International Anesthesia Safety Group Hears Worldwide Perspective at World Congress

The new International Anesthesia Patient Safety Foundation was officially launched at the 12th World Congress of the World Federated Societies of Anesthesiologists in Montreal, Canada, in early June with a symposium featuring presenters from around the world. These anesthesiologists represented a wide variety of countries, practices, and institutions, but all were focused on improving anesthesia patient safety for their home countries. One of the strongest and clearest messages resulting from the day’s presentations was the significant differences between the anesthesia patient safety issues facing the wealthier, highly industrialized, high-tech (often Western) countries and those seen in the less economically advantaged countries of the developing world. Summaries of their talks, provided by the speakers, are presented here.

Egypt Anesthesiology in a Developing Country: Factors Influencing Income by Amr Montasser, Cairo Anesthesiologists spend their time in four main areas: training & learning, clinical practice, research & academic activities, and administrative duties. Each of those areas have a bearing on their income and, therefore, on the time spent in each area – with marked difference between the developing and developed countries. In developing countries, anesthesiologists spend their time in learning their practice as follows:

– In the first 5-10 years of their career: 60-90% of their time is spent in learning to obtain Diplomas & Certificates for Recognition – In the next 10 years: 0-30% of their time is spent in learning to improve their practice skills – From then on: only 0%-20% of their time is spent in learning-only what is needed for clinical survival. The rest of their time is devoted to clinical practice mainly doing private cases to improve their income to maintain a decent or acceptable living. As for research and academic activities, after obtaining specialization degrees, they occupy only a minor part of anesthesiologists’ time due to the low salaries in academic departments. In developing countries, no one can maintain his living doing only academic work. The administrative work is really hell in developing countries, where anesthesiologists do everything themselves; secretarial help is either not available or useless, funds are limited and no one listens to their needs. The lack of prominence of the specialty makes this awful situation even worse. In summary, as important as anesthesia patient safety is, in developing countries, efforts to identify and address safety issues very often must, by definition, assume a secondary role in a profession where basic survival is still a fundamental goal.

The Philippines The Politics of Setting Standards by Florian R Nuevo, MD, Clinical Faculty Department of Anesthesiology University of Santo Tomas Manila There is a triad in the politics of setting standards: the public or the patient, the physicians or the specialty group, and the legislative or administrative body. A strong demand from any of these sectors can initiate the move to develop practice policies ­ either in the form of guidelines or as formal standards. In the field of health care policy making, it is the physicians’ specialty group that takes the lead in the development of standards of care. The main objective is most often to improve the quality of care they provide, and/or to resolve any observed poor outcome or problems in its own field of specialization. For the legislative body or any administrative office to take particular interest in health care standards, the impetus is more on the perspective of reduction in expenses on so-called “unnecessary” health care. This is quite understandable inasmuch as there are always budgetary constraints in any health care program. It is also quite sad to note that an effective catalyst for the government sector to take a lead in setting up health standards is when an accident, either a morbidity or a mortality, has befallen an influential citizen or a prominent government official while undergoing a medical treatment or intervention. The public or the patients are the least expected to demand standards in heath care because of their lack of proper information. The underprivileged citizens should (would) just be contented with whatever health service they get because they have no money. Nevertheless, there are some advocacy groups who would demand standards in health care to ensure that the people shall be given equal attention and treatment, no matter what social class they would belong to, and/or simply to get the most of their money’s worth. Support systems, however, must exist to achieve the sustainability in setting of healthcare standards. There must be a strong promotive support for continuing education, financial assistance, and competent manpower. At best, it is the physicians’ specialty or interest groups that can provide these support systems needed. Linkages amongst specialty groups and advocacy groups are vital. There must also be an open, two-way communication between these groups and government or legislative body in order to get better sanctions and ensure a broader base of implementation. Physicians, on one hand, would hesitate to have legal sanctions imposed on failure to comply, simply because of the fact that medicine is never an exact science. Another important consideration to support the setting up or development of standards is the economic state of affairs in a community. The economy affects the level and quality of health care delivery in a locale. The standards of practice in developed countries cannot be applied in similar scenarios in developing nations. Several questions then come to our minds. Do we really need to have standards in anesthesia care? In what areas (equipment, technique, drugs, manpower) of our specialty do we need these policies? How encompassing should these be? Who can be tasked to make credible, well-studied, unbiased standards? Would these standards ensure delivery of safe and quality anesthesia care? How can these standards be universal? Or should these policies be flexible enough to be adopted in the existing (and widely differing) levels of care? In health care delivery systems, it is the desire to contain unnecessary care and costs that serve as a stimulus in the development of standards in health care: ” Do more with less.” Physicians must ensure that the patient has been rendered the optimum medical care without overspending on too many works-ups, medications and the like. However, we must realize that the issue of unnecessary costs is an interplay of several factors, such as patient preferences, tradition, peer pressure, and the personalities of the physician and patient. Thus, practice policies represent only a beginning in containing these unnecessary care. In anesthesia, the driving force behind the development of standards can be summarized in two words-PATIENT SAFETY. Much of the anesthesia work we do is to facilitate surgery. No further insult or injury must happen during these procedures. Our patients would demand a risk-free anesthetic experience. Hence in anesthesia, the practice policies (guidelines or standards) must be capable of differentiating between patient management scenarios in terms of good outcome perioperatively. These scientific data are, indeed, very difficult to gather. All the more, this makes the development of standards in anesthesia tedious and difficult. Standards when used as voluntary guides to clinical management were found to be rather disappointing. That is: compliance is rather poor. Whereas, when the standards are linked to guidelines in reimbursement of professional fees, or for medico-legal purposes, and in peer-review and quality assurance processes, these areas to which standards are applied become effective tools in the implementation of healthcare practice policies. How can standards work? A major key point to make standards work is the process by which these standards are developed. It refers not only on the people involved in writing these policies, but more on the methodology used to arrive at the prescribed standards. Integral to this process of setting standards is an appreciation and recognition of the historical background of the standards that have already been made. How can standards work? There must be a dedicated system of monitoring their implementation. We must analyze why some standards are not followed at all. Is this because such standards are beyond one’s capabilities in that arena? Or is it because these standards do not make a difference in outcome anyway? Again, an effective strategy in the implementation of standards is a close collaboration with other specialty groups, like the anesthesiologists with the surgeons, and/or with obstetricians. Through this cooperation, common areas of concern can be addressed through a more holistic approach. Another way is to link with government payments, with the reimbursement of professional fees, and/or with accreditation bodies. And of course, it is most desirable to have the support of the national government, particularly if the government shall uphold the standards recommended by the specialty and advocacy groups. Each one of us has the moral obligation to take an active part in this aspect of health care policy making. We cannot all be the “authors” of these standards, but we can all play the role of “followers.” It is only by observing and applying these guidelines and standards that would pave the way for these policies to undergo further evaluation, warranted reviews, and timely revisions. We, the anesthesiologists, shall compose the sound structural framework needed in the politics of setting standards. We must not allow those outside the realm of our profession to design and determine our standards for us. We have to be vigilant so that laws, which foster patient safety, are the ones promulgated by the legislative bodies in our countries. Practice policies present a powerful solution to the complexity of medical decisions. These can bring the clinicians to a collective consciousness, and also put order, direction, and consistency to our everyday clinical decision-making. Let us put our acts together in order to achieve our goal. After all, ladies and gentlemen, “life is what we make it.”

Indonesia Categories of Manpower and Their Training by K Inbasegaran Dept. of Anesthesia and Intensive Care Kuala Lumpur Hospital Introduction The delivery of anesthesia in most countries is done by three distinct groups of personnel: namely physician specialists, physician non-specialists, and nurses or paramedics. The numbers of each group varies enormously and there is a trend in most countries (with the exception of very poor countries) slowly to reduce the non-physician anesthetists. There is also a worldwide shortage of anesthetists which appears to be caused by several factors. Among them are a rapid increase in surgical demand, the involvement of anesthetists in areas of care other than provision of anaesthesia, as well as reduction in intake of new trainees due to a host of reasons. The shortage of anaesthetic manpower is closely linked to the established standards of care in each country and thus there is a shortage in affluent countries such as Australia and Canada where the anaesthetist: population ratio is around 1 per 10,000 as well in the less affluent such as Thailand where it is around 1 per 180,000. In these countries, the majority of anesthetics are delivered by non specialist anaesthetic doctors or by nurses and paramedics. The training standards of many of the providers of anaesthesia also vary considerably both in duration, certification and course contents. Specialist Physician Anesthesiologists This group of providers are considered as the “gold standard” in anaesthesia care as they provide the highest standards of safety by virtue of their training and expertise and are also able to provide a wide range of perioperative services as well. The number of anaesthetist specialists is constantly short in most countries caused by movement into lucrative private practice sectors (which caters for a small segment of the population), attrition by retirement or migration to other countries, and shortage of trainees in teaching institutions. The training of specialists in the developed and higher-end developing countries are quite similar. There is a 3 to 5 year training period with certification by examinations. In some the last examination is an exit qualification and in others further training is needed for consultancy status. In some of the developing countries there is no structured training program and the one may be certified as a specialist after a certain period of work in an accredited institution, e.g. in Indonesia. The distribution of specialist within a country depends on the health systems prevailing there as well as income disparities. Thus in countries which have both public and private health care systems with a large income differential between the two, there is a predominant specialist practice in the private sector, e.g. in Malaysia, Singapore, or Taiwan. In countries where there is a small or non-existent private sector due to the way health care is structured (e.g. in the UK or Canada), the distribution is much more equitable. Similar too is the difference in distribution between urban and rural sectors and there is maldistribution if there is a relatively large rural population – as in most developing countries. Non-Specialist Physician Anesthetists These group of doctors comprise of the trainees or residents or may be just doctors not in the training program but who are simply recruited to provide anaesthesia. In many of the developing countries these non-specialist doctors provide a significant portion of anaesthesia delivery, particularly in the public sector, and the numbers of them in many hospitals are much more than available specialists. In developed countries, however, these doctors are strictly trainees only and the number of posts for such category of staff is controlled by the training and supervision requirements rather than service requirements. Many of these doctors administer anaesthesia under different levels of supervision ranging from direct supervision by specialists to more or less independent practice with the specialist available in another part of the city or hospital. The standard of care provided by these doctors will depend on their status with trainees providing a much better level of care due to better knowledge and non trainees just performing the role of technicians. Depending on the level of training these non- specialists may be capable of decision-making skills because they have had basic medical education. Nurse Anesthetists and Paramedics The quality of these group of personnel and their scope of services provided can vary a lot depending on locations. Again in developed countries, nurse anesthetists undergo very structured training programs for a number of years and undergo formal certification before being allowed to practice. Their practice is supervised by a physician anaesthesiologist and in many of these centers, they are utilized because it is a way of defraying or reducing costs and not because of shortage of physician anesthetists. In many of the developed countries nurses or paramedics are not allowed to give anaesthesia ( the UK or Australia) and anaesthesia is strictly a physician-based practice. On the other hand in developing countries such as Thailand, the Philippines, and China, nurses and paramedics are used to deliver anaesthesia, particularly in remote and rural areas as there is an absolute shortage of doctors and specialists. The standard of training of these nurses and paramedics again is dependent on the reasons for utilizing them in the first place. Where they are used because of shortage of manpower the training is minimal and they are trained to perform as technicians with little decision-making skills (supervised often by the surgeons) and this is the situation in most countries. In the more developed countries because of medico-legal considerations, there is a much better level of structured training and certification and often there are CME programs for these categories to maintain a certain level of professional competence. Conclusions Although in an ideal situation, all anesthetics should be given by a specialist physician anaesthesiologist, in reality this cannot happen in many countries. The utilization of other providers, both physician and non physician, must continue to maintain a service to the surgical population. However, efforts should be made at local, regional and international level to ensure that minimum safety standards are met. Secondly, it may be also cost effective for many countries to use a mix of personnel to deliver anaesthesia and the type of personnel used tailored to the complexity of cases and the degree of expertise needed. The higher-grade personnel could be used for training, teaching and the administration of anesthesia for the more complex cases and also to organize the services while the lower grade personnel to be used for anaesthesia delivery for routine non-complex surgery in relatively fit patients. This I feel is the path many countries ought to take to make the provision of safe anaesthesia a reality and at the same time taking into account the various constraints they are facing. Canada Canada’s Anesthesia Human Resources by Robert Byrick, MD University of Toronto Canada has a comprehensive, universal health care system in which physician costs are reimbursed by a single payor ­ the provincial government. Only physician anesthetists are licensed to deliver these services, and the number of training positions are determined by Ministry of Health. Donen1 projected that the Human Resource gap between service needs and the future availability of providers will widen over the next decade. We suggested2 that the specialty of anesthesia use records of the volume and type of anesthesia services delivered in various regions to analyze the type of future services required and the number of anesthetists who will be needed. The province of Quebec already has such a ‘demand-based’ planning model. Donen’s work provided insight into the causes of the future shortage. The Canadian population will increase by 33.8% by 2026, yet if the 1996 policies regarding International Medical Graduates (IMG) and residency positions remain in place, he projects no change in the number of physician anesthetists. Factors contributing to the shortage include: the decision to limit accreditation of International Medical training to North American graduates, thus reducing licensure of IMG’s. Simultaneously, enrollment in medical schools and postgraduate training positions were reduced, as were re-entry positions from family practice. The 1996 survey showed that almost 60% of Canadian anesthetists were either IMG’s or family practitioners before entering specialty training. Emigration of anesthetists continues to exceed immigration, resulting in a net loss of personnel, largely to the United States. Postgraduate training positions were decreased in 1997, based on the erroneous assumption that there were excess physicians. This was a direct result of failure to anticipate the ‘dynamics’ that drive changes in physician supply.3 For example, the demographics of Canadian anesthetists show that a large cohort immigrated to Canada between 1967-75 and are preparing to retire. Furthermore, these practitioners are working full-time and need to be replaced by full-time anesthetists. Failure to consider the “dynamic aspects of Human Resource planning” led the Ministry of Health to institute these changes. Our specialty, like others, objected, however we did not have current data to support our bias. The use of indices (e.g. population/anesthetist ratio) to estimate the need for anesthesia services, ignores changing patterns of practice and workload issues. A demand-based ‘Physician Resource Planning Model’ would attempt to approximate these dynamic factors which include: emigration, immigration and licensure of IMG’s, number of training positions and transfers in and out of these programs, aging of provider workforce, retirements and part-time working patterns. Forecasting future physician supply is complex and inexact, at best. The Association of Canadian University Departments of Anesthesia (ACUDA) is developing a model that uses data from provincial billing records to provide current estimates of services delivered. The complexity of the issue is emphasized by the enlarging scope of anesthesia practice. Using a population/anesthetist ratio is no longer an acceptable methodology, as it ignores variations in clinical practice related to age, sex, location and patterns of practice. To be effective, such a planning model would need to be updated regularly, thus reflecting current changes in ‘supply’ and ‘demand’. Specialty-specific workforce planning has been a neglected component of health care reform and, in the case of anesthesia, the implications for both availability of service and patient safety are clear. References 1. Donen N, King F, Reid D, Blackstock D. Can J Anesth 1999:46;962-969. 2. Byrick RJ, Craig DB. Consequences of inadequate Canadian Physician Resource Planning. Can J Anesth 1999:46;913-918. 3. Ryten E. None is too many ­ it’s time to discard this bankrupt physician supply policy for Canada. ACMC Forum 1998:31;8-17

Japan Anesthesia Manpower: World-Wide Problem? by Yasuhiro Shimada, MD, PhD Department of Anesthesiology Nagoya University School of Medicine Manpower is the key issue for any specialty in medicine world-wide. Anesthesia has its own manpower problems, because we have to provide anesthesia service to a variety of surgical teams with different demands and abilities. Essentially, anesthesiologists should be a conductor in the OR. During a smooth operation, the anesthesiologist’s role may be invisible but, once crisis occurs, he or she should play a role as a crisis manager. Therefore, when you consider anesthesia manpower, you have to think of the quantity and quality of anesthesia providers. “How to calculate adequate number of anesthesia providers?” To answer this question, three papers are very important. The first one deals with manpower problems in the European Union (EU) countries1, the second one in the US2, and the third one deals with the manpower status in Japan3. Manpower can be compared and/or estimated by a variety of indices, such as workload, staffing pattern, distribution, and in the future, the need for manpower may change according to the expansion of workplace and changes in health care environment. What is the present anesthesia manpower condition in the world? The number of qualified anesthesiologists per 100,000 population differs almost 3-fold among reporting countries, where Japan and UK (4.6) have the lowest number and Italy (15.6) has the highest. Workload can be estimated by the average duration of time an anesthesiologist spends providing anesthesia. Other numbers such as a number of anesthesiologists per table or per cases can be the basis for calculation of manpower for the hospital administrators and department heads. Next, we have to consider the staffing pattern of anesthesia departments. In Japan, we have three kinds of anesthesia providers; all of them are MDs. But in many European countries such as Germany, France, and Denmark, and also in the US, there is almost equal number of nurse anesthetists as manpower resources. Also, some may count trainee anesthetists as manpower. The next issue is maldistribution of specialists in each country. In Japan, we have roughly 3-fold variation among prefectures. “Who would be ideal as anesthesia provider to the patient?” There are several kinds of anesthesia providers in the world, and until now we have no data to answer this question. But I would like to add to Dr. Gravenstein’s comments on this issue. He gave me many questions: “What would be ideal? Does one need to be an MD to be a competent anesthetist for the majority of anesthetics? What does the MD training contributes? Whom should we train in countries with next to no MDs? How should we train them? What does technology have to offer to assist those poorly trained people?” I think these questions are the issues that our new International Anesthesia Patient Safety Foundation has to take into account in dealing with anesthesia manpower, which is the real underlying key to questions of anesthesia safety. References 1. Rolly G, et al. Anaesthesiological manpower in Europe. Eur J Anaesthesiol 1996; 13:325 2. Reves JG. Anesthesia manpower now and in the future. Anesth Analg 1995; 80(suppl):27 3. Yoshimura N, et al. Anesthesia manpower in Japan. Anesth Resusc 1999; 35:135

International Perspective from the US How to Increase the Standing of Anesthesia by JS Gravenstein, MD University of Florida From personal experience in continental Europe, I know that in the early 1950s anesthesia did not enjoy a glamorous reputation. In many countries anesthesia is still viewed as one of the less desirable clinical fields. The fact that the standing of our specialty in the United States and in many European countries has markedly improved gives hope to those working in countries where anesthesiology still lags behind the recognition internal medicine and surgery enjoy. The lament: “I do not get the recognition I deserve” will accomplish nothing. Nor can one hope to improve the image of the specialty through public relations ploys. A stellar reputation has to be earned. Where anesthesia has blossomed, it has made important contributions to patient care, clinical service, teaching, and research. A brief comment on each of these topics. Patient Care In the Operating Room, we have made anesthesia safer than ever before and we are making it possible for surgeons and invasive radiologists to perform new procedures. The names of many anesthesiologists are now firmly linked to important contributions to the intensive care of very sick patients. Increased visibility of anesthesia comes with our expanding role in the care of patients with postoperative or chronic pain. Clinical Service Surgeons, other specialists, and administrators have begun to anticipate competent and efficient services rendered by anesthesiologists. Such services extend to the establishment of safe policies for conscious sedation, the availability in case of emergencies, and the work on the uncounted committees that govern the affairs of hospitals. Administrative Services A number of medical schools and hospitals have appointed anesthesiologists to high administrative offices. Teaching In many institutions anesthesia is called on to teach aspects of cardiovascular and respiratory physiology and pharmacology, not to mention anesthesia. The recent introduction of the simulator, a unique contribution by anesthesiology, into the medical school curriculum has markedly boosted the visibility of anesthesiology. Teaching basic and cardiac life support to students and other physicians also puts the limelight on the specialty. With simulator teaching by anesthesiologists to high school and college students and engineers, the non-medical community becomes aware of the role anesthesia plays. Research All of the above contributions would not suffice to secure our specialty a firm position in the university. For that, anesthesia must show that it has made scholarly contributions advancing the specialty. Many scientific anesthesia journals, national as well as international in scope, attest to that. Beyond that, our specialty can look with great pride at a large number of prominent investigators who have made contributions valued not only in anesthesia but equally by the international academic community. To name just two anesthesiologists who have enhanced the humanity of medicine, anchored in anesthesia but of great importance to medicine in general: H.K. Beecher and human experimentation1, and E.C.Pierce, Jr.2, and the movement to increase the safety of patients. Anesthesiologists, such as John Severinghaus3, have also made technologic contributions that are recognized and appreciated well beyond the field of anesthesia. In summary, in the last half century, anesthesia has come out of the shadow into the limelight on several fronts. These successes hold promise for those working in countries where the field has yet to reach a position of prominence and provide some counterpoint to the discussions presented above which focus on what could be considered the fundamental underlying issue related to anesthesia patient safety problems in many if not most countries: the status of the anesthesiologist within the medical community. References 1. Beecher HK: Research and the Individual. Little Brown, Boston, 1970 2. Pierce EC Jr.: The 34th Rovenstine Lecture. 40 Years Behind the Mask: Safety Revisited, Anesthesiology 1996; 84:965-75 3. Severinghaus JW and Bradley AF: Electrodes for Blood PO2 and PCO2 Determination. J. Appl. Physiol 13, 515

The History of Standards in Anesthesia by Ellison C Pierce, Jr, MD Executive Director, APSF Debate among physicians concerning establishment of Standards of Practice has largely been resolved in the affirmative. The American Society of Anesthesiologists (ASA) notes that the term “practice parameters” may refer to Standards, Guidelines, or Advisories, depending upon how strong they are meant to be. The ASA has long been a leading advocate of practice parameters, if they are developed by specialists, rather than by an outside third party. The ASA first published a guideline, Guidelines for Patient Care in Anesthesiology, in 1968, an amended version of which is still in use. Soon after the 1986 publication of Standards for Patient Monitoring during Anesthesia at the Harvard Medical School, the ASA approved a similar version of the Standards. These have been modified and require among other requirements that qualified anesthesia personnel be present in the operating room at all times and that the patient’s oxygenation, ventilation, circulation, and temperature be continually evaluated. Thus, the Standards demand that during administration of general anesthesia, the concentration of oxygen in the patient breathing system be measured and that, during all anesthetics, blood oxygenation be monitored, utilizing a quantitative method. Since the publication of these initial Standards in 1986, the ASA has continued to develop or amend appropriate Practice Parameters, which now include the following: Basic Standards for Preanesthesia Care (1987), Standards for Postanesthesia Care (1988 and 1994), Guidelines for Ambulatory Anesthesia and Surgery (1973 and 1998), Guidelines for Continuing Medical Education (1972 and 1999), Guidelines for the Practice of Critical Care (1974 and 1999), Guidelines for Expert Witness Qualifications (1987 and 1990), Guidelines for Delineation of Clinical Privileges (1975 and 1998), Ethical Guidelines for the Anesthetic Care of Patients (1993 and 1998), Guidelines for Office-Based Anesthesia (1999), Guidelines for Regional Anesthesia in Obstetrics (1988 and 1991), Guidelines for Patient Care (1967 and 1996), and Guidelines for Nonoperating Room Anesthetizing Locations (1994).