Over 300 Australian anesthetists met in Sydney on June 18, 1988 to consider the present status of the “Patient safety” issue, to gain insight into changes in American standards of practice as presented by Dr. E.C. Pierce, Jr., and to discuss the “Monitoring During Anesthesia” document endorsed by the Board of the Faculty of Anesthetists, Royal Australian College of Surgeons, in early June 1988.
Continuing review by Professor Ross Holland of the deaths reported to the New South Wales Anesthetic Mortality Committee, reinforced that the majority (over 90%) of deaths attributable to anesthesia were avoidable and that the utilization of monitoring apparatus, and in particular oximetry, could have influenced and possibly reduced such mortality by 40%.
Professor Holland observed that the majority of deaths however remained due to human error in the form of inappropriate assessment, techniques, and management, and that a large proportion of the problems arose in the recovery unit. He encouraged the continuation of monitoring modalities well into the recovery phase. He confirmed that of the monitoring modalities available, oximetry more than all other forms, may have prevented mortality in the post-operative period.
Dr. Richards Morris reviewed the impact of oximetry on clinical practice and untoward events, observing that oximeters remain vastly better than the “clinical signs” involved in detecting hypoxia and that they are generally accurate and reliable. However, their performance may be diminished by movement, poor perfusion, and the presence of confounding factors e.g. methylene blue and carbon monoxide. He noted that clinical practice has improved with the presence of oximeters, if practice is quantified by the number of “de-saturation” events occurring intra and post-operatively. Oximeters can be readily demonstrated to be cost effective especially when recorded to diminish the incidence of “high payout” catastrophic events.
Professor Bill Runciman, Adelaide, presented the Faculty’s recommendations, which primarily state that the basis of patient care is by clinical monitoring by a vigilant, appropriately trained and constantly present medical practitioner.
The patient must have the following monitored: Circulation by detection of a pulse and measurement of arterial pressure, Respiration by continuous observation of rate and depth, and adequacy of Oxygenation by appropriate frequent observation.
Such clinical monitoring should be supplemented by:
1) An automatically activated oxygen supply failure alarm must be fitted.
2) An inline inspired oxygen analyzer should be in continuous use.
3) A pulse oximeter must be exclusively available for every anaesthetized patient.
4) Electrocardioscopy and a temperature monitor should be available for every anaesthetized patient.
5) A carbon dioxide monitor and a neuromuscular function monitor should be available for those patients where it is indicated.
An overall program was regarded as necessary within each department for professional and insurance carrier satisfaction. This included: (i) a mechanism to review and diminish “risk factors” associated with anesthetic delivery; and (ii) establishment of a functional quality assurance committee within a department, which developed specific anesthetic quality indicators and actively detected, evaluated, and reported on morbidity and modes of practice.
Dr. Purcell is Chairman, N.S.W. Anesthetic Continuing Education Committee.