Impact of a Daily Huddle on Safety in Perioperative Services.

BACKGROUND: Communication failures contribute to quality gaps and may lead to serious safety events (SSEs) in the operating room (OR). Our perioperative services team experienced an increased rate of SSEs in 2020. Event analysis revealed clustered causes: communication failures and lack of timely information to prepare for cases. Consequently, the team implemented a daily morning OR safety huddle conducted before bringing patients into the OR to reduce quality gaps and improve communication. METHODS: The attending surgeon and anesthesiologist, circulating nurse, and scrub staff are required to be present. Cases are discussed using a standard format designed by the OR team with built-in time for questions and clarifications. The surgeon initiates the huddle; the circulating nurse leads and records the discussion. OR leadership initially performed daily audits but gradually reduced them when huddles became standard operating procedure (SOP). SSEs were recorded from December 2015 to September 2020 preintervention and October 2020 to July 2023 postintervention. RESULTS: Following the implementation of huddles, there were no SSEs for more than 900 days (2.0 SSEs/year preintervention vs. 0.0 SSEs/year postintervention). The first SSE during the postintervention period occurred in March 2023. Huddle compliance was consistently > 95%. No delays were observed in first-case on-time starts postintervention. The huddle is now SOP for all general OR teams and interventional radiology. CONCLUSION: Implementing the morning safety huddle contributed to a reduction in the rate of SSEs without introducing delays to first-case start-times.

How the Wake Up Safe pediatric anesthesia collaborative increased quality improvement capability and collaboration.

Wake Up Safe is a patient safety organization consisting of 40 institutions with a mission to improve the processes of care and outcomes for newborns, infants, and children having anesthesia for surgery and medical procedures. It was recognized that the level of quality improvement (QI), knowledge, and experience varied greatly between member institutions. In Fiscal Year 2015, the group's leadership created a subcommittee on QI and education in efforts to provide member institutions with the skills and resources to use QI methodology to improve care at their own institution. This subcommittee developed a program to improve members' knowledge in safety analytics and QI science and to help members implement change in their own institutions. This review describes the development and implementation of this initiative. As a result of this initiative, significant progress was made improving the QI capability of the collaborative over a two-year period. This educational and support program included workshops, an online discussion forum, site visits, and project presentations.

Novel utilization of strand-specific reverse transcription polymerase chain reaction in perioperative clinical decision making for SARS-CoV-2 polymerase chain reaction positive patients.

In order to prevent in-hospital transmission and potential complications related to SARS-CoV-2 in the perioperative patient, most healthcare institutions require preoperative testing for SARS-CoV-2 prior to proceeding with elective surgery. The Centers for Disease Control and Prevention (CDC) recommends a time and symptom-based duration of isolation for the presumed infectious period. The guidance to avoid retesting of asymptomatic patients in the 90 days following a positive reverse transcription polymerase chain reaction (RT-PCR) test is because of the possibility of detection of non-infectious viral shedding. When to reschedule asymptomatic patients who test RT-PCR positive for SARS-CoV-2 preoperatively is of considerable debate, both from the perspective of ensuring a patient's full preoperative fitness, as well as reducing the risk of viral transmission within the hospital. We describe the novel perioperative use of a strand-specific assay to detect minus strand ribonucleic acid (RNA) in a clinical decision-making algorithm to determine optimal timing of elective surgery after a patient tests RT-PCR positive for SARS-CoV-2. This is the first description in the literature of an attempt to further stratify patients who repeatedly test positive for SARS-CoV-2 into infectious versus non-infectious for perioperative planning.

Pre-operative fasting times for clear liquids at a tertiary children's hospital; what can be improved?

BACKGROUND: The goal of preoperative fasting is to prevent pulmonary aspiration during general anesthesia. Fasting times are often prolonged leading to patient discomfort and risk for adverse events. This retrospective quality improvement survey evaluated effective nil-per-os (NPO) times and causes for prolonged NPO times with the aim to suggest improvement strategies by a newly founded fasting task force. METHODS: Data from all electronic anesthesia records from 2019 at our institution were reviewed for fasting times. Our NPO instructions follow American Society of Anesthesiology guidelines and are calculated based on the patient's arrival time (90 min before operating room [OR] time). Primary outcome was the effective NPO time for clear liquids, secondary outcomes were incidence of delays and the parental compliance with the NPO instructions. Data are presented as median (interquartile range). RESULTS: 9,625 cases were included in the analysis. NPO time was documented in 72.1% with a median effective NPO time of 7:13 h (7:36). OR in room times were documented in 72.8%, 2,075 (29.5%; median time 0:10 h [0:21]) were earlier and 4,939 (70.5%; median time 0:29 h [0:54]) were later than scheduled. Parental NPO compliance showed a median deviation for clear liquid intake of 0:55 h (8:30). CONCLUSIONS: This study revealed that effective NPO times were longer than current ASA guidelines. Contributing causes include case delays and parental non-compliance to NPO instructions. Thus, task force recommendations include change NPO instruction calculations to scheduled OR time versus arrival time, and encourage parents to give their child clear liquids at the instructed time.

Reporting of Perioperative Adverse Events by Pediatric Anesthesiologists at a Tertiary Children's Hospital: Targeted Interventions to Increase the Rate of Reporting.

BACKGROUND: Incident reporting systems (IRSs) are important patient safety tools for identifying risks and opportunities for improvement. A major IRS limitation is underreporting of incidents. Perioperative anesthesia IRSs have been established at multiple pediatric institutions and a national pediatric anesthesia IRS for perioperative serious adverse events (SAEs) is maintained by Wake Up Safe (WUS), a patient safety organization dedicated to pediatric anesthesia quality improvement. A confidential, electronic, perioperative IRS was instituted at our tertiary children's hospital, which is a WUS member. The primary study aim was to increase the rate of incident reporting by anesthesiologists at our institution through a series of interventions. The secondary aim was to characterize our reporting behavior relative to national practice by referencing SAE data from WUS. METHODS: Perioperative adverse events reported over a 71-month period (November 2010 to September 2016) were categorized and the monthly reporting rates determined. Effects of 6 interventions targeted to increase the reporting rate were analyzed using control charts. Intervention 5 involved interviewing pediatric anesthesiologists to ascertain incident reporting barriers and motivators. A key driver diagram was developed and used to guide an improvement initiative. Incidents that fulfilled WUS criteria for SAEs were identified and categorized. SAE reporting rates over a 27-month period for 12 WUS member institutions were determined. RESULTS: 2689 perioperative adverse events were noted in 1980 of 72,384 anesthetics. Mean monthly adverse event case rate was 273 (95% confidence interval, 250-297) per 10,000 anesthetics. A subgroup involving 54,469 cases had 529 SAEs in 440 anesthetics; a mean monthly SAE case rate of 80 (95% confidence interval, 69-91) per 10,000 anesthetics. Cardiac, respiratory, and airway events predominated. Relative to WUS peer members, our institution is a high-reporting outlier. The rate of incident reporting per 10,000 anesthetics was sustainably increased from 149 ± 35 to 387 ± 73 (mean ± SD) after implementing mandatory IRS data entry and Intervention 5 quality improvement initiative. Barriers to reporting included concern for punitive repercussions, feelings of incompetence, poor education about what constitutes an event, lack of feedback, and the perception that reporting had no value. These were addressed by IRS education, cultivation of a culture of safety where reporting is encouraged, reporter feedback, and better inclusion of anesthesiologists in patient safety work. CONCLUSIONS: Electronic mandatory IRS data entry and an initiative to understand and address reporting barriers and motivators were associated with sustained increases in the adverse event reporting rate. These strategies to minimize underreporting enhance IRS value for learning and may be generalizable.

Small-Volume Injections: Evaluation of Volume Administration Deviation From Intended Injection Volumes.

BACKGROUND: In the perioperative period, anesthesiologists and postanesthesia care unit (PACU) nurses routinely prepare and administer small-volume IV injections, yet the accuracy of delivered medication volumes in this setting has not been described. In this ex vivo study, we sought to characterize the degree to which small-volume injections (≤0.5 mL) deviated from the intended injection volumes among a group of pediatric anesthesiologists and pediatric postanesthesia care unit (PACU) nurses. We hypothesized that as the intended injection volumes decreased, the deviation from those intended injection volumes would increase. METHODS: Ten attending pediatric anesthesiologists and 10 pediatric PACU nurses each performed a series of 10 injections into a simulated patient IV setup. Practitioners used separate 1-mL tuberculin syringes with removable 18-gauge needles (Becton-Dickinson & Company, Franklin Lakes, NJ) to aspirate 5 different volumes (0.025, 0.05, 0.1, 0.25, and 0.5 mL) of 0.25 mM Lucifer Yellow (LY) fluorescent dye constituted in saline (Sigma Aldrich, St. Louis, MO) from a rubber-stoppered vial. Each participant then injected the specified volume of LY fluorescent dye via a 3-way stopcock into IV tubing with free-flowing 0.9% sodium chloride (10 mL/min). The injected volume of LY fluorescent dye and 0.9% sodium chloride then drained into a collection vial for laboratory analysis. Microplate fluorescence wavelength detection (Infinite M1000; Tecan, Mannedorf, Switzerland) was used to measure the fluorescence of the collected fluid. Administered injection volumes were calculated based on the fluorescence of the collected fluid using a calibration curve of known LY volumes and associated fluorescence.To determine whether deviation of the administered volumes from the intended injection volumes increased at lower injection volumes, we compared the proportional injection volume error (loge [administered volume/intended volume]) for each of the 5 injection volumes using a linear regression model. Analysis of variance was used to determine whether the absolute log proportional error differed by the intended injection volume. Interindividual and intraindividual deviation from the intended injection volume was also characterized. RESULTS: As the intended injection volumes decreased, the absolute log proportional injection volume error increased (analysis of variance, P < .0018). The exploratory analysis revealed no significant difference in the standard deviations of the log proportional errors for injection volumes between physicians and pediatric PACU nurses; however, the difference in absolute bias was significantly higher for nurses with a 2-sided significance of P = .03. CONCLUSIONS: Clinically significant dose variation occurs when injecting volumes ≤0.5 mL. Administering small volumes of medications may result in unintended medication administration errors.

Patient simulation: a literary synthesis of assessment tools in anesthesiology.

High-fidelity patient simulation (HFPS) has been hypothesized as a modality for assessing competency of knowledge and skill in patient simulation, but uniform methods for HFPS performance assessment (PA) have not yet been completely achieved. Anesthesiology as a field founded the HFPS discipline and also leads in its PA. This project reviews the types, quality, and designated purpose of HFPS PA tools in anesthesiology. We used the systematic review method and systematically reviewed anesthesiology literature referenced in PubMed to assess the quality and reliability of available PA tools in HFPS. Of 412 articles identified, 50 met our inclusion criteria. Seventy seven percent of studies have been published since 2000; more recent studies demonstrated higher quality. Investigators reported a variety of test construction and validation methods. The most commonly reported test construction methods included "modified Delphi Techniques" for item selection, reliability measurement using inter-rater agreement, and intra-class correlations between test items or subtests. Modern test theory, in particular generalizability theory, was used in nine (18%) of studies. Test score validity has been addressed in multiple investigations and shown a significant improvement in reporting accuracy. However the assessment of predicative has been low across the majority of studies. Usability and practicality of testing occasions and tools was only anecdotally reported. To more completely comply with the gold standards for PA design, both shared experience of experts and recognition of test construction standards, including reliability and validity measurements, instrument piloting, rater training, and explicit identification of the purpose and proposed use of the assessment tool, are required.