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.

Continuous improvement of safety in the Intensive Care and Surgical environment according to UNE 179003:2013 standard: 8 years experience. / Mejora continua de la seguridad en el ámbito de un Servicio de Anestesiología y Cuidados Intensivos a través de la certificación según la norma de UNE 179003:2013: 8 años de experiencia.

INTRODUCTION: The UNE 179003:2013 standard requires compliance with protocols to reduce the risks of patients from adverse events. METHODS: A description is presented of the procedure used in the Hospital Povisa to achieve UNE 179003:2010 certification for the intensive care unit, surgical division, and post-anaesthesia recovery unit (PARU). This was based on a risk management system, focusing on pro-active analysis using failure modes and effects analysis (FMEA) with the description of causes, consequences, risk weighting, and specific risk-minimising measures. A description is also presented of the analysis of reported adverse events (reactive analysis) in the Safety in Anesthesia and Resuscitation (SENSAR) notification system and the measures implemented over an eight-year period. RESULTS: The UNE 179003:2010 certification was obtained in July 2012, and the re-certification was achieved in July 2015. A total of 66 potential risks were established, which were weighted using a risk probability index (RPI), and measures were implemented that reduced this RPI by half. It also reflects the analysis of 1114 events declared in the SENSAR system over the past eight years, allowing for the introduction of 2681 measures, of which 98.4% are fully implemented. CONCLUSION: The application of the risk management methodology allowed (a) to improve safety in the area of action by reducing the risk to which the patients are subject, and (b) to gain certification in the UNE 179003 standard.

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.

[Prevention of medical device-related adverse events in hospitals: Specifying the recommendations of the German Coalition for Patient Safety (APS) for users and operators of anaesthesia equipment]. / Prävention Medizintechnik-assoziierter Risiken im Krankenhaus: Spezifizierung der APS-Empfehlungen für Anwender und Betreiber von Anästhesiegeräten.

BACKGROUND: The use and organisation of medical technology has an important role to play for patient and user safety in anaesthesia. OBJECTIVES: Specification of the recommendations of the German Coalition for Patient Safety (APS) for users and operators of anaesthesia equipment, explore opportunities and challenges for the safe use and organisation of anaesthesia devices. METHODS: We conducted a literature search in Medline/PubMed for studies dealing with the APS recommendations for the prevention of medical device-related risks in the context of anaesthesia. In addition, we performed an internet search for reports and recommendations focusing on the use and organisation of medical devices in anaesthesia. Identified studies were grouped and assigned to the recommendations. The division into users and operators was maintained. RESULTS: Instruction and training in anaesthesia machines is sometimes of minor importance. Failure to perform functional testing seems to be a common cause of critical incidents in anaesthesia. There is a potential for reporting to the federal authority. Starting points for the safe operation of anaesthetic devices can be identified, in particular, at the interface of staff, organisation, and (anaesthesia) technology. CONCLUSIONS: The APS recommendations provide valuable information on promoting the safe use of medical devices and organisation in anaesthesia. The focus will be on risks relating to the application as well as on principles and materials for the safe operation of anaesthesia equipment.

Management implications for the perioperative surgical home related to inpatient case cancellations and add-on case scheduling on the day of surgery.

BACKGROUND: The American Society of Anesthesiologists has embraced the concept of the Perioperative Surgical Home as a means through which anesthesiologists can add value to the health systems in which they practice. One key listed element of the Perioperative Surgical Home is to support "scheduling initiatives to reduce cancellations and increase efficiency." In this study, we explored the potential benefits of the Perioperative Surgical Home with respect to inpatient cancellations and add-on case scheduling. We evaluated 6 hypotheses related to the timing of inpatient cancellations and preoperative anesthesia evaluations. METHODS: Inpatient cancellations were studied during 26 consecutive 4-week intervals between July 2012 and June 2014 at a tertiary care academic hospital. All timestamps related to scheduling, rescheduling, and cancellation activities were retrieved from the operating room (OR) case scheduling system. Timestamps when patients were seen by anesthesia residents were obtained from the preoperative evaluation system database. Batch mean methods were used to calculate means and SE. For cases cancelled, we determined whether, for "most" (>50%) cancellations, a subsequent procedure (of any type) was performed on the patient within 7 days of the cancellation. Comparisons with most and other fractions were assessed using the 1 group, 1-sided Student t test. We evaluated whether a few procedures were highly represented among the cancelled cases via the Herfindahl (Simpson's) index, comparing it with <0.15. The rate of scheduling activity was assessed by computing the number of OR scheduling office decisions in each 1-hour bin between 6:00 AM and 3:59 PM. These values were compared with ≥1 decision per hour at the study hospital. RESULTS: Data from 24,735 scheduled inpatient cases were assessed. Cases cancelled after 7 AM on the day before or at any time on the scheduled day of surgery accounted for 22.6% ± 0.5% (SE) of the scheduled minutes all scheduled cases, and 26.8% ± 0.4% of the case volume (i.e., number of cases). Most (83.1% ± 0.6%, P < 10) cases performed were evaluated on the day before surgery. Most (67.6% ± 1.6%, P < 10) minutes of cancelled cases were evaluated on the day before surgery. Most (62.3% ± 1.5%, P < 10) cases were seen earlier than 6:00 PM of the day before surgery. The Herfindahl index among cancelled procedures was 0.021 ± 0.001 (P < 10 compared not only to <0.15 but also to <0.05), showing large heterogeneity among the cancelled procedures. A subsequent procedure was not performed for most cancelled cases (50.6% ± 0.9% compared with >50%, P = 0.12), implying that the indication for the cancelled procedure no longer existed or the patient/family decided not to proceed with surgery. When only cancellations on the scheduled day of surgery were considered, the cancellation rate was 14.0% ± 0.3% of scheduled inpatient minutes and 11.8% ± 0.2% of scheduled inpatient cases. There were 0.59 ± 0.02 OR schedule decisions per hour per 10 ORs between 6:00 AM and 3:59 PM (P < 10, corresponding to ≥1 decision per hour at the 36 OR study hospital). CONCLUSIONS: The study hospital had a high inpatient cancellation rate, despite the fact that most patients whose cases were cancelled were seen by an anesthesia resident by 6:00 PM of the day before surgery. This finding suggests that further efforts to reduce the cancellations by seeing patients sooner on the day before surgery, or seeing even more patients the day before surgery, would not be an economically useful focus of the Perioperative Surgical Home. The wide heterogeneity among cancelled cases indicates that focusing on a few procedures would not materially affect the overall cancellation rate. The relatively low rate of subsequent performance of a procedure on patients whose cases had been cancelled suggests that trying to decrease the cancellation rate might be medically counterproductive. The hourly rate of decisions in the scheduling office during regular work hours on the day of surgery highlights the importance of decisions made at the OR control desk and scheduling office throughout the day to reduce the hours of overused OR time. These data suggest that efforts of the Perioperative Surgical Home related to inpatient cancellations should focus on management decision-making to mitigate the disruptions to the planned OR schedule caused by inpatient case cancellations and add-on cases, more so than on efforts to reduce inpatient cancellation rates.

[Helsinki Declaration on Patient Safety in Anaesthesiology--Part 8: SOP for checking equipment and drugs]. / Deklaration von Helsinki zur Patientensicherheit in der Anästhesiologie--Teil 8: SOP zur Überprüfung von Geräten und Medikamenten.

In 2010 the Helsinki Declaration on Patient Safety in Anaesthesiology was launched. In this joined statement under the auspice of the European Society of Anaesthesiology the need for protocols for different aspects of perioperative procedures that could affect patient safety was stated. All participating institutions should have--among others--protocols for checking equipment and drugs required for the delivery of safe anaesthesia. The background for this being the fact that the lack of carefully checking equipment and drugs--or not adhering to existing checklists--is a latent threat to patient safety and thus may increase morbidity and mortality.In this part of a series the authors present protocols existing in their clinic for checking anaesthesia equipment and drugs.

Managing quality in an anesthesia department.

PURPOSE OF REVIEW: To provide a practical approach to measure and then improve the quality of an academic anesthesia department. RECENT FINDINGS: The quality of any entity is defined by the user. Anesthesia departments should adopt practices that meet their specific operational needs. The relative importance of each of the user groups will be determined by the purpose of an individual department. Four categories of users will be considered: patients, surgeons (and other proceduralists), the hospital organization and the department itself (i.e. faculty and trainees). Patients value avoiding nausea and vomiting and pain after surgery, surgeons want cases to start on time with low turnover times, and the hospital desires high throughput of surgical cases, all facilitated by department faculty who value professional development. Quality improvement efforts in anesthesia should be aligned with broad healthcare quality improvement initiatives and avoid distortions in perceptions of quality by over-emphasizing what is easily measurable at the expense of what is important. SUMMARY: Departments of anesthesia should develop performance criteria in multiple domains and recognize the importance of human relationships (between staff and between staff and patients) in quality and safety. To improve the value of anesthesia services, departments should identify their user groups, survey them to determine what attributes are important to the user, then deliver, measure, monitor and improve them on an ongoing basis.

Reducing surgical site infections through a multidisciplinary computerized process for preoperative prophylactic antibiotic administration.

BACKGROUND: Surgical site infections (SSIs) result in significant postoperative morbidity and mortality. Although many of these infections can be prevented by timely administration of preoperative antibiotics, data suggest that many patients do not receive such therapy. METHODS: A multidisciplinary team was convened that reviewed published guidelines, made antibiotic recommendations, and addressed administration issues. Responsibility for antibiotic administration was shifted from preoperative nursing staff to the anesthetist. Electronic quick orders were developed to encourage appropriate antibiotic selection and simplify order creation. RESULTS: Timely administration of preoperative antibiotics improved from 51% to 98% from February 2005 to February 2006. Appropriate antibiotic administered improved from 78% to 94%. The clean wound infection rate decreased from 2.7% to 1.4% over the same time period. CONCLUSION: A multidisciplinary approach to prophylactic antibiotic use, including computer-guided decision support, facilitates appropriate preoperative antibiotic use, resulting in a significant decrease in surgical wound infections.

Past accomplishments and future directions: risk prevention in anesthesia and surgery.

Anesthesiology has served as a model for patient safety in health care and was the first medical profession to treat patient safety as an independent problem. Anesthesiology has implemented widely accepted guidelines on basic monitoring, conducted long-term analyses of closed malpractice claims, developed patient simulators as meaningful training tools, and addressed problems of human error. The National Surgical Quality Improvement Program is the first national, validated, and peer-controlled program that uses risk-adjusted outcomes for the comparative assessment and improvement of the quality of surgical care. The program has reduced postoperative complications in the Veterans Administration, at both national and local levels. It is becoming more evident that processes and events during surgery can be important determinants of long-term outcomes after anesthesia and surgery.

The effect of national guidelines on the implementation of outpatient preoperative evaluation clinics in Dutch hospitals.

BACKGROUND AND OBJECTIVES: Preoperative evaluation performed by anaesthesiologists primarily aims to estimate the risk of perioperative complications and to create opportunities to optimize the patients' condition before surgery. In this study an inventory was made of the current practice of preoperative evaluation in Dutch hospitals. It was estimated how many hospitals had implemented an outpatient preoperative evaluation clinic in 2004. Subsequently, current practice was compared with the results of a previous inventory (2000). It was also evaluated to what extent the guidelines of the Dutch Health Council and the Netherlands Society of Anaesthesiology were followed. METHODS: The study consisted of two phases. First, a literature research was performed and pilot interviews were constructed. The interviews were conducted face-to-face with anaesthesiologists in a sample of Dutch hospitals. Based on the results, written questionnaires were constructed. In the second phase these questionnaires were sent to all general and academic hospitals in the Netherlands. RESULTS: In 2004, 74% of the hospitals had an outpatient preoperative evaluation clinic, compared with 50% in 2000. The percentage of hospitals with an outpatient preoperative evaluation clinic available for all elective patients increased from 20% to 52%. CONCLUSIONS: The Dutch guidelines on preoperative evaluation seem to have influenced current practice. An increase in the number of outpatient preoperative evaluation clinics was seen after the guidelines were published. The implementation of an outpatient preoperative clinic seems to warrant that anaesthesiologists are carrying out the activities prescribed by the guidelines. Most hospitals without a clinic aim to implement one in the future.

Prospective memory failures as an unexplored threat to patient safety: results from a pilot study using patient simulators to investigate the missed execution of intentions.

This study investigated failures of prospective memory (PM) as a relevant but neglected error type in medicine. A patient simulator was used to investigate PM failures. The influence of subjective importance (high, low) and type of intention (educational, internal, external) on the (missed) execution of intention was investigated in a 2 x 2 design. The effects on missed executions by importance (high < low) and type of intention (educational < external < internal) were hypothesized. Of 73 valid intentions in 40 prepared simulator scenarios 19 (26%) were missed overall. A total of 64% of unimportant and 80% of important intentions were executed 79% of educational 67% of external and 72% of internal intentions were executed. Neither difference was statistically significant using chi(2) tests. Interaction was significant for missed executions (p = 0.025; n = 19; df = 2; chi(2) = 7.41) and for executions (p = 0.002; n = 54; df = 2; chi(2) = 12.50). Despite low statistical support and some methodological limitations, it was possible to show that PM failures are relevant to patient safety and that patient simulators are a suitable but so far unused tool for their investigation.

Preoperative testing is inconsistent with published guidelines and rarely changes management.

PURPOSE: The Canadian Anesthesiologists' Society (CAS), the Ontario Preoperative Task Force (OPTF) and The Ottawa Hospital (TOH) have published guidelines detailing the indications for preoperative testing. The purpose of this study was to: (a) document compliance of testing practice at TOH-Civic Campus with published guidelines; and (b) determine the impact of preoperative testing on clinical management. METHODS: Following Research Ethics approval all patients undergoing elective surgery at TOH-Civic Campus in the first three months of 2004 were identified. One hundred charts from each month were randomly selected and analyzed retrospectively by a single reviewer. The ordering and results of four preoperative tests were characterized. The indication for preoperative testing was identified from preoperative notes and the source of non-compliant orders was identified. Compliance with the CAS, OPTF, and TOH guidelines was documented. Abnormal test results were analyzed for evidence of a subsequent change in clinical management. RESULTS: The charts of 294 of the 2,116 patients who underwent elective surgery at TOH-Civic Campus in the first three months of 2004 were reviewed. A total of 534 tests were ordered on 198 patients (67%). Non-compliance rates varied significantly (5-98%) depending on test and guideline analyzed. Results of 329 tests (61.6%) were normal. Management was changed by 14 of 534 tests ordered (2.6%). Surgery proceeded as scheduled in all cases. CONCLUSION: The majority of elective surgical patients undergo preoperative testing. Non-compliance with guidelines ranged from 5 to 98%. The results of most tests were normal and influenced management in only 2.6% of cases.

Postoperative analgesia in children--current practice in Germany.

German departments of anaesthesia were surveyed to determine current practice of postoperative pain management in children. The response rate of the survey was 58.6%: Questionnaires of 383 departments in which paediatric surgery was performed could be analyzed. 37.3% operated an acute pain service (APS). In 58.8% of the hospitals, postoperative pain management in children was mainly performed by surgeons or pediatricians. Anaesthesiologists or an APS were in charge for pain management in children in 38.6% of the institutions. Non-opioid analgesics were the drugs most widely used (93.4%), whereas i.v. opioids were never used in 20.9% of the hospitals and used less than once a week in 28.7%. The intramuscular route was chosen at least occasionally by 27.7% of the respondents. Peripheral and central regional techniques were performed in most of the departments, however, frequency of use varied considerably between hospitals running or not running an APS. The majority performed the techniques of regional anaesthesia less than once a week. The basic primary quality criterion of pain therapy, a regular measurement and documentation of pain scores, was performed in only 4% of the institutions. Paediatric pain management does not meet quality criteria and standards of care already established in adults. In the future, additional education of the medical staff considering analgesic techniques and measurement of pain scores has to be emphasized.

[Clinical risk management. Implementation of an anonymous error registration system in the anesthesia department of a university hospital]. / Klinisches Risikomanagement. Implementierung eines anonymen Fehlermeldesystems in der Anästhesie eines Universitätsklinikums.

BACKGROUND: The main goal of a medical risk management system is reduction of treatment errors and the primary focus is patient safety. MATERIALS AND METHODS: A task force on risk management in anaesthesia was established in the department of Anaesthesiology and Intensive Care at the University Hospital Dresden with the aim to implement a critical incident reporting system (CIRS) followed by a structured analysis. The theoretical basic principles and tools for the incident analysis are presented. RESULTS: The task force developed a machine-readable, structured, anonymous questionnaire, which was implemented in clinical practice after a primary test period. CONCLUSIONS: Prerequisites for the implementation of an effective CIRS are support from the department head, anonymity, independence of the task force from the department head and competence of the task force to initiate changes and improvements. CIRS is a powerful tool to register and analyse critical incidents and may influence the following domains: education and training (human factors), medical equipment (technical factors), quality of working processes and departmental communication (organisational factors).

[National project for the management of clinical processes. Surgical treatment of inguinal hernia]. / Proyecto nacional para la gestión clínica de procesos asistenciales. Tratamiento quirúrgico de la hernia inguina.

INTRODUCTION: The high prevalence of surgical treatment for inguinal hernia (especially in general surgery) prompted the Spanish Association of Surgeons to perform a national study to identify the most important indicators. OBJECTIVE: To analyze healthcare quality in elective surgery for inguinal hernia by evaluating scientific-technical quality, efficiency, effectiveness, and patient satisfaction. MATERIAL AND METHODS: A prospective, longitudinal, descriptive study from diagnosis to postoperative follow-up was performed. Patients who underwent surgery for unilateral or bilateral, primary or recurrent inguinal hernias were included. Exclusion criteria were emergency surgery and associated surgical procedures. Clinical indicators were selected after a literature review. RESULTS: Forty-six hospitals corresponding to 16 Autonomous Communities with a total of 386 patients participated in this study. The mean follow-up was 18 months. The mean age of the patients was 56.33 years and 88.3% were male. Half the patients (50.1%) were American Society of Anesthesiologists (ASA) grade I. A total of 95.6% did not comply with the protocol for preoperative tests of the Spanish Association of Surgeons. Antibiotic prophylaxis was used in 75.39% and thromboembolic prophylaxis was used in 40.04%. Ambulatory surgery was performed in 33.6%. Local anesthesia and sedation only were used in 16.36% of the patients. The most frequently used surgical procedures involved mesh repair (Lichtenstein 50%, Rutkow-Robbins 17.1%), laparoscopy was used in 5.2% of the patients, and the Shouldice technique was used in 8.5%. The mean length of hospital stay was 47.5 hours in inpatients and was 11.65 hours in patients who underwent ambulatory surgery. Notable among the complications was hematoma in 11.6%. Ninety-six percent of the patients were satisfied or highly satisfied. The most highly scored items in the satisfaction survey were those related to information, personal dealings with staff, and the staffs kindness. The lowest scored items dealt with punctuality and accessibility. Follow-up at 18 months showed a recurrence rate of 4.11% with a total recovery time estimated by patients of 7.26 weeks. CONCLUSIONS: Analysis of the process revealed areas for improvement and strong points. Strong points consisted of up-to-date choice of surgical technique. The most frequently used techniques were tension-free procedures and the Shouldice technique. The following areas for improvement were identified: adherence to protocols for preoperative evaluation, increased use of ambulatory surgery, local anesthesia and sedation, appropriate use of antibiotic and thromboembolic prophylaxis in selected patients and a reduction in the length of hospital stay in inpatients. Patient satisfaction with the treatment was acceptable.