Measuring the immeasurable? Assessing the quality of anaesthetic care.

Quality can be viewed from three perspectives: the requirements of the healthcare system; issues related to delivery of care, such as access; and methods used to measure quality, such as outcome analysis. These viewpoints can be applied to the anaesthetic literature to analyse the assessment of quality of care.

Somatosensory evoked potential monitoring during cardiac surgery: an examination of brachial plexus dysfunction.

OBJECTIVE: To observe the effects of the Favoloro and sternal retractors on the ulnar and median nerve somatosensory evoked potentials (SSEPs) and to identify any relationship with postoperative brachial plexus injury. DESIGN: Prospective study. SETTING: University hospital. PARTICIPANTS: Twenty cardiac patients. INTERVENTIONS: SSEPs were studied in patients undergoing cardiac surgery using normothermic cardiopulmonary bypass. Evoked potentials were obtained from bilateral median and ulnar nerves. MEASUREMENTS: The incidence of nerve-specific SSEP changes and their temporal relationship to retractor usage were determined. The overall incidence of SSEP changes was 75%. There were no differences (p > 0.05) between the group showing changes (n = 15) and the group with no changes (n = 5) with respect to age, body surface area, weight, cross-clamp or cardiopulmonary bypass times. There also were no differences (p > 0.05) between the frequencies of left- and right-sided changes, or in nerve-specific SSEP changes. Seventy-four percent of SSEP changes correlated with retractor usage. No SSEP changes were associated with the Favoloro retractor. Significant SSEP depression, assessed by either percentage reduction in amplitude or persistent amplitude reduction, occurred in the absence of postoperative neurological deficits. There were no detected postoperative brachial plexus injuries. CONCLUSIONS: SSEP changes correlate with the use of the sternal retractor but not the Favoloro retractor. It was not possible to replicate the results of previous investigators in predicting postoperative neurological deficits based on the SSEP changes, and therefore the routine application of SSEP as a monitor cannot be recommended on the basis on these data.

Anaesthetic management of a patient with myasthenia gravis and tracheal stenosis.

PURPOSE: The combination of myasthenia gravis and tracheal obstruction presents a number of difficulties for anaesthetic management. This case illustrates the advantages of careful planning. CLINICAL FEATURES: A 66-yr-old man with myasthenia gravis required resection of a stenosis at the site of an old tracheostomy. The primary goal was to accomplish safe management of the airway, a task made more difficult because the airway was shared with the surgeon. Awake fibreoptic examination of the tracheal stenosis performed in the operating room provided useful information in planning the subsequent anaesthetic. From this examination, it was found that the trachea could be intubated by a normal endotracheal tube passed through the stenosis over the fibreoptic bronchoscope. Intraoperatively, the orotracheal tube was withdrawn temporarily and replaced with an endotracheal tube placed by the surgeon into the distal trachea. Extubation was carried out judiciously and a plan for reintubation prepared in advance. The anaesthetic plan was modified because of the myasthenia gravis. Following careful investigation of the extent of the patient's disease and its treatment, an assessment was made of the patient's need for postoperative ventilation. The anaesthetic plan included maintenance of anticholinergic medications until the time of surgery and their early resumption postoperatively, avoidance of neuromuscular blocking agents, and careful monitoring of neuromuscular function during the anaesthetic. CONCLUSION: Careful examination of the area of tracheal stenosis and a carefully considered plan for reintubation are prerequisites for this type of surgery. Clinically well controlled myasthenia gravis was managed successfully using familiar principles.

Anaesthesia for coronary artery bypass surgery supplemented with subarachnoid bupivacaine and morphine: a report of 18 cases.

We report our experience with general anaesthesia (GA) supplemented with subarachnoid bupivacaine and morphine for coronary artery bypass surgery (CABG) in 18 patients. Fifteen patients were male, and mean age was 62 yr. Anaesthesia (GA) was induced with alfentanil 97 +/- 22 micrograms.kg-1 and midazolam 0.04 +/- 0.02 mg.kg-1 supplemented with a muscle relaxant, and maintained with isoflurane (0.25-0.5%) in oxygen throughout surgery. Spinal anaesthesia (SA) was then performed at a lumber level using hyperbaric bupivacaine (23-30 mg) and/or lidocaine (150 mg) with morphine (0.5-1 mg). Pooled data showed the following haemodynamic results (P < 0.05). Induction of GA produced a decrease in mean arterial pressure (MAP). Addition of SA produced a decrease in heart rate. Heart rate and MAP did not change with sternotomy. Phenylephrine support of arterial blood pressure was used at some time during operation in 17 patients. Supplementation of GA was minimal. Patients received 2.7 +/- 0.7 coronary grafts. Operating room time was 3.9 +/- 0.6 hr. Postoperative analgesic requirements were minimal, and in half of the patients tracheal extubation occurred on the day of surgery. Complications included one myocardial infarction, one resternotomy, a metabolic encephalopathy in a dialysis-dependent patient, and one case of herpes labialis. No patient recalled intraoperative events. Combined GA with SA may be an effective technique for CABG surgery. Further study of the cardiovascular, neurological and metabolic effects of the technique is required.

The cost of an established quality assurance programme: is it worth it?

Although the literature concerning quality assurance (QA) is voluminous, little information exists about the costs or benefits of departmentally based QA programmes. We measured the direct costs and then investigated the financial and nonfinancial benefits derived from a well-funded QA programme over a period of five years. Data were obtained from departmental budgets, annual reports of the QA programme, and several databases used by the programme. The average annual cost was $79,900, with salaries being the largest component, while $14,300 each year were recovered through the activities of the programme. True costs were higher than those calculated since time volunteered by medical staff and resources shared with other programmes could not be determined. Some of the costs encountered at the outset of this programme were later offset by the use of commercial software and employment of volunteers and casual staff. Fifty-three projects were identified over the five-year period. Most lacked directly measurable financial outcomes (because they were based on education, research, patient or practitioner satisfaction). The benefit of the programme has been greater to the department than suggested from cost analysis alone. Although this programme could not be justified on a simple cost recovery basis, the authors felt it to be worthy of continued support because of the nonfinancial benefits. However, modification is required to minimize costs.

A patient presenting for pharyngeal biopsy.

A 68-yr-old man presented for pharyngeal biopsy under general anaesthesia. Coincidentally he was found to have a large mediastinal mass. The evaluation of this patient is described. The exact risk of catastrophic airway collapse on induction of anaesthesia in patients with mediastinal masses is controversial but probably small. As there is no test to prevent airway collapse, it is suggested that attempts at biopsy be performed with regional anaesthesia after radiotherapy.

Simple narcotic kits for controlled-substance dispensing and accountability.

Operating rooms require a storage, dispensing and accounting system for restricted drugs which satisfies narcotics control authorities and is compatible with efficient care of patients. We describe narcotic kits containing fentanyl-morphine-midazolam, alfentanil-midazolam and sufentanil-midazolam, for general operating rooms, and two kits with larger quantities of fentanyl and sufentanil for cardiac operating rooms. The container for each kit is a video cassette holder which has a foam-rubber liner with sculpted depressions for each ampoule. Sealed kits are delivered each morning from pharmacy to the locked narcotics cupboard in the recovery room. On request, the recovery room nurse unlocks the cupboard and the anaesthetist signs out the required kit(s) for the day. A drug utilization form is enclosed with each kit, on which the anaesthetist records the amount of drug administered to each patient, and before returning the kit to the locked narcotics cupboard, the total amount of each drug used, discarded, and returned. Used kits are collected the following morning by a pharmacy technician who reconciles the contents and drug form of each kit. More than 40 staff anaesthetists and a similar number of residents have used the system for seven years, during which time 130,000 patients have passed through the operating rooms. Detection of one case of drug diversion by a staff anaesthetist was made partly by the control system, but mainly by behavioural changes. The system is simple, inexpensive, and effective and has been well received by the departments of pharmacy, anaesthesia, and nursing.

Use of refractometry to identify opioid-containing solutions.

The purpose of this laboratory study was to assess the value of refractometry in identifying the contents of a variety of opioid-containing solutions. A hand-held refractometer was used to document the refraction produced by the undiluted contents of alfentanil, fentanyl, morphine, sufentanil ampoules and by solutions of Ringer's lactate, 0.9% saline, 3.3% dextrose in 0.3% saline, and distilled water. Each opioid was then serially diluted in serial 1:2, 1:4, and 1:8 dilutions in each of these solutions and the refractions of each determined. Based on this information, blinded identification of various diluted opioid solutions was attempted. Refractometer values for undiluted fentanyl and sufentanil were identical with those for distilled water. Those for undiluted alfentanil and morphine were almost identical with each other and with 1:2 and 1:4 dilutions of either drug in Ringer's lactate or 0.9% saline. We conclude that refractometry is an unreliable screening method to detect tampering with opioid solutions.

The oral examination in anaesthetic resident evaluation.

Oral examinations have a traditional place in training and evaluation of professionals. Despite a lack of evidence identifying their value in assessment of candidates seeking anaesthetic specialty certification, oral examinations continue to be widely used. Although there is a considerable body of literature concerning oral examinations, there is no description of how this technique is employed in anaesthesia in Canada. The objective of this review is to provide faculty and residents with information concerning the strengths and weaknesses of this format, and the structure of the oral examination as practised in anaesthesia. Reliability of oral examinations can be affected by a number of factors dependent on the examiner, candidate, and the format. Properly constructed and prepared questions have well-defined characteristics. Components tested during the oral examination include: evaluation of a clinical situation, choice of therapy, medical knowledge, ability to deal with emergency situations, decision-making ability, and communication skills. When appropriately planned, the oral examination can be a useful component of the certification process.

Current models of "quality"--an introduction for anaesthetists.

The purpose of this review is to provide the practicing anaesthetist with an historical perspective of quality, a summary of current models, and an introduction to the expectations of accreditors. Articles were obtained from an electronic literature search on Silver Platter using the search terms Quality, Quality assurance, Anes, and Anaes. In addition, textbooks on quality assurance in health care, quality improvement texts from business management, and accreditation documents were reviewed. Quality systems in health care are derived from business or industrial models. Study of this field is hampered by poorly defined terminology and jargon. Over the years, many different models have been used in health care, but recent studies have investigated the effectiveness of methods such as Quality Improvement. Many of the systems used by hospitals appear to have been prompted by requirements of accreditation standards. Recently, systems of hospital organization have appeared which link Quality Assurance, Quality Improvement, risk management and utilization management. Despite the confusion created by ill-defined terminology and rapid change in some definitions, anaesthetists need to be aware of the basic models of accreditation requirements.

Informed consent for clinical anaesthesia research.

Most surgical patients are first seen by an anaesthetist after admission to hospital, either the evening before or on the day of surgery. Some medical ethicists believe that an approach by an anaesthesia researcher made after admission is unethical because the hospital itself is a coercive environment, and patients have insufficient time for reflection or consultation. Others believe that an approach prior to admission may be an invasion of the patient's privacy and confidentiality. The implications of these views for anaesthesia researchers may not be apparent to research ethics boards (REBs). To determine current practice, a questionnaire concerning the membership and function of REBs and the time of obtaining informed consent was sent to each research representative of the 16 Canadian university departments of anaesthesia. Membership of REBS was similar, but not identical, in all centres. Most representation was from medical disciplines. Consent was generally obtained following the patient's admission to hospital. In one centre, the REB always requested informed consent to be obtained before the patient's admission to the hospital. Surgeons had no involvement with consent for anaesthesia research in 14 centres while in the other two they gave permission for their patients to be studied and informed patients of the potential approach by anaesthesia researchers. We conclude that it is ethically acceptable to obtain informed consent for most low-risk clinical anaesthesia research after the patient's admission to hospital.

Effects of tutors with case expertise on problem-based learning issues.

At the University of Calgary Faculty of Medicine in 1991, the authors sought to determine the effects of tutors' levels of content expertise on learning issues generated within problem-based learning (PBL) tutorials. For an integrative course taken prior to clinical clerkships, the 70 students in the class of 1992 divided into ten small groups, which were facilitated alternately by content experts and non-experts. The authors found that--across 35 simulated-patient case encounters (24 with non-experts and 11 with experts)--when the groups had tutors with expertise in the clinical cases studied, the groups generated approximately twice as many learning issues per case, and these issues were approximately three times more congruent with the case objectives. In addition, when the groups had expert tutors they spent approximately twice as much time per case in overcoming identified learning deficiencies. The authors conclude that it is important for tutors (1) to be well informed about cases and case objectives and (2) to be well versed in the PBL tutoring process.

Accident analysis of large-scale technological disasters applied to an anaesthetic complication.

The occurrence of serious accidents in complex industrial systems such as at Three Mile Island and Bhopal has prompted development of new models of causation and investigation of disasters. These analytical models have potential relevance in anaesthesia. We therefore applied one of the previously described systems to the investigation of an anaesthetic accident. The model chosen describes two kinds of failures, both of which must be sought. The first group, active failures, consists of mistakes made by practitioners in the provision of care. The second group, latent failures, represents flaws in the administrative and productive system. The model emphasizes the search for latent failures and shows that prevention of active failures alone is insufficient to avoid further accidents if latent failures persist unchanged. These key features and the utility of this model are illustrated by application to a case of aspiration of gastric contents. While four active failures were recognized, an equal number of latent failures also became apparent. The identification of both types of failures permitted the formulation of recommendations to avoid further occurrences. Thus this model of accident causation can provide a useful mechanism to investigate and possibly prevent anaesthetic accidents.