Review article: Practical current issues in perioperative patient safety

A Cross-Sectional Study of Anesthesia Safety in Wad Medani, Sudan: A Pre-war Status Indicating a Post-war Crisis

BACKGROUND

As the surgical burden grows, increasing patient safety during anesthesia and surgery becomes a major global public health priority. Anesthesia can be safely administered in higher-income countries, yet it is more challenging in third-world countries. This study focuses on Sudan, a third-world country, and its unmet anesthetic needs before the current war and how these needs might compromise the post-war status.

AIM

The aim of this study is to compare Sudan's outstanding anesthesia requirements to the World Health Organization's safe anesthesia practice standards in terms of workforce, medications, equipment, and anesthesia conduct.

METHODS

This study was carried out in four hospitals (Wad Medani Teaching Hospital, Wad Medani Maternity Hospital, Gezira Centre for Renal and Urological Surgeries, and the National Centre for Pediatric Surgeries) in Wad Medani, two of which were referral and two were state-run. Each hospital from every category was identified using a convenience sampling technique. The World Health Organization-World Federation of Societies of Anesthesiologists International Standard and earlier regional African publications were used to determine the minimum predicted safe anesthesia needs.

RESULTS

The results of our study demonstrate that overall, the hospitals surveyed fulfilled the minimum standards set by the World Health Organization and the World Federation of Societies of Anesthesiologists (WHO-WFSA) for safe anesthesia practice by 73% with no significant difference in the safety of anesthesia practice between state and referral hospitals.

CONCLUSIONS

The state of safe anesthesia care in Wad Medani hospitals surveyed fell well short of the expected minimal criteria due to important requirements such as patient monitoring indicators, the inaccessibility of life-saving facilities such as defibrillators, and difficult intubation instruments. More importantly, the conduct of anesthesia was far below the standard.

Capnography access and use in Kenya and Ethiopia

PURPOSE

Lack of access to safe and affordable anesthesia and monitoring equipment may contribute to higher rates of morbidity and mortality in low- and middle-income countries (LMICs). While capnography is standard in high-income countries, use in LMICs is not well studied. We evaluated the association of capnography use with patient and procedure-related characteristics, as well as the association of capnography use and mortality in a cohort of patients from Kenya and Ethiopia.

METHODS

For this retrospective observational study, we used historical cohort data from Kenya and Ethiopia from 2014 to 2020. Logistic regression was used to study the association of capnography use (primary outcome) with patient/procedure factors, and the adjusted association of intraoperative, 24-hr, and seven-day mortality (secondary outcomes) with capnography use.

RESULTS

A total of 61,792 anesthetic cases were included in this study. Tertiary or secondary hospital type (compared with primary) was strongly associated with use of capnography (odds ratio [OR], 6.27; 95% confidence interval [CI], 5.67 to 6.93 and OR, 6.88; 95% CI, 6.40 to 7.40, respectively), as was general (vs regional) anesthesia (OR, 4.83; 95% CI, 4.41 to 5.28). Capnography use was significantly associated with lower odds of intraoperative mortality in patients who underwent general anesthesia (OR, 0.31; 95% CI, 0.17 to 0.48). Nevertheless, fully-adjusted models for 24-hr and seven-day mortality showed no evidence of association with capnography.

CONCLUSION

Capnography use in LMICs is substantially lower compared with other standard anesthesia monitors. Capnography was used at higher rates in tertiary centres and with patients undergoing general anesthesia. While this study revealed decreased odds of intraoperative mortality with capnography use, further studies need to confirm these findings.

Defining Speaking Up in the Healthcare System: a Systematic Review

BACKGROUND

Communication issues have been shown to contribute to healthcare errors. For years healthcare professionals have been told to "speak up." What "speak up" means is unclear, as it has been defined and operationalized in many ways. Thus, this study aimed to systematically review the literature regarding definitions and measurements of speaking up in the healthcare system and to develop a single, comprehensive definition and operationalization of the concept.

METHODS

PubMed, CINAHL, PsychoInfo, and Communication/Mass Media Complete databases were searched from 1999 to 2020. Publications were included if they mentioned speaking up for patient safety or any identified synonyms. Articles that used the term speaking up concerning non-health-related topics were excluded. This systematic review utilized Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

A total of 294 articles met the inclusion criteria, yet only 58 articles focused on speaking up. While the most common synonym terms identified were "speak up" and "raise concern," only 43 articles defined speaking up. Accordingly, a modified definition was developed for speaking up-A healthcare professional identifying a concern that might impact patient safety and using his or her voice to raise the concern to someone with the power to address it.

DISCUSSION

Speaking up is considered important for patient safety. Yet, there has been a lack of agreement on the definition and operationalization of speaking up. This review demonstrates that speaking up should be reconceptualized to provide a single definition for speaking up in healthcare.

Human errors and their prevention in healthcare

Human errors form a significant portion of preventable mishaps in healthcare. Even the most competent clinicians are not immune to it. Errors in the perioperative period can often have grave consequences, and hence, perioperative clinicians need to be aware of the impact of human errors and how to minimize them. Errors are broadly classified into two kinds: latent and active errors. While active errors need to be addressed at the individual level, latent errors indicate organizational inadequacies. This review describes common errors in perioperative settings, the impact of such errors on healthcare, and preventive strategies to minimize such errors in daily patient care.

Advances in safe insulin infusions

Hyperglycaemia is recognized as a marker of adverse clinical outcomes for hospitalized patients with and without diabetes, including mortality, morbidity, increased length of stay, infections and overall complications. In some cases, intravenous (IV) insulin infusions are the optimal intervention and, to date, these have been compounded in hospital pharmacy departments or, alternatively, at the point of care, when timeliness is a concern or the pharmacy is closed. However, in-house compounding of high-risk medications such as IV insulin poses risks both for patients and institutions. The critical nature of certain high-risk therapies has led to the development of ready-to-administer products to improve the safety, timeliness, efficacy and efficiency of critical infusions. Recently, IV insulin, a high-alert therapy, has been added to the ready-to-use armamentarium. This narrative review explores the expanding indications, risks and opportunities associated with insulin infusions and potential options for improved safety.

A correlation between anaesthesia-related cardiac arrest outcomes and country human development index: A narrative review

Studies have demonstrated gaps between developed and developing countries in the quality of surgical and anaesthesia care. The aim of this review was to provide a critical overview of documented outcomes from the 2010s of anaesthesia-related cardiac arrest events in countries with largely differing Human Development Indexes (HDIs). The HDI ranges from 0 to 1, representing the lowest and highest levels of development, respectively. Most related studies conducted between 2011 and 2020 showed low rates (from 0 to 215 per million anaesthetics) of anaesthesia-related mortality up to the 30th postoperative day in very high-HDI countries (HDI ≥ 0.800) and higher rates (from 0 to 915.4 per million anaesthetics) in high-HDI countries (HDI: 0.700-0.799). Low-HDI countries (HDI < 0.550) showed higher anaesthesia-related mortality rates, which were greater than 1500 per million anaesthetics. The anaesthesia-related mortality rates per quartile demonstrated a gap in the anaesthesia-related safety between very high- and high-HDI countries, and especially between very high- and low-HDI countries. Anaesthesia-related cardiac arrest showed similarly high survival proportions in very high-HDI countries (45.9% to 100%) and high-HDI countries (62.9% to 100%), while in a low-HDI country, the anaesthesia-related cardiac arrest survival was lower (22.2%). Our review demonstrates large gaps among countries with largely differing HDIs regarding anaesthesia-related cardiac arrest outcomes in the last decade. This finding highlights the need to improve patient safety care in low-HDI countries. Anaesthesia patient safety has improved in high-HDI countries, but there is still a persistent gap in the health care systems of these countries and those of very high-HDI countries. Our review also found a consistent improvement in anaesthesia patient safety in very high-HDI countries.

The current state of anesthesia safety in a third world country: a cross-sectional survey among anesthesia providers in Ethiopia

BACKGROUND

Improving patient safety during anesthesia and surgery becomes a major global public health issue due to the increasing in surgical burden. Anesthesia is delivered safely in developed countries, but its safety is hampered by complex problems in third world countries. This survey assesses the unmet anesthesia needs of one of a third world country, Ethiopia.

METHODS

A cross-sectional survey was conducted in Amhara region of Ethiopia from 15/12/2019 to 30/1/2020. All 81 hospitals of the region were stratified by their level as district, general, and referral hospital. The study was conducted in 66 hospitals. The number of hospitals from each strata were calculated by proportional sampling technique resulting; five referral, three general, and fifty eight primary hospitals. Each hospital from each strata was selected by convenience. Each anesthesia provider for the survey was selected randomly from each hospital and questionnaires were distributed. The minimum expected safe anesthesia requirements were taken from World Health Organization-World Federation of Societies of Anesthesiologists International Standard and Ethiopian Hospitals Standard. Anesthesia practice was expected safe if the minimum requirements were practiced always (100%) in each hospital. P < 0.05 with 95% confidence interval were used to compare the safety of anesthesia between higher and lower level hospitals.

RESULTS

Seventy eight (88.6%) anesthesia providers working in 62 hospitals responded to the survey. On aggregate, 36 (58%) hospitals from the total 62 hospitals have met the minimum expected safe anesthesia requirements. Among the different variables assessed; professional aspects 32 (52.45%), medication and intravenous fluid 33 (53.36%), equipment and facilities 33 (52.56%), patient monitoring 43(68.88%), and anesthesia conduct 38 (62.1%) of surveyed hospitals have met the minimum requirements. Anesthesia safety is relatively higher in higher level hospitals (general and referral) 6 (75%) when compared to district hospitals 30 (55.5%), P < 0.001.

CONCLUSION

Anesthesia safety in Ethiopia appears challenged by substandard continuous medical education and continuous professional development practice, and limited availability of some essential equipment and medications. Patient monitoring and anesthesia conduct are relatively good, but World Health Organization surgical safety checklist application and postoperative pain management are very low, affecting the delivery of safe anesthesia conduct.

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.

Association between intra-operative cardiac arrest and country Human Development Index status: a systematic review with meta-regression analysis and meta-analysis of observational studies. Anaesthesia 2021;76:1259-1273. [PMID: 33512708 DOI: 10.1111/anae.15374]

Intra-operative cardiac arrests differ from most in-hospital cardiac arrests because they reflect not only the patient's condition but also the quality of surgery and anaesthesia care provided. We assessed the relationship between intra-operative cardiac arrest rates and country Human Development Index (HDI), and the changes occurring in these rates over time. We searched PubMed, EMBASE, Scopus, LILACS, Web of Science, CINAHL and SciELO from inception to 29 January 2020. For the global population, rates of intra-operative cardiac arrest and baseline ASA physical status were extracted. Intra-operative cardiac arrest rates were analysed by time, country HDI status and ASA physical status using meta-regression analysis. Proportional meta-analysis was performed to compare intra-operative cardiac arrest rates and ASA physical status in low- vs. high-HDI countries and in two time periods. Eighty-two studies from 25 countries with more than 29 million anaesthetic procedures were included. Intra-operative cardiac arrest rates were inversely correlated with country HDI (p = 0.0001); they decreased over time only in high-HDI countries (p = 0.040) and increased with increasing ASA physical status (p < 0.0001). Baseline ASA physical status did not change in high-HDI countries (p = 0.106), while it decreased over time in low-HDI countries (p = 0.040). In high-HDI countries, intra-operative cardiac arrest rates (per 10,000 anaesthetic procedures) decreased from 9.59 (95%CI 6.59-13.16) pre-1990 to 5.17 (95%CI 4.42-5.97) in 1990-2020 (p = 0.013). During the same time periods, no improvement was observed in the intra-operative cardiac arrest rates in low-HDI countries (p = 0.498). Odds ratios of intra-operative cardiac arrest rates in ASA 3-5 patients were 8.48 (95%CI 1.67-42.99) times higher in low-HDI countries than in high-HDI countries (p = 0.0098). Intra-operative cardiac arrest rates are related to country-HDI and decreased over time only in high-HDI countries. The widening gap in these rates between low- and high-HDI countries needs to be addressed globally.

Perioperative mortality in older patients: a systematic review with a meta-regression analysis and meta-analysis of observational studies

STUDY OBJECTIVE

Older patients have a higher probability of developing major complications during the perioperative period than other adult patients. Perioperative mortality depends on not only on a patient condition but also on the quality of perioperative care provided. We tested the hypothesis that the perioperative mortality rate among older patients has decreased over time and is related to a country's Human Development Index (HDI) status.

DESIGN

A systematic review with a meta-regression and meta-analysis of observational studies that reported perioperative mortality rates in patients aged ≥60 years was performed. We searched the PubMed, EMBASE, LILACS and SciELO databases from inception to December 30, 2019.

SETTING

Mortality rates up to the seventh postoperative day were evaluated.

MEASUREMENTS

We evaluated the quality of the included studies. Perioperative mortality rates were analysed by time, country HDI status and baseline American Society of Anesthesiologists (ASA) physical status using meta-regression. Perioperative mortality and ASA status were analysed in low- and high-HDI countries during two time periods using proportion meta-analysis.

MAIN RESULTS

We included 25 studies, which reported 4,412,100 anaesthesia procedures and 3568 perioperative deaths from 12 countries. Perioperative mortality rates in high-HDI countries decreased over time (P = 0.042). When comparing pre-1990 to 1990-2019, in high-HDI countries, the perioperative mortality rates per 10,000 anaesthesia procedures decreased 7.8-fold from 100.85 (95% CI 43.36 to 181.72) in pre-1990 to 12.98 (95% CI 6.47 to 21.70) in 1990-2019 (P < 0.0001). There were no studies from low-HDI countries pre-1990. In the period from 1990 to 2019, perioperative mortality rates did not differ between low- and high-HDI countries (P = 0.395) but the limited number of patients in low-HDI countries impaired the result. Perioperative mortality rates increased with increasing ASA status (P < 0.0001). There were more ASA III-V patients in high-HDI countries than in low-HDI countries (P < 0.0001), and the perioperative mortality rate increased 24-fold in ASA III-V patients compared with ASA I-II patients (P < 0.0001).

CONCLUSION

The perioperative mortality rates in older patients have declined over the past 60 years in high-DHI countries, highlighting that perioperative safety in this population is increasing in these countries. Since data prior to 1990 were lacking in low-HDI countries, the evolution of their mortality rates could not be analysed. The perioperative mortality rate was similar in low- and high-HDI countries in the post-1990 period, but the low number of patients in the low-HDI countries does not allow a definitive conclusion.

Perioperative and anesthesia-related cardiac arrest and mortality rates in Brazil: A systematic review and proportion meta-analysis

INTRODUCTION

Studies have shown that both perioperative and anesthesia-related cardiac arrest (CA) and mortality rates are much higher in developing countries than in developed countries. This review aimed to compare the rates of perioperative and anesthesia-related CA and mortality during 2 time periods in Brazil.

METHODS

A systematic review with meta-analysis of full-text Brazilian observational studies was conducted by searching the Medline, EMBASE, LILACS and SciELO databases up to January 29, 2020. The primary outcomes were perioperative CA and mortality rates and the secondary outcomes included anesthesia-related CA and mortality events rates up to 48 postoperative hours.

RESULTS

Eleven studies including 719,273 anesthetic procedures, 962 perioperative CAs, 134 anesthesia-related CAs, 1,239 perioperative deaths and 29 anesthesia-related deaths were included. The event rates were evaluated in 2 time periods: pre-1990 and 1990-2020. Perioperative CA rates (per 10,000 anesthetics) decreased from 39.87 (95% confidence interval [CI]: 34.60-45.50) before 1990 to 17.61 (95% CI: 9.21-28.68) in 1990-2020 (P < 0.0001), while the perioperative mortality rate did not alter (from 19.25 [95% CI: 15.64-23.24] pre-1990 to 25.40 [95% CI: 13.01-41.86] in 1990-2020; P = 0.1984). Simultaneously, the anesthesia-related CA rate decreased from 14.39 (95% CI: 11.29-17.86) to 3.90 (95% CI: 2.93-5.01; P < 0.0001), while there was no significant difference in the anesthesia-related mortality rate (from 1.75 [95% CI: 0.76-3.11] to 0.67 [95% CI: 0.09-1.66; P = 0.5404).

CONCLUSIONS

This review demonstrates an important reduction in the perioperative CA rate over time in Brazil, with a large and consistent decrease in the anesthesia-related CA rate; however, there were no significant differences in perioperative and anesthesia-related mortality rates between the assessed time periods.

Association between complications and death within 30 days after noncardiac surgery

BACKGROUND

Among adults undergoing contemporary noncardiac surgery, little is known about the frequency and timing of death and the associations between perioperative complications and mortality. We aimed to establish the frequency and timing of death and its association with perioperative complications.

METHODS

We conducted a prospective cohort study of patients aged 45 years and older who underwent inpatient noncardiac surgery at 28 centres in 14 countries. We monitored patients for complications until 30 days after surgery and determined the relation between these complications and 30-day mortality using a Cox proportional hazards model.

RESULTS

We included 40 004 patients. Of those, 715 patients (1.8%) died within 30 days of surgery. Five deaths (0.7%) occurred in the operating room, 500 deaths (69.9%) occurred after surgery during the index admission to hospital and 210 deaths (29.4%) occurred after discharge from the hospital. Eight complications were independently associated with 30-day mortality. The 3 complications with the largest attributable fractions (AF; i.e., potential proportion of deaths attributable to these complications) were major bleeding (6238 patients, 15.6%; adjusted hazard ratio [HR] 2.6, 95% confidence interval [CI] 2.2-3.1; AF 17.0%); myocardial injury after noncardiac surgery [MINS] (5191 patients, 13.0%; adjusted HR 2.2, 95% CI 1.9-2.6; AF 15.9%); and sepsis (1783 patients, 4.5%; adjusted HR 5.6, 95% CI 4.6-6.8; AF 12.0%).

INTERPRETATION

Among adults undergoing noncardiac surgery, 99.3% of deaths occurred after the procedure and 44.9% of deaths were associated with 3 complications: major bleeding, MINS and sepsis. Given these findings, focusing on the prevention, early identification and management of these 3 complications holds promise for reducing perioperative mortality. Study registration: ClinicalTrials.gov, no. NCT00512109.

Recovery and prediction of postoperative muscle power - is it still a problem?

BACKGROUND

In the postoperative period, immediate recovery of muscular power is essential for patient safety, but this can be affected by anaesthetic drugs, opioids and neuromuscular blocking agents (NMBA). In this cohort study, we evaluated anaesthetic and patient-related factors contributing to reduced postoperative muscle power and pulse oximetric saturation.

METHODS

We prospectively observed 615 patients scheduled for minor surgery. Premedication, general anaesthesia and respiratory settings were standardized according to standard operating procedures (SOP). If NMBAs were administered, neuromuscular monitoring was applied to establish a Train of four (TOF)-Ratio of >0.9 before extubation. After achieving a modified fast track score > 10 at 4 time points up to 2 h postoperatively, we measured pulse oximetric saturation and also static and dynamic muscle power, using a high precision digital force gauge. Loss of muscle power in relation to the individual preoperative baseline value was analysed in relation to patient and anaesthesia-related factors using the T-test, simple and multiple stepwise regression analysis.

RESULTS

Despite having achieved a TOF ratio of >0.9 a decrease in postoperative muscle power was detectable in most patients and correlated with reduced postoperative pulse oximetric saturation. Independent contributing factors were use of neuromuscular blocking agents (p < 0.001), female gender (p = 0.001), TIVA (p = 0.018) and duration of anaesthesia >120 min (p = 0.019).

CONCLUSION

Significant loss of muscle power and reduced pulse oximetric saturation are often present despite a TOF-Ratio > 0.9. Gender differences are also significant. A modified fast track score > 10 failed to predict recovery of muscle power in most patients.

TRIAL REGISTRATION

German Clinical Trial Register DRKS-ID DRKS00006032 ; Registered: 2014/04/03.

Perioperative and anesthesia-related cardiac arrests in geriatric patients: a systematic review using meta-regression analysis

The worldwide population is aging, and the number of surgeries performed in geriatric patients is increasing. This systematic review evaluated anesthetic procedures to assess global data on perioperative and anesthesia-related cardiac arrest (CA) rates in geriatric surgical patients. Available data on perioperative and anesthesia-related CA rates over time and by the country's Human Development Index (HDI) were evaluated by meta-regression, and a pooled analysis of proportions was used to compare perioperative and anesthesia-related CA rates by HDI and time period. The meta-regression showed that perioperative CA rates did not change significantly over time or by HDI, whereas anesthesia-related CA rates decreased over time (P = 0.04) and in high-HDI (P = 0.015). Perioperative and anesthesia-related CA rates per 10,000 anesthetic procedures declined in high-HDI, from 38.6 before the 1990s to 7.7 from 1990-2017 (P < 0.001) and from 9.2 before the 1990s to 1.3 from 1990-2017 (P < 0.001), respectively. The perioperative CA rate from 1990-2017 was higher in low-HDI than in high-HDI countries (P < 0.001). Hence, a reduction in anesthesia-related CA rates over time was observed. Both perioperative and anesthesia-related CA rates only decreased with a high-HDI between time periods, and perioperative CA rates during 1990-2017 were 4-fold higher with low- compared to high-HDI in geriatric patients.

Bow-Tie Diagrams for Risk Management in Anaesthesia

Bow-tie analysis is a risk analysis and management tool that has been readily adopted into routine practice in many high reliability industries such as engineering, aviation and emergency services. However, it has received little exposure so far in healthcare. Nevertheless, its simplicity, versatility, and pictorial display may have benefits for the analysis of a range of healthcare risks, including complex and multiple risks and their interactions. Bow-tie diagrams are a combination of a fault tree and an event tree, which when combined take the shape of a bow tie. Central to bow-tie methodology is the concept of an undesired or ‘Top Event’, which occurs if a hazard progresses past all prevention controls. Top Events may also occasionally occur idiosyncratically. Irrespective of the cause of a Top Event, mitigation and recovery controls may influence the outcome. Hence the relationship of hazard to outcome can be viewed in one diagram along with possible causal sequences or accident trajectories. Potential uses for bow-tie diagrams in anaesthesia risk management include improved understanding of anaesthesia hazards and risks, pre-emptive identification of absent or inadequate hazard controls, investigation of clinical incidents, teaching anaesthesia risk management, and demonstrating risk management strategies to third parties when required.

Airway fires during surgery: Management and prevention

Airway fires pose a serious risk to surgical patients. Fires during surgery have been reported for many years with flammable anesthetic agents being the main culprits in the past. Association of airway fires with laser surgery is well-recognized, but there are reports of endotracheal tube fires ignited by electrocautery during pharyngeal surgery or tracheostomy or both. This uncommon complication has potentially grave consequences. While airway fires are relatively uncommon occurrences, they are very serious and can often be fatal. Success in preventing such events requires a thorough understanding of the components leading to a fire (fuel, oxidizer, and ignition source), as well as good communication between all members present to appropriately manage the fire and ensure patient safety. We present a case of fire in the airway during routine adenotonsillectomy. We will review the causes, preventive measures, and brief management for airway fires.

Perceived versus Observed Patient Safety Measures in a Critical Care Unit from a Teaching Hospital in Southern Colombia

Introduction. Patient safety is an important topic. The purpose of this study is to evaluate the perceived versus observed patient safety measures (PSM) in critically ill patients in a teaching hospital in Latin America. Materials and Methods. The level of perceived patient safety was evaluated with the patient safety hospital survey. Three months later, a qualitative study was conducted, including video recording of procedures, graded according to adherence to PSM. Levels of adherence were scored during patient mobilization (PM), placement of central catheters (PCC), other invasive procedures (OIP), infection control (IC), and endotracheal intubation (ETI). Results. The perceived adherence of PSM in the prestudy survey was considered fair by 89.1% of the ICU staff. After the survey, 829 ICU procedures were video-recorded. Mean observed adherence for fair patient safety measures was 20.8%. Perceived adherence was higher than the real patient safety protocol measures observed in the videos. Conclusion. Perception of PSM was higher than observed in the management of critically ill patients in a teaching hospital in southern Colombia.

Anesthesia-Related and Perioperative Cardiac Arrest in Low- and High-Income Countries: A Systematic Review With Meta-Regression and Proportional Meta-Analysis

The anesthesia-related cardiac arrest (CA) rate is a quality indicator to improve patient safety in the perioperative period. A systematic review with meta-analysis of the worldwide literature related to anesthesia-related CA rate has not yet been performed.This study aimed to analyze global data on anesthesia-related and perioperative CA rates according to country's Human Development Index (HDI) and by time. In addition, we compared the anesthesia-related and perioperative CA rates in low- and high-income countries in 2 time periods.A systematic review was performed using electronic databases to identify studies in which patients underwent anesthesia with anesthesia-related and/or perioperative CA rates. Meta-regression and proportional meta-analysis were performed with 95% confidence intervals (CIs) to evaluate global data on anesthesia-related and perioperative CA rates according to country's HDI and by time, and to compare the anesthesia-related and perioperative CA rates by country's HDI status (low HDI vs high HDI) and by time period (pre-1990s vs 1990s-2010s), respectively.Fifty-three studies from 21 countries assessing 11.9 million anesthetic administrations were included. Meta-regression showed that anesthesia-related (slope: -3.5729; 95% CI: -6.6306 to -0.5152; P = 0.024) and perioperative (slope: -2.4071; 95% CI: -4.0482 to -0.7659; P = 0.005) CA rates decreased with increasing HDI, but not with time. Meta-analysis showed per 10,000 anesthetics that anesthesia-related and perioperative CA rates declined in high HDI (2.3 [95% CI: 1.2-3.7] before the 1990s to 0.7 [95% CI: 0.5-1.0] in the 1990s-2010s, P < 0.001; and 8.1 [95% CI: 5.1-11.9] before the 1990s to 6.2 [95% CI: 5.1-7.4] in the 1990s-2010s, P < 0.001, respectively). In low-HDI countries, anesthesia-related CA rates did not alter significantly (9.2 [95% CI: 2.0-21.7] before the 1990s to 4.5 [95% CI: 2.4-7.2] in the 1990s-2010s, P = 0.14), whereas perioperative CA rates increased significantly (16.4 [95% CI: 1.5-47.1] before the 1990s to 19.9 [95% CI: 10.9-31.7] in the 1990s-2010s, P = 0.03).Both anesthesia-related and perioperative CA rates decrease with increasing HDI but not with time. There is a clear and consistent reduction in anesthesia-related and perioperative CA rates in high-HDI countries, but an increase in perioperative CA rates without significant alteration in the anesthesia-related CA rates in low-HDI countries comparing the 2 time periods.

Adherence to guidelines for the management of local anesthetic systemic toxicity is improved by an electronic decision support tool and designated "Reader"

BACKGROUND AND OBJECTIVES

A hardcopy or paper cognitive aid has been shown to improve performance during the management of simulated local anesthetic systemic toxicity (LAST) when given to the team leader. However, there remains room for improvement to ensure a system that can achieve perfect adherence to the published guidelines for LAST management. Recent research has shown that implementing a checklist via a designated reader may be of benefit. Accordingly, we sought to investigate the effect of an electronic decision support tool (DST) and designated "Reader" role on team performance during an in situ simulation of LAST.

METHODS

Participants were randomized to Reader + DST (n = 16, rDST) and Control (n = 15, memory alone). The rDST group received the assistance of a dedicated Reader on the response team who was equipped with an electronic DST. The primary outcome measure was adherence to guidelines.

RESULTS

For overall and critical percent correct scores, the rDST group scored higher than Control (99.3% vs 72.2%, P < 0.0001; 99.5% vs 70%, P < 0.0001, respectively). In the LAST scenario, 0 (0%) of 15 in the control group performed 100% of critical management steps, whereas 15 (93.8%) of 16 in the rDST group did so (P < 0.0001).

CONCLUSIONS

In a prospective, randomized single-blinded study, a designated Reader with an electronic DST improved adherence to guidelines in the management of an in situ simulation of LAST. Such tools are promising in the future of medicine, but further research is needed to ensure the best methods for implementing them in the clinical arena.

Perceived barriers to computerised quality documentation during anaesthesia: a survey of anaesthesia staff

BACKGROUND

Underreporting of intraoperative events in anaesthesia is well-known and compromises quality documentation. The reasons for such omissions remain unclear. We conducted a questionnaire-based survey of anaesthesia staff to explore perceived barriers to reliable documentation during anaesthesia.

METHODS

Participants anonymously completed a paper-based questionnaire. Predefined answers referred to potential barriers. Additional written comments were encouraged. Differences between physician and nurse anaesthetists were tested with t-tests and chi-square tests.

RESULTS

Twenty-five physician and 30 nurse anaesthetists (81% of total staff) completed the survey. The reported problems referred to three main categories: (I) potential influences related to working conditions and practices of data collection, such as premature entry of the data (indicated by 85% of the respondents), competing duties (87%), and interfering interruptions or noise (67%); (II) problems referring to institutional management of the data, for example lacking feedback on the results (95%) and lacking knowledge about what the data are used for (75%); (III) problems related to specific attitudes, e.g., considering these data not useful for quality improvement (47%). Physicians were more sceptical than nurses regarding the relevance of these data for quality and patient safety.

CONCLUSIONS

The common perceived difficulties reported by physician and nurse anaesthetists resemble established barriers to incident reporting and may similarly act as barriers to quality documentation during anaesthesia. Further studies should investigate if these perceived obstacles have a causal impact on quality reporting in anaesthesia.

TRIAL REGISTRATION

ClinicalTrials.gov identifier is NCT01524484. Registration date: January 21, 2012.

The role of the anesthesiologist in perioperative patient safety

PURPOSE OF REVIEW

Despite the benefits of rapidly advancing therapeutic and diagnostic possibilities, the perioperative setting still exposes patients to significant risks of adverse events and harm. Anesthesiologists are in midstream of perioperative care and can make significant contributions to patient safety and patient outcomes. This article reviews recent research results outlining the current trends of perioperative patient harm and summarizes the evidence in favor of patient safety practices.

RECENT FINDINGS

Adverse events and patient harm continue to be frequent in the perioperative period. Adverse events occur in about 30% of hospital admissions, are associated with higher mortality, and may be preventable in more than 50%. Evidence-based recommendations are available for many patient safety issues. No magic bullet practices exist, but promising targets include the prevention and limitation of perioperative infections and of complications of airway and respiratory management, the maintenance of achieved safety standards, the use of checklists, and others.

SUMMARY

Current research provides growing evidence for the effectiveness of several patient safety practices designed to prevent or diminish perioperative adverse events and patient harm. Future investigations will hopefully fill the numerous persisting knowledge gaps.