Matt Sherrer, MD (Host): Welcome to the Fresh Flow Podcast, sponsored by UAB Medicine, the UAB Department of Anesthesiology and Perioperative Medicine, and the Association of Anesthesia Clinical Directors. He's Mitch, I'm Matt, and we like to talk about interesting topics in the perioperative space. Thanks for tuning in.

 Mitchell, good to see you, buddy. How you doing today?

Mitchell Tsai, MD (Host): Hanging in there, sir. Sir, sure. Say that fast three times.

Matt Sherrer, MD (Host): Yeah, good luck. There's a lot of pressure today, man. This is a, this is, this is a big episode for us because we actually have a real podcaster on today. We have somebody who actually knows what they're doing. So, I'm going to ask you to try to be an adult today and to try to be a professional. Okay.

Mitchell Tsai, MD (Host): Yes, dad.

Matt Sherrer, MD (Host): You think you can handle it?

Mitchell Tsai, MD (Host): Yes, dad.

Matt Sherrer, MD (Host): All right. Well, today, uh, I'm excited to welcome our next guest. We have the pleasure, the privilege of having on today, Desiree Chappell. Desiree is the Vice President of Clinical Quality for Northstar Anesthesia, is still active in the clinical setting as a certified registered nurse anesthetist, has been heavily involved in the ERAS movement across the globe, and is, as I mentioned, is a real podcaster, is a kind of a founder, I would say, Editor and Chief Lead Anchor for TopMedTalk. So, Desiree, we are excited to have you here today and thank you for doing this for us. We appreciate you.

Desiree Chappell, CRNA, FAANA: Yeah, absolutely. Thank you so much for having me. It's, you know, the tables are turned and the pressure is on. I feel like. I'm never usually in the hot seat. This is very strange for me. I'm out of, I'm out of my zone.

Matt Sherrer, MD (Host): We don't keep the seat very hot. We throw, we, uh, we throw some pretty softball questions out there most of the time. So, well, tell us more about yourself. I kind of briefly introduced you, but can you give us a little bit of your own bio?

Desiree Chappell, CRNA, FAANA: Yeah, of course. So, thank you for that lovely introduction. I'm glad you kept it a little bit more brief. Sometimes I'm always like, oh gosh, don't say any more. So I am a CRNA. I've been in practice in Louisville, Kentucky for the last 16 years. Private practice for the first 10 of those, at an amazing group where I did a little bit of everything and absolutely loved it.

And then went off on my own and did some locums. So had that experience and started TopMedTalk with Professor Monty Mythan, who is Professor Emeritus now, from University College, London, and have had a ton of fun with that. And that's, our podcast TopMedTalk, which has been around for the last five years, and got into that not having a freaking clue about what a podcast was and how to do it.

Matt Sherrer, MD (Host): Yeah, we can relate. We can relate.

Desiree Chappell, CRNA, FAANA: Yeah. Right. Like you understand. But love to talk and love to, actually we kind of started Top MedTalk after I had been getting out into this space of, going to meetings, presenting at meetings and chatting with people that we found interesting, other presenters, people, attendees at the meeting.

And I thought, Oh my God, I wish everybody could have just heard that conversation that I had with Bobby Gene Schweitzer or Henrik Kellett about enhanced recovery or whatever it was. And so, Monty kind of started the podcast and he asked me to come on and be kind of a guest anchor. And then here we are, six years later.

And then in 2020, you know, I've been doing a lot of the podcasting and learning a lot about all of these things around quality and safety and all these different elements of, of anesthesia care and thought, you know, maybe it's time to put the rubber to the road and actually practice some of this, what we're preaching.

And so, Northstar had been recruiting me for a while. Dr. Brian Woods, had recruited me for a couple of years and had wanted me to come on the team. And finally, there was a space for me to join. Dr. Josh Lumley, who is our chief quality officer for Northstar as vice president of clinical quality.

So that's kind of how I got to where I am now. I will have to say as a disclaimer, and this is not usually what I do for my own podcast, but for this particular one, just so everyone knows all of these comments, thoughts, ideas, anything we talk about today are all my own and not, that of Northstar anesthesia or TopMedTalk for that matter.

 Just level setting there, for everybody. So that's kind of my background where I'm from, love to talk about everything related to perioperative medicine, anesthesia care, taking care of the surgical patient, and looking for ways that we can do it better, because better never stops. That's kind of my motto.

Matt Sherrer, MD (Host): Awesome. You mentioned some names in there and Woods and Lumley, guys that I met kind of along my private practice journey as well. Really cool folks. So, glad to have you on today. And I, you know, when we're talking about the podcast here, TopMedTalk, I've also had the chance to visit with Monty Mythan and he came here to UAB and, hung out with us and did a talk and got to have dinner with him.

Just an incredibly, incredibly brilliant guy. And sounds so smart on the podcast. I would love for my voice to be made to sound like his. It would enhance the credibility of this podcast tremendously.

Desiree Chappell, CRNA, FAANA: Well, let's just talk about an inferiority complex. Okay. So joining Monty. So little girl from Kentucky, who's been sitting in the OR for 10 years, just doing my thing. There was a little bit of that. There still is every once in a while.

Mitchell Tsai, MD (Host): Well, think from a historical perspective, right, and this is the country, this is totally out of left field, but you know, the Country Music Hall of Fame, right? It was the British settlers that brought the banjo to Kentucky, and I think Tennessee into those states, and that's where you got country music from. So I'm full of, full of useless facts.

Matt Sherrer, MD (Host): You're full of something for sure. How did the California to Vermont guy just teach me something in Alabama about country music? This is enhancing my inferiority complex to Mitch.

Mitchell Tsai, MD (Host): Because 10 years ago, 10 years ago, I was in Nashville and I went to the country music hall of fame. And I didn't recognize anybody until I got to Elvis Presley. So that was quite a learning experience.

Desiree Chappell, CRNA, FAANA: Yes I'm sure you were.

Mitchell Tsai, MD (Host): So, Desiree, thank you again. I think given your past experiences, you've seen it all, or, or at least we can say you've seen it all with the workforce shortages and everything that is happening to the healthcare delivery system in this country, what do you think the practice of the future looks like, right? You know, which model out there has the best chance of surviving? So we're, we're asking you to make a horse bet.

Desiree Chappell, CRNA, FAANA: Dang. You are totally diving right into this, aren't you? Not even getting warmed up. Yeah, it's a great question. I think we're horrible at predicting the future, so, who really knows. But, at Northstar, and again, speaking just from my own personal experience, and I'm not an operations person, and this is very much, like, operationally, how do we, how do we make things work?

 We see all models, right? And, we see everything from physician only practices to CRNA only practices and literally everything in between. And where I think that we're going is that we're going to do that even better and figure out what works per site. So, just like we're working on like individualized patient care and really catering to each patient that is in front of us, and not necessarily the masses, I mean, we have some theories and standardized ways we take care of people, but when it comes down to it, we have to use those standard ways to individualize care.

It's the same way with practice. Right? So, like, we have to look at what this practice is and what they need and the type of patients that they're doing and, who's available to do what. And I, there's a couple things in concept as we talk today, you know, I'd love to explore a little bit more between task shifting and task sharing and how we do it all.

But the model of the future is going to be whatever the site needs and best fits the needs of those patients and the OR and to keep efficiency and to be cost effective, while still maintaining the quality of patient care. And so whether that's a bit of a softball. Back to you. But, I don't think that we can say it's an anesthesia care team model everywhere we go.

Now, I will say anesthesia care team models work very well when they work very well, when you have a collaborative team working together. It is a thing of beauty. When they don't work well, they don't. And sometimes that's not always what you need. And so I think what we have to do going forward is open our minds and be, look at the opportunities that we have to be able to do this, to provide high quality care in the most cost effective way, and not just safe care, like high quality care in the most efficient way, I think it's what we're going to do. So, I think that requires a collaborative approach. So whether or not it's a CRNA only model or an MD only model, like we still all have to collaborate and be on the same page about where we're headed for that. So.

Mitchell Tsai, MD (Host): I think, you know I've been having a conversation with Ben Antonio down at the University of North Carolina. He's interested in rural healthcare. And you look at after the pandemic with more than 700 hospitals closing across this country, the disproportionate burden has been on those rural healthcare systems. You know, I live in Burlington, Vermont. We're at the epicenter of a network in a rural setting.

And you know, one of the things that we've talked about, it's just exactly what you're saying with the task sharing and the task shifting and making sure that you're delivering optimal care. I think that one of the opportunities for all of us is that if we can figure out the answers in these rural settings, maybe that actually can scale to a system that can actually become sustainable across this country. So, so, no, not a softball at all. I think you hit it outta the park.

Desiree Chappell, CRNA, FAANA: I mean, here's the thing, task shifting is whenever you transfer care and delegate tasks to someone who is not as qualified to do possibly the same task versus task sharing, where you actually have a collaborative and coordinated effort to make sure the care that you're delivering, that everybody's contributing their own unique skills and assets, to optimize care. Where I think we have been is that we've always thought and been in this mindset, oh, it's task shifting. We're giving this type of care to somebody who's not as qualified as another person. And that is not in fact the case. It just depends on what that situation may be and what type of patient that you're taking care of. Maybe it's in a high risk adult congenital obstetric patient. Well, you need the person who's taken care of most of those and had the most training in those to take care of that patient versus a rural patient that is super high risk because they're morbidly obese and they have all these comorbidities, but you have the person taking care of them is confident, comfortable, and competent at taking care of that patient. And that's the way I kind of look at it.

Matt Sherrer, MD (Host): Desiree, you're actually the first CRNA that we have had on this show. So number one,

Desiree Chappell, CRNA, FAANA: congratulations.

Thanks. You're treading new territory here. It's a big deal, Matt.

Matt Sherrer, MD (Host): Yeah, absolutely. But Mitch and I have said from the beginning, we're not going to shy away from tough topics. And that's kind of in keeping with what you had said, like, I wish people could have heard this conversation that I was having at this conference. And one of the things that comes up frequently, I was at a conference recently, and somebody said, it was an ASA conference, which again, card carrying ASA member love my specialty, right?

 I think that CRNAs should advocate for their specialties as well. But one of the questions came up, are we destined to just fight forever? Is this going to be a turf war forever between us and the CRNAs? Is it one wins and one loses? Is that what we're destined to? Or is there a way, as you just said, to view it more as, task sharing and to move forward together, in a collaborative way,

Desiree Chappell, CRNA, FAANA: Yeah. And I love the concept, Matt. I think you had written a paper on the zero sum game of, of anesthesia and that concept that like, we don't have to have, winners and losers. That's not what this is about. I will say, this is my mantra and I actually, I try and say it, but with my ADHD, I can never quite get the quote right?

Matt Sherrer, MD (Host): You're in good company here.

Desiree Chappell, CRNA, FAANA: Thank you. I knew we were kindred spirits. Rising tides lift all boats. It's about everybody working together and lifting everyone up. That's how we're going to win. We will lose if we continue this fight because the insurance companies, they just want good care for their patients, you know, and what they're going to pay and the payment models and all these things like we got to figure it out.

And again, it's the task sharing, task shifting idea. Like we have to stop thinking that we're, that physicians are somehow giving up something to a less qualified person to do all these jobs. There is a ton of work to be done out there and there, if we were very strategic about who does what, I really feel like we would all be winning.

I mean, if we could go as a unified front, as team anesthesia, physician anesthesiologist, CRNAs, anesthesiologist assistants, we would be incredible. I mean, like we would be a force you couldn't reckon with, you know what I mean? So I feel like I can't take the infighting and, all the political stuff.

Like that's just, it's not me. I'm also Libra. So I want everybody just to get along. But I mean, in reality, like, can you imagine if we really did come together and what we could do? I mean, I don't think we would be having these conversations about how we're getting, how we're dealing with payment reduction and, you know, what, terminology I'm looking for, but, every year dealing with getting cuts to reimbursement is what I'm trying to say.

Matt Sherrer, MD (Host): No, I get it. And it, it, as you were saying that it reminded me is, I'm a state society officer, in my state and, have had to go to Montgomery to the Capitol, right to have these debates and these fights. And I distinctly remember afterwards, after the session was over with, standing around in the state house, mingling and our, and our representatives in our state telling us, Hey guys, we would really love for you guys to handle this.

We would love for you guys to figure this stuff out yourself. This is basically a family issue and we need you guys to sit at the dinner table and we need y'all to figure it out because we're not all healthcare providers. We need you guys to handle it. And kind of one of my points all along has been, as patient safety advocates, all of us, it's really our responsibility to do this.

We owe this to our patients to figure this out instead of allowing the payers or the legislators to be the one that mandate the care models for the future. We owe this to our patients. But I'm so glad we had you on just to, just for the opinions you just expressed.

Desiree Chappell, CRNA, FAANA: I mean, you know, it's probably not a popular opinion, within both of our Professional societies and organizations. Well, no, I take that back think it is actually the popular opinion. I think most of us probably fall in the middle of like, can we all not just get along? I mean, I feel like whenever I hear this rhetoric that's put out by both sides that it's like my kids, my two sons, like fighting over a basketball and who's better or what, you know, whatever.

Like it just, to me, it doesn't make sense. And, as a patient safety advocate and always, everything, every choice that I make and everything that I do within my professional career is all around, is this best for the patient? And if we all really truly put patients at the forefront, like really did that, then we would know that it's coming together, to improve, you know, to work together.

So I don't know. It is a bit of a soapbox. I've probably going over a little over the top here recently, just because I really, I feel the pressure of it. And, it's not good. Like, you know, you walk away from some of these conversations, you're like, Oh, that just didn't feel good. And it could, it could be better.

Mitchell Tsai, MD (Host): So, you know, I, I talked about country music earlier and you know, I'm gonna get on my soapbox from the land of Bernie Sanders, and I've mentioned this in past podcasts. But you know, our department was started by John Abajian. He was called Big John. And then John Mazzuzan was the second chair of this department.

Big John was the chief medical officer for Patton's Third Army. So when he went off during World War II, Betty White was a CRNA who ran the department during the war. And even afterwards, she trained generations of physicians because those are who taught the anesthesiologists. And, you know, I'm, grew up in this department and there was this level of respect that all my attendings that trained me showed the nurses. And it's always been a collaborative team environment here. Most times when I go around the country talking about this, most people think I'm like blowing smoke up, you know, what.

Desiree Chappell, CRNA, FAANA: Yeah. It's like some utopia that doesn't exist.

Mitchell Tsai, MD (Host): And, again, like you said, we have our kind of problems of healthcare delivery here. And you think about what's happening over on the NHS side with 7 million surgeries waiting to be done. They don't have CRNAs. The ability to expand care is limited by what their infrastructure holds. And so, and then the last piece I think is from the WFSA, right? World Federation Society of Anesthesiologists or anesthetists. I don't know which one it is, but I think the number's 150 million surgeries don't get done around the world, right?

150 million because there's not a qualified anesthesia provider. So, you know, with your framework, we can do a lot more and we can do better.

Desiree Chappell, CRNA, FAANA: Yeah. You bring up WFSA and, and some of these things about, giving care in low middle income countries, but even in well developed countries, we have this problem. I was part privileged to be part of the perioperative quality initiative 15. They name each one of their meetings where a group of experts come together and sit around the table to develop consensus guidelines and, and have conversations about different topics. Well, this particular one, and it's part of a series, is called the Value Proposition of Perioperative Medicine. And this one was called Enhancing the Value Proposition of Perioperative Medicine in Lower and Middle Income Countries.

 We did this in Singapore at the World Congress of Anesthesiologists and there were 20 of us in the room from all over the world. And, this concept, you know, came up of saying, how do we deliver, how do we deliver more surgery and make sure that it's being safe and done with appropriate providers and all the things.

And, so we got into this really hot debate that started to go down a path that, it becomes then that conversation of, again, I hate to keep bringing it up, but it's so true. Task shifting versus sharing. And if you feel like you're shifting to people who don't know what they're doing, that does not feel good.

And that's not safe, right? You can't ask a nurse who's not been, and I'm saying like a straight nurse in Nigeria to do an anesthetic that clearly should be done by somebody who has training. I mean, and that's, it's really tough to do that. And that doesn't feel good. But if we educate that nurse and give them basics and give them a patient that is, you know, appropriate for them to take care of; that probably is possible and that's delegation of tasks to someone who has the appropriate skills for what they're doing. So that was a very interesting conversation. I've also been in the UK during some of these hotly debated conversations. And I've been the one in the middle that I'm like the token CRNA in the room.

I'm the token non anesthesiologist or anesthetist as they call them there. And you know, everybody's looking to me like, well, what do you think? And it's really a tough position to be in because as a CRNA, I'm very proud of the practice and my practice. And I feel very competent.

I've done a lot of anesthesia over the years with very complicated cases. I feel very proficient at that. Maybe not as much. I'm not quite as in clinical setting as I used to be. So throw me in a heart, probably I would, wouldn't be comfortable with that, but you know what I mean? Like. I feel very confident that I've worked with amazing anesthesiologists who have educated me more than what my training was.

I want to come out strong and very prideful of what I do, but I also understand where anesthesiologists and anesthetists, especially in a country where they haven't had this model, and they've seen the horrible infighting over in the U.S. Like, what do we do? And, you know, a major issue across the globe is that we look towards, well, do we do this model?

Will we bring nurses in and have nurses who have had critical care experience and have had patient care experience? There's not enough nurses to go around. You know, where do we find nurses? There's a critical shortage in the UK of nurses, especially in critical care units. So are you going to go pull from those?

And we've seen that model kind of go against us here in the US. I mean, our critical care units, whereas before and where I trained, where I worked, there were nurses with tenure of 30, 25, 30 years. They taught me how to do critical care nursing. You don't find anybody in a unit anymore that's worked probably more than five, maybe seven years.

So it's all things to think about, and again, try and shift our mindset to be, well, how do we do this? How do we do it the right way? A collaborative approach, a team, really working with a team. And again, that's what I kind of love about Northstar and where I am right now. We do that. You know, we are really looking towards working collaboratively.

 We're not against physicians. We're not for CRNAs. We are for our teams. And I love that model. I think that that's where we need to be. So.

Mitchell Tsai, MD (Host): I would add that I've learned as much from my attendings as my nurse anesthesiologist working with them. I tell this story at an intern orientation, you know, I ask them who taught me how to put a central line in, and everybody says, your cardiac anesthesiologist who was your attending, and I said, no, no, no, no, no.

It was Janelle Fairbanks, cardiac nurse for 30 plus years. She told me how to put a central line in because the first time when I handed the needle back up, with the needle pointing up, she looked at me and said, if it's not pointing down the next time, I will stab you with it. And I said, yes, ma'am.

Desiree Chappell, CRNA, FAANA: Oh, hard knocks, but that's the way it is, man. You never did that again, did ya?

Mitchell Tsai, MD (Host): Nope.

Matt Sherrer, MD (Host): Before we move on from this topic, and there's plenty of other stuff we can talk about, but, um, you know, as you were talking about all this, one of the things that's always bothered me in these political fights is that, when I would talked about being in the statehouse and we'd be divided into these two camps on one side or the other, and I remember looking across the aisle at guys like David Ford and Justin Carrell and being like, I have literally asked those people to take care of my family. Those CRNAs, I have said, hey, please be there to take care of my family. What am I doing? Why am I fighting this fight? I refuse to accept that being pro anesthesiologist means inherently being anti CRNA. Good grief, there's enough work for everybody to do. There's plenty of work, you know. But again, soapbox for all three of us here. So let's move on before we, before we, uh, before we lose

Mitchell Tsai, MD (Host): Are we standing on the same soapbox?

Matt Sherrer, MD (Host): Yeah, we are, uh, that's good. It's a good thing. So, Desiree, you have been heavily involved in the enhanced recovery movement and a lot of that implementing those new strategies. I guess they're not really new now. They're kind of becoming more common, but, initially new strategies that hadn't been done before. A lot of that is change management, right? It's coming in and it's moving people's cheese. It's saying, Hey, uh, we're going to do things a little bit differently. And change management is really, really hard.

I personally, because I'm a simpleton, love the, our iceberg is melting fable from John Cotter, because you can read it in about 30 minutes and it's basically a cartoon. So that's right up my alley. There's lots and lots of theories of change management, change adoption triad I saw in your CV. How have you found is the best way to implement these things in new facilities and implement change?

Desiree Chappell, CRNA, FAANA: Now that really, if we could solve that, I think we could solve world peace. It's complicated. So yeah, I, I love Enhanced Recovery. That's where I got my start. I was kind of the project person for my group. So I was already working in the space of change manager, right? Like, hey, here's a new pump. We got to figure this out. And I know that you loved your old twisty knobs on whichever pump that was called for that. And you could just dial it right in. It was super easy. No buttons to push. But we have to go to this pre programmed pump that is definitely more safe. And, it's a lot harder to screw up.

And so we need to do this. So I was already in that space of that. And then Enhanced Recovery came along, and I learned a lot more about it. And that actually, that's how I met Monty, was through that. He had come to Louisville and given a lecture on Enhanced Recovery. And my medical director at the time was like, he came back after listening to him and said, we're doing this.

Let's do it. And I thought, Oh, okay. That sounds interesting. I read a lot about it and I'm like how we're going to get our teams to change. And so we had a lot of discussion about it and I've learned a lot over the years. And so I, do speak on this a lot because I'm, pretty, again, it's almost, I hate to use the word soapbox, but it's a passion of mine.

More so than just doing enhanced recovery, which I 100 percent believe is the right thing to do for all of our patients. Like, no one's too sick or too healthy to do enhanced recovery. We should be doing it for everybody. You need to keep it super simple. You don't need 30 interventions. But what I have learned is that change is hard and you can use a lot of the different models.

You mentioned Kotter, so like the eight steps, you know, process for change and all the different things. And there's all these different ways to do it. I have found that a couple key principles, it's engaging your teams and bringing them in to have a seat at the table and to have an opinion about what you're doing and listen to it.

But then also say, while I respect and appreciate this input, this is the way we're going to do it, we're going to try it this time. And when you engage the people, you have to understand who you're talking to. So what you're telling to your anesthesiologist, to a CRNA sitting in the room having to use those pre programmed pumps, to your surgeon, to your administration, to your nursing teams, pre and post, PACU and post, all of that.

That's a different story that you're telling each one of those, but you have to engage with them and get the buy in from your stakeholders. So that's kind of, I think that's like the first thing. You just can't go carte blanche, like, hey, this is what we're doing. You don't talk to anybody about it and go forward.

It will fall flat on its face. I've seen it a million times. Second is getting the team excited about what you're doing. So that's kind of that Kotter, like creating a sense of urgency and getting, you know, creating excitement around it. People have to believe that this is a better way to do whatever it is that you're doing.

So enhanced recovery better way to take care of your patients, even though it is a big pain in the butt when you first do it. Trying to figure out what drugs do I need? I'm going to do a new block. I'm going to you know, for your surgeon, I have to change my NPO times. Is that going to cause a problem? Are you going to delay my surgery or cancel my surgery? Like all those things, but you got to get people excited about the fact like, Hey, patients are going to feel so much better. They're not going complain to you about being hungry and thirsty and like their anxiety is going to be lower if we let that like hydrate them and let them drink up until the time of surgery.

And Hey guys, like, this is a new opportunity to learn something new and grow professionally. And it will get easier as you understand how to bring the pumps in. So I think like, that is a big thing. And then educating the teams about everything. So like, it's one thing to say, do this new block or, you know, PACU nurse, don't give narcotic.

Whatever it is, but you got to educate people about it. Plain and simple. Like they have to have an understanding and it's not enough to tell a nurse, like this is what you need to do. They need to understand the why. And I would say it's not just nursing, all of us. We have to understand the why of what we're doing.

 And lastly, I think empowering individuals to kind of then put it into your hands and make your choice. One of my favorite ways to present on change management. One of the first slides that I put up is the Rogers technology adoption curve. And it's, you know, the bell shaped curve of, early adopters on one side and laggards on the end and everybody in between, you know, and it's like most of us fall in that middle.

I'm probably way on the left side of the spectrum on so many different things, but specifically on change adoption and, looking at new things. I'm definitely on the left side. So it's super early adopter. I want to try out all the new things. But many of the people that we deal with are on the other side, right?

And I hate to say the word deal with, but many of our colleagues can fall anywhere in between, but fall on, being kind of the laggard, not, wanting to be the first ones to take the step or actually want to change at all. And some of the best advice that I got was, from Ramani Moonsinger, who is an anesthetist over in the UK, and she's actually the director of the National Health Services Research Center at the Royal College of Anesthetists, which is a big deal. She's very cool. And she has run some amazing programs there. She has helped with enhanced recovery proliferation around the UK, along with Monty. But one of the things that I was talking to her and saying, how in the heck do you do this for a whole country?

 And her biggest thing was like, don't focus on the people on the laggards, like focus on the early adopters and get them going. And when other people see them and see that things are working, then that's how you get them on. You're never going to change those laggards' opinion. What you need to do with the people who are not convinced that this is the right thing to do, or they want to change is show them that it can be done better. Your patient looks better. And let's not be the poison in the well, you know, like let's just try, can you, you know, guy or girl or physician or CRNA or whomever surgeon that doesn't want to do this. Okay. We won't do that for you, but can you please not like ruin this for everyone else.

And that's kind of been how I go forward is that, I just say like, totally appreciate where you are right now. This is what we're going to do as a group. We're going to try this out and see what it looks like. And over time, I feel like we have changed a lot of minds and hearts for like knowing what the right thing to do is or how to do things better, I guess I should say, because they have seen better outcomes for their patients.

So when it came to enhanced recovery, the example that I always give and how we changed the minds of our group is that there were a core group of us that decided that we were going to do this for a core group of patients with one surgeon. And we started doing this and it was for colorectal patients.

And, our length of stay was like 13 days. It was something really crazy, which we kind of snub our nose at it now, but back in the day, I can tell you, I've done this tons of places and that was an average length of stay for a lot of, a lot of surgeons. They would come out with an NG tube. Patients looked absolutely miserable on their first couple of days of surgery.

And we would know that because all of our clinicians, Anesthesiologists, CRNAs, at some point would get up to go see patients the next day after surgery. So we'd see what they looked like. So we go up there and we knew that these patients looked horrible. Well, the group of us started doing enhanced recovery on a, let's say on a Tuesday.

On Monday, those patients look like hell. On Tuesday, they were up walking around and looked absolutely phenomenal. And that had surgeon A in one room. Well, surgeon B had his patient who had the exact same surgery in the next room. And that patient looked terrible. So when you were going to see this, you're like, Oh my gosh.

And so all of our clinicians would get up and go see patients the next morning after surgery, and that's what changed their mind when they saw the enhanced recovery patient versus the traditional patient. I think we've gotten away from looking what our patients look like because we don't see our patients at many hospitals anymore. Like, as team anesthesia, we don't get to see our patients the next morning, so it's a little bit harder, to know and see the difference.

But I would say, when it comes to change management, changing minds, that you have to engage, excite, educate, empower people to make decisions, and they have to see what their patient, they have to see the difference for themselves. And that's really what does it. So I don't know, long answer to a short question, but.

Matt Sherrer, MD (Host): No, no, that bell shaped curve has helped me a lot as well. Simon Sinek presents it as the law of diffusion of innovation. And on the far right side of that curve, the laggards, I think he calls them flat earthers or somebody, I saw somebody describe it as people who still use rotary phones.

One of the things for me, it's been helpful is just to understand that that is a human sociologic phenomenon. It's going to happen that way. And so you can't necessarily be frustrated by people who oppose the change. And then to focus on that, you know, you as an innovator, focus on that group of early adopters, get the, get the buy in and that's when you kind of cross that chasm. And you get to the point where your early majority get on board and then your late majority. But, you can't convince everybody all at the same time. There's certain people who just aren't going to hop on board and that's okay.

Desiree Chappell, CRNA, FAANA: And that is totally okay. And we have to embrace that. Like, when you are planning to do whatever it is that you're doing, you actually, you plan for those people, too. Like, you can't just say, oh, I'm not going to focus on them, because they will, in fact, kind of poison the well sometimes. I've had that happen, and it's like everything kind of falls apart. So you do have to have a plan for those who are not quite on board yet. But, and that's okay. Like, that's just part of what you got to do whenever it comes to, um, big projects, such as a thing like enhanced recovery.

Mitchell Tsai, MD (Host): I think for perspective, you know, when you talk about Everett Rogers, his book is probably in its fifth or sixth edition, right? But when you think about the original research that was done on farm equipment and agricultural technology, right. And it actually applies to the digital age. I think, what your message, you know, it, echoes, we had Larry Chu from Stanford and we asked him about what keeps him moving in education.

Right. And Matt and I've talked about when you think about education, design, innovation, leadership. They all share the same sort of tenet, right? It's about empathy. And Larry talked about, you know, you made, you made three points, but Larry talked about, engage, connect, and transform, that's what we try to do as educators. That's what we try to do as clinicians. To segue, and I think you set this up, right, we think about value, right, in, in anesthesia. We had Porter a couple years ago at the American Society of Anesthesiologists. He has his platform down at Harvard Business School with Robert Kaplan.

But, you think about that reduction in length of stay from 13 days to hopefully down to like two, three days now, and you're moving patients out of your system, right? In the business world, right, you either got to cut costs become more efficient, and it's sort of ruthless. So where do we go once you've established ERAS, you know, we can talk about the perioperative surgical home.

Duke, for a while under Aronson, was thinking about prehabilitation. I don't think that research has panned out necessarily, but, where's the next value platform for anesthesia providers in this country?

Desiree Chappell, CRNA, FAANA: That's a good question. When I think of value, it is definitely like my definition is kind of the value cost equation, right? So like value is improving quality of care for me in healthcare and in anesthesia, improving the quality of care that's delivered while marginally increasing cost or decreasing costs.

So there are times when you actually, it may cost a little bit more to take care of a patient or cost the same to take care of a patient. You know, you're, for instance, you're using different types of drugs or interventions. Surgeons doing higher cost surgery, whatever.

But the expectation is whatever you're doing, you're actually going to have a greater increase in the quality of care that you're delivering. So like, okay, I am doing a regional anesthetic, which takes time, resources, medications, things like that. So it might cost a little bit more, but you are going to get greater rise in quality and the patient outcomes, better patient outcomes.

So that's kind of the way I think about it. And, for us in as team anesthesia, I think we have to be more than, this is going to sound really bad, probably shouldn't say it like this, may have this cut out. Um, but we need to have more than someone sitting on a stool, just showing up for work.

Like, we can't do that anymore or, you know, someone just doing pre ops in the pre op holding area, you know, or, or getting patients ready for, like, we need to do more than that. We need to show value in what we do by taking things to the next level, offering regional anesthesia, being familiar and, utilizing technology to help improve patient outcomes, which some of that is still being born, you know, coming out in the literature, but I think there are a lot of opportunities for us to see, like, explore things, can we do this better, can we have better patient outcomes, can we do things more efficiently, is there a better way that we can work on throughput, can we optimize our patients, and the prehabilitation thing. True that there is some of it that is maybe not quite as dramatic impact as what originally thought but we do know doing better risk evaluation, using different methods of physical exercise, nutritional optimization, things like that, can have an impact on outcomes. And so getting into this space where it's not just about sitting on the stool, doing anesthesia for eight hours or 10 hours or 12 hours a day. It is how do we expand outside into the perioperative space to optimize our patients through the continuum of care. And I honestly think that if we as team anesthesia do that, we are going to be winning. And if we do that through a model of care that we're all working together collaboratively between the different types of providers, with the different skills and different degrees, we will kill it and our patients will do absolutely fantastic and the cost of care would be reduced. I mean, be more efficient.

Matt Sherrer, MD (Host): We're not cutting any of that out. That's all staying. nope. I'm leaving it. Nothing's getting cut out. That's good stuff.

Mitchell Tsai, MD (Host): I think for our listeners, I would just want to highlight the fact that you said investment, but that we, it's not cutting costs that, that sometimes we have to make an investment so that we can go a little bit farther. I think you're absolutely right about extending beyond the perioperative space.

I think McMaster University now for postoperative care, they have a cardiologist, surgeon, and anesthesiologist surveilling using AI technology to make sure that everybody's doing well. And, Matt and I've talked about this in the past, right? You know, anesthesiology, we've, we've staked our claim on patient safety 1.0. Right. But our job as a specialty, as professionals is to figure out what the next frontier is, right? If we're not looking over a cliff, then we are all not doing our jobs.

Desiree Chappell, CRNA, FAANA: Yeah. 100%. So, Mitch. I know that you haven't listened to TopMedTalk. I'm calling you out right now, buddy on that. Uh, if for the first one that you listen to and for people listening, one of the, one of my favorite podcasts that I've done in a very long time was with Kevin Fong. He's an anesthetist over in the UK.

 He's a flight nurse. The guy is actually incredible. He has an LBE from the Queen. So like, he's a big deal. He's also a podcaster and a voice on the BBC radio. So he has his own podcast. He's doing one right now. Honestly, this guy is like, cool, cool, cool, cool. But he did, he gave the Harold Griffith lecture at the World Congress of Anesthesiologists this year in Singapore.

 And we were able to grab him afterwards. He's actually a Fellow of Monty, of course, cause Monty has trained like some of the coolest people in the world. But Kevin, his presentation was something along the lines, like we're wrong about patient safety. And Mitch, it's to your point of like, we've been patient safety, like 1.0, but maybe we're not looking at this the right way. And again, please listen, cause Kevin does this much better and will talk about this much better than I. But, he talks about the fact that, there's a lot of comparisons with the flight industry, right, and with airline industry to the world of anesthesia and, and safety and how, you know, flights and the airlines have increased safety over the last 50 years by four orders of magnitude. And it's not because pilots are smarter or better at their job. It's because they have worked to improve the systems, the infrastructure of a very complex system. And that's what we can take away for team anesthesia.

It's not anesthesiologists, CRNAs and anesthesiologist assistants are getting smarter. We're doing a better job. Like our skills, our hands are better. It's because we are looking to integrate into more complex health systems and have technology, have processes in place that make it more safe. And I'd like to me when I was talking to him, I just, it was like I had an epiphany, about patient safety and how we're looking at it.

Because I will tell you, like when we go, when I have had conversations in hospitals with systems and with payers and things like that, I want to believe that everybody wants like high quality care and they like quality is the thing. Quality is not the thing. They need efficiency. But what they don't understand is when they talk about I need better efficiency and throughput through my OR.

Like I have these really complex patients and they're getting canceled all the time. Well, that's actually a quality thing and not necessarily just an efficiency thing. So they're, they don't understand that we can focus on quality and improve efficiancy for what they need and in the end, it's better processes in a very complex system.

And that's what patient safety is. I hope I'm making that connection clear. I know it's a little bit gray, but like, I feel like we have to look at patient safety quality in different ways. And look at more of the process and infrastructure, in these very complex models of healthcare to improve patient safety.

So, the other thing that Kevin said that really stuck with me is safety is not cheap, it's not where we cut, cut, cut, cut, cut. And you use the cheapest drug or the cheapest whatever tool. It's not that. It's looking at the system and figuring out what is it that we need to do this more safely.

And maybe it's an investment into that complex system or that technology that helps us do that. But in the end it is more cost effective and we have higher quality of care. Does that all that make sense?

Matt Sherrer, MD (Host): Yeah, there's a numerator and a denominator in that equation, right? It's, uh, it's not just one.

Mitchell Tsai, MD (Host): I, think you glanced upon this at the beginning of the podcast, Desiree, but you think about Alma Burdi over in Europe, and then you got Wyken Sutcliffe managing the unexpected here, right? It's the distinction between ultra safe organizations and high reliability organizations, right? And in level one trauma centers, what we do is high reliability organization. We try to make do, you know, last week we had a motor vehicle accident with four kids. And they all came here and you just make do. And at that point in time, when I was the clinical director, I actually just stopped three rooms.

I said, we're not moving forward till we figure out what we need to do next. Right. And in ultra safe industries, like the airline industry, they won't send a plane up if it's not safe. But on the flip side of that, they also understand that if they don't have a pilot to fly the plane, that's full of passengers, they're going to lose money, then. Right.

And so in the airline industry, there's, we don't see it, but there's backup pilots. If you're not feeling well as a pilot, you can say uncle, and another pilot will come in and fly your plane. And in healthcare, if an interventional radiologist calls out, right, everybody else picks up the workload and tries to finish it by the end of the day. And so that distinction, I think, is very, very important because in ultra safe organizations like aviation, you can halt production. We don't do that in healthcare, especially today.

Desiree Chappell, CRNA, FAANA: hmm. We'd never call an audible or a timeout, right? For like, hey, I mean, we do, but you know, in team anesthesia, like there are a lot of times where that's not always, that's not the cool thing to do. Like you said, we need to shut down three rooms. I'm sure people were not happy about that, but, that's kind of what we got to do.

I don't know, this, I, I really want to explore more. This is really where I'm hoping to go in the next couple years, exploring safety and how, what we need to do to translate into everyday practice and how we make that work as anesthesia, and not just safety. Like I'm more about how do we improve upon what we're doing because what we're doing is relatively safe.

I had a presentation or a plenary that I did again at the World Congress with all the tech industry leaders, so CMOs, COOs of the big ones that we all know in the anesthesia world. And said, my first question was like, you know, patients kind of feel like surgery should be safe, like it's safe.

Why do we continue to talk about patient safety? Like, is there something we're missing? Varied answers, you know, but what patients don't know is like the outcome piece of this. So do patients code on the table as much as they used to? No, that's great, but like that shouldn't be our bar.

Like our bar should be our patients getting back to their, their life, like it's called days at home, DAH, is a, perioperative outcome that Paul Miles and that team have been looking at and this is being one of the, it's becoming the quality indicator to patient's recovery at home.

So how many days do they get to be at home in those first 30 days versus being in a hospital or skilled nursing facility? We should be focused on what we're doing to make sure that our patients are at home, back or above baseline.

Matt Sherrer, MD (Host): Preach. This has been a show of soapboxes, man. This is about one soapbox after. It's

Desiree Chappell, CRNA, FAANA: awesome.

Like this is, anybody that knows me, it's, it's, I'm horrible. Like I just need to,

Matt Sherrer, MD (Host): No, it's been great.

Mitchell Tsai, MD (Host): title The podcast is going to be Soapbox Racers.

Desiree Chappell, CRNA, FAANA: The title. Yeah.

Matt Sherrer, MD (Host): So as we, as we kind of get to the end of our time here, you mentioned a few times technology, right? And you get to, you've been all over the world. Your podcast has 1500 episodes, almost 2 million downloads. I mean, it's insane. And it's because you've gone out there and you've traveled and you've been everywhere. You've seen a lot. What fires you up? What technology out there these days at these conferences just has you excited for the future?

Desiree Chappell, CRNA, FAANA: So that I'm most excited is to keep it simple. That's what I've been learning about. Is that bad? It's not necessarily technology. Although there is, so I have two things. One, is what I have really been taking away from a lot of the conversations that I've had in the last year or so, especially since COVID, I will say, is like really keeping it simple.

Like, you don't have to have a super, a million complex interventions to enhance recovery. You don't have to do the fanciest block with all the gear and all the, fanciest things, you know, really what do we do to standardize how we're taking care of patients? And this is like one of the things that I'm really exploring as well, is that we all know everyone that we, that takes care of patients in the, in our space of anesthesia and as surgeons, as nurses, whomever, take your pick of, of your provider, that there's the bell shaped curve of providers and the quality of care that they deliver.

It's just plain and simple. There has to be, right? We are not all in the middle. And so, though many of us believe that we're on the end of the curve, that we're all the top providers, somebody has to be at the end in the middle or on the other half. I'm kind of thinking about as I have these conversations learning about and getting excited about how do we lift up that other side of the curve?

Like how do we bring people where we're all giving a higher standard of care and delivering that? What I get excited about is technology that gets us there. I think ways that, can pick up on nuances of a patient before we see it with the human eye or we hear it with our, you know, whenever we hear a SAT or a, you know, blood pressure alarm or something like that.

I love that type of stuff because I think that has a huge opportunity to impact patient outcomes. I feel like as, as team anesthesia, we're we would call ourselves very proactive, right? Like 95 percent boredom. The reason that we're bored is because we're always thinking ahead, you know, the 5 percent terror is, when there's things that we can, you know, are kind of out of our control surgeon.

 But, the part to me that I get excited about is like, where can we infuse this technology that's coming down the pike, whether or not it's simple technology or a very complex, monitor or something like that, or a machine, like, how do we bring that and infuse that into our care to improve the care that we're all delivering across the board?

Because if we have these people who think they're great, but they actually are falling on the other end of the curve and they're not utilizing things to do it better, then I feel like we're all kind of losing there and the patient loses. So, the topic of AI, literally, I would say 80 percent of the conversations that I had at the ASA last year, I think we recorded 20 something plus pods and they all had conversations about AI and where we're going. And we actually had conversations with the guys from the innovations committees and things like that. I think there's a lot of hesitancy from anesthesia, but I think there's a lot of things that too that people are getting excited about and figuring out how we do it and how we use it. I think as long as we have an approach to utilizing these things in practice, I think we could, it's going to be great.

I mean, who in the heck knew that we would be using cell phones the way that we use them now? No one really predicted that. So thank you, Steve Jobs. Yeah. So, I mean, you know, we're here. And we have all these people saying, I don't want to use that new technology.

I don't want to use that new monitor. I don't like this anesthesia machine that does, I can dial in my end title CO2 and it's a closed loop and it does it all for me because I can do it better. Well, I don't know about you, but every single time I go to pick up my kids, at rush hour, or I'm going to the airport to catch a plane, I'm using Google Maps and I'm checking to make sure that they're, you know, what the anticipated traffic is, what the actual traffic is, and I'm always, I'm already utilizing this type of stuff in my everyday life.

And I would venture that a lot of people do, like even those guys and girls, I keep saying guys, I'm sorry. Even those clinicians that are the laggards on the other side that still want their fax machine or rotary phone, I guarantee they're still using Google maps whenever they go on their trips.

So, I think there's a place for it. I'm super excited about it. I really truly believe it's going to be safer for our patients. Some of this newer stuff, I think it is a bit of a black box and some of that we're going to have to accept. We're just going to have to say, like, I am not going to understand the algorithms that they, that these companies are using to develop this technology.

I'm okay with that. Does it work? Does it impact patient outcomes? Is it safe? You know, that's where we're going to have to go. So a couple of the other things, there's some different concepts that I've heard recently that I want to learn more about as well and excited about taking our practice to the next level. I was just at SOAP, the Society for Obstetric Anesthesia and Perinatology. And this is a space I've never been in.

I have never done obstetrics in my career, just when I trained. But recently one of our, well, a lot of our sites within Northstar, but one of our sites is has now, added a service line with high risk OB. So I was really excited to go to this meeting. And you know what, I was thinking, Oh, I'm going to learn about, you know, all these different things with like, better control of hemodynamics and, how do we, you know, difficult airway stuff and all these great things.

The biggest concept that I came away with that I think is most transferable to team anesthesia and how we do care better was trauma informed care. I learned about this and I was like, we've all taken care of these patients that are freaking out before they have surgery or when you have an obstetric patient and you've had to rush them to C section and because they feel like they're strapped down, they're having an anxiety attack and we think we know what that's all about and they need to calm down and here's some meds to help you calm down.

Oh my gosh, when I started learning more about this, I'm like, this is so transferable to a lot of our patients. So, in the vein of what gets me excited because I hear all of these things, some of it's not like the latest and greatest shiny toy. Some of it is. Some of it is like the simpler things and learning how we take care of our patients in a more informed way and in a way that's is better for them.

Mitchell Tsai, MD (Host): Matt, Desiree, changed my mind. The title of the podcast is going to be The Meta in Metacognition. So, you know, you talk about the UK side and what you said, Desiree, I think of Rose. He wrote The End of Average, right, and how the average is basically useless because you got people above and people below, right?

How do you get everybody to that top eschelon? And, you know, Albert Einstein did say make things as simple as possible, not simpler. And I think anesthesia has an opportunity to lead here. Because, you know, when you think about the EHR and the contrast versus the anesthesia information management systems, I remember doing cardiac cases on paper, right? You didn't document anything until you got on bypass and then you shoved everything on the paper and then you flew off. But the, the, the AIM system actually offloaded us as providers and gave us our cognitive bandwidth back to focus on the stuff that we needed to focus on. And if you really believe Wright from Princeton, who wrote Non Zero, right, the efficancy of information transfer is the basis of human civilization.

So, so how do we get smarter and how do we get better? Are we going to make fun of Irving?

Desiree Chappell, CRNA, FAANA: Oh my God. Dr. Irving, I love you.

Matt Sherrer, MD (Host): Love Irving too. Irving's a great guy.

Desiree Chappell, CRNA, FAANA: He's a good guy. I know you guys have some history.

Matt Sherrer, MD (Host): Love the guy. Irving's fantastic. No, I will not make fun of him on here. I love Irving and uh, please tell him hi, from both, uh, Mitch and from me. So.

Desiree Chappell, CRNA, FAANA: Of course. And Dr. Lemley and Dr. Mythan and the whole teams. Yeah, absolutely. Yeah.

Matt Sherrer, MD (Host): Well Desiree, I had a feeling this was going to be a blast and it was. Uh, this was, uh, this was incredibly fun. So thank you so much for doing this. We appreciate your, your time and your thoughts.

Desiree Chappell, CRNA, FAANA: Yeah, absolutely. Well, you know, we all love a little bit of self deprecating humor. So, I understand if you totally have to cut it because I'm a wordy little thing. So, it's, it's been fun again. That's why, that's why I told you I love, I love asking the questions. So then I don't talk, I don't take, take the stage.

I like to hear what other people say. So, I just appreciate you guys having me on here, first CRNA. I think that's really cool. Thank you guys for broaching into new, new territory and carving out a path for all of us to have a voice. I think it's super important. I love the work you guys are doing and keep on you know rocking on because it's, it's cool stuff.

Matt Sherrer, MD (Host): Desiree, thanks again. And thank you guys for tuning in to this episode of the Fresh Flow podcast. We'll see you on the next one.