To the Editor
The Belgian Anesthesia Patient Safety Steering-Committee
Reprinted from Acta Anaesth. Belg., 1989, 40, 231-238 with permission.
Mortality and morbidity related ID anesthesia is a continuous threat to the practice of anesthesia (Lauwers, 1978). Fortunately anesthetic mortality has decreased from a death rate of 3.7 per 10,000 anesthetics (Beecher and Todd, 1954) to figure 0.76 per 10 000 anesthetics (Tiret et. al., 1986). Even a low figure of 0.066 per 10 000 was mentioned (Eichhorn, 1989).
Elements which contributed to this fortunate decrease of anesthesia-related mortality are multiple. The continuous presence of an anesthesiologist in the operating room during the entire diagnostic or surgical procedure is very important, and allows a patient linked individual observation. The more elaborate education and experience of the anesthesiologists, witch increased over the last decade, and comprises now in Belgium a ha-tune training of 5 years, is a further important factor. The gradual adaptation of monitoring devices, to improve anesthesia care and to decrease the incidence of anesthesia-related patient injuries is the third crucial factor. Although monitoring is routinely encouraged for every patient under anesthesia, it is even still more mandatory if the vital functions of the patients are disturbed or threatened. Therefore nowadays diverse monitoring devices must be available at all times in each anesthesia location. Nevertheless we may not forge that monitoring and monitoring devices are not end targets, but highly sophisticated means to improve anesthesia cam and that only with a judicious use of them we will reach the final patient safety goal. This also implies that according to the practical situation, which the anesthesiologist is facing, he must decide himself which monitoring he is using and depending on the patients’ condition minimal monitoring equipment can be extended. Clinical vigilance remains essential because even highly sophisticated monitoring devices such as capnographs and oximeters may occasionally not function correctly and may even fail to reveal dangerous circumstances!
Standards for patient monitoring were first adopted in 1985 by the Harvard-affiliated hospitals and later in 1986 encouraged by the American Society of Anesthesiologists. Them is now already provisional strong suggestion that after the application of these standards anesthesia mortality decreased (Eichhorn, 1989). Standards have also been adopted by the Association of Anesthetists of Great Britain and the French Society of Anesthesia. Already for years in the Netherlands strict rules of anesthesia monitoring exist. It is therefore timely that Belgian Standards for patient safety in anesthesia now are published. Months of discussion amongst the professors of anesthesiology of the Belgian Universities, together with representative of the scientific and professional anesthesiology societies of Belgium preceded the present publication.
The adopted standards have to be met at the latest in January 1995. Indeed for practical reasons each individual hospital, or anesthesia location cannot immediately comply with these rules.
The present standards apply only to anesthesia practice done by anesthesiologists for diagnostic and/or surgical procedures. Of course ” is only part of the professional activities of the anesthesiologist. For the practice outside the traditional operating theatre and diagnostic examination room, other standards have still to be elaborated in the future. This concerns activities in the delivery unit, pain clinic, acute pain treatment or intensive care unit.
The Board of Directors of the Belgian Society of Anesthesia and Reanimation.
- Beecher H. K., Todd D. P., A study on the deaths associated with anesthesia and surgery based on a study of 599, 548 anesthesias in ten institutions 1948-1952 inclusive, ANN. SURG., 140, 2-35, 1954
- Eichhorn J.H., Cooper J.B., Cullen D.J., Maier W R., Philip J.H., Seeman R. G., Standards for patient monitoring during anesthesia at the Harvard Medical School, JAMA, 256, 1017-1020,1986
- Eichhorn 1. H., Prevention of intraoperative anesthetic accidents and related severe injury through monitoring ANESTHESIOLOGY, 70,572-577,1989
- Lauwers P., Anesthetic death, ACTA ANAESTH BELG., 29, 19-28, 1978
- Tiret L, Desmont J.J. Halton F., Vourc’h G, Complications associated with anesthesia. A prospective study in France, CAN. ANAESTH SOC. J., 33, 336-344, 1986
The anesthesiologists of the Belgian Society for Anesthesia and Reanimation and of the Belgian Professional Association of Specialists in Anesthesia and Reanimation have undertaken to define safety standards for anesthesia or sedation of patients, undergoing diagnostic or surgical procedures.
These safety standards should be effective by the first of January 1995.
The standards are divided as follows
Part One: Minimal standards
Section I General principles.
Section II Departmental organization.
Section III Assistance for the anesthesiologists. Minimal standards.
Section IV General equipment. Minimal standards.
Section V Monitoring equipment. Minimal standards.
Section VI Transport of the patient.
Section VII Post-anesthetic care unit (PACU). Minimal standards.
Section VIII Maintenance of equipment in anesthesia and PACU.
Part Two: Safety recommendations for the practice of anesthesia
Section I General organization.
Section 11 Preoperative visit.
Section III Basic controls.
Section IV Perioperative patient control.
Section V Transport of the patient.
Section VI Post-anesthetic care unit.
Section VII Anesthesia records.
Section VIII Quality control
Section IX Continuing educational program
In circumstances where the application of the standards in whole or in part is not possible, the reason is noted on the anesthesia record. A lack of staff, equipment or organization is not an acceptable reason.
Until the standards become effective (the transitional period), the chief of a department of anesthesiology, taking into account all local relevant circumstances, submits a written plan listing the requirements for compliance with the new standards, to the hospital management.
During the transitional period, application of the standards receive priority.
1. in workstations outside the main operating theatre area (these locations are frequently poorly equipped),
2. in locations where close observation of the patient is difficult, or where fighting is frequently lowered, or where adequate oxygenation of the patient is more difficult to assess or control.
During the transitional period, it should be useful for the departments of anesthesia to have an independent audit performed by qualified professionals from outside the hospital. In the case of a lawsuit, a previously held audit may provide evidence of the correct running of the department and of the efforts that are being, and have already been, made to comply with the standards.
The standards will be revised in accordance with scientific advances. The upgraded rules will be published in scientific and professional journals.
In a case where hospital management makes it impossible for the anesthesiologist to put these standards into practice despite a duly written request, the anesthesiologist can no longer be held responsible for the consequences. In this situation, the chief anesthesiologist immediately requests an audit.