Clinical Focus

  • Perioperative medicine
  • Anesthesia

Academic Appointments

Administrative Appointments

  • Vice Chair, Quality, Safety and Improvement, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford School of Medicine (2019 - Present)
  • Associate Chief Quality Officer, Stanford Health Care (2018 - Present)
  • Physician Advisor, Care Coordination and Utilization Management, Stanford Health Care (2019 - Present)
  • Physician Improvement Lead, Improvement Capability Development Program, Stanford School of Medicine (2017 - Present)
  • Chair, Clinical Effectiveness Resource Management Committee, Stanford Health Care (2020 - Present)
  • Co-chair, Cost Savings Reinvestment Program, Stanford Health Care (2020 - Present)
  • Medical Director, High Value Care and Clinical Effectiveness, Stanford Health Care (2017 - 2019)

Professional Education

  • Board Certification: American Board of Anesthesiology, Anesthesia (2010)
  • Residency: Massachusetts General Hospital (2007) MA
  • Internship: Beth Israel Deaconess Medical Center (2004) MA
  • MD, University of California, San Francisco (2003)
  • MPH, Harvard School of Public Health (2001)
  • BA, UC Berkeley

Contact

  • Academic
    aclu@stanford.edu
    University - Staff Department: Anesthesia - MSD Position: Clinical Associate Professor
    University - Affiliate Department: Anesthesia - MSD
  • Clinical (Primary)  Anesthesia Department 300 Pasteur Dr Rm H3580 MC 5640 Stanford, CA 94305 (650) 725-8544 (fax)

Additional Clinical Info

Additional Info

  • Mail Code: 5640

All Publications

  • A Protocol for Reducing Intensive Care Utilization After Craniotomy: A 3-Year Assessment. Neurosurgery Ruiz Colón, G. D., Ohkuma, R., Pendharkar, A. V., Heifets, B. D., Li, G., Lu, A., Gephart, M. H., Ratliff, J. K. 2023

    Abstract

    Craniotomy patients have traditionally received intensive care unit (ICU) care postoperatively. Our institution developed the "Non-Intensive CarE" (NICE) protocol to identify craniotomy patients who did not require postoperative ICU care.To determine the longitudinal impact of the NICE protocol on postoperative length of stay (LOS), ICU utilization, readmissions, and complications.In this retrospective cohort study, our institution's electronic medical record was queried to identify craniotomies before protocol deployment (May 2014-May 2018) and after deployment (May 2018-December 2021). The primary end points were average postoperative LOS and ICU utilization; secondary end points included readmissions, reoperation, and postoperative complications rate. End points were compared between pre- and postintervention cohorts.Four thousand eight hundred thirty-seven craniotomies were performed from May 2014 to December 2021 (2302 preprotocol and 2535 postprotocol). Twenty-one percent of postprotocol craniotomies were enrolled in the NICE protocol. After protocol deployment, the overall postoperative LOS decreased from 4.0 to 3.5 days (P = .0031), which was driven by deceased postoperative LOS among protocol patients (average 2.4 days). ICU utilization decreased from 57% of patients to 42% (P < .0001), generating ∼$760 000 in savings. Return to the ICU and complications decreased after protocol deployment. 5.8% of protocol patients had a readmission within 30 days; none could have been prevented through ICU stay.The NICE protocol is an effective, sustainable method to increase ICU bed availability and decrease costs without changing outcomes. To our knowledge, this study features the largest series of patients enrolling in an ICU utilization reduction protocol. Careful patient selection is a requirement for the success of this approach.

    View details for DOI 10.1227/neu.0000000000002337

    View details for PubMedID 36639854

  • Association Between Implementation of a Geriatric Trauma Clinical Pathway and Changes in Rates of Delirium in Older Adults With Traumatic Injury. JAMA surgery Park, C., Bharija, A., Mesias, M., Mitchell, A., Krishna, P., Storr-Street, N., Brown, A., Martin, M., Lu, A. C., Staudenmayer, K. L. 2022

    Abstract

    Importance: Older adults (age ≥65 years) are at risk for high rates of delirium and poor outcomes; however, how to improve outcomes is still being explored.Objective: To assess whether implementation of a geriatric trauma clinical pathway was associated with reduced rates of delirium in older adults with traumatic injury.Design, Setting, and Participants: A retrospective case-control study of electronic health records of patients aged 65 years or older with traumatic injury from 2018 to 2020 was conducted at a single level I trauma center. Eligible patients were age 65 years or older admitted to the trauma service and who did not undergo an operation.Intervention: The implementation of a clinical pathway based on geriatric best practices, which included order sets, guidelines, automated consultations, and escalation pathways executed by a multidisciplinary team.Main Outcomes and Measures: The primary outcome was delirium. The secondary outcome was hospital length of stay. Process measures for pathway compliance were also assessed.Results: Of the 859 eligible patients, 712 patients were included in the analysis (442 [62.1%] in the baseline group; 270 [37.9%] in the postimplementation group; mean [SD] age: 81.4 [9.1] years; 394 [55.3%] were female). The mechanism of injury was not different between groups, with 247 in the baseline group (55.9%) and 162 in the postimplementation group (60.0%) (P=.43) experiencing a fall. Injuries were minor or moderate in both groups (261 in baseline group [59.0%] and 168 in postimplementation group [62.2%]; P=.87). The adjusted odds ratio for delirium in the postimplementation cohort was 0.54 (95% CI, 0.37-0.80; P<.001). Goals of care documentation improved significantly in the postimplementation cohort vs the baseline cohort with regard to documented goals of care notes (53.7% in the postimplementation cohort [145 of 270] vs 16.7% in the baseline cohort [74 of 442]; P<.001) and a shortened time to discussion from presenting to the emergency department (36 hours in the postimplementation cohort vs 50 hours in the baseline cohort; P=.03).Conclusions and Relevance: In this study, implementation of a multidisciplinary clinical pathway for injured older adults at a single level I trauma center was associated with improved care and clinical outcomes. Interventions such as these may have utility in this vulnerable population, and findings should be confirmed across multiple centers.

    View details for DOI 10.1001/jamasurg.2022.1556

    View details for PubMedID 35675065

  • Recommendations from the ICM-VTE: Hand & Wrist JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Beredjiklian, P., Chisari, E., Goh, G. S., Jones, C. M., Lu, A. C., Mack, P., Meermans, G., Tulipan, J. E. 2022; 104 (SUPPL 1): 176-179

    View details for DOI 10.2106/JBJS.21.01213

    View details for Web of Science ID 000769636300004

    View details for PubMedID 35315609

  • In Reply: A Novel Protocol for Reducing Intensive Care Utilization After Craniotomy. Neurosurgery Pendharkar, A. V., Shahin, M. N., Awsare, S. S., Ho, A. L., Wachira, C., Clevinger, J., Sigurdsson, S., Lee, Y., Wilson, A., Lu, A. C., Hayden, M. G. 1800

    View details for DOI 10.1227/NEU.0000000000001874

    View details for PubMedID 35103024

  • Engaging Frontline Physicians in Value Improvement: A Qualitative Evaluation of Physician-Directed Reinvestment. Journal of healthcare leadership Vilendrer, S., Amano, A., Asch, S. M., Brown-Johnson, C., Lu, A. C., Maggio, P. 2022; 14: 31-45

    Abstract

    Purpose: Physicians can limit upward trending healthcare costs, yet legal and ethical barriers prevent the use of direct financial incentives to engage physicians in cost-reduction initiatives. Physician-directed reinvestment is an alternative value-sharing arrangement in which a health system reinvests a portion of savings attributed to physician-led cost reduction initiatives back into professional areas of the physicians' choosing. Formal evaluations of such programs are lacking.Methods: To understand the impact of Stanford Health Care's physician-directed reinvestment in its first year (2017-2018) on physician engagement, adherence to program requirements around safety and fund use, and factors facilitating program dissemination, semi-structured qualitative interviews with physician participants, non-participants, and administrative stakeholders were conducted July-November 2019. Interview transcripts were qualitatively analyzed through an implementation science lens. To support contextual analysis of the qualitative data, a directional estimation of the program's impact on cost from the perspective of the health system was calculated by subtracting annual maintenance cost (derived from interview self-reported time estimates and public salary data) from internal cost accounting of the total savings from first year cohort to obtain annual net benefit, which was then divided by the annual maintenance cost.Results: Physician participation was low compared with the overall physician population (n=14 of approximately 2300 faculty physicians), though 32 qualitative interviews suggested deep engagement across physician participants and adherence to target program requirements. Reinvestment funds activated intrinsic motivators such as autonomy, purpose and inter-professional relations, and extrinsic motivators, such as the direction of resources and external recognition. Ongoing challenges included limited physician awareness of healthcare costs and the need for increased clarity around which projects rise above one's existing job responsibilities. Administrative data excluding physician time, which was not directly compensated, showed a direct cost savings of $8.9M. This implied an 11-fold return on investment excluding uncompensated physician time.Conclusion: A physician-directed reinvestment program appeared to facilitate latent frontline physician innovation towards value, though additional evaluation is needed to understand its long-term impact.

    View details for DOI 10.2147/JHL.S335763

    View details for PubMedID 35422669

  • Enhanced Recovery after Bariatric Surgery: Further Reduction in Opioid Use with the Introduction of Dexmedetomidine and Transverse Abdominis Plane Block Alimi, Y. R., Crawford, E., Hoorzuk, S., Cheng, N., Lu, A., Kennedy, L., Ahmed, T., Esquivel, M., Azagury, D. E., Zak, Y. ELSEVIER SCIENCE INC. 2021: S21

    View details for Web of Science ID 000718303100015

  • More Than an ERAS Pathway is Needed to Meet Target Length of Stay After Pancreaticoduodenectomy. The Journal of surgical research Ayala, C. I., Li, A. Y., Lu, A., Wilson, A., Bergquist, J. R., Poultsides, G. A., Norton, J. A., Visser, B. C., Dua, M. M. 2021; 270: 195-202

    Abstract

    BACKGROUND: Enhanced Recovery After Surgery (ERAS) protocols have been successfully instituted for pancreaticoduodenectomy (PD). This study evaluates reasons patients fail to meet length of stay (LOS) and areas for pathway improvement.MATERIALS AND METHODS: A multidisciplinary team developed and implemented an ERAS protocol for open PD in 2017. The study includes a medical record review of all patients who were perioperatively managed with the ERAS protocol and failed to meet LOS after PD procedures. Target LOS was defined as 7 d.RESULTS: From 2017 to 2020, 44% (93 of 213) of patients using ERAS protocol after PD procedures failed to meet target LOS. The most common reason to fail target LOS was ileus or delayed gastric emptying (47 of 93, LOS 11). Additional reasons included work-up of leukocytosis or pancreatic leak (17 of 93, LOS 14), additional "night" of observation (14 of 93, LOS 8), and orthostatic hypotension (3 of 93, LOS 10). Of these additional 46 patients, 19 patients underwent computed tomography (on or after POD 7) and only four patients received additional inpatient intervention.CONCLUSIONS: The most common reason for PD pathway failure included slow return of gastrointestinal function, a known complication after PD. The remaining patients were often kept for observation without additional intervention. This group represents an actionable cohort to target for improving LOS through surgeon awareness rather than protocol modification.

    View details for DOI 10.1016/j.jss.2021.08.034

    View details for PubMedID 34688991

  • Waste reduction in the operating room - old habits die hard, but change is possible Taylor, J., Kalra, P., Alejandro-Harper, D., Pena, N., Saffary, R., Solomon, S., Law, B., Kadry, B., Macario, A., Lu, A. LIPPINCOTT WILLIAMS & WILKINS. 2021: 1637

    View details for Web of Science ID 000713327102029

  • A Novel Protocol for Reducing Intensive Care Utilization After Craniotomy. Neurosurgery Pendharkar, A. V., Shahin, M. N., Awsare, S. S., Ho, A. L., Wachira, C., Clevinger, J., Sigurdsson, S., Lee, Y., Wilson, A., Lu, A. C., Gephart, M. H. 2021

    Abstract

    BACKGROUND: There is a growing body of evidence suggesting not all craniotomy patients require postoperative intensive care.OBJECTIVE: To devise and implement a standardized protocol for craniotomy patients eligible to transition directly from the operating room to the ward-the Non-Intensive CarE (NICE) protocol.METHODS: We preoperatively identified patients undergoing elective craniotomy for simple neurosurgical procedures with age <65 yr and American Society of Anesthesiologists (ASA) class of 1, 2 or 3. Postoperative eligibility was confirmed by the surgical and anesthesia teams. Upon arrival to the ward, patients were staffed with a neuroscience nurse for hourly neurological examinations for the first 8 h. Patient demographics, clinical characteristics, and outcomes were prospectively collected to evaluate the NICE protocol.RESULTS: From February 2018 to 2019, 63 patients were included in the NICE protocol with a median age of 46 yr and 65% female predominance. Of the operations performed, 38.1% were microvascular decompressions, 31.7% were craniotomy for tumor, 15.9% were cavernous malformation resections, and 14.3% were Chiari decompressions. No patients required transfer to the intensive care unit (ICU). Median length of stay was 2 d. There was an 11.1% overall readmission rate within the median follow-up period of 48 d. Three patients (4.8%) required reoperation at time of readmission within the follow-up period (1 postoperative subdural hematoma, 2 cerebrospinal fluid leak repair). None of these complications could have been identified with a postoperative ICU stay.CONCLUSION: In our pilot trial of the NICE protocol, no patients required postoperative transfer to the ICU.

    View details for DOI 10.1093/neuros/nyab187

    View details for PubMedID 34089323

  • Perioperative Care and Airway Management for a Patient With Sagliker Syndrome. Cureus Chen, Q., Lorenzo, J., Lu, A. 2020; 12 (9): e10691

    Abstract

    In this report, we present a case of a patient with a history of complex airway anatomy secondary to Sagliker syndrome (SS) who presented with acute exacerbation of chronic respiratory failure. The patient's difficult airway, complicated medical comorbidities, and poor psychosocial status posed a unique challenge for providing safe care during an emergency. The perioperative anesthesia service (PAS), led by critical care anesthesiologists, coordinated a multidisciplinary airway management plan. The PAS team also assisted this medically complex patient with her decision-making process. A 37-year-old female with SS, which is characterized by irreversible disfiguring of head and neck anatomy secondary to end-stage renal disease (ESRD) and poorly controlled hyperparathyroidism, presented with acute exacerbation of chronic respiratory failure due to hypervolemia. The patient's respiratory status rapidly deteriorated despite aggressive hemodialysis, requiring transfer to the ICU. Given the challenging anatomy and poor respiratory reserve in this patient, the PAS team helped coordinate a comprehensive airway plan that involved transnasal fiberoptic intubation, and in case of emergency, extracorporeal membrane oxygenation (ECMO) as a bridge to a surgical airway. During the decision-making process, the patient was found to be in psychological distress and had limited insights into her condition. The PAS team helped facilitated multidisciplinary goals-of-care discussions for the patient and her family. Fortunately, the patient's oxygenation improved with noninvasive oxygen support and aggressive hemodialysis without the need for intubation. She was discharged with outpatient follow-up appointments arranged to discuss long-term management. This is the first reported case of SS in the United States. The early involvement by the PAS team helped coordinate a multidisciplinary care plan for this patient with a difficult airway and complex comorbidities. This report highlights an innovative airway algorithm for a potentially "cannot-intubate, cannot ventilate" complex airway, and the PAS team's role in providing support for the patient's physical and psychological needs, suggesting that a comprehensive perioperative service can improve the quality and safety of care, not only for surgical patients but also for medically complex patients as well.

    View details for DOI 10.7759/cureus.10691

    View details for PubMedID 33133856

    View details for PubMedCentralID PMC7593211

  • Perioperative Care and Airway Management for a Patient With Sagliker Syndrome CUREUS Chen, Q., Lorenzo, J., Lu, A. 2020; 12 (9)

    View details for DOI 10.7759/cureus.10691

    View details for Web of Science ID 000573185700003

  • Elective Surgery and COVID-19: A Framework for the Untested Patient. Annals of surgery Lu, A. C., Burgart, A. M. 2020

    View details for DOI 10.1097/SLA.0000000000004474

    View details for PubMedID 32889879

  • The Tipping Point of Medical Technology: Implications for the Postpandemic Era. Anesthesia and analgesia Lu, A. C., Cannesson, M., Kamdar, N. 2020; 131 (2): 335–39

    View details for DOI 10.1213/ANE.0000000000005040

    View details for PubMedID 32511105

  • COVID-19 Preoperative Assessment and Testing: From Surge to Recovery. Annals of surgery Lu, A. C., Schmiesing, C. A., Mahoney, M., Cianfichi, L., Semple, A. K., Watt, D., Fischer, S., Wald, S. H. 2020

    View details for DOI 10.1097/SLA.0000000000004124

    View details for PubMedID 32541233

  • COVID-19: Common Critical and Practical Questions. Anesthesia and analgesia Lu, A. C., Sastry, S. G., Wong, B. J., Deng, A., Wald, S. H., Pearl, R. G., Tsui, B. C. 2020

    View details for DOI 10.1213/ANE.0000000000004938

    View details for PubMedID 32366770

  • N95 Respirator Alternatives And Conservation Strategies. Anesthesia and analgesia Wong, B. J., Lu, A. C., Tarlow, B. D., Tompkins, L. S., Chawla, A. n., Pearl, R. G., Wald, S. H. 2020

    View details for DOI 10.1213/ANE.0000000000005134

    View details for PubMedID 32701549

  • Determination of Length of Time for "Post-Aerosol Pause" for Patients Under Investigation or Positive for COVID-19. Anesthesia and analgesia Wald, S. H., Arthofer, R. n., Semple, A. K., Bhorik, A. n., Lu, A. C. 2020

    View details for DOI 10.1213/ANE.0000000000004921

    View details for PubMedID 32345854

    View details for PubMedCentralID PMC7202114

  • Resuscitation on collapsed healthcare worker while taking care of suspected or confirmed COVID patient: Questions and Answers. Anesthesia and analgesia Lu, A. C., Wong, B. J., Sastry, S. G., Wald, S. H., Pearl, R. G., Tsui, B. C. 2020

    View details for DOI 10.1213/ANE.0000000000005136

    View details for PubMedID 32701548

  • Burnout, Wellness, and Resilience in Anesthesiology. International anesthesiology clinics Answine, J. F., Lu, A. C., Levy, T. S. 2019; 57 (3): 138-145

    View details for DOI 10.1097/AIA.0000000000000235

    View details for PubMedID 31577244

  • Preserving Perioperative Brain Health Through a Patient Safety Lens. International anesthesiology clinics Riccio, C. A., Lu, A. C., Lin, D. M. 2019; 57 (3): 96-110

    View details for DOI 10.1097/AIA.0000000000000238

    View details for PubMedID 31577241

  • Burnout, Wellness, and Resilience in Anesthesiology INTERNATIONAL ANESTHESIOLOGY CLINICS Answine, J. F., Lu, A. C., Levy, T. M. 2019; 57 (3): 138–45

    View details for DOI 10.1097/AIA.0000000000000235

    View details for Web of Science ID 000471668300013

  • Preserving Perioperative Brain Health Through a Patient Safety Lens INTERNATIONAL ANESTHESIOLOGY CLINICS Riccio, C. A., Lu, A. C., Lin, D. M. 2019; 57 (3): 96–110

    View details for DOI 10.1097/AIA.0000000000000238

    View details for Web of Science ID 000471668300010

  • Into the Wilderness?: The Growing Importance of Nonoperating Room Anesthesia Care in the United States. Anesthesia and analgesia Lu, A. C., Wald, S. H., Sun, E. C. 2017; 124 (4): 1044–46

    View details for PubMedID 28319544