Volume 3, No. 2 • Summer 1988

‘Aggressive’ QA at Cook County Hospital

Lata Sabnis, M.D.

To the Editor

The concerns with liability, along with the usual tendency to let complications go without immediate discussion to an undeterminate date, leads to unfavorable trends.

At Chicago’s Cook County Hospital, we have developed an aggressive approach in assessing the quality of care that is available to our patients. Our aim is towards achieving the safest possible atmosphere for administration of anesthetics to indigent, frequently critically ill patients. This is achieved by information obtained from various quality assurance/risk management activities, structured into a coordinated program along with the other hospital departments.

First, we have a consistent reporting mechanism wherein all residents and CRNAs along with faculty report on a monthly basis their professional activities related to quality assurance in the operating room and critical care areas along with the mishaps and “near misses” they had during that month. AN this information is compiled together reflecting an in-depth search for any trend or pattern focusing towards a particular type of anesthetic mishap and/or towards particular CRNA, resident, or faculty.

There is also a mortality/morbidity reporting system wherein the following problems are automatically reported.

1. Difficult intubation

2. Reintubation

3. Aspiration pneumonia

4. Dental complications

5. Nerve damage

6. Adverse drug reaction

7. Blood/component transfusion reaction

8. Iatrogenic patient injuries

9. Wide swings in hemodynarnic and respiratory parameters

10. Unplanned patient transfer to ICU

11. Complications in PACU needing intervention

12. Cardiac arrest in operating room and recovery room

These reports are submitted to the department chairman or his designee within 24 hours of the occurrence and are discussed in the general departmental meeting, every week, wherein (apart from discussion of the case) corrective action and recommendations are made immediately. Depending on the severity of the mishap, these recommendations may be formalized in the form of a protocol which is subsequently followed and monitored for compliance.

A formal report is made on all deaths that occur within the first 48 hours of surgery or regardless of the time, if anesthesia is implicated in the demise to the patient. AD death reports are discussed immediately with the department chairman and faculty members.

A pre-operative checklist for verification of readiness of the anesthesia apparatus has been developed and is attached to the anesthesia machine. It is rigorously followed by the anesthesia personnel. This has resulted in minimizing equipment-related mishaps. Similarly, a protocol for the treatment of malignant hyperthermia is also attached to every anesthesia machine, along with an adequate supply of dantrolene sodium and cold saline solution in the refrigerator, with an MH tray available in each operating room suite.

The Departmental Quality Assurance Committee has produced guidelines for invasive monitoring in high-risk patients. The committee has also been instrumental in developing specific protocols for various situations which have been helpful in reducing mortality and morbidity in high-risk patients.

The department adheres to the guidelines set up by the Blood Bank Committee while administering blood to patients. Moreover, anesthesia equipment and monitoring devices have been included in risk management programs according to ICAH spe6fications. This has resulted in periodic testing, documentation and reporting of problems related to equipment and repair by professional technicians or by the manufacturer when needed.

In the PACU, justification for the presence of an endotracheal tube in place as well as therapy of hypertensive episodes are currently under surveillance.

There is an on-going medical record review wherein certain aspects of pre-operative evaluation, anesthetic records, and post-operative visits are reviewed monthly and compliance is compared with the expected norms. This medical record review has improved charting and record keeping, which is an important element in anesthesia practice.

The Anesthesiology Department is represented in the hospital-wide Quality Assurance Committee where problems related to patient care from all departments are discussed on a monthly basis. There is also a quality assurance hotline, set up by this committee, intending to deal with problems needing immediate attention.

With the help of these Quality Assurance activities, the department has been able to identify, evaluate, and respond appropriately in a timely fashion to problems related to patient cam

Lata Sabnis, M.D. Attending Physician and J. Antonio Aldrete, M.D. Chairman, Department of Anesthesiology and Critical Care, Cook County Hospital.