Anesthesia Safety Workshop Also Considers Cost of Efforts

J.S. Gravenstein, M.D.

The Anesthesia Patient Safety Foundation sponsored a workshop entitled “SAFETY AND COST CONTAINMENT IN ANESTHESW’ on February 27 and 28, 1987. It was hosted by the Department of Anesthesiology of the University of Florida in Gainesville and made possible through a generous grant from Ohmeda.

Anesthesiologists, attorneys, insurance experts, manufacturers, and risk managers were the invited participants. While these professionals interact on many levels, they rarely have an opportunity to exchange ideas and they often find it difficult to understand what motivates their counter parts. The workshop was divided into several sections:

Setting the Stage

Dr. W.K. Hamilton from the University of California, San Francisco opened the meeting with a timely reminder that we have permitted anesthesia care to become more expensive than is necessary for the sake of safety. Then, Dr. F.W. Cheney from the University of Washington in Seattle offered an overview of the risks associated with anesthesia. He and his coworkers concluded from an analysis of national closed-claims data that better monitoring might reduce anesthetic mortality.

While we know that anesthesia does cause some patient morbidity and mortality, even among the healthy undergoing minor operations, it is most difficult to obtain scientifically valid statistics on the true incidence. What is known about the epidemiology of anesthesia as it relates to untoward events and the problems that have plagued workers in this field was discussed by Dr. I.B. Forrest from the University of Ontario.

The Financial Impact of Adverse Outcomes in Anesthesia

Perspectives on the financial impact of adverse outcomes in anesthesia were discussed from several vantage points: by an economist, Kay Plantes, by Mark D. Wood from the St. Paul Insurance Company, by James C. Rinaman, Jr., an attorney, by Burt A. Dole, president of Puritan-Bennett and, finally, by Dr. P.O. Bridenbaugh from the University of Cincinnati. Workshop participants were astonished to learn how far the consequences of a mishap in the operating room can reach and that some of the ripples are magnified into veritable tidal economic waves affecting not only physicians and their insurance premiums but also the companies and their ability to finance research and development. The section vividly demonstrated the extraordinary interdependence between the anesthesiologist, the hospital, and the many professionals who supply equipment, insurance, or defense when necessary. Dr. Bridenbaugh echoed points raised by Dr. Hamilton: defensive medicine may increase the cost of anesthesia care; but there is hardly an anesthetic that could not be rendered less expensive without sacrificing safety.

How to Improve Safety in Anesthesia

A section dealing with ways to improve the safety of anesthesia was introduced by I.E Holzer, an attorney-risk manager from Boston who described the role of the risk manager. What anesthesiologists can do to adopt safe practice patterns was reported by Dr. S.M. Duberman from New York. Dr. E.C. Pierce, President of the Anesthesia Patient Safety foundation, recounted the steps for greater safety taken by the profession as a whole. That the efforts of physicians and risk managers cannot exist in vacuum was the theme of W. Cleverley, a health care finance specialist from Columbus, Ohio, and G. Gore a defense lawyer from Cleveland, Ohio. Dr. Cleverley discussed the difficulties faced by hospitals in a world of changing rules under which capital expenses and operating costs are reckoned. Mr. Gore reminded the audience that adherence to fairly simple and well recognized rules will not only increase safety but also make it easier to defend an anesthesiologist in court, should that ever become necessary.

How Financial Decisions Touching on Safety are Made

In a section on financial decision-making for safety and thrift, the different players in the field were introduced to each other. Each makes demands on the other and each faces constraints. The budgeting process and the competition among clinical department heads in a large-for-profit hospital, was described by Mr. I.M. Birnbaum, an attorney and administrator from New York. The budgeting process in a large for-profit hospital chain was explained by Mr. P. Powell from Humana. The clinician’s perspective was presented by Dr. J.H. Modell from the University of Florida.

What everyone wants to know, namely how insurance premiums are set was revealed in a spirited exposition by Mr. P. Sweetland from the New Jersey Physicians Insurance Company. Finally, Mr. T. Gibson from Ohmeda explained why and how the financial impact of safety in anesthesia pinches the manufacturer. The-physicians who were unaware of the repercussions faced by manufacturers learned about the far-reaching consequences of clinical successes and failures in the operating room.

Current Issues that Affect Safety and Cost

Several speakers addressed timely problems that confront the specialty. Dr. R.J. Kitz from Harvard presented the history of the Harvard and ASA minimal monitoring standards and viewed these within the framework of other general standards that have long since become almost unnoticed in the fabric of our society. Of course, standards have their drawbacks and these were enumerated by Dr. R.K. Stoelting from Indianapolis. Even the best standards on monitoring will contribute little to safety if the clinician on the scene cannot respond to signals presented by the monitors. Thus, education of anesthesiologists and nurse anesthetists may play as big or bigger a role than standards for monitoring. Dr. A.L. Schneider from Hershey, Pennsylvania reported on the current educational requirements in anesthesia which appear impressive, until one looks at performance standards well established in other fields, such as the aviation industry. Captain B. Beach from Eastern Airlines informed the audience on the exacting and well established performance standards in commercial aviation. The contrast was striking.

Commercial aviation, of course, is used to another standard that has no equal in medicine, that of the so-called black box. These devices record both the voices in the cockpit and much data on the performance of the plane and its engines during a flight. In anesthesia, we still generate hand written records that may or may not contain the information that would allow not only timely clinical decisions but also an analysis of problems, should an adverse outcome have resulted because or in spite of the efforts of the medical team. Dr. C.E. Whitcher from Stanford described the first generation of automated anesthesia record systems and their advantages, while Dr. 1. Eichhom from Boston detailed the potential disadvantages, including the concern that the automated record keeping devices has engendered among some who fear automatically recorded artifacts and, also, the absence of both helpful and incriminating data on the hand-written anesthesia chart.

The Proceeding Will Be Published

All participants praised the opportunity to exchange opinions and concerns with representatives from different fields, all of whom contribute in their own way to anesthesia and the safety of patients. The proceedings of this unique workshop will be published by Butterworths and the date of publication will be announced in the APSF Newsletter.

Dr. J.S. Gravenstein, University of Florida, is on the Executive Committee, Anesthesia Patient Safety Foundation.