Factors influencing hospital implementation of acute pain management practice guidelines.

STUDY OBJECTIVE: To identify factors that may influence the implementation of acute pain management guidelines in hospital settings. DESIGN: Two questionnaire surveys. SETTING: Healthcare Association of New York State, Albany, NY. MEASUREMENT: The surveys were administered to 220 hospitals in New York State regarding their acute pain management practices and resources available. One survey was addressed to each hospital's chief executive officer (CEO) and the second survey was addressed to the clinical director of the Department of Anesthesiology or Acute Pain Service. The barriers and incentives to guideline implementation identified by CEOs were analyzed using factor analysis. Logistic regression was employed to determine predictors of guideline implementation by linking the CEOs' survey data with the clinical directors' report of guideline usage. MAIN RESULTS: According to clinical directors, only 27% of the responding hospitals were using a published pain management practice guideline. Factors predictive of guideline implementation include resource availability and belief in the benefits of using guidelines to improve quality of care or to achieve economic/legal advantages. Guideline implementation, however, does not necessarily include applying all key elements recommended by the federal Agency for Healthcare Research and Quality (formerly Agency for Health Care Policy and Research) guideline. For example, a collaborative, interdisciplinary approach to pain control was used in only 42% of the hospitals, and underutilization of nonpharmacologic therapies to control pain was widespread. Resource availability, particularly staff with expertise in pain management and existence of a formal quality assurance program to monitor pain management, was significantly predictive of compliance with key guideline elements. CONCLUSIONS: Resource availability significantly influences the implementation of pain management practice guidelines in hospital settings. Implementation is often incomplete because various factors affect the feasibility of individual guideline elements and may explain the varying results that guidelines have had on clinical practices.

Factors influencing the reporting of adverse perioperative outcomes to a quality management program.

UNLABELLED: Quality management programs have used several data reporting sources to identify adverse perioperative outcomes. We compared reporting sources and identified factors that might improve data capture. Adverse perioperative outcomes between January 1, 1992, and December 31, 1994, were reported to the Department of Anesthesiology Quality Management program by anesthesiologists, hospital chart reviewers, and other hospital personnel using incident reports. The reports were compared for preoperative health status, severity of outcome, and associated human error. Subsequently, personnel representing the various sources were surveyed regarding factors that might affect their reporting of adverse outcomes. Of 37,924 anesthetics, 734 (1. 9%) adverse outcomes were reported, 519 (71%) of which were identified by anesthesiologists, 282 (38%) by chart reviewers, and 67 (9.1%) by incident report. There was no statistically significant difference in reporting rates by anesthesiologists according to preexisting disease, severity of outcome, or presence of human error. Thirteen cases involving human error, however, resulted in disabling patient injury, with a higher rate of self-reporting for these cases (92%, P < 0.05). Rates of reporting by chart reviewers varied (P < 0.05) according to severity of patient illness and severity of outcome. Incident reports identified only 67 adverse outcomes (9.1%), but included a significantly higher percentage of the adverse outcomes involving human error (23.3%, P < 0.05). Twenty attending anesthesiologists, 15 resident anesthesiologists, 29 operating room nurses, 19 postanesthesia care unit nurses, and 6 hospital chart reviewers responded to the survey. Only the potential to improve quality of patient care influenced or strongly influenced a decision by all groups to report an adverse outcome to a peer review process. Physician self-reporting is a more reliable method of identifying adverse outcomes than either medical chart review or incident reporting. IMPLICATIONS: Physician self-reporting is a more reliable method of identifying adverse outcomes than either medical chart review or incident reporting. Reporting by chart reviewers is biased both by the severity of outcome and severity of patient illness, whereas incident reports tend to focus on human error. All groups feel compelled to report adverse outcomes when the data may result in improved patient care.

Haemodynamic stability and ketamine-alfentanil anaesthetic induction.

We have determined if alfentanil could obtund the haemodynamic instability commonly seen at induction of anaesthesia with ketamine. Five groups of ASA I and II patients received ketamine 1 mg kg-1 i.v., preceded by saline (group 1) or alfentanil 10, 20, 30 or 40 micrograms kg-1 (groups 2-5, respectively). Heart rate (HR), mean arterial pressure (AP), postoperative patient complaints and dysphoria were noted. All groups showed increases (P < 0.05) in both HR and AP after administration of ketamine, which were progressively smaller as the dose of alfentanil increased. After tracheal intubation, all groups showed further increases in HR and AP, with groups 3-5 (alfentanil 20-40 micrograms kg-1) showing significant obtundation (P < 0.05) of these increases compared with group 1. No patient in any group reported postoperative dysphoria or dissatisfaction with their anaesthetic. Ketamine 1 mg kg-1 with alfentanil 20-40 micrograms kg-1 provided statistically significant obtundation of the haemodynamic instability that is common with ketamine alone.

Monitoring and analysis of outcome studies.

Monitoring technology appears to be advancing at a rare that exceeds our ability to assess its effectiveness. RCTs are often poorly designed and lacks statistical power. Even high-quality RCTs may not provide inferences that can be generalized across all patient populations. Alternative methods of technology assessment, such as closed claims analysis, meta-analysis, and statistical process control, also have limitations. PORTs using a standard model of combined techniques are beginning to solve some of the more common methodological problems. The future of technology assessment relies on the ability to conduct large-scale cohort studies from routine practice settings. In terms of intraoperative monitors, this may require production of a complete and valid database of all monitored variables that can compared to a complete and valid database of all monitored variables that can be compared to a complete and valid database of appropriate outcome indicators. National standard for collection of data need to be developed. At this time, professional societies should focus more on developing guidelines for technology assessment than on guidelines for technology utilization.

Defining quality of perioperative care by statistical process control of adverse outcomes.

BACKGROUND: Through peer review, we separated the contributions of system error and human (anesthesiologist) error to adverse perioperative outcomes. In addition, we monitored the quality of our perioperative care by statistically defining a predictable rate of adverse outcome dependent on the system in which practice occurs and respondent to any special causes for variation. METHODS: Traditional methods of identifying human errors using peer review were expanded to allow identification of system errors in cases involving one or more of the anesthesia clinical indicators recommended in 1992 by the Joint Commission on Accreditation of Healthcare Organizations. Outcome data also were subjected to statistical process control analysis, an industrial method that uses control charts to monitor product quality and variation. RESULTS: Of 13,389 anesthetics, 110 involved one or more clinical indicators of the Joint Commission on Accreditation of Healthcare Organizations. Peer review revealed that 6 of 110 cases involved two separate errors. Of these 116 errors, 9 (7.8%) were human errors and 107 (92.2%) were system errors. Attribute control charts demonstrated all indicators, excepting one (fulminant pulmonary edema), to be in statistical control. CONCLUSIONS: The major determinant of our patient care quality is the system through which services are delivered and not the individual anesthesia care provider. Outcome of anesthesia services and perioperative care is in statistical control and therefore stable. A stable system has a measurable, communicable capability that allows description and prediction of the quality of care we provide on a monthly basis.

Hemodynamic stability and patient satisfaction after anesthetic induction with thiopental sodium, ketamine, thiopental-fentanyl, and ketamine-fentanyl.

STUDY OBJECTIVE: To examine three commonly used anesthetic induction regimens (thiopental sodium, ketamine, and thiopental plus fentanyl) and one newly described regimen (ketamine plus fentanyl) with respect to hemodynamic stability and patient satisfaction. DESIGN: Randomized, double-blind study. SETTING: University-affiliated Veterans Administration Hospital. PATIENTS: Forty-eight ASA physical status I and II patients (47 males, 1 female) scheduled for surgery requiring general anesthesia. INTERVENTIONS: Patients were randomized to one of four groups to receive intravenous injections of thiopental 5 mg/kg (Group 1), ketamine 1.5 mg/kg (Group 2), thiopental 3 mg/kg plus fentanyl 4 to 6 micrograms/kg (Group 3), or ketamine 0.5 mg/kg plus fentanyl 4 to 6 micrograms/kg (Group 4) for induction of anesthesia. MEASUREMENTS AND MAIN RESULTS: Heart rate (HR) and mean arterial pressure (MAP) were measured during anesthetic induction. Evaluation of patient satisfaction/dissatisfaction and pleasantness/unpleasantness by the Anesthesia Experience Rating (AER) was carried out the day following surgery. Groups 3 and 4 showed the least increase from their baseline values in both HR and MAP after tracheal intubation, but only Group 4 exhibited no statistically significant change in hemodynamic parameters after induction but before intubation (p < 0.05). AER showed a higher level of pleasantness in Group 3 as compared with Group 2 (p < 0.03) and higher levels of satisfaction in Groups 3 (p < 0.03) and 4 (p < 0.02) as compared with Group 2. CONCLUSION: The combination of ketamine plus fentanyl provides superior hemodynamic stability with excellent patient satisfaction.

Prolonged neuromuscular blockade following vecuronium infusion.

Administration of vecuronium by infusion is an increasingly common technique, both in the operating room and in the intensive care unit (ICU), for patients requiring prolonged neuromuscular blockade and mechanical ventilation. The major advantage of vecuronium over older neuromuscular blocking agents is its rapid excretion and intermediate duration of action. Prior to the current case report, the longest reported continuous paralysis after the cessation of a vecuronium infusion was 90 hours. A case of an 81-year-old patient with renal failure and subclinical chronic cirrhosis of the liver, who remained paralyzed for 13 days following a vecuronium infusion, is described. Intensive monitoring of neuromuscular function is recommended whenever muscle relaxants are administered by continuous infusion.

Application of the Grieshaber air system to maintain endotracheal tube cuff pressure.

The Grieshaber Air System was designed to maintain intraocular pressure during ophthalmologic surgery. It also has been used to maintain pressure in leaking endotracheal tube cuffs. It is a very useful device, especially if the intubation is difficult or the patient's position precludes replacement of the endotracheal tube. Two patients are presented in whom the system was used to maintain endotracheal tube cuff pressure.