An iterative process of global quality improvement: the International Standards for a Safe Practice of Anesthesia 2010

Anesthesia Patient Safety: Next Steps to Improve Worldwide Perioperative Safety by 2030

Patient safety is a core principle of anesthesia care worldwide. The specialty of anesthesiology has been a leader in medicine for the past half century in pursuing patient safety research and implementing standards of care and systematic improvements in processes of care. Together, these efforts have dramatically reduced patient harm associated with anesthesia. However, improved anesthesia patient safety has not been uniformly obtained worldwide. There are unique differences in patient safety outcomes between countries and regions in the world. These differences are often related to factors such as availability, support, and use of health care resources, trained personnel, patient safety outcome data collection efforts, standards of care, and cultures of safety and teamwork in health care facilities. This article provides insights from national anesthesia society leaders from 13 countries around the world. The countries they represent are diverse geographically and in health care resources. The authors share their countries' current and future initiatives in anesthesia patient safety. Ten major patient safety issues are common to these countries, with several of these focused on the importance of extending initiatives into the full perioperative as well as intraoperative environments. These issues may be used by anesthesia leaders around the globe to direct collaborative efforts to improve the safety of patients undergoing surgery and anesthesia in the coming decade.

Clinician Monitoring

Since the first public demonstration of general anesthesia in 1846, anesthesiology has seen major advancements as a specialty. These include both important technological improvements and the development and implementation of internationally accepted patient safety standards. Together, these ultimately resulted in the recognition of anesthesiology as the leading medical specialty advocating for patient safety. Modern-day anesthesiology faces a new challenge of automated anesthesia delivery. Despite evidence for a more refined and precise delivery of anesthesia through this platform, there is currently no substitute for the presence of an appropriately trained anesthesia clinician to manage the complex interplay of human factors and patient safety in the perioperative setting.

Continuous quality improvement in HIV and TB services at selected healthcare facilities in South Africa

Background

Continuous quality improvement (CQI) is essential for HIV and tuberculosis (TB) services. Similarly, a thorough understanding of the requirements and impact of CQI is critical to its successful institutionalisation. However, this is currently lacking.

Objectives

The objective of this study is to describe the CQI implementation process and examine its effect on HIV and TB service delivery at selected primary healthcare facilities in two South African districts.

Method

We used a separate sample, pre- and post-test, quasi-experimental study design based on data collected from the clinical audit of patient cohorts seen in 2014 and 2015 respectively. Quality was measured based on the extent to which prescribed services were provided. Tailored CQI interventions were implemented based on service delivery gaps identified by the 2014 CQI audit. Data were summarised and analysed using a combination of univariate and multivariate analysis.

Results

The services identified as low quality were related to opportunistic infections management and laboratory practices. Compliance to prescribed service items in antiretroviral treatment initiation and monitoring, pharmacy and laboratory management, exceeded 70% across study sites. Over 80% of low quality service delivery items were optimised in less than six months with targeted quality improvement support.

Conclusion

The observed improvements signal the effectiveness of the CQI approach, its capacity to rapidly improve under-performance, its high replicability and the need to provide quality maintenance support to sustain or improve healthcare facilities performing well. The study strongly underscores the need to improve the management of opportunistic infections and complications, particularly TB.

The Origins, Evolution, and Spread of Anesthesia Monitoring Standards: From Boston to Across the World

In the mid-1980s, the anesthesia departments at hospitals affiliated with Harvard Medical School were faced with a challenge: mounting medical malpractice costs. Malpractice insurance was provided by the Controlled Risk Insurance Company (CRICO), a patient safety and medical malpractice insurance company owned by and providing service to the Harvard medical community. CRICO spearheaded an effort to reduce these costs and ultimately found a way to decrease the risks associated with anesthesia. Here, we chronicle events that led to the dramatic changes in medical practice that resulted from the activities of a small group of concerned anesthesiologists at Harvard-affiliated hospitals. We place these events in a historical perspective and explore how other specialties followed this example, and end with current strategies that minimize the risk associated with anesthesia. We conducted interviews with principals who formulated original standards of patient monitoring. In addition, we consulted documents in the public domain and primary source material. Efforts of these pioneers resulted in the establishment of the seminal Harvard-based anesthesia monitoring standards for minimal monitoring. What followed was an unprecedented transformation of the entire field. After the implementation of these standards at Harvard-affiliated hospitals, the American Society of Anesthesiologists (ASA) adopted "Standards for Basic Anesthetic Monitoring" for use during the administration of all anesthetics in the United States. Other nations have since adopted similar guidelines and these practices have resulted in significant improvements in patient safety. Currently, we estimate mortality due to anesthesia in healthy patients to be 1:400,000-perhaps as much as 10 times lower since the early 1980s. What began as an attempt to lower medical malpractice costs in a group of university hospitals became a worldwide effort that resulted in improvements in patient safety. Other specialties have adopted similar measures. Currently, an attitude and appreciation of safety are exemplified by several practices that include among others-the adherence to these patient safety guidelines, simulator training, the promulgation of standards and guidelines by ASA, and the use of a safety checklist before induction of anesthesia.

The evolution of pediatric sedation and anesthesia patient safety: An interview with Dr Charles J. "Charlie" Coté

The career of Dr Charles J. Coté covered a period of major advances in pediatric anesthesia patient safety. Dr Coté (1946 --), Professor Emeritus in Anaesthesia at Harvard Medical School, helped develop pediatric sedation guidelines, conducted influential clinical research, edited a major textbook, and promoted pediatric anesthesia training fellowships in low- and middle-income countries. Based on a series of interviews with Dr Coté, this article reviews the career of this Robert M. Smith Award winner through the lens of improvements in pediatric sedation and anesthesia patient safety.

Research priorities for the COVID-19 pandemic and beyond: A call to action for psychological science

The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) that has caused the coronavirus disease 2019 (COVID-19) pandemic represents the greatest international biopsychosocial emergency the world has faced for a century, and psychological science has an integral role to offer in helping societies recover. The aim of this paper is to set out the shorter- and longer-term priorities for research in psychological science that will (a) frame the breadth and scope of potential contributions from across the discipline; (b) enable researchers to focus their resources on gaps in knowledge; and (c) help funders and policymakers make informed decisions about future research priorities in order to best meet the needs of societies as they emerge from the acute phase of the pandemic. The research priorities were informed by an expert panel convened by the British Psychological Society that reflects the breadth of the discipline; a wider advisory panel with international input; and a survey of 539 psychological scientists conducted early in May 2020. The most pressing need is to research the negative biopsychosocial impacts of the COVID-19 pandemic to facilitate immediate and longer-term recovery, not only in relation to mental health, but also in relation to behaviour change and adherence, work, education, children and families, physical health and the brain, and social cohesion and connectedness. We call on psychological scientists to work collaboratively with other scientists and stakeholders, establish consortia, and develop innovative research methods while maintaining high-quality, open, and rigorous research standards.

Key bottlenecks to the provision of safe obstetric anaesthesia in low- income countries; a cross-sectional survey of 64 hospitals in Uganda

Background

Despite recent advances in surgery and anaesthesia which significantly improve safety, many health facilities in low-and middle-income countries (LMICs) remain chronically under-resourced with inability to cope effectively with serious obstetric complications (Knight et al., PLoS One 8:e63846, 2013). As a result many of these countries still have unacceptably high maternal and neonatal mortality rates. Recent data at the national referral hospitals in East Africa reported that none of the national referral hospitals met the World Federation of Societies of Anesthesiologists (WFSA) international standards required to provide safe obstetric anaesthesia (Epiu I: Challenges of Anesthesia in Low-and Middle-Income Countries. WFSA; 2014 http://wfsa.newsweaver.com/Newsletter/p8c8ta4ri7a1wsacct9y3u?a=2&p=47730565&t=27996496). In spite of this evidence, factors contributing to maternal mortality related to anaesthesia in LMICs and the magnitude of these issues have not been comprehensively studied. We therefore set out to assess regional referral, district, private for profit and private not-for profit hospitals in Uganda.

Methods

We conducted a cross-sectional survey at 64 government and private hospitals in Uganda using pre-set questionnaires to the anaesthetists and hospital directors. Access to the minimum requirements for safe obstetric anaesthesia according to WFSA guidelines were also checked using a checklist for operating and recovery rooms.

Results

Response rate was 100% following personal interviews of anaesthetists, and hospital directors. Only 3 of the 64 (5%) of the hospitals had all requirements available to meet the WFSA International guidelines for safe anaesthesia. Additionally, 54/64 (84%) did not have a trained physician anaesthetist and 5/64 (8%) had no trained providers for anaesthesia at all. Frequent shortages of drugs were reported for regional/neuroaxial anaesthesia, and other essential drugs were often lacking such as antacids and antihypertensives. We noted that many of the anaesthesia machines present were obsolete models without functional safety alarms and/or mechanical ventilators. Continuous ECG was only available in 3/64 (5%) of hospitals.

Conclusion

We conclude that there is a significant lack of essential equipment for the delivery of safe anaesthesia across this region. This is compounded by the shortage of trained providers and inadequate supervision. It is therefore essential to strengthen anaesthesia services by addressing these specific deficiencies. This will include improved training of associate clinicians, training more physician anaesthetists and providing the basic equipment required to provide safe and effective care. These services are key components of comprehensive emergency obstetric care and anaesthetists are crucial in managing critically ill mothers and ensuring good surgical outcomes.

Overcoming challenges in implementing the WHO Surgical Safety Checklist: lessons learnt from using a checklist training course to facilitate rapid scale up in Madagascar

The WHO Surgical Safety Checklist was launched in 2009, and appropriate use reduces mortality, surgical site infections and complications after surgery by up to 50%. Implementation across low-income and middle-income countries has been slow; published evidence is restricted to reports from a few single institutions, and significant challenges to successful implementation have been identified and presented. The Mercy Ships Medical Capacity Building team developed a multidisciplinary 3-day Surgical Safety Checklist training programme designed for rapid wide-scale implementation in all regional referral hospitals in Madagascar. Particular attention was given to addressing previously reported challenges to implementation. We taught 427 participants in 21 hospitals; at 3–4 months postcourse, we collected surveys from 183 participants in 20 hospitals and conducted one focus group per hospital. We used a concurrent embedded approach in this mixed-methods design to evaluate participants’ experiences and behavioural change as a result of the training programme. Quantitative and qualitative data were analysed using descriptive statistics and inductive thematic analysis, respectively. This analysis paper describes our field experiences and aims to report participants’ responses to the training course, identify further challenges to implementation and describe the lessons learnt. Recommendations are given for stakeholders seeking widespread rapid scale up of quality improvement initiatives to promote surgical safety worldwide.

Safe surgery: validation of pre and postoperative checklists

Objective:

to develop, evaluate and validate a surgical safety checklist for patients in the pre and postoperative periods in surgical hospitalization units.

Method:

methodological research carried out in a large public teaching hospital in the South of Brazil, with application of the principles of the Safe Surgery Saves Lives Programme of the World Health Organization. The checklist was applied to 16 nurses of 8 surgical units and submitted for validation by a group of eight experts using the Delphi method online.

Results:

the instrument was validated and it was achieved a mean score ≥1, level of agreement ≥75% and Cronbach’s alpha >0.90. The final version included 97 safety indicators organized into six categories: identification, preoperative, immediate postoperative, immediate postoperative, other surgical complications, and hospital discharge.

Conclusion:

the Surgical Safety Checklist in the Pre and Postoperative periods is another strategy to promote patient safety, as it allows the monitoring of predictive signs and symptoms of surgical complications and the early detection of adverse events.

[Nursing care in the anesthetic procedure: an integrative review]

OBJECTIVE

To search for the scientific evidence available on nursing professional actions during the anesthetic procedure.

METHOD

An integrative review of articles in Portuguese, English and Spanish, indexed in MEDLINE/PubMed, CINAHL, LILACS, National Cochrane, SciELO databases and the VHL portal.

RESULTS

Seven studies were analyzed, showing nurse anesthetists' work in countries such as the United States and parts of Europe, with the formulation of a plan for anesthesia and patient care regarding the verification of materials and intraoperative controls. The barriers to their performance involved working in conjunction with or supervised by anesthesiologists, the lack of government guidelines and policies for the legal exercise of the profession, and the conflict between nursing and the health system for maintenance of the performance in places with legislation and defined protocols for the specialty.

CONCLUSION

Despite the methodological weaknesses found, the studies indicated a wide diversity of nursing work. Furthermore, in countries absent of the specialty, like Brazil, the need to develop guidelines for care during the anesthetic procedure was observed.

Efficacy of paediatric anaesthetic trolleys: A call for a basic standard and layout

BACKGROUND

Providing safe anaesthesia to children especially in emergency situations goes hand in hand with instant availability of appropriately sized equipment and monitoring. This is best achieved using a designated paediatric anaesthetic trolley containing essential equipment. Guidance for the contents of such trolleys is neither explicit nor standard. We used a survey and a qualitative enquiry to develop a checklist suitable for standardisation of contents and layout of paediatric anaesthetic trolleys.

METHODS

We conducted an observational study of our current practice and paediatric anaesthetic trolleys in a tertiary care hospital. We also performed a qualitative enquiry from experienced paediatric anaesthetists and operating department practitioners.We developed an empirical checklist to ensure the minimum 'essential' equipment is available on these trolleys and implemented a standard layout to facilitate its use.

RESULTS

We identified 11 areas in our hospital where anaesthesia is provided to children, each with a designated paediatric anaesthetic trolley. There were considerable deficiencies of items in all areas with no standard pattern or layout. Different types of trolleys contributed to the confusion. In addition, overstocking of inappropriate items hindered its efficient use.

CONCLUSION

Standardising the contents and layout of the paediatric anaesthetic trolley is an essential pre-requisite for safer paediatric anaesthetic practice.

Pre-use anesthesia machine check; certified anesthesia technician based quality improvement audit

CONTEXT

Quality assurance of providing a work ready machine in multiple theatre operating rooms in a tertiary modern medical center in Riyadh.

AIMS

The aim of the following study is to keep high quality environment for workers and patients in surgical operating rooms.

SETTINGS AND DESIGN

Technicians based audit by using key performance indicators to assure inspection, passing test of machine worthiness for use daily and in between cases and in case of unexpected failure to provide quick replacement by ready to use another anesthetic machine.

MATERIALS AND METHODS

The anesthetic machines in all operating rooms are daily and continuously inspected and passed as ready by technicians and verified by anesthesiologist consultant or assistant consultant. The daily records of each machines were collected then inspected for data analysis by quality improvement committee department for descriptive analysis and report the degree of staff compliance to daily inspection as "met" items. Replaced machine during use and overall compliance.

STATISTICAL ANALYSIS USED

Distractive statistic using Microsoft Excel 2003 tables and graphs of sums and percentages of item studied in this audit.

RESULTS

Audit obtained highest compliance percentage and low rate of replacement of machine which indicate unexpected machine state of use and quick machine switch.

CONCLUSIONS

The authors are able to conclude that following regular inspection and running self-check recommended by the manufacturers can contribute to abort any possibility of hazard of anesthesia machine failure during operation. Furthermore in case of unexpected reason to replace the anesthesia machine in quick maneuver contributes to high assured operative utilization of man machine inter-phase in modern surgical operating rooms.

Campaigning for safety

There are four challenges to practicing evidence-based medicine: obtaining the evidence; evaluating the evidence; promulgating the evidence; and persuading practitioners to adopt the evidence and practice according to the evidence. The Perfusion Down Under (PDU) Collaboration addresses the first three. The fourth is more difficult, and it typically takes many years for new evidence to be adopted into widespread practice. In the case of innovations related to patient safety, evidence from randomized controlled trials is often very expensive to obtain. Other methods of evaluation may be more appropriate, but these do need to be robust and to take account of the constructs underlying the innovations and the context in which they are to be implemented. In the United States, The Institute for Healthcare Improvement (IHI) aims (among other things) to promote the adoption of best practices and effective innovations. The IHI has articulated a useful framework for doing this. Measurement is fundamental to quality improvement, and sustainable change is likely to be more readily achieved if claims are supported by credible, measurable, and clinically relevant outcome data. The PDU is well placed to support quality improvement in perfusion by providing such data.