The fatigued anesthesiologist: A threat to patient safety?

Timing of Intraoperative Transitions of Care Among Anesthesiologists Is Not Associated With Postoperative Adverse Outcomes: Retrospective Cohort Study

BACKGROUND

The majority of published research suggests that anesthesia handovers during major surgical procedures are associated with unintended harmful consequences. It is still unclear if the number or quality of the transition of care is the main driver of the adverse outcomes. There is even less data if the timing of the anesthesiologist handovers during the critical portion of the anesthetic continuum (induction or emergence versus surgical period) plays a role in patient outcomes. Therefore, we investigated if the anesthesiologist handovers during induction and emergence are associated with adverse patient outcomes.

METHODS

This retrospective investigation included noncardiac surgical procedures occurring between January 1, 2012 and December 31, 2019 that had exactly 1 attending anesthesiologist handover. We categorized transitions of care between attending anesthesiologists as being before incision, between incision and closing, and after closing. Our primary outcome was a composite of 6 categories of surgical complications and in-hospital mortality. We created logistic generalized estimating equation models to estimate the average relative effect odds ratio between each pair of the 3 transition timing groups across the components of the composite outcome. Inverse probability of treatment weights were used to mitigate confounding on a host of baseline variables. We used Bonferroni correction to adjust for multiple comparisons between the transition groups.

RESULTS

In total, we studied 36,937 procedures with exactly 1 attending anesthesiologist handover. Of these records, 4370 had the transition during induction, 24,999 between incision and closure, and 7568 during emergence. No differences were found between the transition periods and the composite outcome. The estimated average relative effect odds ratio (98.3% confidence interval [CI]) across the components of the composite outcome was as follows: (1.0002 [0.81-1.24], P = .99) between the induction and surgical period; (1.10 [0.87-1.40], P = .32) between the induction and emergence periods; and (0.91 [0.79-1.04], P = .08) between the emergence and surgical periods.

CONCLUSIONS

Timing of intraoperative handover among attending anesthesiologists during noncardiac surgery is not associated with adverse patient outcomes.

Protocol for the perioperative outcome risk assessment with computer learning enhancement (Periop ORACLE) randomized study

Background: More than four million people die each year in the month following surgery, and many more experience complications such as acute kidney injury. Some of these outcomes may be prevented through early identification of at-risk patients and through intraoperative risk mitigation. Telemedicine has revolutionized the way at-risk patients are identified in critical care, but intraoperative telemedicine services are not widely used in anesthesiology. Clinicians in telemedicine settings may assist with risk stratification and brainstorm risk mitigation strategies while clinicians in the operating room are busy performing other patient care tasks. Machine learning tools may help clinicians in telemedicine settings leverage the abundant electronic health data available in the perioperative period. The primary hypothesis for this study is that anesthesiology clinicians can predict postoperative complications more accurately with machine learning assistance than without machine learning assistance. Methods: This investigation is a sub-study nested within the TECTONICS randomized clinical trial (NCT03923699). As part of TECTONICS, study team members who are anesthesiology clinicians working in a telemedicine setting are currently reviewing ongoing surgical cases and documenting how likely they feel the patient is to experience 30-day in-hospital death or acute kidney injury. For patients who are included in this sub-study, these case reviews will be randomized to be performed with access to a display showing machine learning predictions for the postoperative complications or without access to the display. The accuracy of the predictions will be compared across these two groups. Conclusion: Successful completion of this study will help define the role of machine learning not only for intraoperative telemedicine, but for other risk assessment tasks before, during, and after surgery. Registration: ORACLE is registered on ClinicalTrials.gov: NCT05042804; registered September 13, 2021.

Surgical Masks Affect the Peripheral Oxygen Saturation and Respiratory Rate of Anesthesiologists

Background

Surgical masks (SMs) protect medical staff and reduce surgical site infections. Extended SM use may reduce oxygen concentrations in circulation, causing hypoxia, headache, and fatigue. However, no research has examined the effects of wearing SMs on oxygenation and physical discomfort of anesthesiologists.

Methods

An electronic questionnaire was established and administered through WeChat, and a cross-sectional survey was conducted to determine SM use duration and related discomfort of operating room medical staff. Then, operating room anesthesiologists were enrolled in a single-arm study. Peripheral blood oxygen saturation (SpO2), heart rate, and respiratory rate were determined at different times before and after SM use. Shortness of breath, dizziness, and headache were subjectively assessed based on the visual analog scale (VAS) scores.

Results

In total, 485 operating room medical staff completed the electronic questionnaire; 70.5% of them did not change SMs until after work, and 63.9% wore SMs continuously for more than 4 h. The proportion of anesthesiologists was the highest. After wearing masks for 4 h, the shortness of breath, fatigue, and dizziness/headache rates were 42.1, 34.6, and 30.9%, respectively. Compared with other medical staff, the proportion of subjective discomfort of anesthesiologists increased significantly with prolonged SM use from 1 to 4 h. Thirty-five anesthesiologists completed the study. There was no difference in anesthesiologist SpO2, heart rate, or respiratory rate within 2 h of wearing SMs. After more than 2 h, the variation appears to be statistically rather than clinically significant—SpO2 decreased (98.0 [1.0] vs. 97.0 [1.0], p < 0.05), respiratory rate increased (16.0 [3.0] vs. 17.0 [2.0], p < 0.01), and heart rate remained unchanged. As mask use duration increased, the VAS scores of shortness of breath, dizziness, and headache gradually increased.

Conclusion

In healthy anesthesiologists, wearing SMs for more than 2 h can significantly decrease SpO2 and increase respiratory rates without affecting heart rates.

Human factors affecting intraoperative patient safety

PURPOSE OF REVIEW

This review addresses the importance of some of the human factors for intraoperative patient safety with particular focus on the active failures. These are the mishaps or sentinel events related to decisons taken and actions performed by the individual at the delivery end of a system. Such sentinel events may greatly affect intraoperative patient safety.

RECENT FINDINGS

Intimidating, aggressive and disruptive communication is a cause of adverse staff interaction, which may then represent an important patient safety threat. Also, anaesthesiologist's physical and mental state and limitations may interfere with patient safety.

SUMMARY

The concept of physician well being is multidimensional and includes factors related to each physician as an individual as well as to the working environment. Creating optimal safe conditions for patients, therefore, requires actions at both the personal level and the working conditions. Also, initiatives to ban rude and dismissive communication should be implemented in order to further improve intraoperative patient safety.

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.

The senior anesthesiologists and their medical profession in Korea: based on a survey

BACKGROUND

The number of aging physicians is increasing as the global population ages. With aging, anesthesiologists would be expected to experience changes in their professional position. Therefore, we aimed to investigate the current professional status of Korean anesthesiologists aged over 60 years.

METHODS

Registered anesthesiologists aged over 60 years in Korea were invited for a survey. The questionnaire addressed 10 subjects with 40 questions that focused on demographics, practical activities, work conditions, difficulties experienced due to physical changes caused by aging, and economic status.

RESULTS

In total, 122 anesthesiologists responded to the survey (response rate: 15.7%). Of them, 30.3% were working in honorary and advisory positions at tertiary hospitals, while 19.7% were working as pain physicians. Majority of the respondents were working for 5 days a week (41.8%) and 6-8 hours/day (48.4%). Majority of them (79.5%) were generally satisfied with their present life.

CONCLUSIONS

Majority of the senior anesthesiologists were working at general hospitals and they reported being "satisfied" with the current status of their life. However, the clinical practice and retirement strategies of senior anesthesiologists need to be evaluated systematically to prepare for the continuing gradual increase in the number of senior anesthesiologists.

Surgical Start Time Is Not Predictive of Microdiscectomy Outcomes

STUDY DESIGN

Retrospective analysis of clinical data from a single institution.

OBJECTIVE

The objective of this study was to assess the time of surgery as a possible predictor for outcomes, length of stay, and cost following microdiscectomy.

SUMMARY OF BACKGROUND DATA

The volume of microdiscectomy procedures has increased year over year, heightening interest in surgical outcomes. Previous investigations have demonstrated an association between time of procedures and clinical outcomes in various surgeries, however, no study has evaluated its influence on microdiscectomy.

METHODS

Demographic and outcome variables were collected from all patients that underwent a nonemergent microdiscectomy between 2008 and 2016. Patients were divided into 2 cohorts: those receiving surgery before 2 pm were assigned to the early group and those with procedures beginning after 2 pm were assigned to the late group. Outcomes and patient-level characteristics were compared using bivariate, multivariable logistic, and linear regression models. Adjusted length of stay and cost were coprimary outcomes. Secondary outcomes included operative complications, nonhome discharge, postoperative emergency department visits, or readmission rates.

RESULTS

Of the 1261 consecutive patients who met the inclusion criteria, 792 were assigned to the late group and 469 were assigned to the early group. There were no significant differences in demographics or baseline characteristics between the 2 cohorts. In the unadjusted analysis, mean length of stay was 1.80 (SD=1.82) days for the early group and 2.00 (SD=1.70) days for the late group (P=0.054). Mean direct cost for the early cohort was $5088 (SD=$4212) and $4986 (SD=$2988) for the late cohort (P=0.65). There was no difference in adjusted length of stay or direct cost. No statistically significant differences were found in operative complications, nonhome discharge, postoperative emergency department visits, or readmission rates between the 2 cohorts.

CONCLUSION

The study findings suggest that early compared with late surgery is not significantly predictive of surgical outcomes following microdiscectomy.

The Health of Health Care Professionals

Health care professionals represent a population at high risk for poor health. Although this may be counterintuitive given their expertise in health, the high stress and long hours of many medical work environments present challenges for health care professionals to engage in healthy lifestyle behaviors. This is extremely problematic for the health and well-being of both health care professionals and the patients they treat. Medical settings are encouraged to implement interventions that intervene at both the enviornmental and personal level to help faciliate behavior change among health care providers.

Secondary Traumatic Stress and Burnout in Healthcare Workers during COVID-19 Outbreak

(1) Background: The present study aims to assess the level of professional burnout and secondary traumatic stress (STS), and to identify potential risk or protective factors among health care workers (HCWs) during the coronavirus disease 2019 (COVID-19) outbreak.; (2) Methods: This cross-sectional study, based on an online survey, collected demographic data and mental distress outcomes from 184 HCWs from 1 May 2020, to 15 June 2020, from 45 different countries. The degree of STS, perceived stress and burnout was assessed using the Secondary Traumatic Stress Scale (STSS), the Perceived Stress Scale (PSS) and Maslach Burnout Inventory Human Service Survey (MBI-HSS) respectively. Stepwise multiple regression analysis was performed to identify potential risk and protective factors for STS; (3) Results: 184 HCWs (M = 90; Age mean: 46.45; SD: 11.02) completed the survey. A considerable proportion of HCWs had symptoms of STS (41.3%), emotional exhaustion (56.0%), and depersonalization (48.9%). The prevalence of STS was 47.5% in frontline HCWs while in HCWs working in other units it was 30.3% (p < 0.023); 67.1% for the HCWs exposed to patients' death and 32.9% for those HCWs which were not exposed to the same condition (p < 0.001). In stepwise multiple regression analysis, perceived stress, emotional exhaustion, and exposure to patients' death remained as significant predictors in the final model for STS (adjusted R2 = 0.537, p < 0.001); (4) Conclusions: During the current COVID-19 pandemic, HCWs facing patients' physical pain, psychological suffering, and death are more likely to develop STS.

Later Surgical Start Time Is Associated With Longer Length of Stay and Higher Cost in Cervical Spine Surgery

STUDY DESIGN

Retrospective study of a surgical cohort from a single, large academic institution.

OBJECTIVE

The aim of this study was to investigate associations between surgical start time, length of stay, cost, perioperative outcomes, and readmission.

SUMMARY OF BACKGROUND DATA

One retrospective study with a smaller cohort investigated associations between surgical start time and outcomes in spine surgery and found that early start times were correlated with shorter length of stay. No examinations of perioperative outcomes or cost have been performed.

METHODS

All patients undergoing anterior cervical discectomy and fusion (ACDF) and posterior cervical decompression and fusion (PCDF) were queried from a single institution from January 1, 2008 to November 30, 2016. Patients undergoing surgery that started between 12:00 AM and 6:00 AM were excluded due to their likely emergent nature. Cases starting before and after 2:00 PM were compared on the basis of length of stay and cost as the primary outcomes using multivariable logistic regression.

RESULT

The patients undergoing ACDF and PCDF were both similar on the basis of comorbidity burden, preoperative diagnosis, and number of segments fused. The patients undergoing ACDF starting after 2 PM had longer LOS values (adjusted difference of 0.65 days; 95% confidence interval [CI]: 0.28-1.03; P = 0.0006) and higher costs of hospitalization (adjusted difference of $1177; 95% CI: $549-$1806; P = 0.0002). Patients undergoing PCDF starting after 2 PM also had longer LOS values (adjusted difference of 1.19 days; 95% CI: 0.46-1.91; P = 0.001) and higher costs of hospitalization (adjusted difference of $2305; 95% CI: $826-$3785; P = 0.002).

CONCLUSION

Later surgical start time is associated with longer LOS and higher cost. These findings should be further confirmed in the spine surgical literature to investigate surgical start time as a potential cost-saving measure.

LEVEL OF EVIDENCE

3.

Avoiding and Managing Error in Interventional Radiology Practice: Tips and Tools

While there are limited data on error in interventional radiology (IR), the literature so far indicates that many errors in IR are potentially preventable. Yet, understanding the sources for error and implementing effective countermeasures can be challenging. Traditional methods for reducing error such as increased vigilance and new policies may be effective but can also contribute to an "error cycle." A hierarchy of effectiveness for patient safety interventions is outlined, and the characteristics of "high-reliability" organizations in other "high-risk" industries are examined for clues that could be implemented in IR. The evidence behind team error reduction strategies such as checklists is considered along with individual approaches such as "slowing down when you should." However, error in medicine is inevitable, and this article also seeks to outline an evidence-based approach to managing the psychological impact of being involved in medical error as a physician.

Variability in risk tolerance and adherence to guidelines in "go or no-go" decisions among anesthetists in Saudi Arabia

Background:

Anesthetists deal with many situations where they decide whether proceeding with anesthesia is safe or not. These are termed “go or no-go” decisions. Although guidelines have been developed to ensure safe anesthesia, many factors affect anesthetists' decision in practice. Therefore, we aimed to assess the variability in risk tolerance when making “go or no-go” decisions among anesthetists in Saudi Arabia.

Materials and Method:

A questionnaire-based study that included anesthetists practicing in Saudi Arabia from 1--14^th October 2017 was conducted. The questionnaire presented 11 clinical scenarios that involved deviation from guidelines, followed by four questions where the participants were asked to decide whether they would proceed with administering anesthesia, write a comment explaining their decision, to predict whether a colleague would make the same decision, and if they had a previous similar experience.

Results:

A total of 124 anesthetists responded, of which 56.5% were consultants. There was no absolute consensus over the decision to proceed in any scenario. Most of the respondents who would proceed (67.35%) expected a colleague to make the same decision. Anesthetists who encountered a previous similar experience were more likely to proceed (P = 0.000). There was no significant difference among the respondents' decisions according to years of experience (P = 0.121). Analysis of the comments showed that procedure urgency and presence of alternatives to deficient resources were the most frequent factors that dictated anesthetists' decision.

Conclusion:

There is a wide variation in risk tolerance among anesthetists. Further simulation-based studies are needed to identify and address factors that affect anesthetists' decisions.

Are Anesthesiology Providers Good Guessers? Heart Rate and Oxygen Saturation Estimation in a Simulation Setting

Background

Anesthesia providers may need to interpret the output of vital sign monitors based on auditory cues, in the context of multitasking in the operating room. This study aims to evaluate the ability of different anesthesia providers to estimate heart rate and oxygen saturation in a simulation setting.

Methods

Sixty anesthesia providers (residents, nurse anesthetics, and anesthesiologists) were studied. Four scenarios were arranged in a simulation context. Two baseline scenarios with and without waveform visual aid, and two scenarios with variation of heart rate and/or oxygen saturation were used to assess the accuracy of the estimation made by the participants.

Results

When the accurate threshold for the heart rate was set at less than 5 beats per minute, the providers only had a correct estimation at two baseline settings with visual aids (p=0.22 and 0.2237). Anesthesia providers tend to underestimate the heart rate when it increases. Providers failed to accurately estimate oxygen saturation with or without visual aid (p=0.0276 and 0.0105, respectively). Change in recording settings significantly affected the accuracy of heart rate estimation (p < 0.0001), and different experience levels affected the estimation accuracy (p=0.041).

Conclusion

The ability of anesthesia providers with different levels of experience to assess baseline and variations of heart rate and oxygen saturation is unsatisfactory, especially when oxygen desaturation and bradycardia coexist, and when the subject has less years of experience.

Survey of occupational fatigue in anaesthetists in Australia and New Zealand

Occupational fatigue in anaesthetists is recognised as a patient safety risk. Better understanding of the issues surrounding their fatigue is needed. This study aimed to ascertain the sources and effects of occupational fatigue amongst anaesthetists in Australia and New Zealand. An anonymous online survey was sent to 979 anaesthetists. The response rate was 38.0%. Most participants reported regularly working over 40 hours per week; men reported five more hours per week than women. Stated contributors to fatigue included long work hours, mental strain at work, and personal and family demands. Fatigue-related behaviour was reported more by men (OR [odds ratio]=2.6) and less by respondents reporting eight or more hours of sleep before work (OR=0.6). Reporting at least one instance of less than five hours off between shifts was predictive of falling asleep while administering an anaesthetic (OR=1.6). More data are required to support practices and policies that promote more time off between work periods and increased time for sleep to reduce risk of fatigue.

Risk of fatigue among anesthesia residents in Saudi Arabia

Objectives:

To quantify fatigue risk and sleepiness among anesthesia residents in Saudi Arabia (SA).

Methods:

Between April 2014 and April 2015, all anesthesia residents training in western, central, and eastern regions in SA were invited to fill a survey. We conducted a cross-sectional self-reporting survey that included demographic data, the Epworth sleepiness scale (ESS), and 2 other scales to assess fatigue risk: a Checklist for Individual Strength (CIS) and a predefined comprehensive fatigue risk assessment previously developed by the Australian Medical Association (AMA).

Results:

We received 102 responses, and more than half of the individuals in the sample were at elevated risk of fatigue according to both fatigue scales. Approximately 70% reported being excessively sleepy during the day.

Conclusion:

All 3 scales used in our survey suggested that local anesthesia residents in SA are sleepy and at risk of becoming fatigued. This could be multifactorial, explained by long shifts, or cultural and lifestyle habits.

Monitoring Anesthesia Care Delivery and Perioperative Mortality in Kenya Utilizing a Provider-driven Novel Data Collection Tool

BACKGROUND

Perioperative mortality rate is regarded as a credible quality and safety indicator of perioperative care, but its documentation in low- and middle-income countries is poor. We developed and tested an electronic, provider report-driven method in an East African country.

METHODS

We deployed a data collection tool in a Kenyan tertiary referral hospital that collects case-specific perioperative data, with asynchronous automatic transmission to central servers. Cases not captured by the tool (nonobserved) were collected manually for the last two quarters of the data collection period. We created logistic regression models to analyze the impact of procedure type on mortality.

RESULTS

Between January 2014 and September 2015, 8,419 cases out of 11,875 were captured. Quarterly data capture rates ranged from 423 (26%) to 1,663 (93%) in the last quarter. There were 93 deaths (1.53%) reported at 7 days. Compared with four deaths (0.53%) in cesarean delivery, general surgery (n = 42 [3.65%]; odds ratio = 15.80 [95% CI, 5.20 to 48.10]; P < 0.001), neurosurgery (n = 19 [2.41%]; odds ratio = 14.08 [95% CI, 4.12 to 48.10]; P < 0.001), and emergency surgery (n = 25 [3.63%]; odds ratio = 4.40 [95% CI, 2.46 to 7.86]; P < 0.001) carried higher risks of mortality. The nonobserved group did not differ from electronically captured cases in 7-day mortality (n = 1 [0.23%] vs. n = 16 [0.58%]; odds ratio =3.95 [95% CI, 0.41 to 38.20]; P = 0.24).

CONCLUSIONS

We created a simple solution for high-volume, prospective electronic collection of perioperative data in a lower- to middle-income setting. We successfully used the tool to collect a large repository of cases from a single center in Kenya and observed mortality rate differences between surgery types.

[Medication errors in anesthesia: unacceptable or unavoidable?]

Medication errors are the common causes of patient morbidity and mortality. It adds financial burden to the institution as well. Though the impact varies from no harm to serious adverse effects including death, it needs attention on priority basis since medication errors' are preventable. In today's world where people are aware and medical claims are on the hike, it is of utmost priority that we curb this issue. Individual effort to decrease medication error alone might not be successful until a change in the existing protocols and system is incorporated. Often drug errors that occur cannot be reversed. The best way to 'treat' drug errors is to prevent them. Wrong medication (due to syringe swap), overdose (due to misunderstanding or preconception of the dose, pump misuse and dilution error), incorrect administration route, under dosing and omission are common causes of medication error that occur perioperatively. Drug omission and calculation mistakes occur commonly in ICU. Medication errors can occur perioperatively either during preparation, administration or record keeping. Numerous human and system errors can be blamed for occurrence of medication errors. The need of the hour is to stop the blame - game, accept mistakes and develop a safe and 'just' culture in order to prevent medication errors. The newly devised systems like VEINROM, a fluid delivery system is a novel approach in preventing drug errors due to most commonly used medications in anesthesia. Similar developments along with vigilant doctors, safe workplace culture and organizational support all together can help prevent these errors.

Intraoperative Care Transitions Are Not Associated with Postoperative Adverse Outcomes

Background

Whether anesthesia care transitions and provision of short breaks affect patient outcomes remains unclear.

Methods

The authors determined the number of anesthesia handovers and breaks during each case for adults admitted between 2005 and 2014, along with age, sex, race, American Society of Anesthesiologists physical status, start time and duration of surgery, and diagnosis and procedure codes. The authors defined a collapsed composite of in-hospital mortality and major morbidities based on primary and secondary diagnoses. The relationship between the total number of anesthesia handovers during a case and the collapsed composite outcome was assessed with a multivariable logistic regression. The relationship between the total number of anesthesia handovers during a case and the components of the composite outcome was assessed using multivariate generalized estimating equation methods. Additionally, the authors analyzed major complications and/or death within 30 days of surgery based on the American College of Surgeons National Surgical Quality Improvement Program–defined events.

Results

A total of 140,754 anesthetics were identified for the primary analysis. The number of anesthesia handovers was not found to be associated (P = 0.19) with increased odds of postoperative mortality and serious complications, as measured by the collapsed composite, with odds ratio for a one unit increase in handovers of 0.957; 95% CI, 0.895 to 1.022, when controlled for potential confounding variables. A total of 8,404 anesthetics were identified for the NSQIP analysis (collapsed composite odds ratio, 0.868; 95% CI, 0.718 to 1.049 for handovers).

Conclusions

In the analysis of intraoperative handovers, anesthesia care transitions were not associated with an increased risk of postoperative adverse outcomes.

Medication errors in anesthesia: unacceptable or unavoidable?

Medication errors are the common causes of patient morbidity and mortality. It adds financial burden to the institution as well. Though the impact varies from no harm to serious adverse effects including death, it needs attention on priority basis since medication errors' are preventable. In today's world where people are aware and medical claims are on the hike, it is of utmost priority that we curb this issue. Individual effort to decrease medication error alone might not be successful until a change in the existing protocols and system is incorporated. Often drug errors that occur cannot be reversed. The best way to 'treat' drug errors is to prevent them. Wrong medication (due to syringe swap), overdose (due to misunderstanding or preconception of the dose, pump misuse and dilution error), incorrect administration route, under dosing and omission are common causes of medication error that occur perioperatively. Drug omission and calculation mistakes occur commonly in ICU. Medication errors can occur perioperatively either during preparation, administration or record keeping. Numerous human and system errors can be blamed for occurrence of medication errors. The need of the hour is to stop the blame - game, accept mistakes and develop a safe and 'just' culture in order to prevent medication errors. The newly devised systems like VEINROM, a fluid delivery system is a novel approach in preventing drug errors due to most commonly used medications in anesthesia. Similar developments along with vigilant doctors, safe workplace culture and organizational support all together can help prevent these errors.

Cognitive and Psychomotor Function Changes Among Anesthesiology Residents After 12 Working Hours in Elective Anesthesia Service

Background:

The practice of anesthesia requires good awareness, parallel decision-making and fine motor skills. The duration of working hours of anesthesiology residents is often more than 12 hours.

Objectives:

This study aimed to measure cognitive and psychomotor functions of anesthesiology residents after 12 working hours.

Patients and Methods:

This was an observational study on anesthesiology residents who underwent 12 working hours. Each subject, who fulfilled inclusion and exclusion criteria, had their cognitive and psychomotor functions tested at 0 and 12 hours. The cognitive function was measured by “Cognitive Stimulation” test, while the psychomotor function was measured by the grooved pegboard. Statistical analysis was conducted to compare the results between 0 and 12 hours.

Results:

Cognitive Stimulation” test revealed statistically significant decrease at sequential image frequency stimulation (P = 0.035). Other stimulation tests did not show any statistically significant result. Grooved pegboard test showed statistically significant decrease in psychomotor function from 0 to 12 hours (P = 0.037).

Conclusions:

There was a decrease in cognitive function, including attention, visual memory, naming, and executive function, as well as psychomotor function among residents of Department of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Indonesia, who underwent 12 working hours.

The impact of transitioning from a 24-hour to a 16-hour call model amongst a cohort of Canadian anesthesia residents at McMaster University - a survey study

PURPOSE

The primary objective of this study was to assess anesthesia residents' opinions and perceptions on wellness/burnout, fatigue, education, and patient safety after the initiation of a reduced call model (16-hour call).

METHODS

A prospective cohort study was conducted at three time points during the 2013-2014 academic year. A web-based questionnaire consisting of 23 questions was electronically distributed to all anesthesia residents from postgraduate years (PGY) 1 to 5 who were part of the active call roster (n=84) at McMaster University in Hamilton, Ontario. Descriptive summaries were calculated, counts and percentages were used for categorical variables, and answers to open text questions were reviewed for themes.

RESULTS

A response rate of 67% was obtained for this study. A majority of anesthesia residents (65%) approved of 16-hour call, felt that their overall quality of life as a senior resident (PGY3 or greater) or junior resident (PGY2 and below) had improved (73% and 55%, respectively), and reported overall feeling less fatigued. Most respondents indicated that the quality of education remained unchanged (47%), or had improved (31%). And most felt better prepared for the royal college exam (52%). Most felt patient safety had improved or was unchanged (both 48%).

CONCLUSION

The study demonstrates that 16-hour call improved resident wellness, reduced burnout and fostered an environment where residents are less fatigued and more satisfied with their educational experience promoting an environment of patient safety. Overall, the anesthesia residency group demonstrated that not only is 16-hour call preferred but beneficial.

[Sleep disorders among physicians on shift work]

Sleep disorders in physicians who perform shift work can result in increased risks of health problems that negatively impact performance and patient safety. Even those who cope well with shift work are likely to suffer from sleep disorders. The aim of this manuscript is to discuss possible causes, contributing factors and consequences of sleep disorders in physicians and to identify measures that can improve adaptation to shift work and treatment strategies for shift work-associated sleep disorders. The risk factors that influence the development of sleep disorders in physicians are numerous and include genetic factors (15 % of the population), age (> 50 years), undiagnosed sleep apnea,, alcohol abuse as well as multiple stress factors inherent in clinical duties (including shift work), research, teaching and family obligations. Several studies have reported an increased risk for medical errors in sleep-deprived physicians. Shift workers have an increased risk for psychiatric and cardiovascular diseases and shift work may also be a contributing factor to cancer. A relationship has been reported not only with sleep deprivation and changes in food intake but also with diabetes mellitus, obesity, hypertension and coronary heart disease. Nicotine and alcohol consumption are more frequent among shift workers. Increased sickness and accident rates among physicians when commuting (especially after night shifts) have a socioeconomic impact. In order to reduce fatigue and to improve performance, short naps during shiftwork or naps plus caffeine, have been proposed as coping strategies; however, napping during adverse circadian phases is less effective, if not impossible when unable to fall asleep. Bright and blue light supports alertness during a night shift. After shiftwork, direct sunlight exposure to the retina can be avoided by using dark sunglasses or glasses with orange lenses for commuting home. The home environment for daytime sleeping after a night shift should be very dark to allow endogenous melatonin secretion, which is a night signal and supports continuous sleep. Sleep disorders can be treated with timed light exposure, as well as behavioral and environmental strategies to compensate for sleep deprivation. Fatigue due to sleep deprivation can only be systematically treated with sleep.

Human factors in anaesthetic crisis

This paper discusses some of the key aspects of human factors in anaesthesia for the improvement of patient safety. Medical errors have emerged as a serious issue in healthcare delivery. There has been new interest in human factors as a means of reducing these errors. Human factors are important contributors to critical incidents and crises in anaesthesia. It has been shown that the prevalence of human factors in anaesthesia can be as high as 83%. Cognitive thinking process and biases involved are important in understanding human factors. Errors of cognition linked with human factors lead to anaesthetic errors and crisis. Multiple errors in the cognitive thinking process, known as “Cognitive dispositions to respond” have been identified leading to errors. These errors classified into latent or active can be easily identified in the clinical vignettes of serious medical errors. Application of the knowledge on human factors and use of cognitive de-biasing strategies can avoid human errors. These strategies could involve use of checklists, strategies to cope with stress and fatigue and the use of standard operating procedures. A safety culture and health care model designed to promote patient safety can compliment this further. Incorporation of these strategies strengthens the defence layers against the “Swiss Cheese” models, which exist in the health care industry.

Current and future directions in clinical fatigue management: An update for emergency medicine practitioners

Physicians worldwide are working round the clock to meet the demands of healthcare systems, especially in acute medical settings such as EDs. Demanding shift work schedules cause fatigue and thus deterioration in mood and motor performance. This article explores the effects of sleep deprivation, focusing on cognition, executive decision-making and the implications for clinical care. Humans are capable of functioning and even adapting to sleep restriction; however, clinicians should be aware of pitfalls and absolute minimums for sleep. Fatigue management training shows promise in enhancing safety in aviation and might have a role in medical shift work. Strategic napping improves performance during night shift in the ED, but does not fully negate fatigue. Drugs offer limited benefit for performance under sleep-deprived conditions, and whenever possible, sleep and/or strategic napping takes precedence.