Mortalidad perioperatoria / Perioperative mortality

Introducción: La tasa de mortalidad perioperatoria representa un indicador global del acceso seguro a la atención quirúrgica y anestesiológica. Objetivo: Caracterizar los pacientes fallecidos durante el perioperatorio en intervenciones quirúrgicas. Métodos: Se realizó un estudio descriptivo transversal en el servicio de Anestesiología del Hospital Clínico Quirúrgico Arnaldo Milián Castro, provincia Villa Clara, en el periodo período de enero de 2015 a diciembre de 2018. La población estuvo constituida por los pacientes intervenidos quirúrgicamente en dicho hospital (N: 133 724). La muestra fueron los pacientes fallecidos durante el período intraoperatorio y primeras 24 h tras la intervención quirúrgica (n: 77). Resultados: La tasa de mortalidad perioperatoria general fue de 5,76/10 000. Incidencia de mortalidad mayor en hombres (59,7 por ciento), ancianos (75,3 por ciento), con varias comorbilidades asociadas (51,9 por ciento), clase 4 de la ASA (41,5 por ciento), riesgo quirúrgico grupo II (62,3 por ciento), cirugía abdominal (63,6 por ciento), intervenciones de urgencia (88,3 por ciento), bajo una técnica anestésica general (84,4 por ciento) y en el período postoperatorio 24 h (68,8 por ciento). El shock séptico constituyó la principal causa de mortalidad (48,1 por ciento). Conclusiones: Predominaron las defunciones en ancianos con comorbilidades asociadas, alto riesgo anestésico y quirúrgico, intervenidos de urgencia bajo anestesia general, con el shock séptico como principal causa de muerte. La tasa de mortalidad perioperatoria fue similar a naciones de desarrollo socioeconómico equivalente(AU)

Introduction: Perioperative mortality rate represents a global indicator for safe access to surgical and anesthesiological care. Objective: To characterize patients who deceased during the perioperative period in surgical interventions. Methods: A cross-sectional and descriptive study was carried out in the anesthesiology service of Arnaldo Milián Castro Clinical-Surgical Hospital, in Villa Clara Province, in the period from January 2015 to December 2018. The study population consisted of patients who received surgery within that hospital (N: 133 724). The sample consisted of patients who died during the intraoperative period and within the first 24 hours after surgery (n: 77). Results: The general perioperative mortality rate was 5.76/10 000. There was incidence of higher mortality among men (59.7 percent), elderlies (75.3 percent), patients with several associated comorbidities (51.9 percent), those classified as ASA-IV (41.5 percent), those belonging to group II for surgical risk (62.3 percent), cases of abdominal surgery (63.6 percent), emergency interventions (88.3 percent), patients under general anesthetic technique (84.4 percent), and at 24 hours after the postoperative period (68.8 percent). Septic shock was the main cause of mortality (48.1 percent). Conclusions: There was a predominance of deaths among elderlies with associated comorbidities, high anesthetic, as well as surgical risk, who received emergency surgery under general anesthesia, being septic shock the main cause of death. The perioperative mortality rate was similar to that in nations of equivalent socioeconomic development(AU)

Transport of Critically Ill Patients by the Anesthesia Versus the Intensive Care Unit Service: A Before-After Study of Operating Room Workflows.

BACKGROUND: We implemented a new policy at our institution where the responsibility for intensive care unit (ICU) patient transports to the operating room (OR) was changed from the anesthesia to the ICU service. We hypothesized that this approach would be associated with increased on-time starts and decreased turnover times. METHODS: In the historical model, intubated patients or those on mechanical circulatory assistance (MCA) were transported by the anesthesia service to the OR ("pre-ICU Pickup"). In our new model, these patients are transported by the ICU service to the preoperative holding area (Pre-op) where care is transferred to the anesthesia service ("post-ICU Transfer"). If judged necessary by the ICU or anesthesia attending, the patient was transported by the anesthesia service ("post-ICU Pickup"). We retrospectively reviewed case tracking data for patients undergoing surgery before (January 2014 to May 2015) and after implementation (July 2016 to June 2017) of the new policy. The primary outcome was the proportion of elective, weekday first-case, on-time starts. To adjust for confounders including comorbidities and time trends, we performed a segmented logistic regression analysis assessing the effect of our intervention on the primary outcome. Secondary outcomes were turnover times and compliance with preoperative checklist documentation. RESULTS: We identified 95 first-start and 86 turnover cases in the pre-ICU Pickup, 70 first-start and 88 turnover cases in the post-ICU Transfer, and 6 turnover cases in the post-ICU Pickup group. Ignoring time trends, the crude proportion of on-time starts increased from 32.6% in the pre-ICU Pickup to 77.1% in the post-ICU Transfer group. After segmented logistic regression adjusting for age, sex, American Society of Anesthesiologists (ASA) physical status, Sequential Organ Failure Assessment (SOFA) score, respiratory failure, endotracheal intubation, MCA, congestive heart failure (CHF), valvular heart disease, and cardiogenic and hemorrhagic shock, the post-ICU Transfer group was more likely to have an on-time start at the start of the intervention than the pre-ICU Pickup group at the end of the preintervention period (odds ratio, 11.1; 95% confidence interval [CI], 1.3-125.7; P = .043). After segmented linear regression adjusting for the above confounders, the estimated difference in mean turnover times between the post-ICU Pickup and pre-ICU Transfer group was not significant (-6.9 minutes; 95% CI, -17.09 to 3.27; P = .17). In post-ICU Transfer patients, consent, history and physical examination (H&P), and site marking were verified before leaving the ICU in 92.9%, 93.2%, and 89.2% of the cases, respectively. No adverse events were reported during the study period. CONCLUSIONS: A transition from the anesthesia to the ICU service for transporting ICU patients to the OR did not change turnover times but resulted in more on-time starts and high compliance with preoperative checklist documentation.

The effects of an aviation-style computerised pre-induction anaesthesia checklist on pre-anaesthetic set-up and non-routine events.

This prospective, observational study compared the proportion of cases with missing critical pre-induction items before and after the implementation of an aviation-style computerised pre-induction anaesthesia checklist. Trained observers recorded the availability of critical pre-induction items and evaluated the characteristics of the pre-induction anaesthesia checklist performance including provider participation and distraction level, resistance to the use of the checklist and the time required for completion. Surgical cases that met the criteria for inclusion in the National Surgical Quality Improvement Program at a single academic hospital were selected for observation. A total of 853 cases were observed before and 717 after implementation of the checklist. The proportion of cases with failure to perform all pre-induction steps decreased from 10.0% to 6.4% (p = 0.012). There was also a significant decrease in the proportion of cases with non-routine events from 1.2% cases before to none after checklist implementation (p = 0.003). In 17 cases, the checklist alerted the anaesthesia provider to correct a mistake in pre-induction preparation.

A Digital Cognitive Aid for Anesthesia to Support Intraoperative Crisis Management: Results of the User-Centered Design Process.

BACKGROUND: Stressful situations during intraoperative emergencies have negative impact on human cognitive functions. Consequently, task performance may decrease and patient safety may be compromised. Cognitive aids can counteract these effects and support anesthesiologists in their crisis management. The Professional Association of German Anesthesiologists set up a project to develop a comprehensive set of digital cognitive aids for intraoperative emergencies. A parallel development for several software platforms and stationary and mobile devices will accommodate the inhomogeneity of the information technology infrastructure within German anesthesia departments. OBJECTIVE: This paper aimed to provide a detailed overview of how the task of developing a digital cognitive aid for intraoperative crisis management in anesthesia was addressed that meets user requirements and is highly user-friendly. METHODS: A user-centered design (UCD) process was conducted to identify, specify, and supplement the requirements for a digital cognitive aid. The study covered 4 aspects: analysis of the context of use, specification of user requirements, development of design solutions, and evaluation of design solutions. Three prototypes were developed and evaluated by end users of the application. Following each evaluation, the new requirements were prioritized and used for redesign. For the first and third prototype, the System Usability Scale (SUS) score was determined. The second prototype was evaluated with an extensive Web-based questionnaire. The evaluation of the third prototype included a think-aloud protocol. RESULTS: The chosen methods enabled a comprehensive collection of requirements and helped to improve the design of the application. The first prototype achieved an average SUS score of 74 (SD 12), indicating good usability. The second prototype included the following main revisions: 2-column layout, initial selection of patient type (infant, adult, or parturient), 4 offered search options, and the option to check off completed action steps. Its evaluation identified the following major revision points: add quick selection for resuscitation checklists, design the top bar and tabs slightly larger, and add more pictograms to the text. The third prototype achieved an average SUS score of 77 (SD 15). The evaluation of the think-aloud protocol revealed a good intuitiveness of the application and identified a missing home button as the main issue. CONCLUSIONS: Anesthesiology-as an acute medical field-is particularly characterized by its high demands on decision making and action in dynamic, or time-critical situations. The integration of usability aspects is essential for everyday and emergency suitability. The UCD process allowed us to develop a prototypical digital cognitive aid, exhibiting high usability and user satisfaction in the demanding environment of anesthesiological emergencies. Both aspects are essential to increase the acceptance of the application in later stages. The study approach, combining different methods for determining user requirements, may be useful for other implementation projects in a highly demanding environment.

An Automated Critical Event Screening and Notification System to Facilitate Preanesthesia Record Review.

BACKGROUND: Anesthesia information management systems make prior anesthesia records readily available for review when patients return for a subsequent procedure but may create a problem of too much documentation to review in a limited amount of time. We implemented a screening tool to facilitate the identification of critical documentation for review. METHODS: An algorithm was developed to electronically search prior anesthesia records for predefined critical events and flag records containing these events. Our web-based daily case schedule was modified to contain a warning message for any patient on the schedule who has a prior record flagged by the system, in addition to a preexisting hyperlink to view the relevant record. A retrospective analysis was performed to determine the impact of the warning messages on the frequency with which the care team reviewed these records before providing anesthesia care. RESULTS: The screening algorithm flagged 13% of archived cases as critical. There were 3329 and 3369 cases in the 6 months before and after system implementation, respectively, that had prior critical records available for review at that time. One or more of these critical records were viewed before the subsequent case start in 39% vs 59% (P < .01) of cases in the pre- versus postimplementation periods. Subgroup analysis revealed that the increase was greatest for attending anesthesiologists working alone. CONCLUSIONS: We created a system to automatically detect critical events in prior anesthesia records for the purpose of forewarning the anesthesia care team when the same patient returns for another procedure. Inclusion of these warnings on the daily case schedule was associated with an increased frequency of preanesthesia review of old records.

Using Lean Six Sigma Methodology to Improve Quality of the Anesthesia Supply Chain in a Pediatric Hospital.

Six Sigma and Lean methodologies are effective quality improvement tools in many health care settings. We applied the DMAIC methodology (define, measure, analyze, improve, control) to address deficiencies in our pediatric anesthesia supply chain. We defined supply chain problems by mapping existing processes and soliciting comments from those involved. We used daily distance walked by anesthesia technicians and number of callouts for missing supplies as measurements that we analyzed before and after implementing improvements (anesthesia cart redesign). We showed improvement in the metrics after those interventions were implemented, and those improvements were sustained and thus controlled 1 year after implementation.

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.

A System for Anesthesia Drug Administration Using Barcode Technology: The Codonics Safe Label System and Smart Anesthesia Manager.

BACKGROUND: Many anesthetic drug errors result from vial or syringe swaps. Scanning the barcodes on vials before drug preparation, creating syringe labels that include barcodes, and scanning the syringe label barcodes before drug administration may help to prevent errors. In contrast, making syringe labels by hand that comply with the recommendations of regulatory agencies and standards-setting bodies is tedious and time consuming. A computerized system that uses vial barcodes and generates barcoded syringe labels could address both safety issues and labeling recommendations. METHODS: We measured compliance of syringe labels in multiple operating rooms (ORs) with the recommendations of regulatory agencies and standards-setting bodies before and after the introduction of the Codonics Safe Label System (SLS). The Codonics SLS was then combined with Smart Anesthesia Manager software to create an anesthesia barcode drug administration system, which allowed us to measure the rate of scanning syringe label barcodes at the time of drug administration in 2 cardiothoracic ORs before and after introducing a coffee card incentive. Twelve attending cardiothoracic anesthesiologists and the OR satellite pharmacy participated. RESULTS: The use of the Codonics SLS drug labeling system resulted in >75% compliant syringe labels (95% confidence interval, 75%-98%). All syringe labels made using the Codonics SLS system were compliant. The average rate of scanning barcodes on syringe labels using Smart Anesthesia Manager was 25% (730 of 2976) over 13 weeks but increased to 58% (956 of 1645) over 8 weeks after introduction of a simple (coffee card) incentive (P < 0.001). CONCLUSIONS: An anesthesia barcode drug administration system resulted in a moderate rate of scanning syringe label barcodes at the time of drug administration. Further, adaptation of the system will be required to achieve a higher utilization rate.

Versatility of delayed reverse-flow islanded sural flap for reconstructing pretibal defects among high-risk patients.

BACKGROUND AND OBJECTIVE: Reconstructing defects related to the leg soft tissue may be quite difficult because the soft tissue over the bone is rather thin and the tendons lie right under the skin. Distal pedicle sural neurocutaneous flap with its long pedicle composed of skin, subcutaneous tissue and fascia is suitable for superficial defects. This study aimed to determine the usability of the delayed reverse-flow (distally based) islanded sural flap for correcting tibial and ankle defects. DESIGN AND SETTINGS: A prospective clinical trial conducted from 2012 to 2013 in Plastic & Reconstructive and Aesthetic Surgery clinic, Necmettin Erbakan University, Turkey. METHODS: Eleven patients with pretibial defects and a visible open bone who underwent reconstruction with reverse-flow islanded sural flap between 2012 and 2013 were included in the study. All patients who had defects between the middle of the tibia and the foot underwent surgery in 2 sessions under spinal anesthesia. In the first session, necrotic tissues were debrided and cultures were taken, and the flap was delayed. Reconstruction was performed in the second session. RESULTS: The biggest flap was 16.11 cm and the smallest one was 5.6 cm. The longest pedicle was 27 cm long and the shortest one 21 cm. A total of 6 patients were smokers and 3 had diabetes mellitus. One patient had partial necrosis of the flap, and the necrosis was healed secondarily. No complications were seen in other patients. CONCLUSION: Delayed reverse-flow islanded sural flaps can be used as an easy, quick, and secure surgical alternative to free flaps for correcting in leg defects involving an exposed bone between the middle portion of the tibia and the heel.

Technology diffusion of anesthesia information management systems into academic anesthesia departments in the United States.

BACKGROUND: Anesthesia information management systems (AIMS) are electronic health records that automatically import vital signs from patient monitors and allow for computer-assisted creation of the anesthesia record. When most recently surveyed in 2007, it was estimated that at least 16% of U.S. academic hospitals (i.e., with an anesthesia residency program) had installed an AIMS. At least an additional 28% reported that they were in the process of implementing, or searching for an AIMS. In this study, we updated the adoption figures as of May 2013 and examined the historical trend of AIMS deployment in U.S. anesthesia residency programs from the perspective of the theory of diffusion of technologic innovations. METHODS: Questionnaires were sent by e-mail to program directors or their identified contact individuals at the 130 U.S. anesthesiology residency programs accredited as of June 30, 2012 by the Accreditation Council for Graduate Medical Education. The questionnaires asked whether the department had an AIMS, the year of installation, and, if not present, whether there were plans to install an AIMS within the next 12 months. Follow-up e-mails and phone calls were made until responses were obtained from all programs. Results were collected between February and May 2013. Implementation percentages were determined using the number of accredited anesthesia residency programs at the start of each academic year between 1987 and 2013 and were fit to a logistic regression curve using data through 2012. RESULTS: Responses were received from all 130 programs. Eighty-seven (67%) reported that they currently are using an AIMS. Ten programs without a current AIMS responded that they would be installing an AIMS within 12 months of the survey. The rate of AIMS adoption by year was well fit by a logistic regression curve (P = 0.90). CONCLUSIONS: By the end of 2014, approximately 75% of U.S. academic anesthesiology departments will be using an AIMS, with 84% adoption expected between 2018 and 2020. Historical adoption of AIMS has followed Roger's 1962 formulation of the theory of diffusion of innovation.

Prevalence of anaesthesia information management systems in university-affiliated hospitals in Europe.

BACKGROUND AND OBJECTIVE: An increasing number of studies suggest that anaesthesia information management systems (AIMS) improve clinical care. The purpose of this web survey study was to assess the prevalence of AIMS in European university-affiliated anaesthesia departments and to identify the motivations for and barriers to AIMS adoption. METHODS: A survey was e-mailed to 252 academic anaesthesia chairs of 294 university-affiliated hospitals in 22 European countries, with 41 e-mails returned as undeliverable, leaving the final sample equal to 211. Responders provided information on demographics, the other information technology systems available in their hospitals, and current implementation status of AIMS. Adopters were asked about motivations for installing AIMS, whereas nonadopters were asked about barriers to AIMS adoption. RESULTS: Eighty-six (29%) of 294 hospitals responded. Forty-four of the 86 departments (51%) were considered AIMS adopters because they were already using (n = 15), implementing (n = 13) or selecting an AIMS (n = 16). The 42 remaining departments (49%) were considered nonadopters as they were not expecting to install an AIMS owing to lack of funds (n = 27), other reasons (n = 13) such as lack of support from the information technology department, or simply did not have a plan (n = 2). The top ranked motivators for adopting AIMS were improved clinical documentation, improvement in patient care and safety, and convenience for anaesthesiologists. AIMS adopters were more likely than nonadopters to already have other information technology systems deployed throughout the hospital. CONCLUSION: At least 44 (or 15%) of the 294 university-affiliated departments surveyed in this study have already implemented, are implementing, or are currently selecting an AIMS. The main barrier identified by AIMS nonadopters is lack of funds.

Differences in safety climate among hospital anesthesia departments and the effect of a realistic simulation-based training program.

BACKGROUND: Safety climate is often measured via surveys to identify appropriate patient safety interventions. The introduction of an insurance premium incentive for simulation-based anesthesia crisis resource management (CRM) training motivated our naturalistic experiment to compare the safety climates of several departments and to assess the impact of the training. METHODS: We administered a 59-item survey to anesthesia providers in six academic anesthesia programs (Phase 1). Faculty in four of the programs subsequently participated in a CRM program using simulation. The survey was readministered 3 yr later (Phase 2). Factor analysis was used to create scales regarding common safety themes. Positive safety climate (% of respondents with positive safety attitudes) was computed for the scales to indicate the safety climate levels. RESULTS: The usable response rate was 44% (309/708) and 38% (293/772) in Phases 1 and 2 respectively. There was wide variation in response rates among hospitals and providers. Eight scales were identified. There were significantly different climate scores among hospitals but no difference between the trained and untrained cohorts. The positive safety climate scores varied from 6% to 94% on specific survey questions. Faculty and residents had significantly different perceptions of the degree to which residents are debriefed about their difficult clinical situations. CONCLUSIONS: Safety climate indicators can vary substantially among anesthesia practice groups. Scale scores and responses to specific questions can suggest practices for improvement. Overall safety climate is probably not a good criterion for assessing the impact of simulation-based CRM training. Training alone was insufficient to alter engrained behaviors in the absence of further reinforcing actions.

Local anesthetic-induced cardiac toxicity: a survey of contemporary practice strategies among academic anesthesiology departments.

Though new local anesthetics (LA), effective test-dosing, and new regional anesthetic techniques may have improved the safety of regional anesthesia, the optimal management plan for LA-induced cardiac toxicity remains uncertain. Accordingly, we evaluated current approaches to LA cardiotoxicity among academic anesthesiology departments in the United States. A 19-question survey regarding regional anesthesia practices and approaches to LA cardiac toxicity was sent to the 135 academic anesthesiology departments listed by the Society of Academic Anesthesiology Chairs-Association of Anesthesiology Program Directors. Ninety-one anonymously completed questionnaires were returned, at a response rate of 67%. The respondents were categorized into groups according to the number of peripheral nerve blocks (PNBs) performed each month: >70 PNBs (38%), 51-70 PNBs (13%), 31-50 PNBs (20%), 11-30 PNBs (23%), and <10 PNBs (6%). Anesthesia practices administering >70 PNBs were 1.7-times more likely to use ropivacaine (NS), 3.9-times more likely to consider lipid emulsion infusions for resuscitation (P = 0.008), and equally as likely to have an established plan for use of invasive mechanical cardiopulmonary support in the event of LA cardiotoxicity (NS) than low-PNB volume centers. We conclude that there are differences in the management and preparedness for treatment of LA toxicity among institutions, but the safety implications of these differences are undetermined.

Predicting anesthesia times for diagnostic and interventional radiological procedures.

We studied anesthesia times for diagnostic and interventional radiology using anesthesia billing data and paper radiology logbooks. For computerized tomography and magnetic resonance imaging procedures, we tried to predict future anesthesia times by using historical anesthesia times classified by Current Procedural Terminology (CPT) codes. By this method, anesthesia times were estimated even less accurately than operating room cases. Computerized tomography and magnetic resonance imaging had many different CPT codes, most rare, and CPT codes reflected organs imaged, not scanning times. However, when, anesthesia times were estimated by expert judgment, face validity and accuracy were good. Lower and upper prediction bounds were also estimated from the expert estimates. For interventional radiology, predicting anesthesia times was challenging because few CPT codes accounted for most cases. Because interventional radiologists scheduled their elective cases into allocated time, the necessary goal was not to estimate the time to complete each case but rather the time to complete each day's entire series of elective cases including turnover times. We determined the time of day (e.g., 4 pm) up to when interventional radiology could schedule so that on 80% of days the anesthesia team finishes no later than a specified time (e.g., 6 pm). Both diagnostic and interventional radiology results were similarly less accurate when Version 9 of the International Classifications of Diseases' procedure codes was used instead of CPT.

Time accuracy of a radio frequency identification patient tracking system for recording operating room timestamps.

A patient tracking system is a promising tool for managing patient flow and improving efficiency in the operating room. Wireless location systems, using infrared or radio frequency transmitters, can automatically timestamp key events, thereby decreasing the need for manual data input. In this study, we measured the accuracy and precision of automatically documented timestamps compared with manual recording. Each patient scheduled for urgent surgery was given an active radio frequency/infrared transmitter. The prototype software tracked the patient throughout the perioperative process, automatically documenting the timestamps. Both automatic and traditional data entry were compared with the reference data. The absolute value of median error was 64% smaller (P < 0.01), and the average quartile deviation of error was 69% smaller in automatic documentation. The average delay between an activity and the documentation was 80 seconds in automatic documentation and 735 seconds in manual documentation. Both the accuracy and the precision were better in automatic documentation and the data were immediately available. Automatic documentation with the Indoor Positioning System can help in managing patient flow and in increasing transparency with faster availability and better accuracy of data.

Current practice in regional anaesthesia in Germany.

BACKGROUND AND OBJECTIVE: Several new techniques and agents (e.g. ropivacaine) have been introduced in regional anaesthesia to improve patients outcome and safety. The beneficial effects on patient outcome are clear with these techniques, however, no information is available about their pattern and frequency of use in clinical practice. This study presents data concerning the current practice of regional anaesthesia in Germany. METHODS: A questionnaire was sent to every German anaesthesia department (n = 1381). Questions focused on the frequency and range of regional anaesthetic procedures employed, with attention also to the organizational structural of the individual institution. RESULTS: Six hundred and sixty-seven questionnaires were returned anonymously, representing a return rate of 48.3%. In hospitals with less than 200 beds, the number of regional anaesthetics was markedly higher compared to large hospitals with more than 400 beds. In contrast, small hospitals tended to provide only basic techniques of regional anaesthesia, whereas larger hospitals implemented more advanced techniques. Bupivacaine remains the most commonly used long-lasting local anaesthetic. Staff structure was also different in small departments - patient care was performed by board certified anaesthesiologists while residents were responsible for the patients in larger departments. CONCLUSIONS: In small hospitals a majority of board certified anaesthesiologists rely on basic regional anaesthesia techniques. In large departments some consultants provide the entire spectrum of regional anaesthesia, with the majority of cases transferred to the residents responsibility. These results indicate the strong need to improve residency programs with regard to regional anaesthesia.