Patient Safety and Production Pressure: Academic Practice

John H. Eichhorn, MD

Moving patients through their operating room experience as fast as possible with the least possible cost has always been more difficult in a teaching hospital than in a private practice community hospital where there are no trainees (residents or SRNAs) or students (medical or nursing) to “slow things down.” In essence, there has always been the potential for some degree of “production pressure” in the teaching hospital OR because administering anesthesia (and also conducting surgery) is inherently slower when trainees and students are involved. Now, however, the realities of the “system” in which academic anesthesia professionals practice in teaching hospitals are creating new and dramatic production pressures that have significant potential to threaten patient safety directly.

The change is largely driven by economics. When reimbursement to teaching hospitals for patient care was relatively generous (certainly by today’s standards), it was usually simply accepted that anesthesia and surgery was slower because of the inexperience of trainees and students and the time taken to teach them during cases, that extra supplies and medications were consumed, and that often more and redundant equipment was involved in anesthesia and surgery in a teaching hospital. Today there is dramatic, even profound, financial pressure on teaching hospitals to increase efficiency and reduce costs. There is significant patient safety inherent in the direct hands-on supervision of an anesthesia trainee by a faculty member and the adoption of a pace which allows the trainee to undertake unfamiliar tasks at first slowly or even haltingly under the watchful eye and guidance of a teacher. This is true for intubating the trachea, doing a regional block, inserting a monitoring cannula, or, especially, turning over ORs between cases. Further, the inexperienced trainee may draw up eight or ten medications into syringes (“just in case”) when only four actually will be used. The learning process of discovering which medications are really indicated is expensive because many unused full syringes will be discarded, but it has traditionally been perceived as more effective and lasting learning if the trainee discovers it on his/her own rather than simply being told precisely the minimum to do, or, worse, following a preprinted protocol. The combination of relative inefficiency of time and extra consumption of medications and supplies characteristic of the academic anesthesia setting was reasonably tolerated for decades because it was accepted as a necessary component of teaching trainees safely while patient care was delivered. Because of a new often near-fanatic drive to cut costs, the traditional teaching hospital anesthesia practice time and resource inefficiency is under intense fire by hospital administrators. The resulting production pressure is removing the safety elements that previously effectively counterbalanced the potential risks of trainees and students learning to administer anesthesia.

BBA, Budget Cuts Provoke Pressures

The financial pressure on teaching hospitals comes from several sources. The federal government capped the number of residents that would earn teaching hospitals extra payments for teaching in 1997 (precisely at the time when there had been a major decreased in the number of anesthesiology residents), so that in some teaching hospitals, there is now much less ability to support teaching programs through providing, for example, direct subsidies for faculty salaries. This has the potential to reduce the number of anesthesiology faculty, which, in turn, can reduce the intensity of resident supervision, creating at least the potential for erosion of the protection afforded patients by the involvement of faculty in directly supervising anesthesiology residents. Further, dramatic cuts in Medicare reimbursement because of the so-called Balanced Budget Amendment have had near-crippling effects in many teaching hospitals. This, coupled with decreased hospital revenue due to managed care contracting and also increased demand for free care due to the national economic downturn, has forced previously unimagined demands for cost cutting in teaching hospitals.

Trainees Pressured To Go It Alone?

Because the OR is such a high-cost area within a hospital, it is a prime target for cost reduction. The goal is to move more patients through the OR schedule much faster while consuming fewer resources (personnel, facilities, equipment, supplies, and medications). The threat, implicit or overt, is the loss of jobs of all types if the cost reductions are not enough. Therefore, the intention is that anesthesia trainees must move and function faster. Even if the amount and intensity of faculty teaching and supervision is unchanged (very unlikely), the logical assumption is that the drive to go faster will increase the risk of errors, some of which may endanger patient safety. One classic scenario involves one faculty member supervising two trainees and being genuinely involved in patient care in one room when the other trainee in the other room is ready to begin an anesthetic and there simply is no other faculty available at that moment to substitute in the second room. Independent of the traditional impatience of surgeons (faculty or resident) in such circumstances, there is now the significant added pressure of the OR environment to avoid wasting time at all costs (even patient safety?), because of the financial cost. If the occupied faculty relents and directs the second trainee to begin alone or, worse, the second trainee decides independently to do so, the potential for error and danger to patient safety is, by definition, markedly increased.

The adverse impact of production pressure on the adequacy of preanesthetic screening of patients is addressed in another article in this series. With the fierceness of the cost-cutting initiatives particularly in some teaching hospitals, it is not unexpected that the preoperative screening clinic may be threatened with elimination. Without ambulatory and same-day-admit patients being seen before the day of surgery (particularly with the usual increased complexity and acuity of the patient population of a teaching hospital and also the incredible pressure to proceed with an anesthetic because the patient, surgeon, and room are right there all waiting), it is axiomatic that there will be acceptance of anesthesia risks that would have been intercepted and dealt with by early screening. It then would be only a matter of time until an adverse outcome eventually results.

Drug Cost Pressures and Potential Post-Op Implications

Similarly, the component of production pressure to cut costs by using less expensive medications can lead to potential decrements in patient safety. While narcotics and even inhalation anesthetics could be considered, probably the most dramatic example involves the insistence in some teaching hospitals that only the cheapest possible muscle relaxants be used. Certain of these are more potent and longer-acting than many of the more modern and much more costly alternatives. It is not difficult at all to imagine that years (decades?) worth of potential savings, even for a big OR, would be wiped out by the legal and settlement costs of a single case of inappropriate extubation (aggravated by intense pressure to turn over the room in minimum possible time) of a still-weak patient who then does not breath adequately, is not monitored appropriately because of short staffing and also the pressure on everyone to hurry, and suffers profound hypoxemic brain damage.

There is no well-documented published evidence that there has been an objectively measured decrement in anesthesia patient safety due to production pressure in the academic setting. There likely never will be. This subject is essentially impossible to study prospectively—for many reasons: absence of a baseline error/injury rate to compare to, the massive data base required to show a difference in what would be (thankfully) still relatively rare events, the incredible logistics of organizing such an investigation, and, especially, the lack of cooperation because of the potential adverse medical-legal implications of exposing information about potential or actual patient injuries. Therefore, anecdotal case reports may be the only source of information to support the contention that economically driven production pressure is endangering anesthesia patient safety in teaching hospitals. However, unfortunately, for the same medical-legal concerns, there likely will not be anything published that details objectively how production pressure caused anesthesia faculty or trainees to cut corners and/or rush in such a way as to harm a patient. It appears that word of mouth, however incomplete and possibly unreliable, remains the only way we will be aware of instances of decreased safety caused by production pressure in a teaching hospital OR. This does not change the fact that this fear is both real and inherently logical. Accordingly, all faculty, trainees, and students must be made aware (initially and repeatedly) of these risks and they should factor them into their conduct continuously. If not already, soon there will be a circumstance in a teaching hospital in which anesthesia professionals draw the line and simply refuse to engage in what they are absolutely convinced is grossly unsafe practice induced by production pressure. That is the time when some appropriate balance is restored to the dynamic tension between OR production pressure and anesthesia patient safety.

Dr. Eichhorn is Professor and Chairman of Anesthesiology at the University of Mississippi School of Medicine and Medical Center in Jackson, and also Editor of the APSF Newsletter.