Anesthesia Patient Safety Foundation Research Articles

Human Factors Engineering in Patient Safety

Human Factors Engineering in Patient Safety

Anesthesia Quality and Safety

Anesthesia Quality and Safety

Listening to breathing again!

Failure to rescue is a measure of quality of care of a health care system. Mortality and complication rates for patients are influenced by the severity of illness of the patients. Therefore ‘‘risk-adjusted’’ rates are produced. A hospital tries to justify that it’s higher complication rate is because their patients are sicker. Failure to rescue a patient who gets into trouble is dependent on the hospital characteristics more than the severity of illness of the patients. This is more a measure of the quality of care that the hospital is providing [1]. To be able to respond to a patient getting into distress in a timely manner, so that the chances of rescue are high are dependent on many factors and one of these is good patient monitoring. The ideal monitor has not been available to prevent respiratory depression from oversedation. Pulse oximetry when used needs to be continuous and observed continually or have a closed loop notification system for alarms. The observer must understand the effect that the administration of supplemental oxygen has on the ability of the pulse oximeter to detect respiratory depression. When oxygen is being administered through a nasal cannula, apnea may exist for many minutes before oxygen desaturation occurs. When the pulse oximeter alarms goes off the partial pressure of arterial carbon dioxide may be over 100 mmHg, making an immediate intervention necessary to avert an adverse outcome [2]. A significant number of patients have been harmed by the unrecognized respiratory depressive effects of postoperative opioids and this has caused the Anesthesia Patient Safety Foundation and the Joint Commission to issue warnings about the need to continually monitor oxygenation together with a monitor of ventilation in patients receiving oxygen [3, 4]. Capnography has been considered the ‘‘gold standard’’ for monitoring ventilation but has many drawbacks. Many patients, especially children, do not tolerate the presence of nasal cannulas for long and will dislodge them [5].The accurate clinical value of end-tidal carbon dioxide (EtCO2) relies on the adequate mixing of expired gas with alveolar gas. If the patient is hypoventilating this mixing may not occur and a low value for EtCO2 may be recorded. Tanaka et al. [6] have examined the problem of detecting apnea during sedation procedures. They have compared the sensitivity of capnography and acoustic monitors in detecting apnea during sedation and also examined the depth of the sedation, as measured by a cerebral function monitor and the calculated Patient State Index, to see if this index—depth of sedation—correlated with the incidence of respiratory pauses. This prospective study confirms the work previously reported that acoustic monitoring is as accurate as capnography for monitoring respiratory rate [7, 8]. However this study also strengthens the data previously reported that the acoustic monitor may be more sensitive in detecting apnea than capnography. The PSI did not correlate with respiratory pauses and this may be because this is a calculated number that there is a lag time to display. It is possible that if the ‘‘real time’’ raw electroencephalograph signal was observed in all the patients, that depth of anesthesia may indeed have been a factor in the presence or absence of respiratory pauses. The development of new more robust and patient friendly technology like the acoustic monitor potentially may improve the safety of our patients. This Editorial refers to the article available at doi:10.1007/s10877014-9556-8.

Board 269 - Program Innovations Abstract The Effect of Hard Stop Implementation of a Pre-Induction Checklist on Resident Performance During a Simulated Anesthetic (Submission #1296)

Introduction/Background Surgical safety checklists have been shown to reduce patient complications and improve communication in the operating room.1,2 Checklists have also been shown to improve the management of operating room crises in high fidelity simulation studies.3,4 The pre-anesthetic induction period has been identified as a time in which medical errors can occur.5 The Anesthesia Patient Safety Foundation (APSF) has developed a pre-anesthetic induction patient safety (PIPS) checklist.6 Using full environment simulation (FES), we hope to detect a significant reduction in missed steps during the pre-anesthetic set up when using this checklist. All participants in this study will be exposed to the same clinical scenario but one group will experience a “hard stop” in the documentation workflow. We hope to use the Results of this study to validate the simulated environment as an effective and novel way to inform the implementation and further study of patient safety and quality improvement initiatives that may be difficult to clinically test. Methods Using a randomized, controlled, observer-blinded design, we compare performance of anesthesiology residents using the APSF PIPS checklist in completing a thorough pre-anesthetic induction evaluation and setup, to residents with no checklist.6 The study is performed using the METI high-fidelity simulator. The simulated OR is set up to represent a previously used anesthesia machine/cart that has not been set up for a new anesthetic, and is missing the components highlighted in the PIPS checklist. The residents will be called in to provide anesthesia for a case that was booked initially as a case only requiring local anesthesia. The surgeon will create time pressure for the residents to induce anesthesia prematurely in this entirely elective setting. In the experimental group, the electronic medical record will create a “hard stop” in which the APSF PIPS checklist is displayed and must be checked and signed off on before any further documentation of the anesthetic can occur. In the control group, this “hard stop” will not be present in the electronic medical record. The simulation will end when the resident provides any medication to the patient, and missed steps will be recorded at that time. The hypothesis is that the required use of the APSF PIPS checklist prevents missed steps in the pre-anesthetic set up under time pressure in a simulated operating room. Results: Conclusion Our study illustrates the importance of the simulated environment in evaluation of new patient safety and quality improvement initiatives as the specific situations in which such initiatives are likely to increase patient safety can never be ethically or successfully replicated in real life.

In Response

We agree with Overdyk et al.1 re their major concern that a more noninvasive, unencumbering, continuous respiratory monitor is desperately needed to detect opioid-induced ventilatory impairment. The Joint Commission and the Anesthesia Patient Safety Foundation have both come out in support for this type of monitoring technology.2,3 Understanding the shortcomings of capnography in terms of patient tolerance and other limitations,4,5 we decided to evaluate the new noninvasive bioacoustic sensor that has recently become available, in a robust clinical setting, that of the postanesthesia care unit. The postanesthesia care unit is an area with much extraneous noise and activity and also an area where respiratory depression is common in all patients, those with or without sleep apnea. We felt that this would give a good clinical test of the new technology. We did use technicians, hired especially for this trial by the sponsor, to count waveforms and respiratory rates. They were blinded to the study protocol and had no knowledge as to the end points of the study. We agree we could have used a pneumotachometer to count respiratory rate but this did not lend itself to the real clinical situation, which was our test laboratory. We are encouraged by new technologies that are being developed that are patient, tolerant, accurate, and will assist in keeping our patients safe. Conflicts of Interest: Michael A. E. Ramsay, MD, receives research funds from Masimo Corporation and is a Speaker Board member and Advisory Board member for Masimo Corporation. Mohammad Usman, PhD, is an employee of Masimo Corporation.

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Introduction: Extubation failure occurs commonly in the intensive care unit (ICU) and is independently associated with morbidity, resource consumption, and death. We implemented a planned extubation safety algorithm to identify patients at risk for extubation failure. Our primary aim was to decrease the overall risk of reintubation and any airway related complications during reintubation. Secondarily, we sought to describe the effects of the intervention on the utilization of advanced airway equipment (Glidescope, fiberoptic scope) and tracheostomy. Methods: The extubation safety quality improvement project (ESQIP) was a before and after quality improvement project taking place from March 2012 to February 2013, consisting of a baseline data collection (first 6 months), an educational component with bedside signage specific to airway risk classification, distribution of laminated pocket cards illustrating the decision algorithm, inclusion of the extubation checklist in the Plan of the Day, and subsequent data collection during the intervention period (6 months). Data were collected prospectively in all intubated ICU patients. Frequency of reintubation or any airway related complications (SBP <90 mm Hg, SPO2 <90%, aspiration, cardiac arrest, or death) were compared between the baseline and intervention periods. Results: A total of 1,804 patients were included; 938 in the baseline and 866 in the post intervention period. The frequency of reintubation (n=188, 20% vs. n=162, 18.7%; p=0.47) and the composite of reintubation or reintubation related complications (n=209, 22.3% vs. n=185, 21.4%; p=0.64) were similar between baseline and intervention periods, respectively. Difficult intubation (n=22, 14% vs. n=35, 22%; p=0.08) tended to be more common and advanced airway equipment utilized more often (n=56, 27% vs. n=42, 19%; p=0.04) in the intervention period compared with baseline period. Conclusions: In the ICUs of a single large academic medical center, an extubation algorithm was associated with more frequent use of advanced airway equipment at reintubation, but did not seem to affect the frequency of reintubation overall and its related complications. The study was supported with funds from the Anesthesia Patient Safety Foundation, APSF/ASA Endowed Research Award and Ellison C. Pierce, Jr., MD Merit Award

Meeting Notes From the 2012 ASA Annual Meeting

ASPAN has long benefited from a collegial relationship with the American Society of Anesthesiologists (ASA) and the Anesthesia Patient Safety Foundation (APSF). Each year, ASPAN leadership attends the ASA Annual Meeting at the invitation of the seated ASA President. ASPAN President, Susan Carter, BSN, RN, CPAN, CAPA, and Vice President/President-Elect Twilla Shrout, BSN, MBA, RN, CPAN, CAPA, attended the 2012 ASA Annual Meeting held October 13-17, 2012, in Washington, DC. The theme of the annual meeting was Transforming Patient Safety Through Education and Advocacy. As the APSF liaison, I attended the inaugural ASA/APSF Ellison (Jeep) C. Pierce Lecture on Patient Safety and the APSF Workshop, and represented ASPAN at the APSF Board of Directors' meeting after the sessions. Kim Kraft, BSN, RN, CPAN, APSF Liason, is a Perianesthesia Nurse Clinician, Surgical Services, Mercy Hospital St. Louis, St. Louis, MO.

Capnography Outside the Operating Rooms

ISTORICALLY, anesthesiologists seem to be the forerunners in implementing tools and standards for safety in the medical fraternity. In the United States, since 1985, there has been a dramatic decrease in the malpractice insurance premiums of anesthesiologists. Such a decrease has not been seen in other medical or surgical specialties over this time frame. Thanks to the foresight of the American Society of Anesthesiologists (ASA), Anesthesia Patient Safety Foundation (APSF), Association of Anaesthetists of Great Britain and Ireland (AAGBI), and the Association of Anesthesiologists in Holland, capnography was embraced and incorporated into the standards of monitoring during anesthesia to enhance patient safety. Currently, anesthesiologists in many developing countries follow these recommendations (India, Government of Andhra Pradesh Order, AST/775/F25/dated September 2011. Capnography is mandatory for laparo

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Introduction: Several factors contribute to medication errors in anesthesia. In 2010, the Anesthesia Patient Safety Foundation set forth a medication safety paradigm consisting of four elements – standardization, technology, culture, and pharmacy/pre-filled/pre-mixed. The purpose of this study is to assess the impact of incorporating standardization and ready-to-use (RTU) medications in the intraoperative setting. Hypothesis: Pharmacy provided RTU medications in standardized concentrations and locations will enhance the safety and quality of medications administered. Methods: A prospective before-and-after anesthesia medication safety study was conducted in an academic medical center consisting of 78 anesthetizing locations and 3 pharmacy satellites. Key performance metrics including labeling compliance, medication preparation details, and waste data were collected for the first surgical cases of the day. After collection of initial state data, anesthesia medication trays were standardized across 64 operating rooms and 14 remote areas. The trays incorporated RTU syringes of medications commonly used for anesthesia induction, reversal, and emergencies. Vasoactive drip concentrations and diluents were standardized across the institution. Pharmacy increased production of several compounded sterile products that were dispensed to anesthesia providers upon request. Six months after the intervention, post-implementation data was collected to assess impact and sustainment. Results: The medication management practices of 200 cases were observed. Inclusion of medication concentration on the label significantly increased from 31% pre-intervention to 78% post-intervention (p<0.001). Provider prepared syringes of medications were significantly reduced from 88.8% to 32.8%. (p<0.001) and provider prepared intravenous admixtures were reduced from 89% to 2.9% (p<0.001). RTU medications also reduced medication waste. The largest reduction was noted for emergency medications such as atropine (93.9% reduction), succinylcholine (93.5% reduction) and phenylephrine (96.3% reduction). Conclusions: Extending pharmacy services throughout the intraoperative setting resulted in a sustained improvement in anesthesia medication safety and quality.

Advances in Drug Safety

The operating room offers a unique setting where anesthetics, preoperative medications, patient comorbidities, and surgery all merge. Anesthesiologists are responsible for combining these concerns into a dependable and safe approach. From formulation to administration, enhancements in nearly every aspect of a given drug have improved the ability of anesthesiologists to accomplish this. Some of these methodologies, including novel anesthetics and analgesics, drug delivery and administration including infusion pumps, antithrombotics, and a reappraisal of previous medications are highlighted in this review. While these advancements are significant, patients and healthcare systems globally are rightfully demanding safer application of drugs at every level. On May 1, 2012, a report issued by the Institute of Medicine advised the United States Food and Drug Administration to undertake a much more rigorous patient-centered effort to evaluate a drug's safety over its entire life-cycle. This recommendation is in agreement with the objectives of the Anesthesia Patient Safety Foundation. With these mutual goals shared by many stakeholders and their continued efforts, the future of the estimated 200 million global surgeries to be undertaken this year hopefully provides a safer experience while under anesthesia.

Meeting Notes From the 2011 ASA Annual Meeting

ASPAN has long benefited from a collegial relationship with the American Society of Anesthesiologists (ASA) and the Anesthesia Patient Safety Foundation (APSF). Each year, ASPAN leadership attends the ASA Annual Meeting at the invitation of the seated ASA President. ASPAN President Chris Price, 2011-2012, MSN, RN, CPAN, CAPA, and Vice President/President-elect Susan Carter, 2011-2012, BSN, RN, CPAN, CAPA, attended the ASA Annual Meeting held October 15-19, 2011, in Chicago, Illinois. The theme of the annual meeting was Transforming Patient Safety Through Science and Innovation.

Anesthesia Patient Safety Foundation Consensus Conference Report

Anesthesia Patient Safety Foundation Consensus Conference Report

More Than Just Taking the Keys Away …

More Than Just Taking the Keys Away …

A Matter of Conscience

Anesthesiologists are continually engaged in selfassessment, and our specialty has been defined by its commitment to minimizing errors and ensuring the safety of all patients. Anesthesiologists were pioneers in safety and continue to be seen as leaders in improving quality of care and outcomes. This is well illustrated by the Anesthesia Patient Safety Foundation, which has led efforts in anesthesia-related safety. Notwithstanding this history, 2 related areas of potentially dangerous practice continue despite numerous previous warnings. What are these dangers? The first is the accidental administration of IV drugs into epidural or intrathecal space. The second is the even more dangerous administration of epidural drugs into the circulation via the IV catheter. With this editorial, we challenge the anesthesiology community, along with the relevant industry and regulatory agencies, to take urgent action and eliminate an unnecessary and preventable risk to our patients.

PT-SAFE

Recent reports by The Joint Commission as well as the Anesthesia Patient Safety Foundation have indicated that medical audible alarm effectiveness needs to be improved. Several recent studies have explored various approaches to improving the audible alarms, motivating the authors to develop real-time software capable of comparing such alarms. We sought to devise software that would allow for the development of a variety of audible alarm designs that could also integrate into existing operating room equipment configurations. The software is meant to be used as a tool for alarm researchers to quickly evaluate novel alarm designs. A software tool was developed for the purpose of creating and annunciating audible alarms. The alarms consisted of annunciators that were mapped to vital sign data received from a patient monitor. An object-oriented approach to software design was used to create a tool that is flexible and modular at run-time, can annunciate wave-files from disk, and can be programmed with MATLAB by the user to create custom alarm algorithms. The software was tested in a simulated operating room to measure technical performance and to validate the time-to-annunciation against existing equipment alarms. The software tool showed efficacy in a simulated operating room environment by providing alarm annunciation in response to physiologic and ventilator signals generated by a human patient simulator, on average 6.2 seconds faster than existing equipment alarms. Performance analysis showed that the software was capable of supporting up to 15 audible alarms on a mid-grade laptop computer before audio dropouts occurred. These results suggest that this software tool provides a foundation for rapidly staging multiple audible alarm sets from the laboratory to a simulation environment for the purpose of evaluating novel alarm designs, thus producing valuable findings for medical audible alarm standardization.

The Anesthesia Patient Safety Foundation at 25

The Anesthesia Patient Safety Foundation (APSF) was created in 1985. Its founders coined the term "patient safety" in its modern public usage and created the very first patient safety organization, igniting a movement that is now universal in all of health care. Driven by the vision "that no patient shall be harmed by anesthesia," the APSF has worked tirelessly for more than a quarter century to promote safety education and communication through its widely read Newsletter, its programs, and its presentations. The APSF's extensive research grant program has supported a great many projects leading to key safety improvements and, in particular, was central in the development of high-fidelity mannequin simulation as a research and teaching tool. With its pioneering collaboration, the APSF is unique in incorporating the talents and resources of anesthesia professionals of all types, safety scientists, pharmaceutical and equipment manufacturers, regulators, liability insurance companies, and also surgeons. Specific alerts, campaigns, discussions, and projects have targeted a host of safety issues and dangers over the years, starting with minimal intraoperative monitoring in 1986 and all the way up to beach-chair position cerebral perfusion pressure, operating room medication errors, and the extremely popular DVD on operating room fire safety in 2010; the list is long and expansive. The APSF has served as a model and inspiration for subsequent patient safety organizations and has been recognized nationally as having a dramatic positive impact on the safety of anesthesia care. Recognizing that the work is not over, that systems, organizations, and equipment still at times fail, that basic preventable human errors still do sometimes occur, and that "production pressure" in anesthesia practice threatens past safety gains, the APSF is firmly committed and continues to work hard both on established tenets and new patient safety principles.

Blood pressure management during beach chair position shoulder surgery: What do we know?

One of the surgical procedures most commonly performed in North America is arthroscopic repair of the shoulder joint. In the United States, approximately two-thirds of these patients undergo anesthesia and surgery in the sitting or beach chair position (BCP). Although the BCP offers several advantages for the surgeon, including reduced risk of neurovascular trauma, ease of conversion to an open approach, and excellent intra-articular visualization, the sitting position introduces several challenges for the anesthesiologist and potential risks to the patient. Recent reports have described catastrophic neurologic injuries occurring in otherwise healthy patients during shoulder surgery in the sitting position. The authors of these reports hypothesized that improper blood pressure management resulted in reductions in cerebral perfusion pressure which led to central nervous system ischemia and injury. At the present time, however, several important questions about ‘‘best practices’’ for blood pressure management in the BCP remain unanswered. In this issue of the Journal, the investigations by YaDeau et al. and Trentman et al. provide important data in this ongoing debate about the prevalence, risk factors, and potential consequences of hypotension during shoulder surgery in the sitting position. The incidence of ischemic brain or spinal cord injury following shoulder surgery in the BCP is unknown. In 2003, Bhatti and Enneking reported that a patient developed visual loss and ophthalmoplegia after shoulder surgery. In 2005, Pohl and Cullen described four cases of severe brain and spinal cord injury in this patient population. In a 2009 survey of 287 members of the American Shoulder and Elbow Surgeons Society (93 responses), eight cases of cerebral vascular events after shoulder surgery were reported, all of which occurred in the sitting position. An analysis of the American Society of Anesthesiologists Closed Claims database for new onset cervical cord injuries published this year revealed that 24% of the events occurred in patients having surgery in the sitting position. It is likely that the incidence of these complications is significantly underreported, as surgeons and anesthesiologists may be reluctant to publish cases where otherwise healthy patients suffered severe neurologic injuries. Through personal communications, the authors of this editorial are aware of eight additional cases of central nervous system injury following BCP surgery that have not been reported in the literature. The Anesthesia Patient Safety Foundation (APSF) has now funded a national registry, the Neurologic Injury after Non-Supine Shoulder Surgery (NINSS) registry (http://depts.washington.edu/asaccp/NINS/ index.shtml), to establish the incidence of central nervous system injury and determine probable causative factors. The adverse neurologic events reported thus far were attributed most commonly to inadequate cerebral perfusion secondary to intraoperative hypotension. Significant hemodynamic changes occur when the patient’s position is changed from supine to sitting. In awake subjects, upright positioning activates the sympathetic nervous system, producing increases in systemic vascular resistance (3040%) and systemic blood pressure (10-15%) and reductions in cardiac output (15-20%). Under general anesthesia, baroreceptor responses are blunted, resulting in an attenuated increase in systemic vascular resistance, a decrease in mean arterial pressure, and a greater reduction in cardiac output compared with the awake state. Not surprisingly, G. S. Murphy, MD (&) J. W. Szokol, MD Department of Anesthesiology, NorthShore University HealthSystem, University of Chicago Pritzker School of Medicine, 2650 Ridge Avenue, Evanston, IL 60201, USA e-mail: dgmurphy2@yahoo.com

Anesthesiology: From Patient Safety to Population Outcomes

Anesthesiology: From Patient Safety to Population Outcomes

Clinical Issues—December 2010

This MonthPerioperative fire prevention recommendation changesKey words: fire safety, ECRI, Anesthesia Patient Safety Foundation, National Fire Protection Association, AORN Fire Safety Tool Kit.New relative humidity standards for health care facilitiesKey words: American Society of Healthcare Engineers humidity standards; National Fire Protection Agency humidity standards; safe environment of care; heating, ventilating, and air conditioning; HVAC system.Prevention of venous stasis in outpatient settingsKey words: deep vein thrombosis prophylaxis, DVT prevention protocol.Mechanical deep vein thrombosis (DVT) prophylaxisKey words: deep vein thrombosis, DVT prophylaxis, mechanical DVT prophylaxis.

Report on the Society for Education in Anesthesia Spring Meeting 2009: “Educating About Safety: Educating Safely” Cosponsored by the Anesthesia Patient Safety Foundation, University of Washington Medical Center and Virginia Mason Medical Center, Seattle, WA, June 4–7, 2009

Report on the Society for Education in Anesthesia Spring Meeting 2009: “Educating About Safety: Educating Safely” Cosponsored by the Anesthesia Patient Safety Foundation, University of Washington Medical Center and Virginia Mason Medical Center, Seattle, WA, June 4–7, 2009