyrocketing, forcing hospitals and physicians to scramble for alternatives and threatening the safety of patients. These shortages have been causing major problems nationwide for several years, but the causes are complex and not easily fixed, and doctors, hospitals, health systems and acute-care facilities continue to struggle to find effective workarounds.

The number of drugs in short supply in this country has more than tripled in the past decade. Since 2012 when the Food and Drug Administration Safety and Innovation Act (FDASIA) took effect, that number has decreased overall. Yet shortages of drugs commonly used for unscheduled acute care in emergency rooms, intensive care units and other health care facilities have continued to increase in both number and length, with an approximately eight-month median duration. 

Multiple Causes Make Drug Shortages Hard to Fix or Prevent

Most U.S. drug shortages are caused by one or more of the following:

  • Manufacturing / production issues:
    • ​Quality control problems
    • Lack of availability of raw materials
    • Shipping delays
    • Production capacities that either cannot or have not yet ramped up to meet increases in demand
  • Economic issues / business decisions: 
    • ​Market share erosion that causes brand-name drug manufacturers to discontinue production when generic versions enter the market
    • Mergers or acquisitions involving pharmaceutical companies that manufacture the same medication, which typically results in one of those drugs being discontinued for business reasons
    • Discontinuation of older medications in favor of newer, more profitable ones
  • Regulatory issues:
    • Slow FDA approvals for new drugs
    • Pricing constraints tied to federal reimbursements
    • FDA warnings and bans that result in the temporary suspension of production at particular plants or permanent discontinuations of certain products, including commonly used injectable opioids such as morphine and oxycodone and injectable benzodiazepines such as diazepam, midazolam and lorazepam

The Sterile Injectable Drugs Shortage: A Perfect Storm

Sometimes more than one of these factors contributes to the shortage of a particular drug or type of drug. The persistent shortage of sterile injectables – including essential drugs like sterile saline solution and antibiotics that can be effective against superbugs – is the result of a perfect storm of manufacturing, economic and regulatory issues. 

According to a recent article in Forbes, sterile injectable drugs are more expensive to manufacture and notoriously difficult to produce safely, yet because they are subject to federal Medicare and Medicaid reimbursement policies they often have artificially low selling prices. In addition, the FDA’s increased scrutiny of sterile IV fluid manufacturers after particulate matter was found in some products a few years ago has led to recalls, manufacturing delays, and product discontinuations of some sterile injectables. 

Shortages of injectable antibiotics that have been shown to be effective in treating drug-resistant bacteria present another serious challenge, especially in light of the alarming evolution of superbugs. A recent example is this year’s shortage of amikacin sulfate. Amikacin has been shown to be active against certain gram-positive and gram-negative bacteria including Staphylococcus series, Klebsiella series and E. coli, both in vitro and in clinical infections. It also may be the aminoglycoside of choice for serious nosocomial gram-negative infections in areas where resistance to gentamicin or tobramycin is present. Teva Pharmaceuticals is one of the few companies that manufacture amikacin. FDA inspectors who visited Teva’s sterile injectables plant in Hungary in January cited issues with the “current good manufacturing practices” (CGMPs), the regulations for pharmaceutical manufacturing processes and facilities that the FDA enforces. Teva responded by suspending production of all but two of the roughly 200 drugs that were being made there “as a precaution” while it continues to work to resolve those issues to the FDA’s satisfaction. Only amikacin and bleomycin, a cancer treatment drug, continued to be produced at the facility. The FDA subsequently issued an import alert banning all the products made at that plant from the U.S., with the exception of amikacin and bleomycin. But on August 2, Teva announced a voluntary recall of seven lots of amikacin sulfate, citing concerns about the potential presence of glass particulate matter, and as of August 31 the ASHP current drug shortages page includes both amikacin and bleomycin. 

Other manufacturers of sterile injectables have also been forced to halt production at plants outside the U.S. while they address FDA warnings and concerns. Over the past several years, FDA warnings for Hospira plants in Europe, North America, Asia and Australia have caused production stoppages. Pfizer, which acquired Hospira last year, announced a temporary production halt at a plant in India last month after a team of inspectors from four of the world’s leading regulatory agencies, including the FDA, found a number of lapses in good manufacturing practices. 

Price Gouging Exacerbates the Problem

Shortages and discontinuations of drugs that have unique applications or are produced by only one manufacturer have even more severe repercussions. And manufacturer price gouging for these medications is becoming a huge problem. The FDA has been slow to approve new medications that could provide market competition that would drive down prices as well as create alternative options for health care providers during shortages of either drug. 

Another emerging source of price gouging is the misuse of the Orphan Drug Act (ODA). More and more companies are purchasing the rights to existing drugs and submitting them to the FDA for approval as orphan drugs for a different use, to treat diseases that affect fewer than 200,000 people in the U.S. Under ODA, makers of approved orphan drugs get tax credits for half the cost of clinical development (even though companies that purchase the older drugs didn’t pay for the development costs), seven years of exclusivity, and waived fees. So once the FDA approves the drug as an orphan, the drug makers relaunch them under a different name and charge exorbitant prices. 

This trend has a wider impact than it might appear because many of those “orphan” drugs are frequently used off-label to treat much more common conditions, making this practice even more profitable for drug makers. And repeated attempts to curb misuse of the law by ending drugs’ ODA status and benefits once the drug’s target population or sales exceeded a certain threshold have been blocked.

International Politics Have Led to Shortages of Sedatives, Paralytics, Anesthetics and Other Drugs

Commonly used sedatives, paralytics, anesthetics and other drugs that have been used not only by hospitals for medical purposes but also by U.S. correctional facilities as anesthetics for lethal injections have become limited or discontinued. A global campaign by opponents of the death penalty or lethal injections against makers of drugs used for that purpose brought intense pressure to bear, causing many of the manufacturers to stop producing them or severely restrict their distribution. That has left physicians and hospitals scrambling for alternate sources as well as alternative medications.

Hospira, the only U.S. manufacturer of sodium thiopental (Pentothal), is one example. The company had halted production of the drug in 2009 because of manufacturing issues in a North Carolina plant, and after spending two years trying to bring the closed facility into compliance with the FDA CGMPs, had planned to shift production to a plant in Italy. But Hospira was forced to exit the market permanently in 2011 instead after Italian officials said they would not permit the product to be released out of Italy if it could potentially be used for lethal injections.

Some paralytic agents also are no longer being produced for similar reasons, and those that are in production are extremely expensive. There also has been a shortage of agents used to reverse those paralytics, and the prices of those that are available have gone up dramatically; a drug that used to cost roughly $10 per vial can now cost close to $100. 

The FDA’s Dilemma: Balancing Quality and Supply

The FDA is under tremendous fire from two opposing factions: those who argue that the agency’s more zealous inspections and enforcement actions in recent years have been largely responsible for the drug shortage problem, and those who say that zeal must be maintained to protect this country’s patients by ensuring the safety and efficacy of the U.S. drug supply. The FDA’s efforts to straddle this supply/quality tightrope by making exceptions or finding loopholes in the enforcement of its good manufacturing quality practices have often been met with criticism. 

Faced with the sudden shortage of sodium thiopental in 2011, several U.S. states imported untested sodium thiopental for use in lethal injections from a questionable distributor in the U.K., leading the British government to ban the sale of sodium thiopental from the U.K. And a federal appeals court later prohibited the FDA from letting sodium thiopental from foreign suppliers into the country.

In another example, when the agency issued an indefinite ban on a factory belonging to one of China’s leading exporters of pharmaceuticals products last year, the FDA made a highly controversial decision to allow the banned plant to continue exporting about 15 ingredients for use in finished drugs in the U.S., including widely used chemotherapy ingredients doxorubicin and daunorubicin, to avoid possible shortages of key drugs. 

FDA’s Push to Modernize the Pharmaceutical Manufacturing

The FDA has begun working with drug makers to modernize manufacturing methods. This proactive collaboration with drug makers is a new approach “to help the industry adopt scientifically sound, novel technologies to produce quality medicines that are consistently safe and effective — with an eye toward avoiding drug shortages.” The agency says it is encouraging pharmaceutical industry to develop advanced manufacturing technologies, as other industries have done, in order to “create a more robust drug manufacturing process with fewer interruptions. This will minimize product failures and provide greater assurance that the product will consistently deliver the expected clinical performance.” The FDA has established an Emerging Technology Team (ETT) that is providing guidance to drug companies pursuing new technologies, engaging in a dialogue with them early in the technology development process to help identify and resolve scientific issues for new technologies before a drug application is submitted. The agency says it worked closely with the manufacturer of the first-ever 3D printed pill, for epilepsy drug Spritam (levetiracetam), to make the use of 3D printing technology for this application a reality. The agency recently approved the pill, which it says “can disintegrate more rapidly in a patient’s mouth, greatly aiding those who have trouble swallowing.” 

What Can Physicians, Hospitals and Health Systems Do?

Until long-term solutions to the underlying problems causing ongoing drug shortages are agreed upon and implemented, physicians, hospitals and health systems need to continue to develop strategies to acquire vital medications in short supply and workarounds for those that are unavailable. They can also become active in advocacy efforts to help shape effective solutions. 

Use Group Purchasing Organizations (GPOs)

Many hospitals belong to group purchasing organizations (GPOs) that leverage member organizations’ aggregated buying power to drive down prices of products in the health care supply chain, including medications. Pharmaceutical companies often give GPOs preferential treatment when shipping drugs in short supply, so GPO member hospitals acquire more of those medications more quickly than non-member hospitals, exacerbating the shortage of those drugs at those facilities. GPOs have been consolidating to further increase their negotiating power with manufacturers, vendors and distributors. 

There are those who blame drug shortages on these large purchasing groups, notably Physicians Against Drug Shortages, a small, nonprofit advocacy group that has been extremely vocal on this subject. 

Purchase Directly From Pharmaceutical Companies

Many of the drugs that have chronically been in short supply are vital, especially for emergency and acute care. More and more health systems have forged direct relationships with drug makers to procure some of those hard-to-get, critically important products, even though one-off purchases may cost more than buying through a GPO or distributor. GPOs are concerned about the increase in direct purchasing contracts, which threaten the long-standing distribution model and the GPO administrative fees that fund those buying groups.

As a last resort, hospitals and health systems sometimes try to import drugs directly from other countries.

Use or Purchase Alternative Medications

When ready-to-administer doses of a medication are unavailable, the drug may be available in a form that requires the doctor or nurse to fill syringes or make other preparations before administering it to patients.

 In many cases, there are medications with similar uses and effectiveness to drugs in short supply that can be used as temporary alternatives. But they often cost more – sometimes many times more – than the unavailable drug. In some cases, doctors who have no other choice may be forced to use older medications that may not be as effective as the drug of choice or may involve more, or more harmful, side effects.

A team of Yale researchers found that using alternative medications in acute and emergency situations raises the risk of medical error, so it may be advisable to familiarize medical staff with the proper procedures, uses and potential side effects of alternative drugs used in acute and emergent care.  

Use Alternative Techniques

When either paralytic agents are in short supply, or cannot be used because of a shortage of paralytic reversal agents, there are alternative techniques such as regional, spinal or epidural anesthesia or nerve blocks that can be used in some cases to reduce the need for paralytic agents. 

Anticipate Shortages at Health Care Facilities

By monitoring hospital pharmacy inventory and tracking drug usage, hospitals and health systems can sometimes predict which drugs will be in short supply and seek alternative sources in advance. If hospitals know that the price of a drug will be going up or going on shortage, pharmacies can sometimes buy up those drugs far enough in advance to maintain a good supply before the price increases or to tide them over during the anticipated shortage. Sheridan meets with its hospital partners’ pharmacies on a regular basis and helps advise them on the best strategies to address specific current and anticipated shortages.

Participate in Advocacy Efforts to Fix the Problem 

The issues causing ongoing drug shortages are complex and interrelated. Arriving at successful short-term and long-term solutions to the drug shortage crisis will likely require the collective input and collaborative efforts of health care providers and facilities, patients, pharmaceutical companies and local and federal government. More physicians need to be vocal advocates for changes to fix the broken U.S. health care supply chain and rethink current regulatory oversight for the ultimate benefit of patients. 

At the national level, Sheridan’s physician leaders are active in the American Medical Association (AMA), the American Society of Anesthesiologists (ASA), the Society of Critical Care Anesthesiologists (SOCCA) and other organizations that have led physician efforts to deal with the drug shortage issue, including lobbying the federal government (including the FDA) and the pharma industry. Although not all of their advocacy efforts have met with success, some have positively influenced federal policy. For example, the FDA’s 2013 Strategic Plan for Preventing and Mitigating Drug Shortages incorporated several AMA policy elements

Physicians can also participate in these efforts at the state level. Many Sheridan anesthesiologists are extremely active in the Florida Society of Anesthesiologists (FSA), a state component society of the ASA, and a number of those physicians have served on the society’s board of directors. 

22 August2016

How Video Laryngoscopy Is Shaping the Future of Anesthesiology

In the new Difficult Airway Management issue of Anesthesiology News, three Sheridan physician leaders who are also prominent anesthesiologists discuss the inexorable shift from fiberoptic intubation and direct laryngoscopy toward video laryngoscopy and how that trend is shaping the future of patient care and the practice of anesthesiology.

Sheridan’s Regional Medical Director Dr. Joseph Loskove, Chief Quality Officer Dr. Gerald Maccioli and National Education Director, Anesthesiology Division Dr. Adam Blomberg say that, although direct fiberoptic intubation has widely been considered a gold standard for anticipated difficult-to-intubate (DTI) patients, a lack of consensus among national anesthesia societies on what constitutes best practice in specific situations brings into question whether a universally applicable gold standard for difficult airway management can, or should, exist.

This lack of agreement on clinical best practices makes the inherently difficult job of intubating DTI patients even harder. Further complicating clinical decisions about difficult airway management practices is that as video laryngoscopy becomes the primarily modality of choice, clinicians who intubate patients only occasionally or who have less experience with fiberoptic intubation and direct laryngoscopy become less comfortable using them.

Drs. Loskove, Maccioli and Blomberg emphasize the need to provide anesthesiologists and other clinicians who might need to intubate DTI patients with better and more consistent guidance that helps them make good judgment calls about the optimal modality for a specific application or case, as well as more helpful guidance on when it might be advisable to change to an alternative modality in the event of complications. The authors also stress the importance of helping anesthesiologists maintain or develop their level of comfort using conventional laryngoscopes, so that they maintain a complete and comprehensive set of laryngoscopy modalities in their DTI tool kits and are comfortable switching from video laryngoscopy to fiberoptic intubation or direct laryngoscopy if the technology fails them.

The article concludes with a discussion of the importance of optimizing and implementing system-wide protocols, such as the extremely successful difficult-to-intubate protocol that Dr. Loskove installed throughout the Memorial Healthcare System (MHS).

Read more about the perspectives of these renowned anesthesiologists and physician leaders in their Anesthesiology News article, The Shift Toward Video Laryngoscopy: The Good, the Bad, and the Future.

15 August2016

Six Physician Communication Strategies to Increase Patient Engagement and Improve Outcomes

Effective physician-patient communication that builds trust and a shared sense of responsibility for the patient’s care is an increasingly important skill for physicians. Doctors whose communication fosters patient engagement has been linked to a wide range of benefits, from increased patient satisfaction, trust and higher quality of care to better patient adherence to treatment and improved physical outcomes. Communication skills are especially important in a hospital setting, which patients often perceive as more impersonal than a visit to their primary care physician’s office.

The challenge is that while the need to involve patients in decisions about their own care continues to grow in importance, the current health care environment – including shorter hospital stays, more complex medical care and a drive for efficiency – makes it harder to achieved good communication among providers, patients and family members.

The Negative Effects of Poor Physician Communication on Patient Experiences … and Outcomes

A 2015 study published in PLOS ONE synthesized qualitative studies exploring patients’ experiences in communicating with a primary care physician to identify the determinants of positive and negative experiences in physician-patient communication and their subsequent outcomes. It found that, overall, primary care physicians’ communications create more negative than positive patient experiences. Patients report that physicians usually lead consultations and sometimes in a paternalistic manner – deciding on the treatment plan without engaging the patient in a conversation about care decisions, asking too few questions or too many closed-ended question, and rushing through explanations of the patients’ illnesses while using complicated, unfamiliar medical jargon. Doctors often orient conversations toward physical symptoms without leaving room to discuss psychosocial aspects related to the condition. As a result, patients say they feel powerless, vulnerable and intimidated and, therefore, less likely to engage in their own care decisions by asking questions or volunteering psychosocial or other information that might affect their diagnosis or treatment. Those who attempt to address psychosocial issues proactively report being dismissed.

Patients say these negative experiences leave them feeling not only helpless, frustrated, unheard and unrecognized but also unmotivated to comply with their treatment plans.

While this study focused specifically on primary care doctors, these problems can be exacerbated in a hospital setting, where a physician-patient relationship may not have been established.

Communication Skills That Promote Patient Engagement

Patients also shared the communication-related skills they value most in physicians:

  • Empathy.
  • Careful listening.
  • An open mind.
  • Friendliness.
  • Compassion.
  • A genuine interest in the patient.
  • Attentiveness.
  • Willingness to ask questions and initiate conversations.
  • Investing time and effort to educate patients and make sure they understand the illness.

These skills are key to fostering collaborative, two-way communication and building trust and mutual respect – things that can provide important contextual information and enable doctors to do a better job of tailoring care and fostering patient engagement.

Cultural Barriers to Effective Communication

Ultimately, whether patients experience a physician’s communication with them as positive or negative is heavily influenced by the context of a patient’s individual background and values. Some of the ethnic minority patients report experiencing additional communication difficulties resulting from language barriers, discrimination, differences in values and beliefs, and acculturation-related issues.

The study offers several examples of how acculturation affects physician-patient communication. One such example is that Hispanic migrants to the U.S. say they need to develop a warm relationship with their physicians before they feel safe sharing private information, while U.S.-born Hispanics attach less importance to developing warm relationships with their doctors because they appear to understand that the physician’s primary role in this country is to heal.

Interestingly, patients who need to consult with informal interpreters during medical visits say those consultations make them feel embarrassed, guilty and uncomfortable. And, not surprisingly, the presence of an informal interpreter not only inhibits patients from discussing sensitive or mental health topics but also makes disclosing intimate information difficult or impossible.

Six Ways to Improve Physician-Patient Communication and Engagement

Solicit Relevant Psychosocial Contexts

Encourage patients to talk about psychosocial factors that might be related to their condition. Try to provide a nonjudgmental atmosphere to help make them comfortable talking about difficult personal issues.

Tailor Communications to Cultural Contexts

Develop a cultural awareness and understanding of the populations you serve and tailor communications appropriately to each patient’s cultural, values- and beliefs-based context to avoid inadvertently giving offense or causing mistrust.

Educate Patients on Care Best Practices

In a recent article in MedPage Today, Dr. Catherine Polera, chief medical officer for Sheridan’s Emergency Medicine division, describes how she uses effective communicate to bridge gaps in patient expectations. For example, patients who are diagnosed with bronchitis often expect a prescription for antibiotics, yet acute bronchitis is usually viral and, therefore, usually should not be treated with antibiotics. She finds that explaining the reason for her decision not to prescribe an antibiotic in that situation, using easy to understand language and showing patients evidence that supports her decision – using online sources they trust – helps educate patients and increase their satisfaction with the care she provides.

Educate Patients About Responsible Antibiotic Stewardship

This is also an opportunity to educate patients not only on their diagnosis but also on the evolution of antibiotic-resistant superbugs and the importance of responsible antibiotic stewardship on the part of both doctors and patients to slow that evolution.

Provide Compassionate, Personalized Care and Reassurance

A great example is radiologists Dr. Lynda Frye and Dr. Orna Hadar at the Jupiter Medical Center’s Margaret W. Niedland Breast Center, who understand that breast cancer screening is often an intimate, stressful experience for patients. To engage patients in their own care, both these physicians build patient relationships based on honest communication and trust, providing timely information and reassurance during what can be a frightening time. They read mammogram imaging immediately and discuss the results with patients. They thereby connect directly with patients and eliminate the dreaded callback to inform patients that they need to take more images. If more images or biopsies are necessary, Dr. Frye and Dr. Hadar will order them at that appointment. Additionally, they insist on delivering news to patients themselves to demonstrate their total commitment to the patient. Their compassionate, personalized care builds trust and encourages their patients to return for annual breast cancer screenings.

Provide Online Information Resources to Educate Patients and Set Expectations

Providing easily accessible, curated, topic-specific information can help reduce patients’ anxiety and properly set their expectations about medical conditions, recommended treatments and upcoming procedures. A good example of the latter is Sheridan’s Anesthesia Patient Education Portal, which not only explains the different types of anesthesia, the roles of anesthesia care team members, and what patients should expect before, during and after surgery, but also provides guidance on the types of questions patients may want to ask the anesthesiologist during the preoperative evaluation. Setting expectations, particularly around pain management, also can have a positive impact on patient experience and satisfaction

2 August2016

Better Pain Control Halves Length of Stay for Westside Regional’s Joint Replacement Surgery Patients

Jonathan Katz MD, a Sheridan Regional Medical Director and Chief of Anesthesiology at Westside Regional Medical Center in Broward County, Florida, and Eric Schiffman, MD, a board-certified orthopedic surgeon and fellowship-trained hip and knee replacement specialist, are the featured guests on a new episode of Dateline Health, a television show produced by Nova Southeastern University (NSU). Drs. Katz and Schiffman spoke with Fred Lippman, R.PH., Ed.D., NSU’s Chancellor of the Health Professions Division and the host of the show, about their extremely successful rapid recovery pathway at Westside Regional, which has significantly improved post-operative pain management and cut the average hospital stay for orthopedic surgery patients in half.

When Dr. Katz first arrived at Westside Regional about eight years ago, he identified opportunities to further improve the hospital’s already robust orthopedic joint replacement program. Back then, “total joint replacement was a tough operation. Patients would be in the hospital for five to seven days,” explains Dr. Katz. “Pain management was one of the major issues,” he says, because the pain medications used at the time had a number of side effects including nausea, vomiting and delirium that prevented patients from going home.

Dr. Schiffman made some recommendations that Dr. Katz discussed with the hospital’s team of orthopedic surgeons, whose collaboration was an important part of the new pathway’s success. Adaptations to the practice were made based on the best available evidence in the relevant medical literature. Then, they looked at ways to improve the experience of patients undergoing joint replacement surgery. Instead of looking at how patients were doing immediately following the operation, the doctors took a more comprehensive look at the entire patient experience and how it could be improved.

Together, they developed a start-to-finish pathway that begins three to four weeks prior to the scheduled surgery, when there is a discussion with the patient to set appropriate expectations and explain his or her role and responsibilities (with regard to pain management, physical therapy, rehab, etc.) in making their overall experience, recovery and outcome as positive as possible. The pathway includes the use of a multi-modal technique throughout the process, beginning with preemptive analgesia that includes medications given to patients in a preoperative holding area as well as nerve blocks administered by an anesthesiologist. At the time of surgery, Dr. Schiffman administers a non-narcotic, anesthetic “cocktail” around the surgical site that combines different medications to help control the pain, reduce blood loss and decrease inflammation.” Post-operative pain is managed effectively with minimal amounts of narcotics.

Dr. Schiffman, who hasn’t used a pain pump in five years, says improvements to the pain management process have dramatically enhanced recovery times and patient’s overall experiences with joint replacement surgery. Patients who had previous joint replacement surgeries are “shocked” by how little pain they have the next day and how quickly they are able to leave the hospital and return home.

Standardization and consistency are key aspects of the process at Westside Regional Medical Center, where joint replacement surgery patients now typically go home in three days or less. And bilateral hip surgeries are now an option, thanks to the hospital’s approach that makes it easier for patients to get around independently immediately after the surgery.

To learn more about these and other innovations in joint replacement surgery at Westside Regional, watch the entire interview with Drs. Katz and Schiffman.

28 July2016

Drs. Drozdow and Sell Honored by Florida Society of Anesthesiologists

The Florida Society of Anesthesiologists selected Sheridan’s Chief Clinical Officer, Gilbert Drozdow, M.D., M.B.A., and Brence Sell, M.D., a Sheridan anesthesiologist who sits on the FSA’s board, to receive awards at the FSA’s 2016 annual meeting at The Breakers in Palm Beach, Florida, that took place June 10–12.

Dr. Drozdow was honored with the Florida Society of Anesthesiologists’ highest award, the Distinguished Service Award. This award is the highest tribute the Society can pay to an FSA member for outstanding clinical, educational or scientific achievement, contribution to the specialty and exemplary service to the Society.

Dr. Drozdow joined Sheridan in 1987 as an associate clinical anesthesiologist and has been a director since 1991. After the company’s major reorganization in 1994, he served as Senior Vice President, President of the Anesthesiology Division and then Executive Vice President for the company. Dr. Drozdow holds a Bachelor of Arts degree in Biology from Brandeis University and received his medical degree from the New York University School of Medicine in 1983. Before completing his residency in anesthesiology and fellowship in cardiovascular anesthesiology at New York University Medical Center/Bellevue Hospital in 1987, he also completed a fellowship in pain management at the University of California Los Angeles Medical Center in 1986. Dr. Drozdow continued his education at the University of Miami School of Business Administration, earning a Master of Business Administration (MBA) degree in 1996. He continues to maintain his Board Certification in Anesthesiology.

Dr. Sell was the first recipient of the society’s new Presidential Engagement Award, created to recognize a physician anesthesiologist who is an “unsung hero,” making a tirelessly commitment to the profession without asking for anything in return.

Dr. Sell, who is also a clinical assistant professor at Florida State University College of Medicine, is the only anesthesiologist in North America who is Board Certified by the American Board of Anesthesiology, the National Board of Echocardiography and the American Board of Neurophysiologic Monitoring. He graduated from the Emory University School of Medicine and completed his residency training in Anesthesiology at Water Reed Army Medical Center. He subsequently completed a fellowship in Neurosurgical Anesthesia at Johns Hopkins Hospital and then served on active duty in the U.S. Army. Following his military service, Dr. Sell has been in private practice as an anesthesiologist in Florida.

Please join us in congratulating Drs. Drozdow and Sell on being chosen by the FSA to receive these prestigious awards!

21 July2016

Key Considerations for Performing Outpatient Total Joint Replacements at Ambulatory Surgery Centers

According to a recent article in Becker’s ASC Review, orthopedic procedures, especially, total knee and hip replacement surgeries, are among the most popular surgical services performed at ambulatory surgery centers (ASCs). The publication interviewed Sheridan anesthesiologist Cameron Howard, M.D., who described some of the key considerations in doing these types of procedures as outpatient surgeries successfully.

Dr. Howard explained that although it is much more cost-effective to do these procedures on an outpatient basis, it is desirable for some patients – e.g., middle aged, non-obese, with no significant medical problems – but not for all. For example, an inpatient setting may be preferable for patients who are morbidly obese, brittle diabetics and patients with cognitive decline.

The other key consideration is whether the family has a support system in place, “with family or friends to help them with ambulating, transferring and transporting them to outpatient rehab,” Dr. Howard said. Inpatient surgery may also be a better option for patients who don’t have that type of support system.

Dr. Howard also said that a comprehensive program that includes extensive preoperative training is required for successful outpatient total joint surgeries. Patients need understand that they will have some pain, and must be educated about the complication risks related to joint replacements.

He also discussed the role of anesthesia and pain management in outpatient joint replacement.

Read more about Dr. Howard’s views on this topic in the Becker’s ASC Review article, “Outpatient TJR rests on these 2 pillars — Sheridan's Dr. Cameron Howard weighs in.”

7 July2016

Sheridan CRNAs Cherene Saradar and Sherri Snell Travel to Greece to Help Syrian and Afghan Refugees

Sheridan certified registered nurse anesthetists (CRNAs) Cherene Saradar and Sherri Snell generously spent a week of their vacation time in Greece recently helping some of the 50,000 Syrian and Afghan refugees living there in camps. Cherene, who works primarily at Mercy Hospital in Miami, Florida, is a Syrian-American whose father is from Syria. They were joined by Cherene’s father, Dr. Riad Saradar, who is originally from Syria and still has family living in that war-torn country, where anti-government protests escalated into a full-scale civil war. Over the past five years, the armed violence has caused the loss of more than 250,000 Syrian lives and forced more than 4.5 million Syrians to flee the country, according to the BBC News.

Cherene was looking for a more effective way to help the refugees than just writing to Congress and donating money, which she has been doing for several years. Her friend Rebecca Johnson, the medical volunteer coordinator for humanitarian aid organization Off Track Health, recruited both Cherene and Sherri, who works at Jupiter Medical Center in Jupiter, Florida, for a medical mission to Greece. Sherri and Cherene had worked together at the Ryder Trauma Center in Miami and were looking forward to joining forces with “to provide compassion and care to our fellow humans that are in desperate need of medical care, food, shelter, hope, kindness and understanding,” as Sherri put it. Cherene also recruited her father, a recently retired doctor whose fluency in both Arabic and English would be very valuable. 

When they arrived in Greece, Sherri and the Saradars divided their time between the brand-new Oinofyta refugee camp and the three-week-old Ritsona refugee camp about 10 minutes away. The trio packed a lot into their one-week stay. They organized a bus-based mobile medical clinic that previously had been used at another refugee camp to ready it for use at the new Oinofyta camp. The clinic bus was in disarray, piled high with boxes of supplies that had been donated by other NGOs (non-governmental organizations) and medications from all over Europe that were labeled in a variety of languages, and it took a day and a half for Cherene, Sherri and Dr. Saradar to finish organizing all the supplies and identifying and categorizing all the medications. 

The Ritsona camp already was the long-term temporary home to more than 900 mostly Syrian but also some Iraqi and Afghan refugees. Cherene, Sherri and Dr. Saradar discovered that their medical skills weren’t as much in need as they had anticipated, because the refugees needed to go to the local clinic or hospital to get things like an x-ray or to have surgery. Since transportation to the medical facilities hadn’t been arranged, the three volunteers took care of transporting anyone needing medical help beyond what they could provide at the camp.

Before leaving the U.S., Cherene and Sherri had raised money to purchase items for the refugees while they were in Greece, thanks in large part to generous donations by Sheridan colleagues. Based on conversations that they and Dr. Saradar had with other NGO volunteers and refugees, they put together a shopping list of items that would improve the residents’ day-to-day lives at the camps, including sunscreen to protect their skin and toys for the children. Once the first refugees arrived at the Oinofyta camp, the Saradars and Sherri organized donations from the locals, set up a soccer field, printed Farsi to English dictionaries and distributed toys.

Despite the terrible circumstances and the horrors the refugees had been through, they were incredibly kind and hospitable to the three volunteers, who spent much of their time listening to the residents’ heartbreaking stories. They were especially grateful to be able to talk with someone who spoke Arabic (Dr. Saradar), and to be able to tell their stories to people who obviously cared so deeply about their plight.

Listening to the refugees’ tragic stories and seeing their living conditions was terribly upsetting to the Saradars and Sherri, who were frustrated that they couldn’t do much, much more for these people who had lost everything, including family members. But there were bright spots as well, such as playing with the children and teaching them to play the games they had purchased, including Connect Four and Jenga, and showing the teenagers how to use the Rubik’s Cube puzzles.

The mission was an unforgettable experience for all three of them. To learn more about it, and about the plight of the Syrian and Afghan refugees and what you can do to help, read Cherene’s detailed account of the trip on her blog. She also wrote about her trip in the Huffington Post.

 

Photos by Cherene Saradar. Used with permission. 

Cherene, Dr. Saradar and Sherri organizing the mobile clinic bus at the Oinofyta camp

The Ritsona refugee camp

An Iraqi refugee named Adnan, who once helped American special forces, playing the musical instrument that Cherene and Sherri bought for him

Refugee children vying for the toys that Sherri and Cherene brought

Sherri and Cherene organizing gifts and supplies for each tent

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