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In the perioperative setting, obstructive sleep apnea (OSA) may result in difficult airway management and postoperative complications, necessitating reduced benzodiazepine and opioid dosages. Because many patients with OSA are not formally diagnosed, risk identification is vital to improve perioperative care and can be achieved with the STOP-BANG questionnaire. This scholarly project examined current care practices for benzodiazepine and opioid administration to perioperative patients with a high-risk of OSA to aid in formulating future best practice recommendations. The guiding PICOT question was: In adult patients ages 40 to 60, who underwent surgical procedures in an ambulatory surgery center, does a STOP-BANG score ≥ 3, compared to STOP-BANG score < 3, result in a reduced dose of benzodiazepines and opioids administered perioperatively during the time frame of May 2024 to June 2024?
This quality improvement project occurred at an ambulatory surgery center. Data were collected via a retrospective chart review of 100 charts, 53 with a STOP-BANG score ≥ 3 and 47 with a STOP-BANG score < 3. Descriptive statistics were conducted for sample demographics. T-tests were used to compare the two groups. No statistically significant differences were noted in the amount of benzodiazepines or opioids administered between the two groups. Clinically, this is a significant finding as it shows there may be room for education and increased awareness on the effects of these medications on high-risk OSA patients. Limitations included convenience sampling, missing data in the electronic health record, and lack of variety in surgical cases. Recommendations include education and guideline implementation at this ambulatory surgery center.
Perioperative care practices for the management of patients taking long-acting Glucagon-Like Peptide 1 Receptor Agonists (GLP-1 RAs) is a relatively new anesthetic concern due to rapidly increased use of these medications. Potential adverse consequences for surgical patients taking GLP-1 RAs include pulmonary aspiration, longer hospital stay, gastrointestinal side effects, and mortality. By examining clinical practices and patient outcomes at a one-day/ambulatory surgical center, the goal was to provide recommendations for perioperative care practices of adult patients taking long-acting GLP-1 RAs. The guiding clinical question was: Among adult patients at an ambulatory surgical center taking long-acting GLP-1 RAs, what are the perioperative care practices being implemented, and how do these affect patient outcomes while receiving anesthesia during surgery? Data were collected via a retrospective chart review of 50 charts and analyzed using descriptive and correlational statistics. In addition, an anonymous survey of anesthesia providers at this clinical site was administered to garner further input on perioperative care practices and outcomes, and findings were analyzed using descriptive statistics and content analysis. Both the chart reviews and the provider survey revealed various clinical practices and inconsistent following of current guidelines. No patients experienced perioperative vomiting or aspiration, and six patients reported postoperative nausea. There was an overarching agreement among survey respondents regarding an increase in concern for patient safety for patients who take GLP-1 RAs, in addition to a reported need for education regarding the anesthetic management of these patients. Recommendations include POCUS education and training for all anesthesia providers, guidelines to promote consistent clinical practices, and increasing awareness of safe perioperative care practices for patients taking GLP-1 RA medications.
The perioperative care practices related to the management of patients taking long-acting Glucagon-Like Peptide 1 Receptor Agonists (GLP-1 RAs) are a relatively new anesthetic concern, as these medications have recently become increasingly popular. Surgical-related consequences of these medications include gastrointestinal side effects, pulmonary aspiration, longer hospital stay, and mortality. Through the examination of clinical practices and patient outcomes at a level 1 trauma center, this quality improvement project sought to provide recommendations for perioperative care practices for adult patients taking long-acting GLP-1 RAs. The clinical question was: Among adult patients taking long-acting GLP-1 RAs at a level 1 trauma center, what are the perioperative care practices being implemented and how do these affect patient outcomes while receiving anesthesia during surgery? Data were collected via a retrospective chart review of 56 charts, six of which were excluded due to being emergent cases. Data were analyzed using descriptive and correlational statistics. In addition, an anonymous survey was completed by 47 anesthesia providers to provide further descriptive information about perioperative care practices and outcomes. Findings showed a lack of POCUS use, inconsistent practices noted in chart review and survey, and providers desiring for further education on this topic, especially in regard to adequate medication hold time. Continued research and projects on this topic are imperative. Recommendations include provider education, implementation of POCUS in the preoperative setting, and creation of a clear policy for these patients that will help guide safe practice.
Perioperative care of patients taking long-acting Glucagon-Like Peptide 1 Receptor Agonists (GLP-1 RAs) is a relatively new anesthetic concern because of the increasing popularity of these medications for promoting weight loss and improving blood glucose. The potential adverse consequences for surgical patients taking GLP-1 RAs include pulmonary aspiration, longer hospital stay, and mortality. Through examining clinical practices and patient outcomes at a community hospital, this quality improvement project’s goal was to be able to provide recommendations for perioperative care practices for adult patients taking long-acting GLP-1 RAs. The clinical question of interest asked: Among adult patients taking long-acting GLP-1 RAs at a community hospital, what are the perioperative care practices being implemented and how do these affect patient outcomes while receiving anesthesia during surgery? A retrospective chart review of 50 charts was conducted and analyzed using descriptive and correlational statistics. Additionally, to further understand perioperative care practices and outcomes, an anonymous survey was distributed to anesthesia providers. This specific set of data were analyzed using descriptive statistics and content analysis. Findings showed inconsistent clinical practices, with limited use of steps to promote patient safety such as preoperative ultrasound (POCUS) and rapid sequence intubation (RSI). Based on this project’s findings, further research is warranted, especially in regard to community hospitals, to be able to create clear clinical guidelines for anesthesia providers. In addition, education is imperative among anesthesia professionals, particularly on conducting POCUS. Establishing and frequently updating a site policy on the care of patients taking GLP-1 RAs is necessary to establish uniformity of care practices among anesthesia professionals.
Guided by provider judgment, the intraoperative use of specific pain medication combinations can affect patients’ self-reported pain scores in the postoperative recovery room (PACU). While many options are available, commonly used intraoperative analgesics include fentanyl, hydromorphone, methadone, ketamine, dexmedetomidine, lidocaine infusions, and magnesium infusions. As part of a larger quality improvement project analyzing cervical, thoracic, and lumbar spinal fusions, this project sought to identify current practices for multimodal analgesia and narcotic administration in lumbar spinal fusion procedures utilizing remifentanil infusions. The literature review supported the use of multimodal analgesia to combat opioid-induced hyperalgesia. Determining the most effective practice may guide provider practices to help decrease self-reported pain scores and postoperative pain medication usage in the PACU. A retrospective chart review was conducted on 50 patients who underwent lumbar spinal fusion surgeries at a level one academic medical center. Postoperative pain scores and pain medication administration were examined for patients who received intraoperative remifentanil infusion in combination with other pain medications. The findings revealed no statistically significant correlations between intraoperative multimodal analgesia combinations and pain medication administration or pain scores in the PACU. Clinically significant findings included an average pain score in the PACU of 5.14 out of 10, potentially indicating poor pain control. Recommendations include evaluating the postoperative pain control effects of a singular analgesic, such as ketamine, during surgeries utilizing remifentanil infusions, and exploring pain assessment tools that evaluate impact on functional status.
This quality improvement project sought to identify current usage of multimodal analgesics in cervical spinal fusion procedures utilizing remifentanil infusions. The choice of specific pain medication combinations can impact patients’ self-reported pain scores in the postoperative recovery room (PACU). The literature review supported the use of multimodal analgesia to combat opioid-induced hyperalgesia (OIH) associated with remifentanil. After conducting a retrospective chart review focused on cervical spinal fusion surgeries for 50 patients, postoperative pain scores and pain medication administration were examined for patients who received intraoperative remifentanil infusion in combination with other analgesics.
Linear regression identified no significant associations between the number of intraoperative multimodals and the number of doses of pain medications in PACU (b = 0.27, t = 1.00, p = 0.322) or the average pain scores in PACU (b = 0.31, t = 1.28, p = 0.207). Pearson’s r correlations found that none of the individual multimodals were associated with pain medication administration or pain scores in PACU. Although there was a lack of statistically significant findings, it was found that nurse anesthetists were employing a multimodal approach to analgesia. More projects need to be conducted to see if multimodal analgesia can combat OIH associated with remifentanil.
Multimodal analgesia has gained favor in analgesic management to improve pain management and minimize opioid use in spinal fusion surgeries. Remifentanil, a short-acting opioid analgesic, is combined with adjuncts such as fentanyl, hydromorphone, methadone, ketamine, dexmedetomidine, lidocaine, and magnesium infusions to produce synergistic pain relief post-surgery. This quality improvement (QI) project evaluated current multimodal and opioid strategies in thoracic spinal fusion procedures using remifentanil infusions as part of a project encompassing cervical, thoracic, and lumbar spinal fusions. The literature review supported multimodal analgesia to combat opioid-induced hyperalgesia. A retrospective chart review of 50 thoracic spinal fusion surgeries at a level one academic medical center examined postoperative pain scores and pain medication administration for patients receiving intraoperative remifentanil infusions with other pain medications. Data were analyzed using linear regression and Pearson’s r correlations. Findings revealed multimodal techniques were employed among anesthesia providers; however, no statistically significant differences were observed in pain scores or postoperative medication administrations based on analgesics used. While multimodal approaches were prevalent, further research is needed to evaluate their effectiveness in reducing postoperative pain. Recommendations include expanding to alternative surgical populations without pre-existing pain conditions and adding comparative groups to enhance understanding of multimodal strategies.
ABSTRACT
JOHN C EVERETT. Preventing institutional failure: a review of operational and financial variables at theological graduate schools. (Under the direction of DR. ALAN MABE)
Theological graduate schools have faced many challenges over the past twenty years, but many have thrived and survived through the efforts of great leaders, strong faculty and staff, dedicated supporters, and supportive organizations. There have been a number of closures, mergers, and accreditation withdrawals with struggling theological graduate schools due to various reasons including enrollment reduction issues, financial exigency, rising tuition, endowment concerns, and the changing landscape of the church just to note a few. Studying the financial strengths and weaknesses at theological graduate schools provides an opportunity to address the relationship of financial and operational variables at these schools.
This quantitative study determined if there is a relationship between financial and non-financial variables and the financial stability and instability at 161 theological graduate schools in the United States. The study utilized financial and non-financial data from two time periods, 2011 and 2021 with the following variables: financial responsibility composite score (FRCS), independent theological schools, university-embedded theological schools, denomination, region, minority serving, enrollment, tuition, expenditures, endowment, library volumes, and faculty FTE.
The study included correlation analysis, trend analysis, and multiple regression analysis. The multiple regression analysis included nine models reviewing the relationship of independent and dependent variables. Independent theological schools had a statistically significant p-value for the financial responsibility composite score with negative differences in these scores compared to the university-embedded theological graduate schools. Roman Catholic theological schools had a statistically significant p-value and yield a difference of .5156 for the financial responsibility composite scores in 2011. In 2021, endowment levels and expenditure levels had statistically significant p-values and yielded differences of -.0012 and -.0002 respectively for the financial responsibility composite scores. Enrollment levels and Midwestern schools had strong p-values, but the results were not statistically significant for financial responsibility composite scores.
Overall, the United States’ population continues to substantially increase in cultural diversity (NCES, 2018; NCES, 2020a; NCES, 2020b), therefore increasing the overall diversity of students in school settings. Children from minoritized groups have a higher risk of experiencing poverty (US Census Bureau, 2017), problem behaviors (Post et al., 2019), adverse childhood experiences (ACEs), trauma (CYW, 2017), mental health concerns and inadequate mental health treatment or counseling (National Survey of Children’s Health, 2011-2012; National Survey of Children's Health, 2019-2020). Effective, culturally, and developmentally appropriate interventions are needed to address the mental health needs of racially/ethnically minoritized youth in elementary school settings. Professional School Counselors (PSCs) are charged with addressing the ongoing social/emotional, behavioral, academic, and mental well-being of all students, including those racially/ethnically minoritized. One way that PSCs can address these needs is through child-centered play therapy (CCPT). A logistic regression was utilized to explore how the amount and quality of play therapy training, adverse childhood experiences (ACEs) of the PSCs, and attitudes toward cultural humility are related to the use of CCPT in addressing student’s mental health needs among elementary school counselors (N=256). Results indicated that there was a significant relationship between the amount and quality of play therapy training, attitudes toward cultural humility, and the use of play therapy, but not ACEs. The results also indicated that there was not a significant relationship between the amount and quality of play therapy training, ACEs, attitudes toward cultural humility, and the use of CCPT. Implications, limitations, and recommendations for future research are discussed.
Climate change presents a pressing challenge for natural disaster management, to quantify its effects and associated disasters is a persistent challenge for regional climate risk studies. As climate-induced hazards escalate in intensity and frequency, infrastructure in hazard-prone regions faces growing risks – A situation especially critical to transportation infrastructures. Recent events, such as Hurricane Helene in 2024, which caused widespread damage to life supporting infrastructures and roadways closures, underscore the urgency of addressing these combined hazards. This dissertation assesses multi-hazard risks to bridge infrastructure in North Carolina’s mountainous regions, focusing on the interplay between landslide, flooding, wildfire, and earthquake risks. We approach the multi-hazard issue using landslide as the basic quantifier and investigate the nesting effect of earthquake and rainfall triggered landslides.
Because forest fire has the potential of diminishing soil moisture and can encourage landslides, wildfire risk is also included as a predictor. Analysis identifies key wildfire-related variables, such as distance to roads, elevation, and proximity to populated areas, as significant predictors of landslide susceptibility, highlighting the role of remote sensing data in extreme weather event prediction. Soil type, included in the landslide model, had limited impact, suggesting the need for refined soil classification methods in future studies.
Utilizing logistic regression (LR) and random forest (RF) models, this study develops predictive maps for landslide and wildfire susceptibility, achieving accuracy rates of 75.7% and 83.9% for landslide prediction and 68.5% and 72.9% for wildfire prediction, respectively. The higher sensitivity of the RF model, as shown in ROC curve analysis, demonstrates its effectiveness for multi-hazard risk modeling.
The wildfire susceptibility map is then incorporated as an independent variable in predicting landslide occurrences, revealing critical interactions between wildfire and landslide risks. The result are two different landslide susceptibility maps. Finally, a novel index, the Assumed Flooding Potential (AFP), is introduced to quantify flood risk. Since it is hard to establish flooding scenarios for bridges in mountain regions. AFP is calculated as the mid-span clearance for bridges. Furthermore, bridges-in-valleys are identified for high flooding risk analysis.
The integration of multi-hazard data allows for a dynamic understanding of bridge vulnerability, resulting in a shift in risk probability for certain structures. Specifically, the number of bridges with over a 50% probability of multi-hazard risk exposure decreased from 47 to 26, while four new bridges emerged in high-risk zones due to the addition of wildfire susceptibility data. These findings provide actionable insights for decision-makers, enabling proactive mitigation strategies tailored to bridges that face increased vulnerability from wildfire-triggered landslides.
This research delivers a high-resolution multi-hazard risk map and model for infrastructure resilience planning, offering critical tools for bridge engineers and policymakers. The 2024 Hurricane Helene landslides and bridge damage data from the state have been used to validate the risk maps. The results indicated reasonable accurate predictions, thus, ascertaining the study contributed to the potential to anticipate future multi-hazard risks. However, it also highlighted the need to address the complex interactions between environmental and anthropogenic factors and the urgency for future studies to advance our understanding of climate effects and to enhance our ability to anticipate and mitigate multi-hazard impacts on critical infrastructure in the face of evolving climate challenges.
