Monday, July 22, 2013

Some of my best friends are anaesthesiologists

This column is prompted by a recent Twitter conversation that was part of a thread based on a previous blog post in which I contrasted the systems approach used for airline safety with the lack of same in many hospitals.  Warning:  You are about to read gross generalizations and stereotypes!

Carolyn Johnston, @DRCJohn, and Barbara Nelson, @SafetyNurse, made the point:

Aviation emulated successfully in anaesthesia, w 1 of best records

This prompted me to ask:

Yes, anaesthesia has led the safety movement--so why can't they help eliminate wrong site surgeries?

Perhaps it is because they are not attuned to crew resource mgmt and how to bring it abt in the ORs.

Perhaps they are overly deferential to the surgeons & revert to passivity in the face of aggression.

To which Dermot O'Riordon, @dermotor, (Surgical/Med Director in Suffolk, UK) replied:

"Overly deferential to surgeons"? You must know v different anaesthetists to those I work with!

I was being lighthearted in my last comment, but a serious question remains, and I'd like to use this post to challenge anaesthesiologists out there to give a good answer.

As I noted above, anaesthesiologists have led the safety movement in hospitals.  They introduced many innovations into their own practice--in terms of procedures, equipment safety, and simulation training.  I have found them, too, to be devoted to the science of process improvement, both in operating room settings and in critical care.  I've also found them to be modest about what they know and what they don't know, always looking to improve their own skills and the work environment.  Finally, many are excellent teachers.  In short, an exemplary group of doctors.  Indeed, they have gotten so good at what they do and cause so little harm that malpractice insurance rates for the profession have dropped and are quite reasonable compared to other specialists.  As noted here:

Decreasing anesthesiologist malpractice premiums reflect the decrease in the number of catastrophic anesthesia claims for esophageal intubation, death, and brain death.

In 1985, the average malpractice insurance premium was $36,224 per year for a $1 Million per claim/$3 Million per year policy.   By 2009, this decreased to $21,480, a striking 40% drop.

The take-home message is that anesthesia has serious risks, but those risks have decreased significantly in recent years because of improvements in monitoring and education.  Compared to other specialties, the risk of an anesthesiologist being sued is about average among American medical specialties.

Notwithstanding that, as we have discussed, the number of wrong site surgeries and other procedures in the US remains remarkably constant.  There is a clear pre-surgical protocol that is well developed that should be followed in every case to prevent this, but it is not always followed. As I noted:

The simple truth is that many doctors don't buy in to this.  I've heard of some anaesthesia writings that cite the statistics indicating the errors continue as evidence that the checklist protocol does not work!  These observers completely ignored whether the protocol was actually being followed or not.

My question is this:  Recognizing that the surgeon is the "pilot of the ship" in the OR, the anaesthesiologist has a critically important role in every case.  Why isn't this profession taking on the advocacy role for full and complete implementation of the pre-surgical checklist?  Beyond this, why doesn't this profession insisting on teaching crew resource management in the high pressure surgical environment.  In short, why isn't anaesthesia as a profession driving the broader kind of process improvement for which it has become legend in its own arena?

Standing by for your answers.


Mike Blackburn said...

Thanks for a thought provoking piece Paul.
Certainly a lot of what you have said holds merit, especially the glowing praise of anaesthesiologists. But the question remains this. Is it really the job of the anaesthesiologist to prevent wrong site surgery? I suspect you may be suffering to some extent from the commonly held misconception that we really don't do too much and could easily take on some more clinical responsibility.

The better the surgeon, the less time I have to safely negotiate induction, regional anaesthesia, positioning and not forgetting to give the antibiotics. Making me drive the surgical pause/safety checklist adds to the burden and slows down the list. Having said this, I run the list in my head before each induction. I check and double check, from Pre-med visit, to receiving patient into theatre which site is being operated on. I've unfortunately been aware of too many wrong side Neuro cases, to the extent that we told our registrars they were not to induce a Neuro patient unless they had personally reviewed the scans. Unfair. But necessary.

My concern with the WHO checklist is that if I drive it, I can easily gloss over my role in it. I sound silly asking myself aloud whether the anaesthetic machine has been checked. So we don't ask and just tick. One day, this will lead to a mistake. The checklist needs to be applied by someone who doesn't have an important role in it. This means anaesthesia, surgeon, scrub nurse. The best person? Floor nurse, or ODP. Someone who can ask the questions without personal investment in the answers.

I tried enforcing that at my old gig. But I was told it was the job of the anaesthesia provider to do the checklist. In that particular environment this represented merely one more in a long list of reasons to blame the anaesthesia dept for everything wrong in the theatre complex. And we didn't bite.

Bit of a rambling response this.. TL;DR - someone not invested in the checklists should administer them and take responsibility for them .


Paul Levy said...

Thanks very much. I may not have been clear: I wasn't suggesting that you would drive the actually checklist each time. (That's actually often in the hands of the circulating nurse, not even the surgeon.) What I'm looking for is a general commitment to help make sure the protocol is implemented in your hospital. In others words, getting it adopted by your medical executive committee as a hospital rule or regulation; helping to design the training; and helping to review compliance overall.

Anonymous said...

Thanks. Also a discussion on checklists over at 'academic life in EM'

I agree that checklist best devolved to someone who has no personal investment in outcome. However he/she also needs to have authority to call 'stop' if a checklist item fails ie to understand the importance of each step

I have seen the checklist be followed as a blind tool - no understanding of steps, just 'checklist is complete' even though anaes has answered a clear 'No' to 'has anaes machine been checked' or indicated a clear 'yes' to 'any concerns' - yet checklist continued without stopping to address issues

Not the fault of checklist...but a fault of understanding what it does when used. Form, not function.

Neville Sarkari MD, FACP said...

Paul I think you've hit up against a very important barrier to patient safety. While it's one thing for the anesthesiologists to improve their own work (and they have), it's quite another for them to "interfere" with a different specialty.

Physicians, culturally, don't get into each other's turf. It's part of that same culture that makes physicians generally lousy team players.

I think your idea has merit, but I am not sure it can get traction until the anesthesia providers have some external motivation to breach the general physician aversion to interfering with someone else's practice. That motivation could be financial incentive or even the threat of liability.

Ideally they will do it just because it's "the right thing to do" but history tells us that process takes a decade or more to work...

Carolyn Johnston(@DrCJohn) said...

Hi Paul,
A thought provoking and interesting blog- as usual, thank you. It has made me think hard about why we anaesthetists don't promote our understanding of safety outside the speciality more. As Don Berwick said, anaesthesia measures errors in parts per 1000, whilst most medical specialities do in parts per 100.

I agree wholeheartedly with previous comments- it is hard to step outside your own boundaries into other specialities- and I think anaesthesia has a particular dislike of this! There are some fabulous anaesthetic medical directors and safety advocates, but for such a large hospital speciality (the largest consultant body in most hospitals) we could do so much more.

There are some structural reasons why the patient safety agenda has worked well for us, that might not work for others:
We are certainly better resourced than most specialities (in the UK we aggressively defend our dr:pt ratio of 1:1 care). This is why I love my job: I can do the best I can for the patient in front of me, without distractions.
We can concentrate on a few core skills (as trainees, we attend *very* few clinics, ward rounds etc)- we mainly concentrate on learning to give a good anaesthetic in the operating theatre, so trainees get up to speed with basic skills quicker than other practical specialities.
The tempo of a list helps: time to watch/do, then time to talk/ debrief/plan during the surgical conduct of the case makes each day an excellent raining opportunity.

I think promotion of human factors skills around the hospital will naturally bring anaesthesia out of our hiding place in theatre- and I good thing too!

Thomas said...

You wrote:
"Recognizing that the surgeon is the "pilot of the ship" in the OR, "

Not in my OR! I run the ship, and the surgeons know it. Nothing happens in my OR without my approval and my knowledge.

Surgery never starts without the checklist (Stop for Safety...Pause for the Cause...).

We have Pre-op huddles where nursing staff members from Pre-op area and OR and CRNA review the Vital Statistics, Pt markings (surgeon does this), laterality, allergies, significant history, antibiotics, and Consent (signed, dated and timed by pt/advocate, surgeon and witness day of surgery).

Pre-incision "Pause" happens in every case.

SCIP measures are tracked and Root Cause Analyzed when failures occur (<1% now).

Everyone has bought into this at our institution and everyone assumes responsibility for his role in this. Surgeons are put on the spot by me and the VPMA if any deviation occurs.

Anesthesiologists and CRNAs working together as a team control flow and stop surgical team whenever there is a concern. Every team member knows she can interrupt or stop a procedure without retribution. It's a cultural mindset directed at Patient Safety and it is now ingrained (hardwired) into our routines. I know that we would all feel naked without it if we stopped tomorrow. The pt's see and participate in this when not under general anesthesia. No blocks or procedures occur without the same precautions.

I can tell you that this has NOT eliminated mistakes, but it has reduced them. We are still studying and revising our Protocols based on those experiences. In addition, we have had several GOOD CATCHES where the process has aborted one about to be made.

We review, amend, modify and tweak things every few months as we learn more. This process never ends.

So, in short, my profession is directly involved at our very local level, and I'm sure there are many similar stories. Nationally this has received some attention, but I agree with you, it's a little bit provincial and should become a major focus at all teaching institutions in order to instill good habits in new anesthesiologists and nurse anesthetists.

One major stumbling block is the ongoing turf battle between the two organizations which has been and will continue to be a distraction to (y)our goal of Zero Harm. This battle is an old one and is primarily a political one based on misperceptions, egos and, ultimately, money. I am fortunate to work with many outstanding nurses who understand and respect my role and our differences. This allows us to work and collaborate in a positive fashion.