Global oximetry: an international anaesthesia quality improvement project.

Pulse oximetry is mandatory during anaesthesia in many countries, a standard endorsed by the World Health Organization 'Safe Surgery Saves Lives' initiative. The Association of Anaesthetists of Great Britain and Ireland, the World Federation of Societies of Anaesthesiologists and GE Healthcare collaborated in a quality improvement project over a 15-month period to investigate pulse oximetry in four pilot sites in Uganda, Vietnam, India and the Philippines, using 84 donated pulse oximeters. A substantial gap in oximeter provision was demonstrated at the start of the project. Formal training was essential for oximeter-naïve practitioners. After introduction of oximeters, logbook data were collected from over 8000 anaesthetics, and responses to desaturation were judged appropriate. Anaesthesia providers believed pulse oximeters were essential for patient safety and defined characteristics of the ideal oximeter for their setting. Robust systems for supply and maintenance of low-cost oximeters are required for sustained uptake of pulse oximetry in low- and middle-income countries.

The Global Oximetry initiative.

Global Oximetry (GO) is an initiative launched recently in Uganda, India, the Philippines and Vietnam. The overall aims are to promote oximetry utilisation and reduce oximetry costs in lower income countries. Research objectives include studying the feasibility of cost reduction; overcoming non-cost barriers to global oximetry including issues of prioritization; education and guidelines; servicing and access to parts. Promotional objectives include creating new policy, influencing oximetry design, and setting new global standards for safer monitoring.

Supervision and responsibility: The Royal College of Anaesthetists National Audit.

BACKGROUND: The Royal College of Anaesthetists audited consultant supervision and responsibility in anaesthesia in the UK during 2003. METHODS: Consultants (supervising) and non-consultants (supervised) were surveyed on their attitudes to supervision, experience of their own hospital system for supervision and of induction for new starters. Local coordination was achieved through anaesthesia audit coordinators who provided information on local policies, induction programmes and anaesthesia charts. Supervision was audited over a 5-day period. RESULTS: 135 departments of anaesthesia took part (43% of 315 departments), questionnaires being returned by 2297 anaesthetists. Anaesthesia record charts in use do not meet criteria considered desirable locally. Most trainees, but less than half staff grade/associate specialists, received an induction programme, often not supported by written documentation. Consultants find conflicting demands of service and supervision difficult. Many work in systems which do not permit providing direct, immediate support to those supervised. Most anaesthetists think supervision is very important. Around half disagree with national guidance that every NHS patient should have a named consultant. Two per cent of non-consultants during the audit period reported assistance from consultants not being obtainable soon enough. CONCLUSIONS: This audit found departure from standards and the potential for risk and failure. New standards may be needed regarding anaesthesia record sheets, induction, accountability, when to seek help and care of sick patients. Supervision systems in over 40% of hospitals need review to ensure they provide a named consultant and immediate direct support for elective lists.

Clinical and economic choices in anaesthesia for day surgery: a prospective randomised controlled trial.

We compared the cost-effectiveness of general anaesthetic agents in adult and paediatric day surgery populations. We randomly assigned 1063 adult and 322 paediatric elective patients to one of four (adult) or two (paediatric) anaesthesia groups. Total costs were calculated from individual patient resource use to 7 days post discharge. Incremental cost-effectiveness ratios were expressed as cost per episode of postoperative nausea and vomiting (PONV) avoided. In adults, variable secondary care costs were higher for propofol induction and propofol maintenance (propofol/propofol; p < 0.01) than other groups and lower in propofol induction and isoflurane maintenance (propofol/isoflurane; p < 0.01). In both studies, predischarge PONV was higher if sevoflurane/sevoflurane (p < 0.01) was used compared with use of propofol for induction. In both studies, there was no difference in postdischarge outcomes at Day 7. Sevoflurane/sevoflurane was more costly with higher PONV rates in both studies. In adults, the cost per extra episode of PONV avoided was pound 296 (propofol/propofol vs. propofol/ sevoflurane) and pound 333 (propofol/sevoflurane vs. propofol/isoflurane).

What information do anaesthetists provide for patients?

BACKGROUND: Information on anaesthesia interventions, plans and risks is needed by patients and carers alike and is a key component of the Good Practice In Consent initiative. Existing information materials may under-represent what patients are able to contribute. METHOD: UK anaesthetic departments were surveyed on provision of written patient information. The response rate was 66% (177/267). RESULTS: Fifty-five per cent of respondents reported providing patient information materials for planned surgical admission, mainly on general anaesthesia, regional analgesia and pain. A minority provided information for children and for critical care patients. Few (32%) had sought feedback from patients, and few used existing sources of guidance. Most (85%) wanted improvements, with a four-to-one majority favouring central resources developed by The Royal College of Anaesthetists. CONCLUSIONS: Working in parallel does not give our hospitals excellent, effective patient information materials. Demand exists for The Royal College of Anaesthetists to lead in this area. Working in partnership with patients and taking into account existing written guidance is important but has often been overlooked.

The management of pain following day-case surgery.

The object of this study was to assess patients' experience of pain management following day surgery. One hundred and two patients agreed to take part in a telephone survey, 2 and 4 days following day surgery. The majority of patients (73%) were broadly satisfied with the quality of pain management they received, however, there was room for improvement. Despite modern anaesthesia and surgery, 17% of patients surveyed reported having severe pain immediately following day-case surgery. The majority (82%) of patients left the day-case ward in pain and an even higher proportion (88%) had pain at some time between 2 and 4 days postoperatively. Severe levels of pain following discharge from hospital were a concern for 21% of patients. It was reported that day-case staff did not always ask patients whether they were in pain. Communication with patients is vital in the delivery of optimal care. More support and more information are needed to manage patients' pain effectively, whilst in the day-case wards and also following discharge, at home.

Anaesthesia clinical directors in the United Kingdom: organisation, objectives and support needs.

A postal survey of all 269 acute hospital trusts identified in the United Kingdom was carried out to study the work of Clinical Directors of anaesthesia. Initial responses from 163 Clinical Directors and 129 completed questionnaires were analysed. Four main areas of concern revealed by the survey were contracts and objectives, funding of managerial sessions, access to information and perceived need for support. Most Clinical Directors had no job description and most had no formal written objectives, despite a substantial body of advice that these should be provided. There was generally substantial underfunding of managerial hours compared with those actually worked and approximately 20% of Clinical Directors surveyed had no funding for managerial duties. Clinical Directors' ratings of the information available to assist their decision making were also a cause of concern. Clinical Directors perceived that they need better networking, more training particularly on human resource management and improved management information.

Acebutolol and coronary artery surgery. Plasma levels following oral pre-operative treatment.

Plasma levels of acebutolol and its major human metabolite, diacetolol, were determined before, during and after aortocoronary bypass grafting in 10 patients who had received a chronic oral regimen of acebutolol 200 mg t.d.s. for at least 6 days before surgery, a 200 mg dose with the premedication and 5-10 mg intravenously immediately before intubation. It was found that this regimen produced beta-adrenoceptor antagonist levels which were within the range in which attenuation of hypertension and tachydysrhythmia occurs. These effective plasma levels were sustained throughout surgery and persisted into the early recovery period.