Intravenous catheters (ICs) are common and necessary for inpatient care. However, peripheral and especially central venous catheters (CVCs) are associated with increased risk for local and systemic complications, including bloodstream infections and endocarditis.

University of Wisconsin School of Medicine and Public Health

Prevention of these complications is important and should be a major focus of infection control and patient safety practices. There are three main points of focus on infection prevention with regard to ICs – proper insertion techniques, proper care of the catheter, and prompt removal when it is no longer necessary.

We focused our review, published in the American Journal of Infection Control (2016 Oct. doi: 10.1016/j.ajic.2016.03.073), on the final point – determining the prevalence, risk factors, and outcomes related to idle intravenous catheters. To accomplish this, we conducted an integrative review of published studies related to idle catheters, excluding reviews, abstracts, and commentaries. Thirteen studies met the inclusion criteria and four of these focused on CVCs.

Generally, an idle catheter is one that remains in place even though it is not being used for patient care. However, the definition of an “idle” catheter varied amongst the reviewed studies, as did the unit of measure, especially for peripheral catheters. Central venous catheter-focused studies were more consistent in using “idle catheter days” and “catheter days.”

Studies of peripheral catheters revealed that 16%-50% of patients had an idle catheter of some type. For the studies focused on CVCs, the percentage of patients with idle catheters ranged from 2.7% in one intensive care unit to 26.2% in a different study. Interestingly, in the study with 2.7% idle CVCs in the ICU, there was a higher percentage of idle CVCs outside of the ICU in the same hospital.

The major reasons for leaving catheters in place in studies where reasons were noted were convenience, future intention to use intravenous medication, and inappropriate use of intravenous medications when oral could be used.

Although data are scarce, complications in the reviewed studies were relatively common with idle peripheral catheters, where 9%-12% suffered thrombophlebitis. Obviously, the risk for catheter-related bloodstream infection increases as the number of catheter days increases – this is especially important with regard to idle CVCs.
 

Decreasing the prevalence of idle catheters is likely to decrease the risk for infection and improve patient safety. Based on our review of the data, a standardized definition of an “idle catheter” is needed. At the very least, a standard definition should be developed at each institution. This would allow an individual hospital the ability to identify and track the presence of these lines, and implement targeted interventions to decrease the proportion of idle lines. Ideally, a common definition would be created and validated so that data and interventions could be comparable across institutions and guidelines could be developed.

The goal of targeted interventions should be zero idle lines. Prevention of idle peripheral catheters should also be pursued, but because CVC-related complications are often more serious, these lines are often the focus of efforts. Use of peripherally inserted central catheters (PICCs) has increased and while these catheters in some settings may have decreased complication risk, compared with femoral/internal jugular/subclavian CVCs, prevention of idle catheter days is paramount for these catheters as well.

Many ICUs, including at our own institution, have instituted programs to closely monitor for ongoing need for CVCs. This increased focus on the CVC likely explains the lower rates of idle catheters in ICUs noted in the reviewed studies. This close surveillance can be done outside of the ICU as well, and could include peripheral catheters.

At our own institution, the need for catheters is reviewed on some units as part of formalized patient safety rounds. Another potential group of interventions could focus on electronic medical record (EMR)-based changes such as limits on the duration of the order, requirement for renewal of the order, or on-screen reminders of the presence of a catheter. This sort of intervention could possibly be expanded as EMR use becomes more common and robust. For instance, if intravenous medications have not been ordered or given in a certain amount of time, an alert might be triggered. Another EMR-based mechanism could be to require an indication for ongoing catheter use.

Education about the potential adverse outcomes of idle catheters is important. Promoting a team-based approach to interventions, where all involved team members can discuss patient safety issues on equal ground is paramount to successfully decreasing idle catheters and improving patient care and safety in general. As with other hospital-wide initiatives, engagement of hospital administration is important to decrease barriers to implementation.

Intravenous catheter use will remain an integral part of patient care, but efforts should be made to create standardization around the definition of an idle catheter, standardize units of measure, and institute programs to prevent idle catheters.

Daniel Shirley, MD, MS, is assistant professor in the division of infectious disease at the University of Wisconsin–Madison School of Medicine and Public Health and the William S. Middleton Memorial Veterans Hospital. Nasia Safdar, MD, PhD, is associate professor in the division of infectious disease at the University of Wisconsin–Madison School of Medicine and Public Health and the William S. Middleton Memorial Veterans Hospital.

Intravenous catheters (ICs) are common and necessary for inpatient care. However, peripheral and especially central venous catheters (CVCs) are associated with increased risk for local and systemic complications, including bloodstream infections and endocarditis.

University of Wisconsin School of Medicine and Public Health

Prevention of these complications is important and should be a major focus of infection control and patient safety practices. There are three main points of focus on infection prevention with regard to ICs – proper insertion techniques, proper care of the catheter, and prompt removal when it is no longer necessary.

We focused our review, published in the American Journal of Infection Control (2016 Oct. doi: 10.1016/j.ajic.2016.03.073), on the final point – determining the prevalence, risk factors, and outcomes related to idle intravenous catheters. To accomplish this, we conducted an integrative review of published studies related to idle catheters, excluding reviews, abstracts, and commentaries. Thirteen studies met the inclusion criteria and four of these focused on CVCs.

Generally, an idle catheter is one that remains in place even though it is not being used for patient care. However, the definition of an “idle” catheter varied amongst the reviewed studies, as did the unit of measure, especially for peripheral catheters. Central venous catheter-focused studies were more consistent in using “idle catheter days” and “catheter days.”

Studies of peripheral catheters revealed that 16%-50% of patients had an idle catheter of some type. For the studies focused on CVCs, the percentage of patients with idle catheters ranged from 2.7% in one intensive care unit to 26.2% in a different study. Interestingly, in the study with 2.7% idle CVCs in the ICU, there was a higher percentage of idle CVCs outside of the ICU in the same hospital.

The major reasons for leaving catheters in place in studies where reasons were noted were convenience, future intention to use intravenous medication, and inappropriate use of intravenous medications when oral could be used.

Although data are scarce, complications in the reviewed studies were relatively common with idle peripheral catheters, where 9%-12% suffered thrombophlebitis. Obviously, the risk for catheter-related bloodstream infection increases as the number of catheter days increases – this is especially important with regard to idle CVCs.
 

Decreasing the prevalence of idle catheters is likely to decrease the risk for infection and improve patient safety. Based on our review of the data, a standardized definition of an “idle catheter” is needed. At the very least, a standard definition should be developed at each institution. This would allow an individual hospital the ability to identify and track the presence of these lines, and implement targeted interventions to decrease the proportion of idle lines. Ideally, a common definition would be created and validated so that data and interventions could be comparable across institutions and guidelines could be developed.

The goal of targeted interventions should be zero idle lines. Prevention of idle peripheral catheters should also be pursued, but because CVC-related complications are often more serious, these lines are often the focus of efforts. Use of peripherally inserted central catheters (PICCs) has increased and while these catheters in some settings may have decreased complication risk, compared with femoral/internal jugular/subclavian CVCs, prevention of idle catheter days is paramount for these catheters as well.

Many ICUs, including at our own institution, have instituted programs to closely monitor for ongoing need for CVCs. This increased focus on the CVC likely explains the lower rates of idle catheters in ICUs noted in the reviewed studies. This close surveillance can be done outside of the ICU as well, and could include peripheral catheters.

At our own institution, the need for catheters is reviewed on some units as part of formalized patient safety rounds. Another potential group of interventions could focus on electronic medical record (EMR)-based changes such as limits on the duration of the order, requirement for renewal of the order, or on-screen reminders of the presence of a catheter. This sort of intervention could possibly be expanded as EMR use becomes more common and robust. For instance, if intravenous medications have not been ordered or given in a certain amount of time, an alert might be triggered. Another EMR-based mechanism could be to require an indication for ongoing catheter use.

Education about the potential adverse outcomes of idle catheters is important. Promoting a team-based approach to interventions, where all involved team members can discuss patient safety issues on equal ground is paramount to successfully decreasing idle catheters and improving patient care and safety in general. As with other hospital-wide initiatives, engagement of hospital administration is important to decrease barriers to implementation.

Intravenous catheter use will remain an integral part of patient care, but efforts should be made to create standardization around the definition of an idle catheter, standardize units of measure, and institute programs to prevent idle catheters.

Daniel Shirley, MD, MS, is assistant professor in the division of infectious disease at the University of Wisconsin–Madison School of Medicine and Public Health and the William S. Middleton Memorial Veterans Hospital. Nasia Safdar, MD, PhD, is associate professor in the division of infectious disease at the University of Wisconsin–Madison School of Medicine and Public Health and the William S. Middleton Memorial Veterans Hospital.

Intravenous catheters (ICs) are common and necessary for inpatient care. However, peripheral and especially central venous catheters (CVCs) are associated with increased risk for local and systemic complications, including bloodstream infections and endocarditis.

University of Wisconsin School of Medicine and Public Health

Prevention of these complications is important and should be a major focus of infection control and patient safety practices. There are three main points of focus on infection prevention with regard to ICs – proper insertion techniques, proper care of the catheter, and prompt removal when it is no longer necessary.

We focused our review, published in the American Journal of Infection Control (2016 Oct. doi: 10.1016/j.ajic.2016.03.073), on the final point – determining the prevalence, risk factors, and outcomes related to idle intravenous catheters. To accomplish this, we conducted an integrative review of published studies related to idle catheters, excluding reviews, abstracts, and commentaries. Thirteen studies met the inclusion criteria and four of these focused on CVCs.

Generally, an idle catheter is one that remains in place even though it is not being used for patient care. However, the definition of an “idle” catheter varied amongst the reviewed studies, as did the unit of measure, especially for peripheral catheters. Central venous catheter-focused studies were more consistent in using “idle catheter days” and “catheter days.”

Studies of peripheral catheters revealed that 16%-50% of patients had an idle catheter of some type. For the studies focused on CVCs, the percentage of patients with idle catheters ranged from 2.7% in one intensive care unit to 26.2% in a different study. Interestingly, in the study with 2.7% idle CVCs in the ICU, there was a higher percentage of idle CVCs outside of the ICU in the same hospital.

The major reasons for leaving catheters in place in studies where reasons were noted were convenience, future intention to use intravenous medication, and inappropriate use of intravenous medications when oral could be used.

Although data are scarce, complications in the reviewed studies were relatively common with idle peripheral catheters, where 9%-12% suffered thrombophlebitis. Obviously, the risk for catheter-related bloodstream infection increases as the number of catheter days increases – this is especially important with regard to idle CVCs.
 

Decreasing the prevalence of idle catheters is likely to decrease the risk for infection and improve patient safety. Based on our review of the data, a standardized definition of an “idle catheter” is needed. At the very least, a standard definition should be developed at each institution. This would allow an individual hospital the ability to identify and track the presence of these lines, and implement targeted interventions to decrease the proportion of idle lines. Ideally, a common definition would be created and validated so that data and interventions could be comparable across institutions and guidelines could be developed.

The goal of targeted interventions should be zero idle lines. Prevention of idle peripheral catheters should also be pursued, but because CVC-related complications are often more serious, these lines are often the focus of efforts. Use of peripherally inserted central catheters (PICCs) has increased and while these catheters in some settings may have decreased complication risk, compared with femoral/internal jugular/subclavian CVCs, prevention of idle catheter days is paramount for these catheters as well.

Many ICUs, including at our own institution, have instituted programs to closely monitor for ongoing need for CVCs. This increased focus on the CVC likely explains the lower rates of idle catheters in ICUs noted in the reviewed studies. This close surveillance can be done outside of the ICU as well, and could include peripheral catheters.

At our own institution, the need for catheters is reviewed on some units as part of formalized patient safety rounds. Another potential group of interventions could focus on electronic medical record (EMR)-based changes such as limits on the duration of the order, requirement for renewal of the order, or on-screen reminders of the presence of a catheter. This sort of intervention could possibly be expanded as EMR use becomes more common and robust. For instance, if intravenous medications have not been ordered or given in a certain amount of time, an alert might be triggered. Another EMR-based mechanism could be to require an indication for ongoing catheter use.

Education about the potential adverse outcomes of idle catheters is important. Promoting a team-based approach to interventions, where all involved team members can discuss patient safety issues on equal ground is paramount to successfully decreasing idle catheters and improving patient care and safety in general. As with other hospital-wide initiatives, engagement of hospital administration is important to decrease barriers to implementation.

Intravenous catheter use will remain an integral part of patient care, but efforts should be made to create standardization around the definition of an idle catheter, standardize units of measure, and institute programs to prevent idle catheters.

Daniel Shirley, MD, MS, is assistant professor in the division of infectious disease at the University of Wisconsin–Madison School of Medicine and Public Health and the William S. Middleton Memorial Veterans Hospital. Nasia Safdar, MD, PhD, is associate professor in the division of infectious disease at the University of Wisconsin–Madison School of Medicine and Public Health and the William S. Middleton Memorial Veterans Hospital.

Gastroenterologists will now have a separate billing code for the use of moderate sedation services under provisions finalized in the 2017 update to the physician fee schedule.

The change comes as a result of billing trends, with the Centers for Medicare & Medicaid Services noting in a statement announcing the final PFS update that anesthesia is “increasingly being separately reported for [certain endoscopic] procedures even though payment for sedation was built-in to the payment to the physician furnishing the primary procedure.”
 

As such, the agency finalized new billing codes for moderate sedation, along with a uniform methodology for valuating procedure codes that currently include moderate sedation as an inherent part of the procedure. Additionally, CMS finalized a separate endoscopy-specific moderate sedation code with valuations that reflect the differences in physician survey data between gastroenterology and other specialties.

gtwachtman@frontlinemedcom.com

Gastroenterologists will now have a separate billing code for the use of moderate sedation services under provisions finalized in the 2017 update to the physician fee schedule.

The change comes as a result of billing trends, with the Centers for Medicare & Medicaid Services noting in a statement announcing the final PFS update that anesthesia is “increasingly being separately reported for [certain endoscopic] procedures even though payment for sedation was built-in to the payment to the physician furnishing the primary procedure.”
 

As such, the agency finalized new billing codes for moderate sedation, along with a uniform methodology for valuating procedure codes that currently include moderate sedation as an inherent part of the procedure. Additionally, CMS finalized a separate endoscopy-specific moderate sedation code with valuations that reflect the differences in physician survey data between gastroenterology and other specialties.

gtwachtman@frontlinemedcom.com

Gastroenterologists will now have a separate billing code for the use of moderate sedation services under provisions finalized in the 2017 update to the physician fee schedule.

The change comes as a result of billing trends, with the Centers for Medicare & Medicaid Services noting in a statement announcing the final PFS update that anesthesia is “increasingly being separately reported for [certain endoscopic] procedures even though payment for sedation was built-in to the payment to the physician furnishing the primary procedure.”
 

As such, the agency finalized new billing codes for moderate sedation, along with a uniform methodology for valuating procedure codes that currently include moderate sedation as an inherent part of the procedure. Additionally, CMS finalized a separate endoscopy-specific moderate sedation code with valuations that reflect the differences in physician survey data between gastroenterology and other specialties.

gtwachtman@frontlinemedcom.com

As we start off 2017, you’re probably thinking about how to plan for the implementation of MACRA (Medicare Access and CHIP Reauthorization Act of 2015), which begins Jan. 1. While the process might seem overwhelming, AGA is here to provide five steps that you can take to prepare yourself and your practice.

1. Meet 2016 Physician Quality Reporting System (PQRS) reporting requirements.

2. Review your practice’s Quality and Resource Use Reports (QRURs) for 2015 and the first part of 2016. The QRUR will help you understand how you are currently being rated on cost and quality.

3. Watch your mail for a CMS letter alerting you if you’ll be considered a low-volume provider for 2017 under the Merit-based Incentive Program (MIPs) and exempt from MACRA in 2017.

4. Check Medicare Physician Compare, which will allow patients to compare providers in ways they haven’t been able to before. Brainstorm ways to improve patient communication and discover whether outside resources may need to be added to help patients stay healthy ... and happy.

5. Visit www.gastro.org/MACRA for prerecorded webinars and other AGA resources designed to help make MACRA implementation as seamless as possible.

To learn more about MACRA, visit www.gastro.org/MACRA.
 

ginews@gastro.org

As we start off 2017, you’re probably thinking about how to plan for the implementation of MACRA (Medicare Access and CHIP Reauthorization Act of 2015), which begins Jan. 1. While the process might seem overwhelming, AGA is here to provide five steps that you can take to prepare yourself and your practice.

1. Meet 2016 Physician Quality Reporting System (PQRS) reporting requirements.

2. Review your practice’s Quality and Resource Use Reports (QRURs) for 2015 and the first part of 2016. The QRUR will help you understand how you are currently being rated on cost and quality.

3. Watch your mail for a CMS letter alerting you if you’ll be considered a low-volume provider for 2017 under the Merit-based Incentive Program (MIPs) and exempt from MACRA in 2017.

4. Check Medicare Physician Compare, which will allow patients to compare providers in ways they haven’t been able to before. Brainstorm ways to improve patient communication and discover whether outside resources may need to be added to help patients stay healthy ... and happy.

5. Visit www.gastro.org/MACRA for prerecorded webinars and other AGA resources designed to help make MACRA implementation as seamless as possible.

To learn more about MACRA, visit www.gastro.org/MACRA.
 

ginews@gastro.org

As we start off 2017, you’re probably thinking about how to plan for the implementation of MACRA (Medicare Access and CHIP Reauthorization Act of 2015), which begins Jan. 1. While the process might seem overwhelming, AGA is here to provide five steps that you can take to prepare yourself and your practice.

1. Meet 2016 Physician Quality Reporting System (PQRS) reporting requirements.

2. Review your practice’s Quality and Resource Use Reports (QRURs) for 2015 and the first part of 2016. The QRUR will help you understand how you are currently being rated on cost and quality.

3. Watch your mail for a CMS letter alerting you if you’ll be considered a low-volume provider for 2017 under the Merit-based Incentive Program (MIPs) and exempt from MACRA in 2017.

4. Check Medicare Physician Compare, which will allow patients to compare providers in ways they haven’t been able to before. Brainstorm ways to improve patient communication and discover whether outside resources may need to be added to help patients stay healthy ... and happy.

5. Visit www.gastro.org/MACRA for prerecorded webinars and other AGA resources designed to help make MACRA implementation as seamless as possible.

To learn more about MACRA, visit www.gastro.org/MACRA.
 

ginews@gastro.org

Round out 2016 by preparing for a 2017 AGA Research Foundation grant. Eight grants are currently open for both established and young investigators, but all will close in January 2017. Make sure you’re prepared to submit your application before the deadline.

Complete information about these and other research awards is available on gastro.org. All recipients will be acknowledged at the Research Recognition Celebration at Digestive Disease Week® 2017 (www.ddw.org) in Chicago, IL.

Jan 6. 2017

• The AGA-Elsevier Gut Microbiome Pilot Research Award will provide $25,000 to support pilot research projects pertaining to the gut microbiome.
• The AGA-Elsevier Pilot Research Award is a 1-year grant providing young investigators, instructors, research associates, or equivalents $25,000 to support pilot research projects in gastroenterology- or hepatology-related areas.
• The AGA-Medtronic Research & Development Pilot Award in Technology grants $31,000 for 1 year to investigators to support the research and development of novel devices or technologies that will potentially impact the diagnosis or treatment of digestive disease.

Jan. 13, 2017

• The AGA-Rome Foundation Functional GI and Motility Disorders Pilot Research Award offers $50,000 for 1 year to early-stage investigators, established investigators, postdoctoral research fellows and combined research and clinical fellows to support pilot research projects pertaining to functional GI and motility disorders.
• The AGA Microbiome Junior Investigator Research Award is a 2-year award of $60,000 for junior investigators engaged in basic, translational, clinical, or health services research related to the gut microbiome.
• The AGA-Pfizer Pilot Research Award in Inflammatory Bowel Disease is a 1-year, $30,000 award offered to established and young investigators to support pilot research projects related to IBD.

Jan. 20, 2017

• The AGA-June & Donald O. Castell, MD, Esophageal Clinical Research Award is a 1-year, $25,000 grant that provides research or salary support for junior faculty involved in clinical research in esophageal diseases.
• The AGA-Caroline Craig Augustyn & Damian Augustyn Award in Digestive Cancer is a 1-year, $40,000 award designed to support a young investigator, instructor, research associate or equivalent who currently holds a federal or nonfederal career development award devoted to conducting research related to digestive cancer.

Round out 2016 by preparing for a 2017 AGA Research Foundation grant. Eight grants are currently open for both established and young investigators, but all will close in January 2017. Make sure you’re prepared to submit your application before the deadline.

Complete information about these and other research awards is available on gastro.org. All recipients will be acknowledged at the Research Recognition Celebration at Digestive Disease Week® 2017 (www.ddw.org) in Chicago, IL.

Jan 6. 2017

• The AGA-Elsevier Gut Microbiome Pilot Research Award will provide $25,000 to support pilot research projects pertaining to the gut microbiome.
• The AGA-Elsevier Pilot Research Award is a 1-year grant providing young investigators, instructors, research associates, or equivalents $25,000 to support pilot research projects in gastroenterology- or hepatology-related areas.
• The AGA-Medtronic Research & Development Pilot Award in Technology grants $31,000 for 1 year to investigators to support the research and development of novel devices or technologies that will potentially impact the diagnosis or treatment of digestive disease.

Jan. 13, 2017

• The AGA-Rome Foundation Functional GI and Motility Disorders Pilot Research Award offers $50,000 for 1 year to early-stage investigators, established investigators, postdoctoral research fellows and combined research and clinical fellows to support pilot research projects pertaining to functional GI and motility disorders.
• The AGA Microbiome Junior Investigator Research Award is a 2-year award of $60,000 for junior investigators engaged in basic, translational, clinical, or health services research related to the gut microbiome.
• The AGA-Pfizer Pilot Research Award in Inflammatory Bowel Disease is a 1-year, $30,000 award offered to established and young investigators to support pilot research projects related to IBD.

Jan. 20, 2017

• The AGA-June & Donald O. Castell, MD, Esophageal Clinical Research Award is a 1-year, $25,000 grant that provides research or salary support for junior faculty involved in clinical research in esophageal diseases.
• The AGA-Caroline Craig Augustyn & Damian Augustyn Award in Digestive Cancer is a 1-year, $40,000 award designed to support a young investigator, instructor, research associate or equivalent who currently holds a federal or nonfederal career development award devoted to conducting research related to digestive cancer.

Round out 2016 by preparing for a 2017 AGA Research Foundation grant. Eight grants are currently open for both established and young investigators, but all will close in January 2017. Make sure you’re prepared to submit your application before the deadline.

Complete information about these and other research awards is available on gastro.org. All recipients will be acknowledged at the Research Recognition Celebration at Digestive Disease Week® 2017 (www.ddw.org) in Chicago, IL.

Jan 6. 2017

• The AGA-Elsevier Gut Microbiome Pilot Research Award will provide $25,000 to support pilot research projects pertaining to the gut microbiome.
• The AGA-Elsevier Pilot Research Award is a 1-year grant providing young investigators, instructors, research associates, or equivalents $25,000 to support pilot research projects in gastroenterology- or hepatology-related areas.
• The AGA-Medtronic Research & Development Pilot Award in Technology grants $31,000 for 1 year to investigators to support the research and development of novel devices or technologies that will potentially impact the diagnosis or treatment of digestive disease.

Jan. 13, 2017

• The AGA-Rome Foundation Functional GI and Motility Disorders Pilot Research Award offers $50,000 for 1 year to early-stage investigators, established investigators, postdoctoral research fellows and combined research and clinical fellows to support pilot research projects pertaining to functional GI and motility disorders.
• The AGA Microbiome Junior Investigator Research Award is a 2-year award of $60,000 for junior investigators engaged in basic, translational, clinical, or health services research related to the gut microbiome.
• The AGA-Pfizer Pilot Research Award in Inflammatory Bowel Disease is a 1-year, $30,000 award offered to established and young investigators to support pilot research projects related to IBD.

Jan. 20, 2017

• The AGA-June & Donald O. Castell, MD, Esophageal Clinical Research Award is a 1-year, $25,000 grant that provides research or salary support for junior faculty involved in clinical research in esophageal diseases.
• The AGA-Caroline Craig Augustyn & Damian Augustyn Award in Digestive Cancer is a 1-year, $40,000 award designed to support a young investigator, instructor, research associate or equivalent who currently holds a federal or nonfederal career development award devoted to conducting research related to digestive cancer.

Did you know you can honor a family member, friend, or colleague whose life has been touched by GI research or celebrate a special occasion such as a birthday while supporting the work of our mission through a gift to the AGA Research Foundation? Your gift will honor a loved one or yourself and support the AGA Research Awards Program, while giving you a tax benefit:

• Giving now or later. Any charitable gift can be made in honor or memory of someone.
• A gift today. An outright gift will help fund the AGA Research Awards Program. Your gift will assist in furthering basic digestive disease research, which can ultimately advance research into all digestive diseases. The financial benefits include an income tax deduction and possible elimination of capital gains tax. A cash gift of $25,000 or more qualifies for membership in the AGA Legacy Society, which recognizes the foundation’s most generous individual donors.
• A gift through your will or living trust. You can include a bequest in your will or living trust stating that a specific asset, certain dollar amount, or more commonly a percentage of your estate will pass to the AGA Research Foundation at your death in honor of your loved one. A gift of $50,000 or more in your will qualifies for membership in the AGA Legacy Society.
• Named DDW Sessions. A named DDW session is established with a minimum gift of $125,000 over the course of 5 years or through an irrevocable planned gift. Gifts of cash, appreciated securities, life insurance, or property are gift vehicles that may be used to establish a named session. Donors will be eligible for naming recognition of a DDW AGA Institute Council session for 10 years. A gift at that level will qualifies for membership in the AGA Legacy Society.

Your next step

An honorary gift is a wonderful way to acknowledge someone’s vision for the future. To learn more about ways to recognize your honoree, visit our website at www.gastro.org/contribute or contact Harmony Excellent at 301-272-1602 or hexcellent@gastro.org.

ginews@gastro.org

Did you know you can honor a family member, friend, or colleague whose life has been touched by GI research or celebrate a special occasion such as a birthday while supporting the work of our mission through a gift to the AGA Research Foundation? Your gift will honor a loved one or yourself and support the AGA Research Awards Program, while giving you a tax benefit:

• Giving now or later. Any charitable gift can be made in honor or memory of someone.
• A gift today. An outright gift will help fund the AGA Research Awards Program. Your gift will assist in furthering basic digestive disease research, which can ultimately advance research into all digestive diseases. The financial benefits include an income tax deduction and possible elimination of capital gains tax. A cash gift of $25,000 or more qualifies for membership in the AGA Legacy Society, which recognizes the foundation’s most generous individual donors.
• A gift through your will or living trust. You can include a bequest in your will or living trust stating that a specific asset, certain dollar amount, or more commonly a percentage of your estate will pass to the AGA Research Foundation at your death in honor of your loved one. A gift of $50,000 or more in your will qualifies for membership in the AGA Legacy Society.
• Named DDW Sessions. A named DDW session is established with a minimum gift of $125,000 over the course of 5 years or through an irrevocable planned gift. Gifts of cash, appreciated securities, life insurance, or property are gift vehicles that may be used to establish a named session. Donors will be eligible for naming recognition of a DDW AGA Institute Council session for 10 years. A gift at that level will qualifies for membership in the AGA Legacy Society.

Your next step

An honorary gift is a wonderful way to acknowledge someone’s vision for the future. To learn more about ways to recognize your honoree, visit our website at www.gastro.org/contribute or contact Harmony Excellent at 301-272-1602 or hexcellent@gastro.org.

ginews@gastro.org

Did you know you can honor a family member, friend, or colleague whose life has been touched by GI research or celebrate a special occasion such as a birthday while supporting the work of our mission through a gift to the AGA Research Foundation? Your gift will honor a loved one or yourself and support the AGA Research Awards Program, while giving you a tax benefit:

• Giving now or later. Any charitable gift can be made in honor or memory of someone.
• A gift today. An outright gift will help fund the AGA Research Awards Program. Your gift will assist in furthering basic digestive disease research, which can ultimately advance research into all digestive diseases. The financial benefits include an income tax deduction and possible elimination of capital gains tax. A cash gift of $25,000 or more qualifies for membership in the AGA Legacy Society, which recognizes the foundation’s most generous individual donors.
• A gift through your will or living trust. You can include a bequest in your will or living trust stating that a specific asset, certain dollar amount, or more commonly a percentage of your estate will pass to the AGA Research Foundation at your death in honor of your loved one. A gift of $50,000 or more in your will qualifies for membership in the AGA Legacy Society.
• Named DDW Sessions. A named DDW session is established with a minimum gift of $125,000 over the course of 5 years or through an irrevocable planned gift. Gifts of cash, appreciated securities, life insurance, or property are gift vehicles that may be used to establish a named session. Donors will be eligible for naming recognition of a DDW AGA Institute Council session for 10 years. A gift at that level will qualifies for membership in the AGA Legacy Society.

Your next step

An honorary gift is a wonderful way to acknowledge someone’s vision for the future. To learn more about ways to recognize your honoree, visit our website at www.gastro.org/contribute or contact Harmony Excellent at 301-272-1602 or hexcellent@gastro.org.

ginews@gastro.org

NEW YORK – Emergency departments are seeing more pediatric and adolescent patients with autism spectrum disorder, and are struggling to meet their needs, experts say.

At the annual meeting of the American Academy of Child and Adolescent Psychiatry, researchers presented results from studies attempting to quantify and better understand the uptick in ED visits, while clinicians shared strategies aimed at improving care in a setting that, nearly all agreed, presents unique obstacles for treating children with ASD.

Bright lights, excess noise, frequently changing care staff, and a lack of training in nonverbal communication strategies were among the problems the clinicians highlighted.

“There’s been a huge increase in recent years in the number of children with ASD that are coming into the ED because of either behavioral crises or general pediatric medical concerns that require us to intervene,” said Eron Y. Friedlaender, MD, MPH, of Children’s Hospital of Philadelphia (CHOP). “Yet, we struggle to offer kids with challenging behaviors or communication vulnerabilities the same standard of care that we’re used to offering.”

John J. McGonigle, PhD, head of the autism center at the University of Pittsburgh, noted that incidents tied to safety issues, such as disruptive behavior, aggression, and self-injury, were occurring among young ASD patients in the ED. In 2015, he said, Pennsylvania’s statewide patient safety data reporting system reviewed hospital records from 2004 to 2014 and recorded 138 events in the ED involving patients with ASD, 86 of them involving children and adolescents.

Finding barriers to care

Dr. Friedlaender described a pilot study she and her colleagues conducted in her institution’s sedation unit that was designed to help them understand the barriers to optimal care for ASD patients, and to find ways around them. Many of the studies the investigators consulted “came from the dental literature, where there is a significant number of special-needs kids who need support during procedural care. [Dentists] were among the first to publish on how to make this a reasonable experience.”

One key insight gleaned from this literature, Dr. Friedlaender said, was that a simple screening question – whether the child could sit still for a haircut – proved sensitive in indicating a need for accommodation.

The CHOP researchers created a three-question universal screening tool that schedulers asked of all caregivers when a child presented to the ED. In addition to asking whether the child could sit still, schedulers asked whether he or she had a behavioral diagnosis or special communication needs. Of 458 families who completed the screening, 96 answered positively to at least one of the questions, and 79, or 17% of the cohort, indicated a behavioral diagnosis.

Such information previously had been missed, Dr. Friedlaender said, because “many families didn’t consider autism part of a medical history – if we didn’t ask about it, they didn’t share it.”

Her group also conducted a study on the effectiveness of self-reported pain scales in 43 verbal ASD children aged 6-17 who had undergone surgical procedures. Dr. Friedlaender said she suspected that it was impractical to ask children with ASD to use only pictures of facial expressions to indicate their pain.

The subjects were asked to circle images of faces with expressions corresponding to their pain. They also were asked to locate their pain by drawing it on tablet computers, and given poker chips to represent their degree of pain, with one chip the least and four the most. Caregivers were recruited to assist with questioning and interpreting responses.

All children in the study were able to describe and locate their pain. “We learned that there isn’t one universal pain tool that works for all kids,” Dr. Friedlaender said, “but that facial expressions and body language don’t often match pain scores” in ASD children. The study also revealed that parent or caregiver mediation is helpful in discerning the location and intensity of pain.

Why ED use is high

Other research presented at AACAP sought to grasp the scope of, and reasons behind, the increase in ASD youth seen in hospital emergency departments.

Michael J. Murray, MD, of Pennsylvania State University in Hershey, found using commercial insurance data from large employers showing that ED visits increased from 3% in 2005 to nearly 16% in 2013 among youth diagnosed with ASD, while a non-ASD comparison cohort saw a far more consistent rate of ED visits across the same time period, of about 3%. Adolescents with ASD were nearly five times more likely to have had an ED visit than were non-ASD adolescents (95% confidence interval, 4.678-4.875).

Dr. Murray said in an interview that the ASD cohort identified in his study “was smaller than it should have been,” compared with Centers for Disease Control and Prevention prevalence data. One likely reason is that not all the insurers had to cover ASD in the first years of the study period. Dr. Murray said he thinks a new study using public insurance data might provide a fuller picture.

Dr. Murray and colleagues’ study, which looked at youth aged 12-21, revealed that being older increased the likelihood of an ED visit. “We think it may have to do with the whole transition out of school,” he said. “This is the first generation with ASD that’s accustomed to having good school-based supports.” The transition to adulthood “is a really important time, and that’s when we’re pulling away from them.”

Sarah Lytle, MD, of University Hospitals Cleveland Medical Center, presented a literature review of ASD youth in the ED from 2006 through 2015. Dr. Lytle found that children with ASD were more likely to visit the ED than were those without ASD. In addition, the review showed a higher proportion of ED visits for psychiatric problems (13% of visits vs. 2% for non-ASD youth). Youth with ASD were more likely to be admitted to a psychiatric unit or medically boarded in the ED, she found. They also were more likely to have public insurance.

Dr. Lytle’s study drew from a dozen published studies in different age groups (subjects ranged from 0 to 24 years across studies). Though it was difficult to draw conclusions related to which saw the highest ED use, one study found the risk of ED use higher in adolescents, compared with younger children, she said. “One thing I see clinically is that when kids hit the age of 12, pediatric psychiatric units often won’t take them,” she said, as children are physically bigger and may be harder to manage. “And then they’re cycled into the ED,” she said.

Creating the ‘ASD care pathway’

Clinicians from New York shared their experiences designing and implementing an autism care pathway within the state’s only pediatric psychiatric emergency department.

At NYU Health and Hospitals/Bellevue, a public hospital, clinicians found themselves struggling to manage ASD patients, who comprise between 10% and 20% of children seen. “Most of our staff, and even our child psychiatrists, had previously had very little experience working with kids with autism, and that was true for most of our child psychiatrists as well,” said Ruth S. Gerson, MD, who oversees the hospital’s Children’s Comprehensive Psychiatric Emergency Program.

NEW YORK – Emergency departments are seeing more pediatric and adolescent patients with autism spectrum disorder, and are struggling to meet their needs, experts say.

At the annual meeting of the American Academy of Child and Adolescent Psychiatry, researchers presented results from studies attempting to quantify and better understand the uptick in ED visits, while clinicians shared strategies aimed at improving care in a setting that, nearly all agreed, presents unique obstacles for treating children with ASD.

Bright lights, excess noise, frequently changing care staff, and a lack of training in nonverbal communication strategies were among the problems the clinicians highlighted.

“There’s been a huge increase in recent years in the number of children with ASD that are coming into the ED because of either behavioral crises or general pediatric medical concerns that require us to intervene,” said Eron Y. Friedlaender, MD, MPH, of Children’s Hospital of Philadelphia (CHOP). “Yet, we struggle to offer kids with challenging behaviors or communication vulnerabilities the same standard of care that we’re used to offering.”

John J. McGonigle, PhD, head of the autism center at the University of Pittsburgh, noted that incidents tied to safety issues, such as disruptive behavior, aggression, and self-injury, were occurring among young ASD patients in the ED. In 2015, he said, Pennsylvania’s statewide patient safety data reporting system reviewed hospital records from 2004 to 2014 and recorded 138 events in the ED involving patients with ASD, 86 of them involving children and adolescents.

Finding barriers to care

Dr. Friedlaender described a pilot study she and her colleagues conducted in her institution’s sedation unit that was designed to help them understand the barriers to optimal care for ASD patients, and to find ways around them. Many of the studies the investigators consulted “came from the dental literature, where there is a significant number of special-needs kids who need support during procedural care. [Dentists] were among the first to publish on how to make this a reasonable experience.”

One key insight gleaned from this literature, Dr. Friedlaender said, was that a simple screening question – whether the child could sit still for a haircut – proved sensitive in indicating a need for accommodation.

The CHOP researchers created a three-question universal screening tool that schedulers asked of all caregivers when a child presented to the ED. In addition to asking whether the child could sit still, schedulers asked whether he or she had a behavioral diagnosis or special communication needs. Of 458 families who completed the screening, 96 answered positively to at least one of the questions, and 79, or 17% of the cohort, indicated a behavioral diagnosis.

Such information previously had been missed, Dr. Friedlaender said, because “many families didn’t consider autism part of a medical history – if we didn’t ask about it, they didn’t share it.”

Her group also conducted a study on the effectiveness of self-reported pain scales in 43 verbal ASD children aged 6-17 who had undergone surgical procedures. Dr. Friedlaender said she suspected that it was impractical to ask children with ASD to use only pictures of facial expressions to indicate their pain.

The subjects were asked to circle images of faces with expressions corresponding to their pain. They also were asked to locate their pain by drawing it on tablet computers, and given poker chips to represent their degree of pain, with one chip the least and four the most. Caregivers were recruited to assist with questioning and interpreting responses.

All children in the study were able to describe and locate their pain. “We learned that there isn’t one universal pain tool that works for all kids,” Dr. Friedlaender said, “but that facial expressions and body language don’t often match pain scores” in ASD children. The study also revealed that parent or caregiver mediation is helpful in discerning the location and intensity of pain.

Why ED use is high

Other research presented at AACAP sought to grasp the scope of, and reasons behind, the increase in ASD youth seen in hospital emergency departments.

Michael J. Murray, MD, of Pennsylvania State University in Hershey, found using commercial insurance data from large employers showing that ED visits increased from 3% in 2005 to nearly 16% in 2013 among youth diagnosed with ASD, while a non-ASD comparison cohort saw a far more consistent rate of ED visits across the same time period, of about 3%. Adolescents with ASD were nearly five times more likely to have had an ED visit than were non-ASD adolescents (95% confidence interval, 4.678-4.875).

Dr. Murray said in an interview that the ASD cohort identified in his study “was smaller than it should have been,” compared with Centers for Disease Control and Prevention prevalence data. One likely reason is that not all the insurers had to cover ASD in the first years of the study period. Dr. Murray said he thinks a new study using public insurance data might provide a fuller picture.

Dr. Murray and colleagues’ study, which looked at youth aged 12-21, revealed that being older increased the likelihood of an ED visit. “We think it may have to do with the whole transition out of school,” he said. “This is the first generation with ASD that’s accustomed to having good school-based supports.” The transition to adulthood “is a really important time, and that’s when we’re pulling away from them.”

Sarah Lytle, MD, of University Hospitals Cleveland Medical Center, presented a literature review of ASD youth in the ED from 2006 through 2015. Dr. Lytle found that children with ASD were more likely to visit the ED than were those without ASD. In addition, the review showed a higher proportion of ED visits for psychiatric problems (13% of visits vs. 2% for non-ASD youth). Youth with ASD were more likely to be admitted to a psychiatric unit or medically boarded in the ED, she found. They also were more likely to have public insurance.

Dr. Lytle’s study drew from a dozen published studies in different age groups (subjects ranged from 0 to 24 years across studies). Though it was difficult to draw conclusions related to which saw the highest ED use, one study found the risk of ED use higher in adolescents, compared with younger children, she said. “One thing I see clinically is that when kids hit the age of 12, pediatric psychiatric units often won’t take them,” she said, as children are physically bigger and may be harder to manage. “And then they’re cycled into the ED,” she said.

Creating the ‘ASD care pathway’

Clinicians from New York shared their experiences designing and implementing an autism care pathway within the state’s only pediatric psychiatric emergency department.

At NYU Health and Hospitals/Bellevue, a public hospital, clinicians found themselves struggling to manage ASD patients, who comprise between 10% and 20% of children seen. “Most of our staff, and even our child psychiatrists, had previously had very little experience working with kids with autism, and that was true for most of our child psychiatrists as well,” said Ruth S. Gerson, MD, who oversees the hospital’s Children’s Comprehensive Psychiatric Emergency Program.

NEW YORK – Emergency departments are seeing more pediatric and adolescent patients with autism spectrum disorder, and are struggling to meet their needs, experts say.

At the annual meeting of the American Academy of Child and Adolescent Psychiatry, researchers presented results from studies attempting to quantify and better understand the uptick in ED visits, while clinicians shared strategies aimed at improving care in a setting that, nearly all agreed, presents unique obstacles for treating children with ASD.

Bright lights, excess noise, frequently changing care staff, and a lack of training in nonverbal communication strategies were among the problems the clinicians highlighted.

“There’s been a huge increase in recent years in the number of children with ASD that are coming into the ED because of either behavioral crises or general pediatric medical concerns that require us to intervene,” said Eron Y. Friedlaender, MD, MPH, of Children’s Hospital of Philadelphia (CHOP). “Yet, we struggle to offer kids with challenging behaviors or communication vulnerabilities the same standard of care that we’re used to offering.”

John J. McGonigle, PhD, head of the autism center at the University of Pittsburgh, noted that incidents tied to safety issues, such as disruptive behavior, aggression, and self-injury, were occurring among young ASD patients in the ED. In 2015, he said, Pennsylvania’s statewide patient safety data reporting system reviewed hospital records from 2004 to 2014 and recorded 138 events in the ED involving patients with ASD, 86 of them involving children and adolescents.

Finding barriers to care

Dr. Friedlaender described a pilot study she and her colleagues conducted in her institution’s sedation unit that was designed to help them understand the barriers to optimal care for ASD patients, and to find ways around them. Many of the studies the investigators consulted “came from the dental literature, where there is a significant number of special-needs kids who need support during procedural care. [Dentists] were among the first to publish on how to make this a reasonable experience.”

One key insight gleaned from this literature, Dr. Friedlaender said, was that a simple screening question – whether the child could sit still for a haircut – proved sensitive in indicating a need for accommodation.

The CHOP researchers created a three-question universal screening tool that schedulers asked of all caregivers when a child presented to the ED. In addition to asking whether the child could sit still, schedulers asked whether he or she had a behavioral diagnosis or special communication needs. Of 458 families who completed the screening, 96 answered positively to at least one of the questions, and 79, or 17% of the cohort, indicated a behavioral diagnosis.

Such information previously had been missed, Dr. Friedlaender said, because “many families didn’t consider autism part of a medical history – if we didn’t ask about it, they didn’t share it.”

Her group also conducted a study on the effectiveness of self-reported pain scales in 43 verbal ASD children aged 6-17 who had undergone surgical procedures. Dr. Friedlaender said she suspected that it was impractical to ask children with ASD to use only pictures of facial expressions to indicate their pain.

The subjects were asked to circle images of faces with expressions corresponding to their pain. They also were asked to locate their pain by drawing it on tablet computers, and given poker chips to represent their degree of pain, with one chip the least and four the most. Caregivers were recruited to assist with questioning and interpreting responses.

All children in the study were able to describe and locate their pain. “We learned that there isn’t one universal pain tool that works for all kids,” Dr. Friedlaender said, “but that facial expressions and body language don’t often match pain scores” in ASD children. The study also revealed that parent or caregiver mediation is helpful in discerning the location and intensity of pain.

Why ED use is high

Other research presented at AACAP sought to grasp the scope of, and reasons behind, the increase in ASD youth seen in hospital emergency departments.

Michael J. Murray, MD, of Pennsylvania State University in Hershey, found using commercial insurance data from large employers showing that ED visits increased from 3% in 2005 to nearly 16% in 2013 among youth diagnosed with ASD, while a non-ASD comparison cohort saw a far more consistent rate of ED visits across the same time period, of about 3%. Adolescents with ASD were nearly five times more likely to have had an ED visit than were non-ASD adolescents (95% confidence interval, 4.678-4.875).

Dr. Murray said in an interview that the ASD cohort identified in his study “was smaller than it should have been,” compared with Centers for Disease Control and Prevention prevalence data. One likely reason is that not all the insurers had to cover ASD in the first years of the study period. Dr. Murray said he thinks a new study using public insurance data might provide a fuller picture.

Dr. Murray and colleagues’ study, which looked at youth aged 12-21, revealed that being older increased the likelihood of an ED visit. “We think it may have to do with the whole transition out of school,” he said. “This is the first generation with ASD that’s accustomed to having good school-based supports.” The transition to adulthood “is a really important time, and that’s when we’re pulling away from them.”

Sarah Lytle, MD, of University Hospitals Cleveland Medical Center, presented a literature review of ASD youth in the ED from 2006 through 2015. Dr. Lytle found that children with ASD were more likely to visit the ED than were those without ASD. In addition, the review showed a higher proportion of ED visits for psychiatric problems (13% of visits vs. 2% for non-ASD youth). Youth with ASD were more likely to be admitted to a psychiatric unit or medically boarded in the ED, she found. They also were more likely to have public insurance.

Dr. Lytle’s study drew from a dozen published studies in different age groups (subjects ranged from 0 to 24 years across studies). Though it was difficult to draw conclusions related to which saw the highest ED use, one study found the risk of ED use higher in adolescents, compared with younger children, she said. “One thing I see clinically is that when kids hit the age of 12, pediatric psychiatric units often won’t take them,” she said, as children are physically bigger and may be harder to manage. “And then they’re cycled into the ED,” she said.

Creating the ‘ASD care pathway’

Clinicians from New York shared their experiences designing and implementing an autism care pathway within the state’s only pediatric psychiatric emergency department.

At NYU Health and Hospitals/Bellevue, a public hospital, clinicians found themselves struggling to manage ASD patients, who comprise between 10% and 20% of children seen. “Most of our staff, and even our child psychiatrists, had previously had very little experience working with kids with autism, and that was true for most of our child psychiatrists as well,” said Ruth S. Gerson, MD, who oversees the hospital’s Children’s Comprehensive Psychiatric Emergency Program.

Approximately 600 cases of operating room (OR) fires are reported annually.¹ The incidence of OR fires in the United States equals that of wrong-site surgeries, and 20% of cases have associated morbidity.^1,2 The estimated mortality rate is 1 to 2 cases per year.^3-5 The most commonly involved anatomical regions are the airway (33%) and the face (28%).⁴ Most surgical fires are reported in anesthetized patients with open oxygen delivery systems during head, neck, and upper chest surgeries; electrosurgical instruments are the ignition source in 90% of these cases.⁶ Despite extensive fire safety education and training, complete elimination of OR fires still has not been achieved.

Each fire requires an ignition source, a fuel source, and an oxidizer.⁷ In the OR, the 2 most common oxidizers are oxygen and nitrous oxide. Head and neck surgeries have a high concentration of these gases near the working field and therefore a higher risk and incidence of fires. Furthermore, surgical drapes and equipment (eg, closed or semi-closed breathing systems, masks) may potentiate this risk by reducing ventilation in areas where gases can accumulate and ignite. Ignition sources provide the energy that starts fires; common sources are electrocautery, lasers, fiber-optic light cords, drills/burrs, and defibrillator paddles. Fires are propagated by fuel sources, which encompass any flammable material, including tracheal tubes, sponges, alcohol-based solutions, hair, gastrointestinal tract gases, gloves, and packaging materials.⁸ Of note, alcohol-based skin-preparation agents emit flammable vapors that can ignite.^9-14 Before draping or exposure to an ignition source, chlorhexidine gluconate-based preparations must be allowed to dry for at least 3 minutes after application to hairless skin and up to 1 hour after application to hair.¹⁵ Inadequate drying poses a risk of fire.¹⁰We present the case of an OR fire ignited by electrocautery near freshly applied bone cement. No patient information is disclosed in this report.

Case Report

Our patient was evaluated in clinic and scheduled for total knee arthroplasty (TKA). All preoperative safety checklists and time-out procedures were followed and documented at the start of surgery. The TKA was performed with a standard medial patellar arthrotomy. Tourniquet control was used after Esmarch exsanguination. The surgery proceeded uneventfully until just after the bone cement was applied to the tibial surface. The surgeon was using a Bovie to resect residual lateral meniscus tissue when a fire instantaneously erupted within the joint space. Fortunately, the surgeon quickly suffocated the fire with a dry towel. The ignited bone cement was removed, and the patient was examined. There was no injury to surrounding tissue or joint space. Surgery was resumed with application of new bone cement to the tibial surface. The artificial joint was then successfully implanted and the case completed without further incident. The patient was discharged from the hospital and followed up as an outpatient without any postoperative complications.

Discussion

Bone cement, which is commonly used in artificial joint anchoring, craniofacial reconstruction, and vertebroplasty, has liquid and powder components. The liquid monomer methyl methacrylate (MMA) is colorless and flammable and has a distinct odor.¹⁶ Exposure to heat or light can prematurely polymerize MMA, requiring the addition of hydroquinone to inhibit the reaction.¹⁶ The powder polymethylmethacrylate affords excellent structural support, radiopacity, and facility of use.¹⁷ Dibenzoyl peroxide and N,N-dimethyl-p-toluidine are added to the powder to facilitate the polymerization reaction at room temperature (ie, cold curing of cement). Premature application of unpolymerized cement increases the risk of fire from the volatile liquid component.

In the OR, bone cement is prepared by mixing together its powder and liquid components.¹⁸ The reaction is exothermic polymerization. The liquid is highly volatile and flammable in both liquid and vapor states.^16,19 The vapors are denser than air and can concentrate in poorly ventilated areas. The OR and the application site must be adequately ventilated to eliminate any pockets of vapor accumulation.¹⁶ A vacuum mixer can be used to minimize fume exposure, enhance cement strength, and reduce fire risk while combining the 2 components.

MMA’s flash point, the temperature at which the fumes could ignite in the presence of an ignition source, is 10.5ºC. The auto-ignition point, the temperature at which MMA spontaneously combusts, is 421ºC.²⁰ The OR is usually warmer than the flash point temperature, but the electrocautery tip can generate up to 1200ºC of heat.²¹ Therefore, bone cement is a potential fire hazard, and use of Bovies or other ignition sources in its vicinity must be avoided.

The Table lists the recommended times for preparing various bone cement products.^22,23Mix time is the time needed to combine the liquid and powder into a homogenous putty.

Approximately 600 cases of operating room (OR) fires are reported annually.¹ The incidence of OR fires in the United States equals that of wrong-site surgeries, and 20% of cases have associated morbidity.^1,2 The estimated mortality rate is 1 to 2 cases per year.^3-5 The most commonly involved anatomical regions are the airway (33%) and the face (28%).⁴ Most surgical fires are reported in anesthetized patients with open oxygen delivery systems during head, neck, and upper chest surgeries; electrosurgical instruments are the ignition source in 90% of these cases.⁶ Despite extensive fire safety education and training, complete elimination of OR fires still has not been achieved.

Each fire requires an ignition source, a fuel source, and an oxidizer.⁷ In the OR, the 2 most common oxidizers are oxygen and nitrous oxide. Head and neck surgeries have a high concentration of these gases near the working field and therefore a higher risk and incidence of fires. Furthermore, surgical drapes and equipment (eg, closed or semi-closed breathing systems, masks) may potentiate this risk by reducing ventilation in areas where gases can accumulate and ignite. Ignition sources provide the energy that starts fires; common sources are electrocautery, lasers, fiber-optic light cords, drills/burrs, and defibrillator paddles. Fires are propagated by fuel sources, which encompass any flammable material, including tracheal tubes, sponges, alcohol-based solutions, hair, gastrointestinal tract gases, gloves, and packaging materials.⁸ Of note, alcohol-based skin-preparation agents emit flammable vapors that can ignite.^9-14 Before draping or exposure to an ignition source, chlorhexidine gluconate-based preparations must be allowed to dry for at least 3 minutes after application to hairless skin and up to 1 hour after application to hair.¹⁵ Inadequate drying poses a risk of fire.¹⁰We present the case of an OR fire ignited by electrocautery near freshly applied bone cement. No patient information is disclosed in this report.

Case Report

Our patient was evaluated in clinic and scheduled for total knee arthroplasty (TKA). All preoperative safety checklists and time-out procedures were followed and documented at the start of surgery. The TKA was performed with a standard medial patellar arthrotomy. Tourniquet control was used after Esmarch exsanguination. The surgery proceeded uneventfully until just after the bone cement was applied to the tibial surface. The surgeon was using a Bovie to resect residual lateral meniscus tissue when a fire instantaneously erupted within the joint space. Fortunately, the surgeon quickly suffocated the fire with a dry towel. The ignited bone cement was removed, and the patient was examined. There was no injury to surrounding tissue or joint space. Surgery was resumed with application of new bone cement to the tibial surface. The artificial joint was then successfully implanted and the case completed without further incident. The patient was discharged from the hospital and followed up as an outpatient without any postoperative complications.

Discussion

Bone cement, which is commonly used in artificial joint anchoring, craniofacial reconstruction, and vertebroplasty, has liquid and powder components. The liquid monomer methyl methacrylate (MMA) is colorless and flammable and has a distinct odor.¹⁶ Exposure to heat or light can prematurely polymerize MMA, requiring the addition of hydroquinone to inhibit the reaction.¹⁶ The powder polymethylmethacrylate affords excellent structural support, radiopacity, and facility of use.¹⁷ Dibenzoyl peroxide and N,N-dimethyl-p-toluidine are added to the powder to facilitate the polymerization reaction at room temperature (ie, cold curing of cement). Premature application of unpolymerized cement increases the risk of fire from the volatile liquid component.

In the OR, bone cement is prepared by mixing together its powder and liquid components.¹⁸ The reaction is exothermic polymerization. The liquid is highly volatile and flammable in both liquid and vapor states.^16,19 The vapors are denser than air and can concentrate in poorly ventilated areas. The OR and the application site must be adequately ventilated to eliminate any pockets of vapor accumulation.¹⁶ A vacuum mixer can be used to minimize fume exposure, enhance cement strength, and reduce fire risk while combining the 2 components.

MMA’s flash point, the temperature at which the fumes could ignite in the presence of an ignition source, is 10.5ºC. The auto-ignition point, the temperature at which MMA spontaneously combusts, is 421ºC.²⁰ The OR is usually warmer than the flash point temperature, but the electrocautery tip can generate up to 1200ºC of heat.²¹ Therefore, bone cement is a potential fire hazard, and use of Bovies or other ignition sources in its vicinity must be avoided.

The Table lists the recommended times for preparing various bone cement products.^22,23Mix time is the time needed to combine the liquid and powder into a homogenous putty.

Approximately 600 cases of operating room (OR) fires are reported annually.¹ The incidence of OR fires in the United States equals that of wrong-site surgeries, and 20% of cases have associated morbidity.^1,2 The estimated mortality rate is 1 to 2 cases per year.^3-5 The most commonly involved anatomical regions are the airway (33%) and the face (28%).⁴ Most surgical fires are reported in anesthetized patients with open oxygen delivery systems during head, neck, and upper chest surgeries; electrosurgical instruments are the ignition source in 90% of these cases.⁶ Despite extensive fire safety education and training, complete elimination of OR fires still has not been achieved.

Each fire requires an ignition source, a fuel source, and an oxidizer.⁷ In the OR, the 2 most common oxidizers are oxygen and nitrous oxide. Head and neck surgeries have a high concentration of these gases near the working field and therefore a higher risk and incidence of fires. Furthermore, surgical drapes and equipment (eg, closed or semi-closed breathing systems, masks) may potentiate this risk by reducing ventilation in areas where gases can accumulate and ignite. Ignition sources provide the energy that starts fires; common sources are electrocautery, lasers, fiber-optic light cords, drills/burrs, and defibrillator paddles. Fires are propagated by fuel sources, which encompass any flammable material, including tracheal tubes, sponges, alcohol-based solutions, hair, gastrointestinal tract gases, gloves, and packaging materials.⁸ Of note, alcohol-based skin-preparation agents emit flammable vapors that can ignite.^9-14 Before draping or exposure to an ignition source, chlorhexidine gluconate-based preparations must be allowed to dry for at least 3 minutes after application to hairless skin and up to 1 hour after application to hair.¹⁵ Inadequate drying poses a risk of fire.¹⁰We present the case of an OR fire ignited by electrocautery near freshly applied bone cement. No patient information is disclosed in this report.

Case Report

Our patient was evaluated in clinic and scheduled for total knee arthroplasty (TKA). All preoperative safety checklists and time-out procedures were followed and documented at the start of surgery. The TKA was performed with a standard medial patellar arthrotomy. Tourniquet control was used after Esmarch exsanguination. The surgery proceeded uneventfully until just after the bone cement was applied to the tibial surface. The surgeon was using a Bovie to resect residual lateral meniscus tissue when a fire instantaneously erupted within the joint space. Fortunately, the surgeon quickly suffocated the fire with a dry towel. The ignited bone cement was removed, and the patient was examined. There was no injury to surrounding tissue or joint space. Surgery was resumed with application of new bone cement to the tibial surface. The artificial joint was then successfully implanted and the case completed without further incident. The patient was discharged from the hospital and followed up as an outpatient without any postoperative complications.

Discussion

Bone cement, which is commonly used in artificial joint anchoring, craniofacial reconstruction, and vertebroplasty, has liquid and powder components. The liquid monomer methyl methacrylate (MMA) is colorless and flammable and has a distinct odor.¹⁶ Exposure to heat or light can prematurely polymerize MMA, requiring the addition of hydroquinone to inhibit the reaction.¹⁶ The powder polymethylmethacrylate affords excellent structural support, radiopacity, and facility of use.¹⁷ Dibenzoyl peroxide and N,N-dimethyl-p-toluidine are added to the powder to facilitate the polymerization reaction at room temperature (ie, cold curing of cement). Premature application of unpolymerized cement increases the risk of fire from the volatile liquid component.

In the OR, bone cement is prepared by mixing together its powder and liquid components.¹⁸ The reaction is exothermic polymerization. The liquid is highly volatile and flammable in both liquid and vapor states.^16,19 The vapors are denser than air and can concentrate in poorly ventilated areas. The OR and the application site must be adequately ventilated to eliminate any pockets of vapor accumulation.¹⁶ A vacuum mixer can be used to minimize fume exposure, enhance cement strength, and reduce fire risk while combining the 2 components.

MMA’s flash point, the temperature at which the fumes could ignite in the presence of an ignition source, is 10.5ºC. The auto-ignition point, the temperature at which MMA spontaneously combusts, is 421ºC.²⁰ The OR is usually warmer than the flash point temperature, but the electrocautery tip can generate up to 1200ºC of heat.²¹ Therefore, bone cement is a potential fire hazard, and use of Bovies or other ignition sources in its vicinity must be avoided.

The Table lists the recommended times for preparing various bone cement products.^22,23Mix time is the time needed to combine the liquid and powder into a homogenous putty.

Fear and anxiety, economic disadvantage, and recent psychosocial adversity contribute significantly to the onset of major depressive disorder in children and adolescents with a strong family history of the condition.

A 4-year longitudinal study followed the offspring of 279 families in which one parent had experienced at least two episodes of major depressive disorder (MDD) and in which there was a biologically related child living with that index parent.

Fear and anxiety showed a strong and significant association with new-onset major depressive disorder, as did irritability. Furthermore, the association between the two symptoms was low but significant, suggesting that they do not often co-occur (JAMA Psychiatry. 2016 Dec 7. doi: 10.1001/jamapsychiatry.2016.3140).

“The results suggested that generalized anxiety symptoms were driving the predictive effect of fear/anxiety on new-onset MDD and that fear/anxiety (and not irritability) predicted an especially early MDD onset,” wrote Frances Rice, PhD, of the division of psychological medicine and clinical neurosciences at Cardiff University, Wales, and coauthors.

Recent psychosocial adversity – stressful events such as the death of a friend, illness, bullying, or parents fighting – also showed a strong association with new-onset major depressive disorder, while economic disadvantage had a lesser but still significant contribution. Both of these also were associated with fear and anxiety, and irritability.

Greater family history and more severe parental depression also contributed significantly to the emergence of depression in the offspring, although those factors were not associated with the clinical antecedents such as fear and anxiety.

“Therefore, the indicators of social risk predicted MDD independent of correlated familial risk, parental depression severity, and clinical antecedents in the child,” the authors wrote. “This result has important implications for treatment and prevention and highlights the need to resolve not only clinical phenomena in the child but also wider contextual difficulties.”

The study also suggested that neither disruptive behavior nor low mood were significantly associated with new-onset MDD in children and adolescents.

The children and adolescents in the study had a mean of 1.85 DSM-IV major depressive disorder symptoms at follow-up, and 20 of them – six males and 14 females – had new-onset MDD, with a mean age of onset of 14.4 years.

“Our findings suggest that primary prevention methods for depression in groups with high familial risk will need to include effective treatment of parental depression, irritability, and fear/anxiety in the child and consider social risk factors,” Dr. Rice and her coauthors wrote.

The research and researchers were supported by the Sir Jules Thorn Charitable Trust, the Medical Research Council, the Economic and Social Research Council, the British Academy, and the British Medical Association. No conflicts of interest were declared.

Fear and anxiety, economic disadvantage, and recent psychosocial adversity contribute significantly to the onset of major depressive disorder in children and adolescents with a strong family history of the condition.

A 4-year longitudinal study followed the offspring of 279 families in which one parent had experienced at least two episodes of major depressive disorder (MDD) and in which there was a biologically related child living with that index parent.

Fear and anxiety showed a strong and significant association with new-onset major depressive disorder, as did irritability. Furthermore, the association between the two symptoms was low but significant, suggesting that they do not often co-occur (JAMA Psychiatry. 2016 Dec 7. doi: 10.1001/jamapsychiatry.2016.3140).

“The results suggested that generalized anxiety symptoms were driving the predictive effect of fear/anxiety on new-onset MDD and that fear/anxiety (and not irritability) predicted an especially early MDD onset,” wrote Frances Rice, PhD, of the division of psychological medicine and clinical neurosciences at Cardiff University, Wales, and coauthors.

Recent psychosocial adversity – stressful events such as the death of a friend, illness, bullying, or parents fighting – also showed a strong association with new-onset major depressive disorder, while economic disadvantage had a lesser but still significant contribution. Both of these also were associated with fear and anxiety, and irritability.

Greater family history and more severe parental depression also contributed significantly to the emergence of depression in the offspring, although those factors were not associated with the clinical antecedents such as fear and anxiety.

“Therefore, the indicators of social risk predicted MDD independent of correlated familial risk, parental depression severity, and clinical antecedents in the child,” the authors wrote. “This result has important implications for treatment and prevention and highlights the need to resolve not only clinical phenomena in the child but also wider contextual difficulties.”

The study also suggested that neither disruptive behavior nor low mood were significantly associated with new-onset MDD in children and adolescents.

The children and adolescents in the study had a mean of 1.85 DSM-IV major depressive disorder symptoms at follow-up, and 20 of them – six males and 14 females – had new-onset MDD, with a mean age of onset of 14.4 years.

“Our findings suggest that primary prevention methods for depression in groups with high familial risk will need to include effective treatment of parental depression, irritability, and fear/anxiety in the child and consider social risk factors,” Dr. Rice and her coauthors wrote.

The research and researchers were supported by the Sir Jules Thorn Charitable Trust, the Medical Research Council, the Economic and Social Research Council, the British Academy, and the British Medical Association. No conflicts of interest were declared.

Fear and anxiety, economic disadvantage, and recent psychosocial adversity contribute significantly to the onset of major depressive disorder in children and adolescents with a strong family history of the condition.

A 4-year longitudinal study followed the offspring of 279 families in which one parent had experienced at least two episodes of major depressive disorder (MDD) and in which there was a biologically related child living with that index parent.

Fear and anxiety showed a strong and significant association with new-onset major depressive disorder, as did irritability. Furthermore, the association between the two symptoms was low but significant, suggesting that they do not often co-occur (JAMA Psychiatry. 2016 Dec 7. doi: 10.1001/jamapsychiatry.2016.3140).

“The results suggested that generalized anxiety symptoms were driving the predictive effect of fear/anxiety on new-onset MDD and that fear/anxiety (and not irritability) predicted an especially early MDD onset,” wrote Frances Rice, PhD, of the division of psychological medicine and clinical neurosciences at Cardiff University, Wales, and coauthors.

Recent psychosocial adversity – stressful events such as the death of a friend, illness, bullying, or parents fighting – also showed a strong association with new-onset major depressive disorder, while economic disadvantage had a lesser but still significant contribution. Both of these also were associated with fear and anxiety, and irritability.

Greater family history and more severe parental depression also contributed significantly to the emergence of depression in the offspring, although those factors were not associated with the clinical antecedents such as fear and anxiety.

“Therefore, the indicators of social risk predicted MDD independent of correlated familial risk, parental depression severity, and clinical antecedents in the child,” the authors wrote. “This result has important implications for treatment and prevention and highlights the need to resolve not only clinical phenomena in the child but also wider contextual difficulties.”

The study also suggested that neither disruptive behavior nor low mood were significantly associated with new-onset MDD in children and adolescents.

The children and adolescents in the study had a mean of 1.85 DSM-IV major depressive disorder symptoms at follow-up, and 20 of them – six males and 14 females – had new-onset MDD, with a mean age of onset of 14.4 years.

“Our findings suggest that primary prevention methods for depression in groups with high familial risk will need to include effective treatment of parental depression, irritability, and fear/anxiety in the child and consider social risk factors,” Dr. Rice and her coauthors wrote.

The research and researchers were supported by the Sir Jules Thorn Charitable Trust, the Medical Research Council, the Economic and Social Research Council, the British Academy, and the British Medical Association. No conflicts of interest were declared.