APSF Awards 2021 Grant Recipients

Steven K. Howard, MD

The APSF’s mission statement explicitly includes the goal to improve continually the safety of patients during anesthesia care by encouraging and conducting safety research and education. The APSF grant program has been funding safety-related grants since 1987 and this support has been integral in the careers of many anesthesia professionals.

The 2020-21 APSF investigator-initiated grant program had 33 letters of intent (LOIs) submitted with the top 16 scoring grants undergoing statistical review as well as detailed discussion among members of the Scientific Evaluation Committee. The top five scoring grants were invited to submit full proposals for final review and were discussed via Zoom virtual meeting on October 3, 2020. Two proposals were recommended for funding to the APSF Executive Committee and Board of Directors and both received unanimous support. This year’s recipients were Karen Domino, MD, from the University of Washington and May Pian-Smith, MD, from the Massachusetts General Hospital.

The principal investigators of this year’s APSF grant provided the following description of their proposed work.

Karen Domino, MD, MPh

Karen Domino, MD, MPh

Karen Domino, MD, MPh

Professor of Anesthesiology and Pain Medicine, University of Washington

Dr. Domino’s Clinical Research submission is entitled “Development and testing of a trigger tool to identify cases at risk of adverse events in non-operating room anesthesia (NORA).”

Background: Providing anesthesia services in non-operating room anesthesia (NORA) settings is a rapidly changing and growing challenge. NORA cases in the North American Clinical Outcome Registry (NACOR) increased from 28% in 2010 to 36% in 2014.1 Nearly 75% of NORA cases occurred in the outpatient setting, with sicker and older patients than those receiving anesthesia care in the operating room.1 Additionally, NORA cases were more frequently started after normal working hours (17% vs. 10% of OR cases, p<0.001).1 The combination of more procedures, patient comorbidities, suboptimal case planning, lack of standard OR equipment, isolation, and limited resources creates the high potential for adverse events (AEs) in NORA settings.2 Most of the understanding of risk associated with NORA comes from retrospective registry analysis or facility-based data.3,4

Trigger tools are an important new development in detection of adverse events.5 Trigger tool methodology uses surveillance algorithms to identify patients at high risk for an adverse event. The presence of risk factors identified via a preprocedure checklist could trigger a change in location, anesthetic plan, and additional staffing and equipment support to reduce potential patient harm.

Aims: We will adapt trigger tool technology to the NORA clinical context and to the need for prospective action to prevent patient harm. Potential triggers include patient factors (e.g., advanced age, comorbidities), anesthetic planning (e.g., lack of preoperative evaluation and preparation), procedure type and complexity, procedure site (e.g., office vs. other settings), anesthetic factors (e.g., deep sedation without ventilation monitoring; availability of equipment, supplies, and personnel), and timing of procedures (daytime hours vs. nighttime or weekend). We will develop the NORA Trigger Tool (TT) to identify cases at risk for AEs in NORA using the modified Delphi technique with an expert panel of anesthesiologists, CRNAs, NORA RNs, and proceduralists. We will utilize data from the Anesthesia Closed Claims Project with case comparison with NACOR, and a systematic literature search to inform the trigger tool. We will incorporate feedback from an expert user panel and then test user acceptance and modify the TT based results. We will prospectively test the sensitivity and specificity of the NORA TT to identify cases at risk for AEs in NORA using low-fidelity simulation.

Implications: NORA care has grown significantly over the past decade with 30–40% of anesthesia cases occurring in NORA areas. There were over 2 million NORA cases in 2019 alone, which represents only a sample of total NORA cases in the U.S. While severe AEs are rare, given the high prevalence of NORA, even a small reduction of preventable harm with pre-procedural use of a NORA TT to result in actionable changes in the anesthetic plan, will improve patient safety for a large number of patients.

Funding: $149,879 (January 1, 2021–December 30, 2022). This grant was designated as the APSF/Medtronic Research Award and was also designated the APSF Ellison Pierce, Jr., MD, Merit Award for $5,000 of unrestricted research.

The author has no conflicts of interest.


  1. Nagrebetsky A, Gabriel RA, Dutton RP, et al. Growth of nonoperating room anesthesia care in the United States: a contemporary trends analysis. Anesth Analg. 2017;124:1261–1267.
  2. Chang B, Urman RD. Non-operating room anesthesia: the principles of patient assessment and preparation. Anesthesiol Clin .2016;34:223–240.
  3. Bhananker SM, Posner KL, Cheney FW, et al. Injury and liability associated with monitored anesthesia care. A closed claims analysis. Anesthesiology. 2006;104:228-34.
  4. Metzner J, Posner KL, Domino KB. The risk and safety of anesthesia at remote locations: the U.S. closed claims analysis. Curr Opin Anaesthesiol. 2009;22:502–508.
  5. Griffin FA, Resar RK. IHI Global Trigger Tool for measuring adverse events (second edition). IHI Innovation Series white paper. Institute for Healthcare Improvement, Cambridge, MA 2009 (available on www.IHI.org).


May Pian-Smith, MD, MS

May Pian-Smith, MD, MS

May Pian-Smith, MD, MS

Associate professor of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School

Dr. Smith’s Clinical Research submission is entitled: “Trust between surgeons and anesthesiologists: developing and implementing a qualitative method to identify keys to relationship and teamwork success.”

Background: Work in the operating room (OR) is characteristically complex and requires that skilled workers are both independent and interdependent. The Institute of Medicine (IOM) has called for increased trust, respect, and transparency in communication to improve the quality of care. The important impact of the surgeon-anesthesiologist dyad to set the tone for collaboration in the OR has been highlighted by Jeffrey Cooper, PhD, in his recent article in the APSF Newsletter.1 According to relational coordination theory, colleagues can collaborate best when there is high-quality communication (frequent, timely, accurate, and problem-solving), which is enhanced by high-quality relationships (shared goals, shared knowledge, and mutual respect).2

This project is intended to gather pilot data for further study. Lingard and others have described observations of the differing perspectives between members of the OR team, but with no specific focus of that between surgeons and anesthesiologists.3 Katz has written about conflict in the OR and how to manage it, but without empirical data of the type we are proposing to gather.4

Aims: We will build on the qualitative interview-based methodology used by Cooper et al. in the Critical Incident studies5 to answer the following questions: What are key behaviors between individual anesthesiologists and surgeons that facilitate trust and collaboration or create barriers to trust and collaboration during perioperative care? Are there differences in the personal relationships between anesthesiologists and surgeons, including their perspectives and preferences, based on sex, practice setting, or whether teams are “dynamic” vs. “intact”? Are there specialty-identities and assumptions or stereotypes that individual anesthesiologists and surgeons hold toward their counterparts that may help or interfere with an effective, patient-safe working relationship?

Implications: We do not know the incidence of poor outcomes in the OR that are precipitated specifically by poor interactions between anesthesiologists and surgeons. Personal anecdotes about the OR and published studies on ICU interactions suggest the incidence of conflict is significant and that this is an important area for study and improvement. Studies have shown that optimizing teamwork has impact on the patient experience, and improving quality outcomes (such as length of hospital stay, and mitigating harm from errors and intraoperative adverse events). Improved relationships can enhance worker resilience, support joy and meaning in the workplace, and decrease the costs of workforce turnover.

This will be the first study to identify behaviors and characteristics that can engender “trust” across surgeon and anesthesiologist role-groups during perioperative care. This information will be important for defining professionalism within both specialties and will impact training methods and content. The results can inform and improve interdisciplinary and interprofessional team-training aimed at improving patient safety outcomes. Key behaviors can also be incorporated into a novel assessment tool of non-technical skills of OR personnel and such tools can subsequently be used to link observed behaviors with real patient clinical outcomes.

Funding: $149,601 (January 1, 2021–December 31, 2022). This grant was designated the APSF/ASA 2021 President’s Research Award.

May Pian-Smith, MD, currently serves on the board of directors for the APSF.


  1. Cooper JB. Healthy relationships between anesthesia professionals and surgeons are vital to patient safety. APSF Newsletter. February 2020;35:8–9. https://www.apsf.org/article/healthy-relationships-between-anesthesia-professionals-and-surgeons-are-vital-to-patient-safety/ Accessed December 12, 2020.
  2. Gittell JH, Weinberg DB, Pfefferle S, et al. Impact of relational coordination on job satisfaction and quality outtcomes: a study of nursing homes. Human Resource Management Journal. 2001;18:154–170.
  3. Lingard L, Espin S, Whyte S, et al. Communication failures in the operating room: an observational classification of recurrent types and effects. BMJ Qual Saf. 2004;13(5):330–334.
  4. Katz JD. Conflict and its resolution in the operating room. J Clin Anesth. 2007,19:152–158.
  5. Cooper JB, Newbower RS, Long CD, et al. Preventable anesthesia mishaps—a human factors study. Anesthesiology. 1978,49:399–406.


The APSF would like to thank the above researchers and all grant applicants for their dedication to improve patient safety.


Steven Howard, MD, is a professor of anesthesiology, perioperative and pain medicine at Stanford University School of Medicine, staff anesthesiologist at the VA Palo Alto Health Care System and the outgoing chair of the APSF’s Scientific Evaluation Committee.

The author has no other conflicts of interest.