|Exam Name||:||Communication Server (CS) Rls. 4.0 Database Administrator|
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|Updated On||:||February 21, 2019|
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920-324 exam Dumps Source : Communication Server (CS) Rls. 4.0 Database Administrator
Test Code : 920-324
Test Name : Communication Server (CS) Rls. 4.0 Database Administrator
Vendor Name : Nortel
Q&A : 58 Real Questions
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LAS VEGAS — June sixteen, 2008 — today at NXTcomm08, Microsoft Corp. and Nortel announced a totally hosted provider solution that grants a unified communications journey to small and midsize companies (SMBs), extending benefits prior to now attainable simplest to gigantic agencies. The hosted answer is in response to the Nortel Communications Server 2000 (CS 2000), a web Protocol multimedia softswitch, and the Microsoft answer for Hosted Messaging and Collaboration version four.5 (HMC 4.5), which contains hosted models of Microsoft office Communications Server 2007 and Microsoft alternate Server 2007. Nortel is providing the primary integration with HMC four.5 to assist control actual-time communications and convey a unified messaging adventure. in addition, to support carriers simplify and speed up deployment, Nortel’s global features portfolio gives a comprehensive suite of integration and conclusion-person functions to comprehensive the end-to-end answer.
via combining the service-grade CS 2000 with HMC four.5, service providers can offer SMBs new, potent unified communications that mix precise-time communications, reminiscent of voice, with Microsoft’s collaboration features, equivalent to click on-to-name, click on-to-conference, missed call electronic mail messages, mobility and telephony presence. These features all work seamlessly with the Microsoft office portfolio and the Microsoft office Communicator client to bring a unique experience to the end user. This new solution additionally makes it possible for SMBs to improvement from unified communications with no need to buy, set up, manipulate and retain additional network infrastructure and sophisticated in-condo techniques, enabling them to retailer operational charges and raise productivity.
“Unified communications is a strategic purchase that, up until nowadays, has been leveraged basically by using the tremendous business,” spoke of Ruchi Prasad, vice chairman and regular supervisor of the innovative Communications Alliance at Nortel. “This better joint Microsoft and Nortel solution makes unified communications attainable to groups of all sizes. For carrier providers, this solution presents new salary opportunities and the ability to expand their addressable market and carry better-value application and service bundles to their valued clientele.”
“we're presently seeing powerful activity within the hosted unified communications answer among our provider issuer valued clientele,” observed Steve Zimba, managing director, international Telecom business, Microsoft. “The entirely hosted unified communications solution offers alternatives for expanded profits and helps provider providers convey the linked work vogue to SMBs, proposing the means to speak almost each time, any place and on any gadget.”
At NXTcomm08, Microsoft and Nortel will exhibit the hosted unified communications answer and display its price in bettering business agility. NXTcomm08 attendees can attain additional info by using journeying the Microsoft booths SL5916 and SL5923 and the Nortel booth SL3516. more information will also be found at http://www.microsoft.com/serviceproviders/nxtcomm08.
Nortel is a recognized leader in supplying communications capabilities that make the promise of company Made elementary a truth for our valued clientele. Our next-generation applied sciences, for both service issuer and commercial enterprise networks, guide multimedia and business-important purposes. Nortel’s applied sciences are designed to assist dispose of nowadays’s limitations to efficiency, pace and efficiency through simplifying networks and connecting americans to the suggestions they want, once they need it. Nortel does business in additional than one hundred fifty international locations all over the world. For extra assistance, consult with Nortel on the net at www.nortel.com. For the newest Nortel news, discuss with www.nortel.com/information.
founded in 1975, Microsoft (Nasdaq “MSFT”) is the international chief in software, services and options that support people and companies know their full talents.
note to editors: in case you are interested in viewing more information on Microsoft, please visit the Microsoft net web page at http://www.microsoft.com/presspass on Microsoft’s corporate information pages. net links, cell numbers and titles had been correct at time of publication, but can also on the grounds that have changed. For further guidance, journalists and analysts may additionally contact Microsoft’s speedy Response group or different appropriate contacts listed at http://www.microsoft.com/presspass/contactpr.mspx.
Communications technology issuer, Nortel, has announced the Nortel communique Server 1500 (CS 1500), a second era VoIP softswitch as a way to enable small and medium-sized wireline service suppliers to satisfy transforming into subscriber demand for native and lengthy-distance voice and next generation features.
The CS 1500 core manage, gateways and operations, administration and renovation interfaces are all housed in a single chassis answer. carrier providers can install the swap for end-office (class 5) and access Tandem (category four) purposes to change an existing switch or as an addition to the community.
The enjoyable thing concerning the VoIP softswitch is that it permits carrier suppliers to leverage their latest funding and infrastructure via providing compatibility with legacy networks. The change presents full latitude of legacy community interfaces and regulatory necessities, including E-911 and CALEA.
Making the announcement, Alan Stoddard, GM, service Multimedia Networks, Nortel noted, “Nortel is leveraging its VoIP leadership to help carrier suppliers seamlessly evolve their networks to a brand new economical packet infrastructure in a position to supplying the advanced communications functions, subscribers are disturbing.”
The product is complemented through a suite of Nortel global capabilities for CS 1500 to help the complete community lifecycle, together with engineering and setting up, security assessment, integration and acceptance, assisted on-web page or far flung community operations, and on-going renovation.
in keeping with Bettina Tratz-Ryan, research Director, Gartner, “VoIP is an expected and virtually required development of all communique networks, and the focal point is on now not best how to make it fit within an evolving network and repair atmosphere, but also how to make it ecocnomic. To this end, carrier providers are turning to softswitch architecture emigrate their networks to IP and carry scalable, multimedia functions to end users that generate new revenues from day one.”
The CS 1500 is scheduled for container trials beginning fourth quarter 2006 and time-honored availability in chosen global markets throughout the primary quarter of 2007.
NYSE : NTTSX : NT
March 05, 2007 09:02 ET
CEO Mike Zafirovski Outlines Nortel UC vision at VoiceCon 2007
ORLANDO, FLORIDA--(CCNMatthews - March 5, 2007) - At VoiceCon Spring 2007 this week, Nortel(1) (TSX:NT)(NYSE:NT) is outlining its vision for unified communications (UC) and unveiling new options designed to supply agencies with essential and official the right way to carry voice, video and records over IP and permit superior unified communications.
Nortel President and CEO Mike Zafirovski could be a keynote speaker on Tuesday, and will focus on how unified communications options and converged purposes are poised to transform enterprise communications.
"Unified communications essentially changes the style corporations speak, simplifying the deluge of communications with a single, seamless interface," observed Zafirovski. "Nortel and our companions are working to create a UC experience that makes people more productive and responsive, with a wealthy communications event within the office or on the go."
Nortel's unified communications imaginative and prescient focuses on featuring options that align to the enterprise atmosphere the business uses these days. These solutions permit clients to event streamlined communications within their business application whereas leveraging their current IT investments - really UC your means.
As a part of its expanding unified communications portfolio, Nortel is introducing a number of new solutions that deliver a richer set of UC equipment whereas making certain the resiliency of the communications community.
Nortel's cornerstone IP Telephony solution, the verbal exchange Server (CS) 1000 will bring new capabilities and enhancements to extra improve this main VoIP platform. a new liberate of CS 1000 will deliver more suitable reliability and redundancy, improved network and voice name safety and new E911 capabilities, all aimed toward making certain organizations can depend on their network for crucial communications needs. through planned interoperability with Microsoft workplace Communications Server 2007, this new release will deliver unified communications capabilities as a part of the creative Communications Alliance roadmap.
the brand new CS a thousand architecture will extend its guide for open requisites, with help for an open working equipment and start on business off-the-shelf (COTS) hardware from IBM and other suppliers, to improve deployment flexibility and manageability of the community. big simplification of the portfolio features and pricing bundles will make it less difficult for partners and resellers to quote and promote. This new free up is deliberate for availability in 2Q07.
additionally nowadays Nortel announced the universal availability of a brand new unencumber of the award-profitable Multimedia conversation Server (MCS) 5100. This new release improves productivity by means of featuring clients with tight integration of telephony and multimedia applications within IBM Lotus Notes. It also features a couple of colossal enhancements, including greater and simplified collaboration capabilities that allow a full range of voice, video, conferencing, email, IM and presence capabilities at the click of a mouse, along with more desirable mobility capabilities that deliver a rich communications experience for cell worker's. the brand new MCS 5100 free up also introduces aid for brand new SIP-primarily based IP telephones improving usability and suppleness and improves the overall protection, reliability, manageability and scalability of the core platform, which now operates on IBM servers with a Linux working gadget.
Nortel is also introducing Unified Messaging (UM) 2000, a function-prosperous, provider-grade answer supporting up to a million clients that allows for voicemail, fax and electronic mail to be accessed together through normal electronic mail functions and integrates with Microsoft's active listing®. UM 2000 is necessities-based so that it could operate in a multivendor voice community, and is focused to international organisations as well as carriers that offer their customers unified messaging options.
To help enterprises installation UC-optimized networks, Nortel is additionally unveiling converged records networking enhancements to its North American advertising campaigns, which build on the a hit IPT 1-2-three campaign launched remaining yr. These crusade enhancements consist of associate equipment, concentrated demand era activities, pre-engineered information programs, and non-compulsory features that make it simpler and more low cost for approved channel companions to install a LAN that supports clients' VoIP and UC wants.
These information packages and functions can be quoted starting in April 2007 and include alternatives to enable the entire deployment of vigor over Ethernet, VoIP-Optimized at ease Routing for WAN entry, and WLAN for mobility and not obligatory renovation, setting up and technical support functions. Nortel's North American campaign also contains promotion and incentive courses purchasable nowadays through approved Nortel channel partners for firms who are customizing their community for unified communications.
Nortel is a identified chief in delivering communications capabilities that make the promise of company Made elementary a truth for our valued clientele. Our subsequent-generation applied sciences, for each provider company and commercial enterprise networks, aid multimedia and company-vital purposes. Nortel's technologies are designed to support get rid of cutting-edge boundaries to efficiency, velocity and efficiency by using simplifying networks and connecting americans to the advice they need, once they need it. Nortel does business in additional than one hundred fifty international locations everywhere. For extra counsel, talk over with Nortel on the internet at www.nortel.com. For the newest Nortel news, seek advice from www.nortel.com/information.
certain statements during this press unencumber can also include words corresponding to "might", "expects", "may additionally", "anticipates", "believes", "intends", "estimates", "pursuits", "envisions", "seeks" and other equivalent language and are considered forward-looking statements or guidance under relevant securities legislations. These statements are in keeping with Nortel's current expectations, estimates, forecasts and projections about the working environment, economies and markets wherein Nortel operates. These statements are area to essential assumptions, dangers and uncertainties, which can be intricate to foretell and the precise effect could be materially distinctive. additional, actual outcomes or routine might differ materially from those reflected in forward-looking statements because of right here(i) hazards and uncertainties regarding Nortel's restatements and related concerns including: Nortel's most contemporary restatement and two previous restatements of its fiscal statements and related hobbies; the poor affect on Nortel and NNL of their most fresh restatement and lengthen in submitting their monetary statements and linked periodic reviews; legal judgments, fines, penalties or settlements, or any gigantic regulatory fines or different penalties or sanctions, related to the continuing regulatory and crook investigations of Nortel within the U.S. and Canada; any giant pending civil litigation movements now not encompassed by way of Nortel's proposed category motion contract; any tremendous cash price and/or big dilution of Nortel's current equity positions as a consequence of the approval of its proposed category action contract; any unsuccessful remediation of Nortel's fabric weaknesses in internal handle over monetary reporting leading to an lack of ability to file Nortel's results of operations and monetary circumstance accurately and in a timely manner; the time required to implement Nortel's remedial measures; Nortel's lack of ability to entry, in its latest kind, its shelf registration filed with the USA Securities and trade commission (SEC), and Nortel's below funding grade credit rating and any additional opposed impact on its credit rating due to Nortel's restatements of its economic statements; any hostile have an effect on on Nortel's enterprise and market fee of its publicly traded securities arising from carrying on with terrible publicity related to Nortel's restatements; Nortel's abilities inability to attract or continue the personnel integral to obtain its company pursuits; any breach through Nortel of the continued listing requirements of the NYSE or TSX inflicting the NYSE and/or the TSX to commence suspension or delisting approaches;(ii) hazards and uncertainties regarding Nortel's enterprise including: each year and quarterly fluctuations of Nortel's working consequences; decreased demand and pricing pressures for its items because of international economic situations, significant competition, aggressive pricing practice, cautious capital spending with the aid of consumers, improved industry consolidation, swiftly altering technologies, evolving industry standards, normal new product introductions and brief product life cycles, and different trends and industry characteristics affecting the telecommunications business; the sufficiency of recently announced restructuring movements, together with the potential for greater actual expenses to be incurred in reference to these restructuring movements compared to the estimated fees of such movements and the skill to obtain the centered charge rate reductions and discounts of Nortel's unfunded pension legal responsibility deficit; any fabric and adverse impacts on Nortel's efficiency if its expectations involving market demand for particular products show to be incorrect or because of certain limitations in its efforts to extend internationally; any reduction in Nortel's working effects and any linked volatility out there expense of its publicly traded securities arising from any decline in its gross margin, or fluctuations in foreign currency trade rates; any negative developments linked to Nortel's provide contract and contract manufacturing agreements together with as a result of the usage of a sole service provider for key optical networking solutions accessories, and any defects or errors in Nortel's present or deliberate items; any negative affect to Nortel of its failure to obtain its company transformation goal; extra valuation allowances for all or a portion of its deferred tax property; Nortel's failure to give protection to its intellectual property rights, or any adversarial judgments or settlements arising out of disputes involving intellectual property; adjustments in law of the cyber web and/or different facets of the industry; Nortel's failure to effectively function or combine its strategic acquisitions, or failure to consummate or be triumphant with its strategic alliances; any negative impact of Nortel's failure to evolve accurately its economic and managerial manage and reporting programs and methods, control and develop its company, or create a superb possibility administration approach; and(iii) hazards and uncertainties concerning Nortel's liquidity, financing preparations and capital including: the have an effect on of Nortel's most fresh restatement and two outdated restatements of its financial statements; any inability of Nortel to manipulate cash movement fluctuations to fund working capital necessities or obtain its business targets in a well timed manner or reap additional sources of funding; excessive stages of debt, boundaries on Nortel capitalizing on enterprise opportunities on account of aid facility covenants, or on acquiring further secured debt pursuant to the provisions of indentures governing certain of Nortel's public debt considerations and the provisions of its help facility; any increase of limited cash requirements for Nortel whether it is unable to comfortable alternative guide for obligations arising from definite general route business actions, or any inability of Nortel's subsidiaries to give it with ample funding; any negative effect to Nortel of the need to make bigger described advantage plans contributions in the future or publicity to client credit score dangers or inability of shoppers to satisfy fee obligations beneath consumer financing preparations; any poor have an effect on on Nortel's capacity to make future acquisitions, raise capital, subject debt and continue employees coming up from stock rate volatility and further declines in the market cost of Nortel's publicly traded securities, or the proportion consolidation leading to a lessen total market capitalization or adverse effect on the liquidity of Nortel's usual shares. For additional info with respect to certain of these and different elements, see Nortel's Annual record on Form10-okay/A, Quarterly experiences on kind 10-Q and other securities filings with the SEC. except otherwise required with the aid of applicable securities legal guidelines, Nortel disclaims any intention or duty to update or revise any ahead-looking statements, even if as a result of new information, future movements or in any other case.
(1)Nortel, the Nortel brand and the Globemark are logos of Nortel Networks.
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The purpose of the Society of Anesthesia and Sleep Medicine (SASM) Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea (OSA) is to present recommendations based on the available scientific evidence. In light of a paucity of well-designed, high-quality studies in this perioperative field, a large part of the present recommendations was developed by experts in the field taking into account published evidence in the literature and utilizing consensus processes, including the grading of the level of evidence. At times, when specific information on patients with OSA was not available in the literature, evidence in highly correlated patient populations, specifically those with obesity, was considered if appropriate. When this was the case, it is explicitly stated in various parts of this document.
The guideline presented may not be suitable for all clinical settings and patients. Thus, its consideration requires an assessment of appropriateness by clinicians on an individualized basis. Among many factors, the existence of institutional protocols, individual patient-related conditions, the invasiveness of an intervention, and the availability of resources need to be considered. The present practice guideline is not intended to define standards or represent absolute requirements for patient care. Adherence to this guideline cannot guarantee successful outcomes but rather should aid health care professionals and institutions to formulate plans for improved management of patients with OSA. The present recommendations reflect the current state of knowledge and its interpretation by a group of experts in the field at the time of publication. Periodic reevaluations of the literature will be needed, and novel scientific evidence should be considered between updates. Deviations from this guideline in the practical setting may be justifiable, and such deviations should not be interpreted as a basis for negligence claims.
OSA is a common and frequently undiagnosed disorder defined by the repeated collapse of the upper airway with resultant blood oxygen desaturation events during sleep.1,2 OSA has been associated with adverse long-term health outcomes and has been linked to increased perioperative complication risk.3–5 Indeed, a comprehensive review of the literature performed by a task force appointed by SASM revealed substantial risk for adverse events, especially pulmonary complications, to be associated with OSA in the perioperative period.6 Based on the elevated risk for perioperative complications, the recently published SASM Guideline on Preoperative Screening and Assessment of Adults With Obstructive Sleep Apnea recommends that attempts should be made to appropriately identify patients with OSA, with the goal to raise awareness among providers, mitigate risk, and improve outcomes.7 While recommendations for preoperative screening and assessment of patients with OSA and their optimal preparation for surgery are now available, there is a paucity of evidence-based guidance for the intraoperative management of this patient population. Thus, there remains a lack of evidence-based practice recommendations regarding techniques for airway management, selection of anesthetic agents, and drugs, as well as choice of anesthetic technique.
This document is derived from results of an extensive consensus process based on a systematic literature search, review, and analysis performed by experts in the field. It is a follow-up to the previously published SASM Guideline on Preoperative Screening and Assessment of Adult Patients With Obstructive Sleep Apnea.7 Given the large amount of related literature in this arena, this study focuses only on intraoperative patient care. Postoperative care issues are not considered and may be the subject of future projects.What Other Guidelines and Reviews Are Available?
Previous OSA-related practice guidelines8–12 have been published by the American Society of Anesthesiologists,8,9 the Society for Ambulatory Anesthesia,10 the American Academy of Sleep Medicine,11 the SASM,7 the International Bariatric Consensus Guideline Group,13 and the task force on best practice recommendations for the anesthetic perioperative care and pain management in weight loss surgery.14Why Was This Guideline Developed and How Does It Differ From Existing Guidelines?
This guideline was developed to provide evidence-based recommendations for the intraoperative management of patients with OSA. Therefore, a careful examination of the current literature using a systematic review approach with a focus on airway management, commonly used anesthesia-related drugs and agents, and anesthetic techniques in this patient population was conducted. The task force recognizes that there has been recent progress in attempts to subcategorize patients with OSA according to anatomic predisposition, arousal thresholds, muscle responsiveness, and ventilatory control characteristics.15 However, given the lack of evidence in this context, statements were made referring to patients with OSA as a general group. Nevertheless, phenotypic subcategorization may allow the development of individual risk profiling in the future.Aims
The aim of this guideline was to present recommendations based on the best current evidence. Clinical research as it relates to best perioperative practices in OSA is burdened by numerous difficulties. The intraoperative setting involves a multitude of concurrent interventions and use of anesthetic medications, making it difficult to single out specific factors that potentially drive the adverse outcome. Lack of preoperative polysomnography data within publications represents a further challenge, making it difficult to include information of the impact of disease severity. Ethical considerations in study designs regarding the randomization of patients with known OSA were additional obstacles in this context. Furthermore, the task force recognizes that there is a tendency to underreport medical complications, rendering it difficult to establish the true perioperative risk.16 Presenting the current available evidence and its limitations should raise awareness regarding the need for high-quality studies in the future.
Specific aims were to: (1) evaluate considerations of difficult airway management in patients with OSA, (2) assess the impact of individual anesthesia-related drugs and agents in the care of patients with OSA, and (3) evaluate best anesthetic techniques in this patient population. To achieve these aims, a question-driven approach was sought.
In areas lacking sufficient published evidence, the task force sought to establish expert consensus while considering related literature. Patients affected by sleep-disordered breathing unrelated to OSA, including hypoventilation syndromes, periodic breathing, and central apnea unrelated to OSA, were not considered in this project. This decision was made a priori to reduce the influence of heterogeneity in our assessment given the lack of evidence on which to base recommendations for these specific populations.GUIDELINE TASK FORCE
The task force was comprised of 14 members of SASM, an international society devoted to advancing the care for clinical problems shared by anesthesiology and sleep medicine clinicians. Given that this project included only intraoperative aspects, the task force included 12 anesthesiologists and 2 anesthesiology research fellows. Members of the task force share expertise on the topic of sleep-disordered breathing in the perioperative setting and included practitioners from both academic and nonacademic settings from various parts of the United States, Canada, and Europe.METHODS Research Questions
A systematic review of the literature addressing the intraoperative management of patients with OSA was conducted after search terms were developed by the task force. Three groups were established, each focusing on one of the focus areas (Table 1). Group 1 investigated whether patients with OSA are at increased risk for difficult airway management. Group 2 investigated the impact of various anesthesia-related drugs and agents used in the intraoperative care of patients with OSA. Group 3 evaluated the effect of anesthesia technique in patients with OSA. Leaders and group members are listed in the acknowledgments section of the article.Literature Search Strategy
With the help of a research librarian, a literature search was performed for each group, including publications from 1946 to September 2016. Databases searched included (1) Medline, (2) ePub Ahead of Print/Medline In-process, (3) Embase, (4) Cochrane Central Register of Controlled Trials, (5) Cochrane Database of Systematic Reviews, (6) PubMed-NOT-Medline, and (7) ClinicalTrials.Gov. The search focused on studies of adult individuals (≥18 years of age) and published in English. Continued literature surveillance was done through January 2018.Excerpt of the Controlled Vocabulary Terms and Key Words Included in the Systematic Search.
Group 1: “sleep apnea, obstructive,” “obstructive sleep apnea,” “obstructive sleep apnea syndrome,” “sleep disordered breathing,” “obesity hypoventilation syndrome,” “apnoea or apnea,” “hypopnoea or hypopnea,” “airway,” “intubation,” “extubation,” “airway management,” “airway obstruction,” “airway extubation,” “intubation, intratracheal,” “intubation.mp,” “laryngeal masks,” “respiration, artificial,” “positive pressure respiration,” “respiratory mechanics,” “continuous positive airway pressure,” “supine position,” “apap.mp,” “bipap.mp,” “cpap.mp,” “facemask,” “ventilat.mp,” “patient positioning,” “difficult mask ventilation,” “supraglottic airway devices,” and “surgical airway.”
Group 2: “sleep apnea, obstructive,” “obstructive sleep apnea,” “obstructive sleep apnea syndrome,” “sleep disordered breathing,” “obesity hypoventilation syndrome,” “apnoea or apnea,” “hypopnoea or hypopnea,” “postoperative period,” “complications or outcome,” “perioperative care,” “perioperative complications,” “intraoperative complications,” “postoperative complications,” “outcome,” “risk,” “morbidity,” “mortality and death,” “anesthesia,” “anesthetics,” “anesthetics, intravenous,” “inhalational anesthesia,” “volatile anesthesia,” “anesthetics local,” “analgesia, opioid,” “hypnotics and sedatives,” “adverse effects,” “intravenous regional anesthesia,” “sedation,” “sedatives,” “short acting,” “nonsteroid of nonsteroid or nasaids,” “opioid,” “complication,” “muscle relaxant,” “rocuronium, atracurium,” “cis-atracurium,” “vecuronium,” “mivacurium,” “suxamethonium or succinylcholine,” “rapacuronium,” “pancuronium,” “skeletal muscle relaxant,” “neuromuscular reversal agents,” “sugammadex,” “residual neuromuscular block,” “drug effects,” “adverse effects,” “adverse drug reactions,” “abnormalities drug induced,” “adverse drug events,” “adverse drug reactions reporting systems,” “morbidity,” and “mortality.”
Group 3: “sleep apnea, obstructive,” “obstructive sleep apnea,” “obstructive sleep apnea syndrome,” “sleep disordered breathing,” “obesity hypoventilation syndrome,” “apnoea or apnea,” “hypopnoea or hypopnea,” “postoperative period,” “complications or outcome,” “perioperative care,” “perioperative complications,” “intraoperative complications,” “postoperative complications,” “outcome,” “risk,” “morbidity,” “mortality and death,” “anesthesia, epidural,” “anesthesia, spinal,” “anesthesia, general,” “major conduction anesthesia,” “treatment outcome,” “treatment failure,” “mortality,” “outcome,” “peripheral nerve blocks,” “nerve blocks,” “anesthesia regional,” “anesthesia technique,” “sedation,” “sedative medication,” “deep sedation,” “secure airway,” “airway,” “multimodal analgesia,” “balanced anesthesia,” “opioid sparing,” and “opioids.”
Full search strategies in Medline for all groups are reported in the Supplemental Digital Content 1, SASM Guideline Intraoperative OSA Appendix, http://links.lww.com/AA/C373; Supplemental Digital Content 2, Search Anesthesia Technique, http://links.lww.com/AA/C374; Supplemental Digital Content 3, Search Difficult Airway and OSA, http://links.lww.com/AA/C375; Supplemental Digital Content 4, Search Intraoperative Medication Use in Patients With OSA, http://links.lww.com/AA/C376; Supplemental Digital Content 5, Search Strategy NMBA, http://links.lww.com/AA/C377.
Furthermore, detailed reviews addressing difficult airway, anesthesia-related drugs and agents, specifically those involving neuromuscular blocking agents (NMBAs) and opioids, were conducted and summarized in separate systematic reviews by the respective SASM focus groups (members listed in the acknowledgments) to share the evidence gathered and expand the scope of the present guideline.Study Selection
In the respective groups, ≥2 reviewers assessed titles and abstracts for eligibility by using the standardized format of the Covidence platform.17 This step was followed by a full-text review and data extraction. Furthermore, a citation search by a manual review of references from primary or review articles was performed to compile additional relevant results. Any disagreements were resolved by consensus among reviewers or by consulting with the respective SASM groups via face-to-face meetings, teleconferences, or email communications. Study designs considered included randomized controlled trials (RCTs), prospective and retrospective observational studies, case series, systematic reviews, and meta-analyses. Within this literature, the presence or risk for OSA was based on polysomnography, screening questionnaires, clinical assessment, chart diagnosis, medical history, or International Classification of Diseases (ICD)-9 codes from administrative or billing records, while studies reported on at least 1 outcome of interest. Existing guidelines were cross-checked for completeness of references.
Data extracted from these studies included type of study, demographic data, comorbidities, procedure type, anesthesia-related interventions and medications, adverse events, as well as other clinically important outcomes and effects.Exclusion Criteria.
Exclusion criteria were: nonhuman studies, non-English language, review articles, single case reports, studies reporting on the chronic use of medications commonly used intraoperatively such as chronic opioid medication, and studies without outcome reporting. For group 3, studies not directly comparing anesthesia modalities were also excluded.Level of Evidence and Recommendations
The Oxford Level of Evidence (Oxford LOE) tool was utilized to evaluate the quality of evidence of individual studies.18 Grading the strength of recommendations and quality of the underlying evidence enhances the usefulness of clinical practice guidelines.19 Therefore, the approach according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system20,21 was utilized with regard to the body of evidence and the development of guideline recommendations.22 As specified by GRADE, the quality of evidence is classified into high, moderate, low, and very low levels, according to factors that include study methodology, consistency and precision of results, and directness of evidence.19 These levels were assigned to the body of evidence of each respective recommendation within their focus area and reflect the confidence in estimates of the true effect.21 When moving from evidence to recommendations, the GRADE approach focuses on 4 factors: balance between benefit and harm, certainty of evidence, values and preferences, and resource considerations.22 The strength of recommendation is separated into strong and weak and defines the extent to which one can be confident that the desirable consequences outweigh its undesirable consequences (Table 2).23
In-person SASM Intraoperative Guideline Task Force meetings took place at special sessions during the SASM annual meetings in Chicago, IL (2016), and Boston, MA (2017), as well as the International Anesthesia Research Society annual meeting in Washington, DC (2017). Furthermore, multiple teleconferences and electronic communications took place throughout this time period. Preliminary results and implications of findings were presented and discussed at the 2017 SASM annual meeting in Boston, MA.1. DIFFICULT AIRWAY AND OSA
Level of evidence: Moderate; Grade of recommendation: StrongRationale
The perception of OSA as an important risk factor for difficult airway management is widely held among anesthesiologists and intensive care physicians. In the absence of RCTs, several prospective and retrospective controlled studies have supported this assumption.24–39Association Between OSA and Difficult Airway Management
After applying the designated search strategy and removing duplicates, 4806 references were screened for title and/or abstract. After reviewing 25 full-text articles, 16 studies were identified as reporting on the association between difficult airway management and OSA, while 9 studies were excluded.40–47 A detailed summary of associations between OSA and various difficult airway management components is provided in Supplemental Digital Content, Table A1, http://links.lww.com/AA/C373.
Among the included studies, 5 were retrospective24,25,27,35,36 and 11 were prospective controlled studies.26,28–34,37–39 Ten studies confirmed OSA by overnight polysomnography24,25,27,29,35 or electronic database entries,28,30,31,34,37 3 used the STOP-Bang screening questionnaire,33,38,39 2 identified patients by clinical diagnosis,26,36 and 1 used both polysomnography and the STOP-Bang questionnaire.32
In total, 266,603 patients were included in 16 studies. Of those patients, 32,052 had OSA (identified by polysomnography, electronic database, chart or clinical diagnoses, and STOP-Bang questionnaires) and 234,551 did not. In summary, 12 studies reported on difficult intubation,24–29,31–33,35,38,39 6 on difficult mask ventilation,28,30,31,36,38,39 2 on both difficult intubation and mask ventilation,28,37 and 2 on failed supraglottic airway.27,34 Several studies reported >1 difficult airway outcome. No study was available on the need for a surgical airway (Supplemental Digital Content, Table A1, http://links.lww.com/AA/C373).
Concerning difficult intubation and OSA, 7 of 12 studies showed positive associations.24,25,28,33,35,38,39 Of 6 studies, 5 demonstrated a significant impact of OSA on difficult mask ventilation.28,30,36,38,39 In the 2 studies that reported on combined difficult intubation and mask ventilation, both demonstrated a significant impact of OSA.28,37 Although 5 studies assessing difficult intubation26,27,29,31,32 and 1 study evaluating difficult mask ventilation31 did not find a significant association with OSA, the overall estimates showed a positive association between OSA and difficult airway. This finding suggests that patients with OSA are at increased risk of difficult airway management compared to patients without OSA. Detailed data, analysis, and results on the association between OSA and difficult airway will be reported in a separate systematic review with meta-analysis by the SASM airway focus group (members listed in acknowledgments).
One prospective controlled study34 reported on the use of the LMA Unique® (Teleflex Incorporated, Morrisville, NC), and an additional retrospective investigation27 reported on a separate unspecified supraglottic airway device. No significant association was found between OSA and failed supraglottic devices.Prevalence of OSA in Patients With Difficult Intubation
Two studies elucidated the association between OSA and difficult intubation in a reverse manner by investigating the rate of OSA among patients with difficult intubation. In a retrospective study, Hiremath et al,24 using an apnea-hypopnea index (AHI) ≥10 as a cutoff, found that 53% of patients with difficult airway had OSA. This finding was confirmed by a prospective controlled study by Chung et al.29 using an AHI ≥5 as a cutoff for OSA diagnosis. Patients who were determined to have a difficult airway were referred for polysomnography after surgery, and 66% were shown to have OSA.
Kim and Lee35 showed that patients with an AHI ≥40 had a significantly higher prevalence of difficult intubation. For patients with OSA with AHIs ≤40, 40–70, and ≥70, the incidence of difficult intubation was 3.3%, 19.3%, and 27.6%, respectively.35 Anatomical skeletal and soft tissue changes may contribute to a difficult airway in OSA. However, these observations are “hypothesis-generating” rather than “hypothesis-proving” findings. The shared anatomical abnormalities explain the positive association between difficult airway and OSA.
A number of studies evaluated the association of difficult airway management with OSA using the STOP-Bang questionnaire to identify patients at high risk of OSA.32,33,38,39 The sensitivity and specificity of the STOP-Bang questionnaire can vary according to the prevalence and severity of OSA.48 This variation can create false-positive and false-negative cases in both OSA and non-OSA groups, leading to potential misclassification bias.
One of the contributing factors for adverse respiratory events in patients with OSA is the increased risk of difficult airway management, such as difficult intubation, difficult mask ventilation, or both. In a recent report, there were 7 litigation cases where OSA was associated with either death or anoxic brain injury due to difficult airway management in the form of failure to reintubate in the postoperative period.49 Knowledge about the association between OSA and difficult airway may improve perioperative airway management and decrease airway-related complications.
In view of ethical considerations, it is difficult to perform RCTs in patients with OSA to determine its associations with difficult airway management. As a result, only observational prospective and retrospective studies are available in the literature. The end estimates of these studies indicate that there is an increased risk of difficult airway management in patients with OSA. Due to the large number of trials and large patient numbers, the overall quality of the body of evidence was considered to be moderate using the GRADE approach20,21 and the Oxford LOE.182. INTRAOPERATIVE MEDICATION USE IN PATIENTS WITH OSA
A large body of literature supports the notion that the effects of surgery and anesthesia pose unique hazards to patients with OSA.5,50,51 Anesthetic agents and analgesic drugs interact with consciousness, sleep, and ventilatory drive,52,53 and thus they deserve consideration when caring for patients with OSA. In addition, upper airway and pulmonary physiology, including upper airway dilator muscle activity, are impacted by pharmacological and mechanical elements (airway manipulation) of anesthesia with possible increased detriment in OSA.54–56 The following section discusses questions related to the effects of various agents and drugs commonly utilized intraoperatively in patients with OSA.2.1 Neuromuscular Blocking Agents
Level of evidence: Low; Grade of recommendation: Weak
Level of evidence: Low; Grade of recommendation: No recommendationRationale.
NMBAs are commonly used to optimize intubation conditions and provide surgical relaxation for various procedures. However, residual neuromuscular blockade has been reported to occur in ≤64% of patients in postanesthesia care units.57 The use of NMBAs and residual neuromuscular blockade has been associated with significant postoperative respiratory complications such as hypoxemia,58 upper airway obstruction,58 and pneumonia.59 High doses of NMBA given during abdominal surgery were associated with an increased risk of 30-day readmission, increased length of hospital stay, and increased hospital cost.60 A retrospective review of a single-center database showed that patients who required tracheal intubation within the first 3 days after surgery had a significantly higher frequency of NMBA administration and reversal with neostigmine.61 Residual neuromuscular blockade may persist despite the administration of neostigmine reversal, especially when neuromuscular monitoring is not utilized.62
It is unclear whether patients with OSA may be at higher risk for postoperative respiratory complications due to the adverse effects of postoperative residual neuromuscular blockade compared to patients without OSA. Moreover, it is uncertain whether the type of reversal agent impacts the risk of postoperative complications in patients with OSA. Patients with suspected61 or confirmed50,63,64 OSA have been shown to be at increased risk for early postoperative respiratory complications, including emergent intubation,63,64 mechanical ventilation,63,64 noninvasive ventilation,63,64 respiratory failure,50 desaturation,6,50 and pneumonia.64 The use of NMBA was not described in these studies.6,50,63,64 Many patients with OSA are obese and have anatomical risk factors that may increase vulnerability to the effects of residual neuromuscular blockade on the upper airway and pharyngeal function.
Our literature search yielded 5 studies that were heterogeneous in terms of study design, types of surgery, and types of respiratory complications.65–69 Many studies were excluded because OSA diagnosis or use of NMBA was not described.
One RCT11 and 2 observational studies66,67 were included to address the question of whether patients with OSA are at a higher risk for postoperative respiratory complications from the use of NMBA compared to patients without OSA. Although the level of evidence was limited (Oxford LOE 2–3), the studies suggest that patients with OSA who received NMBA may be at increased risk of effects of residual neuromuscular blockade, postoperative respiratory failure, and hypoxemia.65–67 The results of our review are consistent with previous studies showing that patients with OSA are at higher risk of postoperative respiratory failure and hypoxemia than patients without OSA.6,61,70,71 Even partial residual neuromuscular blockade that does not evoke respiratory symptoms can impair upper airway dilator muscle function.72 Minimizing the use and dose of NMBA, monitoring the level of neuromuscular blockade, and complete reversal of NMBA before extubation may be particularly important for patients with OSA.9
While not considering OSA status, reversal of NMBA with sugammadex, a cyclodextrin used to reverse rocuronium,73 has been shown to decrease the incidence of residual paralysis compared to the anticholinesterase inhibitor, neostigmine.74 A recent Cochrane review of 41 studies comparing sugammadex with neostigmine concluded that patients receiving sugammadex versus neostigmine had 40% fewer composite adverse events (bradycardia, postoperative nausea and vomiting, and residual neuromuscular blockade).75 Patients receiving sugammadex had less desaturation and need for transitory oxygen supplementation; however, the OSA status was not reported in these reviews, limiting its value to assess its differential effect in this subpopulation.74,75
There are limited studies comparing the impact of different neuromuscular blocking reversal agents on postoperative respiratory complications in patients with OSA. We identified 1 RCT68 and 1 observational study69 that compared sugammadex to neostigmine. In the 2 studies, 209 patients with OSA and 185 patients without OSA were included.68,69 The RCT (n = 74) found that patients receiving sugammadex versus neostigmine had less postoperative respiratory complications (desaturation, hypoxemia, apnea, airway manipulation, airway usage, reintubation, continuous positive airway pressure [CPAP] therapy, and invasive mechanical ventilation).68 There was no difference in airway obstruction. The observational study (n = 320) compared sugammadex to a historical cohort of patients who received neostigmine reversal for laparoscopic bariatric surgeries. Patients with OSA who received sugammadex versus neostigmine had less postoperative chest radiographic changes (atelectasis, pleural effusions), 6.9% vs 16.3% (odds ratio [OR], 0.36; 95% CI, 0.18–0.8),69 but there were no differences in postoperative mechanical ventilation or hospital length of stay. Although both studies showed a reduction in some postoperative respiratory complications, the evidence is limited because the number of patients included in the RCT (Oxford LOE: 2) was small,68 and the observational study (Oxford LOE: 3) reported no difference in clinical outcomes.69
Currently, there is insufficient evidence to recommend the use of sugammadex over neostigmine to reduce the risk of postoperative respiratory complications in patients with OSA. More trials with larger sample sizes are needed in this patient population.2.2 Opioids
Level of evidence: Low; Grade of recommendation: Weak
Level of evidence: Low; Grade of recommendation: WeakRationale.
While opioids are highly effective in treating moderate to severe pain, their intrinsic capacity to suppress ventilatory drive demands caution in OSA. Despite consensus among perioperative physicians to restrict or avoid opioids in OSA,9 the presence of robust, high-quality scientific evidence to demonstrate the merit of heightened concern and guide safe opioid practice in this population is limited.76
Nevertheless, despite limitations with respect to the quality of evidence suggesting an adverse impact of acute opioid administration in OSA, current literature indicates that a heightened concern regarding opioid use in this population may be justified. A summary of evidence is provided in Supplemental Digital Content, Table A2, http://links.lww.com/AA/C373.
Specifically, 17 observational studies exploring the impact of systemic opioid use in OSA were identified. While the majority demonstrated an association between opioid use and adverse perioperative outcomes in OSA,61,77–89 this was not confirmed by all.66,90,91 It should be noted that, particularly among observational analyses, there is notable heterogeneity with regard to the modality of OSA assessment, ranging from the gold standard of polysomnography to identification by screening questionnaires or patient history. Furthermore, potential selection bias should be considered in these studies. In recent publications, a comparison of postoperative complications among patients with and without OSA within the same study cohort revealed that the incidence of postoperative pulmonary (2.49% vs 1.83%), cardiac (2.81% vs 0.23%), gastrointestinal (0.45% vs 0.33%), renal (3.47% vs 1.83%), and thromboembolic (0.41% vs 0.33%) complications was higher in patients with OSA at similar opioid dose levels.88,92 Additional analysis of the impact of opioid dose increase within patients with OSA demonstrated an associated increase in the odds for gastrointestinal complications, prolonged length of stay, and increased hospital cost, while no further increase in risk for pulmonary complications was observed, possibly due to increased levels of monitoring afforded to this population.88 A higher incidence of postoperative complications in OSA versus non-OSA in this context was also found by Blake et al77 and Esclamado et al,80 while the latter conducted their study in upper airway surgery, a procedure with a potentially inherent influence on respiratory outcome.80
Chung et al79 demonstrated an opioid dose-dependent postoperative worsening of sleep-disordered breathing associated with the severity of OSA (expressed by AHI), although this effect may have been fairly small. Male patients with OSA had a significantly higher central apnea index on postoperative night 1 versus female patients with OSA. In this context, numerous other observational studies took a different approach by investigating the occurrence of critical, life-threatening respiratory events, such as respiratory failure and naloxone requirement and identifying drivers for these complications.61,81–84,86,87 Moreover, a recent systematic review reported that the majority of surgical patients with OSA experiencing perioperative death or near-death events received a morphine equivalent dose of <10 mg/d.89 Subramani et al89 suggested that a dose-response pattern with increased odds for complications at increasing opioid dose levels (ORs of 1.0, 1.5, and 3.0 at opioid doses of <10, 10–25, and >25 mg; P for trend <.005) exists.
In contrast, others66,85 who restricted their focus to patients with obesity, a population of high OSA prevalence,2 demonstrated that, although postoperative respiratory complications in the context of opioid analgesia were common, surprisingly, OSA could not be established as an independent risk factor.66,85 However, a factor potentially causing an underestimation of a possible deleterious effect of OSA was the postoperative use of positive airway pressure therapy among patients with OSA.85 Moreover, a proof of concept analysis by Wang et al91 suggested that the experimental oral administration of 30 mg controlled-release morphine in 10 volunteers outside the surgical setting paradoxically improved oxygenation through modulating chemoreflexes.91 In summary, evidence from observational analyses suggests that opioid use in the presence of OSA presents a risk factor for postoperative critical respiratory events (Oxford LOE 3–4).61,79,81–84,86,87,89
With regard to evidence from RCTs, 6 such studies were identified (Oxford LOE 2).93–98 In a volunteer study, Bernards et al94 directly demonstrated that opioid administration during sleep increased the number of central apneas, leading to decreased saturation levels in patients with OSA versus those without OSA.94 Abdelmageed et al93 demonstrated that opioid dose reduction significantly reduced the incidence of central apneas and respiratory events in patients with OSA.93 While interesting, it must be noted that opioid reduction may decrease respiratory depression and related complications in the general population as well.92 Using a nonvalidated OSA prediction instrument, Blake et al95 showed that central apneas and respiratory events were related to the dose of morphine administered postoperatively. However, differences in the occurrence of respiratory complications between patients with standard morphine patient-controlled analgesia and an opioid-sparing regimen could not be established.95
Other studies explored the safety of neuraxial opioid administration in patients with OSA.99–102 In a systematic review, Orlov et al99 found that the incidence of major cardiorespiratory complications after neuraxial opioid administrations was 4.1% among patients with OSA. However, the authors also emphasized that significant limitations in the quality of evidence and persistent underreporting of adverse events prevented an accurate and robust assessment of true perioperative risk.16,99 A prospective study in patients having a cesarean delivery with intrathecal morphine administration demonstrated that OSA and obesity were associated with approximately a 2-fold increase in risk for desaturation.100 However, another observational analysis of 990 patients undergoing orthopedic surgery with intrathecal morphine could not find an association between OSA and adverse pulmonary events.101
In summary, limited literature suggests that patients with OSA may be at increased risk for opioid-related respiratory adverse events. However, high-quality evidence to support and prove this notion is largely lacking (Oxford LOE 2–4).Pain and Opioid Analgesia in OSA.
A systematic evaluation of opioid-related respiratory effects in OSA requires focused attention on closely related issues such as pain perception and pharmacology of opioid analgesia. A summary of evidence is provided in Supplemental Digital Content, Table A3, http://links.lww.com/AA/C373 (Oxford LOE 3). Characterizing these relationships is important because the dose of opioids that is required to treat pain, as well as the sensitivity to these medications, directly influence the likelihood of opioid-induced respiratory depression.
Disturbed sleep continuity and intermittent hypoxia are 2 important features of OSA. Studies in humans have repeatedly demonstrated that fragmented103,104 or chronically curtailed sleep87,105 and insomnia,106 a condition highly comorbid with OSA,107 are associated with heightened sensitivity to pain.108
Among 3 identified studies examining the response to experimental pain in subjects suffering from OSA, 1 study found that patients with OSA and comorbid temporomandibular joint disorder experienced hypoalgesia to pressure-related pain,109 while another reported a significant increase in pain threshold after restoring sleep continuity with the application of CPAP therapy.110 In contrast, the third investigation found no association between wake-after-sleep-onset or nocturnal nadir blood oxygen saturation (SpO2) polysomnographic parameters and threshold/tolerance to thermal pain.111
In the context of chronic pain, a retrospective analysis of prospectively collected data from the Cleveland Family Study showed that chronic intermittent hypoxia was associated with more frequent chronic pain complaints, even after adjusting for the potentially hyperalgesic effect of sleep fragmentation and systemic inflammation.112
Despite the primary goal to focus on the adult patient population in this guideline, a significant amount of evidence originates from the pediatric population and deserves mention here particularly because they show contradictory findings to those found among adults. In children undergoing adenotonsillectomy for treatment of OSA, 2 case–control studies, 1 retrospective113 and 1 prospective,114 showed that patients with a preoperative nocturnal nadir SpO2 <85% required half the dose of morphine to treat postoperative pain, versus those with a nadir SpO2 ≥85%. Two prospective case–control studies in the same population did not confirm these findings.115,116 In the first study, African American children versus Caucasian children with OSA presented with more pain requiring a higher dose of morphine for postoperative analgesia.115 The second study showed that children with OSA (respiratory disturbance index >5) required more morphine for postoperative analgesia, but they also demonstrated a higher incidence of opioid-related respiratory complications.116
In adults, 1 retrospective analysis found that bariatric patients with nocturnal hypoxemia (expressed as percentage of total sleep time spent at oxygen saturation [SaO2] <90%) required less opioids for postoperative analgesia,117 whereas another prospective study did not detect any association between preoperative nocturnal hypoxemia and postoperative opioid use in general surgical patients with OSA.118 A more detailed and comprehensive summary of evidence on the potential impact of acute opioid analgesia in OSA is provided in a separate systematic review by the SASM opioids focus group (members listed in the acknowledgments).2.3 Propofol
Level of evidence: Moderate; Grade of recommendation: StrongRationale.
The literature discussed for the purpose of the recommendation reflects evidence of importance for patients receiving propofol for sedation in a procedural setting, that is, drug-induced sleep endoscopy (DISE), gastroenterological endoscopy, or dentistry. The use of propofol to induce general anesthesia purposefully suppresses respiratory activity and was thus deferred in this section.
Propofol is the most commonly used agent for DISE.119,120 A summary of findings from 5 studies120–124 is shown in Supplemental Digital Content, Table A4, http://links.lww.com/AA/C373 (Oxford LOE: 2–4). Both body mass index (BMI) and severity of OSA correlated with a greater likelihood of a patient having multiple sites of airway collapse and a higher possibility of circumferential and total airway obstruction during DISE.119,125 The goal of propofol administration for DISE is to produce a sleep-like loss of consciousness and muscle relaxation to precipitate pharyngeal narrowing and collapse in vulnerable individuals. To avoid the problem of profound relaxation or central apnea, it has been suggested that initial dosing for DISE be judiciously titrated.120,126
Attempts have been made to formulate a mathematical equation to model the pharmacokinetics for propofol in patients with obesity (Supplemental Digital Content, Table A5, http://links.lww.com/AA/C373).127–130 Uncertainty regarding dosing scalar adjustments that may be required in patients with obesity, as well as the concomitant use of depressant drugs with synergistic effects (midazolam,131 ketamine,132,133 dexmedetomidine,134 opioids135), further add to the need for heightened vigilance when using propofol for patients with OSA. Propofol has a relatively steep dose-response curve compared to other sedatives/hypnotics, thus underscoring the importance of careful titration.131,136,137 Adverse effects are not uncommon in patients with OSA undergoing procedures with propofol sedation. A summary of findings from 5 studies138–143 is shown in Supplemental Digital Content, Table A6, http://links.lww.com/AA/C373. OSA, increased BMI, male gender, American Society of Anesthesiologists physical status ≥III, initial dose of propofol, and increased age were found to be independent risk factors for hypoxemic incidents. Airway interventions were common in patients receiving propofol, although indications for airway intervention were left to the discretion of the anesthesia provider. Whether precautionary or subsequent to an obstructed airway, apneic, or desaturation episode, such airway interventions were undoubtedly done to prevent or mitigate a sedation-related adverse event. The use of capnography was associated with a decreased incidence of hypoxic events compared to standard monitoring alone during sedation with propofol144 in patients with OSA.1402.4 Inhalational Agents
Level of evidence: Moderate; Grade of recommendation: No recommendationRationale.
There is a lack of scientific literature to guide best intraoperative practices in OSA regarding the preferred technique among various inhalational agents and intravenous propofol for the maintenance of anesthesia. Nevertheless, a significant amount of evidence has been published on the general population and patients with obesity.145 Evidence from the population with obesity may merit consideration in this context, given the close association to OSA,146 reflected in the substantial OSA prevalence of ≤90% in male bariatric patients.147,148 Notably, there is significant overlap between obesity and OSA with regard to challenges in general anesthesia because of altered cardiorespiratory physiology, including decreased functional residual capacity, upper airway obstruction, and the propensity to hypoxemia in perioperative settings.149,150
This renders the period of emergence and recovery from anesthesia of high concern regarding the risk for detrimental outcomes.56,146
In this context, 25 studies were identified that compared the efficacy and recovery profile among the most common inhalational agents and intravenous propofol.65,151–174 A summary of evidence is provided in Supplemental Digital Content, Tables A7 and A8, http://links.lww.com/AA/C373. Comparing propofol and isoflurane, propofol was suggested to be associated with a faster recovery from anesthesia and improved postoperative respiratory control in 2 RCTs.154,155 However, sevoflurane was found to be superior to propofol in 2 RCTs due to faster anesthesia recovery and improved hemodynamic stability.152,153 In addition, recently Fassbender et al151 reported no difference with regard to postoperative obstructive and hypoxemic events between the 2 anesthetic agents when combined with remifentanil. Furthermore, comparing propofol and desflurane, 1 study demonstrated that the use of propofol impaired pulmonary function and SpO2 to a greater degree than desflurane,157 while another could not confirm these differences.156 Thus, current evidence indicates that sevoflurane and desflurane might be superior to intravenous propofol in terms of anesthesia recovery in patients with obesity (Oxford LOE: 2).
Similarly, 4 RCTs conducted in the population with obesity supported the notion that sevoflurane was associated with favorable features compared to isoflurane.65,158–160 In particular, Sudré et al65 demonstrated that sevoflurane embedded in a short-acting anesthetic regimen comprised of remifentanil, rocuronium, and ropivacaine improved emergence from anesthesia and reduced respiratory complications, postoperative anesthesia care unit stay, and hospital length of stay when compared to isoflurane within a long-acting regimen. This analysis emphasized the plausible benefit of generally utilizing short-acting medications with regard to all anesthetic drug classes, including opioids and NMBA, among patients at higher perioperative risk.65 The majority of studies, however, focused on the comparative effectiveness between sevoflurane and desflurane,161,163,165,167 demonstrating improved anesthesia recovery with desflurane (Oxford LOE: 2).162,164,166,168,169,174 Notably, limitations inherent to the nature of these comparisons can prevent the detection of differences. For instance, Eger and Shafer175 showed that differences in postoperative wake-up times among anesthetics were minimal at lower anesthetic concentrations,175 while the duration of anesthesia176 and BMI present important covariates.174
Summarizing the evidence, a well-designed systematic review by Liu et al171 provided a comprehensive comparison with quantitative analysis of immediate postoperative recovery after desflurane, isoflurane, sevoflurane, and intravenous propofol anesthesia in patients with obesity. In addition, a rather small clinical trial by Juvin et al170 also compared desflurane, isoflurane, and propofol together in 1 analysis. Both Liu et al171 and Juvin et al170 established desflurane as the most favorable anesthetic agent because of its superior postoperative recovery profile. Specifically, it was observed that patients who received desflurane anesthesia required less time to respond to commands, eye opening, hand squeezing, tracheal extubation, and name stating. Moreover, desflurane reduced sedation levels171 and conferred higher postoperative SpO2.170,171
It appears, therefore, that postoperative recovery might occur faster and with improved hemodynamic stability after anesthesia with desflurane followed by sevoflurane (Supplemental Digital Content, Table A7, http://links.lww.com/AA/C373), and these findings have also been observed in the general population.177–180
Consistently, desflurane and sevoflurane feature low blood-gas partition coefficients,171 conferring greater intraoperative control of anesthesia depth, as well as rapid and consistent postoperative emergence and recovery.161,181,182
These properties, in turn, imply earlier achievement of baseline respiratory function with potentially better protection against aspiration and improved oxygenation.183 This has also been supported by the observation of decreases in hypoxemia in clinical trials.170,171 Both obesity and OSA predispose patients to higher risk of postoperative upper airway obstruction and serious hypoxemia,184 thus suggesting a benefit associated with early and rapid recovery of active airway control and alertness.171
Another intervention, possibly promoting increased safety in OSA, is the intraoperative monitoring of anesthesia depth. This has been suggested by Ibraheim et al172 and Freo et al,173 who demonstrated that monitoring for titration of levels of inhalational agents reduced the required anesthetic dosage and improved the postanesthetic recovery in patients with obesity.
Furthermore, Katznelson et al185 suggested that recovery time after general anesthesia in patients with and without obesity can be accelerated using either isocapnic or hypercapnic hyperpnea.185
In summary, the available evidence supports the use of desflurane and sevoflurane in patients with obesity (Oxford LOE: 2). Given the strong association between obesity and OSA, and the benefits of accelerating and improving postoperative anesthesia recovery, these outcomes are desirable and may apply to patients with OSA as well. However, except for 2 RCTs,151,154 no studies specifically in OSA are available, and thus no specific recommendations can be made.2.5 Ketamine
Level of evidence: Very low; Grade of recommendation: No recommendationRationale.
The literature is scarce with regard to complications associated with ketamine in patients with OSA.
Ketamine has mostly been studied with respect to its potent analgesic effects as a sedative and hypnotic and, more recently, to reduce opioid use.186–188 There are only a few studies involving ketamine use in patients with OSA, but data are insufficient to draw any firm conclusions.189,190
Adverse effects of ketamine, such as neuropsychiatric effects, signs of increased sympathetic system activation (hypertension and tachycardia), and hypersalivation, are well documented in patients without OSA.191,192 Although patients with OSA are not specifically studied, these adverse events most likely translate to increased risk in this patient population as well. Adverse events are mostly seen in patients who received high doses, meaning >0.5 mg/kg boluses and 100 µg/kg/h infusions.193
Ketamine has been shown to have some beneficial effects. Studies demonstrated that ketamine, when combined with other sedative medications, mostly propofol, may decrease respiratory-related adverse effects.194,195 One such prospective observational study looking at sedation-related risk factors (airway obstruction, hypoventilation, and desaturation) for procedural sedation found ketamine to be a protective factor.195 De Oliveira et al194 reported that ketamine decreased duration and severity of hypercapnia in patients undergoing breast surgery under deep sedation.
Furthermore, Drummond196 studied the effect of ketamine versus midazolam on upper airway function. Interestingly, they found decreased upper airway muscle activity in the midazolam group, which resulted in airway obstruction, whereas no change in muscle activity was observed in the ketamine group. In another study, genioglossus muscle activity, tidal volume, and respiratory rate have been shown to be increased after administration of high and low doses of ketamine in rats.197 Upper airway dilator muscle activity plays an important role in patients who are at risk of upper airway obstruction. Despite the lack of data on ketamine in the patient population with OSA, available information suggests that these patients could benefit from potentially favorable respiratory effects over other sedatives. Firm conclusions, however, cannot be drawn at this time.2.6 Benzodiazepines
Level of evidence: Moderate; Grade of recommendation: WeakRationale.
Although the literature is immature on the topic of differential effects of intravenous benzodiazepine sedation in patients with OSA compared to those without OSA, studies suggest that the use of intravenous benzodiazepines is associated with airway compromise in patients with OSA. Intravenous benzodiazepine sedation is routinely used to induce airway collapse for diagnostic purposes in OSA.
Much of the literature revolves around the use of intravenous benzodiazepines for DISE in a diagnostic context to examine locations and patterns of obstruction in patients with OSA.119,198–210 Midazolam is the most commonly used intravenous benzodiazepine for DISE. In 7 studies,199,200,202,205,207,208,210 the majority of patients had multilevel obstruction, especially those with higher AHI. Two studies evaluated sleep staging during midazolam-induced sleep. The first showed that patients spent the most time in nonrapid eye movement sleep stage N1 and N2 but not in stage N3 and rapid eye movement (REM) sleep.198 The second reported that patients reached N2 sleep without further deepening of sleep stage.201 Because most obstructive events occur in N1 and N2 sleep, DISE with intravenous midazolam is considered a good option to study obstructive events in patients with OSA.102,105
Interestingly, Sadaoka et al209 found that patients with OSA had oxygen desaturation and apneas during DISE with intravenous diazepam more frequently than simple snorers.
Another category of studies described the use of intravenous benzodiazepines for sleep imaging.211–214 Thus, a retrospective analysis by Lee et al213 compared 53 patients with OSA to 10 simple snorers. All patients with OSA had desaturation events after 2 mg of midazolam, but none in the simple snorers group had such events.213
We identified 5 studies evaluating intravenous benzodiazepines in the context of other endoscopic or surgical procedures.215–219 Midazolam was used either alone or in combination with fentanyl. One study did not specify which benzodiazepines were used.218 Three studies215,216,219 compared outcomes between patients with and without OSA. In a retrospective cohort study by Adler et al,215 215 patients undergoing routine endoscopy were randomized to 4 groups: patients with OSA undergoing endoscopy with propofol or midazolam + fentanyl and patients without OSA undergoing endoscopy with propofol or midazolam + fentanyl. A comparison of patients with and without OSA receiving midazolam and fentanyl showed that desaturation events and other complications were not significantly different.215 Notably, doses of midazolam and fentanyl needed for colonoscopy were slightly lower in patients with OSA, although the procedure time was moderately longer.
Cha et al216 published a prospective study that compared cardiopulmonary complications during routine esophagogastroduodenoscopy under sedation with midazolam between 31 patients with OSA and 65 healthy controls. Patients with OSA received a higher dose of midazolam than patients without OSA, but cardiopulmonary complications were not increased in patients with OSA.
Mador et al219 conducted a prospective study in 904 patients undergoing endoscopy to investigate whether OSA, assessed by the Berlin questionnaire, increases the risk of complications during sedation with midazolam and fentanyl. Major complications were observed in 3.25% of patients with low risk for OSA and in 1.9% of patients with high risk for OSA (OR, 0.6; 95% CI, 0.26–1.46; P = .21). Minor complications were observed in 10.56% of patients with low OSA risk and 10.63% of patients with high OSA risk (OR, 1.01; 95% CI, 0.65–1.56; P = 1.0), suggesting that OSA was not associated with increased risk for cardiopulmonary complications during endoscopy under sedation with midazolam and fentanyl in this analysis.
In conclusion, 5 studies directly compared outcomes between patients with and without OSA after intravenous benzodiazepine sedation in the context of anesthesia.209,213,215,216,219 However, only 2 studies209,213 were able to establish a higher risk for respiratory complications in patients with OSA (Oxford LOE: 3). A summary of evidence is provided in Supplemental Digital Content, Table A9, http://links.lww.com/AA/C373.2.7 α-2 Agonists
Level of evidence: Low; Grade of recommendation: No recommendationRationale.
Dexmedetomidine and clonidine are centrally acting α-2 agonists with sedative, analgesic, and sympatholytic properties. Dexmedetomidine, in particular, has been suggested to cause minimal respiratory depression. Because OSA is associated with an increased risk of adverse postoperative pulmonary events,6 the potentially favorable respiratory profile and analgesic-sparing effects theoretically make α-2 agonists appealing for this population. When assessing the risk of adverse events with the use of α-2 agonists, no eligible studies compared patients with OSA to patients without OSA. The majority of studies focused on OSA or bariatric populations, comparing the use of α-2 agonists to either placebo or other medications. The body of literature is limited by a small total number of subjects, inconsistent results, lack of uniformity in outcomes, and low adverse event rates. Although many studies demonstrate statistical differences in hemodynamic parameters with α-2 agonists, the translation into clinically meaningful outcome differences is not supported at this time.
Four studies123,124,220,221 compared the use of dexmedetomidine to propofol in DISE as summarized in Supplemental Digital Content, Table A10, http://links.lww.com/AA/C373 (propofol in DISE has also been discussed in Section 2.3). In a series by Capasso et al,123 patients receiving propofol had a significantly increased likelihood of complete tongue base obstruction versus partial or no obstruction compared to those receiving dexmedetomidine. The 2 other studies that examined aspects of airway obstruction did not demonstrate significant differences between the dexmedetomidine and comparison groups.220,221
Three DISE studies measured intraprocedural respiratory and hemodynamic parameters. Two studies demonstrated a decrease in respiratory rate and lower SpO2 with propofol compared to dexmedetomidine.124,221 In the study by Cho et al,220 mean SpO2 of the dexmedetomidine-remifentanil and propofol groups did not differ; however, it was significantly lower in the propofol-remifentanil group.220 This study showed no hemodynamic differences, a finding shared by Kuyrukluyildiz et al.124 Conversely, Yoon et al221 observed similar mean arterial pressure (MAP) but lower mean heart rate (HR) with dexmedetomidine and no episodes of clinically significant bradycardia. Kuyrukluyildiz et al124 measured postprocedure outcomes, finding significantly lower MAP and HR with dexmedetomidine. Mean SpO2 and respiratory rate were higher with dexmedetomidine, although only 1 patient receiving propofol required additional oxygen supplementation.124
These 4 studies were examined in a systematic review, which concluded that dexmedetomidine appeared to yield a more stable cardiopulmonary profile, while propofol offered a faster onset, a shorter half-life, and potentially a greater degree of airway obstruction.222 The authors emphasized that neither propofol nor dexmedetomidine has been validated in replicating the obstruction that occurs during sleep. The obstructive patterns could be due to drug effect rather than reflective of the natural sleep state. Consequently, additional investigation is necessary to ascertain the optimal sedative in DISE.Other Procedures.
For studies involving procedures other than DISE, adverse events were characterized according to respiratory effects, hemodynamic effects, and recovery profile (Supplemental Digital Content, Table A11, http://links.lww.com/AA/C373).
Two studies reported respiratory outcomes during sedation procedures. In a descriptive series of 20 patients at high risk of OSA, 13 required interventions for airway obstruction and 2 for desaturation during endoscopy with combined dexmedetomidine–propofol sedation.134 An RCT in upper respiratory procedures demonstrated that, compared to propofol target-controlled infusion, dexmedetomidine use resulted in lower desaturation incidence, higher SpO2 at most time points, and lower rates of airway obstruction.223
Data are limited regarding respiratory effects of dexmedetomidine in the postoperative recovery period. A descriptive series of bariatric patients reported adequate saturations with supplemental oxygen without the need for CPAP.224 Studies with quantitative data suggest that intraoperative use of dexmedetomidine may not affect the respiratory rate in bariatric patients225 and when compared to placebo may have a better recovery profile in individuals undergoing uvuloplasty.93 In another group of patients receiving postoperative sedation after uvulopalatopharyngoplasty, the dexmedetomidine group experienced less severe and less frequent cough during extubation and less respiratory depression compared to the propofol group.226 Finally, in a retrospective review comparing patients undergoing airway reconstruction surgery who received dexmedetomidine versus those who did not, neither group required interventions for airway compromise.227
Two studies examined the effect of clonidine on respiratory parameters and sleep in patients with OSA.228,229 In an RCT of 8 patients, clonidine compared to placebo suppressed the amount of time in REM sleep and decreased apnea duration during REM while not affecting overall AHI.228 Minimum SpO2 levels were higher in the clonidine group (86% ± 1.5% vs 84% ± 1.0%), reaching statistical but arguably not clinical significance. Pawlik et al229 performed an RCT in patients with OSA undergoing ear, nose, and throat surgery, with patients receiving either oral clonidine or placebo the night before and 2 hours before surgery. AHI in the night of surgery did not differ from baseline or between the 2 treatment groups. In both groups, the desaturation index decreased on the preoperative night, the day of the operation, and the postoperative night compared to their respective baseline measurements but did not differ between groups.
The hemodynamic effects of α-2 agonists were assessed according to varied outcome measures, including vital sign measurements, categorical descriptors, and need for rescue medications. Intraoperatively, 3 studies demonstrated significantly lower MAPs with α-2 agonists,229–231 while 1 study showed no difference.232 Heart rate was significantly lower with dexmedetomidine in 3 studies,223,229,230 while no difference to controls was observed in 2 other studies.231,232 Chawla et al227 reported transient loading dose hypertension followed by “titratable, controlled hypotension, and bradycardia.” Three studies223,227,231 demonstrated less frequent use of rescue antihypertensives or β blockers among α-2 agonist groups intraoperatively; 1 study showed this postoperatively.229 Furthermore, 1 study demonstrated a greater incidence of need for phenylephrine support in patients receiving dexmedetomidine.231 In studies reporting the need for atropine and/or ephedrine, the overall incidence was low, and no differences were reported between treatment groups.223,229 Among studies that measured postoperative hemodynamics, there was inconsistency as to whether MAP was decreased with α-2 agonists229–231 or similar to that of the control patients.93,225 Xu et al226 also characterized outcomes according to categorical variables and found a decreased incidence of hypertension and tachycardia, as well as an increased incidence of bradycardia in the dexmedetomidine-treated group; the frequency of hypotension did not differ.
The potential role of α-2 agonists in modulating the sympathetic response is of clinical interest. Four studies226,229,231,233 examined the effects of α-2 agonists on hemodynamics at points of stimulation, such as intubation, incision, and extubation. Only 1 study compared the measurements of each group to their respective baseline values,226 while all compared the measurements between treatment groups. Blood pressure and HR in the α-2 agonist groups were either lower than or similar to their control groups. Another group observed less frequent spikes in MAP and HR in clonidine-treated patients, but this was not statistically significant.234
The effects of α-2 agonists on recovery profile varied. Three studies demonstrated shorter time to extubation with α-2 agonists,226,230,234 1 showed no difference compared to control patients,231 and another showed increased time to extubation.93 One series described prolonged drowsiness with dexmedetomidine,134 while another study showed no difference in sedation score compared to control patients.93 End points related to postoperative nausea/vomiting were examined in 1 observational study225 and 3 RCTs.93,226,231
In summary, the literature on the differential effect of α-2-agonists in patients with and without OSA is limited and results are nonuniform (Oxford LOE: 2–4). While a trend in statistical outcomes for some cardiorespiratory parameters may be observed, the clinical impact of these findings remains unknown.3. ANESTHESIA TECHNIQUE
Level of evidence: Moderate; Grade of recommendation: StrongRationale
A wide range of literature and earlier guidelines have favored the use of regional anesthesia techniques and multimodal analgesic approaches among patients with OSA despite little scientific evidence to support this practice.8,9 To address this matter, a systematic literature search was performed to summarize evidence on preferable anesthesia techniques in patients with OSA.Anesthesia Technique as a Modifier of Postoperative Outcome.
With regard to comparative effectiveness between general and regional anesthesia specifically in patients with OSA, 6 observational studies were identified.61,235–239 A summary of evidence is provided in Supplemental Digital Content, Table A12, http://links.lww.com/AA/C373. Overall, studies indicated that the utilization of regional as opposed to general anesthesia would improve postoperative outcome.79,235–239 The largest population-based analysis included >30,000 patients with OSA from >400 US hospitals undergoing joint arthroplasty procedures.235 Adjusted risk of numerous major complications was significantly lower in patients with OSA who received neuraxial anesthesia versus general anesthesia. Furthermore, the addition of neuraxial to general anesthesia versus the use of general anesthesia alone was associated with improved outcome profiles. Additionally, the utilization of peripheral nerve blocks was associated with decreased odds for mechanical ventilation, critical care admissions, and prolonged hospital length of stay.235
Subsequent studies236,239 confirmed the previous findings, while 1 suggested benefits with regard to mortality.239 Notably, in a prospective analysis investigating drivers of postoperative worsening of sleep-disordered breathing, Chung et al79 demonstrated that the utilization of general anesthesia was associated with an increased central apnea index postoperatively, while 72-hour total opioid dose was a driver of increased AHI. This finding suggests that the residual effects of general anesthesia may affect postoperative sleep architecture and sleep-disordered breathing in OSA.
Given the necessity of airway manipulation under general anesthesia, other challenges inherent to OSA should be considered as well. The higher risk for a difficult airway in OSA has been discussed in Section 1. However, challenges with regard to airway complications in patients with OSA appear to also extend to the time for emergence from anesthesia and the immediate postoperative period, potentially leading to the requirement of emergent airway interventions.240,241 Thus, consistent with the underlying pathogenesis of OSA, perioperative complications in these patients may be driven by upper airway obstruction.240,241 Recently, Ramachandran et al61 showed that OSA was an independent predictor of respiratory complications and unplanned intubation after general anesthesia.
Another potential hazard associated with the use of general anesthesia is the frequent need for neuromuscular blockade. As described in Section 2.1, studies suggest that patients with OSA who received NMDA may be at increased risk for effects of residual neuromuscular blockade and respiratory failure compared to the general population.67,242 Therefore, the use of regional anesthesia may offer advantages by virtue of avoiding upper airway effects, although the potential for the need to convert to general anesthesia should always be considered.
Neural stimulation appears to be essential in initiating the surgical catabolic stress response,243,244 and regional anesthesia utilizing local anesthetics seems to reliably block this effect.245 Given the evidence suggesting potential OSA-related alterations in pain perception and opioid potency due to intermittent hypoxia and sleep fragmentation, as discussed in Section 2.2, regional anesthesia confers benefits by providing effective pain relief while reducing opioid requirement,246,247 a key factor to consider in patients with OSA.112,248
In summary, despite the lack of high-quality RCTs, some evidence suggests a higher risk of complications with general compared to regional anesthesia in patients with OSA (Oxford LOE 2–4). Thus, regional anesthesia should be considered by anesthesiologists whenever feasible.RECOMMENDATIONS: EXECUTIVE SUMMARY
The SASM task force is divided into 9 groups addressing the questions surrounding (1) airway, (2) neuromuscular blocking agents, (3) opioids, (4) propofol, (5) inhalational agents, (6) benzodiazepines, (7) ketamine, (8) α-2 agonists, and (9) anesthesia technique. The leaders of the respective groups and its individual members were: (1) Difficult airway in OSA: Mahesh Nagappa (Leader), David T. Wong, Frances Chung, Satya Krishna Ramachandran; (2) NMBAs: Jean Wong (Leader), Frances Chung, Mandeep Singh; (3) Opioids: Crispiana Cozowicz (Leader), Anthony G. Doufas, Frances Chung, Stavros G. Memtsoudis; (4) Propofol: Mark H. Stein (Leader), Frances Chung; (5) Inhalational agents: Girish P. Joshi (Leader), Crispiana Cozowicz, Stavros G. Memtsoudis; (6) Ketamine: Meltem Yilmaz (Leader); (7) Benzodiazepines: Stavros G. Memtsoudis (Leader), Lukas Pichler, Crispiana Cozowicz; (8) α 2-agonists: Megan L. Krajewski (Leader), Satya Krishna Ramachandran, Crispiana Cozowicz; and (9) Anesthesia technique: Stavros G. Memtsoudis (Leader), Crispiana Cozowicz. We would like to express special thanks to the following participants in alphabetical order for their significant contribution in the systematic literature search and data analysis process: Marina Englesakis, Library and Information Services, University Health Network, University of Toronto, Toronto, Ontario, Canada; Rie Goto, Kim Barrett Memorial Library, Hospital for Special Surgery, New York, NY; Bridget Jivanelli, Kim Barrett Memorial Library, Hospital for Special Surgery, New York, NY; Eva E. Mörwald, MD, Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria; Khawaja Rashid Hafeez, MBBS, FCPS, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; Arvind Tuteja, MBBS, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; Vwaire Urhuru, MD, Department of Anesthesia, Critical Care, and Pain Management, Beth Israel Deaconess Medical Center, Boston, MA; Sarah M. Weinstein, BA, Department of Anesthesiology, Hospital for Special Surgery, New York, NY.DISCLOSURES
Name: Stavros G. Memtsoudis, MD, PhD.
Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.
Conflicts of Interest: S. G. Memtsoudis is a director on the boards of the American Society of Regional Anesthesia and Pain Medicine (ASRA) and the Society of Anesthesia and Sleep Medicine (SASM). He is a 1-time consultant for Sandoz Inc and the holder of US Patent Multicatheter Infusion System US-2017-0361063. He is the owner of SGM Consulting, LLC, and co-owner of FC Monmouth, LLC. None of these relations influenced the conduct of the present study.
Name: Crispiana Cozowicz, MD.
Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.
Conflicts of Interest: None.
Name: Mahesh Nagappa, MD.
Contribution: This author helped conduct the study, analyze the data, and write the manuscript.
Conflicts of Interest: None.
Name: Jean Wong, MD, FRCPC.
Contribution: This author helped conduct the study, analyze the data, and write the manuscript.
Conflicts of Interest: J. Wong has received research grants from Acacia Pharma.
Name: Girish P. Joshi, MBBS, MD, FFARCSI.
Contribution: This author helped conduct the study, analyze the data, and write the manuscript.
Conflicts of Interest: G. P. Joshi received an honorarium from Baxter Pharmaceuticals, Mallinckrodt Pharmaceuticals, Merck Pharmaceuticals, and Pacira Pharmaceuticals.
Name: David T. Wong, MD, FRCPC.
Contribution: This author helped conduct the study, analyze the data, and write the manuscript.
Conflicts of Interest: None.
Name: Anthony G. Doufas, MD, PhD.
Contribution: This author helped conduct the study, analyze the data, and write the manuscript.
Conflicts of Interest: None.
Name: Meltem Yilmaz, MD.
Contribution: This author helped conduct the study, analyze the data, and write the manuscript.
Conflicts of Interest: M. Yilmaz serves on the advisory board of VitaHEAT Medical.
Name: Mark H. Stein, MD.
Contribution: This author helped conduct the study, analyze the data, and write the manuscript.
Conflicts of Interest: None.
Name: Megan L. Krajewski, MD.
Contribution: This author helped conduct the study, analyze the data, and write the manuscript.
Conflicts of Interest: None.
Name: Mandeep Singh, MBBS, MD, MSc, FRCPC.
Contribution: This author helped conduct the study, analyze the data, and write the manuscript.
Conflicts of Interest: None.
Name: Lukas Pichler, MD.
Contribution: This author helped analyze the data and write the manuscript.
Conflicts of Interest: None.
Name: Satya Krishna Ramachandran, MD.
Contribution: This author helped conduct the study, analyze the data, and write the manuscript.
Conflicts of Interest: S. K. Ramachandran funded research from Merck, Sharp & Dohme, New Jersey.
Name: Frances Chung, MBBS, FRCPC.
Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.
Conflicts of Interest: F. Chung received research grants from Ontario Ministry of Health and Long-Term Care Innovation Fund, University Health Network Foundation, ResMed Foundation, Acacia Pharma, and Medtronics Inc STOP-Bang tool: proprietary to University Health Network, royalties from Up-To-Date.
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Torri G, Casati A, Comotti L, Bignami E, Santorsola R, Scarioni M. Wash-in and wash-out curves of sevoflurane and isoflurane in morbidly obese patients. Minerva Anestesiol. 2002;68:523–527. 161. Arain SR, Barth CD, Shankar H, Ebert TJ. Choice of volatile anesthetic for the morbidly obese patient: sevoflurane or desflurane. J Clin Anesth. 2005;17:413–419. 162. De Baerdemaeker LE, Struys MM, Jacobs S, et al. Optimization of desflurane administration in morbidly obese patients: a comparison with sevoflurane using an “inhalation bolus” technique. Br J Anaesth. 2003;91:638–650. 163. De Baerdemaeker LE, Jacobs S, Den Blauwen NM, et al. Postoperative results after desflurane or sevoflurane combined with remifentanil in morbidly obese patients. Obes Surg. 2006;16:728–733. 164. Bilotta F, Doronzio A, Cuzzone V, Caramia R, Rosa G; PINOCCHIO Study Group. 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The effect of ketamine on hypoventilation during deep sedation with midazolam and propofol: a randomised, double-blind, placebo-controlled trial. Eur J Anaesthesiol. 2014;31:654–662. 195. Taylor DM, Bell A, Holdgate A, et al. Risk factors for sedation-related events during procedural sedation in the emergency department. Emerg Med Australas. 2011;23:466–473. 196. Drummond GB. Comparison of sedation with midazolam and ketamine: effects on airway muscle activity. Br J Anaesth. 1996;76:663–667. 197. Eikermann M, Grosse-Sundrup M, Zaremba S, et al. Ketamine activates breathing and abolishes the coupling between loss of consciousness and upper airway dilator muscle dysfunction. Anesthesiology. 2012;116:35–46. 198. Abdullah VJ, Lee DL, Ha SC, van Hasselt CA. Sleep endoscopy with midazolam: sedation level evaluation with bispectral analysis. Otolaryngol Head Neck Surg. 2013;148:331–337. 199. Bachar G, Feinmesser R, Shpitzer T, Yaniv E, Nageris B, Eidelman L. Laryngeal and hypopharyngeal obstruction in sleep disordered breathing patients, evaluated by sleep endoscopy. Eur Arch Otorhinolaryngol. 2008;265:1397–1402. 200. Bachar G, Nageris B, Feinmesser R, et al. Novel grading system for quantifying upper-airway obstruction on sleep endoscopy. Lung. 2012;190:313–318. 201. Carrasco Llatas M, Agostini Porras G, Cuesta González MT, et al. Drug-induced sleep endoscopy: a two drug comparison and simultaneous polysomnography. Eur Arch Otorhinolaryngol. 2014;271:181–187. 202. De Corsa E, Fiorita A, Rizzotto G, et al. The role of drug-induced sleep endoscopy in the diagnosis and management of obstructive sleep apnoea syndrome: our personal experience. Acta Otorhinolaryngol Ital. 2013;33:405–413. 203. Gregório MG, Jacomelli M, Figueiredo AC, Cahali MB, Pedreira WL Jr, Lorenzi Filho G. Evaluation of airway obstruction by nasopharyngoscopy: comparison of the Müller maneuver versus induced sleep. Braz J Otorhinolaryngol. 2007;73:618–622. 204. 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Evaluation of soft palate changes using sleep videofluoroscopy in patients with obstructive sleep apnea. Arch Otolaryngol Head Neck Surg. 2009;135:168–172. 214. Lee CH, Hong SL, Rhee CS, Kim SW, Kim JW. Analysis of upper airway obstruction by sleep videofluoroscopy in obstructive sleep apnea: a large population-based study. Laryngoscope. 2012;122:237–241. 215. Adler DG, Kawa C, Hilden K, Fang J. Nurse-administered propofol sedation is safe for patients with obstructive sleep apnea undergoing routine endoscopy: a pilot study. Dig Dis Sci. 2011;56:2666–2671. 216. Cha JM, Jeun JW, Pack KM, et al. Risk of sedation for diagnostic esophagogastroduodenoscopy in obstructive sleep apnea patients. World J Gastroenterol. 2013;19:4745–4751. 217. Cillo JE Jr, Finn R. Hemodynamics and oxygen saturation during intravenous sedation for office-based laser-assisted uvuloplasty. J Oral Maxillofac Surg. 2005;63:752–755. 218. Madan AK, Tichansky DS, Isom J, Minard G, Bee TK. 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Last Spring, Microsoft unveiled their plan for Windows and the Internet of Things. It starts with the Raspberry Pi and Windows 10 IoT Core – a stripped down system with Windows API calls running on an ARM architecture. Yes, Microsoft is finally moving away from the desktop, building a platform for a billion Internet of Things things, or filling the gap left by tens of thousands of POS terminals and ATMs running XP being taken offline. Either one is accurate.
Earlier this week, Microsoft announced the first public release of Windows 10 IoT Core. This is the review, but here’s the takeaway: run. Run as fast as you can away from Windows IoT. It’s not worth your time unless you have a burning desire to write apps for Windows, and even then you could do a better job with less effort with any Linux distro.
When Windows 10 IoT was first announced, there was great hope for a Windows RT-like experience. Being able to run real Windows applications on a Raspberry Pi would be a killer feature, and putting Skype on a Pi would mean real Jetsons-style video phones appearing in short order.
The majority of interaction with Windows 10 IoT Core is over the web. After booting and pointing a browser to the Pi, you’re presented with a rather complete web-based interface. Here, you can check out what devices are connected to the Pi, look at the running processes, and run new apps. Think of this feature as a web-based Windows control panel.
While Windows 10 IoT uses the HDMI output on the Pi, this is merely informational, the video output capabilities of the Pi reserved for application-specific displays – digital signage, POS terminals and ATMs are where Windows 10 IoT Core excels. For general-purpose computing, you’re better off looking elsewhere.Installing
Officially, the only way to install Windows 10 IoT Core is with a computer running Windows 10. There are a few ways around this is with the ffu2img project on GitHub. This Python script takes the special Microsoft .FFU image file format and turns it into an .IMG file that can be used with dd under *nix and Win32DiskImager on Windows.
Yes, Windows 10 is free for everyone with a relatively modern Windows box, but since the only requirement for running Windows 10 IoT core is putting an image on an SD card and monitoring a swarm of IoT Core devices, there is no reason why this OS can’t be supplied in an .IMG file.
After putting the image on an SD card, installing Windows 10 IoT Core is as simple as any other Raspi distro: shove the card in the Pi, connect an Ethernet cable, and give it some power. No, you don’t need a keyboard or mouse; there’s very little you can actually do with the Pi. In fact, the only thing that is displayed through the Pi’s HDMI port is a screen giving you the IP address and what USB devices are attached.The totality of the Windows 10 IoT Core experience
You do get a few options for language and network settings, and there are a few tutorials and examples – connecting to Visual Studio and blinking an LED – but that’s it. The base user experience of Windows 10 IoT Core is just network information, a device name, and a picture of a Raspberry Pi.
There are a few shortcomings of the Windows 10 IoT core for the Raspberry Pi. Officially, the only supported WiFi module is the official Raspberry Pi WiFi module with a BCM43143 chipset. By far, the most popular WiFi module used for the Raspberry Pi (and something you should always carry around in your go-bag) is the Edimax EW-7811Un, a tiny WiFi module that uses a Realtek chipset. Odds are, if you have a Raspberry Pi 2, that WiFi module you picked up won’t work. Common sense would dictate that you could install the Windows driver for the Realtek chipset, but this is not the case; no Windows driver will ever work with Windows 10 IoT core. Even devices from the Raspberry Pi foundation, like the Raspberry Pi camera, are not supported by IoT core
If you’ve ever wanted clearer evidence the Windows 10 IoT core is not meant to be an extensible system like every other Linux-based single board computer, you need only look a little deeper. Digital audio is completely ignored, and pins 8 and 10 – normally reserved for a 3.3V UART on every other Raspberry Pi distribution – are reserved pins. Microsoft managed to make a single board computer without a hardware UART.
Fortunately, some of these problems are temporary. A representative from the Windows On Devices team told us more WiFi dongles will be supported in the future; the only driver they were able to bring up in time is the official dongle from the Raspberry Pi foundation. A similar situation of engineering tradeoffs is the reason for the lack of UART support.Who is this for, exactly?
The idea that Microsoft would put out a non-operating system without support for the de facto standard WiFi adapter, a hardware UART, or drivers for the majority of peripherals is one thing. Selling this to the ‘maker movement’ strains credulity. There is another explanation.The Windows 10 IoT Core Watcher, the remote admin app for multitudes of Pis.
Let’s go over once again what Windows 10 IoT Core actually is. By design, you can write programs in Visual Studio and upload them to one or many devices running IoT core. These programs can have a familiar-looking GUI, and are actually pretty easy to build given 20+ years of Windows framework development. This is not a device for makers, this is a device for point of sale terminals and ATMs. Windows XP – the operating system that is still deployed on a frighting number of ATMs – is going away soon, and this is Microsoft’s attempt to save their share of that market. IoT Core isn’t for you, it isn’t for me, and it isn’t for the 9-year-old that wants to blink an LED. This is an OS for companies that need to replace thousands of systems still running XP Embedded and need Windows APIs in kiosks and terminals.Save your SD card
For anyone with a Raspberry Pi 2 and an SD card, the only investment you’ll make in trying out Windows 10 IoT Core is your time. It’s not worth it.
While Windows 10 IoT Core is great for any company that has a lot of Visual Basic and other engineering debt, it’s not meant for hackers, makers, or anyone building something new. For that, there are dozens of choices if you want an Internet-connected box that can be programmed and updated remotely. The Cloud9 IDE for the Pi and BeagleBone allow you to write code on single board computers without forcing you to install Visual Studio, and Linux is king for managing dozens or hundreds of boxes over the Internet.
This is not an OS that replaces everything out there. A Linux system will almost always have better hardware support, and this is especially true on embedded devices. Windows 10 IoT Core is a beginning, and should be viewed as such. It’s there for those who want it, but for everyone else any one of a dozen Linux distributions will be better.
Professionalism may not be sufficient to drive the profound and far-reaching changes needed in the health care system, but without it, the health care enterprise is lost.
— Lesser et al1
The concept of professionalism for health care providers and organizations can offer guidance for decision making in a fiscally difficult, rapidly changing, and ethically challenging environment. Professionalism is based on a specific set of principles and commitments that provide an orientation to the thoughts and actions of a given profession. These principles for physicians were enunciated in the Physician Charter on Medical Professionalism 13 years ago.2 That charter has been widely accepted by physicians, but its impact on the quality of health care and patient experience is increasingly recognized as intertwined with the professionalism of health care organizations.1,3
Indeed, structural factors in the health care system may impede physicians from living up to the charter.4 Health care is now a three-trillion-dollar industry,5 with an estimated one-third of all spending being deemed “systematic waste,” including unnecessary and possibly harmful care.6 Hospitals and health care systems are focused necessarily on their own financial health during a time of major reform in care delivery and payment models; but at the same time, they can ensure the primacy of their missions, ethical and efficient operations, and patient and provider welfare. Professional ideology recognizes a high priority for useful and needed work and its social benefits. It does not avoid economic rewards. It simply requires that these rewards be acquired with appropriate attention to professional service and social responsibility.
Health care systems increasingly dictate the practices of health care professionals, for better or worse, as an increasing number of physicians are employed by hospitals and hospital systems.7 As such, health care organizations have an opportunity to positively and negatively influence the behavior of their employees and affiliated physicians. Most members of the health care team are motivated to do the right thing. There are, however, many opportunities for health care providers and organizations to engage in activities that are not in concordance with the principles of medical professionalism.
This Perspective includes a Charter on Professionalism for Health Care Organizations (referred to as the “Charter”; see Appendix 1) with the aim of stimulating health care leaders, health professionals, policy stakeholders, and society to evaluate their current and preferred ways of operating, to ensure best practices in providing health care and improving health. We also describe the identification and resolution of a number of issues that arose during the creation of the Charter. These include the rationale for a charter for organizational professionalism; the charter process, goals, domains, and obstacles; and finally, what we hope the Charter will accomplish. Our Perspective is offered by a subset of the Charter authors to provide its social context. It represents the ideas of the authors, not their institutions or the organizations that sponsored the Charter project.Why a Charter on Organizational Professionalism?
A charter is a reflection of values and can be effective in bringing about positive changes in a target audience. Evidence indicates that such a document can stimulate conversation and affirmation of the stated values. For example, since its publication in 2002, the Physician Charter on Medical Professionalism has been endorsed by over 130 organizations,8 and the number of related professionalism articles has quadrupled to over 600 annually.9 A charter or mission statement that incorporates social, ethical, or societal goals can also positively influence organizational success. Kanter’s10 research on financially successful companies revealed that an expressed commitment to social responsibility creates a buffer against uncertainty, evokes positive emotions, and stimulates motivation among employees. Along similar lines, Paine11 argues that companies reap financial rewards when their programs feature such elements as community involvement and ethics. These views are supported by the growing list of companies seeking B company certification, which attests to a company’s commitment to society and the environment.12 Additionally, Nielsen’s 2014 survey of 30,000 consumers found that 55% of respondents were willing to pay extra for products and services provided by companies committed to positive social and environmental issues.13
For these reasons and others discussed later in this article, members of the health care professions, patients, and representatives from hospitals and health care systems have collaborated to create a charter that outlines behaviors that support an organizational culture of professionalism. The Charter on Professionalism for Health Care Organizations is aspirational, supports a learning health system, and places the patient first. It seeks to ensure that the concept of fiduciary responsibility of health care organizations is broadened to include not only the financial health of the organizations but also the health of the patients, the well-being of the organizations’ employees, and a responsibility to the community.Charter Process
The Organizational Professionalism Charter Project was funded by grants from the Commonwealth Fund, the American Board of Internal Medicine Foundation, North Shore Long Island Jewish Health System, the Federation of American Hospitals, and the American Hospital Association. The authors of the original organizational professionalism publication3 and representatives of the grantors formed a Steering Committee to direct the project. The Steering Committee nominated individuals for the Writing Group who were approved by consensus and created the Charter. These writers represented a variety of disciplines, points of view, and stakeholders in health care. They included nurses, health system leaders, medical ethicists, and consumer advocates. Although some participants felt that they were to represent the organization that nominated them, the Charter was not subject to approval by any grantor or organization. Over a period of almost two years, the Writing Group met twice in person, first to decide what domains were important to address and that it would make decisions by consensus, and then to plan the writing of the Charter. The Writing Group refined the document by conference calls and e-mail. As might be expected from such a diverse group, compromise was important for the final Charter to be approved by consensus. The issues that required the most vigorous discussions were whether health care is a “right,” whether to stipulate a specific percentage of margin that a health care organization ought to return to the community, and the obligation of health care organizations to address the social determinants of health.Charter Goals
The purpose of the Charter is to describe professionalism behaviors to which for-profit and not-for-profit hospitals and hospital systems may aspire. As the work unfolded, the Writing Group recognized that the principles were relevant to any health care organization. This article describes the evidence-based rationales for the behaviors of hospitals and hospital systems implied by these principles.
No organization can fully embody all of these behaviors. However, if they share the values elaborated in the Charter’s preamble, they may identify activities described in the subsequent domain sections that align with their strategic initiatives. We offer evidence that implementing these behaviors would improve health care as well as the experience of working or being cared for within health care organizations. Engaging outside partners—the community, government, and other organizations—creates the potential to affect population health, because partnerships among these are essential for addressing the social determinants of health.
At times, different sections of the Charter will suggest competing actions. For example, touchstones of the Charter are to prioritize the health of individual patients and to improve the health of the community. However, being a steward of limited resources may conflict with optimizing the health of each individual patient. Organizations may ethically take different actions based on their different missions and cultural values.14 Transparent discussions that include patients and local communities will themselves have social benefit, because they may help health care organizations choose paths that reflect both organizational and local values. However, when ethical dilemmas arise from conflicts between an organization’s self-interest and those of the community or patient, the community or patient interest takes precedence. While this premise of the Charter may seem controversial, it is central to its content, consistent with the seminal Physician Charter on Medical Professionalism,2 and the source of its greatest potential social benefit.Charter Domains
The discussion in the following domain sections provides the rationale and evidence to support the commitments requested in the Charter.Patient partnerships
In 2001, the IOM report Crossing the Quality Chasm: A New Health System for the 21st Century created a sense of urgency for reinventing a health care system built around six aims for improvement considered essential for better meeting patient-family needs.15 Among these six aims is patient-centered care, defined as “providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.”15 It requires collaboration among health care teams and effective partnerships with patients, families, and other caregivers.16,17 Successful navigation from the traditional “doctor knows best” approach to one that engages patients and families to participate in their care and decision making is contingent on a culture of organizational leadership that values multidirectional collaboration and communication.17
The foundational characteristics of this vision for health care transformation are well aligned with the precepts of professionalism. Over time, organizations that integrate person-centric principles can experience greater patient trust and loyalty and teams that function in a more coordinated manner.18 Effective engagement with patients and families can have a measurable impact on organizational improvement and has been cited as having the greatest potential for sustaining long-term system-wide transformation.19 Health systems and organizations that intentionally invite patients and families to participate in rounds, committees, and advisory panels and to share their stories in the boardroom have accelerated improvements in the quality of care they provide.20
In the last decade, many factors have influenced the expectation that patients and families take an active role in decisions that impact their health and health care,21 and studies demonstrate that this practice benefits all involved.22–24
Executive leadership is essential for achieving the cultural transformation needed to support genuine partnerships with patients and families throughout their organizations.25 Leadership that is engaged and provides the resources needed to sustain strategies for patient-family input is critical for successful adoption of these practices. Organizations and systems that uphold patient partnerships as an integrated core value will exemplify professionalism and stand apart from others.20
This domain is aligned with Medicare’s adoption of measures of patient experience measures as an important element of value, and thus payment. Although the exact measures of patient experience and engagement remain controversial, the expectation of patient- and family-centeredness as a core value of health care organizations is here to stay.26Organizational culture
Successful transformation of health care systems will likely depend more on the social capital of organizations than their financial capital.27 While many professional entities provide guidelines for the behavior of individuals within their disciplines, it is the responsibility of leadership to describe a health care organization’s desired culture, articulate its rationale, and create the structures that support it and ensure accountability. With this guidance, organizational culture is cocreated by patients, nonemployed workers, employees, and leadership. Trust in leadership requires that management behavior be consistent with the organizational mission, professional values, and expectations of employees.28 That trust in turn empowers individuals to propagate consonant behaviors into the various units where they work. Organizational culture is thus viewed as a complex adaptive system composed of interrelated microcultures.
There is increasing evidence of relationships between the culture of senior management,29 organizational culture,30 and the performance of health care organizations. Organizational leadership style influences both physician31 and nurse satisfaction and burnout.32 Although physician burnout has not been consistently tied to the quality of care,33 nurse burnout has.34 Physician well-being is correlated with lower rates of turnover and can be improved through focused organizational interventions.35 A Rand study on physician well-being concluded that “the same considerations that apply outside medicine—for example, fair treatment; responsive leadership; attention to work quantity, content, and pace—can serve as targets for policymakers and health delivery systems that seek to improve physician professional satisfaction.”36 Achieving the “triple aim” may indeed require incorporating “care of the provider” into a “quadruple aim.”37 A healing environment can best be achieved when all those in the organization are afforded the same value and respect that clinicians aspire to give to patients. This requires soliciting, respecting, and incorporating the perspectives of employees.
High-value, cost-conscious practice also depends on interprofessional collaboration.38 Validated measures of team cohesion have been developed,39 and numerous studies demonstrate that better teamwork is correlated with better patient outcomes, patient satisfaction, organizational efficiency, patient engagement, and worker satisfaction.40 Studies are beginning to emerge that test whether interventions to improve teamwork also improve clinical outcomes, though more research is needed.41,42Community partnerships
Traditional clinical services account for only 10% to 20% of a population’s health, and genetics account for 20% to 30%.43,44 Spurred by well-articulated missions to create healthy communities, model health care organizations have sought to address the remaining 50% to 70%—the so-called social determinants of health—in rich strategic partnerships with the communities they serve.45 The health of the U.S. population has improved significantly during the last century; however, many high-risk communities have not shared in the gains achieved by traditional health promotion strategies. There is growing recognition that promoting the health of populations requires a systems approach to understanding and addressing the social and environmental factors that can protect or undermine health.46
As awareness of the importance of addressing “health” as a broader construct has grown, so too has awareness of the importance of health care organizations joining together—in full partnership with each other and the communities they serve—to define barriers to health and health care, design interventions, maximize the value of investments, and implement new strategies together to improve a community’s health.47 Partnerships of this type require skill, collaboration, and a level of trust that has not previously existed among most health care organizations and the communities they serve. Still, several notable examples have emerged.48 The Affordable Care Act includes the requirement that nonprofit health care organizations demonstrate their “community benefit” beyond the usual charity care to include community health assessments, planning, implementation, and evaluation.49 The expectation is that health care organizations will provide “a wide range of services and activities that focus on improving health status and quality of life in local communities.”50
In tandem with the mission to create healthy communities, model health care organizations recognize that shifts in public policy toward population and outcomes-based reimbursement make effectively addressing the social determinants of health mission critical to fiscal sustainability in a post-fee-for-service future.51,52 In this way, the long-term health of model health care organizations and the communities they serve are inextricably intertwined and must be addressed in real partnerships where this reality is embraced by all.Operations and business practices
In recent years, a vision for a health care system that continuously learns and improves has evolved.53,54 Efforts to enhance ethical behavior in health care organizations result in best operational and business practices and in real benefits for patients.55 Furthermore, Tsai and colleagues56 found that hospitals that rank high on the use of effective management practices provide a higher quality of care than lower-ranking hospitals, and hospital management’s use of such practices is associated with a high-performing board of trustees.
Paine57 argues that increasingly, companies are launching ethics programs, values initiatives, and community involvement activities premised on management’s belief that “ethics pays.” In health care, this concept goes well beyond the economic value of branding and includes efforts at cost control, service quality improvement, patient and staff safety, risk management, innovation, reputation, loyalty, and satisfaction for both patients and providers.
Bart and Tabone58 found an important relationship between nonprofit hospital leadership satisfaction with mission statement and their organization’s performance. Their primary finding was that leaders do in fact discriminate and differentiate in the wording of mission statements, which in turn influences organizational behavior and performance. Of distinct importance is a commitment to service quality, patient welfare, and satisfaction. Components typically not included in the mission are financial goals and competitive strategies. Ethical guidance in the form of mission statements are valuable tools for health systems to use to improve organizational performance and increase employee motivation.59
Holy Cross Hospital System (HCHS) of South Bend, Indiana, provides an example of a successful organizational program to ensure that HCHS’s organizational structure and performance were value based and mission driven.60 HCHS developed 11 mission standards, created opportunities for ownership, and fostered personal responsibility within the system to ensure the fulfillment of its mission. This process of mission discernment is expanded on by Gallagher and Goodstein54 and represents an ethically grounded and practical process to ensure the moral integrity of an organization. The key operational values of the HCHS mission statement were faith, service, excellence, empowerment, and stewardship. The core values that drove the discussion and development of its mission were social justice and human dignity. Financial and legal issues were considered, but this was proportionate to core service commitments to the poor and vulnerable. As a result of sound moral grounding through its mission statement, HCHS was able to clarify choices among competing goals for the organization and find compromise for stakeholders both internal and external to the organization.
At the Harvard Vanguard Kenmore Medical Associates practice, where previous quality improvement efforts had been associated with deteriorating morale, leadership implemented specific relationship-centered practices which defused pent-up anger and frustration in the staff, decreased isolation, built teamwork, and facilitated significant quality improvement.61 They created an environment in which each clinician and staff person was treated with dignity, involved in identifying and solving quality-of-care issues, and incorporated into a systematic approach to continuous improvement. This facilitated the adoption of process improvement techniques pioneered by Toyota Production Systems, while at the same time improving morale.
Ethics guidance that is formalized in codes and organizational mission statements promotes ethical discourse and deliberation around institutional integrity and responsibility, and influences organizational behavior in meeting those goals.Charter Obstacles
The Charter is aspirational; it is meant to describe the behavior of a “model organization.” Many of its challenges are cultural, requiring both organizational leaders and employees to alter their historical views of their organizations and their roles within them. Traditionally, health care institutions have been hierarchical and physician focused. And despite recent financial, structural, and operational changes, health care institutions have not fundamentally altered the relationship between leadership and employees. Some individuals may be challenged by the more dynamic, open dialogue between leadership and the full spectrum of professions, employed nonprofessionals, and patients as described in the Charter. In addition, the Charter reminds all those individuals to focus on the ultimate goal of medicine, healing the patient. While the pace of work can make each task seem an end in itself, mindfulness of the larger institutional mission and each individual’s role within it can impart a sense of purpose to every job and meaning to each activity.
Another challenge is altering the social determinants of health. The ecology of these determinants is complex and not fully understood. Nor is any social structure in a position to affect all the influences on these determinants. The Charter does not suggest that health care organizations are solely responsible for improving the social determinants of health but, rather, suggests that they seek strategic partnerships with other organizations, government, and local communities, consistent with their means and their unique missions, in order to improve the health of the community.What We Want to Accomplish
This Charter complements existing treatises on professionalism, creating a document directed at health organizations and systems rather than a group of individuals. The Charter defines the professional competencies and behaviors that organizations can leverage to create an environment that promotes professional behavior throughout the organization. Developed by administrators, physicians, nurses, and patients, the Charter is a multidisciplinary effort that melds the aspirations of all involved to provide such an outcome.
We wish to ensure that this is a living document similar to the Physician Charter on Medical Professionalism and will take lessons learned from the process employed with that charter. The task of accomplishing this will rest with a representative multidisciplinary committee. The committee will seek opportunities to publicize the document in professional and trade journals as well as opportunities to present the Charter at professional meetings. The Charter will reside on the Web site of the Foundation for Medical Excellence (www.tfme.org). A list of health care systems, professional organizations, and hospitals that endorse this Charter will be listed. A nonmonetary annual prize will be awarded to the most influential practice resulting from such commitments. We foresee a time when the Charter could be incorporated into criteria for acknowledging excellence in health care organizations by certifying organizations. Further, we will ask for feedback so that the document can be modified in the future as needed to adapt to the dynamically changing world of health care delivery.References 1. Lesser CS, Lucey CR, Egener B, Braddock CH 3rd, Linas SL, Levinson W. A behavioral and systems view of professionalism. JAMA. 2010;304:2732–2737. 2. American Board of Internal Medicine (ABIM) Foundation; American College of Physicians–American Society of Internal Medicine (ACP-ASIM) Foundation; European Federation of Internal Medicine. Medical professionalism in the new millennium: A physician charter. Ann Intern Med. 2002;136:243–246. 3. Egener B, McDonald W, Rosof B, Gullen D. Perspective: Organizational professionalism: Relevant competencies and behaviors. Acad Med. 2012;87:668–674. 4. Campbell EG, Regan S, Gruen RL, et al. Professionalism in medicine: Results of a national survey of physicians. Ann Intern Med. 2007;147:795–802. 5. Martin AB, Hartman M, Benson J, Catlin A; National Health Expenditure Accounts Team. National health spending in 2014: Faster growth driven by coverage expansion and prescription drug spending. Health Aff (Millwood). 2016;35:150–160. 6. Fineberg HV. Shattuck lecture. A successful and sustainable health system—How to get there from here. N Engl J Med. 2012;366:1020–1027. 7. Singleton T, Miller P. The physician employment trend: What you need to know. Fam Pract Manag. 2015;22:11–15. 10. Kanter RM. How great companies think differently. Harv Bus Rev. 2011;89:66–78. 11. Paine LS. Does ethics pay? Bus Ethics Q. 2000;10:319–330. 14. Tilburt JC. Addressing dual agency: Getting specific about the expectations of professionalism. Am J Bioeth. 2014;14:29–36. 15. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. 2001.Washington, DC: National Academy Press. 17. Mechanic D. Managed care and the imperative for a new professional ethic. 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Patients’ perception of hospital care in the United States. N Engl J Med. 2008;359:1921–1931. 25. Taylor J, Rutherford P. The pursuit of genuine partnerships with patients and family members: The challenge and opportunity for executive leaders. Front Health Serv Manage. 2010;26:3–14. 27. Lee TH, Campion EW, Morrissey S, Drazen JM. Leading the transformation of healthcare delivery—The launch of NEJM Catalyst. N Engl J Med. 2015;373:2468–2469. 29. Davies HT, Mannion R, Jacobs R, Powell AE, Marshall MN. Exploring the relationship between senior management team culture and hospital performance. Med Care Res Rev. 2007;64:46–65. 30. Jacobs R, Mannion R, Davies HT, Harrison S, Konteh F, Walshe K. The relationship between organizational culture and performance in acute hospitals. Soc Sci Med. 2013;76:115–125. 31. Shanafelt TD, Gorringe G, Menaker R, et al. Impact of organizational leadership on physician burnout and satisfaction. Mayo Clin Proc. 2015;90:432–440. 32. Poghosyan L, Clarke SP, Finlayson M, Aiken LH. Nurse burnout and quality of care: Cross-national investigation in six countries. Res Nurs Health. 2010;33:288–298. 33. Linzer M, Manwell LB, Williams ES, et al; MEMO (Minimizing Error, Maximizing Outcome) Investigators. Working conditions in primary care: Physician reactions and care quality. Ann Intern Med. 2009;151:28–36, W6. 34. Spence Laschinger HK, Leiter MP. The impact of nursing work environments on patient safety outcomes: The mediating role of burnout/engagement. J Nurs Adm. 2006;36:259–267. 35. Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009;302:1284–1293. 36. Friedberg MW, Chen PG, Van Busum KR, et al. Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. 2013.Santa Monica, CA: RAND Corporation. 37. Bodenheimer T, Sinsky C. From triple to quadruple aim: Care of the patient requires care of the provider. Ann Fam Med. 2014;12:573–576. 38. Stammen LA, Stalmeijer RE, Paternotte E, et al. Training physicians to provide high-value, cost-conscious care: A systematic review. JAMA. 2015;314:2384–2400. 39. Institute of Medicine. Measuring the Impact of Interprofessional Education on Collaborative Practice and Patient Outcomes. 2015.Washington, DC: National Academy Press. 40. Gittell JH. Kim C, Gretchen S. New directions for relational coordination theory. In: Oxford Handbook of Positive Organizational Scholarship. 2011: London, UK: Oxford University Press; Chapter 30. 41. Cameron K, Mora C, Leutscher T, Calarco M. Effects of positive practices on organizational effectiveness. J Appl Behav Sci. 2011;47:266–284. 42. De Meester K, Verspuy M, Monsieurs KG, Van Bogaert P. SBAR improves nurse–physician communication and reduces unexpected death: A pre and post intervention study. Resuscitation. 2013;84:1192–1196. 45. Schlesinger M, Gray B, Carrino G, et al. A broader vision for managed care, Part 2: A typology of community benefits. Health Aff (Millwood). 1998;17:26–49. 46. Lavizzo-Mourey R. Why we need to build a culture of health in the United States. Acad Med. 2015;90:846–848. 47. Westfall JM, Fagnan LJ, Handley M, et al. Practice-based research is community engagement. J Am Board Fam Med. 2009;22:423–427. 52. Jacobson RM, Isham GJ, Finney Rutten LJ. Population health as a means for health care organizations to deliver value. Mayo Clin Proc. 2015;90:1465–1470. http://dx.doi.org/10.1016/j.mayocp.2015.07.010. Accessed November 23, 2016. 53. Institute of Medicine (IOM). Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. 2012.Washington, DC: National Academies Press. 54. Gallagher JA, Goodstein J. Fulfilling institutional responsibilities in health care: Organizational ethics and the role of mission discernment. Bus Ethics Q. 2002;12:433–450. 55. Carter K, Dorgan S, Layton D. Why Hospital Management Matters. 2012.Washington, DC: McKinsey & Company. 56. Tsai TC, Jha AK, Gawande AA, Huckman RS, Bloom N, Sadun R. Hospital board and management practices are strongly related to hospital performance on clinical quality metrics. Health Aff (Millwood). 2015;34:1304–1311. 57. Paine LS. Does ethics pay? Bus Ethics Q. 2000;10:319–330. 58. Bart CK, Tabone JC. Mission statement content and hospital performance in the Canadian not-for-profit health care sector. Health Care Manage Rev. 1999;24:18–29. 59. Forehand A. Mission and organizational performance in the healthcare industry. J Healthc Manag. 2000;45:267–277. 60. Vandenberg P, Grant MK. The necessity of mission integration. A system develops processes to weave values into the life of the organization. Health Prog. 1992;73:32–35. 61. Neuwirth A. Suchman A, Sluyter DJ. The Harvard Vanguard Kenmore practice experience: A focus on human development and relationship building. In: Leading Change in Healthcare. 2011: London, UK: Radcliffe Publishing; Chapter 12. Appendix 1 Charter on Professionalism for Health Care Organizations Preamble
This document is intended to articulate a set of principles and behaviors for health care organizations that aspire to nurture professionalism, to encourage the pursuit of excellence by all employees, and to achieve outstanding health care with the broader community. The document is structured as a set of expectations as to how model health care organizations should be led and managed. It is aspirational and supports a health system that is dynamic and constantly trying to improve.
A key tenet of this document is that health care organizations have been gradually evolving so that the activities of model health care organizations should go beyond trying to treat disease and restore health. The work of model health care organizations should include health promotion, disease prevention, value-driven care, interdisciplinary collaboration, and community involvement, all within a fiscally responsible environment.
This evolution of the health care environment has and will continue to create challenges for all of the traditional professions that operate within health care organizations. As increasing numbers of the members of these professions are employed by and function within these organizations, the organizations will have further opportunities to profoundly affect the professional behaviors of those individuals in both positive and negative ways. Organizational behaviors do more than create an environment that influences the professionalism of those within it. They have a powerful influence on the environment beyond their walls: They interact with other organizations that affect health and can directly impact the social determinants of health in ways that individual professionals or health care professional membership organizations cannot.
This Charter was created to help meet these challenges. There are four themes or concepts that apply to all health care organizations’ activities. First, model health care organizations need to emphasize the primacy of obligations to patients and ensure that all members of the organization reflect this priority in their day-to-day work. Second, model health care organizations promote the goal of broad access to health care. Third, model health care organizations are good stewards of resources invested in health care. Finally, model health care organizations are learning organizations. The organization continually transforms itself to perform its core mission better and to take on new roles as the health system evolves.Patient Partnerships
The primary focus of health care organizations is the care and well-being of patients. Model organizations partner with patients to ensure a patient-centered approach that supports the health of the whole person, not just the treatment of disease.Commitment to engagement
Model organizations invite active participation of patients and their formal and informal care partners in all relevant aspects of care. These partnerships support care that is respectful of and responsive to an individual’s priorities, goals, needs, and values. Utilizing communication strategies that engender trust, model organizations foster an outcomes-based approach to health that goes beyond delivery and receipt of health care.Commitment to shared decision making
Together, patients and their care partners clarify and evaluate all care options and the best available evidence to choose a course of care consistent with the patient’s personal values and preferences. Organizational professionalism ensures that the culture, environment, and infrastructure support the communication and literacy needs of all involved in the decision-making process.Commitment to collaboration, continuity, and coordination
Model organizations foster effective team-based care and support the role of patients as members of teams. In collaboration with patients and their formal and informal care partners, model organizations ensure safe and effective team transitions across settings and time to support a “one patient, one team” model of care.Commitment to measure what matters to patients
In partnership with patients, model organizations identify outcomes of interest to patients and use patient-reported and -generated data to monitor progress and performance on those outcomes. Model organizations establish methods to support their continuous learning from these data. They provide meaningful feedback to patients and their care partners related to these data and the learning from it.Organizational Culture
Organizational culture is the set of beliefs and practices that creates the expectations, norms, and operational behaviors within an organization. Organizational culture is reflected in the well-being of patients and employees, employee retention, quality of care, health outcomes, and elimination of medical error.Commitment to the well-being of individuals
Model organizations promote the well-being of all those who are cared for or work within them. Encouraging and modeling self-reflection and humility ensures that all interactions are respectful and that employees are valued and empowered.Commitment to teamwork
Best care happens when all members of the team, including patients, share information and decision-making responsibility. Ensuring teamwork requires organizational structures and processes that support communication across staff and with patients.Commitment to a healthy workplace
Model organizations create work environments that are physically and psychologically safe and provide tools and incentives for employees to achieve healthy lifestyles.Commitment to inclusion and diversity
Model organizations incorporate the voices of employees and patients in organizational initiatives, including clinical domains. They encourage respectful attention to alternative viewpoints. Communication training for all staff emphasizes teamwork, respect, inclusiveness, and cultural sensitivity. The workforce, including leadership, reflects the diversity of patients and the community.Commitment to accountability
Model organizations create a culture of trust and empowerment by articulating the mission and values of the organization, aligning policies, creating an infrastructure to promote those values, and eliminating activities that undermine professionalism. They align employee incentives with organizational values, reward success, provide supportive remediation for those who struggle to meet expectations, promote job satisfaction, and provide opportunities to learn. Model organizations encourage feedback to leadership regarding any experience and observation of activities that compromise the organization’s values. Model organizations create an environment that encourages disclosure of events or suspect processes using knowledge gained to prevent harm and improve safety for patients and staff.Community Partnerships
Model organizations collaborate with other health care organizations and the communities they serve to reduce health disparities related to factors such as education, income, and the environment. They focus particularly on preventable root causes of illness and access to appropriate, effective, culturally sensitive health care.Commitment to address the social determinants of health
Clinicians frequently encounter root causes of preventable illnesses, such as environmental toxins, nutritional deficits, unhealthy behaviors, and other preventable social factors. Treating these in a clinical vacuum diminishes the organization’s full potential to improve health. Therefore, it is a model organization’s ethical obligation to help identify, understand, and address social determinants of health, and to incorporate this understanding into its work.Commitment to partner with communities
Model organizations engage in strategic partnerships with governmental entities, community organizations, and other organizations serving the community to identify and mitigate root causes of illness as well as to ensure effective, culturally appropriate care. Model health care organizations include the community in organizational activities and governance, and their employees participate in community activities and governance.Commitment to advocate for access and high-value care
Model organizations partner with others to promote universal access and rational allocation of health care resources and to moderate incentive structures that do not directly lead to high-value care and healthier communities. They advocate with communities for regulatory reforms to improve environmental conditions, mitigate barriers to health care access, and improve social services.Commitment to community benefit
Model organizations and their leaders engage generously with community organizations and civic leaders to make innovative, strategic investments that leverage improved community health.Operations and Business Practices
Model organizations ensure patient safety, clinical excellence, transparency, evidence-based practices, high-value care, and professional competence. They provide sensitive, respectful, compassionate, prompt, and courteous patient care.Commitment to safeguard the privacy of patients and their health information
Model organizations must safeguard the privacy of patients and their health information. This is particularly important in the use of electronic health records, which pose continually evolving challenges to the privacy and security of patient information.Commitment to ethical operations
Ethics and compliance programs in model organizations articulate mission and values, guidelines for observing legal requirements, and standards for the highest ethical focus in addressing the health care needs of diverse populations. These programs require qualified senior-level executive leadership, mechanisms to set standards, evidence-based policies, comprehensive training and education, mechanisms to report violations without fear of retaliation, and approaches to monitor compliance and audit performance. Model organizations adhere to credentialing and regulatory standards in their operations, recruitment, training, education, and privileging.Commitment to transparent management of conflicts of interest
Model organizations have systems to identify and address potential conflicts of interest. When patients may be affected, patient welfare is given priority.Commitment to align incentives with values
Model organizations routinely review their incentive systems to ensure that they are in alignment with articulated organizational values.Commitment to fair treatment, education, and development
Model organizations compensate employees fairly; provide appropriate benefit packages; avoid staff shortages; and promote employee education, training, and growth.Commitment to high-value care
The policies and practices of model organizations engender evidence-based care and treatment that are provided to every patient. Model organizations always strive for high-value, optimal clinical outcomes, aligned with the three aims of better care, healthy populations, and reduced costs. They ensure that ordering practices for testing and treatment are evidence based and supported by standards of care.Commitment to innovation
Model organizations strive to improve current models of care. Creating opportunities to assist other organizations to achieve similar success is a form of public service. The search for and implementation of innovative approaches to management, leadership, and patient care are important indicia of organizational professionalism.Commitment to accounting and financial reporting standards
Model organizations ensure that their financial statements accurately reflect the performance of the organization. They create financial control systems and internal auditing mechanisms that ensure financial integrity.Commitment to ensure fair and equitable access to health care
Model organizations display price transparency. They make adjustments to bills for uninsured patients, so that they are not expected to pay substantially more than insured patients. They act fairly in granting “charity status” to patients who have no plausible means of paying the cost of treatment. They show flexibility in settling patient balances that exceed the patient’s financial capabilities.
Note: This Charter was created by the Organizational Professionalism Working Group:
May-Lynn Andresen, RN, BSN
Barry E. Egener, MD (Chair)
Ezekiel Emanuel, MD, PhD
David A. Fleming, MD, MA
Meg E. Gaines, JD, LLM
L. Keith Granger, BSRT
David Gullen, MD
Talmadge King, MD
Wendy Levinson, MD
Diana J. Mason, RN, PhD
Walter J. McDonald, MD
Sally Okun, RN, MMHS
Tim Rice, MPH, RPh
Bernie M. Rosof, MD
Rosemary Stevens, PhD, MPH
Alan Yuspeh, JD, MBA
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Admission-Tests [13 Certification Exam(s) ]
ADOBE [93 Certification Exam(s) ]
AFP [1 Certification Exam(s) ]
AICPA [2 Certification Exam(s) ]
AIIM [1 Certification Exam(s) ]
Alcatel-Lucent [13 Certification Exam(s) ]
Alfresco [1 Certification Exam(s) ]
Altiris [3 Certification Exam(s) ]
Amazon [2 Certification Exam(s) ]
American-College [2 Certification Exam(s) ]
Android [4 Certification Exam(s) ]
APA [1 Certification Exam(s) ]
APC [2 Certification Exam(s) ]
APICS [2 Certification Exam(s) ]
Apple [69 Certification Exam(s) ]
AppSense [1 Certification Exam(s) ]
APTUSC [1 Certification Exam(s) ]
Arizona-Education [1 Certification Exam(s) ]
ARM [1 Certification Exam(s) ]
Aruba [6 Certification Exam(s) ]
ASIS [2 Certification Exam(s) ]
ASQ [3 Certification Exam(s) ]
ASTQB [8 Certification Exam(s) ]
Autodesk [2 Certification Exam(s) ]
Avaya [96 Certification Exam(s) ]
AXELOS [1 Certification Exam(s) ]
Axis [1 Certification Exam(s) ]
Banking [1 Certification Exam(s) ]
BEA [5 Certification Exam(s) ]
BICSI [2 Certification Exam(s) ]
BlackBerry [17 Certification Exam(s) ]
BlueCoat [2 Certification Exam(s) ]
Brocade [4 Certification Exam(s) ]
Business-Objects [11 Certification Exam(s) ]
Business-Tests [4 Certification Exam(s) ]
CA-Technologies [21 Certification Exam(s) ]
Certification-Board [10 Certification Exam(s) ]
Certiport [3 Certification Exam(s) ]
CheckPoint [41 Certification Exam(s) ]
CIDQ [1 Certification Exam(s) ]
CIPS [4 Certification Exam(s) ]
Cisco [318 Certification Exam(s) ]
Citrix [48 Certification Exam(s) ]
CIW [18 Certification Exam(s) ]
Cloudera [10 Certification Exam(s) ]
Cognos [19 Certification Exam(s) ]
College-Board [2 Certification Exam(s) ]
CompTIA [76 Certification Exam(s) ]
ComputerAssociates [6 Certification Exam(s) ]
Consultant [2 Certification Exam(s) ]
Counselor [4 Certification Exam(s) ]
CPP-Institue [2 Certification Exam(s) ]
CPP-Institute [1 Certification Exam(s) ]
CSP [1 Certification Exam(s) ]
CWNA [1 Certification Exam(s) ]
CWNP [13 Certification Exam(s) ]
Dassault [2 Certification Exam(s) ]
DELL [9 Certification Exam(s) ]
DMI [1 Certification Exam(s) ]
DRI [1 Certification Exam(s) ]
ECCouncil [21 Certification Exam(s) ]
ECDL [1 Certification Exam(s) ]
EMC [129 Certification Exam(s) ]
Enterasys [13 Certification Exam(s) ]
Ericsson [5 Certification Exam(s) ]
ESPA [1 Certification Exam(s) ]
Esri [2 Certification Exam(s) ]
ExamExpress [15 Certification Exam(s) ]
Exin [40 Certification Exam(s) ]
ExtremeNetworks [3 Certification Exam(s) ]
F5-Networks [20 Certification Exam(s) ]
FCTC [2 Certification Exam(s) ]
Filemaker [9 Certification Exam(s) ]
Financial [36 Certification Exam(s) ]
Food [4 Certification Exam(s) ]
Fortinet [13 Certification Exam(s) ]
Foundry [6 Certification Exam(s) ]
FSMTB [1 Certification Exam(s) ]
Fujitsu [2 Certification Exam(s) ]
GAQM [9 Certification Exam(s) ]
Genesys [4 Certification Exam(s) ]
GIAC [15 Certification Exam(s) ]
Google [4 Certification Exam(s) ]
GuidanceSoftware [2 Certification Exam(s) ]
H3C [1 Certification Exam(s) ]
HDI [9 Certification Exam(s) ]
Healthcare [3 Certification Exam(s) ]
HIPAA [2 Certification Exam(s) ]
Hitachi [30 Certification Exam(s) ]
Hortonworks [4 Certification Exam(s) ]
Hospitality [2 Certification Exam(s) ]
HP [750 Certification Exam(s) ]
HR [4 Certification Exam(s) ]
HRCI [1 Certification Exam(s) ]
Huawei [21 Certification Exam(s) ]
Hyperion [10 Certification Exam(s) ]
IAAP [1 Certification Exam(s) ]
IAHCSMM [1 Certification Exam(s) ]
IBM [1532 Certification Exam(s) ]
IBQH [1 Certification Exam(s) ]
ICAI [1 Certification Exam(s) ]
ICDL [6 Certification Exam(s) ]
IEEE [1 Certification Exam(s) ]
IELTS [1 Certification Exam(s) ]
IFPUG [1 Certification Exam(s) ]
IIA [3 Certification Exam(s) ]
IIBA [2 Certification Exam(s) ]
IISFA [1 Certification Exam(s) ]
Intel [2 Certification Exam(s) ]
IQN [1 Certification Exam(s) ]
IRS [1 Certification Exam(s) ]
ISA [1 Certification Exam(s) ]
ISACA [4 Certification Exam(s) ]
ISC2 [6 Certification Exam(s) ]
ISEB [24 Certification Exam(s) ]
Isilon [4 Certification Exam(s) ]
ISM [6 Certification Exam(s) ]
iSQI [7 Certification Exam(s) ]
ITEC [1 Certification Exam(s) ]
Juniper [64 Certification Exam(s) ]
LEED [1 Certification Exam(s) ]
Legato [5 Certification Exam(s) ]
Liferay [1 Certification Exam(s) ]
Logical-Operations [1 Certification Exam(s) ]
Lotus [66 Certification Exam(s) ]
LPI [24 Certification Exam(s) ]
LSI [3 Certification Exam(s) ]
Magento [3 Certification Exam(s) ]
Maintenance [2 Certification Exam(s) ]
McAfee [8 Certification Exam(s) ]
McData [3 Certification Exam(s) ]
Medical [69 Certification Exam(s) ]
Microsoft [374 Certification Exam(s) ]
Mile2 [3 Certification Exam(s) ]
Military [1 Certification Exam(s) ]
Misc [1 Certification Exam(s) ]
Motorola [7 Certification Exam(s) ]
mySQL [4 Certification Exam(s) ]
NBSTSA [1 Certification Exam(s) ]
NCEES [2 Certification Exam(s) ]
NCIDQ [1 Certification Exam(s) ]
NCLEX [2 Certification Exam(s) ]
Network-General [12 Certification Exam(s) ]
NetworkAppliance [39 Certification Exam(s) ]
NI [1 Certification Exam(s) ]
NIELIT [1 Certification Exam(s) ]
Nokia [6 Certification Exam(s) ]
Nortel [130 Certification Exam(s) ]
Novell [37 Certification Exam(s) ]
OMG [10 Certification Exam(s) ]
Oracle [279 Certification Exam(s) ]
P&C [2 Certification Exam(s) ]
Palo-Alto [4 Certification Exam(s) ]
PARCC [1 Certification Exam(s) ]
PayPal [1 Certification Exam(s) ]
Pegasystems [12 Certification Exam(s) ]
PEOPLECERT [4 Certification Exam(s) ]
PMI [15 Certification Exam(s) ]
Polycom [2 Certification Exam(s) ]
PostgreSQL-CE [1 Certification Exam(s) ]
Prince2 [6 Certification Exam(s) ]
PRMIA [1 Certification Exam(s) ]
PsychCorp [1 Certification Exam(s) ]
PTCB [2 Certification Exam(s) ]
QAI [1 Certification Exam(s) ]
QlikView [1 Certification Exam(s) ]
Quality-Assurance [7 Certification Exam(s) ]
RACC [1 Certification Exam(s) ]
Real-Estate [1 Certification Exam(s) ]
RedHat [8 Certification Exam(s) ]
RES [5 Certification Exam(s) ]
Riverbed [8 Certification Exam(s) ]
RSA [15 Certification Exam(s) ]
Sair [8 Certification Exam(s) ]
Salesforce [5 Certification Exam(s) ]
SANS [1 Certification Exam(s) ]
SAP [98 Certification Exam(s) ]
SASInstitute [15 Certification Exam(s) ]
SAT [1 Certification Exam(s) ]
SCO [10 Certification Exam(s) ]
SCP [6 Certification Exam(s) ]
SDI [3 Certification Exam(s) ]
See-Beyond [1 Certification Exam(s) ]
Siemens [1 Certification Exam(s) ]
Snia [7 Certification Exam(s) ]
SOA [15 Certification Exam(s) ]
Social-Work-Board [4 Certification Exam(s) ]
SpringSource [1 Certification Exam(s) ]
SUN [63 Certification Exam(s) ]
SUSE [1 Certification Exam(s) ]
Sybase [17 Certification Exam(s) ]
Symantec [134 Certification Exam(s) ]
Teacher-Certification [4 Certification Exam(s) ]
The-Open-Group [8 Certification Exam(s) ]
TIA [3 Certification Exam(s) ]
Tibco [18 Certification Exam(s) ]
Trainers [3 Certification Exam(s) ]
Trend [1 Certification Exam(s) ]
TruSecure [1 Certification Exam(s) ]
USMLE [1 Certification Exam(s) ]
VCE [6 Certification Exam(s) ]
Veeam [2 Certification Exam(s) ]
Veritas [33 Certification Exam(s) ]
Vmware [58 Certification Exam(s) ]
Wonderlic [2 Certification Exam(s) ]
Worldatwork [2 Certification Exam(s) ]
XML-Master [3 Certification Exam(s) ]
Zend [6 Certification Exam(s) ]
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