31 de março de 2011

Monitoring the monitors—beyond risk management

British Journal of Anaesthesia 97 (1): 1–3 (2006) / doi:10.1093/bja/ael139

Monitoring, to health care professionals and in particular anaesthetists, usually means the continuous measurement of patient variables over time. However, the word monitor derives from the Latin monere (to warn) and modern English dictionaries include almost a dozen different connotations. These range from an observational warning or recording device (or individual) to audiovisual terminology, a senior school pupil and types of lizard or warship. In a similar way, the term monitor in anaesthesia, critical care, pain management or perioperative medicine actually encompasses a variety of technologies that address diverse but overlapping aspects of anaesthesia and medical care. Over the past two decades, these technologies have advanced greatly and the availability of monitoring devices has multiplied exponentially. This has occurred in conjunction with the developments in electronics, computing, information technology and mobile communications, which has characterized the past 20 yr. This issue of the British Journal of Anaesthesia is based on the symposium held in March 2006 and organized jointly by The Royal College of Anaesthetists and British Journal of Anaesthesia. The articles range from the interaction between humans and machines, new and emerging technologies and their application not only inside and outside the operating room but also at the extremes of environments where medical care may be needed.

In order to fully understand the panoply of modern monitoring, we should remember the progress made in the very recent past. When exactly instrumental monitoring started in anaesthetic practice is unclear, but the core guiding principle of the profession of anaesthesia has always been ‘For some must watch, while some must sleep’ (Hamlet, W. Shakespeare). ‘Vigilance’ has been the motto of the ASA since it was founded in 1905. While some of us can still remember the days up to the mid-1980s when this vigilance, in practical terms, was restricted to an anaesthetist’s utilization of senses by inspection or palpation for clinical signs (observation of the patient’s colour with a finger on the pulse), there has been convincing evidence that our human senses by themselves, are not reliable in keeping ‘eternal vigilance’. As early as 1947, it was shown that observation could not detect cyanosis reliably. In the 1980s, studies proved the inadequacy of reliably detecting hypoxia or adequacy of ventilation by clinical means alone, and it became clear that more sophisticated aids were required. Advances in technology made it possible to introduce pulse oximetry and capnography into clinical practice and it was immediately evident that these monitors would supplement the deficiencies in our clinical abilities. These devices were incorporated into the recommendations for standards of monitoring by ASA and the Association of Anaesthetists of Great Britain and Ireland. Studies in the 1990s convincingly proved that the use of pulse oximetry and capnography were crucial in the prevention and early detection of many unwanted events, and that they significantly reduced the number of critical incidents. For this reason, in the UK by the mid-1990s, the recommended monitoring standards came to be considered mandatory for safety and risk management, and lack of these during anaesthesia had become indefensible in cases of medical litigation. However, it must be remembered that in some parts of the world these standards may still be considered an unaffordable ‘luxury’. [...]

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17 de março de 2011

Anesthesiology Education: A New Emphasis

Why medical schools and residency programs are having to rethink their approach to training future anethesiologists.
By Mojca Remskar Konia, M.D., and Kumar G. Belani, M.B.B.S., M.S.

Anesthesiology has long been closely linked to surgery. Major advances in surgical care have prompted major advances in anesthesia care and vice versa. Thus, for years training in anesthesiology focused mainly on intraoperative care. Now, however, both advances in surgery and changing dynamics in health care delivery are dictating that anesthesiologists play a broader role—that they serve as perioperative physicians.1 As a result, anesthesia training programs have had to change. The American Board of Anesthesiology has offered subspecialty certification in critical care since 1985 and in pain management since 1991. (Both are components of perioperative medicine.) There are now fellowships in cardiothoracic anesthesia and pediatric anesthesia, and the Board is considering allowing specialty certification in these fields as well. Recently, the Society for Ambulatory Anesthesia approved a competency-based curriculum for a fellowship program in ambulatory and office-based anesthesia that includes training in business management, leadership, and informatics, as anesthesiologists often serve as directors of free-standing facilities.2 Both the specialty and the programs that educate providers are having to evolve in order to adapt to changing times.3,4

One change in medical practice that has had a huge impact on the practice of anesthesiology is the patient safety movement. Anesthesiology has long been a champion of patient safety. The Anesthesia Patient Safety Foundation was the first multidisciplinary organization to focus solely on uncovering, analyzing, and eliminating risks to patients including those related to human error. To equip future anesthesiologists to further that work, anesthesiology training now stresses the value of dynamic patient monitoring, the importance of verification of drug dosing, better communication among members of the surgical team, and other practices that minimize the risk of error and improve the quality of care. In addition, as hospitals and health systems have looked for practical solutions to safety concerns that are unique to their environment, educational programs have sought to help students and residents learn the skills involved in process and quality improvement. Another change in medical practice that has had an impact on anesthesiology education is an emphasis on interdisciplinary teamwork and communication.5 Teamwork is especially important in high-acuity environments such as critical care units and emergency and operating rooms. Thus, in the department of anesthesiology at the University of Minnesota, we are exploring ways to teach students and residents how to be valued team members. We have found one of the most effective ways of doing this is through simulation.

Simulation as a Teaching Tool
Anesthesiologists were among the first in medicine to use computerized simulation, including interactive, high-fidelity mannequins, to train medical students, residents, and faculty. One advantage of simulation training is that it exposes students to realistic clinical situations without posing any risk to a real patient. Participants can learn techniques and practice new skills without feeling pressed for time. With repetition, they can develop proficiency that they can then transfer into real clinical environments.6 In addition, students can see what happens when a situation goes awry and what they can do about it without putting the patient’s life in danger.

Our department has designed its own exercises that replicate real-world clinical scenarios. In addition, our residents take part in simulation exercises developed by other departments including surgery, critical care, emergency medicine, interventional radiology, pediatrics, and neonatology. Thus, simulation is a key tool for exposing students and residents to the unique skills of other professionals and helping them understand the importance of interdisciplinary teamwork.

We also use simulation to teach providers what to do in emergencies such as when a fire breaks out in the operating room. We have developed a simulated exercise about fire during tracheostomy that explores factors that might lead to this problem, actions that can decrease the likelihood of it happening, and what to do if such a complication occurs. We include attending physicians, medical students, nurses, anesthesia technicians, and others in this exercise.

Another benefit of simulation exercises is that they show students, residents, and physicians the importance of clear and respectful communication in high-pressure situations. Communication is especially important in settings such as the operating room, where decisions often must be made quickly.

Changing the Culture
Our department is striving to make a culture shift. We are trying to move from having a single-specialty focus to having an interdisciplinary view. We are making changes to adapt to what is happening in the practice of anesthesiology and in medicine as a whole. We know future anesthesiologists will be perioperative medicine physicians who will need to understand their role in promoting patient safety and preventing problems. They will need to be able to work as members of teams and to communicate clearly and effectively with the other physicians and staff involved in a patient’s care. To ensure that these things happen, anesthesia training programs must continue to change with the times. MM

Mojca Remskar Konia is program director and Kumar Belani is a professor in the department of anesthesiology at the University of Minnesota.

References
1. Adesanya AO, Joshi GP. Hospitalists and anesthesiologists as perioperative physicians: are their roles complementary? Proc Bayl Univ Med Cent. 2007;20(2):140-2. 
2. Coursin DB, Maccioli GA, Murray MJ. Critical care and perioperative medicine. How goes the flow? Anesthesiol Clin North America. 2000;18(3):527-38. 
3. Beattie C. Training perioperative physicians. Anesthesiol Clin North America. 2000;18(3):515-25, v-vi. 
4. Shangraw RE, Whitten CW. Managing intergenerational differences in academic anesthesiology. Curr Opin Anaesthesiol. 2007;20(6):558-63. 
5. Boulet JR, Murray DJ. Simulation-based assessment in anesthesiology: requirements for practical implementation. Anesthesiology. 2010;112(4): 1041-52. 
6. Nishisaki A, Keren R, Nadkarni V. Does simulation improve patient safety? Self-efficacy, competence, operational performance, and patient safety. Anesthesiol Clin. 2007;25(2):225-36.


15 de março de 2011

Artigo: Does Patient Position Influence the Reading of the Bispectral Index Monitor?

Anesth Analg 2009;109:1843–6

Abdullah M. Kaki, FRCPC
Waleed A. Almarakbi, MD†

BACKGROUND: Bispectral index (BIS) was developed to monitor patients’ level of consciousness under general anesthesia. Several factors have been found to alter BIS readings without affecting the depth of anesthesia. We conducted a study to assess the impact of changing patients’ position on BIS readings.

METHODS: General anesthesia was administered to 40 patients undergoing minor surgeries. Patients were kept in neutral position (supine) for 15 min and BIS readings, mean arterial blood pressure, heart rate, end-tidal carbon dioxide, and end-tidal isoflurane were recorded. Patients were then shifted to head-down position (30°), neutral position, and lastly head-up position (30°) each of 15-min duration and the data were recorded.

RESULTS: There was a significant increase in BIS values in head-down position (median 47 vs 40) compared with neutral position, whereas head-up position significantly decreased BIS (39 vs 41) compared with neutral position (P 0.05).

CONCLUSION: Changing a patient’s position significantly affects the BIS values, which might affect the interpretation of anesthetic depth.

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11 de março de 2011

Artigo: Effects of Intraoperative Reading on Vigilance and Workload during Anesthesia Care in an Academic Medical Center

Anesthesiology 2009; 110:275–83

Jason M. Slagle, Ph.D.,* Matthew B. Weinger, M.D.†

Background: During routine cases, anesthesia providers may divert their attention away from direct patient care to read clinical (e.g., medical records) and/or nonclinical materials. The authors sought to ascertain the incidence of intraoperative reading and measure its effects on clinicians’ workload and vigilance.

Methods: In 172 selected general anesthetic cases in an academic medical center, a trained observer categorized the anesthesia provider’s activities into 37 possible tasks. Vigilance was assessed by the response time to a randomly illuminated alarm light. Observer- and subject-reported workload were scored at random intervals. Data from Reading and Non-Reading Periods of the same cases were compared to each other and to matched cases that contained no observed reading. The cases were matched before data analysis on the basis of case complexity and anesthesia type.

Results: Reading was observed in 35% of cases. In these 60 cases, providers read during 25 3% of maintenance but not during induction or emergence. While Non-Reading Cases (n = 112) and Non-Reading Periods of Reading Cases did not differ in workload, vigilance, or task distribution, they both had significantly

higher workload than Reading Periods. Vigilance was not different among the three groups. When reading, clinicians spent less time performing manual tasks, conversing with others, and recordkeeping.

Conclusions: Anesthesia providers, even when being observed, read during a significant percentage of the maintenance period in many cases. However, reading occurred when workload was low and did not appear to affect a measure of vigilance.

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9 de março de 2011

Segurança na Saúde

Este artigo é uma indicação do Dr. Francisco Gondin, anestesiologista do Rio de Janeiro e seguidor do blog Anestesia Segura. O artigo foi publicado originalmente na seção Opinião do site do jornal O Globo.

Segurança na Saúde

WALTER MENDES e WILSON SHCOLNIK

Há uma crescente preocupação com a qualidade dos serviços oferecidos na área da saúde, em virtude de erros continuamente propagados pela mídia. O debate sobre erros na área de saúde e a segurança dos pacientes tem como referência o relatório do Instituto de Medicina da Academia Nacional de Medicina dos Estados Unidos da América, intitulado ”Errar é humano” (“To err is human“), de 1999.

A segurança dos pacientes tem merecido a atenção da Organização Mundial da Saúde. Erros representam também um grave prejuízo financeiro. No Reino Unido e na Irlanda do Norte, o prolongamento do tempo de permanência no hospital devido a erros custa cerca de dois bilhões de libras ao ano, e o gasto anual do Sistema Nacional de Saúde com questões litigiosas associadas a eventos adversos é de 400 milhões de libras. Nos EUA, os custos anuais estão estimados entre 17 e 29 bilhões de dólares anuais.

A maioria dos erros que podem afetar os pacientes são cometidos por pessoas capazes de realizar as tarefas com segurança, que já as realizaram várias vezes no passado. Eles enfrentaram consequências pessoais significativas.

A pergunta que importa é: “Será que o erro ocorrerá de novo?” Cabem duas principais abordagens: a de caráter pessoal tem longa tradição e focaliza os erros ou violações de procedimentos por pessoas diretamente envolvidas nas operações (médicos, enfermeiros e auxiliares de enfermagem). Ela pressupõe que esses erros são originários de processos mentais aberrantes, como esquecimento, desatenção, falta de motivação, descuido, negligência, imprudência e cansaço.

As medidas para se combater tais erros são dirigidas principalmente à variabilidade indesejável do comportamento humano. Os seguidores dessa abordagem tendem a tratar os erros como assuntos morais, assumindo que coisas ruins ocorrem com pessoas ruins. A abordagem pessoal tem sérias deficiências, e o apoio a ela não contribui para o desenvolvimento de instituições de saúde mais seguras.

Já a abordagem sistêmica parte da premissa de que seres humanos são falíveis e erros acontecem, mesmo nas melhores organizações. Os erros são considerados como consequências, ao invés de causas, não sendo atribuídos à perversidade da natureza humana. Isto inclui a recorrência de erros ocasionados por “armadilhas” no local de trabalho ou nos processos organizacionais. As medidas para evitar esses erros são baseadas na suposição de que, embora não se possa modificar a condição humana, podem-se modificar as condições nas quais os humanos trabalham. Quando acontecem, o importante não é saber quem os cometeu, mas verificar como e por que as defesas falharam.

Outro componente já bem conhecido em outras indústrias, como a da aviação e a nuclear, e tido como de fundamental importância no setor de saúde, é o “fator humano”. Não se pode esperar alto desempenho de trabalhadores da saúde provenientes de outros plantões, cansados, apressados, famintos ou estressados.

Nenhuma organização de prestação de serviços de saúde pode se excluir das iniciativas para minimizar a ocorrência de erros. Mudanças em sua cultura, estrutura e processos são condições necessárias para garantir a segurança dos clientes, dos resultados e, por que não, a sua própria existência.

Na medida em que os dados sobre erros se tornam públicos, o papel dos consumidores deverá ser de grande importância para promover mudanças de atitudes e investimentos na melhoria dos serviços. Por outro lado, é preciso que os consumidores e contratantes entendam e aprendam a valorizar os serviços que continuam investindo em qualidade e segurança.

Para que se alcance a satisfação e a confiança da sociedade é preciso adotar sistemas transparentes, abertos, onde a informação seja dividida livremente e as responsabilidades de cada parte sejam amplamente aceitas.

Encarar a questão dos erros não como uma fatalidade ou responsabilidade individual, mas como parte do planejamento dos sistemas de trabalho e exercício profissional, parece ser o melhor caminho na Saúde.

WALTER MENDES é médico e pesquisador da Escola Nacional de Saúde Publica Sergio Arouca (Fiocruz/ RJ). WILSON SHCOLNIK é médico e diretor da Sociedade Brasileira de Patologia Clínica e Medicina Laboratorial.


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2 de março de 2011

Do I need more monitoring to improve outcome

Acta Anaesth. Belg., 2007, 58, 235-241

R. M. GROUNDS

The treatment objective for any anaesthetist and intensivist is to provide the best and most safe treatment for any patient in his or her care. However, sometime this may be a little difficult or confusing if there are different alternatives for the recommended treatment. The patients clearly hope that they will have trouble-free safe anaesthesia and post-operative recovery. The single most important element of monitoring during anaesthesia must be the continuous presence of an expert anaesthetist for the duration of the operation, and so long as that doctor is awake, observant and competent then the patient is likely to have the best possible chance of survival. Over the last 25-50 years there is good evidence that the incidence of death directly attributable to anaesthesia has fallen but despite this the overall incidence of death following surgery has remained almost unchanged. In the mid -1950’s a number of studies suggested that the postoperative mortality solely associated with anaesthesia was approximately 1 in 2500 (1, 2, 3). However over the following 30 years this death rate was greatly reduced, due partly to improvements in anaesthesia but more probably due to the training and quality of anaesthetists and so by 1987 Buck et al. (4) showed that the death rate following surgery attributable solely to anaesthesia was now approximately 1 in 185000. Much more significantly their study showed that the post operative death rate due solely to the quality of surgery had not changed in the same 30 years. Furthermore the United Kingdom confidential enquiries in to peri-operative deaths (NCEPOD) 1989-2003 showed that surgical post operative mortality hardly changed in the 20 years following the publication of the first report (5, 6). In a recent study by PEARSE and colleagues (7) the outcome following surgery in 94 National Health Service hospital in the United Kingdom over a five year period. They studied over 4 million operations. 2.8 million of these were elective surgery and 1.2 million were emergency operations. The death rate following elective surgery was 0.44% and the death rate following emergency surgery was 5.4%. However, this information was more shocking as it was possible from the data they studied to identify a group of patients who were at high risk of post operative death (within 28 days of surgery) and post operative complications and in this group the post operative death rate was 12.3%. Furthermore, this accounted for 83.8% of all postoperative deaths even though they only account for 12.5% of hospital surgical admissions. This same population, of high risk patients, had a prolonged hospital stay (median 16 days inter-quartile range 9-29 days). Worse they also found that less than 15% of these patients at high risk from death and serious complications post-operatively were admitted to an intensive care unit or high dependency unit or other critical care area after their operation. Given that there are 3.3 million surgical operations per year in the United Kingdom and approximately 25,000 deaths then from this and the data from PEARSE et al. (7) it would suggest that there are approximately 166,000 patients per year undergoing major surgery who are a high risk of post operative death or serious complication. With 250 hospitals in the UK then this would mean that the average general hospital undertakes major surgery on 12-13 patients per week who are at high risk of post operative death or serious complications. [...]

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