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 to report that 2006 has been an active and rewarding year as we pursue safety initiatives (safety during patient-controlled analgesia, technology training) intended to further our mission that “no patient shall be harmed by anesthesia.” In addition to safety initiatives, the past year included a greatly expanded investment by the APSF in the support of research, both in the number of grants awarded and the size of the awards. This critically important expansion of research support was made possible by the generous support of the American Society of Anesthesiologists (ASA, $500,000 annually) and by the full support of two $150,000 awards by the Cardinal Health Foundation and Anesthesia Healthcare Partners.
Safety During Patient-Controlled Analgesia (PCA)
This issue of the APSF Newsletter contains a report of the APSF Board of Directors Workshop on “Safety During PCA” held on October 13, 2006, in Chicago, IL. The impetus for this conference was the APSF’s belief that opioid-induced depression of ventilation during PCA (and neuraxial opioids) is a preventable cause of morbidity and mortality.
In the view of the APSF, recognition of patients at increased risk for ventilatory depression and utilization of appropriate continuous monitors (pulse oximetry and indicators of arterial PaCO2), which are linked to a system to summon a health care professional to the patient’s bedside, would improve patient safety during pain management in the postoperative period. Although patients with obstructive sleep apnea (not always recognized) are at the greatest risk for opioid-induced depression of ventilation, it is clear that occasional patients without this perceived risk factor may experience life-threatening depression of ventilation that might be recognized sooner with continuous monitoring.
There is increasing recognition that supplemental oxygen may mask opioid-induced hypoventilation by maintaining oxygen saturation in the presence of impending apnea and carbon dioxide narcosis. Supplemental oxygen should be prescribed only when it is viewed as beneficial by the treating physician.
In addition to the report in this issue of the APSF Newsletter, a summary statement of the workshop appears on the APSF website. This summary statement has been given widespread visibility in the publications of the ASA, American Association of Nurse Anesthetists, American Society of Postanesthesia Nurses, and the American College of Surgeons. Distribution of the results of the workshop among all health care professionals and recognition of the need for continuous monitoring of patients in the postoperative period is critical, as safe pain management following surgery includes more than anesthesia professionals.
Technology Training Initiative
The APSF Committee on Technology is undertaking a technology training initiative based on the observation that anesthesia equipment is increasingly complex and anesthesia professionals need formalized training in its use. New machines have unique and subtle variations in breathing circuit design, automated checkout, volatile anesthetic delivery, hidden piston ventilators, fresh gas delivery, and ventilation modes. Although the incidence of equipment-related critical events is relatively low, morbidity associated with such events can be quite high. Human error is the leading contributor to equipment-related problems, and is typically magnitudes greater than pure equipment failure. The implication is that we need greater training and facility with our equipment.
The most effective method of introducing new anesthesia equipment into the operating room has not been thoroughly investigated. The Fall 2006 issue of the APSF Newsletter addressed the issue of technology training and the difference between mandatory and voluntary participation by anesthesia professionals. The APSF believes that technology training on anesthesia equipment is an important safety issue and will give this initiative high priority in the next year. Just as I would not fly on an airplane if the pilot announced his/her decision to turn off the audible alarms, I wonder how many of us would fly on an airplane with a pilot who knew as much about the airplane’s equipment as we know about our anesthesia machine?
The APSF Newsletter continues its role as a vehicle for rapid dissemination of anesthesia safety information with Robert C. Morell, MD, as Editor. The APSF Newsletter is sent to more than 80,000 recipients including the members of the American Society of Anesthesiologists, American Association of Nurse Anesthetists, American Academy of Anesthesiologist Assistants, and the American Society of Anesthesia Technologists and Technicians. The Spring 2007 APSF Newsletter will be a “special 20th anniversary celebration issue” describing past, present, and future achievements and goals of the foundation.
Important issues presented in recent editions of the APSF Newsletter include a 2-part series on “Patient Perspectives Personalize Patient Safety” and “Dealing with Adverse Events” (Winter 2005-2006 and Spring 2006 issues). Other topics presented in recent issues of the APSF Newsletter include Complications of Cervical Epidural Blocks, System Fixes Needed to Prevent Drug Errors, Oxygen May Mask Hypoventilation—Patient Breathing Must be Ensured, Relevance of Black Box Warnings, and the Technology Training Initiative.
Begun with the Summer 2006 issue of the APSF Newsletter, a special section entitled Question and Answers publishes safety questions submitted by readers and responses from members of the APSF Committee on Technology. The “Dear SIRS” (Safety Information Response System) column in the APSF Newsletter continues to provide rapid dissemination of safety issues related to anesthesia equipment as provided by readers. This column is coordinated by Drs. Olympio and Morell.
The APSF website (apsf.org) is coordinated by Jeffrey B. Cooper, PhD, APSF Executive Vice President for Strategic Planning, and George A. Schapiro, APSF Executive Vice President for Development. All APSF Newsletters are available online. The APSF website now has a question survey document for anesthesia professionals to register their opinions on patient safety topics. The survey document has been developed by the Committee on Education and Training chaired by Richard C. Prielipp, MD.
The APSF and the ASA Committee on Patient Safety and Risk Management cosponsored a joint patient safety booth at the ASA annual meeting in Chicago in October 2006. The booth content was developed by Drs. Joan M. Christie and Robert A. Caplan.
Data Dictionary Task Force (DDTF)/International Organization for Terminology in Anesthesia (IOTA)
As of June 2006, 2334 of 2558 terms had SNOMED ID numbers. In addition to anesthesia terms, Dr. Terri G. Monk, Chair of the DDTF/IOTA working group, is leading a committee to develop terminology standards for the perioperative period. The mission of this group is to merge all the existing standards for the perioperative period and to eliminate the overlap and redundancy that presently exist in perioperative terminology.
The DDTF/IOTA working group continues to work on the development of a standard schema for the anesthetic record. The goal is to create a standard XML schema for the anesthetic record. This will enable anesthetic records to be exchanged between diverse information technology systems and users while ensuring semantic inter-operability and traceability.
Dr. Monk is leading the effort to obtain federal funding for work that will support the further development of the terminology/schema for the specialty. Activities of the DDTF/IOTA have been entirely supported by APSF and the vendors of information technology systems (see APSF website for list of vendor suppor
ters). In October 2006, Dr. Monk’s group was successful in obtaining funding from the VA Health Services Research and Development Merit Review Board. The goals of the funded study are to analyze archived data from disparate automated information systems and develop preliminary data standards that will allow the merging of data from disparate automated information systems. Ultimately it is hoped that these data will facilitate study of the role of intraoperative variables amenable to interventions by the anesthesia professional (heart rate, blood pressure, temperature, oxygen saturation, depth of anesthesia). Currently, there is only sparse evidence to support the impact of such interventions, reflecting the fact that hand-written anesthesia records make it difficult to aggregate data on intraoperative physiology across large numbers of patients.
The Committee on Scientific Evaluation chaired by Sorin J. Brull, MD, received 35 grant applications in 2006 for awards to begin in January 2007. In October 2006, the committee recommended funding of 5 research awards at the $150,000 level. Two of the grants are supported in full by awards from the Cardinal Health Foundation and Anesthesia Healthcare Partners. I take exceptional pride along with my colleagues in endorsing this level of patient safety research support from the APSF. Since the inception of the APSF grant program, nearly 400 grant applications have been reviewed by the APSF. When the first grants were funded in 1987, funding for patient safety research was virtually nonexistent. Since 1987, the APSF has awarded 68 grants for a total of more than $3.5 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.
Financial support to the APSF from individuals, specialty and component societies, and corporate partners in 2006 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 increased research funding. In 2006, the APSF awarded $750,000 in research dollars to patient safety investigators representing more than 50% of the APSF income for the year.
Anesthesia is unique in American medicine in having a foundation dedicated to anesthesia patient safety, and this is reflected by the vision and support of the ASA since the formation of the APSF in 1985.
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 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 2007.
Robert K. Stoelting, MD