A systems science perspective on the capacity for change in public hospitals.

Many types of organisation are difficult to change, mainly due to structural, cultural and contextual barriers. Change in public hospitals is arguably even more problematic than in other types of hospitals, due to features such as structural dysfunctionalities and bureaucracy stemming from being publicly-run institutions. The main goals of this commentary are to bring into focus and highlight the "3 + 3 Decision Framework" proposed by Edwards and Saltman. This aims to help guide policymakers and managers implementing productive change in public hospitals. However, while change from the top is popular, there are powerful front-line clinicians, especially doctors, who can act to counterbalance top-down efforts. Front-line clinicians have cultural characteristics and power that allows them to influence or reject managerial decisions. Clinicians in various lower-level roles can also influence other clinicians to resist or ignore management requirements. The context is further complicated by multi-stakeholder agendas, differing goals, and accumulated inertia. The special status of clinicians, along with other system features of public hospitals, should be factored into efforts to realise major system improvements and progressive change.

Surgical site infection-a population-based study in Australian adults measuring the compliance with and correct timing of appropriate antibiotic prophylaxis.

Prophylaxis for surgical site infection (SSI) is often at variance with guidelines, despite the prevalence of SSI and its associated cost, morbidity, and mortality. The CareTrack Australia study, undertaken by a number of the authors, demonstrated that appropriate care (in line with evidence- or consensus-based guidelines) was provided at 38% of eligible SSI healthcare encounters. Here, we report the indicator-level CareTrack Australia findings for SSI prophylaxis. Indicators were extracted from Australian and international clinical guidelines and ratified by clinical experts. A sample designed to be representative of the Australian population was recruited (n=1154). Participants' medical records were reviewed and analysed for compliance with the five SSI indicators. The main outcome measure was the percentage of eligible healthcare encounters with documented compliance with indicators for appropriate SSI prophylaxis. Of the 35,145 CareTrack Australia encounters, 702 (2%) were eligible for scoring against the SSI indicators. Where antibiotics were recommended, compliance was 49% for contaminated surgery, 57% for clean-contaminated surgery and 85% for surgery involving a prosthesis: these fell to 8%, 10% and 14%, respectively (an average of 11%), when currently recommended timing of antibiotic administration was included. Where antibiotics were not indicated, 72% of patients still received them. SSI prophylaxis in our sample was poor; over two-thirds of patients were given antibiotics, whether indicated or not, mainly at the wrong time. There is a need for national agreement on clinical standards, indicators and tools to guide, document and monitor SSI prophylaxis, with both local and national measures to increase and monitor their uptake.

Strong reciprocity is not uncommon in the "wild".

Guala is right to draw attention to the difficulty of extrapolating from the experimental evidence for weak or strong reciprocity to what is observed in the "wild." However, there may be more strong reciprocity in real-world communities than he allows for, as strikingly illustrated in the example of the Mafia.

Equipment to manage a difficult airway during anaesthesia.

Airway complications are a leading cause of morbidity and mortality in anaesthesia. Effective management of a difficult airway requires the timely availability of suitable airway equipment. The Australian and New Zealand College of Anaesthetists has recently developed guidelines for the minimum set of equipment needed for the effective management of an unexpected difficult airway (TG4 [2010] www.anzca.edu.au/resources/professionaldocuments). TG4 [2010] is based on expert consensus, underpinned by wide consultation and an extensive review of the available evidence, which is summarised in a Background Paper (TG4 BP [2010] www.anzca.edu.au/ resources/professional-documents). TG4 [2010] will be reviewed at the end of one year and thereafter every five years or more frequently if necessary. The current paper is reproduced directly from the Background Paper (TG4 BP [2010]).

Measures of patient safety in developing and emerging countries: a review of the literature.

CONTEXT: The World Alliance for Patient Safety was formed to accelerate worldwide research progress towards measurably improving patient safety. Although rates of adverse events have been studied in industrialised countries, little is known about the rates of adverse events in developing and emerging countries. PURPOSE: To review the literature on patient safety issues in developing and emerging countries, to identify patient safety measures presently used in these countries and to propose a method of measurably improving patient safety measurement in these countries. METHODS: Using the Medline database for 1998 to 2007, we identified and reviewed 23 English-language articles that examined patient safety measurement in developing and emerging countries. Results Our review included 12 studies that prospectively measured patient safety and 11 studies that retrospectively measured safety. Two studies used measures of structure and the remaining used process measures, outcome measures or both. Whereas a few studies used surveys or direct observation, most studies used chart audits to measure patient safety. Most studies addressed safety at a single facility. CONCLUSIONS: Investigation of patient safety in developing and emerging countries has been infrequent and limited in scope. Establishing fundamental safe patient practices, integrating those processes into routine health services delivery and developing patients' expectations that such processes be present are necessary prerequisites to measuring and monitoring progress towards safe patient care in emerging and developing countries.

Towards safer, better healthcare: harnessing the natural properties of complex sociotechnical systems.

OBJECTIVES: To sustain an argument that harnessing the natural properties of sociotechnical systems is necessary to promote safer, better healthcare. METHODS: Triangulated analyses of discrete literature sources, particularly drawing on those from mathematics, sociology, marketing science and psychology. RESULTS: Progress involves the use of natural networks and exploiting features such as their scale-free and small world nature, as well as characteristics of group dynamics like natural appeal (stickiness) and propagation (tipping points). The agenda for change should be set by prioritising problems in natural categories, addressed by groups who self select on the basis of their natural interest in the areas in question, and who set clinical standards and develop tools, the use of which should be monitored by peers. This approach will facilitate the evidence-based practice that most agree is now overdue, but which has not yet been realised by the application of conventional methods. CONCLUSION: A key to health system transformation may lie under-recognised under our noses, and involves exploiting the naturally-occurring characteristics of complex systems. Current strategies to address healthcare problems are insufficient. Clinicians work best when their expertise is mobilised, and they flourish in groupings of their own interests and preference. Being invited, empowered and nurtured rather than directed, micro-managed and controlled through a hierarchy is preferable.

An integrated framework for safety, quality and risk management: an information and incident management system based on a universal patient safety classification.

More needs to be done to improve safety and quality and to manage risks in health care. Existing processes are fragmented and there is no single comprehensive source of information about what goes wrong. An integrated framework for the management of safety, quality and risk is needed, with an information and incident management system based on a universal patient safety classification. The World Alliance for Patient Safety provides a platform for the development of a coherent approach; 43 desirable attributes for such an approach are discussed. An example of an incident management and information system serving a patient safety classification is presented, with a brief account of how and where it is currently used. Any such system is valueless unless it improves safety and quality. Quadruple-loop learning (personal, local, national and international) is proposed with examples of how an exemplar system has been successfully used at the various levels. There is currently an opportunity to "get it right" by international cooperation via the World Health Organization to develop an integrated framework incorporating systems that can accommodate information from all sources, manage and monitor things that go wrong, and allow the worldwide sharing of information and the dissemination of tools for the implementation of strategies which have been shown to work.

Incidents during out-of-hospital patient transportation.

Out-of-hospital patient transportation (retrieval) of critically ill patients occurs within highly complex environments. Adverse events are not uncommon. Incident monitoring provides a means to better understand such events. The aim of this study was to characterize incidents occurring during retrieval to provide a basis for developing corrective strategies. Four organizations contributed 125 reports, documenting 272 incidents; 91% of forms documented incidents as preventable. Incidents related to equipment (37%), patient care (26%), transport operations (11%), interpersonal communication (9%), planning or preparation (9%), retrieval staff (7%) and tasking (2%). Incidents occurred during patient transport to the receiving facility (26%), at patient origin (26%), during patient loading (20%), at the retrieval service base (18%) and receiving facility (9%). Contributing factors were system-based for 54% and human-based for 42%. Haste (7.5%), equipment malfunctioning (7.2%) or missing (5.5%), failure to check (5.8%) and pressure to proceed (5.2%) were the most frequent contributing factors. Harm was documented in 59% of incidents with one death. Minimizing factors were good crew skills/teamwork (42%), checking equipment (17%) and patient (8%), patient monitors (15%), good luck (14%) and good interpersonal communication (4%). Incident monitoring provides sufficient insight into retrieval incidents to be a useful quality improvement tool for retrieval services. Information gathered suggested improvements in retrieval equipment design and use of alternative power sources, the use of pro formae for equipment checking, patient assessment, preparation for transportation and information transfer Lessons from incidents in other areas applicable to retrieval should be linked for analysis with retrieval incidents.

Crisis management during anaesthesia: the development of an anaesthetic crisis management manual.

BACKGROUND: All anaesthetists have to handle life threatening crises with little or no warning. However, some cognitive strategies and work practices that are appropriate for speed and efficiency under normal circumstances may become maladaptive in a crisis. It was judged in a previous study that the use of a structured "core" algorithm (based on the mnemonic COVER ABCD-A SWIFT CHECK) would diagnose and correct the problem in 60% of cases and provide a functional diagnosis in virtually all of the remaining 40%. It was recommended that specific sub-algorithms be developed for managing the problems underlying the remaining 40% of crises and assembled in an easy-to-use manual. Sub-algorithms were therefore developed for these problems so that they could be checked for applicability and validity against the first 4000 anaesthesia incidents reported to the Australian Incident Monitoring Study (AIMS). METHODS: The need for 24 specific sub-algorithms was identified. Teams of practising anaesthetists were assembled and sets of incidents relevant to each sub-algorithm were identified from the first 4000 reported to AIMS. Based largely on successful strategies identified in these reports, a set of 24 specific sub-algorithms was developed for trial against the 4000 AIMS reports and assembled into an easy-to-use manual. A process was developed for applying each component of the core algorithm COVER at one of four levels (scan-check-alert/ready-emergency) according to the degree of perceived urgency, and incorporated into the manual. The manual was disseminated at a World Congress and feedback was obtained. RESULTS: Each of the 24 specific crisis management sub-algorithms was tested against the relevant incidents among the first 4000 reported to AIMS and compared with the actual management by the anaesthetist at the time. It was judged that, if the core algorithm had been correctly applied, the appropriate sub-algorithm would have been resolved better and/or faster in one in eight of all incidents, and would have been unlikely to have caused harm to any patient. The descriptions of the validation of each of the 24 sub-algorithms constitute the remaining 24 papers in this set. Feedback from five meetings each attended by 60-100 anaesthetists was then collated and is included. CONCLUSION: The 24 sub-algorithms developed form the basis for developing a rational evidence-based approach to crisis management during anaesthesia. The COVER component has been found to be satisfactory in real life resuscitation situations and the sub-algorithms have been used successfully for several years. It would now be desirable for carefully designed simulator based studies, using naive trainees at the start of their training, to systematically examine the merits and demerits of various aspects of the sub-algorithms. It would seem prudent that these sub-algorithms be regarded, for the moment, as decision aids to support and back up clinicians' natural responses to a crisis when all is not progressing as expected.

Crisis management during anaesthesia: hypertension.

BACKGROUND: Hypertension occurs commonly during anaesthesia and is usually promptly and appropriately treated by anaesthetists. However, its recognition is dependent on correctly functioning and calibrated monitors. If it is not diagnosed and/or promptly corrected, it has the potential to cause significant morbidity and even mortality. OBJECTIVES: To examine the role of a previously described core algorithm "COVER ABCD-A SWIFT CHECK" supplemented by a specific sub-algorithm for the management of hypertension occurring in association with anaesthesia. METHODS: The potential performance of this approach for each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved. RESULTS: There were 70 reports of intraoperative hypertension among the first 4000 incidents reported to AIMS. Drug related causes accounted for 59% of all incidents. It was considered that, properly applied, this structured approach would have led to a quicker and/or better resolution of the problem in 21% of the cases. CONCLUSION: Once hypertension is identified and confirmed, its rapid control by the careful use of a volatile anaesthetic agent, intravenous opioids, or rapidly acting antihypertensives will usually avoid serious morbidity. If hypertension is unresponsive to the treatment recommended in the relevant sub-algorithm, an unusual cause such as phaeochromocytoma, carcinoid syndrome, or thyroid storm should be considered.

Crisis management during anaesthesia: cardiac arrest.

BACKGROUND: Cardiac arrest attributable to anaesthesia occurs at the rate of between 0.5 and 1 case per 10 000 cases, tends to have a different profile to that of cardiac arrest occurring elsewhere, and has an in-hospital mortality of 20%. However, as individual practitioners encounter cardiac arrest rarely, the rapidity with which the diagnosis is made and the consistency of appropriate management varies considerably. OBJECTIVES: To examine the role of a previously described core algorithm "COVER ABCD-A SWIFT CHECK", supplemented by a sub-algorithm for cardiac arrest, in the management of cardiac arrest occurring in association with anaesthesia. METHODS: The potential performance of this structured approach for each the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved. RESULTS: There were 129 reports of cardiac arrest associated with anaesthesia among the first 4000 AIMS incident reports. Identified aetiological factors were grouped into five categories: (1) anaesthetic technique (11 cases with this category alone; 32 with this and one or more of the other categories, representing 25% of all 129 cardiac arrests); (2) drug related (16; 32, 25%); (3) associated with surgical procedure (9; 29, 22%); (4) associated with pre-existing medical or surgical disease (30; 82, 64%); (5) unknown (8; 14, 11%). The "real life" presentation and management of cardiac arrest in association with anaesthesia differs substantially from that detailed in general published guidelines. Cardiac rhythms at the time were sinus bradycardia (23%); asystole (22%); tachycardia/ventricular tachycardia/ventricular fibrillation (14%); and normal (7%), with a further third unknown. Details of treatment were recorded in 110 reports; modalities employed included cardiac compression (72%); adrenaline (61%); 100% oxygen (58%); atropine (38%); intravenous fluids (25%), and electrical defibrillation (17%). There were no deaths or permanent morbidity in the 11 cases due solely to anaesthetic technique. 24 of the 25 deaths occurred in patients with significant pre-existing medical or surgical disease. CONCLUSION: Because there are often multiple contributing factors to a cardiac arrest under anaesthesia, a complete systematic assessment of the patient, equipment, and drugs should be completed. The "COVER ABCD-A SWIFT CHECK" algorithm was judged to be a satisfactory process in this context and should be carried out even if the cause of the cardiac arrest is already thought to have been found. The diagnosis and management of cardiac arrest in association with anaesthesia differs considerably from that encountered elsewhere. The outcome is generally good, with most patients leaving hospital alive and apparently well.

Crisis management during anaesthesia: problems associated with drug administration during anaesthesia.

BACKGROUND: Modern anaesthetic practice relies upon the administration of a wide range of potent drugs given by a variety of routes, at times in haste or under conditions of stress. Problems associated with drug administration make up the largest group of incidents reported during anaesthesia, with outcomes including major morbidity and death. It was decided to examine the role of a structured approach to the diagnosis and management of drug problems under anaesthesia. OBJECTIVES: To examine the role of a previously described core algorithm "COVER ABCD-A SWIFT CHECK", supplemented by a specific sub-algorithm for drug problems, in the detection and management of drug problems occurring in association with anaesthesia. METHODS: The potential performance of this structured approach for the relevant incidents among the first 4000 incidents reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual performances as reported by the anaesthetists involved. RESULTS: Among the first 4000 reports received by AIMS there were 1199 reports which detailed 1361 incidents involving the use of drugs. Contributing factors named included errors of judgement (20%), lack of attention (17%), and drugs deemed to have been given in haste. Major morbidity or prolonged stay ensued in over one quarter of reports and 15 patients (1.25%) died. Drug overdose, side effects, and allergic reactions accounted for the majority of serious outcomes. CONCLUSION: It was judged that the use of the COVER-ABCD algorithm during the course of an anaesthetic, properly applied, would prevent many drug related incidents from occurring. The sub-algorithm presented here provides a systematic framework for detecting the causes of drug related incidents.

Crisis management during anaesthesia: awareness and anaesthesia.

BACKGROUND: Patient awareness during general anaesthesia has considerable potential for severe emotional distress in the patient as well as professional, personal, and financial consequences for the anaesthetist. OBJECTIVES: To examine the role of a previously described core algorithm "COVER ABCD-A SWIFT CHECK", supplemented by a specific sub-algorithm for awareness, in the detection and management of potential awareness in association with general anaesthesia. METHOD: The potential performance of this structured approach for each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved. RESULTS: Of the first 4000 reports received by AIMS, there were 21 incidents of patient awareness under general anaesthesia, and 20 of patients being paralysed while awake from "syringe swaps" before induction of anaesthesia. In 12 of the 21 reports there was an obvious cause, most commonly a low concentration of volatile agent (8 of 12 reports). The AIMS "core" crisis management algorithm would have detected the cause of awareness in all of these cases. In nine reports the course of anaesthesia appeared unremarkable, and in these the algorithm would not have been expected to detect or prevent awareness. Volatile agent monitoring would have prevented some cases of awareness, as would bispectral index electroencephalographic (BIS) monitoring. The role of BIS monitoring is still contentious, but it should be considered for high risk patients. CONCLUSION: Awareness should be minimised by thorough checking of equipment, particularly vaporisers, and frequent application of a structured scanning routine. Awareness may occur during crisis management and aftermath protocols should include patient follow up to detect and manage awareness when it occurs.

Trauma: development of a sub-algorithm.

BACKGROUND: Anaesthetists are regularly involved in the management of patients who have suffered trauma. Acute physiological derangements can occur at any time after the original injury, with life threatening sequelae. These problems may be complex in nature and evolve rapidly, often with an obscure aetiology, so a systematic approach to them is essential. OBJECTIVES: To examine the role of a previously described core algorithm "COVER ABCD-A SWIFT CHECK" supplemented by a specific sub-algorithm for trauma, in the management of anaesthesia involving trauma cases. METHODS: The potential performance of a structured approach for each of the trauma incidents among the first 4000 incidents reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual performance as reported by the anaesthetists involved. RESULTS: There were 38 relevant reports relating to trauma in the first 4000 reports to AIMS. In 39% of these there was "emergency corner cutting", although in the majority the urgency was thought to have been more perceived than real. The previously described "core" crisis management algorithm for crises during general anaesthesia was an effective means of discovering (82%), diagnosing (68%), and correcting (66%) the majority of trauma incidents. However a sub-algorithm specific for the traumatised patient was required for unusual, obscure, or complex presentations. CONCLUSION: Although the small numbers preclude validation of the sub-algorithm, it would have successfully managed all the trauma cases reported to AIMS.

Crisis management during regional anaesthesia.

BACKGROUND: Regional anaesthesia is widely used and has been considered to pose few risks once the block is established. However, life threatening problems can occur both during the establishment and maintenance phases of a regional block which require prompt recognition and management. OBJECTIVES: To examine the role of a previously described core algorithm "COVER ABCD-A SWIFT CHECK", supplemented by a specific sub-algorithm for regional anaesthesia, in the management of problems arising in association with regional anaesthesia. METHODS: The potential performance of this structured approach was assessed for each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS). RESULTS: There were 252 incidents involving regional anaesthesia, 6.3% of the first 4000 reports to AIMS. Of these, the majority (78%) involved the use of epidural or spinal anaesthesia. The core algorithm AB COVER CD properly applied, would have accounted for 45% of all problems, and is worth applying to eliminate unexpected problems unrelated to the regional anaesthesia technique itself. Hypotension and dysrhythmias made up over 30% of all incidents and accounted for all six deaths in the 252 incidents. The specific sub-algorithm for regional anaesthetic techniques accounted for 55% of all incidents: problems with delivery to the site of action, 49 cases (19%); problems with the block, 30 cases (12%); local anaesthetic toxicity, 30 cases (12%); trauma, infection, or pain, 14 cases (6%), wrong side or wrong patient, five cases (2%). CONCLUSION: Based on an analysis of 252 incidents, the core algorithm and the regional anaesthesia sub-algorithm, properly applied, would lead to swift recognition and appropriate management of problems arising in association with regional anaesthesia.

Crisis management during anaesthesia: recovering from a crisis.

Preventing harm to the patient is the priority during a crisis. After a major incident, and especially when a patient has been harmed, there are a number of matters to be addressed: the ongoing care of the patient; documentation of the incident; investigation of the root causes; completion of reports; interviews with the patient and/or the next of kin, together with apologies and expression of regret; updates and ongoing support for friends and relatives; a word of thanks to the staff involved for their assistance; formal debriefing of staff for quality assurance and possibly ongoing support and a separate debriefing for psychological purposes; ensuring that the recommendations of the root cause analysis are carried out; or, failing that, that the issues are logged on a risk register. The extent and depth of the follow up protocol depends on what, if any, harm may have been done. This may constitute completion of an incident report; notification of an equipment failure to a federal regulatory authority; arranging consultations with a mental health professional to manage psychological sequelae (especially following an awareness episode); follow up during weeks of intensive care treatment; or, when a death has occurred, a full medico-legal and/or coronial set of procedures. A precis is appended in an action card format.

Crisis management during anaesthesia: difficult intubation.

BACKGROUND: Anaesthetists may experience difficulty with intubation unexpectedly which may be associated with difficulty in ventilating the patient. If not well managed, there may be serious consequences for the patient. A simple structured approach to this problem was developed to assist the anaesthetist in this difficult situation. OBJECTIVES: To examine the role of a specific sub-algorithm for the management of difficult intubation. METHODS: The potential performance of a structured approach developed by review of the literature and analysis of each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved. RESULTS: There were 147 reports of difficult intubation capable of analysis among the first 4000 incidents reported to AIMS. The difficulty was unexpected in 52% of cases; major physiological changes occurred in 37% of these cases. Saturation fell below 90% in 22% of cases, oesophageal intubation was reported in 19%, and an emergency transtracheal airway was required in 4% of cases. Obesity and limited neck mobility and mouth opening were the most common anatomical contributing factors. CONCLUSION: The data confirm previously reported failures to predict difficult intubation with existing preoperative clinical tests and suggest an ongoing need to teach a pre-learned strategy to deal with difficult intubation and any associated problem with ventilation. An easy-to-follow structured approach to these problems is outlined. It is recommended that skilled assistance be obtained (preferably another anaesthetist) when difficulty is expected or the patient's cardiorespiratory reserve is low. Patients should be assessed postoperatively to exclude any sequelae and to inform them of the difficulties encountered. These should be clearly documented and appropriate steps taken to warn future anaesthetists.