APSF Survey Helps To Establish Pre-Induction Checklist

Robert K. Stoelting, MD

The Anesthesia Patient Safety Foundation (APSF) Executive Committee believes that a Pre-anesthetic Induction Patient Safety (PIPS) checklist offers an opportunity to pursue the foundation’s vision that “no patient shall be harmed by anesthesia.” In this regard, the APSF created a 22-question survey (www.surveymonkey.com/s/3VHDTJY) to determine anesthesia professionals’ views on the perceived value of a PIPS checklist and the observations that should be part of the checklist. Those responding to the survey were asked to prioritize items for the checklist, based on what they would want to be part of a safety checklist before induction of their anesthetic (the passenger rather than the pilot).

The intent is to ultimately create a template for a PIPS checklist that could be utilized by anesthesia professionals and anesthesia groups as the basis to create a pre-anesthetic induction patient safety checklist that best fits their practices. Such a checklist is not intended to reflect the steps involved in a pre-anesthetic evaluation and formulation of an anesthetic management plan. The proposed checklist would confirm the status of those characteristics most important for proceeding with anesthetic induction (on the runway and cleared for take-off). Success of this APSF safety initiative may well be “stimulating interest and creating the traction for the national professional societies to act.”

An invitation to take the survey was sent 2,229 anesthesia professionals representing members of the American Society of Anesthesiologists, American Association of Nurse Anesthetists, and the American Academy of Anesthesiologist Assistants. Recipients were encouraged to share the survey link with colleagues who wished to express their opinions. Respondents were asked to comment on their perception of the need/value of an APSF PIPS checklist and to rank (high priority, low priority, do not include) the proposed components of the checklist. The survey was opened 738 times and completed 713 times (96.6%) with between 705 and 723 respondents answering each question.

Respondents’ years in clinical practice and characteristics of their clinical practice model are summarized in Tables 1-2. More than 80% of the respondents had been in practice more than 10 years, 46.1% characterized their clinical practice model as academic, and nearly 30% practiced in a group of 10 or more members.

Respondents were asked initially to indicate which statement(s) best reflect(s) your opinion(s) regarding the APSF’s proposal to develop the content for a template that could be utilized to develop a “PIPS Checklist” (Table 3). Clearly the majority of respondents supported the development of a checklist while many endorsed the statement that the “proposed template content should be utilized only if there is evidence to support its value.” Only 2.2% (16 respondents) concluded the “proposed template for development of a checklist is not needed and should not be considered at this time.” Comments were invited for each question and a summary of comments that urged caution and/or were not supportive for the development of a checklist are listed on Table 4.

The results of prioritizing items to place in the template are shown on Table 5. Based on these results:

The APSF is proposing a template of those items that achieved the highest priority plus a “special considerations” box based on comments from several of the respondents (Table 6).

Editor’s Note: The next step is APSF’s request for proposals (RFP) to study the implementation and performance of the proposed APSF PIPS checklist (see box announcement, contact president@apsf.org for RFP guidelines and application).

Robert K. Stoelting, MD President, APSF

Table 1: Responses to survey question, “Please indicate your years in clinical practice.”

Percent of responses

Number of responses (n-723)
Less than 5 years
9%
65
5 to 10 years
10.9%
79
More than 10 years
80.1%
579

Table 2: Responses to survey question, “Please characterize your clinical practice model.”

Percent of responses
Number of responses (n-722)
Group practice (less than 10 members)
5.7%
41
Group practice (10 to 30 members)
10.9%
79
Group practice (more than 30 members)
16.9%
122
Solo practice
2.8%
20
Academic
46.7%
337
Hospital based
13.9%
100
Other
3.2%
23

Table 3: Responses to survey question, “Please indicate which statement(s) best reflect(s) your opinion(s) regarding APSF’s proposal to develop the content for a template that anesthesia professionals and anesthesia groups could utilize to develop a “PIPS Checklist“ that is tailored to the unique needs and characteristics of their practice (check all that apply).“ (723 respondents answered this “check all that apply” question.)

 

Percent of responses
Number of responses (check all that apply)
APSF should give development of the template content for a safety checklist high priority as it will likely enhance patient safety.
51.3%
371
Our patients expect an anesthesia professional to verify the items that are included on a safety checklist so why not document our actions?
36.9%
267
There is no evidence that utilization of a checklist will likely enhance patient safety, but it is the right thing to do.
9.1%
66
A safety checklist that might be developed from the proposed template would only increase “paperwork” and is unlikely to enhance safety.
5.0%
36
A safety checklist that might be developed from the proposed template content should be utilized only if there is evidence to support its value.
32.8%
237
A safety checklist that might be developed from the proposed template content would be burdensome from a time standpoint in an already busy environment and could detract the anesthesia professional from other important patient safety practices.
6.4%
46
The proposed template for development of a safety checklist is not needed and should not be considered at this time.
2.2%
16

Table 4: Summary of comments that were not supportive of developing an APSF Pre-anesthetic Induction Patient Safety (PIPS) Checklist.

Maybe you should first pilot a study to determine if these checklists indeed improve patient safety.
There is ample evidence in aviation literature and now medical literature that checklists DO NOT solve all problems attendant to a “pretake off mode.” Often times the well-intended nature of checklists is defeated by time pressures and frequent interruptions necessitating (under ideal conditions) that the checklist be restarted at the beginning.
There is no reason to increase the complexity and cost of anesthetics unless pilot studies show the potential for enhancing safety.
We may be reaching a point of over-documentation, which elevates the risk of lawyers looking for problems that may not exist, without any real advancement in patient safety.
Little evidence that time outs and checklists have importantly impacted errors in medicine. The solution is not more of the same, but studies to determine other effective means to affect errors.
Duplication of issues already covered in existing checklists (WHO, machine checklist, SCIP protocols) and institutional/universal time out, “huddle.”
Redundant and unnecessary.
Too many checklists already (too many will lead to lower safety).
Time taken to specifically document is likely to be non-fruitful, as it will be easy to just check all boxes (electronic check boxes make this very easy).
We are converting medical care into checklist care.
Most of the issues included should have been done before entering the operating room.
The list would create mindless autobots. This is something you learned, should be second nature, and I’m tired of hearing about the airplane pilot blah blah blah.
If individualized, I think the correct checklists can improve awareness but I don’t want somebody else’s that may not be applicable to our setting.
I do agree that it adds more paperwork, and most people would breeze through the checkmarks anyway. Making providers check off a box may or may not make them more likely to actually DO those things.
Forms/checklists do not substitute for diligence and attention to detail.
These are part of what should-be-routine pre-induction review of our technical readiness. If this proceeds, it should be named more correctly—take out the word Patient from the title.
I am insulted that you think anesthesiologists would need a template to provide good care. Most of these things are basic, like airway assessment (isn’t that what we do???).
Many items you covered are part of pre anesthetic evaluation….are you just changing the name of the the evaluation….I see no need to do the pre anesthesia evaluation and then repeat it with a check list.
We need to be careful not to require too many lists, checklists, etc.
Anyone can check boxes and still not have good practice skills. Time spent “checking”cannot take away from clinical care time.

Table 5: Responses to Survey Questions to Prioritize the Content of a Template for Inclusion on a Pre-anesthetic Induction Patient Safety (PIPS) Checklist.

Template Statement

High Priority

Low Priority

Do Not Include

1. Verify suction is working.
94.4%
2.9%
2.7%
2. Verify anesthesia workstation can provide ventilation with 100% oxygen under positive pressure.
90.8%
4.1%
5.2%
3. Verify upper airway status evaluation and availablity of backup airway devices.
85.8%
7.3%
6.9%
4. Verify review of known drug allergies and consideration of possible drug interactions.
83.9%
10.1%
6.1%
5. Verify NPO status and aspiration risk.
82.2%
9.1%
8.7%
6. Verify monitors are functioning, wave forms are present if appropriate and the audible and visual alarms are set.
79.3%
13.3%
7.4%
7. Verify appropriate medications are available including resuscitation drugs.
78.5%
13.0%
8.4%
8. Verify intravenous access is appropriate and functioning.
73.2%
16.5%
10.3%
9. Time out according to existing institutional protocol.
72.2%
13.2%
14.6%
10. Verify blood available if needed.
70.6%
20.1%
9.3%
11. Verify antibiotics administered if appropriate
68.4%
21.4%
10.2%
12. Verify baseline vital signs (including BP and HR) and desirable range for these values during anesthesia.
62.9%
24.5%
12.5%
13. Verify review of medications, laboratory values and radiographic studies relevant to anesthesia.
59.1%
25.8%
15.2%
14. Verify level of surgical fire risk.
52.2%
29.2%
18.6%
15. Verify appropriate steps taken or planned for protection from peripheral nerve injury.
46.0%
36.8%
17.2%
16. Verify noninvasive blood pressure monitor is in the automatic mode.
41.5%
38.3%
20.3%
17. Verify function of operating room table including head down function.
30.0%
47.2%
22.7%

Table 6: APSF Pre-Anesthetic Induction Patient Safety (PIPS) Checklist

Suction is working.

Anesthesia workstation can provide ventilation with 100% oxygen under positive pressure.

Upper airway status has been evaluated.

Backup airway devices are immediately available.

Patient’s significant drug allergies and possible drug interactions noted.

NPO status and aspiration risk confirmed.

Monitors are functioning with appropriate waveforms.

Audible and visual alarms are set appropriately.

Appropriate medications including resuscitation drugs are available.

Intravenous access (if indicated) is appropriate and functioning.

Special considerations for this patient confirmed (may include but not limited to):

Increased risk for operating room fire.

Surgical positioning requirements.

Goals for blood pressure and/or heart rate management.

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