When the International Committee for Prevention of Anesthesia Mortality and Morbidity (ICPAMM) met in Vienna in September, 1986, one of the aims was to hear reports from participating countries. In my report from Canada, I emphasized the geographic isolation that afflicts those of us ,north of the 49th. For example, only 16% of the population of 26,000,000 lives in six major cities. The effect on anesthetic resources and manpower of such a low density/widely distributed population has been termed the ‘tyranny of geography, and applies also to other countries, e.g. Australia. Thus, although health care practices in Canada and the United States are similar and we perceive that our anesthetic standards should be equal, differences in the financial resources of the two countries mitigate against such equivalence.
However, in general, the standard of anesthetic care in Canada is high. All anesthetists are physicians although the length of training is highly variable. The specialist degree requires internship plus four years of residency. Anesthetic equipment is also well regulated, with the Canadian Standards Association (CSA) having established the first, comprehensive standard for anesthesia equipment.
Since the ICPAMM meeting, developments have occurred in five areas of anesthetic safety.
First an anesthesia manpower survey is underway. The study was organized by the Manpower Committee of the Canadian Anesthetists Society and chaired by Dr. Charles E. Hope, Dalhousie University. It is contributing to the National Manpower Study of Physicians organized by the Canadian Medical Association and the Royal College of Physicians and Surgeons of Canada.
The purpose of the study is to determine who practices anesthesia and in what capacity (full or part time). Stage one of the study involved validating the names and specialties of physicians involved in Canada. The results for anesthesia will be given in a final report to the executive of the Canadian Anesthetists’ Society and the Association of Canadian University Departments of Anesthesia by early August, 1987. Stage two of the study will identify factors which influence future manpower requirements, e.g. lifestyle factors.
Second, in the spring of 1987, the Canadian Anesthetists Society published its Guidelines to the Practice of Anesthesia. 1 This booklet covers such topics as organization of hospital anesthesia services, privileges, residents, auxiliary help, anesthetic equipment, records, and patient monitoring. However, there is no mandatory requirement for monitors of oxygen delivery or patient oxygenation.
Third, despite the lack of requirement of oxygen monitors, many anesthetists think that the pulse oximeter is an absolute necessity. Some have felt so strongly they have held their hospitals virtually to ransom, requiring the purchase by a certain date or threatening closure of operating theaters. Other anesthetists have chosen to add the monitors to the budget, acquiring each one as SC 8,000 becomes available.
Fourth, the problem of ever-increasing malpractice insurance fees is of concern. For example, the Canadian Medical Protective Associa6on last year assessed fees of some SC 60,000,000 to cover about 48,000 doctors. 2 Yet there is a low incidence of malpractice suits, and no epidemic of litigation.
Safety Studies Underway
Fifth, there are three major studies pertaining to anesthetic safety. The International Multi-Center Study of General Anesthesia is now at the stage of final data analysis. This study involved 15 hospitals in North America (three in Canada) and examined 17,201 patients undergoing a general anesthetic. Patients were randomly assigned to receive halothane, enflurane, isoflurane or fentanyl. According to the Chief Investigator, Dr. I.B. Forrest, McMaster University, the study has shown “significant differences in risk associated with specific systemic diseases; we need to reevaluate the way we assess risk” -He added that “the ASA score is not enough” and that he is developing a new risk index, that is “more meaningful with respect to actual risk” ‘
A second study involves investigators at the University of Western Ontario (Dr. WA. Tweed), University of Saskatchewan (Dr. P. Duncan) and the University of Manitoba (Drs. Marsha Cohen and W Pope). The objective is to develop a practical system for anesthesia outcome audit, with two aims:
(a) to establish surveillance of d postoperative patients, so as to determine rates of major and minor complications and mortality, and
(b) to allow in-depth review of cases of major morbidity and mortality, using a critical incident approach.
Dr. Cohen received $US 35,000 from the Anesthesia Patient Safety Foundation for the preliminary stages of this project which is now funded ($C 187,000) by the National Health Research Development Program, under the aegis of the federal government.
The third study concerns the selection, training and assessment of anesthetic residents, by Drs. J.M. Davies, Department of Anesthesia, Foothills Hospital at the University of Calgary, and Ed Boyd, Department of Psychology, University of Calgary. As of July 1987, all anesthetic residents entering training programs will be surveyed for the next four years, with respect to demographics, attitudes to anesthesia, and psychological self-assessment. The study population also includes trainees in Eire (August, 1987) and France (May, 1988). The purpose of the study is to examine those individuals now entering the specialty. Because human error is the most important cause of poor anesthetic outcome, the root of the problem may lie with selection and training of anesthetists. Also, as inexperience, fatigue, and pressure of work all contribute to anesthetic accidents, the training programs and their directors will be similarly examined.
1. Guidelines to the Practice of Anesthesia; Canadian Anesthetists’ Society, 187 Gerrard Street East, Toronto, Ontario M5A 2E5.
2. Canadian Medical Protective Association, Eighty-Sixth Annual Report August 1987; P.O. Box 8225, Ottawa, KIG 3H7.