Johns Hopkins Hospital is one of the world’s leading medical institutions. Many of the surgeons and physicians perform cutting-edge procedures that few others in the country or world have attempted. To add to the complexity, Johns Hopkins has nearly 80 operation/procedure rooms spread over 10 locations. Because of this innovative and dynamic environment, delivery of anesthesia to patients requires special considerations and techniques.
We ensure a smooth transition for newly hired CRNAs with a comprehensive orientation program that extends over 12 weeks. In addition, to create a boutique anesthesia concept, we have created cohorts for the different surgical specialties. Each CRNA who joins a cohort completes a special orientation, is assigned to that cohort at least once a week, and works closely with all of the staff in that specialty.
The Johns Hopkins Clinical Orientation program has been developed to provide our newly hired CRNAs with the tools and experiences necessary to acclimate to the multiple areas where we provide anesthesia. The orientation period (excluding Pediatrics) extends over approximately 12 weeks. New CRNAs are assigned two orientation days for the site where they are initially assigned and one orientation day for every subsequent site. The assignment for each site will last for approximately 2 weeks, and the CRNA will revisit each area before the end of orientation. During these orientation days, a CRNA volunteer will work directly with the new hire to provide information on the site’s workflow, policies, traditions, charting, and cohorts. A CRNA Mentor will also be assigned to every new hire to provide ongoing support. At the completion of orientation, the new CRNA should have achieved a degree of comfort in the various clinical sites and developed workplace connections that will increase satisfaction, productivity, and commitment.
Pediatric CRNA Projects and Initiatives
The Johns Hopkins pediatric CRNAs are an integral component of the anesthesia care team that deliver expert care to the world’s most complex pediatric population. The culture of our pediatric division is one of hard work, collegiality, respectful communication, and professionalism. Our team model ensures safe and efficient care, while achieving both positive patient outcomes and high satisfaction scores from our surgical and nursing colleagues as well as from our patients and their families. Every day we educate and inspire future generations of pediatric CRNAs through our culture of inclusivity, continuing education, and community outreach.
We are fortunate to have an enthusiastic and productive group of pediatric CRNAs that not only give excellent care to our youngest patients, but are also involved in multiple diverse perioperative projects such as mentorship program for high school and undergraduate students interested in a healthcare career; student registered nurse anesthetist pediatric educational experience enhancement project and pediatric airway rotator improvement project. In addition, we have implemented a comprehensive pediatric CRNA orientation program and developed the Pedi-Learn Program.
CRNAs are able to provide anesthesia for a variety of challenging cases in neurosurgery and trauma at Johns Hopkins. They provide anesthesia for cases such as craniotomies, including awake, complex, cervical spine surgeries; posterior fossa tumor resections; endoscopic procedures; spinal fusions; and level I emergency procedures for aneurysms, subarachnoid hemorrhage, and acute trauma to the cervical spine. The CRNAs in this cohort also provide anesthesia for neuro-interventional procedures. Trust and respect are instilled in this group of CRNAs that stems from the attending anesthesiologists, surgeons, and nursing staff. It is a unique area in which to specialize because a patient’s quality of life is involved and constant vigilance is required.
Johns Hopkins Outpatient Center (JHOC) Orthopedic Cohort
The JHOC Orthopedic cohort is composed of a small group of dedicated CRNAs, attending physicians, and nurses who are focused on providing quality, efficient care for outpatient orthopedic procedures. The surgical procedures include shoulder and knee arthroscopies, ACL reconstructions, rotator cuff repairs, hand surgery, and foot surgery. We are focused on minimizing or eliminating postoperative pain through the use of peripheral nerve blocks when indicated. Through great teamwork and communication, we strive to maximize patient satisfaction.
In the Plastics cohort, CRNAs provide care to patients undergoing plastic reconstructive surgery. The main focus of this group is to improve the outcome of patients undergoing mastectomy with reconstructive breast surgery. Our goal is to minimize postoperative pain and nausea. We follow a protocol designed specifically for these patients to reduce length of stay and improve overall satisfaction.
Electrophysiology (EP) Cohort
CRNAs in the EP cohort are expert in providing anesthesia to cardiac patients undergoing minimally invasive procedures such as radiofrequency ablation (RFA) of dysrhythmias, implantation and removal of pacemakers and defibrillators, device lead removal/revision, implantation of pulmonic valves, the Lariat procedure, electrophysiological studies, cardioversion, and transesophageal echocardiograms. The EP cohort currently has 28 CRNAs. This cohort is under the cardiac anesthesia division and has an excellent collaborative practice with the cardiac anesthesiologists.
Since November 2015, we have successfully implemented jet ventilation for procedures involving RFA of atrial fibrillation and for procedures in which minimum ventilatory movement around the ablation site is desired. To date, we have “jetted” over 300 cases without major anesthesia-related complications.
The Endoscopy cohort consists of over 40 CRNAs. The Johns Hopkins Hospital endoscopy unit is extremely busy, providing anywhere from 60 to 80 anesthetics per day. These CRNAs routinely see not only outpatients, but also a large number of inpatients who range in status from healthy ASA 1 to critically ill ASA 4. They also support a very busy bronchoscopy room. CRNAs in the endoscopy unit take care of routine screenings for colonoscopies and upper scopes with sedation. They also provide general anesthesia to patients undergoing very involved procedures such as endoscopic retrograde cholangio-pancreatography, gastric sleeves, endoscopic ultrasound, and Endo Stitch. In conjunction with a cardiac anesthesiologist, they also take care of critically ill patients with left ventricular assist devices who come from the floor for different procedures.
Several times per year, we ask if any CRNA is interested in presenting a topic relevant to their practice to the Endoscopy nurses during their Thursday morning meeting. These talks have been quite successful at bridging the gap in understanding of the CRNAs’ role and helping to promote a great cohesive team.
The Johns Hopkins Hospital Weinberg cohort of CRNA’s excel in providing safe and efficient anesthetic care for a variety of specialized cases in the Weinberg Operating Rooms. These cases include a myriad of Colorectal ERAS cases, GYN, Urology, ENT, plastics, transgender, thoracic, and Liver/Pancreatic resections. Our CRNA’s are expert providers for Colorectal and GYN cases using our award winning ERAS protocols which is fast becoming the anesthetic pathway of choice for many of our surgical specialties. We also provide anesthesia for ENT cases requiring Jet Ventilation as well as many robotics cases that are also becoming more popular throughout the institution.