President Reviews 2009 – Prepares for 2010

Robert K. Stoelting, MD

As President of the Anesthesia Patient Safety Foundation (APSF), it is my privilege to report annually on the activities of the foundation during the past calendar year. I am pleased that 2009 has been an active and productive year as the APSF continues to pursue patient safety initiatives intended to further our vision that “no patient shall be harmed by anesthesia.”

As an advocacy group the APSF does not write standards. Recommendations developed and promulgated by the APSF are intended to assist professionals who are responsible for making health care decisions. The APSF’s recommendations focus on minimizing the risk to individual patients for rare adverse events rather than necessarily on practices that balance all aspects of population health quality and cost. The APSF does not intend for these recommendations to be standards, guidelines, practice parameters, or clinical requirements nor does application of these recommendations guarantee any specific outcome. Furthermore, these recommendations may be adopted, modified, or rejected according to clinical needs and restraints. The APSF recognizes that these recommendations are subject to revision as warranted by the evolution of medical knowledge, technology, and practice.

Research

The APSF Committee on Scientific Evaluation chaired by Sorin J. Brull, MD, received 32 grant applications in 2009 for awards to begin in January 2010. In October 2009, the committee recommended funding 5 research awards for a total of $668,484. Among the named grants were the APSF/American Society of Anesthesiologists (ASA) Endowed Research Award, APSF/ASA President’s Research Award, APSF/Covidien Research Award, and the APSF/Eisai Research Award. The APSF/ASA research award utilizes funds from the APSF endowment fund that were made possible by contributions from the ASA to the APSF over the past 2 decades.

The APSF is the largest private funding source for anesthesia patient safety research in the world. Since the inception of the APSF grant program more than 430 grant applications have been received by the APSF. When the first grants were funded in 1987, funding for anesthesia patient safety was virtually unknown. Since 1987, the APSF has awarded 88 grants for a total of more than $5.96 million. The impact of these research grants is more far-reaching than the absolute number of grants and total dollars, as APSF-sponsored research has led to other investigations and the development of a cadre of anesthesia patient safety investigators.

APSF Newsletter

The APSF Newsletter continues its role as a vehicle for rapid dissemination of anesthesia patient safety information with Robert C. Morell, MD, and Lorri A. Lee, MD, acting as co-editors. The circulation of the
APSF Newsletter exceeds 84,000 recipients and is sent as a member benefit by the ASA, American Association of Nurse Anesthetists (AANA), American Association of Anesthesiologists Assistants (AAAA), and the American Society of Anesthesia Technologists and Technicians (ASATT) to all of their members. This Winter 2009-2010 issue of the
APSF Newsletter represents the last “routine” hardcopy publication, as the newsletter is converting to an electronic format with the Spring 2010 issue (Volume 25, No 1). The APSF Newsletter will continue to be available online (www.apsf.org), and individual subscriptions to the hardcopy of the newsletter will be available for $100 annually.

Important issues presented in recent editions of the
APSF Newsletter include the special edition of the Spring 2009 issue on cerebral perfusion pressure. The topic was introduced by an editorial, "Cerebral Perfusion: Err on the Side of Caution," authored by William L. Lanier, MD. The APSF believes that reports of global ischemic brain damage following surgical procedures in the semi-sitting (“beach chair) position may reflect unrecognized cerebral hypoperfusion. Cerebral perfusion and acceptable systemic blood pressure was also the topic of the APSF Board of Directors Workshop in October 2009.

As a response to the recommendations from the speakers and attendees at the workshop, the APSF has issued a Request for Proposal to study the nature and potential etiological factors of unexpected neurocognitive deficits in patients undergoing general anesthesia during surgery in non-supine positions. There have been increasing reports of severe neurological injury in previously healthy patients having surgery in head-above-heart positions (shoulder surgery in the beach chair position) but the incidence and mechanisms are unknown. The APSF believes this is a major patient safety issue that warrants rigorous study. Thus, the APSF will provide up to $200,000 for a period not to exceed 2 years to study this question. In addition, the APSF is funding the creation of a registry (Neurologic Injury after Non-Supine Surgery Registry, NINS) to collect and analyze adverse neurologic outcomes following shoulder arthroscopy surgery. The NINS will be under the direction of Drs. Domino, Lee, and Posner at the University of Washington in Seattle, WA.

The Summer 2009 issue of the
APSF Newsletter included an editorial entitled "Dangers of Postoperative Opioids—Is There a Cure?" authored by Drs. Stoelting and Weinger. This editorial was a follow-up to the October 2006 APSF Board of Directors Workshop on the safety of patient controlled analgesia in the postoperative period. Despite the recommendations of this 2006 workshop for monitoring of oxygenation and ventilation, unexpected and potentially harmful opioid-induced respiratory depression continues to occur. In the Summer 2009 editorial, Drs. Stoelting and Weinger propose that every patient receiving postoperative opioids should be managed based on specific clinical considerations that include: 1) individualizing the dose and infusion rate of opioid, 2) continuous monitoring of oxygenation as the rule rather than the exception, 3) assessment of the need for supplemental oxygen especially if pulse oximetry or intermittent nursing assessment are the only methods of identifying progressive hypoventilation, and 4) consideration of the value of monitoring ventilation with technology capable of detecting progressive hypoventilation. The APSF believes that unrecognized postoperative opioid-induced respiratory depression can be reliably detected only if an understanding of the pathophysiology of the sequence of events and available monitoring technology are considered for all patients.

The “Questions and Answers” and the “Dear Sirs” (Safety Information Response System) columns in the APSF Newsletter provide rapid dissemination of safety issues related to anesthesia equipment in response to questions from readers. These columns are coordinated by Drs. Olympio and Morell. Dr. Olympio retired as chair of the APSF Committee on Technology at the conclusion of the annual meeting of the APSF Board of Directors in October 2009. A. William Paulsen, PhD, has graciously agreed to become the acting chair. The APSF thanks Dr. Olympio for his years of service to the APSF and devotion to patient safety.

A section of the APSF Newsletter entitled “Innovative Technology and Pharmacology” is intended to describe innovative technological or pharmaceutical developments that may impact patient safety. It is inevitable that this column may discuss products that are sold or distributed by entities that have or continue to support the APSF financially. The APSF will strive to disclose those relationships as appropriate.

Communication

The APSF website (www.apsf.org) is coordinated by APSF Executive Vice President George A. Schapiro. The APSF website includes a monthly poll question related to anesthesia patient safety issues. This poll question is coordinated by Richard C. Prielipp, MD, chair, APSF Committee on Education and Training. The website also permits online donations to the APSF.

Sorin J. Brull, MD, chair, APSF Committee on Scientific Evaluation continues to serve as the Patient Safety Section Editor for Anesthesia and Analgesia.

The APSF sponsored a panel at the 2009 Annual Congress of the International Anesthesia Research Society (IARS) on fire safety in the operating room. This panel was organized and moderated by Dr Prielipp. A panel on intraoperative blood pressure management to be moderated by Dr. Prielipp is planned for the 2010 IARS Annual Congress. Drs. Weinger and Olympio led APSF-sponsored panels on patient safety education curricula and on teaching technology safety at the 2009 annual meeting of the Society for Education in Anesthesia.

Fire Safety Video

The APSF is pleased to announce that the fire safety video entitled “Prevention and Management of Operating Room Fires” is now available. This video was funded by the APSF and produced in cooperation with ECRI Institute. In addition to the 17-minute video a CME course is available. Information regarding the DVD and CME course is available on the APSF website (www.apsf.org).

Medication Safety in the Operating Room

The APSF has identified medication safety errors in the operating room environment as a patient safety concern that needs to be addressed by multidisciplinary experts. In this regard the APSF sponsored a multidisciplinary conference on January 26, 2010, in Phoenix, AZ. Medication errors in the operating room continue to occur and a new paradigm is needed. This new paradigm, designated as STPC (standardization, technology, pharmacy, culture), was the subject of the multidisciplinary conference. The recommendations of the conference will be published in a future issue of the APSF Newsletter.

Financial Support

Financial support to the APSF from individuals, specialty and components societies, and corporate partners in 2009 has been most gratifying. This sustained level of financial support makes possible the undertaking of new safety initiatives, the continuation of existing safety initiatives, and funding for anesthesia patient safety research. The continued uncertainty related to the world-wide economic recovery will require careful attention and analysis of the APSF’s budgetary plans for 2010. The level of research support is particularly dependent on the level of financial support received.

Online Donations

The APSF website permits “online” credit card contributions to APSF. Go to “make a donation” on the APSF home page and follow the prompts.

25th Anniversary

The year 2010 represents the 25th anniversary of the formation of the APSF. The APSF was officially incorporated in September 1985 and the first APSF Newsletter was published in the spring of 1986. In honor of this milestone the APSF Executive Committee will be planning a special recognition of the 25th anniversary during the annual meeting of the ASA in San Diego, CA.

Concluding Thoughts

The APSF regrets the passing of Joachim S. (Nik) Gravenstein, MD, on January 16, 2009. Dr. Gravenstein was instrumental in the initial organization of the APSF, serving as one of the 7 original members of the APSF Executive Committee and as the first chair of the Committee on Education and Training. He was a life-long advocate of patient safety and his contributions are a lasting memory to his genius and compassion for his fellow man.

The APSF is pleased to welcome Patricia A. Kapur, MD, to the APSF Board of Directors and as an at-large member of the Executive Committee. The APSF is also pleased to welcome Maria Magro, CRNA, as a consultant to the Executive Committee.

As in the previous annual report, I wish to reiterate the desire of the APSF Executive Committee to provide a broad-based consensus on anesthesia patient safety issues. We welcome the comments and suggestions from all those who participate in the common goal of making anesthesia a safe experience. There remains much still to accomplish and everyone’s participation and contributions are important.

Best wishes for a prosperous and rewarding year 2010.

Robert K. Stoelting, MD
President