Anesthesiology Safety and Quality for Patients, Hospitals, and The Community

Educational Objectives

The goal of this program is to improve safety scores and quality of care in anesthesiology. After hearing and assimilating this program, the clinician will be better able to:

1. Provide evidence for checklists reducing medical errors.
2. Choose care practices which reduce rates of pressure injuries.
3. Identify patients at increased risk for postoperative cognitive decline.
4. Relate poorly controlled pain during surgery to postoperative opioid use.
5. Use feedback from anesthesia registries to improve care.

Summary

Epidemiological history: Florence Nightingale was one of the first medical statisticians; she focused on urban hospital development, analyzed death rates within hospitals to identify outliers, and evaluated perceived care; the structures of hospitals and wards were examined to identify areas not optimally constructed

Codman: maintained and analyzed records for all patients; developed the first morbidity and mortality meetings; considered the “father of surgical quality”

Donabedian: a physician and epidemiologist who pioneered health services research and systems management; described an integral relationship between structure, process, and outcomes

Medical quality timeline: Nightingale's notes on hospitals were released in 1863; the American College of Surgeons (ACS) was founded in 1913; the Joint Commission on Accreditation of Hospitals (JCAH) was founded in 1951; legislation introducing Medicare/Medicaid was signed in 1965; Dr. Donabedian published “evaluating the quality of medical care” in 1966; the role of JCAH expanded in 1980; the ACS started the National Surgical Quality Improvement Project database in 1994

History of anesthesia: anesthetics were first used in the 1840s; some form of general anesthesia may have been available previously

China: Tuo — performed complex and invasive abdominal surgeries in China in 200 AD; patients slept for days after ingesting a pre-surgical potion; Seishū — a surgeon in the 1820s; tried to recreate recipes for anesthetics; the recipes contained high amounts of anticholinergics and opioids

Ether: Long developed ether anesthesia for dental procedures; Martin delivered the first highly publicized ether anesthetic in the 1840s

Anesthetic records: the first anesthetic records were kept by Codman; Henson published a landmark article titled “The relative safety of anesthetics”; the article was the first study to calculate a death rate during surgery with anesthesia; spinal anesthesia was found to present more risk than inhalational anesthesia; anesthetics that are no longer used, eg, ethylene, may be safe; patients died because of the lack of capacity for monitoring and treating complications; improvement in ventilators and anesthesia delivery systems were seen in the 1950s; use shifted from complex inhalers and insulators to integrated multi-component systems

Improvements in care: Ibsen originated with collaborators the idea of the modern intensive care unit; Beecher and Todd published a study titled “The study of death” in 1954; the paper established the anesthesia death rate to be 1:1560 cases, and higher in cases where curare was used; muscle relaxant use was related to higher mortality, because not all patients were intubated or ventilated; spinal anesthesia improved because of better monitoring techniques; newer inhaled anesthetics evolved, eg, halogenated anesthetics; a TV news episode about anesthesia in 1982 prompted the formation of the Anesthesia Patient Safety Foundation (APSF); the closed claims database became available, which facilitated the analysis of adjudicated cases

Pulse oximetry: developed in the 1930s; Aoyagi and Handa brought pulse oximetry to medicine; routine use of pulse oximetry is one of the most important medical safety developments; the 1980s was a period of rapid growth in anesthesiology; the ASA published standards on monitoring shortly after the APSF was founded; oxygenation, ventilation, circulation, and temperature objectives were monitored; ASA standard I mandated anesthesiologists remain present for the administration of anesthetic drugs; publication in the 2000s of “First, Do No harm” and “Crossing the Quality Chasm” from the Institute of Medicine reported that >3% of hospitalizations are associated with adverse events and predicted that 50,000 to 100,000 people die per year because of preventable medical errors; procedural bundles, scorecards, and checklists were introduced to reduce complication rates

World Health Organization (WHO): started the “Safe Surgery Saves Lives” campaign in 2009 to implement safe surgical practices and procedures to reduce the incidence of adverse events in the perioperative period; surgical safety extends beyond the technical aspects of surgery; involves communication among all participants; the Surgical Safety Checklist was published by WHO; closed claims databases show decreasing mechanical ventilator and gas delivery-related claims; anesthesiologists are responsible for providing safe care to patients in the operating room, but anesthesiologists impact outcomes beyond the operating room

Quality in anesthesia care: the Institute of Medicine defines medical quality through 6 balanced domains; prioritization of domains depends on particulars of cases; the Centers for Medicare and Medicaid Services (CMS) allows anesthesiologists to define their own quality standards through reporting choices; a merit-based pay system makes anesthesiologists accountable for performance, reports to CMS, and links a portion of reimbursement to quality metrics; CMS aims to reduce physician reimbursement, previously with a sustained growth reduction model, and now with a quality-metric based model; quality is evident to patients; quality care must be safe, but safe care may be delivered without all elements of quality; anesthesiologists should strive for quality while maintaining safety; hospitals define quality based on expected and unexpected outcomes, which are associated with throughput, reimbursement, and patient satisfaction; unexpected postoperative complications can be managed through reducing variability in care during the perioperative period, especially within similar patient categories and surgical procedures

Dedicated perioperative anesthesia services: institutions may have dedicated perioperative anesthesia services to address issues, eg, postoperative pain control, safe medication administration; high risk surgical encounter clinics may be formed within institutions to optimize certain patients; the protocol is designed in conjunction with surgeons; facilities lacking the resources to implement an entire bundle can still benefit from implementation of some elements; anesthesiologists can target proper fluid management, prophylaxis and treatment of postoperative nausea and vomiting, temperature control, blood glucose control, and opioid sparing techniques to optimize homeostasis and contribute to overall patient recovery and potential for goal-directed discharge

Surgical site infections: multiple strategies are available to prevent surgical site infections, but none are 100% effective; recommendations from the World Health Organization include the structure of the operating room, devices and equipment used, nursing and surgeon preparations, increasing fraction of inspired oxygen, protocol for blood glucose control, goal-directed fluid therapy, and maintaining control of the operating room

Pressure injuries: a significant issue in post- and perioperative care; measures must be taken to provide the best care to reduce the risk for pressure injuries; non-modifiable risk factors include age, body mass index, and surgical risk; modifiable risk factors include surgical positioning, maintaining hemodynamics, optimizing fluid management, and reducing use of vasopressors

Postoperative pulmonary complications: assessment may be challenging; complications include atelectasis, respiratory failure, pneumonia, bronchospasm, and pleural effusion; anesthetic management has been associated with complications, but most were related to surgical complexities and patient comorbidities; factors related to ventilator management, tidal volume, positive end-expiratory pressure (PEEP), and fluid management may be related to pulmonary complications; atelectasis may develop immediately on induction, especially in patients with severe obesity; a rate of atelectasis of 10% to 11% was reported in patients with severe obesity 5 to 20 min after induction; risk for atelectasis is reduced with use of single recruitment maneuvers and PEEP

Intraoperative ventilation in patients with obesity: pulmonary complications may be reduced through use of, eg, optimal tidal volume, PEEP, mode of ventilation; mobilization of patients shortly after surgery may be preferred; patients who use continuous positive airway pressure and bi-level positive airway pressure at home should continue use in the hospital

Home recovery: return to activity level, cognitive ability recovery, opioid use and dependence, and avoiding long-term complications should be focused on during recovery at home

Survival: elective surgery in patients >65 yr of age has a 1-yr mortality rate of 8%; frailty is a major risk factor for mortality; consider preoperative optimization and mitigation of risk, especially in elective cases

Major adverse cardiac events (MACE): the 30-day incidence of MACE is high because of a risk for perioperative myocardial injury of >10%; injury is usually related to elevated troponin levels (typically asymptomatic); elevated troponin levels are associated with increased risk for negative long- or short-term outcomes; measurable cardiovascular death rate, arrhythmia rate, acute heart failure, spontaneous or ischemic myocardial infarction, and all-cause mortality of 3% in 30 days have been reported in patients after noncardiac surgery; reducing heart rate with β-blockers is not recommended for all patients undergoing surgery, according to one study; patients with elevated heart rate and low blood pressure are at increased risk for myocardial injury and higher mortality; mean arterial pressure of ≤55 mm Hg for prolonged periods may increase risk for acute kidney injury, myocardial injury, and overall organ injury score

Postoperative cognitive decline (POCD): a major problem in the geriatric population, especially in patients with underlying neurocognitive disorders; patients may have increased recovery time, complications, and may not return to their baseline cognitive state; understanding risk factors is essential; patients with advanced age and prior neurological compromise are at higher risk for POCD; patients with postoperative complications, eg, respiratory complications, infections, reoperations, are at higher risk; however, actions may be taken in the operating room which decrease risk; using targeted electroencephalography-guided anesthesia may be helpful; intravenous anesthetics, limiting volatile anesthetics, and optimally managing pain without opioids may reduce the risk for POCD; use of multiple anesthetic techniques increases risk for POCD

Opioids: prescription opioid use is considered one of the biggest drivers of opioid dependence and long-term opioid use; opioid administration is regulated by law; optimize management through reduced-opioid use strategy; anesthesiologists must use other techniques in addition to opioid avoidance; poorly controlled pain can be problematic and may increase the use of opioids after surgery; opioid-sparing techniques should be balanced with multimodal pain control with opioid use limitation; anesthesia may performed without opioids, but acute surgical pain must still be treated

Environmental impact of anesthesiology: volatile anesthetics are released into the atmosphere; environmental benefits of conservation for volatile anesthetics has long term benefits; increased use of plastics, disposable goods, and medications (especially if not properly disposed of) affect the environment

Care quality: structure and process impact outcomes; clinicians may ask patients about outcomes and experiences; scores and scales have been validated for patients to report outcomes and experiences; outcome scoring may not be used at high enough rates; surgical groups may use scoring to optimize their practices; institutions are becoming more involved in generating survey data for feedback for their providers; usefulness of data is not clear for anesthesiologists; types of survey questions include complaints of symptoms (eg, hoarseness, pain at injection or surgery site, drowsiness), overall satisfaction, care in general, treatment, pain control, and emergency information

Outcome reporting: surgeons receive reports of individual patient outcomes; the report analyzes the performance of the surgeon based on various measures; the surgeon may see which areas offer opportunity for improvement; similar measures may be applied to anesthesiology, eg, preoperative medications, intraoperative management, pain control; the National Surgical Quality Improvement Program (NSQIP) breaks down surgical patients into groups and provides complication rates and trends; the Anesthesia Quality Institute maintains the National Anesthesia Clinical Outcomes Registry (NACOR) which submits data to CMS for feedback for operational improvement

Patient safety indicators (PSI): an underappreciated hospital quality measure; CMS PSI 90 consists of 10 scores related to care of surgical patients and is reported back to CMS and other reporting centers; PSIs include pressure ulcer rate, iatrogenic pneumothorax rate, postoperative acute kidney injury, and postoperative respiratory failure

Multicenter Perioperative Outcomes Group (MPOG): takes data from millions of cases from ≈70 practices, groups, and institutions to generate practice and performance data which is fed back to institutions

Readings

Bajwa SJ, Jindal R. Quality control and assurance in anesthesia: A necessity of the modern times. Anesth Essays Res. 2014;8(2):134-138. doi:10.4103/0259-1162.134480; de Vries EN, Eikens-Jansen MP, Hamersma AM, Smorenburg SM, Gouma DJ, Boermeester MA. Prevention of surgical malpractice claims by use of a surgical safety checklist. Ann Surg. 2011;253(3):624-628. doi:10.1097/SLA.0b013e3182068880; Fukase T, Dohi T, Koike T, et al. Long-term impact of β-blocker in elderly patients without myocardial infarction after percutaneous coronary intervention. ESC Heart Fail. 2022;9(1):545-554. doi:10.1002/ehf2.13715; Gan TJ. Poorly controlled postoperative pain: prevalence, consequences, and prevention. J Pain Res. 2017;10:2287-2298. Published 2017 Sep 25. doi:10.2147/JPR.S144066; Gomes ET, Carbogim FDC, Lins RS, Lins-Filho RLM, Poveda VB, Püschel VAA. Effectiveness of supplemental oxygenation to prevent surgical site infections: A systematic review with meta-analysis. Rev Lat Am Enfermagem. 2022;30:e3648. Published 2022 Oct 7. doi:10.1590/1518-8345.6106.3648; Kim JM, Lee H, Ha T, et al. Perioperative factors associated with pressure ulcer development after major surgery. Korean J Anesthesiol. 2018;71(1):48-56. doi:10.4097/kjae.2018.71.1.48; Koster KL, Björklund C, Fenner S, et al. Patient satisfaction with divided anesthesia care. PatientenzufriedenheitmitgeteilterAnästhesiebetreuung. Anaesthesiologie. 2023;72(2):97-105. doi:10.1007/s00101-022-01192-x; Lagier D, Zeng C, Fernandez-Bustamante A, et al. Perioperative pulmonary atelectasis: Part II. Clinical implications. Anesthesiology. 2022;136(1):206-236. doi:10.1097/ALN.0000000000004009; McGain F, Muret J, Lawson C, et al. Environmental sustainability in anaesthesia and critical care. Br J Anaesth. 2020;125(5):680-692. doi:10.1016/j.bja.2020.06.055; Nicolescu TO. Quality trends in healthcare and their impact on anesthesiology. Rom J Anaesth Intensive Care. 2017;24(1):47-52. doi:10.21454/rjaic.7518.241.qty; Paredes S, Cortínez L, Contreras V, et al. Postoperative cognitive dysfunction at 3 months in adults after noncardiac surgery: A qualitative systematic review. ActaAnaesthesiol Scand. 2016;60(8):1043-1058. doi:10.1111/aas.12724; Smilowitz NR, Gupta N, Ramakrishna H, et al. Perioperative major adverse cardiovascular and cerebrovascular events associated with noncardiac surgery. JAMACardiol. 2017;2(2):181-187. doi:10.1001/jamacardio.2016.4792; Vsevolozhskaya OA, Manz KC, Zephyr PM, Waters TM. Measurement matters: changing penalty calculations under the hospital acquired condition reduction program (HACRP) cost hospitals millions. BMC Health Serv Res. 2021;21(1):131. Published 2021 Feb 10. doi:10.1186/s12913-021-06108-w; Yang X, Huang X, Li M, Jiang Y, Zhang H. Identification of individuals at risk for postoperative cognitive dysfunction (POCD). Ther Adv Neurol Disord. 2022;15:17562864221114356. Published 2022 Aug 16. doi:10.1177/17562864221114356.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Henson was recorded at the American Osteopathic College of Anesthesiologists Mid-Year Seminar, held virtually March 16-17, 2024, and presented by the American Osteopathic College of Anesthesiologists. For information on future CME activities from this presenter, please visit https://www.aocaonline.org/. Audio Digest thanks Dr. Henson and the American Osteopathic College of Anesthesiologists for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 2.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 2.00 CE contact hours.

Lecture ID:

AN663101

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.