Editor’s note: In each APSF Newsletter, a pertinent publication from the anesthesia patient safety literature will be summarized. Suggestions for future issues are welcome.
Eichhorn IH, Cooper IB, Cullen DI, Maier WR, Philip JH, Seeman RG. Standards for patient monitoring during anesthesia at Harvard Medical School. JAMA 2%:1017-1020,1986.
Many questions have been raised about the preventability of major anesthesia accidents. Such questions by Harvard’s malpractice self-insurance entity led a risk management committee in the Harvard Department of Anesthesia (nine departments including academic, specialty, and community hospitals) to examine past claims and incidents. This study suggested that more meticulous monitoring of anesthetized patients would significantly help prevent such anesthesia accidents.
Basic monitoring practices were thought by the committee to be so important as to be mandatory, not simply suggestions or guidelines. Therefore, the concept of creating “standards of practice’ was adopted so that each hospital would require its members to institute a minimum level of monitoring for every patient anesthetized. Because of the desirable S” of accident prevention and apparently sufficient communication with the practitioners who would have to live with them, the standards for monitoring were developed and then accepted with minimal dissension.
The standards specify constant presence of an anesthetist during an nesthetic, blood pressure and heart rate measurement at least every five minutes, and continuous display of an EKG tracing. Most importantly, continuous monitoring of ventilation and circulation each by one or more listed methods is the core of the program. Also required are a breathing system disconnect monitor during mechanical ventilation, an oxygen analyzer on every anesthesia machine, and the ready availability of a means to measure the patient’s temperature The various caveats throughout the set of standards indicates that thought about unusual or extenuating circumstances was incorporated. These preserve the emphasis but make the standards realistic in day-to-day practice.
The response of most of those practicing anesthesia hopefully will be that they have been doing all these things for years. Nonetheless, nationwide insurance data (including preliminary reports from the American Society of Anesthesiologists’ dosed claim study) show absence of even such basic monitoring in many accident cases. Guaranteeing minimal monitoring during anesthesia may yield improved overall outcome by decreasing preventable mishaps, which appear to represent a significant fraction of anesthesia-related morbidity and mortality.
Epidural analgesia (as distinct from anesthesia) for labor and pain management is excluded from the standards for alleged practical reasons. Even in the absence of equivalent data on risks in these settings, it seems logical and consistent with the thrust of the paper that some type of minimal monitoring should be mandatory here also.
The authors correctly note that physicians are individuals long accustomed to defining their own destiny and unaccustomed to having others tell them what to do. However, societal forces trying to control health care costs and assure the outcome of care threaten external imposition of potentially unpalatable authority. The Harvard monitoring standards are an example of a creative response generated from within the profession which may inspire others. The American Society of Anesthesiologists recently adopted national monitoring standards (see page 1) covering many of the same points in a different format. However, Eichhom et al. urge replication of the process rather than the standards themselves. There remain multiple other issues in anesthesia that could benefit from attention by such committees within many institutions and groups.
Abstracted by Thomas E Hombein, M.D., Chairman, Department of Anesthesia, University of Washington, Seattle