Recovery room incidents: a review of 419 reports from the Anaesthetic Incident Monitoring Study (AIMS)

A Comparison among Score Systems for Discharging Patients from Recovery Rooms: A Narrative Review

INTRODUCTION

The recovery room (RR) is a hospital area where patients are monitored in the early postoperative period before being transferred to the surgical ward or other specialized units. The utilization of scores in the RR context facilitates the assignment of patients to the appropriate ward and directs necessary monitoring. Some scoring systems allow nurses to select patients who can be discharged directly to their homes.

AIM AND METHODS

The aim of this narrative review was to describe and compare the scoring systems employed to discharge postoperative patients from RR, with a focus on item characteristics.

RESULTS

Nine scoring systems were identified and discussed: the "Aldrete Score System" and its modified version, the "Respiration, Energy, Alertness, Circulation, Temperature Score", the "Post Anesthetic Discharge Scoring System", the "White and Song Score", the "Readiness for Discharge Assessment Tool", the "Anesthesia and Perioperative Medicine Service Checklist", the "Post-Anesthetic Care Tool", the "Post-operative Quality Recovery Scale", and the "Discerning Post Anesthesia Readiness for Transition" instrument.

DISCUSSION AND CONCLUSIONS

To obtain a comprehensive overview, the items included in the scoring systems were compared. Despite the availability of guidelines for patients' discharge readiness from the RR, there is no universally recommended scoring system. Next-generation scores must be improved to ease their use, minimize errors, and increase safety. The main goals of the scores included in this narrative review were to be simple to use, feasible, intuitive, comprehensive, and flexible. However, these goals frequently conflict because patient assessment takes time, and a smart and comprehensive score may not consider some clinical parameters that may be crucial for the discharge decision. Therefore, further research should be conducted on this topic.

Extubation-Related Complications

Extubation represents an essential component of airway management. While being a common procedure in anesthesiology and critical care medicine, it is accompanied by a significant risk of morbidity and mortality. Safe extubation requires considerable skills, risk stratification and advanced planning. It is important to emphasize that intentional extubation is always an elective procedure, and as such should only be executed when conditions are optimal. The purpose of this review is to discuss the complications associated with planned extubation in the adult patient, including risk factors and management strategies, mainly focusing on the postoperative setting.

The nature of the response to airway management incident reports in high income countries: A scoping review

Adverse events associated with failed airway management may have catastrophic consequences, and despite many advances in knowledge, guidelines and equipment, airway incidents and patient harm continue to occur. Patient safety incident reporting systems have been established to facilitate a reduction in incidents. However, it has been found that corrective actions are inadequate and successful safety improvements scarce. The aim of this scoping review was to assess whether the same is true for airway incidents by exploring academic literature that describes system changes in airway management in high-income countries over the last 30 years, based on findings and recommendations from incident reports and closed claims studies. This review followed the most recent guidance from the Joanna Briggs Institute (JBI). PubMed, Ovid MEDLINE and Embase, the JBI database, SCOPUS, the Cochrane Library and websites for anaesthetic societies were searched for eligible articles. Included articles were analysed and data synthesised to address the review's aim. The initial search yielded 28,492 results, of which 111 articles proceeded to the analysis phase. These included 23 full-text articles, 78 conference abstracts and 10 national guidelines addressing a range of airway initiatives across anaesthesia, intensive care and emergency medicine. While findings and recommendations from airway incident analyses are commonly published, there is a gap in the literature regarding the resulting system changes to reduce the number and severity of adverse airway events. Airway safety management mainly focuses on Safety-I events and thereby does not consider Safety-II principles, potentially missing out on all the information available from situations where airway management went well.

Structured postoperative handover protocol improves efficiency and quality of interdisciplinary communication and nursing care in surgical intensive care unit: a randomized controlled trial

This study aimed to evaluate the effectiveness of a structured postoperative handover protocol for postoperative transfer to the SICU. This study was a randomized controlled trial conducted in a comprehensive teaching hospital in China. Patients who were transferred to the SICU after surgery were randomly divided into two groups. The intervention group underwent postoperative structured handover protocol, and the control group still applied conventional oral handover. A total of 101 postoperative patients and 50 clinicians were enrolled. Although the intervention group did not shorten the handover duration (6.18 ± 1.66 vs 5.94 ± 1.91; P = 0.505), the handover integrity was significantly improved, mainly reflected in fewer information omissions (1.44 ± 0.97 vs 0.67 ± 0.62; P < 0.001), fewer additional questions raised by ICU physicians (1.06 ± 1.04 vs 0.24 ± 0.43; P < 0.001) and fewer additional handovers via phone call (16% vs 3.9%; P = 0.042). The total score of satisfaction of the intervention group was significantly higher than that of the control group (76.44 ± 7.32 vs 81.24 ± 6.95; P = 0.001). With respect to critical care, the incidence of stage I pressure sore within 24 h was lower in the intervention group than in the control group (20% vs 3.9%, P = 0.029). Structured postoperative handover protocol improves the efficiency and quality of interdisciplinary communication and clinical care in SICU.Trial registration This study was registered in China on January 8th, 2022 at Chinese Clinical Trial Registry (ChiCTR2200055400).

Sustainability of an Operating Room to Pediatric Postanesthesia Care Unit Handoff Tool

PURPOSE

The purpose of this quality improvement (QI) project was to reintroduce and assess the feasibility of a standardized, electronic health record (EHR) handoff tool and to evaluate the sustainability of a structured, team-based approach in a pediatric postanesthesia care unit (PACU).

DESIGN

This QI project used an observational pre-post design using two separate convenience samples of handoffs and perianesthesia providers.

METHODS

A standardized EHR handoff tool was reintroduced for operating room to pediatric PACU handoff communication. Handoffs between anesthesia providers, surgery team members, and PACU nurses were observed pre- and postreintroduction of the EHR handoff tool. Anesthesia providers and PACU RNs received training for giving and receiving handoffs and were provided directions on locating the EHR handoff tool. A bedside audit of items communicated for the six handoff phases (introductions, situation, background, assessment, recommendations, and questions), handoff duration, team member participation, and handoff tool utilization were performed for 149 handoffs pre- and 146 handoffs postimplementation. To evaluate sustainability, the audits were compared to postimplementation data from the 2014 pilot handoff project.

FINDINGS

Following reintroduction, EHR handoff tool use increased from 4% to 19%. There was a statistically significant increase in items communicated for three of the six handoff phases when using the EHR tool (P < .05). There was no statistically significant increase in handoff duration (mean = 3.66 minutes, SD = 1.57 minutes) with the EHR handoff tool. Surgical team member presence for the team-based handoff increased from 90.7% pre to 95.9% post. Provider compliance with the team-based handoff approach, which includes a PACU RN, surgical team member, and anesthesia team member present for handoff, was sustained and increased 6 years postimplementation. Feedback from anesthesia providers and PACU RNs indicated mixed reports of satisfaction with the EHR tool, perceived handoff efficiency, and consistency in both giving and receiving handoff. Adherence to five of the six structured handoff phases, except introductions, was sustained and even improved 6 years following implementation.

CONCLUSIONS

Evidence-based practice for handoff communication supports the use of a team approach and standardized EHR handoff tools. The reintroduction of a standardized EHR handoff tool improved the completeness of information transfer, yet did not lead to widespread adoption nor improved user satisfaction. There is an ongoing need to identify adoptable and sustainable perioperative handoff methods.

Different Types of Intraoperative Hypotension and their Association with Post-Anesthesia Care Unit Recovery

Background

The underlying causative mechanism leading to intraoperative hypotension (IOH) may vary depending on the stage of anesthesia and surgery, resulting in different types of IOH. Consequently, the incidence, severity, and postoperative complications associated with IOH types may differ. This study explores the association between IOH types and post-anesthesia care unit (PACU) recovery, with a focus on duration and complications.

Methods

From May 2022 to December 2022, we included 4776 consecutive surgical patients aged ≥18 who underwent elective surgery with planned overnight stays at Acibadem Altunizade Hospital and received general anesthesia. Post-induction hypotension (pIOH) was defined as a decrease in blood pressure during the first 20 minutes after anesthesia induction, while maintenance intraoperative hypotension (mIOH) referred to a decrease in blood pressure occurring after the 20th minute following induction, with or without preceding pIOH.

Results

Among the included patients, 22.13% experienced IOH, with a higher prevalence observed among females. Patients with mIOH exhibited higher rates of bleeding, transfusions, hypothermia, longer stays in the PACU, and increased oxygen requirements. The duration of anesthesia did not increase the likelihood of IOH. Multivariate logistic regression analysis revealed that ephedrine usage, hypothermia, the need for additional analgesics, nausea, and vomiting were factors associated with longer PACU duration. Older patients (≥65), patients with ASA≥2 status, those undergoing major surgery, experiencing unexpected bleeding, and exhibiting hypothermia at the end of anesthesia had a higher likelihood of requiring vasopressor support.

Conclusions

Patients experiencing hypotension, particularly during the maintenance of anesthesia, are more prone to complications in the PACU and require closer monitoring and treatment. Although less common, mIOH has a more significant impact on outcomes compared to other factors affecting PACU recovery. The impact of mIOH on PACU duration should not be overlooked in favor of other factors.

Registration

Clinicaltrials.gov identifier: NCT05671783.

Unplanned Post-Anesthesia Care Unit to ICU Transfer Following Cerebral Surgery: A Retrospective Study

Background: Unplanned transfer to intensive care unit (ICU) lead to reduced trust of patients and their families in medical staff and challenge medical staff to allocate scarce ICU resources. This study aimed to explore the incidence and risk factors of unplanned transfer to ICU during emergence from general anesthesia after cerebral surgery, and to provide guidelines for preventing unplanned transfer from post-anesthesia care unit (PACU) to ICU following cerebral surgery. Methods: This was a retrospective case-control study and included patients with unplanned transfer from PACU to ICU following cerebral surgery between January 2016 and December 2020. The control group comprised patients matched (2:1) for age (±5 years), sex, and operation date (±48 hours) as those in the case group. Stata14.0 was used for statistical analysis, and p < .05 indicated statistical significance. Results: A total of 11,807 patients following cerebral surgery operations were cared in PACU during the study period. Of the 11,807 operations, 81 unscheduled ICU transfer occurred (0.686%). Finally, 76 patients were included in the case group, and 152 in the control group. The following factors were identified as independent risk factors for unplanned ICU admission after neurosurgery: low mean blood oxygen (OR = 1.57, 95%CI: 1.20-2.04), low mean albumin (OR = 1.14, 95%CI: 1.03-1.25), slow mean heart rate (OR = 1.04, 95%CI: 1.00-1.08), blood transfusion (OR = 2.78, 95%CI: 1.02-7.58), emergency surgery (OR = 3.08, 95%CI: 1.07-8.87), lung disease (OR = 2.64, 95%CI: 1.06-6.60), and high mean blood glucose (OR = 1.71, 95%CI: 1.21-2.41). Conclusion: We identified independent risk factors for unplanned transfer from PACU to ICU after cerebral surgery based on electronic medical records. Early identification of patients who may undergo unplanned ICU transfer after cerebral surgery is important to provide guidance for accurately implementing a patient's level of care.

Preparing the Patient for ICU Transfer: What Is the Anesthesiologist’s Role?

Purpose of Review

This review summarizes the anesthesiologist’s role in transferring critically ill surgical patients at different phases of care.

Recent Findings

Early recognition of patients at high intraoperative and postoperative risk is one of the most important first steps, followed by preoperative and intraoperative stabilization measures depending on the individual needs. It mainly is the anesthesiologist’s responsibility to decide on postoperative ICU admission. The transfer of the critically ill should be planned; the ICU staff has to be informed as early as possible. Locally developed checklists should be used during the preparation of patient transport. Trained, dedicated staff should be made available in every institution. A detailed handover using dedicated institutional flowcharts should ensure patient safety upon arrival to the ICU.

Summary

Transfer of critically ill patients from the OR to the ICU is an interdisciplinary task with a high probability of eventual incidents. Anesthesiologists should play a key role in all phases of the procedure to improve patient outcomes.

Evaluation of electronic screening in the preoperative process

STUDY OBJECTIVE

Rising patient numbers, with increasing complexity, challenge the sustainability of the current preoperative process. We evaluated whether an electronic screening application can distinguish patients that need a preoperative consultation from low-risk patients that can be first seen on the day of surgery.

DESIGN

Prospective cohort study.

SETTING

Preoperative clinic of a tertiary academic hospital.

PATIENTS

1395 adult patients scheduled for surgery or procedural sedation.

INTERVENTIONS

We assessed a novel electronic preoperative screening application which consists of a questionnaire with a maximum of 185 questions regarding the patient's medical history and current state of health. The application provides an extensive health report, including an American Society of Anesthesiologists physical status (ASA-PS) classification and a recommendation for either consultation by an anesthesiologist at the preoperative clinic or approval for screening on the day of surgery.

MEASUREMENTS

The recommendation of the electronic screening system was compared with the regular preoperative assessment using measures of diagnostic accuracy and agreement. Secondary outcomes included ASA-PS classification, patient satisfaction, and the anesthesiologists' opinion on the completeness and quality of the screening report.

RESULTS

Sensitivity to detect patients who needed additional consultation was 97.5% (95%CI 91.2-99.7) and the negative likelihood ratio was 0.08 (95%CI 0.02-0.32). 407 (29.2%) patients were approved for surgery by both electronic screening and anesthesiologist. In 909 (65.2%) cases, the electronic screening system recommended further consultation while the anesthesiologist approved the patient (specificity 30.9% (95%CI 28.4-33.5); poor level of agreement (ĸ = 0.04)). Agreement regarding ASA-PS classification scores was weak (ĸ = 0.48). The majority of patients (78.0%) felt positive about electronic screening replacing the regular preoperative assessment.

CONCLUSIONS

Electronic screening can reliably identify patients who can have their first contact with an anesthesiologist on the day of surgery, potentially allowing a major proportion of patients to safely bypass the preoperative clinic.

Evaluation of Complication Development in General Surgery Patients Admitted to the Post Anesthesia Care Unit

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The association between unanticipated prolonged post-anaesthesia care unit length of stay and early postoperative deterioration: A retrospective cohort study

This study aimed to investigate whether there was an association between an unanticipated prolonged post-anaesthesia care unit (PACU) length of stay and early postoperative deterioration, as defined as the need for a rapid response team activation, within the first seven days of surgery. We conducted a single-centre retrospective cohort study of adult surgical patients, who stayed at least one night in hospital, and were not admitted to critical care immediately postoperatively, between 1 July 2017 and 30 June 2019. A total of 11,885 cases were analysed. PACU length of stay was significantly associated with rapid response team activation on both univariate (odds ratio (OR) per increment 1.57, 95% confidence intervals (CI) 1.45 to 1.69, P < 0.001) and multivariate analysis (OR per increment 1.41, 95% CI 1.28 to 1.55, P < 0.001). Patients who stayed less than one hour were at low risk of deterioration (absolute risk 3.7%). In patients staying longer than one hour, the absolute increase in risk was small but observable within six hours of PACU discharge. Compar\ed to a one-hour length of stay, a five-hour stay had a relative risk of 4.9 (95% CI 3.7 to 6.1). Other factors associated with rapid response team activation included non-elective surgery (OR 1.78, P < 0.001) and theatre length of stay (OR per increment 1.61, P < 0.001). PACU length of stay was also independently associated with predefined complications and unplanned intensive care unit admission postoperatively. In our cohort, an unanticipated prolonged PACU length of stay of over one hour was associated with an increased incidence of rapid response team activation in the first seven days postoperatively.

Incidence and factors associated with post-anesthesia care unit complications in resource-limited settings: An observational study

Background and aims

Postoperative complications are frequent encounters in the patients admitted to postanesthesia care units (PACU). The main aim of this study was to assess the incidence of complications and associated factors among surgical patients admitted in limited-resource settings of the PACU.

Methods

This is an observational study of 396 surgical patients admitted to PACU. This study was conducted from February 1 to March 30, 2021, in Ethiopia. Study participants' demographics, anesthesia, and surgery-related parameters, PACU complications, and length of stay in PACU were documented. Multivariate and bivariate logistic regression analyses, the odds ratio (OR), and 95% confidence interval (CI) were calculated. p-value < 0.05 was considered as statistically significant.

Results

The incidence of complications among surgical patients admitted to PACU was 54.8%. Of these, respiratory-related complications and postoperative nausea/vomiting were the most common types of PACU complications. Being a female (adjusted odds ratio [AOR] = 2.928; 95% CI: 1.899-4.512) was significantly associated with an increased risk of developing PACU complications. Duration of anesthesia >4 h (AOR = 5.406; 95% CI: 2.418-12.088) revealed an increased risk of association with PACU complications. The occurrences of intraoperative complications (AOR = 2.238; 95% CI: 0.991-5.056) during surgery were also associated with PACU complications. Patients who develop PACU complications were strongly associated with length of PACU stay for >4 h (AOR = 2.177; 95% CI: 0.741-6.401).

Conclusion

The identified risk factors for complications in surgical patients admitted to PACU are female sex, longer duration of anesthesia, and intraoperative complications occurrences. Patients who developed complications had a long time of stay in PACU. Based on our findings, we recommend the PACU team needs to develop area-specific institutional guidelines and protocols to improve the patients' quality of care and outcomes in PACU.

Evaluation of a Broad-Spectrum Partially Automated Adverse Event Surveillance System: A Potential Tool for Patient Safety Improvement in Hospitals With Limited Resources

OBJECTIVE

The aim of the study was to evaluate the sensitivity and resource efficiency of a partially automated adverse event (AE) surveillance system for routine patient safety efforts in hospitals with limited resources.

METHODS

Twenty-eight automated triggers from the hospital information system's clinical and administrative databases identified cases that were then filtered by exclusion criteria per trigger and then reviewed by an interdisciplinary team. The system, developed and implemented using in-house resources, was applied for 45 days of surveillance, for all hospital inpatient admissions (N = 1107). Each trigger was evaluated for its positive predictive value (PPV). Furthermore, the sensitivity of the surveillance system (overall and by AE category) was estimated relative to incidence ranges in the literature.

RESULTS

The surveillance system identified a total of 123 AEs among 283 reviewed medical records, yielding an overall PPV of 52%. The tool showed variable levels of sensitivity across and within AE categories when compared with the literature, with a relatively low overall sensitivity estimated between 21% and 44%. Adverse events were detected in 23 of the 36 AE categories defined by an established harm classification system. Furthermore, none of the detected AEs were voluntarily reported.

CONCLUSIONS

The surveillance system showed variable sensitivity levels across a broad range of AE categories with an acceptable PPV, overcoming certain limitations associated with other harm detection methods. The number of cases captured was substantial, and none had been previously detected or voluntarily reported. For hospitals with limited resources, this methodology provides valuable safety information from which interventions for quality improvement can be formulated.

Clinical handover and handoff in healthcare: a systematic review of systematic reviews

PURPOSE

The purpose of this systematic review is to appraise and summarize existing literature on clinical handover.

DATA SOURCES

We searched EMBASE, MEDLINE, Database of Abstracts of Reviews of Effects and Cochrane Database of Systematic Reviews.

STUDY SELECTION

Included articles were reviewed independently by the review team.

DATA EXTRACTION

The review team extracted data under the following headers: author(s), year of publication, journal, scope, search strategy, number of studies included, type of studies included, study quality assessment, used definition of handover, healthcare setting, outcomes measured, findings and finally some comments or remarks.

RESULTS OF DATA SYNTHESIS

First, research indicates that poor handover is associated with multiple potential hazards such as lack of availability of required equipment for patients, information omissions, diagnosis errors, treatment errors, disposition errors and treatment delays. Second, our systematic review indicates that no single tool arises as best for any particular specialty or use to evaluate the handover process. Third, there is little evidence delineating what constitutes best handoff practices. Most efforts facilitated the coordination of care and communication between healthcare professionals using electronic tools or a standardized form. Fourth, our review indicates that the principal teaching methods are role-playing and simulation, which may result in better knowledge transfer to the work environment, better health and patients' well-being.

CONCLUSIONS

This review emphasizes the importance of staff education (including simulation-based and team training), non-technical skills and the implementation process of clinical handover in healthcare settings.

Improving Handoff by Deliberate Cognitive Processing: Results from a Randomized Controlled Experimental Study

BACKGROUND

Although a number of successful handoff interventions have been reported, the handoff process remains vulnerable because it relies on memory. The aim of this study was to investigate the effect of deliberate cognitive processing (i.e., analytical, conscious, and effortful thinking) on recall of information from a simulated handoff.

METHODS

This two-phased experiment was executed in the Netherlands in 2015. A total of 78 pediatric residents were randomly divided into an intervention group (n = 37) and a control group (n = 41). In phase 1, participants received written handoffs from 8 patients. The intervention group was asked to develop a contingency plan for each patient, deliberately processing the information. The control group received no specific instructions. In phase 2, all participants were asked to write down as much as they recalled from the handoffs. The outcome was the amount and accuracy of recalled information, calculated by scoring for idea units (single information elements) and inferences (conclusions computed by participants based on two or more idea units).

RESULTS

Participants in the intervention group recalled significantly more inferences (7.24 vs. 3.22) but fewer correct idea units (21.1% vs. 25.3%) than those in the control group. There was no difference with regard to incorrectly recalled information.

CONCLUSION

Our study revealed that deliberate cognitive processing leads to creation of more correct inferences, but fewer idea units. This suggests that deliberate cognitive processing results in interpretation of the information into higher level concepts, rather than remembering specific pieces of information separately. This implies better understanding of patients' problems.

Influence of personalised music and ice-tea options on post-operative well-being in the post anaesthesia care unit after general or regional anaesthesia. A pre-post-analysis by means of a questionnaire

OBJECTIVES

Assessment whether patients' wellbeing and disturbances in the post anaesthesia care unit could be influenced by the consecutive introduction of initially personalised music and then additionally various drink options.

DESIGN/SETTING

A pre-post-analysis by means of an anonymised survey with a validated questionnaire in a university hospital in central Europe.

MAIN OUTCOME MEASURES

Wellbeing and disturbances in the post anaesthesia care unit.

RESULTS

Patients' most frequently reported early postsurgical disturbances (n = 1335) were lack of wellbeing, dry mouth and pain in the surgical area. Reported rates of clinically relevant wellbeing were not statistically different in patients that were offered personalised music (46.5%) or additionally ice-tea (50.6%). No correlation could be found between wellbeing or physical discomfort and headphones or when ice-tea were offered.

CONCLUSION

After a decade of increased efforts to improve patients' wellbeing in the postanaesthesia care unit we could not show further influence on it by the introduction of personalised music and ice-tea. We see the need for a more differentiated focus on this topic and the need for exploratory studies on patient perception. The most frequent claims were related to lack of wellbeing, pain in the surgical area and a dry mouth.

Handover Patterns in the PACU: A Review of the Literature

PURPOSE

Currently, there is no standardized handover pattern for patients undergoing general anesthesia when being transferred to the postanesthesia care unit (PACU).

DESIGN

A review of the literature.

METHODS

In this study, a review of the literature was conducted to analyze the PACU handover status, factors for poor handover, and commonly used handover patterns.

FINDINGS

Important handover information was often omitted during the handover of PACU patients, and there were many factors influencing postoperative patient handover quality. This study analyzed and compared several commonly used handover patterns for patients. Among these, the Situation-Background-Assessment-Recommendation tool is relatively mature. However, there is currently no unified standardized patient handover pattern, and the validity and applicability of tools still need to be verified.

CONCLUSIONS

PACU is an important place for the recovery of surgical patients. Anesthesia providers need to provide PACU nurses with complete and comprehensive postoperative handover information. A standardized handover model for clinical nurses is needed to improve patient safety management and work efficiency.

Rapid quantitative determination of blood propofol concentration throughout perioperative period by negative photoionization ion mobility spectrometer with solvent-assisted neutral desorption

Rapid and quantitative determination of blood propofol concentration is important for anesthesiologists to accurately control intraoperative propofol dose, timely monitor physiological statuses of patients and greatly improve the safety of surgery. Herein, a dopant-assisted negative photoionization ion mobility spectrometer with the optimized ionization region structure and the three-way inlet design was developed, increasing the generation ratio of the reactant ions O₂^-, and improving the ionization efficiency of propofol molecules. Besides, the addition of methanol-anisole solution during injection promoted the neutral desorption of propofol in blood, further improving the detection sensitivity by an order of magnitude, eliminating any sample pretreatment and effectively reducing the single analysis time to less than 1 min compared to the previous article. The dual calibration quantitative method, i.e. the method of calibrating the O₂^- concentration and the sample concentration changes during the entire process of detecting propofol through the integral value of M·O₂^- and the maximum signal intensity of O₂^-, successfully achieved accurate quantification of blood propofol. And the linear calibration curve of propofol was obtained with the range of 0.1-15 ng μL^-1 and with the limit of detection of 0.03 ng μL^-1, which was fulfilled to conduct propofol determination throughout the perioperative period. Finally, this method was applied to clinically measure the blood propofol concentration in patients newly regained consciousness with concentrations ranging from 0.2 ng μL^-1 to 3 ng μL^-1, and it turned out that the older patient had the lower propofol concentration in blood.

Development of an aviation-style computerized checklist displayed on a tablet computer for improving handoff communication in the post-anesthesia care unit

Critical patient care information is often omitted or misunderstood during handoffs, which can lead to inefficiencies, delays, and sometimes patient harm. We implemented an aviation-style post-anesthesia care unit (PACU) handoff checklist displayed on a tablet computer to improve PACU handoff communication. We developed an aviation-style computerized checklist system for use in procedural rooms and adapted it for tablet computers to facilitate the performance of PACU handoffs. We then compared the proportion of PACU handoff items communicated before and after the implementation of the PACU handoff checklist on a tablet computer. A trained observer recorded the proportion of PACU handoff information items communicated, any resistance during the performance of the checklist, the type of provider participating in the handoff, and the time required to perform the handoff. We also obtained these patient outcomes: PACU length of stay, respiratory events, post-operative nausea and vomiting, and pain. A total of 209 PACU handoffs were observed before and 210 after the implementation of the tablet-based PACU handoff checklist. The average proportion of PACU handoff items communicated increased from 49.3% (95% CI 47.7-51.0%) before checklist implementation to 72.0% (95% CI 69.2-74.9%) after checklist implementation (p < 0.001). A tablet-based aviation-style handoff checklist resulted in an increase in PACU handoff items communicated, but did not have an effect on patient outcomes.

Debunking the myth that the majority of medical errors are attributed to communication

CONTEXT

Many articles, book chapters and presentations begin with a declaration that the majority of medical errors are attributed to communication. However, this statement may not be supported by the research reported in the literature.

OBJECTIVES

The purpose of this systematic review is to identify where errors are reported in the research literature.

METHODS

A systematised review was conducted of research articles over the last 20 years (1998-2018) indexed in PubMed/MEDLINE and the Cumulative Index to Nursing and Allied Health (CINAHL) using term combinations: medical errors, research and communication. Inclusion was based on reported generalised primary research of medical error and the reported causes.

RESULTS

This systematised review resulted in 2881 research articles, which produced 42 that met the inclusion criteria. Although there was some overlap, three categories of errors were dominant in this research: errors of commission (20 articles; 47.6%), errors of omission (six articles; 14.2%) and errors through communication (four articles; 9.5%). There were 12 (28.5%) articles in which all three categories together significantly contributed to error. Of these 12 articles, errors of commission or omission were dominant in nine articles (21.4%) and errors of communication were prevalent in only three articles (7%).

CONCLUSIONS

The assertion that the majority of medical errors can be attributed to miscommunication is not supported by this systematic review. Overwhelmingly, most reported errors are attributed to errors of omission or commission. Intentionally or unintentionally providing misinformation may mislead patient safety initiatives, and research and funding agency priorities.

An Electronic Handover System to Improve Information Transfer for Surgical Patients

Proper clinical transfers of patient care (known as handovers) are important to patient safety. The aim of this study was to investigate the efficacy and satisfaction of an electronic system for clinical transfers of patients with complex surgical procedures. The design was a single-center observational study auditing the handover process. The electronic handover system combined with an electronic health record system was developed to help verbal handover. The system has a checklist to guide the structured handover process and provided information from the health record system. With the system, the elapsed time for surgical handover decreased from 10.5 to 5.4 minutes. The questionnaire analysis showed that clinician satisfaction with surgical handover increased from 69.4% to 79.3%, and the perception of communication completeness increased from 67.2% to 81.6%. The electronic handover system improved communication for the transfer of care for surgical patients.

Physicians' and Nurses' Attitudes and Actions Regarding Perioperative Medication Management

PURPOSE

To investigate physicians' and nurses' attitudes and actions related to the prescription and administration of perioperative antibiotics and opioids during a 2-week period.

DESIGN

A quantitative descriptive and analytical research design performed at a Danish University Hospital.

METHODS

An email survey using an 18-item questionnaire was sent to 163 nurses and physicians involved in the perioperative period.

FINDINGS

Of 163 participants, 114 (69.9%) returned the questionnaire. Between 12% and 29% of the respondents reported that they did not correctly manage the medication, although they thought it to be important. Between 41% and 68% of the respondents experienced incorrect medication management with significant differences among professions and specialties.

CONCLUSIONS

The study confirms a knowing-doing gap in medication management in perioperative settings, highlighting the need to address this issue, to ensure that physicians and nurses act in accordance with their beliefs and consider the importance of medication safety in interdisciplinary work across specialties.

Handovers in Perioperative Care

Handovers around the time of surgery are common, yet complex and error prone. Interventions aimed at improving handovers have shown increased provider satisfaction and teamwork, improved efficiency, and improved communication and have been shown to reduce errors and improve clinical outcomes in some studies. Common recommendations in the literature include a standardized institutional process that allows flexibility among different units and settings, the completion of urgent tasks before information transfer, the presence of all members of the team for the duration of the handover, a structured conversation that uses a cognitive aid, and education in team skills and communication.

Analysis of adverse outcomes in the post-anesthesia care unit based on anesthesia liability data

STUDY OBJECTIVE

The aim of this study is to provide a contemporary medicolegal analysis of claims brought against anesthesiologists in the United States for events occurring in the post-anesthesia care unit (PACU).

DESIGN

In this retrospective analysis, we analyzed closed claims data from the Controlled Risk Insurance Company (CRICO) Comparative Benchmarking System (CBS) database.

SETTING

Claims closed between January 1, 2010 and December 31, 2014 were included for analysis if the alleged damaging event occurred in a PACU and anesthesiology was named as the primary responsible service.

PATIENTS

Forty-three claims were included for analysis. Data regarding ASA physical status and comorbidities were obtained, whenever available. Ages ranged from 18 to 94. Patients underwent a variety of surgical procedures. Severity of adverse outcomes ranged from temporary minor impairment to death.

INTERVENTIONS

Patients receiving care in the PACU.

MEASUREMENTS

Information gathered for this study includes patient demographic data, alleged injury type and severity, operating surgical specialty, contributing factors to the alleged damaging event, and case outcome. Some of these data were drawn directly from coded variables in the CRICO CBS database, and some were gathered by the authors from narrative case summaries.

RESULTS

Settlement payments were made in 48.8% of claims. A greater proportion of claims involving death resulted in payment compared to cases involving other types of injury (69% vs 37%, p = 0.04). Respiratory injuries (32.6% of cases), nerve injuries (16.3%), and airway injuries (11.6%) were common. Missed or delayed diagnoses in the PACU were cited as contributing factors in 56.3% of cases resulting in the death of a patient. Of all claims in this series, 48.8% involved orthopedic surgery.

CONCLUSIONS

The immediate post-operative period entails significant risk for serious complications, particularly respiratory injury and complications of airway management. Appropriate monitoring of patients by responsible providers in the PACU is crucial to timely diagnosis of potentially severe complications, as missed and delayed diagnoses were a factor in a number of the cases reviewed.

Introduction to surgical and perioperative clinical pharmacy for third-year pharmacy students: A pilot study of an elective course

INTRODUCTION

The objective of this study was to implement and assess an elective course that exposes pharmacy students to clinical pharmacy in the surgical and perioperative setting.

METHODS

A blended-design elective that included synchronous and asynchronous learning was developed and offered to third-year pharmacy students. Students' knowledge and perception regarding clinical topics in perioperative pharmacy was assessed using pre- and post-course assessments, online quizzes, a journal club, and course assignments. Knowledge of pharmacy operations was assessed using course assignments and reflective journal entries.

RESULTS

Pre- and post-course assessment improvement was seen in the categories of perioperative optimization of pharmacotherapy (29.1-70.1%, p=0.006), common surgical complications (45.8-91.7%, p = 0.001), and anesthetic agents (25-71.9%, p <0.001). Overall, the course was successful in increasing clinical pharmacy knowledge and was well received by students. Course evaluations were completed by 100% of students, and all rated the course as "excellent." Students demonstrated mastery of course content, though the course may not have provided optimal exposure to operating room/post-anesthesia care unit operations.

DISCUSSION AND CONCLUSIONS

Students agreed that the course was valuable and helped them develop new skills otherwise not developed by the curriculum; this conclusion was supported by objective assessment data. A team-teaching model allowed for minimal resources to operate the course. Moving forward, an early lecture addressing perioperative operations may supplement an area the course was lacking. Additionally, a longer duration of operating room shadowing may provide requested opportunities for observation of direct patient care.

Systematic review of benefits or harms of routine anaesthetist-inserted throat packs in adults: practice recommendations for inserting and counting throat packs: An evidence-based consensus statement by the Difficult Airway Society (DAS), the British Association of Oral and Maxillofacial Surgery (BAOMS) and the British Association of Otorhinolaryngology, Head and Neck Surgery (ENT-UK)

Throat packs are commonly inserted by anaesthetists after induction of anaesthesia for dental, maxillofacial, nasal or upper airway surgery. However, the evidence supporting this practice as routine is unclear, especially in the light of accidentally retained throat packs which constitute 'Never Events' as defined by NHS England. On behalf of three relevant national organisations, we therefore conducted a systematic review and literature search to assess the evidence base for benefit, and also the extent and severity of complications associated with throat pack use. Other than descriptions of how to insert throat packs in many standard texts, we could find no study that sought to assess the benefit of their insertion by anaesthetists. Instead, there were many reports of minor and major complications (the latter including serious postoperative airway obstruction and at least one death), and many descriptions of how to avoid complications. As a result of these findings, the three national organisations no longer recommend the routine insertion of throat packs by anaesthetists but advise caution and careful consideration. Two protocols for pack insertion are presented, should their use be judged necessary.

The impact of capnography monitoring among children and adolescents in the postanesthesia care unit: a randomized controlled trial

BACKGROUND

Pulse oximetry does not reliably recognize respiratory depression, particularly in the presence of supplemental oxygen. Capnography frequently detects hypoventilation and apnea among children recovering from anesthesia. Although children are routinely monitored with capnography during anesthesia, reducing the rate of adverse events, it is not routinely used in the postanesthesia care unit (PACU), where patients remain at risk for respiratory depression.

AIM

We hypothesized that children monitored with capnography would have more frequent staff interventions and fewer adverse events than children monitored with pulse oximetry alone.

METHODS

Otherwise healthy children of age 1-20 years undergoing general anesthesia for elective surgery were eligible for enrollment upon entering the pediatric PACU. Subjects were randomized as to whether PACU staff could view the capnography monitor (intervention group) or not (control group). All children received standard monitoring with pulse oximetry. Vital signs and patient interventions were recorded every 30 s by a portable monitor or a research associate.

RESULTS

Data from 201 children were analyzed. The rates of hypopneic hypoventilation [5% (95% CI: 2-8%) per minute vs 1% (95% CI: -1% to 3%) per minute, difference 4% (95% CI: 0.2-8%) per minute; P = 0.04] and apnea [11% (95% CI: 8-14%) per minute vs 1.5% (95% CI: -2% to 5%) per minute, difference 9% (5-14%) per minute; P < 0.001] decreased significantly faster in our intervention group as compared to the control group. The rates of bradypnea decreased faster in our control group [5% (95% CI: 2-8%) per minute vs 1% (95% CI: 0-4%) per minute, difference 4% per minute, 95% CI: 0-9%; P = 0.05]. Rates of respiratory events over time between groups were affected by the presence or absence of interventions. There were no differences in rates of hypoxemia between groups over time.

CONCLUSIONS

Children monitored with capnography have different rates of adverse respiratory events over time than children monitored solely with pulse oximetry. The addition of capnography improved the efficacy of staff interventions, however did not impact rates of oxygen desaturation.

Does Checklist Implementation Improve Quantity of Data Transfer: An Observation in Postanesthesia Care Unit (PACU)

BACKGROUND

Omission of patient information in perioperative communication is closely linked to adverse events. Use of checklists to standardize the handoff in the post anesthesia care unit (PACU) has been shown to effectively reduce medical errors.

OBJECTIVE

Our study investigates the use of a checklist to improve quantity of data transfer during handoffs in the PACU.

DESIGN

A cross-sectional observational study.

SETTING

PACU at Memorial Sloan Kettering Cancer Center (MSKCC); June 13, 2016 through July 15, 2016.

PATIENTS OTHER PARTICIPANTS

We observed the handoff reports between the nurses, PACU midlevel providers, anesthesia staff, and surgical staff.

INTERVENTION

A physical checklist was provided to all anesthesia staff and recommended to adhere to the list at all observed PACU handoffs.

MAIN OUTCOME MEASURE

Quantity of reported handoff items during 60 pre- and 60 post-implementation of a checklist.

RESULTS

Composite value from both surgical and anesthesia reports showed an increase in the mean report of 8.7 items from pre-implementation period to 10.9 post-implementation. Given that surgical staff reported the mean of 5.9 items pre-implementation and 5.5 items post-implementation without intervention, improvements in anesthesia staff report with intervention improved the overall handoff data transfer.

CONCLUSIONS

Using a physical 12-item checklist for PACU handoff increased overall data transfer.

Responding to a Respiratory Complication in the Recovery Room: A Simulation Case for Anesthesiology Students

INTRODUCTION

Postoperative respiratory complications have multiple etiologies, are commonly occurring, and are potentially life-threatening complications of anesthesia. Adverse outcomes associated with respiratory complications are a leading cause of injury-related malpractice claims in anesthesiology. Appropriate response to respiratory complications in the postanesthesia care unit (PACU) involves early intervention, development of a differential diagnosis, and an organized approach to respiratory support and patient disposition.

METHODS

This simulation is designed for medical students, student nurse anesthetists, and junior resident physicians rotating clinically in anesthesiology. It is designed as a 1-hour, small-group, simulation-based learning activity centered upon a single patient encounter. It focuses on a postoperative encounter occurring shortly after a patient arrives in the PACU. The patient is recovering from a prolonged emergent upper abdominal surgery using an anesthetic associated with increased risk of respiratory complications, and has multiple risk factors for postoperative respiratory complications. This scenario is easily reproduced on modern simulation mannequins without specialized programming. The patient's vital signs are displayed and remain within normal limits, with the exception of the oxygen saturation and heart rate, which must be adjusted during the exercise.

RESULTS

Learners provided evaluations of their experience with this simulation, and these appraisals and comments have been unanimously positive.

DISCUSSION

We employed this exercise using an anesthesiology resident physician to proctor and debrief, a simulation technician to program and run the model, and a faculty anesthesiologist to mentor each session. We used this simulation case as an educational opportunity for medical students rotating clinically in our department.

An electronic handoff tool to facilitate transfer of care from anesthesia to nursing in intensive care units

Checklists are commonly used to structure the communication process between anesthesia nursing healthcare providers during the transfer of care, or handoff, of a patient after surgery. However, intraoperative information is often recalled from memory leading to omission of critical data or incomplete information exchange during the patient handoff. We describe the implementation of an electronic anesthesia information transfer tool (T2) for use in the handover of intubated patients to the intensive care unit. A pilot observational study auditing handovers against a pre-existing checklist was performed to evaluate information reporting and attendee participation. There was a modest improvement in information reporting on part of the anesthesia provider, as well as team discussions regarding the current hemodynamic status of the patient. While T2 was well-received, further evaluation of the tool in different handover settings can clarify its potential for decreasing adverse communication-related events.

Implementing situation-background-assessment-recommendation in an anaesthetic clinic and subsequent information retention among receivers: A prospective interventional study of postoperative handovers

BACKGROUND

Communication errors cause clinical incidents and adverse events in relation to surgery. To ensure proper postoperative patient care, it is essential that personnel remember and recall information given during the handover from the operating theatre to the postanaesthesia care unit. Formalizing the handover may improve communication and aid memory, but research in this area is lacking.

OBJECTIVE

The objective of this study was to evaluate whether implementing the communication tool Situation-Background-Assessment-Recommendation (SBAR) affects receivers' information retention after postoperative handover.

DESIGN

A prospective intervention study with an intervention group and comparison nonintervention group, with assessments before and after the intervention.

SETTING

The postanaesthesia care units of two hospitals in Sweden during 2011 and 2012.

PARTICIPANTS

Staff involved in the handover between the operating theatre and the postanaesthesia care units within each hospital.

INTERVENTION

Implementation of the communication tool SBAR in one hospital.

MAIN OUTCOME MEASURES

The main outcome was the percentage of recalled information sequences among receivers after the handover. Data were collected using both audio-recordings and observations recorded on a study-specific protocol form.

RESULTS

Preintervention, 73 handovers were observed (intervention group, n = 40; comparison group, n = 33) involving 72 personnel (intervention group, n = 40; comparison group, n = 32). Postintervention, 91 handovers were observed (intervention group, n = 44; comparison group, n = 47) involving 57 personnel (intervention group, n = 31; comparison group, n = 26). In the intervention group, the percentage of recalled information sequences by the receivers increased from 43.4% preintervention to 52.6% postintervention (P = 0.004) and the SBAR structure improved significantly (P = 0.028). In the comparison group, the corresponding figures were 51.3 and 52.6% (P = 0.725) with no difference in SBAR structure. When a linear regression generalised estimating equation model was used to account for confounding influences, we were unable to show a significant difference in the information recalled between the intervention group and the nonintervention group over time.

CONCLUSION

Compared with the comparison group with no intervention, when SBAR was implemented in an anaesthetic clinic, we were unable to show any improvement in recalled information among receivers following postoperative handover.

TRIAL REGISTRATION

Current controlled trials http://www.controlled-trials.com Identifier: ISRCTN37251313.

Critical incidents in a French department of paediatric anaesthesia

BACKGROUND

Several studies have highlighted the importance of critical incident (CI) reporting in order to enhance patient safety. We have implemented an anonymous procedure for CI reporting in our department of paediatric anaesthesia. This study aims at analysing those CIs so as to improve patient care and risk management.

MATERIAL AND METHODS

CIs were reported by the anaesthetic team using the World Health Organization classification and analysed using the ORION methodology. CIs were classified according to type, surgery and complications. Risk factors and consequences for patients and for the institution were analysed. Risk factors with high degree of harm for the patient were identified using a univariate analysis and odds ratios (OR).

RESULTS

Over an 18-month period, 114 CIs were reported for 103 patients (median age: 7.0 years [95% CI: 3.6-9.8]). We found that 29.9% of reported CIs had consequences for the patients and 76.3% were considered preventable. The two main types of CI were "respiratory" (28.8%) and "drug-related" (22.8%) incidents. The main risk factor was 'human error' (42.3%). Several consequences for the patient and the hospital were identified. An ASA score≥3 (OR: 2.52; [95% CI: 1.10-5.78]) was an independent risk factor for a high degree of patient harm.

CONCLUSION

Improving quality of care must be a priority for paediatric anaesthesiologists as most of the CIs observed are preventable and have consequences for the patient and the institution.

Retrospective review of critical incidents in the post-anaesthesia care unit at a major tertiary hospital

INTRODUCTION

We reviewed patients with critical incidents that occurred in the post-anaesthesia care unit (PACU) at a major tertiary hospital, and assessed the effect of these incidents on PACU length of stay and discharge disposition.

METHODS

A retrospective review was conducted of patients in the PACU over a two-year period from 24 June 2011 to 23 August 2013. Data on critical incidents was recorded in the administrative database using a standardised data form.

RESULTS

There were 701 incidents involving 364 patients; 203 (55.8%) patients had American Society of Anesthesiologists (ASA) physical status I or II. The most common critical incidents were cardiovascular-related (n = 293, 41.8%), respiratory (n = 155, 22.1%), neurological (n = 52, 7.4%), surgical (n = 47, 6.7%) and airway-related (n = 34, 4.9%). There were two incidents of cardiac arrest and 25 incidents of unexpected reintubations. Many patients (n = 186, 51.2%) stayed for over four hours in the PACU due to critical incidents and 184 (50.5%) patients required a higher level of care postoperatively than initially planned. Some patients (n = 34, 9.3%) returned to the operation theatre for further management. A proportion of patients (n = 64, 17.6%) had unplanned intensive care unit admissions due to adverse events in the PACU.

CONCLUSION

A wide spectrum of critical incidents occur in the PACU, many of which are related to the cardiovascular and respiratory systems. Critical incidents have a major impact on healthcare utilisation and result in prolonged PACU stays and higher levels of postoperative care than initially anticipated.

Inter-professional clinical handover in post-anaesthetic care units: tools to improve quality and safety

OBJECTIVES

To examine quality and safety in inter-professional clinical handovers in Post Anaesthetic Care Units (PACUs) and make recommendations for tools to standardize handover processes.

DESIGN

Mixed methods combining data from observations and focus groups.

SETTING

Three PACUs, one public tertiary hospital and two private hospitals.

PARTICIPANTS

Observations were made of 185 patient handovers from anaesthetists to nurses. Eight focus groups were conducted with 62 staff (15 anaesthetists and 47 nurses) across the study sites.

INTERVENTION

Inter-professional clinical handovers in PACU's.

MAIN OUTCOME MEASURES

Characteristics of the structure and processes that support safe inter-professional PACU handover practice.

RESULTS

Characteristics of the process, content, activities and risks during anaesthetist to nurse patient handover into the PACU were integrated into four steps in the PACU handover process summarized by the acronym COLD (Connect, Observe, Listen and Delegate), a verbal communication tool (ISoBAR), a checklist of critical information for safe patient transfer into PACU and a matrix of factors perceived to increase handover risk.

CONCLUSIONS

The standard structure and checklists for optimal content of patient handovers were derived from existing practices and consensus, hence, expected to provide ecologically valid and practical resources to improve quality and safety during clinical handovers in the PACU.