Circulation 84,122 • Volume 23, No. 4 • Winter 2008   Issue PDF

APSF Funds 6 New Grants

Sorin J. Brull, MD

The Anesthesia Patient Safety Foundation (APSF) is pleased to report that it continues to attract outstanding applications for funding. The educational focus of the APSF includes innovative methods of education and training to improve patient safety, development of educational content with application to patient safety, and development of testing of educational content to measure and improve safe delivery of perioperative anesthetic care.

The application process continues with an electronic, on-line submission format that was introduced in 2005. The applications, as well as all the required attachments, are uploaded to the newly redesigned APSF website (, a process that facilitates the application review by members of the Scientific Evaluation Committee, improves the timeliness of response to queries, and facilitates transmission of reviewer feedback to the applicants. The Scientific Evaluation Committee members continue to modify and perfect the electronic application and review process.

This year, the Scientific Evaluation Committee is very pleased to report on several significant developments in the APSF Grant Program. The first is the total amount of funding that the APSF continues to award; similar to last year, the APSF has committed a total of $1M to support research and educational projects dedicated to patient safety.

The second development is the continued increase in the number of named awards, including the inauguration of the APSF/American Society of Anesthesiologists (ASA) President’s Endowed Research Award, utilizing funds from the APSF endowment account that was made possible by the generous financial support from ASA over the past 20 years; the APSF/Eisai, Inc. Research Award, made possible by a $150,000 unrestricted grant from Eisai, Inc.; and the APSF/Covidien Research Award, supported by a generous partial ($100,000) grant from Covidien. These new awards join the other fully funded named awards, the APSF/American Society of Anesthesiologists (ASA) Endowed Research Award ($150,000), the APSF/Anesthesia Healthcare Partners (AHP) Research Award, made possible by a $150,000 unrestricted grant from Anesthesia Healthcare Partners, and the APSF/Cardinal Health Foundation Research Award, made possible by a $150,000 grant from the Cardinal Health Foundation.

In addition to the Clinical Research and Education and Training content that is the major focus of the funding program, the APSF continues to recognize the patriarch of what has become a patient safety culture in the United States and internationally, and one of the founding members of the foundation—Ellison C. “Jeep” Pierce, Jr., MD. In his honor, the APSF Scientific Evaluation Committee continues to designate each year one of the funded proposals as the recipient of this prestigious nomination, the Ellison C. Pierce Jr., MD, Research Award.This recognition carries with it an additional, unrestricted award of $5,000.

APSF Named Awards:
APSF/American Society of Anesthesiologists (ASA) Endowed Research Award APSF/Anesthesia Healthcare Partners (AHP) Research Award APSF/Cardinal Health Foundation Research Award Ellison C. Pierce, Jr., MD, Research Award
New This Year:
The Doctors Company Foundation Ann S. Lofsky, MD, Research Award APSF/American Society of Anesthesiologists (ASA) President’s Endowed Research Award APSF/Eisai, Inc. Research Award APSF/Covidien Research Award

The APSF has also inaugurated this year The Doctors Company Foundation Ann S. Lofsky, MD, Research Award. This award is made possible by a $5,000 grant from The Doctors Company Foundation that will be awarded annually for the next 5 years to a research project deemed worthy of the ideals and dedication exemplified by Dr. Ann S. Lofsky. Dr. Lofsky was a regular contributor to the APSF Newsletter, a special consultant to the APSF Executive Committee, and a member of the APSF Board of Directors. Her untimely passing cut short a much-valued and meaningful career as an anesthesiologist and as a dedicated contributor to anesthesia patient safety. It is the hope of the APSF that this award will inspire others toward her ideals and honor her memory.

For the year 2009 (projects to be funded starting January 1, 2009), 6 grants were selected for funding by the APSF Scientific Evaluation Committee (for names of committee members, please refer to the list in this issue). The APSF Scientific Evaluation Committee members were pleased to note that they reviewed a total of 32 applications in the first round, 12 of which were selected for final review at the American Society of Anesthesiologists’ (ASA) annual meeting in Orlando, FL. As in previous years, the grant submissions addressed areas of high priority in clinical anesthesia. The major objective of the APSF is to stimulate the performance of studies that lead to prevention of mortality and morbidity from anesthesia mishaps. A particular priority continues to be given to studies that address anesthetic problems in healthy patients, and to those studies that are broadly applicable and promise improved methods of patient safety with a defined and direct path to implementation into clinical care.

Additionally, the APSF is encouraging the study of innovative methods of education and training to improve patient safety, and methods for the detection and prevention of medication errors.

The APSF Scientific Evaluation Committee convened during the ASA annual meeting on October 18, 2008, in Orlando for final evaluation and selection of the proposals. Of the 12 finalists, the members of the APSF Scientific Evaluation Committee selected the following 6 applications:

WestenskowDwayne Westenskow, PhD—Professor and Director of Bioengineering, Department of Anesthesiology, University of Utah, Salt Lake City, UT.

Dr. Westenskow’s Clinical Research submission is entitled “User Interface to Prevent Intravenous Infusion Pump Errors.

Background: The unintentional administration of incorrect medication doses through intravenous infusion pumps results in dangerous and frequent errors occurring in hospitals. A primary factor in the misuse of infusion pumps is the complicated and unintuitive nature of the user interface. The study’s objective is to improve the user interface and thereby reduce the frequency of drug administration errors. In order to accomplish this goal, the interdisciplinary team will first conduct a Failure Mode and Effects Analysis (FMEA) using 2 commercially available infusion pumps.
Implications: This analysis will describe usability issues with the interfaces. Using this information, the team will then develop a human factors-centered user interface, implemented on a touch-screen and located on the anesthesia workstation. Wireless communication will be used to remotely control infusion pumps that are located close to the patient’s intravenous access. Thus, a major source of error in the operating room will be reduced and patient safety will be improved.

In addition to receiving the requested funding of $149,938 for his project, Dr. Westenskow’s application was designated as the APSF/Cardinal Health Foundation Research Award, made possible by an unrestricted, $150,000 grant from the Cardinal Health Foundation. Dr. Westenskow is also the recipient of the Ellison C. Pierce, Jr., MD, Research Award, which consists of an additional, unrestricted award of $5,000.

RaemerDaniel Raemer, PhD—Associate Professor of Anesthesia, Harvard Medical School, and Bioengineer, Department of Anesthesia and Critical Care, Massachusetts General Hospital, and Center for Medical Simulation, Boston, MA.

Dr. Raemer’s Education and Training project is entitled
“Challenging Others in the Operating Room: Testing an Educational Patient Safety Initiative for Anesthesia Faculty.”

Background: This patient safety education project is aimed at teaching anesthesiologists a guideline and conversational technique for challenging surgeons, nurses, and other anesthesia providers when they have a concern about the actions, judgment, or behavior of others. The guideline is modified from military aviation and is known as the health care two-challenge rule. The conversational technique is modified from the organizational studies literature known as
Advocacy/Inquiry (A/I).

Objective: An experiment will be conducted to determine whether a combination of didactic presentation, cognitive aid, and a role-play exercise is effective in getting anesthesiology faculty to effectively challenge others according to the prescribed rubric. A second experiment will be conducted to determine if a simulation experience in addition to the combination of the didactic presentation, a cognitive aid, and a role play exercise are effective for anesthesiologists’ learning to challenge others according to the prescribed rubric.

The educational interventions will be assessed within a realistic simulation center with 2 experiments. First, a double-blind controlled pre-post-test experiment will evaluate whether anesthesia faculty can learn to apply the conversational technique after exposure to a didactic presentation, a cognitive aid, and a role-play. The second experiment will compare those who have had the experience of participating in the first experiment with those who have not for their proclivity and skill in challenging others in an operating room simulation. Trained blinded raters will assess their adherence to the rubric.

The authors will use qualitative coding of debriefing sessions to test the hypothesis that there are significant barriers to challenge in the operating room. A survey of the anesthesia faculty will be used to examine the hypothesis that there is a difference between espoused values and actions when challenge opportunities are presented.

Implications: If the guideline and conversational technique can be efficiently and effectively taught to an entire academic faculty, a greatly enhanced prospect exists for changing the culture in the operating room to one where patient safety challenges are expected and well received.

In addition to receiving the requested funding of $149,967, Dr. Raemer’s application was designated as the APSF/American Society of Anesthesiologists (ASA) Endowed Research Award, made possible by an unrestricted, $150,000 grant from the American Society of Anesthesiologists.

PerlasAnahi Perlas, MD, FRCPC—Assistant Professor, Department of Anesthesia, University of Toronto, Ontario, Canada.

Dr. Perlas’s Clinical Research project is entitled “Gastric Ultrasonography: A Non-invasive Tool to Determine Gastric Volume. Development of a Quantitative Model.”

Background: Pulmonary aspiration of gastric content is a source of major morbidity and mortality in the fields of emergency medicine, anesthesia, and intensive care. It plays a role in 9% of all anesthesia related deaths, and the presence of a “full stomach” is a risk factor for the development of pulmonary aspiration. However, at the present time there are no noninvasive validated tools that are immediately available at the bedside to assess gastric volume, and risk assessment to guide anesthetic management remains sub-optimal. Widely available and non-invasive, ultrasonography could be an ideal tool for this purpose.

Objective: The authors propose to conduct a prospective, observer blinded, randomized study to validate the use of portable 2 dimensional (2D) ultrasound imaging to assess gastric volume. Specifically, the authors plan to determine in a controlled experiment if there is a correlation between gastric antral cross-sectional area (GAA) as determined by 2D ultrasound, and known volumes of intragastric fluid. After a fasting period of 8 hours, 36 healthy volunteers will be randomized to ingest water in 1 of 6 volumes (0 mL, 50 mL, 100 mL, 200 mL, 300 mL, and 400 mL). They will then be scanned in a standardized fashion by 2 independent sonographers blinded to the volume ingested to identify a cross section of the antrum, and GAA will be determined.

Implications: If a correlation between GAA and intragastric fluid volume is confirmed by this study, it will be a first important step in the validation of ultrasonography as a tool to determine intragastric volume; this may ultimately lead to better evaluation of aspiration risk to guide safe anesthetic management, and will prevent a possibly life-threatening complication.

In addition to receiving the requested funding of $24,068, Dr. Perlas’s application was designated as the APSF/American Society of Anesthesiologists (ASA) President’s Endowed Research Award. Dr. Perlas is also the recipient of The Doctors Company Foundation Ann S. Lofsky, MD Research Award, which consists of an additional, unrestricted grant of $5,000.

LoftusRandy W. Loftus, MD—Anesthesiology Resident (graduated 6/08) and Critical Care Fellow (started 7/09); Department of Anesthesiology and Critical Care Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH.

Dr. Loftus’s Clinical Research project is entitled
“Assessment of Routine Intraoperative Horizontal Transmission of Potentially Pathogenic Bacterial Organisms and Associated Morbidity and Mortality.”

Background: The high prevalence of health care-associated infections and evolving amplification of bacterial resistance are major public health concerns. Intraoperative horizontal transmission (one patient to another) of pathogenic bacteria by anesthesia providers likely occurs on a daily basis in operating rooms. Intraoperative bacterial contamination combined with ineffective postoperative decontamination strategies may lead to horizontal transmission and may in part explain these issues in both acute health care and community settings. The authors have previously demonstrated both a high magnitude of intraoperative bacterial contamination and vertical bacterial transmission (anesthesia work area to patient) exist: 32% of IV stopcock sets were contaminated with bacterial organisms, which was associated with increased patient mortality. Inadequate decontamination of the anesthesia work area despite adherence to current guidelines was also demonstrated previously. This evidence suggests a high likelihood for intraoperative horizontal transmission, leading to significant patient morbidity and/or mortality.

Objective: the authors designed a prospective cohort study with the primary aim of verifying intraoperative horizontal transmission of bacterial organisms and associated morbidity/mortality. This information will then be utilized to identify and characterize breaches in both aseptic and decontamination practice, and will stimulate further work toward the development of intraoperative preventative measures. A multi-centered approach will be used to evaluate 200 randomly selected operative suites at each of 2 large academic medical centers over 3 consecutive months. The primary outcomes will include the rate of patient-to-patient (horizontal) transmission, patient (vertical) transmission, intraoperative contamination, and intraoperative cleaning efficacy. Secondary outcomes will include the species identification and antibiotic susceptibility of isolated organisms, bacterial origin, and the 30-day postoperative health care-associated infection rate and associated mortality.

Implications: This work will ultimately lead to major improvements in intraoperative aseptic practice of anesthesia providers and a reduction in hospital-wide, health care-associated infections and amplification of bacterial resistance.

In addition to receiving the requested funding of $150,000 for his project, Dr. Loftus’s application was designated as the APSF/Anesthesia Healthcare Partners (AHP) Research Award, made possible by an unrestricted, $150,000 grant from the Anesthesia Healthcare Partners.

FaragEhab S.A. Farag, MD, FRCA—Assistant Professor of Anesthesiology, Cleveland Clinic Lerner College of Medicine, Departments of General Anesthesia and Outcomes Research, Cleveland, OH.

Dr. Farag’s Clinical Research proposal is entitled
“Effects of Lactated Ringer’s Solution versus Albumin and Alpha-2 Agonist Brimonidine versus Placebo on Intraocular Pressure During Prone Spine Surgery.”

Background: Visual impairment or loss is a rare but devastating complication following neurosurgery, spine surgery, or cardiopulmonary bypass surgery. Visual loss following spine surgery has a reported incidence from 0.1 to 1%, and is expected to increase with the rise in complex instrumented spinal fusions. However, the cause of vision loss remains poorly understood; it appears to be multifactorial, and may be related to impaired perfusion of the eye or occlusion of retinal vessels due to improper positioning. Increased intraocular pressure (IOP) is suspected, among other causes. Although unproven by a well-designed, prospective study, clinical experience suggests that fluid management using colloids and topical administration of an alpha-2-agonist will reduce IOP, facial edema, postoperative morbidity, and thus the incidence of visual impairment or loss.

Objective: The authors will test the primary hypothesis that IOP and globe perfusion are better preserved with 5% albumin than lactated Ringer’s intravenous fluid replacement, and with brimonidine (an alpha-2 agonist) than placebo. The study will also test the secondary hypothesis that colloid administration decreases postoperative morbidity, time to recovery, and facial edema. This project is a prospective, randomized, pilot study of patients having prolonged, prone spine surgery in a 2 X 2 factorial design. Sixty patients (15 patients per group) will be enrolled.

Implications: This study seeks to determine whether a simple, inexpensive change in clinical practice (intraoperative use of colloid and alpha-2 agonist) can preserve IOP and thus reduce the incidence of vision impairment or loss during prolonged spine surgery.

In addition to receiving the requested funding of $150,000, Dr. Farag’s application was designated as the APSF/Eisai, Inc. Research Award, made possible by an unrestricted, $150,000 grant from Eisai, Inc.

HastingsRandolph H. Hastings, MD, PhD—Professor of Anesthesiology, Department of Anesthesiology, University of California at San Diego, VA San Diego Healthcare System, San Diego, CA

Dr. Hastings’s Education and Training proposal is entitled “Educational Value of an Adjustable and Life-Like Laryngoscopy Simulator.”

Background: Students need to perform between 20-80 direct laryngoscopies to develop a success rate of 90% or greater in normal patients. Expertise, equated to greater than 99% success, and skill with patients with a difficult airway will require a much greater practice base. Students can practice with airway simulators, but existing models are much stiffer than patients, and laryngoscopy in these mannequins is more difficult than in patients. Furthermore, the skills developed in training on one laryngoscopy trainer are specific to that particular model and do not generalize well to other anatomies, such as those of patients.

Objective: Realistic, adjustable mannequins would be a great aid in teaching direct laryngoscopy skills. The investigators have designed and built a new airway mannequin for training direct laryngoscopy, which represents an advance in adjustability and realism. The size and range of motion of key anatomic features can vary over the normal range of human anatomy to provide the student with experience in different patient sizes and shapes. The model mannequin also incorporates force and motion sensors to provide feedback on how well the trainee is performing the procedure. Since the simulator is life-like and adjustable, experience with the mannequin may reduce the number of patient laryngoscopies needed to become proficient. The goal of this proposal is to determine whether the mannequin improves training in laryngoscopy. The desired outcome would be for students to begin intubating patients with a 90% or better success rate developed solely through simulator training, thus improving patient safety.

In addition to receiving the requested funding of $150,000, Dr. Hastings’s application was designated as the APSF/Covidien Research Award, made possible by an unrestricted, partial $100,000 grant from Covidien.

In addition to the 6 research projects, the APSF has also provided a grant for $60,000 to the Society for Pediatric Anesthesia for support in creating an adverse events registry and has contracted with ECRI Institute to produce a fire safety video. Together with the 6 research awards, this represents an investment by the APSF of more than $1 million in patient safety research and initiatives.

On behalf of the APSF, the members of the Scientific Evaluation Committee wish to congratulate all of the investigators who submitted their work to the APSF, whether or not their proposals were funded. The Committee members hope that the high quality of the proposals, the significant amount of resources offered by the APSF, and the important findings that will undoubtedly result from completion of these projects will serve as a stimulus for other investigators to submit research grants that will benefit all patients and our specialty.

Dr. Brull is chair of the APSF Committee on Scientific Evaluation, member of the APSF Executive Committee, and Patient Safety Section editor for the journal Anesthesia & Analgesia in addition to being a Professor of Anesthesiology at the Mayo Clinic in Jacksonville, FL.